pressure ulcers to zero collaborative guide - hseland ulcers to zero... · what is the pressure...

Pressure Ulcers to Zero Collaborative Guide

© National Quality Improvement Programme 1

Table of Contents

Page Number

Purpose of the guide 2

Why get involved? 3

Pressure Ulcer Definition 5

What is the Pressure Ulcers to Zero Collaborative 6

Getting started 7

Driver Diagram 9

SSKIN Bundle 11

Measures 12

Quality Improvement Tools

The Model for Improvement

Plan, Do, Study, Act (PDSA) Cycle

Stakeholder Mapping

Communications Plan

13

Finally… 19

Appendices

Appendix I: Drivers for Quality

Appendix II: Example of SSKIN Bundle in use

Appendix III: Safety Cross

Appendix IV: Risk Assessment

Appendix V: Blank Stakeholder Map

Appendix VI: Blank Communications Plan

20


Purpose of this guide This guide has been designed to prepare senior leaders and frontline teams within our healthcare system to participate in the Pressure ulcers to Zero collaborative and to enable them to successfully implement interventions and change ideas to improve pressure ulcer prevention and care. The guide builds on learning from the first phase of the pressure ulcers to zero collaborative. It includes:

Brief overview of pressure ulcers within the Irish healthcare setting

Introduction to the Pressure Ulcers to Zero Collaborative programme

Evidence based safety bundle (SSKIN bundle) to prevent pressure ulcers

Introduction to Quality Improvement (QI) tools and techniques which will be taught and used during the collaborative to help teams implement their changes for improvement

This guide can be used by Improvement teams as they plan, design, test and apply the SSKIN bundle and other change ideas within their local environments. It will assist teams to achieve success in the work they will undertake during this collaborative. The QI tools provided are designed to be user friendly and practical and can easily be adopted by those involved. This guide will be referenced throughout the learning sessions of the collaborative so please bring it with you to all of these sessions. The separate Pre-Work Pack outlines the pre-work required to be completed by each participating improvement team prior to the first learning session.


Why get involved? The development of a pressure ulcer can have a significant impact on a person’s life. There are both physical and psychological impacts on quality of life as well as the financial cost associated with managing pressure ulcers.

Prevalence Global mortality rates from 187 countries found a 32.5 % increase in deaths directly attributable to pressure ulcers from 1990 - 2010 (Lozano et al, 2010). In Ireland there have been six published studies which have explored pressure ulcer prevalence (Gallagher et al, 2008, Gethin et al, 2005, McDermot-Scales et al, 2009, Moore & Cowman 2012, Moore &Pitman 2000, Sheerin et al 2005). There is at present no published prevalence figures from the hospice, paediatric or obstetric services in Ireland. See some results of these studies below;

Prevalence of pressure ulcers in Ireland

Mean 16%

Community setting 4%

Spinal cord setting 37%

Older person services 9%

Acute setting 12% - 18.8%

Benefits of preventing pressure ulcers Patients and families Preventing pressure ulcers will result in avoiding unnecessary pain for patients, unnecessary admissions to hospital and increased lengths of hospital stay. There is therefore significant benefit in prevention strategies like the SSKIN bundle which aims to prevent pressure ulcers across all settings within our health service. Staff The management of pressure ulcers requires significant resources and staff time. In preventing the occurrence and further management of pressure ulcers, staff can apply and direct resources to other aspects of patient care. Staff participating in this collaborative will also gain practical and simple quality improvement skills and expertise, which can be applied to other areas for improvement.


Organisation The management of pressure ulcers has a significant cost implication to organisations in the health service. One study which explored cost related to pressure ulcers in Ireland estimated that it cost 119,000 euro to treat one patient with a grade 4 pressure ulcer and it was estimated by the same authors that it would cost 250,000,000 euro to manage pressure ulcers across all care settings in Ireland (Gethin et al, 2005). By working towards a common goal through this collaborative programme, the aim is to embed a strong multi-disciplinary shared approach across teams and organisations to pressure ulcer prevention.


Pressure Ulcer Definition “A pressure ulcer is localised injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers: the significance of these factors is yet to be elucidated” (EPNUAP/NPUAP 2009). Pressure damage can occur on any part of the body subjected to sustained localised pressure.

They can range in severity from patches of discoloured skin to open wounds that can expose the underlying bone or muscle. Pressure ulcers can be prevented through the use of risk assessments in combination with the SSKIN bundle.


