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Quality & Patient Safety AN NUAL R EPO RT 2011


President’s message

Guided by “value” Over the past two years, we at Christiana Care have increasingly used the concept of “value” to focus our work. Our concept of value is grounded in the needs of our patients, as they perceive them. It is likewise grounded in a careful scrutiny of the benefits and costs of what we can do to meet our patients’ needs. To focus more formally on the role value plays in our mission, I am pleased to announce the creation of the Christiana Care Value Institute. The Value Institute will formalize our thinking, our work and our learning as an organization committed to “value.” The Institute builds on the strong foundations established by the Christiana Care Center for Outcomes Research, the Office of Quality and Patient Safety and our work in Operational Excellence. A new Center for Health System Design Research will be developed and added. The vision for the Christiana Care Value Institute is to build a healthier Delaware in ways that can be replicated throughout the country. The Institute will enable Christiana Care to develop, implement, and study the benefits of health care delivered to the individuals for whom we care. Better health outcomes and lower costs should be the result of our efforts. This report highlights key FY 2011 initiatives that illustrate the approach we’ve taken to Create a Culture of Safety, Achieve High Reliability and Leverage Technology to help us maintain a steadfast focus on improving Quality & Patient Safety, and ultimately to provide the best, most valuable service and care to our community.

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

In this report Awards, Achievements & Recognition 2 | Creating a Safe Culture 8 | Achieving High Reliability 22 | Leveraging Technology 29 |


Patient safety and quality of care are among our highest priorities.

Focused on Excellence A systemwide Focus on Excellence has become so successfully embedded in the actions and attitudes of our physicians and employees that, today, it truly is part of the Christiana Care culture and what drives each of us to strive for perfection as we care for our patients. The Christiana Care Diamond— one of the most cherished and recognized icons in our health system—best illustrates this concept and serves as a constant reminder of our accomplishments and our drive to deliver excellence, and value, in all that we do. The multiplicity of programs, initiatives, educational opportunities and discussions available at Christiana Care reinforce this cultural focus, and push us to improve continually toward that ultimate goal of perfection. We have learned so much from programs highlighted in this report, such as the Comprehensive Unit-Based Safety Program (CUSP), in which the Intensive Care Unit based teams have decreased central line-associated bloodstream infections by more than 50 percent. This initiative enhances teamwork and collaboration among the frontline staff and demonstrates that harm is, indeed, largely preventable. Using a checklist and having data visible on a real-time basis, these unit-based teams have mitigated safety risks to our most vulnerable patients. We also have discovered the advantages of communication, sharing and learning from each other absent the assignment of blame. Our journey toward a Culture of Responsibility has enabled us to take both individual and collective responsibility to reduce the probability of infections.

Through their proposals and decisions, leaders at the highest levels of our health system repeatedly demonstrate that patient safety and quality of care are among our highest priorities. As we move forward, we continue to build upon this commitment, adding the concept of value to the innovative and creative transformation work we have already accomplished. Driven by our collective Focus on Excellence, we have had a 29 percent reduction in patient harm with an estimated cost impact of $9,135,218.

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AWARDS, ACHIEVEMENTS & RECOGNITIONS

2011

National honors and recognition for our quality and safety leadership initiatives demonstrate the exceptional value we strive to offer those entrusted to our care. Recognition

For the fourth straight year, US News & World Report ranks Christiana Care as one of the nation’s best hospitals. The publication places Christiana Care’s Department of Medicine and Department of Surgery among the top 50 listings in two specialties – Gastroenterology and Urology. Christiana Care is the only hospital in Delaware to make the list this year. Becker’s Hospital Review named Christiana Care one of the 50 best hospitals in America and among the 100 Best Places to Work in Healthcare in 2011. Cleverley + Associates, a leading health care data and consulting services firm, recognized Christiana Hospital as one of the top 100 hospitals for community value in the nation through its 2010 “Community Value Leadership Awards.” Cleverley ranks hospitals based on financial viability and plant reinvestment, hospital cost and charge structure and quality performance. The firm also gave Christiana Hospital Five Stars for placing in the top 20 percent of hospitals nationwide. The Joint Commission continues to recognize Christiana Care Health Services and Visiting Nurse Association with its Gold Seal of Approval based on results of an unannounced on-site review and assessment of the quality and safety of care. This survey validates continuous compliance with nationally developed standards and demonstrates our commitment to the delivery of safe and high-quality care. Our efforts related to this achievement impressed the survey team, who noted our exemplary performance with the National Patient Safety Goals. The goals are guidelines that focus on the highest priority safety and quality practices, such as preventing surgery on the wrong side of the body and reducing medication errors. In addition, Christiana Care maintains the prestigious Gold Seal of Approval from the Joint Commission for Primary Stroke Centers. This honor is the result of a rigorous site visit that demonstrated our health system’s program follows national guidelines and standards that can significantly improve outcomes for stroke patients.

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Best l a t i p s Ho


Christiana Care received three Get With The Guidelines awards from the American Heart Association (AHA) for the treatment of heart attack, heart failure and stroke. The awards for treatment of heart attack and heart failure recognize that Christiana Care reached an aggressive goal of treating patients with 85 percent compliance for at least 24 months to core standard levels of care as outlined by the AHA/American College of Cardiology. The National Cancer Institute’s Cancer and Leukemia Group B clinical research group places Christiana Care’s Community Clinical Oncology Program at the top for recruiting patients for clinical trials for the period May 1, 2009 to April 30, 2010. Christiana Care was fifth overall out of 45 participating organizations. The American Association for Respiratory Care named Christiana Care as one of only 700 hospitals in the national to qualify as a Quality Respiratory Care Recognition Program for 2010. Christiana Care’s Advanced Cardiac Life Support education program received a score of 100 percent and was described as a model training center by the American Heart Association Emergency Cardiovascular Care Program. The Center for Heart & Vascular Health holds the highest national ranking— 3 stars—from The Society of Thoracic Surgeons in its comparison of the quality of heart surgery among hospitals across the country. Only 13.5 percent of hospitals in the Society’s 968-hospital database received the 3-star rating in 2010. The National Committee for Quality Assurance certified the Department of Medicine’s Family Medicine Center, with sites at Foulk Road and the Wilmington Hospital Annex, as the first practice in Delaware named a Physician Practice Connections – Patient-Centered Medical Home. The Family Medicine Center is one of only 2,189 facilities in the nation to achieve the designation for patient-centered, highly coordinated care and use of long-term patient-doctor relationships. Christiana Care’s Kidney Transplant Program has earned the National Kidney Foundation’s Bruce Zakheim, M.D., Memorial Legislative and Advocacy Award for leadership in patient education and support services and in community outreach. Christiana and Wilmington hospitals both enjoy the Partners for Change with Distinction Award from Practice Greenhealth in recognition of Christiana Care’s comprehensive environmental stewardship program and leadership role in both the community and health care sector.

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AWARDS, ACHIEVEMENTS

& RECOGNITIONS

In the Spotlight Nationally

The Helen F. Graham Cancer Center is leading a national colon cancer clinical research trial to determine if the cholesterol lowering drug Crestor® (rosuvastatin)

can prevent new colon tumors from forming after coloncancer surgery. The trial seeks to determine if Crestor can stop the growth of tumor cells by blocking some of the enzymes that affect cell growth. Researchers also hope to determine if Crestor can keep new colon tumors from forming after surgery to remove a patient’s initial colon cancer. The Commission on the Accreditation of Rehabilitation Facilities (CARF) certified the Center for Rehabilitation at Wilmington Hospital Amputation Specialty Program, confirming that the program meets or exceeds more than 400 standards of care.

In the Spotlight Regionally Zohra Ali-Khan Catts joins Delaware Gov. Jack Markell in announcing new laws governing licensing of genetic counselors.

Christiana Care ranks among the top hospitals in the Philadelphia region with a high performance in 12 medical specialties in U.S. News & World Report’s first-ever Best Hospitals metro-area rankings. Christiana Care’s Infant Hearing Assessment Program volunteers received the 2010 Delaware Governor’s Outstanding Volunteer Award.

Delaware’s genetic counselors are among an elite few to hold state licensing thanks to newly passed legislation championed by Zohra Ali-Khan Catts, MS, CGC, of the Helen F. Graham Cancer Center’s Cancer Genetics Program. Ali-Khan Catts and 13 fellow counselors proposed, and helped craft, legislation governing their profession, outlining standards for education, as well as regulations for licensure and penalties for failure to comply. Their proposal also established a Genetic Counseling Council under the Board of Medical Practice. Licensing protects the public by identifying counselors who have appropriate training and expertise in genetic counseling and marks a major step forward in advancing quality and safety in the care provided to our patients.

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For the 15th consecutive year, Christiana Care has been named the top health care provider of choice in Delaware based on a National Research Corporation survey of 200,000 area households. Winning hospitals possess the best doctors, nurses and reputation and provide the best overall quality of care. For the seventh consecutive year, the News Journal named Christiana Care a Top Workplace employer, an honor based on employee surveys from 90 companies in the Delaware region. Only 50 companies made the best place to work list. Christiana Care received special honors from the Philadelphia Chapter of the Gift of Life for being the leading health care facility for transplant donations in the chapter. More than 42 families have donated 100 organs for transplant through Christiana Care.

