Papiya Yeasmin Minu ID 5538725 1

Faculty of Nursing
Mahidol University

Report for Project development

Quality Improvement Planning Project for Adult

Prevention of pressure ulcer among patients with
Decreased mobility
Submitted as a part of term paper on

NSAN 618 Adult Nursing in Critical Illness II

2nd semester / year1

Student name: Papiya Yeasmin Minu

ID 5538725

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Papiya Yeasmin Minu ID 5538725 2

Table of Contents

Contents Page Number

Part 1 Introduction 3
-significance of the problems
-pathophysiology of Pressure ulcer
-objectives
Part 2 Action Plan 9
Part 3 Implementation 19
Part 4 Conclusion 24
Part 5 References 25

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Title of the project: Quality improvement project

Prevention of pressure ulcers among patients with decreased mobility

Part 1 Introduction
Quality improvement is an important measure to improve the quality of health care in
particular the services in hospital settings. The US Agency for Healthcare Research and
Quality defines quality health care as "doing the right thing, at the right time, in the right
way, for the right person—and having the best possible results. Quality was first studied as an
industrial process in 1931 by Shewhart.' Shewhart's concepts include identifying customer
needs, reducing variations in processes, and minimizing inspections. (Varkey, Reller, Roger,
Resar, 2007, p. 735). Quality improvement is an approach to improvement of service systems
and processes through the routine use of health and programme data to meet patient and
programme needs.
Quality Improvement is a regular approach to construction changes that lead to
improved patient outcomes (health), stronger system performance (care) and superior
professional expansion. It draws on the mutual and feverishly efforts of all stakeholders
health care professionals, patients and their families, researchers, planners and educators to
make better and sustained improvements.
The quality of care delivered in our health centre is determined by loads of factors,
counting how its services are geared up, direction, monitoring systems, sufficient road and
rail network and obtainable property, both human being and objects. Quality management
includes: staff that are sufficiently taught and mentored; using the 5 Ss to get better the
physical work surroundings; particular excellence actions for lab tests; and well
implementation patient monitoring systems. In a Quality Improvement organization each and
every health care provider and staff member believes that change and improvement are an
intrinsic part of everyone’s work every day, in all parts of the system. Shifting to this new
focus involves substantial reframing of the idea of the work of health care, as well as the use
of a wide variety of tools and methods.” Ontarians share the common vision of a high-
performing health system that is accessible, effective, safe, patient-centred, equitable,
efficient, appropriately resourced, integrated, and focused on population health.
(http://www.hqontario.ca/quality-improvement)
The ever-increasing require for high quality delivery of patient care has led many
doctor practices, hospitals, and other health care settings to begin monitoring their

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performance in an attempt to ensure that they are delivering care that is: safe, effective,
timely, patient-centered, equitable, and efficient. To help do this, a number of organizations
have introduced the concepts of continuous quality improvement (CQI) to their staff. CQI is
an approach to quality management that builds upon traditional quality assurance methods by
emphasizing the organization and its systems. It is an approach that focuses on the “process”
rather than the individual, recognizes both internal and external “clientele” and promotes the
need for objective data to analyze and get better processes. With a solid understanding of an
organization’s processes and awareness of performance levels for exact tasks, a group of
individuals can bring about needed changes to lend a hand the team performs even better. We
can change model referred to as FOCUS-PDSA, and some basic skills needed to use this
model. FOCUS-PDSA is a common quality improvement approach utilized by many
healthcare organizations. Easy to learn and use, this model can be applied to the management
of any process. Each of its
nine steps stand for the following actions:
F = Find a problem
O = Organize a team
C = Clarify the problem
U = Understand a problem
S = Select an intervention
P = Plan
D = Do
S = Study
A = Act
(https://www.cardiosource.org/~/media/Files/Science%20and%20Quality/Quality%20Progra
ms/QIToolkit/2_IntrotoQIandtheFOCUS_PDSAModel.ashx)
Health services are multifaceted adaptive systems, we need to make it changes to
advance excellence of care. It needs to change that those factors are affected to delivery of
our health service and how we can influence them to achieve improvement. It needs pure
evidence, what we need to support for making decision. We needs to collect data and analyze
the data from various quality domains, Thus problems are often clear and self-evident and the
health service reacts to introduce appropriate improvements. Examples pressure ulcer is
major health problem in health care services. It was estimated that 60,000 deaths occurred
each year in USA. These opportunities become evident when the processes and outcomes

