Quality & Safety Report 2019

Quality & Safety

REPORT

2019

Quality & Safety

REPORT

2019

Achievements 2 High Reliablity

4

Patient & Caregiver Safety

16

Clinical Pathways

20

Population Health

28

Health Equity

32

Exceptional Experience

34

The Christiana Care Way Awards

36

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.

We Serve Together guided by our values of Excellence and Love We commit to being exceptional today and even better tomorrow.

We anticipate the needs of others and help with compassion and generosity.

We seek new knowledge, ask for feedback, and are open to change.

We embrace diversity and show respect to everyone.

We use resources wisely and effectively.

We listen actively, seek to understand and assume good intentions.

We are curious and continuously look for ways to innovate.

We are true to our word and follow through on our commitments.

We tell the truth with courage and empathy.

We accept responsibility for our attitudes and actions.

Quality and Safety Exceptional Today and Even Better Tomorrow

At Christiana Care, our commitment to quality and safety starts with this unifying statement: We serve together, guided by our values, Excellence and Love.

Excellence is in our DNA. Our commitment to being exceptional today and even better tomorrow focuses us on high reliability, best practices and reducing unnecessary variability in care. We carefully consider and implement innovative approaches to quality on the path to greater value.

We also serve with love. When we listen, learn and understand the people we serve — what they want, what they need and the barriers they may face as they try to achieve their personal health goals — we can deliver the highest quality care that yields the safest, most effective outcomes. We’ve learned that when we serve with love, excellence is inevitable.

Serving together, our 12,000 caregivers pursue continuous improvement, always driving toward a zero harm environment where every person in our care can achieve the best possible outcome.

because we get the fundamentals right and we are willing to do the hard work to further improve.

We earn national recognition for these outstanding efforts. Quality and safety are our foundation for delivering the right care, at the right place, at the right time, with the right people partnering together to make it work.

When patients tell me the many ways we make a difference in their lives, I know we have served them well. Making a positive impact on our patients’ health is the sum of many interactions, as our caregivers work together to deliver high quality, safe care with thoughtfulness, compassion and respect for every patient and family.

In the pages that follow, you’ll have the opportunity to read about caregiver-driven improvements that exemplify our quality and safety efforts every day at Christiana Care — and the many ways our actions make a lasting impact on the health of our patients and community.

As a health system intently focused on quality and safety, we successfully meet our goals — and often surpass them — JANICE E. NEVIN, M.D., MPH PRESIDENT AND CHIEF EXECUTIVE OFFICER

CHRISTIANACARE.ORG

1

Quality & Safety Achievements

2018

2018

2

QUALITY & SAFETY REPORT

Leading the nation — again!

Christiana Care continued its sweep of awards for excellence in hospital care and patient safety, including recognitions from Becker’s Hospital Review, Healthgrades, Newsweek and U.S. News. & World Report.

Of special note: Out of more than 4,500 hospitals in the U.S., Christiana Care was one of only 29 this year to achieve the highest ratings in every common condition or procedure in U.S. News & World Report’s Best Hospitals rankings. This is the third consecutive year we have earned that distinction — a record only 14 hospitals in the country have achieved. Christiana Care was also recognized as the best hospital in Delaware and was ranked No. 3 among the 90-plus hospitals in the Philadelphia region.

The conditions and procedures ranked are: • • • • • • • • •

Colon cancer surgery.

Lung cancer surgery.

Chronic obstructive pulmonary disease.

Heart failure.

Heart bypass surgery.

Aortic valve surgery.

Abdominal aortic aneurysm repair.

Knee replacement.

Hip replacement.

“Three areas of focus helped drive these achievements: caregiver engagement, standardized care and data-driven accountability.”

Facts & Figures ADMISSIONS

BIRTHS

OUTPATIENT VISITS

EMERGENCY DEPARTMENT VISITS TOTAL

CAREGIVERS

LAB TESTS

52,339

603,922

11,856

VOLUNTEERS

1,145

6,115

195,998

3,526,159 SCHOOL-BASED HEALTH CENTER’S STUDENT VISITS

26,717

SURGICAL PROCEDURES

RADIOLOGY PROCEDURES

PRIMARY CARE PHYSICIAN OFFICE VISITS

ALZHEIMER’S DAY PROGRAM VISITS

HOME HEALTH VISITS

MEDICAL AID UNIT VISITS

37,634

231,064

419,056

5,597

− − KENNETH L. SILVERSTEIN, M.D., MBA CHIEF CLINICAL OFFICER AND EXECUTIVE VICE PRESIDENT

288,685

74,191

CHRISTIANACARE.ORG

3

High Reliability JOURNEY TO ZERO

Preventable harm rate continues to improve Christiana Care’s focus on eliminating preventable harm continues with the adoption of evidence-based guidelines, best practices and care standardization.

Seventy-eight fewer patients experienced preventable harm in FY 2019 (as of April 2019), compared to the same period in FY 2018 — a 16% reduction in supporting our journey to zero preventable harm.

Preventable Harm Rate

E

S I R E

N

D

D

D

Harm per 1000 patient days

5

4

R

E C T I

O

I

Harm Rate Trend

3

2

1

Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Apr-17 Jul-17 Oct-17 Jan-18 Apr-18 Jul-18 Oct-18 Jan-19 Apr-19

4

QUALITY & SAFETY REPORT

Preventable harm rate is

down 16%

since FY 2018.

Hospital-acquired infections down overall

HAIs decrease since 2018

Hospital-acquired infections (HAI), which lead to increased mortality and morbidity, prolonged hospital stays and higher costs of care, remain among our highest priorities in our journey to zero preventable harm.

↓37%

Compared to the same period in FY 2018, there have been 47 fewer patients with HAIs in FY 2019 — a 22% decrease. Improvements this fiscal year include a 37% decrease in Clostridium difficile (C. difficile) infections; a 26% decrease in catheter-associated urinary tract infections (CAUTI); an 11% reduction in central lineassociated bloodstream infections (CLABSI); and a 25% reduction in methicillin-resistant staphylococcus aureus (MRSA) bacteremia. Incidence of surgical site infections for both colon and hysterectomy procedures was similar to FY 2018. Opportunities for improvement are in surgical site infections for cesarean sections.

Clostridium difficile (C.difficile) infections

↓11%

Central-line-associated bloodstream infections (CLABSI)

↓26%

Catheter-associated urinary tract infections (CAUTI)

↓25%

Methicillin-resistant staphylococcus aureus (MRSA) bacteremia

Hospital-Acquired Infections

↓22%

Hospital-acquired infections (HAI)

-40 -3 -7 +1 +8

E

S I R E

D

D

D

N

-1 R

E C T I

O

I

-6 +1

Number of Infections

■ FY 2018 (Jul-Apr)

■ FY 2019 (Jul-Apr)

CHRISTIANACARE.ORG

5

Clostridium difficile

Number of Infections

O

E C T I

Risk score & real time analytics

18

12

C-Di cile Infections

E

Apr-19

Jan-19

Oct-18

Jul-18

Apr-18

Jan-18

Oct-17

Jul-17

Apr-17

Median

Rolling 12 months

S I R E

N

D

D

D

R

E C T I

O

I

Jan-17

Oct-16

Jul-16

Apr-16

Jan-16

Oct-15

Jul-15

Jan-15

Apr-15

6

7

CAUTI

6

Number of Infections

R

Appropriate Testing Initiative

24

Catheter-Associated Urinary Tract Infections

Efforts to reduce CAUTI focused on standardized insertion and maintenance of foley catheters, as well as the prompt removal of foleys when they no longer meet evidencebased criteria for use. Between July and April, there were seven fewer cases in FY 2019 compared to the same period in FY 2018 — a 26% decrease.

5 4 3 2

CAUTI

Median

QUALITY & SAFETY REPORT

Rolling 12 months

Apr-19

Jan-19

Oct-18

Jul-18

Apr-18

Jan-18

Oct-17

Jul-17

Apr-17

Jan-17

Oct-16

Jul-16

Apr-16

Jan-16

Oct-15

Jul-15

Apr-15

Jan-15

1

6

N

D

I

30

Real-time analytics give a better understanding of antibiotic utilization and proton pump inhibitor use, and support targeted interventions.

