Hospitals across the country are implementing quality and patient safety initiatives to prevent patient harm and improve the level of care. With the growing emphasis on quality and safety, the role of a hospital's CMO is becoming increasingly important. Janice E. Nevin, MD, MPH, CMO of Wilmington, Del.-based Christiana Care Health System, shares the importance of multidisciplinary teams and a patient-centered approach to performance improvement.
Q: What are your current top priorities in terms of patient safety and quality at Christiana Care Health System?
Dr. Nevin: Patient safety and clinical excellence are our top priorities as a system. We are a "Safety First" organization and have a goal to eliminate all preventable harm. Focusing on those outcomes that are of importance to patients guides us to opportunities to improve. Hospital systems are increasingly being evaluated by government and other agencies. We strive to be transparent with our clinical teams as well as with our community.
Two safety initiatives that we are currently focused on include hospital-acquired infections and venous thromboembolism prophylaxis. These are both areas where we have already had impact by putting together interdisciplinary teams and using technology as a way to leverage performance.
Clinical excellence also requires discipline in looking at outcomes, especially those value-based purchasing outcomes that have the potential to impact reimbursement. Our approach has been to create interdisciplinary value improvement teams, for example in heart failure and pneumonia. We have developed a scoring system and give these teams a letter grade. They are accountable for understanding the data and redesigning the clinical work to improve their grade. This has proved to be very motivating — no one wants to get a C. Every year we increase the threshold for the grade. Nobody gets an A-plus and gets to coast.
Q: What are some patient safety and quality initiatives you are implementing?
JN: One specific initiative is the Comprehensive Unit-Based Safety Program. This is a national initiative developed to eliminate hospital-acquired infections. All of the hospitals in Delaware are participating, giving us the chance to learn from each other as well as our colleagues around the country. We started by focusing on CLABSIs — central line-associated bloodstream infections — and ventilator-associated pneumonia. Each intensive care unit at both hospitals has an interdisciplinary CUSP team. All the disciplines that are responsible for the patient in that unit are on the team — physicians, nurses, respiratory therapists, PAs, clinical pharmacists, etc. The emergency department is also involved, because so many lines are inserted when the patients are in the ED. The anesthesia staff and the operating room staff are also involved since they too insert many of those lines.
Those teams are very outcomes focused on the results for the unit and when there has been a CLABSI they dissect the individual circumstances of the patient in order to look for more ways to improve. The team looks at everything related to the line: Was this line needed in this patient? Did we follow the protocol for insertion and use the checklist? Are we providing appropriate maintenance care? Are we taking lines out as soon as possible? We have had remarkable success using this approach. The cardiovascular surgical intensive care unit hasn't seen a line infection for months and months. In the Wilmington intensive care unit, line infections were reduced over 80 percent in less than a year.
What we learned from this project is that it's highly effective when you get an interdisciplinary team, present them with a problem, hold them accountable for the outcome and give them the tools they need to be successful. For example, one of our findings about central lines was that the supplies needed for the line insertions were in several different places. Now each unit has a cart with everything you need to put in central lines so no one has to go looking for the right supplies. It may seem like a small and simple change, but it's incredibly impactful because people are then spending time on what is most important — caring for the patient.
Because this approach has been so effective, we are now in the process of expanding the concept to all patient care units, not just the intensive care units. We are in the process of creating interdisciplinary teams at the patient care unit level. Each unit will put together an interdisciplinary team and will be provided with data to drive performance improvement at the level of the unit. Teams will be focused on those goals that are priorities for the institution. All of the team members will be trained in the science of performance improvement and lean principles. Embedded support will provide in-the-moment assistance to keep projects on track. Learning collaboratives will allow units working on similar projects to share their experience. I believe that we will learn tremendously from our bedside staff using this approach.
Leveraging technology is essential to improving quality and safety. We are very fortunate to have CPOE — computerized physician order entry — implemented throughout the system. We're increasingly finding ways to use this technology to promote patient safety. For example, because we now have modules around prescribing opioids with safety features to support clinical decision making, we have reduced the use of those medications and therefore reduced adverse events related to narcotic use. Using the CPOE system to help guide physicians to the appropriate choice of VTE prophylaxis is another project currently underway. This will help us reduce the number of VTEs that occur in patients.
Q: How has your past experience as senior vice-president and executive director of Christiana Care–Wilmington and associate CMO affected your approach to patient safety and quality?
