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QUALI T Y AND PATIENT SAFETY ANNUAL REP ORT 200 9


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

Accelerating Transformation Health care has never had more scrutiny. Increased oversight from the private sector, government and consumers has led to demands for greater transparency and challenged us to rethink how we deliver care. The good news is that Christiana Care has accepted the challenge and we are transforming how we deliver care. This past year, teams throughout Christiana Care have focused their collective energy and creativity to make dramatic improvements in quality, safety and enhancing the value of what we do for the communities we serve. This report details some of our most successful Focus on Excellence initiatives of the past year. As you will read, the key areas of focus for Christiana Care are improving quality and safety, decreasing costs and building our financial strength to reinvest in our mission of care and service.


FOCUS ON EXCELLENCE Awards, Achievements and Recognition With its focus on developing and maintaining a safe culture grounded in achieving high reliability processes and leveraging technology, Christiana Care continues to be honored as a leader in patient safety and quality of care.

2009 Accreditations Bone Marrow The three-year reaccreditation by the Foundation for the Accreditation of Cellular Therapy (FACT) attests that Christiana Care’s program continues to meet FACT’s rigorous standards for

collecting, processing and transplanting bone marrow and stem cells. Started in 1991, the Christiana Care program remains the only FACT accredited program in Delaware and one of only 169 in the U.S. and Canada.

Bone Marrow Transplant Program team members, are (top row, from left), Patricia Strusowski, RN, MS, Kathy Hinckle, RN, Tina Scherer, RN, MSN, OCN, Yong Zhao, M.D., Betty Stone, RN, Courtney Crannell, RN. (Front row, from left) Dawn Henry, MT, Frank Beardell, M.D., Shirley Amato, RN, Liz West, RN, and Danielle Brown, MSW. Missing from photo is Stem Cell Transplant Coordinator Mary Sheridan, RN.

Level-4 Trauma Center Wilmington Hospital is a participating trauma center (Level-4) in the Delaware

Trauma System. The last site survey was conducted by the State of Delaware Office of Emergency Medical Center on March 17, 2009.

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In the Spotlight Nationally U.S. News and World Reports “America’s Best Hospitals 2008” U.S. News and World Report ranks Christiana Care in the top 50 hospitals in the United States in three specialties: ear, nose and throat (46); endocrinology (37); and gastroenterology (40).

Thomson Reuters 100 Top Hospitals Performance Improvement Leader For the second consecutive year, Thomson Reuters, a nationally-known provider of health care information, puts Christiana Care among the top 100 U.S. hospitals – and among the top 15 major teaching hospitals – for the fastest, most consistent performance improvement over five consecutive years.

Thomson Reuters Healthcare Award Christiana Care won a 2009 Thomson Reuters Healthcare Advantage Award for its “extraordinary improvement” in clinical performance – in reducing length of stay for patients with heart failure, syncope, pneumonia and cellulitis; decreasing practice variations among these populations; and improving compliance with heart failure and pneumonia core measure sets.

American Association of Critical-Care Nurses Beacon Award, Spring 2009 The Medical Intensive Care Unit earned the prestigious Beacon Award, which goes to units that exhibit “high-quality standards and exceptional care of patients and patients’ families.” Christiana Hospital is one of only 35 hospitals nationwide to receive this award.

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THOMSON REUTERS Healthcare Advantage Award


American Heart Association (AHA) “Get with the Guidelines” Awards The AHA awarded Christiana Care an AHA Gold Award for achievement in myocardial infarction care and an AHA Silver Award for achievement in heart failure care. Christiana Care will be featured in the AHA “Get with the Guidelines” advertisement in U. S. News and World Reports July 2009 Best Hospitals issue.

Nursing Professionals’ “Top 100 Hospitals to Work for 2009”

American Hospital Associations Hospitals in Pursuit of Excellence: A Guide to Superior Performance Improvement, May 2009 Christiana Care’s “Automated Patient Tracking in the ED” is one of only 30 case

Nursing Professionals ranked Christiana Care tenth on its list of the best hospitals in the nation to work for 2009.

studies from hospitals nationwide included in the AHA’s new guide to help hospitals reduce health care acquired infections and improve patient safety, patient flow and medication management.

In the Spotlight Regionally National Research Corporation Consumer Choice Award For the 13th consecutive year, Christiana Care earned the Consumer Choice Award as the top hospital in the Delaware region.

Christiana Care hosted the regional American Heart Association “Pursuit of Clinical Excellence” workshop in April 2009. Timothy Gardner, M.D., Medical Director of the Center for Heart & Vascular Health and President of the American Heart Association, opened the conference.

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In the Spotlight at Christiana Care Christiana Care’s annual Focus on Excellence Awards exemplify our commitment to improving the health of all those we serve. This year, 19 of 75 outstanding team entries were recognized for their creativity and ongoing commitment to improving the safety and quality of care for our patients. At the award ceremony, Michael O’Neil, founder and Chief Executive Officer of GetWellNetwork, Inc., spoke about the importance of transforming the patient bedside experience to improve costs and quality of care.

President’s Award

Safety First – Gold Award.

Vigilant Advocacy to Prevent Hospital Acquired Infections: VAP Eradication. The Medical Intensive Care Unit (MICU) had a zero Ventilator Associated Pneumonia (VAP) rate for nine of 10 months. The quarterly VAP rate the MICU fell below the National Health Safety Network mean rate for similar units, reaching zero. Compliance with head-of-bed elevation improved to 100%.

Looking for Mr. Good Bar Code. Pharmacy developed a quality assurance process to validate and certify medication bar codes and to provide a highly reliable scan rate. In two months, Wilmington Hospital administered more than 165,000 doses, with fewer than 20 failures. This success rate of more than 99.99% exceeds the team goal of 99.5% and approaches Six Sigma level.

Clinical Excellence – Gold Award.

Reduction in Inpatient DVT Rate at CCHS Utilizing a Multidisciplinary PI Approach. As a result of focusing on prevention and risk assessment for surgical patients, the deep-vein thrombosis (DVT) rate decreased by about 40%. Availability of pneumatic compression boots in the Christiana Hospital post anesthesia care unit (PACU) increased from 10% to 100%, and availability of boots in surgical inpatient units improved from 50% to 90%. A system-wide DVTreduction steering committee is being formed.

