Quality is Job 1: We’re Making Progress

I have some exciting news to report about our patient care at UF&Shands. Measures of quality and safety at both our Gainesville and Jacksonville campuses are better—much better.

Those of you involved in patient care are probably not surprised to hear this, because you are living this each day—you’re contributing to our success and you’re noticing more and more that others are as well. You’re not only talking the talk, but walking the walk. Quality improvement is in the air. It’s in the promise you keep to each and every patient individually, and it’s in your effort you devote to a health care team collectively dedicated to doing what’s best for our patients.

In this newsletter, I will share some of the details of our achievements. But before we take a look at the data, let me share two of an increasing number of letters from a patient who wanted to tell me what a great job we’re doing:

"Today I came in for my surgical appointment. From the beginning of my visit, all the way through my discharge, every encounter I had with members of the UF&Shands staff was exemplary. Being a longtime Gainesville resident, I have a great deal of confidence in the medical competence of the UF&Shands staff. The experience I had today went so much further than medical competence. I felt like at every turn the nurses, check-in clerks, security staff, residents and of course the doctors really cared about me. They were dedicated to customer service and understood how they could positively affect the customer experience. In such a large operation, service like this is not an accident, not when commitment at this level is so tangible and pervasive. From the Family Practice office right through the Hospital, I applaud what you and your team are doing. Again, today’s experience was so much more than I ever expected. Please share my gratitude with your staff. I thoroughly appreciate not just what they do, but how they do it."

And a story from Jacksonville:

"Becoming a patient in any emergency room is never an experience that one looks forward to, especially after traveling for several hours. And for me, the last time I was in an ER was when I was in high school—which I can honestly say is more than just the other day. Fortunately for me, I presented at the Shands Jacksonville Emergency Room, and from the moment I arrived, the experience far exceeded my expectations. I knew I would receive first-rate medical care, but from the moment I arrived, I found myself in a modern and friendly environment surrounded by a team of professionals, each taking great care, to not only attend to my medical condition, but to also ensure I was treated with excellence. As I was experiencing the care and treatment, I did wonder to myself, as I am known to some of the care providers, am I getting some sort of "VIP" treatment? The answer to my question was no. I purposely watched and quickly realized that every patient was treated with an exceptional level of service. I saw administrators noticing an elderly person having trouble with a form from across the room, and they responded with attentive care without being asked. I watched employees who had completed their tasks ask their fellow employees, "can I help you with that" or "is there something I can do to help you and your patient?" Before I left, I commented to my specific caregiver, it seems that there has been a high level of commitment provided to everyone who comes through the door—her response was simple and meaningful to me, she said that is the Shands way."

What heart-warming anecdotes! Qualitatively, I am pleased to report that there has been a marked trend toward more letters like these and fewer letters of complaint.

Quantitatively, there is exciting news to report that supports the meaningfulness of these anecdotes. Both Shands at UF and Shands Jacksonville belong to the University HealthSystem Consortium, or UHC, which consists of 115 hospitals in academic health centers—i.e., our peers. On a quarterly basis, we receive reports on quality data for the past quarter and past year. The latest report, encompassing data through March 2011, was recently released. While many aspects of patient care quality are summarized in these reports, two of the most important metrics are the observed:expected (O:E) mortality index, and the composite patient safety indicator score.

During the 12-month period April 2010 – March 2011, Shands at UF was ranked 42 out of 115 hospitals in the O: E mortality index and 13 out of 115 hospitals in a composite score of patient safety indicators. These rankings represent a significant improvement from rankings of 57 and 75 out of 113 hospitals in the prior 12 months. That is, in the space of a year we went from the bottom half to the top half in both indices, and in composite safety score we are at the 11th percentile! Shands Jacksonville did not join the UHC until late 2009, so only limited data are available for the most recent 12-month period. For mortality, the results are superb—a ranking of 25/115 in O:E mortality ratio.

Expected mortality in a hospital is the average mortality associated with the severity mix of its patients, estimated statistically by UHC for each hospital from a national data base. If the mortality that actually occurs in a hospital, given its specific severity mix, is equal to what is expected, the O: E ratio is 1.0. A ratio less than one indicates that the observed mortality is less than what’s expected. The O: E ratios at Shands at UF and Shands Jacksonville for April 2010 – March 2011 were 0.75, and 0.68, respectively.

The composite patient safety indicator score aggregates scores for 11 categories of adverse events, including central line-associated bloodstream infections, pressure ulcers, postoperative wound dehiscence, postoperative respiratory failure, and others.

