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Preventing Pressure Injuries
Change Package
Adapted from the Transforming Care Programme 1000 Lives Plus
NHS Wales 1000livesplus@wales.nhs.uk
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 GuideAcknowledgements 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. Introduction 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 2008). 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
below:
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 3 of 24Event 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
period.
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 24First, 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)
DHB
teams
HOP Action Action
Problem Recruit
working period - period -
identified teams
groups PDSA PDSA
Expert
Spread
Group
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 +
Mini
Group (20/01/2012) - Show & Change
Learning
falls & PI definitions Share package -
Sessions
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
Baseline
gathering
data
baseline
Expert Expert Expert
Group Group Group
IA
meeting
5 of 24
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
needed.
• 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 (www.apiweb.org) 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 241. 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.
Ideas
- Development of the evidence based change ideas
Execution
- 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 24and 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 www.firstdonoharm.org.nz 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 24Pressure 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.
bundle
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
damage.
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 11 of 24Secondary 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.
Nutrition
• 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 24Secondary 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
used.
• 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 24Typical 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
education:
o Failure to quickly communicate results of a new or changed risk assessment and associated
intervention.
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 24REFERENCES
Auckland District Health Board (2010). ADHB A+SKINE pressure related tissue damage prevention
– RBP Adult Health (Section 2). Clinical Practice Manual. Auckland DHB.
Baxter, S. and Bartley, A. (2011). Preventing pressure ulcers driver diagram and change package.
Health Improvement Scotland.
Bennett, G., Dealey, C., Posnett, J. (2004). The cost of pressure ulcers in the UK. Age Ageing 33
(3): 230-5.
Berwick, D. M. (2010). Better quality at lower cost: Successful health economics in troubled times.
Paper presented at the Quality and Safety in Healthcare, Nice, relayed in Auckland, NZ.
Brem H, Lyder C. (2004). Protocol for the successful treatment of pressure ulcers. Am J Surg, 188
(1A Suppl):9–17.
Counties Manukau District Health Board. (2011).How to guide for pressure injuries (draft). Auckland.
Counties Manukau District Health Board. (2010). Workforce Forecast 2010-2020. Auckland.
Defloor, T., M. Clark, et al. (2005). EPUAP statement on prevalence and incidence monitoring of
pressure ulcer occurrence. Journal of Tissue Viability 15(3): 20-7.
Gefen, A. (2008). How much time does it take to get a pressure ulcer? Integrated evidence from
human, animal, and in vitro studies Ostomy Wound Management 54(10):26-8, 30-5.
Gethin G., Obrien, J., Moore, Z. (2005). Estimating costs of pressure area management based on a
survey of ulcer care in one Irish hospital. Journal of Wound Care 14, 162-165.
Gorecki C, Brown J, Nelson EA et al (2009) Impact of pressure ulcers on quality of life in older
persons: a systematic review. J Am Geriatr Soc 57: 1175–83.
Graves N, Birrell F. & Whitby M. (2005). Effect of pressure ulcers on length of hospital stay.
Infection Control and Hospital Epidemiology, 26: 293-297
Hope, S., & Cox, M. (2005). Health service need and labour force projections. Statistical report to
Counties Manukau District Health Board. Auckland: Counties Manukau District Health Board.
Institute for Healthcare Improvement (2011). How to guide: Prevent pressure ulcers. IHI.
Landi, F., Onder, G., Russo, A., Bernabei, R. (2007). Pressure ulcer and mortality in frail elderly
people living in community. Arch Gerontol Geriatr 44 (Suppl 1): 217-223.
Langley, G., Nolan, T., Provost, L., Nolan, K. and Norman, C (1996). The improvement guide: A
practical approach to enhancing organizational performance. Jossey-Bass Publishers, San
Francisco.
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.
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 15 of 24National 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. http://www.who.int/publications/en/.
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 16 of 24APPENDIX 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
Methods
- 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.
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 17 of 24APPENDIX 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
(Numerator).
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.
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 18 of 24APPENDIX 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 www.healthcareimprovementscotland.org or
www.tissueviabilityonline.com).
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
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 19 of 24Measure 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
patients).
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.
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 20 of 24APPENDIX 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
(Denominator).
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
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 21 of 24APPENDIX 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.
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).
Complaints
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 22 of 24APPENDIX 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
affected.
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
learning.
Plan
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.
Do
Run the test. Document what happened when you ran the test. Describe problems
and observations.
Study
Describe the measured results and how they compared to predictions.
Act
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
First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 23 of 24APPENDIX 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: Plan to answer questions: Who, What, When, Where. Plan for collection of data: Who, What, When, Where. Predictions (for questions above based on plan): Do: Carry out the change or test; Collect data and begin analysis. Study: Complete analysis of data. Compare the data to your predictions and summarize the learning. Act: Are we ready to make a change? Plan for the next cycle. First, Do No Harm, Preventing Pressure Injuries: Change Package, Version 2, June 2013 24 of 24
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