AHRQ's Safety Program for Nursing Homes
Case Studies
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Contents
New York Nursing Facility Sees 56 Percent Drop in Pressure Ulcers with AHRQ-Funded Program
AHRQ-Funded Program Helps Nursing Home Reduce Pressure Ulcers By 60 Percent
AHRQ Program Helps New York Long-Term Care Facility Reduce Pressure Ulcers 70 Percent
New York Nursing Facility Sees 56 Percent Drop in Pressure Ulcers with AHRQ-Funded Program
St. Barnabas Rehabilitation and Continuing Care Center, Bronx, New York
St. Barnabas Rehabilitation and Continuing Care Center, a 199-bed skilled nursing facility in south Bronx, NY, implemented an AHRQ-funded program that focuses on integrating health information technology into nursing homes to prevent pressure ulcers. As a result of implementing the "On-Time Quality Improvement in Long-Term Care" (On-Time) Program, the percentage of residents with new pressure ulcers decreased by 56 percent, from 4.2 percent prior to implementation to 1.8 percent in the year following implementation.
The On-Time Program integrates clinical reports into nursing home workflow using health information technology to identify residents at risk for pressure ulcer development. Using these reports, participating facilities implement team-based strategies with the help of a facilitator to improve risk identification and care planning. These strategies allow staff to intervene in a timely manner with at-risk residents to reduce the incidence of pressure ulcers.
All On-Time reports are based on certified nursing assistant (CNA) documentation. A preliminary program step is streamlining and standardizing CNA documentation to support these tools. The CNAs at St. Barnabas, in an effort to be compliant with all industry regulations, had historically been overburdened with paperwork. Implementation of the On-Time Program resulted in a 30 percent reduction of paperwork for CNAs.
In addition to the reduction in paperwork across the continuum of care, the primary impact was the improvement in the integration of clinical information and communication between the frontline caregivers-the CNAs-and the dietary staff, social workers, and nursing staff. This resulted in meaningful changes in resident care plans and more timely referrals and treatment.
Zaldy Mateo, RN, Assistant Nursing Home Administrator, says, "The On-Time Program motivated the entire interdisciplinary team to be more engaged. That engagement has been the key component in the success of the program at St. Barnabas. The program brought members of the team to discussions of health care issues that previously were assumed to be the domain of individual disciplines." During the "5-minute standup" huddles that have been held since the program was implemented, CNAs visibly advocated for their residents, a new behavior that developed subsequent to the implementation of the On-Time Program.
Many staff were initially apprehensive about implementing the program because it appeared at the outset to be more labor- and time-intensive. Initially, the CNAs and other members of the interdisciplinary team did put in more time attending meetings, phone conferences, and formal training. Afterward, the general consensus among team members was that the program was not an added burden to their daily routine but, in fact, a practical approach to streamline their documentation and communication. Frontline caregivers acknowledged that the startup activities were worthwhile.
From the administration's viewpoint, the most rewarding aspect of the On-Time Program was the significant involvement of the facility CNAs. Mateo says, "The CNAs owned the project. The On-Time Program made their work more efficient, productive, and rewarding. CNAs have assumed their rightful roles as vital members of the interdisciplinary team who most often-if not all the time-have the most salient information about the functional status of the residents."
AHRQ-Funded Program Helps Nursing Home Reduce Pressure Ulcers By 60 Percent
Schuyler Ridge Nursing Home, New York
Schuyler Ridge Nursing Home, a 120-bed long-term care facility in New York, implemented an AHRQ-funded program that focuses on integrating health information technology into nursing homes to prevent pressure ulcers. As a result of implementing the "On-Time Quality Improvement in Long-Term Care" (On-Time) Program, the percentage of residents with new pressure ulcers decreased from 6.5 percent prior to implementation to 2 percent in the year following implementation.
The On-Time Program integrates clinical reports into nursing home workflow using health information technology to identify residents at risk for pressure ulcer development. Using these reports, participating facilities implement team-based strategies with the help of a facilitator to improve risk identification and care planning. These strategies allow staff to intervene in a timely manner with at-risk residents to reduce the incidence of pressure ulcers. On-Time reports are based on certified nursing assistant (CNA) documentation. A preliminary program step is streamlining and standardizing CNA documentation to support these tools.
Schuyler Ridge uses the On-Time reports at its weekly "5-minute standup" meetings with multidisciplinary team members. Staff use the meetings and reports to identify residents at high risk of developing pressure ulcers and adjust care plans accordingly. The facility rotates the time of the meetings each week in order to accommodate both day and evening shift CNAs and nurses.
The Schuyler Ridge facility incorporated the On-Time reports into its health information system, called CareTracker. Having the On-Time reports in the CareTracker system makes developing and updating the residents' care plans easier and more accurate. Information can be entered at any one of seven touch-screen kiosks in the facility: two at each of the three nurses' stations and one in the dining room.
According to Sandra Smith, Schuyler Ridge Executive Director, "Using kiosks was a huge change for the CNAs, who were used to paper-based recordkeeping done at the end of their shifts. However, staff quickly learned to like it."
