Kingdom of Seudi Arabia

Ministry of Health
Hail Health Cluster
King Salman Specialist Hospital
TQM & Psrient Safety Departmetrt
11rr:ralt Jfb €'o-+I
Haal Health Cluster

The Performance Improvement Methodology

of Nursing Department
I. FOCUS
IMPROVEMENT PROJECT TITLE:
GOAL: TO REDUCE, lF NOT PREVENT, THE OCCITRRENCE OF PRESSIIR.E ULCERS ON ALL PATIENT
ADMITTED TO ONCOLOGY AND CRITICAL CARE UNIT (AICU & BIJRTO OF KSSH BY EIID OF DECEMBER 2O2I TO
ACCE,TABLE INTERNATIONAL BENCHMARX OFr./.. ,4.-..! g.lrl. r-i

E High Risk D High Volume E Problem Prone E High Cost

F
.Od',..ritl tui atrr: I ncreasing I ncidence of Hospital-Acq uired Press ure Ulcer
1its...tty
Find
An opportunity for
imDrovement
(Statement of
problem)

> Sponsored by: Mr. Faiz Mayah Alshammari (Hospital Director)

Members and Roles:
.d*Jill 0'.-rS'r
Organize - a team
Include all
stockholder. meaning
include all the people
that are Dart of the
problem under studv
) Team [,€eder: Ms. Tehrni Awadh Alshammari (Director ofNursing)
> Fscilitrtor: Ms. Rosmin Escuadra (Deputy Director of Nursing)
Ms. Eloisa Gay Castro (Nursing Quelity Coordinrtor)
Ms. Hala Alraked (Nursing Quelity Coordinetor)
Name Position Role
Ms. Amal Fahad AlShammari TQM Director Coordinator
Ms. Nouf Shanan CNE Supervisor Implement Trainings, Lectures
Ms. vancssa Bakakew CNE Instructor and Symposia on Pressure Injury
Mr. Radhi Krim CNE Instructo.
Ms. Lulu Paul Clinical Tutor
Ml Rcfaa Malar Nursing Supervisor Participate in the Monitoring of
Ms. Munifa Naif Pressure Injury Occurrence
Ms. Amal Saud
Ms. Melrcse Virtudazo
Ms. Entesar Saud
Ms. Twinkle Mery John
Ms. Jehan Daud
Ms. Prasanthi Sumesh
Ms. Abdullah Yousef AICU N Desi . Implementation and monitoring of
Ms. Chenie Rose ONCO/Palliative N preventive measures and
Ms. Rose Mariya Francis BCU Nursing Desigree management in the presence of
Pressure Injury
. Data collection and submission of
KPI

Qurlity Mrnrgement & Prtient Srfcty Dep.

Em.il: hrs-kssh-tomAmoh.sov.sa t:rt # 1080

FOCUS-PDCA Template.doc -t-

 Kingdom of Saudi Arabia
Ministry of Health
Hril Herlth Clust€r
Kirg Selmrn Specirlist Hospitrl
qtrLr.t3jl Jrt g-o-+t TQM & Prtient Sefety Deprrtmcnt
Hall Healttr Cluster

PRESSURE ULCER ASSESSMENT PROCESS

All patients are assessed from AED for the presence ofany Pressure Ulcer
developed either from home or previous hospitalization

Assigned staff discovering the presence of Pressure Ulcer will fill-out and
submit the KPI Data Collection Form for Pressure Ulcer to the Nursing Offrce
(Nurse Supervisor/ NQ)

I
Upon patient admission, the receiving unit will receive endorsement from
AED, including the Pressure Ulcer, and will thereafter perform their own
patient assessment and submit Pressure Injury KPI Data Collection Form

