Quality & Safety Report 2014

QUALITY & SAFETY REPORT

The Christiana Care Way We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value.

QUALITY and SAFETY DRIVE CULTURAL TRANSFORMATION

CHRISTIANA CARE’S NEWLY TRANSFORMED QUALIT Y AND SAFET Y PROGRAM

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

Interdisciplinary collaboration and teamwork are paramount, and success is both apparent and motivating. The number of patients harmed is down by 60 percent over the past four years — 12 percent compared to last fiscal year alone — reinforcing our commitment to our culture of safety.

Significant improvements in clinical quality, high reliability and cost reduction include: a 78 percent reduction in ventilator-associated pneumonia and central-line-associated bloodstream infections; 100 percent compliance with Surgical Care Improvement Project measures, such as appropriate prophylactic antibiotic selection and venous thromboembolism prophylaxis aimed at reducing post-operative complications; and a 34 percent reduction in unplanned 30-day hospital readmissions for patients with heart failure.

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

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Value Improvement Teams Intrinsic to our new Quality and Safety operating system are interdisciplinary unit- and population-based value improvement teams. Led by physician and nurse pairings, these teams include physicians, nurses, respiratory therapists, pharmacists, dietitians, care managers, social workers, environmental services staff, pastoral care and others who serve patients directly or indirectly. Furthering our commitment to patient- and family-centered care, teams are encouraged to include patient and family advisers to help the team resolve issues and improve performance.

Ensconced in a Culture of Responsibility, the system drives accountability into daily work responsibilities, promotes immediate actions to resolve issues, encourages staff “Good Catches” and places the ability to “just fix it” at the local level.

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

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

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

In this report: 4 | Creating a Safe Cu l t u re 28 | Achieving High Re l iabil it y 44 | Leveraging Tec hn ol og y 58 | Awards , Recognition & Accompl is hm e n t s 60 | Our Jou r n e y

2 | C h r i sti ana Care Heal th S ys tem

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

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

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

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

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

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A SAFE CULTURE

“When we protect patients — our neighbors and friends — by washing hands and preventing infections, we respect their right to safety and we demonstrate caring.

When we prevent even one serious infection, we reduce suffering.”

ANAND P. PANWALKER, M.D. Associate Vice President, Medical Affairs and Assistant Infection Prevention Officer

4 | C h r i sti ana Care Heal th S ys tem

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

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

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

The Wilmington Intensive Care Unit (WICU) Value Improvement Team was first to be honored with Christiana Care’s newly established Unit-Based Value Improvement Team Recognition Award for sustained efforts to reduce preventable harm, most notably: • Two years without a central-line-associated blood-stream infection (CLABSI).

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

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

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

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

The Wilmington ICU Value Improvement Team.

SANDY WAKAI, MSN , RN , CCRN Nurse Manager Wilmington Intensive Care Unit

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Motivated by their success with CLABSIs, WICU’s value improvement team started to look at CAUTIs, ventilator-associated events, falls and restraints to see what improvements they could make. The team’s current value score letter grade is prominently displayed for patients, staff and families to see in the unit.

While nurse manager Sandy Wakai acknowledges that the data is motivating, and that the WICU is a competitive team that strives for that A, she said, “Our staff sees their success as simply doing the work they should do ―― to provide our patents the best outcome possible.” •

Christiana Care takes Leape toward quality and patient safety Top patient safety education award acknowledges approach to teaching Christiana Care is the winner of the 2014 Leape Ahead Award from the American College of Physician Executives (ACPE).

Leape recognizes Christiana Care’s multipronged approach to teaching the principles of patient safety and quality to medical students, residents and faculty.

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

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

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

Christiana Care’s departments of Medicine, Family and Community Medicine, Emergency Medicine, Nursing, Patient Safety and Quality, the Learning Institute, the Value Institute, Academic Affairs, Organizational Excellence and the Center for Transforming Leadership collaboratively fashioned an approach to training residents, medical students and faculty that combines didactic and experiential learning in patient safety and interdisciplinary team-based care. Elements include: ff Experiential, project-based performance-improvement education: Residents are required to participate in the 12-week Achieving Competency Today course.

ff Administrative fellowship in patient safety and quality: One fellow per year participates in residency curriculum development while focusing on experiential value-based projects, such as appropriate use of telemetry in hospitalized teaching patients. ff Simulation: Residents, students and student nurses collaborate in staged patient-care scenarios to practice difficult patient management, team-based competencies and interprofessional communication skills.

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

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

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

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

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

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

Composite areas with opportunity include:

ff Teamwork within units.

ff Teamwork across units.

ff Organizational learning and continuous improvement.

ff Handoffs and transitions.

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

ff Nonpunitive response to error.

ff Communication openness.

AHRQ 2013 Survey Results | Goal: 90th Percentile Nationally 100% Christiana Care 2013

National Teaching Mean

National 90th Percentile

81% 74%

75%

74%

71%

65%

61% 53%

52%

58%

57%

50%

39%

39%

Patient Safety Culture Composites 25%

0%

Teamwork Within Units

10000%

Management Support for Patient Safety

Organizational Learning – Continuous Improvement

Patient Safety Culture Composites Overall Frequency Communication Perceptions of of Events Openness Patient Safety Reported

Supervisor/ Manager Expectations & Actions Promoting Patient Safety

e Rate (%)

Staffing

National 90th Percentile

Teamwork Across Units

Nonpunitive Response to Error

Culture of Responsibility

Christiana Care

85.6

8 |7500% C h r i sti ana 82.3 Care Heal th S ys tem

78.0

64.6

Feedback and Communication about Error

69.5

74.3

76.3 69.0

Handoffs & Transitions

65.0

80.0 68.1

0%

Patient Safety Culture Composites

AHRQ 2013 Survey Results 100% 10000%

Christiana Care Percentile 2013 National Teaching Mean National 90th Percentile National 90th Culture of Responsibility Christiana Care

81%

82.3 74% 78.0

Positive Response Rate

75% 7500%

74%

71%

64.6 50% 5000%

85.6 65% 74.3 61% 69.5 69.0 53% 62.0

76.3 58% 52% 65.0

80.0 68.1

57%

52.0

61.0 39%

39%

25% 2500%

0% 0%

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

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

In this unit, When aCulture Composites Hospital Patient Safety we discuss mistake is manageways to prevent made that ment seems errors from could harm the interested in happening patient, but patient safety again. does not, how only after an often is this adverse event reported? happens.

10000%

National 90th Percentile

We are informed about errors that happen in this unit.

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

Culture of Responsibility

Christiana Care

Positive Response Rate (%)

85.6 82.3 a Culture of Responsibility, we are In our7500% journey toward 80.0 performance Strategies76.3 to achieve top decile 78.0 74.3 enhancing our efforts to evolve our patient-safety culture.

69.5 Multifaceted strategies to advance our safety culture and 69.0 68.1 Culture of Responsibility is a commitment to create an 65.0 64.6 62.0 achieve top decile performance in the AHRQ survey include: 61.0 environment 5000% of shared responsibility among all members of the health care team, including leaders, 52.0 physicians and staff, Advance our learning from adverse events and and those who create and administer the systems in which care share system improvements more broadly through is delivered. The focus is on improving systems and creating coordinated efforts.

2500% a learning environment that encourages colleagues to voice ff Enhance safety issue reporting and staff recognition. concerns, raise issues and report errors and near misses Our Good Catch Program encourages staff to report safety without fear of retribution or punitive action. issues that have the potential to cause harm to our patients.

0% More than 4,500 reports have been filed since the program’s In comparing those units 1 and departments that have implementation in March 2012, demonstrating a greater implemented Culture of Responsibility programming to the than 200 percent increase in near-miss reporting. rest of the hospital’s results, there is a statistically significant improvement in several key areas of our AHRQ Hospital Survey on Patient Safety Culture. In 2014, we anticipate * local level uestions even qmore improvement as we continue our Culture of Responsibility journey and target frontline providers for education and training in these concepts.

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

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ď Ž Culture of Responsibility

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

continued

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

ff Enact post-event debriefs as a forum for early discussions of adverse events or near misses in a supportive learning environment that focuses on system issues and the caregivers involved. ff Integrate safety practices into our virtual learning environment and simulation activities. ff Partner with the Christiana Care Value Institute Academy to enhance a patient-safety curriculum and maximize both individual and team abilities to lead change. ff Advance culture of patient safety through participation in a pilot program with Nemours/Alfred I. duPont Hospital for Children, initiated and funded by the AHRQ, to help advance the culture of patient safety in our medical community. The program, launched in January 2014, makes it possible for patients and caregivers to report safety concerns, adverse events and errors through a toll-free telephone number and website. The reports are shared with Christiana Care so that we can address opportunities and improve care. ff Participate in the AHRQ demonstration project CandOR: Communication and Optimal Resolution to manage patient safety and medical liability. The focus will be on implementing a toolkit to support better communication and resolution when patients are harmed.

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Design safe and reliable systems of care ff Accelerate human-factors science to design systems that are resilient to unanticipated events, aid in technology assessments and yield sustainable change. ff Use team training to support team communication as an intervention to promote a culture of safety. ff Convene improvement collaboratives to address opportunities for improvement at the system and local level. ff Strengthen scientifically based improvements in collaboration with Value Institute scholars.

Promote an open and fair culture and manage behavioral choices ff Adopt a consistent approach to managing adverse events. ff Console professionals who are involved in or make an error; coach those who drift into at-risk behaviors; and discipline reckless behavior.

•

Desired Direction

Desired Direction

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

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

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

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

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

$50,000,000

0

$37,500,000

Estimated Cost

$37,500,000

Estimated Cost

Number per 1,000 Patient Days

Christiana Care follows the broad definition of harm from the 2.5 for Healthcare Improvement (IHI): “The unintended Institute physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, hospitalization or

$42,37

$42,374,386

10

Preventable harm is tracked in five broad categories on the monthly Focus on Excellence Measurement Report: ff Hospital-acquired infections.

7.5 ff Medication safety. ff Falls. ff Pressure ulcers.

5 ff Complications.

$50,000,000

Estimated Cost Savings

$25,000,000

$20,650,194

$25,000,000

$12,500,000

$12,500,000

$17,234,557 $0

$16,884,342

$0

FY11 FY12 FY13 FY14 annualized J A S O NJD2010 F MAM J J A S O NJD2011 F MAM J J A S O NJD2012 F MAM J J A S O NJD2013 F MAM J J A S O NJD2014 FM

011 F MAM J J A S O NJD2012 F MAM J J A S O NJD2013 F MAM J J A S O NJD2014 FM

Preventable Harm Rate Trend Preventable Harm Rate Number of Patients Harmed per 1000 Patient Days 10

Number per 1,000 Patient Days

Number of Patients Harmed per 1000 Patient Days 7.5

5

2.5

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

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

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FY1

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

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

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

Since the launch of the new hand-washing program in March 2013, demand for sanitizing hand gel at Christiana Care has doubled.