Strengthening Trauma Care: Implementation of INR Point of Care Testing. International Normalized Ratio (INR) Point of Care Testing (POCT) saves at least 30 minutes from an INR lab sample. Less venous blood is required for INR POCT, and the process gives nurses the autonomy to draw blood samples from trauma code patients when they arrive.

Clinical Excellence – Silver Award. Prewarming the Perioperative Patient. The temperature of patients wearing Bear Paws gowns was more than three times more likely to increase than that of patients receiving traditional pre-warming techniques.

Clinical Excellence – Bronze Award. 5A Care Improvement Pilot. A multidisciplinary team rounds used a Patient Care Worksheet to track outstanding issues, prioritize the workload and predict which patients were likely to be discharged within the next 24 hours. The pilot met its goals within 3 months: reduced length of stay by 0.5 days, increased patient turnover by 5%, reduced third-partypayer denied days by 28%, and improved patient satisfaction scores by 25%.

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Safety First – Silver Award.

Safety First – Bronze Award. Tissue Tracking: Accountability for Tissue Surgically Implanted Into Our Patients. Bar coding technology increased the accuracy of tissue tracking to 100%. The system also supports tracing tissue involved in recalls, assuring patients that all tissue is safe for implantation.

Safety First – Honorable Mention Award. Implementation of a Team Training Program for Trauma Care. More than 350 trauma clinicians were trained in team concepts and standardized processes. Positive perceptions of teamwork increased significantly, and preliminary data show a decrease in the length of stay for trauma patients admitted after the training.


Great Place to Work Award.

Learning Excellence Award.

Got Verbal Orders? Sign Online! A multidisciplinary team developed technology that enables physicians to sign off on verbal and phone orders online. Four months after the online system was implemented, 90% of 62,800 verbal or phone orders were signed, compared to 3% at baseline, and 80% met the 48-hour signature standard.

Perioperative Documentation Education. Within six months (3 months ahead of schedule), 100% of the 900+ perioperative staff members were trained on new perioperative on-line documentation. Within five days of training, staff operated independently.

Think of Yourself as a Patient Award. Pharmacy Addresses the Needs of Gluten Allergic Patients. Pharmacy software systems do not detect conflicts between medication and food allergies, including gluten which is used as filler in some medications. Pharmacy established a process to force manual filling of orders for gluten allergic patients. Post implementation, Pharmacy dispensed six medications with gluten but the allergy was identified in all cases and none of the medications were given.

Financial Strength Award. Orthopedic Implants Supply Cost Initiative. To save money without limiting surgeons’ choices, the team secured five vendors who agreed to formulary pricing for total joint implants. Far exceeding its $600,000 savings goal, the team saved $1,500,000.

Nursing Excellence Award. Preparation of Elective Joint Replacement Patients. Because nurses at the Center for Advanced Joint Replacement empower and support patients, 92% of patients are discharged within the threeday goal, and 85% are discharged to their homes, with home or outpatient therapy. The readmission rate is less than 2%, and patient satisfaction scores are in the 97th percentile.

Nursing Excellence – Honorable Mention Award. Implementation of a Constipation Protocol. Within eight months, the Constipation Care Management Guideline team achieved a 52% increase in documenting bowel movements and a 25% decrease in patients with no BM for four or more days. The percentage of patients who had a BM within one to three days increased 18%.

Learning Excellence – Honorable Mention Award. Achieving Competency Today: An Innovative Learning. Funding from the Robert Wood Johnson Foundation has enabled 53 interdisciplinary learners to complete the 12-week ACT curriculum. Seventeen performance improvement projects developing from the course are underway.

Resident’s Award. What Search Engine? Improving an Underutilized and Inaccurate Resource. The implementation of the IS Sharepoint Search increased the percentage of successful searches from 51% to 89%, and the number of searches required dropped more than 50%.

Operational Improvement Award. Emergency Department – Front End Redesign. The front-end redesign of the Emergency Department decreased the Super-Track patients’ median length-of-stay by 70 minutes, the rate of patients who left without treatment dropped 73%, and patient satisfaction scores reached the 99th percentile.

Excellence in Community Health Award. Promoting Clinical Outcomes and Operational Efficiency. Streamlined billing reduced the number of bill holds, the days to request for anticipated payment and cancelled requests for anticipated payment. Clinical Outcomes & Reimbursement also decreased the number of days to payment.

People’s Choice Award. Simulated Code Blue Practice for Radiology. After training, 40 radiologic technologist and technical assistants reported their comfort level in a Code Blue situation increased by 56% and their ability to locate emergency equipment increased by 54%.

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Sharing What We Learn In the past year, Christiana Care nurses, physicians and staff published more than 50 articles in nationally-recognized venues and gave more than 100 invited presentations at national and international conferences. Here are some recent accomplishments.

Publications “Cancer Stem Cells: A Step toward the Cure,” in Journal of Clinical Oncology, 26 (17). “Change Management at the Hospital Front Door: Integrating Automatic Patient Tracking in a High-Volume Emergency Department and Level-1 Trauma Center,” in Nurse Leader, 6 (2). “Christiana Care Health System: Safety Mentor Program,” in the Agency for Healthcare Research and Quality four-volume Advances in Patient Safety: New Directions and Alternative Approaches. “Favorable Toxicity and Biochemical Control Using Real-Time Inverse Optimization Technique for Prostate Brachytherapy,” in Brachytherapy, February 11, 2009. “Five Minute Consult – Safety Mentor Program,” in Media HealthLeaders, May 2009. “Free Them Up…Effective Patient Safety and Quality Improvement Require Skill Development,” in the American Journal of Medical Quality, 2008 (23).

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“Implementation of a Team Training Program for Trauma Care: The BETTER (Bringing Enhanced Team Training to the Emergency Room) Initiative,” in Annals of Emergency Medicine, 52 (4). “Improving Handoff Communication,” in Nursing, February 2009. “Integrating Hospital-Based Pharmacists in a Private Medical Oncology Office,” Oncology Issues, 2009. “Integrating Team Training Strategies into Obstetrical Emergency Simulation Training,” in Journal of Healthcare Quality, scheduled September/October 2009.


