Stage III and IV Pressure Ulcers
Cause Mapping Example:
Stage III and IV pressure ulcers have been added to the list of hospital-acquired conditions whose treatment will no longer be reimbursed by Medicare. Pressure ulcers are also on the list of "Never" events, or incidents that should never occur at healthcare facilities, and can lead to serious complications from patients who suffer from them. It is imperative that healthcare facilities reduce the risk of patients contracting pressure ulcers.
We will use the Cause Mapping method to detail the causes resulting in pressure ulcers and find solutions to prevent them. The three steps of the Cause Mapping method are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions. Each step will be discussed below.
Step 1. Define the Problem
The first step of the Cause Mapping approach is to define the problem. Here, the problem is Stage III and IV Pressure Ulcers. Pressure ulcers can happen anywhere on a patient's skin, and are especially common on the heels. We'll record this as the physical problem location.
We can further refine the problem outline by defining the problem by the impact to the organization's goals. The patient safety and patient services goals are impacted because pressure ulcers cause damage to tissue, muscle and bone. The compliance and organization goals are impacted because these types of pressure ulcers are a "never event", as defined by the National Quality Forum. Additionally, the materials and labor goal is impacted because the hospital costs (averaging $43,180 per case according to Medicare) are no longer reimbursable, as this has been defined as a hospital-acquired condition.
Also according to Medicare, there are more than a quarter of a million cases of Stage III and IV pressure ulcers a year. That adds up to a more than $11 BILLION problem for the medical industry. Shown below is the problem outline for Stage III and IV pressure ulcers.
Step 2. Identify the Causes (The Analysis)
Now that we've defined the problem, we can begin to analyze it. We begin by starting with one of our impacted goals. Here, we'll start with the patient safety and patient services goals. These goals are both impacted by damage to tissue, muscle and bone. These are our first cause-and-effect relationships.
The analysis can continue by asking Why questions and moving to the right of either of the cause-and-effect relationships above. Next, we ask why there is damage to tissue, muscle and bone. It's caused by a patient developing Stage III or IV pressure ulcers. This is in turn cased by the death of tissue.
Tissue death can be caused by poor skin condition and/or mechanical damage to tissue. We'll discuss causes of both of these in turn.
Poor skin condition can be caused by inadequate nutrition. It can also be caused by poor environment, such as direct exposure to moisture, exposure to cold, or low humidity. Additionally, contaminants on the skin, from incontinence, or some other exposure to external contaminants, can also cause poor skin condition.
Mechanical damage to tissue can occur from shear injury, friction injury, or pressure injury. Shear injury can be caused by having the head of the bed elevated. (The skin is pressed against the bed, so it remains mobile, but the body is pulled down by gravity, resulting in shear damage to the skin.)
Friction injury can be caused by bony prominences contacting eachother, or by skin being drug over bed linens. This frequently occurs if a patient is being repositioned and is unable to lift themselves to assist.
Pressure injuries occur when a patient is immobile and either has their body weight resting on their heels, or stays in the same position. Patients generally have their body weight shifted, but may not if their caregivers are unaware of the risk of pressure ulcers, due to lack of knowledge or lack of awareness of a patient's specific risk, or due to insufficient staff, likely due to lack of funding.
Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.
Step 3. Select the Best Solutions (Reduce the Risk)
Once the Cause Map is built to a sufficient level of detail with supporting evidence solutions can be found that control specific causes. The Cause Map is used to identify all the possible solutions for given issue so that the best solutions can be selected. Solutions are placed on the Cause Map above the causes they control. An example cause and associated solution is shown below.
Now we put in the other impacted goals, and other solutions. The entire Cause Map (with 31 cause boxes) is shown below.
The selected solutions are placed in the Action Items list and assigned to a staff member for responsibility. The Action Items list is shown below.
Cause Mapping Improves Problem Solving Skills
The Cause Mapping method focuses on the basics of the cause-and-effect principle so that it can be applied consistently to day-to-day issues as well as catastrophic, high risk issues. The steps of Cause Mapping are the same, but the level of detail is different. Focusing on the basics of the cause-and-effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.
Click on "Download PDF" above to download a PDF showing the Cause Map.
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