Applying the PDSA Framework to Examine the Use of the Clinical

J Nurs Care Qual Vol. 32, No. 4, pp. 293–300 Copyright c 2017 Wolters Kluwer Health, Inc. All rights reserved. Applying the PDSA Framework to Examine the Use of the 1.5 Clinical Nurse Leader to Evaluate Pressure Ulcer Reporting

Shea Polancich, PhD, RN; Sarah Coiner, MSN, RN-BC, CNL; Rebekah Barber, MSN, RN, CNL; Terri Poe, DNP, RN, NE-BC; Linda Roussel, PhD, RN, CNL; Kelley Williams, MSN, RN; Heather Cumbest, MSN, RN; Kristen Noles, MSN, RN, CNL; Ashlea Herrero, MSHQS, LSSGB; Shannon Graham, DNP, RN, NE-BC; Rebecca Miltner, PhD, RN, CNL, NEA-BC

The clinical nurse leader (CNL) role has been cited as an effective strategy for improving care at the microsystem level. The purpose of this article is to describe the use of the CNL role in an academic medical center for evaluating pressure ulcer reporting. The Plan-Do-Study-Act cycle was used as the methodological framework for the study. The CNL assessment of pressure ulcers resulted in a 21% to 50% decrease in the number of hospital-acquired pressure ulcers reported in a 3-month time period. The CNL role has potential for improving the validity and reliability of pressure ulcer reporting. Key words: clinical nurse leader, hospital-acquired pressure ulcer, pressure ulcer reporting, quality improvement

ITHIN a changing health care environ- Inpatient Quality Reporting Program,1 Value W ment, the challenge to improve pa- Based Purchasing,2 and The Joint Commis- tient care processes and clinical outcomes is sion Core Measures3 created through regula- daunting. Organizations are inundated with tion and federal legislation are concerns for performance requirements related to pro- every health care organization in the coun- cess and outcome measures in almost every try. The ultimate goal of these programs is to aspect of care. Programs such as the Hospital challenge health care organizations to meet

Author Afﬁliations: UAB School of Nursing provided in the HTML and PDF versions of this article (Drs Polancich, Roussel, and Miltner), and Center for on the journal’s Web site (www.jncqjournal.com). Nursing Excellence (Ms Herrero and Dr Graham), UAB Hospital (Drs Polancich and Poe and, Mss Correspondence: Shea Polancich, PhD, RN, UAB Coiner, Barber, Williams, Cumbest, and Noles), School of Nursing, 1720 2nd Ave South, NB 352, Birmingham, Alabama. Birmingham, AL 35294 ([email protected]). The authors declare no conﬂicts of interest. Accepted for publication: January 3, 2017 Published ahead of print: March 20, 2017 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are DOI: 10.1097/NCQ.0000000000000251 293

