Pressure ulcers, also known as bedsores, pose a significant challenge in acute care settings. They cause patient discomfort, prolong hospital stays, increase healthcare costs, and are considered a preventable “never event” by Medicare. Effective prevention requires a systematic, multidisciplinary approach. This article provides a comprehensive suite of clinical audit tools designed to improve skin care practices and significantly reduce the incidence of pressure ulcers in hospitals.
These tools, developed by leading institutions such as Boston University Research Team and quality improvement organizations, offer a structured framework for healthcare professionals to assess current practices, identify areas for improvement, and implement evidence-based strategies. By utilizing these templates, hospitals can proactively enhance their skin care protocols, ultimately leading to better patient outcomes and a higher standard of care.
The toolkit is organized into key areas crucial for successful pressure ulcer prevention, starting from initial project planning to continuous monitoring and improvement. Each tool is designed to be practical and easily adaptable to different hospital settings, ensuring a tailored approach to quality improvement.
Tool 0A: Executive Summary for Stakeholder Engagement
Initiating a pressure ulcer prevention project requires buy-in from key stakeholders across various hospital departments. This template serves as an introductory letter to engage these individuals, highlighting the importance and scope of the project. It emphasizes the multidisciplinary nature of pressure ulcer prevention and the need for collaborative effort.
Why is this project important? Pressure ulcers significantly impact patient well-being and hospital resources. Addressing this issue is not just about improving patient care but also about financial responsibility and aligning with healthcare quality standards.
How does this project affect different departments? Effective pressure ulcer prevention is not solely a nursing responsibility. It requires a coordinated effort involving:
- Materials and Supplies: Ensuring access to evidence-based products for skin protection and pressure relief.
- Housekeeping: Optimizing bed-making techniques to minimize moisture retention against the skin.
- Information Technology: Integrating skin assessment and prevention interventions into electronic health records (EHR).
- Respiratory Therapy: Proper placement of respiratory equipment to avoid pressure points.
- Medicine: Ensuring timely orders for specialized support surfaces and preventive measures.
- Quality Improvement: Utilizing QI methodologies to drive and sustain improvement efforts.
- Transport: Minimizing pressure risks during patient transport using appropriate equipment.
This tool helps articulate the project’s goals, benefits, and the collaborative spirit needed for success, ensuring all stakeholders understand their roles and responsibilities.
Tool 1A: Assessing Clinical Staff Attitudes Towards Pressure Ulcer Prevention
Understanding the attitudes of clinical staff towards pressure ulcer prevention is crucial for tailoring interventions and fostering a culture of proactive care. This Staff Attitude Scale, adapted from Moore and Price’s research, provides valuable insights into staff beliefs and perceptions.
The survey uses a 5-point scale to gauge agreement with statements related to pressure ulcer prevention. Scoring is designed to identify both positive and negative attitudes, with scores ranging from 11 (most negative) to 55 (most positive). A median score of 40 was observed in a cited study, serving as a benchmark.
Using the Scale: Administer the survey anonymously to all staff involved in direct patient care to encourage honest feedback. Analyzing the results can reveal potential inconsistencies in attitudes across different staff groups. Scores below 40 might indicate areas where educational interventions and awareness campaigns are needed to address misperceptions and enhance commitment to prevention.
