1. 11/20/2013 1 Georgia Hospital Engagement Network Patient and Family Centered Safe Care Putting Patients First

2. Celebrating Our Success Continuing Our Positive Net Forward Energy

3. 11/20/2013 3 State of the GA HEN

4. 11/20/2013 4 Go Georgia!! We Have Saved So Far….

5. 11/20/2013 5 Georgia’s Improvement Measures Up

6. Georgia Success Stories

7. 11/20/2013 7 Great Partnerships = Great Results!!

8. 11/20/2013 8 Implementing Evidence Works!!!

9. Glycemic Control – Under Control!

10. 11/20/2013 10 INR - Pocket of Excellence

11. 11/20/2013 11 Decreases Need to Be Spread and Sustained

12. 11/20/2013 12 Culture Change in Periop Areas Leads to Lower SSIs

13. Success Then Plateau ….Change is holding at 7.7%

14. Georgia’s readmission rate per 1,000 beneficiaries ranks in the middle of the country

15. Reducing Readmissions -- 2011 – 2012 Progress is being made!

16. Moving Forward in 2014 Success Needs to Spread and Accelerate!!!

17. Moving Forward in 2014 Safety Across the Board for Patients and Staff

18. Safety will not happen without intentional strategy Safety is not in addition to.. it is the strategy

19. 11/20/2013 19 Focus 2014: Safety Strategy Safety Ownership & Accountability for All Leaders (at all levels) change things! All voices heard Align all topics where they intersect Rapid cycle reduction of all harm Adopt first, amend second Standardized tools locally implemented

20. 11/20/2013 20 Net Forward Energy!!!! All Teach, All Learn The Answer Is In This Room!

21. 11/20/2013 21 Leaders Make Change Happen!!!

22. 11/20/2013 22 2014 GHA Board of Trustees Patient Quality and Safety Commitment Your accomplishments resulted in Georgia being one of only six recipients of the Leading Edge Advanced Practice Topics funding. With third-year funding comes a greater emphasis on: – patient and family engagement – eliminating health disparities – enhanced rapid cycle improvement to reduce Catheter Associated Urinary Tract Infections (CAUTI) and readmissions.

23. 11/20/2013 23 Georgia Hospitals Recommit to Goals and Focus Areas Safety Across the Board Meeting 40/20 Goals Reduce Catheter Associated Urinary Tract Infections (CAUTI) – Address the hospital’s culture, criteria, care, competency and communication in reducing CAUTIs. Concentrate on patient and family engagement Reduce Readmission – Use of the 12 point bundle of project RED shown to reduce readmissions which includes, patient education, medication management, and follow-up.

24. 11/20/2013 24 Georgia Hospitals Recommit to Goals and Focus Areas Enhance Patient and Family Engagement (PFE) in Eliminating Health Disparities Prior to admission, hospital staff provides and discusses a discharge planning checklist with every patient who has a scheduled admission, allowing questions or comments from the patient or family (e.g., the planning checklist may be similar to the CMS Discharge Planning Checklist) Hospital conducts shift change huddles and does bedside reporting with patients and family members in all feasible cases. Hospital has a person or functional area, that may also operate within other roles in the hospital, that is dedicated and proactively responsible for patient and family engagement and systematically evaluates PFE activities (e.g., open chart policy, PFE trainings, establishment and dissemination of PFE goals). Hospital has an active PFE Committee OR at least one former patient who serves on a patient safety or quality improvement committee or team. Hospital has at least one or more patient(s) who serve on a governing or leadership board and serves as a patient representative.

25. 11/20/2013 25 Focus 2014: Increasing the Voice of the Patient and Family

26. 11/20/2013 26 Focus 2014: Readmissions

27. 11/20/2013 27 Focus 2014: Readmissions Goal To Reach Our Goal - 9% 9,000 individuals

28. 11/20/2013 28 Focus 2014: Ramp Up Readmissions All 12 components of Project RED 4 Basic Principles of Patient Centered Care

29. 11/20/2013 29 Focus 2014: CAUTI

30. 11/20/2013 30 Focus 2014: Stop CAUTI!! Rapid cycle change to further decrease unnecessary urinary catheter utilization including nurse removal process Focus on ED and OR utilization Adopt then adapt Urinary catheter focus during rounding and bedside handover Observation and inquiry every day to assess necessity Fully engage staff, patients and families in this work HAI Affinity Group webinar : CAUTI: A Hospital Success Story, January 22, 11 -11:45 am