JN: One of the things that personally I'm very committed to is creating a care delivery model that is really grounded in the principles of patient- and family-centered care. In my three years as senior VP, the Wilmington campus adopted those principles as a strategy for safety and quality. A care model that partners with the patient and the patient's family, and brings them into the conversation about quality and safety, is perhaps the most important way to achieve the most successful outcomes.
At Wilmington, we have a number of ongoing initiatives. For example, we developed a team called the Synchronized Wilmington Admissions Team, or SWAT. That team has an experienced physician, a resident, a clinical pharmacist, a social worker/case manager and a nurse. When the ED identifies a patient who needs to be admitted, the team goes to the ED and does admission together. The patient has to tell [his or her] story only once, which patients and families love; they're not repeating the same thing to four or five different people.
And once the history is taken, each of the team members has a job to do. The clinical pharmacist does medication reconciliation — calls pharmacies and physicians to find out what medications the patient is actually taking. The social worker has a conversation with family members in terms of what might be necessary for discharge. (Usually, by the time a patient gets to the floor, the family is ready to go home, and the opportunity to have a conversation early may be missed). For the residents, it has been a tremendous educational experience. They work side by side with a seasoned clinician.
Our outcomes from the SWAT initiative have caught the attention of the entire system. We've met core measures 100 percent of the time, reduced length of stay, eliminated the need for [rapid response team] calls in the first 24 hours and demonstrated a reduction in readmission rates. This approach is very patient- and family-centered because you're meeting the patient and their care givers at the point of entry — if we can get it right from the start of the inpatient journey it bodes well for the entire stay.
We have a patient and family advisory council at Wilmington, and some advisors, completely unprompted, say, "I was in the ED and the whole team took care of me and it was great, I loved it — it's a great thing to do." This is the best outcome of all.
At Christiana Hospital we have adapted this model to the critically ill medical patient. The medical intensive care unit has a team that goes to the ED and begins caring for the patient. The team initiates the care plan and brings the patient out of the ED and into the ICU bed. This has reduced the amount of time the patient is in the ED and provides the ED staff with appropriate support to care for our sickest patients.
Q: How has your past experience affected your leadership style as CMO?
JN: Listening and learning from those who are at the bedside taking care of patients is extremely important to me. When I started my position at Wilmington, one of the first things I did was engage employees in a discussion about how to improve care. The nurse managers started the conversation and we gradually expanded the group to become more interdisciplinary. Although I facilitated these discussions, the team provided the direction in terms of embracing patient- and family-centered care principles as the basis of redesigning care and improving safety, quality and patient satisfaction. As a result of that work, we saw improvements in every dimension — including the financial benefit. I learned tremendously about the importance of developing relationships in order to do the right work in the right place and for the right reasons.
Q: What are the greatest challenges you are facing as CMO?
JN: The challenges in healthcare are enormous as always but perhaps even more so given all of the changes occurring as a result of the Affordable Care Act and some of the new programs at CMS. When I talk to other CMOs, the discussion often focuses on developing relationships with our physicians and finding ways to provide them with leadership opportunities. More than ever, hospitals and health systems need to create effective partnerships with physicians to be able to deliver value to our patients and our communities. At Christiana Care, we have a small number of employed physicians and a larger number of private physicians. Their involvement is absolutely critical in adding value so we can achieve our quality and safety goals.
We are facing questions such as how are we going to adapt to what's inevitable in healthcare? Whether or not all elements of reform stand, certainly the principles of accountable care organizations that put patients first and [emphasize] high quality care over the care continuum are heading our way. We face the question, so to speak, of how to turn the ship so we don't sink the ship on our way to finding this new direction.
Outcomes are emphasized more than ever in healthcare. We want to make sure that we are focusing on those outcomes that really matter to the patient and not simply looking at outcomes for outcomes' sake. How do we use the data to create priorities within our organization so we're working where we need to work? And always, are we looking at the right outcomes, the outcomes that add value to the patient?
Q: How are you working to overcome these challenges?
JN: In a couple ways. One is that we are focused on increasing the emphasis on interdisciplinary teams. Our work in quality and safety is being redesigned with a greater focus on annual and five-year goals. Transparency — making sure that everyone is aware of what work needs to be done — is a significant factor in success. We need to look critically to make sure we are structured in a way that the work to achieve these goals is completed and appropriately resourced. There has to be a way for those teams to [report] back up to leadership and say, "Here's an issue, here's how it was resolved, you might want to think about this." This is an area where we need to spend some resources as an organization, creating that structure so the work that needs to be done has an impact, and that learning occurs vertically and horizontally across the system.
