SE11 ExA Advocate BroMenn Medical Center 1

Structural Empowerment COMMITMENT TO PROFESSIONAL DEVELOPMENT

SE11 - Nurses are recognized for their contributions in addressing the strategic priorities of the organization.

Example A: Provide one example, with supporting evidence, of recognition of a clinical nurse for his or her contribution(s) in addressing the strategic priorities of the organization.

Organizational Strategic Priority and Recognition

Safety is a priority at Advocate BroMenn Medical Center (ABMC) and for the entire Advocate Health Care (AHC) system, as reflected in the ABMC Strategic Framework, Key Result Areas and the Advocate Experience. In support of a systematic approach to achieve and sustain excellence, AHC utilizes a balanced scorecard involving six Key Result Areas 1) Safety, 2) Quality, 3) Service, 4) Growth, 5) Funding our Future, and 6) Coordinated Care. AHC’s vision is to be a faith-based system providing the safest environment and best health outcomes while building lifelong relationships with the people they serve (Exhibit SE11.A.1 Advocate 2020 Mission, Values, Philosophy). ABMC lives its Mission, Values, and Philosophy through the Advocate Experience. The Advocate Experience is the commitment to create the safest and best place for patients to heal, physicians to practice and associates to work - Always. The 2015 ABMC Integrated Quality and Safety Plan highlights safety as an important priority (Exhibit SE11.A.2 ABMC Integrated Quality and Patient Safety Plan 2015).

Each year, nominations are submitted by leaders and associates across the AHC system to recognize individuals and groups who exemplify the attributes of a safety leader. Nominations are submitted utilizing the Safety Star Form (Exhibit SE11.A.3 Safety Star Form). At ABMC, the Patient Safety Committee reviews the nominations and then selects the winner of the annual award.

Clinical Nurse Contribution and Recognition

Whitney Waldschmidt, BSN, RN, a new nursing graduate and clinical nurse on 6 West Surgical Unit since May 2014, was awarded the 2015 ABMC Safety Leader Award.

Whitney cared for a patient on two consecutive days. The patient was scheduled for surgery late in the evening of the second day. When Whitney assessed the patient, she noted a low grade fever, brown urine and low urinary output. Whitney initiated the sepsis screen, and upon finding that it was positive for severe sepsis, notified the patient’s primary care physician, her charge nurse, and the critical care charge nurse. Whitney was concerned about the changes in the patient’s condition and utilized the safety behavior of ARCC (Ask a question, Make a Request, Voice a Concern, Activate the Chain of Command) to address the patient’s needs. Due to Whitney’s persistence

SE11 ExA Advocate BroMenn Medical Center 2

in moving up the chain of command when she did not initially receive the response she needed, the patient received earlier treatment and recovered successfully.

Whitney was awarded the 2015 Safety Leader award on March 4, 2015 by William Santuli, MS, FACHE, AHC’s Executive Vice President and Chief Operating Officer, and Lee Sacks, MD, Executive Vice President and Chief Medical Officer, at the ABMC Associate Forum. Whitney received a personal plaque to share with her family. Her name was also engraved on the Annual Safety Award plaque which is displayed in the medical center Atrium. In recognition of her contribution to patient safety, Whitney’s picture and story were shared throughout the medical center on computer screen savers and on a poster display (Exhibit SE11.A.4 Safety Award Poster 2015). It is through associates like Whitney that AHC and ABMC will achieve the goal to be the safest and best place for patients to heal, physicians to practice, and associates to work-Always.

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Exhibit SE11.A.1 Advocate BroMenn Medical Center

2015 Quality & Patient Safety Plan

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Integrated Quality and Patient Safety Plan

2015

I. Philosophy and Framework

In support of Advocate’s vision to be a faith-based system providing the safest environment and best

health outcomes while building lifelong relationships with the people we serve, the core value of

excellence is fundamental. Excellence at Advocate Health Care is defined as empowering people

to continually improve the outcomes of our service, to advance quality, and to increase innovation

and openness to new ideas.

