The Q Report Summer 2015

Summer 2015

Welcome to theWorld

As a Baby-Friendly designated hospital, UF Health Shands Hospital is giving babies their best start in the world.

Dr. Andrea Duque and her son, Jeronimo

WORKING TOGETHER TO ENHANCE QUALITY AND OUR PATIENTS’ EXPERIENCE

Contents:

1 In the Q 2 Quality Leaders 4 Innovation 6 Cover Story 10 Innovation 12 Great Catch

The Q Report would like to thank UF Health photographer Mindy Miller, UF Health pathology resident Andrea Duque, M.D., and her newborn son, Jeronimo, for spending several hours capturing the perfect photo for this cover. Jeronimo was born at UF Health Shands Hospital and his mother has received care at the Center for Breastfeeding and Newborns.

What our patients think Patient experience survey guides improvements Patient feedback is invaluable. It’s one way we measure results, learn what we’re doing right and learn how we can improve. That’s why we survey a large portion of our patient population about their overall experience at UF Health Shands facilities. Nearly 75 percent of discharged hospital patients receive a written questionnaire to fill out. In 2014, we received 5,672 responses to our patient experience survey. Results are shared anonymously with our Patient Experience team, part of the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety. Managers review positive comments and constructive complaints to improve our processes. “We’re not perfect, but surveys help us see our organization from our patients’ point of view,” said Chris Cassisi, director of the UF Health Patient Experience department within the Sebastian Ferrero Office of Clinical Quality and Patient Safety.

“She (the day shift nurse) took the time to explain everything being done to and for me. She was caring, listened to me and was quite sensitive to my needs.

Since it was life-threatening conditions (that) led to my emergency room admission, I was scared and wanted to know what was involved in my treatment. She was an angel.”

“I was in the presence of the most professional, caring and courteous group of health care people I have ever seen.”

“The majority of all staff members were very pleasant and normal people. They did not talk down to you, and actually made you feel as though you were an equal, although you were discussing things that they had a lot more education and understanding of.”

IN THE Q Randy Harmatz, M.B.A. Chief Quality Officer, UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety

“...the person responsible for improving patient safety is you!”

Our culture of safety Every spring, as part of Patient Safety and Quality Week, we ask staff and physicians across UF Health to take a culture of safety survey and let us know how we are doing. The survey focuses on critical safety “domains” and asks questions about topics such as communication and teamwork, safety event reporting and overall perceptions of safety. Having a strong culture of safety is important because patient safety relies on us all to do our part to improve patient outcomes and reduce preventable harm. I am happy to report that for the fifth year in a row, we have seen improvements in almost

every domain, from handoffs and communication to leadership support for patient safety. Several areas of the hospital saw significant improvements, including our intensive care units, surgical services and obstetrics. I am pleased and proud of our progress, but we must keep our culture moving forward. Each and every one of us is responsible for improving quality and safety, whether you are a nurse, pharmacist, transporter or an accountant.

Just remember that the person responsible for improving patient safety is you!

— RANDY HARMATZ

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“It’s about helping us be the best we can be and protecting us from our humanness.”

— Amy Rosenberg, Pharm.D.

QUALITY LEADERS

Amy Rosenberg Amy Rosenberg, Pharm.D., BCPS, doesn’t ever want to see a patient hurt because of a medication error.

Rosenberg is a clinical specialist in UF Health Shands Pharmacy Services and a clinical assistant professor in the College of Pharmacy. She works to improve patient care through a focus on medication safety.

“I coordinate all of the investigations and riskreduction strategies that we put into place after a safety event has occurred in any department,” Rosenberg said. “I am the pharmacy person who reacts and investigates those events and tries to figure out how to prevent those from happening in the first place.”

She said her job can be broken down into two parts: proactive and reactive. On the proactive level, she works on a large team and together they focus on always looking out for things that could potentially cause an error.

On the reactive level, Rosenberg and her team

work to identify problems in medication safety and come up with solutions to these issues.

“It’s about helping us be the best we can be and protecting us from our humanness,” she said.

