Improving Harm Across the Board Northridge Medical Center Commerce, GA Selina Baskins, RN, Quality Coordinator

HEN PARTIES Hospital Engagement Network Preventing Avoidable Readmissions Through Interactive Engaged Staff

*HAC harm = inpatient hospital acquired conditions 2013 Breakthrough in Reducing HAC HARM*: 96.3 to 62.9 harms/1,000 discharges 2012 DATA TO 2013 COMPARISON. *HAC harm = inpatient hospital acquired conditions

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

All Cause Readmissions to GA Hospitals, GA Medicare Patients only 2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges Slide 5 Source: GCMF Database All Cause Readmissions to GA Hospitals, GA Medicare Patients only

2012 Breakthrough in Reducing Readmissions

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

Number of Opportunities slide13 Risk Profile: The Areas of Risk We Are Committed To Controlling Annual discharges: 1349 HAC risk opportunities/discharge: 8.95 HACs Estimated annual number of patients at risk in each area Number of Opportunities CY 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 Pr Ulcer SSI # of inpatient surgeries: 120 VAP # of patients on a ventilator: 22 VTE TOTAL Risk opportunities for harm across the board 12078   Readmit # of inpatients at risk of readmit: 2 minutes for slides 2-4 13

Our improvement journey Slide 14 Improvement Scale: The stages we move through Number of risk areas (0-11) at each stage 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______ 2 minutes for slides 2-4

Improving Harm Rates (per discharge) HACs Baseline Rate CY2012 Target Rate ADE .0267 CAUTI CLABSI Falls .0689 Pr Ulcer .0007 SSI VAP VTE Total .0964   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 2 minutes for slides 2-4 15

Improving Harm Rates (per discharge) HACs Baseline Rate 2010 Target Rate Current Rate Q1&Q2 2013 Improvement Status (scale) ADE .0322 .0118 Progress CAUTI Ideal CLABSI Falls .0277 .0498 Opportunity Pr Ulcer .0013 SSI VAP VTE Total .0599 .0629   Readmit .1610 .1690 Opportunity  2 minutes for slides 2-4

Our Hospital Risk Score Card Our 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 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 2 minutes for slides 2-4

OUR TEAM: Richard L. Clark, Interim CEO Maura Cobb, CNO, RN, MBA Larry Ebert, CFO Dr Kenneth O’Neal, Hospitalist Selina Baskins, RN, Quality Coordinator Rita Brunner, RN, ICU Coordinator Mary Kathryn Warnock, RN, Med-Surg Unit Coordinator Jim Hennes, RN, Willow Brook Unit Coordinator Tabitha Evans, RN, Case Management Sheila Embrick,RN, Nursing Supervisor Rachel Kean, RN, Surgical Services Coordinator Cindy 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 2 minutes 18

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.