Improving Harm Across the Board

Northridge Medical CenterCommerce, GASelina Baskins, RN, Quality Coordinator

HEN PARTIESHospital

Engagement

Network

Preventing

Avoidable

Readmissions

Through

Interactive

Engaged

Staff

2013 Breakthrough in Reducing HAC HARM*: 96.3 to 62.9 harms/1,000 discharges

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42010 2011 2012 2013

0

20

40

60

80

100

120

5164 62 63 61 57

49

86103 106

111

7054

71

0 0

TimeframeQuarter - Year

Har

ms/

1,00

0 d

isch

arg

es

3

*HAC harm = inpatient hospital acquired conditions

Cut “harm across the board” in 2013: 32.5 patients per quarter to 24

4

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42010 2011 2012 2013

0

10

20

30

40

16 19 16 16 1915 14

23

35 3237

2620

28

0 0

Total Harms by Quarter

TimeframeQuarter - Year

To

tal

# o

f H

arm

s

Source: GCMF DatabaseAll Cause Readmissions to GA Hospitals, GA Medicare Patients only

2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges

Slide 5

2012 Breakthrough in Reducing Readmissions

6

Pearls

• Very supportive Nurse Leaders • We implemented the GHA HEN project ideas to set

our standards. • We chose things easy to achieve first• Chose 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.

Falls Tree on Northeast Wing

Defining 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 staff• Decorated the room with Easter eggs• Easter eggs were filled with door prizes• Powerpoint presentation that focused on

Readmissions and Falls• All were required to do the chicken dance!

9

Defining Moments in Our Journey

7/24/13 HEN PARTIES Picnic• Included 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.

Breakthrough 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.

Dr Kenneth O’Neal, Hospitalist Our HEN Physician Champion

slide13

HACs Estimated annual number of patients at risk in each area Number of OpportunitiesCY 2012

ADE # of discharges: 1349

CAUTI # pts in IP units with catheter in place: 480

CLABSI # pts in IP units with central lines: 60

Falls # of discharges: 1349

Pr Ulcer # of discharges: 1349

SSI # of inpatient surgeries: 120

VAP # of patients on a ventilator: 22

VTE # of discharges: 1349

TOTAL Risk opportunities for harm across the board 12078

Readmit # of inpatients at risk of readmit: 1349

Annual discharges: 1349 HAC risk opportunities/discharge: 8.95

Risk Profile: The Areas of Risk We Are Committed To Controlling

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

____5_____

__________

____1_____

____2______

Number of risk areas (0-11) at each stage

Improvement Scale:The stages we move through

Slide 14

Improving Harm Rates (per discharge)

HACs Baseline RateCY2012

Target Rate

ADE .0267 0

CAUTI 0 0

CLABSI 0 0

Falls .0689 0

Pr Ulcer .0007 0

SSI 0 0

VAP 0 0

VTE 0 0

Total .0964 0

   

Readmit .1692   0

Where the journey began…

• Falls and ADE had the largest room for improvement

• Several areas already meeting the target of zero harms

Improving Harm Rates (per discharge)

HACs Baseline Rate2010 Target Rate Current Rate

Q1&Q2 2013Improvement Status (scale)

ADE .0322 0 .0118 Progress

CAUTI 0 0 0 Ideal

CLABSI 0 0 0 Ideal

Falls .0277 0 .0498 Opportunity

Pr Ulcer 0 0 .0013 Opportunity

SSI 0 0 0 Ideal

VAP 0 0 0 Ideal

VTE 0 0 0 Ideal

Total .0599 0 .0629

 

Readmit .1610 0 .1690 Opportunity 

Our Hospital Risk Score CardOur Safety Mandate

Annual Volume (Discharges) 1349

Total risk: annual harm opportunities 12078

Risks per patients (Total Opportunities / Discharges) 8.95

Number of Risk Areas

Number of PfP Risk Areas Applicable (0 – 11) 8

Number of PfP Risk Areas Applicable & Adopted 8

Our Progress

Number of PfP Areas with Major Improvement Opportunity 2

Number of PfP Areas at Improvement Target 5

Number of PfP Areas at IDEAL 5

OUR TEAM:Richard L. Clark, Interim CEOMaura Cobb, CNO, RN, MBA

Larry Ebert, CFODr Kenneth O’Neal, Hospitalist

Selina Baskins, RN, Quality CoordinatorRita Brunner, RN, ICU Coordinator

Mary Kathryn Warnock, RN, Med-Surg Unit CoordinatorJim Hennes, RN, Willow Brook Unit Coordinator

Tabitha Evans, RN, Case ManagementSheila Embrick,RN, Nursing Supervisor

Rachel Kean, RN, Surgical Services CoordinatorCindy 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 Staff

Slide 19

Next big step to Reduce Harm

Our next big step will be to initiate A 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.