# Presentation: 218266

## On-Time Quality Improvement for Long Term CareThursday, September 27, 2007; 1:30 – 3pm 

**Susan D. Horn, PhD**
**Institute for Clinical Outcomes Research**
**699 E. South Temple, Suite 100 **
**       ****Salt Lake City, Utah  84102-1282**
**801-466-5595 (T)     801-466-6685 (F)**
**shorn@isisicor.com**

**Redesigning Work Processes to **
**Improve Resident Safety and Quality**

## Long Term Care and AHRQ

_**Goal**_
**Broad improvements in quality at a national scale**
_**Strategy**_
**Through adoption of innovations and tools that**
**Foster evidence-based interventions**
**Encourage implementation in day to day practice**
**Disseminate broadly**

## Background

**Pressure ulcer (PrU) rates remain high **
**Despite guidelines**
**Despite training**
**NH staff know how to prevent PrUs**
**Need to identify high risk residents on weekly basis**
**Knowledge not integrated into day to day practice **
**Entire multi-disciplinary team needs to coordinate care better for high risk residents (including CNAs)**

## Research Based Best Practices Nursing Home Study (NPULS)  1996-1997

**6 long-term care provider organizations**
**109 facilities**
**2,490 residents studied**
**1,343 residents with pressure ulcer; 1,147 at risk**
**70% female, 30% male**
**Average age = 79.8 years**
**Funded by Ross Products Division, Abbott Laboratories**

## Long Term Care CPI ResultsOutcome: Develop Pressure Ulcer

**General**
** ****Assessment**

**Incontinence**
**Interventions**

**  ****Nutrition**
**Interventions**

**Staffing**
**Interventions**

**+ Age ******** 85**
**+ Male**
**+ Severity of Illness**
**+ History of PU**
**+ Dependency in **
**   ****>= 7 ADLs**
**+ Diabetes**
**+ History of tobacco use**
**+ Dehydration**
**+ Weight loss**
**    **

**+ Mechanical devices for the containment of urine (catheters) **
**- Disposable briefs**
**- Toileting Program**

**- RN hours per resident day >=0 .5**
**- CNA hours per resident day >= 2.25**

**Medications**

**- SSRI + Antipsychotic**

**Horn et al, *****J. Amer Geriatr Soc***** March 2004; 52(3):359-367 **

**- Fluid Order**
**- Nutritional Supplements**
** ****standard medical**
**- Enteral Supplements**
** ****disease-specific**
** ****high calorie/high **
**  ****protein****   **

## Common Challenges Across Facilities

**Inefficient Processes**
**Incomplete Documentation**
**CNAs: untapped resource**
**Communication Breakdowns / Lack Standard Processes**
**Clinical Decision Support Needs**

## AHRQ-funded Initiatives

**Partnership for Quality Project: ‘****Real-time Optimal Care Plans for Nursing Home QI’****.  2002-2007.**
**Transforming Health Care Quality through Information Systems:  ‘****Nursing Home IT:  Optimal Medication and Care Delivery’****.  2004-2007.**
**‘****On-Time Prevention of Pressure Ulcers – Collaboration with QIOs’****.  2005-2007.**
**Knowledge Transfer****:  Capture and Spread Promising Practices and Lessons Learned from Implementing the “****Real-time Prevention of Pressure Ulcers****” project.  2006-2007. **

## Background: Progression of Work

**Background: Progression of Work**

**1996**

**2003**

**2005**

**AHRQ-funded: **
**“****Real-Time Optimal Care Plans” **
-  Translate evidence-based best practices into daily work

**AHRQ-funded: “Nursing Home IT”**
-  Support HIT adoption in LTC
-  Integrate ‘Real-Time’ knowledge in IT

**Research**

**Integrate with HIT**

**National Pressure Ulcer Long Term Care Study**

**Implement**

**2004**

**Disseminate**

**AHRQ-funded: “On-Time Pressure Ulcer Prevention: Partnering with QIOs”**

## History of On-Time QI for LTC

**In development for 5 years**
**Pilot facilities reduced PrU rate by a third**
**Currently 28 active facilities **
**NY RFA will add at least 10-12 new facilities**
**Recruiting efforts in progress CA, NY, and DC**
**Partnership with California Healthcare Fndn**
**2 web casts : over 600 facilities registered **
**New pilot on PrU **_**healing**_**  (20 facilities)**

