Cross-Setting Pressure Ulcer Measurement & Quality Improvement
Development of a Cross-Setting Quality Measure for Pressure Ulcers
In accordance with the Centers for Medicare & Medicaid Services’ (CMS) priority to “align and harmonize” quality measures across quality reporting programs, RTI International (RTI) studied the feasibility of, challenges in, and opportunities for developing a cross-setting pressure ulcer quality measure. Specifically, RTI examined whether the quality measure Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (short-stay) (National Quality Forum [NQF] #0678) could be harmonized for implementation and use across health care settings. The focus of this work was to evaluate the strengths and weaknesses of this measure, identify future areas for measure refinement and development, and understand the potential implications of expanding this measure into additional health care settings
RTI conducted information gathering and measure evaluation activities between October 1, 2012 and March 2014. RTI compiled the following materials with key findings from these activities and recommendations for exploring next steps for the quality measure.
The following is a summary materials and artifacts related to the Development of a Cross Setting Quality Measure for Pressure Ulcers that are available in Downloads section at the end of this webpage:
- Presentation: Development of a Cross-Setting Quality Measure for Pressure Ulcers: This file includes a summary of the purpose, national context, goals, activities, accomplishments (as of March 2014), and findings of RTI and CMS’ effort to develop a cross-setting quality measure for pressure ulcers.
- Development of a Cross-Setting Quality Measure for Pressure Ulcers: Information Gathering Final Report:
This file includes the following:
- A review of pressure ulcer related quality measures identified through a search of the NQF website and the Agency for Healthcare Research and Quality’s National Quality Measures Clearinghouse, including the identification of measurement trends and support for the decision to focus efforts on NQF #0678.
- A review of feedback and analysis received regarding NQF #0678 (including technical advisor and provider interviews conducted by RTI, Technical Expert Panel (TEP) proceedings, feedback obtained from the NQF, public comments received during federal rulemaking, and technical assistance questions received in each of the three relevant health care settings [Long-Term Care Hospitals, Inpatient Rehabilitation Facilities, and Nursing Homes/Skilled Nursing Facilities]).
- Findings from both a literature scan and a series of key informant interviews RTI conducted to identify successful pressure ulcer prevention and management practices.
- A summary of the findings from the cross-setting pressure ulcer TEP meeting hosted by RTI on June 13, 2013.
- Recommendations for next steps for in the development of NQF #0678
- Table of Feedback Received from All Sources Regarding NQF #0678: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (short-stay): This file includes a compilation of the concerns and recommendations most frequently raised by stakeholders and experts regarding NQF #0678.
- Development of a Cross-Setting Pressure Ulcer Quality Measure: Summary Report on November 15, 2013, Technical Expert Panel Follow-up Webinar
This file summarizes proceedings from a follow-up cross-setting pressure ulcer TEP meeting, which included in-depth discussion regarding five topics:
- Inclusion of unstageable pressure ulcers and suspected deep tissue injuries in the quality measure.
- Development of a quality measure for healed or healing pressure ulcers.
- Inclusion of Stage 1 pressure ulcers in the quality measure.
- Malnutrition as a risk factor for pressure ulcers and indicators of malnutrition.
- Exclusion of patients or residents at the end-of-life from the quality measure.
Successful Practices in Preassure Ulcer Prevention and Management
To supplement the findings regarding a cross-setting quality measure, RTI and CMS also sought to identify successful practices in pressure ulcer prevention and management that could facilitate the development of tools and resources to improve pressure ulcer care. RTI and CMS conducted interviews with representatives from organizations that had implemented successful programs involving pressure ulcer prevention or management, across a range of facility types and health care settings. More information about the interviews is available in Chapter 4 of the Development of a Cross-Setting Quality Measure for Pressure Ulcers: Information Gathering Final Report in the Downloads section at the end of the webpage.
Several of the organizations that participated in interviews with CMS and RTI, also granted permission to share links and materials that they had developed as part of their pressure ulcer work. These resources may be valuable for other organizations seeking to develop pressure ulcer prevention and management programs. In addition to exploring the resources that these organizations shared, RTI and CMS recommend that healthcare facilities that hope to improve pressure ulcer prevention and management explore the Partnership for Patients’ website for a comprehensive list of pressure ulcer resources: http://partnershipforpatients.cms.gov/p4p_resources/tsp-pressureulcers/toolpressureulcers.html
Resources Shared by Organizations with Successful Programs for Pressure Ulcer Prevention and Management that Participated in Interviews with CMS
Please note that some resources are available under the Downloads Section as well.
