NPUAP Mission The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research. npuap.org International Guideline NPUAP in collaboration with the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) has worked to develop a NEW pressure ulcer prevention and treatment Clinical Practice Guideline and a companion Quick Reference Guide. Purchase your copy today at www.npuap.org npuap.org 1
NPUAP Monograph Released in November 2012, the 254-page, 24 chapter monograph, Pressure Ulcers: Prevalence, Incidence and Implications for the Future was authored by 27 experts from NPUAP and invited authorities and edited by NPUAP Alumna Dr. Barbara Pieper. The monograph focuses on pressure ulcer rates from all clinical settings and populations; rates in special populations; a review of pressure ulcer prevention programs; and a discussion of the state of pressure ulcers in America over the last decade. Purchase the monograph today at www.npuap.org Hard Copy $75 E-version $49 Individual Chapters $19 npuap.org Save the date Reducing Pressure Ulcers from Medical Devices Dr. Peggy Kalowes, RN PhD CNS FAHA Dr. Joyce M. Black, PhD RN npuap.org 2
Save the date npuap.org 25 29 September www.wuwhs2016.com 3
Quality Improvement Frameworks to Implement Evidence-based Practices for Pressure Ulcer Prevention William Padula, PhD, MS University of Chicago May 12, 2015 The Donabedian Model Structure Outcomes Process The secret of quality is love. -Avedis Donabedian Donabedian, JAMA 1988 4
Hazards of Hospitalization in the Elderly Creditor, Ann Intern Med 1993 Framework of Implementation and Dissemination Gonzalez et al (2012). A Framework for Training Health Professionals in Implementation and Dissemination Science, Academic Med. 5
Evidence-based Practices (EBPs) for Pressure Ulcer Prevention a. Risk-assessment with Braden Scale b. Patient repositioning c. Managing moisture and incontinence d. Monitoring nutrition e. Modern support surfaces (beds, overlays) f. Continual nursing education about EBPs It s a Checklist Braden, Res Nurs Hlth 1994; Ratliff, NPUAP 2004 Economic Burden Berwick: Eliminating Waste in U.S. Health Care $36-45 Billion spent on failures of care delivery Financial Impact of Pressure Ulcers Most costly hospitalacquired condition Treatment: $500-130,000 Malpractice settlements: $Millions $11 billion/year in U.S. Direct Indirect Pressure Ulcers represent 0.3% of all healthcare Berwick, JAMA 2012; Kuhn, Nurs Econ, 1992; Padula, Med Care 2011 6
Markov Model Discharge No Complication Main comparators Do-Nothing: Inconsistent EBPs implementation Prevention with EBPs Standard Care Prevention M Inpatient Deep Tissue Injury Pressure Ulcer Stage I/II Pressure Ulcer Stage III/IV Nurse & Monitor Acute & Chronic Care Death Evidence-based practices for pressure ulcer prevention are cost-effective Invest $55/patient/day in EBPs Cost-saving Surgery *If practiced consistently* Stakeholders of QI Government National Institutes of Health (NIH) Agency for Healthcare Research and Quality (AHRQ) Dept Health and Human Services (HHS) Payers Centers for Medicare and Medicaid Services (CMS) Commercial Payers Advocacy Institute of Medicine (IOM) Institute for Healthcare Improvement (IHI) The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 7
IOM Reports To Err is Human Human error is a natural occurrence and can lead to adverse events However, systematic flaws within the healthcare environment are what lead to medical error Systematic Improvement could reduce likelihood of compound human error that exposes patients to harm First, Do No Harm IOM Reports Evidence-based directives Failure to employ indicated tests Error in performance of operation, procedure or test Inadequate monitoring of follow-up of preventive treatments other system failures Motivate health care stakeholders 8
