quality & safety report 2014

QUALITY & SAFETY REPORT

The Christiana Care WayWe serve our neighbors as respectful, expert,

caring partners in their health. We do this by creating

innovative, effective, affordable systems of care

that our neighbors value.

2014 Qua l i t y & Sa f e t y Repor t | 1

QUALITY and SAFETY DRIVE CULTURAL TRANSFORMATION

CHRISTIANA CARE’S NEWLY TRANSFORMED QUALITY AND SAFETY PROGRAM provides the framework for our cultural transformation toward value. It aligns priority areas with the health system’s annual operating and long-term strategic goals of enhancing the safety of patients and employees, increasing health care value, and developing efficient and affordable population-based models of care.

Interdisciplinary collaboration and teamwork are paramount, and success is both apparent and motivating. The number of patients harmed is down by 60 percent over the past four years — 12 percent compared to last fiscal year alone — reinforcing our commitment to our culture of safety. Significant improvements in clinical quality, high reliability and cost reduction include: a 78 percent reduction in ventilator-associated pneumonia and central-line-associated bloodstream infections; 100 percent compliance with Surgical Care Improvement Project measures, such as appropriate prophylactic antibiotic selection and venous thromboembolism prophylaxis aimed at reducing post-operative complications; and a 34 percent reduction in unplanned 30-day hospital readmissions for patients with heart failure.

The estimated cost savings from reduction in patient harm exceeds $98 million. Fundamental to this success was recognizing that in order to improve the value of care, we needed to advance our method for measuring and reporting health care safety, quality and costs in a way that was engaging and motivational to transform our organization and culture to “value-driven” care.

2 | Chr is t iana Care Heal th System

4 | Creating a Safe Culture

28 | Achieving High Reliabi l i ty

44 | Leveraging Technolog y

58 | Awards, Recognition & Accomplishments

60 | Our Journey

Value Improvement Teams

Intrinsic to our new Quality and Safety operating system are interdisciplinary unit- and population-based value improvement teams. Led by physician and nurse pairings, these teams include physicians, nurses, respiratory therapists, pharmacists, dietitians, care managers, social workers, environmental services staff, pastoral care and others who serve patients directly or indirectly. Furthering our commitment to patient- and family-centered care, teams are encouraged to include patient and family advisers to help the team resolve issues and improve performance. Ensconced in a Culture of Responsibility, the system drives accountability into daily work responsibilities, promotes immediate actions to resolve issues, encourages staff “Good Catches” and places the ability to “just fix it” at the local level.

Collaboratives bring several patient care units together to identify ways to improve performance or to share and implement findings more broadly. While units face unique challenges based on patient population, sharing insights and solutions that enhance value for patients is an efficient, effective way to stimulate learning and improvement.

Value score cards help unit- and population-based value improvement teams to measure success and identify opportunities for improvement. The score cards track metrics such as mortality, 30-day readmissions, evidence- based guideline compliance and patient experience for population-based teams. For patient care units, the score cards track hand hygiene, falls, hospital-acquired infections, patient experience and other metrics. Scores are calculated for each metric based on its ratio to the goal or target, normalized to a 100-point scale and assigned a standard letter grade.

Value Institute Academy

The Christiana Care Value Institute and Value Institute Academy offer a formalized approach to physician, resident and staff education and training toward the pursuit of improvement and reliability of care. The academy maximizes individual and team abilities to innovate and drive scientifically based improvements in health care delivery. For example, in the award-winning quality-improvement and patient safety course called Achieving Competency Today (ACT) Issues in Health Care Quality, Cost, Systems and Safety, learners work together in diverse, interprofessional teams to identify an improvement opportunity, review literature and best practices, and design and present an evidence-based improvement project mirroring Association of American Medical Colleges Team for Quality report recommendations.

In this report:


Recognizing success

This year we introduced the Unit-Based Value Improvement Team Recognition Program to highlight team success in achieving significant and measurable improvements in clinical quality, patient safety, patient- and family-centered care, compliance with evidence-based best practices, and reduction in costs. The Wilmington Intensive Care Unit and the Surgical Care Improvement Project value improvement teams were first to be honored.

Our annual Focus on Excellence Value Institute Awards Ceremony highlights work by more than 100 teams innovating improvement throughout the year. And our employee gain-sharing Transformation Rewards Program recognizes individual and collective efforts to improve quality, safety, patient experience and financial strength.

Transformation to value is palpable

Although much has been written about bending the cost curve, the real health care challenge facing our nation is not costs, but something more significant: value. At Christiana Care, the value proposition for health care is rooted in the fundamentals of good medicine: listening to the wants and needs of patients, partnering with patients in their care, ensuring the highest quality and safety in caring for patients, and evaluating the cost of care.

The transformation is palpable. We’re named among the 100 Top Hospitals in the major teaching hospital category by Truven Health Analytics. We were recently honored with the top patient safety education award — the 2014 Leape Ahead Award from the American College of Physician Executives —for our multipronged approach to teaching medical students, residents and faculty the principles of patient safety and quality; and we earned a Hospital Safety Score of “A” from the Leapfrog Group, which rates how well hospitals protect patients from accidents, errors, injuries and infections.

Linking value to quality and safety activities provides a framework for creating a safe culture, achieving high reliability and leveraging technology to drive accountability and support innovation. Ultimately, it positions Christiana Care as a national leader in addressing health care resources and population health management, and allows us to serve our neighbors as respectful, expert caring partners in their health.


A SAFE CULTURE

ANAND P. PANWALKER, M.D. Associate Vice President, Medical Affairs and

Assistant Infection Prevention Officer

“When we protect patients — our neighbors and friends — by washing hands and preventing infections, we respect their right to safety and we demonstrate caring. When we prevent even one serious infection, we reduce suffering.”


A mother and child experience the healing power of touch in Christiana Care’s Neonatal Intensive Care Unit.

6 | Chr is t iana Care Heal th System6 | Chr is t iana Care Heal th System

C R E A T I N G A S A F E C U LT U R E

Wilmington Intensive Care Unit leads the charge in reducing hospital-acquired infections

The Wilmington Intensive Care Unit (WICU) Value Improvement Team was first to be honored with Christiana Care’s newly established Unit-Based Value Improvement Team Recognition Award for sustained efforts to reduce preventable harm, most notably:

• Two years without a central-line-associated blood-stream infection (CLABSI).

• One year without a ventilator-associated pneumonia (VAP).

• 17 of 19 months without a catheter-associated urinary tract infection (CAUTI).

“This award is the culmination of three years of working together as an interdisciplinary team, including nurses, physicians, physician assistants, physical therapists, vascular access nurses and staff from Infection Prevention, Respiratory, Pharmacy, Hemodialysis and the Emergency Department,” said Dannette Mitchell, APN, clinical nurse specialist. The current UBVIT carries on the work initiated in 2010 to address CLABSIs with the “Scrub the Hub” program, which took them back to basics with central-line care, then evolved into the Comprehensive Unit-Based Safety Program (CUSP). “We were successful because each team member was personally invested in discovering what our problems were and owning their share of them,” she said.

Motivated by their success with CLABSIs, WICU’s value improvement team started to look at CAUTIs, ventilator-associated events, falls and restraints to see what improvements they could make. The team’s current value score letter grade is prominently displayed for patients, staff and families to see in the unit. While nurse manager Sandy Wakai acknowledges that the data is motivating, and that the WICU is a competitive team that strives for that A, she said, “Our staff sees their success as simply doing the work they should do ―― to provide our patents the best outcome possible.” •

“Our staff sees their success as simply doing the work they should do — to provide our patients the best outcome possible.”

SANDY WAKAI, MSN, RN, CCRNNurse ManagerWilmington Intensive Care Unit

The Wilmington ICU Value Improvement Team.


Christiana Care is the winner of the 2014 Leape Ahead Award from the American College of Physician Executives (ACPE). Leape recognizes Christiana Care’s multipronged approach to teaching the principles of patient safety and quality to medical students, residents and faculty.

“Our programs reflect an institutional priority to build a culture of learning that emphasizes patient safety, professionalism, collaboration, transparency and the importance of the individual learner,” said Hugh R. Sharp, Jr. Chair of Medicine Virginia U. Collier, M.D., MACP. “Our training goal is that the principles of patient safety and team-based care will be inculcated so deeply that learners will instinctively follow best practices without even knowing they are doing so.”

Christiana Care’s departments of Medicine, Family and Community Medicine, Emergency Medicine, Nursing, Patient Safety and Quality, the Learning Institute, the Value Institute, Academic Affairs, Organizational Excellence and the Center for Transforming Leadership collaboratively fashioned an approach to training residents, medical students and faculty that combines didactic and experiential learning in patient safety and interdisciplinary team-based care. Elements include:

f Experiential, project-based performance-improvement education: Residents are required to participate in the 12-week Achieving Competency Today course.

f Resident leadership elective: A two-week, multi-departmental, intensive elective that combines didactic and interactive lectures, field trips and discussions with system and state-level leaders, and ongoing post-course support.

f Train-the-trainer initiative: A nine-month didactic and project-based curriculum in advanced quality and safety improvement science for faculty.

f Administrative fellowship in patient safety and quality: One fellow per year participates in residency curriculum development while focusing on experiential value-based projects, such as appropriate use of telemetry in hospitalized teaching patients.

f Simulation: Residents, students and student nurses collaborate in staged patient-care scenarios to practice difficult patient management, team-based competencies and interprofessional communication skills.

“Our primary targets for the program were resident learners, but our intent was to reach out to all those interested in learning more about quality and safety science to help them in their individual job settings,” said Robert Dressler, M.D., MBA, FACP, vice chair of the Department of Medicine and director of Patient Safety and Quality. “Our program is an essential element in our toolkit for reducing patient harm and achieving high reliability.” •

Christiana Care takes Leape toward quality and patient safetyTop patient safety education award acknowledges approach to teaching

“The evidence is clear: Patient safety is improved when health care professionals work as a team. Christiana Care should be commended for recognizing this need and for its role in taking the initiative to shape the physician leaders of tomorrow.”

PETER ANGOOD, M.D. , FRCS(C) , FACS, FCCM President and CEO, American College of Physician Executives



Achieving top decile performance compared to other hospitals participating in the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture is one of our long-term goals. Christiana Care has historically performed better than the mean of teaching hospitals in almost half of the 12 composites, benchmarked against the Council of Teaching Hospitals and Health Systems (COTH) mean and top decile performance.

Top-performing composite areas remain consistent

Our top performing composite areas, consistent over the past several years, include:

f Teamwork within units.

f Organizational learning and continuous improvement.

f Management support for patient safety (in the top decile nationally).

Composite areas with opportunity include:

f Communication openness.

f Teamwork across units.

f Handoffs and transitions.

f Nonpunitive response to error.

Culture of Responsibility advances safety culturePositions Christiana Care as national leader in safety and quality

Teamwork Within Units

Management Support for Patient Safety

Overall Perceptions of Patient Safety

Frequency of Events Reported

Communication Openness

Handoffs & Transitions

Organizational Learning – Continuous Improvement

Supervisor/ Manager Expectations & Actions Promoting Patient Safety

Feedback and Communication about Error

Staffing Teamwork Across Units

Nonpunitive Response to Error

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Patient Safety Culture Composites

Christiana Care 2013 National Teaching Mean National 90th Percentile

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78.0

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National 90th Percentile Culture of Responsibility Christiana Care

* local level questions

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AHRQ 2013 Survey Results | Goal: 90th Percentile Nationally



In our journey toward a Culture of Responsibility, we are enhancing our efforts to evolve our patient-safety culture. Culture of Responsibility is a commitment to create an environment of shared responsibility among all members of the health care team, including leaders, physicians and staff, and those who create and administer the systems in which care is delivered. The focus is on improving systems and creating a learning environment that encourages colleagues to voice concerns, raise issues and report errors and near misses without fear of retribution or punitive action.

In comparing those units and departments that have implemented Culture of Responsibility programming to the rest of the hospital’s results, there is a statistically significant improvement in several key areas of our AHRQ Hospital Survey on Patient Safety Culture. In 2014, we anticipate even more improvement as we continue our Culture of Responsibility journey and target frontline providers for education and training in these concepts.

Strategies to achieve top decile performance

Multifaceted strategies to advance our safety culture and achieve top decile performance in the AHRQ survey include:

Advance our learning from adverse events and share system improvements more broadly through coordinated efforts.

f Enhance safety issue reporting and staff recognition. Our Good Catch Program encourages staff to report safety issues that have the potential to cause harm to our patients. More than 4,500 reports have been filed since the program’s implementation in March 2012, demonstrating a greater than 200 percent increase in near-miss reporting.

f Hold weekly SAFE Huddles to triage adverse events and safety concerns and promote timely notification and awareness of events. These huddles include an interdisciplinary team that assigns ownership and accountability for follow-up and communication to the appropriate individuals or departments, as indicated.

AHRQ 2013 Survey Results

continued

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Our procedures and systems are good at preventing errors from happening.

The actions of hospital management show that patient safety is a top priority.

In this unit, we discuss ways to prevent errors from happening again.

When a mistake is made that could harm the patient, but does not, how often is this reported?

Hospital manage-ment seems interested in patient safety only after an adverse event happens.

We are informed about errors that happen in this unit.

We are given feedback about changes put into place based on event reports.



Culture of Responsibility continued

f Enact post-event debriefs as a forum for early discussions of adverse events or near misses in a supportive learning environment that focuses on system issues and the caregivers involved.

f Integrate safety practices into our virtual learning environment and simulation activities.

f Partner with the Christiana Care Value Institute Academy to enhance a patient-safety curriculum and maximize both individual and team abilities to lead change.

f Advance culture of patient safety through participation in a pilot program with Nemours/Alfred I. duPont Hospital for Children, initiated and funded by the AHRQ, to help advance the culture of patient safety in our medical community. The program, launched in January 2014, makes it possible for patients and caregivers to report safety concerns, adverse events and errors through a toll-free telephone number and website. The reports are shared with Christiana Care so that we can address opportunities and improve care.

f Participate in the AHRQ demonstration project CandOR: Communication and Optimal Resolution to manage patient safety and medical liability. The focus will be on implementing a toolkit to support better communication and resolution when patients are harmed.

Design safe and reliable systems of care

f Accelerate human-factors science to design systems that are resilient to unanticipated events, aid in technology assessments and yield sustainable change.

f Use team training to support team communication as an intervention to promote a culture of safety.

f Convene improvement collaboratives to address opportunities for improvement at the system and local level.

f Strengthen scientifically based improvements in collaboration with Value Institute scholars.

Promote an open and fair culture and manage behavioral choices

f Adopt a consistent approach to managing adverse events.

f Console professionals who are involved in or make an error; coach those who drift into at-risk behaviors; and discipline reckless behavior.•

Team training in the Virtual Education & Simulation Training Center supports a culture of safety.

Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14Series1 8.5182869647 8.9424572317 7.6616726721 8.4238262536 6.8359375 9.0947368421 7.1562934489 9.8398364287 7.4533186882 9.0710566101 8.9527027027 3.8341029024 6.5302387489 8.2231117299 6.6340633638 7.4682290807 6.9383836621 7.711055176 6.4518867524 4.6102992345 6.8930203246 6.6172995116 6.6502463054 5.13136289 5.9238363893 6.6889632107 5.0784856879 6.035028487 6.0391683202 6.1585835258 5.9982862039 4.9271636675 5.7840616967 5.6126820908 5.698127758 4.6432374867 3.5486212977 3.3258799871 4.0230377865 4.1013085457 3.9252527018 3.6925214039 3.3421351396 3.7784263136 3.3884483437 3.6039916721 3.2804025355 3.5826634044 3.4867220758 2.8675703858 2.8949024544 3.7163855019 3.4391983696 3.2681090473 3.2559724378 2.93189996 3.04099258

0

2.5

5

7.5

10

J A S O N DJ 2010F MAM J J A S O N DJ 2011F MAM J J A S O N DJ 2012F MAM J J A S O N DJ 2013F MAM J J A S O N DJ 2014F M

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$0

$12,500,000

$25,000,000

$37,500,000

$50,000,000

FY11 FY12 FY13 FY14 annualized

$16,884,342

$17,234,557

$20,650,194

$42,374,386

Estim

ated

Cost


Desired Direction

0

2.5

5

7.5

10

Jul-09 Nov-09 Mar-10 Jul-10 Nov-10 Mar-11 Jul-11 Nov-11 Mar-12 Jul-12 Nov-12 Mar-13 Jul-13 Nov-13 Mar-14

Preventable Harm Rate Number of Patients Harmed per 1000 Patient Days

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Harm reduction surpasses goal

Christiana Care surpassed its goal to reduce the number of patients harmed by at least 10 percent over last year, achieving a 12 percent reduction in preventable harm.

This latest success follows a four-year history of reaching the 10 percent reduction goal and has decreased the preventable harm rate during that time from more than 8.5 cases of harm per 1,000 patient days to 3.2 cases per 1,000 patient days.

