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VM Honors Team for Patient Safety Work on Bedsores
SEATTLE - (March 12, 2010) - Virginia Mason Medical Center (VM) honored 31 team members — all registered nurses — at the 5th Annual Mary L. McClinton Patient Safety Award ceremony Wednesday for their work to eradicate hospital-acquired pressure ulcers, commonly known as bedsores. The team's work protected 838 patients last year from developing pressure ulcers by reducing their prevalence at VM.
The prestigious organizational award is given during National Patient Safety Awareness Week each year to a deserving team in memory of Mrs. Mary L. McClinton, who died at VM in 2004 due to a preventable error. Her life and untimely death are an inspiration to staff to do everything possible to eliminate avoidable death and injury at VM.
At the award ceremony, attended by members of Mrs. McClinton's family, VM Chairman and CEO Gary S. Kaplan, MD, explained, "Since that tragic time in 2004, our resolve has been unwavering — to become the safest hospital in the U.S., and in the world. But we can't succeed in the future unless we remember the lessons from our past, which is why we are here today."
The challenge of pressure ulcers
Despite great technological and pharmacological leaps in health care in recent years, hospitals continue to struggle with an age-old problem: hospital-acquired pressure ulcers (HAPU). These wounds are increasingly common, with approximately 60,000 patients dying each year of HAPU complications nationally. The cost of treating these wounds is about $11 billion per year.
Part of the problem is that pressure ulcers are an accepted condition in hospitals, every patient is at risk, and they are difficult to find and a challenge to treat. When the VM Zero Hospital-Acquired Pressure Ulcers team was established in 2007, about 8 percent of VM patients developed pressure ulcers, well below the national average of 15 percent. But for VM, even one patient was one too many. That year, VM reported five Stage 3-4 HAPUs (the most serious type) to the Washington State Department of Health and treated many more Stage 1-2 HAPUs with expensive therapies and extra days of hospitalization.
How did they achieve such great results?
The team began by reviewing guidance materials from national groups and brainstormed how to improve the HAPU program. They used tools of the Virginia Mason Production System (VM's management method based on lean principles) to make improvements. They streamlined the wound/skin assessment forms in the electronic medical record so a patient's skin status is displayed more prominently, which helps staff identify at-risk patients who need more frequent position changes and meticulous skin care.
The team focused first in the highest-risk setting for HAPU, the Critical Care Unit (CCU). They implemented a systematic approach to identifying patients at risk of developing HAPU and established standard actions for at-risk patients. As these standards proved successful they were spread to other units in a way that met the needs of each unit's patient population and staffing mix. As a result, there has not been a serious HAPU on CCU for two years, with similar improvements in other areas. VM now stands in the top-performing group nationally for averting HAPU injuries.
The team's key strategy focused on enhancing the inspection process of patients. Inspection can lead to early, preventive action such as implementing a SKIN bundle (Surface, Keep turning, Incontinence, Nutrition) or asking for help from a wound/skin expert. In addition to developing all nurses' HAPU-prevention competencies, the team also made advanced wound expertise more readily available on units.
"Patients are delighted with our rigor and commitment to eliminating pressure ulcers as we explain our inspection processes and ask for permission to proceed," says Cathie Furman, RN, senior vice president of quality and compliance. "We use these moments to educate patients about the need to mobilize, to turn side-to-side in bed, and to tell us about sensitivity at any pressure points."
In accepting the award for the team, Ellen Noel, RN, explained, "Without a doubt pressure ulcer prevention is the responsibility of our nursing profession. Even Florence Nightingale recognized the nurse's role in this endeavor. Pressure ulcer prevention is nationally recognized as an essential indicator of the quality and competency of nursing."
Team members recognized were Shirley Sherman, RN; Abby Nguyen, RN; Todd Jackson, RN; Penny Gilliatt, RN; Deb Coles, RN; Jackie Matuska, RN; Rowena Ponischil, RN; Michelle Johnson, RN; Danna Priest, RN; Alex Zaremba, RN; Cynthia Pompey, RN; Pat O'Conner, RN; Rachel Crickman, RN; Rachel Campos-Felizardo, RN; Joan Ching, RN; Carl Burrughs, RN; Louise Cole, RN; Kym Brune, RN; Joy Hanson, RN; Tulla Diede, RN; Elizabeth Kim, RN; Kellie Meserve, RN; Edie Newell, RN; Jessica Noeldner, RN; Lynda Parton, RN; Margaret Stapleton, RN; Becky Walsh, RN; Ellen Noel, RN; Christina Long, RN; Jessica Dunn, RN; and Charleen Tachibana, RN.
About Virginia Mason Medical Center
Virginia Mason Medical Center, founded in 1920, is a non-profit comprehensive regional health-care system in Seattle that combines a primary and specialty care group practice of more than 440 physicians with a 336-bed acute-care hospital. Virginia Mason operates a network of clinics throughout the Puget Sound area; manages Bailey-Boushay House, a nursing residence and Chronic Care Management program for people living with HIV and AIDS; and operates Benaroya Research Institute at Virginia Mason, internationally recognized in autoimmune disease research. Virginia Mason is known for applying manufacturing principles to health care to improve quality and patient safety.
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