Continued Advances in Patient Care

Quality is Job 1 — that is our mantra. It is at the core of our strategic plan. While we strive for excellence in research and education as well as patient care, we will not reach our goals as an academic health center unless our patients always come first. This is the right thing to do for our patients’ well-being, and it’s the right strategy for our financial health, which in turn funds our academic programs as a virtuous circle.

Joint Commission Visits

Periodically — about every three years — surveyors from The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations in the United States, assess the quality of our hospital care. The Joint Commission doesn’t tell you in advance when to expect a visit; the idea is always to be prepared as though the visit will be today.

Surveyors showed up at Shands at UF on Monday, June 4, and at Shands Jacksonville on Monday, June 25. The survey teams included physicians, nurses, a licensed clinical social worker, administrators, ambulatory care experts, environment of care professionals, and home care and long-term care experts. They visited a broad cross-section of hospital departments and programs, and checked out every nook and cranny. These direct assessments, as well as interviews with managers, faculty and staff, are used to evaluate our compliance with Joint Commission standards and the Centers for Medicaid and Medicare Services (CMS) Conditions of Participation. We are assessed on approximately 4,500 individual Joint Commission elements of performance and CMS regulations. The process is rigorous and thorough. The surveyors assessed our processes for patient care delivery on our main campuses and off-site locations.

I am pleased to report that survey results were outstanding in both campuses and validated the top quality patient care provided by all members of our UF&Shands teams. As expected, we received a few recommendations for improvement at each site that we will work on in the upcoming months.

The Shands at UF survey took place throughout the week of June 4th and we had up to nine surveyors at a time on site. Gainesville teams were praised for the tremendous progress made in reducing central line and urinary tract infections. One surveyor commended everyone involved for “one of the best systems I’ve seen in terms of daily interaction with your patients and the preparations that take place for patient discharge,” while another indicated that if he were in need of medical care, he would not hesitate to come to our hospital. Survey findings included opportunities to improve documentation, infection prevention and control practices, and procedural safety. Our Accreditation Team is leading improvement efforts under the direction of Shands at UF Chief Nursing Officer Irene Alexaitis.

The Shands Jacksonville survey took place throughout the week of June 25th with up to seven surveyors on site at a time. Again, survey results were outstanding, and surveyors mentioned the Jacksonville teams’ “excellent practices” and “dedicated staff.” The Environment of Care and Emergency Management procedures were “the best that they had ever seen.” They randomly selected and interviewed 20 patients whose feedback was all positive, with testimonials about life-saving experiences and attentive care. Survey findings included opportunities to improve documentation, infection prevention and control practices, and medication management. Our regulatory accreditation committee is leading improvement efforts under the direction of Shands Jacksonville Director of Regulatory Compliance and Accreditation Joni Lourcey.

One Shands Jacksonville postoperative open-heart surgery patient informed a surveyor that he had presented to the emergency department of another Jacksonville hospital on several occasions and had been sent home. When he arrived at Shands Jacksonville with the same symptoms, he was rushed to the cardiac catheterization lab and then to the Operating Room. He said, “Shands Jacksonville saved my life. If I had kept going back to the other hospital, I would be dead.”

The great results that we are tracking and the external, positive validation we have received are a testament to the skills, expertise and perseverance of UF&Shands faculty and staff, and to the spirit of collaboration and shared commitment among our teams. In the past month, several awards, achievements and events reflect this commitment:

Rapid Response Teams Lead to Reduced Hospital Emergency Codes

The acuity of hospitalized patients is increasing. Thus, even patients who are not in intensive care units can be quite sick. Sometimes, warning signs about the deterioration of a patient’s status may not be apparent to caregivers in a ward setting. This can unfortunately lead to a hospital emergency code (usually, cardiac arrest) being called for a ward patient. To address this issue, Rapid Response Teams have been developed at both Shands at UF and Shands Jacksonville, and standardized criteria have been introduced for contacting the Rapid Response Team for early intervention.

At Shands Jacksonville, a formal Rapid Response Team system was introduced in 2007. Since that time, the total number of hospital emergency codes, as well as associated mortality, has decreased dramatically. In 2006, prior to the implementation of the Rapid Response Team, there were 295 codes and only 48 percent of those patients survived. Today, the total number of codes each year is fewer than 100, with an approximate survival rate of 75 to 80 percent. The rapid response team is composed of 11 full-time nurses who respond to more than 300 calls each month and round proactively on approximately 40 to 50 patients daily who, based on criteria, are at risk of deteriorating.

The Rapid Response Team at Shands at UF began in early 2010. The Medical Early Warning Score (MEWS) was introduced as a nurse-driven standard protocol to guide staff in recognizing subtle signs of patient decline, based on prescribed criteria (heart rate, blood pressure, etc.) and scoring to provide a guide for when to contact the team for moderate to aggressive, immediate intervention. Prior to launching the Rapid Response Teams and MEWS, we had an average of 15 hospital emergency codes outside the ICU each month. Post-MEWS, the average number of codes has declined to less than five per month. In Jacksonville, a system similar to MEWS — the Rothman Index, which is a simple yet elegant tracking system of vital signs and other patient data — is being implemented to assist the Rapid Response Teams.

