Preventing Pressure Injuries - Change Package - Northern ...

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Preventing Pressure Injuries - Change Package - Northern ...
Preventing Pressure Injuries
     Change Package

          Adapted from the Transforming Care Programme 1000 Lives Plus
                                 NHS Wales

                                        Healthcare Improvement Scotland
           Preventing Pressure Ulcer Driver Diagram and Change Package

                                    Institute for Healthcare Improvement
                                   How to guide: Prevent pressure ulcers

                      Ko Awatea and Health Quality & Safety Commission
                           Target CLAB Zero Quality Improvement Guide
This ‘Preventing Harm From Falls: Change Package’ was developed in collaboration with the Northern Region Falls and
Pressure Injuries Expert Group as well as individual contributors and is the result of working together for the shared purpose
of reducing harm from falls.

First, Do No Harm would like to thank those involved for their support and expertise.

The First, Do No Harm Falls and Pressure Injuries Collaborative has seen teams from across the
Northern Region district health boards and residential aged care facilities engaged in using the
Institute for Healthcare Improvement (IHI) Model for Improvement to raise the profile and change care
practices to reduce the incidence of patients or residents developing pressure injuries.

The collaborative methodology has been found to work well as a structured way to implement
evidence-based practices that have been enhanced by using local knowledge and skills. The
campaign team supports change in participating facilities with learning sessions, access to subject
matter and improvement experts, provision of improvement tools, highlighting success and the
sharing of learning across the Northern Region. The learning sessions provide a good opportunity
to bring similar teams together to share information and develop new knowledge around the
implementation of change ideas.

This ‘How to’ guide aims to assist teams and care providers to use the Model for Improvement
methodology to drive meaningful improvements in care. Teams involved in the collaborative process
have contributed to this guide by forwarding knowledge they have gained in participating in this
improvement journey.

Why a pressure injuries collaborative?
All over the world, including in New Zealand, health care workers are proving that patient safety can
be greatly improved and many complications or harm events that were previously considered
unavoidable actually are avoidable. They are, in fact, redefining what is acceptable in terms of
patient safety.

Healthcare is a limited resource with the potential for unlimited claim (Berwick, 2010). Evidence
suggests that globally, within New Zealand and locally in the Northern Region, the population is
ageing (Hope & Cox, 2005; World Health Organisation, 2005) realising the potential for increased
chronic long-term health problems and subsequent increased demand for healthcare (Ministerial
Review Group, 2009). As a result, many healthcare organisations and governments, both in New
Zealand and other developed countries, are striving to reduce escalating costs and improve patient
outcomes to meet the growing need for healthcare.

Pressure injuries are a major cause of preventable harm for healthcare services and develop most
commonly over bony prominences as a result of sustained pressure or pressure in combination with
shear (EPUAP/ NPUAP 2009). Injury sustained is classified into four stages, categories or grades
whereby (1) is the least severe with a persistently reddened area of skin and (4) represents full
thickness tissue destruction, frequently characterised by a necrotic ulceration affecting muscle and
bone, placing the patient at high risk of sepsis, renal failure, organ system failure and death (Gefen

Pressure injury is associated not only with significant pain and a decreased quality of life (Gorecki et
al 2009) but also increased mortality (Landi et al 2007, Redelings et al 2007), morbidity and longer
length of hospital stay (Graves et al 2005). Pressure injuries impact upon already overstretched
healthcare budgets with expenditure estimated at 1-4% of total National Health Services (NHS)
spending in the United Kingdom (Bennett et al 2004) with similar high fiscal costs having also been
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013                        2 of 24
identified in other countries (Severens 2002, Gethin et al 2005). Recent cost analysis from robust
patient record data in the United States (Brem et al 2004) identified an average expenditure of more
than US$129,000 to heal a Grade 4 pressure injury and treat the associated complications. This
research highlights the importance of timely recognition and prompt treatment of identified pressure
damage in the early stages which would eradicate much pain and suffering, save thousands of lives
and reduce millions in associated costs.

As a result of this shared learning, established programmes have already:
   • provided a framework to empower front line staff to seek out new ways to continuously
       improve how they provide care, and
   • facilitated an approach which allows for high impact, well defined tools to be tested, adapted
       and adopted.

First, Do No Harm
In 2011 the New Zealand Government required district health boards (DHBs) to work together to
produce regional health plans. The four northern DHBs (Auckland, Counties Manukau, Northland
and Waitemata) is one region and developed a health plan that clearly articulated safety as part of
its work programme: First, Do No Harm is the name given to that programme.