- Prevention Reports

- Standardized CNA documentation

- QI Team

- Access timely information

- Reduce redundancy
- Consolidate documentation

- Front-line team members use reports in daily work

- Identify high-risk residents

- Information Technology

- Step 1

- Step 2

- Step 3

- Step 4

## Implement:  Workflow Redesign Focused to Reduce PrU

**CNA Daily Workflow**
**Standardized data in documentation flow sheets**
**Improved communication with clinical team (RN, CNA, MDS, Dietary)**
**Wound Nurse**** **
**Standardized data in PrU documentation**
**Timely access to compiled information**
**Timely Information for Care Planning Processes**
**Identify residents at risk for pressure ulcer development**
**Access to summarized information for clinical decision-making**
**Shorten response time between identification of resident need and intervention**

## Timely Feedback Reports

**Access to summarized information for clinical decision-making**
**Nutrition, Behavior, High risk triggers, Pressure Ulcer monitoring reports**
**Improve response time between identification of resident need and intervention**
**Identify residents at risk for pressure ulcer development**
**Transform from paper to data culture**
**Link reports to documentation elements**

## Decision Making Reports

**	**
_**Documentation Completeness Report**_**. ****Summary of CNA documentation completeness rates****.  **
_**Nutrition Report**_**. ****Displays average meal intake, resident diet, supplements, resident weight status (presence of weight gain/loss), last diet consult date, history of pressure ulcer indicator, and presence of pressure ulcer. **
_**Behavior Report**_**. ****Displays the total number of times a resident exhibits a behavior by shift****.**
_**Priority Resident Report**_**. ****Displays residents who are at risk for pressure ulcer development and high priority for staff focus.**

_**Nutrition Summary**_
**Meal intake for 4 weeks**
**Fluid intake for 4 weeks**
**Diet order**
**Supplement product **
**Weight change since last week**
**Existing pressure ulcer**
**History of resolved ulcer**

_**Weight Summary**_
**Weight 180 days prior**
**Weight 30 days prior**
**Weight for each of past 4 weeks**
**Weight change since last week **
**5-10% weight loss past 30 days**
**>10% weight loss past 180 days**

**Ex: Nutrition Report**

**Stratified by Risk**
**Provide ‘BIG picture’ over time, not just snapshot of one shift or one day**

## Results

**Decrease Pressure Ulcer Development**
**Increase Adherence to Best Practices**
**Increase Staff Accountability and Satisfaction**
**Inclusion of front-line workers in QI efforts**
**Comprehensive documentation at point of care**
**Communication among care team improved**
**Reduce Inefficiencies**
**# documentation forms for CNAs**
**CNA time looking for documentation book**
**Time to compile reports for State Regulators and MDS **
**Time for Wound RN to summarize and report data**
**Improve State Survey Process**
**Establish a foundation for EHR**

## Impact On Pressure Ulcer QMs

**Impact On Pressure Ulcer QMs**

- Source:  CMS Nursing Home Compare; Facility QM data reports

- The combined facilities’ average shows an **overall reduction of 33% in the QM % of high risk residents with pressure ulcer** from pre-implementation to initial post-implementation time periods

**Combined Facilities**

**National**** ****Norm**

**Q4 03 – Q3 05% Change =  - 33%**** **

## Key Program Benefits

_**Improve Quality**_
**Improve clinical decision making:  integrate reports into day-to-day workflow**
**Identify residents at high risk early **
**Timely communication among multi-disciplinary team members**
_**QI Collaboration**_
**Receive technical assistance from QI experts**
**Collaborate with peers to share experiences and best practices**** **

## Key Program Benefits (cont)

_**Improve CNA Documentation**_
**Consolidate current documentation**
**Standardize data elements and eliminate redundancy**
**Audit and train for accuracy**
_**Gain Efficiency**_
**Reduce time spent searching for multiple sources of information**
**Automated reports replace manual compilation of resident information**
_**Increase Morale**_
**Empower multidisciplinary teams with CNAs as important members**
**CNAs see importance of their work**

## What is different about this approach?

**Integrates sustainable quality improvement into daily operations****. **
**Streamlines documentation with focus on critical data elements and information flow. **
**Translates documentation data into multi-disciplinary clinical reports.**
**Involves front-line staff**
**Links QI and HIT**