1. Improving Harm Across the Board Sibley Memorial Hospital Washington, D.C. The Sibley mission is to provide quality health services and facilities for the community, to promote wellness, relieve suffering, and to restore health as swiftly and safely as can be done, consistent with best service. Presenters: Deb McDonough, RN Peggy Moy, RN Michael Brinkman, RN Kathy Guggino

2. 2012 Improvement in Readmission*: (54 Fewer Readmitted Patients) 2 *all cause 30 day readmissions

4. Sibley Improving Harm Rates HACs Baseline Rate [CY2011] Target Rate 10% improvement Current Rate [CY2012] Improvement Status (scale) ADE 116/11052=.0104.0103122/10617=.0115Opportunity CAUTI 11/518=.0212.01919/681=.0132Exceeds Target CLABSI 5/639=.0078.00715/556=.0089Opportunity Falls 3/11052=.0003.000272/10617=.00018Exceeds Target Ob AE 5/3581=.0014.00137/3405=.0020Opportunity Pr Ulcer 3/11052=.0003.000271/10617=.0001Exceeds Target SSI 47/2525=.0186.016820/2415=.0082Exceeds Target VAP 0/216=000/161=0Ideal VTE 13/11052=.0012.00115/10617=.0005Exceeds Target EED 0/3581=000/3405=0Ideal Readmit 793/11052=.072.065 739/10617=.069 Near Target

6. Pearls Engagement of frontline staff in CUSP (Comprehensive Unit-Based Safety Programs) Use of proactive risk assessment to evaluate availability of assistive devices and equipment on all inpatient units Development of Safe Patient Handling Protocol

7. Our Hospital Risk Score Card CY 2012 Our Safety Mandate Annual Volume (Discharges)10617 Total risk: annual harm opportunities53091 Risks per patients (Total Opportunities)/Discharges)5.0 Number of Risk Areas Number of PfP Risk Areas Applicable (0 – 11)11 Number of PfP Risk Areas Applicable & Adopted7 Our Progress Number of PfP Areas with Major Improvement Opportunity3 Number of PfP Areas at Improvement Target5 Number of PfP Areas at IDEAL2