QUALITY

Improving Quality and Safety at SVMC

Contact Patient Safety
(802) 447-4054
100 Hospital Drive
Bennington, VT 05201
mac1@phin.org

Quality and safety has always been important in health care, but only recently have hospitals focused on improving the systems that doctors and nurses use to provide care. Read on to learn more about how SVMC is working to make our hospital the safest in the nation.

Improving Culture of Safety in the Intensive Care Unit By Improving Nurse-Physician Communication

Problem: 

• The Intensive Care Unit’s (ICU) survey on culture of safety climate showed opportunities for improvement in communication, teamwork and handoffs/ transitions of care. 
• When asked how the next patient would be harmed, ICU staff and physicians cited lack of clarity around the patient’s plan of care and daily goals as their top concern.
• Communication failures were at the root of several recent patient events in the ICU.

Goal: 
To improve the ICU’s culture of safety and reduce the incidence of adverse events through a clinician-driven project to establish a process for clear and direct communication about patients plans of care and daily goals.

Intervention:

• Trained unit leaders in performance improvement methodology and educated all staff on the “Science of Safety”.
• Changed the structure of shift-to-shift handoffs between nurses.
• Established a model for RN-MD team rounding and expectation for face-to-face communication at the patient’s bedside
• Implemented a process for team-based daily goal setting.

Results:

• Improvement in positive responses to all patient safety survey questions. Highlights include:       
  • 39% to 75% improvement in “we discuss ways to prevent errors from happening again”
  • 52% to 79% improvement in “staff not afraid to ask questions when something doesn’t seem right”
  • 77% to 96% improvement in “we work together as a team to get the work done”
  • 74% to 88% improvement in “staff will freely speak up if something may negatively affect patient care”
• 17% increase in patient satisfaction regarding MD-RN consistency in providing information & care 
• No adverse events related to communication breakdowns.
• Marked decrease in physician pages regarding patient goals and care plans

Embedding Diabetes Education into the Medical Home Setting

Background/Problem:
Several years ago, staff at Deerfield Valley Health Service in Wilmington saw a need to help patients better manage their diabetes before they landed in the hospital’s Emergency Department. The practice attempted to provide diabetes education whenever they could fit it into their schedule or when there was a critical need.

One of the nurses with a certification in diabetes education decided to launch a pilot project that would imbed diabetes education services, one-on-one meetings and group sessions into the routine care of patients. The premise of the pilot was to provide timely appointments and initiation of treatment in order to help patients proactively manage their disease. If the pilot was successful, the program would be expanded to other primary care practices.

Goal: 
To improve the health outcomes of the population with diabetes and other related conditions by developing a comprehensive program that is patient-centric, embedded in the community, and focused on prevention, disease management, education and support by qualified interdisciplinary providers.

Description of the Intervention/Initiative/Activity:
A certified Diabetes Educator provided diabetes education to patients eight hours per week. Appointments were scheduled adjacent to provider appointments for patient convenience.

The one year pilot was successful as evidenced by a reduction in A1C (levels of sugar in the blood) in the majority of patients participating in the program. These results coupled with positive feedback from patients and providers assured support for implementation at a second primary care practice commencing in 2013.

In an effort to be pro-active and build a case-load, they identified patients who would benefit from this service and, within 3 months, referrals from providers, clinical staff and chart reviews resulted in building a caseload of over 20 patients who met with the Diabetes Educator. Over the next 12 months, the educator provided services to over 90 patients who had between 1-6 visits depending on their compliance and diabetes management.

Outcomes:

• Diabetes patients participating in the program sustained an average A1C of >8%. Evidenced-based research shows that long term complications associated with diabetes occurs with A1C levels of 8% or greater.
• Although data appeared variable during the intervention phase, in the post intervention phase A1C levels were less than 8% and this effect was sustained for a full 12 months after the intervention phase.

This supports that Diabetes Education/training imbedded within the primary care practices is cost-effective and improves health outcomes as patients maintain better control of their A1C. 

Improving the Care of Patients Diagnosed with Asthma in a Primary Care Practice

Background/Problem: 
The majority of 581 patients seen at a primary care practice had a diagnosis of asthma. These patients received treatment for their asthma only when there was an exacerbation of their symptoms. In addition to seeking care from their primary care physicians, these patients also had frequent Emergency Room visits, hospitalizations and/or urgent care visits. Only 3% of these asthma patients had had incentive spirometry testing despite the effectiveness of the test in measuring severity of a patient’s asthma and classifying the amount of obstruction for diagnosis and disease management. Recognizing the need to shift from providing reactive care of acute episodes to helping patients prevent attacks from occurring in the first place, the practice implemented a program designed to help patients proactively manage their asthma.

Goal: 
A goal was set by the practice to have incentive spirometry testing performed and documented on at least 50% of the patient population.

Intervention:
The practice developed and implemented policies and protocols for managing patients’ asthma based on National Jewish Health NAEPP/NHLBI evidence-based guidelines. Included were newly implemented processes for planned visits for patients with asthma, panel management to assure that patients are seen routinely, and care management and care coordination for asthma patients who are identified as high risk. Among others, the practice established a nurse-driven protocol for spirometry testing on all of the practice’s asthma patients to help determine level of risk as well as control of the disease over time.

Outcomes:
The implementation of the new nurse-driven approach to managing their patients with asthma resulted in an improvement in nursing practice related to the identification of patient level of risk and control over disease over time. Four hundred and fifty-eight patients diagnosed with asthma, or 84% of patients, have been in for a “routine” asthma visit. The goal to improve the percentage of patient receiving incentive spirometry has increased from 3% pre-intervention to 54% post-intervention.