SHCMAQualityReport2020

2019 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: Meet Cristian Our Mission

10 12 14 20 22

Awards and Recognition

2019 by the Numbers

Outcomes Report

Nursing Report

System Report

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 clin- ics, 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. 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.

George H. Thompson, M.D. Interim Chief Medical Officer Shriners Hospitals for Children

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

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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 — Shriners, staff, volunteers and supporters — has an important role in this innovative, compassionate and generous health care system. Your dedication, efforts and commitment to our mission of improving lives 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.

2019 OUTCOMES REPORT | 5

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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 Shiners 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 condition, excluding acute trauma. 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.

2019 OUTCOMES REPORT | 7

meet CRISTIAN

Cristian was born with spina bifida and hydrocephalus. In his first two weeks of life, Cristian had two surgeries. He went on to have nearly a dozen more. Cristian faced several of the same challenges that many other patients with spina bifida do, including gastro-intestinal system and balance issues, as well as complications from various surgeries. For several years, his family had difficulty finding doctors who understood how to best help Cristian. That all changed one day in 2012, when Cristian met a Shriner who referred him to Shriners Hospitals for Children. Cristian was 13 when he had the surgery that he says changed his life and gave him hope, at Shriners Hospitals for Children — Los Angeles (now Shriners for Children Medical Center in Pasadena, California). Devoted to his schoolwork, seminary studies, a part-time job and playing the cello, Cristian has also been active in supporting Shriners Hospitals for Children. He even dedicated his Eagle Scout project to the cause, raising funds to present more than 200 BuildA-Bear toys to our Pasadena medical center. He finds inspiration in the other patients he encounters. “I have been very inspired by many other kids I have met. Most of the people I look up to and admire are the kids I have met through Shriners,” he said.

Cristian enjoyed his responsibilities as a National Patient Ambassador for the 2019-2020 year. “I know that I am who I am because of the Shriners,” he said. “I have been able to see that I can do whatever I want, and I can overcome any obstacle that I face. I want to give back to them because of that – because of the life that they’ve given me. Through Shriners Hospitals for Children and the national ambassadorship that I’ve been given, I hope to share a message of positivity and hope to all those who need it.”

“ I know that I am who I am because of the Shriners. "

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• 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.

2019 OUTCOMES REPORT | 9

hospital RECOGNITIONS

2019 Press Ganey Award Guardian of Excellence Award for Patient Experience: • Shriners Hospitals for Children — Canada • Shriners Hospitals for Children — Greenville • Shriners Hospitals for Children — Mexico City • Shriners Hospitals for Children — Shreveport • Shriners Hospitals for Children — St. Louis 2019 Pinnacle of Excellence Award • Shriners Hospitals for Children — Canada

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awards and RECOGNITION

Galveston Steven Wolf, M.D., chief of staff – Elected as President-Elect of the International Association for Surgical Metabolism and Nutrition Lexington Vish Talwalker, M.D. – Awarded the "Best Doctor's" recognition Henry Iwinski, M.D., chief of staff, and Scott Riley, M.D. – Recognized as “Best Doctors” in Lexington Family magazine 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 Michelle James, M.D., chief of orthopaedic surgery – Received the 2019 University of Michigan’s Comprehensive Hand Center Visiting Professor Program Award Vedant Kulkarni, M.D. – Received the Wester Association of Physicians and Western Society for Clinical Investigations Travel Award Diana Farmer, M.D. – Received the American College of Surgeons Owen H. Wangensteen Scientific Forum Dedication and the Nina Starr Braunwald Award for Outstanding Contributions to the Advancement of Women in Surgery

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 Philadelphia Scott Kozin, M.D., chief of staff – Chosen for the American Society for Surgery of the Hand International Hand Surgery Traveling Fellowship; received the Mustard Seed Award for Recognition of Unwavering Commitment to Children by Touching Hands. Portland Robert Bernstein, M.D., chief of staff – Awarded the Mend Award by Mending Kids 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 Scott Luhman, M.D., chief of staff – Received the Hero with a Heart Award from the Marfan Foundation Perry Schoenecker, M.D. – Received the POSNA Distinguished Achievement Award 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 Department of Orthopaedics Martin Boyer Medical Student Education Award 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

2019 OUTCOMES REPORT | 11

2019 by THE NUMBERS

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.

