Quality and Patient Safety Annual Report 2008

Wilmington, Delaware 19899-1668 www.christianacare.org

Christiana Care is a private not-for-profit regional healthcare system

and relies in part on the generosity of individuals, foundations and

corporations to fulfill its mission.

QUA L I T Y A N D PAT I E N T S A F E T Y

ANNUAL REPORT 2008

A Passion for ExcellenceTo produce excellent results for our patients, Christiana Care must be first rate inknowledge, skills and innovation. Our organization is committed to continuallylearning, enhancing our abilities and investing wisely to adopt new methods and technologies.

We also recognize that excellent relationships between our patients and staff membersinfluence the process of healing and well-being. That's why our most important taskis to earn the trust of each patient and family member as we strive for the highest possible quality in everything we do.

We dedicate this Quality and Patient Safety Report to the passion for excellence that inspires every member of our organization and to the wide variety of neighbors inthe communities we serve. This report describes some of the many ways we apply ourFocus on Excellence, Safety First and Clinical Excellence approaches to patient care. Together, we restore health and productivity, and make life better whenever possible.

Robert J. Laskowski, M.D., MBAPresident and Chief Executive Officer

F O C U S O N E X C E L L E N C E ♦ AWA R D S , AC H I E V E M E N T S A N D R E C O G N I T I O N 1

Joint Commission accreditationshows our commitment toclinical excellence. The Joint Commission is an organizationthat accredits healthcare organizations byassessing their compliance to standardsof quality and safety. While hospital participation is completely voluntarywith the Joint Commission, the rigorousaccreditation process is one of the ways weshow our commitment to Clinical Excellence.Christiana Care Health Services, InfusionServices and Christiana Care Visiting NursesAssociation (VNA) are all accredited andhave earned the Joint Commission GoldSeal of Approval™.

Some of our other accreditations include:American Association of Blood Banks,

American College ofRadiology, AmericanCollege of SurgeonsCommittee on Trauma,American College ofSurgeons Committee onCancer, AmericanAcademy of Sleep Medicine,College of American Pathologists,American Speech and Hearing Association,Accreditation Council for Graduate MedicalEducation and Commission onAccreditation of Rehabilitation Facilities.Christiana Care is also a member of theAmerican Hospital Association, DelawareHealthcare Association, Middle AtlanticHealth Congress and Council on TeachingHospitals of the Association of AmericanMedical Colleges.

Dedication is key.The Centers for Medicare and Medicaid Services (CMS), in combination withthe Joint Commission, requires mandatory reporting of quality hospital measures and their related indications every quarter. This involves having adedicated team of nurses and respiratory care practitioners manually pull2,000 random charts each quarter and enter 50 to 100 elements of data foreach chart into CMS format. From this, CMS randomly chooses only fivecharts to review for audit. If Christiana Care fails to meet a stated requirement,our reimbursement will be impacted.

F A C T

Awards, Achievements and RecognitionWith a Focus on Excellence, Christiana Care continues to receive national recognitionfor our quality and safety initiatives. Our participation in the High ReliabilityLearning Network – a national network of healthcare organizations that designssystems and strategies to anticipate and reduce the effect of human error so thathealthcare is more reliable – allows us to share our innovations with health systemsaround the country. Here are some of our most recent national honors.

F O C U S O N E X C E L L E N C E

Bariatric Surgery Center recognizedfor high quality care.Christiana Care’s Bariatric Surgery Centeris recognized for the high quality of care we provide to our patients with morbidobesity. We have received the highest levelof accreditation from the American Collegeof Surgeons’ (ACS) Bariatric SurgeryCenter Network and have beennamed a Bariatric SurgeryCenter of Excellence by theAmerican Society forMetabolic and Bariatric

Surgery and Surgical Review Corporation.No other hospital in the greater DelawareValley area has these two accreditations.From our preparatory screening program,to actual surgery, and then through post-surgical follow up, we meet standards ofclinical excellence for our clinical practices,

patient outcomes and facility compliance.We first started performing weight

loss surgery in 2001, and haveperformed more than 1,500surgeries as of September 2007.

2 F O C U S O N E X C E L L E N C E ♦ AWA R D S , AC H I E V E M E N T S A N D R E C O G N I T I O N

The Joint Commission named ChristianaCare a 2007 winner of the 11th annualErnest Amory Codman Award for ourSepsis Alert program. Sepsis is the leadingcause of death for patients in intensive careunits. This national award recognizes ourexcellence in pursuing a clinical challengeno one else could overcome.

The Codman Award is presented by TheJoint Commission to a healthcare organizationfor its achievement in improving the quality

and safety of care provided to the public.Named for the physician regarded inhealthcare as the “father of outcomes measurement,” the Codman Award wascreated to showcase the effective use of performance measures to enhance knowledgeand encourage improved quality and safetyof healthcare. In addition to receivingnational recognition for this prestigiousaward, we shared our Sepsis achievementsat the Joint Commission’s Annual Conference.

Sepsis Alert Team earns theprestigious Codman Awardfor innovation and leadership.

Sepsis is a challenging condition that is directly related to patient safety.In a tireless pursuit of excellence, our cross-functional team of physicians,nurses and pharmacists from many different disciplines developed and implemented the Sepsis Alert program that includes care managementguidelines, treatment algorithms, medication kits, order sets and resourcepackets. Through this program, we reduced mortality rates for patientswith severe sepsis to from 61.7 percent to 24.6 percent for an overall reduction of 49.4 percent. This is further proof that with a commitmentto safety, anything is possible.

Marc T. Zubrow, M.D., Director of Critical Care MedicineMedical Director of eCare

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HealthGrades ranks us amongtop 5 percent of all hospitals innation for quality.

HealthGrades, a leading provider ofhealthcare qualitymeasurements, presented ChristianaCare with the 2008Distinguished HospitalAward for ClinicalExcellence. This award

ranks us among the top 5 percent of all hospitals in the nation for overall qualityfor the second consecutive year, and for thethird time in the last four years. No otherhospital in Delaware received this awardfor 2007. This year, only 269 hospitals outof nearly 5,000 earned DistinguishedHospital status.

Our other 2008 HealthGradesachievements

♦ Ranked #1 in Delaware for Overall Cardiac Care, Cardiology Services andCoronary Interventional Procedures– Five Years Straight (2004-2008)

♦ Ranked #1 in Delaware for Treatmentof Stroke – Three Years Straight (2006-2008)

♦ Recipient of the HealthGrades Pulmonary Care Excellence Award™

– Three Years Straight (2006-2008)

♦ Ranked #1 in Delaware for Overall Pulmonary Services – Four Years Straight (2005-2008)

♦ Five-Star Rated for Treatment of Respiratory Failure – Three Years Straight (2006-2008)

♦ Five-Star Rated for the Treatment of Sepsis – Two Years in a Row (2007-2008)

♦ Recipient of the 2008 HealthGrades Gastrointestinal Excellence Award™

Thomson Healthcarenames us among top100 U.S. hospitals andamong top 15 majorteaching hospitals.

Thomson Healthcare, a nationally recog-nized health care information provider,named Christiana Care one of its 2006“Thomson 100 Top Hospitals PerformanceImprovement Leaders.” We rank amongthe top 100 U.S. hospitals — and among thetop 15 major teaching hospitals — for thefastest and most consistent performanceimprovement over five consecutive years.

