Eliminating Harm Across the Board (HAB) Template

Report
Eliminating Harm Across the Board (HAB) Template
Objectives
• Understand what the Eliminating HAB report is,
and why it is important to complete it.
• Understand how to complete your Eliminating
HAB report.
• Understand how to submit your Eliminating HAB
report.
• Know who to contact if you have questions.
2
Why is Eliminating HAB
applicable to the SLHQ?
Eliminating
HAB
You
Quality
Improvement
The
Patient
SLHQ &
Roadmap
Eliminating
Harm
PfP,
HENs &
Roadmap
3
Your W(hat’s) I(n) I(t) F(or) M(e): WIIFM
•We strongly believe that these reports will:
–Help shift your organizational culture;
–Put a face on harm;
–Tell a compelling story to support change;
–Promote transparency;
–Engage patients and their families and/or Patient and
Family Advisory Council (PFAC) members; and
–Help you track your overall harm per discharge,
which in turn will help your team see where your
greatest opportunity is in eliminating harm
4
Eliminating Harm Across the Board (HAB) Template
Insert Your Motto Here, e.g. “Our Bottom-line Line is Patient Safety”
Customize
the motto
Customize the
team info.
Insert a photo of
your hospital and
logo here.
Insert a photo of your
Safety Team, including
your CEO, here.
Insert a caption, including the name
of your hospital and the city and
state where you are located, here.
Slide 1
Insert a caption, including names
for the Safety Team and CEO,
here.
5
Insert a title for your “Total Harms” run chart here
Customize
e.g. “Cut Harm Across the Board in ½”
the heading
Insert your “Total Harm per Discharge” run chart here, and update
this each month. See the example run chart below.
Customize
the run chart
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
0.1000
0.0900
0.0800
0.0700
0.0600
0.0500
0.0400
0.0300
0.0200
0.0100
0.0000
Jan-12
Total Harm/Discharge
Total Harm per Discharge
Jan- Feb- Mar Apr- May Jun- Jul- Aug- Sep- Oct- Nov Dec- Jan- Feb- Mar Apr- May Jun- Jul- Aug- Sep- Oct- Nov Dec12 12 -12 12 -12 12 12 12 12 12 -12 12 13 13 -13 13 -13 13 13 13 13 13 -13 13
Baseline 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09
Hospital 0.06 0.07 0.04 0.08 0.02 0.03 0.02 0.04 0.03 0.01 0.01 0.02 0.01 0.01 0.02 0.00 0.01 0.00 0.01 0.00 0.01 0.00
Goal
0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04
Slide 2
6
Insert a title for your “Topic-specific” run chart here
e.g. “2014 Breakthrough in Reducing CAUTI: Journey to Zero”
Customize
the heading
Insert a your “Topic-specific” run chart here, and update this each
month. See the example run chart below.
Customize
120.0
100.0
80.0
60.0
40.0
20.0
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
CAUTI Rate/1,000 Catheter Days
Catheter Associated Urinary Tract
Infections
the run chart
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100.
Hospital 105. 66.6 33.3 100. 83.3 45.4 0.00 0.00 52.6 0.00 0.00 52.6 0.00 0.00 52.6 0.00 52.6 0.00 0.00 0.00 0.00 0.00
Goal
60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0
Slide 3
7
Run Chart Tips
• Cut and paste graphs from the
improvement calculator (link)
• Customize the heading of each
slide
• Utilize labels or a sub header to
tell the story
8
The Improvement Calculator
abbbbbbbb
bbbbbbbbb
bbbbbbbbb
bbbbbbbbb
9
Risk Profile: The Areas of Risk We Are Committed To Controlling
Annual discharges: __________ AEA risk opportunities/discharge: _______
Customize the
annual discharges
AEAs
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
# of women with deliveries:
HAPU
# of discharges:
SSI
# of inpatient surgeries:
VAE
# 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:
Slide 4
Customize the risk
opportunities/discharge
Number of Opportunities
10
Risk Profile Tips
• These calculations only need to be completed
once
• Use one year of data – using baseline
• For Patient Counts for CLABSI, CAUTI,VAE
o Use charge master for # of catheter trays
ordered, or # of patients with ventilator
charges, or divide your device days by
average length of stay
11
Improving Harm Rates (/ Discharge)
Insert a your harm rates per discharge here, using the following table.
