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Christiana Care Value Institute Newsletter | Spring Issue, May 5, 2017
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Panelists at the iLEAD and the Center for Provider Wellbeing conference included Colin P. West, M.D., Ph.D., a national expert and researcher on physician burnout; Nathan Merriman, M.D., MSCE, co-chief in Christiana Care's Section of Gastroenterology and chair of Christiana Care's Physician Leadership Network Governance Committee; Patricia Moore, M.D., chair, Christiana Care's Surgical Service Line Exceptional Experience Team and chief people officer, Anesthesia Services, PA; Margot Savoy, M.D., MPH, FAAFP, FABC, CPE, CMQ, medical director, Christiana Care's Department of Family & Community Medicine; Joseph Bennett, M.D., FACS, president-elect, Christiana Care Medical Dental Staff and president, Delaware Chapter of the American College of Surgeons
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Christiana Care’s Provider-Wellbeing Initiatives Kick Off with Survey, Event Focused on Burnout
Long committed to achieving the Triple Aim of optimal health, exceptional patient experience and organizational vitality, Christiana Care Health System now is expanding its mission to the Quadruple Aim, which adds improving provider experience as a fourth focus.
Research indicates more than half of physicians nationwide experience symptoms of burnout, characterized by a loss of enthusiasm for work, feelings of cynicism and low sense of personal accomplishment. It is a growing issue that Christiana Care wants to address head-on.
“We acknowledge the challenges providers face every day and we are committed to addressing burnout and fostering wellbeing,” said Heather Farley, M.D., Director of Provider Wellbeing. “When providers are supported and feel fulfilled in their work, they can do their best in providing high-quality care for patients.”
Heather Farley, M.D., director of the Center for Provider Wellbeing at Christiana Care, addresses wellbeing initiatives at Christiana Care.
Recognizing that happy providers perform the best, giving safe, high-quality, efficient care to patients, the health system is investing in programs and interventions to combat burnout and reduce staff turnover. Already, Christiana Care has implemented provider-wellbeing initiatives including the Care for the Caregiver peer support program for adverse events and medical error; the Provider Litigation Program, which provides support and educational resources for providers in medical malpractice litigation; and Vital Worklife, a provider-focused program offering coaching, counseling and worklife concierge services.
Complementing those initiatives, the Center for Provider Wellbeing is working with the Value Institute to investigate burnout among the medical-dental staff, which includes physicians, advanced practice nurses and physician assistants, and establish baseline measures for provider wellbeing.
The Value Institute helped tailor a provider-wellbeing survey, developed by Stanford University’s WellMD program, for Christiana Care and will analyze its results. The survey measures professional fulfillment, burnout and intent to leave; outcomes predicted by factors such as values alignment, meaningfulness of work, efficiency of practice, control over work schedule and appreciation.
The findings will give department and organizational leadership insights into the challenges Christiana Care physicians face when trying to deliver care. Preliminary results from the survey were presented at a pair of Center for Provider Wellbeing kickoff events in March.
Colin P. West, M.D., Ph.D., is a national expert and researcher on physician burnout.
Panelists at the conference included Colin P. West, M.D., Ph.D., a national expert and researcher on physician burnout; Nathan Merriman, M.D., MSCE, co-chief in Christiana Care's Section of Gastroenterology and chair of Christiana Care's Physician Leadership Network Governance Committee; Patricia Moore, M.D., chair, Christiana Care's Surgical Service Line Exceptional Experience Team and chief people officer, Anesthesia Services, PA; Margot Savoy, M.D., MPH, FAAFP, FABC, CPE, CMQ, medical director, Christiana Care's Department of Family & Community Medicine; Joseph Bennett, M.D., FACS, president-elect, Christiana Care Medical Dental Staff and president, Delaware Chapter of the American College of Surgeons.
In order to monitor Christiana Care’s progress, researchers plan to administer the provider wellbeing survey annually. By understanding the stressors facing staff, Christiana Care will be better positioned to introduce meaningful interventions aimed at reducing the burdens that providers often encounter, thus reducing turnover, improving professional fulfillment and achieving the Quadruple Aim.
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SAVE THE DATE
Value Institute 2017 Spring Symposium
Monday, June 12, 2017, 9 a.m. - Noon
Registration and continental breakfast open at 8:30 a.m.
