7. Tools and Resources

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Image shows seven interconnected puzzle pieces labeled Assess Readiness, Manage Change, Implement Practices, Best Practices, Measure, Sustain, and Tools. The piece labeled Tools is highlighted in blue.

0A: Introductory Executive Summary for Stakeholders
1A: Clinical Staff Attitudes Toward Pressure Ulcer Prevention
1B: Stakeholder Analysis
1C: Leadership Support Assessment
1D: Business Case Form
1E: Resource Needs Assessment
2A: Multidisciplinary Team
2B: Quality Improvement Process
2C: Current Process Analysis
2D: Assessing Pressure Ulcer Policies
2E: Assessing Screening for Pressure Ulcer Risk
2F: Assessing Pressure Ulcer Care Planning
2G: Pieper Pressure Ulcer Knowledge Test
2H: Pressure Ulcer Baseline Assessment
2I: Action Plan
3A: Pressure Ulcer Prevention Pathway for Acute Care
3B: Elements of a Comprehensive Skin Assessment
3C: Pressure Ulcer Identification Notepad
3D: The Braden Scale for Predicting Pressure Sore Risk
3E: Norton Scale
3F: Care Plan
3G: Patient and Family Education Booklet
4A: Assigning Responsibilities for Using Best Practice Bundle
4B: Staff Roles
4C: Assessing Staff Education and Training
5A: Unit Log
5B: Preventing Pressure Ulcers Data Tool
5C: Assessing Comprehensive Skin Assessment
5D: Assessing Standardized Risk Assessment
5E: Assessing Care Planning

Tool 0A: Introductory Executive Summary for Stakeholders

Background: This template can serve as a letter to key players in the hospital to introduce them to the goals and purpose of a pressure ulcer project.

Reference: Developed by the Boston University Research Team.

Instructions: Adapt this letter as needed and present it to key players to enlist their support before mounting your pressure ulcer prevention project. You may want to use tool 1B, Key Stakeholder Analysis, to identify individuals and departments that may have an interest in the project.

Dear <Name>:

We would like to introduce you to a new pressure ulcer prevention project. We hope that you will support this exciting new endeavor.

What is this project? <Hospital name> is embarking on an important new initiative focused on the prevention of pressure ulcers among our acute care patients.

Why is this project important? Pressure ulcers acquired during acute care stays present significant treatment and recovery delays for patients, increase length and cost of inpatient stays, and have become a "never" event from the standpoint of Medicare reimbursement.

How might this project affect me/my area? In the past, pressure ulcer care has sometimes been seen as solely a nursing unit responsibility. However, recent research has made it clear that successfully reducing pressure ulcer incidence requires a coordinated multidisciplinary approach. Thus, the implementation of new prevention approaches may require, for example, the efforts of:

Materials and supplies: Do we have the most evidence-based products and equipment necessary for preventing pressure and skin breakdown? Are new products evaluated with this outcome in mind?
Housekeeping: Do standard bed-making techniques and materials result in too much moisture being retained next to patient skin?
Information technology: Is information about skin assessment and pressure ulcer prevention interventions effectively integrated into the electronic medical record?
Respiratory therapy: Is all respiratory equipment appropriately placed to reduce the chances of pressure sores developing where tubing or mouthpieces are in contact with patient skin?
Medicine: Are appropriate orders on file or available for any needed special surfaces or other preventive measures?
Quality improvement: Are QI training and techniques available to the team working on this effort?
Transport: Is patient time on hard wheelchairs or stretchers minimized or mitigated when patients are taken off the unit for diagnostic or therapeutic activities?

What will happen? In this project, we will use the Agency for Healthcare Research and Quality's (AHRQ) new toolkit. This comprehensive toolkit outlines steps in the improvement process and provides relevant tools. Using these tools, we will assess staff awareness and knowledge of pressure ulcer prevention, analyze patient care processes to identify where there are risks to patient skin integrity, and target interventions in those areas. Pressure ulcer incidence while patients are under our care will be tracked and reported more widely so that progress can be assessed.

Everyone has a role: Most important in this effort is a shift of thinking and culture, from seeing pressure ulcers as the inevitable result of patient immobility to seeing them as never events that can be prevented through a comprehensive prevention program. Your support in helping <hospital name> staff make this shift is essential to the success of this effort. Thank you!

