Quality & Patient Safety Annual Report 2012

WORK & TUMBLE 27635 C.Care (Cover) 1 A 06/26/2012 07:52:31 CyanMagentaYellowBlack 12PERF2

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

PO Box 1668 Wilmington, Delaware 19899-1668 www.christianacare.org

Synchronized Admissions Teams collaborate on interdisciplinary assessment. See pages 21-22.

Quality and Safety 2012 ANNUAL REPORT ON 27635_Cover_Layout 1 6/26/12 7:23 AM Page 2

27635_Cover_Layout 1 6/26/12 7:24 AM Page 3

The Christiana Care Quality and Safety Program

Our Journey 2007 Safety First Learning Report

A message from the President and CEO

Enhancements for Follow Up Just Culture Concepts (Planning)

CR GA F SA EC

QUALITY AND SAFETY

TU UL RE

significantly reduce the risk of infection and harm.

Our Value Improvement Teams set the standard for the more efficient use of available resources and adherence to national guidelines. Our journey is not only creating value for Christiana Care; other health systems throughout the nation are learning from our journey.

Human Factor Analysis for Flex Monitoring Team Training Transparency Concepts

CREATING A SAFE CULTURE

Focus on “No Harm, Any is Too Many”

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

— P RO G R A M I N I T I AT I V E S 2 0 0 7 t o 2 0 1 2

Quarterly Environment of Care Consultant Assessments

Skylight Safety Assessment

Cultural Diversity & Inclusion

Worker Fall Protection Policy

Interdisciplinary Rounds

Patient/Family Centered Care

Disclosure Policy & Process

Enhanced Disclosure Process

Safety Mentor Education and Development

Human Factors Analysis for Radiation Oncology

Post Event Debriefs Partners in Safety Updates

‘Good Catch’ Recognition

SAFE Weekly Huddles

Patient and Community Involvement

Culture of Responsibility Phase I (June)

Culture of Responsibility (Planning)

Culture Survey (October)

Culture Survey (January)

Partners in Learning for Safety/ Just Culture Council

2009

2008

Human Resources and Safety Standards for Event Follow Up

No Harm Intended Sessions Speak Up Patient Safety Guide Safety First Advisory Council Safety in New Employee Orientation/ On Boarding Enhanced Focus on Excellence (FOE) Awards

CH I

EV

I

N G HI

BEAT Training Classes Arc Flash Policy and Program Safe Work Permit Improvements

2010

Specialized Training on Compressed Gas Safety

2011

2012

Culture of Responsibility Phase II (Oct.) Standarized Hand Offs for Transitions of Care in Women’s Health Embracing Patient Centered Care through Implementation of AIDET Unit Based Clinical Leadership Teams 5C Nursing Home Project

Culture Survey (April) Culture of Responsibility Phase III (October) Employee Safety Handbook Workplace Violence Committee Established VP Level Monthly Injury Summary Reports

Bedside Shift Report Employee Wellness TRP Safety Education Module Facilities and Services Safety Committee Established Slip, Trip Fall Workgroup Established Department Level Focused Safety Training

Powered Industrial Truck Policy, Education and Inspection Program

A

Our commitment to transformation and innovation is showing dramatic results in operational efficiencies, including shortened length of stay, fewer readmissions and improved outcomes. Most importantly, we are increasing the value of care for our patients because we work with them and not merely for them. This is a testament to the power of the Christiana Care Way.

L G H RE

In all that we do, Christiana Care strives to serve everyone as respectful, expert caring partners in their health. This is the Christiana Care Way, and it is our promise to each person who trusts us to care for them. Embedded in this promise is a commitment to transform how we deliver that care.

This report tells the story of our journey to transform care, quality and safety. Our physicians, nurses and staff are collaborating on new and better ways to enhance safety; to achieve high reliability in consistently delivering safe, effective care through evidence-based practices and outcomes research; and to leverage technology to advance our quality and safety goals. It highlights improvements that

TIN EA

IT Y IAB IL

27635_Cover_Layout 1 6/26/12 7:23 AM Page 1 Contractor Safety Training Video Updated Workplace Safety Risk Review Evaluation Completed by Conner Strong Formalized Systemwide “Good Catch” Program (March)

LEVERAGING TECHNOLOGY The Ch Th Christiana i i C Care Quality Q li and d Safety S f Program P strives i to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.

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

Robert J. Laskowski, M.D., MBA President and Chief Executive Officer

DVT Prophylaxis Development (Planning)

Assessment of CCHS Medication Safety (Planning)

Health care organizations are complex entities where the risk for accidents and injury runs extremely high. High Reliability Organizations (HROs) avoid catastrophes and accidents despite the dangers inherent in their businesses.

Christiana Care employs best practices of other high-risk industries in order to achieve the defining characteristics of HROs.

Institute for Safe Medication Practices (ISMP)

ACHIEVING HIGH RELIABILITY

Medication Safety Officer (Planning) 5 Million Lives Campaign: • System Wide Skin Team to Prevent Pressure Ulcers • Reduce MRSA • High Alert Medications; Anticoagulation Team • Surgical Care Improvement Program (SCIP) • Heart Failure, Heart Disease and Stroke: “Get with the Guidelines” • Board Report of Key Measures

EMAR Implementation

Creating a Safe Culture .................................................................................................................................................. 1 Achieving High Reliability .......................................................................................................................................... 16 Leveraging Technology ............................................................................................................................................... 32 Awards, Recognition & Achievements .................................................................................................................... 39

Barcoding (Bedside Specimen Labeling)

LEVERAGING TECHNOLOGY

Sentinel Event Database

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

Bed Management System Perioperative Documentation Pharmacy Order Management System (POMS)

Clinical Documentation Project MRSA National Patient Safety Goals: • Management of Anticoagulation • Improving Recognition and Response to Changes in Patient Condition “Never Events” Present on Admission Hospital Consumer and Assessment Provider Survey (HCAPS)

National Patient Safety Goal: Reduce Risk of Healthcare Associated Infections: • Central Line Associated Blood Infections • Multiple Drug Resistant Organisms • Prevention of Surgical Site Infection Prevent Harm from High Alert Medications (Hydromorphone)

Hand Hygiene Campaign

Medical bariatric FMEA

Disease Specific Certification Planning • Primary Stroke Center

Medication Safety

ED Super Track

Disease Specific Certification • Stroke Program Comprehensive Unit-Based Safety Program (CUSP) Magnet Recognition Flu Vaccine Program Surgical Safety Team Checklist

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

Pilot Early Warning System (EWS) Patient Identification Best Practice Leadership Forum to Reinforce Culture of Responsibility Concepts Human Factors Consultant “Sponge Counts”

Best Practices for Better Care

SWAT launches at Christiana

Recertification Disease Specific Stroke Program Partnership for Patients Proactive Assessment of Communicating Patient Preferences/ Goals of Care

SWAT (Synchronized Wilmington Admission Team)

Christiana Rapid Transfer Initiative

Pregnancy Screening in Non-OB Locations

Value Improvement Team Training

ED SHARP ED Triage Redesign

ED SPEED

Heart Failure Transformation Team

Obstetrical Emergency Response Team (OBERT) Pharmaceutical Waste Management Program Implemented

Expanded Use of Vocera

Enhanced Web Paging

Wireless Patient Monitoring

CPOE

CPOE: Zynx Phase 3

ADT Interfaces with Micropaq

Wireless Bar Coding-Breast Milk

Equipment Tracking

VNA Heart Failure Telemonitoring Program

Vocera

Language Line Enhancement

Planning for Meaningful Use

CPOE: Zynx Phase 2

Care Fusion Implementation

Infusion Pumps (Smart Pumps)

Enhanced Suicide Risk Assessment

Delaware Health Information Network (DHIN)

Language Line Enhancement Insight Heart Failure (Symptom SelfAssessment)

CPOE: Zynx Implementation (Order Sets/Standards Development) Phase I

Capnography (End-Tidal CO2 Monitoring) During Code Blue Radiation Therapy Positioning Software Enhanced Central Line Checklist Implemented Baseline Pulse Oximetry in OB Triage, L & D and Antepartum Areas

Winter Weather Communications Enhanced Multum Alert View for Duplicates, Allergies and Major-Contraindicated DrugDrug Interactions.

Automation of “Event Follow-Up” Implementation of Meaningful Use

Standardization of Web Page to Mobilize Anesthesia Services Interpreters Care Visibility

Virtual Education & Simulation Training Center (June)

Electronic Signatures

Spill Stations Designed and Ordered

C h ri st i an a C are H e al t h S y s t e m

WORK & TUMBLE 27635 C.Care (Cover) 1 A 06/26/2012 07:52:31 CyanMagentaYellowBlack 12PERF2

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

PO Box 1668 Wilmington, Delaware 19899-1668 www.christianacare.org

Synchronized Admissions Teams collaborate on interdisciplinary assessment. See pages 21-22.

Quality and Safety 2012 ANNUAL REPORT ON 27635_Cover_Layout 1 6/26/12 7:23 AM Page 2

27635_Cover_Layout 1 6/26/12 7:24 AM Page 3

Our Journey

A message from the President and CEO

Creating a Safe Culture .................................................................................................................................................. 1 Achieving High Reliability .......................................................................................................................................... 16 Leveraging Technology ............................................................................................................................................... 32 Awards, Recognition & Achievements .................................................................................................................... 39

GH IG IN EV

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

HI

RE

Robert J. Laskowski, M.D., MBA President and Chief Executive Officer

QUALITY AND SAFETY

U LT CU FE SA GA

— P RO G R A M I N I T I AT I V E S 2 0 0 7 t o 2 0 1 2

2007

2008

2009

2010

2011

2012

Partners in Learning for Safety/ Just Culture Council

Safety First Learning Report

Culture Survey (January)

Culture Survey (October)

Culture of Responsibility Phase II (Oct.)

Culture Survey (April)

Enhancements for Follow Up

Culture of Responsibility (Planning)

Culture of Responsibility Phase I (June)

Human Resources and Safety Standards for Event Follow Up

Just Culture Concepts (Planning)

Patient and Community Involvement

SAFE Weekly Huddles

Standarized Hand Offs for Transitions of Care in Women’s Health

Culture of Responsibility Phase III (October)

Human Factor Analysis for Flex Monitoring

Post Event Debriefs Partners in Safety Updates

Human Factors Analysis for Radiation Oncology

Embracing Patient Centered Care through Implementation of AIDET

Employee Safety Handbook

‘Good Catch’ Recognition Safety Mentor Education and Development

Team Training

Enhanced Disclosure Process

Disclosure Policy & Process

Unit Based Clinical Leadership Teams

Transparency Concepts

Patient/Family Centered Care

Interdisciplinary Rounds

5C Nursing Home Project

Worker Fall Protection Policy

Cultural Diversity & Inclusion

Bedside Shift Report

Skylight Safety Assessment

Quarterly Environment of Care Consultant Assessments

Employee Wellness

Specialized Training on Compressed Gas Safety

Facilities and Services Safety Committee Established

No Harm Intended Sessions Speak Up Patient Safety Guide

Focus on “No Harm, Any is Too Many”

Safety First Advisory Council

BEAT Training Classes

Safety in New Employee Orientation/ On Boarding

Arc Flash Policy and Program Safe Work Permit Improvements

Enhanced Focus on Excellence (FOE) Awards

Department Level Focused Safety Training

Workplace Violence Committee Established VP Level Monthly Injury Summary Reports Contractor Safety Training Video Updated Workplace Safety Risk Review Evaluation Completed by Conner Strong Formalized Systemwide “Good Catch” Program (March)

LEVERAGING TECHNOLOGY Th Ch The Christiana i i C Care Quality Q li and d Safety S f Program P strives i to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.

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

DVT Prophylaxis Development (Planning)

Clinical Documentation Project MRSA

National Patient Safety Goal: Reduce Risk of Healthcare Associated Infections: • Central Line Associated Blood Infections • Multiple Drug Resistant Organisms • Prevention of Surgical Site Infection

Disease Specific Certification • Stroke Program

Prevent Harm from High Alert Medications (Hydromorphone)

Surgical Safety Team Checklist

ACHIEVING HIGH RELIABILITY

Institute for Safe Medication Practices (ISMP)

Health care organizations are complex entities where the risk for accidents and injury runs extremely high. High Reliability Organizations (HROs) avoid catastrophes and accidents despite the dangers inherent in their businesses.

Christiana Care employs best practices of other high-risk industries in order to achieve the defining characteristics of HROs.

Assessment of CCHS Medication Safety (Planning)

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

Medication Safety Officer (Planning)

“Never Events” Present on Admission

5 Million Lives Campaign: • System Wide Skin Team to Prevent Pressure Ulcers • Reduce MRSA • High Alert Medications; Anticoagulation Team • Surgical Care Improvement Program (SCIP) • Heart Failure, Heart Disease and Stroke: “Get with the Guidelines” • WISH program • Board Report of Key Measures

Hospital Consumer and Assessment Provider Survey (HCAPS)

EMAR Implementation

ADT Interfaces with Micropaq

CPOE: Zynx Phase 3

CPOE

Barcoding (Bedside Specimen Labeling)

Wireless Patient Monitoring

Enhanced Web Paging

Expanded Use of Vocera

Infusion Pumps (Smart Pumps)

Care Fusion Implementation

Sentinel Event Database

CPOE: Zynx Phase 2

Planning for Meaningful Use

Bed Management System

Language Line Enhancement

Perioperative Documentation

Vocera

VNA Heart Failure Telemonitoring Program

Pharmacy Order Management System (POMS)

Equipment Tracking

Wireless Bar Coding-Breast Milk

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

Delaware Health Information Network (DHIN) CPOE: Zynx Implementation (Order Sets/Standards Development) Phase I Electronic Signatures

Medication Safety

Disease Specific Certification Planning • Primary Stroke Center

Medical bariatric FMEA

Hand Hygiene Campaign ED Super Track

Comprehensive Unit-Based Safety Program (CUSP) Magnet Recognition Flu Vaccine Program Pregnancy Screening in Non-OB Locations

Disease Specific Certification (May): • Heart Failure • Hip • Knee Recertification Disease Specific Stroke Program Best Practices for Better Care Partnership for Patients Christiana Rapid Transfer Initiative

SWAT (Synchronized Wilmington Admission Team)

Proactive Assessment of Communicating Patient Preferences/Goals of Care

Obstetrical Emergency Response Team (OBERT)

ED SHARP

ED SPEED

ED Triage Redesign

Pilot Early Warning System (EWS) Patient Identification Best Practice Leadership Forum to Reinforce Culture of Responsibility Concepts SWAT launches at Christiana Human Factors Consultant “Sponge Counts” Value Improvement Team Training

Heart Failure Transformation Team

Pharmaceutical Waste Management Program Implemented

Enhanced Suicide Risk Assessment Language Line Enhancement Insight Heart Failure (Symptom SelfAssessment) Virtual Education & Simulation Training Center (June) Spill Stations Designed and Ordered

C h ri sti an a C are H eal th S ys tem

TRP Safety Education Module

Slip, Trip Fall Workgroup Established

Powered Industrial Truck Policy, Education and Inspection Program

AC

Our commitment to transformation and innovation is showing dramatic results in operational efficiencies, including shortened length of stay, fewer readmissions and improved outcomes. Most importantly, we are increasing the value of care for our patients because we work with them and not merely for them. This is a testament to the power of the Christiana Care Way.

