Assessment 3 (2026): Improvement Plan In-Service Presentation \u2013 Preventing Hospital-Acquired Pressure Injuries in the ICU<\/strong><\/p>\n Course:<\/strong> NURS-FPX 4020 \u2013 Improving Quality of Care and Patient Safety (Capella University, FlexPath BSN) This assessment aligns with established NURS-FPX 4020 Assessment 3 expectations that require learners to deliver an in-service education session presenting an evidence-based improvement plan to nurses and interprofessional colleagues, grounded in a previously analysed quality or safety issue.<\/p>\n You will design and present an improvement plan in the form of an in-service education session for ICU nurses and relevant team members. The session will focus on reducing hospital-acquired pressure injuries by addressing the human, system, and environmental factors identified in Assessment 2 and explaining how the proposed plan improves quality, safety, and cost outcomes.<\/p>\n By completing this assessment, you will be able to:<\/p>\n Propose an evidence-informed improvement plan that directly targets a defined quality and safety problem in a specific clinical setting<\/p>\n<\/li>\n Explain how the proposed plan supports improved patient outcomes, safer nursing practice, and more efficient use of healthcare resources<\/p>\n<\/li>\n Communicate the improvement plan in a clear, engaging format suitable for an in-service education session for nurses and interdisciplinary colleagues<\/p>\n<\/li>\n Demonstrate professional, scholarly communication appropriate for BSN-level nursing practice<\/p>\n<\/li>\n<\/ul>\n Include the presentation title, your name, course, and date<\/p>\n<\/li>\n Clearly state the purpose of the in-service in one or two sentences (for example, reducing ICU hospital-acquired pressure injuries through a focused prevention improvement plan)<\/p>\n<\/li>\n<\/ul>\n Briefly restate the ICU practice context from Assessment 2, including unit type, patient population, baseline HAPI rates, and injury severity patterns<\/p>\n<\/li>\n Summarise why hospital-acquired pressure injuries are a priority in this unit, referencing patient harm, regulatory expectations, and cost implications<\/p>\n<\/li>\n Include one or two key data points from your Assessment 2 analysis, such as incidence rates or estimated cost per injury<\/p>\n<\/li>\n<\/ul>\n Use concise bullet points to recap the most significant contributors identified in Assessment 2:<\/p>\n Human factors:<\/strong> workload pressures, competing priorities, gaps between knowledge and practice, and communication during handovers<\/p>\n<\/li>\n System and process issues:<\/strong> repositioning protocols that do not reflect ICU complexity, inconsistent Braden Scale reassessment, lack of electronic prompts, and inconsistent allocation of specialty surfaces<\/p>\n<\/li>\n Environment and technology:<\/strong> ICU room layout, availability of lifts and specialty beds, documentation burden, and reporting culture<\/p>\n<\/li>\n<\/ul>\n Introduce the overarching aim of the improvement plan (for example, reducing stage 2 or higher ICU pressure injury incidence from 14% to 5% or less within 12 months)<\/p>\n<\/li>\n Identify two to three key strategies that will structure the remainder of the presentation<\/p>\n<\/li>\n<\/ul>\n Describe implementing a structured risk-stratification process that combines Braden Scale thresholds with clinical judgement for factors such as hemodynamic instability, proning, or advanced life-support therapies<\/p>\n<\/li>\n Explain how electronic health record alerts will be used to flag high-risk patients and prompt overdue repositioning or skin assessments<\/p>\n<\/li>\n Identify staff responsibilities, including bedside nurses, charge nurses, and wound-care specialists, and specify how frequently risk will be reassessed<\/p>\n<\/li>\n Briefly reference guideline-supported evidence for risk-based prevention and electronic reminders<\/p>\n<\/li>\n<\/ul>\n Outline a risk-based protocol for allocating specialty beds and overlays so that the highest-risk