1. Intermountain-led CMS Hospital Engagement Network Pressure Ulcer Prevention September 23, 2014 Affinity Call Marlyn Conti, BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare

2. Outline for Discussion Review of the HEN Pressure Ulcer work Q1 2014 Data review “Just-one-thing” Recommendations 2012 Participant survey 2014 Participant survey Next steps

3. Overall Progress Through Q1 2014

4. Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3 Patients with Stage III, Stage IV or unstageable pressure ulcers

5. Intermountain HEN 2012-Q1 2014 Pressure Ulcer PSI 3 Patients with Stage III, Stage IV or un-stageable pressure ulcers

6. Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3 Stage 3 or greater from the prevalence survey

7. Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 3 Stage 3 or greater from the prevalence survey Decline in denominator in Q1 2014 is due to anomalous data

8. Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2 => Stage 2 added in 2014

9. Intermountain HEN 2012-Q1 2014 Pressure Ulcer >= Stage 2 => Stage 2 added in 2014

10. Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence All stages from the prevalence survey

11. Intermountain HEN 2012-Q1 2014 Pressure Ulcer Prevalence All stages from the prevalence survey Decline in denominator in Q1 2014 is due to anomalous data

12. High Performing Hospital Highlight… Most Improvement BAYLOR HEART AND VASCULAR HOSPITAL BAYLOR MEDICAL CENTER AT WAXAHACHIE THE HEART HOSPITAL BAYLOR PLANO DENVER HEALTH MEDICAL CENTER CASSIA REGIONAL MEDICAL CENTER DELTA COMMUNITY MEDICAL CENTER SANPETE VALLEY HOSPITAL - CAH BAYLOR MEDICAL CENTER AT IRVING LDS HOSPITAL BAYLOR REGIONAL MEDICAL CENTER AT PLANO Pressure Ulcers Prevalence Lowest Rates THE HEART HOSPITAL BAYLOR PLANO BAYLOR MEDICAL CENTER AT WAXAHACHIE ST PATRICK HOSPITAL UPPER CONNECTICUT VALLEY HOSPITAL SCOTT & WHITE HOSPITAL-ROUND ROCK BAYLOR HEART AND VASCULAR HOSPITAL SCOTT & WHITE CONTINUING CARE HOSPITAL THE ORTHOPEDIC SPECIALTY HOSPITAL HEBER VALLEY MEDICAL CENTER DELTA COMMUNITY MEDICAL CENTER

13. Just One Thing Matrix Recommendations Getting StartedWorking HarderAhead of the Curve Appoint a leadership supported team or work groupto drive improvement & education SWAT (or champion) teams that includes unit nurse. (moderate-high level of evidence) Adopt decision algorithms for nursing staff to select appropriate surfaces, physical therapy and dietary referrals (moderate-high level of evidence) Establish monthly prevalence studies or collect incidence data from electronic medical records, then feed that data back to the SWAT teams. (moderate-high level of evidence)

14. Intermountain SKIN Bundle

15. Participant Survey 2012 38% sites at Improvement stage, 26% challenges, 24% sustaining

16. Participant Survey 2012 Pressure Ulcers ranked at 3 rd at 5.13 for priority by the participating hospital

17. 2014 Pressure Ulcer Survey Report Carlos Barbagelata Intermountain Institute for Healthcare Delivery Research 9/23/14

18. 1. Do you have a team assigned to work on Pressure Ulcer prevention? AnswerResponse% Yes1579% No421% Total19100%

19. 1a. Is your pressure ulcer prevention team multidisciplinary? (if yes, which disciplines are included) AnswerResponse% Yes750% No750% Total14100% Yes Bedside RN, Dietician, Infection Control RN Manager Nursing, Physical Therapy, dietary Wound Care/Ostomy RN, RRT, PT WOC/RRT/HCI/PT/Transport/Nutrition Administration, Nursing, RT, WOC

20. 1b. How frequently does your Ulcer Prevention team meet? (Check all that apply) AnswerResponse% Other (e.g. for RCA, as-needed, etc.) 857% Once a Month750% 2–3 Times a Month00% Once a Week00% Other (e.g. for RCA, as-needed, etc.) Quarterly meetings prior to quarterly prevalence studies RCA done, as well as monthly meetings As-Needed

