Quality & Safety Annual Report - 2016 by ChristianaCare

Quality & Safety Report

2016

The Christiana Care Way We 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.

A new operational and care delivery structure introduced in 2015 advances The Christiana Care Way by focusing on three strategic aims mirroring our industryâ&#x20AC;&#x2122;s Triple Aim of better health outcomes, care and affordability: f Optimal Health. f Exceptional Experience. f Organizational Vitality. Further supported by our commitment to Strategic Partnerships, Innovative Tools and Extraordinary People, the structure reduces unnecessary variation in care, better coordinates care across the continuum and continues to improve the quality, safety and value of care.

I N T H I S R E P O RT

03 O P T I M A L H E A L T H

42 S E R V I C E L I N E S

28 E X C E P T I O N A L E X P E R I E N C E

64 E S S E N T I A L S E R V I C E S

35 O R G A N I Z A T I O N A L V I T A L I T Y

74 F O C U S O N E X C E L L E N C E A N D N AT I O N A L R E C O G N I T I O N

Community focused, nationally recognized!

The extraordinary people of Christiana Care Health System are working in innovative, exciting ways to achieve optimal health and an exceptional experience for everyone we serve, and to foster organizational vitality that enables us to invest back in our community and provide great care today and in the future. There has never been a more exciting time in health care. As we embrace this era of incredible change, Christiana Care is poised to advance the way in creating a health care system that not only meets the needs of the community we serve, but earns us these, and other industry honors as a recognized national leader in the health care conversation: • Joint Commission Certifications and Gold Seals. • Magnet Designation for Nursing Excellence. • U.S. News & World Report Top Hospital. • Truven Health Analytics 100 Top Hospitals and Everest Award. • American College of Surgeons Meritorious Outcomes.

2016 Quality & Safety Report

COMMUNITY FOCUSED NATIONALLY RECOGNIZED

“OUR EXTRAORDINARY PEOPLE

who care for our patients on a day-to-day basis, and those whose support makes high-quality care possible, are the strength behind these awards,” said Kenneth Silverstein, M.D., MBA, Christiana Care's chief clinical officer. “Being recognized for consistent excellence by such reliable, independent, trusted markers suggests we’re building the right system to consistently provide the care our patients deserve.”

“Earning these honors truly demonstrates the commitment of our extraordinary employees, leadership and volunteers to advancing The Christiana Care Way. It is our commitment and our privilege to help our patients by consistently improving care that produces superior outcomes.” JANICE E. NEVIN, M.D., MPH President and Chief Executive Officer

Christiana Care Health System

Focused approach drives success Key measurements of performance in health care quality and safety are the difference makers that earned Christiana Care’s inclusion as one of only 17 hospitals in the Major Teaching Hospital category in the Truven Health Analytics 100 Top Hospitals list. They include lower-than-benchmark mortality and low 30-day readmission rates in key areas, including acute myocardial infarction (more commonly known as heart attack), heart failure, stroke, pneumonia, chronic obstructive pulmonary disease (COPD) and knee and hip replacement surgery. Top 100 hospitals also score well on the Centers for Medicare & Medicaid Services (CMS) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for overall patient satisfaction. “When Christiana Care applies efforts in a focused way, the results are exceptional,” said Virginia U. Collier, M.D., MACP, Hugh R. Sharp Jr. Chair of Medicine and physician leader of the Acute Medicine Service Line. “These awards are validation of the focus we have on patient safety and quality throughout the health care system.”

Dr. Collier credits data sharing among physicians and system leaders to help them continually assess how well the health system is doing and identify opportunities for improvement. “We critically evaluate ourselves and drill deeply into the data to identify opportunities and apply our energies to developing solutions,” she said. “We are consistent in our approach to continuous improvement of patient safety and quality.” High-value care As the national conversation continues to focus on the rising cost of health care, Christiana Care is ahead of the game, focused on delivering the best value to our patients and to our community. Successes include efforts to eliminate waste, such as Christiana Care’s reduction in unnecessary cardiac telemetry, which saved $4.8 million in health care costs and serves as a national model for other hospitals to follow, as well as responsible stewardship of resources, which permeates throughout every department at Christiana Care, where detailed attention to the budgeting process helps to constrain the rise of health care costs. “There is a culture here at Christiana Care where we’re always looking for opportunities to perform better,” said Thomas L. Corrigan, MBA, CPA, executive vice president of health services operations and chief financial officer. “But to be clear,” he adds, “our culture of efficiency is driven, first and foremost, by what is needed in terms of safe clinical care.” 

Optimal Health ACHIEVING TOP PERFORMANCE IN OUTCOMES FOR ALL WITH A SPECIAL FOCUS ON THE POPULATIONS FOR WHICH WE ARE AT RISK.

REDUCE UNNECESSARY VARIATION IN CARE THROUGH THE DEVELOPMENT AND IMPLEMENTATION OF PATIENT-CENTERED, VALUE-BASED PATHWAYS.

DEFINE AND DEMONSTRATE TOP PERFORMANCE ACROSS THE CONTINUUM OF CARE.

Optimal Health is about being a top performer for everyone we serve â&#x20AC;&#x201D; not just for the people coming into our facilities, but for the populations for which we are accountable. To succeed will require a new way of thinking about health care. No longer will it be enough to sit back and wait for patients to show up.

2016 Quality & Safety Report

JOURNEY TO ZERO LEADS TO DECREASE IN PREVENTABLE HARM RATE Patient-centered approach now counts number of patients instead of rates A PATIENT-CENTERED APPROACH

of counting the number of patients harmed, instead of relying on rates of harm, coupled with a robust, systemwide strategic focus on eliminating harm, has led to a more than 66 percent reduction in the incidence of harm over a fiveyear period ending in 2015, prior to the start of the new operational and care delivery structure. More than 5,700 fewer patients experienced harm during their hospitalization since Christiana Care first launched its Journey to Zero in 2010. This is over a five-year period ending in 2015, prior to the start of the new structure (see service lines and essential services sections, beginning on page 42). With accountability for eliminating harm now shifted to the service line leadership, the definition of harm has expanded to more fully encompass additional highrisk patients served by the service lines. Christiana Care’s definition of harm now includes: f Hospital-acquired infections: • In prior years, central-line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) were reported only for intensive care and stepdown units. Reporting, both internally and to the Centers for Medicare & Medicaid Services (CMS), has expanded to all patient care units. • Service lines added additional hospital-acquired infection categories related to infections following certain procedures: ∘ Surgical site infections after hernia procedures (Surgical Services).

Christiana Care Health System

∘ Surgical site infections after cesarean delivery (Women & Children’s). f Hospital-acquired pressure ulcers (HAPU): • The definition of harm was expanded to more closely align with Christiana Care’s Magnet designation by the American Nurses Credentialing Center. In addition to Stage 3 and 4 pressure ulcers, deep tissue injury and unstageable pressure ulcers are now counted as harm.

• Restraints and seclusions added under the Behavioral Health Service Line. • Medication safety (unchanged). • Patient falls with major injury (unchanged). • Complications (unchanged). The definitional change makes trending harm compared to the prior five years a challenge. However, with the revised definition, we continue to see a decrease. Since July 2015, we have seen a 4 percent reduction in harm, with more than 175 fewer patients harmed. 

O P T I M A L H E A LT H

Patient care units honored with Zero Harm Awards

Zero Harm 2015 MICU

Christiana Care’s Zero Harm Award, established in February 2015, recognizes patient care units Jul-‐15

4.239360835

Aug-‐15

3.245132302

Sep-‐15

Oct-‐15

3.447143795

and departments that successfully Nov-‐15 achieve 12 consecutive months

3.401226023

4.518813476

without patient harm in key

Dec-‐15

3.0695908

patient safety measures. In 2015, 22 units achieved Zero Harm Awards, a testament to our culture of safety: CLABSI — Christiana Hospital: Zero Harm 2015 WICU

4D, Neuro Critical Care Unit and Surgical Critical Care Complex. C. difficile — Christiana Hospital: 3A, 3B, 3C, 4A, 4B, and

Preventable Harm Rate

Wilmington Hospital: 7S and DESIRED

HARM PER 1 000 PATIENT DAYS

DIRECTION

Center for Rehabilitation. CAUTI — Christiana Hospital: 3D and 4D.

Patient falls with major injury 3

— Christiana Hospital: 2C, 5C, 5D, 6A, 6B, 6E, Neuro Critical Care Unit, Emergency

Department. Wilmington Hospital: 6S Stepdown and 7S.

0 Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

2016 Quality & Safety Report

JOURNEY TO ZERO LEADS TO FEWER PATIENTS DEVELOPING HOSPITAL-ACQUIRED INFECTIONS HOSPITAL-ACQUIRED INFECTIONS are an area of focus on our journey to zero cases of preventable harm. These infections lead to increased morbidity and mortality, prolonged lengths of stay and increased costs of care. In addition, many types of infections are included in the Centers for Medicare & Medicaid Services pay-forperformance programs, where Christiana Care is at risk for more than $6.5 million if hospital-acquired infections rates are high (see value-based purchasing story, page 37). Through the collaborative efforts of the Infection Prevention Committee, patient care units and the service lines, the five tracked major classes of hospital-acquired infections have decreased 31 percent since fiscal year 2012, with nearly 300 fewer patients developing infection.

Hospital-Acquired Infection Trend 500

DESIRED DIRECTION

NUMBER OF INFECTIONS

375

250

125

Surgical Site Infections MRSA C-difficile CAUTI CLASBI FY12

FY13

FY14

FY15

CLABSI and CAUTI Oncology unit cuts CLABSI rate by 67 percent in just three months Monitoring and reporting of central-line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) expanded this year from the intensive care and stepdown units to now include all patient care units. Lessons learned in prior years through collaborative efforts, such as the Comprehensive Unit Safety Program (CUSP), provided toolkits and best practices helping all units to prevent infections. Overall, we have seen an increase in the incidence of CLABSI during this fiscal year. Analysis of the results identified an opportunity among the high-risk patients on Christiana Hospital’s 6B Oncology unit. By applying Lean Six Sigma principles, the patient care unit learned that the majority of cases involved patients with leukemia; Ú

Christiana Care Health System

* Annualized

FY16*

O P T I M A L H E A LT H

80 percent were neutropenic, and many had Hickman or peripherally inserted central lines (PICC), some in place for more than a month. By implementing specific actions to address the issues, 6B reduced CLABSI on the unit by 67 percent for January-March 2016 compared to the prior three-month period (three versus nine infections for October - December 2015). Standardized practice reduces CAUTI rate by 55 percent By engaging frontline nurses and patient care technicians, Christiana Care successfully reduced catheter-associated urinary tract infection (CAUTI) rates by 55 percent and standardized practice systemwide for Foley catheter insertion and maintenance. An interdisciplinary system CAUTI Reduction Steer implemented multiple initiatives, including new insertion kits and securement devices, a new CAUTI prevention specialist program and education in collaboration with the Virtual Education and Simulation Training center, a new urinary catheter insertion checklist in the Powerchart electronic medical record and a twice-daily Foley electronic report. Key strategies for improvement: f Engaged frontline staff in CAUTI prevention initiatives. # CAUTI Rate f Standardized the process for catheter insertion and maintenance practices. 85 2.77 2014 (from FOE) f Educated nurses and prevention specialist on new catheter insertion kit and 38 1.34 Apr15-‐Mar16 securement device. -‐55% -‐52% % change f Developed 224 CAUTI patient care technicians, or unit champions. f Developed competency checklists for catheter insertion and maintenance to standardize care.

CAUTI Hospital-Acquired Infections: AllHPatient Care Units Infec;ons CAUTI ospital Acquired All Pa;ent Care Units 12

DESIRED DIRECTION

4.0

NUMBER OF INFECTIONS

10 3.0 8

2.0

4 1.0 2

0.0

INFECTION RATE (NUMBER PER 1,000 DEVICE DAYS)

f Embedded CAUTI training in nursing orientation as part of Optimal Health Day. Ú

6 -1 ar M 16 bFe 16 nJa 15 cDe 15 vNo 5 t-1 Oc 15 pSe 15 gAu 5 l-1 Ju 15 nJu 5 -1 ay M 5 r-1 Ap 5 -1 ar M 15 bFe 15 nJa 14 cDe 14 vNo 4 t-1 Oc 14 pSe 14 gAu 4 l-1 Ju Number of Infections CAUTI Rate-6 onth Rolling

2016 Quality & Safety Report

CAUTI Hospital Acquired Infec7ons

Sep-‐15 14 24368 0.574523965856861 0.552026824414579 Oct-‐15 16 25285 0.632786236899347 0.549639299209894 Nov-‐15 21 22351 0.939555277168807 0.639915419874938 13 24759 0.525061593763884 0.598633464298739 JOURNEY TO ZERO | CONTINUED Dec-‐15 Jan-‐16 14 25036 0.559194759546253 0.630849933143621 Feb-‐16 13 24384 0.533136482939633 0.622507405101824 Significant Organism: Clostridium difficile Mar-‐16 10 26733 0.374069502113493 0.585669278617013 C-diff infections decrease 12 percent despite more aggressive detection methods 141 0.633201304125239 FY15 ytd Reducing the incidence of Clostridium difficile (C-diff) infections has been a focus over 124 0.559859854436438 FY16 ytd the past few years due to the relatively large number of infections. In fiscal year 2015, the number of infections showed little improvement due, in part, to the January 2015 -‐17 infection in a more timely implementation of a newer, more sensitive test to detect -‐12% manner. However, since that time, the focus in this area is paying off. C-diff infections have decreased 12 percent fiscal year 2016 to-date, from 141 to 124.

C-Diff Infection Trends

C-‐Diﬃcile Infec>on Trends

DESIRED DIRECTION

0.8

NUMBER OF INFECTIONS

0.6 20

0.4

10 0.2 5

6 -1 ar M 16 bFe 16 nJa 15 cDe 15 vNo 5 t-1 Oc 15 pSe 15 gAu 5 l-1 Ju 15 nJu 5 -1 ay M 5 r-1 Ap 5 -1 ar M 15 bFe 15 nJa 14 cDe 14 vNo 4 t-1 Oc 14 pSe 14 gAu 4 l-1 Ju Number of C-Diff Infections

C-Diff Rate

Rolling 6 Months

Transmission and Environment: Dazo® testing leads to more thorough cleaning and disinfection Thorough environmental cleaning is essential to the eradication of hospital-acquired infections, particularly C-diff. Contaminated environmental surfaces represent an important potential source for transmission of health-care-associated infections. Inadequately cleaned surfaces may recontaminate health care workers’ hands with pathogens, which may then be transmitted to patients. Last year, the Wilmington Intensive Care Unit was successful in reaching zero cases of C-diff through implementation of a five-point bundle that included environmental monitoring 3 of the thoroughness of cleaning. That process was rolled out systemwide beginning in January 2016 with Dazo. Ú

Christiana Care Health System

INFECTIONS PER 1,000 PATIENT DAYS

O P T I M A L H E A LT H

The Dazo environmental room monitoring program is an innovative to Tableapproach 2 identifying opportunities in environmental surface cleaning and disinfection. Dazo is an invisible, fluorescent gel that is placed onFeb-16 room surfaces or equipment prior to the Mar-16 terminal cleaning method used by Environmental Services to control the spread of 0.479032258064516 0.53581321725366 Christiana infections. After cleaning, a penlight-sized black light is used to view how many spots remain (all should beWilmington removed by standard cleaning methods). Aggregate thoroughness 0.394632206759443 0.414814814814815 of disinfection cleaning scores are automatically calculated by the unit and item type Total 0.426814268142681 0.524132999642474 from input data. These data are being used to educate all services on the completeness of environmental cleaning and disinfection. Since implementation, the percentage of tested areas that pass the Dazo test has increased consistently. 

Apr-16 0.589570552147239 0.432432432432432 0.576490438695163

Environmental Room Monitoring: Environmental Room Monitoring: Percentage of Passing Scores % Passing Scores

60%

DESIRED DIRECTION

PERCENTAGE PASSED

45%

30%

15%

Christiana Wilmington Total Feb-16

Mar-16

Apr-16

2016 Quality & Safety Report

SURVEY DEMONSTRATES STRONG CULTURE OF SAFETY OVERALL RESULTS on the 2015 Hospital

Culture of Responsibility

Survey on Patient Safety Culture demonstrate that Christiana Care is at or above the teaching hospital mean for the overall safety grade, with 78 percent of staff rating the health system as excellent or very good. Improvement has also been demonstrated in eight of the 12, or 66 percent, of the composites, while two composites remained the same from 2013 to 2015. When compared to teaching hospitals, we are greater in six composites with two being statistically significant.

Non-punitive response to error remains an opportunity and was the impetus of our adoption of Culture of Responsibility efforts beginning in 2010. Creating an ingrained safety culture within health care — one in which every member of the team aligns in common pursuit to uncover and eliminate even the slightest potential for harm — is essential to preventing errors and delivering a safer, more effective care experience for those we serve. In this cultural transformation, frontline employees, physicians and leadership are adopting just culture principles that emphasize an individual and collective responsibility to identify safety risks in our environment — and to learn continuously from our mistakes.

Areas of Strength: f Teamwork across units. f Organizational learning — continuous improvement.* f Management support for patient safety. * *Statistically significant difference versus other teaching hospitals

The overall perception of patient safety is evident with the achievement of a greater than 60 percent reduction in patient harm since 2010, a 31 percent reduction in hospital-acquired infections and the creation of the Zero Harm Award to recognize units/departments that achieve zero harm for 12 consecutive months. Participation in the CANDOR project — a national research project by the Agency for Healthcare Research and Quality (AHRQ) to promote optimal communication and early resolution for patients who have been harmed from an adverse event — also demonstrates palpable management support for patient safety. Areas for Improvement: f Responding to error in non-punitive ways. f Handoffs and transitions in care.

Our management team, physician leaders and staff have all been trained in the Culture of Responsibility principles. We are learning to recognize at-risk behaviors and drift, and how to approach someone in a respectful manner when behaviors are seen that could cause patient harm or pose the risk of harm. We know that early adopters of Culture of Responsibility principles have significantly higher results than Christiana Care overall scores. These results represent an early indication of our advancing toward high reliability in terms of proactively designing safe systems to prevent errors that lead to patient harm. There is also statistically significant improvement in staff’s perception regarding feedback about changes put into place as a result of Safety First Learning Reports. Handoff and transition-in-care efforts include discharge redesign, problem list management and use of the MPages platform for workflow, purposeful patient-centered rounding and bedside report with the engagement of our patients, all aimed at decreasing risks and enhancing communication during transitions of care. Sustaining our safety culture and reliability Strategies to sustain a safety culture and promote high reliability include: f Best practices around transparency — these strategies include good catch recognition, sharing reported adverse events and the lessons learned, including system improvements, through No Harm Intended sessions. f Engagement of leadership — Embedding and strengthening the messaging of Culture of Responsibility into our leadership behaviors, safety curriculum and The Christiana Care Way, as well as coordinating interdisciplinary post-event debriefs after an adverse event and leadership rounding. f Providing feedback and accountability — Timely event followup and learning through our Culture of Responsibility, technology-enhanced event followup, safe practice behavior monitoring feedback, hand-hygiene campaign and Stand up for Safety daily huddles. Ú

Christiana Care Health System

O P T I M A L H E A LT H

Dimensions with Strong Performance Compared to National Teaching Mean Number of points above national teaching mean

TEACHING MEAN

4.3%

5.4%

4.9%

Ý 1.5%

Teamwork within Units

Organizational Learning

Management Support for Safety

Overall Perceptions of Safety

2.5% 0.5% Teamwork across Units

Staffing

ÝDIFFERENCE IS STATISTICALLY SIGNIFICANT 2016 Quality & Safety Report

STRONG CULTURE OF SAFETY | CONTINUED

Stand Up for Safety We know that strong safety cultures have exceptional patient experience and outcomes, which supports our journey to high reliability. Key elements of a safety culture include teamwork, open communication and an environment that empowers staff to speak up about risks to prevent patient harm. Daily Stand Up for Safety huddles promote each of these factors. In October of 2015, Christiana Care adopted the daily huddle to increase situational awareness at all levels in the organization and reduce risk of harm to our patients, their families and staff. A daily huddle is essentially a report of actual or potential risks to our patients and staff. This entails a 24-hour look back, and look ahead, to share risks and how to address these risks. The huddle includes senior leaders, Patient Safety, Patient Access/ Care Management, Patient Relations, service line representatives, The Medical Group, Environmental Services, Infection Prevention, Pharmacy, Clinical Engineering/Facilities, Public Safety, Information Technology and External Affairs.