I
ils.i.Jl ei..-l: The Nurse Supervisor/ NQ will validate the submiued KPI by personal visit to
lbtt.,t* jt the unit
.d.&di.f+
Chrify - the
current Verifred patients with Pressure Ulcer will be managed according to the
process physician's order/s as well as the independent nursing actions including
Clarifvinp the turning/repositioning every 2 hours, maintenance of wrinkle-free bed linens,
current Droaess cautious care on patient's skin integrity, bed bath once daily, wound
with data dressing/management, health education to the patient's caretaker/family,
collection and
information of
the process
I
based on Continuous monitoring will be implemented as reflected in the daily
brainstormine assessment ofPressure Ulcer Assessment and Reassessment Healing Chart and
and flow chart Compliance to Repositioning and Tuming Clock.

Up-to-date reporting will be ensured depicting the progress ofor any new
occunence of pressure ulcer

Qurlity Mrorgemcnt & P{ticnt Srfcty Dep.

Emril: has-kssh-tqm'a-moh.gov.s{ [\t # I080
FOCUS-PDCA Template.doc -2-
 Kingdom ofSaudi Arabia
Ministry of Health
Hail Heelth Cluster
King Salman Specialist Hospital
TQM & Patient Sefety Departmert
l]n-rEll Jrtr €ro-",
Haal Hc.lth Cluster

Machine Material

.Ai mat8ss aE not pDpedy .lnadequate/ in@prcpriate . No tirnely r€porling thru

iniabd
. P@r qualily of matEss
. No sp€cial ICU tumirc b€d
. No goper t'ainirg 6r trc l.lse of
sudr del,lEs
. Noo€Yailatility of VAC rEd ne
. Nmdilizath of aubnatic
dressing supplies OVR & KPI
. Non€vailability ol dressing .CRRT procedure fial limits
specific only for pressure ulcers the tuming of the patieot
. Linen shortage that can be us€( . Non{elenal to AP
as patient lifters . lnsuffcient assessment &
.Wrinkled and poor linen doarmentation

613 tpr: patient lituE materials

CJ++...l1
.ir(it-t:rJiltl
Pressure
Understrnd -
the resources Ulcer
of the problem incidence
and the
. TumirE do{k not propedy tollo.cd . No competenq br sbfi nuEes Gg6dirE
process . Palienls ondilion & sbtus proper use of rnedbal equipment (air
. R@m BryeratrtB not
variation (d€satrral*r, dbnfEa, maltess) and pressuE ulcer assessnenl
gDpedy nahthed
er) . Unt'aired rH sffi
-Identifv all . Patienls dst h&d comodidilhs . Non-avarcness of APP $ iranagerrE rt
oPatie / retalive retsed
nossible (ob€sity, numion, sueery eb.) PrcssulE Ulce.s Polkry.
h. trming
.l6lrotrG posith oder . tlo avdhle T6sue VEbfrty
variation to prone Team or
PlEssure UherT6n
the Drocess .Str shoGge ad huh *o*lod
such as
brain
storming.
&
cause
effect
diaqram
@ Manpower

(fish bone
diasram).

Qr.lity Mrnrgement & P.ticnt Stfcty Dep.

Emril: has-kssh-tomamoh.sov.s, llrt # l0t0

FOCUS-PDCA Template.doc 3-
 Kingdom of Srudi Arrbi,
Ministry of Health
Hail Heelth Cluster
King Salman Specialist Hospitel
TQM & Patient Safety Department
l]rLal3lt Jlrb SLo-?,
H.ll Hcalttt Cl.rster

l.Conduct a proper head-to-toe examination, including the Braden Scale Skin

Risk Assessment, and document everything properly and accurately.

2.Notification to the Attending Physician as soon as possible for proper

evaluation and management, as well as referral to the appropriate specialty
if necessary.

