Situation audit for a medical hospital

Report Template

REPORT COVER PAGE (1 page; not included in 25page limit)

EXECUTIVE SUMMARY (1 page; not included in 25page limit)

INTRODUCTION (1 page)

MedStar Washington Hospital Center is a not-for-profit, 926-bed, major teaching and research hospital in the nation’s capital. The Hospital Center is among the 100 largest hospitals in the nation,* and is renowned for handling the Washington region’s most complex cases. U.S.News & World Report consistently ranks the Hospital Center’s cardiology and heart surgery program as one of the nation's best; it’s the only hospital in the Washington metropolitan area to earn a national ranking for heart care in FY 2015. A long-standing leader in cardiovascular care, MedStar Washington Hospital Center is home to MedStar Heart & Vascular Institute, which formed a first-of-its kind clinical and research alliance with Cleveland Clinic Heart & Vascular Institute in 2013. The Hospital Center operates the Washington region’s first Comprehensive Stroke Center and the District’s only Cardiac Ventricular Assist Device program, both certified by The Joint Commission. The hospital is also home to MedSTAR, a nationally-verified level I trauma center with a state-of-the-art fleet of helicopters and ambulances, and also operates the region’s only adult Burn Center.

MedStar Health combines the best aspects of academic medicine, research and innovation with a complete spectrum of clinical services to advance patient care. As the largest healthcare provider in Maryland and the Washington, D.C., region, MedStar Health’s 10 hospitals, the MedStar Health Research Institute and a comprehensive scope of health-related organizations are recognized regionally and nationally for excellence in medical care. MedStar Health has one of the largest graduate medical education programs in the country, training 1,100 medical residents annually, and is the medical education and clinical partner of Georgetown University. MedStar Health is a $5 billion, not-for-profit, regional healthcare system based in Columbia, Maryland, and one of the largest employers in the region. Our 31,000 associates and 4,700 affiliated physicians support MedStar Health’s patient-first philosophy that combines care, compassion and clinical excellence with an emphasis on customer service.
 

FACT SHEET (1 page)

2015

MedStar Medicare Choice expands into Baltimore City and Anne Arundel, Baltimore, Charles, Prince George’s, and St. Mary’s counties.

MedStar Health Research Institute (inclusive of the entire MedStar system) wins the ACTION III Award from the Agency for Healthcare Research and Quality (AHRQ) and is now a prime part of the ACTION Network, a vehicle that issues task orders designed for highly-qualified, highly-resourced contractors and partners to undertake rapid-cycle research focused on one or more of AHRQ’s priorities.

2014

MedStar Health opens a comprehensive, integrated, multispecialty care center in Federal Hill located in downtown Baltimore. 

MedStar Health opens four more MedStar PromptCare locations in Belcamp, Federal Hill and Wheaton, Md., and in Alexandria, Va.

Becker’s Hospital Review names MedStar as one of the 150 Great Places to Work in Health Care in 2014.

MedStar Health marks its tenth time as one of the nation’s Most Wired organizations, according to the 2014 survey results published by Hospitals & Health Networks (H&HN) magazine.

MedStar Health enters into a clinical affiliation with CVS Health to enhance access to high-quality, affordable healthcare services.

MedStar National Rehabilitation Network, in partnership with Peninsula Regional Medical Center, opens in Millsboro, Del. This is MedStar NRH Network’s first venture into Delaware.

MedStar Union Memorial Hospital is granted inclusion into the MedStar Heart & Vascular Institute Clinical and Research Alliance with the Cleveland Clinic Heart & Vascular Institute.

A new strategic alliance between MedStar Health and the Cerner Corporation is established to advance the quality and efficiency of patient care through health Information Technology (IT).

MedStar Health becomes the official medical team partner of the Washington Capitals and Wizards, and will serve as the official Sports Medicine physicians for both teams. 

MedStar Health Research Institute receives the Pioneer Research Award as part of the American Association of Medical Colleges Learning Healthcare System Research Initiative.

2013

MedStar Medicare Choice launches in the District of Columbia.

MedStar Health opens four more MedStar PromptCare locations in Perry Hall and Pikesville in the Baltimore area, and in Adams Morgan and Gaithersburg in the Washington, D.C., area.