U.S. Army photo by Heather Graham

A $2.8 million grant from the National Cancer Institute (NCI), is helping the Helen F. Graham Cancer Center expand its community outreach programs, improve health care disparities, leverage information technology to benefit patient safety and enhance survivorship and palliative care, promote smoking cessation among cancer survivors and boost genetics counseling and breast cancer research. Christiana Care is one of 16 NCI-designated Community Cancer Centers selected for this funding.


In the Spotlight at Christiana Care Focus on Excellence Awards Christiana Care’s annual Focus on Excellence Awards formally recognize teams who demonstrate improvement in health care, hospital, safety, business and other processes using the PDCA (Plan-Do-Check-Act) model. The vision, initiative and enterprise so enthusiastically demonstrated by our nurses, physicians, residents, frontline staff, volunteers and management who participate in this competition are a catalyst for continuous performance improvement as we strive to provide greater quality and safety to those who rely on us for their care. The following winners were selected from the 77 outstanding entries from the 2010 competition addressing quality and safety challenges in practically every area of endeavor at Christiana Care.

President’s Award ‘No One Dies Alone’ Clinical Excellence Gold Award Implementation of Medication Management Standards in Nuclear Medicine Clinical Excellence Silver Award The Heart Alert/Heart Code Coverage Program Clinical Excellence Bronze Award Inpatient MRI Screening Process Improvement Safety First Gold Award Know the Plan, Share the Plan: Team Training in Perioperative Services Safety First Silver Award Improved Prescribing and Reduction in Adverse Events Due to Thoughtful CPOE Design Quality and Patient Safety Transformation Award CPOE - A Transformative Leap Operational Improvement Award Computed Tomography (CT) Turnaround Time for Emergency Department Patients

Learning Excellence Award Transformative Quality Improvement Education Think of Yourself As a Patient Award Medication Teaching through Interactive Patient Care Nursing Excellence Gold Award Nursing Vigilance: The Key to Recognizing Compartment Syndrome Nursing Excellence Silver Award March Madness Meets the MICU

Great Place to Work Award SBAR Clinical Web Paging

Residents Award Mind the Gap: Improving Transitions from the ED to the Primary Care Office

Excellence in Community Health Award Partnering with a Managed Care Organization to Improve Heart Failure Outcomes

People’s Choice Award NOURISH: Now Our Understanding Reinforces Improved Senior Health

Financial Strength Award Transformation of HIMS Transcription Services

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AWARDS, ACHIEVEMENTS

& RECOGNITIONS

Sharing

What We Learn

Presenting At the American Cancer Society’s second annual Cancer Center Directors Retreat, Diana DicksonWitmer, M.D., presented “The Importance of the American Cancer Society and the Commission on Cancer Working Together to Increase the Standard of Care in our Communities.”

At the American Academy of Otolaryngology Head & Neck Surgery in Boston, Robert L. Witt, M.D., FACS, was the moderator of “Controversies in the Surgical Management of Parotid Tumors” and presented the instruction course “Update in the Management of Papillary Thyroid Cancer.”

At the Annual Meeting of the Israeli Society of Otolaryngology Head & Neck Surgery in Eilat, Israel, Robert L. Witt, M.D., FACS, presented an instruction course, “The Impact of Molecular Biology on the Surgical Management of Papillary Thyroid Cancer,” and an abstract, “Tissue Engineering an Artificial Salivary Gland: An In Vivo Study.”

Oluwakemi Johnson, M.D., presented “Factors Influencing Acceptance of H1N1 Influenza Vaccine in Pregnancy” at the 48th annual meeting of the Infectious Diseases Society of America in Vancouver.

At the annual American College of Surgeons 96th Clinical Congress in Washington, D.C., Lee Ann Reisenberg, Ph.D., RN, participated in “Improving Patient Safety and Decreasing Error During the Handoff of Surgical Patients.” “Decreased Incidence of Pneumothorax in Very Low Birth Weight Infants Following Increased Monitoring of Tidal Volumes,” was the topic of a presentation by several members of Christiana Care’s Neonatal Intensive Care Unit team at the Vermont Oxford Network Annual Quality Conference in Washington, DC. Edmondo Robinson, M.D., MBA, FACP, assistant medical director of the Medical Group of Christiana Care, presented “Cost-Related Nonadherence in an Employed Population,” at the Robert Wood Johnson Foundation Clinical Scholars National Meeting at Emory University, Atlanta. Omar Khan, M.D., MHS, FAAFP, presented a workshop on mentorship at the annual meeting of the International Association of National Public Health Institutes at the Centers for Disease Control in Atlanta.

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At the 4th World Congress of the International Federation of Head and Neck Oncologic Societies in Seoul, South Korea, Robert L. Witt, M.D., FACS, was a panelist on two programs, “Thyroid Cancer: What’s New?” and “Salivary Gland Cancer.” At the 8th Annual Observation Patient Management Conference in Chicago, Diane C. Bohner, M.D., FACP, presented “Determine the Most Up-to-Date CMS Regulations and How It Impacts Hospital Operations.” Janine Jordan, M.D., presented a poster session on the Synchronized Wilmington Admissions Team at the regional and National Society of General Internal Medicine meetings and participated in a panel discussion at the Association of American Medical Colleges IQ Initiative: Integrating Quality: Linking Clinical and Educational Excellence in the category of Improving Quality and Clinical Performance through Team Training. Terri Corbo, Pharm.D., BCPS, FASHP, presented “Identifying Risks Within Your Organization: Use of Technology Reduction in Hydromorphone Adverse Events Through Education and Technology,” at the MEDSAFE Conference; and co-presented an Institute for Safe Medication Practices Webinar entitled, “The Pharmacist Perspective: The Expected and Unexpected Results of Computerized Prescriber Order Entry (CPOE) Implementation.”


Publishing

Appointments

“Underestimating the Impact of Ventilator Associated Pneumonia by Use of Surveillance Data,” in the Journal of Infection Control and Hospital Epidemiology.

Diana Dickson-Witmer, M.D., associate medical director of the Christiana Care Breast Center at the Helen F. Graham Cancer Center, was appointed vice chair of a task force charged with helping to establish the Commission on Cancer’s new standards for cancer centers around the country.

“Emergency Department Tachypnea Predicts Transfer to a Higher Level of Care in the First 24 Hours After ED Admission,” in Academic Emergency Medicine. “Identification of Overweight, Obesity, and Elevated Blood Pressure: A School-Based Health Center Performance Improvement Initiative,” in the American Journal of Medical Quality. “The Forgotten Parent, NICU Paternal Emotional Response,” in Advances in Neonatal Care. “Respiratory Morbidity in Late Preterm Births: The Consortium on Safe Labor,” in the Journal of the American Medical Association.

Gerald Fulda, M.D., was appointed by the U.S. Department of Health & Human Services to serve as chair of the Scientific Knowledge Subcommittee for the Organ Donor Management Task Force. Neil Jasani, M.D., was appointed to the board of examiners who selected the winner of the 2010 Malcolm Baldrige National Quality Award presented by the President of the United States. Albert A. Rizzo, M.D., is chair-elect of the National Board of Directors for the American Lung Association.

“Heartbeats: Who’s Watching the Cardiac Monitor? Does it Matter?” Nursing 2010 Critical Care. “Global Health Education: International Collaboration at the International Centre for Diarrhoeal Disease Research, Bangladesh,” in the Journal of Health, Population & Nutrition. “Medical Student Exposure to Components of the Patient Centered Medical Home During Required Ambulatory Clerkship Rotations: Implications for Education,” Academic Medicine.

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Creating a Safe Culture

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Primum non nocere – First, do no harm. Each day, with every patient encounter, comes the humbling responsibility of serving our neighbors, who, first and foremost, desire and deserve safe, effective care. Ensuring their safety is a fundamental precept of health care delivery and a responsibility embraced at Christiana Care. Indeed, its pursuit is ingrained in our Culture of Responsibility that fosters an environment of communication, partnership, problem solving and learning from one another. The following initiatives highlight ways we work together and learn from one another to deliver excellent care in the safest possible manner.

A safe culture offers many benefits:

Personal ownership helps WICU team reduce infections Wilmington Hospital’s Intensive Care Unit’s (WICU) central line-associated bloodstream infection (CLABSI) rate decreased by 70 percent between July 2010 and May 2011, and the unit went more than six months without a single CLABSI. WICU Nurse Manager Donna Casey, BSN, MA, RN, FABC, NE-BC, credits her team’s personal accountability for patient safety, strong support from hospital leadership and the nationally acclaimed “On the CUSP: Stop Hospital-Acquired Infections Program” developed by Peter Pronovost, M.D., PhD, at the Johns Hopkins University School of Medicine. This program helps hospitals prevent CLABSI by fostering a culture of patient safety in which all staff members are comfortable speaking up about issues that may harm patients. “Every member of our team feels a strong personal ownership that these infections are preventable and that their individual actions can protect our patients,” acknowledges Casey. Janice Nevin, M.D. MPH, Christiana Care’s chief medical officer, in turn lauds Casey’s role in the unit’s success. “Her leadership has been a key ingredient. She has put together an interdisciplinary team and created an environment that encourages open and honest dialogue. Everyone who is part of the team ‘owns’ this work and wants to contribute. “This team has transformed how they work,” adds Dr. Nevin. “At the end of the day, our patients and families are the beneficiaries of this extraordinary process.”

