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

Pressure Ulcer Prevention Handouts (continued)

Implementation of the Prevention Reports Into Day-to-Day Practice

Review of the Change Team's Process of Choosing On-Time Reports, Incorporating Them Into Huddles and Meetings, and Piloting Those Meetings: Scripted Exercise #1

Completed On-Time Menu of Implementation Strategies

Pressure Ulcer Prevention Menu of Implementation Strategies
  Existing New
On-Time Nutrition Risk Reports
1. Care Plan Meetings X  
2. Dietary Department Internal Review   X
3. MDS Assessment Documentation   X
4. Nurse Shift Change Report X  
5. Root Cause Analysis for New Pressure Ulcers   X
6. Skin Rounds   X
7. Weekly Nutrition Risk Huddle   X
8. Weekly Risk Meetings   X
9. Weekly Wound Review Meetings* X  
10. Wound Rounds* X  
On-Time Weight Summary Report
1. Care Plan Meetings X  
2. Dietary Department Internal Review   X
3. MDS Assessment Documentation   X
4. Risk Management Meetings X Quarterly  
5. Root Cause Analysis for New Pressure Ulcers   X
6. Skin Rounds   X
7. Weekly Nutrition Risk Huddle   X
8. Weekly Risk Meetings   X
9. Weekly Wound Review Meetings* X  
10. Wound Rounds* X  
On-Time Intervention History for Nutrition Risk Report
1. Care Plan Meetings X  
2. Dietary Department Internal Review   X
3. MDS Assessment Documentation   X
4. Risk Management Meetings X Quarterly  
5. Root Cause Analysis for New Pressure Ulcers   X
6. Weekly Nutrition Risk Huddle X  
7. Weekly Risk Meetings (e.g., Pressure Ulcer Risk, Nutrition Risk)   X
On-Time Pressure Ulcer Trigger Summary Report: Resident Level
1. Care Plan Meetings X  
2. CNA Shift Change Report X  
3. MDS Assessment Documentation   X
4. Rehab Department Internal Review   X
5. Restorative Care Internal Review   X
6. Weekly Risk Huddle for Nurse and Rehab   X
7. Weekly Nutrition Risk Huddle   X
8. Weekly Risk Meetings (e.g., Pressure Ulcer Risk, Nutrition Risk)   X
9. Weekly Wound Review Meetings* X  
On-Time Pressure Ulcer Trigger Summary Report: Unit Level
1. Restorative Care Internal Review   X
2. Risk Management Meetings X Quarterly  
3. Root Cause Analysis for New Pressure Ulcers   X
On-Time Risk Change Report
1. Care Plan Meetings X  
2. CNA Shift Change Report X  
3. Dietary Department Internal Review   X
4. MDS Assessment Documentation   X
5. Nurse Shift Change Report X  
6. Rehab Department Internal Review   X
7. Restorative Care Internal Review   X
8. Root Cause Analysis for New Pressure Ulcers   X
9. Skin Rounds   X
10. Weekly Risk Huddle for Nurse and Rehab   X
11. Weekly Risk Meetings (e.g., Pressure Ulcer Risk,  Nutrition Risk)   X
12. Weekly Wound Review Meetings* X  
13. Wound Rounds* X  
On-Time Resident Clinical, Functional, and Intervention Profile Report – 4-Week View
1. Care Plan Meetings X  
2. Dietary Department Internal Review   X
3. MDS Assessment Documentation   X
4. Restorative Care Internal Review   X
5. Risk Management Meetings X Quarterly  
6. Root Cause Analysis for New Pressure Ulcers   X
7. Weekly Risk Meetings (e.g., Pressure Ulcer Risk, Nutrition Risk)   X
8. Weekly Wound Review Meetings* X  

* Although the focus of the meeting is not strictly for prevention, some of the prevention reports can provide helpful information about residents' risks that affect healing as well as prevention, and may help prevent additional pressure ulcers (e.g., nutrition and incontinence status).

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Review of the Change Team's Process of Choosing On-Time Reports, Incorporating Them Into Huddles and Meetings, and Piloting Those Meetings: Scripted Exercise #1

Communication Practices Grid from Self-Assessment Worksheet—for use with Scripted Exercise #1

Section 3: Communication Practices

We are interested in how you communicate the pressure ulcer risk and prevention care plans to the interdisciplinary team. Please review the following list of meetings. For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting, and who attends.

