Improving Harm Across the BoardDODGE COUNTY HOSPITAL
4/17/13HAB Template
Version 12
Improving Harm Rates (per discharge)
HACs Baseline Rate2010
Target Rate
CAUTI 0 0%
CLABSI 0 0
Falls 5.72/1000 5%
Ob AE 0 0
SSI 2% 2%
VAP 0% 0
VTE 94.8% 100%
EED 42% MEDICALLY INDICATED
Readmit 24.03 15%
HACs Estimated annual number of patients at risk in each area Number of Opportunities
ADE # of discharges: 1464
CAUTI # pt days in IP units with catheter in place: 313 FC days
CLABSI # pt days in IP units with central lines: 81 CL days
Falls # of discharges: 1464
Ob AE # of women with deliveries: 157
Pr Ulcer # of discharges: 1464
SSI # of inpatient surgeries: 1524
VAP # of patients on a ventilator: 57
VTE # of discharges: 350
EED # of women with elective deliveries 57
TOTAL Risk opportunities for harm across the board 1464
Readmit # of inpatients at risk of readmit: 1464
Annual discharges: __2011 -1464___________
HAC risk opportunities/discharge: ____
Risk Profile: The Areas of Risk We Are Committed To Controlling
Improving Harm Rates (per discharge)
HACs Baseline Rate2011
Target Rate Current Rate2013
Improvement Status (scale)
ADE
CAUTI 0 CAUTI/ 1000 PT DAYS 0 0 CAUTI/1000 PT DAYS IDEAL
CLABSI O CLABSI/1000 PT DAYS 0 0 CLABSI/1000 PT DAYS IDEAL
Falls 5.72/1000 PT DAYS 2.68 / 1000 PT DAYS TARGET
Ob AE 0 0 0 IDEAL
Pr Ulcer 0 0 0 IDEAL
SSI 0.20% 0 .20% TARGET
VAP 0% 0 0% IDEAL
VTE 94.8% 100% TARGET
EED 42% MEDICALLY INDICATED ALL MEDICALLY INDICATED TARGET
Total
Readmit 24.03% 14.02% TARGET
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______
5__________
0__________
0___________
Number of risk areas (0-11) at each stage
Improvement Scale:The stages we move through
PEARLS
• EARLY ELECTIVE DELIVERY SUCCESS IS ATTRIBUTED TO THE FOLLOWING:
1. Education of OB staff and physicians2. Education of patients at their OB office3. The “Heard” effect4. Hard stop for EEDs at presentation to the OB
unit if they wheel out at <39 weeks
PearlsREADMISSION SUCCESS ATTRIBUTED TO:1. Bedside pharmacy2. Collaborative meetings with all three
nursing homes in the area3. Education for physicians/staff4. Increased patient education at discharge5. Call backs within 24 hours 6. Collaborative meeting with home health
agencies
Defining Moment(s) In Our Journey
The realization of how important the Quality Director position is in todays market place.We had three directors in one year.
10
Breakthrough Strategy
• Communication with outside agencies was not a focus, we were all working in silos. We overcame this by inviting various agencies into our facility and establishing a better working relationship.
• Face to face contact is very important to foster good working relationships.
Next Big Step to Reduce Harm
• Continuing our outreach to the community home health agencies, pharmacies, physicians offices, hospice, and nursing homes to build a collaborative health system to improve the continuum of patient care.
Kevin Bierschenk, CEOJan Hamrick, CFO
Sandra Campbell, CNO