For hospitals, successful quality and patient safety initiatives do more than simply apply the latest best practices; they link executive leaders and clinical experts in pursuit of a common aim. Within the Northern California regional operations of Kaiser Permanente, a successful campaign to reduce the health care-acquired pressure ulcer rate in the region's 21 hospitals has relied on a mix of executive planning and front-line empowerment to produce strong results.

In 2007, Kaiser's senior leadership team launched its Hospital and Emergency department Reliability and Operational Excellence for Safety (HEROES) initiative, bringing together its risk managers and patient-care service administrators for the first time to transform Kaiser's patient-safety culture and reduce the incidence of health care-acquired pressure ulcers.

After analyzing various solutions, the Kaiser team adapted Ascension Health's Destination Zero SKIN Care bundle. The HEROES team then brought in representatives from all 21 hospitals—a mix of physicians, wound-care nurses, dieticians and other key staffers—to develop best practices tailored to Kaiser.

For instance, the HEROES team discovered that the mattresses used in Kaiser's emergency departments and patient floors were ill-suited for current best practices, which call for patients to lie on surface redistribution mattresses whenever possible. The team then developed a business case for replacing all of the system's mattresses at a cost of $3 million, emphasizing the reduction in patient days and associated costs, according to Barbara Crawford, R.N., vice president of quality and regulatory services for Kaiser's Northern California region.

"The best way to demonstrate a return on investment is if you can save lives and reduce hospital days," Crawford says. "In the process of improving quality, you're saving dollars. We were able to recoup that $3 million probably tenfold over the past several years."

The HEROES team also taught staff nurses how to treat and prevent pressure ulcers, which previously had been handled by wound-care nurses. As staff nurses grew comfortable in their new role, wound-care nurses were freed up to spend more time combating community-acquired pressure ulcers, says Nancy Corbett, R.N., a regional risk-management clinical practice leader at Kaiser.

"The day-to-day prevention is what staff nurses know how to do now," Corbett says.

The varied strategies have paid off; between the first quarter of 2008 and the first quarter of 2010, the rate of Stage II health care-acquired pressure ulcers throughout Kaiser's Northern California region declined from slightly more than 2.5 percent to less than 1 percent, and remained significantly below regional averages.

And after targeting many of the leading causes of pressure ulcers, the HEROES team now has begun looking at other areas for potential improvement, and currently is working with Kaiser's respiratory therapists to find respiratory devices and CPAP masks that don't have unnecessary padding, which many experts believe are a hidden cause of pressure ulcers. For Crawford, the initiative's ongoing success has been driven by similar efforts to empower and engage frontline staff in developing innovative solutions.

"It's incumbent on senior leaders to work with the front line to understand the process they go through," Crawford says. "I don't think any organization doing this type of improvement effort can be successful without that engagement."

Haydn Bush, formerly a quality resources specialist with the American Hospital Association's Hospitals in Pursuit of Excellence platform, is now H&HN's senior online editor. For more information, visit