WellStar 2015 Safety & Quality Report

WELLSTAR
SAFETY & QUALITY REPORT
2015
Confidential: Protected pursuant to Georgia law

SAFETY
QUALITY REPORT&MESSAGE
We are pleased to share with you WellStar Health System’s 2015 Annual Quality
Report. This was an exciting year of progress at WellStar! As a dynamic, progressive
healthcare System, WellStar’s team members continued to develop a high reliability
culture, improve processes to remove waste and decrease variation (the enemy
of quality!), and create the highest quality experience for our patients and our
community. Several new leaders have joined WellStar’s team and many more have
leveraged their Lean Six Sigma training to complete important quality projects.
And, we have invested in a strategic quality transformation to achieve higher levels
of performance in patient care and organizational effectiveness.
The synergy from working together as a team, focusing on metrics that matter, and
exemplifying our mission of world-class patient-centered care, is clearly reflected
in WellStar’s accolades for safety and quality from national organizations. While we
celebrate these successes, we remain driven to achieve zero harm, patient experience
that exceeds expectations, and identify opportunities to improve, implement best
practices, and provide the best outcomes for the individuals and communities we serve.
WellStar is fortunate to have visionary leaders fully committed to quality and safety,
including our Board of Directors, System and hospital executives, medical staff and
service line leaders, System and hospital administration. Their inspiration, support
and encouragement help to keep us focused on our goals.
I am excited by the many accomplishments we achieved in 2015 along our journey
to high reliability and world-class healthcare. This report reflects the enormous
efforts of each of you who role model WellStar’s mission and vision every day.
Sincerely,
BOB LUBITZ
ROBERT LUBITZ, M.D., MPH, MACP
System Lead, Quality and Safety
WellStar Health System

TABLE OF CONTENTS
Executive Summary . . . . . . . . . . . . 1
System Safety and
Quality Goal Achievement . . . . . . 2
Patient Experience . . . . . . . . . . . . 10
Performance Improvement . . . . . 10
Regulatory Visits –
Fiscal Year 2015 . . . . . . . . . . . . . . . 11
Safety First. . . . . . . . . . . . . . . . . . . 12
Quality Transformation . . . . . . . . 12
Medication Safety . . . . . . . . . . . . 13
WellStar Safety and
Quality Recognitions . . . . . . . . . . 14
EXECUTIVE SUMMARY
In this past fiscal year, WellStar continued our commitment to improve
quality and patient safety by establishing System goals to reduce
incidences of preventable patient harm, hospital-associated infections
(HAIs) and readmissions.
For FY 2015, WellStar established goals and targets to reduce:
(1) Patient safety indicators (PSIs) by 10 percent to a rate less than 3.7.
(2) Overall HAIs by 10 percent to a rate less than 8.8.
(3) Readmissions by 10 percent for select diagnoses to a rate less
than 14.5.
SAFETY AND QUALITY ANNUAL REPORT I 2015 I 1

SYSTEM SAFETY AND QUALITY
GOAL ACHIEVEMENT
IMPROVEMENT ACTIONS
AND NEXT STEPS:
WellStar initiated a number of
improvement activities to address
PSI performance, including:
> Development and dissemination
of PSI documentation cards and
provider education regarding
respiratory failure versus
respiratory insufficiency and
obstetrical lacerations. We are
working on similar educational
cards for accidental punctures
and lacerations as well as coding
education for providers related
to ICD-10.
> Development and implementation
of a nurse-driven deep vein
thrombosis (DVT) protocol and
revision of the DVT/pulmonary
embolism workflow in Epic.
> Development of PSI audit
screens and record reviews
focusing on select indicators for
identification of trends.
> Facility assessment of Clear
Lungs activities and evaluation
of a nurse-driven protocol for
incentive spirometry. Clear Lungs
is a proven respiratory program
designed at WellStar to prevent
lung or pulmonary complications
through coughing, learning,
exercising, activities and oral
rinsing/brushing (CLEAR).
> Implementation of a
collaborative process between
quality, clinical documentation
and coding for review and
determination of case status.
GOAL 1 | PATIENT SAFETY INDICATORS
WellStar PSI
Events per 100 discharges
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0
3.2
2.5
3.0
2.8
2.6
3.0
April May June July August Sept Oct Nov Dec Jan Feb Mar
2014 2014 2014 2014 2014 2014 2014 2014 2014 2015 2015 2015
2.8
3.1
Target: 3.7
PSI Rate/100
Trendline
3.2
3.1
2.7
2.7
Results: WellStar achieved a FY 15 rate of 2.9 against the target of 3.7 or less with all facilities exceeding established
target, reducing PSIs by 142 cases from the previous year.
2 I 2015 I SAFETY AND QUALITY ANNUAL REPORT

