1. Area of Focus Patient Safety Purpose To develop an infrastructure and engage the frontline line staff to reduce the HAPU rate to improve patient care. Background & Significance According to the Centers for Medicare and Medicaid Services pressure ulcers are considered preventable or never events. The cost for healing Hospital Acquired Pressure Ulcers (HAPUs) is about $40,000 which is not reimbursable (Rosenthal, 2007). It is important to remember that our patients bare the majority of the burden: pain, suffering, and even death. In the clinical setting, we are considered a large hospital with the sickest patients and multiple co-morbidities which puts our patient population at higher risk for acquiring pressure ulcers during their hospital stay. Most frequent pressure ulcers are caused by immobility, device related, or skin failure. Baseline Data Methods It was important to build a strong infrastructure examining Watson’s Science of Caring. Three caring processes were selected: Teaching and Learning: Holistic Care, and Healing Environment. Creating Magic at the Bedside! 3 CARITAS PROCESSES A collaboration with PCS Leadership and Front Line Staff partnered to create a HAPU Prevention Bundle: 2 RN Verification and Turning Practices. The 2 RN Verification actually a head to toe assessment with 2 RNs examining the patient and beneath devices. There are 2 critical times that the 2 RN Verification is performed: upon admission for all patients, upon transfers for all patients The PCS leadership monitored these practices and reinforced practice. Also a chart reviewed occurred with those patients who required turning. Results Evidence of Results Results are as follows: after 1 year (2013), a 72% reduction occurred with HAPUs; within 2 years (2011-2012 to 2013-2014) 73% reduction in reportable events from 2012 to 2013 & 2014 CALNOC Prevalence and Incidence Study consistently below the mean for more than 7 quarters (2012-2014). This Caring approach has improved the quality of patient care in the area of HAPU Prevention by having improved frontline nurse participation with RN Verification monitoring revealed above 85% with admissions and transfers. Ongoing work is still needed for RN Verification during the shift. Turning every 2 hours has exceeded 85% for the last 18 months. Impact Improved quality of patient care in the area of HAPU Reduction had cost savings of the following: from 2012 to 2014 ($2,280,000). Acknowledgements I would like to thank Kaiser Permanente at Santa Clara Medical Center’s Patient Care Services Leadership Team for their support with the development of this Pressure Ulcer Prevention Program and Northern California Nursing Research for their generosity for funding this poster presentation. References DiNapoli, P., Turkel, M., Nelson, J., & Watson, J. (2010). Measuring the Caritas Processes: Caring Factor Survey. International Journal for Human Caring, 14(3), 15-20. Rosenthal, M.B. (2007). Nonpayment for performance? Medicare’s new reimbursement rule. New England Journal of Medicine, 257, 1573 – 1575. Rekindling the Essence of Caring by Developing a Hospital Acquired Pressure Ulcer Prevention Program Katherine Ricossa, RN, MS Kaiser Permanente Santa Clara Medical Center HAPU Data by Volume by Cost Kaiser Permanente Evidence Based Practice