0

S I R E

D

In FY 2018, an interdisciplinary tiger team focused on improving appropriate testing to identify hospital-acquired C. difficile infections. In FY 2019, Christiana Care experts developed a risk score to predict a positive C. difficile test.

The median decreased from 14 to 9 with the tiger team; additional efforts in FY 2019 decreased the median to 6.5. There were 40 fewer cases in FY 2019 (July - April) compared to the same period in FY 2018 — a 37% reduction.

E

D

C. difficile

Foley utilization rates have decreased 30% since 2016.

Driving down the CLABSI rate

Central Line-Associated Bloodstream Infections (Non-Mucosal Barrier Infections)

E

S I R E

D

D

94 days without a CLABSI as of June 24, 2019

2.0

E C T I

Apr-19

Mar-19

Jan-19

Feb-19

Dec-18

Oct-18

Nov-18

Sep-18

Jul-18

Aug-18

Jun-18

Apr-18

May-18

Mar-18

Jan-18

Feb-18

Dec-17

Oct-17

0.0

Nov-17

0

Sep-17

0.5

Jul-17

2

Aug-17

1.0

Jun-17

4

Apr-17

1.5

May-17

6

Christiana Care’s CLABSI rate decreased from 1.2 in 2017 to 0.7 in 2018. While below the national average of 0.8 infections per 1,000 line days, we continue to focus on improvement.

CLABSI Rate (# per 1,000 line days)

N R

O

I

CLABSI Rate CLABSI Rate: 6-Month Moving Average CLABSI

Mar-17

Number of CLABSI (Non-MBI)

D

8

Preventive measures such as disinfecting port protectors and hemodialysis catheter caps — along with the help of unit-based CLABSI champions — now drive best practices to reduce CLABSI at Christiana Care.

Procedure care bundle eliminates Tracheostomy-Related Pressure Injuries in 2018 An interprofessional bundled approach that drives care standardization and reduces variation in nursing, respiratory and provider practice helped Christiana Care sustain the elimination of tracheostomy-related pressure injuries (TRAPI) through calendar year 2018.

Tracheostomy-Related Pressure Injuries

E

N

D E C T I

O

R

3

3

1

Dec-18

Oct-18

Nov-18

Sep-18

Aug-18

Jul-18

Jun-18

May-18

Apr-18

Mar-18

Feb-18

Jan-18

Dec-17

Nov-17

Oct-17

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Sep-17

Apr-17

0 May-17

Mar-17

Feb-17

Jan-17

Dec-16

Nov-16

Oct-16

Sep-16

Jul-16

0 0 0

Aug-17

1 1

Jul-17

1

2

0 Jun-16

Apr-16

May-16

0 0 Mar-16

Jan-16

0 0

1

Aug-16

1

1

2

Jun-17

2

2

Feb-16

Number of Injuries

D

D

I

4

0

S I R E

CHRISTIANACARE.ORG

7

Zero Harm Awards Christiana Care’s Zero Harm Awards program recognizes patient care unit’s achievement of no preventable patient harm in 12 consecutive months for any single harm measure. Seventeen units are now in their fifth year without harm, led by the Center for Advanced Joint Replacement at Wilmington Hospital, which has achieved five years of zero harm in the categories of CAUTI, C. difficile and MRSA.

Catheter-Associated Urinary Tract Infection (CAUTI) 12

MONTHS

24

MONTHS

2E/Cardiovascular Critical Care 5D Medical

Methicillin-Resistant Staphylococcus Aureus (MRSA) 12

MONTHS

5B Medical 8S Acute Care for the Elderly

6E Oncology

Medical Intensive Care

3M Medical

Transitional Surgical

5B Medical

5D Medical

6B Medical

6S Wilmington Intensive Care 4N Medical

4C Surgery/GYN

Neuro Critical Care

5C Medical

6E Medical Oncology

6C Stroke Treatment and Recovery

2E Cardiovascular Critical Care

6S Wilmington Intensive Care 24

36

MONTHS

48

MONTHS

Transitional Medical

MONTHS

7E Spine/Joint Replacement Bone Marrow Transplant

36

MONTHS

3B/3C/4B Maternity/Well Mom & Baby MONTHS

3M Medical 6B Oncology

4N Medical

60

4D Surgery Stepdown

4C Surgery/GYN 6A Acute Care for the Elderly 7E Spine/Joint Replacement 2C Ortho/Neuro/Trauma Surgery

7S Center for Advanced Joint Replacement

4C Surgery/GYN 60

MONTHS

7E Spine/Joint Replacement 7S Center for Advanced Joint Replacement 3A Antenatal 3B/3C/4B Maternity/Well Mom & Baby Neonatal Intensive Care 6W Center for Rehabilitation 4A Pediatrics/GYN

8

QUALITY & SAFETY REPORT

Clostridium Difficile (C. difficile) 12

MONTHS

4N Medical 7E Spine/Joint Replacement Surgery

Falls with Major Injury 12

MONTHS

6W Center for Rehabilitation Christiana Medical Observation

6B Medical

4A Pediatrics/GYN

Transitional Surgical

6E Medical Oncology 6S Wilmington Intensive Care

24

MONTHS

3B/3C/4B Maternity/Well Mom & Baby 6C Stroke Treatment and Recovery

24

MONTHS

6W Center for Rehabilitation 36

MONTHS

5A Medical 6B Medical Surgical Critical Care

7N Psychiatry

6C Stroke Treatment and Recovery 6A Acute Care for the Elderly

60

MONTHS

4A Pediatrics/GYN

7N Psychiatry

7S Center for Advanced

3M Medical

Joint Replacement

4E Cardiac Stepdown 5B Medical

Central Line-Associated Bloodstream Infections (CLABSI) 12

MONTHS

3 Medical

2E Cardiovascular Critical Care 36

MONTHS

6B Medical 4E Cardiac Stepdown 6C Stroke Treatment and Recovery

48

MONTHS

Neuro Critical Care 6S Wilmington Intensive Care Transitional Surgical 24

MONTHS

60

MONTHS

2C Surgical 5C Medical Middletown Emergency Department Medical Intensive Care 5E Heart Failure

4W Surgical

7E Spine/Joint Replacement Wilmington Intensive Care

6A Acute Care for the Elderly 48

4N Medical

Transitional Medical

3A Antenatal Transitional Neuro

MONTHS

5D Medical

Cardiac Short Stay 4C Surgery/GYN

8S Acute Care for the Elderly

4D Surgery Stepdown

7E Spine/Joint Replacement

Transitional Surgical

7S Center for Advanced Joint Replacement

3A Antenatal Stepdown

2C Surgery 6W Center for Rehabilitation

All Falls 12

Transitional Surgical

36

Neonatal Intensive Care

MONTHS

MONTHS

CHRISTIANACARE.ORG

9

The Christiana Care Antimicrobial Stewardship program continued to combat antimicrobial resistance and complications such as C. difficile infection by promoting appropriate, judicious antimicrobial use in FY 2019.

The efforts led to an 11% reduction in broadspectrum antibiotic use at both Christiana and Wilmington hospitals in the last five years.

Fluoroquinolone use is down 70% and aztreonam use has decreased by 43% thanks to provider education, prospective audit and feedback, as well as a clinical decision support tool to assist Emergency Department clinicians with beta lactam allergy assessments.

High-Risk Antibiotic Days of Treatment/1,000 Patient Days Christiana and Wilmington Hospitals

E

S I R E

D

D

D

N

Medication Safety — Antimicrobial Stewardship Program decreases antibiotic use by 11%

Days of Treatment per 1,000 Patient Days

R

E C T I

O

I

↓11%

UCL

since January 2014

Mean

1 6

LCL

7 8

4

9 10

3

2

Intervention Legend

5

1. Restructure of Antibiotic Stewardship Program focusing on education 2. Urinary tract infection and days of treatment at discharge guideline adherence project 3. Pneumonia first dose in Emergency Department clinical decision support 4. Duration added to select singleton orders 5. Drug shortages: piperacillin/tazobactam, carbapenems

11

6. Antibiotic Stewardship Program quarterly lectures 7. Urinary tract infection, first dose in Emergency Department clinical decision support 8. U.S. Food and Drug Administration warning on fluroquinolone and urinary tract infection guidelines update 9. Agency for Healthcare Research & Quality Antibiotics Time Out safety program — 6A and Surgical Critical Care 10. Gastroenterology/Radiology collaboration 11. Antibiotic Indication Project

High-risk antibiotics include: aztreonam, cefepime, ceftaroline, ceftazidime, ceftriaxone, ciprofloxacin, daptomycin, doripenem, ertapenem, imipenem/cilastatin, levofloxacin, linezolid, meropenem, moxifloxacin, piperacillin/tazobactam and vancomycin.

