Wound Care Management and Documentation Non-Compliance in Prevention and Care of Wounds

The incidence of non-compliance and adherence to best practices wound care competence continues to be an issue among the clinical staff of the Veterans Affairs Medical Center (VA). At the VA, there is a practice problem of non-compliance and adherence to best practices wound care competency as evidenced in the electronic medical record (EMR) documentation among the clinical staff. A PICOT question was developed to explore if the establishment of a staff best practices wound care policy focusing on EMR documentation will improve proper wound care management among the clinical staff. The clinical site is a hospital consisting of 40 acute care beds. A new policy adjusted documentation with the use of the Braden scale and the spinal cord impairment monitoring (SCI-PUMT) tools and documentation in the EMR at appropriate times was implemented. A pretest and posttest were conducted to determine the significance of the total documentation using the Braden or SCI-PUMT tools, total accurate documentation using the wound care tools, and the number of multidisciplinary team contacts using the EMR. The results showed no statistically significant improvement with t =1.66, p =.107, t =1.03, p = .310, and t = -0.31, p = .775, respectively. Although the above results did not show any statistical significance after two months of the project implementation, a re-implementation of the project is recommended with the elimination of the barriers encountered during the project implementation. DNP SCHOLARLY PROJECT 4 Wound Care Management and Documentation Non-Compliance in Prevention and Care of Wounds Wound care continues to be an issue in the United States (US) health care institutions, including the Veterans Affairs Medical Center (VA) in Detroit, Michigan (Cowan, Garvan, Rugs, Banks, Chavez, & Orozco, 2018). Due to the complexity and wound types which may be acute or chronic including spinal cord injuries, pressure injuries, surgical wounds, combat wounds, competent wound care management skills by the clinical staff are required to improve and prevention of complications of such wounds (Cowan et al., 2018). According to Cowan et al. (2018), evidence-based wound care among clinicians has been shown to improve wound care management and documentation. Communication of the status of wounds in the electronic medical record (EMR) is essential to ensure a multidisciplinary collaboration of care by standardizing wound care documentation to improve identification of the patients wound status. Effective policies that direct actions of the clinical staff is important in ensuring they can safely and effectively identify, evaluate, and manage patients' wounds (Bamohammed, Mohidin, George, & Al-Aidarous, 2018). Improper wound care extends patients' wound healing length, thereby adding additional cost for treatment (Goudy-Egger & Dunn, 2018). Therefore, a new wound care policy that directs clinical staff in care delivery documentation in the EMR creates alignment between expectations and patient outcomes. The goal of this evidence-based project was to establish a new wound care policy with a focus on EMR documentation supporting improved identification of patient wound status as an effort to decrease patient wound incidences and improve proper wound management. DNP SCHOLARLY PROJECT 5 Significance of the Practice Problem At the VA, there is a practice problem of non-compliance and adherence to best practices wound care competency as evidenced in the EMR documentation among the clinical staff which contributes to poor wound healing and management. An updated wound care policy was established with a focus on EMR documentation to provide policy adherence supporting best practices for preventing and managing wounds including the most complex wounds and injuries (Cowan et al., 2018). A study conducted by Oseni and Adejumo (2014) showed that continuing wound care education helps improve wound care. The new wound care policy focusing on EMR wound care documentation outlines the expectations required for clinical staff to provide wound care. The importance of staff knowledge, skills, and ability in preventing and improving patient wound care is instrumental in achieving best outcomes. Therefore, clinical staff education aligned with the wound care policy was measured through the EMR documentation. According to Walker et al. (2019), pressure injuries are the types of wounds that affects 2.5 million people in the U.S., costing $9.1 to $11.6 billion annually. Although there are other types of wounds, pressure injuries that can be prevented, account for more than 60,000 deaths and 20,000 lawsuits annually (Walker et al., 2019). In the US, almost 8.2 million Medicare beneficiaries have at least one or more types of wounds or wound-related infections, costing Medicare about $28 to $96.8 billion annually (Driver et al., 2019). Globally, in 2014, wound care cost an average of $2.8 billion, and it is projected to increase up to $3.5 billion in 2021 (Sen, 2019). Policy compliance documentation will support improved wound care outcomes and decrease organizational costs. Wounds can be a burden to both the patients and their relatives. According to Driver et al. (2018), untreated or poorly managed wounds can lead to complications such as (a) amputations, DNP SCHOLARLY PROJECT 6 (b) sepsis, (c) social isolation for some patients, (d) decreased ambulation/mobility, (e) depression, (f) pain, and (g) caregiver burnout for relatives taking care of wound patients. Additionally, veterans from combat with spinal cord injuries are predisposed to pressure injuries, where clinicians lacking knowledge on preventing wounds and managing such patients will create more problems (Johnson-Kunjukutty & Delille, 2019). Following wound care policy documentation learned through clinical staff attending continuing wound care training assists in preventing, improving, reducing cost, and burnout associated with wound treatment and management (McCluskey & McCarthy, 2017). Policy-related wound documentation of prevention and wound management is a leadership identified current problem. This lack of policy adherence when corrected will lead to compliance with EMR documentation supporting multidisciplinary collaboration for (a) prevention, reduction of wound complications, (b) an increase proper wound management, and (c) reduction of cost.


