Measurement for improvement: what we can learn from reductions in pressure ulcers

It can be really tricky to get better at something. Sometimes it’s even trickier to know if, when, and how much you’re actually getting better. But there are some things you can do to make improvement easier, and right at the top of the list is measurement.

Not measuring is a bit like a sprinter not timing their runs. Measurement is most important and effective when used on the front line, but we can also look at these data nationally, and see if there are interesting trends or lessons (QualityWatch, a joint Health Foundation and Nuffield Trust project, aims to do this to provide independent scrutiny into how the quality of health and social care is changing over time).

Let's look at an example of measurement in practice. One tool for doing this for pressure ulcers is the Safety Thermometer, a point of care survey. More than five million patients have been surveyed since it started in June 2012. Data from the Safety Thermometer on pressure ulcers since July 2012 can be seen below:

And what do these data tell us?

Firstly, we see an improvement. If you take 20 inpatients, about 1 will have a pressure ulcer (in a community setting it’s slightly more). It takes massive determination and effort to achieve these fairly low levels of harm to patients, particularly when staff are so stretched. Staff should be prouder still of the improvements that have been made, with the prevalence of pressure ulcers falling by more than 25%.

Secondly, we see that while there has been improvement, this seems to have slowed, or even stalled. We need to get to the bottom of this: is it because people have done the ‘quick wins’ and are struggling to tackle the more complex, systemic reasons for harm? Because enthusiasm has waned? Because of changes in data collection? It might be that we need a new approach, and a new burst of energy to do better.

And how about the data across providers? Using the same data we can produce the chart below, which essentially shows the distribution of providers in September 2013, then again in 2014. The improvement is pretty clear, with more providers towards the lower end of the spectrum, and fewer towards the higher end.

In some providers almost no patients are developing pressure ulcers, while in others it is one in six. There are reasons for this that aren’t about the care patients are receiving: variations in data collection, and some care settings and specialities being more conducive to pressure ulcers than others. These factors alone can’t account for all the variation, meaning that some providers are safer than others. Equally some wards, some clinical specialities, and some settings of care are safer than others.

This absolutely isn’t about blaming the least safe, but about trying to understand why some are less safe than others, and how they can improve. It’s not about comparing organisations, but understanding the causes of variation is vital for improvement.

So, what next? Good information on the prevalence of pressure ulcers is useful, particularly when used locally for improvement. But as well as knowing how safe care was last month, it’s important to know how safe care is today, and tomorrow. Based on research by Vincent et al, we’ve found that the really mature, safe organisations have a basket of measures and interventions across the board to really understand these issues and improve.

Staff should be tremendously proud of reducing rates of pressure ulcers. It’s clear that progress needs to be made, but it’s important that we have indicators like these to shine a light on the harm occurring, and to be used as a local improvement tool within organisations.

This blog first appeared on This is Nursing.

Ben is a Policy and Economics Analyst at the Health Foundation, www.twitter.com/BenGershlick.