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Preventing Pressure Ulcers in the Veterans Health Administration Using a Virtual Breakthrough Series Collaborative

Zubkoff, Lisa PhD; Neily, Julia MS, MPH, RN; King, Beth BSN, MA, RN, CCM; Morgan, Storm MSN, RN, MBA; Young-Xu, Yinong PhD; Boar, Shoshana MS; Mills, Peter PhD, MS

doi: 10.1097/NCQ.0000000000000242

The Veterans Health Administration implemented a Virtual Breakthrough Series to prevent pressure ulcers. The pressure ulcer rate decreased from 1.2 to 0.9 per 1000 bed days of care (P = .017). The most common interventions were education (N = 26; 68%), improved documentation (N = 23; 61%), and the use of equipment and supplies (N = 21; 55%). In summary, this project helped improve pressure ulcer rates in the Veterans Health Administration and presents a promising model for implementing a virtual model for improvement.

Supplemental Digital Content is Available in the Text.

VA National Center for Patient Safety, White River Junction, Vermont (Drs Zubkoff, Young-Xu, and Mills and Mss Neily, and Boar); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Dr Zubkoff); National Center for Patient Safety, Ann Arbor, Michigan (Ms King); and Office of Nursing Services, VA Central Office, Washington, DC (Ms Morgan).

Correspondence: Lisa Zubkoff, PhD, VA Medical Center, 215 N Main St (10A4E), White River Junction, VT 05009 (

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

The authors declare no conflicts of interest. All employees are government employees.

Accepted for publication: October 20, 2016

Published ahead of print: November 29, 2016

PREVENTING PRESSURE ULCERS is an important component of patient safety programs. Each year, an estimated 2.5 million patients in the United States develop a pressure ulcer.1 Pressure ulcer incidence rates in acute care hospitals in the United States range from 0.4% to 12%1,2 and from 2.2% to 23.0% in long-term care settings.2 Pressure ulcers are associated with increased morbidity, mortality, longer inpatient stays, and higher costs.3–5 The Veterans Health Administration (VHA) has focused on pressure ulcer prevention (PUP) in all clinical settings, including inpatient acute care, inpatient mental health, spinal cord injury, community living centers (long-term care), home-based primary care, outpatient primary care, and other areas where patients are at risk for pressure ulcer development. Nonetheless, PUP remains a high priority issue for VHA.6

Recent reviews have found that effective prevention efforts include special support surfaces, along with a multicomponent strategy such as a team approach, the use of skin champions, staff education, and audit and feedback.5,7 A systematic review by Sullivan and Schoelles5 reviewed the evidence on multicomponent strategies to prevent pressure ulcers and examined contextual impacts for programs designed to reduce facility-acquired pressure ulcers. This review found moderate evidence for improved care process and pressure ulcer outcomes when a multicomponent program was used. Such programs might include standardization of pressure-ulcer specific interventions and documentation, involvement of multidisciplinary teams and leadership, use of skin champions, staff education, and sustained audit and feedback. A systematic comparative effectiveness review by Chou et al7 reported that among high-risk populations, moderate evidence was found that advanced static support surfaces were associated with lower risk for pressure ulcers when compared with standard mattresses.

Building upon current expertise, the above evidence, and existing efforts in the VHA, we implemented a virtual breakthrough series (VBTS) to further improve implementation of evidence-based interventions. Previous quality improvement efforts in the VHA have focused on data feedback to prompt change, whereas the VBTS utilizes dynamic personalized coaching and group education to facilitate successful implementation of interventions. The purpose of this article is to describe the approaches and experiences of facilities within the VHA system that participated in the PUP VBTS.