The American Heart Associationawards our high standards for cardiovascular care.The American Heart Association

awarded Christiana Care with the“Get With the Guidelines”Silver Performance Achievementaward for coronary artery disease,Bronze Performance award for heart fail-ure and Participation award for stroke. Allthree awards recognize our commitmentto and success in implementing a higherstandard of cardiovascular care thatimproves outcomes for patients hospital-ized with coronary artery disease, heartfailure and stroke.

Quality Insights of Delawareawards us for outstanding achievement in patient care programs.Christiana Care’s Surgical CareImprovement Project (SCIP), AppropriateCare Measure (ACM) program andDepartment of Family and CommunityMedicine received Golden Apple Awardsfrom Quality Insights of Delaware, thestate’s only Medicare quality improvementorganization. The Golden Apple Awardsprogram recognizes excellence, leadershipand outstanding achievement in healthcarequality improvement, especially as itimpacts Delaware’s older adult population.The program also encourages extraordinarycommitment to quality improvement and

innovation and acknowledges collaborationto improve healthcare in Delaware.

Our SCIP and ACM programs receivedQuality Leader Awards. SCIP was recog-nized for a 13 percent overall improvementin prevention of surgical infections. OurACM program was acknowledged for a 15percent improvement in the delivery of allappropriate care to patients hospitalized forheart attack, heart failure and pneumonia.

Our Department of Family and CommunityMedicine received the Quality PartnerGolden Apple Award for its collaborativeefforts with Quality Insights of Delawareon various outreach programs, includingcultural competency training.


Throughout Delaware, we are fortunate to work with healthcare providers likeChristiana Care who are committed to delivering the best possible care to theirpatients. These awards represent our highest level of professional acknowledgementin Delaware’s healthcare quality improvement area.

Les DelPizzo, Chief Operating Officer, Quality Insights of Delaware

U.S.News & World Reportranks us among“America’s Best Hospitals.” U.S. News & World Report’s“America’s Best Hospitals” ranksChristiana Care in the top 50

hospitals nationwide in endocrinology; respiratory diseases; ear, nose and throat;and digestive disorders. We are the onlyhospital in Delaware to receive this prestigious honor.

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Helen F. Graham Cancer Centerawarded for exceptional leadership in the fight againstbreast cancer.Christiana Care’s Helen F. Graham CancerCenter received the annual Susan G.Komen Foundation’s “Light of Life”award, which goes to the organization thatproves to be the Delaware Valley’s mostexceptional leader and provider in the fightagainst breast cancer. Presenters cited the“excellent, compassionate care providedand the bonds of trust that Christiana Carehas formed throughout the community.”

NCI selects Helen F. Graham Cancer Center as 1 of 14 community cancer centers in the nation. The National Cancer Institute (NCI)selected Christiana Care’s Helen F.Graham Cancer Center as one of 14 cancer programs to launch a strategic initiative that will greatly extend accessto NCI-sponsored clinical trials aroundthe country. The NCI Community CancerCenters Program (NCCCP) is a newnational network of community cancercenters striving to expand cancer researchand deliver the latest, most advanced cancer care to more individuals in thecommunities where they live.

Since the Helen F. Graham Cancer Center opened five years ago, we have focusedon a multidisciplinary team approach to cancer treatment, translational research,access to clinical trials and screening/prevention community outreach programs.These strategies have contributed to Delaware's declining cancer rate. With ourexpanded facility, scheduled to open in 2009, we will be able to offer our communityeven more resources in the fight against cancer.

Nicholas J. Petrelli, M.D. Bank of America Endowed Medical Director

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Focus on Excellence AwardsChristiana Care's commitment “to improvingthe health of all those we serve” is exemplifiedby our internal annual Focus on ExcellenceAwards program. This year, 14 employeeteams (of 80 very qualified team entries)were recognized for their creativity andongoing commitment to improving thehealth and safety of our patients asdescribed below. At the award ceremony,former astronaut and national expert onpatient safety, James P. Bagian, M.D., P.E.spoke to employees about the importanceof safe medical practices.

President’s AwardImproving Outcomes through HourlyRounding

Safety First AwardDouble Verification of ContinuousIV Medication Infusions ImprovesPatient Safety

Safety First Award Honorable MentionMedication Reconciliation that Works

Clinical Excellence AwardBLAAST Those MI’s

Clinical Excellence Award Honorable MentionCreation of the Stroke Treatment and Recovery (STAR) Unit

Think of Yourself as a Patient AwardAll’s Quiet in the Eastern Tower

Great Place to WorkOnline Convenience with Chart Completion

Financial Strength AwardCapital Acquisition Program— a Win Win

Nursing Excellence AwardWe WISH to be Restraint Free

Operational Improvement AwardImprovement in In-Lab Turnaround Time

Residents AwardeSignout

Residents Award Honorable MentionWashing Germs Away: A Missionto Improve Hand Hygiene at Christiana Care

Excellence in Community Health AwardReducing Hospital Admissionfor Heart Failure Patients

People’s Choice AwardRooming In... Good for You and Better for Baby


Presentations“Applications of High ReliabilityConcepts” at AHRQ 2007 AnnualConference – Improving HealthcareImproving Lives; September 2007

“Beginners Analysis Model forPerformance Improvement” at Thomson-Reuters Healthcare Advantage NationalConference; May 2008

“Fire Risk Assessment: A Score for PatientSafety” at AORN 55th Congress inAnaheim, CA; March 2008

“Implementing Team STEPPS in LargeTeaching Hospital” at National TeamSTEPPS Consortium at Duke University;January 2008

“Improving Care of the Sepsis Patient—Codman Award” at The Joint CommissionAnnual Conference on Quality & Safety;November 2007

“Incidence of Episiotomy—MeasureSubmission” at National Quality Forum;November 2007

“Learning and Integration of GraduateMedical Education (GME) into QualityImprovement or Patient Safety” round-table discussion at Alliance of IndependentAcademic Medical Centers (AIAMC)National Initiative in Minneapolis,Minnesota; August 2007

“My Medication List” and “Speak-up”brochures shared at DuPont Stine-Haskelland DuPont Barley Mill Employee HealthFairs; May and June 2008

“Myocardial Infarction Treatment:An Acronym Makes the Change” atAmerican Heart Association Quality ofCare & Outcomes Research Conferencefor Cardiovascular Disease and Stroke andTrends in Nursing; May and September 2008

Beyond our communityOur leadership in patient safety and clinical excellence reaches national audiences.Christiana Care’s leadership in patient safety and clinical excellence extendsfar beyond Delaware. This year alone, through conference presentations andjournal articles, our staff members have shared their best practices in patientsafety and clinical excellence with their colleagues throughout the country.Here are some recent accomplishments.

