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Sarah Carmody

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Princeton, MN55371

Constituent member of ANA, Charter member of CAN

The Mission of the Delaware Nurses Association is to represent the interest of professional nurses in the state of Delaware. The Delaware Nurses Association also advocates for health care issues through legislative channels and regulatory activity, resulting in positive outcomes for all Delawareans.

Volume 33 • Issue 3 August, September, October 2008

The Critical Link to Safer Care

Page 7

Nurses Week Photos

1

Inside DNA REPORTER

Constituent member of ANA, Charter member of CAN

the Delaware Nurses Association is to represent the interest of professional nurses in the state of Delaware. The Delaware Nurses dvocates for health care issues through legislative channels and regulatory activity, resulting in positive outcomes for all Delawareans.

Inside DNA REPORTER

ReporterReporter The Offi cial Publication of the Delaware Nurses Association

Executive Director’s Column . . . . . . . . . . . . 1Technology, Safety and Workfl ow—Not Opposite Terms . . . . . . . . . . . . . . . . . . . 3Key Legislative Issues to Watch . . . . . . . . . . 6Delaware Excellence in Nursing Practice Award . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Upcoming Conferences . . . . . . . . . . . . . . . 10Election Time! . . . . . . . . . . . . . . . . . . . . . . 10Spring Conference Photos . . . . . . . . . . . . . 12

Medicine Cabinet Clean-Out Days! Poster . . . . . . . . . . . . . . . . . . . . . . . . . . 13Delaware Nurses Association Sponsors Successful “Medicine Cabinet Clean-Out Day . . . . . . . . . . . . . . . . . . . 14Nurses Mentoring Nurses . . . . . . . . . . . . . 14My Medication List . . . . . . . . . . . . . . . .16-17DNA Membership Application . . . . . . . . . . 19

Patient Safety: A Driving Force

Michele Campbell, RN, MSN, CPHG FABC

Michele Campbel l RN, MSN, CPHQ FABC is presently the Corporate Director for Patient Safety and Accreditation at Christiana Care Health System in Wilmington, Delaware. She is a visionary leader with more then 20 years experience in nursing leadership and 15 years in quality and patient safety. She is a certifi ed professional in healthcare quality and is a current board member of the Delaware Association for Healthcare Quality, a member of Delaware Organization for Nurse Executives, Delaware Nurses’ Association and the American Nurses Association. She is also a consultant at Premier Inc. where she assists healthcare organizations in their ongoing readiness efforts for the Joint Commission survey process. In addition, she has completed an Executive Fellowship from the Advisory Board Company and has presented nationally on applications of High Reliability Concepts. She can be reached by e-mail at [email protected] or her offi ce at (302) 733-4982.

Patient safety continues to be driving force in healthcare and has become much more recognized since the Institute of Medicine published the ground breaking report “To Err is Human.”1 This report indicated that 44,000 to 90,000 unnecessary deaths occur every year in U.S. Hospitals. In 2001, “Crossing the Quality Chasm”2 was published describing the disconnect between health care we have and the health care we could have. These reports generated great interest not only to the healthcare provider but also to the consumer.

One consumer driven effort was the formation of the Leapfrog Group which is a national association of Fortune 500 CEO’s. The goal of this group is to mobilize purchasing power, initiate breakthrough improvements in patient safety and give consumers information to make informed health care decisions. Also, The National Quality Forum is a not-for-profi t membership organization created to develop and implement a national strategy for health care quality measurement and reporting. Another leading organization who is helping to lead the improvement of health care is the Institute for Healthcare Improvement (IHI). In addition to consumer driven efforts; there are multiple external agencies that guide and impact on the national quality and patient safety movement.

The Center for Medicare and Medicaid Services (CMS) has various initiatives to encourage improved quality and safety of care in all health care settings where Medicare benefi ciaries receive their health care services. They have been instrumental in promoting a model of accountability through the Pay for Performance (P4P), promotion of evidence based practices and the public reporting of data. There has been much attention has been paid to the development

Sarah J. CarmodyExecutive Director

Hello Everyone!

The Delaware Nurses Association is moving forward with changes to improve the quality of the overall association and meeting the needs of the membership and nursing in our state. As of June 9, 2008, the offi ce has moved to a better location. The new offi ce is located on the ground fl oor of a brand new building with a conference room, improved parking and an easier to fi nd location. The new address is 5586 Kirkwood Highway in Wilmington 19808. The phone number has also changed to (302) 998-3141. Please make a note of the changes. An open house will be scheduled for August. I look forward to seeing you then.

As with the offi ce location change, there has been a change to the organizational affi liate program. I thank all the representatives of specialty nurse organizations for their input. Through December 31, 2008, the cost to participate in the program will be $199. Thereafter, the fee will be $250 annually. There are many issues that are coming to the forefront-both at the national and state levels. The Board and I look forward to working with other nursing organization to bring a stronger voice for Delaware nurses in addressing these issues. Please visit our website for information and application on the organizational affi liate program.

