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Nursing Management December 2009 19www.nursingmanagement.com
Regulatory readiness
Embracing the use of
skin care champions
By Sandra Bergquist-Beringer, RN, CWCN, PhD; Kelly Derganc, RN, BSN;
and Nancy Dunton, PhD
N
ational 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 Serv-
ices 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.6Hospi-
tals now find themselves reviewing their orga-
nizational policies and practices to improve
pressure ulcer prevention processes and
outcomes.
The literature identifies seven organizational
factors that are important to quality improve-
ment 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 lead-
ers; aligning improvement efforts and organiza-
tional priorities; establishing infrastructure
processes to evaluate performance for ongoing
quality improvement; and developing champi-
ons, teams, and staff.8
The role of champions has often been exam-
ined in management literature. Champions are
opinion leaders, facilitators, or change agents
who promote the use of evidence-based prac-
tice.9Their 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 manage-
ment processes that achieve effective and safe
care and mobilize their colleagues’ involvement
in these quality improvement projects.8They’re
advocates of new ideas or initiatives and work
diligently to promote them.12 Personal owner-
ship of the idea, initiative, or quality improve-
ment 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 prac-
tice 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 lit-
erature 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 Qual-
ity 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 improve-
ment 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
Regulatory readiness
www.nursingmanagement.com20 December 2009 Nursing Management
4 success stories identified were
analyzed to determine the role and
responsibilities of skin care champi-
ons in pressure ulcer prevention
and outcomes.
What makes a champion?
Skin care champions are either
internal or external to an organiza-
tion 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 pro-
gram that assigns a skin care cham-
pion 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, edu-
cates 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 rela-
tionships 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 administra-
tion based on their champion capa-
bilities, or they may volunteer for
the role out of personal or profes-
sional interest in skin and wound
care.18 These skin care champions
receive intensive training on evi-
dence-based pressure ulcer practice
that may include one-on-one educa-
tional sessions with a certified
wound-ostomy-continence nurse,
initial and ongoing formal classes
and workshops, or an extended clin-
ical practice fellowship.19–21 Skin
care champions are empowered to
assist with decision making regard-
ing skin care in their unit and are
provided dedicated time to engage
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Regulatory readiness
www.nursingmanagement.com22 December 2009 Nursing Management
in skin care quality improvement
initiatives.
Skin care champions promote
evidence-based pressure ulcer pre-
vention care and encourage needed
practice changes at the unit level.22,23
They serve as the unit resource for
pressure ulcer prevention care, edu-
cate and update unit staff on pres-
sure 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 iden-
tified as being at risk for pressure
ulcers to ensure implementation of
pressure ulcer prevention interven-
tions, 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 stud-
ies 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 recog-
nized 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 own-
ership 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 pres-
sure 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 pre-
vention, identification, and care
issues.29,30 The skin care team is
also responsible for standardizing
pressure ulcer prevention and
other facility-wide skin care proto-
cols and recommending modifica-
tions 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 pres-
sure ulcers or the 24-hour nursing
documentation may be modified to
include pressure ulcer risk assess-
ment and preventive care. The
team trials new skin care products,
makes decisions on support sur-
faces, and standardizes specialty
bed and surface use.18
Improving outcomes
Use of skin care champions in pre-
vention 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 mil-
lion 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 Hospi-
tal in North Carolina achieved a
98% to 100% compliance with
24-hour nursing assessments,
pressure ulcer prevention inter-
ventions, 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 inci-
dence studies.25
Bringing prevention to the bedside
Pressure ulcers are a serious health-
care problem and the target of care
quality reform. Review of the litera-
ture suggests that skin care champi-
ons 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
Regulatory readiness
www.nursingmanagement.com24 December 2009 Nursing Management
evidence-based pressure ulcer pre-
vention to the bedside, mobilizes
unit staff responsible for quality
improvement, and increases unit
accountability for providing safe
and effective care.
NM
REFERENCES
1. Agency for Healthcare Quality and
Research. Pressure ulcers increasing
among hospital patients. http://www.
ahrq.gov/news/nn/nn120308.htm.
2. Bergquist S. The quality of pressure
ulcer prediction and prevention in
home health care.
Appl Nurs Res.
2005;18(3):148-154.
3. Lyder CH, Preston J, Grady JN, et al.
Quality of care for hospitalized
medicare patients at risk for pressure
ulcers.
Arch Intern Med.
2001;161(12):
1549-1554.
4. Saliba D, Rubenstein LV, Simon B, et
al. Adherence to pressure ulcer pre-
vention guidelines: implications for
nursing home quality.
J Am Geriatr
Soc.
2003;51(1):56-62.
5. Russo CA, Steiner C, Spector W. Hos-
pitalizations related to pressure ulcers
among adults 18 years and older. 2006.
http://www.hcup-us.ahrq.gov/reports/
statbriefs/sb64.pdf.
6. Clancy CM. CMS’s hospital-acquired
conditions lists link hospital payment,
patient safety.
Am J Med Qual.
2009;24
(2):166-168
7. Barron WM, Krsek C, Weber D, Cerese
J. Critical success factors for perform-
ance improvement programs.
Jt Comm
J Qual Patient Saf.
2005;31(4):220-226.
8. Wang MC, Hyun JK, Harrison M,
Shortell SM, Fraser I. Redesigning
health systems for quality: lessons
from emerging practices.
Jt Comm J
Qual Patient Saf.
2006;32(11):599-611.
9. Doumit G, Gattellari M, Grimshaw J,
O’Brien MA. Local opinion leaders:
effects on professional practice and
health care outcomes. http://www.
mrw.interscience.wiley.com/cochrane/
clsysrev/articles/CD000125/frame.html.
