How to Sustain the Gain: One Unit’s Ongoing Goal of Zero HAPI

Background: A 35-bed general medicine unit in a quaternary level, Magnet-designated teaching hospital identified an increasing rate of hospital-acquired pressure injuries. The fourth quarter of 2015 stage 2 and above HAPI rate was 3.85%, above the National Database of Nursing Quality Indicators (NDNQI) benchmark for Magnet facilities. A multidisciplinary team was brought together to develop an evidence-based plan to drive down the HAPI rate. Membership included bedside clinical leaders, patient care technicians, a risk manager, a professional development educator, wound care nurse, clinical nurse supervisors, and the nurse manager.

Goal: Decrease the HAPI rate from 3.85% to 0 by quarter 1 of 2016 and continue to outperform the NDNQI benchmark for the majority of quarters for 2016 and 2017. Since this goal has been met, the team aimed to sustain zero HAPI for the succeeding fiscal years.

Implementation: A literature search was done to determine evidence-based best practices related to HAPI prevention. The team developed a cause-and-effect diagram to determine contributing factors that led to HAPIs. A group of interventions were selected by the team based on the identified opportunities, and staff were educated regarding the assessment and selected interventions. The interventions were implemented. Monthly audits were performed by the team members and just-in-time re-education provided as needed. Additional in-services and just-in-time teaching were provided to the new members of the team to address identified learning gaps. Team members continued to model and encourage peer-to-peer accountability to ensure evidence-based intervention were implemented.

Results: From 2016 to quarter 2 of FY 2020, there were no stage 2 or above HAPIs for 18 quarters. The senior leadership of the health care system rounded on the unit and recognized the staff for the hard work and exceptional outcome. The results have been shared at various internal quality events including the Nursing Quality Forum in January 2018. The best practices have been shared throughout the organization utilizing the shared governance structures.

Sustainment: Staff engagement, ownership, and empowerment drove the sustainment process. To keep the finger on the pulse, monthly audits have been done, fallouts discussed at unit huddles and peers continued to hold one another accountable to implement the evidence-based interventions.

Lessons learned: Clinical bedside leader involvement and ownership in the planning, implementation, and sustainment was crucial to hardwire the clinical practice changes. Inspecting what is expected helped to ensure the staff stayed focused on the best practices. Promoting a culture of accountability takes time and takes all members of the team.