Prevention/Care Management, 2012

St. Barnabas Rehabilitation and Continuing Care Center Implements On-Time Quality Improvement in Long-Term Care

January 2012

St. Barnabas Rehabilitation and Continuing Care Center, a 199-bed skilled nursing facility in south Bronx, NY, 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 by 56 percent, from 4.2 percent prior to implementation to 1.8 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.

All 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. The CNAs at St. Barnabas, in an effort to be compliant with all industry regulations, had historically been overburdened with paperwork. Implementation of the On-Time Program resulted in a 30 percent reduction of paperwork for CNAs.

In addition to the reduction in paperwork across the continuum of care, the primary impact was the improvement in the integration of clinical information and communication between the frontline caregivers—the CNAs—and the dietary staff, social workers, and nursing staff. This resulted in meaningful changes in resident care plans and more timely referrals and treatment.

Zaldy Mateo, RN, Assistant Nursing Home Administrator, says, "The On-Time Program motivated the entire interdisciplinary team to be more engaged. That engagement has been the key component in the success of the program at St. Barnabas. The program brought members of the team to discussions of health care issues that previously were assumed to be the domain of individual disciplines." During the "5-minute standup" huddles that have been held since the program was implemented, CNAs visibly advocated for their residents, a new behavior that developed subsequent to the implementation of the On-Time Program.

Many staff were initially apprehensive about implementing the program because it appeared at the outset to be more labor- and time-intensive. Initially, the CNAs and other members of the interdisciplinary team did put in more time attending meetings, phone conferences, and formal training. Afterward, the general consensus among team members was that the program was not an added burden to their daily routine but, in fact, a practical approach to streamline their documentation and communication. Frontline caregivers acknowledged that the startup activities were worthwhile.

From the administration's viewpoint, the most rewarding aspect of the On-Time Program was the significant involvement of the facility CNAs. Mateo says, "The CNAs owned the project. The On-Time Program made their work more efficient, productive, and rewarding. CNAs have assumed their rightful roles as vital members of the interdisciplinary team who most often—if not all the time—have the most salient information about the functional status of the residents."

Impact Case Study Identifier: CDOM-12-01
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: Process Improvement Study Guide. June 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/ltc/puprocessimpr.htm.

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.

Return to Contents
Proceed to Next Section