Effective Service Improvement Strategy for Pressure Ulcer Prevention and Management in Elderly Patients

This research aims to prevent and manage pressure ulcers in elderly patients in nursing homes. The proposed research hypotheses frameworks are driven by DMAIC and PDSA models of six-sigma. Lean management provides certain operating guidelines that can induce value maximisation in case of patients through reduction in waste and waiting time.

Nursing Research 1
Nursing Research

Nursing Research 2
Executive Summary
Introduction: Owing to an increment in elderly populace and relative comorbidities, prevalence
of these ulcers has heightened in the last decade. Pressure ulcers essentially result in areas of
bony prominences, like sacrum, heels, greater trochanters, lateral malleoli and ischial
tuberosities. Service improvements in terms of ulcer prevention, care and management can be
employed in a can provide a holistic provision of care that in turn can mandate empathetic care
for aged people
Aim: The aim of the proposed research is to frame an effective service improvement strategy to
develop quality and safe service provision.
Methods: Researcher will collect secondary data from databases and text books.
Anticipated outcome: The proposed research hypotheses frameworks are driven by DMAIC
and PDSA models of six-sigma. Lean management provides certain operating guidelines that can
induce value maximisation in case of patients through reduction in waste and waiting time.
Recommendations and conclusion: Nurses are recommended to practice holistic care that can
cater to the needs of elderly patients from a diverse background. Based on the given information,
it can be concluded that the proposed research will enumerate the effects posed by lean
management and six sigma strategies on the quality of care.
Keywords: DMAIC, PDSA, Lean management, Six sigma, Healthcare, Pressure ulcer, Elderly
patients

Nursing Research 3
Table of Contents
Introduction and aim 4
Introduction..................................................................................................................................4
Aim...............................................................................................................................................4
Problem, context and background of the study 4
Problem........................................................................................................................................4
Context.........................................................................................................................................4
Background..................................................................................................................................5
Service improvement 6
DMAIC model of service improvement......................................................................................6
PDSA model of ulcer management..............................................................................................6
Principles of lean management....................................................................................................7
Literature review 8
Concepts of DMAIC model.........................................................................................................8
Governing theories of PDSA model............................................................................................9
Appraisal and application of lean management approaches......................................................11
Methodology for sustaining change11
Theory........................................................................................................................................11
Hypothesis..................................................................................................................................12
Research design..........................................................................................................................12
Concept measurements..............................................................................................................13
Data collection and processing..................................................................................................13
Process mapping........................................................................................................................13
Analysis and interpretation of main finding..............................................................................13
Possible solutions 14
Recommendation 15

Nursing Research 4
Conclusion 15
Reference List 17
Appendices 19
Appendix A: DMAIC model......................................................................................................19
Appendix B: PDSA Cycle..........................................................................................................20
Appendix C: Pre and post test patient design............................................................................21

Nursing Research 5
Introduction and aim
Introduction
Pressure ulcers are common clinical complication in case of elderly care. Owing to an increment
in elderly populace and relative comorbidities, prevalence of these ulcers has heightened in the
last decade. Systemic parameters like skin aging, chronic ailments, functional impairment,
infections and malnutrition contribute to formation and development of ulcers. Low body-mass
index, protein and albumin content are considered predisposing indicators in this situation. The
proposed research would attempt to present an evaluation of clinical change management
paradigms and their affectivity to identify potential influence on prominent ethical issues.
Aim
The aim of the proposed research is to prevent and manage pressure ulcers in elderly patients in
nursing home.