the Institute of Medicine’s4 aims for quality, changing the care delivery model. This solu- including safe, timely, effective, efficient, eq- tion considers putting the “right people” in uitable, and patient-centered care, and to en- the “right positions” to impact improvements. sure evidence informed practice. This may more broadly establish the grass- There are specific organizational require- roots for health care system change. This strat- ments that impact the delivery of nursing egy requires finding the best balance of educa- care. The American Nurses Credentialing Cen- tion and practice with a generalist focus and ter with Magnet5 and the National Database fine-tuned improvement skills that translate to for Nursing Quality Indicators,6 anursing application. The clinical nurse leader (CNL) is database managed by Press Ganey, track and aptly positioned to perform this work. monitor nursing-sensitive measures and pa- The CNL is the first new role in nursing tient care outcomes such as falls, pressure ul- in more than 40 years proposed by the cers, restraints, and infections. Measurement American Association of Colleges of Nursing of these outcomes is used to reflect the quality (AACN)11,12 in 2007. The emergence of of nursing care. the CNL was developed after numerous Pressure ulcers are a significant adverse authors cited the need for developing inno- event or hospital-acquired condition (HAC)7 vative care delivery models that effectively and most often deemed preventable. Nurs- leverage nurses. Both Shirey13 and Kimball ing care is the cornerstone to pressure ul- and colleagues14 address the need for care cer reduction and prevention. The incidence delivery models that use the unique skills and of hospital-acquired pressure ulcers (HAPUs) abilities of nurses within a changing health within the acute care inpatient setting has care system. This calls for individuals who been reported to be 2.9%,8 and the average are educated to impact quality and safety at hospital cost of treating stage IV pressure ul- the microsystem level. CNLs are educated in cers and resulting complications is estimated analytic processes, improvement, and safety to be approximately $129 248 for 1 hospital sciences. admission.9 The financial penalties associated The AACN specifically addresses the CNL with the development of an avoidable pres- role and the associated competencies for sure ulcer, a pressure ulcer that is the result microsystem improvement through the fol- of negligent provider care, results in nonpay- lowing fundamental aspects of practice11: ment of the additional cost of treating pres- participation in identification and collection sure ulcers for Medicare beneficiaries through of care outcomes; accountability for evalua- the HAC program.7 According to current re- tion and improvement of point-of-care out- search, making this situation more challeng- comes, including the synthesis of data and ing, it has been estimated that 39.1% of HA- other evidence to evaluate and achieve op- PUs may be unavoidable; the more significant timal outcomes; design and implementation pressure ulcers, stages III and IV, may be un- of evidence-based practices; and team lead- derreported; and the level of harm generated ership, management, and collaboration with from pressure ulcers is underestimated in the other health professions’ team members. Ben- inpatient setting.8,10 All of these data lend cre- der and colleagues,15-17 leading authors on dence to the importance of valid and reliable the use of the CNL in the clinical setting, HAPU data as a measure of the quality of care have published numerous articles support- provided in an organization. ing the AACN competencies and impact Organizations continue to seek out and of the CNL on clinical outcomes, particu- implement interventions that will meet or larly at the microsystem level. In addition, exceed the requirements and improve pa- Hix and colleagues18 lend credence to the tient care outcomes. Many strategies have work by Bender and colleagues and support been evaluated, but one intervention that may the impact of the CNL at the microsystem address a “strategic design” issue is related to level.

For this study, the CNL role was sup- United States. Institutional review board ap- ported by the literature as an intervention proval was not required. specific to improving care at the microsystem level. In this organization, the chief nursing Microsystem selection officer was seeking to examine the use of the For this improvement project, the microsys- CNL role within the academic medical center, tems identified for the intervention selected specifically within the nursing unit. There were an ICU and a medical-surgical unit. Units were also organizational opportunities to re- were selected on the basis of leadership will- duce pressure ulcers based on HAPU report- ingness to participate and patient composi- ing at the nursing unit level. However, nursing tion of the unit. For this pilot, the authors unit leaders perceived the degree and extent believed it necessary to include both the criti- of the pressure ulcer–reduction opportunities cal care and medical-surgical environments, as to be flawed. This provided the occasion for these microsystems have varying and unique the organization to test the CNL role specif- processes and workflow. These units were ically for data discovery, for examining the selected because they have different perfor- validity and reliability of pressure ulcer mea- mance improvement opportunities; however, surement and reporting. both units had opportunities to decrease reported pressure ulcers. PURPOSE

The overall goal of the organization at the Model for Improvement/PDSA inception of this project was to evaluate the The Model for Improvement (MFI) 3 useoftheCNLrolewithinanacademicmedi- guiding questions and the Plan-Do-Study-Act cal center environment for improving quality (PDSA) small test of change engine19,20 were and safety care coordination. However, a sub- used as the methodological framework for goal was to evaluate the perceived flaws as- this project. The MFI is used for exam- sociated with pressure ulcer reporting. Thus, ining and implementing interventions for this article focuses on the singular objective systems-based process improvement identi- to evaluate pressure ulcer data collection and fied through a systematic process such as mi- reporting and does not detail the other qual- crosystem analysis.21,22 ity and safety metrics and processes evaluated The initial question in the MFI is “What during the CNL project. The clinical question am I trying to accomplish?” In this situation, guiding this aspect of the project was as fol- the organization sought to understand pres- lows: “How does the use of a CNL role in an in- sure ulcer reporting, identify opportunities to tensive care unit (ICU) and a medical-surgical improve reporting, and compare CNL docu- inpatient unit impact the identification and mentation of all stage pressure ulcers with reporting of pressure ulcers within 90 days?” nursing documentation of skin assessment de- This project was deemed an improvement scriptions. The second MFI question, “How design that is descriptive in nature and in- will I know a change is an improvement?” tended for discovery. The 90-day time frame was evaluated using organizational baseline did not allow for robust evaluation of sustain- HAPU reported data, comparing HAPU and able outcomes; however, the review informed community-acquired pressure ulcer counts leadership as to the opportunities to improve from nursing documentation with CNL doc- pressure ulcer reporting, identification, and umentation obtained from a database devel- data collection processes. oped specifically for this project. The final MFI question of “What changes can I implement METHODS that will result in an improvement” was the implementation of 2 CNL roles on 2 inpatient The setting for this study was an urban units within the organization, with a goal of academic medical center in the southeastern evaluating pressure ulcer data and reporting.

