Why Shepherd? Shepherd Center Patients. Here s How We Measure Up: Shepherd Patient Population

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1 Center Patients Total Patients ABI Patients SCI Patients Other Patients Center specializes in medical treatment, research and rehabilitation for people with spinal cord and brain injury. In CY, had 911 combined discharges from its spine and brain injury inpatient programs and over from its outpatient SCI and ABI Day Programs. Patients at Center get more than just medical care; they get an experience that brings healing and hope. takes a team approach to rehabilitation. We understand that patients are going through more than just recovery from an injury; they are learning a new way of life and establishing a new normal. Total # Patients Discharged 1, Center Patient Population CY ere s ow We Measure Up: Patient Population Center has served patients from all states and about 6 foreign countries, with a focus on treating adolescents and young adults. Source: Internal Data Systems (Discharges from January 1, September, 3 ) Average Patient Age/# Rehabilitation Patients Center treats close to 1, inpatients a year, including acquired brain injury (ABI) and spinal cord injury (SCI) rehabilitation patients, as well as medical and surgical patients with complications related to these types of injuries. The average age of Center patients is younger than the national average for other rehabilitation facilities. Compared to the national average, Spinal cord injury patients are around 12 years younger, stroke patients are about 19 years younger, and brain injury patient are around 3 years younger. Around 5 Center inpatients a year participate in at least three hours of therapy per day, allowing these patients to achieve more functional gains compared to those at other rehabilitation facilities. Total SCI Total SCI Total ABI Total ABI Avg. Age # Cases Avg. Age Avg. Age # Cases Avg. Age Avg. Age # Cases Avg. Age Source: UDS 921 Quarterly Trends Report (October 1, September 3, )

2 Center has proven results in helping patients achieve more functional independence and return to their communities. Functional Independence Center Adjusted Total FIM Change Total FIM Change is a measure of how much functional gain the patient received during rehabilitation. It is measured just after admission to Center and again at discharge. Discharge to Community is the percentage of patients who return to a community setting, including their home, transitional living setting, board and care setting, or assisted living residence. FIM Chnage Total Spinal Cord Injury Total Brain Injury ere s ow We Measure Up: Functional Independence Discharge to Community Patients at Center are more likely to experience better functional gains and return to their community than patients at other facilities. Center spinal cord injury and brain injury patients achieved a Total FIM change of up to 5.2 points and 1.9 points higher than the national average respectively. Center Stroke patients achieved a Total FIM change of up to 7.9 points higher than the national average. More Center patients of all injury types discharged to their community up to over 27 percentage points higher than the national average. % of Patients Discharge to Community Total Spinal Cord Injury 69.7% 91% 67.2% 92.3% 7.6% 71.8% % Total Brain Injury 67.9% 86.2% 69.4% 85.2% 68.7% 94.9% 71.9% % 67.8% 82.4% 63% 6.6% 95.2% 58.4% Source: UDS 921 Quarterly Trends Report (October 1, September 3, )

3 An Ounce of Prevention Goes a Long Way ospital-acquired Conditions in Pursuit of Zero CY & Improvement/Achieved Goal ospital-acquired Conditions (ACs) are medical complications defined by CMS that may occur to patients during an inpatient stay at any hospital. Reducing these complications (ACs) is a priority so our patients don t get derailed from participation in rehabilitation. Keeping patients safe and reducing the overall cost of care is a priority in all that we do daily. ere s ow We Measure Up: ospital-acquired Conditions Rate per 1, Vent Days Ventilator-Associated Pneumonia (VAP) CY - % Patients Readmitted 1 8% 6% 4% 2% Readmissions Within 3 Days 6.7% 5.5% CY - The Success of Zero : Zero cases of ventilator-associated pneumonia in over 11 years! Of the over 1, patients who were on a ventilator, none experienced the delays in rehab or medical complications that are common with this type of infection. It is a testament to s dedication to ensuring these vulnerable patients are treated under proven evidence based care ensuring reliable outcomes. The Journey to Zero : Readmission data reflects all patients discharged home from and re-admitted to an acute care hospital for complications. s readmission rate remains below state and national comparisons. focuses on promoting ongoing health and wellness, detailed plans prior to discharge, and access to s Transition Support Program after patients go home. has reliably maintained low falls with harm due to effective reinforcement of safety strategies with staff and families. Staff continues to receive training for Safety over privacy to reduce bathroom falls. continues to reduce catheter associated urinary tract infection through specialized bladder management and catheter maintenance for high risk patients, requiring ongoing catheter use. Since 215, s CAUTI rate has reduced by 43%. Central Line Associated Blood Stream Infections remain below State and al Levels. follows evidence-based protocols to reduce risk of infection. Reinforcing improvement efforts by focus subgroups to identify and implement preventive methods to avoid new or worsening pressure injuries. Working on establishing skin champions as a content experts across the hospital to provide consistent wound/skin care expertise. Several pressure injuries with harm occurred due to equipment changes in preparation for discharge, outings, etc. A rapid action subgroup has been started to address & improve Equipment change communication process and thereby prevent harm. Rate per 1, Device Days Rate per 1, Device Days Central-Line-Associated Blood Stream Infections (CLABSI) CY - Catheter-Associated Urinary Tract Infections (CAUTI) 2.9 CY Falls With arm Pressure Injuries With arm Center Data reflects CY and - Outcomes. Rate per 1, Pt. Days Rate per 1, Discharges CY CY -

