AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Facilitator Training Instructor Guide—Implementation of the Prevention Reports
Note: This part of the training primarily consists of exercises and does not have any associated slides.
Introduction
Say:
Yesterday you were introduced to the components of On-Time Pressure Ulcer Prevention, including the electronic reports and implementation materials. Today we will focus on the role of the Facilitator in implementing the program using these materials. You will participate in scripted and unscripted exercises to help illustrate how the change team and Facilitator would interact during the implementation of the pressure ulcer program. After each exercise we will have a debriefing to discuss the exercise.
In these exercises you will play the parts of the Facilitator and change team members. You will simulate the interaction of the Facilitator and the team as they assess their facility's current pressure ulcer prevention program and choose the On-Time pressure ulcer reports to use in daily practice. In these exercises you will choose the meetings and huddles that will incorporate the reports. Finally, you will decide how to begin to pilot the reports in at least one unit.
Although these exercises compress a number of decisions that the nursing home change team will make, the exercises should stimulate discussion about implementation issues that may arise in actual practice that are specific to On-Time and the Facilitator's role. We understand that to be in this training you already have experience with quality improvement programs in nursing homes and are familiar with nursing home operations and practices. So the goal is to help you understand how your skills can be applied to helping implement On-Time Pressure Ulcer Prevention.
Review of the Nursing Home's Pressure Ulcer Prevention Program
Say:
The first exercise is scripted. Roles are assigned but each person reads their lines. The focus is on assessing the facility's current pressure ulcer prevention program. At the end of the session the team should understand the following:
- What the nursing home staff does in assessing risk.
- How risk information is communicated to clinical staff and how often.
- What the staff does when risk changes are identified.
- How the staff changes care plans to intervene early on those risks to prevent pressure ulcers from forming.
The team should also have a sense of how it can improve prevention activities and members should begin to think about how On-Time Pressure Ulcer Prevention can help them reduce pressure ulcers.
Exercise #1: Scripted Role Play
Materials:
Ten copies of:
- Completed Self-Assessment #1 (Greenleaf Hills Nursing Home).
- Scripted Exercise #1.
Do:
- Provide one copy of the script and one copy of the completed Self-Assessment #1 to each participant.
- Assign a role to each participant.
Say:
There are roles for 10 participants:
- Facilitator: Sandy.
- Program Champion/Administrator: Tom.
- DON: Mary.
- ADON: Joanne.
- Nursing Supervisor: Anita.
- Dietitian: Laura.
- Rehab Director: Pat.
- Nursing Assistant: Francoise.
- Nurse Manager: Nancy.
- QI Coordinator/MDS Nurse: Annie.
Note to Trainer:
If there are fewer than 10 participants, some participants should be asked to take on two roles. If there are more than 10 participants, assign "extras" to take turns playing the Facilitator; or ask some participants to provide feedback to the group when the exercise is completed.
Role names may be changed to better fit a participant's gender if he or she would feel more comfortable using a different name.
Do:
Instruct the "actors" to begin. Read the "setting" to the group.
Debrief:
When the role play exercise is over, choose from the following questions to engage the group in a debrief session. We include appropriate responses below in case these points are not made. Clearly these are not all the possible answers.
- Do you think the Facilitator did a good job of engaging the group during the change team meeting?
- Encouraged group discussion and demonstrated active listening. The Facilitator encouraged all members of the change team to contribute to the discussion and asked clarifying questions.
- Addressed concerns that were raised (e.g., additional meetings, getting input from nursing assistants). The Facilitator offered options for addressing barriers.
- Emphasized key points about On-Time and information from prior sessions.
- Could her facilitation of the meeting be improved?
- She could have tried to encourage more participation by the nursing assistant during the team meeting.
- She could have tried to get more detail about some of the meetings that were mentioned (e.g., the pressure ulcer meeting) such as who attended, what was discussed, and how often they occurred. She could have then brought this meeting up as an opportunity for nursing assistant participation as well as a place to add "prevention" to the discussion.
- She did not allow the other team members who did not fill out the self-assessment to comment about whether they agreed that the responses on the self-assessment truly reflect the processes at the facility.
- Did the Facilitator take advantage of opportunities during the discussions to highlight important points about On-Time? Were there any missed opportunities?
