2012 Quality and Patient Safety Performance Results Annual Report The Quality Committee of the Board Confidential & Privileged Peer Review Materials; Pages 1-31 of this material has been prepared under the direction of the director of Quality/Patient Safety Officer as part of the delegated responsibilities of the role to ensure the state and federal protections: Pursuant to GPR Statutes Georgia Code Sections , and Federal Immunity under the HCQI Act

Table of Contents Downstream Impact: Affordable Care Act # Understanding the Clinical Climate # Patients with Underlying Conditions # Advancement of Safe and Reliable Care # Focus on Harm Reduction: Healthcare Acquired Conditions # Executive Summary # Healthcare Acquired Condition Reports #-# Organizational Responsiveness to Quality and Patient Safety Issues #-# 2

One is Too Many Harm from the Patient’s Point of View 3

Down Stream Impact: Affordable Care Act CMS & Innovation Center (CMMI) $1B to Partnership for Patient Safety (PfP) to Achieve 2 Goals 2013: 1. Reduce HAC’s by 40% 2. Reduce Re-admissions by 20% State level - Healthcare Engagement Networks (HEN’s): 26 HEN’s Across Country GA HEN / Georgia Hospital Association: Drive improvement of 10 HAC’s Local Accountability for [Organization]: Reduce Harm for ___ HAC’s Demonstrate Best Practice Influence policy Report Data to CMS Pay for Performance 4

Patient Volume [amount of change] from 2011 to Total Number of Patient Days [amount of change] from 2011 to Administered doses of medication [amount of change] (__ for Inpatient and __ for Outpatient) from 2011 to Understanding the Clinical Climate of

Patients with Underlying Conditions Most complex secondary med mgmtLeast complex secondary med mgmt Single Focused Injury 6 [Graph of Comorbiditites by Tier] Tier 0Tier 1Tier 2Tier 3 [Graph of Comorbiditites by Tier] Tier 0Tier 1Tier 2Tier 3

Approach Advancement of Safe and Reliable Care THROUGH: Safe and Reliable Care Standardize: High Risk Practice Mindful: Delivery of Care Engage: Patients and Families Adoption: Scientific Evidence 7

Focus on Reduction of Harm CLABSI (Central Line Associated Blood Stream Infection) Adverse Drug Events (INR/Glycemic) CAUTI (Catheter Associated Urinary Tract Infection) Pressure Ulcers VAP (Ventilator Associated Pneumonia) VTE (Deep Vein Thrombosis) Falls with Harm Preventable Readmissions (within 30 days of discharge and readmit to a Georgia hospital) 8

Healthcare Acquired Conditions 2012 Rate 2012 # Patients 2013 CMS Target* Advancement of Safe & Reliable Care Pg. # EvidenceEngageMindful Standardize CLABSI* (Central Line Associated Blood Stream Infection) Blood stream infection related to a central venous catheter Per 1,000 device days CAUTI* (Catheter Associated Urinary Tract Infection) Urinary tract infection related to indwelling catheter Per 1,000 catheter days VAP (Ventilator Associated Pneumonia) Confirmed Pneumonia related to a mechanical ventilator Per 1,000 ventilator days Falls with Harm Fall resulting in injury (category E-I) Per 1,000 patient days Inpatient Fall Rate Assisted and Unassisted Falls – Inpatient only Per 1,000 patient days Adverse Drug Events Adverse Drug Events with harm (category E-I) Per 1,000 Doses 5% pts. INR>5 7% pts. BG<50 22 Pressure Ulcers* New Stage III, Stage IV, and Unstageable PU’s Per 1,000 Discharges VTE (Pulmonary Embolism/ Deep Vein Thrombosis) Any Patient with pulmonary embolism or deep vein thrombosis Per 1,000 Discharges Preventable Readmissions Unplanned all cause readmission within 30 days Medicare # Readmissions / Discharges 20% Reduction from Baseline Organizational Responsiveness to Quality and Patient Safety Issues Reportable Sentinel Events 31 Serious Adverse Events that Triggered Drill Down * Worst, acceptable rates established by CMS: Effective 2013**Mandated by CMS LTCH Quality Reporting Program: Effective October 2012

Central Line Associated Blood Stream Infections CLABSI # Patient Harms 10 [note: Include 1 icon for each harm]

The Person [Patient Profile] The Story of CLABSI Harm [Story of patient Harm] Central Line Associated Blood Stream Infections CLABSI Harm from the Patients Perspective The Impact/Temporary [Impact of patient Harm] The Discharge [Patient’s discharge status] 11

Central Line Associated Blood Stream Infections CLABSI Definition: Rate based on the total number of inpatients with confirmed blood stream infection per 1,000 central line days, based on CDC definition 2012 Rate: 2013 CMS Target: 0.48 / 1,000 device days 2012 Performance: [Summary] Potential Cost of Harm: $45,000 / hospital stay 2 12 [Control Chart of CLABSI Rate]

Catheter Associated Urinary Tract Infections CAUTI # Patient Harms 13 [note: Include 1 icon for each harm]

Catheter Associated Urinary Tract Infections CAUTI Harm from the Patients Perspective 14 The Person [Patient Profile] The Story of CAUTI Harm [Story of patient Harm] The Impact/Temporary [Impact of patient Harm] The Discharge [Patient’s discharge status]

