Quality & Patient Safety
2010 ANNUAL REPORT
Transformation at Christiana Care focuses on improving value—making the care dramatically “better and easier” for the patients we care for. The services we organize and the care we offer should make a real, measurable difference in people’s lives. We must do this in ways that are affordable and sustainable. In the past year as we continued our journey of transformation and innovation, teams throughout Christiana Care have focused their collective energy and creativity to make a difference in the lives of our patients every day. We are working tirelessly to continue to create dramatic improvements in what we do for the communities we serve. This report covers key Focus on Excellence initiatives to improve quality and safety, decrease costs, and strengthen financial capability so that we can reinvest in our mission of care and service to the communities we serve. Robert J. Laskowski, M.D., MBA | President and Chief Executive Officer
Achieving
Transformation In this report Awards, Achievements & Recognition 2 | Safety First 8 | Achieving High Reliability 16 | Leveraging Technology 24 | A Look to the Future 28
Focused on Excellence As we continue our journey of transformation, Christiana Care draws inspiration from Just Culture principles to promote quality and patient safety as shared values and shared responsibilities. The Just Culture philosophy has been adopted by many health systems to minimize errors and adverse events in complex and hazardous work environments. To keep our patients safe from risk, at Christiana Care we use Just Culture principles to drive our “Culture of Responsibility.� We have set our expectations high. A strong safety culture does not rely on blame to fix and prevent errors. Consistent safety comes from good systems that promote good behavioral choices and individual accountability. Fair treatment, coaching and communication encourage each of us to think critically to evaluate behavioral choices, to report errors and adverse events and proactively identify areas for improvement. In this way, risks become more transparent. Near misses become learning opportunities to prevent future errors, and mistakes become recoverable pathways to identifying and correcting root causes. We continue to improve care delivery systems for our patients and to improve the environment for all those who work to provide that care. We strive for excellence and commit to maximizing our resources to minimize the risk of harm to our patients and our employees. This is how we provide health care that is safe, timely, patient-centered, efficient and equitable.
Quality & Patient Safety Annual Report
â?–
1
Awards, Achievements Recognitions
&
Our commitment to a safe culture, grounded in achieving high reliability and leveraging technology, continues to bring us honors as a leader in patient safety and quality of care.
2 0 1 0 R E CO G N I T I ON
Nursing Program Achieves Magnet® Status Christiana Care has achieved Magnet recognition for excellence in nursing by the American Nurses Credentialing Center (ANCC). Only 6 percent of the nation’s hospitals have earned this honor, the highest level of national recognition to health care organizations that demonstrate sustained excellence in nursing care. Christiana Care is the only hospital in Delaware to achieve Magnet status. The Magnet Recognition Program provides consumers with the ultimate benchmark to measure the quality of care that they can expect to receive. Magnet recognition signifies an environment of patient care where nurses are leaders in safe patient handling practices, proactive in risk and error management, and current and competent in best practice standards for quality and patient safety. Research shows there are clear benefits to hospitals that receive Magnet status and to the communities they serve in consumer confidence, recruitment and retention, and in quality of care.
US News & World Report Best Hospital For the third straight year, Christiana Care is one of “America’s Best Hospitals,”an elite list of 174 institutions named by US News & World Report, which evaluated more than 4,800 hospitals. The only hospital in Delaware to make the list, Christiana Care is among the top hospitals in two specialties: Diabetes & Endocrine Disorders and Digestive Disorders.
2
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
Medical Intensive Care Unit wins Beacon Award The Medical Intensive Care Unit at Christiana Care is the recipient of a spring 2009 Beacon Award for Critical Care Excellence, one of only 35 hospitals nationwide and the first in Delaware to achieve the honor. The award from the American Association of Critical-Care Nurses recognizes units that achieve the highest standards in patient outcomes, nurse recruitment and retention, staff training and a healthy work environment.
Thomson Reuters 2009 Healthcare Advantage Award Christiana Care’s efforts at optimizing the number of tests doctors order and the amount of time patients spend in the hospital earned a 2009 Healthcare Advantage Award from Thomson Reuters, a nationally known provider of health information. Christiana Care is one of only five organizations in the U.S. honored in the health and clinical outcomes category.
International Recognition for Quality Innovation The Agency for Healthcare Research and Quality and the Canadian Patient Safety Institute applauded Christiana Care for quality innovations among an elite group of hospitals and health systems who came together at their joint meeting in March 2010, at AHRQ headquarters in Rockville, Md. Three innovations cited: Patient Safety Mentor Program, designed to engage frontline staff in sharing and communicating important safety behaviors, practices and information. Sepsis Alert Campaign, to identify and treat sepsis earlier in the Emergency Department with pre-packaged antibiotic kits on rapid-response carts. eCare System, technology that enables remote teams to monitor patients in the Intensive Care Unit, providing an additional level of support and care.
Cancer Center Accreditation Christiana Care’s Helen F. Graham Cancer Center received three-year accreditation with commendation from the Commission on Cancer of the American College of Surgeons on March 26. The Commission on Cancer has accredited the cancer program at Christiana Care since 1985. Our 26-percent patient enrollment rates into clinical trials at the Graham Cancer Center are nearly seven times the 4-percent national average.
Level I Trauma Center The state of Delaware redesignated Christiana Hospital a Level I trauma center, as verified by the American College of Surgeons Committee on Trauma. Christiana Hospital is the only Level I Trauma Center between Philadelphia and Baltimore.
Living-Donor Kidney Transplants The United Network for Organ Sharing (UNOS) has approved Christiana Care’s Kidney Transplant Program to perform living-donor kidney transplants. This important milestone demonstrates the program meets all UNOS protocol requirements for the living donation process.
Open Heart Surgery Program Christiana Care’s Center for Heart & Vascular Health has been awarded the highest national ranking— 3 stars—from The Society of Thoracic Surgeons (STS) for 2009. Only 11.7 percent of hospitals nationwide received the STS 3-star rating— the highest category of quality of cardiac surgery in 2009. The STS comprehensive rating system compares the quality of cardiac surgery among hospitals across the country.
Stroke Program Certified Christiana Care has earned the Gold Seal of Approval™ from The Joint Commission as a Primary Stroke Center. A regional leader treating more than 1,200 patients a year, Christiana Care demonstrated that our stroke care program follows national standards and guidelines that can significantly improve outcomes for stroke patients. The comprehensive Inpatient Rehabilitation Program and the Stroke Specialty Program at Christiana Care’s Center for Rehabilitation at Wilmington Hospital received a three-year accreditation from the Commission for Accreditation of Rehabilitation Facilities (CARF), an internationally acknowledged, leading independent accreditor of rehabilitation facilities. After visiting Christiana Care in June 2009, CARF surveyors commended the center’s dedication to including patients and family members as part of the health care team. They also remarked on the center’s use of exceptional interdisciplinary communication and teamwork.
