On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide

AHRQ’s Safety Program for Nursing Homes: Implementation of the Healing Reports

Note: This part of the training primarily consists of exercises and does not have any associated slides.

Review of Self-Assessment Worksheet

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Say:
 

Yesterday we introduced the components of On-Time Pressure Ulcer Healing, including the electronic reports and implementation materials. Today we will focus on the Facilitator's role in implementing the program using these materials.

For this session, we will discuss the reading assignment. You will also participate in a scripted exercise to help illustrate how the change team and Facilitator interact on how to integrate the reports into workflow. You will also watch videos that illustrate how the On-Time program can improve wound rounds. After each exercise and the video, we will have a debriefing to discuss what was learned.

In the scripted exercise, you will play the parts of the Facilitator and change team members. You will choose the meetings and huddles that will incorporate the reports. Finally, you will decide how to pilot the reports in at least one unit.

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. The goal is to help you understand how to apply your skills in helping integrate the Pressure Ulcer Healing reports into nursing homes' workflow.

Review of the Nursing Home's Pressure Ulcer Healing Program

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Do:

Ensure that each participant has the following materials available:

  • Script illustrating change team meeting to discuss and complete the Self-Assessment Worksheet
  • Completed Self-Assessment Worksheet

Remind participants that they should have read the script before the session. They should refer to the script as needed during the discussion.

Note: Engage participants in a discussion using the questions below. We include general content areas that should be discussed. Clearly, these are not all the possible answers. Ideally, the discussion would cover specific reports and meetings. Customize the questions to fit the audience.

Ask:

  • Why do you think it is important to include a Self-Assessment in the On-Time Pressure Ulcer Healing implementation process?
    • Self-Assessment allows the team to clearly document their current practices and identify opportunities for enhancement, including inefficiencies in their processes that On-Time can help resolve.
    • Self-Assessment helps the team to foster internal goals and motivation to change their processes from their own point of view, not how someone else sees them.
    • Self-Assessment lets you gain perspectives on what is actually happening in the facility.
  • How can On-Time Pressure Ulcer Healing Assessment and Reports improve the facility's ability to identify changes in the characteristics of pressure ulcers that indicate probable infection or delayed healing?
    • The On-Time Pressure Ulcer Healing Assessment includes a comprehensive evaluation of the tissue changes, exudate, debridement, odor, periwound tissue characteristics, and presence of pain that would enable staff to identify factors likely to hinder pressure ulcer healing. A less comprehensive assessment may not be fully effective in identifying healing problems. If a nursing home uses a less comprehensive assessment, reports would need to be adjusted to account for the missing information.
    • The On-Time reports bring together the background information needed for staff to make better treatment decisions when a possible infection or delayed healing problem is suspected.
    • The On-Time reports can be used to guide root cause analysis of why some pressure ulcers are not healing appropriately.
    • Unit- and facility-level reports provide information about prevalence and basic characteristics of existing pressure ulcers. By using the EMR to populate the reports rather than relying on hand calculations, staff can monitor pressure ulcer information more efficiently.
  • Based on responses to the Self-Assessment, where would you suggest nursing home staff could use On-Time Healing reports to help discuss residents with pressure ulcers and improve treatment?
    • During huddles with nurses, dietary staff, and nurse assistants to discuss residents with healing problems and to discuss nutritional intake, the Existing Pressure Ulcer, Delayed Healing, and Weekly Wound Round Reports can be used.
    • During QAPI meetings, the Delayed Healing report can be added to introduce discussion of patients with slow-healing pressure ulcers.
    • During a brief with nurses, nursing assistants, and Rehab to discuss residents with pressure ulcer healing and mobility issues, the Delayed Healing Report can be used.

Wound Round Videos

Introduction

Three videos demonstrate the value added of using the On-Time reports during wound rounds and the value of a multidisciplinary team approach. The videos show three different approaches to wound rounds:

  1. A minimalist approach,
  2. Involvement of a multidisciplinary team who assembled ahead of time the necessary clinical information to help clinical staff determine if new interventions were needed, and
  3. The On-Time approach, which combines a multidisciplinary team with EMR-generated reports to provide the clinical information necessary to determine if treatment changes are needed.

These videos are designed also to be used in training Facilitators. After being trained with the videos, a Facilitator should be able to use the videos to help in educating the change team on the values of On-Time reports and the multidisciplinary team approach.