Meeting Pressure Ulcer Prevention Discussed Yes/No Meeting Chair/Leader Name and Discipline Staff Invited and in Attendance (indicate A – Always, V- Varies as needed) Frequency of Meeting (Weekly, Biweekly, Monthly, Quarterly, Change in Condition, As Needed)
a. Care plan review Yes Nurse Manager Nursing – A
Social Services – A
Activities – A
Rehab – V
Dietitian – A
Weekly
b. Report or brief with CNAs No Nurse Manager Nursing Assistants – A Every shift
c. Report or brief with department heads No DON Department heads (Nursing, Activities, Social Services, Rehab, Dietary, Maintenance, and Housekeeping) – A Daily
d. Medical staff No N/A N/A N/A
e. QAPI* or performance improvement plan meeting Yes, if pressure ulcers are a problem DON Department heads and medical director – A Quarterly
f. Skin or wound meeting No, unless the resident has a pressure ulcer ADON Nursing – A
Rehab – A
Nursing Assistants – V
Weekly
g. MD/APRN* rounds No N/A N/A N/A
h. Report or brief with Dietary Department No N/A N/A N/A
i. Report or brief with Social Services Department No N/A N/A N/A
j. Report or brief with Therapy Department No N/A N/A N/A
k. Report or brief with "Other"        

* QAPI = Quality Assessment and Performance Improvement; APRN = advanced practice registered nurse.

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Review of the Change Team's Process of Choosing On-Time Reports, Incorporating Them Into Huddles and Meetings, and Piloting Those Meetings: Scripted Exercise #1 and Unscripted Exercise #2

Nursing Meeting Descriptions and Suggested Pressure Ulcer Prevention Reports

Nursing Home Meetings Meeting Description Typical Attendees and Leads Nutrition Risk Reports Weight Summary Report Intervention History for Nutrition Risk Reports Trigger Summary Report (Resident Level) Trigger Summary Report (Unit Level) Risk Change Report Clinical, Functional, and Intervention Profile Report
Care Plan Meetings Weekly review of resident care plans. Reports help in decisions regarding care plan changes. Multidisciplinary team.
DON or ADON typically leads the meeting.
X X X X   X X
CNA Shift Change Report CNAs meet at shift change to share summary of residents' clinical status and residents' care plan interventions for CNA followup. The charge nurse typically generates the On-Time reports for the new CNA staff at the beginning of the shift to identify residents with changes in risk. Usually done weekly. Charge nurse/nurse manager and CNAs.
Charge nurse or nurse manager typically leads the meeting.
      X   X  
Dietary Department Internal Review This is a weekly meeting within the Dietary Department. Report supports nutrition plan review and changes. Dietary department staff
Director of the Dietary Department typically leads the meeting.
X X X     X X
MDS Assessment Documentation Reports may be used to support MDS nurse review of resident records and aids MDS assessment documentation. MDS nurse and other disciplines responsible for MDS assessment documentation, including dietary and rehab. X X X X   X X
Nurse Shift Change Report Nurses meet at change of shift to review resident clinical and risk status. On-Time Risk reports help identify residents at risk for pressure ulcer development who need attention. Nurse managers or charge nurses.
Nurse managers or charge nurses typically lead the meeting.
X         X  
Rehab Department Internal Review Department team weekly review of rehab patients or residents in need of rehab. Report data help identify residents with new ADL decline or worsening ulcers and therefore at risk for pressure ulcer development and in potential need of therapy. Rehab Department staff.
Rehab director typically leads the meeting.
      X   X  
Root Cause Analysis for New Pressure Ulcers Multidisciplinary team review of new pressure ulcers. Focusing on persons with new pressure ulcers. Risk and trended reports provide insight into why these persons had a new pressure ulcer. DON or ADON, nurse manager, wound nurse, QI director
DON, QI director, or QI staff leads the meeting.
X X X   X X X
Skin Rounds Weekly skin rounds to assess resident skin condition. The reports alert staff about residents who may be likely to have a new pressure ulcer forming. Charge nurse, or wound nurse and CNA
A charge nurse or wound nurse typically leads skin rounds.
X X       X  
Weekly Nutrition Risk Huddle Nurse/Dietitian/CNA weekly huddle to review nutrition status and confirm appropriate interventions are in place for pressure ulcer prevention. Reports identify residents with nutrition risk and the meeting elicits feedback from CNA staff caring for the residents, as well as perspectives of the nurse and dietitian. Charge nurse, dietitian, and CNA. Other staff may attend such as wound nurse, social services, and MDS nurse.
Nurse and a dietitian co-lead the meeting.
X X X X      
Weekly Risk Huddle for Nurse and Rehab Weekly huddle to review residents at risk for pressure ulcer development and in potential need of therapy based on specific risk factors for a resident. Nurse manager and rehab director or rehab therapist.       X   X  
Weekly Risk Meetings (e.g., Pressure Ulcer Risk,  Nutrition Risk) Multidisciplinary team review of residents at risk. The reports help to identify persons with risks associated with pressure ulcers, review care plans, and help update interventions. DON or ADON, nurse manager, wound nurse, dietitian, and rehab director or rehab therapist depending on focus of meeting. DON or ADON leads the meeting. X X X X   X X
Weekly Wound Review Meetings* Multidisciplinary team weekly review of residents with pressure ulcers or skin integrity issues. Reports provide information about current and changing risks for pressure ulcers and can aid root cause analyses and decisions about ulcer treatments and interventions. DON or ADON, nurse manager, wound nurse, physician, NP, and QI director. The team conducting wound rounds typically attends this meeting for a more detailed review of the resident chart and current care plan interventions. Physician, dietitian, therapist, and QI staff, who may not attend wound rounds, attend this meeting.
DON typically leads the meeting.
X X   X   X X
Wound Rounds* Multidisciplinary team weekly review of residents with pressure ulcers. The team rounds on residents with a pressure ulcer and uses pressure ulcer prevention reports to support decisionmaking on pressure ulcer treatments and interventions. Nurse manager, wound nurse, wound physician, NP, and CNA
Physician, wound nurse, or DON typically leads the meeting.
X X       X  

