AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits
Implementation Materials: Implementation Steps and Timeline
The goal of the On-Time program is to incorporate the On-Time reports into day-to-day prevention activities and to ensure multidisciplinary input into clinical intervention decisions. The Implementation Steps document was created to help nursing homes understand the implementation steps for carrying out the program and the likely timeline to make the reports part of daily practice. It is intended to be used by the team champion and the Change Team members to help keep the effort on track and methodical.
Step 1: Agree To Use On-Time Preventable Hospital and ED Visits Reports
Nursing home leadership agrees to incorporate the On-Time reports into their workflow. Most facilities begin by implementing one report on one unit and then expand use to all units once the process of using the report is confirmed and effects on daily work, if any, are addressed and workflow redesigned as needed. Leadership agrees to identify a Change Team champion and establish a multidisciplinary Change Team to lead the project.
Step 2: Contact Vendor
The Change Team champion or information technology (IT) representative contacts the facility’s electronic medical record (EMR) vendor to confirm that On-Time Preventable Hospital and ED Visits reports and the data elements included in Intake Notes and Transfer Notes are in the system. He or she takes appropriate steps at the facility to provide frontline staff with access to the reports.
Step 3: Identify Multidisciplinary Team Members To Serve as the Change Team
The Change Team consists of a Change Team champion, nurse managers from each nursing unit, quality improvement coordinator, and nursing assistants. The champion advocates and supports the project and ensures project activities are sustained during turnover of key staff. Nursing leadership may assume this role or delegate responsibility.
Two team leaders co-facilitate project activities; one is a nurse and the second can be from nursing or another discipline. Team leaders share responsibilities to coordinate and implement activities and coordinate calls with an On-Time Facilitator. The director of nursing determines his or her level of involvement.
In some facilities, the director of nursing participates actively as a member of the Change Team. In other facilities, he or she may serve more of a consultative role. Ad hoc team members include the staff educator, medical director, pharmacist, nurse practitioner, and rehabilitation staff.
Step 4: Introduce On-Time Preventable Hospital and ED Visits Reports
On-Time Facilitator provides technical assistance via an initial telephone consultation to confirm EMR capabilities and readiness to start On-Time, to discuss immediate next steps regarding IT, and to guide staff through the introductory material as needed. The Facilitator answers questions and confirms that the facility team members understand how to access reports and tools and establishes the process for working together.
Step 5: Review Reports
The team reviews reports with Facilitator to understand content and potential use of reports.
Step 6: Complete Self-Assessment
The team completes the On-Time Self-Assessment Worksheet that identifies current processes at the facility to identify risk factors for preventable hospital and ED transfers and develop interventions to mitigate the risk, as well as communication processes. The review includes identification of team meetings, huddles, and other communication structures in place, ways risk information is transmitted to clinical staff, and ways care plans are updated and interventions determined. The Facilitator guides the team to identify gaps and begin to think about ways On-Time reports could be used to prevent hospital and ED transfers.
Step 7: Pilot a Report With Data
The On-Time Facilitator assists the team in using one of the reports. The team should decide which report they will use first and then review the material for that report and generate it for one nursing unit. The Facilitator works with the team to understand the first report and answers questions, as needed.
Step 8: Validate Data
This step helps the team gain confidence in the validity of the data in the reports. The team discusses residents populated on the report to ensure that data on the report agree with staff knowledge of residents’ health and risks. Staff may choose to go back to the medical record to confirm if data on the report are consistent with other clinical findings.
In completing this task, the team may identify problems in, for example, nursing assistant documentation incompleteness and may find it necessary to reeducate nursing assistants to improve report validity. In addition, a Facilitator may help to clarify any normal but potentially confusing data situations and how to interpret them. Each report the team uses should go through this process so the team is confident in the information being produced on the reports.
Step 9: Agree To Use Core Reports/Implementation Strategies
With the Facilitator, the Change Team uses the Preventable Hospital and ED Visits Menu of Implementation Strategies to determine which reports will be especially helpful to them considering the results of their Hospital Transfer Self-Assessment Worksheet. The Facilitator describes the strategies and helps the team determine which reports may help them given the findings from the self-assessment (Step 6). The team can use one report more than one way and in multiple meetings.
