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

2. 2012 Breakthrough in Reducing HAC HARM*: 250 to 50 harms/1,000 discharges 2 *HAC harm = inpatient hospital acquired conditions

3. Cut “harm across the board” in half: 60 patients per quarter to under 30 3

4. 2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges 4 % Discharges *all cause 30 day readmissions

5. 2012 Breakthrough in Reducing Readmissions: From 20 per quarter to 10 per quarter 5 Number Readmissions

6. Pearls Your biggest insights about what worked, what caused it to work. Please list the few most important drivers of safety that produced these results. Include patient and family engagement, if relevant

7. Defining Moment(s) In Our Journey Name and date one or two defining moments. Moments that caused the organization to commit to extraordinary safety. Moments that resulted in a big breakthrough in the organization’s ability to deliver safety. 7

8. Breakthrough Strategy What major challenge did you encounter that you were able to overcome to achieve the results you are presenting here? What was the strategy you used to overcome the challenge?

9. 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

10. 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

11. 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.

12. 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

13. 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

14. Names of CEO & Safety Team Photo of Hospital CEO & Safety Team Our Motto

15. Next big step to Reduce Harm What is the next big step your team will take to reduce harm in the future?