Q report spring 2017

Spring 2017

PATIENTS IN PARALLEL WORLDS When teams from throughout our organization share resources and improvement efforts, patients — whether on two legs or four — benefit.

WORKING TOGETHER TO ENHANCE QUALITY AND OUR PATIENTS’ EXPERIENCE

At UF Health, our patients are at the heart of everything we do. We strive to create the best possible experience for everyone who seeks our care. Feedback from patients and their families is one way we gain insight about what we’re doing well and how we can improve our service. Here are a few comments from patients who received care at UF Health Shands. We hope these words will inspire and encourage

Contents: 1 Quality Notes 2 Quality Leader 4 Cover Story

8 EEPC Team Spotlight 10 Innovation

12 Great Catch

everyone in the UF Health family. Remember, you can make a positive impact with every encounter.

From our patients "I would like to thank the nurses, ancillary staff, attending doctors, residents and interns at

The Q Report is the quarterly newsletter of the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety. It features the latest news and initiatives related to quality and improving the patient experience at UF Health. Please email story ideas and comments to Greg Hamilton, UF Health Communications, at gregoryhamilton@ufl.edu.

University of Florida Health for their competent care, knowledge and professionalism.”

Q Report Advisory Committee: Kim Rose, Scott Brown, Chris Cassisi, Laura Castro, Greg Hamilton, Carolyn Holland, Susan Keating, Debbie Lynn, Cristin Owens, Deborah Robins, Michelle Robinson, Amy Rosenberg, Anzeela Schentrup, Douglas Bennett, Irene Alexaitis, Anna Michelle Brandt, Dave Hudson, Kevin Johnson, Diana Richardson

DIRECTOR, STRATEGIC COMMUNICATIONS UF HEALTH COMMUNICATIONS

Kim Rose EDITOR

Greg Hamilton EDITORIAL ASSISTANT

Laura Castro

“We cannot say enough about the quality of care of the different teams that participated in my husband’s care. Everyone worked as a team.”

DESIGNER

Mary Cecelia

“In the E.R., the doctors could not have been more

caring and considerate. They were professional yet comforting and I had complete confidence in what they did and recommended.” qreport.health.ufl.edu

Quality In theNotes Q

Quality Notes WHO WILL SPEAK FOR YOU? In the event of an emergency, who will make health-related decisions for you?

Everyone 18 and older is encouraged to complete an advance directive. This care planning process includes designating a health care surrogate who will speak on your behalf if the need arises, and the completion of a living will.

In honor of National Healthcare Decisions Day in April, we encourage you to complete an advance directive to help you plan for unforeseen medical circumstances and endof-life care.

Visit UFHealth.org/advance-directives for more information.

CELEBRATING SAFE, HIGH-QUALITY CARE Each year, UF Health faculty, staff and students gather to celebrate Patient Safety and Quality Week, presented by the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety. This year’s celebrations will take place March 13-17.

The week is full of fun activities and events that highlight our dedication to quality care and celebrate the progress we’re making.

Join us!

• Tuesday and Wednesday, March 13 and 14: UF Health Shands Hospital Atrium for games and activities • Wednesday, March 14: Keynote speaker Mike Abrashoff, a New York Times best-selling author • Thursday, March 15: Collaborative project poster showcase • All week: Guided, behind-the-scenes tours Look for dates and details on posters and fliers throughout our facilities.

UF HEALTH CANCER NETWORK EARNS NATIONAL ACCREDITATION FOR QUALITY CARE The UF Health Cancer Network, comprising UF Health and the UF Health Cancer Center at Orlando Health, has received a three-year accreditation with commendation by the Commission on Cancer, a quality program of the American College of Surgeons.

The UF Health Cancer Network is one of seven facilities in Florida to have achieved accreditation in the Integrated Network Cancer Program category from the Commission on Cancer, which is given to cancer programs that meet or exceed the organization’s 34 quality care standards.

These standards are evaluated through a survey process and accredited facilities must maintain levels of excellence in the delivery of comprehensive patient-centered care.