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1A: Clinical Staff Attitudes Toward Pressure Ulcer Prevention

Background: The Staff Attitude Scale can be used to provide useful feedback on clinical staff beliefs regarding pressure ulcer prevention. It was adapted from a scale used by Moore and Price and uses a 5-point scoring system ranging from strongly agree to strongly disagree. Nurses who completed the scale in the study cited below had scores ranging from 28 to 50, with a median of 40.

Reference: Moore Z, Price P. Nurses' attitudes, behaviors, and perceived barriers towards pressure ulcer prevention. J Clin Nurs 2004;13:942-52.

Instructions:

Administer the survey. It can be used with all staff involved in direct patient care. Typically, the survey is given anonymously. Depending on your organizational culture, you may want to ask for the name of the respondents to allow followup with individuals after the survey. To score, assign a numeric value to each response. For most, "strongly disagree" =5, "disagree" = 4, and so on. However, questions 1, 6, 7, and 11 should be reverse scored. For those questions, "strongly disagree"= 1, and so on. Scores on this scale range from 11 (most negative attitudes) to 55 (most positive attitudes).

Use: The results from this survey can help to identify existing attitudes toward pressure ulcer prevention. You may want to administer it to different groups and compare the results to obtain insight on potential inconsistencies among staff. If you find scores that are lower than 40, one of the early goals of the interventions may be to address these misperceptions.

Views on Pressure Ulcer Prevention

Your role: _____________________ Date:___________________

	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

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1B: Stakeholder Analysis

Background: The purpose of the stakeholder analysis is to help the project initiators identify what departments/individuals will have an interest in the project, where barriers might exist, and what actions need to be taken to obtain the buy-in and participation of those departments and individuals. This tool was adapted from a template developed by Project Agency, a British company focused on effective project management.

Reference: Available at: www.businessballs.com/project%20management%20templates.pdf.

Instructions: Complete the form with information regarding all the individuals you consider key stakeholders. You may need to set up a meeting with them to obtain their answers. Examples: information technology officer, director of supply/materials, housekeeping director, quality improvement (QI) department, therapy departments, diagnostic departments, emergency department.

Use: Use the completed template to identify actions needed to involve all stakeholders in the project. Ensure that all identified needs have been met before proceeding with the QI initiative. For example, the project may need process assistance from the QI department. Since this project may be competing with other QI priorities, it may be important to determine who shapes the QI agenda and how to get this project prioritized at a higher level. An example is shown in the form below. A blank form follows.

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.

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1C: Leadership Support Assessment

Background: This tool can be used to assess senior leadership support for implementing a pressure ulcer prevention project.

Reference: Developed by Boston University Research Team.

Instructions: Complete the checklist.

Use: Review the responses to ascertain the level of leadership support. If the response to several of these items is no, it could threaten the success of your improvement process. Analyze the areas where support is not evident and take steps to inform leadership about the urgency to change.

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

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1D: Business Case Form

Background: This tool can be used to make the case for the implementation of a quality improvement initiative by addressing the concerns of key leadership. The form was adapted from a template developed by Project Agency to help write a business case.

Reference: Available at: www.businessballs.com/project%20management%20templates.pdf.

Instructions: Complete the form with all the required information.

Use: Present the completed form to your project sponsor and discuss the potential benefits of the pressure ulcer prevention initiative.

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

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1E: Resource Needs Assessment

Background: The purpose of this tool is to identify resources that are available for a quality improvement initiative.

Reference: Developed by Boston University Research Team.

Instructions: Complete this checklist to assess the resources that are available and the resources that are still needed.

Use: Ensure that all resources needed for launching a pressure ulcer prevention initiative are available.

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

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2A: Multidisciplinary Team

Background: Crucial to a pressure ulcer prevention initiative is the creation of a multidisciplinary implementation team that will oversee the improvement effort. This tool can be used to identify people from different interdisciplinary areas to take part on the implementation team.

Reference: Developed by Boston University Research Team.

Instructions: List the names of possible team members from each department or discipline and their area of expertise.

Use: Use this list to form your implementation team.