Source: University Health System Consortium (UHC)

10

QUALITY & SAFETY REPORT

49% Total Antibiotic and Azithromycin Utilization per 100 Patient Visits — Medical Aid Units

E

S I R E

N

D

D

D

R

Total Azithromycin / 100 Visits

E C T I

O

I

80

reduction in total antibiotic use

Total Antibiotics / 100 Visits

70

Start of Antibiotic Stewardship Efforts

88%

50

reduction in azithromycin use

40

30

20

2016

APR

MAY

MAR

FEB

JAN

DEC

NOV

SEP

OCT

JUL

2018

AUG

JUN

APR

MAY

FEB

MAR

JAN

DEC

NOV

SEP

OCT

JUL

2017

AUG

JUN

APR

MAY

FEB

MAR

JAN

0

DEC

10

NOV

Perscriptions per 100 Visits

60

2019

Source: Health Catalyst

CHRISTIANACARE.ORG

11

Survey says … our culture of safety is “very good” to “excellent”

Created by the Agency for Healthcare Research and Quality (AHRQ), the Hospital and Medical Office Surveys on Patient Safety Culture: • Measure conditions that can lead to adverse events and patient harm.

• Raise caregivers awareness about patient safety.

• Reveal and assess the current status of patient safety culture.

• Identify strengths and areas for patient safety culture improvement.

• Evaluate trends in patient safety culture over time.

• Evaluate the cultural impact of patient safety interventions.

Key takeaways: • More than 72% of respondents rated our culture of safety as very good or excellent.

• Top strengths: teamwork within units and organization learning exceed the national teaching benchmark.

We Serve Together every day

365 Stand Up for Patient Safety Huddles in 2018 Management support for patient safety is a top priority at Christiana Care. Every day at 9 a.m., frontline leaders huddle together to increase situational awareness of safety issues across the organization.

12

QUALITY & SAFETY REPORT

6,086 caregivers participated in the 2019 Hospital and Medical Office Surveys on Patient Safety Culture — a 37% increase from 2017 participation rates.

These learnings provide critical guideposts to help us identify strengths and discover areas for continuous improvement as we serve together, guided by our values, Excellence and Love.” − − MICHELE CAMPBELL, MSM, RN, CPHQ, FABC VICE PRESIDENT, QUALITY AND PATIENT SAFETY

118

Patient Safety Leadership WalkRounds

Safety WalkRounds generate ways to make care safer Christiana Care continued the nationally recognized Institute for Healthcare Improvement best practice of Patient Safety Leadership WalkRounds to enhance patient safety by promoting an environment where frontline caregivers feel comfortable speaking up and sharing safety concerns.

Senior leaders conducted 118 weekly rounding sessions in calendar year 2018, asking caregivers:

Safety WalkRounds led to improvements including:

• What three things are going well to prevent patient harm?

• What keeps you up at night?

• What worries you — any unsafe conditions?

• What are the safety risks in your department?

• When will the next safety event occur? What will it be?

• Is there anything we can do to prevent the next safety event? Are there barriers?

✓✓ Replaced stretchers that lack oxygen tank holders. ✓✓ Adopted standard documentation language for central lines on patients with known drug abuse. ✓✓ Rooms cleaned between procedures in interventional CT scan. ✓✓ Addressed speed of elevator door closing with stretchers. ✓✓ Eliminated unnecessary cabinet obstructions.

Safety WalkRounds Positive Items Reported Jan 2018 - Jan 2019

E

S I R E

100

I

R

E C T I

O

100

N

D

D

Number of Positive Items Cumulative Percent of Total

D

100

75

76.4 62.9

50

50 44.2

25

25

24.7

p sh i er ad

in i /T ra St

a

ng

0

Le

n io om

37

C

ul

tu

re /P

sy

C

ic og ol ch

m

al

un

ic

Sa

at

fe

en ui Eq t/ en nm En vi ro

49 ng

49

pm

ed Pr oc y/ lic

68 t

ur e

71

ty

90

0

Cumulative %

75

Po

# Positive Items Reported

89.8

CHRISTIANACARE.ORG

13

Christiana Care helps expand national treatment guidelines for patients with acute stroke RAPID CT perfusion extends lifesaving window by 18 hours Christiana Care contributed to groundbreaking research that compelled the American Heart Association / American Stroke Association to release new guidelines in 2018 extending the window for life-saving mechanical thrombectomy treatment from six hours up to 24 hours.

Using RAPID CT perfusion brain imaging software, neurointerventional specialists can now accurately determine whether a patient still has enough salvageable brain tissue to benefit beyond conventional time frames from a minimally invasive procedure called mechanical thrombectomy to remove the blood clot that is causing the stroke.

This capability is particularly important for patients who experience what is called a “wake-up stroke” — who seem fine before bed but wake up more than six hours later with stroke symptoms. Without knowing when the stroke actually began, and before the benefits of RAPID brain imaging, neuro specialists had limited reliable information to weigh the benefits versus risks of mechanical thrombectomy.

172 patients had RAPID CT perfusion at Christiana Care.

The Joint Commission recognized Christiana Care as a 2018 Pioneers in QualityTM eCQM Proven Practices solution contributor for research on "Improving Stroke Outcomes Through an Interdisciplinary Approach to eCQMs." The Proven Practices program promotes peer-to-peer learning in the use of electronic Clinical Quality Measures (eCQMs) and health information technology for quality improvement.

44 of those patients

benefitted from mechanical thrombectomy to remove the clot in the extended treatment window.

National Patient Safety Awareness Week — 200+ caregivers discover key ways to put patient safety first Christiana Care’s Patient Safety Week 2019 included safety fairs, contests, poster and library displays, social media and a presentation by Craig Clapper, PE, CMQ/OE, a nationally recognized expert in patient safety and high reliability.

14

QUALITY & SAFETY REPORT

Visiting Nurse Association achieves marked decrease in pressure injuries Christiana Care Visiting Nurse Association (VNA) achieved a 64% decrease in pressure injuries this year among home health patients.

Consistent skin assessment, use of the evidence-based Braden Scale risk predicting tool to assess a patient's risk of developing pressure ulcers, and activities such as repositioning every two hours, keeping skin clean and dry to help reduce skin breakdown and visually inspecting pressure points helped lead to the improvement.

Also driving VNA’s strategies for success are an increase in the number of occupational therapists, enhanced education for the VNA nursing team on when to add occupational therapy services, consistent wound and skin assessment education for VNA field caregivers, consultation by wound-certified nurses and increased awareness of the importance of data elements and reporting accuracy. Pressure injuries are of particular concern for patients with limited mobility, those who are wheelchair bound, those whose skin is exposed to moisture due to incontinence, those who do not eat or drink adequately and patients with poor skin turger, or elasticity.

Pressure Injuries Among Home-Health Patients

Number of Events

Total # pressure injury events

A Team Approach: ✓✓ Nutrition education and management of diabetes highlighted during nursing visits. ✓✓ Occupational therapists teach patients how to reposition into pressure-relieving positions every two hours, and self-care skills to keep the skin clean and dry to prevent breakdown. ✓✓ Physical therapists promote increased strength and functional mobility within the home setting. ✓✓ Home health aides help identify areas of risk during personal care treatment. ✓✓ Wound-certified nurses available for consultation on any patient with a pressure injury.

15

fewer pressure injuries from 24 events in 2017 to 9 events in 2019

E

S I R E

N

Number of Infecitons

D

D

D

Number of CLABSI

R

E C T I

O

I

CLABSI Rate

CLABSI Rate (Percent per 1,000 Line Days)

Reduction in Central Line-Associated Bloodstream Infections — Visiting Nurse Association

VNA kicks off 2019 with zero CLABSI

Through sustained, coordinated efforts to standardize clinical practice and supplies for central line care during home visits, Christiana Care VNA continues to decrease central lineassociated bloodstream infections (CLABSI).

