1

On-Time Quality Improvement for Long On-Time Quality Improvement for Long Term CareTerm Care

Thursday, September 27, 2007; 1:30 – 3pmThursday, September 27, 2007; 1:30 – 3pm Susan D. Horn, PhDSusan D. Horn, PhD

Institute for Clinical Outcomes ResearchInstitute for Clinical Outcomes Research699 E. South Temple, Suite 100 699 E. South Temple, Suite 100

Salt Lake City, Utah 84102-1282Salt Lake City, Utah 84102-1282801-466-5595 (T) 801-466-6685 (F)801-466-5595 (T) 801-466-6685 (F)

shorn@isisicor.comshorn@isisicor.com

Redesigning Work Processes to Improve Resident Safety and Quality

2

Long Term Care and AHRQLong Term Care and AHRQ

GoalGoalBroad improvements in quality at a national scaleBroad improvements in quality at a national scale

StrategyStrategyThrough adoption of innovations and tools thatThrough adoption of innovations and tools that

Foster evidence-based interventionsFoster evidence-based interventions Encourage implementation in day to day practiceEncourage implementation in day to day practice Disseminate broadlyDisseminate broadly

3

BackgroundBackground

Pressure ulcer (PrU) rates remain high Pressure ulcer (PrU) rates remain high Despite guidelinesDespite guidelines Despite trainingDespite training

NH staff know how to prevent PrUsNH staff know how to prevent PrUs Need to identify high risk residents on weekly basisNeed to identify high risk residents on weekly basis Knowledge not integrated into day to day practice Knowledge not integrated into day to day practice Entire multi-disciplinary team needs to coordinate Entire multi-disciplinary team needs to coordinate

care better for high risk residents (including CNAs)care better for high risk residents (including CNAs)

4

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

• 6 long-term care provider organizations6 long-term care provider organizations

• 109 facilities109 facilities

• 2,490 residents studied2,490 residents studied

• 1,343 residents with pressure ulcer; 1,147 at risk1,343 residents with pressure ulcer; 1,147 at risk

• 70% female, 30% male70% female, 30% male

• Average age = 79.8 yearsAverage age = 79.8 yearsFunded by Ross Products Division, Abbott LaboratoriesFunded by Ross Products Division, Abbott Laboratories

5

Long Term Care CPI ResultsLong Term Care CPI ResultsOutcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

GeneralGeneral AssessmentAssessment

IncontinenceIncontinenceInterventionsInterventions

NutritionNutritionInterventionsInterventions

StaffingStaffingInterventionsInterventions

+ Age + Age 85 85

+ Male+ Male

+ Severity of Illness+ Severity of Illness

+ History of PU+ History of PU

+ Dependency in + Dependency in >= 7 ADLs>= 7 ADLs

+ Diabetes+ Diabetes

+ History of tobacco use+ History of tobacco use

+ Dehydration+ Dehydration

+ Weight loss+ Weight loss

+ Mechanical devices + Mechanical devices for the containment of for the containment of urine (catheters) urine (catheters)

- Disposable briefs- Disposable briefs

- Toileting Program- Toileting Program

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

MedicationsMedications

- SSRI + Antipsychotic

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

- Fluid Order- Fluid Order- Nutritional Supplements- Nutritional Supplements

• standard medicalstandard medical

- Enteral Supplements- Enteral Supplements• disease-specificdisease-specific• high calorie/high high calorie/high proteinprotein

6

Common Challenges Across FacilitiesCommon Challenges Across Facilities

1.1. Inefficient ProcessesInefficient Processes

2.2. Incomplete DocumentationIncomplete Documentation

3.3. CNAs: untapped resourceCNAs: untapped resource

4.4. Communication Breakdowns / Lack Communication Breakdowns / Lack Standard ProcessesStandard Processes

5.5. Clinical Decision Support NeedsClinical Decision Support Needs

7

AHRQ-funded InitiativesAHRQ-funded Initiatives

• Partnership for Quality Project: ‘Partnership for Quality Project: ‘Real-time Optimal Care Real-time Optimal Care Plans for Nursing Home QI’Plans for Nursing Home QI’. 2002-2007.. 2002-2007.

