Quality & Safety Report 2020
Table of Contents Quality & Safety Recognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 High Reliability/Journey to Zero. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Patient & Caregiver Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Care Standardization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Health Equity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Population Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Exceptional Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 The ChristianaCare Way Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
ChristianaCare Rated Among World’s Best Hospitals Accolade joins numerous other prestigious quality recognitions during the past 12 months For the second year in a row, ChristianaCare was ranked among the World’s Best Hospitals by Newsweek, one of the nation’s most widely read news magazines. ChristianaCare was ranked the 92nd best hospital in the United States, and the top hospital in Delaware. Newsweek recognized ChristianaCare among the hospitals worldwide that “set the standard for excellent care.” The World’s Best Hospitals 2020 ranking lists the best hospitals in 21 countries, mainly selected based on standard of living, life expectancy, population size, number of hospitals and data availability. The recognition by Newsweek comes on the heels of several other quality recognitions during the past 12 months for ChristianaCare:
ChristianaCare earned the Healthgrades 2020 America’s 100 Best Hospitals Award™. The distinction places ChristianaCare in the top 2% of nearly 4,500 hospitals assessed nationwide for its consistent, year-over-year superior clinical performance as measured by Healthgrades. ChristianaCare has
received the America’s 100 Best Hospitals Award for four years in a row (2017-2020) for Christiana Hospital and Wilmington Hospital.
U.S. News & World Report named ChristianaCare as the best hospital in Delaware and No. 3 among the 90-plus hospitals in the Philadelphia region in the 2019 U.S. News & World Report rankings.
ChristianaCare also was named by U.S. News & World Report as one of only 57 hospitals in the United States to achieve the highest ratings in every common condition or procedure in the 2019 U.S. News & World Report rankings. This was the fourth consecutive year that ChristianaCare has earned that distinction.
ChristianaCare was honored as one of only 88 institutions out of 722 by the American College of Surgeons (ACS) Clinical Congress’ National Surgical Quality Improvement Program for achieving “meritorious” outcomes in surgical patient care, and one of only 56 health systems recognized for “meritorious” patient care in the program’s “all-case” and “high-risk” categories.
“At ChristianaCare, we strive to provide the very best care and an exceptional experience to our community, as we’ve demonstrated consistently over the years and especially during the COVID-19 pandemic. These recognitions are a testament to the dedication of our extraordinary caregivers who demonstrate our values of love and excellence daily. We serve together, and we are committed to being even better tomorrow than we are today.” — Janice E. Nevin, M.D., MPH ChristianaCare president and CEO ChristianaCare Quality & Safety Report 2020 | 1
Quality & Safety Recognition Healthgrades
Newsweek World’s Best Hospitals — second year in a row
U.S. News & World Report Best Hospitals Top 1% of hospitals nationwide; Best Hospital in Delaware; No. 3 in Philadelphia region
America’s 100 Best Hospitals for Joint Replacement™ for 5 Years in a Row (2016-2020).
America’s 100 Best Hospitals for Spine Surgery™ for 7 Years in a Row (2014-2020).
America’s 100 Best Hospitals for Gastrointestinal Care™ for 9 Years in a Row (2012-2020). America’s 100 Best Hospitals for General Surgery™ for 9 Years in a Row (2012-2020). Top 5% in the nation in joint replacement, spine surgery and overall pulmonary services.
2 |
America’s 100 Best Hospitals 2020 — fourth year in a row
Top 5% in the nation for overall services for gastrointestinal care, including general surgery and medical treatment.
Becker’s Hospital Review 100 Great Hospitals in America 2020
Leapfrog Hospital Safety Grade — Christiana Hospital - A, Wilmington Hospital - A
Magnet® — twice designated for nursing excellence by the American Nurses Credentialing Center
The Joint Commission Get with the Guidelines Gold Plus Stroke and Heart Failure
The Joint Commission and the Gold Seal of Approval — ChristianaCare Health Services
The Joint Commission Disease Specific Certification — Left Ventricular Assist Device (LVAD) Program, Joint Replacement Hip & Knee, Heart Failure, Primary Stroke Certification — Wilmington Campus, Comprehensive Stroke Certification — Newark Campus
The Joint Commission Perinatal Care Certification — Maternal, Fetal and Newborn Health
Most Wired designation from the College of Healthcare Information Management Executives (CHIME) — Ambulatory and Hospital
FutureEdge 50 Award from International Data Group’s CIO for CritiTrac iOS application real-time documentation during a Code Blue emergency
Meritorious outcomes in surgical patient care by the American College of Surgeons Clinical Congress — eighth consecutive year
American Association of Critical-Care Nurses Beacon Award for Excellence
American Heart Association American Stroke Association Certification Comprehensive Stroke Center
Healthcare Equality Index LGBTQ Healthcare Equality Leader
Addiction Policy Forum recognition in Delaware Innovations to Address Addiction report
2019 Top Workplaces — The Philadelphia Inquirer; The News Journal delawareonline.com; Best Places to Work in IT, IDG’s Computerworld; #1 Employer in Delaware by Forbes
Quality & Safety Recognition
ChristianaCare Quality & Safety Report 2020 | 3
High Reliability/ Journey to Zero Preventable harm rate continues to improve over past two years ChristianaCare’s focus on eliminating preventable harm shows substantial improvement in recent years through increasing emphasis on consistent application of best practices. Due to the COVID-19 pandemic, preventable harm reporting for Fiscal Year (FY) 2020 was suspended after February; thus improvement data examines the time period from July 2018 through February 2020. In the 20 months from July 2018 through February 2020, there were 144 fewer patients harmed, compared to the 12 months of FY 2018 — a 12% reduction in supporting our journey to zero preventable harm.
Preventable Harm Rate
Desired Direction 5.0
3.0
2.0
Jan-20
Nov-19
Jul-19
Sep-19
May-19
Jan-19
Mar-19
Nov-18
Jul-18
Sep-18
Mar-18
May-18
Jan-18
Sep-17
Nov-17
Jul-17
May-17
Jan-17
Mar-17
Nov-16
Jul-16
Sep-16
May-16
Jan-16
Mar-16
Sep-15
0.0
Nov-15
1.0
Jul-15
Harm per 1000 patient days
4.0
The number of patients harmed per 1,000 patient days decreased 12% to 1.96 from 2.31.
“Due to the significant disruption to routine operations of hospitals across the nation during the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) and other external regulatory entities have suspended reporting requirements . In addition, ChristianaCare has experienced a decrease in overall volumes and changes to care areas that have made the zero harm calculation and other indicators on the Quality & Safety Goal/AOP Dashboard difficult to measure. As a result, we are following the lead of CMS and other external reporting entities and are suspending further publication of the dashboard for the rest of the fiscal year. In the meantime, we will continue to foster a culture of quality and safety through routine reporting of any safety-related events, maintenance of our zero harm guiding principles, and reliance on our Making Tomorrow Happen and high-reliability principles .” — Ken Silverstein, M.D., MBA, Chief Physician Executive and Executive Vice President, April 23, 2020
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High Reliability/Journey to Zero
Substantial improvements decrease hospital-acquired infections by 13% Hospital-acquired infections (HAI) are a primary focus of ChristianaCare’s journey to zero harm. HAIs — which increase mortality and morbidity and lead to higher costs of care — are largely preventable through consistent application of evidence-based standards of care. Since July 2018, there have been 40 fewer HAIs, a 13% decrease.
Overall, hospital-acquired infections have decreased by 40 HAIs.
Substantial improvements include a 33% reduction in Clostridium diffi cile (C. diffi cile) infections; a 41% reduction in catheter-associated urinary tract infections (CAUTI), a 30% reduction in methicillinresistant Staphylococcus aureus (MRSA) Bacteremia and a 13% reduction in central line-associated bloodstream infections (CLABSI). Teams are actively addressing opportunities for improvement in surgical site infections, particularly for cesarean sections and spine surgery.
-33%
-41%
Clostridium difficile (C. difficile) infections
Catheter associated urinary tract infections (CAUTI)
-30%
-13%
Methicillan-resistant Staphylococcus aureus (MRSA) bacteremia
Central line-associated bloodstream infections (CLABSI)
ChristianaCare Quality & Safety Report 2020 | 5
Changes in C. diďŹƒcile testing decrease rates ChristianaCare has been making stepwise improvements in the incidence of C. diffi cile since 2017. Previous actions taken to reduce these infections have included a hard stop in computerized physician order entry for testing orders, patient risk scoring and real-time decision support analytics. This fi scal year, a two-step lab testing process was added to differentiate those patients with a true C. diffi cile infection from those colonized, and not infected, with the bacteria. The combined impact of these changes was a reduction in the average number of cases per month from 14 to 3, leading to 43 fewer infections in the past 20 months. Desired Desired Directio Direction n
C. Difficile Trend Number of Infections
Rolling 12 months
Median
Number of infections
30
Testing hard stop
25 20 15
Risk score & real-time analytics
2-part lab testing
10 5
Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 Sep-18 Nov-18 Jan-19 Mar-19 May-19 Jul-19 Sep-19 Nov-19 Jan-20 Mar-20
0
C. diďŹƒcile infections have decreased by 43 in the past 20 months.
6 |
High Reliability/Journey to Zero
Perfect Care practices prevent harm A key enabler to learn and improve within our patient care units is the ongoing monitoring of adherence to evidence-based and best-practice interventions aimed at preventing patient harm. To achieve highly reliable care, Nursing has implemented processes to monitor the implementation of best practices for four harm domains: CAUTI, CLABSI, hospital-acquired pressure injuries (HAPI) and falls. Known as ‘Perfect Care’ bundles, these process-monitoring tools are designed to identify opportunities in practice so that targeted action planning can take place at the unit/practice area level before harm occurs. Within each harm domain, the monitoring includes direct observation and documentation review, which drives real-time feedback and learning with bedside caregivers.
Source:
Perfect Care scores continue to trend up for all four metrics due to the commitment of our caregivers to provide perfect care to patients every day. These process-monitoring tools are used in all inpatient areas and were extended to a subset of ambulatory care areas in January 2020, including all three Emergency Departments (ED), ED observation units, the Express Admissions Unit, Post-Anesthesia Perfect Care Surgical Monitoring Dashboard Care Unit, Admissions and pdf Hemodialysis.
A near-real-time dashboard tracks compliance with each aspect of the Perfect Care Bundles for each patient care area, showing overall “Perfect Care” and trends in average compliance with each aspect of the bundles.
ChristianaCare Quality & Safety Report 2020 | 7
Focus on Perfect Care reduces CAUTIs Patient care unit efforts to decrease CAUTI have focused on a multi-pronged bundle approach that incorporates evidence-based best practice, including proper insertion techniques, cleaning, and prompt removal of Foley catheters when no longer needed. This focus on the Perfect Care bundle has led to a 41% decrease in the number of CAUTI infections, with 13 fewer infections since FY 2018.