Nursing staff and nursing aides on the evening and night shifts are generally not involved in wound rounds, but these materials would be useful for educating these staff members on how the information they put into the EMR is used by the wound team. Those watching the videos will likely also notice the importance of the nursing assistants' verbal input to the team, which may encourage nursing assistants watching the videos to report any concerns they have about residents.

Questions to facilitate discussion before and after the video have been included in today's training materials.

Icon of a microphone Say:

 

We have three videos for you to watch. The videos demonstrate the value added of using the On-Time reports during wound rounds and the value of a multidisciplinary team approach. After watching each video, we will have a discussion. You can also use these videos in your own work with the team to help them understand the benefits of using On-Time reports with a multidisciplinary team approach.

The goals of these exercises are to enable you to:

  • Articulate the value of an interdisciplinary team approach to wound rounds,
  • Describe the potential consequences of incomplete information and lack of an interdisciplinary team approach to wound rounds,
  • Discuss efficiencies surrounding wound rounds gained by implementing the On-Time Healing reports, and
  • Demonstrate how On-Time provides relevant clinical information that would be difficult to obtain by staff and that help clinical staff formulate changes in care plans to foster pressure ulcer healing.

Video #1 Exercise

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Before we watch the first video, I'd like to find out about how wound rounds are conducted.

Note: When materials are used by a trained Facilitator, the focus is on the actual process in their facility.

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Do:

Use a whiteboard, flipchart, or something similar to make notes.

Ask:

  • Who is part of the team that makes rounds?
  • What information is gathered prior to rounds? How long does it take to gather the information? Who gathers it?
  • How long do the rounds (actually seeing the residents and conducting the assessments) take?
  • Does the team meet after rounding to compile the results of the assessments and plan resident care? If not done as a team, how is this done and by whom?
  • How are the rounds and the results (such as changes to treatment plans and recommended consults) documented and communicated to others who care for the resident?
  • What issues do you encounter that lead to preround activities (such as gathering information), rounds, or postround activities (such as documentation and care planning) taking longer than planned?

Summarize:

Using information on the write-on board or notes, highlight key points of discussion, including preparation activities and inefficiencies that are opportunities for enhancement with the implementation of On-Time.

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Is there anything that you feel is important to note regarding wound rounds that we missed?

The first video shows the wound nurse and the nurse manager before and after rounds for one resident. As you watch the video, please note those things that will need to be addressed after rounds that will take extra time. Please consider what preparation you think occurred prior to the rounds and be on the lookout for information that was needed but not readily available to the nurses during rounds.

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Do:

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Let's discuss how things went in the first video.

Ask:

Note: We include several potentially appropriate responses below in case these points are not made. Clearly, these are not all the possible answers.

  • What do you think was done to prepare for rounds in this scenario?
    • The Wound Nurse provides the number of residents that were seen the prior week, and the Nurse Manager lets her know that one person was discharged.
    • The Nurse Manager has the treatment book available to look up Mrs. Jones's treatments. No other information was compiled prior to rounds.
    • The Nursing Assistant (Lorna) is not accompanying the two nurses, so it is not clear what type of notice has been given to her or what planning had been done to ensure that she could join the team for rounds.
  • What information was missing during the rounds?
    • Nutrition information: meal intake, when the Dietitian last reviewed Mrs. Jones's status
    • Information regarding her repositioning plan and what cushion is used
    • Mrs. Jones's temperature
  • What additional tasks need to be completed after rounds?
    • The Nursing Assistant's input regarding meal intake needs to be obtained and the CNA intake sheets need to be found and reviewed.
    • Mrs. Jones's chart needs to be checked to determine when the Dietitian last reviewed her status, and the nurse manager needs to follow up with the Dietitian.
    • The vital signs book needs to be found to determine if Mrs. Jones has had a fever.
    • Information about Mrs. Jones's treatment history is not known other than that her current treatment has been in place for 2 weeks (according to the Nurse Manager's check of the treatment book at the beginning of rounds).
  • What could be done to improve the rounds process? Whose input is needed?
    • The input of the Nursing Assistant and Dietitian would be very helpful.
    • Having all the information readily available would have allowed the team to complete their investigations regarding Mrs. Jones and to plan changes in care while the team was assembled for rounds rather than later in the day.
    • Pressure ulcer measurements are reported to be "about the same" as last week; the team cannot definitively tell if the wound is smaller, larger, or unchanged. More accurate assessments of changes in pressure ulcers are needed.

