1. Improving Harm Across the Board DODGE COUNTY HOSPITAL 4/17/13 HAB Template Version 12

2. Improving Harm Rates (per discharge) HACs Baseline Rate 2010 Target Rate CAUTI 00% CLABSI 00 Falls 5.72/10005% Ob AE 00 SSI 2% VAP 0%0 VTE 94.8%100% EED 42% MEDICALLY INDICATED Readmit 24.03 15%

3. HACsEstimated annual number of patients at risk in each areaNumber of Opportunities ADE# of discharges: 1464 CAUTI# pt days in IP units with catheter in place: 313 FC days CLABSI# pt days in IP units with central lines: 81 CL days Falls# of discharges: 1464 Ob AE# of women with deliveries: 157 Pr Ulcer# of discharges: 1464 SSI# of inpatient surgeries: 1524 VAP# of patients on a ventilator: 57 VTE# of discharges: 350 EED# of women with elective deliveries 57 TOTALRisk opportunities for harm across the board 1464 Readmit# of inpatients at risk of readmit: 1464 Annual discharges: __2011 - 1464___________ HAC risk opportunities/discharge: ____ Risk Profile: The Areas of Risk We Are Committed To Controlling

4. Improving Harm Rates (per discharge) HACs Baseline Rate 2011 Target Rate Current Rate 2013 Improvement Status (scale) ADE CAUTI 0 CAUTI/ 1000 PT DAYS0 IDEAL CLABSI O CLABSI/1000 PT DAYS00 CLABSI/1000 PT DAYSIDEAL Falls 5.72/1000 PT DAYS2.68 / 1000 PT DAYSTARGET Ob AE 000IDEAL Pr Ulcer 000IDEAL SSI 0.20% 0.20%TARGET VAP 0%0 IDEAL VTE 94.8%100%TARGET EED 42% MEDICALLY INDICATEDALL MEDICALLY INDICATEDTARGET Total Readmit 24.03% 14.02% TARGET

5. Our improvement journey 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______ 5 __________ 0 __________ 0 ___________ Number of risk areas (0-11) at each stage Improvement Scale: The stages we move through

7. PEARLS EARLY ELECTIVE DELIVERY SUCCESS IS ATTRIBUTED TO THE FOLLOWING: 1.Education of OB staff and physicians 2.Education of patients at their OB office 3.The “Heard” effect 4.Hard stop for EEDs at presentation to the OB unit if they wheel out at <39 weeks

9. Pearls READMISSION SUCCESS ATTRIBUTED TO: 1.Bedside pharmacy 2.Collaborative meetings with all three nursing homes in the area 3.Education for physicians/staff 4.Increased patient education at discharge 5.Call backs within 24 hours 6.Collaborative meeting with home health agencies

10. Defining Moment(s) In Our Journey The realization of how important the Quality Director position is in todays market place. We had three directors in one year. 10

11. Breakthrough Strategy Communication with outside agencies was not a focus, we were all working in silos. We overcame this by inviting various agencies into our facility and establishing a better working relationship. Face to face contact is very important to foster good working relationships.

12. Next Big Step to Reduce Harm Continuing our outreach to the community home health agencies, pharmacies, physicians offices, hospice, and nursing homes to build a collaborative health system to improve the continuum of patient care.

13. Kevin Bierschenk, CEO Jan Hamrick, CFO Sandra Campbell, CNO