Evaluation of AHRQ's On-time Pressure Ulcer Program (Massachusetts)

Project Details - Ended

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Summary:

Pressure ulcers and injurious falls have serious health and economic consequences for elderly residents in nursing homes. Although substantial research has documented that preventing pressure ulcers and falls is possible, these problems persist across health care settings. The On-Time Quality Improvement for Long-term Care project was funded by AHRQ in part to assist nursing homes to implement best practice guidelines in pressure ulcer care through workflow redesign and process improvements integrated into the daily work of front-line caregivers. While the On-Time program had demonstrated success in early testing, a formal evaluation examining the effectiveness of this unique approach in reducing pressure ulcer incidence was needed as wide-spread dissemination had been considered. In response to this need, AHRQ funded a rigorous evaluation of the On-Time Pressure Ulcer program. 

The objects of the project were to:

  • Evaluate the effect of the On-Time Pressure Ulcer program by comparing 12 New York nursing homes that have implemented the program with 13 control nursing homes.
  • Design the tools and establish the foundation for a fall prevention implementation effort using an approach similar to the On-Time Pressure Ulcer Prevention program, including standardized documentation data elements that can be integrated into everyday practice, actionable reports of resident fall risk factors, and tracking tools.
  • Develop an evidence-based systems approach for identifying, managing, and monitoring multiple risk factors for hospitalizations and ED visits.
  • Develop the On-Time Train-the-Trainer and TeamSTEPPS for long-term care curricula.

Lessons from the On-Time Pressure Ulcer program informed the development of an On-Time Fall Prevention module, which uses documentation data elements, actionable reports, and tracking tools to address residents’ fall risk factors. The module provides resources to support nursing home staff to develop timely interventions for at-risk residents to reduce the incidence of falls. A year-long process of meetings informed the standardization of fall documentation and the development of tools to guide clinical decisionmaking for fall prevention. In addition, several facilities participated in a series of teleconference calls to develop health information technology specifications based on the final set of fall prevention tools. The project team worked with facilities to develop a feasible implementation plan to integrate these tools into daily practice.

A review of literature and analysis of national data was conducted to identify residents in nursing homes who should be targeted for prevention protocols to reduce hospital and emergency department (ED) visits. A training curriculum for the On-Time Pressure Ulcer program was developed and tested. The Team Strategies and Tools to Enhance Performance & Patient Safety (TeamSTEPPS) program was modified for use with nursing home staff. TeamSTEPPS is a training system designed to help health care professionals provide higher-quality, safer patient care and create a culture of safety within their teams. New materials, including the production of three videos, were designed to be relevant and meaningful to the staff at nursing homes. 

The study team found a statistically significant reduction in pressure ulcer incidence associated with the joint implementation of four core On-Time components. Impacts vary with implementation of specific component combinations. On-Time implementation was associated with sizeable reductions in pressure ulcer incidence, implying significant improvements in health outcomes and substantial cost savings.

Evaluation of AHRQ’s On-Time Pressure Ulcer Program - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    Accelerating Change and Transformation in Organizations and Networks (ACTION)
  • Contract Number: 
    290-06-0011-8
  • Project Period: 
    June 2009 – January 2012
  • AHRQ Funding Amount: 
    $499,987
  • PDF Version: 
    (PDF, 239.25 KB)

Summary: Pressure ulcers and injurious falls have serious health and economic consequences for elderly nursing home residents. Although substantial research has documented that preventing pressure ulcers and falls is possible, these problems persist across health care settings.

The On-Time Quality Improvement for Long-term Care project was funded by AHRQ in part to help nursing homes implement best practice guidelines in pressure ulcer care through workflow redesign and process improvements integrated into the daily work of front-line caregivers. While the On-Time program demonstrated success in early testing, a formal evaluation examining the effectiveness of this unique approach in reducing pressure ulcer incidence was needed as wide-spread dissemination was considered. In response, AHRQ funded a rigorous evaluation of the On-Time Pressure Ulcer program.