Hand-Hygiene Compliance Hand Hygiene Compliance Percent of Observations

100%

90%

Target: 90%

80%

70%

60%

50%

Jul-13

Aug-13

Sept-13

100%

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91%

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

e

Hand Hygiene Compliance 100%

Nov-13

Jan-14

Percent of Observations

Y14: 0.96

Mar-14

90%

Target: 90%

80%

70%

60%

50%

Jul-13

Aug-13

Sept-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

FY14: 3.84

Flu station “blitzes” in October 2013 helped drive employee flu vaccination rates to more than 98 Jan-14 Mar-14 percent compliance with the policy to complete the vaccination, exemption or declination forms. Health care personnel flu vaccination rates are now publicly reported through the Center for Medicare and Medicaid Services’ Hospital Compare website. Christiana Care’s vaccination rate of 91 percent is significantly above the national mean of 75 percent.

100%

91% 90%

Percent of Employees

Nov-13

Health Care Personnel Flu Vaccination

Employee flu vaccinations

87%

80%

75% 70%

continued

60%

Christiana Care

State

National

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M

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

Health care-associated infection rates improve

continued

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

Hospital-acquired infections are among the most frequent causes of preventable patient harm, prolonging hospital stays, increasing health care costs and leading to patient death.

Over the past three years, hospital-acquired infections cost Christiana Care an estimated $14.5 million.

Central-Line-Associated Bloodstream Infection Rate Central Line Associated Blood Stream Infection Rate 4 3

FY13: 1.48

100%

FY14: 0.96

2 1 0

Jul-12

Sept-12

Nov-12

Jan-13

Mar-13

May-13

Jul-13

Sept-13

Nov-13

Jan-14

Mar-14

Infections per 1,000 Device Days

Catheter-Associated Urinary-Tract Infection Rate

Percent of Observations

Infections per 1,000 Device Days

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

90%

80%

70%

60%

Catheter Associated Urinary Tract Infection Rate

10

50%

FY13: 4.36

Ju

8

FY14: 3.84

6 4 2 0

Jul-12

Sept-12

Nov-12

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Jan-13

Mar-13

May-13

Jul-13

Sept-13

Nov-13

Jan-14

Mar-14

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

Project CandOR components:

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

ff Reporting.

ff A change readiness assessment. ff Gap analysis.

ff Communication. ff Care for the caregiver. ff Resolution. ff Investigation and process improvement. •

A Culture of CandOR

Organizational Change Readiness

Resolution

Gap Analysis Communication

Caring for Caregiver Event Analysis & Process Improvement

Incident Reporting

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

Nursing, Organizational Excellence partnership cuts combined fall rate by 30 percent Christiana Care’s fall-with-injury rate outperforms the mean National Database of Nursing Quality Indicators (NDNQI) benchmark greater than 50 percent of the time, compared to other Magnet facilities.

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

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

A research associate from the Christiana Care Value Institute The system-wide Fall Prevention Team evaluates falls monthly. the team to apply research methodologies to their workSep-­‐12 Feb-­‐12 Mar-­‐12 Apr-­‐12helpedMay-­‐12 Jun-­‐12 Jul-­‐12 Aug-­‐12 Patient trend graphsJan-­‐12 track the unit fall rate, number of patient and share knowledge gained through internal and external 5.94Fall summits 3.32 4.87 2.85 6.45 6.38 3.87 4.40 falls and comparative 6.26 benchmark data. allow presentations and publishing.

3.44

3.44

3.44

3.48

3.48

3.48

3.41

3.41

3.41

Combined Fall Rate | Patient Care Units 6E, 5D and 6C 8 7

Fall Rate per 1,000 Patient Days

6 5 4 3 2

NDNQI Benchmark 3.4 1

-12 Fe b-1 2 Ma r-1 2 Ap ril12 Ma y-1 2 Jun -12 Jul -12 Au g-1 2 Se p-1 2 Oc t-1 2 No v-1 2 De c-1 2 Jan -13 Fe b-1 3 Ma r-1 3 Ap r-1 3 Ma y-1 3 Jun -13 Jul -13 Au g-1 3 Se p-1 3 Oc t-1 3 No v-1 3 De c-1 3 Jan -14 Fe b-1 4 Ma r-1 4 Ap r-1 4 Ma y-1 4

0 Jan

th ate QI Mean



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

NDNQI Mean

16 | C hri sti ana Care Hea l th S ys tem

Oc

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

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

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

Patient trend graphs available on the Quality and Safety intranet site feature a “person” indicator for each patient fall to underscore the significance of each data point to care providers.

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

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

This new goal reflects an almost 10 percent decrease in recordable injuries. Christiana Care’s total recordable injury LTI FY07 FY08 FY09 rate Rate through May 2014 was 5.05, which is below the FY142.13 Lost Time Injury 2.83 2.36 goal of 5.5 andRate considerably below 0.00 the national0.01 average of 6.5.

Restricted Workday Case 0.03 The lost-time injury rate of 1.5 through May is at First Aid Case Rate 9.68 9.40the national 9.39 hospitalCase average.

Medical Treatment Rate 5.23 7.53 5.87

Total Recordable Injury Rate 8.07 9.90 8.02 To drive this success, Injury Prevention Goal (Total Recordable) 5.5 and Occupational 5.5 5.5

Safety teams incorporated injury investigation principles and safe work behaviors into Christiana Care’s New Leader Orientation, Frontline Leadership and Working courses.

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

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

Christiana Care’s safety teams also focus on high-risk areas to help reduce common injuries such as slips, trips and falls. A pilot involving the use of slip-resistant shoes in areas FY14 ytd FY10 FY11 FY12 FY13 prone to have water on the floor is now 1.31 being evaluated for 1.50 2.02 1.49 1.43 implementation.

0.80 0.18 0.60 0.67 1.11 8.64

9.00

8.31

7.61

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

Recordable Injury Rate 8 7 6

Days

5 4 3 2 1 0

FY10

FY11 Lost Time Injury Rate

18 | C hri sti ana Care Hea l th S ys tem

7.75

Patient handling continues to be a focus area with ongoing 3.74 4.82 3.60 3.36 2.91 education of5.71 lifting equipment.

Ergonomic 5.05 5.94 and installation 6.91 5.78 evaluations of job5.5 tasks and implementation 5.5 5.5 5.5 5.5 of novel solutions helps address this source of injury.

FY12 Total Recordable Injury Rate

FY13 Goal (Total Recordable)

FY14 ytd

Interdisciplinary Lean Six Sigma project improves use of qualified medical interpreters

Limited English proficiency (LEP) and poor health literacy challenge effective patient-provider communication and impact health outcomes. Christiana Care began offering 24/7 telephonic interpreting services in 2010 and a limited number of on-site interpreters in 2012 at both hospitals. However, reased time required for bedside charge report? in a 2012 survey of postpartum women, 41 percent of LEP patients reported an unmet need for an interpreter during their hospital stay. The survey also revealed wide use of unqualified interpreters. A Lean Six Sigma team set a goal to reduce by 50 percent the percentage of postpartum LEP women reporting an decreased time for updating chargeinterpreter report? during their hospital stay. unmet need for athe qualified Following the Lean Six Sigma process of define, measure, analyze, improve and control, the team collected baseline data 0% the intervention.

25% to fully understand the problem and guide Focus groups identified what was critical to quality, as well as staff barriers to utilization of language services. Process maps helped the team understand the current process, identify

value and non-value-added work, and identify opportunities.

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

Inpatient surveys of postpartum women in summer 2013 Yes showed a significant increase in use of qualified interpreters: a No 34.3 percent increase in use of in-person interpreters (p-value < 0.01) and a 41 percent increase in use of phone interpreters 50% 100% an (p-value < 0.001).

The number 75% of LEP moms reporting % of respondents unmet need for an interpreter (p-value < 0.001) also decreased significantly, by 31.8 percent from the initial survey. continued

Patient Self-Reported Medical Interpreter Use Before and After Implementation 100%

Percent of Responses

80%

60%

40%

20%

0%

Family/Friend

Unqualified Staff Member 2012

Medical Interpreter

Phone Interpreter

2013

2 0 1 4 Qu a l i t y & Saf ety Re por t | 1 9



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

Interdisciplinary Lean project improves use of qualified medical interpreters

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

continued

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

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

Christiana Care Learning Institute’s Center for Diversity & Inclusion, Cultural Competence and Equity created LINCC in adherence with 2012 Joint Commission standards to ensure safe, effective communication with patients who have limited English proficiency or other unique communications needs.

One element of performance, in particular, noted by the Joint Commission (Standard HR.01.02.01) requires health care organizations to assess the qualifications of the individuals who provide medical interpretation. This standard addresses the hospital’s responsibility to ensure that staff members and contractors who provide interpreting services in the hospital have defined qualifications and competencies. Untrained individuals — including family members, friends, other patients or untrained bilingual staff — should not be routinely used as interpreters for medical encounters.

20 | C hri sti ana Care Hea l th S ys tem

Akan-­‐Twi Arabic Bengali French Haitian Creole Hindi gbo talian Korean Malayalam Mandarin Portuguese Russian Spanish Tagalog Urdu Yoruba

2 2% 2 2% LINCC’s three phases: 1 1% 4 5% TESTING: Staff members nominated by their managers must pass a validated assessment of speaking fluency 2 2% 2% OPI (oral proficiency interview) in order to be admitted to the program. called2 the ACTFL 1 1% 1 1%Candidates participate in 24 hours of classroom instruction in topics such as basic interpreting TRAINING: 2 2% skills, code of ethics for medical interpreters, cultural mediation and advocacy, and working as an interpreter at 2 2% Christiana Care.

Graduates must pass both a written and oral final examination.

6 7% 1 1% IMPLEMENTATION AND COMPENSATION: Once LINCC interpreters pass the final exam, Language 3 3% 53 works 62% Services with their managers to establish acceptable service guidelines. While all LINCC interpreters 2% have 2the competencies to be able to provide interpretation, their formal work roles may limit the amount of 1 1% interpretation they can offer. LINCC interpreters are compensated according to the volume of interpretation they 1complete 1% each quarter.

86

① ② ③

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

log

2%

Percentage of LINCC-Qualified Medical Interpreters by Language

1%

ga

Tagalog

1%

ba

ru

Yo

Ur

du

Ta

2% Urdu Yoruba % 1% i2 1%Akan-Twi w T

n-

a 2%

Ak

Arabic

ic

2%

ab 2% Ar Bengali

ali

ng 1% Be

Spanish 62%

1%

French

%

5 nch Fre5%

Haitian Creole

Spanish

tian Creole Hai2%

62%

2%

Hindi

Hindi 2% 2% Igbo

Igbo 1% Italian 1% Italia 1%n 1% KoKorean rean 2% 2%

Malayalam M ala yal 2% am

2%

M

Mandarin an

d

7%ari

Po

7%

1%

%

1%

n3

ese

ssia 3%

gu

Ru

Russian

n

rtu

Portuguese

2 0 1 4 Qu a l i t y & Saf ety Re por t | 2 1



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

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

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

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

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

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

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

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

Safety First: ff Janice E. Nevin, M.D., MPH, Chief Medical Officer ff Sharon L. Anderson, MS, BSN, RN, Senior Vice President of Quality, Safety and Population Health Management

Clinical Excellence: ff Virginia U. Collier, M.D., MACP, Hugh R. Sharp, Jr. Chair of Medicine ff Diane P. Talarek, MA, RN, NE-BC, Senior Vice President, Patient Care Services and Chief Nursing Officer

Think of Yourself as a Patient: ff Janine M. Jordan, M.D., Director, Care Transitions and Utilization Management ff Shawn R. Smith, Vice President, Patient Experience ff Janet Cunningham, BSN, MHA, RN, NE-BC, CENP, Vice President, Professional Excellence and Associate Chief Nursing Officer •

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

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

22 | C hri sti ana Care Hea l th S ys tem

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

As a member organization, Christiana Care receives benefits to help support initiatives including: ff Educational and training opportunities focusing on patient safety as a top priority for all staff members. ff Information for patients and their families about how to make their health care safer. ff Tools and resources to engage staff and patients in patient-safety best practices.