John H. Ammon Medical Education Center, Christiana Hospital Campus
Keynote Lecturer: Brent C. James, M.D., MStat
Delaware CTR-ACCEL Community Research Exchange
Monday, May 15, 2017, 7:30 a.m. - 4 p.m.
University of Delaware – Clayton Hall
Partners in Research Town Hall: Confidentiality and Safety of Data
Wednesday, May 24, 2017, 5 - 6 p.m.
Christiana Hospital, Ammon Center – Room 14
Innovative Discoveries Series: Mixed-Methods with Teens: A Research ImperativeFriday, May 12, 2017, Noon - 1 p.m., Christiana Hospital – Room 1100
Innovative Discoveries Series: Single Molecule DNA and RNA Sequencing to Detect Residual Cancer and Clonal HematopoiesisFriday, May 19, 2017, Noon - 1 p.m., Christiana Hospital – Room 1100
Tech Talk: Identifying Optimal Cut-Points for Continuous Predictors to Discriminate Disease OutcomesThursday, June 1, 2017, Noon – 1 p.m., Christiana Hospital – Room 1E80
Innovative Discoveries Series: Advances in Genomics and Sequencing: Dilemmas, Achievements and ChallengesFriday, June 9, 2017, Noon – 1 p.m., Christiana Hospital – Room 1100
Innovative Discoveries Series: Analysis of Interview Data: Neurological, Psycho-biological, and Abuse Histories of Violent WomenFriday, June 16, 2017, Noon – 1 p.m., Christiana Hospital – Room 1100
Innovative Discoveries Series: Big Data to Knowledge: Integrated Bioinformatics towards Systems Biology and Precision MedicineFriday, June 23, 2017, Noon – 1 p.m., Christiana Hospital – Room 1100
Tech Talk: Knowledge Translation in BiostatisticsThursday, July 6, 2017, Noon – 1 p.m., Christiana Hospital – Room 1E80
Innovative Discoveries Series: Using Cancer Registry and Behavioral Risk Factor Survey Data to Describe the Burden of Cancer in DelawareFriday, July 14, 2017, Noon - 1 p.m., Christiana Hospital – Room 1100
Innovative Discoveries Series: How Big Data Can Help us Reduce the Opiate Problem at Individual and Community LevelsFriday, July 21, 2017, Noon – 1 p.m., Christiana Hospital – Room 1100
Innovative Discoveries Series: Sleep, Cardiovascular Risk Factors and Outcomes Friday, July 28, 2017, Noon – 1 p.m., Christiana Hospital – Room 1100
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Christiana Care Early Warning System goes Live at Christiana Care
The Christiana Care Early Warning System (CEWS), a standardized measure of patient acuity that will help proactively identify patients who are deteriorating physiologically and support timely care and improved outcomes, was introduced to clinical practice in select units in May 2017.
The introduction, in which the early warning system is being displayed in five inpatient units at Christiana and Wilmington Hospitals to trigger real-time alerts for at-risk patients, is a key step in the ongoing, iterative development of CEWS. The alerts will give care providers relevant information about patients’ current CEWS values, including 24-hour score trends, as well as clinical recommendations. For example, CEWS could recommend more frequent vital-sign monitoring or activation of a Rapid Response Team should a patient have a concerning score or rapid change in score.
The Value Institute is developing CEWS in collaboration with Nursing and the Office of Quality and Patient Safety. The system couples an electronic health records-based predictive algorithm with electronic Nurse Screening Assessments that collect nurses’ first-hand observations, beyond vital signs, that may be indicative of a patient’s health to identify declining patients earlier and more reliably.
Phased implementation of the system began with a four-unit pilot in early 2015, and then was expanded to 26 units in December 2016. CEWS values were not displayed to providers, nor were alerts or clinical interventions offered, in either phase.
A major focus prior to incorporating live alerts was researching how to balance factors such as alert frequency and timeliness to ensure alerts maintain their effectiveness.
A multidisciplinary team of clinicians, health information technology experts, industrial engineers and human factors experts assessed this issue by developing and evaluating three different alert frameworks. Each framework has two components: a set of criteria for triggering an alert and a set of “blocking rules” to mute alerts when certain criteria are satisfied for a pre-determined time window.