For non-applicable topics – please insert “Z”.
AEAs
Baseline Rate
[time period]
Target Rate
Current Rate
[time period –
last 3 months]
Improvement
Status (scale)
ADE
CAUTI
Customize
the baseline,
target and
current rates
and
improvement
scale
CLABSI
Falls
OB
HAPU
SSI
VAE
VTE
EED
Total
Readmit
Slide 5
12
Improvement Scale
IDEAL: level represents what we see
as best possible or ZERO harms
At Target: level represents meeting
improvement target
Progress: level not yet at target
Opportunity: level represents an
improvement opportunity
13
Hospital Risk Score Card
Insert your risk score card here, using the following table:
Our Safety Mandate
Annual Volume (Discharges)
Total risk: annual harm opportunities
Customize
your score
card
Risks per patients (Total Opportunities)/Discharges)
Number of Risk Areas
Number of Risk Areas Applicable (0 – 11)
Number of Risk Areas Applicable & Adopted
Our Progress
Number of Areas with Major Improvement Opportunity
Number of Areas at Improvement Target
Number of Areas at IDEAL
Slide 6
14
Hospital Risk Score Card Tips
• Our Safety Mandate: use #’s from Risk Profile
• Number of Risk Areas Applicable - includes
Readmissions (the max. = 11)
• Our Progress: use Improvement Scale definitions
from Improving AEAs per Discharge Slide
• Total Risks per patient: is calculated from total harm
opportunities divided by total discharges per
applicable risk areas, e.g. - if no vents. or births: 8
15
Patient and Family Engagement (PFE)
Involvement
What has your hospital done for you and your community?
• Quote from the patient and
family advisory council
(PFAC) member / advocate.
For example: “What is the
most powerful PFE action
your hospital took to bring
the voice of the patient into
its safety program?”
Photo of Patient
Advocate
16
PFE Involvement Example
Joe Clothier
Patient Advocate Council and
Member of the Quality Council
“It is impressive to me that Logansport
Memorial Hospital is excited about
including patient’s input as a necessary
component of their Quality Improvement
Philosophy. Asking members of the
community to be part of the Patient
Advisory Committee, and having a
Patient Advocate Council Member as a
member of the Quality Council can, with
time, open up needed dialogue between
patients and LMH. I believe this is a huge
step towards improving the level of care
given to patients in the Logansport area.”
17
PFAC Insight
What insight or feedback does your PFAC have for
organizational leadership? For Frontline staff? For other
patients and family members?
• Quote from the PFAC /
advocate. For example,
“What took you time to
learn, that others could
avoid, when working with
leadership? Frontline staff?
Other patients and their
family members?
Photo of Patient
Advocate
18
Pearls
Customize
your pearl
• Bullet your biggest insights about what worked, and
what caused it to work here.
• Include what you “tested” and “learned”
• Include how you will advance this topic over the
next month (and beyond).
• List the most important drivers of safety that
produced these results, but make this list succinct,
high-level and clear.
• Include patient and family engagement (PFE)
Slide 7
19
Pearl Tips
• Provide enough detail about the strategy or tactic to
promote spread. For example, ask yourself: “Can the reader
get enough information to replicate the idea?”:
• Provide examples of key cultural change strategies, i.e.
o Transparency of data
o Front line staff engagement
o Senior management support
o Seamless transitions
o Recognition
o Promoting a Culture of Safety
• Share learning's and ideas tested
• Highlight how strategies be taken to the next level
20
Submission Process
•
We encourage you to submit your
Eliminating HAB Report for the
upcoming Quality & Safety Roadmap
Meeting, as well as on our SLHQ
Members LISTSERV®:
[email protected]
•
For more details - please contact us!
See the following slide for contact
information.
21
Questions? Contact Us!
Website: www.aha-slhq.org
Email: [email protected]
LISTSERV®: [email protected]
Phone: (773) 270-3127
Office: 155 N. Wacker Dr., Ste. 400
Chicago, IL 60606
Dr. Maulik Joshi: Senior Vice President, AHA and President, HRET ([email protected])
Charisse Coulombe,Vice President, HRET ([email protected])
Jessica Blake, Senior Program Manager, HRET ([email protected])
Natalie Erb, Administrative Fellow, HRET ([email protected])
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