In addition to the human cost, preventable patient harm adversely impacts Christiana Care’s bottom line. The estimated costs of harm may include additional days in the intensive care unit, and additional treatment costs and medications. Reducing preventable harm by 12 percent in fiscal year 2014 to date saved more than $685,000.

Preventable harm is tracked in five broad categories on the monthly Focus on Excellence Measurement Report:

f Hospital-acquired infections. f Medication safety. f Falls. f Pressure ulcers. f Complications.

Christiana Care follows the broad definition of harm from the Institute for Healthcare Improvement (IHI): “The unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, hospitalization or

results in death. Such injury is considered medical harm whether or not it is considered preventable and whether or not it resulted from a medical error.”

In the spirit of transparency, the report is available to all employees via the Quality and Patient Safety intranet site and is shared bi-monthly with the Quality & Safety Committee of the Board, as well as the Board of Directors. •

Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14Series1 8.5182869647 8.9424572317 7.6616726721 8.4238262536 6.8359375 9.0947368421 7.1562934489 9.8398364287 7.4533186882 9.0710566101 8.9527027027 3.8341029024 6.5302387489 8.2231117299 6.6340633638 7.4682290807 6.9383836621 7.711055176 6.4518867524 4.6102992345 6.8930203246 6.6172995116 6.6502463054 5.13136289 5.9238363893 6.6889632107 5.0784856879 6.035028487 6.0391683202 6.1585835258 5.9982862039 4.9271636675 5.7840616967 5.6126820908 5.698127758 4.6432374867 3.5486212977 3.3258799871 4.0230377865 4.1013085457 3.9252527018 3.6925214039 3.3421351396 3.7784263136 3.3884483437 3.6039916721 3.2804025355 3.5826634044 3.4867220758 2.8675703858 2.8949024544 3.7163855019 3.4391983696 3.2681090473 3.2559724378 2.93189996 3.04099258

0

2.5

5

7.5

10

J A S O N DJ 2010F MAM J J A S O N DJ 2011F MAM J J A S O N DJ 2012F MAM J J A S O N DJ 2013F MAM J J A S O N DJ 2014F M

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$16,884,342

$17,234,557

$20,650,194

$42,374,386Estim

ated

Cost


Desired Direction

0

2.5

5

7.5

10

Jul-09 Nov-09 Mar-10 Jul-10 Nov-10 Mar-11 Jul-11 Nov-11 Mar-12 Jul-12 Nov-12 Mar-13 Jul-13 Nov-13 Mar-14

Preventable Harm Rate Number of Patients Harmed per 1000 Patient Days

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Estimated Cost Savings

Since the launch of the new

hand-washing program in March 2013, demand for sanitizing hand gel at Christiana Care has

doubled.



Christiana Care’s Infection Prevention Committee launched several initiatives to address health care-associated infections. Among them: hand-hygiene surveillance, an intensive employee flu-vaccination campaign and compliance for CLABSI and CAUTI prevention.

Hand hygiene

After several years of “secret shopper” hand-washing observations, the committee determined that the observation methodology had become ineffective. New procedures in FY14 substantially increased the number of staff observing hand-hygiene practices and the number of observations on each patient care unit. More than 1,000 health care workers are now trained to observe and report on hand-hygiene practices, including senior leaders — hand-hygiene champions — assigned to each unit. Nearly 50,000 observations have been completed since July 2013 (7,000 in the first month alone, up from about 500 per month preceding the launch). In the first seven months of the fiscal year, hand-hygiene compliance consistently reached or exceeded the 90 percent target.

Health care-associated infection rates improve

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Christiana Care State National

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Hand Hygiene Compliance

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Central Line Associated Blood Stream Infection Rate

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FY13: 4.36

FY14: 3.84

Hand-Hygiene Compliance


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FY13: 4.36

FY14: 3.84

Health Care Personnel Flu VaccinationEmployee flu vaccinations

Flu station “blitzes” in October 2013 helped drive employee flu vaccination rates to more than 98 percent compliance with the policy to complete the vaccination, exemption or declination forms. Health care personnel flu vaccination rates are now publicly reported through the Center for Medicare and Medicaid Services’ Hospital Compare website. Christiana Care’s vaccination rate of 91 percent is significantly above the national mean of 75 percent.

continued



Hospital-acquired infections

The nine adult intensive care and stepdown patient care units at Christiana and Wilmington Hospitals continued to drive down the incidence of device-associated hospital-acquired infections. The number of central-line-associated bloodstream infections (CLABSIs) per 1,000 central-line days dropped by 35 percent since fiscal year 2013. Key to success are consistent compliance with best-practice methods for line placement and maintenance, as well as timely removal of central lines.

The intensive care units also focused on reducing urinary-tract infections associated with Foley catheters, decreasing the number of hospital-acquired catheter-associated urinary-tract infections (CAUTIs) by 11 percent since fiscal year 2013, with a steady decline over the last six months. As with CLABSIs, prevention of CAUTIs focuses on proper placement and timely removal of Foley catheters. The units also work to improve compliance with evidence-based cleaning practices. •

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Central-Line-Associated Bloodstream Infection Rate

Catheter-Associated Urinary-Tract Infection Rate

Hospital-acquired infections are among the most frequent causes of preventable patient harm, prolonging hospital stays, increasing health care costs and leading to patient death. Over the past three years, hospital-acquired infections cost Christiana Care an estimated $14.5 million.

Health care-associated infection rates improve continued


Christiana Care joins CandOR to advance culture of safety

Christiana and Wilmington hospitals are participating in the expansion of an Agency for Healthcare Research & Quality (AHRQ) funded project surrounding management of patient safety and medical liability.

Project CandOR: Communication and Optimal Resolution focuses on the implementation of a toolkit to support better communication and resolution when patients are unexpectedly harmed. The toolkit is based on a number of effective projects surrounding this topic, including the work of Timothy McDonald, M.D., JD, and his team at the University of Illinois at Chicago.

Project CandOR components:

f A change readiness assessment.

f Gap analysis.

f Reporting.

f Communication.

f Care for the caregiver.

f Resolution.

f Investigation and process improvement. •

A Culture of CandOR

Organizational Change

Readiness

Gap Analysis

Incident Reporting

Event Analysis

& Process

Improvement

Caring for Caregiver

Resolution

Communication



Christiana Care’s fall-with-injury rate outperforms the mean National Database of Nursing Quality Indicators (NDNQI) benchmark greater than 50 percent of the time, compared to other Magnet facilities.

Seeking a different direction to address fall prevention, nurse leaders partnered with change management experts from Organizational Excellence and the Juran Institute to apply Lean Six Sigma methodology.

The system-wide Fall Prevention Team evaluates falls monthly. Patient trend graphs track the unit fall rate, number of patient falls and comparative benchmark data. Fall summits allow

unit staff and leaders to learn about and share ideas for fall prevention. Notations on the medication administration record alert providers to medications that might increase a patient’s risk of fall and suggest alternative therapies. New low beds with built-in bed-exit alarms, portable bed- and chair-exit alarms with larger sensor pads connect into the patient call-bell system. Key to the initiative’s success is active patient engagement in the fall prevention plan of care.

A research associate from the Christiana Care Value Institute helped the team to apply research methodologies to their work and share knowledge gained through internal and external presentations and publishing.

Nursing, Organizational Excellence partnership cuts combined fall rate by 30 percent

Month Jan-‐12 Feb-‐12 Mar-‐12 Apr-‐12 May-‐12 Jun-‐12 Jul-‐12 Aug-‐12 Sep-‐12 Oct-‐12 Nov-‐12 Dec-‐12 Jan-‐13 Feb-‐13 Mar-‐13 Apr-‐13 May-‐13 Jun-‐13 Jul-‐13 Aug-‐13 Sep-‐13 Oct-‐13 Nov-‐13 Dec-‐13 Jan-‐14 Feb-‐14 Mar-‐14 Apr-‐14Fall Rate 6.26 5.94 3.32 4.87 2.85 6.45 6.38 3.87 4.40 2.25 6.39 4.33 6.00 6.01 4.34 2.23 5.85 1.88 2.36 1.47 2.47 1.45 2.47 1.69 4.62 1.38 3.38 1.38NDNQI Mean 3.44 3.44 3.44 3.48 3.48 3.48 3.41 3.41 3.41 3.45 3.45 3.45 3.41 3.41 3.41 3.2 3.2 3.2 3.2 3.2 3.2 3.3 3.3 3.3 3.3 3.3 3.3 3.3

0

1

2

3

4

5

6

7

8

Jan-

12Fe

b-12

Mar

-12

April

-12

May

-12

Jun-

12Ju

l-12

Aug-

12Se

p-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13Fe

b-13

Mar

-13

Apr-1

3M

ay-1

3Ju

n-13

Jul-1

3Au

g-13

Sep-

13Oct

-13

Nov

-13

Dec

-13

Jan-

14Fe

b-14

Mar

-14

Apr-1

4M

ay-1

4

Fall

Rat

e pe

r 1,0

00 P

atie

nt D

ays

Fall Rate NDNQI Mean

Combined Fall Rate | Patient Care Units 6E, 5D and 6C

Fall Rate = Number of falls per 1,000 patient days

NDNQI Benchmark 3.4


Combined fall rate reduction exceeds goal

Christiana Hospital medical units 6E and 5D, and Stroke Treatment and Recovery Unit 6C, had patient fall rates that were above the National Database of Nursing Quality Indicators (NDNQI) mean Magnet facility benchmark of 3.4 in calendar year 2012. The combined fall rate for the three units that same year was 4.8. By August 2013, the combined fall rate had decreased more than 69 percent to 1.5, exceeding the team’s original goal of a 15 percent reduction in patient falls to 4.1.

Guided by change-management experts and the Lean Six Sigma framework, the team gained valuable insight that helped them to understand the sources of falls and target their

improvement efforts. They learned that patient falls were the result of a variety of factors: accountability to the plan of care, the patient’s intrinsic risk, patient perception of his own fall risk, staff perception of fall prevention, environment and the patient’s treatment plan. Decreasing the rate of patient falls requires a multifactorial, multidisciplinary fall-prevention plan, with accountability from all members of the health care team. •

Patient trend graphs available on the

Quality and Safety intranet site feature a “person”

indicator for each patient fall to underscore the significance of each data point to care

providers.



Christiana Care is stepping up its Annual Operating Plan employee safety goal for total recordable injury rate from below 5.5 injuries per 200,000 hours worked in fiscal year 2014 to below 5.0 for 2015.

This new goal reflects an almost 10 percent decrease in recordable injuries. Christiana Care’s total recordable injury rate through May 2014 was 5.05, which is below the FY14 goal of 5.5 and considerably below the national average of 6.5. The lost-time injury rate of 1.5 through May is at the national hospital average.

To drive this success, Injury Prevention and Occupational Safety teams incorporated injury investigation principles and safe work behaviors into Christiana Care’s New Leader Orientation, Frontline Leadership and Working courses.

An interdisciplinary team focuses on reducing, identifying and evaluating the causes of needlestick and sharps injuries — the leading cause of recordable injuries at Christiana Care. In the fourth quarter of FY14, Christiana Care engaged a consultant to observe work tasks in high-risk areas to identify potential

opportunities to prevent needlestick and sharps injuries. This is a complex process, as many of these incidents occur during the care and treatment of our patients.

Christiana Care’s safety teams also focus on high-risk areas to help reduce common injuries such as slips, trips and falls. A pilot involving the use of slip-resistant shoes in areas prone to have water on the floor is now being evaluated for implementation.

Patient handling continues to be a focus area with ongoing education and installation of lifting equipment. Ergonomic evaluations of job tasks and implementation of novel solutions helps address this source of injury.

The management of occupational health and safety programs remains a priority. A vendor selection process currently underway for occupational health and safety software will help teams integrate the information collected by safety staff with the medical findings of Employee Health, ensuring that employees receive needed job safety and medical support. •

More aggressive workplace safety goals set for FY 2015

LTI FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 ytdLost Time Injury Rate 2.83 2.36 2.13 2.02 1.49 1.43 1.31 1.50Restricted Workday Case Rate 0.00 0.01 0.03 0.18 0.60 0.67 1.11 0.80First Aid Case Rate 9.68 9.40 9.39 8.64 9.00 8.31 7.61 7.75Medical Treatment Case Rate 5.23 7.53 5.87 3.74 4.82 3.60 3.36 2.91Total Recordable Injury Rate 8.07 9.90 8.02 5.94 6.91 5.71 5.78 5.05Goal (Total Recordable) 5.5 5.5 5.5 5.5 5.5 5.5 5.5 5.5

desired direction

0

1

2

3

4

5

6

7

8

FY10 FY11 FY12 FY13 FY14 ytd

Day

s

Lost Time Injury Rate Total Recordable Injury Rate Goal (Total Recordable)

Recordable Injury Rate


Limited English proficiency (LEP) and poor health literacy challenge effective patient-provider communication and impact health outcomes. Christiana Care began offering 24/7 telephonic interpreting services in 2010 and a limited number of on-site interpreters in 2012 at both hospitals. However, in a 2012 survey of postpartum women, 41 percent of LEP patients reported an unmet need for an interpreter during their hospital stay. The survey also revealed wide use of unqualified interpreters. A Lean Six Sigma team set a goal to reduce by 50 percent the percentage of postpartum LEP women reporting an unmet need for a qualified interpreter during their hospital stay.

Following the Lean Six Sigma process of define, measure, analyze, improve and control, the team collected baseline data to fully understand the problem and guide the intervention. Focus groups identified what was critical to quality, as well as staff barriers to utilization of language services. Process maps helped the team understand the current process, identify

value and non-value-added work, and identify opportunities. Phone surveys allowed them to collect information about LEP mothers after discharge. They developed an action plan focused on increasing the use of qualified interpreters, increasing the availability of Spanish educational materials, and providing interdisciplinary staff education. Language Services education and training sessions were developed and provided to the admitting registration staff, OB/GYN residents and faculty physician staff.

Inpatient surveys of postpartum women in summer 2013 showed a significant increase in use of qualified interpreters: a 34.3 percent increase in use of in-person interpreters (p-value < 0.01) and a 41 percent increase in use of phone interpreters (p-value < 0.001). The number of LEP moms reporting an unmet need for an interpreter (p-value < 0.001) also decreased significantly, by 31.8 percent from the initial survey.

Interdisciplinary Lean Six Sigma project improves use of qualified medical interpreters

continued

No YesHas eSignout decreased time for updating the charge report?23.1% 76.9%Has eSignout decreased time required for bedside charge report?7.7% 92.3%

2012 2013Family/Friend 76.7% 62.5%Unqualified Staff Member39.5% 72.5%Medical Interpreter23.3% 57.6%Phone Interpreter46.5% 87.5%

Has eSignout decreased time required for bedside charge report?

Has eSignout decreased time for updating the charge report?

0% 25% 50% 75% 100%% of respondents

Yes

No

0%

20%

40%

60%

80%

100%

Family/Friend Unqualified Staff Member Medical Interpreter Phone Interpreter

Per

cent

of R

espo

nses

2012 2013

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

0

25

50

75

100

2007 2008 2009 2010

Region 1 Region 2

Patient Self-Reported Medical Interpreter Use Before and After Implementation



The establishment of an interdisciplinary team to study the complex challenges experienced by staff working with a large LEP population was effective at improving our understanding of barriers to providing excellent clinical care, improving patient safety and delivering patient-centered care. Increased attention and awareness brought to the issue by the team’s initiatives drove significant improvements in use of qualified interpreters for LEP mothers. Interprofessional collaboration, combined with Lean Six Sigma tools — instrumental in understanding and addressing the problem — were critical in helping the team successfully achieve their goal to reduce reported unmet needs by 50 percent.

Qualified bilingual staff interpreters LINCC patients with safer care experienceMore than 80 Christiana Care employees now serve as qualified medical interpreters in 16 languages through the health system’s new Language Interpreter Network at Christiana Care (LINCC).

Rolled out in November 2013, LINCC evaluates, trains and compensates bilingual staff as medical interpreters, skilled in interpretation, knowledgeable about medical vocabulary and trained to recognize and resolve misunderstandings based on cultural differences.

Christiana Care Learning Institute’s Center for Diversity & Inclusion, Cultural Competence and Equity created LINCC in adherence with 2012 Joint Commission standards to ensure safe, effective communication with patients who have limited English proficiency or other unique communications needs. One element of performance, in particular, noted by the Joint Commission (Standard HR.01.02.01) requires health care organizations to assess the qualifications of the individuals who provide medical interpretation. This standard addresses the hospital’s responsibility to ensure that staff members and contractors who provide interpreting services in the hospital have defined qualifications and competencies. Untrained individuals — including family members, friends, other patients or untrained bilingual staff — should not be routinely used as interpreters for medical encounters.

