2020 YEAR IN REVIEW Quality Report

we put KIDS FIRST At Shriners Hospitals for Children ® , we focus on the needs of our patients first – listening to each family's unique concerns and taking the time to determine what is best for each child.

table of CONTENTS

A Message from our Leadership

4 5 7 8 9

About Shriners Hospitals for Children

Our Health Care System

Patient Spotlight: Introducing Mia Our Mission

10 14 16 24 26

Awards and Recognition

2020 by the Numbers

Outcomes Report

Nursing Report

Specialized Services

a message from our LEADERSHIP

Welcome to the Shriners Hospitals for Children annual quality report. We are a pediatric health care system with locations in the United States, Canada and Mexico. In addition to our hospitals and ambulatory surgical/ medical centers, we have domestic and international outreach clinics serving patients all over the world. We are committed to providing high-quality care for children in our specialty areas of orthopaedics, burn care, spinal cord injury, and cleft lip and palate. In addition to these four specialties, we also have a comprehensive rehabilitation program, and provide wrap-around care. We pride ourselves on providing specialized world-class care regardless of a family’s ability to pay for services or insurance status. Shriners Hospitals for Children strives to transform the lives of children by providing exceptional health care influenced by innovative research in a patient and family-centered environment. We are devoted to the pursuit of seminal, cutting-edge discoveries that result in new knowledge and improve the therapeutic treatment, quality of care and outcomes of our patients. We invite you to learn more about our organization and our achievements in outcomes, patient and family experience and quality of care provided.

Fran Farley, M.D. Chief Medical Officer Shriners Hospitals for Children

Marjorie McEttrick-Maloney, RN, BSN, MPA/H Chief Nursing Officer Shriners Hospitals for Children


shriners hospitals FOR CHILDREN

Since opening our first hospital in 1922, we have been committed to providing high-quality care to the children and families who come to us, regardless of the ability to pay. Nearly 100 years later, our mission hasn’t changed — only expanded. Today, we offer care for a full range of orthopaedic issues, as well care for burn injuries, spinal cord injuries and cleft lip and palate. Today, in addition to providing medical care, Shriners Hospitals for Children also conducts innovative research that leads to improved treatment methods, and offers quality educational opportunities for medical professionals. Our staff members are determined to provide the most comprehensive care possible, and help their patients become as healthy, active and independent as possible, able to achieve their goals and believe in their dreams. The goal of Shriners Hospitals for Children is to reach as many children as possible, wherever they may live, and offer them our unique, patient-centered wrap- around care. Everyone associated with Shriners Hospitals for Children has an important role in this innovative, compassionate and generous health care system. Your dedication to improving the lives of children is why Shriners Hospitals for Children is known and respected throughout the world. We are grateful for the vision of the Shriners that led to the creation of Shriners Hospitals in 1922; and we are proud of what it has become over the past 95-plus years, and look forward to a second hundred years of changing and improving the lives of children.



our health CARE SYSTEM

Shriners Hospitals for Children has been serving children with complex and specialized health care needs since 1922. We have become one of the largest specialty pediatric health care systems in the world. In addition to caring for children at our primary locations, we hold outreach clinics all over the world. It is our mission to provide the highest quality care to children with orthopaedic and neuromuscular conditions, burn injuries and other special health care needs within a compassionate, family-centered and collaborative environment. Our physicians are board-certified in their areas of medical specialty. We also strive to provide quality education for our physicians and other health care professionals. Lastly, we pride ourselves on conducting research to discover new knowledge that improves quality of care and the quality of life for our children and families.

Spinal Cord Injury Our comprehensive team of surgeons, physicians, therapists, psychologists, social workers, and dietitians works together to provide innovative treatment for spinal cord injuries. In addition to world-class care, our team focuses on improving the independent living skills and building the confidence of our patients. Cleft Lip and Palate Shriners Hospitals for Children provides specialized care for cleft lip and palate, one of the most common birth defects. Our goal is to improve the child’s appearance, as well as their ability to eat, breathe, and communicate. We have a comprehensive team of health care providers to address the physical and emotional needs of our patients with cleft lip and palate and other craniofacial conditions.

