Patient Safety & Quality Annual Report

This document presents the measures evaluated in the 2016 Vizient Quality and Accountability ranking. This scorecard provides a comparison of your organization’s performance with that of other academic medical centers. The data were obtained from existing Vizient data resources, including the Clinical Data Base (Q3 2015 – Q2 2016), Core Measures Data Base (Q2 2015 – Q4 2015), as well as HCAHPS data from the Hospital Compare Web site (Q2 2015 – Q1 2016) and National Healthcare Safety Network data (Q2 2015 – Q1 2016).

The goal of the Quality and Accountability ranking is to assess organizational performance across a broad spectrum of high-priority dimensions of patient care. The 2016 scoring and ranking cover the domains of mortality, effectiveness, safety, equity, patient centeredness and efficiency using measures developed by national organizations or the federal government. Refer to the methodology white paper (available at vizientinc.com) for specifics regarding the metrics, scoring methods, and data sources used.

Barnes-Jewish Hospital achieved an overall Best-In-Class score of 1.15 in 2016. The Clinical Quality Performance Scorecard outlines performance in patient care or treatment delivery. Performance improvement teams are assigned to each quality indicator to evaluate processes, systems, clinical practice and health care worker behaviors, make recommendations for improvement, and share information on best practices.

Barnes-Jewish Hospital 2016 Best-In-Class Clinical Quality Scorecard

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 20,000 health care organizations and programs in the United States. The Joint Commission is committed to improving health care safety. This commitment is inherent in its mission to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. At its heart, accreditation is a risk-reduction activity; compliance with standards is intended to reduce the risk of adverse outcomes.

Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. Its National Patient Safety Goals (NPSGs) program was established to help accredited organizations address specific areas of concern in regard to patient safety. The adjacent chart provides a review of Barnes-Jewish Hospital’s NPSG measures comparing 2016 targets to year-to-date metrics.

Improve the Accuracy of Patient Identification

Improve Effectiveness of Communication Among Caregivers

Improve Safety of Using Medications

Reduce Health Care-Associated Infections

Improve Safety of Clinical Alarms

Identify Safety Risks Among Patients

Universal Protocol

In 2016, Barnes-Jewish Hospital’s infection prevention team continued to focus on improving high-level disinfection (HLD) practices across the hospital. Perioperative services and infection prevention worked to develop and improve the reprocessing of scopes in 2015. Following this standard work, the infection prevention team led an initiative to standardize practice across the hospital. One new piece of equipment that helps achieve this standardization is the trophon® EPR. This machine achieves high-level disinfection of the probe – including the shaft and handle – in just seven minutes, maximizing productivity.

Multiple tasks to support the progress included:
• Moving the majority of HLD to pre-cleaning and then to the central sterile processing department.
• Recognizing the need to have central sterile processing purchase additional equipment  and having hospital leadership approve it.
• Implementing monthly infection prevention rounding of areas to ensure best practices  for HLD.
• The use of trophon to achieve HDL of certain probes.

In 2017, the hospital will implement a train-the-trainer program, an online training module and some in-person training to expand the understanding of HLD. This will be the next layer of standardization for the hospital.

Eric C. Leuthardt, MD, a Washington University neurosurgeon and director of the Brain Laser Center at Barnes-Jewish Hospital, has been pioneering new innovative approaches to minimally invasive neurological surgery cases for the treatment of brain tumors, seizures and other intracranial procedures. Through the use of the Monteris Laser, patients who undergo this procedure at Barnes- Jewish Hospital are able to have their tumor or seizure foci ablated through a tiny burr hole and return home often within 24-48 hours with only two to three stitches. As the nation's leader in laser ablation cases, Barnes-Jewish offers a tremendous advantage for these patients over the more traditional open craniotomy approach. To date, Dr. Leuthardt has completed 160 of these procedures.

In December 2016, the hospital enhanced its safety and quality in minimally invasive procedures by purchasing the new ROSA® robot. ROSA acts as a kind of “GPS” for the skull, and may be used for all types of cranial interventions requiring surgical planning based on pre-operative data, precise location of the patient’s anatomy and accurate positioning and handling of instruments. Due to increased technical demand for these procedures, the ROSA offers enhanced sterotactic precision, increased operative room efficiency, and enables more complex lesion geometries and multiple target trajectories. By providing enhanced stability, the ROSA removes the risk of frame shift during placement of the trajectory bolts, increases trajectory accuracy to near 100 percent, and offers increased trajectory options making the procedure available to more patients due to complex neuro-anatomy features.