The First, Do No Harm campaign aims to promote systematic changes to improve quality and safety
and thus minimising harm and reducing pressure on health services. The Northern Region has
taken a lead on a sector-wide regional approach to reducing healthcare associated harm and is now
working with the Health Quality and Safety Commission’s National Patient Safety Campaign Open
for better care launched on 17 May 2013 to ensure alignment in this work.

As well as reducing pressure injuries, the other key areas of focus for First, Do No Harm are:
   • reducing harm from falls
   • reducing harm from healthcare-associated infections
   • improving transfer of clinical information, and
   • improving medication safety

In December 2011, First, Do No Harm, in partnership with the Health of Older People Network,
brought together district health board and residential aged care staff working on pressure injuries to
discuss how to define a pressure injury, data collection and measurement, and reporting processes
for the region (Falls and Pressure Injuries Collaborative Learning Session Zero). From this initial
day, the Falls and Pressure Injuries Expert Group met in January 2012 and clarified agreement for
the Northern Region.

As such, the agreed definition for a pressure injury is: “a localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of pressure, or pressure in combination with
shear and/or friction” (National Pressure Ulcer Advisory Panel (NPUAP), 2007). The European
grading system for pressure injuries (Defloor, T., M. Clark, et al. 2005) was adopted. It was agreed
to report Grade 1, Grade 2, Grade 3 and 4 pressure injuries with ungradeable to be included with
the Grade 3 – 4 category. Pressure injuries related to medical devices also to be included in the
data capture.

The regional First, Do No Harm ‘Falls and Pressure Injuries Collaborative’ launched officially in June
2012 with Learning Session (LS) One. Since then teams have been working hard on delivering changes
which have made a positive impact on the care that is delivered to patients. The regional work on
reduction in harm from pressure injuries has continued to progress via learning sessions as outlined

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013      3 of 24
Event           Date                  Main focus
 LS Zero         8 Dec 2011            Building will and enthusiasm, provision of information,
                                       introduction to the collaborative methodology and IHI training
 LS One          27–28 June            Methodology, tools and understanding data. Get ideas for
                 2012                  improvement. Refine aim and measures and provide
                                       participants with the ‘How to Guide’.
 LS Two          5–6 Nov 2012          More ideas for change. Deeper understanding of testing and
                                       implementation. More collaboration. Prepare for next action
 LS Three        8 May 2013            Celebrating successes. ‘Holding the gains’ and the ongoing roll-
                                       out to other areas.
 Phase 2         28 June 2013          Collaborative has been relaunched for new teams recently
 LS One                                engaged in improvement activities aimed at reducing falls and
                                       pressure injuries and those who have previously taken part in
                                       the Collaborative and would like further input or coaching.

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013      4 of 24
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013

                                                                                                                                                                                                                                                                        Example of First, Do No Harm Falls and Pressure Injuries Collaborative structure
                                                                                        Overview of First, Do No Harm & HOP Regional Falls and Pressure Injuries Innovation and Implementation Collaborative
                                                                                                                                                             "Learn our way into improvement"

                                                                                                                       Prework (6 months)                                                        Local adaptation and permanance (12 - 24 months)


                                                                                                                                         HOP                                         Action                          Action
                                                                                         Problem                  Recruit
                                                                                                                                        working                                      period -                        period -
                                                                                        identified                teams
                                                                                                                                        groups                                        PDSA                            PDSA

                                                                                                     Learning Session                                                                                                                                 Sustaining
                                                                                                                                                                        Learning                      Learning                     Learning
                                                                                                     Zero (08/12/2011) -                                                                                                                             improvement -
                                                                                                                                                                       Session 1                     Session 2                    Session 3
                                                                                                      regional falls & PI                                                                                                                             holding the
                                                                                                                                                                       27-28 June                   5-6 Nov 2012                  8 May 2013
                                                                                                          workshop                                                                                                                                       gains

                                                                                                        Smaller Expert                                                              Mini-LS1 +
                                                                                                     Group (20/01/2012) -                                                            Show &                                                             Change
                                                                                                      falls & PI definitions                                                          Share                                                            package -
                                                                                                          and measures                                                                3 Oct                                                          'How to' guides

                                                                                        Nov-11        Dec-11      Jan-12       Feb-12   Mar-12     Apr-12     May-12    Jun-12                                                                           Jun-13

                                                                                                                 Work on

                                                                                                                   Expert                          Expert     Expert
                                                                                                                   Group                           Group      Group

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                                                                                                                                                                                                                                                    FDNH (April 2013)
Purpose of this change package
This booklet attempts to capture the learning from across the Northern Region and provide a guide
and reference for the reduction of harm from pressure injuries. A number of changes have been
identified, tested and proven that can reduce pressure injuries when applied reliably to patient care. The
following sections detail these suggested changes.