ICU patients receive them first<\/p>\n<\/li>\n Describe how specialty surfaces will be monitored and re-allocated as patient risk levels change<\/p>\n<\/li>\n Address safe patient handling by describing team-based turning procedures and improved access to lift equipment<\/p>\n<\/li>\n Explain how this strategy reduces both pressure injury risk and staff injury risk, supporting patient safety and cost control<\/p>\n<\/li>\n<\/ul>\n Describe how repositioning schedules and documentation will be adapted to reflect ICU realities, including clinical instability and unavoidable delays<\/p>\n<\/li>\n Explain planned electronic documentation changes that make recording turns and justified exceptions more efficient<\/p>\n<\/li>\n Include a simple visual overview of the revised workflow from risk assessment to follow-up<\/p>\n<\/li>\n Emphasise how the plan supports a non-punitive learning culture that uses missed turns as improvement data rather than grounds for blame<\/p>\n<\/li>\n<\/ul>\n Identify three to five measurable outcomes, such as reduced HAPI incidence, decreased ICU length of stay, and fewer staff lifting injuries<\/p>\n<\/li>\n Include anticipated cost outcomes, such as reduced treatment costs per pressure injury and avoidance of penalties or litigation<\/p>\n<\/li>\n Explain how outcomes will be monitored, for example through monthly dashboards or protocol compliance audits<\/p>\n<\/li>\n<\/ul>\n Briefly outline expectations for:<\/p>\n Bedside nurses<\/p>\n<\/li>\n Charge nurses and unit leadership<\/p>\n<\/li>\n Wound-care specialists or skin-care champions<\/p>\n<\/li>\n Information technology and materials management teams<\/p>\n<\/li>\n<\/ul>\n Summarise immediate expectations for staff, such as trialling the new workflow and providing feedback<\/p>\n<\/li>\n State the duration of the pilot or initial implementation period and when results will be reviewed and shared<\/p>\n<\/li>\n<\/ul>\n List all sources in current APA format, including clinical guidelines, research studies, and quality-improvement resources<\/p>\n<\/li>\n<\/ul>\n Length:<\/strong> 12\u201315 content slides (excluding title and references), with narration or speaker notes equivalent to 1,200\u20131,500 words<\/p>\n<\/li>\n Audience:<\/strong> ICU nurses and relevant interdisciplinary staff; language should be clear, clinically grounded, and accessible<\/p>\n<\/li>\n Evidence base:<\/strong> Use at least four to six recent scholarly or authoritative sources published between 2018 and 2026<\/p>\n<\/li>\n Consistency:<\/strong> Ensure alignment between this presentation and Assessment 2 regarding problem description, baseline data, and contributing factors<\/p>\n<\/li>\n<\/ul>\n Pressure injuries in the ICU represent more than an isolated clinical complication; they reflect broader misalignment between patient risk, workflow demands, and resource allocation. Evidence suggests that a single stage 3 or 4 pressure injury can substantially increase treatment costs and prolong ICU length of stay, making prevention strategies both a clinical and financial priority (Padula et al., 2019).<\/p>\n Evidence from international critical-care studies demonstrates that multifaceted pressure injury prevention programmes combining risk stratification, staff education, specialty surface allocation, and workflow-integrated documentation produce significantly greater reductions in ICU-acquired pressure injuries than isolated interventions. These findings reinforce the importance of system-level improvement plans that align prevention strategies with real-world ICU constraints, rather than relying solely on individual nurse compliance (Chaboyer et al., 2018).<\/p>\n Alderden, J. et al. (2021) Outcomes associated with hospital-acquired pressure injuries: A systematic review<\/em>, Advances in Skin & Wound Care, 34(10), pp. 1\u201314.<\/p>\n<\/li>\n Padula, W. V. et al. (2019) Value of hospital resources for effective pressure injury prevention: A cost-effectiveness analysis<\/em>, BMJ Quality & Safety, 28(2), pp. 132\u2013141.