Clinical Excellence has been a priority for Ascension Health since it was established in 1999.  Healthcare That Is Safe is a priority reflected in our Strategic Direction along with Healthcare That Works and Healthcare That Leaves No One Behind.

Healthcare That Is Safe is defined by our Clinical Excellence goal:  The care we deliver will be safe and effective.  We commit to having excellent clinical care with no preventable injuries or deaths by July of 2008. 

Learn more about Ascension Health’s commitment to clinical excellence:

• Clinical Excellence
• Healthcare That Is Safe
• Destination Statement II
• Priorities for Action
• Adverse Drug Events
• Mortality Reduction
• Falls and Fall Injuries
• Nosocomial Infections
• Perinatal Safety
• Pressure Ulcers
• Surgical Complications
• Joint Commission National Patient Safety Goals
• Alpha Sites
• Patient Safety Center
• Safety Climate Survey
• safERSystem^TM
• SMART²
• Clinical Foundation Suite
• Nursing Leadership
• Transforming Care at the Bedside
• Caregiver Pipeline
• Healthcare That Works
• Time and Motion Study
• Robert Wood Johnson Foundation
• Nursing Plans of Care
• Physician Alignment
• Physician Experience
• Physician Formation
• Physician Leadership
• Peer Review
• Disclosure of Unanticipated Outcomes and Medical Errors
• Collaboration
• Supply Chain
• Institute for Healthcare Improvement
• 100,000 Lives Campaign
• Faith Community Nursing (formerly Known as Parish Nursing)
• Spread

All of the Clinical Excellence work is based on Destination Statement II, developed by clinical leadership across Ascension Health.  

Destination Statement II
Answering the Call

Together as a ministry, Ascension Health has committed to a Call to Action that defines our purpose and priorities as we lead the transformation of healthcare. This Call includes responsibility in improving healthcare quality and reducing medical errors.  With this document, the Clinical Excellence Team articulates the vision and principles for transforming Ascension Health to provide Healthcare That Is Safe. 

Destination Statement II builds on the foundational work of the Clinical Excellence Team and on that of others, particularly Crossing the Quality Chasm, the Institute of Medicine’s blueprint for creating a new 21st century health system. Destination Statement II was developed in the spirit of leadership and support to all associates of Ascension Health and to those we serve.

To answer the Call, we incorporate the Institute of Medicine’s six aims for improvement of care (Crossing the Quality Chasm, 2001).  As a ministry, we believe the spirit also represents a significant dimension of health. Therefore, we hold that healthcare should be: safe, effective, patient-centered, timely, efficient, equitable and spiritual.

These seven aims guide our efforts in pursuit of our Clinical Excellence goal: The care we deliver will be safe and effective. We commit to having excellent clinical care with no preventable injuries or deaths in five years (by the end of fiscal year 2008).

Ascension Health has developed a manuscript "The Clinical Transformation of Ascension Health: Eliminating All Preventable Injuries and Deaths" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

The Clinical Excellence Team embraces 10 rules for transformation of the healthcare system as outlined in Crossing the Quality Chasm.

1. Care is based on continuous healing relationships
2. Care is customized according to patient needs and values
3. The patient is the source of control
4. Knowledge is shared and information flows freely
5. Decision making is evidence-based
6. Safety is a system property
7. Transparency is necessary
8. Needs are anticipated
9. Waste is continuously decreased
10. Cooperation among clinicians is a priority

Making these rules a reality requires that they become a priority within each ministry.  We commit to eliminating five significant challenges in how we work together to accelerate our quality transformation:

1. Our culture must embrace the safety imperative at all levels.
2. We must standardize and eliminate variation across our health system where doing so provides benefit.
3. Every associate must understand the business case for safety.
4. We must invest in infrastructure.
5. Our work model must recognize the benefits from diverse approaches to safety in our health ministries while embracing the advantages of working collaboratively as a system.

To evaluate our progress over five years, we define three categories of measurement and commit to their use across Ascension Health:

• Long-range goals that identify the specific achievement targeted for the five-year period, such as the elimination of preventable injuries and deaths
• Outcome measures that track actual clinical outcomes, such as total risk-adjusted patient mortality rate
• Process measures that ensure that the way we work supports our long-term goals, such as protocols and practice bundles to improve care.

