An ambitious collaborative led by the New Jersey Hospital Association achieved a 70 percent reduction in the incidence of pressure ulcers among participants in two years.

       Editor’s note: This is the eighth in a series of articles related to topics presented at the 2007 Symposium on Regulatory Issues for Management in Long-Term Care (SORIM LTC). For more information, visit www.SORIMLTC.com.

I

t is a problem that cuts across the healthcare continuum, adding more than one billion dollars in annual costs to the nation’s healthcare system. It costs millions more in legal claims paid. But perhaps the biggest cost is the human one—the immeasurable toll in pain, reduced quality of life and, in extreme cases, deaths.
       The problem is pressure ulcers, and New Jersey had an untenably stubborn prevalence rate in fall 2004. According to the Centers for Medicare & Medicaid Services (CMS) Nursing Home Quality Initiative, its facilities have consistently held a pressure ulcer prevalence rate of 18% for individuals at high risk, which is nearly five points higher than the national average.
       That statistic combined with mounting state and national focus on pressure ulcers was the impetus for the New Jersey Hospital Association (NJHA) Collaborative to Reduce the Incidence of Pressure Ulcers, an ambitious effort by NJHA’s Quality Institute and Department of Continuing Care Services to tackle the pressure ulcer problem across the continuum of care.

Case Study 1

This broad partnership brought together state health officials; New Jersey’s quality improvement organization (QIO); and trade associations representing acute care and specialty hospitals and long-term care, assisted living, home health, and hospice agencies. Most importantly, the initiative engaged more than 150 acute care hospitals, nursing facilities, home health agencies, rehabilitation hospitals, long-term acute care hospitals, assisted living facilities, and hospice programs in a collaborative model to share, learn, and improve. As the two-year initiative officially concluded in July 2007, the results were impressive, with an overall decline of 70% in the incidence of pressure ulcers among participants and strong achievement in process indicators (eg, timely standardized skin assessments and timely preventive interventions).

The Motivation for Change

       NJHA’s Quality Institute has had previous success with the collaborative model, including an effort from 2004 to 2006 that targeted quality of care in hospital intensive care units. That initiative resulted in a 73% reduction in bloodstream infections and a 55% reduction in ventilator-associated pneumonia. Beyond New Jersey’s troublesome data in the Nursing Home Quality Initiative, many factors turned the Quality Institute’s attention to pressure ulcers, including:
• Research that showed the national costs associated with care of pressure ulcers exceeds $1.335 billion annually, with $355 million spent in long-term care settings¹
• Additional research that revealed the grave legal ramifications of pressure ulcers; one study showed that 21% of cases involving pressure ulcers result in a payout of $500,000 or more²
• Implementation of the Federal Tag 314 (F314) guidance from CMS used to assess the prevention efforts of skilled nursing facilities (SNFs)
• New Jersey’s enactment of the Patient Safety Act, which requires reporting of nosocomial stage 3 and 4 pressure ulcers to the state Department of Health and Senior Services, initially for hospitals and soon for all providers.
       And, of course, there was the best motivation of all: it is the right thing to do.
       The 2001 report Crossing the Quality Chasm from the Institute of Medicine called for greater integration of healthcare delivery systems across settings to improve care. Still, SNFs and acute care hospitals routinely pointed at one another as the culprit. It became clear to NJHA staff members that the time had come for a new approach to an age-old problem.
       NJHA established an advisory panel that included the state Department of Health and Senior Services; Healthcare Quality Strategies, Inc. (New Jersey’s QIO); the Health Care Association of New Jersey (representing long-term care and assisted living); the Home Care Association of New Jersey; and the New Jersey Association of Homes and Services for the Aging. The challenge posed to them: How could New Jersey undertake a statewide quality initiative that would bring together providers across the care continuum to tackle the prevention of pressure ulcers, especially in patients who move between levels of care?
       The group discussed a number of potential hurdles, especially the financial commitment and cost of participation that would be expected of participating facilities. New Jersey providers were already operating on thin margins. Half of the state’s hospitals are in the red, and long-term care facilities in New Jersey lose an average of $17 daily for each Medicaid patient, for a total annual loss of $200 million statewide.
       But despite the barriers—and with equal parts of enthusiasm and healthy skepticism—the advisory panel gave a green light to the collaborative.