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Q: What are your current top priorities in terms of patient safety and quality at Christiana Care Health System? Dr. Nevin: Patient safety and clinical excellence are our top priorities as a system. We are a "Safety First" organization and have a goal to eliminate all preventable harm. Focusing on those outcomes that are of importance to patients guides us to opportunities to improve. Hospital systems are increasingly being evaluated by government and other agencies. We strive to be transparent with our clinical teams as well as with our community.
Two safety initiatives that we are currently focused on include hospital-acquired infections and venous thromboembolism prophylaxis. These are both areas where we have already had impact by putting together interdisciplinary teams and using technology as a way to leverage performance.
Clinical excellence also requires discipline in looking at outcomes, especially those value-based purchasing outcomes that have the potential to impact reimbursement. Our approach has been to create interdisciplinary value improvement teams, for example in heart failure and pneumonia. We have developed a scoring system and give these teams a letter grade. They are accountable for understanding the data and redesigning the clinical work to improve their grade. This has proved to be very motivating — no one wants to get a C. Every year we increase the threshold for the grade. Nobody gets an A-plus and gets to coast.
Q: What are some patient safety and quality initiatives you are implementing?
JN: One specific initiative is the Comprehensive Unit-Based Safety Program. This is a national initiative developed to eliminate hospital-acquired infections. All of the hospitals in Delaware are participating, giving us the chance to learn from each other as well as our colleagues around the country. We started by focusing on CLABSIs — central line-associated bloodstream infections — and ventilator-associated pneumonia. Each intensive care unit at both hospitals has an interdisciplinary CUSP team. All the disciplines that are responsible for the patient in that unit are on the team — physicians, nurses, respiratory therapists, PAs, clinical pharmacists, etc. The emergency department is also involved, because so many lines are inserted when the patients are in the ED. The anesthesia staff and the operating room staff are also involved since they too insert many of those lines.
Those teams are very outcomes focused on the results for the unit and when there has been a CLABSI they dissect the individual circumstances of the patient in order to look for more ways to improve. The team looks at everything related to the line: Was this line needed in this patient? Did we follow the protocol for insertion and use the checklist? Are we providing appropriate maintenance care? Are we taking lines out as soon as possible? We have had remarkable success using this approach. The cardiovascular surgical intensive care unit hasn't seen a line infection for months and months. In the Wilmington intensive care unit, line infections were reduced over 80 percent in less than a year.
What we learned from this project is that it's highly effective when you get an interdisciplinary team, present them with a problem, hold them accountable for the outcome and give them the tools they need to be successful. For example, one of our findings about central lines was that the supplies needed for the line insertions were in several different places. Now each unit has a cart with everything you need to put in central lines so no one has to go looking for the right supplies. It may seem like a small and simple change, but it's incredibly impactful because people are then spending time on what is most important — caring for the patient.
Because this approach has been so effective, we are now in the process of expanding the concept to all patient care units, not just the intensive care units. We are in the process of creating interdisciplinary teams at the patient care unit level. Each unit will put together an interdisciplinary team and will be provided with data to drive performance improvement at the level of the unit. Teams will be focused on those goals that are priorities for the institution. All of the team members will be trained in the science of performance improvement and lean principles. Embedded support will provide in-the-moment assistance to keep projects on track. Learning collaboratives will allow units working on similar projects to share their experience. I believe that we will learn tremendously from our bedside staff using this approach.
Leveraging technology is essential to improving quality and safety. We are very fortunate to have CPOE — computerized physician order entry — implemented throughout the system. We're increasingly finding ways to use this technology to promote patient safety. For example, because we now have modules around prescribing opioids with safety features to support clinical decision making, we have reduced the use of those medications and therefore reduced adverse events related to narcotic use. Using the CPOE system to help guide physicians to the appropriate choice of VTE prophylaxis is another project currently underway. This will help us reduce the number of VTEs that occur in patients.
Q: How has your past experience as senior vice-president and executive director of Christiana Care–Wilmington and associate CMO affected your approach to patient safety and quality?
JN: One of the things that personally I'm very committed to is creating a care delivery model that is really grounded in the principles of patient- and family-centered care. In my three years as senior VP, the Wilmington campus adopted those principles as a strategy for safety and quality. A care model that partners with the patient and the patient's family, and brings them into the conversation about quality and safety, is perhaps the most important way to achieve the most successful outcomes.
