Embracing the use of skin care champions

National focus on pressure ulcers is the result of studies that reveal an increase in the number of patients who have them and poor compliance with clinical practice guidelines on pressure ulcer prediction and prevention.1–4 Pressure ulcer-related hospitalizations have also been found to be two times longer and more costly than many other hospitalizations. Medicare and Medicaid pay about 75% of these costs.5 The Centers for Medicare and Medicaid Services no longer reimburses hospitals for the treatment of hospital-acquired Stage III and IV pressure ulcers because most are reasonably preventable with evidence-based care.6 Hospitals now find themselves reviewing their organizational policies and practices to improve pressure ulcer prevention processes and outcomes. The literature identifies seven organizational factors that are important to quality improvement success: ♦ strong administrative support ♦ active board of directors involvement ♦ multidisciplinary involvement ♦ expert performance improvement staff ♦ effective quality data systems ♦ individual staff-level involvement and accountability ♦ effective communication structures and processes.7 One study found that four of the factors were critical to improving patient-safety outcomes: directly involving top- and middle-level leaders; aligning improvement efforts and organizational priorities; establishing infrastructure processes to evaluate performance for ongoing quality improvement; and developing champions, teams, and staff.8 The role of champions has often been examined in management literature. Champions are opinion leaders, facilitators, or change agents who promote the use of evidence-based practice.9 Their activities are based on increasing recognition that communication and interactive social process are key factors in knowledge diffusion and implementation of research into practice.10–12 Champions adopt care management processes that achieve effective and safe care and mobilize their colleagues' involvement in these quality improvement projects.8 They're advocates of new ideas or initiatives and work diligently to promote them.12 Personal ownership of the idea, initiative, or quality improvement project is a central feature of the role. Champions are trained for the job but must also possess strong communication and interpersonal skills and the ability to influence others to practice evidence-based care. In addition, champions must be recognized as credible by those with whom they work and senior management.8 The Institute for Healthcare Improvement (IHI) recommends hospitals consider using skin care champions within the hospital or in each unit.13 However, we know little about the role and responsibilities of skin care champions in pressure ulcer prevention and outcomes. A literature search on PubMed and CINHAL from 1994 to June 2009 was performed using the keywords pressure ulcer prevention, skin care champions, and skin care teams. In addition, abstracts of studies and quality improvement projects approved for presentation at the 3rd Annual National Database of Nursing Quality Indicators (NDNQI) Data Use Conference held in January 2009 and the 41st Annual Wound, Ostomy and Continence Nurses Annual Conference held in June 2009 were reviewed for reference to the use of skin care champions in these studies or quality improvement projects. Examples of success stories related to pressure ulcer prevention posted on IHI's website were also examined. Each of the 5 journal articles, 13 abstracts, and 4 success stories identified were analyzed to determine the role and responsibilities of skin care champions in pressure ulcer prevention and outcomes. What makes a champion? Skin care champions are either internal or external to an organization and act in a formal role to improve pressure ulcer practice. The Canadian Association of Wound Care created a Pressure Ulcer Awareness and Prevention (PUAP) quality improvement program that assigns a skin care champion who has wound and skin care experience to each interested healthcare facility to spearhead the PUAP program.14 This skin care champion acts as a coach for the facility pressure ulcer team, educates facility staff, and promotes self-sustaining change. However, the relationship between the skin care champion and healthcare facility is often short-term or time- limited, and research has shown that improvements in pressure ulcer practice may not be maintained after a skin care champion leaves the healthcare facility.15 Skin care champions who are internal to the organization build longer-term relationships and are recommended for successful system redesign. Most skin care champions are unit-based because studies have found that overcoming resistance to change often requires a champion who's "one of their own" and can "speak the language" of the staff members they're trying to sway.16,17 Unit-based skin care champions are nurses who may be recruited by nursing management or administration based on their champion capabilities, or they may volunteer for the role out of personal or professional interest in skin and wound care.18 These skin care champions receive intensive training on evidence-based pressure ulcer practice that may include one-on-one educational sessions with a certified wound-ostomy-continence