When a Houston hospital found it had a 12 percent incidence of pressure ulcers – exceeding the 7 percent national average – it put a team in place and launched a project to reduce the incidence of pressure ulcers by half within a nine-month period.

By Senaida (Cindy) Garza, Veronica Okere, Jackson Igbinoba, Kristi Novosad and Carolyn Pexton

Lying in a hospital bed, patients can receive the best that medical knowledge, compassion and technology have to offer. But they also can be at risk. A lack of mobility – especially for a prolonged period of time – can increase the chance of developing bed sores, or pressure ulcers as they are most often referred to among practitioners. Pressure ulcers are lesions caused by unrelieved pressure, which leads to damage in underlying tissue.

This condition is a major concern for both patients and caregivers. Along with the obvious cost in terms of human suffering, hospitals spend at least $2.2 billion every year treating pressure ulcers.

Safety and quality are top priorities at Memorial Hermann Southwest Hospital in Houston, Texas, USA, and methods such as Lean Six Sigma and Work-Out are among the hospital’s strategies to help improve the patient care environment. When the hospital found it had a 12 percent incidence of pressure ulcers in 2004 – exceeding the 7 percent national average – it put a team in place and launched a project to reduce the incidence of hospital-acquired pressure ulcers by half within a nine-month period.

They outlined several anticipated benefits from the project:

  • Raise customer satisfaction through better skin and wound care.
  • Avoid the risk of lawsuits.
  • Avoid fines from regulatory agency (Centers for Medicare and Medicaid Services).
  • Reduce specialty bed rental cost by $125,000.
  • Reduce length of stay associated with Stage 3, Stage 4 and “unable-to-stage” pressure ulcers.
  • Increase International Classification of Diseases coding for pressure ulcers.
  • Reduce supply costs.

Beginning the Team Effort

The team included three nurses – a Black Belt guiding the process and two Green Belts. Eventually skin and wound Champions were included to enact specific changes. The team also received input from a physician and a certified wound-ostomy-continence nurse.

The project targeted any area where pressure ulcer prevention and reduction should be a main concern, and excluded the normal newborn nursery unit, emergency department (at least in the beginning) and labor and delivery. A defect was defined as a patient with one or more pressure ulcers acquired while in the hospital.

Various stakeholders in the organization were consulted to collect the voice of the customer. This provided valuable information on incidence rates, process steps and potential factors that may lead to pressure ulcers. The team also examined data from other hospitals to compare performance and identify best practices.

Team members also made sure that the process they were using for data collection would be accurate. Tools such as gage R&R addressed inconsistencies, and provided all the required information. The skin and wound Champions used this process to gather data from each room.
They also used the Braden Scale to score a patient’s risk for developing pressure ulcers. The scale is comprised of six subscales that measure functional capabilities – sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A lower Braden Scale score indicates lower levels of functioning.

Keys: Communication and Focus

Before the team could move ahead with analysis, it had to be sure the skin and wound Champions could accurately identify a wound, beyond the normal assessment capabilities. Expertise and oversight from a newly hired wound-ostomy-continence nurse proved valuable in this regard.

Communication also was a key element in the team’s success, as it sought to build awareness and acceptance for the initiative. The team developed an elevator speech as a brief, consistent description of the project and used change acceleration process tools to foster better understanding and participation.

A fishbone diagram captured any underlying factors such as personnel, materials and environment, and helped the team narrow its focus on the most critical elements. Interestingly, nurses surfaced as a more pivotal group than physicians in terms of critical Xs.

During the Analyze phase, the team also effectively used failure mode and effects analysis (FMEA) to determine how a patient might acquire a pressure ulcer. Through FMEA, the team was able to review and improve existing safeguards to catch opportunities for failure. Tools such as FMEA and regression analysis revealed important information and helped to set the right priorities and direction for the project.

Solutions: Piloting New Procedures

The nurses had been empowered to begin planning and implementing three pilots during the Improve phase. The team conducted a Work-Out session to get everyone involved in creating workable solutions.

Pilot A involved weekly skin documentation audits using a tool based on chart review. Skin and wound Champions would note whether a skin assessment and Braden Scale score had been done both upon admission and then on a daily basis. Additional elements were added later. After a successful two-week pilot, the process moved to other units of the hospital.

