HAPPIER brings oral care into everyday hospital practice, helping interprofessional teams prevent hospital-acquired pneumonia through coordinated care, education, and sustainable improvements.

About the Program

HAPPIER stands for Hospital-Acquired Pneumonia Prevention, Implementation, Education, and Research. It is an interprofessional quality improvement program focused on preventing non-ventilator hospital-acquired pneumonia (NVHAP), which develops in hospitalized patients who are not receiving mechanical ventilation.

The program combines comprehensive oral hygiene with other preventive practices and embeds them into hospital workflows. Its approach includes staff education, structured assessments, electronic health record documentation, performance monitoring, and dedicated clinical leadership.

Who It Serves

HAPPIER is designed for all adult hospital inpatients, regardless of admitting diagnosis or unit, including medical, surgical, and intensive care settings.

The submission reports adoption by more than 200 individual hospital units. It also describes implementation and related evidence across community hospitals, large health systems, and academic medical centers in the United States and internationally.

Organization: California State University, Sacramento / DB Consulting LLC
Sector: Acute care, quality improvement, and patient safety
Geography: United States, with related international implementation and research
Status: Active initiative focused on broader adoption

The Gap It Addresses

Preventing pneumonia in patients who are not on ventilators has often received less attention than preventing ventilator-associated pneumonia. Hospitals may lack consistent surveillance, structured oral care protocols, or reliable access to basic oral hygiene supplies.

HAPPIER treats oral care as an essential patient safety practice and establishes shared responsibility across nursing, medicine, oral health, infection prevention, and hospital leadership.

How the Approach Works

The program organizes prevention around three priorities:

• Improve oral hygiene: Reduce potentially harmful organisms in the mouth through comprehensive oral care.
• Reduce aspiration risk: Incorporate appropriate positioning, feeding tube care, and swallowing assessment.
• Support recovery and resilience: Integrate mobility, blood glucose management, nutrition, and immunization into prevention efforts.

Implementation follows a “4 Ps” framework: People, Processes, Performance, and Products, supported by Plan-Do-Study-Act improvement cycles.

Core components include:

• A structured nursing oral health assessment at admission.
• Oral care documentation within the electronic health record.
• Unit-level monitoring of care delivery.
• Access to appropriate oral hygiene supplies.
• A dedicated clinical champion working with physician partners and an interprofessional team.

Results and Supporting Evidence

The submission draws on HAPPIER implementation experience and independently conducted studies of related oral care and pneumonia prevention approaches.

Sutter Medical Center
A team-based quality improvement program reported a sustained reduction in non-ventilator hospital-acquired pneumonia over four years.

Kaiser Permanente Northern California
A multicomponent prevention program across 21 hospitals reported approximately a 70% reduction in hospital-acquired pneumonia rates and a two-thirds reduction in associated mortality between 2012 and 2018.

Orlando Health
A four-unit randomized study involving 8,709 patients reported an 85% reduction in NVHAP incidence on the medical intervention unit. The surgical intervention unit also showed a reduction, although the surgical comparison did not reach statistical significance.

Australia’s HAPPEN Trial
A multicenter randomized trial reported approximately a 60% reduction in NVHAP associated with an enhanced oral care intervention.

Large U.S. Hospital Network
An observational study covering 144 hospitals and approximately 1.74 million hospitalizations found that oral care documented for at least three consecutive days was associated with a 16% lower NVHAP risk and 6% lower in-hospital mortality.

These findings reflect different interventions and study designs. They support the prevention approach and should not be interpreted as a single outcome measure for HAPPIER.

Current Status and Next Steps

HAPPIER continues to support implementation and sustainable practice change. Its next phase focuses on broader adoption through standardized surveillance, reliable oral care supplies, consistent prevention practices, and greater public awareness.

The submission identifies these priorities as the focus of its current collaboration with the Santa Fe Group.

Resources and Supporting Research

• CDC: Oral Health in Healthcare Settings Toolkit
• Veterans Health Administration: Project HAPPEN
• The Joint Commission: Preventing Nonventilator Hospital-Acquired Pneumonia
• Baker et al. (2019): Sustaining Quality Improvement
• Lacerna et al. (2020): Pneumonia Prevention Across a Large Hospital System
• Giuliano et al. (2021): Oral Care as Prevention for NVHAP
• Mitchell et al. (2026): Australia’s HAPPEN Trial
• Kluberg et al. (2025): Oral Care, Mobility, and NVHAP