ROSA was made possible through a grant from The Foundation for Barnes-Jewish Hospital.

Overwhelming evidence from peer reviewed medical journals has shown that speeding the time a clot is removed from a stroke patient's brain results in fewer cell deaths and decreases likelihood of severe disability. In addition to two decades of tPA research, several studies released in 2015 show the efficacy of mechanical thrombectomy for some ischemic stroke patients within a six-hour window. As a Comprehensive Stroke Center, Barnes-Jewish Hospital has a duty to improve performance in all aspects of care, and has been extremely successful in the area of tPA administration. The next phase of improving acute stroke treatment is to speed the time from the start of a stroke to the angiography suites where thrombectomies are performed.

The stroke program held a two-day endovascular value stream analysis (VSA) in November 2016. Out of the VSA, 10 projects were launched, all designed to improve the communication between providers and the timeliness of brain-saving stroke treatment. A multidisciplinary group of stroke care providers, including nurses, physicians, and radiology technologists, along with team members from patient access, patient placement, and administration, came together to discuss ways to remove barriers to best-in-class care.

One of the projects, “Preregistration of Outside Hospital Transfers” is now achievable because of BJC HealthCare’s single-source registration system. Another project, “Instant Remote Access” for CT angiography allows physicians to quickly review CTs from any location enabling them to evaluate patients in real time.

All 10 projects are scheduled for implementation by second quarter 2017.

The Washington University and Barnes-Jewish Transplant Center is the only comprehensive transplant center in the region offering heart, heart/lung, lung, double lung, kidney, liver and bone marrow transplants. In addition to achieving outcomes that meet or exceed national averages, the transplant program is known for quality and continuity of care.

Part of what contributes to the center’s quality are its efforts to continuously improve patient outcomes. To be able to help as many patients as possible, the transplant center implemented software that allows us to consider severity of illness and donor organ quality to better predict survival. The Real Time Analytics and Process Implementation Dashboard (RAPID) can provide reports every month and updates the expected survival table every six months allowing us to predict outcomes for each of our transplant programs.

RAPID also allows us to track our outcomes in a near real-time scenario to better address decisions with organ donor acceptance and candidate selection.

This is significant because it provides us with a glimpse of our success before we receive official monitoring reports from the Centers for Medicare and Medicaid Services and the U.S. Department of Health & Human Services Organ Procurement and Transplantation Network, which is published every 18 months.

Despite advances in medicine and technology, and increased awareness of organ donation and transplantation, the gap between supply and demand continues to widen. RAPID makes it possible for us to gauge our success, allowing us to potentially provide more patients with transplants.

The Great Catch Awards recognize Barnes-Jewish Hospital team members who intervene to prevent harm, or potential harm, to patients. Annual awards are given in three categories: courageous catch, critical catch and overall best catch. The annual Great Catch Award recipients are chosen from the year’s monthly winners.

The Courageous Catch exemplifies an employee choosing to protect a patient from harm even though it requires them to step out of their normal role or comfort zone and may cause risk to their person, their job or relationships.

The winner of the Courageous Catch Award is Brittany Brandt, BSN, RN. Brittany was working on discharging a patient when she noticed the patient’s heart rate was elevated. Brittany checked the peripheral pulse and found it to be irregular. After recommending and completing an EKG, the patient was found to be in a dangerous, irregular heart rhythm (Afib with RVR). The patient was then transferred to a high-risk cardiology unit and later on to the ICU.

The Critical Catch is awarded to the employee that prevented serious harm from occurring to a patient.

Overall Best Catch is a combination of a courageous and critical catch that honors the employee who courageously protects a patient from harm and catches a critical patient safety error from occurring.