CAUTI Trend
Desired Direction
Number of Infections
Rolling 12 months
Median
8
Number of infections
7 6 5 4 3 2
0
Jan-15 Mar-… May-… Jul-15 Sep-… Nov-… Jan-16 Mar-… May-… Jul-16 Sep-… Nov-… Jan-17 Mar-… May-… Jul-17 Sep-… Nov-… Jan-18 Mar-… May-… Jul-18 Sep-… Nov-… Jan-19 Mar-… May-… Jul-19 Sep-… Nov-… Jan-… Mar-…
1
The Perfect Care bundle has led to a 41% decrease in the number of CAUTI infections since FY 2018.
8 |
High Reliability/Journey to Zero
All-hands-on-deck approach reduces hospital-acquired pressure injuries In response to an increasing trend, ChristianaCare established a Nursing-led team to implement an “all-hands-on-deck” approach to reduce HAPIs. Four subcommittees of the HAPI Integrated Practice Team (IPT) address opportunities in key areas, including clinical practice; documentation; education, training and competency; and interprofessional communication and collaboration.
Hospital-Acquired Pressure Injuries (PSI 3)
10 9 8 7 6 5 4 3 2 1 0
HAPI (PSI3)
HAPI IPT
Rolling 6 months
Perfect Care Monitor
WOC Nurse Validation & Staging
Education & Training
Ja n19 Fe b19 M ar -1 9 Ap r19 M ay -1 9 Ju n19 Ju l- 1 9 Au g19 Se p19 O ct -1 9 N ov -1 9 De c19 Ja n20 Fe b20 M ar -2 0
Number of Medicare cases
Desired Direction
The incidence of coded HAPI (Patient Safety Indicator 3) among patients on Medicare has decreased from an average of 7 per month prior to the start of the IPT to 3 per month.
Improvements include:
Introduced education, training and a hands-on competency assessment for nurses and patient care technicians.
Improved pressure injury prevention processes, practice and documentation for all areas of care, including perioperative services and the Emergency Department.
Increased interprofessional engagement, awareness and practice related to skin integrity, pressure injuries, care planning, documentation and coding.
Developed and implemented a nursing practice accountability toolkit.
Hired a Wound Ostomy Continence (WOC) nurse certifi ed pressure injury preventionist focused on pressure injury prevention, and a medical director for the WOC team.
Implemented a virtual process for WOC nurse-verifi cation of all pressure injuries using cameracapture technology that resulted in a signifi cant increase in validated pressure injuries, including injuries that were present on admission.
Developed a standardized process monitoring pressure injury prevention through the Perfect Care tool and interactive dashboard. ChristianaCare Quality & Safety Report 2020 | 9
OB tiger team tackles surgical site infection rate An interdisciplinary OB (obstetrics) tiger team collaboration in FY 2020 focused on cesarean section surgical site infections (SSI). The team performed a robust review of prior cases of infection to understand root causes and develop appropriate improvement strategies. Many interventions drove the reduction in the infection rate, including home skin preparation prior to scheduled C-sections, chlorhexidine vaginal wash and wipes prior to surgery, re-education to enforce best practices for pre-surgical scrub, changing gloves after delivery of the baby, and changes in wound management post C-section. The resulting bundle also included more thorough penicillin allergy assessment, improvements to the decision, storage and delivery of alternative prophylaxis IV medications for patients allergic to penicillin, and adherence to American College of Gynecology weight-based prophylaxis guidelines recommendations. The SSI rate decreased 25% in just the fi rst three months.
Cesarean Sections: Surgical Site Infections Number of surgical site infections
Surgical site infection rate
SSI rate-roll ing 6 months
7
4.5
Bundle Implementation
Number of SSIs
6 5
4.0 3.5 3.0
4
2.5
3
2.0 1.5
2
1.0 1
0.5
19 Se p19 O ct -1 9 N ov -1 9 De c19 Ja n20 Fe b20 M ar -2 0
9
Au g-
Ju l-1
Ja n1
De c
9 Fe b19 M ar -1 9 Ap r19 M ay -1 9 Ju n19
0.0
-1 8
0
Surgical Site Infections for C-section surgeries decreased by 25% following implementation of an interdisciplinary collaborative bundle.
10 |
High Reliability/Journey to Zero
SSI Rate (Infections per 100 procedures
Desired Direction
Zero Harm Awards celebrate continued months of caregiver-led success ChristianaCare’s Zero Harm Awards recognize patient care units that have maintained zero cases of preventable patient harm in one of six harm categories for at least 12 consecutive months. This fi scal year, through March 2020, 95 awards were earned, including 16 awards for six years (72 months) with zero harm. Since January 2017, 493 awards have been earned.
Central Line-Associated Bloodstream Infections (CLABSI) 4W Medical 5C Medical 5D Medical Bone M arrow Transpl ant Neuro Critical Care 3M Medical 4E Cardiac Stepdown 6C Stroke Treatment and Recovery Transitional Surgical Wilmington Intensive Care 3A Antenatal Stepdown 2C Ortho/N euro/Trauma Surgery 7E Spine/Joint Replacement 7S Center for Advanced Joint Replacement
0
12
24
36
48
60
72
60
72
Zero Harm Months
Catheter-Associated Urinary Tract Infections (CAUTI) 2C Ortho/N euro/Trauma Surgery 4D Surgery Stepdown 4W Surgical 5E Heart Failure 6A Acute Care for the Elderl y 6W, Center for Rehabilitation Medical Intensive Care Surgical Critical Care Transitional Neuro Wilmington Intensive Care 3M Medical 5B Medical 5C Medical 6C Stroke Treatment and Recovery Transitional Medical 3B/3C/4B Postpartum 4N /5W Medical 7E, Spine/Joint Replacement Bone M arrow Transpl ant 7S Center for Advanced Joint Replacement
0
12
24
36
48
Zero Harm Months
ChristianaCare Quality & Safety Report 2020 | 11
Zero Harm Awards (continued) Methicillin-Resistant Staphylococcus Aureus (MRSA) 6A Acute Care for the Elderly 5C Medical 6S Medical Stepdown Bone M arrow Transpl ant Medical Intensive Care Surgical Critical Care Transitional Medical 4N /5W Medical 8S Acute Care for the Elderly Transitional Surgical Wilmington Intensive Care 3M Medical 4D Surgery Stepdown 4C Surgery/GYN 3A Antepartum 3B/3C/4B Postpartum 4A Pediatrics/GYN 6W, Center for Rehabilitation 7S Center for Advanced Joint Replacement Neonatal Intensive Care
0
12
24
36
48
60
72
Zero Harm Months
Clostridium Difficile (C. difficile) 3A Antepartum Stepdown 3M Medical 6A Acute Care for the Elderl y Wilmington Intensive Care 3B/3C/4B Postpartum 6W Center for Rehabilitation 4A Pediatrics/GYN 7S Center for Advanced Joint Replacement
0
12
24
36
48
Zero Harm Months
12 |
High Reliability/Journey to Zero
60
72
Zero Harm Awards (continued) Falls with Major Injury 2C Ortho/N euro/Trauma Surgery 6W Center for Rehabilitation 8S Acute Care for the Elderly Christiana Emergency Department Neuro Critical Care 3M Medical 4A Pediatrics/GYN 6E Oncology 6S Medical Stepdown Medical Observation 4E Cardiac Stepdown 4W Medical 5A Medical 6A Acute Care for the Elderl y 6B Medical 6C Stroke Treatment and Recovery 7N Psychiatry Surgical Critical Care 4N /5W Medical 3A Antepartum 4C Surgical 4D Surgical 7E Spine/Joint Replacement Cardiac Short Stay Medical Intensive Care Middletown Emergency Department Transitional Surgical Wilmington Intensive Care
0
12
24
36
48
60
72
Zero Harm Months
All Falls 3A Antepartum 7S Center for Advanced Joint Replacement Bone M arrow Transpl ant Wilmington Intensive Care Neonatal Intensive Care
0
12
24
36
48
60
72
Zero Harm Months
ChristianaCare Quality & Safety Report 2020 | 13
Medication Safety
High-risk antibiotic use decreased by 13% The ChristianaCare Antimicrobial Stewardship Program continued interventions reducing highrisk antibiotic use by another 2.7% this year. Overall, the program has decreased antibiotic use by 13% since 2014. Interventions by antimicrobial stewardship pharmacists are key to the program’s success. In 2019, 2,950 interventions were completed in which the three antimicrobial stewardship pharmacists reviewed and, when appropriate, recommended alternate courses of treatment. Of those recommended interventions, 87% were implemented.
High-risk antibiotics are those with a broad spectrum of activity and/or high risk for C. difficile infection. This graph includes utilization of aztreonam, ceftazidime, ceftriaxone, imipenem/cilastatin, vancomycin, linezolid, moxifloxacin, ertapenem, daptomycin, doripenem, piperacillin/tazobactam, ciprofloxacin, cefepime, meropenem, levofloxacin and ceftaroline.
14 |
High Reliability/Journey to Zero
The three antimicrobial stewardship pharmacists completed 2,950 interventions in 2019, with an acceptance rate of 87%.
Optimal preoperative antibiotic use and MRSA screening improve surgical safety In just six months, collaborative efforts have led to an increase in the use of optimal preoperative antibiotics for patients having total joint replacement to 87% from 72%. The goal was to optimize surgical antimicrobial prophylaxis, measure compliance and identify opportunities for improvement between the Antimicrobial Stewardship Program and the Spine and Total Joint Replacement workgroups. Screening for MRSA increased by 14%. Outpatient allergy consultation and penicillin skin testing for a group of 16 patients scheduled for spine surgery who were identifi ed for a possible Type 1 beta-lactam allergy identifi ed that 15 out of 16 actually tested negative for penicillin allergy and were appropriate candidates for optimal antibiotic regimen, including preoperative administration of cefazolin.
ChristianaCare Quality & Safety Report 2020 | 15
Collaborative efforts led to a nearly 22% increase in the use of optimal preoperative antibiotics for patients having total joint replacement surgery.
Ambulatory Total antibiotics per 100 patient visits to ChristianaCare urgent care centers decreased by 50.3% over a 20-month intervention period following adoption of Choosing Wisely® campaign guidelines. A new dashboard tracking the prescribing of antibiotics based on practice, diagnosis and medication has already shown a decrease in inappropriate antibiotic prescribing in patients with respiratory tract symptoms from 11.7% to 10.9%. Data will help identify a preventable harm quality metric centered on primary care antibiotic stewardship for a future fi scal year. ChristianaCare caregivers authored two ambulatory antibiotic guidelines this year — one focused on the treatment of rhinosinusitis (infl ammation of the sinuses and nasal cavity) and the second on urinary tract infections. A third guideline for the treatment of Lyme disease is currently being created. Preliminary results show that use of the rhinosinusitis guidelines have helped reduce inappropriate antibiotic prescribing by 7%. Three primary care practices (Christiana — MAP 2, Linden Hill and Concord), two practices within the ChristianaCare HIV Community Program (Wilmington and Kent-Smyrna) and Wilmington Pediatric Associates have joined a national study with the Agency for Healthcare Research and Quality Safety Program to assess antibiotic use in upper respiratory infections. A manuscript on the collaborative efforts of the Antibiotic Stewardship Committee and eBrightHealth Accountable Care Organization has been submitted to the Joint Commission Journal on Quality and Patient Safety.