Virtual Education and Simulation Training Center The Virtual Education and Simulation Training Center at Christiana Care earned three-year accreditation as a Level II Education Institute from the American College of Surgeons. It is the first Level II Institute in the world and the only accredited center in Delaware.
Quality & Patient Safety Annual Report
❖
3
Awards, Achievements Recognitions
&
In the Spotlight Nationally
The Alliance of Independent Academic Medical Centers (AIAMC) named Christiana Care the 2010 Alliance Innovation Award winner. The award recognizes Christiana Care for innovative approaches to medical education and research that result in better patient outcomes.
Christiana Care Wound Care & Hyperbaric Medicine Center earned the Center of Distinction Award from Diversified Clinical Services, the nation’s leading wound care management network, for meeting or exceeding 12-month target goals for healing, outcomes, daysto-heal, outliers and patient satisfaction.
Christiana Care received the award for developing and implementing an innovative graduate-level, 12-week course. The curriculum focuses on inter-professional learning through collaboration on quality improvement projects. The aim of the course is to produce measurable improvements in quality and patient safety.
Christiana Care’s first live surgery webcast “Dramatic Advance in Parathyroidectomy” was selected as one of the year’s best in ORLive’s Best of 2009 awards list.
By joining the American College of Obstetricians and Gynecologists (ACOG) Simulations Consortium, Christiana Care became one of only 13 sites in the nation participating in this innovative system for teaching OB/Gyn residents surgical skills.
The National Institutes of Health selected Christiana Care as one of only six institutions to participate—and first to enroll expectant mothers—in a groundbreaking, three-year research program to establish a national standard for normal fetal growth.
4
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
The Center for Advanced Joint Replacement received the 2008 PEEPS Injury Prevention Award for achieving the highest ratings for leadership in Safe Patient Handling and Mobilization. The mission of PEEPS (Patient, Environment, Equipment, Posture, Safety) is to provide safe environment and work practices to prevent employee injuries and promote patient safety. Christiana Care, a recognized leader in safe patient handling practices, is one of five sites nationwide selected to pilot the American Nursing Association’s “Handle with Care” Safe Patient Handling Program. The PEEPS program has resulted in an 85-percent drop in lost-time injuries since its inception in 2000.
In the Spot light Regionall y
Christiana Care’s Kidney Transplant Program earned the National Kidney Foundation’s Bruce Zakheim, M.D., Memorial Legislative and Advocacy Award for outstanding work in fighting chronic kidney disease. The National Kidney Foundation serving the Delaware Valley presented the award recognizing Christiana Care’s leadership in patient education and support services and in community outreach.
Delaware Health Sciences Alliance The new Delaware Health Sciences Alliance (DHSA) brings together four of the region’s leaders in research, education and health care: Christiana Care Health System, the University of Delaware (UD), Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University. Tapping the collective strengths of these partners could spur Delaware’s economy and transform health care for the people of our state. Central to DHSA’s mission is a large health professions complex slated for development on the UD’s newly acquired 272-acre site adjacent to the campus. The complex will house the Jefferson Campus for Healthcare Education, the Delaware Rehabilitation Institute, state-of-the-art bench and clinical research facilities, and interdisciplinary translational research centers.
Jefferson Campus for Healthcare Education The Jefferson Campus for Healthcare Education, an extension of Thomas Jefferson University, will create, for the first time, a cadre of health care students learning and living in Delaware. Many of these students will have opportunities to complete their training at Christiana Care and Nemours/Alfred I. duPont Hospital for Children. Access to health care across the entire state will improve as these health professionals do clinical rotations throughout Delaware’s urban and rural areas. Graduate degree programs offered jointly through the University of Delaware and Thomas Jefferson University will generate a pool of highly trained policy makers to advance health care research and delivery in the region.
Research DHSA collaborations will stimulate research from bench science through clinical trials to bedside practice, as well as population health and outcomes studies. This work could attract large multicenter grants that might not otherwise be available to our region. Leveraging the centers of excellence at Christiana Care and Jefferson’s Philadelphia campus, DHSA is developing two major interdisciplinary research centers: the Delaware Center for Cancer Biology and the Delaware Cardiovascular Research Center. The alliance also is considering centers in neuroscience and in women’s and children’s health.
Health care services Expanded clinical education and training coupled with cutting-edge research means better patient care. Enhanced disease prevention and health promotion programs will improve the health of the entire community. Given that nearly 50 percent of medical students practice in the state where they complete their training, these programs should help meet Delaware’s projected demands for quality health care services and personnel to care for a population that is aging at one-and-a-half times the national rate.
Quality & Patient Safety Annual Report
❖
5
Awards, Achievements Recognitions
&
Focus on Excellence Awards
In the Spotlight at Christiana Care Christiana Care’s annual Focus on Excellence Awards exemplify our commitment to improving the health of all those we serve. This year, there were 90 outstanding team entries describing the creativity and ongoing commitment our employees have to improving the safety and quality of care for our patients. Listed below are the 2010 winners. President’s Award Improving diabetes care in the Adult Medicine Office Clinical Excellence Gold Addressing the complex needs of the long stay patient Safety First Gold On the sharp end: Safety mentors’ role in reducing harm Think of Yourself as a Patient Enhancing the patient experience through GetWellNetwork
Nursing Excellence Improving shift-to-shift communication among nurses Nursing Excellence Protocol for appropriate use of foley catheters Learning Excellence Simulation technology used to increase clinical competence and confidence
Residents’ Award Who ya gonna call: Reporting critical microbiology results for discharged patients Operational Improvement Bed access project: Perfecting patient flow—looking in real time Excellence in Community Health VNA Call & Care
S h a r i n g W h a t We L e a r n Our leadership in patient safety and clinical excellence reaches national audiences. This year alone, through conference presentations and journal articles, our staff members have shared their best practices in patient safety and clinical excellence with their colleagues throughout the country. Here are some recent accomplishments.
Publishing
6
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
“Delaware’s Inclusive Trauma System: Impact on Mortality,” in The Journal of TRAUMA® Injury, Infection, and Critical Care.
“Nursing Handoffs: A Systematic Review of the Literature,” in the April issue of American Journal of Nursing.
“A Community Cancer Center Program: Getting to the Next Level,” in the March Journal of the American College of Surgeons.
“A Multidisciplinary Approach to Adverse Drug Events in Pediatric Trauma Patients in an Adult Trauma Center,” in Pediatric Emergency Care.
