PUP Center of Excellence Framework

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PUP Center of Excellence Framework

Purpose: To describe a framework of key elements defining a proposed Magnet Center of Pressure Ulcer Prevention Excellence.

Fundamental Premise:

a. Key elements necessary for an organization’s pressure ulcer prevention (PUP) program can be organized into the 4 Magnet model

domains: transformational leadership; structural empowerment; exemplary professional practice, and new knowledge; innovation

and improvement. Successful implementation of these elements yields measurable positive outcomes.(W. V. Padula, Mishra MK,

Makic MB, Valuck RJ, 2014 Apr)

b. Many of the key elements of a comprehensive PUP program can overlap between more than one of the Magnet model domains as

the work of developing a pressure ulcer center of excellence spans the scope and scale of nursing practice within an organization.

c. Organizational cultures vary across the country. A comprehensive PUP program is successful regardless of cultural barriers and in

fact helps transform the organization’s culture to improved patient safety.(Smalarz, 2006)

d. Reporting structures may vary within organizations, however reporting accountability for the PUP program, as a critical element in

the quality processes, is visible on the organizational chart.

e. The processes involved in operationalizing a comprehensive PUP program will vary from organization to organization across the

health care spectrum. The intent of developing this framework is not to be prescriptive about the process, but rather to delineate

the necessary elements of performance.

f. Frameworks for evidence-based quality improvement strategies may vary between organizations (e.g., Lean Six Sigma, FADE, GE

Model, PDSA, structure-process-outcomes etc.), however those used by the organization must be incorporated into the PUP

program process improvement efforts.

1. Transformational Leadership: Are leaders who develop and support organizational values, beliefs, and behaviors to achieve an optimal

level of success. They are able to envision where the organization needs to be, and can successfully lead the organization including rapid

and delayed adopters. Transformational leaders successfully function as change agents and create a desired future state.

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Transformational Leadership Evidence of Performance Specifically…

Executive Level Involvement (C-Suite i.e. Chief Executive Officer, Chief Financial Officer, Chief Nursing Officer, Chief Information Technology Officer, etc.)

Engages in bi-directional, transparent communication. Appoints executive level leader to oversee/facilitate/support PUP program. Identifies PUP clinical program facilitator. Outlines clear reporting structure for the PUP program in the nursing organizational framework. Supports interdisciplinary team development. Sets clear expectations for benchmarking and outcomes. Removes barriers (structures/processes).(Donabedian, 1992) Ensures adequate staffing at unit level. Supports provision of evidence based product resources needed.(Clark, 2006 Jun)

Demonstrates upstream reporting to Board, downstream reporting throughout the organization to the unit/patient level using the organization’s professional practice model Provides appropriate FTE support. Supports time and resources for group meetings and projects. Targets and clear goals are set.(Berwick, 2006 Jan; Duncan, 2007) Demonstrates a culture of quality over cost cutting.(W. V. Padula, Mishra MK, Makic MB, Sullivan PW, 2011 Apr; Pappas, 2008)

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Unit Level Involvement Nurse manager/nursing leadership supports unit based skin champions.(Kelleher, Moorer, & Makic, 2012) Nurse manager/unit leadership accountable for unit acquired HAPUs.(Morton, 2010) Transparency of HAPU data on each unit. (W. V. Padula, Mishra MK, Weaver CD, Yilmaz T, Splaine ME, 2012 Jun) Leadership unit rounding includes focus on pressure ulcer prevention.

Ensures adequate time out of staffing for data collection, data analysis, meeting attendance, and education. Unit based skin champions are visible in unit shared governance model. An investigational analysis (i.e., root cause/modified root cause) on unit acquired PU is conducted on unit level including patient and family when appropriate. PUP accountability is included in employee annual performance review. PU information is shared in daily unit safety huddles. PU patients are identified and prevention interventions are reviewed for appropriateness or escalation. All at risk patients have appropriate PUP interventions incorporated and documented.

Identified Coordinator Accountable for organization wide HAPU PU program:

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1. Tracts, trends HAPU data (outcome & process measures), benchmarks(LeMaster, 2007)

2. Facilitates/co-facilitates interdisciplinary team meetings

3. Facilitates/co-facilitates Unit based skin champions team

4. Coordinates/participates in PUP educational events

5. Facilitates/supports quality improvement tests of change.

6. Supports HAPU research/EBP initiatives

7. Demonstrates excellent stewardship in HAPU prevention/treatment resources

8. Exhibits both leadership and followership within the organization

2. Structural Empowerment: Structure includes the conditions under which care is provided. It encompasses organizational, human,

environmental, and physical resources. Policies, procedures, systems, and programs are part of structure. Donabedian’s

formula(Donabedian, 1992) is the conceptual framework for structural empowerment whereby structure and process are pivotal in

producing desired outcomes (Drenkard, Wolf, & Morgan, 2011).