Nursing Research 6
Problem, context and background of the study
Problem
The problem caused by this issue is the formation of pressure ulcers in elderly patients during
their stay in the hospitals. Pressure ulcers are considered localised injuries, which occur due to
unrelieved pressures on the underlying skin and tissues. Despite effective preventive approaches,
pressure ulcers can be unavoidable in some cases. Even it has been observed that pressure ulcer
rate among elderly people has increased over time. Hence it is necessary to propose a specific
guideline to analyse effective service provision in consideration of patient safety and care
quality.
Context
Pressure ulcers essentially result in areas of bony prominences, like sacrum, heels, greater
trochanters, lateral malleoli and ischial tuberosities. As reported by Wang, Walker and Gillespie
(2018), 70% of the people who suffer from these ulcers belong to the age range of 65 years or
above. This result is prevalent in approximately 21% of patients in the nursing homes and 28%
of residents in hospitals in the United Kingdom. Bryant and Nix (2015) denote external as well
as internal risk indicators for checking the formation of pressure ulcers. External risk parameters
involve constant pressure that can give rise to immobility. In addition to this, excessive moisture
or shear forces on patients can be the causes of ulcers. Internal risk parameters malnutrition and
involve reduced sensory perception.
Background
Prognosis for effective treatment of pressure ulcers are further hindered by a drop in the service
provisions rendered by service providers. However, note at least 70% of secondary stage ulcers
are seen to heal after applying appropriate intervention for 6 months (Qaseem et al. 2015).

Nursing Research 7
Similarly, 50% of tertiary stage ulcers as well as 30% of final stage ulcers can also heal within
approximately a similar period as given above. As mentioned in the problem statement formation
of ulcers in elderly patients can cause a series of secondary comorbidities. As stated by Ackley,
Ladwig and Makic (2016), Braden scale is a prominent checklist that adjuncts risk assessment in
case of bed-bound patients. Skin infections, scabies or further laceration can occur from
continual wear and tear and inappropriate wound management (Mir et al. 2015). Service
providing organisations should therefore target prevention and treatment of pressure ulcers.
Figure 1: Stages of Pressure Ulcers
(Source: Given by Researcher)
An efficient approach that can be used for management of pressure ulcers is prevention.
Utilisation of need-based dynamics can prevent ulcer formation in case of immobile patients.
Nursing caregivers often debride or clean ulcers until they can view granulation tissues.
Application of extensive dressings can maintain moist environment around the wound that can

Nursing Research 8
pace ulcer formation (Sheehan et al. 2016). Fluid, protein and calorie intake are also responsible
for influencing the formation rates. Preventive measures for these ulcers involve reducing
pressure through frequent repositioning, avoiding shear forces, and utilising pressure-reducing
static devices. According to Cereda et al. (2015), the aforementioned static devices involve
water, foam, air or gel mattresses for its construction. In other cases mattress overlays, heels and
joints pads, and foam wedges are also used. In some cases dynamic devices can be sought to help
if the patient is unable to reposition themselves.
Service improvement and prevalent policies
Service improvements in terms of ulcer prevention, care and management can be employed in a
patient-centred approach. This can provide a holistic provision of care that in turn can mandate
empathetic care for aged people, considering their prevalent needs and preferences. A prominent
threat in the management of pressure ulcers is that they are likely to occur in a very fast rate,
essentially within 6 hours after heavy loading. As per Health and Social Care Act (2012),
Pressure Ulcer Prevention Policy has been designed by NHS. Similarly, NICE guidelines also
designate an ECT2550 Pressure Ulcer Prevention and Treatment Policy.
DMAIC model of service improvement
DMAIC methodology offers efficiently governed methodical process that can deliver complete
measurable outcomes. The present protocol is thereby segregated in the following phases. [Refer
to Appendix A]
Define: The definition phase involves brainstorming to successfully enumerate the threats that
can be posed by an issue (Beeckman et al. 2014). In this case, ulcer formation in bedridden
elderly patients is defined as the threat.

