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©Pathway Health 2013
QAPI and Wounds
Lori Krech, RN, CWCN, BSBM Pathway Health Services, Inc.
Director of Community Based Services
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©Pathway Health 2013
• QAPI – Quality Assurance – Performance Improvement
QAPI
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©Pathway Health 2013
• Quality Assurance (F520 QA&A, Quality assessment & assurance) – Identifies and corrects quality issues – Retrospective – Focus on outliers or individuals – Efforts end once achieved – DON, Physician and 3 staff members – Meet quarterly
QAPI
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©Pathway Health 2013
• Performance Improvement – Proactive approach – Efforts are on-going – Focus on system changes – Plan involves input from staff
representing all roles and disciplines within the organization
– Meet at more frequent intervals
QAPI
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©Pathway Health 2013
Assessing Systems • QAPI (Quality Assurance &
Performance Improvement)
– Systematic,
– Comprehensive,
– Data-driven,
– Proactive approach
QAPI
QAPI
System Changes
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5 Elements for QAPI
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Element 1- Design & Scope
• Ongoing & Comprehensive
• Full range of services & departments
• Addresses clinical care, quality of life, resident choice, and care transitions
• Aims for safety while promoting autonomy
• Goals & measures are based on best available evidence
• Will have written QAPI plans with all five elements
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Element 2 – Governance & Leadership
• The governing body & leadership, working with input from staff, residents and representatives, develop and lead the program to assure: – Program has sufficient resources – Training occurs – Policies are in place to sustain program
if turnover – Priorities set & expectations
established – Staff are accountable
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Element 3 – Feedback, Data Systems & Monitoring
• Install systems to monitor care and services
• Get feedback from residents & family • Install performance indicators • Establish targets for performance • Review against benchmarks and
targets • Track and investigate adverse events
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Element 4 – Performance Improvement Projects (PIP)
• Conduct PIPs in areas that need attention
• Identify priority areas (high risk, high volume, problem prone areas)
• Establish teams for concentrated efforts
• Gather data, study a problem, act on improvement ideas, re-study the problem
• Report findings to leadership
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Element 5 – Systemic Analysis & Systemic Action
• Use systemic approach to determine if root cause analysis is needed
• Determine if the problem may be caused by the way the care and services are organized
• Perform in depth analysis of systems • Look comprehensively across systems
to ensure sustained improvement and prevent future adverse events
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Performance Improvement ProgramPerform
ance Improvement Program PIP Focus today Skin Integrity Program
Include all components in PIP
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©Pathway Health 2013
• Management team and front line caregiver’s must support the program and be actively involved
• Success does not come from development; but implementation
Governance & Leadership
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©Pathway Health 2013
Break down your existing systems and identify needed additions: • Sufficient supplies • Wound Care Team and effective
communication and agenda in meetings • Pre-Admission Process • Admission Process • Preventative Program • Treatment Program
Targeting Your Skin Integrity PIP
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©Pathway Health 2013
PDSA Cycle for PIP Implementation
QAPI – PDSA Cycle
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©Pathway Health 2013
Assessing Systems • Correct Team Members • Start small • Root Cause Analysis:
• Review what ACTUALLY happens verses what NEEDS to happen
• Identify Performance Gaps • Identify the data to be used
and set a goal • Develop an action plan
QAPI Assessing Systems
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©Pathway Health 2013
Assessing Systems • Correct Team Members
QAPI Accountability
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©Pathway Health 2013
Assessing Systems • Start small
QAPI Implementation
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©Pathway Health 2013
• Root Cause Analysis Goal
Determine what happened Determine why it happened Figure out what to do to reduce the likelihood that it will happen again
QAPI Assessing Systems
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©Pathway Health 2013
• Root Cause Analysis – Seeks to identify the origin of a
problem – Physical Causes – Human Causes – Organizational Causes
QAPI
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©Pathway Health 2013
Assessing Systems • Root Cause Analysis: • Review what ACTUALLY
happens verses what NEEDS to happen
• Identify Performance Gaps
QAPI Assessing Systems
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©Pathway Health 2013
QAPI Assessing System
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©Pathway Health 2013
Map out what actually happens verses what should happen
Identify Performance Gaps
QAPI Assessing Systems
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©Pathway Health 2013
QAPI
• Root Cause Analysis: Fishbone Diagram
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©Pathway Health 2013
• Root Cause Analysis: Why Diagram
QAPI
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©Pathway Health 2013
Assessing Systems Once the performance Gaps are identified:
• Identify the data to be used and set a goal
• Develop an action plan
QAPI Assessing Systems
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©Pathway Health 2013
Assessing Systems • Identify the area within
the facility to test • Implement the program
QAPI Implement the Plan
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©Pathway Health 2013
Assessing Systems Review the progress of the program
– Where are you compared to the goal
– What is working – What is not working
QAPI Analysis Progress
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©Pathway Health 2013
Assessing Systems • Make adjustments to the program based on the analysis
• Start a new PDSA cycle OR
• If successful, roll out to the entire facility and start a PDSA cycle for the facility
QAPI Adjust the Program
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©Pathway Health 2013
Sufficient Resources • Go look into supply rooms, treatment carts, etc.