For the first half of her career at UF Health Shands, Rosenberg worked as lung transplant pharmacist.

“We had some medication errors that I was involved with investigating and trying to put solutions into place,” she said. “I really enjoyed seeing improvement that broadly and widely affected lots of patients.”

Some of the practices Rosenberg and her team have implemented to prevent medication errors include manually applying heat-sealed wrapping to high-risk medication vials, storing medication in lidded bins and not allowing large concentrations of certain medicines in the hospital.

Rosenberg said, “We have very defined protocols that everyone who is involved in taking care of the patient is aware of.”

— SAM BURROUGHS

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The safest ALARA stands for “As Low As Reasonably Achievable.” It’s an acronym radiology professionals use to refer to a careful balancing act — taking the highest-quality diagnostic images with the least amount of radiation exposure. A new low-dose CT scanner at UF Health Shands Hospital creates optimal imaging with minimal radiation dosage to patients.

There are four low-dose CT scanners at UF Health facilities in Gainesville: two at UF Health Shands Hospital, one at UF Health Springhill and one at UF Health Shands Cancer Hospital. The advanced technology creates images with fewer, more powerful X-rays, allowing patients to receive lower doses of radiation. The image is also completed in less time.

“UF Health was one of the first health systems in the country to implement this technology in the past two years,” said Manuel Arreola, Ph.D., chief of medical physics and an assistant professor of radiology in the College of Medicine. “We’re distinct because we have the expertise to take this technology and apply it to clinical use, which has an immediate and beneficial impact on our patients.”

A CT scan takes detailed pictures of the body, including the brain, chest, spine and abdomen. The test is used to diagnose an infection, guide a surgeon to the right area during a biopsy, identify masses and tumors and study blood vessels.

Generally, higher radiation results in

scan

better imaging, while too little radiation means a loss of detail, contrast and overall image quality.

Every CT ordered at UF Health is studied by a radiologist and tailored according to the patient’s medical history, weight, age and the portion of tissue being scanned. The objective of UF Health medical physicists and radiologists is to mitigate the risks while also obtaining an image that will answer the clinical question facing the patient.

This is especially important when administering CT scans for pediatric patients.

“Children are more susceptible because their tissues are more vulnerable and sensitive to radiation,” said Dhanashree Rajderkar, M.D., an assistant professor of radiology in the College of Medicine. “They also have more time for negative side effects to set in.”

The newest machine, which was installed in March, also has helped the team efficiently manage high patient volumes.

Several patient populations can now benefit from low-dose CT scans, including pediatric patients, patients undergoing cardiac or stroke care, and pregnant patients. The additional scanner has reduced wait times and delays.

“Because of the use of the technology and the work of quality scientists, we guarantee better and faster care, a better life and peace of mind for our patients at UF Health,” Arreola said. “For us, that’s our reward.”

— LAURA CASTRO

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— Manuel Arreola, Ph.D.

INNOVATION

“Because of the use of the technology and the work of quality scientists, we guarantee better and faster care, a better life and peace of mind for our patients at UF Health. For us, that’s our reward.”

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Welcome to the World

As the state’s first Baby-Friendly designated academic health center, UF Health Shands Hospital is giving babies their best start in the world.

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COVER STORY

A baby is born. His mother sees him briefly, but cannot touch his little face. He’s whisked away for observation and bathing and newborn screening tests. It could be hours before she sees him again. She waits, alone, in a recovery room and then a postpartum room.

Although it sounds antiquated, this version of childbirth is a reality for women who undergo cesarean section deliveries at many hospitals across the United States, even when the babies are full-term and healthy. The problem? Not only is it isolating for women, but also the process prevents mothers and babies from bonding during the first hours after a birth, a time considered crucial for attachment and breastfeeding.

Three years ago, these practices were standard at UF Health Shands Hospital, too. But in 2012, a team of doctors, nurses and staff members took on the challenge of a systemwide culture change to make UF Health Shands Hospital a “BabyFriendly” health care facility. The hospital was one of 90 hospitals across the country selected to take part in the National Institute for Children’s Health Quality’s Best Fed Beginnings program to earn

designation as a Baby-Friendly hospital. To earn the designation, health systems must implement a series of changes geared toward encouraging breastfeeding, skin-to-skin contact and bonding after birth.

