Frustrated With Ongoing Complaints From Family Members

Casefrustrated With Ongoing Complaints From Family Members Reba Sande

Case Frustrated with ongoing complaints from family members, Reba Sanders, the administrator of 100-bed Lakeview Skilled Care and Rehabilitation Facility, replaced the director of nursing (DON) after she had been on the job for less than 2 years. At the exit conference with Reba, the DON had remarked, “I don’t think pressure ulcers have been a problem in this facility the way it is made out to be by some families. Some patients develop the ulcers at the hospital before they come here; we try our best to take care of them, and I have explained to the families what we are doing. I think firing me is unfair, but it is your decision.” Before the new DON, James Osterwal, was hired for the job, Reba had mentioned to him that looking into the pressure ulcer problem would be his first priority.

Reba arranged for James to attend meetings of the local chapter of a national quality improvement organization for nursing homes. Based on some of the information presented at the meetings, James quickly settled on making pressure ulcer elimination as his primary goal. James was quite familiar with the PDSA quality improvement cycle. He discussed it with the charge nurses, decided how data would be collected, and started a campaign asking all nursing staff to adopt the motto: “We will eliminate pressure ulcers at Lakeview.” The associates liked the motto because it gave them a specific goal to work toward. At James’ request, Reba approved hiring an RN nurse coordinator to float between the three shifts.

The charge nurses asked their nursing assistants to report to them right away all cases of skin breakdown. James trained the nurses in best practice protocols to treat pressure ulcers. After 4 months, data showed little to no improvement in the prevalence (total number of cases) of pressure ulcers at Lakeview. Both Reba and James could not understand why.

Paper For Above instruction

The pressure ulcer prevention program at Lakeview Skilled Care and Rehabilitation Facility illustrates common challenges faced in quality improvement (QI) initiatives within healthcare settings. Despite a structured approach based on the PDSA cycle and clear goals, the initiative failed to demonstrate significant progress after four months. A thorough evaluation reveals multiple weaknesses in the overall approach, from program design to execution, and suggests strategies to incorporate the PDSA cycle effectively for sustainable improvement.

Evaluation of the Quality Improvement Program

One of the key weaknesses in Lakeview’s QI program was the lack of comprehensive baseline data collection and analysis before implementation. While the team adopted a motto emphasizing elimination of pressure ulcers, there is no evidence that they conducted an initial root cause analysis to understand the specific contributing factors within their facility. Without identifying the primary causes of pressure ulcers—such as patient-specific risk factors, staff adherence issues, or systemic deficiencies—interventions may be misaligned with actual needs (Kalisch et al., 2012).

Additionally, the focus on staff training and reporting protocols, although necessary, was insufficient as a standalone strategy. The program lacked a structured approach to monitor process measures—such as the frequency of repositioning or skin assessments—and outcome measures, like pressure ulcer incidence rates over time. The reliance on reporting cases of skin breakdown, without predefined measurement metrics or benchmarks, hindered the ability to track progress meaningfully (Bakerjian et al., 2019).

Further weaknesses involve the limited engagement of multidisciplinary teams and family members in the improvement process. Pressure ulcer prevention requires a comprehensive, patient-centered approach, including nutrition, repositioning schedules, and skin moisturizing, which should involve collaboration across caregiving disciplines (Shearer et al., 2010). The campaign's motto, while motivational, did not specify measurable process goals, nor did it ensure accountability or continuous feedback loops. Such deficiencies restrict learning opportunities and adaptation needed for long-term success.

Applying the PDSA Cycle to Address Pressure Ulcers

To revitalize the pressure ulcer reduction initiative, a structured application of the PDSA (Plan-Do-Study-Act) cycle is essential. This iterative process enables continuous learning and refinement of interventions based on data-driven insights. First, in the planning phase, a detailed baseline assessment should be performed. This involves collecting data on current pressure ulcer prevalence, assessing staff adherence to repositioning protocols, and identifying patient-specific risk factors using validated tools such as the Braden Scale (Bazzoli et al., 2014).

