Great Things Are Happening In Hospitals!

2017 Virginia Quality and Patient Safety Headlines

Virginia Ranked In The Top 10 Nationally For Health Care Quality “The Commonwealth of Virginia was rated among the top 10 states for health care quality in the latest annual National Healthcare Quality and Disparities Report. The report is mandated by Congress to provide a comprehensive overview of the quality of health care received by the general U.S. population, as well as disparities in care experienced by different ethnic and socioeconomic groups. Among all states, Virginia ranked ninth overall with a score of 62.5 out of 100 for the most recent data year.” Dozens Of Virginia Hospitals Earn “A” Grades For Patient Safety And Satisfaction From National Ratings Organizations “Dozens of Virginia hospitals earned top marks for exceptional patient safety performance in the Fall 2017 Hospital Safety Grade scores from the Leapfrog Group. In all, 41 Virginia hospitals received ‘A’ grades from Leapfrog, a national health care patient safety ranking organization. In the current rankings, eight Virginia hospitals were recognized for receiving an ‘A’ grade 12 consecutive times. The new Leapfrog results place Virginia among the top five states with the highest percentage of ‘A’ grade hospitals.” Focused Efforts By Virginia Hospitals Result In The Lowest Early Elective Delivery Rate In The Nation “Over the past four years, Virginia has reduced its EED rate from 8 percent to 1.3 percent, ranking the Commonwealth first in the nation in reducing EEDs, according to federal Hospital Compare data for 2016. Virginia previously had been ranked 24th in the nation on EED rate based on Hospital Compare data in 2014. Research has shown that babies carried to full term after 39 weeks of gestational age have improved birth outcomes leading to lasting positive effects on lifelong health.”

January 2018 Executive Message

Colleagues, Great things are happening in Virginia hospitals! As 2017 got underway, the benefits of statewide collaborative efforts on quality and patient safety improvement work occurring at Virginia hospitals and health systems became increasingly evident. While quality and safety work has long been a focus for Virginia’s hospitals, the origins of current collaborative efforts can be traced to 2010 when the Virginia Hospital & Healthcare Association’s (VHHA) Board of Directors made an explicit declaration that improving health care quality and safety in the Commonwealth would be a joint imperative for all hospitals, not a competitive differentiator. At that time, the Board agreed that the rate of improvement in clinical outcomes and patient experience of care in hospitals could be accelerated through collaboration among member organizations. In 2015, the VHHA Board strengthened its commitment to these ideals by establishing the Center for Healthcare Excellence as a distinct unit within the Association. The Center was created with a clear mission: to improve the safety and quality of health care in Virginia by assisting members in achieving top-tier performance in quality, safety, and service. In particular, the Center supports and encourages adoption of best practices in patient care and service by all Virginia hospitals and health systems; facilitates effective collaborations among Virginia hospitals, health systems, health care providers, and key stakeholders; and serves as a coordinating agent for seeking, procuring, and administering funding to support patient safety and health care quality initiatives in Virginia. This report from the VHHA Center for Healthcare Excellence highlights some of the recent work and achievements of Virginia hospitals and health systems associated with collaborative improvement efforts. On behalf of the VHHA Board of Directors, we would like to thank the leaders of our 110 Virginia hospital members and the more than 125,000 health care providers and staff working in Virginia hospitals for their engagement and collaboration during the past three years. It is our hope that this report provides examples of the hard work and dedication caring health care professionals like you exhibit each day in care settings throughout the Commonwealth. It is our honor and privilege to support you as you serve your communities in our continuing effort to make Virginia the healthiest state in the nation.