The team evaluated three alerting strategies – conservative, intermediate and liberal – using retrospective data derived from five Christiana Care units to compare the number of alerts generated and the opportunity of early recognition of clinical deterioration at a unit and individual patient level. This allowed the team to select the alerting strategy being implemented in May, which best balances early detection and appropriate alerting frequency.
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William Weintraub, M.D., MACC, FAHA, FESC, the primary investigator for the Delaware CTR-ACCEL program and the founding director of the Center for Outcomes Research, welcomes Gov. John Carney to the Fourth Annual Delaware Clinical and Translational Research Annual Meeting.
Conference Celebrates Fourth Year of Major Clinical and Translational Research Program
The successes of innovative research collaborations between Christiana Care Health Systems and its many partners were celebrated during the Fourth Annual Delaware Clinical and Translational Research (DE-CTR ACCEL) Annual Meeting.
The meeting, held March 6 at Christiana Hospital, brought together almost 200 researchers from Christiana Care and its DE-CTR ACCEL partner institutions – the University of Delaware, Nemours/A.I. duPont Hospital for Children and the Medical University of South Carolina – as well as collaborators from government, academia, health care and other fields.
“The 2017 CTR annual conference showcased the great work and collaboration across the institutions,” said William Weintraub, M.D., Christiana Care’s John H. Ammon Chair of Cardiology and the health system’s representative on the DE-CTR ACCEL executive committee.
During the conference, Daniel J. Rader, M.D., the keynote speaker, delivered an inspirational talk on the increasing importance of genetics in clinical medicine.
Dr. Rader is the Seymour Gray Professor of Molecular Medicine at the University of Pennsylvania’s Perelman School of Medicine, Chair of the Department of Genetics and Chief of the Division of Translational Medicine and Human Genetics at Children’s Hospital of Philadelphia. His research focuses on the genetics and functional genomics of lipoprotein metabolism and translational implications for novel therapeutic approaches to unmet medical needs. His speech was about precision medicine, which is an area DE-CTR ACCEL hopes to target in future research.
Value Institute members presented updates on numerous research projects funded through the DE-CTR program, including use of linked pharmacy claims data to understand patients’ non-adherence to medication prescriptions, development of a statewide Chronic Kidney Disease registry and related patient-centered outcomes, research efforts and development of a sepsis visual risk profiling model.
Also featured were collaborations between DE-CTR and CTR programs in other states – including Montana, Oklahoma and Rhode Island – funded by the U.S. National Institute of Health’s Institutional Development Awards to build research infrastructure.
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Ephraim Kaba, CEO at the Henrietta Johnson Medical Center, reads a proclamation issued from Wilmington Mayor Mike Purzycki declaring March 9 as World Kidney Day.
Wilmington’s World Kidney Day Connects Community to Kidney Disease Screening Education and Research
Partners in Research, a community engagement effort spearheaded by the Value Institute, helped organize a local World Kidney Day event in Wilmington that offered community members free health screenings and education about kidney disease.
The focus of this year’s event, hosted March 9 by Henrietta Johnson Medical Center in Wilmington, was the effect of obesity on kidney disease, and participants were offered free screenings for diabetes, high blood pressure and high body mass index – all risk factors that can lead to the development of chronic kidney disease or speed progression of the disease.
The event also featured a panel discussion with kidney disease patients and Christiana Care physicians, dietitians and other health care providers to share their experiences and answer questions.
As part of its community engagement effort, Partners in Research is reaching out to chronic kidney disease patients and stakeholders to help develop patient-centered outcomes research projects in conjunction with the statewide Chronic Kidney Disease registry it is building.
Partners in Research shared information about its Patient-Centered Outcomes Research Institute-funded community engagement effort, which began in September 2015 with a conference during which patients and stakeholders were introduced to the effort and were asked for their help in identifying outcomes and research topics important to them.
Partners also shared information about the Chronic Kidney Disease registry being developed by the Value Institute, which integrates data from multiple sources to create a unified longitudinal care record. Researchers hope to use the registry to improve the health and quality of life for kidney disease patients in Delaware. Partners in Research was formed to ensure that the registry is useful for patients, providers and other stakeholders.
