annual report 2016.final1pptx - home - methodist hospitals

NursingAnnualReportFY2016

FY2016Outcomes

Strategic PlanImperative/Goal Outcomes

MarketLeaderinQuality CareImplementedProVation evidencebasedcareplans.

Capnography initiatedonNursingunittoreduceriskofrespiratorycompromiseinpatientsreceivingopioids.

BestPlacetoWorkNursing retentionrate83.87%,belowgoalof90%.

BSN/MSNrate59.8%,belowgoalof63%butincreasedfrom58.9%in2015.

CertifiedRNtotalof131,belowgoalof135butincreasedfrom95in2015.

ExcellentPatientExperienceMetInpatientsatisfactionthresholdin3of8domains,

belowgoalof8of8domains.

Outpatient satisfactionscore52,belowgoalof70.

OverallEDsatisfactionscoreof36,belowgoalof50.

NursingProfessionalPracticeMagnet documentssubmittedOctober1,2016.

CultureofSafetyMaintainedHAPUratebelowCMS/VBPPSI-90

benchmarkof0.577inall4quarters.

AcuteCarefallratebelowCMSgoalof< 3.58inall4quarters.

MetgoalforpreventionofCAUTI, MRSAandC-diffratesascomparedtonationalrate.

DidnotmeetgoalforpreventionofCLABSIandSSI.

StewardshipAchieved budgetedLOSin2of4quarters.

ReducedreadmissionratesofCOPD,CABG,andtotalhippatientstotargetasmeasuredbyNationalRateatHospitalCompare.

Didnotmeettargetinreductionofreadmissionratesofheartfailure,pneumonia,andstrokepatients.

Growth&CommunityoutreachPrenatal classesledbystaffRNsimplemented.

EDstaffparticipatedinMerrillvillePoliceDepartmenteventsofsoupkitchenandcoatdrive.

StrategicPlanning

• TheNursingStrategicPlanisabroadlydefinedroadmapforcreatingMethodistHospital’sdesiredfutureandthemeanstoachieveit.AnnualprioritiesaresetbytheNursingLeadership,inalignmentwithsystemgoalsandobjectives,includingtransformationalgoalsforthefuture.Withinputfromalllevelsofnursing,strategiesandtacticsareidentifiedtoachievemeaningfuloutcomes.Nursingsharedgovernancecouncilsandcommitteesdefineactionplansandcarryoutthestrategicplanwithguidancefromandoversightbynurseexecutivesatthehospitallevel.

2016StrategicImperativesare:

I. MarketLeaderinQualityCare

II. CultureofSafety

III.ProfessionalNursingPractice

IV.ExcellentPatient,CustomerandPhysicianExperience

V. BestPlacetoWork

VI. Stewardship

VII.Growth&CommunityOutreach

NursingPhilosophy

• NursingMission:“TheProfessionalNurseatMethodistHospitals’providesrespectfulandcompassionateevidence-basedcaretoourpatients,families,andcommunity.”

• NursingVision:“Tobeinnovativecaregiverscommittedtonursingexcellence.”

• TheINURSEValuesinwhichweprovidecare:Integrity,NursingExcellence,Unity,Respect,

ScholarandEvidence-basedPractice.

Webelievethatweprovideexemplarynursingcaretoourpatients,families,andcommunityandwedothisbyprovidingcareto“EveryPatient,EveryDay.”

NursingAwards2016

DAISYAWARD:April,2016• JeanHerrera,RN,3W3– SouthlakeCampus• KaitlinVianello,RN,4West- NorthlakeCampusSeptember,2016• MerrissaWesley,RN,4West– NorthlakeCampus• EllenLong,RN,5W2– SouthlakeCampusDecember.2016• NicoleAldana,RN,4East/Peds– NorthlakeCampus• SophyGeorge,RN,3W1/Rehab– SouthlakeCampus