TIN EA

This report tells the story of our journey to transform care, quality and safety. Our physicians, nurses and staff are collaborating on new and better ways to enhance safety; to achieve high reliability in consistently delivering safe, effective care through evidence-based practices and outcomes research; and to leverage technology to advance our quality and safety goals. It highlights improvements that

significantly reduce the risk of infection and harm.

Our Value Improvement Teams set the standard for the more efficient use of available resources and adherence to national guidelines. Our journey is not only creating value for Christiana Care; other health systems throughout the nation are learning from our journey.

HR EL IAB ILI TY

CR

In all that we do, Christiana Care strives to serve everyone as respectful, expert caring partners in their health. This is the Christiana Care Way, and it is our promise to each person who trusts us to care for them. Embedded in this promise is a commitment to transform how we deliver that care.

27635_Cover_Layout 1 6/26/12 7:23 AM Page 1

The Christiana Care Quality and Safety Program

Capnography (End-Tidal CO2 Monitoring) During Code Blue Radiation Therapy Positioning Software Enhanced Central Line Checklist Implemented Baseline Pulse Oximetry in OB Triage, L & D and Antepartum Areas Standardization of Web Page to Mobilize Anesthesia Services Interpreters Care Visibility

Winter Weather Communications Enhanced Multum Alert View for Duplicates, Allergies and Major-Contraindicated DrugDrug Interactions.

Automation of “Event Follow-Up” Implementation of Meaningful Use

CREATI NG A SAFE CULTUR E

Instrumental to our commitment to make every patient encounter one of greater value is our determination to provide safety, quality and efficiency in all that we do.

Our landmark effort this year in building a Culture of Responsibility underscores that safe practices can neither be dictated by management nor guaranteed by policies and procedures or by technological advances alone. Because the

nature of our industry is for care to be provided to humans by humans, we acknowledge that the potential for error is inherent. One of the most important factors in achieving safe patient care is overt, palpable and continuous commitment from organizational leadership and staff to foster an environment that encourages and supports safe and reliable care.

Qu a l i t y a n d Sa f ety A nnu al Re por t | 1

CR EATING A SAFE CULTURE

Culture of Responsibility fosters learning environment To date, more than 300 managers and physician leaders have been trained in Culture of Responsibility concepts as part of a multi-year phased implementation plan.

Our Journey in Culture of Responsibility Creating an ingrained culture of safety 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 in delivering a safer, more effective care experience for those we serve. In one of our health system’s most significant culture shifts, Christiana Care frontline employees, physicians and leadership are forging an unprecedented journey toward a Culture of Responsibility.

This calls upon individual and collective responsibility to identify safety risks in our environment.

A Culture of Responsibility is a commitment to create an environment of shared responsibility among all members of the health care team, from leaders, to physicians and staff, and those who create and administer the systems in which care is delivered. The focus is on improving systems and creating a learning environment that encourages colleagues to voice concerns, raise issues and report errors and near misses without fear of retribution or punitive action.

Recognizing that mistakes will happen, Culture of Responsibility helps us define and manage human error, at-risk and reckless behavior to create a consistent managerial approach that removes the potential for unsafe behavior. Ultimately, it will help us design safer systems, support safer behaviors and create a standard for how to treat colleagues when errors do occur.

2 | Chri sti ana Care Heal th S ys tem

Frontline staff, physicians and system leadership are integral partners in this renewed culture that: f Creates an open learning environment where staff feel comfortable talking about errors and have time to reflect upon how we might do things differently. f Focuses on responsible behavioral choices while avoiding individual blame. f Strives to understand why humans make mistakes, drift and participate in at-risk behaviors. f Analyzes adverse clinical events focusing on what happened, what normally happens, why it happened and what we can do to prevent it from happening again. f Consoles professionals who make an error, coaches those who drift into at-risk behavior and disciplines reckless behavior. f Limits the use of warning and punitive actions to where they will benefit and improve safety. f Supports our staff by designing systems that will reduce error and drift as a result of competing demands, such as turnover time, broken systems and misinformation.

Four cornerstones support our Culture of Responsibility: Advance Our Learning Culture

Design Safe Systems

• Acknowledges the thirst for knowledge and need to understand both individual and organizational risk.

• Managers and employees work collaboratively to design systems that anticipate human error, capture errors before they reach the patient or employee, and that allow for recovery when errors do reach the patient.

• Those involved learn from their mistakes and share this learning in a way that supports performance improvement and encourages safe behavioral choices.

Promote an Open and Fair Culture

Manage Behavioral Choices

• Error reporting is transparent.

• Understands and anticipates that humans will and do make mistakes.

• The erring professional feels safe reporting errors, giving others the opportunity to learn from them.

• Management of behavioral choices allows achievement of desired safety outcomes.

• Near misses are reported as a learning opportunity to reduce future risk or error.

“Every day, every where, every one. Culture of Responsibility gets us all thinking about our shared responsibility for making things better.”

—Michele Campbell, RN, MSM, CPHQ, FABC, Corporate Director, Patient Safety and Accreditation

Qu a l i t y a n d Sa f ety A nnu al Re por t | 3

CR EATING A SAFE CULTURE

Christiana Care achieves goal to reduce harm by 10 percent The number of patients harmed or at risk for harm has been reduced by 10 percent due to a steadfast and shared commitment by leadership and frontline staff to four key priorities: f Reducing the risk of health care–associated infections through surveillance and prevention. f Achieving high reliability through adoption of best practices and a focus on National Patient Safety Goals and practices. f Implementing Medication Safety Practices. f Identifying, reporting, managing and learning from near misses and adverse events.

Defining harm and risk Preventable harm is categorized into seven key areas.

Each occurrence or event of harm is counted and compared to the previous year-to-date to determine the percent change. The concept of “any is too many” resonates with frontline staff to reduce and eliminate patient harm. Variations from safe practices and processes that place patients at risk for harm are counted to further limit the potential for patient harm.

Seven Categories of Preventable Harm 1.

2.

3.

4.

Hospital Acquired Infections Medication Safety Events Falls with Major Injury Hospital Acquired Pressure Ulcers – Stage 3 & 4 5. Non-ICU Code Blues 6. AHRQ Patient Safety Indicators 7. Other Serious Safety Events

4 | Chri sti ana Care Heal th S ys tem

As a result of these actions, we reduced the number of patients harmed or at risk for harm by 10 percent.

Strategy to achieve long-term goal of eliminating preventable harm Achieving the long-term goal to eliminate preventable harm required greater focus on priority setting and execution. To strengthen these functions, Christiana Care restructured its Quality and Safety Program, beginning at the leadership level. Organizational priorities based on the Annual Operating Plan and Long-Term Strategic Goals now fall under three major areas: 1. Safety First (Eliminate preventable harm).

2. Clinical Excellence (Evidence-based practice).

3. Think of Yourself as a Patient (Patient care experience).

Each area of focus sets specific priority-driven targets for the patient care unit level. Interdisciplinary unit-level Value Improvement Teams (VITs) trained in performance improvement science drive daily actions to reduce patient harm, improve quality of care and enhance patient satisfaction. The Office of Quality and Safety and Operational Excellence support project-based work, education and training, and mentoring for unit-based VITs. From the unitlevel Value Improvement Teams to the senior leadership suite, the renewed focus to improve safety, quality and efficiency in every patient encounter is an important step toward creating greater value in the overall care experience.

Harm

1275

1351 850 425

# of Patients Harmed

1700

1653

0 FY 11

FY 12

302 fewer patients were harmed compared to the same time period last year.

Preventable Harm Rate

8 6 4 2 0

Harm per 1,000 patient days

10

J09 A S O N D J F M A M J J10 A S O N D J F M A M J J11 A S O N D J F M A Harm rate decreased by 18 percent. trend

Qu a l i t y a n d Sa f ety A nnu al Re por t | 5

CR EATING A SAFE CULTURE

Christiana Care strives for AHRQ top decile in safety Nonpunitive Response to Error

40

20

% Positive Response

60

0 Nonpunitive response to error survey composite.

AHRQ 2010 CCHS 2010 CCHS 2009 CCHS 2006

S feel like their mistakes are held against them.

When an event is reported, it feels like the person is being written up, not the problems.

S worry that mistakes they make are kept in their e.

Improvement demonstrated and is better than national levels.

One of our long-term goals is to place in the top decile performance compared to other hospitals participating in the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture, which assesses hospital staff perceptions about patient safety issues, medical errors and event reporting.

f Engagement of middle management – Embedding Culture of Responsibility into our leadership behaviors; strengthening and re-engineering unit-based CUSP teams into data-driven unit-based Value Improvement Teams; conducting purposeful rounds and coordinating interdisciplinary post-event debriefs at the point of care.

We believe that our journey toward a Culture of Responsibility will help address one of the key opportunities for improvement identified in FY 2010 survey data—nonpunitive response to error.

f Providing feedback and accountability – Timely event follow-up and learning through our Culture of Responsibility; technology-enhanced event follow-up; safe practice behavior monitoring feedback; and our hand hygiene campaign.

Key areas of focus to achieve top decile performance are: f Best Practices around transparency – Good Catch recognition; walking rounds; sharing reported adverse events and lessons learned through system improvements; and continued No Harm Intended sessions.

6 | Chri sti ana Care Heal th S ys tem

f Optimizing survey data – Using organizational and local qualitative and quantitative data related to the specific dimensions of culture to assess effectiveness of interventions and our new Quality and Safety structure.

CREATING A SAFE CULTURE

Good Catch program strengthens staff voice in patient safety FY 2012 Near Miss Events Good Catch Program Kickoff 3/1/12

75%

7%

7%

5%

6%

8%

8%

8%

8%

16%

15% 50% 25%

% of Reported Events

100%

0% 11-Jul

11-Aug

11-Sep

11-Oct

11-Nov

11-Dec

12-Jan

12-Feb

12-Mar

12-Apr

Corrected Before Reached Patients (Good Catch) No Evidence of Injury or Harm Good Catch reporting, as a percentage of all events, has doubled since the March 2012 kickoff.

“Speaking up constructively and intervening to prevent harm not only protects the patient, but also protects the health care professionals involved.”

—Anabelle Navarro, RN, BSN, PCCN, CCRN, Christiana Hospital Cardiovascular Critical Care Complex – Surgical Launched in March 2012 as part of the journey toward a Culture of Responsibility, the “Good Catch” tiered reward program recognizes staff members who identify and report “near misses.” Good Catches increased monthly from 8 – 16 percent of all reporting since implementation, leading to mitigation of harm to our patients in such areas as: f f f f f f

Patient Identification.

Test, treatment and procedure.

Environment.

Change in patient status.

Medication, IV and blood.

Equipment and supplies.

The program engages staff to be attentive and intervene to prevent harm. It also encourages them to suggest opportunities for improvement in system design. By encouraging more reporting, the program will enhance the system’s ability to learn from trends and improve the culture of safety. It also supports achievement of our fiveyear goal to become a national leader in quality and safety and achieve top decile performance in the AHRQ Hospital Survey on Patient Safety Culture.

Rewarding those who speak up not only gets staff involved in patient safety, but, more fundamentally, it changes staff perceptions about reporting Good Catches.

Qu a l i t y a n d Sa f ety A nnu al Re por t | 7

CR EATING A SAFE CULTURE

Post-event debriefs enhance learning from adverse events Post-event debriefs help clinical team members identify system and communication issues relating to adverse events and near misses.

events, in a supportive, learning environment. A clear and common understanding of the facts allows all to discover what can be done differently to mitigate further harm to our patients.

Discussions focus on system issues rather than individual behavioral choices, allowing participants to discuss Organizational Learning-Continuous Improvement Direct/Indirect Care Providers

100%

P <0.001

88% 75%

76.6

76 71

63% 50% 2006

2009

2010

Debriefs led to an 8 percent improvement in organizational learning.

Lessons Were Learned in Discussing Event 0%

20%

40%

60%

Strongly Agree Agree Neither Disagree Strongly Disagree 90 percent of participants tell us they have learned from the discussions.

98 percent would participate in another debrief, given the opportunity.

8 | Chri sti ana Care Heal th Sys tem

N=320

% Positive Response

Statistically Significant Improvement

CREATING A SAFE CULTURE

Patient and family centered approach leads to better care for our patients Overall rating of care 100%

80% 70% 60% 10-Dec

11-Feb

11-Apr

11-Jun

% Top Box (9 –10)

90%

50% 11-Aug

11-Oct

11-Dec

Discharge Date

Discharge Date

12-Feb 12-Mar

40%

Percent of patients rating us 9 or 10 trend

With patient and family centered care practices in place, the percentage of patients giving Wilmington Hospital top rating has increased by more than 14 percent.

Wilmington Hospital’s emphasis on patient and family centered care—placing patients in equal partnership with the health care team—is shifting the culture from one of doing things to and for patients, to one of working with patients and their families. Recognizing that patients tend to view the health care team as the experts, staff now stress that it is the patient and his or her family who are the experts on their individual needs. Combining their input with the science offered by the health care team creates a more effective plan of care.