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Virtual breakthrough series

We used a VBTS method based upon the Breakthrough Series (BTS) model, developed by the Institute for Healthcare Improvement in 1995. This approach is a collaborative model for achieving improvement.8 The model is designed to help organizations close the gap between “what we know and what we do.” The BTS model uses a short-term (∼6 months) learning experience that brings together teams from hospitals to improve care in a specific topic area. The model consists of 4 key elements: aims, measurement, implementing changes, and testing small cycles of change.8 The method has gained increased use during the last 15 years and has been described elsewhere.9–11 We used the BTS approach because even though the interventions to prevent pressure ulcers were not novel, we needed an innovative approach to help teams implement changes. The model not only prompts sites to create interdisciplinary teams, but also ensures leadership support by making the clinical topic a priority and providing resources and support to make changes. The BTS approach also provides a structure in which to create realistic and measurable aims. Participants are taught what changes to make on the basis of the evidence and they are taught how to make those changes based upon the model for improvement. The overall BTS model is depicted in the Supplemental Digital Content, Figure available at:



Building on the Institute for Healthcare Improvement model of the BTS,8 we developed a virtual version to address the improvement needs of VHA facilities across the nation.12–14 This eliminates the need for travel and keeps clinicians at the bedside while providing ongoing access to expert faculty.

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Expert faculty

Given that PUP remains a high priority among VHA leaders, the goal of this VBTS was to provide a virtual learning opportunity to help VHA clinical teams more fully implement evidence-based practices to prevent pressure ulcers. The faculty included VHA staff who are experts in PUP as well as quality improvement methods. Faculty helped set the overall goals and direction for the project, served as advisors to the planning committee, and taught process improvement strategies and interventions. Each team was assigned a coaching pair—an Implementation Coach and a Clinical Coach—to guide the team throughout the VBTS.

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Change package

A Change Package is designed to identify ideal care for a specific clinical area and specific changes that can be applied to improve performance.8 Teams were given a Change Package, which presented the Veterans Affairs (VA) Skin Bundle. Interventions included assessment and inspection, pressure relieving surfaces, turning and repositioning, incontinence management, and nutrition and hydration assessment and intervention.15 Interventions included in the Change Package received A, B, or C ratings for the strength of evidence (Supplemental Digital Content, Change Package available at:

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Recruitment and team enrollment

Teams from VHA hospital facilities nationwide were invited in December 2014 via e-mails from VHA leadership to participate in this project. Our application and participation process for this VBTS was open to all VA facilities and voluntary to reach as many teams as possible that were interested. We recognize that it is possible that this “open call” approach may represent either high-performing sites or low-performing sites. If a hospital had multiple units participating, they were required to have a team for each unit. We directed the participating facilities to develop an interprofessional team to implement the VA Skin Bundle as part of the VBTS process. We advised them to implement changes at the unit level and then spread further once success was achieved. Teams were from acute care or long-term care units and were also required to include a local senior leader. The teams made a 5-month commitment to actively make changes with coaching, followed by 5 months of independent continuous improvement.

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We established three 5-month phases for this project (Supplemental Digital Content, Figure available at:

  • Prework: January 2015–February 2015 (which included October-December 2014 for analysis)
  • Action: March 2015–July 2015
  • Continuous Improvement: August 2015–December 2015
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Prework phase

We used the prework approach as was used in prior projects.12–14 During the prework phase, we held a call (offered twice) to orient teams to the project; educate teams on building a successful team, identifying project goals, and collecting baseline data on the current pressure ulcer rates; and review the Change Package. Coaches also held a “Meet and Greet” call with each of their assigned teams to review their current PUP program and discuss the team goals and baseline data on pressure ulcer rates.

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Action phase

Learning activities

All learning was conducted virtually, via phone, live meeting, and e-mails. There were a total of 10 nationwide learning session calls or webinars over the 5-month Action Phase (2 learning sessions per month). The first call of the month was an educational presentation; the second call was an open-forum discussion. Topics in the webinars included description and evidence for each intervention in the VA Skin bundle, data collection and documentation, lessons learned and best practices, and patient engagement and education. These sessions also provided an opportunity to discuss barriers to implementing evidence-based interventions and methods to overcome those obstacles. In addition to the monthly written feedback, described later, coaches were accessible via e-mail or phone between learning sessions to answer questions or troubleshoot. The frequency of informal contacts was not tracked as part of this project.

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Senior leader reports

Teams were required to submit a “Senior Leader Report”—a progress report that included their overall aims for the collaborative, specific changes implemented during the month, and measures of process and outcomes they were tracking. The reports also included lessons learned that month and plans for the future.