This huddle is facilitated by the senior vice president of Health Services or senior vice president of Service Operations, and takes place daily in the management suite, with the ability for participants to call in. Problem solving occurs during and after the huddle, and accountability to resolve issues is immediately assigned. This huddle has been a means for our team to share and make sense of current situations, safety events, good catches, patient/family concerns, patient flow, and throughput or resource concerns, and has increased a sense of accountability to promote reliable identification, mitigation and escalation of safety concerns. î&#x2DC;&#x20AC;

Early Culture of Responsibility adopters showed substantial improvement between the baseline (yellow bars) and 2015 surveys (orange bars). In addition, their rates are higher than Christiana Care overall (logo) and are approaching national 90th percentile performance (aqua dots).

Culture of Responsibility Results: AHRQ Patient Safety Survey Culture of Responsibility Results: AHRQ Patient Safety Survey

POSITIVE RESPONSE RATE

1.00

DIRECTION

0.75

0.50 82%

85%

77%

88% 70%

80%

79%

72%

66%

68%

70%

67%

64%

62%

0.25

0.00

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

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

E A E A Christiana Care National 90th Percentile

DESIRED

Christiana Care Health System

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 management seems interested in patient safety only after an adverse event happens. (R)

We are informed about errors that happen in this unit.

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

R= Negatively Worded Question

O P T I M A L H E A LT H

f a S

B y et

G EY O I N U RV G S ON IN ITIES F IV AF S T AC T S S GE ES GA DIN N E EA RE N R A C IO NA IS S A I M T Christiana Care held a mock survey in April to assess readiness for our RIS OM CH INT C unannounced triennial Joint Commission survey expected in the coming JO fall. Departments and service lines with potential survey risks noted on the

f e i r

mock survey are participating in action planning to address opportunities. A series of training sessions were held this spring to: f Expand knowledge of the survey process and key areas of focus. f Identify and explain areas of the environment of care that are frequently cited. f Enhance knowledge of medical record documentation requirements. f Describe the National Patient Safety Goals and associated safe practices. f Describe compliance pertaining to infection prevention efforts. f These sessions were coordinated by the Patient Safety and Accreditation Department in collaboration with Infection Prevention, Environment of Care, Human Resources and Nursing. 2016 Quality & Safety Report

CARE LINK HUB SUPPORTS SAFE TRANSITIONS CHRISTIANA CAREâ&#x20AC;&#x2122;S CARE LINK CASE MANAGERS help clients with chronic

illnesses, or those undergoing high-risk procedures, to navigate and coordinate hospital, physician, community and support services. A virtual hub of interdisciplinary Care Link professionals, including more than 40 population health nurses, contributes to significant reductions in re-hospitalizations by navigating patients through transitions of care. Their goal: improved overall health outcomes, better patient experiences and optimal use of resources. The Care Link Hub is part of a network of Care Link services, which includes inpatient and emergency departmentbased care coordinators and social workers, pharmacists, physicians, embedded care coordinators in Christiana Care primary care offices and care coordinators supporting other areas, such as the Helen F. Graham Cancer Center & Research Institute and the Independence at Home programs. Ă&#x161; -

Number of Clients Enrolled in Care Link Case Management Programs

Other Diabetes Long Term Follow Up Spine 198 166 132 255 Heart Disease 306

Cancer programs 1979

Stroke 409

Heart Failure 580

Musculoskeletal 680

Bundles 1820 Joint Replacement 753

Comprehensive Case Management 768 Transition of Care 1502

Christiana Care Health System

O P T I M A L H E A LT H

Specialized case management programs that utilize evidence-based guidelines focus efforts on the highest-risk Care Link clients. More than 9,500 clients are participating in a variety of programs, including cancer and comprehensive case management (for those with multiple chronic conditions). Care Link’s ability to efficiently manage large caseloads is supported by Aerial, a population health management system, and Neuron, a “big data” platform that connects information from Christiana Care and the Delaware Health Information Network. Alerts let case managers know when clients have been admitted to the hospital, or inform pharmacists about abnormal lab values that may indicate a medication issue. In the past three months, Care Link staff have completed more than 45,000 activities to support clients.

“The coordinated Care Link outcomes, to provide better patient experiences, and to ensure the best use of resources.” SHARON ANDERSON, MS, BSN, RN, FACHE Chief Population Health Officer Senior Vice President, Quality & Patient Safety

In January 2015, Care Link began supporting more than 2,500 Medicare beneficiaries in seven bundled populations through participation in the Bundled Payment for Care Improvement project. Fewer than 8 percent have been readmitted within 90 days after discharge, compared to 14 percent during the baseline period before Care Link management. More than 25,000 Delaware Medicare beneficiaries covered by the Christiana Care Quality Partners Accountable Care Organization also now benefit from Care Link’s innovative, highly coordinated, quality-driven approach to care. Ú Retired teachers Kathryn and John Bailey of Bear say Care Link’s help after Kathy suffered a stroke has enabled them to go on enjoying their very active retirement.

What Care Link clients are saying: 72 percent of patients who have total hip/total knee surgery ambulate without a walker at four weeks post-discharge. 70 percent of patients who have joint and spine surgery report that their pain is "extremely improved" or "quite a bit improved" at four weeks post-discharge. 67 percent of patients who have spine surgery report that their mobility is "extremely improved" or "quite a bit improved" at four weeks post-discharge.

2016 Quality & Safety Report

Table 1

CARE LINK | CONTINUED How Care Link advances strategic goals: f Provides personalized, highly coordinated care. f Navigates people through all of their care needs, including follow-up appointments, tests and links to services in the community. f Supports physicians in providing excellent care to their patients by addressing not only their clinical needs, but also behavioral and social determinants of health. 

Table 3 Baseline

Bun

High Volume Joint TasksReplacement Completed 0.07197943444730080.05

High-Volume Activities Completed SOCIAL WORK ASSESSMENT Table 3 10-DAY FOLLOW-UP APPOINTMENT

Baseline

Bundles Program

PRE-CALL BUNDLE SURGERY

Cervical Spine

0.07310704960835510.05

Cardiac Valve

0.221739130434783 0.15

Joint Replacement PHARMACY REVIEW/MEDICATION0.07197943444730080.0573888091822095 RECONCILIATION Cervical Spine 0.07310704960835510.0546448087431694 READMISSION POST-DISCHARGE FOLLOW UP PATIENT ADMISSION TOValve A NON-CHRISTIANA CARE HOSPITAL Cardiac 0.221739130434783

0.158227848101266

90-DAY REASSESSMENT ABNORMAL LAB VALUES AT DISCHARGE 30-DAY REASSESSMENT CALL SKILLED NURSING/REHAB FACILITY ABNORMAL NON-ACUTE LAB VALUES POST-DISCHARGE FOLLOW UP PATIENT ADMISSION

90-‐Day Readmission Rate 0

1,000

2,000

3,000 25%

4,000

NUMBER OF ACT

25% 22 %

PERCENTAGE OF PATIENTS

20%

15%

DESIRED DIRECTION

7 %

7 % % 5%

5 %

10% 7 %

7 % % 5%

7,000

% 10%

15%

6,000

20%

90-‐Day Readmission Rate PERCENTAGE OF PATIENTS

90-Day Readmission Rate

5,000

5 %

JOINT REPLACEMENT Baseline Bundles Program

JOINT REPLACEMENT

Christiana CareBaseline Health System Bundles Program

CERVICAL SPINE

CARDIAC VALVE

CERVICAL SPINE

O P T I M A L H E A LT H

COLLABORATION ADDS VALUE IN MEDICATION SAFETY AND HUMAN FACTORS ENGINEERING

“SMART-PUMP” TECHNOLOGY is an important strategy to

prevent or reduce the types of medication errors that result in the majority of patient harm reported nationally. Unlike infusion pumps of the past, smart-pumps use Dose Error Reduction System (DERS) software to warn users of incorrect dose, rate, calculation or other programming errors that could result in patient harm. While Christiana Care adopted advanced IV bag-based smart-pumps systemwide in 2009, we switched to a new infusion pump from a different vendor in 2015. New technology can change outcomes in predictable and unpredictable ways, potentially introducing new errors to the system. Human factors engineering offers useful frameworks for examining many of the mediating and moderating factors that may affect the use of equipment and outcomes of its use. Christiana Care’s medication safety officer, the Value Institute, Pharmacy and the Virtual Education and Simulation Training (VEST) Center collaborated to evaluate the new infusion pump through simulated use, an approach that provides the opportunity

to detect and analyze potential problems with pump design or software that could cause, or allow, preventable errors. Nurse participants were placed into a high-fidelity simulated environment and asked to set-up and program the new smartpump to administer medications as they would when providing actual direct patient care. Usability testing provided valuable insight into the effectiveness of training and the impact of changed processes and workflows specific to Christiana Care. From this evaluation, the collaborative team is working with health care providers to deliver information and strategies to mitigate risk associated with the use of the infusion pumps. Additionally, Christiana Care is planning for the future adoption of syringe-based infusion delivery by smart-pumps. A second series of simulation tests helped to illuminate which syringe delivery technologies introduce the optimal workflow, as perceived by the nursing staff, and integrate best with smartpump technology already in use. 

2016 Quality & Safety Report

EARLY WARNING SYSTEM ALERTS % with an event HEALTH CARE TEAM TO POTENTIAL % at orDETERIORATION above CEWS %within 24event hours at with an # CEWS # CEWS THE CHRISTIANA CARE EARLY

1 a WARNING SYSTEM (CEWS), collaborative interdisciplinary 12 effort of key stakeholders using implementation 23 science guided by the Value34Institute, is an effort to reduce all-cause45acute clinical 56 deterioration impacting inpatients. 67 CEWS is a clinical recognition 78 system that helps predict future harm 89 events using existing data from electronic health 10 9 records and supports providers’ clinical 11 10 decision making. Its goal:11 to 12identify early signs of physiological deterioration, 13 12 classify patients at risk of 13 adverse 14 outcomes according to acuity 15 level, and 14 facilitate a proactive rescue system and 16 15 17 optimal transition of care.16 17

21 22 21 19 22 13.6 19 8.4 13.6 8.46 3.7 6 2.1 3.7 1.2 2.1 1.2 1.2 0.3 1.2 0.4 0.3 0.3 0.4 0.2 0.3 0.1 0.2 0.1 0.1 0.10 0

%Value at or above CEWS Value 100 79 100 56.7 79 37.7 56.7 24.1 37.7 15.7 24.1 9.7 15.7 9.76 3.9 6 2.7 3.9 1.5 2.7 1.2 1.5 0.8 1.2 0.5 0.8 0.3 0.5 0.2 0.3 0.1 0.2 0.1

or above the CEWS within 24 hours at vaue or above the CEWS 4.5 vaue 5.6 4.5 7.5 5.6 9.6 7.5 12.8 9.6 15.7 12.8 20.9 15.7 28.5 20.9 35.1 28.5 40.6 35.1 54.1 40.6 57.1 54.1 68.4 57.1 72.7 68.4 75 72.7 80 75 100 80 100

Threshold Analysis: Expected Events Based on CEWS 100

100 100

20 0

10 11 12 13 14 15 16 17

CEWS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Percent at or bove CEWS Value CEWS Percent with n Event ithin 24 ours t or bove the CEWS Value Percent at or bove CEWS Value Percent with n Event ithin 24 ours t or bove the CEWS Value

Data analysis results showed that CEWS provided strong predictive capability for RRT occurrence, transfer to higher-level care, and other harm events within 24 hours. This figure shows the number of alerts that would be generated at different score values if that value was used to trigger an alert. As an example, if CEWS value of 6 is considered to initiate an intervention, this would impact approximately 10 out of 100 patients, and two out of those 10 would be at risk of experiencing a harm event within the next 24 hours.

PERCENT WITH NO EVENT PERCENT WITH NO EVENT

PERCENTAGE AT OR ABOVE CEWS VALUE PERCENTAGE AT OR ABOVE CEWS VALUE

100

Christiana Care Health System

1 1

0 0

After successfully piloting the Nursing Screening Assessment (NSA) on four units, an expanded pilot was implemented in December 2015 on 26 medical, surgical and stepdown units at Wilmington and Christiana hospitals, and on the inpatient rehabilitation unit at Wilmington Hospital. Findings suggest that electronic capture of NSA, combined with vital sign-based monitoring, facilitates early detection of physiological deterioration in non-intensive care unit settings, improving the CEWS score’s performance in detecting early signs of deterioration in patients in the non-intensive care unit setting. Proactive Rapid Response Team (RRT) rounding of patients on 10 units at Christiana Hospital using the vital sign portion of CEWS began in December and is currently being evaluated. Currently there are no CEWS scores displayed to the nurses or physicians, nor defined clinical interventions. Next steps include the phased rollout, continuous improvement and data visualization. 

O P T I M A L H E A LT H

Predictive Capability for Differentiating Between Patients: Experiencing and Not Experiencing an Event Within 24 Hours

The interdisciplinary team, including representatives from the

0.85

Christiana Care Value CEWS (Vital Signs and Nurse Screening Assessment)

0.81 0.80

0.78

Institute, the Department of Nursing, the Office of Quality and Safety and Information Technology,

Vital Signs Only

published their findings on CEWS in Health

0.75

Systems (2015) 1-10, and presented their progress

Table 1

DESIRED

0.70

on CEWS and its impact

DIRECTION

on decreasing Code Blue

This graph shows that the vital signs alone have a fairly significant performance for differentiating between patients experiencing, and not experiencing, an adverse outcome 0.65 within the next 24 hours using the area under the receiver operator characteristic curve. Adding each NSA component improves the performance. The best discriminatory performance is achieved if all NSA components are added to the score.

events 0.7756 with the electronic health record-based 0.8101

predictive surveillance tool to the Society of Medical Decision Making.

0.60

0.55

0.50

y t e af NO

Br E ND

ief S LE

E SL N SO

D NE

TIE PA

F SA

In April, the Christiana Care Value Institute and the Department of Nursing presented progress on the Christiana Care Early Warning System (CEWS) and its impact on decreasing Code Blue events with electronic health record-based predictive systemwide surveillance and tools. The goal is to identify deterioration early, inform timely interventions, and rescue before an adverse outcome. The system was piloted on four units from January 26 to April 19, 2015, leading to development of a Nursing Screening Assessment tool that augments quantitative findings, such as vital signs, to improve the performance of the CEWS score to detect early signs of deterioration. Proactive rounding on patients began in December 2015.

1 2016 Quality & Safety Report

ENHANCED SAFETY FOCUS LOWERS FOR TOP THREE ON-THE-JOB RISKS SPILL STATIONS, CAUTION SIGNS for slippery sidewalks in sub-freezing temperatures, and an initiative to bundle cords safely under desks have led to a 34 percent decrease in slips, trips and falls per 100 FTEs this year to-date over last fiscal year.

DESIRED DIRECTION

2.44

RATE PER 100 FTEs

2.14 1.83

1.15 1

FY12

FY13

FY14

FY15

FY16

All Slips, Trips, Falls through March 2016

All Slip Trip Falls

DESIRED DIRECTION

RATE PER 100 FTEs

Robust focus on these three greatest risks for injury on the job for health care workers have helped drive down the total injury rate by 26 percent this year-todate. At 4.57 injuries per 100 full-time equivalents, Christiana Care’s recordable injury rate through March has decreased an additional 3.4 percent, and is currently 26 percent below the Bureau of Labor Statistics national average of 6.2 injuries per 100 FTEs for hospitals. 

2.88

Struck-by injuries — for example, those where an employee’s hand gets caught between a stretcher and F due to more doorway — are down 36 percent, also 6.71 8.62 15.33 FY11 diligent safety awareness protocols. 5.65 8.04 13.69 FY12 Needlestick and sharps injuries are decreasing slightly. 5.78 7.61 13.39 FY13 To accelerate progress in this area, an interdisciplinary 5.01 7.58 12.59 FY14 needlestick prevention team has investigated additional 4.73 4.97 9.7 FY15 needle-safety technologies and is in the process of 4.57 in the Emergency 2.55 7.12 piloting a FY16 new needle-safety device Departments. New this year was the creation of a fulltime laser safety/needlestick prevention officer position, who leads an interdisciplinary committee advancing vigorous education on the importance of safe handling and disposal of needles and sharps.

1.66 FY10 1.85 FY11 1.95 FY12 RATES 1.98 FY13 1.7 FY14 1.1 FY16 1.67 FY15 Struck by Injuries through March 2016

1.85

1.66

1.95

1.98 1.7

1.67

1 1.1

FY10

FY11

FY12

FY13

FY14

FY15

FY16

Total Recordable Injuries: Rate per 100 FTEs through March 2016 16 Recordable First Aid Total

RATE PER 100 FTEs

DESIRED 0

DIRECTION

FY11

FY12

Christiana Care Health System

FY13

FY14

FY15

FY16

VNA Surgical Wound Healing

O P T I M A L H E A LT H

Surgical Wound Healing

HOME WOUND CARE PROGRAM IMPROVES RECOVERY, REDUCES READMISSIONS

facilities, improving recovery and addressing high-risk factors for hospital readmissions. Last year, 84 percent of Christiana Care VNA patients with complex or hard-to-heal surgical wounds were discharged with improvement in status — a 4 percentage point improvement from the previous fiscal year. Wound care is one of the fastest-growing reasons for home care services, with surgical wounds and pressure ulcers accounting for more than half of all wounds. Christiana Care VNA treats approximately 475 patients with wounds each week, accounting for more than 25 percent of all home care delivered. By educating patients and their caregivers about wound management, and partnering more collaboratively with physicians and hospital partners, the new wound care program is helping patients and their families better cope with wounds in the home environment. Using digital photography incorporated into the electronic medical record, wound-certified nurses consult with nurses, physicians and wound care centers in the field, offering evidence-based care recommendations on stateof-the-art wound-healing products and modalities, such as negative pressure wound therapy or compression wrapping. Patient-centered treatment plans, based on wound etiology/comorbidity, include nutrition, infection prevention and interventions to improve patient comfort. Christiana Care VNA provides uninterrupted access to IV therapy at home for infections, medication management, rehabilitation services, personal care by a home health aide, and coordination with social services and medical transportation, as needed. Patients with pressure ulcers are evaluated for positioning and the need for therapeutic surfaces by a multidisciplinary team of nurses and rehabilitation therapists. Patient and caregiver education promotes health and prevention of complications. 

