2018 Quality Summit - Enloe Medical Center · Gold Certification for Excellence in Patient-Centered...

A Commitment to Keep Moving Forward

Quality Summit ANNUAL REPORT

2018

2018 Quality Summit ■ 1

CONTENTS

Where it Began 2

Decade of Quality Summits 3

Maintaining the Gain 6

2017 – 2018 Quality Initiatives 8

Quality Improvement Posters 10

Quality Summit Awards 24

2018 – 2020 Quality Initiatives 26

2018 Perspective 27

2 ■ 2018 Quality Summit

INTRODUCTION

What happened on April 1, 2009?

Besides it being April Fools’ Day, this day marked an important occasion for Enloe and our patients. April 1, 2009 was the date of Enloe’s first Quality Summit. This annual gathering was intended to look at Enloe’s place in the broader environment of health care, to be transparent about our own performance and to set three to five important quality improvement goals that were to be attained in one year. After that year, we would come back to report our progress and set more goals.

The three years prior to 2009 were very challenging for Enloe. Patient experience and outcomes were at a low point. Organizational morale was low. Through the Quality Summit, we declare the kind of hospital we want to be and set our sights on becoming that hospital.

WHERE IT BEGAN


Over the 10 Quality Summit cycles, 39 projects were selected as organizational quality initiatives. Chosen for their broad impact, these projects were led by multidisciplinary teams, each with a physician champion. Examples of the quality initiatives include:

Surgical Safety Checklist (2009)

Inspired by the Institute for Healthcare Improvement and Dr. Atul Gawande (author of “The Checklist Manifesto”), Enloe created and implemented a pre-surgical safety checklist that was utilized in 98% of surgeries within two weeks of introduction.

Protecting Patients’ Sleep (2014)

The Enloe lab shifted routine blood-test draw times from 4 a.m. to 6 a.m., giving patients two more hours of health-promoting sleep to enhance healing.

Imaging Wisely – Spine and Head CT Imaging (2016)

By incorporating evidence-based guidelines for use of CT imaging in the Emergency Department (ED), 56% fewer non-contrast low-back (lumbar spine) CT scans were ordered, avoiding significant radiation exposure to patients.

Scans for Emergency Department Patients

2016 Baseline

1st Quarter 2017

Change

With non-contrast CT cervical spine 1.45% 1.14% –21.37%

With non-contrast CT head 5.46% 5.39% –1.28%

With non-contrast CT lumbar spine 0.39% 0.17% –56.41%

HIGHLIGHTSDECADE OF QUALITY SUMMITS


Annually since 2010, Enloe has selected one quality improvement project from the prior year to receive the Quality Summit Award. The recipient is selected based on votes from all Enloe caregivers. There have been 10 Quality Summit Award winners, examples of which include:

Stroke Care (2011)

Consistently superior stroke care earned recognition from the American Heart and American Stroke Associations, as well as designation by the Joint Commission as a Stroke Receiving Center.

The Final Check (2013)

Improved accuracy of clinical lab specimen labeling enhances patient safety and experience.

Healthy Hospital (2016)

Recycling efforts reduced waste going to landfills, lowered carbon dioxide emissions, saved gas and generated savings of over $91,000 in one year.


Poster Presentations

Also beginning in 2010, caregivers in all areas of the hospital are encouraged to create poster presentations to widely share their quality improvement achievements. These posters are exhibited before and after the Quality Summit and then rotated in displays along the main patient corridor at Enloe’s Esplanade Campus. Since 2010, 504 posters have been created by care teams throughout Enloe, showing pride in the kind of work that is done every day.

Supporting Hospital Quality

A highlight of this year’s Quality Summit was a special presentation by Julianne Morath, RN, MS, CPPS, president and chief executive officer, Hospital Quality Institute (HQI). She spoke on the partnership afforded hospitals through the HQI. The organization supports hospitals as they strive to improve patient experience and outcomes. One of its focus areas, maternity care, guides work at Enloe that has reduced elective deliveries before 39 weeks and reduced the C-section rate for first-time mothers with one baby in a head-down position.


Striving for consistency in process and outcome, Enloe continually monitors progress made on earlier quality initiatives.