GOAL 2 | HOSPITAL-ASSOCIATED INFECTIONS
WellStar HAI
Rates per 1000 discharges
10
9
8
7
6
5
4
3
2
1
0
8.4
5.8
8.6
7.2
8.9
9.5
July August Sept Oct Nov Dec Jan Feb Mar April May June
2014 2014 2014 2014 2014 2014 2015 2015 2015 2015 2015 2015
6.8
7.1
Target: 8.8
HAI Rate/1000
Trendline
6.8
6.1
6.8
5.0
Results: WellStar achieved a FY 15 rate of 7.2 against the target of 8.8 or less with four of five facilities exceeding
established target; the remaining facility achieved a negative variance of only 0.44. There were 152 fewer cases
this fiscal year than in the previous period.
IMPROVEMENT ACTIONS
AND NEXT STEPS:
WellStar has initiated a number of
improvement activities to address
HAIs, including:
> Continued Xenex usage in
isolation rooms with revisions
to schedule as well as training
of additional staff to maximize
areas and cycles.
> Urinary catheter care competencies
created for nursing personnel.
> Isolation compliance surveillance
and feedback.
> Evaluation of daily urinary
catheter and central line device
necessity in daily rounding and
patient assessments.
> Implementation of a new Foley
urinary catheter care kit with
more intuitive packaging to
prompt best practice insertion
techniques.
> Standardization of urinary Foley
care across the System and
implementation of nurse-driven
Foley protocol.
> Covering central lines during
patient transport.
> Development of A Team
Approach to Reduction of
Surgical Site Infections (SSIs);
through the project, Cobb’s
multidisciplinary SSI team
dramatically decreased the
rate of SSIs, specifically in
hysterectomies and colon
surgeries.
> Reinforcement of hand hygiene
through a designed safety
coach /secret shopper activity
across the System.
> Implementation of stethoscope
cleaning stations during National
Patient Safety Week with
concurrent provider education.
> Increased awareness of hand
hygiene importance through
distribution of personal hand
sanitizers to team members,
patients, families and visitors during
National Patient Safety Week.
> Created Epic-generated reports
to identify patients with lines,
drains and airway devices to serve
as a daily prompt to the care team
for ongoing assessment.
I 2015 I SAFETY AND QUALITY ANNUAL REPORT I 3

GOAL 3 | READMISSIONS
Select patient population includes: Age 65 or older, Chronic Obstructive Pulmonary Disease (COPD), Stroke,
Pneumonia, Heart Failure, Acute Myocardial Infarction (MI), Isolated Coronary Artery Bypass Grafting (CABG),
and Total Knee Arthroplasty/Total Hip Arthroplasty for all patients readmitted to the same facility.
GOAL #3: REDUCE READMISSIONS FOR SELECT DIAGNOSES (FY 2015)
Facility FY 14 FY 15 Target
CH 14.5% 13.4% 13.9%
DH 15.1% 10.9% 14.5%
KH 16.1% 13.1% 15.5%
PH 10.5% 8.4% 10.1%
WMG 15.1% 12.5% 14.5%
System 15.1% 12.5% 14.5%
Results: WellStar achieved a FY 15 rate of 12.5 against the target of 14.5 or less with all facilities exceeding
established target.
IMPROVEMENT ACTIONS
AND NEXT STEPS:
WellStar initiated a number of
improvement activities to address
readmissions, including:
> Creation of a readmission work
group to address discharge and
post-discharge opportunities.
> Readmission Task Force and
Performance Improvement
Committees to review outliers
and adverse patterns.
> Creation of the Heart Failure
Academy in conjunction with
Cardiovascular Medicine
Douglasville office.
> Development of individualized
care plans for patients with
frequent admissions.
> Provision of 30-day supply of
medications for patients with
heart failure.
> Placement of Population Health
Case Managers for Accountable
Care Organizations (ACO) patient
population:
– Embedded in Primary Care
Physician (PCP) offices and one
Pulmonary Specialist Practice
– Telephonic Case Managers
> Hospitalist Care Coaches at Cobb,
Douglas and Kennestone working
with high-risk patient populations
face-to-face prior to discharge.
Direct hand-off to Population
Health Case Managers in the
outpatient (OP) setting.
> Development of COPD taskforce
to standardize care for the COPD
patient population.
> Initiatives to increase the volume
of post-discharge follow-up visits
with a physician. Daily discharge
list being sent to each PCP
practice. Practices are tasked with
reaching out to their patients and
scheduling the follow-up
appointments.
> Skilled Nursing Facility (SNF)
collaborative. Monthly meetings
with community SNFs to share
data on readmissions and other
quality indicators and participate
in joint action planning.
4 I 2015 I SAFETY AND QUALITY ANNUAL REPORT

WellStar’s team members continue to develop a high
reliability culture, improve processes to remove waste and
decrease variation.

