Prevention/Care Management, 2012

Schuyler Ridge Nursing Home Implements On-Time Quality Improvement in Long-Term Care

January 2012

Schuyler Ridge Nursing Home, a 120-bed long-term care facility in New York, implemented an AHRQ-funded program that focuses on integrating health information technology into nursing homes to prevent pressure ulcers. As a result of implementing the "On-Time Quality Improvement in Long-Term Care" (On-Time) Program, the percentage of residents with new pressure ulcers decreased from 6.5 percent prior to implementation to 2 percent in the year following implementation.

The On-Time Program integrates clinical reports into nursing home workflow using health information technology to identify residents at risk for pressure ulcer development. Using these reports, participating facilities implement team-based strategies with the help of a facilitator to improve risk identification and care planning. These strategies allow staff to intervene in a timely manner with at-risk residents to reduce the incidence of pressure ulcers. On-Time reports are based on certified nursing assistant (CNA) documentation. A preliminary program step is streamlining and standardizing CNA documentation to support these tools.

Schuyler Ridge uses the On-Time reports at its weekly "5-minute standup" meetings with multidisciplinary team members. Staff use the meetings and reports to identify residents at high risk of developing pressure ulcers and adjust care plans accordingly. The facility rotates the time of the meetings each week in order to accommodate both day and evening shift CNAs and nurses.

The Schuyler Ridge facility incorporated the On-Time reports into its health information system, called CareTracker. Having the On-Time reports in the CareTracker system makes developing and updating the residents' care plans easier and more accurate. Information can be entered at any one of seven touch-screen kiosks in the facility: two at each of the three nurses' stations and one in the dining room.

According to Sandra Smith, Schuyler Ridge Executive Director, "Using kiosks was a huge change for the CNAs, who were used to paper-based recordkeeping done at the end of their shifts. However, staff quickly learned to like it."

Since implementation of the On-Time Program, documentation completeness rates at Schuyler Ridge are typically 98 to 99 percent on all shifts. Prior to implementation of the program, the paper documentation completeness rate was 70 to 80 percent.

Smith notes, "The issue with the paper documentation was not only incomplete records but how factual the documentation was when compared with the actual care being provided. This was due, in part, to staff waiting until the end of the shift to enter their information. Additionally, because staff could see the documentation from the previous shift, the question arose as to whether they were just checking off the same boxes as the previous shift. With the On-Time Program in place, the level of information now documented is much more thorough and a more accurate reflection of the residents' care needs."

Leslie Campbell, Unit Manager, says, "The On-Time Program also helped staff to better understand how weight loss and behaviors affect skin integrity. The reports help catch 'medium-risk' residents before they become 'high risk' for pressure ulcers. Additionally, staff are excited to know that management is listening to them and taking their suggestions seriously. It has promoted a better team approach to the care of our residents."

Prior to using the On-Time reports, CNAs may have noticed a reddened area on a patient during dressing or bathing, but this information was not always communicated to the correct person. CNAs now enter the information into CareTracker at the kiosk, and the reports help identify an average of two to three new high-risk residents weekly. The unit managers review completeness throughout the shift using CareTracker compliance reports. In addition, the On-Time Completeness Report is reviewed weekly to monitor trends.

Smith concludes, "The On-Time Program provided the framework to deploy the appropriate resources and staff to high-risk residents. This ensures timely intervention, helps improve outcomes, and prevents potential negative clinical outcomes."

More information about the "On-Time Quality Improvement for Long-Term Care" Program can be found at: http://www.ahrq.gov/research/ltc/puprocessimpr.htm.

Impact Case Study Identifier: CDOM-12-02
AHRQ Products: On-Time Quality Improvement in Long-Term Care
Topic(s): Long-Term Care, Health Information Technology
Scope: New York

On-Time Quality Improvement for Long-Term Care: Download Information. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/ontime.htm.

Sharkey S, Hudak S, Horn SD, Spector W. Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: the On-Time Quality Improvement Program to Prevent Pressure Ulcers. Adv Skin Wound Care 2011;24(4):182-188.

Horn SD, Sharkey SS, Hudak S, Gassaway J, James R, Spector W. Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports. Adv Skin Wound Care 2010;23(3):120-131.

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