Lessons from the On-Time Pressure Ulcer program informed the development of an On-Time Fall Prevention module, which uses documentation data elements, actionable reports, and tracking tools to address resident fall risk factors. The module provides resources to help nursing home staff develop timely interventions to reduce at-risk residents’ incidence of falls. A year-long process of meetings informed the standardization of fall documentation and the development of tools to guide clinical decisionmaking for fall prevention. In addition, several facilities participated in a series of teleconference calls to develop health information technology specifications based on the final set of fall prevention tools. The project team worked with facilities to develop a feasible implementation plan to integrate these tools into daily practice.

Early in the project, the original scope of work was expanded to include several additional tasks. A review of literature and analysis of national data was conducted to identify nursing home residents who should be targeted for prevention protocols to reduce hospital and emergency department (ED) visits. A training curriculum for the On-Time Pressure Ulcer program was developed and tested. The Team Strategies and Tools to Enhance Performance & Patient Safety (TeamSTEPPS) program was modified for use with nursing home staff. TeamSTEPPS is a training system designed to help health care professionals provide higher-quality, safer patient care and create a culture of safety within their teams. New materials, including the production of three videos, were designed to be relevant and meaningful to nursing home staff. Lastly, work on an additional On-Time module to prevent avoidable hospitalizations and ED visits was begun. A workgroup consisting of representatives from several nursing homes worked with the research team to develop reports and tools to identify residents at high risk of ED visits and inpatient hospitalizations and to support root cause analysis of treat-and-release patients.

Project Objectives:

  • Evaluate the effect of the On-Time Pressure Ulcer program by comparing 12 New York nursing homes that have implemented the program with 13 control nursing homes. (Achieved)
  • Design the tools and establish the foundation for a fall prevention implementation effort using an approach similar to the On-Time Pressure Ulcer Prevention program, including standardized documentation data elements that can be integrated into everyday practice, actionable reports of resident fall risk factors, and tracking tools. (Achieved)
  • Develop an evidence-based systems approach for identifying, managing, and monitoring multiple risk factors for hospitalizations and ED visits. (Achieved)
  • Develop the On-Time Train-the-Trainer and TeamSTEPPS for long-term care curricula. (Achieved)

2012 Activities: This project was completed in June 2012. The focus of activity in the first half of the year was on completing and delivering the final report of the project.

Impact and Findings: The study team found a statistically significant reduction in pressure ulcer incidence associated with the joint implementation of four core On-Time components. Impacts vary with implementation of specific component combinations. On-Time implementation was associated with sizeable reductions in pressure ulcer incidence, implying significant improvements in health outcomes and substantial cost savings.

Target Population: Adults, Elderly*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

*This target population is one of AHRQ’s priority populations.

Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Contract Number: 
    290-06-0011-8
  • Project Period: 
    June 2009 - January 2012
  • AHRQ Funding Amount: 
    $1,699,797
  • PDF Version: 
    (PDF, 198.14 KB)

Summary: Pressure ulcers and injurious falls have serious health and economic consequences for elderly residents in nursing homes. Although substantial research has documented that preventing pressure ulcers and falls is possible, these problems persist across health care settings. In the last decade, many initiatives- including an earlier Agency for Healthcare Research and Quality (AHRQ)-funded On-Time Pressure Ulcer (PrU) Healing program, which helps nursing homes implement best practice guidelines in PrU care through workflow redesign and process improvements- have been undertaken to improve quality of pressure ulcer care in nursing homes. While the On-Time program has unique characteristics, it had not previously been formally evaluated and thus was not ready for wide dissemination.

This project evaluated AHRQ's On-Time PrU program. The findings will help make guidelines available to other practices. Lessons from the PrU program will also inform the development of an On-Time Fall Prevention Module, which will use documentation data elements, actionable reports, and tracking tools on risk factors from the On-Time PrU program. These resources will allow nursing home staff to intervene in a timely manner with at-risk residents to reduce the incidence of injurious falls. The project team worked with facilities to develop a feasible implementation plan to integrate these tools into daily practice.