21. 1c. Does your pressure ulcer prevention team have resources to collect/interpret/review data? (If yes, please explain below) AnswerResponse% Yes1393% No17% Total14100% Yes Online education using NDNQI tool, survey review, quarterly data collection, analysis by quality lead and team P&I, floor staff are assigned to be on the committee and help with survey results. Pressure Ulcer Tracking Sheet, Weekly skin assessments Wound Care/Ostomy Provided with corporate data. Collect and evaluate internal data Prevalence Study WOC, RN Mgr/Supv, HCI incident reports and NDNQI

22. 2. Do you provide hospital-acquired pressure ulcer reports foruse by hospital staff and teams? (If yes, please describe how reports are distributed or made available) AnswerResponse% Yes1583% No317% Total18100% Yes Available on system report center, can be accessed by unit staff, taken to governing board, patient safety council and medical staff quality councils Intermountain generated, Reports portal We have used P&I results each quarter and send to the managers of each floor and reported in hospital quality reports. Standard Corp Reports Discussed with staff in staff meetings WOC to RN Mgr to Unit Staff They are placed on our swat team space and sent to managers, and reviewed in our PCC meeting Reports are available upon request or via email HAPU team to RN Mgr to Unit Staff RCA and unit-based outcome graphs

23. 2a. Do your reports include prevalence, incidence, or both? AnswerResponse% Both1173% Prevalence320% Incidence17% Total15100% 2b. How are reports updated or made available? AnswerResponse% Other (please specify)1173% Once a Month533% 2-3 Times a Month00% Once a Week00% Other (please specify) Unit boards updated weekly Quarterly surveys Quarterly e-mailed report As-needed Quarterly after P&I survey

24. 2c. Could you share an example of how the reports are used by hospital staff/teams? Text Response Used for Quality Assurance and Performance Improvement. Nursing Manager shares with unit staff Track and trend unit performance. Recommend more follow up with Wound Care specialists if units seeing an increase in ulcers Continuing education to discuss what preventions may have been done sooner (HAPU identified earlier). Discuss at staff/unit meetings Reviewed by the hospital managers and quality team for process improvement. It could be improved to be reported more frequently. We also use the hospital event reporting system for all 3 & 4 pressure ulcers and DTI. The manager will have to comment on the patient immediately. When a pressure ulcer is found the team discusses the best approach to care for the p.u.. Also each staff member is to be on alert for possible breakdown and take action before a pressure ulcer starts. All pateints have some form of pressure ulcer prevention. It shows what hospital acquired ulcers were found, which units and what the ulcer was. The managers are then able to review the documentation and find ways to prevent it in the future. It is also used as quality improvement throughout our hospital. Incident reports are completed on all pressure ulcers (hospital-acquired and present on admission). Hospital acquired ulcers are sent to each unit's manager for review and a RCA is completed. A meeting is held to discuss significant occurences, the RCA is reviewed by the multidisciplinary team, and a remedial plan is determined to prevent reoccurence.

25. 3. What tools do you use to educate staff about assessment and properly staging pressure ulcers? (check all that apply) AnswerResponse% Posters1059% Fact Sheets1376% Assigned Computer-Based Training1376% EMR Reminders953% Care Process Models741% Other212% Other Braden scale in EHR for PrU documentation Swat meeting education, swat members take education back to floor nurses

26. 4. Do you have skin and/or pressure ulcer assessment prompts embedded in your Electronic Medical Record (EMR)? AnswerResponse% Yes1694% No16% Total17100%

27. 4a. How often are the staff prompted to repeat the assessment? AnswerResponse% Every 12 hours1169% Every 24 hours319% Other213% Every 8 hours00% Total16100% Other On admisson and then criteria based Shift assessment

28. 4b. What EMR vendor is being used? Text Response Internal Internally developed system. Transistioning to Cerner over next 18 months Currently Tandem (Intermountain EMR) soon to change to Cerner/Intermountain EMR (iCentra) We use Tandem at this time and transitioning to iCentra Currently a home grown EMR. Changing to a Cerner Hybrid program within the next year. Tandem/ Help1 Allscripts Cerner

29. 4c. What type of assessment is being used? Text Response Braden, "naked man" on admissions to document any non HAPU, Braden Score, Overall wound/skin assessment Braden, BradenQ Head-to-toe

30. 5. What is the one intervention that has had the most impact in reducing pressure ulcers at your site in the past two years? Text Response Upgraded mattresses Hourly rounding on patients Standardized pressure reduction surface mattresses with an option for an air pump is the standard for all beds. New bed surfaces Nursing Staff Education TAPS or PUP Repositioning of patients and the use of specialty mattresses. Pressure reducing mattresses for all patients Wound Care/Ostomy rounds on all ICU patients daily and teaches "real" patient turning. Also, implementing the use of foam wedges Education regarding use of skin care creams and lotion for prevention. We did a big initiative to stock each unit with the correct products in a way that it is easy for staff to access and use. Then we did a big education on how to use the products in a way that will prevent skin issues. It has really helped to reduce our hospital acquired ulcers. Turning Q 2 hrs when patient does not or is unable to reposition themselves. A heightened focus on pressure ulcer prevention from the top down with admin support across the full spectrum of care.