Improved central line-care knowledge by field nurses and improved patient education about self-care helped reduce the number of CLABSI from 20 cases per 1,000 line days in 2015 to fewer than two cases per 1,000 line days in 2018. That number plummeted to zero cases in the first quarter of 2019.

CHRISTIANACARE.ORG

15

Patient & Caregiver Safety

Recordable Injury Rate Trend

Injuries per 100 full-time equivalents

Injury Rate (# per 100 FTE)

QUALITY & SAFETY REPORT

N

D

O

5 4 3

6.71 5.65

5.78

5.01

4.93

FY14

FY15

2

4.48

4.95

4.5

4.2

1

FY11

FY12

FY13

Recordable Injury Rate

FY16

FY17

FY18

FY19 YTD

National Average for Hospitals

Safe Patient Handling Recordable Injuries

Due to Falling Patients, Transferring/Lifting, Repositioning

47

FY15

E

S I R E

N

I

R

E C T I

O

41

FY16

37

FY17

Excluding VNA/Outpatient Satellites - Field/Atypical Non-

35

FY18

Specific-Event-Type Categories (Sustained Awkward Postures, Repetitive Tasks, Push-Pull

FY19 (Jul - Apr)

Stretchers and Beds)

26 Number of Injuries

16

E C T I

D

The Needlestick Safety Team continues to pilot new needlestick safety technology, as well as hardwiring needlestick safety education into the training for new and existing caregivers.

R

6

D

Occupational Safety, in coordination with Facilities & Services, continues to implement interior and exterior initiatives, such as spill stations, cord management, slip-resistant flooring, ice-alert signs, heated entrance ramps, brine application, ice melt and use of shuttles to move caregivers from parking lots to buildings during inclement weather to prevent slip, trip and fall injuries.

I

7

D

Between July 1, 2018 and April 26, 2019, there were 159 needlestick/sharp injuries, compared to 131 for the same time period in FY 2018. There were 58 recordable work-related injuries from slips, trips and falls between July 1, 2018 and March 31, 2019, compared to 48 for the same time period in FY 2018.

D

Christiana Care’s recordable injury rate at the end of the third quarter of FY 2019 remained well below the national average for hospitals. FY 2018 and FY 2019 rates show a slight upward trend primarily due to increases in needlestick and sharp injuries, slips, trips and falls, and physicaldemands injuries.

S I R E

D

Caregiver recordable injury rate remains well below national hospital average

E

Christiana Care’s Adult Epilepsy Monitoring Unit is one of the few in the U.S. to feature patient lifts to prevent falls.

Fit Stop: Warm Up and Stretch Program A six-month warm-up and stretch pilot program helped caregivers in Textiles Services, Environmental Services and Patient Escort reduce chronic muscle and joint pain, increase energy, flexibility and feelings of strength, achieve better balance and reduce the number of needed rest periods due to tiredness on the job. A partnership of the Employee Fitness Center, the Office of Safety and Emergency, Textiles Services and Environmental Services, the Fit Stop project provides time-efficient exercises at the beginning of every shift that employees can perform independently or as a group.

While injury data did not support a definitive conclusion on the effectiveness of the program, caregivers surveys conducted during the program indicated reductions in pain and increases in strength, energy, balance and flexibility.

Christiana Care opens first epilepsy monitoring unit in Delaware Christiana Care opened the first Adult Epilepsy Monitoring Unit in Delaware, increasing access to the safest possible advanced neurological care. While most patients with epilepsy are successfully treated by a general neurologist or epileptologist, a significant number of patients have persistent fainting or seizure episodes, or have unwanted side effects from medications.

Specially outfitted private hospital rooms in the Transitional Neuro Unit at Christiana Hospital provide state-of-the-art equipment for video and audio monitoring. Brain waves are tracked with electroencephalography (EEG) and electrical activity in the heart is recorded with electrocardiography (EKG), helping clinicians understand what is happening during a seizure.

To further enhance safety, nurses assist patients at all times.

Patients wear a mobility vest that connects to an overhead lift whenever they are out of bed. This prevents them from falling to the floor if they have a seizure while moving around the room.

Thanks to mobility vests and patient lifts, the unit fall rate is less than

1%

CHRISTIANACARE.ORG

17

Center for Provider Wellbeing supports caregivers in caring for others A growing body of evidence demonstrates that clinicians who are supported and feel fulfilled in their work can do their best to provide the highest quality care for their patients. Christiana Care’s Center for Provider Wellbeing spearheads efforts to improve clinicians’ personal wellbeing by promoting a culture that fosters joy and meaning in work.

The Center hosts programs tailored to support health and wellbeing, enabling caregivers to care for others, stay energized and to feel good about the exceptional work they do every day. Of note, Christiana Care was one of 34 academic medical centers selected to participate in the 18-month National Initiative VI: Stimulating a Culture of Well-Being in the Clinical Learning Environment, sponsored by the Chicago-based Alliance of Independent Academic Medical Centers.

Programs & Services

45 trained peer support persons

10 OASIS rooms for caregiver rejuventation

8 Mindfulness Workshops

Executive coaching services — 100+ 1:1 session conducted

Reflective Rounds — 15-20 participants each month

Women’s Physician Leaders Coaching Group — 12 attendees monthly

4 Paws to De-stress events each quarter, averaging more than 100 attendees each

Resilient Leaders Series — 20-25 attendees quarterly

Writing as Healing Workshops — 6-10 attendees monthly

Vital Worklife™ — 384 contacts supporting 98 providers/family members (955 uses of the mobile app/web)

Care for the Caregiver Since its inception in 2015, the Care for the Caregiver Program, which offers 24/7 peer support to Christiana Care health professionals experiencing stress following an adverse patient event, has supported hundreds of colleagues.

18

QUALITY & SAFETY REPORT

Report2Learn takes event reporting to whole new level

5,366 2,408

Medication

1,683

Fall (Patient or Visitor) Lab/Pathology

1,359

IV/Vascular Access Device

1,357 1,028

Surgery/Procedure

699

Skin/Tissue

681

Good Catch

502

Maternal/Childbirth

462

Medical Imaging/Radiation Oncology

442

Adverse Drug Reaction

175

Airway Management

128

Healthcare IT

125

Blood Product

E

I

73

Critical Care Transportation

3

HIMS MR Review

3

S I R E

N

Equipment/Supplies/Medical Device

D

Phase II R2L implementation will focus on enhancing accessibility, reporting capability and data analytics to make it even easier for caregivers to report safety concerns.

Event Type Care and Treatment

D

As a result of reported safety events, a number of strategies aimed at prevention of harm to patients, as well as system enhancements and actions, have been implemented.

May 2018 - April 2019 (Total n = 16,488)

R

E C T I

O

Since its implementation, there have been, on average, about 1,400 reports per month with 79% and 80% being reported as “no harm” to our patients. The number of “good catches” consistently averages about 330 per month, indicating that caregivers are identifying and reporting potential safety risks that are able to be corrected before they reach the patient.

Type of Reported Safety Events

D

Christiana Care advanced its journey to zero preventable harm with the launch of Report2Learn (R2L), a next-generation online event management platform that elevates patient and caregiver event reporting to a whole new level.

Number of Events

Early identification and reporting through R2L enable us to activate the Communications and Optimal Resolution (CANDOR) process to evaluate serious safety events that may have contributed to permanent harm or death. The analysis often allows us to make system improvements that can prevent a recurrence, making us exceptional today and even better tomorrow.

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CARE STANDARDIZATION

Clinical Pathways

Ensuring the right care for every patient, at the right time and place, with the right people involved.

To create healthier communities, our Optimal Health goals center on high reliability and relationship-centered approaches. Guided by the strategic goals in our Annual Operating Plan, Christiana Care is implementing highly reliable care standards across all service lines and essential services, with a focus on five key chronic conditions: congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and substance use disorder.

■ Acute — Continuous supply of opioid medications of 30 days or less.

S I R E

N

D R

E C T I

O

I

1500

Number of Patients

OPIOID USE

E

D

A multi-pronged strategy aimed primarily at reducing opioid prescribing has led to a steady reduction across all categories of opioid use, with the largest reduction in the Acute category.

