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Call for Storyboards! The 2014 Quality & Patient Safety Roadmap will feature keynote speakers, panelists and storyboard sessions focused on engaging patients and families in eliminating harm across the board. Submit your harm across the board storyboard to share your organization’s experience in eliminating harm and be featured during the storyboard sessions at Roadmap! Details on how to complete the storyboard template and submission details are included in this slide deck. Please contact [email protected] with any questions. Eliminating Harm Across the Board (HAB) Template Objectives • Understand what the Eliminating HAB report is and how it is a helpful tool in improving care. • Understand how to complete your Eliminating HAB report. • Understand how to submit your Eliminating HAB report. • Know who to contact if you have questions. 3 How is Eliminating HAB applicable to SLHQ? Eliminating HAB You Quality Improvement The Patient SLHQ & Roadmap Eliminating Harm PfP, HENs & Roadmap 4 Your W(hat’s) I(n) I(t) F(or) M(e): WIIFM • The Eliminating HAB report will: • Help shift your organizational culture; • Put a face on harm; • Tell a compelling story to support change; • Promote transparency; • Engage patients and their families and/or Patient and Family Advisory Council (PFAC) members; and • Help you track your overall harm per discharge and identify the greatest opportunities for eliminating harm. 5 Eliminating HAB Storyboard Example 6 Sharing Your Eliminating HAB Storyboard at Roadmap In 2013, Roadmap participants shared their HAB storyboards with colleagues. In 2014, the Roadmap HAB storyboards will focus on engaging patients and families in eliminating harm. 7 The Eliminating HAB Template: Eight key slides and tips for how to complete them. 8 Insert Hospital Name Here Insert Your Motto Here, e.g. “Our Bottom-line Line is Patient Safety” Slide 1 Customize the motto Customize the team info. Insert a photo of your hospital and logo here. Insert a photo of your Safety Team, including your CEO and PFA(s) here. Insert a caption here, including the name of your hospital and the city and state where you are located. Insert a caption here, including the names of your Safety Team, CEO and PFAs. Insert a title for your “Total Harms per Discharge” run chart here e.g., “Cut Harm Across the Board in ½” Customize the heading Slide 2 Insert your total harm run chart Dec-13 Nov-13 Oct-13 Sep-13 Aug-13 Jul-13 Jun-13 May-13 Apr-13 Mar-13 Feb-13 Jan-13 Dec-12 Nov-12 Oct-12 Sep-12 Aug-12 Jul-12 Jun-12 May-12 Apr-12 Mar-12 Feb-12 0.1000 0.0900 0.0800 0.0700 0.0600 0.0500 0.0400 0.0300 0.0200 0.0100 0.0000 Jan-12 Total Harm/Discharge Total Harm per Discharge Jan- Feb- Mar Apr- May Jun- Jul- Aug- Sep- Oct- Nov Dec- Jan- Feb- Mar Apr- May Jun- Jul- Aug- Sep- Oct- Nov Dec12 12 -12 12 -12 12 12 12 12 12 -12 12 13 13 -13 13 -13 13 13 13 13 13 -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 Insert a title for your “topic-specific” run chart here e.g., “2014 Breakthrough in Reducing CAUTI: Journey to Zero” Customize the heading and slide based on which specific measure you want to highlight. Insert a topic-specific run chart Slide 3 120.0 100.0 80.0 60.0 40.0 20.0 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 CAUTI Rate/1,000 Catheter Days Catheter Associated Urinary Tract Infections Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec 12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 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 0.00 0.00 52.6 0.00 0.00 52.6 0.00 0.00 52.6 0.00 52.6 0.00 0.00 0.00 0.00 0.00 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 Risk Profile: Areas of Risk We Are Committed To Controlling Annual discharges: __________ AEA risk opportunities/discharge: _______ Customize the annual discharges Slide 4 AEAs Estimated annual number of patients at risk in each area ADE # of discharges: CAUTI # pts in IP units with catheter in place: CLABSI # pts in IP units with central lines: Falls # of discharges: EED # of women with elective deliveries OB # of women with deliveries: HAPU # of discharges: SSI # of inpatient surgeries: VAE # of patients on a ventilator: VTE # of discharges: TOTAL Risk opportunities for harm across the board Readmit. # of inpatients at risk of readmit: Customize the risk opportunities/discharge Number of Opportunities Improving Harm Rates (/ Discharge) Insert a your harm rates per discharge here, using the following table. For non-applicable topics – please insert “Z”. Slide 5 AEAs ADE Customize the baseline, target and current rates and improvement scale CAUTI CLABSI Falls EED OB HAPU SSI VAE VTE Total