1. Best Care – Best Way – Every Patient – Every Day

2. Cut “harm across the board” by 37% 2

3. 2012 Breakthrough in Readmission: From 246 to 144

4. Reduced 30 Day Readmission Rate From 9% to 5%

5. Drivers of safety that produce these results include: Patient and family engagement - Caught You Washing” cards - “Turn” signals throughout hospital - Joint Camp/Heart Camp Physician led improvement efforts. Empowering staff to “speak up” in the interest of safety leads to a culture of safety. Pearls

6. Pearls (continued) Development of best practice protocols and checklists. This can lead to recognition for disease specific certifications. Providing data to direct caregivers and involving them in developing improvement plans. For instance, stratifying why patients are non-compliant leads to process changes that impact their care. For example: The Heart Failure patient readmitted because they do not have funds to fill prescriptions or do not have a private physician to follow up with for care.

7. Defining Moment In Our Journey A landmark was reached with VAP compliance when we went 884 days with ZERO VAP cases! Staff realized they could get to zero Staff realized they could reduce harm We began tracking on our Intranet in real time – this was a commitment to transparency 7

8. Risk Profile: The Areas of Risk We Are Committed To Controlling Annual discharges: 10,756 HAC risk opportunities/discharge: 5.55 Slide 8 HACsEstimated annual number of patients at risk in each areaNumber of Opportunities ADE# of inpatients:10,756 CAUTI# pts in IP units with catheter in place:1,613 CLABSI# pts in IP units with central lines:6,445 Falls# of discharges:10,756 Ob AE# of women with deliveries:0 Pr Ulcer# of discharges:10,756 SSI# of applicable surgical pts:9,013 VAP# of patients on a ventilator:1,310 VTE# of inpatients:9,013 EED# of women with elective deliveries0 TOTALRisk opportunities for harm across the board59,662 Readmit# of inpatients at risk of readmit:10,756

9. Our improvement journey Improvement Scale: The stages we move through 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 Number of risk areas (0-9) at each stage _____4_____ _____2_____ _____0____ _____3_____ Slide 9

10. Improving Harm Rates (per discharge) HACs Baseline Rate [2010] Target Rate ADE 0.0040.003 CAUTI 0.0030.002 CLABSI 0.0010.000 Falls 0.0120.011 Pr Ulcer 0.0030.002 SSI 0.0040.003 VAP 0.000 VTE 0.0100.009 Total 0.0370.030 Readmit 0.0660.056 Areas of strength at the beginning were CLABSI and VAP Areas that represented biggest challenges were all others

11. Improving Harm Rates (per discharge) HACs Baseline Rate [2010] Target Rate Current Rate [Q1 – Q2 2012] Improvement Status ADE 0.0040.0030.006Opportunity CAUTI 0.0030.0020.000Ideal CLABSI 0.0010.000 Ideal Falls 0.0120.0110.013Opportunity Pr Ulcer 0.0030.0020.000Ideal SSI 0.0040.0030.002At Target VAP 0.000 Ideal VTE 0.0100.0090.011Opportunity Total 0.0370.0300.032 Readmit 0.0660.0560.047At Target

12. Our Hospital Risk Score Card Our Safety Mandate Annual Volume (Discharges)10,756 Total risk: annual harm opportunities59,662 Risks per patients (Total Opportunities)/Discharges)5.55 Number of Risk Areas Number of PfP Risk Areas Applicable (0 – 11)9 Number of PfP Risk Areas Applicable & Adopted9 Our Progress Number of PfP Areas with Improvement Opportunity3 Number of PfP Areas at Improvement Target2 Number of PfP Areas at Progress0 Number of PfP Areas at Ideal4 Slide 10

13. Hospital CEO and Safety Team

14. Next Big Step to Reduce Harm Hardwiring safety tools to impact daily operations Teamwork training utilizing proven patient safety methodologies Training in clinical processes to impact patient safety and quality, creating greater efficiency and reliability