13 Jul Identify and discuss a quality improvement issue in nursing practice ( Reducing Hospital-Acquired Pressure Injuries on a Medical-Surgical Unit: A Quality Improvement Plan)
Identify and discuss a quality improvement issue in nursing practice
Discuss tools for quality improvement.
Develop a plan for improvement of the issue/problem.
Reducing Hospital-Acquired Pressure Injuries on a Medical-Surgical Unit: A Quality Improvement Plan
Identifying the Problem
Among the most persistent and preventable harms in inpatient nursing practice, hospital-acquired pressure injuries (HAPIs) occupy a unique position — they are painful, costly, measurable, and almost entirely within the nurse’s sphere of influence. A pressure injury is localized damage to the skin and underlying soft tissue, typically over a bony prominence, resulting from sustained pressure or pressure combined with shear. What distinguishes a hospital-acquired pressure injury from one present on admission is accountability: the facility created the conditions for the injury, and it is therefore both a quality failure and, since 2008, a non-reimbursable “never event” under Centers for Medicare and Medicaid Services policy.
The scale of the problem justifies serious attention. Approximately 2.5 million patients develop pressure injuries in United States healthcare facilities each year, and HAPIs specifically account for roughly 60,000 deaths annually. The financial burden is substantial — treating a single full-thickness pressure injury can cost between $20,000 and $151,000, and CMS no longer reimburses hospitals for the additional care costs when a stage 3 or higher injury develops after admission. On a medical-surgical unit, the risk is concentrated in patients who are older, immobile, nutritionally compromised, or hemodynamically unstable — a description that fits a large proportion of the typical census. Despite this, HAPI rates on general medical-surgical units remain persistently above zero at most institutions, even those with active prevention programs, which signals a gap between stated policy and consistent bedside practice.
Quality Improvement Tools
Three tools are particularly well-suited to understanding and addressing this problem.
The Braden Scale is the most widely validated pressure injury risk assessment instrument in use. It evaluates six subscales — sensory perception, moisture, activity, mobility, nutrition, and friction/shear — producing a score that stratifies patients into mild, moderate, and high-risk categories. Its role in a QI effort is not merely screening; it is a standardization tool. When Braden assessments are completed inconsistently, at the wrong intervals, or without triggering a corresponding care response, the score becomes documentation rather than action. A QI initiative must distinguish between completion rates and meaningful use.
The Plan-Do-Study-Act (PDSA) cycle is the IHI Model for Improvement’s operational engine. It structures change as a small, rapid experiment: plan the intervention and the hypothesis, implement it on a small scale, collect data, and evaluate before spreading. For pressure injury prevention, a PDSA cycle might begin with testing hourly rounding with repositioning documentation on one pod of four patients during the night shift, measuring HAPI incidence and Braden reassessment rates over four weeks, then adjusting before unit-wide implementation. The PDSA structure prevents two common QI failures — launching a change too broadly before it is tested, and collecting data without ever deciding what to do with it.
Root Cause Analysis (RCA) provides the retrospective complement. When a HAPI occurs despite a prevention protocol, the instinct is to identify who missed a turn. RCA resists that instinct. Using a structured method such as the fishbone (Ishikawa) diagram, it maps contributing factors across people, processes, equipment, environment, and policy, and asks “why” iteratively until a system-level cause emerges. Staffing ratios, skin care product availability, shift-handoff communication gaps, mattress procurement, and documentation design have all been identified as root causes of HAPIs in the literature — none of which are solved by reminding nurses to do better. RCA transforms individual failures into system insight.
The Improvement Plan
Step 1 — Establish a baseline (Weeks 1–4). Before any intervention can be evaluated, the unit needs accurate data. A point-prevalence audit, conducted by a trained wound care nurse using standardized staging criteria, establishes the current HAPI rate. Simultaneously, a review of the previous six months of incident reports and Braden documentation identifies the patterns: Are injuries clustered on night shifts? Among patients with specific admitting diagnoses? Following admission from the emergency department, where initial skin assessments are often rushed? Baseline data defines the target and prevents the common error of implementing a solution before understanding the problem.
Step 2 — Identify gaps through RCA (Weeks 3–5, overlapping). A structured fishbone analysis of the two or three most recent HAPIs on the unit, conducted by a small team that includes bedside nurses, the charge nurse, a wound care nurse specialist, and a nursing supervisor, surfaces the system-level contributors. This is the step most institutions skip — they move directly from identifying a problem to distributing a policy — and it is why many HAPI prevention programs improve compliance metrics without improving outcomes.
Step 3 — Implement a PDSA-based bundle intervention (Weeks 5–12). Based on RCA findings, a targeted bundle is developed and tested on one nursing team before spreading. The bundle, consistent with current evidence and the National Pressure Injury Advisory Panel guidelines, includes four elements: Braden assessment within two hours of admission and every 12 hours thereafter with a mandatory care-plan trigger for scores below 18; structured two-hour repositioning with documentation linked to the nurse’s electronic workflow; heel-offloading devices applied at admission for all high-risk patients; and a standardized skin assessment and verbal handoff template embedded in shift-change communication. Each element addresses a commonly identified root cause rather than being selected from a generic checklist.
Step 4 — Monitor, adjust, and spread (Weeks 12–24). The initial PDSA team presents four-week outcome data — HAPI incidence, Braden completion rates, repositioning documentation rates, and any new injuries — at a unit practice council meeting. Adjustments are made based on what the data shows, not on what staff thought would happen. Once the bundle is refined and demonstrating measurable improvement, implementation spreads to the full unit with peer champions from the pilot team serving as frontline educators.
Step 5 — Sustain through policy and culture (Ongoing). Hardwiring the change into new-nurse orientation, annual competency validation, and the unit’s quality dashboard prevents the well-documented decay of QI gains once project attention moves elsewhere. A visible, regularly updated HAPI rate on the unit board makes the outcome real and communal rather than administrative.
Conclusion
Hospital-acquired pressure injuries are not an inevitable consequence of caring for vulnerable patients — they are a system output, shaped by workflow, staffing, equipment, education, and culture. Quality improvement is the discipline of changing systems rather than scolding individuals. Applying validated risk stratification, iterative testing, and honest root cause analysis to this problem does not require exceptional resources. It requires clarity about what is causing the harm, commitment to measuring whether the change is working, and enough organizational patience to let the data, rather than intuition, guide the next step.
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