Interdisciplinary Lean project improves use of qualified medical interpreters continued


Percentage of LINCC-Qualified Medical Interpreters by Language

LINCC’s three phases:

① TESTING: Staff members nominated by their managers must pass a validated assessment of speaking fluency called the ACTFL OPI (oral proficiency interview) in order to be admitted to the program.

② TRAINING: Candidates participate in 24 hours of classroom instruction in topics such as basic interpreting skills, code of ethics for medical interpreters, cultural mediation and advocacy, and working as an interpreter at Christiana Care. Graduates must pass both a written and oral final examination.

③ IMPLEMENTATION AND COMPENSATION: Once LINCC interpreters pass the final exam, Language Services works with their managers to establish acceptable service guidelines. While all LINCC interpreters have the competencies to be able to provide interpretation, their formal work roles may limit the amount of interpretation they can offer. LINCC interpreters are compensated according to the volume of interpretation they complete each quarter.

LINCC offers the potential to significantly enhance patient care by improving the quality of communication and increasing staff knowledge and cultural competency for our patients representing multiple ethnic groups. •

Akan-‐Twi 2 2%Arabic 2 2%Bengali 1 1%French 4 5%Haitian Creole 2 2%Hindi 2 2%Igbo 1 1%Italian 1 1%Korean 2 2%Malayalam 2 2%Mandarin 6 7%Portuguese 1 1%Russian 3 3%Spanish 53 62%Tagalog 2 2%Urdu 1 1%Yoruba 1 1%

86

Yoruba

1%

Urdu

1%

Tagalog

2%

Spanish

62%

Russian

3%

Portuguese

1%

Mandarin

7%

Malayalam

2%

Korean

2%

Italian

1%

Igbo

1%

Hindi

2%

Haitian Creole

2%

French

5%

Bengali

1%

Arabic

2%

Akan-Twi

2%

Taga

log

2%Urd

u 1%

Yoruba 1

%

Akan-Twi 2

%

Arabic 2%

Bengali 1%

French 5%

Haitian Creole 2%

Hindi 2%

Igbo 1%Italian 1%

Korean 2%

Mandarin 7%

Malayalam 2%

Russian 3%

Portuguese 1%

Spanish 62%



“Our unit-based value improvement team winners are excellent examples of how interdisciplinary professionals come together to explore an opportunity for improvement, create a solution and carry forth the successful outcomes.”

SHARON ANDERSON, MS, BSN, RN Senior Vice President of Quality, Safety and Population Health Management Co-Chair, Safety First Committee

The new Unit-Based Value Improvement Team Recognition Award program recognizes teams who create innovative systems of care that lead to significant and measurable improvements in clinical quality, patient safety, patient- and family-centered care, compliance with evidence-based best practices and reduction in costs.

Wilmington Hospital’s Intensive Care Unit’s (WICU) Value Improvement Team was first to be honored with the new award for sustained efforts to reduce preventable harm, most notably by achieving two years without a central-line-associated bloodstream infection; one year without a ventilator-associated pneumonia; and 17 of 19 months without a catheter-associated urinary-tract infection.

The Surgical Care Improvement Project (SCIP) team was second to earn the honor for transforming the entire perioperative process by reviewing and updating indicators; creating algorithms and computerized nursing protocols for Foley catheter insertion and removal; developing a venous thrombolytic embolism prophylaxis risk score; and determining appropriate selection and timeframe for antibiotic administration.

Winning teams present their accomplishment at President’s Cabinet, chaired by the president and CEO and attended by members of the senior and medical leadership teams. Winners also present to No Harm Intended Sessions and the system’s Management Council.

“The transformative work our unit-based value-improvement teams are doing each and every day on our patient care units is ensuring greater value for our neighbors by measurably improving the quality and safety of the care we provide, and doing things more efficiently to reduce costs,” said Sharon Anderson, MS, BSN, RN, senior vice president of Quality, Safety and Population Health Management, who co-chairs the Safety First Committee.

WICU and SCIP will compete against other honorees for the Annual Unit-Based Value Improvement Team Award to be presented at Christiana Care’s Focus on Excellence celebration in late fall.

Any Christiana Care employee or member of the Medical-Dental Staff may nominate a unit-based value-improvement team for the award. Nominations are reviewed and winners selected by the Quality and Safety Program’s Coordinating Council, which includes the co-chairs of the three main Quality and Safety committees:

Safety First:

f Janice E. Nevin, M.D., MPH, Chief Medical Officer

f Sharon L. Anderson, MS, BSN, RN, Senior Vice President of Quality, Safety and Population Health Management

Clinical Excellence:

f Virginia U. Collier, M.D., MACP, Hugh R. Sharp, Jr. Chair of Medicine

f Diane P. Talarek, MA, RN, NE-BC, Senior Vice President, Patient Care Services and Chief Nursing Officer

Think of Yourself as a Patient:

f Janine M. Jordan, M.D., Director, Care Transitions and Utilization Management

f Shawn R. Smith, Vice President, Patient Experience

f Janet Cunningham, BSN, MHA, RN, NE-BC, CENP, Vice President, Professional Excellence and Associate Chief Nursing Officer •

Recognition program honors value-improvement team success


Christiana Care stands up for patient safety

Christiana Care is now part of the National Patient Safety Foundation’s (NPSF) Stand Up for Patient Safety Program, which links health care organizations to enhance education and awareness of health care safety among management, staff, patients and the communities they serve.

As a member organization, Christiana Care receives benefits to help support initiatives including:

f Educational and training opportunities focusing on patient safety as a top priority for all staff members.

f Information for patients and their families about how to make their health care safer.

f Tools and resources to engage staff and patients in patient-safety best practices.

“Stand Up for Patient Safety member organizations are providing the leadership necessary to create measurable improvements in the safety and care of patients across the country,” said NPSF President Tejal K. Gandhi, M.D., MPH, CPPS. “Participants in this ongoing program are committed to adopting a culture of safety, system improvement and continuous learning.” •

“In becoming a member of the Stand Up program, we continue to advance our commitment to patient and employee safety.”

MICHELE CAMPBELL, RN, MSM, CPHQ, FABC Vice President of Patient Safety and Accreditation



The Christiana Care Value Institute hosts semiannual symposiums to share important advances in approaches to improving patient-centered value in health care research, practice and policy. Recent themes included health care through the eyes of the patient, palliative care and connecting data to decisions.

BioBreakfast examines health care through the eyes of the patient

A July 2013 collaboration with the Delaware BioScience Association on the growing importance of value in health and scientific innovation urged health care providers to take a closer look at how their approaches, processes and treatments make a difference in the lives of those they serve.

This symposium highlighted a study of Emergency Department “superusers” in which Value Institute researchers are identifying predictors for success in achieving decreased hospital admissions and emergency department visits. Superusers are patients who, due to multiple chronic health problems, consume a high volume of health care resources.

Also featured was Christiana Care’s Bridging the Divides project, funded by a $10 million grant from the Centers for Medicare and Medicaid Innovation. This research harnesses information technology to transcend gaps in health care and provide more coordinated care and greater value for patients with chronic diseases. Bridging the Divides exemplifies the Triple Aim to achieve health care that improves the individual patient experience, improves the health of populations and reduces the per capita costs of care for populations.

Palliative care focuses on patients and families

In December, the Value Institute hosted national experts to explore the power of palliative care to deliver value to patients and families confronting serious, life-threatening illnesses. Said one panelist, “Palliative care is the quintessential patient-centered care because it starts with the patients and their goals.”

Featured was a Harvard University led study of patients with metastatic lung cancer that found that early palliative care resulted in better quality of life, fewer patients with depressive symptoms and nearly three months longer survival compared with patients who received aggressive disease treatment alone. “If this was a chemotherapy agent … everybody would be on it,” said panelist Diane E. Meier, M.D., FACP, founder of the Hertzberg Palliative Care Institute at Icahn School of Medicine at Mount Sinai Medical Center in New York.

Value Institute symposiums explore value in research, practice and policy


Bridging the Gap: Connecting data to decisions

The Value Institute marked its third anniversary in May 2014 with presentations of research on some of the most pressing topics in health care today, including prevention of patient falls in hospitals, halting the spread of the infectious disease MRSA, and how the electronic health record can affect hospital staffing ratios. Among the presenters were health care thought leaders whose innovative work converts research from data into solutions that help patients, populations and society.

“The goal is to make sure each care policy represents the best evidence and is informed by science,” said Eric V. Jackson Jr., M.D., MBA, associate director of the Value Institute and director of the Value Institute’s Center for Health Care Delivery Science. “Data drives everything. We recognize that data doesn’t tell the whole story, but it positions us to be closer to the source of the truth.” •



Daily team huddles, a deepening partnership with patient and family advisers, and a shared commitment to promptly respond to patient call lights all contributed to a steady rise in patient experience scores in the Staff Responsiveness domain on the Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) in FY 2014.

Responsiveness scores climbed from 68.2 to 74.3 percent in the first eight months, following the general pattern of success reported during the same time period with response to call bell scores, which rose from 65 to 71.7 percent.

No Pass Zones

No Pass Zones — in which the first available member of the care team responds to the patient’s request for assistance, regardless of position — improve patient satisfaction and help to reduce falls from patients getting out of bed alone while waiting for assistance. On one unit at Christiana Hospital, the No Pass Zone helped cut the number of patient falls in half.

“Patients First!”

Team huddles help set the stage for improving patient experience by ensuring that all staff start the shift with information that helps them to respond efficiently and effectively to patients. Huddles enhance communication by allowing staff to share updates on safety concerns, special patient needs or operational issues. The use of team huddles is increasing throughout Christiana Care among clinical and service staff.

Staff responsiveness score rises steadilyPrompt response to call lights key to improving satisfaction, reducing falls

Aug-‐13 Sep-‐13 Oct-‐13 Nov-‐13 Dec-‐13 Jan-‐14 Feb-‐14 Mar-‐14 Apr-‐14Responsiveness 68.2% 70.0% 71.3% 71.6% 70.6% 71.0% 72.5% 71.9% 74.3%Call bell 65.0% 68.4% 69.5% 68.9% 71.3% 67.7% 70.9% 69.8% 71.7%

69.8

63.0%

66.0%

69.0%

72.0%

Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14

65.0%

68.4%

69.5%68.9%

71.3%

67.7%

70.9%

69.8%

71.7%

System Response to Call Bell

Discharge Date

Call bell Trend Response to call bell

65.0%

68.3%

71.7%

75.0%


68.2%

70.0%

71.3% 71.6%70.6% 71.0%

72.5%71.9%

74.3%

System Staff Responsiveness Domain

Discharge Date

Responsiveness Trend Response to call bell


Staff responsiveness

is one of eight dimensions in the patient experience domain

score, which comprises 30 percent of the Hospital Value-Based Purchasing

total performance score.

Trend Response to Call BellResponsiveness


Marty Makary, M.D., MPH, renowned advocate for transparency in medicine and common-sense solutions to health care’s problems, visited Christiana Care during National Patient Safety Awareness Week to present “Modern Medicine’s Transparency Revolution: Taking Quality & Safety to the Next Level.”

His talk underscored the need to be transparent, accountable and provide standardized care, in order to decrease harm to patients, prevent unnecessary tests and procedures, and provide high-quality care.

Makary developed The Surgical Checklist at Johns Hopkins, where he is surgical director of the Pancreas Multidisciplinary Cancer Clinic and associate professor of surgery. The checklist has since been popularized in Atul Gawande’s best-selling book, “Checklist Manifesto.” Makary himself is the New York Times best-selling author of “Unaccountable,” in which he proposes that common-sense solutions can fix the health care system by empowering patients with information to choose where to go for their medical care. •

Transparency and common-sense advocate Makary inspires Christiana Care to take quality and safety to next level

Marty Makary, M.D., MPH

Aug-‐13 Sep-‐13 Oct-‐13 Nov-‐13 Dec-‐13 Jan-‐14 Feb-‐14 Mar-‐14 Apr-‐14Responsiveness 68.2% 70.0% 71.3% 71.6% 70.6% 71.0% 72.5% 71.9% 74.3%Call bell 65.0% 68.4% 69.5% 68.9% 71.3% 67.7% 70.9% 69.8% 71.7%

69.8

63.0%

66.0%

69.0%

72.0%


65.0%

68.4%

69.5%68.9%

71.3%

67.7%

70.9%

69.8%

71.7%


Discharge Date

Call bell Trend Response to call bell

65.0%

68.3%

71.7%

75.0%


68.2%

70.0%

71.3% 71.6%70.6% 71.0%

72.5%71.9%

74.3%


Discharge Date

Responsiveness Trend Response to call bell


Patient and Family Advisory CouncilHaving recently been the recipient of care as a patient or family member, advisory council members play an integral role in helping staff respond more effectively to patient needs to ensure the safest possible care experience.

Christiana Hospital welcomed its own team of advisory partners in FY 2014, patterned after the successful Wilmington Hospital Patient and Family Advisory Council. Advisers suggest or weigh in on proposed initiatives and the potential impact on the patient experience. •

Trend Response to Call BellCall Bell


HIGH RELIABILITY

A transformed surgical process ensures safer care and promotes high reliability.


EMILY J. PENMAN, M.D.Associate Vice Chair of Surgery

Chair, Surgical Care Improvement Project

“ Imagine changing everything about the surgical process, from what happens in the doctors’ offices before surgery to care delivered on the floor after surgery. We meet and surpass the standards created by the quality organizations. The transformation is amazing.”


A C H I E V I N G H I G H R E L I A B I L I T Y

Surgical Care Improvement Project team transforms surgical culture, surpasses national quality measures

“Through this process, we’ve taken the guesswork out of what to do next. Evidence-based practice is now second nature to all of us involved in SCIP.”

CRAIG MARTINE, BSN, RN, CCRNPerformance Improvement Manager Surgery

The collaborative partners of the Surgical Care Improvement Project (SCIP) are the second group to be honored with Christiana Care’s new Value Improvement Team Recognition Award. SCIP is one of Christiana Care’s population-based value-improvement teams; its measures impact all surgical patients throughout the health system — some 60,000 a year. Members include staff from all perioperative teams: pre-op, prep and holding, surgical, post-op and all surgical patient-care units, as well as doctors’ offices, pharmacy and respiratory care. While they are many in number, geographically separated and serve different functions in the perioperative process, all SCIP members share a common commitment to making care safer and more effective for surgical patients.

Christiana Care’s SCIP team emerged a decade ago in response to nationally mandated guidelines collectively released by a quality partnership of 10 national organizations — including the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research & Quality, the Joint Commission and the Institute for Healthcare Improvement — all interested in improving surgical care by significantly reducing surgical complications.

Craig Martine, BSN, RN, CCRN, performance improvement manager for Surgery, describes the value-improvement team’s success as the result of a lot of persistence and one-on-one dialogue, educating perioperative staff about the latest evidence-based guidelines. The team reviewed and updated indicators, created algorithms and computerized nursing protocols for Foley catheter insertion and removal, developed a venous thromboembolism prophylaxis risk score and determined the appropriate selection and timeframe for antibiotic administration.

“Through this process, we’ve taken the guesswork out of what to do next,” said Martine. “Evidence-based practice is now second nature to all of us involved in SCIP.”

Emily J. Penman, M.D., associate vice chair of Surgery, credits the SCIP team’s persistence over many years with creating a huge culture change in how we care for patients.

“Imagine changing everything about the surgical process, from what happens in the doctors’ offices before surgery to care delivered on the floor after surgery,” she said. “We meet and surpass the standards created by the quality organizations. The transformation is amazing.”•


Under the leadership of the Clinical Excellence Committee, the five population-based value-improvement teams continue to report improvement from baseline in overall value score and identify reductions in mortality and readmission rates, lengths of stay and costs.

