2024 Quality & Safety Report

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Table of Contents 5 – Clinical Effectiveness Structure 6 – Achievements and Recognitions 7 – Zero Harm 31 – Patient Experience 36 – Quality 44 – Flow 49 – Health Equity 53 – ChristianaCare Way Awards

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Clinical Effectiveness Structure Clinical effectiveness is fundamental to improving patient safety and health service delivery that is current, effective, efficient and equitable.

In membership and structure, ChristianaCare Clinical Effectiveness has executed on the organization-wide commitment to being exceptional today and even better tomorrow to positively impact the quality and safety of care delivered by our caregivers to our patients and the communities we serve. The Clinical Effectiveness Committee, which reports to the Quality & Safety Committee of the ChristianaCare Health Services Board, serves as the interdisciplinary forum to lead the design, governance and implementation of initiatives used to meet our organization’s mission and goals. Clinical Effectiveness oversees integration of the best evidence into practice through processes including the use of evidence-based standards of care, implementation science and effectiveness monitoring. The committee prioritizes collaboration, action and follow-up to achieve strategic plan goals. The six Pillars of Clinical Effectiveness—Zero Harm, Quality, Patient Experience, Patient Flow, Health Equity and Care Standardization—are the

in the quality and safety of the care provided to our patients—thanks to the exceptional efforts of all

ChristianaCare is nationally recognized for high quality, safe care and was named one of the

of our caregivers.”

Maryland as No. 1 and Delaware as No. 2 in the nation. ChristianaCare's Union Hospital is in Maryland, and Christiana and Wilmington hospitals are in Delaware.

ChristianaCare has achieved national recognitions, awards and accreditations for quality and safety. (See next page.) |

phenomenal improvement

driving force behind our success.

World’s Best Hospitals by Newsweek. In hospital quality, U.S. News & World Report ranked

5

“This fiscal year has seen

QUALITY & SAFETY REPORT 2024

Kert Anzilotti, M.D., MBA, System Chief Medical Officer

FISCAL YEAR 2024

Achievements and Recognitions

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Zero Harm Achieve year-over-year improvement in clinical excellence through a highreliability approach, a culture of safety and a commitment to the identification, prevention and elimination of patient and caregiver harm.

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Preventable Harm

On the journey toward Zero Harm, ChristianaCare’s preventable harm decreases 9% in FY 24 According to the Institute for Healthcare Improvement, despite an increased

14%, while the harm rate, the number of harm cases per 1,000 patient days in

focus on patient safety over the past twenty years, preventable harm remains

the hospital, decreased 9%.

an urgent priority for health care systems. A 2023 study published in the New England Journal of Medicine found that 23.6% of admitted patients experienced an adverse event — 9% of the admissions suffered serious harm. This resulted in an average hospital stay of 9.3 days compared to 4.2 days for admissions without adverse events.

ambulatory practices, encompassing hospital-acquired infections, complications of care and other preventable events, such as falls.

As seen nationally, harm cases increased during the COVID-19 pandemic.

Focused efforts across ChristianaCare led to a reduction in harm this fiscal year. The number of patients with potentially preventable harm decreased

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the system: in the five years since FY 20, there have been estimated cost savings of more than $9.9 million.

Teams responsible for driving improvement in hospital-acquired infections,

ChristianaCare tracks 20 measures of harm across our hospital campuses and

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The reduction in patient harm has led to year-over-year reductions in costs to

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patient safety indicators (PSI) and ambulatory measures report to the Zero Harm Council. Those teams include the Infection Prevention Steer and Triads, PSI-90 Steer, and designated Ambulatory Safety subcommittees.

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Preventable Harm

On the journey toward Zero Harm, ChristianaCare’s preventable harm decreases 9% in FY 24 C O N T I N U E D Preventable Harm Rate

Preventable Harm Trend Harm Cases

Harm Rate

2.5 700

1.4 500 1.2

Number of Cases

1.5

1.0

400

1.0 0.8

300

0.6 200

0.5

0.4 100

0.2

Ju l-2 0 Se p20 No v20 Ja n21 M ar -2 M 1 ay -2 1 Ju l-2 1 Se p21 No v21 Ja n22 M ar -2 M 2 ay -2 2 Ju l-2 2 Se p22 No v22 Ja n23 M ar -2 M 3 ay -2 3 Ju l-2 3 Se p23 No v23 Ja n24 M ar -2 4

0.0

Through April, the FY 24 Preventable Harm Rate has decreased 9%, from 1.44 to 1.30. The number of patients harmed decreased by 14%, from 536 to 462.

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0

0.0 FY20

FY21

FY22

FY23

FY24*

Since FY 20, reductions in patient harm at ChristianaCare have led to an estimated cost savings of more than $9.9 million.

Harm cases per 1,000 patient days

1.6

600

2.0

Harm cases per 1000 patient days

1.8

Hospital-Acquired Infections (HAIs) RLDatix Palooza 2024: ChristianaCare

Hospital-acquired infections decrease 21% in FY 24

takes home Empower Award for HAIs, which increase mortality and morbidity and lead to higher costs of care, are a primary focus of

advancing a proactive culture of

ChristianaCare’s journey to zero harm. They are largely preventable through the consistent application

continuous improvement

of evidence-based standards of care.

Palooza is an annual conference hosted by RLDatix, a

Four of the six HAIs tracked

organizations deliver safer care. At the 2024 event,

as part of the preventable

ChristianaCare earned the organization’s Empower

harm rate improved during

Award, which highlights the power of transparency in

FY 24, with an overall

FY24 YTD Cases

FY23 YTD Rate

FY24 YTD Rate

to FY 23. Opportunities

50

6.00

CPHQ, risk senior program manager, found new ways

remain in surgical site

40

to leverage RL6, our incident reporting system, to

infections for colon

decrease of 21% compared

A team led by Doug Coleman, MBA, BS, CBET, CHFM,

procedures. (See page 14.)

5.00 4.00

30 3.00 20

I-H ys te re ct om y SS

SS

continuous improvements to mission-critical safety

M RS

transparently showcase trends and help foster

I-C ol on

0.00 A

0 CDi ffi ci le

1.00

CA UT I

caregivers with easy-to-use dashboards that

10

I

collection and deliver shared learnings, providing

2.00

CL AB S

The team used tailored ICAST forms to enhance data

measures.

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Cases

7.00

around HAIs.

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FY23 YTD Cases 60

health care.

advance follow-up and improvement measures

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Hospital-Acquired Infections

Overall, the number of HAIs decreased by 21% in FY 24, from 187 to 148. |

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Rate

health care technology company that helps

Catheter-Associated Urinary Tract Infections (CAUTI)

PREP for the Foley Vacation

Reduction in Foley use contributes to 29% decrease in CAUTI rates

From January to September 2022, the Transitional

In FY 24, the systemwide CAUTI Steer led several activities to help reduce CAUTI rates. Among them:

Medical Care Unit (TMU) noted increased use of

implementing PREP (see sidebar) systemwide with plans to automate, revising Foley orders and indications

indwelling urinary catheters, also known as Foley catheters, as well as higher CAUTI rates.

and bladder scan/straight catheterization orders, developing competency training kits that include efficient, just-in-time training at bedside and removing the order "Urine Culture if" from all PowerPlans.

The TMU CAUTI Prevention Team instituted a new

of urinary retention and begin bladder training using bladder scanning and intermittent catheterization. The protocol consisted of an algorithm — Post Retention

SUR

a 29% decrease in 10

CAUTI FY 24 to date 35 to 25. The rate

decision-making steps.

decreased 11%, to 1.01 from 1.14 cases per 1,000 Foley days.

0.6

9

through April, from

Elimination Protocol (PREP) — listing criteria and

84% reduction in CAUTI cases on TMU

Foley Utilization

0.5

8 7

0.4

6 5

0.3

4 0.2

3 2

0.1

1 0

0 2022 Q3

2022 Q4

2023 Q1

2023 Q2

2023 Q3

Systemwide, Foley catheter utilization decreased 15%, from 8.3 to 7.0 Foley days per 100 patient days.

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2023 Q4

2024 Q1

Standardized Utilization Ratio

nurses to remove Foleys for patients with indications

Foley Utilization Rate

These actions led to

Foley Days per 100 Patient Days

protocol called the “Foley Vacation,” empowering

Central Line-Associated Bloodstream Infections (CLABSI)

CLABSI cases decrease 31%, perfect care compliance nears 100% In FY 24, the CLABSI Steer implemented several improvements across all three hospital campuses to lower incidences of CLABSI. When patients are admitted with central venous catheters (central line), nursing documentation of the central line now automatically triggers a daily task for chlorhexidine bathing and treatment and Nasal Povidone Iodine application. The order “Blood Cultures if” was removed from all PowerPlans and “Obtain blood cultures x 2 for temp>38.5” was removed from order sets. Additionally, there was a transition to the new chlorhexidine (CHG) Tegaderm dressing and a non-CHG wipe has replaced the CHG wipe for patients with a documented CHG allergy.

CLABSI CLABSI Cases

CLABSI Perfect Care Monitor

CLABSI Rate

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Dry Biopatch Dry Dressing

2.5

Site Scrub Compliance

8 1.5 6 1.0 4 0.5

2

Ju l-2 Au 2 g2 Se 2 p22 Oc t -2 No 2 v2 De 2 c22 Ja n2 Fe 3 b2 M 3 ar -2 3 Ap r-2 M 3 ay -2 3 Ju n23 Ju l-2 Au 3 g2 Se 3 p23 Oc t -2 No 3 v2 De 3 c23 Ja n24 Fe b2 M 4 ar -2 4 Ap r-2 4

0.0

In FY 24, the number of CLABSI cases decreased by 31%, from 54 to 37.

The rate decreased 26%, from 0.94 to 0.69 cases per 1,000 line days.

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Lumens Flush Provider Order Universal Protocol Dressing Date Line Indication by Criteria Universal Decolonization Disinfecting Port Protectors

0

12

Clear of Residual Blood/Debris

2.0

Cases per 1,000 line days

Number of Cases

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Daily CHG Disinfecting Bath 0%

20%

40%

60%

80%

% Compliance

Overall compliance with the set of evidence-based “perfect care” line insertion and maintenance practices that help prevent CLABSI is 98%. Top opportunity is the daily chlorhexidine disinfecting bath.

100%

Clostridioides difficile (C. difficile)

C. difficile SmartZone alert leads to 22% decrease in cases and keeps ChristianaCare below Vizient benchmark Like CLABSI and CAUTI, hospital-onset C. difficile is part of the CMS hospital-acquired

C. Difficile Trend

condition pay-for-performance program. The C. difficile Steer identified an opportunity

16

Cases

related to the timing of C. difficile identification and testing. Cases found within three days

0.5

To assist clinicians in the timely identification and testing of potential C. difficile, a

enabling identification of a potential C. difficile early. Early identification supports appropriate classification of C. difficile as community vs. hospital onset, leading to timely treatment and reducing harm. Since go-live the Smart Zone alert has identified 24 cases as community onset v. hospital onset contributing to the 22% decrease in C. difficile cases seen this fiscal year.

