Integrating Quality Improvement into

1

• Integrating Quality Improvement into
• Health IT
• Pressure Ulcer Prevention

Siobhan SharkeyInstitute of Clinical Outcomes
Research Sandra HudakHealth Management
Strategies Alan GibsonCountry Villa Health
Services Eileen WolfardLumetra
2
On-Time Prevention of Pressure Ulcers
Partnering with Quality Improvement
OrganizationsAHRQ-funded2005-2007

• Siobhan Sharkey
• Institute for Clinical Outcomes Research
• ssharkey_at_isisicor.com
• Sandy Hudak
• Health Management Strategies
• shudak_at_hmstrat.com

3
Problem

• Evidence for prevention of pressure ulcers exists
• AHRQ/AMDA guidelines
• Training is being done
• Not implemented and sustained in day to day
  practice

4
Objectives

• Share practical strategies and lessons learned to
  incorporate evidence-based best practices into
  everyday workflow.
• Present Nursing Home Case Study
• Present QIO Perspective

5
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

6
Approach Care Management At the Front Line

• Establish indicators of high risk
• Standardize assessment process to categorize and
  prioritize patient needs

• Increase time spent proactive care planning
• Improve link between care planning and daily care
  activities
• Maximize collaborative working session and team
  problem-solving with clear, accountable follow
  up/action items

• Increase early interactions with patient / family
  to set expectations
• Increase RN role facilitating and coordinating
  activities of multi-disciplinary team (versus
  doing it themselves)

Team Communication
Resident/Family Communication

• Increase early interactions with patient / family
  to set expectations

• Information feedback on process and outcomes
  measures to link to quality improvement efforts

Monitoring/ Evaluating
7
Intervention

• CNA Daily Documentation and Workflow
• Standardized data in documentation flow sheets
  includes best practice elements
• Improved communication with clinical team (RN,
  CNA, MDS, Dietary)
• Wound Nurse PU Tracking Documentation
• Standardized data in documentation
• Timely access to compiled information
• Clinical Reports Timely Information for Care
  Planning
• Identify residents at risk for pressure ulcer
  development
• Access summarized information for clinical
  decision-making
• Shorten response time between identification of
  resident need and intervention

8
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

9
Decision Making Reports

• Documentation Completeness Report. Summary of CNA
  documentation completeness rates.
• Incontinence Care Report. Displays information
  related to resident incontinence status, care
  provided by the frequency of incontinence,
  presence of existing pressure ulcer.
• Nutrition Report. Snapshot of average meal
  intake, resident diet, supplements, resident
  weight status (presence of weight gain/loss),
  last diet consult date, history of pressure ulcer
  indicator, and presence of pressure ulcer.
• Behavior Report. Displays the total number of
  times a resident exhibits a behavior by shift.
• Priority Resident Report. Displays residents who
  are at risk for pressure ulcer development and
  high priority for staff focus.

10

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

• Nutrition Summary
• Average meal intake for 4 weeks
• Fluid intake for 4 weeks
• Supplement use
• Dietary consult date
• Weight change since last week
• Existing pressure ulcer
• History of resolved ulcer

• 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
• Psychiatric medications received

11
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

12
Impact On Pressure Ulcer QMs Study Facilities
Combined
Q4 03 Q3 05 Change - 33
Source CMS Nursing Home Compare Facility QM
data reports
13
Approach Overview
Month 1
1
Finalize IT Plans
Month 4-12
Month 1-3
Month 12-18
2
3
4
Facility-wide implementation
Review progress Assess impact
Plan for Workflow Redesign Pilot implementation

• Implement facility-wide
• IT training / orientation
• Education of staff new forms, reports,
  communications processes

Integrate into Operations

• Establish facility implementation team

Assess impact

• Confirm standardized documentation
• CNA
• Wound RN

• Integration of reports into clinical
  decision-making
• Use of reports in daily work

Pilot implementation of redesigned forms and use
of reports

• Change management strategies
• Data culture
• Accountabilities

• Facility-wide implementation plan

14
What is different about this approach?

• Integrates sustainable quality improvement into
  daily operations.
• Project activities are integrated into versus
  added on to daily work.
• Streamlines documentation with focus on critical
  data elements and information flow.
• Involves front-line staff.
• Establish multi-disciplinary design and
  implementation teams, including CNAs, nurses,
  dieticians, wound nurses, MDS nurses, social
  services, and restorative care.

15
What is different about this approach?

• 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.

16
What has been feedback from participating
facilities?

• We were not ready to invest in EMR. However,
  we know we need to focus on improving CNA
  documentation. Participating in a collaborative
  effort with other nursing homes to streamline
  documentation and impact pressure ulcers using
  low-cost IT is very exciting. VP
  Clinical Services, LTC organization in West
• One of the best things about this effort is the
  focus on CNAs as important members of the team
  providing critical information for clinical
  decision-making. DON, CA provider

17
Country Villa Health Services
Alan Gibson Director, CQI and Customer
Service alan_at_countryvillahealth.com
18
Who We Are

• Country Villa Health Services
• 49 Skilled Nursing Facilities, all in Southern
  California
• Privately owned, some are management facilities
• Average beds 99 beds
• Project facility beds 81, 99, and 131 beds
• Open to research - company has a history of
  involvement with USC and UCLA research projects.

