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4.3 How do we put the new practices into operation?

After you determine the bundle of pressure ulcer prevention practices (described in section 3) and how roles will be defined and work organized to carry out those practices at the care level in the units (described in section 4.1), you will need to develop strategies for putting these practices into action. In this section, we focus on pilot testing and initial implementation of the new practices. In section 6, we will move to sustaining your improvement efforts.

To guide the changes that will be needed, you should consider four questions:

• How do we manage the change process at the front line?
• How do we pilot test the new practices?
• How do we get staff engaged and excited about pressure ulcer prevention?
• How can we help staff learn new practices?

The plans and activities triggered by these questions will need to be addressed simultaneously because while separate conceptually, they will overlap in practice.

4.3.1 How do we manage the change process at the front line?

As highlighted in earlier sections, incorporating the new bundle will involve changes in the way people do their work, which is often difficult. In some cases the changes will be minor, but in others they will be substantial. Therefore, to make the needed changes:

• It will be important to ensure that staff understand the new roles and have the knowledge and tools to carry them out.
• Help reduce resistance to change by ensuring that staff understand the reasons for change and agree that change is needed.
• To help staff accept the new bundle of practices fully, ensure that they understand that those practices offer promising strategies for providing high-quality care for patients.
• Identify and minimize practical barriers to using the new practices, such as inadequate access to supplies.
• At all levels, engage staff to gain their support and buy-in to the improvement effort and help tailor the practices in pressure ulcer prevention.

To manage the change process effectively, the Implementation Team will guide, coordinate, and support the implementation effort during the pilot phase and as the new prevention practices are rolled out across the hospital. The Implementation Team will work with the Unit Champions described in section 4.1.4 or with others designated as the unit-level lead for this improvement effort. They will need to work in a variety of areas, discussed below.

Refining the implementation plan

The assessments and planning that your Implementation Team conducted earlier in the process will provide the basis for addressing these issues and thus managing this change process successfully at the front line. The assessments and planning will have helped you identify the issues you need to deal with and chart the paths for dealing with them. If the Implementation Team did not work through those sections earlier, you should consider working through them now.

• Tools are provided in section 1.2 to assess staff understanding of the reasons for change and in 2.2.3 to assess current levels of knowledge about pressure ulcer prevention and to identify gaps in knowledge, such as beliefs that a certain incidence of pressure ulcers is inevitable. Together, these assessments can help you determine where attitudes need to be changed and knowledge improved, and what barriers need to be addressed at the unit level.
• Section 2.2.2 provided guidance for process mapping and gap analyses of current practices that can help you systematically assess barriers to consistently using best practices, such as lack of awareness, lack of assignment of responsibility, or lack of training. These assessments can help you target training to areas where there were gaps and where practices will now be changed and to reinforce existing practices that will be continued.
• Section 1.5 provided guidance on determining the types of resources needed to support the improvement process and the level of pressure ulcer prevention care that will result from the process. Sections 1.1 and 1.2 provided guidance on working to ensure that your colleagues and organizational leaders understand why change is needed. Together, these sections can help you make the case for obtaining the resources needed.

Building on your understanding of your organization and the issues you need to address, you should review and may want to refine your Implementation Plan (discussed in section 2.3.2). You can outline your strategies for introducing and supporting the new practices (described in this section), pilot testing the bundle (discussed in section 4.2.2), and engaging and educating staff to implement the new bundle (discussed in more detail in sections 4.2.3 and 4.2.4).

Getting started

The Implementation Team should work with Unit Champions to get the implementation process started and to coordinate it. The Unit Champions will provide an important link between the Implementation Team and the Unit-Based Team in the pilot and early implementation efforts. Their roles should be clearly defined so that both they and others in the unit know what to expect.

Unit Champions can work with the Implementation Team to introduce the new practices to the unit staff. Champions can talk both about organizational change and the specifics of the new pressure ulcer practices and engage staff in tailoring the practices to their unit. Champions also can address perceived barriers and potential resistance and troubleshoot problems if any arise when implementation begins.

All shifts should be included in these discussions. Unit Champions should be available to answer questions and problem solve. You should consider whether Implementation Team members will also be available for frontline questions and troubleshooting or whether they will work at a higher level.

Involving staff, clinicians, and middle managers

At the unit level, it will be important not only to involve frontline nurses and support staff but also to involve nurse managers and physicians. We talked earlier about the importance of leadership support for improvement efforts. The focus then was on senior leadership, but support of middle managers is also needed. For example, nurse managers and service chiefs should be involved in early discussions about how the new bundle will be introduced and strongly supported in their units.

Physician involvement is often overlooked in wound care but needs to be encouraged. This is especially true if much of the medical care is provided by a small number of hospitalists. Make sure they are aware of best practices in pressure ulcer prevention and hospital policies and procedures.

