1. Slide 1 1 Eliminating Harm Across the Board Mary M. Pizzino, Executive Director, Informatics/Quality Data Management

2. Slide 2 2 Our Mission To provide access and delivery of quality, cost effective, community based healthcare to all the citizens of Effingham County. Our Vision Every patient will experience compassionate, quality care and service at a level of excellence that will make Effingham Health System the healthcare provider of choice. Our Valued Principles We believe the success of Effingham Health System is directly related to the values we hold, share, and practice. These values must form the basis for every action we take toward patients, families, physicians, volunteers, and each other with commitment to: Quality Service Compassion Leadership Education Accountability Teamwork Creativity

3. Adverse Drug Events (ADE) 3

4. Readmissions –All cause 4

5. Pearls  Collaboration from Medical Staff  Involvement of multi-disciplinary team members  Education of staff  Commitment from Administration  Standardization of E.H.R. 5

6. Defining Moment(s) In Our Journey  2012: Realization that all ADE’s were not being included in our data collection. Implementation of remote Pharmacy Medication Management in-service Increase of ADE reporting by nurses Computer Based Learning Modules  2012: Realization that the discharge instructions were not always understood/followed by the patient. Review of all readmissions Identified the top ten re-admission diagnoses Developed post-discharge call backs by nursing Reviewed/revised patient education Implemented pharmacy rounding 6

7. Breakthrough Strategy  ADE: Encouraging nursing to view reporting as an opportunity to improve patient safety; not as a “black mark” on their individual performance.  Readmissions: Helping nursing understand that patient education does not end at the time of discharge. 7

8. Slide 8 8 HACsEstimated annual number of patients at risk in each areaNumber of Opportunities ADE# of discharges: 239 CAUTI# pts in IP units with catheter in place: 45 CLABSI# pts in IP units with central lines: 10 Falls# of discharges: 239 Pr Ulcer# of discharges: 239 SSI# of inpatient surgeries: 90 VTE# of discharges: 239 TOTALRisk opportunities for harm across the board 1101 Readmit# of inpatients at risk of readmit: 239 Annual discharges: _239__ __________ HAC risk opportunities/discharge: 4.60 % Risk Profile: The Areas of Risk We Are Committed To Controlling

9. OUR IMPROVEMENT JOURNEY: It’s all about “always” giving the best possible care. IDEAL: level represents zero harm At Target: level represents meeting target for improvement Progress: level shows improvement but not yet at target Opportunity: level is an opportunity to launch aggressive action for improvement 5 __________ 0 __________ 2 __________ 1 ___________ Number of risk areas (0-11) at each stage Improvement Scale: The stages we moved through Slide 9 9

10. Getting to ZERO Harm HACs Baseline Rate 2012 Target Rate *ADE 102 Reduce by 40% CAUTI 0IDEAL CLABSI 0 IDEAL Falls 3 Reduce by 40% Pr Ulcer 0 IDEAL SSI 1Target VTE 0 IDEAL Total 10642 *Readmissions 9 3 Our journey began in 2012 with a base rate of 239 annual Inpatient discharges. ADE’s, Falls and Readmissions were areas for improvement HAI (Hospital Acquired Infections) is an area of strength. Our clinical staff is diligent following infection control protocols/processes. 10

11. Improving Harm Rates (per discharge) HACs Baseline Rate 2012 Target Rate Current Rate QTR 1 & 2 2013 Improvement Status (scale) ADE 102REDUCE BY 40%61 =59% OPPORTUNITY CAUTI 0REDUCE BY 40%0 IDEAL CLABSI 0REDUCE BY 40%0 IDEAL Falls 3REDUCE BY 40%1 = 33% OPPORTUNITY Pr Ulcer 0REDUCE BY 40%0 IDEAL SSI 1REDUCE BY 40%0 IDEAL VTE (POST OP) 0REDUCE BY 40%0 IDEAL Total 106 REDUCE BY 40% 62PROGRESS Readmit 9 REDUCE BY 20% 1.8 1 PROGRESS 11

12. Our Hospital Risk Score Card Our Safety Mandate Annual Volume (Discharges) 2012239 Total risk: annual harm opportunities1101 Risks per patients (Total Opportunities)/Discharges)4.60 Number of Risk Areas Number of PfP Risk Areas Applicable (0 – 11)8 Number of PfP Risk Areas Applicable & Adopted8 Our Progress Number of PfP Areas with Major Improvement Opportunity3 Number of PfP Areas at Improvement Target0 Number of PfP Areas at IDEAL5 12

13. Norma Jean Morgan, CE0Joseph Ratchford, MD, Quality Medical Director Claude Sanks III,MD, Hospitalist*Mary Pizzino, Exec. Dir. of Informatics/Quality *James Edwards, RN, Quality and Risk Management *Sara Corley, RN Quality Nurse *Jeff Boswell, RN Informatics NurseDurwin Logan, Director of Pharmacy *Linda Rigsby, RN, Nursing CouncilShirley Rahn, RN, Nursing Council *Amy Roddenberry, RN, Senior Staff NurseJane Miller, Infection Preventionist Erin Conway, Core Measure Coordinator*Monica Jones, Data Resource Specialist Matthew Moore, Decision Support*Denika O’Rourke-Systems Trainer *Karen Harden O’Neal, HIM Coordinator Marie Livingstone, CNO *Pictured Team Member’s QUALITY AND PATIENT SAFETY TEAM 13

14. Next steps to Reduce Harm  Implementing additional protocols for patient care  Increasing the use of CPOE (computerized physician order entry) to assist in the reduction of medication errors  Implementing standardized order sets  Implementing Electronic physician documentation to improve patient care and reduce errors due to illegibility 14

15. Slide 15 15 QUESTIONS?