Presenting Christiana Care Vascular & Interventional Radiology Fellowship program director and Vascular & Interventional Radiology Section Chief Mark J. Garcia, M.D., presented pioneering work at Christiana Care on deep vein thrombosis (DVT) at the 36th annual VEITHsymposium™ for Vascular & Endovascular Issues, Techniques and Horizons. Bank of America endowed medical director of the Helen F. Graham Cancer Center Nicholas J. Petrelli, M.D., was a featured speaker at the American College of Surgeons 95th Annual Clinical Conference, sharing information about reducing Delaware’s cancer rate. The Christiana Care Obstetrical Emergency Response Team presented its new program at the Quality Improvement Initiatives in Obstetrical Care Forum at the Obstetrical Society of Philadelphia. “Conducting Clinical Trials in India—a U.S. Perspective” was presented by Christiana Care’s Institutional Review Board Corporate Director Jerry Castellano, Pharm.D., CIP, at an international workshop on ethics in clinical and biomedical research hosted by Sri Ramachandra University in Chennai Province, India. The workshop was in collaboration with the University of Miami as part of the Collaborative Institution Training Initiative.
Omar Khan, M.D., led a workshop on “Mentorship for National Public Health Institutes” in Johannesburg, South Africa, as part of a World Health Organization-affiliated learning group. “Creating Winning Publications and Educational Offerings” was presented by Loretta Consiglio-Ward, MSN, RN and Dianne Bradtke, MSA, RN, CPHQ at the National Association for Healthcare Quality 2nd Annual State Leaders’ Summit. Ken Silverstein, M.D., conducted “Surgical Fire Safety Update: Best Practices for Prevention” a live, interactive web conference presented by ECRI Institute.
Linda Brittingham presented “The Complexities of Acute Care Discharges Today” to the Health Care Facilities Association and “Hospital Discharge Planning” to the Aging and Disabilities Resource Center lead partners and the Division of Aging and Adults with Physical Disabilities staff. More than 30 Christiana Care colleagues, including nurses, physicians, pharmacists, social workers, pastoral care professionals and others, presented posters at the 6th Annual 21st Century Visions of Nursing conference, sponsored by Christiana Care Patient Care Services Education and the Department of Nursing.
“So You’re Doing Quality Safety & Improvement: How Can you Tell Whether It’s Working?” and Christiana Care’s nationally recognized Safety Mentor Program were presented by Michele Campbell, RN, MSM, CPHQ, corporate director of Patient Safety & Accreditation at the annual AHRQ meeting. Carol Kerrigan Moore, RN, MS, Nicholas Gagliano, M.D., Kathleen McNicholas, M.D., JD, Michelle Wheeler, RN, BA, Leslie Konizer, MA, Judy Townsley, RN, MSN, and Ken Silverstein, M.D., presented, “TeamSTEPPS 101: Know the Plan, Share the Plan— Implementing a Customized Surgical Safety Checklist as a Team Communication Tool” at the 6th Annual Maryland Patient Safety Conference in Baltimore.
Quality & Patient Safety Annual Report
❖
7
Safety
First 8
â?–
C H R I S T I A N A CA R E H E A LT H S Y S T E M
Creating a Safe Culture Delivering safe, quality patient care starts with a clear vision and active leadership that leads caregivers to seek opportunities for improvement, learn from our mistakes, and strive for effective communication. safe culture offers manybenefits: benefits: A safe A culture offers many ◆ Contributes to consistent delivery of high-quality, safe patient care. ◆ Supports better interactions with patients and their families, and places them at the center of their health care. ◆ Promotes communication throughout the organization. ◆ Encourages multidisciplinary, collaborative problem solving. ◆ Allows staff to learn from mistakes to support performance improvement. ◆ Helps care providers to understand how to work together effectively in complex processes. ◆ Designs systems that anticipate and capture errors.
Agency for Healthcare Research and Quality (AHRQ) Hospital Survey Health care has become so complex, so highly technical, so multidisciplinary that we must “ constantly assess where we are, how far we’ve come, and where we need to focus. The AHRQ survey helps us understand how our organization is committed to keeping our patients safe.
”
— James Newman, M.D. | Chief Medical Officer and Patient Safety Officer
Accessing our culture is critical to becoming an error-free hospital. Christiana Care joined 190 teaching hospitals nationwide to participate in the 2009 AHRQ hospital survey on patient safety culture. Compared with the 2006 survey results, Christiana Care shows significant improvement in its culture of safety. The percentage of respondents—health care providers within Christiana Care—who gave an overall patient safety grade of either “A” or “B” rose from 69 to 75 percent, above the national benchmark for teaching hospitals.
Quality & Patient Safety Annual Report
❖
9
AHRQ Hospital Survey continued
Anticoagulation Management
The 2009 results demonstrate the following areas of strength:
The multidisciplinary team charged with improving the safe use of anticoagulants continued to make progress by:
15% improvement in communication during handoffs and transitions.
11% improvement in management support for patient safety.
8% improvement in teamwork across units. 7% improvement in organizational learning/continuous improvement.
Areas that will continue to be a focus for improvement:
Creating a culture that supports safety Balancing open reporting with appropriate accountability for behavioral choices Responding to error in non-punitive ways Addressing staff concerns that mistakes count against them and go in their personnel file Encouraging staff to speak up to those with more authority regarding risks
• Developing CPOE PowerPlans that provide for two different heparin dosing regimens in which prescribers choose between standard and lowerdose regimens based on the patient’s condition. • Embedding orders for recommended laboratory monitoring into PowerPlans and care sets. • Fine-tuning the process for identifying inpatients ordered warfarin (Coumadin) without a baseline international normalized ratio (INR) and obtaining that value prior to dispensing of the medication. • Developing a process for review of an outpatient’s INR and intervention by the retail pharmacist, if needed, prior to dispensing of warfarin (Coumadin) at our retail pharmacies. The review of the INR values has resulted in good catches in inpatient and outpatient areas. New this year is the publication of the first Christiana Care Anticoagulant Formulary. With oversight by the Pharmacy & Therapeutics Committee, a core group of physicians and pharmacists developed this pocket guide that provides key information for the management of patients receiving an anticoagulant. The guide pulls into one place standard dosing and monitoring information along with key Christiana Care guidelines.
AHRQ Hospital Survey
Respondents who gave an overall patient safety grade of A or B increased and is above the benchmark for teaching hospitals.
OVERALL SAFETY GRADE 10
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
Handoff Communication Communication breakdowns are the No. 1 cause of errors and a threat to patient safety. To promote sharing of accurate and complete information at time of transfer, an interdisciplinary team at Christiana Care continues to enhance the handoff process.
