Target Zero Harm: Our Q4 Patient Safety Wins and Winners
Target Zero Harm is on Inside Carilion and in the ePulse every quarter to keep you in the know about the great work that's happening systemwide to keep our patients and team members safe—and how you can help! Check it out and watch for other stories that demonstrate our commitment to quality and patient and staff safety.
Keeping our patients safe isn’t as easy as following one formula or a single set of rules. It requires research, process improvement, practice—and connecting with resources that help us build on our strengths.
We work with many organizations and resources that help us ensure we’re delivering quality care to our patients and community, including the American College of Surgeons (ACS). The ACS has a long history of helping patient care providers and health care organizations improve how they care for patients.
I’m pleased to share that our work with them – which involved an extensive two-day virtual site visit in 2023 – has landed us a designation few hospitals receive. Learn more about how our surgical team earned the ACS Quality Verification Program designation in the team spotlight below.
Whatever our role and wherever we work, we all play a part in improving patient care. I want to encourage everyone – from non-clinical staff to physicians, nurses and other clinicians – to engage in finding ways to take even better care of our patients. We can’t rely on what we’ve always done because there’s always room to hone our processes and best practices to get better outcomes.
Being a leader in both Clinical Advancement and Patient Safety, and the Department of Surgery, gives me a unique opportunity to help influence work in both areas by communicating priorities and sharing information between the two groups to act on change at a system level.
This edition of Target Zero Harm is just a snapshot of the amazing work happening across the system. Thank you for your part in keeping our patients safe and striving to give them the best possible experience and outcome. – Jacob Gillen, M.D., FACS, MHCDS, Associate Chief Quality Officer and Medical Director of Surgical Quality
New Designation!
We are the second health system in Virginia, and one of only 17 in the nation, to receive the Focused Verification designation from the American College of Surgeons (ACS) Quality Verification Program (QVP). This program evaluates surgical quality across all surgical specialties at CRCH and CRMH.
Being an ACS Quality Partner demonstrates our commitment to giving our surgical teams the tools and resources they need—like the best data, expert input and proven processes—so they can deliver the highest quality care. Learn more in the spotlight below.
Our Annual Quality Report
This one-page front-and-back fact sheet highlights many of our organization’s achievements in 2023. You can also find it on the Quality and Patient Safety page on CarilionClinic.org.
The report gives us an opportunity to show our patients and community how we work to keep them safe and provide quality care—and also celebrate your amazing work, including the great news about our Quality Verification Program designation (below).
Pediatrics
CRMH's PICU is celebrating a remarkable achievement! Their leaders and staff exceeded their goal of reducing the Carilion Children’s unplanned extubation rate by 20% by Dec.31, 2023. Between January 2022 and December 2023, they successfully reduced their UE rate from 1.54 to 1—a 35% decrease! Check out Carilion Children's other accomplishments for 2023:
"I'm extremely proud of the work we have done here," said senior director Karrie Moses. "We have been able to accomplish these goals by restructuring our pediatric quality and safety program to help break down silos. It has also been helpful to communicate more frequently with staff about performance, deep-dive findings and education reminders.”
imPACT Awards
The first imPACT award winners have been selected! Congratulations to the following:
- Bethany David, R.N. on 7S ICU is our inaugural individual winner. She was nominated by a fellow nurse who noted her critical thinking and applauded her curiosity, which prevented continuation of an unnecessary treatment upon arrival to Carilion that could have been potentially harmful to her patient.
- The Emergency Department (ED) not only won the first team imPACT award, but also inspired its development. The ED was nominated for demonstrating exceptional care and rapid treatment for a patient with a ruptured AAA. This care team showed fantastic communication and flawless movement and collaboration with different hospital departments.
- Ellen Harvey, DNP, APRN, ACNS-BC, CCRN, TCRN, SCRN, FCCM, recently won the imPACT award in celebration of her dedication to best practice. She was nominated for her work to ensure best practices for SCDs, armbands and oral care through staff and patient education.
The imPACT award recognizes excellence in Practice And Clinical Transformation related to bedside care, documentation, standardized order-set utilization and guideline adherence. Submit nominations online!
Great Catches
You reported 9,200 Great Catches for calendar year 2023! That is an increase by 2,000 from calendar year 2022 and makes five years in a row with over 6,000 Great Catches! That means you helped us prevent harm and make improvements to keep our patients safe by reporting 37,000 unsafe conditions and near misses in the past five years. Great work, everyone!
Being a Surgical Quality Partner with the American College of Surgeons (ACS) means you have met the gold standard in the nation and the world for providing the highest quality of surgical care to your patients—and it’s a designation our surgical team has proudly received! This hard-earned designation represents our dedication to quality and ongoing self-improvement, showing our patients they can trust the care they receive from us because as a Surgical Quality Partner hospital we adhere to the most rigorous standards in surgical quality.
These leaders led the charge to participate in the ACS Quality Verification Program (QVP), which offers hospitals a proven, standardized method for establishing, measuring and improving their quality structure across all surgical departments.
“The ACS QVP helps hospitals assess and implement the infrastructure needed to ensure optimal surgical quality and patient safety,” says Dr. Lucktong, General Surgery. “Through this program, our medical center has gained a more comprehensive understanding of the processes and resources we have in place to provide the best care to our patients.”
“Our job as a surgical quality department is to make sure patient outcomes are as good as possible and to always strive to be better,” says Dr. Gillen. “Working with ACS gives us the opportunity and tools to look at our systems and processes to see how we collectively can do better.”
After nearly a year of reviewing surgical processes and outcomes for every specialty and collecting documents and data from departments across our system to submit to ACS, we had an extensive two-day virtual visit with the ACS. They interviewed our surgeons, examined peer reviews, physician credentials, our leadership structure and quality culture, among other details, to evaluate outcomes and surgical quality across all surgical specialties in Roanoke (CRMH and CRCH). Ultimately, we received the ‘Focused Verification’ designation from the ACS Quality Verification Program (QVP).
“I’m so proud of the work that’s been done,” says Jami Salzberg, Nursing senior director. “This designation shows our team works really, really hard to protect and care for our patients – knowing we always have opportunities to learn and grow.”
“To me, this verification program means that we have a good quality program in place that allows us to continue to improve, develop and provide excellence in surgical care, which leads to greater outcomes of healing, decreased complications and lower costs” says Cindy Hodges, ORS unit director, Quality. “These are all benefits for our patients and our organization.”
If you have any questions or content suggestions for Target Zero Harm, contact Shawn Blackwell, CAPS Process Improvement, at sablackwell@carilionclinic.org.
