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1. Slide 1 Eliminating Harm Across the Board Mary M. Pizzino, Executive Director, Informatics/Quality Data Management

2. Our Mission To provide access and delivery of quality, cost effective, community based healthcare to all the citizens of Effingham County. Our Vision Every patient will experience compassionate, quality care and service at a level of excellence that will make Effingham Health System the healthcare provider of choice. Our Valued Principles We believe the success of Effingham Health System is directly related to the values we hold, share, and practice. These values must form the basis for every action we take toward patients, families, physicians, volunteers, and each other with commitment to: Quality Service Compassion Leadership Education Accountability Teamwork Creativity Slide 2

3. Adverse Drug Events (ADE)

4. Readmissions –All cause

5. Pearls • Collaboration from Medical Staff • Involvement of multi-disciplinary team members • Education of staff • Commitment from Administration • Standardization of E.H.R.

6. DefiningMoment(s) In Our Journey • 2012: Realization that all ADE’s were not being included in our data collection. • Implementation of remote Pharmacy • Medication Management in-service • Increase of ADE reporting by nurses • Computer Based Learning Modules • 2012: Realization that the discharge instructions were not always understood/followed by the patient. • Review of all readmissions • Identified the top ten re-admission diagnoses • Developed post-discharge call backs by nursing • Reviewed/revised patient education • Implemented pharmacy rounding

7. Breakthrough Strategy • ADE: Encouraging nursing to view reporting as an opportunity to improve patient safety; not as a “black mark” on their individual performance. • Readmissions: Helping nursing understand that patient education does not end at the time of discharge.

8. Slide 8 Risk Profile: The Areas of Risk We Are Committed To Controlling Annual discharges: _239__ __________ HAC risk opportunities/discharge: 4.60 %

9. OUR IMPROVEMENT JOURNEY: It’s all about “always” giving the best possible care. Slide 9 Number of risk areas (0-11) at each stage Improvement Scale:The stages we moved through • IDEAL: level represents zero harm • At Target: level represents meeting target for improvement • Progress: level shows improvement but not yet at target • Opportunity: level is an opportunity to launch aggressive action for improvement 5 __________ 0 __________ 2 __________ 1 ___________

10. Getting to ZERO Harm • Our journey began in 2012 with a base rate of 239 annual Inpatient discharges. • ADE’s, Falls and Readmissions were areas for improvement • HAI (Hospital Acquired Infections) is an area of strength. Our clinical staff is diligent following infection control protocols/processes.

11. Improving Harm Rates (per discharge)

12. Our Hospital Risk Score Card

13. QUALITY AND PATIENT SAFETY TEAM Norma Jean Morgan, CE0 Joseph Ratchford, MD, Quality Medical DirectorClaude Sanks III,MD, Hospitalist *Mary Pizzino, Exec. Dir. of Informatics/Quality *James Edwards, RN, Quality and Risk Management *Sara Corley, RN Quality Nurse*Jeff Boswell, RN Informatics Nurse Durwin Logan, Director of Pharmacy*Linda Rigsby, RN, Nursing Council Shirley Rahn, RN, Nursing Council*Amy Roddenberry, RN, Senior Staff Nurse Jane Miller, Infection Preventionist Erin Conway, Core Measure Coordinator *Monica Jones, Data Resource SpecialistMatthew Moore, Decision Support *Denika O’Rourke-Systems Trainer*Karen Harden O’Neal, HIM Coordinator  Marie Livingstone, CNO*Pictured Team Member’s

14. Next steps to Reduce Harm • Implementing additional protocols for patient care • Increasing the use of CPOE (computerized physician order entry) to assist in the reduction of medication errors • Implementing standardized order sets • Implementing Electronic physician documentation to improve patient care and reduce errors due to illegibility

15. Slide 15 QUESTIONS?