16 |
High Reliability/Journey to Zero
Provider Name
An interactive dashboard supports comparative analysis of antibiotic use by practice, provider and diagnosis to drive improvement.
Need to block provider names!
ChristianaCare Quality & Safety Report 2020 | 17
Neonatal Intensive Care Unit ChristianaCare’s Neonatal Intensive Care Unit (NICU) earned designation in 2019 as a Center of Excellence in Education and Training for Antibiotic Stewardship in Newborn Care by the Vermont Oxford Network based on targeted collaborative efforts that have decreased average yearly antibiotic use within the NICU by 22% since 2014.
Average yearly antibiotic use within the NICU has decreased 22% since 2014.
18 |
High Reliability/Journey to Zero
Opioid use for pain management down 42% Standardized protocols, education and alternative treatments, as well as programmatic support from the Delaware Division of Substance Abuse and Mental Health and ChristianaCare-created recommendations for pain management during and after surgeries, have decreased opioid use among ChristianaCare patients by 42% through February 2020. The success translates to safer, more successful treatment of pain.
Opioid Pill Count Reduction
Desired Direction
Primary Care
-20%
Emergency Departments
-55%
-62%
Inpatient Settings
-42% -80%
-60%
Systemwide -40%
-20%
0%
% Reduction ChristianaCare reduced its opioid pill count 62% in inpatient settings; 55% in emergency departments; 20% in primary care and 42% systemwide.
Now in its second year, ChristianaCare’s patient-centered, clinical best-practices program promotes safe use of opioids when necessary, eliminates them when possible, and educates patients and providers so they can align their goals. Targeted areas for this program include outpatient primary care, surgical and emergency department settings.
Primary Care New protocols will be embedded into a patient’s electronic medical record, allowing primary care providers to wean a patient off of opioids, if required, using guidelines and a step-by-step process. Protocols help physicians consider all treatments, monitor risk and safely discontinue opioids, and improve patient safety by helping patients taper the amount of their medication. The protocols also include prescribing Narcan, an emergency treatment for overdose, to patients who are prescribed opioids. ChristianaCare’s opioid pill count decreased 20% in the primary care setting between July 2018 and February 2020.
ChristianaCare Quality & Safety Report 2020 | 19
Surgery ChristianaCare partnered with the Delaware Opioid Prescribing Engagement Network in 2017, outlining which medications and quantities should be administered during and after surgeries. Data demonstrates a 62% reduction in prescribing opioids, which relates to more than 50 types of surgical procedures performed between July 2017 and February 2019. Prescriptions for 10 pills or fewer increased to more than 50% from 30% and prescriptions for 30 or more pills decreased to 8% from 29% in the same timeframe.
Emergency Department The ED adopted guidelines developed by the Delaware Chapter of the American College of Emergency Physicians that stipulate more appropriate treatment and prescribing of opioids to address pain. The ED also works with ChristianaCare’s nationally renowned Project Engage in which peers in recovery, called “engagement specialists,” meet with hospitalized patients about their substance use and help motivate them to take the fi rst critical step in seeking help. Also supporting safety in prescribing:
Opioid Tapering Pathway — provides standardized guidelines that support providers in identifying when a taper is required. Step-by-step process enables providers to consider a variety of treatments and monitors risk while safely discontinuing opioids.
Delaware’s statewide START Initiative (Substance Use Treatment and Recovery Transformation) engages primary care and family medicine providers, school-based health centers and EDs to transform the full range of care for substance-use disorder.
New initiatives for non-opioid pain management include Psychiatry pharmacological evaluations and group therapy, the creation of a comprehensive pain center, and a Treatment Alternatives and Resources for Pain program featuring such interventions as acupuncture, aromatherapy, cognitive behavior therapy, meditation and specialized physical therapy for pain.
Opioid dispensed quantity
Desired Direction
Trend in Dispensed Opioids 120,000 100,000 80,000 60,000 40,000 20,000
Jan-20
Jul-19
Oct-19
Apr-19
Jan-19
Oct-18
Jul-18
Apr-18
Jan-18
Oct-17
Jul-17
Jan-17
Apr-17
Jul-16
Oct-16
Apr-16
Jan-16
0
The dispensed quantity of opioids decreased by 66% between 2016 and 2019, and continues to improve. The average prescription rate decreased to 5 from 17.
20 |
High Reliability/Journey to Zero
Weight-based dosing and a continued decline in the use of plasma for warfarin reversal drive transfusion safety achievements Guidelines for warfarin reversal using plasma transfusions continue to drive sustained improvements in patient safety, quality of care and effi cient use of resources. Plasma orders for reversal of warfarin have declined to just 4% in 2019 from 9% in 2017 with vitamin K or KcentraÂŽ as the reversal agent of choice depending on urgency. The introduction of weight-based plasma transfusion dosing to computerized physician order entry has also improved care. In 2019, 71% of applicable plasma orders were weight-based, following established national guidelines and the Choosing Wisely campaign.
Desired Direction
Plasma Orders for Warfarin Reversal
Desired Direction
160 137
120 100
80
80
80.0%
73.5%
70.0%
Number of orders
Number of orders
140
Weight-Based Dosing for Plasma Orders
60 40
29
60.0% 50.0% 38.4%
40.0%
34.6%
30.0% 20.0% 10.0%
20
0.0%
0 2017
2018
2017
2019
Appropriately, plasma orders for warfarin reversal have decreased to 4% in 2019 from 9% in 2017.
2019
The number of weight-based plasma orders increased 91% to 73.5% in 2019 from 38.4% in 2017.
Percent Non-Guideline Red Blood Cell Transfusions
Desired Direction
Percent of RBC transfusions
2018
20% 18%
18.25%
16% 14% 12% 10% 8% 6% 4%
3.64% 1.67%
2% 0% 2015
2016
2017
0.95%
0.44%
2018
2019
Red Blood Cells (RBC) transfusions not meeting established guidelines dramatically declined to an average of 0.4% in 2019.
ChristianaCare Quality & Safety Report 2020 | 21
You Said, We Listened
Survey feedback drives teamwork to provide safe care Improving patient flow, handoffs and leadership visibility are key steps to improving ChristianaCare’s Culture of Safety based on feedback from frontline caregivers on the 2019 Hospital Survey on Patient Safety Culture created by the Agency for Healthcare Research and Quality (AHRQ).
Multifaceted Approach to Safety Culture Zero Harm Safety Culture/Engagement Psychological Safety Core Values & Behaviors Making Tomorrow Happen High Reliability Accountability
• • • • • • • • •
Zero Harm/Awards R2L - Event Management - Just Culture CANDOR Organizational Stand Up for Safety Huddle Standardized Communication Tools Leadership Safety Walk Rounds Organizational Strategies Quality & Safety Officers Seeking new knowledge/Lessons Learned Humble Inquiry • • • • • • • •
Just Culture CUSP Hand Off Communication No Harm Intended Sessions Local (Unit) Patient Safety Newsletters Strategies Safety Mentors Seeking new knowledge/Lessons Learned Unit Based Safety Huddles
In 2019, ChristianaCare achieved its highest number of caregiver participation with 5,223 caregivers completing the survey — a response rate of 70%. Key positive takeaways from the survey:
22 |
83% of caregivers indicate that there is strong teamwork within units, higher than the national benchmark of teaching hospitals.
75% of caregivers indicate that their supervisors and managers promote patient safety.
72% of caregivers indicate that ChristianaCare is an organization that strives to continuously learn and improve.
High Reliability/Journey to Zero
Culture of Safety Survey Responses Desired Direction
ChristianaCare score
National teaching
80% 60% 40% 20%
iza
W ith in
Su pe rv i
rg an
O
Te a
U ni tio ts na l so Le r/ ar M ni gr ng M -P an r om ag Fe ot em e ed e Pt nt ba … Su ck pp an or d tCo Co Pt m … m m m un u ni ic Fr at ca eq io tio ue n n nc O y p of en O ne Ev ve en ss ra ts ll Pe Re rc po ep rt tio ed ns Te -P am tS w af or et k y Ac ro ss U ni ts H an St N do af on fin ffs pu g & ni T tiv ra e ns Re iti on sp s on se to Er ro r
0%
m w or k
Top box score (% postive)
100%
9 of the 12 composites have either exceeded or reached the National Teaching benchmark.
Key opportunities for improvement:
Management support for patient safety — 67% of caregivers indicate that management supports patient safety; this composite decreased 5.6% compared to the 2017 survey.
Teamwork across units — 55% of caregivers indicate that there is teamwork across units; this composite decreased 3.5% compared to the 2017 survey.
This year, ChristianaCare embraced a “You Said, We Listened” approach to improve the performance of the survey question, “Hospital units work well together to provide the best care for patients.” Actions include: Patient-fl ow and handoff improvements from the ED to inpatient care units.
Making Tomorrow Happen local and organizational huddles to promote collaboration, escalation and resolution of safety concerns, and concerns with how well we are working together as a team.
Humble Inquiry techniques to gain caregiver perspective on concerns and their thoughts on how to address.
Leadership visibility and support of frontline caregivers, including Safety Walk Rounds and “Go Sees” — going to where the work is being done — help leaders gain frontline caregiver perspective, understand operations and assist with removal of any barriers.
Extended wellbeing services to all caregivers with expansion of the Center for WorkLife Wellbeing.
Opened new patient care areas — new Center for Women’s & Children’s Health, Express Admissions Unit, Inpatient Behavioral Health Unit and the Discharge Lounge upgraded technology systems — computerized physician order entry, bar-coded medication administration, monitor alarms and infusion pumps.
Trained leaders with use of tools supporting Love & Excellence: Humble Inquiry, Psychological Safety and Just Culture principles. ChristianaCare Quality & Safety Report 2020 | 23
Making Tomorrow Happen offers framework for daily work Making Tomorrow Happen is an approach to helping us achieve our promise of Exceptional Caregiver Experience, Exceptional Experience, Optimal Health and Organizational Vitality. Grounded in our mission of service, it represents a set of leadership practices and proven problem-solving methods, which create an environment where all 13,000 caregivers feel psychologically safe alerting fellow caregivers and leaders in team huddles to barriers and sharing ideas for improvement.
Making Tomorrow Happen: A Framework for ourr daily work • Encourages seeking new
• Encourages curiosity, humility
knowledge and openness to change.
and compassion.
Love & Excellence • Encourages telling the truth
with courage and empathy, and accepting responsibility for creating solutions.
• Encourages truth-telling
and wise use of resources.
Each component of the Making Tomorrow Happen framework is vital. To date, more than 500 core leaders have completed Humble Inquiry and Psychological Safety training sessions, and more than 300 huddle boards have been installed across the organization, with 60% of teams huddling daily or by shift. Issues that cannot be solved locally are now routinely escalated to the System Support & Resolution huddle, where senior leaders from across the system work on them collaboratively. New practices, called Go Sees, allow leaders to be physically present in their departments and support caregivers in creating an environment of continuous improvement.