Sarah Feeherty, BSN, RN, received the award for Overall Best Catch. Sarah was caring for a patient admitted from an outside hospital with concerns of acute myeloid leukemia. The patient was to receive a bone marrow biopsy and begin chemotherapy. However, the patient began complaining of abdominal pain, distention and increased shortness of breath. She also was experiencing pain in her left leg along with numbness and coolness in her left foot. Sarah was unable to doppler the patient’s left pedal pulse. The physician was notified immediately and the patient was taken to the OR within hours for life saving procedures unrelated to the leukemia.

Colorectal Enhanced After Recovery Surgery Team

Barnes-Jewish Hospital was identified as a high outlier of colorectal surgical site infections with a rate greater than 20 percent. This was the impetus to create an Enhanced Recovery After Surgery (ERAS) protocol. ERAS is a framework for how colorectal surgical patients are managed across the perioperative period, with the goal of improving patient outcomes. A multidisciplinary ERAS workgroup was created and practices were changed. The ERAS protocol has resulted in a dramatic reduction in surgical site infection rates – less than 10 percent – and a significant reduction in length of stay. ERAS principles from this project are now being shared with other surgical services to continue to improve patient outcomes.

Data Management and Performance Measurements Team

The Data Management and Performance Measurements team (DMPM) developed and enhanced technology solutions to facilitate data aggregation, analysis and performance improvement opportunities for throughput initiatives at Barnes-Jewish Hospital. Goals were to maximize availability of information assets, prioritize areas for business improvement and develop a feedback mechanism for process improvement.

The throughput team was charged with identifying goals to enhance throughput and capacity, plus standardize definitions of key metrics related to throughput. The team also determined the frequency and methods of data distribution.

One of the deliverables – the Flash report – is a highly accurate and timely report that pulls data from nine sources. It is automatically emailed to stakeholders three times a day to facilitate bed placement and inpatient throughput. The report provides a variety of information to assess current state and assist in planning for the future by displaying 80 measures including current census, bed availability, patients waiting and perioperative cases for the day. Since the roll-out of the 7 a.m. Flash report, blocked beds have decreased by an average of 20 per day. The report is updated and emailed again at noon and 7 p.m. The noon report provides a measure for physician discharge orders by 11 a.m.

In addition, in 2015 and early 2016, the team completed 53 projects (137 tasks), and emailed over 141,336 reports. DMPM manages email subscriptions for 33 different reports to over 450 customers. Eighteen of these reports are emailed daily to clinical directors, nurse managers, assistant nurse managers, charge nurses, physicians and other key stakeholders.

Division 6900 “Red” Zone Team

The fall rate on division 6900 had been on the rise for years and the unit was determined to make improvements. Through analysis of fall data, the team determined 40 percent of the patients who fell on division 6900 had five things in common, which became known as the 5 Ds. Any patient identified as having two or more of the 5 Ds is placed into the “Red Zone” and interventions are put into place.

Following extensive staff training, the project was launched. In the first six months, the “Red Zone” helped identify high fall-risk patients early in their care. In the second quarter of 2016, the division went 42 days without a patient fall, and had only 8 falls during the quarter for an average of 2.6 falls per month. During the third quarter, there were 6 falls. It is a continued effort of all 6900 staff to sustain the “Red Zone” process and decrease patient falls.

Since implementation, other units within the oncology departments began looking at their patient population and how they could implement a similar process.

Doctors’ Access Line

Case Management Services developed a new process for screening transfer patients from outside hospitals that better suits incoming patients in terms of care and insurance.

Previously, receiving services, contacted through the Doctor’s Access Line, accepted most transfers without considering insurance network coverage or the medical necessity for transfer. This led to a substantial number of patients being transferred great distances to receive care that, often could have been provided closer to home. The hospital also faced challenges with capacity and throughput, and patients faced potential financial liability from being transferred outside of their insurance network.

A process was developed that focused on patients with non-urgent medical diagnosis to ensure patients met criteria for admission and developed tools to ensure Barnes-Jewish was an in-network medical provider for the patients. For more complex situations, physician advisors reviewed the plan. For those patients who did not meet criteria, additional resources were developed to make recommendations for outpatient alternatives such as clinic appointments and consultations.

The hospital is now meeting its goals for:
• reducing out of network admissions
• reducing the number of patients transferred who do not specifically require resources at   Barnes-Jewish
• directing our resources more effectively to those patients who truly need a tertiary   setting

Cost savings for redirecting out-of-network patients to their proper in-network facility has exceeded two million dollars.