Inpatient Discharges

0 1000 2000 3000 4000 5000 6000 7000 8000 9000

8313

7400

6351

6159

6022

5713

5525

2013

2014

2015

2016

2017

2018

2019

15,026 OUTPATIENT SURGERIES

3,525 THERAPEUTIC REHAB VISITS

5,713 INPATIENT DISCHARGES

9,674 OUTREACH VISITS

282,746

OUTPATIENT CLINIC VISITS

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National Health Care Safety Network

SHC - System Central Line Associated Bloodstream Infection (CLABSI) SIRs Q3 2017 - Q3 2019

2.5

SIR <1 = below expected rate SIR >1 = above expected rate Each SIR value- no statistical significance found

2.018

2

1.426

1.5

0.931

0.879

1

0.512

0.49

0.453

0.5

0

0

0

2015Q4

2016Q1

2016Q2

2016Q3

2016Q4

2017Q1

2017Q2

2017Q3

2017Q4

SHC System Spinal Fusion Surgical Site Infection (SSI) SIRs Q1 2017 - Q1 2019

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2

1.777

1.523

1.41

1.38

0.776

0.669

0.666

0.375

SIR <1 - below expected rate SIR >1 - above expected rate Each SIR value no statistical significance found except 2nd qtr

0

p = 0.04

1st qtr 2016 2nd qtr 2016 3rd qtr 2016 4th qtr 2016 1st qtr 2017 2nd qtr 2017 3rd qtr 2017 4th qtr 2017 1st qtr 2018

13

2019 OUTCOMES REPORT |

outcomes REPORT

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 about what is most meaningful to their quality of life. Using iPads and other technology, we ask patients questions, and gather information about their mobility, upper extremity function, quality of relationships, and how pain interferes with daily activities. Physicians rely on this information to link clinical variables with health-related quality of life. Since this initiative began in December 2016, we have 12 Shriners Hospitals for Children locations using the technology and have collected over 71,000 questionnaires. 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.

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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 As of year-end 2019, five (5) Shriners Hospitals for Children hospitals are participating in the NSQIP Peds program. Two additional hospitals will begin participating in Q2 2020.

2019 OUTCOMES REPORT | 15

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.

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as

NIMH TOOLKIT Suicide Risk Screening Tool

-

Ask Suicide-Screening

uestions

.

l

Ask the patient:

1. In the past few weeks, have you wished you were dead?

m Yes

m No

2. In the past few weeks, have you felt that you or your family would be better off if you were dead?

m Yes

m No

3. In the past week, have you been having thoughts about killing yourself?

m Yes

m No

4. Have you ever tried to kill yourself? m No If yes, how? _______________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ When? ___________________________________________________________________ _________________________________________________________________________ m No If yes, please describe: ______________________________________________________ Next steps: • If patient answers “No” to all questions 1 through 4, screening is complete (not necessary to ask question #5). No intervention is necessary (*Note: Clinical judgment can always override a negative screen). • If patient answers “Yes” to any of questions 1 through 4, or refuses to answer, they are considered a positive screen. Ask question #5 to assess acuity: o “Yes” to question #5 = acute positive screen (imminent risk identified) • Patient requires a STAT safety/full mental health evaluation. Patient cannot leave until evaluated for safety. • Keep patient in sight. Remove all dangerous objects from room. Alert physician or clinician responsible for patient’s care. o “No” to question #5 = non-acute positive screen (potential risk identified) • Patient requires a brief suicide safety assessment to determine if a full mental health evaluation m Yes If the patient answers Yes to any of the above, ask the following acuity question: 5. Are you having thoughts of killing yourself right now? m Yes

Shriners Hospitals for Children has worked diligently since the beginning of 2018 in successfully implementing a suicide screening and evaluation tool to over 5500 patients ages 10 and older. This five question screeni g tool will allow the front line clinical staff to take any necessary steps needed for each patient to address their mental health needs and to provide individualized guidance and support. This screening tool will also be available for use on our Tonic platform. Our decision to join the small group of pediatric hospitals that have implemented u iversal suicide risk screening signals that a few hospitals are beginning to anticipate an inevitable and necessary change to the standards of care for suicide prevention. Suicide Risk Screening and Assessment

is needed. Patient cannot leave until evaluated for safety. • Alert physician or clinician responsible for patient’s care.