Patient A DrivinP Patient safety continues to be driving force

Michele Campbell

continued on page 2

continued on page 2

—August, September, October 2008—DNA Reporter

OFFICIAL PUBLICATION

of the

Delaware Nurses Association

5586 Kirkwood Highway

Wilmington, DE 19808

Phone: 302-998-3141 or 302-998-3142 FAX 302-998-3143

Email: [email protected]

Web: http://www.denurses.org

The DNA Reporter, (ISSN-0418-5412) is published 4 times annually, by the Arthur L. Davis Publishing Agency, Inc., for the Delaware Nurses Association, a constituent member association of the American Nurses Association.

EXECUTIVE COMMITTEE

President Treasurer

Penelope Seiple, RN, Gloria Zehnacker, CRNA, APNMSN, CNA, BC

President-Elect Secretary

Norine Watson, RN, Lori Shifl ett, BSN, RNMSN, NEA-BC

COMMITTEE CHAIRS

Continuing Education Advanced Practice

Nancy Rubino, EdD, RNC Leslie Verucci, MSN, RN, (Acting) CNS, ARPN-BC, CRNP Nominating Professional Development Moonyeen “Kloppy” Karen Carmody, MSN, Klopfenstein, MS, RN, CRNPIBCLC, CPUR Legislative Communications Ann Darwicki, RN Daryl Miller, RN, BSN Bonnie Osgood

DNA DELEGATES to the ANA House of Delegates

New Castle County: Nati Guyton, RN, MSNKent County: Karen Panunto, RN, MSNSussex County: Kelly Davis, RN, MSN

DNA President: Penelope Seiple, RN, MSN, CAN, BCAlternates-at-Large:

Melanie Marshall, RNVacantVacant

Executive Director

Sarah J. Carmody, MBA

Offi ce Assistant

Rosemary Finlayson, BS

Subscription to the DNA Reporter may be purchased for $20 per year, $30 per year for foreign addresses.

Acceptance of advertising does not imply endorsement or approval by the Delaware Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or its use. DNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily refl ect views of the staff, board, or membership of DNA or those of the national or local associations.

Advertising Rates Contact—Arthur L. Davis Publishing Agency, Inc., 517 Washington St., P.O. Box 216, Cedar Falls, Iowa 50613, 800-626-4081. DNA and the Arthur L. Davis Publishing Agency, Inc., reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement. Material is copyrighted 1997 by the Delaware Nurses Association and may not be reprinted without written permission from DNA.

Managing Editors

Daryl Miller, RN, BSNBonnie Osgood

Photographer

William Campbell, EdD, RN

The DNA Reporter welcomes unsolicited manuscripts by DNA members. Articles are submitted for the exclusive use of The DNA Reporter. All submitted articles must be original, not having been published before, and not under consideration for publication elsewhere. Submissions will be acknowledged by e-mail or a self-addressed stamped envelope provided by the author. All articles require a cover letter requesting consideration for publication. Articles can be submitted electronically by e-mail to Daryl Miller, RN, BSN, @ [email protected] or Bonnie S. Osgood, RN, MSN, CNA,BC, @ [email protected].

Each article should be prefaced with the title, author(s) names, educational degrees, certifi cation or other licenses, current position, and how the position or personal experiences relate to the topic of the article. Include affi liations. Manuscripts should not exceed fi ve (5) typewritten pages and include APA format. Also include the author’s mailing address, telephone number where messages may be left, and fax number. Authors are responsible for obtaining permission to use any copyrighted material; in the case of an institution, permission must be obtained from the administrator in writing before publication. All articles will be peer-reviewed and edited as necessary for content, style, clarity, grammar and spelling. While student submissions are greatly sought and appreciated, no articles will be accepted for the sole purpose of fulfi lling any course requirements. It is the policy of DNA Reporter not to provide monetary compensation for articles.

OFFICIAL PUBLICATION

of the

Delaware Nurses Association

5586 Kirkwood High a

ReporterReporterof patient safety measurements. For example we have witnessed the promulgation of “never events” and “safe practices” increased transparency and accountability. Another area of impact on patient safety is the release of National Patient Safety Goals by the Joint Commission. The compliance to these goals and practices are evaluated on during the organizations survey process. The Joint Commission is also leading a standards improvement project to streamline standards to focus solely on quality and safety. Federal funding for patient safety initiatives through the Agency for Healthcare Research and Quality (AHRQ) has resulted in a wealth of papers published on patient safety. In addition, Healthgrades identifi es patient safety incident rates for nearly every hospital in the country using the ARHQ Patient Safety indicators.3

This wide range of public agencies and private organizations has a common goal of improving quality and avoiding unnecessary health care costs. This public attention has prompted many hospitals to re-think their quality and safety strategies. Currently, most hospitals have identifi ed patient safety as an integral component of their existing Performance Improvement efforts.

Some organizations are adopting lessons learned from the airline industry and implementing Crew Resource Management (CRM) concepts. Structured communication techniques are being used to promote effective communication among the health care team. Some of these techniques include briefi ngs, short discussions between the team to promote collaboration and shared plan of care. Checklists are also being employed to help defi ne clear roles and responsibilities. The Situation-Background -Assessment and Request (SBAR) technique is useful from framing brief and concise conversation. Many of these techniques are being used in a healthcare setting and are essential to safe management of patient care, treatment and services.