Significance of the Practice Problem
At the VA, there is a practice problem of non-compliance and adherence to best practices wound care competency as evidenced in the EMR documentation among the clinical staff which contributes to poor wound healing and management. An updated wound care policy was established with a focus on EMR documentation to provide policy adherence supporting best practices for preventing and managing wounds including the most complex wounds and injuries (Cowan et al., 2018). A study conducted by Oseni and Adejumo (2014) showed that continuing wound care education helps improve wound care. The new wound care policy focusing on EMR wound care documentation outlines the expectations required for clinical staff to provide wound care. The importance of staff knowledge, skills, and ability in preventing and improving patient wound care is instrumental in achieving best outcomes. Therefore, clinical staff education aligned with the wound care policy was measured through the EMR documentation.
According to Walker et al. (2019), pressure injuries are the types of wounds that affects 2.5 million people in the U.S., costing $9.1 to $11.6 billion annually. Although there are other types of wounds, pressure injuries that can be prevented, account for more than 60,000 deaths and 20,000 lawsuits annually (Walker et al., 2019). In the US, almost 8.2 million Medicare beneficiaries have at least one or more types of wounds or wound-related infections, costing Medicare about $28 to $96.8 billion annually (Driver et al., 2019). Globally, in 2014, wound care cost an average of $2.8 billion, and it is projected to increase up to $3.5 billion in 2021 (Sen, 2019). Policy compliance documentation will support improved wound care outcomes and decrease organizational costs.
Wounds can be a burden to both the patients and their relatives. According to Driver et al. (2018), untreated or poorly managed wounds can lead to complications such as (a) amputations, (b) sepsis, (c) social isolation for some patients, (d) decreased ambulation/mobility, (e) depression, (f) pain, and (g) caregiver burnout for relatives taking care of wound patients.
Additionally, veterans from combat with spinal cord injuries are predisposed to pressure injuries, where clinicians lacking knowledge on preventing wounds and managing such patients will create more problems (Johnson-Kunjukutty & Delille, 2019). Following wound care policy documentation learned through clinical staff attending continuing wound care training assists in preventing, improving, reducing cost, and burnout associated with wound treatment and management (McCluskey & McCarthy, 2017). Policy-related wound documentation of prevention and wound management is a leadership identified current problem. This lack of policy adherence when corrected will lead to compliance with EMR documentation supporting multidisciplinary collaboration for (a) prevention, reduction of wound complications, (b) an increase proper wound management, and (c) reduction of cost.

PICOT Question
The PICOT question that guided this project was through clearly identifying the population (P), intervention or implementation (I), comparison to current practice (C), expected outcomes from the intervention or implementation (O), and the time frame of the project (T).
The PICOT question for this project is as follows: Among the wound care clinical staff members at the VA (P) will establishment of a staff best practices wound care policy focusing on EMR documentation (I) compared to current staff practices (C) improve multidisciplinary collaboration to decrease wound incidences and improve proper wound care management (O) within two months of initiation of the practice change (T)?
Population (P): The population that benefited from the project were the patients, supported by the following stakeholders: clinical staff members, including the nursing staff, physicians, nurse practitioners, physician assistants, nursing assistants, and the nursing managers. Intervention (I): The intervention was the establishment of the wound care policy with a focus on documentation. The policy was addressed through wound care training protocol and procedures to be documented in the EMR. The policy was adjusted to improve staff compliance.

