Key Takeaways

• Hospital Harm–Pressure Injury (HH-PI) eCQM, adult inpatients: Measures hospitalizations with new stage 2, 3, 4, DTPI, or unstageable pressure injuries, linking bedside prevention with documentation and electronic quality reporting. 
• Present-on-admission documentation: Accurate admission skin assessment is critical; qualifying pressure injuries documented as present on admission may meet denominator exclusion criteria. 
• Nursing leadership: HH-PI requires alignment among bedside nurses, wound specialists, nurse managers, quality, informatics, and coding teams to ensure clinical care and electronic reporting accurately reflect patient status.

For decades, pressure injury prevention has largely been viewed as a clinical responsibility. Bedside nurses assessed risk and monitored skin changes; wound care specialists were called when concerns developed; quality teams reviewed outcomes through prevalence surveys and retrospective data.^1,2 Those responsibilities remain important, but the Hospital Harm-Pressure Injury (HH-PI) electronic clinical quality measure (eCQM) changes the way hospitals must think about pressure injury prevention.^3,4

The conversation is no longer only about whether nurse leaders prevented a pressure injury. It now includes how staff assessed the patient when they entered the hospital, how staff documented the findings, and whether the electronic health record accurately reflects what happened during the hospitalization.

The HH-PI measure evaluates the proportion of adult inpatient hospitalizations in which a patient develops a new stage 2, stage 3, stage 4, deep tissue pressure injury (DTPI), or unstageable pressure injury during the hospital stay.^3–5

For nurse leaders, this is much more than another quality measure. It shows how closely bedside care has become connected to documentation, technology, regulatory expectations, and day-to-day nursing operations. From our perspectives in nursing leadership and wound care, HH-PI is also a reminder that these areas can no longer function separately. Preventing pressure injuries requires clinical expertise, but it also requires leadership that can build systems around that expertise.⁶

Why Pressure Injury Prevention Is a Leadership Issue

Some organizations still approach hospital-acquired pressure injuries as primarily a wound care service line problem. HH-PI makes it increasingly difficult to think that way. Pressure injury prevention is influenced by what happens throughout the inpatient hospital course. Staffing affects whether nurses have time to reposition high-risk patients and complete thorough assessments while admission processes influence whether existing skin conditions are identified early. Nurses also need clear pathways for escalating findings they are unsure about.^2,6

These changes pose important leadership challenges. A nurse manager may never perform a comprehensive wound consultation, but that manager still has an important role in pressure injury prevention. The environment that the leader creates affects whether admission skin assessments are completed, whether nurses feel comfortable raising concerns, and whether prevention practices remain a priority during a busy shift.^1,6

At the same time, the role of the wound care specialist continues to expand. Wound care specialists are no longer involved only after a wound develops. They educate staff, help improve clinical practice, review quality trends, and collaborate with other departments when clinical documentation or workflow opportunities are identified.^1,2

How to Succeed Under the HH-PI

HH-PI brings all these multi-factorial responsibilities together. One of the biggest changes associated with HH-PI is the importance placed on documentation. Clinicians must continue to focus on providing holistic patient care. However, electronic quality reporting creates another reality: if the care provided and the patient's condition are not accurately represented in the electronic health record, the data may tell a different story.^3,4

Consider a patient who arrives at the hospital with an existing pressure injury. Clinically, the team may recognize that the injury was already present. However, if the admission assessment does not clearly capture that finding, the electronic record may not reflect the patient's true condition on arrival. This makes present-on-admission documentation especially important. Qualifying pressure injuries documented as present on admission may meet criteria for exclusion from the measure denominator. Missing or unclear documentation can therefore affect how the hospitalization is ultimately represented in quality reporting.

Nurse managers need to understand what is happening at the bedside and what the documentation looks like afterward. Are nurses actually completing admission skin assessments as expected? Do nurses know what to do when they are uncertain about staging? Can they easily reach someone for guidance? Are nurses entering findings in the correct areas of the electronic health record?

The organizations that will perform well under HH-PI will likely be those that successfully align bedside practice with documentation workflows rather than treating workflows as separate activities. This alignment begins at the bedside, where staff nurses must be able to identify and stage pressure injuries accurately at the point of initial contact, ensuring that clinical assessment, documentation, coding, and quality reporting reflect the patient’s true condition.^3–5

Why Coding and Clinical Practice Must Speak the Same Language

Electronic quality measurement also exposes a challenge that has existed in healthcare for years: what clinicians mean and what the data ultimately shows are not always the same thing.

HH-PI depends on structured electronic data and standardized terminology. A description that makes perfect sense to a bedside nurse may not translate clearly into coding or electronic quality reporting. That means nurse leaders will increasingly find themselves involved in conversations with coding specialists, quality teams, and informatics staff.^2,6

This is an important shift. Nurse managers do not need to become coders, but they do need to understand how nursing documentation can affect reported outcomes. They should also recognize when a workflow or documentation design is making it harder for nurses to accurately capture what they see.^2,6

Wound care specialists have a similar responsibility because understanding how wound terminology is represented within the electronic record is becoming increasingly important. If the clinical team describes a condition one way, but the documentation system captures it another way, and quality reporting interprets it differently, the organization has a problem. The goal should be for clinical practice and electronic reporting to tell the same story.^2,6

The Emerging Role of the Nurse Manager

Nurse managers are particularly important in preparing organizations for HH-PI because they operate where hospital strategy meets bedside reality. Policies may be developed at the organizational level, but implementation happens on nursing units. Nurse managers are the ones who see whether a process actually works during a busy admission, whether staff have the right equipment available, and whether education has translated into practice.⁶

This makes HH-PI much more than a wound care initiative. Education about pressure injury staging is important, but education alone will not solve every problem. A nurse may know exactly what should be done and still struggle if prevention equipment is difficult to obtain or the admission workflow does not support a thorough skin assessment.