We have invested in a strategic quality transformation to achieve higher
levels of performance in patient care and organizational effectiveness.
POPULATION HEALTH MANAGEMENT |
READMISSION ANALYSIS
> Population Health Case management reviewed and
tracked 837 patients
– A routine analysis is conducted by each OP case
manager for every patient readmitted
> Most readmissions occur within three days of
discharge for patients with relatively short index
admission lengths of stay
> Approximately 45 percent of readmissions occur
within the first week of index discharge
> 17 percent of readmissions are sent back to the
hospital from their PCP practice
> 11 percent of readmissions are scheduled admissions
(elective)
> Although the patient may have been on the
appropriate treatment and still required some medical
intervention or support, care potentially could have
been provided in a different care setting or by
changing the treatment plan in the OP setting
6 I 2015 I SAFETY AND QUALITY ANNUAL REPORT

TOP REASONS FOR READMISSION
Reason # %
Failed OP treatment 354 42%
New diagnosis - unrelated 244 29%
Vital Signs or Mental Status
Changes
INDEX ADMISSIONS LOS
50 6%
New infection 35 4%
Function/Mobility Changes 32 4%
End-of-life diagnosis/
prognosis
31 4%
Recurrent infection 28 3%
Non-adherent - By choice 16 2%
Medications not taken as
prescribed
Medication-related
complication
15 2%
9 1%
All others 23 3%
Total 837 –
Days # %
0-1 63 8%
REFERRAL SOURCE FOR READMISSION
Source # %
Self/family direction 636 76%
Sent to hospital by/
from Dialysis
Sent to hospital by/
from Home Health or
Hospice
Sent to hospital by/
from MD office
Sent to hospital
by/from Subacute
Rehab/Skilled Nursing
Facility/Long-Term
Acute Care
15 2%
13 2%
142 17%
31 4%
Total 837 101%*
* Percentage greater than 100 due to rounding
ELECTIVE ADMISSION
# %
Yes 91 11%
No 746 89%
Total 837 –
2-5 473 57%
5-10 304 36%
10-15 83 10%
15-25 43 5%
25-50 10 1%
DAYS BETWEEN READMISSIONS (0-30)
Days # %
0-3 154 18%
4-6 113 14%
7-9 108 13%
10-12 90 11%
13-15 92 11%
16-18 85 10%
19-21 66 8%
22-24 48 6%
25-27 51 6%
28-30 30 4%
Total 837 –
The synergy from working together as a team, focusing on metrics that matter, and
exemplifying our mission of world-class patient-centered care, is clearly reflected in
our accolades for safety and quality from national organizations.
I 2015 I SAFETY AND QUALITY ANNUAL REPORT I 7

WINDY HILL HOSPITAL
WINDY HILL KEY MEASURE PERFORMANCE
WH Key Measure Performance for Goal FY 14 (Apr-June) Key Measure Goal
Beta Blocker Therapy Received (perioperative) Outpatient 100.00% 95%, 100%
Falls with Injury per 1000 patient days 0.52 0.70, 0.61
Nosocomial Pressure Ulcers per 1000 patient days 0.57 0.50, 0.25
Pain Reassessment (%) 93.86% 97%, 100%
Pneumovax Immunization Rate 96.38% 90%, 95%
Ventilator Wean Rate 80.49% 80%, 90%
Catheter-Associated Urinary Tract Infection (CaUTI) Rate
(based upon 1000 device days; baseline rate 4.0)
3.4 3.75, 3.50%
Mammography Follow Up within 45 Days 100.00% 95%, 100%
Total Goals Met
Apr-11 points, May-11 points
All measures are cumulative. FY 15 performance will be judged by a full fiscal year (July 2014-June 2015)
Results: WellStar Windy Hill Hospital met or exceeded six of eight key
performance indicators: Beta Blocker Therapy, Falls with Injury, Immunization
for Pneumovax, CaUTI, Mammograms and Ventilator Weaning.
IMPROVEMENT ACTIONS AND NEXT STEPS:
Though the ventilator-weaning rate exceeds national
benchmarks, Windy Hill has established exceptional
performance expectations for this indicator.
In addition to the previously identified efforts
to reduce PSIs and HAIs, Windy Hill initiated a
number of improvement activities to address these
performance indicators, including:
> Pain reassessment audits and reinforcement of
documentation in the electronic medical record
> Revised screening tools and implementation of
Best Practice Alerts for immunizations
> Interdisciplinary rounds with the Skin and Wound
Assessment Team for prevention of pressure ulcers
> Falls prevention team for post-occurrence
assessment and proactive action planning
8 I 2015 I SAFETY AND QUALITY ANNUAL REPORT

We remain driven to achieve zero harm, patient experience that
exceeds expectations, and identify opportunities to improve,
implement best practices, and provide the best outcomes for
the individuals and communities we serve.

