Improving Harm Across the Board Dalton, Georgia

2012 Breakthrough in Identification of HARM: 2

Increased Identification 3

Slide 4 4

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.

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 6

Risk Profile by Areas of Risk # Risks per patient: 1.77 HACsEstimated 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: 463 CLABSI# pts in MI SI NICU units with central lines: 461 Falls# of discharges: Ob AE# of women with deliveries: 1777 Pr Ulcer# of discharges: for PSI SSI# of applicable surgical pts. for colon and hysterectomy 308 VAP# of patients on a ventilator: 277 VTE# of inpatients for PSI EED# of women with elective deliveries (Began monitoring in Q2 2012) 391 TOTALRisk opportunities for harm across the board Readmit# of inpatients at risk of readmit Medicare All-Cause 3291

Improving HAC Rates (per discharge) HACs Baseline Target Current YR Improvement Status (scale) ADE > 4HMC 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% Q = 3.8% (foley pts reduced by 69%) Opportunity Progress 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% Q = 0% Target Falls HAC = 0.087/1000 discharges 0.94% HMC HAC Target: 0.05 GA HAC = 0.29 HMC Target: 0.56% HAC=0.295/0.0= Q YR 2012 = 1.25% Q =0.97% Target Progress Falls /1000 pt. days2.7HMC Target: YTD 1.54Target OB AE22.2 per 1000 deliveriesHMC Target: YR 2012 = 25.8 Q =15.8 Progress/ Opportunity Pr Ulcer PSI HMC Target: 0.93 GA: 0.47 YR 2012 =0.56 Q = 2.3 Target Progress SSI-colon, hysterectomy 1.7 HMC Target: 1.0 GA Target 1.7 YR 2012 = 1.9 Q = 0 Progress Target VAP per 1000 pts.6.6HMC Target: 3.96 YR 2012 = Q = Opportunity VTE PSI HMC Target: 2.3 GA: 4.05 YR 2012 = 1.42 Q = 4.6 Target / Opportunity EEDQ Baseline = 11.8% HMC Target: 7.1% GA 5% / GA 2013: 2% Year 2012 =12.5% Q = 9% Apr 2013= 0% Opportunity / Progress Readmit Medicare HMC Target: 12.8% GA YR 2012 =16.1% Q = 14.5% Opportunity/ Progress

Our Hospital Risk Profile & Result Annual Volume (Discharges) Total risk: annual harm opportunities18056 Risks per patients (Total Opportunities)/Discharges)1.77 Number of PfP Harm Areas Applicable (0 – 11)11 Number of PfP Harm Areas Applicable & Adopted11 Number of PfP Areas at Improvement Target7 Number of PfP Areas at IDEAL1

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