Surgical Wound Healing Surgical Wound Healing PERCENTAGE OF CLIENTS PERCENTAGE OF CLIENTS

CHRISTIANA CARE VISITING NURSE ASSOCIATION’S (VNA) WOUND CARE PROGRAM is leading to smoother transitions to home from inpatient

Surgical Wound Healing 100%

100% 80%

84%

DESIRED

84%

DIRECTION

80% 60% 40% 60% 20% 40% 0% 20%

Strategic Healthcare Programs, LLC

Emergent Care Due to Wound Complications Emergent Care

Emergent Care 1%

No Emergent Care 9

No Emergent Care 99%

Christiana Care Visiting Nurse Association received a Three-Star Rating from the Centers for Medicare & Medicaid Services for quality of care, and Four Stars for patient experience for the 12-month time period ending September 2015.

2016 Quality & Safety Report

NATIONAL PATIENT SAFETY WEEK SPEAKER: LISTENING IMPROVES PATIENT SAFETY AS KEYNOTE SPEAKER for Christiana Care’s observance of National Patient Safety Week in March, patient advocate and safety specialist Carole Hemmelgarn shared the story of 9-year-old Sally, whose condition deteriorated rapidly after she was admitted to a Colorado hospital with leukemia.

Carole Hemmelgarn

After hours with no improvement in her condition, Sally’s parents demanded to see an attending, who rushed her into surgery — but it was too late. Sally died of sepsis that resulted from an untreated hospitalacquired infection. “Labels only belong on jars,” said Hemmelgarn, who, as the audience learned as the story unfolded, was Sally’s mother. “They do not belong on patients.

important for care providers to hear in order to establish respectful, caring and honest partnerships with patients and families. We are trying to open all lines of communication so

The resident on duty prescribed medication for anxiety. When Sally complained of abdominal pain, the resident attributed it to Sally’s mental distress, even though her mother insisted that Sally was not an anxious child. Sally continued to worsen. Her mother complained to nurses and the resident, but no one called an attending physician.

“These types of stories are

that we can be transparent. Telling stories is how we learn.” CHRISTINE CARRICO, MSN, RN, CPHQ Director, Patient Safety and Accreditation

We get locked into a diagnosis.” Hemmelgarn stressed the importance of face-to-face communication in preventing medical errors, citing studies that conclude that only about 7 percent of a message is effectively absorbed through non-verbal communication. That number goes up to 55 percent with vocal and facial communication, she said. “Still, we know we are not talking as much as we should since the advent of the electronic medical

record,” said Hemmelgarn. “We don’t find our patients in the medical records. We find them in the beds.” Hemmelgarn cites many reasons why communication between patients and clinicians fails, including culture, ethnicity, language, age, hierarchy, busyness, lethargy, outside interference and distractions. “We have to break down those barriers,” she said. “We can learn so much more from our patients if we just listen.” 

55%

of a message is absorbed when using vocal and facial communication.

Christiana Care Health System

O P T I M A L H E A LT H

CAMPAIGN STRESSES TWO UNIQUE IDENTIFIERS FOR PATIENT SAFETY A NEW PATIENT IDENTIFICATION INITIATIVE called “It Takes Two” has reduced risks associated with patient identification by 16.4 percent. The campaign underscores the importance of properly verifying a patient’s identity using two unique identifiers — patient’s full name and date of birth — before administering medication, performing diagnostic tests or procedures, or sharing personal health information.

Identification verification starts at registration and continues through all phases of care, including hospital and outpatient care. The health system educates all incoming nurses, residents and physicians on the importance of proper patient identification using two identifiers. The campaign also educates patients and their families that accurate patient identification involves two parties — the provider and the patient. For patients who are unable to verbally participate in the verification process, the provider matches the patient’s full name and date of birth on the patient’s wristband with the lab slip, medication label or medical record. 

is fundamental to patientcentered care and helping patients achieve optimal health. It reduces the potential for patient harm and is a critical partnership between providers and patients.” STEPHEN PEARLMAN, M.D., MSHQS Quality and Safety Officer, Women & Children’s Services

16.4% Stephen Pearlman, M.D., MSHQS, quality and safety officer for Women and Children’s Services, said for hospitalized patients, the moment the patient identification bracelet is put on is “an important teachable moment in explaining to patients and their families why we are going to be asking them again and again for their name and date of birth.”

reduction in risks associated with patient identification.

2016 Quality & Safety Report

CHRISTIANA CARE ENHANCES SAFE SURGERY PRACTICES Redesigned safety procedures reduce variation, promote safe surgery and procedure practices CHRISTIANA CARE REDESIGNED the

Universal Protocol processes in 17 service lines and essential services, resulting in reduced variation and enhanced safe surgery practices. By October, physicians and staff in both hospital and outpatient settings had been trained in new safe surgery and procedure practices. Teams analyzed their current processes, identified gaps and customized new processes to align with their respective workflows. This work entailed redesign of the following three processes:

Harder, Ph.D., director of the Center for Design in Health and director of graduate studies for the Human Factors Program at the University of Minnesota. Universal Protocol teams: f f f f f f

f Pre-operative/pre-procedure verification process.

f f

f Marking of the operative/ procedure site.

f Time out performed immediately before starting the operation/ procedure. Christiana Care’s redesign process was led by the Office of Quality and Patient Safety, in collaboration with Kathleen

f f f f f f

Breast Center. Cancer Multidisciplinary Care Center. Emergency Medicine. Endoscopy Suites. Family & Community Medicine. Heart & Vascular Interventional Services. Labor & Delivery. The Medical Group of Christiana Care. Oral & Maxillofacial Surgery and Hospital Dentistry. Pediatrics. Perioperative Services. Psychiatry. Radiation Oncology. Radiology. Surgery. 

Perioperative team video engages clinical team in “designing for zero.” Safe procedures processes offer critical structure that helps improve quality, enhance patient safety and reduce patient harm. This new process includes all members of the care team — including the patient — as active participants in verifying correct patient, correct procedure and correct site. Frontline staff were instrumental in identifying and evaluating process gaps, developing solutions, offering valuable insight regarding workflow and incorporation of new safe procedure processes, including helping to create an informative educational video. By cognitively engaging the clinical team — and sustaining their attention with memorable, meaningful learning — the Universal Protocol team is “designing for zero” in eliminating preventable patient harm.

Christiana Care Health System

O P T I M A L H E A LT H

e ur t ed en oc m ion Pr cu at e- Do ific r Ve

Pr Process to verify patient identifiers (name, date of birth, medical record number) and procedure information match all applicable documentation.

te Si e ing ur rk ed Ma

Pr Required for all invasive procedures involving predetermined laterality unless the proceduralist is in continuous presence with the patient from the time of obtaining informed consent through to performing the procedure. Proceduralistâ&#x20AC;&#x2122;s initials are placed at or near the procedure site.

ed iz t rd Ou da e an Tim

St Final prescriptive safety check, performed just prior to incision/procedure start, to verify correct patient, correct procedure and correct site. Each team role audibly contributes role-specific information at this time.

2016 Quality & Safety Report

STANDARDIZED PATIENTS AND HIGH-FIDELITY MANIKINS HELP CLINICIANS TRAIN FOR REAL-LIFE EMERGENCIES CHRISTIANA CARE’S VIRTUAL EDUCATION AND SIMULATION TRAINING CENTER is intimately involved in patient safety efforts on a

systemwide level, including subsequent training for process redesign of interprofessional team training, training for new skills and training to ensure achievement of a mastery-level skill set. The team uses many simulation modalities to replicate both the patient and the environment. In the clinical environment, high-fidelity manikins are used in situ to train interprofessional teams on their units. This allows teams to train together, practicing for high-risk, low-volume patient events. Teams work together in simulation for short periods of time during their normal workday to ensure they can function well together in an actual emergency event. Standardized patients, usually community members, are trained to play the role of a patient so well that the acting is not detected by the learner. They are used in many patient safety training efforts for training standardized communication skills, most recently in CANDOR and AIDET* training. 

“I just wanted to personally thank you. The very next day after our training, we had a code in our PACU. I ran to grab the crash cart and we immediately began compressions and placed the AED pads simultaneously, while turning the AED on in the automatic mode. The patient came back after three rounds of CPR and didn't have a shockable rhythm. I wanted to thank you because, due to your training, I felt as comfortable and prepared as one could feel in all the commotion of a code. The training and preparation you are doing is valuable — and it works!” LATESHSHA COLLICK, MHA, BSN, RN, CNOR Nurse Manager, Gastrointestinal Lab, Christiana Hospital

l ta f To er o rs b ne um ar N Le

ng ni ns ai sio Tr es S AED Training

920 Nurses In Situ

CAUTI Prevention Training

336 in the VEST Center; 1,253 Nurses In Situ Completed the Competency Skills Checklist for Catheter Insertion

Cricothyrotomy Procedural Training

43 Anesthesiologists and CRNAs

PROMPT Team Training

76 Interprofessional Team Members

CANDOR Training

80 Interprofessional Members

AIDET Communication Training

85 (Hospitalists, PAs, NPs and Environmental Services Staff)

iROUNDS Communication Training

84 Nurses

Ventilator Day Training

53 Resident Physicians

In Situ Code Blue Training

108 Interprofessional Team Members

EBOLA Donning and Doffing

311 Interprofessional Team Members *AIDET = Acknowledge, Introduce, Duration, Explanation, Thank

Christiana Care Health System

O P T I M A L H E A LT H

NATIONAL MEDIA SPOTLIGHTS CHRISTIANA CARE’S FLU VACCINATION CAMPAIGN NBC NIGHTLY NEWS visited Christiana Care in October

to film a feature story about our highly successful flu vaccination campaign for employees. The story reached more than 30 million viewers between television and online coverage. Forbes and Modern Healthcare also noted Christiana Care’s success in their coverage of flu season. Christiana Care’s efforts result in nearly 95 percent of employees voluntarily receiving the flu vaccine well before flu activity becomes widespread — well exceeding the Centers for Disease Control and Prevention’s reported national rate for health care workers, which is consistently below 65 percent. 

B y t e f Sa AH

U AT FE

S RE

F AF ST

f e i r IN

E OD

TE UE

N IVE

B WE

An Agency for Healthcare Research and Quality (AHRQ) webinar entitled “Enhancing Code Blue Team Effectiveness Leveraging TeamSTEPPS*”, features multiple Christiana Care staff members. The presentation focuses on the development and implementation of a training curriculum for Code Blue team leaders who can lead and shape expected team behaviors through the use of TeamSTEPPS tools, such as briefs, call-outs, check-backs and post-code briefs. *TeamSTEPPS = Team Strategies and Tools to Enhance Performance and Patient Safety

2016 Quality & Safety Report

Exceptional Experience UNDERSTANDING AND PERSONALIZING THE NEEDS OF THOSE WE SERVE. PROVIDE CONSUMER-CENTRIC AND PATIENTCENTRIC ACCESS TO SERVICES AND CARE.

DELIVER PERSONALIZED, INTEGRATED AND EQUITABLE HEALTH CARE THAT MEETS AND ANTICIPATES THE NEEDS OF INDIVIDUAL MEMBERS OF OUR DIVERSE COMMUNITY.

Exceptional Experience recognizes that not everyone is ready to identify themselves as a patient. As we move outside the walls of our hospitals and facilities to address the health of the community,

Christiana Care Health System

EXCEPTIONAL EXPERIENCE

SERVICE LINE FOCUS IMPROVES RATING OF CARE Quietness Quietnessof ofhospital hospitalenvironment environment

SERVICE LINE FOCUS across the spectrum of care — from 58% 58%

primary care and specialty practices to outpatient procedural and other areas, and to inpatient care — has resulted in above-stretch57% 57% goal increases in the Continuum of Care score. New this year, the Continuum of Care score is a weighted summation of the total 55% positive55% (“top box”) responses to survey questions divided by the total number of responses. At 80 percent, the Continuum of Care score has increased by more than 5 percentage points since the 54% 54% end of FY 2015, and is above the stretch goals of 78 percent. 52% 52%

FY15 FY15

Continuum of Care Score

FY16 FY16(current) (current)

On the inpatient side, the service lines’ focus on environment of care, communication regarding medications, communication with physicians, pain management and discharge information has increased our overall rating of inpatient care on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to 76 percent, a 1 percent increase over last year. Ratings for outpatient services have improved 2 percent, while physician practices scores have improved 4 percent since last year. Multiple initiatives to impact patient experience, spearheaded by the Exceptional Experience Oversight Committee, are promoting sustained improvement. Ú

Continuum Continuumof ofCare CareScore Score

85% 85%

TOP TOP BOX BOX SCORE SCORE

80% 80%

System 75% 75% 70% 70% 65% 65%

DESIRED DIRECTION

60% 60%

6 r--116 aar M M -1166 ebbFFe -166 1 annJJa -155 ecc-1 DDe -1155 ovvNNo 155 ctt-1 OOc -155 1 eppSSe -1155 uggAAu 55 1 ull-1 JJu -155 1 unnJJu -1155 aayyM M -155 prr-1 AAp -155 arr-1 Ma 155 M b--1 FFeeb 5 -115 annJJa -144 ecc-1 DDe -1144 ovvNNo -144 ctt-1 OOc 144 p--1 SSeep 144 -1 uggAAu -144 ull-1 JJu

Top Box Score by Survey Type

Top Box Score by Survey Type DESIRED

TOP BOX SCORE

100%

DIRECTION

90%

Physician Practices

80%

Inpatient Services

70%

Outpatient Services

60%

6 -1 ar M 16 bFe 16 nJa 5 1 cDe 15 vNo 5 t-1 Oc 5 1 pSe 15 gAu 5 l-1 Ju 15 nJu 15 ay M 5 r-1 Ap 5 -1 ar M 15 bFe 5 1 nJa 14 cDe 14 vNo 4 t-1 Oc 4 1 pSe 14 gAu 4 l-1 Ju Inpatient Services Outpatient Services Physician Practices

2016 Quality & Safety Report

SERVICE LINE FOCUS | CONTINUED

Nurse leaders top 175,000 iRound visits An innovative framework designed specifically for use with iPads is supporting nurse leaders as they collect real-time patient feedback, set immediate response plans in action and drive care that is more responsive to patients and their families. Known as iRound for Patient Experience, this innovative use of technology leads to more purposeful interactions and keeps nurse leaders actively involved in the patient care team. iRound encounters logged to-date exceed 175,000. “iRound gives us the opportunity to analyze data in real time regarding our patients and their families,” said Shawn Smith, MBA, vice president of Patient Experience. “It guides us to look for ways in which we can find deeper understanding and learn about the unique, individualized needs of our patients.” Christiana Care partnered with The Advisory Board to create a video highlighting the advantages of iRound, including improved patient care, engagement, satisfaction and opportunities for staff recognition. According to The Advisory Board, patients who experience an iRound encounter with a nurse leader are four times more likely to return an HCAHPS survey and 2.3 times more likely to strongly recommend the hospital.

patients are 2.3 times

more likely to strongly recommend the hospital after an iRound encounter.

Quiet at Night success hits 60 percent The third Quiet-at-Night challenge is generating stronger partnerships between nursing units and essential services now that intensive care units and essential services are included in the challenge.

In December, Christiana Care hit an alltime high of 60 percent, which improves the overall Quiet-at-Night HCAHPS score by more than two points for FY 2016. More than half of the inpatient units (13 out of 24) have improved their scores. The intensive care units are also trending positive, as are essential services. Key to this campaign’s success is continued commitment by leadership to meet monthly at a time convenient for overnight staff — at 10 p.m. FY 2016 is ending with a 4 percent gain in the HCAHPS question, “Was the area around your room quiet at night?” Ú

Quietness of Hospital Environment

Quietness of hospital environment

58%

A video jointly produced by Christiana Care and The Advisory Board shows how iRound upholds the patient experience. https://www.youtube.com/ watch?v=yJSrPbGAhZk

DIRECTION

55%

54%

52%

DESIRED

57%

Christiana Care Health System

FY15

FY16 (current)

Continuum of Care Score 85%

EXCEPTIONAL EXPERIENCE

Patient and family advisers instrumental in creating exceptional experience Patient and family advisers play a key role in meeting the challenges of sweeping changes in health care. Their insights are essential to the collaborative process that will help the health system achieve its goals, particularly in the arena of exceptional experience. More than 180 former patients or their family members, as well as staff members who have received care as a patient, are now engaged systemwide, supporting work within the service lines, on the Wilmington Hospital campus, the Christiana Hospital campus, and at the Helen F. Graham Cancer Center & Research Institute and the Center for Rehabilitation at Wilmington Hospital. This year the two hospital councils held their first collaborative meeting, where they focused on two important projects: redesigning patient gowns and enhancing the patient discharge process. Diversity of the councils has broadened, including the addition of a representative from the Latino/ Hispanic community and the creation of an LGBTQ community advisory group. Plans are in place to attend monthly community events to garner feedback from those served beyond hospital walls. 

Milestones in the Patient and Family Advisers’ Journey

2011

2013

2014

2015

WILMINGTON HOSPITAL INTRODUCED THE SYSTEM’S FIRST PATIENT AND FAMILY ADVISORY COUNCIL.

WILMINGTON HOSPITAL COUNCIL BECAME SELF-GOVERNING.

CHRISTIANA HOSPITAL ESTABLISHED ITS PATIENT AND FAMILY ADVISORY COUNCIL.

COUNCILS CONVENE QUARTERLY TO PROVIDE INPUT FOR CLINICAL PATHWAYS AND QUALITY AND SAFETY PROJECTS.

“Patient experience scores are steadily improving, and we know that a lot of that has to do with our advisers’ powerful feedback.” SHAWN SMITH, MBA Vice President, Patient Experience

2016 Quality & Safety Report

FROM DEMONSTRATION PROJECT TO ‘GO LIVE’: Christiana Care implements CANDOR approach to advance culture of safety

“We believe that dealing with

AS A NATIONAL LEADER in quality and safety, in September Christiana Care fully

and forthrightly is the right

implemented CANDOR: Communication and Optimal Resolution. The CANDOR approach enables Christiana Care to advance its culture of patient safety by further supporting patients through open communication and optimal resolution when an analysis and event review confirms unexpected patient harm.

thing to do. Learning from error

Christiana Care was one of only three health systems in the nation to partner with the Agency for Healthcare Research and Quality and the Health Research & Education Trust of the American Hospital Association in a demonstration project to develop educational resources and tools for CANDOR implementation.

medical error transparently

and making improvements are essential to the process.” SHARON ANDERSON, MS, BSN, RN, FACHE Chief Population Health Officer and Senior Vice President, Quality, Patient Safety & Population Health Management

More than 150 participants and key stakeholders at Christiana Care have received training in the four main components of CANDOR: ●

COMMUNICATION: Focusing on the importance of disclosure,

patient and family communication, and teaching others about disclosure. ●

EVENT REPORTING AND ANALYSIS: Detailing the CANDOR

method for harm event reporting, review and analysis. ●

●

CARE FOR THE CAREGIVER: Focusing on the ways to identify and support second victims — the caregivers impacted by serious adverse events. RESOLUTION AND LEADING THE CHANGE:

Describing how to establish a robust resolution process, integrating all knowledge gained through the event review and analysis.

CANDOR Process Elements Provide immediate emotional first aid to patient, family and caregiver. Maintain ongoing communication. Learn to prevent similar adverse events. Provide just and timely resolution. Explain how care will be safer for future patients.

Christiana Care Health System

Care for the Caregiver Christiana Care is a pioneer in establishing a peer-support program for second victims through its Care for the Caregiver program. Activation of the program in 2015 was an integral component of implementing the CANDOR approach, enabling us to reach out to staff who may be impacted by a safety event contributing to patient harm. Known as the “second victim,” these clinicians may feel personally responsible for the patient outcome, or as though they have failed the patient, and may second-guess their clinical knowledge and skills. Thirteen percent of staff surveyed tell us that in the past 12 months, they experienced anxiety, depression or concerns about their ability to do their job, as a result of an adverse event. As more colleagues become aware of this resource, the Care for the Caregiver program will continue to grow. After being live for only eight weeks, 70 percent of staff were already familiar with the Care for the Caregiver program. 