Of particular note, the Surgical Care Improvement Project continues to achieve A+ value scores. As a whole, the system not only exceeded the target goal to increase the process-of-care domain score to 68, but achieved the stretch domain score of 70 on the most recent Focus on Excellence Measurement Report in April 2014.•

Population-based value score cards highlight improvements, reveal opportunities

SURGICAL CARE IMPROVEMENT PROJECT: Value score increased by 5.4 points from baseline. Seven of the eight measures are at the top decile for Council of Teaching Hospitals, and 99.5 percent of patients received “perfect care.”

continued

PNEUMONIAPNEUMONIAPNEUMONIAPNEUMONIAACTUAL O/E or

TARGETTOP DECILE

COTH

Guideline ComplianceBlood Culture Pre Antibiotic* 94.4%Initial Antibiotic Selection* 95.0%OutcomesPatient Experience 72.2%Mortality 2.9%Readmission 14.1%Cost/UtilizationLength of Stay 4.59Estimated Direct Cost $9,657

Value Based Purchasing ImpactValue Based Purchasing ImpactCurrent Value Score 83.7 B

BASELINE 76.9 C C

Clinical Excellence | Increase Value & Be Ready for Healthcare Reform

Christiana Care Health System

GOAL: !Increase the Process of Care Domain Score to 68

April 2014

PROCESS OF CARE DOMAIN SCORE



Current 70

Threshold 66

Target 68

Stretch 70

ACUTE MYOCARDIAL INFARCTIONACUTE MYOCARDIAL INFARCTIONACUTE MYOCARDIAL INFARCTIONACUTE MYOCARDIAL INFARCTIONACTUAL O/E or

TARGETTOP DECILE

COTH

Guideline CompliancePCI Within 90 Minutes of Arrival* 90.0%Aspirin at Discharge 100.0%Statin at Discharge 98.5%OutcomesPatient Experience 73.9%Mortality 6.5%Readmission 19.3%Cost/UtilizationLength of Stay 4.16Estimated Direct Cost $24,415Value Based Purchasing ImpactValue Based Purchasing ImpactCurrent Value Score 85.5 B

BASELINE 84.0 B B

HEART FAILUREHEART FAILUREHEART FAILUREHEART FAILUREACTUAL O/E or

TARGETTOP DECILE

COTH

Guideline ComplianceDischarge Instruction*Evaluation of LVS Function 100.0%ACE/ARB for LVSD 92.7%OutcomesPatient Experience 84.0%Mortality 0.8%Readmission 21.3%Cost/UtilizationLength of Stay 4.54Estimated Direct Cost $9,008Value Based Purchasing ImpactValue Based Purchasing ImpactCurrent Value Score 87.1 B+

BASELINE 79.6 C+ C+

SURGICAL CARE IMPROVEMENT PROJECTSURGICAL CARE IMPROVEMENT PROJECTSURGICAL CARE IMPROVEMENT PROJECTSURGICAL CARE IMPROVEMENT PROJECTACTUAL O/E or

TARGETTOP DECILE

COTH

Guideline Compliance Proph Antibiotic Pre Incision* 100.0% Proph Antibiotic Selection* 100.0% Proph Antibiotic Discontinued* 100.0% Postop Glucose Control* 96.9% Periop Beta Blocker* 100.0% VTE Prophylaxis Given* 100.0% Postop Catheter Removed* 100.0% Postop Normothermia 100.0% Value Based Purchasing Impact Composite Score 99.5% Current Value Score 99.6 A+

BASELINE 94.2 A A

SEPSISSEPSISSEPSISSEPSISACTUAL O/E or

TARGETTOP DECILE

COTH

Guideline ComplianceLactate Level Within 3 Hours 100.0%Blood Cultures Prior to Antibiotics 79.5%Broad Spectrum Antibiotics ≤ 3 Hours 70.1%Fluid Resuscitation ≤ 3 Hours 85.8%OutcomesMortality 8.9%30-Day Readmission 16.8%Patient Experience 62.9%Cost/UtilizationLength of Stay 9.24Estimated Direct Cost $27,201Value Based Purchasing ImpactCurrent Value Score 81.4 B-

BASELINE (FY12) 76.0 C CPNEUMONIAPNEUMONIAPNEUMONIAPNEUMONIAACTUAL O/E or

TARGETTOP DECILE

COTH



BASELINE 76.9 C C




April 2014




Current 70

Threshold 66

Target 68

Stretch 70


TARGETTOP DECILE

COTH


BASELINE 84.0 B B


TARGETTOP DECILE

COTH


BASELINE 79.6 C+ C+


TARGETTOP DECILE

COTH


BASELINE 94.2 A A


TARGETTOP DECILE

COTH


BASELINE (FY12) 76.0 C C

HEART FAILURE: Value score improved by 7.2 points from baseline. Mortality rates improved by over 70 percent; readmission rates have decreased 26 percent and length of stay is down 7 percent. Overall cost savings exceeds $890,000.



Population-based value score cards continued

PNEUMONIA: The value score improved by 6.8 points. Guideline compliance increased by an average of more than 10 percent, mortality rates dropped by over 40 percent, readmission rates improved by 12 percent and length of stay decreased by 0.4 days. Estimated cost savings is $590,000.


TARGETTOP DECILE

COTH



BASELINE 76.9 C C




April 2014

PROCESS OF CARE DOMAINSCORE



Current 70

Threshold 66

Target 68

Stretch 70


TARGETTOP DECILE

COTH


BASELINE 84.0 B B


TARGETTOP DECILE

COTH


BASELINE 79.6 C+ C+


TARGETTOP DECILE

COTH

Guideline ComplianceProph Antibiotic Pre Incision* 100.0%Proph Antibiotic Selection* 100.0%Proph Antibiotic Discontinued* 100.0%Postop Glucose Control* 96.9%Periop Beta Blocker* 100.0%VTE Prophylaxis Given* 100.0%Postop Catheter Removed* 100.0%Postop Normothermia 100.0%Value Based Purchasing ImpactComposite Score 99.5%Current Value Score 99.6 A+

BASELINE 94.2 AA


TARGETTOP DECILE

COTH




TARGETTOP DECILE

COTH



BASELINE 76.9 C C




April 2014




Current 70

Threshold 66

Target 68

Stretch 70


TARGETTOP DECILE

COTH


BASELINE 84.0 B B


TARGETTOP DECILE

COTH


BASELINE 79.6 C+ C+


TARGETTOP DECILE

COTH


BASELINE 94.2 A A


TARGETTOP DECILE

COTH



ACUTE MYOCARDIAL INFARCTION: The value score improved by 1.5 points. The mortality rate has improved to below the risk-adjusted predicted rate and length of stay decreased by 10 percent. The team has reduced estimated costs by about $950,000



TARGETTOP DECILE

COTH



BASELINE 76.9 C C




April 2014




Current 70

Threshold 66

Target 68

Stretch 70


TARGETTOP DECILE

COTH


BASELINE 84.0 B B


TARGETTOP DECILE

COTH


BASELINE 79.6 C+ C+


TARGETTOP DECILE

COTH


BASELINE 94.2 A A


TARGETTOP DECILE

COTH



SEPSIS: The value score improved by 5.1 points from baseline. Mortality decreased by almost 50 percent, readmission rates dropped 14 percent and length of stay improved by over 1.5 days. Estimated cost savings for this population is almost $7 million.


TARGETTOP DECILE

COTH



BASELINE 76.9 C C




April 2014




Current 70

Threshold 66

Target 68

Stretch 70


TARGETTOP DECILE

COTH


BASELINE 84.0 B B


TARGETTOP DECILE

COTH


BASELINE 79.6 C+ C+


TARGETTOP DECILE

COTH


BASELINE 94.2 A A


TARGETTOP DECILE

COTH



The FY 2014 Hospital Value-Based Purchasing (VBP) Program adjusts hospitals’ payments based on their performance on three domains that reflect hospital quality: the Clinical Process of Care domain, the Patient Experience of Care domain and the Outcome domain. The Clinical Process of Care domain score is weighted as 45 percent of the total performance score.

VBP uses 13 quality measures that hospitals already report to Medicare via the Hospital Inpatient Quality Reporting (IQR) program. The measures fall under five clinical areas where Medicare is focused on improving care and paying for good quality care: acute myocardial infarction; heart failure; pneumonia; surgical care improvement project; health-care-associated infections.

Guideline Compliance:

✱ Measure is included in Value Based Purchasing

● >= Threshold (for measures with baseline performance < threshold)

▲ Between baseline & threshold

◆ < Baseline

Outcomes: ● Observed to Expected <= 1.0

▲ O/E > 1.0 and <= 1.10

◆ O/E > 1.10

COTH: Council of Teaching

Hospitals and Health Systems

Key to symbols:



Christiana Care’s Surgical Care Improvement Program (SCIP) demonstrates 100 percent compliance with administering venous thromboembolism (VTE) prophylaxis, placing it in the top decile for the Council of Teaching Hospitals and Health Systems (COTH).

Our health system also compares favorably with state and national rates in venous thrombosis prevention and, at 8.8 percent, our rate of potentially preventable VTE is below the national mean of 10 percent.

Deep vein thrombosis (DVT) and pulmonary embolism (PE) — the two conditions associated with VTE — impose a major public health burden in the United States, affecting up to 600,000 individuals and accounting for approximately 100,000 deaths each year. Hospitalization is a major risk factor for DVT/PE, with a tenfold increased risk for VTE among hospitalized patients with acute medical illness.

Christiana Care’s physician-driven interdisciplinary VTE Steer Team leads efforts to reduce and prevent DVT/PE incidence, including multiple collaborative interventions among physicians, nurses and staff from Pharmacy, Case Management, Performance Improvement and Information Technology.

The team is now focusing on interventions within the electronic medical record to initiate opportunities to guide practitioners toward effective DVT/PE risk assessment, prevention and treatment opportunities. •

VTE prevention measures surpass state and national compliance

Venous Thrombosis Prophylaxis

ICU Venous Thrombosis Prophylaxis

Anticoagulation Overlap Therapy

50% 60% 70% 80% 90% 100%

93%

92%

85%

88%

92%

83%

97.5%

97.5%

92.2%

Venous Thrombosis Prevention Measures

Percent ComplianceChristiana Care State National

0%

5%

10%

15%

20%

Christiana Care National

10%8.8%

Incidence of Potentially Preventable Hospital-Acquired VTE




50% 60% 70% 80% 90% 100%

93%

92%

85%

88%

92%

83%

97.5%

97.5%

92.2%


Percent ComplianceChristiana Care State National

0%

5%

10%

15%

20%

Christiana Care National

10%8.8%






More than 114,000 men, women and children in the United States are waiting for a lifesaving organ transplant. Each day, 18 people die because an appropriate organ match is not found in time. There are more than 600 people on waiting lists for organ transplants in Delaware, while thousands more wait for a tissue transplant that could improve the quality of their lives.

A single organ and tissue donor can help 50 people. In the past two years at Christiana Care, 57 people donated 125 organs, and there were more than 160 tissue donations. •

Christiana Care continues commitment to promote organ procurement

2012 2013 2014Organ Donors 32 25 8 57Total Organs Donated 65 60 24 125Organs per Donor 2.03 2.4 3Tissue Donors 97 66 21 163Referral Rate 100% 100% 100%Effective Request Rate 92% 82% 92%Conversion Rate 60% 56% 57%

Kidney Transplants

2007 2008 2009 2010 2011 2012 2013 UNOS (2010)UNOS (2010)Patient Population# of Patients Transplanted 16 17 16 23 32 31 45 16898 180Living Donor 7 5 5 7 9 7 6 0.3715 46 0.2555556Deceased Donor 9 12 11 16 23 24 39 134 0.7444444

Jul10-‐Jun11Jul10-‐Jun11Observed O/E U.S. Rate

Graft survival -‐ 1 month 97.9 1.00235487 97.67Graft survival -‐ 1 year 95.04 1.01592731 93.55Graft survival -‐ 3 years 91.67 1.07872441 84.98Patient survival -‐ 1 month 100 1.00684656 99.32Patient survival -‐ 1 year 100 1.03316458 96.79Patient survival -‐ 3 years 95.6 1.04071413 91.86

source: United Network for Organ Sharing (UNOS)source: United Network for Organ Sharing (UNOS)source: United Network for Organ Sharing (UNOS)

Tissue Donors

Total Organs Donated

Organ Donors

0 25 50 75 100

32

65

97

25

60

66

Number of Donors/Organs

2013

2012

0

12.5

25

37.5

50

2007 2008 2009 2010 2011 2012 2013

Num

ber o

f Transplan

ts

Deceased DonorLiving Donor

50

60

70

80

90

100

Patient survival -‐ 1 month Patient survival -‐ 3 years

100 10095.699.3

96.891.9

Christiana CareU.S. Rate

Organ and Tissue Donation

More than 600 people are on

Delaware’s transplant waiting list. A single

organ and tissue donor can help

50 people.



Christiana Care’s first group of certified Lean Six Sigma Green Belts completed 14 customer-focused performance improvement projects resulting in elimination of waste and error rates; greater efficiency, effectiveness and affordability of care; and improved patient outcomes.

Learners in Christiana Care’s Lean Six Sigma program devote 25 percent of their work time to projects over six to eight months. They follow the five-step DMAIC process — define, measure, analyze, improve and control — to design such projects as the Medical Intensive Care Unit (MICU) effort to lower the number of packed red blood cell transfusions, shortening length of stay for patients with chronic obstructive pulmonary disease, finding ways to reduce food waste and streamlining the time required to assign medical equipment work orders.

Christiana Care’s Lean Six Sigma program is a collaboration between the Organizational Excellence Department and the Value Institute’s Center for Organizational Excellence, sponsored in partnership with the internationally recognized Juran Institute quality-management company.

Guideline compliance improves

A Lean Six Sigma Green Belt project lowered the number of packed red blood cells (pRBC) transfusion units not meeting clinical practice guidelines from 3.8 to 0.9 per week. This 77 percent decrease in the project’s first six months surpassed the set goal of reducing non-adhering units by 50 percent to 1.9 per week.

The interdisciplinary Green Belt team of critical care assistants, intensivists and MICU nurses — jointly led by a finance project manager from the Department of Medicine and the lead physician assistant from the MICU — developed a high-level process map to identify key elements of the transfusion process. First reviewing multiple studies clarifying appropriate clinical thresholds for transfusions of pRBC in the critical care setting, the team looked at whether the MICU’s transfusion practices adhered to best practice guidelines. Their discovery: between October and December of 2012, almost half of transfused units did not meet clinical-practice guidelines — the equivalent of 3.8 units per week, or 200 units per year. Far exceeding their goal to decrease that number by half, the annualized number of units not meeting clinical-practice guidelines dropped to 46 units per year.

Lean Six Sigma Green Belts advance performance improvement

Number of Units per Year

Baseline Current Year

596 564 (32)

544 398 (146)

200 46 (154)

1,340 1,008 (332)

Baseline | Number of Units per Week

# weeks

13 BAR CHART DATABAR CHART DATABASELINE # Units % total # Units/week DescriptionDescription Baseline (10-‐‑12/12)Current (7-‐‑12/13)

149 44% 11.5 Guideline Transfused (GT) < 7.0Guideline Transfused (GT) < 7.0Guideline Transfused (GT) < 7.0 11.5 10.8136 41% 10.5 Guideline Transfused (GT) > 7.0Guideline Transfused (GT) > 7.0Guideline Transfused (GT) > 7.0 10.5 7.750 15% 3.8 Non Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 Hgb 3.8 0.9335 100% 25.8 pRBC TransfusedpRBC Transfused

26 13

CURRENT # Units # Units % total # Units/week DescriptionDescription282 141 56% 10.8 Guideline Transfused (GT) < 7.0Guideline Transfused (GT) < 7.0Guideline Transfused (GT) < 7.0199 100 39% 7.7 Guideline Transfused (GT) > 7.0Guideline Transfused (GT) > 7.0Guideline Transfused (GT) > 7.023 12 5% 0.9 Non Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 Hgb504 252 100% 19.4 pRBC TransfusedpRBC Transfused

$ 761REDUCTION $ Cost # Units/Yr # Units/week DescriptionDescription

$ 24,352 32 0.6 Guideline Transfused (GT) < 7.0Guideline Transfused (GT) < 7.0Guideline Transfused (GT) < 7.0

$ 111,106 146 2.8 Guideline Transfused (GT) > 7.0Guideline Transfused (GT) > 7.0Guideline Transfused (GT) > 7.0

$ 117,194 154 3.0 Non Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 HgbNon Guideline Transfused (NGT) > 7.0 Hgb$ 252,652 332 6.4 pRBC TransfusedpRBC Transfused

0

3.8

10.5

11.5

Baseline - # Units per Week

Guideline Transfused (GT) < 7.0

Guideline Transfused (GT) > 7.0

Non Guideline Transfused (NGT) > 7.0 Hgb

0.9

7.7

10.8

Current - # Units per Week




0

2.0

4.0

6.0

8.0

10.0

12.0

14.0


CH-‐‑MICU pRBC # Units per Week

Baseline (10-12/12) Current (7-12/13)

# Units per Year# Units per Year# Units per YearBaseline Current Var596 564 (32)544 398 (146)200 46 (154)1,340 1,008 (332)

Current | Number of Units per Week

# weeks



26 13






0

3.8

10.5

11.5





0.9

7.7

10.8





0

2.0

4.0

6.0

8.0

10.0

12.0

14.0





# weeks



26 13






0

3.8

10.5

11.5





0.9

7.7

10.8





0

2.0

4.0

6.0

8.0

10.0

12.0

14.0






Christiana Care President and CEO Robert J. Laskowski, M.D., MBA, congratulates Christiana Care’s first Lean Six Sigma Green Belts.

