Hospital Performance Stories: Reducing Harm Across the Board (HAB) April 11, 2013 1pm – 2:30pm ET

What You will Hear Today “Charge” to be in action on HAB with your hospital C-Suite to adopt a culture of safety Two powerful hospital leadership stories on HAB Guidance on how to use the HAB template How to get support to develop your hospital’s leadership story

Welcome! Dennis Wagner, Partnership for Patients Jack Jordan , Partnership for Patients Maulik Joshi, AHA/HRET Debbie Reed-Gillette , Partnership for Patients

Harm Across the Board Hospital Leadership Stories Susan Bowen Shepherd Center, Georgia HEN Tammy Dye Schneck Medical Center, Indiana Hosp. Assoc., AHA/HRET HEN

Promoting Safety and Injury Prevention Improving Harm Across the Board Shepherd Center Atlanta, GA Susan M. Bowen, RN, CPHQ, CLNC, CSHA Promoting Safety and Injury Prevention

Data reflects ALL Inpatient Units, including ICU. Breakthrough in “All Harm” Reduction: From Average of 109 To 66 Harms/1,000 Discharges Harms / 1,000 discharges shown a reduction from ~109 / quarter in 2010 to 66 / quarter in 2011 Decreased rate of about 40 harms / 1,000 discharges is from improvement in ADE, Falls, and VTE Ongoing 0 VAP rate Data reflects ALL Inpatient Units, including ICU. VTE Data includes all patients (Medical AND Surgical) with VTE defined codes that were not coded as present on admission. CY 2010 / CY 2011 VTE data is forecasted due to data artifacts in the data set.

Data reflects ALL Inpatient Units, including ICU. Reduce Number of Patient All Harm “Across the Board”: From Average of 25 to 15 Total Harms Per Quarter Data reflects ALL Inpatient Units, including ICU. VTE Data includes all patients (Medical AND Surgical) with VTE defined codes that were not coded as present on admission. CY 2010 / CY 2011 VTE data is forecasted due to data artifacts in the data set.

Source: Shepherd Internal Discharge Phone Calls Breakthrough in Readmission: From Average of 2.4% to 1.9% of Discharges (3 / 231) (5 / 252) (6 / 258) (9 / 226) (7 / 230) (1 / 222) (5 / 231) (4 / 232) Source: Shepherd Internal Discharge Phone Calls

Pearls Culture of Safety promoted from the top Board conducts Patient Safety Rounds monthly Senior Leaders / Staff receive financial reward for decreasing Harm Ownership at point of care - “Workgroup” design and strategy 11 WG’s align regulatory / evidence based safe practice Surveillance and real-time coaching; at point of care delivery A Quality Department that employs the “Right” resources Trained Internal Improvement Advisors Clinical specialist and Industrial Health System Engineers Promoting “Mindful Behavior” vs. Mandates without rationale Mindful Practice Information Tools define expectations of : Consumer, Clinician, and our organization Be Alert / Be There - what you do or what you fail to do  outcome Continually challenging “status quo” Unacceptable to rest on our own laurels Mentality that even one is not acceptable Celebrate innovative care

Defining Moments In Our Journey Realizing that we were DRIP’s… Redesigned our Structure Defined data that drove “safety” and what mattered most Communication of data had to go from bottom up/back Facing we were guilty of “Word Abuse”… Misuse of “empowerment” and “transparency” Began to Walk the talk

Strategies that Drive Results Challenge of Pre-Existing Beliefs “Medical stuff is not a problem for us; we don’t have to worry since it’s not required” Rehab not Acute Strategies to Overcome Trend data to understand medical complexity Ahead of the Curve mentality Hardwire “Process Thinking” Internal Advertisement: Safe Performance Outcomes Mindful Practice Culture: E. Scott Geller

Our Risk Profile: Potential for Harm by HAC HACs 2012 Annual number of patients at risk in each area ADE # of inpatients that were discharged from ALL units: 915 CAUTI # of inpatients on ALL Units with indwelling catheters: 699 CLABSI # of inpatients on ALL Units with central lines: 470 Falls Pr Ulcer VAP # of inpatients on ALL Units with a ventilator: 203 VTE # of inpatients that were discharged from ALL units: medical/surgical: 915 TOTAL Risk opportunities for harm across the board: 5032 Readmit 2 minutes for slides 2-4 SSI, OB AE, and EED are not applicable All Data includes ALL Inpatient Units, including ICU

Our Hospital HAC Rates: Per Discharge HACs Baseline CY 2010 Actual CY 2011 Ideal Target Annual 10% Improvement Target Actual CY 2012 (# Harms) Year End Improvement Status ADE ALL Inpatient Units .0078 .0041 .0037 .0022 (2) Exceeding Target CAUTI .0255 .0196 .0177 .0372 (34) Opportunity CLABSI .0055 .0066 (6) Falls (with harm) .0011 .0021 .0019 .0011 (1) Pr Ulcer .0022 .0033 (3) VAP VTE* Medical AND Surgical Patients .0671 (Baseline) .0481 .0432 .0153 (14) Total .1092 .0801 .0721 .0645 (60) Readmit ALL Inpatient Discharges - .0238 .0214 .0186 (17) 2 minutes for slides 2-4 Note: Calculations are based on rate per discharge, NOT rate per device days as seen in NSHN * VTE Data includes all patients with VTE defined codes that were not coded as present on admission. CY 2010 / CY 2011 VTE data is forecasted due to data artifacts in the data set.

