External pressure injury reports were defined as a report generated by an external agency using a national standard or agency definition. These data are primarily generated from administrative or coded data from physician or advanced practice provider health record documentation. The AHRQ Patient Safety Indicator (PSI) 03 is a comparative report used by organizations as an external comparison measure with benchmarks from similar facilities.8
The AHRQ pressure injury PSI 03 is a patient safety measure designed to capture pressure injuries of a higher stage or complexity using administrative billing data. Stage III pressure injuries or higher are the target for this patient safety measure because of the additional resources and potential increase in patient morbidity and mortality associated with this level of pressure injury event. After an operational definition and using a series of inclusion and exclusion criteria, a patient encounter is assigned a PSI 03 when a medical/surgical patient meeting the inclusion and exclusion criteria for the measure is attributed an International Classification of Disease-10 (ICD-10)9 code consistent with a patient obtaining a pressure injury of a Stage III or higher during the hospital stay.
An improvement team from the IST initiated an iterative Plan-Do-Study-Act10,11 improvement effort in 2018 that consisted of two interventions. The two interventions included a WOC nurse workflow redesign, and two technology innovations designed to improve the accuracy and timeliness of hospital acquired pressure injury reporting.
Wound, Ostomy, and Continence Nurse Workflow Redesign
The first improvement cycle implemented by the improvement team included changing the workflow of the WOC nurses. Before the improvement redesign, the WOC nurses were not confirming all stages of pressure injuries. The staff nurses in this organization describe skin events using a defined set of skin descriptors that are mapped to the NPUAP5 staging criteria (Table 1). Before the workflow intervention, the WOC nurses only evaluated nurse described skin events consistent with a Stage III pressure ulcer or higher using an automatic, electronic consult order.
In 2017, the organization committed additional funding to increase the number of WOC nurses from 4 to 12. Each WOC nurse is assigned responsibility for a caseload of approximately 100 beds in the hospital and tasked with unit surveillance of patients, treatment and management of wounds, and staff education. The additional WOC resources allowed for the expansion of wound expertise in the inpatient settings, expanded coverage in the ambulatory clinics, and provided bandwidth for the confirmation of all pressure injuries by a wound expert. In the first improvement cycle, the WOC nurses began proactively evaluating and confirming all skin descriptors documented by the staff nurses consistent with any stage of pressure injury, a significant change from the previous automatic consult process.
Series of Technology Interventions
The second improvement cycle focused on innovative technology solutions developed to complement the process changes in the WOC nurse workflow. The new technology solutions enhanced the timeliness and display of pressure injury data for both internal process improvement and external comparative data reporting.
The first technology innovation was the development of a provider dashboard with real-time display of pressure injury staging and staff nurse documentation of wound descriptors. The second technology innovation was the development of a HAPI reporting platform that provides actionable, daily reports containing a variety of visual displays.
The provider dashboard is available to all clinical providers and was created in the EHR to exhibit real-time documentation of individual patient-level detail of pressure injury stages reported by WOC nurses and the skin descriptors documented by the nursing staff. The provider dashboard was a custom-built application in the EHR developed to serve as a clinical checklist for providers. This dashboard creates a patient list highlighting existing clinical risk factors that are considered important for clinician awareness and could potentially be unnoticed in the interprofessional documentation.
Skin observations documented by the staff nurse and staged pressure injuries by the WOC nurse team are one of the items highlighted on the provider dashboard and are available by unit or provider-specific patient list. The pressure injury information provided on the dashboard is reflective of real-time documentation and available on the completion of the documentation by the provider during the provision of care. For example, if a staff nurse documents a skin event of “red, skin intact” for a sacrum, and the WOC nurse evaluates the skin assessment and confirms the staff nurse observation and documents a “Stage I” pressure injury, both the WOC nurse and staff nurse skin assessments will show on the provider dashboard. The clinical providers understand that the staging language is the WOC nurse assessment, and the descriptor language is the staff nurse assessment. The provider is able to adjust the plan of care and documentation based on the real-time pressure injury information available from the WOC and nursing staff.
The provider dashboard provides pressure injury information on single patients but does not provide a summary of pressure injuries across the organization. The improvement team developed the second technology innovation, the HAPI reporting platform, using a business intelligence tool to address pressure injury incidence and incidence density. Incidence is defined as the frequency of pressure injury within the organization, and incidence density is defined as the most frequent geographic locations and types of pressure injuries that occur. The improvement team developed reports to address both incidence and incidence density.
Monthly retrospective reports for pressure injuries had initially been developed using skin observations available within the nursing documentation section of the EHR. In previous pressure injury reports, report writers were unable to use WOC nurse staging information because these data existed in nondiscrete fields. In addition to increased WOC nurse resources and the revised workflow described, the WOC nurse documentation was revised in the second improvement cycle to include new pressure injury data fields. These added data fields in the EHR include WOC nurse staging reflective of a pressure injury, present on arrival and present on transfer to another unit, WOC nurse-specific fields to document progression in staging, and the ability for the WOC nurse to delineate “no pressure injury” when the staff nurse documentation was incorrect. The addition of and use of new fields for data capture in the WOC nurse documentation allowed for more accurate information to be electronically displayed, abstracted, and harvested for redesigned pressure injury reports.
The HAPI reporting platform was designed to capture pressure injury information on incidence and incidence density using the newly established WOC nurse fields described above. Users are able to log into the HAPI reporting platform on a daily basis and evaluate the status of pressure injuries at the unit and the organization level. The reports within the HAPI reporting platform are generally structured to provide summary data and the individual patient detail. Useful information is provided in the individual patient level detail including dates and times for the documentation of both the nursing staff and the WOC nurse team. From these data, nurse leaders are able to track the progression of each pressure injury during the patient encounter for an admission.
The reporting repository within the HAPI reporting platform contains seven pressure injury reports used for internal improvement (Table 2). Six of the seven reports are specific to incidence and incidence density for internal reporting. A summary incidence report is available two times per day and provides a count of unit and organization-wide, all-stage HAPI with trended information and statistical process control.
The seventh report is the AHRQ PSI 03 report containing incidence data for external reporting. The IST developed this report in response to organizational leadership review of comparative data for PSI 03, and questions regarding internally reported data as compared to externally reported data on pressure injuries. The report connects attributed PSI 03 data to WOC nurse and nursing documentation found in the EHR, and all information documented in the internal pressure injury report. Review of these data assists leaders in the development of knowledge related to differences in internal and external reports and improvement in workflow such as the identification of opportunities in coding or in provider documentation.
After implementation of the redesigned process and a 3-month period of data confirmation, documented all-stage HAPI decreased from 164 total (raw) count in March 2018 to an average of approximately 100 reported all-stage pressure injuries per month from April 2018 to February 2019, a 39% decrease. The all-stage hospital acquired pressure injury counts range monthly from 83 to 119. Statistical process control has shown only common cause variation in the first 9 months after implementation of the new process.
There have been no reported data discrepancies by nursing leaders or the WOC nurse team since May 2018. The last data discrepancy reported in May 2018 related to patients captured on the report with a present on admission flag, which is an exclusion. After investigation by the report team, the error was not in the functionality of the report, but rather in the data definition for inclusion and exclusion criteria. The AHRQ PSI 03 report exposed evidence of variation between internally and externally reported HAPI, which highlighted the need to examine the discrepancies in more detail.
Confirming pressure injury data resulted in the identification of inaccurate pressure injury reports, highlighted opportunities to improve pressure injury documentation workflow, and emphasized the need for just-in-time, actionable data. Developing innovative quality informatics solutions that result in timely and accurate pressure injury reports may lead to improvements in patient care outcomes, and better understanding and knowledge by organizational leadership of the differences in the internal and external pressure injury reports.
The project team found that the improvements in pressure injury reporting highlighted several key factors. First, confirming data at the point of care is critical to the development of accurate reports. Second, workflow redesign should precede technological solutions and redesigned reporting. The positive outcomes of this project would not have been realized had the workflow had not been revised to be inclusive of the documentation of the wound experts.
To achieve actionable data, leaders need both accurate and consistent information in a timely fashion. Retrospective information has little to no value in real-time improvement. In the clinical environment, providers must be able to proactively mitigate risk. For pressure injury, early identification of lower-stage pressure injuries may allow for the prevention of stage progression. This risk mitigation may only be accomplished if providers have access to timely information on all at-risk patients in the census.
Confirming documented health record data is necessary for developing accurate reports. This project team began work by listening to the stakeholders regarding the perception that pressure injury data lacked accuracy. The team completed a data confirmation process with members of the WOC nurse team evaluating each reported pressure injury identified in the report and contacting the report developer when expected pressure injuries were absent from the report. This data confirmation process resulted in a degree of accuracy for the reported information that had not occurred in previous reports.
The project team identified opportunities in reporting not realized at the inception of the report redesign. Exclusions had to be developed for patients moving between inpatient and outpatient areas of the facility. Operational definitions should be clearly defined at the onset of report development.
