Children's Hospital Colorado, Aurora, Wins Quest for Quality Prize

Winner: Children’s Hospital Colorado | Aurora

Target Zero: data and a personal touch to improve young patients’ safety

Parent involvement at Children’s Hospital Colorado goes far beyond partnering with physicians in their child’s care.

Administrators and providers recruit parents to add their voices to more than 50 committees. Their ideas for innovation in project and strategic planning, process improvements and facilities upgrades come up front instead of through satisfaction surveys on the back end.

Parents are invited on rounds, they are included in shift handoffs, and families are allowed to visit patients 24 hours a day, every day. Parents’ “appropriate and passionate input has truly been one of the more magical parts of our quality and safety work and really has helped us drive our agenda,” says CEO Jena Hausmann.

That agenda has included a “full-court press” in the past two years with its Target Zero campaign for eliminating harm. Visual reminders are posted throughout the hospital and all staff members are trained to know the goals of the campaign and their parts in achieving them, says Daniel Hyman, M.D., MMM, chief quality and patient safety officer.

One engagement tool is “100 days of Zero” when divisions compete to see who can go the most days without harm in a three-month period. “It’s the focus of pretty much everything we do,” Hyman says.

The hospital’s board became fully engaged in accelerating patient safety improvement after a focused presentation at a board retreat that included pictures and stories of children harmed in the hospital.

The hospital was surprised to recognize that one of the most common causes of patient identification errors was providers ordering tests and treatments in the wrong electronic record. Since then, patient pictures have been embedded in every electronic health record to reduce the risk of these errors. When a provider places a medication or treatment order, a photo pops up in the middle of the screen and a prompt asks whether the order matches the child.

Picture prompts, a low-cost intervention, made the difference in “almost immediately” dropping the rate of patient identification errors due to ordering by 90 percent, says Hyman. Those safety measures, in addition to bar coding for medication administration among other unit-based initiatives, helped to result in having no serious adverse drug events in the pediatric intensive care unit in 2014.

Reduction in harm is one of three anchors in the hospitalwide “Take it To Heart” incentive program and represents one-third of each employee’s potential bonus. The other two-thirds is based on how the organization performs financially and in patient/family satisfaction. The incentives for meeting quality goals extend to every hospital employee.

“We are here for the best patient experience — we all pull toward that even if we don’t directly touch patients,” Hausmann says.

Through a partnership with the Ryan Seacrest Foundation, the hospital built a state-of-the-art recording studio and hired a programming manager “like our disc jockey” and child life specialist to engage children in performances. Visiting celebrities have a place to perform sing-alongs and children participate in everything from radio shows to yoga classes. Those who can’t leave their rooms can enjoy the entertainment on a closed-circuit screen.

Staff satisfaction is also important as evidenced by a nine-month/three-month program that allows nurses, many of whom have young children at home, to take extra time off in the summer when the school year surge in health care demand calms. “We let nurses work how they want to work,” Hausmann says.

The hospital provides support for all staff as they work through compassion fatigue or the aftermath of mistakes and poor outcomes. Small groups of residents meet every other month to verbalize emotions and sift through stress.

Tracking satisfaction is part of an advanced data collection system that also allows the hospital to analyze trends and spot problems quickly. Last year, unit-specific data on pressure ulcers, for example, alerted staff to a spike in the ulcers in certain units. Those units recently had switched equipment manufacturers and the hospital was able to link the spike to the use of the new equipment, prompting a change in staff practice and a reduction in these largely preventable injuries.

Hausmann says data-driven precision in comparing equipment, procedures and care teams helps to push the organization forward.

“When you understand your specific performance in the context of the larger crowd, you really are able to change behavior in a way that can be very powerful.”

FINALIST: Duke University Hospital | Durham, N.C.

Taking quality improvement efforts beyond its walls

Excellence at Duke takes the combined energy and creativity of a committed staff, and a focus on engagement with patients, their families and the community, says President Kevin Sowers.

Duke University Hospital, which received an AHA–McKesson Quest for Quality Citation of Merit in 2009, engages patients and their families not only in all aspects of their care, but also in the operation of the organization.

When there was a vice president slot open for the women’s and children’s division, members of the patient advisory group were asked to be among those who interviewed final candidates.

Patients and families also were asked to help design the patient experience for the hospital’s recently opened cancer center. Families told administrators they didn’t want to see lines, for instance. “They wanted to feel as though they were coming home,” Sowers says. So now the front lobby is a living area with a fireplace. They wanted labs and scans and appointments to be in one location. “They don’t leave the clinic; providers come to them,” he says.

Elderly patients at Duke have benefited from preoperative screening and discussions with a geriatrician about the possibility of delirium in the intensive care unit after surgery. Together they discuss the most appropriate interventions. The consultations have helped to cut length of stay in the ICU, Sowers says.

