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Leveraging Certified Nursing Assistant Documentation and Knowledge to Improve Clinical Decision Making

The On-Time Quality Improvement Program to Prevent Pressure Ulcers

Sharkey, Siobhan MBA; Hudak, Sandra RN, MS; Horn, Susan D. PhD; Spector, William PhD

Author Information
Advances in Skin & Wound Care: April 2011 - Volume 24 - Issue 4 - p 182-188
doi: 10.1097/01.ASW.0000396244.65415.7f


The On-Time Quality Improvement for Long-term Care Program (On-Time) has 3 main components:

  • (1) Leveraging documentation and knowledge of certified nursing assistant (CNA) staff, who serve as primary informants to licensed staff
  • (2) Supporting collaborative clinical decision making of a multidisciplinary team using clinical decision support tools-reports summarizing information from weekly documentation
  • (3) Establishing practices for proactive risk identification and early intervention to prevent pressure ulcers (PrUs) as part of frontline caregivers' daily work.

The program is an innovative blend of research evidence, quality improvement (QI) principles, health information technology (HIT), clinical decision-making tools, culture change, and facilitation of frontline teams responsible for implementing process improvements. On-Time was developed with funding from the Agency for Healthcare Research and Quality (AHRQ; formerly called the Agency for Health Care Policy and Research), in collaboration with the California Health Care Foundation, and more than 75 long-term-care (LTC) facilities across the United States. Although PrU prevention is the initial clinical area of focus, applying the On-Time approach to other clinical areas such as PrU healing, falls prevention, and avoidable hospitalization or emergency department visits is under way.

The On-Time PrU prevention effort differs from other efforts by focusing on frontline provider participation and facilitating implementation of practical improvements to blend into daily workflow. Leveraging the observations of CNA staff, who serve as primary informants to licensed staff, is a key ingredient of the On-Time approach. Weekly clinical decision-making reports based on CNA documentation provide more timely information of residents at high risk than Minimum Data Set (MDS) assessments and has resulted in a 42% decline (from 4% to 2.3%), based on initial implementation of the program in 21 facilities with a high level of implementation.

After reading this article, the clinician will be better able to interpret the key components of the On-Time approach and demonstrate examples of process improvements that integrate clinical decision-making reports into daily practice.


PrU incidence (new facility-acquired) and prevalence (existing and new facility-acquired) remain high among LTC facility residents, despite efforts to create and implement guidelines for prediction and prevention of ulcers (eg, AHRQ guidelines on prevention and treatment of PrUs, American Medical Directors' Association guidelines to prevent PrUs, and International Prevention and Treatment Guidelines from National and European Pressure Ulcer Advisory Panels). It is clear that a more effective prevention strategy is needed, including implementing best PrU prevention practices and supporting integration of best practices into daily workflow in LTC facilities.1-13

PrUs, defined as "any lesion caused by unrelieved pressure resulting in damage of underlying tissue," are a serious and common problem in the frail and in older adults.1 They cause pain and disfigurement, interfere with activities of daily living, and are associated with longer hospital stays and increased rates of morbidity and mortality.2,3 In LTC facilities, reported rates of PrU incidence range from 2.2% to 23.9%, and prevalence rates range from 2.3% to 28%.4 Recent research indicates that factors, such as nutritional interventions, fluid orders, medications, specific incontinence interventions, and staffing patterns, are associated with prevention of PrUs in LTC residents.5-9

Every year, PrUs affect more than 1 million acute-care and LTC patients. More than $355 million is spent annually on PrU treatment in LTC settings.2,4,10 The cost of PrUs is high, projected between $1.3 and $6.8 billion yearly,1,2,10 and there are serious consequences of ulcers: resident morbidity, mortality, and loss of quality of life. There are additional costs associated with liability and litigation. Although the financial costs associated with PrUs are high, the human toll of pain, depression, altered self-image, stress, infection, and increased morbidity and mortality is immeasurable.

Efforts focused on reducing PrU incidence are common in long-term care.11-13 Despite knowledge about how to prevent PrUs in LTC facilities, too often practice improvements are designed and implemented without thinking through how they will be integrated efficiently with existing staff workflow, documentation processes, and HIT implementation.11


On-Time implementation is a 15- to 24-month facilitated QI program.