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are examined more closely. Data therefore helps to ‘push’ improvement by identifying
problems, and to ‘pull’ improvement by identifying opportunities.

There are variety models on quality improvement which focusing on

difference mode
I have selected the clinical outcome mode because of the followings reasons; this
model is very effective for improve the quality of care Clinical outcome. We all want to
improve our healthcare. All aspects of this, from the improved health of an individual to
improved hospital experience, can be measured. Clinical outcomes are broadly agreed,
measurable changes in health or quality of life that result from our care. Constant review of
our clinical outcomes establishes standards against which to continuously improve all aspects
of our practice. Clinical outcomes can be measured by activity data such as hospital re-
admission rates, or by agreed scales and other forms of measurement. They can be recorded
by administrators or by clinical staff such as doctors, nurses, psychologists or allied health
professional’s .This model assesses exacting health structures, processes, and outcomes. They
can be rate- or mean-based, providing a quantitative basis for quality improvement, or
sentinel, identifying incidents of care that trigger further investigation. They can assess
aspects of the structure, process, or outcome of health care. Furthermore, clinical outcome
can be generic measures that are relevant for most patients or disease-specific, expressing the
quality of care for patients with specific diagnoses. Many of our clinical services provide
outcomes data to national or international registries. Clinical Outcome measures can also be
reported by patients and their families.
(www.fda.gov/Drugs/DevelopmentApprovalProcess/.../ucm284077.htm‎)
The significance of the problem
My interesting topic is prevention of pressure ulcer among patients with decrease
mobility. I know from the clinical evidence and the research article from website, it is a
burning issue in the world wide According to Brain and Lyder (2004), it was estimated that
60,000 deaths occurred each year in USA.
In Bangladesh few records are available about pressure ulcer prevalence and
incidence. Hoque, Grangeon, & Reed (1999) conducted a study among paralyzed patients in
Bangladesh and found that 94 out of 247 patients (38%) had developed pressure ulcer.

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According to Hamm & Rappl 2009, Incidence in USA, an estimated 2.5 million
persons in the U.S. are treated each year for pressure ulcers. The prevalence of pressure
ulcers in the USA are described as follow;
Among Hospitalized elders rate is 15%, Nursing homes – up to 24%, Rehab facilities
up to 25% Home health-care settings 6-9% . The incidence of pressure ulcer, Orthopedic
patients up to 19%, Spinal cord injury patients up to 44%, The estimated cost of treating
these patients is $11 billion per year. Pressure ulcers are common problems in healthcare
system and produce a significant burden on patients, relatives and caregivers. It is one of the
most common complications for bed-ridden patients in hospital. First and foremost, these
wounds are very painful, thus causing patients a great deal of suffering. Number of affected:
2.5 million patients per year. Pressure ulcers cost $9.1-$11.6 billion per year in the US. Cost
of individual patient care ranges from $20,900 to 151,700 per pressure ulcer. Medicare
estimated in 2007 that each pressure ulcer added $43,180 in costs to a hospital stay.‎It also
leads to Lawsuits. More than 17,000 lawsuits are related to pressure ulcers annually. It is the
second most common claim after wrongful death and greater than falls or emotional distress.
Patients with pressure ulcers are suffering with pain. About 60,000 patients die as a direct
result of a pressure ulcer each year. This problem require to take immediate action. We
cannot wait and see because this problem is very big and has impact on our organization.
That’s why we need to develop project and guideline for the organization as well as the
nation.

