Quality-Assessment System to Evaluate Pressure Ulcer Care
Quality-Assessment System to Evaluate Pressure Ulcer Care
Objectives: To demonstrate reliability and feasibility of a standardized protocol to assess and score quality indicators relevant to pressure ulcer (PU) care processes in nursing homes (NHs).
Design: Descriptive.
Setting: Eight NHs.
Participants: One hundred ninety-one NH residents for whom the PU Resident Assessment Protocol of the Minimum Data Set was initiated.
Measurements: Nine quality indicators (two related to screening and prevention of PU, two focused on assessment, and five addressing management) were scored using medical record data, direct human observation, and wireless thigh monitor observation data. Feasibility and reliability of medical record, observation, and thigh monitor protocols were determined.
Results: The percentage of participants who passed each of the indicators, indicating care consistent with practice guidelines, ranged from 0% to 98% across all indicators. In general, participants in NHs passed fewer indicators and had more problems with medical record accuracy before a PU was detected (screening/prevention indicators) than they did once an ulcer was documented (assessment and management indicators). Reliability of the medical record protocol showed kappa statistics ranging from 0.689 to 1.00 and percentage agreement from 80% to 100%. Direct observation protocols yielded kappa statistics of 0.979 and 0.928. Thigh monitor protocols showed kappa statistics ranging from 0.609 to 0.842. Training was variable, with the observation protocol requiring 1 to 2 hours, medical records requiring joint review of 20 charts with average time to complete the review of 20 minutes, and the thigh monitor data requiring 1 week for training in data preparation and interpretation.
Conclusion: The standardized quality assessment system generated scores for nine PU quality indicators with good reliability and provided explicit scoring rules that permit reproducible conclusions about PU care. The focus of the indicators on care processes that are under the control of NH staff made the protocol useful for external survey and internal quality improvement purposes, and the thigh monitor observational technology provided a method for monitoring repositioning care processes that were otherwise difficult to monitor and manage.
Pressure ulcers (PUs) are an important quality measure in nursing homes (NHs) because they are common, often preventable, and associated with morbidity, mortality, and other quality-of-care problems. This study describes nine quality indicators that reflect PU care processes determined by expert consensus to be related to positive outcomes that are valid and feasible to implement in NHs. The quality indicators have been operationalized into a standardized system that incorporates explicit measurement protocols and scoring rules. Indicator scores based on direct observation and medical record data for residents in eight NHs are provided to illustrate how conclusions can be drawn about the quality of PU care using the indicators and standardized scoring system.
The description and testing of a standardized assessment system is the major contribution of this paper because little information is available about how to accurately assess NH care processes from medical records and observations of staff and residents. Problems with subjectivity and inconsistency in the federal and state survey processes have been documented; lack of a standardized system to evaluate quality contributes to these problems. The goals of this study were to describe data sources, assessment protocols, and scoring rules for nine PU quality indicators and to provide preliminary data about the feasibility of implementation and the reliability of the standardized protocol.
Objectives: To demonstrate reliability and feasibility of a standardized protocol to assess and score quality indicators relevant to pressure ulcer (PU) care processes in nursing homes (NHs).
Design: Descriptive.
Setting: Eight NHs.
Participants: One hundred ninety-one NH residents for whom the PU Resident Assessment Protocol of the Minimum Data Set was initiated.
Measurements: Nine quality indicators (two related to screening and prevention of PU, two focused on assessment, and five addressing management) were scored using medical record data, direct human observation, and wireless thigh monitor observation data. Feasibility and reliability of medical record, observation, and thigh monitor protocols were determined.
Results: The percentage of participants who passed each of the indicators, indicating care consistent with practice guidelines, ranged from 0% to 98% across all indicators. In general, participants in NHs passed fewer indicators and had more problems with medical record accuracy before a PU was detected (screening/prevention indicators) than they did once an ulcer was documented (assessment and management indicators). Reliability of the medical record protocol showed kappa statistics ranging from 0.689 to 1.00 and percentage agreement from 80% to 100%. Direct observation protocols yielded kappa statistics of 0.979 and 0.928. Thigh monitor protocols showed kappa statistics ranging from 0.609 to 0.842. Training was variable, with the observation protocol requiring 1 to 2 hours, medical records requiring joint review of 20 charts with average time to complete the review of 20 minutes, and the thigh monitor data requiring 1 week for training in data preparation and interpretation.
Conclusion: The standardized quality assessment system generated scores for nine PU quality indicators with good reliability and provided explicit scoring rules that permit reproducible conclusions about PU care. The focus of the indicators on care processes that are under the control of NH staff made the protocol useful for external survey and internal quality improvement purposes, and the thigh monitor observational technology provided a method for monitoring repositioning care processes that were otherwise difficult to monitor and manage.
Pressure ulcers (PUs) are an important quality measure in nursing homes (NHs) because they are common, often preventable, and associated with morbidity, mortality, and other quality-of-care problems. This study describes nine quality indicators that reflect PU care processes determined by expert consensus to be related to positive outcomes that are valid and feasible to implement in NHs. The quality indicators have been operationalized into a standardized system that incorporates explicit measurement protocols and scoring rules. Indicator scores based on direct observation and medical record data for residents in eight NHs are provided to illustrate how conclusions can be drawn about the quality of PU care using the indicators and standardized scoring system.
The description and testing of a standardized assessment system is the major contribution of this paper because little information is available about how to accurately assess NH care processes from medical records and observations of staff and residents. Problems with subjectivity and inconsistency in the federal and state survey processes have been documented; lack of a standardized system to evaluate quality contributes to these problems. The goals of this study were to describe data sources, assessment protocols, and scoring rules for nine PU quality indicators and to provide preliminary data about the feasibility of implementation and the reliability of the standardized protocol.
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