Agency for HealthCare Research and Quality (AHRQ), On-Time Pressure Ulcer Program
- AHRQ’s On-Time Pressure Ulcers Program
- Olsho LE, Spector WD, Williams CS, Rhodes W, Fink RV, Limcangco R, Hurd D. Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision support intervention for nursing homes. Med Care. 2014 Mar; 52(3):258-66. http://journals.lww.com/lww-medicalcare/Abstract/2014/03000/Evaluation_of_AHRQ_s_On_Time_Pressure_Ulcer.11.aspx
American Nurses Association (ANA)
- National Database of Nursing Quality Indicators (NDNQI®) Free Pressure Ulcer Prevention/Staging Tutorial: https://members.nursingquality.org/NDNQIPressureUlcerTraining/
- ANA Presentation on the eMeasure for Pressure Ulcer Incidence: http://www.iom.edu/Activities/Quality/CoreMetricsForBetterHealth/2014-MAR-05.aspx
- ANA’s Safe Patient Handling and Mobility (SPHM): http://www.nursingworld.org/SPHM-Standards
- Ascension Health: A System Model of Pressure Ulcer Success and Spread:
- Available in Downloads section at the end of the webpage.
- Pressure Ulcers at Ascension Health:
- Available in Downloads section at the end of the webpage.
Greater New York Hospital Association
- GNYHA -CCLC Pressure Ulcer Improvement Toolkit: Implementing a Communication Tool for Pressure Ulcer Improvement http://gnyha.org/ResourceCenter/NewDownload/?id=2821&type=2
National Pressure Ulcer Advisor Panel
- International Pressure Ulcer Prevention and Treatment Guidelines http://www.npuap.org/resources/educational-and-clinical-resources/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guideline/
- Tew C, Hettrick H, Holden-Mount S, Grigsby R, Rhodovi J, Moore L, Ghaznavi AM, Siddiqui A. Recurring pressure ulcers: identifying the definitions. A National Pressure Ulcer Advisory Panel white paper. Wound Repair Regen. 2014 May-Jun; 22(3):301-4 http://onlinelibrary.wiley.com/doi/10.1111/wrr.12183/abstract
- Edsberg LE, Langemo D, Baharestani MM, Posthauer ME, Goldberg M. Unavoidable pressure injury: state of the science and consensus outcomes. J Wound Ostomy Continence Nurs. 2014 Jul-Aug; 41(4):313-34. http://journals.lww.com/jwocnonline/Fulltext/2014/07000/Unavoidable_Pressure_Injury__State_of_the_Science.6.aspx
- National Pressure Ulcer Advisory Panel: Educational and Clinical Resources http://www.npuap.org/resources/educational-and-clinical-resources/
OSF St. Francis Medical Center
- Courtney BA, Ruppman JB, Cooper HM. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage. 2006 Apr; 37(4):36, 38, 40 passim. http://www.nursingcenter.com/lnc/journalarticle?Article_ID=639480
University of Minnesota
- Westra BL, Bliss DZ, Savik K, Hou Y, Borchert A. Effectiveness of wound, ostomy, and continence nurses on agency-level wound and incontinence outcomes in home care. J Wound Ostomy Continence Nurs. 2013 Jan-Feb; 40(1):25-53. http://journals.lww.com/jwocnonline/Abstract/2013/01000/Effectiveness_of_Wound,_Ostomy,_and_Continence.5.aspx
- Bliss DZ, Westra BL, Savik K, Hou Y. Effectiveness of wound, ostomy and continence-certified nurses on individual patient outcomes in home health care. J Wound Ostomy Continence Nurs. 2013 Mar-Apr; 40(2):135-42. http://journals.lww.com/jwocnonline/Abstract/2013/03000/Effectiveness_of_Wound,_Ostomy_and.4.aspx
Presentation-Development of a Cross-Setting Quality Measure for Pressure Ulcers (PDF)
Table of Feedback Received from All Sources Regarding NQF #0678-Percent of Residents or Patients with Pressure Ulcers (PDF)
Development of a Cross-Setting Pressure Ulcer Quality Measure Summary Report on November 15, 2013, Technical Expert Pa (PDF)
Ascension Health - A System Model of Pressure Ulcer Success and Spread (ZIP)
Development of a Cross-Setting Quality Measure for Pressure Ulcers - Information Gathering Final Report (PDF)
Pressure Ulcers at Ascension Health (PDF)