Indiana Pressure Ulcer Reduction Initiative Overview The IHI Breakthrough Series Collaborative is a systematic approach to healthcare quality improvement in which organizations and providers test and measure practice innovations, then share their experiences in an effort to accelerate learning and widespread implementation of best practices. More than 1000 teams from over 400 international healthcare organizations have participated in this best-practice collaborative. The Indiana Pressure Ulcer Reduction Initiative The Indiana Pressure Ulcer Reduction Initiative is comprised of 100 nursing homes and over 80 hospitals, home care and hospices statewide who will work together for 12 months to individually test system changes aimed at preventing and treating pressure ulcers, and to collectively share learning. Health Care Excel -- the State s QIO -- and an expert faculty of medical directors, wound, ostomy and continence nurses (WOCNs), and RNs will be available to each health care setting local resources and will be active observers of the Collaborative to ensure successful implementation, evaluation and sustainability. The four main components of the Indiana Pressure Ulcer Reduction Initiative are pre-work activities, learning sessions, action periods, and the outcomes congress. Pre-work is the period between receipt of this handbook and the Webinars held in November and Learning Session #1 held on January 22 nd for hospitals and January 29 th for Home Care & Hospice. During this time, the nursing homes, hospitals and home care, and hospice agencies have several important tasks to accomplish in order to prepare for the first learning session. The pre-work section of this handbook details these tasks, provides a checklist for pre-work activities, and provides a worksheet for documentation. Learning sessions are the major interactive events of the Collaborative. Through plenary sessions, small group discussions, and team meetings, attendees have the opportunity to: learn from expert faculty and colleagues, receive individual coaching and technical assistance, gather knowledge on the subject matter and on process improvement," share experiences and collaborate on improvement plans, and problem-solve barriers to improving care. Page 1
Action periods are the times between learning sessions. During action periods, health care teams work within their organizations to test and implement changes aimed at preventing and treating pressure ulcers. Teams share the results of their improvement efforts in team reports and also participate in shared learning through coaching calls, teleconferences, and a bi-monthly newsletter. Participation in action periods is not limited to those who attend the learning sessions; we encourage and expect the participation of other team members and supporters in the health care setting and surrounding community. Outcomes Congress. On August 26, 2009, the Collaborative will share its findings and achievements at an outcomes congress that will highlight the accomplishments of the teams across health care settings and present effective models of pressure ulcer prevention, treatment and care coordination between nursing homes, hospitals, and home care & hospice. Schedule The sequence of events for the Indiana Pressure Ulcer Reduction Initiative is as follows: Pre-work Learning Session 1 (nursing homes) Pre-work Coaching Call/Webinar (hospitals) Learning Session 1 (hospitals) Learning Session 1 (home &hospice) Action Period 1 2 nd. Coaching Call/Webinar Learning Session 2 (regional 1-day sessions) Action Period 2 Outcomes Congress October 2008 Oct. 28, 29, 30 & Nov 5 & 6, 2008 November 12 January 22, 2009 November 12, 19 & January 29, 2009 November 2008-March 2009 March (date TBD) April 14, 15, 16 & April 29-30, 2009 May - August 2009 August 26, 2009 Page 2
Pre-work Activities This section includes a checklist of pre-work activities, information about how to complete each pre-work activity, and a worksheet for documentation. Checklist for completing pre-work activities To prepare for Learning Session 1, participating health care teams should complete the tasks listed below: 1. Form a team 2. Register for November 12, 2008 Teleconference and November 19, 2008 Coaching Call/Webinar 3. Complete the pre-work activities worksheet 4. Develop an aim statement 5. Define population of focus 6. Complete pressure ulcer self-assessment worksheet 7. Administer Pressure Ulcer Knowledge Questionnaire 8. Plan for data collection 9. Plan for preparing team summary reports outlining process changes before each Session 10. Prepare a storyboard for Learning Session 1 The following pages provide more detail about each task. Page 3
