Improving Harm Across the Board

Sibley Memorial Hospital

Washington, D.C.

The Sibley mission is to provide quality health services and facilities for the community, to promote wellness, relieve suffering, and to restore health as swiftly and safely as can be done, consistent with best service.

Presenters:Deb McDonough, RNPeggy Moy, RNMichael Brinkman, RNKathy Guggino

2

2012 Improvement in Readmission*: (54 Fewer Readmitted Patients)

*all cause 30 day readmissions

Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 20130

50

100

150

200

250

211 207

183192

174

195 190180

2012 Improvement in ReadmissionFrom 7.3% to 7.0%

30-Day all cause readmits

All C

ause

30

Day

Ream

its

Sibley Improving Harm Rates

HACs Baseline Rate[CY2011]

Target Rate10% improvement

Current Rate[CY2012]

Improvement Status (scale)

ADE 116/11052= .0104 .0103 122/10617= .0115 Opportunity

CAUTI 11/518=.0212 .0191 9/681=.0132 Exceeds Target

CLABSI 5/639= .0078 .0071 5/556= .0089 Opportunity

Falls 3/11052=.0003 .00027 2/10617=.00018 Exceeds Target

Ob AE 5/3581=.0014 .0013 7/3405=.0020 Opportunity

Pr Ulcer 3/11052=.0003 .00027 1/10617=.0001 Exceeds Target

SSI 47/2525=.0186 .0168 20/2415=.0082 Exceeds Target

VAP 0/216=0 0 0/161=0 Ideal

VTE 13/11052= .0012 .0011 5/10617= .0005 Exceeds Target

EED 0/3581=0 0 0/3405=0 Ideal

       

Readmit  793/11052=.072  .065  739/10617=.069  Near Target

Pearls

• Engagement of frontline staff in CUSP (Comprehensive Unit-Based Safety Programs)

• Use of proactive risk assessment to evaluate availability of assistive devices and equipment on all inpatient units

• Development of Safe Patient Handling Protocol

Our Hospital Risk Score Card CY 2012Our Safety Mandate

Annual Volume (Discharges) 10617

Total risk: annual harm opportunities 53091Risks per patients (Total Opportunities)/Discharges) 5.0

Number of Risk AreasNumber of PfP Risk Areas Applicable (0 – 11) 11Number of PfP Risk Areas Applicable & Adopted 7

Our ProgressNumber of PfP Areas with Major Improvement Opportunity 3Number of PfP Areas at Improvement Target 5Number of PfP Areas at IDEAL 2