Improving Harm Across the Board

Transcription

1 Improving Harm Across the Board Kassie Waters, Manager Quality Management Marshall Medical Center Placerville, California Opened in 1959 Independent, nonprofit, 113 beds Over 190 affiliated physicians and 1200 employees providing care to more than 150,000 residents in El Dorado County, California Mr. James Whipple, CEO

2 Hospital Trend in Reducing Harm per 1000 Discharges 37% Reduction from 2010 to Current We re Almost to 40% Areas of Applicable Harm for Marshall: CAUTI CLABSI HAPU SSI VAP VTE EED Falls

3 Total Number of Patients Harmed From Average of 38 Per Quarter to 24 Per Quarter Areas of Applicable Harm for Marshall: CAUTI CLABSI HAPU SSI VAP VTE EED Falls

4 Hospital Trend in Reducing Readmission All Cause Readmission/All Discharges From a 2011 Baseline Rate of 13.2 to a Current Rate of 9.9: A 25% Improvement

5 Number of Readmissions by Quarter From a 2011 Baseline of 148 Per Quarter to 116 Per Current Quarter: Cost Saving To-Date $470,000

6 Pearls Leadership Team skilled in creating organization quality and safety goals, setting AIMs, and consistently communicating to frontline staff and physicians. Leadership Team which creates and mobilizes resources to realize patient safety/quality goals. VP Quality on Senior Team. Performance Improvement Specialist hospital-wide. Performance Improvement Specialists embedded in Home Care, Med/Surg, and Teleunits. Multidisciplinary Improvement Teams in place to realize AIM. An organization with a well developed culture of patient safety as evidenced by top decile/top quartile performance on 10 of the 12 AHRQ Hospital Culture of Patient Safety Survey Dimensions, 2012.

7 Strategies to Drive Results Multidisciplinary Process Improvement Teams Consisting of Frontline Staff, Physicians, PI Specialist, & Executive Champion. Teams chartered to realize AIM. Team make-up, focus, and meeting schedule change as process improvement are hardwired. Improved Event Analysis to Enhance Learning & Mitigating Harm. System and process design issue focused. Reinforces the well developed perceptions of a just culture with staff knowing that they will not be punished unfairly. Review of CAUTI, Falls, HAPU cases twice a month. Acknowledgment of Harm Reduction within Units and Across the Organization.

8 Risk Profile by Areas of Risk 2012 Data Marshall Medical Center HAC s Estimated Annual Number of Patients at Risk in Each Area Adverse Drug Events (ADE) # of inpatients: 4440 Catheter-Associated Urinary Tract Infections (CAUTI) # patients in IP units with catheter in place: 666 Central Line Associated Blood Stream Infections (CLABSI) # patients in IP units with central lines: 450 Injuries from Falls and Immobility (FALLS) # of discharges: 4440 Obstetrical Adverse Events (Ob AE) # of women with deliveries: 500 Pressure Ulcers (PrU) # of discharges: 4440 Surgical Site Infections (SSI) # of applicable surgical patients: 1313 Ventilator-Associated Pneumonia (VAP) # of patients on a ventilator: 595 Venous Thromboembolism (VTE) # of inpatients: 4440 Early Elective Deliveries (EED) # of women with elective deliveries 83 TOTAL Risk Opportunities for Harm Across the Board # Readmissions # of inpatients at risk of readmission: 4440

9 Improving HAC Rates Marshall Medical Center HAC s Baseline [2011] Target 40% Reduction Current [Last 3 Data Points CDS] Improvement Status (scale) CAUTI Opportunity CLABSI Ideal FALLS (Injury) At Target Pr Ulcer Ideal SSI Opportunity IVAC Ideal VTE At Target EED 1.8 <3.0 0 Ideal Target 20% Reduction Readmissions At Target

10 Our Hospital Risk Profile & Result Annual Volume (Discharges) 4440 Total risk: annual harm opportunities 21,367 Risks per patients (Total Opportunities)/Discharges) 4.8 Number of PfP Harm Areas Applicable (0 11) 11 Number of PfP Harm Areas Applicable & Adopted 9 Number of PfP Areas at Improvement Target 2 Number of PfP Areas at IDEAL/At Target 7

11 Marshall Safety Team PI Team

12 Future Actions to Reduce Harm Decrease Harm Across the Board at MMC by 40% by September & Maintain Improvement through Dec, Eliminate CAUTIs at Marshall Medical Center Continue to Create Reliable Process for Insertion and Timely Removal. 2. Reduce SSI by at least 40% from a 2011 Baseline Rate of 1.9 to an average rate of no more than 1.1 by September, Continue to enhance Event Analysis methodology to increase learning from errors and mitigating harm. 4. Support managers communication of reported harm events within each unit and across the organization to heighten learning from errors.