Qi Final

Devonne Husband, Javi
Perez & Ceci McGalliard

Southern Arizona Veterans Association
Hospice Unit
Focus: Patient safety related to implentation of process
audits for pressure ulcer reduction
Leaders are those individuals who are
out front, taking risks, attempting to
achieve shared goals, and inspire
others to action
Authoritarian leadership
Centralized
Institute of Healthcare Improvements. (2015). Clinical microsystem assessment tool [PDF document]. Retrieved
fromhttps://d2l.arizona.edu/d2l/le/content/587784/viewContent/5256079/View
Marquis, B.L., & Huston, C.J. (2017). Leadership roles and management functions in nursing theory and application (9th
ed.). Philadelphia, PA: Wolters Kluwer
The larger organization is inconsistent and
unpredictable in providing the recognition, information
and resources needed to enhance my work
Organizational Structure
No Huddles
Hierarchical
Teaching Hospital
Organizational Culture
Physical Environment
Social Environment (Communication)
We provide quality healthcare to veterans in an environment of
compassion, education, and research
Actively working to provide care that is respectful and responsive to
individual patient preferences, needs and values
Patient care is organized first and foremost around the needs of patients
No consistent audits, which increases patient risk and decreases safety
Staff Focus
I feel like I am a valued member of the microsystem, but I dont think the
microsystem is doing all that it could to support education and training
of staff, workload, and professional growth
Continuing education
Incentives for staff
U.S. Department of Veterans Affairs. (2017). About the Southern Arizona Health care System. Retrieved from
https://www.tucson.va.gov/about/
Lack of collaboration and a lack of
appreciation for the importance of
complementary roles
Interdisciplinary team meetings for patients
Independent work is valued
Phone technology for communication
Patients have a variety of ways to get the
information they need
Not utilized
I am always tracking down the information I need to

do my work
Charting system dated and complex
The technology I need to do my work is either not

available to me or it is available but not effective
Focus on charting rather than on patient
Some resources are available to support
improvement work but we dont use them as
often as we could. Change ideas are
implemented without much discipline
High pressure ulcer rates
CAUTI/CLABSI prevention not emphasized
Lack of follow-up on never events
We dont collect data on the processes of
care we provide
Poor feedback to staff
Patient safety compromised
Staff performance greatly improves with lower
patient to nurse ratio leading to increased
staff feedback
Implementing regular audits and benchmarking in
order to reduce pressure ulcer rates in patients
A study by Gullen Gill demonstrated that reviewing
and updating the staff with evidenced based
pressure ulcer prevention guidelines. Additionally
the use of auditing and benchmarking has even
further decreased pressure ulcer occurrences.
Goal: Decrease number of hospital acquired
pressure ulcers.
Cullen Gill, E. (2015). Reducing hospital acquired pressure ulcers in intensive care. BMJ Quality Improvement Reports, 4(1), u205599.w3015.
doi:10.1136/bmjquality.u205599.w3015
Evaluate current pressure ulcer prevalence, Within 8 weeks Week 8
stages, education and knowledge throughout
hospital
Educate unit managers Within 4 weeks Week 12
Managers educate all staff members on the Within 4-8 weeks Week 20
unit
Create committee of unit nurses for skin Within 4 weeks Week 24

survey
Implementation of first monthly skin audit Within 2 weeks Week 26
After 6 months of skin surveys, analyze data Within 6 months Month 12
Evaluate effectiveness of skin audit Within 2 weeks Month 13

Aim: Increase staff knowledge and utilization
of prevention methods for pressure ulcers
through hospital-wide audits.
Measure: qualitative (surveys) and
quantitative (prevalence, stage) data
Changes: Decrease hospital acquired
pressure ulcers and increase the utilization
of audits in providing high quality patient
centered care
Cullen Gill, E. (2015). Reducing hospital acquired pressure ulcers in intensive care. BMJ Quality Improvement Reports, 4(1),
u205599.w3015. http://doi.org/10.1136/bmjquality.u205599.w3015
Michael, S., Gompels, M., Sabin, C., Curtis, H., & May, M. T. (2017). Benchmarked performance charts using principal components
analysis to improve the effectiveness of feedback for audit data in HIV care. BMC Health Services Research, 171-10.
doi:10.1186/s12913-017-2426-6
U.S. Department of Veterans Affairs. (2017). About the Southern Arizona Health care System. Retrieved from
https://www.tucson.va.gov/about/

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Devonne Husband, Javi

Perez & Ceci McGalliard

Independent work is valued

Phone technology for communication

I am always tracking down the information I need to

Charting system dated and complex

The technology I need to do my work is either not

Educate unit managers Within 4 weeks Week 12

Create committee of unit nurses for skin Within 4 weeks Week 24

Implementation of first monthly skin audit Within 2 weeks Week 26

After 6 months of skin surveys, analyze data Within 6 months Month 12

Evaluate effectiveness of skin audit Within 2 weeks Month 13

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