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

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

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

2 0 1 4 Qu a l i t y & Saf ety Re por t | 2 3



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

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

Palliative care focuses on patients and families In December, the Value Institute hosted national experts to explore the power of palliative care to deliver value to patients and families confronting serious, life-threatening illnesses.

Said one panelist, “Palliative care is the quintessential patientcentered care because it starts with the patients and their goals.”

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

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

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

24 | C hri sti ana Care Hea l th S ys tem

Featured was a Harvard University led study of patients with metastatic lung cancer that found that early palliative care resulted in better quality of life, fewer patients with depressive symptoms and nearly three months longer survival compared with patients who received aggressive disease treatment alone.

“If this was a chemotherapy agent … everybody would be on it,” said panelist Diane E. Meier, M.D., FACP, founder of the Hertzberg Palliative Care Institute at Icahn School of Medicine at Mount Sinai Medical Center in New York.

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

“The goal is to make sure each care policy represents the best evidence and is informed by science,” said Eric V. Jackson Jr., M.D., MBA, associate director of the Value Institute and director of the Value Institute’s Center for Health Care Delivery Science. “Data drives everything.

We recognize that data doesn’t tell the whole story, but it positions us to be closer to the source of the truth.” •

2 0 1 4 Qu a l i t y & Saf ety Re por t | 2 5



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

Staff responsiveness score rises steadily

Prompt response to call lights key to improving satisfaction, reducing falls Aug-­‐13 Sep-­‐13 Oct-­‐13 Nov-­‐13 Dec-­‐13 Jan-­‐14 Feb-­‐14 Mar-­‐14 Apr-­‐14 Daily team huddles, a deepening No Pass70.6% Zones 71.0% Responsiveness 68.2% partnership 70.0%with patient 71.3% and 71.6% 72.5% 71.9% 74.3% family advisers, and a shared commitment to promptly respond Call bell 65.0% 68.4% 69.5% 68.9% 71.3%— in which 67.7%the first 70.9% 69.8% of the71.7% No Pass Zones available member to patient call lights all contributed to a steady rise in patient care team responds to the patient’s request for assistance, experience scores in the Staff Responsiveness domain on the 69.8 satisfaction and help regardless of position — improve patient Hospital Consumers Assessment of Healthcare Providers and to reduce falls from patients getting out of bed alone while Systems (HCAHPS) in FY 2014. waiting for assistance. On one unit at Christiana Hospital, the No Pass Zone helped cut the number of patient falls in half.

Responsiveness scores climbed from 68.2 to 74.3 percent in

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

“Patients First!”

Team huddles help set the stage for improving patient experience by ensuring that all staff start the shift with information that helps them to respond efficiently and effectively to patients.

Huddles enhance communication by allowing staff to share updates on safety concerns, special patient needs 71.7%or operational 71.3% 70.9%huddles is increasing throughout issues. The use of team Christiana Care among clinical69.8% and service staff.

System Response to Call Bell 72.0%

Staff 69.0%

responsiveness 69.5% is one of eight dimensions in 68.4% the patient experience domain

68.9%

67.7%

score, which comprises

66.0%

30 percent of the Hospital 65.0% Value-Based Purchasing 63.0% Aug-13

total performance Sep-13

score.

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

Discharge Date Call bell

Trend Response to call bell

System Staff Responsiveness Domain System Staff Responsiveness Domain 75.0%

74.3% 71.7%

71.3%

70.6%

70.0%

68.3%

72.5%

71.6%

71.0%

71.9%

68.2% 65.0% Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

Discharge Date Responsiveness Responsiveness

26 | C hri sti ana Care Hea l th S ys tem

Trend Trend Response ResponsetotoCall callBell bell

Aug-­‐13 68.2% 65.0%

Responsiveness Call bell

Sep-­‐13 70.0% 68.4%

Oct-­‐13 71.3% 69.5%

Nov-­‐13 71.6% 68.9%

Dec-­‐13 70.6% 71.3%

Jan-­‐14 71.0% 67.7%

Feb-­‐14 72.5% 70.9%

Mar-­‐14 71.9% 69.8%

Apr-­‐14 74.3% 71.7%

69.8

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

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

System Response to Call Bell

System Response to Call Bell

72.0%

71.3% 69.0%

71.7%

70.9% 69.8%

69.5%

68.9%

68.4%

67.7%

66.0%

65.0% 63.0% Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

Discharge Date Call CallBell bell

Trend Response ResponsetotoCall callBell bell

System Staff Responsiveness Domain 75.0%

Transparency and common-sense advocate Makary inspires 74.3% Christiana Care to take quality and safety72.5% to next level 71.9% 71.7%

71.3%

70.0%

68.3%

68.2% 65.0% Aug-13

Sep-13

Oct-13

71.6%

70.6%

71.0%

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

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

Discharge Datethe need to be transparent, accountable and provide His talk underscored Responsiveness Trend Response to call bellunnecessary tests standardized care, in order to decrease harm to patients, prevent and procedures, and provide high-quality care.

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

2 0 1 4 Qu a l i t y & Saf ety Re por t | 2 7

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

HIGH RELIABILITY

28 | C hri sti ana Care Hea l th S ys tem

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

EMILY J. PENMAN, M.D. Associate Vice Chair of Surgery Chair, Surgical Care Improvement Project

2 0 1 4 Qu a l i t y & Saf ety Re por t | 2 9



ACHIEVING HIGH RELIABILITY

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

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

“Through this process, we’ve taken the guesswork out of what to do next.

Evidence-based practice is now second nature to all of us involved in SCIP.” CRAIG MARTINE, BSN , RN , CCRN Performance Improvement Manager Surgery

30 | C hri sti ana Care Hea l th S ys tem

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

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

“Through this process, we’ve taken the guesswork out of what to do next,” said Martine. “Evidence-based practice is now second nature to all of us involved in SCIP.” Emily J. Penman, M.D., associate vice chair of Surgery, credits the SCIP team’s persistence over many years with creating a huge culture change in how we care for patients.

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

DECILE OTH

B

DECILE OTH

B+

SEPSIS

PNEUMONIA O/E or TARGET

ACTUAL

TOP DECILE COTH

O/E or TARGET

ACTUAL

TOP DECILE COTH

Guideline Compliance

Guideline Compliance Blood Culture Pre Antibiotic*

94.4%

Initial Antibiotic Selection*

95.0%

Lactate Level Within 3 Hours

Outcomes

100.0%

Blood Cultures Prior to Antibiotics

79.5%

Broad Spectrum Antibiotics ≤ 3 Hours

70.1%

Fluid Resuscitation ≤ 3 Hours

85.8%

Population-based value score cards highlight improvements, reveal opportunities

Christiana Care Health System

Patient Experience

72.2%

Mortality

Outcomes

2.9%

Readmission

Mortality

14.1%

8.9%

30-Day Readmission

Cost/Utilization

16.8%

Patient Experience 62.9% Clinical Excellence | Increase Value & Be Ready for Healthcare Refor Length Stayleadership Underofthe of the Clinical4.59 Excellence Committee, the five population-based value-improvement teams Cost/Utilization improvement $9,657 from baseline in overall value score and identify reductions in mortality and Length of Stay readmission rates, lengths of stay and costs.

Value Based Purchasing Impact Estimated Cost continueDirect to report

GOAL: Current Value!Increase Score

Estimated Direct Cost the Process 83.7 of Care Domain Score to 68 B

9.24

$27,201

Of particular note, the Surgical Care Improvement Project continues to achieve A+Purchasing value scores.

As a whole, the system Value Based Impact 76.9 C BASELINE not only exceeded the target goal to increase the process-of-care domain score to 68, but achieved the stretch domain 81.4 Current Value Score score of 70 on the most recent Focus on Excellence Measurement Report in April 2014.• 76.0 BASELINE (FY12)

ACUTE MYOCARDIAL INFARCTION O/E or

TOP DECILE

O/E or TARGET

TOP DECILE COTH

ACTUAL SURGICAL CARE IMPROVEMENT PROJECT TARGET COTH

Guideline Compliance

PCI Within 90 Minutes of Arrival* Guideline Compliance Aspirin at Discharge Proph Antibiotic Pre Incision* Statin at Discharge Proph Antibiotic Selection* Outcomes Proph Antibiotic Discontinued* Patient Experience Postop Glucose Control* Mortality Periop Beta Blocker* Readmission VTE Prophylaxis Given* Cost/Utilization Postop Catheter Removed* Length of Stay Postop Normothermia Estimated Direct Cost Value Based Purchasing Impact Value Based Purchasing Impact Composite Score Current Value Score Current Value Score BASELINE BASELINE

ACTUAL

90.0%

100.0% 100.0% 98.5% 100.0% 100.0% 73.9% 96.9% 6.5% 100.0% 19.3% 100.0% 100.0% 4.16 100.0% $24,415

85.5 99.6

84.0 94.2

B A

B A+

O/E or TARGET

TOP DECILE COTH

Guideline Compliance Discharge Instruction* ACE/ARB for LVSD

100.0% 92.7%

Outcomes Patient Experience Mortality Readmission

84.0% 0.8% 21.3%

Cost/Utilization Length of Stay Estimated Direct Cost

4.54

87.1 79.6

Guideline Compliance Blood Culture Pre IMPROVEMENT Antibiotic* 94.4% SURGICAL CARE Initial Antibiotic PROJECT: ValueSelection* score increased by95.0% 5.4 points from baseline.

Seven the eight Outcomes PROCESS OFofCARE DOMAIN SCORE measures are at the top decile for Council Patient Experience 72.2% ofMortality Teaching Hospitals, and 99.5 percent Current 70 2.9% ofReadmission patients received “perfect care.”14.1% Threshold Cost/Utilization

66

Length of Stay Target

68

4.59

Current Value Score

83.7 76.9

BASELINE

ACTUAL

HEART FAILURE: Value score improved by Guideline Compliance 7.2 points from baseline. Mortality rates Proph Antibiotic Pre Incision* 100.0% improved by over 70 percent; readmission Proph Antibiotic Selection* rates have decreased 26 percent and100.0% Proph Discontinued* 100.0% length of Antibiotic stay is down 7 percent. Overall Glucose Control* 96.9% costPostop savings exceeds $890,000.

