Improving Harm Across the Board

1. Improving Harm Across the Board Northridge Medical Center Commerce, GA Selina Baskins, RN, Quality Coordinator

2. HEN PARTIES Hospital Engagement Network Preventing Avoidable Readmissions Through Interactive Engaged Staff

3. 2013 Breakthrough in Reducing HAC HARM*: 96.3 to 62.9 harms/1,000 discharges *HAC harm = inpatient hospital acquired conditions

4. Cut “harm across the board” in 2013: 32.5 patients per quarter to 24

5. 2012 Breakthrough in Readmission*: From 20% of discharges to 10% of discharges Slide 5 Source: GCMF Database All Cause Readmissions to GA Hospitals, GA Medicare Patients only

6. 2012 Breakthrough in Reducing Readmissions

7. Pearls Very supportive Nurse Leaders We implemented the GHA HEN project ideas to set our standards. We chose things easy to achieve first Chose key personnel to be our champions. Falls tree on both inpatient units with a reward system to create a little competition. Heightened awareness in the ED for nurses to check if the patient had any alternative care options rather than being a readmission.

8. Falls Tree on Northeast Wing

9. Defining Moments In Our Journey We decided that our base topic was to make everything that was required FUN!! 4/4/12 In-services for all clinical staff Decorated the room with Easter eggs Easter eggs were filled with door prizes Powerpoint presentation that focused on Readmissions and Falls All were required to do the chicken dance! 9

10. Defining Moments in Our Journey 7/24/13 HEN PARTIES Picnic Included several familiar items as Fried Chicken, Deviled Eggs, and Egg Custard Pie! After eating each clinical staff member had to participate in a mini inservice related to best practices to prevent falls and reduce readmissions.

11. Breakthrough Strategy The biggest challenge: Physician “Buy In” Concurrent chart review daily intervention with physicians and staff. Have one Hospitalist as our “Champion”. Share Specification Manual for specific documentation needed and he not only does it, but shares with the other physicians to help meet requirements.

12. Dr Kenneth O’Neal, Hospitalist Our HEN Physician Champion

13. slide13 Risk Profile: The Areas of Risk We Are Committed To Controlling Annual discharges: 1349 HAC risk opportunities/discharge: 8.95

14. Our improvement journey Slide 14 Improvement Scale:The stages we move through Number of risk areas (0-11) at each stage • 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 ____5_____ __________ ____1_____ ____2______

15. Improving Harm Rates (per discharge) • Where the journey began… • Falls and ADE had the largest room for improvement • Several areas already meeting the target of zero harms

16. Improving Harm Rates (per discharge)

17. Our Hospital Risk Score Card

18. OUR TEAM:Richard L. Clark, Interim CEOMaura Cobb, CNO, RN, MBALarry Ebert, CFODr Kenneth O’Neal, HospitalistSelina Baskins, RN, Quality CoordinatorRita Brunner, RN, ICU CoordinatorMary Kathryn Warnock, RN, Med-Surg Unit CoordinatorJim Hennes, RN, Willow Brook Unit CoordinatorTabitha Evans, RN, Case ManagementSheila Embrick,RN, Nursing SupervisorRachel Kean, RN, Surgical Services CoordinatorCindy Smith, RN, ED Unit CoordinatorLois McMahon, RN, Northridge Health and Rehab DONOur Motto:“HEN PARTIES”Hospital Engagement Network Preventing AvoidableReadmissions Through Interactive Engaged Staff

19. Slide 19

20. Next big step to Reduce Harm Our next big step will be to initiate A Passion for Patients Committee Meetings. This will not only include frontline staff, but also Case Management, local Home Health, Hospices, and Patient or Patient Representatives to help evaluate our processes at a higher standard.