NUR 684 Module 7 Milestone Three Example

Milestone Three: Implementation and Outcomes Management Plan for a Heel Pressure Injury Bundle

[Student Name]

Southern New Hampshire University

NUR 684: Clinical Nurse Leader Capstone

Module Seven Milestone Three

[Instructor Name]

[Date]

Milestone Three: Implementation and Outcomes Management Plan for a Heel Pressure Injury Bundle

Managing outcomes is one of the defining responsibilities of the clinical nurse leader. It means more than counting results at the end; it means watching processes and outcomes as a change unfolds and adjusting in time to matter. This milestone sets out how the heel pressure injury bundle will be introduced on Clearwater General's orthopedic floor and in the emergency department's orthopedic bays, how its delivery and effects will be measured and how the CNL will respond to what the data show.

Staged Rollout

The bundle will be introduced over sixteen weeks. Weeks one and two prepare the ground: the champion role is filled on each shift, the consolidated bundle checklist goes live in the electronic record, lighter heel boots arrive and staff complete a fifteen-minute session at huddles. Weeks three and four pilot the bundle on eight beds, the section of the unit where most hip fracture patients are placed, with daily check-ins between the CNL and the champions. The team will review pilot data at the end of week four and adjust the checklist, boot choice and rounding times before spreading. From week five, the bundle runs on all 32 beds, and the emergency department's orthopedic bays begin the arrival heel check. Weeks five through sixteen are the main measurement period.

Starting small allows problems to surface where they can be fixed quickly. During planning, for example, night nurses warned that the checklist prompt would fire during the 4 a.m. vital signs round, when patients are asleep; the pilot will test whether moving it to 6 a.m. helps.

Measuring Delivery

Chaboyer et al. (2016) tested a patient-centered pressure injury bundle across several hospitals and found fewer injuries in the intervention group, yet not enough to be statistically confident, and their process evaluation showed that many patients did not receive the full bundle. The lesson for this project is that a bundle must be measured as delivered, not as designed. The primary process measure will therefore be all-or-none bundle completion: the percentage of hip fracture patients who, on a given day, have a documented Braden score, boots in place, a repositioning plan, a nutrition referral within 24 hours of admission and a skin round in the past four days. A patient missing any element counts as incomplete.

Individual elements will also be tracked so the team can see which part is slipping: emergency department heel checks, boots on spot audit, repositioning documentation and time to dietitian review.

Implementation Outcomes

Proctor et al. (2011) argue that implementation success should be measured separately from clinical success, using outcomes such as whether a practice is acceptable to staff, whether they adopt it, whether it is delivered as intended and whether it lasts. They point out that a failed clinical result is uninterpretable without these measures, because it may reflect poor implementation rather than a poor intervention. The project will measure acceptability with a five-item survey of nurses, assistants and therapists at week four and week sixteen; adoption by counting how many nurses fill in a bundle checklist in a given week; fidelity through the all-or-none measure; and sustainability as bundle completion three months after the immersion ends.

Outcome and Balancing Measures

The primary outcome counts stage 2 and deeper heel wounds that hip fracture patients acquire on the unit each month, expressed per 100 hip fracture admissions, found by weekly skin rounds and confirmed by the wound nurse. Quarterly prevalence surveys continue for all sites and all patients. Balancing measures watch for harm the bundle could cause: device-related skin injuries from boot straps, falls among patients wearing boots, since boots can catch on floors during early walking, and delays to therapy sessions caused by boot changes.

Table 1. Measures and Targets

Note. Targets were agreed with the nurse manager and wound nurse.

Reading the Data

Perla et al. (2011) describe how run charts, which plot a measure over time around its median, can distinguish meaningful change from random fluctuation using a few probability-based rules, such as a long streak of weeks stuck on one side of the middle value, or a steady climb or fall across consecutive weeks. Run charts suit this project because weekly audit samples are small and outcome events are rare. Weekly bundle completion will be plotted from the pilot onward, with the pilot and spread dates marked. Heel injuries are too rare for weekly charts, so the team will plot the number of hip fracture admissions between injuries, where longer gaps show improvement.

Responding to the Data

Outcomes management requires decisions. If all-or-none completion stays below 70% for two weeks, the CNL will identify the element most often missed and meet with its owner group within a week. If a heel injury occurs, the skin round team will review the case within 48 hours to see which bundle element failed. If falls in boots rise, the team will switch patients to pillows for heel floating during mobility sessions. Results will be posted at huddles weekly and shared with the emergency department monthly.

Data Roles and Protection

Data collection is shared so that it does not rest on one person. Champions complete the weekly spot audit of boots and repositioning on eight randomly chosen at-risk patients per shift, the wound nurse confirms each suspected injury within a day, the unit secretary pulls falls from the incident system each month and the CNL assembles the charts. Audit sheets carry bed numbers but no names, and the spreadsheet is kept on the hospital's secure drive. The quality department reviewed the project and classified it as quality improvement, so no research ethics review is needed, but patients' families are told about the bundle and can decline boots.

Conclusion

The plan rolls out the bundle in stages, measures whether it is delivered, whether staff accept and adopt it, whether heel injuries fall and whether new harms appear and ties each signal to a response. That is how a CNL manages outcomes rather than merely reporting them.

References

Chaboyer, W., Bucknall, T., Webster, J., McInnes, E., Gillespie, B. M., Banks, M., Whitty, J. A., Thalib, L., Roberts, S., Tallott, M., Cullum, N., & Wallis, M. (2016). The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. International Journal of Nursing Studies, 64, 63-71. https://doi.org/10.1016/j.ijnurstu.2016.09.015

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7