Structural Empowerment is the Magnet model component that addresses how the workplace environment supports exemplary

professional practice, new knowledge, and improved outcomes. This includes:

a. Professional engagement

b. Commitment to Professional Development

c. Teaching and Role Development

d. Commitment to Community Involvement

e. Recognition of Nursing

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Structural Empowerment Evidence of Performance Specifically…

Interdisciplinary Team Bi-directional reporting/ accountability Recognition of excellence- facility, unit, individual

Up the chain to Executive level, down the chain to Unit level and across disciplines

Interdisciplinary Team Membership (standing+/ad hoc*)

Standing Members: Identified Coordinator+: Certified Wound Clinician+ CNA/ nurse aide+ Direct Care Nurses+ Executive Sponsor+ Nutrition+ Physical Therapy+ Physician+ QI/PI+ Respiratory Therapy+ Social Work+ Transitional care representative/ case management + Ad Hoc Members: Ethics* IT* Lift team* Materials Management* Nurse educator* Patient/Family Advocate* Risk Management*

Evident Leadership Skills

Champion

Passionate

Motivator

Change Agent

Educator CWOCN, CWON, CWCN, or CWS may be on staff or consultant Preferable: former PU patient and/or family

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Professional membership of standing members (WOCN, ANA, AORN, ACCN, APTA, ABWM etc.) Publications Conference presentations/attendance

member

PUP team – Unit/facility based skin champions

Bi-directional reporting/ accountability

Reports up to Interdisciplinary Team, down to unit level staff and across disciplines/departments

All patient units represented

Supported by unit leadership Has protected time out of staffing to perform functions/responsibilities

Responsibilities:

Function as unit-based PUP resource

Provide unit based education

Disseminate/post HAPU data

Perform PU audits/data collection and analysis

Accountable for HAPU prevention best practices on unit

Communicate unit challenges and report successes to Interdisciplinary Team

Role model PUP in every patient assignment

Patient advocate

Peer monitor

Attends PUP team meetings

Disseminates PUP team information to unit based practice council/committee and staff

Makes PUP visible on the unit

Example: bulletin boards, flyers, etc.

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Policies & Procedures Evidence based policies, procedures, clinical practice guidelines, algorithms, power orders, power plans, interdisciplinary plans of care, decision trees all reflect current best practices.(Makic, 2007)

All documents are referenced with current publications.

Education PUP annual competencies for direct care staff Optional venues: on-line, skills day

NDNQI education for all data collectors (4 modules) (Bergquiest-Beringer, 2009 Jun)

PUP included in new employee orientation

Routine PUP education for members of IDT

Patient/family education completed and documented on all at risk patients

Patient/family input into development of educational materials

Bedside shift to shift and all handoff communication includes skin status

New Graduate nurse incorporation into PUP Example: Nurse residency program

Optional: pursue WTA program via WOCN

Active support staff (i.e., care partner, nurse aid) education/competency

Visible organizational education Example: newsletter, e-message board information

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3. Exemplary Professional Practice: Practice that is designed, implemented and reiterated over time (e.g. PDSA) until it reaches a point of

standardization.(Lyder, 2004) Practical methods of conducting work…ensures autonomy, accountability, and peer review, supports

competence and ethical practice, builds a culture of safety, interdisciplinary collaboration and leadership, methods of quality care

monitoring and improvement. It is defined by the organization’s professional practice model.

Exemplary Professional Practice Evidence of Performance Specifically…

Implementation of Current Evidence-based Practices for PUP (C. R. Ratliff, Bryant DE, 2003)

Integrates PUP clinical practice guidelines and ensures implementation into clinical practice.(W. V. Padula, Wald, & Makic, 2013) Must include:

Risk assessment on admission and at least daily thereafter and with change of condition.(Bergstrom, 1987)

Skin assessment on admission and at least daily thereafter.(Black, 2005)

Appropriate implementation of PUP interventions

o Pressure redistribution support surface selection, repositioning, consider device-related HAPU, (Mackey, 2005)

Institute of Healthcare Improvement (IHI), Wound Ostomy Continence Nurses (Ratliff & Tomaselli, 2010), National Pressure Ulcer Advisory Panel (NPUAP EPUAP, 2014), American Hospital Association (AHA), Minnesota Hospital Association, Agency for Healthcare Research and Quality (AHRQ, 2011) Must use a validated risk assessment tool for all ages. EMR must reflect assessment findings. EMR must reflect interventions provided.

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o Nutrition management(Reddy, 2006 Aug 23)

o Manage moisture

o Reduce Friction/Shear

Revision of PUP interventions according to patient condition.