24 |
High Reliability/Journey to Zero
Accelerating the work of Making Tomorrow Happen To achieve lasting impact in creating a culture that truly refl ects the understanding that where love leads, excellence is inevitable, additional tools and methodologies to advance the framework are being tested through pioneering work in model areas. These include Wilmington Environmental Services, Preventive Medicine & Rehabilitation Institute, Newark Campus Patient Care Unit 4E, Patient Escort and Sterile Processing.
What our caregivers are saying: “Making Tomorrow Happen empowered us to raise issues and collaborate for solutions .” “Huddles have improved communication .” “Team members speak up about important issues .” “Huddles are a good way to communicate updates with everyone and to celebrate our staff.” “We are now looking at barriers as a way to improve the process .”
ChristianaCare Quality & Safety Report 2020 | 25
CANDOR contributes to system improvements Continued improvements to the CANDOR (Communication AND Optimal Resolution) process — including reducing the time needed to complete CANDOR reviews, better aligned efforts with event review teams and programs to improve a feeling of psychological safety for caregivers and clinicians — have helped drive a 20% increase in event reporting since the program’s inception. Adverse patient safety events managed through CANDOR
Care for the Caregiver peer support following an adverse patient safety event
300+
700+
The CANDOR approach to disclosure of medical errors guides accurate, open communication following unexpected permanent harm or death and offers a more transparent way to communicate with patients and family members about safety events. Educational apps on initial disclosure are now available for caregivers through the Learning Center and a newly developed risk-management dashboard helps assess the impact of the program on medical legal outcomes. National Patient Safety Week activities in March featured a virtual program by Thomas Gallagher, M.D., of the University of Washington, who developed the national CANDOR toolkit. CANDOR contributed to system improvements, such as standardized reporting for radiographic fi ndings of spinal surgery, a standardized process for optimal image-guided breast biopsies, a change process for documenting adequate renal function before giving nephrotoxic drugs, and revision of the anticoagulation pathway to include imaging of the central nervous system for patients with a high international normalized ratio for clotting. Enhancements to the CANDOR process include:
Mapped core values to support behaviors that promote psychological safety.
Developed a toolkit for nursing and physician leaders to introduce the idea of participating in an event review in a way that is psychologically safe.
Humble Inquiry: all event review team leaders and support staff participated in an education session specifi cally focused on event review.
Introduced Zero Harm template to share learnings and knowledge gained from safety events.
Developed a post-debrief survey to generate feedback from participants to inform leadership of caregiver needs.
Engaged Care for the Caregiver in all debriefs; participants encouraged to reach out both at the beginning and the end of each debrief.
Redesigned CANDOR conference call checklist to enhance privacy and confi dentiality.
Hosted Just Culture training to support event-management and peer-review processes.
Standardized event management; convened an event redesign team to minimize impact on caregivers involved in a safety event.
26 | High Reliability/Journey to Zero
Patient & Caregiver Safety Center for Worklife Wellbeing The Center for Worklife Wellbeing expanded in scope this year to include all ChristianaCare caregivers, including members of the Medical-Dental Staff, advanced practice clinicians and all caregivers in the health system. Key highlights from the year include an advanced operational framework to describe and guide our wellbeing journey, a new internal website where caregivers can access online resources, and release of an interactive provider-wellbeing dashboard that provides transparency around provider-wellbeing survey results and allows users to interact with data subsets. New, recurring programs include guided mindfulness for caregivers practice and group discussion, Time for You: an arts, humanities and wellbeing series, and increased opportunities for small-group leadership development coaching. Milestones marked in 2019: Care for the Caregiver provided peer support to more than 1,000 caregivers since inception in June 2015. More than 50 multidisciplinary peer supporters throughout the organization volunteer their time to support colleagues after adverse safety events. Nearly 15% of providers took advantage of VITAL WorkLifeTM coaching, consulting, counseling and other unique solutions that support individual well being and improve organizational culture. Utilization doubled from 2017 to 2018 and then doubled again from 2018 to 2019. OASIS education modules were offered to 2,400 caregivers. In 2019, five additional OASIS rooms were opened for a total of 10 protected spaces now available systemwide to all caregivers for reflection, relaxation and restoration.
Center for Worklife Wellbeing top services by number of participants Time for You Series, 120
Vital Worklife, 517
Thank You Project, 30 Reflective Rounds, 120 Narrative Medicine Workshops, 96
Care for the Caregiver, 355
COMPASS, 43
Ice Cream Rounds, 275
Mindfulness for Caregivers, 600
Paws to DeStress, 400
Small Group Leadership Coaching, 360
The Center for Worklife Wellbeing provided services to more than 3,000 caregivers in 2019.
ChristianaCare Quality & Safety Report 2020 | 27
Caregiver injuries and illnesses incidence rate lowest ever, and well below national average ChristianaCare’s caregiver incidence rate for injuries and illnesses for the fi rst three quarters of FY 2020 decreased 18% from the same period last year, achieving the lowest rate in a decade. The decline is a result of signifi cant multidisciplinary efforts to decrease recordable needlestick/sharps injuries, (down 28%) and physical demands and material lifting/moving (down 19%), as well as fewer slip, trip and falls (down 40%) in large part due to mild winter weather. Increases were recorded this fi scal year in caught between/struck by injuries (up 50%), and follow a national upward trend for assault by patient (up 40%) due to clinical circumstances such as dementia and opioid addiction. The patient handling recordable injury rate remained unchanged. In March 2020, nine COVID-19 caregiver illness cases were included in the recordable rate. ChristianaCare’s rate, which measures injuries and illnesses per 100 full-time equivalents (this year at 4.07), consistently trends well below the national average for hospitals, which is currently 5.6.
Caregiver Injuries and Illnesses Incidence Rate Trend
Desired Direction
Injuries/Illnesses per 100 full-time equivalents
Injuries and illness incidence rate
Injuries and illness incidence rate
National average for hospitals
8.0 7.0 6.0
National Avg: 5.6
6.71
5.0
5.65
5.78 5.01
4.0
4.93
3.0
4.48
4.20
4.50
FY16
FY17
FY18
4.07
2.0 1.0 0.0 FY11
FY12
FY13
FY14
FY15
ChristianaCare’s injuries and illnesses incidence rate reached the lowest level in a decade.
28 |
4.80
Patient & Caregiver Safety
FY19
FY20 YTD
Activity and mobility pilot gets inpatients moving ChristianaCare has partnered with Johns Hopkins on a structured Activity and Mobility Promotion pilot to get inpatients moving each day. Immobility and inactivity may have associated negative outcomes, such as increased length of stay and hospital-acquired conditions and illnesses. In the Hopkins study, multifaceted interventions helped sustain a 17% decrease in initial rehabilitation visits and a 33% decrease in total rehabilitation visits. They also led to an increased intensity of rehabilitation therapy for patients in the highest tertile of mobility impairment and, most importantly, did not lead to a change in the rate of injurious falls per patient day. ChristianaCare launched this pilot on seven units of both campuses in November 2019. All pilot units showed an overall improvement in mobility scores. Across all units, 57% of patients demonstrated improved mobility status over their length of stay, with a goal being >70%. There has been no increase in recorded injuries for ambulation, transfers or repositioning during the pilot, and the number of days between caregiver injuries has increased to more than 35 days from 11 days prior to the pilot.
Mobility Status
Desired Direction
100%
Regressed, 13%
Percent of patients
80% Unchanged, 30%
60%
40%
20%
Improved, 57%
0%
Patient mobility status improved, on average, 57% during the pilot.
The number of days between caregiver injuries increased from 11 days to 35 days during the pilot.
ChristianaCare Quality & Safety Report 2020 | 29
#HitMeWithYourFluShot campaign continues to exceed vaccination goals As part of our second #HitMeWithYourFluShot campaign, 8,035 ChristianaCare caregivers were vaccinated in one day at 100 locations in four states. A huge team of caregivers stepped up to vaccinate their colleagues at vaccination stations on both hospital campuses — including an outdoor drive-thru station — while a mobile team delivered vaccinations to colleagues at more than 100 locations in four states.
More than 8,000 caregivers were vaccinated in one day. By the end of March 2019, more than 90% of caregivers had received the flu vaccine (Other caregivers include volunteers and Medical-Dental Staff.).
30 |
Patient & Caregiver Safety
Care Standardization Setting patients up for success reduces readmissions ChristianaCare’s clinical pathways, which offer algorithms for consistent screening, evaluation, diagnosis and treatment, are designed to reduce waste and optimize the health and experience of populations of patients with like conditions and diseases. By sharing patient information electronically among integrated practice teams (IPTs), primary care providers and specialists — an effort known as “one patient, one chart”— physicians understand what has occurred in the patient’s condition, and are prompted with questions to ensure that the patient is getting optimal care. One patient, one chart also allows all caregivers to communicate with the patient in a consistent way to reduce the need for readmissions.
“Quit” services key to reducing COPD A holistic 360-degree approach by IPTs, including care standardization, patient education and pulmonary rehabilitation, is helping ChristianaCare limit the progression of chronic obstructive pulmonary disease (COPD). Because this lung disease is usually the result of smoking or environmental factors, capturing patients while still in the hospital with referrals to smoking cessation “quit” services is key. Of the 4,259 patients identifi ed as smokers who were admitted to ChristianaCare in 2019, 1,428, or 33.5%, were visited at the bedside. 23% of the smokers had been diagnosed with COPD.
% of admitted smokers
35%
Smoking Abstinence after 1 Month
Smoking Cessation Bedside Counseling
Desired Direction
50%
33.5% 27.9%
27.5%
30% 25%
21.6%
20% 15% 10% 5% 0% Visited at Bedside
Received Bedside Counseling
Accepted Follow-up
Smoking Cessation Referral
27.9% of patients visited at the bedside were referred to either the DE Quitline or face-to-face counseling for cessation help.
% of patients reached
Desired 40% Direction
Last known status = Smokefree 7 days 44.9%
40% 29.5%
30% 20% 10% 0% Received Bedside Counseling
No Bedside Counseling
44.9% of patients who received bedside counseling and were reached for follow-up reported being smoke-free for at least seven days.
ChristianaCare Quality & Safety Report 2020 | 31
BP management and treatment program helps control hypertension To improve high blood pressure treatment, ChristianaCare has made a systemwide effort to educate all medical offi ces to take the time to get accurate blood pressure (BP) measurements and talk with patients whose numbers elevate beyond 130/80. By implementing proper measurement techniques and a blood pressure management and treatment program, patients’ blood pressures in the ChristianaCare Cardiology Consultants practice decreased in just six months to an average of 130/78 from 152/88.