Handoffs to nurses: the DATAS tool The team developed this tool in response to a random survey of nurses asking what information they most need to know during a shift-to-shift or unit-to-unit handoff: Demographic and diet information Assessments and allergies Tests and test results Alerts such as do-not-resuscitate orders Status of the patient within the plan of care Going a step further, surgical nurses on 4C developed a standardized format for shift-to-shift reports incorporating the DATAS tool. The format focuses on the needs of their particular patient population, emphasizing the plan of care, addressing and communicating home health needs, and identifying barriers to discharge. Use of the standardized format has led to a number of improvements on the unit, including falls prevention, better bed management and decreased length of stay (7.79 down to 3.95 days).
Web Paging Implementation: Physician Response
Web paging with SBAR Nurses and hospitalists collaborated to develop a new web paging tool using SBAR, an acronym detailing information necessary for a safe handoff: Situation Background information Assessment of current situation Requests related to problems being reported The new pager system allows physicians and nurses to better communicate with each other and to respond quickly and effectively to meet the needs of patients at both Christiana and Wilmington hospitals. Special features include prompts to describe the reason for the call (e.g., chest pain, need discharge order), priority status (e.g., STAT or FYI), and space for a 10-digit direct call-back number.
Respondents noted significant improvement of the quality and organization of information for both physicians and nurses.
Web Paging Implementation: Nursing Response
Quality & Patient Safety Annual Report
â?–
11
Team Training Perioperative Services, Trauma, Emergency Department and Women and Children’s Health are currently engaged in Team Training efforts. To improve teamwork and ensure safer practices, Christiana Care developed an evidence-based Team Training curriculum built on the Team STEPPS™ framework with four core competency areas:
The skills, tools and strategies of Team Training are used in our Virtual Education Simulation Training center. Numerous departments have incorporated Team Training concepts into their daily practices. Christiana Care was featured for the second consecutive year at the National Team STEPPS Consortium.
• Leadership.
Successful management of shoulder dystocia
• Situation monitoring. • Mutual support. • Communication. Team Training also encourages an atmosphere where frontline staff members feel free to speak up if they think something is wrong. This engages all clinical staff in a systems-based, error prevention process.
This year, Women and Children’s Health gained national recognition with the publication of their success in incorporating team-training concepts into a simulation curriculum for responding to shoulder dystocia and other obstetrical emergencies during deliveries.
Changes in positive responses following shoulder dystocia team training
67% of survey respondents felt that team training improved care delivery.
12
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
Surgical Safety Checklist Every surgery should be a safe surgery. Christiana Care has advanced our culture of surgical safety to the next level by implementing use of the Surgical Safety Checklist and Team Briefing at all operating room sites. Aligned with the World Health Organization’s Safe Surgery Saves Lives program, the Surgical Safety Checklist is an evidencebased team training tool to help make operations safer for our patients.
The checklist focuses on three phases of surgery: • Sign In, before induction of anesthesia. • Time Out, before the skin incision. • Sign Out, before the patient leaves the operating room.
At each phase, the OR team communicates key clinical information that helps to ensure safe and effective care. Conducting team briefings using this tool offers these important safeguards and benefits: • Promotes effective OR teamwork and communication. • Ensures the right patient, right operation, right site, and right equipment. • Promotes safe anesthesia and resuscitation. • Minimizes risk of infections. • Reduces preventable harm. • Lowers costs due to medical errors. After implementation more than 60 percent of OR team survey respondents agreed that communication improved.
Obstetrical Emergency Response Teams (OBERT) Expectant mothers in peril receive care within minutes, thanks to the Obstetrical Emergency Response Team (OBERT). Instead of going through traditional escalation steps, OBERT brings immediate help to obstetricians and nurses responding to such conditions as shoulder dystocia, hemorrhage and fetal distress.
OBERT Calls by Reason April ‘09 to May ‘10
The team has responded not only to cases in Labor and Delivery and maternity units, but also in the Emergency Department and, on one occasion, in the hospital parking lot. Each year, more than 7,000 babies come into the world at Christiana Hospital. We have one of the highest birth volumes in the nation. As a high-risk obstetrical referral center in Delaware, we take care of the most complex patients. OBERT is part of our safety net.
Quality & Patient Safety Annual Report
❖
13
Innovation Unit Rapid Response Teams Christiana Care encourages patients and their family members to take an active role in patient care. As of April 2010 at both hospitals, all inpatients and their family members have access to our Rapid Response Team (RRT). The access enables patients or family members to call for help if they think there is a serious condition change and the care team does not recognize the change. The family RRT extension, 6385 at either hospital, connects directly to a nursing coordinator to respond quickly and assess the situation. If necessary, the coordinator calls the RRT. Posters in every patient room and appropriate public areas explain the process.
Spanish Language Interpreter Caring for all of our patients includes meeting the health care needs of the increasingly diverse communities of Delaware. Because patients are more satisfied with their health care experience when quality language services are available to them, Christiana Care hired a full-time Spanish interpreter in August 2009. Patients can request Spanish interpretation services eight hours a day, Monday through Friday, or use one of 150 convenient dual language phones.
14
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
In February 2010, as part of Christiana Care’s ongoing effort to transform patient safety and satisfaction, the Department of Medicine and the Inpatient Medicine Service Line officially launched the Care Coordination program on 5C, a large general medicine floor at Christiana Hospital. Based on best practices nationwide, the Christiana Care model assigns highly trained and skilled nurses as Patient Care Facilitators (PCFs), responsible for coordinating and communicating care plans to patients and their families. PCFs are available 24/7 as the primary contacts for patients, families and care team members. Each PCF works with 13 to 15 patients from the time they come onto the unit until discharge. PCFs collaborate on each patient’s plan of care with the physician and staff nurses, lead daily interdisciplinary rounds and oversee the transition to post-acute care to ensure appropriate and timely discharge. The result is seamless coordination of care.
IHI Open School Christiana Care has joined the Institute for Healthcare Improvement (IHI) Open School for Health Professions. The IHI Open School is an online curriculum in quality improvement. It offers health care students and professionals access to an online curriculum about health care quality and safety. As an IHI Open School Chapter, Christiana Care is a forum for interested students and health care professionals to interact and help each other become skilled in patient safety and quality improvement. Christiana Care has the highest number of staff in the world who have completed IHI Open School quality and safety curriculum.
Infection Prevention Christiana Care is working aggressively to prevent and control the spread of both hospital and community acquired infections.
• Promotes strategies for recognizing top performers.
Hand washing is the most effective way to stop the spread of infection. A systemwide hand-hygiene initiative requires the use of soap and water or an alcohol based hand gel as a precaution against transmission of harmful organisms.
