A collaborative project to address hospital-acquired pressure injuries (HAPI) has resulted in more than a 60% reduction in a common but preventable issue that claims over 60,000 U.S. lives each year. Led by the Joint Commission Center for Transforming Healthcare, the improvement initiative — including The Johns Hopkins Hospital, Kaiser Permanente South Sacramento Hospital and Memorial Hermann Southeast Hospital — saw these significant reductions sustained even as the COVID-19 pandemic accelerated in the United States.
The project launched to identify solutions to prevent and reduce the rate of pressure injuries, also known as decubitus ulcers or bedsores, in health care facilities after seeing that HAPI were rising nationally. Experts estimate more than 2.5 million patients in U.S. acute-care centers experience pressure ulcers and injuries each year. Because pressure injuries are a significant risk for immobile patients, the country is experiencing a jump in this condition as COVID-19 patients require long hospitalizations.
Using Robust Process Improvement (RPI) — a proven combination of Lean, Six Sigma and formal change management — the Center worked with participating hospitals to determine and address root causes that contribute to pressure injuries in their facilities. Because many different factors contribute to any given problem and can vary across organizations and even units, understanding the elements contributing to a problem is critical to successfully solving it.
The three participating organizations identified their own unique contributing factors across the facility and, using RPI in collaboration with Center experts, implemented a plan for improvement. Organizations achieved an average 55% relative reduction in intensive care unit pressure injuries from May 2018 to December 2019. They continued building on that momentum from January to April 2020, experiencing a 62% average relative reduction and preventing 78 pressure injuries annually. This outcome resulted in a cost savings in aggregate of $15.3 million for the length of the project by reducing an expensive condition that costs the health care industry $11 billion a year.
“Our staff have become more aware of the outcome of improvement work and how it helps them save a life — but they’re saying that’s not enough,” said Rachel Wyatt, RN, BSN, MHA, clinical adult services director for Kaiser South Sacramento Medical Center. “We’ve seen an incredible shift in our focus and culture around this issue to ask: How do we save a whole person and make sure to protect their quality of life?”
The pressure injuries improvement project is one of many undertaken by the Center, created in 2008 to drive high reliability health care by empowering teams with the knowledge and tools needed to address the industry’s most pressing quality and safety issues.
“Tackling a persistent issue like hospital-acquired pressure ulcers and injuries requires strong leadership, vision and a deep commitment to pushing toward zero harm,” said Anne Marie Benedicto, vice president of the Joint Commission Center for Transforming Healthcare. “The Johns Hopkins Hospital, Kaiser Permanente South Sacramento Hospital and Memorial Hermann Southeast Hospital are seeing the measurable – and immeasurable — benefits of using a successful improvement methodology to improve outcomes. We hope to see continued momentum in this space as other organizations see what is possible.”
For more information, visit the Center for Transforming Healthcare website at www.centerfortransforminghealthcare.org.