In Pursuit of Zero Harm: A Focused Approach to Quality Improvement (99H)

Leaders across the Veterans Health Administration recognized the need to make pressure ulcer prevention a High Reliability Organization (HRO) Zero Harm Focus Area and convened a team of key stakeholders and subject matter experts for a quality improvement project on pressure injury prevention. Although pressure injuries are often preventable, they remain a significant cause of morbidity and mortality in vulnerable populations in inpatient, outpatient and extended care settings. Reducing preventable harm across a vast integrated healthcare system, such as VHA, requires a wide range of modalities. VHA developed a systematic approach to the reduction of pressure ulcer injuries to achieve zero preventable harm using HRO as a framework. This included, but was not limited to, establishing a network of clinical, data, change management and education experts to provide enterprisewide support and guidance in addressing pressure injuries. For example, VHA established practice-sharing communities, asynchronous learning events, and peer-to-peer coaching from wound care experts who were available for consultation to address barriers and share lessons learned. Furthermore, VHA monitored its progress on pressure injury prevention by featuring the associated zero harm measure on its accessible and interactive HRO Enterprise Dashboard, thereby enhancing transparency, fostering a culture of safety, and indicating where additional support is needed. Since October 2023, VHA has seen increased front-line staff engagement in reducing pressure injuries while closely monitoring outcomes on the HRO Enterprise Dashboard. Participants will hear from a panel primed to discuss relevant processes, outcome measures and strategies for advancing patient safety efforts around a singular focus area while promoting systemwide transparency and unified effort.