Step 10: Create Report/Meeting Strategies
Strategies are based on self-assessment identification of pre-On-Time communication and care plan meetings/huddles and the Menu of Implementation Strategies. Some new huddles and other meetings may be created and meetings may be altered to accommodate report discussion. The team reviews the Menu of Implementation Strategies for each On-Time report and discusses options for using the reports within current communication structures. The team considers meetings, huddles, care plan, or other existing meetings where a report would enhance the current process to identify risk and coordinate care across disciplines.
At this time, the team identifies potentially new processes that may be developed to use the reports. Teams pilot reports and incorporate report discussion into existing meetings or new meetings. Changes in requirements to attend meetings may be needed to increase the number of disciplines and nursing assistants providing input and to change communication networks to improve risk identification.
The Facilitator helps the team initiate the first report meeting strategy. The team makes sure it understands the criteria for identifying residents profiled on the report, knows the definitions of risk factors that are profiled, and receives advice on how to structure existing meetings or create new meetings to best incorporate report discussions. Advice includes who should attend the meeting, what their roles are, who is responsible for the reports, and who will lead the discussion.
Step 11: Pilot All Report/Meeting Strategies in One Unit
The team discusses implementation issues with the Facilitator after piloting report/meeting strategies. This process is iterative, so it should be repeated until the process is smooth and effective.
Step 12: Ensure Implementation Strategies Are Carried Out
Once a new report is incorporated into a meeting, the champion decides on role changes for staff to ensure the report is used at designated meetings with appropriate multidisciplinary team input. It is important for the champion to have supervisory responsibility so these changes can be informed and enforced.
Step 13: Develop Plan and Implement New Strategies in All Units
The training and implementation planning process for integrating reports in one unit should take approximately 3 to 4 months once the facility has confirmed that the On-Time Preventable Hospital and ED Visits reports are available and staff have been granted access to view and print the reports (Steps 3-12). The timeline depends on leadership commitment, stability of staff, how familiar the facility is with using computerized reports, and quality improvement (QI) experience of staff.
Implementing on all units is likely to add another 3 months. The Facilitator will help the team during the next 3 months to problem solve implementation issues until all reports and all units are implementing the reports as planned and the team becomes more independent.
Step 14: Monitor Facility Implementation Progress Monthly
After about 6 months, the Facilitator’s role is to check in to identify obstacles that could occur and to troubleshoot issues such as turnover of key staff, computer glitches, and implementation issues as needed. The expectation is that reports will be used on a weekly basis except for meetings that occur less frequently (e.g., monthly).
Step 15: Review Hospital and ED Transfer Rates
The Facilitator works with the team to generate On-Time Monthly Summary of Preventable Hospital and ED Visits Report that identifies hospital/ED transfer rates to provide feedback to the Change Team and support reporting requirements.
Step 16: Sustain the Effort
After 9 months, the nursing home Change Team develops a plan for incorporating implementation strategies for report use into facility policies and procedures. The plan includes incorporating educational in-service for new hires and training material for temporary employees. The facility needs to establish a permanent champion for this QI effort and champions on units.
Likely champions for each nursing unit are the nurse managers, with backup support by the QI staff, who may be assigned to conduct periodic monitoring of implementation strategies that ensure they are sustained. It is suggested that on a weekly basis, the director of nursing ensures that On-Time process improvements are carried out on each nursing unit and holds each nurse manager accountable.
Approximate Timeline
Implementation Steps | Estimated Duration/Time From Implementation |
---|---|
1. Agree To Use On-Time Preventable Hospital and ED Visits Reports | |
2. Contact Vendor | Start time is after confirmation of access to reports for frontline staff |
3. Identify Multidisciplinary Team Members To Serve as the Change Team | Within 2 weeks |
4. Introduce On-Time Preventable Hospital and ED Visits Reports | 1st month |
5. Review Reports | 1st month |
6. Complete Self-Assessment | 1st month |
7. Pilot a Report With Data | 2nd month |
8. Validate Data | 2nd month |
9. Agree To Use Reports/Implementation Strategies | 2nd month |
10. Create Report/Meeting Strategies | 2nd month |
11. Pilot All Report/Meeting Strategies in One Unit | 2nd month |
12. Ensure Implementation Strategies Are Carried Out | 3rd month–4th month (some facilities implement in all units simultaneously) |
13. Develop Plan and Implement New Strategies in All Units | 4th month-6th month |
14. Monitor Facility Implementation Progress Monthly | 6th month-9th month |
15. Review Hospital and ED Transfer Rates | As required |
16. Sustain the Effort | End of 9th month–12th month |