Hospital Harm Index Presentation to MAPS Exploratory Work Group for Tracking Safety Progress April 10, 2013

November 30, 1999: The Institute of Medicine Committee on Quality of Health Care in America announces its first report: To Err is Human: Building a Safer Health System 2

Care-associated injuries in hospitals account for 44,000 – 98,000 preventable deaths per year in the United States More people die from hospital-based preventable medical injuries than from breast cancer or AIDS or motor vehicle accidents Brennan et al. New Engl J Med 1991 Thomas et al.1999 Injuries drive direct health care costs totaling $9 – 15 billion per year Thomas et al.1999 Johnson et al

Key Findings in IOM report: Injuries occur because of system failures Preventing injuries means designing safer systems of care Organizations, not individual physicians and nurses, control those systems of care 4 Committee on Quality of Health Care in America. To Err is Human. Institute of Medicine, 2000.

Harm Index Harm Index was developed to provide a single value that reflects the priority focus adverse events. The measurement shows the variance from expected, displayed as a single composite. Expected events are goal values, based on historical performance and targets Harm Index = Actual Events – Expected Events

Priority Focus Adverse Events Inpatient Falls With Harm Clostridium difficile (C-Diff) Cent. Line Assoc. Blood Stream Infection (CLABSI) Catheter Assoc. Urinary Tract Infections (CAUTI) Wrong Site Surgery/Procedure Pressure Ulcers 6

7 Harm Index Calculations – Hospital Level Allina Health HospitalJanuary 2013 Hospital Level Falls Goal = 0.76 Harmful Falls / 1,000 Patient Days 0.76 Inpatient Days15,096 Expected Falls Based on Days (0.76 x (15,096 /1,000)) = Actual Harmful Falls Jan Lives Positively Affected (Harm Index) 2.5 The following table shows actual January 2013 results, of the harm index calculation for falls for a single Allina Health Hospital.

Harm Index Calculations – Hospital Level Clostridium difficile Reduce CDI run rate from 8.72 per 10,000 patient days to 7.2 CDI per 10,000 patient days. Utilizes the same basic calculation as falls (Actual C. diff Patients - (Goal x (Days / 10,000))) Catheter Assoc. Urinary Tract Infection Reduce CAUTI pooled rate to 3.0 per 1,000 catheter days in specific areas. (Actual CAUTI Pts – (Goal x (Cath Day / 1,000)))

Harm Index Calculations – Hospital Level Wrong Site Surgery Achieve absolute zero (Actual Wrong Site Patients – 0 Expected) Pressure Ulcer Reduce reportable pressure ulcers Number of reportable PU <= 10 annually (Actual Reportable PU – 10 Expected) Central Line Assoc. Blood Stream Infections Reduce to 25 th percentile of national rate Number of CLABSI <= 4 annually (Actual CLABSI Patients – 4 Expected)

Other Patient Safety Indicators 1. Hand Hygiene Compliance 2. # PVSRs Reported (Voluntary Incident Reporting System) 3. Effective Opioid Management (Clinics) In Addition: 1. 3 Years of AHRQ Patient Safety Culture Survey (Hospitals) 2. 2 Years of AHRQ Patient Safety Culture Survey (Clinics) 10