Presentations The Agency for Healthcare Research and Quality's Health Care Innovations Exchange featured Christiana Care’s Patient Safety Mentor Program innovation in a nationwide webinar, “Improving Innovations: How to Make Data Work for You,” United States and Canada, April 2009.

“Maintaining the ACE Unit: Interdisciplinary Teams, Protocol, and Quality Improvement Outcomes on the ACE Unit,” at the 12th Annual Nurses Improving Care for Health System Elders (NICHE) Leadership Conference, February 23.

“Focus on Excellence: A Team Plan to Stop Falls,” at the Institute for Healthcare Improvement Forum on Quality Improvement in Healthcare, December 2008.

“Process Improvement in Cardiac Rehabilitation Outcome Data Collection,” at the Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Conference, April 29.

“Implementation of a Team Training Program for Trauma Care: The BETTER (Bringing Enhanced Team Training to the Emergency Room) Initiative,” at American College of Emergency Physicians Conference, October 2008. “Is Zero VAP Truly Achievable” at the 2009 American Association of Critical Care Nurses Conference May 2009.

“Survey of Post-Bariatric Surgery Patients: Characteristics Associated with Follow-Up Practices,” at the 26th Annual Meeting of the American Society for Metabolic & Bariatric Surgery, June 2009. “TeamSTEPPS Implementation and Sustainment in a Large Independent Academic Medical Center,” at the Team STEPPS Collaborative, June 2009.

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SAFETY FIRST Creating a Safe Culture Creating outstanding patient safety and quality of care depends on developing and maintaining a vibrant culture that engages caregivers in proactively finding solutions to problems, sees mistakes as opportunities to learn, and focuses on effective communication. Creating a safe culture offers several benefits: • Supports communication among all levels and areas of the organization. • Encourages multidisciplinary, collaborative problem solving. • Contributes to the consistent delivery of high quality, safe patient care. • Allows staff to learn from mistakes rather than placing individual blame. • Helps care providers understand how to work together effectively in complex processes. • Supports better interactions with patients and their families and places them at the center of their health care. • Provides mentorship and a sense of community.

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Agency for Healthcare Research and Quality (AHRQ) Hospital Survey One of the first steps in changing culture involves assessing that culture. Christiana Care is one of 190 teaching hospitals to participate in the 2009 AHRQ hospital survey on patient safety culture. The survey, which was also administered in 2006, measures

The 2009 results demonstrate the following areas of strength: • Teamwork within units. • Supervisor/Manager expectations and actions to promote safety. • Organizational learning and continuous improvement. • Management support for patient safety.

patient safety culture in detail at the unit/department and at an overall hospital level. From 2006 to 2009, Christiana Care has shown significant improvement in its culture of safety. The percentage of respondents giving Christiana Care an overall safety grade of either an “A” or a “B” increased significantly, from 69 percent to 75 percent.

Areas that will continue to be a focus for improvement: • Communication between units with coordination and exchange of key clinical information. • Non-punitive response to error and staff concern that mistakes are held against them and are placed in their personnel file. • Staff feeling free to speak up and question those with more authority.

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Handoff Communication Breakdowns in communication are a major cause of error and a threat to patient safety. To ensure that complete information is transferred along with the patient, an interdisciplinary team at Christiana Care has implemented tools for three types of handoffs: handoffs to other departments, handoffs to other nurses and handoffs to physicians.

• Handoffs to nurses: the DATAS tool The team created this tool in response to a random survey of nurses asking what information they most need to know during a shift-to-shift or unit-tounit handoff: - Demographic and diet information - Assessments and allergies - Tests and test results - Alerts such as do-not-resuscitate orders

• Handoffs to patient escorts and other departments – Round Trip Ticket Acute care patients often leave their unit for tests, procedures or therapies but are usually always accompanied by a nurse who knows the patient’s information. To ensure that the information goes with the patient, the team developed a two-part ticket. The unit nurse fills out the top part, answering questions such as “Can the patient ambulate and transfer independently?” or “Does the patient speak English?” Someone in the receiving department fills out the bottom part, indicating any important events or changes in the patient’s condition while the patient was away from the unit. Names of staff members involved in the patient’s care and their contact numbers are also included.

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- Status of the patient within the plan of care. • Handoffs to physicians: SBAR After reviewing tools other hospitals use to improve handoffs to physicians, the team chose SBAR, an acronym detailing information necessary for a safe handoff: - Situation. - Background information. - Assessment of the current situation. - Requests related to the problems being reported.


Team Training

• Mutual Support

Although safe and effective patient care demands that diverse health care professionals work together, most have no training in communicating across disciplines or in being productive team members. To improve teamwork and ensure safer practices, a Christiana Care multidisciplinary team used Team STEPPSTM, an evidence-based teamwork system designed to improve patient outcomes by building communication and other teamwork skills to develop a team training curriculum with four core competency areas: • Leadership

• Communication. Most Emergency Department and Trauma Operating Room staff have participated in the training. All members of the perioperative staff are expected to complete the training by the end of 2009; numerous departments have incorporated elements of Team STEPPSTM Training into their daily practices. Integrating team concepts into its obstetrical emergency response training, for example, Women and Children’s has developed a coordinated, rapid response to shoulder dystocia.

• Situation Monitoring

From the surgeon's perspective, Team Training has been a tremendous opportunity for success. Not only have we improved our overall patient safety, but the training has positively affected relationships between the departments of anesthesia, surgery, emergency medicine and nursing. For the attending surgeons and surgical housestaff, Team Training has been a transformative journey, using the concepts of communication, leadership and professionalism to build a foundation for better practice patterns and performance improvement in trauma care. I strongly believe that this initiative will propel CCHS into the future, developing effective team building, potentially eliminating medical errors and applying a true multidisciplinary approach to patient care. Team Training has the potential to reduce emergency department, OR, ICU and ward disposition times and ultimately length of stay. This program has now been written into our resident and midlevel practitioners' curriculum and will be an integral part of our simulation training.

