Improving Harm Across the Board Northridge Medical Center Commerce, GA Selina Baskins, RN, Quality Coordinator HEN PARTIES Hospital Engagement Network Preventing Avoidable Readmissions Through Interactive Engaged Staff Harms/1,000 discharges 2013 Breakthrough in Reducing HAC HARM*: 96.3 to 62.9 harms/1,000 discharges 103 106 111 120 100 86 80 60 64 51 62 63 61 71 70 57 54 49 40 20 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2010 2011 2012 2013 Timeframe Quarter - Year *HAC harm = inpatient hospital acquired conditions 3 Cut “harm across the board” in 2013: 32.5 patients per quarter to 24 Total # of Harms Total Harms by Quarter 40 35 30 25 20 15 10 5 0 35 16 19 16 16 19 37 32 23 15 28 26 20 14 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2010 2011 Timeframe Quarter - Year 2012 2013 4 2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges Slide 5 Source: GCMF Database All Cause Readmissions to GA Hospitals, GA Medicare Patients only 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 Risk Profile: The Areas of Risk We Are Committed To Controlling slide13 Annual discharges: 1349 HAC risk opportunities/discharge: 8.95 HACs Estimated annual number of patients at risk in each area Number of Opportunities CY 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 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 ____5_____ At Target: level represents meeting improvement target __________ Progress: level shows movement but not yet at target ____1_____ Opportunity: level is an opportunity to launch aggressive action ____2______ Improving Harm Rates (per discharge) HACs Baseline Rate CY2012 Target Rate .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 ADE 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) Baseline Rate 2010 Target Rate Current Rate Q1&Q2 2013 Improvement Status (scale) .0322 0 .0118 Progress CAUTI 0 0 0 Ideal CLABSI 0 0 0 Ideal .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 HACs ADE Falls Opportunity Our Hospital Risk Score Card Our Safety Mandate Annual Volume (Discharges) 1349 Total risk: annual harm opportunities 12078 Risks per patients (Total Opportunities / Discharges) 8.95 Number of Risk Areas Number of PfP Risk Areas Applicable (0 – 11) 8 Number of PfP Risk Areas Applicable & Adopted 8 Our Progress Number of PfP Areas with Major Improvement Opportunity 2 Number of PfP Areas at Improvement Target 5 Number of PfP Areas at IDEAL 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.