EXCEPTIONAL EXPERIENCE

Care for the Caregiver Job Ability: Over the past 12 months, were there any patient events, causing anxiety, depression or concerns or about your ability to do your job?

National experts reinforce need for CANDOR Thomas Gallagher, M.D., professor and associate chair in the Department of Medicine at the University of Washington, and Bruce Lambert, Ph.D., professor in the Department

Yes, 13%

of Communication Studies and director of the Center for Communication and Health at Northwestern University — both nationally recognized experts in the CANDOR Approach — led symposiums reinforcing Christiana Care’s newly implemented CANDOR approach to effective response following

No, 87%

adverse events resulting in death or permanent harm.

“CANDOR advances our promise of The Christiana Care for the Caregiver Awareness:

Care Way to be respectful, expert, caring partners

Are you aware of available resources?

with our patients in their treatment, especially when they are harmed. It supports our culture of responsibility, promotes our learning and

No, 30%

reporting culture and enhances our commitment to patient- and family-centered care.” MICHELE CAMPBELL, MS, RN, CPHQ, FABC

Yes, 70% CANDOR FLOW CHART PURPLE.pdf

The CANDOR Approach

Vice President, Patient Safety and Accreditation

6/9/16

12:35 PM

Harmful Event Reported Departmental Actions Page Risk Management

Initial Communication/Disclosure

Assess and Triage

Initiate Data Protocol

Activation of CANDOR Team

Care for the Caregiver

Interviews and Event Analysis

Sharing, Process Improvements, Lessons Learned

Ongoing Patient/Family Communication

CMY

CANDOR Review Panel Final Disclosure/Resolution Communication

Claims Advisory

Resolution

2016 Quality & Safety Report

INTEGRATING LEGAL HELP INTO CARE ADDRESSES SOCIAL DETERMINANTS OF HEALTH Delaware Medical Legal Partnership is the first initiative to receive funding from the newly established Harrington Value Institute Community Partnership Fund. The innovative medical legal partnership between Christiana Care and the Community Legal Aid Society, Inc. (CLASI), is the first funded program through the Harrington Value Institute Community Partnership Fund. From left to right: Amy Ball, MBA, health guide; Sandra Tineo, BSW, social worker; Katelyn Lentz, J.D., law clerk; Aimee Mantell, paralegal; and Elsie Evans, health guide program assistant.

A COLLABORATIVE EFFORT of Christiana Care and the

nonprofit Community Legal Aid Society, Inc., which provides civil legal services to low-income, disabled and elderly people, was the first initiative selected to receive funding from the newly established Harrington Value Institute Community Partnership Fund. One of the fund’s key goals is to foster innovative partnerships that help to reduce health care disparities for underserved and disadvantaged populations. Understanding that medical conditions can be aggravated by legal or social problems, the Delaware Medical Legal Partnership is designed to improve the health of low-income patients who are frequent hospital users, enhance their health care experience, and reduce health care costs by integrating lawyers into the health care team. For example, an attorney’s assistance can help ensure proper mold remediation takes place in an asthmatic resident’s rental home, or help prevent a utility company from cutting off electricity to the home of someone who requires supplemental oxygen. By addressing the social determinants of health, this program hopes to improve those individuals’ health and reduce their need to seek repeated emergency treatment at the hospital. “Providers often don’t think about legal issues when treating patients, and the patients themselves are often not aware a legal remedy exists for their problem, or they cannot afford legal

Christiana Care Health System

representation,” said Susan Howard-Smola, J.D., MBA, senior clinical researcher, Value Institute. “Linking these typically disparate resources provides patients with more comprehensive care that benefits the patient and health system.” The Harrington Value Institute Community Partnership seeks submissions from new or existing innovative community programs that target one or more social determinants of health — factors that affect daily life and health, such as neighborhood, education and economic stability — and include both a community focus and a clinical outcome. The community partnership will select programs annually, with awards averaging $100,000 per year that can be renewed for up to three years, depending on the previous year’s progress. “This program is important because it directly serves our New Castle County neighbors by offering innovative ways to add value to the patients in these communities,” said Jennifer Ostertag-Stretch, MBA, Value Institute project manager. The fund fosters innovative partnerships between Christiana Care and the community, supporting population health research and program development to address community needs and reduce health care disparities for underserved and disadvantaged populations. 

Organizational Vitality MEETING OR EXCEEDING OUR FINANCIAL GOALS. INCREASE PERCENTAGES OF REVENUE EARNED THROUGH VALUE-BASED PAYMENT TO 50 PERCENT.

REDUCE THE TOTAL COST FOR POPULATIONS FOR WHICH WE ARE AT RISK.

DEMONSTRATE SUCCESSFUL FINANCIAL MANAGEMENT OF RISK-BASED CONTRACTS.

through value-based payment. We believe itâ&#x20AC;&#x2122;s achievable.

2016 Quality & Safety Report

QUALITY METRICS FOR THREE FOCUSED BUNDLED POPULATIONS SAVE $1.5 MILLION IN ALIGNMENT WITH STRATEGIC GOALS to advance The Christiana Care

Way, Christiana Care is moving from volume- to value-based payment. Six ‘bundles’ are now implemented under Medicare’s Bundled Payments for Care Improvement (BPCI) initiative:

Organiza(onal Vitality -‐ Bundles

Cases Jan-‐Dec Jan-‐Dec Jul-‐Dec

f Major joint replacement of the lower extremities.

Cervical Spine Joint Replacement Non-‐Cervical Spine

f Cervical spine surgery. f Cardiac valve surgery. f Non-cervical spine surgery. f Coronary artery bypass graft surgery. f Heart failure.

-2.9% -4%

-6%

-6.2%

-8%

DESIRED

-7.7%

DIRECTION

-10%

t en

lS ica rv Ce

nNo

l ep tR

Christiana Care’s internal average direct cost per case has decreased since implementation of the bundle program.

Christiana Care Health System

-2%

in Jo

Keys to the cost savings were reduction in length of stay by more than half a day, and reductions in operating room supply costs — particularly related to implants. 

Change in Average Cost case per Case

ica rv Ce

Christiana Care is measuring internal cost savings for the bundle populations as part of our annual operating plan goals for fiscal year 2016. The health system created incentives for participating surgeons to gainshare in a portion of cost savings for three surgical populations — cervical spine, joint replacement and non-cervical spine. In the program’s first year, the average internal direct cost, per case, for patients having major joint replacement decreased $900 and cervical spine costs decreased $841 per case. The average cost, per case, for non-cervical spine decreased $585 in six months. Total savings from the three programs are more than $1.5 million.

Internal Cost Savings:

Internal Cost Savings: change in average cost per

PERCENT DECREASE IN COST PER CASE

The BPCI initiative is an innovative payment model that combines reimbursement for defined episodes of care, from an inpatient admission up to 90 days post-discharge, along with financial and quality accountability. It supersedes the traditional Medicare payment model, in which hospitals, physicians and post-acute providers are each paid separately for the services provided to Medicare beneficiaries — a structure rewarding the quantity of services provided rather than quality, which leads to fragmented care with minimal coordination across settings. By bundling payments, Medicare’s objective is to better align incentives, leading to higher-quality, better-coordinated care at a lower cost.

Av pe sa 185 1396 196 1777

O R G A N I Z AT I O N A L V I TA L I T Y

CHRISTIANA CARE EXCEEDS STATE AND NATIONAL PERFORMANCE IN VALUE-BASED PURCHASING MEASURES

50 Value-Based Purchasing

Target

VBP POINTS

As part of the Affordable Care Act, CMS began linking payment for hospital services to performance through three programs: Value-Based Purchasing (VBP), Readmission Reduction and HospitalAcquired Conditions. Under Value-Based Purchasing, implemented in October 2012, CMS awards 50 provide high-quality and hospitals that efficient care. The program looks at clinical process, safety and outcome measures, as 40 experience and cost of care. well as patient Each year, an increasing percentage of all hospitals’ Medicare payments are pooled. Hospitals 30 have the opportunity to earn money back from the pool, based on their performance on selected quality metrics. Now in its20fifth year, 2 percent of Medicare payments were pooled. For Christiana Care, this is about $6 million. VBP POINTS

FOR THE PAST THREE YEARS,

Christiana Care has exceeded state and national performance in Value-Based Purchasing (VBP) measures, earning a total of almost $2 million (over and above the initial withdrawals) from the Centers for Medicare & Medicaid Services (CMS) pool, and is on track to increase those earnings this year. Strong performance on the outcome measures, 30-day mortality for heart attack, heart failure and pneumonia, as well as safety measures, all exceed targets.

Unlike VBP, the Readmission Reduction and Hospital Acquired Conditions programs penalize hospitals that perform 0 poorly. In the Readmission Reduction Efficiencyhospitals up to program, CMS penalizes Safety 3 percent of Diagnosis-Related Group Patient Experience (DRG) payments,Outcomes almost $9 million for

Process

Christiana Care, for 30-day readmissions exceeding risk-adjusted expected rates in six high-volume or high-risk patient populations: Acute Myocardial Infarction (AMI), Heart Failure (CHF), Pneumonia (PNEU), Chronic Obstructive Pulmonary Disease (COPD), Total Hip/Total Knee Replacements (Joints) and Coronary Artery Bypass Grafts (CABG). Five of the six populations are performing well compared to estimated expected rates, due in large part to the concerted efforts of the health system’s nine new service lines. For the sixth population, COPD, readmission rates are slightly higher than expected. To address this opportunity, the Acute Medicine Service Line has developed a clinical pathway for this population that focuses on improving care and reducing unnecessary readmissions (see page 45). Christiana Care’s longstanding goal to eliminate preventable patient harm is aligned with CMS’s Hospital Acquired Conditions program. Hospitals performing in the bottom 25th percentile nationally are penalized 1 percent of the DRG payment — for Christiana Care, $3 million was at risk. Ú

Readmission Reduction

DESIRED

0.7

DIRECTION

0.39

0.4

BETTER . . . EXPECTED

. . . WORSE

Efficiency Safety Patient Experience Outcomes Process

0.2

Readmission Reduction BETTER . . . EXPECTED . . . WORSE

0.6

0.4

-0.03

-0.1

-0.08

-0.10

-0.13

-0.24 -0.4

AMI

CHF

Pneu

Joints

COPD

CABG

0.1

-0.2

2016 Quality & Safety Report -0.4

Hospital Acquired Conditions AMI

CHF

Pneu

Joints

COPD

CABG

VALUE-BASED PURCHASING | CONTINUED

Christiana Care Health System

. . . . WORSE

Hospital-Acquired Conditions

BETTER . . . EXPECTED

HAC includes the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators and hospital-acquired infections. Christiana Care’s performance in these areas is equal to or better than other hospitals in almost all of the measures. The health system’s incidence of surgical-site infections (SSI) following colon procedures is higher than expected, although the Surgical Services Service Line is making substantial progress in decreasing the rate through the use of chlorhexidine gluconate (CHG) cloth and implementation of the Duke Protocol bundle, which bundles preventive interventions to reduce surgical site infections after colorectal surgery (see page 59). 

DESIRED

2.0

1.65

DIRECTION

1.5 1.0 0.5 0.0 -0.5 -1.0

-0.5 CLABSI

-0.2

-0.29

CAUTI

SSI

PSI-90

O R G A N I Z AT I O N A L V I TA L I T Y

IMPROVING QUALITY WITH LEAN SIX SIGMA CHRISTIANA CARE’S LEAN SIX SIGMA PROGRAM trains employees as quality-improvement experts who can recognize opportunities, identify root causes of problems and develop quality-improvement interventions to deliver meaningful, sustained value in health care from the inside out. The program expanded this year to include its first Black Belt class. Key improvements realized through Lean Six Sigma methodology include:

Bed-request to bed-ready By implementing change processes, enhancing shared data, establishing standards, enhancing communication and streamlining work, this Black Belt project decreased the mean time between the Emergency Department (ED) posting a patient for admission and having a bed ready on the receiving unit by 36.4 percent, from 156.5 minutes to 99.5 minutes on 15 Christiana Hospital patient care units. Reducing ED boarding time to admit patients more expediently improves patient safety. ED Boarding Time

Improving first dose antibiotic administration in the NICU This Green Belt project significantly improved turnaround time of antibiotic first doses administered in the Christiana Hospital Neonatal Intensive Care Unit (NICU), resulting in more sick babies receiving lifesaving medication when they need it most. The number of doses delivered within the targeted 60-minute window from order to administration soared 215 percent in the project’s first quarter, with the targeted turnaround time achieved in 67.4 percent of cases, up from a baseline of 21.4 percent.

Reducing the percentage of late-start MRIs 36.4 percent reduction in admission time

99.

This Green Belt project reduced the percentage of late-start magnetic resonance imaging (MRI) studies from 60 to 40 percent, leading to a more positive patient experience and greater operational efficiency. This sustained, improved efficiency, which reduces variation in MRI processes, technician staffing levels, communication with other diagnostic departments and availability of slings, has the potential to increase annual revenue by $400,000. MRI Study of Efficiency: Late Start MRIs

M I N U T E S

60%

DESIRED DIRECTION

A shift-change brief, mid-shift team huddles and purposeful hourly rounds allow nurses to work at the “top of their license” by decreasing the amount of time spent on non-value-added work — that is, activities not directly related to patient care. In this Black Belt project, time spent on non-value-added activities decreased from 34 to 26 percent on one patient care unit, offering a potential annual cost savings of $269,573. Research suggests the reduction will help increase nurse satisfaction and engagement and may improve quality and safety outcomes, as well as patient satisfaction.

MRI STUDIES

Transforming nursing care delivery 40%

60% 40%

20%

Pre-Project

Post-Project

Quality improvement professionals by belt level: f 100 Lean Six Sigma Green Belts (60 certified, 40 in training). f 20 Lean Six Sigma Black Belts (7 certified, 13 in training).  Total through FY 2016 since program inception.

2016 Quality & Safety Report

QUALITY PARTNERS ACO APPROVED FOR SHARED SAVINGS PROGRAM Strategy aims to lower growth in costs; improve quality, clinical indicators and outcomes “Armed with comprehensive information and carecoordination support, physicians will have the tools to drive comprehensive changes in the member’s care plan with the clinical indicators and health outcomes.” DANIEL ELLIOTT, M.D., MSCE, FACP Medical Director of Christiana Care Quality Partners ACO

CHRISTIANA CARE QUALITY PARTNERS ACCOUNTABLE CARE ORGANIZATION (ACO) became an

approved Shared Savings Program (MSSP) participant with Medicare on January 1, allowing more than 25,000 Delaware Medicare beneficiaries to benefit from an innovative, highly coordinated qualitydriven approach to care. In an innovative statewide partnership, the Quality Partners ACO Shared Savings Program brings together physicians, three of Delaware’s health systems — Bayhealth Medical Center, Christiana Care and Nanticoke Health Services — and Westside Family Healthcare, a federally qualified health center. The approximately 190 primary care physicians and other health care providers who form the base of the ACO team are now delivering care in a new way aimed to lower growth in health care costs while putting Medicare beneficiaries first. 40

Christiana Care Health System

Launched by Medicare to advance the Affordable Care Act, the MSSP facilitates coordination and cooperation among providers both to improve the quality of care for Medicare beneficiaries, and to reduce unnecessary costs. Its three-part aim: f Better care for individuals. f Better health for our Medicare community. f Lowering growth in expenditures. Those whose physicians are part of the new Shared Savings Program should see little difference in terms of process as they continue established relationships with primary care providers and specialists, said Alan Greenglass, M.D., president of Christiana Care Quality Partners ACO and senior vice president of network development. “The Medicare approach is built on patient choice and an exceeding amount of flexibility,” he said.

A unique aspect of the Quality Partners ACO is Care Link, Christiana Care’s information-technology-enabled, care-coordination network that works directly with physicians to support their patients. Care Link harnesses an information technology platform that integrates available resources of a person’s health data giving providers realtime access to the information they need to address clinical, behavioral, social and other needs that may affect someone’s ability to achieve optimal health and wellness. 

The new Shared Savings Program rewards ACOs that lower their growth in health care costs while meeting performance standards on 33 measures of quality care and clinical indicators.

O R G A N I Z AT I O N A L V I TA L I T Y

Beneficiaries by Gender

Beneficiaries by Age

Title

Less than 65 65 to 69

Male

15%

25%

85 or older

10%

Female

11% 23%

16%

70 to 74

75 to 79

Beneficiaries by High Risk Disease Group select categories 3,000

2,751

80 to 84

Beneficiaries by High Risk Disease Group select categories 2,331

2,250 3,000

PERCENT OF BENEFICIARIES

Beneficiaries by2,536 High-Risk Disease Group: Select Categories 2,751

2,536

the ACO beneficiaries have

2,331

1,500 2,250

high-risk or complex chronic

1,581

conditions.

2,044 1,581

750 1,500

More than 50 percent of

2,044

516

295

750

201

V S HI IV U E H AT AS ST SE IS us DI V t L YS HI AL sta NA E DI is ys E R e us al as at Di AG se st ST Di is Dal ys EN se enOL al ea R H Di s i geCO ES l D taAL l OS na d-S/ Re EnUG oho GN e IA lc D ag DR A / St IC l rug do R es D h T En IA os lco gn CH /A Y ia ug PS es ic DRE Dr s tr no ia ILU ag ch FA Di Psy T ric AR at E HCEHF hi UR yc L I Ps FA F L re CH NA ilu RE Fa al re en ED lu R ai AT D lF IC na OPPD PL C Re CO OM -C d te ES PD ica ET pl CO AB m DI ted -co s ica te pl e m iab co D

es et

516

211

295

211

201

Care Link Tasks for ACO Beneficiaries

ACO Beneficiaries Care Link Activities PHARMACY REVIEW/ MEDICATION ISSUE

Care Link Tasks for ACO Beneficiaries

SOCIAL WORK REFERRAL

PATIENT ADMISSION TO NON-CHRISTIANA CARE HOSPITAL PHARMACY REVIEW/ MEDICATION ISSUE CALL SKILLED NURSING/REHAB FACILITY SOCIAL WORK REFERRAL 30/90 DAY ASSESSMENT PT ADMISSION TO NON-CCHS HOSPITAL POST-DISCHARGE CALL SNF/REHAB FACILITY FOLLOW UP 30/90 DAY ASSESSMENT FOLLOW UP OTHER POST DISCHARGE FOLLOW UP ABNORMAL FOLLOW UP LAB VALUES HOSPITAL/ED UTILIZATION REVIEW OTHER 0

ABNORMAL LAB VALUES

1,000

2,000

3,000

4,000

NUMBER OF TASKS

HOSPITAL/ED UTILIZATION REVIEW 0

1,000

2,000 NUMBER OF TASKS

3,000

2016 Quality & Safety Report 4,000

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

Acute Medicine Behavioral Health Cancer Heart & Vascular Health Musculoskeletal Health Neurosciences Primary Care & Community Medicine Surgical Services Women & Children's 42

Christiana Care Health System

S E RV I C E L I N E S

Service lines organize care around the people we serve With its new operating structure organized around service lines and essential services. Christiana Care is leading the way through tremendous changes in health care in our country by building care around patients and their experiences across the continuum, emphasizing the Triple Aim of better health outcomes, better experience of care and lower health care costs. Leading each of the nine service lines are executive teams comprised of physicians, nurses and operations leaders who help coordinate and integrate many system change initiatives and quality and safety efforts to achieve excellence in patient experience and high-value care. The Clinical Value Council is the coordinating committee that oversees the nine service lines. A smaller working group known as the Clinical Value Council Executive Committee meets regularly to deal with issues around quality and safety.

