Preventing Pressure Ulcers in Hospitals
1. Are we ready for this change?
Because pressure ulcer care is complex, efforts to improve pressure ulcer prevention require a system approach that will involve organizational change. Bringing about organizational change of any type is difficult. It is even more difficult when it involves multiple, simultaneous modifications to workflow, communication, and decisionmaking as are needed in a pressure ulcer prevention initiative. Failure to assess your organization's readiness for the change at multiple levels can lead to unanticipated difficulties in implementation, or even the complete failure of the effort. Each of the questions below will help you and your organization explore readiness and identify action steps to improve it, if necessary.
- Do organizational members understand why change is needed?
- Is there urgency to change?
- Does senior administrative leadership support this initiative?
- Who will take ownership of this effort?
- What resources are needed?
- What if we are not ready?
1.1 Do organizational members understand why change is needed?
Readiness requires both the capability to make changes (e.g., knowing what the new prevention protocol is and how to use it) and the motivation to make the change. That motivation may be helped along by external factors, such as Federal or State mandates. But it is most likely to be strong and enduring if based on a clear understanding of the concerns behind the planned change at all levels of the organization.
There are many potential reasons to implement a pressure ulcer prevention program. While we offer general reasons and statistics in the box below, local reasons or cases may be more tangible and compelling. For example:
- Has your facility experienced a significant increase or spike in pressure ulcer rates?
- Is your facility responding to changes in CMS reimbursement policy?
- Have there been any notable adverse events that were pressure-ulcer related?
- Has your facility been the target of a legal action related to a pressure ulcer?
- Do staff members have personal experience of a family member affected by a pressure ulcer?
Did you know?
Number affected: 2.5 million patients per year.
Cost: Pressure ulcers cost $9.1-$11.6 billion per year in the US. Cost of individual patient care ranges from $20,900 to 151,700 per pressure ulcer. Medicare estimated in 2007 that each pressure ulcer added $43,180 in costs to a hospital stay.
Lawsuits: More than 17,000 lawsuits are related to pressure ulcers annually. It is the second most common claim after wrongful death and greater than falls or emotional distress.
Pain: Pressure ulcers may be associated with severe pain.
Death: About 60,000 patients die as a direct result of a pressure ulcer each year.
Links to the source of these facts are included in the resources section on the next page.
While those who have initiated a focus on pressure ulcer prevention may clearly understand the needed changes and the reasons for them, there may be great variation across the organization in levels of knowledge and motivation in this area. Others in your hospital may have different reasons, so it is important to define the issues and reasons for change. This process will help make the case for why a pressure ulcer prevention initiative is needed now.
Updating knowledge and changing attitudes requires not only sharing new information but also assessing and addressing existing knowledge and attitudes that may undermine change efforts if left unaddressed. Past surveys of both medical and nursing staff have shown that both groups have a poor understanding of the costs and importance of pressure ulcers. Be sure to survey all types of staff members involved in clinical care, since awareness of the importance of pressure ulcer prevention is an interdisciplinary responsibility.
- Identify the reasons serving as the impetus for a pressure ulcer prevention program in your health care organization. If they are general and not specific to your hospital, you may want to find cases or examples that will help bring the issue home to your facility.
- Determine your facility leadership's interests and needs in this area, and assess how much effort will be needed to obtain and sustain their support.
- Talk with other people (from various levels, roles, and clinical areas) who support implementing a pressure ulcer program. This group may include as many as 10 or 20 people who have a stake in this issue.
- Gather their input and begin to clarify the reasons for needed change.
- Develop consensus on reasons this program needs to go forward.
- Assess the extent to which organizational members beyond potential supporters understand the reasons that a comprehensive pressure ulcer prevention program is important. This step can be completed in a variety of ways, such as small group meetings, surveys, or a review of quality concerns raised by organizational members.
- Consider identifying one unit where the pressure ulcer problem is worst or where staff are most enthusiastic about pressure ulcer reduction. These staff are most likely to understand why change is needed, so find out what they think.
