Pressure Ulcer Prevention Improvement - Juran Institute

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A Quality Case Study“What is important to you regarding skin care when in the hospital, especially woundscaused by pressure, commonly called bed sores?"Analysis of the answers, or Voice of the Customer, helped determine the elements critical toquality in the process. If the process can address the needs seen as critical by its customers, thenit is seen as a highly effective process. The three key issues discovered were:• Maintain skin integrity• Education and standardized integrated process• Communication and collaborationMeasure:With the key issues in mind, the team set out to measure the current state of the process anddetermine the baseline status against which any future changes could be compared. From aquantitative approach, after validation of the measurement system and collection of data, theteam determined that the current process operated at a sigma level of 2.4, reflecting the 18%incident rate. Aiming to achieve a maximum target incident rate of 5%, the process wouldimprove to a capability of 3.2 sigma. Because there was a lack of good data for process metricsat the beginning of the project, the team developed plans for acquiring these data during thecourse of the project.From a qualitative approach, a more detailed map was created identifying the process flow forpressure ulcer prevention and in caring for a pressure ulcer patient. Brainstorming and discussionof the map provided possible theories (potential root causes) as to why, how, and where pressureulcers occurred. The team constructed a cause and effect diagram to identify the potential factors(Xs) that contribute to Hospital Acquired Pressure Ulcers (Y).Analyze:Analysis of the cause and effect diagrams consolidated the overwhelming number of possibleroot causes to a list of 11. These were:• X1: The development of a hospital-acquired pressure ulcer in a patient is dependent onthe Braden score being done on admission (within eight hours).• X2: The development of a hospital-acquired pressure ulcer in a patient is dependent onpatient turnover.• X3: Nurses do not have easy access to appropriate knowledge and interventioninformation regarding pressure ulcers.• X4: The development of a hospital-acquired pressure ulcer in a patient is dependent onbeing admitted through the ED to the IP unit within the last 72 hours.• X5: The development of a hospital-acquired pressure ulcer in a patient is dependent onhours of care. (Number of hours on unit that nurse and tech have hands on, andnumber of staff x shift hours / # patients).All Rights Reserved, Juran Institute, Inc. 2
A Quality Case Study• X6: The development of a hospital-acquired pressure ulcer in a patient is dependent onhaving had surgery within the past 72 hours.• X7: The development of a hospital-acquired pressure ulcer in a patient is dependent ondocumentation of nursing skin care plan based on NICP goal.• X8: There are not enough additional pillows (at least five total per patient) available inat-risk patient rooms for proper positioning.• X9: Pressure redistribution devices are not being used with at-risk patients.• X10: If a waffle mattress is in use, it is not inflated when the at-risk patient is in bed.• X11: Skin care products are not available on the at-risk patient's unit.Data were collected for each of the 11 possible Xs and analyzed to determine if statisticalevidence supported the claim of cause and effect. Six of the 11 possible root causes weredropped out of the list due to a lack of evidence of statistically significant relationships withpressure ulcer incidence. The remaining five were consolidated into three, final root causes ofhigh incident rates of pressure ulcers acquired in the hospital and taken into the Improve phase.Improve:Strategies to address and ameliorate the vital few, proven root causes were created by the team towhich further detailed solutions/action items then were created (Table 1).Table 1 - Sample list of proposed strategies to address specific Vital Few Xs (proven root causesof patient falls).Proven Xs (Causes)X 1: Braden score is not completedwithin eight hours of admission totrigger preventions for at risk patients.X 3: Nurses do not have easy accessto appropriate knowledge andintervention information regardingpressure ulcers.X 8,9,10: Preventions for at-riskpatients are not used or not usedcorrectly (pillows, pressureredistribution devices, etc.).StrategiesAutomate and embed Bradenscoring in documentation software.Align and fine tune the triggers for atriskpatients.Pair electronic “skin pathways” withdocumentation for real-timeinformation on interventions. Visualaids for Braden scoring andinterventions with at-risk patients.Standardized pressure ulcer “Bucket& Bundle” for all at-risk patients.Standardize mattresses to mistakeproofpressure redistributionsurfaces. Visual cues and turningschedule.All Rights Reserved, Juran Institute, Inc. 3
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