Thanks to strong nursing leadership, collaboration with clinical teams, and involving and educating patients and their family members, these remarkable Rapid Response Teams have saved lives.

Hospital-acquired Infections

Hospital-acquired infections, also known as nosocomial infections, are unfortunately common in hospitals and lead to significant morbidity and mortality. Both bacterial and fungal infections may be favored in a hospital environment, especially because hospitalized patients often have reduced immune function and resistance. Nosocomial infections most commonly involve the bloodstream, lungs and urinary tract. The Centers for Disease Control and Prevention estimates that about 1.7 million hospital-associated infections in the United States cause or contribute to 99,000 deaths each year. Thus, a major initiative in our patient quality program has been to attack the problem of nosocomial infections. A hospital-acquired infection rate of zero is the Holy Grail.

Since 2009, 400 fewer patients per year have hospital-acquired infections at Shands at UF. Seven ICUs have gone without a single patient acquiring ventilator-associated pneumonia for at least a year. Three inpatient units have gone without a single patient acquiring a central-line-associated bloodstream infection (CLABSI) for at least a year. The 4 East Surgical ICU team has received prestigious external validation for its efforts to prevent CLABSIs. They have been recognized with a Health and Human Services Office of Healthcare Quality Outstanding Achievement and Leadership Award for eliminating CLABSIs for 12 consecutive months. Only 12 hospitals have received such recognition nationwide. HHS plans to visit the hospital and award the staff of 4 East in person “for a job exceptionally well-done!”

Shands Jacksonville’s intensive care units have also implemented a number of strategies to decrease infection rates, and there have been similar excellent outcomes. The Medical/Surgical ICU and the Surgical ICU decreased their catheter-associated urinary tract infection rate by more than 25 percent. The Critical Care Unit and Cardiovascular ICU have seen sustained periods of zero catheter-associated urinary tract infections. In addition, two units have maintained rates of zero for both ventilator-associated pneumonia and central line-associated bloodstream infections for about two years. In the CCU, there have now been 24 consecutive months with zero ventilator-associated pneumonia cases and 23 consecutive months with zero bloodstream infections. And in the Pediatric ICU, there have been 24 consecutive months with zero bloodstream infections and 17 consecutive months without any ventilator-associated pneumonia.

Quality Retreat and Award Program

On July 14, more than 250 UF&Shands faculty and hospital managers attended our third annual UF&Shands Quality Retreat for Shands at UF. Physicians, nurses, pharmacists, technicians, residents, researchers, educators and administrative staff spent an entire Saturday together to plan our next steps and hear from leaders at other institutions. Two keynote speakers complemented a valuable break-out session in which multidisciplinary groups brainstormed specific strategies to address barriers in communication and teamwork that are critical to forward progress in our quality journey. In addition, there were 39 excellent research project poster presentations. The winning poster, presented by Frederick Moore, M.D., Victoria Klink, and Peggy Marker was titled “Got Sepsis? A Process for Improving Recognition and Treatment of Sepsis.”

To spur innovation in quality and safety, we launched the Clinical Quality Award program, which provides up to $25,000 in funding to support new projects. It is co-sponsored by the Continuing Medical Education office and the Self-Insurance Program. This year the program funded 13 diverse projects in Gainesville and Jacksonville. An example includes the Second Victim Program to provide support to front-line care providers involved in adverse events.

Goals for the Upcoming Year

Looking ahead, UF&Shands on the Gainesville campus will build on the successes we have achieved by continuing to focus on our Quality Big Aims: Reducing Harm, Reducing Variation in Care, Improving the Patient Experience. At this year’s Quality Retreat, attendees identified a fourth aim, which has now been added: Improving the Patient Safety Culture. A major focus this year will be on improving transitions of care at all levels including outpatient, ED and inpatient. Interdisciplinary teams across UF&Shands will work on ways to improve communication and hand off processes between patients, families and care providers at critical transitions as well as developing programs to reduce unplanned readmissions.

Shands Jacksonville came within inches of being a UHC Four-Star Hospital in the most recent calendar year. This year we are determined to get there. Time has been spent reviewing the data and determining the areas where improvement is needed to achieve this goal. The organization has joined two collaboratives to boost performance in these areas. The first is a UHC collaborative focusing on readmission reduction. The hospital will implement practices that have been shown to reduce readmissions such as making follow-up appointments for patients at discharge and calling patients shortly after discharge to identify any barriers to follow-up care or changes in condition that may need to be addressed. The second is a collaborative in partnership with the Florida Hospital Association, Johns Hopkins and the American College of Surgeons. This surgical improvement group will focus on decreasing surgical site infections and building a patient safety culture in our operating rooms. The organization is also working on improving our patient’s overall experience with our organization. Subcommittees are currently working on nurse communication, physician communication, discharge instructions, pain management, responsiveness to patient needs, medication information, hospital environment, outpatient experience, the employee experience and measuring results.

Forward Together,

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