Eliminating Harm Across the Board (HAB) Template

Objectives 2 Understand what the Eliminating HAB report is, and why it is important to complete it. Understand how to complete your Eliminating HAB report. Understand how to submit your Eliminating HAB report. Know who to contact if you have questions.

Why is Eliminating HAB applicable to the SLHQ? 3 Quality Improvement Eliminating Harm PfP, HENs & Roadmap SLHQ & Roadmap You Eliminating HAB The Patient

Your W(hat’s) I(n) I(t) F(or) M(e): WIIFM 4 We strongly believe that these reports will: –Help shift your organizational culture; –Put a face on harm; –Tell a compelling story to support change; –Promote transparency; –Engage patients and their families and/or Patient and Family Advisory Council (PFAC) members; and –Help you track your overall harm per discharge, which in turn will help your team see where your greatest opportunity is in eliminating harm

Eliminating Harm Across the Board (HAB) Template Insert Your Motto Here, e.g. “Our Bottom-line Line is Patient Safety” Insert a photo of your hospital and logo here. Insert a photo of your Safety Team, including your CEO, here. Insert a caption, including names for the Safety Team and CEO, here. Insert a caption, including the name of your hospital and the city and state where you are located, here. Slide 1 5 Customize the motto Customize the team info.

Insert a title for your “Total Harms” run chart here e.g. “Cut Harm Across the Board in ½” 6 Customize the heading Slide 2 Insert your “Total Harm per Discharge” run chart here, and update this each month. See the example run chart below. Customize the run chart

Insert a title for your “Topic-specific” run chart here e.g. “2014 Breakthrough in Reducing CAUTI: Journey to Zero” 7 Customize the heading Slide 3 Insert a your “Topic-specific” run chart here, and update this each month. See the example run chart below. Customize the run chart

Run Chart Tips 8 Cut and paste graphs from the improvement calculator (link) Customize the heading of each slide Utilize labels or a sub header to tell the story

The Improvement Calculator 9 abbbbbbbb bbbbbbbbb bbbbbbbbb bbbbbbbbb

10 AEAsEstimated 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# of women with deliveries: HAPU# of discharges: SSI# of inpatient surgeries: VAE# 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: Risk Profile: The Areas of Risk We Are Committed To Controlling Annual discharges: __________ AEA risk opportunities/discharge: _______ Slide 4 Customize the risk opportunities/discharge Customize the annual discharges

Risk Profile Tips 11 These calculations only need to be completed once Use one year of data – using baseline For Patient Counts for CLABSI, CAUTI, VAE o Use charge master for # of catheter trays ordered, or # of patients with ventilator charges, or divide your device days by average length of stay

12 Slide 5 Improving Harm Rates (/ Discharge) AEAs Baseline Rate [time period] Target Rate Current Rate [time period – last 3 months] Improvement Status (scale) ADE CAUTI CLABSI Falls OB HAPU SSI VAE VTE EED Total Readmit Insert a your harm rates per discharge here, using the following table. For non-applicable topics – please insert “Z”. Customize the baseline, target and current rates and improvement scale

Improvement Scale 13 IDEAL: level represents what we see as best possible or ZERO harms At Target: level represents meeting improvement target Progress: level not yet at target Opportunity: level represents an improvement opportunity

Hospital Risk Score Card 14 Slide 6 Our Safety Mandate Annual Volume (Discharges) Total risk: annual harm opportunities Risks per patients (Total Opportunities)/Discharges) Number of Risk Areas Number of Risk Areas Applicable (0 – 11) Number of Risk Areas Applicable & Adopted Our Progress Number of Areas with Major Improvement Opportunity Number of Areas at Improvement Target Number of Areas at IDEAL Insert your risk score card here, using the following table: Customize your score card

Hospital Risk Score Card Tips 15 Our Safety Mandate: use #’s from Risk Profile Number of Risk Areas Applicable - includes Readmissions (the max. = 11) Our Progress: use Improvement Scale definitions from Improving AEAs per Discharge Slide Total Risks per patient: is calculated from total harm opportunities divided by total discharges per applicable risk areas, e.g. - if no vents. or births: 8

Patient and Family Engagement (PFE) Involvement Quote from the patient and family advisory council (PFAC) member / advocate. For example: “What is the most powerful PFE action your hospital took to bring the voice of the patient into its safety program?” Photo of Patient Advocate What has your hospital done for you and your community? 16

17 PFE Involvement Example Joe Clothier Patient Advocate Council and Member of the Quality Council “It is impressive to me that Logansport Memorial Hospital is excited about including patient’s input as a necessary component of their Quality Improvement Philosophy. Asking members of the community to be part of the Patient Advisory Committee, and having a Patient Advocate Council Member as a member of the Quality Council can, with time, open up needed dialogue between patients and LMH. I believe this is a huge step towards improving the level of care given to patients in the Logansport area.”

PFAC Insight What insight or feedback does your PFAC have for organizational leadership? For Frontline staff? For other patients and family members? Quote from the PFAC / advocate. For example, “What took you time to learn, that others could avoid, when working with leadership? Frontline staff? Other patients and their family members? Photo of Patient Advocate 18

Pearls 19 Bullet your biggest insights about what worked, and what caused it to work here. Include what you “tested” and “learned” Include how you will advance this topic over the next month (and beyond). List the most important drivers of safety that produced these results, but make this list succinct, high-level and clear. Include patient and family engagement (PFE) Slide 7 Customize your pearl

Pearl Tips 20 Provide enough detail about the strategy or tactic to promote spread. For example, ask yourself: “Can the reader get enough information to replicate the idea?”: Provide examples of key cultural change strategies, i.e. o Transparency of data o Front line staff engagement o Senior management support o Seamless transitions o Recognition o Promoting a Culture of Safety Share learning's and ideas tested Highlight how strategies be taken to the next level

Submission Process 21 We encourage you to submit your Eliminating HAB Report for the upcoming Quality & Safety Roadmap Meeting, as well as on our SLHQ Members LISTSERV®: For more details - please contact us! See the following slide for contact information.

Questions? Contact Us! Website: LISTSERV®: Phone: (773) Office: 155 N. Wacker Dr., Ste. 400 Chicago, IL Dr. Maulik Joshi: Senior Vice President, AHA and President, HRET Charisse Coulombe, Vice President, HRET Jessica Blake, Senior Program Manager, HRET Natalie Erb, Administrative Fellow, HRET 22