Patients by Opioid Use Category

D

Substance Use Disorder — Opioid prescriptions decline steadily

1000

500

20

QUALITY & SAFETY REPORT

2019-Mar

2019-Feb

2019-Jan

2018-Dec

2018-Nov

2018-Oct

2018-Sep

2018-Aug

2018-Jul

2018-Jun

2018-May

2018-Apr

2018-Mar

0

2018-Feb

■ Chronic — Continuous supply of opioid medications of greater than 120 days.

2018-Jan

■ Sub-acute — Continuous supply of opioid medications of 31 to 121 days.

Opioid Prescriptions Over Time

S I R E

E

N

D

D

D

E C T I

2000

1500

1000

2019-Mar

2019-Feb

2019-Jan

2018-Dec

2018-Nov

2018-Oct

2018-Sep

2018-Aug

2018-Jul

2018-Jun

2018-May

2018-Apr

2018-Mar

0

2018-Feb

500

2018-Jan

Number of Prescriptions

R

O

I

2500

Embedded pathways for opioid alternatives for pain, coupled with partnerships among key specialties regarding optimal post-surgical pain management, drives a steady decline in the number of prescriptions for opioids.

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Diabetes — Point-of-care retinal cameras provide radical convenience for detecting diabetic retinopathy

Retinal Camera Exam

More than 70% of identified patients with retinopathy had mild severity.

22

QUALITY & SAFETY REPORT

S I R E

N

D

D

E C T I

All Pilot Sites

200

HealthCare Center at Medical Arts Pavilion 2

129

77

R

O

I

As part of our care standardization efforts aligned with a goal of radical convenience for our patients with diabetes, retinal cameras were embedded in four primary care practices to improve overall eye exam screening. This allows images to be taken in the primary care office and reviewed remotely by ophthalmologists.

Screening rates increased in three of the four pilot sites.

Nearly 20% of the exams revealed abnormalities that required further evaluation.

E

(Sep 2018 - May 2019)

D

Diabetes is the leading cause of preventable blindness.

The American Diabetes Association recommends patients with Type 2 diabetes be screened for retinopathy annually.

The earlier diabetic retinopathy is detected, the greater the number of available treatment options at a much lower cost.

Nationally, retinopathy screening is quite low, in part due to limited access to ophthalmologic care and also due to limited follow-up by patients.

Family Medicine Center at Foulk Road

33

Limestone Medicine and Pediatrics

30

Wilson Primary Care

Number of Exams

Diabetes registry supports focus on improving A1c control A diabetic registry implemented at the Concord, Limestone, Smyrna and Wilson primary care pilot sites enables the practices to proactively identify and target patients whose blood sugar is uncontrolled (hemoglobin A1c>9) or who have no recent A1c test on file.

The work also fosters collaboration between Primary Care and Endocrinology to co-manage patients through group visits and collaborative case discussions, and increases referrals to Behavioral Health for identified stressors impacting diabetes control.

Patients with Diabetes â&#x20AC;&#x201C; Current A1c < 9

E

S I R E

N

D

D

D

100%

R

E C T I

O

I

% of Population

80%

62%

by caregiver and provider engagement

90%

70%

Proactive outreach

65%

67%

70%

72%

72%

72%

74%

76%

in the four pilot sites increased A1c control from 62% to 76%.

60%

A1c < 9 Goal

50%

Baseline Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

Apr-19

May-19

Primary Care & Community Medicine Service Line launches improvement collaborative Success in driving population health outcomes will require a deliberate approach to quality improvement in the ambulatory environment. In FY 2019, the Primary Care & Community Medicine Service Line partnered with The Christiana Care Institute for Learning, Leadership & Development to create a collaborative driving projects in three core areas (shown at right) across 14 practices.

The collaborative involved five intensive workshops for clinical and operational leaders of each practice, as well as a structured curriculum and milestones for engaging the practice in an improvement journey using the PDCA model. The Diabetes A1c Control project (highlighted above) deployed a chronic disease registry and concierge partnership with Endocrinology. The Emergency Department Utilization and Transitions of Care projects targeted the accountable care organization population, in partnership with Carelink CareNow. This work lays the foundation for outcomes that will continue to be monitored in FY 2020.

Diabetes A1c Control

Primary Care Improvement Collaborative ED Utilization

Transitions of Care

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23

Heart failure readmissions trending downward Newly implemented in FY 2019, the Heart Failure Readmission Reduction Program includes daily multidisciplinary huddle review of patients with the highest readmission risk and a discharge bridge clinic that closely monitors best practice medication escalation.

Overall, 30-day, all-cause readmissions for all patients with heart failure as a primary diagnosis is trending downward.

30-Day Inpatient All-Cause Heart Failure Readmission Rate

E

N

D

20.4%

21.8%

22.8%

22.4%

R

23.6% 21.4% 19.3%

18%

16.2%

15.2%

16.9%

16.4% 13.8%

12%

QUALITY & SAFETY REPORT

19-Mar

19-Feb

19-Jan

18-Dec

18-Nov

18-Oct

18-Sep

18-Aug

18-Jul

18-Jun

18-May

6%

18-Apr

E C T I

O

I

24%

18-Mar

Readmission Rate Per 1,000 Patient Days

25.6%

D

24

D

30%

S I R E

What is care standardization?

At Christiana Care, care standardization is an important strategy to achieve optimal health and an exceptional experience of care for each patient, at costs that are affordable.

The work of care standardization begins with key questions: â&#x20AC;˘ What are the most current evidence-based guidelines?

For any disease or condition, guidelines for screening, diagnosis and treatment are continually updated as new information and new technology becomes available.

Ensuring that these evidence-based best practices are applied at every touchpoint is crucial to achieving the best health outcomes for our patients. â&#x20AC;˘ When and where is care needed? We know that our patients want care that is effective, convenient and affordable. Sometimes they might need to receive that care in a hospital or an emergency department, but at other times the primary care doctor's office, a home health care visit or another site of care is the better option.

â&#x20AC;˘ What members of the care team should be involved?

Every patient at Christiana Care has a team of expert caregivers working for them--including many people behind the scenes. By understanding whose skills are needed at each step in the process--and whose are not-we can coordinate to ensure that resources are managed appropriately and each patient benefits from the right expertise at the right time.

Once we know what the most current guidelines are for a given disease or condition, and we understand the right time, right place and right people involved for each step in the care process, then we can begin to identify unnecessary variations in care that might represent ineffective use of resources or interventions that aren't creating any real benefit for the patient. By eliminating these unnecessary variations, we can eliminate waste and reduce the cost of care, and we can reduce inconvenience to our patients or exposure to tests or interventions that they don't need. The end result is better, safer care at affordable costs.

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Supportive care and enhanced care navigation reduce ED visits, hospitalizations and cost of care

A new clinical pathway ensures that patients in curative radiation and chemotherapy treatment, who also receive targeted referrals to needed supportive care and enhanced care navigation, are less likely to require an emergency department visit, hospitalization or readmission within 30 days. The Supportive Care of Oncology Patients (SCOOP) Program has reduced ED visits by 35.2%, hospital admissions by 35.3%, 30-day readmissions by 46.9% and saved an estimated $259,000 by reducing the average cost of care per patient by more than $1,500.

Impact of SCOOP on Hospital Utilization

The pathway was inspired by a landmark study that revealed not only improvement in quality of life, but also a two-month improvement in survival among patients with advanced non-curative cancers receiving supportive care in addition to standard curative care. Our program uniquely applies similar principles to patients undergoing combination chemotherapy and radiation for cure. By aiding nurse navigators in providing more consistent, effective care coordination, the pathway reduces the number of missed appointments, unaddressed nutritional and psychosocial needs and unmanaged symptoms.

E

S I R E

N

D

D

D

R

E C T I

O

I

60% 54%

SCOOP patients were admitted

% of Patients

50%

to the hospital, compared to

40% 32%

35%

34% of the control group â&#x20AC;&#x201D; a 34%

30%

35% reduction.

32% 25%

22%

20%

20%

17%

10%

% Patients with ED visits

26

In its second year, 22% of

% Patients with admission

QUALITY & SAFETY REPORT

% Patients with readmission

TIME pathway reduces NICU admissions

TIME on the road

Christiana Care presented the TIME clinical pathway at the 2018 Pediatric Academic Society Conference in Toronto, the American Nurses Association Magnet National Convention, the Healthcare Information and Management Systems Society New Jersey Delaware Valley Chapter conference, the Pennsylvania Safety Summit, the Pediatric Perspective conference and to the Delaware Association of Neonatal Nurses.

