3*HAC harm = inpatient hospital acquired conditions 2013 Breakthrough in Reducing HAC HARM*: to 62.9 harms/1,000 discharges2012 DATA TO 2013 COMPARISON.*HAC harm = inpatient hospital acquired conditions
4Cut “harm across the board” in 2013: 32.5 patients per quarter to 24
5All Cause Readmissions to GA Hospitals, GA Medicare Patients only 2012 Breakthrough in Readmission*: From 20% of discharges to 10% of dischargesSlide 5Source: GCMF DatabaseAll Cause Readmissions to GA Hospitals, GA Medicare Patients only
7Pearls Very supportive Nurse Leaders We implemented the GHA HEN project ideas to set our standards.We chose things easy to achieve firstChose 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.
9Defining 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 staffDecorated the room with Easter eggsEaster eggs were filled with door prizesPowerpoint presentation that focused on Readmissions and FallsAll were required to do the chicken dance!9
10Defining Moments in Our Journey 7/24/13 HEN PARTIES PicnicIncluded 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.
11Breakthrough 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.
12Dr Kenneth O’Neal, Hospitalist Our HEN Physician Champion
13Number of Opportunities slide13Risk Profile: The Areas of Risk We Are Committed To ControllingAnnual discharges: 1349HAC risk opportunities/discharge: 8.95HACsEstimated annual number of patients at risk in each areaNumber of OpportunitiesCY 2012ADE# of discharges:1349CAUTI# pts in IP units with catheter in place:480CLABSI# pts in IP units with central lines:60FallsPr UlcerSSI# of inpatient surgeries:120VAP# of patients on a ventilator:22VTETOTALRisk opportunities for harm across the board12078Readmit# of inpatients at risk of readmit:2 minutes for slides 2-413
14Our improvement journey Slide 14Improvement Scale: The stages we move throughNumber of risk areas (0-11) at each stageIDEAL: level represents zero harmAt Target: level represents meeting improvement targetProgress: level shows movement but not yet at targetOpportunity: level is an opportunity to launch aggressive action____5___________________1_________2______2 minutes for slides 2-4
15Improving Harm Rates (per discharge) HACsBaseline RateCY2012Target RateADE.0267CAUTICLABSIFalls.0689Pr Ulcer.0007SSIVAPVTETotal.0964Readmit.1692 0Where the journey began…Falls and ADE had the largest room for improvementSeveral areas already meeting the target of zero harms2 minutes for slides 2-415
16Improving Harm Rates (per discharge) HACsBaseline Rate2010Target RateCurrent RateQ1&Q2 2013Improvement Status (scale)ADE.0322.0118ProgressCAUTIIdealCLABSIFalls.0277.0498OpportunityPr Ulcer.0013SSIVAPVTETotal.0599.0629Readmit.1610.1690Opportunity 2 minutes for slides 2-4
17Our Hospital Risk Score Card Our Safety MandateAnnual Volume (Discharges)1349Total risk: annual harm opportunities12078Risks per patients (Total Opportunities / Discharges)8.95Number of Risk AreasNumber of PfP Risk Areas Applicable (0 – 11)8Number of PfP Risk Areas Applicable & AdoptedOur ProgressNumber of PfP Areas with Major Improvement Opportunity2Number of PfP Areas at Improvement Target5Number of PfP Areas at IDEAL2 minutes for slides 2-4
18OUR 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 Staff2 minutes18
20Next big step to Reduce Harm Our next big step will be to initiateA 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.