Sepsis

Sepsis is a serious, life-threatening condition where an infection has threatened many important functions in a person’s body. Mortality rates can be very high with severe sepsis and septic shock: 20% and 46% respectively, according to published benchmarks. At the first Quality Summit, in 2009, Enloe formally adopted best practices in the treatment of sepsis. The results have shown sustained reductions in mortality that consistently outperform published benchmarks. Lives are being saved.

Planetree and Patient Satisfaction

In 2007, patients expressed their dissatisfaction with Enloe by ranking the hospital in the lowest 2nd percentile in the nation. They did so by answering the question: On a scale of 1-10, how would you rate your hospital? As measured by the Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS), this metric indicated the work needed to create a patient-centered healing environment. Enloe committed to this effort, and in 2018 achieved the Planetree Gold Certification for Excellence in Patient-Centered Care. Part of that

PROGRESSMAINTAINING THE GAIN

Severe Sepsis and Septic Shock Mortality

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10

20

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Published Enloe 2015

Severe Sepsis Septic Shock

Enloe 2016 Enloe 2017

50


achievement was input from patients about their experience. Since 2011, Enloe’s patients have consistently ranked Enloe in the top 25th percentile, reflecting the strong impact of Planetree’s patient-centered culture.

Improving Mother and Baby Care

Enloe obstetricians and pediatricians, with their nursing colleagues, turned their focus on the optimal time to electively deliver babies. Data shows that babies do better when delivered no earlier than 39 weeks gestational age. From a high of 7.75% elective deliveries before 39 weeks (2007), Enloe now achieves best-practice performance with less than or equal to 1.5% elective deliveries before 39 weeks. (This is better than the national goal of less than or equal to 5%). Also, Enloe maintains a primary Cesarean-section rate for first-time mothers at term with the single baby in the head-down position at below (better than) the state target of less-than or equal to 23.9%. Both projects were part of the Hospital Quality Institute’s California Maternal Quality Care Collaborative.

HCAHPS Rate Hospital: 2007 – 2017Patients who rated Enloe a 10 on a scale of 1 to 10

Perc

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0

20

40

60

80

100

2007

*Note: starting July 2014, data is adjusted with CMS parameters. Difference is about 1%.

49%

47%

51%

54% 64

% 70% 77%

78%

79%

77%

80%

2008

2009

2010

2011

2012

2013

*201

4

2015

2016

2017

Elective Delivery Rate Earlier than 39 Weeks Gestation

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2015 2016 2017

Enloe California Average Leapfrog Target


Three quality initiatives were selected as priorities at last year’s Quality Summit.

Epic Electronic Health Record

In mid-2018, Enloe transitioned all services, both inpatient and outpatient, to the Epic electronic health record (EHR) platform. Having a single EHR throughout the organization promised to enhance communication among all locations where care is provided, improving clinical quality and patient experience. This change required close to two years of planning. Not only did the steps of every process performed in this complex organization require translation into the Epic system, but the ways all caregivers interact had to be considered. It was with a great feeling of accomplishment that all Enloe caregivers participated in the successful go-live on April 29. The Epic organization rated the result of Enloe’s implementation at 8 out of 10 gold stars, which is attained by only 10-15% of hospitals.


INITIATIVES2017 – 2018 QUALITY INITIATIVES


Improving Safe Use of Novel Anticoagulant Medications

Novel anticoagulation medications have emerged in recent years. With these new therapies, Enloe recognized the need to develop guidelines for their safe use, and for the safe transition from one medication class to another. Clinicians and pharmacists partnered to create a document that provides clear, useful information for clinicians throughout the organization and the community.

Enhanced Recovery After Surgery

Evidence shows that patients can experience less post-operative pain and nausea when certain therapies are instituted. Called Enhanced Recovery After Surgery (ERAS), this protocol specifies pre-operative carbohydrate loading to support nutritional reserves; improved pain management using pre-operative non-opioid medications; and minizing post-operative nausea through the scheduled use of antiemetic medications. ERAS was piloted first with bariatric patients. These patients required less opioid pain medication, had less nausea and left the hospital sooner. Enloe will refine this protocol for different surgery types to further its benefit to patients.


Bariatric Surgery Medication Use Off and On ERAS Protocol

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Opioid Use (in MME*) Antiemetic Use

Off ERAS Protocol On ERAS Protocol

*Opioids are measured in morphine milligram equivalents (MME).


