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Patient Safety & Quality Annual Report

2017 By The Numbers

2017 By the Numbers

From the CMO

Welcome to the Barnes-Jewish Hospital 2017 Patient Safety & Quality Report. This year, we continued our close collaboration with our physician partners at Washington University. Perhaps more than ever before, we have integrated processes with our physicians that have had a cascading effect throughout our clinical care teams.

In 2017, our focus was on standards and communication to support our E3 model of Every Patient, Every Person, Every Moment. These included:

An update of the nursing bedside shift report and more purposeful hourly rounding
Patient handoff from physician to physician
A framework for physician-to-physician communication particularly with consults and referring physicians

Another area of concentration was on enhancing recovery after surgery. Our orthopedics and colorectal services significantly improved quality of care with their enhanced recovery programs a couple of years ago. This year, components of enhanced surgical recovery were identified to be deployed in all 48 of the hospital’s elective surgeries.

Patient journey guides that explain the enhanced recovery programs also help align our patients’ expectations with the surgical process from beginning to end, which has improved outcomes.

Our goal in all of these efforts is to be a high reliability organization. There are many parts of this equation but the most important is our Barnes-Jewish Hospital team, both clinical and non-clinical. Our ICARE values and culture remain at the center of our ability to fulfill our mission of taking exceptional care of people. Our team’s commitment is unwavering as we forge new paths to ensure the best possible outcome for every patient, every person, every moment.


John Lynch, MD
Chief Medical Office, Chief Operations Officer and Chief of Clinical Operations
Barnes-Jewish Hospital

Priorities, Goals & Scores

2017 Strategic Priorities
Objective 2017 Improvement Priorities
Improve Vizient ranking from 3 stars to 4 stars
Develop culture, implement best practices and engage leaders, team members and our WUSM partners to improve the patient experience with a focus on equity of care
Develop and execute a process for enhancing the patient experience entering through the ED by improving workflows and facilities
Develop and implement a process to stabilize staffing and to facilitate predictive staffing needs
Continue to develop and begin to implement plan for understanding, defining and activating an “operating system”
Create resources to support our mission and pursue our vision
Develop and execute improved labor management processes and tools
Build processes to monitor key non-labor metrics and timely countermeasure processes
Vizient Scorecard
2017 By the Numbers
Barnes-Jewish Hospital 2017 Year-End
Best-In-Class Clinical Quality Scorecard

Barnes-Jewish Hospital achieved an overall Best-In-Class score of 1.04 in 2017. 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 healthcare worker behaviors, make recommendations for improvement, and share information on best practices.

Maximum Target Threshold Minimum Below Minimum
Indicator 2017 Target YTD 12/16 - 1/17 YTD vs. Goal
Safe (Common Measures)
Falls with injury per 1,000 patient days (excludes gero-psych units) 0.60 0.58
Hypoglycemia event rate per 1,000 at risk patient days 1.50 1.04
Standardized infection ratio for lab identified clostridium difficile infection (NHSN) 0.60 0.65
Safe (Hospital-Specific Measures)
PSI Roll-up (Composite) 181 131
PSI-6: Iatrogenic Pneumothorax 10
PSI-9: Postoperative Hemorrhage or Hematoma 11
PSI-11: Postoperative Respiratory Failure 37
PSI-13: Postoperative Sepsis 73
Pressure ulcer incidence per 1,000 patient days 1.81 1.97
Standardized infection ratio for catheter-associated urinary tract infection (CAUTI) ICU (NHSN) 0.82 0.77
Standardized infection ratio for central line-associated bloodstream infection (CLABSI) ICU (NHSN) 0.87 1.14
Standardized infection ratio for hysterectomy surgical site infection (NHSN)* 0.60 0.00
UHC risk adjusted mortality (Vizient) 0.93 0.84
Effective (Hospital-Specific Measures)
Readmission: Ischemic stroke for CMS patients age 65 and older (Vizient) 7.14% 9.36%
VTE-6: Hospital acquired potentially preventable venous thromboembolism (CMS-IP) 1.00% 0.44%
Efficient (Hospital-Specific Measures)
Median time from ED arrival to ED departure in HMED for admitted ED patients 427.0 434.0
UHC length of stay index (Vizient) 0.95 0.94
Patient Centered (Hospital-Specific Measures)
HCAHPS - Overall Patient Experience: Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) (HCAHPS) 77.5% 74.2%
Barnes-Jewish Hospital 2017 National Patient Safety Goals

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 chart below provides a review of Barnes-Jewish Hospital’s NPSG measures comparing 2017 targets to year-to-date metrics.

