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  1. 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

  2. Stopping Pressure UlcersOne Root Cause at a Time June 27, 2012

  3. Today’s Presenter Melody A. Malone, PT, CPHQ Quality Improvement Consultant TMF Health Quality Institute

  4. 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.

  5. 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.

  6. 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

  7. 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).

  8. Polling Question: Do you have facility-acquired pressure ulcers in your setting? • Yes • No • I don’t know • Doesn’t apply in my setting

  9. Quiz… Why focus on pressure ulcers?

  10. Actual harm to the patient!

  11. 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

  12. 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

  13. 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

  14. 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

  15. Nursing Homes in TMF’s Previous QIO Contract Reduced FA PUs from • 39% (237) December 2009 to • 32% (130) June 2011 *47 nursing homes

  16. How do we change this and… Keep it fixed? We focus on quality improvement (QI).

  17. 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!

  18. Root Cause The most fundamental reason a problem has occurred (When performance does not meet expectations)

  19. 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

  20. Facility-Acquired PU Investigation Tool • Compile and analyze: • Clinical • Environmental • Operational issues that contributed to the development of a pressure ulcer

  21. 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

  22. 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.

  23. 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

  24. 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

  25. Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, First Quarter

  26. Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Second Quarter

  27. Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Third Quarter

  28. Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 1, Fourth Quarter

  29. Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 2, First Third

  30. Facility-Acquired PU Investigation ToolPrivileged Confidential Work Product of the QAA CommitteePage 2, Last Third

  31. Determination of Root Cause and Quality Improvement Plan • Usual findings: • Superficial causes • Not systems issues

  32. 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

  33. 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

  34. REALRoot Causes, continued • 38% gap between last full body skin assessment • 20% care plan not updated with risk changes

  35. 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

  36. Training on the Tool is Available

  37. 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!

  38. Q&A (during a polling question) Will you try using the FA PU Investigation Tool? • Yes • No • Doesn’t apply in my setting

  39. 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

  40. 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

  41. 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

  42. Contact Melody Malone, PT, CPHQ Quality Improvement Consultant TMF Health Quality Institute 214-632-2238 melodymalone@txqio.sdps.org 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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