The UF Health Cancer Network has also achieved the three-year accreditation with commendation, which is awarded to facilities that exceed standard requirements at the time of the survey.

C L E A R I N G

T H E

C L U T T E R

Revised after-visit summary streamlines discharge instructions for patients

A

—KARIN LILLIS

UF Health Shands In the new template, quality-improvement information and instructions initiative aims to simplify deemed most important by discharge instructions that the care team — such as the patients receive before they leave reason for admission, specific the hospital. instructions, phone numbers “If patients don’t understand and medications — are now on the discharge process, there is the first page of the AVS. If a a higher chance of readmission patient has a specific disease or to the hospital,’’ said Juan Mira, disorder, additional information M.D., a UF College of Medicine and instructions print out with department of surgery surgical the AVS. research resident. Mira played a “The AVS needed to be more lead role on a multidisciplinary personal so the patients felt like Juan Mira, M.D., a UF College of committee that revised the afterwe were really talking with them Medicine department of surgery surgical research resident visit summary, or AVS, for surgical and not just giving them a stack and medical patients. of paper,” said Cassie Marcelle, R.N., RN-BC, the UF The new AVS, introduced about a year ago, is Health Shands Nursing and Patient Service Nursing designed to provide patients with information Informatics administrative director. about their stay or surgical procedure, how to care Revising the AVS also emphasized the importance for themselves after discharge and who to call of medication reconciliation from patient admission if there are questions or problems. The AVS also through discharge, said Ben Staley, Pharm.D., BCPS, includes information mandated by the U.S. Centers a UF Health Shands Clinical Pharmacy Services for Medicare and Medicaid Services on topics clinical specialist in quality improvement and clinical including smoking cessation, heart attack, stroke decision support. awareness and suicide prevention.

Additionally, UF Health’s medical interpreters The project involved input and coordination identified errors in the lengthy AVS and brought from nurses, case managers, medical interpreters potential patient safety concerns to the team that and physicians. they had found when translating the documents While the previous AVS provided most of the into Spanish, said Anne Meiring, LCSW, CPXP, a necessary information, follow-up appointments UF Health Sebastian Ferrero Office of Clinical and important phone numbers were hard to Quality and Patient Safety patient experience and find. Instructions for self-care were buried in the language-access improvement specialist. document, and a significant amount of information Mira said the new AVS is available for all — including medication lists — was redundant. discharges. He is currently working with residents “We were getting a number of complaints from from other disciplines to improve instructions for patients and nurses,” said Rhea Broyles, R.N., medical patients. a UF Health Sebastian Ferrero Office of Clinical Clinicians with questions about the AVS can call Quality and Patient Safety senior quality the EPIC help desk at 352-265-0526. There is also a improvement specialist. tip sheet available on how to fill out the AVS.

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Quality Leader

“If patients don’t understand the discharge process, there is a higher chance of readmission to the hospital."

— Juan Mira, M.D.

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Clinicians with questions about the AVS can call the EPIC help desk at 352-265-0526

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PATIENTS IN PARALLEL WORLDS When teams from throughout our organization share resources and improvement efforts, patients — whether on two legs or four — benefit.

— L AU R A C A S T RO

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Cover Story

T

he worlds of human and animal medicine are indelibly intertwined.

While the procedures, equipment and roles are comparable, the similarities between the two disciplines are far more profound. Health care experts who care for species characterized by fur, feathers and scales experience the same pressures, face the same complications and work with the same marked purpose as providers who treat humans: To provide the best care for their patients.

Though collaboration between the two fields has strengthened in the past decade, the transfer of best practices and processes is still fairly isolated. At UF Health, interdisciplinary teams are looking past the difference between snout and nose, flippers and feet, to learn from each other how to continually improve quality care.

In the past year and a half, the UF College of Veterinary Medicine became the first veterinary health system to implement a series of standardized quality improvement initiatives previously alien to the field of animal medicine. With invaluable, step-by-step guidance from faculty and staff working in the human medicine arena of our organization, the

college is pioneering a new standard of safety reporting.

