Kingdom of Saudi Arabia

Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING QUALITY

PROJECT CHARTER

PROJECT NAME
Reduce the Incidence of Hospital Acquired Pressure Ulcer from 7 to 0
(Benchmark: 1.3 per 1000 patient care days- H.A.P.U of PMNH 3.5 of 1000 per patient day)

PROJECT SUMMARY
This initiative will improve the rate of Hospital Acquired Pressure Ulcer incidence in Prince Mohd bin
Nasser Hospital by early detection of patients who are at risk in developing pressure ulcer.
Nursing Department will review its practices in all units for preventing pressure ulcers; adopt best
practices were it is applicable, and develop process measures for tracking improvement of preventing
hospital acquired pressure ulcer.

PROBLEM STATEMENT
There was 7 reported Hospital Acquired Pressure Ulcer out of 1950 patients admitted in
PMNH on August, 2019.Data were gathered thru Nursing Performance Indicator which
exceeding the National benchmark of 1.3 per 1000 patients due to 3.5 rate of Hospital
Acquired Pressure Ulcer in PMNH.

PROJECT GOAL
By the end of 3 months (November 2019) PMNH will decrease the occurrence of Hospital
Acquired Pressure Ulcer from 3.5 % of benchmarking to 1% as evidenced by reports given in
Nursing Performance Indicator & Clinical Audit.

PROPOSED SOLUTION
In able to decrease the incidence of Hospital Acquired Pressure Ulcer the following measurements &
actions should be strictly implemented by all nurses in PMNH. Measurements & actions were based on the
finding of Root Cause analysis.
1. Nurses Education/workshop on prevention & management of Pressure ulcer must be provided.
2. Clinical Resource Nurses must enhance the knowledge of staff nurses on delivery of patient care.
3. Monitor implementation of the policy & procedure of patient care (Pressure ulcer, Basic hygiene of
patients).

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 Kingdom of Saudi Arabia
Ministry Of Health
Jazan Health Directorate
Prince Mohammed Bin Nasser Hospital

NURSING QUALITY

4. Activate the roles & participation of all nursing leaders to ensure the patient process of care is
fully implemented.
5. All patients with High Risk for pressure ulcer (Braden Scale ≤ 16) will be closely monitored by
staff nurses & Nursing Managers
6. All head nurses must request from medical supply additional air mattress & cushions and barrier
cream for patient use
7. Maintenance to fix the Air-condition
8. To request from medical supply of barrier cream/ moisturizing cream
9. Instruct nurses that during bed linen changing sheer and friction should be avoided
10. Increase manpower on evening and night shift.

MAIN PROJECT DELIVERABLES:

1. Minutes of meeting & attendance Sheet
2. Root Cause Analysis
3. Educational lecture (PowerPoint Slides)
4. Monitoring Sheet of Patient at Risk of Bedsore
5. Requisition of all supplies needed from Medical Supply Dept.
6. Project Report

PROJECT TEAM
NAME DEPT. TEL.#
PROJECT MANAGER Mr. Moath Farasani Nursing Service 1332
Mr. Ahmed Abudiyab Nursing Education 1331
Mr. Asim Mongary Nursing Quality 2300
Ms. Hazel Hadeel Cabaddu Nursing Quality 2300
TEAM MEMBERS
ALL Unit Head Nurses Ward
All E.R Head nurses E.D
All admitting ward/unit All Wards/Unit

Prepared by: Reviewed by: Reviewed & Approved by:

Ms. Hazel Hadeel Cabaddu Mr. Moath Farsani Mr. Abdurahman Moorei Al Ameri
NTQM Coordinator Project Manager/Deputy Nursing Director Nursing Director