Patient and family-centered initiatives improving the care experience include: f One Voice Steer Committee (focused team effort on improving communication).

f Bedside shift-to-shift reports (involving nurses, technicians, patient and family). f In-room white boards (provide two-way communication, engage patient and family in plan of care, customize care coordination and discharge planning, hold staff accountable and promote collaboration between patient and health care team). f AIDET (staff reminder to Acknowledge, Introduce, predict Duration, provide Explanation, and Thank.) f Hourly rounds (staff proactively check on patient comfort and needs before issues emerge that may negatively impact safety or satisfaction). f Patient and Family Advisory Council.

Patient and Family advisers share invaluable insight to improve care experience A cadre of 12 community members—all either former Wilmington Hospital patients or family members—share their experiences with hospital management and staff at monthly forums, offering a unique perspective to help shape policies, programs, facility design and day-to-day service interactions to continuously improve the care experience.

Qu a l i t y a n d Sa f ety A nnu al Re por t | 9

CR EATING A SAFE CULTURE

Value Institute encourages providers to start with the patient

“We don’t want to finance unnecessary care; we want to finance care that adds value to our patients because that, in the end, is most sustainable.”

—Peter L. Slavin, M.D., President, Massachusetts General Hospital

“It’s about learning what we used to know; the things we knew before we became so well educated.”

Chris Coons, U.S. Senator, Delaware

The medical profession must refocus attention on the patient to deliver quality care at greater value, according to speakers at the Christiana Care Value Institute’s inaugural symposium “Value: Medicine’s New Frontier.”

More than 200 health care experts from many of the nation’s top institutions discussed how returning to the basics of medicine—listening to the patient, better use of resources and a greater emphasis on quality and safety— can transform patient care and deliver far greater value.

Christiana Care established the Value Institute to study and design solutions to the questions of value in the real world settings of health care delivery. It aims to implement strategies to achieve better health outcomes at lower costs.

1 0 | Chri sti ana Care Hea l th S ys tem

“The concept of value is grounded in the needs of our neighbors, as they perceive them.”

Robert J. Laskowski, M.D., MBA, President and CEO, Christiana Care Health System and Founder, Christiana Care Value Institute

“To tap into the value proposition, health care must address the emotional side of the equation.”

Arkadi Kuhlmann, HBA, MBA, LLD, ING DIRECT USA’s founder

The speaker lineup included widely respected thought leaders in the health care industry. Virginia L. Hood, M.D., immediate past president, American College of Physicians; David B. Nash, M.D., MBA, dean of the Jefferson School of Population Health; Michael Lauer, M.D., director of the Division of Cardiovascular Sciences at the National Heart, Lung and Blood Institute, National Institutes of Health; Peter L. Slavin, M.D., president of Massachusetts General Hospital; U.S. Senator Chris Coons (Delaware) and Arkadi Kuhlmann, HBA, MBA, LLD, founder of ING DIRECT USA, all joined Christiana Care President and CEO Robert J. Laskowski, M.D., MBA, on the dais.

“Value is more than the benefits of cross serving our patients’ needs,” said Dr. Laskowski in his address, “Value:

the Patient’s Perspective.” He added, “Those who deliver and finance health care must continually remind themselves that it is, first and foremost, the patient who is served.”

“Our issue of patient care, what the individual ‘feels,’ appears to matter at least as much as the facts,” he said.

“We who lead health care must understand these feelings as well as the facts if we are to improve quality and safety

and reduce costs.” Dr. Laskowski outlined his views in an April 26, 2012 op-ed on The Hill Congress Blog.

The April 30 debate covered conserving resources at the physician-patient level; quality and safety in health care, including educational reform for medical students; addressing consumers’ emotional assessment of the value equation; the scientific value of clinical trials; ways to make health care more affordable; and returning to the basics of care.

Surgical symposium offers insight to function, efficacy, cost and use of devices Christiana Care’s OB/GYN Value Improvement Team presented a comprehensive review of cost effectiveness data and comparative use of supplies and equipment relative to value at a December 2011 Value Institute-sponsored symposium entitled “Defining Value in the Surgical Environment.”

The symposium highlighted evidence-based guidelines to review and evaluate outcomes, quality and cost of the 14 priciest devices used by the departments of Surgery and Obstetrics and Gynecology. Surgeons received a detailed listing of GYN surgical supplies used in the preceding 18 months, as well as the hospital average supply cost for each procedure, allowing them to reassess individual surgical preferences based on best available data and apply new practices, if appropriate, to maximize value while maintaining optimal outcomes.

Keynote speaker Barbara Levy, M.D., former president of the American Association of Gynecologic Laparoscopists and a frequent guest on “The Oprah Winfrey Show,” suggested that with the right steps in place, gynecologists can successfully perform hysterectomies on an outpatient basis, reducing the need for inpatient stays and reducing costs substantially.

Mark J. Garcia, M.D., RSIR, chief of Interventional Radiology at Christiana Care and one of the few interventionalists nationwide specializing in the treatment of chronic clots, compared the clinical effectiveness and cost efficiency of fibroid embolization to other surgical methods.

Qu a l i t y a n d S a f ety A n nu al Re por t | 1 1

CR EATING A SAFE CULTURE

Advancing health care equity through cultural awareness, education and qualified medical interpretation 2500 1875 1250 625 0 11-Jul

11-Aug

All Languages Spanish Non-Spanish

11-Sep

11-Oct

11-Nov

11-Dec

12-Jan

12-Feb

# of Telephonic Interpretations

FY12 Telephonic Interpretations

12-Mar

Christiana Care’s network of 625 Cyracom telephones provides immediate access to trained and qualified interpreters in more than 170 languages. The top five languages in 2011 were: Spanish, Brazilian, Portuguese, Arabic, Mandarin and Korean. From July 2011 to March 2012, telephonic interpreters assisted in 16,095 patient encounters in 25–30 languages per month.

Our patients’ increasing cultural and linguistic diversity creates unique challenges for patient safety. Our ability to provide safe, high quality and equitable care depends on understanding the unique cultural needs of our patients and using qualified resources to communicate safely and effectively.

Christiana Care’s Center for Diversity, Cultural Competence and Communications offers various role-based education programs, including online educational modules, simulation labs, departmental training, online resources and cosponsored educational events with Nursing, Patient Safety, Quality and other departments. This year, we launched the first Diversity and Cultural Competency e-Learning module, which helps generate awareness and knowledge among employees of Diversity and Inclusion strategy expectations, basic concepts related to cultural competence, impact of language barriers on quality and patient safety, and available resources and tools.

A critical goal in establishing a culture of safety is the increased use of appropriate and qualified interpretation

1 2 | Chri sti ana Care Hea l th S ys tem

resources to communicate with patients who have limited English proficiency, and the elimination of “ad-hoc” interpretation by family, friends or staff members who have not been tested or trained as medical interpreters.

Qualified interpreters reduce such common errors as misinterpretation of medical information, violation of confidentiality laws and conflicts of interest.

While telephonic interpretation provides immediate access to qualified interpreters, this communication method is not always appropriate or feasible due to the complexity of the information being transmitted, patient mental status or other barriers. Christiana Care has increased staffing to four full-time Spanish-speaking medical interpreters. The number of in-person interpretation encounters has increased to an estimated 550 per month.

More than 200 consent forms, patient education and other documents are now translated into Spanish, with translation planned for other languages.

CREATING A SAFE CULTURE

HCAHPS scores exceed national median in most areas Patient Satisfaction

75%

50%

25%

Top Box Score (9 –10)

100%

Christiana Care scores above national levels in 6 of 8 survey areas, with the strongest performance in nursing and physician communication and pain management.

Christiana Care continues to exceed the national median in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) value-based scores in all but two areas—hospital environment and discharge planning.

Scores relating to how well we prepare patients for leaving the hospital on the HCAHPS survey—a government study for measuring patient perception of care across the country—escalated by as much as 22.7 percent on one nursing unit. A current average of 77.2 percent for all units combined indicates a positive trend.

Di Pro scha ce rge ss

Co Me mm dic un ati icat on io n– s

Pa ma in na ge me nt

Ho en spit vir al on me nt

Re ho spo sp nse ita l st of aff

Co Do mm cto un rs icat ion –

Co Nu mm rse un ica s tio n–

Ov of eral Ca l R re ati ng

0%

Christiana Care (July 11–Mar 12) National Median

Improving our hospital environment An audit measuring noise level variations and observations in eight rooms at Christiana Hospital will provide valuable guidance in improving our hospital environment scores.

Unit-based pilots are also studying ways to make patients more comfortable, such as: f Replacing wheels and castors on hospital equipment, such as blood pressure carts and IV poles. f Providing dual earpiece television headsets.

Discharge planning focuses on needs at home A renewed focus on consistently asking patients and their loved ones if they need help once they leave the hospital— in some cases supplemented by a phone call checking on the patient at home—is improving patient satisfaction with our discharge process.

f Placing or adjusting silencers on doors in patient care areas. f Installing white noise units and closing patient doors to minimize noise from the nursing station filtering into patient rooms.

Qu a l i t y a n d S a f ety A n nu al Re por t | 1 3

CR EATING A SAFE CULTURE

Employee Safety efforts create safer work environment Lost Time Injury Rate 4 3.5 3 2.5 2 1.5 CY2000

1 CY2002

FY2004

FY2006

0.5 FY2008

trend

FY2010

Injuries per 200,000 Hours Worked

4.5

0 FY2012

Christiana Care’s PEEPS© (Patient, Environment, Equipment, Posture, Safety) Employee Injury Prevention Program is credited with significantly reducing the number of lost time injuries suffered by nurses and patient care technicians due to transferring and repositioning patients. Lost time injuries decreased by 85 percent over the last decade.

Commitment to Safety First helps drive lost time injuries rate below industry average A systemwide commitment to Safety First, supported by sustained efforts to reduce lost time injuries (LTIs), continues to promote a safer work environment for Christiana Care employees. In FY 2011, the system adopted an aggressive goal of reducing LTIs below the national average of 1.7 (as benchmarked by the Bureau of Labor Statistics). Impressively, Christiana Care’s actual LTI rate for that period decreased to below 1.5. This represents a 33 percent reduction in injuries from FY 2010 to FY 2011 (176 injuries in FY 2010; 118 in FY 2011).

The Injury Reduction Team continues its efforts to further reduce workplace injuries, committing to maintain a

1 4 | Chri sti ana Care Hea l th Sys tem

lost time injury rate below 1.4 in FY 2012. The team is also expanding efforts to reduce all three categories of recordable injuries—those causing employees to lose time on the job; those that require the employee to assume restricted duty; and those, while not impacting the employee’s ability to work, still result in the need for medical treatment—with an established goal of reducing total recordable injuries to below 5.5 in FY 2012.

Christiana Care’s Employee Safety Program is a significant approach, incorporating technology, wellness and educational programming, aimed at changing behavior and practices, and, ultimately, keeping those who provide care throughout our facilities safe and on the job.

CREATING A SAFE CULTURE

Simulated scenarios drive interprofessional communication Simulated Scenarios

% Positive Responses

0%

25%

50%

75%

100%

Able to identify ETOH withdrawal Comfortable with CIWA Able to communicate with team members Able to identify delirium Comfortable with CAM

CIWA = Clinical Institute Withdrawal Assessment CAM = Confusion Assessment Method ETOH Withdrawal = Alcohol withdrawal Surveys show that practicing with actors increases nurses’ and residents’ ability to recognize and treat potentially aggressive symptoms, as well as to communicate more effectively with team members.

While working with robots and mannequins is paramount to honing technical skills required in patient care, there is no stand-in for human interaction when it comes to improving doctors’ and nurses’ ability to handle emotionally charged clinical situations. A collaboration between Christiana Care Health System and the University of Delaware, as one of the Delaware Health Science Alliance initiatives, sets the stage for nurses and residents to gain experience and confidence in

handling patients experiencing the effects of either alcohol withdrawal or delirium.

As a human-centered teaching tool, the process also allows the “patient” to offer health care providers such constructive feedback as “too much medical terminology,” “not enough eye contact” or “so focused on reviewing charts and checking IV lines that the patient felt ignored.”

Qu a l i t y a n d S a f ety A n nu al Re por t | 1 5

AC HIEV ING HIG H RELI ABI LI TY

Inspired by high reliability organizations in other riskladen industries, such as aviation and nuclear power, health care governing bodies such as the Joint Commission, the federal Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services are calling for industry-wide restructuring of leadership, goals and operations to ensure consistently reliable levels of safety and quality when it comes to patient care.

Christiana Care fervently embraces this opportunity to work toward near-perfect processes and to sustain the

1 6 | Chri sti ana Care Hea l th Sys tem

highest levels of safety and quality. Employing robust process improvement methods, such as Lean and change management, we are better able to identify root causes for systemic challenges and to create consistently employable solutions for success. Measuring and reporting outcomes leads to greater transparency and higher accountability.

While health care, in its service to people, will never be 100 percent reliable, our commitment toward achieving high reliability leads to a safer, more efficient, more cost-effective and higher quality care delivery system of value for our community.

ACHIEVING HIGH RELIABILITY

CUSP approach helps reduce central line associated bloodstream infections

60 50 50

40

-44%

30 28

20 10 0

FY11

Number of Patients Harmed

Central Line Associated Bloodstream Infections

FY12

The number of patients harmed by CLABSI has decreased by 44 percent.

Christiana Careâ&#x20AC;&#x2122;s all-out effort to eliminate central line associated bloodstream infections (CLABSI) is credited with a 44 percent decrease overall, with a majority of improvement realized in the intensive care units.

Using the Comprehensive Unit-Based Safety Program (CUSP) approach to identifying and learning from defects, Christiana Care joined a national collaborative to address the significant increase in patient morbidity and mortality, higher length of stay and greater costs associated with CLABSI. CUSP teams introduced several initiatives to improve insertion techniques, including: f Proper hand hygiene. f Full barrier drapes. f Skin preparation with chlorhexidine before insertion.

f Use of BiopatchÂŽ dressing (chlorhexidine impregnated sponge) that, unless compromised, is changed every seven days. This reduces the prior practice of more frequent dressing changes with greater associated opportunity to compromise the line. f Avoiding femoral lines or changing site as soon as possible.

