Pressure Ulcer Prevention Project sign off By Amy Haines NURS 495 Senior Capstone Leadership Practicum Ferris State University

Project Overview Pressure ulcer prevention in Long term care facilities essential with quality measures and patient satisfaction. Centers for Medicare and Medicaid Services (CMS), Michigan Department of Consumer and Industry Services (MDCH) and American Medical Directors Association (AMDA) strongly suggest use of clinical practice guideline as the evidence-based best practice. Project reason/purpose for the project. Project supported by the literature/nursing data bases.

Project Overview 1,383,700 residents in long term care and 11% of them having some sort of pressure ulcer (CDC, 2009). Average cost per patient per month for pressure ulcers is $9000. Hospital in India implemented process guideline and went from 6% of their residents having pressure ulcers to zero percent. (Paul, 2014)

Project Overview Hospital in India implemented process guideline and went from 6% of their residents having pressure ulcers to zero percent. (Paul, 2014)

Goal- By August 3, 2015 Form a successful pressure ulcer prevention plan, identify care interventions in order to prevent pressure ulcers based on best practice/research (AMDA/MDCH) educate and present to the nursing staff and to the nurse aides the plan for pressure ulcer prevention implement the pressure ulcer prevention plan

Objectives Identify team of change agents by June 16, 2015 Identify care interventions in order to prevent pressure ulcers based on best practice/research by June 26, 2015. Form a successful pressure ulcer prevention plan by July 3, 2015. Define content of presentation by July 10, 2015. Support the project with additional emphasis on evidence-based practice/nursing data bases. Project implemented with guidance from the clinical practice guideline by MDCH and AMDA.

Overview continued Present plan to team and gather feedback by July 17, 2015. Educate and present to nursing staff and to the nurse aides on the short term unit, the plan for pressure ulcer prevention by July 21, 2015. Implement the plan on the short term unit (rehabilitation) by July 28, 2015. Evaluation of the process by August 3, 2015.

Culture of Quality and Safety Interdisciplinary team Process guideline adoption and review Staff education Regulations being followed Pressure ulcer prevention Patient satisfaction and improved quality of life Interdisciplinary team consisting of DON, Director of Quality, administrator, social worker, therapy, RN/LPN, provider and aide. Team important to keep all aspects of care in the forefront. Ensuring some actions do not affect others.

Process of project The plan and process guideline reviewed by the team. Team adopted Lippencott as the means of education along with a test at the end. All nurses and aides educated on the clinical practice guideline and the method to enroll in the education. Staff educated 7/14/15. Manager to hold staff accountable for education and ensure new hires are assigned the course. Analysis of the progress and completion of the project. Project education complete.

Process of project Care manager to review documentation to ensure proper care planning and staff follow process. Therapy, dietician, social workers available for consult and to discuss all patients as they are admitted, readmitted, return from a stay out side of facility.

Process of project Present plan to team and gather feedback by July 17, 2015. Educate and present to nursing staff and to the nurse aides on the short term unit, the plan for pressure ulcer prevention by July 21, 2015. Implement the plan on the short term unit (rehabilitation) by July 28, 2015. Evaluation of the process by August 3, 2015.

Progress of project Aides and Nurses educated on the project July 14, 2015 Educated on how to enroll into the netlearning July 14, 2015 with due date of July 21, 2015 Pressure ulcer prevention course (nurses and aides) 3 nurses and 8 aides completed Skin assessment (nurses) Unsure of completion-Email out to Katie Alignment and pressure-reducing device application, long term care Unsure of completion- Email out to Katie

Completion of project Add netlearnings to pathway for new hires Jean or Michelle need to request Jean or Michelle to hold nurses and aides accountable for completing the education Amy Cady to monitor documentation and report to appropriate person

Completion of project System work being done on pressure ulcer prevention Will have more information from Paula when it is ready to be rolled out. Who will take ownership now that Amy H is stepping out?

Questions? Satisfaction survey Site representative evaluation Thank you to everyone that had a part of this project!