Achieve significant improvement in the pressure ulcers incidence rates and quality indicator rates for participating nursing homes. 

• Proportion of residents with appropriate risk assessment completed within two days of admission*
• Proportion of high-risk residents with appropriate care plan for ALL selected triggers*
• Proportion of high-risk residents whose care reflects the triggered care plan interventions*
• Proportion of residents with pressure ulcers that are given weekly skin assessments*
• Proportion of facility-acquired and community-acquired pressure ulcers with appropriate ulcer description within 24 hours of ulcer recognition*
• Proportion of residents with pressure ulcers and mobility issues using a pressure relief mattress/overlay
• Proportion of residents identified as high-risk using a pressure relief mattress/overlay
• Proportion of SNFs that currently have a wound protocol
• Proportion of residents whose treatment orders and care plan interventions for pressure ulcers reflect facility-based wound care protocols*
• Proportion of low-risk residents that have acquired pressure ulcers during their stay
• Proportion of high-risk residents that have acquired pressure ulcers during their stay
• Proportion of high-risk residents with facility-acquired pressure ulcers whose care plan intervention reflects treatment orders*

* Composite indicator consisting of several separately measured component indicators

In the absence of research providing evidence-based support for the use of various press ulcer prevention techniques, Texas Medical Foundation relied on information from AHRQ guidelines, the Rhode Island Quality Partners, feedback from participating nursing homes and regulatory requirements (both federal and state) when developing tool kit interventions. 

• Provided facility wide education and training on continuous quality improvement processes and interventions
• Performed scheduled monthly onsite visits or visits at the request of facilities to review process changes, make recommendations for continued improvement, and provide just-in-time CQI training
• Developed and implemented a tool kit of materials to assist nursing homes in implementing process of care system changes to include:
  • Nurses’ station reference cards (prevention/prediction pathways, managing tissue loads, support surface)
  • Pocket Pressure Ulcer assessment card
  • Color-coded mobility reminder system indicating the mobility needs of at-risk residents
  • External chart sticker to identify at-risk residents
  • Physician/Facility fax communication form
  • Care Planning tool to provide immediate plan of care documentation for potential and actual pressure ulcer prevention and treatment procedures
  • Resident and Family Education brochure
• Performed periodic measurement during onsite visits to assess progress
• Received promotional support from
• Developed weekly tracking tool to set incidence rate thresholds for intensive analysis

These results show that nursing homes in a Collaborative effort with TMF implementing CQI techniques were able to significantly improve their processes of care and reduce the incidence rates of pressure ulcers.  Although significant improvement was noted on most of the quality indicators, opportunity remains for further improvement.  Furthermore, these results suggest that implementation of process of care system changes by nursing homes in a collaborative relationship with a QIO may yield improvements in measures of patient outcome (e.g. pressure ulcer incidence).

• Strive to transition from quality assurance to quality improvement, moving from defect detection to defect prevention, while making continuous improvement in the process of care delivery.
• Incorporate interventions designed to address barriers to preventive care while sustaining existing processes that have proven effective. 
• Publicly recognize the front line staff for the successes and accomplishments of improvement. 
• Share data as often as possible.
• Implement change on one unit/hall at a time to ensure ultimate success of the intervention and staff buy-in.
• Accept failures in the systems as an opportunity to improve.
• Operationalize systems that utilize continued measurement to monitor and improve performance that is reported to be below a designated threshold.
• Allow staff to maintain a level of autonomy in the intervention design process to promote continued commitment and a sense of ownership of the process. 
• Ensure accountability in following agreed upon process changes to avoid reverting to previous approaches, and rendering change ineffective.
• Ensure consistency in a formalized staff training/orientation related to documentation requirements.
• Include those staff that directly effect the process in the intervention design.

Kevin Warren, MHA, LNFA, CPHQ
Director of Quality Improvement
Texas Medical Foundation
kwarren@txqio.sdps.org

[Storyboard presentation at IHI's National Forum, December 2004]