Pilot B involved nurse-to-nurse communication to increase reporting on the patient’s skin status, Braden Scale score and interventions. Some areas audio tape reports from shift to shift, so skin and wound Champions would ask nurses not to erase reports before an audit could be performed. The intensive care unit implemented “daily interdisciplinary rounds” which involves pharmacists, infection control and a case manager coming together to discuss a patient. This provided the opportunity to talk about the Braden Scale score or skin status and treatment. Pilot B also was monitored for two weeks before taking it hospitalwide.

Nurse-to-physician communication was identified as the third pilot, but a decision was made to postpone this phase until nurses completed their process changes. They would then work with physician Champions to develop new skin and wound management protocols.

Figure 1: Pressure Ulcers Acquired in Memorial Hermann

Conclusion: Results an Industry Best

When new procedures were in place and functioning, the hospital saw excellent results. In the Control phase, the team surpassed its goal of 6 percent (a 50-percent reduction), and actually achieved a rate of just 5.4 percent. This subsequently improved to 2.7 percent, considered the best practice in the industry. Memorial Hermann Southwest Hospital was able to reduce hospital-acquired pressure ulcers by 78 percent. Along with safety and quality improvement, the financial benefits from the project include a $1.2 million cost savings within the first six months and a projected $2.4 million annualized cost savings.

Skin audits and monitoring continues to make sure the results are maintained. The team found that one of the most positive outcomes of the project was development of a strong network among the nurses. Better collaboration and communication should translate to providing better care for patients.

Table 1: Implement Process Control: Risk Assessment Plan
Risk Element




Abatement Plan
Skin Assessment
Not Performed




> Weekly Skin Assessment Documentation Audits with Reports to Directors
> Daily Pressure Ulcer Reporting (Charge Nurse)
> Nurse-to-Nurse Shift Report

Braden Pressure
Ulcer Risk Score
Not Performed




> Weekly Skin Assessment Documentation Audits with Reports to Directors
> Nurse-to-Nurse Shift Report
Pressure Ulcers
Not Managed




> Daily Pressure Ulcer Reporting (Charge Nurse)
> Wound Documentation Form
> Wound Management Protocol
> Stage 1 and 2 Pressure Ulcers Are Reported to Skin/Wound Champions
> Stage 3 and 4 Pressure Ulcers Are Reported to Certified Wound-Ostomy-Continence Nurse

Skin/Wound Team
Commitment Declines




> Project Champions Identified to Lead Team
> Team Members to Oversee Initiatives
Specialty Bed
Rentals Fall
Out of Protocol




> Sign-on Provided

About the Authors: Senaida (Cindy) Garza is a certified Six Sigma Black Belt at Memorial Hermann Southwest Hospital in Houston. She served for 19 years as a nurse in roles such as ICU staff nurse and charge nurse, medical/surgical staff nurse, administrative coordinator for nursing administration and coordinator for pain management and continuing nursing education. Ms. Garza is currently working toward a master’s degree in nursing at the University of Texas, Tyler. She can be reached at [email protected]. Veronica Okere has been a nurse for more than 32 years and currently is a clinical educator for the Memorial Hermann Healthcare System in Houston. She has a bachelor’s degree in biology and psychology from the University of Minnesota, and a bachelor’s degree in nursing from the University of Texas, Houston. She also is a graduate of the wound, ostomy and continence specialty program at the University of Texas M. D. Anderson Cancer Center in Houston. She can be reached at [email protected]. Jackson Igbinoba is a clinical manager and Six Sigma Green Belt at Memorial Hermann Southwest Hospital. He has been a nurse for 11 years and in his current role as a nurse manager for the last eight years. He received the Memorial Hermann Southwest Nursing Clinical Excellence Award in 2001 and the Nurse Week Nursing Excellence Award for Mentoring, in 2004. He can be reached at [email protected]. Kristi Novosad is director of health information management at Memorial Hermann Southwest Hospital and serves as the hospital and corporate team leader for the information management chapters of the Joint Council on Accreditation of Healthcare Organizations and Centers for Medicare and Medicaid Services accreditation standards. She is a certified Six Sigma Green Belt and has recently completed a project which reduced catheter-related bloodstream infections in the intensive care unit by 50 percent. She can be reached at [email protected]. Carolyn Pexton has more than 20 years of experience in communications and healthcare and is the director of communications for Performance Solutions at GE Healthcare. She is a certified Green Belt and has presented and published on topics including Lean Six Sigma and change management within the healthcare industry. She can be reached at [email protected].

About the Author