31. 11/20/2013 31 Focus 2014: New Safety Topics OB Adverse Events – Postpartum Hemorrhage – OB Trauma with/without instrumentation ADEs – Opioid Safety HAI – Focus on SSI – VAE (IVAC, Possible, Probable VAP)

32. 11/20/2013 32 Focus 2014: Expanded Data Requests New HAI Data Submission for 2014 – All inpatient CLABSI and CAUTI – Additional SSI: Hip and knee prosthesis – VAE: IVAC, Possible, probable VAP ADE – Opioid Safety Monitor SCIP: VTE:1 and VTE:2 from Core Measure data

33. GAPP /LEAPT : Innovation to Improve Safety Topics Sepsis C. difficle with antimicrobial stewardship Procedural Harm Failure to Rescue Culture of Worker Safety Atlanta Medical Center Chatuge Regional Hospital Crisp Regional Medical Center DeKalb Medical Center Doctors Specialty Hospital Effingham Health System Floyd Medical Center Habersham Medical Center Midtown Medical Center Newton Medical Center Northside Medical Hospital South Georgia Medical Center Spalding Regional Medical Center St. Mary's Healthcare System Ty Cobb Regional Medical Center Union General Hospital University Hospital

34. Call to Action on Sepsis from GAPP Action Required Now to Save Lives!!!! Learn. Act. Improve. Spread

35. 11/20/2013 35 Fighting Sepsis: Actions You Can Take Today to Save Lives Implementing the Surviving Sepsis Campaign Bundles can reduce the mortality from severe sepsis an septic shock. Identify local champions and form a multidisciplinary committee to support bundle implementation: – Consider the ED, Inpatient Staff, ICU, Administration, pharmacy, pediatrics, nursing and infection prevention, etc. Educate your staff and present the evidence. Break it down into manageable pieces and pick an area of focus: – Measure lactate at time of triage for patients who meet SIRS criteria – Reduce time to antibiotics – Administer at least 30ml/kg fluid bolus within three hours

36. 11/20/2013 36 Fighting Sepsis: More Actions You Can Take Today Time is critical! Prioritize pts with SIRS criteria from triage Create protocols and order sets which empower nurses and reduce delays Don’t let a prolonged search for source delay the administration of antibiotics Track your data and provide feedback to providers Let staff know how they are doing & celebrate success

37. 11/20/2013 37 Fighting Sepsis: More Actions You Can Take Today Implement ‘Code Sepsis’ to emphasize the importance of immediate treatment. “Say Sepsis” - use the word sepsis early. Utilize your EHR to create sepsis alerts and order sets – e.g., Link lactate order with blood culture orders so you have to opt out of the lactate measurement Create posters with your sepsis protocol and post them prominently Educate families on red flags–make them a member of the team.

38. 11/20/2013 38 Preparing for 2014 HEN Kickoff : Feb. 6 Request Analyze data, identify units for improvement Have Staff Complete the Staff Safety Assessment Give feedback back to the staff Prioritize work on each unit Bring results with you to kickoff

39. Let’s Celebrate the First 2 Years

40. In appreciation Executive Quality Advisory Committee Steve Mayfield, Medical Center of Central Georgia Mindy McStott, Tift Regional Medical Center Norma Jean Morgan, Effingham Health System Heidi Nelson, University Hospital Teri Newsome, Habersham Medical Center Mary M. Pizzino, Effingham Health System Sherry Sweek, Southeast Georgia Health System Tina Thomas, Ty Cobb Regional Medical Center David Andrews, Patient Advocate, Georgia Regents Medical Center Sheila Bennett, Chair, Floyd Medical Center Susan Bowen, Shepherd Center Montez Carter, Good Samaritan Nicole Franks, MD, Emory University Hospital Midtown Freya Gilbert, Columbus Health Roy Gilbreath, M.D., DeKalb Medical Babs Hargett, Emory Healthcare Angie King, St. Francis Hospital

41. Sharing Our Success Nationally

42. 2013 Leaders Circle Award Winners Congratulations!!

43. Let’s Celebrate Our Work! Thank You for Making Patients Safer!