Monitoring implementation progress

The Implementation Team and Unit Champions should develop a process for ongoing monitoring of implementation progress. Part of the process will be gathering feedback from staff and clinicians. For example, Unit Champions can compile questions and problems from staff to send back to the Implementation Team.

In addition, the monitoring process should include tracking changes in assessment and incidence and prevalence rates, as described in section 5. Results should be communicated to staff and to the Implementation Team. The information loop should be closed by having the Implementation Team report to the unit what it did with the information the unit provided.

Sustaining management support

Above the unit level, the Implementation Team should continue to engage senior leaders and middle managers to sustain their early support for the improvement effort. Progress and performance should be reported to senior leadership regularly. Management support will be needed during implementation in multiple ways:

• Leaders and managers are important sources of communication. Their expressed support for improving pressure ulcer prevention will reinforce its importance and thus increase the impetus among staff to adhere to the new practices.
• Leaders and managers can help remove barriers across departments. While the Implementation Team by design should include all divisions affected by pressure ulcer prevention and thus have the right people at the table to work across them, some issues may not be resolved within the Implementation Team but need to be taken to a higher level of authority. This will be particularly important if your organization does not have a strong history of quality improvement that gives staff and managers on the improvement team authority to change procedures as needed.
• Senior leaders may need to authorize resources for the prevention initiatives. In the pilot and early implementation phases, the Implementation Team may need, for example, to negotiate with administration (and unit managers) to secure release time for Unit Champions and for staff training. Management's financial support will be needed, for example, if new support surfaces are recommended in the bundle or if a pressure ulcer prevention campaign needs visibility tools such as posters or buttons. You initially considered resource needs for pressure ulcer prevention in section 1.5. As suggested above, the Implementation Team should review that list and update it if needed.

Action Steps

• Building on the work from earlier sections, refine your Implementation Plan to outline the details of your strategies, including lead responsibility and timelines, for managing change at the front line.
• Clarify the roles of the Implementation Team and Unit Champions for the implementation period. Communicate those roles to frontline staff and leadership.
• Confirm management support for the resources needed for hospitalwide implementation in terms of (among other things):
  • Expressed support for the initiative.
  • Additional months for Implementation Team to work.
  • Training resources and release time for unit staff involved in prevention.
  • Resources for equipment and supplies.
  • Policies and procedures in place.
• Develop a process for monitoring implementation closely and making midcourse corrections as needed.
• Carry out your strategies so that you successfully implement the new practices.

4.3.2 How do we pilot test the new practices?

In starting the implementation process, many organizations begin the rollout of new practices in one or two units before launching them across the hospital. Pilot testing will allow you to identify and work out any problems in the recommended practices and processes at an early stage and thus refine the program to better fit your hospital before you do the entire launch. It also can generate early success that will build momentum for later spread across the organization.

Small hospitals may have only be few units, so a formal pilot may not be practical. If so, it is still important to consider a trial period where you get feedback and allow for program refinements. It can bring the same advantages of a more formal pilot in identifying problems and customizing the bundle of prevention practices to fit your hospital needs early in the implementation process.

To begin the pilot, you should choose one or two units to participate. Different criteria may be applied to the selection. You may identify one unit that was successful with a past improvement project and one that was not so successful. You may use a unit with low pressure ulcer incidence and a unit with high incidence, or units that present different implementation challenges, such as surgery and ICU. By selecting several very different units, your Implementation Team can hear from the Unit Champions and staff what they like and problems they have had implementing the project. Two widely different units will give you a better overall feel for refinement that may be needed and how to answer staff questions that arise.

You will also need to decide what information you will want to collect, and from that decide how long to try out the new bundle. The pilot test can provide two types of information: (1) the outcomes you will collect to judge the pilot's success, such as rates of completion of comprehensive risk assessments or better adherence to repositioning guidelines, and (2) feedback from participants on how the new bundle is working in terms, for example, of the clarity of expectations or the impact of the new practices on their workflow. Section 5 provides tools that will help in measuring outcomes.

You should use information from the pilot to change the bundle to meet your hospital needs and to change the ways in which it is introduced to staff. You also can use the pilot to identify additional staff barriers to change. Rather than designing the pilot like a research project where the intervention—in this case the pressure ulcer prevention bundle—is held constant for the duration of the test period, consider conducting a formative pilot in which changes are made as needed during the pilot to maximize the likelihood of success. In this case, pilot information will be provided to the participating units, Unit Champions, and the Implementation Team on a regular basis throughout the pilot period, rather than simply after it has been completed. Minor modifications can be made along the way and their impact followed within the pilot phase.

