The Best Way to Approach Never Events
An interview with Ellen Noel, faculty member at Virginia Mason Institute
When you think of never events, what’s the first thing that comes to mind?
EN: I look at never events from a nursing perspective because I know how much impact a nurse can have on prevention. Before I began teaching at Virginia Mason Institute, I was a clinical nurse specialist for many years at the Virginia Mason hospital — and I have seen amazing progress in the way we care for patients.
I know how tragic and disabling never events are for patients and the staff who cares for them. People come to us to get better, and they expect to not receive any harm from our processes. There is so much risk inherent in everything we do, and we need to work together to bring that risk to zero.
What have you done to stop never events from happening?
EN: In my career I participated in a lot of improvement work in the areas of pressure ulcers, blood transfusions and patient falls. And of all the work I’ve done, the work around pressure ulcers stands out the most. Patients with pressure ulcers are so vulnerable — they’re among the sickest patients — and they depend on us to protect them. As a young nurse, I cared for patients who suffered from stage 4 pressure ulcers. They experienced pain, disability, and many therapies and treatments, and sometimes they didn’t recover. In health care at that time, severe pressure ulcers were not uncommon.
But times have changed, and providers agree that pressure ulcers are almost always preventable, and today there are clear standards on prevention. Teams are now obligated to execute those strategies, and the execution can be incredibly challenging. At Virginia Mason, we agreed to follow the standards set by The Collaborative Alliance of Nursing Outcomes (CALNOC), a benchmarking reporting system, and to use our lean methodology to create our improvement team, study, measure, learn from our progress and keep getting better.
What did you do to decrease the incidence of pressure ulcers?
EN: To begin our journey to get to zero pressure ulcers, my team engaged leaders and staff, and then we designated our accountable individuals: clinical nurse specialists, respiratory therapists, physical therapists, perioperative-services leaders, hospitalists and some specialists. Our physicians were crucial to improving documentation of pressure ulcers upon admittance. Just as critical was the standard work we created to deliver training to nursing staff. Our team also developed skin champions on the local units to mentor and coach other nurses, and these champions participated in weekly rounding with other nurses and assistants to assess patients’ skin and ensure preventative measures were in place.
To make the biggest difference the most quickly, we started on the floor that had the most incidents of pressure ulcers — in the critical care unit — and where the patients needed a lot of attention to get well. Our leaders and staff were really motivated to make a difference, and our lean methodology helped make our work possible.
Our skin champions — in their role as nurses, mentors and coaches — brought peer nurses to the bed to do head-to-toe and front-to-back assessments of our patients’ skin and discuss any issues or misunderstandings about what constituted a pressure ulcer. There were four main inspection buckets: surface, turning, incontinence and nutrition deficits. The goal was to empower the nursing staff with knowledge and enable them to collect data that showcased their progress. The nurses all collected and entered their own data so they could track firsthand what was happening.
How did your team spread the improvement work from one unit to the rest of the organization?
EN: Two units showed great improvement. The progress was evident after about 12 weeks, and then it kept getting better. We worked as a team to build the work into the huddles and the daily standard work. It took time and effort to get the standards in place.
But it paid off. The other units saw the data, and they said, “We want that!” They asked the two units to share their success stories and give them improvement tips. That’s how it really started to spread.
“The other units saw the data, and they said, ‘We want that!’ They asked the two units to share their success stories and give them improvement tips. That’s how it really started to spread.”
– Ellen Noel
What lessons did you learn during your improvement work?
EN: The skin champions made the peer-to-peer mentoring and coaching successful — there was real power in their interactions. The skin champions were modeling and demonstrating good behavior while they and their peer nurses were seeing patients together. The skin champion would fix the problem in real time at the bedside, and would do it in a respectful way. The team started out with skin champion rounds every week, and as improvements became evident, their rounds shifted to a monthly frequency.
The mandatory online training for all nurses was provided by the National Database of Nursing Quality Indicators (NDNQI). This free resource was excellent, and there were great visual photos to help build understanding. The nursing competencies grew substantially.
We also learned that some nurses were calling a certain condition a pressure ulcer when other nurses were not. It led to great discussions and great learning, and the dialogue helped build competencies.
Our patients and families were very welcoming when nurses came in together and described what they were looking for. They knew we didn’t want them to experience any skin injury, and they knew it was because we all cared so deeply about their quality of care. Skin rounds was an opportunity to engage patients and families in pressure ulcer prevention and safety.
Did the team realize its goals?
EN: The team wanted pressure ulcers to stop being common and become rare, and today they are rare. The skin champion team did achieve zero pressure ulcer prevalence, and our nursing team is still working every day to keep it that way.
