Improving Harm Across the Board
Northridge Medical Center
Commerce, GA
Selina Baskins, RN, Quality Coordinator
HEN PARTIES
Hospital
Engagement
Network
Preventing
Avoidable
Readmissions
Through
Interactive
Engaged
Staff
Harms/1,000 discharges
2013 Breakthrough in Reducing HAC HARM*:
96.3 to 62.9 harms/1,000 discharges
103 106 111
120
100
86
80
60
64
51
62
63
61
71
70
57
54
49
40
20
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2010
2011
2012
2013
Timeframe
Quarter - Year
*HAC harm = inpatient hospital acquired conditions
3
Cut “harm across the board” in 2013:
32.5 patients per quarter to 24
Total # of Harms
Total Harms by Quarter
40
35
30
25
20
15
10
5
0
35
16
19
16
16
19
37
32
23
15
28
26
20
14
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2010
2011
Timeframe
Quarter - Year
2012
2013
4
2012 Breakthrough in Readmission*:
From 20% of discharges to 10% of discharges
Slide 5
Source: GCMF Database
All Cause Readmissions to GA Hospitals, GA Medicare Patients only
2012 Breakthrough in Reducing Readmissions
6
Pearls
• Very supportive Nurse Leaders
• We implemented the GHA HEN project ideas to set
our standards.
• We chose things easy to achieve first
• Chose key personnel to be our champions.
• Falls tree on both inpatient units with a reward
system to create a little competition.
• Heightened awareness in the ED for nurses to check if
the patient had any alternative care options rather
than being a readmission.
Falls Tree on Northeast Wing
Defining Moments In Our Journey
We decided that our base topic was to make everything
that was required FUN!!
4/4/12 In-services for all clinical staff
• Decorated the room with Easter eggs
• Easter eggs were filled with door prizes
• Powerpoint presentation that focused on
Readmissions and Falls
• All were required to do the chicken dance!
9
Defining Moments in Our Journey
7/24/13 HEN PARTIES Picnic
• Included several familiar items as Fried Chicken,
Deviled Eggs, and Egg Custard Pie!
• After eating each clinical staff member had to
participate in a mini inservice related to best
practices to prevent falls and reduce readmissions.
Breakthrough Strategy
• The biggest challenge: Physician “Buy In”
• Concurrent chart review daily intervention with
physicians and staff.
• Have one Hospitalist as our “Champion”. Share
Specification Manual for specific documentation
needed and he not only does it, but shares with the
other physicians to help meet requirements.
Dr Kenneth O’Neal, Hospitalist
Our HEN Physician Champion
Risk Profile: The Areas of Risk We Are Committed To Controlling
slide13
Annual discharges:
1349
HAC risk opportunities/discharge: 8.95
HACs
Estimated annual number of patients at risk in each area
Number of Opportunities
CY 2012
ADE
# of discharges:
1349
CAUTI
# pts in IP units with catheter in place:
480
CLABSI
# pts in IP units with central lines:
60
Falls
# of discharges:
1349
Pr Ulcer
# of discharges:
1349
SSI
# of inpatient surgeries:
120
VAP
# of patients on a ventilator:
22
VTE
# of discharges:
1349
TOTAL
Risk opportunities for harm across the board
12078
Readmit
# of inpatients at risk of readmit:
1349
Our improvement journey
Slide 14
Improvement Scale:
The stages we move through
Number of risk areas
(0-11) at each stage
IDEAL: level represents zero harm
____5_____
At Target: level represents meeting
improvement target
__________
Progress: level shows movement
but not yet at target
____1_____
Opportunity: level is an opportunity
to launch aggressive action
____2______
Improving Harm Rates (per discharge)
HACs
Baseline Rate
CY2012
Target Rate
.0267
0
CAUTI
0
0
CLABSI
0
0
Falls
.0689
0
Pr Ulcer
.0007
0
SSI
0
0
VAP
0
0
VTE
0
0
Total
.0964
0
Readmit
.1692
0
ADE
Where the journey
began…
• Falls and ADE had the
largest room for
improvement
• Several areas already
meeting the target of
zero harms
Improving Harm Rates (per discharge)
Baseline Rate
2010
Target Rate
Current Rate
Q1&Q2 2013
Improvement
Status (scale)
.0322
0
.0118
Progress
CAUTI
0
0
0
Ideal
CLABSI
0
0
0
Ideal
.0277
0
.0498
Opportunity
Pr Ulcer
0
0
.0013
Opportunity
SSI
0
0
0
Ideal
VAP
0
0
0
Ideal
VTE
0
0
0
Ideal
Total
.0599
0
.0629
Readmit
.1610
0
.1690
HACs
ADE
Falls
Opportunity
Our Hospital Risk Score Card
Our Safety Mandate
Annual Volume (Discharges)
1349
Total risk: annual harm opportunities
12078
Risks per patients (Total Opportunities / Discharges)
8.95
Number of Risk Areas
Number of PfP Risk Areas Applicable (0 – 11)
8
Number of PfP Risk Areas Applicable & Adopted
8
Our Progress
Number of PfP Areas with Major Improvement Opportunity
2
Number of PfP Areas at Improvement Target
5
Number of PfP Areas at IDEAL
5
OUR TEAM:
Richard L. Clark, Interim CEO
Maura Cobb, CNO, RN, MBA
Larry Ebert, CFO
Dr Kenneth O’Neal, Hospitalist
Selina Baskins, RN, Quality Coordinator
Rita Brunner, RN, ICU Coordinator
Mary Kathryn Warnock, RN, Med-Surg Unit Coordinator
Jim Hennes, RN, Willow Brook Unit Coordinator
Tabitha Evans, RN, Case Management
Sheila Embrick,RN, Nursing Supervisor
Rachel Kean, RN, Surgical Services Coordinator
Cindy Smith, RN, ED Unit Coordinator
Lois McMahon, RN, Northridge Health and Rehab DON
Our Motto:
“HEN PARTIES”
Hospital Engagement Network Preventing Avoidable
Readmissions Through Interactive Engaged Staff
Slide 19
Next big step to Reduce Harm
Our next big step will be to initiate
A Passion for Patients Committee Meetings.
This will not only include frontline staff, but also Case
Management, local Home Health, Hospices, and Patient
or Patient Representatives to help evaluate our
processes at a higher standard.