4 Patient Safety Center continually strives to achieve excellence in patient safety. To better understand how our front-line clinicians perceive the level of effectiveness that exists at Center during delivery of care, we voluntarily participate annually at a national level in the Agency for ealthcare Research and Quality (ARQ) Culture of Patient Safety Survey. al Culture of Patient Safety Survey BEAVIORAL CATEGORIES: n n n Georgia 215 N G N G N G Teamwork Within Units 9 81% 79% 88% 82% 83% 87% 82% 82% Supervisor/Management Expectations & Actions Promoting Patient Safety 82% 76% 73% 84% 78% 77% 85% 79% 78% ere s ow We Measure Up in the Behavioral Categories Organizational Learning Continuous Improvement 85% 73% 71% 8 73% 73% 79% 69% 72% Patient Safety is our highest priority! We have been continually striving to develop a culture that is transparent among caregivers and this independent national survey demonstrates the perception of the clinicians at Center. While some categories demonstrate a slight downward trend, in Out Performs the and the State of Georgia in these Behavioral Categories. Management Support for Patient Safety Overall Perception of Patient Safety Feedback & Communication About Error 86% 72% 71% 87% 72% 73% 87% 73% 73% 8 67% 64% 78% 66% 67% 77% 66% 66% 76% 66% 7 73% 68% 69% 73% 68% 68% Communication Openness 66% 66% 61% 67% 64% 61% 67% 64% 61% Frequency of Events Reported 7 62% 69% 69% 67% 68% 67% 67% 68% Teamwork Across Units 78% 61% 59% 73% 61% 62% 73% 61% 63% Staffing 69% 55% 53% 67% 54% 56% 63% 54% 52% andoffs & Transitions 61% 47% 45% 52% 48% 46% % 48% 47% Nonpunitive Response to Errors 54% 44% 4 58% 45% 45% 57% 45% 46% If you have any questions, please contact the department of Quality/Outcomes/Patient Safety at

5 Ventilator Management Ventilator weaning is the active process of liberating the patient from the ventilator. Ventilator Medical Management is provided by two Physicians with Board Certifications in Pulmonary Medicine and Internal Medicine. ere s ow We Measure Up: Ventilator Weaning The rates are impressive in light of the small sample size. Overall, reveals positive progress with improved ventilator weaning rates for each level of injury compared to prior years. Ventilator weaning rate for Traumatic Spinal Injury at C4 Injury Level is statistically better than prior years. Center has an active Diaphragm Pacing (DPS) Program. These patients are not included in the weaned numbers as they are not considered weaned from mechanical ventilation and are discharged home with a ventilator in addition to the DPS. Ventilator weaning data is validated annually by Andrew Zadoff, MD, Medical Director, ICU and Pulmonary Services Center Ventilator Weaning Rates Data represents medically complex patients only. It is influenced by the clinical acuity and primary/secondary diagnosis. The following are considered significant factors in potential capability to wean a patient from ventilator assistance: Level of Injury Patient Age Level of Injury Complete vs. Incomplete Spinal Cord Injury Co-morbidities C1 - C % % C3 1 6% 1 7% % C % % % C5 - C % T1 - T Brain Injury % % % # D/C ome on Vent # Weaned Avg Days to Wean