4/17/13 HAB Template Version 12 Improving Harm Across the Board Harms/1,000 discharges 2012 Breakthrough in Reducing HAC HARM*: 250 to 50 harms/1,000 discharges 350 300 250 200 150 100 50 0 Q1 Q2 Q3 2010 Q4 Q1 Q2 Q3 2011 Timeframe Quarter - Year Q4 Q1 Q2 2012 *HAC harm = inpatient hospital acquired conditions 2 Cut “harm across the board” in half: 60 patients per quarter to under 30 Total # of Harms Total Harms by Quarter 100 80 60 40 20 0 55 56 64 66 78 52 58 57 30 12 Q1 Q2 Q3 2010 Q4 Q1 Q2 Q3 2011 Timeframe Quarter - Year Q4 Q1 Q2 2012 3 2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges Readmission: % Discharges 25 % Discharges 20 15 10 5 0 Q1 Q2 Q3 2011 Q4 Q1 Q2 Q3 Q4 2012 *all cause 30 day readmissions 4 2012 Breakthrough in Reducing Readmissions: From 20 per quarter to 10 per quarter Number Readmissions Readmissions 25 20 15 10 5 0 Q1 Q2 2011 Q3 Q4 Q1 Q2 Q3 Q4 2012 5 Pearls Your biggest insights about what worked, what caused it to work. • Please list the few most important drivers of safety that produced these results. • Include patient and family engagement, if relevant Defining Moment(s) In Our Journey Name and date one or two defining moments. • Moments that caused the organization to commit to extraordinary safety. • Moments that resulted in a big breakthrough in the organization’s ability to deliver safety. 7 Breakthrough Strategy • What major challenge did you encounter that you were able to overcome to achieve the results you are presenting here? • What was the strategy you used to overcome the challenge? Risk Profile: The Areas of Risk We Are Committed To Controlling Annual discharges: _____________ HAC risk opportunities/discharge: ____ HACs Estimated annual number of patients at risk in each area ADE # of discharges: CAUTI # pts in IP units with catheter in place: CLABSI # pts in IP units with central lines: Falls # of discharges: Ob AE # of women with deliveries: Pr Ulcer # of discharges: SSI # of inpatient surgeries: VAP # of patients on a ventilator: VTE # of discharges: EED # of women with elective deliveries TOTAL Risk opportunities for harm across the board Readmit # of inpatients at risk of readmit: Number of Opportunities Our improvement journey 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 ___________ Improving Harm Rates (per discharge) HACs ADE CAUTI CLABSI Baseline Rate [time period] Target Rate Where the journey began -- comment on baseline and target as challenge: Falls Ob AE Pr Ulcer SSI • Note which areas represented biggest challenges. VAP VTE EED Total Readmit • Note areas of strength at the beginning. Improving Harm Rates (per discharge) HACs ADE CAUTI CLABSI Falls Ob AE Pr Ulcer SSI VAP VTE EED Total Readmit Baseline Rate [time period] Target Rate Current Rate [time period] Improvement Status (scale) 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 Names of CEO & Safety Team Photo of Hospital CEO & Safety Team Our Motto Next big step to Reduce Harm • What is the next big step your team will take to reduce harm in the future?