Nursing home
Rehab home
25%

20% Hospital elders

15%
Home health Series1
10%

5%

0%
1 2 3 4
.
Figure-1 Prevalence of pressure ulcer in different health care setting.

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pie chart
1 2
Orthopaedic
patients
19%

Spinal cord
injury
patients
44%

Figure-2: Incidence of pressure ulcer

Pathphysiology of pressure ulcer
Concept mapping

External force Friction

Microcirculatory occlusion

ure Capillary filling pressureure

Ischemia

Inflammation Tissue anoxia

Cell death

Necrosis

Pressure ulcer

Figure: - 3

The inciting event for a pressure ulcer is compression of the tissues by an external
force, such as a mattress, wheelchair pad, or bed rail. Other traumatic forces that may be

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present include shear forces and friction. These forces cause microcirculatory occlusion as
pressures rise above capillary filling pressure, resulting in ischemia. Ischemia leads to
inflammation and tissue anoxia. Tissue anoxia leads to cell death, necrosis, and ulceration.
The main factors contributing to pressure ulcer is: pressure; when soft tissues are compressed
between bony prominences and contact surfaces, micro vascular occlusion with tissue
ischemia and hypoxia occurs; if compression is not relieved, a pressure ulcer can develop in 3
to 4 h. This most commonly occurs over the sacrum, ischial tuberosities, trochanters,
malleoli, and heels, but pressure ulcer can develop anywhere. Friction: friction (rubbing
against clothing or bedding) can help trigger skin ulceration by causing local erosion and
breaks in the epidermis and superficial dermis. Shearing forces: shearing forces (eg, when a
patient is placed on an incline) stress and damage supporting tissues by causing forces of
muscles and subcutaneous tissues that are drawn down by gravity to oppose the more
superficial tissues that remain in contact with external surfaces. Shearing forces contribute to
pressure ulcer but are not direct causes. Moisture: moisture (e.g., perspiration, incontinence)
leads to tissue breakdown and maceration, which can initiate or worsen pressure ulcer.
Because muscle is more susceptible to ischemia with compression than skin, muscle ischemia
and necrosis may underlie pressure ulcer resulting from prolonged compression. (Sharp &
McLaws, 2005).

Objective:

I would like to establish the project in my organization to reduce pressure ulcer 38%
to 0%. IT will improve the quality nursing care and bring the fame for the hospital and
decrease the cost and burden on patients, relatives and caregivers.
‎
Objective: General objective:
To prevent Pressure Ulcers among patients with decreased mobility.

Specific objective:
1. To identify the risk factors for pressure ulcers.
2. To reduce the risks of pressure ulcers
3. To reduce the severity or complications when patients develop pressure ulcers

Part 2

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Action Plan

Action plan is a part of our effort to develop and deliver excellent services to
healthcare; I have finished my assessment, and now I want to take action to improve my
Programme. Now is the time to think about writing an action plan. An action plan is a plan
for how to improve the program. It takes far-off goals and hard to changes and breaks them
down into steps it can keep track of and complete. An action plan usually includes goals,
steps, assignments, and deadlines.
I want to improve our program every year and respond to changes in our program every year.
But it may take more than a year to make major changes or achieve big goals. I have to give
more time for these major changes and goals.
Now I have developed an action plan for prevention of pressure ulcers among patients
with decreased mobility. It is designed to increase awareness of pressure ulcers and
underlying causes and risks. I will implement it in my own setting.
I will apply this action plan for quality improvement in clinical outcome model with
support of my government and authority. The US Agency for Healthcare Research and
Quality defines quality health care as "doing the right thing, at the right time, in the right
way, for the right person and having the best possible result. I know from the clinical
evidence and the research article from website, it is a burning issue in the world wide
According to Brain and Lyder (2004), it was estimated that 60,000 deaths occurred each year
in USA. In Bangladesh few records are available about pressure ulcer prevalence and
incidence. Hoque, Grangeon, & Reed (1999) conducted a study among paralyzed patients in
Bangladesh and found that 94 out of 247 patients (38%) had developed pressure ulcer. This
will decrease the hospital stay and save economic and national burden.

