1 Beds Avg. Daily Census 114 34.3 2 Highlights and - - PowerPoint PPT Presentation

Beds

• Avg. Daily

Census 114 34.3

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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

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Dawn Barlow, M.D. IM/Hospitalist April 2016 Courtney Cummings, M.D. IM August 2017 Kurt Gilbert, M.D. IM/Hospitalist August 2017 Lindsey Myers, M.D. FP/OB August 2017 Nick Clough, MD FP August 2017 Andrew Todd, D.O. IM/ID July 2016 Martha Moore, M.D. FP November 2016 Rory Lewis, M.D. Orthopedic Surgery September 2017

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IT’S A TEAM EFFORT!

163 114 100 85 66 44

2012 2013 2014 2015 2016 2017 Harm Rate: 10.616 Harm Rate: 7.798 Harm Rate: 7.105 Harm Rate: 6.070 Harm Rate: 3.741

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CDI implementation HARMs Committee Daily Patient Safety Brief NQP Journey Began March 2016 5 Foundational Tool’s Implemented Leadership Rounding – 2nd Qtr Leadership Rounding Validation 4th Qt Just Culture Antibiotic Stewardship

Harm Rate: 7.926

LRH Total Harms YOY - December

LRH Total HAP’s YOY - December

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47 33 26 17 12 9

2012 2013 2014 2015 2016 2017

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2.03 2.22 2.1 2.14 0.72 0.81 2012 2013 2014 2015 2016 2017 - Nov.

LRH Mortality Rate YOY

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• Human error is not punished, but we

acknowledge those errors and find solutions for correction.

• We will not shame staff for mistakes, but

rather will work to educate and retrain staff without public humiliation.

• Reckless behavior will not be tolerated.
• Our Just Culture will ensure accountability

for actions and commitment to improvement.

• We encourage staff to report problem

methods or protocol so that change can be made.

• Just Culture is the key to quality, patient safety,

support of physicians, employee resilience, and community pride in our hospital.

• Our Just Culture focus ensures the highest

quality of care to each patient delivered in a culturally sensitive, compassionate and respectful manner.

• We all encounter issues, large and small where

a uniform and systematic approach to interpreting the situation is interpreting the situation would be valuable.

• A Just Culture supports a “learning
• rganization.”

ADVANCING THE CULTURE

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How We Got There

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• 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

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

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Contact Information

MAKING

COMMUNITIES

HEALTHIER

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