slide 1 1 eliminating harm across the board mary m. pizzino, executive director, informatics/quality...
TRANSCRIPT
Slide 1
1
Eliminating Harm Across the Board
Mary M. Pizzino,Executive Director,Informatics/Quality Data Management
Slide 2
2
Our MissionTo provide access and delivery of quality, cost effective, community based healthcare to all the citizens of Effingham County.
Our VisionEvery patient will experience compassionate, quality care and service at a level of excellence that will make Effingham Health
System the healthcare provider of choice. Our Valued Principles
We believe the success of Effingham Health System is directly related to the values we hold, share, and practice. These values must form the basis for every action we take toward patients, families, physicians, volunteers, and each other with commitment to:
• Quality• Service• Compassion• Leadership• Education• Accountability• Teamwork• Creativity
Adverse Drug Events (ADE)
3
Janu
ary
Febr
uary
Marc
hApr
ilM
ayJu
ne
July
Augus
t
Sept
embe
r
Octobe
r
Novem
ber
Decem
ber
0
5
10
15
20
25
30
35
40
45
Total harms by Month
Adverse drug events (ADE) in 2012
Adverse drug events (ADE) in 2013
January 2012 - August 2013
# of
Har
ms
Readmissions –All cause
4
Januar
y
Febru
ary
Mar
chApril
May
June
July
August
Septem
ber
October
November
Decem
ber0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Preventable Readmissions
Preventable readmissions- all cause 2011
Preventable readmissions- all cause 2012
Preventable readmissions- all cause 2013
January 2011 - August 2013
Re-
adm
issi
ons
Pearls
Collaboration from Medical StaffInvolvement of multi-disciplinary team membersEducation of staffCommitment from AdministrationStandardization of E.H.R.
5
Defining Moment(s) In Our Journey
2012: Realization that all ADE’s were not being included in our data collection.• Implementation of remote Pharmacy• Medication Management in-service• Increase of ADE reporting by nurses• Computer Based Learning Modules
2012: Realization that the discharge instructions were not always understood/followed by the patient. • Review of all readmissions • Identified the top ten re-admission diagnoses• Developed post-discharge call backs by nursing• Reviewed/revised patient education• Implemented pharmacy rounding
6
Breakthrough Strategy
ADE: Encouraging nursing to view reporting as an opportunity to improve patient safety; not as a “black mark” on their individual performance.
Readmissions: Helping nursing understand that patient education does not end at the time of discharge.
7
Slide 8
8
HACs Estimated annual number of patients at risk in each area Number of Opportunities
ADE # of discharges: 239
CAUTI # pts in IP units with catheter in place: 45
CLABSI # pts in IP units with central lines: 10
Falls # of discharges: 239
Pr Ulcer # of discharges: 239
SSI # of inpatient surgeries: 90
VTE # of discharges: 239
TOTAL Risk opportunities for harm across the board 1101
Readmit # of inpatients at risk of readmit: 239
Annual discharges: _239____________
HAC risk opportunities/discharge: 4.60 %
Risk Profile: The Areas of Risk We Are Committed To Controlling
OUR IMPROVEMENT JOURNEY:It’s all about “always” giving the best possible care.
IDEAL: level represents zero harm
At Target: level represents meeting target for improvement
Progress: level shows improvement but not yet at target
Opportunity: level is an opportunity to launch aggressive action for improvement
5__________
0__________
2__________
1___________
Number of risk areas (0-11) at each stage
Improvement Scale:The stages we moved through
Slide 9
9
Getting to ZERO Harm
HACs Baseline Rate2012
Target Rate
*ADE 102 Reduce by 40%
CAUTI 0 IDEAL
CLABSI 0 IDEAL
Falls 3 Reduce by 40%
Pr Ulcer 0 IDEAL
SSI 1 Target
VTE 0 IDEAL
Total 106 42
*Readmissions 9 3
Our journey began in 2012 with a base rate of 239
annual Inpatient discharges.
• ADE’s, Falls and Readmissions were areas for improvement
• HAI (Hospital Acquired Infections) is an area of strength. Our clinical staff is diligent following infection control protocols/processes.
10
Improving Harm Rates (per discharge)
HACs Baseline Rate2012
Target Rate Current RateQTR 1 & 2 2013
Improvement Status (scale)
ADE 102 REDUCE BY 40% 61 =59% OPPORTUNITY
CAUTI 0 REDUCE BY 40% 0 IDEAL
CLABSI 0 REDUCE BY 40% 0 IDEAL
Falls 3 REDUCE BY 40% 1 = 33% OPPORTUNITY
Pr Ulcer 0 REDUCE BY 40% 0 IDEAL
SSI 1 REDUCE BY 40% 0 IDEAL
VTE (POST OP)
0 REDUCE BY 40% 0 IDEAL
Total 106 REDUCE BY 40% 62 PROGRESS
Readmit 9 REDUCE BY 20% 1.8 1 PROGRESS
11
Our Hospital Risk Score CardOur Safety Mandate
Annual Volume (Discharges) 2012 239
Total risk: annual harm opportunities 1101
Risks per patients (Total Opportunities)/Discharges) 4.60
Number of Risk Areas
Number of PfP Risk Areas Applicable (0 – 11) 8
Number of PfP Risk Areas Applicable & Adopted 8
Our Progress
Number of PfP Areas with Major Improvement Opportunity 3
Number of PfP Areas at Improvement Target 0
Number of PfP Areas at IDEAL 5
12
Norma Jean Morgan, CE0 Joseph Ratchford, MD, Quality Medical DirectorClaude Sanks III,MD, Hospitalist *Mary Pizzino, Exec. Dir. of Informatics/Quality *James Edwards, RN, Quality and Risk Management *Sara Corley, RN Quality Nurse*Jeff Boswell, RN Informatics Nurse Durwin Logan, Director of Pharmacy*Linda Rigsby, RN, Nursing Council Shirley Rahn, RN, Nursing Council*Amy Roddenberry, RN, Senior Staff Nurse Jane Miller, Infection Preventionist Erin Conway, Core Measure Coordinator *Monica Jones, Data Resource SpecialistMatthew Moore, Decision Support *Denika O’Rourke-Systems Trainer*Karen Harden O’Neal, HIM Coordinator Marie Livingstone, CNO
*Pictured Team Member’s
QUALITY AND PATIENT SAFETY TEAM
13
Next steps to Reduce Harm Implementing additional protocols for patient care Increasing the use of CPOE (computerized physician
order entry) to assist in the reduction of medication errors
Implementing standardized order sets Implementing Electronic physician documentation to
improve patient care and reduce errors due to illegibility
14
Slide 15
15
QUESTIONS?