This change package has been adapted from the 1000 lives campaign in Wales, Quality
Improvement Scotland, K-HEN – Race to Quality, Target CLAB Zero Quality Improvement Guide,
and the Institute for Healthcare Improvement How to guide: Prevent pressure ulcers. The change
package identifies and establishes recommended interventions which have been proven to
collectively bring about improvements in pressure injury prevention. This package illustrates what
interventions care areas should consider in order to start to improve pressure area care as part of a
whole system of care.

There are three distinct parts to this change package:
   • driver diagram
   • change concepts, and
   • measures.

A driver diagram is a way of describing the theory of elements that need to be in place to achieve
an improvement aim (see below). The initial driver diagram for an improvement project is a tool to
demonstrate the improvement team’s ideas and theories as to how to achieve the improvement
outcome. It helps to focus on the cause and effect relationships that can exist in complex situations,
such as pressure injuries reduction. Driver diagrams identify what process changes will help people
to ‘do the right thing’. The primary drivers are high level concepts or levers that, if implemented, will
achieve the improvement aim. The best way of implementing primary drivers is to identify a series of
actions or projects (otherwise known as secondary drivers) which, when undertaken, will contribute
to achieving the primary drivers and in turn, the aim. Interventions or change concepts show the
actions that have been shown to make a difference and bring about improvements. The driver
diagram is a living document that is updated throughout the improvement project to reflect the new
knowledge gained through the improvement process.

A change concept is a general notion or an approach to improving an aspect of care. A change
idea is an action which is expressed as a specific example of how a particular change concept can
be applied in real life.

Also included in this package is a suite of different measures: process, outcome and balancing
measures (see Appendix 1). Measures are important as they can provide information on the
effects of the changes that have been tested to see if they have actually led to an improvement.
Data collected for quality improvement purposes needs to be just good enough to answer the
question ‘How do I know the changes I am making are an improvement’? In order to answer this
you will need a defined process (such as compliance with all elements of a care bundle) which is
evidently linked to an outcome (such as a reduction in the numbers of pressure injuries). Both
process and outcome data which are linked are essential to evaluate the effectiveness of change.
The data you collect in real time can be used to tell the improvement story and build the case and/or
argument to change practices in order to improve outcomes. Remember that data collection and its
interpretation does not need to be complicated. A simple check on the process(es) with the use of
annotated ‘run chart’ over time will do. There is real value in ensuring that data is displayed for
those involved in the improvement effort and it should be easy to understand.

Examples of types of measures that may be useful can be found in Appendix 1.

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013      6 of 24
How to use this change package
Users of this change package are encouraged to review the change package to determine:
   • What practices might already be in place in their care area(s) and decide if further work is
   • Identify and prioritise the first few changes that a team will undertake, and determine if these
       changes lead to an improvement (remember that improvement takes time).
   • What other changes will be undertaken at a later date by the team.
   • We suggest that a formal improvement method is used and have included information on
       the Model for Improvement to guide your improvement work. This model is a simple but
       powerful tool for accelerating improvement (see Appendix 2).

The Institute of Healthcare Improvement’s (IHI) Model for Improvement and care bundle
methodology have been used to drive forward improvements in various services and for various
patient safety initiatives.

Bundles of care are grouping of best practice in relation to a specific health problem or disease that
individually improve care, but when applied together may result in a substantially greater
improvement for patients. The science supporting each component of the bundle is sufficiently
established to be considered the current standard of care.

A bundle of care is not intended as a comprehensive list of all actions within a process, nor is it a
care pathway. What it does is reduce the opportunity for omission of those components of a process
that are thought to be essential.

The aim of using bundles of care in the care planning and management of people who are a high
pressure injuries risk will be to ensure that core assessments, interventions and any management
post fall are delivered consistently and in line with current guidance.

The bundle of care is:
   • all patients received universal interventions
   • risk factors identified for patients have correct interventions applied, and
   • high risk patients have additional interventions in place.

The Model for Improvement
The Model for Improvement (MFI) provides a framework in order to structure improvement efforts. It
was originally developed by Associates in Process Improvement ( to provide the
best chance of achieving goals and adopting ideas (Langley et at, 1996). The model is based on
three key questions, known as the thinking components:

           1.    What are we trying to accomplish?
           2.    How will we know that a change is an improvement?
           3.    What change can we make that will result in improvement?

