title: Design, application and impact of quality improvement 'theme months' in orthopaedic nursing: a mixed method case study on pressure ulcer prevention.
abstract: BACKGROUND
  While there is growing awareness of quality problems in healthcare systems, it remains uncertain how best to accomplish and sustain improvement over time.
  
  
  OBJECTIVE
  To report on the design and application of quality improvement theme months in orthopaedic nursing, and evaluate the impact on pressure ulcer as an example.
  
  
  METHODS
  Retrospective mixed method case study with time series diagrams.
  
  
  METHODS
  An orthopaedic department at a Swedish university hospital.
  
  
  METHODS
  The interventions were led by nursing teams and focused on one improvement theme at a time in two-month cycles, hence the term 'improvement theme months'. These included defined objectives, easy-to-use follow-up measurement, education, changes to daily routines, "reminder months" and data feedback. The study draws on retrospective record data regarding one of the theme topics, pressure ulcer risk assessment and prevalence, in 2281 orthopaedic admissions during January 2007-October 2010 through point prevalence measurement one-day per month. Data were analysed in time series diagrams and through comparison to annual point prevalence data from mandatory county council-wide measurements prior to, during and after interventions from 2003 to 2010. By using document analysis we reviewed concurrent initiatives at different levels in the healthcare organisation and related them to the improvement theme months and their impact.
  
  
  RESULTS
  The 46 monthly point prevalence samples ranged from 28 to 66 admissions. Substantial improvements were found in risk assessment rates for pressure ulcers both in the longitudinal follow-up (p<0.001) and in the annual county council-wide measurements. A reduction in pressure ulcer rate was observed in the annual county council-wide measurements. In the longitudinal data, wider variation in the pressure ulcer rate was seen (p<0.067); however, there was a significant decrease in pressure ulcer rates during the final ten-month period in 2010, compared to the baseline period in 2007 (p=0.004). Improvements were moderate the first years and needed reinforcement to be maintained.
  
  
  CONCLUSIONS
  The theme month design and the way it was applied in this case showed potential, contributing to reduced pressure ulcer prevalence, as a way to conduct quality improvement initiatives in nursing. For sustainable improvement, multi component interventions are needed with regular monitoring and reminder efforts.
authors: Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Orthopaedics, Stockholm, Sweden. maria.unbeck@ds.se
authors: Maria
authors: M
authors: Unbeck
authors: Eila
authors: E
authors: Sterner
authors: Mattias
authors: M
authors: Elg
authors: Bjöörn
authors: B
authors: Fossum
authors: Johan
authors: J
authors: Thor
authors: Karin
authors: K
authors: Pukk Härenstam
mesh_terms: D006801:Humans; D016530:Orthopedic Nursing; D003668:Pressure Ulcer / Q000517:prevention & control*; D011787:Quality of Health Care