Periop Beta Blocker*

100.0%

VTE Prophylaxis Given*

100.0%

Postop Catheter Removed*

100.0%

Postop Normothermia

100.0%

Composite Score

Value Based Purchasing Impact BASELINE

TOP DECILE COTH

B C

O/E or TARGET

TOP DECIL COTH

Value Based Purchasing Impact

$9,008

Current Value Score

O/E or TARGET

ACTUAL

SURGICAL CARE IMPROVEMENT PROJECT

HEART FAILURE

Evaluation of LVS Function

PNEUMONIA

Estimated Direct Cost $9,657 Stretch 70 Value Based Purchasing Impact

99.5%

ACTUAL

BC

B+ C+

99.5%

Current Value Score BASELINE

99.6 94.2

continued

A+ A

2 0 1 4 Qu a l i t y & Saf ety Re por t | 3 1

Christiana Care Health System  ACHIEVING HIGH RELIABILITY

Clinical Excellence | Increase Value & Be Ready for Healthcare Refor Population-based value score cards

continued

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

ACUTE MYOCARDIAL INFARCTION ACTUAL

O/E or TARGET

PNEUMONIA

TOP DECILE COTH

Guideline Compliance PCI Within 90 Minutes of Arrival*

90.0%

Aspirin at Discharge

100.0%

Statin at Discharge

98.5%

Outcomes

e Health System Patient Experience

73.9%

Mortality

Mortality

6.5%

Readmission

14.1%

Length of Stay

Length & of Stay 4.16 ease Value Be Ready for Healthcare ReformEstimated Direct Cost Estimated Direct Cost

$24,415

85.5 84.0

BASELINE

Guideline Compliance

Guideline Compliance Blood Culture Pre Antibiotic* Discharge Instruction* Initial Antibiotic Selection*

Evaluation of LVS Function Outcomes ACE/ARB for LVSD Patient Experience

B

Outcomes Mortality Patient Experience Readmission Mortality Cost/Utilization Readmission Length of Stay Cost/Utilization Estimated Direct Cost Length of Stay Value Based Purchasing Impact Estimated Direct Cost Current Value Score Value Based Purchasing Impact BASELINE Current Value Score BASELINE

ACTUAL

B B

PNEUMONIA HEART ACTUAL FAILURE O/E or

P DECILE COTH

4.59 $9,657

Value Based Purchasing Impact

Value Based Purchasing Impact

main ScoreCurrent to 68 Value Score

April 2014

Cost/Utilization

Cost/Utilization

TOP DECILE COTH

2.9%

Readmission

19.3%

O/E or TARGET

ACTUAL

ACUTE MYOCARDIAL INFARCTION: The value Guideline Compliance score improved by 1.5 points. The mortality Blood Culture Pre Antibiotic* 94.4% rate has improved to below the risk-adjusted Initial Antibiotic Selection* 95.0% predicted rate and length of stay decreased by Outcomes 10 percent. The team has reduced estimated Patient Experience 72.2% costs by about $950,000

TARGET O/E or TARGET

TOP DECILE COTH TOP DECILE COTH

95.0%

100.0% 92.7% 72.2% 2.9% 84.0% 14.1% 0.8%

PNEUMONIA: The value score improved by ACTUAL Guideline 6.8 points.Compliance Guideline compliance increased Lactate LevelCompliance Within 3 Hours 100.0% Guideline by an average of more than 10 percent, Blood Cultures to Incision* Antibiotics 79.5% Proph Antibiotic Pre 100.0% mortality ratesPrior dropped by over 40 percent, Broad Spectrum Antibiotics ≤ 3 Hours 70.1% readmission rates improved by 12 percent Proph Antibiotic Selection* 100.0% Fluid Resuscitation ≤decreased 3 Hours 85.8% and length of stay by 0.4 100.0% days.

Proph Antibiotic Discontinued* Outcomes Estimated cost savings Postop Glucose Control*is $590,000. 96.9%

Patient Experience Postop Catheter Removed* Cost/Utilization Postop Normothermia

$9,657 4.54 83.7

76.9

87.1

B C

79.6

B+

C+

B C

SEPSIS O/E or TOP DECIL SURGICAL CARE IMPROVEMENT PROJECT ACTUAL

Mortality Periop Beta Blocker* 30-Day Readmission VTE Prophylaxis Given*

21.3% 4.59

83.7 76.9

BASELINE

94.4%

$9,008

Current Value Score

Length Stay Purchasing Impact ValueofBased Estimated Direct Cost Composite Score Value Based Purchasing Current Value Score Impact Current Value Score BASELINE BASELINE (FY12)

TARGET O/E or TARGET

8.9% 100.0% 16.8% 100.0% 62.9% 100.0%

100.0% 9.24 $27,201 99.5%

94.2 76.0

99.6 81.4

SURGICAL CARE IMPROVEMENT PROJECT

P DECILE COTH

ACTUAL

O/E or TARGET

TOP DECILE COTH

Guideline Compliance Proph Antibiotic Pre Incision* Proph Antibiotic Selection* 32 | C hri sti ana Care Hea l th S ys tem Proph Antibiotic Discontinued* Postop Glucose Control* Periop Beta Blocker*

100.0% 100.0% 100.0% 96.9% 100.0%

PROCESS OF CARE DOMAIN SCORE Current

COTH TOP DECIL COTH

70

A C

A+ B-

April 2014

rm

April 2014

are Reform SEPSIS ACTUAL

Guideline Compliance TOP DECILELevel Within 3 Hours Lactate COTH

100.0%

O/E or TARGET

SEPSIS

TOP DECILE COTH

ACTUAL

Blood Cultures Prior to Antibiotics Guideline Compliance 79.5%

O/E or TARGET

TOP DECILE COTH

Broad Spectrum Antibiotics ≤ 3 Hours 70.1% Lactate Level Within 3 Hours

C

100.0% Fluid Resuscitation ≤ 3 Hours 85.8% Blood Cultures Prior to Antibiotics 79.5% Outcomes Broad Spectrum Antibiotics ≤ 3 Hours 70.1% Mortality 8.9% Fluid Resuscitation ≤ 3 Hours 85.8% 30-Day Readmission 16.8% Outcomes Patient Experience 62.9% Mortality 8.9% Cost/Utilization 30-Day Readmission 16.8% Length of Stay 9.24 Patient Experience 62.9% Estimated Direct Cost $27,201 Cost/Utilization Value Based Purchasing Impact Length of Stay 9.24 Current Value Score 81.4 BEstimated Direct Cost $27,201 B 76.0 C BASELINE (FY12) Value Based Purchasing Impact Current Value Score

81.4 76.0

BASELINE (FY12)

E

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

BC

Key to symbols:

PROJECT

T

TOP DECILE COTH

PROCESS OF CARE DOMAIN SCORE Current Threshold

A+ A

Guideline Compliance: ✱ Measure is included in

70

PROCESS OF CARE DOMAIN SCORE 66

Target

Current 68

70

Stretch

Threshold 70

66

Target

68

The FY 2014 Hospital Value-Based Purchasing (VBP) Program adjusts Stretch 70 hospitals’ payments based on their performance on three domains that reflect hospital quality: the Clinical Process of Care domain, the Patient Experience of Care domain and the Outcome domain. The Clinical Process of Care domain score is weighted as 45 percent of the total performance score.

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

Value Based Purchasing

●

Threshold >= (for measures with

baseline performance < threshold)

▲ Between baseline &

threshold

◆ < Baseline Outcomes:

to Expected Observed <= 1.0 ▲ O/E > 1.0 and <= 1.10 ◆ O/E > 1.10

●

COTH: Council of Teaching Hospitals and Health Systems

2 0 1 4 Qu a l i t y & Saf ety Re por t | 3 3

Anticoagulation Overlap Therapy



ACHIEVING HIGH RELIABILITY 50%

60%

70%

Percent Complianc Christiana Care

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

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

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

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

State

National

Incidence of Potentially Preventable Hospital-Acquired VTE 20%

15%

10%

10%

8.8%

5%

0% Christiana Care

National

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

Venous ThrombosisVenous Prevention Measures Prevention Measures Thrombosis 92.2%

Venous Thrombosis us Thrombosis Prophylaxis Prophylaxis

83% 85%

97.5%

ICU Venous

us Thrombosis Prophylaxis Thrombosis

92%

Prophylaxis

92%

97.5%

Anticoagulation oagulation Overlap OverlapTherapy Therapy

88% 93% 50%

60%

70%

80%

Percent Compliance Christiana Care

34 | C hri sti ana Care Hea l th S ys tem

State

National

90%

100%

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

A single organ and tissue donor can help 50 people. In the past two years at Christiana Care, 57 people donated 125 organs, and there were more than 160 tissue donations. â&#x20AC;˘

More than 600 people are on Delawareâ&#x20AC;&#x2122;s transplant waiting list. A single organ and tissue donor can help 50 people.

Organ and Tissue Donation 66

Tissue Donors

97 60

Total Organs Donated

65 25

Organ Donors

32 0

25

50

75

100

Number of Donors/Organs 2013 2012

2 0 1 4 Qu a l i t y & Saf ety Re por t | 3 5



ACHIEVING HIGH RELIABILITY

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

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

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

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

The interdisciplinary Green Belt team of critical care assistants, intensivists and MICU nurses — jointly led by a finance project manager from the Department of Medicine and the Baseline | Number of Units per Week Current - # Units per Week Baseline - # Units per Week lead physician assistant from the MICU — developed a highlevel process map to identify key elements of the transfusion 0.9First reviewing multiple studies clarifying appropriate process.

3.8 clinical thresholds for transfusions of pRBC in the critical care setting, the team looked at whether the MICU’s transfusion practices adhered to best practice guidelines. Their discovery: 11.5 7.7 between October and December of 2012, almost half of 10.8 transfused units did not meet clinical-practice guidelines — the equivalent of 3.8 units per week, or 200 units per year.

10.5 Far exceeding their goal to decrease that number by half,per the Week Current - # Units Baseline - # Units per Week annualized number of units not meeting clinical-practice guidelines dropped to 46 units per year.

0.9 3.8 Guideline Transfused (GT) < 7.0

Guideline Transfused (GT) < 7.0

Guideline Transfused (GT) > 7.0

Guideline Transfused (GT) > 7.0

Number of Units per Year

Current | -Number ofper Units per Week Current # Units Week Non Guideline Transfused (NGT) > 7.0 Hgb

Non Guideline Transfused (NGT) > 7.0 Hgb

Baseline

11.5

0.9

10.5 7.7

Current

Year

596

7.7 564

(32)

544

398

(146)

200

46

(154)

1,340

1,008

10.8

(332)

10.8

# weeks 13

Guideline Transfused (GT) < 7.0

Guideline Transfused (GT) < 7.0

Guideline Transfused (GT) > 7.0

Guideline Transfused (GT) > 7.0

Non Guideline Transfused (NGT) > 7.0 Hgb

Non Guideline Transfused (NGT) > 7.0 Hgb

# Units # Units/week Description Guideline Transfused (GT) < 7.0% total 36 | C hri sti ana Care Hea l th S ys tem Guideline Transfused Guideline Transfused (GT) < 7.0 149(GT) > 7.0 44% 11.5 Non Guideline Transfused (NGT) > 7.0 Hgb 136 41% Guideline Transfused (GT) > 7.0 10.5 Non Guideline Transfused (NGT) > 7.0 Hgb 50 15% 3.8

BASELINE

BAR CHART DATA

Baseline (10-­‐‑ Current (7-­‐‑ 12/12) 12/13 11.5 10.8 10.5 7.7 3.8

0.9

136 Guideline Transfused (GT) > 7.0 10.5 $ Cost 41% # Units/Yr # Units/week Description Guideline Transfused (GT) < 7.0 Non Guideline Transfused (NGT) > 7.0 Hgb 50 15% 32 0.6 $ 24,352 3.8 Guideline Transfused (GT) > 7.0 2.8 335111,106100% 146 25.8 pRBC Transfused $

REDUCTION

URRENT

EDUCTION

26

$ 117,194

154

$ 13 252,652

332

3.8

3.0 Non Guideline Transfused (NGT) > 7.0 Hgb 6.4 pRBC Transfused

# Units 282 199

# Units 141 100

% total 0 56% 39%

23

12

5%

0.9

Non Guideline Transfused (NGT) > 7.0 Hgb

504

252

100%

19.4

pRBC Transfused

$

10.5

# Units/week Description Guideline Transfused (GT) < 7.0 10.8 Guideline Transfused (GT) > 7.0 7.7

761

$ Cost

# Units/Yr # Units/week Description CH-­‐‑MICU pRBC # Units per Week 32 0.6 Guideline Transfused (GT) < 7.0 14.0 $ 24,352 146 2.8 Guideline Transfused (GT) > 7.0 $ 111,106 12.0 # Units per Year $ 117,194 154 3.0 Non Guideline Transfused (NGT) > 7.0 Hgb Baseline Current Var $ 252,652 332 6.4 pRBC Transfused 10.0 596 564 (32) 0 8.0 544 398 (146) Christiana Care President and CEO Robert J. Laskowski, M.D., MBA, congratulates 200 46 (154) Christiana Care’s first Lean Six Sigma Green Belts.