Action plan 1.
1. To identify the risk factors for pressure ulcers.
Activities:
1.1 I will Implement written pressure ulcer prevention system that includes policies and
procedures for the prevention and treatment of pressure ulcers.
1.2 Education and Staffing: Provide pressure ulcer training during staff orientation. Ensure
that all staff is able to recognize pressure ulcer risk factors.

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1.3 Conduct a preliminary risk assessment for pressure ulcers at the time of admission and
implement any needed immediate measures.
1.4 Individualize the care provided actively involve aides and therapy staff in care planning.
Involve resident/patient and families in care planning.
1.5 Develop care plans on admission and with change in condition that focus on interventions
based on Braden sub-scores vs. Braden total score.
1.6 Ongoing program to raise staff awareness about pressure ulcer prevention, equipment and
supplies.
1.7 Ensure system communicates changes in interventions in a timely manner.
1.8 Track all nosocomial and admitted pressure ulcers
1.9 Inspect skin daily.

Risk assessment
A comprehensive risk assessment for pressure ulcers will be completed on admission
for every patient using the Pressure Ulcer Risk Assessment Tool, incorporating the
Malnutrition Screening Tool, or the Braden Q Modified tool.
Braden’s model
Braden score (scale)
Braden Pressure Ulcer Risk Assessment
NOTE: Bed- and chair-bound individuals with impaired ability to reposition themselves
should be assessed for risk developing pressure ulcers.
Patients with established pressure ulcers should be reassessed periodically.
Table 1.
Date of Assessment/Reassessment (day/month/year)

SENSORY 1. 2. Very 3. Slightly 4. No

PERCEPTIO Completely Limited: Limited: Impairment:
N Limited: Responds Responds to Responds to
ability to Unresponsiv only to verbal verbal
respond e (does not painful commands, commands, has
meaningfully moan, stimuli. but cannot no sensory
to flinch, or Cannot always deficit which
pressure- grasp) to communicate communicate would limit

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related painful discomfort discomfort or ability

discomfort stimuli, due except by need to be to feel or voice
to moaning turned. OR pain or
diminished or has discomfort.
level restlessness. some sensory
of OR has a impairment
consciousne sensory which limits
ss or impairment ability to feel
sedation. which pain
OR limited limits the or discomfort
ability to ability to feel in 1 or 2
feel pain pain or extremities.
over most of discomfort
body over 1/2 of
surface. body
MOISTURE 1. 2. Very 3. 4. Rarely
degree to Constantly Moist: Occasionally Moist:
which Moist: Skin is often, Moist: Skin is usually
skin is Skin is kept but not Skin is dry, linen only
exposed to moist almost always, occasionally requires
moisture constantly moist. Linen moist, changing at
by must be requiring an routine
perspiration, changed extra linen intervals.
urine, etc. at least once change
Dampness is a shift. approximatel
detected y once a day.
every time
patient is
moved or
turned.
ACTIVITY 1. Bedfast: 2.Chairfast: 3. Walks 4. Walks
degree of Confined to Ability to Occasionally Frequently:
physical bed. walk : Walks outside

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activity severely Walks the room at

limited occasionally least twice a
or non- during day, day and inside
existent. but for very room at least
Cannot bear short once every 2
weight distances, hours during
and/or must with or waking hours.
be assisted without
into chair or assistance.
wheelchair. Spends
majority of
each shift
in bed or
chair.
MOBILITY 1.Completel 2. Very 3. Slightly 4. No
ability to y Immobile: Limited: Limited: Limitations:
change Does not Makes Makes Makes major
and control make even occasional frequent and frequent
body slight slight though slight changes in
position changes in changes in changes in position
body or body or body or without
extremity extremity extremity assistance.
position position but position
without unable to independentl
assistance make y.
frequent or
significant
changes
independentl
y.
NUTRITION 1. Very 2. Probably 3.Adequate: 4. Excellent:
usual food Poor: Inadequate: Eats over Eats most of
intake Never eats a Rarely eats a half of most every meal.

