PUTTING TOGETHER A PRESSURE ULCER PREVENTION TOOLKIT FOR AHRQ

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1 PUTTING TOGETHER A PRESSURE ULCER PREVENTION TOOLKIT FOR AHRQ Dan Berlowitz, MD, MPH Center for Health Quality, Outcomes and Economic Research; Bedford VA. Boston University School of Public Health

2 Knowing is not enough. We must apply. Willing is not enough. We must do. ---Goethe

3 BEST PRACTICES IN PRESSURE ULCER CARE Clinical Practice Guidelines published over 15 years ago Widely disseminated New ones have been developed Yet recommended processes often not performed* Risk documentation 23% Pressure reducing device 7% Pressure ulcer rates remain high *See Lyder et al; Arch Intern Med 2001;161: 1549

4 PRESSURE ULCER CARE IS COMPLEX Incorporates many different elements Multidisciplinary Highly routinized Same tasks performed over and over Must be tailored to individual needs No individual clinician able to do on own- it takes a team

5 Barriers to Best Practices Resistance to change this is how we have always done it Failure of management No clear expectations Competing Priorities one sick patient Lack of safety focus culture of blame Lack of quality improvement infrastructure Many staff have limited training Unfamiliar with best practices

6 MODEL OF CHANGE TO STRENGHTEN EVIDENCE-BASED PRACTICES Organizational infrastructure Active top leadership commitment Impetus to change Links to senior management structures and processes Increased use of evidence-based clinical practices Multi-disciplinary evidence-based clinical process redesign

7 IMPROVING CARE: GOALS OF AHRQ ACTION Accelerating Change and Transformation in Organizations and Networks Evaluating interventions and strategies to improve quality, safety and efficiency of US health care. Promoting the dissemination and uptake of evidence-based products, tools and strategies that result from these projects to improve delivery systems.

8 PREVENTING PRESSURE ULCERS IN HOSPITALS A project sponsored by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Veterans Affairs

9 GOALS OF PRESSURE ULCER PROJECT Review successful approaches to prevention of pressure ulcers in hospitals. Develop and pilot test a toolkit of pressure ulcer prevention practices through the adoption or adaptation of existing instruments or development of new ones. Implement a quality improvement project using the toolkit in our partner hospitals. Assess lessons learned during the quality improvement project. Incorporate these lessons learned into a final pressure ulcer prevention toolkit.

10 WHAT IS A TOOLKIT? An action-oriented compilation of related information, resources or tools that together can guide users to develop a plan or organize efforts to conform to evidence-based recommendations or meet evidence-based specific practice standards. Toolkit is not a guideline.

11 COLLABORATING HOSPITALS Boston Medical Center Billings Clinic Denver Health Medical Center Montefiore Medical Center VA North Texas VA West Haven

12 LITERATURE REVIEW-KEY IDEAS Assessment of organizational readiness Initial assessment of staff knowledge Leadership support Unit-based champion as motivator and resource for staff Engagement of frontline staff in the improvement process Regular feedback of results and recognition of improvement Use of acronyms and other memorable reminders Importance of turning prompts

13 PRELIMINARY DIMENSIONS FOR TOOLKIT Readiness for change Creating urgency to change practices Willingness to buy into new processes Organizational culture of improvement Knowledge about QI process (Ex: PDSA cycles) Management support Must ensure support from top Adequate resources provided

14 PRELIMINARY DIMENSIONS FOR TOOLKIT Systems to ensure pressure ulcer best practices Use standardized tool to identify at-risk individuals Perform comprehensive skin assessments Develop appropriate care plans Implement care plans (Ex: repositioning q2h) Measurement of pressure ulcer rates For audit and feedback Unit culture & operations

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16 ORGANIZATION OF TOOLKIT Addresses six questions: Are we ready for this change? How will we manage change? What are the best practices in pressure ulcer prevention that we want to use? How should those practices be organized in our hospital? How do we measure our pressure ulcer rates and practices? How do we sustain the redesigned prevention practices?

17 Are we ready for this change? Why is change needed? Do organizational members understand why change is needed? Is there a sense of urgency about the change? Is there leadership support for this effort? Who will take ownership of this effort? What kinds of resources are needed?

18 How will we manage change? Implementation Team composition Leader/members identified Linkage to senior leadership established Team start-up Charge to committee Gathering necessary resources Current state for pressure ulcer practice & knowledge assessed Starting the work of re-design Setting goals and plans for change

19 What are the best practices in pressure ulcer prevention that we want to use? Bundle of best practices created and incorporated into clinical pathway Risk assessment tool Skin examination Care planning Customize the bundle for specific work units Compare ideal practices with current practices

20 How should those practices be organized in our hospital? Roles and responsibilities of staff Implementation team Unit-based team Wound care team Unit champion Organizing the prevention work Paths of communication identified Incorporate new practices into routine Putting practices into operation Pilot new practices Develop strategies to engage staff Education plan

21 How do we measure our pressure ulcer rates and practices? Measuring pressure ulcer rates Incidence versus prevalence Measuring key processes of care What is emphasized in bundle

22 How do we sustain the redesigned prevention practices? What is needed to keep new practices in place Has the system changed How can it be further reinforced

23 CONCLUSIONS Improving pressure ulcer preventive care is hard Need to focus on how care organized Tools are available to facilitate change Impact of toolkit still being assessed