Wilmington Mayor Mike Purzycki issued a proclamation declaring March 9 as World Kidney Day in Wilmington, in honor of the work being done by Henrietta Johnson Medical Center and Partners in Research to combat kidney disease and improve community health.
For more information about Partners in Research, go to delaware-ckd.org.
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Capacity Management Study will Use Predictive Modeling to Tackle Hospital Congestion
The Value Institute is applying its expertise in predictive analytics to prevent hospital congestion, an issue that vexes health systems around the globe.
When hospital beds are at or near capacity, waiting rooms get overcrowded and emergency departments that can’t close their doors typically bear the brunt of the backlog, admitting patients who face long, sometimes detrimental “boarding” times while waiting for space to open in appropriate units. The issue is well-researched, but most of the existing responses to it are reactive, with health systems developing tactical plans that are triggered only once the hospital is overcrowded.
Researchers at Christiana Care’s Value Institute, in collaboration with Nursing Administration, Christiana Care Hospitalist Partners and Organizational Excellence, hope to develop a more proactive approach to the issue. They are in the early stages of a project that will use predictive models to help predict when the hospital is approaching a congestive situation six to 12 hours in advance so that interventions can be enacted to prevent or mitigate it.
The Value Institute is taking several approaches to developing its predictive models on hospital congestion, considering both in-patient occupancy rates and emergency department boarding and looking into various factors associated with congestion, from weather to holidays to time of day. The team is developing methods appropriate to Christiana Hospital at a system level, as well as at a unit-group level, in order to ensure the models are appropriately constructed to reflect operational needs.
Predictive models also could be used to help with staff scheduling and other strategic planning, as well as contingency response, such as expediting patient transfers or discharges. The project is slated for completion by August.
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Value Institute Members Selected to Serve on National Science Foundation Grant Review Panels
Four Value Institute staff members recently were invited by the National Science Foundation to review grant submissions for the Smart and Connected Health program. The program is a joint effort of the National Science Foundation and the U.S. National Institutes of Health.
Eric V. Jackson, Jr., M.D., MBA, associate director of the Value Institute and director of the Center for Health Care Delivery Science; Muge Capan, Ph.D., associate director of health systems optimization; Kristen Miller, DrPH, CPPS, associate director of human factors; and Ryan Arnold, M.D., MS, Emergency Medicine physician and Value Institute Clinical Investigator, were selected as experts in their fields to serve on different multidisciplinary grant-review panels for Smart and Connected Health.
All are involved in a three-year, $350,000-per-collaborator-site grant given by Smart and Connected Health to the Value Institute and two collaborators, Mayo Clinic and North Carolina State University. The grant is supporting development of the Sepsis Early Prediction Support Implementation System, a project for which Capan serves as principal investigator.
"Our work is inspired by the mission of the National Science Foundation’s Smart and Connected Health program, which is to develop next generation health care solutions and encourage breakthrough ideas in health care. This is a complex mission, but one that is in the beginning of being achieved by our team with the right mix of engineering, computer science, and clinical translational research,” Capan said. “Applying engineering systems analysis, we develop algorithms – fueled by harmonized electronic health records data – that will reduce the time to diagnosis and treatment from onset of sepsis symptoms and lead to significant patient-outcome improvement."
Each Value Institute member was assigned several grant proposals to review in detail before attending the two-day panels, held at National Science Foundation headquarters in Arlington, Va.
They worked with peers to review the scientific merits of various grant proposals and make funding recommendations to the National Science Foundation based on each proposal’s intellectual merit and broader societal benefits.
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Nurses in Opioid Withdrawal Pathway Gained Confidence in Identifying At-Risk Patients
Nurses on pilot units for Behavioral Health Service Line’s Opioid Withdrawal Pathway gained confidence in recognizing patients at risk of withdrawal, according to a survey administered by the Value Institute.
The survey was given to nurses on four participating medical units both before and after the pathway was piloted. Its goal was to identify and compare the nurses’ knowledge, perceptions and attitudes concerning patients in opioid withdrawal. The overall goal of the pathway was to standardize the process of screening, identifying and treating admitted patients at risk for opioid withdrawal.
Prior to the pathway pilot, nurses completed the initial survey and participated in an education session that included training on how to administer a two-question opioid screening tool developed by Christiana Care Health System as well as a nationally recognized instrument, the Clinical Opioid Withdrawal Scale.