• Transforming Health Care Quality through Information Transforming Health Care Quality through Information Systems: ‘Systems: ‘Nursing Home IT: Optimal Medication and Care Nursing Home IT: Optimal Medication and Care Delivery’Delivery’. 2004-2007.. 2004-2007.

• ‘‘On-Time Prevention of Pressure Ulcers – Collaboration with On-Time Prevention of Pressure Ulcers – Collaboration with QIOs’QIOs’. 2005-2007.. 2005-2007.

• Knowledge TransferKnowledge Transfer: Capture and Spread Promising : Capture and Spread Promising Practices and Lessons Learned from Implementing the “Practices and Lessons Learned from Implementing the “Real-Real-time Prevention of Pressure Ulcerstime Prevention of Pressure Ulcers” project. 2006-2007. ” project. 2006-2007.

8

Background: Progression of WorkBackground: 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”

9

History of On-Time QI for LTCHistory of On-Time QI for LTC

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

10

Prevention Reports

Standardized CNA documentation

QI Team

Access timely information

Reduce redundancy

Consolidate documentationFront-line team members use reports in daily work

Identify high-risk residents

Information TechnologyStep 1

Step 2 Step 3

Step 4

11

ImplementImplement: Workflow Redesign : Workflow Redesign Focused to Reduce PrUFocused to Reduce PrU

1.1. CNA Daily WorkflowCNA Daily Workflow» Standardized data in documentation flow sheetsStandardized data in documentation flow sheets» Improved communication with clinical team (RN, CNA, Improved communication with clinical team (RN, CNA,

MDS, Dietary)MDS, Dietary)

2.2. Wound NurseWound Nurse » Standardized data in PrU documentationStandardized data in PrU documentation» Timely access to compiled informationTimely access to compiled information

3.3. Timely Information for Care Planning ProcessesTimely Information for Care Planning Processes» Identify residents at risk for pressure ulcer developmentIdentify residents at risk for pressure ulcer development» Access to summarized information for clinical decision-Access to summarized information for clinical decision-

makingmaking» Shorten response time between identification of resident need Shorten response time between identification of resident need

and interventionand intervention

12

Timely Feedback ReportsTimely Feedback Reports

Access to summarized information for clinical Access to summarized information for clinical decision-makingdecision-making» Nutrition, Behavior, High risk triggers, Pressure Ulcer Nutrition, Behavior, High risk triggers, Pressure Ulcer

monitoring reportsmonitoring reports

Improve response time between identification of Improve response time between identification of resident need and interventionresident need and intervention» Identify residents at risk for pressure ulcer developmentIdentify residents at risk for pressure ulcer development

Transform from paper to data cultureTransform from paper to data culture» Link reports to documentation elementsLink reports to documentation elements

13

Decision Making ReportsDecision Making Reports• Documentation Completeness ReportDocumentation Completeness Report. . Summary of Summary of

CNA documentation completeness ratesCNA documentation completeness rates. . • Nutrition ReportNutrition Report. . Displays average meal intake, Displays average meal intake,

resident diet, supplements, resident weight status resident diet, supplements, resident weight status (presence of weight gain/loss), last diet consult date, (presence of weight gain/loss), last diet consult date, history of pressure ulcer indicator, and presence of history of pressure ulcer indicator, and presence of pressure ulcer. pressure ulcer.

• Behavior ReportBehavior Report. . Displays the total number of times a Displays the total number of times a resident exhibits a behavior by shiftresident exhibits a behavior by shift..

• Priority Resident ReportPriority Resident Report. . Displays residents who are Displays residents who are at risk for pressure ulcer development and high priority at risk for pressure ulcer development and high priority for staff focus.for staff focus.

