Implementing Best Practices to Prevent Pressure Ulcers in Nursing Homes

Real-time Optimal Care Plans for Nursing Home QI.  Dates: 2002-2006.  Funded by AHRQ Partnership for Quality Cooperative Agreement.  The goals of this practiced based evidence (PBE) study are to design, support, and facilitate change that, according to evidence from the National Pressure Ulcer Long-Term Care Study and other published sources, is predicted to lead to documented improvements in health care quality and ensure that these improvements become part of the ongoing practice of health care providers and clinicians in long-term care. 

Nursing Home IT:  Optimal Medication and Care Delivery.  Dates: 2004-07.  Funded by AHRQ Challenge Grants and Partnerships Program Cooperative Agreement. The goals of this practiced based evidence (PBE) study are to implement a health information technology (HIT) system with added best-practices decision support modules in seven nursing homes and evaluate the impact on care processes, resident health outcomes, and staff efficiency and satisfaction. 

On-Time Prevention of Pressure Ulcers: Partnering with Quality Improvement Organizations.  Dates: 2005-07.  Funded by AHRQ.  The aim of this project is to (1) partner with Quality Improvement Organizations (QIOs) and at least 30 long-term care providers to implement an evidence-based practice quality change strategy developed in the “Real Time Optimal Care Plans for Nursing Home QI” project, and (2) track the impact of this strategy on the rate of pressure ulcers acquired by high risk residents as well as on workflow in key operational processes:  documentation, quality reporting, and care planning.

AHRQ-funded projects help subsidize nursing home costs to redesign daily operations and improve quality

 Preventing Pressure Ulcers: Partnering with Quality Improvement Organizations

I.                   Are you ready and interested in redesigning clinical workflow while improving quality of care?

The ISIS project team has worked with nursing home facilities for the past 10 years to standardize documentation and redesign clinical workflow resulting in operational efficiencies, improved communication among clinical team members, and 33% reduction in pressure ulcer QM in 18 months from before to after implementation. 

II.                Why should a nursing home facility consider implementing this QI initiative?

1.       Streamline CNA and Wound tracking documentation and reduce workflow inefficiencies. Multi-disciplinary teams eliminate redundant documentation across disciplines, reduce paperwork, improve accuracy of information, and improve communication among multi-disciplinary care teams. 

RESULTS:           

-          Reduce # documentation forms for CNAs approximately 50%

-          Reduce CNA time looking for documentation book

-          Reduce time to compile reports for State Regulators and MDS

-          Reduce time for Wound RN to summarize and report data 

2.       Decrease pressure ulcer development and hence reduce costs associated with pressure ulcer treatment.  Decreased high-risk pressure ulcer rate approximately 33% in 18 months.  Long term care treatment costs for a pressure ulcer average in FY 05 dollars (not including hospitalization) are:

-        $1,932 per Stage 1

-        $7,170 per Stage 2

-        $11,534 per Stage 3

-        $14,077 per Stage 4

If prevent one Stage 3 ulcer or two Stage 2 ulcers, savings will more than cover cost of project for one year. 

3.       Improve State Survey process and documentation completeness, while integrating CMS and State Regulatory reporting requirements into daily workflow. 

4.       Increase staff accountability and satisfaction by including front-line workers in QI efforts, comprehensive documentation at point of care, and improving communication among care team. 

5.       Take steps toward an electronic health record (EHR):  Organization of clinical data elements and process redesign are two initial steps to prepare for implementation of an EHR.  If your facility is considering investment in an EHR, participation in this effort will promote staff adoption of technology, ensure future technology will support clinical documentation and workflow, and streamline the implementation process.

 III.             III. What is different about this approach to QI?

·         Integrates sustainable quality improvement into daily operations.  Translate evidence-based best practices for pressure ulcer prevention into daily documentation and establish processes for sustainable quality improvement in nursing homes.  The focus is redesign of daily workflow, team communication, and integration of clinical report information into care planning; project activities are integrated into versus added on to daily work. 

·         Streamlines documentation with focus on critical data elements and information flow. Multi-disciplinary teams work to eliminate redundant documentation across disciplines by standardizing and reducing total number of daily documentation forms and eliminating multiple sources of documentation.

·         Involves front-line staff.  Establish multi-disciplinary design and implementation teams, including CNAs, nurses, dieticians, wound nurses, MDS nurses, social services, and restorative care.  Strengthen relationships across disciplines and improve effectiveness of multi-disciplinary team collaboration and communication.

·         Translates documentation into data.  Migrate from a paper/form document environment toward a data culture environment. 

·         Translates data into multi-disciplinary clinical reports.  Migrate from a culture of accessing quarterly reports for retrospective analysis to using weekly clinical reports by multi-disciplinary team for timely resident care planning. 

This project is based on 10 years of practice-based evidence research to determine better interventions to prevent pressure ulcers and ways to successfully implement better interventions consistently in nursing home daily work.