Pressure Injury Prevention Program Implementation Guide

Appendix F. Hospital Practice Insights: Challenges and Solutions

The hospitals involved in the 2-year AHRQ pilot initiative encountered a variety of barriers. They identified innovative and inspiring solutions to overcome these obstacles and decrease pressure injury rates. Below are brief descriptions of their challenges and solutions, along with suggestions for how to operationalize these ideas at your facility.

Module 1: Understanding Why Change Is Needed

Hospital: 600+ beds
Pilot Units: ICU, Vascular Surgical; 85 beds

Challenge: Lack of leadership buy-in or support.

Solution: Invite the chief executive officer (CEO) and other leaders to conduct pressure injury prevention rounds on the pilot units.

Description: Early in the program, the hospital CEO made rounds on the pilot unit. Three months later, the Executive Team and divisional leaders were scheduled to round on the units to check on progress and identify any gaps in the program. Leaders updated the visibility board with strategies to improve deficiencies that were noted when monitoring process measures.

The visibility board is a valuable strategy to engage unit staff with the prevention approaches being used and to follow progress of the process and outcome metrics on their unit. It also is an excellent strategy to visually show hospital leadership how the prevention program is improving care on a particular unit.

What You Can Do:

  • Ask the CEO or other executive leadership to commit to rounding on pilot units to check on progress and identify any gaps. Leadership rounding can help demonstrate the importance of the Pressure Injury Prevention Program in reducing pressure injuries.
  • Be sure to have process and outcome data available or plans to collect metrics, to discuss with the hospital leader during rounds. Rounds can be an excellent opportunity to justify resources for the prevention program.

Module 1: Understanding Why Change Is Needed

Hospital: 50–200 beds
Pilot Units: ICU, 6 West, 7 East; 133 beds

Challenge: Lack of leadership buy-in or support.

Solution: Present a business case and other information about pressure injury prevention to hospital leadership.

Description: The Implementation Team shared details about their initiative via a board report, a presentation at the quarterly board meeting, and a meeting of the Quality Committee (which includes some leaders and board members). The team made a financial case for preventing pressure injuries—a savings of close to $700,000. It was helpful to have a representative from the Finance Department on the team to put costs and outcomes together.

The charter included:

  • The Pressure Injury Prevention Program and how the hospital used the AHRQ Toolkit to implement best practices.
  • Critical success factors from the team’s metrics and overall goal (i.e., reduce HAPI Stage 2 and above). The team also shared metrics for the tools.
  • A detailed action plan.
  • Core Team members.
  • Web portal for collaboration among team members.
  • Approximate cost of HAPI. Using the national average of $43,000 for each >stage 2 HAPI that occurred at the organization; the team, with a member from their Finance Department, estimated costs the hospital saved by preventing >stage 2 HAPI.

As shown in Table F-1, there were 11 fewer HAPIs in the first 6 months of 2015 compared with 12 months in 2014. The 6-month cost savings were estimated at $473,000. At this same rate of prevention, there was an estimated cost savings of $946,000 for 12 months in 2015.

Table F-1. Hospital-Acquired Pressure Injuries and Costs

January-June 2015 January-December 2014
Stage # HAPI ~Cost Stage # HAPI ~Cost
Stage 1 0 N/A Stage 1 3 N/A
Stage 2 6 N/A Stage 2 14 N/A
Stage 3 4 $172,720 Stage 3 7 $302,260
Stage 4 0 $0 Stage 4 0 $0
Unstageable 4 $172,720 Unstageable 5 $215,900
Deep Tissue Injury 8 $345,440 Deep Tissue Injury 15 $647,700
TOTAL (> Stage 2) 16 $690,880 TOTAL (> Stage 2) 27 $1,165,860

They also took the opportunity of having the board as an audience to show how information technology (IT) issues were impeding their efforts. The presentations sparked the interest of a board member who is a physician with expertise in wound care and became involved in the team’s efforts.

What You Can Do:

  • Consider requesting assistance from the Finance Department in calculating cost-benefit ratios and savings for patient safety and quality improvement programs. Adding costs and savings can add extra incentives to patient safety and quality efforts.
  • Share information with your board and other administrative leaders through multiple avenues (e.g., meetings, reports), and show them ongoing progress and improvement.
  • Determine what expertise is available at your facility.