F A C T


Presentations (continued)“Risk Of Carotid Endarterectomy preceding Coronary Artery BypassGrafting in Patients with ConcomitantSignificant Coronary Artery Disease andCritical Carotid Stenosis,” Scientific Sessions,Orlando, FL and published in Circulation Vol 116(16); November 2007

“Time to Antibiotic AdministrationIndependently Predicts Survival fromSevere Sepsis in Patients Treated accordingto the Surviving Sepsis Guidelines”at CHEST Conference; October 2007

“Top 6 Performing Sites” an ACT courseat Robert Wood Johnson National Meeting,University of Virginia; September 2007

“Use Of Collagen Based Device forFemoral Artery Puncture Site Closure following Coronary Intervention”at American Heart Association Quality ofCare and Outcomes Research Conferencefor Cardiovascular Disease and Stroke;May 2008

Publications“Becoming a High ReliabilityOrganization-Operational Advice forHospital Leaders,” in the online AHRQReport; March 2008

“Improving Care of the Sepsis Patient”The Joint Commission Journal on Qualityand Patient Safety; September 2007

“Protocol for the Rapid Normalization ofINR in Trauma Patients with IntracranialHemorrhage on Prescribed WarfarinTherapy,” in American Surgeon; article accepted June 2008

“Putting Reliability into Practice: Lessonsfor Healthcare Leaders,” in Patient Safety& Quality Healthcare Journal; May/June 2008

“Safety Mentor Program: Engaging Front-line Staff as Leaders in Patient Safetythrough Pre-occupation with Failure,”in Advances In Patient Safety: New Directionsand Alternative Approaches; abstract acceptedMay 2008

10 S A F E T Y F I R S T ♦ S A F E C U LT U R E

A safe culture is a way of life at ChristianaCare. It reinforces teamwork, standardizescommunication and helps us to share andlearn from opportunities that may affectour ability to provide safe, effective andpatient-centered care. It engages all of ourteam members in a systems-based, error-prevention process.

Patient Safety Indicators help usprioritize patient safety efforts.To help prioritize our opportunities forsafety, Christiana Care measures many ofour patient safety efforts against a varietyof indicators such as the Patient SafetyIndicators developed by the Agency forHealthcare Research and Quality (AHRQ).These indicators provide information onpotential inpatient complications followingsurgeries, procedures and childbirth. They measure healthcare quality by usingreadily available hospital inpatient adminis-trative data against which we compareour successes to identify opportunitiesfor improvement.

For example, based on the AHRQ’s PatientSafety Indicators for inpatient complicationsrelated to surgery, we saw an opportunityto reduce blood clots in certain patientsafter surgery. After reviewing this data, weidentified opportunities for improvementand put teams in place to focus their effortson improving the prevention and manage-ment of deep vein thrombosis and othercomplications.

S A F E T Y F I R S T

Culture, Best Practice and TechnologyOur Focus on Excellence is based on building a safe culture, incorporating bestpractices and using technology to keep our patients safe from harm. The followingexamples highlight some of our major successes in each of these areas.

C U LT U R EAHRQ PatientSafety Indicators

FY07 | Current

Death in Low • •Mortality Diagnostic Related Groups

Decubitus Ulcer • •

Failure to Rescue • •

Foreign Body Left • •During Procedure

Iatrogenic • •Pneumothorax(Accidental Lung Collapse)

Infections Due • •to Medical Care

Post-op Hip • •Fracture

Post-op Hemorrhage • •or Hematoma

Post-op Physiological/ • •Metabolic Derangement

Post-op Respiratory • •Failure

Post-op Pulmonary • •Embolism or Deep Vein Thrombosis

Post-op Sepsis • •

Post-op Wound • •Dehiscence (Rupture)

Accidental Puncture • •or Laceration

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◆ Meets or exceeds goal

◆ Initiatives are in place to meet goal

◆ Priority safety effort

S A F E T Y F I R S T ♦ S A F E C U LT U R E 11

Safety Mentors foster high reliability teams. The Safety Mentor Program helps Christiana Care staff members improveerror reporting and reduce severity of errorsby learning from near misses, good catchesand potential hazards. Safety mentors helpfacilitate communication between front-linestaff and the quality and safety experts whostay on top of safe practices and infectioncontrol. They are selected by unit managersand are front-line ambassadors representingnearly all areas of the organization includingclinical and support departments. As theliaison between the unit and the Safety

Teams, safety mentors help build workablesolutions for patient safety issues basedon evidence-based best practices. Their successes include:

♦ Standard methods of communication

♦ Safety First Alerts that describe a safetyconcern and related practices to be implemented

♦ Performance Improvement Safety Hotline for proactive reporting

♦ Safe Practice Behavior Monitoring Program that encourages peer-to-peerfeedback

Unit Based Medical Directormodel helps staff embrace qualityand safety initiatives.To help staff understand and embrace themany quality and safety initiatives goingon at Christiana Care, each front line nursingunit has a medical director who helps itsolve issues and shares best practices fromother units. The medical director also educates staff members about national

patient safety standards and encouragesa quick adherence to them.

For example, after the medical directorshared national standards of care with staffmembers, they developed the BLAAST bestpractice program for heart attack patients.

(See page 20 for more information aboutBLAAST.)

The success of our Safety Mentor Program can be measured in our improved reporting of errors, reduced severity of errors and changes in safety culture.


Storytelling: A powerful methodthat enhances patient safety.The technique of storytelling through ourNo Harm Intended: Lessons Learned inPatient Safety session is one of the strategiesChristiana Care uses to promote learningand reinforce patient safety practices.Although many of our staff membershave used storytelling in the work place,formalizing the process so it is visibleand reaches all disciplines is our goal.

Safe Practice Behavior Monitoringserves as the foundation for a patient safety organization.The foundation of a patient safety organization is built on the real-time observations by our safety mentors andthe positive reinforcement and coachingof our safety behaviors from the frontline staff. The success of this system isdemonstrated in our compliance toNational Patient Safety Goal data.

Safe Practice BehaviorsResults FY08

Patient Identification ◆Telephone Order Read Back ◆Critical Result Read Back ◆Critical Result Timeliness ◆Non-use of Dangerous ◆Abbreviations

Hand Hygiene ◆Medication Reconciliation ◆Hand Offs ◆Medication Labeling ◆Universal Protocol ◆



◆ Priority safety effort

S A F E T Y F I R S T ♦ S A F E C U LT U R E 13

Team Training empowers staffto speak up.Christiana Care piloted a team training program in the emergency department(ED)/trauma bay based on the Agency forHealthcare Research and Quality (AHRQ)and Department of Defense Team STEPPSprogram. The program is an evidence-based system aimed at optimizing patientoutcomes. It provides skills and strategiesto improve communication and teamworkamong healthcare professionals. Team training also fosters an atmosphere wherefrontline staff members feel free to speakup if they think something is wrong.

Over 350 of our trauma care providers(emergency medicine, surgery, nursing,anesthesiology, advanced practice nurses,physician assistants and family supportstaff) have been trained in this system thathas been well documented in the militaryand aviation industries to improve efficiency,safety and team communication. We haveincorporated team training principles into

our trauma policies. Sustainment strategiesinclude monthly trauma conference teamdebriefings and quarterly interdisciplinarycombined grand rounds. An observationtool for trauma care has been developedto allow team scores to be correlated withclinical intervention times to further assessimpact of training on care. Preliminary datapre- and post-training also shows an impacton emergency department length of stay fortrauma patients with a significant decreasein disposition time to the operating room.