1,340

1,008

6.0

(332)

4.0 2.0

Strategies included: ff Educating MICU nurses, critical-care physician assistants, intensivists, consultants and medicine residents on clinical practice guidelines. ff Removing the daily lab option from the MICU admission# Units per Year order set to reduce unnecessary blood Baseline Current Var draws and decrease phlebotomization.

596 564 (32) ff Redesigning the transfusion process to foster 544 398 (146) communication by including a transfusion tracker 46 nurses to(154) form200 that enables the confirm transfusion order with the MICU 1,340 1,008staff, attending, (332) resident and physician assistant before the patient receives blood.

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

The team is now expanding the initiative to criticalcare units system-wide. continued

MICU pRBC | Number of Units per Week

0

CH-­‐‑MICU pRBC # Units per Week Guideline Transfused (GT) < 7.0 14.0 Baseline (10-12/12)

Current (7-12/13)

12.0 10.0 8.0 6.0 4.0 2.0 0

Guideline Tranfused Guideline Transfused (GT) < 7.0 (GT) < 7.0 Baseline (10-12/12)

Current (7-12/13)

PRBC transfusion is associated with increased risk of health-care-associated infection, multi-organ failure, increased intensive care and hospital days, and mortality.

Christiana Care’s Lean Six Sigma team decreased the number of transfused units by 25 percent, with an estimated annualized savings of $253,000.

2 0 1 4 Qu a l i t y & Saf ety Re por t | 3 7



ACHIEVING HIGH RELIABILITY

Lean Six Sigma Green Belts advance performance improvement continued

TATMtg TAT Ed Total 85 1579 2164 Baseline Sigma delivers laboratory 25 1525Lean Six 2050 Baseline improvement for the ED 31 1499performance 2030 Baseline 36 1593 2029 Baseline Lean Six Sigma methods helped the Department of Pathology 37 1673 2110 Baseline and Laboratory Medicine — which performs 6.73 million 03 1618 2121 Baseline tests per year — reduce variation in laboratory performance 15 1567 2082 Baseline and achieve breakthrough improvement in providing urinalysis 76 1722results for 2198 the Baseline Emergency Department (ED) within a 70 183630-minute 2306 Baseline target. The success rate improved from 78 percent 48 1916of urinalyses 2364prior Baseline to the pilot, to a sustained 90 percent 70 1798(p<0.01)2268 Not Met Met total in theBaseline control phase.

56 1884 2340 Baseline 5852 20210 26062 laboratories and clinicians have 73 1132Historically, 1305pathology Pilot competing definitions 219 for quality:1550 laboratories1769 focus 46 418maintained 464 Pilot on maximizing precision and achieving accuracy goals, while 55 1514 1769 Sustain expect rapid, reliable and efficient service at low cost.

33 1834clinicians2067 Sustain 19 1940Today’s labs 2159increasingly Sustain focus on turnaround time as a primary performance indicator, 12 1962 2174 Sustain especially in the ED, where delayed test results canSustain delay treatment, increase boarding time and 41 1876 2017 negatively impact patient outcomes.

24 1898 2122 Sustain 1284 11024 12308

A Green Belt medical laboratory scientist led the project team’s effort to analyze existing work streams, and identify both the needs of clinicians and current process owners, as well as opportunities for efficiencies and improvements. To meet their established target turnaround time of 30 minutes or less for urinalysis results reported to the ED, they employed high-level process mapping known as SIPOC: suppliers, inputs, process, outputs and customers. They also used such tools as voice of Baseline the 78% customer, process CY12 load calculations, fishbone analysis, value stream attribute mapping and solution selection matrices.

88%the Pilot S/O a1nine-step 3 Finally, team created implementation checklist spanning the full work stream, from the lab’s receipt of the sample to reporting of results to the ED. The result: the proportion of results not meeting the targeted 30-minute turnaround time improved significantly post-pilot, from 0.22 to 0.12 percent (p< 0.01), then further improved 90% Sustain Mar-­‐14 and remains sustained at 0.10 percent (p<0.01) in the control phase. •

Urinalyses Not Meeting Target Turnaround Time

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

Baseline (2012)

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

30%

27%

26% 26%

20%

24%

Proportion

21% 21%

25% 22%

20%

19%

21%

19% 14%

13%

10%

10%

11%

11%

10% 10% 7%

0%

Jan

12

2

b1

Fe

rch

Ma

2 2 2 2 4 4 4 2 2 2 3 2 3 12 il 12 3P 3 P ct 13 r1 y1 v1 v1 c1 c 1 Jan 1 g 1 ept 1 Oct 1 e 1 uly 1 b1 r p 1 Oct 1 O Fe J Au No No Ma De De Ma Ap Jun S Se

38 | C hri sti ana Care Hea l th S ys tem

Month Jan 12 Feb 12 March April 1 May 12 June 12 July 12 Aug 12 Sept 12 Oct 12 Nov 12 Dec 12 Sep 13 Oct 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14

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

A review of 118 patients referred to home care by the ED in a six-month period reveals that 3 percent of patients were admitted to the hospital within 72 hours of ED discharge.

Five percent of patients returned to the ED within seven days, but were not admitted to the hospital.

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

92% o rema f patien t i with ned safe s VNA at h ome

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

Emergency Department Patient Returns | October 2013 to April 2014

5% returned to the ED 3% hospitalized

8/14

-­‐3/2

9/20 /13

d ho m e care duri ng

ive

rece

118 ED p atien ts

92% of patients remained safe at home with VNA

2 0 1 4 Qu a l i t y & Saf ety Re por t | 3 9

ting in Harm

2



Jul-­‐12 3.00 3

Aug-­‐12 3.00 3

Sep-­‐12 Oct-­‐12 Nov-­‐12 Dec-­‐12 Jan-­‐13 3.00 2.50 3.00 2.83 3.00 3 A C H I E V 1I N G H I G H5 R E L I A B 2I L I T Y 4

Feb-­‐13 2.63 0

Mar-­‐13 2.89 5

Apr-­‐13 2.90 3

May-­‐13 2.91 3

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

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

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

Sep-12

Nov-12

Jan-13

Mar-13

May-13

Jul-13

Sep-13

Nov-13

Jan-14

Creating a Safe Culture

Errors resulting in Harm ©

Rolling 12 months

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

Jul-­‐12 3 3.00

Medication Errors Resulting in Harm Rolling 12 Months

Aug-­‐12 3 3.00

Sep-­‐12 3 3.00

information, teamed with our Safety First Learning Report data, helps us understand where to focus our efforts. ff MEDICATION SAFETY TRAINING: Meeting an educational need absent from many medical and pharmacy school curricula by providing medication-safety and strategyawareness training during new resident orientation.

Oct-­‐12 1 2.50

Nov-­‐12 5 3.00

Dec-­‐12 2 2.83

Jan-­‐13 4 3.00

Feb-­‐13 0 2.63

Medication Errors Resulting in Harm 10 Rolling 12 Months Medication Errors Resulting in Harm Number of Errors with Harm

8

6

4

2

0

Jul-12

Sep-12

Nov-12

40 | C hri sti ana Care Hea l th S ys tem

Jan-13

Mar-13

May-13

Jul-13

Sep-13

Nov-13

Jan-14

Mar-14

Mar-­‐13 5 2.89

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

DEAN BENNETT, RPH, CPHQ Medication Safety Officer

Achieving High Reliability

Leveraging Technology

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

ff BAR-CODED MEDICATION ADMINISTRATION (BCMA) EXPANSION: Adding decision support to hand-held scanners to help staff determine when it may be too early for the patient to receive a medication with sedating sideeffects, or when a patient’s daily dose of acetaminophen is nearing the recommended maximum.

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

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

Medication Safety | Pharmacy, Safety First Learning Reports

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

Medication Errors

9 -65.4% Resulting in Harm

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

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

2 0 1 4 Qu a l i t y & Saf ety Re por t | 4 1



ACHIEVING HIGH RELIABILITY

Medical Home Without Walls enrolls second patient cohort based on pilot’s success Medical Home Without Walls — not a place, but a community-based careScreened Screened 223 management team that engages and empowers uninsured, chronically ill Eligible Eligible 60 individuals in managing their own60 care — reduced the total volume of patient Enrolled Enrolled 28 days by 79 percent, comparing pre- and post-enrollment data from a six-month 47% pilot in 2013. Enrollment began for 45a second cohort of in January 2014, and in February, the program expanded to include Medicaid patients with Delaware Physicians Care (DPCI).