The use of technology such as an Electronic Medication Administration Record (EMAR) and

In June, the DNA Delegates traveled to Washington DC to attend the American Nurses Association House of Delegates. Some of the issues that were addressed were:

• Delegates approved a resolution that recognizes the impact global climate change has on the health of the world’s population and encourages nurses to advocate for change on both individual and policy levels. The measure calls on ANA to incorporate global climate change into its legislative agenda, and support public policies that endorse sustainable energy sources and reduce greenhouse gases. (DE, ANA Board)

• ANA also resolved to advocate for research to identify real or perceived gaps and barriers to health care for veterans and their families.

• Recognizing concerns over the adverse affects linked to food additives and contaminants, ANA has resolved to work collectively with CMAs, affi liates and health care organizations to eliminate purchasing milk and dairy products for use in the health care industry that contain hormones.

• ANA resolved to recognize the impact human traffi cking has on the public health and the profession of nursing, and to advocate for and seek opportunities to ensure nurses have the skill sets to properly identify and refer victims of human traffi cking. ANA has also resolved to advocate and support legislation that further enhances protection and prosecution in an effort to decrease the incidence of human traffi cking.

• ANA, one of the original supporters for the establishment of the nation’s Social Security program, resolved to work with Congress and the President to strengthen Social Security and extend its solvency beyond 2042.

• ANA resolved to advocate for the expansion of Medicare from the traditional “medical model” to include a focus on prevention, wellness and primary care services.

• ANA resolved to advocate and promote legislative and educational activities that support advanced degrees in nursing. Increasing the level of education required for continued registration as a registered nurse by requiring RNs to attain a baccalaureate degree in nursing within ten years after initial licensure, while maintaining the multiple entry points into the profession.

• ANA further resolved to advocate for legislation that increases access to oral health care for older adults and support efforts to raise awareness of the importance of oral health and preventive care for older adults.

• ANA resolved to begin a dialogue with the American Red Cross over the elimination of its Chief Nurse Offi cer position, and to urge the Red Cross to re-instate a Chief Nurse Offi cer position at its national headquarters.

For the next few months, the DNA will be putting out a series of surveys on a variety of topics such as conferences, benefi ts and legislative topics. Your input will make a difference in how your association moves forward. Please take a few minutes to complete the surveys. Your opinion does make a difference!

Lastly, CONGRATULATIONS to all that were nominated for the Nurse Excellence awards. As I read through the applications, I was truly impressed and amazed by the absolutely wonderful work that is being done by nurses in our state. THANK YOU also to the reviewers. It was a tough job to select one winner from each category with so many excellent applications.

I look forward to seeing you at the Open House in August or at any of our upcoming events. As always, please call or email with any questions, comments or concerns you may have.

Computerized Order Entry are also promising for improving patient safety. The focus needs to be on the patient and do whatever it takes to reduce the chance of error, mitigate harm and become more reliable.

While there may be widespread agreement that action needs to be taken, to improve patient safety, there is not universal agreement as to how to get this accomplished. Though, it is evident that hospital leaders are making patient safety a priority and at times comes fi rst above fi nancial and operational goals. It will be interesting to watch the future motivator’s and momentum of patient safety efforts.

As a nurse and healthcare quality professional deeply committed to infl uencing quality and patient safety, I salute the role nurses play in this exciting journey. It is clear that the dedication and achievements of healthcare quality professionals have a tremendous impact on organizational quality and patient safety efforts. Please join me in recognizing my colleagues as they describe some of their efforts and contributions to improving patient safety.

References 1. Kohn, L, Corrigan, J, Donaldson, M. editors To Err is

Human: Building a Safer Health System. National Academy Press: Washington D.C; 1999

2. Crossing the Quality Chasm: A New Health System for the 21st Century National Academy Press: Washington D.C., 2001

3. Bagian J et al, Developing and Deploying a Patient Safety Program in a Large Health Care Delivery System. The Joint Commission on Accreditation of Healthcare Organization 200; 10: 522-532.

Guest Editor...continued from page 1

Executive Directorʼs Column...continued from page 1

Delaware Nurses

Association has Moved!Effective June 9, 2008, the Delaware Nurses

Association is moving down the street from our current location to a new offi ce complex. The DNA offi ces will be housed in a brand new offi ce building complete with a conference room, easy ground fl oor access, easier to fi nd location and better parking.

Please note the new address:Delaware Nurses AssociationOrchard Commons Complex

5586 Kirkwood Highway, Wilmington, DE 19808 Phone:(302) 998-3141-NEW

(302) 998-3142-NEWFax: (302) 998-3143-NEW

DNA Reporter—August, September, October 2008—

By now, most of us have heard about the Institute of Medicine’s landmark report published in 1999, “To Err Is Human.” If you have not heard about it, let me share the most important statistic of the report. It states, “Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals.”1 After that report was released, healthcare organizations around the country began looking for ways to integrate care delivery and documentation into a seamless system through the use of technology.

