We believe that care is better where we are, and there is no limit to how far we'll go to deliver whole person care. We are pleased to announce that 13 of our hospitals are 5-star rated in various procedures and outcomes according to research released by Healthgrades, the leading resource that connects consumers, physicians and health systems. Every year, Healthgrades evaluates hospital performance at nearly 4,500 hospitals nationwide for 32 of the most common inpatient procedures and conditions using Medicare data, and additional analyzes outcomes in appendectomy and bariatric surgery using all-payer data provided by 16 states.

“At Centura Health, our culture of ‘Safety First, People Always’ is at the forefront of everything we do, and we are committed to achieving zero preventable harm for all our patients,” said Dr. Shauna Gulley, Senior Vice President and Chief Clinical Officer. “These achievements from Healthgrades come as no surprise but are well-deserved for our incredible caregivers, who work day and night to deliver high quality, whole person care.”

This analysis shows that patients treated at hospitals receiving a 5-star rating have a lower risk of dying and a lower risk of experiencing one or more complications during a hospital stay than if they were treated at hospitals receiving a 1-star rating in that procedure or condition.

We are proud of the following Centura Health facilities that were recognized with 5-star ratings from Healthgrades within specific service lines:

• Avista Adventist Hospital is a 5-star recipient for Treatment of Sepsis.
• Castle Rock Adventist Hospital is 5-star rated in the areas of cardiac, gastrointestinal and critical care.
• Littleton Adventist Hospital is 5-star rated in the areas of cardiac, neurosciences, pulmonary, critical care and labor and delivery^*.
• Longmont United Hospital is a 5-star recipient for Colorectal Surgeries.
• Mercy Hospital is 5-star rated in the areas of cardiac, orthopedics, pulmonary, gastrointestinal and critical care. Mercy is also the proud recipient of the Healthgrades Outstanding Patient Experience Award for 13 years in a row.
• Parker Adventist Hospital is 5-star rated in the areas of neurosciences and critical care.
• Penrose-St. Francis (PSF) is the proud recipient of Healthgrades® America’s 250 Best Hospitals Award for three years in a row. PSF was also named one of Healthgrades America’s 100 Best Hospitals for coronary intervention, orthopedic surgery, joint replacement, spine surgery and prostate surgeries. In addition, PSF was named one of Healthgrades America’s 50 Best Hospitals for Surgical Care.
• Porter Adventist Hospital (PAH) was named one of Healthgrades America’s 100 Best Hospitals for Joint Replacement^TM for eight years in a row. PAH is also 5-star rated in the areas of cardiac, orthopedics and critical care.
• St. Anthony Hospital (SAH) was named among the top 10% of the nation for cardiology services for seven years in a row and was named one of Healthgrades America’s 100 Best Hospitals for Cardiac Care. SAH was also a recipient of the Healthgrades 2022 Cardiac Care Excellence Award and is 5-star rated in the areas of cardiac, pulmonary and critical care.
• St. Anthony North Hospital is a recipient of the Healthgrades Critical Care Excellence Award for four years in a row and the recipient of the Healthgrades Outstanding Patient Experience Award for two years in a row. SAN is 5-star rated in cardiac and critical care.
• St. Catherine Hospital is a 5-star recipient for Hip Fracture Treatment.
• St. Mary-Corwin Hospital is 5-star rated in pulmonary and gastrointestinal.
• St. Thomas More Hospital is 5-star rated in orthopedics and labor and delivery*.

For its analysis, Healthgrades evaluated approximately 45 million Medicare inpatient records for nearly 4,500 short-term acute care hospitals nationwide to assess hospital performance in 32 common conditions and procedures, and evaluated outcomes in appendectomy and bariatric surgery using all-payer data provided by 16 states. Healthgrades recognizes a hospital’s quality achievements for cohort-specific performance, specialty area performance, and overall clinical quality. Individual procedure or condition cohorts are designated as 5-star (statistically significantly better than expected), 3-star (not statistically different from expected) and 1-star (statistically significantly worse than expected).

Hospital quality is an important indicator in our journey to zero preventable harm. Please join us in celebrating our incredible caregivers who help make achievements like this possible! View a full list of our awards from Healthgrades here. The complete Healthgrades 2021 Report to the Nation and detailed study methodology can be found at https://partners.healthgrades.com/healthgrades-quality-solutions/healthgrades-quality-awards/.