PATIENT EXPERIENCE
WELLSTAR HEALTH SYSTEM HCAHPS PATIENT EXPERIENCE DATA
Fiscal Year 2016 To-Date with FFY 2017 Thresholds and Benchmarks
November Response Rates (Natl. Avg. is 24.4% ) 15.7% 15.7% 19% 21.1%
HCAHPS Pt.
Experience Data
Jul. 1 - Dec. 31 ,
2015
Number of
Surveys
Rate hospital
0-10
FFY
2017
Threshold
Est.
CMS
60th
%tile
FFY 2017
Benchmark
(90th
%tile)
Cobb
(goal = 8/8 at
Threshold)
Douglas
(goal = 8/8 at
Threshold)
Kennestone
(goal = 4/8
Threshold, 4/8
60th %tile)
Paulding
(goal = 4/8
Threshold, 4/8
60th %tile)
System
(goal = 6/8
Threshold, 2/8
60th %tile)
1147 VTT* 360 VTT* 2193 VTT* 518 VTT* 4218 VTT*
Top Box Percentage (plus and minus represent change from last month)
70.0 73.7 84.6 69.0 = -1.0 71.7 1.7 71.3 + 1.3 77.2 + 7.2 71.4 = 1.4
WellStar / Safety First Program
Comm w/ Nurses 78.2 80.3 86.6 75.5 -2.7 79.6 1.4 78.2 + 0.0 80.1 + 1.9 77.8 -0.4
Response of
Hosp Staff
Comm w/
Doctors
Hospital
Environment
Pain
Management
Comm About
Medicines
Discharge
Information
Recommend the
hospital
Care Transitions
(mean score)
65.1 68.8 80.0 63.9 -1.2 68.7 3.6 66.4 = 1.3 66.1 + 1.0 65.9 0.8
80.5 82.6 88.8 81.6 1.1 76.9 -3.6 81.3 + 0.8 77.7 + -2.8 80.6 + 0.1
65.3 68.8 79.4 67.2 = 1.9 69.8 + 4.5 67.5 + 2.2 75.5 + 10.2 68.6 + 3.3
70.3 72.3 78.3 70.5 0.2 71.3 = 1.0 72.4 + 2.1 70.7 + 0.4 71.6 + 1.3
62.9 65.5 73.4 61.0 -1.9 63.8 0.9 64.7 + 1.8 66.3 + 3.4 63.8 + 0.9
85.9 87.2 91.2 85.2 + -0.7 86.0 = 0.1 85.8 = -0.1 86.4 + 0.5 85.7 = -0.2
Not a Part of Goals or VBP
73.5 76.3 84.8 68.7 -4.8 70.4 + -3.1 75.8 + 2.3 78.7 = 5.2 73.8 = 0.3
81.6 82.5 85.3 81.1 -0.5 82.7 + 1.1 82.0 + 0.4 83.1 + 1.5 81.9 + 0.3
Gap Index -9.6 7.6 12.1 28.5 7.8
*Variance-to-Threshold
Results: Eight of ten indicators for WellStar exceed threshold and the remaining indicators are within 1 to 2 points
of target. Each facility has an established patient experience team that serves as an internal resource to department
and unit efforts. Kennestone leads the patient experience efforts and serves as a resource to all sites, sharing
established practices.
PERFORMANCE IMPROVEMENT
WellStar leadership set expectation
for Lean Six Sigma training for all
managers and above in order to
provide a foundation for consistent
process improvement (PI) methodology
and efforts. As of June 2015,
997 WellStar leaders had completed
training. In addition, from the
training, 172 yellow and green belt
performance improvement projects
have been completed. Through
increased executive sponsor
engagement throughout the year
as well as selection of improvement
projects from different areas of the
organization, including Human
Resources, Clinical, Information
Technology, Finance, Marketing,
Operations, and social media,
WellStar achieved the following:
> $8.6 million in cost savings
> $2.1 million in revenue generation
> $1.7 million in soft savings
10 I 2015 I SAFETY AND QUALITY ANNUAL REPORT