19
Lessons Learned

• Total paradigm shift
• Realization that it turns your world upside
  down
• Workflow changes are immense
• Requires thinking about big picture
• Examine every process every step necessary?
• Examine all data captured all data elements
  necessary?

20
What is needed to be successful?

• Need consistency in leadership
• Stay focused
• Dedicated support
• Plan more manpower than you think
• Staff requires lots of IT support no matter how
  simple
• Process changes require on-going monitoring
• Dedicated Project Champion at the facility

21
Opportunity

• AHRQ-funded collaborative partnering with QIOs
  On-Time Pressure Ulcer Prevention
• Use an established process as a foundation
  (previous AHRQ-funded project) to impact pressure
  ulcer rates
• Use existing clinical IT or Digital Pen Systems
  solution to implement established process
• Collaborate with 30 providers across country
• Implement and assess impact in 18 months

22
Why Interested in Digital Pen?

• Ease of use practical for CNA staff (pen and
  paper solution)
• Minimal training requirements (good for turnover)
• Anticipate rapid staff adoption (no need to learn
  how to use a computer or alter clinical workflow
  to meet limitations of new product)
• Minimal impact to existing clinical workflows

23
What Is the Digital Pen?
Thin and light device that writes like an
ordinary pen Includes camera that records pen
strokes in pen memory that stores up to 200
pages Used with digitized form, digital pen
reads unique pattern of dots to interpret the
data Pen uses docking station for battery
charging and uploading data from memory to
database via Internet
24
Who Uses The Solution?

• CNA staff for daily documentation
• Wound nurse for tracking pressure ulcers
• Nursing Management, charge nurses, and Dietary
  will access on-line reports to support
  decision-making, care planning, and CQI activities

25
Using the Information

• Monitor CNA compliance with form use
• Completeness Reports
• Nurse Consultants facilitate process to
  incorporate clinical reports into care planning
• Nutrition Report
• Behavior Report
• Weight Summary
• High Risk Indicator Report for Pressure Ulcers
• Use of reports by front-line clinical teams to
  impact pressure ulcer prevention and care
• Develop strategy for mining data for quality
  reporting analysis
• Implement the PU tracking sheet and PU reports

26

• QIO Case Study

Eileen WolfardLumetraEWOLFARD_at_caqio.sdps.org
27
Recruitment Overview

• California recruitment goal 1500 beds or 15
  nursing homes
• July - December 2005 4 nursing homes with signed
  letter of intent
• September 2006 14 nursing homes participating
  (1464 beds)

28
Recruitment Challenges

• Competing priorities
• Strong business case not enough
• Financial
• California Health Care Foundation (CHCF) grant to
  help subsidize the cost to facilities

29
Reasons for Participation

• Use everyday documentation for quality
  improvement
• Providers looking for out-of-box intervention
  innovative approach to pressure ulcer reduction
• HIT Low cost, easy to implement system could
  use with existing computer infrastructure

30
Provider Feedback

• Helpful reports
• Timely, useful information
• Easy IT solution (digital pen)
• CNAs empowered by the information they collect
• more diligent charting
• Beginning to see the potential of reported data

31
Provider Challenges

• Difficult to integrate the reports into everyday
  workflow requires substantial workflow redesign
• Need to communicate differently to maximize
  utilization of data
• Organizational structure - traditionally work in
  silos

32
Lessons Learned
Goal

• Integrate the data you have into every day
  practice
• Integrate data capture into daily work
• Culture change
• Process change

Realities
33
Clinical Strategy

• Early identification of high risk residents
• Monitor changes in PUs, nutrition, incontinence,
  and behaviors
• Integrate with guidelines and evidence based
  practices

34
QI Organization Strategy

• Leverage CNA daily documentation to provide data
  for reports
• Improve accuracy of CNA observations
• Electronic checking of data now possible
• Integrate timely information into day to day
  practice
• Easy access to summarized information
• View resident trends and multiple risks
• Multidisciplinary input

35
Current Contract

• Involving QIOs in 5 States
• Lumetra in California most involved
• 25 facilities (gt3,000 beds)
• Using forms and reports from original study
• Fine tuning and adding reports
• Flexibility for customizations
• Using hand held or digital pen and paper
  technologies

36
Use of ReportsAssistance Provided

• Analyze current workflow
• In person site-visit
• Facilitate working phone calls with team weekly
  and then bi-weekly
• Develop plan to use reports
• Existing processes e.g., reports used in
  existing QI meetings (replace manual reports)
• New processes
• Weekly stand-up meetings to review residents at
  high risk
• Reviewing implementation of protocols
• Determine assignments and timeline
• Who will access each report and how is it used
• Facilitate participant collaborative phone calls
  to share implementation approaches after reports
  implemented

37
Next Steps Healing

• Review evidence for treatments
• Standardize treatment elements
• Develop wound nurse documentation
• Develop risk reports
• Feasibility and accuracy of PUSH
• Expand to other areas (e.g., ADL decline)