These questions are then used in conjunction with small-scale testing of
change concepts. The doing component is known as plan-do-study-act
cycles (PDSA) as outlined in Figure 1.

                                               Figure 1: The Model for Improvement (IHI)
                                                      Improvement Guide, Chapter 1, p.24

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013      7 of 24
1. What are we trying to accomplish?
Undertaking improvement work is extremely challenging. Creating clarity by establishing the
specific problem to be addressed is a key step. What are we attempting to improve? How much
by when?

The Northern Region has established the aim of reducing pressure injuries by 20% by June 2014.

2. How will we know that a change is an improvement?
Once a clear outcome is defined, a set of measures is required. The principles to follow when
selecting a suite of measures are that the measure should be:

      -   well defined
      -   allow comparison between areas and over time
      -   be easy to collect or part of the current process, and
      -   specific and sensitive enough to allow outcomes to be regularly assessed.

In selecting measures it is critical that there is clarity in how they are defined. Teams must be clear
on the process for data collection and why it is being collected. A key learning is the value of staff
being involved in collecting data – data should be easily visible as this helps to build will and
engages the team in the improvement process.

There are times when it is not possible to have good outcome measures for the improvement work.
It is important to differentiate that improvement work is not the same as an experiment process.
Improvement is about adopting and adapting practice, based on evidence. It is also necessary to
have at least one measure to indicate the process that is to change.

3. What changes can be made that will result in improvement?
It is essential to link outcome measures to the ‘interventions’ – the systems and processes that will
help achieve the desired outcome.

The IHI has identified specific elements that have been shown to improve the success of
improvement teams.

      Creating will
      - The support of leadership for the improvement project and the resources to do the
        improvement work
      - Engagement of the team – champions and effective leadership, and
      - Establishing the need for improvement.

      - Development of the evidence based change ideas

      - Of ideas – active and frequent testing of ideas, and
      - Using real-time measurement at the outset to guide the testing.

      Components of an improvement initiative
      Form the team
      The team must be small enough to be effective, but must also include opinion leaders from
      each stakeholder group (i.e. doctors, nurses, and allied health staff). It is essential to be
      multidisciplinary and extra effort may be needed to secure times for medical clinicians to be
      involved. When starting out it is important to identify those who want to work on the project

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013     8 of 24
and work with them, rather than try to persuade detractors to be involved from the outset –
      work with the willing and expand the team as the results show credibility.
      It is useful to have a named coordinator of the team – a ‘go to’ person for questions and
      coordinator of meetings, etc.

      Complete a project charter
      A project charter is a statement of the scope, objectives and participants in a project. It
      provides a preliminary delineation of roles and responsibilities, outlines the project objectives,
      the methodology to be used, identifies the main stakeholders and outlines the expected
      outcomes and measures. For an example of a project charter, see the First, Do No Harm
      Campaign Charter on under ‘About us/About First, Do No Harm’.

      Complete a driver diagram
      A driver diagram is a way of describing the elements that need to be in place to achieve an
      improvement aim (see p3). See next page for an example of a pressure injuries driver diagram
      with secondary drivers and suggested change concepts and change ideas for testing.

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013      9 of 24
Pressure injuries driver diagram

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013   10 of 24
Secondary drivers

 Secondary drivers               Key change concepts and change ideas for PDSA testing

 • Understand pressure           • Educate staff, patients/residents on pressure injury factors.
   injury risk factors           • Utilise patient/resident and carer information leaflet.
 • Understand local              • Engage with the multidisciplinary team and develop a shared
   context and analyse             vision.
   local data to assess
   patient/residents at          • Set a clear local aim for reducing pressure injuries.
   risk                          • Engage with staff to learn about the barriers to risk assessment
 • Utilise ‘at risk‘ visual        being done within 6 hours from admission/transfer.
   cue/systems to quickly        • Work with staff to develop a system where at risk patients/residents
   identify those at risk          can be identified easily.
                                 • Utilise Safety Briefings/SBAR approach (situation, background,
                                   assessment, and recommendation) at handovers.
                                 • Documentation – SSKIN care bundle in use (visual cues).
 • Assess pressure               • Monitor compliance with on admission/transfer pressure injury risk
   injury risk on                  assessment and increase aim for >95% compliance by developing a
   admission/transfer              monitoring/feedback and learning loop to improve this process.
 • Reassess risk                 • Build reliable risk assessment into care bundle process (first step –
   regularly and when              see above).
   change in condition           • Visually communicate – use visual cues above the beds/doors of
 • Communicate risk                at risk patients/residents to alert staff to patients/residents risk of
   status                          acquiring a pressure injury.
                                 • Verbally communicate – incorporate patients/residents at risk into
                                   safety briefings/handover processes.
                                 • Monitor compliance with regular reassessment of risk and
                                   increase      compliance       to    >95%     by  developing    a
                                   monitoring/feedback and learning loop.
                                 • Develop a reliable method for patients/residents to be reassessed
                                   when there is a change in their condition.
 Reliably implement all          All elements of the care bundle must be evident and effectively
 elements of SSKIN care          carried out or it will not be counted as compliant.
    S - Surface                  Surface
    S - Skin inspection          • Ensure patient/resident is on the correct surface (mattress/cushion).
    K - Keep moving              • Ensure competency in surface choice and use of equipment.
    I - Incontinence             • Build reminder checks into routine care process and regular re-
    N – Nutrition                  assessment.

