Presentation

[Audio] Good evening. This presentation explores key performance measures that drive quality improvement in wound, ostomy, and continence care — with a specific focus on the Family of Measures framework as it applies to hospital-acquired pressure injury prevention..

[Audio] Quality improvement in healthcare requires us to look through four distinct lenses. The Family of Measures framework organizes performance data into outcome measures, process measures, structure measures, and balancing measures. Together, these four categories give leaders a complete picture of whether a change initiative is truly working — or whether it is solving one problem while creating another. No single measure type tells the whole story on its own..

[Audio] Outcome measures answer the most important question: did the patient's health improve? In wound and continence care, this includes tracking HAPI incidence and prevalence, time to healing, readmission rates for post-operative ostomy patients, and patient satisfaction scores. We also monitor PSIs, NDNQI benchmarking for Stage 2 or higher pressure injuries, IAD rates, Foley catheter days, and prevalence survey results. These metrics carry enormous weight — they are directly tied to CMS Star ratings, Leapfrog scores, and reimbursement decisions. They also shape patient loyalty and the public reputation of our facilities..

[Audio] Process measures tell us whether our teams are consistently applying evidence-based practices. Are risk assessments and skin assessments being completed within 24 hours of admission, daily, and on every unit transfer? Are individualized care plans being initiated? Are consult requests happening in a timely manner? Are preventive devices being used appropriately? And is nursing time being invested in patient ostomy education? Process measures are where we find the root causes of adverse outcomes — and where we focus improvement efforts..

[Audio] Structure measures ensure the right resources are in place to make good care possible. This includes the number of Certified Wound, Ostomy, and Continence Nurse Specialists on staff, daily CWOCN coverage ratios, access to therapeutic bed surfaces, cushions, heel protectors, and positioners, as well as the composition of the multidisciplinary team — physicians, surgeons, nurses, nurse practitioners, and physician assistants — and standardized wound and ostomy product formularies..

[Audio] Balancing measures are the most frequently overlooked component of the Family of Measures — and yet they may offer the greatest opportunity for deeper understanding. A balancing measure asks: did our improvement create an unintended consequence elsewhere? As we pursue better outcomes in one area, we must be vigilant that we are not inadvertently worsening another. This is especially true in complex inpatient environments where interventions ripple across multiple systems and patient needs..

[Audio] This case study illustrates the balancing measure concept perfectly. As the use of external female urinary catheters increased, we observed a meaningful reduction in incontinence-associated dermatitis and a decrease in HAPI incidence — both desirable outcomes. However, a critical unintended consequence also emerged: patient immobility increased significantly. And immobility, of course, is itself one of the primary risk factors for pressure injury. This circular risk is precisely why balancing measures must be tracked alongside every primary outcome metric..

[Audio] This 12-month run chart visually captures that relationship. The blue line shows external female catheter use rising steadily from 12% in January to 40% by December. Simultaneously, the red line shows IAD incidence declining from 18% to 8% — a clear improvement. But look at the amber line: immobility rate climbs from 22% to 34% over the same period. Pressure injury incidence, shown in green, also rises from 4 to 11. The median lines for each metric reinforce these trends. This chart is not just a data display — it is a conversation starter about the true complexity of care improvement..

[Audio] Now that we have seen how balancing measures reveal the true complexity of care improvement, it is important to understand which frameworks are guiding that measurement — and how they differ from one another. This table compares three major quality frameworks across eight key dimensions. While AHRQ, CMS eCQMs, and the Baldrige Framework all share the goal of reducing hospital-acquired pressure injuries, they approach that goal in very different ways. AHRQ operates at the national level — it provides the research, definitions, and evidence-based guidance that inform clinical best practices. CMS eCQMs operate at the hospital level — they are regulatory, prescriptive, and tied directly to reimbursement and public reporting. The Baldrige Framework takes the broadest view — it evaluates the entire organizational system that produces results, asking not just did a HAPI occur, but how and why, and whether the systems in place will prevent it consistently over time. Notice the difference in flexibility as well. AHRQ and Baldrige allow organizations to adapt their approach, while CMS is highly prescriptive with little room for interpretation. Together, these frameworks create a layered accountability structure — from the bedside to the boardroom..

[Audio] Three major quality frameworks reinforce HAPI reduction from different angles. AHRQ drives evidence-based safety research and national quality reporting. CMS electronic clinical quality measures tie pressure injury rates directly to hospital reimbursement and public star ratings, creating a powerful financial incentive for prevention. The Baldrige Performance Excellence Framework takes a systems-level view, integrating leadership, strategy, measurement, and outcomes into a unified model for organizational excellence. Together, these frameworks align clinical practice with financial and reputational accountability..

[Audio] In closing: the Family of Measures is not a checklist — it is a comprehensive lens for sustainable improvement. Outcome data drives accountability. Process data drives action. Structure data ensures capacity. And balancing data ensures we are not trading one problem for another. Robust, multi-dimensional performance measurement is the foundation of safe, accountable, and continuously improving wound and continence care..

[Audio] The sources supporting this presentation include AHRQ, CMS, NDNQI, the Institute for Healthcare Improvement, the Baldrige Program, and Spath's Introduction to Healthcare Quality Management, Full citations are listed on screen. Thank you..