Module 1: Understanding Why Change Is Needed

Hospital: 400+ beds
Pilot Unit: Neuro Medical ICU (MICU); 9 beds

Challenge: Lack of leadership buy-in or support.

Solution: Discuss pressure injury prevention with leaders at regular meetings.

Description: At the beginning of the Pressure Injury Prevention Program, the Implementation Team added a standing monthly meeting with the chief nursing officer (CNO) to update her on the program. The program was reported to both management and C-suite staff and at every quality meeting.

In addition, the Implementation Team conducts a rapid cycle improvement meeting at their weekly management huddle. C-suite staff attend this meeting and can assist in implementing immediate action. Pressure injuries are discussed during these meetings.

Some of the pretraining tools (e.g., Tool 1C: Leadership Support Assessment, Tool 4C: Assessing Staff Education and Training) highlighted a gap in education for ancillary departments. To help other staff members evaluate the care processes at the facility, C-suite staff shared the information from the AHRQ Toolkit and the pretraining tools with other units and with quality improvement committees on other topics (e.g., central line-associated bloodstream infections, hospital-associated infections, general safety).

What You Can Do:

  • Determine how administration/C-suite can be involved in the Pressure Injury Prevention Program (e.g., monthly meetings).
  • Consider rapid cycle improvement meetings for any pressure injuries.
  • Consider using the AHRQ Toolkit tools for other quality improvement projects.

Module 1: Understanding Why Change Is Needed

Hospital: 50–200 beds
Pilot Units: ICU, 6 West, 7 East

Challenge: Resource support.

Solution: Conduct a 90-day pilot study of a device.

Description: Pressure Injury Prevention Program leadership conducted a trial for a floatation turning device intended to offload pressure, minimize friction and shear, manage moisture, and make it easier to turn the patient. Staff were in favor of the device, but the Value Analysis Committee could not see a true picture of benefits and costs based on the criteria used to evaluate the devices. The committee proposed a 90-day pilot study in the ICU. The Implementation Team revised the criteria to include nurse and patient satisfaction, cost of underpads, and cost of employee injury.

What You Can Do:

  • Evaluate whether you have the appropriate criteria when reviewing devices.

Module 1: Understanding Why Change Is Needed

Hospital: 200–400 beds
Pilot Units: Telemetry, Med/Surg, Neuro-Medical; 56 beds

Challenge: Resource support.

Solution: Provide a calendar to help unit managers schedule skin champions’ attendance at Skin Care Team meetings.

Description: Due to schedule conflicts, the hospital’s skin champions were unable to participate in Skin Care Team meetings, trainings, and prevalence studies. In response to this issue, the team gave unit managers a color-coded calendar marked with these activities. Unit managers then scheduled replacements so that skin champions could participate.

What You Can Do:

  • Coordinate with participating units.
  • Create a calendar so that staffing can be adequate for both the unit and the Implementation Team.

Module 1: Understanding Why Change Is Needed

Hospital: 50–200 beds
Pilot Units: Telemetry, Med/Surg; 24 beds

Challenge: Resource support.

Solution: Use available evidence to assist in advocating for equipment and other resources.

Description: In a review of at-risk patients, the wound care ostomy nurse found that about one-third of the organization’s patients were at risk of developing a pressure injury and that the hospital needed additional equipment to prevent these injuries. A literature review was performed to determine the best devices to purchase.

What You Can Do:

  • Implement literature searches as part of product evaluation.
  • Determine the at-risk population in your facility to drive resource needs.

Module 2: How To Manage Change

Hospital: 200–400 beds
Pilot Units: Telemetry, Med/Surg, Neuro-Medical; 56 beds

Challenge: Defining roles.

Solution: Clarify job duties using Tool 4B.

Description: Staff nurses had expectations of the wound care nurse that were not in line with his or her job duties. For example, staff nurses thought the wound care nurse should change patient dressings. Using Tool 4B: Staff Roles and the support of the Implementation Team Lead, the nurse managers clarified job duties.

To further clarify roles and outline working relationships, wound care nurses and staff nurses made a partnership agreement. The agreement led to increased collaboration between frontline nursing staff and wound care consultants during the evaluation and treatment planning process to optimize patient outcomes related to skin and wound management.