Service lines support consistent delivery of safe, affordable, high-quality, high-value care on a consistent basis. They do not replace the familiar clinical departments and sections. Instead, they provide a natural way for departments and essential services to work together (read more about essential services on page 64). Each service line develops clinical pathways to help doctors, nurses and other care providers implement comprehensive, individualized care plans for their patients using the most up-to-date information and connections to resources in the community. Pathways address the needs of people with specific conditions or diseases before, during and after they seek treatment at one of our hospitals or facilities. They reduce variations in care â&#x20AC;&#x201D; which in turn can reduce cost â&#x20AC;&#x201D; while ensuring that patients are getting the optimal, evidencebased care at the right time, with the right team. The following pages highlight performance improvement projects and clinical pathways from each of the nine service lines. î&#x2DC;&#x20AC;

Each of the nine service lines is led by a team called a service line executive division, or SLED. Each SLED includes physician, nursing and operations leaders, plus a leader representing Christiana Care Quality Partners.

Service Line Associate Physician Leader

Service Line Operations Leader

Service Line Physician Leader

Service Line Executive Division

Service Line Quality Partners Physician Leader

Service Line Nurse Leader

2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

IMPROVEMENTS :

Acute Medicine

Reducing unnecessary phlebotomy orders enhances safety, improves efficiency A new Choosing Wisely initiative to reduce unnecessary daily blood draws for 24-hour repetitive laboratory testing is helping to minimize the potential for patient harm, inconvenience and costs associated with automatically recurring lab studies that do not impact clinical decision making. Team leaders also expect the effort to improve the efficiency of ordering and performing resulting lab studies that are clinically appropriate. Eliminating the early-hour wake up for unnecessary lab work provides more restful sleep for patients, cuts down on the discomfort and hematomas caused

by frequent blood draws and may even help prevent iatrogenic anemia, a potentially harmful lowered hematocrit and hemoglobin count resulting from large or frequent laboratory testing. Lab charges are the second highest charge category for Acute Medicineâ&#x20AC;&#x2122;s top 10 DRGs, with more than 90 percent of specimen volume generated from daily lab orders without a defined duration. By eliminating the ability to order automatically recurring daily labs in the computerized physician order entry system, the volume of unnecessary lab tests has decreased 13 percent across Christiana and Wilmington hospitals. î&#x2DC;&#x20AC;

Inpatient 24-Hour Order Rates: Basic Metabolic Panel and Complete Blood Count With and Without Differential. Christiana and Wilmington Hospitals, Census Adjusted Program Implementation

Christiana Care Health System

Upper Control Limit Mean Lower Control Limit

DESIRED DIRECTION

S E RV I C E L I N E S

“Just as our clinicians decide on a daily basis — based upon a patient’s clinical condition — which

Inpatient 24-Hour Order Rates: Basic Metabolic Panel and Complete Blood Count With and Without Differential. Christiana and Wilmington Hospitals, Census Adjusted

diagnostic studies and consultations

1.8

are indicated, this Choosing Wisely

DESIRED

recommendation encourages clinicians

VIRGINIA U. COLLIER, M.D., MACP Hugh R. Sharp Jr. Chair of Medicine and Acute Medicine Service Line Physician Leader

TOTAL ORDER RATE PER PATIENT

to do the same for blood studies.”

DIRECTION

1.6 1.4903

13% decrease in the number of orders per patient

1.4 1.2964

1.2

1.0

Baseline

ACUTE MEDICINE’S FIRST CLINICAL PATHWAY FOCUSES ON POST-ACUTE- CARE HOSPITALIZATION FOLLOW-UP For patients with chronic obstructive pulmonary disease (COPD), Christiana Care’s Acute Medicine Service Line aims to fill in gaps in care and improve care coordination beyond hospital walls. The first step included building a care coordination team that will optimize the multidisciplinary care of patients in the hospital and provide a standardized pathway for their follow-up after discharge. The team is a resource for providers outside of the hospital to ensure that all the elements of care are being delivered, including smoking-cessation classes and home health care, and making sure patients can afford their medication. Patients who meet certain criteria are followed 90 days after leaving the hospital through Christiana Care’s Care Link service. A postdischarge clinic serves as a one-stop shop for patients to get follow-up in the immediate post-hospitalization period. “It’s really standardizing evidence-based best practices,” said Francis Gott III, MBA, RRT, administrative director, Primary Care & Community Medicine Service Line.“By embedding the GOLD guidelines (Global Initiative for Chronic Obstructive Lung Disease) in our pathway, we should be providing the latest and greatest care for patients with COPD.”

2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

IMPROVEMENTS :

Behavioral Health

Warm handoffs improve access to outpatient behavioral health care Recognizing that many physical ailments are exacerbated by mental health concerns, Christiana Care’s new integrated primary care behavioral health model, which embeds behavioral health specialists within primary care and many specialty practices, is significantly improving access to outpatient behavioral health services. In 2014, we consulted with 1,438 patients in about 8,000 sessions. Under the new model, formally launched in July 2015, we’ve already seen more than 4,600 patients in more than 11,000 sessions — increases of 224 and 37 percent respectively. Use of a standardized measure to screen for depression, track and assess outcomes has also

soared, used now in 72 percent of initial assessment sessions, up from just 5 percent before launch of the new model. More frequent use of the Patient Health Questionnaire (PHQ-9) depression module of the PRIME-MD diagnostic instrument for common mental disorders not only improves detection and assessment of the severity of depression, but also is an important tool in guiding treatment decisions. The patient-centered model prioritizes integration and collaboration, initially through in-room consultations, in which the behavioral health specialist is called into the exam room to meet with the patient and physician. The behavioral health specialists provide initial assessment for mental health issues, such as Ú

Behavioral Health Consult Sessions DESIRED

NUMBER OF SESSIONS

900

DIRECTION

675

450

225

Jul-15 BHC-Initial Eval

Christiana Care Health System

Aug-15

Sep-15 BHC-In-Room Consult

Oct-15

Nov-15

Dec-15

BHC-Follow-Up

Other

Jan-16

Feb-16

BHC-Initial Eval

BHC-In-Room Consult

BHC-Follow-Up

Other

S E RV I C E L I N E S

depression, anxiety or stress, as well as for issues including substance abuse, managing medical problems, compliance with medication or medical treatment and lifestyle concerns. In consultation with the primary care physician, they provide behavioral health interventions, and can provide a bridge to connect patients with more intensive ongoing care. The embedded specialists also provide consultation and communication with the treatment team. Several patient education and support groups have also evolved from the new model. 

Patient Health Questionnaire (PHQ-9) Administration in Primary Care by Behavioral Health Consultants PHQ-9: Depression Severity Screening and Monitoring 80%

Usage (percentage administered the PHQ-9) 60%

40%

DESIRED DIRECTION

Frequency (percentage of sessions in which PHQ-9 is administered)

An April 2016 broadcast by National Public Radio’s Delaware news outlet

20%

WDDE spotlighted Christiana Care as a national leader in integrating behavioral health in primary care.

Jul-15

Sep-15

Nov-15

Jan-16

BEHAVIORAL HEALTH’S FIRST CLINICAL PATHWAY STANDARDIZES SCREENING, REDUCES VARIATIONS IN CARE FOR OPIOID ADDICTION

Mar-16

The Behavioral Health Service Line’s inaugural clinical pathway is standardizing the screening, identification and treatment of patients at risk of opioid withdrawal and reducing variations in care. “It’s really part of a bigger effort to integrate behavioral health into health care,” said Terry L. Horton, M.D., FACP, chief of the Division of Addiction Medicine, medical director of Project Engage and associate physician leader for the Behavioral Health Service Line. Variations in care, as well as untreated withdrawal, increase the number of patients who sign themselves out against medical advice (AMA). They also increase the length of hospital stays, readmissions and the cost of care. And they result in poor patient experience, low staff morale and even safety issues when patients engage in illicit drug use while hospitalized.

users are monitored using the Clinical Opiate Withdrawal Scale, which is linked with the computerized order entry system to help manage their symptoms.

A screening tool developed in partnership with the Christiana Care Value Institute will help providers identify and assess opioid addiction when patients present at the emergency department with other medical issues and don’t self-identify their opioid use. Patients identified as opioid

The pathway optimizes health care outcomes and patient experience by treating at-risk patients effectively with medicine, reducing the AMA rate and readmissions, enabling patients to complete treatment, and subsequently connecting them to proper community-based care.

2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

IMPROVEMENTS :

Cancer

Decrease Lead Time at the Infusion Suite at Helen F. G Cancer

Time from Pa+ent Check-‐In to Chemotherapy Start

Baseline Im 59 Lead T ime 51 Based on demand capacity analysis and project gains Pa+ents with Lab Rsuite esults at Arrival in efficiency, the infusion could potentially see as many Goalas 44 patients, up from 15-20 currently seen 36

Initiative to secure lab results prior to chemo shaves infusion wait time by 30 percent N

A concerted effort to ensure that, whenever possible, patients have required lab work completed prior to arrival at the infusion suite has cut wait times by 30 percent — 17 minutes — and negated the need to expand the infusion suite in preparation for an anticipated 18 percent increase in patient volume. The estimated cost savings of not having to purchase, renovate and equip additional space is $185,360. A Lean Six Sigma Green Belt team identified missing lab results as the primary cause of longer lead times for patients in assessing the wait cycle from patient check-in to the actual start of the infusion — including time involved for the patient to check in at the reception area, for the nurse to assess the patient for chemotherapy, receiving medication prepared by the pharmacy and then readying the patient for infusion. An action plan calling for physician orders, lab results and consents to be received by the infusion suite the day before a patient’s scheduled treatment, coupled with patient reminder calls regarding the importance of completing lab work prior to scheduled chemotherapy time, has shaved the patient wait time from 51 to 34 minutes. Engagement is working. Lab results are now ready for 91 percent of patients upon arrival, up from just 58 percent at the start of this improvement process.

Christiana Care Health System

per day, without needing to expand. 

Lead Time at Graham Cancer Center Infusion Suite: Time from Patient Check-In to Chemotherapy Start

DESIRED

DIRECTION

Goal 36 Minutes

51 45 TOTAL LEAD TIME (MINUTES)

Cutting down the time patients must wait from checkin to start of chemotherapy treatment is not only enhancing the patient experience, but has dramatically increased efficiency and cost savings at the Helen F. Graham Cancer Center & Research Institute.

36 30

Baseline

Improve PROJECT PHASE

Control

S E RV I C E L I N E S

CANCER SERVICE LINE DEVELOPS CLINICAL PATHWAY FOCUSING ON OPERABLE STAGE 2 NON-SMALL- CELL LUNG CANCER The Helen F. Graham Cancer Center & Research Institute sees about 35 patients with Stage 2 non-small-cell lung cancer each year. Among the Cancer Service Lineâ&#x20AC;&#x2122;s goals for its new pathway are decreasing the number of imaging procedures from diagnosis through survivorship and reducing the cost of care by standardizing chemotherapy protocols. The pathway also increases screening for earlier-stage cancers and encourages smoking cessation programs. Increased communication between the thoracic team and primary care physicians is a key element of the new pathway, as is a newly created roadmap that mirrors the clinical pathway to help patients become more engaged in the process of their own care. Clinical pathways arenâ&#x20AC;&#x2122;t a new concept in cancer care, which has followed standardized guidelines for more than three decades. The team is focusing intensely on the guidelines, measuring variation in care and seeking opportunities to improve processes of care.

The Thoracic, Esophageal and Lung Cancer Multidisciplinary Center team meets weekly and is helping to guide the development of the clinical pathway for operable Stage 2 non-small-cell lung cancer.

2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

IMPROVEMENTS :

Heart & Vascular Health

Heart and Vascular

STEMI patients consistently benefit from gold-standard door-to-balloon time 95 percent wasn’t good enough. Christiana Care’s Heart & Vascular Interventional Services team strove for, achieved, and is maintaining 100 percent of patients with ST Segment Elevation Myocardial Infarction (STEMI) meeting the 90-minute goldstandard door-to-balloon time, placing the health system above the impressive national top decile performance standard of 99 percent compliance. STEMI is the heart attack often referred to as the “widow maker.” A delay in initiating device inflation in the cardiac catheterization lab could negatively impact patient outcomes. Shaving the door-to-EKG time is crucial in fast-tracking patient flow, allowing for more timely activation of the heart alert/heart code system. The Lean Six Sigma team also set out to reduce wait times for cardiologist call backs and eliminate variations in patient preparation upon arrival in the cath lab.

System improvements include: f 24-hour, seven-day EKG tech coverage in the Emergency Department with standardized EKG transmission to cardiologist to improve heart alert upgrade to heart code. f Direct call from ED attending to cardiologist (use of answering services eliminated and standardized information implemented). f Cath lab staff now respond to ED upon activation of heart alert to assist with patient preparation and transport. f Standardized patient prep process in cath lab. f Defined heart code team member roles and responsibilities to reduce redundancies. 

PERCENTAGE OF PATIENTS

Door to Balloon: Within 90 Minutes of Arrival 100% 90%

DESIRED DIRECTION

80% 70% 60% 50%

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Steps in Door to Balloon Time

AVERAGE TIME (MINUTES)

DESIRED DIRECTION

8 6 4

Baseline Pilot Improve Control Goal

2 0

Cardiologist Call Back

EKG to Heart Alert

Cardiac Cath Lab Prep Time

HEART & VASCULAR NSTEMI PATHWAY GUIDES TREATMENT FROM EMERGENCY DEPARTMENT TO CARDIAC REHABILITATION Patients suffering the most common type of heart attack are the beneficiaries of the first clinical pathway developed by the Heart & Vascular Service Line. Although well-recognized guidelines exist for non-ST-segment elevation myocardial infarction, or NSTEMI, variability in care of the roughly 50 patients treated each month at 2 Christiana Care provides opportunity for improvement with a large patient population. Patients and providers first experience the new pathway in the Emergency Department, where it is designed to expedite and improve diagnoses by increasing the amount of information provided to physicians early on. In addition to administering an EKG, techs employ a scoring system that predicts who is at high risk to die or bleed and, therefore, should be taken first to the catheterization lab. The scoring system — known as the thrombolysis in myocardial infarction, or TIMI — is classic, but hasn’t been used systematically because it is up to the provider. The process also front-loads the drawing of blood so that it is in the lab being tested for elevated troponins before a doctor consults with the patient.

ATTACKS ARE SEEN AT CHRISTIANA CARE EACH

Computerized “hard” and “soft” stops guide the provider through the computerized drug ordering system once diagnosis is confirmed. And the pathway also makes it easier for providers to help patients understand their individual plan of care by telling them what to and when, depending on the treatment course they are on. A key post-discharge piece of the pathway is getting patients engaged in cardiac rehabilitation. “What we hope is that patients will spend less time in the emergency department, have a more coherent educational experience and become more engaged in secondary prevention and the lifestyle modifications they need to make,” said Henry Weiner, M.D., FACC, Christiana Care’s associate section chief for quality and safety, Cardiology.

2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

IMPROVEMENTS :

Musculoskeletal Health

Patient readiness enhances overall value in joint replacement An upstream focus on patient readiness for joint replacement surgery is maximizing clinical outcomes, improving the patient experience during admission and better preparing patients to be discharged to home following surgery. It’s also enhancing efficiencies in care delivery, including shortening the length of stay, reducing readmissions and lowering the number of surgical cancellations. Key from the patient perspective is that it is improving the community discharge rate — the percentage of patients who are able to recover at home following joint replacement surgery — from 88 to 93 percent.

30-Day Readmission Rate

A small-scale Joint Replacement Pre-Operative Assessment Center (JPAC) piloted on Christiana Care’s Wilmington campus in June 2015 specializes in preoperative assessments, including patient and family education, discharge planning, lab testing and medical evaluation. Length of stay for patients in the pilot was 1.7 days, compared to 2.1 days for patients not in the pilot. Readmissions, both 15 and 30-day, were 0.4 percent for those in the pilot, compared to 1.6 and 2.0 percent, respectively for other patients. Of those pilot patients discharged to someplace other than home following surgery, 5.2 percent went to a skilled nursing Ú

Community Discharge Rate: Percentage Discharged to Home or with Home Health Services

2.50%

PERCENTAGE OF PATIENTS

1.50%

1.00%

% 0.43%

0.50%

Non-JPAC

JPAC

0.00%

Christiana Care Health System

Non-JPAC

93%

DIRECTION

JPAC

DESIRED DIRECTION

88%

88% PERCENTAGE OF PATIENTS

2.00%

88%

2.50%

DESIRED

2.01%

PERCENTAGE OF PATIENTS

93%

100%

75%

63%

50%

2.00%

1.50%

1.00%

0.50%

Non-JPAC

JPAC

0.00%

Non

S E RV I C E L I N E S

facility, compared to 9.4 percent of those not in the pilot; while 1.7 percent of PILOT patients needed a rehabilitation facility, compared to 2.4 percent of patients not participating in the pilot. JPAC model advantages: f Patients and their families feel better prepared for surgery, more fully understanding what to expect in the post-operative period. f Clinical outcomes improve. f Process leads to seamless handoff between surgeon and primary care provider. f Learnings are translatable to the broader perioperative evaluation and preparation process across the service line. The value-driven JPAC concept embodies key principles of population health by focusing on the unique needs of a specific patient population; providing patients with the information needed to fully participate in their own care; and establishing an interdisciplinary team positioned to address the myriad clinical and social needs, before, during and after the procedure. 

VERTEBRAL FRAGILITY FRACTURES PATHWAY BUILDS ON STRONG BONES PROGRAM FOR EVIDENCE-BASED OSTEOPOROSIS CARE The Musculoskeletal Health Service Line’s clinical pathway for vertebral fragility fractures is a natural extension of the health system’s Strong Bones initiative, which already provides a system-based, consistent approach to evidence-based osteoporosis care. The pathway extends the program’s focus from hip and proximal humeral fractures to include vertebral fragility fractures. The pathway enhances follow-up to ensure that patients are connected with an appropriate osteoporosis provider who can guide them through treatment to prevent future fractures. A second key component is to focus spine surgery consults to the minority of patients who might benefit from it. Most patients will heal on their own and don’t require procedural intervention, yet most are currently referred to a spine surgeon for an evaluation. The pathway’s new focus on outpatient treatment, including screenings and treatments to build up bone strength, promotes optimal health and exceptional experience for patients. A nurse navigator reaches out to every patient who presents at Christiana Care with a vertebral fragility fracture to coordinate outpatient follow-up and bone-density scanning in preparation for seeing an osteoporosis doctor. Nurse practitioners consult with patients admitted to the hospital to provide education, order appropriate lab testing and evaluate fall risks in concert with physical therapy. Each patient receives an automatic discharge referral to the health system’s Strong Bones program, along with a checklist of tasks to complete as a partner in their own care. The pathway is expected to reach about 400 patients each year, creating greater awareness of the importance of bone health. “We hope to see increased rates of early bone-density screening and treatment and appropriate utilization of spine surgery consults,” said Eric Russell, D.O., associate physician leader for the Musculoskeletal Health Service Line.