“Every member of our team feels a strong personal ownership that these infections are preventable and that their individual actions can protect our patients.” — Donna Casey, BSN, MA, RN, FABC, NE-BC, WICU Nurse Manager

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CREATING A SAFE CULTURE

Nurses teach children how to “Get Your Clean On” to prevent infections The award-winning “Get Your Clean On” video about handwashing netted Christiana Hospital’s 4D Surgical Stepdown Unit’s Quality & Safety Council a $1,000 cash prize for third place in a 3M-sponsored national Innovation Award YouTube video contest highlighting innovative infection prevention practices.

Surgical outcomes among top in nation The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) recognizes Christiana Care among only 26 hospitals in the nation—and as the only facility in the Delaware Valley—to achieve exemplary outcomes for surgical patient care in the management of deep vein thrombosis, cardiac incidents, pneumonia, surgical site infections and urinary tract infections. As an ACS NSQIP participant, Christiana Care tracks the outcomes of inpatient and outpatient surgical procedures and collects data that direct patient safety and the quality of surgical care improvements. “This study demonstrates that Christiana Care is one of the national leaders in high quality surgical outcomes,” says Michael Rhodes, M.D., chair of the Department of Surgery.

Performing more than 40,000 procedures each year—ranging from common to highly complex, minimally invasive and robotic—Christiana Care ranks among the nation’s top 20 hospitals in surgical volume, according to the American Hospital Association. The unit’s Quality & Safety council created, performed and produced the award-winning entry, and used the prize money to spread the education further, taking the show on the road to two elementary schools where they taught 125 students the right way to, and importance of thoroughly washing their hands. Using surface cleaning detection gel and an ultraviolet light, the 4D Clean Team was able to show students who thought they had washed their hands well just how many germs were left behind ready to cause infection. The team presented each student a t-shirt, coloring book and bottle of hand sanitizer to help drive home the message “Get Your Clean On.” Watch the award winning video at http://www.youtube.com/watch?v=4v89ErpXXkg.

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Surgical safety checklist improves team communication in the OR; leads to safer surgeries Team briefings using a Surgical Safety Team Communication Tool take place in every Christiana Care operating room, every day, for every patient, helping to improve the quality and reliability of communication among all members of the Perioperative team, and ultimately providing a safer surgical experience. Christiana Care was an early adopter of the World Health Organization’s Surgical Safety Checklist, and, through pilots at three Christiana Care sites, customized the content and integrated key regulatory requirements. Following the TeamSTEPPSTM evidencebased teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), the entire Perioperative Services team—including surgeons, residents, anesthesiologists, nurse anesthetists, physician assistants, nurses, advanced practice nurses and surgical technologists—all participate in each phase of the team briefing: prior to the induction of anesthesia, before the incision is made and before the patient leaves the OR. In a 2010 survey of Perioperative Services personnel, almost all agreed that team briefings either improved, or did not negatively impact efficiency in the OR. Sixty percent agreed that communication has improved and 46 percent indicated the briefings made them aware of patient-specific clinical issues they might not have known about otherwise. In addition, selected AHRQ Hospital Survey on Patient Safety Culture questions demonstrate positive trends. These team briefings have helped staff identify a number of “good catches,” such as identifying allergies, clarifying and appropriately administering pre-op antibiotic orders, accurately identifying specimen collection needs, validating surgical site prior to incision, and anticipating equipment function and needs. Results also suggest a more collegial atmosphere in the OR.

Patient satisfaction surveys during the initial pilot revealed that patients felt safer with staff using this communication tool. Team briefings using the Surgical Safety Checklist are proving effective, yet the potential for loss of information when personnel changes occur during a case still exists. To effectively address this opportunity for improvement, the Thoracic Surgery service line has embarked upon a hand-off communication demonstration project to ensure that key information communicated during the team briefing process is reliably shared during staff and shift changes. Videos demonstrating effective use of the team communication tool, and standardized information transfer during shift and personnel changes, were produced in FY 2011, in collaboration with Academic Affairs and the Virtual Education and Simulation Training Center. These videos will be used for ongoing training activities to support effective OR team communication.

We continue to offer training on teamwork tools to address identified opportunities for improvement, including encouraging staff members to speak up when they identify a potential problem, and reliably communicating information shared in briefings during personnel and shift changes. The ultimate goal is zero wrong site/side surgeries or blocks; as well as decreased surgical complications, readmissions, morbidity and mortality.

Christiana Care’s Perioperative Services Team presented a national webinar hosted by the Institute for Healthcare Improvement on implementing the Surgical Safety Checklist. Christiana Care was also featured, along with three other health care organizations, in an American Institute for Research national webinar on TeamSTEPPS implementation highlighting team training efforts in Trauma, Surgery and Obstetrics.

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CREATING A SAFE CULTURE

Post-event debriefs invite open discussion of safety issues

“No Harm Intended:” Lessons learned in patient safety

As we continue to transform our culture of safety, we draw from other high-reliability industries, such as aviation and nuclear power, to become more reliable. Our commitment to creating a culture of safety is evident in our adoption of a Culture of Responsibility, which includes:

In a bi-monthly series, a multidisciplinary group of patient care providers—ranging from physicians and nurses to pharmacists, allied health professionals and support staff—gather to share “good catches,” where harm to patients was intercepted, analyze processes that have potential to cause patient harm, and review current best practice recommendations.

• Advancing a learning culture where we strive to learn from adverse events and view “near misses” as learning opportunities. • Promoting an open and just culture where we recognize our own fallibility and acknowledge that humans will make errors. Individuals also feel comfortable in reporting and speaking up when there is a potential safety issue. • Designing and implementing safe systems aimed a becoming more reliable and making it easier for our staff to practice safe behaviors. • Managing behavioral choices where staff members make safe behavioral choices to follow safety procedures. Integral to this effort are our newly established post-event debriefs, which allow staff to discuss openly Safety First Learning Reports and events in a supportive and educational environment. Debriefs focus on what happened, what normally happens and how we can prevent such a situation from happening again. Christiana Care has implemented a variety of system improvements as result of these debriefs, but more importantly, we have learned that we can be nimble and timely in addressing adverse events.

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The staff and leadership who present each No Harm Intended session represent departments or units involved in either a good catch or an incident that may have contributed to unanticipated outcome. The team presents the case and leads discussion on what happened, how it happened and changes that have been implemented to prevent it from happening again. Christiana Care providers are embracing the opportunity for discussion; average attendance at each session is 150, with evaluation feedback indicating that participants intend to follow recommendations and change their practices consistent with presented best practices.

No Harm Intended sessions held in FY 2011: •

A Prescription for Safety (Anticoagulation).

Preventing Central Line Infections, a two-part series.

Good Catch! Teamwork + Reporting = Prevention of Harm.

When Bad Things Happen to Good People: Impact of Harm on Health Care Providers.


Christiana Care scores improve in AHRQ Hospital Survey on Patient Safety Culture For the third consecutive survey, our staff and physicians who care directly for patients in our health system grade Christiana Care’s efforts to transform our culture of safety with an overall patient safety grade of B or higher on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture. With 73 percent of the almost 7,500 respondents rating us “good” or “excellent,” this year’s numbers mark a nine percent increase in those respondents who rated us “excellent” as compared to 2009. Our steadfast commitment to eliminate harm to our patients and efforts through our Culture of Responsibility continue to protect those for whom we care.

Areas that continue to be a focus for improvement: • Responding to error in non-punitive ways and establishing feedback mechanisms to share improvements made from submitting Safety First Learning Reports. • Creating an open and fair culture. • Balancing open reporting with appropriate accountability for behavioral choices. • Addressing staff concerns that mistakes count against them and go in their personnel files. • Encouraging staff to speak up to those with more authority regarding safety risks. • Promoting effective hand-offs and transitions of care.

Our results are benchmarked against 285 participating teaching hospitals.

In addition to earning a top patient safety grade, the survey also highlights the following improvements: • 10 percent improvement in management support for patient safety. • 8 percent improvement in teamwork within units. • 6 percent improvement in organizational learning and continuous improvement. • 3 percent improvement in supervisor/manager expectations & actions promoting safety.