• Reviews and recommends personal protective supplies and equipment.
The Infection Prevention Committee (IPC), restructured in 2009, improves governance and oversight of the Infection Prevention Program and sets program priorities. The Committee’s primary focus is on increasing transparency and accountability through data sharing and best-practice education. Infection control teams identify and recommend prevention and control measures related to outbreaks of highly resistant organisms, such as Methicillin-resistant Staphylococus aureus (MRSA) and Vancomycinresistant Enterococci. Christiana Care is also participating in a MRSA patient-safety initiative with Quality Insights of Delaware and the Centers for Medicare and Medicaid’s Services. Pharmacists and infectious disease specialists are spearheading an Antimicrobial Stewardship Program to ensure safe use of medications, including antibiotic drugs, with oversight programs and prescription guidelines. Efforts continue to focus on further reducing the incidence of ventilator associated pneumonia (VAP) and catheter associated urinary tract infections (CAUTI) with targeted interventions following updated national guidelines. The IPC spearheads its efforts through task forces including:
Transmission Prevention • Drives our system-wide Hand Hygiene Campaign. • Sponsors guest speakers. • Shares best practices for hand hygiene.
• Creates bilingual isolation signs.
• Monitors compliance data.
Procedures & Devices • Generally focused on surgical site infections, central line-associated bloodstream infections (CLABSI), CAUTI, and VAP-associated pneumonia. • Specifically focused on prevention of CLABSI in intensive care units and non-ICU settings, with the following best-practice recommendations implemented: –
Insertion checklist to monitor sterile technique and hand hygiene.
–
Use of sterile gown, gloves, hat, facemask and eye protection.
–
Continued use of Chlorhexidine (CHG) skin disinfectant.
–
Continued use of large drape.
–
Continued use of antibiotic-impregnated central line catheters.
–
Use of a CHG-impregnated sponge to decrease bacterial load on the skin.
Central Line Insertion Checklist
?Inserted by ?Hand hygiene observed ?Maximum sterile barriers ?Skin prep ?Insertion site Quality & Patient Safety Annual Report
❖
15
Achieving
High Reliability Christiana Care is committed to continually improving our service to our patients. That is why we constantly evaluate our initiatives as they relate to current best practices and national standards. Identified through clinical trials and studies, best practices are evidence-based, effective procedures that evolve through continual testing and measurement to ensure the highest quality, safest and most reliable outcomes for both our patients and the health care system. Best practices rest on the conviction that quality and safety are the products of well-designed processes and systems which, in effect, standardize excellence.
Each of us brings a unique perspective to the table. Hospital nurses, physicians, care managers, “ social workers, pharmacists ... with the entire provider team working collaboratively, we can draw
”
upon our individual and collective experiences to discern what works best for the patient. — Diane Talarek, RN, MA, NE-BC | Chief Nursing Officer
16
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
Inpatient Medicine Part of how we improve the process of care is by looking at how we deliver care as a team. The Department of Medicine is taking a fresh look at operations and clinical care provided by Internal Medicine and Family Medicine physicians for inpatients at Christiana and Wilmington hospitals. The Inpatient Medicine Service Line has enlisted the talents of the entire provider team to identify and develop opportunities to promote superior value, quality and safety by bringing the people who deliver patient care into the problem-solving and decision-making processes. Current projects under development target infection prevention, pneumonia care and the discharge process.
Protocol changes resulting from a cardiac surgery team initiative in 2005 reduced the need for transfusions and lowered both mortality and infection rates. During the following three years, the number and volume of blood transfusions during Cardiac Artery Bypass Graphing (CABG) and valve-replacement surgery dropped dramatically. In a study tracking 2,100 CABG patients treated at Christiana Care, the in-hospital mortality rate declined to 1.4 percent in 2008, down from 1.7 percent in 2006. The external wound infection rate fell to zero in 2008, compared with 0.5 percent in 2006. CABG patients also spent less time in the hospital. In 2008, 67 percent of patients went home in less than six days, compared to 50 percent in 2006.
Improving Heart Surgery Outcomes Cardiac patients at Christiana Care are experiencing better post-surgical outcomes, thanks to hospital efforts to reduce blood transfusions during coronary artery bypass grafts, valve replacements and other heart surgeries. Even though blood transfusions can save lives— and may be necessary for some patients—research shows they also may boost a patient’s risk of developing inflammation, lung infections or other infections such as hepatitis or HIV. A growing body of data also shows that cardiac surgery patients who do not receive a transfusion tend to rebound more quickly and leave the hospital sooner following surgery than patients who receive a transfusion.
Intraoperative-Postoperative Blood Product Use
Percentage of Short-Stay Patients Discharged within 6 Days after Surgery
Quality & Patient Safety Annual Report
❖
17
Improving Patient Flow and Throughput in the Emergency Department To ensure that the rapidly growing number of patients in the Emergency Department does not compromise patient safety and quality of care, Christiana Care is implementing a number of changes to reduce bottlenecks and improve efficiency.
Expediting patient transfers
Spinal Anesthesia Project As baby boomers line up in increasing numbers at Christiana Care’s Center for Advanced Joint Replacement for new knees and hips, a change in anesthesia protocols has significantly decreased their wait times. Ingenuity aided by advances in electronic monitoring now enables patients to receive anesthesia before entering the operating room. With support from the nursing staff and orthopedic surgeons, the Anesthesia Department has set up a spinal induction room, complete with staff and equipment, to meet the same safety and monitoring standards as the OR. The new protocol shaves minutes of wait time for patients and adds hours of available OR time for the surgeons to accommodate growing caseloads.
Decreased boarding hours lead to better patient outcomes, fewer delays and more productivity.
18
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
In an effort to reduce Emergency Department overcrowding, Christiana Care’s Clinical Decision Unit (CDU) initiated a new “pull system” to expedite patient transfers. The CDU provides ongoing observation, testing and treatment, up to 24 hours, for emergency care patients who do not require inpatient admission to the hospital. Collaboration between ED and CDU teams helped to identify and eliminate barriers to timely patient transfers using a system that monitors demand over time and makes a bed ready so a patient in the ED can be moved (“pulled” by the CDU charge nurse) as soon as the demand occurs. The result—a significant drop in the number of patients awaiting beds in the ED with a corresponding decrease in average ED “boarding” hours to well under one hour. Decreased boarding hours lead to better patient outcomes, fewer delays and more productivity, fewer patients who leave without treatment, greater patient satisfaction and improved fiscal management. CDU: Emergency Department Boarding
CDU infusion services
Faster CT scans
Christiana Care’s Clinical Decision Unit (CDU) now provides expanded outpatient infusion services at Christiana Hospital. The CDU, located down the hall from the Ambulatory Infusion Center, offers extended hours and the comfort of a bed for patients who have trouble sitting in a chair or recliner and, due to their conditions, require longer treatment sessions.