Summarize:

In the first video, several key pieces of information were not available to the nurses who were making rounds. Lack of this information led to additional work that needed to be done after rounds and, more importantly, led to an incomplete picture of the resident and treatments received.

There was no interdisciplinary input during rounds. As we move through the next video, you'll see just how much was missed.

Video #2 Exercise

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Our second video shows an interdisciplinary approach to rounds. As you watch the video, be on the lookout for what information was gained by the two nurses by involving the Nursing Assistant and Dietitian. In other words, try to identify what information the team did not have in video #1 that they do in #2 because of the input of these other two team members.

Also try to notice what sources of information had been assembled to bring on rounds and if any followup investigations need to be conducted.

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Do:

Ask:

  • What do you think was done to prepare for rounds in this scenario?
    • Each person attending rounds had compiled different sources of information.
      • The Nurse Manager had assembled a list of residents to be seen and gathered all the residents' medical records.
      • The Dietitian had collected the diet and supplement orders, weights, lab results, and meal intake information for each resident.
      • The Nursing Assistant had collected the CNA flow sheets, the vital sign book, and her assignment sheet.
      • The Wound Nurse had compiled information from the prior week's rounds; however, she did not have up-to-date information about the number of residents seen.
  • How long do you think that preparation would take in your facility (in a facility you might be working with) if all the sources of documentation brought on rounds in this scenario were gathered?

    Note: Answers will vary and will depend on who collects the information (e.g., one person or multiple people as in this video) and multiple other factors. Here are possible questions to use to stimulate discussion:

    • Who collects this information and where is it located?
    • Is everything that is needed for rounds generally in one place or is time spent searching for various books and records at different places in the facility?
    • Are resident charts and other documents/sources mentioned in the video taken off the unit for use by others (e.g., by the physician to dictate information regarding a visit)? Does everyone know when they are removed and returned?
  • What information was gained by including the Nursing Assistant and the Dietitian?
    • Because of the Nursing Assistant's input, the Dietitian can now follow up with Mrs. Jones after the meeting to make adjustments to the meal plan.
    • The Nursing Assistant reported that Mrs. Jones had a red area on her spine.
    • When toileting and continence were discussed, the Nursing Assistant reported that Mrs. Jones didn't like to get out of bed to go to the bathroom at night and a commode at the bedside at night was suggested.
    • When discussing off-loading devices, the Nursing Assistant reported that the gel cushion was missing.
  • What are some benefits of involving Nursing Assistants in rounds other than those resident-level benefits that have been discussed?
    • Nursing Assistants are more likely to be seen as important members of the team providing critical information for clinical decisionmaking.
    • Staff satisfaction for Nursing Assistants is likely to increase as is their sense of being part of a team.
    • More engaged staff are more likely to feel empowered to report resident changes because they feel their input is valued.

Summarize:

More information was available to the team in video #2 than in video #1, but there were approximately 10 separate sources that were assembled for the meeting in addition to all the resident charts. This is cumbersome and time consuming. It is labor intensive to gather all the materials that were used for rounds in this scenario and these materials are not available to others who may need them while they are being used for rounds.

The input provided from different disciplines and nursing aides may provide a better picture of the patient's health status. It also may help the staff feel valued and increase the likelihood that they will communicate changes they observe in resident's functioning or health with the nursing staff, which will help identify residents at risk for pressure ulcers.

Video #3 Exercise

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The third video shows an interdisciplinary approach to rounds using the On-Time Pressure Ulcer Healing reports. In the beginning of the video, consider what steps were needed to prepare for rounds. Then as you watch the rest of the video, try to identify what information was available to the team via the reports that was not available in the other scenarios. Also try to identify how the reports have saved the team members preparation time, such as calculating trends, investigating treatments received, and gathering other relevant clinical information.