Action Steps

• Design and conduct the pilot, making changes as needed if that is your chosen approach.
• Compile staff questions and problems that arose to guide changes and analyze measures of success.
• Communicate the results to the participating units, the Unit Champions, the Implementation Team, and hospital leadership.
• Refine the practices to address problems that surfaced in the pilot test.
• Use the list of staff questions from the pilot units and answers to create an implementation tool for the hospitalwide launch.

4.3.3 How do we get staff engaged and excited about pressure ulcer prevention?

Engaging the buy-in, commitment, and ongoing participation of staff members is particularly important for staff who are involved in hands-on care and whose involvement will be needed to achieve the improvement objectives.

Should we mount a pressure ulcer prevention campaign?

Given the many competing demands for time on busy clinicians and clinical staff, how can you best achieve engagement in pressure ulcer prevention across the hospital? Just as we all celebrate birthdays, weddings, and other life-changing events differently, changing practice in your hospital depends on knowing the culture of your own organization. For some, launching a very public and highly publicized campaign is vital to the success of the improvement project. For other health care organizations, a large campaign could provoke a negative reaction from staff. For instance, some might think, "What's all the fuss about?" or "Here they go again with the latest campaign of the month. Let's do nothing, it will blow over, and there will be something else in a few months." Knowing what will work best in your institution is critical to the success of getting your staff motivated, involved, and committed.

Consider how the focus on pressure ulcer prevention fits into the core mission and values of your institution. Also consider whether there have been local events or cases that would help staff meaningfully connect with the importance of pressure ulcer prevention. Look at past improvement projects that involved multiple processes and disciplines across the hospital, and consider what the characteristics are of the most successful efforts in bringing about change.

An important aspect of engagement and something key to success in any change strategy will be clear communication through multiple paths. Be sure staff know the program is coming and are familiar with the new materials and roles prior to start. For example, you might have information sheets for the staff outlining changes to proactive, enhanced, and accountable prevention, and posters for unit display; also include information on how the program will be evaluated, what rewards will be, and how their results will be known.

Practice Insights

Examples of campaigns in other hospitals:

• One collaborative used a "No Ulcer" logo with staff lapel pins and unit posters. To launch the program, brochures on pressure ulcer prevention education were developed to give to patients and families on admission.
• Another hospital identified a theme called PUPPI on Patrol. This program used a puppy picture outside the room of a high-risk patient to remind staff to turn/reposition the patient and gave "best of show" awards to units with the highest documentation of prevention practices.
• A third site used the theme "no pressure at <name of site> <name of site> " to raise awareness of their pressure ulcer prevention program. Their activities included a "no pressure" theme song played at staff training sessions, ID holders, and a mannequin named Uncle Ulcer for hands-on staff training.

How should we work with staff at the unit level?

Regardless of whether you decide to mount a visible campaign or pursue a more low-key approach, you will need to work with staff at the unit level. Each unit has its own culture; some people will be willing to try something new and others will have difficulty or be unwilling to make any changes. To have any program be a success, unit staff need to have input and be able to make suggestions on how to individualize the program for their unit.

In preparation for the initial rollout or pilot testing on each unit, the Implementation Team or Unit Champion should meet with unit staff on all shifts. They should review the newly defined roles and responsibilities and work with the staff to determine how those roles and the paths for communication and reporting among staff need to be adjusted for their unit and how to address barriers to adherence. This process can be done with a unit-level improvement team or with the entire staff, for example, at a regular staff meeting.

You should choose the approach that works best for improvement efforts in your organization. A challenge in facilitating these discussions will be to distinguish between constructive tailoring that will enhance adherence to the new bundle and watering down the new practices that reflects reluctance to change or failure to accept the new practices.

Even with involvement in tailoring the changes to their unit or position, some clinicians and staff may be reluctant to use the new bundle. Strategies for dealing with such reluctance will depend on a number of factors, including the stage of implementation, the positions of and number of people resisting, and the reasons for and strength of resistance. If reluctance, or active resistance, is localized to specific parts of the hospital or to specific individuals, you may decide not to include those units or individuals in the early implementation. Focus instead on the units and people with the greatest interest and highest likelihood of success. Their early success may convince others that the new bundle is worth using. Or as implementation advances and the new bundle becomes the norm, peer pressure may spur resisters to change their minds.

Including pressure ulcer prevention in staff performance evaluations can formalize the new practices as the norm and enhance commitment. If resistance during early implementation is widespread, you will need to understand why and then either redesign the bundle or implementation strategy to accommodate the resisters' concerns or reconsider your earlier conclusion that the hospital is ready for this change. If the latter, you may want to continue to use the new bundle in volunteer units until you can build a successful case for hospitalwide use.