Percent of Respondents

AHRQ Hospital Survey

A Excellent

B Good

C Acceptable

D Poor

E Failing

Overall Safety Grade

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CREATING A SAFE CULTURE

Enhanced assessment helps reduce risk of life-threatening clots Surgical patients and patients on medical units who spend extended time in bed—especially those who are over age 60, obese or who have cancer—are at increased risk for venous thromboembolism, or VTE, a blood clot in the deep veins of the legs that travels through the bloodstream to the lungs, causing a lifethreatening blockage known as pulmonary embolism. Christiana Care’s VTE Prophylaxis steer group, with newly added representation from the Orthopedic Surgery section, has standardized Christiana Care’s surgical VTE prevention process, established new risk assessment scoring for medicine patients and implemented a doctor’s order set in CPOE (computerized provider order entry) to ensure that all patients receive preventive measures as indicated by guidelines established by the American College of Chest Physicians and other national organizations. VTEs are potentially preventable through recommended measures, including anticoagulant medications such as heparin, Lovenox® or Fragmin® and mechanical options, such as pneumatic compression boots. Nurses now complete a risk factor assessment on all medical and surgical patients. Orders for VTE prevention are available through CPOE for physicians to initiate VTE prophylaxis. Risk assessment reports are electronically distributed each morning to case managers and clinicians allowing them to address VTE prophylaxis needs during daily interdisciplinary

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rounds on all nursing units. This system ensures that all Christiana Care patients are assessed for this unnecessary and dangerous complication. VTEs are now designated as hospital-acquired conditions by the Centers for Medicare & Medicaid Services, and are considered reasonably preventable through adherence to evidence-based guidelines.

Patient Safety in Three Words Safety First appears atop Christiana Care’s Focus on Excellence Diamond for many good reasons. Our collective focus on safety is fundamental to everything we do. As part of National Patient Safety Awareness Week, the Office of Quality and Patient Safety invited Christiana Care departments, staff and volunteers to enter a contest. The challenge: think of three words to describe an action or activity that best helps us deliver the safest possible care to our patients. More than 200 entries submitted offered a wide range of safety messages across a broad range of categories. The submissions came from many different areas throughout Christiana Care, both clinical and non-clinical. Entrants were eligible for random prize drawings, and certain submissions were selected as systemwide computer screensavers and to be used in other communications as seen below.


Efforts are underway to plan for the 2011-2012 season and achieve our institutional goal of >90 percent vaccination coverage for all health care personnel.

Three key safety messages to prevent transmission of the flu virus: 1. Get vaccinated.

2. Wash hands thoroughly. 3. Cover your cough.

Quality TIPs consultations help staff design, measure and report on quality and patient safety projects

Protecting patients from influenza begins with a healthy staff Keeping our patients safe often requires us to care for ourselves first, and such is the case with preventing transmission of the influenza (flu) virus. Christiana Care administered more than 8,300 doses of seasonal flu vaccine to employees, Medical-Dental Staff, volunteers, students, retirees and even members of the public during the 2010-2011 season. Vaccination is particularly crucial for health care personnel who come in frequent contact with sick patients and can transmit the flu virus to others, even when not having symptoms themselves. Building upon unprecedented governmental, media and public attention generated by the 2009 H1N1 influenza pandemic, a multidisciplinary group led by Infection Prevention, Employee Health Services and Public Safety enhanced efforts in 2010 to prevent flu transmission by: • Setting up roving flu clinics to make the flu vaccine as widely available as possible. • Maintaining the Influenza site on all of the portals for up-to-date information. • Creating a “Flu Myth-busters” quiz to educate and correct common staff misperceptions about the flu vaccine.

Quality and patient safety is every employee’s responsibility, and many are embracing leadership roles by participating in projects to help transform the way we provide care. But project design, survey creation, data management and methodology aren’t second nature to everyone. Now, employees working on quality and patient safety projects, individually or as part of teams, benefit from the ready assistance of improvement advisers experienced in patient safety, improvement methods and data management through the Quality Teams Improving Processes (Quality TIPs, or QTIPs) initiative. Representatives from the Office of Quality and Patient Safety and Operational Excellence offer QTIPs, a monthly series giving “just in time” education and consultation on improvement projects. These mentors provide valuable feedback and advice on elements such as project design, process flow mapping & analysis, implementing a change, and measuring and quantifying improvement consistent with Plan-Do-Check-Act and Lean methodologies. QTIPs has already helped 45 employees, representing 30 project teams, maximize the use of improvementrelated tools and methodologies, helping the system advance its never-ending goal of seeking and effectively addressing opportunities to transform care delivery.

• Adding an influenza Web-ed online education session for all employees to improve vaccination and compliance with the mandatory declination process. Quality & Patient Safety Annual Report

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CREATING A SAFE CULTURE Education and equipment help reduce lost-time injuries Over the last decade, Christiana Care has worked aggressively to reduce lost-time injuries resulting from patient repositioning and transfer by as much as 85 percent through its Employee Injury Prevention Program. The program has earned national recognition as an industry leader in the American Nurses Association’s (ANA) Safe Patient Handling effort. Known as PEEPS© (Patient, Environment, Equipment, Posture, Safety), the program features a sustained education component ensuring all nurses and frontline staff receive initial and ongoing instruction on the proper way to move patients. Supporting that effort is Christiana Care’s unmatched commitment to outfitting its hospitals with innovative safety equipment, including ceiling-mounted lifts installed in virtually every patient room and many ancillary areas. With more than 725 lifts between its two campuses, Christiana Care provides a true benefit for our staff.

The new internal PEEPS Recognition Program— introduced in 2010 on 30 nursing units and soon to be rolled out on additional units as well as in ancillary areas—encourages nurse managers and their respective teams to strive for full staff compliance of safe patient handling initiatives. Three nursing units each at Christiana and Wilmington hospitals achieved Gold Level recognition for their commitment to safe patient handling practices in this inaugural year of the award program. Wilmington Hospital Gold Level nursing units: Center for Rehabilitation Acute Care for the Elderly (ACE) 3 Medical-Surgical Christiana Hospital Gold Level nursing units: Transitional Stepdown Unit 4D Surgical Stepdown 5A Medical Stepdown

“Christiana Care’s commitment to providing needed equipment and sustained education is invaluable to protecting our staff and reducing lost-time injuries resulting from repositioning or transferring patients. In turn, our patients are safer, as well, when these proven safe patient handling techniques are employed.” — Carys Price, PT, MS, CEAS, Director, Employee Injury Prevention/PEEPS Program

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When communication barriers are eliminated, patients and health care providers are better able to: • Eliminate disparities. • Exchange clinical information crucial to treatment and decrease medical errors. • Negotiate an acceptable treatment plan. • Improve adherence and outcomes. • Decrease unnecessary return visits.

Building bridges to better care for all patients In an ideal world, adhering to principles of patientcentered care would lead to universally excellent health care. But in reality, the many differences in culture, language and beliefs among patients, health care providers and systems create health care disparity. Christiana Care’s Diversity & Inclusion Council has instituted a strategy to address the needs of our increasingly diverse population of patients and staff. This includes educational workshops for physicians and health care providers, kicked off by such renowned speakers as Alexander R. Green, M.D., MPH, associate director of the Disparities Solutions Center at Massachusetts General Hospital and assistant professor at Harvard Medical School; and R. Roosevelt Thomas Jr., DBA, whose Strategic Diversity Management Process is helping to set new standards for defining and managing our nation’s diversity challenges. Health care disparities arise from differences in age, gender, race, language abilities, insurance status, education level and even veteran status. By designing systems and practicing cultural competency, health care providers can provide equitable care while addressing disparities.

Among the Learning Centers comprising the new Learning Institute of Christiana Care is the Center for Diversity, Cultural Competency, and Communications. This Center expands our language services with additional full time interpreters and enhanced technology, including more than 500 dual handset phones that allow patients and health care providers to simultaneously access interpreters at any hour in more than 150 languages. Many of our documents are readily available in Spanish with translations planned for additional languages, as well. A series of e-learning modules are also available to help care providers improve their level of cultural competency.

“To be effective, it is critical for me to understand all of the factors that contribute to my patients’ conditions and to communicate in an effective and understandable manner that will ultimately lead to positive outcomes and increased patient safety.” — Ray Blackwell, M.D., Cardiovascular Surgeon and Co-Chair of both the Diversity & Inclusion Council and Health Equity Council

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More than 200 graduate from Achieving Competency Today Course earns national innovations award Today’s health care professionals need to be competent in complex systems-based practice and practice-based learning and improvement, as well as in working collaboratively with colleagues from other disciplines to improve patient safety and quality. Christiana Care’s 12-week graduate level course, Achieving Competency Today (ACT): Issues in Health Care Quality, Cost, Systems and Safety, launched in 2004 by Academic Affairs and the Office of Quality & Patient Safety, responds to this need to improve confidence and skills in applying quality improvement principles and team skills to the practice environment, and increases our organizational capacity to transform care delivery. Since inception, 244 interdisciplinary learners have completed the course, developing 44 rapid-cycle tests with detailed project plans handed off to project champions. More than half of these projects have gone on to create systemwide improvements with direct benefit to our patients. Christiana Care was named a 2010 Alliance of Independent Academic Medical

Centers National Innovations Award Winner, recognizing us for the course and the innovative approach to medical education and research resulting in demonstrated improvements in patient outcomes. ACT incorporates modules from the Institute for Healthcare Improvement (IHI) Open School for Health Professions, an online quality improvement and patient safety curriculum. Christiana Care shared the story of our success in integrating quality improvement and patient safety curriculum into graduate medical education at national forums such as the Association of American Medical Colleges; the Association for Hospital Medical Education and the American Society for Quality; as well as serving as an invited presenter at the Institute for Healthcare Improvement national forum on quality improvement in health care and via Webex conference to the IHI Graduate Medical Education Interest Group.