Administered six months later, the survey found nurses were significantly more confident in their ability to identify patients at risk of opioid withdrawal, with 56 percent more saying they were “highly confident/extremely confident” in identifying at risk patients.
The survey also identified potential opportunities for improvement, with nurses indicating that working with opioid-addicted patients remained challenging and that more could be done by physicians to address opioid use among their patients.
“The development, administration and completion of this survey by participating nurses represent a tremendous collaborative effort between the Acute Medicine and Behavioral Health Service Lines and the Value Institute,” said Terry Horton, M.D., leader of the Associate Behavioral Health Service Line, chief of Christiana Care’s Division of Addiction Medicine, medical director of Christiana Care’s unique addiction recovery program known as Project Engage. Dr. Horton also is a Value Institute Scholar.
This collaboration continues with Christiana Care leadership in the Service Lines working to develop real-time, proactive bedside nursing education to address nursing concerns and increase coordination of care for patients in opioid withdrawal on medical units.
The Value Institute presented a poster with the survey results during the annual Delaware-CTR ACCEL Program Meeting in March and will do the same at the AcademyHealth Annual Research Meeting in June.
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The clinical view of a patient through Google Glass. Source: Augmedix
Primary Care Providers Piloting Technology meant to Reduce Time Spent on Documentation
The Medical Group of Christiana Care, in collaboration with the Office of Transformation and the Value Institute, is testing technology designed to increase the time physicians can spend with their patients by decreasing time they must spend on computers documenting patient care.
A group of 23 mostly primary care providers are piloting a service, known as Augmedix, that connects clinicians with Google Glass via a live feed to a remote team of trained scribes. The scribes document patient visits into the electronic health record and display patient information to the provider on the Google Glass screen.
The pilot program, which will take place at 10 primary care clinics and three medical aid units, began April 24. Doctors were trained on using the glasses and paired with remote scribes who transcribe the appointments, provide patient data and compile patient notes for physicians to review. The biggest change to the providers’ typical workflow – other than reducing documentation time – is learning to narrate appointments, sharing out loud what they are doing and finding out, in real time, so that both patient and scribe can hear.
By relieving providers of documentation duties, the hope is to reduce time providers spend on such work to improve job satisfaction and help avoid potential burnout. Handing off documentation duties also gives providers more time to spend with patients, potentially allowing more patients to be seen during the day.
The Value Institute is contributing its expertise in research design to evaluating and conducting a proactive risk assessment of Augmedix to help the Medical Group make an evidence-based purchasing decision. The evaluation will measure impact on productivity, provider work satisfaction, note quality and patient satisfaction, the latter being a metric that has not previously been examined scientifically. If the pilot is successful, the technology could be expanded to more primary care practices.
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New Scholars
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Monica Rochman, Ph.D., RN
Trauma Research Performance Improvement Coordinator, Nemours/Alfred I. duPont Hospital for Children
Senior Fellow, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing |
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EDUCATION SPOTLIGHT
Value Institute’s Student-Powered Design Lab Developing Innovative Decision-Making Tools
The Value Institute Design Lab, an innovative new intern program within Christiana Care Health System, is making its mark with meaningful research in its first year.
The Design Lab’s mission is to facilitate the translation of data to decisions by designing clinical tools and applications that meet patients’ and providers’ needs. Its team – currently four University of Delaware undergraduates pursuing degrees in topics as varied as engineering, biology, computer science and finance – operates under the leadership of Value Institute clinical investigators.
The Design Lab uses its multidisciplinary team to turn innovative ideas for medical practice into practical solutions meant to transform the experience and delivery of health care with a patient-centered focus.
The program was established through the CTR Visual Sepsis Risk Profiling Pilot Program Grant. As part of that project, the Value Institute created the Design Lab to help develop web-based visualizations for two sepsis risk calculators that are part of a larger research initiative aimed at improving early recognition and treatment of sepsis.
Design Lab students develop innovative health information technologies and clinical decision tools, such as user-friendly interfaces and computer-assisted design software systems that incorporate clinical expertise.
Current Design Lab efforts include an “alert density” project that examines the quantity and burden of alerts in Christiana Care’s emergency departments and in-patient units. Data from that project is being analyzed and should help inform decisions about effective alert implementation.
