AHRQ’s Safety Program for Nursing Homes: On-Time Prevention
The Agency for Health Care Research and Quality (AHRQ) is developing tools to assist nursing homes that have electronic medical record systems (EMRs). The goal is to improve clinical decisionmaking by helping clinical staff identify residents at risk for four costly adverse events that residents may face—e.g., pressure ulcers, pressure ulcers that are not healing appropriately, falls, and avoidable hospitalizations—and to help them make decisions on interventions that help prevent these adverse events. Generally, a nursing home works on one adverse event at a time.
Nursing home staff have difficulty preventing adverse events because clinical information needed to intervene on risk factors is often not easily available. They cannot easily identify residents with increasing risks, or easily assemble the clinical information needed to appropriately intervene before the adverse event occurs. An EMR helps centralize the information, but accessing this information is still very time consuming. With On-Time, specialized clinical reports are developed from the EMR to provide clinical staff with the information needed to prevent adverse events in a timely manner.
For each of the four adverse events, On-Time includes:
- A set of electronic clinical reports that is updated weekly. These reports identify who is experiencing increasing risks and provides easy access to important clinical information that is needed to help clinical staff make timely adjustments to care plans.
- Functional specifications for health information technology vendors to program the reports.
- Implementation materials to help a multidisciplinary change team integrate the reports into the nursing home's care planning processes.
- Training for On-Time facilitators.
- On-Time facilitation from trained facilitators to help nursing home staff learn how to use the reports and integrate these reports into the nursing home's care planning meetings and huddles, or if needed, add new meetings that enhance prevention. The facilitator also helps the team encourage input from all relevant staff into care plan decisions (e.g., certified nurse assistants [CNAs], director of nursing [DON], wound nurses, and dietary, rehab, and pharmacy staff).
To participate in On-Time, facilities require the following:
- EMR vendor willing to produce the reports.
- Commitment from key leadership including the DON or administrator to establish a multidisciplinary change team that works with an On-Time trained facilitator to integrate On-Time reports into care planning processes.
- Commitment from key leadership to sustain program once change process is complete.
AHRQ is designing two types of reports:
- Reports that identify residents who have had recent clinical changes that put them at higher risk and that profile their risks or profile intervention history.
- Reports that identify residents who have had an adverse event and that show risk information, treatment, and intervention history preceding the event.
The first set of reports helps clinical staff prevent adverse events; the second set helps staff prevent these events from recurring and can be used to help analyze root causes. Some reports can be generated at unit or facility levels for clinical managers to help identify systemic issues.
Evidence Base for Reports
The risk factors in the reports were identified using evidence from published studies in the clinical literature. A workgroup of nursing home staff with knowledge of nursing home operations provided input on the design and content of the reports to assess usefulness, appropriateness, acceptability, and feasibility. The workgroup also provided input on ways to redesign workflow to facilitate implementation of reports. In addition, a panel of clinical experts reviewed the reports to confirm the evidence for the risk criteria and clinical content. Reports were piloted in a small number of facilities to establish feasibility of use.
Some reports were subjected to evaluation studies to assess their impact on patient outcomes. The table below describes the level of evidence for each topic.
|Topic||Level of Evidence|
|Pressure ulcer prevention||Pilot tested in more than 50 nursing homes across the country; 59% reduction in monthly incidence rates from outcome evaluation study in New York (see Olsho LE, Spector WD, Williams CS, et al. Evaluation of AHRQ's On-Time pressure ulcer prevention program: a facilitator-assisted clinical decision support intervention for nursing homes. Med Care 2014;52:258-66).
Pilot study showed 33% reduction in pressure ulcer prevalence rate (see Horn SD, Sharkey SS, Hudak S, et al. Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports. Adv Skin Wound Care 2010;23:120-31).
|Pressure ulcer healing||Tested for feasibility, usefulness, and clinical content.|
|Falls prevention||Evaluation of limited number of reports in progress.|
|Avoidable hospitalization||Tested for feasibility, usefulness, and clinical content.|
Two worksheets are provided for each adverse event. Staff members use these worksheets to integrate the reports into available clinical meetings or huddles or to reengineer these clinical meetings. The first worksheet, "Self-Assessment," has been designed to help staff review how they currently identify residents who have experienced a change in risk, how they determine if new clinical interventions are needed, and how they determine what those interventions are.
The self-assessment worksheet is intended to help identify the current processes and structures the nursing home is using and to identify gaps and places for improvement. It is intended to help staff think about ways to transform these processes and ways to begin to use the On-Time reports in clinical discussions.
The second worksheet, "Menu of Implementation Strategies," is a list of suggested meetings and huddles with recommended staff participants. Some of these meetings are probably already happening in the facility but may need to be restructured to incorporate the reports into resident care discussions. In other cases a new meeting or huddle may be needed.
Both worksheets are intended to be used with the help of an On-Time trained facilitator. The facilitator helps with the discussion generated by the self-assessment worksheet and the menu of strategies so that the change team can reengineer current day-to-day practice, with appropriate input from CNAs and all relevant disciplines.
An additional item included to help integrate the On-Time reports into workflow is "Implementation Steps and Timeline." It provides a step-by-step description of all the steps needed to integrate the reports into daily workflow and an approximate timeline.
For each of the adverse events, a Facilitator training curriculum is being developed. The training prepares Facilitators to teach the content of the electronic reports and guide a nursing home team to integrate reports into existing workflow and make changes in prevention processes when needed.
Visit the On-Time pressure ulcer prevention Web page to access the latest curriculum for pressure ulcer prevention. Other prevention training curricula will also be made accessible online as they become available.
In 2015 AHRQ is planning to train Facilitators using the pressure ulcer prevention curriculum. More information will be provided when details of the training are finalized.
Health Information Technology/EMR Resources
Functional specifications for each of the On-Time reports are currently being developed or updated. Functional specifications are intended to provide enough information for EMR vendor programmers to produce the reports as designed, and incorporate reports into the vendor's EMR product.
Visit the On-Time pressure ulcer prevention Web page to access the latest functional specifications for pressure ulcer prevention reports. As other prevention reports are added the functional specifications will also be made accessible on-line.
Page originally created August 2014