Since implementation of the On-Time Program, documentation completeness rates at Schuyler Ridge are typically 98 to 99 percent on all shifts. Prior to implementation of the program, the paper documentation completeness rate was 70 to 80 percent.
Smith notes, "The issue with the paper documentation was not only incomplete records but how factual the documentation was when compared with the actual care being provided. This was due, in part, to staff waiting until the end of the shift to enter their information. Additionally, because staff could see the documentation from the previous shift, the question arose as to whether they were just checking off the same boxes as the previous shift. With the On-Time Program in place, the level of information now documented is much more thorough and a more accurate reflection of the residents' care needs."
Leslie Campbell, Unit Manager, says, "The On-Time Program also helped staff to better understand how weight loss and behaviors affect skin integrity. The reports help catch 'medium-risk' residents before they become 'high risk' for pressure ulcers. Additionally, staff are excited to know that management is listening to them and taking their suggestions seriously. It has promoted a better team approach to the care of our residents."
Prior to using the On-Time reports, CNAs may have noticed a reddened area on a patient during dressing or bathing, but this information was not always communicated to the correct person. CNAs now enter the information into CareTracker at the kiosk, and the reports help identify an average of two to three new high-risk residents weekly. The unit managers review completeness throughout the shift using CareTracker compliance reports. In addition, the On-Time Completeness Report is reviewed weekly to monitor trends.
Smith concludes, "The On-Time Program provided the framework to deploy the appropriate resources and staff to high-risk residents. This ensures timely intervention, helps improve outcomes, and prevents potential negative clinical outcomes."
AHRQ Program Helps New York Long-Term Care Facility Reduce Pressure Ulcers 70 Percent
Gurwin Jewish Nursing and Rehabilitation Center, upstate New York
Gurwin Jewish Nursing and Rehabilitation Center, a 460-bed long-term care facility in upstate New York, implemented an AHRQ-funded program that focuses on integrating health information technology into nursing homes and long-term care facilities. As a result of using the On-Time Quality Improvement in Long-Term Care (On-Time) program, the facility reduced the incidence of pressure ulcers in residents by 70 percent, from 2.0 percent prior to implementation to 0.6 percent in the 1-year period following implementation.
The On-Time program integrates clinical decision-support tools into nursing home workflow processes by using health information technology to identify residents who are at risk for pressure ulcers and to track the results of efforts to reduce those risks. The program provides a core set of certified nursing assistant (CNA) documentation elements and timely clinical reports to staff in nursing homes. Streamlining and standardizing documentation help incorporate best practices and provide the foundation for useful decision-support reports for caregivers. Interdisciplinary teams embed quality improvement changes into daily work routines and bring CNAs to the forefront in team collaboration. Together, these program elements link efficiency and effectiveness in the care delivery process with sustainable improvement in resident pressure ulcer outcomes.
Working with the On-Time quality improvement consultants, Gurwin Jewish Nursing and Rehabilitation Center integrated four On-Time reports: Nutrition, Weight Summary, Trigger Summary, and Completeness. These reports help guide staff in identifying residents at risk for pressure ulcers and focus interdisciplinary efforts to intervene in a timely manner.
Information from CNA documentation about each resident's activities of daily living-such as eating, incontinence episodes, behaviors, and weight loss-is used to generate On-Time reports that are used in a series of process improvements by front-line staff, such as "5-Minute Stand-Up" meetings and other weekly forums with multidisciplinary teams. The On-Time reports have been important not only in improving communication among members of the interdisciplinary team, but as a basis for effective clinical decisionmaking.
An additional benefit of implementing the program at Gurwin Jewish was the positive nutritional impact on residents. Over a 2-year period, information from the Weight Summary and Nutrition reports was reviewed weekly. Interventions (such as adapting serving times for the larger daily meals to the time preferred by residents) were developed to address unplanned weight loss, and the results were monitored and compared to dietary department notes. Potential issues and strategies were discussed with CNA staff during the 5-minute meetings. By identifying food preferences and eating patterns, the facility targeted appropriate ways to avoid unintended weight loss. As a result, the number of residents identified as having significant weight loss was reduced from 3.5 percent to 1.7 percent.
The On-Time Completeness report allows nursing staff to monitor CNA documentation to ensure complete information. This report also provides information on any inaccuracies in the documentation and is used to further educate staff during in-service training. Monitoring the Completeness reports revealed a lack of documentation in the areas of behavior and bowel management. Working with the On-Time facilitators, Gurwin staff discovered that CNAs were documenting only positive resident responses.
Staff development educators then taught the CNAs that bowel and behavior patterns-whether negative or positive-must be documented during each shift. As a result of reviewing the reports and providing targeted training, bowel documentation completion rates increased from 49 percent to 85 percent, and documentation related to behaviors increased from 35 percent to 85 percent.
The On-Time project was developed by AHRQ with support from the California Health Care Foundation. The research was conducted by Susan Horn, PhD, Senior Scientist at the Institute for Clinical Outcomes Research and Vice President for Research at International Severity Information Systems, Inc. The design of the program and implementation process and the facilitation of facility teams were provided by Siobhan Sharkey, MBA, and Sandy Hudak, MS, RN, Principals at Health Management Strategies, Inc.