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pattern complete complete meals. Never refuses a

meal. meal Eats a total meal. Usually
Rarely eats and generally of 4 servings eats a total of 4
more than eats only of or more
1/3 of about protein servings of
any food 1/2 of any (meat, dairy meat and dairy
offered. Eats food offered. products) products.
2 Protein each day. Occasionally
servings or intake Occasionally eats
less of includes only will between meals.
protein 3 servings refuse a Does not
(meat or of meat or meal, but require
dairy dairy will usually supplementatio
products) products per take a n.
per day. supplement
day. Takes Occasionally if offered.
fluids will take a OR is on a
poorly. Does dietary tube feeding
not take a supplement. or
liquid OR TPN regimen
dietary receives less which
supplement. than probably
OR is NPO optimum meets most
and/or amount of of nutritional
maintained liquid diet or needs.
on clear tube
liquids or feeding.
IV's for
more than 5
days.
FRICTION 1. Problem: 2. Potential 3. No
AND Requires Problem: Apparent
SHEAR moderate to Moves Problem:

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maximum feebly or Moves in bed

assistance in requires and in chair
moving. minimum independentl
Complete assistance. y and has
lifting During a sufficient
without move skin muscle
sliding probably strength to
against slides to lift
sheets some extent up
is against completely
impossible. sheets, during move.
Frequently chair, Maintains
slides restraints, or good
down in bed other position in
or chair, devices. bed
requiring Maintains or chair at all
frequent relatively times.
repositionin good
g with position in
maximum chair or bed
assistance. most of the
Spasticity, time but
contractures occasionally
or slides down
agitation
lead to
almost
constant
friction.
TOTAL
SCORE:
INITIAL
S:

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NOTE: Patients with a total score of 16 or less are considered to be at risk of developing
pressure ulcers.
(15 or 16 = mild risk. 13 or 14 = moderate risk. 12 or less = high risk)

1988 Barbara Braden and Nancy Bergstrom.

1. Braden B. Bergstrom N. Clinical utility of the Braden Scale for Predicting Pressure Sore
Risk. Decubitus. 1989:2:44-51.

Table 2. Risk categories for the modified Braden Q risk scale and the revised
Waterlow pressure ulcer risk assessment tool.

Risk tool Patient ‘at risk’ / ‘Moderate risk’ ‘High risk’ ‘Very high risk’
mild risk
Waterlow Score > 10 Not applicable Score > 15 Score > 20
Braden Q* 16 – 23 13 – 15 10 – 12 9 or below
*based on the work of Curley et al 34

Action Plan 2.
2. To reduce the risks of pressure ulcers.
Activities:
2.1 Pressure ulcer team: Apply multidisciplinary pressure ulcer team that includes nursing,
aides, and support services.
2.2 Ongoing program to provide education and training for residents, patients, families, and
caregivers.
2.3 Apply a protocol in place for when a new pressure ulcer is identified.
2.4 Have nurse(s) who specialize in wound care and management nurse(s) who measure,
document and report all wounds consistently. .

2.3 Communicate results of risk assessment to appropriate staff. Implement a validated risk
assessment tool.
2.4 Identify “skin champions”(staff with specific education and responsibilities related to
pressure.