Many nurses I encounter throw up their hands and say, “Computers? How am I supposed to spend any time with my patients if I’m always staring at a screen?” Another statement I frequently hear is, “I can’t use computers. I’m stupid on a computer.” These questions and statements always make me wonder. Throughout our history, it has been the nurse at the bedside working and monitoring the newest technologies to improve patient safety and promote better outcomes. Any nurse, whether in acute or long term care, routinely uses equipment such as intravenous pumps, automatic blood pressure cuffs and telemetry, usually without a second thought. Tubes of blood that used to be sent to the lab for glucose, blood gas and chemistry testing can all be done at the bedside with a few drops of blood.

So why then is there this fear of using computers to monitor and document on our patients? Is it because it is not connected to the patient in the way a ventilator is? Or are we afraid that by using a computer, technology will overshadow safety and workfl ow and some day we will all be replaced by machines?

As a Nurse Informaticist for Christiana Care Health System, I have seen fi rst-hand how technology can be integrated into a workfl ow that is effective and safe. The use of technology such as computers on mobile medication carts, handheld scanning devices and online documentation have helped identify medication errors and have started to bring many of the “near misses” to light as well.

Wilmington Hospital inpatient units have been up using barcode scanning/point of care technology since January, 2008. In the morning, the nurse creates a personal list of patients that they will be taking care of for the day. Medications that are due, as well as some nursing tasks, display in hourly columns on this list. When the nurse is ready to administer medications, his/her badge is scanned against a handheld device and their password is entered. Then the patient’s wristband is scanned and the nurse verifi es the patient’s name and date of birth. At that point, the medication cart is wheeled into the patient room.

Each medication is scanned and prepared at the bedside. The carts contain needed supplies such as saline fl ushes and alcohol preps so that the nurse can maximize time in the room. Once the medications are administered, the nurse then can sign off all the

meds with a few taps on the handheld device. No more missing signatures! The nurse then can move on to the next patient. Sounds smooth and easy, but learning anything new is always challenging, both for the Information Technology staff and the nurses.

Initially, many nurses were nervous about preparing medications at the bedside. If the medication scanned perfectly, everything was all right, but if any error messages, such as too small/too large a dose, or a medication scanned was not really intended for the patient, anxiety abounded. You want a patient to think that you know what you’re doing, right? Our Nursing Informatics Team worked around the clock coordinating and giving support during this critical time. We helped the nurses integrate the technology into their workfl ow and they started to realize the benefi ts of electronic “5 rights” checking and documentation.

As time has passed, confi dence has increased. Nurses now stop me now to give me suggestions on how to improve the display on the computer and I frequently hear sentences that start with, “You know, it would be great if the computer could…” and I think, “Yes, it would be great if...but the computer is a tool, not an answer.”

The answer lies in the nurse doing what he or she does best—assessing and coordinating patient care. To keep patients safe, technology and workfl ow must work together, but they must do so under the guidance of the nurse. The nurse is the critically thinking brain behind the computer, and the nurse needs to carefully assess the information being fed to her.

I experienced this as a Graduate Nurse. I am sure every nurse has their own GN horror story, and mine centered on a ventilated patient. I had recently started on a stepdown unit and I was fortunate to have great preceptors. One of them kept reminding me to “focus on the patient, not the equipment,” but I was too overwhelmed to really “hear” her message. One afternoon, the patient I was taking care of was having some respiratory distress. Respiratory had been to see the patient, and had done some adjustments, but the alarms kept ringing and beeping.

Frustrated, I stared at the panel on the foreign machine willing it to tell me something… anything. But it just kept making noise. I stared out the door at my preceptor, hoping she would see MY distress. She looked at me and turned back to her charting. The message was obvious—fi x it. I fi nally looked at the patient and saw that he had coughed his t-piece off and was no longer connected to the vent! As soon as I reconnected him, the alarms stopped and he (of course) began to breathe easier. So did I.

I went out to my preceptor and asked her, “How long were you going to wait before you came in and stopped me?” Her answer was, “Another 10 seconds. But I fi gured if you could tear your eyes away from the lights long enough to look at me, you could look at the patient fi nally.” I never forgot that lesson, even as I moved into the world of computers and technology.

My patient did not become one of the 98,000 preventable deaths, because I fi nally learned to use technology in my workfl ow to focus on the patient. When technology comes to you and your workplace, remember these three words can—and do—live very happily together.

ReferencesKohn, L.T., Corrigan, J.M. & Donaldson, M.S., (Ed.).

(1999). To err is human: building a safer health system. Washington, DC: National Academy Press.

Carolyn Zsoldos, RN, BACarolyn received her ADN from Delaware Technical

and Community College in 1993, and has worked on both surgical and cardiac fl oors. For 5 years, she and another RN designed and implemented Christiana Care Health System's intranet. This not only entailed the maintenance of the web infrastructure, but also entailed assisting employees in other departments in the design and promotion of web content. In 2000 she received her BA from the University of Delaware. Currently, she is a member of the Nursing Informatics Team and is a Clinical Support Specialist, helping to design, implement and support Christiana Care's Integrated Clinical Care System.