Maximum Target Threshold Minimum Below Minimum
Indicator 2017 Target YTD 12/16 - 1/17 YTD vs. Goal
Medication Safety
Medications reconciled at discharge 90% 97%
Medications reconciled at admission 90% 98%
Medication labeling 90% 100%
Suicide Risk Assessment Overall
Percentage on suicide precautions - mental health units 95% 100%
Percentage given mental health resources - mental health units only 95% 100%
Percentage on suicide precautions - emergency department 95% 100%
Percentage given mental health resources - emergency department 95% 100%
Improve the Effectiveness of Communication Among Caregivers
Use two patient identifiers when taking specimens, administering medications, treatments or blood and blood products 95% 100%
“Read back” performed for received telephone/verbal orders or critical test results - nursing 95% 100%
“Read back” obtained for reported critical test results and values - lab 95% 100%
Critical results/values reported by lab within 30 minutes of availability of results 95% 100%
Critical results/values reported to licensed person who can act, within 60 minutes of notification of results 95% 97%
Universal Protocol: Eliminate Wrong-Site, Wrong-Patient and Wrong-Procedure Surgery
Preoperative verification process completed:
Operating room: checklist completed
95% 100%
Procedure areas: checklist and/or area-specific elements documented
95% 95%
Surgical or procedure-site marking completed prior to procedure:
Operating room
95% 100%
Procedure areas
95% 98%
Time out (final verification process) conducted prior to the start of procedures:
Operating room
95% 100%
Procedure areas
95% 99%
Bedside procedures (No Sept.-Nov. data available) 95% 98%

Barnes-Jewish Hospital works to ensure processes remain in place that address the following National Patient Safety Goals established annually by The Joint Commission.

Improve the Accuracy of Patient Identification

Use two patient identifiers when providing care, treatment and services
Eliminate transfusion errors related to patient identification

Improve Effectiveness of Communication Among Caregivers

Report important test results to the right staff and in a timely manner

Improve Safety of Using Medications

Label medications and solutions when removed from original containers
Follow established procedures to reduce likelihood of harm to patients on blood thinners
Compare patient home medications to those ordered in the hospital to identify discrepancies; provide the patient with a new medication list at discharge

Reduce Health Care-Associated Infections

Follow hand-hygiene guidelines
Use proven guidelines to prevent health care-associated infections related to the use of certain devices and surgical procedures

Improve Safety of Clinical Alarms

Establish alarm safety as a priority and identify the most important alarm signals to manage
Ensure alarm management procedures address key aspects such as alarm settings, changing or turning off alarms, response to alarms and checking equipment for proper operation of alarms
Educate staff and providers about the purpose and proper operation of alarm systems for which they are responsible

Identify Patients at risk for Suicide

Assess patients being treated for emotional or behavioral disorders for risk of suicide
Address the patient's immediate safety needs, including an appropriate setting for treatment
Provide suicide prevention information at discharge

Universal Protocol

Prevent wrong-site, wrong-procedure and wrong-person surgery
Use a pre-procedure checklist to verify correct items are available and match to the correct patient
Mark the procedure site
Preform a "time-out" just prior to the start of the procedure to verify a patients name, procedure and site

Preventable harm

Connecting the dots for all patient handoffs

In July 2017, the Handoff and Communication Summit had its initial meeting, prompted by the results of the Culture of Safety Survey that showed room for improvement, particularly with physician communication. Sam Bhayani, MD, professor of surgery and Faculty Practice Plan chief medical officer, Thomas Ciesielski, MD, assistant professor of medicine and GME medical director, and Chellie Butel, JD, BSN, RN, director, Washington University Patient Safety, Quality & Performance Improvement, are leading the effort with the help of many multidisciplinary team members.