*2021 achievement

Our ministry is committed to achieving zero preventable harm to caregivers, patients and their families. WorkSafe, our new workspace safety surveillance system that launched this week, prioritizes Safety First, People Always by improving our ability to analyze and respond to health and safety concerns impacting caregivers across our connected ecosystem.

We appreciate your excitement about WorkSafe and have heard your feedback and questions about how to best utilize this new tool. As we continue to support you with using WorkSafe to report associate and physician safety events, it’s important to lean heavily on our High Reliability Organization (HRO) principles of preoccupation with failure, sensitivity to operations and commitment to resilience.

In the spirit of supporting a culture of reporting and learning, we would like to provide additional clarity on WorkSafe based on your clarifying questions. Below is a summary of additional details about how WorkSafe is supporting our efforts to promote safe environments for caregivers in our hospitals, clinics and ambulatory care sites, and what information it captures when associate and physician safety workplace events or injuries occur:

What is WorkSafe?	WorkSafe is our new online tool and tracking system that replaces the paper-based occupational health safety event form.
Where is WorkSafe?	The WorkSafe icon is on every desktop to support convenient reporting of associate and provider safety events and near misses.
What should I report through WorkSafe?	Any workplace event or workplace injury should be reported through WorkSafe. Examples include patient handling, needle stick, falls or other physical or psychological harm events.
What should I NOT report through WorkSafe?	All safety events, near misses involving patients will continue to be tracked through our Midas Learning System. Important note: If a safety event involves a patient and a care team member, please: Report the patient event detail through the Midas Learning System to allow follow up from our patient safety program managers; AND Report the associate safety event or injury through WorkSafe to allow follow up from our occupational health team.
Who can complete WorkSafe reports?	The electronic platform allows any team member – clinical and non-clinical and Centura-employed or contracted – to report workplace injuries and other workplace incidents they feel pose a risk to the health or safety of our work environment.
Who will contact me after I complete a WorkSafe report?	After a workplace safety event is reported in WorkSafe, an occupational health associate will contact the individual directly and support them through the remainder of the process.
Why are we moving from paper to electronic?	An electronic solution allows us to better track data to identify workplace safety trends and opportunities within the entities and across our connected ecosystem.

Please continue to speak up for safety to elevate any clarifying questions or concerns to your leaders.

Thank you for your unwavering commitment to the safety and wellbeing of our caregivers, patients and communities.

Questions?
Contact your local Occupational Health lead.

We are proud to walk alongside our patients during every step of their health care journey. As we acknowledge Breast Cancer Awareness Month, we recognize our cancer patients and caregivers who are blazing the way to recovery with bravery and compassion. This week, join us in congratulating Donna who recently finished treatment for breast cancer at the newly opened St. Francis Hospital Cancer Center!

Regular mammograms are the best tests doctors have to find breast cancer early. The sooner you have a mammogram, the greater your chances of finding cancer in its early stages and making a full recovery. Talk to your doctor about breast cancer screening that is right for you. To find a Centura Health mammography center near you, click here.

When Donna, the first breast cancer patient at the new St. Francis Hospital Cancer Center, finished treatment she had a simple request. Donna wanted to celebrate her brave milestone by ringing the bell. She had family members who had rung the bell and knew it was a special moment and one that meant a lot to her.

Her care team was excited and looked forward to honoring Donna at the ceremony. There was only one problem – there wasn’t a bell to ring. The bell the new cancer center had ordered was still on back order and would not arrive in time for Donna to participate in the ceremony.

Natalie Myers, supervisor of radiation oncology at Penrose and St. Francis hospitals, heard about Donna’s bell request and jumped into action. Her husband is a firefighter, and she knew that fire stations used bells for more somber events like funerals and memorials. She started making some calls and in less than a few hours, the Hanover Fire Department was on their way to St. Francis Hospital with their bell.

“I couldn’t think of a better use for the bell,” said Hanover Fire Chief Carl Tatum. “These patients were on a really difficult journey and ringing the bell allows them to close that chapter and start another one.”

According to Donna, cancer runs in her family and she has lost so many family members including her parents and sister to the disease. Being able to ring the bell meant so much to her.

“My family was never ‘done’ with cancer, but the doctors say I should be around for another 30 years, so I am DONE with cancer!” Donna exclaimed. “I hope that my ringing the bell would be the first of positive things for the bell and for others and they would find hope and be around many more years.”

The bell ringing tradition traces back to the mid-1990s when a Rear Admiral and Navy Seal named Irve Le Moyne, a head and neck cancer patient, wrote a poem and installed a brass bell at the radiation center at MD Anderson in Houston, Texas.

