C4I Executive Summary – August 2006

Vision

John Dempsey Hospital will become the safest hospital in Connecticut.

Mission

Create a culture of excellence based upon the highest quality of patient care delivered by the best staff in the safest environment.

Goals

1. Develop and follow standards of excellence.

2. Cultural transition:
        a. Develop organizational pride and sense of community
        b. Foster collaborative work
        c. Foster a no blame environment
        d. Develop policies and processes that are transferable
        e. Identify and foster research opportunities

3. Track, evaluate and provide feedback to enhance outcomes.

4. Educate and communicate goals to everyone.

Clinical Operations of John Dempsey Hospital has initiated an organized effort to become the safest health care operation in Connecticut. This effort is the defining principle for the Collaborative Center for Clinical Care Improvement (C4I). John Dempsey Hospital clinicians, practitioners focused in outpatient services, and health center faculty practicing in University of Connecticut schools have all embraced the vision, mission and goals established for C4I.

The journey to provide the safest patient care began in 2004 when C4I was successfully introduced to the University of Connecticut Board of Directors. It was then presented to clinical staff to initiate groups to address issues that would improve both quality of patient care and patient safety. The following is a description and summary of these groups, their work to date, and the plans for the next phases of C4I work.

C4I currently has seven working groups dedicated to addressing and improving practice and patient outcomes for: Medication Safety; Nosocomial Infections; Pain and Palliative Care; Patient Falls; Culture Assessment and Transition; Ambulatory Care; and Performance Improvement Measures. The selection of these seven groups was based on internal data that represented potential or actual errors in practice, and on commitment to adhere to best practice guidelines for patient care. All seven groups initiated regular group meetings throughout 2005 and 2006, and have implemented action plans that were developed specific for each area of focus.

Medication Safety has developed an action plan to address:

1. Assessment of current practice for medication ordering, dispensing and administration. Assessment was completed through a survey tool, Institute for Safe Medication Practices (ISMP) Medication Safety Self Assessment for Hospitals. Data from this tool have been used to enhance the current action plan for this group.

2. Implementation of technology for pharmacy services systems, e.g., computer based physician order entry. Technology changes are in progress, e.g., Siemens System for physician order entry was implemented in May 2006.

3. Improvement in pharmacy review and delivery of medications to each hospital unit. Use and expansion of Pyxis products allows more efficient review by pharmacy of medication orders with more timely dispensing of medications to hospital units.

4. Provision of ongoing education to hospital staff on medication safety and practice standards.

Nosocomial Infections/Infection Control has four subgroups focused on:

1. Influenza Immunization for high risk patients and employees. The goal for this group is to improve vaccination rates to 75 percent for both groups for the flu season of 2005-2006 and to reach 100 percent vaccination rates for both groups by the flu season of 2006 to 2007.

2. Hand Washing has been part of an ongoing campaign in the clinical care areas. Personnel are continually reminded to wash hands with a disinfectant solution before and after every patient contact. Education for the importance of hand washing will continue one-on-one with staff through infection control liaison teams, and through annual infection control education programs. Patient cultures will be monitored for organisms commonly spread by hand contamination.

3. Surgical Site Infections has initiated review of data for compliance with national guidelines for pre-operative antibiotic administration and the time of the surgical incision. Data are reviewed for procedure-specific infection rates with corrective actions determined to improve patient outcomes.

4. Central Venous Catheter Infections are being carefully studied with attention to determining data for the number of days individual patients are treated with a central venous catheter. These data will support accurate calculation of central venous associated blood stream infection occurrences and comparison with benchmark data from the National Nosocomial Infection Study (NNIS). Clinical protocols for insertion of central venous catheters, and ongoing care of the central lines/dressings have been revised and implemented to meet standards for best practice.

Pain and Palliative Care has implemented an action plan with attention to improving staff education in pain management and in improving clinical outcomes for patients experiencing pain:

1. A computer based education program has been designed that provides information on a range of education issues critical to successful assessment and management of patient pain. Content for the physician perspective is complete; content for nursing staff is being developed.

2. An equianalgesic tool has been developed and distributed to all hospital health care providers. The tool is a pocket guide that provides information on equianalgesic dosing and pain management practices at John Dempsey Hospital.