Toni R. Ardabell Sean T. Connaughton Chair, VHHA Center for Healthcare Excellence Advisory Council President and CEO CEO, Bon Secours Virginia Health System Virginia Hospital & Healthcare Association

The VHHA Center for Healthcare Excellence Team Abraham Segres: Vice President, Quality and Patient Safety Joan Williamson: Director, Virginia Patient Safety Organization 804-965-1214; [email protected] 804-965-1226; [email protected]

Betsy Archer: Senior Director, Grants & Performance Improvement Mike Gaetano: Project Manager, Quality & Patient Safety 804-965-1216; [email protected] 804-965-1208; [email protected]

Joyce Dayvault: Director, Performance Improvement Theresa Lindamood: Administrative Assistant 804-297-3402; [email protected] 804-965-1202; [email protected]

Great Things Are Happening In Virginia Hospitals! 2 Great Things Are Happening In Virginia Hospitals! 3 Shared Learning and Improving in 2017

Antibiotic Stewardship More than 125 health care professionals, stakeholders from across Virginia, and national experts gathered in Richmond in February to discuss the antibiotic resistance burden that is currently upon our communities and to spark and renew a commitment to implement effective antibiotic stewardship in all settings. Patient Falls Seventy-seven (77) health care professionals from 38 Virginia hospitals attended learning sessions sponsored by the Virginia Patient Safety Organization (VPSO) at three locations around the Commonwealth in March to share and discuss best practices in fall prevention efforts, including why certain strategies aren’t working, overcoming barriers, and accomplishing success. Medication Safety Thirty (30) health care professionals representing 39 Virginia hospitals participated in a VPSO-sponsored session at VHHA headquarters in Glen Allen in July to share and learn best practices and strategies for preventing adverse medication events associated with high-alert medications such as opioids, insulins, and anticoagulants. Patient Experience More than 90 representatives from Virginia hospitals participated in virtual and in-person shared learning sessions to discuss patient experience and patient and family engagement strategies and best practices; the state’s overall HCAHPS rating has improved to 72 percent of patients ranking their hospital as a nine or 10. Hospital Readmissions One hundred sixty-seven (167) hospital staff and stakeholders participated in a web-based learning session series named “Home is the Hub” to discuss high-leverage strategies for reducing preventable hospital readmissions in Virginia hospitals. Hospital-Skilled Nursing Facility Readmissions Administrative and clinical representatives from Virginia hospitals and skilled nursing facilities gathered for regional forums at three locations throughout the Commonwealth in December to discuss efforts to improve the transition of patients between health care settings, and to eliminate avoidable hospital readmissions. Sepsis Thirty-three (33) Virginia hospitals and 34 Virginia skilled nursing facilities enrolled in a joint learning collaborative focused on early sepsis recognition and intervention, sepsis bundle compliance, and sepsis mortality reduction. NICU and Early Intervention (EI) Services Seventy-nine (79) professionals from Virginia hospitals and community-based early intervention (EI) services organizations gathered at regional meetings throughout the Commonwealth during the summer and fall to enhance their collective understanding of potentially eligible conditions for children seen in Virginia NICUs, and to provide education for NICU staff to partner with parents to safely transition children to home and EI services. High Reliability Organization (HRO) One hundred twenty-eight (128) representatives from 20 VHHA member health systems participated in a statewide, high reliability organization (HRO) webinar series that highlighted innovative practices and strategies being implemented in Virginia hospitals which have adopted principles of high reliability within their organizations. Rural Hospital Leaders Sixty-five (65) administrative and clinical leaders from 13 Virginia rural hospitals participated in a group coaching collaborative that provided leaders of Virginia rural hospitals with a set of concepts and skills to assist them in leading organizations that provide high quality health care and ideal patient and family experiences.