An automated Central Line Insertion Checklist is incorporated in the Powerchart electronic medical record.

Nurses monitor and complete the checklist for all central line insertions and are empowered to stop the process if any checklist items are not complete. Nurses now assess daily the necessity of all invasive devices, including central lines.

Central line carts are now available to all units, and central line insertion simulation training is now required of all medical/surgical residents.

Qu a l i t y a n d S af ety A n nu al Re por t | 1 7

ACHIEVING HIGH RELIA BILITY

Reducing the risk of health care â&#x20AC;&#x201C;associated infections Ventilator Associated Pneumonia

95

80

-72%

60 40 20 27

Number of Patients Harmed

100

0 FY11

FY12

There were 68 fewer VAP cases this year. Efforts continue toward reaching the goal of zero VAP and sustaining improvements over time.

Unit-specific strategies to prevent Ventilator Associated Pneumonia (VAP), outlined by the Comprehensive UnitBased Safety Program (CUSP) teams and the Device and Procedures Task Force, include: f f f f

Head of bed >30 degrees.

Improved oral care (chlorhexidine).

Sedation vacations.

Daily weaning attempts.

Aggressive VAP prevention efforts continue through daily evaluation of the patientâ&#x20AC;&#x2122;s readiness to extubate and monitoring compliance with nursing interventions. CUSP teams concurrently review and discuss patient-specific strategies and share successes with bedside staff across nursing units.

Hand Hygiene Trend 100%

% of Observations

90%

Goal 90%

80% 70% 60% 50% 40% 9-Jun

1 8 | Chri sti ana Care Hea l th Sys tem

9-Nov

10-Apr

10-Sep

11-Feb

11-Jul

11-Dec

12-Apr

We exceeded our handwashing goal of 90 percent in five of the last six months.

ACHIEVING HIGH RELIABILITY

VTE incidence rate improves by 62 percent VTE prevention is an identified priority based on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, as well as comparative results from the National Surgical Quality Improvement Project (NSQIP).

A pre-operative risk assessment tool is the driving force behind a successful effort to help prevent venous thromboembolism (VTE), leading to a 62 percent improvement in the incidence of pulmonary embolism (PE) or deep vein thrombosis (DVT).

DVT is a blood clot in a deep vein, typically in the legs; the clot inside the blood vessel is called thrombosis. The thrombosis can dislodge, or embolize, without warning or symptoms and travel to the lungs, causing a lifethreatening pulmonary embolism.

To reduce harm associated with VTE, a Steer Committee focusing on surgical patients recommended the following pre-operative prevention strategies to complement the risk assessment tool:

f Implementation of an evidence-based algorithm to guide selection of appropriate prophylaxis based on the patientâ&#x20AC;&#x2122;s risk score. f Generation of a daily unit-level list of patients not receiving prophylaxis to prompt caregivers to intervene at point of care.

Compliance with VTE prevention guidelines will be concurrently monitored through the Lighthouse system in the Powerchart electronic patient record in accordance with Meaningful Use requirements. Lighthouse enables clinicians and frontline staff to immediately identify and intervene on patients without appropriate prophylaxis to prevent pulmonary embolism/DVTs.

Post-operative VTE rate

% of Surgical Cases

3% 2.5% 2% 1.5% 1% 0.5% 0% 10-Jul

11-Nov 12-Jan 11-May 11-Jul 11-Sep 10-Sep 10-Nov 11-Jan 11-Mar trend

The percent of patients with VTE decreased by 62 percent.

Qu a l i t y a n d S a f ety A n nu al Re por t | 1 9

ACHIEVING HIGH RELIA BILITY

Synchronized approach leads to safer patient-centered admissions Staff report that synchronized admission promotes a smooth work flow, facilitates communication among all stakeholders and promotes quality and safety during the transition from the Emergency Department to the inpatient unit.

Admissions from the Emergency Department (ED) to an inpatient unit arranged in concert by an experienced physician, resident, nurse, clinical pharmacist and social worker/case manager team working as a Synchronized Admission Team are improving quality and efficiency in the delivery of care.

Data shows a reduced length of stay, eliminating the need for Rapid Response Team (RRT) calls in the first 24 hours of the patientâ&#x20AC;&#x2122;s stay, while demonstrating no increase in readmission

rates or ED boarding hours. The process also increases core quality measure compliance for treatment of congestive heart failure, acute myocardial infarction and pneumoniaâ&#x20AC;&#x201D;with pneumonia compliance reaching 100 percent.

Synchronized admission makes the entire admissions process more expedient and efficient. Within minutes of receiving the alert of a patient requiring admission, the team huddles to review all available information in the electronic health record. They then meet as a team with the patient and family

Hospital Average Length of Stay

4 3.8

3.55

3 3.22

2 1 0

Pre-SWAT

Non-SWAT

Efficient admission processes and improved safety led to a 9 percent decrease in length of stay.

2 0 | Chri sti ana Care Hea l th Sys tem

SWAT

Number of Days

5

ACHIEVING HIGH RELIABILITY

Piloted at Christiana Careâ&#x20AC;&#x2122;s Wilmington campus in 2009 and expanded to the Stanton campus in January 2012, this re-engineered admissions process addresses the National Quality Forumâ&#x20AC;&#x2122;s national priorities of promoting effective communication and care coordination, as well as ensuring personand family-centered care. to collect additional information, allowing the patient to share his or her story only once to all involved in the admissions process. Each member then carries out his or her respective role in the admissions process, including partnering with the patient and family members for the plan of care.

Among its many benefits, the process offers the potential to reduce medication errors by ensuring the placement of medication orders by physicians at the time of admittance; consultation with the pharmacist at the time of order

entry; patient knowledge of the rationale for medication prescriptions; more accurate and timely medication allergy review; more timely medication order processing; fewer phone calls made to clarify medication orders with physicians; increased formulary compliance; and by giving the pharmacist a bedside role in patient care.

Rapid Response Team Calls within 24 hours of leaving ED 1.2%

% of patients

1.0%

20

23

0.8%

15 0.6% 10 0.4%

11 5

0.2%

Number of RRT Calls

25

0

0.0% 2 Pre-SWAT RRT within 24 hrs % of patients

Non-SWAT

SWAT

Effective communication and appropriate patient placement significantly reduce the need for calls to the Rapid Response Team.

Qu a l i t y a n d S a f ety A n nu al Re por t | 2 1

ACHIEVING HIGH RELIA BILITY

Structured interdisciplinary bedside rounds improve safety and efficiency Creation of a team-based approach to care that incorporates Structured Interdisciplinary Bedside Rounds (SIDRs) on one Christiana Hospital medical unit points to improved quality and safety, more efficient hospital operations and better communication between the physician and unit staff.

Physician-led SIDRs occur daily at the patient’s bedside, involving the patient and family, physician, bedside nurse, charge nurse, clinical pharmacist, respiratory therapist,

case manager and social worker. The patient and family are integrally involved in discussions, including plan of care and tentative discharge date, and participate in completing the safety checklist. Afternoon huddles were also implemented to enhance safe and efficient transitions out of the hospital.

SIDRs demonstrate impressive results to date. Plans are to spread to other hospitalist-based units.

Inpatient Average Length of Stay 5 4

4.51

3 3.71

3 2 1

Number of Days

4.73

0 Baseline Jul10–Jun11

Cohorting Aug11–Oct11

SIDRs Nov11–Apr12

Inpatient average length of stay decreased by 22 percent thanks to structured interdisciplinary rounds.

Readmissions within 30 Days of Discharge 20%

13%

15% 13.2%

10% 7% 3% 0%

Baseline SIDR process led to a 25 percent reduction in 30-day readmission rates.

2 2 | Chri sti ana Care Hea l th Sys tem

Cohorting

SIDRs

% of Patients

17% 17.7%

ACHIEVING HIGH RELIABILITY

Heart Failure core measure performance rises steadily Core measures for heart failure treatment are rising steadily and improving the reliability of care for patients with heart failure. Progress includes: f More timely identification of patients requiring specialized heart failure treatment. f More appropriate bed assignments from the Emergency Department to the heart failure unit or appropriate cohort. f Reduced length of stay. f Reduced 30-day readmissions. f Improved patient satisfaction. f Greater compliance with evidence-based guidelines.

One of nation’s busiest for heart failure care Christiana Care is one of the nation’s busiest heart failure treatment centers, ranking anywhere from fifth in volume

for mid-acuity to 22nd for high-acuity patients. More than 90 percent of heart failure patients admitted to Christiana Care come through the Emergency Department. Nearly two-thirds of patients with heart failure are cared for by a select group of hospitalists, community cardiologists or primary care physicians. Due to bed availability or cohorting for comorbidity, approximately half of the patients are admitted to the dedicated heart failure unit at Christiana Care’s Stanton campus; the other half are admitted throughout the nursing units at both campuses.

By engaging those providing the majority of heart failure care in the value improvement effort—and by involving representatives from the Emergency Department and the Visiting Nurse Association, which provides ongoing home disease management—the Value Improvement Team is working to improve the reliability of heart failure care at any touch point throughout the health system.

Christiana Care’s heart failure program holds the Joint Commission Gold Seal of Approval ™.

HF Overall Core Measure Performance improves each year Heart Failure Core Measure Composite Score Since Program Inception

90% 85%

87

86.2 85.1

80%

79.5

75% 76.2

Composite Score

90

70% FY 2007

FY 2008

FY 2009

FY 2010

FY 2011

FY 2012

Compliance with core measures increased by 20 percent through efforts of the Heart Failure Program. trend

Qu a l i t y a n d S a f ety A n nu al Re por t | 2 3

Value score cards track Value Improvement Team progress Christina Care is reducing variation in care and achieving high reliability through population-based Value Improvement Teams. Heart failure, acute myocardial infarction (heart attack), pneumonia and complications following surgery are among the priority areas where we focus on delivering greater value to our patients.

Heart Failure – 8% improvement in core measures, 20% reduction in readmissions, cost savings of $0.6 million.

Heart Failure ACTUAL

O/E or TARGET

PROGRESS

Guideline Compliance Discharge Instruction*

92.5%

+

Evaluation of LVS Function

100.0%

+

ACE/ARB for LVSD

100.0%

+

Patient Satisfaction

89%

+

Mortality

3.8%

○

24.8%

+

4.25

+

$7,867

+

Outcomes

Readmission Cost/Utilization Length of Stay Estimated Direct Cost Value Based Purchasing Impact

+

Current Value Score BASELINE

Acute Myocardial Infarction – Mean time to percutaneous coronary intervention decreased by 9 minutes, mortality improved by 8%, estimated cost savings of $1.5 million.

83.1 79.9

C+

ACTUAL

O/E or TARGET

B

Acute Myocardial Infarction PROGRESS

Guideline Compliance PCI Within 90 Minutes of Arrival*

96.9%

+

100.0%

+

96.2%

+

Patient Satisfaction

77%

+

Mortality

4.5%

+

12.5%

-

5.11

+

$23,056

+

Aspirin at Discharge Statin at Discharge Outcomes

Readmission Cost/Utilization Length of Stay Estimated Direct Cost Value Based Purchasing Impact

+

Current Value Score BASELINE

2 4 | Chri sti ana Care Hea l th S ys tem

85.2 84.0

B

B

Pneumonia – 7% increase in core measures, 14% reduction in readmissions, 7% decrease in length of stay, cost savings of $0.5 million.

Pneumonia ACTUAL

O/E or TARGET

PROGRESS

Guideline Compliance Blood Culture Pre Antibiotic*

89.4%

+

Initial Antibiotic Selection*

86.0%

○

Pneumococcal Vaccination

100.0%

+

Influenza Vaccination

100.0%

+

Patient Satisfaction

76%

+

Mortality

0.8%

○

Readmission

7.4%

+

4.07

+

$7,599

+

Outcomes

Cost/Utilization Length of Stay Estimated Direct Cost

○

Value Based Purchasing Impact Current Value Score BASELINE

87.4 76.9

B+

C

Surgical Care Improvement Project – Improvement in 7 of 9 measures.

Surgical Care Improvement Project ACTUAL

O/E or TARGET

PROGRESS

Guideline Compliance Prophylaxis Antibiotic Pre Incision*

97.5%

+

Prophylaxis Antibiotic Selection*

99.2%

○

Prophylaxis Antibiotic Discontinued*

99.1%

+

100.0%

+

98.5%

○

VTE Prophylaxis Order*

100.0%

+

VTE Prophylaxis Given*

100.0%

+

Postop Catheter Removed

94.1%

+

Postop Normothermia

93.3%

+

Postop Glucose Control* Periop Beta Blocker*

Value Based Purchasing Impact Composite Score

+ 93.0

Current Value Score BASELINE

+ 95.8

94.2

A

A

KEY TO SYMBOLS Guideline Compliance: *

Outcomes:

Progress:

Measure is included in VBP

Observed to Expected <= 1.0

YTD compared to baseline

>= Threshold (for measures with

O/E > 1.0 and <= 1.10

+

Improving toward target

baseline performance < threshold)

O/E > 1.10

-

Worsening compared to target

○

Flat compared to target

Between baseline & threshold < Baseline

Qu a l i t y a n d S a f ety A n nu al Re por t | 2 5

ACHIEVING HIGH RELIA BILITY

COPD disease management program reduces hospitalization

Im O pro Ma ral M vem na ed en ge t in m en t

D Co ischa m rg m e un to ity

Im Be pro d T ve ran me sfe nt i rri n ng

Im in pro Ba ve th me ing n t

Im in pro Ea ve tin m g ent

Im Am pro bu vem lat en ion t i n

Im in pro Dy ve sp me ne nt a

nt Em Ca erg re e

Ac Ho ute sp Ca ita re liz ati on

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

% of Patients

Outcomes for COPD Patients CY2011

CCHS VNA *Reference *Strategic Healthcare Programs, LLC

Patients enrolled in Christiana Care VNA’s disease management program do better in dyspnea (shortness of breath), ambulation, nutrition, bathing, bed transfer and oral medication management, and are less likely to need hospitalization than the national reference.