In addition, members of the implementationteam have consulted with obstetrics (OB)colleagues to integrate team concepts into asimulation curriculum for OB emergenciesduring deliveries. We are also enhancing theinitial phase of a standardized pre-procedurebriefing process for various service lines.And, a pilot is underway for bringing teamskills, tools and strategies to social workand care management to facilitate efficientcare and discharge planning.

The completion of team training for ED/Trauma marks an organizational turningpoint toward enhancing our culture of safety at Christiana Care. The knowledgeof team composition, roles and responsibilities, along with structured tools andstrategies to improve communication and behavior, enhances the high quality ofcare that is delivered to our patients."

Nicholas Gagliano, M.D.Physician Champion for Team Training

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We encourage patientsto SpeakUp™ for safety. Christiana Care’s SpeakUp™ program provides useful information and suggestionsto enhance a patient’s safety in the hospitaland during their recovery time after beingreleased. SpeakUp™ encourages patients to:

♦ Speak up if they have questions or concerns and continue to ask untilthey fully understand

♦ Pay attention to the care they receive

♦ Educate themselves about their diagnosis,the medical tests they receive and theirtreatment plan

♦ Ask a trusted family member or friendto be their advocate

♦ Know what medications they take andwhy they take them

♦ Use a hospital, clinic, or other type ofhealthcare organization that has experiencein treating their type of illness

♦ Participate in all decisions about theirtreatment

Information about SpeakUp™ is providedto patients when they are admitted to thehospital . It is also available online throughour Get Well Network™, an innovativetechnology interactive system that empowerspatients to be involved in their care.SpeakUp™ is a trade mark of The Joint Commission

Just Culture Council focuses onerror prevention. Seizing a key opportunity from our PatientSafety Culture survey, Christiana Care hasassembled an interdisciplinary team to pursue adoption of Just Culture principles.This team is made up of representativesfrom throughout the system and is respon-sible for building the foundation of a JustCulture. In addition, during NationalPatient Safety Week, a national speakerintroduced the concepts of Just Culture toour staff and management team. Our journeyin establishing a Just Culture will focus onthe following key elements:

♦ Learning is valued at every level. We can identify solutions by learningfrom our errors.

♦ Employees can admit mistakes and willbe treated fairly, balancing the accounta-bility of the system and the accountabilityof the individual in a manner that supportspatient safety.

♦ Safe systems are designed to anticipateerrors before they become critical.These systems give employees the bestopportunity to get the job done rightthe first time.

♦ Behavioral choices are managed to recog-nize we all have a shared accountability

Through the implementation of a Just Culture, our managers learn how to coachemployees to promote safe behaviorsand recognize when an employee needsmentoring or remedial intervention.

BEST PRACTICE

Evidence-Based Interventions dramatically reduce ventilator- associated pneumonia.The leading cause of death from hospital-acquired infections is ventilator-associatedpneumonia (VAP). Up to 15 percent ofpatients who receive mechanical ventilationdevelop VAP. It is estimated that betweenone-third and one-half of deaths from VAPare preventable. VAP also contributes toprolonged mechanical ventilation, extendedintensive care unit (ICU) stay and overalllength of stay and increased cost of admis-sion of more than $40,000 per patient.

To help reduce the risk of VAP, ChristianaCare’s Critical Care Committee incorporatedthe Institute for Healthcare Improvement’s(IHI’s) evidence-based interventions intoour standard care plan for patients onmechanical ventilation. Research shows

that when these interventions are imple-mented together the incidence of VAP isdramatically reduced. The interventionsinclude:

♦ Elevating the hospital bed top 30 to 45 degrees

♦ Waking patients every day so that theyget a “sedation vacation”

♦ Assessing patients every day for theirreadiness to be weaned off the ventilator

♦ Providing treatment to prevent deep veinthrombosis

♦ Providing treatment to prevent peptic ulcer

Since we implemented these interventionsto reduce VAP in March 2005, we have seena dramatic reduction in the number of patients developing VAP. In fact, in 22 ofthe 32 months since the program began,not a single patient has developed VAP.

Infection Control Team protects patients, employees and neighbors. Christiana Care’s Infection Control teamaddresses infection control throughoutthe health system and the community.The team is involved in local and nationalprojects and in monitoring compliancewith local state and federal regulations.As part of our Emergency ManagementCommittee, the team has helped developpolicies relating to national and interna-tional concerns such as pandemic flu andbio-terrorism preparation.

Infection control heightens during flu sea-son, November through May. The InfectionControl team augments its efforts with ahigh-tech automated data mining systemknown as SafetySurveillor. We are one ofthe few health care systems in the countryto use this kind of technology. The systemprovides us with information that we sendto the Delaware Division of Public Healthto show when the flu begins and how itprogresses, statewide.

Designing Optimal Clinical Care Processes Best practices are based on evidence from accepted medical literature. Learning andteaching best practices is a team effort. At Christiana Care, we foster communicationbetween front line staff and our quality and safety experts who have their pulse onthe latest in safe practices, infection control and prevention strategies.

S A F E T Y F I R S T ♦ B E S T P R AC T I C E 15

Rapid Response Team contributesto a 15 percent reduction in patientmortality.At Christiana Care, nurses and other staffmembers who are concerned that a patientis deteriorating or becoming unstable maycall on the rapid response team (RRT) tobring critical care expertise to the patient’sbedside. The RRT comprises a critical carenurse, respiratory therapist and resident.

The team assists the patient caregiver toassess and stabilize patient’s condition andorganizes information to be communicatedto the patient’s physician. The RRT alsoeducates and supports the staff. By respond-ing quickly to the signs and symptoms ofpotential cardiac or respiratory arrest, theRRT has helped prevent many deaths.

16 S A F E T Y F I R S T ♦ B E S T P R AC T I C E

Inpatient Mortality

Code Blue Rate (for patients who need immediate resuscitation)

63% of patients stay on their unit after the call; 33% are transferred to a higher level of careNon-ICU code blue rate dropped by 32% after implementation of the RRT; overall code rate decreased 28%

S A F E T Y F I R S T ♦ T E C H N O L O G Y 17

Momentum is accelerating for ourSafe Medication Culture.To take Christiana Care’s safe medicationculture to the next level, we are workingwith the Institute for Safe MedicationPractices (ISMP). This organization reviewsmedication errors and prevention strategiesthroughout the nation and shares themwith the Food and Drug

Administration (FDA). We are reviewingand implementing ISMP’s specific medicationsafety recommendations for ChristianaCare, including evaluating our data foropportunities for improvement. Ourdepartment chairs will serve as physicianchampions for accelerating the momentumof this initiative.

Improving Medication Safety By using technology such as the computerized bar code for patient identificationand the electronic medication administration record (EMAR), Christiana Carewill have an electronic safety net that will help systematically reduce errors andset the foundation for many other safety practices.

Medication Safety is an important facet of our patient safety program.A high reliability strategy is to design systems that do not solely rely onhuman performance. The use of technology can enhance patient safetyand achieve a more reliable system.

TECHNOLOGY

Full implementation Partial implementation

18 S A F E T Y F I R S T ♦ T E C H N O L O G Y

Bar-Coded Wristbands improve accuracy of patient identification.With the nation’s hospitals reaching nearcapacity for their already busy inpatientunits, the risk for mistakes in patient identification increases and therefore, therisk of treatment errors continues to rise.