CNL pilot and bundled rounding Supplemental Digital Content, Figure 1, avail- approach intervention able at: http://links.lww.com/JNCQ/A318) The CNL role was implemented and that the CNLs created, which was located the PDSA cycle was initiated between on the mobile workstation. The elements of May and July 2016. The 2 CNLs were as- the bundle were collected using “Yes/No/NA” signed a variety of quality and safety-related responses. All of this information was col- responsibilities; however, specific to this lected on the daily rounds for each patient project objective, one of the roles included in each unit by the CNLs and evaluated by the implementation of a “bundled rounding” them. Within the Excel file, formulas were process for skin assessment. “Bundled round- built to evaluate skin-related bundled care ad- ing” was a term used to describe the process herence. In addition to the Excel spreadsheet, of evaluating each patient for the evidence- a Microsoft Access database (see Supplemen- informed practices for a group of nursing- tal Digital Content, Figure 2, available at: http: sensitive quality measures. The term “bundled //links.lww.com/JNCQ/A319) was developed process measures” is used interchangeably to collect the pilot information. The Ac- to refer to this rounding process and the re- cess database included the CNL’s skin as- sulting measures that were evaluated. For the sessment and the IRR data from the WOCN. evaluation of pressure ulcers, the “bundled” Pressure ulcer reports were developed from approach was specific to practices used in these 2 data sources, the Excel spreadsheet the organization that are associated with and CNL Access database. The Supplemen- the prevention or management of pressure tal Digital Content, Figures 1 and 2 (avail- ulcers. able at http://links.lww.com/JNCQ/A318 and The CNLs were initially tasked with build- http://links.lww.com/JNCQ/A319), provides ing expertise in skin assessment and patient a listing of the variables collected in each data rounding to assess for evidence-informed bun- source. dle practices. The CNLs used the time spent in An organizational HAPU report was already the patient rounds to evaluate and collect data in existence based on data obtained from nurs- related to both process and outcome mea- ing documentation in the EHR. Data from this sures relevant for skin assessment. Interrater report included a description of the skin as- reliability (IRR) was established for the CNL sessment by the staff nurse. The nursing de- documentation by the wound, ostomy, and scription of the skin assessment was mapped continence nurse (WOCN) team, and com- to a corresponding pressure ulcer stage, with parison assessments were documented in a the location/site of each potential pressure database for both providers. Bedside nursing ulcer. This HAPU report was used as the base- documentation was also available from the or- line data for pressure ulcer reporting for the ganization’s electronic health record (EHR). organization. The HAPU report and CNL Ac- The organization currently uses a 6-stage pres- cess database provided the 2 sources for com- sure ulcer staging system defined by the Na- paring nursing documentation of described tional Pressure Ulcer Advisory Panel.23 This skin assessment entries that were mapped to standardized process was used by the staff a pressure ulcer stage. nurse for the documentation of the skin as- Outcome variation in reporting was deter- sessment descriptions, as well as for the CNL mined by comparing the CNL pressure ulcer and WOCN skin assessments and assignment assessment with the nursing documentation of pressure ulcers. in the EHR. There were 3 types of data in these data sets: matching records, records found only in the CNL database, and records found Data collection and data analysis only in the nursing documentation. Matching Bundled process measures were captured records were those in which the CNL database on a Microsoft Excel spreadsheet (see and nursing documentation in the EHR