Innovative telehealth technology, which allows Christiana Care’s Visiting Nurse Association (VNA) to monitor appropriate patients with chronic obstructive pulmonary disease, plays a key role in improving patient outcomes and leads to 13 percent fewer hospitalizations than the SHP* reported national reference.

Telehealth allows direct daily cellular transmission of vital signs, such as weight, blood pressure and pulse oximetry, and other symptom information to a nurse who reviews the data. Any information outside the patient’s doctor-ordered “Patients who participate in their care through daily monitoring connect the dots to identify that healthy behaviors coincide with feeling their best.”

—Gale Bucher, MSN, RN, COS-C, Director of Quality & Risk Management, Christiana Care Visiting Nurse Association

2 6 | Chri sti ana Care Hea l th S ys tem

parameters is discussed with the patient, field clinician and doctor, as warranted, to plan appropriate interventions.

VNA home health nurses use a coaching approach to empower patients to manage their chronic disease.

Following evidence-based care plans, they educate patients on symptom recognition, disease process, treatment regime, medication management and, if appropriate, telehealth.

Physical therapists may also work with these patients on energy conservation and increasing endurance. A VNA pilot program studies the benefits of having a respiratory therapist educate patients on medication and equipment.

When patients learn how to better manage their condition, fewer emergency room visits are needed. Many times, VNA’s timely intervention means less time in the emergency room and less need for costly hospitalization.

ACHIEVING HIGH RELIABILITY

Perioperative Services redesigns process flow to improve efficiency Room Turnover Time

Median Minutes

45 40 35 30 25 10-Jun

10-Aug

10-Oct

10-Dec

11-Feb

11-Apr

11-Jun

11-Aug

Process flow improvement decreased operating room turnover time by 8 1/2 minutes—a 20 percent reduction. With more than 50 surgeries scheduled a day, that translates to seven hours.

In its first few months, a restructured process flow— spearheaded by the Perioperative Services Financial Strength and Operational Efficiency Steer group—is already improving value to surgical patients by minimizing patient waits and synchronizing care tasks.

The improvement starts days before surgery when a case posts to the Christiana OR. More than 90 percent of patient charts are now complete 48 hours prior to

11-Dec

11-Oct baseline

surgery—negating historic last-minute surgical delays due to incomplete documentation. The group also streamlined processes on the day of surgery through efficient assignment of patient care tasks and by improving handoffs and communication among the Special Procedures Unit, Prep & Holding, the Operating Room and the Post-Anesthesia Care Unit. Their efforts increased OR turnaround time by 20 percent, increased the percentage of first case on-time starts by 65 percent and lowered costs.

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% On-Time Baseline Current

On-Time plus 5 min

% of First Cases

On Time Surgical Case Starts

On-Time plus 10 min

Percentage of first cases started on time improved by 65 percent.

Almost 90 percent now start within 10 minutes of scheduled time.

Qu a l i t y a n d S a f ety A n nu al Re por t | 2 7

Christiana Care helps develop national episiotomy guidelines Christiana Care is taking a leading role in developing national guidelines for the obstetrical practice of episiotomy, the surgical incision to enlarge the vaginal opening during childbirth in order to aid delivery and prevent tissue damage. Evidence shows that the procedure, once thought to prevent more serious vaginal tears and reduce the patient’s risk of incontinence, in fact increases the risk of serious lacerations and contributes to stool incontinence.

Christiana Care and the National Perinatal Information Center (NPIC) petitioned the National Quality Forum (NQF) to support the goal of establishing episiotomy rate as an indicator of the quality of perinatal services.

NQF’s November 2011 endorsement takes the standard of low episiotomy rates a step closer to becoming adopted

by the Joint Commission. Matthew Hoffman, M.D., MPH, Christiana Care’s director of OB/GYN Education & Research, serves on the Joint Commission Technical Advisory Panel, which makes the final decision on all adopted quality markers.

Christiana Care launched an educational program for OB/GYN providers on the procedure and the lack of benefit to patients in October 2008. Between the fiscal years 2008–2010, Christiana Care’s episiotomy rate declined 55 percent. In 2010, only 1 percent of the health system’s obstetricians had an episiotomy rate of more than 20 percent, compared to 25 percent of physicians in 2004. The system’s overall episiotomy rate is currently under 2 percent.

“In the future, hospitals will be judged on their episiotomy rates as a quality marker. Christiana Care is already there.”

—Matthew Hoffman, M.D., MPH, Director of OB/GYN Education & Research Episiotomy Rate FY04 - FY11

13% 11% 8% 5% 3% 0% FY04

FY05

FY06

FY07

FY08

Between fiscal years 2008 and 2010, Christiana Care’s episiotomy rate declined 55 percent. Currently, our rate is under 2 percent.

2 8 | Chri sti ana Care Hea l th Sys tem

FY09

FY10

FY11

FY12 YTD (March 2012)

Episiotomy Rate

16%

ACHIEVING HIGH RELIABILITY

MICU Alert expedites care

Improves reliability; shortens length of stay The Christiana Rapid Transfer Initiative: MICU Alert ensures that acutely ill Emergency Department (ED) patients are either rapidly transferred to the Medical Intensive Care Unit (MICU) or, in high capacity situations when a MICU bed is not readily available, stabilized and intensively cared for right in the ED by a dedicated MICU team.

The initiative, which expanded from pilot to deployment in January 2012, ensures a highly reliable, consistent level of care and expedites critical clinical decision making and

therapy for patients requiring the most intense level of care.

It also frees up Emergency Department beds and ED staff resources required by critically ill patients. f Median response time to ED is under 15 minutes. f Median ED length of stay reduced by 47%, or 4.2 hours (compared to the baseline time period Januaryâ&#x20AC;&#x201C; March 2011). f Projected to save 3,967 ED hours this year. f Average MICU length of stay reduced by 1.5 days.

Emergency Department Length of Stay

ED Length of Stay (Hours)

40

30

20

10

0 2010

2011

2012

For the ED length of stay above the 25th percentile, the new process statistically shortened the LOS for our sickest patients.

Qu a l i t y a n d S a f ety A n nu al Re por t | 2 9

ACHIEVING HIGH RELIA BILITY

An “out of the block” approach to surgical scheduling Number of Cases per Operating Room 1300 1253

1140 980

1054

820

# of Cases

19%

660 500 2010

2011

The Christiana Surgicenter achieved a 19 percent increase in OR productivity with the improved scheduling process.

New system gets cases scheduled sooner; enhances productivity Productivity is at an all-time high for the Christiana Surgicenter thanks to an improved scheduling model that allows greater room availability to about 200 community surgeons. The facility now schedules 20–45 cases per day; about 7,000 each year.

regardless of whether the surgeon actually scheduled a case for that time slot. As competition in the ambulatory surgery market increased in recent years, the Surgicenter found itself unable to meet scheduling requests from other practices due to block time. Surgical volume decreased while operating rooms sat empty—staffed and ready—but with no scheduled cases.

A new approach to surgical scheduling, based on type of surgery instead of the traditional block-by-surgeon model, allows surgical practices to schedule cases more promptly and shaves weeks off of the time patients previously waited for worrisome diagnostic procedures at the Christiana Surgicenter. Not only does the move free up desirable OR time and improve accessibility for surgeons and patients, it also improves efficiency at the Surgicenter itself. In the first nine months of the new service-specific scheduling model, cases increased by 2.6 percent after eight consecutive years of declining surgical volume, and productivity soared by 19.6 percent per operating room.

The revised scheduling model allocates OR time by service line, and no longer limits blocks to a specific surgeon.

Cases are now scheduled first come, first served. Blocks of time continue to be allocated based on historical use by service line, with gynecology cases accounting for more than 40 percent of block time. One un-blocked room is on reserve for last-minute add-ons.

Historically, operating rooms allocated blocks of time to select high-volume surgeons, reserving a room and staff

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With this dramatic, but necessary shift from traditional OR scheduling, accessibility is enhanced, wait times are reduced, cases are no longer unnecessarily turned away, and overall provider and patient satisfaction levels have increased.

ACHIEVING HIGH RELIABILITY

Project Engage transitions addicted patients to community-based treatment Christiana Care’s Project Engage is successfully transitioning a high rate of addicted patients with substance-related medical problems to community-based treatment programs following screening, intervention and referral by engagement specialists embedded within both Christiana and Wilmington hospitals.

In September 2011, White House Deputy Director of the Office of National Drug Control Policy David K. Mineta visited Christiana Care to learn more about the program that, in its pilot phase at the Wilmington campus, achieved:

33% reduction in emergency n room and inpatient utilization

88% increase in primary care utilization

30–40% increase in drug treatment utilization

$89,000 savings

A $1.1 million anonymous gift expanded Project Engage in November 2011 from a Wilmington campus–based pilot to a fully funded three-year program now launched at the Stanton campus, as well, with two additional patient engagement specialists. A full-time social worker—an expert in addictionrelated community resources—serves both campuses as team leader. The gift also funds a robust program evaluation conducted in collaboration with Christiana Care’s Center for Outcomes Research and the University of Pennsylvania.

Since the pilot’s launch in September 2008, Project Engage specialists have worked with 667 patients, 36 percent of whom are now successfully transitioned to community based substance abuse treatment. A recent health care cost analysis

by DPCI-Aetna reveals $190,000 in inpatient savings when comparing the pre- to post-intervention costs of 30 patients seen in 2011.

Project Engage is in collaboration with Brandywine Counseling & Community Services and Aetna Medicaid Plan Delaware Physicians Care for innovative reimbursement and access to fiscal outcome data.

“We’re going after people who are very dependent and stuck in that revolving door between the community and the emergency room and the hospital. It burns up tremendous health care resources and doesn’t tend to the root cause issue, which is their addiction.”

—Terry Horton, M.D., Chief of Addiction Medicine

Qu a l i t y a n d S a f ety A n nu al Re por t | 3 1

LEV ER AGIN G T EC HNO LO GY

Long recognized for its capacity to help us provide more sophisticated care, technology now, too, is credited in limitless ways with making that care safer and more efficient.

Electronic health records connect thousands of providers throughout the state with common access to patient health histories, lab and procedure results, vaccination data and medication lists, leading to more carefully aligned, coordinated care. Computerized order entry negates the risks associated with interpreting handwritten physician orders and allows the pharmacy to immediately screen prescriptions to

3 2 | Chri sti ana Care Hea l th Sys tem

verify accuracy and efficacy. Interpretation of transmitted data allows a real-time approach to disease management and alerts clinicians to the possibility of required intervention.

Technology will never completely replace paper, nor can it ever negate the need for human knowledge or talent.

But it is of inestimable worth in helping us to enhance the quality and safety of our care, as well as to measure and report successes and opportunities.

Qu a l i t y & S a f ety A n nu al Re por t | 3 2

LEVERAGING TECHNOLOG Y

Electronic health records poised to demonstrate Meaningful Use Christiana Care’s four certified electronic health record (EHR) platforms—PowerChart, Centricity, GEMMS and AllScripts—are aligned to meet Stage 1 criteria and proceed to Stage 2 for operational use of 19 pre-defined Meaningful Use criteria by June 2012.

This first stage confirms that an electronic health system is capable of capturing and sharing required information, such as demographics, medications, allergies, lab results and clinical decision support. Future stages require that the EHR helps advance clinical processes and contribute to improved outcomes.

While Meaningful Use aligns with and will provide financial support to execute Christiana Care’s clinical Information Technology strategy, it goes far beyond dollars and cents to ensure safer, more reliable and more efficient care. Electronic health records reduce medication errors caused by illegibility. Prescriptions go directly to the pharmacy, increasing efficiency. Shared information among providers allows ready access to

Meaningful Use • Improves quality, safety and efficiency.

• Improves care coordination.

• Engages patients and families in their care.

• Improves population and public health and reduces disparities in care.

• Ensures privacy and security protections.

“Meaningful Use ensures that the investment in electronic health records impacts the quality of care delivered to patients.”

—Janice Nevin, M.D., MPH, Chief Medical Officer clinical outcomes and public health data, helping to improve performance in managing chronic diseases.

Repeated tests and other inefficiencies are eliminated, and evidence-based results on treatment alternatives and outcomes are readily available to clinicians.

Part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, Meaningful Use provides incentive dollars, and likewise carries stiff penalties, to ensure that providers complete three stages of requirements by 2015. In FY 2012, Christiana Care is expected to receive approximately $2.7 million in stimulus funds from the state Medicaid program for adopting, implementing or upgrading an EHR, with a grand total of approximately $17 million from both state and federal programs over the six-year Meaningful Use timeframe.

Targeted areas for Meaningful Use: CPOE Problem List Medication List Medication Allergy List Record Vital Signs Record Smoking Status Record Demographics Patient-Specific Education Medication Reconciliation

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LEVERAGING TECHNOLOGY

Electronic sign-in system streamlines trauma response A custom-designed electronic communication tool streamlines Christiana Care’s trauma response documentation system, allowing responders to work quickly and seamlessly, while addressing trauma resuscitation challenges, such as role delineation, crowd control issues and noise-related concerns.

Trauma bays are hectic, crowded environments with multiple providers caring for critically injured patients. Responders’ photos, names and role appear on the screen promoting communication and teamwork and clearly defining each responder’s role at sign in.

The system features easily viewable 22-inch monitors posted outside the trauma room; 42-inch screens inside. These large displays replace conventional paper forms on clipboards for easy and simultaneous viewing of trauma-related information, including pre-hospital reports and trauma responder sign-in.

This reduces the need for verbal repetition of the report—a prime contributor to the increased noise level and care provider interruptions trauma teams struggled with using the old paper system. Electronic sign-in also solves the problem of identifying gowned, gloved and masked responders for documentation required by the American College of Surgeons.

A multidisciplinary team of trauma responders, Emergency Department practitioners and clerical staff, and Information Technology developers designed and built the customized electronic process credited with:

Improves Identification of Staff

6%

f f f f

Improving communication.

Enhancing identification of role delineation.

Reducing the noise level in the trauma bay.

Reducing the number of non-participating personnel in the room.

Improves Identification of Roles

2%

4% 12%

43%

54% 38% 41%

Strongly Agree Agree Undecided Disagree Strongly Disagree 92 percent of respondents agreed or strongly agreed that the process is simple and that the system improves identification of staff in the trauma bays.

