4/17/13
HAB Template
Version 12
Improving Harm Across the Board
Harms/1,000 discharges
2012 Breakthrough in Reducing HAC HARM*:
250 to 50 harms/1,000 discharges
350
300
250
200
150
100
50
0
Q1
Q2
Q3
2010
Q4
Q1
Q2
Q3
2011
Timeframe
Quarter - Year
Q4
Q1
Q2
2012
*HAC harm = inpatient hospital acquired conditions
2
Cut “harm across the board” in half:
60 patients per quarter to under 30
Total # of Harms
Total Harms by Quarter
100
80
60
40
20
0
55
56
64
66
78
52
58
57
30
12
Q1
Q2
Q3
2010
Q4
Q1
Q2
Q3
2011
Timeframe
Quarter - Year
Q4
Q1
Q2
2012
3
2012 Breakthrough in Readmission*:
From 20% of discharges to 10% of discharges
Readmission: % Discharges
25
% Discharges
20
15
10
5
0
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
*all cause 30 day readmissions
4
2012 Breakthrough in Reducing Readmissions:
From 20 per quarter to 10 per quarter
Number Readmissions
Readmissions
25
20
15
10
5
0
Q1
Q2
2011
Q3
Q4
Q1
Q2
Q3
Q4
2012
5
Pearls
Your biggest insights about what worked, what
caused it to work.
• Please list the few most important drivers of
safety that produced these results.
• Include patient and family engagement, if
relevant
Defining Moment(s) In Our Journey
Name and date one or two defining moments.
• Moments that caused the organization to
commit to extraordinary safety.
• Moments that resulted in a big breakthrough
in the organization’s ability to deliver safety.
7
Breakthrough Strategy
• What major challenge did you encounter that
you were able to overcome to achieve the
results you are presenting here?
• What was the strategy you used to overcome
the challenge?
Risk Profile: The Areas of Risk We Are Committed To Controlling
Annual discharges: _____________
HAC risk opportunities/discharge: ____
HACs
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:
Ob AE
# of women with deliveries:
Pr Ulcer
# of discharges:
SSI
# of inpatient surgeries:
VAP
# of patients on a ventilator:
VTE
# of discharges:
EED
# of women with elective deliveries
TOTAL
Risk opportunities for harm across the board
Readmit
# of inpatients at risk of readmit:
Number of Opportunities
Our improvement journey
Improvement Scale:
The stages we move through
Number of risk areas
(0-11) at each stage
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
___________
Improving Harm Rates (per discharge)
HACs
ADE
CAUTI
CLABSI
Baseline Rate
[time period]
Target Rate
Where the journey began
-- comment on baseline
and target as challenge:
Falls
Ob AE
Pr Ulcer
SSI
• Note which areas
represented biggest
challenges.
VAP
VTE
EED
Total
Readmit
• Note areas of strength
at the beginning.
Improving Harm Rates (per discharge)
HACs
ADE
CAUTI
CLABSI
Falls
Ob AE
Pr Ulcer
SSI
VAP
VTE
EED
Total
Readmit
Baseline Rate
[time period]
Target Rate
Current Rate
[time period]
Improvement
Status (scale)
Our Hospital Risk Score Card
Our Safety Mandate
Annual Volume (Discharges)
Total risk: annual harm opportunities
Risks per patients (Total Opportunities)/Discharges)
Number of Risk Areas
Number of PfP Risk Areas Applicable (0 – 11)
Number of PfP Risk Areas Applicable & Adopted
Our Progress
Number of PfP Areas with Major Improvement Opportunity
Number of PfP Areas at Improvement Target
Number of PfP Areas at IDEAL
Names of CEO & Safety Team
Photo of Hospital CEO & Safety Team
Our Motto
Next big step to Reduce Harm
• What is the next big step your team will
take to reduce harm in the future?