PRBC transfusion is associated with increased risk of health-care-associated infection, multi-organ failure, increased intensive care and hospital days, and mortality. Christiana Care’s Lean Six Sigma team decreased the number of transfused units by 25 percent, with an estimated annualized savings of $253,000.

continued

# weeks



26 13






0

3.8

10.5

11.5





0.9

7.7

10.8





0

2.0

4.0

6.0

8.0

10.0

12.0

14.0





MICU pRBC | Number of Units per Week

# weeks



26 13






0

3.8

10.5

11.5





0.9

7.7

10.8





0

2.0

4.0

6.0

8.0

10.0

12.0

14.0





Guideline Tranfused (GT) < 7.0

Strategies included:

f Educating MICU nurses, critical-care physician assistants, intensivists, consultants and medicine residents on clinical practice guidelines.

f Removing the daily lab option from the MICU admission order set to reduce unnecessary blood draws and decrease phlebotomization.

f Redesigning the transfusion process to foster communication by including a transfusion tracker form that enables the nurses to confirm transfusion order with the MICU staff, attending, resident and physician assistant before the patient receives blood.

f Designing a quick reference pocket card to capture pRBC transfusion guidelines.

The team is now expanding the initiative to critical-care units system-wide.



Lean Six Sigma Green Belts advance performance improvement continued

Lean Six Sigma delivers laboratory performance improvement for the ED

Lean Six Sigma methods helped the Department of Pathology and Laboratory Medicine — which performs 6.73 million tests per year — reduce variation in laboratory performance and achieve breakthrough improvement in providing urinalysis results for the Emergency Department (ED) within a 30-minute target. The success rate improved from 78 percent of urinalyses prior to the pilot, to a sustained 90 percent (p<0.01) in the control phase.

Historically, pathology laboratories and clinicians have maintained competing definitions for quality: laboratories focus on maximizing precision and achieving accuracy goals, while clinicians expect rapid, reliable and efficient service at low cost. Today’s labs increasingly focus on turnaround time as a primary performance indicator, especially in the ED, where delayed test results can delay treatment, increase boarding time and negatively impact patient outcomes.

A Green Belt medical laboratory scientist led the project team’s effort to analyze existing work streams, and identify both the needs of clinicians and current process owners, as well as opportunities for efficiencies and improvements. To meet their established target turnaround time of 30 minutes or less for urinalysis results reported to the ED, they employed high-level process mapping known as SIPOC: suppliers, inputs, process, outputs and customers. They also used such tools as voice of the customer, process load calculations, fishbone analysis, value stream attribute mapping and solution selection matrices. Finally, the team created a nine-step implementation checklist spanning the full work stream, from the lab’s receipt of the sample to reporting of results to the ED.

The result: the proportion of results not meeting the targeted 30-minute turnaround time improved significantly post-pilot, from 0.22 to 0.12 percent (p< 0.01), then further improved and remains sustained at 0.10 percent (p<0.01) in the control phase. •

Urinalyses Not Meeting Target Turnaround Time

Month Not Mtg TATMtg TAT Ed Total Month Percent defectiveUas meeting TATJan 12 585 1579 2164 Baseline Jan 12 27% 73%Feb 12 525 1525 2050 Baseline Feb 12 26% 74%March 12 531 1499 2030 Baseline March 12 26% 74%April 12 436 1593 2029 Baseline April 12 21% 79%May 12 437 1673 2110 Baseline May 12 21% 79%June 12 503 1618 2121 Baseline June 12 24% 76%July 12 515 1567 2082 Baseline July 12 25% 75%Aug 12 476 1722 2198 Baseline Aug 12 22% 78%Sept 12 470 1836 2306 Baseline Sept 12 20% 80%Oct 12 448 1916 2364 Baseline Oct 12 19% 81%Nov 12 470 1798 2268 Baseline Not Met Met total Nov 12 21% 79%Dec 12 456 1884 2340 Baseline 5852 20210 26062 78% Baseline CY12 Dec 12 19% 81%Sep 13 P 173 1132 1305 Pilot Sep 13 P 13% 87%Oct 13 P 46 418 464 Pilot 219 1550 1769 88% Pilot S/O 13 Oct 13 P 10% 90%Oct 13 255 1514 1769 Sustain Oct 13 14% 86%Nov 13 233 1834 2067 Sustain Nov 13 11% 89%Dec 13 219 1940 2159 Sustain Dec 13 10% 90%Jan 14 212 1962 2174 Sustain Jan 14 10% 90%Feb 14 141 1876 2017 Sustain Feb 14 7% 93%Mar 14 224 1898 2122 Sustain 1284 11024 12308 90% Sustain Mar-‐14 Mar 14 11% 89%

0%

10%

20%

30%

Jan 12Feb 12

March 12

April 12

May 12

June 12July 1

2Aug 1

2

Sept 12

Oct 12

Nov 12

Dec 12

Sep 13 P

Oct 13 P

Oct 13

Nov 13

Dec 13

Jan 14Feb 14

Mar 14

27%26% 26%

21% 21%

24% 25%

22%20%

19%21%

19%

13%

10%

14%

11%10% 10%

7%

11%

Pro

port

ion

0%

25%

50%

75%

100%

Jan 12 April 12 July 12 Oct 12 Sep 13 P Nov 13 Feb 14

UAs meeting Target TAT

Sustain (10/8/13 - 3/30/14)Baseline (2012)

Pilot (9/17 to 10/7/13)

118 ED patients received home care during 9/20/13-‐3/28/14

92% of patients

remained safe at hom

e

with VNA


A newly formed partnership between Christiana Care’s Visiting Nurse Association (VNA) and the Emergency Department (ED) demonstrates that home care services following ED discharge dramatically reduce patient returns to the ED, avoidable hospital admissions and cost of care.

A review of 118 patients referred to home care by the ED in a six-month period reveals that 3 percent of patients were admitted to the hospital within 72 hours of ED discharge. Five percent of patients returned to the ED within seven days, but were not admitted to the hospital.

The success stems from collaboration by internal and external providers — including those representing outpatient services, physician offices and home care — who gathered to discuss care flow.

Patients referred to VNA receive a home visit within 24 hours of ED discharge. VNA clinicians complete a comprehensive assessment, reconcile medications and recommend other services, when appropriate. •

Home care following ED visit dramatically reduces patient returns

118 ED patients received home care during 9/20/13-‐3/28/14

92% of patients

remained safe at hom

e

with VNA

92% of patients remained safe at home with VNA

5% returned to the ED

3% hospitalized

Emergency Department Patient Returns | October 2013 to April 2014



Medication-related patient harm is down by 65 percent this fiscal year thanks to shared, sustained commitment to multidisciplinary collaboration.

“We’re highly focused on learning where our opportunities are and designing reliable, sustainable system-level improvements,” explains Dean Bennett, RPh, CPHQ, medication safety officer. “We recognize the only way to successfully accomplish our goal of eliminating medication-related harm is to have all the stakeholders working side-by-side in every aspect of our Medication Safety Program. Our collaboration and commitment by front-line staff and leaders from physician groups, nursing, respiratory therapy, pharmacy and information technology has led to promising early results.”

Collaboration across disciplines and strategic planning by the Medication Safety, Pharmacy & Therapeutics and Safety First committees resulted in meaningful progress in key areas:

Creating a Safe Culture

f AU MEDS©: Assessing our medication-use process through a pilot program utilizing a scientifically validated observation method that helps us learn about medication errors and why they occur. AU Meds-certified observers from nursing, patient safety and pharmacy watch medication administration throughout our hospitals and learn how effective our processes are at preventing errors. This

information, teamed with our Safety First Learning Report data, helps us understand where to focus our efforts.

f MEDICATION SAFETY TRAINING: Meeting an educational need absent from many medical and pharmacy school curricula by providing medication-safety and strategy- awareness training during new resident orientation.

Multidisciplinary collaboration leads to safer medication use

Jul-‐12 Aug-‐12 Sep-‐12 Oct-‐12 Nov-‐12 Dec-‐12 Jan-‐13 Feb-‐13 Mar-‐13 Apr-‐13 May-‐13 Jun-‐13 Jul-‐13 Aug-‐13 Sep-‐13 Oct-‐13 Nov-‐13 Dec-‐13 Jan-‐14 Feb-‐14 Mar-‐14 Apr-‐14Rolling 12 months 3.00 3.00 3.00 2.50 3.00 2.83 3.00 2.63 2.89 2.90 2.91 2.92 2.92 2.83 2.67 2.58 2.25 2.08 1.83 1.83 1.50 1.33Medication Errors resulting in Harm 3 3 3 1 5 2 4 0 5 3 3 3 3 2 1 0 1 0 1 0 1 1

0

2

4

6

8

10

Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-140

0.75

1.50

2.25

3.00

Medication Errors resulting in Harm Rolling 12 months

Jul-‐12 Aug-‐12 Sep-‐12 Oct-‐12 Nov-‐12 Dec-‐12 Jan-‐13 Feb-‐13 Mar-‐13 Apr-‐13 May-‐13 Jun-‐13 Jul-‐13 Aug-‐13 Sep-‐13 Oct-‐13 Nov-‐13 Dec-‐13 Jan-‐14 Feb-‐14 Mar-‐14 Apr-‐14Medication Errors Resulting in Harm 3 3 3 1 5 2 4 0 5 3 3 3 3 2 1 0 1 0 1 0 1 1Rolling 12 Months 3.00 3.00 3.00 2.50 3.00 2.83 3.00 2.63 2.89 2.90 2.91 2.92 2.92 2.83 2.67 2.58 2.25 2.08 1.83 1.83 1.50 1.33

0

2

4

6

8

10

Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14

Num

ber

of E

rror

s w

ith

Har

m

Rolling 12 Months

Medication Errors Resulting in Harm



New inpatient and outpatient guidelines, standardized patient educational materials and electronic record modifications supporting appropriate anticoagulation therapy are reducing the incidence of venous thrombosis in hospitalized patients.

The Anticoagulation Task Force is now educating third-party payers about the importance of anticoagulation therapy; developing relationships with pharmaceutical companies to help advance patient education on the importance of preventing blood clots; and educating providers via Grand Rounds. Continuing medical education events are planned. •

Anti-Coagulation Task Force reduces clotting incidence

“The only way to successfully accomplish our goal of eliminating medication-related harm is to have all stakeholders working side-by-side in every aspect of our Medication Safety Program.”

DEAN BENNETT, RPH, CPHQ Medication Safety Officer

Medication Safety | Pharmacy, Safety First Learning Reports

FY14 - Year-to-Date Harm Year-to-Date Harm % Change

9 -65.4%


Achieving High Reliability

f EXPECTED PAIN PROGRAM: Anticipating and providing for our patients’ pain control needs in physical therapy, dressing changes or other care that could temporarily increase discomfort or interfere with their ability to complete therapy.

f PASERO SEDATION MONITORING: Monitoring the effects on a patient’s level of sedation shortly after administration of opioid or benzodiazepine medications.

Leveraging Technology

f BAR-CODED MEDICATION ADMINISTRATION (BCMA)

EXPANSION: Adding decision support to hand-held scanners to help staff determine when it may be too early for the patient to receive a medication with sedating side-effects, or when a patient’s daily dose of acetaminophen is nearing the recommended maximum.

f CPOE, EMAR AND BCMA: Expanding our fully integrated Computerized Prescriber Order Entry (CPOE), the electronic Medication Administration Record (eMAR) and Bar-Coded Medication Administration (BCMA) in labor and delivery and maternity patient-care units. •



Screened 223 Self-‐PaySelf-‐Pay DPCIEligible 60 Eligible 29 122 59Enrolled 28 Enrolled 59

47% Jan-‐14 Feb-‐14 Mar-‐14 Apr-‐14Active 12 22 33 45Graduated 4 3 0 0Discharged 3 1 5 10

Pilot ResultsPilot ResultsEligible Enrolled

Self-‐Pay 29 18DPCI Medicaid 122 39

0

15

30

45

60

Eligible Enrolled

1 Total Patient Days= ED visit + IP/Obs Visit1 ED visit= 1 patient day; IP/Obs = actual days from admit to discharge

0

30

60

90

120

150

Self-Pay DPCI Medicaid

39

18

122

29

Num

ber

of P

atie

nts

Eligible Enrolled

0

12.5

25

37.5

50

# ofpatients

Jan-‐14Feb-‐14

Mar-‐14Apr-‐14

MHWW Program Participation

ActiveGraduatedDischarged

0

50

100

150

200

Self-Pay Self-Pay DPCI

59

59

122

29N

umbe

r of

Pat

ient

s

Eligible Enrolled

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

0

25

50

75

100

2007 2008 2009 2010

Region 1 Region 2

0

50

100

150

200

Self-Pay Self-Pay DPCI

59

59

122

29

Num

ber

of P

atie

nts

Eligible Enrolled

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

0

25

50

75

100

2007 2008 2009 2010

Region 1 Region 2

Medical Home Without Walls — not a place, but a community-based care-management team that engages and empowers uninsured, chronically ill individuals in managing their own care — reduced the total volume of patient days by 79 percent, comparing pre- and post-enrollment data from a six-month pilot in 2013. Enrollment began for a second cohort of in January 2014, and in February, the program expanded to include Medicaid patients with Delaware Physicians Care (DPCI).

In this system-wide, patient-centered care-management strategy, a social worker and nurse partner as an intervention team to help our community’s most vulnerable people to navigate the complex health system and access community resources. The program’s goals are to improve this population’s access to health care, educate individuals about available health and social-service resources to help them maintain their health, and reduce inappropriate acute-care utilization.

f 69 patients enrolled in 2013; 57 patients enrolled to-date in 2014

f 25 graduates from 2013 cohort. Nine graduates to-date in 2014.

f Active “intervention” takes an average of 90 days. There is also a 90-day post-graduate follow-up period before patients complete the program. •

Medical Home Without Walls enrolls second patient cohort based on pilot’s success

Medical Home Without Walls Outcomes Data: Jan-Jul 2013 Total Patient Utilization

Screened 223 Self-‐Pay DPCI TotalEligible 60 Eligible 29 122 103Enrolled 28 Enrolled 18 59 45

47% Jan-‐14 Feb-‐14 Mar-‐14 Apr-‐14Active 12 22 33 45Graduated 4 3 0 0Discharged 3 1 5 10

Pilot ResultsPilot ResultsPre EnrollmentPost Enrollment% Change

30 Days (N=49) 335 72 -‐78.5%60 Days (N=44) 386 80 -‐79.3%90 Days (N=35) 416 79 -‐81.0%

0

15

30

45

60

Eligible Enrolled

1 Total Patient Days= ED visit + IP/Obs Visit 1 ED visit= 1 patient day; IP/Obs = actual days from admit to discharge

0

100

200

300

400

500

30 Days (N=49) 60 Days (N=44) 90 Days (N=35)

798072

416386

335

Num

ber

of P

atie

nts

Pre-Enrollment Post-Enrollment

-‐100.0%

-‐87.5%

-‐75.0%

-‐62.5%

-‐50.0%

-‐78.5% -‐79.3% -‐81.0%

30 Days (N=49) 60 Days (N=44) 90 Days (N=35)

0

12.5

25

37.5

50

# of patients

Jan-‐14 Feb-‐14Mar-‐14 Apr-‐14

MHWW Program Participation

ActiveGraduatedDischarged

0

50

100

150

200

Self-Pay DPCI

59

18

122

29

Num

ber

of P

atie

nts

Eligible Enrolled

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

0

25

50

75

100

2007 2008 2009 2010

Region 1 Region 2

Medical Home Without Walls Second Cohort Enrollment 2014


Delaware’s first multisite National Committee for Quality Assurance-certified patient-centered medical home is helping patients to quit smoking and lower their blood pressure.

The Patient-Centered Medical Home is a multisite partnership of Wilmington Health Center’s Pediatrics, the Internal Medicine Residents’ Practice and the Internal Medicine Faculty Practice.

The model creates a highly coordinated long-term relationship between the patient and a care team featuring doctors, nurses, a clinical pharmacist, health coach and social worker. Along with episodic care, teams also help patients navigate insurance paperwork and link them with resources to overcome obstacles such as loss of health insurance, inability to pay out-of-pocket for needed medications and medical supplies.

For example, the program has already helped 20 patients — 25.6 percent of those who enrolled in one of three smoking-cessation sessions — quit smoking.

Nearly half of the patients who visit the Adult Medicine Office, and almost a third of those in the Internal Medicine Faculty Practice have hypertension, with nearly half of them on three or more medications. Employing an evidence-based approach to care and empowering patients in self-management, the team exceeded their goal to reduce systolic blood pressure by 10mmHg in 20 percent of patients with Stage 2 hypertension during a six-month pilot, ultimately achieving success with 26.8 percent of participants. The average drop in systolic blood pressure was 5 points.

The team helped one woman — who was working but had lost her health insurance — secure $1,500 medication free from a pharmaceutical company by demonstrating that a sudden illness caused her to run out of sick time and cut off her income.