“I joined the Design Lab because I recognized its potential as a small-but-mighty workforce of students mentored by incredible experts,” said Becca Kowalski, a University of Delaware student studying biomedical engineering who leads the Design Lab. “I felt I could bring my clinical experience as a research student in the Emergency Department to the table, but also learn a lot from the other team members. The Design Lab fills what I now see as a critical gap in research – translating predictive analytics into usable clinical tools.”
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Getting Involved
The Value Institute is built on a model of high-level collaboration. The Value Institute partners with academic institutions, corporations, health care professionals, and thought leaders who share our commitment to improving health care value and delivery by turning evidence into reality. We cultivate relationships with patients, clinicians, sponsors and professional colleagues who recognize the importance of improving health care delivery and health outcomes, organizational excellence and quality and safety.
You can partner with the Value Institute on collaborative research, including clinical trials, database studies and demonstration projects. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. One of our team members will then contact you to discuss your research plans. Value Institute staff members are actively involved in 108 research projects in a variety of disciplines.
Contact: Email Lisa Marie Maturo or call 302-733-2071.
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Awards
Muge Capan, Ph.D., associate director of health systems optimization at the Value Institute and Kristen Miller, DrPH., associate director of human factors at the Value Institute were selected as the Delaware CTR Researchers of the Quarter for their Pilot Program Grant for the project “Sepsis Visual Risk Profiling Model."
Value Institute student Rosymar Magana from the University of Delaware was awarded the Weston Scholarship by the American Association of University Women Wilmington Branch at the 96th Annual Celebration of Scholars.
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Selected Publications
Mayer F, Mosby DL, Nightingale A, Brown EJ, Heckler S, Caplan R, , Ortiz J, Reyes-Hull CA, Gbadebo A, Chiam T. Quantifying medical interpreter activity: A time-motion study. Delaware Journal of Public Health. 2016 Dec 2(5)22-27.
Torrance CA, Williams K, Brown E, Olson K, Miller A, Newman L, Papas MA. Adverse childhood experiences negatively impact health behaviors and chronic disease risk among adults residing in Delaware. Delaware Journal of Public Health. 2016 Dec 2(5):68-69.
Fanari Z, Barekatain A, Kerzner R, Hammami S, Weintraub WS, Maheshwari V. Impact of a multidisciplinary team approach including an intensivist on the outcomes of critically ill patients in the cardiac care unit. Mayo Clinic Proceedings. 2016 Dec.91(12):1727-1734.
Goldstein N, Ingraham B, Eppes SC, Drees M, Paul DA. Assessing occupancy and its relation to healthcare-associated infections. Infection Control and Hospital Epidemiology. Jan;38(1):112-114.
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Selected Presentations
Miller K, Capan M, Mosby D, Jackson E, Seagull J, Catchpole K, Schwartz S, Arnold R. Brining our Toys to your Sandbox: Developing Database Driven EMR Indifferent Sepsis Alerts. Presented at: International Symposium on Human Factors and Ergonomics in Health Care. 2017 March 1-4. New Orleans, LA.
King J, Bellows B, Bress A, Ruiz-Negron N, Hess R, Zhang Z, Berlowitz D, Moran A, Weintraub W. Cost-Effectiveness of Intensive Blood Pressure Goals in Patients with Prior Cardiovascular Disease. Presented at: American College of Cardiology Annual Scientific Meeting. 2017 March 17-19. Washington, DC.
Hoover S, Capan M, Kraft R, King K, Jackson EV, Locke R. Predicting Pediatric Asthma-Related Admissions Using Public Air Quality Data. Presented at: Eastern Society for Pediatric Research Annual Meeting. 2017 March 24-26. Philadelphia, PA.
Bhamidipati S, Hicks L, Williams K, Robinson E. Concordance of Knowledge of Care Plan in Hospitalized Adults: Outcomes and Drivers. Presented at: Alliance of Independent Academic Medical Centers Annual Meeting. 2017 March 31-April 2. Amelia Island, FL.
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Collaborations is a quarterly release of Value Institute news and events. Visit our website to learn more about the Value Institute. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. To subscribe to Collaborations, please send an e-mail with “Subscribe to Collaborations” in the subject line.
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