Organization: Solution Title: Ulcers Atlantic General Hospital Putting Perfection Into Practice to PreventHospital Acquired Pressure Program/Project Description: What was the problem to be solved? How was it identified? What baseline data existed? What were the goals how would you know if you were successful? Problem: There existed inconsistency in the benchmarking and reporting of quality data related to hospital acquired pressure ulcers (HAPUs) which led to differing interpretations of actual performance improvement and deployment of premature action plans. How identified: In response to poor financial performance related to Potentially Preventable Conditions (PPCs) centered on the prevention of pressure ulcers, nursing leadership was asked to present to the Board Quality Committee. We recognized conflicting data analyis when direct care nurses which served as members of the AGH Skin Team were concurrently invited to share their data collection and action plan with the Shared Governance Performance Improvement Council. What baseline data existed: 1. Quarterly HAPU incidence from system improvement reports submitted by direct care nurses, but not reported as a rate or at the unit-level. 2.Monthly prevalence data on the percent of patients with HAPU collected by Skin Care Team at the unit-level. 3. Quarterly prevalence data on the percent of patients with HAPUs, in which the best monthly prevalence data in the quarterwas selected and benchmarked against a variety of national benchmarks, such as Hill-Rom and the National Database of Nursing Quality Indicators (NDNQI). 4. Duplicative action plans created by Skin Care Team and nurse leaders. What were the goals--how would you know if you were successful: 1. Increase data validity and unit-level accountability through centralized data collection and storage. 2. Utilization of standard and robust HAPU benchmarks throughout entire organization. 3. Standardize reporting format and structure with transparency at all levels, to include the Skin Team members reporting directly to the organization's quality committees. 4. Demonstrate collaborative efforts towards performance improvement, as well as financial savings,related to HAPU prevention as a result of consistent and robust data collection. Process: What methodology or process was used to develop the Solution? Using the Nursing Executive Center's recommendations for "Putting Perfection into Practice: Achieving and Sustaining Zero-Defect Quality Goals," the AGH Skin Committee outlined the key steps for prevention of HAPUs. Several of the key steps in this overview were to determine the target metrics for HAPU data collection as well as to standardize reporting and communication processes (The Advisory Board Company, 2007).
Solution: What Solution was developed? How was it implemented? 1. All baseline sources of data were reviewed and standardized down to the unit-level. Raw incidence data reported as a rate. 2. Benchmarks were selected using the highest, broadest and most robust benchmarking data available. 3. Broad understanding and acceptance for utilizing the most robust and frequently collected HAPUs data indicators to measure performance improvement. 4. Transparent and centralized data entry by Skin Team members for all HAPU indicators at the unit-level was initiated in an electronic format.electronic data entry protected once submitted. 5. Excel spreadsheets were formatted with macros to automatically update standardized HAPU run charts upon data entry. Each indicator run chart displays our data, the benchmark, and our performance median, allowing us to accurately analyze performance improvement or degradation. Some run charts also display our internal goals, financials and annotations of interventions over time. 6. Summary sheets of run charts were also created to automatically update with data entry, allowing the Skin Team and nurse leaders to easily analyze and disseminate all unit-specific HAPU indicators at one time, rather than in isolation. 7. Unit-specific HAPU data now reported to organizational quality teams by direct care nurses serving as Skin Team members. Measurable Outcomes: What are the results of implementing the Solution? Provide qualitative and/or quantitative results to data. (Please include graphs, charts, or tools as attachments.) See attached samples of some of our standardized run charts which graphically and visually display our HAPU data indicators and are now interpreted and understood at all levels within the organization. Sustainability: What measures are being taken to ensure that results can be sustained and spread? AGH Leaders and the Skin Care Team are now engaged and working together to implement interventions and involve key players at the direct care level to prevent HAPUs. Only by standardizing our HAPU data collection, understanding the results and disseminating this information to the key players could we move forward to implement evidence based interventions and measure performance improvement related to these interventions. Reporting is consistent and transparent with accountablity held at all levels within the organization. Additionally, the financial implications of HAPUs haveestablished continual organizational commitment to performance improvement in the prevention of HAPUs. Role of Collaboration and Leadership: What role did teamwork and collaboration play in the Solution? What partners and participants were involved? Was the organization s leadership engaged and did they share the vision for success? How was leadership support demonstrated? Upon discovery of the discrepancy in data reporting and analysis, the Skin Care Team and nurse leaders worked together to standardize data collection and reporting and establish interdisciplinary transparency. Whenfinancial penalties for HAPUs went into effect in Maryland, hospital administrators and leaders became more involved and dependent on the Skin Care Team's data collection, reporting and formal recommendations for evidence based interventions to improve quality outcomes related to HAPUs. Leaders actively participate in the Skin Care Team meetings, communicate expectations openly with their direct care associates, and support the "experts" as they move forward with putting perfection into practice in the prevention of HAPUs.
Innovation: What makes this Solution innovative? What are its unique attributes? More than ever, today's healthcare environment demands that our organizations become more transparent in their performance improvement efforts, while remaining focused on the patient. As organizations compete to meet requirements for reimbursement, awards and recognitions, it is sometimes easy to get caught up in presenting quality data as "impressive" and "pretty"to meet eligibility requirements, without really taking a step back to look at the big picture through the patient's eyes. When it comes to the prevention of HAPUs, Atlantic General has decided to take the high road as caregivers who have chosen robust data reporting to get a true grasp of where we really stand in putting perfection into practice for our patients. Contact Person: Lisa Jeffers Title: CRNP, CWS Email: ljeffers@atlanticgeneral.org Phone: 410-629-6863
Attachments Atlantic General Hospital MPSC Presentation 1
Attachments Atlantic General Hospital MPSC Presentation 2