QI Report of Project: Written

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Structure or Process Indicators

List the steps or key pieces that your clinical practice guideline or systematic review suggest that should be in place to improve outcomes (these become your indicators):

	Process or Indicator	What data will be collected
1.	Assessment of all patients, whole body skin every shift	Any skin issues, redness, or skin break down
2.	Reposition patients with limited mobile activity every 2 hours	Helps monitor patients
3.	Mandatory staffs education about pressure ulcer	Knowledge of staffs regarding HAPU
4.	Continuing of education 3-5 times a year to up-date all staffs	Staffs Knowledge
5.	Close monitoring of patients who are at great risk of developing pressure ulcer like immobile patients	Condition of skin
6.	Use of barrier cream and emollient to protect the skin	Area of redness
7.	Collaborate all health care team and effective communication between staff	Newest patients situation
8.	Use of air mattress	Skin condition
9.
10.

Plan for Improvement

Indicator: _____Decrease the rate of developing Pressure ulcer among patients

_______________________________________________________________________________________________

This is key to improving outcomes because: By decrease the rate of PU, it proves that right intervention has been done.

Operational definition: perform EBP to decrease rate of HAPU

Numerator: All patients with PU who treated based on EBP

Denominator: All patients with PU or at risk to develop PU

Data collection method

Who	All health care team: doctor, nurse, PCT, PT,OT, dietitian
What	-Assess the patient with HAPU or at rick for HAPU -Do ISKIN bundle -Effective communication between staff - Proper patient’s education regarding pressure ulcer prior discharge
Where	In patients room, during shower time to closely observe all skin issues
Why	Prevent getting pressure ulcer and improve those who are already developed PU
When	-At the time of admission until being discharged. -skin care every shift or as needed
How	-Assessment every shift -Provide poster with indication of how PU develops and how take care of patients with skin issues

Goal for this indicator: No more pressure ulcer among patients during hospitalization or 100% PU free

Benchmark: 100% compliance