3 4 | Chri sti ana Care Hea l th Sys tem

Strongly Agree Agree Undecided Disagree Strongly Disagree 84 percent of respondents say the information displayed improves identification of who is filling each role.

LEVERAGING TECHNOLOG Y

Information Week 500 ranks Christiana Care among nation’s top in innovation Trauma room touchscreens lauded as “idea to steal” Information Week 500 recognized Christiana Care’s use of large touch-screen monitors to better manage Emergency Department trauma rooms among the “20 IT innovative ideas to steal.” The magazine also ranks Christiana Care among the top 500 (#232) of North American enterprise IT.

Computerworld bestows Laureate award for self-assessment software The tool was piloted for use by patients with cancer or heart failure and will soon be released to a wider patient audience for use with an Apple iPad. Seventy-six percent of patients report they like using Insight, with 67 percent saying the tool better prepares them to speak with their doctor.

The International Data Group’s Computerworld Honors Program selected Christiana Care’s Information Technology team from among 500 nominees for a 2012 Laureate award in the health category for the health system’s Insight software. This self-assessment tool promotes meaningful dialogue between patients and their physicians by allowing patients to report severity of symptoms and how those symptoms affect quality of life using a tablet-based, clinician-friendly wireless format.

Teresa Gillis, M.D., medical director of Oncology Pain and Symptom Management and Rehabilitation Services, and Mitchell Saltzberg, M.D., medical director of the Heart Failure Program, along with Information Technology team members Mike Bledsoe, Jon Reynolds, John DiGiovanni, and Catherine Burch, are named as 2012 Computerworld Honors Laureates for their innovative thinking and for their clinical and technical expertise.

Christiana Care also earned Top Five recognition in Computerworld’s health category competition at its annual awards ceremony in June 2012.

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LEVERAGING TECHNOLOGY

Electronic health record improves vaccination rates A more streamlined “smart” process incorporated into the Powerchart electronic health record ensures that all eligible patients now receive seasonal influenza and pneumococcal vaccinations, contributing to a safer care environment.

Vaccination rates rose steadily with the process redesign coinciding with the start of influenza season in October 2011, followed by the launch of the “smart” pneumococcal vaccination process in January 2012 in accordance with

regulatory changes for public reporting of these measures.

Both rates are now steadfast at 100 percent for patients with pneumonia, and exceed 90 percent for all eligible patients.

Electronic health records are an instrumental tool in completing assessment, administration and documentation in a timely manner, leading to efficiencies and safety enhancements. The renewed process simplifies the vaccination process, aligning it with nursing workflow.

Pneumococcal Vaccination

% of Qualified Patients

100% 80% 60% 40% 20% 0%

Nov-09

Jul-09

Mar-10

Jul-10

Nov-10

Mar-11

Jul-11

Nov-11

Mar-12

trend

Influenza Vaccination 100% 80% 60% 40% 20% 0% Aug-09

Dec-09

Mar-10

Jul-10

Nov-10

Mar-11

Jul-11

Nov-11

Electronic health records help track compliance with standing orders for all qualified patients. Historically measured for pneumonia patients for public reporting, Christiana Care’s influenza vaccination rate reached 100 percent between December 2011 and February 2012—prime influenza season.

3 6 | Chri sti ana Care Hea l th Sys tem

Mar-12

LEVERAGING TECHNOLOG Y

Flex monitoring technology shows predictive pattern in Code Blue Analysis may help define why patients are coding Research fueled by innovative flex monitoring technology suggests that a slow heart rate known as bradycardia— not fast or erratic episodes of ventricular tachycardia or fibrillation as previously believed—is the most common cause of a non-ICU code blue (cardiopulmonary arrest) in the hospitalized patient. Those patients that experience the bradycardia prior to the code blue have a much worse prognosis, suggesting that bradycardia may be a key indicator of impending cardiopulmonary arrest.

The finding, published online by Resuscitation in March 2012, underscores a need for better and more consistent monitoring of patients outside the intensive care unit.

Now that research suggests the technology can actually detect if a patient is going to code, a team can be dispatched sooner to initiate life-saving care.

Christiana Care’s cutting edge flex monitoring telemetry system, noted among the largest, most advanced in the United States, allows uninterrupted telemetry monitoring of any patient at any location throughout Christiana and Wilmington hospitals.

Christiana Care researchers joined colleagues from Children’s Hospital of Philadelphia to author the study.

Telemetry monitoring depicts a predictive pattern in code blue.

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LEVERAGING TECHNOLOGY

Vocera improves communication and patient safety

6,120 Vocera calls

X

3 saved minutes

The Vocera two-way, real-time, hands-free communication system allows Christiana Care nurses and patient care technicians to remain with their patients while keeping abreast of information that formerly tied them to the computer or telephone. The technology also improves efficiency by locating the right person in time-critical situations, allows information to be broadcast to multiple users simultaneously—critical in convening resources to mitigate and manage patient safety issues—and improves communication both among departments and between nurses and physicians.

Vocera targets for quality and safety: • Patient safety.

• Patient flow.

• Staff efficiency.

3 8 | Chri sti ana Care Hea l th S ys tem

=

306 hours staff remained involved in patient care

More than 28 departments throughout the health system are now linked via Vocera, which uses voice activation to directly contact either an individual team member or the person filling a particular role on that shift.

Prior to Vocera, when the flex monitoring team needed to contact the unit regarding a critically ill patient, the call went to a central line. Urgent calls now go directly to the patient’s nurse, allowing him or her to remain at the bedside while in communication. The system also allows ancillary departments and nurses to more efficiently prepare for patient handoffs.

Prior to Vocera, it took a nurse between 2–5 minutes to log on to a computer, look up a number in the directory and place a telephone call. Vocera enables immediate notification.

Awards, Recognition and Accomplishments FY 2012

The Christiana Care Breast Center at the Helen F. Graham Cancer Center achieved the American College of Radiology Gold Standard in Imaging Accreditation in breast magnetic resonance imaging (MRI).

Christiana Care’s Center for Heart & Vascular Health holds the American Heart Association/American Stroke Association’s Get with the Guidelines® Gold Plus Quality Achievement Award for Stroke and Gold Quality Achievement Award for Heart Failure.

Becker’s 2011 Hospital Review/Becker’s ASC Review lists Christiana Care among the Best Places to Work in Healthcare.

The Centers for Medicare & Medicaid Services presented Certificates of Excellence to Christiana Care for collaboration in hospital-acquired methicillin-resistant staphylococcus aureus (MRSA) and pressure ulcer prevention projects conducted by Quality Insights of Delaware.

Diversified Clinical Services recognized Christiana Care’s Wound Care for delivering outstanding results in wound healing and patient satisfaction for 12 consecutive months.

The Foundation for the Accreditation of Cellular Therapy accredited Christiana Care’s Bone Marrow Transplant Program for high quality medical and laboratory practice in cellular therapies.

GetWellNetwork presented the Care Process Integration Award to Christiana Care at the organization’s third annual Patient Care Awards.

For the third consecutive year, the Society of Thoracic Surgeons granted a three-star gold standard rating to Christiana Care’s Center for Heart & Vascular Health. Fewer than 15 percent of the more than 1,000 heart programs surveyed achieve this highest designation bestowed in the comparison of the quality of heart surgery among U.S. hospitals.

Standard & Poor’s upgraded Christiana Care’s long-term debt rating to AA, indicating “very strong capacity” to meet financial obligations.

Thomson Reuters named Christiana Care a 2012 recipient of its Healthcare Advantage Award, which recognizes the use of data analytics to improve quality of care and business results.

Training magazine ranked Christiana Care’s employer-sponsored training and development program number 60 in the Top 125 companies in the nation.

U.S. News & World Report ranks Christiana Care among the Top 10 Best Hospitals in the Philadelphia Metropolitan Area for high performance in 11 adult medical specialties.

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IN THE SPOTLIGHT NATIONALLY Christiana Care achieved a hospital safety score of “A” from The Leapfrog Group in the first-ever report card on safety in the nation’s hospitals.

The Agency for Healthcare Research and Quality (AHRQ) Innovations Exchange recognizes Christiana Care’s efforts in applying high reliability concepts in creating and sustaining a Safety Mentor Program, the Sepsis Alert campaign, the eCare system and Alcohol Withdrawal Risk Evaluation and Treatment guidelines.

Christiana Care’s Community Clinical Oncology Program ranks among the nation’s top enrollers in cancer clinical trials in the newly formed Alliance of Clinical Trials in Oncology, placing sixth in treatment trials and first in cancer control trials that seek to prevent cancer or control its incidence.

The Association of American Medical Colleges features Christiana Care’s UnitBased Clinical Leadership Model on MedEdPORTAL®, the association’s peer-reviewed publication service and repository for medical and oral health teaching materials, assessment tools and faculty development resources.

In collaboration with ECRI Institute, in June 2012 Christiana Care hosted the national conference, “Building Bridges: Connecting Comprehensive Event Investigation with Effective Analysis and Strategic Correction of Causative Factors.”

Christiana Care holds Joint Commission Disease Specific Certification for joint replacement (hip and knee) and Advanced Certification for heart failure and primary stroke center. Certification acknowledges compliance with consensus-based national standards, effective use of evidence-based clinical practice guidelines to manage and optimize care, and an organized approach to performance measures and improvement activities.

The U.S. Department of Health and Human Services selected Christiana Care as one of 16 Independence at Home participants. A provision of the Affordable Care Act, this threeyear, in-home pilot program encourages doctors to visit the sickest Medicare beneficiaries in their homes to avoid unnecessary emergency room visits, hospitalizations and long-term care.

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IN THE SPOTLIGHT REGIONALLY The News Journal names Christiana Care a Top Workplace Employer, ranking it sixth in the large workplace category and best in career opportunities.

Christiana Care is an approved participating hospital in Jefferson Medical College’s Delaware Branch Campus.

Christiana Care’s Stanton campus is designated a Level-2 pediatric center, and the Wilmington campus is designated a Level-3 pediatric center in Delaware’s newly launched Pediatric Emergency Care Facility Recognition Program.

The Helen F. Graham Cancer Center joins Philadelphia’s Wistar Institute and Temple University in developing the world’s first practical blood test for lung cancer.

Christiana Care is teaming up with Thomas Jefferson and Temple universities in Philadelphia to form one of only nine elite National Institutes of Health Heart Failure Clinical Research Centers in the nation, providing scientific leadership for the seven-year project that focuses on small-to-intermediate randomized clinical trials devoted to improving outcomes for patients with heart failure.

IN THE SPOTLIGHT AT CHRISTIANA CARE Focus on Excellence Awards

Christiana Care’s Ninth Annual Focus on Excellence Awards program formally recognized 24 teams of employees and physicians whose projects demonstrate improvement in process or outcomes using the Plan-Do-Check-Act model.

The annual gathering is a way for Christiana Care employees and physicians to celebrate shared beliefs, including a culture of safety and commitment to value.

President’s Award

Clinical Excellence – Gold

A Multidisciplinary Approach to Reducing Unit Acquired Pressure Ulcers

S.O.S.! Standardized Order Sets Answer a Distress Call for Inpatient Chemotherapy

Value Award

Clinical Excellence – Silver

Impact of a Dedicated Respiratory Team: Liberating Patients from Ventilation

Improving Processes for Vaccine Compliance

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Clinical Excellence – Bronze

Nursing Excellence –

Individual Discharge Assessment: Identification of Patients at Risk for Readmission

Structural Empowerment

Safety First – Gold

Reducing Peripheral Long Line Associated with Blood Stream Infections in Preterm Infants

Nursing Excellence –

Safety First – Silver

Learning Excellence

Post Event Debriefs: “Facts as Known”

Quality TIPS (Teams Improving Processes)

Great Place to Work

Residents’ Award

Keeping Employees Healthy for Life

Hemoglobin and Lead Screening

Think of Yourself as a Patient

Operational Improvement – Gold

Phase II: Innovation in Patient Education

Heart & Vascular Intervention Services: Redesigning a System for Success

Financial Strength

Transformational Leadership

Building Nursing Quality and Safety

Prescription Drug and Pharmacy Restructure

Operational Improvement –

Nursing Excellence –

Trauma Sign-in Initiative

Empirical Outcomes

Excellence in Community Health – Gold

Falls Prevention Champion Team at the Center for Advanced Joint Replacement

Chemotherapy in the Home: Changing the Process to Improve Patient Safety

Nursing Excellence –

Excellence in Community Health –

Exemplary Professional Practice

Honorable Mention

Daily Communication and Goal Planning Board

Improving Therapeutic Time in Range for the AMO Anticoagulation Patients

Nursing Excellence –

Employee Safety

New Knowledge – Gold

Ceiling Mounted Lift Usage in the Christiana Emergency Department

Cozy Cuties: Reducing Delivery Room Hypothermia Nursing Excellence – New Knowledge – Silver

Improve Pain Assessment and Documentation

4 2 | Chri sti ana Care Hea l th S ys tem

Hand Hygiene Campaign: Get Your Clean On

Honorable Mention

People’s Choice

Safe at Home Base: Improving Discharge Medication Reconciliation

PRESENTATIONS “The Road Less Traveled: An Adult Combined Medical and Surgical Intensive Care Unit’s Journey to Integrate Patient and Family into the Health Care Team.” June 2012. 5th International Conference on Patient and Family-Centered Care. Washington, DC. “Medicine Unit Structured Interdisciplinary Rounds to Improve Patient Safety.” June 2012.

2012 AAMC Integrating Quality Meeting. Chicago.

“Improving Quality and Cost – A Value Team Approach.” May 2012. Visiting Nurses Association of America Hospice and Home Health Conference. Phoenix.

“Christiana Care’s Home Visit Program: Further Success in House Call Medicine.” May 2012. American Geriatric Society Conference. Seattle.

“Using a Value Score Card to Improve Quality and Decrease Costs While Enhancing the Patient Experience.” May 2012. Thomson Reuters Advantage Conference. Orlando.

“Post-Event Debriefs: A Commitment to Better Care for Our Patients and Staff.” May 2012.

