Overview of the 2008-2009 Pressure Ulcer Quality Improvement Initiative
In early 2007 the Indiana State Department of Health (ISDH) began development of a statewide campaign to prevent pressure ulcers. The campaign was initiated in response to data indicating that Indiana health care facilities had a high rate of pressure ulcers. Pressure ulcers are a challenging health care problem. For health care providers, pressure ulcers are difficult to prevent, assess, and treat. For residents and their families, pressure ulcers are a serious detriment to quality of life.
The ISDH planned a three-phase initiative to assist with the prevention of pressure ulcers. The three-phase initiative included the following phases:
- The Indiana Pressure Ulcer Quality Improvement Initiative formally kicked off on October 30, 2007 with a Leadership Conference focusing on pressure ulcers. The conference was attended by nearly 1,100 participants from over 400 health care facilities.
- The ISDH purchased a high-end pressure redistribution mattress and wheelchair cushions for every Indiana nursing home and provided training on use of the mattress and cushions. This ensured the availability of at least one mattress at every nursing home for immediate needs of at-risk residents at the time of admission. Distribution of the products occurred in January 2008.
- Implementation of a 15-month collaborative initiative utilizing a system-based approach to preventing and treating pressure ulcers. The collaborative initiative included nursing homes, hospitals, and home health agencies. The collaborative initiative began in June 2008. A second phase of the collaborative initiative is being planned to begin in July 2009.
Indiana Pressure Ulcer Collaborative Initiative
The ISDH selected the University of Indianapolis Center for Aging & Community (CAC) to coordinate the collaborative initiative. The CAC has a history of academic excellence along with experience in collaborative efforts to improve healthcare. The CAC is one of Indiana’s leading centers for aging studies, with an interdisciplinary approach to developing partnerships between higher education, business organizations and the community to improve the quality of life for older adults.
A collaborative team was assembled in June 2008 to plan the initiative. An evidence-based initiative was designed to assist health care facilities implement improved pressure ulcer prevention and care coordination systems. A component of the initiative was that direct assistance would be provided to participating facilities and families by expert faculty. In recent years, states such as New Jersey and Minnesota had undertaken successful initiatives to reduce the number of pressure ulcers reported in their hospitals and long term care facilities.
In developing the initiative, the collaborative team identified the following benefits of participation:
- First and foremost, increased patient quality of life for Hoosiers
- Improved care coordination between hospitals, home health agencies, and long term care facilities
- Educational opportunities for health care providers and caregivers
- Opportunity for improved quality of care through the prevention of pressure ulcers
- Opportunity for improved reputation within the community
- Opportunity to work with and learn from expert faculty
- Cost savings from fewer pressure ulcers requiring treatment
Pressure Ulcer Collaborative Team
The University of Indianapolis Center for Aging and Community coordinated the initiative. The collaborative team included stakeholders in the prevention of pressure ulcers and was responsible for the planning of the initiative. The collaborative team included:
- Bingham McHale LLP – Melissa Wray
- Bottomline Performance – Nancy Harkness, Gayle Beebe, Sharon Boller
- Cabello Associates – Rick Field
- Clarian Health Methodist – Joyce Pittman
- Health Care Excel – Sandy Hampton; Kathy Hybarger; Rebecca Royer; Connie Steigmeyer, Jo Dyer
- Hoosier Owners and Providers for the Elderly – Becky Bartle
- Indiana Association for Home & Hospice Care – Todd Stallings; Jean Macdonald
- Indiana Association of Homes and Services for the Aging – Linda Woolley
- Indiana Family and Social Services Administration - State Ombudsman, Arlene Franklin
- Indiana Health Care Association – Eric Vermeulen
- Indiana Hospital Association – Evelyn Catt
- Indiana Patient Safety Center – Betsy Lee
- Indiana State Department of Health – Nancy Adams; Sue Hornstein; Terry Whitson, Burton Garten, Matt Doades
- Indiana University School of Medicine Division of Biostatistics – Tim Stump
- Pathways Health Services – Jeri Lundgren
- Riverview Hospital – Dea Kent
- United Senior Action Foundation – Robyn Grant
- University of Indianapolis Center for Aging and Community – Jennifer Bachman; Ellen Miller; Lidia Dubicki
- Wound Professionals, LLC – Dr. Jodie Harper
The collaborative team met monthly with additional subcommittees for various specific activities and events. The collaborative planning team is expected to continue through 2010 to oversee a second phase of the collaborative initiative.