| Strongly agree | Agree | Neither agree nor disagree | Disagree | Strongly disagree | |
|---|---|---|---|---|---|
| 1. All patients are at potential risk of developing pressure ulcers | |||||
| 2. Pressure ulcer prevention is time consuming for me to carry out | |||||
| 3. In my opinion, patients tend not to get as many pressure ulcers nowadays | |||||
| 4. I do not need to concern myself with pressure ulcer prevention in my practice | |||||
| 5. Pressure ulcer treatment is a greater priority than pressure ulcer prevention | |||||
| 6. Continuous assessment of patients will give an accurate account of their pressure ulcer risk | |||||
| 7. Most pressure ulcers can be avoided | |||||
| 8. I am less interested in pressure ulcer prevention than other aspects of care | |||||
| 9. My clinical judgment is better than any pressure ulcer risk assessment tool available to me | |||||
| 10. In comparison with other areas of care, pressure ulcer prevention is a low priority for me | |||||
| 11. Pressure ulcer risk assessment should be regularly carried out on all patients during their stay in hospital |
Tool 1B: Stakeholder Analysis for Collaborative Prevention Strategies
Successful implementation of a pressure ulcer prevention program hinges on identifying and engaging key stakeholders. This Stakeholder Analysis tool helps map out individuals and departments with vested interests in the project. By understanding their perspectives, potential barriers can be anticipated and addressed proactively.
Adapted from a Project Agency template, this tool guides project initiators to consider the interests, requirements, and potential attitudes of stakeholders. It facilitates the development of targeted actions to ensure buy-in and active participation.
How to Use: Complete the form by identifying key stakeholders, their interests in the project, what the project needs from them, their perceived attitudes and potential risks, and planned actions to engage them. This systematic approach ensures no critical stakeholder is overlooked and that their needs are considered throughout the project lifecycle.
| Stakeholder | Interest or requirement in the project | What the project needs from stakeholder | Perceived attitudes and risks | Actions to take |
|---|---|---|---|---|
| Example: health information systems officer | Gatekeeper for making any changes to the electronic medical record (EMR) system. Not necessarily interested in the project beyond his general mandate to keep the EMR tied to clinical documentation needs. | The project may need to add or make changes to any parts of the EMR that concern skin assessment, preventive measures, and skin care. | May not want to make changes until other changes are also in process, or other changes may already be in process. | Seek information about the process for requesting/making these kinds of changes and how this person relates in the overall organizational structure to project leaders/advocates. |
Tool 1C: Leadership Support Assessment for Project Success
Leadership support is paramount for the success of any hospital-wide initiative. This Leadership Support Assessment checklist helps evaluate the level of commitment from senior leadership towards pressure ulcer prevention.
Developed by the Boston University Research Team, this tool comprises key indicators of leadership engagement in patient safety and quality improvement.
Interpreting the Assessment: Review the responses to identify areas where leadership support may be lacking. “No” answers to multiple items could signal potential challenges to project implementation. Addressing these gaps by informing leadership about the urgency and benefits of pressure ulcer prevention is a crucial step in securing their backing.
| 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 |
Tool 1D: Business Case Form for Resource Justification
To secure resources and funding for a pressure ulcer prevention initiative, a compelling business case is essential. This tool, adapted from a Project Agency template, provides a structured format to present the rationale and benefits of the project to hospital leadership.
Building the Business Case: Complete the form with concise information about the project’s background, aims, potential risks, expected outcomes, and initial cost and time estimates.
Presenting the Case: Use the completed form to discuss the project with sponsors and leadership, highlighting the return on investment in terms of improved patient outcomes, reduced costs associated with pressure ulcer treatment, and alignment with quality and safety goals.
| Project Background (keep this brief) |
|---|
| General aims |
| Initial Risks |
| Expected Outcomes |
| Benefits of Implementing This Project |
| Initial Estimates of Cost and Time $: Time: |
| Outcome of the Business Case |
| Decision From (Project Sponsor) |
| Date |
Tool 1E: Resource Needs Assessment for Project Planning
Effective project execution requires adequate resources. This Resource Needs Assessment checklist helps identify available resources and pinpoint any gaps that need to be addressed.
Developed by the Boston University Research Team, this tool covers various resource categories essential for a successful pressure ulcer prevention initiative.