As a result, communication and work relations improved. In addition, the nurse manager of the outpatient wound care program has become more involved with the Inpatient Team, bringing enhanced skills and clinical support.

What You Can Do:

  • Review job duties and expectations.
  • Survey staff to ensure that they understand their responsibilities related to skin care and pressure injury prevention.
  • Work with all staff to ensure that the skin care and pressure injury prevention activities are adequately covered.

Module 2: How To Manage Change

Hospital: 400+ beds
Pilot Unit: Neuro MICU; 9 beds

Challenge: Defining roles.

Solution: Set requirements for Skin Wound Analysis Team (SWAT) members.

Description: The Implementation Team outlined requirements for SWAT members in a document, which each SWAT member must review and sign. The requirements include providing peer-to-peer education on their units every 3 months, educating other staff members on pressure injury prevention, conducting audits, reviewing policy changes that affect skin care practices, and attending SWAT meetings. This activity clarified expectations of SWAT members.

What You Can Do:

  • Develop a contract or commitment form for those involved in SWAT to outline expectations.

Module 2: How To Manage Change

Hospital: 200–400 beds
Pilot Units: Medical ICU and Medicine floors; 40 beds

Challenge: Process analysis assessment.

Solution: Develop a nurse-driven protocol to facilitate timely selection and placement of appropriate support surfaces.

Description: The Implementation Team identified delayed placement of support surfaces for at-risk patients as a root cause of many hospital-acquired pressure injuries (HAPIs). They wanted to standardize the bed ordering process for these surfaces. To facilitate timely selection and placement of appropriate support surfaces, the hospital developed a nurse-driven protocol. The protocol includes risk factors and the patient’s body mass index (BMI). It also allows nursing to be alerted once the patient’s risk factors have been identified.

What You Can Do:

  • Review your facility’s pressure injury prevention processes to determine areas that can be streamlined and improved.

Module 2: How To Manage Change

Hospital: 400+ beds
Pilot Unit: Neuro MICU; 9 beds

Challenge: Process analysis assessment.

Solution: Conduct a shadowing program to ensure SWAT is consulted when needed and orders are implemented.

Description: To confirm that nurses were consulting SWAT as appropriate and implementing orders, a SWAT representative, a nurse manager, and a quality representative shadowed nursing staff for 2 months. The nurse manager validated orders, and the quality representative checked charts and conducted random bedside checks. Nurses who did not follow the process were held accountable.

What You Can Do:

  • Shadow pilot unit staff to ensure that tasks are completed correctly and in a timely manner after initial implementation.

Module 2: How To Manage Change

Hospital: 50–200 beds
Pilot Units: ICU, 6 West, 7 East; 133 beds

Challenge: Process analysis assessment to ensure at-risk patients have the right equipment.

Solution: Develop an algorithm for selecting and ordering beds.

Description: The Implementation Team compared chart documentation, wound care nurse data, and ICD 10i coding to see if staff were documenting and billing appropriately for bed rental that was or should have been used on patients. The data showed that patients were not placed on the appropriate specialty bed in a timely manner and that the payer was not billed appropriately for the cost of the rental bed. Therefore, the facility was losing money.

Staff also contacted the rental bed company and analyzed data regarding the types of beds they were renting, the rental fee, and how many days they were renting the beds on average. The hospital owns specialty beds, but staff had a hard time locating them.

With input from nursing staff, the team developed a bed algorithm to address the Braden Scale score/type of patient appropriate for each type of bed and whether that bed was already in the facility or whether it required a rental. The team distributed a printed copy of the algorithm to each nursing staff member, placed it on each computer on wheels, and made it available electronically.

What You Can Do:

  • Examine policies and procedures for ordering and procuring support surfaces and assess billing practices.
  • Review policies and procedures for providing appropriate support surfaces for each at-risk patient.

Module 2: How To Manage Change

Hospital: Up to 50 beds
Pilot Units: Med/Surg, ICU; 37 beds

Challenge: Process analysis assessment for ensuring adequate supplies.

Solution: Stock a mobile cart with skin and wound treatment information and supplies.

Description: Staff found it difficult to gather all the needed supplies for pressure injury prevention and wound care. In response, the Implementation Team stocked a mobile cart with supplies for skin and wound prevention and treatment and included a binder with care plan guidelines for preventing each Braden Scale subscale deficiency. The team inventories and resupplies the cart on a weekly basis.