Surgeons from The Curtis National Hand Center at MedStar Union Memorial Hospital perform their first double arm transplant—one of only seven successful bilateral arm transplants in the United States.

MedStar Heart Institute and the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic announce a first-of-its-kind clinical and research alliance. The collaboration will provide new and enhanced treatment options to patients, as well as accelerated access to the most advanced research, technologies and techniques in Cardiology and Cardiac Surgery.

2012

MedStar Health launches a new systemwide brand strategy to evolve the MedStar Health corporate signature and how the system is presented and promoted to Maryland and Washington, D.C., region communities.

MedStar Visiting Nurse Association expands services and regional scope through the acquisition of Southern Maryland Home Health, Inc., further penetrating, Prince Georges, Calvert, Charles, and St. Mary’s counties.

MedStar Southern Maryland Hospital Center becomes part of MedStar Health.

MedStar Health establishes the MedStar Heart Institute to enhance access to excellence, experience, innovation, and a commitment to research and the advancement of heart medicine.

MedStar launches its systemwide Population Health Management Initiative, moving the organization toward a more comprehensive approach in providing healthcare benefits that care for people in a way that transforms their healthcare experience.

MedStar launches its systemwide initiative to become a High Reliability Organization, with the goal of creating a patient safety culture that achieves zero preventable patient harm.

MedStar Family Choice, MedStar’s Medicaid insurance plan, expands into the Washington, D.C., region.

MedStar Health opens it first two MedStar PromptCare locations in Towson and Wheaton, Md.

MedStar Health opens a comprehensive, integrated, multispecialty care center in Mitchellville, Md., by co-locating three existing community practices and adding new specialties needed in the community.

2011

MedStar Diabetes Institute Recognized as Winner of Microsoft Health Users Group 2011 Innovation Award.

Cleveland Clinic and MedStar Health Form Collaborative Innovation Alliance.

MISSION, VISION, VALUES, AND GOALS (2 pages)

Mission

MedStar Washington Hospital Center, a valued member of MedStar Health, is dedicated to delivering exceptional PATIENT FIRST health care. We provide the region with the highest quality and latest medical advances through excellence in patient care, education and research.

Our Vision

To be the trusted leader in caring for people and advancing health.

Guiding Principle

To treat each patient as we would a member of our own family by providing the best medical treatment with caring and compassion, responsive service, and intelligent use of resources. Through this achievement, we will be recognized as a national model for excellence in patient-centered care.

Values

• Service - We strive to anticipate and meet the needs of our patients, physicians and co-workers.

• Patient First - We strive to deliver the very best to every patient every day. The patient is the first priority in everything we do.

• Integrity - We communicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards.

• Respect - We greet each individual, those we serve and those with whom we work, with the highest professionalism and dignity.

• Innovation - We embrace change and work to improve all we do in a fiscally responsible manner.

• Teamwork - System effectiveness is built on the collective strength and cultural diversity of everyone, working with open communication and mutual respect.

STRATEGY AND OBJECTIVES (2 pages)

Strategies to Address Chronic Disease

• To offer heart health education courses. • To provide smoking cessation programs. • To conduct free blood pressure screenings. • To offer community-based healthy lifestyle lectures/classes. • To teach nutrition education classes in the community, as well as classes focused on heart health and diabetes. • To teach weekly exercise classes. • To teach health literacy and compliance education courses. • To provide health fair education sessions.

Current and Future Programming

• Offer four sessions of classes about diabetes and provide individual sessions on diabetes self-management. • Offer “Living Well: Take Charge of Your Diabetes” selfmanagement program. • Provide nutritional classes and food demonstrations throughout the year to support behavior change for nutrition and wellness. • Offer the “Get Heart Smart Program.” • Teach exercise/fitness classes, including senior programs. • Partner with the American Lung Association’s Freedom From Smoking® program.