What is the Pressure Ulcers to Zero Collaborative? A collaborative in health care is when multi-disciplinary teams come together with a common aim to improve an aspect of patient care and outcomes. This involves group based learning sessions, practical improvement projects and shared thinking towards a common aim. This collaborative aims to reduce the number of pressure ulcers in the Irish healthcare system. This is done by enabling staff to put in place reliable systems which will continue to support local improvement after involvement in the collaborative. The collaborative will provide teams with the support and resources needed to undertake these improvements. The model that will be used during this initiative is based on the Breakthrough Series Collaborative Model which was developed by the Institute for Health Improvement (IHI 2003). Within this collaborative there will be four learning sessions which will commence in December and conclude in June along with individual site visits to all improvement teams and continual mentoring of the teams throughout the collaborative.


Getting started Including the right people in an improvement project is critical to a successful improvement effort. Within this collaborative each participating organisation will have a local steering group and an improvement team. These teams may vary in size and composition. Below are suggested members for each team and the corresponding responsibilities of each.

Local steering groups Role: Enable local improvement teams to achieve their aim in improving the care provided to prevent and manage pressure ulcers within their ward/population.

By*:

Raising awareness of the pressure ulcer to zero collaborative at local level and the participating ward/unit/team.

Building the initiative into local quality governance.

Supporting participating team in attending the workshops and completing pre-work requirements.

Supporting the team throughout the collaborative through regular contact and supporting them in addressing any challenges in making improvements.

Tracking local progress on a regular basis e.g. reviewing the monthly safety cross and sharing across the local governance system.

Acting as a contact point for the Collaborative working group and engage with pressure ulcer network within the collaborative.

Planning for successful participation of the local improvement team in the collaborative and for sustaining and spreading the work of the team across the organisation after the collaborative (appendix 1 will support the group in developing their plan for success)

*These bullets can be used to inform terms of reference for local steering groups

Suggested membership of local steering groups:

Acute Community

Director of Nursing Director of Public Health Nursing

Patient/family representative Patient/family representative

Physiotherapy manager Physiotherapy manager

Occupational therapy manager Occupational therapy manager

Dietetics manager Dietetics manager


Tissue viability nurse Tissue viability nurse

Consultant physician General practitioner

Quality and safety lead Quality and safety lead

Practice development lead Practice development lead

Improvement Teams

Role: To test and champion improvements to prevent pressure ulcer development across their specified ward, unit, team.

By*:

Attending and engaging with all of the collaborative learning sessions and site visits

Working with the wider multidisciplinary team to test changes for improvement

Raise awareness of the pressure ulcer to zero collaborative across the ward/unit/team where improvement team works.

Linking with the local steering group to update on progress and improvements being tested.

Share the learning and experience with other parts of the organisation regarding improvements made to preventing and managing pressure ulcers.

*These bullets can be used to inform terms of reference for improvement teams.

Suggested membership of improvement teams:

Acute Community

Nursing representatives (2) Public Health Nurse

Physiotherapist~ Physiotherapist~

Occupational therapist~ Occupational therapist~

Dietitian~ Dietitian~

Healthcare Assistant Healthcare Assistant

Tissue viability nurse Tissue viability nurse

Member of the local steering group Member of the local steering group

~attached to ward/unit /team/geographical area


Driver Diagram A driver diagram is an improvement tool that helps to drive the path of your project. It has also been described as a ‘simple, visual somewhat intuitive display to help you understand where you are going with your work’ (Goldmann, IHI). It clearly defines an aim, along with both primary and secondary drivers.

On the next page is the Driver Diagram for use in this collaborative. You will be guided on how to use it throughout the programme.

The Driver Diagram is made up of an aim, primary drivers and secondary drivers.

The aim is what you are working towards in your project and should be specific, measureable, achievable, realistic and timely (SMART).

The primary drivers are major components which will contribute to achieving the aim. The secondary drivers are change concepts, ideas or actions related to the primary drivers.

Where possible, the drivers in a driver diagram should be measurable. That way a driver diagram can become a measurement tool for tracking progress in achieving the aim.

When does it work best?

Driver diagrams can fulfil a range of functions. They can:

help a team to explore the factors that they believe need to be addressed in order to achieve a specific overall goal

show how the factors are connected

act as a communication tool for explaining an improvement project.

provide the basis for identifying measures in an improvement project.

Driver diagrams therefore lead into activities such as developing project plans and undertaking Plan-Do-Study-Act cycles.