Abbreviations: ADON: Assistant Director of Nursing; DON: Director of Nursing; CNA: Certified Nursing Assistant; NP: Nurse Practitioner; MDS: Minimum Data Set; QI: Quality Improvement.
* Although the focus of the meeting is not strictly for prevention, some of the prevention reports can provide helpful information about residents' risks that affect healing as well as prevention, and may help prevent additional pressure ulcers (e.g., nutrition and incontinence status).

Return to Handouts Contents

Review of the Change Team's Process of Choosing On-Time Reports, Incorporating Them Into Huddles and Meetings, and Piloting Those Meetings: Scripted Exercise #1

Scene 1: Change Team Meeting

Setting: At this point, the team has completed their review of the self-assessment and is ready to move ahead with implementation of the On-Time program. The Menu of Implementation Strategies Worksheet has been completed by the ADON and reviewed by the Facilitator and Program Champion. The team is assembled—the Facilitator, Program Champion, DON, ADON, Nurse Manager, Nursing Supervisor, Dietitian, Rehab Director, QI Coordinator/MDS Nurse, and the Nursing Assistant.

Facilitator: Good morning, team, and welcome back to the On-Time training. We are meeting today because we're going to talk about ways to integrate the On-Time reports into existing or new meetings.

Nurse Manager: More meetings? We already have so many.

Facilitator: I hear your concern, and we'll talk about that in a bit. Right now, let's take a minute to do a quick review of where we are in the training process. Two weeks ago we talked about On-Time Pressure Ulcer Prevention and went over each of the electronic reports. Last week we reviewed the self-assessment and what I heard was that you'd like to increase your focus on prevention but are concerned with adding any new meetings and that information on resident's risk and changing risk may not be as accessible or current as you'd like. Does that sound accurate?

DON: Yes, and we also don't use the input of our nursing assistants as much as we should.

Nursing Assistant: Thanks, Mary [DON]. We are interested in anything we can do to help prevent pressure ulcers in our residents.

Rehab Director: Same for us in Rehab. We feel like we have a lot to offer around positioning and seating options, but we don't get asked for our input very often.

DON: I hear you and we should be doing a better job collaborating across departments. But I think we can improve by using these reports, so let's get back to Sandy [Facilitator] explaining how to do that.

Facilitator: Thanks. Let's start by looking at the On-Time reports. It's been a few weeks since you've seen these. I've brought some sample reports along. I've also brought along the Menu of Implementation Strategies Worksheet that Joanne [ADON] completed. Pass these around, please.

Nursing Supervisor: Wow, this is a lot of meetings. There must be 20 meetings on this list.

Program Champion: We won't need to implement report reviews at all the meetings on the list. The Menu Worksheet displays ways other facilities have implemented On-Time and suggests reports that may be useful. The list is intended to give us ideas. It's there to help us think about our options. The beauty of  On-Time is that it's not a one size fits all approach. You select ways to use reports that make sense for your facility.

Nursing Supervisor: O.K., that makes a lot of sense.

Program Champion: Let's think about our goals. Can the reports help us to achieve our goals?

ADON: First and foremost, we want to reduce pressure ulcers. We also want to collaborate better across departments and we want to have more input from our nursing assistants.