NURSINGEXCELLENCEAWARDS2016:• PatriciaGesin,RN– NurseExcellence,ICU– SouthlakeCampus• PatMarianovich,RN– NurseExcellence,Rehab– SouthlakeCampus• NatalieBurgos,OutstandingCaregiver,Labor&Delivery– NorthlakeCampus• ArleneDurr,OutstandingCaregiver,2W3– SouthlakeCampus

EMPLOYEEoftheYEAR,2016:• JenniferKirk,RN,ED– SouthlakeCampus

EMPLOYEEoftheMONTH:• January,2016– TinaSalter– Buyer,Purchasing• February,2016– DeborahVancleef,SpeechPathologist– Southlake• March,2016– AngelaThomas,MentalHealthTechnician- Northlake

LindaHughes,LPN,OrthoSpineCenter- Southlake• April,2016– JenniferKirk,RN,EmergencyDepartment– Southlake• May,2016– PaulaEstill,RN,ClinicalDocumentSpecialist,MedicalRecords

NursingAwards,cont.EMPLOYEEofTHEMONTH,cont.• June,2016– CarolClausen,SpeechPathologist,HomeHealth• July,2016– SlavicaIlievski,ApplicationAnalyst• August,2016– CharmaineMcGee,PharmacyTech– Southlake• September,2016– MargaritaMeltzer,RN,4West– Northlake

JenniferCerta,Director,MethodistPhysicianGroup• October,2016– KatinaElmore,RN,NeuroIMCU5W2– Southlake

SharonJones,Housekeeper,EnvironmentalServices• November,2016– MariaAlcantara-Samalio,TeamLeader,OutpatientRehab

JuliusJohnson,PatientTransporter• December,2016– MichelleThurmond,RN,CaseManager– HomeHealth

EllenWhitlock,Pharmacist- Southlake

2016EducationalAccomplishmentsCongratulationsto:

BSNDegreeAchieved:• JenniferKirk• KourtneyCole• CrystalSadzweicz• AngelaWedel• AngeliqueSmith• LouiseJurgensen• VickyPhillips• PamelaKrill• DebCurless• JeanParks

MSNDegreeAchieved:• CindyMele• ParisDraine• LaDawn Thomas• AllanRodriguez

StructuralEmpowerment2016NursingSharedGovernance

CouncilAccomplishments

ProfessionalDevelopmentCouncil:• Continuestorecognizeallnurseswhoachievenursingcertification.• Focusedoncreatingaworkenvironmentfornursingstaffthatembodiescollaboration,

teamwork,engagementandfun.• HostedaNursingScrubSale.• PlannedandcoordinatedtheNursesWeekCelebration,withrecognitionofselected

participantstoberecognized.• DevelopedaRetentionCommitteetomonitorandrecommendinitiativesrelatedtonurse

recruitmentandretention.• ContinuedtheTEAM(TogetherEveryone’sAttendanceMatters)initiativetorecognize

unitswhoachievenocall-offs.• Heldapreceptorin-servicetobetterpreparepreceptorsinassistingnewgradsand

experienceRNswiththeirorientation.• BeganworkwithITtodevelopanursingacuitysysteminEPIC.• Developedworkscheduleguidelinestomoreeffectivelyhandlenursestaffingand

standardizetheschedulingprocess.

OperationsCouncil:• WorkedonthehardwiringofanaccurateI&Oprocessforeverypatient.• BeganworkonthetransitiontoProVationcareplanswhichprovidenursedeveloped,

evidence-basedcareplans.• MetwitharepresentativefromDietarytoimprovetheprocessforpatientdietaryrequests.• WorkedonideastoimprovecommunicationbetweenPhysiciansandNursesthroughchart

documentation.

QualityCouncil:• Servesasthepeerreviewcommitteeinaddressingconcernswithpatientcareand

providinganavenueforimprovementinprocess,byidentifyingareasofopportunityforimprovement,andfollowingthroughwithrecommendations,andreviewingactionplans.

• AddressedNursingPIOCstoprovidepeerreviewandensureevidence-basedcareisbeingprovidedtoourpatients.