                                 Skin inspection
                                 • Inspect skin/pressure areas regularly to quickly identify pressure

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013       11 of 24
Secondary drivers

 Secondary drivers             Key change concepts and change ideas for PDSA testing

 Reliably implement all        Keep moving
 elements of SSKIN             • Ensure patients/residents are encouraged/assisted to move position
 care bundle                     regularly.
    S - Surface                • Use visual cues to ensure position changes regularly.
    S - Skin inspection        • Minimise pressure damage by ensuring manual handling equipment is
    K - Keep moving              available when turning patients/residents, kept by the bedside of
    I - Incontinence             patients/residents who have been assessed as at risk.
     N - Nutrition             • Introduce systems acceptable to all so that ward/care home team can
                                 reposition at risk patients/residents or encourage all patients/residents
                                 to move themselves at regular intervals.
                               • Introduce intentional rounding to prompt all patients/residents to
                                 change position.
                               • Introduce, in partnership with the patient/resident, a daily goals/plan of
                                 care sheet which will ensure that both the patient/resident and the
                                 wider multidisciplinary team are aware of how long the patient/resident
                                 should be sitting out of bed, when anti embolic stockings should be
                                 removed, if they should have repose boots (a pressure relieving
                                 device for heels) in situ etc.

                               Incontinence (increased moisture)
                               • Manage the moisture of patients/residents whose skin is exposed to
                                 increased      moisture      (wound     drainage/continence    issues/
                                 leaks/discharge/excessive sweating).
                               • Ensure skin is kept clean and dry (but note that excessively dry skin
                                 presents an increased risk so use barrier creams appropriately).
                               • Consider introducing a continence assessment tool which will inform
                                 the care plan/pathway.
                               • Move supplies nearer to the bedside to enable prompt cleansing when
                                 required. Include barrier cream, cleansing wipes, etc.
                               • Use prompts to remind staff to ask at regular intervals if the
                                 patient/resident would like to go to the toilet (check catheter
                                 patent/draining etc). Introduce intentional rounding prompts to offer
                                 the opportunity of going to the toilet.
                               • Where appropriate, introduce written guidance for staff for the
                                 appropriate use of faecal management systems to protect skin.

                               • Introduce prompts that alert nursing and catering staff to
                                 patients/residents who are at risk of malnutrition (and/or dehydration)
                                 and who may need support at mealtimes, e.g. ‘red tray‘ system.
                               • Use water jugs with prompts e.g. coloured lids to alert staff to
                                 encourage fluids and to refill.

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013        12 of 24
Secondary drivers

 Secondary drivers             Key change concepts and change ideas for PDSA testing

 Reliably implement all        Nutrition
 elements of SSKIN             • Consider use of food charts to monitor intake. Alternatively record fluid
 care bundle                     input/output on SSKIN care bundle communication tool.
    S - Surface                • Undertake a nutritional risk assessment to identify all patients /
    S - Skin inspection          residents at risk of malnutrition and refer to dietician as appropriate.
    K - Keep moving            • Introduce intentional rounding prompts such as ‘would you like a
    I - Incontinence             drink?’ ‘can you reach your drink?‘, or ‘soft drink cocktail hour‘ where
     N - Nutrition               juices are served to encourage patients/residents to keep hydrated.
                               • Ensure patients/residents on fortified supplements receive their drinks.
 • Utilise EPUAP               • Agree use of national pressure injury grading tool (EPUAP grading
   grading                       tool).
 • Initiate and maintain       • Make sure staff know about tool to aid with pressure injury
   correct and suitable          recognition and assist with their education.
   treatment                   • Utilise the SSKIN care bundle approach.
 • Utilise local nursing       • Work in partnership with patients/residents, their family and
   wound expertise               multidisciplinary team members.
                               • Know how to contact local wound nurse/other specialist if required.
 • Staff education             • Utilise formal and informal learning opportunities to educate staff
 • Educate patient and           about pressure injury risk.
   family                      • Use patient/resident stories to educate, motivate and inspire staff.
 • Utilise ‘How to             • Provide patients/residents and relatives with information on the risks
   Guide’ for relevant           of pressure injury on admission/transfer or when there is a change in
   tools                         their condition that puts them at risk.
 • Feedback loop for           • Educate patients/residents and families as to how they can help to
   staff on data and             minimize pressure injury risk whilst in hospital/care home, at home
   Plan-Do-Study-Act             where relevant (e.g. the SSKIN care bundle).
   (PDSA) outcomes             • Work with patients/residents and families as co-partners in their care.
                               • Use the guides for various tools to educate staff on how they could be
                               • Provide visual management for displaying data and Plan-Do-Study-
                                 Act (PDSA) outcomes (e.g. Patient Safety Cross).