1. Forming a Team Each nursing home, hospital and home care & hospice needs to form a Collaborative team to test and implement system changes related to the prevention and treatment of pressure ulcers. It is recommended that each team have three to four team members. These members, along with other staff, comprise the home team. Selecting team leaders When forming your home team, you will need to fill three-four leadership roles: system leader, clinical champion, day-to-day leader, and front line leader. Individuals in these roles represent the team at the learning sessions and the outcomes congress, and they share their learning with other members of the team. Team members will report progress to the system leader, who is encouraged to attend all learning sessions and the outcomes congress. Ideal team members are described below. System leader The ideal system leader has direct authority to allocate the time and resources to achieve the team's aim, has direct authority over the systems affected by the change, and will champion the spread of successful changes throughout the department or service area. An example of a system leader would be the administrator, director of nursing or a charge nurse. The system leader can also be the Senior Leader and attends all learning sessions and the outcomes congress. Clinical champion The ideal clinical champion is a respected clinical staff person with interest and expertise in pressure ulcer prevention and treatment, understands current processes of care, has a good working relationship with colleagues and the day-to-day leader, and wants to drive improvements in the system. An example of a clinical champion would be a physician, geriatric nurse practitioner, clinical nurse specialist, wound nurse, or other interested nurse. It is essential to have a clinical champion on the team. The clinical champion attends all learning sessions and the outcomes congress. Day-to-day leader The ideal day-to-day leader drives the project, ensuring that cycles of change are tested, implemented, and documented. coordinates communication between the team and the Collaborative, oversees data collection, and works effectively with the clinical champion. The day-to-day leader should understand how changes will affect systems and have the time to keep the project moving forward. The day-to-day leader should have the skills necessary to write Page 4
summary reports of quality improvement progress. A quality improvement, charge nurse, or highly motivated staff nurse might serve as day-to-day leader. The day-to-day leader attends all learning sessions and the outcomes congress. This role also may be the clinical champion. Front-Line Leader The ideal front line leader provides direct care for residents/patients and is a strong advocate providers input on changes needed, ways to get support for changes among peers, and helps problem solve willingly participates in cycles of change being tested and helps evaluate effectiveness An example of a front-line leader would be a staff nurse. The front line leader should understand the need for change and how it will impact resident/patient care and staff work. This leader should have good communication skills and be able to explain reasons for change and implementation to peers. The front-line leader attends all learning sessions and the outcomes congress. Other team members In addition to the home team leaders, the Collaborative team should also include members from health care departments potentially affected by system changes related to pressure ulcer prevention and treatment. These members should include people from departments and work areas that will be affected by the changes, to ensure that the team understands the system it is trying to redesign and to promote support for the changes. These members learn about the Collaborative from the home team and participate in implementation at the nursing home, hospital and home care & hospice. Potential team members include paraprofessional nursing and rehab staff (nursing assistants), staff deve1opment personnel, dieticians, professiona1 rehabilitation staff (OT and PT), health information managers, activities and social services staff, central supply staff, and maintenance and environmental services. Page 5
Checklist for selecting team members An effective team has members who work well together and who have a combination of skills, styles, and competencies. An effective team has members who are leaders, (not necessarily managers) are team players, have specific skills and technical proficiencies relevant to the prevention and treatment of pressure ulcers, possess excellent listening skills, communicate well verbally, are problem-solvers, are motivated to improve current systems and processes, believe it is possible to improve pressure ulcer prevention, and are creative, innovative, and enthusiastic. 2. Registering and arranging for travel, lodging Team leaders represent the team at the learning sessions and the outcomes congress, and they share their learning with other members of the nursing home team. The system leader, the clinical champion, and the day-today leader should attend all learning sessions and the outcomes congress. Learning session #1 will be held regionally for the nursing homes and in Indianapolis for the hospitals and home care & hospice. Learning session #2 will be held regionally for all health care settings which will eliminate the need for overnight accommodations. The Congress will be held in Indianapolis and may require lodging. Registering Individuals must register for each session of the Collaborative. Information regarding registration for the webinar is included in the pre-work packet. The only charge to attend the Collaborative Learning Sessions and Congress is a small fee for food. An electronic registration to complete for the January Learning Session #1 will be sent to you at a later date. 3. Completing the worksheet The pre-work activities worksheet at the end of this section will help you document progress as your team forms, develops an aim statement, determines data collection procedures Page 6