REGULATORY VISITS-FISCAL YEAR 2015
JULY 2014
> Home Care – Joint Commission
Accreditation
AUGUST 2014
> Douglas Hospital – Centers for
Medicare and Medicaid Services
Validation Survey
> Kennestone Hospital – Food and
Drug Administration (FDA)
Biannual Survey of the Blood Bank
SEPTEMBER 2014
> Windy Hill Hospital – Joint
Commission Accreditation
> Paulding Hospital – Joint
Commission Accreditation
OCTOBER 2014
> Paulding Hospital – Joint
Commission Accreditation
> Paulding Hospital – Inpatient
Advanced Diabetes Recertification
NOVEMBER 2014
> Kennestone Hospital – Joint
Commission Disease-Specific
Certification (DSC) – Total
Joint Program (Hip and Knee)
Recertification
> Douglas Hospital – Joint
Commission Accreditation
DECEMBER 2014
> Cobb Hospital – Joint
Commission Accreditation
JANUARY 2015
> Kennestone Hospital – Joint
Commission- Lab Accreditation
> Kennestone Hospital – Joint
Commission DSC – Heart Failure
Recertification
> Kennestone Hospital – Joint
Commission DSC – CABG and
Valve Recertification
> Kennestone Hospital – American
Association of Blood Banks and
College of American Pathologists
(CAP) – Blood Bank Semi-Annual
Survey
FEBRUARY 2015
> Kennestone Hospital – CAP
– Main Lab
> Kennestone Hospital – Joint
Commission – DSC
Comprehensive Stroke Survey
> Douglas Hospital – CAP Survey
for Lab
> Douglas Hospital – FDA
Mammography
MARCH 2015
> Windy Hill Hospital – Joint
Commission DSC-Respiratory
Failure Program
> Douglas Hospital – Joint
Commission Unannounced
Extension Survey for ICU
APRIL 2015
> Kennestone Hospital – Pediatric
Center Barrett Parkway Joint
Commission
> Windy Hill Hospital – DSC-
Respiratory Failure Accreditation
MAY 2015
> Kennestone Hospital –
Occupational Safety and Health
Administration Unannounced
Survey Main Lab
> Kennestone Hospital – FDA
Mammography Inspection- Town
Lake Imaging
JUNE 2015
> Kennestone Hospital – FDA
Recall Follow-up Inspection –
CareFusion Avea Ventilator
Product #AHY 03116, AKV 01165
and BAV 04700
> Kennestone Hospital – Georgia
Department of Natural Resources
– Nuclear Medicine
– Radiation Oncology
> Kennestone Hospital – National
Accreditation Program for Breast
Cancer
> Cobb County Detention
Center – National Commission
on Correctional Health
Care – Accreditation with
Commendation
> Windy Hill Hospital – East Cobb
Health Park State Inspection
Outpatient Surgery Center
JULY 2015
> Kennestone Hospital –
Bariatric Program Metabolic
and Bariatric Surgery
Accreditation and Quality
Improvement Program
> Kennestone Hospital –
FDA– Women’s Imaging-
Mammography Quality
Standards Act Facility Inspection
AUGUST 2015
> Douglas Hospital – Nuclear
Medicine Georgia Department
of Natural Resources
I 2015 I SAFETY AND QUALITY ANNUAL REPORT I 11

SAFETY FIRST
QUALITY
TRANSFORMATION
The Safety First program continues to be transformational as we
strive to develop a High Reliability Organization through our safety
culture work. As of December 2015, our Serious Safety Event Rate
has decreased by 52 percent since 2008. In 2014, we focused on
error reporting and cause analysis training resulting in improved
error reporting rates and increased volume of cause analysis for
precursor and near miss events. WellStar also implemented additional
high reliability training for all members of leadership to reinforce
expectations, behaviors and techniques to drive preventable harm
events to zero. Facility safety huddles were implemented across the
System in early 2014 and have expanded to unit and department
levels, second shifts and weekends. These huddles allow team
members to convey concerns from the past 24 hours and work
toward resolution as well as proactively identify potential concerns
or needs for the next 24 hours. In addition, during these huddles,
individuals and teams can be publicly acknowledged as “safety stars”
for exhibiting safety behaviors and using error prevention techniques
that contribute to reducing or avoiding harmful situations further
reinforcing WellStar’s expectation of making every day a safe day.
WellStar administered the Agency for Healthcare Quality Culture of
Safety Survey in March 2015 as a way to evaluate organizational
culture of safety. Over 50 percent of WellStar team members completed
the survey. Of those responding, over 70 percent rated WellStar as very
good or excellent in providing
patient safety. In addition, several
narrative responses were very
complimentary of hospital
leadership in their safety efforts.
Leadership recognized that our scope
of improvement, rate of improvement
and process reliability must accelerate
in order for us to achieve and sustain
our overarching 2020 goal of being
a top decile performer. Leadership
engaged expertise from Chartis Group
to assist us in completing a gap analysis
of our current and desired state. From
our gap analysis, WellStar created a
strategic plan with tactics and key
tasks to:
1. Strengthen governance and
management oversight
2. Refine quality organization structures
3. Create “next generation” quality
improvement systems and processes
and
4. Establish an enduring culture
of quality and patient safety
To strengthen governance and
management oversight, we created
a quality transformation steering
committee. Key organizational leaders
were selected and oversee our quality
and safety priorities by focusing
resources on targeted improvement
efforts which are communicated and
implemented throughout our System.
We established standardized process
improvement tools and reports using
a combination of Lean and Six Sigma
methodology and are refining our
structures to support our robust efforts.
WellStar has embraced our
opportunities and we are committed
to make the changes needed to
transform our existing quality program
into a leading quality program
supportive of achieving our vision.
12 I 2015 I SAFETY AND QUALITY ANNUAL REPORT