0.4 10 8

0.3

6 0.2 4 0.1 2 0

To further reduce C. difficile, recent actions of the team in FY 24 include implementing an

0.0

2022 Q2

2022 Q3

2022 Q4

2023 Q1

2023 Q2

2023 Q3

2023 Q4

2024 Q1

automated C. difficile risk calculator in PowerChart and expanding use of UV light for

Following the SmartZone Alert go-live, the C. difficile standardized infection ratio decreased by 13%, from 0.36 to 0.31, and it remains below the Vizient benchmark.

room cleaning.

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Standardized Infection Ratio (SIR)

The alert notifies providers of patients entering the health system with significant diarrhea,

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Number of C. Difficile Cases

PowerChart Smart Zone alert was implemented in FY 23.

0.6

Vizient SIR Goal

SZA Go-Live

14

of hospital admission are considered community onset and not counted as patient harm.

SIR

Colon Surgical Site Infections (SSI)

Increased compliance with Colon Bundle Pathway shows promise for reducing surgical site infection rates Surgical site infections (SSIs) are one of the most common

Colon SSI - Bundle Compliance

causes of health care–associated infections. In FY 24, the Colon

Jul-23

Care Pathway team implemented numerous interventions to address SSI infections related to colorectal surgery.

Mar-24

PowerPlan Pre-Op Chlorhexidine-in Prep & Hold

Updates to the Colon Bundle Pathway include requesting feedback from surgeons about barriers to bundle element use

Chlorhexidine-in OR Fascial Wound Protector-Surgeon Fascial Wound Protector-Nurse

and/or other intangible factors that may have contributed to

New Surgical Gown-Surgeon

SSI cases, ensuring understanding and accessibility of preop

New Surgical Gown-Nurse

antibiotic ordering, improving capture of emergent/elective

New Sterile Gloves-Surgeon New Sterile Gloves-Nurse

cases, changing nursing documentation to ensure wound class

New Drape-Surgeon

reconciliation and expanding the team to include Emergency

New Drape-Nurse

Medicine, General Surgery and Trauma Surgery.

Clean Closure Tray-Surgeon Clean Closure Tray-Nurse PowerPlan Post-Op

The team is now reviewing antiseptic irrigation and moving review of SSIs to R2L to improve collaboration. (See page 10.)

While the team has not yet seen an overall trend down, it has seen an increase in compliance with the Colon Bundle components during the fiscal year.

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0%

20%

40%

60%

80%

100%

Percent Compliance

Compliance with the Colon Bundle components during the fiscal year increased by an average of 13%. The greatest improvement was in the use of clean closure trays for fascia closure: 59% increase, from 54% to 86%.

Patient Safety Indicators (PSI) 90

PSI 90 Steer efforts lead to 18% decrease in the PSI 90 composite

47% Decrease in AKI rates.

ChristianaCare measures 11 Agency for Healthcare Research and Quality (AHRQ) patient safety indicators in our journey to zero harm.

PSI 90 Composite Rate The Patient Safety Indicator Composite (PSI 90) is a weighted

4.0

composite of 10 individual PSI metrics, largely associated with post-

3.5

surgical complications. The Centers for Medicare & Medicaid Services

3.0

(CMS) uses the PSI 90 in its pay-for-performance programs and star

2.5

employ the measure to rank hospital performance.

Among the FY 24 activities to drive Zero Harm across all PSI 90

Rate

ratings. Leapfrog and other national hospital ratings systems also

2.0 1.5

indicators, ChristanaCare’s PSI 90 Steer, under our Surgical service line,

1.0

created review teams—each with a physician, advanced practice

0.5

clinician, and nurse—for every PSI. Each team reviews cases together

0.0

and then reports observations and opportunities at regular collective

2022 Q1

2022 Q2

2022 Q3

2022 Q4

2023 Q1

2023 Q2

2023 Q3

2023 Q4

2024 Q1

Discharge Quarter

PSI 90 Group meetings.

The PSI 90 rate decreased 18%, to 2.15 FY 24 year-to-date from 2.61 in FY 22.

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Patient Safety Indicators (PSI) 90

ChristianaCare PSI rates come in better than academic medical center peers in 9 of 11 indicators ChristianaCare's patient safety indicator risk-adjusted rates were better than our comprehensive academic medical center peers in 9 of the 11 PSIs. We are especially strong in perioperative PE/DVT (PSI 12) and postoperative hemorrhage/hematoma (PSI 9). We see the greatest opportunity for improvement in PSI 10 postoperative acute kidney injury (AKI).

AHRQ Patient Safety Indicators FY 24 Year-to-Date vs. AMC Compare Group ChristianaCare

Iatrogenic Pneumothorax PSI 6)

0.06 0.15

In Hospital Fall w Fracture (PSI 8)

0.24 0.25

Postop Hemorrhage/Hematoma (PSI 9)

0.35

page), the PSI AKI review team implemented several interventions to

Postop Respiratory Failure (PSI11)

Overall, AKI rates have improved 47% since FY 22, to 1.57 from 2.98 cases per 1,000 procedures.

1.19 1.28

Death in Surgical Pts w Complications (PSI4)

Postop Acute Kidney Injury (PSI10)

PowerChart, and is currently developing a predictive model for AKI.

0.59 0.89

Hosp Acquired Pressure Injuries (PSI 3)

In FY 24, informed by its multifaceted review of cases (see previous improve AKI incidents, including an AKI dashboard and an AKI alert in

Academic Medical Centers

Periop PE/DVT (PSI12)

2.04 1.37 1.09 4.30 0.71

3.42 2.18

Postop Sepsis (PSI13)

0.00

3.05

1.79 1.73

Postop Wound Dehiscence (PSI14) Accidental Puncture/Laceration (PSI15)

5.36

0.61

0.99

1.00

2.00

3.00

4.00

5.00

Risk-Adjusted Rate

In FY 24, ChristianaCare's patient safety indicator risk-adjusted rates were better than our comprehensive academic medical center peers in 9 of the 11 PSIs. 16

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6.00

Management of Severe Gastrointestinal (GI) Bleeding

New GIRT Alert raises visibility and drives action on severe gastrointestinal bleeding GIRT Activations by Location At ChristianaCare, a multidisciplinary team of caregivers skilled at triage, resuscitation, diagnosis and treatment manages cases of severe GI bleeding, regardless of whether the Union ED, 1

patient arrives in the Emergency Department or is already hospitalized.

In FY 24, a team consisting of physician leaders and subject matter experts from Emergency Medicine, GI, Colorectal surgery, Trauma surgery, Pulmonary intensivists, Vascular Interventional radiology, and Hospitalists reviewed past events involving GI bleeding. The

Christiana ED, 4 Christiana Floor, 3

team was led by Clinical Effectiveness and Patient Safety. During the review, they identified common themes and opportunities for improvement, including communication delays, siloed communication among specialties, ambiguity of care plans, management of patients on anticoagulants and ineffective policy.

MICU, 3

Wilmington ED, 4

To improve care coordination, the team implemented the Gastrointestinal Response Team (GIRT) Alert. Sent via Vocera, the software solution used for systemwide two-way messaging, the alert goes to a multidisciplinary group when a patient shows signs of a severe GI bleed. Caregivers receiving GIRT Alerts represent emergency general surgery, gastroenterology, intensive care and vascular interventional radiology, among others. Upon receiving an alert, a group call is initiated for planning care and determination of the best course of action for the patient.

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Since the GIRT Alert’s deployment in March 2024, there have been 15 alerts, nine of which were in the Emergency Department.

Universal Protocol for Preventing Surgical Events

Monitoring shows improvement to 95% in perfect care The Universal Protocol is a set of guidelines that aims to prevent wrong person, wrong procedure and wrong site surgeries in hospitals and outpatient settings.

Universal Protocol Perfect Care

The protocol consists of three steps to improve patient safety during

100%

surgical and nonsurgical procedures: verifying the patient, procedure and procedure site; marking the operative or procedure site; and

In FY 24, the Surgical service line began revising ChristianaCare’s Universal Protocol education, which caregivers will need to complete bi-annually when it is relaunched. Also, in October 2023, the team

Percent of Cases

correct patient, procedure and site.

86%

86%

Oct-23

Nov-23

Dec-23

95%

80%

initiating a Time Out immediately before starting the procedure for all members of the procedure team to raise questions and confirm

85%

90%

93%

60%

40%

20%

restarted Universal Protocol audits, switching the audits to patient rounds for better participant-level data. January 2024 saw the launch of a live auditing process, where auditors review live cases in the operating room and provide feedback to team members in real time.

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0% Jan-24

Feb-24

The percentage of audited cases meeting all aspects of the Universal Protocol increased 12% from October 2023 to March 2024, from 85% to 95%.

Mar-24

Falls

Falls decrease nearly 16% across hospital campuses In FY 24, a multidisciplinary, systemwide Fall Prevention & Mobility team redesigned protocols and implemented

Acute Care Fall Rate by Campus

new tools to preempt falls with major injuries. In addition

FY23

to updated documentation, procedure guides and

FY24 YTD

3.0

standardized weekly fall reviews, ChristianaCare’s electronic medical record system now triggers mandatory

2.47

2.5

2.36

QR code added to the foot of all beds links to educational resources about the bed for caregivers to maximize safety with bed exit alarms.

Patient fall rates improved across all three campuses.

Through April 2024, the number of falls across all three hospital campuses decreased by 130 compared to the

Falls per 1,000 patient days

interventions when a patient is at high risk for falls and a 2.07

2.16

2.0 1.68 1.5

1.37

1.0

0.5

same period in FY 23, declining from 690 to 560. During the same period, falls with major injury decreased by 4, from 16 to 12. The fall rate decreased almost 16%.

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Newark

Cecil County

Patient fall rates improved across all three campuses, with an overall decrease of almost 16%, from 1.87 to 1.58 falls per 1,000 patient days.

CONTINUED>

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Wilmington

Falls C O N T I N U E D

Union Hospital unit standardizes approach to falls, sees decline in incidents

Falls in ambulatory settings down 25% since December Ambulatory Falls Trend

In FY 24, the Ambulatory Practices Ambulatory 14

Falls Subcommittee was established to educate ambulatory caregivers on best

Decision Unit initiated a fall prevention strategy

practices to reduce patient falls in ambulatory

that included not leaving a patient to toilet

settings. The committee:

alone, using bed and chair exit alarms for all patients, using gait belts in all rooms, using gait

•

Practices weekly.

belts for all ambulating patients, wearing nonslip footwear for all patients and educating

•

patients on fall prevention strategies upon

Shared Huddle Tips on Falls Best

Developed comprehensive web-ed for all

arrival at the unit.

As a result, the unit’s falls decreased

•

by 70% in FY 23, from 17 to 5.

•

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8

6

4

non-mandatory web-ed.

2

Disseminated Falls Best Practice tip

0

sheet to all practices.

Created a virtual Best Practice Training step-by-step reference guide.