IOM Reports Crossing the Quality Chasm Calls for complete system redesign of U.S. Health Care Concept that medical errors cannot be patched up with straightforward recommendations Adjusting not only how EBPs reach the patient, but how clinical teams reorganize to ensure that EBPs are implemented consistently [without harmful variation] Fallout of IOM Reports Create Center for Patient Safety within AHRQ A national system of mandatory and voluntary reporting of medical error within hospitals to create provider transparency Regulators need to raise standards FDA The Joint Commission Healthcare organizations should create safety systems of safe, evidence-based practices 9
IHI Campaigns 100,000 Lives Encourage hospital adoption of preset goals preset timeframe Garner a personal [hospital] sense of responsibility towards improving quality and patient safety Prevention of several hospital-acquired conditions (HACs) Surgical Site Infections (SSIs) Central Line Infections (CLABSI) Adverse Drug Events (ADEs) IHI Campaigns Continue mission of 100,000 Lives Add 5 more preventable conditions CAUTI, pressure ulcers, falls, etc. An effort to move past EBPs and into patient-centered care (PCC) to improve prevention Over 4,000 hospitals adopted this QI campaign HACs dropped as much as 72% 10
Issue with EBP -> PCC in 2006 Providers, especially nurses at the interface of change, not adhering to EBPs 64% of nurses read 1 or more specialty journals 53% read a nursing journal 20% did not read any professional journals 0% read a journal dedicated to publication of original research The Joint Commission The regulatory body of hospital quality and performance Accredit payer reimbursements (e.g. CMS) Mandate adherence to EBPs Errors and preventable harms that occur are recorded and noted and associated to EBP implementation failures Misreporting quality/performance measures can jeorpardize accreditation 11
CMS Largest single-payer in the U.S. 46 million Medicare beneficiaries 50 million Medicaid eligible Powerful stance on reimbursement policy Has used reimbursement to influence QI Nonpayment for harms Pay for performance Monitors quality/performance measures of health systems to deduct reimbursements CMS Nonpayment Policy Spring, 2007: CMS announces nonpayment policy for hospital-acquired conditions October, 2008: Implementation of nonpayment policy for hospital-acquired conditions Present: Hospitals absorb costs for all hospitalacquired conditions e.g. Pressure Ulcers; Falls; Ventilator-associated Pneumonia; Catheter-associated UTI; Surgical-site Infections; MRSA; Central-line Infections; etc. 2 Theoretical redistribution of estimated $40+ billion per year 3 12
CMS Policy Updates: P4P 1% payment reduction to hospitals ranking in the lowest quartile of HAC prevention HAC including: PSI-03 Pressure Ulcer; PSI-06 Iatrogenic Pneumothorax; PSI-07 CLABSI; PSI-08 Hip Fracture; PSI-12 Pulmonary embolism and DVT; PSI-13 Sepsis; PSI-14 Wound Dehiscence: PSI- 15 Accidental puncture/laceration Affects all hospitals reimbursed through the inpatient prospective payment system (IPPS) Timeline of Culture of Improving Quality 7% (Whittingon, 2004) $10,000 $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 4.6% $0 (Bergquist- Beringer, 2009) $5436 4.5% $6721 $1285 $8905 $3469 2-3% (Padula, 2013) AMI (Lyder, AMI 2012) + UTI AMI + Urosepsis Reimbursement for AMI at University of Significant Reductions Colorado in Hospital, Pressure 2007 Ulcer Incidence since mid-2000s (Stotts, 2013) Wald, JAMA 2007? Goal is 0% (The Joint Commission) 13
Health care has developed EBPs for many patient safety issues UHC Hospital Rates of HAPUs AHRQ PSI-3 CMS Policy Interruption Padula, Jt Comm J Qual Pat Saf 2015 14
Pressure Ulcer Prevention Protocol Quality Improvement Definition The combined and unceasing efforts of everyone health care professionals, patients and their families, planners, administrators, educators to make changes that lead to better patient outcomes, better systematic performance, and better professional services. -Quality by Design 15
Key Terms in QI Evidence-based Practices vs. Quality Improvement Evidence-based Practices Must be implemented in order to achieve better outcomes Guidelines that should be followed Quality Improvement Tools designed to increase effective implementation of EBPs A theoretical framework of tools and resources Lead to systematic change for improved adherence to evidence-based practice Implement vs. Adopt Implement = evidence-based practices Institutionalized by CMS and The Joint Commission Measured quality indicators Adopt = quality improvement interventions Establishing a culture of better care Up to individual practitioners to develop QI Best-practice Framework 16