Data on Pressure Ulcers in Indiana
Pressure ulcers are a significant health care problem. The Centers for Medicare and Medicaid Services (CMS) and ISDH have attempted over the years to track the problem and monitor pressure ulcer rates. CMS 2003 data indicated a 9.2% pressure ulcer rate in Indiana long term care facilities. Through the efforts of health care providers, that rate was reduced to 8.6% in October 2005. In 2005, CMS designated pressure ulcers as one of two priority goals for CMS Region V and directed the state quality improvement organizations to assist facilities in addressing the problem. As of September 30, 2007, Indiana’s rate was down to 8.1%. A goal of the Indiana initiative was to continue the progress in decreasing the rates towards the CMS goal of 7.4% with a future goal of 6.8%.
In January 2005 Governor Daniels issued an Executive Order for the development of a Medical Error Reporting System. One of the twenty-seven standards was the development of a stage 3 or stage 4 pressure ulcers while admitted to a hospital. In the Report for 2007, pressure ulcers were the top reportable event for hospitals. Of the 85 reported events, 26 events were the development of stage 3 or 4 pressure ulcers while admitted to a hospital.
The Institute for Healthcare Improvement (IHI) Breakthrough Series (BTS) Collaborative model was initially used as the framework to reach the goal of reducing pressure ulcers in health care facilities. A BTS Collaborative is short term - lasting for 12-15 months. It provides a hands-on, highly interactive education and training model that has a proven record for bringing about dramatic, lasting change. Clinical and medical experts in the assessment and treatment of pressure ulcers provide the education and training, consultation and technical assistance throughout the initiative.
In the summer of 2008, the collaborative team invited Indiana health care facilities and agencies to participate in the initiative. Selected were 105 nursing homes, 40 hospitals, and 24 home health agencies. Also participating in the initiative are representatives from state surveyors and health care organizations.
The initiative was funded by the ISDH through its health care facility civil money penalty fund and state general funds. There was no registration fee for participating facilities and agencies. All materials and resources were provided to participants at no cost.
This initiative included many activities and resources. The following are a few of the resources provided to participants through the initiative:
- Participating facilities received a tool kit that included assessment and coordination tools.
- Participating facilities were provided onsite technical assistance in implementing the initiative.
- Three one-day implementation meetings with expert faculty were provided for representatives of participating facilities to discuss their experiences and identify solutions.
- Six online education modules on pressure ulcer prevention were developed and provided to all Indiana nursing homes.
- A consumer guide/brochure was developed and published to provide information on pressure ulcers to residents, patients, family, and resident representatives.
Description of Indiana Pressure Ulcer Initiative
The following are the activities and events of the initiative:
- June 2008: Collaborative team formed to begin planning the initiative
- September 2008: Selection of participants
- September/October 2008: A knowledge exam was administered to staff of the participating facilities and agencies to determine their level of knowledge about pressure ulcers
- September/October 2008: Each participating facility and agency completed a self-assessment to determine the components of their pressure ulcer prevention system
- Throughout initiative: Each participant tracked pressure ulcer data for their facility or agency
- October/November 2008: An all day learning session was conducted regionally for participating facilities and agencies. There were seven total sessions. Separate sessions were provided for nursing home, hospital, and home health participants. Each participant sent up to five staff members. The first learning session provided information on the essentials of pressure ulcer prevention, risk assessment, rapid improvement events, and skin inspection. A toolkit was provided with resources for those areas.
- October/November 2008: Webinars were conducted for nursing home, hospital, and home health participants as well as a webinar for consumers
- Ongoing throughout the initiative: Support visits to each participating facility from initiative partners to assist in implementing system improvements
- April 2009: A second learning session was conducted regionally for participating facilities and agencies. There were five sessions. The session focused on lessons learned, consistency (staging), and care coordination. All three provider types were integrated at each session to discuss care coordination issues. Additional tools and resources were provided on the topics.
- April 2009: A consumer brochure was published
- April/May 2009: A second set of webinars were conducted for nursing home, hospital, and home health participants as well as a webinar for consumers
- July 2009: Six online education modules were completed and posted on the ISDH Web site. The modules provide education on pressure ulcers.
- July 2009: An Indiana Health Care Quality Resource Center was developed and posted on the ISDH Web site. The Resource Center provides information, toolkits, and resources for health care topics. The Center includes all tools and materials included in the initiative as well as information and links to other resources.
- July 2009: A knowledge exam was administered to staff of the participating facilities and agencies to determine their level of knowledge about pressure ulcers post-initiative
- July 2009: Each participating facility and agency completed a self-assessment to determine the components of their pressure ulcer prevention system post-initiative
- August 26, 2009: An Outcomes Congress for all participants. The event will celebrate accomplishments and provide information on continuity.
Updated: July 29, 2009