20

10

20 23 -0 20 1 23 -0 20 2 23 -0 20 3 23 -0 20 4 23 -0 20 5 23 -0 20 6 23 -0 20 7 23 -0 20 8 23 -0 20 9 23 -1 20 0 23 -1 20 1 23 -1 20 2 24 -0 20 1 24 -0 20 2 24 -0 20 3 24 -0 4

caregivers. 81% of caregivers completed the

12

Number of Falls

In February 2022, Union Hospital’s Clinical

In FY 24, 76 patients have fallen in ChristianaCare's ambulatory settings, such as Medical Group practices, rehabilitation services and diagnostic testing locations. The number of falls is trending down, with a 25% decrease in the most recent four months.

HomeHealth Pressure Injuries

HomeHealth Pressure Injury group meets 0.33% target Pressure injuries are a core HomeHealth focus. In

Increase in Pressure Injuries 1.0

Committee subgroup dedicated to pressure injury

0.9

identification and reduction.

0.8

office- and field-based nurses and therapists, found gaps in our Braden Scale assessment scores.

To drive improvement, the group established

0.7 0.6 0.5 0.4 0.3 0.2

the agency care plan with risk-specific

0.1

interventions aligning with the Braden Scale. This

0.0 Ju l- 2 2 Au g22 Se p22 Oc t-2 2 No v-2 2 De c-2 2 Ja n23 Fe b23 M ar -2 3 Ap r-2 3 M ay -2 3 Ju n23

virtual visits with a wound specialist and updated

work resulted in a desired reduction in the onset or

Target: 0.33%

Ju l- 2 3 Au g23 Se p23 Oc t-2 3 No v-2 3 De c-2 3 Ja n24 Fe b24 M ar -2 4 Ap r-2 4

The multidisciplinary group, comprised of both

Percent increase (%)

FY 24, HomeHealth established a Quality & Safety

progression of pressure injuries in patients receiving HomeHealth services

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The percentage of patients with a new or evolving pressure injury of stage 2 or higher in FY 24 through April is at the target of 0.33%.

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Medication Safety

Smart Pumps prevents 327 dose “magnitude errors” in medication administration, saving lives and costs Medication administration is the most error-prone step in a complex medication process that includes prescribing, transcribing, dispensing, and administering. This final step can lead to significant patient harm,

Dose Magnitude-Error Good Catches High-Volume Drugs

especially with intravenous drug administration. To administer medication intravenously, ChristianaCare uses Smart Pumps, which

100

feature Drug Error Reduction Software (DERS).

90 80 70

Program and Clinical Pharmacy, DERS is a software library with more than 2,000 entries specific to ChristianaCare that calculates safe drug and concentration rates and doses, adding limits and alerts to prevent manual programming errors.

Count

Developed and maintained by the health system’s Medication Safety

60 50 40 30 20 10

From July 2023 through April 2024 (10 months), DERS prevented 327 dose magnitude errors, potentially avoiding harm-associated costs of $54,000 to $330,000 (conservative estimates).

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_O YL R EP HR IN HY E_ OR DR OM OR PH ON E OX YT OC IN M OR PH NO IN RE E PI NE PH RI N E

OF OL

FE NT AN YL

OF OL PR OP

IL IF EN TA N

SI N

IN HE PA R

OM

PR ES

RE M

PR OP

PH EN

reducing unnecessary alerts.

VA SO

and updates to monthly, enhancing error prevention safety features and

DE XM ED ET

In FY 24, the DERS Team increased the cadence of Smart Pump reviews

ID IN E

0

The top volume dose magnitude-error drugs accounted for more than 90% of the 380 “good catches” or interceptions of potential safety events before they reach patients.

Caregiver Safety

ChristianaCare's total recordable injury rate, including days away from work, restricted work and medical treatment, increased 13% in FY 24 year-to-date through April compared to the same period in FY 23, but

Injuries per 200,000 Worked Hours

ChristianaCare continues trending below national average for recordable and lost-time injury rates

Recordable and Lost-Time Injuries FY23 YTD

7

FY24 YTD

BLS (2021)

The Total Recordable Injury Rate increased 13%, to 4.5 from 4.0, but remains well below the U.S. Bureau of Labor Statistics (BLS) national average of 6.1. The LostTime Injury Rate increased 25%, to 2.0 from 1.6, and is below the BLS average of 2.2.

6 5 4 3 2 1 0 Total Recordable Rate

Lost Time Injury Rate

remains below the national average for medical/surgical hospitals of 6.1 injuries per 200,000 worked hours.

Top Recordable Injuries FY23 YTD

Needlestick/sharps injuries account for 40% of recordable injuries and decreased 4% due to resolving supply chain issues, and

Cut-Puncture Needlestick/Sharp

prevention initiatives, such as sharps safety rounds, systemwide safety

Slips, Trips, Falls

communications and focused education.

Patient Handling

Efforts to reduce other caregiver injuries include the addition of spill stations in off-campus settings to address the 46% increase in Slips, Trips & Falls and Patient Handling initiatives including insulation of ceiling mounted lifts on Cecil County campus and an online educational module to educate caregivers on safe patient handling on non-hospital sites.

FY24 YTD

Recordable injuries increased to 425 in FY 24 from 382 during the same period in FY 23. Hours worked for the same period remained fairly consistent, decreasing by 74,999 in FY 24 (18,804,732.79 FY 24 vs. 18,879,731.94 FY 23).

Struck By-Caught Between Physical Demands Patient Assault Lift-Move Material Exposure-Communicable Dis 0

20

40

60

80

100

120

Number of Injuries

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140

160

180

200

Caregiver Safety

Daring to de-escalate: Educating caregivers in workplace violence

Preventing workplace violence with education, enhanced protocols, detection and training Our Interdisciplinary Workplace Civility Steering Committee helps create an environment safe and free of

In response to a rise in reported workplace

violence for caregivers and visitors.

violence incidents from 574 (FY 21) to 626 (FY 23), training caregivers in de-escalation techniques,

outcomes that included creating a

increasing the number of trained staff by 77.59%

Workplace Violence (WPV) Leader

through FY 23 and far exceeding Our Workplace

Toolkit; implementing a WPV Huddle

Civility Steer Committee’s 15% goal. While de-

Response Team activation; and

escalation training may not necessarily reduce

deploying Evolv Weapons Detection

workplace violence incidents, it can improve

System to screen for weapons at our

caregiver knowledge, confidence, attitudes, and

Wilmington campus. Plans include

skills in identifying and managing escalating

bringing the system to our other

behavior and help lessen the impact of

campuses; launching HomeHealth caregiver education; training more than

aggression and violence.

Nearly 5,000 caregivers received training in Nonviolent Crisis Intervention or Verbal Intervention during FY 23.

1,500 caregivers in the Medical Groups on ALICE (Alert, Lockdown, Inform, Counter, Evacuate); implementing Dynamic Assessment of Situational Aggression (DASA) in all adult acute care medical, surgical, step-down and ICU units, and increasing use of staff duress

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QUALITY & SAFETY REPORT 2024

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ZERO HARM

badges.

Number of Assaults

6

Physical Assault Rate

Linear (Physical Assault Rate) 50 45

5

40 35

4

30

3

25 20

2

Number of Events

In FY 24, the committee led activities and

Rate (Events per 200,000 Worked Hours)

ChristianaCare made significant progress in

Physical Assault Rate

15 10

1

5

0

0 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24

In FY 24, through March 2024, 799 workplace violence events were reported, with nurses accounting for 60% of these reports. The majority (66%) of the incidents were physical or verbal assaults.

Zero Harm Awards

Celebrating love and excellence on the journey to Zero Harm ChristianaCare’s Zero Harm Awards recognize hospital patient care units, HomeHealth teams, Perioperative Services departments and Ambulatory Practices that have maintained zero cases of preventable harm in one of nine harm categories for at least three consecutive months for falls and at least 12 months for other categories. From July 2023 through April 2024, 179 awards were given, including four awards for 10 years (120 months) with zero harm. Since January 2017, 1,173 awards have been earned.

NEWARK CAMPUS

C. difficile 60 months - TNU

CLABSI

48 months - CEAD

108 months - 2C

24 months - 6MS

72 months - TSU

12 months - 4B, Hospital at Home, 3A, 7E, TMU, 3C, BMT, 5C, TSU

48 months - EAD, TNU, 3A 12 months - Hospital at Home, 4E, 3B, 5B, 6MS, 5E

CAUTI

All Falls

24 months - 8S

** awarded for 3 consecutive months (and multiples of 3)

C. difficile

12 months - 4W

120 months - 7S

CAUTI

84 months - 6W

9 months - BMT, CVCCC, SCCC, P6M, 6MS

12 months - 5A, 3C, 5D, 5E, 3A

6 months - 6M/7M, NCCU, TMU

MRSA

3 months - 3C, CEAD, 4B, MICU, CSSU, 5E, 7E, LBR

84 months - 4D, TNU 60 months - BMT

Antenatal Steroids

48 months - CEAD, 5D

24 months - OB Triage

36 months - 6A, 6MS 24 months - 5E 12 months - 7E, TSU, C 5A, 3B, 4E, 5C, CVCC, 6E, SCCC, TMU, 3C 25

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QUALITY & SAFETY REPORT 2024

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36 months - 5N, WCCU 12 months - WICU,4N/5W, 8S

12 months - TNU, 2M

36 months - WCCU

84 months - W3M

36 months - WCCU

18 months - TSU

48 months - CEAD

72 months - W3M

120 months - 7S, 6W

24 months - 7N

33 months - OB Triage

60 months - TNU

108 months - 7S

MRSA

48 months - 6W

96 months - NICU

108 months - BMT

WILMINGTON CAMPUS CLABSI

ZERO HARM

120 months - 7S

48 months - 7N

108 months - 4N/5W

36 months - WCCU

84 months - 6S

24 months - 5N

60 months - WICU, 6W

12 months - 4N/5W, 4W, 6S

36 months - WCCU

All Falls

24 months - 5N

** awarded for 3 consecutive months (and multiples of 3)

12 months - 4W, 8S

9 months - WICU 3 months - WCCU, 6S, 7S, W3M, 8S

Zero Harm Awards

Celebrating love and excellence on the journey to Zero Harm CECIL CAMPUS

HOSPITAL AT HOME

AMBULATORY PRACTICES

PERIOPERATIVE

CLABSI

CLABSI

Hypertension Admissions

Perioperative Services

24 months - SSU

12 months

(primary care & cardiology practices)

12 months - PCU, ICU

C. difficile

CAUTI

12 months

36 months - PC Woodstown 24 months - PC Kirkwood

36 months - GI Lab-Wilmington, PACUWilmington 24 months - OR-Wilmington, Christiana Surgery Center 12 months - HVIS, Endoscopy-Union, Interventional Radiology-Union, Wound Care Center-Union, PACU-Christiana, OR-Union, Wound Care Center

60 months - ICU, PCU 24 months - SSU, MSU

HOMEHEALTH

MRSA

CLABSI 72 months - CD Team 3, NC Team 2, NC Team 7 60 months - NC Team 6

60 months - SSU 24 months - ICU, MSU

12 months - NC Team 8

C. difficile

(primary care & endocrinology)

36 months - CDU

CAUTI

All Falls

12 months - NC Team 2

24 months - PC Smyrna, PC Kirkwood 12 months - PC Middletown East

24 months - FBC 6 months - CDU, SSU 3 months - ICU

|

Complications of Diabetes Admissions 48 months - PC Woodstown 36 months - PC Whitehall

** awarded for 3 consecutive months (and multiples of 3)

26

12 months - PC Kennett, CHF CHR 1070, PC Linden Hill, PC Concord, PC Limestone, PC at Home

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ZERO HARM

Patient Safety

Zero Hero Awards recognize caregivers who prevent patient harm at the point of care The Zero Hero program recognizes the importance of caregivers making “good catches” that prevent patient harm at the point of care. A good catch may be an unsafe condition that increases risk for patients or caregivers and needs to be corrected. It may also be a near miss, when a safety risk is corrected before it reaches the patient. Reporting good catches promotes increased learning at the system level and allows caregivers to be proactive in preventing harm.