30 In this system-wide, patient-centered care-management strategy, a social worker 15 and nurse partner as an intervention team to help our community’s most vulnerable people to navigate the complex health system and access community 0 resources. The program’s goals are to improve this population’s access to health care, educate individuals about available health and social-service resources to Eligible acute-care utilization. help them maintain their health, and reduce inappropriate

223 60 28 47%

Elig Enro

60 45

Acti Gra Disc

30 15 0

Eligible

Enrolled

ff 69 patients enrolled in 2013; 57 patients enrolled to-date in 2014 ff 25 graduates from 2013 cohort. Nine graduates to-date in 2014. ff Active “intervention” takes an average of 90 days. There is also a 90-day Pilot Results post-graduate follow-up period before patients complete the program. • Pilot Results Eligible Enrolled Pre Enrollment Post Enrollment % Change Self-­‐Pay 29 18 30 Days (N=49) 335 72 -­‐78.5% 39 60 Days (N=44) 386 80 -­‐79.3% DPCI Medicaid 122 Walls 90 Days (N=35) Medical 416 Home79Without -­‐81.0%

Outcomes Data: Jan-Jul 2013

Medical Home Without Walls

Total Patient Utilization

Second Cohort Enrollment 2014 200 150

500

416

122

386

400

120 150

Number of Patients Number of Patients

Number of Patients

335 300

200

59

90 100 60

122 50 100

30

80

72

79

39

18 29 18

0

00

30 Days (N=49)

60 Days (N=44)

Pre-Enrollment

90 Days (N=35)

Self-Pay Self-Pay

2007

Enrolled Enrolled

2007 2008

17

DPCI DPCI Medicaid

Eligible Eligible

Post-Enrollment

42 | C hri sti ana Care Hea l th S ys tem

Region 1

29

2009

26

2010

53

Region 1 96Region 2

2008

17 55

2009

26 43

53 70

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

Nearly half of the patients who visit the Adult Medicine Office, and almost a third of those in the Internal Medicine Faculty Practice have hypertension, with nearly half of them on three or more medications. Employing an evidence-based approach -­‐e pts re 4 The Patient-Centered Medical Home is a multisite partnership 3

/ s t to care and empowering patients in self-management, the 14 p ure ts re-­‐e of Wilmington Health Center’s Pediatrics, the Internal team exceeded their goal to reduce systolic blood pressure by pts /16 p 6 Medicine Residents’ Practice and the Internal Medicine 10mmHg 20 percent of patients s) with Stage 2 hypertension n Patients with Patients Stage 2wHypertension ith % Stage OF Patients 2 Hypertension Goal seen in past yinear o i s s Faculty Practice. ll 3 seultimately achieving success with ce 329 190 31.30% 20% during a six-month am (apilot, m r g oking o r p s

e t i h The average drop in systolic blood ed t percentmofaparticipants. amily Practice The Clinic 65 coordinated 46 long-term 26%relationship 20%plet26.8 nd qu model creates a highly ra 5 points. om pressure g c

78 o s was r t p p

8 nurses, 394 26.80% 20% he between the patient and a care team236 featuring doctors,

/7

34 pts

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

Comp g mokin Quit S rolled Re-­‐En

Improvement of Systolic

t

pleted

com a clinical pharmacist, health coach and social worker. tsAlong 6/20 p 1 with episodic care, teams also help patients navigate insurance ts: led link them %) resources to overcome obstacles Resul paperwork 5.6with enroland

s t p

ing (2 8 k 7 o -­‐ l m a suchsas it sof health insurance, inability to pay out-of-pocket Tot t quloss 0 pneeded 2 l a t for medications and medical supplies.

To

44%

The team helped one woman — who was working but had lost 26% her health insurance — secure $1,500 medication free from a 40% pharmaceutical company by demonstrating that a sudden illness caused her to run out of sick time and cut off her income.

They helped another uninsured patient apply for medical 78 supplies from the Delaware Diabetic Fund and initiated steps to34 get him orthopaedic shoes to prevent pressure wounds. • 16

4 24

Smoking Cessation Program

ed Pressure | iPercent of Success Rate | N=78 Enroll Blood ted withita Sdecrease ok ngof at least e l m p patients m Co & Qu lete 10mmHG leted p m compof patients with a decrease of at least 10mmHG o n I C Blood Pressure vement in Systolic P ercent m a Progr 40% plete Quit, Incom

m a r % of Patients Prog Goal

Program Incomplete 31%

30% Percent of Patients

Completed 44%

20%

10%

0%

Adult Medicine Office

Internal Medicine Faculty Practice

Quit Program Incomplete 5%

Completed & Quit Smoking 20%

2 0 1 4 Qu a l i t y & Saf ety Re por t | 4 3

TECHNOLOGY

â&#x20AC;&#x153;These robust new technologies not only offer enormous patient and public-health benefits, they also help attract the highest quality medical laboratory scientists to work at Christiana Care, where they can provide the highest standard of care for our patients.â&#x20AC;?

CHERYL KATZ Vice President, Pathology and Laboratory Services

44 | C hri sti ana Care Hea l th S ys tem

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

2 0 1 4 Qu a l i t y & Saf ety Re por t | 4 5



LEVERAGING TECHNOLOGY

Faster, more accurate diagnostic results improve outcomes

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

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

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

46 | C hri sti ana Care Hea l th S ys tem

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

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

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

Molecular Diagnostics

Steady advances in microbiology Turn Around Time Comparison In Christiana DCare’s ays microbiology lab, a new diagnostic instrument is for infectious such as C. difficile.

HPV Hspeeding R -­‐2012 up testing times 9 HPV Hdiseases R= HPV High Risk Previously, it took up to 48 hours to obtain a result that now be HPVG-­‐2012 14 HPV G= HPV 16 and 18 can Genotype completed in four hours. Similar turnaround-time improvements have achieved with other assays transferred to the new molecular HPV Hbeen R-­‐2013 7 HPVG-­‐2013 technology, including13screening for Group B Streptococcus (GBS), influenza and methicillin-resistant Staphylococcus aureus (MRSA).

HPV HBy R-­‐2014 5 Care will use this device to test for year’s end, Christiana HPVG-­‐2014 tuberculosis, yielding5results within two hours instead of weeks.

“These robust new technologies not only offer enormous patient 2012 2013 2014 and public-health benefits, they also help attract the highest quality HPV High to work at7Christiana Care, Risk medical laboratory scientists 9 5 where they can provide the highest standard of care for our patients,” Katz said. • HPV 16 and 18 Genotype 14 13 5

HPV Lab Test Result Turnaround-Time 15

14

13

2012

Number of Days

12

9

2013 2014

9 7

6

5

5

3

0

HPV High Risk

15

HPV 16 and 18 Genotype

14 13

2 0 1 4 Qu a l i t y & Saf ety Re por t | 4 7

94 92 LEVERAGING TECHNOLOGY



90 Mar-13

Apr-13

May-13

Jun-13

Jul-13

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

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

Prep Complete Roadblock Removal Pre Data Post-implementation, average time 75 required 59 to remove roadblocks for Post Data tagged providers dropped from 69 65 to 34 minutes.

43 Average time-toprep completion improved by 19 percent, and average procedure-room turnaround times improved by between 11 and 27 percent.

Month

80

60

40

20

0 Prep Complete Pre Data

Roadblock Removal Post Data

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

100 98 96 94 Target

92 90 Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Overall Rating of Care

48 | C hri sti ana Care Hea l th S ys tem

Sep-13

Overall Rating of Care

Average Times Pre- and Post-RTLS Implementation Chart 2

Prior to RTLS implementation, scores fell short of the Overall Rpatient-satisfaction ating of Care 95 percent satisfaction rating for overall care.

Post-implementation, the Mar-­‐13 96.2 scores have consistently Apr-­‐13 exceeded 96.1the 95 percent target, and a stretch goal of 98 percent is now targeted. A patient-tracking board enables visiting May-­‐13 98.1 family members to follow the progress of patients in real time, driven by the Jun-­‐13 98.1 automated recording of movement and care milestones.

Jul-­‐13 95.4 Aug-­‐13 93.4 The team plans to integrate tracking-system data with clinical data to Sep-­‐13 standardize length-of-stay and96.5 post-procedure-recovery protocols. • Oct-­‐13 97.7 Nov-­‐13 95.2 Dec-­‐13 96.4

Oct-13

Nov-13

Dec-13

Aug-13

S

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

Video surveillance 5A equipment Fall Rate installed in six patient rooms on one district of the unit offered the capability to monitor 10 patients. The equipment included a stationary camera with live video feed of the patient room via a closed-circuit TV. A video camera was mounted on the wall at the foot of the patient’s bed. Patient-care technicians trained in video surveillance were stationed in a private location on the unit to monitor the video. Video was not recorded and patients were given the option to opt out of surveillance.

Factors that made patients eligible for fall-prevention surveillance included: ff Mild to moderate confusion. ff High risk for fall.

ff Lack of awareness or understanding of their risk for a fall. ff Demonstration of impulsive behaviors while still responsive to verbal cues and redirection. ff High risk for major injury related to fall. ff History of falling within the past three to six months.

Patients experiencing alcohol or substance withdrawal, exhibiting aggressive NDNQI Meanor violent behavior, on suicide precautions, or with 3.41 difficulty communicating through an 1.87 intercom system were excluded from surveillance.

4.22 3.41 0 The process included3.41 a nurse-driven protocol that did not require 2.94 a physician order.

3.19 The video-monitoring process was explained 3.96 to each patient 3.19 and family considered appropriate for this modality.

Staff continued to follow the fall-prevention 0 3.19 protocol; video monitoring was not a substitute for frequent 3.91 3.25 nursing assessment and interventions. When a monitored 1.02 required testing 3.25or a procedure that normally would be patient 1.04 off of the unit, 3.25consideration was given to whether it provided 1.06be performed at 3.25 could the bedside. • 3.36 3.25 2.71 3.25

Patient Fall Rate

An estimated 30 percent

5

of patient falls result in serious injury. An aging population, rising patient acuity, use of opioids and sedatives,

4

and patient and family underestimation of fall risk all underscore the need for fall-prevention

3

strategies.

1

0 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 5A Fall Rate

NDNQI Mean

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

2 0 1 4 Qu a l i t y & Saf ety Re por t | 4 9



LEVERAGING TECHNOLOGY

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

The new Quality

and Safety intranet site provides reports at unit, service line, campus and system levels and tracks measures aligned with strategic goals.

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

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

50 | C hri sti ana Care Hea l th S ys tem

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

1 6

Nu

hange ned

10

5

0 A

B

30

Patient Care Units Average Value Score 100 25

20 90 15

83.2 81.0

80 10

5 70 0 A

B

C

Baseline

C

Baseline

60

0 B

D FY14

Patient-Care Units Grades Patient Care Unit Grades

5

A

C

Baseline

Average Value Score Number of Units

Number of Units

The voice of the patient is included through a patientsatisfaction measure. Run charts were created for each metric s to assist unit-based value-improvement teams to identify Baseline FY14 for improvement and monitor progress. opportunities 3 Patient 2 Care Unit Grades In 16 the most recent 30 24 12 months, the site received more than 210,000 visits, with 9 3 more than 109 unique staff viewing the scorecard information.