QI Adoption in 53 UHC Hospitals Overall Between domains Trends in Scope of QI strategies (N=55) Proportion of Hospitals 1 0.8 0.6 0.4 0.2 0 1 6 11 16 21 Quarter (January, 2007 - June, 2012) Hospitals with 0 domains Hospitals with 1 domain Hospitals with 2 domains Hospitals with 3 domains Hospitals with 4 domains Padula, Wordviews Evid Based Nurs (In Press) Longitudinal Data Analysis Effect Size Analysis Changes in HAPU rates associated with QI adoption Unadjusted comparison of clinically meaningful QI interventions according to CMS reduction threshold: 1 HAPU case per 1,000 Mixed-effects Poisson Regression Counts of HAPU rates over time, nested in Hospitals Random intercept Random effect: CMS nonpayment policy Adjusted comparison of statistically significant QI interventions Outcome Measures: Associations between QI interventions and HAPU counts Empirical Bayes estimates of hospital-level rates Padula, BMJ Qual Saf 2012 17
Unadjusted Effect Size Analysis Padula, Jt Comm J Qual Pat Saf 2015 Combinations of QI Interventions Leadership Visual Tools HAPU Skin Care Nutrition QI Intervention Initiatives Staging Leadership Initiatives x x x x x Visual Tools 0.0011 x x x x HAPU Staging 0.0013 0.0011 x x x Skin Care 0.0013 0.0012 0.0014 x x Nutrition 0.0013 0.0012 0.0012 0.0013 x BOLDED effect sizes indicate statistical significance at the 95% confidence-level. HAPU indicates Hospital-acquired Pressure Ulcer; QI, Quality Improvement. 18
Unadjusted Effect Size Analysis 5 QI interventions found to have clinically meaningful impact on prevention Leadership Initiatives to present data in clinics Visual Tools (e.g. checklists, posters) Updates to HAPU staging protocol Use of new skin care products or creams Emphasis on patient nutrition Padula, Jt Comm J Qual Pat Saf 2015 Mixed-effects Poisson Regression Adjusting for QI interventions Poisson[E(Y ij )] = (β 0 + u i0 ) + β 1 quarter j + β 2 QI ij + (β 3 + u i1 ) policy j + + Ζ ij Relative treatment effects of effective QI interventions over time Poisson[E(Y ij )] = (β 0 + u i0 ) + β 1 quarter j + β 2 QI ij + (β 3 + u i1 ) policy j + + β 5 quarter j QI ij + β 6 policy j QI ij + Ζ ij Hedeker & Gibbons, Longitudinal Data Analysis 2006 19
ME Results all QI interventions Padula, Hospital Med 2015 ME Results - Updates to EBPs Mixed-effects Poisson Regression Model Hospital-level empirical Bayes estimates EBP Updates associated with 1 HAPU case Reduction per Year = $130,000 Padula, Hospital Med 2015 20
Limitations Fair response rate (30.5%; 55 / 180 hospitals) Reporting bias from survey responses Recall bias for QI interventions dating back 4-5 years Difficult to imply all HAPU outcomes on adoption of QI interventions Results of QI adoption are co-linear to CMS policy Conclusions Hospital Implications Updates to EBPs leads to improve patient outcomes Identifies the best QI interventions to explore for HAPU prevention Effective QI strategy to bundle with EBPs: Leadership: Leadership Initiatives P&I: Visual Tools; HAPU Staging; Nutrition; Skin Care CMS nonpayment policy provided incentive for hospitals to prevent HAPUs Model framework for CER of QI and HACs Utilize the best-practice framework: Leadership, Staff, IT, Perform & Improve Reapply to other areas: Falls; CAUTI; Pain management; C. Difficile 21
Final Thoughts Every system is perfectly designed to get the results it gets. Paul Batalden, MD Co-founder of IHI Any indication of a forced concept or practice upon clinicians receives pushback Peter Pronovost, MD, PhD Director of Armstrong Inst. CEU Information To earn the 1.0 continuing education credit from today s webinar please visit the link below. This information will also be emailed out to participants at the conclusion of the webinar. https://www.blueqsurveys.creighton.edu/se.ashx?s=46beee7f640f 6849 npuap.org 22