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©2017 National Pressure Ulcer Advisory Panel | www.npuap.org

Let’s Start at the Top: Getting Administrative Buy-inWilliam Padula, PhD

Assistant Professor

Johns Hopkins University

Twitter: @DrWmPadula

Acknowledgements

• AHRQ 1-F32-HS023710-01

• Board of Directors, NPUAP

• Commissioner, ANCC Magnet®

Recognition Program

• Consultant and Speakers Bureau,

Molnlycke Health Care

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Background

The Donabedian Model

The secret of quality is love.

-Avedis Donabedian

Structure

ProcessOutcomes

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Structure

Structure – Pressure Injury Prevention

• NPUAP/EPUAP International Guidelines

for PI Prevention

What we know about

this checklist:

• It holds good value

• It’s effective at

reducing pressure

injury rates

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Value of Pressure Injury Prevention

• Epidemiology- 2.5 million patients develop PIs every year1

- National incidence rate of 2.5% in hospitals1

- 60,000 deaths/year1

• Economics- Costs U.S. Health System $9-11 billion/year2

$70-150 thousand per patient for Stage III/IV PI2

$250,000+ per settlement3

- Second most common hospital billing claim2

1. Lyder, JAGS 2012; 2. Padula, Med Care 2011; 3. Bennet et al, JAGS 2000

A Timeline of Hospital Quality

1999: IOM Report First Do

No Harm

•HAPI Rate: 7% (Whittington, 2004)

•Hospitals cause patients preventable harm

2004: NPUAP PI Prevention

Guidelines

•HAPI Rate: 4.6% (Bergquist-Beringer, 2009)

•Most Pressure Injuries are Preventable

•Guidelines must be implemented consistently to all hospitalized patients

2006: IHI 5million Lives

Campaign

•HAPI Rate: 4.5% (Lyder, 2012)

•Hospital leaders vow to participate in nationwide campaign to reduce rates of preventable harms

•HAPIs

•CAUTI

•CLABSI

•Falls

•VAP

•VTE

2008: CMS Nonpayment

Policy

•Reduced payments for patients who develop Hospital-acquired conditions

•Hospitals no longer financially incentivized to allow preventable harm to patients

2010: Patient Protection and Affordable Care

Act

•HAPI Rate: 2-3% (Padula, 2013)

2014: CMS Performance

Measure Policy

•Establishment of PSI-90: a composite rate of hospital-acquired conditions

•HAPI

•CLABSI

•VTE

•Object left in patient

•Etc.

•Hospitals in lowest 25th-percentile penalized 1% of total CMS reimbursement

These CMS payment policies created financial

incentives which drew C-suite attention to

Pressure Injury Prevention

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Pressure Injuries remain an Issue

HAPI

HAPI

Data Source: 350 member academic medical institutions from the Vizient-UHC clinical database

Current Issues Requiring further Attention

• We know what effective tactics in

pressure injury prevention are...

• We know that pressure injuries are

costly...

• And, we know that if pressure injury

rates are rising, a lack of action will lead

to higher hospital costs.

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Need to Transform Leadership

• Hospital Leadership (i.e. C-suites Executives)

control finances that can be used to engage

staff in pressure injury prevention

– Hire additional WOCNs to train nursing staff

– Increase Nursing FTEs

– Nursing Education

– Purchase Expensive Equipment (beds, underpads,

creams, dressings, etc.)

• Can link Skin/Wound Teams to Support

Structure for further action

– Hospital Information Technology (e.g. EHRs)

– Researchers (e.g. Biostatistics, Epidemiology)

– Engineering

Transformational Leadership

Creehan et al. JWOCN 2016

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Connecting Leadership to the Bedside – a complex task

Formal and Informal

Leaders

Team members

Hospital-level Formal: Hospital

Administration

(e.g. CNO, CQO, CEO)

Skin/Wound Team members

(e.g. CWOCN, CWCN)

Division-Level Formal: Skin Team Lead

(e.g. CWOCN in

Surgery, Gen Med, etc.)

