improving harm across the board sibley memorial hospital washington, d.c. the sibley mission is to...
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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, RNPeggy Moy, RNMichael Brinkman, RNKathy Guggino
2
2012 Improvement in Readmission*: (54 Fewer Readmitted Patients)
*all cause 30 day readmissions
Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 20130
50
100
150
200
250
211 207
183192
174
195 190180
2012 Improvement in ReadmissionFrom 7.3% to 7.0%
30-Day all cause readmits
All C
ause
30
Day
Ream
its
Sibley Improving Harm Rates
HACs Baseline Rate[CY2011]
Target Rate10% improvement
Current Rate[CY2012]
Improvement Status (scale)
ADE 116/11052= .0104 .0103 122/10617= .0115 Opportunity
CAUTI 11/518=.0212 .0191 9/681=.0132 Exceeds Target
CLABSI 5/639= .0078 .0071 5/556= .0089 Opportunity
Falls 3/11052=.0003 .00027 2/10617=.00018 Exceeds Target
Ob AE 5/3581=.0014 .0013 7/3405=.0020 Opportunity
Pr Ulcer 3/11052=.0003 .00027 1/10617=.0001 Exceeds Target
SSI 47/2525=.0186 .0168 20/2415=.0082 Exceeds Target
VAP 0/216=0 0 0/161=0 Ideal
VTE 13/11052= .0012 .0011 5/10617= .0005 Exceeds Target
EED 0/3581=0 0 0/3405=0 Ideal
Readmit 793/11052=.072 .065 739/10617=.069 Near Target
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
Our Hospital Risk Score Card CY 2012Our Safety Mandate
Annual Volume (Discharges) 10617
Total risk: annual harm opportunities 53091Risks per patients (Total Opportunities)/Discharges) 5.0
Number of Risk AreasNumber of PfP Risk Areas Applicable (0 – 11) 11Number of PfP Risk Areas Applicable & Adopted 7
Our ProgressNumber of PfP Areas with Major Improvement Opportunity 3Number of PfP Areas at Improvement Target 5Number of PfP Areas at IDEAL 2