annual report 2016.final1pptx - home - methodist hospitals
TRANSCRIPT
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.
• [email protected]/VBPPSI-90Goal
• [email protected]/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