It is Holzer’s vision to partner with our patients, employees, and communities to improve the quality, access, and value of our services. A patient safety culture is embedded in the practices of daily care throughout our system. We employ many resources to measure our quality of care, including Centers for Medicare and Medicaid Services (CMS), National Database for Nursing Quality Indicators (NDNQI), Leapfrog Safety Grade and Hospital Survey as well as internal resources.
Understanding Hospital-Acquired Pressure Injuries and How Holzer Health System is Working to Prevent Them
January 2026
Hospital-Acquired Pressure Injuries, often referred to as HAPIs, are a serious concern in health care today. HAPIs, sometimes known as bedsores, occur when a patient’s skin and underlying tissue are damaged because of prolonged pressure, friction, or shearing of the skin. A pressure injury is defined as localized damage to the skin or underlying tissue as the result of intense and/ or prolonged pressure in combination with shear. Often, they form over bony areas of the body, such as the heels, hips, or the tailbone. When a patient stays in one position for too long, blood flow to the area decreases. Without enough blood flow, the skin and tissue begin to break down. Moisture, friction from bedding, or medical devices can also contribute to the development of these injuries.
Why are HAPIs a Serious Concern?
Pressure injuries are not only painful- they can also lead to serious complications. They can slow a patient’s recovery, increase the length of a hospital stay, and raise the risk of infection. In severe cases, they can even contribute to life-threatening conditions. There are also significant financial impacts. The treatment of a single pressure injury can cost thousands of dollars.
Evidence-Based Interventions
In the constant changing landscape of healthcare, it is imperative to utilize evidence-based interventions to provide the best care for our patients. Holzer employs the following interventions:
- Regular skin assessments: Nurses check patients’ skin frequently to identify early signs of pressure or irritation.
- Repositioning schedules: Patients who cannot move on their own are repositioned at regular intervals to relieve pressure on vulnerable areas.
- Support surfaces: Specialized mattresses, cushions, and pads help distribute pressure more evenly.
- Moisture management: Staff members ensure that skin stays clean and dry, reducing the risk of breakdown.
- Nutrition support: Dieticians help identify patients who may need additional nutritional support to maintain healthy skin.
- Education and training: Staff receive ongoing training in the latest best practices in pressure injury prevention.
These interventions align with national recommendations and reflect proven strategies for reducing the risk of HAPIs.
Holzer Health System's Commitment to High Quality Care
Holzer Health System is deeply committed to preventing Hospital-Acquired Pressure Injuries (HAPIs) and ensuring exceptional care for every patient, every time. Through continuous monitoring, the HAPI Prevention Team reviews data, evaluates interventions, and adapts strategies based on trends and outcomes. This focused, data driven approach—combined with empowering patients and families to speak up about early skin changes—has helped reduce HAPIs by half in just one year. Collaboration remains central to this success, as early detection and shared awareness are essential to preventing pressure injuries before they develop.
This commitment is reinforced by Holzer’s investment in prevention, education, and multidisciplinary teamwork. Staff members receive the training, tools, and support needed to identify risks early and respond quickly, ensuring that each patient receives safe, compassionate, and high‑quality care. By approaching HAPI prevention from every angle and continuously striving for improvement, Holzer Health System upholds its promise to deliver the highest standard of care to every patient we serve.
Click the link below to see how Holzer Health System addresses HAPIs and other patient safety concerns to ensure our patients receive friendly visits, excellent care; every patient, every time.
See Holzer's Leapfrog Hospital Safety Grade
Holzer Senior Care: Elevating Quality Care for Seniors
April 2024
What does quality mean in a skilled nursing facility? Quality means quality care and outcomes for loved ones needing short- and long-term placement in our post-acute facilities. The quality department focuses on patient outcomes for improvement in patient coordination and continuity of care during their journey at Holzer Senior Care. CMS requires specific quality metrics to be monitored and reported. The quality department tracks and trends these quality measures, identifies areas that need improvement, and provides guidance to post-acute facilities. Quality areas that are focused on include acute care hospital re-admissions, infections, falls, skin impairments, restraint use, behaviors, psychoactive medications, weight loss, and ADLs. Identified areas for improvement are closely examined for trends, root causes, or possible process improvements.
Holzer Senior Care Center has positively impacted their quality improvement and their star rating with their hard work and dedication. Their interventions for improvement include monthly meetings of tiger teams, falls committee, infection review, behaviors/psychotropics, and quality measures. Weekly meetings of nutrition and wound care. Daily meetings of the prior day’s fall huddle, admissions, and quality MDS measures review. Other interventions include annual skills checks, monthly education on infection prevention, antibiotic stewardship, and psychoactive medication use, and daily one on one education as needed. They continue their efforts daily to improve the quality of care for their residents.
View Holzer Senior Care CMS Star Ratings Here
Improving quality measures improves patient outcomes and quality of care.
Ensuring Safe Medication Administration During Hospitalization
One method that Holzer utilizes to provide safe patient care during a hospitalization is Bar Code Medication Administration (BCMA). BCMA is an electronic method of verification that provides an efficient check of the 5 Rights of Medication Administration, the right patient, the right medication, the right dose, the right time, and the right route. This technology provides a workflow process that limits the chances of human error.