Consider administering a survey to assess clinical staff attitudes about pressure ulcers. An 11-item survey adapted from a larger survey by Moore & Price provides a sample tool. The survey instrument and scoring information can be found in Tools and Resources (Tool 1A, Clinical Staff Attitudes Toward Pressure Ulcer Prevention ).
Several hospitals that recently used this tool to assess staff attitudes discovered some surprises that had immediate implications for staff education in this area.
If you want to create your own survey, sites such as Survey Monkey (www.surveymonkey.com) are free for simple surveys. Consider using this to field an anonymous survey assessing awareness of the clinical and cost impact of pressure ulcers, and of the perceived importance of this area.
Facts and other important data can be found in Statistical Brief #64: Hospitalizations Related to Pressure Ulcers Among Adults 18 Years and Older, 2006. This resource can be accessed through the Healthcare Cost and Utilization Project: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.jsp.
More information about the Moore & Price attitude survey can be found in their article: Moore Z, Price P. Nurses' attitudes, behaviors, and perceived barriers towards pressure ulcer prevention. J Clin Nurs 2004;13(8):942-52.
1.2 Is there urgency to change?
Beyond understanding why the change is needed to improve the prevention of pressure ulcers, do organizational members find the need compelling? If a sense of urgency does not yet exist among key organizational leaders and members, your job as change agents is to increase or create it. At this early stage, the focus is on urgency at the organizational level. Awareness and knowledge for change at the unit level will be discussed in section 2.2. Consider the aspects of the problem that will be most compelling to your stakeholders. Are there different aspects that are relevant and persuasive for different audiences within the hospital?
In considering your arguments, you will want to take into account current organizational attention to pressure ulcers. For example, does the organization have a certified wound care nurse? If not, who has lead responsibility for wound care? Are pressure ulcer rates regularly documented and reported? If so, who receives the reports and acts on them? Answers to these questions will influence the way you make your case for improving pressure ulcer prevention.
To the extent that the building blocks for improving prevention are not present, your task of increasing urgency will be more difficult. And mounting an effective improvement effort will likely require leadership support of greater investment, as discussed in section 1.3, and more resources, as described in section 1.5.
Based on your assessment of the current understanding of the situation, begin to explore topics or themes that can be used to increase awareness and urgency.
- Reach out beyond those already supportive of efforts to strengthen pressure ulcer prevention to begin talking with your colleagues about pressure ulcer prevention and why it is important at your health care organization.
- Listen to their responses to gather important information about barriers of awareness and understanding that you may need to address later with education. (The responses to the survey questions suggested above may be helpful here).
- Conduct a stakeholder analysis in order to identify key people and departments that may have a stake in the success of this project.
A template for stakeholder analysis can be found in Tools and Resources (Tool 1B, Stakeholder Analysis).
Consider the introductory slide presentation and other resources available through the Institute for Healthcare Improvement: http://www.ihi.org/IHI/Programs/Campaign/PressureUlcers.htm.
The template for stakeholder analysis in Tools and Resources was adapted from a set of project management templates available at: http://www.businessballs.com/project%20management%20templates.pdf
Urgency can be created in a variety of ways. At one hospital, nurses in the surgical intensive care unit (SICU) felt they were delivering exceptional care. Unfortunately, due to a high incidence of pressure ulcers (33%) patients were not being accepted to the "good" rehabilitation hospital in town and their recovery slowed. A meeting with the rehabilitation hospital helped nurses learn best practices to prevent pressure ulcers. Now incidence of pressure ulcers is down to 2 percent. At this hospital, understanding how a high incidence of pressure ulcers was affecting patient outcomes helped create urgency among the staff nurses.
At another hospital, a new pressure ulcer monitoring system and an external review by the Department of Public Health motivated nurses to work on decreasing pressure ulcer rates. The hospital implemented a new automated mechanism to identify patients at risk for developing pressure ulcers, along with a referral system for patients who were at risk on the Braden Scale. This new way of identifying and monitoring pressure ulcers increased awareness among the staff and helped them better target their efforts. Around the same time, the State Department of Public Health came to the hospital for a site visit in response to a serious reportable event. The external review of clinical practices created additional urgency to keep rates low.