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2.5 Individualize the care provided actively involve aides and therapy staff in care planning.
Involve resident/patient and families in care planning

2.6 Inspect skin daily

2.7 Manage moisture.

2.8 Optimize nutrition and hydration: Perform regular nutrition and hydration assessments as
determined by risk assessments.
2.9 Minimize pressure: Turn/reposition patients/ residents at least every two hours.
Use patient/resident specific, unit or facility-wide cues to remind staff to turn/reposition all
at-risk patients/residents.
2.10 Implement a turn team
2.11 Create culture of collegiality and learning between partners to enhance advocacy on
behalf of patients/residents/clients/families.
2.12 Pressure Ulcer System: Conduct plan-do-study-act (PDSA) cycles to test and implement
new processes. Participate in a patient safety coalition with area providers
2.13 Establish regular meetings with area facilities, agencies and care providers to coordinate
communication, discharge, transfers and emergencies.

2.14 Conduct evaluation of pressure ulcer program at least annually.

2.15 Apply thai message to increase mobility.

Table 2 Skin assessment audit tool Date

Ro Bra Skin Ski Press Press Measure Pict Skin Treat Event Hospi
om den visua n ure ure ment ure team ment report tal
Scor lly IPO ulcer ulcer Taken Tak Consu plan compl acquir
e Asses C locat stage en lted starte eted ed?
sed star ion d
ted

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Abbreviation: IPOC, interdisciplinary plan of care.

Table: 3 Skin care plan
Pressure ulcers
Skin tears Stage I Stage II Stage III or Unstageable Deep tissue
IV necrotic injury
tissue
Cleanse with Position Lesion with Notify Notify Notify
physiological patient off intact physician physician physician
saline affected area blister: Order wound Order wound Order wound
Close Elevate heels Position consultation consultation consultation
approximate off bed patient off Wet lesion: Dry eschar Position
edges Turn patient affected Cover Position patient off
Cover with every 2 area with multiple patient off affected area
nonadherent Hours Lesion layers affected area Elevate heels
dressing shallow and of gauze, Cover with off bed
and gauze moist: Cover secure, multiple Turn patient
roll with 1 and change layers of at least
Change layer of daily nonadherent every 2 hours
dressings nonadherent Dry lesion: gauze,
daily and as gauze Cover secure, and
needed dressing, with multiple change
secure, and layers daily
change of Turn patient
daily nonadherent at least
Lesion gauze, every 2 hour
shallow and secure, and
dry: Cover change daily
with 3 Turn patient
layers of at least
nonadherent every 2 hours
gauze

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dressing,
secure, and
change
daily
Turn patient
at least
every 2 hours

Action plan 3
Activities:
3. To reduce the severity or complications when patients develop pressure ulcers
3.1 Ongoing program to provide education and training for residents, patients, families, and
caregivers.
3.2 Individualize the care provided actively involve aides and therapy staff in care planning.
Involve resident/patient and families in care planning.
3.3 Create culture of collegiality and learning between partners to enhance advocacy on
behalf of patients/residents/clients/families.
3.4 Ensure system communicates changes in interventions in a timely manner.
3.4 Create the optimum wound healing environment by using modern dressings –
(e.g. hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones) in
preference to basic dressing types – e.g. gauze, paraffin gauze
and simple dressing pads.
3.5 Antimicrobial agents in the treatment of pressure ulcers. In the presence of systemic and
clinical signs of infection in the patient with a pressure ulcer, systemic anti-microbial therapy
considered.
3.6 Mobilizing, positioning and repositioning interventions for individuals with pressure
ulcers (including those in beds, chairs and wheelchairs) by:general health status and location
of ulcer.
3.7 Nutrition in the treatment of pressure ulcers by identifying nutritional deficiency
3.8 Referral for surgical interventions for patients with pressure ulcers.
3.9 Topical negative pressure, electrotherapy and electromagnetic therapy, and therapeutic
ultrasound in the treatment of pressure ulcers.The use of adjunct therapies (electro-therapy