S
irJn I &l.J frtrs
3.Prompt reporting to Risk Manager and Nursing Quality via OVR and KPI
form for further assessment and monitoring.

a series of pressure ulcer assessment, reassessment, and

4.Conduct
FJ rrrr: gr cdr"4JiIJ documentation trainings, lectures, and competency assessments for staff
nurses, particularly new nurses.
'eJJ'dt
Select - the
improvement S.Provide a presentation/lecture on the APP 90 Management of Pressure Ulcer
When the causes Policy.
have been
identified. select
6. Coordinate with RNA to deploy additional nurses in order to enhance the
strategv for
imDrovement staffing ratio.
such as
brainstorming
or other T.Request additional good quality mattresses, a special ICU tuming bed, a
methods of
VAC machine, sheets, and pressure ulcer dressing supplies from the hospital
developing
ideas. administration.
Then, choose the
nrior solution bv
using Impact/ S.Coordinate to the Biomedical Departrnent to train the staff on how to use
Effort matrix &
medical devices to prevent pressure ulcers.
Multivotins The
solution must be
alien with all
9.Conduct daily rounds to check the staffcompliance with the Tuming clock
organization
strategv. and impose OVR for non-compliance.

l0.Formulation of Tissue Viability Team to properly assessed and treat the

pressure ulcer.

Qurlity Mrn.gcmcnt & Prlient Srfcty Dep.

Emril: has-kssh-tamAmoh.qov.sa E\t # l0E0

FOCU S-PDCA Template.doc -4


qtrE.rall gltb gr.o-+r-
Hall Healttt Cluster
Kingdom of Saudi Arabia
Ministry of Health
Hail Health Cluster
King Salmsn Specialist Hospital
TQM & Petient Safety Department

The Performance Improvement Methodology of Nursing Department

II. PDCA
STEPS FOR IMPLEMENTATION OF IMPROVEMENT OPPORTI.I\ITIES. PDCA

Plen - the im rovement

Action plan Responsible Timeline Status
.iiisl ili person .JJrr.'.'.J iltr
o.3.ill .irijsrt
.dJ3,r.ll
To conduct proper head-to- All StaffNurses End ofseptember Met
toe assessment including Charge Nuses 2021
Braden Scale Skin Risk
Assessment and document
appropriately and
accurately.
Prompt notification to All StaffNurses End ofSeptember Met
Attending Physician for Charge Nurses 2021
proper evaluation and
management and referral to
appropriate specialty if
needed
Data collection and KPI Nursing Quality End of September Partially Met
analysis Coordinator 2021
NQ Desi$ees

P
i'r!ilr,}.9
Prompt reponing thru OVR
to Risk Manager and KPI
form to Nursing Quality for
further assessment and
monitoring.
To conduct series ofrainings,
All StaffNurses
NQ Designee

CNE
End ofSeptember
2021

End of202l
Met

Open
&lrll lectures and competency for Charge Nuses
.l-.,;i.ll staff nurses regarding pressure
ulcer assessment, reassessment
and documentation especially
for new nurses.
To provide awareness lecture Nuning Quality End of 2021 Open
regarding APP 90 Management Coordinator
of Pressure Ulcer Policy NQ Desigrees
To request for additional staff Director of Nursing End of202l Open
fiom RNA to improve stafiing
ratio
To request from the Hospital Director ofNursing End of202l Open
Administration additional good Nurse Manager
quality mattress, special ICU
tuming bed, VAC Machine,
linens and dressing supplies for
pressure ulcer
To request Biomed Department Director ofNursing End of September Open
to conduct training for staffon CNE 2021
the use ofmedical devices to
prevent pressure ulcer

Qurlity Mrnrgcment & Prticnt Srfcty Dep.