Our Hospital’s Risk Profile Total annual risk opportunities Across the Board 5032 2012 Annual Volume of Inpatient Discharges 915 Number of Risk Opportunities per patient Discharge 5.5 Number of PfP Harm Areas Applicable (0 – 11) 8 Number of PfP Harm Areas Applicable & Adopted Number of PfP Areas at or “Exceeding Target” status 4 Number of PfP Areas at “IDEAL” status 1 2 minutes for slides 2-4

Future Actions to Reduce Harm Continuance on imbedding ABC’s of Mindful Practice: “Treat every procedure/every task with the same level of attention to detail as the first time” Review every piece of data for communication to ensure clarity: “If it is unclear to the people it doesn’t matter” Reduce confusion when transitioning from Policy to Practice Implement Process Maps

Patient Safety Leaders 2 minutes

Panel Discussion: Focusing on “Results” What is the most exciting message you heard? What is the biggest insight this gave you?

Improving Harm Across the Board Schneck Medical Center Seymour, Indiana Tammy Dye, VP Clinical Services & CQO To be a healthcare organization of excellence, every person, every time.

Hospital Trend In Reducing HARM Harms/1,000 discharges Readmissions

Hospital Trend In Reducing HARM Total # of Harms Readmissions 20

Hospital Trend In Reducing HARM 21

Hospital Trend In Reducing HARM 22

Pearls Leadership (It always starts here) Leaders must create, support, and role model a culture of excellence Just Culture Quality is a strategic priority Aligning Processes & People Standing agenda item in staff meetings Becoming process literate Standardize processes Cascading goals

Pearls Transparency Share progress / opportunities Dashboards Unblinded Scorecards Patient Family Advisory Council Just Culture

Strategies to Drive Results Schneck’s fosters a culture for reporting harm, good catches & hazards so that that they learn and improve patient care safety Just Culture & Good Catch Program On-line event reporting Safety rounds RCA’s Unblinded physician scorecards Mortality audits Patient Family Advisory Council Good Catch Program Just Culture

Risk Profile by Areas of Risk HACs Estimated annual number of patients at risk in each area ADE 4587 of inpatients: CAUTI 1268 pts in IP units with catheter in place: CLABSI 668 pts in IP units with central lines: Falls 4587 of discharges: Ob AE 747 of women with deliveries: Pr Ulcer SSI 5502 of applicable surgical pts: VAP 183 of patients on a ventilator: VTE EED 283 of women with elective deliveries Readmit 4587 of inpatients at risk of readmit: TOTAL 31,586 Risk opportunities for harm across the board

Improving HAC Rates (per discharge) HACs Baseline [time period] Target Current Improvement Status (scale) ADE 0.008 (2011) 40% ↓ 0.005 0.007 (Jan-Dec 2012) Progress CAUTI 0.0008 (2011) 40% ↓ 0.0005 0 (Jan-Nov 2012) Ideal CLABSI 0 (2011) Sustain 0 (Jan-Dec 2012) Falls w Injury 0 (Jan-Dec 2011) 0 (Jan-Sep 2012) Ob AE 0.012 (Dec 2011) 40% ↓ 0.0072 0.0011 (Jan-Sep 2012) EED 0 (Dec 2011) Pr Ulcer 0 (Oct-Dec 2011) 0.0002 (Jan-Sep 2012) SSI 0.003 (2011) 0.003 (Jan-Sep 2012) VAP 0.0 (2011) VTE 0.0002 (2011) 40% ↓ 0.0011 Readmit 0.066 (2011) 0.068 (Jan-Sep 2012)

Our Hospital Risk Profile & Result Annual Volume (Discharges) 4587 Total risk: annual harm opportunities 31,586 Risks per patients (Total Opportunities)/Discharges) 6.9 Number of PfP Harm Areas Applicable (0 – 11) 11 Number of PfP Harm Areas Applicable & Adopted Number of PfP Areas at Improvement Target 1 Number of PfP Areas at IDEAL 10

1 Hospital Acquired Conditions Q1 11 Q2 11 Q3 11 Q4 11 Q1 12 Q2 12 CAUTI 1 CLABSI Pressure Ulcer VAP Standardized processes through care bundles and protocols Assign Champions / Educate Transparency of performance data

Future Actions to Reduce Harm Creation of HAC Dashboard with Self Directed Stakeholder Teams assigned to the oversight and improvement of key metrics and outcomes. Ongoing participation with educational opportunities and collaboratives to learn and educate on best practice. Continuing performance and process improvement initiatives

Safety Committee 2 minutes

Panel Discussion: Focusing on “Leadership Story” What was the most exciting message you heard? What is the biggest insight this gave you?

