Pressure Ulcers: Zero Ambition

The Fishbone Diagram was developed by

the Project Team and helped identify the

system linkage map

System Linkage Map

By Nina Fraser, Deputy Director of Nursing, Northampton General Hospital

The Project Team were identified by

developing a pareto chart and mapping P.U

champions to the chart. The Team comprised

the Deputy Director of Nursing , Improve-

ment lead, tissue viability nurse, Matron,

sisters and staff nurse.

The System Linkage Map enabled the

prioritisation of sub-processes that would

bring about the greatest gains

Examples of Integrated Projects run as PDSAs:

Over 200 staff attended the first launch

event, giving many opportunities for

teaching.

One of the pilot ward sisters teaching

students and nurses about the new tools

The Project Team:

Aim statement: To reduce the incidence of avoidable hospital

acquired Grade 2,3 and 4 pressure ulcers to

zero in 3 wards by December 2012 as

measured by Safety Thermometer

Sponsor: Dr Gerry McSorley, Chief Executive

1. Matron’s Walk Round

In August 2012, 5 members of the project team

self assessed using the sustainability model and

guide (NHS Institute for Innovation & Improve-

ment 2010) This illustrated a gap in terms of

building an infrastructure for sustainability

The Sustainability and Spread Challenge

The Systems Linkage Map was transferred on-

to a diagram to show links between macro,

meso and micro levels

2. Body Mapping

3. Waterlow Risk Assessment