Frustrated with ongoing complaints from family members, Reba Sanders, the administrator of 100-bed Lakeview Skilled Care and Rehabilitation Facility, replaced the director of nursing (DON) after she had been on the job for less than 2 years. At the exit conference with Reba, the DON had remarked, "I don't think pressure ulcers have been a problem in this facility the way it is made out to be by some families. Some patients develop the ulcers at the hospital before they come here; we try our best to take care of them, and I have explained to the families Eliminating Pressure Ulcers at Lakeview what we are doing. I think firing me is unfair, but it is your decision." Before the new DON, James Osterwal, was hired for the job, Reba had mentioned to him that looking into the pressure ulcer problem would be his first priority. Reba arranged for James to attend meetings of the local chapter of a national quality improvement organization for nursing homes. Based on some of the informa- tion presented at the meetings, James quickly settled on making pressure ulcer elimination as his primary goal. James was quite familiar with the PDSA quality improvement cycle. He discussed it with the charge nurses, decided how dat would be collected, and started a campaign asking all nursing staff to adopt the motto: "We will eliminate pressure ulcers at Lakeview." The associates liked the motto because it gave them a specific goal to work toward. At James' reauest Reba approved hiring an RN nurse coordinator to float between the three shifts The charge nurses asked their nursing assistants to report to them right away all cases of skin breakdown. James trained the nurses in best practice protocols to treat pressure ulcers. After 4 months, data showed Jittle to no improvement in the prevalence (total number of cases) of pressure ulcers at Lakeview. Both Reba and James could not understand why.

Questions:

1. Based on what you have learned in this chapter, evaluate the quality improvement program as it pertains to pressure ulcers at Lakeview. Provide a specific outline of weaknesses in the overall approach.

2. Use the PDSA cycle to address the issue of pressure ulcers. Be specific. For example, how should data be collected? How would you go about identifying rood causes of the problem? What interventions would you implement? What roles should the various personnel and the administrator have?