Skin Team Champion

(e.g. RN Manager)

Unit-Level Skin Team Champion Bedside RNs and other

providers

Padula et al. JWOCN, 2017.

How to Engage Leadership in 3 steps?

1. Develop Tools to Engage Leadership

2. Illustrate Value

3. Show Progress

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Develop Tools to Engage Leadership

Best-Practice Framework of Quality Improvement Interventions for Pressure Injury Prevention in U.S. Hospitals

4-Domain Framework

Leadership Components

Domain Intervention

Leadership

1 Program Mission

2 Prevention Awareness

3 Leadership Initiatives

4 Admin Support

5 Prevention Protocol

6 Benchmarking

7 Wound Team

Staff

1 Performance Measures

2 Team Huddles

3 All-Staff Meetings

4 Wound/QI Team

5 Prevention Education

6 Staff Training

1 Data Tracking

2 EHR Risk Assess

3 Electronic Alarm

4 EHR Implementation

1 Braden Scale

2 Visual Tools

3 Beds

4 HAPU Staging

5 Skin Care

6 Incontinence

7 Repositioning

8 Nutrition

Information & Information Technology (IT)

Performance & Improvement (P&I)

Padula et al. Adv Skin Wound Care, 2014.

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Trends in Leadership Engagement

Padula et al. JWOCN, 2017.

HAPI rates went down in hospitals using some of these leadership tactics

Padula et al. Medical Care, 2016.

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Connecting Leadership Support and Quality Empirically

• NPUAP/EPUAP updated PI

prevention guidelines in

2004, 2007, 2010 and 2014

• Hospitals adhering to

updates had significant PI

reductions

- Average hospital had 7.5 PI

case reduction per year

- $500,000+ savings per year

Padula et al. Medical Care, 2016.

Connecting Leadership Support and Quality Empirically

Leadership in Combination with Other QI

Interventions to Prevent HAPIs

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Illustrate Value

Production Frontier of CWOCNs

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Theory behind CWOCN Value

Illustrating Value

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Economic Evaluation

Incremental Cost-effectiveness Ratio (ICER)

Effectiveness

Decreases

Effectiveness

Increases

Cost

Increases

Never Do Cost-effective

Cost

Decreases

Cost-effective Always Do

Cost-effectiveness of NPUAP Guidelines

Inpatient

Deep Tissue

Injury

Discharge

Pressure

Ulcer

Stage I/II

Death

Pressure

Ulcer

Stage III/IV

No

Complication

Nurse &

Monitor

Acute &

Chronic

Care

Surgery

Standard Care

Prevention

M

• Main comparators- Standard Care:

Inconsistency

- Strategic Prevention with

QI

• Pressure Injury

Prevention Leads to

Cost-Savings- $55/patient/day to

Implement Guideline

- Upper limit on prevention

cost-effectiveness is

$300/patient/day

Padula, Med Care 2011

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Relative Value to Patient and Hospital

Forgo Air-fluidized BedCase. This is the case of a 55-year-old woman with a

body-mass index (BMI) over 40 who was in post-

operative care for a coronary-artery bypass graft (CABG).

Prior to her hospitalization, she was wheelchair-bound for

15 years due to deteriorating health and uncomfortable

walking. The CABG went well but following surgical

recovery she began complaining about pains in her legs

and lower back. Nurses performing a routine skin exam

discovered non-blanchable redness on her sacrum and

deep bruising on her heels, although no open wounds

were noted. Given her immobility, nurses ordered an air-

fluidized bed to reduce risk for pressure injury (PrI)

development. However, the patient preferred a traditional

hospital bed, noting that the air fluidized bed during a

prior hospitalization was uncomfortable and kept her from

sleeping well

StageIIHAPU

Air-fluidizedbed

Noadvancement

AdvancementtostageIII/IVHAPU

Discharge

Die

Discharge

Die

Noair-fluidizedbed

Noadvancement

AdvancementtostageIII/IVHAPU

Discharge

Die

Discharge

Die

Padula, J Med Econ 2016

Relative Value to Patient and Hospital

Padula, J Med Econ 2016

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Translating Value: ICER -> BIA -> ROI