National Patient Safety Foundation Patient Safety Congress. Washington, D.C. “Measuring and Improving the Value of Healthcare Using a Value Score.” May 2012.

American Society for Quality World Conference on Quality and Improvement. Anaheim.

“Transforming Healthcare Through a Unit-Based Clinical Leadership Model.” May 2012.

SCIM Annual Meeting: Innovations Poster Session 1. Orlando; and March 2012.

AIAMC Annual Meeting. Tucson.

“Case Study for Curriculum Development for Medical Education: A Six-Step Approach.”

March 2012. AIAMC National Initiative III: Improving Patient Care Through Medical Education, Meeting Two. Tucson.

“Teamwork and Technology; A Unique Collaboration for Patient Safety with an Automated Implantable Cardioverter-Defibrillator (AICD), Neuromuscular Electrical Stimulation and Flexible Monitoring;” “Interprofessional growth: Building a model for advanced nursing practice in rehabilitation;” and “Show That We Care Campaign: Working Smarter Using State-of-the-Art Technology.” November 2011. 36th annual Association of Rehabilitation Nurses Education Conference. Las Vegas.

“Determining the Most Up-to-Date CMS Regulations and How it Impacts Hospital Operations.” October 2011. World Congress 8th Annual Observation Patient Management Conference — West Coast. San Diego.

“OB/GYN Value Improvement Team Project.” October 2011. CWISH 2011 Annual Conference. Pittsburgh.

“Creating an Education Program for Competent Care of the LVAD Patient in a Preimplantation Facility.” June 2011. American Association of Heart Failure Nurses (AAHFN) Annual Conference. Seattle.

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PUBLICATIONS “Epidemiology of stillbirth in low-middle income countries; a global network study.” Acta Obstetricia et Gynecologica Scaninavica. September 2011.

“The impact of guidelines limiting elective delivery prior to 39 weeks on rates of elective induction and cesarean delivery: 552.” American Journal of Obstetrics & Gynecology. 2011; 204(1): SS21–S222.

“Balancing the Risks and Benefits of Proton Pump Inhibitors.” Annals of Family Medicine.

2011; 9(3):200–202.

“Experiences with Community Kangaroo Mother Care in Very Low-Income Settings.”

Current Women’s Health Reviews. August 2011; Vol. 7(3):310–316(7).

“Chemotherapy in Home Care: One Team’s Journey towards improving Patient Safety.”

Home Healthcare Nurse — Medscape/WebMD on “HIV/Aids at 30.” (http://www. medscape.com/viewarticle/746153).

“Prevalence and Outcomes of Same-Day Discharge After Elective Percutaneous Coronary Intervention Among Older Patients.” Journal of the American Medical Association. 2011; 306(13):1461–1467.

“Ensuring Safe and Quality Medication Use in Nuclear Medicine: A Collaborative Team Achieves Compliance with Medication Management Standards.” Journal of Nuclear Medicine Technology. 2012 Jan 25.

“Obesity and Cancer Screening According to Race and Gender.” Journal of Obesity. Volume 2011, Article ID 218250, 10 pages doi: 1155/2011/218250.

“Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy.”

New England Journal of Medicine. 2011; 365:2255–2267.

“Nurse Staffing, Hospital Operations, Care Quality, and Common Sense.” Nursing. August 2011.

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WORK & TUMBLE 27635 C.Care (Cover) 1 A 06/26/2012 07:52:31 CyanMagentaYellowBlack 12PERF2

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

PO Box 1668 Wilmington, Delaware 19899-1668 www.christianacare.org

Synchronized Admissions Teams collaborate on interdisciplinary assessment. See pages 21-22.

Quality and Safety 2012 ANNUAL REPORT ON 27635_Cover_Layout 1 6/26/12 7:23 AM Page 2

27635_Cover_Layout 1 6/26/12 7:24 AM Page 3

Our Journey

A message from the President and CEO

Creating a Safe Culture .................................................................................................................................................. 1 Achieving High Reliability .......................................................................................................................................... 16 Leveraging Technology ............................................................................................................................................... 32 Awards, Recognition & Achievements .................................................................................................................... 39

GH IG IN EV

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

HI

RE

Robert J. Laskowski, M.D., MBA President and Chief Executive Officer

QUALITY AND SAFETY

U LT CU FE SA GA

— P RO G R A M I N I T I AT I V E S 2 0 0 7 t o 2 0 1 2

2007

2008

2009

2010

2011

2012

Partners in Learning for Safety/ Just Culture Council

Safety First Learning Report

Culture Survey (January)

Culture Survey (October)

Culture of Responsibility Phase II (Oct.)

Culture Survey (April)

Enhancements for Follow Up

Culture of Responsibility (Planning)

Culture of Responsibility Phase I (June)

Human Resources and Safety Standards for Event Follow Up

Just Culture Concepts (Planning)

Patient and Community Involvement

SAFE Weekly Huddles

Standarized Hand Offs for Transitions of Care in Women’s Health

Culture of Responsibility Phase III (October)

Human Factor Analysis for Flex Monitoring

Post Event Debriefs Partners in Safety Updates

Human Factors Analysis for Radiation Oncology

Embracing Patient Centered Care through Implementation of AIDET

Employee Safety Handbook

‘Good Catch’ Recognition Safety Mentor Education and Development

Team Training

Enhanced Disclosure Process

Disclosure Policy & Process

Unit Based Clinical Leadership Teams

Transparency Concepts

Patient/Family Centered Care

Interdisciplinary Rounds

5C Nursing Home Project

Worker Fall Protection Policy

Cultural Diversity & Inclusion

Bedside Shift Report

Skylight Safety Assessment

Quarterly Environment of Care Consultant Assessments

Employee Wellness

Specialized Training on Compressed Gas Safety

Facilities and Services Safety Committee Established

No Harm Intended Sessions Speak Up Patient Safety Guide

Focus on “No Harm, Any is Too Many”

Safety First Advisory Council

BEAT Training Classes

Safety in New Employee Orientation/ On Boarding

Arc Flash Policy and Program Safe Work Permit Improvements

Enhanced Focus on Excellence (FOE) Awards

Department Level Focused Safety Training

Workplace Violence Committee Established VP Level Monthly Injury Summary Reports Contractor Safety Training Video Updated Workplace Safety Risk Review Evaluation Completed by Conner Strong Formalized Systemwide “Good Catch” Program (March)

LEVERAGING TECHNOLOGY Th Ch The Christiana i i C Care Quality Q li and d Safety S f Program P strives i to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.

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

DVT Prophylaxis Development (Planning)

Clinical Documentation Project MRSA

National Patient Safety Goal: Reduce Risk of Healthcare Associated Infections: • Central Line Associated Blood Infections • Multiple Drug Resistant Organisms • Prevention of Surgical Site Infection

Disease Specific Certification • Stroke Program

Prevent Harm from High Alert Medications (Hydromorphone)

Surgical Safety Team Checklist

ACHIEVING HIGH RELIABILITY

Institute for Safe Medication Practices (ISMP)

Health care organizations are complex entities where the risk for accidents and injury runs extremely high. High Reliability Organizations (HROs) avoid catastrophes and accidents despite the dangers inherent in their businesses.

Christiana Care employs best practices of other high-risk industries in order to achieve the defining characteristics of HROs.

Assessment of CCHS Medication Safety (Planning)

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

Medication Safety Officer (Planning)

“Never Events” Present on Admission

5 Million Lives Campaign: • System Wide Skin Team to Prevent Pressure Ulcers • Reduce MRSA • High Alert Medications; Anticoagulation Team • Surgical Care Improvement Program (SCIP) • Heart Failure, Heart Disease and Stroke: “Get with the Guidelines” • WISH program • Board Report of Key Measures

Hospital Consumer and Assessment Provider Survey (HCAPS)

EMAR Implementation

ADT Interfaces with Micropaq

CPOE: Zynx Phase 3

CPOE

Barcoding (Bedside Specimen Labeling)

Wireless Patient Monitoring

Enhanced Web Paging

Expanded Use of Vocera

Infusion Pumps (Smart Pumps)

Care Fusion Implementation

Sentinel Event Database

CPOE: Zynx Phase 2

Planning for Meaningful Use

Bed Management System

Language Line Enhancement

Perioperative Documentation

Vocera

VNA Heart Failure Telemonitoring Program

Pharmacy Order Management System (POMS)

Equipment Tracking

Wireless Bar Coding-Breast Milk

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

Delaware Health Information Network (DHIN) CPOE: Zynx Implementation (Order Sets/Standards Development) Phase I Electronic Signatures

Medication Safety

Disease Specific Certification Planning • Primary Stroke Center

Medical bariatric FMEA

Hand Hygiene Campaign ED Super Track

Comprehensive Unit-Based Safety Program (CUSP) Magnet Recognition Flu Vaccine Program Pregnancy Screening in Non-OB Locations

Disease Specific Certification (May): • Heart Failure • Hip • Knee Recertification Disease Specific Stroke Program Best Practices for Better Care Partnership for Patients Christiana Rapid Transfer Initiative

SWAT (Synchronized Wilmington Admission Team)

Proactive Assessment of Communicating Patient Preferences/Goals of Care

Obstetrical Emergency Response Team (OBERT)

ED SHARP

ED SPEED

ED Triage Redesign

Pilot Early Warning System (EWS) Patient Identification Best Practice Leadership Forum to Reinforce Culture of Responsibility Concepts SWAT launches at Christiana Human Factors Consultant “Sponge Counts” Value Improvement Team Training

Heart Failure Transformation Team

Pharmaceutical Waste Management Program Implemented

Enhanced Suicide Risk Assessment Language Line Enhancement Insight Heart Failure (Symptom SelfAssessment) Virtual Education & Simulation Training Center (June) Spill Stations Designed and Ordered

C h ri sti an a C are H eal th S ys tem

TRP Safety Education Module

Slip, Trip Fall Workgroup Established

Powered Industrial Truck Policy, Education and Inspection Program

AC

Our commitment to transformation and innovation is showing dramatic results in operational efficiencies, including shortened length of stay, fewer readmissions and improved outcomes. Most importantly, we are increasing the value of care for our patients because we work with them and not merely for them. This is a testament to the power of the Christiana Care Way.

TIN EA

This report tells the story of our journey to transform care, quality and safety. Our physicians, nurses and staff are collaborating on new and better ways to enhance safety; to achieve high reliability in consistently delivering safe, effective care through evidence-based practices and outcomes research; and to leverage technology to advance our quality and safety goals. It highlights improvements that

significantly reduce the risk of infection and harm.

Our Value Improvement Teams set the standard for the more efficient use of available resources and adherence to national guidelines. Our journey is not only creating value for Christiana Care; other health systems throughout the nation are learning from our journey.

HR EL IAB ILI TY

CR

In all that we do, Christiana Care strives to serve everyone as respectful, expert caring partners in their health. This is the Christiana Care Way, and it is our promise to each person who trusts us to care for them. Embedded in this promise is a commitment to transform how we deliver that care.

27635_Cover_Layout 1 6/26/12 7:23 AM Page 1

The Christiana Care Quality and Safety Program

Capnography (End-Tidal CO2 Monitoring) During Code Blue Radiation Therapy Positioning Software Enhanced Central Line Checklist Implemented Baseline Pulse Oximetry in OB Triage, L & D and Antepartum Areas Standardization of Web Page to Mobilize Anesthesia Services Interpreters Care Visibility

Winter Weather Communications Enhanced Multum Alert View for Duplicates, Allergies and Major-Contraindicated DrugDrug Interactions.

Automation of “Event Follow-Up” Implementation of Meaningful Use

WORK & TUMBLE 27635 C.Care (Cover) 1 A 06/26/2012 07:52:31 CyanMagentaYellowBlack 12PERF2

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

PO Box 1668 Wilmington, Delaware 19899-1668 www.christianacare.org

Synchronized Admissions Teams collaborate on interdisciplinary assessment. See pages 21-22.

Quality and Safety 2012 ANNUAL REPORT ON 27635_Cover_Layout 1 6/26/12 7:23 AM Page 2

27635_Cover_Layout 1 6/26/12 7:24 AM Page 3

The Christiana Care Quality and Safety Program

Our Journey 2007 Safety First Learning Report

A message from the President and CEO

Enhancements for Follow Up Just Culture Concepts (Planning)

CR GA F SA EC

QUALITY AND SAFETY

TU UL RE

significantly reduce the risk of infection and harm.

Our Value Improvement Teams set the standard for the more efficient use of available resources and adherence to national guidelines. Our journey is not only creating value for Christiana Care; other health systems throughout the nation are learning from our journey.

Human Factor Analysis for Flex Monitoring Team Training Transparency Concepts

CREATING A SAFE CULTURE

Focus on “No Harm, Any is Too Many”

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

— P RO G R A M I N I T I AT I V E S 2 0 0 7 t o 2 0 1 2

Quarterly Environment of Care Consultant Assessments

Skylight Safety Assessment

Cultural Diversity & Inclusion

Worker Fall Protection Policy

Interdisciplinary Rounds

Patient/Family Centered Care

Disclosure Policy & Process

Enhanced Disclosure Process

Safety Mentor Education and Development

Human Factors Analysis for Radiation Oncology

Post Event Debriefs Partners in Safety Updates

‘Good Catch’ Recognition

SAFE Weekly Huddles

Patient and Community Involvement

Culture of Responsibility Phase I (June)

Culture of Responsibility (Planning)

Culture Survey (October)

Culture Survey (January)

Partners in Learning for Safety/ Just Culture Council

2009

2008

Human Resources and Safety Standards for Event Follow Up

No Harm Intended Sessions Speak Up Patient Safety Guide Safety First Advisory Council Safety in New Employee Orientation/ On Boarding Enhanced Focus on Excellence (FOE) Awards

CH I

EV

I

N G HI

BEAT Training Classes Arc Flash Policy and Program Safe Work Permit Improvements

2010

Specialized Training on Compressed Gas Safety

2011

2012

Culture of Responsibility Phase II (Oct.) Standarized Hand Offs for Transitions of Care in Women’s Health Embracing Patient Centered Care through Implementation of AIDET Unit Based Clinical Leadership Teams 5C Nursing Home Project

Culture Survey (April) Culture of Responsibility Phase III (October) Employee Safety Handbook Workplace Violence Committee Established VP Level Monthly Injury Summary Reports

Bedside Shift Report Employee Wellness TRP Safety Education Module Facilities and Services Safety Committee Established Slip, Trip Fall Workgroup Established Department Level Focused Safety Training

Powered Industrial Truck Policy, Education and Inspection Program

A

Our commitment to transformation and innovation is showing dramatic results in operational efficiencies, including shortened length of stay, fewer readmissions and improved outcomes. Most importantly, we are increasing the value of care for our patients because we work with them and not merely for them. This is a testament to the power of the Christiana Care Way.

