On-Time Quality Improvement for Long-Term Care

1. 1 On-Time Quality Improvement for Long-Term Care Using Nursing Home IT for Optimal Care Delivery Presentation to AHRQ Annual Conference Track 1. HIT Improving Quality of Care for Vulnerable Populations Through HIT September 8, 2008 by 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 Health Information Technology (HIT)Health Information Technology (HIT)

2. 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 Nursing Home (NH) Quality Improvement (QI) Nursing Home (NH) Quality Improvement (QI)

3. 3 Integrate evidence-based research on pressure ulcer prevention into long term care daily practice Implement pre-IT and HIT solutions in long term care to support redesigned processes and improved outcomes Identify HIT implementation best practices NURSING HOME IT: OPTIMAL CARE DELIVERY Pressure ulcer (PrU) Outcomes to be improved upon include lower pressure ulcer rates, faster healing of pressure ulcers, and less weight loss. Pressure ulcer (PrU) Outcomes to be improved upon include lower pressure ulcer rates, faster healing of pressure ulcers, and less weight loss.

4. 4 Background � Clinical Quality 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) 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.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.

5. 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 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 CMS for nursing home reporting.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 CMS for nursing home reporting.

6. 6 Steps to Success Research-based foundation Partnerships; bottom-up approach Standardized comprehensive documentation Timely feedback reports Integrate into daily workflow and care planning Incorporate into IT � explicit link between IT and QI 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.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.

7. 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 Funded by Ross Products Division, Abbott Laboratories

8. 8 Long Term Care CPI ResultsOutcome: Develop Pressure Ulcer 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 nurseFindings 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

9. 9 Effects of Nutritional Supportin Long Term Care 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.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.

10. 10 Bladder Incontinence Management in Long Term Care 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.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.

11. 11 Step 2: Partnerships Empower all members of a facility team Front-line workers actively participate in QI activities Share across facilities Share what has worked in your facility with other facilities implementing the program with the same or different HIT tools.Share what has worked in your facility with other facilities implementing the program with the same or different HIT tools.

12. 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

13. 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

14. 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 Continuous Quality Improvement (CQI)Continuous Quality Improvement (CQI)

15. 15 Illustration of digital pen in a medical form.Illustration of digital pen in a medical form.

16. 16 Digital Pen Systems In the absence of existing HIT, 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.

17. 17 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.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.

18. 18 Example technology #2 Electronic Medical Record Profile: Add CNA standardized documentation data elements into EMR 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 Electronic Medical Record (EMR)Electronic Medical Record (EMR)

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

20. 20 The QI Trigger Report indicates those residents that meet criteria indicating at risk for pressure ulcer development and why.The QI Trigger Report indicates those residents that meet criteria indicating at risk for pressure ulcer development and why.

21. 21  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 Low meal intake flag refers to eating less than 50% of 2 meals in any one day. Weight change reports any change in weight.Low meal intake flag refers to eating less than 50% of 2 meals in any one day. Weight change reports any change in weight.

22. 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

23. 23 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. 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.

24. 24 QM stands for Quality Measure (CMS � Nursing Home Compare website) 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. QM stands for Quality Measure (CMS � Nursing Home Compare website) 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.

25. 25 On-Time Quality Improvement for Long-Term Care 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. 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.

26. 26 On-Time Quality Improvement for Long-Term Care 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.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.

27. 27 On-Time Quality Improvement for Long-Term Care 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%. 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%.

28. 28 On-Time Quality Improvement for Long-Term Care Director of Nursing (DON) Director of Staff Development (DSD)Director of Nursing (DON) Director of Staff Development (DSD)

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

30. 30 Standardize data focusing on critical data elements Reduce documentation duplication Streamline processes Front-line driven; include all caregivers in redesign of workflow and documentation Lessons Learned

31. 31 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 Obstacles to Improvement

32. 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

33. 33 On-Time Prevention of Pressure Ulcers 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

34. 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/puwebcast.htm