GMCF Prevents Pressure Ulcers in 53 Georgia Nursing Homes

For the Georgia Medical Care Foundation (GMCF), the Medicare QIO for Georgia, strong partnerships with nursing homes and other health providers are critical to improving patient care processes and reducing pressure ulcers. Under the Patient Safety theme of the current QIO contract, GMCF is working with 53 nursing homes statewide. GMCF’s implementation of facility-centered improvement plans in Georgia nursing homes resulted in a 20.99 percent relative improvement for the period of October 2009 to March 2010 as compared to baseline pressure ulcer rates.

“We are a trusted partner to providers and health care organizations in the state,” said Anne Hernandez, patient safety manager at GMCF. “Providers know they can count on regular, face-to-face contact with a Quality Advisor from GMCF.”

Root Cause Analysis

GMCF begins its work by conducting a root cause analysis (RCA) to drill down into each nursing home’s processes for pressure ulcer prevention and treatment. By pinpointing the causes that are most closely related to high pressure ulcer rates, the RCA leads to effective solutions to remedy the problem and prevent recurrence. Based on the RCA findings, GMCF develops an individualized improvement plan for the nursing home. These plans often incorporate tools from the Advancing Excellence in America’s Nursing Homes campaign, including;

• Experiential sessions like “Skin Care Fairs” to improve staff competency in preventing pressure ulcers
• Sessions to enhance patient care communication among staff and between shifts
• Educational DVDs on skin care and pressure ulcer prevention for non-Caucasian skin, for which the warning signs of ulcer formation can be different
• Pocket guides for staff on the body’s pressure points 
• “Stop and Watch” cards that help staff identify the early signs that a resident’s health is declining
• Posters to support structured communication between patient care staff using the “Situation, Background, Assessment and Recommendation” format

Cross-setting Meetings

According to GMFC, strong participation in community meetings that brought together staff from local nursing homes, hospitals, home health agencies, dialysis centers and transportation services is one of the most successful outcomes of the project. The meetings, which occur in 15 locations throughout the state, generate discussion on how to improve transitions between and within settings of care – for example, from hospital to nursing home – and on how to promote open communication to address other common challenges to pressure ulcer prevention.

“Pressure ulcers are a systemic problem,” Hernandez said. “Most often, they are the result of poor communication or a failure to transfer knowledge across care settings. Together, GMFC and its partners are bridging this gap.”