During the process nurses scan both the patient armband and the medication. The system then notifies the nurse if any of the 5 Rights do not match up, allowing the nurse a double check of the medication order and patient.
A medication error is commonly known as “any preventable event that may cause or lead to inappropriate medication use or harm while the medication is in the control of the healthcare professional, patient, or consumer” (Tariq RA, 2023). One study estimates that 10% of hospitalized patients will have an experience with a medication error (Zauderer, 2023). The monetary cost of providing care to patients with medication-related errors exceeds $40 billion a year (Tariq RA, 2023). These types of errors don’t only influence cost of care, they also have an emotional and physical effect on patients, families, and staff members. Utilizing BCMA has shown a reduction of 50% in adverse drug events in the inpatient setting, as well as a reduction of 80% within the emergency department setting (Leapfrog Group, 2020).
Patient safety at all stages of care is a high priority at Holzer. All inpatient units and Emergency Departments utilize BCMA for medication administration. Each unit has a goal of 95% compliance with scanning both patient armbands and medications and are monitored to ensure the high standards are maintained. Monitoring unit compliance allows identification of areas for improvement that can then be addressed quickly and efficiently. Units with consistently higher than goal compliance rates are recognized each quarter for providing safe and high-quality care to their patients.
A BCMA team meets regularly to analyze data and methods of constantly improving scanning rates. The BCMA team consists of multiple departments, which provides different viewpoints and knowledge concerning the scanning process. The team provides support to staff in many ways, such as ensuring they have the equipment needed to scan correctly. Holzer voluntarily reports BCMA data to the Leapfrog Hospital Survey annually. This data is then reported publicly on their website and utilized in their Leapfrog Safety Grade. For more information on BCMA, Holzer data, and Leapfrog, visit:
Leapfrog Hospital Survey
Leapfrog Safety Grade
Holzer Improves Quality of Sepsis Care
Over the past several years, Holzer has dramatically improved the quality of sepsis care we provide our communities, with the goal of quick recognition and rapid treatment. This truly takes a team effort, and Holzer’s Sepsis Committee has been working hard to make sure staff and providers have the tools they need to provide excellent sepsis care, every patient, every time. Because of the work of our Sepsis Committee, we are now consistently performing well above the state and national averages for quickly utilizing the sepsis treatment bundle.
To celebrate Sepsis Awareness Month, Holzer’s Sepsis Committee hosted Sepsis Week activities September 11-15, and traveled to our inpatient units and emergency departments to talk with our staff and providers about sepsis. At Holzer, you and your loved ones can count on quick recognition and treatment of sepsis to provide the best possible care, and to decrease long-term complications.
For more information on sepsis, visit www.sepsis.org.
Hospital Medical Emergency Response
Improving outcomes for patients that have had medical emergencies is one of many quality goals within Holzer Health System.
Medical emergencies, or “code blue,” occur when adult patients experience a loss of respiratory and/or cardiac function or may include any other medical emergency. Staff that are with the patient send an alert and a trained team responds to provide immediate medical attention. The team that arrives is specially trained in Advanced Cardiac Life Support (ACLS). This training allows team members to assess, recognize and manage medical emergencies. ACLS protocols are evidence-based and consistently updated allowing fast and effective interventions. Since certification is required every two years, staff stay up to date with new and improved management techniques. The responders include a physician, respiratory therapist, nurses, and laboratory personnel. Each member plays a vital role in the care of the patient, which requires clear communication and teamwork.
A code blue committee was developed to look specifically at ways Holzer could improve response time, interventions, and patient outcomes. This group gathers data and analyzes all medical emergency events with only one goal in mind, to improve patient care.
Since the group began, many changes have occurred including easier documentation, mock code blue drills, code blue classes and participating in the American Heart Association's Get with the Guidelines – Resuscitation program.
Mock code blue drills occur throughout the system both in the hospital and clinic settings. Debriefing occurs after the drill to discuss with the staff what went right and opportunities for improvement. The code blue classes are held for all staff members that want to increase their knowledge in the code blue response process.
The Get with the Guidelines program allows Holzer to compare itself to other facilities and provides guidance and education through regular educational meetings involving hospital facilities throughout the country. Data has shown that the changes and awareness that the code blue committee put into action have made a positive impact. Improvements have been noted in medications and response times as well as other areas. The code blue committee continues to work with staff to provide training, education, and awareness as they work towards the goal of high-quality patient care.
What is a CAUTI?
"A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.”
Source: According the Centers for Disease Control and Prevention (CDC), see CDC information here
Historically Holzer has very few infections that meet the NHSN definition of CAUTI. We had an average of 3 per year for the 5-year period prior to the start of the COVID Pandemic. During the Pandemic, we saw an increase in our usage of indwelling urinary catheter and an increase in related Urinary tract infections. Seeing this increase a team was pulled together to identify and address issues. In April 2022, due to interventions such as daily review for the need of a catheter, introduction of external urinary collection devices and an enhanced personal cleansing process we successfully decreased not only our UTI infection rate (Zero CAUTI since April 2022) but the use of foley catheters in our patient population.
See more information about Catheter Associated UTIs