Readmit. Baseline Rate [time period] Target Rate Current Rate [time period – last 3 months] Improvement Status (scale) Hospital Risk Score Card Slide 6 Insert your risk score card here, using the following table: Our Safety Mandate Annual Volume (Discharges) Total risk: annual harm opportunities Customize your score card Risks per patients (Total Opportunities)/Discharges) Number of Risk Areas Number of Risk Areas Applicable (0 – 11) Number of Risk Areas Applicable & Adopted Our Progress Number of Areas with Major Improvement Opportunity Number of Areas at Improvement Target Number of Areas at IDEAL How We Engage Patient/Family Advisors in Eliminating HAB Slide 7 Engaging Patient/Family Advisors Customize the Model for Improvement, answering the questions to best describe your hospital’s eliminating HAB journey Our Results and Pearls Slide 8 Results: Customize your responses Pearls: the A concise description of what you achieved, as it relates to eliminating HAB and engaging PFAs. Bullet your biggest insights about what worked and how. - Include what you tested and learned. - Include how you will advance this topic over next month (and beyond). - List the most important drivers of safety that produced these results. Make this list succinct, high-level and clear. - Include the PFA insights, thoughts and feedback PFA Quote: Insert a PFA quote here about eliminating HAB. Eliminating HAB Template: Examples and Tips 17 How we Incorporated a Patient/Family Advisor (PFA) into our Journey to Eliminate HAB Slide 7 (EXAMPLE) Patient/Family Advisors Suggestions for reducing ADE Reduce the incidence of preventable adverse drug events 14 ADEs/month to 8 ADEs/month Have pictures of medications taken at the bedside for patients and families 18 Our Results and Pearls Slide 8 EXAMPLE Results: Reduced ADE by 25% over 6 months. Pearls: • Two patient/family advisors were on the ADE committee • They shared the various ways that they organized medications at home and suggested that providing patients with pictures of the pills they were taking in the hospital (since some looked different than what they were taking at home) would help patients and families to know what they were being given and why • At discharge patients received up to date medication lists that included pictures “ I always taped a pill on to the medication list for my father so he knew what he was taking. It was so meaningful to share this idea and to see it help other patients” 19 Run Chart Tips • Cut and paste graphs from the improvement calculator: o www.aha-slhq.org / Resources / Using Data for Improvement • Customize the heading of each slide • Utilize labels or a subheader to tell the story 20 The Improvement Calculator Tip: Access the Improvement Calculator here! 21 Risk Profile Tips • These calculations only need to be completed once • Use one year of data – using baseline • For Patient Counts for CLABSI, CAUTI,VAE o Use charge master for # of catheter trays ordered, or # of patients with ventilator charges, or divide your device days by average length of stay 22 Improvement Scale Tips 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 23 Hospital Risk Score Card Tips • Our Safety Mandate: use #’s from Risk Profile • Number of Risk Areas Applicable - includes Readmissions (the max. = 11) • Our Progress: use Improvement Scale definitions from Improving AEAs per Discharge Slide • Total Risks per patient: is calculated from total harm opportunities divided by total discharges per applicable risk areas, e.g. - if no vents. or births: 8 24 Pearl Tips • Provide enough detail about the strategy or tactic so others can easily replicate • Provide examples of key cultural change strategies. For example: o Transparency of data o Front line staff engagement o Senior management support o Seamless transitions o Recognition o Promoting a Culture of Safety • Share learnings and ideas tested • Highlight how strategies be expanded and spread 25 Submission Process • We encourage you to submit your Eliminating HAB Report for the upcoming Quality & Safety Roadmap Meeting, as well as on our SLHQ Members LISTSERV®: [email protected] • For more details - please contact us! See the following slide for contact information. 26 Questions? Contact Us! Website: www.aha-slhq.org Email: [email protected] LISTSERV®: [email protected] Phone: (773) 270-3127 Office: 155 N. Wacker Dr., Ste. 400 Chicago, IL 60606 Dr. Maulik Joshi: Senior Vice President, AHA and President, HRET ([email protected]) Charisse Coulombe,Vice President, HRET ([email protected]) Jessica Blake, Senior Program Manager, HRET ([email protected]) Natalie Erb, Administrative Fellow, HRET ([email protected]) 27