Evidence-Based Practice Framework
The Johns Hopkins evidence-based framework guided the development and implementation of the VA evidence-based practice problem change (Dang & Dearholt, 2017).
According to Dang and Dearholt (2017), the Johns Hopkins model involves three steps: practice question, evidence, and translation (PET process).
The first step is the clinical practice question which is, why are there increased incidences of wounds and missing documentation for high-quality care delivery. This clinical practice question the lead to the PICOT question, which is: Among the wound care clinical staff members at the VA (P) will establishment of a staff best practices wound care policy focusing on EMR documentation (I) compared to current staff practices (C) improve multidisciplinary collaboration to decrease wound incidences and improve proper wound care management (O) within two months of initiation of the practice change (T)? Identifying the practice question, directed the project (Dang & Dearholt, 2017). The next step of the Johns Hopkins model was the use of the best evidence to answer the identified question. For this project, best evidence practices as stated by Cowan et al. (2018) among other researchers, was to identify the clinical issue and solution options aligning with the environment. Lastly, "translation," was the last process that required the utilization of the evidence found applied in practice where change was needed. Concerning the evidence-based practice change at the VA, the evidence found was utilized to reestablish a wound policy focusing on EMR documentation and improve documentation of best practices outlined in the policy to improve clinical staff practice leading to multidisciplinary collaboration to ultimately improve patient outcomes.

Change Theory
Lewin's change theory (as cited in Batras et al., 2016) served as the foundation for the evidence-based project. Lewin's change theory is a three-phase model that includes "unfreezing," "change," and "refreeze" (Batras, Duff, & Smith, 2016). The theory uses the three phases in identifying an organizational problem that needs change, implementing the change, and lastly, sustaining the change implemented (Batras et al., 2016).
In the first phase change theory (unfreezing) the practice problem was identified as an increase incidence of wounds due to improper documentation of wound management by the clinical staff compared with best practices of wound care. During this phase, the current VA wound care policy was evaluated. In addition, the staff opinions for the rationale for their noncompliance was assessed. According to Lewin, as individuals are sometimes influenced by group behavior and group norms, the group behaviors and group norms of the clinical staff that do not conform with the practice change will be noted, and leadership will plan for correction (Batras et al., 2016). During this phase, the stakeholders were identified and involved in the process.
The second phase of the Lewin change theory is called the "change." At this phase, the proposed change was implemented. The change, which is the implementation of the new wound care policy with a focus on documentation, was implemented through good communication, support, stakeholders' involvement, and use of other measures that enhanced the smooth implementation such as flyers, emails, and so forth. During the implementation phase, feedback from the clinical staff were sought and acknowledged with reinforcement and clarification where needed while monitoring EMR documentation.
The last phase of Lewin's theory of change is the "refreeze" phase. This phase involved sustaining the practice change (Mulholland, 2017). After implementing the policy as the practice change, the change made was anchored into the clinical staff culture. The following were put in place for the sustainability of the implemented change; (a) staff encouragement, (b) sending due dates reminders of wound care updates to the staff, (c) rewards, (d) periodic staff evaluation, and (e) leader expectations via establishment of a periodic documentation audit.

Evidence Search Strategy
The electronic databases used for the literature search included Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Medline, Ovid, ProQuest, and ScienceDirect. The following key words were used for the search: Combat Veteran Health Administration, wound management, wound care educational training, wound providers, competence, knowledge, wound healing, multi-professional practice, evidence-based practice, wound care, pressure injury, prevention, and control. Combat (wounded) veterans were noted in some databases used "combat veterans" while some used "wounded veterans," patients with both acute and chronic wounds, patients with different stages of wound, inpatient and outpatient veterans with wound, veterans of all ages, sex, and ethnicity were the inclusion criteria. Veterans with only psychological pain not related to wound, self-managed wounds, textbooks were excluded.
Both full text and non-full text, evidence-based journals, peered reviewed articles were included. English was set as the language for the literature search, and the number of years of publication was limited to 5 years (2015-2020). Initially, 30 evidence-based articles were retrieved and10 evidence-based articles were finally selected after careful review using the exclusion criteria.

