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Georgia Hospital Engagement NetworkPatient and Family Centered Safe Care

Putting Patients First

Celebrating Our Success

Continuing Our Positive Net Forward Energy

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State of the GA HEN

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Go Georgia!!

We Have Saved So Far….

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Georgia’s Improvement Measures Up

Georgia Success Stories

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Great Partnerships = Great Results!!

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Implementing Evidence Works!!!

Glycemic Control – Under Control!

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INR - Pocket of Excellence

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Decreases Need to Be Spread and Sustained

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Culture Change in Periop Areas Leads to Lower SSIs

Success Then Plateau ….Change is holding at 7.7%

Georgia’s readmission rate per 1,000 beneficiaries

ranks in the middle of the country

Reducing Readmissions -- 2011 – 2012Progress is being made!

Moving Forward in 2014

Success Needs to Spread and Accelerate!!!

Moving Forward in 2014

Safety Across the Board

for

Patients and Staff

Safety will not happen without intentional strategy

Safety is not in addition to..

it is the strategy

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Focus 2014: Safety Strategy

• Safety Ownership & Accountability for All• Leaders (at all levels) change things!• All voices heard • Align all topics where they intersect• Rapid cycle reduction of all harm • Adopt first, amend second• Standardized tools locally implemented

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Net Forward Energy!!!!

All Teach, All Learn

The Answer Is In This Room!

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Leaders Make Change Happen!!!

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2014 GHA Board of TrusteesPatient Quality and Safety Commitment

• Your accomplishments resulted in Georgia being one of only six recipients of the Leading Edge Advanced Practice Topics funding.

• With third-year funding comes a greater emphasis on: – patient and family engagement

– eliminating health disparities – enhanced rapid cycle improvement to reduce Catheter

Associated Urinary Tract Infections (CAUTI) and readmissions.

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Georgia Hospitals Recommit to Goals and Focus Areas

• Safety Across the Board

• Meeting 40/20 Goals

• Reduce Catheter Associated Urinary Tract Infections (CAUTI)

– Address the hospital’s culture, criteria, care, competency and communication in reducing CAUTIs.

• Concentrate on patient and family engagement

• Reduce Readmission– Use of the 12 point bundle of project RED shown to reduce

readmissions which includes, patient education, medication management, and follow-up.

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Georgia Hospitals Recommit to Goals and Focus Areas

Enhance Patient and Family Engagement (PFE) in Eliminating Health Disparities•Prior to admission, hospital staff provides and discusses a discharge planning checklist with every patient who has a scheduled admission, allowing questions or comments from the patient or family (e.g., the planning checklist may be similar to the CMS Discharge Planning Checklist)

•Hospital conducts shift change huddles and does bedside reporting with patients and family members in all feasible cases.

•Hospital has a person or functional area, that may also operate within other roles in the hospital, that is dedicated and proactively responsible for patient and family engagement and systematically evaluates

•PFE activities (e.g., open chart policy, PFE trainings, establishment and dissemination of PFE goals).

•Hospital has an active PFE Committee OR at least one former patient who serves on a patient safety or quality improvement committee or team.

•Hospital has at least one or more patient(s) who serve on a governing or leadership board and serves as a patient representative.

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Focus 2014: Increasing the Voice of the Patient and Family

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Focus 2014: Readmissions

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Focus 2014: Readmissions Goal

To Reach Our Goal - 9%

9,000 individuals

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Focus 2014: Ramp Up Readmissions

• All 12 components of Project RED

• 4 Basic Principles of Patient Centered Care

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Focus 2014: CAUTI

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Focus 2014: Stop CAUTI!!

• Rapid cycle change to further decrease unnecessary urinary catheter utilization including nurse removal process

• Focus on ED and OR utilization

• Adopt then adapt

• Urinary catheter focus during rounding and bedside handover

• Observation and inquiry every day to assess necessity

• Fully engage staff, patients and families in this work

HAI Affinity Group webinar : CAUTI: A Hospital Success Story, January 22, 11 -11:45 am

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Focus 2014: New Safety Topics

• OB Adverse Events

– Postpartum Hemorrhage

– OB Trauma with/without instrumentation

• ADEs

– Opioid Safety

• HAI

– Focus on SSI

– VAE (IVAC, Possible, Probable VAP)

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Focus 2014: Expanded Data Requests