We fulfill the Mission of Ascension Health by transforming our health system in response to the Call to Action.  In turn we contribute our leadership in the national effort to improve healthcare.

To achieve our goal of zero preventable injuries or death by July of 2008, we developed eight Priorities for Action.  All of the Ascension Health Ministries are working on Adverse Drug Events, Mortality Reduction and the Joint Commission National Patient Safety Goals.  Specific Health Ministries, called Alpha sites, have been working on one or more of the Priorities for Action. 

As Alpha sites have lessons to share about their Priority for Action, they begin to spread it to other Health Ministries across the country.  We believe that in order achieve our goal of zero preventable injuries and deaths, we must share information and learn from each others’ successes and failures.

Priorities for Action

Adverse Drug Events (ADEs)

The Adverse Drug Events (ADEs) Priority for Action is focused on four areas that have been identified as having the most promise for eradicating ADEs – anticoagulants, insulin, medication reconciliation and narcotics/sedatives.

Ascension Health has developed a manuscript "Eliminating Adverse Drug Events at Ascension Health" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

Mortality Reduction

The Mortality Reduction Priority for Action is looking at reducing hospital mortality with a special emphasis on compassionate care of the terminally ill, unexpected mortality of patients and the proper placement of critically ill patients into the ICU.  Six tactics are being used to reduce mortality include:  Rapid Response Teams (RRTs); controlling patient blood sugars; SBAR Communication; Multidisciplinary Rounds, Ventilator Associated Pneumonia bundles; and Central Line Blood Stream Infections bundles.

Ascension Health has developed a manuscript "Eliminating Preventable Death at Ascension Health" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

Joint Commission National Patient Safety Goals

The Joint Commission on Accreditation of Healthcare Organizations has developed National Patient Safety Goals for every hospital in the country.  All Ascension Health hospitals are required to be in compliance with the Joint Commission goals.  For more information, go to: http://www.jointcommission.org

Ascension Health is developing 10 manuscripts for the Joint Commission Journal on Quality and Patient Safety. The Journal is a peer-reviewed publication that serves as a forum for practical approaches to improving quality and safety in healthcare. Manuscripts will be published in the Journal every other month through November 2007. Following publication of the last manuscript, all of the articles will be put together in a book that will chronicle Ascension Health's transformation of healthcare. Manuscripts include:

• The Clinical Transformation of Ascension Health: Eliminating All Preventable Injuries and Deaths
• A Leadership Framework for Culture Change in Health Care
• Eliminating Facility-Acquired Pressure Ulcers at Ascension Health
• Eliminating Nosocomial Infections at Ascension Health
• Eliminating Birth Trauma at Ascension Health
• Eliminating Preventable Death at Ascension Health
• Eliminating Perioperative Adverse Events at Ascension Health
• Preventing Falls and Eliminating Injury at Ascension Health
• Eliminating Adverse Drug Events at Ascension Health
• Journey to Zero

Falls and Fall Injuries

The Falls and Fall Injuries team is looking at ways to eliminate patient falls and injuries by identifying known risk factors at admission and at change of caregiver, using a standardized risk assessment tool (e.g., Hendrich II Fall Risk Model), and implementing fall risk prevention strategies such as staff education about the prevalence and detrimental outcomes that falls have on our patients, using posters and colored red socks to identify patients at risk for falling.  All of the Ascension Health Ministries are involved in this initiative.

Ascension Health has developed a manuscript "Preventing Falls and Eliminating Injury at Ascension Health" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

Nosocomial Infections

Hospital Acquired, or Nosocomial Infections, work is focused on two key areas:  reducing hospital acquired infections and improving communication among care team members.  In order to reduce Nosocomial Infections the Alpha sites are working on eliminating Central Line Blood Stream Infection; eliminating Ventilator Associate Pneumonia; eliminating Urinary Tract Infections; and, implementing Multidisciplinary Rounds.

