Transcript Harm Across the Board Template, Version 9
Improving Harm Across the Board
Northridge Medical Center Commerce, GA Selina Baskins, RN, Quality Coordinator
HEN PARTIES
H
ospital
E
ngagement
N
etwork
P
reventing
A
voidable
R
eadmissions
T
hrough
I
nteractive
E
ngaged
S
taff
2013 Breakthrough in Reducing HAC HARM*: 96.3 to 62.9 harms/1,000 discharges
120 100 80 60 40 20 0 51 64 62 63 61 57 49 86 103 106 111 70 54 71 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2010 2011
Timeframe Quarter - Year
2012 2013
*HAC harm = inpatient hospital acquired conditions
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Cut “harm across the board” in 2013: 32.5 patients per quarter to 24
40 35 30 25 20 15 10 5 0 16 19 16
Total Harms by Quarter
35 32 23 19 16 15 14 37 26 20 28 Q1 Q2 Q3 2010 Q4 Q1 Q2 Q3 Q4 Q1 2011
Timeframe Quarter - Year
Q2 Q3 2012 Q4 Q1 Q2 2013 4
2012 Breakthrough in Readmission*:
Slide 5
From 20% of discharges to 10% of discharges
Source: GCMF Database All Cause Readmissions to GA Hospitals, GA Medicare Patients only
2012 Breakthrough in Reducing Readmissions
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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!
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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
HACs Risk Profile: The Areas of Risk We Are Committed To Controlling
slide13 Annual discharges: 1349 HAC risk opportunities/discharge: 8.95
Estimated annual number of patients at risk in each area
ADE CAUTI CLABSI Falls Pr Ulcer SSI VAP VTE
TOTAL
# of discharges: # pts in IP units with catheter in place: # pts in IP units with central lines: # of discharges: # of discharges: # of inpatient surgeries: # of patients on a ventilator: # of discharges:
Risk opportunities for harm across the board
Number of Opportunities CY 2012
1349 480 60 1349 1349 120 22 1349 12078
Readmit # of inpatients at risk of readmit:
1349
Our improvement journey
Slide 14
Improvement Scale: The stages we move through Number of risk areas (0-11) at each stage
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______
Improving Harm Rates (per discharge)
HACs
ADE CAUTI CLABSI Falls Pr Ulcer SSI VAP VTE
Total
Readmit
Baseline Rate CY2012
.0267
0 0 .0689
.0007
0 0 0 .0964
.1692
Target Rate
0 0 0 0 0 0 0 0 0 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
ADE CAUTI CLABSI Falls Pr Ulcer SSI VAP VTE
Total
Readmit
Baseline Rate 2010 .0322
0 0 .0277
0 0 0 0 .0599
.1610
Target Rate 0 0 0 0 0 0 0 0 0 0 Current Rate Q1&Q2 2013 .0118
0 0 .0498
.0013
0 0 0 .0629
.1690
Improvement Status (scale) Progress Ideal Ideal Opportunity Opportunity Ideal Ideal Ideal Opportunity
Our Hospital Risk Score Card
Our Safety Mandate
Annual Volume (Discharges) Total risk: annual harm opportunities Risks per patients (Total Opportunities / Discharges)
Number of Risk Areas
Number of PfP Risk Areas Applicable (0 – 11) Number of PfP Risk Areas Applicable & Adopted
Our Progress
Number of PfP Areas with Major Improvement Opportunity Number of PfP Areas at Improvement Target Number of PfP Areas at IDEAL
1349 12078 8.95
8 8 2 5 5
OUR TEAM:
Richard L. Clark, Interim CEO Maura Cobb, CNO, RN, MBA Larry Ebert, CFO Dr Kenneth O’Neal, Hospitalist Selina Baskins, RN, Quality Coordinator Rita Brunner, RN, ICU Coordinator Mary Kathryn Warnock, RN, Med-Surg Unit Coordinator Jim Hennes, RN, Willow Brook Unit Coordinator Tabitha Evans, RN, Case Management Sheila Embrick,RN, Nursing Supervisor Rachel Kean, RN, Surgical Services Coordinator Cindy 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.