| Primary Author: | Judith Ann Moran, RN, DNSc, NE-BC |
| Organization: | Huntington Hospital |
Abstract
Purpose
The purpose of this quality improvement project is to demonstrate how transformational leadership, demonstrated by a Chief Nursing Officer, inspired direct care nurses to create a culture of patient safety with “Zero Tolerance” for hospital acquired pressure ulcers (HAPUs).
Background
National guidelines on prevention and treatment of hospital acquired pressure ulcers (HAPUs) have been available for many years. Research has demonstrated that HAPUs, a nursing sensitive quality indicator, are preventable via the use of evidence-based nursing practices. Nevertheless, HAPUs are becoming increasingly common in the United States, with 2.5 million patients treated last year, at an estimated cost of over 11 billion dollars. CMS no longer assigns a higher diagnosis-related category (DRG) for pressure ulcers that develop during hospitalization. The prevalence of HAPUs in hospitals is publicly reported on healthcare web sites. Therefore, preventing HAPUs is essential to the survival of hospitals. In 2009, the prevalence of HAPUs was above the NDNQI benchmark at a 408 bed, Magnet-designated, community hospital.
Materials & Methods
The Chief Nursing Officer (CNO) empowered her nursing staff to establish a culture of patient safety with “Zero Tolerance” for the development of HAPUs. The cornerstone of this patient safety initiative is CNO involvement in weekly HAPU Prevalence Rounds, and peer review conducted by direct care nurses appointed as Skin Care Champions on every clinical unit. Every week, the CNO, Nurse Managers and Skin Care Champions disuss the findings of the HAPU Prevalence Rounds. Factors contributing to pressure ulcers are identified and immediate corrective action is taken to provide evidence-based education, protocols, equipment, supplies and support staff necessary to prevent HAPUs.
Results
Since the initiation of weekly HAPU Prevalence Rounds and associated activities, the prevalence of HAPUs has met or come under the NDNQI benchmark on a regular basis.
Conclusion
Transformational nursing leadership can inspire direct care nurses to provide high quality, evidence-based nursing care which results in improved patient outcomes.
© Improvement Science Research Network, 2011