Ascension Health has developed a manuscript "Eliminating Nosocomial Infections at Ascension Health" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

Perinatal Safety

The Perinatal Safety Priority for Action is a collaboration between Clinical Excellence and Risk Management.  The main objective of the Perinatal Safety initiative is to improve safety for mothers and babies and achieve zero preventable birth traumas to the neonate through the Ascension Health HANDS (Handling All Neonatal Deliveries Safely) program.  This will be achieved by creating high-reliability OB Units that implement evidence-based obstetrical practices.  Ultimately, improvement in safety for mothers and babies will not only improve care, but also reduce potential claims against Ascension Health Ministries.

Ascension Health has developed a manuscript "Eliminating Birth Trauma at Ascension Health" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

Pressure Ulcers

The goal of the Pressure Ulcers Priority for Action is to eliminate all facility acquired pressure ulcers by December of 2006.  Ascension Health nursing leadership has committed to 100 percent participation in the Pressure Ulcers initiative.  To achieve zero facility acquired pressures ulcers, the teams use the Braden Scale for standardized assessment of patients and they use the SKIN Bundle (Surface selection, Keep them turning, Incontinence management an Nutrition support) as the standardized plan of care for patients at risk for pressure ulcers. 

Ascension Health has developed a manuscript "Eliminating Facility-Acquired Pressure Ulcers at Ascension Health" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

Surgical Complications

The Surgical Complications Priority for Action goal is to reduce harm in the operating room by 50 percent. To achieve this goal, the Alpha sites are focused on four main areas that include:  surgical site infections; peri-operative myocardial infarction; post-operative hemorrhage; and, post-operative deep vein thrombosis. The Alpha sites have implemented several initiatives that have successfully reduced harm in the operating room and the include:  pre-procedural briefings; pre-procedure risk assessments to identify cardiac, bleeding and DVT risks; maintaining body temperature and normal blood sugar levels; no razor use at surgical site, appropriate use: and management of prophylactic antibiotics. In addition, Ascension Health is a Partner Organization with the Surgical Complications Improvement Project being lead by the Centers for Medicare and Medicaid.

Ascension Health has developed a manuscript "Eliminating Perioperative Adverse Events at Ascension Health" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

In addition to the Priorities for Action, we are working on other initiatives that will help us achieve our goal of care that is safe and effective with no preventable injuries or deaths.  These additional strategies have been adopted in order to improve the safety culture across Ascension Health, to truly transform healthcare as we know it. 

Ascension Health has developed a manuscript "A Leadership Framework for Culture Change in Health Care" for the peer-reviewed Joint Commission Journal on Quality and Patient Safety.

Patient Safety Center

The Patient Safety Center is working with Health Ministries across the country to develop a comprehensive patient safety program for Ascension Health. The Patient Safety Center work underscores Ascension Health’s commitment to constantly improving patient safety. 

The Patient Safety Center team, which includes associates from Clinical Excellence and Risk Management, are taking a three-pronged approach to improving patient safety, including: the Patient Safety Climate Survey; safersystem (formerly Event Reporting System ERS); and, Safe Medication Approaches for Reaching Therapeutic Targets (SMART²).

Safety Climate Survey

A culture of safety creates the glue that holds quality and safety improvements in place and keeps us focused on safety and safety improvement opportunities.  Clinical leadership from throughout Ascension Health recognizes and supports the need to measure and understand caregiver attitudes about safety, particularly about patient safety. 

The Safety Climate Survey completed in 2004 established a baseline of the safety climate throughout Ascension Health. The 2004 Survey, which included data from 60 sites and represented more than 28,000 respondents, had an astounding 80 percent response rate.  The Survey measured perceived teamwork climate and safety climate. 

The Safety Climate Survey was administered again in FY06 in order to measure changes over 18 months. 

safERSystem^TM

Ascension Health Ministries are working to build a culture of safety is by identifying and understanding occurrences that cause, or could cause, injury or loss through an event reporting system.  The term has been used by many to describe the web-based tool used to enter and store event data.  However, the event reporting process includes follow-up activities that are used to create a safer healthcare environment. To better reflect the role of event reporting as a central element in creating our safety culture, Ascension Health’s Patient Safety and Event Reporting System has been renamed safersystem^TM.

