The NYS Gold STAMP Initiative 1 PRESSURE ULCERS A PATIENT SAFETY CONCERN SHIFTING THE PARADIGM PHYSICIAN ENGAGEMENT PAMELA LOUIS JOHN CAPPA, DPM The NorMet Collaborative 2 Phelps Memorial Hospital Center Cedar Manor NH & Rehab Dominican Sisters Family Services 1
Who is Accountable 3 Regulatory Structure 4 2
Engaging Physicians in Pressure Ulcer Improvement Opportunities: o Reduce complexities thereby improving efficiencies o Create independent checks for key processes o Measure and evaluate o Standardization of formularies o Improve communications 5 6 Interested party Quality Assurance Communication Program Development Outreach Standardization Quality Assurance 3
Potential Outcome 7 Lawsuits over pressure ulcers are increasingly common in both acute and long-term settings with judgments as high as $312 million in a single case. http://www.medline.com/media/assets/pdf/legalimplicationsofpressureulcers.pdf Obstacles Silo approach to care (ie. inpt. outpt. HHC, SNF) Tasks centered around discharge rather than transition Inability to change think out of the box Absence of systems to access/share critical patient info Increasing demands for compliance of documentation by payor/regulatory agencies Inability to effectively manage time by staff Lack of resources (reimbursement and knowledge) Coordination of care is placed on patient/care giver Lack of alignment of goals at each care setting transition 8 4
GOALS 9 1. Empower RN to make clinical decisions and provide care for their patients 2. Enhance inter-rater reliability in assessment 3. Present direct care providers with tools to implement care plan 4. Streamline care processes to ease RN workload 5. Standardize documentation 6. Assure RN accountability for compliance with standards of care 7. Engage and educate physicians Re-Engineering Care 10 5
Perspective and culture impact activity Opportunities Threats Observations Solutions 11 Interdisciplinary Team Approach 12 Team members may include, but are not limited to the following: Clinical Champion for pressure ulcer improvement Wound Care Specialist Senior Leadership Medical Director or other designee for pressure ulcer improvement Frontline Staff such as a certified nursing assistant Case Managers who can assist in efficiently communicating transfers Nutritionist and Dietician Occupational Therapist and Physical Therapist Information Systems Quality Assurance/Quality Improvement Specialist 6
Dilemmas 13 Focus on discharge versus transition of the patient No clear line of shared ownership for the transition Burden of coordination is placed on patient/caregiver Caregiver may not be available/involved at discharge Absence of system to access/share critical patient information Lack of timely Care Summary at time of transition Existence of communication gaps between each care setting Inconsistent reassessment of patient and goals at each transition Competing priorities between health care settings Collaborative Goals Communicate across care settings Communicate risk factors 14 Engage the rest of the interdisciplinary team (ie. CNAs, Techs, therapists, physicians, case managers) Improve consistency in documentation Measure effectiveness of pressure ulcer prevention involving direct care staff 7
Engaging Physicians in Pressure Ulcer Improvement Strengths: Interdisciplinary Team Involvement CWOCN/wound team involvement and the multi-disciplinary roles. Education of frontline clinician and standardization of knowledge. Expectation to meet basic competency. Some physicians recognize their knowledge deficit. Building Relationships Open dialogue and effective communication. Mutual respect. Communication and Documentation Wound team collaborates with physicians regarding: dietary needs, pressure reduction strategies, treatment selection, PT/OT, wound care products, offloading devices, etc. Standardization of wound documentation. 15 Engaging Physicians in Pressure Ulcer Improvement Challenges: Education and Competency Other physicians do not recognize their knowledge deficit. Other physicians feel they have used a treatment for X years Always worked before. Not open to suggestions: I m the Doctor. I.e., wet-to-dry, QD (to prevent infection). Unfamiliar with new staging guidelines, and products and their appropriate usage. Interdisciplinary Team Involvement and Communication Lack of ownership. Efforts to communicate are unwelcome. Wound care is not a priority. Not my problem. Skin assessment not part of physicians physical. Physician unavailable during wound rounds. 16 8
WHAT DID WE DO AS A COLLABORATIVE? 17 Engaged senior leadership Educated and engaged physicians Rounding with interdisciplinary team Enhanced wound care documentation Inter-Rater Reliability 18 9
Communication and Collaboration Across Health Care Settings 19 Agreement of the essential elements for communicating pertinent pressure ulcer information IT involvement to develop an encrypted 3-mail system Staff Education and Training 20 Plan ongoing education and training to uphold program competency and sustainability and consider opportunities to invite partners across settings. Educate staff, all shifts, on pressure ulcer improvement program and cross-setting collaboration using the following activities conducted regularly: Team meetings. In-services (e.g., scheduled in-services per unit, half or full day ongoing training per unit to train staff as available during certain points in the day). Rounding with clinical team, and possibly with one administrative leader. Peer-to-peer assistance. Screen savers and whiteboards to promote Gold STAMP Presentation to Medical Board Incorporate patient and family education. 10
The Braden Bunch IT helps to pick a Bed 21 Braden Scores Available on Intranet Ranked Highest Risk to lowest. Simple update of empty beds. A colored sticker means a special mattress. Nurse Managers can easily find patients that need special beds and the special beds they need. Even ER patients are scored, so that when admitted they can be placed in the proper beds. Intranet and other programs developed in house. Queries in ED 22 To identify patients coming to Phelps ED from: Cedar Manor Dominican Sisters Wound Healing Institute First report included 130 patients coming in to the hospital and 4 queries going out. Updates include: Revised queries for intake to breakdown data by facility. Audit tool created for tracer Revision of intake report to send over a secure e-mail. Nursing to review the nursing discharge assessment to include on the checklist. 11
Collaborative Successes Reported by Participants 23 Overall improvement in communications with respect to patients and residents moving between care settings. More efficient method of tracking pressure ulcers which are present on admission and to develop an individualized care plan for the resident. Opportunity to share and partner on patient and resident goals of care across institutions and care providers. Improve communication between nurse to nurse and physician to nurse. Current State of Affairs 24 12
Next Steps 25 BUILD THE PRACTICE BRING ON NEW PARTNERS The NYS Gold STAMP Initiative 26 Tug-of-War Partnership 13
Acknowledgements Margie Salazar, RN Cedar Manor Nursing & Rehab Mary Beth Soucy, RN, BSN Dominican Sisters Family Health Service And to the never-ending commitment of the: Senior Leadership, Physicians, Information systems, QA/QI specialists, Nutritionists/Dieticians, Case Managers, Wound Care specialists, Clinical Managers and Frontline staff 27 QUESTIONS? 28 THANK YOU! 14
CONTACT INFORMATION 29 PAMELA LOUIS DIRECTOR,PHELPS WOUND HEALING INSTITUTE PLOUIS@PMHC.US JOHN CAPPA, DPM DOCTOR OF PODIATRIC MEDICINE, PHELPS MEMORIAL HOSPITAL JCAPPA@PMHC.US 15