Technology, Safety and Workfl ow—Not Opposite Terms


Stephen J. Dentel, BSN, RN and Michele Spino-Bolles, CHES

Michele Spino-Bolles earned her Bachelor of Science degree in Public Health from West Chester University. She is a Certifi ed Health Education Specialist from the National Commission For Health Education Credentialing Inc. Michele has worked for the American Heart Association for the past 18 years and her primary area of expertise is in stroke education and quality improvement. She is a past-president of the PA Chapter of the Society of Public Health Educators. In her currently role with the AHA, she is the Vice President of Quality Improvement Initiatives for the American Heart Association in Delaware, Pennsylvania, Ohio, Kentucky and West Virginia. Michele can be reach by email at [email protected] or at her offi ce at (610) 234-2448

Steve Dentel earned his BSN from Duquesne University in Pittsburgh, Pa. Steve has worked for the past 10 years in various post acute care capacities including the Regional Program Director of Stroke and Parkinson’s disease for a Pittsburgh metropolitan rehab company. He is currently the Director of Quality Improvement for the Great Rivers Affi liate of the American Heart Association/Stroke Association. He works with approximately 75 hospitals in the Western Pennsylvania area in the coordination of the Get With The GuidelinesSM (GWTG) program.

As consumer awareness of the value of quality improvement grows, hospital quality improvement programs are becoming an important factor in how patients evaluate and select healthcare providers. Even more important is how these quality improvement programs result in positive patient outcomes and reduction of recurrent events through effective secondary prevention efforts.

Performance and quality measures provide the basis for evaluating and improving treatment of cardiovascular disease patients. When evidence for a process or aspect of care is so strong that the failure to act on it reduces optimal patient outcome, a performance measure may be developed regarding that process or aspect of care. As such, performance measures help speed the translation of strong clinical evidence into practice.

However, studies show that although healthcare providers are familiar with the treatment guidelines, provider awareness does not always equal successful implementation of the guidelines when treating patients. Research reported in the Feb. 17, 1999 issue of the Journal of the American Medical Association showed that only half of the eligible heart patients were prescribed beta-blockers, slightly more than half received ACE inhibitors and only two-thirds were treated with clot busting therapies.1

In an effort to reduce risk from heart disease and stroke and ultimately improve patient outcomes, the American Heart Association/American Stroke Association developed the Get With The

GuidelinesSM (GWTG) hospital quality improvement program. GWTG touches the lives of hundreds of thousands of patients in more than 1500 hospitals nationwide. The Get With The Guidelines program is designed to positively impact in-hospital patient care and reduce the incidence of secondary heart disease, stroke and heart failure. This is done through the consistent application of the most up-to-date scientifi c, evidence-based guidelines.

The team approach to patient care is a critical success factor in setting up a GWTG program. The program empowers a multi-disciplinary team, utilizing each individual’s unique knowledge and skills to better serve the patient and the nursing staff is a keystone to the team’s success. At a hospital level, GWTG is designed to enhance the nursing staff’s ability to treat and educate their patients toward positive health outcomes. This is done with a standardized approach, including the use of standing order sets, establishment of care pathways and consistent treatment protocols from the time of admission through the patient’s discharge.

Additionally, the collaborative nature of the GWTG program lends itself to hospitals learning from one another and from hospital personnel networking with peers from other hospitals to identify and share best practices for patient care. GWTG facilitates hospital teams to be become more effi cient and to ensure that all patients receive a standard level of care regardless of time of day, day of week or which clinician treats that patient. The program also has a national recognition component which gives successful hospital teams a way to be recognized for the efforts not only by their hospital administration but also by their peers from across the country.

Since GWTG was launched in 2002, there have

been more than one million patient records entered into the GWTG database. Research gained from this information is invaluable for identifying gaps in care and developing systems and protocols for improving patient care.

Information compiled from the GWTG database shows that as of the end of 2006, more than 94 percent of heart patients in the GWTG-CAD module were being counseled on smoking cessation, compared with only 58.7 percent when the program began. For stroke patients that number increased from 38.8 percent to 83.8 percent and for heart failure patients it improved from 74.3 percent to 91.4 percent. More than 94 percent of heart attack patients were receiving aspirin upon admission, compared to 76.4 percent at baseline. Stroke patients arriving at the hospital less than two hours after symptom onset were receiving tPA more than 63 percent of the time, much improved from the 23.5 percent at baseline. There has also been signifi cant improvement in the percentage of patients getting treatment to improve their cholesterol, as well as those getting beta blockers and other medications known to improve their health outcomes.2

GWTG creates quality, seamless patient care at the point of service. As part of the program, hospitals focus on ongoing data measurement and rapid improvement cycles using the Patient Management Tool. The tool also provides hospitals with immediate access to the guidelines that are customized for each patient to reduce cardiovascular risk factors and ease reporting to government agencies as well as customized, printed on-demand educational materials.

Key features of the GWTG initiative include: • A nationwide network of quality improvement

professionals.• Continuing professional education

and development training workshops; collaborative opportunities through national, regional and local teleconferences and webinars,

• Digital/interactive products such as on-line courses e-newsletters and an online resource center designed to support hospitals through program implementation and beyond.

