The best practices of quality improvement (QI) used by high-performing clinical units has been advocated as a critical element for centers of clinical excellence in wound care.1,2 Nelson and colleagues3 describe a framework that includes a variety of QI interventions organized around 4 best practice categories: (1) leadership; (2) staff; (3) information technology (IT); and (4) performance and improvement. These QI interventions are meant to alter established processes of health care delivery in order to implement evidence-based practices (EBPs) more effectively.3,4 The result of this framework of change is improvements in measures of quality and performance and reductions in patient harm in many areas.
Padula and colleagues2 developed this best practice QI framework using pressure injury prevention (PIP) programs in acute care. The interventions are meant to be adopted and enhanced by a skin care team in a hospital with support from administration and complementary providers. Many of the QI interventions presented initially by Nelson and colleagues3 required little modification since concepts such as daily staff huddles or data tracking are commonly understood heuristics. However, the best practice framework of QI interventions for PIP, which defines leadership roles among hospital administrators and nursing providers, may not be as well understood. In order for a clinical microsystem (unit or ward) to achieve changes in the process that improve the implementation of EBPs, collaborative leadership roles are required of administrators and staff. Practice change is influenced by nurses and providers understanding and embracing evidence to support a culture supporting evidence-based PIP practice.5 We believe that both formal and informal leadership styles are necessary to effectively translate EBPs into increased performance, and the differences in these styles create an important synergy for QI.
LEADERSHIP TYPOLOGY
Skin teams form around formal leadership.6 Generally, a hospital administrator (eg, chief nursing officer, director of quality) recognizes a problem that is impacting the facility in terms of cost or hospital performance, such as higher than anticipated or desired pressure injury occurrences, resulting in formation of a skin team. Administrators typically appoint an expert in wound care as a formal team leader, such as a certified WOC nurse, with experience, energy, and motivation to act in a leadership role. This appointment creates a duality in formal leadership, whereby the clinical expertise lies within the certified WOC nurse team leader while resource allocation remains under the control of hospital administration.
As the certified WOC nurse takes charge of translating evidence-based PIP interventions within the acute care setting, she or he becomes a hospital "champion." As champions, their formal leadership role is confirmed by staff nurses and providers requesting consultation related to pressure injury management or prevention. This role is associated with multiple challenges, including disseminating knowledge about PIP across the heterogeneous mix of cultures within any acute care facility.
The process of dissemination and translation of evidence into practice for these champions requires partnership and perspective. As formal leader of the skin care team, the certified WOC nurse has an opportunity to make influential decisions about what types of IT and performance and improvement QI interventions staff nurses could use to improve PIP. This influence is based on their recognized experience and empowerment from hospital administration. However, a champion's success remains dependent upon his or her ability to easily integrate QI interventions within the unique cultures of each unit that frequently require applications or adjustments of a facility-wide PIP program.
To gain perspective on changing and improving practice, the certified WOC nurse team leader and unit-based champions must partner with frontline nurses on each unit to create a skin team. Staff nurses who are self-motivated and interested in PIP and QI are most likely to step forward and offer their perspectives on the functionality of their unit culture, thus becoming informal leaders.7 Skin care team champions count on these informal leaders to help innovate sustainable QI programs for PIP within their individual units. They work frequently within the domain of staff QI interventions alongside certified WOC nurse champions and team leaders and occasionally interact with hospital administrators to receive resources for the expansion of a unit-based QI program.
The Padula and colleagues8 analysis of the best practice framework in US academic medical centers showed that most PIP QI interventions began with leadership at the level of hospital administration (Figure 1). A survey of certified WOC nurses indicated that the greatest factor influencing PIP is financial pressures felt by administration, followed by availability of nurse specialists who can act as champions to a cause.9 The eventual adoption of QI interventions to improve performance at later times indicated successful teamwork to effectively reduce pressure injury incidence occurrences.10
PRACTICE APPLICATION
The hierarchy of the hospital naturally forms levels of formal and informal leaders who continually strive to improve the quality of care with respect to PIP (Table 1). Hospital administrators formally communicate their support to a skin champion, usually a certified WOC nurse, who then takes on the role of devising QI programs to meet the needs of each unit. Under this person's leadership, first-line unit staff evolve into informal leaders as they communicate the needs of their units to the champion topic expert and they implant the facility's QI programs within their unit in order to promote effective translation of current EBPs to their colleagues. We advocate using the framework for QI proposed by Nelson and colleagues3 in order to maximize the formal and informal leadership team comprising hospital administration, a certified WOC nurse champion leader, and informal staff leaders who ultimately translate PIP into the daily care of patients.
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