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Do:

Ask:

  • What do you think was done to prepare for rounds in this scenario?
    • On-Time reports were gathered. In the case of the Dietitian, the report was not printed out but was accessed electronically via a tablet.
  • How long do you think that preparation would take? Does the nurse need to do this preparation or could someone else (e.g., a unit secretary) help?
    • Anyone trained to use the facility's software and with access to confidential resident information found in the reports can run them, including ancillary staff such as a unit secretary. While the time to print the reports will depend on the speed of the hardware (e.g., the computer and printer), printing the reports needed for rounds will likely take a fraction of the time needed to compile all the information the team used in video #2.
  • What information about the resident is available to the team that was not available in the other two scenarios?
    • Resident information was available from the Risk for Delayed Healing Report.
    • The surface area of her pressure ulcer had not improved for 5 weeks and is actually larger this week.
    • She has had four treatment changes.
    • Her weight is stable but her meal percentages have decreased over the past few weeks.
    • She is on a low-air-loss mattress.
    • She has had an increase in urinary incontinence.
    • Her albumin was 3.4 on admission.
  • How did an interdisciplinary approach to rounding combined with the use of the On-Time reports benefit the resident? The staff? The facility?
    • Interdisciplinary rounds enhance resident, family, and staff satisfaction.
    • The scope of the discussion on the rounds is broadened when various disciplines engage in it.
    • Successful collaboration on wound rounds will likely enhance collaboration in other areas.
    • Improved collaboration leads to better care planning, which leads to better care, decreases in pressure ulcer incidence, and faster healing.
    • Process efficiencies and enhanced team communication save the staff time.
    • Clinical issues are addressed more proactively.

Summarize:

In this video, preparation for rounds consists of either printing the reports or accessing them electronically (e.g., via a tablet). This preparation could be easily conducted by support staff such as a unit secretary, thereby saving clinical staff time.

Information available in the reports in some cases is based on complex calculations. Without the reports, staff would have to do these calculations (for example, wound surface area comparisons, average meal intake percentages) and the calculations would be very time consuming. Using the reports provides this information without using staff time to mechanically make these calculations and provides protection from calculation errors.

In video #2 there was no mention of the wound being at risk for delayed healing. On-Time provides this information to the team based on the characteristics of the wound documented in the assessment. The report provides enough detail to help the team begin their root cause investigation of the actual or potential causes of the delayed healing.

Much more is known about Mrs. Jones's status in the third video and the team could make their care planning decisions on the spot. At the end of the other scenarios, many things about Mrs. Jones needed to be investigated to allow a plan of action to be formulated. It is likely that after the additional investigations were done, the team would need to meet again before care plans could be appropriately adjusted.

Ask:

Do you have any questions or additional comments about the videos or the exercises that accompany them?

Review of the Change Team's Process for Choosing On-Time Reports, Incorporating Them Into Meetings, and Piloting Those Meetings

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Our next exercise is a role-playing exercise to illustrate the role of the Facilitator and change team in determining which On-Time Reports to use and which meetings the change team will decide to pilot. The handouts we will use include a filled in Menu of Implementation Strategies, the Communication Practice grid from the Self-Assessment Worksheet, and a Meeting Descriptions document. The handouts are provided to illustrate materials available to the team reflected in the script. They are intended to stimulate discussion at the end of the exercise.

Since nursing home staff may call meetings or huddles by different names, the Meeting Descriptions document was created to help clarify the content of meetings or huddles listed in the Menu. It also includes suggested attendees and pressure ulcer healing reports that may be useful in those interactions. These handouts are intended to help the change team make their implementation decisions. As before, we will have a debriefing after the exercise.

The intent of this exercise is to illustrate how a change team decides which On-Time electronic reports from On-Time Pressure Ulcer Healing they will use and at which clinical team meetings they will use these reports. Once they decide, the team determines if they have existing meetings that meet their needs or if a new meeting is needed. The change team then decides how to pilot the use of the reports. They may opt to trial one or more of the reports on one unit and then gradually roll the use of the reports out to the entire facility, as is commonly done, or implement across the facility at one time.

The exercise also illustrates the appropriate role for the Facilitator in working with the change team. In reality, a change team may make these decisions over a number of change team meetings. But to familiarize the Facilitator with his or her role, the exercise treats this as one session. An important part of the Facilitator's role during the implementation period is to help the change team maintain their momentum toward change when they may be slowing in the process and to help them problem solve.

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 exercise. 