Christiana Care's new Triple I to Manage Early-Onset Sepsis (TIME) clinical pathway uses the evidence-based Kaiser Permanente sepsis risk calculator to reduce admissions of term newborns to the Neonatal Intensive Care Unit (NICU). Prior to pathway implementation, 100% of newborns identified as at-risk for early-onset sepsis went to the NICU, had blood cultures and received a minimum of 48 hours of IV antibiotics. The TIME pathway consistently enables more than or greater than 75% of at-risk newborns and their moms to have optimal time to bond on the postpartum unit after delivery.

Labor and Deliveryâ&#x20AC;&#x2122;s recent move to PowerChart Maternity further streamlines the process and tracks performance to standards with integration of the sepsis risk calculator and a newly built compliance report for temperature monitoring every two hours during labor.

E

S I R E

N

D

D

D

R

40%

E C T I

O

I

14

Number of Newborns

12

32%

10

24%

8 6

16%

4

8%

Apr-19

Mar-19

Feb-19

Jan-19

Dec-18

Nov-18

Oct-18

Sep-18

Aug-18

Jul-18

Jun-18

May-18

Apr-18

Mar-18

Feb-18

0

Jan-18

2

% of Newborns with Sepsis Flag

Newborns with Sepsis Flag Direct to NICU after Labor & Delivery

% Newborns with Sepsis Flag Newborns with Flag direct to NICU

0%

25%

fewer newborns at risk for early-onset sepsis require admission to the NICU. CHRISTIANACARE.ORG

27

Population Health

S I R E D

The technology-driven and relationship-based approach to care management has led to high rates of member engagement, with almost 24% of our 100,000 members engaging with the team. Once reached, fewer than 5% of members decline participation.

E

N

30%

D

1. Enhanced transitional care to ensure that the experience is seamless in the transition between inpatient and outpatient settings.

2. Longitudinal disease management to address evidencebased standards of care and prevention goals.

3. Collaboration with physicians, other caregivers and patients to improve quality of care, reduce unnecessary utilization of health care services and reduce expenditures.

Transition of Care Program 30-Day Unplanned Hospital Utilization

I

■ Transition of Care Complete ■ No Transition of Care/Incomplete

25%

R

E C T I

20%

15%

25% 20%

10%

13.2%

5%

30-Day Hospital Return (ED, Observation, Inpatient)

11%

30-Day Readmisson (Inpatient)

Chronic Obstructive Pulmonary Disease The Chronic Obstructive Pulmonary Disease (COPD) Program focuses on evidenced-based standards of care to drive improved outcomes for our members. In the first year, almost 300 members with COPD enrolled in the program and participated for at least 30 days:

28

QUALITY & SAFETY REPORT

• 83% had spirometry testing and were appropriately staged according to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) standard. 50% were either Stage 3 (severe) or Stage 4 (very severe).

• Over 95% of members received flu and pneumococcal vaccinations.

• 15% of the stage 3 or 4 members participated in pulmonary rehabilitation.

• Following program participation, hospital readmissions within 30 days of discharge decreased by 54.3% for stage 3 or 4 members (from 31.3% to 14.3%), and by 12.6% (from 25.6% to 22.4%) for all members.

O

The care coordination “hub” has three key functions:

D

Christiana Care’s national award-winning care coordination program, Carelink CareNow, continues to explore methods for leveraging technology to enhance member engagement and improve outcomes.

Discharge planning support through the Transition of Care (TOC) program increases the likelihood of a patient recovering successfully and avoiding complications and readmissions.

Patients who complete the program have significantly fewer unplanned hospital returns or readmissions, with an estimated cost avoidance of over $2.5 million.

% of Members Discharged

Care coordination technology enhances patient engagement

CARE COORDINATION

Carelink CareNow Community The Carelink CareNow Community program is focused on reducing hospital utilization and improving health outcomes for individuals and families in our community with a combination of social barriers to health and at least one poorly controlled medical diagnosis.

Carelink CareNow Community: Top Interventions Type of Intervention Community Medical Care Transportation Health Education Financial Assistance Housing Programs Other

E

S I R E

D

D

Insurance Coverage

D

I

R

E C T I

O

The Community program has engaged almost 900 members, and succeeded in reducing hospital utilization in the 60 days post-engagement by 56%.

N

Nursing Interventions

Pharmacy/Meds Mental Health Substance Abuse Legal Services Abuse/Neglect Job Search Advance Directives

Number of Interventions

eBrightHealth ACO achieves Delaware’s highest ACO Quality Score By helping participating clinicians and health systems proactively and collaboratively focus on clinical best practices, transitions of care and utilization of community resources, eBrightHealth ACO, an accountable care organization, improved quality of care and achieved costs savings of nearly $2 million for 50,000 regional Medicare beneficiaries in its first two years of operation.

According to 2017 financial and quality performance results released in late 2018 by the Medicare Shared Savings Program, eBrightHealth ACO reduced health care spending by approximately $880,000 in 2017, building upon savings of $860,000 in the ACO’s first year. The ACO also earned the highest overall ACO Quality Score in Delaware for 2017 with high scores in all quality domains.

eBrightHealth ACO brings together more than 1,200 primary and specialty care clinicians from four regional health systems — Bayhealth, Beebe Healthcare, Christiana Care Health System and Nanticoke Health Services, as well as two federally funded qualified health centers and 15 private primary care practices.

$2 million reduction in Medicare spending in first two years

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29

Virtual primary care increases access to care Radical convenience Right care Right time

The Medical Group of Christiana Care launched a primary care virtual practice for Christiana Care employees, spouses and dependents in mid-November 2018. The primary care virtual team consults with members via the portal using secure videoconferencing, HIPAAcompliant texting and secure electronic messaging. Feedback indicates very high member satisfaction with the virtual practice.

Member Enrollment

S I R E

E

N

D

D

D

R

E C T I

O

I

240

Number of Patients

200

In 2018, 39% of Christiana Care’s virtual practice members visited an emergency department for conditions that could have been treated in a primary care office at up to four times the cost.

The virtual practice’s goal is to improve access to primary care and reduce unnecessary hospital use.

57

160

80

0

I am excited that we have the

71

120 14

15 30

40 37

37

Nov-18

Dec-18

Jan-19

167

opportunity to participate in such a great new benefit. This is invaluable for a positive work/life

96

82

67

balance.”

Feb-19

Existing Members

30

Of the 21,000 members on Christiana Care’s Aetna medical plan; 50% have no recorded primary care provider (PCP). Research shows that adults with a PCP have 19% lower odds of premature death and save 33% on health care over peers who do not.

QUALITY & SAFETY REPORT

Mar-19

New Members

Apr-19

− − VIRTUAL PRIMARY CARE PRACTICE MEMBER TESTIMONIAL

Virtual Practice Survey Responses

(Nov. 2018 - June 2019; N = 96)

Yes, definitely

Yes, mostly

Yes, somewhat

No

Would you recommend the Virtual Primary Care Practice to your family and friends?

91%

9%

0%

0%

Did you trust the care provider?

91% 96%

9% 4%

0% 0%

0% 0%

91%

6%

3%

0%

Did the Virtual Practice interdisciplinary team work together to assist in coordinating your care?

87%

7%

6%

0%

Did you know what do to if you had more questions afterwards?

89%

6%

2%

3%

Were you able to talk to a care provider in a timely manner?

98%

2%

0%

0%

Was this method of connecting with a care provider easy to use?

81%

15%

2%

2%

Was the quality of the video or call good enough?

77%

15%

6%

2%

Did the care provider listen carefully to you?

Did the care provider give you enough information?

Who's using virtual primary care?

17% 33%

Average age: 40 Youngest member: 22 Oldest member: 62 Females: 71%

50% Generation X (1965-1980) Baby Boomers (1943-1964)

Millennials (1980-2000) Generation Z (2001-2013)

Access to immediate care is provided through a mobile app, with 2,247 conversations and more than 5,200 messages.

Telehealth video conferencing on smartphone, tablet or computer allows members to easily access primary care at convenient times, from any location with self-scheduling. Secure electronic messaging is used for appointment reminders, sending member education materials and driving improved quality through timely reminders for mammograms or other screenings.