• StrokeDatapresentedquarterlytocouncil.• NursingScorecardandVarianceReportsarereviewedMonthly.• 541PoliciesandProcedures(RevisedandReviewed)thataffectNursingwere

reviewedandapproved.• ViewedapresentationbyDr.SevierregardingplansforanewSEPSISprotocol.

CouncilAccomplishments– cont….

Evidence-BasedPractice&ResearchCouncil:• DevelopedaprocessfortheCounciltoreviewallnursingresearchorprojectspriortotheir

submissiontothehospitalInstitutionalResearchBoard.• Beganworkonanevidence-basedcurriculumtobeprovidedviaHealthstreamin2017.• HostedtheAnnualCertifiedRegisteredNursesDinneronMarch23,2016.• Pilotedthe“TicketHome”programon4W3whichincludesanadmissionquestionnaireto

facilitatepatientneedsupondischarge.• Initiatedapilotprogramon5SouthatNorthlakeand4W3atSouthlakeforanewPatient

InformationFolderwhichincludesatearoutmedicationcardandlabeledtabstomakeiteasierforpatientstolocateinformationafterdischarge.

UBETSCouncil:• SomeofthetopicsofposterpresentationsduringNurses’Week,whichreflectthehard

workofourUBETS,includedCHFmanagement,cancerpreventionandscreenings,osteoporosis,healthylifestylesandexercise,andcontrollingbloodpressureanddiabetes.

• ThePICCteamwonapizzapartyfortheirposterentitled“SuccessfulImplementationofMid-lineProgramforPatientSafety”.

• TheICUscontinuedworkonCDiffprecautionsandalsoaddressedtubefeedings.• 2C/2Wfocusedoncommunicationbetweennursesandpatientmedicationeducation.• Surgeryconcentratedonreducingturnaroundtimebetweencases.• HomeHealthworkedonspotroundingtoimprovepatientsatisfactionscores.• 5W1workedonbedsideshiftreportandupdatingwhiteboards.• 4W1continuedtheirworkonimprovingtheRNandCNAworkrelationship.• Manyunitsatbothcampusesworkedonimprovingpatientsatisfaction.• Labor&Deliverymadesuretoofferhealthieroptionsforpatientsnacksandworkedon

improvingstaffmorale.• EDUBETsspenttimeworkingonimprovingthefocusonpaincontrolandkeepingpatients

informed.

CoordinatingCouncil:• ProvidesoversightanddirectiontomaintaintheintegrityofENACT (E-empowering,N-

nurses,A-as,C-collaborative,T– teams)tomakesurethatnursesareprovidingthebestevidencebasedcaretoourpatients.

• CoordinatingCouncilisthefinallevelofapprovalforallcouncilactivities.

NursingPublications,Posters,Presentations,ResearchStudiesandAffiliates

2016PosterPresentations:• Massow,A.andJury,A.(2016)“AverageLengthofStayforElectiveKneeand

HipSurgery”PosterpresentationattheNorthwestIndianaResearchConsortium,Merrillville,IN.

• Reed,B.(2016)“TheMethodistHospitals’OncologyInstituteSurvivorshipCarePlanProtocol”PosterpresentationattheNorthwestIndianaResearchConsortium,Merrillville,IN.

• Wiggins,L.E.,Rogers,C.,Turner,J.,Ostby,K.&Lopez,M.(2016)“GoingHomeandStayingHomeSafely”Posterpresentationatthe2016AMRPAConference,NewOrleans.

2016IRBApprovedNursingResearch:• Devries,M.&Rickard,K.(2016)“ProtectedClinicalIndication:Keeping

PatientsSafe”.• Coleman-Givens,D.(2016)“PromotingTeamworkWithinaCultureofNursing

Innovation”.• Reed,B.(2016)“TheMethodistHosPitals’ OncologyInStitue LongITudinal

SurvIVorship CarePlanProtocol(POSITIV)”.• White,J.(2016)“TheImpactofChargeNurseTransformationalLeadership

WorkshopsonReducingPatientFalls”.