Promote the agreed definition of pressure ulcers amongst all staff

Develop/promote an agreed grading chart across the ward/team/unit.

Ensure that the grading chart forms part of all information session on pressure ulcer

assessment and prevention.

Build momentum behind local work through posters, display of safety cross, and regular

updates on progress at team/ward/unit meetings.

Identify a champion for pressure ulcers in the ward/unit/team e.g. healthcare assistant, staff

nurse, Physiotherapists etc.

Provide regular information session for staff, patients, families and other wards on the

initiative.

Seek regular feedback from staff, patients, families to improve pressure ulcer prevention and

management

Build pressure ulcer management as a safety issue into daily ward practices e.g. handover,

ward rounds

Celebrate progress and achievements; review and learn as a team when pressure ulcers

develop.

Promote the SSKIN bundle across the Ward/Unit/Team e.g. posters, bedside alerts

Education programme/sessions on each step of the SSKIN bundle

Develop a bedside SSKIN bundle checklist for use for patients at risk

Involve patients and their families in preventing pressure ulcers by discussing the SSKIN bundle

with them, displaying posters, information leaflets, informal and formal education sessions.

Agree an evidenced based risk assessment tool that will be performed on every patient on

admission (and per policy)

Develop/promote the policy for pressure ulcer assessment across the team/ward.

Use visual cues to identify people at risk e.g. stickers on charts, logos on doors

Agree procedure for the communication of at risk patients across the ward/unit/team.

Develop regular information sessions for all staff on the policy and use of tool and policy

To reduce the number of

pressure ulcers by 50% within 6 months on

participating ward or population.

Reliable risk assessment

Reliable SSKIN bundle

implementation

Use of an agreed Grading Chart for pressure

ulcers

Support of entire

team/ward

Pressure Ulcers to Zero Collaborative Driver Diagram

AIM PRIMARY DRIVERS

SUGGESTED CHANGES


SSKIN Bundle The use of a care bundle which defines best practice and care is a valuable tool. Care bundles are designed to help health care providers to deliver the best possible care for patients undergoing particular treatments with inherent risks (Institute for Healthcare Improvement). A bundle is a ‘structured way of improving the processes of care and patient outcomes’. As part of an American healthcare initiative, representatives from the Ascension Health systems in the USA developed a blueprint for improvement in pressure ulcer prevention. Part of this blueprint involved defining and prioritising best known evidence and practices, into a bundle of care. This bundle is now known as the SSKIN bundle. It provides a specific process for safely preventing pressure ulcer development and will be used in this collaborative. Key to the success of this bundles implementation is ensuring that each element is applied to each patient, the same way by every person, every time. This will help to build reliability into the process. The five step process for pressure ulcer prevention includes the following elements:

SSKIN Bundle

SURFACE Has the person got the correct surface and surface supports?

SKIN INSPECTION What is the integrity status? Have high risk areas been checked?

KEEP PATIENTS MOVING Has the person been encouraged to move independently or with assistance?

INCONTINENCE / MOISTURE Does the person require assistance with toileting or require incontinent barriers?

NUTRITION / HYDRATION Is their diet/fluid intake adequate to prevent skin breakdown? Are oral supplements required and being used?

See appendix II for an example of how the SSKIN Bundle was incorporated into a daily bedside checklist.


Measures Each month every improvement team will collect the following data:

1. A Safety Cross reflecting the incidence of pressure ulcers in your area (See Appendix III for further details)

2. A snapshot of risk assessments from five random patient notes and any missing elements (See Appendix IV for further details)

The tables below explain the purpose of these measures.

Measure Title Number of pressure ulcers

Type of Measure Outcome Measure

Rationale for Inclusion This will be the key measure that indicates that participation in the collaborative has resulted in fewer PUs for service users.

Definition A pressure ulcer is 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.

Data Source Safety Cross to be filled in manually, daily by each Participating team

Targets or Goals To reduce the number of new Pressure Ulcers by 50% by the end of May 2016.

Measure Title

Risk Assessments

Type of Measure Process Measure

Rationale for Inclusion Assessing patients risk of developing pressure ulcers is the first step in preventing pressure ulcers

Definition "Take 5" – for a sample number of charts, was a risk assessment undertaken?

Data Source Once a month, a sample of five charts are randomly selected and checked for inclusion of a risk assessment for development of a pressure ulcer.