A Collaborative Model for Improvement

       It is important to first clarify what a breakthrough collaborative is not. It is not research for new knowledge, a single-setting focus, or a small change to existing systems. NJHA’s model, based on the Institute for Healthcare Improvement’s work, is built upon three main planks:
• Create a culture of safety
• Standardize what is done, when it is done (with independent checks for key processes)
• Measure and evaluate defects.
       The model stresses measurement as well as an improvement method that relies on “spread” and adaptation of existing knowledge to multiple settings to accomplish a common goal.
       Some of the key elements to breakthrough improvement are the will to change, the ideas on which to design a new system, and execution of the ideas. When team members began their work, they were guided by three key questions:
• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in improvement?
       NJHA and its advisory panel also discussed the culture it hoped to create in its collaborative. The consensus was to keep it action-oriented, encourage an atmosphere of “all teach, all learn,” and create a sense of family and support.
       The group also felt strongly that the chairperson needed to be a nationally recognized figure with strong clinical expertise. The collaborative found the right leader in Elizabeth Ayello, PhD, RN, APRN, BC, CWOCN, FAPWCA, FAAN, a senior adviser at The John A. Hartford Institute for Geriatric Nursing at New York University, who agreed to chair the collaborative in February 2005.
       There were also practical matters to consider—namely, finances. NJHA developed a year-one budget of $188,000. Sage Products, Inc., and 3M signed on as sponsors. The New Jersey Department of Health and Senior Services agreed to sponsor nursing facilities’ participation by dedicating civil monetary penalty funds for any SNF that completed all of the collaborative’s requirements.
       The all-inclusive participation fee was $5,000 for acute care hospitals and $1,000 for all other providers. This fee covered all learning sessions, materials, conference calls, an e-mail listserv, an exclusive collaborative website, and technical support from NJHA staff for one year.

Putting the Model Into Practice

       A long list of tasks preceded the Collaborative’s official launch. We needed to define the expectations of both the sponsoring organization (NJHA) and the participants. We needed to clearly state our mission and goals, establish processes and timetables, prepare resources, and develop a process for baseline data collection.
       As a sponsor, NJHA was expected to provide education on the latest and best subject matter and research as well as the tools and interventions for process improvement. NJHA also was responsible for coaching

Case Study 2

participating teams, gathering data, assessing progress monthly, and providing feedback. Participants, meanwhile, were expected to align the Collaborative’s goals within their own organizations, provide a senior leader and team members, provide the resources the team needed to be successful, perform tests of change for process improvements, communicate regularly with partners in other healthcare settings, and share information during the Collaborative’s learning sessions.
       And what, precisely, were those goals?
• Reduce the incidence of pressure ulcers by 25%
• Achieve 95% adherence to three components of the pressure ulcer prevention bundle
• Improve communication, collaboration, and teamwork between professionals across multiple settings to improve hand-offs and transitions
• Demonstrate an improved culture of safety.
       Working with its advisory panel, NJHA developed a bundle of preventive practices, which included evidence-based protocols and practices that have been tried and tested. The philosophy is that if one of these practices is proven effective, then grouping a number together will work even better. By applying the bundle to all patients and residents, the same high-quality care is delivered to all, no matter the caregiver or the setting. The Pressure Ulcer Collaborative bundle included:
• Completing a head-to-toe skin assessment within eight hours of admission
• Assessing risk factors, using the Braden Scale, within eight hours of admission and reassessing weekly in long-term care (every 24 hours for at-risk patients and every 24 hours in acute care)
• Instituting appropriate prevention techniques for those determined to be “at risk” (ie, a score of 18 or lower on the Braden Scale), including the use of pressure redistribution surfaces.
       Many tools and resources were identified to support the effort, including a pressure ulcer prediction, prevention, and treatment pathway; a treatment product categories table; a turning and repositioning tool; baseline data elements and tools; and senior leadership reports for monthly submission.

