SPOTLIGHTO U R C U L T U R E A N D M I S S I O N I N A C T I O N • A U G U S T 2 0 1 4

Quality is key How do you help to assure quality?

An interview with Jim Tune

BY THE NUMBERS IN YOUR WORDS BETTER MEDICINE2 3 6

Above: Kate Hodge, R.N., demonstrates proper hand hygiene.

Quest for Quality

Important indicators are on the rise, thanks to St. Anthony’s commitment to owning safety.

4Page

SPOTLIGHT

Number of agencies that survey St. Anthony’s annually

Improvement in the Joint Commission’s Strategic Surveillance System (S3) score. This tool helps hospitals improve their care processes and prioritize their actions.

Reduction in blood clots among St. Anthony’s patients since last year

Number of quality core measures publicly reported by St. Anthony’s

Reduction in hospital readmissions of heart failure patients during the past two months

Reduction in patient falls since April 1

Up to24 88%

42%

33%

Increase in St. Anthony’s scores from the Centers for Medicare and Medicaid Services (CMS)

( July 2013) (February 2014)89% to

8,200 patient records83,000 individual fields

99%

Quality is key

2

B Y T H E N U M B E R S

700+Active members of

St. Anthony’s medical staff

23%

AUGUST 2014

3

Increase in St. Anthony’s scores from the Centers for Medicare and Medicaid Services (CMS)

Visit SAMCare to see more responses.

Our winner:

Quality is key What are some of the ways you have worked to improve quality at St. Anthony’s?

The culture here at our hospital has changed and people realize that kindness to each other and to the patient and their family is an important part of the patient’s healthcare and well-being, as well as their own. When I visit a patient room for a repair, it is unusual not to see a kindness to the patient on the part of our staff. It has become the norm.

Wayne Fritts Building Services

B Y T H E N U M B E R S

I help discharged patients with problems they didn’t anticipate once they get home.Anita Rogers, L.P.N.Discharge Call Nurse

My goal when I interact with anybody is to have them walk away feeling good about their experience. I always smile when patients come in the door. And when I speak to them I tell them my name and that we are glad they are here. Rhonda HongsermeierOperations Assistant, St. Anthony’s Orthopedic & Sports Rehab

I make a point to help ‘lost’ visitors/patients find the room or department they are looking for. Often I walk with them to make sure they get to their destination. Barb QuirinAdministrative Assistant, Therapy Services

My work takes me throughout the entire hospital and campus. Often I find visitors who need directions, especially on the third floor at the south elevators. I try to take each lost person to where he or she needs to go.Rev. Bill CardyPastoral Care

I treat every patient, family, visitors, co-workers as I would want my family or myself treated— in other words, as if they were my own! Brenda RhodesRespiratory Therapy

My mission is to consistently provide prompt assistance for our nurse customers by taking the time to fully understand their request and communicate how the problem will be resolved. I often call the nurse back to ensure his or her problem has been resolved. Confidence in knowing that their request will be handled in a prompt manner brings job satisfaction to our nurses and quality outcomes for our number-one customer, the patient. Ted Sitek, R.PhInpatient Clinical Pharmacist

Improving quality at St Anthony’s for me means taking excellent care of our patients as well as their family members, no matter what the situation. Sometimes I am that shoulder to cry on, while other times I’m a smiling face that brightens their day.Sarah Jaber, CCRN, B.S.N., R.N.Surgical/ Neuro ICU

Just this week the elevators by the garage were not working and I met a gentleman who was having a hard time walking with his cane. I offered to get a wheelchair, but, his daughter told me that she had one in her car - but, since the elevators weren’t working. . . I told her I would go back to her car with her and help her bring the wheelchair in. They were very upset about the situation and I tried to help decrease their frustration by providing assistance.Cindy RivitusoPharmacy Tech

SPOTLIGHT

..

4

SPOTLIGHT

When eight surveyors from the Joint Commission arrived in February, nine months ahead of schedule, Regulatory Nurse Liz Schelp, R.N., was among those on hand at St. Anthony’s to greet them. Like her co-workers in Quality Management that week, she worked from before dawn to late night

as she provided support to surveyors, assisted hospital teams and staff, and even kept the surveyors’ command center vacuumed.

Then, on the second day of the Joint Commission visit, six separate surveyors from Missouri agencies also showed up.

“Am I in a bad dream?” Schelp recalled, and smiled. “We had the systems for hosting surveyors in place, but it was the first time using them: very stressful, a sink-or-swim moment.”

It was smooth sailing, thanks to an impressive and professional hospital-wide response. This effort was aided by assisting teams from Education and Human Resources; and by extensive advance planning by the 11-member staff of Quality Management, which serves as the command center for surveyors. They provided educational materials and tips; prepared a scribe and escort for each surveyor; sent out frequent emails and e-pages to staff with best-practice reminders; and fulfilled numerous requests for data.

After scrutinizing St. Anthony’s policies and practices for five days, Joint Commission surveyors found no systemic problems and recommended that the hospital’s fall-reduction program, medical staff performance evaluation and peer review process be submitted to The Joint Commission’s “Best Practice Library” for others to see.

“If we ever have a family member that needs hospitalization, we hope they can come to St. Anthony’s,” a surveyor noted in the exit conference.

Results like these are the goal of the Quality Management department, which was established by senior leaders in 2013 as part of St. Anthony’s continuing cultural transformation. Led by Vice President of Quality Jim Tune, Quality Management

forQualityC

ongestive heart failure, or the inability of the heart to pump enough

blood to meet the body’s needs, is the number one cause of hospital readmissions. St. Anthony’s heart failure program has decreased hospital readmissions by 33 percent.

It was developed by St. Anthony’s Heart Failure Readmission Reduction Task Force, which includes representatives from departments hospital-wide. During a 35-day care path, doctors and caregivers work closely with discharged patients on their diets, their rehab and their needed medications.

“Close follow-up is very important,” said Charles Carey, M.D., chairman of the Heart Failure Readmission Reduction Task Force.

Lessons learned from the Heart Failure Readmission Reduction program are being duplicated for other chronic diseases such as Chronic Obstructive Pulmonary Disease (COPD) and pneumonia, said Jim Tune, Vice President of Quality.

Quest

Heart Failure Program reduces readmissions

AUGUST 2014

..

5

AUGUST 2014

Proper hand hygiene is the single most important way to prevent the spread of infection.

“We have re-engaged the Hand Hygiene Task Force with new membership from senior leadership, physician champions, management and frontline staff to help identify barriers, develop plans for behavior change and discuss best-practice strategies,” said team member Linda Merz, Manager of Infection Prevention & Control/Employee Health & Wellness. “Since February the task force has been working hard to ensure we provide the safest environment to our employees, patients and their families.”

The programs include:• A “Secret Shopper” hand hygiene observation

program that identified key departments and individuals as partners to improving hand hygiene compliance rates.

• A reporting portal for hand hygiene observations, developed in cooperation with the IS analytics department, that allows leaders to monitor compliance rates in real time for units of their choice.

• A survey for staff, to identify barriers to performing hand hygiene.

• A 90-day trial of a wearable hand hygiene monitoring device by a leading company, BIOVIGIL. Within the first two weeks, a 97 percent compliance rate was observed.

partners with departments across the medical center and works with caregivers to provide the best care through data and process improvement tools.

“The Quality Management team provides an environment for everyone to own safety and the quality of care we provide for our patients and the community,” Tune said.

The ownership is growing:

CMS quality scoresThe Centers for Medicare and Medicaid Services (CMS)

has set strict quality indicators for various patient populations, for heart failure, surgery infection prevention, heart attack and pneumonia. St. Anthony’s CMS score increased from 89 percent in July 2013 to 99 percent in February 2014.

To achieve this, Quality Management’s Quality Measure R.N. team now analyzes patient care while the patient is still in the hospital, as opposed to the past practice of post-discharge analysis. These RNs also provide timely feedback to the medical staff and engage hospital staff early in the treatment process.

For example:Quality Management’s

Quality Measure nurses worked with the Nursing Service team to improve compliance with evidence-based practices in promptly removing Foley catheters, a leading cause of post-surgical

infections. The hospital has been in 100-percent compliance since December, resulting in a 43 percent decrease in patients with documented urinary tract infections.

Quality Management’s Quality Measure nurses worked with staff to improve compliance with evidence-based practices for documenting written discharge instructions and education for preventing blood clots, resulting in a current compliance rate of 90 percent (formerly 74 percent) and a 42-percent reduction in blood clots among hospital patients.

Jim Tune and the members of the Regulatory Compliance Command Center. This group includes Nursing, Education and Quality Management.

HAND HYGIENEBest Practices

An indicator light on this wearable monitoring device turns green when hands have been washed.

Qual i ty Management Dept.

RESPONSIBILITIES: • Quality

• Regulatory compliance

• Patient safety

• Public reporting measurement or core measures

• Medical staff performance evaluation

• Policy coordination

Learn more about the Quality Management team members on the home page of SAMCare.

SPOTLIGHT

6

An interview with

Jim Tune

SPOTLIGHT

Jim, what does your job entail?I provide senior leadership support to the hospital’s patient safety and quality effort. Departmental responsibility includes: quality management, care management and health information management – which include regulatory compliance, patient safety, publicly reported quality measures, medical staff performance evaluation, policy management, clinical documentation and transition or care coaching.

My goal is to provide support, facilitation and a positive environment for our medical staff, clinicians, nurses and other employees to provide the best care they can through data and process improvement tools.