Steven A. Johnson, M.D., FACS, attending surgeon and faculty, Surgery Residency Program S A F E T Y F I R S T ♦ C R E AT I N G A S A F E C U LT U R E

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No Harm Intended: Lessons Learned in Patient Safety The No Harm Intended sessions are based on the premise that all harm is preventable. These sessions are designed to increase visibility of errors, show the human

Storytelling Rather than presenting only graphs and charts, which show error rates and good catches as numbers, No Harm Intended presents stories that make errors or good catches real by putting a human face on them. Sharing stories about actual errors or good catches in a blameless environment enables staff not only to address systems-based failures but also to realize

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impact of errors and involve staff actively in developing solutions to enhance patient safety. In embracing transparency, these sessions allow for openly discussing and analyzing our errors so we can learn from them.

the important role of each staff member in actively preventing errors. After selected presenters relate their stories, participants identify points in the process and other factors that may have led to the error – always without placing blame – and discuss changes that will help prevent the error from happening again.


The safety mentor program has been so successful that Christiana Care was invited to describe its development and implementation at “Improving Innovations: How to Make Data Work for You,” an international AHRQ webinar in April 2009.

Safety Mentor Program Serving as interdepartmental ambassadors for safety and infection control, safety mentors from each unit help staff throughout the system understand and implement safety initiatives. Selected by unit managers, the mentors are key factors in developing a culture of safety. They encourage communication throughout the unit, helping to create a blame-free environment where people can give each other feedback and discuss and learn from safety issues. Through monthly monitoring of patient safety behaviors that

focus on National Patient safety goals, safety mentors also promote safe practices within their units. Real time observations promote peer-to-peer feedback and positive reinforcement of safety behaviors. The Safety Mentor Program served as the focus group to redesign the web-based Safety First Learning Reports, an event reporting system. The redesign has resulted in a 17 percent increase in event reporting and an 8 percent decrease in serious events with harm.

Major Outcome Rate Chart

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Rapid Response Team The Rapid Response Team Program has focused its efforts on actively engaging patient and families. Patients and families are now encouraged to call the Rapid

Response Team to discuss any concern they may have about a change in a patient’s condition. Each room now has a poster reminding patients and families that they can call for help.

At Christiana Care, we encourage our patients and families to take an active role in patient care.

Your comfort and safety are paramount to us. If you (or your loved one) are experiencing a serious change in condition, and feel that this change is not being recognized by your caregivers, use the phone in your room and dial 6385.

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

09NURS7

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www.christianacare.org


Achieving Competence Today (ACT) The 12 week graduate course, “Issues in Health Care, Quality, Cost, Systems and Safety,” is designed to improve patient safety and quality of care. Through a collaborative process guided by a trained facilitator, interdisciplinary teams of physicians, residents, nurses, pharmacists, other health professionals and executives: • Identify practice-based problems • Develop consensus to select a team project • Work together to design and test a solution. As they practice and improve their interdisciplinary team skills, participants learn to investigate and evaluate existing patient care practices and to use research-based evidence to improve them. This year, more than 120 people have taken the class. Since the course began in 2004, teams have developed 20 quality and safety improvement projects, many of which have been integrated into Christiana’s daily operations. One of the projects – “My Tissue, My Result, My Expectation,” which sets out a new OR protocol to reduce error and delay in lab processing and test results – is being integrated into the World Health Organization’s Surgical Safety Checklist, which will be in all ORs by September 2009.

The program’s momentum is increasing along with the number of graduates who bring their knowledge and the benefits of their ACT experience to our health system. Moving forward, we anticipate that focused educational opportunities like ACT, which involve interdisciplinary professional learning and performance, will become even more familiar in our community teaching hospital setting.

Brian Little, M.D., Ph.D. Vice President, Academic Affairs and Research

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ACHIEVING HIGH RELIABILITY

In its ongoing effort to achieve the highest quality, safest and most reliable patient care, Christiana Care has adopted the concept of best practices, which seeks to minimize and eliminate errors in systems. Designing and implementing processes and systems based on best practices is a first step in achieving high reliability. Identified through clinical trials and studies, best practices are evidence-based, effective procedures that evolve through continual testing and measurement to ensure the best possible outcomes for both the health care system and its patients. Best practices rest on the conviction that quality and safety are the products of well designed processes and systems that, in effect, standardize excellence.

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Our mission is to serve members of our community in their time of need, so when one of our neighbors is sick, the right bed must be available at the right time, every time. The Bed Access project ensures that we start each morning anticipating the needs of our community and making sure that we can accommodate our neighbors when they need us.

�

Diane C. Bohner, M.D., FACP Medical Director, Utilization Management

Bed Access Project Designed to improve access to inpatient services, the Bed Access project is improving the inpatient journey by matching daily patient demand with available inpatient capacity. After identifying significant mismatches in bed capacity to meet daily demand and gaps in care coordination and communication, the team implemented new processes that have led to significant reductions in overall average length of stay (LOS) and Emergency Department boarding hours. Bed-Access Project Discharge Rates. CCHS - Discharge before 2 p.m.

Bed-Access Project Avarage Length of Stay. CCHS Acute LOS. Source - Monthly Finacial Statements

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Emergency Department To ensure that the rapidly growing number of patients in our Emergency Department (ED) does not compromise patient safety and quality of care, Christiana Care is redesigning the entire ED triage and treatment process. Super Track In January 2008, a team of ED leaders and front-line staff began the arduous task of identifying steps in the process that adversely affected both patients and staff. Their goal was to improve quality and safety by: • Reducing average length of stay. • Reducing the percentage of patients who leave without treatment (LWOT). • Increasing patient satisfaction. As a start, the team re-engineered the triage and flow of low-acuity, level-four and level-five, patients. Once it identified bottlenecks and system waste, such as rework, the team implemented changes in the system, tested them, modified them and retested, continuing to modify and retest until the change met patient needs and the staff could sustain the changes. In tracking the results of the changes, Christiana Care’s existing EDTrackerTM Completed Project Christiana ST

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system was critical. With EDTrackerTM, each patient, each staff member and each piece of mobile equipment is tagged with infrared badges monitored by sensors throughout the ED. The sensors relay the real-time location of every person and piece of equipment in the ED to on-screen maps of the area, eliminating wasted search-andfind time. In addition to changes such as modifying order entry and establishing different methods of communicating among staff and departments, the redesign stationed a team of a physician’s assistant, a nurse and a patient-care technician in each of two small treatment rooms close to the patientarrival area. Having the team participate together in the assessment process with each patient eliminates the patient’s having to repeat information and speeds the triage and treatment process. To continue to improve patient satisfaction, continuity and the safety and reliability of care and to decrease fragmentation and the number of adverse events, the team continues to refine the process and expand the redesign to the Wilmington Hospital and to higher-acuity patients. As the following numbers show, the redesign is an impressive success.


