1. Salcido, Richard MD, EdD

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This month's continuing education activity on "Improving Processes to Capture Present on Admissions-Pressure Ulcers" (page 566) is an opportune time to discuss quality improvement. The task of improving processes requires use of data input by gathering qualitative or quantitative intelligence about the problem to be solved or process to be improved. The data collected can be used for process improvement by observing and measuring and evaluating processes of wound care delivery through improvement in safety, cost, efficiency or better clinical outcomes and enhanced quality of life for the persons served. Many process improvement theories in the manufacturing world have been adopted and modified in healthcare, such as the use of "quality improvement bundles." In this context, the term bundling should not be confused with finance processes used to process payments for services provided. However, cost must be factored into any equation of quality measures.

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Quality Improvement Bundles

The Institute for Health Care Improvement (IHI) advanced the concept of a "quality improvement bundles."1 The IHI defines a "bundle" as a small set of evidence-based interventions for a defined patient segment or population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually.1


In collaboration with the IHI, the Ascension Health Care System developed a significant system-wide quality initiative to reduce the incidence of hospital-acquired pressure ulcers (PrUs).2 They instituted the concept of a quality improvement bundle, which they designated by the acronym SKIN (Surface, Keep turning Incontinence and Nutrition).2 In addition, they were required to document a skin assessment every 8 hours. The goal of the program was to reduce or eliminate facility-acquired PrUs. The authors reported that patients were free of Stages III and IV facility-acquired PrUs from August 2004 to February 2006, and the culture of the organization was such that the "SKIN Bundle" was deemed a practice across the 67 hospitals of Ascension Health.2 More recently, others have utilized the bundling concept with varying modifications. The "Penn Medicine Pressure Ulcer Collaborative"3 expanded the use of the bundle concept by adding to the SKIN Bundle as described by Gibbons et al2 by adding CARE as the suffix, to the aforementioned "SKIN" acronym2: Careful lifting (ceiling lifts), Assess risk and skin, Reduce head of bed 30 degrees or less, and Elevate heels. They also captured meaningful data through the use of electronic order sets and data specific to the workflow and processes involved in the quality improvement initiative. Wound photography was deemed part of the protocols, as well. The aggregated percent change for all 4 entities in the health system reduced hospital-acquired PrUs from fiscal year 2009, ending June 30, 2009, through the period ending April 30, 2011, was 37%.3


Collaboration with Quality Improvement Organizations

Quality Improvement Organizations (QIOs) are private, mostly not-for-profit, organizations that contract with the Centers for Medicare & Medicaid Services (CMS) as required by law. Staffed by experienced health professionals, QIOs are trained to review medical care and to help beneficiaries with issues related to the quality of the care they receive across the continuum.


The QIOs work under the auspices of CMS through quality improvement in specific areas,4 such as the following:


(1) serving as an ombudsman for beneficiaries and their families and ensuring their involvement in the process of improvement,


(2) using evidence-based "change packages" and other improvement tools to improve safety, efficacy, and patient-centered outcomes,


(3) working with hospitals and skilled nursing facilities to reduce PrUs,


(4) reducing central line and bloodstream infections,


(5) using electronic medical records to increase preventive screening services and immunizations, and


(6) reducing readmissions to hospitals within 30 days of discharge by 20% over 3 years by changing processes of care at every level including community healthcare.



These projects are deemed as "one more tool in the fight against poor, uncoordinated, and unsafe care in America's nursing homes, physician offices, hospitals, and other care settings."4


Richard "Sal" Salcido, MD, EdD

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1. Resar R, Griffin FA, Haraden C, Nolan TW. Using care bundles to improve health care quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. Last accessed October 21, 2013. [Context Link]


2. Gibbons W, Shanks HT, Kleinhelter P, Jones P. Eliminating facility-acquired pressure ulcers at Ascension Health. Jt Comm J Qual Patient Saf 2006; 32: 488-96. [Context Link]


3. Carson D, Emmons K, Falone W, Preston AM. Development of a pressure ulcer program across a university health system. J Nurs Care Qual 2012; 27: 20-7. [Context Link]


4. Centers for Medicare & Medicaid Services. Current work. Last accessed October 21, 2013. [Context Link]