Utilizing the PDCA Methodology to Create Change Leads to an Interdisciplinary Approach to Pressure Ulcer Prevention

Problem:

Our hospital system chose the National Database of Nursing Quality Indicators (NDNQI) to publicly report data required by CMS.   Survey results showed that our Hospital Acquired Pressure Ulcer (HAPU) rate was higher than national average mean as noted by the NDNQI submission report.

Purpose:

This reporting requirement did not produce any change in practice or reflect improvement in overall incidence. Staff feedback reflected they felt the data collection was yet another futile task and was disengaged from the process. We indeed had no formal pressure reduction strategy. 

Plan:

Create a culture that embraced pressure ulcer prevention with staff that held themselves accountable for outcomes both at the unit level and the organizational level by looking at tasks we performed and turn them into valued activities to create change and monitor progress.

Methodology:

The PDCA methodology was chosen to guide our path and implement improvement in our organization. Use of the Shewhart Cycle would allow for continuous improvement to the process as issues and needs are identified.

Actions: Perform data collection monthly instead of quarterly.Organize prevalence team from each unit to participate in study.Have CWOCN perform Interrater reliability with every HAPU.Develop tool to organize data collection. Develop process to organize results and take them back to staff in realtime so they may address identified needs in a timely fashion. Create a venue for staff to work as a group to identify system issues and develop solutions. Provide opportunity for multidisciplinary cooperation to create change in outcomes.

Outcomes:

Appropriate and real-time data collection with validation of results can move the task of data collection to a tool to drive quality of care.

Reference List:

Quarterly Report: Staffing and Outcomes Indicators. Reports Section: Pressure Ulcers All Units By Indicator Report. (2012, July 2). Retrieved from NDNQI National database of Nursing Quality Indicators: https://www.nursingquality.org/NDNQIPortal/NDNQI/QuarterlyReport.aspx