1.3 Does senior administrative leadership support this initiative?
It is crucial to make sure that your organization's leadership team shares the urgency to change pressure ulcer practices and is willing and able to provide complete and ongoing support for this change effort. Lessons learned from key pressure ulcer prevention initiatives provide us with the evidence that support is needed from both the top-level administration as well as those at the bedside. Facilities that have already transitioned to a shared leadership model may be able to take a different approach through the channels that already exist for bottom-up input and leadership.
In a shared leadership model, the interdependence and expertise of staff at all levels is appreciated and staff are involved in key committees, developing the ability to analyze decisions from multiple perspectives. For other facilities that have a more traditional leadership structure and approach, the assessment and cultivation of senior leadership support will be a more crucial process.
Consider how support for this effort fits with other institutional values and commitments in order to frame it most effectively to obtain and maintain leadership attention. While you may not know at the outset all the kinds of support that will be needed, it is clear that the changes are going to require new or reallocated resources, most likely both human and material. The changes will also require focus and accountability for results, which will also need senior leadership oversight.
If senior leaders do not already support the effort to strengthen prevention of pressure ulcers, you will need to build the case for change. Building the case for some stakeholders, such as your chief financial officer, may be a business case. You may discuss how much pressure ulcers cost the hospital each year in terms, for example, of longer lengths of stay, additional staff time, and, as reimbursements change, increased readmissions. For other stakeholders, such as the clinical chiefs and nurse executive, it may be a clinical case around increased pain, morbidity, and mortality.
Many hospitals have a strong emphasis on quality improvement and an improvement infrastructure to support it. Consider contacting quality improvement (QI) leaders in your organization for guidance and possible assistance in enlisting leadership support. Also, you may want to enlist quality improvement advisors to participate on your Implementation Team as described in section 2.1.1.
In order to assess leadership support and other questions raised here, consider using a facility-level assessment similar to this one.
|Leadership Support Assessment||Yes||No|
|Patient safety is clearly articulated in the organization's strategic plan|
|Someone in senior management is in charge of patient safety|
|The facility has implemented a shared leadership model|
|There is a dedicated budget allocated for patient safety activities|
|The budget includes funding for education and training on patient safety issues such as pressure ulcer prevention|
|Improved pressure ulcer prevention is a priority within the facility|
|The facility has implemented a pressure ulcer prevention policy|
|Current pressure ulcer prevention goals are being addressed|
|There are visible role models/champions for pressure ulcer prevention|
The tool for assessing leadership support can also be found in Tools and Resources (Tool 1C, Leadership Support Assessment).
- Assess the level of leadership support for this change effort. Look carefully at the yes and no answers in the leadership support assessment. If there is no senior management responsibility for patient safety, earmarked funds for patient safety, patient safety education, or champions for pressure ulcer prevention, launching a pressure ulcer prevention project is likely to be extremely difficult, if not impossible. Ideally, they will share the urgency to improve and help drive that urgency through the organization. However, if their support is not adequate, take steps to inform leaders of the importance and potential benefits associated with pressure ulcer prevention.
- Answer the following questions: Who are the key leaders? What will get them on board, if they are not already on board? What will keep them on board? Which senior leader can be the sponsor, link, or champion for this effort.
- Use what you learned about reasons for change identified by the management and staff in your assessments.
- Develop the case for pressure ulcer prevention targeted to the priority concerns of the key leaders using templates linked below as examples.
A template for developing a business case for pressure ulcer prevention can be found in Tools and Resources (Tool 1D, Business Case Form).
Consider adapting the approach recommended by the Canadian Association of Wound Care to make a quantitative case for improving pressure ulcer prevention: http://www.preventpressureulcers.ca/decision-maker/decision-maker.html.
