A hospital that had struggled to reduce hospital-acquired pressure injuries (HAPIs) has found success with an approach that emphasizes empowering frontline staff and consistent, structured huddles. After one year, the culture has changed, and HAPIs have been cut by 50%. Northwestern Medicine Lake Forest Hospital in Illinois had attempted to reduce HAPIs for years, with some success, but hospital leaders remained unhappy with the rate of pressure ulcers, says Kathryn Thomas, MSN, RN, CPHQ, director of quality and patient safety for the North Region of Northwestern Memorial HealthCare.
Lindsay Werth, MSN, RN, CMSRN, patient safety program manager at the hospital, led a new effort that took advantage of quality improvement workshops in conjunction with Vizient, a healthcare performance improvement company based in Irving, TX. The workshops focused on high reliability organization (HRO) principles. Thomas and Werth saw an opportunity to learn techniques that would help the hospital sustain HAPI improvements.
“We had tried to address pressure injuries in the past, but nothing would really stick,” Thomas says. “We really needed to change the culture.”
Deep Data Dig
Starting with an effort to understand why patients were experiencing HAPIs, the Northwestern Memorial team dug into the data and engaged frontline leadership. The nurses were interested in reducing the injuries and eager to find a solution.
“We interviewed almost every staff member in the units and tried to truly understand the gaps in knowledge and assessment, the interventions currently in use, to get a good assessment of where we were,” Werth says. “Having that frontline buy-in was instrumental in getting us a good assessment of where we were and where we wanted to go.”
Thomas says the hospital had implemented the well-known best practices for HAPI and seen some improvement, but over time the rate still was not what they wanted to see. This new effort put a particular focus on the hospital’s own data.
“Not only did we take the HRO principles from the patient safety workshop, but we stayed data-driven and fixed what the data was showing us,” Thomas says. “We wanted to keep our frontline staff highly engaged. One thing we did was implement weekly huddles. The huddles were very focused and structured, centered on a visual management board.”
Originally, Werth led the huddles. Eventually, leadership transitioned to the charge nurse. The huddle participants examine what the barriers were last week and what they should do differently this week.
“They were kind of quiet in the beginning but slowly everyone started opening up, throwing out ideas, talking openly about barriers. Through that, we discovered one of the main barriers for the nurses,” Thomas says. “We found that in during their skin time-outs, the documentation was not in their actual workflow. A frontline nurse spoke up about it, and then we were able fix that and bring the solution back to them.”
Gaining Trust of Nurses
Making that change in the electronic medical record was a significant step forward, even though it was not especially difficult to achieve.
“It showed the nurses that their voices really do matter. They were really excited, and the compliance with the documentation really went up,” Werth says. “Keeping that engagement with the team, being honest and open, really helped us.”
In addition to weekly huddles, the charge nurses check with their nurses daily to identify problems. Leadership rounding also was included in the effort. The hospital’s chief nurse began rounding on a weekly basis with Werth, with a structured format to assess HAPI reduction rather than a general check-in. “They would start with the visual management board, go over the data to see how they were doing with both outcomes and process measures. The chief nurse would ask nurses what concerned them most about pressure injuries that day, what barriers they were encountering, what interventions they were using,” Thomas says.
The rounds with the chief nurse have been reduced to monthly intervals, but Werth conducts weekly rounds with a nursing director to check on HAPIs on all units.
Another important change was for Thomas and Werth to “stop being the doers and start being the coaches,” Thomas says. That meant teaching people how to fix their own problems rather than trying to fix everything themselves. It also meant focusing less on the presentation of data and more on encouraging frontline staff to use that information effectively.
“We had to learn that display of data doesn’t have to be pretty and perfect. Our visual management boards are not PowerPoints with lots of colorful, perfect graphs,” Thomas says. “Our visual management boards are literally graph paper where they plot how they are doing on whatever process they’re watching, and another graph paper where they can write with a pen where they’ve had any events. They can write in any barriers for the week, and that becomes a focus of the huddles.”
Thomas says through consistency with huddles and other measures, the strategy became the new normal. “It was all about change management. It was changing everyone’s perspective about their role in managing a problem,” Thomas says.
The hospital is on track to reduce HAPIs by another 50% this year, Werth says. Looking back on the effort, Thomas says support from top leadership was crucial to success, but perhaps they could have involved middle management more.
“I think better prep of our middle management might have been helpful because it does change their workflow the most,” she observes. “It is quite an adjustment for middle management. If we had more training and education for them up front, it might have been a smoother transition.”
Werth emphasizes patient safety and quality leaders should not assume they know what is happening on the front line. “Not only does going to that unit show you what is actually happening, but it also builds confidence among your frontline nurses and techs, everyone on the front line, when they actually see you there,” Werth says. “There are days when I sit in my office all day long, but we make an effort now to go out there and round with a purpose. We want them to know that when they are experiencing a problem, this is a problem that we all should work to solve together.”