In support of a systematic approach to achieve and sustain excellence, Advocate Health Care

utilizes a balanced scorecard involving six Key Result Areas (KRA’s):

• Safety and Quality

• Service

• Growth

• Funding Our Future

• Coordinated Care

Advocate lives our MVP through the Advocate Experience, with our commitment to create the

safest and best place for our patients, associates and physicians – always. The Advocate

Experience is:

• An experience without harm – Safety

• An experience of excellence – Quality

• An experience of engagement and trust – Service

• Always

II. Quality Management System

Quality Policy: The leadership and associates of Advocate Health Care execute our quality policy

through our quality management system and a commitment to continual improvement to enhance

patient safety, health outcomes, operational excellence, and patient satisfaction. Quality and

Patient Safety Plans are maintained by the sites to provide operational framework.

Advocate Health Care is committed to evidence-based performance improvement using a holistic

approach to problem solving. The organization is steeped in a culture of continual improvement

to enhance patient safety, health outcomes, service and operational excellence from the patient’s

perspective. Accountability for performance is addressed through an objective leadership

evaluation system in which management performance objectives directly align to KRA

performance.

Performance improvement initiatives are driven by performance gaps as measured by KRA’s and

opportunities identified by leadership. Advocate’s measurement philosophy is supported by a

robust business intelligence environment:

• Responsible leadership demands familiarity with and rigorous use of data

Exhibit SE11.A.2 Advocate BroMenn Medical Center

2015 Quality & Patient Safety Plan

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• Processes are in place to accurately and consistently obtain a balanced set of measures that

monitor health outcomes, customer satisfaction, functional status, and resource utilization

that ultimately supports a culture of accountability

• Data driven decisions are made that assist in identifying opportunities and corresponding

improvement strategies

ISO 9001 is the foundation for performance improvement for Advocate. The ISO foundation

includes a holistic approach to performance improvement methods that includes PDSA as the core

performance improvement approach and includes the Change Acceleration Process (CAP), Lean

and Six Sigma tools and methodologies. The Change Acceleration Process is a change model

designed to increase the success and accelerate the implementation of organizational change

efforts. It addresses how to create a shared need for the change; understand and deal with

resistance from key stakeholders; and build an effective strategy and communication plan for the

change. Lean Six Sigma is a business process philosophy that focuses on the customer and

increasing value and improving quality, safety and productivity. Recognizing the complementary

nature of the two methodologies, Advocate uses a blended approach of Lean and Six Sigma

concurrently, utilizing different tools to address specific improvement problems along a value

stream and/or project.

The 2015 KRAs are listed in the 2015 Balanced Scorecard posted on the intranet.

A. Quality Management System Oversight and Structure

The Advocate Health Care Board of Directors oversees the business management functions of the

Advocate System. There is two way communication and interaction between the Board and

Advocate system senior leadership and the site Governing Councils. The system ISO 9001 Quality

Management Review Committee interacts and is accountable to these two groups. The Medical

Executive Committees at each hospital report to the site Governing Councils. The site Quality

Management Oversight Committees report to the site Governing Councils and to the system

Quality Management Oversight Committee. The system and site Quality Management Oversight

Committees provide leadership and resources to support the quality management system

objectives.

For the purposes of quality review, improved patient outcomes and reduction in morbidity and

mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee

will designate specific site committees to provide professional and peer self-evaluation of the

adequacy of patient care. These may include but are not limited to:

• Patient Safety Committees

• Health Outcomes Committees

• Morbidity and Mortality Committees

• Peer Review Committees

• Cause Analysis Committees

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The system and each hospital have a Quality Management Representative. The site Quality

Management Representatives report site information to the system Quality Management

Representative.

The Advocate Health Care Quality Manual provides an overview of the Quality Management

System. Results from the quality management system audits, corrective and preventive actions

will be reviewed and acted upon by the Quality Management Review Committees at the site and

system level.