Nursing Research 9
Measure: The measurement of ulcer formation rates is done through Braden Scale to identify
risk exposure of patients in consideration of pressure ulcer development.
Analyse: One-Way data analysis of revealed critical factors of ulcer formation are heel
protectors and compliance to incontinence protocols. Braden score of 23 to 18 can identify lower
risk, while 12 or less resembles high risk exposure.
Improve: 60% reduction in cognitive nosocomial rate of pressure ulcer can result in
approximately £80,000 cost avoidance per annum.
Control: Nosocomial rates must be monitored each month to focus on patient-based care
indicators to maintain performance.
PDSA model of ulcer management
Plan: The plan conforms to manage pressure ulcers by applying therapeutic intervention after its
occurrence. This plan is based on timely washing and documentation of ulcer development in
elderly patients. [Refer to Appendix B]
Do: Bryant and Nix (2015) state appropriate washing techniques must be utilised for each stage
of pressure ulcer (soap wash for stage 1, saline wash for stage 2 ulcers). Stage 3 and 4 ulcers can
rarely be treated permanently; hence nurses should maintain effective protocols to prevent
further infections.
Study: During the treatment, frequent observations should be made and documented to analyse
the reduction rate pressure ulcers (Qaseem et al. 2015). The documentation charts can be aided
with weekly photographs to measure the diameter, depth and tenderness of the ulcers.
Act: Further modifications can be implemented in the prevalent cycle by utilisation of
therapeutic drugs for stage 1 and stage 2 pressure sores. Amoxicillin-potassium clavulanate can
be used to induce a faster healing process in case of infected ulcers in elderly patients.

Nursing Research 10
Principles of lean management
The researcher proposes utilisation of lean management strategies on elderly patients to
understand its efficacy in the present issue. The practices that can be conducted are tabulated in
the given representation with their probable rates of implementation and success. As commented
by Posthauer et al. (2015), documentation of specific practices can help carers as well as the
management to understand efficacy of each approach in the current scenario.
Best Lean Management Practices Probable implementation
rates (in percentage)
Admission assessment of pressure ulcer in elderly patients 65
Daily risk reassessment 94
Daily inspection of high-risk patients 51

Nursing Research 11
Appropriate maintenance of moisture on patient’s skin 99
Optimisation of hydration and nutrition levels 35
Pressure minimisation 98
Table 1: Implementation of lean management practices
(Source: Given by Researcher)
Inclusion of weekly audits based on skin documentation can enable clinical teams to devise
efficient chart review tools. Wang, Walker and Gillespie (2018) suggest these tools can be
reviewed each week to understand the development of ulcer on the criteria of condition of the
surrounding skin and wound tenderness. Overall assessment of hydration and nutrition levels can
be implemented for daily maintenance of cognitive well-being of the elderly patients, on the
basis of the needs.
Overall, these three frameworks are suggested by the researcher in consideration of effective
wound management in a professional healthcare ambience. Additional parameters that can be
utilised to increase success rates are monthly pilot studies and comparative analysis of cohort
based observation driven by contrasting medication.

Nursing Research 12
Literature review
Concepts of DMAIC model
Application of six sigma strategies and relevant DMAIC model have facilitated healthcare over
the last decades. According to Thomas and Compton (2014), extrapolation of above-mentioned
outcomes can extend the application of DMAIC approach in the healthcare sector. As stated by
Cereda et al. (2015), clinicians are more prone to embrace DMAIC model due to its utilisation of
familiar paradigms and in the presence of sustainability and scientific rigor. The ability to clearly
outline and manage healthcare ambience presents a massive organisational benefit. Beeckman et
al. (2014) opine DMAIC improves the measurable outcomes of an activity through response
variables. This is in consideration of a common issue in aged residents of nursing home, which
contribute to care mortality and morbidity. Rates of pressure ulcers can thus be controlled
through implementation of six sigma DMAIC practices.
Figure 2: Effective outcome attainment
(Source: Given by Researcher)
The response variables in healthcare sector can be segregated into quality improvement and
technical strategies. The prominent medication error and its reduction can be achieved by
DMAIC in consideration for improvement at patient safety. As stated by Clark (2018),
management of cost and revenue enhancement can help to enhance satisfaction among patients