for topical dressings in the facility Do an overview of equipment: • Bed surfaces • Wheelchair cushions • Heel lift • Positioning devices • Incontinence products • Nutritional supplements • Lifting and repositioning devices
Sufficient Resources PIP
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©Pathway Health 2013
• Set up a wound care formulary of products
Sufficient Resources PIP
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©Pathway Health 2013
• If possible have an approval system for
anything ordered off of your product formulary
• Educate your Physicians, NP’s, Wound
Clinics, etc. on your product formulary
Sufficient Resources PIP
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©Pathway Health 2013
Topical Supplies Categories: • Moisture dressings (i.e., hydrogels, hydrocolloids and transparent films) • Absorptive dressings (i.e., foams and calcium alginates) • Debriding Agents (Santyl, Medical grade honey) • Antimicrobials (silver, cadexomer Iodine, medical grade honey, etc.) • Collagen Dressings
Sufficient Resources PIP
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©Pathway Health 2013
Make a streamlined topical management guideline with limited products in each major category: • Guideline should guide the nurse by
characteristics of the wound (i.e., superficial dry wound)
• Recommend product category for ordering (i.e., Hydrogel sheets versus hydrogel gel)
Sufficient Resources PIP
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©Pathway Health 2013
Access to adjunctive therapies: • E-Stim • NPWT (Negative Pressure Wound
Therapy) • Celleration MIST • Hyperbaric Chambers
Sufficient Resources PIP
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©Pathway Health 2013
• Barrier ointments/creams to protect from incontinence (are they accessible to the caregivers)
• Absorptive products for incontinence
Sufficient Resources PIP
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©Pathway Health 2013
• Lifting and positioning devices • Heel Lift Devices
Sufficient Resources PIP
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©Pathway Health 2013
• Dietary supplements as appropriate • Protein & Calories • Multivitamins
Sufficient Resources PIP
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©Pathway Health 2013
• Lotions • Protective garments
Sufficient Resources PIP
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©Pathway Health 2013
• Compression Therapy for Venous Insufficiency
• Compression wraps
• Compression stockings
• Compression pumps
• Protective/appropriate footwear
Sufficient Resources PIP
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©Pathway Health 2013
• Pressure redistribution bed surfaces • Preventative Mattresses • Advanced Therapy (i.e., low-air-loss,
alternating air, etc.) • Wheelchair cushions
Sufficient Resources PIP
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©Pathway Health 2013
Remember the most expensive product is the one
that doesn’t work!!!!
Sufficient Resources PIP Remember the most
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©Pathway Health 2013
Access to:
• Podiatrists • Wound Clinics/Physicians • Certified Wound Care Nurses • Vascular Surgeons/Physicians
Sufficient Resources PIP
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©Pathway Health 2013
Wound Care Nurse • Utilized when a wound happens • Typically is responsible for the weekly
documentation of a wound • Ensures appropriate treatment
strategies
Skin Integrity Team PIP
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©Pathway Health 2013
Oversight of the program • Prevention • Education • Compliance • Accuracy of documentation • Monitoring
Skin Integrity Team PIP
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Investment in Knowledge • Consider WOCN (www.wocn.org) or WCC (www.wcei.net) certification • Prevention • Etiology of wounds • Assessment & Documentation • Treatment modalities • Training • Documentation Training • Compliance Items
Skin Integrity Team PIP
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• Wound Care Expertise takes education AND experience
• No one wound nurse can manage a prevention and treatment program alone
Skin Integrity Team PIP
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Development of a Skin Care Team • Key Nursing Assistants from ALL shifts • Key Floor Nurses from ALL shifts • Nurse Managers or Case Managers • Therapy Consultation • Dietary Consultation • Physician/NP/Medical Director • Housekeeping/Maintenance
Skin Integrity Team PIP
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Skin Team Meetings • Develop a SET schedule for the Skin
Care Team meetings – Management MUST support
• Initially may need to be weekly to bi-weekly
• Monthly
Skin Integrity Team PIP
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©Pathway Health 2013
Skin Team Meeting Agenda • Review current residents with wounds • Progress • Topical Treatment • Support surfaces/equipment • Heel lift • Turning Schedule • Incontinence management • Nutritional Support • Therapy Involvement • Compliance/Barriers to plan of care
Skin Integrity Team PIP