What You Can Do:

  • Evaluate whether supplies are easy for staff to obtain and are consistently stocked.
  • If not, determine the best method to ensure products are adequately stocked.

Module 2: How To Manage Change

Hospital: 50–200 beds
Pilot Units: ICU, 6 West, 7 East; 133 beds

Challenge: Process analysis assessment for ensuring adequate supplies.

Solution: Assess the supply dispensing system, and stock it with needed skin supplies.

Description: The Implementation Team found that skin products and their general storage location varied by unit. The team met with Central Supply to discuss the organization of the Pyxis dispensing machines and how to make all wound care products available in a logical and similar manner in all the machines. Nursing staff saw this initiative as a way to help them provide the same products on all units and access to the products.

In addition, nursing staff provided input about the products they felt were missing. Some of the unit’s Pyxis machines have been completed to date, but the machines continue to be installed. Once the Pressure Injury Prevention Program has been completed, the Pyxis units will be maintained.

What You Can Do:

  • Conduct a process analysis of your facility’s supply dispensing system to ensure skin and wound care supplies are available for at-risk patients.

Module 3: Best Practices in Pressure Injury Prevention

Hospital: 200–400 beds
Pilot Unit: Telemetry; 36 beds

Challenge: Improving care planning.

Solution: Integrate care plans into the electronic health record (EHR).

Description: The Implementation Team worked with the IT department to integrate care plans into the EHR. When a patient scores less than a certain number in the Braden subscale, a popup appears and asks the nurse whether a care plan should be started to address the score. After the nurse begins the care plan, the EMR provides recommendations for the patient.

The care plans are also added to the nurse’s action list, which reminds the nurse to complete the care plan. A documentation screen appears when the nurse completes the action list items. A date and time stamp are provided.

What You Can Do:

  • Determine whether your facility’s EHR can be modified.
  • Determine the best ways to integrate risk assessment with the patient care plan.

Module 3: Best Practices in Pressure Injury Prevention

Hospital: 200–400 beds
Pilot Units: Medical ICU and Medicine floors; 40 beds

Challenge: Improving care planning.

Solution: Automatically notify the nutritionist via task list when a patient has a pressure injury.

Description: The facility modified its EHR to automatically notify the nutritionist for a consult via the task list when a patient has a Stage 2, 3, 4, or unstageable pressure injury. Audits found that more than 90 percent of staff had a task order sent to the nutritionist for a consult if a patient had a Stage 2 or greater pressure injury. In addition, nutrition consults became more timely: 100 percent of Stage 2 or greater HAPIs got a nutrition consult within 24 hours.

What You Can Do:

  • Determine whether your facility’s EHR can be modified.
  • Using gap analysis, determine if any areas of the pressure injury prevention process can be streamlined to make patient care easier for staff.

Module 3: Best Practices in Pressure Injury Prevention

Hospital: 200–400 beds
Pilot Unit: Med/Surg

Challenge: Improving care planning and standardizing care.

Solution: Take and store a photo of each wound.

Description: The hospital purchased new software for staff to take and store a photo of each identified pressure injury. They take the photos using a tablet. The photos are then automatically downloaded into the EHR and stored on a secure server.

What You Can Do:

  • Determine whether the use of photo documentation in wound care is an option for your facility.
  • Make sure your institution is familiar with the rules on wound photography in your State and have a policy in place to ensure patient privacy and confidentiality.

Module 3: Best Practices in Pressure Injury Prevention

Hospital: 600+ beds
Pilot Units: ICU, Vascular Surgical; 85 beds

Challenge: Improving care planning and standardizing care.

Solution: Develop a skin care navigator within the EHR.

Description: The Implementation Team worked with the informatics nurse to develop a skin care navigator within the EHR. The navigator suggests interventions and correct products based on the combined factors from the Braden Scale risk assessment. It also ensures that the CNA task list is populated from the care plan. The navigator has decreased the number of places where nurses must document skin and wound care and drives the clinical care plan.

What You Can Do:

  • Determine whether your facility’s EHR can be modified.
  • Streamline nurse documentation by developing a skin care navigator within the EHR.