They helped another uninsured patient apply for medical supplies from the Delaware Diabetic Fund and initiated steps to get him orthopaedic shoes to prevent pressure wounds. •

Patient-centered medical home helps patients lower blood pressure, quit smoking

Improvement of Systolic Blood Pressure | Percent of patients with a decrease of at least 10mmHG

Systolic Blood Pressure

Patients with Stage 2 HypertensionPatients with Stage 2 Hypertension seen in past year% OF PatientsGoalAdult Medicine Office 329 190 31.30% 20%Internal Medicine Family Practice Clinic 65 46 26% 20%Total 394 236 26.80% 20%Target

0%

10%

20%

30%

40%

Improvement in Systolic Blood Pressure Percent of patients with a decrease of at least 10mmHG

Per

cent

of

Pat

ient

s

% of Patients

Goal

Adult Medicine

Office

Internal Medicine Faculty

Practice

Smoking Cessation Program Success Rate | N=78

Results:

Total-‐78 pts enrolled

34 pts/78 pts completed the program (all 3 sessions)

14 pts/ 34 pts re-‐enrolled0.4117647

Total 20 pts quit smoking (25.6%)16/20 pts completed the program and quit smoking

6 pts /16 pts re-‐enrolled

0.375

Enrolled

78

Completed

44%

Quit Smoking

26%

Re-‐Enrolled

40%

Enrolled

78

Completed

34

Completed & Quit Smoking

16

Quit, Program Incomplete

4

Program Incomplete

24

0%

10%

20%

30%

40%

50%

Completed Quit Smoking Re-Enrolled

Completed 44%

Program Incomplete

31%

Completed & Quit Smoking 20%

Quit - Program

Incomplete 5%

“These robust new technologies not only offer enormous patient and public-health benefits, they also help attract the highest quality medical laboratory scientists to work at Christiana Care, where they can provide the highest standard of care for our patients.”

CHERYL KATZVice President, Pathology and Laboratory Services

TECHNOLOGY


State-of-the-art, high-volume, automated diagnostic testing equipment boosts turnaround time and accuracy of critical test results.



L E V E R A G I N G T E C H N O L O G Y

Faster, more accurate diagnostic results improve outcomes

Christiana Hospital’s central lab received a significant speed boost with the purchase of state-of-the-art, high-volume, automated diagnostic testing equipment. Combining equipment from competing manufacturers, the new system supports further integration of data at Christiana Care’s central lab, reducing the time required for many critical diagnostic tests.

“This extremely unusual integration of advanced equipment involved more than a year of intensive planning by two competing vendors working closely with the Christiana Care general lab staff and the IT Department,” said Cheryl Katz, vice president, Pathology and Laboratory Services. The collaboration required the custom-coding of complex electronic rules to route patient samples for testing and transmit patient data electronically from the equipment to PowerChart — Christiana Care’s electronic medical record system. Only one other hospital in the world has achieved this feat with this mix of instrumentation, according to Katz.

Detecting high-risk HPV genotypesPathology’s Molecular Diagnostics Laboratory at Christiana Hospital implemented a faster, more sophisticated human papillomavirus (HPV) qualitative test in March. This FDA-approved instrument uses polymerase chain-reaction technology to detect 14 high-risk HPV genotypes and simultaneously differentiate HPV 16 and 18, the two types responsible for about 70 percent of cervical cancer. This new method has reduced test-result turnaround time from two to three weeks to only five days.

“Our laboratories employ leading-edge technologies to increase test accuracy, improve patient care and achieve clinical excellence,” said Molecular Diagnostics Lab Director Abraham Joseph, MA, MBA, CG, MB, DLM (ASCP).

“The possibilities open to us now are broadly useful to develop other genetics tests that are valuable for our patients and help physicians to manage their care more effectively. This is the fastest growing realm of medical knowledge and diagnostic technology.”

ABRAHAM JOSEPH, MA, MBA, CG, MB, DLM (ASCP)Director of Molecular Diagnostics Lab


Steady advances in microbiologyIn Christiana Care’s microbiology lab, a new diagnostic instrument is speeding up testing times for infectious diseases such as C. difficile. Previously, it took up to 48 hours to obtain a result that can now be completed in four hours. Similar turnaround-time improvements have been achieved with other assays transferred to the new molecular technology, including screening for Group B Streptococcus (GBS), influenza and methicillin-resistant Staphylococcus aureus (MRSA). By year’s end, Christiana Care will use this device to test for tuberculosis, yielding results within two hours instead of weeks.

“These robust new technologies not only offer enormous patient and public-health benefits, they also help attract the highest quality medical laboratory scientists to work at Christiana Care, where they can provide the highest standard of care for our patients,” Katz said. •

2012 2013 2014HPV High RiskHPV 16 and 18 Genotype

9 7 5

14 13 5

Molecular Diagnostics Molecular Diagnostics Molecular Diagnostics Molecular Diagnostics Molecular Diagnostics Molecular Diagnostics Molecular Diagnostics Molecular Diagnostics Turn Around Time ComparisonTurn Around Time ComparisonTurn Around Time ComparisonTurn Around Time ComparisonTurn Around Time ComparisonTurn Around Time ComparisonTurn Around Time ComparisonTurn Around Time Comparison

DaysHPV HR -‐2012 9 HPV HR= HPV High RiskHPV HR= HPV High RiskHPV HR= HPV High RiskHPVG-‐2012 14 HPV G= HPV 16 and 18 GenotypeHPV G= HPV 16 and 18 GenotypeHPV G= HPV 16 and 18 Genotype

HPV HR-‐2013 7HPVG-‐2013 13

HPV HR-‐2014 5HPVG-‐2014 5

0

3

6

9

12

15

HPV HR -2012 HPVG-2012 HPV HR-2013 HPVG-2013 HPV HR-2014 HPVG-2014

55

13

7

14

9

Num

ber

of D

ays

0

3

6

9

12

15

HPV High Risk HPV 16 and 18 Genotype

55

13

7

14

9

Num

ber

of D

ays

2012

2013

2014

HPV Lab Test Result Turnaround-Time

Prep CompleteRoadblock RemovalRoadblock RemovalPre Data 75 59Post Data 65 43

Month Overall Rating of CareOverall Rating of CareMar-‐13 96.2Apr-‐13 96.1May-‐13 98.1Jun-‐13 98.1Jul-‐13 95.4Aug-‐13 93.4Sep-‐13 96.5Oct-‐13 97.7Nov-‐13 95.2Dec-‐13 96.4

90

92

94

96

98

100

Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

Overall Rating of Care

0

20

40

60

80

Prep Complete Roadblock Removal

Chart 2

Pre Data Post Data



The ability of a “smart” real-time locating system (RTLS) to foresee delays and bottlenecks in patient flow helped minimize delays and improve proactive communication with families about patient status, resulting in patient-satisfaction scores exceeding a 95 percent target.

The Christiana Care Center for Heart & Vascular Health implemented smart RTLS within the interventional lab suites in 2013. The tracking system features a dashboard and unit map that visualizes the location and status of radio-frequency identification (RFID)-tagged patients, clinicians and rooms throughout the department in real time, and intelligently automates workflow to streamline communication, care coordination and patient throughput.

Post-implementation, average time required to remove roadblocks for tagged providers dropped from 69 to 34 minutes. Average time-to-prep completion improved by 19 percent, and average procedure-room turnaround times improved by between 11 and 27 percent.

Prior to RTLS implementation, patient-satisfaction scores fell short of the 95 percent satisfaction rating for overall care. Post-implementation, the scores have consistently exceeded the 95 percent target, and a stretch goal of 98 percent is now targeted. A patient-tracking board enables visiting family members to follow the progress of patients in real time, driven by the automated recording of movement and care milestones.

The team plans to integrate tracking-system data with clinical data to standardize length-of-stay and post-procedure-recovery protocols. •

Smart RTLS patient-tracking system minimizes delays, improves satisfaction

Prep CompleteRoadblock RemovalRoadblock RemovalPre Data 75 59Post Data 65 43

Month Overall Rating of CareOverall Rating of CareMar-‐13 96.2Apr-‐13 96.1May-‐13 98.1Jun-‐13 98.1Jul-‐13 95.4Aug-‐13 93.4Sep-‐13 96.5Oct-‐13 97.7Nov-‐13 95.2Dec-‐13 96.4

90

92

94

96

98

100

Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

Overall Rating of Care

0

20

40

60

80

Prep Complete Roadblock Removal

Chart 2

Pre Data Post Data

Average Times Pre- and Post-RTLS Implementation

Christiana Care’s smart RTLS earned the 2014 Most Innovative Use of Business Intelligence Award for innovative healthcare technology solutions from the RFID in Healthcare Consortium and Intelligent Hospital.org.

Target

Month 5A Fall Rate NDNQI MeanJan-13 1.87 3.41Feb-13 4.22 3.41Mar-13 0 3.41Apr-13 2.94 3.19May-13 3.96 3.19Jun-13 0 3.19Jul-13 3.91 3.25Aug-13 1.02 3.25Sep-13 1.04 3.25Oct-13 1.06 3.25Nov-13 3.36 3.25Dec-13 2.71 3.25

0

1

3

4

5

Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

5A Fall Rate NDNQI Mean2014 Qua l i t y & Sa f e t y Repor t | 49

A video surveillance pilot on medical unit 5A helped eliminate patient falls during and after the pilot, and pushed the unit fall rate below the National Database of Nursing Quality Indicators (NDNQI) mean four of five months, from July through December 2013. Surveillance also decreased the use of safety companions from a unit average of 10 per month to three per month between July 2013 and January 2014.

Video surveillance equipment installed in six patient rooms on one district of the unit offered the capability to monitor 10 patients. The equipment included a stationary camera with live video feed of the patient room via a closed-circuit TV. A video camera was mounted on the wall at the foot of the patient’s bed. Patient-care technicians trained in video surveillance were stationed in a private location on the unit to monitor the video. Video was not recorded and patients were given the option to opt out of surveillance.

Factors that made patients eligible for fall-prevention surveillance included:

f Mild to moderate confusion.

f High risk for fall.

f Lack of awareness or understanding of their risk for a fall.

f Demonstration of impulsive behaviors while still responsive to verbal cues and redirection.

f High risk for major injury related to fall.

f History of falling within the past three to six months.

Patients experiencing alcohol or substance withdrawal, exhibiting aggressive or violent behavior, on suicide precautions, or with difficulty communicating through an intercom system were excluded from surveillance.

The process included a nurse-driven protocol that did not require a physician order. The video-monitoring process was explained to each patient and family considered appropriate for this modality. Staff continued to follow the fall-prevention protocol; video monitoring was not a substitute for frequent nursing assessment and interventions. When a monitored patient required testing or a procedure that normally would be provided off of the unit, consideration was given to whether it could be performed at the bedside. •

Video surveillance eliminates patient falls, decreases safety companion use

Patient Fall Rate An estimated 30 percent of patient falls result in serious injury. An aging population, rising patient acuity, use of opioids and sedatives, and patient and family underestimation of fall risk all underscore the need for fall-prevention strategies.



A new Quality and Safety intranet site launched in July 2013 as a collaborative effort among the Office of Quality and Safety, Nursing and Information Technology. The new site improves data availability and creates a framework for system and unit accountability.

The intranet site supports organization-wide transparency of performance by providing reports at the unit, service line, campus and system levels. Each patient-care unit is provided a report card that tracks measures aligned with Christiana Care strategic goals, such as hand hygiene, patient falls, hospital-acquired infections and patient experience.

The report card uses a value score methodology based on the value equation “Value = Quality ÷ Cost.” The value score assigns a numeric (0-100) and letter grade (F to A+) based on each unit’s performance on selected metrics compared to defined goals. The letter grades simplify the often complex outcomes-measurement process and motivate teams to improve. Metrics were chosen in conjunction with service line and nursing leadership and include, for example, hospital-acquired infections and hand-hygiene compliance as measures of quality. Length of stay is included as a surrogate for costs in the value equation and focus patient-care units on patient flow.

Newly launched Quality and Safety intranet site ensures data transparencyFeatures value equation methodology

The new Quality and Safety intranet site provides reports at unit, service line, campus and system levels and tracks measures aligned with

strategic goals.


UnitsBaseline FY14

A 3 2B 16 24C 9 3D 2 1Average 81.0 83.2

Improved 23No Change 1Declined 6

-‐20

0

5

10

15

20

25

30

A B C D

Patient Care Unit Grades

Num

ber

of U

nits

Baseline FY14

60

70

80

90

100

Baseline FY14

83.281.0

Patient Care Units Average Value Score

Aver

age

Valu

e S

core

0

5

10

15

20

25

30

Improved No Change Declined

6

1

23


Num

ber

of U

nits

UnitsBaseline FY14

A 3 2B 16 24C 9 3D 2 1Average 81.0 83.2


-‐20

0

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A B C D


Num

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Baseline FY14

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UnitsBaseline FY14

A 3 2B 16 24C 9 3D 2 1Average 81.0 83.2


-‐20

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10

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25

30

A B C D


Num

ber

of U

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Baseline FY14

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Baseline FY14

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Patient-Care UnitsGrades

Patient-Care UnitsAverage Value Score

The voice of the patient is included through a patient-satisfaction measure. Run charts were created for each metric to assist unit-based value-improvement teams to identify opportunities for improvement and monitor progress.

In the most recent 12 months, the site received more than 210,000 visits, with more than 109 unique staff viewing the scorecard information. All surveyed nursing leaders found the value scorecards easy to find and read, and the majority felt they were easy to understand. As of March 2014, 23 of the 30 units (77 percent) had improved their value score grade by an average of 5.7 points.

Also featured are: survey readiness documents, such as tracer information and rounding tools; clinical resources, such as Joint Commission and Centers for Medicare & Medicaid Services, State of Delaware and other accrediting bodies’ acute and behavioral health standards; CMS information, disease-specific certification and educational resources. •



Concurrent early warning triggers that predict a patient’s risk of sepsis, oversedation or clinical deterioration are giving clinicians the opportunity to modify medications and increase nursing oversight to prevent further decline and mitigate patient harm.

The trigger database — which captures information already in the electronic medical record, including vital signs and lab test results — identifies patients at greatest risk for harm. Research by the Christiana Care Value Institute indicates that a patient’s vital signs begin to deteriorate four to six hours prior to the time of a Rapid Response Team call. Early warning system triggers reduce the need for frontline staff to call a Code Blue or rapid response team.

In a sepsis pilot conducted on four medical-surgical patient-care units, trigger advisories identified 335 patients at risk for sepsis in the first six months. Based on assessment, the care team ordered lactate level measures for 30 percent of those patients. Of them, 57 percent required antibiotics. Median time to antibiotic administration was less than four hours. Only 10 percent of triggered patients required transfer to an intensive care unit, suggesting that triggered staff interventions may have positively changed the trajectory of care.

Milestones for the trigger database include enhanced timeliness of vital sign documentation, standardization of abnormal vital sign parameters requiring nurse notification,

development of risk factors for patients at risk for oversedation; online documentation of a sedation score and implementation of an algorithm for early detection of sepsis, with an advisory alert and evidence-based advisory quickset orders to reduce variation in care.

Christiana Care Value Institute researchers will continue to analyze the database to identify potential harm to our patients. •

Triggers alert clinicians to patient decline, positively change trajectory of care

Figure 1

Hours

% of triggers ≥

4n (Total # Trigger)

# of triggers ≥

42 35.1% 57 20 0.35087724 22.0% 59 13 0.2203396 14.5% 62 9 0.14516138 13.7% 51 7 0.1372549

10 15.8% 57 9 0.157894712 15.4% 52 8 0.1538462

Sepsis Advisory TriggerRapid Response Team CallICU TransferLactate MeasuredLA >4 Antibiotics ProvidedAbx <=3 Median time to abxAbx ChangeAbx Change58 45 13 8 20 2 26 10 3.9 5 2974 48 12 7 16 0 23 10 3.3 2 2250 41 9 7 12 1 24 15 4.4 6 2668 51 14 12 19 2 32 9 4 5 2925 17 6 3 6 0 12 4 3.5 1 12

275 335 54 37 102 5 192 48 3.9 19 1183.125 23.3% 10.1% 30% 5% 57% 25% 0.6732673 35%

Lactate < 2 690.0891089 Lactate 2-‐14 25

Lactate >4 6

0%

10%

20%

30%

40%

2 4 6 8 10 12

35.1%

22.0%

14.5% 13.7%15.8% 15.4%

Trend in Early Warning System Scores Prior to RRT

% of trig

ger scores >

= 4

6

25

69

Lactate < 2 Lactate 2 – 4 Lactate >4

0

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Number of Patients with Trigger Percent of Triggers

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Sepsis Advisory Trigger Lactate Measured Antibiotics Provided0%

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335

102

19230%

57%

Sepsis Trigger


Sepsis Advisory

ICUTransfer

Rapid Response Team Call

Care Processes Following Sepsis Trigger

Outcome of Sepsis Triggers

Figure 1

Hours

% of triggers ≥


# of triggers ≥

42 35.1% 57 20 0.35087724 22.0% 59 13 0.2203396 14.5% 62 9 0.14516138 13.7% 51 7 0.1372549

10 15.8% 57 9 0.157894712 15.4% 52 8 0.1538462


275 335 54 37 102 5 192 48 3.9 19 1183.125 23.3% 10.1% 30% 5% 57% 25% 0.6732673 35%

Lactate < 2 690.0891089 Lactate 2-‐14 25

Lactate >4 6

0%

10%

20%

30%

40%

2 4 6 8 10 12

35.1%

22.0%

14.5% 13.7%15.8% 15.4%


% of trig

ger scores >

= 4

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69


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335

102

19230%

57%

Sepsis Trigger


Sepsis Advisory

ICUTransfer


Figure 1

Hours

% of triggers ≥


# of triggers ≥

42 35.1% 57 20 0.35087724 22.0% 59 13 0.2203396 14.5% 62 9 0.14516138 13.7% 51 7 0.1372549

10 15.8% 57 9 0.157894712 15.4% 52 8 0.1538462


275 335 54 37 102 5 192 48 3.9 19 1183.125 23.3% 10.1% 30% 5% 57% 25% 0.6732673 35%

Lactate < 2 690.0891089 Lactate 2-‐14 25

Lactate >4 6

0%

10%

20%

30%

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2 4 6 8 10 12

35.1%

22.0%

14.5% 13.7%15.8% 15.4%


% of trig

ger scores >

= 4

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335

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19230%

57%

Sepsis Trigger


Sepsis Advisory

ICUTransfer


Lactate Level with Sepsis Trigger

Has eSignout decreased time required for bedside change report?