An LTC facility's readiness to implement On-Time is assessed by the following:

  • PrU rates are high, and improving in-house PrU incidence rates is a priority. Typically, On-Time nursing homes have an in-house PrU incidence rate greater than 2% on at least 1 nursing unit.
  • Leadership commitment and endorsement and support of top leadership to enhance care processes related to PrU prevention. Although frontline staff are the cornerstone of On-Time, a nursing home is not ready to start On-Time without the support of top leadership.
  • Experience with QI. An LTC facility is more likely to implement On-Time successfully if there is previous experience with QI, such as implementing a QI project in the last 6 to 12 months or participation in state or national QI efforts such as the Advancing Excellence Campaign.14
  • Electronic CNA documentation (existing or planned). Adoption of HIT for CNA documentation is necessary to implement On-Time.

On-Time Tools

On-Time tools are organized into 4 categories:

  • (1) Set of CNA documentation data elements developed and refined by 50+ facilities to standardize and streamline CNA documentation processes and incorporate key measures of clinical best practices for CNAs and care team use Table 1.
  • (2) Clinical decision-making reports (On-Time reports) are viewed weekly and contain trended information using daily CNA data: (a) Completeness Report for CNA documentation, (b) Nutrition Report, (c) Weight Summary Report, (d) Trigger Summary Report, (e) Priority Report, and (f) Red Area Report.
  • (3) Process improvements linked to use of each On-Time report.
  • (4) Tracking tools to monitor progress of implementation strategies. Tracking tools are available for each On-Time report and demonstrate effectiveness of process improvement efforts.
Table 1
Table 1:

On-Time Implementation

For successful implementation, an LTC facility starts by

  • establishing an engaged project management nursing team that includes director of nursing (DON) or assistant DON, staff development, and QI;
  • designating a multidisciplinary clinical team to champion the QI effort including CNAs, nurses, dietitians, rehabilitation therapists or restorative nurses, and social workers;
  • identifying a facilitator/consultant who is responsible to facilitate the implementation process, mentor clinicians to use data for effective clinical decision making, and serve as a resource to the facility team and HIT vendor.

There are 4 phases of On-Time implementation:

  • (1) Preparation includes action items related to HIT (if necessary), identifying staff and facilitator resources, and establishing the work plan.
  • (2) Documentation review and redesign focus on review of CNA documentation data elements and process.
  • (3) Process improvement implementation involves the facility team working with a facilitator to implement On-Time reports and process improvements on all units.
  • (4) Impact monitoring includes gathering and reporting impact data at baseline (preimplementation) and ongoing every 6 months.


Prior to implementing On-Time, a nursing facility must confirm whether technology resources, staff resources, and facilitation are available to support the program. Technology resources include a software module for CNA daily documentation and access to On-Time reports. A facility is not required to use a specific software vendor to implement the program, but the software must include On-Time HIT minimum requirements-a set of core data elements for documentation and clinical decision-making reports. More than 10 HIT vendors have met the requirements. If a facility has implemented electronic CNA documentation, the next step is to confirm that the On-Time requirements are met. These HIT requirements are available at

Each team reviews the generic On-Time work plan Table 2 and customizes it to its specific situation.

Table 2
Table 2:

Documentation Review and Redesign

Review CNA documentation and confirm that standard On-Time elements are embedded. Required On-Time data elements are linked to best practices and are the result of research that analyzed factors associated with fewer residents developing PrUs: meal intake, weight, and bowel, bladder, and skin observations.5 The first step is conducting a review of existing CNA documentation and confirming availability of On-Time elements for CNA daily charting. Gaps in documentation are identified during this process, and plans are established to work with the software vendor to address missing elements.

Process Improvements Implementation

Process improvements for On-Time and use of clinical decision-making reports in daily practice, are implemented unit by unit throughout the facility and include the following:

Monitor CNA documentation completeness: Because On-Time clinical reports are generated completely from CNA daily documentation, monitoring completeness is an important first step in report use. The Completeness Report helps staff monitor CNA documentation completeness trends and identify areas that may require follow-up. Nurse managers, charge nurses, staff educators, MDS nurses, and other members of the multidisciplinary team can use the report to monitor documentation completeness at the unit or shift level, provide feedback to staff, and focus in-service sessions.

Some facilities have found that monitoring completeness alone may not be enough to achieve and/or sustain high completion rates. By moving to the On-Time process improvements outlined below, CNA staff see the link between their daily documentation and clinical reports used by the multidisciplinary team and ultimately become more accountable for their documentation when they see how licensed staff use it.

Identify residents earlier who are at risk for decreased meal intake and weight loss: Nutritional status is critical for PrU prevention, and CNA documentation of meal intake and weight information is important to the entire team to understand resident risk. The Nutrition Report is used to identify and monitor residents with decreased meal intake and/or weight loss, both of which are indicators for high risk of PrU development. Weekly meal intake for the past 4 weeks is trended for each resident. Weight changes for the past 30, 90, and 180 days are reported.