Active Project Wilmington ST Target Go-Live July 2009

Synchronous Provider Evaluation in the Emergency Department (SPEED) SPEED, which continues the redesign of the Emergency Department triage and treatment process, will improve care of ESI-3 patients in Christiana Hospital’s ED. Because ESI-3 patients – 50 percent of all patients seen at Christiana Hospital – may have moderate to severe, but not lifethreatening illnesses, many of them wait an average of 90 minutes before seeing a physician and have an average length of stay of nearly 5 ½ hours.

Building on experience in process redesign and waste reduction from the Super Track project, a team of direct healthcare workers and physicians is developing a new process that will standardize many procedures, improve room use, decrease ancillary department delays and improve patient communication and flow through the ED. Most important, the process’s great potential to improve overall care and access to emergency services is evident in the dramatic decrease in left-withouttreatment rates since the inception of the program.

Active Project CH SPEED Target Go Live Dec. 2009

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Infection Control Christiana Care’s goal is to reduce and control both hospital- and community-acquired infections. The risk of acquiring these infections is present in all health care settings. Whether endemic (common cause) or epidemic (special cause), they may affect everyone, including patients who come into contact with infected individuals. Efforts to reduce the risk of infection have focused on improving surveillance and prevention in three areas: • Clostridium difficile infection, with the goal of reducing the number of spores in c. difficile-patient rooms and ultimately reducing the risk of transmission.

Ventilator Associated Pneumonia (VAP) To improve VAP rates, in October 2008 a team of Christiana Care physicians and nurses began reviewing current research and guidelines and instituting pilot projects. The team has updated and is currently evaluating Clinical Practice Guidelines, with the intent of offering training and going live by Fall 2009. Because the literature has identified oral care, including toothbrushing and use of chlorhexidine, as an effective measure to decrease plaque and risk of VAP, the team instituted a pilot project in the CardioOverall VAP Rate (MICU, WICU, SCCC, CVICU, CICU)

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• Methicillin-resistant Staphylococcus aureus (MRSA), in both inpatient and outpatient rooms, with the goal of identifying positive patients and isolating them promptly. Christiana Care is also participating in a MRSA patient-safety initiative with Quality Insights of Delaware, through the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). • Device-associated infections in nonintensive-care units, with the goal of monitoring these infections more accurately and devising targeted interventions accordingly.

vascular ICU to improve toothbrushing and begin use of chlorhexidine. Each patient receives the following: • Preoperative chlorhexidine mouth rinse. • New toothbrush with a built-in suction device. • Perioperative chlorhexidine mouth rinse twice a day. The pilot is currently being evaluated. A subgroup of the team is examining the possibility of standardizing VAP diagnosis. VAP data are evaluated by NHSN Center for Disease Control criteria. The VAP rate for all Christiana Care intensive care units are below the NHSN mean for like units.


Anticoagulation Monitoring Because of complex dosing, necessary follow up and inconsistent patient compliance, anticoagulation therapy poses potential risks to our patients. The anticoagulation monitoring program is an effort to develop and implement protocols for pre-

Gluten Allergy Monitoring Christiana Care has begun monitoring gluten allergies to prevent administering medications that contain gluten to glutenallergic patients. Gluten is commonly used

Virtual Education Simulation Training (VEST) Center The state-of-the-art VEST Center provides safe, educationally valid, multidisciplinary training in a variety of simulations, from laparoscopic surgery to intubation to acute medical emergencies to code blue practice to episiotomies, all with no possibility of patient harm. Often introducing healthcare professionals to new equipment and new techniques, the

scribing, dispensing, administering, monitoring and educating patients. Our goal is to ensure that everyone has an International Normalized Ratio (INR) warfarin level before administering warfarin. Before the program, 86 percent of patients had an INR; now, 93.2 percent do.

as filler in many oral medications. Before the program was instituted, up to 90 percent of patients with gluten allergies received a medication containing gluten. That percentage has now dropped to zero.

center’s simulated, real-life patient-care situations improve learners’ skill levels and confidence. The simulations vastly improve patient safety and quality of care. In the past fiscal year, the center has offered more than 400 simulations, involving 691 hours of simulation, to more than 3,000 trainees – attending physicians, residents, fellows, nurses, respiratory therapists, allied health practitioners and medical, nursing and allied health students.

In response to the public’s demand for safe healthcare and a highly skilled medical staff, Christiana Care Health System has developed a virtual hospital, the Virtual Education Simulation Training center. The VEST center trains healthcare providers in direct patient care, birthing, trauma and surgery and endovascular procedures, in a safe, controlled and educationally valid environment. Providing uniform training for and the opportunity of evaluating all CCHS employees, physicians and staff can only further improve our delivery of safe, quality care.