“The ACT program provides an amazing opportunity for colleagues from different disciplines to work together to improve all aspects of care delivery. Empowering participants by giving them the skills to make a positive difference in patient care, the course forever changes people who take it. They will never be satisfied with the status quo, but will work to drive improvements that will benefit our patients, our families and ultimately our community.” — Sharon Anderson, RN, BSN, MS, FACHE, Senior Vice President, Quality & Patient Safety 18

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Volunteers boost patient satisfaction scores; help improve safety In a recent pilot program conducted at Christiana Hospital, specially trained volunteer ambassadors focused on improving the sense of caring in the patient environment through personal visits and assistance. These ambassadors not only helped patients feel better about their care, but also helped improve safety and increased patient loyalty among those they visited. By engaging patients with questions about ® GetWellNetwork , the volunteers were able to give pointers on using the bedside computer system to check their medications and other information about their care and treatment. “Patient safety improves when patients learn how to be more involved members of their own health care teams,” notes Margarita Rodriguez-Duffy, manager of Volunteer Services. Christiana Care Volunteer Services assembled teams of ambassadors to focus on patient satisfaction in three nursing units in a pilot program December 2010 and January 2011. Results were positive on all three units, with one unit achieving a 21 percent rise in patients being likely to recommend Christiana Care.

Radiation dose tracker software helps physicians weigh benefits and risk of radiation-based tests A new software scanning system helps physicians to determine a patient’s cumulative radiation exposure level to better weigh the benefits of a diagnostic exam involving radiation against the potential risk of additional exposure. Christiana Care’s progressive radiation dose tracker monitors all radiation doses administered to patients throughout our facilities, through such studies as X-rays, CT scans, intra-operative fluoroscopy, or through images performed in the Cardiac Catheterization or Nuclear Medicine labs. The program’s color-coded rating alerts physicians to a patient’s relative exposure level. Corresponding to a traffic signal, a green score indicates an acceptable level of prior exposure; yellow indicates that the patient is getting close to a cumulative exposure that is too high; and red indicates that the patient has already reached a lifetime exposure limit. Physicians incorporate this information into the decision to order further imaging in specific clinical situations and may opt for another diagnostic exam involving less or no radiation. Currently, 14 radiation dose trackers are installed throughout Christiana Care. Emergency Department physicians are the most frequent users, and an ED team is piloting its capabilities as a one-click tool for ordering diagnostic imaging. “Knowing the patient’s radiation exposure gives us important additional information when weighing the risks and benefits of performing a radiologic study,” explains Heather Farley, M.D., Department of Emergency Medicine assistant chair. “At some point, we may be able to incorporate this tool into Powerchart so that the score will be actively presented at the time an order is placed.”

“Christiana Care is doing what it can to make sure all the radiation it provides to patients is accounted for and can be monitored on a ongoing basis.” — Kert Anzilotti, M.D., Chairman, Department of Radiology

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WILMINGTON HOSPITAL

CREATING A SAFE CULTURE

Wilmington Hospital embraces Patient and Family Centered Care

Patient & Family Advisers help guide more coordinated care

Wilmington Hospital has embraced the concept of Patient and Family Centered Care, an initiative that truly focuses on making the patient and his or her family partners in their own care. The transformation redefines relationships in health care, directly involving the patient and family members in the care plan decision-making process and creating mutually beneficial partnerships with the health care team. The idea recognizes the crucial responsibility patients have in becoming responsible partners in their own care, as well as the vital role family members play in ensuring and improving the health and well-being of their loved ones. Research indicates it leads to better health outcomes, wiser allocation of resources and greater patient and family satisfaction. With a collaborative team of individuals all working toward a common goal, this important culture change ultimately leads to safer, higher quality service and a more valuable care experience.

A newly introduced Patient & Family Advisory Council is an important step in our journey toward Patient and Family Centered Care. A cadre of 16 community members, all either former patients or family members themselves, will share their experiences with hospital management and staff at monthly forums, offering a unique perspective to help shape such things as policies, programs, facility design and day-to-day service interactions to continuously improve the care experience. Staff chose the advisers for their personal experiences with care and familiarity with the services provided at Wilmington Hospital. Most had positive experiences, but equally as important to the success of this effort is that some were selected because they effectively shared constructive opportunities for service improvement.

“We learn a lot from the stories our patient advisers tell us. They watch our behavior closely. They will help us be far better care providers.” — Janice E. Nevin, Chief Medical Officer and Patient Safety Officer

“One of the most important things we can do is to listen to your observations and insights on how we can improve the care we provide our neighbors.” — Robert J. Laskowski, M.D., MBA, president and CEO, in his welcoming remarks to the new Patient & Family Advisory Council members.

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Patient and Family Centered Care highlights value of partnerships Hundreds of signatures on an oversized pledge card signify a collective commitment by Wilmington Hospital colleagues to embrace initiatives toward Patient and Family Centered Care.

Bedside shift reporting improves care

The new AIDET communication tool helps staff keep communication—one of the principles of Patient and Family Centered Care—at the forefront of all encounters with patients and their family members.

AIDET It’s a simple patient and family centered approach that reflects on you and Christiana Care Health System. A – Acknowledge the patient and family. I – Introduce yourself. D – Duration – How long will this take? E – Explanation – What are we doing and why. T – Thank the patient and his/her family.

www.christianacare.org 11WHSP13

To promote effective communication of critical clinical information, Christiana Care nurses are moving toward a standardized change-of-shift procedure called bedside shift reporting. The practice is part of our Patient and Family Centered Care initiative, and involves nurses, patients and their family members. All nursing units at Wilmington Hospital now use bedside shift reporting and Christiana Hospital is currently rolling out the practice. For patients and families, the procedure transfers trust from the off-going nurse to the oncoming nurse, and increases the patient’s involvement in the plan of care. For nurses, bedside shift reporting increases teamwork, accountability, patient safety, quality and time management. Bedside shift reporting addresses the National Patient Safety Goals and other safe practices to: • Improve the accuracy of patient identification and improve effectiveness of communication among caregivers. • Manage hand-off communications. • Encourage patients’ active involvement in their own care.

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Achieving High Reliability Today’s medical advances were unimaginable just a generation ago and possibilities on the horizon for tomorrow’s patients are equally impressive. What’s most exciting is that they are not only happening in major metropolitan areas, but now available right here at Christiana Care, led by many of the nation’s most respected industry experts. We continue to introduce new preventive, diagnostic, treatment and rehabilitation services to our community. And we’re continually looking for ways to measure our results and improve processes to ensure that our care is best-practice, evidence-based, high-quality, safe and delivered in a manner deemed to be of value to our patients and their families.

Department of Medicine rolls out new clinical leadership model The Department of Medicine, Nursing, the Office of Quality and Patient Safety, Operational Excellence and System Learning are collaborating to develop a new, unit-based clinical leadership model designed to improve patient care and satisfaction, drive performance improvement and develop highly functioning health care teams.

Further, it fosters communication and collaboration by drawing in other team members, including Pharmacy, Nursing councils and frontline staff. “The goal of these teams is to identify and problem solve, targeting unit-based opportunities for improvement that are connected to our broader system goals,” says Virginia U. Collier, M.D., FACP, Hugh R. Sharp Jr. Chair of Medicine. The clinical leadership model has three specific areas of focus: 1. A dramatically increased time commitment on the floor by the physician medical director. 2. A structured training and on-boarding program to educate the medical director and nurse manager in leadership skills and management science.

The new approach encompasses the best practices of similar medical director/nurse manager partnership models from across the country, including expanding the role of unit-based medical director on eight Medical Nursing units to an average of 10 hours a week, up from about one hour a week in our previous medical director model.

3. Embedded support by Christiana Care Quality & Patient Safety and Operational Excellence resources. “We expect the collaborative effort of these teams to enhance the quality and safety of the care provided to our patients.” — Diane Talarek, MA, RN, NE-BC, Senior Vice President, Patient Care Services and Chief Nursing Officer

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Value Score Cards map improvement in quality and cost metrics The A for which we strive on a daily basis Determining value in health care can be an elusive equation. This past year, Christiana Care created a process to help quantify value through Value Score Cards, a dynamic and innovative initiative that examines performance in seven high-volume or high-risk populations. A Value Score is calculated through a 50/50 equation of five quality metrics and two cost/utilization metrics.

Performance in each metric is denoted by a symbol. A green circle indicates a better-than-expected performance; a yellow triangle denotes coming within 10 percent of the target; and a red diamond indicates that performance is more than 10 percent below the goal. Scores are calculated on a 100-point scale, which translates to a letter grade, sparking lively discussion among doctors, who are used to getting all As. It inspires everyone to do better in a very positive way.