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013       13 of 24
Typical failures associated with patient assessment include the following:
  o Lack of standardized or reliable process for pressure injury risk assessment.
  o Lack of identification of patients/residents at increased risk for a pressure related injury.
  o Lack of expertise in administering the assessment.
  o Lack of clarity in expectations regarding patient assessments.
  o Failure to intervene quickly based on assessment findings.
  o Failure to recognise the limitations of the pressure injury risk screening tools.

Typical failures associated with reassessments include the following:
  o Lack of standardized process for reassessments.
  o Failure to recognise change in condition as a prompt for reassessment.
  o Lack of procedure or time to consistently reassess change in patient/resident condition.

Typical failures associated with staff communication and patient/resident and family
  o Failure to quickly communicate results of a new or changed risk assessment and associated
  o Failure to incorporate and document prevention interventions in the plan of care.
  o Unclear or incomplete handovers between department and among staff within a unit.
  o Incorrect assumption that the patient/resident is the key or sole learner.
  o Delivery of safety education that fails to fit individual patient/resident and family needs.

Typical failure associated with standardizing interventions to create safe care:
  o Failure to specify protective interventions based on individual needs.
  o Lack of reliability in performing comfort or toileting rounds as scheduled.
  o Missing or inconvenient placement of intervention supplies (e.g. visual alert markers).

Typical failures associated with customizing interventions for patients/residents at highest
risk of pressure related injury include the following:
   o Lack of nurse observation of patient/resident.
   o Failure to identify in a patient/resident at greater risk for pressure-related injury that a change
      in status represents a new risk of pressure injury.
   o Failure to individualise the plan of care based on needs.
   o Lack of reliable implementation of interventions to prevent pressure-related injuries.
   o Lack of staff knowledge about interventions for more challenging patient populations (e.g.
      patients/residents who are confused or impulsive, tend to wander or have had previous
      pressure injury).

Critical success factors for improvement:
   o Teams (multidisciplinary) involved.
   o Measurements / data feedback to clinical staff.
   o Small steps and testing of changes on a frequent, small-scale basis.
   o Ongoing learning of systems and processes and how they can be improved.

First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013     14 of 24
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     practical approach to enhancing organizational performance.                 Jossey-Bass Publishers, San
Ministerial Review Group. (2009). Meeting the challenge: Enhancing sustainability and the patient
     and consumer experience within current legislative framework for health and disability services
     in NZ.
National Institute for Health and Clinical Excellence (2005). CG29 Pressure ulcer management.
     London: National Institute for Health and Clinical Excellence.
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National Pressure Ulcer Advisory Panel (NPUAP) - European Pressure Ulcer Advisory Panel (2009).
     Pressure ulcer prevention and treatment guidelines. NPUAP/EPUAP.
Quality Improvement Scotland (2010). Up and about: Pathways for the prevention and management
     of falls and fragility fractures. Quality Improvement Scotland, National Health Service.
Redelings MD, Lee NE and Sorvillo F. (2005). Pressure Ulcers: More Lethal Than We Thought?
     Advances in Skin & Wound Care 18 (7): 367-372.
Residential Aged Care Integration Programme (2010). Care giver guides for residential aged care.
     Waitemata District Health Board.
Residential Aged Care Integration Programme (2012). RN care guides for residential aged care.
     Waitemata District Health Board.
Severens JL, Habraken JM, Duivenvoorden S, Frederiks CM. (2002). The cost of illness of pressure
     ulcers in The Netherlands. Adv Skin Wound Care 15(2):72–77
World Health Organisation. (2005). World Alliance for Safety.