• A local and national recognition program. • A system of checks and balances to aid

validation of individual patient care.• Access to real-time, hospital-specifi c and

aggregate benchmarking reports to check progress and pinpoint areas that need attention.

The Get With The Guidelines (GWTG) program was recognized as a leader in using health information technology to improve healthcare delivery at the point of patient care. In 2004, it became the fi rst hospital-based program to receive the Innovation in Prevention Award from the U.S. Department of Health and Human Services. The program was noted as the premier hospital-based healthcare improvement program for cardiac and stroke patients and as a model in addressing a growing health issue. In 2007, the program also received the eHealth Initiative’s fi rst-ever Improving Healthcare Quality through Information and Information Technology Award, in the category of Transforming Care Delivery at the Point of Care.

The American Heart Association has always been in the business of helping establish the Guidelines and Scientifi c Statements and supporting research, but Get With The Guidelines is a direct practical translation of those research efforts from guideline development and dissemination to application in the clinical in-patient setting.

References1) Gerald T. O'Connor, PhD, DSc; Hebe B.

Quinton, MS; Neal D. Traven, PhD; Lawrence D. Ramunno, MD, MPH; T. Andrew Dodds, MD, MPH; Thomas A. Marciniak, MD; John E. Wennberg, MD, MPH; Geographic Variation in the Treatment of Acute Myocardial Infarction: The Cooperative Cardiovascular Project; JAMA. 1999;281:627-633.

2) Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics--2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-171.

National QI Program Focuses on Evidence-Based Guidelines, Team Approach in Caring for Heart and Stroke Patients

Michele Spino-Bolles

Steve Dentel


Linda is a nurse with over 22 years of experience in Women and Children Service in a variety of roles. Currently she is responsible for directing and providing clinical oversight to the development and implementation of system-wide, cross-continuum care management processes and outcomes for the maternal-child population. The primary objective is to reduce undesirable variation in clinical practice and promote the delivery of high quality, safe and effi cient care for women and children.

Linda Daniel, MSN, RN, CCMDirector, Performance Improvement & Care

Management Women & Children ServicesChristiana Care Health Services4755 Ogletown-Stanton Rd. Newark, DERoom 1934Newark, DE 19718Phone Number: 302-733-3770Fax Number: 302-733-3794Email: [email protected]

Ellen is a master’s prepared nurse with over 30 years of maternal-child experience. As a staff development specialist she is responsible for prov id i ng educat ion to staff of Women and Children’s Services at Christiana Care.

Ellen Simpson, MSN, RNC

Sta f f Development SpecialistChristiana Care Health Services4755 Ogletown-Stanton Rd.Room 2948Newark, DE 19718Phone Number: 302-733-2745Fax Number: 302-733-3794Email: [email protected]

Simulation education provides an alternative to hands on training by providing an opportunity to learn and practice skills, and evaluate performance in a safe, non-threatening environment. It enhances the application of knowledge, the utilization of complex decision making, and the development of clear communication skills. Simulation training offers a safety net for providers to master simple as well as more complex technical skills needed in emergent clinical situations that may be infrequent.1

Shoulder dystocia is an obstetrical emergency that requires immediate recognition and prompt treatment. It is diagnosed after the delivery of the head, when further progress toward delivery is prevented by impaction of the fetal shoulder within or above the maternal pelvis2. It often occurs without warning and requires rapid and correct interventions to improve both maternal and fetal outcomes.3 It’s an excellent example of a situation that lends itself to simulation training because it is relatively rare (0.6–1.4%)4 and is risky to permit hands on training. Recognizing the need to promote excellence in care delivery, Christiana Care purchased the Gaumard’s NoelleTM S575 maternal and neonatal birthing simulator with newborn Hal to build essential skills in managing obstetrical emergencies such as shoulder dystocia.5

An education program utilizing simulation technology and team building skills was developed by a multidisciplinary team consisting of obstetricians, L&D nurses, staff development specialists, neonatology, anesthesiology and performance improvement staff. The concepts of Team STEPPS6, an evidence-based educational curriculum, were incorporated in the training session to optimize performance among our health care team. Team training clarifi es roles and responsibilities, enhances

communication and expedites excellent care delivery. Team work principles and training skills include leadership, communication, mutual support and situational monitoring.

Research has shown that poor team work and miscommunication are contributing factors to adverse obstetrical outcomes and may lead to delays in treatment.7 Early in the development of the educational program as we practiced with Noelle; a lack of communication was identifi ed. Staff asked, “How will we know when a shoulder dystocia has been diagnosed?” It exemplifi ed how basic and important it is to have the health care provider (leader) send a clear message by stating, “We have a shoulder dystocia.” Once the diagnosis has been made, the nurse communicates the need for additional staff to respond to the emergent situation.

During training sessions, health care providers identify barriers to safe patient care and discuss interventions to promote a culture of safety. Team members are expected introduce themselves on arrival and roles are clarifi ed to facilitate mutual support and situational monitoring. Good communication is promoted by using tools such as SBAR (Situation, Background, Assessment, and Request) to communicate critical information to team members. When team members share the same knowledge and understanding about a clinical situation, a shared mental model exists. A shared mental model brings the knowledge and skills of each team member together for more effective and timely care delivery to the patient. Educational videos reinforce the importance of a shared mental model, situational awareness and clear communication to enhance team performance.