Glen Tinkoff, M.D., FACS, FCCM Associate Vice Chair, Department of Surgery

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Outpatient Laparoscopic Cholecystectomy The Outpatient Laparoscopic Cholecystectomy Project, begun at the end of 2008, is intended to transform the patient-care pathway. A cross-departmental focus group of perioperative nurses, administrators, educators and physicians is producing protocols and data gathering systems that are already enhancing several areas of the Focus on Excellence model. Surgical Safety Checklist: Working with the Perioperative Services Team Training Work Group, the focus group developed and implemented a Surgical Safety Team Communication Tool that the World Health Organization (WHO) has adopted. Post-Operative Protocol: The anesthesia protocol effectively provides a comfortable post-operative experience. Most patients

Primary Stroke Center Accreditation Preparation In pursuing accreditation as the first Primary Stroke Center in Delaware, the Christiana Care stroke team is in the final stages of preparing for an upcoming site

Unit-Based Medical Director (UMBD) Program Christiana Care’s Unit-Based Medical Director program not only improves quality and safety – it also improves communication between physicians and nurses. Physician medical directors in each front-line nursing unit help everyone in the unit – nurses,

have left the surgicenter within 2-3 hours. Of the 23 patients participating in the program to date, only two patients have been admitted, one for reasons unrelated to the perioperative process. History and Assessment Document: To reduce redundancy and paper consumption, the team is now creating an effective history and assessment electronic document. Costs: Patients receiving outpatient laparoscopic cholecystectomy spend less time in treatment, reducing cost of service for Christiana Care. Ultimately, we hope to apply this process to a broad spectrum of case types that flow through the outpatient system. The surgical participants, for example, hope to develop a similar process for general surgical procedures currently provided in the main OR.

visit by the Joint Commission. During fiscal year 2009, the team focused on deep-vein thrombosis prophylaxis, anti-coagulation efforts and cholesterol reducing drugs, demonstrating significant improvement in each. other physicians, residents – understand and implement new quality and safety initiatives. Collaborating with others in the unit, the directors help develop new quality and safety projects. Their weekly unit education sessions foster collaboration and collegiality.

Our unit based medical directors continue to provide leadership along with the nurse managers in system-wide performance improvement and patient safety initiatives. This collaborative effort between physicians and nurses has been instrumental in the success and ongoing implementation of projects such as Electronic Medication Administration Record, Medication Reconciliation, Falls Prevention and reduction of length of stay. Our UBMDs provide invaluable insight into how to engage our physician colleagues in important quality and safety efforts.

Janice E. Nevin, M.D., MPH Senior Vice President and Executive Director, Christiana Care - Wilmington & Associate CMO 22

ACHIEVING HIGH RELIABILITY


Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Patient Satisfaction Survey Measuring patient satisfaction is critical to creating a patient and family-centered approach to acute care. Although the Centers for Medicare & Medicaid Services (CMS) has mandated that all hospitals report only a sample of patient responses to the HCAHPS survey, in fiscal year 2009 Christiana Care expanded use of the survey to most inpatient units.

Survey Categories

The main purpose of the survey, which assesses major areas of hospital performance through standardized questions and format, is to allow the public to compare hospitals. Christiana Care also uses the survey results to measure progress toward internal goals. Christiana Care has set a benchmark that at least 80 percent of patients will check the top box, indicating they would “Always” recommend us to family and friends. To date, 75 percent of patients check the top box – compared to the national mean of 68 percent.

FY 2009 YTD

National Mean

Recommend this hospital

76%

68%

Communication - Nurses

76%

74%

Communication - Doctors

78%

80%

Response of Hospital Staff

68%

62%

Hospital Environment

55%

62%

Pain Management

71%

68%

Communcation - Medications

57%

59%

Discharge Process

80%

80%

Year to Date March 31, 2009

Patient and Family-Centered Care To deepen its commitment to creating a patient-centered culture, Christiana Care is adopting the core concepts of patient and family-centered care defined by the Institute for Family-Centered Care: • Dignity and Respect Listening to and honoring patient and family perspectives and choices; incorporating their knowledge, values, beliefs and cultural backgrounds into planning and delivering care. • Information Sharing Giving patients and their families timely, complete, unbiased and accurate information so they may participate effectively in care and decision making. • Participation Encouraging and supporting patients and families to participate in care and decision making. • Collaboration Collaborating with patients and families in developing, implementing and evaluating policies and programs; designing healthcare facilities; professional education; and care delivery. With pilot studies at both Wilmington Hospital and Christiana Hospital, Christiana Care is beginning to integrate these concepts into patient care.

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Visiting Nurse Association The Visiting Nurse Association (VNA) promotes and maintains the health and safety of all members of our community, from the newest to the oldest, where they feel most comfortable—at home.

Managing Medications Home-care nurses promote medication safety among at-home patients. The nurses: • Review all drugs – prescribed medications, over-the-counter medications, herbal remedies and nutritional supplements. • Reconcile newly prescribed medications with ones taken previously for chronic conditions. • Identify allergies and potential medicationmedication or medication-food interactions and communicate them to physicians. • Send the medication list to physicians for verification. • Teach patients and caregivers medication actions, dosing, side effects and reportable signs. • Work with patients to organize a system to improve adherence. If necessary, VNA nurses even help identify resources to obtain medications.

Managing Diseases and Chronic Conditions Based on best practices and national standards, the VNA’s heart failure, chronic obstructive pulmonary disease (COPD) and oncology programs help improve patient health and safety.

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ACHIEVING HIGH RELIABILITY

In the COPD and heart failure programs, TeleHealth, an electronic monitoring system with more than 100 monitors statewide, promotes self-monitoring and healthy behaviors. It enables VNA nurses to identify immediately any decline in a patient’s condition or any developing problem and to alert physicians so they can act more quickly and effectively to resolve the problem. During the past year, TeleHealth patients required acute care hospitalization less than the Strategic Healthcare Program (SHP) reference. Adding rehabilitation services to the disease management programs has helped improve patient endurance and function. Improved ambulation for disease-management patients now exceeds the SHP reference.

Enhancing the Health of Our Communities As part of the VNA’s effort to improve the health and safety of everyone in the community, the new Caregiver Education Series helps caregivers learn not only how to care for patients but also how to care for themselves. Since its inception in 2008, more than 100 people have participated in the classes, which are offered free of charge throughout Delaware.