Catheter Associated Urinary Tract Infections CAUTI Definition: Rate based on the number of patients with indwelling catheters who are symptomatic with confirmed infection per 1000 catheter days, based on CDC definition Rate: 2013 CMS Target: 0.48 / 1,000 catheter days 2012 Performance: [Summary] Potential Cost of Harm: $44,043 / hospital stay 8 15 [Control Chart of CAUTI Rate]

Ventilator Associated Pneumonia VAP ZERO Patient Harm ____ Days : free from Harm ____ Years: based on the CDC definition + ____ Patients: were kept free from Ventilator Harm 16

Ventilator Associated Pneumonia VAP Definition: Rate based on total number of inpatients with confirmed infection per 1,000 ventilator days. National Healthcare Safety Network's definition of VAP: patient on ventilator, physician diagnosis of pneumonia post admission based on diagnostic, imaging, and/or laboratory results Rate: 2013 CMS Target: 0.66 / 1,000 vent days 2012 Performance: [Summary] Potential Cost of Harm: $40,000 / hospital stay 1 17 [Control Chart of VAP Rate and Device Utilization]

Falls with Harm # Patient Harm 18 [note: Include 1 icon for each harm]

Falls with Harm Harm from the Patients Perspective 19 The Person [Patient Profile] The Story of Fall with Harm [Story of patient Harm] The Impact/Temporary [Impact of patient Harm] The Discharge [Patient’s discharge status]

Falls with Harm Definition: Figures are based on number of individual falls with harm reported through incident reports. The hybrid scale developed by Georgia Hospital Association (GHA) defines categories E - I as "with harm." The range is between temporary harm, prolonged hospitalization, permanent harm, near death and death Rate: 2013 CMS Target: 0.5 injury falls / 1,000 pt. days 2012 Performance: [Summary] Potential Cost of Harm: Variable 20 [Control Chart of Falls with Harm Rate]

Inpatient Fall Rate Definition: Individual inpatient falls are reported through incident reports capturing assisted and unassisted falls. Rate is number of falls per 1,000 pt days 2012 Rate: 2013 CMS Target: 2.15 / 1,000 patient days 2012 Performance: [Summary] Potential Cost of Harm: Variable 21 [Control Chart of Assisted Falls Rate] [Control Chart of Unassisted Falls Rate]

Adverse Drug Events ADE 22 # Patient Harms [note: Include 1 icon for each harm]

Adverse Drug Events ADE Harm from the Patients Perspective 23 The Person [Patient Profile] The Story of ADE Harm [Story of patient Harm] The Impact/Temporary [Impact of patient Harm] The Discharge [Patient’s discharge status]

Adverse Drug Events ADE Definition: Harm is defined on a scale developed by Georgia Hospital Association, categories E - I (temporary Harm to Death). Figures based on number of individual medication incidents with harm as reported through incident reports Rate: 2013 CMS Target: 5% INR>5 & 7% BG< Performance: [Summary] Potential Cost of Harm: Variable 24 [Control Chart of ADE Rate]

Pressure Ulcers 25 # Patient Harms [note: Include 1 icon for each harm]

Pressure Ulcers Harm from Patients Perspective 26 The Person [Patient Profile] The Story of PU Harm [Story of patient Harm] The Impact/Temporary [Impact of patient Harm] The Discharge [Patient’s discharge status]

Pressure Ulcers Definition: Hospital Acquired Pressure Ulcers with Harm are Stage III and Stage IV pressure ulcers that developed while in the hospital Rate: 2013 CMS Target: 3.21 / 1,000 discharges 2012 Performance: [Summary] Potential Cost of Harm: $1,600 / day 4 27 [Control Chart of HA PU Rate]

Venous Thromboembolism VTE 28 # Patient Harms [note: Include 1 icon for each harm]

Venous Thromboembolism VTE Harm from Patients Perspective 29 The Person [Patient Profile] The Story of VTE Harm [Story of patient Harm] The Impact/Temporary [Impact of patient Harm] The Discharge [Patient’s discharge status]

Definition: Any Patient with pulmonary embolism or deep vein thrombosis per 1,000 discharges Venous Thromboembolism VTE 2012 Rate: 2013 CMS Target: 5.6 cases/1,000 discharges 2012 Performance: [Summary] Potential Cost of Harm: $19,000 (DVT) $37,000 (PE) 30 [Control Chart of VTE Rate]

Preventable Readmissions 31 # Patient Harms [note: Include 1 icon for each harm]

Preventable Readmissions Harm from Patients Perspective 32 The Person [Patient Profile] The Story of Readmission Harm [Story of patient Harm] The Impact/Temporary [Impact of patient Harm] The Discharge [Patient’s discharge status]

Definition: Definition: Unplanned all cause readmissions within 30 days - Medicare patients only Preventable Readmissions 2012 Rate: 2013 CMS Target: Reduce hospital baseline by 20% 2012 Performance: [Summary] Potential Cost of Harm: TBD 33 [Control Chart of Readmission Rate]

Organizational Responsiveness to Quality and Patient Safety Issues 34

Significance: A significant adverse event, also known as a sentinel event, is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof and signals the need for immediate drill down and organizational response. The terms "sentinel" and "error" are not synonymous. Not all serious adverse (sentinel) events occur because of an error, and not all errors result in a serious adverse (sentinel) event. Analysis: Organizational Responsiveness to Quality and Patient Safety Issues + + Q1Q2Q3Q42012 Total All Types Medication Error Procedural Error Infection Allergy Delay in Care 35

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