To protect patients at Christiana Care, we areimplementing bar-coded wristbands to enableour staff to reliably identify all patients whenadministering certain lab tests, medicationsand blood products or taking specimen samples.

When patients enter the hospital, they willreceive a bar-coded identification wristbandthat can transmit information to the hospital’scomputer. Nurses check the patient’s nameand then scan the bar-coded wristband toconfirm identify. This kind of accuracy inpatient identification will reduce risk for errorand improve outcomes. It also serves asthe foundation for our electronic medicationadministration practice as well as our upcoming initiatives for streamlining clinicalprocesses such as blood dispensing and specimen collection.

According to the Institute of Medicine, approximately 400,000 preventablemedication-related injuries occur in the nation’s hospitals each year, resultingin an estimated $3.5 billion in extra medical costs. Christiana Care is takinga proactive approach to preventing medication errors.

“EMAR puts nurses and pharmacists on the same page when it comes to dispensingand administering medications. Together, we are working from one electronic record.Before the project was initiated, pharmacy laboriously checked the manufacturer’sbar code on each of our approximately 4,000 medications to ensure it was properlyidentified by bar code scanning to ensure correctness from the start.

Al Helmeczi, R.Ph., MS, FASHP, Vice President, Pharmacy Services

F A C T

Bar Code Point of Care

Electronic Medication Administration Record (EMAR)

Computerized Physician OrderEntry (CPOE)

Projected FY 09

Right Right Right Right Right StatusPatient Medication Time Dose Route

✓ ✓ ✓

✓ ✓ ✓ ✓ ✓

✓ ✓ ✓ ✓

The Five Rights of Medication Safety

Electronic Medication Technologyhelps prevent medication errors.One of Christiana Care’s major patient safety initiatives has been the successfulimplementation of the electronic medica-tion administration record (EMAR) atWilmington Hospital. EMAR is a powerfultool that helps prevent medication errors.At the patient’s bedside, a nurse uses a

hand-held scanner to check the bar code oneach medication against the bar code on thepatient’s hospital wristband. At this point,the nurse can verify the “five rights—rightpatient, right medication, right time, rightdose and right method of administration—thus preventing many adverse drug eventsas well as documenting the patientencounter.

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S A F E T Y F I R S T ♦ T E C H N O L O G Y 19

Computerized Physician OrderEntry completes our advancedmedication process.As we maximize the potential of bar codingand electronic medication administrationrecords (EMAR) technology to enhancepatient safety, we are setting the foundationfor our computerized physician order entry(CPOE), a highly evolved system that closesthe loop for the practice of safe medication.This process is based on best practices andclinical excellence and takes many years todesign and implement. Christiana Care isin the development phase and plans toimplement it within the next two years.

CPOE is an electronic medication prescribingsystem that detects errors when medicationsare prescribed, dispensed and/or adminis-tered. With CPOE, physicians enter ordersfor medications as well as lab and diagnostictests into a computer rather than on paper.Orders are added to a patient’s electronicrecord. As soon as an order is entered, it isautomatically checked against the patient’sexisting information for potential errors orproblems. In addition to detecting inconsis-tencies, CPOE reduces medication errors,helps to reduce the need for repeat testsand increases laboratory, pharmacy andradiology turnaround.

BLAAST has achieved national recognition from the Institute for Healthcare Improvement (IHI). It has asked Christiana Care to be a mentor hospital for acutemyocardial infarction. IHI mentor hospitals provide support, advice, clinical expertise and tips to other hospitals seeking help with their implementation efforts.In addition to expanding to a hospital-wide implementation of Ask me aboutBLAAST, we will share this best practice with other hospitals across the country.

Maria Albert MSN, RN, Program Manager for Heart & Vascular Performance Improvement

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20 C L I N I CA L E X C E L L E N C E

C L I N I C A L E X C E L L E N C E

Our Focus on Clinical Excellence includes performance improvement, use of technology, clinical innovation, research and an unending commitment to alwaysdoing better in the service of our patients.

“BLAAST” Engages Patients andtheir caregivers in heart attack care.Current research from the American HeartAssociation (AHA) shows that results forheart attack patients are much improvedwhen patients and their caregivers areengaged in care from the start. Patientssuffer fewer complications and hospitalreadmissions and have improved healthand overall quality of life.

Based on the AHA’s “Get with theGuidelines” education program,Christiana Care's team of nurses andphysicians developed a pilot program toempower healthcare providers to consis-tently treat heart attack patients accordingto the latest evidence-based guidelines.

The initiative focused on a creativeacronym, “BLAAST,” that made patientsand their caregivers aware of the guide-lines relating to heart attack care: B (betablockers) L (lipid-lowering therapy)A (aspirin) A (ACE inhibitors and/or ARB)S (smoking cessation) and T (talk to yourdoctor or healthcare provider).

The “Ask me about BLAAST” programprovides both patients and caregivers witha prompt to make sure care is consistent inand out of the hospital and reminds themto ask important questions such as“Should I be on a beta blocker?” or “Am Igoing home with lipid lowering therapy?”

Since the introduction of the pilot program,our compliance with the AHA’s performancemeasures have increased from 91 percent to100 percent.

C L I N I CA L E X C E L L E N C E 21

JC/CMS*Quality Indicators Compliance Rate (percent of patients who receive appropriate care)

National 90thPercentile

Acute MyocardialInfarction (AMI)

FY08 YTD*

National Mean

FY08 year to date = July 2007 to April 2008

*The Joint Commission (JC)/Center for Medicare & Medicaid Services (CMS) Quality IndicatorsCompliance rate (percent of patients who receive appropriate care) Measures are publicly re-ported on the JC website and CMS's Hospital Compare website

Aspirin at Arrival 99 93 100

Aspirin at Discharge 98 90 100

ACE Inhibitor/ARB for Eligible Patients 97 83 100

Smoking Cessation Advice/Counsel 100 89 100

Beta Blocker at Discharge 99 90 100

Beta Blocker at Arrival 98 87 100

PCI within 90 Minutes 83 55 90

Inpatient Mortality 2.6 Goal: less than 5%


Kidney Transplant Program elimi-nates barriers to care in Delaware.Christiana Care started the kidney trans-plant program to help eliminate barriersto care for Delawareans. Before the programexisted, kidney patients in Delaware hadto travel an hour or more, on short notice,to the closest transplant center when a kidneybecame available. Research shows thatwhen care is far away, patients wait longerto receive care and as a result, return todialysis more quickly. In addition, whenfaced with the choice of receiving a livingdonor’s kidney (which has a higher survivalrate) or a deceased donor’s kidney, patientsare less likely to choose living-donor kidneysbecause they don’t want to inconveniencetheir friends and family to prepare for thetransplant and then make them travel fardistances for the procedure.