400 PATIENTS A YEAR ARE EXPECTED TO BE REACHED — BRINGING AWARENESS TO BONE HEALTH.

2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

IMPROVEMENTS :

Neurosciences

Door-to-needle time for stroke surpasses elite new national targets Christiana Care’s Neurosciences Service Line is surpassing a new target of a shortened door-to-needle time for patients presenting with acute ischemic stroke. The American Heart Association/American Stroke Association recently raised the goal to 50 percent or greater patients receiving intravenous alteplase (IV tPA) treatment within 45 minutes of arrival at the emergency department. Christiana Care’s median door-to-needle times have steadily diminished over time from 62 to 43 minutes, consistently achieving the 50 percent or greater goal, and outperforming the national benchmark of 75 percent of patients treated within 45 minutes since January 2015.

Christiana Care Health System

This robust success translates to substantial improvement in patient outcomes, including death, disability and hemorrhage. “Time lost is brain lost” during an acute stroke, making prompt IV tPA treatment essential for improving patient outcomes. In such a multistep treatment process, small improvements in multiple processes result in overall large improvement. Solutions included creating a stroke-specialist-only neurologist call team, designating a single phone number for direct neurologist contact, ED team education on the criticality of timing, deferring EKG, direct door-to-CT project, administering tPA in CT scan with pharmacist present and the introduction of a stroke resource nurse. 

S E RV I C E L I N E S

Percentage of Patients with Ischemic Stroke Receiving IV tPA: Within 45 Minutes of Hospital Arrival

PERCENTAGE OF PATIENTS

100% 80% 60% 40%

National Benchmark 50%

20%

DESIRED DIRECTION

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Small gains in time-to-treatment create big gains for patient outcomes IV tPA is standard treatment to open blocked blood vessels and reduce disability in patients who present within 4.5 hours of symptom onset of acute ischemic stroke. For every 15 minutes faster the medication is given:

• The odds of walking independently at discharge increase 4 percent.

• The odds of discharge directly to home increase 3 percent.

• The odds of dying in the hospital decrease 4 percent.

• The odds of symptomatic brain hemorrhage decrease 4 percent. Reference: Time to Treatment with Intravenous Tissue Plasminogen Activator and Outcome from Acute Ischemic Stroke. JAMA 013 Jul 302;23.

NEUROSCIENCE PATHWAY FOR ACUTE ISCHEMIC STROKE STREAMLINES, YET INDIVIDUALIZES CARE Early focus of the Neurosciences clinical pathway for acute ischemic stroke is on making sure the interdisciplinary team is engaged throughout the patient’s stay, with occupational and speech therapy employed when appropriate. On discharge, the pathway helps ensure that patients are on the correct blood thinner and medicine to address risk factors, such as high cholesterol, and ensuring that case managers have devised a follow-up plan. “Since we serve a large and complex group of stroke patients, we have a large opportunity to streamline care,” said Valerie Dechant, M.D., associate Neurosciences Service Line leader and medical director of Neuro Critical Care. “Every stroke patient who comes to Christiana Care receives the same standard and quality of care, regardless of which physician is treating them or what nursing unit they are on.” A new component to optimizing patients’ health outcomes and experience is heightening the level of patient education. This involves communicating expectations and milestones to patients — and to the family — that they can bring back to the 2 provider. The commitment is to standardize care, yet still provide individualized care.

2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

IMPROVEMENTS :

Primary Care & Community Medicine

Front office staff sustain improvements in patient experience scores

Staff in the physician office set the tone of any patient encounter, and thanks to the Patient Experience Academy, patient experience scores on the Centers for Medicare & Medicaid Services’ Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey (CG CAHPS) are now sustainably higher in the primary care community and teaching practices.

Christiana Care Health System

A novel partnership between Christiana Care and the University of Delaware’s Lerner College of Business and Economics — the first ever of its kind between a health system and a university — the Patient Experience Academy applies the hospitality industry’s best customer service practices within the hospital setting, and in the ambulatory services. It’s all in the name of providing patients and families with the best, most Ú

S E RV I C E L I N E S

f First impressions.

helpful experience possible, starting from the moment they first call for an appointment or with a question. Office staff are the first and last of the practice care team to see or interact with a patient during or between visits. “Patients expect care to be perfect on the clinical side,” said Shawn R. Smith, MBA, vice president of Patient Experience. “It’s the compassionate care, which, if it’s not there 100 percent by every employee, every time, that they’ll remember. Giving our care team members the tools to do that is truly a major milestone in our journey of sustained success as a health system.” Now part of the patient experience curriculum of the Value Institute Academy, the 10-week experience includes such key skills as:

f The relationship between attitude, behavior and cognition. f How to deal with service failures. f Encouraging patient feedback. f Creating a culture of service recovery. f Conflict resolution. Practice care team members (defined as clerks and receptionists by CG CAHPS) improved their scores on treating patients and families with courtesy and respect and for being helpful, setting the tone for an exceptional patient experience with patient experience scores reaching as high as 93 percent. 

95%

Office Staff Quality

TOP BOX SCORE TOP BOX SCORE

95%

1st Patient Experience Academy

90%

Team Communication

90% 85%

85% 80%

Jul-14

Oct-14

Jan-15

Apr-15

Jul-15

Oct-15

Jan-16

DESIRED 80%

DIRECTION

Jul-14

Oct-14

Jan-15

Apr-15

Jul-15

Oct-15

Jan-16

Improvement in Office Staff Quality Questions 95.0% 92.3% TOP BOX SCORE

95.0% 90.0%

93.0%

DESIRED 89.0%

93.0%

92.3%

DIRECTION

86.9%

90.0% 85.0%

89.0% 86.9% Pre (Nov14-Jun15) Post (Jul15-Feb16)

85.0% 80.0%

Clerks & Receptionists Treat with Courtesy and Respect

Clerks & Receptionists Helpful Pre (Nov14-Jun15) Post (Jul15-Feb16)

80.0%

ks er

2016 Quality & Safety Report

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Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

PRIMARY CARE & COMMUNITY MEDICINE | CONTINUED

PATHWAY FOR TREATMENT OF ADULTS WITH TYPE 2 DIABETES INCREASES CONSISTENCY OF CARE AND COORDINATION FOR 25,000 DELAWAREANS The Primary Care & Community Medicine Service Line clinical pathway for the treatment of Type 2 diabetes has the potential to increase consistency and coordination of care for as many as 25,000 Delawareans seen annually at Christiana Care for the condition. 70,000 DELAWAREANS

“As we build innovative ways to care for diabetes, the care of all patients is expected to improve,” said Omar Khan, M.D., MHS, FAAFP, physician leader for the Primary Care & Community Medicine Service Line. “This new pathway also aligns many components of our large service line, which includes primary care specialties, such as family medicine and internal medicine; medical subspecialties, such as endocrinology; and related support services, such as nutrition services and diabetes education.” While the pathway aims to standardize some of the delivery components of care, flexibility, particularly in educational materials for patients, remains a priority. Not only will educational materials vary by culture, patients may select from a variety of platforms for engaging with their providers, including virtual visits, telehealth and shared appointments that provide both education and a chance for peer bonding. The goal of the pathway is for the primary care and endocrinology practices to work toward improving compliance and outcomes within the diabetes metrics bundle, which includes nine key care elements for diabetes, such as eye and foot exams, and HgA1c monitoring. In the longer term, it aims to reduce emergency department visits and hospital admissions. The intent is to reduce variation among the practices in such areas as blood glucose control, medication management and office-visit expectations.

Christiana Care Health System

S E RV I C E L I N E S

IMPROVEMENTS :

Surgical Services

Chlorhexidine wipes emerge as key tactic to reducing surgical site infections following colorectal surgery

Multiple pre-operative and post-operative interventions and sustained improvement efforts, many centered around the use of chlorhexidine wipes, have reduced the rate of surgical site infections (SSI) for Christiana Care patients undergoing colorectal surgery from a baseline of eight infections per 100 procedures to fewer than two infections per 100 procedures within six months.

A key target for surgical quality, lower infection rates translate to reduced length of stay and fewer readmissions. Following evidence-based protocols, a task force appointed by the Surgical Services Service Line implemented a number of quality improvements to safeguard patients and reduce the risk of hospital-acquired infections by reducing unnecessary variations in care. Ă&#x161;

2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

SURGICAL SERVICES | CONTINUED

SURGICAL SERVICES PATHWAY CALLS FOR EARLIER ENGAGEMENT OF CARE TEAM FOR IMPROVED COORDINATION OF CARE

# Infec(ons/SSI Rate (# infec(ons per 100 procedures)

Among the implemented changes are the pre-operative use of chlorhexidine Number of INumber nfec-onsof PSSI rocedures Rate /100 6-‐mo. procedures Moving average Surgical Site Infec-ons -‐ Colon Procedures The Surgical Services’ clinical pathway on recurring ventral hernia wipes on the patient upon arrival at Jul-‐11 0 63 0.00 abdominal wall reconstruction allows team members to track every step the the hospital on the morning of Aug-‐11 2 surgery 44 4.55 roughly 120 patients take along their care journey. and chlorhexidine prep of the surgical Sep-‐11 0 52 0.00 field by theOct-‐11 OR team. Post-operatively, Patients 1 45 2.22 undergoing this procedure have had multiple abdominal operawounds are washed daily with tions, Nov-‐11 1 40 2.50 often with multiple incisions that don’t heal properly due to diet, obechlorhexidine. sity, Dec-‐11 2 56 3.57prior infection or recurrent hernias. The abdominal wall is so unhealthy 11 health conditions, it requires extensive repair. Patients often live with other Oral preparations to 56 Jan-‐15 are administered 5 8.93 8.53994490358127 8.93 as well, including sleep apnea or diabetes. They have a long length of remove fecal material from the Feb-‐15 6 bowel, 57 10.53 8.22281167108753 9.73 hospital stay — about 7.5 days on average — and a prolonged recovery. and antibiotic use is now standardized 8.25 Mar-‐15 7 63 11.11 9.25449871465296 10.23 both for patients at home the day prior “This pathway hit all the 10.88 buttons of what we’re trying to do for all surgical Apr-‐15 8 63 12.70 9.48905109489051 to surgery and for pre-operative IVs. patients,” said Mark Schneider, and May-‐15 4 55 7.27 10.2689486552567 10.20 M.D., MBA, chair of anesthesiology 5.5 associate service line leader for Surgical Services. “How do we optimize 8 57 14.04 10.5769230769231 10.83 To protect Jun-‐15 the patient from bacteria the co-morbidities? What can we do to standardize, where possible, the while an incision Jul-‐15is open, OR 6traffic is 73 8.22 10.377358490566 10.60 procedure itself? Is there any opportunity to provide 2.75 more coordinated limited, fascial wound protectors Aug-‐15 4 are 55 7.27 10.1654846335697 10.11 care that will result in a shorter hospital stay for the patient? And how can used and staff change both gowns and 58 Sep-‐15 1 1.72 8.96226415094348.59 patients get back to work and daily activities?” gloves before closure with a dedicated Oct-‐15 7 71 9.86 8.79629629629638.13 0 wound closure tray that includes new, One the clinical pathway the care team Nov-‐15 4 48 8.33process 8.15347721822542 8.29 aims to change is how soon Jan-‐15 Mar-‐15 sterile instruments. becomes engaged with a patient. Straying from the idea that providers

Dec-‐15

The sterile Jan-‐16 dressing is left in place for 4 48 hours post-operatively.  Feb-‐16 2

56 63 56

10.71 8.45665961945032 7.76 only become aware of the patient when they are scheduled for surgery, the 6.35 7.54716981132075 7.41 pathway looks at candidates for surgery, considering their health status,Number of Infec-ons 3.57 6.87960687960688 6.82 resources available at home and the patient’s level of awareness of what they need to do.

Surgical Site Infections: Colon Procedures DESIRED

Number of Infections SSI Rate - Rolling 6 Months INFECTIONS/SSI RATE   (PERCENT OF INFECTIONS PER 100 PROCEDURES)

DIRECTION

November 2015: Began Use of Chlorhexidine Wipes July 2015: Task Force Begins

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5 r-1

Christiana Care Health System

5 -1 ar

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5 -1

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S E RV I C E L I N E S

IMPROVEMENTS :

Women & Children

Women & Children's

High compliance with delayed cord clamping results in clinical benefits for preterm infants

DELIVERED EACH YEAR

NICU.

Christiana Careâ&#x20AC;&#x2122;s quality improvement initiative to delay umbilical cord clamping (DCC) in very-low-birth-weight preterm infants continues to demonstrate a number of clinical benefits, including decreased need for intubation or chest compression in the delivery room, fewer orders for red-blood-cell transfusion, reduced need for ventilation at any time during the hospital stay and a reduction in late-onset sepsis rates. With more than 50 obstetricians delivering 6,500 babies and a dozen neonatologists caring for 1,100 infants in the Neonatal Intensive Care Unit each year, Christiana Hospital is one of the busiest maternity centers on the East Coast. In July 2013, a coordinated, multidisciplinary DCC protocol was introduced to educate physicians

and staff involved in delivery room care. The goal: to achieve greater compliance with evidence-based recommendations by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics supporting a 30- to 60-second delay in clamping the umbilical cord following the births of preterm infants, a practice shown to lower the risk of intraventricular hemorrhage. Christiana Careâ&#x20AC;&#x2122;s detailed protocol called for a 60-second delay in clamping, during which time the infant is wrapped in a warm, dry, sterile towel and held 10-15 inches below the level of the birth canal or the incision site. Upon noticing an increase in the number of hypothermic infants, the initial protocol was modified to sandwich the babies between two pre-warmed blankets during the 60 seconds of DCC. Apgar scores are reported from the time of delivery, not from cord clamping, and, once the cord is cut, the infant is placed under a radiant warmer. Ă&#x161; 2016 Quality & Safety Report

Service Lines

CLINICAL PATHWAYS KEY TO ACHIEVING STRATEGIC AIMS

WOMEN & CHILDREN’S | CONTINUED

The health system’s high compliance rate is all the more impressive considering that the protocol focused on very-low-birth-weight (<1500 grams) preterm infants, who require the most aggressive delivery room management. Physicians retained clinical decisionmaking authority in outlier cases but successfully came together to reduce variations in care in common desire to offer the best possible start of life for these vulnerable young patients. 

Percent of Very-Low-Birth-Weight (VLBW) Infants Receiving Delayed Cord Clamping (DCC) DESIRED DIRECTION

100.0%

PERCENTAGE OF VLBW INFANTS

Christiana Care achieved 73.2 percent compliance for DCC during the initial cohort and now maintains nearly 94 percent compliance during the control phase. Important associated clinical benefits continue to be realized, including a 33 percent decrease in packed red blood cell transfusions, a 62 percent decrease in delivery room chest compressions, a 20 percent decrease in the need for respiratory support and a 66 percent reduction in late-onset sepsis. Although concerns arose in the literature about concomitant increases in balancing measures, such as admission hypothermia and the need for phototherapy to treat an increased risk of jaundice from DCC, none was realized during Christiana Care’s protocol.

93.7%

73.2%

75.0%

50.0%

25.0%

0.7%

0.0%

Pre-DCC

Post-DCC

Control Phase

Clinical Outcomes Following Delayed Cord Clamping (DCC)

CLINICAL OUTCOMES

DESIRED

38.7%

DESIRED DIRECTION

16.6%

DELIVERY ROOM  CHEST COMPRESSIONS

6.3% 53.7%

RED BLOOD CELL   PRBC) TRANSFUSION

35.9% 69.1%

VENTILATION   DURING HOSPITALIZATION

54.9% 10.3%

LATE ONSET SEPSIS

Pre-DCC Post-DCC

3.5% 0%

15%

30%

45%

PERCENTAGE OF VLBW INFANTS

DIRECTION

57.4%

DELIVERY ROOM   INTUBATION

Christiana Care Health System

60%

75%

S E RV I C E L I N E S

GESTATIONAL DIABETES PATHWAY IMPROVES HEALTH OF MOTHER AND BABY With nearly one-third of Delaware adults classified as obese, it’s little surprise that Christiana Care is seeing more women with gestational diabetes. Equally as important as early diagnosis and treatment in pregnancy is the follow-up care of patients with gestational diabetes. By guiding women with gestational diabetes through every stage of the process, from diagnosis through follow-up care and education, the Women & Children’s Service Line aims to improve the health of mothers during pregnancy and throughout their lives, and reduce the likelihood that their babies will need care in the Neonatal Intensive Care Unit (NICU). By reducing variations in care for women with gestational diabetes, the Women & Children’s Service Line also hopes to effect healthier outcomes for babies. Currently 27 percent of children born to women with gestational diabetes need care in the NICU. “We want to see if by implementing a different model, we can have an impact on the NICU admission rate,” said Elizabeth Zadzielski, M.D., MBA, FACOG, medical director for ambulatory women’s health and associate Women & Children’s Service Line leader.

The clinical pathway calls for a two-hour diagnostic test that delivers results earlier in pregnancy for women identified at 28 weeks as high-risk for gestational diabetes. The pathway also focuses on postpartum care, hoping to increase follow-up screening via warm handoff to the primary care physicians. A gestational diabetes prenatal care group, offered in both English and Spanish, will be key to educating a vulnerable population. Care Link care managers will ensure that patients schedule diagnostic tests and will follow up if results are not returned in a timely manner. Because women with gestational diabetes have a significantly increased risk of becoming Type 2 diabetic within five years and are at a lifetime risk, the clinical pathway involves an important bridge between the Women & Children’s Service Line and the Primary Care & Community Medicine Service Line, which is addressing Type 2 diabetes with its own clinical pathway. “We want to keep women informed after they’ve delivered and manage them appropriately, so should they become pregnant again, they’re in better shape,” Dr. Zadzielski said.

By guiding women with gestational diabetes through every stage of the process, from diagnosis through followup care and education, the Women & Children’s Service Line aims to improve the health of mothers during pregnancy and throughout their lives, and reduce the likelihood that their babies will need NICU care.

2016 Quality & Safety Report

Essential Services

PROVIDING CRITICAL SUPPORT AND EXPERTISE

Christiana Care Quality Partners Clinical Engineering Compliance and Audit Design and Construction Environmental Services External Affairs Facilities Services Finance Food and Nutrition Services Human Resources iLEAD Imaging Services Information Technology Legal and Risk Management Nursing Organizational Excellence Pathology and Laboratory Services Pharmacy Services Population Health Management Patient Escort Quality and Patient Safety Rehabilitation Services Supply Chain The Medical Group of Christiana Care Value Institute Visiting Nurse Association 64

Christiana Care Health System

E S S E N T I A L S E RV I C E S

Extraordinary people on essential services teams drive successful delivery of a positive patient and family experience At the heart of every encounter with every patient and every family member are the extraordinary people of Christiana Care’s essential services, who drive the delivery of optimal care and exceptional experience and ensure that everything we do provides value for our patients and their families. All of Christiana Care’s extraordinary people are essential members of our patient-care team, but not all are evident to those we serve. Behind every physician and nurse are the team members who keep the lights on and the buildings comfortable. They are those who prepare the food, launder sheets and gowns, clean the rooms, keep our campuses safe, transport people between sites and make sure prescribed medications are available when needed. They keep our information technology platforms seamless, manage our cash flow, renovate and design spaces to better serve those who rely on our facilities, and lead our organizational excellence efforts toward continual performance improvement.

They perform integral diagnostic tests, capture critical images and rehabilitate patients to get them back on the road to optimal health. They keep us safe; they keep us comfortable; they keep us supplied; they keep us moving; they keep us connected. They keep us operational. They are, quite simply, essential. This report highlights just a handful of the countless performance improvements efforts led by our essential services teams. Beyond these pages, examples of their work abound on every campus, every day, with every patient at the center, as they work tirelessly to support the success of our new care delivery model and advance our organization in providing safe, individualized team-based care with the patient at the center. 

