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Identifying Root Causes and Solutions for Hospital Acquired Pressure Injuries


By Michael King, Lean Six Sigma Black Belt
Despite an 8 percent decrease in all hospital-acquired conditions from 2014-2016, hospital acquired pressure ulcer and injury (HAPU/I) rates have risen by 10 percent, according to the Agency for Healthcare Research and Quality (AHRQ).
More than 2.5 million patients in U.S. acute-care facilities are estimated to suffer from pressure ulcer/injuries, and 60,000 die from their complications each year.
Hospital-acquired pressure ulcers and injuries (HAPU/I) result in significant patient harm, including:
  • Pain
  • Expensive treatments
  • Increased length of institutional stay 
  • Premature mortality 
The cost of treating a single full-thickness pressure ulcer/injury can be as high as $70,000. Total costs for treatment of pressure ulcer/injury in the U.S. are estimated at $11 billion annually. 
The potential impact of addressing the root causes of HAPU/Is are clear. HAPU/Is are not a new problem. Despite many processes currently in place to reduce them, healthcare organizations continue to struggle with HAPU/Is.  So, what do we do? We identify and eliminate the root causes.
Multi-Hospital Initiative
The Joint Commission Center for Transforming Healthcare launched a new project in August in partnership with teams at The Johns Hopkins Hospital, Kaiser Permanente South Sacramento Hospital and Memorial Hermann Southeast Hospital in Houston to identify root causes and solutions to reduce HAPU/I rates in hospitals. Through the targeted initiative, the three hospitals will apply Robust Process Improvement® (RPI®) — a blend of Lean, Six Sigma and change management principles and practices — to measuring and analyzing HAPU/I rates at their organizations, and testing solutions targeted to solving identified root causes. 
The initiative will be completed in summer 2019. Following completion, the Center for Transforming Healthcare will analyze the teams’ findings to determine whether targeted solutions can be replicated and tools to implement them can be developed and made available to all hospitals.  
Prevalence in the ICU
A common saying in process improvement circles is that a one-size-fits-all approach only works for simple problems. HAPU/Is are rarely simple – and defining the problem frames the entire project approach. The team is using the DMAIC framework to improve this process in five phases — Define, Measure, Analyze, Improve, and Control.  
Let’s walk through what that means, and what work is done. The teams are currently working through the Measure Phase. Project progress highlights by the teams so far include:  
  • Completing a project charter — defining the business case, problem statement, dates, scope, and goals  
  • Refining the project scope to the unit with the highest percentage of HAPIs — the intensive care unit
  • Mapping the processes so that it was clear to all team members what is happening today (baseline), and how it contributed (or didn’t) to a reduction in HAPU/Is
  • Building core teams — who will do the project work and investigate the root causes, including the (critical) subject matter experts
The next step is aligning on what will define project success — the outcome metrics. This decision is especially important because how a process is measured will heavily influence the framing of a process investigation, the root causes, and the future improvements. To that end, the teams agreed on three outcome metrics:
  1. ICU HAPU/I rates: based on monthly patient surveys of the ICU to identify HAPIs in the ICU
  2. AHRQ/PSI-03 HAPI rate — rate of hospital acquired pressure injuries measured by EMR codes and discharge counts — to identify hospital wide HAPIs as CMS defines them
  3. Unit (ICU) acquired pressure injuries — to identify for those HAPIs in the ICU, how many patients did not have an ICU before arrival on the unit
Collecting Data
Each team investigates in detail their HAPI reduction process (smaller step breakdown) to identify the elements of the process that should be further investigated.  They do this with “gemba walks”, or observing the process and then asking questions.
For example, for patient skin assessments: what actions are in place to ensure accurate assessments? Or patient education? Or nutrition?  
These investigations focus on process, not people. They require open dialogues and an agreement that this problem is worth spending time on — collecting data, evaluating the measurement, and perhaps most importantly, agreeing on how a process element will be evaluated (operational definition). One example of a question designed to develop an operational definition is: 
  • How often (the %) does each patient receive a comprehensive skin assessment within 24 hours? How do we know?
It can be difficult for the teams to garner support to collect data in the process. The teams are careful to consider which process elements warrant data collection, and how long the data collection periods needs to last. The project leads remind the teams of the need to investigate, discuss, align, and work for the long term benefit of the project, and the long term benefit of all involved in the HAPU/I reduction process.
You might be wondering…how do the teams know how many process elements to investigate to identify the root causes? Are there a thousand? Are there ten?  This is the power of the pareto rule and data analysis in the analyze phase. The pareto rule will show us that 20% of the steps cause 80% of the actions that contribute to HAPU/Is.  
Don’t miss the next blog post where we will delve into greater detail about the analyze phase of DMAIC, including the process elements, and the validated root causes.
Michael King is a Lean Six Sigma Black Belt at The Joint Commission. Prior to this position, he worked in process improvement at Nielsen Company, Menlo Worldwide and a variety of engineering firms.