A yearlong process of workgroup meetings has already informed the standardization of fall documentation and the development of tools to guide clinical decisionmaking for fall prevention. In addition, several facilities participated in a series of teleconference calls to develop health information technology specifications based on the final set of fall prevention tools. Early in the project, the original scope of work was expanded to include two additional tasks: 1) a review of literature and analysis of national data to identify residents in nursing homes who should be targeted for prevention protocols to reduce hospital and emergency department (ED) visits; and 2) development and testing of a training curriculum for the On-Time PrU Prevention program and modification of the Team Strategies and Tools to Enhance Performance & Patient Safety (TeamSTEPPS) program for nursing homes. TeamSTEPPS is a training system designed to help health care professionals provide higher-quality, safer patient care and create a culture of safety within their health care teams.

Project Objectives:

  • Evaluate the effect of the On-Time PrU by comparing 15 New York nursing homes that have implemented the program with 12 to 15 control nursing homes. Information on pressure ulcer incidence provided by the facilities for a 12-month period and adjusted for resident risk factors using minimum data set (MDS) data will provide the data needed to assess the effectiveness of the On-Time program for reducing pressure ulcers. (Achieved)
  • Design the tools and establish the foundation for a fall prevention implementation effort using an approach similar to the On-Time PrU prevention, including standardized documentation data elements that can be integrated into everyday practice, actionable reports of resident fall risk factors, and tracking tools. (Achieved)
  • Develop an evidence-based systems approach for identifying, managing, and monitoring multiple risk factors for hospitalizations and ED visits. (Achieved)
  • Develop the On-Time Train-the-Trainer and TeamSTEPPS for long-term care curricula. (Achieved)

2011 Activities: Thirteen control and 13 intervention facilities were recruited and worked with the project team to submit census and pressure ulcer data for this study. The study team made site visits to four facilities. The project team found that each facility, including control and intervention sites, has required an individualized strategy to facilitate submission of the data needed for the study instead of the standardized approach initially envisioned. Therefore, the team conducted many rounds of followup telephone calls and emails to determine the agreed-upon data submission strategies. All facilities were eventually able to submit electronic census data and some form of pressure ulcer data. Data received from facilities were then checked and cleaned, which necessitated further rounds of followup telephone calls and emails with control and intervention facilities to check missing and inconsistent data. The most common problem was residents listed in the pressure ulcer records with no corresponding information in the census data for the same dates.

The study team has linked census data to the MDS using facility-provided resident identifiers. Preliminary testing of the data linking process showed that in some cases the linking could be accomplished quite readily using the medical record number supplied by the facility, while in other cases the linking yielded numerous problems. At the end of 2011, construction of the analytic file was completed, with an overall MDS match rate of 75 percent.

Meanwhile, various modules in the TeamSTEPPS manual have been revised, including those focused on leadership, team structure, situation monitoring, mutual support, and communication. Filming for a TeamSTEPPS video was completed in September 2011 and revisions are ongoing.

Sections of the draft final report were submitted to AHRQ in November. The draft report included sections on background, data collection, and analysis methods (nursing home recruitment, data sources and data collection, analytic file construction), and baseline description of intervention and control facilities. Analysis of the data continues and final details of the analytic model are under discussion.

Prior to 2011, there were substantial delays (out of the team's control) in obtaining the data files needed for the avoidable hospitalization analysis. In 2011, the project team proposed a revised timeline that would not affect the estimated cost or performance of the contract. The project was extended 12 months and completed in January 2012.

Preliminary Impact and Findings: The project has no findings to date.

Target Population: Adults, Elderly*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Evaluation of AHRQ's On-time Pressure Ulcer Program - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Contract Number: 
    290-06-0011-8
  • Project Period: 
    June 2009 – January 2012
  • AHRQ Funding Amount: 
    $1,699,797
  • PDF Version: 
    (PDF, 404.45 KB)


Target Population: Elderly*

Summary: Pressure ulcers and injurious falls have serious health and economic consequences for elderly residents in nursing homes. Substantial research has documented that prevention of pressure ulcers and falls is possible, yet these problems persist across health care settings. Many initiatives to improve quality of pressure ulcer care in nursing homes have been undertaken in the last decade, including the Agency for Healthcare Research and Quality (AHRQ) funded On-Time Pressure Ulcer (PrU) Healing Project which helps nursing homes implement best practice guidelines in PrU care through workflow redesign and process improvements. While the On-Time program has unique characteristics, it has not yet been formally evaluated and thus is not ready for wide dissemination.