Great Things Are Happening In Virginia Hospitals! 2 Great Things Are Happening In Virginia Hospitals! 3 We Extend Our Thanks To Virginia Hospitals and Health Systems

Augusta Health Parham Doctors’ Hospital Riverside Shore Memorial Hospital Bath Community Hospital Reston Hospital Center Riverside Tappahannock Hospital Bon Secours Health System Retreat Doctors’ Hospital Riverside Walter Reed Hospital Bon Secours DePaul Medical Center Spotsylvania Regional Medical Center Bon Secours Mary Immaculate StoneSprings Hospital Center Sentara CarePlex Hospital Hospital HealthSouth Sentara Halifax Regional Hospital Bon Secours Maryview Medical HealthSouth Rehabilitation Hospital of Sentara Leigh Hospital Center Fredericksburg Sentara Martha Jefferson Hospital Bon Secours Memorial Regional HealthSouth Rehabilitation Hospital of Northern Medical Center Sentara Norfolk General Hospital Virginia Bon Secours Rappahannock General Sentara Northern Virginia Medical HealthSouth Rehabilitation Hospital of Hospital Center Petersburg Bon Secours Richmond Community Sentara Obici Hospital HealthSouth Rehabilitation Hospital of Hospital Fredericksburg Sentara Princess Anne Hospital Bon Secours St. Francis Medical The Rehabilitation Hospital of Southwest Sentara RMH Medical Center Center Virginia Sentara Virginia Beach General Bon Secours St. Mary’s Hospital HealthSouth Rehabilitation Hospital of Virginia Hospital Buchanan General Hospital Inova Health System Sentara Williamsburg Regional Carilion Clinic Medical Center Inova Alexandria Hospital Carilion Franklin Memorial Hospital Sheltering Arms Inova Fair Oaks Hospital Carilion Giles Community Hospital Memorial Regional Campus Carilion New River Valley Medical Center St. Francis Campus Inova Loudoun Hospital Carilion Roanoke Community Hospital Universal Health Services Inova Mount Vernon Hospital Carilion Roanoke Memorial Hospital Cumberland Hospital for Children and Lake Taylor Transitional Care Hospital Adolescents Carilion Stonewall Jackson Hospital LifePoint Health Kempsville Center for Behavioral Health Carilion Tazewell Community Clinch Valley Medical Center Hospital Newport News Behavioral Health Center Fauquier Hospital Centra Health North Spring Behavioral Healthcare, Inc. SOVAH Health — Danville Centra Bedford Memorial Hospital Poplar Springs Hospital SOVAH Health — Martinsville Centra Lynchburg General Hospital Virginia Beach Psychiatric Center Twin County Regional Healthcare Centra Southside Community Hospital University of Virginia Health System Wythe County Community Hospital Centra Virginia Baptist Hospital University of Virginia Medical Mary Washington Healthcare Center Chesapeake Regional Healthcare University of Virginia Transitional Care Hospital Children’s Hospital of The King’s Daughters Stafford Hospital UVA-HealthSouth Rehabilitation Hospital Children’s National Medical Center Mountain States Health Alliance Valley Health Community Health Systems Dickenson Community Hospital Valley Health Page Memorial Hospital Southampton Memorial Hospital Johnston Memorial Hospital Valley Health Shenandoah Memorial Hospital Southern Virginia Regional Medical Norton Community Hospital Valley Health Warren Memorial Hospital Center Russell County Medical Center Valley Health Winchester Medical Center Southside Regional Medical Center Smyth County Community Hospital VCU Health HCA Virginia Novant Health UVA Health System Children’s Hospital of Richmond at VCU Chippenham Hospital Culpeper Medical Center VCU Health Community Memorial Hospital Dominion Hospital Haymarket Medical Center VCU Health VCU Medical Center Henrico Doctors’ Hospital Prince William Medical Center Vibra Hospital of Richmond John Randolph Medical Center Riverside Health System Virginia Hospital Center Johnston-Willis Hospital Hampton Roads Specialty Hospital Wellmont Health System LewisGale Hospital Alleghany Riverside Behavioral Health Center Wellmont Lonesome Pine Hospital LewisGale Hospital Montgomery Riverside Doctors’ Hospital Williamsburg Wellmont Mountain View Regional LewisGale Hospital Pulaski Medical Center Riverside Regional Medical Center LewisGale Medical Center Riverside Rehabilitation Institute Great Things Are Happening In Virginia Hospitals! 4