Process improvements using the Nutrition Report include a 5-minute stand-up meeting held weekly with dietary, nursing, and CNAs. This "huddle" is an example of how a team integrates the use of the Nutrition Report into practice, improves communication across disciplines, and includes CNA staff in collaborative discussions with nursing and dietary. Although a facility may have one-on-one communication between CNA and nurse or CNA and dietitian or may have a similar briefing process in place, the On-Time "stand-up" is distinctive in being a weekly meeting that is brief, focused, team-based, and data driven. The 5-minute stand-up meeting objectives are as follows:

  • Elicit CNA feedback on resident eating habits and preferences that may provide insights for dietitian and nurse follow-up.
  • Confirm that appropriate care plan interventions are in place and establish follow-up plans with frontline staff.
  • Promote CNAs as an integral part of team discussions and key informants to licensed staff.

Identify residents at highest risk for PrU development: The Trigger Summary Report is used to identify residents at potential risk for PrU development based on meal intake, weight, urinary incontinence, bowel incontinence, and Foley catheter use. The report focuses staff on high-risk residents to determine if they need additional follow-up, such as referrals, tests, or changes in the care plan.

Process improvements using the Trigger Summary Report include identifying and communicating high-risk residents on a weekly basis, enhancing rehabilitation team focus on high-risk residents, and monitoring unit-level trends of high-risk triggers. For example, nursing can focus Skin Team discussion on residents with a high number of triggers or an increased number of triggers, assess appropriateness of interventions, and monitor interventions for residents with improvement from the previous week. Rehabilitation liaisons can review the Trigger Summary Report and identify high-risk residents for rounds with CNAs to review residents' positioning needs and assess need for rehabilitation referrals.

Identify priority residents with potential weekly changes: A key part of PrU prevention is identifying changes in resident status from week to week. The Priority Report identifies residents with changes from the previous week in 5 areas that place a resident at potential risk for developing a PrU: decreased meal intake, weight loss, increased incontinence episodes, change in or increased behavior problems, and new or worsening PrU.

Process improvements using the Priority Report include unit coordinator and dietitian reviewing the Priority Report in conjunction with the Nutrition Report prior to 5-minute stand-up meetings to focus on high-risk residents. Also, nurse managers and MDS nurses use the Priority Report to identify residents with potential changes in health status and flag residents to discuss at morning meetings.

Identify residents with red areas on skin: The Red Area Report contains a list of residents with red areas observed by CNAs and can be used as a worksheet by nursing to confirm that follow-up on red areas has occurred and that care plans are updated each week. Also, the report helps identify need for additional education for CNAs if errors in documentation are noted. Using the Red Area Report does not replace verbal reporting that is in place, but rather provides a secondary check to ensure nothing falls through the cracks.

Impact Monitoring

Each facility establishes a process to gather and summarize key measures on an ongoing basis including clinical outcomes, measures of quality of care, and process measures such as CNA documentation completeness rates. Key measures of outcome and process are collected at baseline, prior to implementing On-Time process improvements, and continue on a quarterly basis after implementation.


More than 75 participating facilities have found many positive effects of the On-Time program. Results, profiled from the initial pilot and dissemination efforts, have been published in one journal article and several AHRQ Final Reports.15 On a broad scale, On-Time has improved clinical outcomes (PrU rates), increased CNA engagement in process improvements, improved communication about high-risk residents among the entire care team, improved prevention practices and timely interventions for high-risk residents, and supported HIT adoption in a meaningful way linked to QI. Results to date include the following:

  • reduced in-house incidence of PrUs
    • ○ 42% decline (from 4% to 2.3%), based on initial implementation of program in 21 facilities with a high level of implementation
    • ○ 55% decline 12 months after implementation, based on New York State On-Time early results for rapid implementers (n = 3 facilities)
  • reduced Centers for Medicare & Medicaid Services and quality measure-high-risk residents with PrUs
    • ○ 33% reduction within a year, based on pilot program among 11 participating LTC facilities16
    • ○ 30.7% decline (from 13.1% to 9.1%), based on initial implementation of program with 21 facilities with a high level of implementation
    • ○ 30% decline (from 11.7% to 8.2%) 9 months after implementation, based on New York State On-Time, early results for rapid implementers (n = 3 facilities)
  • feedback from On-Time QI teams in more than 75 facilities includes the following:
    • ○ "Reviewing the reports with the dietitian, nurse, and other CNAs is very helpful. We have a lot of information to share. We feel like we are being listened to."-CNA
    • ○ High-risk residents are identified earlier and more consistently. "CNAs are clearly identifying residents who are declining, for example, residents who cannot feed themselves or not eating-anything they see that is different is being reported."-Nurse manager
    • ○ Communication has improved among the entire multidisciplinary team. "The On-Time process has fostered open communication between dietitians and CNA staff. CNAs are more comfortable approaching dietitians throughout the day to communicate issues."-Dietitian
    • ○ "The 5-minute stand-up meeting has led to earlier identification of meal preferences, diet changes, dental issues, swallowing problems, new pain identification, device problems, and skin issues."-Nurse manager


The On-Time program was developed to embed HIT into QI at the frontline and incorporate culture change, workflow redesign principles, and current best clinical practices to prevent PrUs in LTC facilities.

