Eliminating HAPU

HQI Toolkit

This HQI toolkit will assist hospitals in measuring hospital-asociated pressure ulcers (HAPU), identifying and engaging key stakeholders, providing harm elimination tools that work, and learning through the success of other hospitals.

This toolkit is divided into five sections, which will open individually by clicking on each green tab below (blue indicates the open tab):

  • What to Measure, listing the outcome and process measures focused upon in this toolkit;
  • Key Improvement Team Members, providing a basic list of who should be involved;
  • Tools that Work, a compilation of proven tools and methods;
  • Success Stories, highlighting the success of hospitals that used the tools within this toolkit; and
  • Additional Resources, websites beyond this toolkit that have proven resourceful.

A link to the toolkit evaluation form is also provided in order to receive feedback.

What to Measure

Refer to the HRET-HEN website “AHA/HRET Comprehensive Data System Encyclopedia of Measures” for the full list of improvement measures and additional information.

  • EOM-PU-58 Patients with at least One Stage II or Greater Nosocomial Pressure Ulcer (NSC 2) 
  • EOM-PU-57 Patients with Skin Assessment Documented Within 24 Hours of Admission 

Key Improvement Team Members

There are many people that should have an interest in eliminating VAEs within a hospital. Provided below is a minimal list of stakeholders who should be required as Team Members. Additional inclusions at hospital discretion are suggested.

Key Members Role

Executive Sponsor

  • Helps the team prioritize improvement efforts
  • Helps the team navigate organizational bureaucracy
  • Ensures the team has resources to fix problems
  • Makes rounds and meets regularly with members of health care team in the care areas

Clinical and Physician Co-Lead

  • Serves as role model for team activities
  • Meets with team regularly
  • Participates in senior executive partnership meetings
  • Communicates with physician group and clinical leadership as needed
  • Assists with implementation of interventions

Quality Leader

  • Supports team activities
  • Ensures results of activities are shared with staff
  • Assigns project leaders to interventions and tracks progress

Content Specialists

  • Provide their expertise on the harm area to team

Ancillary Department Representation

  • Provide their expertise on the involvement of their service regarding the harm area
  • Obtains ancillary staff feedback to initiatives

Frontline Staff Members

  • Encourages unit staff involvement
  • Obtains staff feedback
  • Manages documentation of activities

Patient/Family Representative

  • Provide the voice of the patient/family
  • Review all patient/family education

Tools that Work

Tools that work are key resources to reduce HAPU.  Hospitals noticing an increase in HAPU should focus on the tools with “**”. Hospitals successful in reducing HAPU but not quite reaching Aim should focus on the additional tools provided.

These example tools have been compiled by HQI staff, and are intended for consideration in hospitals as current practices are evaluated and specific programs are developed. These are examples, not fixed protocols that must be followed, nor are they entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results.


  1. **Four Eyes Assessment – Form to document the assessment of wound abnormalities as noted in ED and hand off to inpatient unit.


  1. **Pressure Ulcer Prevention Algorithm – Algorithm to determine intervention based on assessment.
  2. **Nutrition Protocol – Guide to nutritional management for at risk patients at stage of pressure ulcer development.
  3. **Pressure Ulcer Prevention in the Operating Room – Policy identifying patients at risk for pressure ulcer development in the OR and noted interventions.


  1. **Target RED – Visual tool to reinforce with team the importance of repositioning, patient engagement and documentation in pressure ulcer prevention.


  1. **Skin Care Flowsheet – Form to document assessment and intervention of skin care.
  2. **New Wound Identification – Format for conducting and documenting  a root cause analysis of newly identified pressure ulcers.


  1. **”Days Since Last Pressure Ulcer” checklist and poster – A poster to use in daily huddles to bring the data to the frontline staff.

Additional Resources

NDNQI Pressure Ulcer Training Program
Online training for pressure ulcer identification, staging and prevention.

AHRQ Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care
Comprehensive toolkit for pressure ulcer prevention in hospitals.