BY: NANCY COLLINS
For a decade, HealthGrades' industry-standard ratings have provided patients with a way to compare the quality of care at local hospitals in more than 26 different categories. The hospital ratings — one, three or five stars — reflect mortality and complication rates, adjusted for different patient populations.
In 2010, HealthGrades released the results of its first study of pediatric patients at children's hospitals. According to the study, which looked at 2,080 U.S. hospitals during a three-year period, 97 had pediatric patient-safety event rates that were statistically lower than the rest. These hospitals received the HealthGrades 2010 Pediatric Patient Safety Excellence Award. Pediatric patients at these hospitals had, on average, a 29.48 percent lower risk of experiencing one or more of eight designated patient-safety events compared with all other hospitals.
If all hospitals had performed at this level, roughly 6,500 pediatric patient-safety events could have been avoided, HealthGrades noted in its report.
St. Joseph's Children's Hospital at St. Joseph's Regional Medical Center, a part of the St. Joseph's Healthcare System located in northern New Jersey, rated in the top 5 percent in the 2010 report, according to HealthGrades.
The eight pediatric patient safety indicators include avoidance of unintended punctures and lacerations, hospital-acquired pressure sores, breakdown of surgical wounds and hospital-acquired infections. Other indicators are related to surgery or procedures performed on patients, and they include avoidance of bruising or bleeding, collapsed lung, respiratory failure or severe infection.
MULTI-FACETED APPROACH
Safety at St. Joseph's Children Hospital is the product of a multi-faceted approach, which includes an individual employee dimension, an organizational dimension and a family-patient dimension.
Michael Lamacchia, MD, chairman of pediatrics, describes it as a matter of focus. "Our primary focus is always on patient safety and quality," he said. "Addressed by the patient safety and quality committee, by health care teams, by individual staff members, and with patients and families, safety and quality are essential to all that we do."
The award reflects teamwork by physician-experts, a nursing staff that has been recognized with the Magnet Award for Nursing Excellence since 1999 and clinicians. All work together consistently, in all areas, on all levels, reevaluating and adjusting practices to better serve patients and their families."
'EMBRACING EXCELLENCE' SYSTEMWIDE
"From the founding sisters to our most recent employees, we share an enduring commitment to the Sisters of Charity's mission," said Sr. Maryanne Campeotto, SC, vice president, mission, St. Joseph's Healthcare System. "In keeping with our mission, St. Joseph's Healthcare System starts each new employee off with an introduction to 'Embracing Excellence' at a new-hire orientation, followed by daylong 'Embracing Excellence' retreats and continuing education and interaction."
Implemented in 2009, 'Embracing Excellence' is an ongoing systemwide customer service training, communication and action initiative dedicated to enhancing the organization's collaborative culture of caring. 'Embracing Excellence' utilizes interactive grassroots structures composed of employees from every level of the organization. These structures include a steering committee leadership team, action teams that focus on identifying and resolving issues and department representatives selected by their peers. The department representatives report back to the steering committee each month with suggestions, questions and concerns.
In practice, 'Embracing Excellence' means that staff members identify themselves before treating a patient. They tell patients what medication they are about to receive before administering it. They regularly solicit input from patients and family members regarding the patient's health.
The goal? By embracing excellence in all patient interactions, the staff will champion safety while providing quality compassionate care.
The 'Embracing Excellence' initiative encourages open collaboration for planning, implementation and resolution of issues. Peer support and accountability are vital components of formal and informal program retraining as staff works closely together to maintain a high level of customer service excellence.
Employees, who are expected to commit to St. Joseph's value-based standards of behavior as part of 'Embracing Excellence,' benefit from training and retraining. New tactics, tips and techniques are shared at retreats, department and team meetings and on a monthly basis using a variety of internal communications vehicles such as email, intranet, newsletter articles, and displays.
"'Embracing Excellence' is now a shared language, a collective fiber for our organization," Sr. Campeotto said. "The outcome is evident in the customer-friendly and patient-focused care provided in all areas."
