Implementing Systems Change in Policy, Procedure and Documentation in 10 Days or Less

Tuesday, 13 July 2010: 3:45 PM

Holly Kirkland-Walsh, RN, FNP, MSN
Wound Care NP, University of California at Davis, Sacramento, CA

Learning Objective 1: The learner will be able to describe the Plan, Do, Study, Act cycle for implementing change.

Learning Objective 2: The learner will be able to identify ways to involve bedside nurses in implementing evidence based practice changes.

Accurately identifying and documenting pressure ulcers is a necessity given the new Joint Commission on Accreditation of Healthcare Organizations priority focus on pressure ulcers. This presentation will discuss the development of a Skin Wound Assessment-Treatment (SWA-T) Team, the processes involved in an institutional adoption of Braden Risk Assessment and associated nursing documentation for Electronic Medical Records (EMR). This 8 month planned change in policy and procedure involved over 30 nurses who were empowered to implement initiatives to improve patient care.  The results were startling. Two months before inception of the Braden, Intensive Care Units (ICU) were audited for compliance on whether this question had been answered on admission:  “Is this patient at risk for developing a pressure ulcer”? The results were 36% of RNs answered yes, 38% answered no, and 26% did not address this question. Ten days after the planned change occurred an audit throughout the hospital showed 98% compliance for completion of pressure ulcer assessment and documentation. Two months later this hospital maintains success with 96-98% compliance for completion of assessment of pressure ulcer risk on admission and every shift on every unit.
This presentation will guide the learner through the Plan, Do, Study, Act cycle for performance improvement and introduce multiple strategies for implementing a desired change in clinical practice. The Plan, Do, Study, Act cycle outlines steps needed to implement a program with success related to coordination of all components and continual assessment and revision. As each cycle was initiated, evaluation and goal adjustment occurred before the next cycle was implemented. Use of the plan, do, study, act model offers a method for changing processes of care delivery in a structured, sequential approach. (1)