Value Improvement Teams transform care The heart failure and stroke teams were the first to report on their progress. The program also focuses on three OB/GYN populations: vaginal delivery, cesarean section and hysterectomy; as well as pneumonia and total knee replacement. Each team improved their Value Score, and achieved substantial improvement in many of the quality and cost metrics over the last year. Highlights of their accomplishments: Heart Failure: Value Score increased by 10 points; 8% improvement in guideline compliance; 18% increase in patient satisfaction; 0.3 day decrease in average length of stay; 35% reduction in the readmission rate; annual cost savings of approximately $204,255. Pneumonia: Value Score increased by 6.6 points; 9% improvement in guideline compliance; 15% increase in patient satisfaction; and an almost half-day decrease in average length of stay; cost savings were about $79,000. Stroke: Value Score increased by 2.7 points; 10% improvement in guideline compliance; 8% improvement in patient satisfaction; a 0.2 day reduction in length of stay; readmissions reduced by 15%. Total Knee Replacement: Value Score increased by 0.6 points; 100% compliance with evidence-based guidelines; 6% increase in patient satisfaction; 0.2 day reduction in length of stay; 12% decrease in operating room supply costs. Hysterectomy: Value Score increased by 8.8 points; morbidity (complications) decreased by more than 50%; length of stay decreased by 0.2 days; costs decreased an average of $1,750 per patient. Vaginal Delivery: Value Score increased by 7 points; increased patient satisfaction by 10%; morbidity reduced by 11%; readmissions by 23%; costs reduced an estimated $415,200. Cesarean Section: Value Score increased by 5 points; patient satisfaction increased 18%; length of stay dropped 0.3 days; readmission rates decreased by 30%; morbidity decreased 14%; costs reduced an estimated $278,910. In the end, our patients determine the final grade, both through their medical outcomes and hoped-for improved quality of life, as well as their satisfaction with the service they received while in our care. Ultimately, that is the grade that holds the greatest value for us and the A for which we strive on a daily basis. Quality & Patient Safety Annual Report

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Heart failure team studies blood volume analysis for more effective treatment

Pioneering cancer gene therapy now available at Helen F. Graham Cancer Center

Christiana Care’s Heart Failure Program is studying a promising new approach called ultrafiltration to determine if it can relieve fluid retention for patients with congestive heart failure (CHF) more effectively and safely than conventional use of diuretics, such as furosemide (Lasix®), which cause patients to excrete water.

Christiana Care doctors are using genetically engineered cells from a patient’s own blood to trigger the destruction of cancer cells.

Physicians often rely on clinical criteria, such as improvement in swelling of the legs, chest X-rays and changes in various blood markers, to estimate how much fluid to remove. But it is difficult to determine when the patient has achieved normal fluid volume. Ultrafiltration is a more systematic approach, taking advantage of data obtained during a blood volume analysis test to determine how much fluid to remove without dehydrating the patient. By measuring changes in the serum blood concentration, the ultrafiltration machine automatically stops removing fluid once reaching a target volume. Ultrafiltration separates salt water from the bloodstream and safely removes it from the patient at a rate of up to one pound of fluid per hour to get the patient back to baseline weight as quickly as possible. Fluid retention is the primary presenting symptom in approximately 90 percent of the one million annual hospitalizations for heart failure. Medical Director Mitchell Saltzberg, M.D., published on the ultrafiltration trial in the clinical journal, US Cardiology.

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This historic clinical trial for advanced melanoma marks the Helen F. Graham Cancer Center’s foray into cancer gene therapy. Christiana Care is the only East Coast center participating in this early phase study and one of only 11 sites nationwide.

“We are crossing a number of thresholds with this clinical trial,” says Michael Guarino, M.D., principal investigator for the study, who explains that a personalized vaccine derived from the patient’s own white blood cells and a specially designed pill control the body’s defense mechanisms. The pills contain a molecule that signals the cells to release protein to the tumor and recruit other immune system “killer cells” to attack. The vaccine potentially reduces the patient’s drug level for a safer treatment and, in the case of Christiana Care’s first patient entered into the trial, hopefully will be what finally stops the cancer that has spread down his left calf to his foot. The trial is open for patients with stage 3 or 4 melanoma who have not responded well to chemotherapy or other treatments and who have tumors accessible for biopsy. Our emerging leadership in cancer genetics and clinical research is making it increasingly preferable for patients to entrust their care to the Helen F. Graham Cancer Center, where the newest, most promising cancer treatments continue to become available.


Diabetes resource nurses improve patient education and medication compliance for outcome-driven care All patients newly diagnosed with diabetes, and those with high risk conditions such as diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic coma (HHNK), or risk factors, now receive personalized health education by a diabetes resource nurse. The program stems from a rate of adult Delawareans being diagnosed with diabetes that more than doubled between 1995 and 2007 (from 4.3 to 9 percent). Delaware’s rate is now estimated as higher than national average, with more than 58,000 adults affected. Nineteen percent of Delawareans over the age of 65 are diabetic; another almost 9,300 are considered pre-diabetic. Diabetes is either a primary or secondary diagnosis for 22 percent of patients admitted to our hospitals. Diabetes resource nurses serve several crucial roles: • Act as unit-based diabetes experts providing appropriate diabetes resources and care to patients. • Coordinate with case management and social services to meet patient needs. • Provide best practice in diabetes care to all patients. • Utilize Christiana Care’s standardized diabetes care management guidelines, patient education policies and protocols. • Collect, analyze and report clinical outcomes. Providing patient education is an integral part of the initiative. Diabetes resource nurses teach diabetic patients how to give themselves prescribed injections or take oral medications, how to test their own blood sugar, how to recognize symptoms of hypoglycemia and where to find more information about their conditions. They communicate with the patients’ unit nurses regarding ongoing education needs, provide the patients and family members appropriate education to prepare for safe self-care once the patients leave the hospital, and they follow-up with patients once they are home to review compliance with discharge instructions and ensure that follow-up appointments have been scheduled as appropriate. A diabetes nurse practitioner oversees the program. A diagnosis of diabetes adds approximately 1.1 days to length of stay. This initiative helps us more efficiently manage care for diabetic patients and address length of stay to help improve bed access.

Christiana Care teams with Public Health to curb prematurity and improve infant mortality rates in Delaware Christiana Care’s participation in a national study has helped demonstrate that the hormone progesterone is highly effective in preventing premature labor, a leading factor in infant mortality. In 2007, Christiana Care began providing progesterone to obstetrical providers statewide. As a result, more than 200 at-risk women per year have received progesterone, with more than 80 percent of them delivering after 34 weeks, when the baby is no longer considered premature and is most likely to survive. The initiative is one of the factors helping to reduce significantly Delaware’s infant mortality rate an impressive 10 percent. “By partnering with Division of Public Health and obstetrical providers throughout the state, we have been able to translate research into meaningful changes in the lives of mothers and their newborns,” says Matthew K. Hoffman, M.D., MPH, Christiana Care’s director of OB/GYN Education & Research. Christiana Care also worked with Public Health to launch the Healthy Beginnings program in the women’s health practices, offering preconception/prenatal care and support to women at risk because of dangerous living conditions, high stress levels and chronic health conditions. Women in the program are more likely to adhere to healthy behaviors such as eating nutritious foods, quitting smoking and exercising regularly. In turn, these steps help them deliver healthier babies.

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Addiction outreach program offers low-tech approach to high-stakes illness More patients with substance abuse issues are receiving potentially life-saving treatment for addictions, thanks to an innovative peer-to-peer outreach program. Christiana Care is partnering with Brandywine Counseling and Community Services to provide intervention for Wilmington Hospital patients who are addicted to drugs or alcohol. Instead of the hospital merely referring the patient for community counseling— which few patients subsequently schedule—a counselor initiates the relationship with the patients while they are still on the Wilmington campus at a time when early studies indicate intervention efforts may be most successful.

Cooling cap helps prevent brain injuries in NICU Christiana Care’s Neonatal Intensive Care Unit (NICU) is the only facility between Philadelphia and Baltimore to offer infant head cooling to help prevent brain injuries caused by a condition known as hypoxic-ischemic encephalopathy (HIE), in which there is a shortage of blood going to the baby’s brain. The cooling is done by a specially fitted cap with cool water circulating through it. The notion of induced hypothermia for newborns dates back to the 18th century, when physicians prescribed immersing babies in cold water to stimulate breathing. In recent years, controlled cooling has emerged as the standard of care for babies with HIE and asphyxia, a condition in which carbon dioxide builds up in an organ that isn’t receiving enough oxygen. In its first year, the head-cooling program treated eight babies.

Christiana Care’s NICU cares for 1,100 babies a year, including 150 transferred from regional hospitals.

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The program has produced dramatic results that could ultimately reduce serious illnesses associated with addiction, such as pancreatitis, heart disease, kidney failure, cirrhosis and pneumonia. More than a third of the individuals who received intervention through the program went on to participate in a licensed inpatient or outpatient treatment program. In a study of the first 24 patients—comparing six months prior to and six months after intervention—hospital admissions declined by 58 percent, and there were 12 percent fewer visits to the Emergency Department, resulting in significant savings of almost $72,000. Visits to primary care providers increased 88 percent for patients visited by the peer counselor, which is important because those who receive treatment for their addictions and routine care from their primary care physicians are less likely to develop more serious diseases. Terry Horton, M.D., an internist on the faculty of the Department of Medicine heading up the program for Christiana Care, describes the program as, “a low-tech method that is having a positive impact on health care costs.”


CT turnaround time streamlined to better serve ED patients

Innovative flow helps SPEED up care process in the Emergency Department

Thanks to a streamlined process, patients in the Emergency Department now get CT results much more quickly. Devised by the Computerized Tomography (CT) section, along with the Emergency Department, Radiology, Information Technology and Operational Excellence, the improved process has streamlined order-to-exam and examto-results processes to reduce the overall turnaround time for results on diagnostic CT scans performed in the ED.

