Frustrated with ongoing complaints from family members, Reba Sanders, the administrator of 100-bed Lakeview Skilled Care and Rehabilitation Facility, replaced the director of nursing (DON) after she had been on the job for less than 2 years. At the exit conference with Reba, the DON had remarked, “I don’t think pressure ulcers have been a problem in this facility the way it is made out to be by some families. Some patients develop the ulcers at the hospital before they come here; we try our best to take care of them, and I have explained to the families what we are doing. I think firing me is unfair, but it is your decision.” Before the new DON, James Osterwal, was hired for the job, Reba had mentioned to him that looking into the pressure ulcer problem would be his first priority. Reba arranged for James to attend meetings of the local chapter of a national quality improvement organization for nursing homes. Based on some of the information presented at the meetings, James quickly settled on making pressure ulcer elimination as his primary goal. James was quite familiar with the PDSA quality improvement cycle. He discussed it with the charge nurses, decided how data would be collected, and started a campaign asking all nursing staff to adopt the motto: “We will eliminate pressure ulcers at Lakeview.” The associates liked the motto because it gave them a specific goal to work toward. At James’ request, Reba approved hiring an RN nurse coordinator to float between the three shifts. The charge nurses asked their nursing assistants to report to them right away all cases of skin breakdown. James trained the nurses in best practice protocols to treat pressure ulcers. After 4 months, data showed little to no improvement in the prevalence (total number of cases) of pressure ulcers at Lakeview. Both Reba and James could not understand why. 1.  Based on what you have learned to this point in the course, evaluate the quality improvement program as it pertains to pressure ulcers at Lakeview. Provide a specific outline of weaknesses in the overall approach. 2.  Use the PDSA cycle to address the issue of pressure ulcers. Be specific. For example, how should data be collected? How would you go about identifying root causes of the problem? What interventions would you implement? What roles should the various personnel and the administrator have?

1. Evaluation of the Quality Improvement Program at Lakeview Skilled Care and Rehabilitation Facility

The quality improvement program at Lakeview Skilled Care and Rehabilitation Facility, specifically regarding the issue of pressure ulcers, has several weaknesses in its overall approach. These weaknesses can be identified and analyzed in the following areas:

1.1 Lack of thorough data collection: The program fails to collect comprehensive and accurate data on pressure ulcers. It is crucial to gather data on the prevalence and incidence of pressure ulcers, as well as information on the patients who develop them while in the facility. Without this data, it becomes difficult to track progress, identify trends, and measure the effectiveness of interventions.

1.2 Inadequate root cause analysis: The program does not effectively identify the root causes of pressure ulcers. To address the issue, a thorough analysis of the factors contributing to pressure ulcers, such as patient characteristics, care practices, and facility environment, is necessary. Without a comprehensive understanding of the underlying causes, interventions may not effectively target the problem.

1.3 Limited staff training and education: The program lacks sufficient training and education for nursing staff regarding pressure ulcer prevention and treatment. It is essential for nurses to be trained in evidence-based best practices for pressure ulcer care. Without proper education, staff members may not have the necessary knowledge and skills to effectively prevent and manage pressure ulcers.

1.4 Inadequate communication with families: The program does not prioritize transparent and effective communication with families regarding pressure ulcers. Open and honest communication is essential in addressing family concerns and building trust. By keeping families informed about pressure ulcers, their causes, and the measures being taken to prevent and treat them, the facility can collaborate with families and manage their expectations.

2. Addressing the Issue of Pressure Ulcers using the PDSA Cycle

To address the issue of pressure ulcers at Lakeview Skilled Care and Rehabilitation Facility, it is advisable to use the Plan-Do-Study-Act (PDSA) cycle, a widely recognized approach for quality improvement. The following steps can be taken to implement the PDSA cycle:

2.1 Data Collection: To collect accurate and comprehensive data, a standardized method should be established to track the prevalence and incidence of pressure ulcers. This may involve conducting regular assessments of all patients upon admission and at regular intervals, as well as documenting any changes or new cases. Additionally, other relevant data, such as patient characteristics and risk factors, should also be collected. This quantitative and qualitative data will provide a baseline to measure progress and evaluate interventions.

2.2 Root Cause Analysis: A thorough root cause analysis should be conducted to identify the underlying factors contributing to pressure ulcers. This can be done through interdisciplinary team discussions, literature reviews, and consultations with external experts if necessary. By identifying the root causes, the facility can develop targeted interventions to address the specific issues contributing to the development of pressure ulcers.

2.3 Interventions: Based on the findings from the root cause analysis, specific interventions should be implemented to prevent and manage pressure ulcers. This may include revising care protocols, implementing evidence-based best practices, providing ongoing education and training for staff, improving skin assessment and care documentation, and addressing environmental factors that contribute to pressure ulcer development. These interventions should be evidence-based and tailored to the unique needs and challenges of Lakeview Skilled Care and Rehabilitation Facility.

2.4 Roles and Responsibilities: Clear roles and responsibilities should be assigned to different personnel involved in the program. The administrator should provide necessary support, resources, and leadership to ensure the success of the program. The nursing staff, including the RN nurse coordinator and charge nurses, should be responsible for implementing the interventions and collecting data. It is essential to foster a culture of accountability and collaboration among all staff members to achieve the goal of pressure ulcer elimination.

In conclusion, the quality improvement program at Lakeview Skilled Care and Rehabilitation Facility has weaknesses in its overall approach to prevent and manage pressure ulcers. By adopting the PDSA cycle and addressing the identified weaknesses, the program can be improved. Thorough data collection, root cause analysis, targeted interventions, and clear roles and responsibilities are vital components for a successful quality improvement program that focuses on pressure ulcer reduction and elimination.