Virtual Practice: Overall Member Experience E

N

D

I

R

E C T I

O

Satisfaction Score

D

90

D

100

S I R E

80 70 60 50

Over the past 5 months, overall member experience scores averaged 95%.

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31

Health Equity Addressing disparate post-partum readmissions with innovative text messaging The Women & Childrenâ&#x20AC;&#x2122;s Health Service Line has developed and implemented an innovative technology-based pilot program to address hypertension as a cause of readmissions among women who give birth at Christiana Care. The intervention is part of a portfolio of programs to address disproportionately higher readmissions among African-American mothers.

Post-partum women in the pilot are prompted via a mobile app called Twistle to measure their blood pressure. The mothers submit their readings to their clinicians through secure text transfer.

Real-time information on blood pressure allows caregivers to intervene in a timely way, keeping patients healthy, close to their families and out of the hospital.

32

QUALITY & SAFETY REPORT

OB Hypertension Twistle Enrollment

E

S I R E

N

D

D

D

R

E C T I

O

I

60

40 Patients Invited Patients Registered Target

30 20

Apr-19

Mar-19

Feb-19

Jan-19

Dec-18

Nov-18

Oct-18

Sep-18

Aug-18

Jul-18

Jun-18

May-18

Apr-18

Mar-18

Feb-18

10

Jan-18

Number of Patients

50

CHRISTIANACARE.ORG

33

Exceptional Experience We Serve Together

Patient Experience is more than just “patient satisfaction.”

Exceptional Experience scores show positive trends

Patients consider: ✓✓ Quality & Safety of the clinical encounter. ✓✓ How much they’re paying for it (value). ✓✓ Clinical outcome. ✓✓ Customer service.

Christiana Care’s Serving Together metric for Exceptional Experience score, as of May 2019, is 78.1%, exceeding our target of 78.0%. The metric measures our top box score for the survey question, “How well staff worked together to care for you.”

Patient perception of teamwork is a top driver of the patient experience across all settings. A positive patient experience is tied to safer, higherquality health outcomes.

E

S I R E

75%

70%

QUALITY & SAFETY REPORT

-19 ay

M

r-1 9 Ap

-19 ar

19

M

19

Fe b-

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Ja

De c18

8

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N

ct -1

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-18

Se p

8

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l-1 Ju

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Ju

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-18

-18 Ap r

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18

M

b-

Ja

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18

65%

Fe

Top Box Score (% "Always")

80%

34

N

D

D

D

R

E C T I

O

I

Serving Together

Nursing Bundle YES, YES, YES answers raise top-box scores for patient experience Three key components of the nursing bundle for relationship-based care are helping to drive top-box scores for patient experience: Purposeful hourly rounding Bedside change of shift report Leadership rounding

The percentage of patients reporting that all three practices were done increased to 60% in March 2019 from 55% one year earlier, meeting the annual improvement goal.

Scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey were 20% to 40% higher when patients were able to answer YES, YES, YES to questions

The bundle makes care safer, improves workflow for the clinical team and leads great patient experiences.

Nursing Bundle Impact on Patient Engagement Scores

E

S I R E

D

D

D

N

✓✓ ✓✓ ✓✓

pertaining to whether they experienced each of these three key components. In fact, when patients answered YES to all three questions on the nursing bundle, top-box scores were higher across all domains of patient satisfaction. Top-box scores for patients receiving all three practices were 81.1%, compared to 43.2% for patients who did not receive any of the bundle steps.

Response of Hospital Sta

86.1%

40.4%

Rate Hospital 0-10

84%

35.1%

Hospital Environment

71.2%

41.1%

Discharge Process 48.3%

Communication with Meds

87.7%

57.7% 63.5%

21.4%

20%

90.6% 74.9%

30%

Communication with Doctors Care Transitions

94.3%

64.9%

Communication with Nurses

E C T I

80.5%

40.4%

Recommend the Hospital

R

O

I

40%

60%

80%

100%

Top Box Score

Full Bundle

No Bundle

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35

2018 Christiana Care Way Awards More than 300 caregivers attended the 16th Annual Christiana Care Way Awards Ceremony in January 2019 — an inspiring annual event that personifies our organization’s commitment to Excellence and Love. The program challenges physicians, nurses and other caregivers to identify opportunities for improvement, then collaborate in using the Plan-Do-Check-Act or Lean Six Sigma DMAIC models to develop and execute plans that achieve positive results.

President’s Award

Coder University — Talent Acquisition Innovations To meet a 2015 mandate from the Centers for Medicare and Medicaid Services to implement ICD-10 diagnosis codes, Christiana Care launched an internal full-time nine-month training class, hired 23 new coding associates and filled 95% of vacant positions.

Transformation Award

Transition to a Systemwide ECG System Within nine months, a new system removed unnecessary variations in the ordering, performance and interpretation of ECGs in the emergency departments, acute care and outpatient settings. ECGs are also immediately available in the patient record. Overall ECG-volume capture improved by 6.6%, and the team achieved a 99% order-completion rate.

Value Award

Get the “SCOOP” (Supportive Care of Oncology Patients) Clinical Pathway The SCOOP pathway standardized care for cancer patients receiving combined modality treatment resulted in lower emergency department use (32% v. 54% of the control group), fewer hospital admissions (25% v. 34% of the control group) and estimated savings of $275,900.

36

QUALITY & SAFETY REPORT

32

winning projects

120

projects

130 volunteer

judges from across the health system

Best Learning Through Failure Award

Digital Medicines — Avoiding Unnecessary Heart Failure Hospitalization A pilot program used ingestible digital medications to improve medication adherence to reduce heart failure hospitalization. Mean medication adherence was 80%, and hospital utilization decreased 73% with estimated cost savings of $282,000. While not continued, the pilot provided extensive learnings that will inform future initiatives.

Optimal Health Gold Award

Respecting the Value of Antibiotics The medical aid units introduced an antibiotic stewardship program including patient and provider education and chart audits with timely feedback. Within 17 months, total antibiotic use decreased 34%, with azithromycin use decreasing 73%, from 11 to 3 prescriptions per 100 visits.

Optimal Health Safety Silver Award

Reduce Spinal Fusion SSI Rate By implementing a standardized spine bundle, including skin prep, glucose control, antibiotic administration, Perioperative Evaluation Program (PEP) / Perioperative Evaluation and Treatment Service (POETS) and MRSA screening, surgical site infections for spinal fusions decreased 44%, from 1.94% to 1.09%. Cost of poor quality was reduced by $550,000 annually.

Optimal Health Safety Bronze Award

Organizational Vitality Silver Award

Optimal Health Quality Gold Award

Extraordinary People Award

Optimal Health Quality Silver Award

Innovative Tools Award

Exceptional Experience Gold Award

Magnet Structural Empowerment Gold Award

Intervention for Suicide Prevention in the Emergency Department Implementation of standardized, evidence-based clinical guidelines for identification and treatment of individuals with suicide ideation or at risk for suicide resulted in screening of 97% of emergency department patients and inpatients, psych consult orders for 100% of high-risk patients and only 0.25% inappropriate safety companion use for low-risk patients.

Value-Based Care for Substance-Dependent Newborns Through care standardization, the team improved care for babies with neonatal abstinence syndrome, decreasing morphine treatment time to 17.5 days and length of stay for babies treated with morphine to 22.5 days.

Reducing the Rate of Abdominal Hysterectomies Performed at Christiana Care Through standardized patient education classes, surgeon education and training, and post-surgical chart review, the total abdominal hysterectomy rate decreased to 13.8% from 25.2%.

Nursing Bundle for Patient Experience Nursing implemented a bundled set of three evidencebased best practices to enhance patient experience: bedside shift report, nurse leader rounding and purposeful hourly rounding. Top box scores on the Hospital Consumer Assessment of Healthcare Providers and Systems for patients receiving all three practices were 81.4%, compared to 39.7% for patients not receiving the bundle practices.

Exceptional Experience Silver Award

Staying in Line Decreases Time After investigating the unit's staffing model and geographic location, 4W modified the patient care technician workflow into a linear style. The top box score for "Call Bell Help" increased from 50% to 60% and caregiver response times decreased by about 60 seconds.