Anticipated Outcomes for Chronic Disease

• Reduced weight/body mass index • Improved self-management of diabetes • Improved clinical measures associated with blood glucose levels and HbA1c levels • Improved adherence to instructions for prescribed medications • Improved diet, increased fruit and vegetables intake, and decreased sodium intake • Increased physical activity and muscle mass • Increased percentage of people who stop smoking at four weeks, one year and more than one year • Improved mental health

Metrics for Chronic Disease

Key factors will be tracked to determine the impact of programs deployed and to track relevance to external public health targets. Program-Specific • Percentage of program participants reporting recommended levels of physical activity • Percentage of program participants with elevated blood pressure and blood sugar • Percentage of program participants who successfully quit smoking cigarettes • Percentage of program participants aware of risk factors associated with chronic diseases • Percentage of program participants who adopt sustainable lifestyle behaviors that help reduce the prevalence of chronic diseases

ORGANIZATIONAL SIZE AND STRUCTURE (1 page)

CRITICAL RESOURCES: HUMAN RESOURCES (2 pages)

CRITICAL RESOURCES: FINANCIAL (2 pages)

CRITICAL RESOURCES: TECHNOLOGY(2 pages)

CRITICAL RESOURCES: MAJOR PHYSICAL ASSETS (2 pages)

CRITICAL RESOURCES: OTHER (1 page)

LEADERSHIP, GOVERNANCE, AND MANAGEMENT (2 pages)

ORGANIZATIONAL STRENGTHS AND WEAKNESSES (1 page)

ORGANIZATIONAL LEARNING AND CHANGE (2 pages)

MedStar Washington Hospital Center’s CBSA includes adults ages 18 or older who reside in Wards 5, 7 and 8 of the District of Columbia. Ward 5 was selected due to its close proximity to the hospital, coupled with an opportunity to build upon longstanding programs and services in that ward. Wards 7 and 8 were selected because most residents in those wards are underserved and accounted for more than 11,970 visits to MedStar Washington Hospital Center’s inpatient, observation, outpatient, and emergency rooms from July 1, 2013, to June 30, 2014.

Community Health Priorities

• Chronic disease prevention and management (heart disease/stroke, cancer, diabetes, and obesity)

• Teen births and child development

Objective:

Promote heart health and address risk factors of heart disease/stroke, cancer, diabetes, and obesity in Wards 5, 7 and 8 of Washington, D.C.

Secondary Data: Framing the Issue- Heart Disease and Stroke2, 8

• Heart disease is the second leading cause for hospitalization in Washington, D.C., at an annual rate of 882 visits/100,000 people.

• The prevalence of high blood pressure is 28 percent and high cholesterol is 34 percent. These prevalences are highest in adults ages 65 and older, male adults and African Americans.

• Geographically, the prevalence of hypertension is highest in Ward 7 (42 percent) and Ward 8 (40 percent), where socioeconomic status is the lowest. Comparatively, in Ward 3, where socioeconomic status is the highest, the prevalence of hypertension is 20 percent.

Compared to all U.S. counties, the age-adjusted death rate due to heart disease in Washington, D.C., falls within the range of the worst quartile.

Cancer2

• Cancer is the second leading cause of death in the District of Columbia. The incidence of breast, cervical and prostate cancer, and the age-adjusted death rate due to breast and prostate cancer, all fall within the range of the worst quartile

nationally.

• The overall death rate due to cancer in D.C. is 193/100,000 people, compared to 163/100,000 nationally. The overall death rate due to cancer is higher for African Americans relative to Whites—a disparity that persists for the death rates due to breast, colorectal, lung, and prostate cancer.

Diabetes2

• Diabetes is the seventh leading cause for hospitalization in the District, at an annual rate of 305 visits/100,000 people.

• The age-adjusted death rate due to diabetes is 18/100,000. Adults 65 and older (28 percent) are the most likely to be diagnosed with diabetes across age groups. The prevalence among African Americans (13 percent) is more than six times higher than the prevalence among Whites (2 percent).

Obesity2, 8

• Nearly a quarter (23 percent) of adults in the District of Columbia are obese, a trend that has not changed in recent years. The prevalence of obesity is highest in adults between the ages of 35 to 64 and women and is significantly higher in African American residents (36 percent) than Hispanics (15 percent) or Whites (10 percent).

CONCLUSIONS AND RECOMMENDATIONS (2 pages)

REFERENCES (not included in 25page limit)

http://www.medstarhealth.org/mhs/about-medstar/facts-and-figures/#q={}

ADDENDA (if needed; not included in 25page limit