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On-Time Quality Improvement for Long On-Time Quality Improvement for Long Term CareTerm Care

Redesigning WorkflowRedesigning Workflow

Thursday, September 27, 2007; 1:30 – 3pmThursday, September 27, 2007; 1:30 – 3pm Siobhan S. Sharkey, MBASiobhan S. Sharkey, MBA

Health Management StrategiesHealth Management Strategies

Redesigning Work Processes to Improve Resident Safety and Quality

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Workflow Redesign FrameworkWorkflow Redesign Framework• Define scopeDefine scope

» Why redesign?Why redesign?» What processes?What processes?

• Establish list of success measuresEstablish list of success measures• Establish redesign process and timelineEstablish redesign process and timeline

» ReadinessReadiness» RolesRoles» Communications and coordinationCommunications and coordination» MonitoringMonitoring

• Confirm resourcesConfirm resources» Technical: process flowcharts/maps; data definitions; pilot Technical: process flowcharts/maps; data definitions; pilot

teststests» Educational and staff developmentEducational and staff development» Project managementProject management

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On-Time BackgroundOn-Time Background

Pressure ulcer (PrU) rates remain highPressure ulcer (PrU) rates remain high Despite guidelinesDespite guidelines Despite trainingDespite training

NH staff know how to prevent PrUsNH staff know how to prevent PrUs Need to identify high risk residents on weekly basisNeed to identify high risk residents on weekly basis

Knowledge not integrated into day to day practice Knowledge not integrated into day to day practice

Entire multi-disciplinary team needs to coordinate Entire multi-disciplinary team needs to coordinate care better for high risk residents (including CNAs)care better for high risk residents (including CNAs)

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Scope: Common Challenges Across Scope: Common Challenges Across FacilitiesFacilities

1.1. Inefficient ProcessesInefficient Processes

2.2. Incomplete DocumentationIncomplete Documentation

3.3. CNAs: untapped resourceCNAs: untapped resource

4.4. Communication Breakdowns / Lack Communication Breakdowns / Lack Standard ProcessesStandard Processes

5.5. Clinical Decision Support NeedsClinical Decision Support Needs

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Inefficient ProcessesInefficient Processes

I have difficulty completing documentation before end of shift: % responding NEVER

19% 17%26%

50% 50%40%

14%

0%

20%

40%

60%

80%

100%

Site A Site C Site D Site E Site F Site G Site H

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

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Inefficient ProcessesInefficient Processes

I document the same information in more than one place: % responding NEVER

10% 8%

41%49% 49%

28%

14%

0%

20%

40%

60%

80%

100%

Site A Site C Site D Site E Site F Site G Site H

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

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CNAs, a Resource To Be Leveraged?CNAs, a Resource To Be Leveraged?

I feel that what I document each day is valued and used by the doctors, nurses, and other clinical staff

48%

77%

46% 44% 49%

34%43%

0%

20%

40%

60%

80%

100%

Site A Site C Site D Site E Site F Site G Site H

46% Avg

Source: Sample survey results from 7 facilities, 250+ CNAs, in 5 states.

46% CNAs on average feel their work is valued….

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I feel that I understand ALL of what needs to be done for the residents before I start my work

57%

92%

70%81%

50%55%

61%

0%

20%

40%

60%

80%

100%

Site A Site C Site D Site E Site F Site G Site H

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

Communication BreakdownCommunication Breakdown

63% Avg

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Clinical Decision Support NeedsClinical Decision Support Needs

% RNs report Completely Agree

37%

75%

27%33%

0%

20%

40%

60%

80%

100%

Site 1 Site 2 Site 3 Site 4

% RNs report Completely Agree

33%

17%

37% 40%

0%

20%

40%

60%

80%

100%

Site 1 Site 2 Site 3 Site 4

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’

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Key Success MeasuresKey Success Measures

• # CNA documentation forms; # CNA documentation forms; redundancyredundancy

• CNA documentation completenessCNA documentation completeness

• Nurse and CNA awareness of high Nurse and CNA awareness of high risk residentsrisk residents

• In-house pressure ulcer ratesIn-house pressure ulcer rates

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Approach:Approach:HIT + Workflow RedesignHIT + Workflow Redesign

• Develop Core TeamDevelop Core Team» Stakeholders: CNAs, Floor Nurses, Dietician, Staff Stakeholders: CNAs, Floor Nurses, Dietician, Staff

Development, Wound Nurse, DONDevelopment, 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. VarianceIntegrate reports into existing processes: QI, Wt. Variance» Establish new processes for report useEstablish new processes for report use– Weekly 5-Minute Stand ups: CNA staffWeekly 5-Minute Stand ups: CNA staff– Staff Development Weekly Review: in-servicing needsStaff Development Weekly Review: in-servicing needs– MDS Nurse Weekly ReviewMDS Nurse Weekly Review– Management Monitoring Management Monitoring – End of Shift Report Format: CNAsEnd of Shift Report Format: CNAs

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How Can Technology Support How Can Technology Support Workflow Redesign?Workflow Redesign?

