improving harm across the board
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Improving Harm Across the BoardNorthridge Medical CenterCommerce, GASelina Baskins, RN, Quality Coordinator
HEN PARTIESHospital Engagement Network Preventing Avoidable Readmissions Through Interactive Engaged Staff
2013 Breakthrough in Reducing HAC HARM*: 96.3 to 62.9 harms/1,000 discharges
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42010 2011 2012 2013
0
20406080
100120
5164 62 63 61 57
49
86103 106
111
7054
71
0 0
TimeframeQuarter - Year
Har
ms/
1,00
0 di
scha
rges
3
*HAC harm = inpatient hospital acquired conditions
Cut “harm across the board” in 2013: 32.5 patients per quarter to 24
4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42010 2011 2012 2013
0
10
20
30
40
16 19 16 16 1915 14
23
35 3237
2620
28
0 0
Total Harms by Quarter
TimeframeQuarter - Year
Tota
l # o
f Har
ms
Source: GCMF DatabaseAll Cause Readmissions to GA Hospitals, GA Medicare Patients only
2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges
Slide 5
2012 Breakthrough in Reducing Readmissions
6
Pearls
• Very supportive Nurse Leaders • We implemented the GHA HEN project ideas to set
our standards. • We chose things easy to achieve first• Chose key personnel to be our champions.• Falls tree on both inpatient units with a reward
system to create a little competition.• Heightened awareness in the ED for nurses to check if
the patient had any alternative care options rather than being a readmission.
Falls Tree on Northeast Wing
Defining Moments In Our Journey
We decided that our base topic was to make everything that was required FUN!!
4/4/12 In-services for all clinical staff• Decorated the room with Easter eggs• Easter eggs were filled with door prizes• Powerpoint presentation that focused on
Readmissions and Falls• All were required to do the chicken dance!
9
Defining Moments in Our Journey
7/24/13 HEN PARTIES Picnic• Included several familiar items as Fried Chicken,
Deviled Eggs, and Egg Custard Pie!• After eating each clinical staff member had to
participate in a mini inservice related to best practices to prevent falls and reduce readmissions.
Breakthrough Strategy
• The biggest challenge: Physician “Buy In” • Concurrent chart review daily intervention with
physicians and staff.• Have one Hospitalist as our “Champion”. Share
Specification Manual for specific documentation needed and he not only does it, but shares with the other physicians to help meet requirements.
Dr Kenneth O’Neal, Hospitalist Our HEN Physician Champion
slide13
HACs Estimated annual number of patients at risk in each area Number of OpportunitiesCY 2012
ADE # of discharges: 1349
CAUTI # pts in IP units with catheter in place: 480
CLABSI # pts in IP units with central lines: 60
Falls # of discharges: 1349
Pr Ulcer # of discharges: 1349
SSI # of inpatient surgeries: 120
VAP # of patients on a ventilator: 22
VTE # of discharges: 1349
TOTAL Risk opportunities for harm across the board 12078
Readmit # of inpatients at risk of readmit: 1349
Annual discharges: 1349 HAC risk opportunities/discharge: 8.95
Risk Profile: The Areas of Risk We Are Committed To Controlling
Our improvement journey
IDEAL: level represents zero harm
At Target: level represents meeting improvement target
Progress: level shows movement but not yet at target
Opportunity: level is an opportunity to launch aggressive action
____5_____
__________
____1_____
____2______
Number of risk areas (0-11) at each stage
Improvement Scale:The stages we move through
Slide 14
Improving Harm Rates (per discharge)
HACs Baseline RateCY2012
Target Rate
ADE .0267 0
CAUTI 0 0
CLABSI 0 0
Falls .0689 0
Pr Ulcer .0007 0
SSI 0 0
VAP 0 0
VTE 0 0
Total .0964 0
Readmit .1692 0
Where the journey began…
• Falls and ADE had the largest room for improvement
• Several areas already meeting the target of zero harms
Improving Harm Rates (per discharge)
HACs Baseline Rate2010 Target Rate Current Rate
Q1&Q2 2013Improvement Status (scale)
ADE .0322 0 .0118 Progress
CAUTI 0 0 0 Ideal
CLABSI 0 0 0 Ideal
Falls .0277 0 .0498 Opportunity
Pr Ulcer 0 0 .0013 Opportunity
SSI 0 0 0 Ideal
VAP 0 0 0 Ideal
VTE 0 0 0 Ideal
Total .0599 0 .0629
Readmit .1610 0 .1690 Opportunity
Our Hospital Risk Score CardOur Safety Mandate
Annual Volume (Discharges) 1349Total risk: annual harm opportunities 12078Risks per patients (Total Opportunities / Discharges) 8.95
Number of Risk AreasNumber of PfP Risk Areas Applicable (0 – 11) 8Number of PfP Risk Areas Applicable & Adopted 8
Our ProgressNumber of PfP Areas with Major Improvement Opportunity 2Number of PfP Areas at Improvement Target 5Number of PfP Areas at IDEAL 5
OUR TEAM:Richard L. Clark, Interim CEOMaura Cobb, CNO, RN, MBA
Larry Ebert, CFODr Kenneth O’Neal, Hospitalist
Selina Baskins, RN, Quality CoordinatorRita Brunner, RN, ICU Coordinator
Mary Kathryn Warnock, RN, Med-Surg Unit CoordinatorJim Hennes, RN, Willow Brook Unit Coordinator
Tabitha Evans, RN, Case ManagementSheila Embrick,RN, Nursing Supervisor
Rachel Kean, RN, Surgical Services CoordinatorCindy Smith, RN, ED Unit Coordinator
Lois McMahon, RN, Northridge Health and Rehab DON
Our Motto:
“HEN PARTIES”Hospital Engagement Network Preventing Avoidable
Readmissions Through Interactive Engaged Staff
Slide 19
Next big step to Reduce Harm
Our next big step will be to initiate A Passion for Patients Committee Meetings. This will not only include frontline staff, but also Case Management, local Home Health, Hospices, and Patient or Patient Representatives to help evaluate our processes at a higher standard.
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