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

Implementation Steps and Timeline

The goal of On-Time is to incorporate the On-Time reports into day-to-day prevention activities and to ensure multidisciplinary input into clinical intervention decisions. The Implementation Steps document was created to help nursing homes understand the implementation steps for carrying out On-Time and the likely timeline to make the reports part of daily practice. It is intended to be used by the team champion and the change team members to help keep the effort on track and methodical. The timeline is meant as a guide because quality improvement project timelines often vary depending on the quality improvement skills and resources available to the participating facilities.

Step 1: Verify Nursing Home Readiness

The facilitator meets with nursing home leadership to confirm willingness to implement the On-Time Pressure Ulcer Prevention Program. Leadership agrees to identify a change team champion and establish a multidisciplinary change team to lead the project. The facilitator develops a plan with the change team on how they work together.

Step 2: Confirm Access to Electronic Reports

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 prevention reports are in the system and takes appropriate steps at the facility to provide frontline staff with access to prevention reports.

Step 3: Identify Multidisciplinary Team Members To Serve on the Change Team

The change team consists of a change team champion, nurse managers from each nursing unit, a dietitian, and certified nursing assistants (CNAs). The champion advocates and supports the project and ensures that 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.

Step 4: Provide Overview of On-Time Pressure Ulcer Prevention

The On-Time facilitator provides an overview on the On-Time Pressure Ulcer Prevention Program to the change team. The facilitator answers questions and confirms that the facility team members understand how to access reports and tools.

Step 5: Review On-Time Pressure Ulcer Prevention Reports

The team reviews reports with the facilitator to understand the purpose, content, potential uses, and likely users of the reports.

Step 6: Complete Pressure Ulcer Prevention Self-Assessment

The facilitator meets with the champion to fill out the worksheet and helps the team review findings. The team completes the self-assessment worksheet that identifies details about the current processes at the facility to identify residents at risk for pressure ulcers. They also identify prevention practices and processes for root cause review. The review includes identification of existing team meetings, huddles, and other communication structures at the facility.

The 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 they can use On-Time reports to help prevent pressure ulcers.

Step 7: Pilot a Report With Data

The On-Time facilitator guides the team in generating and reviewing a report with actual resident data on one unit.The facilitator works with the team to understand the 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 that 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 the team uses should go through this process so the team is confident in the information being produced on the reports.

Step 9: Have Team Choose To Use 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.

Step 10: Decide on Meetings To Incorporate Reports

With the help of the facilitator, the change team decides which meetings/huddles will incorporate reports. Some new meeting/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.

Step 11: Pilot All Reports/Meetings in One Unit

The team pilots each report in 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 that 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 informed and enforced.

Step 12: Implement All Reports in All Units

The facilitator, champion, or unit representative introduces the On-Time Pressure Ulcer Prevention Program 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.

Step 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.

Step 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.

Step 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.

Step 16: Sustain the Effort

After 9 months, the nursing home change team develops a plan to incorporate implementation strategies for report use into facility policies and procedures. The plan includes incorporating educational inservice 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 DON is responsible for ensuring that On-Time process improvements are carried out on each nursing unit and holds each nurse manager accountable.

Pressure Ulcer Prevention Program Implementation Steps and Timeline Grid

Implementation Step Estimated Duration/Time Materials Role of Facilitator1
1. Verify Nursing Home Readiness Within 1st month   Facilitator verifies preliminary requirements:

  1. On-Time Reports are available to frontline staff.
  2. Champion is designated.
  3. Change team is formed.

Facilitator develops plan with change team on how they work together.

2. Confirm Access to Electronic Reports Within 1st month
3. Identify Multidisciplinary Team Members To Serve on the Change Team Within 1st month
4. Provide Overview of On-Time Pressure Ulcer Prevention 1st month - 2nd month Use On-Time Facilitator Train-the-Trainer Materials for presentation:

  • Overview of the On-Time Program.
  • Pressure Ulcer Prevention Electronic Reports.
  • Implementation Materials.
Facilitator introduces to change team Overview of On-Time program and materials:

  1. Overview of On-Time Program.
  2. Pressure Ulcer Prevention Electronic Reports.
  3. Self-Assessment Worksheet for Pressure Ulcer Prevention.
  4. Pressure Ulcer Prevention Menu of Implementation Strategies.
  5. Implementation Steps and Timeline.
5. Review On-Time Pressure Ulcer Prevention Reports 2nd month - 3rd month Pressure Ulcer Prevention Report descriptions Facilitator teaches pressure ulcer prevention reports to change team so they understand purpose, content, potential uses, and likely users of reports.
6. Complete Pressure Ulcer Prevention Self-Assessment 2nd month - 3rd month Pressure Ulcer Prevention Self-Assessment Worksheet Facilitator meets with champion to fill out worksheet and helps team review findings and understand how reports may help improve prevention practices.
7. Pilot a Report With Data 2nd month   Facilitator guides team through process of generating and reviewing a report with actual resident data and answers any questions from the team.
8. Validate Data 2nd month Adapt On-Time Facilitator Train-the-Trainer Materials for presentation: Checking the Accuracy of On-Time Reports Facilitator advises team on how to validate data. Validation is done for each report with real resident data.
9. Have Team Choose To Use At Least Three Core Reports 3rd month Pressure Ulcer Prevention Program Menu of Implementation Strategies Facilitator advises team on reports and recommended meetings/huddles that could accommodate report discussions.
10. Decide on Meetings To Incorporate Reports 3rd month
  • Pressure Ulcer Prevention Program Menu of Implementation Strategies.
  • Pressure Ulcer Prevention Self-Assessment Worksheet.
Facilitator helps team choose meetings and restructure meetings to add report discussions.
11. Pilot All Reports/Meetings  in One Unit 3rd month - 4th month Actual pressure ulcer prevention reports from unit downloaded for meeting discussions
  • Facilitator, champion, or unit representative introduces On-Time
  • Pressure Ulcer Prevention Program to the first unit.
  • Facilitator provides support to change team during report piloting.
12. Implement All Reports in All Units 4th month - 6th month Actual pressure ulcer prevention reports from all units downloaded for meeting discussions
  • Champion or facilitator introduces On-Time Pressure Ulcer Prevention Program to other units.
  • Facilitator provides support to change team if needed during report implementation in new units.
13. Monitor Facility Implementation Progress Monthly 6th month - 9th month Pressure Ulcer Prevention Program Implementation Steps and Timeline Facilitator provides support to change team and helps the team monitor progress. The Implementation Steps provide a basis for monitoring implementation progress.
14. Review Pressure Ulcer Incidence   Examples of what facility can use: facility’s existing pressure ulcer incidence reports, CMS quality measures reported on Nursing Home Compare Facilitator assists the change team in selecting an outcome metric and monitoring pressure ulcer incidence.
15. Use Optional Reports Adds approximately 3 months or more, depending on time for vendor to program reports
  • Resident Clinical, Functional, and Intervention Profile Report.
  • Intervention History for Nutrition Risk. Reports: High Risk and Medium Risk.
Facilitator helps with implementation of reports as above.
16. Sustain the Effort End of 9th month - 12th month    

1 Facilitators receive a 2-day training that will provide the following: (1) Overview of On-Time; (2) instruction on the role of a facilitator; (3) Introduction to On-Time Reports and Implementation Materials; training on specific reports; and (4) hands-on practice using the reports and specific implementation materials in simulated situations.

Return to Pressure Ulcer Prevention

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/pruprev-timeline.html