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Gurwin Jewish Nursing and Rehabilitation Center, a 460-bed long-term care facility in upstate New York, implemented an AHRQ-funded program that focuses on integrating health information technology into nursing homes and long-term care facilities. As a result of using the On-Time Quality Improvement in Long-Term Care (On-Time) program, the facility reduced the incidence of pressure ulcers in residents by 70 percent, from 2.0 percent prior to implementation to 0.6 percent in the 1-year period following implementation.

The On-Time program integrates clinical decision-support tools into nursing home workflow processes by using health information technology to identify residents who are at risk for pressure ulcers and to track the results of efforts to reduce those risks. The program provides a core set of certified nursing assistant (CNA) documentation elements and timely clinical reports to staff in nursing homes. Streamlining and standardizing documentation help incorporate best practices and provide the foundation for useful decision-support reports for caregivers. Interdisciplinary teams embed quality improvement changes into daily work routines and bring CNAs to the forefront in team collaboration. Together, these program elements link efficiency and effectiveness in the care delivery process with sustainable improvement in resident pressure ulcer outcomes.

Working with the On-Time quality improvement consultants, Gurwin Jewish Nursing and Rehabilitation Center integrated four On-Time reports: Nutrition, Weight Summary, Trigger Summary, and Completeness. These reports help guide staff in identifying residents at risk for pressure ulcers and focus interdisciplinary efforts to intervene in a timely manner.

Information from CNA documentation about each resident's activities of daily living-such as eating, incontinence episodes, behaviors, and weight loss-is used to generate On-Time reports that are used in a series of process improvements by front-line staff, such as "5-Minute Stand-Up" meetings and other weekly forums with multidisciplinary teams. The On-Time reports have been important not only in improving communication among members of the interdisciplinary team, but as a basis for effective clinical decisionmaking.

An additional benefit of implementing the program at Gurwin Jewish was the positive nutritional impact on residents. Over a 2-year period, information from the Weight Summary and Nutrition reports was reviewed weekly. Interventions (such as adapting serving times for the larger daily meals to the time preferred by residents) were developed to address unplanned weight loss, and the results were monitored and compared to dietary department notes. Potential issues and strategies were discussed with CNA staff during the 5-minute meetings. By identifying food preferences and eating patterns, the facility targeted appropriate ways to avoid unintended weight loss. As a result, the number of residents identified as having significant weight loss was reduced from 3.5 percent to 1.7 percent.

The On-Time Completeness report allows nursing staff to monitor CNA documentation to ensure complete information. This report also provides information on any inaccuracies in the documentation and is used to further educate staff during in-service training. Monitoring the Completeness reports revealed a lack of documentation in the areas of behavior and bowel management. Working with the On-Time facilitators, Gurwin staff discovered that CNAs were documenting only positive resident responses.

Staff development educators then taught the CNAs that bowel and behavior patterns-whether negative or positive-must be documented during each shift. As a result of reviewing the reports and providing targeted training, bowel documentation completion rates increased from 49 percent to 85 percent, and documentation related to behaviors increased from 35 percent to 85 percent.

The On-Time project was developed by ´óÏóAPPwith support from the California Health Care Foundation. The research was conducted by Susan Horn, PhD, Senior Scientist at the Institute for Clinical Outcomes Research and Vice President for Research at International Severity Information Systems, Inc. The design of the program and implementation process and the facilitation of facility teams were provided by Siobhan Sharkey, MBA, and Sandy Hudak, MS, RN, Principals at Health Management Strategies, Inc.