Action Steps

• Identify implementation strategies that have worked successfully in your hospital before or that sound promising based on the way things are done in your organization.
  • Consider whether your organization uses big, visible campaigns to introduce new initiatives, or is more comfortable with lower key incremental change.
  • Review staff engagement materials from other health care organizations and from past quality improvement efforts at your hospital.
  • Based on your hospital's culture, history, and values, begin identifying the characteristics of an approach that would engage staff members at large.
• Develop strategies for working with staff at the unit level to get staff input in tailoring the new practices to and reducing barriers in their units; include all shifts in this process.
• From the staff input and earlier analyses of current practices, identify potential barriers to the uptake of new practices, including staff resistance to change, and develop strategies for removing or working around them.
• Develop plans for ongoing communication about the progress, successes, and challenges of the change efforts at multiple levels of the organization.

Practice Insights

Examples of strategies for reducing staff resistance:

• To reduce staff resistance, continue to persuade staff of importance of prevention:
  • It is a standard of care and a nurse-sensitive issue.
  • It is a reportable event and a highly visible indicator of safety and quality.
  • Hospitals will lose reimbursement for hospital-acquired pressure ulcers.
• Involve staff in defining the problems and testing solutions so they feel ownership of the changes and see the success that can result.
• Provide staff with data (e.g., through staff meetings, unit bulletin boards, and e-mail) that initially highlight the problem of high pressure ulcer rates and later show success in preventing them.

Additional Information

Examples of methods and strategies to increase staff engagement can be found in the following article. Key points from this article include:

• Ongoing, multilevel staff education for all clinical staff and physicians.
• "Skin tips" newsletter.
• Annual skin fairs and wound conferences.
• Certificate for "most improved" unit in terms of outcomes.

Hiser B, Rochette J, Philbin S, et al. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage 2006;52(2):48-59.

4.3.4 How can we help staff learn new practices?

Once the initial needs assessment has been completed, you will have information about areas in which education is required to enhance staff knowledge. This aspect, while valuable, is not enough to change practices. Staff members also need help figuring out how to integrate their new knowledge into their existing practice and how to replace existing practices and skills that may be less effective with others that are more effective. Thus, a variety of methods for sharing information about new practices is needed.

Adult learning theory suggests that adults learn best through experiential methods that build on their own experiences. Since individuals have different learning styles and are at different levels of practice proficiency, a variety of educational approaches is best, including, but not limited to, the following:

• Didactic methods can include a variety of formats, such as lectures, interactive presentations, online lessons, case study analysis, listserve discussion, and grand round talks.
• Care practice simulations, expert practitioner observation of care delivery, and competency validation are also strategies that can enhance learning.
• Clinical bedside rounds, patient case review, or "spend a day with the WOC [wound, ostomy, and continence] nurse" are excellent ways of translating abstract knowledge into behavior changes.

Any and all plans for new or changed staff education should be worked out in close collaboration with the content experts, the Wound Care Team. As discussed in section 6 on sustaining the redesigned prevention practices, learning will need to be supported on an ongoing basis, both as refreshers for existing staff and as training for new staff.

Action Steps

• Choose appropriate settings for staff education about best practices in pressure ulcer prevention and the changes that will be needed to incorporate those practices in this organization, consistent with adult learning principles. For example, combine traditional training sessions, individual coaching, or ongoing discussion in staff meetings.
• Work with your staff education department and other key stakeholders (e.g., residency directors) to interpret the results of the staff pressure ulcer knowledge assessment and to develop an educational strategy. We have suggested a number of materials to use throughout this document that can be found in Tools and Resources.

Tools

To assess current staff education practices, complete this checklist found in Tools and Resources (Tool 4C, Assessing Staff Education and Training).

Practice Insights

A recent nursing home project used 5-minute standups to improve communication and provide ongoing staff education. The key steps in that process include:

1. Review medical record audit data for pressure ulcer risk and skin assessment and associated care planning for the past week. Did planning match needs? Was care documented as completed using medical record documentation specific to the particular unit?
2. Discuss unit goals for the upcoming week (for example, "This week we will focus on nutrition").
3. Provide specific strategies for meeting the upcoming week's goal (usually only one or two strategies are presented).
4. Show a brief video clip or use a case example or handouts of the specific strategy in use (video clips should be 1 to 2 minutes at most in length).
5. Discuss any questions or concerns from staff and discuss possible solutions.

Resources

• A model curriculum to use for staff education: .
• A range of resources, including many that can be used for staff education: .

In addition, the AHRQ-sponsored On-Time nursing home initiative used 5-minute standup meetings to integrate the use of a nutrition report into clinical practice and to facilitate communication among CNAs, nurses, and dietary staff. 

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4.4 Checklist for implementing best practices

4. Checklist for implementing best practices