Call for Storyboards!
The 2014 Quality & Patient Safety Roadmap will feature
keynote speakers, panelists and storyboard sessions focused
on engaging patients and families in eliminating harm across
the board.
Submit your harm across the board storyboard to
share your organization’s experience in eliminating
harm and be featured during the storyboard sessions
at Roadmap! Details on how to complete the storyboard
template and submission details are included in this slide deck.
Please contact slhq@aha.org with any questions.
Eliminating Harm Across the Board (HAB) Template
Objectives
• Understand what the Eliminating HAB report is
and how it is a helpful tool in improving care.
• Understand how to complete your Eliminating
HAB report.
• Understand how to submit your Eliminating HAB
report.
• Know who to contact if you have questions.
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How is Eliminating HAB applicable to SLHQ?
Eliminating
HAB
You
Quality
Improvement
The
Patient
SLHQ &
Roadmap
Eliminating
Harm
PfP,
HENs &
Roadmap
4
Your W(hat’s) I(n) I(t) F(or) M(e): WIIFM
• The Eliminating HAB report will:
• Help shift your organizational culture;
• Put a face on harm;
• Tell a compelling story to support change;
• Promote transparency;
• Engage patients and their families and/or Patient
and Family Advisory Council (PFAC) members;
and
• Help you track your overall harm per discharge
and identify the greatest opportunities for
eliminating harm.
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Eliminating HAB Storyboard Example
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Sharing Your Eliminating HAB Storyboard at Roadmap
In 2013, Roadmap participants
shared their HAB storyboards with
colleagues. In 2014, the Roadmap
HAB storyboards will focus on
engaging patients and families in
eliminating harm.
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The Eliminating HAB Template:
Eight key slides and tips for how to
complete them.
8
Insert Hospital Name Here
Insert Your Motto Here, e.g. “Our Bottom-line Line is Patient Safety”
Slide 1
Customize
the motto
Customize the
team info.
Insert a photo of your
hospital and logo
here.
Insert a photo of your
Safety Team, including your
CEO and PFA(s) here.
Insert a caption here, including the
name of your hospital and the city
and state where you are located.
Insert a caption here, including
the names of your Safety Team,
CEO and PFAs.
Insert a title for your “Total Harms per Discharge” run chart here
e.g., “Cut Harm Across the Board in ½”
Customize
the heading
Slide 2
Insert your
total harm
run chart
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
0.1000
0.0900
0.0800
0.0700
0.0600
0.0500
0.0400
0.0300
0.0200
0.0100
0.0000
Jan-12
Total Harm/Discharge
Total Harm per Discharge
Jan- Feb- Mar Apr- May Jun- Jul- Aug- Sep- Oct- Nov Dec- Jan- Feb- Mar Apr- May Jun- Jul- Aug- Sep- Oct- Nov Dec12 12 -12 12 -12 12 12 12 12 12 -12 12 13 13 -13 13 -13 13 13 13 13 13 -13 13
Baseline 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09
Hospital 0.06 0.07 0.04 0.08 0.02 0.03 0.02 0.04 0.03 0.01 0.01 0.02 0.01 0.01 0.02 0.00 0.01 0.00 0.01 0.00 0.01 0.00
Goal
0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04
Insert a title for your “topic-specific” run chart here
e.g., “2014 Breakthrough in Reducing CAUTI: Journey to Zero”
Customize the heading and slide
based on which specific measure
you want to highlight.
Insert a
topic-specific
run chart
Slide 3
120.0
100.0
80.0
60.0
40.0
20.0
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
CAUTI Rate/1,000 Catheter Days
Catheter Associated Urinary Tract
Infections
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100. 100.
Hospital 105. 66.6 33.3 100. 83.3 45.4 0.00 0.00 52.6 0.00 0.00 52.6 0.00 0.00 52.6 0.00 52.6 0.00 0.00 0.00 0.00 0.00
Goal
60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0
Risk Profile: Areas of Risk We Are Committed To Controlling
Annual discharges: __________ AEA risk opportunities/discharge: _______
Customize the
annual discharges
Slide 4
AEAs
Estimated annual number of patients at risk in each area
ADE
# of discharges:
CAUTI
# pts in IP units with catheter in place:
CLABSI
# pts in IP units with central lines:
Falls
# of discharges:
EED
# of women with elective deliveries
OB
# of women with deliveries:
HAPU
# of discharges:
SSI
# of inpatient surgeries:
VAE
# of patients on a ventilator:
VTE
# of discharges:
TOTAL
Risk opportunities for harm across the board
Readmit.
# of inpatients at risk of readmit:
Customize the risk
opportunities/discharge
Number of Opportunities
Improving Harm Rates (/ Discharge)
Insert a your harm rates per discharge here, using the following table.
For non-applicable topics – please insert “Z”.
Slide 5
AEAs
ADE
Customize
the baseline,
target and
current rates
and
improvement
scale
CAUTI
CLABSI
Falls
EED
OB
HAPU
SSI
VAE
VTE
Total
Readmit.