Nurse managers have the ability to identify those barriers and can also reinforce expectations through staff conversations and unit-based quality review. Most importantly, they can create an environment where pressure injury prevention becomes part of everyday nursing practice rather than another initiative that appears only when data begins moving in the wrong direction. HH-PI is ultimately a systems issue, and nurse managers are central to making those systems work.^3,6

Where Wound Care Specialists and Nurse Managers Meet

One of the most important lessons from HH-PI is that clinical expertise and operational leadership cannot remain in separate lanes. Wound care specialists understand pressure injury risk, prevention, staging, and treatment. They also understand the clinical details that may be difficult for frontline staff to interpret. Nurse managers understand the realities of operational responsibilities of managing a patient care unit. They know where workflow breaks down, how staffing affects practice, and what barriers nurses encounter during patient care. Both perspectives are necessary. A wound care specialist may recognize a pattern in hospital-acquired pressure injuries, but meaningful improvement often depends on changing how staff delivers care in the unit. A nurse manager may recognize that nurses are struggling with skin assessments, but the solution may require clinical guidance from someone with deeper wound care expertise.^3,4,6

Pressure injury prevention works best when bedside nurses have access to both strong clinical support and responsive leadership. Quality professionals, informatics teams, and coding specialists also become part of that work when documentation and electronic reporting are involved. HH-PI makes these connections much more visible.^3,6

Preparing How the HH-PI eCQM Helps Prepare for the Future

The HH-PI eCQM is more than a new reporting requirement. It reflects where healthcare quality measures are heading. Clinical outcomes will be drawn directly from electronic data. As that happens, the accuracy of documentation and the design of clinical workflows become increasingly important. Leaders can no longer assume that good care will automatically translate into accurate, quality data.^1,3

For nurse managers, pressure injury prevention and management should no longer be viewed as something that belongs primarily to the wound care team. It is part of nursing operations and patient safety. Leaders need to understand the conditions on their units that either support prevention or make it more challenging. For wound care specialists, the opportunity is just as significant. Their role is expanding beyond wound care consultation and treatment. Their clinical expertise can help shape education, improve documentation practices, identify system gaps, and guide organizational pressure injury prevention strategies.^1,2,6

The organizations that will succeed under HH-PI will not simply be the ones that document more. They will be the organizations in which the documentation accurately reflects strong clinical practice. That requires wound care specialists who understand both clinical and quality implications, and nurse managers who understand how to turn clinical operational priorities into reliable everyday nursing practice. That is where these roles truly come together, by creating a system that makes carrying out evidence-based practice easier for nurses and ultimately reduce preventable patient harm.^2,3,6

Fortunato Catanzaro, MSN, RN, NEA-BC, PCCN, is a Nurse Leader with nearly a decade of clinical experience in progressive and cardiac telemetry nursing. He is part of the nursing management team of two hospitals in New York while also serving as adjunct nursing faculty and a member of the Board of Directors of the Coalition for At-Risk Skin (CARS). His professional interests include progressive care nursing, pressure injury prevention, patient safety, and quality improvement. He is particularly interested in advancing pressure injury prevention through evidence-based practice, accurate clinical documentation, meaningful quality measurement, and nursing leadership strategies that support improved patient outcomes and organizational performance.

Alex Aningalan, DNP, RN, CWON, NEA-BC, CPHQ is a Board-Certified Wound and Ostomy Nurse Specialist with clinical and leadership expertise in multiple care settings. He is currently the Program Manager of Wound and Ostomy Care at a hospital in New York. He also serves as part-time faculty to BSN and DNP students. He has published multiple scholarly articles and is also a peer reviewer in several nursing journals. In addition to wound healing, he is passionate about nursing quality, nursing education, and nursing mentorship.

References

1. Cordina J, Rolls K, Sim J. Nurses’ clinical decision‐making about pressure injury prevention in hospital settings: a scoping review. J Adv Nurs. 2025;81(9):5763-5792. doi:10.1111/jan.16776
2. Nieto-García A, Nieto-García L, Roca-Biosca MA, Moreiro-Barroso MT, Carpio-Pérez A, Alonso-Sardón M. Pressure injury prevention knowledge in nursing professionals. J Tissue Viability. 2026;35(1):100968. doi:10.1016/j.jtv.2025.100968
3. Centers for Medicare and Medicaid Services. Hospital Harm - Pressure Injury. eCQI Resource Center. May 13, 2026. Accessed September 7, 2026. https://ecqi.healthit.gov/ecqm/hosp-inpt/2025/cms0826v2
4. National Pressure Injury Advisory Panel. eCQM: What You Need to Know. 2026. Accessed September 7, 2026. https://npiap.com/page/ecqm
5. Centers for Medicare and Medicaid Services. Electronic Clinical Quality Measures Basics. September 10, 2024. Accessed September 7, 2026. https://www.cms.gov/medicare/regulations-guidance/promoting-interoperability-programs/electronic-clinical-quality-measures-basics
6. Warshawsky NE, Pascale A, Duemig MJ. Impact of nurse manager span-of-control on turnover and patient safety in acute care. J Nurs Adm. 2026;56(4):186-190. doi:10.1097/NNA.0000000000001709