Teams at both of our hospitals have been working on ways to reduce the frequency of these events, and it is working. In Gainesville, for example, the number of central line infections has dropped significantly, from an average of 14 infections per month from July 2009 to June 2010 to an average of only 7 infections a month in recent months. In Jacksonville, rates were also down significantly, from 7 central line infections per month in June 2010 to only 3 infections per month in June of 2011.

Beyond these overall measures, there are other measures of quality to celebrate. In Jacksonville, for example:

• The most recent survey of inpatient satisfaction, as performed by Professional Research Consultants, revealed that 92 percent of patients rated overall satisfaction as ―excellent,‖ the highest ranking ever achieved by Jacksonville.
• For operative procedures, the UHC composite O:E ratio for inpatient mortality improved in the past year from 1.02 to 0.88. In this category, the UHC ranking for Shands Jacksonville improved in the past year from 46/113 to 10/115.
• For four operations in this composite measure of surgical procedures, Jacksonville was ranked No. 1 among all UHC hospitals. Those procedures are coronary artery bypass graft, percutaneous transluminal coronary angioplasty, abdominal aortic aneurysm repair, and hip replacement.
• In the area of Pediatric Surgery, Shands Jacksonville is ranked first among hospitals in 8 of 11 operations during the first quarter of 2011. Five were sustained rankings and three were improved over the prior year’s performance.
• Shands Jacksonville received the Florida Governor’s Sterling Award for Sustained Performance Improvement, one of the first hospitals in Florida to attain this coveted award.
• Shands Jacksonville also received Magnet Designation from the American Nurses Credentialing Center, joining Shands at UF among an elite group of only 386 facilities worldwide to receive this designation for nursing excellence.

In Gainesville, there also are wonderful stories to tell. For example:

• Continued and sustained reduction in the number of hospital-acquired ventilator-associated pneumonias, or VAPs, in our intensive care units. During the second quarter of 2011, there were no VAPs in our ICUs.
• Improvement in our Surgical Care Improvement Program, or SCIP, core measure results. For example, from April 2010 to March 2011, the UHC ranked Shands at UF 10th for the timely administration of antibiotics to our surgical patients.
• As a result of the implementation of both adult and pediatric early warning programs, which are designed to identify the early signs of patient distress, the number of code blues outside our ICUs reduced from 30 per month in May 2010 to seven per month in August 2011.
• Significant reduction in the rate of postoperative pulmonary embolus and deep vein thrombosis, from 14 to 7 per 1,000 surgical discharges in a year-over-year comparison. Shands at UF ranked 18th overall in this category in the UHC report.

I will close with another letter I recently received that captures the spirit of what we are trying to achieve throughout UF&Shands. It describes the experience of a new faculty member with the Shands at UF blood-drawing lab.

"Essentially, my doctor ordered a very important series of blood tests for me. The test can only be completed during a two-day window each month. This month, those days were Sunday and Monday, Aug. 21 and 22. Obviously labs are closed on Sundays. And on Monday, I was teaching a class at UF for the first time. I don't know how to get around campus, much less where the blood labs are in Gainesville...By the time I discovered the Shands lab, which closes at 5 p.m., it was already 4:05 p.m., and I was a 20-minute walk away from my car (where the blood order was) and then a 10-minute drive from Shands. I reached your staff on the phone. They gave me clear directions and an address for my GPS. By the time I got to Shands and parked and arrived at the lab, it was 4:48 p.m., but they were unbelievably gracious and agreed to run the tests. This was no small order: It turned out that these tests are rather unusual…so the lab staff made some calls to, I believe, physicians to make sure they were reading my doctor's blood order correctly. By that point, it was after hours, but they were gracious in every way. I walked out of there at 5:45 p.m. and had given so much blood that they directed me to where I should go to have something to eat before the drive home. They were patient and kind at every step even though I was obviously keeping them from their own lives and obligations after hours. I cannot begin to tell you what your staff's treatment meant to me. For reasons quite personal, getting this test done was vitally important, and the window of opportunity for the test is achingly small (and, of course, fell on a very frantic day)…I certainly left Shands with a smile on my face and a deep appreciation for your staff's kindness and professionalism."

What a wonderful way to show our patients that, at UF&Shands, quality is Job 1.

Forward Together,

David S. Guzick, M.D., Ph.D. Senior Vice President, Health Affairs President, UF&Shands Health System