Ready to Launch

       With the organizational structure, faculty members, and resources in place, NJHA distributed invitations to all New Jersey healthcare facilities in June 2005, urging them to join this unprecedented effort. The invitees included 83 acute care hospitals, 20 rehabilitation hospitals, six long-term acute care hospitals, 50 home health agencies, 365 SNFs, and 130 assisted living residences. New Jersey’s QIO and the state’s Department of Health and Senior Services endorsed the effort and encouraged providers to participate.
       The first of several two-day learning sessions was held in September 2005, with 122 organizations on board. They included 43 acute care hospitals, three rehabilitation hospitals, 59 SNFs, 11 home health agencies, three continuing care retirement communities, two assisted living residences, and one hospice. The participants formed regional teams that spanned the continuum. That first learning session began with the participants completing two aim statements—one for their individual facility and one for their partnership. We launched this endeavor with a specific question that launched two years of work: “What will you do by next Tuesday?” We also introduced a knowledge survey that became a staple at each of our learning sessions to determine baseline knowledge and improvement over time. The learning sessions were designed for networking, breaking down barriers, working together as a team, sharing ideas, and discussing successes.
       The learning sessions, held three times a year, were supplemented by monthly conference calls highlighting specific topics. These calls included Barbara Braden, PhD, RN, FAAN, offering an in-depth look at the risk assessment scale she developed; Michele Elkins, MD, PhD, CMD, discussing end-of-life care and pressure ulcers; and an introduction to New Jersey’s Patient Safety Act and reporting rules by Lisa Mazzia, MD. Other resources included a password-protected website, an online listserv, and a tool kit with staff buttons, posters, and a patient/family education pamphlet.

Year-One Impressions

       At its launch, the Collaborative encountered some skepticism and, to some degree, resistance. After all, these were professionals committed to providing quality care, and they were being asked to acknowledge their shortcomings and change their culture and processes. But by the end of the project’s first year, camaraderie, education, and evidence-based results prevailed.
       Many participants said the collaborative provided them their first opportunity to work together with other providers to improve coordination of care and implement best practices. The technical support and encouragement to pursue partnerships across care settings helped break down barriers. Increased knowledge about pressure ulcers translated into improved practice, and the best-practice bundle resulted in reduced prevalence.
       Year-one participants also recommended improvements for the Collaborative as it moved forward. They noted that emergency department and operating room nurses needed to be included in the effort. They also identified a need for a consistent, uniform set of data that would travel with the patient between settings. That need is now being addressed with the state’s pilot test of a standardized patient transfer form.
*       With much progress behind them but additional work to be done, participants agreed to continue into a second year. All charter members were invited to return with a reduced registration fee, and non-participants were invited to join for year two. All told, two-thirds of the original participants re-upped for the second year; another 29 new organizations joined the effort. In addition, another corporate sponsor, HEALTHPOINT Ltd., came on board for the second year.

Year-Two Success

       The momentum for change carried the Collaborative into its second year. It continued its focus on assessment and prevention with an added emphasis on treatment, spreading the work to other areas, and sustaining change in practice. The two-day sharing-and-learning sessions continued, and conference calls addressed issues such as bariatrics, documentation, critical care, and infections. The knowledge scores compiled from a questionnaire at the start of each learning session approached the 100% mark. Participants also showed strong compliance with the process measures from the prevention bundle, averaging in the mid-90s.
       But the most dramatic result was the overall decline in the incidence of new pressure ulcers. The overall incidence rate for all settings was 18% at the launch of the Collaborative in September 2005. At its conclusion in July 2007, that number had declined to 5%. That 70% decline significantly surpassed the goal of 25%, and 48 of the participating organizations reported no new pressure ulcers in a period of three months or longer.
       Those accomplishments were celebrated in July as the Collaborative members gathered for a final learning session and recognition ceremony. Faculty members Elizabeth Ayello, PhD, RN, APRN, BC, FAAN, and Dr. Karen Zulkowski, DNS, RN, CWS, joined NJHA staff and hundreds of participants to celebrate the profound impact their work has had for the patients and residents of New Jersey’s healthcare facilities.
       As Dr. Ayello succinctly expressed: “We dared to envision a world that may not have pressure ulcers. After hearing your data, I think we can tell the naysayers that it is possible.”