- The Facilitator did a good job pointing out risk factors that were included in the On-Time reports. She talked about the Nutrition Risk Report with the Program Champion. But she did not refer to any specific reports during the group meeting, which might have helped reinforce some of the information on the reports that was presented in the earlier session.
- Did the Program Champion support the program in a convincing way? Could he have improved on his promotion of the program?
- Like the Facilitator, the Program Champion talked about the benefits of On-Time but did not mention specific reports.
- Was the Facilitator effective in addressing questions and challenges from members of the change team?
- The Facilitator addressed concerns the group raised about taking nursing assistants away from their assignments and letting them attend meetings. She showed that by applying some flexibility and creativity, the team can find a solution that will be satisfactory to all members. She could have used that opportunity to further make the point that meetings are enhanced by having the perspective and input of the nursing assistants.
- What did you learn from participating in this exercise?
- To be prepared to help the team address barriers and challenges.
- To be ready to take every opportunity to reinforce the value of On-Time.
- That it is important to know the content of the individual On-Time reports very well and be able to point out features that can help the facility improve the care they provide to residents.
Exercise #2: Unscripted Role Play
Say:
In the second exercise, you are assigned a role and asked to role play the process for assessing the nursing home's pressure ulcer prevention program. However, this time, you will not have a script. Short bios are provided for each character. A completed Self-Assessment worksheet is included.
Materials:
- Bios for each participating "actor"
- Completed Self-Assessment Worksheet #2 (Shady Manor Nursing Home)
- Suggested Prompts for Facilitator
Do:
- Print one copy of the page of short bios. Cut the page to separate the bios.
- Distribute one bio to each of the participating "actors."
- Make enough copies of the completed Self-Assessment for everyone attending the meeting and distribute one copy to each participant.
- Provide the Facilitator with the list of suggested prompts or questions that can be used during the meeting.
Note to Trainer:
If there are fewer than 10 participants, some participants should be asked to take on two roles. If there are more than 10 participants, assign "extras" to take turns playing the Facilitator; or ask some participants to act as observers and provide feedback to the participants when the exercise is over.
Say:
The scene takes place at Shady Manor, an average size facility located in a suburban neighborhood. They do OK on surveys but recently have had a spike in their pressure ulcer rates, particularly on one of their long-term care units. The administrator recently heard a presentation about On-Time and thinks it would be ideal for their facility.
You all have your roles. Let's assume that the Self-Assessment Worksheet has been filled in and reviewed by the Facilitator. They have decided that the Facilitator will lead the meeting. The scene begins with the change team assembled and ready to discuss the self-assessment. All team members are in attendance.
In this session, the Facilitator walks the group through the sections of the Self-Assessment Worksheet, asking clarifying questions and confirming with the group the information contained in the worksheet. The goal of the meeting is to identify what is being done to prevent pressure ulcers and to clarify how information about residents' pressure ulcer risks is obtained. The group should also discuss how information about pressure ulcer risks results in changes in care plans, what huddles and team meetings are used to discuss pressure ulcer risk factors or pressure ulcer prevention, and what they do to identify the root cause of new pressure ulcers.
The Facilitator has been given a list of questions to help structure the discussion if needed. This meeting is intended to set the stage for making the decisions about which On-Time Pressure Ulcer Prevention reports the team wants to use and at which meetings or huddles they want to use those reports.
Let's spend 10 minutes looking at the Self-Assessment Worksheet that has been provided to you, and then we will begin this role-playing exercise.
Do:
Instruct the Facilitator to begin the Self-Assessment review with his or her team.
If the Facilitator is having difficulty leading the team through the review, provide guidance to help move the discussion along.
Debrief:
When the role play is over, the trainer engages the group in a debrief session. The following are questions that can be used in the discussion:
- How did you feel the Facilitator did in leading the self-assessment discussion? Did the steps of the process make sense? Was the Facilitator able to engage participants in a discussion covering all sections of the self-assessment?
- Did this exercise give you a sense of the types of questions and challenges that might arise during a review of the self-assessment?
- How did you feel the Facilitator did in addressing any challenges that arose?
- What did you learn about the Facilitator role?
- What would help a Facilitator prepare for this role?
- For those of you who played the Facilitator, how did you feel? Were you able to engage all members of the team?