Ring this bell
Three times well
Its toll to clearly say,
My treatment’s done
This course is run
And I am on my way!

Within the fire department, the tradition of ringing the bell goes back hundreds of years. The ringing bell would signify that all the firefighters were safely back at the station after responding to a call. Now, bells are rung three times at a firefighter’s memorial or funeral to honor the firefighter’s service and signifies the “end of the line.”

However, the bell will signify the start of new line or chapter for cancer patients at St. Francis. We appreciate the generosity of the Hanover Fire Department and look forward to the arrival of a permanent bell that was purchased by the associates and caregivers at the hospital.  

To continually support and strengthen our culture of security at Centura Health, the following two changes will be implemented in November 2021:

• Nov. 15: Updated Email Retention Policy will go into effect
• Nov. 30: Access to personal email on the Centura network and devices will no longer be allowed

Changes to Email Retention Policy
To increase cybersecurity and reduce cyber vulnerability at Centura, Information Security is reducing the email retention period from three years to one year.

Presently, emails received are subject to the Centura Three Year Retention Policy. Beginning Monday, Nov. 15, all emails that are older than one year will automatically be deleted. For example, emails received on Nov. 14, 2020 or earlier, will automatically be deleted when this new policy goes into effect on Monday, Nov. 15, 2021.

Directors and above who require an exemption to the new email retention policy should submit an Email Retention Exception Request via the Self Service Hub. Please note, you must be a director and above to submit this request. The Email Retention Policy will be available in Policy Tech on Nov. 15. To view an advance read of the policy, click here.  

Changes to access private email on the Centura network and devices
To continue with our focus on keeping our system secure, effective Tuesday, Nov. 30, 2021 associates will no longer be able to access private email accounts (@yahoo, @gmail, etc.) on any Centura Health network or device.

Accessing personal email on the Centura Health network or devices can substantially increase the likelihood of downloading a virus, resulting in a data breach. Restricting the ability to access your private email accounts increases the safety at Centura and decreases the vulnerability of a data breach.

As our work and home lives become more and more digitally connected, we all must be responsible for taking an active role in cybersecurity, which ultimately benefits our patients, the communities we serve, as well as our friends and family.  

To learn more, please review these FAQs.

Sunday, Nov. 7, Daylight Savings Time ends, and the clocks will be turned back one hour, resulting in a second 1 a.m. hour. This will impact activities that are dependent upon a timing sequence (e.g. patient transfers, hourly medications, and flowsheet documentation). Please refer to the instructions below for specific direction regarding how to handle this duplicate hour within Epic.

Tip sheets are also available via the Learning Home Dashboards that provide further step-by-step instruction.

Inpatient transfers and discharges
Overall, ADT activity for transfers and discharges should be limited during the two 1 a.m. hours. If you must do a discharge or transfer during the second 1 a.m. hour, you will need to wait until the original event time has passed. The system will not allow a subsequent event to happen before the time of the previous event. Example: Patient is admitted at 0115 – Patient needs to be transferred to a different unit during the second 1 a.m. hour at 0100. Event management will see this as an error. User will need to wait until original admit time has passed and therefore can transfer the patient at 0116.

Hourly medications
If a patient requires an hourly medication, clinicians should document the first hour and add a reference of “daylight savings time” in the comment field. The second hour should be documented at a time later than the first documented time with a comment of “standard time” and actual time given. Example: Med is given at 0115 – document at 0115 with comment “daylight savings time,” the second hour med is given at 0110 – document at 0116 with comment “Actual time given 0110 standard time”. For Alaris Pump Recovery, follow the “Fall Daylight Savings Time – Alaris IV Pumps” tip sheet.

Flowsheets
Last filed values and graphs may be incorrect due to the repeating of the 1 a.m. hour. Complete the first 1 a.m. documentation within the window 1 a.m. – 1:30 a.m. Then, complete the second 1 a.m. documentation within the window of 1:31 a.m. – 1:59 a.m. and add a comment indicating “daylight savings time.”

Blood Bank
Ordering and administration of blood products must be completed on paper for the two 1 a.m. hours. At 2 a.m., the total infusion volumes must be re-documented into the system.

Lab
For Lab POC and blood bank systems, the time change will be automated. For Lab middleware system, the time change will be managed by Lab IT.

