QUALITY AND INNOVATION AWARDS 2016
Quality Improvement Team of the Year
A team at Responsive Health Management succeeds in
reducing pressure ulcers
esidents, families and staff are
aware that pressure ulcers are
painful, slow to heal, and are
often seen as an indication of poor
quality of care. No one wants to see a
resident develop pressure ulcers, but
the root causes always clear.
When a team at Responsive Health
Management decided to tackle this
issue, they were able to cut the
number of pressure ulcers by half in
just one year.
Changes to their wound management program as a result included
new training modules, having skin
and wound rounds take place at the
bedsides of high-risk residents, and
empowering personal support workers (PSWs) to use iPod cameras to
report changes to skin. But
the process itself also revealed some
insights on change management that
Responsive would like to pass on to
The management team knew from
their research that gaps in education
and training are often reasons why
pressure ulcer prevention best practices are inconsistently applied, audited
and evaluated. In addition, there can
be gaps in the quality and consistency
of skin checks and skincare for fragile
and ulcer-prone skin, delays in catching early redness before ulcers start,
and challenges in communication
between shifts and among interdisciplinary teams.
ake sure your data is accurate.
There were some different interpretations of wound staging among
staff, and that was reflected in the
data and team communications.
The team provided consistent
education around how to assess
the stages of a wound, how to code
this correctly in MDS, and how
to share the information in
In May 2015, three of
long-term care homes started a process improvement project to reduce
the incidence of pressure ulcers.
They established a special group, the
Pressure Ulcer Prevention Process
Improvement Team (PUPPIT), which
used LEAN methodologies to assess
the situation and determine what
steps to follow.
LONG TERM CARE TODAY
nsure the existing program is being
followed. assume a process
improvement is necessarily needed.
Check first that everyone knows
and is following your protocols.
nclude frontline staff in the proI
cess improvement initiative. Including PSWs and registered staff from
all three homes on the team was
very important to the management
team. These people provided
valuable insight into the current
state of pressure ulcer care, and opportunities for improvement. They
also championed the changes with
ave a sustainability plan in place
and execute the plan. People come
and go, and management teams
have heavy workloads. Policies,
training documents and audit programs should all be updated where
appropriate to reflect the change
ideas adopted as a result of the initiative. the way to ensure they
will be followed in the future.
process improvement is new to
the team, factor in time to teach it.
If this skill is new to the team, then
be sure to build in teaching and
Staff continue to have a high level of
awareness around early detection of
pressure ulcers, the PUPPIT team
says, and the new process they
developed is being applied to other
quality improvement activities in
Responsive homes. LTCT
For more information, contact
Cathy Fiore, Director of
Operations and Quality, at