Getting started Patient safety reporting is a mainstay in human medicine. It is used at UF Health Shands and UF Health Physicians outpatient practices and was recently implemented in the UF College of Dentistry. In veterinary medicine, however, standardized reporting systems are virtually nonexistent.

A little over a year ago, leadership from the UF College of Veterinary Medicine and UF Health Shands set out to adapt best practices from the world of human medicine to enhance care for thousands of animals treated at UF Health’s small and large animal hospitals.

While safe, excellent care is a foremost priority, quality advances tend to be made at individual team levels and their reach across the discipline is limited. This may be because veterinary medicine traditionally has fewer state and federally mandated regulations about reporting. The Joint Commission and legislation in many states requires adverse event reporting in human medicine, but veterinary medicine has yet to implement such guidelines.

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"We modeled it off of our system for human patients, then changed it to fit their needs."

—

Linda Allen, UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety’s Quality Systems director

“There’s not much in veterinary literature about outcome-oriented process improvements,” said Chris Sanchez, D.V.M, Ph.D., UF Large Animal Hospital medical director and an associate professor of large animal medicine. “The culture of identification and discussion in an organized fashion, with a system in place to report and track, is far behind. It just hasn’t been talked about much until now.”

UF Health uses a reporting system called IDinc that collects and aggregates details about safety events submitted by staff. The system is also used to report patient grievances, peer reviews and potential safety events. This helps identify underlying factors that cause errors and it mitigates future risk to patients through process improvement efforts.

“Information is power,” said Linda Allen, UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety Quality Systems director. “The more

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we understand, the better we can help facilitate making improvements.”

Since a reporting system for the veterinary college was the first of its kind, Allen had to take a system suited to the human medicine world and customize it entirely. Simple things, like species, needed to be added. And when a patient’s name was displayed, Allen made sure the corresponding owner’s name also showed up.

“We modeled it off of our system for human patients, then changed it to fit their needs,” Allen said. “We told them what worked for us and why, then we were open to their environment and how it may or may not apply.”

It took six months to get it just right. But now they faced the biggest challenge — convincing staff that the system wasn’t a way of punishing individuals for mistakes, but of improving systems.

Sanchez and Gareth Buckley, D.V.M.,UF Small Animal Hospital medical director and a clinical assistant professor for emergency medicine and critical care, became champions for the system. They visited every clinical area of the Small Animal Hospital and the Large Animal Hospital to introduce the new system and address staff concerns. They explained what they planned to do with the information and spoke about the benefits to patient safety and care.

“People were naturally a little bit nervous that this would be a way of punishing people who make mistakes, but I think we’ve dispelled that myth,” said Buckley. “Our staff understands that it’s all about looking at what we’re doing to always offer the best clinical service and asking ourselves if we can do better.”

When the system launched, Sanchez and Buckley developed a core safety team with Dana Zimmel, D.V.M., UF College of Veterinary Medicine chief medical officer and associate dean for clinical services, and

Megan Eide, Pharm.D., the UF College of Veterinary Medicine pharmacy manager.

The team met for weekly huddles to discuss safety events and figure out ways to prevent them from happening again.

They added a permanent agenda item to the quarterly hospital assembly to discuss the reports being generated and what steps they were taking as a result. Monthly meetings with service area leaders also helped to disseminate information, and regular gatherings with smaller groups helped address concerns and garner feedback.

As staff became familiar with the system and saw improvements develop from their work, a shift in perspective became apparent.

Cover Story

A culture change

Linda Allen, UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety Quality Systems director, along with risk management experts, helped the UF College of Veterinary Medicine establish a patient safety reporting system and analyze data.

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We’re all just trying to answer

Gareth Buckley, D.V.M., UF Small Animal Hospital medical director and a clinical assistant professor for emergency medicine and critical care, championed the new quality initiatives.

“It’s very encouraging,” said Sanchez.

“They feel substantially empowered and like someone is listening to them. They’re part of the team.”

Kelly Higgs-Rick, L.V.T., the UF Large Animal Hospital internal medicine manager, said that when the system first launched, her staff would call her every time they logged a report. Now, they’re inputting information independently. It was a turning point, Higgs-Rick said.

