On-Time Quality Improvement for Long-Term Care: Using Nursing Home IT for Optimal Care Delivery

Slide Presentation from the AHRQ 2008 Annual Conference

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On September 8, 2008, Susan D. Horn, Ph.D, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.2 MB; Plugin Software Help).

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Slide 1

On-Time Quality Improvement for Long-Term Care: Using Nursing Home IT for Optimal Care Delivery

Presentation to AHRQ Annual Conference Track 1. Health Information Technology (Health IT)
Improving Quality of Care for Vulnerable Populations Through Health IT

September 8, 2008
Susan D. Horn, Ph.D
Institute for Clinical Outcomes Research
699 East South Temple, Suite 100
Salt Lake City, Utah 84102
801-466-5595 (V) 801-466-6685 (F)
shorn@isisicor.com
www.isisicor.com

Notes:

• Health Information Technology (HIT)

Slide 2

AHRQ Transforming Healthcare Quality through Information Technology Findings from 3 Projects

1. Real-Time Optimal Care Plans for Nursing Home QI
2. Nursing Home IT:  Optimal Care Delivery
3. On-Time Quality Improvement for Long-Term Care

Notes:

• Nursing Home (NH); Quality Improvement (QI)

Slide 3

Nursing Home IT: Optimal Care Delivery Objectives

1. Integrate evidence-based research on pressure ulcer prevention into long term care daily practice.
2. Implement pre-IT and HIT solutions in long term care to support redesigned processes and improved outcomes.
3. Identify HIT implementation best practices.

Notes:

• Pressure ulcer (PrU).
• Outcomes to be improved upon include lower pressure ulcer rates, faster healing of pressure ulcers, and less weight loss.

Slide 4

Background—Clinical Quality

• Pressure ulcer (PrU) rates remain high:
  • Despite guidelines
  • Despite training
• National Institutes of Health (NIH) 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).

Notes:

• High rate of PrU are rates above the national average of 14%.
• The high risk factors for patients to develop PrUs include incontinence, immobility, weight loss, poor meal intake, dehydration, depression, loss of sensation.
• Certified Nursing Aide (CNA).
• Other members of the multi-disciplinary team include nurses, dietary, social worker, restorative, etc.

Slide 5

Background—Operations

• CNAs document in 7-8 different places.
• Communication is fragmented.
• Difficult to track down information for MDS assessments.
• CNA documentation often incomplete and inaccurate, yet they spend the most time with residents.

Notes:

• The typical scenario in a nursing home: CNAs document the status of residents in different logbooks for, e.g., weight, meal intake, behaviors, bathing, incontinence episodes, etc.
• MDS = Minimum Data Set established by the Centers for Medicare & Medicaid Services (CMS) for nursing home reporting.

Slide 6

Steps to Success

1. Research-based foundation.
2. Partnerships; bottom-up approach.
3. Standardized comprehensive documentation.
4. Timely feedback reports.
5. Integrate into daily workflow and care planning.
6. Incorporate into IT—explicit link between IT and QI.

Notes:

• The standardized data elements for PrU prevention are integrated into routine CNA daily documentation workflow. They are not an add-on. Daily or weekly reports produced from this documentation are used in care planning meetings to recognize residents at risk for PrU development and quickly institute interventions to prevent them.

Slide 7

Step 1—Research Based Foundation

National Pressure Ulcer Long-term Care Study (NPULS) 1996-1997

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

Slide 8

Long Term Care CPI Results Outcome: Develop Pressure Ulcer

• General Assessment:
  • Age ≥85
  • Male
  • Severity of Illness
  • History of PrU
  • Dependency in
  • ≥7 ADLs
  • Diabetes
  • History of tobacco use
  • Dehydration
  • Weight loss
• Incontinence Interventions:
  • Mechanical devices for the containment of urine (catheters)
    • Disposable briefs
    • Toileting Program
• Nutrition Interventions:
  • Fluid Order
  • Nutritional Supplements:
    • Standard medical
  • Enteral Supplements:
    • Disease-specific
    • High calorie/high protein
• Staffing Interventions:
  • RN hours per resident day ≥0.5
  • CNA hours per resident day ≥2.25
• Medications
  • SSRI + Antipsychotic
• Note: Horn et al, J Amer Geriatr Soc March 2004; 52(3):359-367

Notes:

• Findings from NPULS study of the factors associated with greater or less likelihood of pressure ulcers developing.
• ADLs = activities of daily living including any daily activity we perform for self-care (such as feeding ourselves, bathing, dressing, grooming), work, homemaking, and leisure.
• SSRI = Selective serotonin re-uptake inhibitors
• RN = registered nurse

Slide 9

Effects of Nutritional Support in Long Term Care

Nutritional Treatment Strategies	N	Pressure Ulcer Develop Rate
Oral Supplement/Standard Medical Nurtritional	134	21.60%
Enteral Formula	210	23.80%
Fluid Order	396	25.00%
Snacks, House Shakes	403	27.30%
No Nutritional Risk— No Nutritional Treatment	195	27.20%
At Nutritional Risk— No Nutritional Support	323	35.60%

Notes:

• Use of oral supplements known as complete products or standard medical nutritionals was associated with the lowest rate of pressure ulcer development compared with the use of other supplements or no supplements.

Slide 10

Bladder Incontinence Management in Long Term Care

Treatments	N	PU Develop Rate
Incontinent-Use one or more of following treatments:	1,441	34.20%
Briefs, disposable	501	23.60%
Toileting program	549	23.90%
Briefs, reusable	118	26.30%
Topical Treatment	1,159	29.10%
Bed pads, disposable	193	29.50%
Bed pads, reusable	221	32.10%
Use of catheter	195	51.30%
Continent-No incontinence treatment	209	26.30%

Notes:

• Use of disposable briefs was associated with the lowest rate of pressure ulcer development compared with the use of other incontinence products or no incontinence treatments.

Slide 11

Step 2: Partnerships

• Empower all members of a facility team.
• Front-line workers actively participate in QI activities.
• Share across facilities.

Notes:

• Share what has worked in your facility with other facilities implementing the program with the same or different HIT tools.

Slide 12

Step 3: Standardized Documentation

• Redesign work flow—consolidate documentation and eliminate duplication
• Allow individual facility customization
• Encourage inter-facility sharing and observe facilities come to consensus over time

Slide 13

Redesign Documentation CNA

• Daily flow sheet
• Single form replaced multiple logs, clipboards, bedside charts
• Reduced redundant documentation "document one thing, one time, in one place"

Care Planning Team

• Nurses, dietitians, wound nurses contribute to care plans
• Used by multiple members of the care team to plan/implement care

Slide 14

Transition from Paper to HIT

• CNA staff for daily documentation
• Wound nurse for documentation - tracking pressure ulcers
• Nursing Management, charge nurses, and Dietary access on-line reports to support decision-making, care planning, and CQI activities

Notes:

• Continuous Quality Improvement (CQI)

Slide 15

Example Technology #1: Digital Pen & Paper

• Digital Pen:
  • Thin and light device that writes like an ordinary pen.
  • Includes camera that records pen strokes.
  • Used with digitized form, digital pen reads unique pattern of dots to interpret the data.
• Docking Station:
  • Battery charging.
  • Uploading data from memory to database via Internet.

Notes:

• Illustration of digital pen in a medical form.

Slide 16

Digital Pen Systems

In the absence of existing Health IT, the Digital Pen and Paper solution was used because of its:

• Ease of use and low cost.
• Minimal staff training requirements.
• Minimal set up and support requirements.
• Minimal impact to existing clinical workflow resulting in rapid staff adoption rates.
• Rapid report development cycle supports accelerated implementation timeline.
• The Digital Pen and Paper solution does not interfere with existing facility IT applications.

Slide 17

Ex: CNA Documentation

The document image shows a sample CNA standardized documentation form.

Notes:

• This is a sample page from the CNA standardized documentation form. It contains columns for each shift for 7 days during a week. The CNAs check the appropriate boxes, so no other writing is required, making the documentation more efficient and accurate. The content includes information about meal intake and the need for assistance, bathing, grooming, etc. If the CNA records a value in the shaded highlighted areas, it reminds the CNA to notify the RN about resident risk factors for pressure ulcer development.

Slide 18

Example technology #2: Electronic Medical Record

Profile:

• Add CNA standardized documentation data elements into electronic medical records (EMRs).
• Add Wound RN standardized documentation data elements into EMR.

Project Requirements:

• Incorporate standardized data elements, including best practices, into application.
• Produce On-Time reports.

Vendors to date:

• Optimus EMR, Lintech, CareTracker, eHealth, Reliable.

