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While we wait to begin the conference, please answer this polling question:. Please tell us your primary work area: Hospital Physician Office Nursing Home Outpatient Office Hospice Dialysis Center Home Health Other. Stopping Pressure Ulcers One Root Cause at a Time. June 27, 2012.

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while we wait to begin the conference please answer this polling question
While we wait to begin the conference, please answer this polling question:

Please tell us your primary work area:

Hospital Physician Office

Nursing Home Outpatient Office

Hospice Dialysis Center

Home Health Other

today s presenter
Today’s Presenter

Melody A. Malone, PT, CPHQ

Quality Improvement Consultant

TMF Health Quality Institute

about tmf
About TMF

TMF Health Quality Institute focuses on improving lives by improving the quality of health care through contracts with federal, state and local governments, as well as private organizations. For more than 40 years, TMF has helped health care providers and practitioners in a variety of settings improve care for their patients.

tmf is the quality improvement organization qio for texas
TMF is the Quality Improvement Organization (QIO) for Texas

About the QIO Program

  • Leading rapid, large-scale change in health quality:
    • Goals are bolder.
    • The patient is at the center.
    • All improvers are welcome.
    • Everyone teaches and learns.
    • Greater value is fostered.
objectives
Objectives
  • The learner will be able to:
    • Facilitate completion of the Facility-Acquired Pressure Ulcer (FA PU) Investigation Tool
    • Identify potential areas for root causes
    • Identify potential areas for systems improvement
pressure ulcer definition
Pressure Ulcer Definition

Any lesion caused by unrelieved pressure

resulting in damage of underlying tissues.

Source: F314 42 CFR 483.25(c), U.S. Department of Health & Human Services Agency for Healthcare Research and Policy. www.ahrq.gov. National Pressure Ulcer Advisory Panel Monograph (pp. 181).

polling question
Polling Question:

Do you have facility-acquired pressure ulcers in your setting?

  • Yes
  • No
  • I don’t know
  • Doesn’t apply in my setting
slide9
Quiz…

Why focus on pressure ulcers?

facility acquired pressure ulcers
Facility-Acquired Pressure Ulcers
  • Develop in the health care facility AFTER admission
  • FA PUs cause:
    • Pain to the resident
    • Scarring of the body
    • Increased risk of infection
    • Increased costs of care
national partnership for patients goal
National Partnership for Patients Goal
  • “Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.”

Partnership for Patients. U.S. Department of Health & Human Services. April 2011. Retrieved from: http://www.healthcare.gov/news/factsheets/2011/04/partnership04122011a.html

pressure ulcers are a problem
Pressure ulcers are a problem!
  • NH Quality Measure: High-risk residents with PUs in Texas: 7.4% 1
    • 4,007 HR residents with a PU out of 54,479
    • 87,533 nursing home residents in Texas 2

1 Facility Quality Measure (2011 Q4)

2 Regulatory Services Fiscal Year 2011 Annual Report January 2012

pressure ulcers are a problem1
Pressure ulcers are a problem!
  • 12% hospitalized patients developed at least 1 pressure ulcer during the stay
    • 383 surgical patients out of 3,225

Tschannen, D., Bates, O., Talsma, A. and Guo, Y. Patient-specific and Surgical Characteristics in the Development of Pressure Ulcers. American Journal of Critical Care

nursing homes in tmf s previous qio contract
Nursing Homes in TMF’s Previous QIO Contract

Reduced FA PUs from

  • 39% (237) December 2009 to
  • 32% (130) June 2011

*47 nursing homes

how do we change this and
How do we change this and…

Keep it fixed?

We focus on quality improvement (QI).

if pressure ulcers are in
If Pressure Ulcers are “IN”
  • Then nothing can be “OUT”
  • If all systems are GO – no pressure ulcers!
  • Got pressure ulcers?