All surveyed nursing leaders found the 2 1 25 value scorecards easy to find and read, and the majority felt age 81.0 83.2 they were easy to understand. As of March 2014, 23 of the 30 units (77 percent) had improved their value score grade by 20 an23 average of 5.7 points. oved hange 1 -­‐20 Also featured are: survey readiness documents, such as tracer 15 ned 6 information and rounding tools; clinical resources, such as Joint Commission and Centers for Medicare & Medicaid 10 Services, State of Delaware and other accrediting bodies’ acute and behavioral health standards; CMS information, disease-specific certification and educational resources. •

Baseline

D

D FY14

FY14

FY14

Patient-Care Units Value Score Value Score Patient CAverage are Units Average

Patient Care Units Average Value Score Patient-Care Units Average Value Score Patient Care Units Average Value Score

100

100

30 90

Average Value Score

90

-­‐20 83.2 81.0 80

Average Value Score Number of Units

25

23

83.2 81.0

20 80

15 70 10

70

6 5 60 Baseline

60

1

FY14

0 Baseline

FY14

Improved

No Change

Declined

Patient Care Units Average Value Score 30

Patient Care Units Average Value Score 30

25

25

20

23

2 0 1 4 Qu a l i t y & Saf ety Re por t | 5 1

335

8 54 13.7% 3751 1023.3% 15.8%10.1%57 12 15.4% 52

102 7 30% 9 8



0.1372549 5 192 0.1578947 5% 57% 0.1538462

48 25% 20% % of trigger sco

275 3.125

19 0.6732673

118 35% 14.5% 13.7%

L E V E R A G I N G T E C H N O L10% OGY

Lactate < 2 Lactate 2-­‐14 Lactate >4

0.0891089

69 25 6

0%

4 6 8 Triggers alert clinicians to patient decline,2 Figure 1 positively change trajectory of care % of # of Trend in Early Warning System Scores Prior to RRT

% of trigger scores >= 4

triggers ≥ n (Total # triggers ≥ 6 40% Hours Concurrent 4 earlyTrigger) 4 35.1% warning triggers that predict a patient’s development of risk factors for patients at risk for 2 of sepsis, 35.1% 20 ICU 0.3508772 risk oversedation or clinical deterioration onlineP25 documentation of a tsedation score Sepsis A57 dvisory Rapid Trigger Response TTransfer eam CLactate all are giving Measured LA >4oversedation; Antibiotics Abx rovided <=3 Median ime Abx to aCbx hange 4 22.0% 59 13 0.220339 clinicians the opportunity to modify and implementation for3.9 early detection5 of 58 45 13 medications 8 and increase 20 2 26 of an algorithm 10 30% 6 14.5% 912 decline 0.1451613 nursing oversight to62 prevent further and sepsis,0 with an advisory alert and evidence-based advisory 74 48 7 mitigate 16 23 10 3.3 2 22.0% 8 13.7% 51 7 0.1372549 patient 50 harm. quickset in care.

41 9 7 12 1 orders to 24reduce variation 15 4.4 6 10 15.8% 57 914 0.1578947 20% 69 68 51 12 19 2 32 9 4 5 14.5% 13.7% The trigger database52 — which captures information already6 in Christiana Care 12 Value Institute4 researchers 12 15.4% 86 0.1538462 25 17 3 0 3.5will continue 1 the electronic medical record, including vital signs and lab test to analyze the database to identify potential harm to our 275 335 54 37 102 5 192 48 3.9 19 10% results — identifies patients at greatest risk for harm.

Research patients.

• 3.125 23.3% 10.1% 30% 5% 57% 25% 0.6732673 by the Christiana Care Value Institute indicates that a patient’s Lactate < 2 Lactate 2 – 4 Lactate >4 vital signs begin to deteriorate four to six hours prior to the 0% Outcome of Sepsis Triggers time of a Rapid Response Team call. Early warning system 2 4 6 8 triggers reduce the need for frontlineLactate staff to<call 400 30% 2 a Code Blue 69 or rapid response team.

60% 0.0891089 Lactate 2-­‐14 25 57% 25% Lactate > 4 6 In a sepsis pilot conducted on four medical-surgical patient300 50% care units, trigger advisories identified 335 patients at risk for 335 20% 40% sepsis in the first six months.

Based on assessment, the care <=3 Median time Abx to aCbx hange Sepsis Advisory Rapid Trigger Response ICU TTransfer eam CLactate all Measured LA >4 Antibiotics PAbx rovided 200 15% team ordered level 58 45lactate 30% 13measures for8 30 percent 20of those30% 2 26 10 3.9 5 6 patients.

Of them, 57 percent required antibiotics.

Median 74 48 12 7 192 16 0 23 10 3.3 2 10% time to antibiotic administration was less than four hours.

20% 50 41 9 7 12 1 24 15 4.4 25 6 100 Only 10 percent of triggered to an 2 68 51 102 14 patients12required transfer 19 32 9 4 5 5% 10% intensive care unit, suggesting that triggered staff interventions 25 17 6 3 6 0 12 4 3.5 1 may have 335 positively changed of care.

0 0% 0% 5 275 54 the trajectory 37 102 192 48 3.9 19

2 2 2 15.8% 2 1 11 35%

10

Sepsis Trigger

sis Advisory Trigger

400

3.9

Lactate Measured Antibiotics Provided 3.125 23.3% database 10.1% 30% 5% Milestones for the trigger include enhanced Number of Patients with Trigger Percent of Triggers timeliness of vital sign documentation, standardization of abnormal vital sign parameters requiring nurse notification,

Lactate < 2 Lactate 2-­‐14 Lactate >4

0.0891089

Sepsis ICU 25% Rapid Response 0.6732673 Advisory Team Call Transfer

57%

Number of Patients with Trigger

69 25 6

Percent of Triggers

Lactate < 2

Lactate 2 – 4

Lactate >4

Lactate Level with Sepsis Trigger 400

Care Processes Following SepsisTTrigger Sepsis rigger 400

300

69

29 22 26 29 12 118 35%

57%

60% 25%

6

300

50%

335

30%

20% 40%

30%

200

192 100

200

30%

100

10%

0

Lactate Measured

Number of Patients with Trigger

Antibiotics Provided

0%

Number of Patients with Trigger

Sepsis Trigger

52 | C hri sti ana Care Hea l th S ys tem

5%

Sepsis Rapid Response ICU Call Transfer Lactate < 2 Advisory Lactate 2 –Team 4 Lactate >4

Percent of Triggers

400

57%

69

0

0%

Sepsis Advisory Trigger

15% 10%

20%

102

25

Percent of Triggers

30%

60% 25%

ut decreased time required for bedside charge report?

eSignout improves efficiency of patient handoff

gnout decreased time for updating the charge report?

Yes No

0% A new eSignout template converting handwritten patient handoff documentation to electronic form ensures more consistent handoff of high-acuity patient information, improves nurse satisfaction with the formcompletion process, and reduces nursing hours spent recopying information.

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

50%

75%

100%

Percent of Respondents

Effectiveness of Methods 100%

80%

Percent Respondents % of rof espondents

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

25%

60%

40%

20%

0%

Ineffective Somewhat Effective Old Method (Paper)

Effective

Very Effective

New Method (eSignout)

Time Savings of eSignout

Has eSignout decreased time 7 2008time 2009 2010 required gnout decreased required for bedside charge report? for bedside change report?

17 26 53 96

55

43

70

58

7 2008 2009 2010 for eSignout decreased timeHas for eSignout updating decreased the charge time report?

17 26 53 the charge report?

96 updating

55

43

70

Yes

58

No 0%

25%

50%

75%

100%

Percent of Respondents 2 0 1 4 Qu a l i t y & Saf ety Re por t | 5 3



LEVERAGING TECHNOLOGY

Speech recognition speaks volumes in transformation to digital medicine In just the first two weeks of introducing Dragon speechrecognition software, more than 700 Christiana Care credentialed clinicians created some 15,000 Progress Notes in the electronic medical record. This dynamic tool — which negates the need for clinicians to dictate or hand-write documentation in the medical record — promises to lower transcription costs, speed efficiency and populate data for achieving Meaningful Use. By 8 a.m. on the software’s go-live day at Christiana Care, credentialed providers had created more than 150 electronic notes. By 10 a.m., nearly 400; by noon more than 700; and by 3 p.m., that number broke 1,000 notes entered by 162 unique note signers. With Dragon, clinicians can update patient status or events in minutes. Updates took up to three days to appear in the chart with conventional transcription services.

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

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

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

Progression of Electronic Notes | Day One 1000

1000

Number of Electronic Notes

800

700

600

400

400 200

150 0

8:00 AM

10:00 AM

NOON

Electronic Notes

54 | C hri sti ana Care Hea l th S ys tem

3:00 PM

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

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

BARBARA HENRY, MLS Director, Medical Libraries

2 0 1 4 Qu a l i t y & Saf ety Re por t | 5 5



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

Goal 90% 90% 90% 90% 90% 90% 90% 90%

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

Vocera usesPhlebotomy voice activation locateCaollection specific team member, STAT toBlood Response Time or allows information to be broadcast to multiple users Percent within 30 minutes simultaneously in time-critical situations. The technology improves quality and safety of care by allowing unit staff to remain at the patient’s side while calling for assistance, and improves response time by negating the need for the phlebotomy team to relay information received via overhead, web or phone requests. Direct notification of staff and ease of communication among staff reduces frustration and leads to prompter, more efficient response and ultimately to safer, higher quality care. Goal: 90%

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

by May 2014, in 95.4 percent of stat orders. •

Within two weeks of Vocera’s implementation there was a 12.5 percent increase in our response times.

Goal 90%

Vocera Implementation 100%

Percent of Responses Within 30 Minutes

d

LEVERAGING TECHNOLOGY

75%

50%

73.0%

75.5%

82.1%

83.5%

90.3%

91.0%

93.2%

95.4%

Vocera Implemented

25%

0%

Q2 2012

Q3 2012

{ Baseline }

56 | C hri sti ana Care Hea l th S ys tem

Q4 2012

Q1 2013 { Pre Vocera }

Q1 2013

Q2 2013 Q3-4 2013 Q2 2014



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

Focus on Excellence Awards

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

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

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

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

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

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

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

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

2 0 1 4 Qu a l i t y & Saf ety Re por t | 5 7



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

Focus on Excellence Awards 2013 AWARD

PROJECT TITLE

RESULTS

President’s Award

Improving Glycemic Control in the Adult Medicine Office

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

Value Award Gold

Applying EvidenceBased CPOE to Telemetry

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

The reduction in total telemetry days is estimated to save $4.8 million annually.

Clinical Excellence Award Gold

Improving Early Mobilization of Critically Ill Patients in the MICU

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

Safety First Award Gold

Ending VAP with Real-Time Feedback

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

Employee Safety Award

Integrating Lifting Equipment into Rehabilitation

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

Great Place to Work Award

The Culture of Responsibility Grows in the Lab

Over a three-year period, the Laboratory leadership team incorporated Culture of Responsibility into workflow, investigation and performance management throughout the Department of Pathology and Laboratory Medicine.

AHRQ Culture of Patient Safety survey results show that safety is a top priority, error feedback and communication has improved, reporting of near misses has increased, event investigation is less punitive, and there is an increase in the overall perception of patient safety in the laboratory.

Think of Yourself as a Patient Award Gold

Improving Patient Satisfaction Using Multimodal Communication Tools

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

Financial Strength Award

Fentanyl & Financial Stewardship: Mutually Inclusive

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

Nursing – Empirical Outcomes Award Gold

Cleaner Catches

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

58 | C hri sti ana Care Hea l th S ys tem

2013 AWARD

PROJECT TITLE

RESULTS

Nursing – New Knowledge, Innovations & Improvements Award Gold

Patient-Care Unit Dashboards Drive Excellence

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

Nursing – Exemplary Professional Practice Award Gold

Mothers and Newborns Win with Skin-to-Skin

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

Nursing – Structural Empowerment Award

Handle with Care: Improving Post-Surgical Transitions

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

Nursing – Transformational Leadership Award

Highway to the SCCC: Decreasing ED LOS for Trauma Codes

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

Learning Excellence Award Gold

VNA TV Learning Anytime Anywhere

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

Operational Improvement Award Gold

Wilmington General Laboratory TAT Improvement

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

Excellence in Community Health Award Gold

The Value of a SystemIntegrated Health Coach Model in Primary Care

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

Resident’s Award Gold

Never TMI

This Achieving Competency Today (ACT) team’s goal was that every patient being transferred out of the Christiana Medical Intensive Care Unit (MICU) to a lower level of care will be accompanied by a standardized transfer note summarizing essential information and plan of care. A standardized handoff transfer note resulted in a 32 percent increase in inclusion of useful information; template notes increased inclusion of content on 12 of 17 essential points.