The fact-finding meeting targeted issues and identified specific areas for improvement:

Patient handoffs from physician to physician within a service
Physician communication when obtaining a consult
Physician communication with referring providers

Three subcommittees were formed and challenged with preparing a plan and a proposal within six months. At the January 2018 meeting, the subcommittees reported their progress.

Handoff Subcommittee

Although a written handoff is being used, there is variation in the way it is used. With the implementation of Epic, our new electronic medical record, this process will be more streamlined but the committee believes it’s important to standardize inpatient change-of-shift handoff. The model selected is IPASS (I– Illness severity; P – Patient summary; A – Action list for the next team; S - Situation awareness and contingency plans; S – Synthesis and “read-back” of the information, which has the best evidence for safety and efficacy.

Consult Subcommittee

The group finding here was significant variability in the process of obtaining a consult. This creates a frustrating situation for all parties involved. The group aligned their work with the Faculty Practice Plan’s update to the consultation standards approved in November 2017, which require the following:

Consultations are provided within a reasonable time frame as determined by the patient’s condition. Requestor of the consultation may clarify on discussion with the consultant during initial request.
An abbreviated note is entered in the chart at the time of the consultation. Full consultation notes are in the chart within 24 hours, with attending physician identified.

Referring Physician Subcommittee

The lack of a standard process to identify a patient’s primary care physician also exists and, if a physician is identified, the information provided is not comprehensive. Epic will again streamline the process allowing:

Primary care physicians to receive patient notification reports with specific updates on patients
All notes and results routed based on a single communication preference for each provider

Says Ciesielski, “These groups will continue to be active to impact the safety culture and communication at the medical center.”

Physician to physician handoff

Patient Experience

Taking bedside shift report and rounding to the next level

Bedside shift report for Barnes-Jewish nurses has been part of their daily work for more than a decade. In Barnes-Jewish Hospital’s culture, this typically means it’s time for a refresh.

One of the components of the 11300 neurosurgical innovation unit, established at the hospital in 2016, was to trial new processes and procedures and then, if successful, implement house-wide. In 2017, the standards of the updated bedside shift report and hourly rounding done on 11300 were implemented on every patient care unit in the hospital.

More than 900 nurses participated in a 90-minute simulation lab to be trained on the new processes. According to Joan Becker, patient experience partner who led the simulations, “It’s all about building relationships with patients and being purposeful and proactive in meeting patients’ needs.”

To validate that bedside shift report and hourly rounding are meeting the standards put in place, hospital leaders round to ask patients specific questions. These questions are the same ones patients are asked in their follow-up call after discharge:

Did bedside shift report occur at the bedside?
Were you as the patient included in the report?
Was there purposeful hourly rounding?
Were your needs met?
Did leaders round?

The new standards and additional training have yielded a five percent improvement from 2016 to 2017 in the hospital’s HCAHPs (Hospital Consumer Assessment of Healthcare Providers and Systems) score measuring responsiveness.

Enhancing surgical recovery housewide

In 2015, the Barnes-Jewish orthopedic and colorectal services implemented an enhanced surgical recovery process that reduced surgical site infections and decreased length of stay for their patients. The results improved quality of care so much, in 2017, components of enhanced surgical recovery have been identified to be deployed in all 48 of the hospital’s elective surgeries.

To expand this effort, the hospital dedicated additional resources including Liz Pratt, DNP, ACNS-BC, RN, director of enhanced surgical recovery, to lead the program. Says Pratt, “One of the first ‘Aha’ moments was the redundancy and inconsistency that existed across services. We now have protocols and pathways so every surgeon may use the same approach. These pathways also make it much easier for nurses to follow, which streamlines outcomes.”

The protocols and pathways developed support one or all of these points. For example, best practice shows that in the first 45 minutes of every surgery, room temperature should be 69-70 degrees. After that, the temperature can decrease slightly. “This may seem like a small and very specific requirement but it’s these details that produce the best possible outcomes for patients. The cumulative effect of all of these details has a significant impact on how and how quickly patients recover from their surgery,” says Pratt.

Another part of the enhanced recovery process are journey guides that are being created for each type of surgery. These journey guides outline details before, during and after surgery for patients so they know what to expect and what they need to do to achieve their best possible outcome.

