Harm Across the Board Reporting: How your Hospital Can Get There Presentation to KHA Annual Quality Conference March 19, 2014 Jackie Conrad RN, BSN, MBA Improvement Advisor Cynosure Health
Objectives Upon completion, participants will be able to Summarize HAB report expectations Utilize the Improvement Calculator tool to populate HAB report Identify the 2014 updates to the HAB report and Improvement calculator Formulate a plan to prepare HAB reports for their hospital
What s new? Harm Across the Board reports are replacing hospital progress reports 3
Why Change? The idea of all harms or harm across the board helps shift organizational culture What Else?
Moving from Micro Many pieces Topic related strategies & teams Competing priorities Silos
Many Pieces
To Macro Big Picture Cross Cutting Strategies Cultural Transformation Unified Approach to Safety
One vision, one goal
How do we make the shift? Transformational Leadership Culture of Safety Transparency Innovation Blame free Empowerment Systems Approach Reporting Learning Environment Story Telling Motivate Teach Change
Story Telling Using Harm Across the Board to tell your hospital story of Harm Reduction
ISMP Sept 2011 Compelling stories draw attention to problems and encourage people to act exposing humanity in stories serves as a catalyst for change story telling is a way to inspire and sustain culture change no matter how powerful the data, there is nothing more powerful than a story to motivate, teach, change
Story Telling to Build Culture Data tells a story Patient experiences tell a story
What story do you want to tell?
This?
Or This? A new way of looking at harm data Harm Across the Board
Or This? Number of Patients Harmed per Quarter Total Number of Harms 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 4 1 SSI 3 EEDs 3 3 EEDs 2 EEDs 2 Q1 2012 Q2 Q3 Q4 Q1 Q2 2013 0 1 CAUTI 1 Fall 2 0
Step 1 Improvement Calculator
Improvement Calculator Updates 2014 18
What s New? Hospital name carries over to each slide Baseline period (# of months) needs to be entered for each tab Percent improvement is based upon most current 3 months Quarterly data can be entered Harms per discharge tab added to populate the HAB report 19
Improvement Calculator Live Demo 20
Data flowing to Harm per D/C If ADE and ADE2 are both populated -only ADE will flow to HAB If Falls and Falls with Injury are both populated only Falls with injury will flow If HAPU II and HAPU III are both populated, only HAPU III will populate Discharges must be entered into HAB tab for all months for Harm per d/c to populate 21
Step 2 Create Harm Across The Board Report 22
Harm Across the Board 2014 Updates 23
What s New? The report has been streamlined to 7 slides Each hospital will display 2 Run Charts Harms per Discharge (HAB) One topic specific run chart This report will take the place of monthly progress reports 24
Harm Across the Board (HAB): Quarterly Update Hospital: State: Month:
Improving Harm Across the Board Insert your Team Motto here Insert a photo of your hospital and logo here. Insert a photo of your Safety Team, including your CEO, here. Insert a caption, including the name of your hospital and the city and state where you are located, here. Insert a caption, including names for the Safety Team and CEO, here. Last Updated: 1/6/2014 26
Putnam County Hospital Greencastle, Indiana QUALITY HEALTH CARE: EVERY PATIENT, EVERY TIME Presented by the Quality Champion Team Joni Perkins, RN CNO L. Annette Handy, RN Quality Mary Beth Kaiser, PharmD Teresa Decker, RN Case Management Kammie Meek, RN ICU/Medical-Surgical Beth Woolums, Credentialing Katie Bennett, RHIT, Medical Records Stefanie McCombs, Medical Records Jennifer McGaughey, Laboratory Sharon Black, RD Nutrition & Dietetics Crista Miller, RN Clinical IT Julie Norlin, RN MSN ICU/ED/Medical-Surgical Kyle Johnson, PharmD Deborah Miller, RN Surgery Center Rachel Hopkins, RN Infection Prevention
2 Run Charts Topic-specific Run Charts you pick the topic Total Harm per Discharge Tips Cut and paste graphs from the improvement calculator Customize the heading of each slide Utilize labels or sub header to tell the story
Total Harm/Discharge Slide 2 Insert a title for your Total Harms run chart here, e.g. Cut Harm Across the Board in ½ Insert your Total Harm per Discharge run chart here, and update this each month. See the example run chart below. 0.1000 0.0900 0.0800 0.0700 0.0600 0.0500 0.0400 0.0300 0.0200 0.0100 0.0000 Total Harm per Discharge Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Customize the Heading Jan- 12 Feb- 12 Mar -12 Apr- 12 May Jun- Jul- -12 12 12 Aug- 12 Sep- Oct- 12 12 Nov -12 Dec- 12 Jan- 13 Feb- 13 Mar -13 Apr- 13 May Jun- Jul- -13 13 13 Aug- 13 Sep- Oct- 13 13 Nov Dec- -13 13 Baseline 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 Hospital 0.06 0.07 0.04 0.08 0.02 0.03 0.02 0.04 0.03 0.01 0.01 0.02 0.01 0.01 0.02 0.00 0.01 0.00 0.01 0.00 0.01 0.00 Goal 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04 29