Notes:

• Electronic Medical Record (EMR)

Slide 19

Step 4: Timely Feedback

• Use comprehensive standardized documentation data.
• First reports provide feedback on completeness.
• Other reports target specific components of care.
• Summarize clinical information in variety of formats for use by RNs, MDS coordinators, dieticians, CNAs, etc.
• Reports contribute to care planning processes.

Notes:

• Registered Nurse (RN).
• Minimum Data Set (MDS) coordinators gather information for reporting mandated information to federal or state agencies.

Slide 20

Integrate Research-Based Specifications into Timely Reports

Weekly Reports:

• Nutrition Report/Weight Summary
• Incontinence Report
• Behavior Report
• Pressure Ulcer Report
• QI "Trigger Report"

Notes:

• The QI Trigger Report indicates those residents that meet criteria indicating at risk for pressure ulcer development and why.

Slide 21

Example: Nutrition Report Stratified by Risk

Provide 'BIG picture' over time, not just snapshot of one shift or one day

• Nutrition Summary:
  • Low meal intake flag
  • Average meal intake for 4 weeks
  • Tube feeding indicator
  • Dietary consult date
  • Weight change
  • Existing pressure ulcer
  • History of resolved ulcer
• Weight Summary:
  • Weight 180 days prior
  • Weight 30 days prior
  • Weight trends
  • Recent weight change
  • 5-10% weight loss past 30 days
  • >10% weight loss past 180 days

Notes:

• Low meal intake flag refers to eating less than 50% of 2 meals in any one day.
• Weight change reports any change in weight.

Slide 22

Step 5: Integrate Reports into Care Planning Processes

• Support clinical team in understanding reports:
  • Education in use of reports.
• Facilitate use of reports in team processes:
  • Multi-disciplinary team processes for care planning.
  • Accountability for best practice implementation and resident outcomes monitoring.

Slide 23

• Step 1: Standardized CAN documentation:
  • Reduce redundancy.
  • Consolidate documentation.
• Step 2: Information Technology:
  • Access timely information.
• Step 3: Prevention Reports:
  • Identify high-risk residents.
• Step 4: QI Team:
  • Front-line team members use reports in daily work.

Notes:

• Illustration features a four step process:
  • Step 1: Presents a standardized paper based CNA document that is used by the CNA to record information once in a consolidated fashion. Information also can be entered directly into a computer.
  • Step 2: Illustrations of Information Technology that can record information digitally. First image shows an electronic pen that can transcribe written information into digital format. Second image shows a docking station with a data entry screen. Both technologies enable the recording of digital information and facilitate access to information in a timely format.
  • Step 3: Picture of two people reading a report on a computer screen. The electronic database is used to generate standardized reports to identify nursing home residents that are at high risk of pressure ulcers.
  • Step 4: Illustration shows three people engaged in a quality improvement team meeting. At the meeting, front-line members review standardized reports to identify and implement opportunities for improvement in prevention of pressure ulcers through improvements in daily work practices.

Slide 24

Impact On Pressure Ulcer QMs: Study Facilities Combined Q4 03 (Pre-Implementation) to Q3 05 (Post-Intervention Review) Combined Facilities Average

• The graph shows the percentage of high risk residents with pressure ulcers among patients at facilities and patients for the national norm from Q3 03-Q3 05.

	Q3 03	Q4 03	Q1 04	Q2 04	Q3 04	Q4 04	Q1 05	Q2 05	Q3 05
Facilities Average	14.0	13.0	12.9	10.6	9.6	9.4	12.0	9.1	8.7
National Form	14.0	14.0	14.0	13.0	13.0	13.0	14.0	14.0	13.0

• Note: Q4 03—Q3 05 % Change = - 33%

Notes:

• QM stands for Quality Measure (CMS—Nursing Home Compare Web site)
• Illustration features two lines showing percentage of high risk residents with pressure ulcers from Quarter 3, 2003 until Quarter 3, 2005.
• The blue line represents the quarterly average percentage of high risk patients with pressure ulcers among patients at facilities in the studies.
• The red line represents the quarterly average percentage of high risk patients with pressure ulcers for the national norm.
• In the first quarter of study the percentage of high risk residents with pressure ulcers in study sites was the same as the national norm. Over time, the study facilities had lower percentage of high risk residents with pressure ulcers. In general there was a downward trend from quarter to quarter except in first quarter of 2005 when the percentage shot from 9.4 to 12.0 due to one outlier study facility. Yet, it dropped to 9.1 in Q2 2005.