The Emergency Department has shortened turnaround times for CT scans, minimizing wait times for patients and reducing average ED length of stay. The SPEED team (Synchronous Provider Evaluation in the Emergency Department) introduced several improvements, including:
All types of medications (except chemotherapy) are available at the CDU infusion center under the supervision of a registered nurse. The center is open from 8 a.m. to 10 p.m., seven days a week. The new CDU infusion center minimizes wait time for lifesaving infusions and offers patients consistency of care by a dedicated team of infusion specialists. Access to the center reduces length of stay for infusion patients and relieves ED overcrowding by eliminating the need for infusion beds in the main hospital or the surgical and procedure unit that would otherwise be available for inpatients.
• Using escort teams for more rapid patent transport. • Documenting labs on PowerChart for easy retrieval by CT technologists. • Streamlining patient preparation and order entry. • Expediting the reporting process to enable radiologists to generate and send a final report to ED physicians in under one hour. These improvements facilitated a 12-percent decrease in scanning times and 35-percent faster read times for final reports.
MICU Express Patients who come to the Emergency Department requiring medical intensive care can be transported immediately with MICU Express. For patients who qualify— for example, those with gastrointestinal bleeding, serious diabetic reaction or who are intubated without surgery—MICU Express can shorten ED wait times by as much as two hours. Those patients go directly to the MICU for evaluation by the resident on duty. As the number of patients seeking treatment in the ED continues to increase, potentially hundreds of hours will be saved by MICU Express in the process of evaluating and administering lifesaving care.
Quality & Patient Safety Annual Report
❖
19
Achieving Competency Today (ACT) This 12-week, award-winning graduate level course teaches quality and team skills, while teams develop projects that promote interdisciplinary interaction. Christiana Care won the 2010 Alliance of Independent Academic Medical Centers Innovation Award for creative approaches to medical education and research, such as ACT, which result in better patient outcomes. In a collaborative process guided by a trained facilitator, interdisciplinary teams of physicians, residents, nurses, pharmacists, other health professionals and executives: • Identify practice-based problems. • Develop consensus to select a team project. • Work together to design and test a solution. Participants practice and improve interdisciplinary team skills as they learn to investigate and evaluate patient-care practices and use research-based evidence to improve them. So far, 180 people have taken the class. Since the course began in 2004, nearly 30 teams have completed quality and safety improvement projects, many now integrated into Christiana Care’s daily operations. Recent projects include: • Developing of a Pediatric Rapid Response Team. • Improving patient confidence regarding discharge medication instructions. • Smoothing transitions from the ED to primary care. One of the projects—My Tissue, My Result, My Expectation, which sets out a new OR protocol to reduce error and delay in lab processing and test results—was integrated into the World Health Organization’s Surgical Safety Checklist, used in all ORs as of September 2009.
New procedures and a new MRI unit shortened the process from 13 to eight hours—a 40 % improvement.
20
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
SWAT
Preventing Deep Vein Blood Clots
At Wilmington Hospital, the Synchronized Wilmington Admissions Team, known as SWAT, focuses on increasing coordination. The team’s goal is to improve the patient stay and outcomes by initiating orders, care plans and the discharge process at the time of admission. Preliminary results of the SWAT program are strong. They demonstrate a 30-percent reduction in inpatient length of stay compared to non-SWAT patients admitted to the teaching service, appropriate assignment of patient status (either inpatient or observation) at the time of admission, decreased Rapid Response Team calls after admission, and improved compliance with CMS quality indicators for heart failure and pneumonia. In addition, the program has not increased boarding hours even though SWAT typically evaluates the patient in the emergency room.
An interdisciplinary team of physicians, nurses, clinical pharmacists, and quality and patient safety staff focuses on preventing venothromboembolism (VTE) among at-risk hospitalized patients.
MRI: Improved Safety and Efficiency Christiana Care’s commitment to performance improvement has reduced inpatient wait times for Magnetic Resonance Imaging (MRI) and reduced length of stay. New procedures and a new MRI unit shortened the process from 13 to eight hours— a 40-percent improvement. Nursing, Radiology and Operational Excellence joined forces to improve communication and ensure appropriate handoffs—using the Round Trip Ticket— so important information stays with the patient. They streamlined physician MRI orders and safety checklists through PowerChart and instituted standing orders for X-rays. MRIs are used to obtain detailed images of organs and tissues throughout the body using a powerful magnetic field to create images. These magnetic fields can pose a possible risk of injury to patients and staff since the magnets can cause ironcontaining objects, such as pacemakers and implants, to move with great force. A comprehensive safety screening is required to keep patients and staff safe. Patient safety screening shifted to the MRI department to save time and avoid misinterpretations. Teamwork transformed the whole MRI process, eliminating backlogs and improving patient satisfaction and safety.
Highlights of the team accomplishments include: • A standardized surgical VTE prophylaxis protocol initiated by the physician pre-operatively implemented. • Evidenced-based CPOE order sets implemented. • Daily VTE prophylaxis reports produced for each nursing unit and used during the daily, unit-based clinical rounds. • Data-driven improvements in identification of blood clots present on admission. • Clinical documentation and post-discharge coding of deep vein thrombosis (blood clots).
Health Initiatives - Electronic Health Records Implemented at Therapy Sites Physical Therapy Plus Electronic Health Records (EHR) will improve the patient experience at all Physical Therapy Plus locations. The first pilot site went live in December 2009, with the other eight locations soon to follow for full implementation by the end of the fiscal year, in July 2010.
Occupational Health Services EHRs are up and running at all three Occupational Health Services sites. Use of an EHR provides a consistent and legible manner for treatment documentation. Clinicians have information they need from previous treatments, including medical history and precautions, ultimately providing safer, more consistent and effective treatment for patients.
Quality & Patient Safety Annual Report
❖
21
The GetWell Network The GetWell Network, a bedside communication tool directly involving patients in their own care, puts Christiana Care at the forefront of using innovative technology to improve patient satisfaction and safety, quality outcomes and compliance and nursing efficiency.
Improved medication safety Patients now can view their medications online during their hospital stay with the GetWell Network’s Medication Integration feature on PowerChart. The network alerts patients to view their “My Medication” list whenever new medications are prescribed or any are discontinued. Automatic documentation helps nurses monitor when patients view their medications, enhancing education effectiveness. Planned network upgrades include:
GetWell Network improved outcomes Christiana Care is one of three sites in the nation to implement GetWell Network’s Heart Failure Interactive Care Plan (HFICP), following a successful one-year pilot study of the technology at the 282-bed Sentara Virginia Beach General Hospital. Results from the study show remarkable improvement in outcomes from 2007 to 2008:
13% reduction in length of stay. 74% reduction in the rate of readmission 30 days. after discharge.