All this has changed since the opening ofour kidney transplant program in the fallof 2006. We assist patients at several levelsof care, starting with thorough educationabout end stage renal disease and treatmentoptions including living donor transplant,deceased donor transplant, standard criteria

donors and expanded criteria donors.Our patients meet the entire multidisciplinaryteam (including medical director, transplantsurgeon, transplant coordinator, socialworker, pharmacist and dietician) earlyin the process to ensure better outcomes.We believe in establishing close relationshipswith our patients, seeing them every sixmonths while they’re on the transplantwaiting list and encouraging them to notifyus of any changes in their condition whichcould affect transplant.

Since the program opened, we have received500 patient referrals, evaluated 300 patients,placed 160 patients on the transplant waitinglist and performed 20 transplants. To addressrequests for increased access to educationfor the residents of lower Delaware, ourstaff recently presented an educational symposium in Dover. More than 200patients, family members and friendsattended an afternoon of lectures by transplant specialists as well as a patientpanel discussion which included patientsrecently transplanted and recent living kidney donors.

Good data is essential to asafe culture.At Christiana Care we go beyond the standard to collect clinical data.This enables us to compare our performance with other organizations, determine opportunities for improvement and share our best practiceswith other health systems across the country.

Our transplant nephrologists hope to provide the same level of transplant careavailable in large centers, but with personal relationships and one special personto oversee care. As one of our transplant surgeons describes, ‘we provide universitylevel care with a personal touch.’ At Christiana Care, our transplant team mem-bers have committed to providing the best education and we believe our patientsneed to be active members of their transplant healthcare team.

Geri LiBetti RN CCTC, Administrative Director of Renal and Transplant Services

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F A C T


Treating Heart Failure patients inthe hospital and at home.When patients are admitted to Delaware’sonly dedicated heart failure unit atChristiana Care, they receive the specializedcare they need at the onset of their conditionand through their transition back home.Not only are their outcomes better, but theyalso have fewer readmissions to the hospital.

Our dedicated heart failure unit, with astaff of 110 nurses and a multidisciplinaryteam of heart failure pharmacists, dieticians,social workers, psychiatric nurses and casemanagers is dedicated to providing the careand education our patients need.

Our heart failure telemonitoring programis a year-long telephone education programfor heart failure patients who have recentlyreturned home after being hospitalized.

The case manager calls patients once aweek for the first four weeks and gives theminformation about medications, low-sodiumdiets and the need to stay active. Patientsadvance through the program based on theprogress they achieve. The program is basedon studies that show patients who have inter-actions with case managers have a higherquality of life and fewer hospital admissionsthan those patients who have no interaction.

The VNA telemonitoring program hasbeen designed to look for signs and symptomsof complications in heart failure patients whoreturn home. Through daily blood pressure,pulse and weight readings that are transmittedfrom the patient’s phone to the VNA modem,the nurse can detect a problem and provide thenecessary intervention to prevent readmissionto the hospital.

“The Heart Failure Program at Christiana Care is focused on providing the highestquality of care to a broad spectrum of heart failure patients within our healthcaresystem. Our comprehensive program provides outstanding care from admission untillong after discharge and provides services that were previously unavailable in the state.Heart failure outcomes continue to improve, variability in care is being reducedand transitions in care are being refined to ensure a seamless care continuum.

Mitchell Saltzberg, M.D., Medical Director, Heart Failure Program”National 90thPercentile

Heart FailureJC/CMS* Quality Indicators

FY08 YTD*

National Mean

Complete Discharge Instructions 80 62 87

Left Ventricular Function Assessment 98 84 98

ACE Inhibitor/ARB for Eligible Patients 88 82 100


PneumoniaJC/CMS* Quality Indicators


Antibiotic within 4 Hours of Arrival 71 80 91

Initial Antibiotic Selection 94 84 90

Influenza Vaccination 75 64 n/a

Pneumococcal Vaccination 76 71 88


Oxygenation Assessment 100 98 100


FY08 YTD*

National Mean

*The Joint Commission (JC)/Center for Medicare & Medicaid Services (CMS) Quality IndicatorsCompliance rate (percent of patients who receive appropriate care)Measures are publicly reported on the JC website and CMS's Hospital Compare website


VNA Heart Failure Managementprogram reduces acute care hospitalization for participants by 27 percent.Based on best practices and national guidelines, Christiana Care’s Heart FailureManagement program helps heart failurepatients improve medication compliancethrough increased understanding andself -monitoring of their conditions. The program includes at-home telemonitoringservices so patients can transmit daily vitalsigns over the phone to a nurse’s computer.

Nurses can easily detect patient changesand work with physicians and other care-givers to make necessary treatmentmodifications. Another unique programfeature is the inclusion of therapists in thepatient’s home to prevent disability, achievean optimal functional level, reinforce use ofthe telemonitor and help patients recognizeand report symptoms.

VNA Wound Care Program reducesemergent care relating to woundcomplications.With three wound care certified nursesin the New Castle County VNA officeand a wound ostomy continence certifiednurse serving patients in Kent and SussexCounties, more than 50 percent of patientsreceiving wound care are treated withadvanced products such as alginates, collagen products, composite and compression dressings, enzymatics, hydrocolloids and hydrogels.

The expertise of the wound certified nurses in making recommendations andcollaborating with physicians has reducedemergent care due to wound complicationsfrom 1.03 percent to 0.97 percent for morethan 6,800 patients requiring wound care.There has been a 12 percent increase innumber of wound care patients during fiscal year 2008.

Visiting Nurse Association (VNA)is a leader in caring for our neighbors where they feel mostcomfortable, at home.Christiana Care’s Visiting NurseAssociation (VNA) offers a comprehensiveselection of services and provides totalcoordination for specialized home healthcare needs, including nursing and specialtycare services, adult day care programs and rehabilitative services. Here are someof the VNA’s recent successes in providingquality and safe care to our patients at home.

VNA Rehabilitation Departmenthelps seniors stay SAFE at homeby preventing falls and reducinghospitalizations.Using evidence-based assessment tools andactivities of daily living outcome measures,the VNA’s Safety, Assessment, Function

and Exercise (SAFE) program therapistsaddress seniors’ specific activity levels, barriers to independence and risks for hospitalization, falls or overall decline.Since the program’s implementation lastautumn, hospitalization and fall rates havealready been improved.

Percentage of Term Babies Admitted to Neonatal IntensiveCare Unit (NICU)


Revised Protocol reduces electivelabor inductions and term neonatalNICU admissions.For some women, when labor is slow tobegin, they may elect to have labor inducedwith medications or by other methods.However, as with most medical procedures,elective induction can pose a risk to bothmother and baby. To help address this concern, Christiana Care had adopted

the American College of Gynecology ofObstetrics and Gynecology’s (ACOG) gestational age requirement of 39 weeksor beyond for elective labor inductions.Since the adoption of this protocol, wehave noted a significant decrease in thenumber of total elective inductions as well asterm neonatal NICU admissions. A similar policy is being implemented for patientsundergoing elective repeat cesarean sections.


Raising the Bar for inpatient imaging report turnaround time. Christiana Care’s commitment to perform-ance improvement in inpatient imagingreport turnaround time is exceeding thestandard. According to the AmericanCollege of Radiology, the standard for inpatient MRI consult to exam completionis 24 hours. However, last year our imagingdepartment set its own standard to 12 hourswith a goal of 75 percent for the first year,which we expect to meet. Not only doesreducing the imaging report turnaroundtime reduce waiting times for patients, italso reduces their length of hospital stay.