Review of HAB Template

Improving Harm Across the Board

(**Delete this slide when content of presentation is complete) TEMPLATE GUIDE Treat harms as events that can be summed Focus on harms (outcomes) rather then preventive measures (process) Special conditions can be considered a harm (e.g., EED, Readmits, …) Produce an overall harm trend for the hospital (**Delete this slide when content of presentation is complete)

2012 Breakthrough in Reducing HARM: 250 to 50 harms/1,000 discharges

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

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

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

Pearls Please list the drivers of safety that produced these results. Include one about patient and family engagement, if relevant

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.

Strategies to Drive Results What challenges did you encounter that you were able to overcome to achieve the results you are presenting here? What were the strategies you used to overcome them?

Risk Profile by Areas of Risk HACs Estimated annual number of patients at risk in each area Number ADE # of inpatients: 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 SSI # of applicable surgical pts: VAP # of patients on a ventilator: VTE EED # of women with elective deliveries TOTAL Risk opportunities for harm across the board   Readmit # of inpatients at risk of readmit: 2 minutes for slides 2-4

(**Delete this slide when content of presentation is complete) Improving Harms by HAC Scale: number of hospital-acquired conditions (HACs) at each level IDEAL: level represents what we see as best possible At Target: level represents meeting improvement target Progress: level not yet at target Opportunity: level represents an improvement opportunity (**Delete this slide when content of presentation is complete) 2 minutes for slides 2-4

Improving HAC Rates (per discharge) HACs Baseline [time period] Target Current Improvement Status (scale) ADE CAUTI CLABSI Falls Ob AE Pr Ulcer SSI VAP VTE EED Total   Readmit 2 minutes for slides 2-4

Improving HAC Rates (per discharge) HACs Baseline [CY 2011] Target Current [CY 2012] Improvement Status (scale) ADE 0.008 CAUTI 0.0008 CLABSI Falls w Injury Ob AE 0.012 EED Pr Ulcer SSI 0.003 VAP 0.0 VTE 0.0002 TOTAL 0.024 Readmit 0.066

Improving HAC Rates (per discharge) HACs Baseline [CY 2011] Target Current [CY 2012] Improvement Status (scale) ADE 0.008 40% ↓ 0.005 CAUTI 0.0008 40% ↓ 0.0005 CLABSI Sustain Falls w Injury Ob AE 0.012 40% ↓ 0.0072 EED Pr Ulcer SSI 0.003 VAP 0.0 VTE 0.0002 40% ↓ 0.0011 TOTAL 0.024 40%  0.0144 Readmit 0.066

Improving HAC Rates (per discharge) HACs Baseline [CY 2011] Target Current [CY 2012] Improvement Status (scale) ADE 0.008 40% ↓ 0.005 0.007 CAUTI 0.0008 40% ↓ 0.0005 CLABSI Sustain Falls w Injury Ob AE 0.012 40% ↓ 0.0072 0.0011 EED Pr Ulcer 0.0002 SSI 0.003 VAP 0.0 VTE 40% ↓ 0.0011 TOTAL 0.024 40%  0.0144 0.0113 Readmit 0.066 0.068

Improving HAC Rates (per discharge) HACs Baseline [CY 2011] Target Current [CY 2012] Improvement Status (scale) ADE 0.008 40% ↓ 0.005 0.007 Progress CAUTI 0.0008 40% ↓ 0.0005 Ideal CLABSI Sustain Falls w Injury Ob AE 0.012 40% ↓ 0.0072 0.0011 EED Pr Ulcer 0.0002 SSI 0.003 VAP 0.0 VTE 40% ↓ 0.0011 TOTAL 0.024 40%  0.0144 0.0113 Readmit 0.066 0.068

Our Hospital Risk Profile & Result Annual Volume (Discharges) Total risk: annual harm opportunities Risks per patients (Total Opportunities)/Discharges) Number of PfP Harm Areas Applicable (0 – 11) Number of PfP Harm Areas Applicable & Adopted Number of PfP Areas at Improvement Target Number of PfP Areas at IDEAL 2 minutes for slides 2-4

Future Actions to Reduce Harm What other actions will you take to reduce harm in the future?

Photo of Hospital CEO & Safety Team 2 minutes

Patient Voice: A Call to Action Bob and Barb Malizzo

CMS & AHA/HRET: Call to Action Dennis Wagner Jack Jordan Charisse Coulombe Debbie Reed-Gillette