43% improvement in patient satisfaction metrics. Heart failure is one of the most common and growing reasons for hospitalization and requires the involvement of patients in managing their chronic conditions. GetWell Network’s HFICP engages patients and their families early in the process—with outstanding results.
22
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
• Automated white boards for patients to monitor who is on staff and what their care plan is for the day. • Cameras for viewing patients in the NICU and ICU. • Discharge planning protocols. • Enhanced, easy-view computer screens for geriatric patients.
Visiting Nurse Association The Visiting Nurse Association (VNA) is a leader in caring for our neighbors where they feel most comfortable: At home. VNA offers a comprehensive selection of services and coordinates home health care needs, including nursing and specialty care services, adult day care programs and rehabilitative services. Here are some examples.
High-tech wound care New digital imaging enables VNA nurses and wound specialists to treat wounds more effectively and efficiently. The Wound Advisor allows VNA nurses to send photos of a patient’s wound to VNA headquarters, where one of the agency’s four wound-care specialists can evaluate the patient’s progress quickly, without having to visit the patient. Because the agency treats about 1,000 wound-care patients across the state each year, making in-home visits has posed a challenge for the four wound-care specialists. By eliminating the time involved in home visits, the new system enables the wound-care specialists to notify a patient’s physician immediately if a wound is not healing as it should. The physician can then change the course of treatment more quickly.
of qualified nurses has led to significant discharge delays from acute care settings for these patients. VNA’s new program—which offers classroom training and an assigned preceptor for each student, annual competency labs and ongoing support from a supervisor, clinical coordinator, case management and office staff—increased the number of qualified private duty nurses by 28 percent, with 76 newly hired nurses from July 2007 to July 2009.
Home telemonitoring project for heart failure patients The VNA is helping reduce costly hospital readmissions and improve outcomes for heart failure patients through home telemonitoring technology. Analysis shows 40 percent of heart failure patients incur 60 percent of the costs associated with multiple inpatient stays and emergency department visits. The VNA pilot study tracked complications among discharged heart failure patients. Through daily blood pressure, pulse and weight readings transmitted by phone to a VNA nurse, VNA provided necessary interventions to prevent hospital readmissions.
From novice to expert nurse VNA nurses developed an orientation and continuing education program to prepare private duty nurses to provide quality care for medically complex patients. Typically, these patients are youngsters, under age 21 and ventilator dependent, who require between eight and 16 hours of skilled service every day. VNA’s private duty nurses have provided care throughout Delaware since 1988. However, a shortage
Home telemonitoring patients experienced fewer hospital readmissions and fewer ED visits, with cost reductions of 85 percent and 73 percent, respectively. Patients also reported decreased symptoms of anxiety and depression at discharge and a high sense of satisfaction with the monitoring program. Plans call for enrolling more patients in home telemonitoring and a support group.
This partnership serves as a model to bridge “ different industries, mitigate unnecessary health care expenditure and improve quality of life.
”
— Rhonda Combs, MSN, RNC, C.O.O. Christiana Care VNA
Quality & Patient Safety Annual Report
❖
23
Leveraging
Technology
A high reliability strategy is a strategy to design systems that do not rely solely on human performance. Leading-edge technology at Christiana Care undergirds every quality and safety initiative. ◆ Speeding diagnoses and effective treatment plans through split-second communication. ◆ Connecting large health care systems to remote rural practices. ◆ Standardizing forms and medication processes. ◆ Ensuring correct and accessible patient information. ◆ Analyzing systems to pinpoint opportunities for improvement. ◆ Tracking people, supplies and equipment. ◆ Enhancing training. ◆ Facilitating testing and measurement—so vital to developing and maintaining best practices.
High tech should never obviate the need for critical thinking. Rather, it should infuse critical thinking through every process and at every juncture by every individual in our health system. 24
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
Medication Safety With barcoded wristbands, the Electronic Medication Administration Record (EMAR) and Computerized Physician Order Entry (CPOE), Christiana Care is transforming its care delivery process—increasing efficiency and taking a proactive approach to preventing medication errors. The wristband-EMAR-CPOE loop ensures the “five rights” of medication safety:
Right patient Right medication Right time Right dose Right route
Barcoded wrist bands Step one in preventing medication errors is to correctly identify the patient. Barcoded wristbands, which contain key patient identifiers such as name and date of birth, eliminate patient identification errors. Each patient receives a barcoded wristband upon admission to the hospital. Nurses scan the wristband to confirm the patient’s identity and match it to orders and prescriptions before dispensing blood, administering lab tests, collecting specimens or administering medications.
EMAR and barcoded medication administration One of Christiana Care’s major patient safety initiatives is the successful implementation of EMAR—a powerful tool that helps prevent medication errors. Using a wireless handheld scanner, screen and keyboard, a nurse scans the patient’s wristband at bedside to identify the patient in the system. When a list of medications ordered for the patient appears, the nurse scans the medication barcode on the medication on cart. To ensure accuracy, EMAR software matches the medication, the dosage and the route against the medications list. If the medication, dosage or route does not match, or if the patient is allergic to the medication, the handheld device issues a safety alert. Beyond ensuring accuracy in administering medications, EMAR also facilitates double verification of high-risk medications and improves medication-related documentation, such as vital signs and pain reassessments.
Barcoded wristbands, which contain key patient identifiers such as name and date of birth, eliminate patient identification errors.
Quality & Patient Safety Annual Report
❖
25
Computerized Physician Order Entry
Engaging community physicians
In late March, Christiana Care joined an elite group of hospitals—only 3.7 percent nationwide— by implementing Computer Physician Order Entry (CPOE) at both Wilmington and Christiana hospitals. CPOE—a generic name for software that physicians use to write orders for patients— is a major step toward the completion of our state-of-the-science paperless medical record.
Community physicians who collaborated for 18 months to develop our order sets contributed to a successful launch. Order sets (based on diagnosis or admission condition) enable physicians to enter orders quickly and see the best evidence-based order choice. Following a rigorous approval process, more than 300 order sets now exist for Anesthesia, Medicine, Surgery, Psychiatry, Pharmacy, Rehabilitation and Emergency Medicine.
Because CPOE introduces supportive technology for doctors orders, it can transform how we deliver care and dramatically improve safety. CPOE provides opportunities to: • Streamline practice standards. • Incorporate clinical decision support into daily practice. • Improve interdepartmental communication.