All surfaces within patient care services must have pressure redistribution qualities, including patient chairs and stretchers. Support surfaces have a finite lifespan, follow manufacturer recommendations and ongoing assessment (NPUAP/EPUAP, 2014). Replacements are made when necessary. Must demonstrate the ability to escalate surface to a higher level if risk indicates Nutritional support (Registered dietician) available. Incontinence products available- breathable pads, moisture barriers, fecal management options.

Ancillary Areas Pressure Ulcer Prevention strategies are available in all ancillary areas including but not limited to:

OR

Emergency Department

Endoscopy

Dialysis

Diagnostic Areas: o Cardiac Procedural areas o Interventional Radiology o Diagnostic Radiology

All hand off communication includes skin

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condition and pressure ulcer risk.

Operating Room: Emergency Department:

1. All OR tables will have pressure redistribution OR table pads. Support surfaces have a finite lifespan, follow manufacturer recommendations and ongoing assessment (NPUAP/EPUAP, 2014). Replacements are made when necessary.

2. Procedure in place to ensure susceptible bony prominences are appropriately protected/offloaded during surgery depending on patient positioning. For supine positioning this includes heels, occiput, and sacrum.

3. OR associated HAPUs are investigated by designated OR team.

4. Hand off communication in peri-surgical services includes skin condition.

5. Attempts are made in pre-operative and PACU areas to position patients in a manner other than that required for the surgical procedure.

6. OR clinical staff completes annual PUP competency.

1. All ED stretchers will have pressure redistribution qualities. Support surfaces have a finite lifespan, follow manufacturer recommendations and ongoing assessment (NPUAP/EPUAP, 2014). Replacements are made when

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Dialysis Diagnostic Procedural Areas

necessary. 2. All patients in the ED with an active

admission order and LOS >2hr. will have a skin and pressure ulcer risk assessment completed.

3. Based on risk assessment, appropriate PUP nursing interventions will be implemented.

4. All PU POA will be staged and documented.

5. Products to manage moisture and provide pressure ulcer prevention are easily accessible for staff.

1. All surfaces will have pressure redistribution qualities. Support surfaces have a finite lifespan, follow manufacturer recommendations and ongoing assessment (NPUAP/EPUAP, 2014). Replacements are made when necessary.

2. Dialysis staff will ensure patients are repositioned during treatment regardless of shunt location as even incremental shifts are beneficial.

3. Staff have access to skin care products and provide incontinence care as needed.

1. All diagnostic surfaces are

evaluated annually by designee to ensure skin safe qualities. Replacements are made when necessary.

2. Pre and post procedural care

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includes turning and repositioning at least every 2 hours on determined ‘at risk’ patients when clinically appropriate.

PU Data collection Participates in benchmarking (NDNQI e-measures, UHC)

1. Uses data to drive improvement changes to PUP program

2. Shares data creatively in a bi-directional manner.

3. Demonstrates transparency internally, actively working to achieve improvement within PU injuries that are not reportable.

4. Sets internal stretch targets

EMR IT actively participates in IDT meetings EMR design promotes accurate PUP documentation EMR design triggers specific nursing interventions based on risk assessment EMR generates daily/real time PU occurrences Ideally, the EMR is able to capture status of PU across the care continuum. Adopts consistent hand off communication transfer form when transferring patient to alternate care sites.

A method to ensure consistent delivery of care specific to an individual’s risk. Occurrences are tracked and action plans developed

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Builds a Culture of Safety through Root Cause Analysis

HAPUs are investigated. Incorporate patient and family when appropriate. Determined root causes are corrected using organizational processes. Bi-directional communication of analysis occurs.

4. New Knowledge, Innovations, and Improvements: Evidence-based nursing practice, nursing research, quality and performance

improvement plus innovation all fall in this final Magnet model component. The organization has a culture of inquiry which operates

within an established evidence-based practice infrastructure. Active nursing research efforts add to the growing body of new nursing

knowledge which is communicated, disseminated and translated into practice yielding measurable positive patient outcomes.

Innovation is encouraged, captured and translated into the fabric of nursing practice.

New Knowledge, Innovations, & Improvements

Evidence of Performance Specifically….

Contributing to the body of knowledge associated with the science of PUP

Organization participates in research activities Supports EBP projects to improve PUP

Organization supports publication of clinical work in the form of peer review journal articles, abstract submissions, poster presentations at national meetings, podium presentations at local, regional and national meetings.

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Promotes innovation in PU care Organization recognizes innovation Organization has an active rewards and recognition program tied to PUP

Includes “innovative practice” as a standing agenda item on IDT meetings or PUP unit based staff meetings. Innovative ideas are captured, evaluated and spread in a timely manner.