L G H RE

In all that we do, Christiana Care strives to serve everyone as respectful, expert caring partners in their health. This is the Christiana Care Way, and it is our promise to each person who trusts us to care for them. Embedded in this promise is a commitment to transform how we deliver that care.

This report tells the story of our journey to transform care, quality and safety. Our physicians, nurses and staff are collaborating on new and better ways to enhance safety; to achieve high reliability in consistently delivering safe, effective care through evidence-based practices and outcomes research; and to leverage technology to advance our quality and safety goals. It highlights improvements that

TIN EA

IT Y IAB IL

27635_Cover_Layout 1 6/26/12 7:23 AM Page 1 Contractor Safety Training Video Updated Workplace Safety Risk Review Evaluation Completed by Conner Strong Formalized Systemwide “Good Catch” Program (March)

LEVERAGING TECHNOLOGY The Ch Th Christiana i i C Care Quality Q li and d Safety S f Program P strives i to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.

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

Robert J. Laskowski, M.D., MBA President and Chief Executive Officer

DVT Prophylaxis Development (Planning)

Assessment of CCHS Medication Safety (Planning)

Health care organizations are complex entities where the risk for accidents and injury runs extremely high. High Reliability Organizations (HROs) avoid catastrophes and accidents despite the dangers inherent in their businesses.

Christiana Care employs best practices of other high-risk industries in order to achieve the defining characteristics of HROs.

Institute for Safe Medication Practices (ISMP)

ACHIEVING HIGH RELIABILITY

Medication Safety Officer (Planning) 5 Million Lives Campaign: • System Wide Skin Team to Prevent Pressure Ulcers • Reduce MRSA • High Alert Medications; Anticoagulation Team • Surgical Care Improvement Program (SCIP) • Heart Failure, Heart Disease and Stroke: “Get with the Guidelines” • Board Report of Key Measures

EMAR Implementation

Creating a Safe Culture .................................................................................................................................................. 1 Achieving High Reliability .......................................................................................................................................... 16 Leveraging Technology ............................................................................................................................................... 32 Awards, Recognition & Achievements .................................................................................................................... 39

Barcoding (Bedside Specimen Labeling)

LEVERAGING TECHNOLOGY

Sentinel Event Database

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

Bed Management System Perioperative Documentation Pharmacy Order Management System (POMS)

Clinical Documentation Project MRSA National Patient Safety Goals: • Management of Anticoagulation • Improving Recognition and Response to Changes in Patient Condition “Never Events” Present on Admission Hospital Consumer and Assessment Provider Survey (HCAPS)

National Patient Safety Goal: Reduce Risk of Healthcare Associated Infections: • Central Line Associated Blood Infections • Multiple Drug Resistant Organisms • Prevention of Surgical Site Infection Prevent Harm from High Alert Medications (Hydromorphone)

Hand Hygiene Campaign

Medical bariatric FMEA

Disease Specific Certification Planning • Primary Stroke Center

Medication Safety

ED Super Track

Disease Specific Certification • Stroke Program Comprehensive Unit-Based Safety Program (CUSP) Magnet Recognition Flu Vaccine Program Surgical Safety Team Checklist

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

Pilot Early Warning System (EWS) Patient Identification Best Practice Leadership Forum to Reinforce Culture of Responsibility Concepts Human Factors Consultant “Sponge Counts”

Best Practices for Better Care

SWAT launches at Christiana

Recertification Disease Specific Stroke Program Partnership for Patients Proactive Assessment of Communicating Patient Preferences/ Goals of Care

SWAT (Synchronized Wilmington Admission Team)

Christiana Rapid Transfer Initiative

Pregnancy Screening in Non-OB Locations

Value Improvement Team Training

ED SHARP ED Triage Redesign

ED SPEED

Heart Failure Transformation Team

Obstetrical Emergency Response Team (OBERT) Pharmaceutical Waste Management Program Implemented

Expanded Use of Vocera

Enhanced Web Paging

Wireless Patient Monitoring

CPOE

CPOE: Zynx Phase 3

ADT Interfaces with Micropaq

Wireless Bar Coding-Breast Milk

Equipment Tracking

VNA Heart Failure Telemonitoring Program

Vocera

Language Line Enhancement

Planning for Meaningful Use

CPOE: Zynx Phase 2

Care Fusion Implementation

Infusion Pumps (Smart Pumps)

Enhanced Suicide Risk Assessment

Delaware Health Information Network (DHIN)

Language Line Enhancement Insight Heart Failure (Symptom SelfAssessment)

CPOE: Zynx Implementation (Order Sets/Standards Development) Phase I

Capnography (End-Tidal CO2 Monitoring) During Code Blue Radiation Therapy Positioning Software Enhanced Central Line Checklist Implemented Baseline Pulse Oximetry in OB Triage, L & D and Antepartum Areas

Winter Weather Communications Enhanced Multum Alert View for Duplicates, Allergies and Major-Contraindicated DrugDrug Interactions.

Automation of “Event Follow-Up” Implementation of Meaningful Use

Standardization of Web Page to Mobilize Anesthesia Services Interpreters Care Visibility

Virtual Education & Simulation Training Center (June)

Electronic Signatures

Spill Stations Designed and Ordered

C h ri st i an a C are H e al t h S y s t e m

WORK & TUMBLE 27635 C.Care (Cover) 1 A 06/26/2012 07:52:31 CyanMagentaYellowBlack 12PERF2

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

PO Box 1668 Wilmington, Delaware 19899-1668 www.christianacare.org

Synchronized Admissions Teams collaborate on interdisciplinary assessment. See pages 21-22.

Quality and Safety 2012 ANNUAL REPORT ON 27635_Cover_Layout 1 6/26/12 7:23 AM Page 2

27635_Cover_Layout 1 6/26/12 7:24 AM Page 3

The Christiana Care Quality and Safety Program

Our Journey 2007 Safety First Learning Report

A message from the President and CEO

Enhancements for Follow Up Just Culture Concepts (Planning)

CR GA F SA EC

QUALITY AND SAFETY

TU UL RE

significantly reduce the risk of infection and harm.

Our Value Improvement Teams set the standard for the more efficient use of available resources and adherence to national guidelines. Our journey is not only creating value for Christiana Care; other health systems throughout the nation are learning from our journey.

Human Factor Analysis for Flex Monitoring Team Training Transparency Concepts

CREATING A SAFE CULTURE

Focus on “No Harm, Any is Too Many”

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

— P RO G R A M I N I T I AT I V E S 2 0 0 7 t o 2 0 1 2

Quarterly Environment of Care Consultant Assessments

Skylight Safety Assessment

Cultural Diversity & Inclusion

Worker Fall Protection Policy

Interdisciplinary Rounds

Patient/Family Centered Care

Disclosure Policy & Process

Enhanced Disclosure Process

Safety Mentor Education and Development

Human Factors Analysis for Radiation Oncology

Post Event Debriefs Partners in Safety Updates

‘Good Catch’ Recognition

SAFE Weekly Huddles

Patient and Community Involvement

Culture of Responsibility Phase I (June)

Culture of Responsibility (Planning)

Culture Survey (October)

Culture Survey (January)

Partners in Learning for Safety/ Just Culture Council

2009

2008

Human Resources and Safety Standards for Event Follow Up

No Harm Intended Sessions Speak Up Patient Safety Guide Safety First Advisory Council Safety in New Employee Orientation/ On Boarding Enhanced Focus on Excellence (FOE) Awards

CH I

EV

I

N G HI

BEAT Training Classes Arc Flash Policy and Program Safe Work Permit Improvements

2010

Specialized Training on Compressed Gas Safety

2011

2012

Culture of Responsibility Phase II (Oct.) Standarized Hand Offs for Transitions of Care in Women’s Health Embracing Patient Centered Care through Implementation of AIDET Unit Based Clinical Leadership Teams 5C Nursing Home Project

Culture Survey (April) Culture of Responsibility Phase III (October) Employee Safety Handbook Workplace Violence Committee Established VP Level Monthly Injury Summary Reports

Bedside Shift Report Employee Wellness TRP Safety Education Module Facilities and Services Safety Committee Established Slip, Trip Fall Workgroup Established Department Level Focused Safety Training

Powered Industrial Truck Policy, Education and Inspection Program

A

Our commitment to transformation and innovation is showing dramatic results in operational efficiencies, including shortened length of stay, fewer readmissions and improved outcomes. Most importantly, we are increasing the value of care for our patients because we work with them and not merely for them. This is a testament to the power of the Christiana Care Way.

L G H RE

In all that we do, Christiana Care strives to serve everyone as respectful, expert caring partners in their health. This is the Christiana Care Way, and it is our promise to each person who trusts us to care for them. Embedded in this promise is a commitment to transform how we deliver that care.

This report tells the story of our journey to transform care, quality and safety. Our physicians, nurses and staff are collaborating on new and better ways to enhance safety; to achieve high reliability in consistently delivering safe, effective care through evidence-based practices and outcomes research; and to leverage technology to advance our quality and safety goals. It highlights improvements that

TIN EA

IT Y IAB IL

27635_Cover_Layout 1 6/26/12 7:23 AM Page 1 Contractor Safety Training Video Updated Workplace Safety Risk Review Evaluation Completed by Conner Strong Formalized Systemwide “Good Catch” Program (March)

LEVERAGING TECHNOLOGY The Ch Th Christiana i i C Care Quality Q li and d Safety S f Program P strives i to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.

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

Robert J. Laskowski, M.D., MBA President and Chief Executive Officer

DVT Prophylaxis Development (Planning)

Assessment of CCHS Medication Safety (Planning)

Health care organizations are complex entities where the risk for accidents and injury runs extremely high. High Reliability Organizations (HROs) avoid catastrophes and accidents despite the dangers inherent in their businesses.

Christiana Care employs best practices of other high-risk industries in order to achieve the defining characteristics of HROs.

Institute for Safe Medication Practices (ISMP)

ACHIEVING HIGH RELIABILITY

Medication Safety Officer (Planning) 5 Million Lives Campaign: • System Wide Skin Team to Prevent Pressure Ulcers • Reduce MRSA • High Alert Medications; Anticoagulation Team • Surgical Care Improvement Program (SCIP) • Heart Failure, Heart Disease and Stroke: “Get with the Guidelines” • Board Report of Key Measures

EMAR Implementation

Creating a Safe Culture .................................................................................................................................................. 1 Achieving High Reliability .......................................................................................................................................... 16 Leveraging Technology ............................................................................................................................................... 32 Awards, Recognition & Achievements .................................................................................................................... 39

Barcoding (Bedside Specimen Labeling)

LEVERAGING TECHNOLOGY

Sentinel Event Database

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

Bed Management System Perioperative Documentation Pharmacy Order Management System (POMS)

Clinical Documentation Project MRSA National Patient Safety Goals: • Management of Anticoagulation • Improving Recognition and Response to Changes in Patient Condition “Never Events” Present on Admission Hospital Consumer and Assessment Provider Survey (HCAPS)

National Patient Safety Goal: Reduce Risk of Healthcare Associated Infections: • Central Line Associated Blood Infections • Multiple Drug Resistant Organisms • Prevention of Surgical Site Infection Prevent Harm from High Alert Medications (Hydromorphone)

Hand Hygiene Campaign

Medical bariatric FMEA

Disease Specific Certification Planning • Primary Stroke Center

Medication Safety

ED Super Track

Disease Specific Certification • Stroke Program Comprehensive Unit-Based Safety Program (CUSP) Magnet Recognition Flu Vaccine Program Surgical Safety Team Checklist

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

Pilot Early Warning System (EWS) Patient Identification Best Practice Leadership Forum to Reinforce Culture of Responsibility Concepts Human Factors Consultant “Sponge Counts”

Best Practices for Better Care

SWAT launches at Christiana

Recertification Disease Specific Stroke Program Partnership for Patients Proactive Assessment of Communicating Patient Preferences/ Goals of Care

SWAT (Synchronized Wilmington Admission Team)

Christiana Rapid Transfer Initiative

Pregnancy Screening in Non-OB Locations

Value Improvement Team Training

ED SHARP ED Triage Redesign

ED SPEED

Heart Failure Transformation Team

Obstetrical Emergency Response Team (OBERT) Pharmaceutical Waste Management Program Implemented

Expanded Use of Vocera

Enhanced Web Paging

Wireless Patient Monitoring

CPOE

CPOE: Zynx Phase 3

ADT Interfaces with Micropaq

Wireless Bar Coding-Breast Milk

Equipment Tracking

VNA Heart Failure Telemonitoring Program

Vocera

Language Line Enhancement

Planning for Meaningful Use

CPOE: Zynx Phase 2

Care Fusion Implementation

Infusion Pumps (Smart Pumps)

Enhanced Suicide Risk Assessment

Delaware Health Information Network (DHIN)

Language Line Enhancement Insight Heart Failure (Symptom SelfAssessment)

CPOE: Zynx Implementation (Order Sets/Standards Development) Phase I

Capnography (End-Tidal CO2 Monitoring) During Code Blue Radiation Therapy Positioning Software Enhanced Central Line Checklist Implemented Baseline Pulse Oximetry in OB Triage, L & D and Antepartum Areas

Winter Weather Communications Enhanced Multum Alert View for Duplicates, Allergies and Major-Contraindicated DrugDrug Interactions.

Automation of “Event Follow-Up” Implementation of Meaningful Use

Standardization of Web Page to Mobilize Anesthesia Services Interpreters Care Visibility

Virtual Education & Simulation Training Center (June)

Electronic Signatures

Spill Stations Designed and Ordered

C h ri st i an a C are H e al t h S y s t e m