Improving Harm Across the Board

Dalton, Georgia

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2012 Breakthrough in Identification of HARM:

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Increased Identification

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Pearls• Leadership commitment and their active involvement in quality and

safety initiatives are critical to creating a Safety Culture.• The responsibility for preventing patient harm lies with everyone in the

organization.• The Patient Safety Committee must be multidisciplinary and involve

staff at all levels.• Use Root Cause Analysis when reviewing harm events and near misses

to identify opportunities for improvements that may otherwise be overlooked.

• Use small test of change prior to implementing house-wide initiatives.• Communication and teamwork are key ingredients to success.• Celebrate successes and recognize staff contributions.• Seek ways to involve patients and family members in safety initiatives.

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Defining Moment(s) In Our Journey• Defining Moments

– Completion of Organizational Culture of Safety Survey-March, 2012– Completion of Organizational Assessment Tool- March, 2012– Completion of Employee Satisfaction Survey-September, 2012– Implementation of CMS 40/20 by 2013 Hospital Engagement Network initiative in

2012• Moments that resulted in a big breakthrough in the organization’s ability to

deliver safety• Expansion of Patient Safety Committee to include non clinical departments • Increased use of Root Cause Analysis• Involvement of front-line staff • Development of Culture of Safety Steering Committee with Executive Leadership

champions• Formal leadership rounding process and reporting mechanism• Annual Patient Experience and Culture of Safety Fair

Risk Profile by Areas of Risk # Risks per patient: 1.77

HACs Estimated annual number of patients at risk in each area Number (2012)

ADE # of patients on anticoagulation 1021 CAUTI # pts in MI SI units with catheter in place: 463CLABSI # pts in MI SI NICU units with central lines: 461Falls # of discharges: 10183Ob AE # of women with deliveries: 1777Pr Ulcer # of discharges: for PSI-3 1765SSI # of applicable surgical pts. for colon and hysterectomy 308VAP # of patients on a ventilator: 277VTE # of inpatients for PSI-12 1410EED # of women with elective deliveries (Began monitoring in Q2 2012) 391TOTAL Risk opportunities for harm across the board 18056Readmit # of inpatients at risk of readmit Medicare All-Cause 3291

Improving HAC Rates (per discharge)HACs Baseline

2010- 2011Target Current

YR 2012-2013Improvement Status (scale)

ADE > 4 HMC 5.63% HMC Target: 3.6% GA: 5% for INR >5 / GA 2013 = 2%

YR 2012 = 4.5% Q1 2013= 2.8%

Target

CAUTI (MI SI) HMC 0.56% HMC Target: 0.34%GA: 1.3 per device days

YR 2012 = 1.4%Q1 2013 = 3.8% (foley pts reduced by 69%)

OpportunityProgress

CLABSI (MI SI NICU) HMC 1.2% HMC Target: 0.69%1.3-GA/ 2013 GA = 1.1 per device days

YR 2012 = 0.65%Q1 2013 = 0%

Target

Falls HAC = 0.087/1000 discharges0.94%

HMC HAC Target: 0.05 GA HAC = 0.29 HMC Target: 0.56%

HAC=0.295/0.0= Q1 2013YR 2012 = 1.25%Q1 2013 =0.97%

TargetProgress

Falls /1000 pt. days 2.7 HMC Target: 1.62 2013 YTD 1.54 Target

OB AE 22.2 per 1000 deliveries HMC Target: 13.32 YR 2012 = 25.8 Q1 2013 =15.8

Progress/ Opportunity

Pr Ulcer PSI-3 1.56 HMC Target: 0.93GA: 0.47

YR 2012 =0.56Q1 2013 = 2.3

TargetProgress

SSI-colon, hysterectomy

1.7 HMC Target: 1.0GA Target 1.7

YR 2012 = 1.9 Q1 2013 = 0

ProgressTarget

VAP per 1000 pts. 6.6 HMC Target: 3.96 YR 2012 = 18.05Q1 2013 = 12.99

Opportunity

VTE PSI-12 3.9 HMC Target: 2.3GA: 4.05

YR 2012 = 1.42Q1 2013 = 4.6

Target /Opportunity

EED Q2 2012 Baseline = 11.8% HMC Target: 7.1%GA 5% / GA 2013: 2%

Year 2012 =12.5%Q1 2013 = 9% Apr 2013= 0%

Opportunity / Progress

Readmit Medicare 16.05 HMC Target: 12.8%15.24-GA

YR 2012 =16.1%Q1 2013 = 14.5%

Opportunity/ Progress

Our Hospital Risk Profile & Result

Annual Volume (Discharges) 10183Total risk: annual harm opportunities 18056Risks per patients (Total Opportunities)/Discharges) 1.77

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

Number of PfP Areas at Improvement Target 7Number of PfP Areas at IDEAL 1

Future Actions to Reduce Harm

• Continue focus on overall harm• Increase use of Root Cause Analysis • Greater focus on transition of care and readmissions• Increase patient and family involvement in safety and

quality initiatives and teams• Continued involvement of front line staff and use of

multidisciplinary safety team• Expansion of formal Leadership Rounding Process to

include patients and family members

Photo of Hospital CEO &Safety Team