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APPENDIX 1 – Measurement Plan
Avoid confusion over measurement for performance and measurement for improvement. The table
below outlines the key differences between these measures:

 Aspect                        Improvement                    Accountability            Research
 Aim                           Improvement of care            Comparison, choice,       New knowledge
                               (efficiency and                reassurance,              (efficacy)
                               effectiveness)                 motivation for change
 - Test observability          Test observable                No test, evaluate         Test blinded or
                                                              current performance       controlled
 - Bias                        Accept consistent bias         Measure and adjust to     Design to eliminate
                                                              reduce bias               bias
 - Sample size                 ‘Just enough’ data,            Obtain 100% of            ‘Just in case’ data
                               small sequential               available, relevant
                               samples                        data
 - Flexibility of              Flexible hypotheses,           No hypothesis             Fixed hypothesis
 hypothesis                    changes as learning                                      (null hypothesis)
                               takes place
 - Testing strategy            Sequential tests               No tests                  One large test
 - Determining if a            Run charts or                  No change focus           Hypothesis, statistical
 change is an                  Shewhart control               (maybe compute a          tests (t-test, F-test,
 improvement                   charts (statistical            percent change or         chi square, p-values)
                               process control)               rank order the results)
 - Confidentiality of the      Data used only by              Data available for        Research subjects’
 data                          those involved with            public consumption        identities protected
                               improvement                    and review

Ref: Lief Solberg et al, Journal of Quality Improvement, Vol. 23, No 3, March 1997.

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APPENDIX 1 – Measurement Plan

 Measure name                  Compliance with pressure injury risk assessment/skin examination
                               within 6 hours of admission / transfer.

 Measure type                  Process (percentage).

 Measure description           % Compliance with pressure injury risk assessment/skin examination
                               on admission/transfer.

 Numerator                     Number of patients/residents who had a pressure injury risk
                               assessment/skin examination within 6 hours of admission/transfer.

 Denominator                   Number of patients/residents admitted/transferred.

 Sampling plan                 To collect this measure randomly sample twenty patient/residents
                               records on a monthly basis (could be broken down to looking at five
                               records a week) and identify from these records (Denominator), how
                               many patients/residents had a pressure injury risk assessment/skin
                               examination completed within 6 hours of admission/transfer

                               Calculate: N/D x 100 = %.
 Reporting frequency           Monthly.

 Numeric goal                  >95% compliance with pressure injury risk assessment/skin
                               examination within 6 hours of admission/transfer.

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APPENDIX 1 – Measurement Plan

 Measure name                  Compliance with SSKIN care bundle.

 Measure type                  Process (percentage).

 Measure description           This is a composite measure (all or nothing) requiring a simple Yes/No
                               outcome. If the individual patient/resident did not have ALL elements of
                               the bundle completed/in place then they are considered non compliant
                               with the SSKIN care bundle (e.g. 4 out of 5 is not good enough).

 Numerator                     Number of patients/residents who had all five elements of the SSKIN
                               care bundle completed.

 Denominator                   Number of patients/residents on the SSKIN care bundle.

 Sampling plan                 To collect this measure randomly sample the care bundle sheets of
                               twenty patients/residents on a monthly basis (could be broken down to
                               reviewing five sheets on a given day once a week) and identify from
                               these sheets (Denominator), how many individuals had all five elements
                               of the bundle completed (Numerator) at each opportunity for that day.
                               For example, from your sample of 5 patients, 4 patients have all 5
                               bundle elements completed, then 4/5 (80%) is the compliance with the
                               SSKIN care bundle. If all 5 patients had all 5 elements completed,
                               compliance would be 100%. If all 5 were missing even a single item,
                               compliance would be 0%. If a single bundle element is contraindicated
                               for a particular patient/resident and this is documented appropriately,
                               count it as appropriately performed for the purposes of measuring
                               compliance. Consider using the compliance measurement tool to
                               help staff understand exactly which elements of the SSKIN care
                               bundle are not being delivered reliably so that these elements are
                               the focus of improvement (the compliance measurement tool can
                               be accessed through or

                               You are encouraged to sample over a range of conditions (i.e.
                               weekends, week days, different shifts, etc).

                               Calculate: N/D x 100 = %.

 Reporting frequency           Monthly.
 Numeric goal                  >95% with SSKIN Care Bundle.

APPENDIX 1 – Measurement Plan
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Measure name                  Number of pressure injuries.