Each year, departments throughout Enloe share their quality improvement journeys with colleagues and the community. The quality stories highlight clinical and non-clinical achievements that, together, elevate care at Enloe.

EMS Trauma Time Out

The trauma team leader conducts a trauma time out using the MIST (mechanism of injury, injuries, symptoms, treatments) mnemonic to improve trauma patient care through the sharing of critical information.

Epic Order Set Development and Approval

This 10-month project created the order sets needed for Epic go-live at Enloe, translating complex care into the new electronic format.

Eliminating Immediate Use-Steam Sterilization

Sterile Processing has not had to utilize immediate-use steam sterilization cycles for five years due to improved processes.

Stop the Bleed

Enloe adopted this worldwide program to save lives through rapid response to life-threatening bleeding. Nearly 200 community members have received training from Enloe trainers so far.

QUALITY IMPROVEMENT POSTERS

IMPROVEMENTS


U-100 Insulin Syringe Change

Insulin syringes now have a shorter needle. This improves safety by avoiding intramuscular injections and maintaining a one-hand safety mechanism. The needle’s more comfortable, less frightening size is also a patient satisfier.

Pediatric Readiness Quality Collaborative

Enloe is one of seven northern California hospitals collaborating with UC Davis to improve early assessment of pediatric patients in the Emergency Department.

Teaming Up to Treat Vertigo

Emergency Department providers and physical therapists collaborated to offer vestibular rehabilitation therapy to patients with vertigo in the ED. Of these patients, 85% reported they were no longer dizzy after one physical therapy visit, and 95% did not require a second visit for continued symptoms.

Enloe ENT Clinic

The four ENT physicians see patients with concerns involving the ears, nose, throat, head and neck from across the north state, receiving 100 consultations daily.

Pulmonary Rehabilitation Reduces Hospital Readmissions

COPD patients who participate in pulmonary rehabilitation classes show a significant decrease in readmissions the following year.

Pineapple Express

Emergency Department staff strive to convey a professional, patient-centered environment and use the code word “pineapple” to remind each other when voices and humor need to be reined in.

IMPROVEMENTS


Peer Support Team

Mother & Baby Care, Emergency Department, Critical Care and Case Management staff created the peer support team, receiving education to better assist their teams during and after a crisis.

Heart Dissection Class

Cardiac Cath Lab staff partnered with heart valve producer St. Jude and studied heart electrophysiology and cardiac anatomy using pig hearts as models.

Managing Advanced Illness

Since 2016, AIM (Advanced Illness Management) Committee members have provided compassionate, patient-centered education to patients nearing the end of life to help them and their families at this important time.

Enloe Cardiology Services Clinic

This team promotes healthier hearts by encouraging healthy habits and lifestyles for their patients.

Cardiac Rehabilitation Classes Improve Outcomes

Patients who participate in cardiac rehabilitation classes demonstrate improved mood, quality of life and exercise capacity in addition to reduced mortality rates.


Preventing Deep Vein Blood Clots in Trauma Patients

Venous Thromboembolism (VTE) is a common and serious complication after trauma. Enloe Trauma Services created treatment guidelines to standardize VTE prophylaxis and promote patient safety.

Supporting Vaginal Births and Reducing Primary C-sections

Using a California Maternal Quality Care Collaborative (CMQCC) Toolkit, the Mother & Baby Care Center staff developed drills to help support laboring mothers. As a result, Enloe’s primary C-section rate for NTSV births was 20.4% in 2017, better than the Healthy People Target of 23.9%.

Midline Catheters

Midline IV catheters are appropriate for many therapies that will continue up to 29 days. With low complication rates, their use has increased from 20 per month in 2017 to 29 per month in 2018.

Supportive and Palliative Care Interdisciplinary Team

This team is composed of a physician, two nurse practitioners, a nurse, a social worker and a volunteer chaplain. It addresses the patient’s body, mind and spirit while helping the patient cope with chronic, often life-limiting illness.

Enloe Outpatient Therapy

As the largest physical, speech and occupational therapy group north of Sacramento, this team of experienced professionals is rated as “excellent” by over 92% of patients in the past five years.

Urolift Treatment for Prostate Gland Enlargement

Urolift is a new treatment for benign prostatic hypertrophy. Also known as prostate gland enlargement, this condition affects 40 million U.S. men annually.