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Team cohorts of 6 to 8 teams were assigned a coaching pair (1 implementation coach and 1 clinical coach). The Implementation Coaches were master's level prepared with quality improvement knowledge and experience. The Clinical Coaches were nurses with expertise in PUP. Each coaching pair conducted a monthly group call with the members of their respective teams (ie, 1 call for all teams together). The goal was to provide the team members a collaborative learning opportunity using an “all teach, all learn” approach. All team members presented on their accomplishments for the prior month and shared the successes and challenges they currently face in implementing appropriate PUP interventions. The coaches also provided written feedback on the monthly senior leader reports. Coaching feedback focused on process improvements to trial interventions as well as ideas to manage or eliminate barriers impeding frontline changes. Feedback from coaches was sent to the entire team, including the team's senior leader (see Sample Senior Leadership Report and Feedback, Supplemental Digital Content, Exhibit available at:

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Process assessment

To assess participation, we used final reports submitted by teams at the end of the continuous improvement phase (the last submitted report) to quantify the number and type of new or modified interventions. Interventions were coded by consensus by 2 of the authors. Coders reviewed each final report together and classified the types of interventions and the number implemented by consensus. At the end of the VBTS, we conducted a survey about the coaching provided. We asked what worked well and could be improved, what was the most and least helpful, and a question about the helpfulness of coaching using a 5-point rating scale (1 = poor, 5 = excellent).

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Outcome evaluation

Pressure ulcer rates were the outcome measures. Staff from community-living centers (long-term care) submitted data using the self-reported Advancing Excellence database.16 Acute care inpatient units' pressure ulcer rates were collected through an automated data pull based on coding information at discharge according to the Patient Safety Indicator guidelines for pressure ulcers.17 However, since we were doing quality improvement work at the unit level and the Patient Safety Indicator rates are produced at the facility level, we asked units to complete a template with the number of new unit-acquired pressure ulcers and bed days of care for each month of the project. This produced an incidence rate of the number of pressure ulcers per 1000 bed days of care.

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Statistical analysis

We compared data before, during, and after the project for participating teams for the time frames described earlier. The rates were calculated as the total number of events divided by the total bed-days of care. Comparisons of rates were conducted using Poisson regression model. All tests were 2-tailed, and a P value of < .05 was considered to indicate a statistically significant difference. Analyses were performed using STATA statistical software version 11 (College Station, Texas).

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Team participation

Thirty-eight teams participated in the project. Teams submitted monthly reports on average 88% (range: 76%-100%) of the time. Of the 38 teams, 12 teams were focused in acute care units and 22 teams were focused in long-term care or community-living centers. Of the remaining 4 teams, 1 focused on both acute care and community-living center, 2 focused across the entire facility, and 1 team focused on short-term care. Teams in the project represent 15 of the 20 Veterans Integrated Service Networks. At least 1 team is located in each of the VA geographic regions.

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Process evaluation


There were 23 unique interventions implemented (Tables 1 and 2). Table 1 presents the interventions from VA Skin Bundle that teams implemented. Table 2 presents additional nonbundle interventions that teams implemented. The most frequently implemented change was provider and/or staff education (N = 26; 68% of teams). The next most common interventions were improvement of documentation such as the assessment template or skin or wound note (N = 23; 61%), and the use of equipment and supplies such as protective boots or heel dressings, protective sacral dressings, turn systems, wheelchair cushions, catheter-related products, or use of locked box in veteran room to store products (N = 21; 55%). Consistent with standards of care, turning and repositioning were not reported as a new or modified intervention. The average number of interventions implemented by teams was 4. The most common number of interventions implemented by a team was 3, with a range of 0 to 8.