Reporting and learning are vital in our journey to zero harm and advancing a culture of safety.

Every month, a Zero Hero awardee is selected from the nominees. Clinical Effectiveness leaders in the System Support & Resolution Huddle recognize the awardees for contributing to important system improvements, and they’re highlighted throughout internal platforms. Monthly winners are eligible for the annual Zero Hero Award presented at the ChristianaCare Way Awards ceremony (see page 53).

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ZERO HARM

Patient Safety

Zero Heroes 2023–24 May 2023

August 2023

Timothy Shiuh, M.D., Information Technology

Amy Whalen, RN, Performance Improvement

Good catch: When patients were transferred from Union Hospital to a Delaware facility,

Good catch: A software malfunction ordered C. auris PCR tests for all admitted patients,

it wasn’t possible to document their experience as a single encounter in the electronic

regardless of their risk factors. This caused Emergency Department delays.

health record.

As a result: The IT department identified the misstep in the rule configuration that

As a result: The IT department developed strategies that made it possible to transfer

caused the error, quickly disabled it, corrected the rule and resolved all inappropriately

patient health data across state lines without creating new episodes of care.

placed orders.

June 2023

September 2023

Beth Austin, Respiratory Supervisor, Respiratory Care

Beth Austin, Respiratory Supervisor, Respiratory Care

Good catch: The Respiratory Care department ran out of medium BiPAP masks for

Good catch: The exhalation housing for ventilators left for sterile processing weren’t

three days; patients who required BiPAP would have been placed on ventilators.

cleaned for 24 hours because they were dropped off without identifying details or

As a result: The Supply Chain department addressed the shortage, correcting the

instructions.

problem within days and maintaining the supply on an ongoing basis.

As a result: The Sterile Processing department is creating a system of labeled bins so that items may be dropped off for reprocessing if a tech is unavailable for intake.

July 2023

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Brittany Drake, Speech Therapist, HomeHealth

October 2023

Good catch: During a home health visit, a speech therapist realized that the patient’s

Michelle Jonkiert, RN, Cardiovascular Critical Care Complex

heart rate and blood pressure levels were elevated and required emergency care.

Good catch: The medication scanners weren’t working, making it impossible for

As a result: The speech therapist recommended calling 911, which the patient refused,

caregivers to use the scanners or the backup system.

but they went the Emergency Department, where they were diagnosed with elevated

As a result: The problem was quickly identified and corrected, and no patients were

troponins.

impacted by the temporary problem.

QUALITY & SAFETY REPORT 2024

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ZERO HARM

Patient Safety

Zero Heroes 2023–24 November 2023

January 2024

Neonatal Intensive Care Unit

Angelina Marie Stevens, RN, 3D Transitional Medical Unit

Good catch: A newborn in the Neonatal Intensive Care Unit had two medications

Good catch: A medication amount was listed in mL instead of mg in the system

automatically ordered for them through the system, even though the drugs are

because the PCA banner requests mg and the iView documentation is in mL.

inappropriate for newborns.

As a result: Nurses were told to document the medication volume infused in the

As a result: The IT department updated the custom rule so that babies in the NICU can

nursing task, which then lists the volume in mg in iView. Educational materials were

no longer be prescribed these two inappropriate medications.

shared to inform nurses.

December 2023

February 2024

Pharmacy

Amanda Williams, NP, 3A

Good catch: The pharmacy received an order for Kevzara 1.14 mL syringes, available in

Good catch: Although a patient was given medication once, the Medication

two-packs. The prescription was written for two each, but it should have said 2.28 mL

Administration Record showed they were given it twice, 10 minutes apart.

to mean two syringes.

As a result: The IT department continues to investigate with Cerner/Oracle the root

As a result: The pharmacy added product messages to the system to clarify the

cause of this incorrect documentation.

number of syringes in a package and how many should be dispensed for each prescription.

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ZERO HARM

Patient Safety

Zero Heroes 2023–24 March 2024

May 2024

Kari Matthews, RN, Cardiovascular Critical Care Complex

Judi Smith, Ambulatory Operations Manager

Good catch: An intra-aortic balloon pump (IABP) was malfunctioning and measuring a

Good Catch: Lynx Messenger was deployed in the PMRI Lab in 2023. During the

patient’s heart rate in the 180s when it was actually in the 80s, causing hypotension.

deployment of the remaining practices and services in PMRI, Public Safety tested one

As a result: The IABP has since been repaired and adjusted, with help from the Clinical

of the workstations in the lab to ensure it had been moved to the correct group and

Engineering department and the IABP’s manufacturer.

identified that Lynx Messenger was no longer on that desktop. After speaking with the lab caregivers, it was determined that the desktop had been refreshed since the

April 2024 (Tie)

original deployment in 2023. The keyboard was still marked with the panic stickers, but

Alexis Martin, RN, Emergency Department

no alert would have been sent if the keys were pressed. The Lab caregivers indicated

Good catch: Hours after an Emergency Department patient was sent to an intensive

they were not aware that the new desktop did not have Lynx Messenger on it.

care unit (ICU), the nursing coordinator was told that no beds were available for the

As a result: Ambulatory Workplace Safety & Civility leadership is working with IT and

patient.

Security to resolve this issue.

As a result: New processes were developed so that when an ICU is at capacity, other ICUs can take on the overflow patients.

April 2024 (Tie)

Shannan Shelton, Clinical Pharmacy Specialist, Pharmacy Good catch: Because the PowerChart dosage calculator couldn’t differentiate between elemental and total iron, a patient’s weight-based ferrous sulfate prescription would have been underdosed.

As a result: New language is being developed for weight-based orders relating to the amount of elemental iron that should be prescribed to patients.

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ZERO HARM

Patient Experience Engage all caregivers to serve our patients with love and excellence, providing an ideal experience across the continuum of care.

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PATIENT EXPERIENCE

Improving Patient Experience

New Patient Experience structure to guide improvement work Leadership Accountability

In FY 24, a key goal and priority for ChristianaCare is year-over-year progress to achieve exceptional patient experience by refining processes to drive improved experience as measured by survey scores.

In early spring 2024, the Patient Experience governance structure was

Continuous Performance Improvement

All Caregiver Engagement

redesigned to include an overall steer responsible for strategy, oversight of projects and metrics; an interdisciplinary improvement team responsible for

Patient Experience

improving the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs) metric for “Overall Rating of Hospital,” and a subcommittee structure.

The Patient Experience Improvement team has established focus areas that include executive leader rounding, clinical/discharge follow-up, and a

Commitment to Evidence Based/Best Practices

Accountability and Recognition

reward and recognition program.

The concentration of the five subcommittees is on data analysis, environment of care elements, establishing service excellence standards, nurse communication, and provider communication.

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PATIENT EXPERIENCE

Data Transparency

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs) Survey

HCAHPS scores improve by 4.5 points on DE campuses and by 2.5 points on MD campus HCAHPS survey scores. The HCAHPS survey provides valuable information on how patients perceive our care and their experience.

FY23

Q3-4 2023

Q1 2024

Benchmark

100

Percent Positive

In the first nine months of FY 24, we saw improvements in our

HCAHPS Domain Scores: Newark & Wilmington

100 90 80 70 60 50 40 30 20 10 0

80 60 40 20

m

m

Co m

Co m

increased by an average of 4.5 points and five domains now exceed

w

w

D

N

On the Newark and Wilmington campuses, domain scores the CMS 50th percentile benchmark. The greatest improvements are in Cleanliness & Quietness (+7.3), Communication with

HCAHPS Domain Scores: Cecil County

Medications (+6.5) and Communication with Doctors (+5.4).

FY23 100

to all Union hospital patient care units, leading to improvements in

80

points. Discharge Information exceeds the CMS 50th percentile.

Percent Positive

The intensive patient experience efforts (see next page) expanded seven of nine domains. Scores increased an average of 2.5

Re sp on siv en es Co s m m Ab ou tM Di sc ed ha s rg e In fo rm at io n Ca re Tr an Cl si ea ti o nl ns in es s / Qu ie tn es s Ov er al lR at W in ou g ld Re co m m en d

ur se s

oc to rs

0

Q3-4 2023

Q1 2024

Benchmark 100 90 80 70 60 50 40 30 20 10 0

60 40 20

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PATIENT EXPERIENCE

Re sp on siv en es Co s m m Ab ou tM Di ed sc ha s rg e In fo rm at io n Ca re Tr an Cl si ea ti o nl ns in es s / Qu ie tn es s Ov er al lR at W in g ou ld Re co m m en d

w m Co m

Co m

m

w

D

N

ur se s

oc to rs

0

Intensive Unit and Practice Patient Experience (PX) Work

Intensive hospital initiative increases scores by 2.5 %

1

In FY 23, Patient Experience began a collaboration with Nursing to drive

01

Patient Experience (PX) performance data review & analysis w/ unit leaders

improvement in PX measures across hospital inpatient units and the emergency departments.

02

PX Improvement team immersion & observation on unit

03

Coaching and on-site training on PX best practices, incl. communication, anticipating patient needs

04

1:1 Leadership development and creation of sustainment plan by unit leaders

05 Ongoing PX performance data review & analysis w/ unit leaders

Initially, 17 inpatient units at Newark and Wilmington were selected to

PX Intensive Model: 6-week cycles, 4 to 6 units/cohort

receive intensive support based on PX metric performance: intensive, moderate and local leader support. Intensive support included in-depth, unit-specific data reviews; coaching; education; observation and reinforced Nursing Bundle resources over a six-week period. Through February 2024,

Domain Score Improvement - All Inpatient Cohorts

five additional intensive cohorts were completed. The 27 participating areas

Pre-Intensive Score 80

increased key survey scores by an average of 2.5%. Improvements have

70

PX intensive interventions for the ambulatory practices saw a phased rollout of best-practice bundle components: AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You), HEAT service recovery (Hear, Empathize, Apologize, and Take Action) and Teach-back that incorporated mandatory education for all practice caregivers and toolkits.