Heparin Bedside Rounds

Daily charge-nurse rounds on patients with heparin drips reduced medication errors associated with this medication on the Telemetry Care Unit. With this practice now implemented hospital-wide, those improvements are expected to be seen on other units.

Reducing Hospital-Acquired Infections

Ultraviolet light disinfection is used to reduce hospital-acquired infections (HAIs) by eliminating difficult-to-remove infectious agents. With its use, the HAI rate decreased by close to 50%.


Hospital-Acquired Infections Before and After Room Sterilization With UV Light

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1st Quarter 2nd Quarter

2017 2018

3rd Quarter

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Top and Below Left: These are among the many caregivers at Enloe who have been awarded quarterly for kindness, clinical care and customer service. Bottom Right: Scott Mellum, M.D., received the 2018 Physician Legacy Award.


Enloe Stroke Program

Treating the 266 patients with a brain attack in 2017, the Stroke Program team continues to deliver best-practice performance in national metrics.

Enloe Security Team

To improve the safety of patients, visitors and staff, the Security team added 13 officers who are all highly trained to prevent and respond to unsafe situations.

Sexual Assault Response Team

The Butte County Sexual Assault Response Team helps survivors of sexual violence by treating them with dignity and providing them with information about their rights and resources to help them on their path to healing.

Reducing Paper Usage

The Medical Staff Office transitioned to electronic rather than paper meeting packets. It now prints materials double-sided and saves minutes electronically rather than on paper. Printing cost savings for one Medical Executive Committee meeting are as much as $1,875.

Improving Care of Newborns Exposed to Drugs

From 2014-2017, Enloe experienced a 150% increase in the number of babies born with Neonatal Abstinence Syndrome. Through the Cuddler Volunteers Program and other high-touch interventions, these babies require fewer medications to calm them and leave the hospital sooner.

2018 Quality Summit ■ 1 7

Physician Influenza Vaccination

Medical Staff Office nurses administer flu shots to physicians at special clinics and physician meetings, increasing compliance with the annual vaccine from 61% in 2015 to 81% in 2017.

Human Trafficking

Human sex trafficking happens in Butte County. Emergency Department staff received specialized training to identify these victims to get them the needed protections and resources.

Improving Access to Information for Spanish Speakers

In addition to telephone-based translation services, the Cancer Center offers patients and families Spanish-language information on cancer treatments and cancer types.

New Specialty Care Units

From one Definitive Care Unit, two units were formed: the Telemetry Care Unit and the Cardiovascular Unit. These sister units provide specialty care focused on specific patient needs and interventions.

Enloe, the Cancer Sniffing Dog

In collaboration with Dina Zaphiris of the In Situ Foundation, Enloe the hospital sponsors Enloe the dog to learn to identify the presence of cancer in exhaled breath samples.


Leadership Development on the Cardiovascular Unit

Charge nurses on the Cardiovascular Unit (CVU) built upon house-wide charge nurse leadership training to form stronger teams, improve efficiency and increase leaders’ confidence.

Continuing Medical Education and Tumor Boards

The physician Continuing Medical Education (CME) program is changing with the times to offer online education, journal clubs and video education. Tumor boards grew from one general cancer tumor board to three: breast, colorectal and general cancer tumor boards.

Anticoagulation Clinic

Time in Therapeutic Range (TTR), linked to positive outcomes, is greater than 82% for patients taking warfarin monitored at the clinic or doing self-testing at home.

What Matters to Me?

Changing from a culture of “What’s the matter with you?” to “What matters to you?” Fifth Floor Medical/Neurological implemented the “What Matters to Me” program to improve patient and staff experience.


Ensuring Clean Surfaces

To reduce hospital-acquired infections, Environmental Services uses the adenosine triphosphate (ATP) cleaning verification system to confirm the cleanliness of patient rooms after patient discharge and before another patient occupies the room.

Spirit of Planetree Awards

Representing some of the best in patient-centered care, hospitalist Edward O’Regan, M.D., received Enloe’s 2018 Physician Champion Award, Roxanne Roberts, resource lab assistant, received the Caregiver Award, and the Endoscopy Clinic received the Program Award.

Enloe Inpatient Pediatrics

Enloe’s pediatric nurses help ease anxiety, pain and fear for their young patients with art supplies, fun blankets and pillows, and even wagons and “princess carriages” to encourage them to play and move about.