SMART²

The goal of SMART² is to develop and implement a system for safe and reliable medication practices to eliminate Adverse Drug Events (ADEs), which frequently cause preventable injuries or deaths.  The SMART² team is working on four areas that have been identified as having the most promise for eradicating ADEs:  care transition medication reconciliation; real-time medication administration; medication preparation and distribution processes; and medication selection, order entry and monitoring processes. 

Developing and implementing a safe medication system will not only help eliminate preventable injuries or deaths, but also create an environment that is valued by patients, families, practitioners and communities. 

Infrastructure

Clinical Foundation Suite

The Clinical Foundation Suite (CFS) is an important part of Ascension Health‘s commitment to deliver safe, clinically excellent care. The CFS will create an Electronic Health Record (EHR) for our Health Ministries, encouraging and fostering clinical excellence and operational efficiency across our System.

The CFS will provide the following solutions delivered through software developed by Ascension Health associates and the Cerner Corporation:

Solutions: Access to Care EMR and Results Viewing Orders Management Clinical Documentation Care Plans Rules and Alerts Medication Management Messaging and Workflow Tools Emergency Medicine Critical Care Health Information Management

CFS Capabilities Enterprise Master Person Index Enterprise Scheduling Electronic Medical Record with Results Viewing Nursing Workflow Nutritional Services Workflow Case Management / Social Work / Pastoral Care Workflow Respitory Therapy Workflow Physical/Occupational/Speech Therapy Workflow Pharmacy Physician Workflow Emergency Medicine Critical Care Health Information Management

The Clinical Foundation Suite is being implemented to help ensure the quality and consistency of the care we deliver, regardless of the setting. This in turn means better outcomes for those we serve, fulfilling our commitment to healthy individuals and healthy communities.

Nursing Leadership

Ascension Health nurses have taken a strong leadership role in all of the Clinical Excellence work.  Not only are they providing the highest-quality care to our patients every day, they are also leading the way to the safest healthcare possible for all.  The following nursing initiatives are just a sample of the groundbreaking work they are doing across the country.

Transforming Care at the Bedside

Ascension Health’s Transforming Care project is a collaboration between Healthcare That Works and Healthcare That Is Safe.  This project’s focus is on grassroots innovation, integrative technologies, and nursing leadership to change the way medical/surgical nursing care is provided. The Ascension Health Ministries’ work stems from the Transforming Care at the Bedside (TCAB) project originally funded by Robert Wood Johnson and supported by IHI. Our System’s efforts to spread the innovations and processes pioneered in the TCAB project received an RWJ grant in 2005/2006. The effort to spread the TCAB model system wide started in November 2005 when more than 300 nurses from across Ascension Health came together in a two-day meeting to learn about innovation and accountability in changing bedside care. Since then, units in hospitals throughout the System are applying innovative ideas and empowering med/surg nurses to lead the effort. Four Health Ministries committed to serve as demonstration sites and accelerate the testing and measurement of TCAB principles. They, and all the TCAB units system wide, focus their efforts around four main goals: (1) safe and reliable care, (2) vitality and teamwork, (3) patient-centered care, and (4) value-added care processes

Caregiver Pipeline

Healthcare That Is Safe is working with the Healthcare That Works team, along with the Chief Nursing Officers and Chief Human Resources Officers advisory groups, to advance the work of creating a vital Caregiver Pipeline, designed to ensure an adequate supply of qualified, values-compatible, inspired nurses and allied care professionals to care for those we serve. The work is focused on three areas -- staffing forecasting, travelers/mobility of registered nurses, and education models -- which are discussed in the Caregiver Pipeline area of the Healthcare That Works section.

Time and Motion Study

Nurses from across Ascension Health, Kaiser Permanente and numerous other health systems are participating in the Robert Wood Johnson Time and Motion Study. This Institutional Review Board (IRB) approved national multi-site study collected data from approximately 35 diverse medical surgical units.  The three-part study will establish a baseline of data that will define and describe the impact of variables on nursing time and motion.  The Time and Motion Study has enormous potential to help us learn more about nurse staffing and work environments.  In addition, it will provide evidence-based information for designing nursing units of the future. For more information on the Time and Motion Study, go to http://www.rwjf.org/.