Module 3: Best Practices in Pressure Injury Prevention

Hospital: 400+ beds
Pilot Unit: Neuro MICU; 9 beds

Challenge: Skin assessment barriers to practice.

Solution: Conduct peer audits.

Description: The SWAT implemented a peer-auditing program housewide. Nursing units evaluate and calculate the prevalence of pressure injuries for a different unit that provides the same level of care (e.g., ICU A reviews ICU B). This approach helps standardize and reinforce pressure injury prevention and determination of prevalence. It also provides a second opinion on each patient’s skin integrity. By reviewing a different unit, the nurse may recognize discrepancies in processes that the unit may not discover. It could be easier to see what is happening on the other units.

What You Can Do:

  • Have similar units audit each other to reinforce desired processes and to ensure that all at-risk patients and pressure injuries are adequately captured.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 50–200 beds
Pilot Units: Telemetry, Med/Surg; 24 beds

Challenge: Staff turnover.

Solution: Assign new nurses to help with pressure injury prevalence studies.

Description: It was challenging to get enough staff to participate in monthly pressure injury prevalence studies. To remedy this shortage, new nurses were assigned to help with the prevalence studies. Wound champions partnered up with and taught the new nurses how to conduct chart audits (including how to find the information they need in the chart) and product reviews. This approach helps reinforce what the new nurses have learned and ensures that there are enough staff members to perform the prevalence study.

What You Can Do:

  • Determine how your facility can best incorporate new nurses into the Pressure Injury Prevention Program and other patient safety efforts.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 200–400 beds
Pilot Unit: Med/Surg

Challenge: Staff turnover.

Solution: Start a new residency program for new nursing graduates.

Description: The hospital started a residency program for new nursing graduates with the goal of retaining new graduate nurses, getting the nurses interested early in skin care, and developing wound care champions. The program includes monthly classes, mentoring, and skin training. Residents also help with quarterly prevalence surveys and attend a 3-hour class on pressure injuries, skin integrity, and wound care.

What You Can Do:

  • Determine creative ways to retain new nursing graduates.
  • Educate new nurses on the Pressure Injury Prevention Program and other patient safety efforts.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 400+ beds
Pilot Unit: Neuro MICU; 9 beds

Challenge: Staff turnover.

Solution: Require the units to provide SWAT representatives from all units and shifts.

Description: The SWAT has a representative from each unit and shift. There are also backups in case a representative is unavailable or leaves the unit. While not every SWAT representative can make it to all meetings all the time, at least one representative per unit is expected to attend the SWAT meeting. Attendance is reported to leadership to ensure the continuing participation of SWAT members.

What You Can Do:

  • Determine the best way to form committees dedicated to enacting change.
  • Ensure participation from members.
  • Replace members when they leave the organization.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Various hospitals and units

Challenge: Staff engagement.

Solution: Various engagement methods.

Description: Participating hospitals have used a variety of methods to engage staff:

  • At one hospital, a banner designed specifically for the Pressure Injury Prevention Program travels each month to a unit that is performing well.
  • One hospital branded its pressure injury prevention efforts as Save Our Skin (SOS). It used a life preserver logo and passed out Life Savers® candy to communicate the program to staff.
  • The corporate office of one hospital recognized the Implementation Team’s work to define roles and responsibilities. This led to increased collaboration between frontline nursing staff and wound care consultants related to evaluation and treatment planning.
  • To motivate staff to attend safety fairs, participating hospitals used the following techniques: awards for entire unit attendance, mandatory attendance, and themed fairs.

What You Can Do:

  • Tell facility personnel about your team’s pressure injury prevention efforts.
  • Determine ways to increase the visibility of the Pressure Injury Prevention Program.
  • Reward staff members who are doing well in pressure injury prevention.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 200–400 beds
Pilot Units: Telemetry, Med/Surg, Neuro-Medical; 56 beds

Challenge: Staff engagement.

Solution: Provide financial support for the Pressure Injury Prevention Program.

Description: The hospital provides financial support for the Pressure Injury Prevention Program. Skin champions get a complimentary lunch during training every other month in recognition of their extra duties. Staff are paid if they attend the annual safety fair (which includes skin care education) during their time off. The hospital also provided funds for marketing the initial rollout of the program.

