Eliminating Harm Across the Board (HAB) Template

Objectives

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• Understand what the Eliminating HAB report is, and why it is important to complete it.

• Understand how to complete your Eliminating HAB report.

• Understand how to submit your Eliminating HAB report.

• Know who to contact if you have questions.

Why is Eliminating HAB applicable to the SLHQ?

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Quality Improvement

Eliminating Harm

PfP, HENs &

Roadmap

SLHQ & Roadmap

You

Eliminating HAB

The Patient

Your W(hat’s) I(n) I(t) F(or) M(e): WIIFM

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•We strongly believe that these reports 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, which in turn will help your team see where your greatest opportunity is in eliminating harm

Eliminating Harm Across the Board (HAB) TemplateInsert Your Motto Here, e.g. “Our Bottom-line Line is Patient

Safety”

Insert a photo of your hospital and

logo here.

Insert a photo of your Safety Team, including

your CEO, here.

Insert a caption, including names for the Safety Team and CEO,

here.

Insert a caption, including the name of your hospital and the city and state where you are located,

here.

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Customize the motto

Customize the team info.

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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

Total Harm per Discharge

Insert a title for your “Total Harms” run chart heree.g. “Cut Harm Across the Board in ½”

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Customize the heading

Slide 2

Insert your “Total Harm per Discharge” run chart here, and update this each month. See the example run

chart below. Customize the run chart

Insert a title for your “Topic-specific” run chart here e.g. “2014 Breakthrough in

Reducing CAUTI: Journey to Zero”

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Customize the heading

Slide 3

Insert a your “Topic-specific” run chart here, and update this each month. See the example run chart

below. Customize the run chart

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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

Catheter Associated Urinary Tract Infections

Run Chart Tips

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• Cut and paste graphs from the improvement calculator (link)

• Customize the heading of each slide

• Utilize labels or a sub header to tell the story

The Improvement Calculator

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AEAs 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 # of women with deliveries:

HAPU # of discharges:

SSI # of inpatient surgeries:

VAE # 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: The Areas of Risk We Are Committed To Controlling

Annual discharges: __________ AEA risk opportunities/discharge: _______

Slide 4

Customize the risk opportunities/discharge

Customize the annual discharges

Risk Profile Tips

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• These calculations only need to be completed once

• Use one year of data – using baseline

• For Patient Counts for CLABSI, CAUTI, VAEo Use charge master for # of

catheter trays ordered, or # of patients with ventilator charges, or divide your device days by average length of stay

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Improving Harm Rates (/ Discharge)

AEAs Baseline Rate[time period]

Target Rate Current Rate[time period – last 3 months]

Improvement Status (scale)

ADE

CAUTI

CLABSI

Falls

OB

HAPU

SSI

VAE

VTE

EED

Total

       Readmit        

Insert a your harm rates per discharge here, using the following table. For

non-applicable topics – please insert “Z”.

Customize the baseline, target and current rates and improvement scale

Improvement Scale

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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

Hospital Risk Score Card

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Our Safety MandateAnnual Volume (Discharges)Total risk: annual harm opportunitiesRisks per patients (Total Opportunities)/Discharges)

Number of Risk AreasNumber of Risk Areas Applicable (0 – 11)Number of Risk Areas Applicable & Adopted

Our ProgressNumber of Areas with Major Improvement OpportunityNumber of Areas at Improvement TargetNumber of Areas at IDEAL

Insert your risk score card here, using the following table:

Customize your score card

Hospital Risk Score Card Tips

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• 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

Patient and Family Engagement (PFE) Involvement

• Quote from the patient and family advisory council (PFAC) member / advocate. For example: “What is the most powerful PFE action your hospital took to bring the voice of the patient into its safety program?”

Photo of Patient Advocate

What has your hospital done for you and your community?

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PFE Involvement Example Joe Clothier

Patient Advocate Council and Member of the Quality

Council“It is impressive to me that

Logansport Memorial Hospital is excited about including patient’s input as a necessary component

of their Quality Improvement Philosophy. Asking members of the community to be part of the Patient Advisory Committee, and

having a Patient Advocate Council Member as a member of

the Quality Council can, with time, open up needed dialogue between patients and LMH. I

believe this is a huge step towards improving the level of care given to patients in the

Logansport area.”

PFAC InsightWhat insight or feedback does your PFAC have for organizational leadership? For Frontline staff? For other patients and family members?

• Quote from the PFAC / advocate. For example, “What took you time to learn, that others could avoid, when working with leadership? Frontline staff? Other patients and their family members?

Photo of Patient Advocate

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Pearls

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• 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)

Slide 7

Customize your pearl

Pearl Tips

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• Provide enough detail about the strategy or tactic to promote spread. For example, ask yourself: “Can the reader get enough information to replicate the idea?”:

• Provide examples of key cultural change strategies, i.e.o Transparency of datao Front line staff engagemento Senior management supporto Seamless transitionso Recognitiono Promoting a Culture of Safety

• Share learning's and ideas tested• Highlight how strategies be taken to the next

level

Submission Process

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• We encourage you to submit your Eliminating HAB Report for the upcoming Quality & Safety Roadmap Meeting, as well as on our SLHQ Members LISTSERV®: AHA-SLHQ@ahals.aha.org

• For more details - please contact us! See the following slide for contact information.

Questions? Contact Us!

Website: www.aha-slhq.org Email: slhq@aha.org

LISTSERV®: AHA-SLHQ@ahals.aha.orgPhone: (773) 270-3127

Office: 155 N. Wacker Dr., Ste. 400Chicago, IL 60606

Dr. Maulik Joshi: Senior Vice President, AHA and President, HRET (mjoshi@aha.org)Charisse Coulombe, Vice President, HRET (

ccoulombe@aha.org)Jessica Blake, Senior Program Manager, HRET (jblake@aha.org)

Natalie Erb, Administrative Fellow, HRET (nerb@aha.org)

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