Implementation Steps and Timeline

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

Implementation Steps and Timeline

The goal of the On-Time program is to incorporate the On-Time reports into day-to-day prevention activities and to ensure multidisciplinary input into clinical intervention decisions. We created the Implementation Steps document to help nursing homes understand the implementation steps for carrying out the program and the likely timeline to make the reports part of daily practice. This document is intended to be used by the team champion and the change team members to help keep the effort on track and methodical.

Step 1: Agree To Use On-Time Pressure Ulcer Healing

Nursing home leadership agrees to incorporate theOn-Time reports into their workflow. Most facilities begin by implementing one report on one unit. They then expand use to all units once the process to use the report is confirmed and effects on daily work, if any, are addressed and workflow is redesigned as needed. Leadership agrees to identify a change team champion and establish a multidisciplinary change team to lead the project.

Step 2: Contact Vendor

The change team champion or information technology (IT) representative contacts the facility’s electronic medical record (EMR) vendor to confirm that On-Time Pressure Ulcer Assessment and Pressure Ulcer Healingreports are in the system. He or she takes appropriate steps at the facility to provide frontline staff with access to pressure ulcer reports.

Step 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 nursing assistants. 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 co-facilitate 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 determines his or her level of involvement. In some facilities, the director of nursing participates actively as a member of the change team whereas in other facilities, he or she may serve in more of a consulting capacity to the team. Ad hoc team members include wound nurse, staff educator, physicians, nurses, and rehabilitation staff.

Step 4: Introduce On-Time Pressure Ulcer Healing

The On-Time facilitator provides technical assistance via an initial telephone consultation to confirm EMR capabilities and readiness to start On-Time, to discuss immediate next steps regarding IT, and to guide staff through the introductory material as needed. The facilitator answers questions and confirms that the facility team members understand how to access reports and tools and establishes the process for working together.

Step 5: Review Reports

The team reviews reports with the facilitator to understand the content and potential uses of the reports.

Step 6: Complete Self-Assessment

The team completes the self-assessment worksheet that identifies current processes at the facility to track and monitor pressure ulcers, pressure ulcer healing practices, and communication processes. The review includes identification of team meetings, huddles, and other communication structures in place, ways risk information is transmitted to clinical staff, and ways care plans are updated and interventions determined. The facilitator guides the team to identify gaps and begin to think about ways On-Time reports can be used to improve pressure ulcer healing practices.

Step 7: Pilot a Report With Data

The On-Time facilitator assists the team in using one of the reports. The team should decide which report they will use first and then review the material for that report and generate it for one nursing unit. The facilitator works with the team to understand the first report and answers questions as needed.

Step 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 whether data on the report are consistent with other clinical findings.

In completing this task, the team may identify problems in, for example, nursing assistant documentation incompleteness. They may find it necessary to reeducate nursing assistants to improve report validity. In addition, a facilitator may help to clarify any normal but potentially confusing data situations and how to interpret them. Each report the team uses should go through this process so the team is confident in the information produced on the reports.

Step 9: Agree To Use Core Reports/Implementation Strategies

With the facilitator, the change team uses the Pressure Ulcer Healing Menu of Implementation Strategies to determine which reports will be especially helpful to them considering the results of their Self-Assessment Worksheet for Pressure Ulcer Healing. The facilitator describes the strategies and helps the team determine which reports may help them given the findings from the self-assessment (Step 6). The team can use one report more than one way and in multiple meetings.

Step 10: Create Report/Meeting Strategies

Strategies are based on self-assessment identification of pre-On-Time communication and care plan meetings/huddles and the Pressure Ulcer Healing Menu of Implementation Strategies. Some new huddles and other meetings may be created and meetings may be altered to accommodate report discussion. The team reviews the Pressure Ulcer Healing Menu of Implementation Strategies for each On-Time report and discusses options for using the reports within current communication structures. The team considers meetings, huddles, care plan discussions, and other existing meetings where a report would enhance the current process to identify risk and coordinate care across disciplines.

At this time, the team identifies potentially new processes that may be developed to use the reports. Teams pilot reports and incorporate report discussion into existing meetings or new meetings. Changes in requirements to attend meetings may be needed to increase the number of disciplines and nursing assistants providing input and to change communication networks to improve risk identification.

The facilitator helps the team initiate the first report meeting strategy. The team makes sure they understand the criteria for identifying residents profiled on the report, know the definitions of risk factors profiled, and receive advice on how to structure existing meetings or create new meetings to best incorporate report discussions. Advice includes who should attend the meeting and their roles, who is responsible for the reports, and who will lead the discussion.

Step 11: Pilot All Report/Meeting Strategies in One Unit

The team discusses implementation issues with the facilitator after piloting report/meeting strategies. This is an iterative process that should be repeated until the process is smooth and effective.

Step 12: Ensure Implementation Strategies Are Carried Out

Once a new report is incorporated into a meeting, the champion decides on role changes for staff to ensure the report is used at designated meetings with appropriate multidisciplinary and nursing assistant input. It is important for the champion to have supervisory responsibility so these changes can be informed and enforced.

Step 13: Develop Plan and Implement New Strategies in All Units

The training and implementation planning process for integrating reports in one unit should take approximately 3 to 4 months once the facility has confirmed that the On-Time Pressure Ulcer Healingreports are available and staff have been granted access to view and print the reports (Steps 3-12). The timeline depends on leadership commitment, stability of staff, facility familiarity with using computerized reports, and quality improvement (QI) experience of staff. Implementing on all units is likely to add another 3 months. The facilitator will help the team during the next 3 months to address implementation issues until all reports and all units are implementing the reports as planned and the team becomes more independent.

Step 14: 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 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).

Step 15: Review Pressure Ulcer Healing Rates

The facilitator works with the team to generate the On-Time Pressure Ulcer Counts by Month Report that identifies pressure ulcer healing rates to provide feedback to the change team and support reporting requirements.

Step 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 inservice training 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 staff, who may be assigned to conduct periodic monitoring of implementation strategies that ensure they are sustained. It is suggested that 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.

Approximate Timeline

Implementation Steps Estimated Duration/Time From Implementation
1. Agree To Use On-Time Pressure Ulcer Healing Module  
2. Contact Vendor Start time is after confirmation of access to reports for frontline staff
3. Identify Multidisciplinary Team Members To Serve as the Change Team Within 2 weeks
4. Introduce On-Time Pressure Ulcer Healing Module 1st month
5. Review Reports 1st month
6. Complete Self-Assessment 1st month
7. Pilot a Report With Data 2nd month
8. Validate Data 2nd month
9. Agree To Use Reports/Implementation Strategies 2nd month
10. Create Report/Meeting Strategies 2nd month
11. Pilot All Report/Meeting Strategies in One Unit 2nd month
12. Ensure Implementation Strategies Are Carried Out 3rd month–4th month (some facilities implement in all units simultaneously)
13. Develop Plan and Implement New Strategies in All Units 4th month–6th month
14. Monitor Facility Implementation Progress Monthly 6th month–9th month


15. Review Pressure Ulcer Healing Rates As required
16. Sustain the Effort End of 9th month–12th month

Return to On-Time Pressure Ulcer Healing Page

Page last reviewed January 2017
Page originally created January 2017
Internet Citation: Implementation Steps and Timeline. Content last reviewed January 2017. Agency for Healthcare Research and Quality, Rockville, MD.