What You Can Do:

  • Provide paid time for activities related to the Pressure Injury Prevention Program, which shows staff their work is valued and allows time to complete the program work.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 600+ beds
Pilot Units: ICU, Vascular Surgical; 85 beds

Challenge: Staff engagement.

Solution: Hold celebrations.

Description: Pressure Injury Prevention Program leaders felt that small successes should be rewarded early on. One month after implementation of the program, the Implementation Team held a breakfast to celebrate the staff’s active participation. They also held a performance improvement celebration at the 7-month mark because they felt that at that time the success was sustainable.

What You Can Do:

  • Determine what types of rewards can be shared with staff members and units that are doing great work related to the Pressure Injury Prevention Program.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 400+ beds
Pilot Unit: Neuro MICU; 9 beds

Challenge: Staff education.

Solution: Educate SWAT members, who in turn educate unit staff.

Description: Educating SWAT representatives occurs through various methods. SWAT representatives receive education via an online program. Every other month, the SWAT meeting includes an educational session for the team that focuses on current pressure injury prevention strategies at the facility. SWAT representatives, in turn, provide peer-to-peer education on pressure injury prevention to staff on their unit every 3 months.

A sign-in sheet is used to record peer-to-peer education. If education of a staff member is not completed due to staff vacations or other absences, the unit SWAT representative must create an action plan to ensure that education is completed, and the staff member has an extra week to complete the education.

What You Can Do:

  • Coordinate education for staff.
  • Use the pressure injury prevention unit champions as one way to disseminate education and information about the program to staff.
  • Ensure adequate followup and ownership of the education by checking that education has been conducted.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 200–400 beds
Pilot Units: Telemetry, Med/Surg, Neuro-Medical; 56 beds

Challenge: Staff education.

Solution: Take a boot camp approach to education.

Description: The Implementation Team took a boot camp approach to educating skin champions and other interested staff. The education was carried out over 2 days and covered the AHRQ Toolkit, along with hospital-specific pressure injury prevention and treatment. Staff took a knowledge-assessment test before and after the training. There was a notable increase in correct answers after the training: The pretest average score on Tool 2G: Pieper Pressure Ulcer Knowledge Test was 69 percent; the average score on the posttest was 94 percent.

What You Can Do:

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Various hospitals and units

Challenge: Staff education.

Solution: Use newsletters to educate staff.

Description: Participating hospitals have used newsletters in a variety of ways to educate staff. For instance, they have used them to:

  • Announce the Pressure Injury Prevention Program kickoff.
  • Announce the schedule for trainings and prevalence studies.
  • Give short quizzes about pressure injury prevention and treatment.
  • Provide information about outcome and process measures.
  • Provide information about such topics as staging and support surfaces.
  • Show photos of pressure injury prevention staff (such as wound care nurses, skin champions, and Skin Care Team members).
  • Showcase pressure injury data.

What You Can Do:

  • Include Pressure Injury Prevention Program information in a newsletter.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 400+ beds
Pilot Units: MICU, Med/Surg; 48 beds

Challenge: Staff education.

Solution: Provide pressure injury prevention education.

Description: The Implementation Team determined that the organization needed a coordinated educational plan and provided the following to all nurses on the pilot units:

  • Case study to test proper EHR documentation.
  • Pressure injury prevention education targeted to different types of nurses.
  • Simulation with a mannequin to educate on wounds, proper head-to-toe skin assessment, and appropriate dressings.
  • Structured education classes for nurses related to Braden Scale scoring, associated interventions, and implementation of those interventions.

After testing the education in the pilot units and making any necessary changes, the team provided the following education housewide:

  • Annual Skin Fair.
  • Focused “arm-in-arm” training, which includes audits to ensure education is translated into action.
  • Online pressure injury prevention education.
  • Audits to identify areas that need more education.
  • Based on audit results, additional education (one issue per quarter), including direct staff education and rounding to provide real-time education.

What You Can Do:

  • Educate staff on new processes, implement the new processes, and then audit the processes so you can ensure they are hardwired into practice.
  • Offer multiple educational opportunities for staff to learn of the new processes, which helps you reach more staff members and reinforce the processes.

Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization

Hospital: 400+ beds
Pilot Unit: Neuro MICU; 9 beds

Challenge: Staff education.

Solution: Hold a Patient Safety Fair and provide education for all hospital staff.