Organization Vitality Gold Award

Ambulatory Collaboration for Improved Risk Adjustment An Ambulatory Clinical Documentation Improvement program increased appropriate risk adjustment through improved documentation of Hierarchical Condition Category (HCC) codes. Quality documentation resulted in more accurate claims submission as well as a projected 2.95% increase in payment.

340B Federal Drug Discount Program The 340B Federal Discount Drug Pricing Program enables qualifying health systems to purchase drugs for eligible outpatients at a discount, and is intended to support expanded services for uninsured or underinsured populations. Christiana Care implemented the program at Wilmington Hospital and two other sites in April 2018, and saved more than $9 million in the first five months.

Promoting a Culture of Continuous Quality Improvement Since 2003, almost 1,500 quality improvement projects were shared via The Christiana Care Way Awards, a grassroots approach to continuous performance improvement fostering Christiana Care's culture of learning and innovation.

Better Understanding C. diff via Health Catalyst An analytic application developed in Health Catalyst predicts a positive clostridium difficile test in near-real time, provides a better understanding of antibiotic and proton pump inhibitor use and supports targeted interventions. The application contributed to a decrease in C. diff incidence from 5.8 to 3.2.

Delirium Scoring on ICU Patients The daily Intensive Care Delirium Screening Checklist score identifies delirium in the intensive care unit. Face-to-face education and easy access to scoring guides via PowerChart decreased the percentage of patients without a daily score from 47% to 23%.

Magnet Structural Empowerment Silver Award

Improving Stroke Measures in the NCCU After identifying opportunities for re-designation as a Comprehensive Stroke Certification program, the team conducted an educational needs assessment, provided education and completed daily compliance monitors.

Accomplishments including 99% blood pressure parameter compliance, 88% stroke plan of care completion and 97% individualized patient stroke education led to certification.

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Magnet Exemplary Professional Practice Gold Award

Learning Award

If UAPI and You Know It — Reducing Unit-Acquired Pressure Injuries by 50 Percent 4D formed a skin integrity team that led educational efforts, conducted weekly skin audits on at-risk patients and monitored charts to improve accuracy, resulting in a 52% decrease in the unit-acquired pressure injury rate (from 1.16 to 0.55).

CLABSI Reduction Through Staff Engagement and Process Monitoring After identifying variations in insertion, maintenance and removal of central lines as the root cause of a high central line-associated bloodstream infection (CLABSI) rate, a triad of Nursing, providers and Infection Prevention created greater oversight, introduced disinfecting port protectors and reduced variation, resulting in a decrease in the CLABSI rate of 425 (from 1.3 to 0.7).

Magnet Exemplary Professional Practice Silver Award and People’s Choice Award

Operational Improvement Gold Award

Reducing Unit-Acquired Pressure Injuries on 4E After having 14 unit-acquired pressure injuries during FY 2017, 4E re-educated caregiver on prevention and started two-nurse skin assessments for all new patients. This unit had no pressure injuries in the three months after implementation, and has rates better than the National Database of Nursing Quality Indicators target rates.

Magnet Transformational Leadership Gold Award

ED to Stepdown: Optimizing Patient Flow & Boarding Times An emergency department and stepdown unit team focused on patient flow, patient safety through face-to-face handoff and increased communication across departments. Using the new process, the average Bed Ready to Left ED time decreased from 77.3 minutes to 57.5 minutes.

Magnet Transformational Leadership Silver Award

Improving Access to Trauma Care — Building a Level III Trauma Program Wilmington Hospital was successfully verified as a Level III Trauma Center in October 2017. 855 trauma patients were admitted in 2017, primarily with low-to-moderate injury severity scores, and the number of transfers to Christiana Hospital decreased, enhancing the level of trauma care provided to the community.

Magnet New Knowledge, Innovation & Improvement Award

Virtual Reality — Chemotherapy Suite Positive Distraction Nurses, volunteers and the Health & Technology Innovation Center implemented virtual reality to provide positive distraction to patients receiving chemotherapy. The team provided 143 virtual experiences with an overall satisfaction rate of 4.5 out of 5.

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QUALITY & SAFETY REPORT

Signing Is Vital: Multidisciplinary Collaboration to Reduce Unsigned Orders Unsigned orders decreased 58% thanks to the redesign of clinical workflow for nursing orders, development of an inbox functionality to route verbal orders, disabling order entry under group names and establishment of a department audit report.

Operational Improvement Silver Award

Decrease Percent of MRI Patients Receiving Sedation for MRI Through Lean Six Sigma improvements in education, removing safety questionnaire ambiguity and requiring patients to receive sedation only in the MRI department, sedation use during MRIs decreased 14.4%, with a cost reduction of $11,300 annually.

Operational Improvement Bronze Award

Chest Pain Pathway Reduces Length of Stay in Cardiology Observation Patients The Cardiac Short Stay Unit implemented an evidence-based multidisciplinary chest pain pathway to accelerate diagnostic testing for patients admitted for chest pain. The pathway reduced length of stay by two hours, from 21.3 to 19.3 hours.

Population Health Award

Improving Colorectal Cancer Screening in Primary Care A primary care team implemented electronic medical recordembedded prompts, proactive outreach to patients and colonoscopy alternatives; increasing colon cancer screening to 73.2%. Cologuard use tripled, and pay-for-performance revenue increased 37%.

Health Equity Award

Creating Healthy Smiles: Community Partnership to Improve Pediatric Dental Care Christiana Care Dental Administration and Outpatient Social Work collaborated with Reeds’ Refuge Center, a nonprofit community organization serving low-income families in Wilmington, to connect children who have oral health issues with dental care. By mitigating social, financial and transportation barriers, 35 children received 111 dental exams/procedures in 10 months, and dental residents’ exposure to pediatric dental issues increased.

Resident’s Gold Award

NOPAIN — Non-Opioid Prescription Alternative Initiative Residents created an evidence-based non-opioid prescription alternative protocol outlining classes of medications for treatment of low-back pain. Patients with low-back pain on chronic opioid therapy had an 19.8% decrease in the average daily morphine equivalent dose, and the use of pain-adjunct prescriptions increased by 30%.

Resident’s Silver Award

Goals of Care in the Outpatient Setting Residents from the Wilmington Adult Medicine office created a flyer and conducted educational sessions addressing goals-of-care conversations. Conversations with patients over age 60 increased by almost 50%, demonstrating increased comfort with conversations related to goals of care.

Good Catch Awards

The Gastrointestinal Lab created a systemwide safety alert to reduce the risk of patient harm associated with missing allergy bands.

We Care Awards — New in 2018

The We CARE Award (Committed, caring and compassionate; Anticipating needs of others, and taking action; Responsible, responsive and respectful; and Embracing others and being empathetic) recognizes caregivers who go above and beyond to ensure the safety of our neighbors by exemplifying our Values and Behaviors in action. Inaugural honorees are Carly Wilson and Demetria Bennefield of VNA and Jamal Armbrister and Jeremiah Dean of Environmental Services/Escort.

Christiana Care presented a poster highlighting The Christiana Care Way Awards at the 2018 National Association of Health Care Quality conference in Minneapolis. “Strategies to Support a Grassroots Approach to Performance Improvement” highlights Christiana Care’s sustainable strategy to foster the transformation into a learning organization, which engages caregivers at all levels, fosters innovation, shares learning and recognizes accomplishments.

Just by participating, we are improving the safety and quality of care we deliver to our patients, families and the communities we serve.

This awards ceremony is now part of the fabric of our organization.” − − SHARON ANDERSON, MS, BSN, RN, FACHE CHIEF POPULATION HEALTH OFFICER AND SENIOR VICE PRESIDENT, QUALITY AND PATIENT SAFETY

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93.8% In 17 hours at more than 71 Christiana Care locations, 7,868 Christiana Care caregivers were vaccinated against the flu as part of a monumental #HitMeWithYourFluShot vaccination campaign. The single-day campaign doubled as a drill to determine Christiana Careâ&#x20AC;&#x2122;s ability to quickly vaccinate all employees in the event of a bioterrorism attack or other emergency. Nearly 300 caregivers volunteered for this important systemwide effort, which won six national awards.

christianacare.org

of Christiana Careâ&#x20AC;&#x2122;s workforce was vaccinated for the 2018-2019 flu season, exceeding the goal of 92%.

PO Box 1668 Wilmington DE 19899-1668 800-693-CARE (2273)

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

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