1. Improving Harm Across the Board

2. TEMPLATE GUIDE Treat harms as events that can be summed Focus on harms (outcomes) rather then preventive measures (process) Special conditions can be considered a harm (e.g., EED, Readmits, …) Produce an overall harm trend for the hospital (**Delete this slide when content of presentation is complete)

3. 2012 Breakthrough in Reducing HARM: 250 to 50 harms/1,000 discharges 3 WHA has created a excel template for all 4 graphs in this template

4. Cut “harm across the board” in half: 60 patients per quarter to under 30 4 WHA has created a excel template for all 4 graphs in this template

5. 2012 Breakthrough in Readmission: From 20% of discharges to 10% of discharges 5 WHA has created a excel template for all 4 graphs in this template

6. 2012 Breakthrough in Reducing Readmissions: From 20 per quarter to 10 per quarter 6 WHA has created a excel template for all 4 graphs in this template

7. Pearls Please list the drivers of safety that produced these results. Include one about patient and family engagement, if relevant

8. Defining Moment(s) In Our Journey Name and date one or two defining moments. Moments that caused the organization to commit to extraordinary safety. Moments that resulted in a big breakthrough in the organization’s ability to deliver safety. 8

9. Strategies to Drive Results What challenges did you encounter that you were able to overcome to achieve the results you are presenting here? What were the strategies you used to overcome them?

10. Risk Profile by Areas of Risk HACsEstimated annual number of patients at risk in each areaNumber ADE# of inpatients: CAUTI# pts in IP units with catheter in place: CLABSI# pts in IP units with central lines: Falls# of discharges: Ob AE# of women with deliveries: Pr Ulcer# of discharges: SSI# of applicable surgical pts: VAP# of patients on a ventilator: VTE# of inpatients: EED# of women with elective deliveries TOTALRisk opportunities for harm across the board Readmit# of inpatients at risk of readmit:

11. Improving Harms by HAC Scale: number of hospital-acquired conditions (HACs) at each level – IDEAL: level represents what we see as best possible – At Target: level represents meeting improvement target – Progress: level not yet at target – Opportunity: level represents an improvement opportunity (**Delete this slide when content of presentation is complete)

12. Improving HAC Rates (per discharge) HACs Baseline [time period] Target Current [time period] Improvement Status (scale) ADE (Med Rec, Anticoagulant or Insulin – Choose one) CAUTI CLABSI Falls Ob AE Pr Ulcer SSI VAP VTE EED Readmissions TOTAL

13. Our Hospital Risk Profile & Result Annual Volume (Discharges) Total risk: annual harm opportunities Risks per patients (Total Opportunities)/Discharges) Number of PfP Harm Areas Applicable (0 – 11) Number of PfP Harm Areas Applicable & Adopted Number of PfP Areas at Improvement Target Number of PfP Areas at IDEAL

14. Future Actions to Reduce Harm What other actions will you take to reduce harm in the future?

15. Photo of Hospital CEO & Safety Team