In 2007, St. Louis-based BJC HealthCare set a goal of eliminating all major preventable harm. Data showed that pressure ulcers accounted for two-thirds of preventable harm at BJC HealthCare hospitals. The system thus launched a five year initiative to reduce all preventable harm, including pressure ulcers, which ultimately led to a combined 58 percent decrease in hospital-acquired ulcers in three pilot units over two years. System-wide, BJC HealthCare saw a 30 percent decrease from 2009 to 2011. In fact, BJC HealthCare's success reducing pressure ulcers led to its recognition as the only healthcare organization named as a finalist this year in ASQ’s International Team Excellence Awards process. Liz Schulte, CAPM, CHES, project manager at BJC HealthCare's Center for Clinical Excellence, and Pat Matt, RN, MSN, CIC, ASQ-CSSBB, clinical lead for the pressure ulcer initiative, explain how the system achieved success in pressure ulcer prevention.
Focusing efforts
To focus its efforts, a system team at BJC HealthCare analyzed the occurrence of pressure ulcers at each hospital in the system and investigated data by unit type and by specific units. The team found that 25 units were responsible for 80 percent of the system's hospital-acquired pressure ulcers. BJC HealthCare decided that targeting these units would have the biggest overall impact on pressure ulcer occurrence in the system.
In July 2010, the team began collaborating with the top three pressure ulcer units: an intensive care unit at BJC HealthCare's academic hospital, an ICU at one of the system's large community hospitals and a neuro renal unit at a different large community hospital. Based on the success of these units, in December 2010, the team began implementing the pressure ulcer prevention toolkit on other units among the top 25. The intervention has now been rolled out in 12 units — nearly halfway to the system's goal of implementing the tools in all 25 units by the end of this year. For hospitals that were not among the top 25 sites of pressure ulcers, they can still access the intervention toolkit on a BJC HealthCare intranet site.
Getting to the root of things
BJC HealthCare conducted a root cause analysis of pressure ulcers by looking at each hospital's current processes from admission to discharge. The system team, including subject matter experts, found three major causes of hospital-acquired pressure ulcers to target for prevention: inadequate pressure redistribution, a lack of data transparency and a lack of standard training and education on pressure ulcer prevention.
The BJC HealthCare team engaged team members from each of the three pilot units to develop best practices, or standard criteria, around the three problem areas. One of the criteria for pressure redistribution is turning patients every two hours if the patient has a risk score of 18 or less, based on a standard pressure ulcer risk assessment. In addition, best practice requires two people turn the patient. Some risk factors include poor nutrition, limited mobility and unresponsiveness to painful stimuli.
Implementing best practices
Although all three pilot units were required to follow the best practices they developed, each unit could decide how to best implement the practices. "While gaps were similar among hospitals or units, many of the [specific] barriers were different," Ms. Schulte says. For example, Ms. Matt says one unit's biggest challenge may have been identifying high-risk patients, while another unit's biggest challenge was having enough pillows needed to turn and reposition patients. Due to these differences, hospitals used Lean to tailor interventions that would best meet their unit's needs.
Pressure redistribution
One standard criterion was having a visual cue to identify high-risk patients. One unit used a red dot on a patient's board, whereas another unit recorded pressure ulcer risk on a bedside board and used a timer and page to signal nurses when it was time to turn patients every two hours. "We found that leaving [implementation] up to the individual unit not only helped increase buy-in, but because the unit came up with the solution to meet criteria, [staff] felt more involved in the process," Ms. Schulte says.
Data transparency
Data transparency involved tracking measures, identifying gaps and taking ownership of the problems to solve them. All units had performance improvement boards where they documented a pressure ulcer event and why it occurred. These boards helped units identify trends and develop targeted interventions. "One of the huge culture changes through doing this work was more transparency and accountability at the unit level," Ms. Schulte says.
By tracking data, one ICU found pressure ulcers were occurring despite turning patients every two hours. The data revealed that these ulcers were device-related and required additional intervention. After further analysis, the ICU found that most device-related pressure ulcers occurred in patients with endotracheal tubes secured by tape instead of other devices less likely to cause pressure. The ICU thus began routinely repositioning these devices to shift pressure and is trialing different securement devices.