“They have always been patient safety advocates as individuals, but now they see these broad initiatives and real changes that are coming out of it,” she said. “They get to have a voice at the table. That’s really critical.”

Changes across the continuum of care As Allen and risk managers from the quality department helped the team analyze data from incoming reports, they focused on several areas of opportunity.

EEPC TEAM SPOTLIGHT

Imaging

GOAL Decrease unnecessary use of portable chest X-rays and develop a process for improving other areas of overutilization.

Team’s efforts lead to improved efficiency and quality care More than 250 executive leaders, managers and frontline staff are working together to address key quality and patient experience measures at UF Health. The Efficiency, Effectiveness and PatientCenteredness initiative, which launched about a year ago, is composed of 14 interdisciplinary work groups assigned to improve factors that affect the patient experience and length of stay.

Here, we highlight one of the teams. To learn more about the initiative, read the Fall 2016 edition of The Q Report online: qreport.health.ufl.edu.

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TEAM

Imaging

—

Cover Story

the same question — how do we improve care for our patients?”

Gareth Buckley, D.V.M., UF Small Animal Hospital medical director

Small changes have already led to substantive improvements.

For example, the reports revealed issues with patient identification at the small animal hospital. Staff had to fill out patient identification bands by hand, which caused legibility issues. The information on the bands, which fit around the neck of each animal, was also occasionally covered up if the animal was particularly small.

Now, the details are printed in black typeface on a bright orange strip that ensures visibility no matter the size of the patient.

The reports also illuminated the parallels between the human and animal medicine world. As in the human medicine world, the veterinary teams are examining issues like antibiotic use, sepsis recognition, mortality rates and other key quality metrics.

“It was fascinating to see the similarities,” said Buckley. “It’s the same medicine, the same specialists and similar

procedures and turnover of cases. We’re all just trying to answer the same question — how do we improve care for our patients?”

Looking to the future The team continues to work with Allen and other experts from the quality department to understand what triggers safety events. They plan to implement more targeted quality improvement initiatives and engagement activities, and are also attending regular safety meetings at UF Health Shands Hospital. Hearing how similar issues are solved in the human medicine world is helpful and they, in turn, are able to share their perspective.

“I think this is something that will be as important in veterinary medicine in the next 10 years as it is now in human medicine,” Buckley said. “It’s just a matter of how ready you are when the time comes. I think we’ll be very well prepared and at the forefront of it all.”

WHY? Reducing unnecessary X-rays ensures that developed reports are more meaningful and can contribute to better medical decision-making, enhanced patient care and appropriate use of resources.

“I’m enthusiastic. We’ve got a great team

doing a job that probably hasn’t been done in many other places, with a level of expertise that will make it effective.

PROCESS • Analyze current imaging use through IT analytics • Create a management platform to track usage • Educate staff and encourage internal culture change • Use evidence-based guidance to address outliers

Our methodology hopefully will become a global model for addressing other areas of overutilization.”

— Anthony Mancuso, M.D., UF College of Medicine department of radiology chair and a neuroradiology professor

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A I M I N G

F O R

E XC E L L E N C E

Committee tirelessly seeks ways to improve emergency response

W

hen a patient at a UF Health Shands hospital shows signs of cardiopulmonary arrest, sepsis, stroke or another serious condition, an alert process quickly mobilizes a team of physicians, nurses, respiratory therapists and often pharmacists to the bedside.

The goal is a perfectly organized, rapid and thorough emergency response. Analyzing and improving that reaction falls to the Clinical Emergency Response Committee, whose mission is simple: Improve the hospitals’ handling of the most urgent or threatening conditions in adult and pediatric patients. The committee constantly scrutinizes information from medical alert incidents and asks detailed debriefing questions, all with the singular aim of excellence.

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— DOUG BENNETT

“We drill down on all the data that’s collected and respond where we think we need to provide additional resources or make improvements,” said committee chair Brenda Fahy, M.D., UF College of Medicine division of critical care medicine anesthesiology chief and department of anesthesiology professor.

The committee’s efforts have led to a system that electronically documents the work performed during a medical alert. Better documentation leads to more effective responses, Fahy said.