Provide resources to all patients • 24/7 National Suicide Prevention Lifeline 1-800-273-TALK (8255) En Español: 1-888-628-9454 • 24/7 Crisis Text Line: Text “HOME” to 741-741

asQ Suicide Risk Screening Toolkit

NATIONAL INSTITUTE OF MENTAL HEALTH (NIMH)

6/13/2017

2019 OUTCOMES REPORT | 17

Keeping our Patients Safe

Reducing the amount of time your child is in the hospital helps reduce infections, prevent readmissions and keeps them safer.

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SHC System- Unplanned Returns to OR Within 72hrs

0.012

0.01

2019 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.

0.008

Target (<1.00%)

0.006

0.004

0.0013

0.0013

0.0012

0.002

0.001

0

2016

2017

2018

2019

SHC System- Accidental Cut, Puncture, Laceration

0 0.001 0.002 0.003 0.004 0.005 0.006 0.007 0.008 0.009 0.01 0.011 0.012

Target (<1.0%) National Rate 2.05%

0.0009

0.0007

0.0005

0.0004

2016

2017

2018

2019

SHC System- Accidental Cut, Puncture or Laceration

0.05

Target <2.50% National Rate 4.71%

0.04

0.03

0.02

0.01

0.0029

0.0007

0.0004

0.0005

0

2016

2017

2018

2019

SHC System- Post-Op Respiratory Failure

0.05

Target (<3.00%)

0.04

0.03

0.02

0.0098

0.01

0.0036

0.0033

0.0032

0

2016

2017

2018

2019

SHC System- Unplanned Readmissions Within 30 Days of Discharge

0.2

Target (<5.00%) National Rate - 8.00%

0.15

0.1

0.05

0.0227

0.0218

0.0178

0.0219

0

2016

2017

2018

2019

2019 OUTCOMES REPORT | 19

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. In March 2019, the National Academy of Medicine (NAM) held a public session to launch a new study on the future of nursing. The goal of the Committee on the Future of Nursing 2020-2030, tasked by the RWJF, was to extend the original vision 2020-2030 and chart a path for the nursing profession to help our nation create a culture of health, reduce health disparities, and improve the health and well-being of the U.S. population in the 21st century.

SHC Nursing - BSN Degree or Higher 80% is the system-wide target

0.8

0.7634

0.7332

0.75

0.6959

0.7

0.661

0.65

0.6

0.55

0.5

2016

2017

2018

2019

SHC Nursing - Advanced Certifications >20% is the system-wide target

0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4

0.2791

0.2611

0.2051

0.1889

2016

2017

2018

2019

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FOCUSED™ on Nursing Excellence

To mark the 200th anniversary of Florence Nightingale’s birth, the World Health Organization has designated 2020 as the Year of the Nurse and Midwife. Florence Nightingale, the founder of modern nursing is described as a public health pioneer who addressed the link between poor hospital sanitation and the high mortality rate among wounded soldiers during the Crimean War of 1854. Nightingale, while serving as a nurse at the Barrack Hospital in Istanbul, established standards of care, which decreased the mortality, rate during her tenure from near 60% to approximately 1%. These practices, hand washing, sanitizing surgical tools, regularly changing bed linens, and making sure all wards were clean; remain as fundamental structures and processes in modern health care and influence current quality metrics such as hospital acquired infections, surgical site infections and antibiotic resistant organisms. Throughout our system, unsurpassed quality care is provided for each patient within our hospitals, ambulatory surgical centers and clinics. Our nurses lead at every level through direct patient care and beyond, focusing on quality monitoring and ongoing improvement. Shriners Hospitals for Children is FOCUSED™ on nursing and patient care excellence and we are proud of the interprofessional collaborative practices which focus on patient safety, quality improvement and exceptional outcomes. As we celebrate Florence Nightingale’s bicentenary, (and Shriners Hospitals for Children’s nearly 100 years of service) we remember all she has contributed to nursing, evidence-based practice and quality outcomes.

95% patient satisfaction

91%

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

76%

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

2019 OUTCOMES REPORT | 21

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

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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.

2019 OUTCOMES REPORT | 23

stay connected

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@ShrinersHospitalsforChildren

@ shrinershospitals

@shrinershosp

International Headquarters 2900 Rocky Point Dr. Tampa, FL 33607 Tel.: 813-281-0300

© SHRINERS HOSPITALS FOR CHILDREN ® 2020