How our pediatric nurses include play in our pediatric patient’s hospitalization and recovery

Providing pediatric

patients with art supplies allows

an outlet for expression. This also helps them

cope with hospitalization.

Using distraction techniques like bubbles and light up wands, the nurses help ease

anxiety, pain, and fear.

Donated blankets, stuffed animals and pillowcases make

the hospital room more inviting.

Using wagons, cars, and princess

carriages, the nurses are

able to get the pediatric

patients out of their room to

encourage play.

Using the donated

Starlight Fun Center as

motivation, our pediatric

patients are encouraged to ambulate the

halls.


Patient and Family Advisory Council (PFAC)

The PFAC brings the patient and family voice to hospital leadership, giving guidance on projects from wayfinding signage to the “What Matters to Me” communication tool. Enloe member Ronnie Campbell was selected to join the Planetree International PFAC.

Planetree Gold

After a 12-year journey, Enloe achieved Planetree Gold Certification for Excellence in Patient-Centered Care. Enloe is one of only 79 hospitals worldwide and one of four in California to achieve this major milestone.

Enloe Inpatient Rehabilitation

Compared with national benchmarks, patients at the Enloe Rehabilitation Center receive significantly more minutes of therapy treatments and are able to be discharged home more often.

Respiratory Support for Hospice Patients

Enloe Hospice is able to provide patients with specialized respiratory support that allows them to be more comfortable and alert when at home for end-of-life care.

Culture of Safety

Responding to staff input, staff are educated about the importance of a culture of safety, both physical and psychological, and are given tools to create this culture in the workplace.


Top: Leaders at Enloe Medical Center, Judy Sitton and Connie Rowe, RN, were recognized as Planetree Scholars by Planetree International. Below Left: Employees Richard Cornett and JC Cummings received an Enloe Stories of Excellence Award. Bottom Right: Participants get into the spirit of Enloe’s Heart & Soul: Run for Wellness.


Documenting Patient Progress at Enloe HomeCare

HomeCare staff improved their use of Medicare assessment tools and better described the success of their interventions.

Vital Sign Monitoring System

The lighted central alarm monitoring system now signals important changes in vital signs, contributing to improved patient safety.

Reducing COPD Readmissions

Over 18 months, the Transitional Care Coordination team worked with over 1,300 COPD patients, providing over 1,500 contacts, and improved COPD readmissions from “worse than national average” to “on target.”

Reporting Efficiency with Epic

The Enloe Rehabilitation Center is required to submit a complex report to Medicare for each patient discharged. Before the Epic electronic health record was implemented, this required 120 minutes to create. With Epic, it takes 90 minutes, saving about 250 hours per year of staff time.

Stop Pressure Ulcers in Critical Care

Critical Care teams developed a plan to eliminate pressure ulcers through implementing preventative measures, proactive documentation and thorough team communication.

First Floor Medical Surgical Unit

Demonstrating the core values of ownership and empowerment, this unit took steps to create a more quiet nighttime environment for patients, improve patient safety and reduce waste in many processes.


Bereavement Care

Case Management saw a need to improve care provided to those experiencing grief. To achieve this, team members received training, and expanded participation in support groups and special services.

Enhanced Recovery After Surgery

The ERAS (Enhanced Recovery After Surgery) protocol expedites patient recovery and improves outcomes after surgery. For bariatric surgery patients, use of the protocol resulted in a 46% reduction in opioid use post-operatively.

Standardized Communication for Nursing Handoffs

Using the Situation-Background-Assessment-Recommendation (SBAR) tool, nurses communicate important patient information to their colleagues so that handoffs are safe and efficient.

Stroke Rounds

Expanded team rounds for stroke patients ensures those patients receive the evidence-based therapies that will improve their outcomes.