“One of the things we know is that hospital practices can sometimes inadvertently undermine the success of breastfeeding,” said Sandra Sullivan, M.D., IBCLC, a clinical associate professor of pediatrics in the College of Medicine. “The goal of Baby-Friendly is to keep moms and babies together and support breastfeeding because it is the best food for most babies. This is one of the ways we can help moms and babies get the best start so that when they leave us, they have the knowledge and support to meet or exceed their own goals.”

— APRIL FRAWLEY LACEY

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77%

In Florida, 77 percent of new mothers initiate breastfeeding.

Only 48 percent are still breastfeeding after six months.

48%

* Source: Centers for Disease Control and Prevention

In March 2015, UF Health Shands Hospital became the first academic health center in the state to earn the Baby-Friendly designation. Because the hospital was part of NICHQ’s collaborative, the timeline for the process was accelerated, Sullivan says.

“If a hospital decides to do this on its own, it usually takes about 10 years,” she said. “We did it in two-and-a-half. It was intense.

“The culture change (at UF Health) is night and day.”

Becoming Baby-Friendly involves implementing 10 steps to successful breastfeeding. Because the steps involved all parts of the hospital as well as outpatient practices in Gainesville, the initial team — neonatologist Sullivan, quality improvement specialist Kati Harlan, R.N., M.S.N., LHRM, and the Center for Breastfeeding and Newborns’ Mary Ryngaert, M.S.N., ARNP, IBCLC — had to expand to take on the various changes. Representatives from nursing, administration, nutrition, lactation, audiology, purchasing, outpatient practices and nurse education as well as pediatric and obstetric physicians were all integral to the success.

They started small, tackling what they perceived to be simpler steps and moving on to more complicated ones. One of the steps is to ensure babies stay with their mothers as much as possible to facilitate bonding and breastfeeding. Their first challenge was to determine why babies spent so much time away from the mother’s room after birth and to devise solutions to change that.

Aside from cesarean section protocols, which resulted in babies spending significant time away from their mothers in the first hours of life, babies were leaving the rooms for many other reasons too.

After both cesarean and vaginal births, babies left the room for newborn hearing screenings, other newborn assessments, check-ups with pediatricians and for breaks when mom and dad wanted to sleep.

Sullivan said the team thought this would be one

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of the toughest things to change, but when they met with audiologists, they learned they could do the checks in the room using portable equipment.

The team then worked with pediatrics and nursing staff members to learn what was needed for other assessments and checks to be completed in the room.

Now, all newborn screenings are performed right in the room.

“The babies only go to the nursery now if they need a procedure,” Sullivan said. “We even renamed it the Procedure Room. We don’t have a ‘nursery’ anymore.”

After birth, the focus is now on getting a baby to his or her mother for skin-to-skin contact and breastfeeding as soon as possible, even after a cesarean delivery. Pediatricians are now trained to assess babies quickly and get them back to their mothers.

“In the Baby-Friendly plan, there is immediate skin to skin,” said Ryngaert, a pediatric nurse practitioner and trained lactation consultant. “This reduces stress and helps the baby naturally latch on within the first hour or two. We reduce separation throughout the hospital stay and also have assistance nearby so mothers can recognize what feeding cues look like, what good swallowing looks like and how to know when the baby is satisfied.

“We have seen (in the breastfeeding clinic) what happens when less than optimal care occurs in the hospital, so it is important to establish things in the first days of life.”

For each Baby-Friendly step, the committee identified obstacles and tested each solution on a small scale first before implementing a big change.

This allowed them to see how well things worked and how solutions needed to be adapted to work systemwide, Harlan said.

One of the biggest challenges was training all staff members involved in prenatal and postnatal care, largely because of time constraints. Another

“In the Baby-Friendly plan, there is immediate skin to skin.”

challenge was cutting out the free supplies and samples from formula companies. Prior to seeking Baby-Friendly designation, the hospital received nearly all of the formula it provided to babies for free from the companies that make formula. Now, the hospital purchases formula at fair market value and no longer accepts items branded with formula names.

