Improving Harm Across the Board

1. Improving Harm Across the Board Dalton, Georgia

2. 2012 Breakthrough in Identification of HARM:

3. Increased Identification

4. Slide 4

5. Pearls • Leadership commitment and their active involvement in quality and safety initiatives are critical to creating a Safety Culture. • The responsibility for preventing patient harm lies with everyone in the organization. • The Patient Safety Committee must be multidisciplinary and involve staff at all levels. • Use Root Cause Analysis when reviewing harm events and near misses to identify opportunities for improvements that may otherwise be overlooked. • Use small test of change prior to implementing house-wide initiatives. • Communication and teamwork are key ingredients to success. • Celebrate successes and recognize staff contributions. • Seek ways to involve patients and family members in safety initiatives.

6. DefiningMoment(s) In Our Journey • Defining Moments • Completion of Organizational Culture of Safety Survey-March, 2012 • Completion of Organizational Assessment Tool- March, 2012 • Completion of Employee Satisfaction Survey-September, 2012 • Implementation of CMS 40/20 by 2013 Hospital Engagement Network initiative in 2012 • Moments that resulted in a big breakthrough in the organization’s ability to deliver safety • Expansion of Patient Safety Committee to include non clinical departments • Increased use of Root Cause Analysis • Involvement of front-line staff • Development of Culture of Safety Steering Committee with Executive Leadership champions • Formal leadership rounding process and reporting mechanism • Annual Patient Experience and Culture of Safety Fair

7. Risk Profile by Areas of Risk # Risks per patient: 1.77

8. Improving HAC Rates (per discharge)

9. Our Hospital Risk Profile & Result

10. Future Actions to Reduce Harm • Continue focus on overall harm • Increase use of Root Cause Analysis • Greater focus on transition of care and readmissions • Increase patient and family involvement in safety and quality initiatives and teams • Continued involvement of front line staff and use of multidisciplinary safety team • Expansion of formal Leadership Rounding Process to include patients and family members

11. Photo of Hospital CEO &Safety Team