PATIENT SAFETY AND QUALITY COMMITTEE
To address patient safety in a formal ongoing way, the multidisciplinary patient safety and quality committee meets regularly to analyze and close any gaps in space, resource and care needs. Can the environment better address patient safety needs? Is the space developmentally appropriate for pediatric patients? Can it accommodate physical and cognitive limitations? Is the patient and family repeatedly made aware of how to get help? Is the staff taking all appropriate measures to mitigate safety concerns?
"We stress that this is a collaborative effort with a nonpunitive tone of the committee and throughout our patient safety work," said Maria Brennan, chief nursing officer, St. Joseph's Healthcare System, and vice president, patient care services, St. Joseph's Regional Medical Center. "We are all working toward constantly improving safety, not casting blame."
The committee also reviews cases and generates ideas for improvements. They form teams as needed to deal with specific safety issues, such as falls or postoperative infections, throughout all levels and areas. For example, the pediatric intensive care unit has a team of nurses, physicians, pharmacists, respiratory therapists and case managers that work together to address unit-specific safety issues.
"We identify surgical safety issues, then look at how we can use clinical guidelines and checklists to address them," Lamacchia said. "We also examine the way we take care of central lines, how we care for surgical site infections and how we can prevent surgical site infections and ventilator-associated pneumonia."
A major patient safety concern for most hospitals is medication error. St. Joseph's addresses this concern with a multicheck system developed by the Patient Safety and Quality Committee. After the physician writes the order and checks the dosage, a nurse verifies the order and dosage and then submits it to the pharmacy. A pharmacist confirms the order and dosage against a pharmacy database. As the medication is being dispensed on the unit, the nurse verifies the order against a second database. Finally, the nurse administering the medication checks the order and dosage,and tells the patient and family what medication is being administered, why and how much.
"Dealing with safety issues can add an extra burden, but our employees appreciate the tools and procedures we have in place," said Brennan. "Everyone, from custodians to nurses and neurosurgeons, participates in the safety process. All safety teams have representatives from all disciplines."
FAMILIES TAKE PART
Communication is critical for maintaining safety and quality care throughout each patient's stay. It is important that patient and family understand what is happening and why.
To that end, all pediatric inpatients and their families receive a patient orientation booklet, which includes a section for notes from the daily bedside rounds as well as common phrases in different languages to aid in translation and communication. Language translation services also are readily available to patients and their families. Clinicians take into account the physical and developmental age of pediatric patients and, with young patients, work with families to communicate appropriately. Good communication is a vital step in reducing errors.
Throughout St. Joseph's Children's Hospital, the patient and family are involved in all care, every day of a patient's stay. To let the patient and family know who is providing care on a given day, bedside boards feature pictures of the attending nurse and doctor, along with information on contacting them. The pictures help even young children identify their caregivers.
All care providers, including patients and appropriate family members, participate in daily bedside multidisciplinary rounds. The patient and family are invited to contribute information that will enhance care. Older children, who are able to express pain and discomfort, are encouraged to participate in discussions and asked to describe how they feel physically and emotionally. After the rounds, care providers determine daily goals and expected outcomes and write them in a book held by the young patient's family care provider.
Another way St. Joseph's reduces errors is by using templates for daily progress notes for vitals, pain assessment and management and diagnostic work-ups. The templates are problem-focused. Clinical staff members also use formal sign-off sheets, along with the oral report given at a shift change. The next caregiver uses these documents for reference.
In an effort to catch errors before they happen, St. Joseph's has developed a Rapid Response System. If something unusual is happening or the patient or family determines that something just doesn't "feel right," they or the medical staff can initiate a pre-code alarm. A special team on the unit assesses what's happening, using a formal assessment tool called the Pediatric Early Warning Score to determine the next action.
Finally, providers share the care plan, including medications, diet and bedside care, with the patient and family. Sharing information ensures that all participants, including the patient and family, take an active role in patient safety.