In an effort to make the simulation as realistic as possible, training sessions are held in a labor and delivery room (LDR). Staff is oriented to Noelle, roles are clarifi ed, and scenarios are presented. The team is videotaped as they respond to the emergent situation. Post scenario debriefi ng, an interactive activity, encourages the team to evaluate their performance in a non-threatening and non-

punitive environment. The ability to practice clinical skills without fear promotes self-confi dence, strong teamwork and effective communication.

Our vision at Christiana Care Health Services is to improve our organizational culture of safety and build high reliability teams for safe care delivery. Building a high reliability organization requires integration of evidence-based practices, innovative technology, and a culture of patient safety. High reliability teams need to Know the Plan, Share the Plan, and Review the Risks6. Teams are able to rapidly respond and adapt to changing situations when there is a shared vision of the plan; clear communication, and appropriate application of skills and resources. Shoulder Dystocia is only one example of the many uses of simulation technology. Future educational opportunities planned with Noelle and newborn Hal include postpartum hemorrhage, precipitous and breech deliveries, and neonatal resuscitation.

References1. Johannsson H, Ayida G, and Sadler C. Faking

it? Simulation in the training of obstetricians and gynecologists: editorial review. Curr Opin Obstet Gynecol 2005 17:557-561.

2. Seeds, J. W. Malpresentations: Shoulder dystocia. In S. Gabbe, J. Niebyl, & J. Simpson (Eds.), Obstetrics: Normal and problem pregnancies 2nd ed. New York: Churchill Livingstone; 1991: 562-568.

3. Deering S, Poggi S, Macedonia C, Gherman R, and Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. ACOG 2004:103(6):1224-1227.

4. American College of Obstetrics and Gynecology. Shoulder dystocia. ACOG practice bulletin No. 40: 2002: http://www.acog.org/publications/educational_bulletins/pb040.cfm

5. Gaumard®—Simulators for health care education. Miami, FL. www.gaumard.com

6. Team STEPPS. Agency for Health Care Research and Quality. 2005. www.ahrq.gov

7. Gardner R, Walzer TB, Simon R, and Raemer DB. Obstetric simulation as a risk control strategy: Course design and evaluation. Society for Simulation in Healthcare 2008:3(2):119-127.

Linda Daniel

Ellen Simpson

Obstetric Simulation and Team Building Education


Ann Darwicki R.N.

State LevelHouse of Representatives

HB 479—Bill implements recommendations of the Delaware Health Care Commission and it’s Small Business Health Insurance Committee to reform rating rules for small employer group health insurance.

HB 478—Bill establishes the Delaware State Health Insurance Risk Pool.

HB 477—Bill allows for insurance companies to offer minimum coverage based policies and contracts to consumers within the State of Delaware.

HB 476—Act allows the Division of Revenue to use the data that they collect to help identify eligible families for the state CHIP program.

HB 472—Bill creates a procedure by which the Child Death, Near Death, and Stillbirth Commission will perform reviews of maternal deaths occurring in Delaware. The review is to provide meaningful, prompt, system wide recommendations in an effort to prevent future deaths and to improve services to pregnant women. The Bill also extends the time frame from 3 to 6 months for expedited reviews of all child abuse and neglect deaths, near death and provides for compliance with Federal Child Abuse Prevention and Treatment Act.

HB 446—Bill establishes the Adult Correctional Health Care Review Committee and sets forth it’s purpose to provide advice and counsel in relation to the provision of adequate health care services to the incarcerated population in the State of Delaware.

HB419—This act establishes a Community Mental Health Treatment Act with rights paralleling those of patients in the substance abuse treatment system. It also defi nes minimum patient rights in community facilities, as treatment moves from institutional settings to community facilities.

HB 408 with HA 1—Bill requires mental

hospitals and residential centers covered by Mental Health Patients Bill of Rights Act to report deaths and critical incidents to the State Protection and Advocacy Agency authorizing investigation by order of Federal Law.

HB 407 with HA 1—Bill adds protection to the Mental Health Patient’s Bill of Rights Act including safeguards in administration of restraint and requirement of an enhanced patient grievance system for DPC patients.

HB 405 with HA 1—Bill requires that the Secretary of Delaware Health and Social Services to implement a mandatory uniform policy for all staff within 1 year to help distinguish staff members from patients for safety purposes.

HB 403 with HA 1—Bill creates a committee to assess deaths of individuals receiving residential mental health services through the Division of Substance Abuse and Mental Health or funded private providers. The committee will assess causation, promote improvement in policies/ practices and the service delivery system, as well as reduce prospects for preventable deaths.

HB 381 with HA 1—Act enables an agent, surrogate, or guardian of an incapacitated person to have full authority and standing under HIPPA to act as the personal representative even if the advance health care directive , surrogate confi rmation or guardianship order does not expressly provide it. The representative would qualify to obtain protected medical information of the incapacitated person that is protected under HIPPA, enabling them to make healthcare decisions. (Passed)

HB 377 with HA 1 and SA 1—Bill provides for the licensing of professional Acupuncturists in the State of Delaware and establishes an Acupuncture Advisory Council. The Bill sets out standards that are needed to become licensed and defi nes a scope of practice.