Significant efforts also were made to improve information and care provided to women before their babies were born and after they went home, too. Staff members working in obstetrics and gynecology and family medicine practices were trained on how to prepare women for breastfeeding. In addition, women are now sent home with the resources they need to access support if they have problems after they leave the hospital.

In addition to being able to call UF Health lactation consultants, women can visit UF Health’s Center for Breastfeeding and Newborns, which operates a breastfeeding clinic. UF Health also offers a weekly support group for new moms.

The team is also seeing positive results in patients.

“Over the last six months I’ve operated on five women who were breastfeeding. We provided them with hospital breast pumps that they were able to use in the preoperative and postoperative area so they were able to maintain their lactation schedule and provide breastmilk for their babies. This was something we never saw or needed in the past,” said Kay RoussosRoss, M.D., an associate professor of obstetrics and gynecology in the College of Medicine and a member of the steering committee.

Aside from keeping up with the culture changes already in place, the team has other improvements they aim to make in the near future — namely continuing to improve lactation support for employees. New UF Health facilities will prospectively plan for pumping rooms.

Ryngaert said, “We want to provide a good experience for everyone.”

COVER STORY

— Mary Ryngaert, M.S.N., ARNP, IBCLC

The 10 Steps to Successful Breastfeeding

➊ ➋ ➌ ➍ ➎ ➏ ➐

Have a written breastfeeding policy that is routinely communicated to all health care staff.

Train all health care staff in the skills necessary to implement this policy.

Inform all pregnant women about the benefits and management of breastfeeding.

Help mothers initiate breastfeeding within one hour of birth.

Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

Give infants no food or drink other than breast milk, unless medically indicated.

Practice rooming in — allow mothers and infants to remain together 24 hours a day.

➑ Encourage breastfeeding on demand.

Give no pacifiers or artificial nipples to ➒ breastfeeding infants. ➓

Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.

* Source: Baby-Friendly USA

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Improving health, one award at a time

W. Martin Smith Interdisciplinary Patient Quality and Safety Awards help build culture of quality at UF Health Sometimes a little funding can go a long way.

The W. Martin Smith Interdisciplinary Patient Quality and Safety Awards Program, established by the UF Health Self-Insurance Program and the College of Medicine Continuing Medical Education office, exemplify the fact that a small amount of funding can have a big impact.

The awards are geared toward improving patient safety and quality.

Their name derives from W. Martin Smith, the originator of academic self-insurance for the University of

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Florida, who retired in 2012.

“He gave more than 40 years of his life to building these programs, and they’ve been a model throughout the country,” said Randall C. Jenkins, SIP administrator and a clinical associate professor in the College of Public Health and Health Professions.

The awards are presented twice annually, and the application process is competitive. The review committee receives around 15 applicants per cycle and accepts only three to five.

“We select the ones we think

have a project that will most likely show some meaningful improvement,” Jenkins said.

Nicole Paradise Black, M.D., M.Ed., an associate professor of pediatrics in the College of Medicine and one of the awards’ earliest recipients, used her award to improve patientand family-centered care.

Paradise Black’s award involved the development of a family partner role for the UF Health Shands Children’s Hospital. The family partner, who serves as a link between families and staff, helped improve communication efforts

7 days of quality

Every year, UF Health celebrates Patient Safety and Quality Week to reinforce quality care and safety practices.

The week, which occurred March 9-13, featured a series of fun, educational and interactive activities that helped to raise awareness among UF Health faculty and staff about patient safety and quality issues. Participants tested their patient safety knowledge in a “problem” patient room constructed in the UF Health Shands Hospital Atrium, competed in an online scavenger hunt and learned about quality endeavors at a poster session that featured more than 70 initiatives.

National speaker and quality expert Colleen Sweeney, R.N., shared three compelling presentations about the patient experience and how to create a culture of caring. Activities focused on engaging faculty and staff, and hospital visitors and patients also participated to learn how we are making quality Job 1 at UF Health.