- After participating in the scripted and unscripted role-play exercise, what additional activities would help you prepare for the Facilitator role?
Review of the Change Team's Process for Choosing On-Time Reports, Incorporating Them Into Meetings, and Piloting Those Meetings
Say:
We have a similar set of role-playing exercises to illustrate the role of the Facilitator and change team in determining which On-Time Reports and which meetings the nursing home will decide to pilot. We provide handouts as before. The handouts include a filled in Menu of Implementation Strategies, the Communication Practice grid from the Self-Assessment Worksheet, and a Meetings Description document.
Since nursing home staff may call meetings by different names, the Meeting Description document was created to help clarify the content of meetings and huddles listed in the Menu. It also includes suggested attendees and pressure ulcer prevention reports that may be useful in those meetings. These handouts are intended to help the change team make their implementation decisions. As before, we will have a debriefing after each exercise.
For the two exercises, the change team is attempting to decide which electronic reports provided by the Pressure Ulcer Prevention Program the nursing home will use and at which clinical team meetings they will use these reports. Once they decide, the team determines if they will use the reports at existing meetings or a new meeting. The change team then decides how to pilot the use of the reports. They may opt to trial one or more of the reports in one unit and then gradually roll out to the entire building, as is commonly done, or implement across the facility at one time.
The Facilitator guides the meeting. The Facilitator's role is to help the change team when the team gets bogged down. In reality a change team may make these decisions over a number of change team meetings. But for purposes of familiarizing the Facilitator with his or her role, the exercise treats this as one session. We are ready to do the scripted exercise. Let's spend 10 minutes reviewing the filled in materials provided as handouts. Then we will begin the scripted exercise.
Materials:
- Completed Menu of Implementation Strategies Worksheet.
- Completed Communication Practice Grid from Self-Assessment Worksheet.
- Meeting Descriptions document.
Exercise #1 Scripted Role Play
Do:
Assign each participant a role and provide each person with the script.
Say:
There are roles for 10 participants:
- Facilitator: Sandy.
- Program Champion/Administrator: Tom.
- DON: Mary.
- ADON: Joanne.
- Nursing Supervisor: Anita.
- Dietitian: Laura.
- Rehab Director: Pat.
- Nursing Assistant: Francoise.
- Nurse Manager: Nancy.
- QI Coordinator/MDS Nurse: Annie.
Note to Trainer:
If there are fewer than 10 participants, some participants should be asked to take on two roles. If there are more than 10 participants, assign "extras" to take turns playing the Facilitator; or ask some participants to provide feedback to the group when the exercise is completed.
Materials:
- Ten copies of the script (one for each participant role).
Do:
Begin by reading aloud the "setting" at the beginning of "Scene 1: Change Team Meeting." Instruct the "actors" to begin reading their parts.
Debrief:
When the role play exercise is over, choose from the following questions to engage the group in a debrief session. We include appropriate responses below in case these points are not made. Clearly these are not all the possible answers.
- What did the Facilitator do that helped engage the group?
- Encouraged group discussion and demonstrated active listening. The Facilitator asked for details about the team's existing processes and posed open-ended questions for the group to consider and respond to.
- Proposed potential uses for implementation materials. The Facilitator provided examples of how On-Time reports could be incorporated into staff's current workflow (e.g., existing meeting, new huddle).
- Emphasized shared decisionmaking and coordination across disciplines. The Facilitator reacted to and addressed group feedback about the reports and solicited input from all types and levels of staff. He/she also allowed the team to decide which reports would be implemented and how.
- Underscored key takeaways. The Facilitator reiterated key takeaways and discussion points from the team's prior sessions, to ensure all team members were aware of and familiar with work completed to date.
- Do you feel the team has a clear plan to implement the reports?
- Yes. The team agreed to pilot the Nutrition Risk Report on Nancy's unit during a 5-minute staff huddle with the nurse, dietitian, and nursing assistants, to be held on Wednesdays at 11:15 a.m. with day shift nursing assistants.
- Do you think the team's plan to use the reports is effective? Why/why not? Would you do anything differently?
- Yes. They agreed to start slowly by implementing one report during one meeting and evaluating and adjusting the process before rolling out to other shifts and adding more reports. This process is slower but allows for any necessary course correction to take place on a small scale.