MEDICATION SAFETY
The System medication reconciliation committee implemented various
safety initiatives, including multiple changes to WellStar Connect to
enhance ease of use and give providers information on their medication
reconciliation efforts. Dialogue between providers and the committee
resulted in WellStar Connect functionality changes.
During 2015, WellStar created and implemented the Medication History
Specialist program, overseen by a pharmacist. These specialists are
pharmacy technicians in the Emergency Departments who collect patient
medication histories to aid in medication reconciliation.
In addition, medication error and adverse drug reporting was transferred
to our existing online incident reporting system beginning in January 2015
so all incidents could be reported in the same system.
Multiple Systemwide performance improvement projects were initiated
in the pharmacies, including a process to administer nimodipine via oral
syringes, neuromuscular blocker segregation and a process to manage
concentrated human insulin (Humulin R U500).
The 2014-15 Institute of Safe Medication Practices targeted medication
safety best practices were addressed via facility medication use system
improvement committees as well as the newly implemented pharmacy
medication safety liaisons. The liaisons assist in operationalizing medication
safety initiatives and perform quarterly proactive risk assessments via the
ISMP quarterly action agenda.
In FY 2015, there were 152 fewer
cases of HAIs than in the previous
year. Four of five facilities exceeded
the established target; the remaining
facility achieved a negative variance
of only 0.44.
Our medication use policy subcommittee, chaired by our medication
safety officer (MSO), facilitated review and update of policies to ensure they
reflect best practice and meet regulatory standards. Our MSO presented
nationally at Epic’s user group meeting and the midyear clinical meeting of
the American Society of Health-System Pharmacists.
The connect order set maintenance committee, an interdisciplinary team,
assumed responsibility for governance over development and approval
of all WellStar Connect electronic health record order sets for Systemwide
deployment, based on clinical evidence of safety, efficacy and cost
effectiveness. Multiple order sets and best practice alerts (BPAs) were
created and revised. The team also addressed BPA fatigue, reducing alerts
by over 50 percent.
Another major initiative in 2015 included our new infusion pump technology
acquisition process and subsequent implementation planning. This
involved several months of coordination between nursing and pharmacy to
create and build the new drug library and to identify and resolve practice
discrepancies to ensure standardization and a successful and safe go-live.
I 2015 I SAFETY AND QUALITY ANNUAL REPORT I 13

WELLSTAR SAFETY AND QUALITY RECOGNITIONS
WELLSTAR CONTINUES TO RECEIVE STATE, REGIONAL, NATIONAL AND
INTERNATIONAL RECOGNITION FOR SAFETY AND QUALITY IMPROVEMENTS.
SYSTEM
> WellStar was recognized by VHA
National through VHA’s Leading
Practices Blueprinting process.
Working with hospitals with
recognized leading clinical
practices, VHA Inc., developed
an innovative methodology for
generating and transferring
knowledge using a visual story
format that incorporates structural,
process and contextual elements
into a comprehensive knowledge
transfer vehicle called a VHA
Leading Practice Blueprint. VHA
blueprinted both WellStar’s Safety
First Harm Reduction program and
Blood Management Program.
> Systems Society announced
WellStar has achieved Stage 6
on the Electronic Medical Records
(EMR) Adoption Model SM . Of the
more than 5,400 hospitals tracked
by Healthcare Information and
Management Systems in the
United States, only 18 percent
achieve this high-level of
integration. Stage 6 represents
a level of sophistication that only
1,040 U.S. hospitals have reached
to date.
> WellStar received the American
Cancer Society’s Excellence Award
in Workplace Tobacco Control,
commending its Systemwide,
comprehensive tobacco control
program for team members.
WellStar, which went smoke-free
in 2012, is the only health system
in Georgia to receive the highest
level of recognition.
> WellStar Cancer Network was
one of only four accredited
cancer programs in Georgia to
receive the 2013 Outstanding
Achievement Award from the
Commission on Cancer (CoC)
of the American College of
Surgeons. A select group of only
74 accredited cancer programs
throughout the nation received
the award, representing
approximately 14 percent of
programs surveyed by the CoC.
In addition, the WellStar Cancer
Network was granted three-year
accreditation with commendation
from the CoC. WellStar received
eight commendations and earned
the highest possible achievement.
To earn accreditation, a cancer
program must meet or exceed
34 CoC quality care standards,
be evaluated every three years
through a survey process and
maintain levels of excellence in
the delivery of comprehensive
patient-centered care.
> Annual Leapfrog Hospital Survey
results showed that all WellStar
hospital safety scores improved.
Only 17 Georgia hospitals received
a grade of “A” and WellStar
Douglas and Paulding were among
top performers. WellStar Cobb and
Kennestone received a grade of
“B.” Windy Hill Hospital is not
rated by Leapfrog.
14 I 2015 I SAFETY AND QUALITY ANNUAL REPORT