Nursing Research 13
and care providers. Significant modifications can also be exhibited in supply chain management
with increase in opportunities of marketing growth. As commented by Wang, Walker and
Gillespie (2018), development of intrinsic leadership skills can streamline and optimise
technologies that can be related to workflow management. Achievement of regulatory and
compliance requirements can be mandated by successful implementation of the DMAIC model
in ulcer and wound care management. Pressure ulcers are prevalently managed through
preliminary hygiene care in a clinical ambience.
Governing theories of PDSA model
The cyclic model of PDSA accounts for an integral part of cognitive healthcare improvement
concepts. As stated by Ladwig and Makic (2016), this approach is an uncomplicated yet effective
tool to accelerate quality enhancement. This process initiates with an appropriate establishment
of an objective, which guides the following protocol in terms of its membership establishment.
The PDSA cycle develops appropriate measures for determining possible impacts of a change on
a clinical ambience. Boyko et al. (2018) state this helps to create a simulation for the strategic
implementation in next step is to test necessary modifications in a real world setting. As care for
pressure ulcer involves complex efforts to enhance prevention rates, this requires system-based
approach that involves distinct organisational changes (Qaseem et al. 2015). Bringing due
changes in healthcare organisations can be hindered by multiple obstacles when that includes
simultaneous improvements to communication, decision making and workflow.

Nursing Research 14
Figure 3: Relationship of interdependent initiatives in PDSA model of ulcer care
(Source: Given by Researcher)
As per the consideration of initiative of pressure ulcer prevention, assessment failure in can
induce changes on multiple tiers that result to unanticipated complications in the implementation
stages. Posthauer et al. (2015) state PDSA cycle is an effective testing method that can planning
and implements a change as well as takes critical decisions based on observing its outcomes. The
significance of growing needs can be considered for clinical audits owing to integral portions of
clinical practices (American Hospital Association, 2018). These practices essentially highlight
better data management in the healthcare sectors. Indeed, processes of clinical audits can
ultimately be made retrievable through by-products of routine care therapies to modify quality
care and continuous improvements.

Nursing Research 15
Appraisal and application of lean management approaches
This segment ensures analysis and implementation of lean management to promote maximum
progress in clinical sectors. Lean management provides certain operating guidelines that can
induce value maximisation in case of patients through reduction in waste and waiting time.
Patient needs consideration through additional employee involvement can bring continuous
improvement in healthcare organisations (Institute for Healthcare Improvement, 2018). The
conceptual paradigm of lean management is originally provided by production system of Toyota
through continuous improvement strategies. Whitehead and Trueman (2018) state the strategies
of lean management can fundamentally transform organisational values and thinking styles.
Ackley, Ladwig and Makic (2016) state lean is driven by a process-based methodology of
improvisation and management.
This modification can be responsible for transformation of organisational culture and behaviour.
A basic tenet can be considered for existing clinical taskforce. This can be studied with the help
of Toyota model and its capacity to allocate different resources as per priorities. The utilisation
can shed light on the added values mediated for patients. The recent study of Boyko et al. (2018)
evaluates demonstrations of lean in healthcare management and successful outcomes that can be
applicable in Australian Ministry of Health. However, Thomas and Compton (2014) argue
implementation of lean can be patchy, fragmented and pragmatic. Implementation of lean in
healthcare sector can be evaluated from a holistic perspective such as overall transformation of
the organisational strategy. Nevertheless, lean thinking is driven by design and research on
sustainability in healthcare.

Nursing Research 16
Methodology for sustaining change
Theory
The guiding theory for lean management condenses around the approach of sustainable
organisational management in support of continuous improvement. This strategy recognises
long-term working approaches that can methodically seek to attain small, but considerable
changes to enhance quality and efficiency.
Figure 4: Research methodology
(Source: Bryman, 2016)
Hypothesis
The hypothesis of the proposed research is given in the form of null (h0) and alternative (h1)
assumptions.
● H0: Application of lean management and six sigma strategy cannot reduce the rates of
pressure ulcer formation in elderly patients.