"In pediatrics, to make sure that all voices are heard, the patient safety and quality committee use various monitoring methods to ensure that the quality of care at St. Joseph's is consistently superior. This includes working with the parent advocacy board to get feedback on care and implemented systems," Lamacchia explained.
CONTINUAL ADJUSTMENT
"At St. Joseph's Children's Hospital, patient safety starts with caring for the 'whole child'," Lamacchia said. "We've implemented a number of quality improvement and safety initiatives. For example, we participate in a [Centers for Disease Control] collaborative about infection rates, and we always meet or exceed their standards."
Pediatric patients require special safety considerations. Medication is measured in milliliters per kilogram, not as a standard dose as with adults. Also, because pediatric patients can't always tell you what is wrong, providers need formal assessment tools. A fever can signal something more serious than it would in an older child or adult. Physicians and nurses take all these factors into consideration to provide care in a safe way.
St. Joseph's is constantly reevaluating care procedures and systems, using standards of comparison and showing staff what works and what needs to be adjusted. For example, members of the hospital staff follow a variety of national initiatives to gather data and improve safety. The hospital is a member of the National Association of Children's Hospitals and Related Institutions (NACHRI) and participates in a study that benchmarks data with multiple children's hospitals across the nation. Pediatric intensive care unit focus groups collaborate on research and best practices regarding end-of-life care, ventilator-associated pneumonia and nutritional aspects.
As part of the virtual performance system database for pediatric intensive care, St. Joseph's Children's Hospital measures length of stay, complications and bloodstream infections. The hospital participates in the National Health and Safety Network, which monitors central line, Foley catheter and ventilator infection rates. The Neonatal Intensive Care Unit (NICU) is a member of the Vermont Oxford Neonatal Network that comprises 300 hospitals throughout the world.
"The St. Joseph's NICU ranks among the best in this network for survival, critical care outcomes and respiratory management," Lamaccia said.
All divisions of St. Joseph's Children's Hospital collect monthly data on quality outcomes specific to their primary care and specialty guidelines. These outcomes are reported regularly to the patient safety and quality committee for review and suggestions for improvement.
MOVING FORWARD
According to the National Patient Safety Foundation, safety is the result when components of the health care system interact properly. The foundation defines the goal of patient safety systems as "the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of care."1
William A. McDonald, President and Chief Executive Officer, St. Joseph's Healthcare System, said, "We are very proud of our HealthGrades ranking. Patient safety is part of our mission to render quality health care in northern New Jersey with a special concern for the poor and underserved."
NANCY COLLINS is director of public relations and marketing, St. Joseph's Healthcare System, Paterson, N.J.
NOTES
- Linda Emanuel et al, "What Exactly Is Patient Safety?" The article is available at www.ncbi.nlm.nih.gov/books/NBK43629/
The Sisters of Charity of Saint Elizabeth founded St. Joseph's Hospital in 1867 in Paterson, N.J., with a mission to care for the sick poor. Today, St. Joseph's Healthcare System serves people with a wide range of ethnic, religious, socioeconomic and educational backgrounds. It is the largest employer in Passaic County, with nearly 1,100 physicians and more than 5,000 employees, and the second-largest provider of charity care in New Jersey.
CHA MEMBERS WHO RECEIVED THE HEALTHGRADES 2010 PEDIATRIC PATIENT SAFETY EXCELLENCE AWARD
IOWA
Covenant Medical Center, Waterloo
Mercy Medical Center - Des Moines
Mercy Medical Center - Dubuque
MARYLAND
Holy Cross Hospital, Silver Spring
Mercy Medical Center, Baltimore
NEW JERSEY
Holy Name Hospital, Teaneck
Saint Joseph's Regional Medical Center, Paterson; including Saint Joseph's Children Hospital, Paterson
Saint Peter's University Hospital, New Brunswick; including The Children's Hospital at Saint Peter's University Hospital, New Brunswick
NEW YORK
Mercy Hospital of Buffalo
Sisters of Charity Hospital, Buffalo
PENNSYLVANIA
Holy Redeemer Hospital & Medical Center, Meadowbrook
WISCONSIN
Ministry Saint Joseph's Hospital, Marshfield; including Ministry Saint Joseph's Children Hospital, Marshfield
Infusion Room Redesign Enhances Environment of Care at St. Joseph's Children's Hospital
After seeing St. Joseph's Children's Hospital at St. Joseph's Regional Medical Center in Paterson, N. J. from a parent's perspective, NBC home improvement expert George Oliphant was inspired to give back.