Rehab Director: Just recently, the restorative nursing staff started an incontinence management group. I think the Risk Change Report would be very helpful to them. It shows increases in bowel and bladder incontinence. That way, they could target those residents who are most in need of incontinence management before their skin integrity is compromised.

DON: And, Pat, we also have our meeting to go over the list of residents currently receiving therapy. I think we could use information from the Risk Change Report to target people with ADL decline, to see if they could benefit from therapy to increase mobility and head off the development of a pressure ulcer.

Facilitator: That's perfect. Does anyone else have other ideas for using this report or other reports?

Dietitian: I would definitely like to use the Nutrition Risk Report and Weight Summary Report at a nutrition huddle. The Nutrition Risk Report has the trended weekly average meal intake for all of the residents on one unit in one report. This is the type of information that I'd like to be able to review with the nurses and the nursing assistants. When I see decreased meal intake, I like to get more details from the nursing assistants, like is there a problem at one particular meal or is it a problem with a particular type of food? If I could review this on a weekly basis in a short meeting with the nurses and nursing assistants, that would really help me come up with an intervention before weight loss occurs and puts that resident at risk for a pressure ulcer.

Facilitator: That's right, and the process would promote team collaboration about meal intake trends. The discussion would incorporate the perspective of the nurse, nursing assistant, and dietitian. We should definitely talk about using the Nutrition Risk Report at a weekly nutrition huddle and include the nursing assistants. You also mentioned the Weight Summary Report. How would you use that?

Dietitian: I'd like to use that with the Nurse Managers to monitor weights over time. Don't the Nurse Managers meet with Mary on a weekly basis in a nursing management meeting? I wonder if I could sit in for a few minutes and bring the Weight Summary Report.

DON: That would be fine with me, and it will help keep me informed as to what's going on with weights.

Facilitator: So, what I'm hearing is that you'd like to use the Risk Change Report in a meeting with Rehab and Nursing, and suggest to the incontinence management team that it may benefit them as well; the Nutrition Risk Report with nurses, nursing assistants and dietary, and the Weight Summary Report with dietary, the Nurse Managers, and the DON. Have I got it right? Do you all agree?

DON: Yes. Sounds like a plan.

Facilitator: Great. Now what is the best way to get started? Do you want to trial the use of one report or several? Do you want to try using the report or reports on one unit first and see how it goes or do you want to roll it out to the whole building?

DON: What are the pros and cons for each?

Facilitator: Well, trialing one report on one unit will allow you to see how it goes and allows you to adjust the process before moving on to other units or adding new reports. That way you can fix things that aren't working well before more staff are involved, which is a true quality improvement cycle. But, it will take longer this way and a longer period of time before you notice any difference in your pressure ulcer rates.

QI Coordinator: We have to implement three reports for On-Time to be effective.

Nurse Manager: Why three reports?

QI Coordinator: Research about On-Time has shown if we implement at least three reports we should get improvement in our rates. This is in the literature.

Program Champion: I think we should start with one report on one unit and get the process to where we like it. We can always add more reports later, correct?

Nurse Manager: Which unit are you going to pick?

Program Champion: I would suggest starting with the unit with the highest pressure ulcer rate.

DON: That makes sense to me. Nancy, that would be your unit. Are you comfortable with this plan?

Nurse Manager: O.K., but I don't particularly like that distinction.

DON: Well, let's see if On-Time can help.

Facilitator: Which report would you like to implement?

Nurse Manager: I'd like to pilot the Nutrition Risk Reports in a huddle with the nursing assistants and Laura [Dietitian] each week and if that works perhaps we can add the Weight Summary Report.

Program Champion: Yes. Just to confirm, this would be a huddle with the nursing assistants on Nancy's [Nurse Manager] unit, once a week for 5 minutes to discuss residents listed on the Nutrition Risk Report, correct? Laura [Dietitian], you would be there, and Nancy, I'm assuming you'd attend as well.

Nurse Manager: Yes, I'll be there.

Dietitian: Yes, that's right.

Program Champion: O.K., that sounds fine to me. Mary, can you work out the details?

DON: Nancy [Nurse Manager], could you arrange a time for you and the nursing assistants to meet with Laura [Dietitian] for 5 minutes once a week?

Nurse Manager: You know, that sounds easy, but it's hard to find a time when we can all be off the floor at the same time.

DON: You don't have to leave the floor, just be available for 5 minutes.

Nursing Assistant: I think we could manage 5 minutes. I think it would be worth it, if it would help prevent a pressure ulcer.

Nurse Manager: O.K., but not during meal times.

DON: Agreed. Which days are you here, Laura?

Dietitian: Monday all day, Wednesday in the morning, and Thursday afternoons.