B. Quality Management System Metrics

The following are required to be reported to the Quality Management Oversight Committee:

• Results of Quality Management System (QMS) audits

• Patient feedback

• Process performance and product conformity

• Status of preventive and corrective actions

• Follow-up actions from previous management reviews

• Changes that could affect the QMS, and

• Recommendations for improvement.

Additional data may also be submitted.

III. Patient Safety Program

The goal of Advocate’s patient safety program is to eliminate all events of serious harm within

the system by December 31, 2020, with a target of achieving an 80% reduction in the rate of

serious events between 2013 and 2017.

In 2012, a strategic plan for patient safety was completed and implementation initiated. This plan

maps out a multi-year plan for achieving high reliability in care delivery across Advocate. The

development of the plan involved the collective efforts of key executive leaders from across the

system, site and system patient safety leaders as content experts together with input from front

line associates and physicians. The strategic plan outlines four key strategies, including:

1. Establish patient safety as the foundation of care

2. Teach leaders how to lead to safety

3. Empower the front line to address safety issues

4. Engage patients and families in patient safety

The strategic plan will serve as the primary roadmap for operational work in patient safety for the

system in the near future. In 2014, the focus of the patient safety program included:

1. Completion of the high reliability leader training series.

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2. Greater focus on the integration of the Advocate Experience through the development of a

Leader tool box for safety, quality and service.

3. Initiation of actions to address items on the Safety Top Ten list.

4. Improved reporting of patient safety events.

5. Establishing a baseline for Advocate’s hospital Serious Safety Event Rate.

6. Full standardization of the RCA process throughout the system.

7. Realignment of the patient safety reporting structure across the system to enable safety

standard work.

8. Implementation of the updated version of the Cause Analysis Database (CAD 2.0) for the

collection and utilization of system causal data.

9. Improved focus and utilization of Advocate’s Just Culture Decision Matrix.

In 2015, the focus of the patient safety program as outlined in the strategic plan strategies and

tactics will include:

1. Transition from a primary focus on leadership to a focus on safety at the front line through the

creation of High Reliability Units (HRUs). HRUs will be clinical departments in which there is a

focused training effort in high reliability healthcare, training on error prevention techniques,

coaching to integrate the techniques into front line clinical work, and front-line problem

solving with issues that impact the safety of care delivered.

2. Engagement of the front line in safety efforts through implementation of a Safety Coach and

Physician Champion program

3. Launch of the system simulation program focused on in-situ simulated learning, along with

establishing the first hospital-based simulation lab.

Classifying and Measuring Patient Harm

Advocate utilizes the Serious Safety Event Rate (SSER), through Healthcare Performance

Improvement (HPI) as the foundational measure of patient harm within the system. The SSER

classifies patient harm according to severity (severe, moderate or minimal) and duration

(temporary or permanent), using standardized definitions. The methodology used also

classifies near miss events based on the type of barrier that prevented the event from reaching

the patient. The SSER will serve as a key metric for the advancement of Advocate toward a

culture of high reliability.

In 2013 Advocate revised the medical staff peer review process in order to align peer review

cases classified as a patient safety event with key reporting metrics. As such, the SSER will

include cases identified as a patient safety event by the peer review process and determined to

be a serious safety event through application of harm classification.

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AHRQ Culture of Safety Survey

Advocate Health Care participates annually in the AHRQ Culture of Safety Survey for associates.

This survey serves as a key metric for the movement towards high reliability facilitated by the

strategic plan. It is the expectation that Advocate sites will implement unit/department based

action planning to facilitate advancement of the culture.

A. Patient Safety Program Oversight and Structure

Advocate’s patient safety program is endorsed by the Advocate Board of Directors. The Health

Outcomes Committee of the Board is the safety and clinical oversight committee of the Board.

Advocate’s Health Outcomes Council oversees the system-wide safety and clinical performance

improvement projects and initiatives. The Health Outcomes Council reports to Advocate's Quality

Management Oversight Committee.