2016AffiliateAgreements§ 13undergradaffiliations§ 4APRNcontracts§ 1contractforRNFirstAssistTraining§ 1contracttoserveassitefor

WOCNtrainingandclinicalhours

ICU– Southlake• NancyDoughty,RN,ASN,CCRN• SharnitaRice,RN,BSN,CCRN• NancyHill,RN,ASN,CCRN• ReynaMink,RN,BSN,CCRN• AudreyNess,RN,BSN,CCRN• TylerRussell,RN,BSN,CCRN,CMC• AshleighSzwet,RN,BSN,CCRN• Chnedu Diala,RN,BSN,CCRN• SusanneLange,RN,BSN,CCRN• DeborahColeman-Givens,DNP,MSN,

RN,CCRN• DarlaKupsis,RN,ASN,CCRN• TiffanyPowers,RN,BSN,CCRN• BarbaraBoese,RN,ASN,CCRN

2W1– Southlake• MichelleLobo,RN,BSN,IBCLC• LaToyaParhm,RN,BSN,RN-OBBoard

CertifiedL&D- Southlake• DarcyFivecoat,RNASN,CEFM• DeborahMurfitt,RN,BSN,CEFM• LorriNettles,RN,BSNCEFM

NeonatalICU– Southlake• MaryKaySchreiner,RNASN,RNC-NIC• KashmirHollister,RN,BSN,RNC-NIC

Pediatrics– Southlake• MicheleBillings,RN,ASN, CPN• DonnaMihalikRN,ASN,RNC-Peds

3W2– Southlake• SaraZilz,RN,BSN,CMSRN• DebraVanWoerden,RN,BSNCMSRN• MichelleMcKinley,RN,ASN,CMSRN• KaraBaltz,RN,ASN,CMSRN• KimberlyKormendy,RN,ASN,CMSRN• ClaireWest,RN,BSN,CMSRN

4W1- Southlake• KarneBlimm,RN,BSN,ANP-BC

4W3– Southlake• ShawnaClemmonsRN,BSN,OCN• JacquelineCurtisRN,ASN,OCN• JoanneKuykendall,RN,ASN,OCN

5W1– Southlake• KimBuford,RN,BSN,CMSRN• BiljanaDobrijevic,RN,ASN,CMSRN• SuzanneRichards,RN,BSN,CMSRN

5W2– Southlake• VivianRuiz-Howard,RN,BSN,CNRN• LindsayWaskiewiczRN,BSN,SCRN

5W2– ICU• RonaldHarris,RN,ASN,CNRN• BeckyLackey,RN,ASN,SCRN• CarolOaks,RN,ASN,SCRN• ChristineRohl,MSN,MSCN/FNP-BC,

CNRN• ScottWilliams,RN,MSN,CNRN,ACNS-

BC• KayEngland,RN,BSN,CNRN,MSCN

EmergencyRoom– Southlake• JeanMiller,RN,BSN,CEN• ColleenMcDermott,RN,BSN,CEN

HeartInstitute– Southlake• ConstanceAdams,RN,MSNCCNS,

CCRN

CardiacCathLab– Southlake• SonjaDoreski,RN,BSN,RCIS

Endoscopy– Southlake• MichaelBreitweiser,RN,BSN,RCIS

Nursing Certifications

NursingCertifications,cont’d…EndoSurgicenter– Southlake• JulieBarney,RNBSN,CAPA

PACU– Southlake• DonitaScott,MSN,CGRN

2West– Northlake• RosemaryMeux,RN,MSN,CNS-Adult

Health

2South– Rehab,Northlake• JacquelineTurner,RN,ASNCRRN• LorettaWiggins,RN,MSN,CRRN

3Center– Northlake• AndreaDavies,RN,BSN,CBCN,RN-LEC• KimberlySausman,RN,ASN,RN-LEC• MariaBrewer,RN,MSN,NEA-BC

NeonatalICU- Northlake• JanetEllis,RN,ASN,RNC-NIC• EllenMaravilla,RN,ASN,RNC-NIC• ChristinaLopez,RN,MSN,ACCNS

Labor&Delivery– Northlake• HeatherNorwalk,RN,ASN,C-EFM• DarcyRanegar,RN,BSN,C-EFM• CaleySchroeder,RN,BSN,C-EFM

5South– Northlake• RenitaJackson,RN,ASN,CMSRN

5West– Northlake• TerriMcCullough,RN,ASN,CMSRN

ICU– Northlake• ShatylaMoore,RN,BSN,CCRN• MarthaMoffett,RN,ASN,CCRN• CherylWhite,RN,ASN,CCRN• JacobElman,RN,BSN,CCRN• WandaJordan,RN,MSN,CCRN

EmergencyRoom– Northlake• JanisAstle,RN,BSN,CEN• VictoriaKuiken,RN,BSN,CMSRN

4East– Northlake• AmberWilliams,RN,ASN,CMSRN

Surgery– Northlake• RebeccaEscoe,RN,BSN,CNOR

PACU– Northlake• MichelleSallaris,RN,BSN,CNOR

HomeHealth– Northlake• NancyZondor,RN,ASN,CWOCN• DavidHartford,RN,BSN,WCC• MarthaSutkowski,RN,MSN,RN-BC

Psych– Northlake• PaulaBaisden,RN,BSN,RN-BC-Board

CertifiedPsychiatricMentalHealth

TraumaCenter– Northlake• JenniferMullens,RNBSN,CEN,TNS

PICCTeam• KarolWilcher,RN,ASN,VA-BC

EnterostomalTherapy• LisaMarieHayes,RN,BSN,CWOCN,

CFCN

SurgeryEvaluationCenter• BerniceWright,RN,BSN,CAPA• MariaLaorden,RN,MSN,CAPA,ACNS-BC

DiabetesCenter– Southlake• CarolSakelaris,RN,BSN,CDE

NursingCertifications,cont’d…CaseManagement• BethByrd,RN,BSN,ACMC• JillianSkingley,RN,BSN,ACMC• ChaundraEichmeier,RN,BSN,ACMC• AudreySevers,RN,ASN,ACMC• OlaboduninSobomehin,RN,ASN,ACMC• KerryGallaher,RN,ASN,ACMC

QualityImprovement• LawandaJones,RN,MSN,CSSBB

PatientCareCoordinator• RobertHnida,RN,MSN,CEN

InfectionControl• NancyScott,RN,DNP,ACNS-BC,SCRN,

CIC,PCCN,CNRN

NursingDevelopment• JillSarbenoff,RN,MSN,CCRN• SallySwartz,RN,MSN,ACNS-BC• MarianneHarman,RN,MSN,CCRN

ITApplications• RhondaPlanck,RN,BSN,CNRN

Hyperbarics• PatsieJackson,RNASN,CWS,ACHRN• DebraCrane,RN,ASN,ACHRN

MedicalRecords• PaulaEstill,RN,ASN,CCDS

NeuroScienceInstitute• BillieChildress,RN,BSN,CNRN,MSCN• SarahBaran,RN,MSN,MSCN• LaurelValentino,,RN,MBA,CNRN

StrokeCenter– Northlake• SherryMosier,RN,MSN,CNRN

SpineCareCenter• MaryHoffman,RN,BSN,CNRN

OncologyInstitute• StacyKnox,RN,BSN,CBPN_IC• BridgetReed,RN,BSN,CCRC

FloatPool• KimberlyMorgan,RN,ASN,CCRN• KellyBanks-Enorense,RN,DNP,ACNS-

BC,RN-BC• TajGubatanga,RN,BSN,CCRN• PatriciaGesin,RN,CCRN

PatientCareAdministration• MaryValentine,RN,MSN,OCN• DoreenNorris-Stojak,RN,MSN,NEA-BC• JeannetteWhite,RN,MSN,NE-BC• SheilaCook,RN,MSN,ACNS-BC

CorporateAdministration• ShellyMajor,NEA-BC

NursingCertifications,cont’d…

MSO-Group• DebraEquihua,RN,BSN,CNM

MPG-5800Broadway• LauraRodriguez,RN,MSN,CCNS• MaryHutchinson,RN,MSN,FNP-BC

MPG-NS-Midlevel• KristieDarnell,RN,MSN,FNP-BC,CNRN• NancyWhite,RN.MSN.ANP-BC,CNRN

MPG• TonyaHarvey,RN,MSN,CNP• MaryHutchinson,RN,MSN,NP-BC• OnyinyeEcheymuna,RN,MSN,NP-C• AngelLewis,RN,MSN,CNP• KristinStok,RN,MSN,NP-C• RosieAtkinson,RN,MSN,CNP

MPGHospitalists• KimberlyGoodrich,RN,MSN,FNP-BC

MPGCrownPointSportsplex• LeynaAnderson,RN,FNP-BC• AnnSchilling,RN,MSN,FNP-BC

NursingDivisionAccomplishments

ProfessionalGrowth&Development

§ WeeklyTuesdayTalksdevelopedtoreinforcekeyNursingeducationinitiatives

§ UtilizedconsultanttopromoteNurseleaderdevelopment§ NursingManagersbeganattendingNurseExecutiveCouncil(NEC)§ ShareddrivedevelopedforSharedGovernanceCouncils§ Re-implementeddidactictrainingforbasicEKGclasses§ CNSheldMedSurgcertificationreviewcourses§ “CookiesandConversations”andWorkAnniversaryBreakfasts

initiatedbyShellyMajor,CNOtoestablishopendialoguewithstaffnurses.

§ Careofspinalsurgeryclassesheldforstaffon3W2§ Careofepiduralpatienttrainingwasdonefor5W1staff§ PreceptorclassesheldtoimprovethenewRNonboardingprocess§ ProVation CarePlancreation,implementationandeducation§ EducationtotargetCAUTIreductionstartedon4W3,5W2,ICUand

IMCUandthencontinuedhousewide§ RiskacuityscoringinEpicforRNtopatientratioshasbeenstarted§ Developedmedicationholdordersfordialysispatients

NursingDivisionAccomplishments

EmergencyServices

• IdentifiedstakeholdersthroughouttheorganizationtomeetmonthlyorasneededtodecreasethroughputtimesofpatientsintheED.Thosethroughputtimesbeingmonitoredare:

DoortoBedDoortoDoctorDoortoDischargeDoortoAdmissionDispositiontoAdmission

• ThroughputtimesforDoortoBed,DoortoDoctor,andDoortoDischargearebelownationalbenchmarks.

• Thedevelopmentofthisgroupofstakeholdershasleadtoimprovingthereportsforup-to-the-minutetransparentdashboardsontheadmissionprocess.

• Builtanddeveloped“EDDepartButton”inEpictoimprovedatacaptureforthroughputmeasures

• PublishedweeklyFYItoimprovecommunicationsforphysiciansandstaff• SkillslabsheldintheEDtoreinforceAIDETandroundingskills• SLCparticipatedintheMerrillvillePoliceDepartmentcoatdriveandsoup

kitchen• EstablishedapartnershipwiththeShareGroupandLakeCountySARTon

communityoutreachawarenessonhumantrafficking.• BeganconstructionatNorthlake• DecreasedEmergencyDepartment’sleftwithoutbeingseen(LWBS)atboth

campuses:– NLCat1.7%frombaselineof3.9%– SLCat0.9%frombaselineof2.3%– Nationalstandardis1.9%

NursingDivisionAccomplishments

Maternal Child

• NewNurseManageraddedtotheteamforSLCWomenandChildren

• OneNICUcentrallineinfectioninJanuarywithnonesince• ImplementedprenatalclassesattheNLC• Continuedwithcommunityoutreachbabyshowerswhichhave

beenverysuccessful• BecamethesecondhospitalinLakeCountytobecomeaMilkBank• ReceivedFoundationGrantfortheNLCandSLCNICUtopurchase

newequipment• ReceivedAndersonFoundationGranttoupgradeNeonatal

DevelopmentalClinicattheNLC• 3RNsattheNLCand2RNsattheSLCobtainedNursing

Certifications• MeganWalker,RN,3CenternominatedNurseoftheRegionin

NorthwestIndiana• KrystleHoward,RN,3CenterawardedNursingScholarship• PerinatalSafetySWIGteamimplemented• RenovationoftheNLCLDRsstarted• InitiatedvisitswiththeStateofIndianaforlevelingofLaborand

DeliveryandNurseries• ParticipatedintheMarchofDimeswalk• 2W1had7HCAHPSdomainsatthresholdand1atbenchmark• 3Centerhad5HCAHPSdomainsatthresholdand0atbenchmark

NursingDivisionAccomplishments

RehabUnits/Therapies/PsychUnits§ MaintainedRehabfallratebelowthebenchmarkof5atbothcampuses.

2SPrate3.78and3W1rate3.77whichrepresentsadecreasefrom2015rate.

§ RehabstaffrepresentedMethodistHospitalsatthe2016AMRPAconferenceinNewOrleanswithaposterpresentationtitled“GoingHomeandStayingHomeSafely”

§ 2SPhada95%overallpatientsatisfactionratingfor2016.§ 3W1hada68%overallpatientsatisfactionratingfor2016.

Therapies§ OutpatientRehabvisitsincreased6.94%§ RCChada99%overallpatientsatisfactionratingfor2016§ MidlakeRehabhada71%overallpatientsatisfactionratingfor2016§ FourtherapistscertifiedinGraston Technique§ OneMidlake OccupationalTherapistreceivedherDoctoratein

OccupationalTherapy§ TheSpeechPathologydepartmenthostedanin-serviceforareaSpeech

PathologistsatwhichDr.B.SafadipresentedonlinkingPulmonologywithSpeechPathology

§ OutpatientvolumesatMidlake andtheRehabCenterincreasedby6%overprioryear

PSYCH• NewnursemanagerhiredforBehavioralMedicine§ WorkedwithPorter-StarkeonSafetyPinGrant§ Filled7RNvacantpositionsin3months§ GeriatricBehavioralMedicinevolumesup128.8%

NursingDivisionAccomplishments

ACUTECARE&ICU’s

§ Implemented“DomainDosing”toimprovepatienteducationandHCAHPSresults

§ NursingDirectorandNursingManagerservedasmentorforJointCommissionpreparation

§ NursingDirectorsservedaschapterleadersforJointCommissionpreparation

§ AlignedMedicalRecordIndicatorswithJointCommissionstandards§ DevelopedaJointCommissionmedicalrecordaudittool§ SuccessfulIHSBsurvey§ Capnographyaddedtoacutecareunitstoreducerespiratoryevents

relatedtoopioiduse§ DesignedacompetitiveResourcePooltiertorecruitandretain

experiencednurses§ ProVationcareplansincorporatedintoEPICtoprovideEvidence

Basedcareplanmeasures§ NewICUunitopenedatNLCwithimprovedtechnologyandsecurity§ DischargehuddlesdevelopedincollaborationwithCase

Managementtoimprovetimelinessofdischargesandpatientthroughput

§ ImplementedGeneralStaffMeetingsforallRNsandCNAstoattendtodiscussNursinggoals,qualityoutcomesandotherNursingDepartmentpriorities.

NursingDivisionAccomplishments

NURSINGQUALITY

• ContinuedwithOverallNursingScorecards,aswellasUnitSpecificScorecardsforallNursingUnits.

• MaintainedrecordsofallHospitalAcquiredPressureUlcers,StageIIandaboveforreportingtoNDNQI,andforMagnetPreparation.