Step 1:

Perform

Budget

Impact

Analysis

(BIA) of

Prevention

Translating Value: ICER -> BIA -> ROI

Step 2:

Calculate

Return on

Investment

(ROI)

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Show Progress

Descriptive Statistics

• Staging

• Body Location

• Unit

Incidence/Prevalen

ce Rates

• High-risk Patient

Cohorots

– Age and Sex

– Race/Ethnicity

– DiagnosesPadula et al, BMJ Qual Saf 2012

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SPC Charts

• Statistical process control (SPC) charts offer helpful insight to strengths and weaknesses of a complex clinical process (e.g. HAPI prevention)

• Utilize SPC charts to identify points for quality improvement (QI) intervention

• These Measurements can Inform Leadership that their Investments are leading to effective HAPI prevention

Proportions (P) Charts

P-chart of HAPU Incidence in a Surgical Ward

Upper Control Limit = 0.025

Mean =0.0117

0

0.005

0.01

0.015

0.02

0.025

0.03

0.035

1 2 3 4 5 6 7 8 9 10 11 12 13

Quarter (4th Qtr 2004 to 4th Qtr 2007)

Inci

den

ce

P-chart of Patient Assessment with Braden Scale on Admission

Lower Control Limit = 0.70

Mean = 0.93

0.5

0.6

0.7

0.8

0.9

1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Week

Pro

po

rtio

n o

f P

ati

ents

Ass

esse

d

Padula et al, BMJ Qual Saf 2012

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Time (T) Chart

Padula et al, BMJ Qual Saf 2012

Concluding RemarksWhat has your hospital done to engage leadership?

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Paul Batalden, MD [The Dartmouth Institute]

Co-founder of Institute for Healthcare Improvement (IHI)

References

1. Lyder CH, Wang Y, Metersky M, Curry M, Kliman R, Verzier NR, Hunt DR. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc 2012 Sep;60(9):1603-8.

2. Padula WV, Mishra MK, Makic MB, Sullivan PW (2011). Improving the Quality of Pressure Ulcer Care with Prevention: a cost-effectiveness analysis. Med Care 49(4): 385-392.

3. Bennett RG, O'Sullivan J, DeVito EM, et al. The increasing medical malpractice risk related to pressure ulcers in the United States. J Am Geriatr Soc 2000;48(1):73-81.

4. Creehan et al. The VCU Pressure Ulcer Summit – Developing Centers of Pressure Ulcer Prevention Excellence: A Framework for Sustainability. J Wound Ostomy Continence Nurs2016;42(3):1-8.

5. Padula WV, Mishra MK, Makic MB, Valuck RJ. A framework of quality improvement interventions to implement evidence-based practices for pressure ulcer prevention. Adv Skin Wound Care 2014;26(6):280-4.

6. Padula WV, Makic MBF. View from here: Formal and Informal Leadership Translating Evidence-based Practices for Pressure Injury Prevention in the Hospital Setting. J Wound Ostomy Continence Nurs 2017;44(2):1-2

7. Padula WV, Gibbons RD, Valuck RJ, et al. Are Evidence-based Practices Associated With Effective Prevention of Hospital-acquired Pressure Ulcers in US Academic Medical Centers? Med Care 2016;54(5):512-8.

8. Padula WV, Mishra MK, Makic MB, Sullivan PW (2011). Improving the Quality of Pressure Ulcer Care with Prevention: a cost-effectiveness analysis. Med Care 49(4): 385-392.

9. Padula WV, et al. Individualized Cost-effectiveness analysis of Patient-centered Care. Journal of Medical Economics. 2015 November [Epub ahead of print].

10. Padula et al. Building information for systematic improvement of the prevention of hospital-acquired pressure ulcers with statistical process control charts and regression. BMJ QualSaf 2012;21(6):473-80

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Thank you

Questions?

@DrWmPadula

#NPUAPregistry