Orthopaedics Providing innovative and high quality care to patients with congenital or acquired orthopaedic conditions has been a cornerstone of Shriners Hospitals for Children since we opened our first hospital in 1922 in Shreveport, Louisiana. We have the ability to help children with a variety of orthopaedic conditions. Below are several examples of conditions we treat:

• Foot disorders • Cerebral palsy • Injuries • Syndromes • Hip disorders • Limb deficiencies • Scoliosis • Hand disorders • Osteogenesis imperfecta Burn Care

We pride ourselves on being a leader in pediatric burn care, research, and education. Our hospitals are equipped with state-of-the-art technology and staff are able to provide reconstructive and restorative surgery for burns and other skin related conditions. Our interdisciplinary approach to care has increased the survival rate of children with burns and helps our patients go on to lead full, productive lives.


introducing MIA National Patient Ambassador 2020-2021

Mia, 16, was born with a severe case of infantile idiopathic scoliosis. Her journey with Shriners Hospitals for Children began when she was 2, when she was first seen at the St. Louis location. Mia’s treatments have included halo traction to gradually straighten and stretch her spine, as well as nearly 20 surgeries. During her extensive time in the hospital, Mia and her care team developed a tight bond, and Mia considers the people she knows at Shriners Hospitals – her doctors, nurses, therapists, and even the security guard – family. She has served as a patient ambassador for Shriners Hospitals for Children — St Louis since she was 4 and has spoken to numerous audiences on behalf of the hospital. She has also appeared in promotional videos and media interviews. Mia’s passion is theater and singing, and she was featured singing I’ll Be Home for Christmas in our holiday commercials. Mia is also part of the Shriners children’s choir that performed in a recent recording of Foreigner’s hit song I Want to Know What Love Is .

“I am so honored to be in this position,” Mia said. “For as long as I can remember, I have always loved Shriners Hospitals. Not just because of the life it has given me, but the real love that comes from it. This community consists of the best people, and it truly makes

my heart soar to know I’m a large part of it. It makes me proud to know that I will be giving back to a hospital that not only gave me a normal life but is a second home for myself and my family.”

“ We thank Mia for her willingness to represent Shriners Hospitals for Children as a National Patient Ambassador and share her story. "


• Provide the highest quality care to children with neuromusculoskeletal conditions, burn injuries and other special health care needs within a compassionate, family-centered and collaborative care environment. • Provide for the education of physicians and other health care professionals. • Conduct research to discover new knowledge that improves the quality of care and quality of life of children and families. This mission is carried out without regard to race, color, creed, sex or sect, disability, national origin, or ability of a patient or family to pay. the mission of SHRINERS HOSPITALS FOR CHILDREN IS TO: Our three-part mission has one goal: To change and improve lives.


hospital RECOGNITIONS 2020 Press Ganey Award Guardian of Excellence Award for Patient Experience:

• Shriners Hospitals for Children — Canada • Shriners Hospitals for Children — Chicago • Shriners Hospitals for Children — Greenville • Shriners Hospitals for Children — Honolulu • Shriners Hospitals for Children — Mexico City • Shriners Hospitals for Children — Northern California • Shriners Hospitals for Children — Portland • Shriners Hospitals for Children — Salt Lake City • Shriners Hospitals for Children — St. Louis 2020 Pinnacle of Excellence Award • Shriners Hospitals for Children — Canada • Shriners Hospitals for Children — Northern California • Shriners Hospitals for Children — Salt Lake City


awards and RECOGNITION

Boston Jeevendra Martyn, M.D., Received the 2020 –American Burn Association Harvey Stuart Allen Distinguished Service Award Matthias Donelan, M.D. – Received a Presidential Citation from the American Society for Laser Medicine & Surgery Chicago Kelsey Davidson, M.D. – Received the 2020 AACPDM Mac Keith Press Promising Career Award Galveston Steven Wolf, M.D., chief of staff – President-Elect of the International Association for Surgical Metabolism and Nutrition Mexico Felipe Haces, M.D., chief of staff – Recognized and awarded by the Universidad Nacional Autonoma de Mexico for his 20 years as part of the National Pediatrics Orthopaedics Teaching Program and as Head Professor Roberto Galvan-Lizarraga, M.D. – Recognized and awarded by the Universidad Nacional Autonoma de Mexico for his 20 years as part of the National Pediatrics Orthopaedics Teaching Program Northern California David Greenhalgh, M.D., chief of staff, burns – Elected President of the International Society for Burn Injuries Brian Haus, M.D. – Awarded Top Doctor recognition by Sacramento Magazine

