Improving Harm Across the BoardDODGE COUNTY HOSPITAL

4/17/13HAB Template

Version 12

Improving Harm Rates (per discharge)

HACs Baseline Rate2010

Target Rate

CAUTI 0 0%

CLABSI 0 0

Falls 5.72/1000 5%

Ob AE 0 0

SSI 2% 2%

VAP 0% 0

VTE 94.8% 100%

EED 42% MEDICALLY INDICATED

Readmit 24.03   15%

HACs Estimated annual number of patients at risk in each area Number of Opportunities

ADE # of discharges: 1464

CAUTI # pt days in IP units with catheter in place: 313 FC days

CLABSI # pt days in IP units with central lines: 81 CL days

Falls # of discharges: 1464

Ob AE # of women with deliveries: 157

Pr Ulcer # of discharges: 1464

SSI # of inpatient surgeries: 1524

VAP # of patients on a ventilator: 57

VTE # of discharges: 350

EED # of women with elective deliveries 57

TOTAL Risk opportunities for harm across the board 1464

Readmit # of inpatients at risk of readmit: 1464

Annual discharges: __2011 -1464___________

HAC risk opportunities/discharge: ____

Risk Profile: The Areas of Risk We Are Committed To Controlling

Improving Harm Rates (per discharge)

HACs Baseline Rate2011

Target Rate Current Rate2013

Improvement Status (scale)

ADE

CAUTI 0 CAUTI/ 1000 PT DAYS 0 0 CAUTI/1000 PT DAYS IDEAL

CLABSI O CLABSI/1000 PT DAYS 0 0 CLABSI/1000 PT DAYS IDEAL

Falls 5.72/1000 PT DAYS 2.68 / 1000 PT DAYS TARGET

Ob AE 0 0 0 IDEAL

Pr Ulcer 0 0 0 IDEAL

SSI 0.20% 0 .20% TARGET

VAP 0% 0 0% IDEAL

VTE 94.8% 100% TARGET

EED 42% MEDICALLY INDICATED ALL MEDICALLY INDICATED TARGET

Total

       

Readmit  24.03%    14.02%  TARGET

Our improvement journey

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

____5______

5__________

0__________

0___________

Number of risk areas (0-11) at each stage

Improvement Scale:The stages we move through

PEARLS

• EARLY ELECTIVE DELIVERY SUCCESS IS ATTRIBUTED TO THE FOLLOWING:

1. Education of OB staff and physicians2. Education of patients at their OB office3. The “Heard” effect4. Hard stop for EEDs at presentation to the OB

unit if they wheel out at <39 weeks

PearlsREADMISSION SUCCESS ATTRIBUTED TO:1. Bedside pharmacy2. Collaborative meetings with all three

nursing homes in the area3. Education for physicians/staff4. Increased patient education at discharge5. Call backs within 24 hours 6. Collaborative meeting with home health

agencies

Defining Moment(s) In Our Journey

The realization of how important the Quality Director position is in todays market place.We had three directors in one year.

10

Breakthrough Strategy

• Communication with outside agencies was not a focus, we were all working in silos. We overcame this by inviting various agencies into our facility and establishing a better working relationship.

• Face to face contact is very important to foster good working relationships.

Next Big Step to Reduce Harm

• Continuing our outreach to the community home health agencies, pharmacies, physicians offices, hospice, and nursing homes to build a collaborative health system to improve the continuum of patient care.

Kevin Bierschenk, CEOJan Hamrick, CFO

Sandra Campbell, CNO