<\/p>\n<\/li>\n Mervis, J. S. and Phillips, T. J. (2019) Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation<\/em>, Journal of the American Academy of Dermatology, 81(4), pp. 881\u2013890.<\/p>\n<\/li>\n Tayyib, N. and Coyer, F. (2016) Effectiveness of pressure ulcer prevention strategies for adult ICU patients<\/em>, Worldviews on Evidence-Based Nursing, 13(6), pp. 432\u2013444.<\/p>\n<\/li>\n Agency for Healthcare Research and Quality (2020) Preventing pressure ulcers in hospitals<\/em>.<\/p>\n<\/li>\n Chaboyer, W. et al. (2018) A multifaceted intervention to prevent pressure injuries in intensive care units<\/em>, American Journal of Critical Care, 27(6), pp. 486\u2013494.<\/strong><\/p>\n<\/li>\n<\/ul>\n <\/p>\n #Sample PPT Presentation Slides.<\/strong><\/em><\/p>\n An Evidence-Based Improvement Plan<\/strong> Purpose:<\/strong> Key Focus Areas:<\/strong><\/p>\n Risk-stratified prevention with automated alerts<\/p>\n<\/li>\n Optimized specialty surface allocation<\/p>\n<\/li>\n Workflow-realistic repositioning protocols<\/p>\n<\/li>\n<\/ul>\n Unit Profile:<\/strong><\/p>\n 20-bed medical-surgical ICU<\/p>\n<\/li>\n Average patient age: 62 years<\/p>\n<\/li>\n High-acuity patients: mechanical ventilation, vasopressors, CRRT<\/p>\n<\/li>\n Nurse-patient ratio: 1:1 to 1:2<\/p>\n<\/li>\n<\/ul>\n Current State Data:<\/strong><\/p>\n 18 pressure injuries documented over 6 months<\/p>\n<\/li>\n 14% incidence rate for patients >72 hours<\/p>\n<\/li>\n 11 stage 2, 5 stage 3, 2 unstageable<\/p>\n<\/li>\n Common injury locations: sacrum, heels, occiput<\/p>\n<\/li>\n<\/ul>\n Additional Metrics:<\/strong><\/p>\n Current incidence rate: 14%<\/p>\n<\/li>\n Repositioning compliance: 62%<\/p>\n<\/li>\n Braden Scale reassessment: 54%<\/p>\n<\/li>\n<\/ul>\n Patient Impact:<\/strong><\/p>\n Pain, delayed mobilization, increased infection risk<\/p>\n<\/li>\n Extended ICU stays, functional decline<\/p>\n<\/li>\n<\/ul>\n Regulatory and Quality Standards:<\/strong><\/p>\n Hospital-acquired pressure injuries classified as never events<\/p>\n<\/li>\n Linked to value-based purchasing penalties and quality rankings<\/p>\n<\/li>\n<\/ul>\n Financial Burden:<\/strong><\/p>\n Stage 2: $10,000 per injury<\/p>\n<\/li>\n Stage 3-4: $43,000-$129,000 per injury<\/p>\n<\/li>\n Extended ICU stays: $3,000-$5,000 per day<\/p>\n<\/li>\n<\/ul>\n Staff Morale:<\/strong><\/p>\n Moral distress when preventable harm occurs despite knowledge of prevention strategies<\/p>\n<\/li>\n<\/ul>\n High Cognitive Load & Competing Priorities:<\/strong> Nurses manage alarms, vasopressors, procedures, and family communication; pressure injury prevention competes with more urgent tasks<\/p>\n<\/li>\n Communication Gaps at Handoff:<\/strong> Shift reports focus on hemodynamics; skin integrity and turning schedules often omitted<\/p>\n<\/li>\n Knowledge-Practice Gap:<\/strong> Staff understand principles but struggle to translate knowledge into consistent action under high-acuity conditions<\/p>\n<\/li>\n<\/ul>\n Protocols Not Adapted for ICU Complexity:<\/strong> Two-hour repositioning standards do not account for hemodynamic instability, proning, or ECMO support<\/p>\n<\/li>\n Inconsistent Risk Reassessment:<\/strong> Braden Scale reassessed every 48 hours; no prompts for patient condition changes<\/p>\n<\/li>\n Documentation Burden:<\/strong> Multiple EHR screens; no automatic alerts for overdue turns<\/p>\n<\/li>\n First-Come, First-Served Surface Allocation:<\/strong> High-risk patients wait 12-24 hours while lower-risk patients occupy specialty beds<\/p>\n<\/li>\n<\/ul>\n Room Layout & Equipment Access:<\/strong> Limited space, difficulty using lifts; specialty surfaces stored far from bedside<\/p>\n<\/li>\n Technology Workflow Interruptions:<\/strong> Mobile EHR terminals interfere with repositioning workflows<\/p>\n<\/li>\n Safety Reporting Culture:<\/strong> Staff fear reporting injuries may be interpreted as individual failure<\/p>\n<\/li>\n<\/ul>\n Enhanced Risk Assessment:<\/strong><\/p>\n Braden Scale plus ICU-specific