HB 361—Bill allows LPNs to instruct students during the clinical phase of CNA training programs while under the supervision of RN instructors.

HB 355—Bill requires individual and group health insurance contracts to provide coverage for hearing aids up to $1000.00 per ear every 3 years for dependents aged 18 and younger. (Passed)

HB 352—Act establishes an Offi ce of Cardiovascular Disease and Stroke Prevention within the Division of Public Health. The intent of the act is to decrease the incidence of cardiovascular disease and strokes in the State of Delaware through the creation of a state offi ce to promote health education, public awareness and community outreach activities and to improve access for treatment and prevention.

HB 330—Bill ensures that Delaware students who benefi t from the SEED program enrolled in Delaware nursing or medical programs stay in Delaware to ease the state nursing shortage.

SenateSB 321 W/SA1—Bill requires all medical

practitioners in the state of Delaware to write prescriptions on a tamper resistant pad to reduce or eliminate prescription fraud. (Passed)

SB 318—Amends Delaware Health Record Privacy statute to allow protected health information to be released for specifi c health research purposes while adhering to Federal HIPPA Regulations.

SB 315—Bill extends health data reporting requirements to include outpatient and free standing surgical centers since increasingly procedures are performed in greater numbers in those facilities.

SB 313—Bill reforms method in which criminally mentally ill juveniles are treated, rehabilitated, and punished. The Department of Correction places individuals under the age of eighteen in a facility other than Delaware Psychiatric Center (DPC). Ensures inmates receive adequate and effective due process with the transfer process.

SB 307—An act to establish May as Melanoma and Skin Cancer Detection and Prevention Month in the state of Delaware.

SB 305—Bill implements September 2006 CDC and prevention recommendations for increased HIV testing. Healthcare providers in clinical settings may adopt an HIV opt out policy in which patients will have the opportunity to choose to be tested for HIV as part of their routine medical care.

SB 235—Legislation makes cancer incidence rates available by census tract enabling cancer clusters to be identifi ed. (Passed)

Federal LevelHouse Concurrent Resolution (HCR) 134—

Expressing the sense of the Congress that there should be an established a Bebe Moore Campbell National Minority Mental Health Awareness Month to enhance public awareness of mental illness especially within minority communities.

HCR 302—Supporting the observance of Colorectal Cancer Awareness Month.

HCR 331—Supporting the goals and ideals of National Women’s Health Week.

HR 20—To provide for research on and services for individuals with postpartum depression and psychosis.

HR 477—To amend public Health Service Act to strengthen education, prevention and treatment programs relating to strokes.

HR 1198—To amend the Public Health Service Act regarding early detection, diagnosis and treatment of hearing loss.

HR 1237—To amend Public Health Service Act to provide revised standards for quality assurance in screening and evaluation of gynecological cytology preparations.

HR 2063—To direct the Secretary of Health and Human Service to develop a voluntary policy for managing the risk of food allergies and anaphylaxis in schools.

Key Legislative Issues to Watchn

Ann Darwicki


Gina H. Moore RN BSN CPHQ

Gina H. Moore earned her nursing diploma from Sewickley Valley Hospital School of Nursing and her BSN from Wilmington University. She is a Certifi ed Professional in Healthcare Quality and has worked in the Quality and Safety realm for 16 years. She is currently an Oncology Research Nurse at the AI DuPont Hospital for Children. Gina is a member of both the National and Delaware Associations for Healthcare Quality. She serves as a Board and Education Committee member in the Delaware Association and has presented poster and podium sessions on the topics of handoff communication and family centered care. Gina can be reached by email at [email protected] or at her offi ce at (302) 651-5584.

Each of us has a story that illustrates the impact of communication on patient safety. A story of missing information that resulted in a long shift of correction and catch up. The following scenario demonstrates how important communication is to the safety of patient care.

A 20 year old female was seen in an outpatient dialysis unit. While being dialyzed, it was discovered that she appeared to have an infected shunt.Surgery was consulted and examined the patient in the dialysis unit. Surgery decided to admit her for observation and IV antibiotics. Prior to going to the fl oor, the nephrologist ordered IV Vancomycin 1 gram to be given in the dialysis unit. The medication was given at 1200 and charted on the dialysis fl owsheet. She was then transferred to the fl oor for admission. Report was given to receiving unit and all paperwork accompanied her at the time of transfer. The surgical resident wrote admission orders, including and order for Vancomycin 500 mg q 12 hours. This order was activated and the patient received a second dose of Vancomycin at 1800.

In the setting of renal impairment, multiple doses of Vancomycin, in close succession, could be catastrophic. Is this type of communication mishap an anomaly or does it occur frequently?

Statistics from The Joint Commission suggest that approximately 65% of sentinel events include communication failures among their root causes. (Figure 1) Handoffs, the communication that occurs during transfers of care, are vulnerable periods for communication failure. They are a frequent occurrence in healthcare and are not often taught as part of nursing or physician education. