This document discusses the development of quality indicators for skin care and wound management in the UK, focusing on pressure ulcers. It describes how pressure ulcers were identified as a quality indicator in the 1990s but saw limited progress until more recent frameworks like CQUIN that financially incentivized hospitals to meet targets for reducing pressure ulcers. This led to debates around avoidable vs unavoidable ulcers and assessments of root causes. Tissue viability nurses collaborated on a consensus document to standardize reporting and definitions across organizations.

1. Quality Indicators in Skin Care
and Wound Management
Professor Carol Dealey
Birmingham, UK

2. Today
• I am going to talk about what has
happened in the UK
• I hope that some of the things we have
learnt will be useful to you in raising the
profile of skin and wound care in Brazil

3. Skin and Wound Care
• In the UK the interest has been mainly in
pressure ulcers and to a lesser extent on
surgical site infection
• There are guidelines for prevention and
management of diabetic foot ulcers and
leg ulcers, but they are not seen a quality
issue

4. I am going to focus on pressure
ulcers

5. Some basic information
• Up to 20% of patients in acute hospitals in
England have pressure ulcers
• The cost of treating them is about £4
billion pa
• Data is collected in different ways – either
by measuring prevalence or incidence –
there is often confusion about these terms

6. Prevalence
• Prevalence is the total number of cases
measured at particular point in time
• It includes those who came in with PU and
those who developed them in hospital
• It is measured on one day and usually
done annually.
• It is easier to measure than incidence

7. Incidence
• Measures the number of new cases
developing in hospital
• It needs to be measured over time
• Prevalence identifies the overall burden of
PU
• Incidence is a better indicator of the
quality of care provision
• Both are useful

8. • How have pressure
ulcers been used as a
quality indicator?

9. In1992
• The Dept of Health published Health of
the Nation. Pressure ulcers were seen to
be avoidable and classed as a quality
indicator. Target to reduce by 5 - 10%.
• I was ecstatic – at last something was
going to happen to make hospital
managers see pressure ulcers were
important!
• There was only a small ripple – and then
everything went back to normal

10. We had a new government
• 1998 - A First Class service - quality in the new
NHS - identified the need to improve quality in
relation to pressure ulcers using benchmarking
• Pressure ulcers were back on the agenda and
by this time it was expected that all hospitals
would have a TVN
• There was some monitoring usually annual
prevalence surveys although I was measuring
incidence at this time

11. We had a different government…
• 2010 - High quality care for all - NHS next
stage review - Darzi report to ensure a safe
and effective health care service.
• Quality was to be the organising principle and
a framework was developed to encourage
organisations to focus on quality
improvements and innovation.

12. QIPP
QUALITY, INNOVATION, PRODUCTIVITY AND PREVENTION
• “We need to fashion a vibrant,
creative NHS that really fizzes with
ideas of how to improve quality and
reduce costs ……. We must look to
ourselves to make savings”
Earl Howe 2010

13. Essential standards of quality and
safety
• New essential standards on quality and
safety for health and social care
• 28 Focused outcomes
• Outcome 1 - Respecting and involving
people who use services
• Outcome 4 - Care and welfare of people
who use services
• Outcome 11 - Safety, availability and
suitability of equipment

14. CQUIN
COMMISIONING FOR QUALITY AND INNOVATION FRAMEWORK
• CQUIN framework was developed to help
produce a system which actively
encourages organisations to focus on
quality improvements and innovation in
commissioning and contract decisions.
• Measuring what we do is the basis for
transforming quality.
• Encourages an open dialogue and local
negotiation.

15. CQUIN
• CQUIN framework to reward
genuine ambition and stretch
• Goals in 3 domains of quality;
safety, effectiveness and patient
experience
• Not intended to replace existing
quality initiatives.

16. CQUIN SCHEMES
• Enables providers to earn 1.5% on
top of the total contract value. Rise
from 0.5% in 2009 / 2010.
• Schemes to have goals and
objectives using defined indicators.
• Reflect local priorities and reflect
NHS operating framework.
• Developed with clinical engagement

17. Some background information
• In England we have local Commissioners
who ‘purchase’ healthcare from the
‘providers’ (hospitals)
• It is negotiated locally
• So the CQUIN targets for PU were to be
agreed at a local level

18. Examples of Local Targets
• To reduce all grades of pressure ulcers
• To have no Grade 4 and a reduction in
Grade 3
• To maintain low levels of Grade 3 and 4
• Year on year reduction of no less than
25% above baseline
• A reduction in all preventable pressure
ulcers

19. What does it really mean?
• Getting paid for achieving targets that
have been locally negotiated.
• Extra income - but not necessarily for the
services driving the quality initiatives!!
• Not getting paid if the targets haven’t been
achieved.
• Additional work within target areas!!!

20. Pressure ulcers
“A localised injury to the skin and / or
underlying tissue over a bony prominence
as a result of pressure, shear or friction”
(NPUAP/EPUAP 2009)
AVOIDABLE OR NON AVOIDABLE??
The majority are avoidable

21. This was a new area of debate
• Previously we had said 95% of PU are
preventable (avoidable) although there
was little evidence to support it.
• It had been raised by the NPUAP who had
produced definitions for both avoidable
and unavoidable
• It was important because now there could
be financial penalties

22. Unavoidable
• Some groups had
developed a definition of
unavoidable PU that was
so long it could be said to
classify virtually all
pressure ulcers as
unavoidable!

23. Alongside Avoidable and Unavoidable
were more new terms for PU
• Root Cause Analysis (RCA) to be
undertaken to determine if PU avoidable
or unavoidable
• A Serious Incident Requiring Investigation (SIRI)
was undertaken depending on the findings of the
RCA

24. What could happen?
• Differences in
reporting across
country
• RCA methodology
varies
• SUIs variation
• We already know the
workload is
considerable – it
could get worse!

25. Comment
• Sometimes the saying ‘be careful what
you wish for’ is true!
• Many of us had fought for the importance
of pressure ulcers to be recognised as a
quality care indicator and we had been
fairly united over this aim – CQUINS had
the potential to fragment opinion

26. Something had to done
• The Tissue Viability Society set up a
working group to involve all groups of
TVNs across the country to agree on what
should be reported
• We also contacted people at the DOH and
amongst Commissioners to come to a
consensus meeting to discuss the issues
• From this we produced a document..

28. Scope of Document
• This document was for all organisations
that are involved in the reporting of
pressure ulcers. It represented the
consensus view of a large number of
Tissue Viability Nurses from across
England

29. It contained….
•Clear statements on all the contentious issues
with explanations on why they had been selected
•It was presented at the TVS Conference earlier
this year and widely accepted
•Since then it has been circulated via DOH and
published in JTV

30. What is the moral of this story?
• It is important to fight for what you believe
in
• Remember that managers may not always
get things right
• Working together is the best way to get
the outcome you wish for.