HAB Template: A Leadership Story Part 1 (Slide 1): Who we are Part 2 (Slides 2-5): Our results on HAB (HAC + Readmissions) Part 3 (Slides 6-8): Insights:

HAB Template: A Leadership StoryPart 1 (Slide 1): Who we are

Part 2 (Slides 2-5): Our results on HAB (HAC + Readmissions)

Part 3 (Slides 6-8): Insights: Pearls, Defining Moments, Breakthrough Strategy

Part 4 (Slides 9-13): Our improvement worksheet and score card

Part 5 (Slides 14-15): Our team, Our next Step

Part 1

Who We Are

Improving Harm Across the Board

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4/17/13HAB Template

Version 12

Part 2

Our results on HAB (HAC + Readmissions)

2012 Breakthrough in Reducing HAC HARM*: 250 to 50 harms/1,000 discharges

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q22010 2011 2012

050

100150200250300350

TimeframeQuarter - Year

Har

ms/

1,00

0 d

isch

arg

es

5

*HAC harm = inpatient hospital acquired conditions

Cut “harm across the board” in half: 60 patients per quarter to under 30

6

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2010 2011 2012

020406080

100

55 56 64 6652 58

7857

3012

Total Harms by Quarter

TimeframeQuarter - Year

To

tal

# o

f H

arm

s

2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges

7

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q40

5

10

15

20

25

Readmission: % Discharges

2011 2012

% D

isch

arge

s

*all cause 30 day readmissions

2012 Breakthrough in Reducing Readmissions: From 20 per quarter to 10 per quarter

8

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q40

5

10

15

20

25

Readmissions

2011 2012

Num

ber R

eadm

issi

ons

Part 3

Insights: Pearls, Defining Moments, Breakthrough Strategy

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.

11

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?

Part 4

Our improvement worksheet and score card

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 Number of Opportunities

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:

Our improvement journeyImprovement Scale:The stages we move through

• 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

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

__________

__________

__________

___________

Improving Harm Rates (per discharge)HACs Baseline Rate

[time period]Target Rate

ADE

CAUTI

CLABSI

Falls

Ob AE

Pr Ulcer

SSI

VAP

VTE

EED

Total

Readmit    

• Where the journey began -- comment on baseline and target as challenge:

• Note which areas represented biggest challenges.

• Note areas of strength at the beginning.

Improving Harm Rates (per discharge)

HACs Baseline Rate[time period]

Target Rate Current Rate[time period]

Improvement Status (scale)

ADE

CAUTI

CLABSI

Falls

Ob AE

Pr Ulcer

SSI

VAP

VTE

EED

Total

Readmit        

Our Hospital Risk Score CardOur 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

Part 5

Our team, Our next Step

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?