nurse, initial and ongoing formal classes and workshops, or an extended clinical practice fellowship.19–21 Skin care champions are empowered to assist with decision making regarding skin care in their unit and are provided dedicated time to engage in skin care quality improvement initiatives. Skin care champions promote evidence-based pressure ulcer prevention care and encourage needed practice changes at the unit level.22,23 They serve as the unit resource for pressure ulcer prevention care, educate and update unit staff on pressure ulcer practice issues, and assist the staff to develop individualized plans of prevention for patients in the unit.18,19,24,25 These champions round on unit patients who are identified as being at risk for pressure ulcers to ensure implementation of pressure ulcer prevention interventions, perform chart reviews to monitor compliance, and identify unit-level barriers to providing evidence-based prevention care.23–26 They participate in facility pressure ulcer incidence and prevalence studies and communicate results to unit staff, the unit manager, the nursing quality improvement committee, and nurse administrators.18,20,24 (See Table 1.) Successes are recognized and celebrated.26,27 For all incident pressure ulcers in the unit, champions conduct a medical record review to determine the cause and develop an action plan for process improvement.23,25 It's important that unit staff feel direct and active ownership of the redesign efforts.8 Creating teams Unit-based skin care champions meet together weekly or monthly. The skin care champion team is usually chaired by one or more certified wound care nurses and may be attended by performance improvement staff and other nurse leaders.21,23,24 The purpose of the team meetings is to review unit pressure ulcer prevalence and incidence results and unit root cause analysis results, address pressure ulcer prevention issues, and discuss unit-level improvement experiences.18,23–25 Progress reports are usually shared at all levels of the organization to promote accountability and encourage ongoing achievements.26,28 The skin care champion team is responsible for the education of new staff on pressure ulcer quality of care and the ongoing education for all staff on pressure ulcer prevention, identification, and care issues.29,30 The skin care team is also responsible for standardizing pressure ulcer prevention and other facility-wide skin care protocols and recommending modifications to documentation processes to include evidence-based pressure ulcer prevention care.21,31,32 For example, the patient admission assessment may be enhanced to include a skin inspection for pressure ulcers or the 24-hour nursing documentation may be modified to include pressure ulcer risk assessment and preventive care. The team trials new skin care products, makes decisions on support surfaces, and standardizes specialty bed and surface use.18 Improving outcomes Use of skin care champions in prevention programs has improved pressure ulcer outcomes. Hospitals that included unit-based skin care champions in a pressure ulcer prevention program commonly reported a 40% to 50% decrease in hospital-acquired pressure ulcers rates; in some cases a 70% to 80% reduction was noted.24,33 At OSF Saint Francis Medical Center in Peoria, Ill., the rate of hospital-acquired pressure ulcers was reduced from 9.4% to 1.8% over a 5-year period when skin care champions were one of the Six Sigma strategies.23 One study reported a 50% reduction in hospital-acquired pressure ulcers within 9 months of implementing a pressure ulcer program that involved use of unit-based skin care champions; financial benefits from the project included a 1.2 million cost savings.21 At Ascension Health, skin care champions helped to reduce the incidence of pressure ulcers from greater than 2% to less than 1%.26 Pressure ulcer severity also declined and no new Stage III or IV pressure ulcers developed from 2004 to 2006. Owensboro Medical Health System in Owensboro, Ky., reduced its rate of hospital-acquired pressure ulcers from 24% to 0% over a 5-year period with the assistance of skin care champions.32 Increased staff knowledge and use of evidence-based prevention interventions were commonly noted.25 Onslow Memorial Hospital in North Carolina achieved a 98% to 100% compliance with 24-hour nursing assessments, pressure ulcer prevention interventions, and risk assessment scoring when unit-based skin care champions were included in the prevention program.29 Additional benefits included the formation of a consistently well-trained pool of data collectors for more reliable results from prevalence and incidence studies.25 Bringing prevention to the bedside Pressure ulcers are a serious healthcare problem and the target of care quality reform. Review of the literature suggests that skin care champions improve the quality of pressure ulcer prevention and reduce the rate of hospital-acquired pressure ulcers. Although use of skin care champions is one component in a comprehensive pressure ulcer prevention program that requires multidisciplinary effort, it brings evidence-based pressure ulcer prevention to the bedside, mobilizes unit staff responsible for quality improvement, and increases unit accountability for providing safe and effective care.