“Our view of quality extends well beyond the walls of the hospital — what happens outside the hospital is just as important as what happens inside the hospital when it comes to ensuring positive health outcomes,” says Michelle J. Lyn, assistant professor and chief of Duke’s division of community health. “It is imperative that we collaborate with community members and organizations to ensure a seamless care continuum.”

Duke University Hospital has multiple shared-employment agreements with the Durham County Departments of Health, Social Services, Mental Health Management Organization and Durham’s federally qualified community health center, Lincoln Community Health Center. The shared-employment contracts enhance the capacity for each institution to share information within their electronic records, develop and implement individualized care plans for socially and medically complex patients, and increase access to primary care for its vulnerable population. As an example, Duke shares the employment costs of training and placing Durham County Health Department enhanced-role nurses in public elementary schools to conduct well-child visits, tooth varnishing and immunizations. In another example, Duke University Hospital embeds two licensed clinical social workers from the Mental Health Management Organization inside its emergency department to identify and appropriately transition patients with mental health issues to their community-based providers.

The agreements benefit patients and providers. Fred Johnson, vice chief for the division of community health, gives an example of a substance-abuse patient from Lincoln who broke both ankles jumping from a wall. With shared records, providers were able to “come up with a care plan in seven minutes” to treat physical and mental issues. “Two years ago we’d be faxing, copying charts, trying to get people on the phone. This could have taken weeks,” Johnson says.

CITATION OF MERIT: Nationwide Children’s Hospital | Columbus, Ohio

Reducing harm is great: eliminating it is the ultimate goal

When Nationwide Children’s Hospital executives look at the numbers, the one they most want to see is zero.

That’s the target number the hospital has set for preventable harm. “It wasn’t about reducing. It wasn’t about decreasing. It was about eliminating,” says Richard Brilli, M.D., chief medical officer.

They’re not there yet, he says. “I don’t think any hospital is.” But Nationwide has been striving to meet that goal since 2009 with the Zero Hero program. So far it has achieved an 88 percent decrease from peak in serious safety event rates; a 50 percent cut in all harm events; a 25 percent reduction in severity-adjusted hospital mortality; and a 22 percent reduction in harm-related costs.

Increasing transparency was part of the project. “We were the first hospital in the country to put our serious safety event rates not only on the intranet, but also on the Internet,” Brilli says.

Nationwide has also seen success in bridging cultural divides.

CEO Steve Allen, M.D., gives the example of reaching out to the large Somali population, which came to the Columbus area in the ’90s with different cultural norms and language. Another example is a large concentration of Amish just to the northeast who may have different viewpoints from their caregivers on health care.

At Nationwide Children’s Hospital, not just physicians, but housekeepers, dietary staff and even business office personnel are trained in cultural competencies to serve patients “so that every one of them feels that they’re being treated with dignity and respect,” Allen says.

A program called Healthy Neighborhoods, Healthy Families extends that outreach to impoverished surrounding neighborhoods. Hospital staff work with religious organizations, schools and community agencies to work on issues surrounding jobs, housing and violence to improve the futures of children before they ever get to the hospital.

Healthy Neighborhoods, Healthy Families is being tested in three ZIP code areas with the hope that many aspects of it ultimately will be rolled out across Columbus.

CITATION OF MERIT: Schneck Medical Center | Seymour, Ind.

Teaming up with nursing homes and even a competitor

Identifying gaps in care from discharge to long-term facilities helped Schneck Medical Center reduce admissions by 40 percent in three years, says Chief Quality Officer Tammy Dye.

When administrators investigated why most readmissions were coming from nursing homes, they found that the nursing homes “were challenged to get access to medical providers, to be able to do assessments and early intervention, and to deliver the care that would allow them to stay in the long-term care facility,” Dye says.

Schneck responded by hiring a medical director and a nurse practitioner to assist in the continuum of care and provided long-term providers with education that included clinical and customer service training in Schneck’s simulation lab.

The largest faction of readmissions was for chronic obstructive pulmonary disease. Hospital volunteers donated pulse oximeters to the nursing homes and respiratory therapists were sent to work with the patients.

In addition to readmissions, Schneck has targeted emergency department door-to-provider times. By splitting the flow between high and low acuity, the hospital cut waits by more than half from 52 to 23 minutes since 2012 while seeing a volume increase of more than 15 percent, Dye says. Often, midlevel providers treat the lower-acuity patients in a separate area.

The changes made a dramatic difference. “Customer service went from the 25th percentile to the 80th percentile,” Dye says.

Optimizing resources also led Schneck to take an unusual step: teaming up with its major competitor, Columbus Regional Health, to share some of the costs for population health. Schneck President and CEO Warren Forgey says the independent hospitals combined resources to more efficiently and effectively serve their patient populations. Now, when one team has a successful strategy in treating diabetes or hypertension, for example, experts at both hospitals can learn from each other.

The two hospitals also share a third-party administrator, Forgey says, which enhances continuity. “We wanted to be able to pair that insurance product with our new health care delivery system, which focuses on achieving the Triple Aim,” he says.