Oliphant visits communities across America and tackles renovation projects for a television series called "George to the Rescue." The show airs weekends on NBC local media stations, covering nearly one-third of the country. Often times, Oliphant helps families with medical issues.
One of the first pediatric hospitals designated by the State of New Jersey in the early 1990s, St. Joseph's Children's Hospital offers a complete spectrum of specialty and subspecialty services. Its sponsors, the Sisters of Charity of Saint Elizabeth, founded St. Joseph's in 1867. The hospital is renowned for such advanced pediatric services as cardiology, neurology, neonatology, orthopedics and nephrology. It offers a comprehensive birth defects center, regional craniofacial center, center for pediatric feeding and swallowing disorders, and global telemedicine programs.
Oliphant's family benefitted from the care provided at St. Joseph's Children's Hospital, and he later brought his team to the hospital for a remodeling project. They decided to concentrate on the busy infusion room in the hospital's center for pediatric cancer and blood disorders. With more than 4,000 pediatric outpatient visits and over 2,000 pediatric inpatient days recorded in 2010, the center evaluates and treats a wide spectrum of hematologic and oncologic conditions affecting children and young adults.
"Our team of physicians, nurses and therapists work to provide the very best care in the region," said Jill Menell, MD, chief of the pediatric hematology/oncology division of St. Joseph's Children's Hospital. "We are affiliated with Columbia University, St. Jude Children's Research Hospital and the Children's Oncology Group — a premier collaborative group of more than 200 pediatric oncology centers nationwide."
The infusion room at St. Joseph's Children's Hospital is considered a "day hospital," a place where outpatients receive intravenous treatments, such as chemotherapy. Patients come on a regular basis — daily, a few times a week, or monthly. The room is a quiet, comfortable place that allows for play and interaction, as patients are often there for several hours at a time.
Oliphant and his team used design, color and specialized furniture to create an upbeat environment for the children of varying ages. Walls were torn down and the space enlarged. The decor in the remodeled room features the four elements — earth, water, air and fire. Each wall vibrantly highlights a different element, and ceiling and floor tiles add to the cheery atmosphere. More space accommodates coloring, craft activities, games and homework, allowing children to be children regardless of the therapies they are receiving.
New child-friendly furniture and recliners designed for infusion therapy grace the new space. The Oliphant team also brought in gaming systems, laptops and iPads for patients and families to use. Internet connectivity enhances schoolwork and playtime while patients and their families pass the time during treatment. A new magnetic wall features rewritable, brick-shaped tiles that feature patients' mottoes, jokes, fun facts and bits of wisdom.
The remodel has allowed St. Joseph's to better meet the needs of its young patients, their families and the center's staff alike. The lively, yet comfortable atmosphere, added space and ultramodern amenities enable the staff to interact with patients and their families with more flexibility. A separate room, adjacent to the main treatment area, has been created as a dedicated space for parents to read, fill out paperwork or just chat with other parents facing the same medical issues and treatments. It also is a private, quiet spot for staff to consult with parents, to answer their questions and provide guidance.
"This remodel enhances our ability to treat the 'whole child,' resulting in better outcomes," said Menell. "The infusion room is the hub of the Center for Pediatric Cancer and Blood Disorders. We now have more space and an invigorated environment in which to treat patients affected by hematologic and oncologic conditions."
— Nancy Collins