Hypertension Control ChristianaCare Cardiology Practices
% of patients with hypertension
Desired Direction
100%
91.0%
80%
65.9%
60% 37.9%
40% 20% 0%
Control at 130/80
Control at 140/90
Control at 160/100
37.9% of patients with hypertension receiving care from ChristianaCare cardiology practices are controlled with BP below 130/80; almost two-thirds are controlled at less than 140/90. (N=12, 196 total patients)
Health Equity: Hypertension Control by Race All ChristianaCare Practices
Desired Direction
Prevalence of hypertension
Control at 130/80
Control at 140/90
% of patients
70% 60% 50% 40% 30% 20% 10% 0% White
Black or African American
Asian
Other Race
American Native Indian or Hawaiian or Alaskan Native Other Pacific Islander
Unknown
Black/African American patients have a higher prevalence of hypertension than do patients of other races, and their hypertension is less likely to be controlled.
32 |
Care Standardization
Care standardization improves management of congestive heart failure A care standardization approach to treating heart failure, built on best practices, technology and education, now reaches across specialties and services to optimize care. The work, which includes a machine-learning algorithm that can predict a hospitalized patient’s risk for heart failure — a score that helps us begin guideline-based treatments and disease education more effi ciently — helps ensure that patients consistently receive the best coordinated care for their individual needs at every touchpoint within ChristianaCare. ChristianaCare introduced a four-week outpatient intensive care program at the Heart Failure Bridge Clinic at Christiana Hospital/Newark Campus offering nutrition and education and use of ReDS Vest technology (see page 40) to detect early fl uid accumulation in a patient’s lungs before signs or symptoms are present. The readmission rate for patients with congestive heart failure is down to 17.5%, far below the national average of 25%.
Heart Failure 30-Day Readmission Rate
Desired Direction
30%
30-Day Readmit Rate
Fiscal year average
% of discharges
25% 20% 15% 10% 5% 2018-03 2018-04 2018-05 2018-06 2018-07 2018-08 2018-09 2018-10 2018-11 2018-12 2019-01 2019-02 2019-03 2019-04 2019-05 2019-06 2019-07 2019-08 2019-09 2019-10 2019-11 2019-12 2020-01 2020-02 2020-03
0%
Readmissions for heart failure decreased 21.6% to 17.5% in Fiscal Year 2020 (through February) from 22.4% in Fiscal Year 2018.
ChristianaCare Quality & Safety Report 2020 | 33
Health Equity ChristianaCare’s vision is to be at the forefront of population health and a nationally recognized leader in developing a social care framework, where care, services, connections and community investments advance health outcomes and health equity, and support a strong, vibrant community. A Community Health Needs Assessment in 2019, which included a series of community meetings with more than 100 adult stakeholders and 75 local teenagers, as well as internal meetings of ChristianaCare caregivers, identified five key needs that have a steady impact on health. These include: Social Determinants of Health, including poverty, food insecurity, housing, affordability of care, education and employment and economic opportunity; mental health and substance use disorder; violence and public safety; maternal and child health and infant mortality; and access to primary care and dental care. ChristianaCare is investing nearly $2 million into the community to improve health through the ChristianaCare Community Investment Fund. The funded initiatives address a diverse array of healthrelated needs, including behavioral health, housing, food and workforce development. A 2019 gift of $1 million to Purpose Built Communities’ REACH Riverside Community Development Initiative is helping to fund community health and wellness outreach and education; facilities and resources for teen programs and activities; support for seniors and children; transportation and programs to support economic opportunity and mobility through workforce development and financial health programs in one of Wilmington’s oldest and most underserved neighborhoods. ChristianaCare also engaged Unite Us to develop a care coordination network connecting social services and clinical care providers across the state. Within this network, any health care provider or social service organization can help an individual address diverse needs, taking advantage of existing resources and better understanding areas that need additional resources or investment. A striking 10.8% of Delaware households are food-insecure — defined as not knowing how or not being able to provide food to your family or yourself. ChristianaCare is in the early stages of devising a research project with our Value Institute that will provide home delivery of medically tailored meals to food-insecure patients and their families for the first 30 days after discharge from the hospital. The Wilmington Hospital Food Pantry, established in early 2019, in partnership with the Food Bank of Delaware, serves outpatients of Wilmington Hospital, the Center for Special Health Care Needs, Independence at Home and our care coordination community team with boxes of non-perishable food to patients identified as needing access to food.
34 |
Health Equity
Household Members Served by Wilmington Food Pantry
Desired Direction
Children
Elderly (65+)
60 50 40 30 20 10
9 Fe b19 M ar -1 9 Ap r19 M ay -1 9 Ju n19 Ju l-1 9 Au g19 Se p19 O ct -1 9 N ov -1 9 De c19 Ja n20 Fe b20 M ar -2 0
0
Ja n1
Number of community members
Adults
374 people in 181 households, including 91 children and 29 elderly, have received food through the Wilmington Food Pantry & Food Bank of Delaware collaboration. Of the food box recipients, 73% come from areas impacted by poverty and located in a food desert.
Bilingual reproductive health classes improve student knowledge of risks and resources Adolescent friendly, bilingual presentations in the classroom setting helped raise scores on a test of reproductive health knowledge by more than 25 points among Delaware high school students for whom English is not their primary language. The goal was to increase student awareness of risky sexual behaviors and potential consequences, sexually transmitted infection and HIV prevention strategies and testing resources, as well as birth control methods and resources. Overall, students’ knowledge of reproductive health increased largely — scores rose to 68 from 43 among all students, and even higher among English Language Learner students taking the test in Spanish. Improved awareness of the availability of adolescent-friendly reproductive health services led to a 33% increase in use of services.
Desired Direction
Reproductive Health Pre/Post Score Increase School Year 2019 Pre
Post 75
80
68
70
59
Test score
60 50
48
43
38
40 30 20 10 0 Overall
English
Spanish
English Language Learners taking the reproductive health test in Spanish showed greater improvement in test scores, with an increase of 27 points.
ChristianaCare Quality & Safety Report 2020 | 35
Population Health Teamlet model to “Share the Care” enhances patient experience The ChristianaCare Medical Group opened three new primary care practices this year — Primary Care Linden Hill in June 2019, Primary Care Middletown East in July 2019 and Primary Care Lantana Square in March 2020 — all based on the “teamlet” team-based model of care. Multiple clinicians, including one physician, one nurse practitioner or physician assistant, one registered nurse, three medical assistants and support services staff “share the care” as a teamlet to improve patient outcomes, patient experience and caregiver satisfaction, and to contain costs through continuity of care, access to care and allowing caregivers to work top of license. Two unique features of the teamlet model include pre-visit planning (referral tracking, care gap closure and care coordination) by a charge medical assistant, and group medical visits encouraging open conversation among patients with like diagnoses. Pre-visit planning alerts providers to care gaps, such as outstanding referrals or preventive measures including fl u vaccines, mammography or colonoscopies, to be addressed in a timely manner with the patient. The group medical visit format improves access and engagement by allowing providers to see more patients, and provides a forum for patients who wish to share experiences in managing chronic conditions with peers. The Primary Care Linden Hill practice was the fi rst to implement the full teamlet model resulting in decreased hospital utilization. In that practice, inpatient admissions per 1,000 patients are 69% below target. ED visits per 1,000 patients are 38% below target. All 21 ChristianaCare primary care practices currently offer parts of the teamlet model and are in the process of transitioning entirely to this exciting model of care that offers better experiences for patients and caregivers.
Patient Experience Performance FY20 YTD (Feb 2020)
Year-end target
100% 80% 60% 40% 20%
To ge th er ng Se rv i
C n ia Ph ys ic
O
ffi
ce
St af
fQ
om m un ic
at io n
ua lit y
l Gl ob a
Co or di n
Ca re
3 Ca re to es s Ac c
at io n
0% m on th s
% of eligible patients
Desired Direction
All six of the survey domains* are performing above the FY 2020 year-end target. The strongest performance was seen in Access to Care (+10.5%), Serving Together (+6.5%) and Office Staff Quality (+4.3%). At 93% overall, the Linden Hill practice has the highest patient experience scores among the primary care practices, which have an overall score of 89.1%.
36 |
Population Health
eBrightHealth ACO partnership leads to better care, lower cost eBrightHealth ACO, an accountable care organization, reduced overall health care spending by $11.3 million in calendar year 2018*, its third year of operation, while also maintaining a high level of quality care for approximately 40,000 Medicare benefi ciaries in Delaware, Pennsylvania and Maryland. Supporting this care is our award-winning CareVio care coordination program that harnesses real-time data and predictive analytics to identify opportunities for helping patients better manage their health and avoid complications leading to unnecessary hospitalizations or ED visits.
Reduced Medicare Spending eBrightHealth ACO
Desired Direction
Total: $13 MM
$14,000,000
Reduced spend ($)
$12,000,000 $10,000, 000 $8,000,000 2018, $11.3MM
$6,000,000 $4, 000,000 $2,000,000
2017, $.84MM 2016, $.86MM
$0
On Jan. 1, 2020, eBrightHealth ACO entered a two-sided risk model with opportunity to share cost savings if total health care spending falls below an established target, or responsibility to repay a portion of costs that exceed the target spending amount.
eBrightHealth ACO achieved nearly $13MM in reduced health care costs in its ďŹ rst three years of partnership.
*Most recent data publicly reported by the Centers for Medicare & Medicaid Services
eBrightHealth ACO Quality Payment Program Results Falls: Screening for Future Fall Risk
89.0% 49.4%
Diabetes Composite
71.1%
HTN: Controlling High Blood Pressure
78.1%
Breast Cancer Screening Colorectal Cancer Screening
69.3%
Influenza Immunization
81.3% 94.7%
Med Reconciliation Post Discharge 81.2%
Pneumococcal Vaccination 14.7%
*All-Condition Readmission (Risk-Std) Getting timely care, appts, and info
83.1%
How well your doctor communicates Desired Direction
94.8% 0%
20%
40%
60%
80%
100%
*Reverse measure, lower numbers are better
eBrightHealth ACO’s 2018 quality results show strong performance with 9 measures performing better than the mean for all ACOs.
ChristianaCare Quality & Safety Report 2020 | 37
CareVio’s care coordination technology and evidence-based disease management improves member outcomes Christiana Care’s national award-winning care coordination program CareVio continues to explore methods for leveraging technology and integrating evidence-based disease management to improve outcomes. CareVio has developed a standard approach to disease management to ensure that each member receives evidence-based, best-practice care. The methodology involves:
38 |
Identify top 5-10 evidence-based best standards of practice for a given population.
Stage members according to objective data criteria, such as hemoglobin A1c for diabetes or ejection fraction for heart failure.
Level members, from Level 1 to Level 4, according to objective staging data results and machinelearning risk scoring.
Level 1 and 2 members are managed by nurse care coordinators according to short-term and long-term standards of care goals, with outreach to other team members, as needed.
Level 3 and 4 members are managed by a population health CareVio team which includes pharmacists, social workers, respiratory therapists (for COPD), care coordinators and health coaches, with specific outreach and touch points.
Specific tools used with new technologies to drive outcomes include: −
Secure text messaging daily self-assessments.
−
Video conferencing.
−
Telephonic and in-person communication.