All of note senders felt the template was useful.

Diversity, Inclusion & Cultural Competency Excellence Award

Improving Care for LEP Patients

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

People’s Choice Award

Peripherally Inserted Central Catheter Tip Placement by Vascular Access Nursing

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

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2 0 1 4 Qu a l i t y & Saf ety Re por t | 5 9

Creating a Safe Culture Every individual shares a deep commitment to make safety a priority. Christiana Careâ&#x20AC;&#x2122;s culture of safety is characterized by our patient-centered care, open communication, a blame-free environment and collective responsibility for safety.

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

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

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

60 | C hri sti ana Care Hea l th S ys tem

Leveraging Technology Our commitment to invest heavily, yet prudently, in technology â&#x20AC;&#x201D; whether for patientcare equipment, electronic medical records or operational software to streamline our efficiencies â&#x20AC;&#x201D; leads to safer, better care and ultimately greater value for our patients.

Our Journey — PROGRAM INITIATIVES 2008 to 2014 2008

2009

2010

2011

Safety First Learning Report

Culture Survey (January)

Culture Survey (October)

Culture of Responsibility Phase II (Oct.)

Enhancements for Follow-Up

Culture of Responsibility (Planning)

Culture of Responsibility Phase I (June)

Just Culture Concepts (Planning)

Patient and Community Involvement

SAFE Weekly Huddles

Standarized Handoffs for Transitions of Care in Women’s Health

Human Factor Analysis for Flex Monitoring

Post-Event Debriefs Partners in Safety Updates Enhanced Disclosure Process

Human Factors Analysis for Radiation Oncology

Embracing Patient-Centered Care through Implementation of AIDET

Team Training

Patient- and Family-Centered Care

Disclosure Policy & Process

Unit-Based Clinical Leadership Teams

Transparency Concepts

Worker Fall Protection Policy

Interdisciplinary Rounds

5C Nursing Home Project

Focus on “No Harm, Any is Too Many”

Skylight Safety Assessment

Cultural Diversity & Inclusion

Bedside Shift Report

BEAT Training Classes

Quarterly Environment of Care Consultant Assessments

Employee Wellness

Specialized Training on Compressed Gas Safety

Facilities and Services Safety Committee Established

Arc Flash Policy and Program Safe Work Permit Improvements

TRP Safety Education Module

Slip, Trip Fall Workgroup Established Department Level Focused Safety Training

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

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

Disease-Specific Certification • Stroke Program Comprehensive Unit-Based Safety Program (CUSP) Magnet Recognition

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

Prevent Harm from High-Alert Medications (Hydromorphone)

Flu Vaccine Program

Disease-Specific Certification Planning • Primary Stroke Center

Pregnancy Screening in Non-OB Locations

Hand Hygiene Campaign

SWAT (Synchronized Wilmington Admission Team)

Proactive Assessment of Communicating Patient Preferences/Goals of Care

Obstetrical Emergency Response Team (OBERT)

ED SHARP

ED SPEED

ED Triage Redesign

ED Super Track

Surgical Safety Team Checklist

Best Practices for Better Care Partnership for Patients Christiana Rapid-Transfer Initiative

Heart Failure Transformation Team

Pharmaceutical Waste Management Program Implemented

ADT Interfaces with Micropaq

CPOE: Zynx Phase 3

CPOE Expanded Use of Vocera

Capnography (End-Tidal CO2 Monitoring) During Code Blue

Wireless Patient Monitoring Infusion Pumps (Smart Pumps)

Enhanced Web Paging

Care Fusion Implementation

Radiation Therapy Positioning Software

CPOE: Zynx Phase 2

Planning for Meaningful Use

Enhanced Central Line Checklist

Language Line Enhancement Vocera

VNA Heart Failure Telemonitoring Program

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

Equipment Tracking

Wireless Bar Coding of Breast Milk

Standardization of Web Page to Mobilize Anesthesia Services

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

Interpreters Care Visibility

2012

2013

Culture Survey (April)

Focus Groups on Speak Up (April)

Workgroup Assessing Blood and Body Fluid Splashes

Culture of Responsibility Phase III (October)

Culture of Responsibility Phase IV (June)

Employee Safety Handbook

Event Investigation Management Training

Consultant Observing Behaviors Related to Handling Needles and Sharps

Workplace Violence Committee Established

Integration of Medication Safety Concepts into VEST Center Simulation Training

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

Implementation of MedMarx Database and Each Medication Error Benchmarking Capability

Creation of a Workplace Safety Intranet Site

Pilot AU Meds (Sept)

No Pass Zone

Tram Safety Program Improvements to Reduce Risk of Accidents and Injuries

Phase IV CoR Manager Training

VP Level Monthly Injury Summary Reports Contractor Safety Training Video Updated Workplace Safety Risk Review Evaluation Completed by Conner Strong Formalized Systemwide “Good Catch” Program (March) Patient Safety Organization-PSES evaluation

2014

Restraint Reduction

Administration of AHRQ Culture Survey Engaged in Health Care Safety Hotline Project with AHRQ & Rand

Value Improvement Team Addresses Needlesticks, Sharps, and Exposure Injuries Improvements to Reduce Risk of Slips, Trips and Falls

Engaged in CandOR (Communication and Optimal Resolution) Demonstration Project

Communications Strategy for Employee Safety

Vendor Selection for Event Reporting & Management

Pilot Early Warning System (EWS) Patient Identification Best Practice Leadership Forum “Event Analysis” SWAT Launches at Christiana Human Factors Consultant “Sponge Counts” Value Improvement Team Training

Levels of Complexity of VI Projects

Focused Safety Assessments in High-Risk Departments

VTE Prophylaxis Surveillance

Pilot Program for Slip-Resistant Shoes

Deep Dive for Lab Events

Adoption of National Telemetry Guidelines

Creation of an Acute Pain Treatment Service

Post Rapid Response Team Huddles

Evaluation of Network Downtime Procedures and Operations

Lean Six Sigma Fall Reduction Hand Hygiene Campaign Scenario-Based Interprofessional Simulation Training

ISMP ED Medication Consult

Video Surveillance Project (5A)

ECRI RRT Assessment

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

ECRI Fall Insight Assessment Expansion of SPBM to Outpatient Sites

Adoption of PASERO Sedation Assessment

Adoption of NCCMERP Harm Scale & Classification Taxonomy for Medication Events

Collaborative for Improving Transitions of Care Developed Anticoagulation Management Guidelines

Implemented Evidence-Based Indications for Telemetry (March)

Created Acute Pain Management Service

Expanded Behavioral Emergency Assistance Team (BEAT) Training

Expansion of Antimicrobial Stewardship Program

Active Shooter & Workplace Violence Policies Trained Incident Management Team to Staff Command Centers in Response to Emergencies

OBIS Interface

Vendor Selection for Occupational Health and Safety Management Software

Microtab for Infection Prevention

Vendor Selection for Emergency Mass Notification System

Automation of “Event Follow-Up”

Dose Edge IV Production

Creation of a Network Downtime Census

Implementation of Meaningful Use

Enterprise Rx Outpatient Pharmacy Bar Coded Dispensing Verification

Electronic Standardized RRT Documentation

Promanger Inpatient Initial Dose Automation

New Quality & Safety Intranet Site

AcuDose Bar Code Restocking Processes

Vendor Selection for Smart Pump Replacement

Oncology CPOE

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

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

Development of Global Triggers – Sepsis, EWS and Over-Sedation Procurement of TRU-D® SMARTUVC™ Room Disinfection System Capture “Flu” Administration Online Central Lines & Foley Day Documentation Current Orders in DATAS Acoustic Engineer Engaged to Study Noise Levels in Patient-Care Areas Injury Summary Reports Distributed to Directors for Review and Follow-up

Power Chart Upgrades (Aug)

Electronic Schmid Fall Risk and High Risk for Injury Assessment

Electronic Progress Notes Electronic Critical Test Results Sticker

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

In the regional and national spotlight AMERICAN COLLEGE OF PHYSICIAN EXECUTIVES 2014 LEAPE

THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION’S

AHEAD AWARD for multipronged approach to teaching medical

ACTION REGISTRY AWARDED ITS GWTG GOLD PERFORMANCE

students, residents and faculty the principles of patient safety and quality.

Vascular Health.

ACHIEVEMENT AWARD for 2013 to the Center for Heart &

HOSPITAL SAFETY SCORE OF “A” FROM THE LEAPFROG GROUP,

EMERGENCY NURSES ASSOCIATION 2013 FORENSIC NURSE

which rates how well hospitals protect patients from accidents, errors, injuries and infections.

EXAMINER TEAM AWARD, calling Christiana Care’s program

“a model for the country.”

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

MEDICAID HEALTH PLANS OF AMERICA 2013 BEST PRACTICES

IN DELAWARE AND ONE OF THE NATION’S BEST HOSPITALS.

AWARD for Christiana Care Visiting Nurse Association’s “Control

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

Your Heart for the Future” telehealth program.

NICHE (NURSES IMPROVING CARE FOR HEALTHSYSTEM ELDERS) PROGRAM EXEMPLAR STATUS for outstanding elder care.

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

IVANTAGE HEALTH ANALYTICS TOP 100 HEALTHSTRONG

SOCIETY OF THORACIC SURGEONS.

HOSPITAL. COMPETENCY & CREDENTIAL INSTITUTE CNOR® STRONG COMMUNITY VALUE FIVE-STAR HOSPITAL scoring in the

DESIGNATION.

top 20 percent of “high-intensity teaching hospitals” by Cleverley and Associates.

INFORMATIONWEEK 500 LIST OF TOP TECHNOLOGY INNOVATORS in the U.S. for third consecutive year.

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

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

THE AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL

HELEN F. GRAHAM CANCER CENTER & RESEARCH INSTITUTE

QUALITY IMPROVEMENT PROGRAM recognized Christiana Care

SCORED HIGHEST IN PATIENT EXPERIENCE FOR THE QUALITY

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

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

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

LGBT LEADER IN THE HUMAN RIGHTS CAMPAIGN

CENTER OF EXCELLENCE IN MINIMALLY INVASIVE GYNECOLOGY (COEMIG) DESIGNATION by the American Association of Gynecologic Laparoscoposits and the Surgical Review Corporation.

FROM THE CONQUER CANCER FOUNDATION OF THE AMERICAN SOCIETY OF CLINICAL ONCOLOGY.

RESEARCH.

FOUNDATION’S HEALTHCARE EQUALITY INDEX 2013.

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

NEWS JOURNAL (GANNETT) TOP WORK PLACE IN DELAWARE AND THE NATION.

TRAINING MAGAZINE TOP 125 COMPANY for training and

learning development.

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

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

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

LEVERAGING TECHNOLOGY

Christiana Care is recognized for excellence

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

Christiana Care is a private, not-for-profit regional health care system that relies in part on the generosity of individuals, foundations and corporations to fulfill its mission.

To learn more about our mission, please visit christianacare.org/donors.

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