1. Getting to Zero Pressure Ulcers
Some Practical Advice
Matt Tite
Required additional resources:
You must have copies of the Sustainability Model & Guide and Improvement Leaders Guide (ILG) on Sustainability to present this module. Strongly recommended that you mark applicable pages with placeholders / bookmarks as you will be referring to both frequently…
Prepare flipchart template for the scoring exercise
Put the flipchart of Ground Rules up created on their first day.
Organising for Quality and Value
Delivering Improvement Programme 1

2. Health Service Executive http://www.hse.ie/pressureulcerstozero/

3. How the NHS implements change…

4. 7 Steps to measurement A road map of the ‘Alps’ 4 Collect Data
1 Decide Aim
2 Choose Measures
3 Define Measures
7 Steps to measurement
7 steps to measurement
Say that measurement doesn’t just happen. It requires a well defined process. The diagram shows the 7 steps necessary to get measurement to work for you. We will be covering each of the 7 steps during the day.
Move to next slide
For reference
Step 1 – Decide your aim
Step 2 – Choose your measures
Step 3 – Confirm how to collect and display your data
Step 4 – Collect your baseline data
Step 5 – Analyse and present your data
Step 6 – Meet to decide what it is telling you
Step 7 – Repeat steps 4 to 6 each month or more frequently
4 Collect Data
5 Analyse & Present
6 Review Measures
A road map of the ‘Alps’
7 Repeat steps 4-6

5. Health Service Executive http://www.hse.ie/pressureulcerstozero/

6. Applying Pareto to Harm Free Care
You may know this but this is ‘evidence’ to support this
80% of the Harms

7. Pareto using the Trigger Tool

8. Step 2 – Choose Measures

9. Three types of Measures for a Good Project
Outcome Measures
Process Measures
Balancing Measures
The Donabedian Model
The Donabedian Model is a conceptual model that provides a framework for examining health services and evaluating quality of care

10. Step 5 – Analyse & Present
Presentation
Dot plot
Individual value Plot
Interval Plot
Bar Chart
Run
Chart
SPC
Pareto
Scatter Plot
Tally Chart
Pie Chart
Radar Chart
Area Chart
SPC
Run Chart

11. Let me train you to be an analyst...

12. Mohammed A Mohammed THE LANCET • Vol 357 • February 10, 2001

13. How did we catch Harold?
A taxi-driver in Hyde, who had a niche business ferrying elderly people to the shops, markets, and meetings, had noticed that twenty two of his regular customers, whom he judged to be in reasonably good health and whom he knew to be registered with Shipman, had died suddenly over a six-year period.

14. Walter A. Shewhart (early 1920’s, Bell Laboratories)
Data contains both signal and noise. To be able to extract information, one must separate the signal from the noise within the data.

15. What does this data tell us?
Patients with Ulcers in April
600
550
610
540
560
570
580
590
Congratulations,
Aren’t we doing well
Keep up the good work
2013
2014

16. What does this data tell us?
Patients With Pressure Ulcers
650
600
550
500
450
400
350
300
All data needs to be put into context.
April 2013
April 2014

17. Looking for a trend Time  Upward trend Time  Downward trend
A run of 7 points is. All up, down or all above or below a centre line.
7 points all in
downward direction
7 points all in
upward direction

18. Looking for a trend Time  Above centre Time  Below centre
A run of 7 points is. All up, down or all above or below a centre line.
7 points above centre line
7 points below centre line

19. http://www. institute. nhs

20. Import your data…

21. Use the Pareto Principle…

22. Create Statistical Process Control Charts…

23. The Royal Wolverhampton NHS Trust

24. “In God we trust, all others bring data”
- W. Edwards Deming

25. Always there to help you care.
Head Office
Tooraree, Knock Road, Ballyhaunis, County Mayo.
Tel: Web:
Always there to help you care.