Real-time hospital utilization and laboratory result alerts from the Delaware Health Information Network (DHIN) identify members at risk for disease exacerbation and or hospital utilization, so that care coordinators can intervene at the time members are most vulnerable.
Continuous monitoring of quality measures and clinical outcomes to drive improvements.
Population Health
CareVio engagement helps members improve control of HbA1c levels Members with diabetes in CareVio’s risk contracts are identifi ed for intervention based on real-time abnormal hemoglobin A1c (HbA1c) lab alerts from the Delaware Health Information Network. Any member with a result over 8.5 is considered high risk (Level 3 or 4) and fl agged for outreach by the CareVio team. Standards of care include medication optimization (appropriate ACE/ARB and statin), education and self-management, and healthy lifestyle. Since January 2019, 1,765 members with diabetes have been identifi ed; 55% engaged with CareVio to help manage their condition. To date, 35% of participants have HbA1c levels below 9%. Estimated cost avoidance, based on estimates from the American Diabetes Association, is $3.2 million.
Diabetes Glycemic Control
Controlled: HbA1c < 9%, 35%
Uncontrolled (HbA1c â&#x2030;Ľ 9%), 65%
With CareVio support, 35% of participants in the Diabetes program have controlled glycemic levels.
ChristianaCare Quality & Safety Report 2020 | 39
ReDS Vest technology leads to marked reduction in hospital admissions for heart failure complications ChristianaCare is using innovative ReDS Vest (Remote Dielectric Sensing) technology to detect early fl uid accumulation in a patient’s lungs, which can occur before the patient feels any signs or symptoms of worsening heart failure. The real-time readings by trained HomeHealth aides with monitoring and followup by CareVio have helped prevent hospital admissions when inpatient care isn’t necessary. Admissions for the 46 Vest participants decreased to 21.7% during program enrollment from 56.5% in the 90 days prior to participation , with an estimated cost avoidance of $230,432. Desired Direction
ReDS Vest: Impact on Hospitalizations 56.5%
60.0%
% of participants
50.0% 40.0% 30.0% 21.7% 20.0% 10.0% 0.0% 90 Days Pre-Program Participation
90 Days Post-Program Participation
Inpatient admissions decreased 62% in the 90 days after ReDS Vest program participation.
CareVio ReDS Vest Physician Contacts Referred to emergency department, 1 Schedule office visit within 2 days, 3 Change other medications, 1
Other, 7
Change diuretic dose, 50
CareVio reached out to physicians 51 times since July 2018 based on ReDS Vest readings flagged by ChristianaCare HomeHealth aides. In most cases, physicians were able to order diuretic dose changes to help avoid unnecessary hospitalizations.
40 |
Population Health
Pulmonary function staging, education and self-management tools are key to reducing COPD readmissions Appropriate Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging based on pulmonary-function testing is key to managing the care of members with chronic obstructive pulmonary disease (COPD). CareVio levels members based on GOLD stage and hospital utilization, focusing on member education and self-management. Participants complete a daily selfassessment using secure text messaging. Those with signs of exacerbation — about 30% of all assessments — are prompted to complete a COPD assessment tool and are immediately followed up by CareVio’s respiratory therapist. Since June 2017, 692 members have participated in the COPD program. Of them, 95% have been staged using GOLD criteria with 20% categorized as Stage 4 (very severe) and 38% categorized as Stage 3 (severe). The program has had a positive impact on hospital readmissions. Thirtyday readmission rates decreased more than 37% in the 90 days after engagement with CareVio compared to 90 days pre-engagement. The reduction is greater for participants with Stage 3 COPD. Estimated cost avoidance based on reduced readmissions is $137,529. Desired Direction
30-Day Readmission Rates 90 Days Pre/Post CareVio Engagement
% of inpatient discharges
40.0% 35.0%
37.1% 31.3%
30.0% 25.0% 20.0%
19.6%
18.6%
15.0% 10.0% 5.0% 0.0% All COPD Enrollees Pre-Program Engagement
Stage 3-4 COPD Post-Program Engagement
30-day readmission rates decreased 37.4% in the 90 days during/after engagement with CareVio compared to 90 days pre-engagement.
ChristianaCare Quality & Safety Report 2020 | 41
Healthy Mom/Healthy Baby addresses risk of preterm birth ChristianaCare is leading a local research trial that uses a unique blood test to detect the risk of preterm birth and treat women with daily aspirin and vaginal progesterone. Through a collaboration between CareVio and the Department of Obstetrics & Gynecology, 285 women at risk for pre-term delivery participated in weekly monitoring via secure text messaging, with other interventions in response to early signs or symptoms that develop. To date, 99% of participants reported compliance with standards of care â&#x20AC;&#x201D; taking daily aspirin and vaginal progesterone.
The AVERT PreTerm clinical trial is evaluating the effectiveness of daily aspirin and vaginal progesterone on reducing pre-term delivery among high-risk women.
CareVio uses claims analytics, in addition to referrals, to identify women early in their pregnancy to engage them in the Healthy Mom/Healthy Baby pregnancy program. Since August 2018, CareVio has outreached to almost 2,400 members; 75% have engaged with the team.
42 |
Population Health
Interventions by CareVio Community team help decrease hospitalizations Since its beginning as Medical Home Without Walls in 2012, the CareVio Community team has focused on reducing hospital utilization and improving health outcomes for more than 1,200 individuals and families in our community struggling with a combination of social barriers to health and at least one poorly controlled medical diagnosis. Based on standardized Social Determinants of Health questionnaires on more than 260 program participants, top opportunities identifi ed included depressive disorders, stress, lack of transportation, concern with bills and homelessness. Desired Direction
Social Determinants of Health Top Factors Identified Told have depressive disorder Stress Lack of transportation Concern with bills No steady place to live Told have manic/depr, bipolar, schizophrenia Threat to cut off utility services Don't feel safe at home Social Isolation Worry about running out of food Urgent needs Unable to afford going to doctor Needs help find/keep job Jail/ prison in last year >2 nights in a row
0%
20%
40%
60%
% of respondents
80%
Behavioral health, transportation and homelessness are among the top Social Determinants of Health issues.
ChristianaCare Quality & Safety Report 2020 | 43
The CareVio Community team provides a wide array of services to vulnerable members based on identifi ed needs, including referrals to community services and providers, food boxes, utility bill assistance, advocacy for services and accompanying members to appointments.
Community Team: Top Interventions & Referrals
Rental assistance/subsidize d housing, 51
Food bank, 83 Advocate for the member with services, 147
Referred to therapy provider, 87
Accompany member to appointments, 70
Referred to LTC (community or facility support), 41
Utility bill pay assistance, 32
Referred to psychiatric provider, 34
SNAP or WIC, 27
Referred to home health agency, 50
Community based organization, 80
Bus route/tickets, 54
Pharmacy assistance, 46
Emerge ncy food box, 26
DME agency, 25
Logisticar e, 22 SSI/SSDI, 16
The Community Team advocates for members with housing, social services and other resources.
The individualized interventions provided by the CareVio Community Team have a substantial impact on the participantsâ&#x20AC;&#x2122; use of hospital services. By addressing Social Determinants of Health needs and supporting participants to access community services, hospital utilization decreased 61% in the 60 days after program participation, compared to the 60 days prior. The greatest decrease was seen in ED use. Desired Direction
Hospital Utilization: 60 Days Pre/Post Program Participation
Avg encounters per member
Pre-program 2.50
Post-program
2.20
2.00 1.50 1.00
0.81
0.64
0.50
0.29
0.00 Emergency
Inpatient/Obs
ED use decreased 63% to 0.81 visits per member from 2.20 visits in 60 days.
44 | Population Health
Referred to a shelter, 27
Comm housin g, 16
Community Health Workers provide critical outreach Community health workers are now embedded within womenâ&#x20AC;&#x2122;s health, school-based health centers, primary care practices and within our care coordination community team. This team underscores ChristianaCareâ&#x20AC;&#x2122;s commitment to critical community outreach and is a key component of our effective population health strategy.
Community Health Workers, 2017
Full-Time Community Health Workers, 2020
0
20
In just three years, ChristianaCare has established a team of 20 community health workers to provide critical community outreach.
ChristianaCare Quality & Safety Report 2020 | 45
Telehealth — The future of health care is here — and home ChristianaCare’s Telehealth team hosted a Telehealth Summit in October 2019 and completed certification training in December, providing a framework to think more systemically about the future of virtual health care delivery and positioning ChristianaCare at the forefront of industry trends in an ever-changing and evolving marketplace. The CEO Roundtable approved three main strategic ideas 1. The future of health is virtual. 2. Care will be virtual, except where it cannot be. 3. Care will be provided in the home except that which cannot be.
Telehealth highlights from FY 2020
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Centralized safety sitters monitored more than 3,100 patients at risk for falls and those in alcohol withdrawal on five inpatient units via electronic surveillance using alerting technology adopted from the Xbox gaming platform.
Between September 2019 and May 2020, 10 stationary and mobile “robots” beamed intensivists into hospital rooms to watch over the sickest patients, round with bedside caregivers and collaborate with educating our ICU residents. The robots facilitated 1,056 intensivist encounters resulting in 14,018 minutes of expedited patient care.
Cerner employees across the nation preparing for and recovering from weight loss surgery performed by our expert bariatric surgery team participated in virtual education and support groups and receive virtual postoperative follow-up care from the comfort of their own homes.
Hundreds of dedicated, inpatient iPads allowed staff to limit their infection risk from shared devices, eliminate waste of personal protective equipment (PPE) and reduce patient and caregiver feelings of isolation when confined to rooms for extended periods of time.
Multiple skilled nursing locations utilized iPads to connect their facility staff with ChristianaCare clinical caregivers to offer assessments and support remotely, saving PPE, reducing the risk of infection and avoiding the need for transportation to the ED for care.
Nearly 400 employees and dependents took advantage of a virtual urgent care visit this fiscal year through May, providing prompt, right-place, right-time care and saving ChristianaCare several thousand dollars in delayed or inappropriate site-of-care costs.
Population Health
Where would patients have gone if not for the Virtual Urgent Care Center? Seen my doctor in person, 23% Done nothing, 14% Emergency room, 4%
More than 400 visits were made to ChristianaCare’s virtual urgent care center in FY 2020. Without that virtual visit option, 59% of those patients said that they would have visited an in-person urgent care or retail clinic; 23% would have seen their doctor; 4% would have gone to the emergency department and 14% would have done nothing. Cost savings totaled $28,944, with more than half of that from eliminating visits to the ED.
