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2015 HSR&D/QUERI National Conference Abstract

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1115 — Rapid, Partnered Evaluation of Pressure Ulcer Documentation to Improve Clinical Practices and Patient Care

Chavez MA, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); Duffy A, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); Toyinbo P, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); Besterman-Dahan K, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); Rugs D, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); Powell-Cope G, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); Cowan L, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR); Priefer B, Office of Nursing Services;

Objectives:
The VHA Blueprint for Excellence prioritizes operations partnered research and implementation science to quickly assess and improve clinical care. This presentation discusses the qualitative findings from a rapid, ONS-partnered evaluation of pressure ulcer documentation practices, and shows how findings will inform revisions of the VHA Handbook 1180.02, Prevention of Pressure Ulcers and processes of clinical care.

Methods:
We conducted 28 telephone focus groups with 46 clinicians from 31 VA facilities. Facilities were identified as either high or low performing based on the amount of missing data in automatically-generated monthly reports (low = 46; high = 33). A semi-structured interview guide elicited information about the barriers and facilitators for ensuring the validity of pressure ulcer data as reported in VA Nursing Outcomes Database (VANOD) skin assessment reports. Data were collected and analyzed using rapid assessment and a structured iterative process. Major domains were identified and analyzed comparatively based on facility performance.

Results:
Study results suggested that staff at both high and low performing facilities face barriers related to burdensome documentation processes and VANOD skin assessment templates. Barriers negatively affected both facility-level skin reassessment rates and the perceived validity of data. High performing facilities reported implementing strategies to overcome barriers and monitor the validity of their data. Successful strategies included: limiting wound staging to nurses with specialized knowledge and training, instituting a strong data validation plan, customizing the skin assessment template and shift notes to reflect the facility context and clinical workflow, using Clinical Applications Coordinators or Nursing informatics staff to remove erroneous health factors, and an active interdisciplinary pressure ulcer prevention committee.

Implications:
Understanding barriers and facilitators to clinical documentation can inform changes to the VANOD template and processes of data validation that match clinical workflow. This evaluation suggests that facilities may improve skin assessment rates and validity of their data by incorporating strategies identified by high performers.

Impacts:
Findings will be used by the Office of Nursing Services to address nurses' concerns about inefficient and burdensome documentation that reduces time available for patient care. Future partnered evaluations aimed at improving clinical practices are needed to inform system change to optimize Veteran care.