1. Success Harm Across the Board Story 4/17/13 HAB Template Version 12

2. Our Story Focusing on harm across the board How it helped improve safety, quality, & patient-centered care in our hospital

3. Need to Change What sparked the move to new or improved approach to quality improvement or elimination of harm? Provide examples as appropriate

4. Cut “harm across the board” in half: 60 patients per quarter to under 30 4

5. Implementation How did hospital implement the HAB program that is responsible for this success story? Department or individual champions? What approvals were needed Specific actions taken Costs involved

6. Improvement Measures Specific measures that demonstrate care is saver across the board

7. Pearls/Insights Describe biggest insights about what worked and why What was the defining moments that produced these results?

8. Challenges and Successes Challenges encountered when implementing changes Strategies used to overcome these challenges

9. Vulnerable Populations Does your story include examples of how the needs and concerns of vulnerable populations were considered? ( VP defined as those who may need adjusted service because of disability status, income, race, ethnicity, language, religion, sexual orientation, veteran status, or poor access to health care services)

10. Sustaining the Vision What have you done to sustain changes implemented? What is your vision or hospital’s future plan for continuing to focus on Harm Across the Board?

11. Quotes Provide quote from hospital executive, physician, or frontline staff describing their perspective on your story

12. Commitment to Share Provide names & contact information for individuals we may contact if additional information is needed Is there a leader in your hospital who would be willing to serve as a resource for other hospitals that wish to learn from your story?

13. Resources Provide examples or attach copies of relevant tools or other materials that you used to bring about change in your hospital.

14. HACsEstimated 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: Ob AE# of women with deliveries: Pr Ulcer# of discharges: SSI# of inpatient surgeries: VAP# of patients on a ventilator: VTE# of discharges: EED# of women with elective deliveries TOTALRisk opportunities for harm across the board Readmit# of inpatients at risk of readmit: Annual discharges: _____________HAC risk opportunities/discharge: ____ Risk Profile: The Areas of Risk We Are Committed To Controlling

15. 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 __________ ___________ Number of risk areas (0-11) at each stage Improvement Scale: The stages we move through

16. Improving Harm Rates (per discharge) HACs Baseline Rate [time period] Target Rate ADE CAUTI CLABSI Falls Ob AE Pr Ulcer SSI VAP VTE EED Total Readmit Where the journey began -- comment on baseline and target as challenge: Note which areas represented biggest challenges. Note areas of strength at the beginning.

17. Improving Harm Rates (per discharge) HACs Baseline Rate [time period] Target Rate Current Rate [time period] Improvement Status (scale) ADE CAUTI CLABSI Falls Ob AE Pr Ulcer SSI VAP VTE EED Total Readmit

18. Our 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 PfP Risk Areas Applicable (0 – 11) Number of PfP Risk Areas Applicable & Adopted Our Progress Number of PfP Areas with Major Improvement Opportunity Number of PfP Areas at Improvement Target Number of PfP Areas at IDEAL