Kathryn Fuchs, M.D. – Awarded Top Doctor recognition by Portland Magazin e Ellen Raney, M.D. – Awarded Top Doctor recognition by Portland Magazine ; Received the 2020 American Academy of Pediatrics Section on Orthpaedics Distinguished Service Award Michelle Welborn, M.D. – Awarded a multicenter POSNA grant for $700,000 to study spine growth using collagen biomakers and the Scoliosis Research Society Thomas E. Whitecloud Award in Best Basic Science; Honored as “Top Doctor” by Portland Monthly magazine St. Louis Charles Goldfarb, M.D. – Awarded the Paul R. Manske Best Publication on Congenital Upper Extremity Differences 2019 Brian Kelly, M.D. – Awarded the 2019 Washington University Scott Luhman, M.D., chief of staff – Received the Hero with a Heart Award from the Marfan Foundation ; Received the Excellence in Education Award from POSNA Perry Schoenecker, M.D. – Received the POSNA Distinguished Achievement Award; Inducted into the POSNA Hall of Fame Salt Lake City Kristen Carroll, M.D., chief of staff – Awarded the Sherman S. Coleman, M.D. Presidential Endowed Chair in Pediatric Orthopaedics in the Department of Orthopaedics at the University of Utah Department of Orthopaedics Martin Boyer Medical Student Education Award

Eric Klineberg, M.D. – Awarded Top Doctor recognition by Sacramento Magazine Hol ly Leshikar, M.D. – Awarded Top Doctor recognition by Sacramento Magazine R.L. Randall, M.D. – Awarded Top Doctor recognition by Sacramento Magazine Roberto Rolando, M.D. – Awarded Top Doctor recognition by Sacramento Magazine Pasadena Robert Cho, M.D., chief of staff – Elected to the POSNA Board as the Communication Council Chair Andres Panossian, M.D. – Appointed to the Mending Kids International Board of Directors Alexander Van Speybroeck, M.D. – Clinical Care Partners Recognition for Spina Bifida Center of Excellence Philadelphia Corinna Franklin, M.D. – Awarded Top Doctor Recognition in Philadelphia Magazine Dan Zlotolow, M.D. – Awarded Top Doctor Recognition in Philadelphia Magazine Portland Robert Bernstein, M.D., chief of staff – Awarded the Mend Award by Mending Kids Jeremy Bauer – Awarded Top Doctor recognition by Portland Magazine Daniel Bouton, M.D. – Awarded Top Doctor recognition by Portland Magazine Krister Freese, M.D. – Awarded Top Doctor recognition by Portland Magazine


Shriners Hospitals for Children has once again been ranked nationally in two specialties in the 2021-22 Best Children’s Hospitals rankings published by U.S. News & World Report , the global leader in quality rankings that empower consumers to make better, more informed decisions about important issues affecting their lives. The Best Children’s Hospitals rankings are designed to help families facing complex and rare conditions find the best medical care for their children. Shriners Hospitals for Children RECOGNIZED SIX TIMES BY U.S NEWS & WORLD REPORT

The following locations ranked in pediatric orthopedics: #7 – Shriners Hospitals for Children — St. Louis (in partnership with St. Louis Children’s Hospital — Washington University) #13 – Shriners Hospitals for Children — Erie (in partnership with UPMC Children's Hospital of Pittsburgh) #22 – Shriners Hospitals for Children — Northern California (in partnership with UC Davis Children’s Hospital) #28 – Shriners Hospitals for Children — Salt Lake City (in partnership with University of Utah Health and Primary Children’s Hospital) #41 – Shriners Hospitals for Children Medical Center — Lexington (in partnership with Kentucky Children's Hospital)