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PATIENT EXPERIENCE

% Postive Score

been sustained; scores for the first cohort have exceeded their baseline by five points. Positive results were seen on HCAHPS (see page 33).

Post-Intensive Score

60 50 40 30 20 10 0 Care Transitions

Communication About Meds

Communication with Doctors

Communication with Nurses

The six PX Intensive cohorts, involving 27 patient care units over six months, improved HCAHPS scores in key domains by an average of 2.5 percentage points—an over 5% improvement from their baselines.

Responsiveness of Hospital Staff

Virtual Acute Care Nursing (VACN)

VACN transforms care delivery and helps improve Patient Experience scores

Explain Things Back Pre (Jul-Sep 2022)

45.0

39.8

40.0 35.0

acute care nursing (VACN) program, launched in 2022. Offering a critical extra set of eyes and connection to patients, our virtual

% Positive Score

30.0

ChristianaCare is in the vanguard of care delivery with our virtual

FY24 YTD (Jul-Mar)

nurses are helping to alleviate staffing shortages and improve

27.3

26.8

25.0 20.0

19.0

15.0 10.0 5.0

patient experience.

0.0 W5W

The percent of patients saying that they “always” had the opportunity to Explain Things Back increased by 43% for W5W Surgical and by 48% for C4B Medical.

In the VACN innovative model, nurses use virtual technology (such as computer tablets) to provide care that doesn't require in-person, at-the-bedside care, such as medication and discharge education.

Information About Symptoms

Since the program launch, PX scores in key domains have 80.0

improved. On the two pilot units (Wilmington 5W and Christiana 4B),

discharge increased by 14% for 5W and remained high for 4B.

60.0

% Positive Score

scores for receiving information about symptoms to watch for at

Pre (Jul-Sep 2022)

50.0

FY24 YTD (Jul-Mar) 68.6

68.0

70.0

patients responding that they always had the opportunity to explain things back after receiving instruction increased by over 40% and

C4B

58.8

51.5

40.0 30.0 20.0 10.0

Since the program’s launch in 2022, patient experience scores have

W5W

risen across all domains.

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QUALITY & SAFETY REPORT 2024

0.0

|

PATIENT EXPERIENCE

C4B

The percent of patients saying that they “always” received Information about Symptoms by 14% for W5W Surgical and by 1% for C4B Medical.

Quality Drive health outcomes as a national leader in clinical excellence through continuous improvement in effectiveness, timeliness and efficiency of care provision.

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QUALITY

Vizient Quality & Accountability Scorecard Vizient Ranking

Vizient ranking improves 12 points in our journey to Top 25 by 25

100 90

83

87

84 76

80

Rank

70

Vizient, the health care services organization that supports our

71

60 50 40 30 20

comparative risk-adjusted data analyses to drive quality and

10 0

safety improvements, provides a comprehensive annual

2020

Quality & Accountability Performance Scorecard that ranks

2021

2022

2023

2024 Q2

ChristianaCare's ranking against our academic medical center peers improved from 83 of 100 hospitals to 71 of 116 hospitals.

ChristianaCare among more than 100 comprehensive academic medical centers in six domains: mortality, efficiency, effectiveness, patient centeredness, safety and equity.

Domain Scores: 2024 Q2

In 2020, ChristianaCare was ranked 83. At that point, we set an

Score

audacious goal to reach the top 25 by 2025. Extensive efforts,

100.0% 80.0%

initiatives and service line clinical advancements are driving

60.0% 40.0% 20.0%

Eq ui ty

Ef fe ct iv en Pa es t ie s nt Ce nt er ed ne ss

Sa fe ty

Ef fic ie nc y

0.0% M or ta lit y

currently ranked 1 in Equity and 17 in Mortality (see next page).

Score

including Clinical Documentation Integrity, patient safety improved rankings across the domains. Most notably, we are

Vizient Median

In the second period of 2024 (July–Dec 2023), scores in three domains exceeded the Vizient median: Mortality, Safety and Equity. The greatest opportunity is in Patient Centeredness.

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QUALITY

Mortality

46% improvement in observed-to-expected mortality index Hospital coding is critical for ensuring accurate risk adjustment and payment as well as

Mortality Index

reliable comparative quality ratings. At ChristianaCare, incomplete documentation/

1.2

diagnosis code capture led to a Vizient mortality ranking based on the observed to score that was not reflective of our high-quality clinical care.

A multidisciplinary team led by Clinical Documentation Integrity and Health Information Management Services leaders assured alignment with clinicians, the finance team and coders. The team established a bill-hold process for quality review with a promised 48hour turnaround time, engaged physicians by demonstrating the link between

Observed vs. Expected Ratio

risk-adjusted expected index of 72 out of over 100 academic medical center peers, a

1.0

0.8

0.6

0.4

0.2

mortality metrics and documentation, and created a process to identify cases with cause standardized mortality review model and developed a continuous monitoring

0.0 2022-01 2022-02 2022-03 2022-04 2022-05 2022-06 2022-07 2022-08 2022-09 2022-10 2022-11 2022-12 2023-01 2023-02 2023-03 2023-04 2023-05 2023-06 2023-07 2023-08 2023-09 2023-10 2023-11 2023-12 2024-01 2024-02 2024-03

clinical opportunities for improvement. Additionally, the team transitioned to an allprocess, including case mix index and observed vs. expected service line level data.

The interventions led to a 46% improvement in the mortality index. During the same period, observed mortality decreased to 1.7% from 3.0%. ChristianaCare's Vizient mortality ranking improved to 17.

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QUALITY

The Mortality observed vs. expected index improved 46%, to 0.55 in the first quarter of 2024 from 1.01 in the first quarter of 2022.

The Mortality domain score increased from 43.2% to 72.8%. The Vizient ranking improved from 72nd to 17th.

Overall Hospital Quality Star Rating

Star Rating Measure Group Scores Jul-23

Ratings improve across all measures for Delaware campuses, four of five measures for Cecil County campus

Worse . . . National . . . Better

1.5

Jul-24

1.0 0.5 0.0 -0.5 -1.0 -1.5

The CMS Overall Hospital Quality Star Rating summarizes hospital

Mortality

Readmission

Safety of Care

Patient Experience

performance on 45 measures across five areas of quality—mortality, readmission, safety of care, patient experience, and timely and effective care—into a single star rating. Hospitals earn from 1 (worst) to 5 (best)

Timely & Effective Care

Scores improved in all five measure groups, with the greatest increases in Readmissions, Timely & Effective Care, and Mortality.

stars compared to other hospitals in the U.S. CMS used data published

Star Rating Measure Group Scores

on CareCompare (www.medicare.gov) to calculate the star ratings.

Jul-23

Jul-24

In FY 24, ChristianaCare Delaware campuses improved from three to four stars and saw increased scores across all five measures, with an average improvement of over .4 points.

Our Cecil County campus improved from two to three stars, with improvements in four of five measure groups, with an average improvement of .7 points.

Worse . . . National . . . Better

1.5 1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 Mortality

Readmission

Safety of Care

Patient Experience

Timely & Effective Care

Scores improved in four of five measure groups, with the greatest increases in Patient Experience, Safety and Mortality. There is opportunity in Readmissions.

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QUALITY

Union Hospital improves Quality-Based Reimbursement score by 18 points, reduces in-state readmissions by 3% Quality Based Reimbursement

Maryland’s Total Cost of Care Model combines all-payer global budgets with hospital

40%

accountability for quality care. The state’s Quality-Based Reimbursement (QBR)

35%

program incentivizes quality improvement in person and community engagement.

30%

both in- and out-of-state 30-day readmissions after an inpatient discharges. Both the

25%

Score

Maryland’s Readmission Reduction Incentive Program (RRIP) sets expectations for

34%

20%

16%

15% 10%

QBR and RRIP put 2% of inpatient hospital revenue at risk with penalties or rewards

5% 0%

based on performance.

FY 2024 (CY 2022)

This year, Union Hospital improved its QBR score by 18 percentage points and

FY 2025 (CY 2023)

Union Hospital improved the total QBR score to 34% for the FY 25 payment period from 16% for FY 24.

reduced in-state readmissions by 3% leading to an overall reduction in penalties of $1.04 million. By implementing an improvement plan focused on better patient

CRISP Readmission Rates

experience and reduced mortality, Union Hospital increased its QBR score to 34% in

To improve performance under RRIP, a campus workgroup implemented multiple initiatives, including creating a workflow so that high-risk patients having challenges being seen at ambulatory practices could have a home visit by a primary care nurse practitioner and optimizing community resources such as smoking cessation programs and mobile health van visits to underserved neighborhoods.

16.00%

Percent of Inpatient Discharges

CY 23 compared to the CY 22 score of 16%.

FY 2024 (CY 2022)

14.10%

14.00% 12.00%

FY 2025 (CY 2023)

11.42%

14.81%

11.07%

10.00% 8.00% 6.00% 4.00% 2.00% 0.00% In State

In & Out of State

Union Hospital reduced in-state 30-day readmission rates by over 3%, to 11.07% for the FY 25 payment period from 11.41% for FY 24.

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QUALITY

Sepsis

Sepsis Mortality Septicemia without Mechanical Vent 96+ Hours

country. Timely recognition and diagnosis of sepsis enables rapid treatment

Expected Mortality 2.0 1.8

20.00

1.6 1.4

15.00

1.2 1.0

10.00

0.8 0.6

5.00

0.4

to improve the likelihood of survival.

0.2

0.00

0.0

2022-1

2022-2

2022-3

In FY 23, ChristianaCare identified barriers to sepsis documentation and implemented a systemwide sepsis guideline. In FY 24, an initiative was launched to identify signs of sepsis early, setting goals to improve both timely

2022-4

2023-1

2023-2

2023-3

2023-4

2024-1

Discharge Quarter

Sepsis mortality improved from more than 10% in FY 23 to 8% in FY 24 year-todate. In that same period, the mortality index decreased 47%, from 0.72 to 0.38.

identification and accurate coding (capture) of sepsis.

Sepsis Capture Rate Septicemia without Mechanical Vent 96+ Hours

To reach the goal, ChristianaCare launched “Get Ahead of Sepsis,” an initiative that echoes the CDC’s efforts to help providers recognize, document and treat Clinical Decision Support (CDS) Tool. The tool directly links to the St. John Sepsis Surveillance Agent, a Cerner-developed alert for sepsis, and displays relevant clinical information to providers via an open chart alert in PowerChart.

Clinicians are also able to order sepsis bundle elements directly from the CDS.

% of total inpatient cases

sepsis in patients early and includes an enhanced Sepsis Alert and Sepsis

ChristianaCare 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 2022-1

Following the November go-live, ChristianaCare’s sepsis capture rates increased 68%. Mortality rates decreased 21%, to 8% from over 10%. The mortality observed to risk-adjusted expected index decreased 47%.