2012-2013 Trend in Reducing Harm Across the Board Total Harm/Discharge 0.0800 0.0700 0.0600 0.0500 0.0400 0.0300 0.0200 0.0100 Baseline 2011 (.037) Goal (.022) Wagoner Community Hospital Total Harm per Discharge Collection of retrospective data began; data shared with staff Tools/protocols for hypoglycemic management shared with staff 0.0000 Includes: ADE, Falls with injury, Pressure ulcers, VTE, CAUTI, CLABSI, SSI, VAP
Improvement Calculator Harm Across the board includes all harms except Readmissions
Slide 3 Insert a title for your Topic-specific run chart here, e.g. 2014 Breakthrough in Reducing CAUTI: Journey to Zero Insert a your Topic-specific run chart here, and update this each month. See the example run chart below. Customize the Heading CAUTI Rate/1,000 Catheter Days 120.0 100.0 80.0 60.0 40.0 20.0 0.0 Catheter Associated Urinary Tract Infections Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan- 12 Feb- 12 Mar -12 Apr- 12 May Jun- Jul- -12 12 12 Aug -12 Sep- 12 Oct- Nov 12-12 Dec -12 Jan- 13 Feb- 13 Mar -13 Apr- 13 May Jun- Jul- -13 13 13 Aug -13 Sep- 13 Oct- Nov Dec 13-13 -13 Baseline 100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100.100. Hospital 105.66.6 33.3 100.83.3 45.4 0.000.0052.6 0.000.0052.6 0.000.0052.6 0.0052.6 0.000.000.000.000.00 Goal 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 60.0 32
Zero Fall with Injury for 6 months! Falls with Injury Fall Rate/1,000 Patient Days 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 Implemented Hourly Rounding Nov 12 Implemented Post Fall Huddles Mar 13 0.5 0.0 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Baseline 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 Hospital 0.0 4.4 0.0 1.8 1.7 0.0 0.0 0.0 4.6 2.2 4.4 2.6 0.0 2.5 2.3 0.0 2.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Goal 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5
Improvement Calculator
Slide 4 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:
Risk Profile Tips These calculations only need to be completed once. Use one year of data may use baseline For Patient Counts for CLABSI, CAUTI, VAP. These are only ESTIMATES. Divide your device days by average length of stay OR Use charge master for # of catheter trays ordered, or # of patients with ventilator charges 36
Risk Profile: The Areas of Risk We Are Committed To Controlling Annual discharges: 592 HAC risk opportunities/discharge: 4.5 HACs Estimated annual number of patients at risk in each area Number of Opportunities ADE # of discharges: 592 CAUTI # pts in IP units with catheter in place: 95 CLABSI # pts in IP units with central lines: 76 Falls # of discharges: 592 Ob AE # of women with deliveries: 100 Pr Ulcer # of discharges: 592 SSI # of inpatient surgeries: 20 VAP # of patients on a ventilator: 20 This slide only needs to be completed once to populate the Risk Score Card VTE # of discharges: 592 EED # of women with elective deliveries 10 TOTAL Risk opportunities for harm across the board 2769 Readmi t # of inpatients at risk of readmit: 592
Slide 5 Improving Harm Rates (/ Discharge) Insert a your harm rates per discharge here, using the following table. For non-applicable topics please insert Z. HACs Baseline Rate [time period] Target Rate Current Rate [time period last 3 months] Improvement Status (scale) ADE CAUTI CLABSI EED OB Falls PU SSI VAP VAE Total Readmissions 38
Improving Harm Rates per Discharge Identifies where greatest degree of harm is in the organization to assist in determining where resources and improvement efforts are allocated. Harms for each topic are divided by the discharges for the same time period. This calculation can be found in the Improvement Calculator
Improving Harm Rates (per discharge) HACs Baseline Rate CY 2011 Target Rate 40/20 Goal Current Rate 1-2Q 2013 Improvement Status (scale) ADE 0.005 0.003 0 IDEAL CAUTI 0.005 0.003 0.003 AT TARGET CLABSI 0 0 0 IDEAL Falls with Injury 0.0118 0.0071 0.0032 AT TARGET OB AE 0 0 0 IDEAL Pr Ulcer 0 0 0 IDEAL SSI 0.0067 0.004 0 IDEAL VTE 0 0 0 IDEAL EED 0.0303 0.0182 0 IDEAL Total 0.0588 0.0353 0.0062 AT TARGET Readmit 0.0571 0.0457 0.0421 AT TARGET Where was the greatest opportunity during the baseline period?