Ensuring Resource Availability: Complete the checklist to assess the availability of funds, staff education programs, QI expertise, IT support, specialized products, and other necessary resources. Addressing any identified resource gaps is crucial before launching the project.
| Resource | Needed: Yes/No | Notes on what is needed |
|---|---|---|
| Funds | ||
| Other Resources | ||
| Staff education programs | ||
| Quality improvement experts | ||
| Physical/occupational therapy consultation on work practices | ||
| Information technology support | ||
| Specific products/tools (e.g., support bed and chair surfaces) | ||
| Facilities and supplies (e.g., meeting rooms) | ||
| Printing/copying | ||
| Graphics/design | ||
| Nonclinical time for team meetings and activities | ||
| Other |
Tool 2A: Forming a Multidisciplinary Team for Comprehensive Care
A multidisciplinary team is the cornerstone of a successful pressure ulcer prevention program. This tool assists in identifying individuals from diverse disciplines who should be part of the implementation team.
Developed by the Boston University Research Team, this template lists various disciplines and prompts for names of potential team members and their areas of expertise.
Building a Strong Team: Use this tool to ensure representation from senior management, quality improvement, wound care specialists, nursing staff, dietary, therapy, and other relevant departments. A diverse team brings varied perspectives and expertise, leading to more effective and sustainable solutions.
| Discipline | Names of possible implementation team members from each area | >Area of expertise |
|---|---|---|
| Senior manager | ||
| Quality improvement/Safety/risk manager | ||
| Wound staff | ||
| Wound nurse | ||
| Wound physician | ||
| Staff nurse | ||
| Nursing assistants | ||
| Registered dietitian | ||
| Hospitalist physicians | ||
| Physical therapists | ||
| Occupational therapists | ||
| Medical/surgical staff | ||
| Other providers | ||
| Patient representative | ||
| Educator | ||
| Materials manager | ||
| Information systems staff | ||
| Clerical staff |
Tool 2B: Evaluating Quality Improvement Processes for Skin Care
Assessing the existing quality improvement (QI) infrastructure is essential before implementing new initiatives. This tool helps evaluate the organization’s capacity for QI and identify areas for strengthening.
Adapted from the Turning Point Initiative’s Performance Management Self-Assessment Tool, this form helps assess the operationalization of QI processes within the hospital.
Leveraging QI Infrastructure: The implementation team leader, in consultation with the QI department, should complete this tool. If robust QI processes are in place, the pressure ulcer prevention project can be integrated seamlessly. If gaps exist, advocating for strengthening these processes becomes a priority, leveraging the pressure ulcer initiative as a driver for broader QI improvements.
| Assessment Question | No | Somewhat | Yes (fully operational) |
|---|---|---|---|
| 1. Do you have a process(es) to improve quality or performance? | |||
| Is an entity or person responsible for decision-making based on performance reports (e.g. top management team, governing or advisory board | |||
| Is there a regular timetable for your QI process? | |||
| Are the steps in the process communicated? | |||
| 2. Are managers and employees evaluated for their performance improvement efforts (i.e., is performance improvement in their job descriptions)? | |||
| 3. Are performance reports used regularly for decisionmaking? | |||
| 4. Is performance information used to do the following? (check all that apply) | |||
| Determine areas for more analysis or evaluation | |||
| Set priorities and allocate/redirect resources | |||
| Inform policymakers of the observed or potential impact of decisions under their consideration | |||
| 5. Do you have the capacity to take action to improve performance when needed? | |||
| Do you have processes to manage changes in policies, programs, or infrastructure? | |||
| Do managers have the authority to make certain changes to improve performance? | |||
| Do staff have the authority to make certain changes to improve performance? | |||
| 6. Does the organization regularly develop performance improvement or QI plans that specify timelines, actions, and responsible parties? | |||
| 7. Is there a process or mechanism to coordinate QI efforts among programs, divisions, or organizations that share the same performance targets? | |||
| 8. Is QI training available to managers and staff? | |||
| 9. Are personnel and financial resources allocated to your QI process? |
Tool 2C: Analyzing Current Processes for Pressure Ulcer Prevention
Before implementing changes, a thorough understanding of current processes is essential. This Current Process Analysis tool helps map out existing workflows related to pressure ulcer prevention.