Targets or Goals For each month, 100% of risk assessments completed.

There is one addition measure that is taken below and at the end of the Collaborative. Each improvement team collects data to assess their patient’s awareness of pressure ulcers and the SSKIN bundle. This measure is called the ‘engagement with patients’ measure.


Quality Improvement Tools This collaborative will utilise a range of quality improvement tools and techniques which will be discussed further during the learning sessions. The basic principles will be outlined here along with an outline regarding measurement for improvement.

The Model for Improvement

The Model for Improvement, developed by Associates in Process Improvement, is a simple yet powerful tool for accelerating improvement. The model is not meant to replace change models that organisations may already be using, but rather to accelerate and enhance specific improvements.

This model has been used very successfully by hundreds of health care organisations in many countries to improve many different health care processes and outcomes.

The model has two parts:

Three fundamental questions, which need to be answered in sequential order.

The Plan-Do-Study-Act (PDSA) cycle to test changes in real work settings. The PDSA cycle guides the test of a change to determine if the change is an improvement.

Figure 2. The Model for Improvement


Plan, Do, Study, Act (PDSA) Cycle

What is it and how can it help me?

You can use plan, do, study, act (PDSA) cycles to test an idea by temporarily trialing a change and assessing its impact.

The four stages of the PDSA cycle:

Plan - the change to be tested or implemented

Do - carry out the test or change

Study - data before and after the change and reflect on what was learned

Act - plan the next change cycle or full implementation

Figure 3. Steps in the PDSA Cycle

Plan

DoStudy

Act


Step 1: Plan

Plan the test or observation, including a plan for collecting data.

State the objective of the test.

Make predictions about what will happen and why.

• Develop a plan to test the change. (Who? What? When? Where? What data need to be collected?)

Step 2: Do

Try out the test on a small scale.

• Carry out the test.

• Document problems and unexpected observations.

• Begin analysis of the data.

Step 3: Study Set aside time to analyze the data and study the results.

• Complete the analysis of the data.

• Compare the data to your predictions.

• Summarize and reflect on what was learned.

Step 4: Act Refine the change, based on what was learned from the test.

• Determine what modifications should be made.

• Prepare a plan for the next test.

After each PDSA cycle and considering the learning obtained, the process is refined, reapplied and monitored until the aim is achieved. This process is illustrated in Figure 4.


Figure 4. Multiple PDSA cycles leading to improvement


Stakeholder Mapping This is a useful tool to identify all of the stakeholders involved in your project and how they might impact it. Using a measure of levels of influence on the project, and levels of support for the project you plot out where each stakeholder lies. Below is an example of a stakeholder map for a QI project on reducing HCAI’s in a ward;

In Appendix V you will find an empty template you can use.


Communications plan Following completing your stakeholder map, it is recommended to develop a communications plan. This will help to prioritise key stakeholders and ensure that all of your stakeholders receive appropriate and timely communications around the project. Effective communication will help with developing your project and increase the chances of achieving your aim. Below is an example of a stakeholder map. A template can be found in Appendix VI.

Stakeholder Level of Support

Level of Influence

Key Concern Steps to getting buy in

Nursing staff Medium Medium Other priorities taking time

Need to be engaged with early. Show the data; create ownership (made to feel part of solution)

Cleaning staff Medium Medium Uncertain of their role in infection prevention

Constant communication – It’s about safety

DON Medium High Nurses are not taking on more work

Constant communication – It’s about the MDT and patient outcomes

CEO Low High Cost of prevention Patient safety and reduced length of stay. Financial savings long term

Chief Financial Officer

High Medium Cost of HCAI’s Financial savings long term

Physicians Medium Low Unaware of data and significance

Data

Clinical Director

Medium High Not sure it is an issue for the medics

Show the data, communicate the benefits for staff and patients.

AHP’s Low Low Not interested in being involved

Need to be engaged with early. Show the data; create ownership (made to feel part of solution)

Project team High Medium Not making progress

Keep motivated and keep communicating with them


Finally…. We hope that this guide provides you with the necessary material to support your improvement effort. If there are any queries feel free to contact us at [email protected] You can also access further resources and a discussion forum at the community of practice page for the Pressure Ulcers to Zero Collaborative. This page is found on HSeLanD in the Change Hub under Projects and Initiatives. We would like to take this opportunity to thank you all for your time and effort and we look forward to working with you all in the coming months.


