2. Wisconsin Pressure Ulcer Coalition Data Update Outcomes Congress Nathan Williams Jody Rothe, RN, WCC December 2, 2009

3. Timely Risk Assessment: Percent of admissions with timely risk assessment performed Denominator: Number of admissions for the month to your facility or pilot population Numerator: Number of above admissions that have timely assessments with a standardized risk-assessment tool, such as the Braden Scale Hospitals and Nursing Homes: within 8 hours of admission Home Health, Hospice and Assisted Living: at time of admission evaluation

5. Timely Risk Assessment February 2009 AggregationDenominatorNumerator Rate (%) Hospitals 1,09996888% Nursing Homes 86378991% Total (including other provider types) 2,4252,19290%

6. Timely Risk Assessment October 2009 AggregationDenominatorNumerator Rate (%) Hospitals 1,7131,65196% Nursing Homes 72763487% Total (including other provider types) 2,9292,73894%

7. Timely Skin Assessment: Percent of admissions that have a timely, comprehensive skin assessment performed Denominator: Number of admissions for the month to your facility or pilot population Numerator: Number of above admissions that have timely, comprehensive skin assessments Hospitals and Nursing Homes: within 8 hours of admission Home Health, Hospice and Assisted Living: at time of admission evaluation

9. Timely Skin Assessment February 2009 AggregationDenominatorNumerator Rate (%) Hospitals 1,0991,01893% Nursing Homes 86480894% Total (including other provider types) 2,4262,26293%

10. Timely Skin Assessment October 2009 AggregationDenominatorNumerator Rate (%) Hospitals 1,7181,63795% Nursing Homes 72762386% Total (including other provider types) 2,8942,74995%

11. Timely Preventive Strategies: Percent of patients/residents/clients who receive preventive strategies soon after being identified as at-risk Denominator: Number of admissions for the month to your facility or pilot population, who are identified as at-risk Numerator: Number of above admissions that receive timely, preventive strategies Hospitals and Nursing Homes: within 24 hours of admission Home Health, Hospice and Assisted Living: within 48 hours of admission evaluation

13. Timely Preventive Strategies February 2009 AggregationDenominatorNumerator Rate (%) Hospitals 28823080% Nursing Homes 79769988% Total (including other provider types) 1,15595282%

14. Timely Preventive Strategies October 2009 AggregationDenominatorNumerator Rate (%) Hospitals 49644490% Nursing Homes 57742874% Total (including other provider types) 1,10397989%

15. Pressure Ulcer Prevalence: Percent of patients/residents/clients with pressure ulcers at one point in time during the month Denominator: Number of patients/residents/clients who had their skin assessed on the chosen day Numerator: Number of patients/residents/clients with (a) pressure ulcer(s) Number of patients with at least one pressure ulcer are counted, not the number of pressure ulcers All patients with at least one pressure ulcer are included, regardless of the stage(s)

17. Pressure Ulcer Prevalence February 2009 AggregationDenominatorNumerator Rate (%) Hospitals 2572610.1% Nursing Homes 4,0273578.9% Total (including other provider types) 4,8704569.4%

18. Pressure Ulcer Prevalence October 2009 AggregationDenominatorNumerator Rate (%) Hospitals 270207.4% Nursing Homes 3,2592096.4% Total (including other provider types) 4,1822997.1%

19. Facility-Acquired Rate: Percent of patients/residents/clients with facility-acquired pressure ulcers Denominator: Number of patients/residents/clients who had their skin assessed on the chosen day Numerator: Number of patients/residents/clients with at least one facility-acquired pressure ulcer Count the number of patients with at least one pressure ulcer, not the number of pressure ulcers Include all patients with at least one pressure ulcer, regardless of the stage(s)

21. Facility-Acquired Rate February 2009 AggregationDenominatorNumerator Rate (%) Hospitals 339123.6% Nursing Homes 3,9262055.2% Total (including other provider types) 4,8482204.5%

22. Facility-Acquired Rate October 2009 AggregationDenominatorNumerator Rate (%) Hospitals 270103.7% Nursing Homes 3,2591263.9% Total (including other provider types) 4,1821513.6%

23. Assessment Totals in 2009 January – October 2009 DenominatorNumerator Rate (%) Risk 28,06825,77592% Skin 28,01826,07493% Timely Preventive 12,60910,77385%

24. Progress Summary Rates for all five measures have improved! Risk and Skin assessments & preventive strategies are up Pressure ulcers and facility-acquired pressure ulcers are down Please continue to send us your monthly data This helps us to evaluate the overall success of our project Thank you for your continued interest and participation!

25. Prevention & Reduction Project Lessons Learned Year One Beginning measure rates ran high Raising rates higher is more challenging Implementing process changes take time Trending the data points to the need for standardization Benchmarking against yourself is the best policy

26. Prevention & Reduction Project Lessons Learned Year One Showing the most positive change and impact in preventing and reducing Pressure Ulcers Prevalence Facility acquired Understanding that slow progress is still progress towards the goal of preventing and reducing pressure ulcers

27. Contact Information: MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 (608) 274-1940 or (800) 362-2320 www.metastar.comnwilliam@metastar.comjrothe@metastar.com This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-WI-PS-09-226.