The following location ranked in pediatric urology: #37 – Shriners Hospitals for Children — Northern California (in partnership with UC Davis Children’s Hospital)

The Best Children's Hospitals rankings, which rate eligible medical centers in 10 pediatric specialties, are based on hospital-submitted data, including measurements such as survival and complex surgical outcomes, as well as use of best practices, infection prevention, advanced technologies, nursing quality, specialty-specific certifications and services, and the expert opinion of specialists in the field. This year’s rankings will be published in the U.S. News & World Report’s Best Hospitals 2022 Guideboo k, available in stores Oct. 5.



Giving Every Patient All the Attention and Care They Deserve The staff of Shriners Hospitals for Children is committed to giving each patient their full attention, to ensure the child receives the best possible care and every resource available so they can recover to the fullest extent possible, and have a full, productive life. In addition to providing medical care, our staff works with each patient and family to build understanding of the complexities and implications of the child’s medical condition. We are proud of taking the time to listen to our patients and help them develop the confidence and self-esteem needed to overcome their challenges and move into the adult world successfully.

42,005 NEW









National Health Care Safety Network



patient-reported OUTCOMES (PROS)

Over the past five years, Shriners Hospitals for Children has succeeded in restructuring the clinical encounter by gathering patient-reported outcomes (PRO) questionnaires in order to obtain information from our patients on what is most meaningful to their quality of life. SHC had been collecting this information from patients and their families at the beginning of their clinic visit through the use of iPads. In 2020, SHC implemented new technology which allows patients to answer these questionnaires via text or email in advance of their upcoming visit. The ability to collect this important information in advance of the visit has been beneficial to both patients and their families, physicians and clinical staff, and the organization as whole. Some of the benefits we have seen include: • Amount of time to complete the questionnaires has been reduced to 3-4 minutes, instead of 5-7 minutes when taken onsite. • Reduced burden on staff administering questionnaires, cleaning, and maintaining iPads. • Cost savings as fewer iPads and related supplies need to be purchased.

Overall compliance rates

In Clinic • December 2020 ~ 76% • January 2021 ~ 78% • February 2021 ~ 82%

Email • December 2020 ~16% • January 2021 ~ 40% • February 2021 ~ 33%

SMS/Text • December 2020 ~ 50% • January 2021~ 52% • February 2021 ~ 37%

The information gathered from patients’ on their physical and social health are heavily used by physicians to link clinical variables with health-related quality of life. Since this initiative began in December 2016, we have collected over 178,000 questionnaires, making us one of the largest repositories of Pediatric PRO data. This information provides crucial patient information to clinicians that is obtained outside of the traditional hospital/clinic environment, supports patient and provider interaction and helps promote health literacy in our patients and their families. We are improving patient outcomes while delivering more personalized care.



National Surgical Quality Improvement Program

In 2017, Shriners Hospitals for Children began participating in the American College of Surgeon’s National Surgical Quality Improvement Program for Pediatrics (NSQIP Pediatrics). NSQIP Pediatrics collects pre and post outcomes data for most surgical specialties and allow hospitals to: • Demonstrate a commitment to quality improvement by participating in the first national database to measure surgical outcomes in all specialties of children's surgery • Collect actionable clinical outcomes data specific to children's surgery • Act on clinical data to improve care in children's surgery Participating in NSQIP Pediatrics is essential to obtaining Children’s Surgery Verification by the American College of Surgeons. As of year-end 2020, seven (7) Shriners Hospitals for Children hospitals are participating in the NSQIP Peds program. The ACS provides semi-annual reports which look at outcomes in the following areas: • Morbidity • Pneumonia • Reintubation

• Urinary Tract Infection (UTI) • Surgical Site Infection (SSI)

• Return to OR • Readmissions • Transfusions

The outcomes are compared to the national database and ranked into the following three categories: 1) As Expected, Exemplary, or Needs Improvement. Shriners Hospitals for Children consistently scores Exemplary in morbidity, surgical site infection, and length of stay for spine fusion surgeries.