Christiana Care is moving patients through the Emergency Department (ED) process with greater SPEED thanks to an emergency care access redesign project by the same name. SPEED, or the Synchronized Provider Evaluation and Efficient Disposition Project, teams a resident or physician assistant with three nurses: one for assessment, the next for treatment and a third for disposition, to synchronize the care process. It reduces the time a patient waits to see a physician, have and receive results of diagnostic tests, learn a diagnosis, receive ordered medications and treatments, and finally either be admitted to the hospital or treated and released from the ED.

By implementing a dedicated escort team, improving processes for oral contrast administration, streamlining pregnancy test documentation, clarifying reading time expectations and making necessary ED Tracker display changes, the team was able to decrease turnaround times by 20 percent for contrast abdomen scans; 24 percent for kidney stone protocol scans; and 57 percent for head scans. These solutions earned them the 2010 Operational Improvement Award in the health system’s 2010 Focus on Excellence Award competition, and are helping ED physicians diagnose and begin treatment more expeditiously for patients.

Lean enterprise helps PT Plus cut down on missed appointments; improve quality of care Following the renowned principles of Lean methodology, hallmarked by Japanese auto makers striving for greater efficiency and customer value, PT Plus now enjoys a significantly reduced no-show rate for patient appointments, and, as a result, patients reap the benefits of improved quality of care. A patient no-show rate of 4.7 percent reported by the Health Care Center at Christiana therapy site prompted the two-pronged initiative. First, the PT Plus team initiated consistent appointment reminder calls for each patient’s initial evaluation, for those with scheduled Saturday appointments and for all patients with a history of missed appointments. Once the patients did arrive for their initial appointments, the therapists emphasized the clinical importance of consistent treatments throughout the course of therapy. The result – a drop to just 2 percent in the patient no-show rate in just three months.

Initially piloted two days a week, SPEED is now the standard of service seven days a week for both the day and evening shifts. During its inaugural testing in FY 2010, SPEED cut ED length of stay by 40 percent during rapid cycle tests and reduced the number of patients leaving the ED without treatment to less than two percent. Now the team is committed to even greater efficiencies, with a goal to reduce total ED length of stay to 3.2 hours, aiming for faster, safer, better care, as well as improved patient satisfaction. The ED team is testing several efficiencies in the quest to subtract even more time from the patient’s overall experience, starting with streamlining the triage process. Next, using a synchronized discharge process, physicians and nurses now meet with the patient together to discharge the patient, allowing the patient to ask questions and receive information. Finally, they are testing whether having a team of “consistent providers”—assigning the same RN, tech and doctor to work together—further decreases length of stay. Initial indications show this concept bringing real value to the patient experience.

Encouraging patients to honor their appointments ensures more consistent treatment, improves quality of care, delivers a more positive physical therapy experience and, ultimately, improves value to our patients. Quality & Patient Safety Annual Report

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Cancer Task Force coordinates ‘best practice’ for safer home chemotherapy Home-care patients throughout the state of Delaware requiring intravenous chemotherapy treatments now have a stronger safeguard against medication infusion errors thanks to the creation of a Cancer Task Force. This multidisciplinary collaboration of home-care agencies, cancer centers, infusion companies and pharmacists, was spearheaded by Christiana Care’s Visiting Nurse Association in an effort to eliminate varying home-care practice changes statewide. By determining a “best-practice” approach, the group strives to reduce dosing errors that result from varying processes among agencies and providers; and ultimately to improve patient safety for those receiving care in the home. The Cancer Task Force formed in late 2010 under the auspices of the Delaware Cancer Consortium’s Quality of Care Committee as a platform for dialogue among each group with a role in the home chemotherapy process. Cancer centers and physicians writing the initial chemotherapy orders; infusion companies who provide the pumps used to administer chemotherapy; pharmacists who fill the prescriptions; and finally the home-care agencies who administer the chemotherapy in the home, all have a voice in the process. Their collective agenda: To focus on the safest possible single process for care for home chemotherapy administration.

As their first major quality improvement change, task force members concurred that the ideal method of chemotherapy administration for patient safety is for chemotherapy infusion to be initiated in the cancer center, where critical checks for pump settings such as dosing and flow rate information can be verified by two providers. This provides a safeguard not possible when a home-care nurse initiates infusion in the home as a sole provider. To ensure consistent adherence to the newly established best-practice process among physicians and home-care agencies statewide, they created the Home Chemotherapy Infusion Process flow sheet, outlining the recommended steps. 28

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The Cancer Task Force continues to meet quarterly to examine practice, review protocols and look for new opportunities to improve safety for patients receiving care in the home.

Delaware’s first paired living kidney donation strengthens chain of life A Delaware mother has a renewed lease on life thanks to a precious gift from her daughter and an exciting new relationship between Christiana Care’s Kidney Transplant Program and the National Kidney Registry that culminated in the state’s first paired living kidney donation. The daughter’s kidney was not a medical match for her mother. But Christiana Care helped the two join a “chain of life” that matches willing donors with waiting recipients who, in turn, have their own paired donors willing to “pay it forward” to someone else. The wait for a kidney from a deceased donor is about four years. But through the paired living kidney program, in just over a month, a kidney became available from an altruistic living donor in New York who simply wanted to help someone and entered the registry without being paired with a waiting potential recipient. The New York kidney came to Delaware; the Delaware kidney went to Texas; and a patient in Chicago received the kidney from Texas. For living donors, having their kidneys become part of a paired donation is the next best thing to donating their organ directly to a family member or friend. Explains Dr. Sidney (John) Swanson, M.D., chief of Transplant Surgery, “Just because the donor and recipient aren’t a match for one another doesn’t mean they can’t be part of this amazing life-changing chain.”


Leveraging Technology Investing in technology to help provide safer, better care for our patients is a priority for Christiana Care. Whether for diagnostic or treatment equipment, or for operational software to streamline our efficiencies, educate our staff, improve patient satisfaction and enhance safety, the return is immeasurable when it makes better care possible. Technology alone is not an answer, but in the hands of our talented and capable health care providers and operational managers, it is an invaluable means to achieving greater value for our patients.

Electronic health records and DHIN connect providers for safer, more effective care delivery More than 100 Delaware community physicians will soon employ electronic health records in their practices through a Christiana Care pilot project advancing the use of electronic health information technology. And, by hardwiring electronic content into our residency training program, as well as offering continuing education to our approximately 1,500 community physicians on the benefits of integrating electronic health records into their practices, we are setting the stage for all Delaware providers to become meaningful users of medical informatics for safer and more effective care. Partnering with Quality Insights of Delaware, we provided $1 million in seed money for equipment, software and training to incentivize a core group of community-based primary care physicians to convert their practices to an electronic platform.

Assisting these doctors in getting the right equipment and training was a significant jumping-off point in achieving the advances in health care coordination and outcomes envisioned in the Health Information Technology for Economic and Clinical Health (HITECH) Act.

send results to doctors, and a reliable way for doctors to access information about registered patients. Already installed in many physician offices throughout the state, we expect that 80 percent of Delaware providers will use DHIN by the end of 2011.

Linking doctors and patient information to statewide networks is a critical component in realizing the value of electronically connected health information. Through the pilot, participants also connect with Christiana Care’s computerized provider order entry (CPOE) and with the Delaware Health Information Network (DHIN). Established in 2007 as the country’s first statewide network, DHIN is a conduit for hospitals and labs to

“This call to action to effectively use health information technology for improving quality and safety represents a sea change for many physicians,” acknowledges Robert J. Laskowski, M.D., MBA, president and CEO. “Hospitals and health systems are in the best position to help facilitate this transformation, and, at Christiana Care, we will continue to help our physicians adopt electronic health records into their practices.”

Recent regulations for electronic health records, known as meaningful use regulation, makes the delivery of care more uniform and collaborative – all aimed at modernizing and improving the care we deliver to our patients. Quality & Patient Safety Annual Report

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LEVERAGING TECHNOLOGY

CPOE and eMar now widely deployed throughout Christiana Care Christiana Care’s journey to fully implement an electronic health record took another giant step forward in late October when the Emergency Departments (EDs) at both Christiana and Wilmington hospitals joined patient care units and ancillary areas already using Computerized Provider Order Entry (CPOE) and the Electronic Medication Administration Record (eMar). Bringing the EDs online advances the goal to have the entire health system ordering, delivering and verifying medications and tests electronically by year’s end. The ED launch builds on last year’s inaugural implementation of CPOE, first at Wilmington Hospital in January, and then at Christiana Hospital in March of 2010. Physicians have an integral role in refining and embracing this state-of-the-science paperless medical record, providing input to make it safer, more efficient and user friendly. Because orders are entered electronically, one of the technology’s key safety advantages is that it eliminates errors in deciphering doctors' handwriting. It also reduces repeat tests and improves turnaround time for results. Our Emergency Department is one of the nation’s busiest, caring for more than 165,000 people each year between the two hospitals. Given the high volume of patients and the fast pace of care, nowhere is the need greater for a standardized electronic system for ordering medications and tests. Yet that same high volume and level of care presented unprecedented challenges for implementing the technology at this vital entry point to our health system. A collaborative approach involving teams from Information Technology, Pharmacy, Nursing and Radiology worked with the ED team to design its unique component of the program. CPOE transforms patient care throughout our health system by dramatically reducing the risk of medication and order entry errors. Christiana Care is among a select group of hospitals nationwide leveraging CPOE technology at this high level of use to improve patient care and deliver that care more efficiently.