INNOVATION

Patient Safety and Quality Week celebrated safe practices

— LAURA CASTRO

about the newly implemented white boards in patient rooms. The white boards provided a new way for families and parents to communicate with staff members while allowing them to feel more involved in their child’s care.

“Studies show that when you have patients as your partners, care is better overall,” Paradise Black said.

“The quality is better, so it just makes sense to carry out your care in that way.”

Paradise Black also helped organize the hospital’s general parental advisory board, composed

of family members who have experienced both the inpatient and outpatient sides of UF Health and who could contribute to the mission of the hospital. Her project is one of many the awards program has helped finance.

“There are some very interesting, innovative applications,” said Phillip M. Cox II, the associate director of patient safety, research and education for the Self-Insurance Program. “Now our objective is to see these awards implemented with an effect as far-reaching as possible.”

— DOROTHY HAGMAJER

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“The emergency room teams are very good, helping each other when they need help and working as a team.”

— Mark Hotchkiss, D.O.

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

When the victim of a car accident came into the UF Health Shands Hospital emergency room, the patient’s symptoms did not seem serious enough to warrant a Level 1 trauma alert — an alert given to critically ill patients when they arrive.

But when Mark Hotchkiss, D.O., an intern in the College of Medicine department of anesthesiology, assessed the patient, he noticed symptoms of much more serious problems.

“She was requiring more and more oxygen, and had a tender belly,” Hotchkiss said. “Those two things are not good for someone who had been in a car accident. Her blood pressure was also low.”

The patient appeared to become much more unstable, and Hotchkiss immediately sought help from the attending physician, Michael Marchick, M.D., an assistant professor of emergency medicine in the College of Medicine. Using an ultrasound, the physicians saw that the patient had intraabdominal bleeding.

The patient was transported back to the trauma bay, where her condition worsened and she became less and less responsive. She immediately underwent surgery and has recovered fully.

“The emergency room teams are very good, helping each other when they need help and working as a team,” Hotchkiss said. “It’s a good testament to how well they share the workload.”

Hotchkiss, who was completing the emergency department rotation of his internship, said any physician would react in the same way.

“It’s all about recognizing the patterns — especially those types of patterns, which have been drilled into our heads,” Hotchkiss said.

Even so, Hotchkiss’s recognition got a patient help quickly when it was needed the most.

— MORGAN SHERBURNE

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GREAT CATCH The Q Report | Summer 2015 | 13

âœą Continuing Education Opportunities 2nd Annual Stroke Conference, May 30-31.

Hilton University of Florida Conference Center, Gainesville.

To register, visit stroke.cme.ufl.edu.

41st Annual Educational Conference of the Florida Association of Medical Examiners, July 16-18.

The Hyatt Regency Grand Cypress, Orlando.

For more information, visit fame.cme.ufl.edu.

8th Annual Update in Liver & Gastrointestinal Diseases: Hot Topics for the Clinical Practice, Aug. 1-3.

Sandpearl Resort and Conference Center, Clearwater.

For more information, email Christopher Black at blackcm@medicine.ufl.edu or call 352-273-9475 or visit liverconference.cme.ufl.edu.

The Q Report is the quarterly newsletter of the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety,

featuring the latest news and initiatives related to quality and improving the patient experience at UF Health. To suggest ideas for content, please email April Frawley Lacey, UF Health Communications, at afrawley@ufl.edu.

Q Report Advisory Committee:  Laura Castro, Gale Danek, Ph.D., R.N.; Kayser Enneking, M.D.; Andrew Galligan, M.D.; Randy Harmatz, M.B.A.; Theresa Hughes, R.N.; April Frawley Lacey; Maureen LaTour, M.S.N.; Debbie Robins; Kim Rose; Amy Rosenberg, Pharm.D., Ph.D.; Anne Schentrup, Pharm.D., Ph.D.; Gail Stahl, R.N., M.B.A.; Lynn Westhoff, M.B.A.

THE Q REPORT IS PRODUCED BY UFHEALTH COMMUNICATIONS.