The success of the enhanced recovery program has been a combination of grass roots efforts and executive leadership. Each surgical service views the program as another step to being a high reliability organization, which has been a motivating factor in embracing the standards.

The implementation of Epic on the Washington University Medical Campus in June 2018 will enhance the patient experience with a single integrated database on a common platform. Providers will have the ability to view the most current patient information in all phases of surgical care, from the clinic to the Center for Preoperative & Assessment Planning, through the perioperative experience and discharge.

Pharmacist With Patient

Awards & Achievements

Great catch Awards

Overall Best Catch Award – Claire Jensen, RN

Claire Jensen, RN

Claire’s patient had a traumatic injury to the arm at work, causing both a bone forearm and humerus fracture. The patient was at an increased risk for swelling and pain and his arm was placed in a sling. Claire did a fantastic job monitoring the patient with diligence and detail. She noticed the patient was complaining of a gradual increase in pain. She also noted the swelling was advancing despite elevation and that his neuro exam was possibly worsening. Claire immediately escalated the situation. The patient was found to have acute carpal tunnel and returned to surgery that day. Due to Claire’s meticulous assessment skills, the patient was able to keep his arm and dominant hand.

Courageous Catch Award – Beth Edler, RN

During a surgical procedure, a sterile cotton ball (non radiopaque) was used in a surgical wound per surgeon preference. Toward the end of the case, another surgeon relieved the attending surgeon. As the new surgeon began to close the wound, Beth stated she had not received the cotton ball back. The surgeon believed it had already been removed, but Beth was concerned and requested the attending be contacted prior to waking the patient to verify the exact location of the cotton ball. After speaking to the attending, the decision was made to re-open the incision and the retained cottonoid was located and removed.

Beth Edler, RN

Critical Catch Award – Jessica Antisdel, RN

Claire Jensen, RN

Jessica was caring for a critically ill patient, recently post-op mitral valve/aortic valve replacement with multi-system compromise. She was able to discern the patient’s EKG changes from his post-op baseline EKG and realize the presence of new ischemia. She alerted the medical team and started the process of the patient going to the cath lab for placement of two stents. It was reported that the cardiologist performing the cath stated that if the patient’s right ventricle hadn’t been working as good as it was, the patient would be dead. Jessica’s ability to detect the EKG changes in a myriad of complex vital signs removed a potentially lethal roadblock to the patient’s recovery.

Team Award for Quality Improvement

Neurosurgery and ENT Pod 5 Team

Starting surgeries on time and turning around operating rooms quickly is important for high-volume operating room suites, like those at Barnes-Jewish Hospital. Concentrating on these objectives also improves patient and staff satisfaction. To improve performance, the team cross-trained staff to support both ENT and neurosurgeries, purchased equipment that was previously borrowed from other areas and standardized work processes. As a result, on-time starts for first cases have increased from about 35 percent, to 88 percent, room turnaround times were cut in half, and communication and staff morale has improved.

Neurosurgery and ENT Pod 5 Team

Star Billing Team

Accounting for every supply item used during a surgery is important for proper inventory control, data analysis, as well as accurate billing. With about 4,500 items per day utilized and documented in the ORs every day, this becomes a sizeable challenge. Any item that does not carry a BJC item ID number requires manual entry and increases the chance for error. In a little over a year of implementing new work processes, the team exceeded its initial goal and reduced the number of manual entries from more than 1,000 items per month, to less than 200 items per month.

Interventional Neuroradiology Team

Interventional radiology currently treats more than 100 patients per year for ischemic stroke, which is caused by loss of blood flow to the brain. Looking for ways to speed time to treatment, this team identified an outdated, time-consuming pre-procedure set-up process involving 17 individually packaged sterile items. The team replaced these items with a single, custom-made supply kit, which improved treatment times in these critical, time-sensitive cases, with the long-term goal of improving patient outcomes

Division 6900 “Red” Zone Team

Improvement of Triple Lumen Catheter Clamp Team

The pheresis department was experiencing an unusually high number of broken central venous catheter clamps when providing apheresis therapy to patients. This team took action by partnering with the manufacturer over a 5-year period to design a new clamp. Since the new clamps have entered the supply stream, no broken clamps have been reported.