14

• Nutrition SummaryNutrition Summary» Meal intake for 4 weeksMeal intake for 4 weeks» Fluid intake for 4 weeksFluid intake for 4 weeks» Diet orderDiet order» Supplement product Supplement product » Weight change since last weekWeight change since last week» Existing pressure ulcerExisting pressure ulcer» History of resolved ulcerHistory of resolved ulcer

• Weight SummaryWeight Summary» Weight 180 days priorWeight 180 days prior» Weight 30 days priorWeight 30 days prior» Weight for each of past 4 weeksWeight for each of past 4 weeks» Weight change since last week Weight change since last week » 5-10% weight loss past 30 days5-10% weight loss past 30 days» >10% weight loss past 180 days>10% weight loss past 180 days

Ex: Nutrition ReportEx: Nutrition Report

Stratified by RiskStratified by Risk

Provide ‘BIG picture’ over time, not just snapshot of one shift or one dayProvide ‘BIG picture’ over time, not just snapshot of one shift or one day

15

ResultsResults Decrease Pressure Ulcer DevelopmentDecrease Pressure Ulcer Development Increase Adherence to Best PracticesIncrease Adherence to Best Practices Increase Staff Accountability and SatisfactionIncrease Staff Accountability and Satisfaction

– Inclusion of front-line workers in QI effortsInclusion of front-line workers in QI efforts– Comprehensive documentation at point of careComprehensive documentation at point of care– Communication among care team improvedCommunication among care team improved

Reduce InefficienciesReduce Inefficiencies– # documentation forms for CNAs# documentation forms for CNAs– CNA time looking for documentation bookCNA time looking for documentation book– Time to compile reports for State Regulators and MDS Time to compile reports for State Regulators and MDS – Time for Wound RN to summarize and report dataTime for Wound RN to summarize and report data

Improve State Survey ProcessImprove State Survey Process Establish a foundation for EHREstablish a foundation for EHR

16

Q4 03 (Pre-Implementation) to Q3 05 (Post-Intervention Review) Combined Facilities Average

0.0

5.0

10.0

15.0

20.0

% H

igh

Ris

k R

esid

ents

Facilities Average 14.0 13.0 12.9 10.6 9.6 9.4 12.0 9.1 8.7

National Norm 14.0 14.0 14.0 13.0 13.0 13.0 14.0 14.0 13.0

Q3 03 Q4 03 Q1 04 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05

Impact On Pressure Ulcer QMsImpact 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%

17

Key Program BenefitsKey Program Benefits

Improve QualityImprove Quality Improve clinical decision making: integrate reports Improve clinical decision making: integrate reports

into day-to-day workflowinto day-to-day workflow Identify residents at high risk early Identify residents at high risk early Timely communication among multi-disciplinary Timely communication among multi-disciplinary

team membersteam members

QI CollaborationQI Collaboration Receive technical assistance from QI expertsReceive technical assistance from QI experts Collaborate with peers to share experiences and best Collaborate with peers to share experiences and best

practicespractices

18

Key Program Benefits (cont)Key Program Benefits (cont)Improve CNA DocumentationImprove CNA Documentation Consolidate current documentationConsolidate current documentation Standardize data elements and eliminate redundancyStandardize data elements and eliminate redundancy Audit and train for accuracyAudit and train for accuracyGain EfficiencyGain Efficiency Reduce time spent searching for multiple sources of Reduce time spent searching for multiple sources of

informationinformation Automated reports replace manual compilation of Automated reports replace manual compilation of

resident informationresident informationIncrease MoraleIncrease Morale Empower multidisciplinary teams with CNAs as important Empower multidisciplinary teams with CNAs as important

membersmembers CNAs see importance of their workCNAs see importance of their work

19

What is different about this approach?What is different about this approach?

1.1. Integrates sustainable quality improvement Integrates sustainable quality improvement into daily operationsinto daily operations. .

Streamlines documentation with focus on Streamlines documentation with focus on critical data elements and information flow. critical data elements and information flow.

Translates documentation data into multi-Translates documentation data into multi-disciplinary clinical reports.disciplinary clinical reports.

2.2. Involves front-line staffInvolves front-line staff3.3. Links QI and HITLinks QI and HIT