How has St. Anthony’s progressed in quality excellence during the year you’ve been here?I am proud to say that I routinely receive comments from members of

Vice President of Quality

EDUCATION

• Bachelor of Science degree in Business Administration, Columbia College

• Master of Business Administration degree, William Woods University

• Certified Black Belt in the Lean Six Sigma performance improvement methodology

• Certified Professional in Healthcare Quality by the National Association for Healthcare Quality

• Served as examiner for the Malcolm Baldrige National Quality Award and the Kentucky Center for Performance Excellence Award

AUGUST 2014

our community telling me that they are seeing the “new St. Anthony’s.” These comments continue to confirm that the entire healthcare team’s hard work in reducing the time our patients spend in the Emergency Department, reducing infection rates, improving the quality of care by following evidence-based medicine practices, eliminating hospital- acquired conditions or “never events,” reducing our unnecessary or preventable hospital readmissions and improving our patient experience are being noticed. We are building new stories about St. Anthony’s.

What small steps can our employees take to improve their quality of care on a daily basis? I am an avid football fan, and I once heard a coach say, “The goal today is to become faster, stronger and smarter than we were yesterday.” I believe that we can apply this concept to our daily work. We should strive to provide better care today than we did yesterday. This could be as simple as smiling more when we greet our patients, families and each other; improving the care we provide to our patients by expanding our knowledge and

abilities; taking the time to make sure we are following evidence-based medicine practices when caring for our patients; and truly believing that each of us “own quality and patient safety.”

Tell us about your family and hobbies.Last month, my wife, Nancy, and I celebrated our 35th wedding anniversary. As they say, time flies when you are having fun. Family is very important to us, and now that our two children are grown and have families of their own we spend our time traveling and visiting them. Brian lives in the Kansas City area; Ashley, at the Lake of the Ozarks; and our mothers, in Salem, Missouri. Nancy and I have been MIZZOU season-ticket holders for years and have also enjoyed rejoining the Cardinal Nation. Nancy and I also enjoy spending time on the family farm near Salem or hiking in the beautiful state and national parks.

Jim Tune

“We should strive to provide better care today than we did yesterday.”

Jim with his wife, Nancy

AUGUST 2014

PREVIOUS POSITIONS

• Former paramedic and respiratory therapist

• Has served 25 years in the quality field

• Director of Quality and Performance Engineering, Boone Hospital Center

• Before coming to St. Anthony’s in 2013, served five years as Vice President of Clinical Effectiveness for Ephraim McDowell Health System near Lexington, Ky.

Spotlight is published quarterly by the Marketing Department of St. Anthony’s Medical Center.

Writer: Robbi Courtaway, ext. 4003 Photography: Christy Siebert, ext. 4934 Graphic design: Stephen Walker, ext. 4767

S P O T L I G H T O N

Patient Safety

8

After joining St. Anthony’s in September as Director of Medical-Surgical Services, Karen Gist observed in three of her areas problems with patients falling and injuring themselves.

“We knew that we needed to do something to improve the safety of our patients,” Gist said. “I was very committed to doing that.”

Gist worked with Quality Management and Education in February to establish a fall-prevention steering committee and a hands-on, multidisciplinary workgroup, headed by Beth Riemer, nurse manager of the fifth floor. They developed a program that has achieved a 23 percent reduction in patient falls since it went live April 1.

“In my experience, it’s a best practice to involve all the disciplines,” Gist said. “For instance, Pharmacy (Sara Gibson). Our patients often are on so many medications, it puts them at a high risk for falls. Most importantly, we wanted to prevent injuries to our patients who do fall. Having Supply Chain (Jim Gleich) there, we knew there were helmets and hip pads that could help. The mortality rate is high for elderly people with hip fractures.”

The old program took a cookie-cutter approach, Riemer said. “You didn’t know why the person was a fall risk: you just knew they were,

because all the interventions were the same for everyone.” she said. “Now, among other measures, we have a risk assessment tool. For instance, does my patient have cognition issues? Specific interventions go with that, such as taking them to the bathroom regularly, since they may not remember that they need to ask for help. We’ve also added injury risk questions. If they’re older and have osteoporosis, they may need a hip protector and helmet.”

Every patient door now has a sign on which staff indicate fall and/or injury risk, and the assistance necessary to help the patient get out of bed. This allows anyone entering the room to help the patient immediately.

“Our caregivers have embraced the program and made it an integral part of their daily practice,” Riemer said. “They own patient safety.”

Fall- and injury-prevention program protects patientsEvidence-based practice:

Nurse Assistant Amy Klotz uses a gait belt to help her patient, Larry Leidner.

Send us your

FEEDBACK!We want to know what you think about Spotlight Magazine. Take our quick survey and be entered into a drawing for a $50 Target Gift Card!

Visit surveymonkey.com/s/SpotlightSurvey2014