Hemodynamic systems
The interface for the MacLab Hemodynamic systems will be going down at 12 midnight and will be turned back on at 2 a.m. Note that this will be a 3-hour period due to the repeated 1 a.m. hour. Following downtime policy, please use the Hemodynamic system for documentation and plan to manually post logs for any cases in Epic following the DST period.

Best Practice Advisories
Best Practice Advisories (BPAs) are unreliable during the two 1 a.m. hours. Due to the time change, the BPAs could appear at incorrect times or not at all.

Surgery/OpTime
Please note on the snapboard you will want to assign staff to the case rather than the room during the DST period. Additionally, it is important for case tracking events to reflect the actual amount of time between events. Please change the case tracking event times so that the amount of time between events is accurate rather than the actual times. Add a nursing note that includes the actual times for that patient, even if it looks incorrect because of the time change. Example: A trauma patient enters the OR at 1:40 a.m. Then, as 1:59 a.m. passes it becomes 1:00 a.m. again. The case ends at 1:20 a.m. The case tracking event should reflect “In Room” at 1:40 a.m. and “Out of Room” at 2:20 am. This will correct the time in the room to 40 minutes (instead of -20 minutes). The nurse will write a note explaining the alteration in times. OR Manager/Directors: If there are any cases during the DST event, you must manually enter the anesthesia start and stop event for hospital billing purposes.

Anesthesia
Anesthesia cannot be documented in the system during the two 1 a.m. hours. All documentation must take place on paper so that it can be scanned back into the system later by HIM. An admin event will need to be documented in Epic to close the encounter.

OB/Stork
Time calculations will not be accurate during the two 1 a.m. hours. This includes hours of life of newborn, labor length, time since ROM, time since cervical exam, and labor and delivery events. Clinicians must manually calculate times and document the sequence of events in a note electronically. *Please work with your biomed department to change the times on the fetal monitors as you normally would.

Device integration
Device integration cannot be used for a total of 3 hours. Device integration will be turned off at 12 midnight and will be turned back on at 2 a.m. The impacted documentation will need to be completed on paper to be scanned back into the system later by HIM. This includes the interfaces for Data Captor, Mac Lab, GE Carescape, Philips Intelivue, Epiphany – Rhythm Strips only and Obix.

ED/ASAP

• Patients who have an event that caused a status change during first 1 a.m. hour will incorrectly revert during the second 1 a.m. hour until that event time is reached again. This can cause track boards to filter incorrectly. If statuses are incorrect, they will need to be manually corrected.
• Emergent situations normally done in specialty narrators such as codes, traumas, strokes and STEMIs must be documented on paper during the two 1 a.m. hours and then scanned back into the system.
• Providers will need to manually adjust their shift times in Epic to account for the extra hour.
• ED alerts will be unreliable during the two 1 a.m. hours.
• Transfers and discharges of patients during the two 1 a.m. hours should be limited. If errors occur while trying to move the patient in the system, change the event times manually.

If you need further assistance, please contact the Service Center at 303-643-4200 or ext. 84000.

The Midas Care Management Application requires a scheduled downtime while Information Technology (IT) upgrades Midas to the newest version. The downtime will take place from 10 a.m. until 6 p.m. (1000 until 1800 MT) Tuesday, Nov. 2.

The following Midas applications will NOT be available during the planned downtime:

• Midas RDE
• Midas Care Management
• Midas Focus Study

Please follow downtime procedures during this planned downtime.

Questions?
If you have any questions regarding this upgrade, please contact Sarah Moss or Leslie Russell or call the Service Center at 303-643-4200 and reference Change Number C47275.

Keep track of your apps. Cybersecurity is increasingly important as we continue to operate virtually in both our work and personal lives. Be aware that mobile applications are used to access and operate many household devices (e.g. appliances, gaming devices, children’s toys, security systems, etc.) as well as work devices.

Your mobile device could be filled with suspicious apps running in the background or using default permissions you never realized you approved. These apps could be gathering your personal information without your knowledge while also putting your identity and privacy at risk. To keep track of your apps:

• Only download apps from trusted vendors and sources.
• Check app permissions and use the “rule of least privilege” to delete what you don’t need or no longer use.
• Just say “no” to privilege requests that don’t make sense.
• Give your mobile app services and passwords a check-up.
  • Replace default, weak or reused passwords with something unique and stronger, more complex passwords (e.g. phrases) that include special characters, symbols, and capitalized letters.

Thank you for your engagement and participation in Cyber Security Awareness Month and beyond!

Please contact the Service Center at 303.643.4200 or ext. 84000 for further assistance.