identified common patients. Common pa- the CNL database, cases were reviewed by the tients may or may not have resulted in match- CNLs, and the majority of variances occurred ing counts of pressure ulcers or locations. because of misidentification by the staff nurse Records found only in the CNL database were (eg, skin tears, abrasions, or even dermatitis). pressure ulcers not identified or not docu- If the patient had a pressure ulcer, the CNL mented by the staff nurses. Records found documented the presence of the evidence- only in the nursing documentation were the informed bundle elements used by the or- opposite of the previous data where the staff ganization (dressings if applicable, appropri- nurses identified varied counts and types of ate bedding, and heel protectors) that were pressure ulcers that were not identified by the in place or if there were missing bundle ele- CNL. Supplemental Digital Content, Figure ments. In analysis from these data, 13 (33%) 3 (available at: http://links.lww.com/JNCQ/ patients with a pressure ulcer had some el- A320), depicts these data outputs. ement of the bundle “missing” or not com- pleted and 26 (67%) patients with a pressure RESULTS ulcer met all the defined organizational bundle elements. Using data obtained from June and July The cost of the project was deemed mini- 2016, the counts of pressure ulcers from the mal in comparison with the projected impact CNL Access database for matching records for improving reporting of pressure ulcers, were evaluated. Data for the month of May providing bedside coaching and mentoring 2016 were not used in the analysis because for more accurate skin assessment in the of necessary training and orientation for the future, and limiting wasted resources for in- new CNLs. During the month of May, data terventions based on data discrepancies. The were potentially skewed while data collection salary costs associated with the project were processes were being developed and revised the salaries of the 2 CNL roles for the pilot and by the CNLs. In the months of June and July the salaries for the 2 staff roles vacated by the 2016, the CNLs documented 13 fewer HAPUs, CNLs for the 90-day duration of the project. which is an approximately 33% decrease in There were minimal supply costs, primarily the count of this type of pressure ulcer com- the assignment of a pager for one of the CNLs pared with information documented by the who did not previously have this resource. staff nurses. They also identified 8 or 27% ad- Both CNLs were currently employed by ditional pressure ulcers present on admission the organization, so there were no costs (Table). In cases in which the nursing docu- associated with training about organizational mentation in the EHR identified HAPUs not in processes, technology, and equipment.

Table. Comparison of CNL and Staff Nurse Documentation

Hospital-Acquired Pressure Ulcers Community-Acquired Pressure Ulcers

CNL Staff Nurse % CNL Staff Nurse % Document, Document, Variation Document, Document, Variation Month n n CNL n n CNL

Jun 2016 19 24 21 11 10 10 Jul 2016 8 16 50 27 20 35 Total 27 40 33 38 30 27

Abbreviation: CNL, clinical nurse leader.

DISCUSSION and documentation capabilities within nursing documentation. Workflow revisions are On review of the PDSA outcomes, the being established to provide a flag for the authors found that the results support the identification of modified or revised skin effectiveness of the CNL role in identifying assessment documentation. When the WOCN opportunities associated with pressure ulcer provides consultation, a data field within the reporting in this organization. As a result nursing documentation has been provided to of data collected by the CNL, there was a update the skin assessment should changes deeper understanding of the process and need to occur. This will allow the report pro- outcome data associated with pressure ulcers. grammer to modify the organization HAPU Opportunities uncovered in the process and report to reflect more accurate information. outcome data warrant workflow and system The most common source of the variation revisions to produce more accurate reporting in skin assessment was due to misidentifica- of pressure ulcers. tion of the type of wound and the description Specific to the documentation of pressure of the skin assessment by the staff nurse. This ulcers, the skin assessment reported in the revelation was not deemed a negative out- EHR was found to vary in both validity and re- come for the project, as one of the limiting liability when compared with that of the CNL factors prior to this implementation was lack in the Access database. The CNL documenta- of the ability to provide information on skin tion over the course of the pilot consistently assessment inaccuracies for bedside teaching resulted in a decreased number of HAPUs and and mentoring. For example, until this pilot with slightly more or equivalent reporting of was initiated, there was no method to com- community-acquired ulcers when compared pare the skin assessment of a more skilled with the EHR nursing documentation. evaluator with the descriptions provided by A portion of the pressure ulcer reporting the bedside staff nurse. As previously stated, variation was deemed to be a technical func- the WOCNs consult only on higher-stage pres- tionality limitation in the ability to delineate a sure ulcers (stage III and above) and there- modified skin assessment in the nursing doc- fore prior to this project, the ability to review umentation when an error in reporting had all perceived skin assessment opportunities been intentionally revised to reflect more ac- were unavailable. The ability of the CNL to curate information. For example, if a staff provide real-time skin assessment feedback nurse had assessed a wound and determined to a more novice nurse was deemed a posi- a potential pressure ulcer, but after consulta- tive outcome for the project due to the high tion, the WOCN found that the wound was a volume of new graduate nurses who are em- vascular ulcer, the documentation would be ployed by the organization. The CNL coach- revised to reflect the more accurate assess- ing and mentoring were also believed by the ment. If staff nurses discontinued the skin as- authors to promote a more collegial inter- sessment documentation or recorded “in er- action versus an apprehensive response that ror” on the EHR, the wounds were still at- may result from feedback from other unit tributed to the unit in the organizational HAPU leadership. report. The CNLs performed analysis of the unit In the current functionality of the EHR sys- pressure ulcer information and then identi- tem, it was difficult to determine whether the fied unit trends and educated staff where ap- documented pressure ulcer was true or false propriate through all-staff meetings or using due to the system functionality in the EHR for other staff communication functions such as deactivation of documentation postdischarge. bulletin boards. This also allowed them to This finding was found to promote greater un- uncover the source of many special circum- derstanding of the reported data in the organi- stance pressure ulcers in the ICU, includ- zation and a call to action by the organization ing device-related ulcers, bariatric-related ul- to improve the functionality of the technology cers, and those caused by certain anatomic