Evidence Search Results
An extensive evidence-based research article search was made using the following

Themes with Practice Recommendations
A practice problem at the VA is the non-compliance of the clinical staff with current documentation practice expectations related to wound care. The following themes were discovered: continuing education/in-service education, prevention practices, tools for wound care evaluation, and wound care policy will be used to discuss the practice recommendations.

Continuing Education/In-Service Education:
Continuing education/in-service education among the clinical staff is vital in the prevention and wound care management. Ousey and Blackburn (2019) indicated that competence and confidence are connected and needed in managing the wound. Ousey and Blackburn (2019) explained that competence acquired through wound care education or training is associated with increased staff confidence in caring for patients with wounds. Awali et al. (2018) studied 200 nurses on the effects of the implementation of pressure injury (PI) educational prevention protocol on nurses' knowledge, attitude and practices showed that there is a positive relationship between continuous clinical staff wound care prevention educational program and its effects on pressure injury prevention. Awali et al. (2018) recommend healthcare institutions' development of continuous educational programs that will improve the nurses' knowledge, attitude, and practice related to PI prevention. These studies support that clinical practice education that includes comprehensive documentation improves wound care outcomes.
A cross-sectional, descriptive study by Cowan et al. (2018) found that clinical staff education and documentation were the two areas that the staff lacked regarding wound prevention and management. Oseni and Adejumo (2014)  determined that hospital-acquired pressure injuries are preventable, the CMS decided not to pay organizations for pressure injuries that occurred while the patients were in the hospital (Nussbaum et al., 2018). Based on this information, hospitals must implement strategies such as policy and training, that will help prevent wounds. The patients at the VA are prone to developing pressure injuries due to the nature of their wounds, which may lead to immobility and neurological deficit (Awali et al., 2018). In their meta-synthesis, Walker et al. (2020) recommended the importance of clinical staff knowledge in preventing wounds through repositioning, nutrition, and support surfaces. Awali et al. (2018) also noted in their study that strategies such as education of health care staff, implementation of PI guidelines, and appropriate equipment used to reduce PI would make a tremendous difference in preventing PI is among patients. These sources support the establishment of a wound care policy as a means for improving wound care.

Tools for Wound Care Evaluation: The Braden scale and the Spinal Cord Impairment
Pressure Ulcer Monitoring (SCI-PUMT) tools are some of the tools that can be used in the evaluation of pressure injury and healing. The Braden scale is a pressure injury risk assessment tool which consists of six subscales: (a) sensory perception, (b) moisture, (c) activity, (d) mobility, (e) nutrition, and (f) friction and shear (Adibelli & Korkmaz, 2019). Each item is given a score from 1-4, the lower the score, the more the patient is prone to developing pressure injury (Adibelli & Korkmaz, 2019). According to Adibelli and Korkmaz (2019), the Braden scale is a valid and reliable wound assessment tool with a sensitivity of .95 and specificity of .75. See Appendix K for the Braden Scale tool.
Due to the pathophysiological factors involved in individuals with spinal cord injury, the SCI-PUMT was developed (Thomason et al., 2016). The SCI-PUMT includes two subscales; the geometrical factors and the substance factors (Thomason et al., 2016). The geometrical factors measure the surface area, depth, edges, tunneling, and undermining. While the surface factors measure exudate type, necrotic tissue, and amount. When the scores are added, an SCI-PUMT score of 2 means healed wound, and a score of 26 means the most severe wound (Thomason et al., 2016). In research performed by Thomason, Luther, Powell-Cope, Harrow, and Palacio (2014), the SCI-PUMT tool was found to be valid, reliable, and sensitive in detecting pressure injury healing over time in Veterans with spinal cord injury. See Appendix L for the SCI-PUMT.
At the VA (Detroit), the staff are expected to use the tools mentioned above in the assessment, evaluation of wound healing and to document appropriately in the electronic medical records (EMR). The OIG, in their recommendation, added that facility managers need to monitor employee compliance and appropriate action instituted where required. With this project, establishing a wound care policy with a focus on EMR documentation provided the means to monitor wound care compliance and identify actions for non-compliance.

Setting
The project setting was a veterans affairs medical center, which comprises of an inpatient and outpatient units. The inpatient unit consists of 40 acute care beds, 11 intensive care unit beds, and 9 step-down unit beds. This veterans affairs medical center is one of the largest in the United States and provides services to about 350,000 veterans.