The evaluation of the On-Time PrU Program will help make guidelines available to other practices. Lessons learned from the PrU program will also serve to inform the development of an On-Time Fall Prevention Module, which will use documentation data elements, actionable reports, and tracking tools on risk factors from the On-Time PrU program. These resources will allow nursing home staff to intervene in a timely manner with at-risk residents to reduce the incidence of injurious falls. The project team will work with facilities to develop a feasible implementation plan to integrate these tools into daily practice.

A yearlong process of workgroup meetings informed the standardization of fall documentation and the development of tools to guide clinical decisionmaking for fall prevention. In addition, six to eight facilities are participating in a series of teleconference calls to develop health information technology (IT) specifications based on the final set of fall prevention tools. Since December 2009, the scope of work has also been expanded to include two additional tasks including: 1) a review of literature and analysis of national data to identify residents in nursing homes who should be targeted for prevention protocols to reduce hospital and emergency department (ED) visits, and 2) development and testing of a training curriculum for the On-Time Pressure Ulcer Prevention Program and modification of the Team Strategies and Tools to Enhance Performance & Patient Safety (TeamSTEPPS) program for nursing homes.

Project Objectives:
  • Evaluate the effect of the On-Time PrU by comparing 15 New York nursing homes that have implemented the program with 12 to 15 control nursing homes. Information on pressure ulcer incidence provided by the facilities for a 12-month period and adjusted for resident risk factors using minimum data set data will provide the data needed to assess the effectiveness of the On-Time program for reducing pressure ulcers. (Ongoing)
  • Design the tools and establish the foundation for a fall prevention implementation effort using an approach similar to the On-Time PrU prevention, including standardized documentation data elements that can be integrated into everyday practice, actionable reports of resident fall risk factors, and tracking tools. (Ongoing)
  • Develop an evidence-based systems approach for identifying, managing, and monitoring multiple risk factors for hospitalizations and ED visits. (Ongoing)
  • Develop the On-Time Train-the-Trainer and TeamSTEPPS for long-term care Curricula. (Upcoming)

2010 Activities: Many project-related activities were achieved throughout the year. Thirteen control facilities were selected based on their similarity to the intervention facilities. Site visits were scheduled with each control facility and four site visits were completed by the end of the year. The project team also continued to work with the intervention facilities throughout the year, assisting them with submitting their patient census and pressure ulcer data. A majority of the facilities have submitted all the required data and the remaining facilities have submitted at least a portion of the required data.

The draft fall prevention tools were reviewed with members of the Advisory Panel in September and October to get their feedback and input. A preliminary draft of health IT specifications was developed as part of these materials. The Advisory Panel provided recommendations on the tools and the final versions were delivered to AHRQ in December. Included in the tools were:

  • Standardized set of documentation data elements and definitions
  • Clinical Reports and Tracking Tools
  • Falls Prevention: High Risk Report
  • Falls Quality Improvement Monitor Reports

The avoidable hospitalization literature review was completed in August and revisions to the summary are in progress. Data collection of the nursing home stay information was delayed because the initial files had been copied onto cartridges, which the project team was not able to read. Subsequent negotiation with the Centers for Medicare and Medicaid Services allowed for the data to be provided in another format and was received by the project team in November. During the delay, the project team focused on defining diagnosis codes for identifying hospitalizations and ED visits.

In addition to having an Advisory Panel, a Technical Expert Panel is in the process of being established and AHRQ has approved the list of potential candidates. The analysis plan is also being finalized as the analytic files and variable definitions are developed.

Preliminary Impact and Findings: The project has no findings to date.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

*AHRQ Priority Population.

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