National Anesthesia Clinical Outcomes Registry (NACOR)

In early 2019, Shriners Hospitals for Children began reporting data to the National Anesthesia Clinical Outcomes Registry (NACOR). NACOR is a data warehouse housed by the Anesthesia Quality Institute (AQI) and developed by the American Society of Anesthesiologists (ASA). Some of the information reported includes total cases, provider ID, ASA physical status, payment type, case duration, age, sex, and adverse outcome (if indicated). With millions of cases in the registry, AQI’s clinical data provides an evidence-based rationale that informs treatment choices and helps control treatment costs. NACOR is enthusiastically endorsed by the Shriners Anesthesia Executive Council (AEC), Quality & Safety Council, and Physician Executive Team. Participating in the registry provides Shriners Hospitals for Children the following benefits: • Access to patient care management tools, education, and IT vendors • National performance indicators • Custom continuous performance monitors • Ability to measure performance beyond local facility • Performance gap analysis and patient outlier identification • National comparative analytic reports • Peer-to-peer benchmarks To fully realize the benefits of NACOR participation, we improved data collection and automated reporting. Medical Informatics, in conjunction with the AEC, continues to make improvements to the electronic medical record to allow anesthesia providers to document outcomes more easily. Twenty-six adverse outcome event types were identified and reported to the registry.Reporting through a certified vendor allows the process to be fully automated. By putting the data we receive from NACOR to work, Shriners Hospitals for Children can ensure delivery of care of the highest quality. In 2020, we reported data on over 6,000 anesthesia cases. Sixty- six total adverse event occurrences were reported, of which Shriners Hospitals for Children outperformed the NACOR Benchmark for all twenty-six events. Below are a few notable benchmark reports. Quarterly reports are provided to each site’s Chief of Anesthesia for analysis and quality improvement efforts.


Patient Experience

In addition to providing the highest quality clinical care, Shriners Hospitals for children strives to deliver the best experiences for our patients and families. Our team of caregivers provides compassionate wrap- around care for children with specialized health care needs. Our hospitals have been nationally recognized for excellence in patient and family satisfaction. Our hospitals rank in the 99th percentile for inpatient and outpatient and family experience when compared to other pediatric hospitals nationwide.

Based on patient and family responses to Press Ganey survey. On a scale from 0 to 100, the average score of respondents when asked if they would recommend our hospitals/medical centers to others.


Health Information EXCHANGE (HIE) CommonWell/Care Quality is a Health Information Exchange (HIE) network that allows secure data exchange across the nation. It allows clinicians to securely access patient’s health data that occurred outside of Shriners Hospitals for Children, including information from other EHR vendors. SHC registration staff will obtain consent from the patient/family. Once enrolled, providers will have access to patient data from outside organizations that also participate in CommonWell/Care Quality. We are actively engaged in implementation the CommonWell/ Care Quality solution and anticipated Go Live in April 2021. CommonWell/Care Quality will provide quick reliable access to patient health information from within our electronic medical record and allow clinicians to securely access and share patient data without interrupting their workflow. CommonWell/Care Quality allows clinicians to incorporate data from external sharing partners into the electronic medical record Connection to the CommonWell/Care Quality network allows Shriners Hospitals for Children to improved coordination of patient care and patient safety. In addition, connection to the CommonWell/Care Quality network meets the Promoting Interoperability regulatory requirements for Health Information Exchange (HIE) and data sharing


Keeping our Patients Safe

Reducing the amount of time our patients spend in the hospital helps reduce infections, prevent readmissions and keeps them safer.


2020 Quality Measures When monitoring patient safety we collect the data, review each facility, compare facility processes, address outliers and identify all areas for improvement opportunities. We then share information across the organization to ensure best practice adoption as we strive toward becoming a zero harm organization.


nursing REPORT

In 2009, the Robert Wood Johnson Foundation (RWJF) partnered with the Institute of Medicine (IOM) to produce The Future of Nursing: Leading Change, Advancing Health, which set a vision for nursing in 2020. Beginning January 2017 Shriners Hospitals for Children created a special BSN 2020 tuition reimbursement program to increase the percentage of direct care nurses with a Bachelor’s degree, or higher, in nursing from 67% to the recommended 80%. We are proud to say we accomplished that objective and expect to exceed 80% when the Special BSN 2020 program concludes at the end of this fiscal year.