Improvement Calculator - HAC per D/C
Estimates of Hospital HAC and Readmission Rates for the Nation (AHRQ) Table 1: Improving Harms table for 2010 from AHRQ Harm Across The Board HAC per discharge (2010) ADE 0.049 CAUTI 0.012 CLABSI 0.0005 Falls 0.008 Ob AE 0.003 Pr Ulcer 0.040 SSI 0.003 VAP 0.0012 VTE 0.0005 EED Other 0.027 Total HAC 0.145 Readmit/discharge Readmission 0.144 42
Improving Harm Rates (/ Discharge) HACs Insert a your harm rates per discharge here, using the following table. For non-applicable topics please insert Z. Baseline Rate [time period] Target Rate Current Rate [time period] Improvement Status (scale) ADE CAUTI CLABSI EED OB Falls PU SSI VAE VAE Total Readmissions 43
Improvement Scale IDEAL: level represents what we see as best possible or ZERO harms At Target: level represents meeting improvement target Progress: level not yet at target Opportunity: level represents an improvement opportunity
Slide 6 Our Hospital Risk Score Card Insert your hospital risk score card here, using the following table. Our 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 45
Our Hospital Risk Score Card Our Safety Mandate Annual Volume (Discharges) 7298 Total risk: annual harm opportunities 36,613 Risks per patients (Total Opportunities)/Discharges) 5.02 Number of Risk Areas Number of PfP Risk Areas Applicable (0 11) 11 Number of PfP Risk Areas Applicable & Adopted 11 Our Progress Number of PfP Areas with Major Improvement Opportunity 2 Number of PfP Areas at Improvement Target 3 Number of PfP Areas at IDEAL 5 46
Hospital Risk Score Card Our Safety Mandate use numbers from Risk Profile. Risks per D/C will be 3.5-7 Number of Risk Areas # of Risk Areas Applicable Includes Readmissions. Max is 11 # Risk Areas Applicable and Adopted. Our Progress use Improvement Scale definitions from Improving HACS per Discharge Slide
Slide 7 Pearls Bullet your biggest insights about what worked, and what caused it to work here. Include what you tested and learned Include how you will advance this topic over the next month (and beyond). List the most important drivers of safety that produced these results, but make this list succinct, high-level and clear. Include patient and family engagement (PFE), if relevant. 48
Pearls Tips Provide enough detail about the strategy or tactic to promote spread Can the reader get enough information to replicate the idea? Provide examples of key cultural change strategies, i.e. Transparency of data Front line staff engagement Senior management support Seamless transitions Recognition Promoting a Culture of Safety Share learnings and ideas tested How will the strategies be taken to the next level?
Pearls Followed Evidence Based Best Practices Focused surveillance Transparency with results Implementation of checklists Standardized products used Implemented daily review
Pearls ORGANIZATIONAL CULTURE OF SAFETY PROMOTED FROM SENIOR LEADERS Staff Safety Survey results have vastly improved showing Patient Safety Initiatives have been effective at addressing potential harm/safety issues. Environmental Patient Safety Rounds are conducted monthly Increased reporting of Near Misses by front-line staff reveals an increased awareness of Safety and the Prevention of Patient Harm QUALITY IS A STRATEGIC PRIORITY Golden Path to Success includes: 1) Strategic Objectives under Quality Pillar 2) department goals that align with strategic objectives; 3) All Staff set annual My Quality Commitment goals TRANSPARENCY THROUGHOUT THE ORGANIZATION Progress reports to Board of Trustees, Senior Leaders, Quality Council, & various committee meetings Scorecards, White Boards, Progress Posters, Days since last posted in each unit for certain healthcare associated conditions Weekly GVMH in Action from CEO, Capsulized News Town Hall & Staff Meetings GVMH Intranet
How to Submit your HAB Reports Submit your Eliminating HAB report to the topic list-serv that correlates to the topic run chart on your HAB report.
Questions / Wrap Up
Contact Information Improvement Advisor Cynosure Health @cynosurehealth.org