Coach’s Award: Planetree Gold Certification for Excellence in Patient-Centered Care

In 2006, Enloe started out on a journey to create a hospital where clinical excellence blends seamlessly with exceptional patient experience. After 12 years of designing all processes and environments with the patient in mind, Enloe was awarded Planetree Gold Certification for Excellence in Patient-Centered Care, becoming one of 83 health care sites in the world to achieve this distinction. Specific honors awarded to Enloe for patient-centered care are: > National Spirit of Planetree Program Award: Bariatric Surgery

Program (2016), Total Joint Replacement Program (2014) > Planetree Scholars: Connie Rowe (2018), Judy Sitton (2017) > Planetree Video Award (2018) > Planetree Bronze Recognition (2013) > National Spirit of Planetree Arts & Entertainment Award:

Healing arts program (2008)

QUALITY SUMMIT AWARDS

AWARDS


Quality Summit Award: Preventing Infection with Short Wavelength Ultraviolet Light

Patients come to hospitals with a multitude of conditions, some of which are infections caused by particularly hardy organisms that may persist on surfaces after standard cleaning. This year’s Quality Summit Award winner harnessed short wavelength ultraviolet (UV) light in the fight against hospital-acquired infections. Enloe implemented technology that uses this light to clean rooms that have been occupied by patients with certain infections, such as the intestinal organism Clostridium difficile (C. diff). With this technology, the incidence of hospital-acquired C. diff infections was reduced by as much as 52%.

AWARDS

2018 Quality Summit ■ 2 6

Three initiatives will form the backbone of the 2018-2020 quality improvement cycle.

Safer Opioid Use

Opioid pain medications have a place in medical therapeutics, but their ongoing use carries significant risk to patient safety. In Butte County, the need to address the opioid epidemic is particularly urgent. Residents receive twice as many opioid prescriptions compared to the rest of California, and the amount of opioids prescribed in Butte County is three times the average amount prescribed per person in the United States. In collaboration with community providers and Butte County Public Health, Enloe will implement actions recommended by the Butte County Opioid Coalition to reduce the impact of opioids on our patients.

Improving Diabetes Care: Diabetic Ketoacidosis

People with Type 1 diabetes are at significant risk for diabetic ketoacidosis (DKA). This results from very high blood sugars and requires aggressive inpatient treatment. This quality improvement project will use the latest research to ensure patients receive DKA care in the setting most appropriate for them and will also focus on empowering patients to remain healthy after discharge.

Enloe Concussion Clinic

Closed head injuries can cause a serious condition known as concussion. A concussion may have long-term consequences but that impact may not immediately show up. Because of this, it is that much more important to closely follow patients after they suffer this kind of injury. When developed, the Enloe Concussion Clinic will provide continuity of care to those who have experienced a concussion, with expert evaluation and monitoring.


2018 – 2020 QUALITY INITIATIVES

INITIATIVES


Three weeks after the Quality Summit, the town of Paradise and smaller surrounding hamlets were consumed by the raging Camp Fire. This wildfire, the deadliest and most destructive in California history, will leave scars on Butte County’s close-knit communities for many years to come. Enloe’s caregivers rose to the occasion, welcoming patients transferred emergently from severely damaged Adventist Health Feather River hospital. Despite experiencing loss from the fire themselves, many Enloe staff cared for patients and each other with grace and compassion.

Continual quality improvement, which is the fabric of Enloe Medical Center, played a front and central role during the weeks after the Camp Fire. This year’s Quality Summit Award innovation, using UV light to prevent the spread of infections, played a crucial role as the hospital cared for the many Camp Fire evacuees who suffered from a norovirus outbreak. Thanks to the introduction of UV light technology, Enloe could guard against the spread of this highly infectious gastrointestinal virus.

INITIATIVES COMMITMENT2018 PERSPECTIVE


The 2018 Quality Summit was held in the autumn rather than the spring, due to the organization-wide focus on launching the Epic electronic health record in April. The next Quality Summit will be held in 2020, returning to the typical quality cycle that begins each spring. This will also allow additional time to make changes in the face of helping our Butte County communities heal from the Camp Fire’s impact.

Enloe caregivers’ quality improvement work has saved lives, improved the patient experience and delivered best-practice medicine to our region. The Quality Summit continues to represent our commitment to keep moving forward as we strive toward our mission: to improve the quality of your life thorough patient-centered care.

“ The journey toward a culture of safety is in no way a solitary one.” — Julianne Morath, President and CEO, Hospital Quality Institute, from her book, “To Do No Harm”

For more information about quality initiatives at Enloe Medical Center, contact Marcia Nelson, MD, MMM, CPE, FAAFP, FAAPLChief Medical Officer(530) 332-5414 or email: [email protected].

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Our Mission To improve the quality of your life through patient-centered care

2018 Quality Summit - Enloe Medical Center · Gold Certification for Excellence in Patient-Centered...

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