1 Beds Avg. Daily Census 114 34.3
2 Highlights and Celebrations • Joined HIIN in 2016 • YOY 2016 – 2017 Overall Harms Reduction by 38.36% • Antibiotic Stewardship Program Implemented August 2017 • Hospital Medicine Service Line Advancement August 2017 • New Primary Care Physicians • Readmission Penalty Reduction from 3% to 1.5% • Healthstream Excellence through Insight Award for most improved physician engagement August 2017 • 2017 YTD Mortality Index 0.81
3 Andrew Todd, Nick Clough, MD D.O. Courtney Cummings, FP Martha Moore, M.D. IM/ID M.D. August 2017 FP July 2016 IM November 2016 August 2017 Kurt Gilbert, M.D . IM/Hospitalist August 2017 Lindsey Myers, Dawn Barlow, M.D. Rory Lewis, M.D. M.D. IM/Hospitalist Orthopedic Surgery FP/OB September 2017 April 2016 August 2017
4 IT’S A TEAM EFFORT!
LRH Total Harms YOY - December 5 Leadership Rounding – 2 nd Qtr NQP Journey CDI implementation Leadership Rounding Validation 4 th Qt Began March 2016 HARMs Committee 163 Just Culture 5 Foundational Tool’s Implemented Daily Patient Safety Brief Antibiotic Stewardship 114 100 85 66 44 Harm Rate: Harm Rate: Harm Rate: Harm Rate: Harm Rate: Harm Rate: 10.616 7.926 7.105 7.798 6.070 3.741 2012 2013 2014 2015 2016 2017
LRH Total HAP’s YOY - December 6 47 33 26 17 12 9 2012 2013 2014 2015 2016 2017
LRH Mortality Rate YOY 7 2.22 2.1 2.14 2.03 0.72 0.81 2012 2013 2014 2015 2016 2017 - Nov.
8
9 ADVANCING THE CULTURE • Just Culture is the key to quality, patient safety, • Human error is not punished, but we support of physicians, employee resilience, and acknowledge those errors and find solutions community pride in our hospital. for correction. • Our Just Culture focus ensures the highest • We will not shame staff for mistakes, but quality of care to each patient delivered in a rather will work to educate and retrain staff culturally sensitive, compassionate and without public humiliation. respectful manner. • Reckless behavior will not be tolerated. • We all encounter issues, large and small where • Our Just Culture will ensure accountability a uniform and systematic approach to for actions and commitment to improvement. interpreting the situation is interpreting the • We encourage staff to report problem situation would be valuable. methods or protocol so that change can be • A Just Culture supports a “learning organization.” made.
How We Got There 10 - Leadership Development - Advancing the Culture - Visual Accountability for Leadership Rounding - 5 Foundational Safety Tools Competencies - 100% Directors - Leadership Rounding Validation - audit tool for accountability - Successful Readmission Coalition - LEAD Measures – tracers for validation - Performance Improvement with Data Transparency in each department
Contact Information 11 Marcy Dickerson RN, BSN, CPPS Chief Quality Officer Livingston Regional Hospital Phone: 931-403-2321 Marcy.Dickerson@lpnt.net Penny Kirby RN, MSN Chief Nursing Officer Livingston Regional Hospital Phone: 931.403.2127 Penny.Kirby@LPNT.net
12 MAKING COMMUNITIES HEALTHIER
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