hab template: a leadership story part 1 (slide 1): who we are part 2 (slides 2-5): our results on...
TRANSCRIPT
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?