Another challenge experienced was that process redesign and accurate data may increase or decrease pressure injury counts in unexpected ways. The team found that there was a decrease in the total number of internally reported HAPI because duplicates in previous reports or erroneously classified injuries were eliminated. Externally reported data potentially increased due to better documentation from the WOC nurse team, which may have allowed for query opportunities in coding that had previously been missed.
There was also increased incidence of deep tissue injury (DTI). The confirmation of a DTI may be problematic physiologically. A suspected DTI may not be an actual DTI. However, if the DTI terminology is documented by a provider in the health record, coders must abide by coding guidelines and default the attribution of a code for the wound to an unstageable pressure injury whether or not there is an actual DTI. Provider confirmation of a DTI is imperative for accurate reporting of external data.
Evaluating the consistency in internal and external data is an essential process. The improvement team found evidence of variation in internally reported and externally reported AHRQ PSI 03 data. Because of the significance of the impact of erroneous data on reimbursement, after analysis of the internal and external pressure injury data, the IST established a second improvement project aimed at refining the accuracy of externally reported pressure injury data. Attention to the attribution of DTI is a specific focus of the next iterative improvement effort.
The key to successful reporting of pressure injury data is to develop a workflow that supports data accuracy, and a process that consistently provides accurate and timely information. Table 3 provides information on key determinants for creating accurate and consistent pressure injury reporting.
Shea Polancich, PhD, RN, is column editor for the Journal for Healthcare Quality's department “Translation of Research into Healthcare Quality Practice.” Dr. Polancich has been practicing in quality and patient safety for over a decade. She is currently an assistant professor and assistant dean at the University of Alabama at Birmingham (UAB) School of Nursing, with a primary practice at the UAB Medical Center, Birmingham, Alabama, as a director specializing in nursing improvement, innovation, and analytics. Formerly, her roles included the Director for Quality and Patient Safety at Vanderbilt University Medical Center, Director of Data Analysis and Measurement at Texas Health Resources, NIH/NINR research intern, and health policy fellow at George Mason University. She served on an NQF advisory group specific to patient safety and adverse events. She may be contacted at email@example.com.
Jason Williamson, BS, is a manager of Financial Systems at the University of Alabama at Birmingham (UAB). Jason works with the Department of Nursing and the School of Nursing at UAB to guide and assist with software development and nursing analytics projects to help identify ways to reduce cost and improve the quality of care for patients. Jason has over a decade of experience in research and development related to clinical applications and was formerly a product development manager with one of the nation's largest providers of health care systems.
Terri Poe, DNP, RN, NE-BC, is the Senior Associate Vice President and Chief Nursing Officer (CNO) for the University of Alabama Hospital (Birmingham). She received her Bachelor's degree of Nursing (1986), Master's degree of Public Administration (1993) and Doctorate degree of Nursing Practice (2013) all from the University of Alabama at Birmingham (UAB). Before her role as the CNO, she was the Administrative Director for Emergency Services and has served as a nursing leader for over 3 decades. Poe serves on the Board of the Alabama Chapter of AONE. She is a 2015 graduate from the America's Essential Hospital fellowship program.
Amy Armstrong, MSN, RN, CWOCN, CNL, is a certified wound, ostomy, and continence nurse for the UAB Hospital Acute Care Surgery WOC Nurse team. She is a masters prepared nurse and Clinical Nurse Leader (CNL).
Ross Martin Vander Noot, MD, is a physician and associate professor in the department of acute care surgery at UAB hospital. He serves as the medical director for the Wound, Ostomy, Continence Team (WOCT).
The authors acknowledge the work of the Wound, Ostomy, Continence Team (WOCT) for their efforts in revising the workflow to create more actionable data.
1. Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: Results from the national medicare patient safety monitoring system. J Am Geriatr Soc. 2012;60(9):1603–1608.
5. National Pressure Ulcer Advisory Panel. Educational and clinical resources. 2018. http://www.npuap.org/
. Accessed December 4, 2018.
6. Ma C, Park SH. Hospital magnet status, unit work environment, and pressure ulcers. J Nurs Scholarsh. 2015;47(6):565–573.
7. Polancich S, Coiner S, Barber R, Poe T, Roussel L, Williams K. Applying the PDSA framework to examine the use of the clinical nurse leader (CNL) to evaluate pressure ulcer reporting. J Nurs Care Qual. 2017;32(4):293–300.
9. Centers for Diseases Control and Prevention: National Center for Health Statistics. International classification of diseases, tenth revision (ICD-10). 2016. https://www.cdc.gov/nchs/icd/icd10.htm
. Accessed February 22, 2019.
10. Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L. The Improvement
Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009.
Keywords:© 2019 National Association for Healthcare Quality
Pressure injury; improvement; informatics