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

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

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

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

5. 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

6. 2012 Breakthrough in Reducing Readmissions

7. 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.

8. Falls Tree on Northeast Wing

9. 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

10. 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.

11. 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.

12. Dr Kenneth O’Neal, Hospitalist Our HEN Physician Champion

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Slide 19

20. 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.