Facilitator: How about Wednesday morning?

Nurse Manager: O.K. I'm suggesting 11:15. Will that be O.K. for you, Laura [Dietitian]?

Dietitian: Fine with me. How will that work for you and the other nursing assistants, Francois?

Nursing Assistant: I think 11:15 is good, as long as it doesn't run too long. We start getting the residents into the dining room for lunch at 11:30.

Facilitator: O.K., then, Wednesdays at 11:15 with the day shift nursing assistants. Laura, will you print the report?

Dietitian: Yes, I'll print the report and review it prior to the meeting. Let's meet here at the nurses' station.

Facilitator: It looks like we have a plan. We'll trial the Nutrition Risk Report on Nancy's [Nurse Manager] unit during a "5-minute huddle" with the day shift nursing assistants on Wednesdays at 11:15. Let's plan to check back in 2 weeks to see how this trial went. We will need feedback from everyone—what worked, what didn't work, and any suggestions for improving the process. Thanks, everybody. For our next meeting, I won't need to be here. I'll call into the conference room.

Scene 2: Change Team Followup Meeting

Program Champion: Thank you all for coming. We're meeting today to hear how the trial of the Nutrition Risk Report on Nancy's unit went. Sandy [Facilitator] is on the phone:

Facilitator: Hi, everyone. How did it go?

Dietitian: It went pretty well. We had our meeting and the nursing assistants verified for me that several residents who were listed on the report with decreased meal intake were indeed eating less. I followed up with one of the residents about food preferences and made some changes to her diet. Another had some issues with a sore gum that we wouldn't have looked into unless we had seen the very gradual decline in her meal intake. That was a good save. Being able to see weekly trends in average meal intake really helps.

Facilitator: Did you run into any problems?

Dietitian: Not really, except that our first meeting was a little too long.

Facilitator: It's not unusual for the first meeting or two to take longer, but once you get the process down the meetings will go much faster. The nursing assistants will know what is expected of them and everyone will be more familiar with the report and which report data to focus on. How many residents were on the report?

Dietitian: There were about 10 on the report.

Facilitator: The report can be run for high risk and medium risk. How about prioritizing residents at highest risk? Try that next week and see if that helps. It's important to get the meetings down to a reasonable time. If they're too long, it's likely staff will start skipping them. And remember, you don't have to review everyone on the report; use your clinical judgment when it comes to choosing the residents to discuss.

Dietitian: The second week, the nursing assistants didn't show up for their meeting.

DON: Nancy [Nurse Manager], it is important for the nursing assistants to attend these meetings; it is up to leadership to see that they can attend and important to demonstrate that we are supporting On-Time. Do you remember what happened that day with your nursing assistants? And remember that I am here to help you.

Nurse Manager: No, I don't remember what happened, but I'm not so sure it's really necessary to have the nursing assistants meeting with the dietitian. I talk to Laura all the time. The nursing assistants report their concerns to me; I pass them along to Laura, when appropriate.

Facilitator: How is your in-house pressure ulcer rate on this unit? Is it still high?

Nurse Manager: Unfortunately, yes.

Facilitator: Laura, what do you think? Is the information that you get directly from the nursing assistants valuable? How do you feel about continuing the 5-minute huddles?

Dietitian: I would like to see them continue. I mentioned earlier the resident with the gum problem that came out during one of the Nutrition Report meetings. Mrs. Jones was listed on the report with decreased meal intake. I asked Francois [Nursing Assistant] about that and he said Mrs. Jones was drinking O.K. but eating less than normal. I asked Francois to try to find out why. He followed up with Mrs. Jones and she told him that her mouth was sore and it turned out that her dentures were causing an irritation on her gums. That was a subtle change that could have developed into a major problem if it had continued.

Facilitator: Nancy, was this something that you had been aware of prior to the Nutrition Report meeting?

Nurse Manager: No. I just heard about it when Francois told me about her gums. We got a dental consult right away, but you're right, this was something that could have gone on for a while before someone discovered what the problem was.

Facilitator: And I'm sure you want to get your unit's pressure ulcer rate down, right?

Nurse Manager: Of course.

Facilitator: Sounds like we should try this on day shift for a few more weeks before we make a decision to expand to other units. Does everyone agree?

All: Yes.

Facilitator: O.K., we are in agreement about that.

Facilitator: Good discussion, team. Making these changes takes flexibility on everyone's part and I appreciate your efforts. Keep up the good work. I think you'll find that this will pay off for you and especially for your residents.

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Page last reviewed December 2014
Page originally created March 2013
Internet Citation: AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention. Content last reviewed December 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/prev-handouts2.html