HIT Implementation

1
HIT Implementation Quality Improvement in
Nursing Homes

• Siobhan Sharkey
• Principal
• Health Management Strategies, Inc
• ssharkey_at_hmstrat.com

2
Discussion Objectives

• Describe links between translating best practices
  into daily work and HIT implementation.
• Present updates and lessons learned to date on
  several AHRQ-funded initiatives

3
Progression of Work

• AHRQ-funded
• Real-Time Optimal Care Plans
• Translate evidence-based best practices into
  daily work

• AHRQ-funded Transforming Healthcare Quality
  through IT
• Support HIT adoption in LTC
• Integrate Real-Time knowledge in IT

National Pressure Ulcer Long Term Care Study
AHRQ-funded On-Time Pressure Ulcer Prevention
Partnering with QIOs
Integrate with HIT
Research
Implement
Disseminate
1996
2003
2005
2004
4
Partners

• Nursing home facilities
• 20 facilities
• Plan to increase to 45 facilities by July 06
• State QIOs Trade Associations
• CA, MD/DC, ID, AZ, TX, NC
• California Health Care Foundation (CHCF)

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Research Based Best Practices

• Nursing Home Study (NPULS) 1996
• 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

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Background NPULS
Significant Associations with Development of
Pressure Ulcer
General Assessment
Incontinence Interventions
Pressure Relief Interventions
Staffing Interventions
- RN hours per resident day gt0 .25 - CNA hours
per resident day gt 2 -LPN hours per resident day
gt0.75
Age ? 85 Male Severity of Illness History
of PU Dependency in gt 7 ADLs Diabetes
History of tobacco use
Mechanical devices for the containment of urine
(catheters) - Disposable briefs - Toileting
Program
Static pressure reduction protective device
Positioning protective device
Medications
- SSRI Antipsychotic
7
Background NPULS
Nutritional Care
Nutritional Assessment
Nutritional Interventions
Dehydration signs and symptoms low systolic
blood pressure, high temperature, dysphagia, high
BUN, diarrhea, dehydration Weight Loss gt5
in last 30 days or gt10 in last 180 days

• - Dietary consult
• - Fluid Order
• - Nutritional Supplements
• standard medical
• - Enteral Supplements
• disease-specific
• high calorie/high
• protein

Horn et al, J. Amer Geriatr Soc March 2004
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Implementation In Daily Work
Real-Time

• Establish an implementation team at each facility
• Define core data elements standardize
  documentation for CNA and Wound RN to include
  best practice elements
• Redesign clinical workflow
• Integrate feedback reports into care planning
• Improve care team communication using reports as
  prompt / guide
• Assess impact workflow efficiencies clinical
  outcomes
• Sustain using HIT

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Timely Feedback Reports

• Access to summarized information for clinical
  decision-making
• Nutrition, Behavior, High risk triggers, Pressure
  Ulcer monitoring reports
• Improve response time between identification of
  resident need and intervention
• Identify residents at risk for pressure ulcer
  development
• Transform from paper to data culture
• Link reports to documentation elements

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Ex Nutrition Report
Provide BIG picture over time, not just
snapshot of one shift or one day

• Nutrition Summary
• Risk stratification Decreased meal intake and
  weight loss
• Avg. meal intake for 4 weeks
• Fluid intake for 4 weeks
• Supplement product
• Weight change since last week
• Date of dietary consult
• Existing pressure ulcer(s)

• Weight Summary
• Weight 180 days prior
• Weight 30 days prior
• Weight for each of past 4 weeks
• Weight change since last week
• 5-10 weight loss past 30 days
• gt10 weight loss past 180 days

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HIT Workflow Redesign

• Determine assignments
• Who will access each report and how is it used
• How often
• Integrate reports into existing processes
• Reports used in existing QI meetings (replace
  manual reports)
• Establish new processes
• Weekly stand-up meetings to review residents at
  high risk
• Reports used as part of shift report
• Management monitoring reports and discussing with
  unit managers / team leads