You’ve got systems failures!

facility acquired pu investigation tool
Facility-Acquired PU Investigation Tool
  • Incident report and root cause analysis tool
  • Privileged & Confidential Work Product of the QAA Committee
  • Takes the focus off the individual and puts it on the system
facility acquired pu investigation tool1
Facility-Acquired PU Investigation Tool
  • Compile and analyze:
    • Clinical
    • Environmental
    • Operational issues

that contributed to the development of a pressure ulcer

facility acquired pu investigation tool2
Facility-Acquired PU Investigation Tool
  • Focus the team to:
    • Gain the ability to anticipate issues for risk identification
    • Enhance staff knowledge
    • Take action to implement interventions
    • Boost the ability to sustain improvements
    • Critical thinking
nursing home results
Nursing Home Results
  • Three nursing homes (NH) during three years:
    • 1 NH achieved > 400 days between the development of an FA PU.
    • 1 NH achieved two cycles of > 100 days between the development of an FA PU.
    • 1 NH achieved one cycle of 100+ days.
nursing home results continued
Nursing Home Results, continued
  • Plus, they had other significant periods of time between new FA PUs, such as:

69, 76, 78, 103 and 148 days

process for use of the tool
Process for Use of the Tool
  • Begin tool when PU is identified – day 1
    • Resident/patient changes start today!
  • Designated individual completes tool – day 1 or 2
      • Wound nurse or nursing leadership
  • Team reviews the tool – day 1, 2 or 3
  • Tests of change identified and plan developed
slide27
Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, First Quarter
slide28
Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Second Quarter
slide29
Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Third Quarter
slide30
Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Fourth Quarter
slide31
Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 2, First Third
slide33
Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 2, Last Third
determination of root cause and quality improvement plan
Determination of Root Cause and Quality Improvement Plan
  • Usual findings:
    • Superficial causes
    • Not systems issues
nh s root causes included
NH’sRoot Causes Included:
  • Resident on hospice
  • Refuses care
  • Resident has increased pain
  • Resident leans to side
  • Resident does not eat well
  • Constant motion
  • Resident has loose stool episode before skin breakdown
  • Heels pressing against geri-chair while up during the day
what were the real root causes
What were the REAL root causes?

Findings from compiling the 65 FA PU Inv. Tools:

  • 43% did not have a validated risk assessment timely prior to the FA PU
  • 42% mattress/bed was not appropriate to the level of risk prior to the FA PU
real root causes continued
REALRoot Causes, continued
  • 38% gap between last full body skin assessment
  • 20% care plan not updated with risk changes
real root causes continued1
REALRoot Causes, continued
  • 31% did not have nutritional interventions prior to the FA PU
  • 34% abnormal lab values identified to the FA PU were unaddressed
action items
Action Items
  • Share the FA PU Investigation Tool with your QI team.
  • View the training webinar.
  • Have someone use it, review it and learn.
  • Implement a test of change.
  • Celebrate your successes.
  • Count your days between FA PUs!
q a during a polling question
Q&A (during a polling question)

Will you try using the FA PU Investigation Tool?

  • Yes
  • No
  • Doesn’t apply in my setting
references
References
  • Department of Health & Human Services, Centers for Medicare & Medicaid Services Appendix PP/483.25(c)/Pressure Sores/Tag F314. Guidance to Surveyors for Long Term Care Facilities
  • Facility Quality Measure Report. (2011 Quarter 4).
  • Partnership for Patients. U.S. Department of Health & Human Services. April 2011. Retrieved from: http://www.healthcare.gov/news/factsheets/2011/04/partnership04122011a.html
references continued
References, continued
  • Regulatory Services Fiscal Year 2011 Annual Report January 2012. Texas Department of Aging and Disability Services.
  • Tschannen, D., Bates, O., Talsma, A. and Guo, Y. Patient-specific and Surgical Characteristics in the Development of Pressure Ulcers. American Journal of Critical Care. 2012;21:116-125 doi: 10.4037/ajcc2012716
additional information can be found at
Additional information can be found at:

http://qmweb.dads.state.tx.us

Agency for Healthcare Research and Quality (AHRQ). www.ahcpr.gov

www.npuap.org

http://TexasQIO.tmf.org

contact
Contact

Melody Malone, PT, CPHQ

Quality Improvement Consultant

TMF Health Quality Institute

214-632-2238

[email protected]

http://TexasQIO.tmf.org

This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-TX-C7-12-81

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