Education
The BJC HealthCare team and rapid improvement event teams from the pilot units developed a standard educational brochure to distribute to patients. Staff training varied based on the individual unit. While some units conducted training one on one throughout the day, others had more formal sessions. One unit created quick reference cards nurses could use as reminders of lessons learned in training.
Part of staff members' education was also about the performance improvement project — how to apply Lean principles to real problems and how to maintain improvements. "[We made] sure that after the rapid improvement event they understood that it wasn't just a flavor of the month, that the improvements were integrated into their daily work and each unit would continue to monitor their performance," Ms. Matt says.
Focusing efforts
To focus its efforts, a system team at BJC HealthCare analyzed the occurrence of pressure ulcers at each hospital in the system and investigated data by unit type and by specific units. The team found that 25 units were responsible for 80 percent of the system's hospital-acquired pressure ulcers. BJC HealthCare decided that targeting these units would have the biggest overall impact on pressure ulcer occurrence in the system.
In July 2010, the team began collaborating with the top three pressure ulcer units: an intensive care unit at BJC HealthCare's academic hospital, an ICU at one of the system's large community hospitals and a neuro renal unit at a different large community hospital. Based on the success of these units, in December 2010, the team began implementing the pressure ulcer prevention toolkit on other units among the top 25. The intervention has now been rolled out in 12 units — nearly halfway to the system's goal of implementing the tools in all 25 units by the end of this year. For hospitals that were not among the top 25 sites of pressure ulcers, they can still access the intervention toolkit on a BJC HealthCare intranet site.
Getting to the root of things
BJC HealthCare conducted a root cause analysis of pressure ulcers by looking at each hospital's current processes from admission to discharge. The system team, including subject matter experts, found three major causes of hospital-acquired pressure ulcers to target for prevention: inadequate pressure redistribution, a lack of data transparency and a lack of standard training and education on pressure ulcer prevention.
The BJC HealthCare team engaged team members from each of the three pilot units to develop best practices, or standard criteria, around the three problem areas. One of the criteria for pressure redistribution is turning patients every two hours if the patient has a risk score of 18 or less, based on a standard pressure ulcer risk assessment. In addition, best practice requires two people turn the patient. Some risk factors include poor nutrition, limited mobility and unresponsiveness to painful stimuli.
Implementing best practices
Although all three pilot units were required to follow the best practices they developed, each unit could decide how to best implement the practices. "While gaps were similar among hospitals or units, many of the [specific] barriers were different," Ms. Schulte says. For example, Ms. Matt says one unit's biggest challenge may have been identifying high-risk patients, while another unit's biggest challenge was having enough pillows needed to turn and reposition patients. Due to these differences, hospitals used Lean to tailor interventions that would best meet their unit's needs.
Pressure redistribution
One standard criterion was having a visual cue to identify high-risk patients. One unit used a red dot on a patient's board, whereas another unit recorded pressure ulcer risk on a bedside board and used a timer and page to signal nurses when it was time to turn patients every two hours. "We found that leaving [implementation] up to the individual unit not only helped increase buy-in, but because the unit came up with the solution to meet criteria, [staff] felt more involved in the process," Ms. Schulte says.
Data transparency
Data transparency involved tracking measures, identifying gaps and taking ownership of the problems to solve them. All units had performance improvement boards where they documented a pressure ulcer event and why it occurred. These boards helped units identify trends and develop targeted interventions. "One of the huge culture changes through doing this work was more transparency and accountability at the unit level," Ms. Schulte says.
By tracking data, one ICU found pressure ulcers were occurring despite turning patients every two hours. The data revealed that these ulcers were device-related and required additional intervention. After further analysis, the ICU found that most device-related pressure ulcers occurred in patients with endotracheal tubes secured by tape instead of other devices less likely to cause pressure. The ICU thus began routinely repositioning these devices to shift pressure and is trialing different securement devices.
Education
The BJC HealthCare team and rapid improvement event teams from the pilot units developed a standard educational brochure to distribute to patients. Staff training varied based on the individual unit. While some units conducted training one on one throughout the day, others had more formal sessions. One unit created quick reference cards nurses could use as reminders of lessons learned in training.
Part of staff members' education was also about the performance improvement project — how to apply Lean principles to real problems and how to maintain improvements. "[We made] sure that after the rapid improvement event they understood that it wasn't just a flavor of the month, that the improvements were integrated into their daily work and each unit would continue to monitor their performance," Ms. Matt says.
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