Doctors’ Access Line

Patient Experience for South General Diagnostic Radiology Team

The South General Diagnostic Patient Experience Focus Group improved several processes that enhanced the patient experience. In less than a year, they increased their PRC percentile of excellence by 106 percent and increased their current percent of excellent by 24 percent. The team set a goal of eliminating all outpatient wait times, and as a result, no outpatients needed to use the waiting room. The team also streamlined the handoff between registration and diagnostic radiology and kept awareness high by distributing a newsletter that identified team goals, current scores and improvement initiatives.

Joint Replacement Patients Discharging to Home Team

Goldfarb Compliance Project Team

Goldfarb School of Nursing at Barnes-Jewish College identified that required documentation of mandatory student, faculty and staff compliance training was not centralized, so therefore was hard to verify. The same was true of licensure and certification tracking requirements for nursing students and faculty. By working with the hospital’s performance improvement department, the team identified key stakeholders and developed standardized processes that were previously being completed by seven different departments using six different systems. As a result of the team’s work, the college can now track and validate students, faculty and staff completion of training required by the Department of Education and other agencies.

Beth Edler, RN

ICU Mobility Team

For ICU patients, early mobility is beneficial and is endorsed by multiple national critical care organizations. However, early mobility was not being emphasized in all of the Barnes-Jewish ICUs. So this team implemented mobility protocols in the six hospital ICUs over a period of eight months. Data collection demonstrated decreased ICU and hospital length-of-stay, a decrease in pressure injuries and a decrease in delirium-positive days. Early mobility protocols also have been shown to be safe with a low rate of complications.

Low Acuity Throughput Team

Familiar Faces Team

Familiar Faces is a new program at Barnes-Jewish focused on reducing avoidable emergency room visits by high utilizers. By working with patients to establish goals and connect them with community resources, Familiar Faces has significantly reduced ED visits for many patients and improved their quality of life. The care team now serves as “catalysts” to enable housing placement, substance abuse treatment, and many other interventions to coordinate care while patients are in the hospital and after discharge. After experiencing remarkable results in the first year of the program, the team is hopeful this program will continue to positively impact the lives of our patients while preparing the hospital for potential changes in reimbursement for low-acuity and non-emergent ED visits.

OR to ICU Handover Process Improvement Team

Inpatient Obstructive Sleep Apnea Screening Implementation Team

For some time, our hospital has screened patients scheduled for surgery for obstructive sleep apnea. This team recognized the need to expand this screening to all inpatients. By collaborating across teams, they developed a way for the screening to integrate with our electronic medical records system so that it’s clear to everyone on the care team that the screening was performed, and the patient’s result. They also evaluated the screening and reporting process to assure that patients were not “over-identified” with OSA, which would diminish the value of the screening tool. As a result, our patients are now in a safer, more aware environment and sometimes they learn that they indeed have an undiagnosed case of obstructive sleep apnea.

Transplant Medicare Cost Report Team

Endovascular Acute Stroke Committee

For stroke patients, time is brain. For patients whose stroke is caused by a blocked brain artery, their long-term outcome is dependent on the timeliness of procedures like a mechanical thrombectomy. The multidisciplinary endovascular acute stroke committee and the interventional neuroradiology team worked together to re-engineer complex clinical workflows that could delay administration of a thrombectomy. Through their efforts, the time between patient arrival and procedure start has fallen from an average 147 minutes to 39 minutes. This best-in-class performance far exceeds the 120-minute benchmark recommended by the American Heart Association.

Workload Assignment


Patient Care Quality & Safety Committee of the Board of Directors

Chair: Kathryn Bader


Warner Baxter
Sam Bhayani, MD
Robert Cannon
James Crane, MD
Ralph Dacey, MD
Clay Dunagan, MD
Susan Goldberg

Harvey A. Harris
Gary Henley, DDS
Michael Lefton
John Lynch, MD
Brian Nussenbaum, MD
George Paz

Craig Schnuck
Kenneth Suelthaus
Sally Terrace
Herbert Virgin IV, MD, PhD
Coreen Vlodarchyk

BJH Staff Members (non-voting)

Roslyn Corcoran

Katherine Henderson, MD

Scott Groesch, MD

Committee Staff Support

Sherry Hume

Chris Ianni

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