Measuring the Success of Hospital Acquired Pressure Ulcer Prevention

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Clinical PI

Janet Jonah
Corporate Performance Improvement Manager
MedStar Health System

Joe McDanials RN, MBA
Corporate Performance Improvement Manager
MedStar Health System

For many hospitals preparing for the CMS proposed value-based reimbursement changes has been a top priority but do they really know they will stand with repsect to the true incidence of facility- acquired pressure ulcers.This presentation will talk about unexpected hurdles, great applications of data and creative solutions.

MedStar Health is an integrated delivery system comprising seven acute care facilities, one rehabilitation facility and related businesses. A task force, chartered to make recommendations for pressure ulcer prevention and education across the system, found many of their basic assumptions challenged during implementation. An e-learning format for staging and assessment of pressure ulcers for nurses and physicians was essential to prepare the system for upcoming CMS value based regulations. In addition, a voluntary electronic reporting system was designed to report patient harm related to pressure ulcers and address unique problems in reporting the true incidence of facility-acquired pressure ulcers. The team coupled the occurrence data with clinical outcomes from CareSciences report of hospital related conditions not present on admission for an accurate model of facility- acquired ulcers. Trends in the prevalence data between facilities are reversed when looking at incidence and facility-acquired stage III and IV ulcers, although a small proportion of the total, are on the rise. Through integration of a clinical outcome database with the voluntary occurrence reporting system, functional units are beginning to get a true picture of the effectiveness of their prevention initiative and their actual facility-acquired pressure ulcer rates.