Perhaps the single most transformative feature of CPOE is that it provides a single, mutually shared platform from which the prescriber, the nurse and the pharmacist can work. Since our CPOE journey began three years ago, close to 3,000 physicians and nurses have completed web-based and classroom training. Today, 778 physicians are using the system regularly. Many departments report 100-percent system CPOE participation.
• Facilitate patient transfers. • Capture data for management, research and quality monitoring. CPOE introduces
Studies show CPOE can prevent more than half of all serious medication errors and adverse drug events. These errors include incorrect choice or dose of medication for the patient’s condition or physiologic state or allergies. CPOE potentially can significantly reduce costs associated with additional breaches in safety and quality. Standard CPOE modules encourage best practices for use of pain medications, anti-emetics, laxatives, DVT prophylaxis, stress ulcer prophylaxis, smoking cessation medications and hypnotics. CPOE facilitates antibiotic stewardship, since antibiotics orders are reviewed by our Pharmacy and Infectious Disease specialists. By allowing for real-time patient identification, drug dose recommendations and adverse drug reaction reviews, these clinical-decision support tools reduce opportunities for medical errors, ambiguity and incomplete orders. Early results following CPOE implementation indicate duplications in drug orders fell 60 percent.
26
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
supportive technology for doctors orders. It can transform how we deliver care and dramatically improve safety.
One example of the positive impact of CPOE is the change in hydromorphone (Dilaudid) prescribing patterns. Christiana Care has consistently educated providers about the potency of this narcotic. Now, with CPOE, we have mechanisms to hard-wire recommended dosing into everyday practice.
Mother’s Own Milk Bank System (MOMS)®
The Pharmacy & Therapeutics Committee and CPOE Project Team worked together to build best practice medicine into CPOE.
The Level 3 Neonatal Intensive Care Unit at Christiana Hospital specializes in providing the highest standards of care for newborns. Part of that care includes feeding them their mothers’ expressed breast milk, which is stored onsite.
Design tools included: • Use of a standardized pain module throughout PowerPlans. • Pre-built order sentences. • Custom decision support alerts to remind prescribers of suggested starting doses in opioid naïve and elderly patients. Post-CPOE implementation, 99 percent of hydromorphone orders for elderly patients fall within the recommended dosing range. This improvement in prescribing has translated into a reduction in adverse events. Since CPOE go-live, no moderate or severe hydromorphone-related adverse events have been reported.
Christiana Care continues to strengthen our electronic safety net to protect all of our patients— especially the tiniest and most vulnerable.
The Mother’s Own Milk Bank (MOMS) System ensures that the right milk is given to the right newborn at every feeding. Wireless bar-coding technology recognizes a unique identifier assigned to every element (mothers, babies, bottles, inventory bins and caregivers) and uses the same type of cross matching used in blood banks to ensure safeguards cannot be circumvented. The system has the ability to track prepared, stored and expired milk. With MOMS®, milk management in the NICU is safe, efficient and accurate.
ExitCare ExitCare is online in the Emergency Department at both Christiana and Wilmington hospitals to provide discharged patients with important information they need when leaving the hospital. The software links to Christiana Care’s existing EDTracker™ system, which monitors the real-time location of each patient in the ED from admission to discharge. ExitCare enhances patient communication at discharge and eases the transition from hospital to home or other care setting by providing clearly documented prescriptions and instructions for care at home, as well as instructions on how to followup with other physicians.
Quality & Patient Safety Annual Report
❖
27
A Look to the
Future
As we look forward to the next fiscal year, we are beginning to introduce value and cost into our Quality and Patient Safety programming. Quality and Patient Safety, long at the forefront of national and local health reform discussions, are becoming even more of a central concern. We know that by delivering high-quality, safe care, we will actually reduce the cost of care. We have identified several high-volume populations and created interdisciplinary teams to look at the quality of care delivered as well as the cost and utilization of services. Armed with comparative data, these teams will identify opportunities for improving resource management, standardization and outcomes. We will also show the financial impact of not delivering “perfect care.” Costs
28
❖
C H R I S T I A N A CA R E H E A LT H S Y S T E M
associated with hospital-acquired infections, complications and adverse events have been quantified and will be reported as we strive to eliminate harm to our patients. Targeting system vulnerabilities which cause harm to patients, our Quality and Patient Safety Program’s systems approach reflects best practices from high-reliability organizations (HROs), such as the airline or nuclear power plant industries. The goal of high-reliability thinking is to create a culture and processes that radically reduce system failures and apply effective responses when failures occur. To ensure we continue our mission of preventing harm, we will persist in our efforts to identify opportunities for improvement and design good systems to enable optimum, safe performance. These efforts will set our agenda as we move forward with safer, better quality care.
Creating a Safe Culture. Next year, our efforts will focus on advancing the transformation of our culture through implementation of a standard system for shared responsibility. To keep our patients safe, Christiana Care will integrate “Culture of Responsibility” principles that emphasize both system and individual responsibility. The focus of our work is based upon four cornerstones: • Advance our learning culture. • Promote an open and responsible culture. • Design and implement safer systems. • Manage behavioral choices.
Achieving High Reliability. By integrating highreliability practices in our care-delivery processes, we are making patient care safer, better and more efficient. We will expand the use of one such highreliability practice—human factors engineering— to design safer systems of care that protect patients from human error. These tools have helped us further analyze adverse events and develop more effective improvements. We will be expanding the use of human factors analysis in our work this fiscal year.
Leveraging Technology. Implementing wrist barcoding at the point of care, the Electronic Medical Administration Record (EMAR), and Computer Physician Order Entry (CPOE) this year has enabled us to close the loop in the medication cycle, with all steps computerized and checked for accuracy. These transformational projects greatly decrease the possibility of medication errors, enhance clinical decision making and improve efficiency. Next year, the next step in automation is applying decision-support software to aid our clinicians in caring for our patients. Decision-support software helps our care providers quickly verify evidencebased courses of treatment and appropriate medications, as well as potential drug interactions and other issues that may adversely affect a patient. Interactive decision-support software supports just-in-time learning, assists in compiling useful information to identify and solve problems, and helps determine sound clinical decisions.
.
James Newman, M.D., FACP | Chief Medical Officer Patient Safety Officer
Sharon Anderson, R.N., M.S., FACHE | Senior Vice President Quality and Patient Safety
Quality & Patient Safety Annual Report
❖
29
P.O. Box 1668 Wilmington, Delaware 19899-1668 800-693-CARE (2273)
www.christianacare.org
Christiana Care is a private, not-for-profit regional health care provider and relies in part on the generosity of individuals, foundations and corporations to fulfill its mission. 10PERF9