 Measure type                  Outcome (ACUTE CARE) Number of patients with pressure injuries per
                               100 patients.
 Measure description           Monthly random prevalence audit / survey (percentage per 100
 Numerator                     Number of patients with pressure injuries acquired in the hospital
                               Grades 1 to 4.
 Denominator                   Per 100 patients.

 Sampling plan                 Random selection of 5 patients per ward or 15% of ward or unit patients
                               rounded up to whole patients.

                               Survey audit to be conducted first week of each month.

                               Survey to be conducted by consistent staff who have received training.

 Reporting frequency           Monthly.

 Numeric goal                  To reduce the incidence of hospital acquired pressure injuries by 20 %
                               by month year.

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APPENDIX 1 – Measurement Plan

 Measure name                  Pressure injury incidence per 1000 occupied bed days*

 Measure type                  Outcome – Age related residential care (ARRC).

 Measure description           Number of pressure injuries Grade 3 – 4 developed on a ward/care
                               home per 1000 occupied bed days (pressure injuries not patients/
                               residents – could have more than one pressure injury).

 Numerator                     The total number of pressure injuries Grade 3 – 4 developed on a
                               ward/care home during the month.

 Denominator                   The total number of occupied bed days.

 Reporting frequency           Monthly.

 Sampling plan                 For each individual who develops a pressure injury whilst in
                               hospital/care home. The pressure injury rate is calculated by dividing
                               the total number of pressure injuries developing in the month
                               (Numerator) by the total number of occupied bed days in the month

                               Record every time a resident acquires a pressure injury (i.e. a new
                               case is identified) on tool such as Pressure Injury Safety Cross.

                               Calculate: N/ x 1000; as rate.
 Numeric goal                  For example - To reduce the rate of facility acquired pressure injuries
                               by x % on by month year.

  *Use of a rate measure enables comparison between different sites

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APPENDIX 1 – Balancing Measures

These are measures designed to identify the impact (positive or negative) of this work and
interventions on other parts of the care system. In order to demonstrate cost savings, please
complete the productivity calculator (information given below). Other impacts of this programme
might be a reduction in average length of hospital stay or number of complaints. It is a good idea at
the outset of your improvement work to gather baseline data for the following balancing measures.

 Cost (productivity)           Reduction in the cost of managing pressure injuries.

 Average length of             Reduction in the average length of stay.
                               Add the total number of days stay per month. This number can then be
                               divided by the total number of patients/residents discharged per month.
                               Once you have worked out the average length of stay per month, you
                               can record this number in a calendar chart.
 Number of                     Reduction in the number of complaints from service users (family etc).

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APPENDIX 2 - Model for Improvement

The Model for Improvement* is a simple yet powerful tool for accelerating improvement, which has two parts:
      • Three fundamental questions, which can be addressed in any order.

        • The plan-do-study-act (PDSA) cycle to test and implement changes. The PDSA cycle guides the
          test of a change to determine if the change is an improvement.

                         Setting aims - Improvement requires setting aims. The aim should be time-specific
                         and measurable; it should also define the specific population of patients that will be

                         Establishing measures - Teams use quantitative measures to determine if a
                         specific change actually leads to an improvement.

                         Selecting changes - All improvement requires making changes, but not all changes
                         result in improvement. Organizations therefore must identify the changes that are
                         most likely to result in improvement.

                         Testing changes - The plan-do-study-act (PDSA) cycle is shorthand for testing a
                         change in the real work setting — by planning it, trying it, observing the results, and
                         acting on what is learned. This is the scientific method used for action-oriented

                         List the tasks needed to set up the test of change. Predict what will happen when the test is
                         carried out. Determine who will run the test.

                         Run the test. Document what happened when you ran the test. Describe problems
                         and observations.

                         Describe the measured results and how they compared to predictions.

                         Determine what your next PDSA cycle will be based on your learning.

                                                *The Model for Improvement was developed by Associates in Process
                                                          Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP.
                                The Improvement Guide: A Practical Approach to Enhancing Organizational Performance

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APPENDIX 3 – Plan-Do-Study-Act (PDSA) form

  Act     Plan       MODEL FOR IMPROVEMENT                                              Date: __________

 Study     Do        Objective for this PDSA cycle:

Is this cycle used to develop, test, or implement a change?

What question(s) do we want to answer on this PDSA cycle?

Plan to answer questions: Who, What, When, Where.

Plan for collection of data: Who, What, When, Where.

Predictions (for questions above based on plan):

Carry out the change or test; Collect data and begin analysis.

Complete analysis of data.

Compare the data to your predictions and summarize the learning.

Are we ready to make a change? Plan for the next cycle.

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