Health Initiatives across Christiana Care Occupational Health Services Occupational Health Services (OHS) is working with all clinicians involved in the Executive Health program – cardiologists, psychologists, dietitians, exercise

Physical Therapy PLUS Without compromising quality of care, Physical Therapy PLUS has reduced its appointment times to increase accessibility

Imaging Services Imaging Services implemented a quality assessment of MRI, CT, Ultrasound and X-Ray procedures, such as correct and complete imaging, correct markers and complete documentation. After the

Cardiac Rehabilitation When patients are admitted to cardiac rehabilitation, they are assessed for health, clinical and behavioral outcomes using evidence based measures established by the American Heart Association. When

physiologists – to improve communication among them and to improve turnaround time on the comprehensive report executives receive after their evaluation.

and productivity. The change allows each clinician to see three more patients a day, but still allows clinicians to spend individual time with each patient.

assessment, Imaging Services held section meetings to discuss areas for improvement and to provide training. As part of its ongoing performance improvement, Imaging Services has scheduled monthly evaluations and assessments of technical quality. patients are discharged, they are reassessed to determine their progress toward reaching their goals. Each patient’s primary care physician and the attending cardiologist receive the progress report.

Trauma Services To provide consistent oversight and patient care, the Trauma Program restructured its services throughout the continuum of care. The program expanded Advanced Practice Nurse (APN) and trauma social work evening and weekend coverage and engaged the Clinical Decision Unit in managing blunt cardiac injury and concussion cases.

Facilitated by bedside nurses using the Trauma Rounds ABC checklist, a trauma APN leads daily bedside interdisciplinary rounds. Combined, these efforts have led to decreased length of stay , better coordination of care and services, and increased employee satisfaction.

Lenght of Stay: July 2008 - January 2009

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LEVERAGING TECHNOLOGY

Cutting-edge technology at Christiana Care undergirds every quality and patient safety initiative: • Tracking people, supplies and equipment. • Connecting large healthcare systems to remote rural practices. • Standardizing forms and medication processes. • Ensuring correct and readily available patient information. • Analyzing systems to pinpoint opportunities for improvement. • Speeding diagnoses and effective treatment plans; offering split-second communication. • Enhancing training. • Facilitating testing and measurement – so vital to developing and maintaining best practices.

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L E V E R AG I N G T E C H N O L O G Y


Delaware Health Information Network (DHIN) In 2007, with the launch of the Delaware Health Information Network, Delaware became the first state in the U.S. to connect health care providers statewide. Christiana Care is a vital part of this network that connects: • Four hospital systems with six hospitals – BayHealth Medical Center, Beebe Medical Center, Christiana Care Health System and St. Francis Hospital. • 900 providers. • Four Federally Qualified Health Centers – Delmarva Rural Ministries, La Red Health Center, Henrietta Johnson Medical Center and Westside Family Health. • Two National Reference Laboratories and a local pathology provider. • Six electronic medical records (EMR) vendors that serve more than 130 physicians in 24 practices. In addition to almost 650,000 patient charts, DHIN provides users instant access to a wide variety of records and reports: • Patient demographic data. • Payor information. • Admission, discharge and transfer data. • Laboratory and pathology results. • Complete prescription and non-prescription patient medication histories.

Administered by a board of directors and guided by a Consumer Advisory Committee, DHIN greatly improves patient safety and quality of care throughout the state – from Christiana Care, the largest medical center in the state, to small rural practices. • Receiving reports immediately enables physicians to begin appropriate treatments immediately. • Instant access to patient bloodwork results, antibiotic-related decision support and out-of-range alerts enables providers to prescribe, dispense and administer medications more effectively. • Electronic transmission reduces the number of lost test results and subsequent duplicate tests. • The standardized data format reduces the possibility of misinterpreting reports and allows physicians to easily recognize abnormal results. • Clear and concise printed reports eliminate the possibility of error resulting from poor-quality fax copies. • Because practitioners can act upon critical results of diagnostic tests within hours rather than days, the system enables officials to respond more rapidly and effectively to public health threats.

• Radiology and transcribed reports. • Biosurveillance data.

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Infusion Pumps To increase patient safety and to make medication administration virtually error free, Christiana Care implemented Hospira Symbiq infusion pumps, beginning in January 2009 at Wilmington Hospital and in April 2009 at Christiana Hospital. The pumps are commonly referred to as “smart pumps” because pump software provides alerts during programming to prevent dosing error – “soft” alerts that can be

Our nurses and physicians demonstrate their commitment to patient safety every time they use the drug library software when programming patients’ infusions. From the very beginning, staff has used the drug libraries in programming more than 97 percent of all infusions.

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overridden if appropriate and “hard” alerts that cannot be overridden. For individual patient or service lines in each nursing unit, nursing, pharmacy, and medical-dental staff developed customized drug libraries with sub modules that display generic medications, “tall man” lettering for look-alike and sound-alike medications and standardized intravenous infusion concentrations.

L E V E R AG I N G T E C H N O L O G Y

Terri Corbo, Pharm.D., BCPS, FASHP Medication Safety Officer


Electronic Medication Technology With bar-coded wrist bands, the electronic medication administration record (EMAR) and computerized physician order entry (CPOE), Christiana Care is transforming its care delivery process – increasing efficiency and significantly reducing the number of medication errors.

The wristband-EMAR-CPOE loop ensures the five rights of medication safety: • Right patient. • Right medication. • Right time. • Right dose. • Right route.

Bar-Coded Wrist Bands Correctly identifying patients is the foundation of patient safety. Bar-coded wrist bands, which contain a number of patient identifiers such as name and date of birth, virtually eliminate patient identification errors. When admitted to the hospital, a patient receives a bar-coded wristband that nurses scan to confirm the patient’s identity and match it to orders and prescriptions before dispensing blood, administering lab tests, collecting specimens or administering medications.

Electronic Administration Record EMAR = Bar-Coded Medication Administration (BCMA) at Point of Care (POC) Using a wireless handheld device with a scanner, screen and keyboard, a nurse scans the patient’s wristband to identify the patient in the system. When a list of medications ordered for the patient appears, the nurse scans the barcode on the medication on the cart. To ensure accuracy, EMAR software then matches the medication, the dosage and the route against the medications list.

If the medication, dosage or route does not match or if the patient is allergic to the medication, the handheld device issues a safety alert. Beyond ensuring accuracy in administering medications, EMAR also facilitates double verification of high-risk medications and improves medicationrelated documentation, such as vital signs and pain reassessments. Using EMAR ensures safe medication. The scanning compliance rate is greater than 90 percent.