Urgent Care/Retail Clinic, 59%
Pandemic accelerates 5-year telemedicine plan to 20-day launch At the October telehealth summit, work was expected to progress “quickly” to develop a plan to bring the Center for Virtual Health vision to life. No one could have imagined just how quickly ChristianaCare’s virtual practice would progress once the novel coronavirus pandemic struck our nation. ChristianaCare was charting a course to transform care based on a vision that all care that can be done in the home, in the community or on a smartphone should be. This transformation accelerated exponentially during the coronavirus pandemic. To identify and prioritize patients needing urgent virtual provider access or additional medical service, and to reduce unnecessary patient and caregiver COVID-19 exposure, ChristianaCare established a comprehensive and sophisticated COVID-19 virtual provider visit and interactive telehealth program. Between March 15 and May 15, 577 caregivers were trained to provide telehealth services; 360 iPads were deployed to inpatient patient care units and 377 providers and provider locations were enabled for remote care. During that period, more than 10,500 telemedicine visits were provided.
Inpatient Consults via iPads Other Services Primary Care Virtual COVID-19 Practice Specialty/Behavioral Health
Telemedicine visit volume (through May 15, 2020; Virtual Practice through May 23.
698 1889 2041 2333 3565
ChristianaCare Quality & Safety Report 2020 | 47
Virtual COVID-19 Practice Screening form referral
CareVio escalation
All others
Total patients (cumulative) 2000 1800
50
1600 1400
40
1200 30
1000 800
20
600 400
10
Cumulative patient count
Number of patients engaged
60
200 0 17-Mar
0 24-Mar
31-Mar
7-Apr
14-Apr
21-Apr
28-Apr
5-May
12-May
19-May
Through May 23, the Virtual COVID-19 Practice had engaged 1,900 patients in 2,333 virtual visits.
During the week of March 15, ChristianaCare’s virtual practice quickly shifted gears from virtual primary care to caring for patients who were symptomatic and/or diagnosed with COVID-19. Referrals to the virtual COVID-19 practice were initially through The Medical Group primary care and specialty practices, but expanded to include patients with escalating symptoms referred from CareVio, ED referrals, caregiver escalations from Employee Health or self-referral, community practice and eBrightHealth ACO partner referrals. In addition, CareVio is helping to get ChristianaCare caregivers and other workers across the state of Delaware safely back to work with text message symptom monitoring. As of May 23, the practice had engaged 1,900 patients in more than 2,300 virtual visits; 56% were referred by ChristianaCare primary care and other practices after screening for COVID symptoms, 16% were referred by CareVio for escalating symptoms. The estimated cost avoidance of virtual visits for escalation of symptoms instead of ED visits is $490,800. Since the coronavirus crisis began (through May 15), CareVio has monitored more than 5,994 patients — in many cases, whole families were monitored through a single phone number — through more than 260,800 secure text messages, translated into Spanish, when appropriate. CareVio also provided COVID-19 education to more than 5,800 members at high risk due to underlying chronic conditions, and called more 9,870 patients following COVID-19 testing to answer questions and ensure they have a primary care provider.
COVID-19 by the numbers: As of May 24, 2020
48 |
More than 16,560 patient tests for COVID-19.
17% of completed tests were positive.
23% (624) of patients testing positive for COVID-19 were hospitalized.
Population Health
82% (510) of hospitalized patients to date have been discharged.
35% (939) of positive patients have recovered to date.
Health equity collaborations promote culturally responsible care A number of health equity collaborations were implemented to promote culturally responsible care. These included sustaining continuity of service for culturally responsible care; increasing access to testing through trusted community partners; addressing increasing social needs and supporting vulnerable populations; and mobilizing data, research and evaluation to identify disparities and support culturally informed education and outreach. Examples include:
Mobile testing with language access in Georgetown, Delaware, and in high-need communities throughout New Castle County.
Spanish-language hotline for COVID-19 inquiries and support.
Expansion of Healthy Families program featuring community health workers and health guides to address changing social needs and COVID-19 awareness.
Statewide predictive modeling by ChristianaCare’s Value Institute to identify and evaluate disparities.
Inclusion of race, ethnicity and language data on COVID-19 dashboards.
Implementation of virtual access lines in Spanish, American Sign Language, Haitian Creole, Korean and Mandarin Chinese.
Virtual access lines in multiple languages and translated materials promote culturally informed education and outreach.
ChristianaCare Quality & Safety Report 2020 | 49
FCC CARES Act grant will expand telehealth capabilities, address disparities ChristianaCare is one of just 17 health care providers in the U.S. to receive a grant from the Federal Communications Commission (FCC) under the CARES Act to support telehealth services during the COVID-19 pandemic. The $714,000 grant will expand telehealth capabilities by increasing broadband access to telehealth services for vulnerable and underserved residents by providing devices and data plans. It will also allow ChristianaCare to expand our transformative model for COVID-19 care and offer on-site telehealth services to communities with high disease burden and challenging accessing virtual health services.
“Providing broadband telehealth services to our disconnected vulnerable patients and neighborhoods will help build a telemedicine foundation to address disparities in access to primary and specialty care that extends beyond COVID-19.” Sharon Anderson, MS, BSN, RN — Chief Virtual Health Officer and President, CareVio
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Population Health
Exceptional Experience The Serving Together metric measures patient experience across the continuum of care, based on responses to the question “How well staff worked together to care for you.” In FY 2020 through February, Serving Together performance increased to 80.1% favorable from a 2019 baseline of 78.0%, exceeding the year-end target of 78.5%.
Serving Together 85% 80% 75% 70% 65% 60% 55% 50% Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20
Top box score (% 'very good')
Desired 90% Direction
The Serving Together performance has increased 3.4 percentage points since FY 2018.
The improvement in the overall Serving Together metric was driven by a specifi c focus on collaboration within and between teams from across the organization; interteam collaboration was identifi ed as a specifi c area of opportunity in ChristianaCare’s most recent Culture of Safety survey. Driven by the positive performance in the Serving Together metric, patient experience performance increased across all three care settings — inpatient services, outpatient services and medical practices — with all three areas exceeding the year-end targets.
ChristianaCare Quality & Safety Report 2020 | 51
Serving Together Top Box Trend by Care Setting
Desired Direction
FY 2019
FY 2020
Top box (% "very good")
90% 80% 73.2%
75.2%
78.5%
80.1%
79.5%
81.3%
70% 60% 50% Inpatient Services
Outpatient Services
Medical Practices
Inpatient services increased by 0.7%, outpatient services by 0.8% and medical practices by 4.1%
A uniform methodology was developed to deploy best practices for improved patient experience across the continuum of care. The methodology involved identifying specifi c drivers of patient experience performance across various domains, such as communication. ChristianaCare and hospital industry survey data were analyzed to identify the key domain aspects that drive exceptional patient experience. For each, best practices and improved processes have been implemented over the past few years in each care setting – such as teach back for improved communication around medication or discharge education, and rounding with service recovery to identify and mitigate patient issues.
Patient Experience Best Practice Deployment Elements of the Score: (example areas on surveys)
All:
• Communication • How Well We Work Together • Courtesy & Respect
Inpatient: • • • • •
Call Lights & Help Toileting Quiet Cleanliness Food Discharge
Community:
• Access to Care • Office Staff Quality • Pre & Post Care Coordination
52 |
Exceptional Experience
Drivers of Experience:
(based on industry & CC data)
All:
• Communication • How Well We Work Together • Responsiveness to Concerns
Inpatient:
• Quiet • Cleanliness
Community:
• Access • Care Coordination
Best Practices & Improvements: (evidence based where applicable)
All: • • • • •
Teach Back Serving Together Frontline Engagement Plan Service Recovery & NRC Relationship Based Care
Inpatient: • • • • • •
Purposeful Hourly Rounding Bedside Shift Report Nurse Leader Rounding Quiet Ambassadors Hospital Environment Challenge 4Ms / Matters Most
Community:
• Access Strategy / Improvements • Ambulatory Bundle (VNA & MG) • 4Ms / Matters Most
Nurse leader rounding enhances patient and family experience Rounding by nurse leaders is an evidence-based best practice that improves patient and family outcomes of care. Rounds connect the nurse leader with the patient and family to uncover opportunities for our care to be even better tomorrow. They also provide patients and families an opportunity to express their gratitude for the exceptional care they have received. Information is collected and analyzed in real-time through a digital rounding solution known as CipherRounds.
Leadership Rounds on Patient Care Units
Desired Direction
At least 1 round
Rounded within 24 hours of admit
50% 40% 30% 20% 10% 0%
Ja n19 Fe b19 M ar -1 9 Ap r1 M 9 ay -1 9 Ju n19 Ju l-1 Au 9 g1 Se 9 p19 O ct -1 N 9 ov -1 De 9 c19 Ja n2 Fe 0 b2 M 0 ar -2 0
Percent of encounters
Issue follow up within 24 hours 60%
Since January 2019, more than 125,500 leadership rounds were made. That represents 44% of total patient encounters. Of the nearly 2,600 issues identiďŹ ed; 32% were addressed within 24 hours.
4Ms lead to optimal health for older patients ChristianaCare earned designation as an Age-Friendly Health System from the John A. Hartford Foundation and the Institute for Healthcare Improvement for work addressing the 4Ms essential to ensuring that older adults receive the best care possible to achieve optimal health. 1.
What Matters: Know and align care with each older adultâ&#x20AC;&#x2122;s specifi c health outcome goals and care preferences.
2.
Mentation: Prevent, identify, treat and manage dementia, depression and delirium across settings of care.
3.
Mobility: Ensure that older adults move safely every day in order to maintain function.
4.
Medication: If medication is necessary, use age-friendly medication that does not interfere with mentation, mobility and what matters to the older adult.
ChristianaCare Quality & Safety Report 2020 | 53
Milestone! ChristianaCare’s online Patient Portal now offers secure virtual access to essential care to more than 100,000 patients.
Homepage/Dashboard for ChristianaCare’s online Patient Portal
The Patient Portal is a secure personal site that makes it easy for patients to:
54 |
Message their providers, and even include attachments.
View health records and provider notes.
Request a prescription renewal.
View or schedule an appointment with a provider.
Print order slips for testing (laboratory, imaging, etc.).
Complete forms sent by the care team.
Visit a provider electronically (video/phone).
Sync records with the Apple Health app.
Exceptional Experience
ChristianaCare Way Awards President’s Award
Improve New Provider Access to IT Applications at Onboarding iLead, Information Technology (IT), Medical Affairs and ChristianaCare Hospitalist Partners created a formal onboarding process and intranet site, and automated requests that increased the percentage of new providers with timely full access to all necessary IT applications to 74%. The process now applies to all new provider hires across ChristianaCare’s 84 practices.
Value Gold Award
Creating Value for High-Risk Diabetic Population CareVio, Population Health IT, Population Health Analytics and the Center for Strategic Information Management collaborated to reduce diabetes complication risk and total cost of care. More than 1,500 high-risk members with uncontrolled diabetes engaged with CareVio; 44% reduced their hemoglobin A1C levels to below 9. Estimated annual cost avoidance was $2.46 million.
Value Silver Award
Implementing Care Standards for the Diagnosis & Treatment of Syncope The Heart & Vascular and Acute Medicine service lines collaborated to design a future state for the management of syncope using an electronic health record-embedded tool. Direct cost per case decreased by 17.8% in calendar year (CY) 2018 and 33.9% in CY 2019 (through July), from $1,541 per case in CY 2017 to $1062. The syncope admission rate dropped 7.1%; observation length of stay dropped 2.97 hours.