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Do:

Ensure that each participant has the following materials available:

  • Completed Menu of Implementation Strategies Worksheet
  • Completed Communication Practices Grid From Self-Assessment Worksheet
  • Meeting Descriptions Document
  • Role play script

Assign a role to each participant, including:

  • Facilitator [Sandy]
  • Program Champion [Tom]
  • Director of Nursing (DON) [Mary]
  • Nurse Manager A [Nancy]
  • Nurse Manager B [Jane]
  • Evening Nursing Supervisor [Amanda]
  • Dietitian [Kim]
  • Quality Assessment and Assurance (QAA) Coordinator [Sally]
  • Nursing Assistant [Tricia]

If there are fewer participants than available roles, assign participants to more than one role; if there are more participants than roles, assign "doubles" who will share a given role.

Implementation Scripted Exercise

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After the scripted exercise, we'll have some questions for discussion.

The goals of this exercise are to enable you to:

  • Describe how the Facilitator will draw on the facility's Self-Assessment to aid the change team in choosing which On-Time reports to use and how they will use them,
  • Outline strategies to overcome concerns regarding the potential burden to staff of attending meetings or huddles in which On-Time reports are discussed,
  • Explain how some reports could be used in specific meetings or huddles to improve a discussion, and
  • Explain the advantages of piloting reports in one unit before rolling out on a larger scale.

Ask:

Do you have any questions before we begin the scripted exercise?

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Do:

Begin by reading aloud the "setting" at the beginning of "Scene 1: Change Team Meeting." Then, instruct the "actors" to begin reading their parts.

When participants are finished reading the script:

Debrief:

When the role play exercise is over, choose from the following questions to engage the group in a debrief session. We include several potentially appropriate responses below in case these points are not made. Clearly, these are not all the possible answers.

  • In our scenario, how did the Facilitator draw on the facility's Self-Assessment to aid the change team in choosing which On-Time reports to use and how to use them?
    • She began by summarizing the team's decisions about opportunities for process enhancement from the change team meeting. She then shared that the Program Champion had completed the Menu of Implementation Strategies Worksheet based on the priorities for change that the team determined during the Self-Assessment process.
  • Our Facilitator described trialing one report on one unit, evaluating how it is working, and adjusting the processes as needed prior to rolling it out to the facility at large as consistent with a true quality improvement or QAPI cycle. Is this approach different from other quality improvement or change processes you have been involved with?
    • When referring to a quality improvement or QAPI cycle, the Plan-Do-Study-Act (PDSA) model for improvement may be the cycle that comes to mind. This cycle allows people to test a change and refine it to ensure that it can be carried out and that it will actually result in improvement. By planning a small test of change before rolling it out facilitywide, the team can address problems and unexpected findings before the larger rollout.
    • The change team should be reassured that process improvement cycles such as PDSA are successful ways to test a change and allow examination and refinement. They should be encouraged to view hurdles that they find in that examination as potential opportunities to make the process the best that it can be before rolling it out to the facility at large. The On-Time implementation approach is similar to other quality improvement projects.
  • What are ways to help the team decide which reports to incorporate into team meetings to discuss potential care changes that could affect pressure ulcer healing?
    • The Facilitator should prepare by being familiar with how pressure ulcer rounds are carried out and what other wound meetings discuss residents with pressure ulcers.
    • The Facilitator should discuss how the team could use the reports during rounds and in these other meetings.
    • The Facilitator should discuss how the use of these reports will ultimately save time and provide richer information for making care changes.
    • If needed, the Facilitator should point out how input from Rehabilitation, Dietary, and other departments can provide input into the care plan for treating pressure ulcers.
  • The Facilitator may experience some resistance from the change team participants regarding potential burden on staff regarding the need to attend more meetings. What strategies can Facilitators use to overcome these concerns?
    • Facilitators can acknowledge the concerns of the team and then reassure them that they are in control of what meetings On-Time reports will be used in.
    • Facilitators can reassure the team that their goal is not to add more work but rather to help the team more efficiently use their time together.
    • Reflecting on a previously successful change that felt overwhelming at the time of implementation can also help with resistance to new processes. Facilitators may find it helpful to ask about a particular meeting or process that the team feels is especially successful and ask them about how the initial implementation of it went. They can encourage the staff to reflect on the hurdles they faced and how they, as a team, overcame them.
Page last reviewed December 2016
Page originally created December 2016
Internet Citation: On-Time Pressure Ulcer Healing: Facilitator Training Instructor's Guide. Content last reviewed December 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-factraining-guide.html