Meeting Medicare Guidelines andensuring quality at Physical Therapy Plus.Physical Therapy Plus conducts regularchart audits to meet Medicare guidelinesand to make sure that patients receive thecare they need throughout the rehabilita-tion process. For example, we make suredocumentation includes the patient’s medicalhistory, the patient’s acknowledgement ofhis or her diagnosis, treatment goals as wellas notes about objective gains to show theneed for therapy and progress towards goals.We track the plan for the next treatmentas well as what is expected of the patientto maintain his or her gains after being discharged from therapy.

Setting New Standards in Health InitiativesChristiana Care is setting new standards for our Imaging, Physical Therapy andOccupational Health and Safety health initiatives. Here are some examples of oursuccesses to date.

Establishing Best Practice for reducingblood borne pathogen exposure.Christiana Care's occupational health serv-ices has developed a process to improveconsistency in following national protocolsto treat blood borne pathogen exposure.By using chart audits to determine ouradherence to national standards for bloodborne pathogen exposure, we ensure thatevery member of our medical and adminis-trative team participates in this crucial

aspect of patient safety. For example, after asignificant exposure to HIV-infected blood,a patient’s risk of contracting HIV isapproximately 3 per 1,000 cases. However,with appropriate post-exposure medicationand medical monitoring, this risk diminishesto almost zero. Based on the results of periodic chart audits, our year-to-date compliance in following the blood bornepathogen protocols is 92 percent amongstaff members.


WISH and ACE are improvingsenior care.With almost 50 percent of our inpatientpopulation age 65 or older, Christiana Carerecognized the need to create system-wideawareness of the special care needs of ourelderly patients. Based on a national initiativecalled Nurses Improving Care to HealthSystem Elders (NICHE), the We ImproveSenior Health (WISH) program was devel-oped to focus on preventing and managingcommon geriatric syndromes such as falls,skin breakdown, delirium, medication safety,incontinence and sleep disorders.

The WISH program is a collaborative effortof nurses, physicians, pharmacists, rehabili-tative therapists, social workers, dieticiansand others who care for seniors. The key toimplementing WISH is the development ofthe Senior Health Resource Team (SHRT).The SHRT is comprised of healthcareproviders who are committed to improvinggeriatric care and who have completed a16-hour course in specialized geriatric train-ing. Since the implementation of WISH,close to 1,000 Christiana Care providershave attended the program.

The Acute Care for the Elderly (ACE) inpatient hospital unit grew out of theWISH initiative. ACE is an inpatient caremodel for senior patients. With a dedicated39-bed unit at Christiana Hospital and 11-bedunit at Wilmington Hospital, the ACE units provide an interdisciplinary approach tocare for patients. Specialized disciplinesinvolved include a medical director (geriatrician), a dedicated geriatric clinicalnurse specialist, geriatric pharmacist, dietician, physical therapist, social workerand case manager.

Since the implementation of the ACE inpatient hospital unit, results show:

♦ Average length of ACE inpatient stayis about one day less than it is for similarpatients on other units

♦ Restraint rate is zero percent

♦ Fall rates and hospital acquired pressureulcer rates are about 25 percent lowerthan the rates for similar patients in other units

Impact of WISHRecent survey results show 99 percent of our Senior Health Resource Teammembers put the WISH education into practice. More than 87 percent report that the WISH training was valuable in helping them provide bestpractice geriatric care to their patients.

Our goal is to ensure that we are providing best practice to our senior patients atChristiana Care.

Denise L. Lyons, MSN, CNS, BC, Clinical Specialist in Gerontological Nursing, WISH Program Coordinator

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F A C T


Gold STAR treatment for stroke patients.Christiana Care’s Stroke TreatmentAnd Recovery (STAR) Unit is dedicatedto providing safe and effective care thatconsists of a multi-disciplinary care teamdedicated to meeting specific needs ofstroke patients. Care is based on best practice standards and benchmarksfrom the American Stroke Association.Recent results show that average lengthof stay for patients on the STAR unit is5.2 days compared to 5.9 days for strokepatients on other units.

The moment a stroke patient enters the hospital we are already thinking rehabilitation.We have created a defined pathway that includes the family in making sure patientsget the medication, rehabilitation and other care they need.

Shirley Moran, Director, Patient Care Services

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Get with the GuidelinesAmerican Heart Association/American Stroke Association

FY08

Deep Vein Thrombosis ◆Prophylaxis by Day

Antithrombotics at ◆Discharge

Anticoagulation at ◆Discharge for Atrial Fibrillation

t-PA within 180 Minutes ◆(Clot Busting Drug)

Antithrombotics Therapy ◆by Day 2

Cholesterol Drugs at ◆Discharge

Screening for Dysphagia ◆(Difficulty Swallowing)

Complete Patient Education ◆Smoking Cessation ◆Assessment for ◆Rehabilitation Services



◆ Priority quality effort


NSQIP and SCIP help identify opportunities for improvement.Christiana Care proudly participates in theAmerican College of Surgeons NationalSurgical Quality Improvement Program(ACS NSQIP). Named “best in the nation”for measuring and reporting surgical qualityand outcomes in 2002 by the Institute ofMedicine (IOM), the NSQIP can contributeto improving surgical care and outcomesand lowering costs.

We also participate in the Surgical CareImprovement Project (SCIP) through theJoint Commission and Center for Medicareand Medicaid Services hospital quality initiative.

Through NSQIP and SCIP, we can identifyopportunities for improvement in surgerybased on data collected from other hospitalsfor the same conditions and measure ourresults against the standard.

For example, last year NSQIP data revealedthat we had a higher-than-average rate ofsurgical patients who developed blood clotsafter surgery. Upon evaluation, we realizedthat several factors were involved includinglack of an adequate supply of leg compres-sion pumps used to prevent the blood clotsin surgery patients. This led to our purchaseof additional compression pumps, whichalong with some other changes, reduced thenumber of patients developing blood clotsafter surgery to the standard rate of otherhospitals, based on NSQIP data.

NSQIP and SCIP stress an ongoing review of our processes and results and howwe compare to others. It’s nice to see the support across the health system for whatwe’re doing. When we have a potential patient safety concern – at all levels –staff members want to know what they can do to help.

Gerry Fulda, M.D. Medical Director, Surgical Intensive Care Unit

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Surgical Care Improvement Project


Surgical Care ImprovementJC/CMS Quality Indicators

FY08 YTD*

National Mean


Prophylactic Antibiotic within 1 Hour 87 78 93

Prophylactic Antibiotic Selection 97 89 n/a

Antibiotic Discontinued within 24 Hours 87 74 95

Controlled Post-op Serum Glucose 90 n/a n/a

Appropriate Hair Removal 99 n/a n/a

Post-op Normothermia (Normal Body Temperature) 93 n/a n/a

Perioperative Beta Blocker 87 n/a n/a

VTE Prophylaxis Ordered 97 79 n/a

VTE Prophylaxis Pre- or Post-Surgery 93 75 n/a

The Joint Commission (JC)/Center for Medicare & Medicaid Services (CMS) Quality IndicatorsCompliance rate (percent of patients who receive appropriate care)Measures are publicly reported on the JC website and CMS's Hospital Compare website


A New Approach for managingcare in the emergency department.Emergency department (ED) overcrowdingis widespread throughout US hospitalsand has reportedly reached near crisis proportions. Typically, when a hospital’sinpatient units are filled to capacity (whichis becoming the norm due to increasedhospital shut downs, aging populationand increased illness and injury), patients coming from the ED have to wait until abed becomes available (called boarding).This increases the wait for ED patientswho do not have life-threatening situationsand contributes to overcrowding. On abusy day during flu season, ChristianaCare can see up to 350 patients a day inthe ED. Of these 350 ED patients, 28 percent(approximately 100 new patients) will beadmitted to the hospital.