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Results

• Decrease Pressure Ulcer Development
• Increase Adherence to Best Practices
• Increase Staff Accountability and Satisfaction
• Inclusion of front-line workers in QI efforts
• Comprehensive documentation at point of care
• Communication among care team improved
• Reduce Inefficiencies
• documentation forms for CNAs
• CNA time looking for documentation book
• Time to compile reports for State Regulators and
  MDS
• Time for Wound RN to summarize and report data
• Improve State Survey Process
• Establish a foundation for EHR

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Impact On Pressure Ulcer QMs Study Facilities
Combined
Q4 03 Q3 05 Change - 33
Source CMS Nursing Home Compare Facility QM
data reports
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Case Study Examples

• 4 Facilities in OH
• Decreased high risk pressure ulcer QM 21 from Q4
  03 to Q3 05.
• Developed standard documentation across all 4
  facilities that includes best practice elements.
• Project provided foundation for future IT
  implementation All the units that used
  Real-Time documentation on paper before the IT
  implementation rapidly adopted IT.
• Facility in SD
• Decreased high risk pressure ulcer QM 33 from Q4
  03 to Q3 05.
• Decreased incidence of Stage 3 and Stage 4 ulcers
  translated into cost savings of 80,000.
• CNA documentation completeness rates are over 95
  consistently with new documentation form.

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HIT Implementation Grant
Objectives

• Support implementation of HIT solutions in long
  term care
• Integrate evidence-based research into HIT
  solutions
• Work with clinical teams to address how to use
  HIT to impact clinical decision making and
  communication practices
• Identify HIT implementation best practices

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Common Themes Across Facilities

• Inefficient Processes
• Incomplete Documentation
• CNAs untapped resource
• Communication Breakdowns
• Clinical Decision Support Needs

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Inefficient Processes
74 of CNAs on average have difficulty completing
documentation before end of shift
26 Avg
Source Sample survey results from 7 facilities,
250 CNAs, in 5 states.
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Inefficient Processes
78 of CNAs on average document the same
information in more than one place each day
22 Avg
Source Sample survey results from 7 facilities,
250 CNAs, in 5 states.
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CNAs, a Resource To Be Leveraged?
46 CNAs on average feel their work is valued.
46 Avg
Source Sample survey results from 7 facilities,
250 CNAs, in 5 states.
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Communication Breakdown
CNAs report . Average of 63 report that I
understand all of what needs to be done for the
resident before I start work.
63 Avg
21
Clinical Decision Support Needs
27 - 75 of RNs report ... At the
beginning of my shift, I am aware of all
residents on my unit who have a pressure
ulcer(s).
17 - 40 of RNs report . At the
beginning of my shift, I am aware of residents
who are at risk of developing a pressure ulcer
Source Sample baseline results at 4 facilities
total of 70 RNs
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Clinical Decision Support
Costs of treating a pressure ulcer demonstrate
the potential to impact quality and cost
Source The cost of pressure ulcers in the UK,
Age and Ageing, 2004
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How Can Technology Impact Quality?

• Translate data into information to support
  clinical decisions care planning
• Access to right information when needed
• Timely Reports queries vs. quarterly (e.g.MDS)
• Alerts, Reminders, Prompts
• Monitor Compliance
• Streamline workflow
• Standardize/streamline data
• Improve communications

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Lessons Learned Key Success Factors for
Implementation

• Focus use of HIT as a tool to sustain quality and
  operational improvement
• Standardize data elements and use of redesigned
  forms facilitate CNA adoption of HIT
• Redesign workflow prior to HIT implementation
• Demonstrate value of data culture
• Establish partnerships and local champions
• Dedicate project management resources

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Lessons LearnedHIT Products for LTC

• Current HIT products for LTC require modification
  to incorporate best practice data elements
• Reports often lack clinical decision-making
  capabilities
• Modification to existing products can be costly
  and time consuming

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QI is Primary Objective?

• Define specific HIT requirements to meet quality
  objective
• decision support reports
• team communication
• alerts or prompts
• Establish implementation plan to include workflow
  redesign to incorporate HIT as tool for quality
  improvement