The leadership support assessment above is based on one developed for hand hygiene improvement work; other aspects of the original project may also be of interest to you: http://www.health.gov.on.ca/en/ms/handhygiene/docs/9_8_Facility-Level_Assessment_15Feb08.pdf
1.4 Who will take ownership of this effort?
Beyond the support of organizational leaders, improvement and change projects need strong advocates, members of the organization who are committed to the project's goals and who can influence others to get involved. Successful change projects must have broader support than just one or two champions. These individuals would be from various disciplines and may include physicians, unit managers, wound care nurses, nutritionists, or staff members with a particular interest in this area. Some or all of these staff should make up the interdisciplinary Implementation Team that will guide the improvement effort, as described in section 2.
- Assess your organization to identify who the potential advocates of pressure ulcer prevention are likely to be. Some may be obvious, such as the Wound, Ostomy, and Continence Nurse (WOCN), but others may not be immediately evident.
- Who cares about this issue? Why might it be important to them?
- Organizationally, what would be the logical home base for this effort?
- Are there individuals in that part of the organization who would be willing to take ownership?
In identifying potential owners or champions for the effort, consider the tips at http://teamstepps.ahrq.gov/abouttips.htm.
1.5 What kinds of resources are needed?
In addition to the Implementation Team, improvement projects require resources of various kinds, depending on the size and scope of the project. Launching an effort without first ensuring adequate resources can derail your project at almost every step. Resources needed are likely to include staff time for team meetings and initiatives, leadership time to monitor and support team efforts, training and education time, and more tangible resources such as new care products and communication materials.
Are funds available for the program? Any new initiative will cost money indirectly in staff time and resources or directly for printing and materials. It is important to meet with senior administrators to determine what budget may be available.
Consider creating a checklist to identify resource needs, such as funds, staff education programs, and information technology support. At the beginning of the project, the list of resources needed is likely to be broad and will require refinement as the improvement efforts progress. In developing the list, consider the resources already in place, such as wound care nurses, data system for reporting pressure ulcer rates, and staff education programs. A detailed approach to determining current prevention practices is described in section 2.2.2. At this early stage of determining whether change is needed, the assessment of resources can be at a more general level.
A checklist for identifying resource needs can be found in Tools and Resources (Tool 1E, Resource Needs Assessment).
- Take the time to develop a list of resources that are likely to be needed as part of a pressure ulcer prevention project.
- Ask for what you will need to accomplish some significant changes.
1.6 What if we are not ready?
You should not move ahead until you are confident of organizational readiness. You can use the checklist in section 1.7 below to assess each of the areas of organizational readiness for change that has been discussed in this section. To the extent that readiness is not yet evident, or is only partial, it is critical to take steps to address those areas. At a minimum, the facility must have one senior leader who understands the importance of this effort and is committed to supporting the effort both in terms of resources and necessary changes to work processes. In addition, evidence of a broader commitment to patient safety is an essential component. If any of these elements are missing, it is essential to build support and readiness before launching a full-scale change effort.
Some ways to build support and readiness may include:
- Trying the changes in a single receptive unit to demonstrate success to the rest of the organization and build the case for change.
- Holding one-on-one meetings with key formal and informal leaders to present information about the need for change and persuade them that the improvement efforts will pay off.
- Collecting and sharing data on magnitude of pressure ulcer incidence in your facility to establish project relevance.
- Identifying and recruiting project allies who can help spread the word.
- Conducting a general staff awareness campaign.
1.7 Checklist for assessing readiness for change
This and other end-of-chapter checklists are designed to provide toolkit users with ways to check their progress through the assessment and implementation steps discussed in the toolkit. They may be useful in ensuring that toolkit users have not skipped essential steps (e.g., ensuring leadership support) in pursuing their pressure ulcer prevention efforts.
1. Organizational Readiness Checklist
|Why is change needed?|
|Do organizational members understand why change is needed?|
|Is there a sense of urgency about the change?|
|Is there leadership support for this effort?|
|Who will take ownership of this effort?|
|What kinds of resources are needed?|