4. Developing an aim statement The present Collaborative is modeled after the IHI Breakthrough Series Collaborative, which use the Model for Improvement, a "trial-and-learn" approach to quality improvement. The Model for Improvement couples three fundamental questions with plan-do-study-act (PDSA) cycles: 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in an improvement? The first question is answered in an aim statement. An aim statement is a concise written statement describing what the team expects to accomplish in the Collaborative; it provides guidance for the team's specific improvement efforts. The aim statement ensures that team activities align with the strategic goals of the team's organization. Involving senior leadership in developing an aim statement can help teams ensure support for their work. An example of an aim statement consistent with the goals of this Collaborative is as follows: To improve the prevention and treatment of pressure ulcers among patients at General Home Health Care & Hospice, we will redesign practice and delivery systems. Within one calendar day of admission, 100% of admissions will have a risk assessment performed using the Braden Scale. Of the patients at risk for pressure ulcers, 100% will be using appropriate pressure reducing support surfaces while in bed. Our aim is to prevent all pressure ulcers unless the patient is terminally ill. In setting your aim, be sure to Involve senior leaders. Senior leaders must align the aim with strategic goals of the organization. They must also provide for support personnel and resources from information systems, finance and reimbursement, medical affairs, etc. Base your aim on data or organizational needs. Examine data within your organization. Focus on issues that matter. State the aim clearly and use numerical goals. Teams make better progress when they have an unambiguous, specific aim. Setting numerical targets clarifies the aim, helps create tension for change, and directs measurement. For example, an aim to "ensure that 100% of admitted residents will have a risk assessment performed using the Braden Scale within one calendar day of admission" will be more effective than an aim to "improve risk assessments of admitted residents." There will be time to refine your work at the learning session and time during the year to complete work on the aim statement. Page 7
5. Defining a population & Unit/Department of Focus For most participating nursing homes, the population of focus will be residents. It is recommended that teams select populations that will be affected by the changes being made. That is, if the nursing home staff working to test and implement changes as part of this Collaborative interacts with residents regularly, then these residents should be considered the population of focus. In hospitals, it is recommended to choose a unit or department to focus on and test changes. Home care & hospice will be working in the community and in the home and the population of focus will be on patients and caregivers. 6. Defining measures Measuring performance during the Collaborative will enable the team to evaluate the impact of changes it makes in an effort to improve the delivery of care. Performance measurement is not an end in itself. Measurement should be designed to accelerate improvement, not slow it down. Each team will monitor progress on three required measures and it is strongly suggested each team choose two to four additional, or "optional," measures. Required measures 1) Incidence and prevalence of pressure ulcers. a. One simple data collection tool b. Collected and tracked monthly 2) Pressure Ulcer Knowledge Questionnaire administered pre/post initiative 3) Number of changes implemented as a result of the initiative a. Risk assessment worksheet b. Administered pre/post c. Team summaries Page 8
7. Preparing a storyboard for Learning Session 1 At learning session #1, health care teams will receive a flip chart (2.5 x2.0 ), tape, markers, and other supplies, so that teams can present what they have accomplished and learned so far. Storyboards help create an environment conducive to sharing and learning from the experiences of others. At the first learning session, your storyboard will be a way to help introduce your team to the other Collaborative participants. The storyboard is an opportunity to have some fun and show the unique character of your organization and your team. The storyboard should be as clear and concise as possible. The audience for storyboards consists of other health care teams, Collaborative leadership, observers, and expert faculty who are not familiar with your facility, your aim, and your work. Suggested content for a team storyboard is brief description of your nursing home, hospital or home care & hospice team name, with team members and their titles, a picture would be nice draft aim statement, draft description of your resident/patient population, and description of progress so far. Page 9
Pre-work Activities Worksheet " 1. Team members (Name) (Title) a. Senior leader b. System leader c. Clinical champion d. Day-to-day leader e. Other team members 2. Working draft of aim statement 3. Definition of population of focus Page 10
4. Working list of measures selected Required measures: Data collection tool documenting incidence and prevalence of pressure ulcers in the past month and if admitted with pressure ulcer(s). Pressure Ulcer Knowledge Questionnaire administered to all staff at the beginning of the initiative and again at the end of the initiative Pressure Ulcer Self-Assessment worksheet completed at the beginning of the initiative and again at the end of the initiative. Page 11