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QUALITY

Top AMC 2023

2022-2

2022-3

2022-4

2023-1

2023-2

2023-3

2023-4

2024-1

Discharge Quarter

ChristianaCare's sepsis capture rate—the percentage of cases coded appropriately with sepsis—increased to 4.9% in FY 24 year-to-date through March from 2.9% in FY 23, and now exceeds the 4.1% capture rate of top academic medical centers.

Better . . . Expected . . . Worse

Sepsis is a top cause of death in hospital intensive care units across the

Observed Mortality

25.00

% Mortality

Get Ahead of Sepsis drives 21% decrease in mortality

Mortality Index

Malnutrition

NutriCatch: Enhancing malnutrition detection in hospitalized patients Malnutrition Coding

In FY 24, our Clinical Documentation Integrity team partnered with dietitians and our

Mar-Apr 2023

Organizational Excellence team on NutriCatch, a multidisciplinary performance 700

improvement initiative that includes Information Technology, Informatics, Nursing,

600

This initiative aims to enhance malnutrition screening, detection, treatment and

500

diagnosis capture. It also aims for excellence in compliance with the Global Malnutrition Composite Score, the first nutrition-focused quality measure included in the CMS Hospital Inpatient Quality Reporting Program.

One of the initiative’s key achievements was the implementation of the Malnutrition Screening Tool in PowerChart. Positive screenings trigger a referral to a registered dietitian for evaluation. When malnutrition criteria are detected, a PowerChart Smart Zone alert notifies treating clinicians and updates the patient's chart with a malnutrition diagnosis to drive patient care protocols.

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QUALITY

Number of Patients

clinicians, Health Information Management Services and others.

documentation processes to best support our patients and improve appropriate

Mar-Apr 2024

605

400 312

300 200

248 179

100 0 Severe

Moderate

In the first two months after go-live, coding of Severe Malnutrition increased 74% compared to the same period in 2023; Moderate Malnutrition more than doubled; and revenue increased an average of $77,000 monthly due to the assignment of higher-level Diagnosis Related Groups with improved capture of complications.

Mobility

Standardization leads to 18% improvement in achieving inpatients’ daily mobility goals To improve mobility care at ChristianaCare, a multidisciplinary team of nurses, clinicians and Rehabilitation Services caregivers collaborated

Mobility Goal Achievement

to pilot the Johns Hopkins Activity and Mobility Promotion (JH-AMP) in

C5C

four units (5C and 6A at Newark, 4N and 6S/WICU at Wilmington). The

of patients meeting their daily mobility goals by 18%. Since that time, the program has expanded to all patient care units across all three campuses. Progress is monitored through the Activity and

% of Patients Achieving Goal

and creates a system to monitor patient mobility at system, campus,

During the three-month pilot, the units improved the percentage

W6S/WICU

80%

60%

40%

20%

Implementation

Mobility dashboard; in April 2024, over 70% of all eligible patients met their daily mobility goal.

C6A

100%

JH-AMP sets a Daily Mobility Goal for each patient via validated tools unit and patient levels.

W4N

0% Feb-23

Mar-23

Apr-23

May-23

Jun-23

Jul-23

Next steps are to share the strategies and lessons learned with all nursing units, standardize communication of patient mobility performance to frontline caregivers and leadership, and partner with Care Standardization.

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QUALITY

All mobility pilot units improved the percent of patients achieving their mobility goals, with an average improvement of 18%.

Aug-23

Flow Streamline the flow of patients across our health care system through improved organizational efficiencies, elimination of waste and coordination of transitions of care.

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FLOW

Hospital Length of Stay (LOS)

ChristianaCare’s Flow Committee drives 5% improvement in hospital LOS index An FY 24 Strengthen the Core annual operating plan goal focused on

incremental improvement toward the end of FY 24, with a 5% improvement in

reducing hospital LOS as well as the observed to risk-adjusted LOS index,

the LOS index and a decrease in hospital length of stay to fewer than six days.

which accounts for patient severity.

ChristianaCare’s Flow Committee drives improvement in key opportunity

Hospital Length of Stay LOS

hospital, such as timely discharge planning, efficient transitioning to postacute care, advancing effective communication among members of the care

through multidisciplinary rounds, collaboration with post-acute facilities and modifications of the patient/family choice process to reduce delays in placement.

In addition, a Challenging Emergency Department Discharge Process was implemented to avoid inpatient hospital stays for patients presenting to the ED without medical needs but with social or logistic barriers that prolong length of stay. Social workers collaborate with the ED team to support appropriate discharge from the emergency room. These efforts led to

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FLOW

7

1.4

6

1.2

5

1.0

4

0.8

3

0.6

2

0.4

1

0.2

0

0.0

Ju l-2 Au 2 g2 Se 2 p22 Oc t -2 No 2 v2 De 2 c22 Ja n2 Fe 3 b2 M 3 ar -2 3 Ap r-2 M 3 ay -2 3 Ju n23 Ju l-2 Au 3 g2 Se 3 p23 Oc t -2 No 3 v2 De 3 c23 Ja n2 Fe 4 b2 M 4 ar -2 4 Ap r-2 4

With care management, the Flow Committee worked to reduce barriers

Hospital LOS (days)

team and addressing patient complexity.

LOS Index

Overall in FY 24, the LOS Index (observed to expected ratio) improved 5%, from 1.190 to 1.126. During the same period, LOS decreased 2%.

LOS Index (Observed v. Expected)

areas that may adversely impact the number of days patients remain in the

Multidisciplinary Rounds (MDRs)

Over 90% compliance with standardized MDR process reduces discharge barriers In FY 22 and FY 23, ChristianaCare implemented MDRs focused on optimizing care transitions and addressing discharge barriers across our three campuses. The MDR emphasizes efficiency through a standardized process and script, with specific topics assigned to each member of the MDR team.

Escalation to Utilization Management Reasons Discuss discharge readiness w clinical team Escalation of system delays

In FY 24, the following activities occurred to advance the efficacy of MDRs: ongoing quality review and coaching for compliance with the established MDR processes; changes to physical therapy discharge recommendation documentation; and standardized Vocera use among the Medical Group to

Assistance with safe discharge planning Other Addressing consultant delays UM Review of current admission status

improve consult communication.

Patient/family refusing safe discharge plan

A March 2024 review of process compliance showed the standard process and script were followed in 91% of MDRs reviewed; 64% of these cases showed an escalation opportunity.

Possible custodial care case Evaluate for transfer back to referring facility 0

50

100

150

200

250

300

350

Number of Escalations

Barriers to timely patient discharge are escalated to utilization management physician advisors, service line leaders or campus leaders. The most frequent reasons for escalation include readiness for discharge, system delays and discharge planning.

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FLOW

In FY 24, through April, more than 1,200 escalations were made. Top reasons included discussion of discharge readiness with the primary clinical team, escalation of system delays and assistance with safe discharge planning.

Observation (OBS) Length of Stay

OBS length of stay flat with 22% increase in patients served Observation care involves treatment, assessment and reassessment to determine if

Observation Length of Stay Medical Observation

a patient may be safely discharged or requires inpatient care. Generally, observation patients stay in the hospital for less than 48 hours. In FY 24, several

Patients

improvements were advanced to improve LOS in observation areas: 35

Co-located Christiana Hospital complex medical observation patients on two units; new Medical Observation Unit (MOU) opened in April.

Appointed a dedicated Observation Care team that includes physicians and advanced practice clinicians and embedded daily MDRs and huddles.

•

Admission criteria revised to serve higher complexity Medical Observation patients.

•

Revised diagnosis-specific observation admission order sets with > 85%

400

30

OBS length of stay (hours)

•

450

350 25 300 20

250

15

200 150

10

utilization adherence.

100

Set expectation for use of Vocera to improve timing of consults and communication.

|

Apr-24

Mar-24

Feb-24

Jan-24

Dec-23

Nov-23

Oct-23

Sep-23

Aug-23

Jul-23

Jun-23

May-23

Apr-23

Mar-23

Feb-23

Jan-23

Dec-22

Nov-22

Oct-22

Collaborated with MRI and transport to expedite observation patients,

0 Sep-22

0

decreasing Turnaround Time by 2.75 hours.

47

50

Aug-22

•

5

Jul-22

•

Number of OBS Patients

•

OBS LOS Rolling 3-month

Through cohorting, the number of OBS patients treated on the MOU increased 22%.

Length of stay for medical observation patients remained flat at 26.2 hours for the most recent three-month period (February–April 2024) compared to February–April 2023.

Length of stay remained flat at 26.2 hours increased patient complexity.

The number of monthly medical observation patients increased by 22%, from 265 to 325.

QUALITY & SAFETY REPORT 2024

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FLOW

HomeHealth Timeliness of Service In FY 24, a new process improvement

96% of patients seen within 48 hours of referral

subgroup of the HomeHealth statewide Quality & Safety Committee prioritized Timeliness of Service

improving the time it takes to get 100%

Through chart audits, the

90%

multidisciplinary group identified staffing challenges and gaps in the referral process. To help improve the process and promote timely admissions, HomeHealth intensified caregiver

Percent in 48 Hours

patients started in home care.

Target: 95%

80%

70%

60%

education on best practices with data

Ju l-2 Au 2 g2 Se 2 p22 Oc t -2 No 2 v2 De 2 c22 Ja n2 Fe 3 b2 M 3 ar -2 3 Ap r-2 M 3 ay -2 3 Ju n23 Ju l-2 Au 3 g2 Se 3 p23 Oc t -2 No 3 v2 De 3 c23 Ja n24 Fe b2 M 4 ar -2 4 Ap r-2 4

entry of referral information.

50%

The percentage of HomeHealth patients seen within 48 hours of referral or on the Physician-Ordered Date improved from 94% in FY 23 to 96% FY 24, exceeding the agency’s 95% target.

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FLOW

Health Equity Address disparities and achieve equity in our quality of care, assuring culturally, linguistically and socially responsive care, particularly for underserved members of our community.

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HEALTH EQUITY

Sexual Orientation and Gender Identity (SOGI) Information & Race, Ethnicity and Language (REL) Information

96% Complete REL Data

Gender identity data collection improves by 25% in four months

SOGI Data Completeness

The National Institutes of Health, Centers for Disease Control, American Academy of Pediatrics, American Academy of Family

Gender Identify 80%

recommend that health care providers adopt patient naming

70%

conventions and inclusive models for collecting patient gender identity

60%

information.

In FY 24, ChristianaCare's Health Equity Office implemented the "We Ask Because We Care" campaign to improve capture of patientreported SOGI and REL demographic information. The extensive

% of Encounters

Physicians and many other national and international organizations

Birth Sex

50% 40% 30% 20%

multidisciplinary effort involved updating systemwide protocols for data collection, documentation and reporting of five elements: patient’s name used, gender identity, sex at birth, sex on legal

10% 0% 12/3/2023

1/3/2024

2/3/2024

3/3/2024

4/3/2024

5/3/2024

identification and pronouns, educating caregivers and patients as well as modifying the electronic medical record and workflows to appropriately use the additional gender identity data. At the same time, efforts were made to improve the collection and accuracy of patient-reported race, ethnicity and language.