Slide 25

On-Time Quality Improvement for Long-Term Care On-Time QI in Long Term Care:  High Risk Pressure Ulcer Quality Measure (17 facilities-Implementation Start Q2-Q4 2006*)

• The graph shows the percentage of High Risk Pressure Ulcers QM for High Implementers, Mod/Low Implementers, All On-Time facilities, and National from QM 05 Q2 to QM 07 Q2.

	QM 05 Q2	QM 05 Q3	QM 05 Q4	QM 06 Q1	QM 06 Q2	QM 06 Q3	QM 06 Q4	QM 07 Q1	QM 07 Q2
High Implementers (n=7) combined QM	11.1	11.0	10.2	13.1	13.0	10.7	9.8	7.0	9.1
Mod/Low Implementers (n=10) combined QM	17.3	14.6	13.3	12.9	13.3	12.8	14.5	13.9	14.4
All On-Time Facilities	14.2	12.8	11.9	12.1	13.2	10.9	10.7	10.2	10.6
National	13.7	13.1	12.9	12	12.8	12.5	12.5	12.8	12.5

• Note: Percent change in QM Q1 06 to Q2 07.

High implementers: -30.7%
Low implementers: +11.5%
All On-Time facilities: -12.9%
National: +4.2%

• Note: 4 facilities implementing Q2-Q4 '06 (high level implementation) did not have reported QM data

Notes:

• High Risk Pressure Ulcer (HRPU)
• On-Time facilities are facilities that have implemented the On-Time QI program by using the standardized CNA documentation tools and integrating the facility feedback reports based on the CNA documentation into their workflow and care planning practices. Average reduction in HRPU QM was 12.9%.
• Facilities with high level of implementation had average reduction in HRPU QM of 30.7%. Compared to facilities with low level of implementation, they took the following steps:
  • Designated a project lead—collaborated with project facilitator to support team participation and confirm On-Time activities were carried out.
  • Multi-disciplinary team participated in On-Time activities
  • Adopted processes for implementing On-Time within own facility process and structure; made clear assignments for team members.
  • Various team members used On-Time reports.
  • Integrated On-Time reports into existing meetings and implemented new processes such as 5-minute stand-up meeting with dietary and CNAs.
• The facilities with moderate level of implementation took clear steps to get started implementing On-Time, but did not fully integrate On-Time reports into daily work of the multi-disciplinary team. These facilities focused on the first step of implementing the redesigned CNA documentation form, using the Completeness Report to improve CNA documentation completeness and accuracy, and started to make a plan to use other reports.
• The facilities with low level of implementation did not commit leadership or team time to implement On-Time and were non-compliant with project activities. Low implementers did not participate on project conference calls or commit to implementation. They had challenges implementing HIT due to lack of IT knowledge internally and/or lack of on-site IT support.

Slide 26

On-Time Quality Improvement for Long-Term Care (Graph) On-Time QI in Long Term Care: Weight Loss Quality Measure (17 facilities-Implementation Start Q2-Q4 2006)

• The graph shows the percentage of weight loss QM for High Implementers, Mod/Low Implementers, All On-Time facilities, and National from QM 05 Q2-QM 07 Q2.

	QM 05 Q2	QM 05 Q3	QM 05 Q4	QM 06 Q1	QM 06 Q2	QM 06 Q3	QM 06 Q4	QM 07 Q1	QM 07 Q2
High Implementers (n=9) combined QM	6.4	8.6	7.1	9.2	9.1	8.4	6.2	6.0	5.8
Low Implementers (n=8) combined QM	7.5	9.5	7.9	6.5	8.7	8.6	7.6	7.6	8.1
All On-Time Facilities	7.0	9.1	7.5	7.7	8.9	8.5	7.0	6.9	7.1
National	9.2	8.6	8.5	9	8.7	8.5	8.4	9.1	8.8

• Note: Percent change in QM Q1 06 to Q2 07

High implementers: -37.2%
Low implementers: +24.3%
All On-Time Facilities: -8.2%
National: -2.2%

Notes:

• On-Time facilities are facilities that have implemented the On-Time QI program by using the standardized CNA documentation tools and integrating the facility feedback reports based on the CNA documentation into their workflow and care planning practices. Average reduction in Weight Loss QM was 8.2%.
• Facilities with high level of implementation had average reduction in weight loss QM of 37.2%. Compared to facilities with low level of implementation, they took the following steps
  • Designated a project lead—collaborated with project facilitator to support team participation and confirm On-Time activities were carried out.
  • Multi-disciplinary team participated in On-Time activities.
  • Adopted processes for implementing On-Time within own facility process and structure; made clear assignments for team members.
  • Various team members used On-Time reports.
  • Integrated On-Time reports into existing meetings and implemented new processes such as 5-minute stand-up meeting with dietary and CNAs.
• The facilities with moderate level of implementation took clear steps to get started implementing On-Time, but did not fully integrate On-Time reports into daily work of the multi-disciplinary team. These facilities focused on the first step of implementing the redesigned CNA documentation form, using the Completeness Report to improve CNA documentation completeness and accuracy, and started to make a plan to use other reports.
  The facilities with low level of implementation did not commit leadership or team time to implement On-Time and were non-compliant with project activities. Low implementers did not participate on project conference calls or commit to implementation. They had challenges implementing HIT due to lack of IT knowledge internally and/or lack of on-site IT support.

Slide 27

On-Time Quality Improvement for Long-Term Care On-Time QI in Long Term Care Quarterly Pressure Ulcer Incidence Rates (acquired in-house)

8 facilities (900 beds)-high level implementation:

• The graph shows the percentage of nursing home residents with in-house acquired pressure ulcers from Q1 06 to Q3 07.

	06Q1	06Q2	06Q3	06Q4	07Q1	07Q2	07Q3
High implementers- Combined rate	4.0%	4.5%	3.6%	4.1%	2.7%	2.6%	2.3%

Notes:

• Illustration presents the percentage of nursing home residents with in-house acquired pressure ulcer over a seven quarter period, Quarter 1, 2006 through Quarter 3, 2007. The baseline value was 4.0%.
• During the three-quarter implementation phase percentage rate of pressure ulcers vacillated from 4.5%, 3.6%, 4.1%. For each of the three quarters post implementation, the percentage rate of pressure ulcers decreased: 2.7%, 2.6%, 2.3%.

Slide 28

On-Time Quality Improvement for Long-Term Care

• Area of Impact:
  • Impact Summary (Dec 2007)
• CNA documentation:
  • Improvements in CNA documentation completeness reported (DON, DSD, Dietary, and MDS nurses)
  • Improvements in CNA documentation accuracy reported (Dietary and MDS nurses)
• Workflow efficiencies:
  • Improvements in identifying residents at risk and communications among team members reported (facility feedback).
  • Reduced time gathering information (Dietary and MDS nurses up to 30 min per review).
• CAN satisfaction:
  • Improvements in CNA satisfaction reported (facility feedback)

Notes:

• Director of Nursing (DON)
• Director of Staff Development (DSD)

Slide 29

Lessons Learned

Focus HIT implementation as a tool to sustain process redesign

• Identify inefficient and efficient steps in existing workflow to focus HIT implementation.

Notes:

• Lessons Learned as reported by nursing home team members in all-facility working sessions and team conference calls.

Slide 30

Lessons Learned

Standardize data elements and redesign workflow prior to HIT implementation:

• Reduce documentation duplication.
• Standardize data focusing on critical data elements.
• Streamline processes.
• Front-line driven; include all caregivers in redesign of workflow and documentation.

Slide 31

Obstacles to Improvement

• HIT development challenges.
• Resistance to changing documentation.
• Staff turnover and/or Administrator and DON turnover.
• Resistance to adopt reports and redesign processes to use reports.
• Resistance to delegate to team members.
• IT knowledge deficit in nursing homes.

Slide 32

Summary

• Start with automating CNA documentation.
• Monitoring compliance is on-going.
• Training needs are on-going.
• HIT by itself does not lead to QI.
• Plan for how information will be used by clinical team.
• Assign a consistent dedicated person or team of resources to manage the HIT implementation.

Slide 33

On-Time Prevention of Pressure Ulcers

• On-Time has been expanded to:
  • 55 Nursing Homes in California, New York, Idaho, Maryland, Arizona, North Carolina, Washington, DC.
• Funded by AHRQ, CHCF.
• Partners: NY State Health Dept, Delmarva Foundation.

Slide 34

Available On-Time Tools

• CNA documentation:
  • http://ahrq.gov/research/ltc/pucnaform.pdf.
• On-Time Reports:
  • http://ahrq.gov/research/ltc/pusamplerep.pdf.
• Video and other resources:
  • http://ahrq.gov/research/ontime.htm.

Current as of December 2008

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Internet Citation:

On-Time Quality Improvement for Long-Term Care: Using Nursing Home IT for Optimal Care Delivery. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090808slides/Horn.htm

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