1. Improving Harm Across the Board

2. TEMPLATE GUIDE • Treat harms as events that can be summed • Focus on harms (outcomes) rather then preventive measures (process) • Special conditions can be considered a harm (e.g., EED, Readmits, …) • Produce an overall harm trend for the hospital (**Delete this slide when content of presentation is complete)

3. 2012 Breakthrough in Reducing HARM: 250 to 50 harms/1,000 discharges Exclusion: Calculation above does not include Readmission Data (2011 data is baseline) VTE)Note: VTE data reflects Patient’s with CMS Codes 453.40, 453.41, 453.42, 453.50, 453.51, 453.52, 453.72, and 453.82 Our past coding did not always assign present on admission or hospital acquired VTE. Data shown includes all patients with VTE codes (listed above) that were not coded as present on admission.

4. Cut “harm across the board” in half: 60 patients per quarter to under 30 Exclusion: Calculation above does not include Readmission Data (2011 data is baseline) Note: VTE data reflects Patient’s with CMS Codes 453.40, 453.41, 453.42, 453.50, 453.51, 453.52, 453.72, and 453.82 Our past coding did not always assign present on admission or hospital acquired VTE. Data shown includes all patients with VTE codes (listed above) that were not coded as present on admission.

5. 2012 Breakthrough in Readmission: From 20% of discharges to 10% of discharges

6. 2012 Breakthrough in Reducing Readmissions: From 50 per quarter to 25 per quarter

7. Pearls • Please list the drivers of safety that produced these results. • Include one about patient and family engagement, if relevant

8. DefiningMoment(s) In Our Journey • Name and date one or two defining moments. • Moments that caused the organization to commit to extraordinary safety. • Moments that resulted in a big breakthrough in the organization’s ability to deliver safety.

9. Strategies to Drive Results • What challenges did you encounter that you were able to overcome to achieve the results you are presenting here? • What were the strategies you used to overcome them?

10. Risk Profile by Areas of Risk

11. Improving Harms by HAC • Scale: number of hospital-acquired conditions (HACs) at each level • IDEAL: level represents what we see as best possible • At Target: level represents meeting improvement target • Progress: level not yet at target • Opportunity: level represents an improvement opportunity (**Delete this slide when content of presentation is complete)

12. Improving HAC Rates (per discharge)

13. Our Hospital Risk Profile & Result

14. Future Actions to Reduce Harm • What other actions will you take to reduce harm in the future?

15. Photo of Hospital CEO &Safety Team