risk factors for high-acuity patients<\/p>\n<\/li>\n<\/ul>\n Electronic Health Record Alerts:<\/strong><\/p>\n Automated alerts flag patients with Braden scores <13<\/p>\n<\/li>\n Notifications for overdue repositioning by 30 minutes<\/p>\n<\/li>\n Prompts for overdue skin assessments<\/p>\n<\/li>\n<\/ul>\n Evidence Base:<\/strong><\/p>\n Automated reminders improve repositioning compliance when integrated into workflow (Tayyib & Coyer, 2016)<\/p>\n<\/li>\n<\/ul>\n Risk-Based Allocation Protocol:<\/strong><\/p>\n Highest-risk patients (Braden <10 or multiple risk factors) receive specialty beds within 4 hours<\/p>\n<\/li>\n Medium-risk patients (Braden 10-12) receive alternating-pressure overlays<\/p>\n<\/li>\n Daily review and reallocation based on patient risk<\/p>\n<\/li>\n<\/ul>\n Safe Patient Handling:<\/strong><\/p>\n Team-based turning procedures for ECMO, proned, or line-heavy patients<\/p>\n<\/li>\n Lift equipment staged in-unit to reduce delays<\/p>\n<\/li>\n Pre-turn huddles to coordinate staff and equipment<\/p>\n<\/li>\n<\/ul>\n Dual Benefit:<\/strong><\/p>\n Reduces both pressure injury risk for patients and musculoskeletal injury risk for staff<\/p>\n<\/li>\n<\/ul>\n Adapted Repositioning Schedules:<\/strong><\/p>\n Standard two-hour turns for stable patients on specialty surfaces<\/p>\n<\/li>\n Modified intervals (1-3 hours) based on clinical stability and risk<\/p>\n<\/li>\n Document delays with clinical rationale in non-punitive format<\/p>\n<\/li>\n<\/ul>\n Streamlined Documentation:<\/strong><\/p>\n One-click repositioning documentation in EHR<\/p>\n<\/li>\n Dropdown menu for justified exceptions (procedures, instability, family presence)<\/p>\n<\/li>\n Simplified skin assessment checkboxes<\/p>\n<\/li>\n<\/ul>\n Culture Shift:<\/strong><\/p>\n Use missed turns as improvement data, not grounds for blame<\/p>\n<\/li>\n<\/ul>\n Admission or Status Change:<\/strong> Complete Braden Scale + ICU risk factors<\/p>\n<\/li>\n EHR Alert Triggers:<\/strong> High-risk patients flagged; surfaces requested<\/p>\n<\/li>\n Surface Allocation:<\/strong> Within 4 hours based on risk tier<\/p>\n<\/li>\n Repositioning Schedule:<\/strong> Tailored to patient stability and risk<\/p>\n<\/li>\n Documentation and Alerts:<\/strong> One-click turns; overdue alerts<\/p>\n<\/li>\n Daily Review:<\/strong> Charge nurse reviews patient risk and surface allocation<\/p>\n<\/li>\n<\/ol>\n Quality Outcomes:<\/strong><\/p>\n Reduce stage 2+ injuries from 14% to <5%<\/p>\n<\/li>\n Improve repositioning compliance to >90%<\/p>\n<\/li>\n Increase Braden reassessment to >95%<\/p>\n<\/li>\n<\/ul>\n Safety Outcomes:<\/strong><\/p>\n Decrease patient pain and complications<\/p>\n<\/li>\n Reduce staff lifting injuries<\/p>\n<\/li>\n Strengthen safety reporting culture<\/p>\n<\/li>\n<\/ul>\n Cost Outcomes:<\/strong><\/p>\n Avoid $400,000-$600,000 in treatment costs<\/p>\n<\/li>\n Reduce ICU length of stay<\/p>\n<\/li>\n Avoid regulatory penalties<\/p>\n<\/li>\n<\/ul>\n Monitoring Methods:<\/strong><\/p>\n Monthly pressure injury incidence dashboards<\/p>\n<\/li>\n Weekly compliance audits<\/p>\n<\/li>\n Quarterly cost analysis<\/p>\n<\/li>\n<\/ul>\n Projected 12-Month Impact:<\/strong><\/p>\n Prevent 10-12 pressure injuries, saving $200,000-$400,000<\/p>\n<\/li>\n<\/ul>\n Immediate Actions for Bedside Nurses:<\/strong><\/p>\n Complete Braden Scale assessment at admission and with status changes<\/p>\n<\/li>\n Respond to EHR alerts for high-risk patients and overdue repositioning<\/p>\n<\/li>\n Use one-click documentation for turns and skin assessments<\/p>\n<\/li>\n Request specialty surfaces through charge nurse when Braden <13<\/p>\n<\/li>\n Report newly identified injuries using non-punitive incident reporting<\/p>\n<\/li>\n<\/ul>\n Implementation Timeline:<\/strong><\/p>\n Pilot begins February 2026<\/p>\n<\/li>\n Full implementation April 2026<\/p>\n<\/li>\n First outcome review May 2026<\/p>\n<\/li>\n<\/ul>\n Message to Staff:<\/strong> Alderden, J., Zhao, Y. L., Zhang, Y., Thomas, D., & Butcher, R. (2021). Outcomes associated with hospital-acquired pressure injuries: A systematic review. Advances in Skin & Wound Care, 34<\/em>(10), 1-14. https:\/\/doi.org\/10.1097\/01.ASW.0000751409.26879.0a<\/a><\/p>\n<\/li>\nCourse and Assessment Positioning<\/h2>\n
