1. Photo Documentation RUHS
Daniel Mazzanti, Guadalupe Zepeda, Herb Ng, and Zobair Moaleji

2. These!
Background
MS Patient Settles Pressure Sore Lawsuit Against Home Health Agency for $600,000.
Can save these! D

3. It’s the right thing to do:
Better patient safety
Better healthcare outcomes
It’s the smart thing to do:
Regulations are coming
spread outlay over time
prevent fines and penalties
Protection against civil liability
Why this proposal?
Dan- After big investments, Riverside County hospital still shows $15 million shortfall
Since 2015, $25 million has been spent on new hospital equipment, including a new MRI machine and a surgical robot, and $53 million on a new electronic medical records system that allows the hospital to share patient information with other medical centers.

4. After big investments, Riverside county hospital still shows $15 million shortfall.
MS Patient settles pressure Sore Lawsuit Against Home Health Agency for $600,000
Point-of-care wound visioning technology: Reproducibility and accuracy of a wound measurement app.
Literature Review

5. Wound Photography – How it Benefits Clinical Documentation: A visual confirmation to the written record confirms that images:
Facilitate better diagnosis
Enhance clinical documentation
Help to monitor the progress of wound healing
Help prevent litigation in wound management
Allow inter-disciplinary communication among the wound care team
Reduce costs (Wound Care Advisor., 2017)
Patient perception of wound photography: Photographic documentation of difficult to see wounds from the perspective of the patient improved patient involvement in the wound care process (Wang et al., 2016).
Literature Review
Zobair

6. Root Cause Analysis Inaccurate documentation
and lack of supportive documentation during litigation.
Not all facilities have equipment. Resistance to change.
The inability of the management team to see the importance of wound documentation.
Lack of knowledge and lack of most UpToDate evidence based methods
Complacency and bureaucracy
If adherence is not perceived, The hospital is exposed to regulatory and civil lability L
Root Cause Analysis

7. Lewin’s Change Management ModelZ

8. Lewin’s Change Management Model
Communicating with all the stakeholders about the change, which will create a sense of trust and therefore reducing resistance.  
Unfreeze - Organization must get prepared for the change
Period of actual change including the planning and implementation stages of the project.  
Change - change takes place
Ongoing support of all stakeholders, with continuing training.   
Refreeze - change has been accepted, embraced and implemented by people, the company begins to become stable again.
Lewin’s Change Management Model Z

10. Problem:
Current wound documentation is not most accurate and can lead to detriment. H

11. PDSA: Aim
Registered Nurses of RUHS clinics will take pictures of wounds of all patients with Diabetes by June 2019. H

12. Tasks Person responsible When Where
Discuss the benefits of proper wound documentation.
Quality and Safety Team.
Immediately
At meeting with all facilities
2. Present the consequences of improper wound documentation
3. Review the standard protocol for wound documentation
All medical personnel.
4. Determine budget and number of cameras needed.
Finance, RN’s, and MD’s.
Various RUHS sites. H

13. Measures to determine if prediction succeeds
Incidence of pressures ulcers decrease.
Review and Analyze wound report monthly
Improved assessment of patient by referring back to wound pictures
Survey of nurses’ responses and opinion with the incorporation of wound pictures.
RNs more accountable to prevent pressure ulcers.
Incidence of pressure ulcers after 24 hours from admission
Doctors have a better picture of wound and does not have to rely solely on Nurse’s documentation.  
 Survey and questionnaire of doctors feedback of camera implementation. H

14. -Educate nurses, nurse Managers, and administrators, get buy-in
Introduction of camera
Start taking pictures on admission
Change becomes permanent L
(Monitor the use of the camera )
Reeducate as needed

15. Prediction Outcome Incidence of pressures ulcers decrease.
Pressures ulcer incidence decreased.
Improved assessment of patient by referring back to wound pictures
Doctors and nurses have mentioned that having a picture to compare with helps to see progression.
RNs more accountable to prevent pressure ulcers.
The focus has shifted, and RNs feel more pressure to ensure patient is turned Q2
Doctors have a better picture of wound and does not have to rely solely on Nurse’s documentation.  
Doctors report getting a more complete picture of what is happening with their patient.   H

16. Problem Solution Inaccurate documentation
Taking pictures to help support RNs documentation.  
Lack of supportive documentation during litigation.
Having pictures help support RN documentation during litigation.  
Summary
Pressures ulcer incidence decreased.
Doctors and nurses have mentioned that having a picture to compare with helps to see progression.
The focus has shifted, and RNs feel more pressure to ensure patient is turned Q2
Doctors report getting a more complete picture of what is happening with their patient.   D

17. Recommendations
Recommendations having extra camera and batteries, in case the primary one goes out.
It is also important that not everyone will consent to getting their pictures taken, therefore, documenting as normal without the picture.
We also recommend that people having a secondary light source in the event lighting is limited.
To prevent injury and take accurate pictures, the nurse should always be accompanied by a helper.
If funding is available, it may be appropriate to use a camera phone with an app integrated with the current system.

18. Stakeholder Analysis Internal stakeholder
RN, MD, PA, NP, nurse manager, CEO
External Stakeholder
Patient, Family, Insurance Companies, Tax payers L

19. Forcefield Analysis Forces For Forces Against Better Documentation
Introduction Of
Wound
Camera
The Cost of Purchasing a Camera
Better patient outcome
Patient Privacy
Accountability of RN
Management of the Camera System
Evidence for Litigation
Contamination of wound
Cost saving
Resistance to change

20. References
Horseman, J., & Horseman, J. (2018, February 21). After big investments, Riverside County hospital still shows $15 million shortfall. Retrieved from -riverside-county-hospital-still-shows-15-million-shortfall/ 
Newman, E. (2018). Photography should be used to document injury, forensic nursing expert says. Retrieved from -nursing-expert-says/
Nursing Home Law Center. (2019). MS Patient Settles Pressure Sore Lawsuit Against Home Health Agency for $600,000. Retrieved from -lawsuit-against-home-health-age.html 
Wang, S. C., Anderson, J. A., Jones, D. V., & Evans, R. (2016). Patient perception of wound photography. International wound journal, 13(3),
Wang, S. C., Anderson, J. A. E., Evans, R., Woo, K., Beland, B., Sasseville, D., & Moreau, L. (2017). Point-of -care wound visioning technology: Reproducibility and accuracy of a wound measurement app. Plos One, 12(8), e
Wound Care Advisor. (2017, August 06). Wound Photography – How it Benefits Clinical Documentation. Retrieved from documentation/