31. 6. What is the most innovative approach that you feel has contributed to reducing pressure ulcers? Text Response Pressure reducing mattresses, pumps, and increased education with staff. Not "innovated", but continued education, wound care nurses, implementation of "SWAT" teams TAPS-Turn & positioning systems I think that the continual education to nursing staff about the importance of it and outcomes has been the most beneficial. We have sent the wound nurses to the ICU rounds for the patients on the specialty beds to assess wounds at the time of the unit assessment and that has helped. Our organization created a standard for using the PUP dressing and that has assisted as well in the OR cases and ICU cases from what we can tell so far. Waffle (EHOB) mattressess and seals Setting up our clean utility rooms so that the skin care products are all in the same area, easy to grab all of them at one time without searching forever to find them. Assessment-based intervention and monitoring Skin care assessment at shift change (both AM & PM) for low Braden scored patients Partnering with respiratory therapy to address respiratory device related pressure ulcers

32. 7. To help us measure progress, please indicate your facility's program status since starting the HEN collaboration to reduce pressure ulcers. What level do you feel your facility is at? AnswerResponse% Working Harder953% Getting Started424% Ahead of the Curve424% Total17100% A. "Getting Started": This level consists of identifying areas that need the most attention and appointing a leader that will help drive improvement and education SWAT (or champion) teams. B. "Working Harder": This level focuses on adopting decision algorithms for RNs to select appropriate surfaces and independently make decisions. C. "Ahead of the Curve": This level focuses on establishing monthly prevalence studies or incidence rates from Electronic Medical Records (EMR), then feed that data back to the SWAT teams.

33. 8. What barriers are you experiencing that are preventing you from achieving your goals to reduce pressure ulcers. Text Response Resources - both people and time - to do more frequent prevalence studies and to add incidence. Many competing priorities with change in EMR. Not a "barrier" - time for continued education & stressing the importance Lack of resources to continually turn and reposition patients. Nutrition support (although we now have a clinical dietician that is advancing our nutrition care), lack of RN wound specialist Staff turnover, supply cost, compromised patients in ICU that lose perfusion Acurate reporting of weekly skin assessment findings. Failure to recognize the beginning of skin breakdown. Up until approx 1.5y ago - did not have a FT Wound/Ostomy RN Rate of turnover of staff. In the last 2 years we have had a large amount of new nurses hired and it is difficult to educate them on proper prevention measures, especially if they are on the night shift. We used to be a part of the nurse residency educaion program, but were cut because of not enough time in their program. I see a difference in the nurses coming from the program, they dont know essential info to prevent pressure ulcers as they did in the past. Resources both time and money Acuity and staffing issues It is difficult to get time with nurses for education.

34. 9. What is your role at your facility? Text Response Member of pressure ulcer prevention team. Patient Safety Coordinator/Quality Consultant Clinical Effectiveness - Operations for Baylor Scott & White Health, NTX HAPU Council ICU manager Wound Care Nurse Manager Quality Lead Med/Surg coordinator Certified Wound, Ostomy and Continence nurse. I lead the SWAT team and perform P&I studies quarterly and coordinate education throughout the facility regarding new skin and wound care products. Manager Staff RN and wound champion Data Collector Wound Specialty Nurse Wound Care Specialist. Operations - Clinical Effectiveness WOCN

35. 10. What is the size of your facility? AnswerResponse% >200 people1059% 50 - 99 people318% 100 - 200 people318% 20 - 49 people16% Total17100%

36. There’s still time to complete the survey! If the survey has not been completed for you hospital or organization, please go to: https://csbsutah.co1.qualtrics.com/SE/?SID=SV_1XD83SpQdlnNw9f We follow up and develop a resource guide based on the survey responses to be shared across the HEN

37. 2014 plans for improvement Quarterly Affinity Calls 2015 CMS HEN contract renewals - unknown Sustainability? Collect and share best practices across our network hospitals & system in a single document