Let`s Be Frank: An Honest Improvement Plan for Wound Clinic Program Managers

As an experienced wound care provider who’s been staffed in numerous outpatient clinics for nearly 30 years, I find myself asking the same series of questions when meeting with program managers and hospital administrators: “How do you intend to run a successful wound clinic if basic tenets of care are not being utilized or utilized consistently? What are your goals pertaining to care quality? How are you planning to meet those goals? How is vital information and education being disseminated at various levels throughout your organization? What is the overall vision, mission, or purpose that you and your staff members are striving towards?” This new column from Today’s Wound Clinic will seek to assist those who oversee wound care clinics in answering these questions while offering practical advice for achieving clinical and business-related best practices. Another goal for this column will be to discuss the challenges that exist in wound center management. As the author, I hope to encourage readers to take an objective look at their clinics to assess whether they’re providing evidence-based care and whether they’re advancing business practices that will ensure financial success as we continue the transition to quality-based reimbursement. I’ll share some insights, offer guidance, and solicit suggestions from readers (that means you). As an introduction, this article will focus on appointing a physician “champion” to steer educational initiatives and making better use of today’s technology to help clinicians avoid the “supervised neglect” of patients. 

Need for Evidence-Based Concepts

I think we can agree the overarching goal of anyone tasked with managing an outpatient wound clinic is to attain the best possible patient outcomes. Most likely, that person will be someone attempting to incorporate evidence-based care and standardized treatment algorithms into practice. Today’s wound clinics are seeing more patients living with more chronic wounds and multiple comorbidities. That’s why it amazes me that there isn’t more effort devoted to in-house education across the continuum of care about the most recent advancements in evidence-based wound care. We’ve got to ensure our own staff members are up to date. This problem is not unique to rural facilities, although they’re a particular interest of mine because I’ve spent the past 12 years living and working in the small town of Natchitoches, LA, a community plagued with staffing crises and a lack of financial resources. However, I’m told that many of my colleagues who work in major urban areas struggle with the same barriers when they try to foster wound care educational initiatives among their fellow clinicians. Additionally, the US Wound Registry has staggering data on the number of clinics not utilizing appropriate compression on venous leg ulcers (VLUs). Other studies also demonstrate improper offloading using total contact casting (TCC) for diabetic foot ulcers (DFUs). Aren’t each of these practices supposed to be considered standards of care? (In regards to compression, studies have noted patients living with VLUs were in appropriate compression in only 17% of visits.¹ DFU studies have shown only 2% of practitioners utilize TCC during treatment² and only 6% of wound facilities utilized offloading TCC on DFUs.¹) These providers should know better. Probably most frustrating about this apparent lack of evidence-based care is that technology has never been better or more available. What’s keeping these clinicians from doing the right thing? Do that many people in our industry really not know what the right thing is? Or is it a pervasive lack of finances and/or resources? The solution would seem to be to designate one “champion” within the facility to be responsible for ongoing staff education and ensuring open lines of communication across the organization’s continuum.

Employing A Physician ‘Champion’

We all want to be winners — it’s human nature. As healthcare providers, we all want to help our patients “win” too. But what does it mean to be a true champion? It starts with accountability. Any healthcare facility’s success and growth is going to be contingent on having a physician champion who’s willing to be accountable for ensuring the knowledge, skills, and competency of staff members. This can only be accomplished by supporting and maintaining appropriate communication, education, coordination of care protocols, and interaction between various clinical disciplines. Wound healing is a complex, dynamic process. However, we can become complacent with chronicity. We know outcomes improve when a multidisciplinary approach is utilized, yet as an industry we still tend to be “working in silos.” Appointing a physician champion can certainly help reverse this trend. The characteristics required to staff this position will likely be different for each clinic. The physician champion should be someone who possesses the following attributes: passion for the work, high expectations for the clinic’s performance, approachability and strong communication skills, respect amongst peers, ability to problem solve in various situations, mentoring nature, willingness to affect change as needed, and an inclination for patient advocacy. The responsibilities expected for such a position should be detailed in the facility’s policies and procedures prior to any interviewing/selection process that may be conducted. This will establish healthy expectations from the start and avoid misunderstandings as processes are implemented and/or restructured.

Taking Time On Our Side

During a recent Wound Healing Roundtable³ I hosted in Natchitoches, one of our speakers, Caroline E. Fife, MD, FAAFP, CWS, FUHM (you know her as the clinical editor of this journal), spoke about “supervised neglect.” Supervised neglect is when a patient is regularly seen, examined, and shows signs of a disease or medical problem, but effective treatment for that problem is not provided. A wound care clinician who may be guilty of this is someone who knows what the standard of care is, but does not consistently offer it. If there’s a chronic defect in the integumentary system, the question should be, “Why is this present?” or “What’s keeping the wound from progressing through the phases of healing?” Standard of care is not just about covering the defect with a dressing and then waiting to see what will happen over time. It’s what we as clinicians do within that timeframe that matters. Examining and assessing the “whole” patient as well as the “hole in the patient,” so that we can follow best-practice guidelines, is what makes the difference between poor care and world-class care. We all struggle with time pressures, so it’s easy to lose track of the details. Here’s a checklist to remember when caring for a patient, no matter how “simple” the wound may seem:

• Concentrate on patient outcomes one patient (and one wound) at a time.
• Provide a strong clinical education explanation to each patient, as well as the caregivers and your fellow staff members, regarding the treatment of the wound and the overall care plan — especially at the time of transition to home.
• Do not practice “advanced” wound care until basic wound care interventions have been explained, implemented, and documented.  
• Share and explain the ongoing results with staff members and patients as often and as comprehensively as possible. (Experience becomes knowledge.)

Utilizing Technology

There are many obstacles we will continue to face as we practice in an evolving healthcare system. The only constant for us is change itself, as clichéd as that sounds. Although we will have to adapt our clinical practices to the new realities of reimbursement, we will have access to more technology. Incorporating that technology into our protocols is challenging. If you were to ask practitioners who are still using wet-to-dry dressings why they continue to do so, their answers will probably be that it’s “what they have always done.” We tend to be creatures of habit. Those who don’t use new technology/dressings as they become available will not be able to form new habits. These clinicians who are resistant to change are sometimes described as having “neophobia,” but I think that’s a copout. Dr. Maxwell Maltz (1889-1975), a cosmetic surgeon and author of Psycho-Cybernetics, a system of ideas he claimed could improve self-image, observed that it took patients about 21 days to become used to seeing their new facial features or amputated extremity following a procedure. A study by Phillippa Lally, a psychologist and researcher of behavioral health, found it takes about 66 days for a new behavior to become a habit. That means it takes more than two months of consistent effort to transform newly learned clinical information into practice habits.  Champions continuously try to understand new and advanced technologies that may some day be considered standard practice. Champions make it a priority to improve communication between clinical staff members, taking advantage of all available resources. Let’s learn from one another and develop a new generation of champions. Please contact me at frank.aviles@nrmchospital.org to request any topics to be covered in this space moving forward. 

Frank Aviles Jr is wound care service line director at Natchitoches Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapist/wound care consultant at Louisiana Extended Care Hospital, Lafayette, LA; and physical therapist/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

References

1.  Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care? Wound Rep Regen. 2010;18(2):154-8.

2.  Wu SC, Jensen JL, Weber AK, Robinson DE, Armstrong DG. Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care. 2008;31(11):2118-9.

3.  Fife CE. From the editor. TWC. 2016;10(5):4-6.