We had 32 harm events in 2021 and we were able to reduce the overall number of harms to 24 in 2022 (which was our regional goal). The Quality Director, with the assistance of a physician dyad Quality Medical Director collaborator, partnered with Operational Excellence and our Business Analytics partners to create a multi-disciplinary structure both locally and regionally, to look at overall harm events, create dashboards to help visualize our data, and ultimately reduce the overall number of harm events. Our region is a busy 4-facility group in the Midwest, part of a larger 16-hospital system. Our region contains 3 hospitals and 1 critical access hospital.
Problem: We were attempting to lower the number of our overall harm events (CLABSI, CDIFF, and CAUTI) to meet our 2022 harm goal
Measurement: We began with a spider diagram to visualize who we wanted to include in our multi-disciplinary team (including Pharmacy for antibiotic stewardship), CNS (for overall clinical expertise and knowledge of evidence-based medicine), and PT/OT for optimizing mobility. We created a Gantt chart to track our progress and developed an A3
Analysis: We utilized Microsoft forms to gather CLABSI/CAUTI bundle elements and then tracked those metrics, as well as overall metrics that led to harm events in Power Bi dashboards for each harm event at each facility and regionally
Implementation: We implemented a CDIFF algorithm and real-time physician education to help reduce the number of CDIFF orders, we increased our utilization of external catheters (instead of indwelling catheters), and we implemented daily quality/safety facility huddles at each site in our region to discuss lines and indication house-wide