Nursing Research 17
● H1: Utilisation of lean management and six sigma strategy can effectively reduce the
rates of pressure ulcer formation in elderly patients.
Research design
A mixed research design will guide this study, which is a blend of both qualitative and
quantitative methods. As stated by Bryman (2016), qualitative data will help to understand the
perceptions of patients as well as the healthcare service providers in the given issue of pressure
ulcer formation. In addition, quantitative data will provide empirical information that can be used
as ample evidence for the qualitative opinions obtained.
Concept measurements
Concepts would be measured with the help of secondary data. This information will facilitate
evaluating prevalent trends in elderly healthcare sector in the UK. On the contrary, secondary
data from published literature can evaluate the established paradigms on the basis of their
efficiencies.
Data collection and processing
Secondary data will be accumulated from databases and government healthcare reports. The
researcher will ensure utilisation of valid and credible information by retrieving them from
reliable sources, such as NCBI, SCOPUS, ProQuest and CINAHL. The accumulated data will be
analysed thematically in consideration of appropriate lean management and six sigma strategies.
Process mapping
Process mapping has helped to analyse the process that has been followed by the researcher
during this process. Pre and post measurement maps have been given in the appendix that
provides a graphical flow to the protocol. The baseline measurement of the proposed project is
the original medication that is prescribed to the patients. [Refer to Appendix C]

Nursing Research 18
Analysis and interpretation of main finding
Analysis of the accumulated data can give rise to the formulation of the main finding. This will
give rise to the strategic design of implementing lean and six sigma management strategies in a
fast-paced clinical workplace. As stated by Bryant and Nix (2015), analysis of the data can shed
light on patient needs and the efficacy of recommended strategies to meet the aforementioned
requirements. This will also facilitate drawing a definite conclusion about the affectivity of one
of the two hypotheses. Data documentation will be done in compliance with Copyright Act 1968
(Cth) to ensure information is cited with their authentic sources. This can avoid presence of legal
charges pertaining to copyright protection of the original works.
Possible solutions
Principles of lean system management and six-sigma can be implemented in a healthcare setting
to reduce the rates of elderly patients developing pressure ulcers. These recommendations are
used to introduce improvisations in quality care of the elderly patients and enhance their
experience.
Description of the
solution
Communication is
a vital key in the
area of elderly care.
Some of the
patients belong
from ethnic
communities in
diversity
Holistic care
collaboration must
be achieved
between multiple
departments
Key advantages Sheehan et al.
(2016) state
communication
helps nurses to
interact with aged
patients.
This strategy can
exhibit awareness
and mutual respect
towards the cultural
values and beliefs of
the patients and their
families (Boyko,
Holistic
collaboration among
nurses, caregivers
and families of the
patients can enable
quality improvement
in care strategies of

Nursing Research 19
Longaker and Yang,
2018).
elderly residents
Disadvantages Communication can
sometimes enable
patient’s families to
exercise undue stress
on the nursing
practitioners
In case of special
needs patients, there
is noticed a
significant contrast
in the values, beliefs
and spiritualities of
the patients.
It depends on
rigorous lean
management to
achieve
collaboration
between multiple
departments.
Cost and time
considerations
£500 1 week £870, 10 days £495, 5 days
Rationale for the
chosen solution
Holistic collaboration approach is chosen as it takes lesser time and is less
expensive to implement.
Table 2: Possible solutions
(Source: Given by Researcher)
Recommendation
Holistic approach of clinical service is the main recommendation in the given scenario. Pressure
ulcers can increase financial burden on patient family by enhancing substantial costs of
medication and treatments. Utilisation of the DMAIC model as stated above can widen the
documentation phase to enhance turnaround time for patients. PDSA audit can also influence the
modification in the database management systems of the hospital. This, in turn, can help nurses
to keep track of the information systems that can be give rise to better and faster service

Nursing Research 20
deliveries. Lean strategies can implement expert-driven continuous cycle of learning for in
healthcare processes.

Nursing Research 21
Conclusion
Based on the given information, it can be concluded that the proposed research will enumerate
the effects posed by lean management and six sigma strategies on the quality of care. The
aforementioned care services are applicable for elderly patients who are exposed to a risk of
developing pressure ulcers as co-morbidity to hospital stay. The proposed research hypotheses
frameworks are driven by DMAIC and PDSA models of six-sigma. In addition to this, lean
management strategies have influenced the recommendation that motivates a rise in care quality.
A prominent limitation of these strategic frameworks for implementing quality care is that they
require effective change to be introduced in the organization. In case of clinical bodies, change is
not usually accepted in high emergency working environment such as hospitals and nursing
homes. Management thus has to carefully handle human resource and mitigate issues that may
arise with the help of an appropriate change management.