1.1. Translate data into information to support Translate data into information to support clinical decisions and care planningclinical decisions and care planning» Access to right information when neededAccess to right information when needed» Timely Reports and queries vs. quarterly Timely Reports and queries vs. quarterly

(e.g., MDS)(e.g., MDS)» Alerts, Reminders, PromptsAlerts, Reminders, Prompts» Monitor ComplianceMonitor Compliance

2.2. Streamline workflowStreamline workflow» Standardize/streamline dataStandardize/streamline data» Improve communicationsImprove communications

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Approach: Approach: Process –Information –Decision MakingProcess –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

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New Process #1:New Process #1:CNA 5-Minute Stand UpCNA 5-Minute Stand Up

ObjectiveObjective: Conduct focused feedback sessions with CNA staff : Conduct focused feedback sessions with CNA staff each week to ensure front-line team aware of residents at each week to ensure front-line team aware of residents at risk, plan of action, and follow uprisk, plan of action, and follow up

ProcessProcess• 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, Nutrition Report: Meal intake - current % and trends, TF, New or worsened ulcerNew or worsened ulcer

» Priority Report: Red areas, open areasPriority Report: Red areas, open areas• Confirm report information is consistent with clinical picture, Confirm report information is consistent with clinical picture,

care plan is in place, and communicate to front-line staff 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.

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Results:Results:CNA 5-Minute Stand UpCNA 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 CNA documentation of meal intake becomes more accurate

and completeand complete• Dietician more aware of resident needs: earlier identification Dietician more aware of resident needs: earlier identification

of residents at nutritional riskof residents at nutritional risk• Dietician more involved in follow up: e.g., monitor snack Dietician more involved in follow up: e.g., monitor snack

intakeintake• Staff development more aware of CNA in-service needs and Staff development more aware of CNA in-service needs and

follow upfollow up“The overall communication is improved. We

talk more with each other.”

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New Process #2:New Process #2:Management MonitoringManagement Monitoring

ObjectiveObjective:: Review reports with Unit Managers each week – Review reports with Unit Managers each week – establish plan for week establish plan for week

ProcessProcess• 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 development Identify CNA in-service needs w/staff development » BehaviorsBehaviors» Red areasRed areas» Open areasOpen areas

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Results:Results:Management MonitoringManagement Monitoring

• Inaccurate documentation of resident behaviors by Inaccurate documentation of resident behaviors by CNA staffCNA staff» Discrepancy between CNA and RN observation of Discrepancy between CNA and RN observation of

behaviorsbehaviors• 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.”

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Facility Time CommitmentFacility Time Commitment

• For leadershipFor leadership: approximately 1-2 days to : approximately 1-2 days to confirm plans and discuss HIT options. confirm plans and discuss HIT options.

• For the multi-disciplinary team:For the multi-disciplinary team: » Weekly conference calls for the first 3 months Weekly conference calls for the first 3 months

lasting 30 minutes to 1 hour, and lasting 30 minutes to 1 hour, and » Bi-weekly calls for the next 12 months.Bi-weekly calls for the next 12 months.

• For staff developmentFor staff development: 4 hours per week for : 4 hours per week for the first 2-3 months to support initial the first 2-3 months to support initial implementation.implementation.

• One-day meetingOne-day meeting with the consultants on-site. with the consultants on-site.

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HIT InvestmentHIT Investment

• Low cost optionLow cost option (Digital Pen Systems) (Digital Pen Systems)» $12K to $15K for 100 bed facility in yr 1$12K to $15K for 100 bed facility in yr 1

• High cost optionHigh cost option » $65 - $100k for 100 bed facility in yr 1 $65 - $100k for 100 bed facility in yr 1

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Lessons Learned: Lessons Learned: CNA documentationCNA 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 formOne 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

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Lessons Learned: Lessons Learned: ImplementationImplementation

On-going implementation strategy involves On-going implementation strategy involves bothboth top leadership and front-line clinical teams.top leadership and front-line clinical teams.

Start small: focus on 1-2 reports for team to use.Start small: focus on 1-2 reports for team to use.Keep review of report information focused: do Keep review of report information focused: do

not slip into lengthy meetings.not slip into lengthy meetings.Identify how report can eliminate manual work Identify how report can eliminate manual work

or make work easier for staff.or make work easier for staff.On-going training and follow-up on reports is On-going training and follow-up on reports is

necessary: how to access, how to print, and when necessary: how to access, how to print, and when to use.to use.

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Lessons Learned: Lessons Learned: ImplementationImplementation

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 workflowEstablish partnerships and local championsDedicate project management resources

– Nursing home facilities lack knowledgeable and Nursing home facilities lack knowledgeable and experienced team to implement information technology, experienced team to implement information technology, train staff, and managing change to achieve results.train staff, and managing change to achieve results.

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ImpactImpact

• Reduce workflow inefficienciesReduce workflow inefficiencies::» Eliminate an average of 3-4 CNA daily Eliminate an average of 3-4 CNA daily

documentation forms (a reduction of documentation forms (a reduction of 53.2%)53.2%)

» Achieve >90% documentation Achieve >90% documentation completeness rates for CNAscompleteness rates for CNAs

» Decrease staff time to compile reports for Decrease staff time to compile reports for MDS and State RegulatorsMDS and State Regulators

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ImpactImpact• Prevent pressure ulcers: Decrease high risk pressure Prevent pressure ulcers: Decrease high risk pressure

ulcer rate ~ 33% ulcer rate ~ 33% » Potential savings of Potential savings of

– $1,932 per Stage 1$1,932 per Stage 1

– $7,170 per Stage 2 $7,170 per Stage 2

– $11,534 per Stage 3 $11,534 per Stage 3

– and $14,077 per Stage 4 pressure ulcer event (FY 05$, not and $14,077 per Stage 4 pressure ulcer event (FY 05$, not including hospitalization)including hospitalization)

• Better utilize investment in CNA staff time to document Better utilize investment in CNA staff time to document each shifteach shift» Rough estimate: $37K per year for 100 bed facilityRough estimate: $37K per year for 100 bed facility