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Improving Harm Across the Board Northridge Medical Center Commerce, GA Selina Baskins, RN, Quality Coordinator.

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Presentation on theme: "Improving Harm Across the Board Northridge Medical Center Commerce, GA Selina Baskins, RN, Quality Coordinator."— Presentation transcript:

1 Improving Harm Across the Board Northridge Medical Center Commerce, GA Selina Baskins, RN, Quality Coordinator

2 HEN PARTIES H ospital E ngagement N etwork P reventing A voidable R eadmissions T hrough I nteractive E ngaged S taff

3 2013 Breakthrough in Reducing HAC HARM*: 96.3 to 62.9 harms/1,000 discharges 3 *HAC harm = inpatient hospital acquired conditions

4 Cut “harm across the board” in 2013: 32.5 patients per quarter to 24 4

5 Source: GCMF Database All Cause Readmissions to GA Hospitals, GA Medicare Patients only 2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges Slide 5

6 2012 Breakthrough in Reducing Readmissions 6

7 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.

8 Falls Tree on Northeast Wing

9 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

10 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.

11 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.

12 Dr Kenneth O’Neal, Hospitalist Our HEN Physician Champion

13 slide13 HACsEstimated 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 TOTALRisk opportunities for harm across the board12078 Readmit# of inpatients at risk of readmit:1349 Annual discharges: 1349HAC risk opportunities/discharge: 8.95 Risk Profile: The Areas of Risk We Are Committed To Controlling

14 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 ____5_____ __________ ____1_____ ____2______ Number of risk areas (0-11) at each stage Improvement Scale: The stages we move through Slide 14

15 Improving Harm Rates (per discharge) HACs Baseline Rate CY2012 Target Rate ADE CAUTI00 CLABSI00 Falls Pr Ulcer SSI00 VAP00 VTE00 Total Readmit Where the journey began… Falls and ADE had the largest room for improvement Several areas already meeting the target of zero harms

16 Improving Harm Rates (per discharge) HACs Baseline Rate 2010 Target Rate Current Rate Q1&Q Improvement Status (scale) ADE Progress CAUTI000Ideal CLABSI000Ideal Falls Opportunity Pr Ulcer Opportunity SSI000Ideal VAP000Ideal VTE000Ideal Total Readmit Opportunity

17 Our Hospital Risk Score Card Our Safety Mandate Annual Volume (Discharges)1349 Total risk: annual harm opportunities12078 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 & Adopted8 Our Progress Number of PfP Areas with Major Improvement Opportunity2 Number of PfP Areas at Improvement Target5 Number of PfP Areas at IDEAL5

18 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

19 Slide 19

20 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.

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