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technologies and topical negative pressure therapy) for the treatment of pressure ulcers
should be based on:
Ulcer assessment
level of risk from holistic assessment
general skin assessment
general health status
previous positive effects of the technology/therapy
patient preference (lifestyle, abilities and comfort), and
practitioner's competence.
3.10 Summary of prevention strategies:
 Multidisciplinary: Nurses, physicians, dieticians, physical therapists, and patients
and families are among those who need to be invested.
 Multidimensional: Many different discrete areas must be mastered.
 Customized: Each patient is different, so care must address their unique
needs.
 Reutilized: The same tasks need to be performed over and over, often
many times in a single day without failure.
 Assess: all patients using the revised Waterlow Pressure Ulcer Risk Assessment Tool
for Adults and the Braden Q Modified tool. Assess the patient’s nutrition, general
medical condition and home Environment. Involve relevant members of the
multidisciplinary team and family.

Part 3 Implementation:
For implementation of action plan I have a Sample, Action Plan format in my mind
that based on my needs:
Steps to take,
Who is responsible?
Due date for reaching the goals
Above this project for implementation we need multidisciplinary team and expertise
for coordination an interdisciplinary team, and members from many areas with the necessary
expertise to address the problem. When Hospitals authority found it’s very important that
their team was truly interdisciplinary. This work ensured that as a group, they could
understand pressure ulcer prevention from multiple perspectives and integrate the hands-on

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knowledge and expertise into their prevention efforts. They will be taking the action to
implement it.
Select the member for implementation team.

The most effective teams for initiating and management a change project such as this
one have several characteristics:
 An interdisciplinary team, including members from many areas with the necessary
expertise to address the problem.
 Strong link to leadership.
 Link to quality improvement expertise
Implementation team

Department Names of possible Area of expertise

Implementation Team
members from each area
Senior manager
QI/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

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Clerical staff

This tool will help identify the extent to which resources for quality improvement (QI) in the
organization. This tool filled out by the implementation team leader in consultation with the
QI department.
Team relationships:

Implementation Team

Interdisciplinary team charged

with designing and
implementing
Pressure ulcer change
Project.

Wound care team Unit-Based Team

Interdisciplinary group of staff on the unit who provide

experts that provides day-to- daily care to the patient,
day care of skin, wound care including skin and pressure
and resource for staff, patients ulcer risk assessment and care
family. planning.

Figure-3

No single team can make the program a success by itself. This figure illustrates the
overlapping and interdisciplinary nature of the team roles. In beginning its work, the
Implementation Team needs to outline roles for the other teams that are clear and workable.
Resources:
For implementation the project we need recourses, without resources project cannot
run well. The Implementation Team, improvement projects require resources of various
kinds, depending on the size and scope of the project. Foreword an effort without first
ensuring adequate resources can disrupt the project at almost every step. Resources needed
are likely to include staff time for team meetings and initiatives, leadership time to monitor
and support team efforts, training and education time, and more tangible resources such as
new care products and communication materials. It is important to meet with senior
administrators to determine what budget may be available. Consider creating a checklist to

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identify resource needs, such as funds, staff education programs, and information technology
support.
Quality monitoring and measurement:
The Implementation Team and Unit Champions build up a process for constant
monitoring of implementation progress. Part of the process will be gathering feedback from
staff and clinicians. For example, Unit Champions can compile questions and problems from
staff to send back to the Implementation Team. In addition, the monitoring process should
include tracking changes in assessment and incidence and prevalence rates, Results should be
communicated to staff and to the Implementation Team.

Pilot test:

In starting the implementation process, we have to do the pilot test of new practices in
one or two units before beginning them across the hospital. Pilot testing will allow
identifying and working out any problems in the recommended practices and processes at an
early stage and thus refine the program to better fit in hospital before open. It also can
generate early success that will build drive for later spread across the organization.
It can bring the advantages to identifying problems and customizing the bundle of prevention
practices to fit the hospital needs early in the implementation process.