Description of a typical participant
The patients of this facility are typical participants for this project, and the patients are comprised of United States veterans. The patients either have wounds inflicted during combat or a wound acquired as a result of pressure injury. Due to the nature of the wounds acquired during combat, the patients are prone to having complications, while some patients who have other medical issues that are not wound-related develop pressure injuries. The patients at this facility deserve proper wound care management and prevention. As the patients of this facility are the primary focus of this project, the non-compliance of the clinical staff to the wound care best practices and documentation prevents effective management and documentation the patient wounds.

The Organizational Mission and Vision
The mission of the organization is one that has the veterans' interest at heart in fulfilling President Lincoln's promise "To care for him who shall have borne the battle, and for his widow.
And his orphans" by serving and honoring the men and women who are America's veterans (U.S. Department of Veterans Affairs, 2015). This project supports the accomplish the organization's mission of caring for the veterans by preventing and managing wounds. The organization's vision is to provide the veterans world-class benefits and services by employing the highest standard of compassion, commitment, excellence, professionalism, integrity, accountability, and stewardship (U.S. Department of Veterans Affairs, 2015).

Organization Need Establishment
The organizational need was established after discussing and identifying different practice problems with the organization-affiliated preceptor. Increased wound incidences and improper management of patients' wounds due to the non-compliance of the clinical staff to wound care was identified as its most pressing problem. This deficit leads to poor patient outcomes and increased cost for care. Organizational leadership support and will approve the new wound care policy.

The Stakeholders
The stakeholders included the patients, nurses, nurse practitioners, physicians, physician assistants, certified nursing assistants, unit managers, chief nursing officer, and wound care specialists. Organizational stakeholders represented the multidisciplinary team that collaborated on patient wound care.

The Organizational Support and Project sustainability
The organizational support was confirmed by introducing the practice change project topic to the stakeholders by the preceptor. Approval for the new wound policy was provided by leadership. As the practice problem has been an ongoing organizational problem, the stakeholders and team members supported in achieving the project's purpose. Staff encouragement, rewards, celebrating improvements, updates, feedback with EMR audits, were used for the sustainability of the project.

Required Interprofessional Collaboration
Multidisciplinary, also called interprofessional collaboration was needed in achieving the purpose of the project. The dietician provided nutrition guidance for the support of wound healing (Awali et al., 2018). The interprofessional collaboration with physical and occupational therapy were needed in mobilizing the patients. Additionally, other stakeholders such as the nurses, nurse practitioners, physicians, physician assistants focused on the care delivery based on documentation to make recommendations to adjust or support current wound care processes.

SWOT Analysis
The following were the strengths, weaknesses, opportunities, and threats (SWOT) as it related to the project change. The strengths and weaknesses are considered as the internal organizational factors, while the opportunity and threats are the external factors that can influence the project's outcome. The strength of the VA as related to this project included (a) the support of the stakeholders for the practice change, (b) electronic medical record (EMR) availability, which were used in inputting and retrieval of information, and (c) interprofessional staff and clinical staff members availability. The weaknesses were (a) staff time constrain, (b) staff resistance to change, and (c) staff lack of motivation. Identified opportunities were factors that influenced the project, including the federal government's willingness to provide financial support for the practice change project. Lastly, the threats identified that could have negatively affected the project include (a) an uncertain economic environment, (b) a sudden change in the national wound care guidelines, and (c) employee turnover. See Appendix F for the SWOT analysis diagram.
Level of system change of the project and the system change.
The project was supposed to create a meso level of system change. The establishment of the wound care policy required the clinical staff participation in mandatory policy update.
Sustaining the wound care policy with focus on EMR documentation was to improve multidisciplinary collaboration leading to the number of patients with wound complications reduced as the clinical staff applies wound care policy.