Transformation Award
Improving A1C Control in Primary Care Four primary care practices partnered with Endocrinology to improve the care of patients with diabetes while deploying the Diabetes Health Registry. Patients with hemoglobin A1C levels <9 improved to 78% from 62%. Diabetes registry accuracy improved by 11% and the number of patients overdue for lab tests decreased 50%.
Optimal Health Safety Gold Award The Team Approach to Fall Prevention
4 West focused on reducing patient falls through multiple interventions including purposeful hourly rounding with the “6Ps” and modifying patient assignments to reduce call bell response times. Hourly rounding scores increased to 81% from 74% and call bell response time decreased to 31-60 seconds from 121-150 seconds. Falls were reduced from 12 in the first 10 months of FY 2018 to 0 falls in the first 7 months after project implementation.
Optimal Health Quality Gold Award
Reduce the Ventilator-Associated Event Rate in SCCC and NCCU by 50% by March 2019 The Surgical Critical Care Complex (SCCC) and Neuro Critical Care Uni (NCCU) modified standard ventilator settings to prevent triggering of ventilator-associated events (VAEs) during spontaneous breathing trials. The change resulted in statistically significant decreases in VAE rates in both units. SCCC improved to 3.7 events per 1,000 device days from 18.9, and NCCU improved to 2.6 from 15.7. The practice change was implemented systemwide in February 2019. ChristianaCare Quality & Safety Report 2020 | 55
Optimal Health Safety Silver Award
Changing Stylet Feeding Tube Insertion to Reduce Patient Harm Radiology, iLead, the Medical Intensive Care Unit, and Wilmington Intensive Care Unit implemented a two-step insertion process for small bore stylet (guidewire) feeding tubes involving an additional chest X-ray at midlevel to prevent placement deeper into the lung. Since go-live with the two-step insertion procedure, there have been zero cases of stylet advancement into the lung, and zero patient harm. Four patient harm events were prevented by the mid-level chest X-ray.
Exceptional Experience Award
Improving Patient Satisfaction in OB-Triage Standardized processes to streamline and improve the process from patient obstetrics (OB) triage arrival to vital signs and to seeing the provider were implemented. The time from arrival to initial vital signs decreased to 10.17 minutes from 19.19 minutes. Patient experience top box responses for “helpfulness of the first person” increased to 76% from 59%, and “wait time for doctor” improved to 49% from 38%.
Organizational Vitality Gold Award
Reducing Rehabilitation Services Denial of Payment for Services Rendered Rehabilitation Services created an authorization and visit tracking process, and implemented a documentation peer review process focused on shared learning and community-style auditing. Denial of payment for lack of authorization was reduced by 78%, and documentation-related denials dropped 51%, leading to an annual increase in revenue of $197,526.
Organizational Vitality Silver Award
Reduce Write-Offs for Patients with Inpatient Only Procedures Finance, Health Information Management Services and Compliance designed PowerChart rules for physician-facing alerts, defined a pre-bill review process and updated all processes to reduce duplicative work efforts and retouches. Write-offs for CMS’s “inpatient only list” decreased from $2.4M in FY 2017 to $1.3M in FY 2018, and the team was on track for a reduction to $500K for FY 2019. In total, inpatient-only write-offs were reduced by 79%.
Strategic Partnerships Award
Hunger Relief: Addressing Social Health Issues After identifying food insecurity as a primary need for patients seen by the Rocco A. Abessinio Family Wilmington Health Center, Social Work partnered with the Food Bank of Delaware to address food needs during patient appointments. In the first eight months, food boxes were provided to 161 people in 90 households. 73% of the food box recipients came from areas impacted by poverty and located in a food desert.
Innovative Tools Award
Predictive Modeling to Determine the Future: Reducing Cancer Readmission The Cancer team built and utilized a predictive model to reduce the readmission rate for patients with cancer to prioritize efforts and interventions for high-risk patients. The model and interventions significantly improved the 30-day readmission rate for patients from 34% to 24%. Length of stay decreased by 0.5 days and there were 4% fewer ED visits after discharge.
Extraordinary People Award
#HitMeWithYourFluShot: How Many People Can ChristianaCare Vaccinate in One Day? For the 2019-20 flu season, Infection Prevention partnered with Emergency Management and many others to consolidate to a one-day flu shot campaign, fulfilling a dual purpose of conducting an emergency vaccination drill, while maintaining a 92% or better caregiver vaccination rate. During the one-day event, 7,267 (69%) ChristianaCare and 162 (29%) ChristianaCare HomeHealth caregivers, along with 1,594 non-employed persons (including physicians, volunteers and retirees) were vaccinated. Final vaccination rates were 93% for Christiana Hospital and 94% for Wilmington Hospital. 56 |
ChristianaCare Way Awards
Magnet New Knowledge, Innovations & Improvements Gold Award
Decreasing Pressure Injuries Utilizing Tilt-in-Space Wheelchairs Decreasing Pressure Injuries Utilizing Tilt in Space Wheelchairs Occupational Therapy worked with Nursing to reduce sacral, hip, and buttock HAPIs on the Surgical Critical Care Complex, Transitional Surgical Unit and the Neuro Critical Care Unit through the use of tilt-in-space wheelchairs and a specialized seating protocol. The pilot units’ HAPI rates decreased 22%, from 3.72% to 2.9%.
Magnet Exemplary Professional Practice Gold Award Lions and Tigers and Falls….Oh My!!!!
The Christiana ED used cost-neutral red non-skid socks to increase fall risk awareness of patients at high risk for falls. Red signs posted on the rooms of at-risk patients served as a secondary reminder. Post-implementation, the fall rate decreased 63%, from 19 falls in the first quarter of 2019, to seven in the 2nd quarter. The Ruby Red Slipper project has been expanded to the Wilmington and Middletown EDs, as well as to other units.
Magnet Transformational Leadership Gold Award Organizing Success and “Actioneering” Change
The 6A, Acute Care for the Elderly, CUSP team arranged supplies and equipment at the nurses’ station and day room to help prevent falls, increase time at the bedside and improve staff satisfaction. Post implementation, the fall rate decreased to 1.11 from 1.77 falls per 1,000 patient days, a 37% improvement.
Magnet Structural Empowerment Award
“Turning” Down the Prevalence of Unit Acquired Pressure Injuries on 5B 5B enrolled the Comprehensive Unit-Based Safety Program skin lead in a Wound Treatment Associate program for education and hands-on training with a Wound Ostomy and Continence (WOC) nurse to increase knowledge and skills to decrease pressure injuries. 5B then began weekly rounds on highrisk patients taking a pro-active approach to preventing skin breakdown. Following implementation of their interventions, 5B did not have a unit-acquired pressure injury for 14 months.
Magnet New Knowledge, Innovations & Improvements Silver Award & People’s Choice Award CLABSI - Breaking the Chain of Infection
The Transitional Medical Unit created a CLABSI Prevention Bundle with a Blood Culture Algorithm that standardized care to meet best practice for ordering blood cultures. CLABSIs decreased to 1 in 2019 from 3 in 2018. Non-evidence based central-line blood culture ordering decreased to 12 in 2019 from 44 in 2018. Cost savings associated with the reduction are approximately $90,000.
Magnet Exemplary Professional Practice Silver Award C. the Diff-erence on 4E
After conducting a root-cause analysis, the 4E Unit Practice Council mandated use of the C-Diff Scoring Tool for ordering, enforced appropriate hand hygiene, revamped cleaning processes and instituted a daily huddle. The number of hospital-acquired C. difficile infections on the unit decreased to four in FY 2019 from 10 in FY 2018, a 60% reduction.
ChristianaCare Quality & Safety Report 2020 | 57
Magnet Transformational Leadership Silver Award TSU Interunit Transfer Process
The Transitional Surgical Unit (TSU) developed a new interunit transfer process that involved immediate dispatch of Patient Escort after room cleaning, a two-nurse skin check prior to departure and mandatory bedside nurse-to-nurse report. After four months, bedside report was completed in all transfers out of TSU to 2C, 4C and 4D. The average transfer time decreased to 90.1 minutes from 120.7 minutes, a 25% improvement.
Operational Improvement Gold Award
Improve Revisit Documentation Timeliness in Home Health HomeHealth piloted interventions to establish a standardized management process to monitor revisit documentation timeliness and clinician feedback. During the four-week pilot, average daily documentation timeliness improved to 85% from 74%. Full-scale implementation of validated solutions increased timeliness to 89%.
Operational Improvement Silver Award Smooth Moves Through the NCCU and TNU
Average patient transfer time in the Neuro Critical Care Unit and Transitional Neuro Unit was 280 minutes, exceeding the target of 110 minutes. Patient Care techs used a form to track transfer times and identify barriers to timely transfer. Improvements were made and in six months, the transfer times were decreased by 35%, surpassing the teamâ&#x20AC;&#x2122;s goal of a 30% decrease.
Population Health Award
Heart Failure Re-Admission Reduction Program The Heart Failure (HF) Integrated Practice Team task force used a Health Catalyst readmission risk prediction tool to identify and see six patients with heart failure weekly, with four weeks of followup at the HF Bridge Clinic. CareVioâ&#x20AC;&#x2122;s ReDS Vest program monitored lung fluid volume in the hospital and at home, and an outpatient IV diuretic clinic was implemented. 213 patients were seen by the HF task force between November 2018 and August 2019. 30-day readmissions for this group were 17.3%, below the goal of 20%. Annualized cost savings are $480,000.
Health Equity Award
Providing Reproductive Health Education to English Language Learners School-based health centers addressed reproductive health education disparities for English Language Learning (ELL) students. Classes received in-class reproductive health education developed in a bilingual format. 67 students participated over two-years. Results showed improvement to 71% on the post-test from 46% on the pre-test, with greater improvement for students taking the tests in Spanish.
Learning Award
Improved Resident Learning Outcomes in Medication Reconciliation Using Simulation The Medication Reconciliation Committee teamed with the Virtual Education and Simulation Training Center to create a two-part educational experience consisting of online modules followed by a case-based simulation experience built on best practice for medication reconciliation. Pre- and post- intervention testing showed an improvement to 80% correct from 64%. 83% of residents surveyed indicated they would use 100% of the curricular content in their jobs.
58 |
ChristianaCare Way Awards
The ChristianaCare Way We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value.
We Serve Together Guided by Our Values of Excellence & Love Excellence We commit to being exceptional today and even better tomorrow. We seek new knowledge, ask for feedback and are open to change. We use resources wisely and effectively. We are curious and continuously look for ways to innovate. We are true to our word and follow through on our commitments.
Love We anticipate the needs of others and help with compassion and generosity. We embrace diversity and show respect to everyone. We listen actively, seek to understand and assume good intentions. We tell the truth with courage and empathy. We accept responsibility for our attitudes and actions.
ChristianaCare, PO Box 1668, Wilmington, DE 19899 | 800-693-CARE ChristianaCare.org
20QPS4