“Essential services are the foundation on which our new operating and clinical delivery structure stands. The important work done by the individuals on these teams is interwoven with all nine service lines, allowing our frontline providers to deliver consistent, safe, high-quality care. The contributions of every one of our extraordinary people who wear a Christiana Care badge are inherent to the daily success of our operations.” SHARON KURFUERST, EdD, OTR/L, FACHE, FAOTA, FABC Senior Vice President, Health Services Operations

2016 Quality & Safety Report

Essential Services

PROVIDING CRITICAL SUPPORT AND EXPERTISE

IMPROVEMENTS :

Pathology & Laboratory Services

Faster lab results mean antibiotics can start sooner

Christiana Care Health System

E S S E N T I A L S E RV I C E S

Average Time from Culture to Results and Initiation of Optimal Therapy

DIRECTION

50 46.5

38.6

-69% (32 Hours)

75% With the capacity to simultaneously detect and identify common pathogenic bacteria, viruses 58% and genetic virulence markers, this automated, multiplexed molecular diagnostic 50% test is a rapid, cost-effective alternative to traditional culture methods and confirmation tests. 25%

30 TIME IN HOURS

Molecular testing methods enhance the recovery of clinically significant pathogens without the 72—96 hour delay for identification. Earlier identification of causative pathogens 0% reduces the need for and cost of unnecessary downstream testing, allows patients to start receiving appropriate antibiotic therapy more expediently, shortens length of stay and offers earlier peace of mind for both patients and physicians. 

DESIRED

-92% (36 Hours)

PERCENTAGE OF PATIENTS

Laboratory blood culture testing performed with the new Verigene molecular assay is dramatically reducing the wait time for test results and allowing optimal therapeutic care to begin almost a full day sooner, improving both patient safety and clinical outcomes. Lab results identifying positive blood culture organisms that once took two to three days are now 100% available in as few as four hours, leading to an average onset of treatment shortened by almost 18 hours. 80%

14.2

Percent of Patients Who Received Optimal Therapy

PERCENTAGE OF PATIENTS

100%

3.0 80%

75%

DESIRED DIRECTION

58% 50%

Time to Results

Time to Initiation   of Therapy

Baseline Post-Intervention

25%

Baseline Post-Intervention

50 46.5

2016 Quality & Safety Report

Essential Services

PROVIDING CRITICAL SUPPORT AND EXPERTISE

IMPROVEMENTS :

Pharmacy Services

Leaving hospital with medications in hand leads to lower readmission rates, higher HCAHPS scores The Pharmacy’s new Patient Discharge Program, which gives patients the option of having prescriptions filled at a Christiana Care retail pharmacy before leaving the hospital, is reducing seven and 30-day readmissions and improving pharmacy-related scores for patient experience on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The seven-day readmission rate has decreased 27 percent with the new program; 30-day readmissions have decreased more than 10 percent as the number of nursing units offering the program has nearly tripled. Patients are not only staying healthier, but also report being more satisfied with their stay as it relates to pharmacy services. Scores rose by 5 percentage points for patients rating their hospital stay and by 8 points for clearly understanding the purpose of taking prescribed medications. Leaving the hospital with prescribed medications in hand allows patients to settle in comfortably at home sooner, saving a separate trip to pick up medication at a neighborhood pharmacy. It also allows the patient to begin complying with dosing instructions sooner, helping to avoid complications that could lead to readmission. Remaining prescription refills are automatically transferred from Christiana Care to the patient’s community pharmacy of choice.

Christiana Care Health System

The program advances several annual operating plan goals, including: f Lower readmission rates. f Higher HCAHPS scores. f Improved financial performance of the retail

pharmacies.



E S S E N T I A L S E RV I C E S

7- and 30-Day Readmission for Pharmacy Discharge Participants (PDP) vs. Control Group 7 & 30 Day Readmission for Pharmacy Discharge Participants (PDP) v. Control Group

Patient Experience Scores for Pharmacy Discha

12%

80%

8.7% 8%

4.1%

60%

3.0%

7-Day Readmission

40%

20%

30-Day Readmission

Rate Hospital 0-10

Control PDP

Patient Experience Scores for Pharmacy Discharge Participants (PDP) vs. Control Group

DP) v. Control Group

Patient Experience Scores for Pharmacy Discharge Participants (PDP) v. Control Group

80% 69% 8.62%

admission

74%

DIRECTION

TOP BOX SCORE

PERCENTAGE OF PATIENTS

9.7%

69%

DESIRED

74%

DESIRED DIRECTION

59%

60% TOP BOX SCORE

67%

40%

20%

Rate Hospital 0-10

Understood Purpose of Taking Meds

Control PDP

2016 Quality & Safety Report

Essential Services

PROVIDING CRITICAL SUPPORT AND EXPERTISE

IMPROVEMENTS :

Imaging Services

Radiologist review leads to safer, most cost-effective diagnoses Radiologist review of high-end imaging utilization (HEIU) is helping to improve the quality, safety and appropriateness of diagnostic imaging by reducing the number of unnecessary computed tomography (CT) or magnetic resonance imaging (MRI) scans ordered for low-risk patients for whom a study offers little or no useful information. By “rejecting” unnecessary tests or recommending safer, more cost-effective methods leading to equivalent diagnostic information, radiologists are helping to prevent both unnecessary radiation exposure to patients and unnecessary costs. In a 12-month review of more than 2,000 outpatient diagnostic imaging exams ordered at one of Christiana Care’s 16 accredited imaging sites, 13.3 percent were flagged as excessive or inappropriate, and either rejected or altered following consultation between the ordering physician and reviewing radiologist.

Key findings: f 24 of the 45 tests and treatments identified by the

Choosing Wisely initiative as over-used are directly related to diagnostic imaging. f Review of outpatient high-end images by in-house

radiology staff is a simple, cost-effective way to reduce excess HEIU with minor hindrance to ordering physicians. f More than half of the review requests were resolved

within two hours; 80 percent were resolved within 12 hours of the order being placed. f The push of information from radiologists during

the review process keeps ordering physicians up-to-date with HEIU-appropriate guidelines. f The program encourages collaboration between

ordering physicians and the radiology staff and actively positions radiologists as positive influencers of quality patient care providing value beyond image interpretation. 

Results of High-End Imaging Exam Review

Approved without Discussion

13% Images Prevented / Altered

Approved with Discussion

Christiana Care Health System

Rejected

Altered

E S S E N T I A L S E RV I C E S

IMPROVEMENTS :

Rehabilitation Services

Family coaches help to get rehab patients home A program designed to more integrally involve families in a patientâ&#x20AC;&#x2122;s recovery by training them for preparation for home has increased the discharge-to-community rate from the Center for Rehabilitation at Wilmington Hospital by more than 10 percent since the project launched in October 2015. This enhanced family training program is sending patients home with greater functional improvement and has increased the patient experience score regarding preparation for home above the national HCAHPS average. Discharge to the community is not only an expectation of our patients and families following a stay in an inpatient rehabilitation facility, but is a nationally monitored marker of quality and performance by the CMS Inpatient Rehabilitation Facilities Quality Reporting Program.

While patient and family training for home is common practice among inpatient rehabilitation facilities, a more robust and structured approach was developed at the Center for Rehabilitation to increase the rate of discharges to the community versus discharges to skilled nursing facilities. When a patient suffers from an acute event requiring rehabilitation, inpatient rehabilitation is one level of care that is considered. Inpatient rehabilitation facilities offer intensive rehabilitation utilizing an interprofessional approach to patient- and family-centered care. Discharge to home is the ideal disposition, and is reviewed with patient and family even prior to being admitted to the Center for Rehabilitation, and therefore preparation Ă&#x161;

2016 Quality & Safety Report

Essential Services

REHABILITATION | CONTINUED 3.64 3.58 ing home 3.42

PERCENTAGE OF REHABILITATION PATIENTS

DIRECTION

90% 85% 80%

77%

70%

60%

50%

Pre Go-Live (Jul-Sep 2015) Discharge to Community National Average

Rehab unit prepared me for going home 3.42 FIM Score Change: Functional Improvement

Christiana Care Health System

3.64

3.58 DESIRED

35%

30%

28.9% 27.5%

25%

20%

100%

DIRECTION

Pre Go-Live (Jul-Sep 2015) FIM Score Change National Average

Post Go-Live (Oct-Dec 2015)

PERCENTAGE OF REHABILITATION PATIENTS

This enhanced family training schedule, focusing on patient- and family-centered care, opens the door to many patients who might otherwise require a stay in a skilled nursing facility, allowing them to instead recover in the comfort and safety of their own homes. 

DESIRED

100%

PERCENTAGE OF REHABILITATION PATIENTS

2015)

Discharge to Community Rate

to go home starts on day one. However, as a patient progresses in therapy, the realization of the burden of care once discharged to home can become evident to families, making an intensive family training program crucial. 28.9% vigorous A structured and more approach was developed to increase family involvement and better prepare family for when patients return home. Each patient identifies one or two family members who will serve as a rehabilitation coach for all of their rehabilitation needs, through training during their Post Go-Live (Oct-Dec 2015) inpatient stay and at home. Upon admission, the case manager contacts the coach, schedules the personalized training schedule and communicates the schedule to the entire rehabilitation team. The initial training commences within the first three days of the inpatient stay, then weekly depending on the patient’s length of stay. The final training occurs within the last 48 hours before discharge. Each appointment includes individualized training with physical therapy, occupational therapy, speech therapy or nursing.

PROVIDING CRITICAL SUPPORT AND EXPERTISE

90%

80%

70%

60%

50%

2016 Quality & Safety Report

Focus on Excellence ADVANCING IMPROVEMENTS AND ACHIEVEMENTS FOCUS ON EXCELLENCE AWARDS BY THE NUMBERS:

155

PROJECTS SUBMITTED

200 STAFF JUDGES

WINNING PROJECTS

3.6 M

IN ESTIMATED COST SAVINGS

3.3 M

IN POTENTIAL REVENUE GAIN

The President’s Award recipients

Christiana Care’s annual Focus on Excellence Awards program highlights the best efforts, improvements and successes achieved during the past year. TEAMS ARE ENCOURAGED to identify an opportunity for

improvement, then develop and carry out a plan to achieve improvements in process or outcomes using the Plan-Do-CheckAct or Lean Six Sigma Define, Measure, Analyze, Improve and Control (DMAIC) models. Storyboards detailing the project are exhibited during National Healthcare Quality Week. The highest honor at the January 2016 ceremony — the President’s Award — went to the “Bundling Care to Create Value” project for an innovative new payment model that combines reimbursement for defined episodes of care, along with financial and quality accountability. 74

Christiana Care Health System

Successful journey to value-based payment Christiana Care began the journey from volume- to value-based payment, in alignment with long-term strategic goals, by implementing two bundles under Medicare’s Bundled Payments for Care Improvement (BPCI) initiative, which combines reimbursement for defined episodes of care with financial and quality accountability. Christiana Care is participating in Model 2 of the BPCI program, which defines an episode of care as the acute-care hospital stay and all services provided to patients for 90 days after discharge. Two “bundles” were implemented in January 2015: joint replacement and cervical spine surgeries. Ú

A WA R D S

“Every project entry represents Christiana Care’s commitment to drive improved performance in all that Christiana Care’s innovation and teamwork to better serve our patients, families and community.” SHARON ANDERSON, MS, BSN, RN, FACHE Chief Population Health Officer and Senior Vice President, Quality, Patient Safety & Population Health Management

Clinicians and key stakeholders redesigned clinical care and developed a longitudinal care-management infrastructure. Care Link’s team of nurses, case managers, social workers, pharmacists and physicians provides comprehensive care from pre-surgery through 90 days after hospital discharge. To reduce supply expenses related to joint and spine implant costs, formulary pricing contracts were established with vendors. The team also collaborated with post-acute-care services, including Christiana Care’s Visiting Nurse Association and skilled nursing facilities, to redesign care and improve patient experience. A third bundle, cardiac valve surgery, was added in April 2015. In the first eight months, the Care Link team served more than 1,040 Medicare beneficiaries who had joint replacement and

n i y e h t a Car p Em alth He TH

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D. M.

R ,P

S ES

cervical spine surgery. Patients discharged to the community (home or home health services) increased by 9 percent for the three populations combined, and discharges to skilled nursing facilities decreased by 7.5 percent. In addition to increasing patient satisfaction, these results reduced Medicare expenditures in the 90-day post-discharge period. Thirty-day and 90-day readmission rates decreased by about 26 percent overall. Internal financial analyses show savings of $850,000 for joint replacement and cervical spine procedures in the first six months. The successful methodology was expanded to four more bundle populations in 2015: lumbar spine and coronary artery bypass surgery in July, and heart failure and stroke in September. 

CM EY

Sharon Anderson with Drs. Thomas H. Lee and Janice E. Nevin

FOE Awards Ceremony guest speaker Thomas H. Lee, M.D., chief medical officer of Press Ganey, shared insights from his book “An Epidemic of Empathy in Healthcare: How to Deliver Compassionate, Connected Patient Care That Creates a Competitive Advantage.” At a time when consumers are increasingly engaged in their health care decisions and providers are being called upon to deliver even greater value, Dr. Lee said an “epidemic of empathy” in health care presents a clear path to patient-centered care and a valuable resource to reduce patient suffering and improve the patient experience. 2016 Quality & Safety Report

FOCUS ON EXCELLENCE AWARD

P RO JE C T T I T L E

DE S C R I P T I O N AN D R E SU LT S

PRESIDENT’S AWARD

Bundling Care to Create Value

Christiana Care implemented two ‘bundles’ under Medicare’s Bundled Payments for Care Improvement (BPCI) initiative in January 2015: Total Joint Replacement and Cervical Spine surgeries. Under Bundles, Christiana Care has clinical and financial accountability that extend to 90 days post-discharge. Results: Through clinical redesign and improved coordination via Care Link for more than 1,100 patients, discharges to the community increased by 9 percent, while those going to skilled nursing facilities decreased by 7.5 percent; 90-day readmission rates dropped 26 percent; and key quality and safety measures — including functional outcomes — also improved. Internal financial analyses show savings of $850,000 in the first six months.

VALUE GOLD AWARD

Antifibrinolytics: Improving Joint Replacement Outcomes

The Center for Advanced Joint Replacement evaluated the effectiveness of topical antifibrinolytic tranexamic acid (TXA) use in reducing postoperative blood loss, transfusion rates, complications, length of stay and readmission rates for patients having total hip and knee replacement. Results: Patients who received TXA had an 80 percent reduction in allogeneic blood transfusions compared to patients who did not receive TXA. There was a 25 percent reduction in hemoglobin loss, decreased length of stay and a 38 percent reduction in readmissions, with no difference in complications. In addition, use of TXA saves an estimated $650,000 annually by eliminating pre- and post-op blood tests.

VALUE SILVER AWARD

Team Based Quality Improvement in Home Health

Christiana Care Visiting Nurse Association implemented continuous quality improvement team scorecards to engage direct care staff clinicians and improve overall financial and quality outcomes for Medicare patients receiving home health services. Results: All 10 teams improved, leading to a 24 percentage point increase overall for 8,194 Medicare patients receiving care during FY 2015. Acute care hospitalization improved 2 percent; clinical outcomes and process measures improved 20 percent. Average nursing visits per episode of care reduced by one visit, contributing $134,025 in total savings over budget.

OPTIMAL HEALTH SAFETY GOLD AWARD

Best Practice for Catheter-Associated Urinary Tract Infection (CAUTI) Reduction

An interdisciplinary system CAUTI Reduction Steer implemented multiple initiatives, including new insertion kits and securement devices, a new CAUTI Prevention Specialist program and education with the VEST center, a new urinary catheter insertion checklist in Powerchart, and a twice-daily Foley electronic report. Results: The multi-pronged effort led to a 55 percent decrease in the number of CAUTI infections (55 to 25) and a 49 percent decrease in the CAUTI infection rate (2.95 to 1.5). Nursing staff surveys showed an improvement in catheter practices post implementation of changes.

OPTIMAL HEALTH SAFETY SILVER AWARD

Evaluation of Adherence to Urinary Tract Infection Guidelines

In 2014, Christiana Care’s Antimicrobial Stewardship Program committee developed guidelines for the treatment of urinary tract infections (UTIs) to promote appropriate and judicious antibiotic use. The team of PharmDs’ goal was to improve adherence to empiric antibiotic selection, de-escalation of therapy and duration of therapy in patients with a UTI admitted on 5A, 5B, 5C and 5D. Results: During guideline implementation and education phases, there was a 41 percent improvement in de-escalation of therapy, a 66 percent improvement in duration of therapy, and limited improvement in antibiotic selection.

OPTIMAL HEALTH QUALITY GOLD AWARD

STEMI Door-toBalloon Time Reductions

A review of Christiana Care data for fiscal year 2013-2014 showed that, on average, only 95 percent of STEMI patients met the 90-minute door-to-balloon time goal, below the national top decile performance of 99 percent. Action plans were implemented for each area with identified process variation. Results: Post-implementation door-to-EKG times went from 3.3 minutes to 2.1 minutes; cardiologist call-back times dropped from 8.2 to 3.5 minutes; and prep times upon patient arrival in the lab dropped from 9 to 7.5 minutes. The percent of STEMI patients meeting the 90-minute door-to-balloon time goal increased from 95 to 100 percent and has been sustained to-date. Ú

Christiana Care Health System

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OPTIMAL HEALTH QUALITY SILVER AWARD

Emergency Department (ED) Pharmacists Decrease Time to Antibiotics for Sepsis Patients in the ED

Delays in antibiotic administration have been shown to increase mortality in patients with septic shock. Guidelines require antibiotics to be administered within three hours of presentation. This team assessed the impact of ED pharmacists’ bedside clinical support on reducing time to appropriate antibiotics for patients with sepsis. Results: With ‘EPharmD’ intervention, time to antibiotic administration was 46 minutes faster, and more than 86 percent of patients met the three-hour guideline. Secondary outcomes, including in-hospital mortality, ICU length of stay and hospital length of stay were also decreased in the EPharmD group.

OPTIMAL HEALTH QUALITY BRONZE AWARD

Sepsis Sleuth – Show me your Lactate and I’ll Follow you Anywhere

A Wilmington Hospital team hypothesized that by performing point of care (POC) lactate testing in the Emergency Department, time-to-serum lactate results could be reduced, allowing for earlier patient intervention. Results: Almost 1,600 POC lactate tests were performed during the nine-month pilot. The POC results provided information in 2.7 minutes — 17.3 minutes sooner than the lab results. This, in turn, enables the physician to determine course of treatment in a more timely fashion, ultimately increasingly the chance of a good outcome for the patient.

EXCEPTIONAL EXPERIENCE GOLD AWARD

Mission Impossible: Cutting the Clutter for the Delivered Mother

An interdisciplinary team, including the Mother Baby Value Improvement Team and the Family Advisory Council, worked to improve the patient experience by streamlining discharge information, and improving Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores related to physician and nurse communication with patients. Results: The group reviewed and organized all pertinent handouts into four sections of a spiralbound resource booklet titled, “Care of You and Your Baby.” Nurses and postpartum patients strongly agreed the booklet was useful. Doctors and nurse communication HCAHPS scores improved more than 5 percent within nine months, and the booklet received a Healthcare Marketing Award.

EXCEPTIONAL EXPERIENCE SILVER AWARD

Heat on Demand Implementation for Christiana Care Food and Nutrition Services

With the goal to achieve and maintain the Council of Teaching Hospitals top-quartile rank for food quality and temperature based on the Press Ganey satisfaction surveys, a Food and Nutrition Services team worked with Nursing, Information Technology and Facilities Engineering to identify the best meal-delivery system for Christiana Care’s patients. Results: The team identified a system that uses a magnetically activated base and insulated lid to keep plated food hot. Wilmington Hospital reached the 93 percentile rank for meal temperature and 91 percent for meal quality. Christiana Hospital achieved a percentile rank of 61 percent and continued to strive for the goal of top quartile by December 2015.