10. Backer, TE. Knowledge utilization.
Sci
Comm.
1991;12(3):225-240.
11. Rogers EM.
Diffusion of Innovations.
4th ed. Toronto, Canada: The Free
Press; 1995.
12. Thompson GN, Estabrooks CA, Degner
LF. Clarifying the concepts in knowl-
edge transfer: a literature review.
J
Adv Nurs.
2006;53(6):691-701.
13. Institute for Healthcare Improvement.
Prevent pressure ulcers: Getting
started kit. http://www.ihi.org/IHI/Pro-
grams/Campaign/PressureUlcers.htm.
14. Orsted HL, Rosenthal S, Woodbury
MG. Pressure ulcer awareness and
prevention program: a quality improve-
ment program through the Canadian
Association of Wound Care.
J Wound
Ostomy Continence Nurs.
2009;36(2):
178-183.
15. Xakellis GC, Frantz RA, Lewis A,
Harvey P. Translating pressure ulcer
guidelines into practice: it’s harder
than it sounds.
Adv Skin Wound Care.
2001;14(5):249-256,258.
16. Barker KK, Bosco C, Oandasan IF. Fac-
tors in implementing interprofessional
education and collaborative practice
initiatives: findings from key informant
interviews.
J Interprof Care.
2005;
19(Suppl 1):166-176.
17. Saint S, Kowalski CP, Banaszak-Holl J,
Forman J, Damschroder L, Krein SL.
How active resisters and organiza-
tional conspirators affect health care-
acquired infection prevention efforts.
Jt Comm J Qual Patient Saf.
2009;35(5):
239-246.
18. Stoelting J, McKenna L, Taggart E,
Mottar R, Jeffers BR, Wendler MC.
Prevention of nosocomial pressure
ulcers: a process improvement proj-
ect.
J Wound Ostomy Continence
Nurs.
2007;34(4):382-388.
19. Cowie K. Skin care champions making
a difference in the ICU.
CACCN.
2008;
19(2):37.
20. Duke University Medical Center. Put-
ting the pressure on pressure. http://
inside.duke.edu/article.php?IssueID=
162&ParentID=15245l.
21. Garza S, Okere V, Igbinoba J, Novosad
K. Reducing hospital-acquired pres-
sure ulcers. http://www.psqh.com/
marapr06/sixsigma.html.
22. Wound, Ostomy and Continence
Nurses Society.
Guideline for Preven-
tion and Management of Pressure
Ulcers.
Glenview, IL: WOCN; 2003:11-17.
23. Griffin B, Cooper H, Horack C, Klyber
M, Schimmelpfenning D. Best practice
protocols: reducing harm from pres-
sure ulcers.
Nurs Manage.
2007;38(9):
29-31,69.
24. Courtney BA, Ruppman JB, Cooper
HM. Save our skin: initiative cuts pres-
sure ulcer incidence in half.
Nurs
Manage.
2006;37(4):36,38,40.
25. Salisbury C, Dingley C, Johnson D,
Rose C, Rees K. The PUPPI (Pressure
Ulcer Prevention Performance
Improvement) Program: Waging
war on wounds. Poster presented
at: the 3rd Annual NDNQI Data Use
Conference; January 21-23, 2009;
Dallas, TX.
26. Gibbons W, Shanks HT, Kleinhelter P,
Jones P. Eliminating facility-acquired
pressure ulcers at Ascension Health.
Jt Comm J Qual Patient Saf.
2006;32(9):
488-496.
27. Maklebust J. Pressure ulcers: the
great insult.
Nurs Clin North Am.
2005;40(2):365-389.
28. Daniels MJ, Cann-Taylor J, Diamond V.
Linking nursing staff, unit, and divi-
sions performance with nursing sensi-
tive quality indicators. Poster pre-
sented at: the 3rd Annual NDNQI Data
Use Conference; January 21-23, 2009;
Dallas, TX.
29. Hayden C. Champions improve staff
education and compliance with pres-
sure ulcer prevention strategies.
http://www.ihi.org/IHI/Topics/Medical
SurgicalCare/MedicalSurgicalCare
General/ImprovementStories/Champions
ImproveStaffEducationCompliance
PressureUlcerPrevention.htm.
30. Meyers T. Skin care team reduces pres-
sure ulcer prevalence and incidents dis-
trict-wide. Poster presented at: the 3rd
Annual NDNQI Data Use Conference;
January 21-23, 2009; Dallas, TX.
31. Conti MT. Pressure ulcer prevention
success in an integrated healthcare
system (abstract).
J Wound Ostomy
Continence Nurs.
2009;36(3S):S27.
32. Jones M. Pressure ulcer prevention:
Our journey (abstract).
J Wound Ostomy
Continence Nurs.
2009;36(3S):S44.
33. Pinches A. Empowering nurses to
reduce hospital acquired pressure
ulcers. Poster presented at: the 3rd
Annual NDNQI Data Use Conference;
January 21-23, 2009; Dallas, TX.
At the University of Kansas, School of
Nursing in Kansas City, Kansas, Sandra
Bergquist-Beringer is an associate profes-
sor and NDNQI pressure ulcer consultant,
Kelly Derganc is a master’s student, and
Nancy Dunton is a research professor and
NDNQI principal investigator.
Nancy Dunton, PhD, research associate
professor, University of Kansas Medical
Center School of Nursing, NDNQI, Kansas
City, Kansas, is the coordinator of the
monthly Regulatory Readiness column for
Nursing Management
.