AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention

Handouts: Overview of On-Time (continued)

Implementation Steps and Timeline

Implementation Steps Estimated Duration / Time
1. Verify Nursing Home Readiness
Leadership agrees to identify a change team champion and establish a multidisciplinary change team to lead the project. Facilitator develops plan with change team on how they work together.
Within 1st month
2. Confirm Access to Electronic Reports
The change team champion or information technology (IT) representative contacts their electronic medical record (EMR) vendor to confirm that On-Time pressure ulcer prevention reports are in the system and takes appropriate steps at the facility to provide frontline staff with access to prevention reports.
Within 1st month
3. Identify Multidisciplinary Team Members To Serve as the Change Team
The change team consists of a change team champion, nurse managers from each nursing unit, a dietitian, and CNAs. The champion advocates and supports the project and ensures project activities are sustained during turnover of key staff. Nursing leadership may assume this role or delegate the responsibility. Two team leaders may co-lead project activities; one is a nurse and the second can be from nursing or another discipline.
Team leaders share responsibilities to coordinate and implement activities and coordinate calls with an On-Time facilitator. The director of nursing (DON) determines his or her level of involvement. Ad hoc team members include wound care staff, staff educator, physicians, nurses, and rehabilitation staff.
Within 1st month
4. Provide Overview of On-Time Pressure Ulcer Prevention
On-Time facilitator provides an overview of On-Time Pressure Ulcer Prevention to change team. The facilitator answers questions and confirms that the facility team members understand how to access reports and tools.
1st month-2nd month
5. Review Pressure Ulcer Prevention Reports
Team reviews reports with facilitator to understand purpose, content, potential use, and likely users of reports.
2nd month-3nd month
6. Complete Pressure Ulcer Prevention Self-Assessment
Facilitator meets with champion to fill out worksheet and helps team review findings. Team completes the self-assessment worksheet that identifies details about current processes at the facility to identify residents at risk for pressure ulcers, prevention practices, and process for root cause review. The review includes identification of team meetings, huddles, and other communication structures in place. Facilitator reviews ways risk information is transmitted to clinical staff, and ways care plans are updated and interventions are determined. The facilitator guides the team to identify gaps and begin to think about ways On-Time reports can be used to modify pressure ulcer prevention practices.
2nd month-3nd month
7. Pilot a Report With Data
On-Time facilitator guides team in generating and reviewing a report with actual resident data on one unit. Facilitator works with team to understand the report and answers questions, as needed.
2nd month
8. Validate Data
This step helps the team gain confidence in the validity of the data in the reports. The team discusses residents populated on the report to ensure that data on the report agree with staff knowledge of residents' health/risks. Staff may choose to go back to the medical record to confirm if data on the report are consistent.
In completing this task, the team may identify problems in, for example, CNA documentation completeness and may find it necessary to have the nurse educator retrain CNAs, to improve report validity. In addition, the facilitator can clarify any normal but potentially confusing data situations and how to interpret them. Each report that is used by the team should go through this process so the team is confident in the information being produced on the reports.
2nd month
9. Have Team Choose To Implement At Least Three Core Reports
With the help of the facilitator, the change team uses the Pressure Ulcer Prevention Menu of Implementation Strategies. The facilitator helps the team determine which reports may help them given the list of existing meetings from the Self-Assessment Worksheet (Step 6). The team can use one report more than one way and in multiple meetings but is required to implement at least three Pressure Ulcer Prevention reports.
3rd month
10. Decide on Meetings To Incorporate Reports
With the help of the facilitator, the change team decides at which meetings/huddles to incorporate reports. Some new meetings/huddles may be created or existing meetings may be altered to accommodate report discussions.
The facilitator helps the team initiate the first report meeting and provides advice on how to structure existing meetings or create new meetings to best incorporate report discussions. Advice includes who should attend the meeting, what their roles are, who is responsible for the reports, and who will lead the discussion.
3rd month
11. Pilot All Reports in One Unit
The team pilots each report at a designated meeting. The facilitator helps with implementation issues. This is an iterative process that should be repeated until the process is smooth and effective.
Once new reports are incorporated into meetings, the champion decides on role changes for staff to ensure reports are used at designated meetings with appropriate clinical and CNA input. It is important for the champion to have supervisory responsibility so these changes can be shared and enforced.
3rd month-4th month
12. Implement All Reports in All Units
Facilitator, champion, or unit representative introduces On-Time Pressure Ulcer Prevention Reports to other units. The facilitator will help the team during the next 3 months to train staff and to problem solve implementation issues until all reports and all units are implementing the reports as planned and the team becomes more independent. The timeline depends on leadership commitment, stability of staff, how familiar the facility is with using computerized reports, and quality improvement (QI) experience of staff.
4th month-6th month
13. Monitor Facility Implementation Progress Monthly
After about 6 months, the facilitator's role is to check in to identify obstacles that could occur and to troubleshoot issues as needed, such as turnover of key staff, computer glitches, and implementation issues. The expectation is that reports will be used on a weekly basis except for meetings that occur less frequently (e.g., monthly). The Implementation Steps provide a basis for monitoring implementation progress.
6th month-9th month
14. Review Pressure Ulcer Incidence
The facilitator works with the team to generate QI monitoring reports that identify pressure ulcer rates to provide feedback to the change team and to support reporting requirements.
15. Use Optional Reports
In 2014, two new reports were added. The first report, Intervention History for Nutrition Risk Reports: High Risk and Medium Risk, focuses on intervention history of residents with nutrition risks. The second report, Resident Clinical, Functional, and Intervention Profile Report, focuses on detailed information for any resident and can be used to provide a clinical history for residents with new pressure ulcers. Since the evaluation results were based only on the original reports, use of new reports is optional, but these reports provide more insight on the clinical and intervention history of residents and may help in developing better care plans that can improve pressure ulcer prevention practices in the nursing home.
The vendor needs to program these new reports; all data elements for this report are currently available and new programming is expected to be a low effort by the participating vendor. The team implements reports into current practice as above.
Adds approximately 3 months or more, depending on time for vendor to program reports
16. Sustain the Effort
After 9 months, the nursing home change team develops a plan for incorporating implementation strategies for report use into facility policies and procedures. The plan includes incorporating educational in-service for new hires and training material for temporary employees. The facility needs to establish a permanent champion for this QI effort and champions on units.
Likely champions for each nursing unit are the nurse managers, with backup support by the QI department, who may be assigned to conduct periodic monitoring of implementation strategies to ensure they are sustained. But on a weekly basis, the director of nursing assumes the responsibility of ensuring On-Time process improvements are carried out on each nursing unit and holds each nurse manager accountable.
End of 9th month-12th month

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Page last reviewed December 2017
Page originally created March 2013
Internet Citation: AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/overviewhandouts4.html