Improving Harm Across the Board
Kathleen M. Louth
Director of Quality Management
Monroe County Hospital
P. O. Box 1068
Forsyth, GA 31029
478.994.2521 ext. 2150
klouth@monroehospital.org
Hospital Trend Rate in Reducing Harm
Harms/1,000 discharges
30%
25%
20%
15%
10%
5%
0%
Q1 11 Q2 11 Q3 11 Q4 11 Q1 12 Q2 12 Q3 12 Q4 12 Q1 13
*HAC harm = inpatient hospital acquired conditions
2
Number of Harms
10
9
8
7
6
5
4
3
2
1
0
Q1 11
Q2 11
Q3 11
Q4 11
Q1 12
Q2 12
Q3 12
Q4 12
Q1 13
3
30 Day Total Readmission Rate All Cause
30%
27.91%
25%
21.28%
20%
15%
18.00%
16.36%
13.16%
12.96%
11.11%
10%
9.09%
9.52%
5%
0%
Q1 11
Q2 11
Q3 11
Q4 11
Q1 12
Q2 12
Q3 12
Q4 12
Q1 13
*all cause 30 day readmissions
4
Number of Readmissions All Cause
14
12
12
10
10
9
9
8
7
6
6
5
4
4
4
2
0
Q1 11
Q2 11
Q3 11
Q4 11
Q1 12
Q2 12
Q3 12
Q4 12
Q1 13
5
Pearls
Multidisciplinary
•It is not just the work of the Quality Improvement Department; all
departments must be involved
• Must be a collaborative effort from the top-down and bottom-up
• Increased communication and input from management staff
Assign ownership and expectations
• Establish timelines for project deliverables
•Continue to meet with definite reporting timeframes
Educate
•Keep the staff, medical staff, and board informed
Defining Moments In Our Journey
Defining Moments & Commitment to Patient Safety:
• 2009-New CEO who had experience in Quality & Patient Safety; new
Director of Quality Management hired
• 2010- Patient Safety Plan & Commitment to Patient Safety developed;
revised incident reporting system & tools; fall team formed; medication error
team formed; Quality Council & reporting revised; education of changes to all
(hospital wide); Culture of Patient Safety Survey implemented; Patient Safety
Week recognized
•2011-Fall prevention program revised; education of changes to all (hospital
wide); Glycemic Control team formed; CLABSI team formed
7
Defining Moments In Our Journey
• 2012- Participation in the Hospital Engagement Network (HEN) &
education to management team; Regrouped on readmissions due to data
issues; formation of Readmission Reduction team; OATS team formed;
HCAHPS training; CAUTI team formed; Marketing of Patient Safety through
website, banners, boards, & local newspaper
• 2013-Strategies to reduce readmissions implemented-bedside shift
reporting, white boards, rounding (hourly, nurse manager, leadership),
discharge follow up calls, follow up appointments made, discharge folder,
pharmacist educating high risk patients, follow up calls for ER patients,
working with hospice and home heath agencies, participating in GMCF
Care Transitions, participating in MATCH, Patient & Family Engagement;
Case Manager position job duties aligned with reducing readmission
efforts to include discharge process
Breakthrough Strategy
• Major Challenges Encountered
–
–
–
–
Limited Resources (human, time, financial)
Implementation of EHR
Culture change
Training
• Strategies to Overcome
–
–
–
–
Time management, utilizing resources from the HEN
Constant education and re- education, dedicated point person for EHR
Reinforcement of rationales, hearing stories from peers at other facilities
Make it fun, pertinent, convenient, personal, and using personalized teaching
methods
Risk Profile: The Areas of Risk We Are Committed To Controlling
Annual discharges: 378 year 2010
Slide 10
HAC risk opportunities/discharge: 4.37
HACs
Estimated annual number of patients at risk in each area
Number of Opportunities
ADE
# of discharges:
378
CAUTI
# pts in IP units with catheter in place:
127
CLABSI
# pts in IP units with central lines:
0
Falls
# of discharges:
378
Ob AE
# of women with deliveries:
0
Pr Ulcer
# of discharges:
378
SSI
# of inpatient surgeries:
15
VAP
# of patients on a ventilator:
0
VTE
# of discharges:
378
EED
# of women with elective deliveries
0
TOTAL
Risk opportunities for harm across the board
1654
Readmit
# of inpatients at risk of readmit:
378
Slide 11
Our improvement journey
Improvement Scale:
The stages we move through
Number of risk areas
(0-11) at each stage
IDEAL: level represents zero harm
7
At Target: level represents meeting
improvement target
1
Progress: level shows movement
but not yet at target
0
Opportunity: level is an opportunity
to launch aggressive action
0
Improving Harm Rates (per discharge)
HACs
Baseline Rate
[2010]
Target Rate
ADE
0%
0%
CAUTI
0%
0%
CLABSI
0%
0%
Falls
0%
0%
Ob AE
0%
0%
Pr Ulcer
0%
0%
SSI
0%
0%
VAP
0%
0%
VTE
0%
0%
EED
0%
0%
Total
0%
0%
Readmit
15.15%
15.24%
Improving Harm Rates (per discharge)
HACs
Baseline Rate
[2010]
Target Rate
Current Rate
[2012]
Improvement
Status (scale)
ADE
0%
0%
0%
IDEAL
CAUTI
0%
0%
0%
IDEAL
CLABSI
0%
0%
0%
IDEAL
Falls
0%
0%
0%
IDEAL
Ob AE
0%
0%
0%
N/A
Pr Ulcer
0%
0%
0%
IDEAL
SSI
0%
0%
0%
IDEAL
VAP
0%
0%
0%
N/A
VTE
0%
0%
0%
IDEAL
EED
0%
0%
0%
N/A
Total
0%
0%
0%
IDEAL
Readmit
15.15%
15.24%
14.47%
Target
Our Hospital Risk Score Card
Our Safety Mandate
Annual Volume (Discharges)
378
Total risk: annual harm opportunities
1654
Risks per patients (Total Opportunities)/Discharges)
4.37
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
0
Number of PfP Areas at Improvement Target
1
Number of PfP Areas at IDEAL
7
Pictured 1st row left to right:
Shawnelle Lupton, Operating Room Nurse Manager; Dr. Dana Peterman, PT, DPT; Casey Fleckenstein,
Medical/Surgical Nurse Manager
Pictured 2nd row left to right:
Dr. Craig Caldwell, Past President of the Medical Staff/Hospital Authority Board Member; Sherry Mays, Clinical
Coordinator; Kathleen Louth, Director of Quality Management; and Tim Allen, Director of Engineering and
Environmental Services.
Not pictured:
Kay Floyd, CEO; Tony Ussery, Chairman of the Quality Council/Vice Chairman of the Hospital Authority Board;
Megan Randall, Director of Radiology; Pam Lankford, Emergency Room Nurse Manager; Hugh Cromer, Director
of Pharmacy; Laura Roush, Director of Laboratory; Jean Riley, Director of Respiratory Therapy/Infection Control;
Cindy Renno, Dietary Manager; Ticia Hicks, Case Management; Michelle Wiggins, Swing Bed Coordinator; and
Mamie Patterson, Diabetes Support Group.
Next big step to Reduce Harm
• Continue our efforts that we already started
• Enhance patient & family engagement
• Implement teach back