Adapted from Quality Partners of Rhode Island, this tool guides the implementation team in defining each step of the current process, considering staff roles, tools, and activity flow.
Identifying Gaps and Inefficiencies: By systematically outlining current processes, teams can identify gaps, bottlenecks, and areas of inefficiency. This analysis forms the basis for targeted process improvements. The example of “Making Buttered Toast” illustrates how to break down even simple processes into discrete steps for analysis.
Process for Making Buttered Toast Example:
- Check for bread, butter, knife, and toaster.
- Purchase missing supplies.
- Check if toaster is plugged in.
- Adjust toaster setting.
- Insert bread.
- Turn toaster on.
- Wait for toast.
- Remove toast and place on plate.
- Cut butter.
- Spread butter on toast.
Applying to Pressure Ulcer Prevention: The team should collaboratively define each step in their current pressure ulcer prevention process, documenting policies, procedures, forms used, environmental factors, staff involved, and identifying process breakdowns, redundancies, and delays.
Team Discussion Points:
- Existing policies and procedures?
- Forms used?
- Environmental support or hindrances?
- Staff involvement?
- Process breakdowns?
- Redundancies?
- Delays and causes?
This detailed analysis paves the way for effective process redesign and improvement.
Tool 2D: Assessing Pressure Ulcer Prevention Policies and Protocols
A robust policy framework is fundamental to standardized and effective pressure ulcer prevention. This Pressure Ulcer Policy Assessment worksheet helps evaluate the comprehensiveness of the facility’s existing policies.
Adapted from Quality Partners of Rhode Island’s Facility Assessment Checklists, this tool focuses on key components that should be included in a comprehensive pressure ulcer prevention and management policy.
Ensuring Policy Completeness: Complete the checklist, consulting relevant staff as needed, to determine if the facility’s policy addresses critical elements such as commitment statements, risk assessment protocols, reassessment schedules, skin assessment protocols, monitoring and evaluation mechanisms, treatment goals, and steps for non-healing ulcers.
Policy Improvement: The assessment results highlight areas where the current policy may be lacking or incomplete. These findings should inform the development of goals for the pressure ulcer prevention initiative, focusing on strengthening and updating policies to reflect best practices.
| Yes | No | Person Responsible | Comments | |
|---|---|---|---|---|
| 1. Does your hospital’s policy include a statement regarding your facility’s commitment to pressure ulcer prevention and management? | ||||
| Does your hospital’s policy include a standard protocol for assessing a patient’s risk for developing pressure ulcers? | ||||
| Does your hospital’s policy state that all patients be reassessed for pressure ulcer risk at the following times: 1. Upon admission 2. Upon transfer 3. When a change in condition occurs | ||||
| Does your hospital’s policy state that a skin assessment should be performed on all patients at risk for pressure ulcers at the following times: 1. Upon admission 2. Daily 3. Upon transfer | ||||
| Does your hospital’s policy include who, how and when pressure ulcer program effectiveness should be monitored and evaluated? | ||||
| Does your hospital’s policy include goals of pressure ulcer management such as: 1. Prompt assessment and treatment 2. Specification of appropriate pressure ulcer risk and monitoring tools 3. Steps to be taken to monitor treatment effectiveness 4. Pressure ulcer treatment techniques that are consistent with clinically-based guidelines | ||||
| Does your hospital’s policy address steps to be taken if pressure ulcer is not healing? |
Figure 1: Interconnected stages of pressure ulcer prevention, highlighting the crucial role of tools in achieving best practices and sustainable improvement.
By systematically utilizing these clinical audit tools, healthcare facilities can embark on a journey towards enhanced skin care and significant reduction in pressure ulcer incidence. These templates provide a practical and evidence-based framework for driving quality improvement and ensuring the best possible outcomes for patients.
