Transcription
Keeping Patients SafeLeslie Safier, Adrian Smith, LisaWinston
ZSFG TRUE NORTH6/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center2
ZSFG A36/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center3
BACKGROUND Adverse patient outcomes, including infections andfalls, increase the costs of health care, affectreimbursement, and decrease value to the patient. ZSFG leadership prioritized safety through the Hoshinprocess in FY 16-18, and saw significant reductions inharm events. The focus shifted in FY 19-20 to support value-basedpayment programs and PSI-90. With the change in executive safety focus, transitionto the Epic system, and the COVID-19 pandemic, wehave seen an increase in harm events.6/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center4
CURRENT CONDITIONSKey PointsSupporting Data The rate of catheterassociated urinary tractinfection in FY 19-20 was thehighest rate in the last 6 FY. We are starting to see animprovement in our colonsurgical site infection metric. We have seen an increase infalls with major injury from 3 in2019 to 13 in 2020. Despite increasing infectionmetrics, the task forces workingon these topics have not beenas active as they were in prioryears.6/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center5
PROBLEM STATEMENT In FY 19-20, ZSFG patients experienced 109instances of the targeted preventable harmmetrics and ZSFG fell below national safetyand value-based care benchmarks.6/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center6
TARGET AND GOALS The patient safety composite strives to meet 3of the 4 targets each month.6/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center7
COUNTERMEASURESProposed CountermeasureCompletion DateStatus UpdateClearly identify and define safety indicators andgoals to include in a ZSFG safety composite score12/1/20CompletedCreate workgroups around each prioritized harmevent1/31/21CompletedAlign harm dashboard with harm target goalsand priorities3/1/21CompletedCatchball A3s for CAUTI, CLABSI, Colon SSI andFalls with Injury4/26/21CompletedSupport countermeasure implementation andassist with barrier removal for harm workgroups1/31/21Ongoing6/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center8
ICU CAUTI A36/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center9
ACHIEVEMENTS On-target for Colon SSI and CLABSI6/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center10
NEXT STEPS PDSA countermeasures to reduce CAUTIincidence in the ICU. Spread successfulcountermeasures to Med-Surg setting asappropriate. PDSA countermeasures to reduce falls throughDMS system. Join Hospital Services Advisory Group fallprevention peer group. Support Enhanced Recovery after Surgery(ERAS) EPIC pathway.6/16/2021Zuckerberg San Francisco GeneralHospital and Trauma Center11
Zuckerberg San Francisco General Hospital and Trauma Center 2. ZSFG A3 6/16/2021 Zuckerberg San Francisco General . Zuckerberg San Francisco General Hospital and Trauma Center 5. PROBLEM STATEMENT In FY 19-20, ZSFG patients experienced 109 . Support Enhanced Recovery after Surgery (ERAS) EPIC pathway.