3. Evaluation of clinical practice in alleviation of patient pain has been reviewed through audit of patient records. Further actions will be implemented specific to data review.

4. Non-pharmaceutical strategies for pain management are being evaluated for inclusion in patient plans of care, e.g., diversion activities/options.

Patient Falls has worked on a series of actions to address:

1. Assessment and care of patients at risk to fall: fall risk assessment is completed by nursing staff using a tool adapted from the work of Janice M. Morse (1997), Preventing Patient Falls. Actions are implemented based on the level of patient risk.

2. Safety of the hospital care environment to decrease patient injury should a fall occur. The hospital environment is continually evaluated for safety, and actions have been taken to decrease risk of injury in the event a fall does occur, e.g., hospital beds purchased in 2004 have a number of patient safety features: a night light on the bed, an exit alarm for patients who need assistance to safely get out of bed, and the ability to lower the bed to within 16 inches of the floor.

3. Interdisciplinary collaboration to develop and implement protocols of care that support the safest practice. Current work is focused on the implementation of an interdisciplinary protocol to identify and treat Delirium.

Culture Assessment and Change completed the survey of University of Connecticut Health Center staff using a tool to assess staff perception of Health Center organizational culture. Fourteen hundred and ten of 4,622 Health Center staff returned completed surveys. Data have been analyzed and focus groups will be convened to discuss themes derived from survey analysis. Information gathered during these focus group discussions will supplement quantitative data from the survey tool to organize and develop strategies to address key areas for transition in Health Center culture.

Ambulatory (Outpatient) Care group has identified two foci for clinical care review and opportunities for improvement. Both have been selected from the measures developed by the National Committee for Quality Assurance; these measures are designed to review appropriate care in the ambulatory/outpatient setting. The two areas selected are:

1. Preventive Measures: timely evaluation/testing for: breast cancer; colorectal screenings; cervical cancer; smoking cessation counseling; and influenza and pneumococcal vaccinations.

2. Diabetes Management: monitoring and management of HbA1C blood levels; blood pressure management; lipid measurement; and regular examination by an eye care professional.

Concurrent to review of these data is coordination of a data collection/review process for these clinical measures in the outpatient settings where care is provided.

Performance Improvement Measures was convened as group in April 2006. This group is reviewing all the data currently being collected to evaluate our performance with clinical care. Data is collected and submitted to JCAHO, Qualidigm and other review agencies as components for insuring the best, evidence based practice is provided. This group plans to evaluate how these data are effectively shared throughout the clinical enterprise and a process to coordinate selection of new clinical indicators.

C4I has successfully engaged students and University faculty in department and subgroup work. A graduate student in the School of Social Work, and faculty from the School of Pharmacy have been active members of C4I subgroups for Pain and Palliative Care and Patient Falls. Efforts will continue to invite and encourage student involvement from University of Connecticut undergraduate, graduate and professional schools. Student involvement has been extremely helpful to provide perspective and advice on C4I current efforts and phases for expansion.

Road Map for C4I was initiated in 2004 with the decision to develop a program to design and sustain John Dempsey Hospital as the safest health care environment in Connecticut. Preparation was initiated throughout 2004 to launch this program in December of 2004. During 2005 and to date in 2006, efforts have expanded to ambulatory care, potential research and funding endeavors with a request for funding for a proposal for a community health program, and participation of students in C4I endeavors. Future goals and plans for C4I will continue to expand and sustain the goals that have been met and the goals that will evolve from C4I review of patient care, education of students, support for community services, and development of models of care that can be transferred successfully to other care environments.

Communication of C4I work has been coordinated through a series of C4I Newsletters distributed throughout the UConn Health Center. Newsletters have been developed to describe the work of the C4I subgroups for Culture Assessment and Change, Pain and Palliative Care, Patient Falls, Nosocomial Infections, Patient and Staff Safety, and Good Catch awards for reports of staff intervention that improved patient care/safety. The first meeting with the C4I External Advisory Board was held in September of 2005 and a second is planned for October of 2006. Members of this Board represent a range of health care disciplines and expertise in defining the best practices for safe, high quality patient care. We plan to conduct annual meetings with this board as means to solicit and maintain an eternal review of C4I plans and progress.