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Skin Team Meeting Agenda • Review ALL Residents significant change in
condition-does this affect mobility • Review Treatment sheets • Decrease/change in mobility • Change in appetite, eating habits or weight loss • Change in continence • Change in cognition • Overall changes/decline
Skin Integrity Team PIP
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©Pathway Health 2013
Skin Team Meeting Agenda • Review Supplies/Equipment • Support Surfaces (bed & wheelchair) • Heel lift devices • Positioning devices • Perineal cleansers and barrier
ointments/creams • Lifting devices • Topical dressings
Skin Integrity Team PIP
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• All staff should be involved • Continuous
Monitoring Your PIP Programs
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Wound Nurse to Monitor on a Monthly Basis: • Treatment record • Charts of high risk AND wound care residents • Weekly skin checks • Supplies • Dressing Change technique • Have nurses involved with oversight for
monitoring ability to turn, toileting abilities and equipment
Monitoring Your PIP Programs
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PLAN-DO-STUDY-ACT (PDSA)
Sufficient Supplies Wound Care Team and Effective Meetings Effective Communication between team members Pre-Admission, admission, post-admission Preventative and treatment programs
Targeting your Skin Integrity PIP
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• Example: Skin Assessment on Admission – What: Admission Skin Assessment – Why: To get a baseline of their skin on
admission/identify issues – Who: Licensed Nurse should do the
assessment – When: Within 24 hours of admission
QAPI-PIP Monitoring
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Example: Skin Assessment on Admission • Developing a team to
evaluate the Admission Process:
– Assess when and where your admissions are happening
– Who is Doing the Admission Assessments
QAPI- PIP Monitoring
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Example: Skin Assessment on Admission
• Start Small
– Which Community are most of your admissions admitted to?
QAPI-PIP Monitoring
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©Pathway Health 2013
Example: Skin Assessment on Admission
• Root Cause Analysis: Map out what actually Happens
– Who does the skin assessment and when?
– Is it completed accurately?
– Is the skin assessment part of the admission packet/checklist?
– How are the results communicated
– What is done if a skin concern is found?
QAPI- PIP Monitoring
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Example: Skin Assessment on Admission
• Identify Performance Gaps:
– The nurses who admit most residents are not comfortable with assessing skin concerns
QAPI-PIP Monitoring
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Example: Skin Assessment on Admission
• Set Goal
– 100% of all admissions will have an accurate skin assessment within 24 hours by the end of the next month
QAPI-PIP Monitoring
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Example: Skin Assessment on Admission
• Develop the Action Plan
– All admission nurses will be trained on skin assessment
– The nurses will be competency tested at the bedside
QAPI- PIP Monitoring
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©Pathway Health 2013
Assessing Systems Example: Skin Assessment on Admission • Provide the training and
competency testing over a set time period
QAPI- PIP Monitoring
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Assessing Systems Example: Skin Assessment on Admission • Review the progress of
the program – 90% where completed
within 24 hours – The 10% that were not
completed were weekend admissions
QAPI- PIP Monitoring
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©Pathway Health 2013
Assessing Systems
QAPI- PIP Monitoring
Example: Skin Assessment on Admission • Modify the Action Plan
• All weekend nurses will be trained on skin assessment
• Start a new PDSA cycle
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©Pathway Health 2013
Assessing Systems Taking the Time to Utilize a Quality
Improvement Process Can Improve Resident Outcomes and Workflow
Happy Residents and Staff
QAPI Celebrate Success
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©Pathway Health 2013
Questions????
Lori Krech, RN, CWCN, BSBM Director of Community Based Services
Pathway Health [email protected]
651-343-0925
Thank you!!
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©Pathway Health 2013
• www.wcei.net(Certifies in wound care) • www.npuap.org (National Pressure
Ulcer Advisory Panel) • www.woundsource.com Great source to
find wound care products and companies/vendors
Resources
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©Pathway Health 2013
• www.wocn.org (Wound, Ostomy & Continence Nurse Society) • Provide Certification for 4 year RNs • Available Guidelines: • Prevention and Management of Pressure Ulcers • Management of Wounds in Patients with Lower-Extremity Arterial Disease • Management of Wounds in Patients with • Lower-Extremity Neuropathic Disease • Management of Wounds in Patients with Lower-Extremity Venous Disease
Resources