2. Veteran Affairs facilities
● The US has the most comprehensive system of assistance for
Veterans of any nation around the world. (Veteran Affairs,
2016)
● There are over 1000 VA facilities across the US
● The VA Health Administration’s system has 152 medical
centers along with almost 1400 community based outpatient
clinics, community living centers.
3. Bedsores found on patients
● Definition: Bedsores — also called pressure sores or pressure ulcers — are injuries to skin and underlying
tissue resulting from prolonged pressure on the skin.
○ They most often occur on skin that covers bony areas such as hips, heels, ankles, etc.
● Causes:
○ Sustained Pressure
○ Friction
○ Shear
● Four Stages of Severity:
○ Stage one
○ Stage two
○ Stage three
○ Stage four
○ Unstageable
Bedsores (pressure sores). (2014, December 13). Retrieved April 19, 2016, from http://www.mayoclinic.org/diseases-conditions/bedsores/basics/causes/con-20030848
4. Bedsores vs. VA facilities
● About 12.3% of all facilities reported increased
rates of bedsores
● Highest increased rates were long-term care
facilities
● One severe bedsore can cost a facility up to
$70,000
● Throughout the United States $17 billion is
spent on treatments for bedsore per year
● Medical and Medicare see bedsore as
preventable, so in many occasions will not
reimburse for additional services
Peterson MJ, Gravenstein N, Schwab WK, van Oostrom JH, Caruso LJ. Patient repositioning and pressure ulcer risk—Monitoring interface pressures of at-risk patients. J Rehabil Res Dev.
2013;50(4):477–88. Retrieved April 19, 2016, from http://dx.doi.org/10.1682/JRRD.2012.03.0040
5. Fishbone Diagram
Patients
developing
bedsores.
People
Environment
Patient Risk
Factor Equipment
In adequate amount
of nurses
Age
Lack of knowledge about
bedsores
Patients staying in one position
for a long period of time.
Nurses lack enough time
to turn and check patients
every two hours
Monitoring the amount of
times patients have been turned
Moist and Warm environment
Poor nutrition and hydration Patients need of higher surface to
spread body weight
Patients on certain medications or
with certain medical conditions
Outdated beds and
wheelchairs
Changing wound dressings frequently to
prevent moisture and bacteria from forming
● Bedsores (pressure sores). (2014, December 13). Retrieved April 19, 2016, from http://www.mayoclinic.org/diseases-conditions/bedsores/basics/causes/con-20030848
6. Current state of issues
• Statewide comprehensive bedsore prevention and policies
needed
• Improve reporting and documenting bedsores
• 75% of our patients need to be educated on bedsores and
bedsore prevention
• Increase of 24% of patients need to be educated on
bedsores and bedsore prevention
7. Purpose Statement
To develop a reliable system to help decrease the
amount of facility acquired bedsores on patients while
staying in VA facilities.
8. Goals
● To design a program that would reduce the amount
of uneducated patients by 50 patients (21%)
● To prevent the development of bedsores, while
decreasing cost and patient complications.
9. Scope
● 240 Patients of whom developed bedsores during
their stay at 24 VA facilities
10. Data Points
Data Points Source How Long? How Often? Baseline
A quarterly survey
that will show the
percentage of
facilities being
informed on
bedsores
Quarterly survey 1 year 1 time/month 8 of 24 (33%) of
facilities
Frequency of
reported education
on bedsores to
patients
Documentation
(reports of education
on bedsores for
patients by staff)
6 months As it occurs 117/240 (49%)
patients
http://www.va.gov/oig/54/reports/VAOIG-05-00295-109.pdf
11. Data Points
Data Points Bedsores development during
Hospitalization- Baseline
Target
Patients NOT being educated on
bedsores
123 (51% of patients) Reduce to 50 patients (21%)
Percentage of facilities requiring
clinicians to educate their patients
on bedsores
8 of 24 (33%) of facilities Increase by 10 facilities (18
facilities in total, 75%)
http://www.va.gov/oig/54/reports/VAOIG-05-00295-109.pdf
12.
13. Patients
develop
bedsores
Improper
assessment
Reduce the development of facility
acquired bedsores while in the VA
Facilities by 20% in the next six months
Contribution
20% of patients
developing bedsores
during
hospitalization
70% currently
developing bedsores
during hospitalization
Bedsore
development
rate is at 50%
above the
expected target
of 20%
{Ultimate Goal}
{Current Situation}
Facilities must
have clinician
spend 3 minutes
educating the
patients on bed
sores
Patients need to
become educated
on bedsores
{Problem To Tackle}
{Target}
{Process}
Patients are
not turning or
adjusting
themselves
Clinicians are
not educating
patients about
bedsores
Facility policies
are not addressing
bedsore education
to clinicians
Patients are
not being
turned
Clinicians are
busy
Patients are
not educated
on bedsores
Clinicians
assess
patient for
bedsores
Patient is
classified
“at risk”
Clinician
explains
care plan to
patient
Clinician
reassesses
patient for
bedsores
Clinicians
and team
create a care
plan
14. Target Condition
Target: Facilities must have a policy in place which has clinicians need to spend at least 3
minutes educating the patient on bedsores
● Causes of bedsores needs to be discussed
● Proper turning methods and weight shifting
● Q2H turning importance
● Risk factors and prevention
In order to achieve the target:
● The education department needs to create an instructional class which prepares
clinicians on how to educate their patients on bedsore prevention.
15. Break Down the Problem
Reasons for developing Hospital Acquired Bedsores:
1. Patients not turning themselves (We are addressing this one)
a. High severity and easier to address
b. Allows for repositioning without clinician interaction (problem 2)
2. Patients not being turned by clinicians
a. Due to clinician unavailability from distractions and interruptions
b. Harder to address
3. Initial assessments flawed
a. Assessments deal with risk factors and not actual causes
b. Requires more data from multiple departments
16. Analyze the Root Cause
● Patients are developing Facility Acquired bedsores
● Patients apply pressure to at risk locations
● Patients are not being turned and are not turning themselves
● Patients do not have the proper education to turn themselves
● Clinicians are not educating patients on bedsores
● No facility wide policies to address teaching patients on
bedsores
17. Implementation Projects
Phase one: Education departments need data on proper teaching and
proper turning and prevention
Phase two: Create classes either online clinician portal or in
classroom
Phase three: Application to patient
Phase four: Monitoring amount of facility acquired bedsores
18. Counter-Measure Plan
Who will be involved in test? All VA facilities, Education departments, Clinician staff, patients
What specifically are they going to do? Education department is going to create an informational program for
nurses in order to teach patients about bedsores and bedsore prevention. Clinicians will use new information to teach
patients about bedsores and bedsore prevention. Patients with the new information will know the importance of
bedsore prevention and will turn themselves.
When will we test? Day? Time of day? How many times? We will test Mondays and Fridays of each week. 7am
to 7pm per admission. Within four hours of each admission with 7am and 7pm.
Where will we do it? The patients rooms and the training at an off site location.
How will we know if the changes worked? A decrease in facility acquired bedsores from educated patients.
Risk in implementing the counter-measure? Clinicians may not have enough time to do this. Some patients will
not be able to turn themselves due to current conditions. Some patients might refuse to turn themselves. Patients
might forget to change positions.
19. Data Points
Data Points Baseline Target Expected Results
Patients NOT being
educated on bedsores
123 (51% of patients) Reduce to 50 patients
(21%)
80 patients (33% of
patients)
Percentage of facilities
requiring clinicians to
educate their patients on
bedsores
8 of 24 (33%) of facilities Increase by 10 facilities
(18 facilities in total, 75%)
15 of 24 (62%) of facilities
20. Our Reflection: Team
Ohana and Project
Ohana: means family, family means no one gets left behind.
. Develop and describe the team meeting management skills used to
accomplish your project to tell a story (Includes Team Dynamics)
• Darren being Type 1 was able to come up with options that has helped
the group decide on what to do to make the project better as well as
improved listening skills and explained very well about the details
needed to cleared up.
• Yesenia being Type 2 was able to work with everyone in the group as
well as helped with connecting with Youngjae to clarify any of the issues
that occurred during the project completion.
• Lauren being Type 2 was able to give and find the group information that
was needed to complete the project.
• Jennifer being Type 3 was able to connect all group members together to
make sure things were getting done. Also helped set up our PowerPoint.
• Morgan being Type 4 helped explain the group's’ confusion as well as
helped manage how the group was able to complete the project.
- Darren Type 1: Controller
- Yesenia Type 2:
Persuader
- Lauren Type 2: Persuader
- Jennifer Type3:
Organizer
- Morgan Type 4: Analyzer
Overall with a group that has all types of personalities, we were able to come
together and figure out the issues of our project, settle confusion, and come to a
compromise of opinions and really listen to everyone to finally make this
project happen.
21. Reference
About VA. (n.d.). Retrieved March 30, 2016, from http://www.va.gov/about_va/vahistory.asp
Peterson MJ, Gravenstein N, Schwab WK, van Oostrom JH, Caruso LJ. Patient repositioning and pressure ulcer
risk—Monitoring interface pressures of at-risk patients. J Rehabil Res Dev. 2013;50(4):477–88. Retrieved April 19,
2016, from http://dx.doi.org/10.1682/JRRD.2012.03.0040
Bedsores (pressure sores). (2014, December 13). Retrieved April 19, 2016, from http://www.mayoclinic.
org/diseases-conditions/bedsores/basics/causes/con-20030848
Watrous, J. (2006, March 22). Management of Patients with Pressure Ulcers in Veterans Health Administration
Facilities. Retrieved February 22, 2016, from http://www.va.gov/oig/54/reports/VAOIG-05-00295-109.pdf