Nursing Research 22
Reference List
Ackley, B.J., Ladwig, G.B. and Makic, M.B.F., (2016) Nursing Diagnosis Handbook-E-Book:
An Evidence-Based Guide to Planning Care. London: Elsevier Health Sciences.
American Hospital Association (2018) Pressure Ulcer Reduction using Lean Six Sigma, Viewed
on 12 September 2018 <http://www.hpoe.org/resources/iha-case-studies/2526>
Beeckman, D., Van Lancker, A., Van Hecke, A. and Verhaeghe, S., (2014) A systematic review
and meta‐analysis of incontinence‐associated dermatitis, incontinence, and moisture as risk
factors for pressure ulcer development. Research in nursing & health, 37(3), pp.204-218.
Boyko, T.V., Longaker, M.T. and Yang, G.P., (2018) Review of the current management of
pressure ulcers. Advances in wound care, 7(2), pp.57-67.
Bryant, R. and Nix, D., (2015) Acute and chronic wounds. London: Elsevier Health Sciences.
Bryman, A., 2016. Social research methods. UK: Oxford university press.
Cereda, E., Klersy, C., Serioli, M., Crespi, A. and D'andrea, F., (2015) A nutritional formula
enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized
trial. Annals of internal medicine, 162(3), pp.167-174.
Clark, M., (2018) Microclimate: Rediscovering an Old Concept in the Aetiology of Pressure
Ulcers. In Science and Practice of Pressure Ulcer Management, pp. 103-110.
Institute for Healthcare Improvement (2018) Available at:
http://www.ihi.org/resources/Pages/ImprovementStories/RelievethePressureandReduceHarm.asp
x (Accessed: 9th october, 2018).
Mir, T.P., Qaseem, A., Starkey, M. and Denberg, T.D., (2015) Risk assessment and prevention
of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals
of internal medicine, 162(5), pp.359-369

Nursing Research 23
Posthauer, M.E., Banks, M., Dorner, B. and Schols, J.M., (2015) The role of nutrition for
pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer
advisory panel, and pan pacific pressure injury alliance white paper. Advances in skin & wound
care, 28(4), pp.175-188.
Qaseem, A., Humphrey, L.L., Forciea, M.A., Starkey, M. and Denberg, T.D., (2015) Treatment
of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals
of internal medicine, 162(5), pp.370-379. http://annals.org/aim/fullarticle/217350
Sheehan, K.J., Sobolev, B., Chudyk, A., Stephens, T. and Guy, P., (2016) Patient and system
factors of mortality after hip fracture: a scoping review. BMC musculoskeletal disorders, 17(1),
p.166. https://doi.org/10.1186/s12891-016-1018-7
Thomas, D.R. and Compton, G.A., (2014) Pressure ulcers in the aging population. New York:
Humana Press.
Wang, I., Walker, R. and Gillespie, B.M., (2018) How well do perioperative practitioners
implement pressure injury prevention guidelines? An observational study. Wound Practice &
Research, 28(1).
Whitehead, S.J. and Trueman, P., (2018) To what extent can pressure relieving surfaces help
reduce the costs of pressure ulcers?. Senior nurse, 4, p.21. https://www.nursingtimes.net/clinical-
subjects/wound-care/to-what-extent-can-pressure-relieving-surfaces-help-reduce-the-costs-of-
pressure-ulcers/5017910.fullarticle

Nursing Research 24
Appendices
Appendix A: DMAIC model
(Source: http://www.tqmi.com/blog/use-dmaic-model-problem-solving/)

Nursing Research 25
Appendix B: PDSA Cycle
(Source: https://coachingandleading.wordpress.com/presentation1/pdsa-and-types-of-change/)

Nursing Research 26
Appendix C: Pre and post test patient design
(Source: Given by Researcher)