FOCUSED™ on Nursing Excellence

The World Health Organization (WHO) declared 2020 the International Year of the Nurse and Midwife to honor the 200th anniversary of Florence Nightingale’s birth and to advance nurses’ vital role in transforming healthcare around the world. Due to the impact of the COVID-19 pandemic and the increased visibility of nurses’ contributions, the American Nurses Association (ANA) joined the WHO in extending the Year of the Nurse and Midwife into 2021. The pandemic continues to burden our global healthcare systems and as we look to our future, it is important for us to question what does the future hold for nurses and the nursing profession? To respond to this vital question, the Shriners Hospitals for Children’s Nursing Executive Council (NEC) is FOCUSED™ on defining the scope of professional nursing practice in our ambulatory care models and continually highlighting nursing’s’ influence on patient care outcomes throughout our healthcare system. The NEC is dedicated to nursing and patient care excellence and are committed to investing in structures and processes to promote and support system-wide programs to promote interprofessional collaborative practice to ensure optimal patient care quality and outcomes. Throughout our system, unsurpassed quality care is provided for each patient within our hospitals, ambulatory surgical centers and ambulatory centers without surgery. Our nurses lead at every level through direct patient care and beyond, focusing on quality monitoring and ongoing process and quality improvement.


national patient satisfaction mean score


of our nurses report they have sufficient time to provide the best care to their patients and families in their clinical areas


of our nurses hold a Bachelor’s degree

Our Model of Care for Clinical Service

amily and patient-focused care

pen communication

ollaborative nderstanding and compassionate

xpertise and education afe and seamless

riven by research and best practices


rehabilitation SERVICES

Shriners Hospitals for Children sites offer therapy for inpatients and outpatients, depending on the specific location. Our specialized outpatient programs also address comprehensive therapy and education needs. Our therapists use evidence-based methodologies and work in concert with community and school therapists to support changing needs of the child. Our therapists are also instrumental in transitioning patients to adult care. We consider our relationship with the families as important as the one with the child, and include them in education and exercise activities. Many of our therapists hold national certifications which demonstrates our commitment to quality.

Our CertifIcations

• Pediatric Certified Specialists • Certified Hand Therapy • Certified Advanced Practice Hand and Physicial Agent Modalities • Rehabilitation Engineering and Assistive Technology Society of North America • Mackenzie Certification • Manual Therapy Certification • Driving • Early Intervention Certification • Wound Certification • Scoliosis Specific Exercise Certification • Clinical Instructor Certification • Lymphadima Certification • Oral and Sensory Certification

• National Board for Certification in Occupational Therapy

• Neuro-Developmental Treatment • Interactive Metronome Certification • Saebo • Ponseti Method • Fine Wire EMG Certification • Neurokinetic Therapy Certification • Child life • Recreation Specialist • Neuro-Integrative Functional Rehabilitation and Habilitation • Sensory Integration and Praxis Tests


EOS The EOS Imaging System is a Nobel Prize- winning technology that will produce life size, whole body images with up to 85% less radiation compared to conventional X-rays. EOS provides full-body images of patients in a natural standing or seated position in both 2D and 3D. These weight-bearing images reveal a patient’s natural posture and allow physicians to analyze the interactions between bones, joints and ligaments from different angles. Research shows that the radiation from repeated X-rays increases the child’s risk factor for cancer later in life. This is a great concern to our medical team, as Shriners Hospitals for Children is committed to providing the safest treatment available to children. Radiation exposure is cumulative over one’s lifespan, so it is particularly helpful for use with children who have the need for multiple imaging. In 2011, the first EOS system was acquired by Shriners Hospitals for Children — Canada. We have since added EOS at our other orthopaedic hospital sites.


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