• ContinuedasMentoronQualitySharedGovernanceCouncilwhereallnursingpolicies,aswellasanydepartmentalpolicies,thatreferencedanythingtonursingwerereviewed.

• WOCN'scontinuedtoworkwithunit"SkinChampions"1Wednesdayamonthfor1hour-- withvendorsavailableforeducationofskinsupplies,woundvacs,ostomies,etc.andproperusageonthenursingunits.

• HeldaMANDATORYCompetencyDayforWound"SkinChampions".• CollaboratedwithStore-RoomDirectorinpressuremappingofbeds/

mattressesforthenewlyremodeledICUandtoutilizemovingforwardwithreplacementofallbedsfacilitywide.

• ContinuedwithdatacollectionneededforMAGNETpreparation,andgraphedallresultsbynursingunitforeightquartersofcomparativedatainclusiveof:CLABSI,CAUTI,HAPUs,FallswithInjury,andSpecificHCAHPsscores.

• Assistedwithimplementationofthe2016HospitalSurvey,toassureallquestionsspecificforMAGNETwereincluded.

• ThesurveyshowedthatNursingscoredinthe48thPercentilefor"PercentEngaged"in2016,withanEngagement"mean"ofthe44thPercentile.

• UpdatedtheNursingStrategicPlanquarterly.

NursingDivisionAccomplishments

NURSINGQUALITY,cont.

• MaintainedHAPUsStageII@0.154whichwasbelowthe0.577CMS/VBPPSI-90Goal

• MaintainedHAPUsStageIII@0.020whichwasbelowthe0.577CMS/VBPPSI-90Goal

• MaintainedAcuteCareFalls@1.916whichwasbelowtheCMSgoaloflessthanorequalto3.58

• MaintainedCAUTIandMRSAratesforQ1throughQ4,2016belowtheNHSNQuarterlyRatebenchmark.

• MaintainedCLABSIratesforQ1throughQ3,2016belowtheNHSNQuarterlyRatebenchmark

“JOURNEY”toMAGNETACCOMPLISHMENT• OngoingcommunicationonMagnetJourneywitheducational

supportonMagnetcomponents• DocumentssubmittedtoANCCOctober1,2016.• DevelopedMagnetsteeringcommittee• ImplementedEnculturationCommitteetosupportimplementation

ofMagnetprinciples• PresentationonMagnetJourneytonewnursehiresatmonthly

orientation

2017NursingGoals

QualityPillarGoals:• ImproveEDpatientthroughputtimestogoalof< 30minutesdoortoMD,

<134minutesdoortodischargehome,and< 247minutesdoortoIPadmission

• Evaluatetechnologyavailableforpatienteducationneeds

SafetyPillarGoals:• 10%reductioninoccurrenceofHAIs/HACstoincludeCLABSI,CAUTI,Colon

SSI,HAPUsandC-DiffasmeasuredbyCMS/NHSN• Reduceuseofrestraintstobelowbenchmarkmeanasmeasuredby

NDNQI

RelationshipsPillarGoals:• ReceiveMagnetDesignation• DevelopandimplementNurseResidencyProgram• AchieveBSN/MSNrate64%• AchievecertifiedRNtotalof161

PatientExperiencePillarGoals:• ImprovetheInpatientresultstothresholdin5of9domainsasmeasuredby

HCAHPSsurvey• ImprovetheEDresultstothe50th percentileasmeasuredbyPress-Ganey• ImprovetheOutpatientresultstothe70th percentileasmeasuredbyPress-

Ganey

StewardshipPillarGoals:• ReduceALOSto5.54• 15%reductioninreadmissionratesofAMI,heartfailure,pneumonia,CABG,

COPD,stroke,andtotalhip/kneepatientstotargetasmeasuredbyNationalRateatHospital Compare

GrowthPillarGoals:• Focusonobesity,diabetes,substanceabuseandmentalhealthprograms

basedonresultsoftheCommunityHealthNeedsAssessment