Old Method (Paper)New Method (eSignout)New Method (eSignout)New Method (eSignout)Ineffective 0.0% 0.0%Somewhat Effective53.8% 0.0%Effective 23.1% 7.7%Very Effective 23.1% 92.3%



0% 25% 50% 75% 100%Percent of Respondents

Yes

No

0%

20%

40%

60%

80%

100%

Ineffective Somewhat Effective Effective Very Effective

% of respondents

Old Method (Paper) New Method (eSignout)

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

0

25

50

75

100

2007 2008 2009 2010

Region 1 Region 2

Time Savings of eSignout


eSignout improves efficiency of patient handoff


Old Method (Paper)New Method (eSignout)New Method (eSignout)New Method (eSignout)Ineffective 0.0% 0.0%Somewhat Effective53.8% 0.0%Effective 23.1% 7.7%Very Effective 23.1% 92.3%



0% 25% 50% 75% 100%Percent of Respondents

Yes

No

0%

20%

40%

60%

80%

100%

Ineffective Somewhat Effective Effective Very Effective

% of respondents

Old Method (Paper) New Method (eSignout)

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

2007 2008 2009 2010Region 1Region 2

17 26 53 9655 43 70 58

0

25

50

75

100

2007 2008 2009 2010

Region 1 Region 2

Effectiveness of Methods

Perc

ent o

f Res

pond

ents

A new eSignout template converting handwritten patient handoff documentation to electronic form ensures more consistent handoff of high-acuity patient information, improves nurse satisfaction with the form-completion process, and reduces nursing hours spent recopying information.

A pilot on the Transitional Care Unit found time required to complete the bedside charge report dropped 92.3 percent with the electronic format that features labeled text boxes and auto-populated patient demographics pulled from the PowerChart electronic medical record. Hours spent updating charge reports — many of which previously ran into incidental overtime with the handwritten system — were cut 76.9 percent. Other improvements noted by surveyed nurses included more effective and accessible communication and improved time management, with 92.3 percent rating the eSignout “very effective.”

eSignout negates the need for nurses to fill in paper charge reports by hand, update them throughout the day and for the charge nurse to recopy them each night. It also eliminates issues such as omitted patient updates due to lack of available space on the handwritten form, the potential for lost paper forms and difficulty reading others’ handwriting. •



In just the first two weeks of introducing Dragon speech-recognition software, more than 700 Christiana Care credentialed clinicians created some 15,000 Progress Notes in the electronic medical record. This dynamic tool — which negates the need for clinicians to dictate or hand-write documentation in the medical record — promises to lower transcription costs, speed efficiency and populate data for achieving Meaningful Use.

By 8 a.m. on the software’s go-live day at Christiana Care, credentialed providers had created more than 150 electronic notes. By 10 a.m., nearly 400; by noon more than 700; and by 3 p.m., that number broke 1,000 notes entered by 162 unique note signers. With Dragon, clinicians can update patient status or events in minutes. Updates took up to three days to appear in the chart with conventional transcription services.

The technology appears to be equally embraced by seasoned attending physicians and fellows, as well as younger residents and medical students — many of whom, thanks to speech-recognition software will never experience the old method of dictating or handwriting progress notes.

Two surgical critical care residents took one hour to do what normally takes five residents three hours. According to one pediatrician, the tool allowed him to complete by 9 a.m. work that he expected to take the entire day.

The next step toward digital medicine will soon allow nurses, pharmacy and radiology technicians to use voice recognition capabilities to create or update Clinical Notes in the electronic medical record. •

Speech recognition speaks volumes in transformation to digital medicine

NoHas eSignout decreased time for updating the charge report?23.1%Has eSignout decreased time required for bedside charge report?7.7%

Electronic NotesElectronic Notes8:00 AM $150.00

10:00 AM 400NOON 700

3:00 PM 1,000

0

200

400

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1000

8:00 AM 10:00 AM NOON 3:00 PM

150

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Num

ber

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lect

roni

c N

otes

Electronic Notes

Electronic Notes8:00 AM 0.0%

10:00 AM 53.8%NOON 23.1%

3:00 PM 23.1%

Progression of Electronic Notes | Day One


Mobile apps link clinicians to evidence-based support

Christiana Care’s medical libraries are now mobile-friendly, featuring such highly requested apps as UpToDate Anywhere, which offers real-time access to comprehensive, evidence-based clinical decision support, and the Mendeley reference manager and academic network software. Mendeley allows libraries to connect their journal collection directly to researchers, and in turn allows researchers to create private groups with up to 25 collaborators with similar research interests to share documents, access papers on the Web or mobile devices. •

“We’re continually listening to our clinicians, students, researchers and consumers to ensure that they have the tools and information they need to create, innovate and provide expert care to our patients.”

BARBARA HENRY, MLS Director, Medical Libraries



The Vocera two-way, real-time, hands-free communication system plays a key role in helping the phlebotomy team increase response times, meeting a goal of responding in 30 minutes or less to 90 percent of inpatient stat blood collection orders on the Christiana Hospital campus. Response time improved 12.5 percent in the first two weeks of use, and now a full year into use, Vocera helps the phlebotomy team meet their response time goal for 95.4 percent of requests (up from 73 percent prior to Vocera and exceeding their set goal).

Vocera uses voice activation to locate a specific team member, or allows information to be broadcast to multiple users simultaneously in time-critical situations. The technology improves quality and safety of care by allowing unit staff to remain at the patient’s side while calling for assistance, and improves response time by negating the need for the phlebotomy team to relay information received via overhead, web or phone requests. Direct notification of staff and ease of communication among staff reduces frustration and leads to prompter, more efficient response and ultimately to safer, higher quality care.

At the end of FY 2012, the phlebotomy team was only able to meet their 30-minute response-time goal in 73 percent of stat orders. In the first half of FY 2013, thanks to team-led initiatives, that number inched up to 80 percent of requests, yet still fell short of goal. Communication issues were the obvious roadblock. In just two weeks of introducing Vocera, that percentage soared 12.5 percent to meeting the goal in 90.3 of stat orders. Nine months later, they were meeting the 30-minute response-time goal in 93.2 percent of orders and, by May 2014, in 95.4 percent of stat orders. •

Hands-free communication tool speeds response time for stat blood draws

Goal 90%

{ Baseline } { Pre Vocera }

Response Time GoalQ2 2012 (Base line) 73.0% 90%Q3 2012 75.5% 90%Q4 2012 82.1% 90%Q1 2013 (Pre Vocera) 83.5% 90%Q1 2013 (Vocera) 90.3% 90%Q2 2013 91.0% 90%Q3-‐4 2013 93.2% 90%Q2 2014 95.4% 90% Phlebotomy STAT Blood Collection Response Time

Percent within 30 minutes

0%

25%

50%

75%

100%

Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q1 2013 Q2 2013 Q3-4 2013 Q2 2014

73.0% 75.5%82.1% 83.5%

90.3% 91.0% 93.2% 95.4%

Per

cent

of R

espo

nses

Withi

n 3

0 M

inut

es

Goal: 90%Vocera implemented

Vocera Implementation

Vocera Implemented

Within two weeks of Vocera’s

implementation there was a 12.5 percent

increase in our response times.


A WA R D S , R E C O G N I T I O N & A C C O M P L I S H M E N T S

Annual Focus on Excellence awards program marks decade of health care innovation

OVER THE LAST DECADE, Christiana Care’s annual Focus on Excellence awards program has challenged all who work within the health system to be health care innovators.

Physicians, nurses and staff collaborate to identify an opportunity for improvement, then develop and carry out a plan to achieve improvements in process or outcomes using the Plan-Do-Check-Act model. Teams create storyboards to explain their projects, which are displayed in an exhibit in October, in conjunction with National Healthcare Quality Week.

In the inaugural 2003 competition, 53 submissions vied for 11 trophies in four award categories. This year’s competition attracted 144 entries with 36 taking honors in 19 categories.

The 2013 competition featured a new category designed by Christiana Care’s Value Institute to identify projects with the greatest research potential. Four award winners are now teamed with a Value Institute researcher for possible expansion of their projects.

“The quantity and diversity of the submissions have always adjusted to Christiana Care’s annual goals and operating plans, and the constant changes and improvements inspire innovation and cooperation,” said Sharon Anderson, RN, BSN, MS, FACHE, senior vice president, Quality, Patient Safety & Population Health Management, and director, Value Institute Center for Quality & Patient Safety.

More than 149 colleagues volunteered as judges for the 2013 entries. The program culminates each year in an awards celebration featuring a nationally known guest speaker. This year, Raymond J. Fabius, M.D., CPE, FACPE, founder of HealthNEXT, lectured on the need to form population health management organizations driven by value rather than volume, and motivated by both penalties and incentives provided by rollout of new federal laws. •

The President’s Award recognized a team of 25 from the Department of Medicine and the Ammon Diabetes Prevention and Care Project for their concerted, successful effort to improve uncontrolled diabetes among patients of the Adult Medicine Office.

Focus on Excellence Awards



Focus on Excellence Awards

2013 AWARD PROJECT TITLE RESULTS

President’s Award Improving Glycemic Control in the Adult Medicine Office

The Ammon Diabetes Prevention and Care Project convened a multidisciplinary team to develop and implement a com-prehensive diabetes disease management program to meet the needs of the AMO diabetic population. Over 25 percent of the 178 poorly controlled and active diabetic patients achieved control with a mean reduction in HA1c of 0.6 percent and the overall rate of glycemic control increased from 63.7 to 70.8 percent. In addition, performance in six of seven diabetic measures, including two important intermediate outcomes (glycemic and LDL control), improved significantly.

Value Award Gold

Applying Evidence-Based CPOE to Telemetry

A cardiac telemetry team reduced unnecessary utilization of cardiac telemetry in non-intensive care unit settings through the application of national guidelines to the provider-ordering process in PowerChart. The redesign project yielded a prompt and sustained 43 percent reduction in average weekly number of telemetry patients, and a 47 percent reduction in the average telemetry hours per patient. There was no change in the number of adverse events. The reduction in total telemetry days is estimated to save $4.8 million annually.

Clinical Excellence Award Gold

Improving Early Mobilization of Critically Ill Patients in the MICU

The Medical Intensive Care Unit (MICU) developed a multi-layered set of interventions to increase awareness of the adverse effects of prolonged bed rest and increase the amount of appropriate physical therapy consultations. The per-centage of patients receiving a PT consult increased from 16 to 37 percent. MICU length of stay decreased 1.6 days, and mechanical ventilator length of stay decreased 1.1 days. Early mobility is now part of the everyday standard in MICU.

Safety First Award Gold

Ending VAP with Real-Time Feedback

The Ventilator-Associated Pneumonia Collaborative team standardized a patient care rounding tool to support full implementation of every evidence-based care bundle element. Real-time reports provide immediate feedback to the care team, while monthly trend reports enable the unit-based value-improvement teams to adjust practices as needed. Through these efforts, the number of annual VAP infections decreased by 33 percent.

Employee Safety Award Integrating Lifting Equipment into Rehabilitation

A work group of therapists from Injury Prevention and the acute-care and rehabilitation facilities identified uses of ceiling-mounted lifts in practical, everyday therapeutic interventions to help progress patients’ mobility, while pro-tecting therapists against injury due to patient handling. Therapists’ rate of perceived exertion decreased from eight (really hard) to two (easy), while patients’ functional improvement measures increased significantly.

Great Place to Work Award

The Culture of Responsibility Grows in the Lab

Over a three-year period, the Laboratory leadership team incorporated Culture of Responsibility into workflow, investigation and performance management throughout the Department of Pathology and Laboratory Medicine. AHRQ Culture of Patient Safety survey results show that safety is a top priority, error feedback and communication has improved, reporting of near misses has increased, event investigation is less punitive, and there is an increase in the overall perception of patient safety in the laboratory.

Think of Yourself as a Patient Award Gold

Improving Patient Satisfaction Using Multimodal Communication Tools

The Christiana Care Hospitalist Partners (CCHP) group used Lean tools to standardize admission packets on 5D, increase patient awareness of their physician and improve communication. The percentage of patients who correctly named the physician responsible for their care increased from 2 to 55 percent, while the percentage who could name their discharging physician increased from 7 to 64 percent. In one quarter, HCAHPS results increased from 68 to 78 percent.

Financial Strength Award

Fentanyl & Financial Stewardship: Mutually Inclusive

Anesthesiologists, CRNAs and a pharmacist investigated replacing high-cost Remifentanil, a potent, ultra-short acting opioid analgesic utilized in anesthetics, with Fentanyl infusions in appropriate cases. Within a two-month period, the transition to Fentanyl resulted in a 77 percent decrease in costs, with a savings of $174,000.

Nursing – Empirical Outcomes Award Gold

Cleaner Catches This 5W interdisciplinary team improved the quality and efficiency of treatment decisions by reducing the number of contaminated urine specimens and expediting followup to contaminated specimen results. The number of contaminated samples decreased by 50 percent, and 40 percent of contaminated results were communicated within the established 90-minute window.


2013 AWARD PROJECT TITLE RESULTS

Nursing – New Knowledge, Innovations & Improvements Award Gold

Patient-Care Unit Dashboards Drive Excellence

Data Acquisition & Measurement analysts worked with nursing, service-line leaders and the IT intranet team to communicate opportunities for improvement to patient-care units through dashboards on the Quality & Safety intranet site. All surveyed nursing leaders found the value scorecards easy to find and read, and the majority felt they were easy to understand. 76 percent of units had improved their grade by an average of 6.5 points.

Nursing – Exemplary Professional Practice Award Gold

Mothers and Newborns Win with Skin-to-Skin

As part of an organizational goal to become a Baby Friendly-designated hospital, the practice of skin-to-skin contact in the first hour after delivery, which has been shown to improve bonding, breastfeeding and stabilization of the newborn, was implemented. Skin-to-Skin for vaginal births increased from 18 percent to over 80 percent in the four months following implementation. Skin-to-skin for C-sections improved from 11 to 43 percent.

Nursing – Structural Empowerment Award

Handle with Care: Improving Post-Surgical Transitions

Low handoff communication scores on both the Culture of Safety and employee satisfaction surveys motivated the team to improve and standardize patient handoff communication and surgical transitions between the PACU and nursing units 4C and 4E. Transition times from PACU to escort decreased by 64 percent, from report time to patient arrival on 4C by 15 percent and from report time to patient arrival on 4E by 49 percent. Staff perception of handoff communication improved 40 percent.

Nursing – Transformational Leadership Award

Highway to the SCCC: Decreasing ED LOS for Trauma Codes

The Trauma program, Surgical Critical Care Complex and Christiana Emergency Department streamlined trauma patient transport to reduce ED length of stay and improve handoff communication. Average ED length of stay decreased more than 90 minutes; ICU length of stay dropped by 2.3 days; and overall hospital stays dropped by almost two days. The improvements resulted in a direct variable cost savings of $278,000.

Learning Excellence Award Gold

VNA TV Learning Anytime Anywhere

Christiana Care’s VNA and the Learning Institute’s Center for Innovation, Instructional Design and Technology collaborated to provide anytime, anywhere access to education utilizing principles of adult learning. Seven videos with VNA-specific education were developed in a library in VNA TV, a Sharepoint site.

