1. 1 On-Time Quality Improvement for Long Term Care Redesigning Workflow Thursday, September 27, 2007; 1:30 – 3pm Siobhan S. Sharkey, MBA Health Management Strategies Redesigning Work Processes to Improve Resident Safety and Quality

2. 2 Workflow Redesign Framework Define scopeDefine scope » Why redesign? » What processes? Establish list of success measuresEstablish list of success measures Establish redesign process and timelineEstablish redesign process and timeline » Readiness » Roles » Communications and coordination » Monitoring Confirm resourcesConfirm resources » Technical: process flowcharts/maps; data definitions; pilot tests » Educational and staff development » Project management

3. 3 On-Time Background  Pressure ulcer (PrU) rates remain high  Despite guidelines  Despite training  NH staff know how to prevent PrUs  Need to identify high risk residents on weekly basis  Knowledge not integrated into day to day practice  Entire multi-disciplinary team needs to coordinate care better for high risk residents (including CNAs)

4. 4 Scope: Common Challenges Across Facilities 1.Inefficient Processes 2.Incomplete Documentation 3.CNAs: untapped resource 4.Communication Breakdowns / Lack Standard Processes 5.Clinical Decision Support Needs

5. 5 Inefficient Processes 74% of CNAs on average have difficulty completing documentation before end of shift … Source: Sample survey results from 7 facilities, 250+ CNAs, in 5 states. 26% Avg

6. 6 Inefficient Processes 78% of CNAs on average document the same information in more than one place each day … Source: Sample survey results from 7 facilities, 250+ CNAs, in 5 states. 22% Avg

7. 7 CNAs, a Resource To Be Leveraged? 46% Avg Source: Sample survey results from 7 facilities, 250+ CNAs, in 5 states. 46% CNAs on average feel their work is valued….

8. 8 CNAs report …. Average of 63% report that “I understand all of what needs to be done for the resident before I start work.” Communication Breakdown 63% Avg

9. 9 Clinical Decision Support Needs Source: Sample baseline results at 4 facilities; total of 70 RNs 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’

10. 10 Key Success Measures # CNA documentation forms; redundancy# CNA documentation forms; redundancy CNA documentation completenessCNA documentation completeness Nurse and CNA awareness of high risk residentsNurse and CNA awareness of high risk residents In-house pressure ulcer ratesIn-house pressure ulcer rates

11. 11 Approach: HIT + Workflow Redesign Develop Core TeamDevelop Core Team » Stakeholders: CNAs, Floor Nurses, Dietician, Staff Development, Wound Nurse, DON Standardize CNA documentationStandardize CNA documentation Use information to improve clinical decision-makingUse information to improve clinical decision-making » Integrate reports into existing processes: QI, Wt. Variance » Establish new processes for report use –Weekly 5-Minute Stand ups: CNA staff –Staff Development Weekly Review: in-servicing needs –MDS Nurse Weekly Review –Management Monitoring –End of Shift Report Format: CNAs

12. 12 How Can Technology Support Workflow Redesign? 1.Translate data into information to support clinical decisions and care planning »Access to right information when needed »Timely Reports and queries vs. quarterly (e.g., MDS) »Alerts, Reminders, Prompts »Monitor Compliance 2.Streamline workflow »Standardize/streamline data »Improve communications

13. 13 Approach: Process –Information –Decision Making Screening & Assessing Team Communication Establish indicators of high risk Standardize assessment process to categorize and prioritize patient needs Monitoring/ Evaluating Establish forum for proactive care planning Maximize collaborative working session and team problem-solving Increase RN role facilitating and coordinating activities of multi-disciplinary team (versus doing it themselves) Information feedback on process and outcomes measures Resident/Family Communication Care Planning Increase early interactions with patient / family

14. 14 New Process #1: CNA 5-Minute Stand Up Objective : Conduct focused feedback sessions with CNA staff each week to ensure front-line team aware of residents at risk, plan of action, and follow up Process Establish a routine time: non-meetingEstablish a routine time: non-meeting Identify facilitator: Dietician, DSD, NM, or CNIdentify facilitator: Dietician, DSD, NM, or CN Keep sessions brief, focusedKeep sessions brief, focused Determine report information to reviewDetermine report information to review » Nutrition Report: Meal intake - current % and trends, TF, New or worsened ulcer » Priority Report: Red areas, open areas Confirm report information is consistent with clinical picture, care plan is in place, and communicate to front-line staffConfirm report information is consistent with clinical picture, care plan is in place, and communicate to front-line staff Ensure action plan and follow up are understood by team.Ensure action plan and follow up are understood by team.