Implementation Plan with Timeline
As wound incidences and improper management of wounds is an issue at the VA, the objective of this practice problem change was to improve wound care policy adherence as evidenced by EMR documentation of patients' wound care management and prevention within two months of re-establishing the organization's current wound care policy. The objectives that guided the project's policy creation, implementation, and evaluation were to improve documentation compliance with the policy, prevent patients from developing pressure injury wounds, and support multidisciplinary management of patients' staff, and increased wound care compliance and adherence by the clinical staff. The change in staff behavior was measured by their compliance with the policy through the EMR documentation. Attachment of professional evaluation credit to the policy update by the wound care educator served as an incentive to ensure that knowledge was transferred to daily wound care management and documentation.
Through clear and effective communication, the stakeholders' involvement, and feedback from the clinical staff via EMR documentation, the objectives were met. During the implementation and evaluation period, every step was clearly and effectively communicated to the clinical staff and patients who were the primary stakeholders. Any questions from the stakeholders were answered. The stakeholders were involved with the progress updates shared throughout the implementation and evaluation periods, which gave them a sense of being part of the project. The stakeholders were encouraged to provide feedback during the implementation and evaluation phases. See Appendix H for the implementation plan with a timeline.

Budget
The cost of the project was very minimal. The cost consisted of the hourly wage for the Information Technology (IT) personnel for time spent in educating the program manager on the computer applications and assistance in retrieving data. The project manager was not paid any wage or compensation. The money was spent on purchasing office supplies that were used in printing handouts and posters during the dissemination of the project's period. The financial support from the institution was used wisely to accomplish the project goal. See Appendix I for the budget plan.

EBP and Change Models as Guide to the Recommended Practice Change
The EBP model used for the project was that of Johns Hopkins evidence-based framework for practice change. The PET steps of the Johns Hopkins evidence-based framework werw used to guide the recommended practice change. The PICOT question for this project was clearly stated as: Among the wound care clinical staff members at the VA (P) will establishment of a staff best practices wound care policy focusing on EMR documentation (I) compared to current staff practices (C) improve multidisciplinary collaboration to decrease wound incidences and improve proper wound care management (O) within two months of initiation of the practice change (T)? With the question as the guide, evidence-based research articles were evaluated and synthesized to answer the PICOT question. The Johns Hopkins evidence-based framework guided in grading and leveling of the evidence-based research articles ensuring quality evidencebased articles were selected for the project. With the Johns Hopkins evidence-based framework, one Level 1, three Level 2, four Level 3, and two Level 4 evidence-based research articles were synthesized for this project. Two Grade A, four Grade B, and three Grade A/B research articles were found. During the Johns Hopkins evidence-based frameworks transition phase, the best evidence gathered from the synthesized research articles were selected and used in the implementation of the practice change.
The Lewin's change theory (Mulholland, 2017) was used to manage the change process through three phases: unfreezing, change, and refreezing. At the unfreezing phase of the project, a practice problem was identified as non-compliance with the current wound care policy and EMR documentation. During this phase, (a) the current wound care policy was evaluated and adjusted for establishment, (b) the rationale for the clinical staff non-compliant to the wound care were determined with strategies for compliance, and (c) trends of patients developing pressure injuries because of missed multidisciplinary collaboration evaluation of treatment plans. All the stakeholders were identified and involved during this phase. This phase took one week to gather the needed information.
At the "change" phase, the proposed project change was implemented. The change that was be implemented was the reestablishing the wound care policy-based analysis of the information obtained from the stakeholders. During the implementation phase, good communication, support, and involvement of the stakeholders were employed. Feedback from the stakeholders were acknowledged. PowerPoint presentations, email, staff meetings, and meetings of the stakeholders were used to disseminate information and communicate the change implementation's progress. EMR documentation using the two evaluation tools and multidisciplinary collaboration were monitored.
The last phase is the "refreezing," where the implemented change is sustained. After the implementation of the proposed change, it was sustained through (a) staff encouragement, (b) sending due dates reminders of wound care training to the staff, (c) rewards, (d) periodic staff evaluation, successes were celebrated of the improved number of staff attending the wound care training, (f) weekly updates of the staff on the number of pressure injuries, and (g) leadership audits of the EMR documentation. The strategies as mentioned above, were supported by staff engagement while sustaining the practice change. The "change" and the refreezing phases took 7 weeks.

Interprofessional collaboration required during Implementation
During the implementation phase of the project, interprofessional collaboration commenced. The nurses were charged with wound care documentation using the two wound care tools mentioned earlier. The dietician was consulted to determine nutritionally deficient patients and make sure that those patients were nutritionally stable. The physical therapists and occupational therapists evaluated and mobilize the patients as required. Other professionals involved include the prosthetic department because some patients had pressure injuries related to their prosthetics, and wound care specialists, nurse practitioners, and physicians were given updates on the clinical staff EMR documentation supporting the wound care practice. There were weekly meetings to assess progress and feedback for the project during the implementation phase.