At Wilmington, we have a number of ongoing initiatives. For example, we developed a team called the Synchronized Wilmington Admissions Team, or SWAT. That team has an experienced physician, a resident, a clinical pharmacist, a social worker/case manager and a nurse. When the ED identifies a patient who needs to be admitted, the team goes to the ED and does admission together. The patient has to tell [his or her] story only once, which patients and families love; they're not repeating the same thing to four or five different people.
And once the history is taken, each of the team members has a job to do. The clinical pharmacist does medication reconciliation — calls pharmacies and physicians to find out what medications the patient is actually taking. The social worker has a conversation with family members in terms of what might be necessary for discharge. (Usually, by the time a patient gets to the floor, the family is ready to go home, and the opportunity to have a conversation early may be missed). For the residents, it has been a tremendous educational experience. They work side by side with a seasoned clinician.
Our outcomes from the SWAT initiative have caught the attention of the entire system. We've met core measures 100 percent of the time, reduced length of stay, eliminated the need for [rapid response team] calls in the first 24 hours and demonstrated a reduction in readmission rates. This approach is very patient- and family-centered because you're meeting the patient and their care givers at the point of entry — if we can get it right from the start of the inpatient journey it bodes well for the entire stay.
We have a patient and family advisory council at Wilmington, and some advisors, completely unprompted, say, "I was in the ED and the whole team took care of me and it was great, I loved it — it's a great thing to do." This is the best outcome of all.
At Christiana Hospital we have adapted this model to the critically ill medical patient. The medical intensive care unit has a team that goes to the ED and begins caring for the patient. The team initiates the care plan and brings the patient out of the ED and into the ICU bed. This has reduced the amount of time the patient is in the ED and provides the ED staff with appropriate support to care for our sickest patients.
Q: How has your past experience affected your leadership style as CMO?
JN: Listening and learning from those who are at the bedside taking care of patients is extremely important to me. When I started my position at Wilmington, one of the first things I did was engage employees in a discussion about how to improve care. The nurse managers started the conversation and we gradually expanded the group to become more interdisciplinary. Although I facilitated these discussions, the team provided the direction in terms of embracing patient- and family-centered care principles as the basis of redesigning care and improving safety, quality and patient satisfaction. As a result of that work, we saw improvements in every dimension — including the financial benefit. I learned tremendously about the importance of developing relationships in order to do the right work in the right place and for the right reasons.
Q: What are the greatest challenges you are facing as CMO?
JN: The challenges in healthcare are enormous as always but perhaps even more so given all of the changes occurring as a result of the Affordable Care Act and some of the new programs at CMS. When I talk to other CMOs, the discussion often focuses on developing relationships with our physicians and finding ways to provide them with leadership opportunities. More than ever, hospitals and health systems need to create effective partnerships with physicians to be able to deliver value to our patients and our communities. At Christiana Care, we have a small number of employed physicians and a larger number of private physicians. Their involvement is absolutely critical in adding value so we can achieve our quality and safety goals.
We are facing questions such as how are we going to adapt to what's inevitable in healthcare? Whether or not all elements of reform stand, certainly the principles of accountable care organizations that put patients first and [emphasize] high quality care over the care continuum are heading our way. We face the question, so to speak, of how to turn the ship so we don't sink the ship on our way to finding this new direction.
Outcomes are emphasized more than ever in healthcare. We want to make sure that we are focusing on those outcomes that really matter to the patient and not simply looking at outcomes for outcomes' sake. How do we use the data to create priorities within our organization so we're working where we need to work? And always, are we looking at the right outcomes, the outcomes that add value to the patient?
Q: How are you working to overcome these challenges?
JN: In a couple ways. One is that we are focused on increasing the emphasis on interdisciplinary teams. Our work in quality and safety is being redesigned with a greater focus on annual and five-year goals. Transparency — making sure that everyone is aware of what work needs to be done — is a significant factor in success. We need to look critically to make sure we are structured in a way that the work to achieve these goals is completed and appropriately resourced. There has to be a way for those teams to [report] back up to leadership and say, "Here's an issue, here's how it was resolved, you might want to think about this." This is an area where we need to spend some resources as an organization, creating that structure so the work that needs to be done has an impact, and that learning occurs vertically and horizontally across the system.
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