In 2006, the Agency for Healthcare Research and Quality (AHRQ) introduced a program, On-Time Quality Improvement, which leverages information technology to improve documentation and information flow, enabling real-time information to influence care planning for patients.
Specifically, the program is targeted at helping Certified Nursing Assistants (front-line staff) reduce the occurrence of pressure ulcers, which commonly plague both short- and long-term care patients in nursing home settings. To date, over 50 nursing homes have participated in the program.
The Program
Facilities that have adopted the program organize their staff into multidisciplinary teams, including CNAs, dieticians, nursing coordinators and managers, and work with quality improvement consultants to re-organize their work flow. This involves streamlining and standardizing the CNA’s documentation, implementing tools to identify and track residents at high risk of developing pressure ulcers, facilitating the flow of information between the entire team, and ultimately enabling fast response and treatment.
The interdisciplinary team is provided with weekly reports that paint a clear picture of each identified high-risk patient. Based on these reports, the team works together to determine the required changes to the patients’ care plan. The process also facilitates a discussion around workflow and documentation in addition to care planning.
The end goal for the program is to equip the facility with a strong pressure ulcer prevention program and a corresponding set of tools and skills to support on-going quality improvement in this regard.
Program Shows Promise in Nursing Homes
Looking at the most recent data from among nursing homes that attempted to fully implement the program, the Centers for Medicare and Medicaid Services’ high-risk pressure ulcer quality measure (measures new or worsened ulcers) decreased by 30.7 percent and pressure ulcers acquired in-house decreased by 42 percent.
Not only does the program appear successful in reducing the number of pressure ulcer cases as well as the rate of new occurrences, but all participating facilities experienced improved documentation, information flow and communication across the team as well as improved identification of residents at risk of developing pressure ulcers.
Furthermore, the program had the added benefit creating a “culture of data”, supporting additional quality improvement initiatives, in which front-line staff showed strong interest and engagement.
Nursing Home Case Studies
Gurwin Jewish Nursing and Rehabilitation Center
Gurwin Jewish Nursing and Rehabilitation Center is a 460-bed skilled nursing home in Long Island, New York. Gurwin implemented the On-Time Quality Improvement program as part of its on-going desire to improve the quality of care delivered to patients and due to the nature of its population, which tends to be at high-risk for pressure ulcer development.
Integral to the program are the team aspect and use of standardized, timely reports. Johanna Graham, Wound Care Coordinator, describes how the program works at Gurwin: “The reports help us to identify residents that are at high risk for developing pressure ulcers. The unit knows the residents who are at risk, but for me, I have twelve units, so by having the ability to run the report I am able to view the scores for all residents as well as the factors that predispose the residents to developing pressure ulcers, which is of great help. I then collaborate with the nurses to ensure that preventative measures are in place, for example: heel pads, air mattresses and out of bed schedules for residents. We also take a look at the resident’s nutritional status, their preferences and the need for supplements.”
After implementing ARHQ’s On-Time Quality Improvement program, pressure ulcer incidence decreased from 2.0 percent to 0.6 percent – a 70 percent improvement over the span of one year. When asked about the key factors that contributed to the success of the program, Sonia DeSouza-Brown, Assistant Director of Nursing, remarked, “What I think is important is that the leaders are very involved and enthused about the program, and this in turn elicits the same response from the line staff, which is key to the program’s success.”
The program has not only had a positive impact in terms of pressure ulcer reduction, but has also made in-roads in other areas as well. For example, the team started taking a closer look at late-loss activities of daily living (ADLs), which consist of eating, transferring, toileting and bed mobility. These residents are assessed and placed on a nursing restorative program when appropriate or a plan of care is developed to provide assistance where needed. By addressing ADLs, not only would patients improve specifically in that regard, but improvement in ADLs also has a direct, positive impact on pressure ulcers.
In addition to the above, the team also started paying closer attention to medical conditions that predispose residents to pressure ulcers. Sonia explains, “Certain medical conditions, i.e. diabetes, anemia, and peripheral vascular disease, and certain medications, such as prednisone, place these residents at high risk for developing pressure ulcers. Therefore it is important to be attentive to these residents and address their medical conditions, involving the doctors as necessary.”
Furthermore, the Nutrition and Weight reports that were instituted as part of the On-Time program were leveraged to address other issues such as unplanned weight loss among residents. As a result of the improved documentation and information flow, the number of residents that experienced significant weight loss halved, from 3.5 percent to 1.7 percent.
Schuyler Ridge Nursing Home
Schuyler Ridge is a nursing home in Clifton Park, New York. After implementing ARHQ’s On-Time Quality Improvement program, pressure ulcer incidence decreased from 6.5 percent to 2 percent – a near 70 percent improvement over the span of one year.
All relevant information is input into Schuyler Ridge’s CareTracker IT system at one of the facility’s seven touch-screen kiosks. While prior to program implementation paper documentation completeness rates were only 70 to 80 percent, these rates are now touching 98 to 99 percent. Administration feels that not only is the information more complete, but it is more thorough and accurate as well.
The new system has enabled staff to start identifying medium-risk patients in addition to high-risk, and empowered front-line staff as they feel that they have a platform to have their thoughts and suggestions heard and recognized by management.