STRATEGIC PARTNERSHIPS AWARD

5C Discharge by Appointment Before Noon

In an effort to generate earlier discharges and improve patient flow, the 5C Patient Care Round team and unit staff initiated a Discharge by Noon project. The project targeted discharging a patient on 5C before noon by identifying the patient the day prior, streamlining the discharge process, communicating open items needed for discharge and coordinating activities. Results: 5C Discharges by Noon increased from 30 percent at baseline to 68 percent. The median discharge time moved up from 3:13 p.m. to 2:07 p.m. The changes resulted in 5C being able to admit and discharge an additional 244 patients annually.

EXTRAORDINARY PEOPLE AWARD

Emotional Intelligence

In 2014, 5C had the second highest rate of reported patient assaults. 5C worked with Public Safety, Injury Prevention and the Department of Psychiatry to create a training program to educate staff about the five domains of emotional intelligence (self-awareness, self-regulation, motivation, empathy and social skills), de-escalation techniques and other strategies. Results: The Emotional Intelligence project showed a 75 percent reduction in assaults, from 13 in FY 2014 to one in FY 2015. Lost Time Injuries related to assaults decreased from 129 days prior to implementation to 0 days post implementation.

2016 Quality & Safety Report

FOCUS ON EXCELLENCE

AWARD

P RO JE C T T I T L E

DE S C R I P T I O N AN D R E SU LT S

INNOVATIVE TOOLS GOLD AWARD

Improving HCAHPS Scores Using iRound Technology

“iRound for the Patient Experience” is a software platform tool designed to improve the patient experience by gathering patient satisfaction data in real time, facilitating service recovery via automatic service requests, and providing a data dashboard on a mobile device. Implementation of the iRound for the Patient Experience rolled out systemwide across 31 inpatient units beginning June 2014. Results: The Value Institute analyzed pilot data comparing patient experience round responses to the HCAHPS survey. Exposure to patient rounding using iRound technology at least once during a hospital stay resulted in a statistically significant positive response.

INNOVATIVE TOOLS SILVER AWARD

Infection Prevention Perception

4 West created a hand hygiene survey on the GetWellNetwork to allow patients to answer “yes” or “no” to the question, “Have you witnessed a staff member wash their hands with soap and water or wash them with gel hand sanitizer?” A hand hygiene pathway was also developed asking patients to watch a short video titled, “Preventing the Spread of Infections.” Results: Based on an analysis of responses to the GetWellNetwork survey, 4W moved glove boxes and gel dispensers to make hand hygiene compliance more visible to patients. 4 West exceeded their goal by improving hand hygiene compliance for FY 2015 to 92 percent, a 7 percent increase over FY 2014.

NURSING EXCELLENCE STRUCTURAL EMPOWERMENT GOLD AWARD

Potential “Side Effects” of Education

To increase comprehension of medications with their complex and challenging geriatric population, the Acute Care of the Elderly (ACE) unit Education Council on 6A set a goal of improving nursing compliance with medication side effect education via the GetWellNetwork. Results: Through patient care technician and nurse education, 6A increased the percentage of patients using “My Medications” on the GetWellNetwork from 7.8 percent to a high of 66 percent. Total sessions in “My Medications” increased from fewer than 100 to more than 700 per month. Early HCAHPS results were promising: communication of medications increased from 56 to 83 percent.

NURSING EXCELLENCE STRUCTURAL EMPOWERMENT SILVER AWARD

Strengthening the Student Nurse Extern Onboarding Experience

To improve the overall onboarding experience for student nurse externs and lead to an increased hire and retention rate, student nurse externs were paired with Christiana Care’s patient care technician and/or student nurse extern staff on the unit for clinical days to learn basic bedside patient care. The curriculum and structure were also redesigned. Results: The number of student nurse externs hired to RN/GN position increased 66 percent and retention increased 96 percent.

NURSING EXCELLENCE NEW KNOWLEDGE, INNOVATIONS & IMPROVEMENT

Vanishing VAIs (Vascular Access Infections) in Hemodialysis Patients

With a goal of reducing blood stream infection rates among dialysis patients by 20 percent within 12 months, this team monitored hand hygiene, catheter-exit-site care, accessing/ de-accessing catheters, accessing/de-accessing fistulas and grafts, and dialysis station disinfection. They also educated staff, patients and families. Results: Hand hygiene, and staff access/de-access of fistulas/grafts was 100 percent. Staff performed exit site care with 90 percent accuracy. The average blood stream infection rates decreased 51 percent, from 4.91 to 2.39 percent.

NURSING EXCELLENCE EXEMPLARY PROFESSIONAL PRACTICE

Total Knockout with CAUTI Prevention

The 3D Value Improvement Team implemented multiple initiatives including debriefs, Foley rounds and extensive staff education to reduce the number of hospital-acquired catheterassociated urinary tract infections on the unit. Results: 3D’s CAUTIs decreased from eight in FY 2014 to one in FY 2015. At the time of the FOE exhibit, the unit had been CAUTI-free for more than 420 days.

Christiana Care Health System

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NURSING EXCELLENCE TRANSFORMATIONAL LEADERSHIP AWARD

15 Minutes or LessTransfer the Best

The Transitional Care Unit (TCU) identified a need to implement a unit standard for report call time in order to decrease the amount of time it takes to transfer a patient out of the TCU to another nursing unit within Christiana Care. Observation showed that if the report was called to a receiving unit in less than 15 minutes, the patient transfer time would decrease to less than one hour. Results: At the conclusion of the 90-day period, the team achieved their goal by decreasing the first attempt to call report to 11.6 minutes. They were able to increase the number of patients who transferred out of the TCU in less than one hour to 69 percent, an increase of 146 percent.

LEARNING EXCELLENCE AWARD

CAUTI Prevention Education: Engaging Frontline Staff

A team of direct care nurses formed to reduce higher- than-benchmark CAUTI rates by standardizing practice for indwelling catheter insertion and maintenance care. Results: The team procured a new Foley insertion kit and reeducated nursing staff using CAUTI prevention specialists (CPS). Two hundred and twenty-four specialists completed training and assisted with unit-based training. Christiana Care has experienced a 49 percent decrease in CAUTI rates since the implementation of the CAUTI prevention initiative.

OPERATIONAL IMPROVEMENT GOLD AWARD

Nursing + Escort + EVS = 1 Timely Interunit Patient Transfer

To reduce patient flow bottlenecks during interunit transfers, a team of Environmental Services, Nursing and Escort staff used Lean Six Sigma methods and tools to reduce the mean transfer from MICU to 3D time from the baseline of 155 minutes. Results: Interventions, including transfer unit “pulling” of patients by nursing and changes to the dirty/clean bed process in Bed Management reduced the transfer time to 130 minutes, for a savings of $62,000. Escort and Environmental Services changes have been spread systemwide.

OPERATIONAL IMPROVEMENT SILVER AWARD

Improve Turnaround Time of First Dose of Antibiotics in NICU

Infections in newborns can progress quickly if not treated properly. After analysis showed that only 21 percent of antibiotic first doses in the Christiana Neonatal Intensive Care Unit (NICU) were administered within the target turnaround time of 60 minutes, a Lean Six Sigma team led by Neonatology modified processes to reduce the average administration time. Results: A bundle of interventions, including streamlining of processes through implementation of computerized physician order entry in the NICU, significantly improved timely receipt of antibiotics. The percent of first doses with a turn-around time of 60 minutes increased to 63.5 percent, and the mean time to administration decreased to 60 minutes.

OPERATIONAL IMPROVEMENT BRONZE AWARD

Christiana Operating Room Instrument Set Consolidation

A Lean Six Sigma Perioperative Services team looked at opportunities to reduce the $1.9 million annual cost of instrument repair and replacement by focusing on reducing the overall number of instruments in major and minor dissecting instrument trays in the Christiana operating room, leading to a reduction in both the weight and the cost of the trays. Results: Based on analysis of instrument use, the team reduced the number of instruments on the major tray from 95 to 74, and on the minor tray from 102 to 77, dropping the tray weight by two pounds. Cost savings were $225 and $267 per tray, respectively.

EXCELLENCE IN COMMUNITY HEALTH AWARD

Tobacco Use: Quit the Habit!!!

The Medical Group of Christiana Care Performance Improvement Committee instituted a primary care clinician preventive health quality measure focusing on screening patients over the age of 13 years for smoking, and tobacco counseling and/or advice to quit for patients 18 and over. Results: Electronic medical record prompts providing data feedback to clinicians and management, as well as staff education and engagement, increased identification of tobacco use and intervention from 73 to 90 percent, reaching almost 7,000 patients.

2016 Quality & Safety Report

FOCUS ON EXCELLENCE AWARD

P RO JE C T T I T L E

DE S C R I P T I O N AN D R E SU LT S

DIVERSITY, INCLUSION & CULTURAL COMPETENCY EXCELLENCE AWARD

Piloting the CareManagement and Palliative Care (CMAP) Program

The goal of the Care Management and Palliative Care Program (CMAP) is to provide dignity and respect for homebound patients while improving quality of life. This is done by providing more intensive care management with a focus on patient oriented outcomes and decreased hospital utilization. Results: Forty-six patients participated in CMAP’s first 10 months. Eighty-seven percent of patients had advanced directives, 100 percent of patients had a documented symptom assessment and 100 percent had goals of care discussion documented within their charts. There was a 50 percent decrease in readmissions and a decrease in overall hospital days from 797 pre- to 171 post CMAP.

ORGANIZATIONAL VITALITY GOLD AWARD

Improving Recognition and Documentation of Sepsis on 5A

Delayed recognition of sepsis has been shown to be associated with higher rates of inappropriate therapy and mortality. In addition, lack of adequate documentation regarding sepsis impacts Christiana Care’s ability to accurately code and bill sepsis cases. Results: Lean Six Sigma methodologies were used to evaluate gaps in early recognition and documentation of sepsis. Interventions, including an electronic medical record-based sepsis alert system and education increased accurate documentation of sepsis cases from 17 to 75 percent. The increased case mix index translates to a potential revenue gain of more than $3.3 million.

ORGANIZATIONAL VITALITY SILVER AWARD

Prospective Appropriateness Testing for Stress Nuclear Cardiac Perfusion Studies

A Nuclear Medicine and Non-Invasive Cardiovascular Services team established a prospective review system for outpatient nuclear myocardial perfusion imaging (MPI) studies on Blue Cross/Blue Shield of Delaware members, offering an opportunity to reduce “rarely appropriate” scans from a baseline of more than 15 percent to fewer than 10 percent. Results: Use of the MPI decision support software resulted in a decrease of rarely appropriate MPIs to fewer than 5 percent, and a reduction in the overall volume of MPI scans performed, from 427 in 2012 to 260 (annualized) in 2015.

RESIDENT’S AWARD

Building CLER Infrastructure: Integrating Improvement Science into Daily Work

The Accreditation Council for Graduate Medical Education’s Clinical Learning Environment (CLER) program emphasizes the integration of graduate medical education within Christiana Care’s quality infrastructure for our more than 270 residents and fellows. This project increased resident engagement and participation in patient safety through the creation of a Resident Quality & Safety Council that consists of faculty-resident participation from the 18 residency programs. Results: The number of resident-submitted Safety First Learning Reports increased from 108 to 288, and resident participation in health system forums (root cause analysis and debriefs) increased by 75 percent. In addition, the program strengthened mentoring relationships and the council’s advice was sought on multiple issues.

PEOPLE’S CHOICE AWARD

Total Knockout with CAUTI Prevention

The 3D Value Improvement Team implemented multiple initiatives, including debriefs, Foley rounds and extensive staff education, to reduce the number of hospital-acquired catheterassociated urinary tract infections on the unit. Results: 3D’s CAUTIs decreased from eight in FY2014 to one in FY2015. At the time of the FOE exhibit, the unit had been CAUTI-free for more than 420 days. 

“The creativity and diligence of this exceptional work allows us to continue to adapt to the ever-changing world of health care.” JANICE E. NEVIN, M.D, MPH President and Chief Executive Officer

Christiana Care Health System

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National Recognition A LEADER IN HEALTH CARE

American Association of Critical Care Nurses Gold Beacon Award to the Medical Intensive Care Unit at Christiana Hospital and Silver Beacon Award to the Wilmington Intensive Care Unit. This is the third Beacon for MICU. American College of Surgeons (ACS) Clinical Congress “Meritorious” outcomes in surgical patient care. This is the third consecutive year that Christiana Care has been recognized through the organization’s National Surgical Quality Improvement Program, the only nationally validated quality improvement program that measures and enhances the care of surgical patients. American Diabetes Association Health Champion designation. American Hospital Association Institute for Diversity in Health Management Best in Class Hospital for increasing diversity and reducing disparities in care in the category of Cultural Competency and Engaging Communities.

Cleverley + Associates nationally top-ranked Community Value Five-Star Hospital. Christiana Care ranks as one of the top hospitals in the United States in terms of the value it provides to the community, scoring in the top 20 percent of facilities across the country. Cribs for Kids Gold Sleep Safe Champion for best practices and parent education concerning safe sleep for infants — one of only seven in the nation to earn this highest level of certification available. The Human Rights Campaign Foundation Leader in Healthcare Equality for the fifth consecutive year. The Joint Commission Designations: • Advanced Certification in Heart Failure. • Comprehensive Stroke Center Certification to Christiana Hospital. • Disease-Specific Certification to the Left Ventricular Assist Device Program.

American Nurse Credentialing Center Magnet designation for nursing excellence — first in Delaware to achieve consecutive designations.

• Gold Seal of Approval to the Center for Advanced Joint Replacement for its Hip and Knee Replacement programs.

Baby Friendly designation by the World Health Organization and the United Nations Children’s Fund. Only 10 percent of U.S. birthing facilities achieve this designation distinguishing hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding.

• Primary Stroke Center Certification to Wilmington Hospital.

Becker’s Hospital Review 100 Great Hospitals in America /2015 and 100 Hospitals and Health Systems with Great Women’s Health Programs 2015.

The Leapfrog Group Hospital Safety Score of “A” to Wilmington Hospital, and “B” to Christiana Hospital. National Cancer Institute National Clinical Trials Network (NCTN) top accruing member. Christiana Care’s Helen F. Graham Cancer Center & Research Institute ranks 8th among NCI Community Oncology Research Program sites enrolling the highest numbers of patients into network clinical trials led by NRG Oncology research group, one of five U.S. research groups now participating in the NCTN.

NICHE (Nurses Improving Care for Healthsystem Elders) Exemplar. This is the third consecutive year Christiana Care has been recognized for the care it provides to older adults. The SafeCare Group 100 SafeCare Hospitals — a listing of high performing hospitals in evidence-based metrics of Hospital Value Based Program, Hospital Readmissions Reduction Program and Hospital-Acquired Conditions Reduction Program. TAMPA VA Research & Education Foundation’s Audrey Nelson Best Practices Award in Safe Patient Handling for our comprehensive safe patient handling program and for being one of the best in the country due to a commitment to staff education and development of safe patient handling best practices. Training Magazine Top 125 list of outstanding training organizations. This is the fourth consecutive year Christiana Care placed in the top 50 on the list of all industries and in the top 10 of health care organizations. Truven Health Analytics 100 Top Hospitals in the major teaching hospital category and Everest Award winner for the fastest long-term improvement among health systems over the last five years. U.S. News & World Report No. 1 in Delaware, No. 3 in the Philadelphia region and one of the nation’s top 50 best hospitals for Obstetrics and Gynecology, Endocrinology and Metabolic Diseases and Pulmonary and Critical Care Medicine. 

2016 Quality & Safety Report

About Christiana Care ONE OF THE COUNTRY'S LARGEST HEALTH CARE SYSTEMS EAST COAST RANKINGS*:

10 TH

IN ADMISSIONS

15 TH

IN BIRTHS

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IN SURGICAL PROCEDURES

Christiana Care Health System is one of the country’s largest health care systems, ranking as the 21st leading hospital in the nation and 10th on the East Coast in terms of admissions. The health system includes The Medical Group of Christiana Care, a network of primary care physicians, medical and surgical specialists, as well as home health care, preventive medicine, rehabilitation services and patient/family advisers for core health care services. A not-for-profit teaching hospital affiliated with Sidney Kimmel Medical College at Thomas Jefferson University, Christiana Care is recognized as a regional center for excellence in cardiology, cancer and women's health services. Christiana Care has an

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IN EMERGENCY DEPARTMENT VISITS

extensive range of outpatient services, and through Christiana Care Quality Partners works closely with its medical staff to achieve better health, better access to care and lower cost. Christiana Care is home to Delaware's only Level I trauma center, the highest capability center and the only one of its kind between Philadelphia and Baltimore. Christiana Care features a Level III neonatal intensive care unit, the only delivering hospital in Delaware that offers this highest level of care to the most critically ill newborns. Christiana Care includes two hospitals with 1,100 patient beds. For more information about Christiana Care, visit www.christianacare.org/whoweare. 

Christiana Care serves patients from Delaware, Maryland, New Jersey, Pennsylvania and beyond. Our network of facilities makes it easy for neighbors to receive expert care at the right place, at the right time. C H R I S T I A N A C A MP US

W I L M ING T ON C A M P US

R EG ION A L FAC IL I T IE S

Christiana Hospital (906 beds) Level I Trauma Center and Level III Neonatal Intensive Care Unit

Wilmington Hospital (290 beds)

Concord Health Center

The Rocco A. Abessinio Family Wilmington Health Center Center for Advanced Joint Replacement

Eugene du Pont Preventive Medicine & Rehabilitation Institute

Helen F. Graham Cancer Center & Research Institute

Center for Rehabilitation

Middletown Emergency Department

Roxana Cannon Arsht Surgicenter

Middletown Care Center

Center for Translational Cancer Research

Swank Memory Care Center

Smyrna Health & Wellness Center

First State School

Rehabilitation Services

Wilmington Hospital Gateway Building

School-Based Health Centers

Center for Heart & Vascular Health

John H. Ammon Medical Education Center Virtual Education & Simulation Training Center Christiana Care Breast Center

HealthCare Center at Christiana

Imaging Services

Christiana Care Surgicenter

Primary Care Centers (in DE, PA and NJ)

Medical Arts Pavilion

Alzheimer’s and Dementia Day Programs Home Health & Community Services – Visiting Nurse Association

*Rankings by American Hospital Association survey database for fiscal year 2013.

Christiana Care Health System

CHRISTIANA HOSPITAL

WILMINGTON HOSPITAL

CENTER FOR HEART & VASCULAR HEALTH

HELEN F. GRAHAM CANCER CENTER & RESEARCH INSTITUTE

CONCORD HEALTH CENTER

SMYRNA HEALTH & WELLNESS CENTER

MIDDLETOWN EMERGENCY DEPARTMENT

Best of the best. For the fourth time, Christiana Care Health System ranks among the â&#x20AC;&#x153;best of the bestâ&#x20AC;? hospitals in the nation based on independent comparison of quality data, value and performance.

*American Hospital Associations survey of more than 6,000 U.S. hospitals.

To learn more about Christiana Care visit: news.christianacare.org P.O. Box 1668 Wilmington, Delaware 19899-1668 800-693-CARE (2273)

www.christianacare.org

facebook.com/christianacare twitter.com/christianacare flickr.com/christianacare youtube.com/christianacare pinterest.com/christianacare

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. 16PERF18