Description: Through the evaluation of their program, the facility realized that their educational offerings focused mainly on nurses, but other staff members can be educated to recognize when patients need assistance. Therefore, the facility held a Patient Safety Fair, which all staff, regardless of their involvement in patient care, were expected to attend.

The fair included pressure injury prevention and maintenance of skin integrity. It provided information on such topics as available resources to use with patients, ways to reduce friction and shear, and other factors contributing to pressure injuries. The facility plans to hold an annual Patient Safety Fair for all employees.

In addition to the fair, the facility provided updated hospitalwide education. Attendance at the Education Fair in June 2015 was 100 percent of staff, including secretarial staff, transport staff, and ancillary departments. The Implementation Team will continue to provide updated education every 6 months.

What You Can Do:

  • Hold a Patient Safety Fair to share information about pressure injury prevention practices and other patient safety issues with all staff.

Module 5: How To Measure Pressure Injury Rates and Prevention Practices

Hospital: 50–200 beds
Pilot Units: Telemetry, Med/Surg; 24 beds

Challenge: Inaccurate staging and coding.

Solution: Improve pressure injury terminology to facilitate accurate staging.

Description: The Implementation Team found inconsistencies in clinical documentation and staging of pressure injuries and deep tissue injuries. This inconsistency could result in revenue loss for the hospital. In addition, a review of the ICD-10 billing system showed that some pressure injuries that were listed as hospital acquired were in fact present on admission, according to the wound care nurse notes in the patient’s EHR.

The team reviewed the charts of patients with pressure injuries before discharge, and nursing worked with the Coding Department to ensure that the patient documentation and coding information matched. The team also worked closely with the coding specialists to ensure that documentation was adequate for accurate coding. Nursing now uses better terminology that facilitates accurate staging and coding.

What You Can Do:

  • Determine whether the staging of pressure injuries is accurate.
  • Coordinate between the Billing Department and the Implementation Team to ensure that nursing is providing enough information for the Billing Department to accurately code skin issues, including pressure injuries.

Module 5: How To Measure Pressure Injury Rates and Prevention Practices

Hospital: 50–200 beds
Pilot Units: ICU, 6 West, 7 East; 133 beds

Challenge: Quality improvement.

Solution: Showcase data.

Description: The facility’s quality boards are frequently updated with new information. Pressure injury data are updated quarterly, but some of the other items, such as the action plan, are updated more often. The boards are visible to staff, patients, and visitors. Nurse leaders, the Pressure Injury Prevention Program Lead, and bedside nurses are available to answer questions about the boards.

What You Can Do:

  • Display information about the Pressure Injury Prevention Program.
  • Be transparent with and update the tracking data from your prevention efforts.

Module 5: How To Measure Pressure Injury Rates and Prevention Practices

Hospital: 600+ beds
Pilot Units: ICU, Vascular Surgical; 85 beds

Challenge: Quality improvement.

Solution: Showcase data.

Description: As part of the facility’s Lean QI approach, visibility boards are posted on nursing units. These boards show trended data (such as audit results) specific to the unit for the quality indicators measured and monitored. Leaders round and update the boards with countermeasures, such as auditing using the “four eyes principle” of cross-checking.

Executive leaders visit the units and discuss results with staff. It is the unit manager’s responsibility to discuss poor scores and to close any gaps with more education, time management strategies, or whatever will help staff perform better.

A visibility board forces structure and attention to the prevention program. Each board is unit specific and showcases the process and outcome data from that patient care unit.

For each True Northii organizational goal, this hospital identifies the following on the unit’s visibility board:

  • Unit-specific pressure injury prevention goal.
  • Baseline data and current process and outcome metrics.
  • What you are measuring and how you are measuring improvement.
  • How you are doing with your goals.

What You Can Do:

  • Display information about the Pressure Injury Prevention Program and the unit’s efforts.

i. ICD-10 = International Classification of Diseases, 10th Revision.

ii. *True North is a Lean QI term that describes the goals (i.e., compass needle visual) to take the organization from the current condition to where they want to be (ideal condition).

Page last reviewed October 2017
Page originally created September 2017
Internet Citation: Appendix F. Hospital Practice Insights: Challenges and Solutions. Content last reviewed October 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/systems/hospital/pressureinjurypxtraining/implguide-appendixf.html
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