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HEALTH EQUITY

Collection of gender identity data across all settings improved 25%, from less than 51% in December 2023 to 75% in April 2024. During the same period, birth sex completeness increased 29%, to 71% from 43%.

Social Drivers of Health (SDoH)

82% of eligible patients prescreened for SDoH SDoH Prescreen Needs Identified

To provide equitable care to the communities we serve, we must do more than provide excellent clinical services—we must

No Social Needs

understand who our patients are and what their lives are like. This

100% 13%

includes knowing and addressing SOGI, REL and social drivers of health. In 2024, CMS began requiring hospitals to screen patients housing insecurity, transportation insecurity and utilities.

Through the registration and nursing assessment process, all adult medical, surgical and maternity patients are prescreened. When patients indicate social care needs or their needs are undetermined, our Acute Care Social Care Connectors complete a full needs assessment. To address identified needs, the care

9%

12%

10%

88%

90%

Wilmington

Total

80%

% of Prescreened Patients

for five domains of SDoH: food insecurity, interpersonal safety,

1+ Social Need

60%

40%

87%

91%

20%

connectors make appropriate referrals for services to Unite Delaware, which provides a closed loop communication to

0% Cecil County

Newark

indicate when services are received.

Overall, 10% of prescreened patients had one or more social needs identified. Positive rates were higher at Cecil County (13%) and Wilmington (12%) campuses.

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HEALTH EQUITY

Limited English Proficiency (LEP)

Translated discharge instructions for LEP patients up by 30%

LEP Translated Discharge Instructions

Understanding hospital discharge plans is crucial for patients, as 35%

it directly impacts their recovery and overall health outcomes.

Clear instructions in patients’ preferred languages help ensure

30%

and attend follow-up appointments. Miscommunication can lead to medication errors, complications and readmissions, increasing health care costs and risking patient safety.

In FY 24, ChristianaCare increased the percentage of patients with limited English proficiency receiving translated discharge

% of LEP Patient Discharges

they follow prescribed medications, adhere to activity restrictions 25%

20%

15%

10%

instructions in their preferred language from 0% to 30%. Among the activities enacted to drive this increase were adding automatic alerts for the Language Services' translation team, improving documentation of interpreters used in the PowerChart

5%

0% Jul-23

Aug-23

Sep-23

Oct-23

Nov-23

Dec-23

Jan-24

Feb-24

Mar-24

Apr-24

ARP, and asking patients for their preferred method to receive

After the implementation of FY 24 activities, the percentage of patients with LEP who received translated discharge instructions increased from 0% to 30% across ChristianaCare’s three campuses.

discharge instructions.

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HEALTH EQUITY

ChristianaCare Way Awards

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards 2023 President’s Award

Clean Catheter, Happy Bladder: A CAUTI Prevention and Foley Vacation Project A new program reduced the incidence of catheter-associated urinary tract infection (CAUTI) in the Transitional Medical Unit (TMU). Between July and September 2022, the TMU’s CAUTI comprehensive unit-based safety program (CUSP) found an increase in CAUTI rates. They identified that timely Foley removal could prevent infection. In January 2023, an algorithm-based protocol, Foley Vacation, was implemented, empowering nurses to remove Foleys when patients began retaining urine so they could begin bladder training. CAUTI rates dropped from 6.3 to 0.0. No removed Foleys were reinserted, and every patient resumed voiding independently (100%). The algorithm, now called PREP (Post Retention Elimination Protocol), was implemented across all three hospital campuses in May 2023.

Zero Hero Award – Whitney Lane, RN, Labor & Delivery

Incorrect Documentation of Insulin Drip Premix Bags Insulin drip premix bags were scanning incorrectly in the Medication Administration Record, even with an override. The concentration was listed as 1 unit to 0.1 mL, instead of 1 unit to 1 mL. After the issue was escalated, a background mapping issue, which had mismatched the adult product concentration (1 unit/mL) with a product for neonates (0.1 unit/mL), was detected and corrected.

Magnet New Knowledge, Interventions & Improvements – Silver Award

To Using the Ipsilateral Arm in Breast Cancer Patients: A Practice Change Caregivers hadn’t used a patient’s ipsilateral arm (the arm on the side where the procedure occurred) for blood pressure measurement, blood draws or IV access after mastectomy or related procedures, although the practice wasn’t evidence-based. This sometimes led to inaccurate calf blood pressures, foot stick orders for phlebotomy or the need for tunneled central venous catheters. The team replaced patients’ orange “limb restriction – do not use” bands with gray “limb alert” bands, which could be used if the other arm could not be used. After eight months of lifted limb restrictions, there was zero incidence of lymphedema with ipsilateral arm use, zero orders for foot sticks and zero calf blood pressure measurements.

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards Magnet New Knowledge, Interventions & Improvements – Gold Award

Harry, Not All Wizards Are Good! Obliviating the Medication Administration Wizard PowerChart gained a new tool in July 2020, to chart emergency doses of medication to certain patients. The Medication Administration Wizard (MAW) was used to document emergently given medication doses when there was no order in PowerChart and a delay could harm the patient. The MAW was also used at times to bypass required patient and medication bar code scans, and to chart non-emergent doses of active orders. Medication Safety created a report of non-emergent MAW use and engaged leadership in Nursing and Respiratory Therapy regarding the intended usage of MAW in emergent situations. This helped the overall scan rate increase from 95% to 98%. At the same time, the number of non-emergent doses that were not scanned decreased by 76%.

Magnet Transformational Leadership Award

Innovating Nursing Practice: Virtual Care Nurse Model Delivers Outcome Improvements A collaboration among Nursing, Information Technology and the Center for Virtual Health resulted in an innovative care delivery model that reduces the burden on clinical nurses while providing high-quality care. The Virtual Acute Care Nurse uses tablet devices so that virtual nurses can see, hear and communicate with patients, family members and clinicians. The virtual nurses handle tasks like patient safety, education, care coordination and discharge. The virtual delivery model was piloted incrementally on Wilmington 5W and Newark 4B between September 2022 and March 2023. The patient experience percentile ranks improved in both units. Length of stay decreased by an average of 0.6 days, and there were 6% fewer readmissions.

Magnet Exemplary Professional Practice Award

Fall Reduction in the Clinical Decision Unit—A Standardized Approach Seventeen patients in Union Hospital’s Clinical Decision Unit experienced falls in FY 22. The root causes included variations in nursing assessments of patients’ risk for falls, as well as a need for interventions to prevent falls. Different strategies were implemented to decrease the risk of falls. Patients in the unit were not allowed to toilet alone. Exit alarms were placed on all patient beds and room chairs. All ambulating patients were placed in gait belts, and all patients wore nonslip footwear. Patients were taught fall-prevention strategies when they arrived in the unit. These changes helped decrease falls by 70%—with only five falls—in FY 23.

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards Magnet Structural Empowerment Award

Reduce Inpatient HAPI rate by 30% in FY 23, Union Hospital The rate of hospital-acquired pressure injuries (HAPI) at Union Hospital was too high in FY 22, with 79 cases overall and 25 cases at stage 2 or higher. Despite many initiatives in the second half of FY 22, the HAPI rate didn’t decrease. To change this, a multidisciplinary Pressure Injury Prevention team educated the entire inpatient nursing staff, aligning with the Delaware campuses’ best practices and policies. Nurses learned about the Braden Risk Assessment Tool and interventions, and how to modify documentation for medical device use. After the education initiative, HAPI cases dropped by 53%. There were 30 HAPI cases in FY 23, a decrease from 79, and only 10 HAPI cases reached stage 2 or higher, compared to 25 cases in FY 22.

Transformation Award

Mastering the Mortality Matrix When ChristianaCare received a Vizient mortality ranking of 71 out of 107 academic medical centers, the numbers did not reflect ChristianaCare’s high-quality clinical care.

The result prompted Clinical Documentation Integrity (CDI) to create a multidisciplinary approach to mortality reviews, to ensure accurate risk capture. In order to capture more complete data, CDI aligned with physicians, finance and coders, and implemented 48-hour bill-hold for case review, query escalation, all-cause mortality review, clinical opportunity improvement and continuous monitoring. The change improved patient acuity capture, which led to a 23% reduction in the observed-to-expected mortality index, from 0.91 to 0.68. ChristianaCare’s Vizient mortality ranking rose to 24 out of 116 academic medical centers.

Accelerate Growth: Environmental Sustainability Award

Using an Electronic Tool for MRSA Surgical Status Documentation Spine surgery patients who test positive for methicillin-resistant Staphylococcus aureus (MRSA) are prescribed perioperative antibiotic prophylaxis to reduce the risk of surgical site infection. Previously, Infection Prevention ordered patients’ antibiotics manually, which involved manual medical record review, manual data entry and faxing prescriptions to clinical pharmacists. The process took more than 11 hours monthly, and more than 120 pages were faxed each month. Infection Prevention had Perioperative Clinical Support create an electronic report that pre-populates with patients’ known MRSA status. Electronic reports are ecofriendly, decreasing paper usage and printing costs. The change has decreased the amount of time that Infection Prevention spends on MRSA perioperative antibiotic prescriptions by 59%.

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards Enable Every Caregiver to Thrive Award

Daring to De-escalate: Increasing Caregiver Access to Workplace Violence Education The number of workplace violence incidents at ChristianaCare increased from 574 in FY 21 to 626 in FY 22. During that time frame, only 848 caregivers were trained in de-escalation techniques. To increase the number of trained caregivers, the Workplace Civility education subcommittee teamed with LearningSpace and iLEAD to expand training. Caregivers in high-risk areas were offered an eight-hour Nonviolent Crisis Intervention course. Caregivers in moderate- and low-risk areas were offered a four-hour Verbal Intervention course. The team increased the number of instructors and created flexible training options. In FY 23, the number of caregivers who were trained in de-escalation techniques increased by more than 77%, to 1,506.

Radically Simplify Access Award – Silver – and People’s Choice Award

Access Made Easy: Improving WAM Follow–up Appointments Patients who were discharged from the Emergency Department (ED) between September and November 2022 had to wait 29 days on average to follow up with their Wilmington Adult Medicine primary care providers because of scheduling conflicts. The team revised their scheduling process, creating specific hold slots for ED follow-ups, pre-op appointments and inpatient follow-ups. They also had a senior scheduler review to ensure correct scheduling. This increased the efficiency of the scheduling process by 62%. By March 2023, patients discharged from the ED waited only seven days, on average, for follow-up appointments.

Radically Simplify Access – Gold

Increasing Wilmington OR Ophthalmology Surgery First Case On-Time Starts Wilmington Ophthalmology has 63 surgical cases each month, on average, but the percentage of first case on-time starts was only 35%. The team of nurses, surgeons, surgical technicians and anesthesia providers adopted strategies to improve the percentage of on-time starts. Eyedrop orders were prioritized by noon the business day before the scheduled surgery. First case calls were used to emphasize the importance of two-hour patient arrival time. The team provided nursing education and cross-training for post-op focus, to move patients through phase 2 more quickly. Within two months, first case on-time starts increased to 43%.