situations. A list was created of these instances initial PDSA cycle, the CNL role has evolved and used to educate the nursing staff on pre- to a broader, more encompassing view of pa- vention and treatment. tient care and the system of care for each unit, The CNLs were able to identify the opportu- which may have a varying impact on outcome nities to improve evidence-informed practice reporting. In addition, this organization is a implementation on the unit based on the data large, academic medical center with the ca- collection established through the bundled pacity to shift resources to test an improve- rounding process. A nurse manager was able ment intervention. Filling staff nursing roles to view opportunities where the CNL evalu- that were vacated by the CNL during the pilot ated a patient with a confirmed pressure ulcer. was available to cover the pilot project, and Each instance that the patient with the pres- funding was possible through an administra- sure ulcer was evaluated by the CNL provided tive budget that did not impact patient care an opportunity to validate that the appropri- efforts. ate pressure ulcer treatment or bundled mea- An opportunity from the project that sures were being used. The variations iden- should be addressed is related to data analyt- tified were not used in a punitive fashion ics. Data necessary to evaluate the outcomes but instead to understand process or system using statistical methods other than descrip- failures. tive statistics were not available. Because of Data obtained by the CNLs highlighted the the short duration of the pilot PDSA interven- utility of a unit-based skin champion. There is tion, there were insufficient data points nec- a need to ensure that there are skin experts essary to produce appropriate statistical pro- available on each unit and also to expand the cess control to evaluate the implementation reach and capacity of the WOCNs. The orga- over time. Parametric procedures such as the nization is also evaluating tele-nursing tech- use of the t test to evaluate a statistically sig- nology to enhance communication with the nificant difference in outcomes should be a WOCN team and has already added additional future addition of the evaluation of the out- staffing resources to increase the number of comes specific to pressure ulcer analysis, in WOCNs available to the nursing units. addition to statistical process control. The project has highlighted the importance of a dedicated role within the nursing mi- CONCLUSIONS crosystem for improvement activities. The training and education of the CNL create a This project exemplifies the complexity of nurse leader uniquely qualified to advance im- accurate pressure ulcer reporting and need provement at point of care, distinct and sep- for focused attention at the point of care arate from nursing managers, assistant man- for accurate assessment and documentation agers, and nurse educators. Within a complex of skin status. Following the implementation health care system, there should be a role ded- of a 90-day PDSA intervention using the CNL icated to improving care at the microsystem role to examine pressure ulcer reporting, the level. While all providers have a role in ensur- authors support that the CNL role has a di- ing quality outcomes, the CNL is poised and rect impact on improving quality at the mi- capable of leading the improvement charge. crosystem level. The CNL was found to iden- This project has several limitations. The pi- tify gaps in the validity and reliability of pres- lot included only 2 units, and the time frame sure ulcer reporting, as well as opportunities was limited to 90 days. At this time, the au- to improve compliance with bundle of care thors cannot provide information on the sus- processes for pressure ulcer management and tainability of the results identified. In addition, prevention. Organizations are challenged to the pilot provided the CNLs with the opportu- review their processes for data collection nity to evaluate an ideal situation; in this case, and reporting to ensure they are achieving a dedicated position focused on pressure ul- the most accurate information for actionable cer data collection and reporting. After the improvement.

The results of the project support the nursing leadership within this organization expanded use of the CNL role for improv- believe that there is a role for the CNL but ing processes and outcomes within an that the role should be implemented in organizational nursing care delivery model. phases, identifying the best balance between The sustainability of the project over time the intraprofessional roles that currently will need to be established. However, exist.