FACILITY
At the 2014 Annual VHA Georgia Leadership Expo:
– For Category 50-125 beds, WellStar Douglas Hospital won second and third place, respectively, for “Stabilization
of the Sick Newborn” and “Surge Protection: Overcoming Throughput Barriers in the Hospital Macro System.”
– For Category Greater than 350 Beds, WellStar Kennestone Hospital received second place for “COPD Care
Management across the Continuum.”
> WellStar Cobb Hospital continues
to garner recognition for its
impressive improvements in
decreasing post-operative surgical
site infection rates. Cobb recently
received the Josh Nahum Special
Achievement Award for Infection
Prevention and Control at the
Georgia Hospital Association’s
annual Patient Safety Summit.
The award was given to Cobb for
its project, “A Team Approach to
Reduction of Surgical Site
Infections (SSIs).” Through the
project, Cobb’s multidisciplinary
SSI team dramatically decreased
the rate of SSIs, specifically in
hysterectomies and colon
surgeries.
> Cobb Hospital remains the only
hospital in Georgia to receive
“Meritorious” status for surgical
patient outcomes from the
American College of Surgeons
and only one of 37 facilities
worldwide, representing the top
10 percent of participating
hospitals. Meritorious distinction
is awarded for quality composite
scores in the outcomes for
mortality, DVT or pulmonary
embolism, cardiac incidents,
respiratory (pneumonia),
unplanned intubation, ventilator
greater than 48 hours, renal
failure, SSI and UTI.
> Cobb was identified as the
first and only General Surgery
EpiCenter in Georgia and only
one of 29 in the nation by
DaVinci Surgical Systems.
> Kennestone Hospital received
Consumer Reports magazine’s
highest ranking for CABG. It is
the only hospital in Georgia, and
one of only two in the U.S. to
receive the disease-specific
certification for coronary bypass
surgery and valve replacement
and repair from The Joint
Commission. In addition this year,
Kennestone received the top
rating from the Society of
Thoracic Surgeons for CABG.
> Kennestone Hospital is one of
only two Georgia hospitals on
the Becker’s Hospital Review
“100 Hospitals with Great
Oncology Programs” list. This
is the second consecutive year
Becker’s has recognized
Kennestone.
> Paulding Hospital earned
The Joint Commission’s Gold
Seal of Approval for its
inpatient diabetes care program.
The inpatient diabetes
certification program is based
on the American Diabetes
Association Clinical Practice
recommendations.
> Paulding Hospital was recognized
as a 2013 Top Performer on Key
Quality Measures ® by The Joint
Commission. Paulding was
recognized as part of The Joint
Commission’s 2014 annual
report, “America’s Hospitals:
Improving Quality and Safety,”
for attaining and sustaining
excellence in accountability
measure performance for
pneumonia and surgical care.
It is one of the 1,224 hospitals
in the U.S. to achieve the Top
Performer distinction and the
second year Paulding has
received the honor.
I 2015 I SAFETY AND QUALITY ANNUAL REPORT I 15