Operational Improvement Award Gold

Wilmington General Laboratory TAT Improvement

The Department of Pathology and Laboratory Medicine’s project focused on improving the electrolyte in-lab turnaround time for Emergency Department patients. Through several rapid-cycle changes, the team improved electrolyte turnaround time to 95 percent within 30 minutes, and then expanded the process to improve TAT for troponin to 92 percent.

Excellence in Community Health Award Gold

The Value of a System-Integrated Health Coach Model in Primary Care

The Department of Family and Community Medicine and the Value Institute examined the value of interaction and care-coordination within a system-integrated health coach model among high-risk uninsured and underinsured patients. Interactions with a health coach significantly predict lower rank of HbA1c in diabetics, lower rank of systolic pressure in hypertensives and that patient’s transition from acute toward outpatient interactions.

Resident’s Award Gold

Never TMI This Achieving Competency Today (ACT) team’s goal was that every patient being transferred out of the Christiana Medical Intensive Care Unit (MICU) to a lower level of care will be accompanied by a standardized transfer note summarizing essential information and plan of care. A standardized handoff transfer note resulted in a 32 percent increase in inclusion of useful information; template notes increased inclusion of content on 12 of 17 essential points. All of note senders felt the template was useful.

Diversity, Inclusion & Cultural Competency Excellence Award

Improving Care for LEP Patients

The multidisciplinary team focused on improving the quality and safety of care for limited English proficient mothers delivered by the Women’s & Children’s inpatient obstetrical service by increasing utilization of qualified medical interpret-ers and decreasing patient-reported unmet need for interpreters. Use of in-person interpreters increased by 34 percent and phone interpreters by 41 percent. In addition, there was a 32 percent decrease in the reported unmet need for interpreter.

People’s Choice Award Peripherally Inserted Central Catheter Tip Placement by Vascular Access Nursing

To improve the timely delivery of intravenous therapy through PICC lines by reducing potential delays of radiologist verification of placement, the Vascular Access Nursing team gained Delaware Board of Nursing approval for the reading of a simple radiograph for placement of a PICC line to be within the scope of practice of a specially trained RN. Within the first six months, the VAN nurses completed 1,133 interpretations, with 99 percent in agreement with radiologist final reading. •

The Christiana Care Quality and Safety Program strives to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.

To achieve these goals, the program targets three strategic areas: creating a safe culture, achieving high reliability and leveraging technology.


Leveraging TechnologyOur commitment to invest heavily, yet prudently, in technology — whether for patient- care equipment, electronic medical records or operational software to streamline our efficiencies — leads to safer, better care and ultimately greater value for our patients.

Creating a Safe CultureEvery individual shares a deep commitment to make safety a priority. Christiana Care’s culture of safety is characterized by our patient-centered care, open communication, a blame-free environment and collective responsibility for safety.

Achieving High ReliabilityHealth care organizations are complex entities where the risk for accidents and injury runs extremely high. High reliability organizations (HROs) avoid catastrophes and accidents despite the dangers inherent in their businesses. Christiana Care employs best practices of other high-risk industries in order to achieve the defining characteristics of HROs.

2008

Safety First Learning Report

Enhancements for Follow-Up

Just Culture Concepts (Planning)

Human Factor Analysis for Flex Monitoring

Team Training

Transparency Concepts

Focus on “No Harm, Any is Too Many”

2009 2010 2011

Our Journey — PROGRAM INITIATIVES 2008 to 2014

Culture Survey (October)

Culture of Responsibility Phase I (June)

SAFE Weekly Huddles

Human Factors Analysis for Radiation Oncology

Disclosure Policy & Process

Interdisciplinary Rounds

Cultural Diversity & Inclusion

Quarterly Environment of Care Consultant Assessments

Specialized Training on Compressed Gas Safety

Culture of Responsibility Phase II (Oct.)

Standarized Handoffs for Transitions of Care in Women’s Health

Embracing Patient-Centered Care through Implementation of AIDET

Unit-Based Clinical Leadership Teams

5C Nursing Home Project

Bedside Shift Report

Employee Wellness

TRP Safety Education Module

Facilities and Services Safety Committee Established

Slip, Trip Fall Workgroup Established

Department Level Focused Safety Training

Culture Survey (January)

Culture of Responsibility (Planning)

Patient and Community Involvement

Post-Event Debriefs Partners in Safety Updates

Enhanced Disclosure Process

Patient- and Family-Centered Care

Worker Fall Protection Policy

Skylight Safety Assessment

BEAT Training Classes

Arc Flash Policy and Program

Safe Work Permit Improvements

Clinical Documentation Project

MRSA

National Patient Safety Goals: • Management of Anticoagulation • Improving Recognition and Response to Changes in Patient Condition

“Never Events” Present on Admission

Hospital Consumer and Assessment Provider Survey (HCAPS)

Medication Safety

Medical Bariatric FMEA

Disease-Specific Certification • Stroke Program

Comprehensive Unit-Based Safety Program (CUSP)

Magnet Recognition

Flu Vaccine Program

Surgical Safety Team Checklist

Pregnancy Screening in Non-OB Locations

SWAT (Synchronized Wilmington Admission Team)

Obstetrical Emergency Response Team (OBERT)

ED SPEED

Pharmaceutical Waste Management Program Implemented

Disease-Specific Certification (May): • Heart Failure • Hip • Knee

Recertification Disease-Specific Stroke Program

Best Practices for Better Care

Partnership for Patients

Christiana Rapid-Transfer Initiative

Proactive Assessment of Communicating Patient Preferences/Goals of Care

ED SHARP

Heart Failure Transformation Team

ED Triage Redesign

National Patient Safety Goal: Reduce Risk of Health-Care-Associated Infections: • Central-Line-Associated Bloodstream Infections • Multiple Drug-Resistant Organisms • Prevention of Surgical-Site Infection

Prevent Harm from High-Alert Medications (Hydromorphone)

Disease-Specific Certification Planning • Primary Stroke Center

Hand Hygiene Campaign

ED Super Track

ADT Interfaces with Micropaq

Wireless Patient Monitoring

Infusion Pumps (Smart Pumps)

CPOE: Zynx Phase 2

Language Line Enhancement

Vocera

Equipment Tracking

CPOE

Expanded Use of Vocera

Care Fusion Implementation

Planning for Meaningful Use

VNA Heart Failure Telemonitoring Program

Wireless Bar Coding of Breast Milk

Enhanced Suicide Risk Assessment

Language Line Enhancement

Insight Heart Failure (Symptom Self-Assessment)

Virtual Education & Simulation Training Center (June)

Spill Stations Designed and Ordered

Capnography (End-Tidal CO2 Monitoring) During Code Blue

Radiation Therapy Positioning Software

Enhanced Central Line Checklist

Implemented Baseline Pulse Oximetry in OB Triage, L & D and Antepartum Areas

Standardization of Web Page to Mobilize Anesthesia Services

Interpreters

Care Visibility

CPOE: Zynx Phase 3

Enhanced Web Paging

2012 2013

Our Journey — PROGRAM INITIATIVES 2008 to 2014

Culture Survey (April)

Culture of Responsibility Phase III (October)

Employee Safety Handbook

Workplace Violence Committee Established

VP Level Monthly Injury Summary Reports

Contractor Safety Training Video Updated

Workplace Safety Risk Review Evaluation Completed by Conner Strong

Formalized Systemwide “Good Catch” Program (March)

Patient Safety Organization-PSES evaluation

Value Improvement Team Addresses Needlesticks, Sharps, and Exposure Injuries

Improvements to Reduce Risk of Slips, Trips and Falls

Communications Strategy for Employee Safety

Pilot Early Warning System (EWS)

Patient Identification Best Practice

Leadership Forum “Event Analysis”

SWAT Launches at Christiana

Human Factors Consultant “Sponge Counts”

Value Improvement Team Training

ISMP ED Medication Consult

ECRI RRT Assessment

ECRI Fall Insight Assessment

Expansion of SPBM to Outpatient Sites

Adoption of NCCMERP Harm Scale & Classification Taxonomy for Medication Events

Implemented Evidence-Based Indications for Telemetry (March)

Expanded Behavioral Emergency Assistance Team (BEAT) Training

Active Shooter & Workplace Violence Policies

Trained Incident Management Team to Staff Command Centers in Response to Emergencies

Winter Weather Communications

Enhanced Multum Alert View for Duplicates, Allergies and Major-Contraindicated Drug-Drug Interactions

Automation of “Event Follow-Up”

Implementation of Meaningful Use

Development of Global Triggers – Sepsis, EWS and Over-Sedation

Procurement of TRU-D® SMARTUVC™ Room Disinfection System

Capture “Flu” Administration

Online Central Lines & Foley Day Documentation

Current Orders in DATAS

Acoustic Engineer Engaged to Study Noise Levels in Patient-Care Areas

Injury Summary Reports Distributed to Directors for Review and Follow-up

Workgroup Assessing Blood and Body Fluid Splashes

Consultant Observing Behaviors Related to Handling Needles and Sharps

Injury Investigation/Safety Behaviors Introduced into New Leader Orientation, Frontline and Working Courses

Creation of a Workplace Safety Intranet Site

Restraint Reduction

No Pass Zone

Phase IV CoR Manager Training

Administration of AHRQ Culture Survey

Engaged in Health Care Safety Hotline Project with AHRQ & Rand

Engaged in CandOR (Communication and Optimal Resolution) Demonstration Project

Vendor Selection for Event Reporting & Management

Focused Safety Assessments in High-Risk Departments

Pilot Program for Slip-Resistant Shoes

Adoption of National Telemetry Guidelines

Post Rapid Response Team Huddles

Lean Six Sigma Fall Reduction

Hand Hygiene Campaign

Scenario-Based Interprofessional Simulation Training

Video Surveillance Project (5A)

Collaboration with Value Institute on Predictive Modeling for EWS, Sepsis, and Oversedation with Pilot of Early Warning System

Adoption of PASERO Sedation Assessment

Collaborative for Improving Transitions of Care

Developed Anticoagulation Management Guidelines

Created Acute Pain Management Service

Expansion of Antimicrobial Stewardship Program

Vendor Selection for Occupational Health and Safety Management Software

Vendor Selection for Emergency Mass Notification System

Creation of a Network Downtime Census

Electronic Standardized RRT Documentation

Electronic Schmid Fall Risk and High Risk for Injury Assessment

New Quality & Safety Intranet Site

Vendor Selection for Smart Pump Replacement

eMar/BCMA/CPOE implemented in Women & Children’s Service

Electronic Progress Notes

Electronic Critical Test Results Sticker

2014

Focus Groups on Speak Up (April)

Culture of Responsibility Phase IV (June)

Event Investigation Management Training

Integration of Medication Safety Concepts into VEST Center Simulation Training

Implementation of MedMarx Database and Each Medication Error Benchmarking Capability

Pilot AU Meds (Sept)

Tram Safety Program Improvements to Reduce Risk of Accidents and Injuries

Levels of Complexity of VI Projects

VTE Prophylaxis Surveillance

Deep Dive for Lab Events

Creation of an Acute Pain Treatment Service

Evaluation of Network Downtime Procedures and Operations

Power Chart Upgrades (Aug)

OBIS Interface

Microtab for Infection Prevention

Dose Edge IV Production

Enterprise Rx Outpatient Pharmacy Bar Coded Dispensing Verification

Promanger Inpatient Initial Dose Automation

AcuDose Bar Code Restocking Processes

Oncology CPOE


In the regional and national spotlight

AMERICAN COLLEGE OF PHYSICIAN EXECUTIVES 2014 LEAPE

AHEAD AWARD for multipronged approach to teaching medical students, residents and faculty the principles of patient safety and quality.

HOSPITAL SAFETY SCORE OF “A” FROM THE LEAPFROG GROUP, which rates how well hospitals protect patients from accidents, errors, injuries and infections.

U.S. NEWS & WORLD REPORT RANKS CHRISTIANA CARE NO. 1

IN DELAWARE AND ONE OF THE NATION’S BEST HOSPITALS. Our Department of Obstetrics and Gynecology ranks among the top 50 hospitals nationwide in the specialty of gynecology. In the past five years, Christiana Care has received U.S. News Best Hospitals rankings in Ear, nose and Throat, Endocrinology, Gastroenterology, Digestive and Respiratory Disorders and Urology.

IVANTAGE HEALTH ANALYTICS TOP 100 HEALTHSTRONG

HOSPITAL.

COMMUNITY VALUE FIVE-STAR HOSPITAL scoring in the top 20 percent of “high-intensity teaching hospitals” by Cleverley and Associates.

JOINT COMMISSION GOLD SEAL OF APPROVAL AND

RECERTIFICATION for Advanced Primary Stroke, Heart Failure and Joint Replacement (Hip and Knee) and our Left Ventricular Assist Device Program. Successful initial accreditation survey for Comprehensive Stroke program at Christiana Hospital in May 2014.

THE AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL

QUALITY IMPROVEMENT PROGRAM recognized Christiana Care for clinical excellence in mortality, unplanned intubation, ventilator more than 48 hours, renal failure, DVT, cardiac incidents, respiratory (pneumonia), surgical-site infections and urinary-tract infection.

GOLD BEACON AWARD FOR EXCELLENCE from the American Association of Critical Care Nurses (AACN) – presented to the Cardiovascular Critical Care Complex.

CENTER OF EXCELLENCE IN MINIMALLY INVASIVE

GYNECOLOGY (COEMIG) DESIGNATION by the American Association of Gynecologic Laparoscoposits and the Surgical Review Corporation.

TRAINING MAGAZINE TOP 125 COMPANY for training and learning development.

THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION’S

ACTION REGISTRY AWARDED ITS GWTG GOLD PERFORMANCE

ACHIEVEMENT AWARD for 2013 to the Center for Heart & Vascular Health.

EMERGENCY NURSES ASSOCIATION 2013 FORENSIC NURSE

EXAMINER TEAM AWARD, calling Christiana Care’s program “a model for the country.”

MEDICAID HEALTH PLANS OF AMERICA 2013 BEST PRACTICES

AWARD for Christiana Care Visiting Nurse Association’s “Control Your Heart for the Future” telehealth program.

NICHE (NURSES IMPROVING CARE FOR HEALTHSYSTEM

ELDERS) PROGRAM EXEMPLAR STATUS for outstanding elder care.

4TH CONSECUTIVE THREE-STAR (HIGHEST) RATING FROM THE

SOCIETY OF THORACIC SURGEONS.

COMPETENCY & CREDENTIAL INSTITUTE CNOR® STRONG

DESIGNATION.

INFORMATIONWEEK 500 LIST OF TOP TECHNOLOGY

INNOVATORS in the U.S. for third consecutive year.

One of only seven community oncology research programs in the nation to receive a CLINICAL TRIALS PARTICIPATION AWARD

FROM THE CONQUER CANCER FOUNDATION OF THE

AMERICAN SOCIETY OF CLINICAL ONCOLOGY.

HELEN F. GRAHAM CANCER CENTER & RESEARCH INSTITUTE

SCORED HIGHEST IN PATIENT EXPERIENCE FOR THE QUALITY

OF CANCER CARE among six U.S. centers in a survey report issued by the MAYO CLINIC AND THE AMERICAN INSTITUTES FOR

RESEARCH.

LGBT LEADER IN THE HUMAN RIGHTS CAMPAIGN

FOUNDATION’S HEALTHCARE EQUALITY INDEX 2013.

APEX QUALITY AWARD presented to the Glasgow Medical Center’s Ambulatory Surgery Center for the highest level of patient satisfaction and overall care (fifth consecutive year).

NEWS JOURNAL (GANNETT) TOP WORK PLACE IN DELAWARE

AND THE NATION.

Christiana Care Health System, headquartered in Wilmington, Delaware, is one of the country’s largest health care providers, ranking 22nd in the nation for hospital admissions.

We are a major teaching hospital and recognized as a regional center for excellence in cardiology, cancer and women’s health services. We operate Delaware’s only Level I trauma center, the only center of its kind between Philadelphia and Baltimore, and a Level III neonatal intensive care unit, the only delivering hospital in the state to offer this level of care for newborns.

A not-for-profit, nonsectarian health system, Christiana Care includes two hospitals with more than 1,100 patient beds, a home health care service, preventive medicine, rehabilitation services, a network of primary care physicians and an extensive range of outpatient services.

CREATING

A SAFE CULTU

RE

ACHIE

VIN

G H

IGH

REL

IABI

LITY

LEVERAGING TECHNOLOGY

QUALITYAND

SAFETY

Christiana Care is recognized for excellence

P.O. Box 1668Wilmington, Delaware 19899-1668www.christianacare.org

Christiana Care is a private, not-for-profit regional health care system that relies in part on the generosity of individuals, foundations and corporations to fulfill its mission. To learn more about our mission, please visit christianacare.org/donors.

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quality & safety report 2014

Documents

value of care

health care value

care managers

pastoral care

valuedriven care

patient care units

reporting health care

t iana care