REFERENCES

1. Centers for Medicare & Medicaid Services. Inpa- cal nurse leaders education and practice. http://www tient measures. https://www.cms.gov/Medicare/ .aacn.nche.edu/cnl/CNL-Competencies-October-2013. Quality-Initiatives-Patient-Assessment-Instruments/ pdf. Published 2013. Accessed September 7, 2016. HospitalQualityInits/InpatientMeasures.html.Pub- 12. Harris JL, Roussel L, Thomas PL. Initiating and sustain- lished 2013. Accessed September 7, 2016. ing the clinical nurse leader role, a practice guide. 2nd 2. Centers for Medicare and Medicaid Services. Hospital ed. Burlington, MA: Jones & Bartlett Learning; 2014. value based purchasing. https://www.cms.gov/ 13. Shirey MR. Nursing practice models for acute and Medicare/Quality-Initiatives-Patient-Assessment- critical care: overview of care delivery models. Crit Instruments/HospitalQualityInits/InpatientMeasures Care Nurs Clin North Am. 2008;20(4):365-373. .html. Published 2015. Accessed September 7, 2016. 14. Kimball B, Joynt J, Cherner D, O’Neil E. The quest for 3. The Joint Commission. Performance measurement. new innovative care delivery models. JNursAdm. https://www.jointcommission.org/performance_ 2007;37(9):392-398. measurement.aspx. Published 2016. Accessed 15. Bender M, Connelly CD, Glaser D, Brown C. Clini- September 7, 2016. cal nurse leader impact on microsystem care quality. 4. Institute of Medicine. Crossing the quality chasm. Nurs Res. 2012;61(5):326-332. http://www.nationalacademies.org/hmd/Reports 16. Bender M, Connelly CD, Brown C. Interdisciplinary /2001/Crossing-the-Quality-Chasm-A-New-Health- collaboration: the role of the clinical nurse leader. System-for-the-21st-Century.aspx. Published 2001. J Nurs Manag. 2013;21(1):165-174. Accessed September 7, 2016. 17. Bender M. The current evidence base for the clini- 5. American Nurses Credentialing Center. ANCC Mag- cal nurse leader: a narrative review of the literature. net Recognition program. http://www.nursecreden J Prof Nurs. 2014;30(2):110-123. tialing.org/Magnet. Published 2016. Accessed 18. Hix C, McKeon L, Walters S. Clinical nurse leader September 7, 2016. impact on clinical microsystems outcomes. JNurs 6. Press Ganey. Nursing quality. http://www.press Adm. 2009;39(2):71-76. ganey.com/solutions/clinical-quality/nursing-quality. 19. Langley G, Moen R, Nolan K, Nolan T, Norman C, Published 2016. Accessed September 7, 2016. Provost L. The Improvement Guide: A Practical Ap- 7. Centers for Medicare & Medicaid Services. Hos- proach to Enhancing Organizational Performance. pital acquired conditions. https://www.cms.gov/ 2nd ed. San Francisco, CA: Jossey-Bass; 2009. Medicare/Medicare-Fee-for-Service-Payment/Hospital 20. Associates in Process Improvement. PDSA Cycle. AcqCond/Hospital-Acquired_Conditions.html. Pub- http://www.apiweb.org. Published 2016. Accessed lished 2015. Accessed September 7, 2016. September 7, 2016. 8. Levine JM, Zulkowski KM. Secondary analysis of of- 21. Nelson E, Batalden P, Godfrey M, Lazar J. (Eds.). Value ﬁce of inspector general’s pressure ulcer data: in- by Design: Developing Clinical Microsystems to cidence, avoidability, and level of harm. Adv Skin Achieve Organizational Excellence. San Francisco, Wound Care. 2015;28(9):420-428. CA: Jossey-Bass; 2011. 9. Brem H, Maggi J, Nierman D, et al. High cost of 22. Dartmouth Microsystem Academy. Microsystem stage IV pressure ulcers. Am J Surg. 2010;200(4): Academy workbooks. https://clinicalmicrosystem. 473-477. org/. Published 2015. Accessed September 7, 2016. 10. Coomer NM, McCall NT. Examination of the accuracy 23. National Pressure Ulcer Advisory Panel. Pressure of coding hospital-acquired pressure ulcer stages. ulcer stages. http://www.npuap.org/resources/ Med Med Res Rev. 2013;3(4):E1-E11. educational-and-clinical-resources/npuap-pressure- 11. American Association of Colleges of Nursing. injury-stages. Published 2016. Accessed October 26, Competencies and curricular expectations for clini- 2016.

The CE test for this article is available online only at http://nursingcenter.com/ce/JNCQ.