- Did the Facilitator take advantage of opportunities during the discussions to highlight important points about On-Time? Were there any missed opportunities?
- The Facilitator could have provided more detail about the actual content included in the Nutrition Risk Report. Also, the Facilitator could have reminded the group that the Medium-Risk Nutrition Report can be a good tool to use to help prevent weight loss.
- Do you think the team understands the importance or the potential impact of On-Time?
- Yes and no. Team leadership (i.e., the Program Champion/Administrator, DON, Nurse Manager, and Dietitian) all appear committed to implement the program, but they reported problems getting nursing assistants and other nursing staff to attend the newly instituted huddles. It is important for the champion to communicate priorities for attending prevention meetings. If reports aren't used and meetings aren't held, then no impact is likely.
- Was the Facilitator effective in addressing questions and challenges from members of the change team? If yes, why? If not, why not?
- Yes and no. The Facilitator addressed all of the major questions raised by the group regarding the reports' content and use. But she could have done more to address some of the logistical concerns raised by the Nurse Manager (e.g., adding to staff workload, increased administrative burden).
- Do you think this role play was an accurate representation of a typical nursing home team? If not, in what way would a typical change team be different?
- Yes, but change teams may have difficulty scheduling meetings such that all members of the team can attend. This means that not every discipline will be represented at each meeting and that the team champion will have to make the effort to keep those not attending up to date on the team's work.
Exercise #2 Unscripted Role Play
Say:
We are ready for the unscripted exercise. You will be provided with a short bio describing your role and a new set of handouts. Since this is an unscripted exercise, we have also provided a list of potential prompts for the Facilitator to help the team meet the goals of the exercise.
Materials:
- Bios for each participating "actor" (same materials used in review of the nursing home's pressure ulcer prevention program unscripted exercise).
- Suggested Prompts for Facilitators.
- Completed Menu of Implementation Strategies Worksheet.
- Completed Communication Practice Grid from Self-Assessment Worksheet.
- Meeting Descriptions document (same materials used in review of the nursing home's pressure ulcer prevention program unscripted exercise).
Do:
- Print one copy of the page of short bios. Cut the page to separate the individual bios and distribute one bio to each of the participating "actors."
- Make enough copies of the completed Menu Worksheet, completed Self-Assessment with Communication Practice Grid, and Meetings Description document for everyone and distribute.
Note to Trainer:
If there are fewer than 10 participants, some participants should be asked to take on two roles. If there are more than 10 participants, assign "extras" to take turns playing the Facilitator; or ask some participants to act as observers and provide feedback to the participants when the exercise is over.
Say:
Today's session will allow you to be an active participant in a change team meeting. The task of your team is to choose the On-Time Pressure Ulcer Prevention reports that your nursing home will begin to pilot in specific huddles or clinical meetings to help prevent pressure ulcers. At the meeting you will review and discuss the Menu of Implementation Strategies Worksheet and relate it to the Communication Practice grid to help you determine which reports would be most helpful and how the nursing home should use them.
Look at your bio to help you think about the role you are playing. The scene takes place once again at Shady Manor, which if you recall is an average size facility located in a suburban neighborhood. They do OK on surveys but recently have had a spike in their pressure ulcer rates, particularly on one of their long-term care units. The facility has decided to implement On-Time.
The purpose of today's meeting is for the team to decide on an implementation plan for one or more of the On-Time reports. The team will identify reports to use at meetings and develop a plan to pilot these reports and meetings.
You have the facility's Menu of Implementation Strategies Worksheet that has been filled out, the Communication Practice grid, and the Meetings Description document. We're ready to get started. You each have your roles as team members. Please briefly familiarize yourself with the materials. We will begin in 15 minutes.
Based on the information provided to you, you are now the Shady Manor Pressure Ulcer Prevention Change Team. In this unscripted exercise, you want to accomplish the following:
- Decide which meetings and which On-Time Pressure Ulcer Prevention reports you want to pilot.
- Determine if the reports will be introduced at an existing meeting or huddle or a new meeting.
- Discuss issues that need to be settled if it is an existing meeting. How will the meeting be affected?
- Identify who should attend the meetings and assign any necessary roles (e.g., printing reports, leading discussions).
- Determine how you plan to pilot meetings and which units will be used.