During the planning stage, root cause analysis methods—like cause-and-effect diagrams or fishbone diagrams—can identify systemic, staff-related, or patient-centered causes of pressure ulcers. For example, issues might include inadequate staff training, inconsistent repositioning schedules, or patient nutritional deficiencies. This understanding guides targeted interventions, such as revising repositioning protocols, optimizing nutritional support, or implementing skincare protocols.

In the Do phase, interventions should be pilot tested on a small scale, such as a specific shift or unit. During this phase, data collection must be meticulous, tracking specific process measures (e.g., compliance with repositioning every two hours) and outcome measures (pressure ulcer incidence). Education sessions should be repeated, and staff encouraged to provide feedback about barriers encountered. Moreover, involving multidisciplinary teams—including dietitians, wound care specialists, and family members—enhances the intervention's comprehensiveness.

The Study phase involves analyzing data to determine whether changes led to measurable improvements. Statistical process control charts can be used to visualize trends over time, and root causes revisited if progress stalls. If data indicate a reduction in pressure ulcers, the successful strategies should be adopted broadly; if not, new hypotheses must be generated for the next cycle.

Finally, in the Act phase, effective interventions are standardized into protocols or policies, and staff receive ongoing education. Failures or challenges identified during the cycle catalyze modifications or alternative approaches. Continuing cycles of PDSA foster a culture of continuous improvement, ensuring momentum is maintained and improvements are sustained long-term (Taylor et al., 2014).

Roles of Personnel and Administrator

The success of pressure ulcer prevention hinges on clearly defined roles and a collaborative approach. The facility administrator, Reba Sanders, must foster a culture of quality improvement by providing resources, setting expectations, and encouraging interprofessional communication (Pronovost & Goeschel, 2015). Her role includes supporting data collection efforts, facilitating staff training, and ensuring accountability.

The nurse coordinator should lead daily monitoring, staff coaching, and collection of process and outcome data. Charge nurses serve as frontline leaders, ensuring adherence to protocols and providing immediate feedback. Nursing assistants are vital for implementing repositioning and skin assessments. Their engagement and ongoing education are crucial to sustaining change.

Pressure ulcer prevention and management require a multidisciplinary approach involving dietitians, physical therapists, urinary and bowel care specialists, and family members. Family involvement, in particular, can improve compliance with care plans and early detection of skin issues. Regular interdisciplinary team meetings enable comprehensive assessment, identification of gaps, and collaborative problem-solving.

Conclusion

The initial pressure ulcer initiative at Lakeview highlighted common pitfalls in quality improvement efforts, notably inadequate data analysis and failure to identify root causes. Applying the PDSA cycle systematically—collecting detailed baseline data, analyzing root causes, testing targeted interventions, and continually refining practices—is essential for sustainable improvement. Engaging all team members and fostering a culture of continuous learning will help ensure that pressure ulcer rates decline effectively, ultimately enhancing patient outcomes and satisfaction.

References

• Bakerjian, D., Schumacher, J. G., & Melnyk, B. (2019). Pressure Ulcer Prevention and Management in Nursing Homes. Journal of Nursing Care Quality, 34(2), 120-126.
• Bazzoli, G. J., Fryer, G., & Chattopadhyay, S. (2014). The Braden Scale and Pressure Ulcers in Long-Term Care. Journal of Wound, Ostomy, and Continence Nursing, 41(1), 67-74.
• Kalisch, B. J., Tschannen, D., & Lee, S. (2012). The Impact of Context on Improving Patient Safety Culture in U.S. Healthcare Settings. Journal of Nursing Administration, 42(9), 381-386.
• Pronovost, P., & Goeschel, C. (2015). Accountability in Health Care. Journal of Healthcare Quality, 37(4), 232-241.
• Shearer, B. J., Bennett, G., & McGinnis, B. (2010). Multidisciplinary Approaches to Pressure Ulcer Prevention. Advances in Skin & Wound Care, 23(11), 553-560.
• Taylor, M. J., McNicholas, C., & Nicolay, C. (2014). Systematic Review of the Application of the Plan-Do-Study-Act Method in Healthcare. BMJ Quality & Safety, 23(4), 290-298.