Assessment:<\/strong> Assessment 3 \u2013 Improvement Plan In-Service Presentation (based on Assessment 2 problem analysis)
Level:<\/strong> Upper-division BSN (quality and safety focus)
Format:<\/strong> 12\u201315 slide narrated in-service presentation or<\/em> a presentation script of 1,200\u20131,500 words, plus a reference slide
Focus:<\/strong> Translating your Assessment 2 analysis of hospital-acquired pressure injuries (HAPIs) in the ICU into a practical improvement plan for frontline staff<\/p>\nAssessment 3 Overview<\/h2>\n
Intended Learning Outcomes<\/h2>\n
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Presentation Content Requirements<\/h2>\n
1. Title and Purpose Slide (1 slide)<\/h3>\n
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2. Problem Summary and Context (1\u20132 slides)<\/h3>\n
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3. Root Causes and Contributing Factors (2\u20133 slides)<\/h3>\n
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4. Improvement Plan Overview (1 slide)<\/h3>\n
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5. Strategy 1 \u2013 Risk-Stratified Prevention and Alerts (2\u20133 slides)<\/h3>\n
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6. Strategy 2 \u2013 Optimised Use of Specialty Surfaces and Safe Handling Resources (2\u20133 slides)<\/h3>\n
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7. Strategy 3 \u2013 Workflow-Realistic Repositioning and Documentation (2\u20133 slides)<\/h3>\n
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8. Expected Outcomes: Quality, Safety, and Cost (1\u20132 slides)<\/h3>\n
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9. Roles and Responsibilities (1 slide)<\/h3>\n
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10. Call to Action and Next Steps (1 slide)<\/h3>\n
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11. References Slide (1 slide)<\/h3>\n
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Presentation Delivery Requirements<\/h2>\n
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References<\/h2>\n
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Preventing Hospital-Acquired Pressure Injuries in the ICU<\/h1>\n
NURS-FPX 4020: Improving Quality of Care and Patient Safety
Student Name | Capella University | January 2026<\/p>\n
\n1. Purpose and Objectives<\/h2>\n
Present an evidence-based improvement plan to reduce hospital-acquired pressure injuries in the ICU from 14% to below 5% within 12 months.<\/p>\n\n
\n2. The Problem: ICU Context<\/h2>\n
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\n3. Why Pressure Injuries Are a Priority<\/h2>\n
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\n4. Root Causes: Human Factors<\/h2>\n
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\n5. Root Causes: System and Process Issues<\/h2>\n
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\n6. Root Causes: Environment and Technology<\/h2>\n
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\n7. Strategy 1: Risk-Stratified Prevention<\/h2>\n
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\n8. Strategy 2: Optimized Specialty Surfaces<\/h2>\n
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\n9. Strategy 3: Workflow-Realistic Repositioning<\/h2>\n
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\n10. Implementation Workflow<\/h2>\n
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\n11. Expected Outcomes: Quality, Safety, and Cost<\/h2>\n
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\n12. Next Steps and Call to Action<\/h2>\n
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Your engagement is critical to preventing harm and improving patient outcomes.<\/p>\n
\n13. References<\/h2>\n
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