- Schedule when the Facilitator and change team should meet to discuss how the pilot went.
Facilitators, you will need to help the team accomplish these goals. Let's get started.
Note to Trainer:
If the team or Facilitator is having difficulty reaching the goal of each step, be prepared to step in to help guide the discussion. It is important for the team to articulate why the report and meeting combination is chosen. When the team has completed all steps in the process, engage the group in a debrief session.
Do:
When the role play is over, the trainer engages the group in a debrief session. The following are questions that can be used in the discussion:
- How did the Facilitator help with making sure the meeting accomplished what was planned? What else could he/she have done? Was it difficult to go through the decisionmaking process to pick meetings and appropriate reports?
- For those of you who were part of the team, in your experience, did the exercise play out realistically? Were typical questions and challenges raised? Were they addressed appropriately by the Facilitator?
- What do you anticipate may be issues during the piloting of On-Time reports? Would you expect the pilot to work well immediately? What is likely to go wrong? What approach would you take to address these issues?
Guidance for Common Situations Facilitators May Face
Say:
Now that we have gone through these implementation exercises, let's consider some situations that may occur and discuss appropriate ways to handle them.
Do:
Choose from the following scenarios listed below for discussion. We provide some possible responses consistent with the implementation strategy used in On-Time. Discuss other scenarios that may have come up during the training as well and ask the participants for other scenarios that they would like to discuss.
- Dietitian reports that she plans to hold a nutrition huddle during lunch, in the dining room. That way, she can observe the residents eating and the nursing assistants feeding the residents. It doesn't take time away from the nursing assistants' day.
- While this may appear to "save time," it does so at the expense of nursing assistant input. Staff cannot and should not be expected to contribute to meetings while actively providing care to residents. If limited time is an issue, suggest that the dietitian and nursing staff meet briefly before or after the lunch hour for a quick check-in. If nursing assistants know the residents who will be discussed after lunch, they can pay special attention to those residents during the meal and be prepared to discuss them with the dietitian after the meal has ended.
- Nursing says that the dietitian is too busy to attend the nutrition huddle; nursing can run the meeting and update the dietitian later about the discussion.
- It is critical that representatives from all disciplines and levels participate in the discussion; as such, the team must identify a time that accommodates all necessary staff. It's important to have everyone's perspective on the residents.
- When everyone is present it alleviates the need to pass along information to those missing the meeting. Interventions can be discussed and initiated immediately, with no delay.
- Dietitian says she has her own process to review meal intake and doesn't feel the need to change a process that's working well.
- Although this process may "work well" for the dietitian, it can be greatly improved by structured check-ins with nursing assistants and other nursing staff. Given their direct and ongoing care of residents, these staff can offer valuable insight into subtle changes in a resident's health status. They also may provide information about the resident that could lead to changes in care to prevent nutritional decline before more serious deterioration occurs, and they may have some common sense suggestions.
- The On-Time reports can provide helpful clinical information that would otherwise be time consuming to collect.
- We have such a hard time with our nursing assistant documentation. For many of our nursing assistants, English is not their first language. I don't think we'll ever have accurate data from them.
- Nursing assistant data do not have to reach 100 percent completion. On-Time reports will run with 75 percent of the nursing assistant data. When nursing assistants understand the value of their data, they will be motivated to do a good job with their documentation. Consider having experienced nursing assistants mentor newer or less experienced staff. Also, if particular nursing assistants are documenting poorly, they may need additional training. In addition, it is important to confirm at the meeting if the data don't seem to reflect the actual condition of the resident as the staff knows it.
- If nursing assistant documentation is a problem, the On-Time reports will readily show this with a dash (-) in the cell to indicate insufficient data. Regular dialogue with the nursing assistants during weekly meetings will help management monitor the accuracy of their data and encourage higher completion rates as nursing assistants see the importance of data accuracy and high completion rates. Their documentation is now being used and they are getting a bigger role in prevention practices and are a more integral part of the team.
- During a pilot of a new meeting, some staff members designated to attend have not been attending.
- Staff members do not have to attend every meeting but if this becomes chronic it is important to discuss this with the champion because it is necessary to get input from all relevant disciplines. Also, some of the participants have specific roles such as leading the discussion or printing the reports, and their absence can lengthen the meeting or make the meeting less productive.