WellStar Paulding Nursing and
Rehabilitation Center received
the highest possible overall rating
of five stars in the U.S. News &
World Report’s sixth annual Best
Nursing Homes. This is the
second year the center has
achieved top recognition.
> WellStar Kennestone received the
2015 Healthgrades Distinguished
Hospitals for Clinical Excellence
Award, recognizing it as a hospital
performing in the top five percent
nationally for overall clinical
excellence. While many hospitals
have specific areas of expertise
and high-quality outcomes in
one or two areas, hospitals
awarded this distinction exhibit
comprehensive high-quality care
across all areas based on riskadjusted
mortality and complication
rates for a comprehensive set of
procedures and conditions.
> Additionally, Healthgrades named
Kennestone Hospital one of
America’s 100 Best Hospitals
for Cardiac Care, Critical Care,
Pulmonary Care and Stroke Care.
WellStar Kennestone also received
the 2015 Excellence Award for
Gastrointestinal (GI) Care and
Neurosciences. Finally, Kennestone
received 11 Healthgrades “Five
Star” ratings in the areas of Acute
MI, Heart Failure, Pulmonary
Embolism, Respiratory Failure,
Sepsis, Esophageal/GI Surgery,
GI Bleed, Small Intestinal Surgery,
Stroke, COPD and Pneumonia.
> WellStar Cobb Hospital received
seven Healthgrades “Five Star”
ratings in the areas of Heart Failure,
Diabetes, Respiratory Failure,
Esophageal/Stomach Surgery, GI
Bleed, Stroke and Pneumonia.
> WellStar Douglas Hospital
received the 2015 Healthgrades
Excellence Award for Pulmonary
Care. In addition, Douglas
received six Healthgrades “Five
Star” ratings in the areas of Heart
Failure, Pulmonary Embolism,
Respiratory Failure, Sepsis,
COPD and Pneumonia.
> Paulding Hospital received
Healthgrades “Five Star” rating
for Respiratory Failure.
> WellStar Medical Group Internal
Medicine Associates of Marietta
received Level 3 certification for
Patient-Centered Medical Homes,
the highest level of distinction
from the National Committee for
Quality Assurance (NCQA).
> WellStar Medical Group Family
Medicine at East Cobb received
Level 2 certification for Patient-
Centered Medical Homes from
the NCQA.
> WellStar Health Place ranked
fourth in the Top 10 Fitness
Centers recognized by the
Atlanta Business Chronicle.
> WellStar Cobb, Douglas,
Kennestone and Paulding were
recognized by Georgia Trend
Magazine as Georgia Top
Hospitals. Douglas ranked first in
Top Small Hospitals (400 beds).
16 I 2015 I SAFETY AND QUALITY ANNUAL REPORT

TEAM MEMBERS
> Candice Saunders, WellStar president and chief operating officer, was
named chair-elect of the Board of Trustees of the Georgia Hospital
Association (GHA) at the association’s annual convention in November
2014. She will serve as the 2016 Chair.
Candice Saunders
Scotty Hancock
Randall Huey,
MS RN CEN
> WellStar Paulding Hospital team members Scotty Hancock, Safety and
Emergency Preparedness manager, and Randall Huey, MS RN CEN,
unit-based educator, were selected to serve on the board for the
Region 1 Regional Trauma Advisory Committee (RTAC). The mission of
the RTAC is to develop and maintain the Regional Trauma System Plan
and monitor system compliance and improvement activities.
> Three WellStar nurses were among 16 Georgia nurses honored by
The Georgia Chapter of the March of Dimes. Through the annual
Nurse of the Year awards, the March of Dimes recognizes nurses who
demonstrate exceptional patient care, compassion and service. Award
recipients were determined by a distinguished selection committee of
healthcare professionals. WellStar award winners included:
Sarah Holt, RN
Laura Fugitt, RN
LeeAnna Spiva,
MSN, Ph.D.
Amy Macy, RN
– Sarah Holt, RN – WellStar Kennestone. Sarah received top honors for
her work with patients, colleagues and Third World Communities.
She spent time teaching the importance of hand washing, first aid
and water sanitation in Kenya.
– LeeAnna Spiva, MSN, Ph.D., director of Nursing Research and
Professional Practice, was honored for her work mentoring nurses
and providing guidance in developing research studies and
analyzing data. She has been instrumental in strengthening the
relationship between academia and practice to improve nursing.
She is an abstract reviewer for the 2015 American Nurses
Association’s Quality Care Conference and a member of the
American Academy of Nursing.
– Laura Fugitt, RN – WellStar Kennestone, was recognized for her
advocacy in founding the Georgia Overdose Prevention Group. The
advocates lobbied to get a Georgia bill passed that expands access
to naloxone, an opioid overdose antidote, and offers medical
amnesty for 911 calls at the scene of alcohol and drug overdoses.
The law was signed and went into effect on April 24, 2014.
> WellStar Kennestone Hospital GI Lab manager, Amy Macy, RN, was
chosen from more than 500 nominees as one of the top 10 nurses
in Georgia in The Atlanta Journal-Constitution’s Nursing Excellence
awards. This is the fourth consecutive year WellStar has had at least
one top 10 honoree.
I 2015 I SAFETY AND QUALITY ANNUAL REPORT I 17

Confidential: Protected pursuant to Georgia law