Eliminating Harm Across the Board (HAB) Template

Objectives 2 Understand what the Eliminating HAB report is and how it is a helpful tool in improving care. Understand how to complete your Eliminating HAB report. Understand how to submit your Eliminating HAB report. Know who to contact if you have questions.

How is Eliminating HAB applicable to SLHQ? 3 Quality Improvement Eliminating Harm PfP, HENs & Roadmap SLHQ & Roadmap You Eliminating HAB The Patient

Your W(hat’s) I(n) I(t) F(or) M(e): WIIFM 4 The HAB report will: Help shift your organizational culture; Put a face on harm; Tell a compelling story to support change; Promote transparency; Engage patients and their families and/or Patient and Family Advisory Council (PFAC) members; and Help you track your overall harm per discharge and identify greatest opportunities for eliminating harm.

Eliminating HAB Storyboard Example 5

Sharing Your Eliminating HAB Storyboard at Roadmap 6 In 2013, Roadmap participants shared their HAB storyboards with colleagues. In 2014, the Roadmap HAB storyboards will focus on engaging patients and families in eliminating harm.

The Eliminating HAB Template: 8 key slides, and tips for how to complete them. 7

Insert Hospital Name Here Insert Your Motto Here, e.g. “Our Bottom-line Line is Patient Safety” Slide 1 Customize the motto Insert a photo of your hospital and logo here. Insert a photo of your Safety Team, including your CEO and PFA(s) here. Insert a caption, including names for the Safety Team, CEO and PFAs here. Insert a caption, including the name of your hospital and the city and state where you are located, here. Customize the team info.

Insert a title for your “Total Harms per Discharge” run chart here e.g., “Cut Harm Across the Board in ½” Customize the heading Insert your total harm run chart Slide 2

Insert a title for your “topic-specific” run chart here e.g., “2014 Breakthrough in Reducing CAUTI: Journey to Zero” Customize the heading Insert a topic-specific run chart Slide 3

AEAsEstimated annual number of patients at risk in each areaNumber 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: EED# of women with elective deliveries OB# of women with deliveries: HAPU# of discharges: SSI# of inpatient surgeries: VAE# of patients on a ventilator: VTE# of discharges: TOTALRisk opportunities for harm across the board Readmit.# of inpatients at risk of readmit: Risk Profile: Areas of Risk We Are Committed To Controlling Annual discharges: __________ AEA risk opportunities/discharge: _______ Customize the risk opportunities/discharge Customize the annual discharges Slide 4 Note: “AEA” = Adverse Event Areas

Improving Harm Rates (/ Discharge) AEAs Baseline Rate [time period] Target Rate Current Rate [time period – last 3 months] Improvement Status (scale) ADE CAUTI CLABSI Falls EED OB HAPU SSI VAE VTE Total Readmit. Insert a your harm rates per discharge here, using the following table. For non-applicable topics – please insert “Z”. Customize the baseline, target and current rates and improvement scale Slide 5

Hospital Risk Score Card Our Safety Mandate Annual Volume (Discharges) Total risk: annual harm opportunities Risks per patients (Total Opportunities)/Discharges) Number of Risk Areas Number of Risk Areas Applicable (0 – 11) Number of Risk Areas Applicable & Adopted Our Progress Number of Areas with Major Improvement Opportunity Number of Areas at Improvement Target Number of Areas at IDEAL Insert your risk score card here, using the following table: Customize your score card Slide 6

How We Engage Patient/Family Advisors in Eliminating HAB Engaging Patient/Family Advisors Customize how you answered the Model for Improvement questions, together, as they relate to your hospital’s eliminating HAB journey Slide 7

Our Results and Pearls Results: A concise description of what you achieved, as it relates to eliminating HAB and engaging PFAs. Customize your responses Slide 8 PFA Quote: Insert a PFA quote here about eliminating HAB. Pearls: Bullet your biggest insights about what worked and how. Include what you tested and learned. Include how you will advance this topic over the next month (and beyond). List the most important drivers of safety that produced these results, but make this list succinct, high-level and clear. Include the PFA insights, thoughts and feedback

16 Eliminating HAB Template: Examples and Tips

How we Incorporated a Patient/Family Advisor (PFA) into our Journey to Eliminate HAB 17 Patient/Family Advisors Suggestions for reducing ADE Slide 7 (EXAMPLE) Reduce the incidence of preventable adverse drug events 14 ADEs/month to 8 ADEs/month Have pictures of medications taken at the bedside for patients and families

Our Results and Pearls 18 Results: Reduced ADE by 25% over 6 months. Slide 8 EXAMPLE “ I always taped a pill on to the medication list for my father so he knew what he was taking. It was so meaningful to share this idea and to see it help other patients” Pearls: Two patient/family advisors were on the ADE committee They shared the various ways that they organized medications at home and suggested that providing patients with pictures of the pills they were taking in the hospital (since some looked different than what they were taking at home) would help patients and families to know what they were being given and why At discharge patients received up to date medication lists that included pictures

Run Chart Tips 19 Cut and paste graphs from the improvement calculator: o / Resources / Using Data for Improvement Customize the heading of each slide Utilize labels or a subheader to tell the story

The Improvement Calculator 20 Tip: Access the Improvement Calculator here!here!

Risk Profile Tips 21 These calculations only need to be completed once Use one year of data – using baseline For Patient Counts for CLABSI, CAUTI, VAE o Use charge master for # of catheter trays ordered, or # of patients with ventilator charges, or divide your device days by average length of stay

Improvement Scale Tips 22 IDEAL: level represents what we see as best possible or ZERO harms At Target: level represents meeting improvement target Progress: level not yet at target Opportunity: level represents an improvement opportunity

Hospital Risk Score Card Tips 23 Our Safety Mandate: use #’s from Risk Profile Number of Risk Areas Applicable - includes Readmissions (the max. = 11) Our Progress: use Improvement Scale definitions from Improving AEAs per Discharge Slide Total Risks per patient: is calculated from total harm opportunities divided by total discharges per applicable risk areas, e.g. - if no vents. or births: 8

Pearl Tips 24 Provide enough detail about the strategy or tactic so others can easily replicate Provide examples of key cultural change strategies. For example: o Transparency of data o Front line staff engagement o Senior management support o Seamless transitions o Recognition o Promoting a Culture of Safety Share learnings and ideas tested Highlight how strategies be expanded and spread

Questions? Contact Us! Website: LISTSERV®: Phone: (773) Office: 155 N. Wacker Dr., Ste. 400 Chicago, IL Dr. Maulik Joshi: Senior Vice President, AHA and President, HRET Charisse Coulombe, Vice President, HRET Jessica Blake, Senior Program Manager, HRET Natalie Erb, Administrative Fellow, HRET Victoria Hledin, Program Manager, HRET