Nursing Plans of Care

Nurses from across the country are participating in eight-week rapid design process to identify evidenced-based best practices that align with the 100 top Diagnosis Related Groupings (DRGs) in Ascension Health facilities.  Currently Ascension Health nurses are working on the first 20 Nursing Plans of Care (NPCs).

Physician Alignment

Ascension Health Ministries are always looking for ways to develop meaningful relationship with their medical staff. Several initiatives are currently being considered to increase our physician loyalty and to attract the best possible physicians in the future. 

Creating the Ascension Health Physician Experience will help create a competitive advantage for all Ascension Health Ministries based on what physicians rank as most important – physician expertise; nursing competency; and, hospital efficiency.

One of the Physician Experience initiatives that is unique to Ascension Health is our work on Physician Formation. Through Physician Formation, Ascension Health Ministries assist caregiver in reconnecting with their call to be healers; encourage physicians to develop a greater understanding of how their personal spirituality impacts their relationship with their patients, peers and practice; and helps physicians understand and live the Mission, Vision, Values and Strategic Direction of Ascension Health.

Physician Leadership Development is one the areas is focusing its efforts to increase physician loyalty and opportunities. Work is currently going on in qualities of effective leadership; communication skills; team development; change management; and, conflict resolution.

In addition, Peer Review is expected to increase quality and safety while reducing costs. Peer Review includes:  technical quality of care; quality of service; resource utilization; peer and coworker relationship; patient safety; and, participation in Medical Staff affairs.

Working with our physicians, Ascension Health is committed to Disclosure of Unanticipated Outcomes and Medical Errors.  Not only is disclosure the right thing, but also it supports our Mission, Vision and Values. Disclosure is expected to build trust among patients; improve patient safety reduce liability costs; and, improve the outcomes for caregivers affected by adverse events.

Collaboration

Ascension Health believes that collaboration is one of the keys to transforming healthcare. Our philosophy of a clinically obligated group is where everyone teaches and everyone learns. The most important forms of collaboration are those that occur from one Health Ministry to another. We are also engaged in multiple internal collaborations such as the ones between our Call to Action strategies of Healthcare That Works and Healthcare That Is Safe, Supply Chain, Risk Management, Information Technology and Finance. Externally, we collaborate with a variety of organizations dedicated to improving patient safety.

Some examples of our external collaboration can be seen in our work with the Institute for Healthcare Improvement (IHI) and the Robert Wood Johnson Foundation (RWJ).  Ascension Health was one of the charter members of IHI’s 100,000 Lives Campaign. Through the 100,000 Lives Campaign hundreds of hospitals and healthcare systems are working to save lives and improve patient care.  For more information, go to http://www.ihi.org/ihi.  Ascension Health and RWJ are currently working on the Transforming Care at the Bedside project and the Time and Motion Study.  For more information, go to http://www.rwjf.org/.

Faith Community Nursing (formerly Known as Parish Nursing)

Ascension Health is recognized as a leader in the field of Faith Community Nursing. (The ANA officially changed the title from Parish Nursing to Faith Community Nursing). A recognized nursing specialty since 1984, Faith Community Nursing focuses on issues of health promotion and disease prevention, health care cost containment, chronic disease management, and culturally sensitive services offering a much-needed safety net in an increasingly complex health care delivery system. Ascension Health is one of the largest sponsors of Faith Community Nursing in the country with more than 1,000 RNs practicing within the specialty. Located in a variety of settings from soup kitchens to mobile vans to traditional faith communities, Ascension Health Faith Community Nurses help fulfill our Mission by reaching out to those most in need, i.e. the uninsured, underinsured, working poor, children and the elderly in creative and innovative ways.

Spread

Besides working with Health Ministries to identify opportunities and develop effective programs, the true transformation of healthcare will only be made by connecting the dots of all the work being done throughout Ascension Health and sharing the lessons learned – both good and bad – with all of our facilities.  The only way we will each our goal of eliminating preventable injuries or deaths by July of 2008, is if we all learn from each other. 

None of this work could be done without the expertise and dedication of the more than 106,000 Ascension Health associates in our 67 acute care facilities in 20 states and the District of Columbia. Physicians, nurses and other care providers are working together every day to identify opportunities to improve safety for our patients.

© 2007 Ascension Health