• New HAI Data Submission for 2014

–All inpatient CLABSI and CAUTI

–Additional SSI: Hip and knee prosthesis

–VAE: IVAC, Possible, probable VAP

• ADE – Opioid Safety

• Monitor SCIP: VTE:1 and VTE:2 from Core Measure data

GAPP /LEAPT : Innovation to Improve Safety

Topics

• Sepsis

• C. difficle with antimicrobial stewardship

• Procedural Harm

• Failure to Rescue

• Culture of Worker Safety

• Atlanta Medical Center

• Chatuge Regional Hospital

• Crisp Regional Medical Center

• DeKalb Medical Center

• Doctors Specialty Hospital

• Effingham Health System

• Floyd Medical Center

• Habersham Medical Center

• Midtown Medical Center

• Newton Medical Center

• Northside Medical Hospital

• South Georgia Medical Center

• Spalding Regional Medical Center

• St. Mary's Healthcare System

• Ty Cobb Regional Medical Center

• Union General Hospital

• University Hospital

Call to Action on Sepsis from GAPP

Action Required Now to Save Lives!!!!

Learn. Act. Improve. Spread

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Fighting Sepsis:Actions You Can Take Today to Save Lives

Implementing the Surviving Sepsis Campaign Bundles can reduce the

mortality from severe sepsis an septic shock.

•Identify local champions and form a multidisciplinary committee to support

bundle implementation:

– Consider the ED, Inpatient Staff, ICU, Administration, pharmacy,

pediatrics, nursing and infection prevention, etc.

•Educate your staff and present the evidence.

•Break it down into manageable pieces and pick an area of focus:

– Measure lactate at time of triage for patients who meet SIRS criteria

– Reduce time to antibiotics

– Administer at least 30ml/kg fluid bolus within three hours

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Fighting Sepsis:More Actions You Can Take Today

• Time is critical!

• Prioritize pts with SIRS criteria from triage

• Create protocols and order sets which empower nurses and

reduce delays

• Don’t let a prolonged search for source delay the

administration of antibiotics

• Track your data and provide feedback to providers

• Let staff know how they are doing & celebrate success

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Fighting Sepsis:More Actions You Can Take Today

• Implement ‘Code Sepsis’ to emphasize the importance of immediate treatment.

• “Say Sepsis” - use the word sepsis early.

• Utilize your EHR to create sepsis alerts and order sets

– e.g., Link lactate order with blood culture orders so you have to opt out of the lactate measurement

• Create posters with your sepsis protocol and post them prominently

• Educate families on red flags–make them a member of the team.

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Preparing for 2014 HEN Kickoff : Feb. 6

Request•Analyze data, identify units for improvement

•Have Staff Complete the Staff Safety Assessment

•Give feedback back to the staff

•Prioritize work on each unit

•Bring results with you to kickoff

Let’s Celebrate the First 2 Years

In appreciationExecutive Quality Advisory Committee

• Steve Mayfield, Medical Center of Central Georgia

• Mindy McStott, Tift Regional Medical Center

• Norma Jean Morgan, Effingham Health System

• Heidi Nelson, University Hospital

• Teri Newsome, Habersham Medical Center

• Mary M. Pizzino, Effingham Health System

• Sherry Sweek, Southeast Georgia Health System

• Tina Thomas, Ty Cobb Regional Medical Center

• David Andrews, Patient Advocate, Georgia Regents Medical Center

• Sheila Bennett, Chair, Floyd Medical Center

• Susan Bowen, Shepherd Center

• Montez Carter, Good Samaritan

• Nicole Franks, MD, Emory University Hospital Midtown

• Freya Gilbert, Columbus Health

• Roy Gilbreath, M.D., DeKalb Medical

• Babs Hargett, Emory Healthcare

• Angie King, St. Francis Hospital

Sharing Our Success Nationally

NAME HOSPITAL Angie King St. Francis Hospital Susan Bowen Shepherd Center Teri Newsome Habersham Medical Center Freya Gilbert Columbus Regional Health Nancy Curdy Dekalb Medical Bernard Roberson Georgia Regents Medical Center Norma Jean Morgan Effi ngham Health System Mary Pizzino Effi ngham Health System Brandon Reece Floyd Medical Center

2013 Leaders Circle Award Winners

Congratulations!!

Let’s Celebrate Our Work!

Thank You for Making Patients Safer!