To begin the pilot, we have to choose one or two units to participate. It needs to
improve and successful than past improvement project, I have to select the unit with low
pressure ulcer incidence unit with high incidence, the Implementation Team can hear from
the Unit Champions and staff what they like and problems they have had implementing the
project. The pilot test can provide two types of information:
(1) The outcomes collect to judge the pilot‘s success, such as rates of completion of
comprehensive risk assessments or better adherence to repositioning guidelines, and
(2) Feedback from participants on how the new bundle is working in terms, for
example, of the clarity of expectations.
 Drawing and conduct the pilot project for making changes as needed
 Accumulate staff questions and problems that arose to guide changes and
analyze measures of success.
 Talk about the results to the participating units, the Unit Champions, the

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Implementation team and hospital leadership.

 Refine the practices to address problems that surfaced in the pilot test.
 Use the list of staff questions from the pilot units and answers to create an
implementation tool for the hospital wide launch.
I will placed the pilot project to my authority before running the final
project.

Limitation:
When we take initiative for developing a project much limitation and barrier can
come like resources, staff education but it needs to take stronger support and leadership
activities

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Part 4 Conclusion
Pressure ulcer is a burning issue in the world wide it is major health problem in health
care services. It was estimated that 60,000 deaths occurred each year in USA. In Bangladesh
we found that 94 out of 247 patients (38%) had developed pressure ulcer.
Quality improvement is an important measure to improve the quality of life, we needs
high quality of service for health care in particular in hospital settings. According to the
WHO It is the human right to get standered care and high quality of service. The US Agency
for Healthcare states that "doing the right thing, at the right time, in the right way, for the
right person—and having the best possible results.
Quality Improvement is a regular approach to construction changes that lead to
improved patient outcomes (health), stronger system performance (care) and superior
professional expansion. It draws on the mutual and feverishly efforts of all stakeholders’
health care professionals, patients and their families, researchers, planners and educators to
make better and sustained improvements.
We needs to take immediate steps to make a action plan, Nurses training, staff
training, patients and family education. Set the priorities to identify specific areas for
improvement. Define a performance measurement method for improvement project and use
existing data, or collect data that you will use to monitor successes and needs to establish an
improvement team. Understand the processes of the underlying system of care so that
improvements can be implemented to effectively address problems.
Make changes to improve care, and continually measure whether those changes
actually produce the improvements in service delivery and achieving the goals that bring the
good image in nursing profession and the organization. We wish to achieve high performance
of care I would like to establish it in my organization to reduce pressure ulcer 38% to 0%. IT
will improve the quality of nursing care, reduce work load and bring the fame for the hospital
and decrease the cost and burden on patients, families, caregivers and safe economics in the
organization as well as nation.

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References
.Brem, H., & Lyder, C. (2004). Protocol for the successful treatment of pressure

ulcer. American Journal of Surgery, 188, 9-17.

.Hoque, M. F., Grangeon, C., & Reed, K. (1999). Spinal cord lesions in Bangladesh: An

epidemiological study 1994- 1995. Spinal Cord, 37, 858-861.

Hamm, R., & Rapple, L. (2009) Path physiology, prevention and

treatment of pressure ulcer. ……………………………………….

.Preventing Pressure Ulcers in Hospitals agency for healthcare Retrieved form

www.ahrq.gov/research/ltc/pressureulcertoolkit/putoolkit.pdf‎(2013).

http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-

ulcers/pressureulcertoolkit/putool1.html‎.

Sharp, C. A. & McLaws, M. L. (2005). A discourse on pressure ulcer physiology: the

implications of repositioning and staging. Retrieved from http://www.worldwide

wounds.com / 2005/october/Sharp/Discourse-On-Pressure-Ulcer-Physiology.html

National Institute for Health and Clinical Excellence (NICE). (2005). The management of

pressure ulcers in primary and secondary care: A Clinical Practice Guideline.

Retrieved from http://www.nice.org.uk/nicemedia/pdf/cg029fullguideline.pdf

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