2013 Report on Quality and Safety

Th e C h r i s t i a n a C a r e Wa y We serve our neighbors as respectful, expert, caring partners in their health.

2013 Report on Quality and Safety

I N THIS R EPORT

C R E AT I N G a Safe Culture

2

AC H I E V I N G High Reliability 22 L E V E R AG I N G Technolog y 38 Awards & Achievements 48 O U R J O U R N E Y – Program Initiatives 52

Photos feature the dedication, teamwork and expertise of the Unit Based Value Improvement Team as they care for patients at The Center for Heart & Vascular Health.

C h ri sti ana Care Heal th S ys tem

A message from the President and CEO

HEALTH CARE IN DELAWARE, AND ACROSS THE NATION, IS AT A CROSSROADS.

Implementation of the Affordable Care Act will help provide access to care for a much wider and more diverse patient population. At the same time, providers are being held to greater accountability as we are simultaneously challenged to dramatically transform the care we deliver.

At Christiana Care Health System, we embrace our role as a leader in meeting the needs of our neighbors in this new era. To guide us, we created The Christiana Care Way, a simple statement of how we seek to meet the challenges of health care in the 21st century. Guided by these principles, we serve our neighbors by: engaging patients and their families as partners in health and wellness; being innovative in the implementation of new technologies, practices and therapies; and, as we do all of these things, creating greater value for those we serve.

This report tells the story of how we are improving our patients’ experience by delivering greater value – creating a more affordable and accessible system of care.

My colleagues and I are privileged to serve every patient, every family member who comes to us seeking help.

ROBERT J. LASKOWSKI, M.D.

President and Chief Executive Officer

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 1

C R E AT I N G a Safe Culture

C

hristiana Care is named among the nation’s 100 top hospitals—and in fact is one of only 15 major teaching hospitals—in an independent analysis of quality, safety and efficiency of care. For the third consecutive time, we’ve also scored an “A” in hospital safety from The Leapfrog Group, an independent national nonprofit group dedicated to improving safety, quality and affordability of health care. Just 31 percent of hospitals achieve this top score.

2 | C h r i sti ana Care Heal th S ys tem

C R E AT I N G a Safe Culture

ge 3 -­‐ Culture of Responsibility

Culture of Responsibility promotes safety AHRQ

CCHS

CoR Phase improvement 1 2012 AHRQ survey results speak to statistical

AHRQ Patient Safety Survey Questions

18

Our procedures and systems are good at preventing errors from happening.

1

We are given feedbackCare’s about changes into place Christiana ongoingputcommitment based on event reports.

5

3

76%

for its 65% more than of the health care team. As an integral component of 55% 500 managers and physician leaders to complete Culture Christiana Care’s safety program, it encourages colleagues of Responsibility education to understand individual and organizational risks, allows We are informed about errors that happen is in making this unit. a measurable 70% impact 62% on creating a culture of safety, as demonstrated by the them to feel safe reporting unsafe practice and near In this unit, we discuss ways to prevent errors from 74% Agency for Healthcare Research and Quality (AHRQ) misses, and promotes learning from mistakes, managing happening again.

66% Hospital Survey Patient Safety Culture behavioral choices and designing safe systems to prevent When a mistake is made that on could harm the patient, but results.

76% does not, how often is this reported? harm to our patients.

70% Culture of Responsibility is a commitment to create an The actions of hospital management show that patient of shared responsibility among all86% members 77% continued safety is aenvironment top priority.

Hospital management seems interested in patient safety only after an adverse event happens. (R)

68%

61%

Survey results show statistical improvement in 2012 across Pharmacy, Laboratory AHRQ SURVEY RESULTS and Medical Patient Care Units (Phase I areas), when compared to Christiana Care overall results. Efforts have demonstrated greatest improvement in the queries about AHRQ Patient Safety Culture Survey Results “Feedback given about changes put into place based on event reports,” and whether “The actions of hospital management show that patient safety is a top priority.”

CoR Phase 1

CCHS 2012

n CoR Phase 1

n Christiana Care 2012

100% 86%

82% 76%

ff Percent of Positive Response

3

82%

70% 65%

62%

77%

76%

74%

75%

66%

70%

68% 61%

55% 50%

25%

0% Our procedures and systems are good at preventing errors from happening.

We are given feedback about changes put into place based on event reports.

We are informed about errors that happen in this unit.

In this unit, we discuss ways to prevent errors from happening again.

When a mistake is made that could harm the patient, but does not, how often is this reported?

Hospital The actions management seems of hospital management interested in patient show that patient safety only after an adverse event safety is a happens. (R) top priority.

(R) Reversely worded question

Improvement demonstrated and is better than national levels.

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 3

Culture of Responsibility promotes safety continued

Christiana Care launched its Culture of Responsibility journey in 2010 with a multi-year phased implementation plan. Leaders learn Culture of Responsibility concepts in a full-day session, followed by online training modules and practice sessions analyzing events using the Culture of Responsibility algorithm.

Managers apply Culture of Responsibility principles through behaviors that include: ff Discussing adverse events at leadership, staff or unitlevel council meetings. ff Sharing improvements made and lessons learned as a result of Safety First Learning Reports. ff Identifying and addressing at-risk behaviors and the “5 Whys” in event analysis.

The concepts are now embedded in orientation for new employees, leaders and residents; in physician peer review, leadership behaviors, post-event debriefs, root-cause analysis process, frontline leadership training and the health system’s positive discipline policy. Transforming Leadership Forums enhance and strengthen leaders’ capability to analyze adverse events, identify human error and address at-risk behaviors.

“Culture of Responsibility is demonstrated in management of adverse events through post-event debriefs that enable learning from mistakes and identify best practices,” said Michele Campbell, RN, MSM, CPHQ, FABC, corporate director, Patient Safety and Accreditation.

“The conversation is about what happened, why it happened and what system improvements can be implemented to prevent it from happening again.”

ff Observing and understanding variation and drift among staff. ff Recognizing staff who report “Good Catches.”

ff Number of Event Reports

NEAR MISS EVENTS

n Corrected Before Reached Patients (Good Catch) n No Evidence of Injury or Harm

4 | C h r i sti ana Care Heal th S ys tem

Increased reporting of Near Miss Events following implementation of Good Catch Program which started in March of 2012

C R E AT I N G a Safe Culture

Good Catch Program Christiana Care’s Good Catch Program encourages environment; change in patient status; medication, IV providers to report and correct an unsafe situation that and blood; and equipment and supplies (see pie chart for has the potential to cause harm as a reinforcement of distribution from first year). This program strengthens the Culture of Responsibility. Good Catches increased each staff member’s voice in patient safety, and supports monthly since the program’s launch in March 2012, our five-year goal to become a national leader in quality Change in of harm Testing/to our Technology Skin Related— Patient and Other—69 Medication/IV Environmental Communicatio leading to mitigation patients in such areas safety by achievingEquipment/ top decile performance in the Patient Status Treatment/ Related—43 3 Identification/ Therapy/Blood Supplies—118 —49 n (language —39 Procedure Arm Band/ Related—955 barrier/ as: patient identification; test, treatment and procedure; AHRQ Hospital Survey on Patient Safety Culture.

Related—302 Medical deafness)—1 Region 1

2

13

2

0

Record—784 33

3

40

5

2

0

GOOD CATCH CATEGORY SUMMARY MARCH 2012 TO FEBRUARY 2013 ff 40% | Medication/ IV Therapy/Blood Related—955

40%

ff 5%

5% 2% 2%

ff

13% 3%

Change in Patient Status—39 Testing/Treatment/Procedure Related—302 Technology Related—43 Skin Related—3 Patient Identification/Arm Band/Medical Record—784 Other—69 | Equipment/Supplies—118 Medication/IV Therapy/Blood Related—955 2% |Equipment/Supplies—118 Environmental—49 Environmental—49 Communication (language barrier/deafness)—1

ff 2% | Change in Patient Status—39

ff 13% | Testing/Treatment/ Procedure Related—302

2%

ff 3% | Other—69

ff 2% | Technology Related—43

33%

ff 0% | Skin Related—3

ff 33% | Patient Identification/Arm Band/ Medical Record—784

ff 0% | Communication (language barrier/deafness)—1

“As a learning organization, Culture of Responsibility helps us focus on creating value.

Learning from our mistakes in an environment that allows for open discussion enables us to continually improve the safety of our system’s care.”

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

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 5

New Quality and Safety structure drives accountability, promotes action Christiana Care restructured its Quality and Safety program, aligning priority areas with the annual operating plan and long-term strategic goals. This drives accountability and promotes actions to eliminate preventable harm, improves quality of care through evidence-based practice and enhances the patient care experience.

The restructure begins at the leadership level, with three new committees co-chaired by a physician and a nurse leader:

❶ Safety First (eliminate preventable harm). ❷ Clinical Excellence (evidence-based practice). ❸ Think of Yourself as a Patient (patient care experience).

Each committee sets and oversees priority-driven targets at the patient care unit level, as well as for other teams throughout the system. At the heart of the new structure are these unit-based interdisciplinary value improvement teams, co-chaired by the nurse manager and a designated physician leader. Teams include physicians, nurses, respiratory therapists, pharmacists, dietitians, care

managers, social workers, Environmental Services staff, Pastoral Care and others who care for patients in either a direct or indirect way in each patient care area. Units are additionally encouraged to include patient and family advisers to improve the value of the care delivered as viewed by our patients, with everyone working together as part of a team to resolve issues and improve performance. Trained improvement science methodology personnel offer support.

In addition, the new operating system for quality and patient safety includes the use of “collaboratives” to stimulate improvements and learning. These collaboratives bring several patient care units together to work on the same clinical initiative to identify ways to improve performance or to share and implement findings more broadly. While units face different challenges based on patient population, sharing insights and solutions that enhance value for patients is an efficient, effective way to improve the system.

A new website is in process as a vehicle to enhance communication of quality and safety efforts, to provide reports on performance to targets, and to provide educational tools and resources for improvement efforts.

based Medicine unit ent team em ov value impr priorities y tif en id s er lead t. en em for improv

6 | C h r i sti ana Care Heal th S ys tem

C R E AT I N G a Safe Culture

The Patient Care Unit 7E staff at Christiana Hospital.

Patient care score cards emphasize team approach Unit-based score cards track such measures as hand hygiene, falls, hospital acquired infections and patient satisfaction through a mechanism that provides timely feedback on key elements of performance as the teams work toward accessible, high-quality care that costs less.

On 7E at Christiana Hospital, a floor for spine, bariatric and joint replacement patients, the team earned the distinction of an A-plus in January 2013, with a score of 97.2 out of 100 points. That month, 7E garnered the only A-plus in the health system; but other units were not far behind.

The Wilmington Intensive Care Unit improved from a score of 75, or C, for 2012, to 86, a solid B, in 2013 to

date, due, in part, to exceeding expectations in reducing the use of restraints. Wilmington’s 5N stepdown unit showed a significant uptick from 78.4 or C-plus, to 92.4 or A-minus. On that floor, urinary tract infections per 1,000 catheter days declined from 3.78 to zero.

“Long-term working relationships develop trust and dependability among the staff, who have respect for new ideas and the acceptance of carrying them out, such as bedside reporting and purposeful hourly rounding.”

— Jennifer Johnson, RN, Nurse Manager

Patient and family advisers lend voice to enhance quality and safety Christiana Care’s Wilmington Hospital is recognized for its approach to patient and family centered care, which places patients in equal partnership with the health care team to create a more effective plan of care.

A dedicated group of 12 community members— all former patients or family members—share their experiences with hospital management and clinical staff at monthly forums, offering invaluable perspective to help shape policies, programs, facility design and day-to-day service interactions.

As part of our ongoing commitment to this endeavor, several of the advisers now also have a voice as equal partners with administration and clinical leadership serving under our new Quality and Safety operating structure on three systemwide committees: • Safety First.

• Clinical Excellence.

• Think of Yourself as a Patient.

Their input further guides us toward eliminating patient harm and improving the care experience.

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 7

Patient harm continues to decline Hospital acquired infections remain areas of focus

The number of patients harmed has decreased by 25 percent compared to last fiscal year to date (July through March).

Christiana Care continues to report strong performance related to hospital acquired infections (HAIs), particularly central line associated blood stream infections (CLABSI).