APPENDICES

Appendix I Drivers for Quality Local Steering Groups can use the following drivers of quality and associated suggestions to inform their plan for success in the pressure ulcer to zero collaborative.

Driver Suggestions

Leading for Improvement

Identify a senior leader within the organisation who will take on a champion role for pressure ulcer prevention.

Progress is highlighted and discussed at monthly senior management meetings.

Leaders discuss pressure ulcer prevention and management on wardrounds, quality walkrounds, MDT clinical meetings.

Engaging and enabling service users

Include a service user/family member on local steering group

Work with service users and families to co-design information resources on pressure ulcers

Seek feedback from patients and families on pressure ulcer prevention and management and how to improve.

Use patient stories to highlight the importance of the initiative to wards/units and management.

Engaging and enabling staff

Include a staff member from the improvement team on the local steering group

Support information and educational sessions for all staff on pressure ulcer prevention across the organisation

Using a systematic approach to quality improvement

Become familiar with the methodologies and tools that will be taught during the Collaborative by engaging with the Collaborative Development workshops

Support the delivery of local education sessions on these methodologies and tools or build into existing sessions.

Seek to identify staff trained in QI to support the initiative and the local improvement team.

Plan for spread to the next ward (s) by engaging with the Collaborative workshop on spread and sustainability.

Measuring and sharing learning

Ensure that there is clear understanding within the improvement team/local steering group of the measures that will be collected during the initiative.

Identify how these measures might be included in local quality profiles or dashboards.

Include progress and results from the improvement team in local newsletters, information emails, notice boards etc.

Governance for quality

Pressure ulcer prevention is identified as a key safety priority across the organisation through strategic and operational plans.

Identify the senior lead accountable for engaging and supporting the delivery of this initiative.

Ensure appropriate membership of the local steering group (as advised above)

Link the local steering group into the established governance for quality within the organisation within the organisation.

Ensure that progress and results are shared across quality committees and up to the senior management/board.


Appendix II

Example of SSKIN bundle in use


Appendix III

Safety Cross The safety cross is a visual tool used to collect data for improvement. It should be displayed in your care setting to encourage the communication of goals and results to the team. It can also help to empower ownership of the data locally.

The safety cross should be filled out at the same time daily. The safety cross can be filled in by any member of the team. By filling in the safety cross at the same time every day it will ensure that the data recorded is correctly captured within each 24-hour timeframe. For the acute and residential setting this is usually done at midnight in and can be a prompt at morning handover. For the primary care and community settings, this data can be documented at the same time every evening prior to staff finishing duty. The legend below (which is included with the safety cross) details which colour represents how the pressure ulcer was acquired;

Green = no new pressure ulcer identified. Red = new pressure ulcer (ward acquired) identified. Yellow = admitted with pressure ulcer from other organisation. Blue = transferred with pressure ulcer from same setting/organisation.

What if....

• You have a number of pressure ulcers for different reasons on the same day? Answer: you can divide the colour in the box to show this. See Day 10 in Figure 5.

• You have more than 1 new pressure ulcer in the care setting on a single day? Answer: fill in the number of new pressure ulcers in the smaller box in the corner of the day of the month. See Day 3 or 10 or 20 in Figure 5.

• You have a Grade 1 pressure ulcer? Answer: record it as a newly identified pressure ulcer. Record all pressure ulcers irrespective of their grade as the aim is to prevent all avoidable pressure ulcers.

• The pressure ulcer came from outside your care setting? Answer: you should still record it in the safety cross. This gives an accurate reflection of the patients in the care setting and the source of development. See Day 20 in Figure 5.


Figure 5. One month of a Safety Cross filled in

A blank Safety Cross is available on the next page with a table that enables you to record the date of identification, the grade and location of pressure ulcer.


Appendix IV

Risk Assessment In order to consider if patients in your service area have had a risk assessment undertaken you need to undertake a compliance check of this process. Improvement teams are requested to undertake a ‘snapshot’ compliance check once every month. This involves reviewing five random patient notes to see if a risk assessment was carried out and if it was thoroughly completed. Findings can be shared and discussed with the improvement team and steering group. Table 1. ‘Snapshot’ of risk assessments

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

State YES or NO if the Risk Assessment was 100%

completed: (document

fully filled out correctly)

If there were any elements

missing or incorrect,

record what they were

here:


Appendix V

Blank Stakeholder Map


Appendix VI

Blank Communications Plan

Stakeholder Level of support

Level of influence

Key Concern How to get buy in

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