Hca 450 final presentation

Pressure Ulcers Drew Bystedt Katie Glenn Linda Le Javier Solis Bri Weed

Background ●

A pressure ulcer is an area of skin that breaks down when something keeps rubbing or creating friction against the skin.

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Pressure on the skin reduces blood flow to the area. Without enough blood, the skin can die. An ulcer may form.

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Symptoms A.

Red skin that gets worse over time

B.

The area forms a blister, then an open sore

“If you can’t measure it, you can’t improve it” ●

If we do not measure our pressure ulcer rates than we cannot determine how well we are doing in preventing pressure ulcers.

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Counting skin lesions does not result to pressure ulcers.

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Measuring the incidence and prevalence rates of pressure ulcers in our facility.

Measure & Aim Measure: Percentage of patients developing pressure ulcers after admission to facility.

Aim: Reduce the incidence rate of facility acquired pressure ulcers by 6% in the next 4 months.

Skilled Nursing Facility ● Highest level of care for older adults outside of a hospital ● Post-Acute Care ● Best choice for patients who require 24-hour medical care and supervision ● Services include: Assessment, treatment, injections, and administration of medications, rehabilitation ● 93.1% of facilities reported pressure ulcers

Root Cause Analysis ●

Root cause analysis ● An accident investigation technique undertaken to find and fix the fundamental causes of an adverse event ● Used following a sentinel event, an incident in which death or serious harm to a patient occurs ● Also used following a near miss event, an incident that did not result in death or injury but could have, only by chance was the patient not harmed ● Ask and understand what went wrong in the process to result in adverse outcomes ● Follows the same steps as PDSA cycle ● Should evaluate whether risk reduction strategies achieved desired results

Improvement Processes ●

Plan-Do-Study-Act Cycle ○ Plan ■ State objectives: Lower pressure ulcers incidence rate ■ State improvements: Quality of care to patients ■ Process changes: Refine rotation process through a new care plan ■ Data collected: Rate of pressure ulcers before implementation plan ○ Do ■ Implement changes: More specific care plan established for patients ■ Document problems: Record issues that arise from the implementation plan ■ Gather data: Record pressure ulcers prevalence rates after implementation

Improvement Processes ●

PDSA continued ○ Study ■ Analyze data: Determine if implementation reduced pressure ulcer rates by comparing before and after rates ■ Compare results: Contrast data with other SNFs ■ Summarize lessons learned: Team collaboration, importance of rotation and detailed care plan ○ Act ■ If unsuccessful, repeat PDSA ■ If successful, implement them on a wider scale with maintaining change in facility

Pressure Ulcer RCA ●

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Outline the problem ○ Reducing the incidence of pressure ulcers anywhere on the skin of patients ○ Patient safety, organization compliance, reduced reimbursements Analysis of problem: Damage to tissue, muscle, bone ○ death of tissue ■ Poor skin condition, poor environment, inadequate nutrition, contaminants on skin ■ Damage of tissue, shear injury, pressure injury ●

Friction injury from patient being repositioned, patient unable to assist in moving

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Pressure injury from patient staying in same position,

Team Management ●

Team Dynamics ○ Learning the essential elements of a functioning team ○ Learning important aspects of team building and team functioning ○ Working as a group to accomplish a task ■ Productive meetings ■ Team composition and roles ■ Decision-making

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Stages of Team Development ○ Forming ○ Norming ○ Storming ○ Performing

Change Management ● ●

Change management is a systematic approach to dealing with change, both from the perspective of an organization and on the individual level.

Kotter’s 8- Step Change Model ○ Step 1: Create a Sense of Urgency- Developing a need to change ○ Step 2: The Guiding Team- creating a trusted group to influence others into accepting change ○ Step 3: A Change Vision and Strategy- developing the right vision and strategy for the change efforts ○ Step 4: Communicate the change vision- Create buy-in ○ Step 5: Fewer Obstacles, More Empowerment-Remove obstacles that stop people from acting on the vision

Change Management Cont. â—‹ â—‹ â—‹

Step 6: Identify and celebrate Short-Term Wins- build momentum and energize others Step 7: Consolidate gains and produce more change- Keep implementing change until the vision is fulfilled Step 8: Anchor new approaches in the culture- Create a support structure which will continue the new-winning behavior

Value & Context ● Can be classified as a facility acquired condition that is preventable 2% - 28% of residents have them 60% are at risk for developing them CMS does not reimburse (cost can add up to $70,000) Nearly 60,000 deaths are attributed from acquired pressure ulcers ○ Pressure Ulcer event reduction falls within CMS’ top HAC reduction priorities ○ ○ ○ ○

Value & Context ● CMS launched National Nursing Home Collaborative ● The National Pressure Ulcer Advisory Panel (NPUAP) ● New York State Gold STAMP Program ○ (Success Through Assessment, Management Prevention) ○ Partnership of hospital, home health, skilled

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nursing, hospice, assisted living provider settin and other healthcare stakeholders and partner across New York State.

References ●

http://www.nlm.nih.gov/medlineplus/ency/article/007071.htm

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http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressureulcers/pressureulcertoolkit/putool5.html

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http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressureulcers/pressureulcers/puqio4.htm

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https://healthy.kaiserpermanente. org/static/health/pdfs/quality_and_safety/multi/multi_pressure_ulcers.pdf

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http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-root-causeanalysis-rca-template/

References ●

http://www.nmmra.org/providers/nursinghomes_ulcers.php

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http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Downloads/2012-Nursing-Home-Action-Plan.pdf

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http://www.cdc.gov/nchs/data/databriefs/db14.pdf

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http://www.health.ny.gov/professionals/nursing_home_administrator/gold_stamp/docs/2013-1217_resource_guide.pdf