Utilizing the Quality Management System to Maintain Skin Integrity

Background:

The organization had effectively reduced pressure ulcer rates by 86% with the implementation of Pressure Ulcer Prevention bundle recommended in literature.  Despite successful implementation through education and process improvement, there continued to be inconsistency in practice which resulted in pressure ulcers.  These inconsistencies varied in charting, product use and understanding of skin integrity maintenance.

Aim: Hardwire the process to reduce the number of Stage 2, 3, 4 and unstageable pressure ulcers throughout the organization.

Methods: Utilizing the Packard Quality Management System and Daily Management Systems (DMS) to facilitate implementation and sustainability of pressure ulcer prevention bundle throughout the organization. In collaboration with the Center for Quality and Clinical Effectiveness, and each unit Local Improvement Team, the Wound Care Specialist implemented the pressure ulcer prevention bundle recommended by the CHCA and OHIO Solutions for Patient Safety.

Monitoring consists of CNS/ANM daily audits of high risk patients for bundle compliance, visual tracking utilizing the DMS board for process and outcome compliance, integration into daily Gemba rounds, weekly surveillance rounds performed by Wound Care Champions and Wound Care Specialists. The results are integrated into the monthly Dashboard for each unit.

Results: Since the integration of risk management the pressure ulcer rates in the organization have decreased by 100% in the high risk patients and compliance with documentation has increased by 90%.

Conclusion: Through a Quality Management system with collaboration from Center for Quality and Clinical Effectiveness pressure ulcer rates can be reduced. Utilizing a standardized approach to bundle implementation and monitoring it is possible to reduce to zero pressure ulcers in the high risk environment.