Promotes PUP beyond organization, into the community

Provides education to local health care workers, including patients and families. Promotes collaboration across the healthcare continuum- Home health, LTAC, Rehab, SNF, Hospice Promotes pressure ulcer prevention education to area schools of nursing

References

Agency for Healthcare Research and Quality (AHRQ). (2011 July). AHRQ toolkit helps to prevent hospital-acquired pressure ulcers: Research Activities. Rockvill, MD: AHRQ.

Bergquiest-Beringer, S., Davidson J, Agosto C, Linde NK, et al. (2009 Jun). Evaluation of the National Database of Nursing Quality Indicators (NDNQI) Training Program on Pressure Ulcers. J Contin Educ Nurs, 40(6), 252-258.

Bergstrom, N., Braden B, Laguzza A, Holman A. (1987). The Braden Scale for predicting pressure sore risk. Nurs Res, 36(4), 205-210. Berwick, D. M., Calkins DR, McCannon CJ, Hackbarth AD. (2006 Jan). The 100,000 lives campaign: setting a goal and a deadline for improving care

quality. JAMA, 295(3), 324-327. Black, J. M. (2005). National Pressure Ulcer Advisory Panel: Moving toward consensus on deep tissue injury and pressure ulcer staging. Adv Skin

Wound Care, 18, 415. Clark, M. L. (2006 Jun). The Magnet Recognition Program and evidence-based practice. J Perianesth Nurs, 21(3), 186-189.

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Donabedian, A. (1992). Quality assurance. Structure, process and outcome. Nurs Stand, 7(11 Suppl QA), 4-5. Drenkard, K., Wolf, G. A., & Morgan, S. H. (2011). Magnet: The Next Generation: Nurses Making the Difference. American Nurses Credentialing

Center. Duncan, K. (2007). Preventing Pressure Ulcers: The Goal is Zero. The Joint Commission Journal on Quality and Patient Safety, 33(10). Kelleher, A. D., Moorer, A., & Makic, M. F. (2012). Peer-to-peer nursing rounds and hospital-acquired pressure ulcer prevalence in a surgical

intensive care unit: a quality improvement project. J Wound Ostomy Continence Nurs, 39(2), 152-157. doi: 10.1097/WON.0b013e3182435409

LeMaster, K. (2007). Reducing Incidence and Prevalence of Hospital-Acquired Pressure Ulcers at Genesis Medical. The Joint Commission Journal on Quality and Patient Safety, 33(10).

Lyder, C. H., Grady J, Mathur D, Petrillo MK, Meehan TP. (2004). Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement. Jt Comm J Qual Safe, 30(4), 205-214.

Mackey, D. (2005). Support Surfaces: Beds, Mattresses, Overlays--Oh My! Nurs Clin N Am, 40, 251-265. Makic, M. B. (2007). Evidence-based practice for the prevention of pressure ulcers. (Doctor of Philosophy), University of Colorado, Denver, CO. Morton, A., Mengersen K, Waterhouse M, Steiner S. (2010). Analysis of aggregated hospital infection data for accountability. J Hosp Infection,

76(4), 287-291.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

Padula, W. V., Mishra MK, Makic MB, Sullivan PW. (2011 Apr). Improving the Quality of Pressure Ulcer Care with Prevention: a cost-effectiveness analysis. Med Care, 49(4), 385-392.

Padula, W. V., Mishra MK, Makic MB, Valuck RJ. (2014 Apr). A Framework of Quality Improvement Interventions to Implement Evidence-Based Practices for Pressure Ulcer Prevention. Adv Skin Wound Care, (In Press).

Padula, W. V., Mishra MK, Weaver CD, Yilmaz T, Splaine ME. (2012 Jun). Building Information for Systematic Improvement of the Prevention of Hospital-acquired Pressure Ulcers with Statistical Process Control Charts and Regression. BMJ Quality & Safety, 21(6), 473-480.

Padula, W. V., Wald, H. M., & Makic, H. M. (2013). Pressure ulcer risk assessment and prevention. Ann Intern Med, 159(10), 718. doi: 10.7326/0003-4819-159-10-201311190-00016

Pappas, S. (2008). The Cost of Nurse-Sensitive Adverse Events. JONA, 38(5), 230-236. Ratliff, C. R., & Tomaselli, N. (2010). WOCN update on evidence-based guideline for pressure ulcers. J Wound Ostomy Continence Nurs, 37(5),

459-460. doi: 10.1097/WON.0b013e3181f17cae Reddy, M., Gill SS, Rochon PA. (2006 Aug 23). Preventing Pressure Ulcers: a systematic review. JAMA, 296(8), 974-984. Smalarz, A. (2006). Physician group cultural dimensions of quality performance indicators: Not all is equal. Health Care Manag Rev, 31(3), 179-

187.