For the purposes of quality review, improved patient outcomes and reduction in morbidity and

mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee

will designate specific site committees to provide professional and peer self-evaluation of the

adequacy of patient care. These may include but are not limited to:

• Patient Safety Committees

• Health Outcomes Committees

• Morbidity and Mortality Committees

• Peer Review Committees

• Cause Analysis Committees

Patient Safety Team

A corporate patient safety department supports system-wide safety initiatives, reports, data,

education and consultation. Strategic collaboration occurs to enhance this work, including but

not limited to:

• The risk management department collaborates with patient safety to reduce and eliminate

actual and potential risk factors that may impact the safety of care provided to our patients.

• The center for health information services (CHIS) oversees system-wide clinical data

measurement, reporting, analytics and provides public data expertise.

• The department of regulatory and clinical projects collaborates to integrate safety with

Advocate’s ISO 9001 Quality Management System, and into the Advocate Experience.

• The patient experience department collaborates to integrate safety into the Advocate

Experience.

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All sites of care within Advocate Health Care have identified safety leaders that report directly to

the system safety department. Additionally, each site has a committee that guides clinical safety

and quality initiatives. Together, leaders at the system and site collaborate on key strategies,

programs and tactics that enhance the safety of the system.

B. Patient Safety System Metrics

A variety of metrics are used in the patient safety program. The majority are included in either

the 2015 Balanced Scorecard or the Safety & Quality Close. Both dashboards are distributed to

sites monthly.

The following are key patient safety metrics for 2015 reported on the Safety & Quality Close and

reported to the Quality Management Oversight Committee:

• Safety Event Reporting Rate

• AHRQ Culture of Safety Survey Results

• Serious Safety Event Rate Change

• Hospital Harm Rate

• RCA Aging

• Medication Scan Rate

• OSHA Illness & Injury Rate

• Mislabeled Specimen Rate

Authorities and Structures that Support Performance Improvement and Patient Safety

at Advocate BroMenn Medical Center

The Advocate BroMenn Medical Center (BroMenn) Quality Management Oversight Council,

together with the Advocate Health Care (AHC) System ISO 9001 Quality Management Oversight

Council, are ultimately responsible for the quality of patient care delivered at the hospital and for

providing the leadership and resources necessary to support the hospital’s quality management

objectives. The Advocate BroMenn and Eureka Governing Council guides the direction of the

hospital’s performance improvement and patient safety programs, and delegates functional

responsibility to Administration, the BroMenn Quality Management Oversight Council, and the

Executive Committee of the Medical Staff to implement and maintain the scope of activities

addressed in this plan. Authority for these activities is further delineated in the Medical Staff

Bylaws/Rules and Regulations, a variety of hospital committee and council charters, and at times,

hospital policy and procedure.

The organization structure and reporting of activities addressed in this plan are illustrated within

the BroMenn Quality Management Oversight Reporting Structure, which has been included as an

attachment to this document. A Quality Management Reporting Plan is established annually,

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outlining the information to be reported to the Quality Management Oversight Committee over

the course of the year. In addition, a listing of Performance Improvement Priorities is established

annually, outlining the hospital’s performance improvement initiatives, development in

conjunction with the Advocate Health Care KRA structure.

VI. Attachments

BroMenn Quality Management Oversight Reporting Structure

Exhibit SE11.A.3 Advocate BroMenn Medical Center

2015 BroMenn Safety Leader

Whitney Waldschmidt, 6 West

Whitney, a new nursing graduate, used a questioning attitude when a patient she was caring for started to exhibit signs and symptoms of severe sepsis. Whitney contacted the resident who did not agree with Whitney’s concerns and provided no new orders. Still concerned with the patient’s deteriorating condition, she used ARCC and contacted the Critical Care Charge Nurse as well as the surgeon with her concerns in patient condition. The patient was subsequently taken to surgery earlier than scheduled and recovered successfully.