Increasing Joint Replacement Patients Discharging to Home Team

The Barnes-Jewish Hospital and Washington University Hip & Knee Center of Excellence signed up for CMS’ Bundled Payment for Care Improvement (BPCI) programs in order to re-design major joint replacement care. Financially responsible for patient care for 90 days after admission, the team identified and implemented a number of interventions intended to improve clinical outcomes and reduce variation in care. One intervention was to increase the number of patients discharging directly to home, instead of post-acute facilities, reducing the risk of admission. Through consistent messaging throughout the continuum of care and enhanced patient education and engagement, 80 – 90 percent of hip and knee replacements performed at Barnes-Jewish Hospital and Washington University in 2016 went directly home after surgery.

Influenza Inpatient Vaccine Compliance Team

For several years, Barnes-Jewish Hospital’s inpatient influenza vaccine compliance had been less than the goal of 95 percent. This led to the formation of a team focused on achieving 95 percent compliance for the flu season beginning in October 2015.

The team began by mapping the current process and identifying potential breakdowns. Possible solutions were gathered, along with ideas to improve the process. These were prioritized based on the amount of effort needed to complete the task versus the benefit to be gained. The team met every two weeks and established standard work to ensure influenza vaccination is appropriately addressed during a patient’s stay.

Technology was used to create automations in the electronic medical record, minimizing the risk for human error. When appropriate, administering the vaccine earlier in the patient’s stay was encouraged. An internal report was created in COMPASS to pull daily reports on discharged patients to assess performance, enabling us to immediately identify and investigate outliers and use these as learning opportunities. A limited supply of vaccines were stocked on the floors in Pyxis so nurses could quickly obtain and administer the vaccine. As a result, the hospital experienced five consecutive months of exceeding or achieving its goal of 95 percent compliance.

Low Acuity Throughput Team

The Low Acuity Throughput team identified a need for a parallel path of treatment for patients seeking care in the Barnes-Jewish Hospital emergency department for non-life threatening medical conditions. This change has had a positive impact on patient satisfaction, decreased length of stay and increased efficiency in treating these patients. The multidisciplinary team worked to implement and maintain a new process that has impacted patients in a positive manner, providing them with excellent care in a reasonable time frame. This has also had a positive impact on our more acute patients by freeing up resources that would have previously been allocated to these less sick patients.

OR to ICU Handover Process Improvement Team

Safety issues during patient handover from the OR to the ICU were identified in 44ICU and 56ICU, which led to the creation of a multidisciplinary process improvement team from the CTICU, SICU, anesthesia, respiratory and the operating room. To improve safety, standard work was developed for all roles involved in the handoff process:
1)  ICU room set-up
2)  Notification process from OR-ICU
3)  Notification process on arrival to ICU
4)  OR-ICU handoff script

This improved work flow was shared with anesthesia providers, surgeons from all surgical services, and RN, RT, PCT, secretarial and ICU staff in all areas. The new handoff process has been in effect since 2014. Significant improvements have been sustained in the quality of the handoff report with no interruptions, presence of all team members required for handover, necessary equipment present in the room and a more thorough report in a shorter time period.

Transplant Medicare Cost Report Team

The Transplant Medicare Cost Report Team successfully implemented a process to identify and flag transplant organ acquisition-related charges. The process will help ensure every charge is identified and captured as a part of Medicare Cost Reporting. The team also developed a Soarian interface that will help capture approximately 95 percent of transplant-related organ acquisition charges.

Workload Assignment - 100 percent Consistent, 50+ percent faster

In December 2015, Clinivision, the system respiratory care services had relied on since the 1980s to pull inpatient order sets and assign scheduled services was about to become obsolete. IT, Compass and outside vendors were unable to offer a workable successor, and the benchmarking of other respiratory care departments both within BJC and across the country provided no suitable alternatives.

In the absence of a solution, respiratory care services would have to manually find and organize orders, which is an extremely time-consuming and error-prone option.

In just four months, a committed, cross-departmental team developed a new way to execute the process internally resulting in a process more than 50 percent faster and completely eliminating all consistency and reliability issues inherent in the original process.