Baseline Rate
[time period]
Target
Rate
Current Rate
[time period –
last 3 months]
Improvement
Status (scale)
Hospital Risk Score Card
Slide 6
Insert your risk score card here, using the following table:
Our Safety Mandate
Annual Volume (Discharges)
Total risk: annual harm opportunities
Customize
your score
card
Risks per patients (Total Opportunities)/Discharges)
Number of Risk Areas
Number of Risk Areas Applicable (0 – 11)
Number of Risk Areas Applicable & Adopted
Our Progress
Number of Areas with Major Improvement Opportunity
Number of Areas at Improvement Target
Number of Areas at IDEAL
How We Engage Patient/Family Advisors in
Eliminating HAB
Slide 7
Engaging Patient/Family Advisors
Customize the Model for
Improvement, answering the
questions to best describe your
hospital’s eliminating HAB journey
Our Results and Pearls
Slide 8
Results:
Customize
your responses
Pearls:
the
A concise description of what you achieved, as it
relates to eliminating HAB and engaging PFAs.
Bullet your biggest insights about what worked
and how.
- Include what you tested and learned.
- Include how you will advance this topic over
next month (and beyond).
- List the most important drivers of safety that
produced these results. Make this list
succinct, high-level and clear.
- Include the PFA insights, thoughts and feedback
PFA Quote: Insert a PFA quote here about eliminating HAB.
Eliminating HAB Template:
Examples and Tips
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How we Incorporated a Patient/Family Advisor
(PFA) into our Journey to Eliminate HAB
Slide 7 (EXAMPLE)
Patient/Family Advisors
Suggestions for reducing ADE
Reduce the incidence of preventable
adverse drug events
14 ADEs/month to 8 ADEs/month
Have pictures of medications
taken at the bedside for patients
and families
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Our Results and Pearls
Slide 8 EXAMPLE
Results: Reduced ADE by 25% over 6 months.
Pearls:
• Two patient/family advisors were on the ADE committee
• They shared the various ways that they organized
medications at home and suggested that providing patients
with pictures of the pills they were taking in the hospital
(since some looked different than what they were taking at
home) would help patients and families to know what they
were being given and why
• At discharge patients received up to date medication lists
that included pictures
“ I always taped a pill on to the medication list for my father
so he knew what he was taking. It was so meaningful to share
this idea and to see it help other patients”
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Run Chart Tips
• Cut and paste graphs from the improvement
calculator:
o
www.aha-slhq.org / Resources / Using Data for
Improvement
• Customize the heading of each slide
• Utilize labels or a subheader to tell the story
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The Improvement Calculator
Tip: Access the Improvement Calculator here!
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Risk Profile Tips
• These calculations only need to be completed
once
• Use one year of data – using baseline
• For Patient Counts for CLABSI, CAUTI,VAE
o Use charge master for # of catheter trays
ordered, or # of patients with ventilator
charges, or divide your device days by
average length of stay
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Improvement Scale Tips
IDEAL: level represents what we see
as best possible or ZERO harms
At Target: level represents meeting
improvement target
Progress: level not yet at target
Opportunity: level represents an
improvement opportunity
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Hospital Risk Score Card Tips
• Our Safety Mandate: use #’s from Risk Profile
• Number of Risk Areas Applicable - includes
Readmissions (the max. = 11)
• Our Progress: use Improvement Scale definitions
from Improving AEAs per Discharge Slide
• Total Risks per patient: is calculated from total harm
opportunities divided by total discharges per
applicable risk areas, e.g. - if no vents. or births: 8
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Pearl Tips
• Provide enough detail about the strategy or tactic so others
can easily replicate
• Provide examples of key cultural change strategies. For
example:
o Transparency of data
o Front line staff engagement
o Senior management support
o Seamless transitions
o Recognition
o Promoting a Culture of Safety
• Share learnings and ideas tested
• Highlight how strategies be expanded and spread
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Submission Process
•
We encourage you to submit your
Eliminating HAB Report for the upcoming
Quality & Safety Roadmap Meeting, as well
as on our SLHQ Members LISTSERV®:
AHA-SLHQ@ahals.aha.org
•
For more details - please contact us! See
the following slide for contact information.
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Questions? Contact Us!
Website: www.aha-slhq.org
Email: slhq@aha.org
LISTSERV®: AHA-SLHQ@ahals.aha.org
Phone: (773) 270-3127
Office: 155 N. Wacker Dr., Ste. 400
Chicago, IL 60606
Dr. Maulik Joshi: Senior Vice President, AHA and President, HRET (mjoshi@aha.org)
Charisse Coulombe,Vice President, HRET (ccoulombe@aha.org)
Jessica Blake, Senior Program Manager, HRET (jblake@aha.org)
Natalie Erb, Administrative Fellow, HRET (nerb@aha.org)
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