15. 15 Results: CNA 5-Minute Stand Up CNA input valuedCNA input valued CNAs see link between documentation and reportsCNAs see link between documentation and reports CNA documentation of meal intake becomes more accurate and completeCNA documentation of meal intake becomes more accurate and complete Dietician more aware of resident needs: earlier identification of residents at nutritional riskDietician more aware of resident needs: earlier identification of residents at nutritional risk Dietician more involved in follow up: e.g., monitor snack intakeDietician more involved in follow up: e.g., monitor snack intake Staff development more aware of CNA in-service needs and follow upStaff development more aware of CNA in-service needs and follow up “The overall communication is improved. We talk more with each other.”

16. 16 New Process #2: Management Monitoring Objective : Review reports with Unit Managers each week – establish plan for week Process Monday: DON reviews reportsMonday: DON reviews reports Tuesday: DON reviews report results with Unit ManagersTuesday: DON reviews report results with Unit Managers Discuss report variances and establish follow up, prioritiesDiscuss report variances and establish follow up, priorities Identify CNA in-service needs w/staff developmentIdentify CNA in-service needs w/staff development » Behaviors » Red areas » Open areas

17. 17 Results: Management Monitoring Inaccurate documentation of resident behaviors by CNA staffInaccurate documentation of resident behaviors by CNA staff » Discrepancy between CNA and RN observation of behaviors Focused in-services conducted by staff developmentFocused in-services conducted by staff development Regular follow up with CNAs by nursing staffRegular follow up with CNAs by nursing staff “Our nurses weren’t seeing what the CNAs were seeing so it was important for CNAs to communicate resident behaviors to nurses. CNAs had to understand what to document and report. CNA communication of behaviors has greatly improved.”

18. 18 Facility Time Commitment For leadership: approximately 1-2 days to confirm plans and discuss HIT options.For leadership: approximately 1-2 days to confirm plans and discuss HIT options. For the multi-disciplinary team:For the multi-disciplinary team: » Weekly conference calls for the first 3 months lasting 30 minutes to 1 hour, and » Bi-weekly calls for the next 12 months. For staff development: 4 hours per week for the first 2-3 months to support initial implementation.For staff development: 4 hours per week for the first 2-3 months to support initial implementation. One-day meeting with the consultants on-site.One-day meeting with the consultants on-site.

19. 19 HIT Investment Low cost option (Digital Pen Systems)Low cost option (Digital Pen Systems) » $12K to $15K for 100 bed facility in yr 1 High cost optionHigh cost option » $65 - $100k for 100 bed facility in yr 1

20. 20 Lessons Learned: CNA documentation   CNA documentation previously has not been closely monitored on weekly basis: contained knowledge deficits, inaccuracies   CNA documentation of ADLs is new and requires time to learn the coding   CNA codes differ from MDS codes on new form   One-person assist is represented by “1” on CNA form   One person assist is represented by ‘2” for MDS nurse documentation.   MDS nurses have to adjust to change in codes.   CNA documentation requires ongoing monitoring and follow-up by staff to maintain accuracy and high documentation completion rates

21. 21 Lessons Learned: Implementation  On-going implementation strategy involves both top leadership and front-line clinical teams.  Start small: focus on 1-2 reports for team to use.  Keep review of report information focused: do not slip into lengthy meetings.  Identify how report can eliminate manual work or make work easier for staff.  On-going training and follow-up on reports is necessary: how to access, how to print, and when to use.

22. 22 Lessons Learned: Implementation   Focus use of HIT as a tool to sustain quality and operational improvement   Standardized data elements and use of redesigned forms facilitate CNA adoption of HIT   Redesign workflow prior to HIT implementation - Current workflow idiosyncratic and difficult to automate   Involve front-line in teams to redesign workflow   Establish partnerships and local champions   Dedicate project management resources –Nursing home facilities lack knowledgeable and experienced team to implement information technology, train staff, and managing change to achieve results.

23. 23 Impact Reduce workflow inefficiencies :Reduce workflow inefficiencies : » Eliminate an average of 3-4 CNA daily documentation forms (a reduction of 53.2%) » Achieve >90% documentation completeness rates for CNAs » Decrease staff time to compile reports for MDS and State Regulators

24. 24 Impact Prevent pressure ulcers: Decrease high risk pressure ulcer rate ~ 33%Prevent pressure ulcers: Decrease high risk pressure ulcer rate ~ 33% » Potential savings of –$1,932 per Stage 1 – $7,170 per Stage 2 –$11,534 per Stage 3 –and $14,077 per Stage 4 pressure ulcer event (FY 05$, not including hospitalization) Better utilize investment in CNA staff time to document each shiftBetter utilize investment in CNA staff time to document each shift » Rough estimate: $37K per year for 100 bed facility