PREVENTABLE HARM RATE TREND

Harm Rate has dropped 43 percent

ff Per 1,000 Patient Days

ff Patients harmed per 1,000 patient days

“No Pass Zone” reduces risk for patient falls The number of patients placed at risk for harm is slightly below Christiana Care’s target of 10 percent reduction due to a 10 percent increase (over last year) in the number of patients who fell. Although the number of falls has increased, ongoing efforts across all units have decreased the percentage of falls with major injury.

Opportunities continue to reduce preventable harm related to patient falls. A Nursing-led team is participating in a Value Institute Academy-sponsored Lean Six Sigma education program focusing on units with the highest fall rates. In addition, two medicine units at Christiana Hospital have started a “No Pass Zone,” encouraging all staff to promptly answer patient call bells.

The organization is intensely focused on this issue, and the Unit-Based Value Improvement Teams are prioritizing efforts to reduce patient falls. In addition, Christiana Care is working with ECRI Institute—an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care—in fall reduction efforts. Although considered a “nursing sensitive” indicator, addressing patient falls requires an interdisciplinary approach because there are many factors which influence fall rates.

8 | C h r i sti ana Care Heal th S ys tem

C R E AT I N G a Safe Culture

Central line associated bacteremia (CLABSI) Christiana Care continues to closely monitor central line associated bacteremia (CLABSI) in its intensive care units (ICUs). Three of the health system’s ICUs have gone one year or longer without a central line infection.

Continued efforts led to improved outcomes in 2012— an overall 48 percent reduction in central line infections in all units under surveillance compared to 2010, and a 15 percent reduction compared to 2011.

Over the past several years, CLABSI surveillance has expanded to areas outside the ICU—to stepdown units beginning in 2009, and to selected medical-surgical floors beginning in 2010)—with the same expectations for central line insertion practices and compliance with bundle elements. In early 2013, new central line orders were implemented as a trigger to engage clinicians and reduce variation in central line care. Christiana Care now tracks which patients have central lines and will eventually track CLABSI in all medical-surgical floors, helping to ultimately reduce the risk of CLABSI and make care safer for patients.

48 percent reduction in CLABSI

ff Infections Per 1,000 Line Days

CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTIONS

Wilmington Hospital was honored with an HAI Watchdog Award for its CLABSI Prevention Initiative to reduce harm.

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 9

Patient harm continues to decline continued

Ventilator associated pneumonia (VAP) Christiana Care’s ICU ventilator associated pneumonia (VAP) rates continue to decline as a result of adherence to evidence-based standards of care. Compared to 2010, VAP rates have declined nearly 70 percent, and 2012 rates were stable compared to 2011. Beginning in January 2013, new surveillance definitions were implemented, broadening the scope of ventilator-associated complications beyond pneumonia. The new definitions will make it challenging to compare progress to prior years, but expand the safety net for our at-risk patients.

Daily assessment of patients on mechanical ventilation during patient care rounds provides caregivers information to safely wean and discontinue ventilator support.

This past year, under the new Quality and Safety operating system, a collaborative focused on capturing data concurrently to provide real-time assessment of adherence to standards. This also enabled comparison of the value improvement team’s performance.

VENTILATOR ASSOCIATED PNEUMONIA ff Adult Intensive Care Units

ff Infections Per 1,000 Device Days

Rates below national compare in 9 of the past 12 months

n National Healthcare Safety Network Compare n VAP Rate n Linear (VAP Rate)

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C R E AT I N G a Safe Culture

Catheter associated urinary tract infection (CAUTI)

CAUTI AND FOLEY UTILIZATION TRENDS

Interventions to decrease the risk of catheter associated urinary tract infections (CAUTIs) resulted in a 25 percent decrease in device utilization in Christiana Care intensive care and stepdown units, and a 15 percent reduction in CAUTIs in 2012 compared to 2011.

ff Number of Foley Catheter Days

ff Number of Infections

CAUTIs have the potential for longer lengths of stay and higher costs. Interventions include revision of the accepted indications for Foley catheters, an automated Foley order, links to Foley care orders aimed at decreasing the number of catheters inserted in the first place, improved catheter care and timely removal of non-essential catheters.

Decrease in Foley use reduced infections by 15 percent

 CAUTI n Foley Utilization Hand hygiene Christiana Care exceeded its goal of 90 percent for hand hygiene compliance in 13 of the past 18 months, using a multi-pronged approached addressing prevention, staff and patient education, consistent application of best practices and transparency of results employing a variety of methods to communicate to clinicians, employees, patients and the community.

Hosptial acquired infection (HAI) rates are shared with all employees, system leaders and the board through the monthly “Focus on Excellence Measurement Report.”

HAI and hand hygiene compliance cascade to the patient care unit level to allow unit-based interdisciplinary teams to drive improvement. Highlights are shared regularly through web-based portals and internal publications.

HAND HYGIENE COMPLIANCE

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 1 1

Surgical Site Infection Rate

Patient harm continues to decline continued

3.00 2.50

Compliance with surgical infection prevention measures reduces infection risk Prior to surgery, patients are given preventive (prophylactic) antibiotics to reduce the risk of surgical wound infections.

To be most effective, the appropriate antibiotic should be given for most patients within one hour prior to the start 2.36 of surgery. Continuing prophylactic antibiotics for more 2.21 than 24 hours after surgery is problematic and may increase 1.84 patient risk.

Christiana Care’s Perioperative Services, Anesthesia and Surgical departments have embedded confirmation of FY11 antibiotic administration FY12 into the Surgical Safety Team Communication Checklist. Since 2007, theFY13 percentage of

PROPHYLACTIC ANTIBIOTIC WITHIN ONE HOUR OF INCISION

2.00 meeting the 1-hour goal has improved from a low patients of 77 percent to consistent performance at 98 percent or better.

1.50The post anesthesia care units and surgical patient care units successfully have discontinued antibiotics within 24 hours after surgery for 100 percent of patients reviewed 1.00 since July 2012.

The0.50 efforts have been successful in reducing the number of surgical site infections. Since fiscal year 2010, the number of infections per 1,000 operating room cases has decreased 0 from 2.5 to 1.8, a 26 percent improvement.

ANTIBIOTIC DISCONTINUED WITHIN 24 HOURS AFTER SURGERY

Antibiotic Discontinued w/i 24 Hours After Surgery Prophylactic Antibiotic within One Hour of Incision

100%

100%

80%

60%

40%

20%

20% Q1'07Q4'07 Q3'08

Q2'09

Q1'07 Q4'07 Q1'10 Q4'10

12 | C hri sti ana Care Hea l th S ys tem

Q3'11

0% Q2'12

Q1'13

Q3'08 Q2'09

Q1'10 Q4'10

Q3'11 Q2'12

0% Q1'13

Percent of Patients

40%

Percent of Patients

60%

ff Percent of Patients

80%

Surgical Site Infection Rate

C R E AT I N G a Safe Culture

SURGICAL SITE INFECTION RATE

3.00

2.00

2.49

1.50

2.36

2.21

1.00

1.84 0.50 FY10

0

FY11

ff Infections per 1000 Procedures

2.50

FY12 FY13

Clostridium difficile (CDiff)

After a period of strong decline, incidence of clostridium ultraviolet system, and antibiotic stewardship. CDiff Prophylactic Antibiotic within One Hour of Incision difficile (CDiff) has risen slightly. In response, a pilot for prevention efforts were underscored D byiscontinued the award-winning Antibiotic w/i 24 Hours Aft increasing the use of Tru-D, an innovative robotic infrared staff-produced video, Seven Mother’s Day Flowers, disinfection device, was implemented in April 2013 on the featuring family testimonials regarding the impact of failed medicine units at Christiana Hospital. (see pg. 44) infection prevention. The video was shared at a “No Harm Intended” session, leading 92 percent of respondents to 100% CDiff and Methicillin-resistant Staphylococcus Aureus indicate they were more likely to take action to prevent (MRSA) infection reduction efforts include daily infection. CDiff infections dropped on one unit by 55 surveillance of patients, staff education, hand hygiene percent post airing of the video, which is now incorporated precautions and environmental cleaning of rooms, in orientation.

80% including bleach disinfection and Tru-D Smart UVC™

60%

40%

More likely to take action to prevent CDiff

Percent of Patients

RESPONSE TO CLOSTRIDIUM DIFFICILE (CDIFF)VIDEO

20%

Video is anQ1'07 important Q4'07 Q3'08factor in changing behavior Q2'09

Q1'10 Q4'10

Q3'11

0% Q2'12

Q1'13

Q1'07 Q4'07

Q3'08 Q2'09

Q1'10 Q4'10

Q3'11 Q2'12

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 1 3

Q

Christiana Care broadens Medication Safety Program

Collaboration creates medication safety officer post; revitalizes Medication Safety Committee Christiana Care’s Safety First and Pharmacy and Therapeutics committees are collaborating on a systemwide Medication Safety Program that centers on patients, is measurable, and encompasses the entire process of providing medications.

Christiana Care’s newly established medication safety officer post. “It’s an effort that requires the benefits of technology, plus human initiative.

“By taking a multidisciplinary approach, we are working together and looking closely at how events occur to come up with ways to make the medication process safer and more efficient,” he continues. “Medication safety truly is everyone’s concern.”

The health system has broadened the program from a priority centered mainly in the pharmacy to a systemwide, multidisciplinary approach, establishing the role of medication safety officer and revitalizing the health system’s Medication Safety Committee. The intent: to eliminate patient harm related to the use of medications.

Additionally, Christiana Care has adopted the NCC MERP Taxonomy as a standard way to classify medication errors that result in patient harm.

“The idea is to take medication safety beyond the pharmacy, because everyone has a role in patient safety,” explains Dean Bennett, RPh, CPHQ, first to serve in

NCC MERP INDEX CATEGORIZING MEDICATION NCC MERP Index forFORCategorizing Medication Errors SAFETY ERRORS

DEFINITIONS

NCC MERP Index forMERP Categorizing Medication Errors NCC Index for Categorizing Medication Errors

Harm: Impairment of the physical, emotional, or psychological function or structure of the body and/or pain resulting therefrom.

Monitoring: To observe or record relevant physiological or psychological signs.

Category I: An error occurred that may have contributed to or resulted in the patient’s death

Category I: An error occurred that may have contributed to or resulted in the patient’s death

Category H: An error occurred that required intervention necessary to sustain life

Intervention: May include change in therapy or active medical/surgical treatment.

Intervention Necessary to Sustain Life: Includes cardiovascular and respiratory support Category G: An error occurred that (e.g., CPR, defibrillation, intubation, etc.). may have contributed to or resulted in permanent patient harm

Error, Harm Error, Death

Category F: Error, No An thatHarm may Noerror Erroroccurred have contributed to or resulted in temporary harm toError, the patient andHarm required NoError, Harm initial or prolonged hospitalization

Error, Harm Error, Death Error, Death

Category G: An error occurred that may have contributed to or resulted in permanent Category G: patient harm

An error occurred that may have contributed to or resulted in permanent patient harm

No Error

Error, No Harm

Category A: Circumstances or events that have the capacity to cause error

required intervention necessary to sustain life

Category H: An error occurred that required intervention necessary to sustain life

No Error

Category A: Category I: Circumstances or An error occurred that events thathave havecontributed the may to capacity to Category H: error orcause resulted in the patient’sthat death An error occurred

Category A: Circumstances or events that have the capacity to cause error

Category B: An error occurred but the error did not reach the patient (An "error of omission" does reach the patient)

Category C: An error occurred that reached the patient but did not cause patient harm

Definitions Category B:

HarmAn error occurred but the error did not reach Impairment of the the patient (An "error physical,ofemotional, omission"or does Category B: psychological or reachfunction the patient) An error occurred but structure of the body the error did not reach and/or the patient (An "errorpain resulting of omission" does therefrom. reach the patient)

MonitoringCategory C: An or error occurred that To observe record reached the patient but did relevant physiological not cause patient harm or psychological signs.

Category C:

An error occurred that Intervention reached the patient but did May include not cause patient harm change

Category D: in therapy or active Category F: An error occurred that An error occurred that may reached the patient and medical/surgical have contributed to or required monitoring to Category D: Category D: treatment. resulted in error temporary harm confirm occurred that Category F: An An error occurred that that it resulted in no Category E: the patient to thethat patient required reached the patient and An error occurred may and harm the patient and/or reached andtoIntervention required monitoring to An error occurred initial or prolonged have contributed to or required intervention requiredthat monitoring to Necessary to to confirm resulted in temporary harmthat it resulted in no may have contributed hospitalization confirm that it resulted in preclude no harm Category E: and harm to the patient and/or E: to or resulted Category to the patient required in patient and/orSustain Life harm to the An error occurred required intervention to temporary An error occurred that initial orthat prolonged required to Includes cardiovascular harm to intervention the may have contributed preclude harm may have contributed hospitalization preclude harm patient and required to or resulted in and respiratory support to or resulted in intervention temporary harm to the patient and required intervention

temporary harm to the patient and required intervention

(e.g., CPR, defibrillation, intubation, etc.)

Definitions

Harm Impairment of the physical, emotional, o psychological function structure of the body and/or pain resulting therefrom.

Monitoring To observe or record relevant physiologica or psychological signs Intervention May include change in therapy or active medical/surgical treatment.

Intervention Necessary to Sustain Life Includes cardiovascula and respiratory suppo (e.g., CPR, defibrillat intubation, etc.)

© 2001 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. * Permission is hereby granted to reproduce information contained herein provided that such reproduction shall

© 2001 National Coordinating Council for Medication ErrorCoordinating Reporting and Prevention.

All RightsError Reserved. © 2001 National Council Medication Reporting Prevention.

Reserved. not modify the text and shallforinclude the copyright noticeand appearing onAll theRights pages from which it was copied. * Permission is hereby granted to reproduce information contained hereintoprovided that such reproduction shall * Permission is hereby granted reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing oninclude the pages from which it wasappearing copied. on the pages from which it was copied. not modify the text and shall the copyright notice

14 | C hri sti ana Care Hea l th S ys tem

PSF030G

P

C R E AT I N G a Safe Culture

Reducing employee injury rate remains top priority on annual operating plan

Recordable and lost time injury rates both well below national average Christiana Care is working toward an aggressive employee safety goal to reduce the total recordable injury rate to below 5.5 injuries per 200,000 hours worked. The FY 2013 injury rate through the month of March was 5.67, considerably below the national average of 6.8. The health system’s lost time injury rate of 1.22 is also well below the national hospital average of 1.6.

An important strategy to reduce the injury rate is to learn from injuries that already have occurred and work to implement changes that will prevent the same or similar injuries from happening again. Incident investigation

uncovers the root cause of an employee injury and helps identify the appropriate corrective action to prevent recurrence.

Christiana Care Injury Prevention and Occupational Safety teams, in partnership with the Christiana Care Learning Institute, have created a two-hour employee safety education module focusing on the theme “Make Safe Choices.” The module uses videos featuring employee actors and interactive learning to increase workplace safety awareness and is included in the Education Center agenda for all employees.

EMPLOYEE INJURY RATES

ff Injuries Per 200,000 Worked Hours

Lost time injury rate decreased by 40 percent since FY10

n Lost Time Injury Rate n Total Recordable Injury Rate Target

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 1 5

accination

% Vaccinated 66% 92% 94%

Employee and inpatient influenza vaccination rates exceed 90 percent for 2012-13 season Combined approach increases vaccination rate by 40 percent over FY 2010-11 A multi-modal campaign for employee influenza vaccination with collective and individual responsibility, as well as financial incentives, achieved a sustained greater-than 90 percent vaccination rate for two influenza seasons.

Employee Vaccination

EMPLOYEE VACCINATION RATES 100%

92%

92%

75%

94% 94% % of eligible employees

ff Percent of Eligible Employees

Y11 Y12 Y13

66%

50%

66%

25%

0% FY11

FY12

Inpatient influenza vaccination rate tops 92 percent Inpatient influenza vaccination rates increased from 90.1 percent in 2012 to 92.2 percent in 2013. A total of 3,518 inpatient flu doses were administered; 31 percent of those patients were age 65 or older and, of them, 62 percent opted for the recommended high-dose vaccine.

New in the 2012-13 season: The high-dose flu vaccine was offered to eligible patients over the age of 65; and a discharge alert now helps capture patients who either were not assessed during their inpatient stay or who had not received vaccine, if eligible, at the time of discharge.

Evaluation of the inpatient vaccine process continues to further improve patient vaccination rates as Christiana Care strives for the 95 percent inpatient vaccination rate set forth by the Council of Teaching Hospitals and Health Systems (COTH) Top 10%.

FY13

The campaign, launched in FY 2011-12 and sustained for 2012-13, included:

INPATIENT INFLUENZA VACCINATION RATES

Rates approach top teaching hospitals

ff Mandatory declination policy. ff Mask-wearing for non-vaccinated health care personnel. ff “I’m Vaccinated” badge hang tags. ff Improved tracking via bar code scanning technology. ff Weekly compliance reports. ff Vaccination stations at hospital/ancillary site entrances. ff Inclusion of a target employee vaccination rate of greater than 75 percent in a pre-existing employee bonus program.

Results were significant. In 2011-12, 92 percent of employees were vaccinated for influenza; 94 percent in 2012-13, a substantial increase over the 66 percent vaccinated in the 2010-11 season.

16 | C hri sti ana Care Hea l th S ys tem

n Christiana Care  COTH Median  COTH Top 10%

C R E AT I N G a Safe Culture

Christiana Care joins national partnership to eliminate preventable fetal and maternal harm Christiana Care is partnering with the National Quality Forum, the Joint Commission and the American College of Obstetricians and Gynecologists to avoid early elective deliveries and reduce Cesarean births among low-risk women.

The national group is working to reduce elective inductions before 39 weeks gestation to 5 percent or less, and to reduce the rate of primary Cesarean section deliveries for low-risk women.

Strategies to meet these goals include standardized administration of Oxytocin, a high-alert medication used to induce labor, and implementation of hard stops and

checklists to improve adherence to established guidelines for elective induction.

Formal educational efforts include Grand Rounds on “Preventing the First Cesarean Delivery” and reinforcement of adherence to national guidelines.

The results of these efforts are impressive. Christiana Care’s rate of elective induction prior to 39 weeks was below the 5 percent target in 22 of the past 23 months. The primary Cesarean section rate for the low-risk population has decreased by more than 15 percent since FY 2012, and is trending toward the national target.

ELECTIVE DELIVERIES BEFORE 39 WEEKS GESTATION

ff Percent of Deliveries

 Target  Less than 39 weeks elective induction delivery rate

15 percent decrease in rate

ff Percent of Patients

LOW RISK PRIMARY CESAREAN SECTION RATE

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 1 7

Nursing collaboration improves handoff communication to enhance patient safety Nursing collaboration between the Emergency Department and inpatient units addressing communication during patient handoffs improved staff rating of communication by 18.5 percent; and positively impacted staff perception of quality, completeness, accuracy, timeliness, organization and attention to patient-specific information.

Results of our hospital survey on patient safety culture identified handoff communication as an opportunity for improvement at Christiana Care. Literature supports that handoffs are a point of vulnerability, citing them as contributing to medical errors.

Addressing identified barriers with the handoff process— including variation in the method of communication used, lack of a shared mental model and differences in the report content—nurses in the ED began verbally communicating all reports to nurses in the inpatient units. The two groups

also collaborated to create a standardized DATAS report template to be used during the verbal report, creating a shared mental model.

The initiative was successfully piloted with the Christiana Emergency Department and medical-surgical unit 5C, and expanded to 2C stepdown, the Express Admission Unit, 5A medical-surgical, 4D surgery/stepdown, all at Christiana Hospital; as well as to the Wilmington Emergency Department and 5N/stepdown. Based on the pilot’s success, the initiative expanded to all ED-to-inpatient admissions.

DATAS

❯ Demographics ❯ Assessment/Allergies ❯ Tests and Test/Lab Results ❯ Alerts ❯ Status/Discharge Planning

PRE AND POST IMPLEMENTATION DATA RESULTS ff Staff Rating of ED to Inpatient Report/Information Pre Pilot Answer/Strongly Agree Post Pilot Answer/Strongly Agree Post Systemwide Answer Agree/Strongly Agree

ff Percentage of Positive Response Rate

All areas showing improvement on post implementation survey

Quality

18 | C hri sti ana Care Hea l th S ys tem

Completeness

Accuracy

Timeliness

Organization

Attention to Patient Specific Information

C R E AT I N G a Safe Culture

Medical interpreters ensure language isn’t a barrier to high-quality care A recent pilot research project by Christiana Care’s Health Services Research for Women and Children discovered that among the 391 mothers who delivered babies at Christiana Hospital during a six-week period were women who spoke 19 different languages, including seven different tongues originating in India. Of them, 58 percent indicated needing an interpreter at some point during their stay and not receiving this service.

Number of Prescheduled Engounters (by Month)

Apr-12

Mar-­‐12

When providers rely on patients’ family or friends Region 1 26 to 56 interpret, important information often gets lost in translation.

Mar-­‐12 26

May-12

Jun-12

80

Jul-12

109

Aug-12

164

Sep-12

289

Apr-­‐12 56 To address the growing demand for qualified medical May-­‐12 80 interpretation, and in response to Joint Commission standards Jun-­‐12 109 for effective communication, Christiana Care Language Jul-­‐12 164 Services employs 10 interpreters—seven who speak Spanish Aug-­‐12 289 and three who are fluent in American Sign Language—and Sep-­‐12 254 Oct-­‐12 283 interpreting service in 150 languages. offers telephonic Nov-­‐12 331 Prescheduled Dec-­‐12 320requests for interpreters rose exponentially, from 26 in536 March 2012 to 457 in February 2013.

Jan-­‐12 Feb-­‐12 457

With a qualified medical interpreter, both patients and providers benefit from clear communication. Interpreters make certain that patients understand their care so that they can make informed decisions, and that staff understand patients in a way that lowers the risk of mistakes caused by miscommunication.

PRESCHEDULED REQUESTS FOR MEDICAL INTERPRETATION

“Having access to a qualified, in-house individual who speaks the patient’s language is an essential step in improving patient safety, education and quality of care.”

— Jacqueline Ortiz, Manager of Cultural Competency, Equity and Language Services

536

600

457 450

289

300

331 254

283

320

164 150

26

56

80

109

0 Mar-­‐12 Apr-­‐12 May-­‐12 Jun-­‐12 Jul-­‐12 Aug-­‐12 Sep-­‐12 Oct-­‐12 Nov-­‐12 Dec-­‐12 Jan-­‐13 Feb-­‐13

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 1 9

254

NICU achieves reduction in severe peripheral intravenous infiltrates as incomplete skin development (fewer layers and less cohesion), decreased dermal thickness and decreased perfusion—as well as positioning and comfort processes unique to neonatal care—increase the risk of injury from infiltration. Yet while infiltration is the most common (52 percent) reason for PIV removal, industry-wide infiltrates are not traditionally tracked in the NICU setting.

Christiana Care NICU nurses recognized a concerning number of severe (grades 3 and 4) infiltrations and embarked on a solution to reduce harm. Between November 2009 and April 2010, the unit reported 504 PIVs, 19 or 3.7 percent of them with severe infiltrates, grade 3 or higher. With a baseline average of 7.3 infiltrates/ 1,000 catheter days, the team set a goal to reduce infiltrates by 50 percent to 9.5 in six months, or 3.7/1,000 catheter days and ultimately achieved a 69 percent reduction at 2.3/1,000 catheter days.

Rapid cycle improvement and bundled interventions led to a 53 percent reduction in severe peripheral intravenous (PIV) infiltrates in the neonatal intensive care unit (NICU) in the first six months. A statistically significant reduction by 69 percent within 19 months of the nursingdriven program may now serve as a model for use in NICUs nationwide.

PIVs are one of the most common procedures performed in the NICU for infusion of fluids for nutritional support, medication delivery and blood transfusions.

Infiltrations are the unintended leakage of solution into surrounding tissue. They often resolve, but can result in serious complications requiring reconstructive surgery, and can cause long-term pain and suffering, longer hospital stays and increased costs. Unique neonatal factors, such

20 | C hri sti ana Care Hea l th S ys tem

Interventions included formulation of a multidisciplinary team, employing a standard grading method, educating nurses, improving site visualization, increasing vigilance and monitoring and providing ongoing notification of the unit’s infiltration rate and days between infiltrations.

Nurses performed in-depth analysis and audits and recommended care practices such as securing IVs, ensuring visibility of site and performing frequent site checks, including joint site checks at shift handoff.

They also increased days between severe infiltrates, extending the baseline average of 22 days by 50 percent to 33 days, and achieved a 109 percent increase in average time between severe infiltrates from 22 to 46 days. Through April 2013, Christiana Care’s NICU had achieved 96 days without occurrence.

C R E AT I N G a Safe Culture 69 percent reduction in severe inflitrates; Average days between infiltrates doubled

PERIPHERAL INTRAVENOUS INFILTRATE RATE ff Infiltrates per 1,000 Catheter Days

ff Number of Cases Per 1,000 Days

Desired direction

TARGET: 3.7

DAYS BETWEEN PERIPHERAL INTRAVENOUS INFILTRATES

ff Number of Days

TARGET: 33

Desired direction

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 2 1

AC H I E V I N G High Reliability

T

he desire of our neighbors to be healthy is simple. It is our responsibility, then, to simplify medicine’s complexity. We do this by organizing our efforts as “systems of care” so that we may be effective partners in the health of our neighbors. By organizing care well, we can make it affordable so that all will have access, both today and tomorrow.

22 | C hri sti ana Care Hea l th S ys tem

AC H I E V I N G High Reliability

Synchronized admissions reduce length of stay, readmission rate and Rapid Response Team calls Synchronized Admission Teams continue to expand at both Wilmington and Christiana hospitals, enabling more effective communication and care coordination and ensuring patient and family centered care. The interdisciplinary care model brings together an experienced physician, resident, clinical pharmacist, nurse and social worker or case manager to admit patients from the Emergency Department.

To date, more than 1,000 patients have been admitted through the synchronous process at Wilmington Hospital, helping to reduce length of stay by nearly 0.5 days and

cutting down the rate of patients who required a Rapid Response Team call to less than 1 percent. The launch of the Synchronized Admission Teams at Christiana Hospital is credited with a reduced length of stay to 3.96 days compared to 4.30 days for like patients without Synchronized Admission Teams. Fewer than 1 percent of patients have experienced a Rapid Response Team call.

Patient safety is further enhanced through pharmacist intervention to reduce medication-related adverse events.

Twenty percent of pharmacist interventions are related to high-risk medications such as insulin.

CASE MIX ADJUSTED LENGTH OF STAY – CHRISTIANA HOSPITAL

ff Days

The synchronized admission team launch is credited with a reduced length of stay

338 patients served by synchronized admission teams since roll-out in Christiana ED with two hospitalist groups

Synchronized admission Compare

ff January - April 2013

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 2 3

Value improvement scores continue to climb Under the leadership of the Clinical Excellence Committee, all four Value Improvement Teams continue to show improvement from baseline.

Heart Failure value score increased from 79.9 (C+) to 91.6 (A-) Guideline compliance improved by almost 10%, mortality decreased 77% and is at the top 10% of major teaching hospitals. Readmissions dropped over 40%, and length of stay decreased by 0.5 days, a 10% improvement. Estimated costs dropped 12%, with a total savings of $2.3 million.

Pneumonia value score increased from 76.9 (C) to 86.1 (B) Compliance with guideline measures improved by 10%, mortality dropped 40% and length of stay improved 8% (0.4 days).

Estimated costs declined by 16%, for an overall savings of $2.2 million.

24 | C hri sti ana Care Hea l th S ys tem

AC H I E V I N G High Reliability

Acute Myocardial Infarction value score increased from 84.0 (B) to 90.0 (A-) Time to Percutaneous Coronary Intervention (PCI) improved more than 6%, mortality rates declined 15%, readmissions dropped by 14%, and length of stay improved by 1/2 day, a decrease of over 11%. The estimated cost observed to expected ratio improved by 11% following team efforts to improve accuracy of patient severity of illness.

Surgical care improvement program value score improved from 94.2 (A) to 99.4 (A+) The percentage of patients receiving perfect care improved 8%. Eight of the 9 measures are at the top 10% of major teaching hospitals.

KEY TO SYMBOLS

Guideline Compliance:

Outcomes:

✱ Measure is included in Value Based Purchasing ● >= Threshold (for measures with baseline performance < threshold) ▲ Between baseline & threshold ◆ < Baseline

● Observed to Expected <= 1.0 ▲ O/E > 1.0 and <= 1.10 ◆ O/E > 1.10

COTH – Council of Teaching Hospitals and Health Systems

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 2 5

Pre-­‐Operative Ca

Dev 7:07:54

rvention Intervention Group Group 41% 15.0% 1.1% Median Std Dev .18 4.94 5.53 .22

2D Echocardiograms

Fracture intervention team decreases length of stay by almost a full day 1%

urs)

Median Std Dev :00 24:20:00 27:07:54 Creation of a Hip Fracture Intervention Team (Hip FIT) :00

to improve the timeliness of operation for the hight-risk population of patients with hip fractures is credited with a e Baseline Intervention Intervention Group Group in the length of stay, nearly an entire 194 ology Consults 89% 15 percent decrease41% of Orthopaedic Surgery, s33 15.14% day. Led by the Department 15.0% a partnership with representatives from 2 0.92% Hip FIT includes 1.1% Rehabilitation, Cardiology, Anesthesia, and Internal and Emergency Medicine. This initiative is designed to increase awareness of the risk factors that lead to fragility fractures, in order to better coordinate prevention and treatment services and to significantly reduce the number of injuries of this kind.

Average Length of Stay

Pre-­‐O

Stress Tests

1% use of Hip FIT also resulted in a more prudent consultants. Although the percentage of hip fracture patients requiring echocardiograms and stress tests 5% 0% remained constant before and after Hip FIT was initiated, the percentage of pre-operativeBaseline cardiology consults decreased by 47.6 percent.

Intervention Group

10%

2D Echocardiograms

Overall, Hip FIT decreased hospital length of stay by 0.9 days or 17 percent and shortened the time from the emergency department to the operating room for surgery by three hours and 20 minutes.

1%

Stress Tests

1% 5%

0%

6.18 AVERAGE LENGTH OFLSTAY Average ength of Stay 5.22 7

Pre-­‐Operative Cardio CBaseline onsults

PRE-OPERATIVE CARDIOLOGY CONSULTS

Intervention Group

17 percent decrease in length of stay

48 percent improvement in consultant use

90%

6 Intervention Group 60%

ff Days

3

6.18 5.22

2

Percent of Patients

4

ff Percent of Patients

5 Baseline

89%

Pre-­‐Operative Cardio Con 30% 90%

41%

1

0

Baseline

Intervention Group

0%

Intervention Group Baseline 60%

89% 30% 26 | C hri sti ana Care Hea l th S ys tem

41%

AC H I E V I N G High Reliability

Helen F. Graham Cancer Center contributes to landmark Breast Cancer Study within The Cancer Genome Atlas Christiana Care’s Helen F. Graham Cancer Center is among an elite group of institutions that provides tumor samples for groundbreaking research hailed as the largest, most comprehensive breast cancer genomic study ever.

The results emerging from this study are redesigning our understanding of breast and other cancers, and signal a transformation in future treatment that will benefit a wide range of patients.

The Graham Center contributed 37 of the study’s 825 breast tumor samples specimens. Recent discoveries, published in the October 2012 issue of Nature, identify four genetically different subtypes of breast cancer, and within those, the genetic drivers of many different types of cancer. Researchers identified at least 40 genetic alterations that could be targeted with anti-cancer drugs, many of which are being developed or already used to treat other cancers with the same mutations.

the Mayo Clinic, and is one of only two National Cancer Institute Community Cancer Centers chosen to participate in the breast cancer study.

Reports from The Cancer Genome Atlas on similar studies of colon and lung cancer, in which the Helen F. Graham Cancer Center also participated, were published in Nature in July and September of 2012. They pair colon and rectal tumors as a single type of cancer—not separate as previously thought—and identify potential new anticancer drug targets.

A surprising finding distinguishes a particularly poorprognosis breast cancer subtype found in the deep skin layer of basal cells linked to ovarian cancer. This opens up the possibility of routine treatment for ovarian cancer with some commonly available breast cancer drugs.

The Cancer Genome Atlas, funded by the National Institutes of Health, uses genomic technologies and large-scale gene sequencing to map out an atlas of genetic changes for specific types of cancers and shares that information publicly with scientists.

The Helen F. Graham Cancer Center is on a short list of tissue-collection centers that includes major universities and leading hospitals, such as MD Anderson Cancer Center, Memorial Sloan-Kettering Cancer Center and

FAC T: Christiana Care’s Tissue Procurement Center has banked about 3,000 human tissue specimens, and, since 2009, has provided some 300 tissue samples of up to 20 tumor types—including breast, brain, lung and ovarian—to The Cancer Genome Atlas for analysis.

“Our proven tissue procurement capability to match The Cancer Genome Atlas standards enables our contribution to this unprecedented effort to improve cancer therapies.”

— Nicholas Petrelli, M.D., Bank of America Endowed Medical Director of the Helen F. Graham Cancer Center

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 2 7

Medical Home Without Walls reduces frequent Emergency Department visits; improves quality of life for the homeless, disenfranchised Christiana Care’s Medical Home Without Walls initiative reaches “super users” of the acute-care system – a group that comprises fewer than 10 percent of all patients but accounts for more than 20 percent of all visits to the hospital. Among the first 20 patients enrolled in the program for at least 50 days, Christiana Care reported a 15 percent reduction in Emergency Department visits, a 24 percent reduction in hospital admissions and a 58 percent reduction in total hospital days.

By visiting patients at their home or shelter, accompanying them to medical appointments and addressing social ills such as hunger, addiction and domestic violence, the program provides coordinated care to people who might

CHANGE IN HOSPITAL ENCOUNTERS

n Pre Intervention n Post Intervention

28 | C hri sti ana Care Hea l th S ys tem

otherwise only receive care through frequent visits to the emergency department.

Medical Home Without Walls is modeled on a successful program in Camden, N.J., that reduced health care costs 56 percent by dramatically decreasing the need for emergency care. A dedicated multidisciplinary team identifies super users and then connects them with a medical home, coordinates clinical care and addresses their psychological and social needs.

“Doctors can write prescriptions all day, but they can’t buy the medicine and make patients take it,” says Erica Locke, M.D., a third-year resident in Emergency and Family Medicine, who helped launch the program.

AC H I E V I N G High Reliability

“This program is about trust—patients working with a doctor or nurse and realizing that their health is their own, and they have a say in it.” She says this hands-on initiative has the potential to transform the lives of patients who feel disenfranchised from the mainstream health care system.

CHANGE IN TOTAL HOSPITAL DAYS ff Inpatient & Observation Patient Days A 58 percent reduction in hospital use

Locke and social worker Tracy Pearson shadowed a team in Camden to gain firsthand experience before launching Christiana Care’s program in Wilmington, Del., in August 2012. In its initial stage, Medical Home Without Walls is focusing on patients in three ZIP codes who do not have health insurance. Many are homeless.

“We connect them with resources in the community, such as shelters, food banks and medical insurance,” said Pearson, the team’s social worker and health coach. “We are building relationships with other organizations so we can work together to help these people.”

Medical Home Without Walls is part of Christiana Care’s Care Link Services – a population health approach that tackles the health issues of specific groups of individuals.

Funding from the Jessie Ball duPont Fund will help expand the program’s reach.

“These are patients with complex medical problems, as well as high risk factors such as homelessness and substance abuse. If we can help to keep a patient healthy in the community, the health system saves the cost of hospitalization, which is about $1,300 a day. But more importantly, it greatly improves the patient’s quality of life, as defined by the patient.” ­— Diane Bohner, M.D., Medical Director of Patient and Family Centered Care and Resource Management

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 2 9

Overall Rating of Care Communication - Nurses Communication - Doctors Response of hospital staff Hospital environment Pain management Communication - Medications Discharge Process Recommend this hospital

68.9% 77.7% 86.3% 66.6% 57.3% 64.7% 74.9% 77.0% 76.8%

68.8% 77.7% 86.6% 66.8% 57.6% 64.9% 74.9% 77.7% 77.0%

69.0% 77.7% 86.3% 66.8% 57.6% 64.7% 75.0% 78.2% 76.8%

69.3% 77.6% 86.2% 66.6% 57.4% 64.7% 75.3% 78.3% 77.0%

69.4% 69.7% 69.8% 70.1% 77.9% 78.3% 78.7% 79.2% 86.1% 86.4% 86.5% 86.7% AC H I E V I N G High Reliability 67.3% 67.4% 67.8% 68.5% 57.4% 57.7% 58.0% 58.3% 65.0% 64.8% 64.7% 65.3% 75.8% 75.9% 76.4% 76.5% 78.6% 78.9% 79.0% 78.5% 77.0% 77.1% 77.3% 77.4%

Patient experience scores climb

Solid discharge process reduces unnecessary readmissions Patient satisfaction with Christiana Care’s discharge process has improved steadily in the last year and a half, rising from 72 to 82 percent in 2012, and moving upward again to 84 percent for FY 2013 to-date as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

The checklist is now in place system-wide based on success of the surgical pilot results shared in a Nursing Advisory Committee meeting.

The standardized discharge checklist is also credited with a notable improvement in the communication regarding medications domain value-based score.

The increase is attributed, in part, to a new discharge checklist developed and piloted by the surgical team at Christiana Hospital for use when reviewing discharge instructions with patients. Standard questions help the nurse zero in on whether the patient clearly understands the discharge instructions, including whether he or she understands potential side effects of prescribed medications and has a family member, friend or care provider available to help at home or needs assistance in making those arrangements.

Christiana Care compares favorably against value-based purchasing national medians in 75 percent of HCAHPS domains, and places in the top decile among Council of Teaching Hospitals and Health Systems (COTH) hospitals for domain scores in: ● Communication by nurses.

To align the enhanced discharge planning process with Christiana Care’s commitment to patient and family centered care—in which the patient is regarded as an informed and involved member of the care planning team—both the nurse and patient sign the checklist once instructions have been reviewed indicating that the patient understands and agrees with his or her plan of care.

● Response of hospital staff. ● Pain management. ● Communication regarding medications.

PATIENT/FAMILY EXPERIENCE WITH DISCHARGE PROCESS 85.0%

82.0%

79.0%

Jul-­‐10 Oct-­‐10 Jan-­‐11 Apr-­‐11 Jul-­‐11

Oct-­‐11

Jan-­‐12

Apr-­‐12

Jul-­‐12

Oct-­‐12

Jan-­‐13

76.0%

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 3 1

70.3% 79.5% 86.8% 69.2% 58.6% 65.8% 76.5% 78.4% 77.7%

Collaborative model controls acute care utilization and improves health outcomes

Pre

36.70% An interdisciplinary team model studied by Christiana 32.70% Care’s Visiting Nurse Association (VNA) and the Department of Family & Community Medicine’s Home Visit Program suggests that a collaborative provider approach that pairs all of one physician’s home care Post patients with the same home care nurse streamlines 33.3% 30.0% communication, optimizes continuity of care and improves 36.7% 32.7% management of provider resources.

The collaborative provider model is credited with reducing acute care hospitalization by more than 10 percent and shortening length of stay by 45 percent for study participants, while improving patient function in such areas as ambulation, ability to dress and bathing for more than 50 percent of participants.

“Improvement in acute care hospitalization and length of stay can be attributed to a collaborative team ready to resume care of the patient upon discharge,” notes study

co-author Gale Bucher, MSN, RN, COS-C, who adds that social workers and psychiatric nurses were key in assisting with patients’ basic needs and behavioral health issues.

“Functional improvement allows our patients to enjoy independence at home, while improving such functions as the ability to dress one’s lower body reduces fall risk.”

In the studied provider model, all of a physician’s home care patients are cared for by one home care nurse assigned to that practice, negating the need for physicians to coordinate care with multiple home care nurses assigned to patients by ZIP code in an alternative geographic model. Weekly interdisciplinary case conferences among home care nurses promoted efficiency in communication and information sharing, and prompted interdisciplinary learning, leading to more coordinated care.

VNA ACUTE CARE HOSPITALIZATIONS

Acute Care Hospitalizations pre and post

ff Pre-Post Collaborative Model

40%

ff Percentage of Patients Hospitalized

Pre Post

30%

20%

36.7%

32.7%

10%

0%

32 | C hri sti ana Care Hea l th S ys tem

Post Pre

AC H I E V I N G High Reliability HOSPITALIZATION LENGTH OF STAY ff Pre-Post Collaborative Model

Thirteen Patients in HV ProgramLOS

ff Number of Patient Days

50

45 percent reduction in hospital utilization

40 30 20

44 24

10 0

Post Pre

IMPROVEMENT IN PATIENT FUNCTIONAL STATUS

More than half of patients improved in seven areas

Target 50%

ff Percentage of Patients with Improvement

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 3 3

Second Annual Value Symposium explores the Triple Aim in transforming health care Don Berwick, M.D, former Administrator of the Centers for Medicare and Medicaid Services and founding Chief Executive Officer and President Emeritus of the Institute for Healthcare Improvement, delivered the keynote address at Christiana Care Health System’s Second Annual Value Symposium: “Transforming Health Care in America: Making the Triple Aim a Reality.”

Dr. Berwick told the audience of nearly 200 physicians, nurses and health care executives the U.S. health care system must endure the growing pains of change in order to transform into a system that provides for its citizens affordable, accessible, high-quality care. Referencing the Affordable Care Act, Dr. Berwick said that “health care is shifting. It is at a point where the United States is trying to attach payments to quality. The transitions are tough, but the opportunity to achieve the Triple Aim is right now.”

Following Dr. Berwick’s talk, Christiana Care President and CEO Robert J. Laskowski, M.D., moderated a discussion about the challenges and solutions to achieving the Triple Aim. Joining Dr. Berwick on the panel were: ff Bettina Riveros, health policy adviser to Delaware Governor Jack Markell and chair of the Delaware Health Care Commission. ff Stephen J. Kushner D.O., FAAFP, president of the Medical Society of Delaware and a physician at the Medical Group of Christiana Care’s Hockessin Family Medicine Office. ff Former Delaware Governor Pierre S. “Pete” duPont IV, current board member of the Delaware Public Policy Institute. ff Timothy J. Gardner, M.D., executive director of the Christiana Care Value Institute, medical director of Christiana Care’s Center for Heart and Vascular Health and former national president of the American Heart Association.

The “Triple Aim” concept—the brainchild of Dr. Berwick—is defined as delivering health care that improves the individual patient experience, improves the health of populations and reduces the per-capita costs of care for populations. Christiana Care established the Value Institute in 2011 to study and design solutions for conundrums that arise in the real-world settings of health care delivery while also focusing on balancing our neighbors’ perceptions of the value of care against measurable benefits and costs.

“There has never before been a better time for health care professionals to lead the reform and improvement of American health care as a system,” Dr. Berwick said. “The transition is hard, so it is going to take real courage to walk with the public to help them find their way and what they need.”

34 | C hri sti ana Care Hea l th S ys tem

Eric Jackson, M.D., MBA, director of the Center for Health Care Delivery Science and associate director of the Christiana Care Value Institute, talks with Don Berwick, M.D.

AC H I E V I N G High Reliability

“I am inspired and impressed by what I am seeing here at Christiana Care. I can tell you that your organization has the right pieces in place to bring about real change.” ­— Don Berwick, M.D., leading U.S. advocate for high quality health care

Virginia Collier, M.D., MACP, Hugh R. Sharp Jr. Chair of Medicine, asks a question of the panel.

Bettina Riveros, health policy adviser to Delaware Gov. Jack Markell, answers a question on the panel.

Robert J. Laskowski, M.D., Christiana Care president and CEO, leads a panel discussion at Christiana Care’s Second Annual Value Symposium, featuring (from left) Don Berwick, M.D., Bettina Riveros; Stephen J. Kushner D.O., FAAFP; former Delaware Gov. Pierre S. “Pete” duPont IV; and Timothy J. Gardner, M.D.

2 0 1 3 R e p o r t o n Qu a l ity and Saf ety | 3 5

Value Institute Academy offers formalized approach to staff education and training to build organizational capability Through a formalized approach to staff education and training, The Value Institute Academy will facilitate changes in health care delivery to create innovative, effective, affordable systems of care that our neighbors value.

Initial curriculum focuses on three key tracks, with more to be introduced in the coming year: • Improvement Science • Research Methodologies • Patient Safety The Academy maximizes both individual and team abilities to innovate and lead change and drive scientifically based improvements in health care delivery, with programs designed to promote basic through advanced skill levels.

The Value Institute Academy has set a goal of becoming a regional center for the education and training of individuals or groups outside of Christiana Care Health System in health care value.

Improvement Science Course Curriculum

Achieving Competency Today One of the integral components of the Improvement Science Track is the award-winning Achieving Competency Today (ACT): Issues in Health Care Quality, Cost, Systems and Safety – a quality improvement/patient safety course launched in 2005 with a grant from the Robert Wood Johnson Foundation and Harvard’s Partnership for Quality Education. Using Institute for Healthcare Improvement (IHI) Open School modules as a learning foundation, and interactive presentations by faculty leaders from Christiana Care and Nemours/Alfred I. duPont Hospital for Children, learners representing multiple disciplines and departments work together in diverse, interprofessional teams to identify a health care system-based improvement opportunity, review best practices and relevant literature, and design and present an evidence-based improvement project mirroring Association of American Medical Colleges Teaching for Quality report recommendations.

368 Christiana Care learners, including residents and attending physicians, nurses, physician assistants, pharmacists, allied health and staff representatives, have completed 61 rapid cycle tests. More than half resulted in unit or system-level improvements with direct benefits to patients.

Learners report significant improvement immediately post course completion in 10 key quality improvement skills with demonstrated sustainment at six months post-course measurement.

Examples of improvements

» Improve antibiotic duration adherence to guideline recommendations

for Community Acquired Pneumonia by 25 percent on the Internal Medicine teaching teams within 14 days.

» Decrease the inappropriate use of oxygen by 50 percent in two weeks

on two Christiana Hospital medical patient care units (5A and 5B).

»

www.christianacare.org/valueinstituteacademy

36 | C hri sti ana Care Hea l th S ys tem

Increase the percent of essential information communicated during transfer from the MICU to a lower level of care by 50 percent within one week.

AC H I E V I N G High Reliability

“ACT is recognized by IHI and meets goals of the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review Patient Safety and Quality Improvement focus areas: • Participation in interprofessional teams to provide and enhance safe care.

• Engaging residents in the use of data to improve systems of care and patient outcomes.

• Professionalism.”

— Anilkumar Neil Jasani, M.D., MBA, FACEP, Vice President, Academic Affairs/Emergency Medicine

Lean Six Sigma training program leads transformation Operational Excellence has partnered with the internationally recognized Juran Institute in offering an onsite training and mentorship program aimed at building organizational capacity to lead change. Participants earn certification from the Juran Institute after successful completion of the program requirements. The program is co-led by more than a dozen service line leaders across the organization. Our shared goal is to create an “army of Operational Excellence practitioners” who have protected time to drive on going improvement in our clinical and operational systems.

Participants receive hands-on coaching from expertly trained coaches from Operational Excellence and The

Juran Institute. By the end of 2013, Christiana Care will have 48 certified Operational Excellence practitioners embedded in key Christiana Care service lines.

FAC T: ❯ LEAN/ Six Sigma concept that allows a project team to “rapid cycle” test a process improvement intervention or solution.

Juran Lean/ Six Sigma initiatives include: • Reduce food waste

• Reduce unassigned nonurgent work orders

• Reduce accudose stock-outs in the ED • Increase admission conversions to rehab

• Reduce MICU PRBC transfusions not meeting guidelines

• Reduce AMO no-show rate

• Reduce OB triage TAT

• Decrease bed ready to left ED

• Improve perioperative utilization from 1400-1930

• Reduce COPD (DRG 190) LOS on 3D • Decrease patient falls • Improve use of LEP services

• Improve discharge prescription capture rate • Improve urinalysis TAT

“The Juran Green Belt certification program is a disciplined approach to problem solving.

Using the Lean / Six Sigma methodology, individuals and teams learn to define, measure, analyze, improve and control key clinical and operational systems. We’re teaching leaders and teams how to use the science of improvement to work smarter and speed up transformation.”

— Vernon Alders, Corporate Director of Operational Excellence

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L E V E R AG I N G Technolog y

RayStation速 4D radiotherapy treatment planning software

T

he expansion of scientific knowledge and new technologies leads to miraculous advances in the ability to heal and, often, to cure. The implications of this explosion of knowledge, however, are complex. Innovations must be transformed into practical approaches to clinical care. Technology plays a critical and continuing role in helping us enhance the quality and safety of our care in ways unimaginable just a few years ago.

38 | C hri sti ana Care Hea l th S ys tem

L E V E R AG I N G Technol og y

Christiana Care one of only 10 U.S. sites with advanced 4D tumor tracking radiation software Christiana Care’s Helen F. Graham Cancer Center is only the 10th U.S. institution to install the 4D treatment planning software RayStation® that provides precise radiation treatments with greater efficiency for cancer patients.

With standard systems, it can take two to three days to review the progress of a tumor and establish a plan to deliver the precise dose of radiation required to attack the cancer. RayStation condenses that process to about half a day.

The fourth dimension is time. RayStation 4D software uses special adaptive techniques to adjust for anatomical changes that can occur in tumors and surrounding normal tissues during the course of treatment, allowing far greater control in tumor targeting while sparing normal tissue.

RayStation is used to plan treatment of cancers of the head and neck, which account for about 3 percent of cancers in the U.S., according to the American Cancer Society, and are difficult to treat unless detected in their earliest stages.

Intensity-modulated radiation therapy, or IMRT, is so highly conformal that even minor changes in the patient’s anatomy can have profound effects on outcomes.

“This technology is revolutionary in that it allows rapid adaptation of our original IMRT treatment plan to re-conform to changes in the patient contour due to weight loss and tumor response. Rapid adaptive IMRT is the next wave of technology that can be applied with immediate clinical benefit of additional accuracy and side-effect reduction.” ­— Adam Raben, M.D., Radiation Oncologist

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New protocol ensures telemetry is ordered for right patient at right time Reduction in monitoring improves safety, leads to greater value A commitment to reduce the utilization of nonintensive care cardiac telemetry creates greater value for the patients we serve. By ensuring that telemetry is used only on the right patient at the right time, value is enhanced by improving patient safety, allowing clinical staff to focus on their patients’ direct care requirements, and by using health care resources more wisely.

While telemetry provides critical monitoring for patients with appropriate clinical indications, wide-spread use of the technology has created multiple challenges to the delivery of safe, high-quality care in low-risk patients for whom it offers little or no clinical value. In one study period, as many as 99 percent of calls from the flex monitoring command center were for nonemergent issues, a vast majority of them for technical malfunctions such as loose leads or low batteries. The interruptions created by these false alarms pull nurses from necessary clinical care duties and increase the potential for error. Telemetry packs and wires increase risk of patient falls, especially among the

elderly. Being tethered to a telemetry unit disrupts patient sleep and encumbers mobility for post-surgical patients.

In a recent Department of Medicine study entitled “Assessing the Cost for Providing Cardiac Monitoring,” Christiana Care researchers discovered that, on average, 277 patients receive cardiac telemetry per day, each requiring at least 20 minutes of nursing time or a collective 92 hours every day throughout the health system for nurses to manage the administrative, equipment and patient care needs associated with the technology. For example, nurses must review telemetry strip results and orders, respond to telemetry alarms, adjust leads and change batteries, and accompanying patients on all transports. While the benefits of telemetry are real in appropriate patients, fewer than 1 percent of the calls from the flex monitoring center are for medical emergencies, while 70 percent are due to technical problems, such as lead or reception problems or battery-related issues.

Leading the way Non-intensive care cardiac telemetry is one of the five frequently ordered tests or procedures that doctors and their patients should question, as potentially unnecessary, according to a list released Feb. 21, 2013 by the Society of Hospital Medicine, a participant in the American Board of Internal Medicine’s (ABIM) Choosing Wisely® Campaign. Choosing Wisely promotes conversations between physicians and patients to choose care that is: • Supported by evidence.

• Not duplicative of other tests or procedures already received.

40 | C hri sti ana Care Hea l th S ys tem

• Free from harm.

•Truly necessary.

Christiana Care’s cardiac telemetry redesign initiative, which launched in September 2012, was well under way and resulted from internal recognition of both overutilization and the unintentional harm cardiac telemetry may cause. The ABIM has requested Christiana Care physician leadership to share the results of this redesign effort during Choosing Wisely networking activities.

L E V E R AG I N G Technol og y

Following national guidelines endorsed by the American Heart Association, Christiana Care’s new telemetry order set through PowerChart predetermines the duration of cardiac telemetry according to clinical indications and provides a checklist to support the bedside nurse’s discontinuation of telemetry in stable clinical conditions.

These interventions minimize the unnecessary use of resources.

Within the new protocol’s first full month of operation, telemetry use dropped from a mean of 383 patient orders per day to 186, with no adverse impact on patient safety, leading to a more valuable care experience.

Telemetry orders dropped more than 50 percent

ff Number of Patients with Telemetry Order

IMPACT ON TELEMETRY UTILIZATION

Includes all noncritical patients age 18 or older admitted to inpatient or observation status within Christiana Care Health System

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Christiana Care wins prestigious Center for Medicare and Medicaid Innovation grant Breakthrough analytics technology enhances discharge process, care management protocols A $10 million grant from the Center for Medicare and Medicaid Innovation to Christiana Care makes possible a new care model harnessing information technology to transcend the gaps that currently exist within health care to provide more coordinated care and greater value for patients with ischemic heart disease (IHD), who tend to experience higher rates of health complications and hospital readmissions.

Known as Bridging the Divide, the initiative allows a comprehensive care management hub—staffed by a physician, case managers, social workers, health ambassadors and a pharmacist—to respond quickly and effectively to the patients recuperating from myocardial infarction, enhancing the discharge process by enabling them to recuperate in their homes, and manage their symptoms to avoid unnecessary, costly readmissions The program’s patient-centric interventions are driven by an outpatient algorithm designed in conjunction with Christiana Care Cardiology Consultants and Delaware Cardiovascular Associates, and are aimed at increasing the patient’s self-management skills and standardizing care.

Increased coordination with all of the patient’s health care providers will result in better health, better outcomes and lower costs while investing in the infrastructure for population management.

Bridging the Divide partners Christiana Care with Medecision, Inc., Coldlight Solutions, LLC, Booz Allen Hamilton, the Delaware Health Information Network (DHIN), the University of Delaware, the Society of Thoracic Surgeons and the American College of Cardiology in an exciting integration of clinical data to coordinate care remotely. The data will support evidencebased longitudinal care management for patients with IHD over the next three years and beyond.

Program goals include creation of an integrated, longitudinal data platform for patients with IHD, and implementation of evidence-based care management protocols to manage patient populations after myocardial infarction.

Christiana Care is in the process of designing an electronic patient portal and personal health record for Bridging

WHAT OUR REPRESENTATIVES SAY ABOUT THE GRANT:

“This project helps to improve patients’ health and reduces unnecessary visits to emergency rooms and hospitals, increasing the quality and efficiency of health care services in Delaware while also lowering costs.”

— U.S. Senator Thomas R. Carper

“Technology, information and innovation are critical to reducing health care costs and improving quality of care. Christiana Care will help us move from a sick care system to a health care system.”

— Delaware Governor Jack Markell

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L E V E R AG I N G Technol og y

the Divide, enabling patients to communicate with their care management team in order to respond to their health problems.

Bridging the Divide includes: • Using predictive analytics to identify patients who are more likely to experience readmissions, develop complications and need a higher level of care.

• Comparing patient-specific outcomes with evidencebased recommendations in managing heart disease.

• Using a software-driven care management program to improve patient outcomes.

While the care management of heart and vascular disease patients by and large has been delivered in the same way to every patient in order to achieve optimal results, Christiana Care’s model is aimed at identifying whether resources can be applied to small segments of the population who need them the most in order to use the resources most prudently and effectively.

Christiana Care is uniquely suited to develop this care model because of the Delaware Health Information Network (DHIN). The network functions as a data collector for all Delaware hospitals and collects more than 92 percent of lab results statewide. DHIN allows health care professionals to access the most current, critical information on patients.

“This model wraps the patient’s information around the patient to close the divide that hinders the delivery of effective, high quality, sustainable patient care,”

said Randall Gaboriault, chief information officer for Christiana Care and the chair of the Delaware Health Information Network. “We are using information and technology to change the way care is delivered in a way that is meaningful, evidence-based and outcome-driven.”

“Our work through this grant will result in patients experiencing an improved quality of care and an improved quality of life,” said William Weintraub, M.D., Christiana Care’s John H. Ammon Chair of Cardiology and the director of the Christiana Care Center for Outcomes Research. “The advantage of our proposal is that it is designed to work with existing hospital information systems so we can zero in and customize our care of patients in the most efficient and effective manner.”

Pilot phase (began Feb. 4, 2013)

Go Live – Phase I (launched April 22, 2013)

Administered a survey on quality of the discharge and care transitions—as well as Seattle angina questionnaire focusing on chest pain and ability to perform activities of daily living—to more than 340 patients by phone, post-discharge. Care management services, such as transportation, translator services, pharmacy assistance and discharge instruction education, provided to approximately 10 percent of those patients.

63 patients enrolled in first 10 days • 25 high-risk or highest severity • 38 low risk Pharmacist provided enhanced medication reconciliation services to all high-risk patients.

Social workers intervened in 20 percent of cases for depression screening, Medicaid application assistance and wellness coaching.

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Tru-D Smart UVC system uses ultraviolet technology to enhance safety of patients, visitors and staff Christiana Careâ&#x20AC;&#x2122;s Department of Environmental Services now supplements its traditional disinfecting regime with the Tru-D Smart UVCTM systemâ&#x20AC;&#x2122;s ultraviolet light to kill pathogens as part of a multi-faceted effort to curb the spread of bacteria such as clostridium difficile (CDiff), Methicillin-resistant Staphylococcus Aureus (MRSA), central line associated blood stream infections (CLABSI) and other hospital acquired infections (HAIs). Tru-D technology is a rapid room disinfection system that disinfects contaminated surfaces by rendering spores unable to reproduce.

Tru-D is one among many interventions used to reduce preventable harm from HAI, including hand hygiene, isolation, rapid diagnosis, education, the reduction of certain acid-suppressing medications and a robust reminder program. An antibiotic stewardship committee also has been formed to optimize antimicrobial prescribing in order to improve individual patient care, reduce hospital costs and slow the spread of antimicrobial resistance.

HOSPITAL ACQUIRED INFECTION RATE

ff Number Per 1,000 Discharges

ff Cases Per 1,000 Discharges

Christiana Care was honored with an HAI Watchdog Award for its systemwide efforts to reduce hospital acquired infections.

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4 2

Project Days

L E V E R AG I N G Technol og y

0 Christiana Care named Computerworld Honors Laureate Actual Results for eSignout handoff software For the second consecutive year, Christiana Care Health eSIGNOUT RESULTS System is a Computerworld Honors Laureate winner, ffTAverage Hand-Off Average ime Time to toCComplete omplete Hand-­‐Off this time for its software program that enables safe and confidential patient handoffs.

50 percent reduction in handoff times

Studies show an estimated 80 percent of serious medical errors involve miscommunication between caregivers during patient handoffs.

Different from clinical systems used for ordering tests and treatments and documenting care, eSignout provides information only relevant to patient handoffs, such as changes or potential changes in patient conditions that alert clinicians to problems and concerns. The tool allows caregivers to document recommendations.

The results of eSignout are significant. During ICU implementation in 2012, there was 100 percent caregiver use and satisfaction level in less than 72 hours. Handoff times reduced more than 50 percent.

Over the past year, 495 unique users of eSignout managed handoffs for 300-400 patients a day. Because clinician feedback helped develop the program, a process for receiving, evaluating and implementing enhancements is in place, with upgrades planned at least annually.

45

60

30

28 Pre With eSignout

15

0

Average Time (minutes)

Christiana Care’s winning customized software program, eSignout, eliminates handwritten documents, capturing detailed patient information, such as demographic data and care plans, in a confidential, secure and easy-to-view format. The tool also makes clear the name of the clinician caring for the patient at any moment, critical in a hospital system with teams of caregivers.

60

ff Minutes

mentation Plan

6

“This tool not only improves communication, efficiency and patient safety, it decreases the time a doctor or nurse spends during the handoff process, permitting more time with the patient.” ­— Karen Gifford, Director of Information Technology

Christiana Care’s patient self-evaluation tool, Insight, received Top Five recognition in the health category competition from Computerworld after the magazine previously named the program a Laureate award winner.

In addition, the publication recognized Christiana Care Vice President and Chief Information Officer Randall Gaboriault as a Computerworld 2013 Premier 100 IT Leader honoree.

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Christiana Care brings tomosynthesis to Delaware Technology heightens accuracy for breast cancer screening Christiana Care’s Breast Center at the Helen F. Graham Cancer Center is one of an elite group of institutions—and the first in Delaware—to offer tomosynthesis, the latest in breast cancer screening and diagnostic technology.

Breast tomosynthesis uses 3D technology to capture images of the breast at multiple angles during a short scan. The individual images are then reconstructed into extremely thin, high-resolution slices, which can be displayed individually or as a set.

Tomosynthesis eliminates the challenges associated with detecting cancer in overlapping structures in the breast, which is the primary drawback of conventional 2D analog and digital mammography. The technology also makes it easier to see lesions and localize structures in the breast.

“There is no perfect test for breast cancer and 15–30 percent of cancer is missed in traditional 2D mammograms,” says Jacqueline Napoletano, M.D., director of breast imaging at the Christiana Care Breast Center. “Tomosynthesis is an exciting step forward in both detecting cancer and avoiding repeat mammograms for women.”

“Tomosynthesis reflects our commitment to providing our patients with leadingedge technology. Patients in Delaware have access to the latest in diagnostic tools and treatment close to home.” ­— Nicholas J. Petrelli, M.D., Bank of America Endowed Medical Director of the Helen F. Graham Cancer Center

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Because tomosynthesis provides a look inside the breast, it is easier to detect tumors at an early stage of development. In an analysis presented at the Radiological Society of North America conference in 2011, there was a relative increase of 47 percent in cancer detection using tomosynthesis compared to 2D mammography alone.

Because tomosynthesis is more accurate, it also greatly reduces callbacks for repeat mammograms.

Typically, 10 percent of women who have traditional mammograms are called back for a subsequent screening because the results of their first mammogram were uncertain. Preliminary results indicate tomosynthesis reduces callbacks by more than 40 percent.

FAC T ❯ Preliminary results of tomosynthesis indicate a more than 40 percent reduction in callbacks.

L E V E R AG I N G Technol og y

Christiana Care named one of nation’s most innovative users of technology for Insight tablet-based tool Christiana Care was highlighted in the 2012 Information Week 500 list as one of the nation’s most innovative users of technology because of its Insight program, which uses an efficient, tablet-based self-evaluation tool that enables patients to report the severity of their symptoms and how those symptoms affect their quality of life.

Patients with cancer first used the patient-friendly wireless tool in a pilot program in May 2010, followed by patients with heart failure. Christiana Care’s Information Technology team launched a release last year for a wider patient audience using iPads.

This year, the Multidisciplinary Center’s Hepatobiliary and Lung Insight programs were launched to identify patients who are: ff Suffering significant distress. ff Facing potential psychosocial barriers to treatment. ff Experiencing significant cancer-related symptom burdens and who may be in need of treatment to aggressively manage their symptoms.

Insight also won top-five honors last year in the health category from Computerworld Magazine after the publication named the innovative tool a Laureate Award winner from among 500 nominations.

The rate of patients who either agree or strongly agree that the questionnaire is easy to complete was 90 percent for oncology patients; 93 percent for lung patients; and 87.9 percent for hepatobiliary patients.

The rate of patients who either agree or strongly agree that they liked performing the assessment electronically was 82.3 percent for oncology patients; 87.3 percent for lung patients; and 81.8 percent for hepatobiliary patients.

The rate of patients who either agree or strongly agree that the questionnaire better prepared them to speak to a doctor was 71.7 percent for oncology patients; 60.6 percent for lung patients; and 69.7 percent for hepatobiliary patients.

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AWA R D S & AC H I E V E M E N T S

Recognition through national honors and industry awards is an important measure of Christiana Care’s success as a leader in patient safety and quality of care.

In the Regional and National Spotlight ff Advisory Board best practice model in employee customer service ff American Association of CriticalCare Nurses Silver Beacon Award for Critical Care Excellence ff American College of Radiology Breast Imaging Center of Excellence Gold Seal of Accreditation for the Christiana Care Breast Center at the Helen F. Graham Cancer Center ff American College of Surgeons National Surgical Quality Improvement Program — exemplary outcomes for surgical patient care in deep vein thrombosis, thrombophlebitis and pulmonary embolism; cardiac incidents, including cardiac arrest and myocardial infarction; pneumonia; surgical site infections, including superficial and deep incisional and organspace infections; and urinary tract infections ff American Heart Association Get With the Guidelines® — Heart Failure Gold Plus Quality Achievement Award (third consecutive year)

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ff American Heart Association Get With The Guidelines — Stroke Gold Plus Quality Achievement Award (second consecutive year)

ff Information Week Magazine 2012 Information Week 500 List of innovative users of technology (second consecutive year)

ff American Heart Association/ American Stroke Association Target: Stroke Honor Roll

ff Joint Commission continued Gold Seal of Approval™ for recertification as a Primary Stroke Center and for the hip, knee and heart failure programs

ff American Nurses Credentialing Center Magnet designation ff American Psychological Association Psychologically Healthy Workplace Award ff Commission on Accreditation of Rehabilitation Facilities for brain injury, amputation and stroke programs and for comprehensive adult inpatient care ff Competency & Credential Institute CNOR® Strong designation ff Computerworld Honors Laureate winner (second consecutive year) for eSignout software program ff HAI Watchdog Award presented

by Kimberly-Clark for the CLABSI Prevention Initiative; first place for reducing CLABSI rates at Wilmington Hospital and for hospital acquired infections systemwide

ff The Leapfrog Group Hospital Safety Score of “A” (third consecutive time) ff Morehead Apex Workplace of Distinction (Christiana Care Visiting Nurse Association) for patient care, patient safety, employee safety and supporting diversity and commitment to the community ff NICHE (Nurses Improving Care for Healthsystem Elders) program exemplar status for outstanding elder care ff NursingDegrees.com 10 Nursing Internships Offering Exceptional Training Opportunities

In the Regional and National Spotlight (continued) ff Robert Wood Johnson Foundation video contest semifinalist for productions highlight innovative efforts to improve care transitions and reduce avoidable readmissions

ff Society of Thoracic Surgeons three stars (highest designation) ff Training Magazine Top 125 company for training and learning development

ff Truven Health Analytics 100 Top Hospitals in the major teaching hospital category ff U.S. News & World Report best hospitals — gastroenterology

Focus on Excellence Awards use performance improvement science to achieve meaningful outcomes Each year, the Focus on Excellence Award Program gives formal recognition to teams of employees whose projects demonstrate improvement in process or outcomes using the PDCA (plan-do-check-act) model. The 111 exhibits submitted to the 2012 program hightlight staff’s ability

to work in an interdisciplinary fashion using performance improvement science to achieve meaningful outcomes.

The program’s 10-year history includes 161 winning entries among 774 entered projects – including 31 winners in 2012. Those taking top honors are listed below.

2012 AWARD

PROJECT TITLE

RESULTS

President’s Award

Improving VTE Prophylaxis: One Unit’s Journey

5B focused on improving venous thromboembolism prophylaxis compliance in all patients admitted to 5B through consistent utilization of the VTE Risk Assessment tool. VTE Risk Assessment compliance improved from 84% to 100% within a three-month period. Since that time, the unit has maintained a 95% compliance rate.

Value Award

Lowering Blood Culture Contamination Rate

The Microbiology Laboratory and Phlebotomy developed strategies to assure that the blood culture contamination rate remained below the national standard of 3%. Updating the blood culture collection procedure and re-educating staff has resulted in the lowest contamination rates in 11 years: 0.9%.

At an estimated cost of $4,000-$8,000 per contamination, the decrease has saved Christiana Care about $2.2 million since 2006.

Clinical Excellence

A Collaborative Study on Reducing Length of Stay for Chest Pain Patients

A multidisciplinary team of Clinical Decision Unit and Christiana ED staff, Doctors for Emergency Services, Christiana Care Cardiology Consultants and Christiana Care Hospitalist Partners physicians developed criteria for early identification of patients and evidenced-based treatment guidelines for low and intermediate risk chest pain patients. ED length of stay was decreased by 2 hours and overall length of stay dropped by more than 9 hours.

Safety First

Strategies to Reduce Maternal Falls

Women’s & Children’s nursing units developed a falls reduction program focusing on the physiologic changes during pregnancy that increase fall risk. The number of maternal falls dropped from 26 in 2009 to 18 in 2011. Through October 2012, the units have had only seven falls, a reduction of over 70%. continued

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Focus on Excellence Awards 2012 AWARD

PROJECT TITLE

RESULTS

Employee Safety

Improving Employee Flu Vaccination Rates Using a Universal Program Approach

An Infection Prevention-led multidisciplinary team used a multimodal approach to increase employee flu vaccination from a baseline of 66%. Ninety-two percent (9,393 employees) were vaccinated, exceeding the Transformation Rewards Program goal of 85%. Over 98% of employees were compliant with the declination policy, with only 4% declining vaccination.

Great Place to Work

Improving Clinician Orientation through Onboarding

The Visiting Nurse Association revised the orientation process to include onboarding principles, a mentor/preceptor program, and a pilot test of critical thinking. Retention in the first year increased from 72% to 90%, with productivity of the nurses remaining stable through the extended orientation process.

The onboarding orientation is now being rolled out statewide.

Think of Yourself as a Patient

Patient and Family Centered Care

The One Voice team integrated patient and family centered care throughout the Wilmington campus, resulting in an increase in patients’ overall hospital rating from 65% to 80% in two years. Improvements were also seen in other HCAHPS domains, including nurse communication, response of hospital staff, hospital environment, pain management, medication communication and discharge process.

Financial Strength

Does the Physician Know About the Telemetry Monitor?

By increasing the awareness of telemetry orders, the percentage of 5D patients on telemetry dropped 47%, and average telemetry days for monitored patients decreased by 28%. 5D has seen a total reduction in use of 1,300 monitor days (estimated cost per day of $683).

Nursing Excellence: Empirical Outcomes

Reducing NICU Severe Peripheral IV Infiltrates

Rapid cycle improvement and bundled interventions led to a reduction in severe peripheral IV infiltrates of 53% in the first 6 months, and statistically significant reduction within 19 months. There has been only one severe infiltrate in the past 6 months.

Nursing Excellence : Exemplary Professional Practice

Tightening the Belt on Safety: Safe Patient Handling

Center for Rehabilitation at Wilmington Hospital worked with Injury Prevention/PEEPS, Environmental Services and Infection Prevention to increase staff use of new non-disposable & easy-to-clean gait belts.

In the 15 week pilot, gait belts placed at the point of care were used 2,044 times. There were no patient falls and no staff injuries. Over 97% of staff felt the new belt was better and they liked having it at the bedside. Use of the belt has expanded to over 19 units with the potential to reduce patient falls by 20% and save over $7,300 annually.

Nursing Excellence: New Knowledge

Show That We Care Campaign: Working Smarter Using State-ofthe-Art Technology

Center for Rehabilitation at Wilmington Hospital’s Injury Prevention/PEEPS team had zero staff injuries in 18 months through improved safe patient handling using repositioning slings. Patients’ cognitive and motor skills also improved. The program has been expanded to other Christiana Care units.

Nursing Excellence: Structural Empowerment

Improving Patient’s Flow: The Transition of Thrombolytic Patients

Didactic and simulation training on care of venous thrombolytic patients undergoing catheter directed thrombolysis therapy for 4E nursing staff allowed CDT patients to recover on 4E instead of the ICU, leading to improved continuity of care, effective and safe hand offs between VIR and 4E, positive feedback from patients and staff, and a decrease in cost per day of stay of 48%.

Nursing Excellence: Transformational Leadership

A Collaborative Model for Physician Practices and Home Care Agencies

The VNA and Family Medicine created an interdisciplinary team model for the Home Visiting Program.

Acute care hospitalization and hospital length of stay reductions met the 10% goal, patient functional improvement decreased fall risk and supported independence at home and staff were satisfied with the new model. The pilot established a baseline for expansion planning and resource utilization. continued

“Your focus on excellence has a significant impact on our long-term goals as a health system, but most importantly, it demonstrates that we are honoring our covenant with our neighbors, our community, to provide the access and care they need when they are sick, as well as to keep them in good health.”

— Janice E. Nevin, M.D., MPH, Chief Medical Officer

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AWA R D S & AC H I E V E M E N T S Fiscal Year 2013 2012 AWARD

PROJECT TITLE

RESULTS

Learning Excellence

RPI Workshops Drive Continuous Improvement

144 participants from 74 departments worked on 20 projects in 12 Rapid Process Improvement Lean training sessions led by Operational Excellence. 100% of participants completed the 30-, 60-, and 90-day report outs. 89% of participants reported that they would be able to apply the RPI training within one week. 79% felt they would use the knowledge daily.

Resident’s Award

“Leaning” Towards Patient Centered Teaching Rounds

94% of Christiana Care Hospitalist Partners teaching patients received their plan of care by 11:30 am, time from sign-out to completion of attending note was decreased by 4.75 hours, the majority of rounds occurred at the patient’s bedside, and resident education was improved.

Operational Improvement

Perioperative Patient Process Pilot Redesign

Perioperative Services streamlined perioperative processes and reduced the time from elective outpatient surgical arrival to when the patient was ready for surgery by 15-22 minutes by reducing waste and shifting processes from SPU to Prep & Hold. Time stamps, delay codes and daily huddles contributed to the group’s success

Excellence in Community Health

Each One, Reach One! Raising BP Awareness in the African American Community

21 blood pressure ambassadors were trained to increase awareness of hypertension in African Americans using a model of health promotion that encompassed peer education, motivation and collaboration.

The BP Ambassadors have reached 519 community members, screened 281 for hypertension, and referred 24 to primary care physicians. In addition, they have created additional programs within their communities, such as walking clubs and community seminars

People’s Choice

Impact of Blood Hemolysis on Patient Throughput in the ED

By obtaining blood specimens via steel needle, the Wilmington ED Education Committee was able to reduce the number of hemolyzed specimens by 37%. Patients expressed satisfaction with faster disposition.

Diversity, Inclusion and Cultural Competency Excellence

Identifying and Honoring Blood Transfusion Preferences

Compliance with the blood consent process increased by over 60% and the patient counseling process is now consistent for patients most at risk for a blood transfusion. Physicians not comfortable with providing care to a patient refusing blood have had colleagues step in to provide the care. Members of our community feel the process is now more respectful.

Nationally recognized patient safety expert ties “Seven Pillars” message to Christiana Care’s Focus on Excellence approach Nationally recognized patient safety speaker Timothy McDonald, M.D., J.D., professor of anesthesiology and pediatrics, chief safety and risk officer for health affairs at the University of Illinois Hospital and Health Science System, was guest speaker at Christiana Care’s 10th Annual Focus on Excellence Awards program in January 2013.

Dr. McDonald created the nationally recognized, pro-patient philosophy known as the “Seven Pillars,” which calls for notifying patients early about medical mistakes and for the hospital to waive all medical bills when a medical error harms a patient.

Since instituting the Seven Pillars philosophy at the University of Illinois Medical Center, Dr. McDonald said the overall malpractice premium expenses dropped by $22 million during the past three years. He explains that patients are less likely to sue when a hospital is so forthcoming and transparent. Additionally, reports of patientsafety incidents have skyrocketed at the medical center, providing hospital officials with valuable insight as to where mistakes occur and how to fix them.

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The Christiana Care Quality and Safety Program The Christiana Care Quality and Safety Program strives to achieve care that is safe, effective, patient-centered, timely, efficient and equitable.

To achieve these goals, the program targets three strategic areas: creating a safe culture, achieving high reliability and leveraging technology.

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Every individual shares a deep commitment to make safety a priority. Christiana Care’s culture of safety is characterized by our patient-centered care, open communication, a blame-free environment and collective responsibility for safety.

TIN EA

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CREATING A SAFE CULTURE

LEVERAGING TECHNOLOGY

ACHIEVING HIGH RELIABILITY Health care organizations are complex entities where the risk for accidents and injury runs extremely high. High Reliability Organizations (HROs) avoid catastrophes and accidents despite the dangers inherent in their businesses. Christiana Care employs best practices of other high-risk industries in order to achieve the defining characteristics of HROs.

LEVERAGING TECHNOLOGY Our commitment to invest heavily, yet prudently, in technology—whether for patient care equipment, electronic medical records or operational software to streamline our efficiencies—leads to safer, better care and ultimately greater value for our patients.

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Our Journey 2007

— P RO G R A M I N I T I AT I V E S 2007 to

2008

2009

2010

Partners in Learning for Safety/ Just Culture Council

Safety First Learning Report

Culture Survey (January)

Culture Survey (October)

Human Resources and Safety Standards for Event Follow Up

Enhancements for Follow Up

Culture of Responsibility (Planning)

Culture of Responsibility Phase I (June)

Just Culture Concepts (Planning)

Patient and Community Involvement

SAFE Weekly Huddles

‘Good Catch’ Recognition

Post Event Debriefs Partners in Safety Updates

Safety Mentor Education and Development

Human Factor Analysis for Flex Monitoring

Enhanced Disclosure Process

Human Factors Analysis for Radiation Oncology

No Harm Intended Sessions

Team Training

Patient/Family Centered Care

Disclosure Policy & Process

Speak Up Patient Safety Guide

Transparency Concepts

Worker Fall Protection Policy

Interdisciplinary Rounds

Safety First Advisory Council

Focus on “No Harm, Any is Too Many”

Skylight Safety Assessment

Cultural Diversity & Inclusion

Safety in New Employee Orientation/On Boarding

BEAT Training Classes

Enhanced Focus on Excellence (FOE) Awards

Arc Flash Policy and Program

Quarterly Environment of Care Consultant Assessments

Powered Industrial Truck Policy, Education and Inspection Program

Safe Work Permit Improvements

DVT Prophylaxis Development (Planning)

Clinical Documentation Project

Institute for Safe Medication Practices (ISMP)

MRSA

Assessment of CCHS Medication Safety (Planning) Medication Safety Officer (Planning) 5 Million Lives Campaign: • System Wide Skin Team to Prevent Pressure Ulcers • Reduce MRSA • High Alert Medications; Anticoagulation Team • Surgical Care Improvement Program (SCIP) • Heart Failure, Heart Disease and Stroke: “Get with the Guidelines” • WISH program • Board Report of Key Measures

National Patient Safety Goals: • Management of Anticoagulation • Improving Recognition and Response to Changes in Patient Condition “Never Events” Present on Admission Hospital Consumer and Assessment Provider Survey (HCAPS) Medication Safety Medical bariatric FMEA

National Patient Safety Goal: Reduce Risk of Healthcare Associated Infections: • Central Line Associated Blood Infections • Multiple Drug Resistant Organisms • Prevention of Surgical Site Infection

Specialized Training on Compressed Gas Safety

Disease Specific Certification • Stroke Program Comprehensive Unit-Based Safety Program (CUSP) Magnet Recognition

Prevent Harm from High Alert Medications (Hydromorphone)

Flu Vaccine Program

Disease Specific Certification Planning • Primary Stroke Center

Pregnancy Screening in Non-OB Locations

Hand Hygiene Campaign

SWAT (Synchronized Wilmington Admission Team)

ED Super Track

Surgical Safety Team Checklist

Obstetrical Emergency Response Team (OBERT) ED SPEED Pharmaceutical Waste Management Program Implemented

EMAR Implementation

ADT Interfaces with Micropaq

CPOE: Zynx Phase 3

CPOE

Barcoding (Bedside Specimen Labeling)

Wireless Patient Monitoring

Enhanced Web Paging

Expanded Use of Vocera

Infusion Pumps (Smart Pumps)

Care Fusion Implementation

Sentinel Event Database

CPOE: Zynx Phase 2

Planning for Meaningful Use

Bed Management System

Language Line Enhancement

Perioperative Documentation

Vocera

VNA Heart Failure Telemonitoring Program

Pharmacy Order Management System (POMS)

Equipment Tracking

Wireless Bar Coding-Breast Milk

Delaware Health Information Network (DHIN)

Enhanced Suicide Risk Assessment

CPOE: Zynx Implementation (Order Sets/ Standards Development) Phase I

Language Line Enhancement

Electronic Signatures

Insight Heart Failure (Symptom Self-Assessment) Virtual Education & Simulation Training Center (June) Spill Stations Designed and Ordered

2013 2011

2012

Culture of Responsibility Phase II (Oct.)

Culture Survey (April)

Standarized Handoffs for Transitions of Care in Women’s Health

Culture of Responsibility Phase III (October)

Embracing Patient Centered Care through Implementation of AIDET

Workplace Violence Committee Established

Unit Based Clinical Leadership Teams 5C Nursing Home Project

Employee Safety Handbook VP Level Monthly Injury Summary Reports Contractor Safety Training Video Updated

Bedside Shift Report

Workplace Safety Risk Review Evaluation Completed by Conner Strong

Employee Wellness

Formalized Systemwide “Good Catch” Program (March)

TRP Safety Education Module

Patient Safety Organization-PSES evaluation

Facilities and Services Safety Committee Established Slip, Trip Fall Workgroup Established

Value Improvement Team addressing needlesticks, sharps, and exposure injuries

Department Level Focused Safety Training

Improvements to reduce risk of slips, trips, and falls

2013 Focus Groups on Speak Up (April) Culture of Responsibility Phase IV (June) Event Investigation Management Training Integration of medication safety concepts into VEST Center Simulation Training Implementation of MedMarx Database and each medication error benchmarking capability Pilot AU Meds (Sept) Tram safety program improvements to reduce risk of accidents and injuries

Communications strategy for employee safety

Disease Specific Certification (May): • Heart Failure • Hip • Knee Recertification Disease Specific Stroke Program Best Practices for Better Care Partnership for Patients

Pilot Early Warning System (EWS)

Levels of Complexity of VI projects

Patient Identification Best Practice

VTE prophylaxis surveillance

Leadership Forum “Event Analysis”

Deep Dive for Lab events

SWAT launches at Christiana

Creation of an Acute Pain Treatment Service

Human Factors Consultant “Sponge Counts”

Evaluation of network downtime procedures and operations

Value Improvement Team Training

Christiana Rapid Transfer Initiative

ISMP ED Medication Consult

Proactive Assessment of Communicating Patient Preferences/Goals of Care

ECRI RRT Assessment ECRI Fall Insight Assessment

ED SHARP

Expansion of SPBM to outpatient sites

Heart Failure Transformation Team

Adoption of NCCMERP Harm Scale & Classification Taxonomy for Medication Events

ED Triage Redesign

Implemented evidence based indications for Telemetry (March) Expanded Behavior Emergency Assistance Team (BEAT) Training Active Shooter & Workplace Violence Policies Trained Incident Management Team to staff command centers in response to emergencies

Winter Weather Communications

Power Chart Upgrades (Aug)

Enhanced Multum Alert View for Duplicates, Allergies and Major- Contraindicated Drug- Drug Interactions

OBIS Interface

Radiation Therapy Positioning Software Enhanced Central Line Checklist

Automation of “Event Follow-Up”

Dose Edge IV Production

Implemented Baseline Pulse Oximetry in OB Triage, L & D and Antepartum Areas

Implementation of Meaningful Use Development of Global Triggers – Sepsis, EWS and Over Sedation

Enterprise Rx Outpatient Pharmacy Bar Coded Dispensing Verification

Standardization of Web Page to Mobilize Anesthesia Services

Procurement of TRU-D® SMARTUVC™ Room Disinfection System

Promanger Inpatient initial dose automation

Capture “Flu” Administration

AcuDose bar code restocking processes

Online Central Lines & Foley day documentation

Oncology CPOE

Capnography (End-Tidal CO2 Monitoring) During Code Blue

Interpreters Care Visibility

Current orders in DATAS Acoustic engineer engaged to study noise levels in patient care areas Injury summary reports distributed to Directors for review and follow-up

Microtab for Infection Prevention

P.O. Box 1668 Wilmington, Delaware 19899-1668 www.christianacare.org

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

To learn more about our mission, please visit christianacare.org/donors.

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