Sky Lakes Medical Center March 2014 · Jeremy Westover, Nursing Discharge and Quality Coordinator;...
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Harm Across the Board (HAB): Quarterly Update Sky Lakes Medical Center March 2014
Transcript of Sky Lakes Medical Center March 2014 · Jeremy Westover, Nursing Discharge and Quality Coordinator;...
Harm Across the Board (HAB): Quarterly Update
Sky Lakes Medical Center March 2014
Harm Across the Board (HAB): Quarterly Update
Sky Lakes Medical Center March 2014
Improving Harm Across the Board Don’t hurt me, heal me if you can, be nice to me while you’re doing it
Our core PfP Team includes: Jeremy Westover, Nursing Discharge
and Quality Coordinator; Laurie Gurske, Director of Quality
Management; and Annette Cole, CNO.
We have numerous other ad hoc team members and the full support of our CEO,
Paul Stewart.
Sky Lakes Medical Center is located in the beautiful Klamath Basin at the
foot of the Southern Cascades
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Don’t hurt me, heal me if you can, be nice to me while you’re doing it
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0.0000
0.0050
0.0100
0.0150
0.0200
0.0250
Total Harm per Discharge Baseline Hospital Goal
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Reducing Inpatient Falls using Lean methodology for
implementing improvements
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Falls with Injury Baseline Hospital Goal
Risk Profile: The Areas of Risk We Are Committed To Controlling
Annual discharges: 2907* HAC risk opportunities/discharge: 4.5 *6 month baseline period
HACs Estimated annual number of patients at risk in each area Number of Opportunities
ADE # of discharges: 2907
CAUTI # pts in IP units with catheter in place: 288
CLABSI # pts in IP units with central lines: 250
Falls # of discharges: 2907
Ob AE # of women with deliveries: 382
Pr Ulcer # of discharges: 2907
SSI # of inpatient surgeries: 434
VAP # of patients on a ventilator: 76
VTE # of discharges: 2907
EED # of women with elective deliveries 118
TOTAL Risk opportunities for harm across the board 13176
Readmit # of inpatients at risk of readmit: 2907
Improving Harm Rates (/ Discharge) GOAL: 40% reduction in harm
HACs Baseline Rate
[Jan-Jun 2012] Target Rate Current Rate
[Oct-Dec 2013] Improvement Status (scale)
ADE 0.0010 0.0006 0.0022 Opportunity
CAUTI 0.0000 0.0000 0.0000 Ideal
CLABSI 0.0003 0.0002 0.0000 Ideal
EED 0.0007 0.0004 0.0015 Opportunity
OB 0.0014 0.0008 0.0000 Ideal
Falls 0.0041 0.0025 0.0015 At Target
PU 0.0000 0.0000 0.0000 Ideal
SSI 0.0003 0.0002 0.0000 Ideal
VAP 0.0010 0.0000 0.0000 Ideal
VTE 0.0003 0.0002 0.0000 Ideal
Total 0.0093 0.0056 0.0030 At Target
Readmissions 0.0513 0.0410 0.0525 Opportunity 7
Our Hospital Risk Score Card
Our Safety Mandate Annual Volume (Discharges) 2907 Total risk: annual harm opportunities 13176 Risks per patients (Total Opportunities)/Discharges) 4.5
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 3 Number of PfP Areas at Improvement Target 1 Number of PfP Areas at IDEAL 7
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Pearls
• We had the greatest sustained improvement from
the Fall Prevention project because we used Lean methodologies for implementing hourly rounding.
• We learned that sustained improvement requires constant and prolonged follow up at the “tip of the spear” – the Gemba.
• We learned to celebrate small successes while remaining focused on the greater goal – the future state.
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Pearls
• We learned that it takes a village to care for a
patient and all the villagers need to know what the goal is. Constant communication is key.
• We learned that not all are as focused and passionate about improving patient safety - decreasing harm - as we are.
• We learned to influence those people using peer and leadership accountability.
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Our Contact Info
• Paul R. Stewart, President and CEO • [email protected]
• Annette Cole, CNO • [email protected]
• Laurie Gurske, Director of Quality Management • [email protected]
• Jeremy Westover, Nursing Discharge and Quality Coordinator • [email protected] 11