To address these issues, our ED leadersare working on a new initiative based onoperational excellence, best practiceresearch and staff-based teams to reduceED boarding hours. One of the first stepsis to categorize specific patient groupswho use the ED and remove barriers totheir care. We have identified three groupsof patients: those who have life threateningsituations, those who have illness or injuryand those who have minor injuries.

The first group of patients we are focusingon are the patients who have minor injuries.These are the patients who come to the EDwith a sprained ankle, skin rash or brokenfinger and are relatively easy to treat.We are designing processes with a goalto get these patients in and out of the EDwithin sixty minutes. So far, as a result ofthese processes, we have reduced length ofstay for ED patients with minor illness andinjury by 30 percent to 60 percent. Once werefine this process, we will apply it to ourother patients.

F U T U R E I N I T I AT I V E S 31

F U T U R E I N I T I AT I V E S

Focus on ExcellenceNext year we will focus on improved ways of reporting to increase the transparencyof our quality and safety challenges. Our commitment to the relentless pursuit ofexcellence and “perfection” will continue to be the focus of the Quality and PatientSafety Program next year and for years to come.

Future Initiatives to Improve Quality and Patient Safety at Christiana Care

Christiana Care’s dedication to excellence has enabled us to achieve high levels of successin improving quality and delivering safe care to our patients. We need to celebrate thesesuccesses, but never rest or be satisfied with our level of achievement. Learning fromour experiences, planning carefully and taking action are vital to maintaining our Focuson Excellence.

Our quality and safety programming efforts are organized around culture, best practiceand technology. We have developed action plans for each area and will measure progressusing comparative data from internal and external sources to benchmark our performance.Examples for each area are decribed below.

Culture. Since our last culture survey in 2006, we have focused on improving hand-offsand transitions, non-punitive response to error and teamwork across units. We will continue to develop “just culture” concepts, team training and other techniques such ashuman factor analysis to keep our patients safe.

Best Practice. We are going beyond identifying and addressing practice “errors” to discover other types of adverse events that can potentially harm patients. We assumethat all harm is preventable and search for creative solutions. High-risk procedures,increasing complexity of cases and multifaceted care delivery in a variety of settingsadd to this challenge. Next year we will focus on increasing transparency of our qualityand safety efforts to further promote our focus on excellence.

Technology. Through implementation of the computerized physician order entry (CPOE)system, we will continue to transform our organization by providing real-time clinical decision support to physicians. This brings together technology with best practice so wecan decrease variation in care delivery and improve medication safety.

Our commitment to the relentless pursuit of excellence and “perfection” will drivethe Quality and Patient Safety Program for years to come.

James Newman, M.D., FACP Sharon Anderson, RN, MS, FACHEChief Medical Officer Sr. Vice President Patient Safety Officer PI and Care Management

32 F U T U R E I N I T I AT I V E S

Agency for Health-care Research and Quality(AHRQ) Culture Sur-vey

My Medication List

Simulation

SBAR/DATAs

Team Training

Safety First LearningReports

Safety First Alerts

Safety Hotline

Partners in Learningfor Safety (Just Cul-ture Council)

Human Resourcesand Safety Standardsfor Event Follow Up

‘Good Catch’ Recog-nition

Safe Mentor Educa-tion and Development

No Harm IntendedSessions

Speak Up PatientSafety Guide

Safety First Advisory

Council

Safety in New Em-ployee Orientation/On Boarding

Enhanced Focus onExcellence (FOE)Awards

Safety First LearningReport Enhance-ments for Follow Up

Just Culture Con-cepts (Planning)

Human Factor Analy-sis for Flex Monitoring

Team Training

Transparency Con-cepts

Focus on “No Harm”

Reversal of Anticoag-ulation

Heart Failure Unit

Stroke Treatment andRecovery (STAR) Unit

Spine Center of Ex-cellenceHospital QualityMeasures:

– Heart Attack

– Heart Failure

– Surgical Care Improve-ment Program (SCIP)

Reduce Surgical Complications

DVT Prophylaxis De-velopment (Planning)

Institute for SafeMedication Practices(ISMP) Assessmentof CCHS MedicationSafety (Planning)

Medication Safety Of-ficer (Planning)

5 Million Lives Cam-paign

– System Wide SkinTeam to Prevent Pressure Ul-cers

– Reduce MRSA

– High Alert Medica-tions; WISH program,Anticoagulation Team

– Sugical Care Improve-ment Project

– Heart Failure, HeartDisease and Stroke;‘Get with the Guide-lines’

– Board Report of KeyMeasures

Clinical Documenta-tion Project

MRSA

National PatientSafety Goals (NPSG):Management of Anticoagulation

Improving Recogni-tion and Response toChanges in PatientCondition

“Never Events” Pres-ent on Admission

Hospital Consumerand Assessment ProviderSurvey (HCAPS)

Disease Specific Cer-

Setnet

Computerized Physi-cian Order Entry(CPOE), Planning

Electronic MedicationAdministrationRecord (EMAR), Planning

Infusion Pumps(Safety Software)

Bed ManagementSystem

Get Well Network

EMAR Implementa-tion

Barcoding (BedsideSpecimen Labeling)

Sentinel Event data-base

Bed ManagementSystem

Perioperative Docu-mentation

Pharmacy OrderManagement System(POMS)

Delaware Health In-formation Network

(DHIN)

CPOE: Zynx Imple-mentation (Order

Sets/Standards Develop-ment)Phase 1

ADT Interfaces withMicropaq WirelessPatient Monitoring

Infusion Pumps

CPOE: Zynx Phase 2

Our Journey in Quality and Patient SafetyQuality and patient safety program development requires an ongoing evaluation of our initiativesas they relate to current best practices and national standards. Here is a snapshot of the initia-tives we've focused on in the past and those that are a priority today and in the future.

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2006 2007 2008 20092006 2007 2008 2009 ▼

Within minutes of our arrival it was clear that,

if Christiana Hospital is anything to go by,

Thomas Jefferson had it right when he deemed

Delaware a jewel among states. Everything– from

the opening remarks by Christiana Care’s CEO

Dr. Robert Laskowski, to our tours of the emergency

department and their simulation lab to the very last

presentation on their medical residency program–

demonstrated how thoroughly they have embedded

their devotion to excellence into practically

everything they do. Institute for Healthcare Improvement (IHI) Representatives,

summing up a Christiana Care Site Visit in 2007

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Quality and Patient Safety Annual Report 2008

Documents

Transcript of Quality and Patient Safety Annual Report 2008