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

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2B: Quality Improvement Process

Background: This tool will help you and your team identify the extent to which you have the resources for quality improvement (QI) in your organization. The form was developed by the Turning Point Initiative to assess if an organization has the needed systems in place to improve quality and performance.

Reference: Turning Point Performance Management National Excellence Collaborative. Performance Management Self-Assessment Tool. Available at: http://www.turningpointprogram.org/toolkit/pdf/PM_Self_Assess_Tool.pdf.

Instructions: This tool should be filled out by the implementation team leader in consultation with the QI department. The "you" refers to your organization as a whole. Check the box that most accurately describes your organization's current resources.

Use: If you find that your organization has fully operationalized QI processes, connect the pressure ulcer prevention initiative with these existing processes. If some processes are missing, advocate for them to be put into place in the context of the pressure ulcer initiative.

Quality Improvement Process

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?

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2C: Current Process Analysis

Background: Before beginning a quality improvement initiative, you need to understand your current methods. This tool can be used to describe key processes in your organization where pressure ulcer prevention activities could or should happen.

Reference: Adapted from: Quality Partners of Rhode Island. QI Worksheet E, Current Process Analysis. Available at: https://www.qualitynet.org/dcs/ContentServer?c=MQTools&pagename=Medqic%2FMQTools%2FToolTemplate&cid=1096585074914.

Instructions:

Have the implementation team identify and define every step in the current process for pressure ulcer prevention.
When defining a process, think about staff roles in the process, the tools or materials staff use, and the flow of activities.
Everything is a process, whether it is admitting a resident, serving meals, assessing pain, or managing a nursing unit. The ultimate goal of defining a process is identifying problems in the current process.

Use: Determine if there are any gaps and problems in your current processes, and use the results of this analysis to systematically change these processes.

Tips:

Take time to brainstorm and listen to every team member.
Make sure the process is understood and documented.
Make each step in the process very specific.
Use one post-it note, index card, or scrap piece of paper for each step in the process.
Lay out each step, move steps, and add and remove steps until team agrees on the final process.
If a process does not exist (for example, there is no process to screen for pain upon admission and readmission), identify the elated processes (for example, the process for admission and readmission).
If the process is different for different shifts, identify each individual process.

Example: Process for Making Buttered Toast

Step Define

Check to see if there is bread, butter, knife, and toaster.
If supplies are missing, go to the store and purchase them.
Check to see if the toaster is plugged in. If not, plug in the toaster.
Check setting on toaster. Adjust to darker or lighter as preferred.
Put a slice of bread in toaster.
Turn toaster on.
Wait for bread to toast.
When toast is ready, remove from toaster and put on plate.
Use knife to cut pat of butter.
Use knife to spread butter on toast.

Identify the steps of your defined process.

Press for details.
At the end of the gap analysis, compile the results in a document that displays each step so that team members have the map of the current process in front of them during the team discussion (Step 2).

Team discussion

Evaluate your current process as you define it:

What policies and procedures do we have in place for this process?
What forms do we use?
How does our physical environment support or hinder this process?
What staff are involved in this process?
What part of this process does not work?
Do we duplicate any work unnecessarily? Where?
Are there any delays in the process? Why?

Continue asking questions that are important in learning more about this process.

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2D: Assessing Pressure Ulcer Policies

Background: This worksheet can be used to determine if your facility has a policy for preventing and managing pressure ulcers. The tool is one of a series of Facility Assessment Checklists used to identify areas that need improvement in nursing homes and has been modified for hospitals.

Reference: Adapted from: Quality Partners of Rhode Island. Pressure Ulcers: Facility Assessment Checklists. Available at: https://www.qualitynet.org/dcs/ContentServer?cid=1098482996140&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools.

Instructions: Complete the checklist. For certain questions, you may want to consult with appropriate staff in your organization.

Use: Use the results of this assessment to identify issues that you need to deal with, and formulate goals for your pressure ulcer prevention initiative.

Pressure Ulcer Policy Assessment

Does your facility's policy for the prevention and management of pressure ulcers include these components?

	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: Upon admission Upon transfer 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: Upon admission Daily 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: Prompt assessment and treatment Specification of appropriate pressure ulcer risk and monitoring tools Steps to be taken to monitor treatment effectiveness 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?

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Preventing Pressure Ulcers in Hospitals