Table 1

Table 1

Table 2

Table 2

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Coaching survey

Among the 33 respondents, 82% reported that their experience with coaching was excellent or very good. For those individuals who responded to open-ended questions, coaching and feedback were viewed as helpful and constructive and offered “fresh eyes” on the issue. Informal communication (phone calls, e-mails) were appreciated as an extra layer of support. For example, 1 respondent stated, “I liked the ability to have a teleconference with our coaches” while another stated, “Receiving the feedback on our monthly reports and the open-ended questions helped us think about the areas we were missing.” At the same time, respondents reported that not all coaching was individualized and that being coached was a time commitment and resulted in a large number of e-mails. Respondents particularly liked the group discussion calls when participants were allowed to share, hear about the work of other teams, and network.

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Outcome Evaluation

Data on pressure ulcer incidence rates were available for 26 of the 38 teams that participated in the project. The mean aggregated pressure ulcer rate decreased from 1.6 during the prephase to 1.2 per 1000 bed days of care during the action phase (P = .015). The mean aggregated pressure ulcer rate decreased from 1.2 during the action phase to 0.9 per 1000 bed days of care during the continuous improvement phase (P = .017) (see the Figure). Across the 3 phases of the project, the pressure ulcer rates decreased by 44%.

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Participating units in the VBTS showed improvements in decreasing pressure ulcer incidence rates. This is similar to improvement findings in a previous BTS on reducing hospital-acquired pressure ulcers in acute care settings.13 This project built upon our prior success and expanded to include long-term care and acute care settings. This additional success supports that the VBTS may be an appropriate improvement methodology to help VHA and other teams to make changes that result in reduced rates.

Teams were engaged and focused with a mode of 3 interventions per team. This is different from other BTS with more interventions where teams struggled to prioritize and focus based on need. For example, in a project to reduce falls and fall-related injuries on average teams implemented 6.44 interventions with a range of 1 to 12 and a mode of 6. This is twice the mode of the current project. In the falls project, teams were encouraged to implement a multicomponent fall prevention program. Therefore, at times teams struggled to prioritize and focus leading to the implementation of many interventions. This points to the value of focus and simplicity of the evidence-based interventions in the VA Skin Bundle and is consistent with recommendations for simplicity and standardization of PUP interventions.5

The 2 most commonly implemented interventions were provider and/or staff education and improved documentation. In alignment with the strength of actions hierarchy for patient safety, education and documentation would be considered weaker actions.18 While there is value in implementing education or improved documentation, the strongest approach would be to pair these with clinical changes at the bedside. On the basis of the coding scheme, we categorized education and improved documentation as separate and distinct actions from clinical changes. More frequent implementation of education and documentation actions may also be related to staff response to prompts. For example, it is easier to assign accountability to document than it may be to ensure that a patient was turned and repositioned as needed. It may also be that education and documentation interventions are more easily measured. For instance, to measure adequate turning and repositioning managers would ideally use observation. However, observation may also create resentment among staff members or give a false measure of improvement due to the Hawthorne effect.19 Overall, the interventions of education, documentation, and use of equipment/supplies are similar to changes that teams have made in other BTS.12

We are aware that staff members are frequently asked to do more during change efforts; however, the 1 intervention that involved doing less was using fewer layers of linen with a patient to prevent pressure ulcer development due to multiple layers. This was implemented only by 3 teams. This contradiction might be a deterrent to the de-implementation of certain interventions. In future BTS, it may be beneficial to highlight what teams can do less of to allow more time for high-impact evidence-based interventions.

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This work has several limitations. Results are based on self-reported data from 26 of the 38 teams, limiting the generalizability of the findings. Data to compare outcomes between participating and nonparticipating units were not available. Despite these data limitations, there was still improvement. In addition, we did not observe the teams implementing changes or verify their reported rates. Since the educational sessions were virtual, we reliably tracked team attendance. However, we do not know if attendance indicated 1 person or several team members. Another limitation is that we did not capture long-term sustainability of improvement. Future work should integrate measurement of long-term sustainability for quality improvement projects.

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These limitations notwithstanding, the current project provides evidence that the participation of local interprofessional teams in a VBTS was associated with significant reductions in pressure ulcer rates. The VBTS approach was implemented in VHA and presents a promising model for patient safety improvement.

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evidence-based nursing; pressure ulcer; pressure ulcer prevention; quality improvement; virtual breakthrough series collaborative

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