In summary, the set of principles at the foundation of the On-Time program is as follows:

  • QI efforts integrated into daily work are more readily adopted and sustained.
  • Multidisciplinary teams are essential for QI efforts.
  • CNAs are critical members of the multidisciplinary team and can be better utilized in QI efforts with a clear role and well-structured process.
  • HIT alone will not lead to improved quality. Use of HIT for improved clinical decision making requires redesign of workflow and links to specific process improvement activities.

After reading this article, the clinician will be better able to interpret key components of the On-Time QI approach; demonstrate examples of how On-Time QI clinical reports-summarizing CNA documentation into trended resident information, such as meal intake, weight, and so on-can be used to design staff education to ensure credibility (completeness and accuracy) of CNA documentation, target PrU prevention to the highest-risk residents, and result in earlier interventions; illustrate the process improvement using Nutrition Report-5-minute stand-up meetings with CNA, dietary, and nursing-to identify residents at nutritional risk and at risk for PrU development; and evaluate areas of PrU prevention that could be strengthened with use of the On-Time approach.

Additional information about On-Time can be found on these AHRQ Web sites: and



1. Morris J, Lipsitz L, Murphy K, Belleville-Taylor P. Quality Care in the Nursing Home. St Louis, MO: Mosby Lifeline; 1997.
2. Miller H, Delozier J. Cost implications of the pressure ulcer treatment guideline. A report to the Agency for Health Policy and Research, Panel for the Treatment of Pressure Ulcers. Rockville, MD: AHCPR; August 1994.
3. Berlowitz DR, Brandeis GH, Anderson J, et al. Effect of pressure ulcers on the survival of long-term care residents. J Gerontol A Biol Sci Med Sci 1997;52A:106-10.
4. Cuddigan J, Ayello EA, Sussman C, eds. Pressure Ulcers in America. Prevalence, Incidence, and Implications for the Future. Reston, VA: National Pressure Ulcer Advisory Panel; 2001.
5. Horn SD, Bender SA, Ferguson ML, et al. The National Pressure Ulcer Long-term Care Study: pressure ulcer development in long-term care residents. J Am Geriatr Soc 2004;52:359-67.
6. Horn SD, Bender SA, Bergstrom N, et al. Description of the National Pressure Ulcer Long-term Care Study. J Am Geriatr Soc 2002;50:1816-25.
7. Jaul E. Assessment and management of pressure ulcers in the elderly: current strategies. Drugs Aging 2010;27:311-25.
8. Kwong EW, Pang SM, Aboo GH, Law SS. Pressure ulcer development in older residents in nursing homes: influencing factors. J Adv Nurs 2009;65:2608-20.
9. Shahin ES, Meijers JM, Schols JM, Tannen A, Halfens RJ, Dassen T. The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes. Nutrition 2010;26:886-9.
10. Brem H, Maggi J, Nierman D, et al. High cost of stage IV pressure ulcers. Am J Surg 2010;200:473-7.
11. Milne CT, Trigilia D, Houle TL, Delong S, Rosenblum D. Reducing pressure ulcer prevalence rates in the long-term acute care setting. Ostomy Wound Manage 2009;55(4):50-9.
12. Tippet AW. Reducing the incidence of pressure ulcers in nursing home residents: a prospective 6-year evaluation. Ostomy Wound Manage 2009;55(11):52-8.
13. Reynolds TM. Risk assessment for prevention of morbidity and mortality: lessons for pressure ulcer prevention. J Tissue Viability 2008;17(4):115-20.
14. Advancing Excellence Campaign. Last accessed January 24, 2011.
15. AHRQ Final Reports summarized on web site. Last accessed February 14, 2011.
16. Horn SD, Sharkey SS, Hudak S, Gassaway J, et al. Pressure ulcer prevention in nursing homes: a pilot study implementing standardized nurse aide documentation and feedback reports. Adv Skin Wound Care 2010;23:120-31.

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On-Time Quality Improvement for Long-term Care Program; certified nursing assistant documentation; improve clinical decision making

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