Improving Harm Across the Board

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4/17/13HAB Template

Version 12

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2012 Breakthrough in Reducing HAC HARM*: 250 to 50 harms/1,000 discharges

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q22010 2011 2012

050

100150200250300350

TimeframeQuarter - Year

Har

ms/

1,00

0 d

isch

arg

es

*HAC harm = inpatient hospital acquired conditions

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Cut “harm across the board” in half: 60 patients per quarter to under 30

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2010 2011 2012

020406080

100

55 56 64 6652 58

7857

3012

Total Harms by Quarter

TimeframeQuarter - Year

To

tal

# o

f H

arm

s

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2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q40

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10

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Readmission: % Discharges

2011 2012

% D

isch

arge

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*all cause 30 day readmissions

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2012 Breakthrough in Reducing Readmissions: From 20 per quarter to 10 per quarter

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q40

5

10

15

20

25

Readmissions

2011 2012

Num

ber R

eadm

issi

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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

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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.

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?

HACs Estimated annual number of patients at risk in each area Number of Opportunities

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:

Annual discharges: _____________ HAC risk opportunities/discharge: ____

Risk Profile: The Areas of Risk We Are Committed To Controlling

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

__________

__________

__________

___________

Number of risk areas (0-11) at each stage

Improvement Scale:The stages we move through

Improving Harm Rates (per discharge)

HACs Baseline Rate[time period]

Target Rate

ADE

CAUTI

CLABSI

Falls

Ob AE

Pr Ulcer

SSI

VAP

VTE

EED

Total

   

Readmit    

Where the journey began -- comment on baseline and target as challenge:

• Note which areas represented biggest challenges.

• Note areas of strength at the beginning.

Improving Harm Rates (per discharge)

HACs Baseline Rate[time period]

Target Rate Current Rate[time period]

Improvement Status (scale)

ADE

CAUTI

CLABSI

Falls

Ob AE

Pr Ulcer

SSI

VAP

VTE

EED

Total

       

Readmit        

Our Hospital Risk Score CardOur Safety Mandate

Annual Volume (Discharges)

Total risk: annual harm opportunitiesRisks per patients (Total Opportunities)/Discharges)

Number of Risk AreasNumber of PfP Risk Areas Applicable (0 – 11)Number of PfP Risk Areas Applicable & Adopted

Our ProgressNumber of PfP Areas with Major Improvement OpportunityNumber of PfP Areas at Improvement TargetNumber 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?