Emril: lg$$bllgJqeoqlgqr:$ rrr # l0lt0

FOCUS-PDCA Template.doc -5-

 Kingdom ofSeudi Arabia
Ministry of Health
Hail Health Cluster
King Salman Specialist Hospital
TQM & Patient Safety Department
lJn-ftall JJb €r.o+I
Haat Heatth Cl.rster

Do - the improvement

Action plan Procedures that has bcen Percentage

achieved of
compl€tion
To Conduct series of
trainings and lectures for Ward lectures and short activities 730/"
staff nurses regarding and in-service program
presswe ulcer assessment
and management 62 saff(ICU, Burn,
Oncou.rctures conducted (45)
* 100

To request from Medical PAR level and availability of Air

Store Manager appropriate mattress t00%
and sufficient supplies to
manage pressure ulcers (Policy (33) on PAR level and # of
effectively available air mattress in the
unit's/bed capacity)

To enhance the disseminated

approved Policy regarding Uploaded in the system r00%
) Pressure Ulcer Management

rJrltli+lL
qreil
i tr:xl To monitor reports of newly
developed pressure ulcers Submission of KPI for newly
among KSSH patients develop pressure injury 9lo/"

(Reported Month/Jvlonths of the

year+ 100)

To disseminate tuming Monitoring of compliance rate on

clock to all units and change on position. 9lYo
daily monitoring for
staffcompliance (Reported Month/Months of the
year* 100)

Qurlity Mrnrgement & Prticnt Srfcty Dep.

Emril: !g!:kEhjg!g@gqh.g9f.!s E\r # l0t0

FOCUS-PDCA Template.doc -6-

 Kingdom of Saudi Arabia
Ministry of Health
Hail Health Cluster
King Salman Specialist Hospital
TQM & Patietrt Safety Departmert
ln5Ell JJtr po+,
Hall Healttr Cluster

Check - the results

During the l$ quarter, pressue ulcer incidence rate for KSSH inpatients was minimal, however
there was increased during the second till the third quarter ofthe year due to increased number of
CovID patient and limited repositioning activity caused by underlying disease. In the last quarter
ofthe year the pressure ulcer slightly decreased.

INCIDENT RATE

C 2.5G$ 2.24
La2Yo
2-W 1.70v"
1.50%
(, 1.36%
7-50)6 a.t2
z 1_Oa"/"

7.OAA
ciujlr o. sBl
o.60%
o.s096
O.3alo
.l{ii.ji.r a 096 o9/o
o.oe/.

** $* *1""]X"s?.$"!""'
os1ll""s\""e "$
CALENOAR MONTH 2021

Act - to hold the gain

o Continuously follow-up the staff for prompt reporting of newly developed pressure
ulcers
. Follow up the staffs compliance in proper pressure ulcer assessment and management
including 2-hourly repositioning
. Request for appropriate and sufficient supplies to manage pressure ulcers effectively
dl,,3Sl +rl . To conduct additional training and lectures for staffnurses regarding proper
,q!ejJ&ll assessment and management ofpressure ulcers
JIJ.l{ . Active referrals to Tissue Viability Team whose primarily focus is wound care and
J-r e1.tlJ.f-Yl
pressure ulcer management among KSSH patients
.dJiIPDCA
. To continuously monitor the incidence rate of pressure injury as goal was not yet met.

Prepared by Prepared by Prepared by Reviewed & Approved by

-4.9f"^ia
Ms. Eloisdcsy Castro
-1*
Ms. Hala Alrakad Ms.
,l__1
BAmir Escuadra IM
a
AND
Nulsing Quality Coordi$atoJ Nursing Quality CoordiDator DeputrDiieclor of Nulsing P
a(lwl_n rylwln 4 ''' xlolw>,t nJn
Reviewed &Approved b/: Approved by Approved by / Appro'tdby

o
4{
&
Alsha
Fahad
arl
Parient Safety Dirqclor
>9 lt+l*a
*N
Ms. Tahani Awadh
Alshatuari -'/
t
rayem Mr. Faiz Ma
Hospital D
Quality
mmarr
of
and Patient

tlrr/".,r 7( ,\
(. \Y 1
Quality Mrragement & Prtient Safety Dep.
f,mail: b4:L$h:tlqgAEgb:g9!:!4 E\t # t0E0

FOCUS-PDCA Template.doc -7 -