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards End Disparities Award

Expansion of High-Level Imaging on the Wilmington Campus: A Multi-Modality Approach Imaging discovered disparities in care relating to high-level imaging services at the Wilmington campus compared to the Newark campus. When patients were transferred to the Newark campus, turnaround times for imaging were nearly 24 hours, increasing inpatients’ length of stay. Changes were made on the Wilmington campus so that more patients could be offered high-level imaging there. Software and hardware were implemented, and caregivers received training to support cardiac computed tomography angiography (CCTA) and pacemaker placement, as well as CT- and ultrasound-guided procedures. Within eight months, 86 inpatient CCTA exams were completed on the Wilmington campus. Because patients didn’t need to be transferred, the turnaround time decreased from nearly 24 hours to eight hours, and the cost savings was $96,000. Having the ability to offer MRI to patients reduced transfers, saving $44,000. The addition of an on-site radiologist allowed for 36 outpatient procedures.

Strengthen the Core: Flow Award – Bronze

Let’s Get VERT-ical Because of the COVID-19 pandemic, the ChristianaCare Emergency Department (CED) has experienced a return to greater numbers of patients, including higher acuity patients, as well as throughput barriers. The CED Leadership Team and Organizational Excellence partnered to improve door-to-doctor time, left-without-treatment rates and length of stay. They implemented three pilot programs. During check-in, immediately after window intake, patients had their vital signs collected. A dedicated nursing and physician team provided patient evaluation and triage. And vertical care identified middle-acuity, ambulatory patients who could safely receive care in a nontraditional setting through a new care pathway. These changes led to a 30% improvement in median door-to-doctor time (47 minutes instead of 67 minutes) and left-without-treatment rates decreased by 2%.

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards Strengthen the Core: Flow Award – Silver

The Newborn Hospital Stay: Maximizing Value Without Sacrificing Patient Experience When a mother and baby are medically stable, timely discharge of the couplet is an important cost-saving measure that aligns with ChristianaCare’s organizational goals. Timing of discharge varies, depending on the method of delivery, maternal and neonatal medical conditions and maternal preference. ChristianaCare pediatric hospitalists see more than half of all well newborns. They focused on readiness for discharge with day-of-birth discharge planning, as well as standardized processes and clinical care to increase efficiency.

These changes helped increase the number of babies discharged by noon from 59% to 71%. Length of stay decreased from 54.9 hours to 52.2 hours. When these changes were implemented, net promoter scores for the Postpartum unit increased.

Strengthen the Core: Flow Award – Gold

Streamlining Success: Enhancing Efficiency in Express Admissions In 2019, the Clinical Express Admissions (CEAD) Unit opened to improve flow among patients who were admitted through the Emergency Department (ED). CEAD completed admission work and started treatment for admitted patients, aiming to move them to their intended medical units within four hours. However, CEAD had become a boarding unit

by December 2022, with the median length of stay at 40.2 hours. To improve patient flow, the CEAD staffing model was changed from unit-based with a floating nurse to 100% unit-based. Transitional beds were added, with criteria for low-acuity patients. The role of the charge nurse was changed to a flow resource nurse to facilitate flow among the ED, CEAD and floor units. Within six months, the CEAD median length of stay decreased to 11 hours, saving an estimated $1.3 million.

Strengthen the Core: Quality Award – Bronze

Achieving Inpatients Daily Mobility Goal Inpatient immobility has been associated with decline in patient function, longer lengths of stay and increased patient harm, such as pressure injuries. The Johns Hopkins Activity and Mobility Promotion (JH-AMP) program standardizes mobility language for inpatients. It embeds tools, so caregivers can set personalized daily mobility goals for each patient and monitor the daily progress toward their goals. After the JH-AMP program was implemented systemwide, a nursing and rehabilitation team established a pilot program, working with four units to focus on meeting daily mobility goals through nursing tasks and physical therapist documentation. All units demonstrated performance improvements, and an additional 9% of patients met their daily goals. There were no adverse effects during the pilot program, such as patient falls or caregiver patient-handling injuries.

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards Strengthen the Core: Quality Award – Silver

An Aspiration to Eliminate Aspiration: Implementing a Post-Extubation Swallow Screen Patients who are intubated for more than 48 hours are at greater risk of dysphagia, silent aspiration and aspiration pneumonia. ChristianaCare’s intensive care units did not have standard protocols to assess patients’ swallowing after extubating. A Post-Extubation Dysphagia Screen was developed and implemented in ICUs across all three hospital campuses. Four hours after extubating, a PowerChart task triggered for nurses to screen for dysphagia. When patients fail the screen, an evaluation by a speech language pathologist is triggered in PowerChart. The screening tool increased the percentage of swallow screens from 43% to 96%. The percentage of patients who failed the screen who met with a speech language pathologist increased from 48% to 96%, resulting in a 62% increase in the number of patients who received a modified diet to prevent aspiration.

Strengthen the Core: Quality Award – Gold

Protecting the Preemie Brain: Preventing Intraventricular Hemorrhage in Tiny Babies Infants born before 29 weeks are at risk of complications, including intraventricular hemorrhage (IVH), or bleeding in the brain. IVH may cause neurologic damage or death.

Hypothermia increases the risk of IVH, sepsis and death. ChristianaCare’s rate of admission hypothermia was higher than peer rates, and there was opportunity to improve IVH rates. The NICU team modified evidence-based protocols to focus on thermoregulation during the first hour of life, known as the Golden Hour. They also developed neuroprotective strategies that focused on markers for the first 72 hours and the first week of an infant’s life. Implementation of these strategies led to a significant decrease in rates of admission hypothermia, dropping from 44% to less than 7%. Despite the fact that the number of extremely premature babies delivered at ChristianaCare has increased, the incidence of severe IVH has decreased by more than 15%—above the risk-adjusted expected rate.

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards Strengthen the Core: Safety Award – Bronze

I’m OVER the Risk: Pharmacists Find Ways to Reduce ADC Overrides in Women’s Health Medications dispensed to inpatients from automated dispensing cabinets (ADCs) bypass pharmacist review, which may lead to medication errors in some instances. The Joint Commission’s medication management standards require that hospitals using ADCs must have a policy that describes the types and frequency of medication override review. ChristianaCare’s Center for Women and Children’s Health did not have a specific override list, and override rates were as high as 30% in some areas. Pharmacy conducted a medication-use evaluation to correct this oversight. They added orders to PowerPlan for commonly overridden medications. They also created an override list specific to women’s health, with 16 additional medications. These changes met Joint Commission standards, and overrides in Women and Children’s Health decreased by over 18%.

Strengthen the Core: Safety Award – Silver

Suicide Prevention Pathway ChristianaCare was the first hospital in Delaware to routinely screen all admissions for suicide risk, but changes were needed to meet Joint Commission requirements for suicide prevention relating to screening, tracking and follow-ups. A multidisciplinary team led by Psychiatry & Behavioral Health developed a Patient-Answered Risk Prevention Questionnaire to assess patient risk and protective factors, and to improve access for patients at low and moderate risk. The questionnaire created automatic firing for opt-in evaluations, based on patient responses, and a dashboard allowed for improved patient tracking. More than 2,000 risk-stratified patients received evaluations using the new questionnaire, at an opt-in rate of 60%. If only 1% of the evaluations prevent suicide, 22 lives may be saved each year.

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CHRISTIANACARE WAY AWARDS

ChristianaCare Way Awards Strengthen the Core: Safety Award – Gold

Don’t Wait! A SmartZone Alert Prevents Hospital-Onset C. difficile A case review of hospital-onset C. difficile cases found that half of the cases could have been prevented by earlier testing. Hospital-onset C. difficile cases have an incremental average length of stay of 11 days. They also have an attributable cost of $34,000 per patient, while community-onset cases have an attributable cost of $20,000 per patient. A SmartZone alert was created to notify clinicians when patients have diarrhea within the first three days of admission, when the C. difficile is attributable to community onset versus hospital onset. The SmartZone alert was adopted systemwide in March 2023, after a successful pilot program. Within a four-month period, the SmartZone alerts prevented eight cases of hospital-onset C. difficile.

Through August 2023, at least 12 hospital-onset cases were prevented.

Value Award

Maximizing Value of Type and Screen Testing for Obstetrical Patients Type and Screen (T&S) blood tests may be offered during pregnancy to ensure that patients who need blood transfusions receive transfused blood that is compatible with them to prevent adverse reactions. Most pregnant patients who receive T&S blood tests at ChristianaCare never need blood transfusions, yet more than $1 million has been spent annually on the tests. In 2021, only 7% of obstetric patients who had a T&S test received blood transfusions. Because T&S tests have quick turnaround times and there is minimal risk of using emergency release (uncross-matched) blood, the team created a screening protocol to focus testing efforts on the highest-risk patients. In one year, the OB Type & Screen protocol decreased the number of tests administered by more than 50%, reducing costs by $607,000. There was no increase in the number of patients who needed blood transfusions or emergency-release blood during that time frame.

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CHRISTIANACARE WAY AWARDS

ChristianaCare by the Numbers ADMISSIONS

61,103

RADIOLOGY PROCEDURES

HOSPITAL-BASED LAB TESTS

549,391

4,535,338

BIRTHS SURGICAL PROCEDURES

PRIMARY CARE OFFICE VISITS

39,425

294,844

HOMEHEALTH VISITS

URGENT CARE CENTER VISITS

208,075

209,514

TOTAL CAREGIVERS

RESIDENTS & FELLOWS

VOLUNTEERS

13,784

308

6,709 OUTPATIENT VISITS

873,875

VIRTUAL VISITS

22,188 EMERGENCY DEPT. VISITS

227,145 Christiana Hospital 97,676 Wilmington Hospital 61,795 Union Hospital 35,051 Middletown ED 32,623

OUR PEOPLE

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(72,802 Volunteer hours)

669

Quality & Patient Safety

About ChristianaCare Headquartered in Wilmington, Delaware, ChristianaCare is one of the country’s most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible and lowering health care costs.

ChristianaCare includes an extensive network of primary care and outpatient services, home health care, urgent care centers, three hospitals (1,430 beds), a freestanding emergency department, a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women’s health. It also includes the pioneering Gene Editing Institute.

ChristianaCare is nationally recognized as a great place to work, rated by Forbes as the 2nd best health system for diversity and inclusion, and the 29th best health system to work for in the United States, and by IDG Computerworld as one of the nation’s Best Places to Work in IT. ChristianaCare is rated by Healthgrades as one of America’s 50 Best Hospitals and continually ranked among the nation’s best by U.S. News & World Report, Newsweek and other national quality ratings.

ChristianaCare is a nonprofit teaching health system with more than 260 residents and fellows. With its groundbreaking Center for Virtual Health and a focus on population health and value-based care, ChristianaCare is shaping the future of health care.

800-693-CARE | ChristianaCare.org

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ZERO HARM