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Errors Intercepted

Computerized Physician Order Entry CPOE is a transformational clinical initiative that will improve patient safety and enhance efficiency. Because orders will be transmitted as soon as physicians enter them, orders will reach departments with no delays. With bar-coded wristbands and EMAR, CPOE provides a closed loop medication process. To ensure optimal patient safety, all steps in the medication cycle are computerized and have been reviewed for accuracy. A significant component of work on the system during FY2009 was to transition the current order entry system to a “physician friendly” one that supports single-click

Additionally, more than 300 order sets (collections of orders based on diagnosis or admission condition) or Medicine, Surgery, Psychiatry and the Emergency Department have been developed to date. Order sets enable physicians to enter orders quickly and see the best evidence-based order choice. To ensure that they are accurate and comply with regulatory agency standards, all order sets go through a rigorous approval process. Physician training will begin in Fall 2009 to prepare for the rollout at the end of January 2010.

Building an order-entry system that streamlines the ordering process for the physician and, at the same time, ensures optimal safety for the patient has been challenging. Because hundreds of physicians, nurses and pharmacists participated in designing the system, it supports the clinical workflow and is easy to use. It’s clear to the clinicians and to those who work on this project that we are well positioned for success.

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entry, defaults and other ease-of-use changes so that physicians will embrace the new process.

L E V E R AG I N G T E C H N O L O G Y

Terri Steinberg, M.D., MBA Chief Medical Information Officer


The system acts as a guide for the patients through their hospital stay, providing access to the people and resources they need to have an optimal care experience– more actively engaging them in their own care.

Diane Talarek, RN, MA, CAN Chief Nursing Officer and Senior Vice President, Patient Care Services

GetWell Network The GetWell Network, a bedside communication tool directly involving patients in their own care, puts Christiana Care at the forefront of using innovative technology to improve patient satisfaction and safety, quality outcomes and compliance and nursing efficiency. In October 2008, Christiana Care became the first health care system in the country to link the network to hospital clinical documentation software, the Cerner PowerChart. In addition to enabling nurses to prescribe specific education videos to patients, the network offers many pathways to engage patients. Speak Up About Your Safety – Patients receive a daily alert asking if they have safety concerns. If they do, patients can document their concerns and the documentation notifies the nurse manager and the Patient Safety department directly. Smoking Cessation – Patients identified on admission as smokers receive a pathway prompt inviting them to watch the smoking cessation video. If they decline, an alert appears listing resources to help them quit smoking.

Question of the Day – This feature enables patients to provide daily feedback about their stay. If things are not going well, staff can immediately address patient concerns and improve patient perceptions while patients are here. The GetWell Network also provides a bedside computing station where patients and their families can access the Internet, research medications and request nonclinical services – freeing nurses to focus on clinical duties. In addition to ongoing interaction between patients and staff, the network also enhances communication through translating notes into other languages and providing a tool for patients who are unable to speak. Since 2006, the GetWell Network’s original four units in Christiana Hospital’s E Tower, consistently receive patient satisfaction scores greater than the ninetieth percentile. As Christiana Care continues to implement the network, patient satisfaction scores continue to rise.

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FOCUS ON EXCELLENCE

Patient safety is one of the most critical healthcare challenges that we face. As we look forward to the next fiscal year, we are aiming our patient safety efforts at reducing events that harm our patients. Setting the bar high, we assume that all harm is potentially preventable. Although separating preventable from inevitable harm is difficult, with the evolution of scientific knowledge and technology, the inevitable may soon become preventable. To ensure that we continue to move toward preventing all harm, we will persist in our efforts to identify clinical as well as documentation and coding opportunities for improvement. These efforts will set our agenda for the next several years, with perfect care delivery our ultimate goal.

The Future of Quality and Patient Safety at Christiana Care Creating a Safe Culture. “Just Culture” principles support a culture that includes and values well established accountability practices for both the system and the individual. To keep our patients safe from risk, Christiana Care uses Just Culture principles as we continue transforming our culture to create reliable care delivery and staff accountability. A highly effective tool in transforming our culture, Team Training emphasizes open communication, idea sharing and problem solving, all essential for safe and reliable delivery of care. Expanding this program is a key strategy for the next year. Achieving High Reliability. Unwilling to accept even rare failures of critical processes, high reliability organizations (HROs) are committed to incorporating best practices into quality and safety issues. Five key concepts are at the core of HROs: • Sensitivity to operations. Constantly aware of systems and processes that affect patient care, HROs work persistently to identify risks and to prevent them. • Reluctance to simplify. Although simple processes can be highly reliable, understanding the true reasons patients are placed at risk requires avoiding overly simplified explanations of failure (unqualified staff, inadequate training, communication failure, etc.).

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T H E F U T U R E O F Q U A L I T Y A N D PAT I E N T S A F E T Y


• Preoccupation with failure. Rather than being taken as proof that the system has effective safeguards, near-misses should stimulate improving processes to reduce potential harm. • Deference to expertise. To create a safe culture and to promote highly reliable processes, leaders must listen and respond to the insights of staff who know from practical experience how processes really work and the risks patients really face. • Resilience. Leaders and staff must be trained and prepared to respond effectively when system failures do occur. Continuing to integrate the work of our physicians, nurses, ancillary staff and leadership, we will focus next year on continuing to create highly reliable care delivery. Leveraging Technology. By January 2010, we will implement Computerized Physician Order Entry, a transformational project that will improve patient safety and quality of care. Because the orders as well as the identity of the ordering physicians will be clear, this project will greatly decrease the possibility of medication error. And because orders will be transmitted as soon as physicians enter them, orders will reach departments and patients more quickly. This transformational project also creates an opportunity to use decision support tools in diagnosing and treating disease.

Buoyed by the commitment, focus and skill of Christiana Care’s physicians, nurses, and clinical staff we look forward to another challenging year of continued growth and improvement.

James Newman, M.D., FACP Chief Medical Officer Patient Safety Officer

Sharon Anderson, RN, MS, FACHE Sr. Vice President PI and Care Management Quality and Patient Safety


PO Box 1668 Wilmington, Delaware 19899-1668

www.christianacare.org

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

09PERF12


Quality and Patient Safety Annual Report 2009