Staff Awareness and Process Strategies to Reduce Skin Tears - Anglican Retirement Villages.

Anglican Retirement Villages (ARV) is a not for profit organisation that has been providing care for older Australians for 50 years. Currently the organisation operates 17 accredited Residential Aged Care services (nursing homes and hostels) which accommodate a total of nearly 1700 aged care residents. The organisation also services over 1800 residents who live in independent living accommodation and provide community care services to over 1600 clients who remain living in their own homes.

The QPS Benchmarking program has helped to raise awareness and drive continuous improvement changes throughout ARV Residential Aged Care Facilities (RACF). ARV has been submitting data for 2 years on a variety of clinical indicators. These include the indicators: Skin Tears - General 2.11.3 and Skin Tears - Dementia Specific 2.11.4. The way the data is used to contribute to the organisations overall continuous improvement process is discussed below.

The quarterly trend results are reviewed through a governance structure of clinical and risk management committees where common themes are identified for local and organisational improvement. In addition to this, each Residential Aged Care Facility Manager (RACF) is responsible for analysing trends and implementing local strategies. This is done quarterly during the collation of QPS results and on an ongoing basis during review of incident forms. QPS provides the external benchmarking and the internal processes drive change.

Not long after commencing benchmarking it was identified that skin tears were showing to be above the mean in several villages. A consultation process was undertaken to engage Managers in developing a strategy for improvement. Anecdotal feedback identified that there was an increase in frailty, residents were knocking/bumping their hands on beds and furniture, eye sight, environmental issues and inappropriate clothing all contributed to the increase in skin tears.

Documentation and the reporting of incidents is also improving because staff members are engaging more with the continuous improvement systems. The improved reporting of incidents has had the impact of increasing the numbers of reported incidents in some facilities.

A further analysis of other QPS indicator results was undertaken which compared "other risk factors" including falls, aggression and restraints. For the RACFs who were over the mean a review of trends for the past six quarters was undertaken. There were some examples of increases in falls and aggression but no consistent quarterly trends across the board were identified. There was no co-relational statistical data analysis undertaken just a comparison of trends.

Further to this, a review sample of 65 incidents forms (as recorded in the ARV register/data base) indicated that frailty, manual handing and environment were causal factors (Figure 1). Falls rates were noted to be a factor but not consistent across each of the villages.

Figure 1. Analysis of contributing or causal factors relating to 65 incidents of skin tears.
Source ARV Data Base 2008

Mangers were also undertaking their review and implementing continuous improvement processes. For example, one village undertook a cause/effect process to identify causal factors and solutions. This was driven by the Manager working together with the quality improvement team in an endeavour to improve outcomes for residents.

Figure 2 shows that cause and effect (fishbone) was used to help staff identify the possible causes of variation and to assist in the analysis of data.

The interrelationship diagram clearly identifies the relationship between people, manual handling and skill. This tool is useful in studying the relationship between causes of variation.


Figure 2: Cause/Effect and Inter-relationship Process

Collectively, the data analysis has indicated a few key ideas for improvement.

To enhance the review of trends and causal and contributing factors for all incidents, ARV further developed and implemented a Clinical Indicator Data Base for:

a. Individuals analysis (with record of ALL incidents)

b. timely (monthly)

c. trend causes, times, activities causing skin tears

Family Education re: footwear, clothing, furnishings - limb and bed rail protectors:

Staff Education -

• The Business Process Review (BPR) committee has identified the need to include a preventative component to the Skin Tear Procedure. A literature search was undertaken to inform a guideline for the Prevention of Skin Tears. The guideline has been included in the Organisational Care Manual.
• An education "blitz" has been planned and will be implemented throughout the organisation through the workplace trainers.
• Posters have been developed for all facilities to help raise awareness.

A great deal of work has been done to put these improvements into place and our improved data collection systems and benchmarking will enable us to continually monitor and evaluate the outcomes of these strategies over the next twelve months.

Prepared by Kris Rice, Group Manager Care Development Marolyn Seaman, Village Manager Gowrie Villages