Role of the Project Manager
As the project manager, the Doctor of Nursing Practice (DNP) student was the person at the helm of the affairs of the project implementation. The project manager coordinated with project team members and ensured the smooth implementation of the project. The project manager who was the director of the project, gathered information, monitored, and ensured smooth project implementation. The leadership skills applied by the project manager for the successful completion of the project were the ability to communicate effectively, listen attentively, and manage time appropriately. The project manager was trustworthy, respectful, and was open to suggestions.

Results
The project manager was incharge of the project plan. After the problem change intervention implementation, the total documentation using the "Braden scale" or the "spinal cord impairment pressure ulcer monitoring" tools, the total number documented accurately, and the number of multidisciplinary team contacts were evaluated. Clinical staff compliance was measured by the level of completion of the two tools in the EMR. Outcomes improvement of wound care was evaluated by the number of multidisciplinary team encounters (See Appendix J: Data Collection Tools).
Data was collected by the project manager with the assistance of the facility's IT department. Pre-and post-intervention of the clinical staff documentation in the EMR using the= EMR embedded Braden scale and SCIPUM tools were retrieved and analyzed. During the data collection/ retrieval process, HIPAA was observed because only individuals directly involved in the patients' retrieval process was allowed access to the patients' information. During the retrieval, the computer was password protected when not in use. Unidentifiable identification numbers were assigned to the patients. Extra HIPAA protection was also in place because patients' information could only be assessed from the facility's computers to protect the patients' information.
A two-tailed independent samples t-test was conducted to examine whether the mean of  Table 1. A bar plot of the means is presented in Figure 1.

Figure 1
The mean of Total_Documentation_using_Braden_or_SCIPUM_tools by levels of Time Period.
A two-tailed independent samples t-test was conducted to examine whether the mean of  Table 3. A bar plot of the means is presented in Figure 3.   Table 5. A bar plot of the means is presented in Figure 5. Note. N = 33. Degrees of Freedom for the t-statistic = 31. d represents Cohen's d.

Figure 5
The mean of Number_of_Multidisplinary_team_contacts by levels of Time Period

Impact
At the VA, the clinical staff are not new to rules, regulations, and policies. Therefore, establishing a staff best practices wound care policy focusing on EMR documentation was needed at the VA to improve multidisciplinary collaboration to decrease wound incidences and improve proper wound care management. As a result of the intervention implementation, the clinical staff were able to see new perspectives of reducing and preventing wounds in their hospital. Unfortunately, due to the present pandemic, the COVID-19, and its restrictions, not a huge positive outcome after implementing the intervention was observed.
Although the wound care educator educated the staff on the "Braden Scale" and the "SCI-PUMT" tools policies, utilizing the intervention implemented on using the tools will go a long way in helping in reducing wounds in the facility. For the intervention to be sustained, the unit manager(s) should help reinforce the intervention implemented and hold the staff accountable through frequent EMR wound care chart auditing. While the charge nurses remind the clinical staff of the use and proper documentation of the Braden scale and SCI-PUMT tools during daily hurdle.
Some of the barriers and limitations encountered were the inability to follow up face-toface with the staff due to the implemented restrictions due to COVID-19 and wound staging and charting inconsistency. In addition, due to inadequate staffing, the available staff were more focused on direct care to the patient instead of documentation. More awareness needs to be created among the clinical staff. Some of the staff were not aware that wound care documentation using the tools mentioned above should be performed on every patient and not only on the patients with wounds. Reimplementation of the project is recommended where the barriers mentioned above would be removed, allowing for a greater opportunity for staff mentoring, coaching, and oversight to ensure processes are fully completed based on the protocols.

Dissemination Plan
After

Conclusion
The goal of this evidence-based project was to establish wound care policy with a focus on EMR documentation supporting improved identification of patient wound status as an effort to decrease patient wound incidences and improve proper wound management as aligned with VA expectations. The issue with current practice was the non-compliance with current best practices which was supposed to have been alleviated through the new wound care policy updates and evaluation of wound care documentation. Unfortunately, due to some barriers encountered by the project manager, the result was not statistically significant. A reimplementation of the project without barriers is recommended by the project manager.