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CPOE helps us: • Standardize clinical practice through implementation of electronic order entry using evidence-based order sets. • Reduce medication error with rules and alerts to guide ordering decisions. • Enhance the ordering process by transitioning from handwritten orders to electronic orders.

Institute for Safe Medication Practices recognizes Christiana Care Christiana Care’s efforts to improve patient safety through safe use of injectable hydromorphone earned the health system national kudos. The Institute for Safe Medication Practices (ISMP) named Christiana Care as a Cheers Awards recipient. The Cheers Awards honor organizations that have set a superlative standard of excellence in the prevention of medication errors and adverse drug events. Christiana Care Health System improved the safe use of injectable hydromorphone, improving patient safety throughout its hospitals. To promote proper dosing, Christiana Care established recommended dosage ranges, standardized order sets and conducted a robust educational campaign.


CyberKnife® technology revolutionizes tumor surgery

Advanced Stereotaxis capability improves heart rhythm disorder treatment

Christiana Care’s Helen F. Graham Cancer Center’s CyberKnife Robotic Radiosurgery System offers a noninvasive alternative to surgery with fewer side effects for the treatment of tumors anywhere in the body. The technology delivers very high doses of radiation to tumors with extreme accuracy – no anesthesia, no pain, and minimal recovery.

A generous gift of the new Stereotaxis Niobe Magnetic Navigation System positions Christiana Care’s Gerret and Tatiana Copeland Arrhythmia Center as the only one in Delaware, and among a select group of highvolume centers nationally, with the capability to perform a new and safer type of ablation, a corrective procedure that cures many types of heart rhythm disorders.

Unlike traditional radiosurgery systems that can only treat tumors in the skull, CyberKnife can also reach the lung, pancreas, liver, spine and prostate. Its advanced maneuverability offers complete access and coverage for any tumor size or shape, even in difficult-to-reach areas. This allows maximal radiation doses to be delivered for the greatest benefit with minimal damage to surrounding healthy tissue and organs.

Stereotaxis is particularly helpful in the treatment of atrial fibrillation, the most common type of heart rhythm problem. Atrial fibrillation occurs when the heart rhythm gets “out of sync,” or the heart races. The condition, which disables many patients and often leads to congestive heart failure or stroke, affects more than two million Americans, and, to date, has proven to be a difficult condition to treat.

Christiana Care offers the only CyberKnife in Delaware and one of only a few in the mid-Atlantic region.

“I could have had radiation in Philadelphia or Baltimore at any one of several treatment centers, but the more I learned about the Helen F. Graham Cancer Center and CyberKnife, the more I was reassured that this was the right choice,” shares one woman about her experience with CyberKnife treatment for a brain tumor. She says, “Wait time was always short, explanations about procedures were clear, and my questions were treated with respect and a desire to have me understand the process.” Her tumor has stopped growing and no long-term effects are expected from the radiation.

Innovative Stereotaxis remote navigation technology, coupled with state-of-the-art mapping systems, allow electrophysiologists to create real-time, threedimensional pictures, while precisely manipulating catheters in the heart through the blood vessels. What make Stereotaxis so revolutionary are magnetic fields that allow physicians to directly control of the tip of soft catheters with the aid of computer technology. Unlike other manual catheters used for radiofrequency ablation, Stereotaxis catheters are extremely flexible and easier to manipulate through the cardiac chambers. Because physicians can work faster, with greater precision, the patient can be exposed to less radiation, making the treatment safer and more effective. “Stereotaxis is a state-of-the-art, technically advanced system that allows us to approach complex heart rhythm disorders safely and effectively, with greater confidence and precision,” explains Brian H. Sarter, M.D., FACC, FHRS, medical director of Heart & Vascular Interventional Services/Electrophysiology Laboratory.

“Stereotaxis puts us at the forefront in the treatment of heart rhythm disturbances and gives us the technology to make our treatment of patients with heart rhythm disturbances safer and better.” — Timothy J. Gardner, M.D., Medical Director, Center for Heart & Vascular Health

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LEVERAGING TECHNOLOGY

New patient assessment tool offers clinicians holistic insight into patients’ symptoms Christiana Care now uses a computerized assessment tool called Insight to capture more accurate and detailed holistic information from patients during the initial assessment process. On average, patients spend fewer than four minutes completing the 20-question assessment electronically. Yet the information provided gives physicians a clearer picture of how a patient is dealing with her illness than that typically gathered in a traditional live interview. Research shows that some patients don’t reveal symptoms such as pain or depression to an interviewer. But answering questions via laptop or computer tablet helps these same patients overcome anxiety that might cause them to give incomplete, inaccurate information to a nurse or physician. Studies from the initial pilot involving 429 patients indicate that patients are more likely to report symptoms when given time to consider responses, and the process helps them gain a greater understanding of the symptoms related to their chronic disease. The automated print-out allows clinicians to easily see trends in patient symptoms, and gives them a sense of the severity of those symptoms and how important it is to the patient, allowing them to focus attention on high-severity concerns.

“This clinical tool improves patient-to-provider reporting of symptoms and creates more meaningful and focused dialogue so we can more accurately address problems. The ability of the software to monitor trends in symptoms over time will provide another measure of clinical progress.” — Mitchell Saltzberg, M.D., Medical Director of the Heart Failure Program and Co-Leader of the Insight patient assessment tool

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High-tech system transforms medical equipment tracking A new, electronic monitoring system keeping track of sophisticated, clinical devices will greatly improve the ability to manage vital, high-tech resources at our hospitals and surgicenters. The new tracking system was piloted initially on 1,500 IV infusion smart pumps. This cutting-edge tracking technology uses about 3,400 sensors strategically placed throughout our facilities to locate items to within 20 feet, a level of accuracy currently experienced by few other hospitals. Previous technology tracked equipment within only 100 feet, which proved problematic for a nine-story tower at Christiana Hospital, where it was hard to determine on which floor the item was. Staff in our Equipment Room can now monitor the real-time location of all tagged equipment; dramatically cutting down on the time previously spent trying to search for needed equipment. This advancement helps us more efficiently manage, allocate and share available resources, and ensures a greater level of patient safety, as all equipment is now returned to and cleaned at a central location according to Infection Control guidelines before being sent back out for patient use. Once the results of this pilot are reviewed and accepted, a leadership team will help determine which equipment can be added to the system for monitoring in the coming months.


GetWellNetwork® customizes patient education

Virtual Education and Simulation Training Center featured in ORLive webcasts

Christiana Care’s GetWellNetwork takes the conventional bedside television screen to a new level, with interactive educational information that helps patients stay informed about their diagnoses, procedures and medications. The innovative technology allows nurses to prescribe individually appropriate educational materials for their patients, who receive prompts encouraging them to view material tailored to their needs. For example, a post-surgical patient might receive information about pneumatic compression boots, while new mothers view information about breast-feeding or car seat safety.

Through the multi-faceted technology of ORLive webcasts, online viewers from around the world have the opportunity to virtually visit the John H. Ammon Medical Education Center on the Christiana Hospital campus and observe physicians, surgeons and nurses training on some of the nation’s most advanced patientsimulation training technology. The Web provides a transparent vantage point for such procedures as trauma resuscitation, laparoscopic surgery team training and delivery of an infant with shoulder dystocia.

To help address the National Patient Safety Goal of Medication Safety, GetWellNetwork also allows the nurse to pull up patients’ medication lists and review with them the purpose, use and potential side effects of each. Notes one patient, “My nurse was exceptional. He took the time to go over each of my medicines and explained the reason for each new med I was given. He is a credit to Christiana Hospital.” GetWellNetwork features medical information and more than 350 educational videos, many also available in Spanish.

An accredited Academic Education Institute by the American College of Surgeons, Christiana Care’s Virtual Education and Simulation Training Center is outfitted to function like a hospital, complete with a trauma bay, intensive care unit, operating room and standardized patient rooms. Computerized patient-simulator mannequins react like human patients. The technology allows medical personnel of all disciplines to gain crucial experience dealing with high-risk conditions that rarely occur so they can provide the best care when those situations do arise. This training is essential in shaping field-leading medical providers and improving patient safety. “We have an obligation to our community, our families and ourselves to provide a training environment that does not compromise patient safety,” says Glen Tinkoff, M.D., medical director, Virtual Education and Simulation Training Center. “Previously, the only way we could teach these skills was at the bedside.”

Webcasts are available on the Watch Surgery Videos page of the Christiana Care Web site.

“I hear and I forget. I see and I remember. I do and I understand.” — Confucius

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PO 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. 11PERF3

Quality & Patient Safety Annual Report 2011  

2011 Quality & Patient Safety Annual Report for Christiana Care Health System in Delaware

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