Other changes fostered by the committee since its 2013 inception include having a pharmacist at most Code Blue cardiac arrest cases. That has been particularly helpful in terms of medication compliance, protocols and overall

Innovation

“We drill down on all the data that’s collected and respond where we think we need to provide additional resources or make improvements."

— Brenda Fahy, M.D., UF College of Medicine division of critical care medicine

anesthesiology chief and department of anesthesiology professor

patient support, said Rohit Patel, M.D., a UF College of Medicine department of emergency medicine assistant professor and a committee member who co-chairs the adult subcommittee.

“If there’s a question, the pharmacist is right there to answer it. Their presence has been very supportive,” said Angela Larson, R.N., CCRN, a UF Health Shands critical care clinical nurse specialist and a committee member who cochairs the adult subcommittee.

In pediatrics, the committee’s work has led to the formation of two specialized rapid-response teams, one for newborns and another for all other infants and children. The Neonatal Response Team includes an advanced practitioner, such as a neonatology fellow, as well as a respiratory

therapist. Overall, it has tailored the team’s response to include specialized team members and resources for critically ill neonatal patients, said Leslie Avery, M.D., UF Health Shands Children’s Hospital division of pediatric critical care chief and a UF College of Medicine department of pediatrics associate professor, who chairs the pediatric subcommittee.

While the committee solves big-picture issues, its members also pour over details. Avery said nurses have received additional training that has led to fewer response team alerts for neonatal low-blood sugar cases. The committee also studied the carts that are used for emergency resuscitations. The result: The carts are streamlined but still contain everything that’s needed for pediatric respiratory or adult cardiac resuscitation.

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Each month, the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety recognizes staff members who have made a “Great Catch” to prevent medical errors.

S E P S I S

S H U T D OW N

Quick thinking and action saves patient’s life

W

hat was supposed to be a routine appointment for an outpatient at UF Health Internal Medicine at Tower Hill turned into a test for the clinical care staff. A test for which they were well-prepared.

Beverly Humphreys, C.M.A., a medical assistant, noticed that one of her patients was agitated, with a fever of 101 degrees Fahrenheit and elevated heart and respiratory rates. Humphreys realized something was wrong.

She quickly notified Katherine Huber, M.D., a professor of medicine and the medical director of UF Health Internal Medicine at Tower Hill. After an examination, Huber determined that the patient was experiencing a severe case of sepsis and called in a sepsis alert. The patient was immediately transported to the UF Health Shands E.R., where staff promptly treated the patient and identified the source of infection. A quick referral to UF Health Urology specialists resulted in a life-saving surgery.

“This situation was different because the patient was coming from an outpatient practice, which is not usually where a sepsis alert is started,” Huber said. “The care of sepsis requires a team approach and the patient survived because of the quick

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— CO U R T N E Y G R I G S BY

responses from all of the services involved.”

Because of Humphrey's close attention and action and Huber's quick response, and the help of each team’s dedicated care and adherence to protocol, the patient was saved from a potentially fatal situation.

“Sepsis is a life-threatening condition that arises when the body mounts a massive response to an infection,” said Thomas Payton, M.D., M.B.A., FACEP, the UF College of Medicine department of emergency medicine vice chair for clinical operations and UF Health Shands E.R. medical director. “Our initial goal for a patient identified as having sepsis begins with aggressive fluid resuscitation and giving the patient appropriate antibiotics as soon as possible.”

Huber, who is on the UF Health Shands Board of Directors Executive Quality Committee, said she is familiar with the alert process because information about sepsis is frequently discussed among teams at UF Health.

“One of the keys to this patient’s care was the early notification,” Payton said.

“Within the last few years, our entire health system has renewed its commitment to identifying sepsis to provide the best care as early as possible. In this case, the system worked.”

Great Catch

When Beverly Humphreys, C.M.A., a UF Health Internal Medicine at Tower Hill medical assistant, noticed something was wrong with a patient, she immediately notified Katherine Huber, M.D., the UF Internal Medicine at Tower Hill medical director, who initiated a sepsis alert.

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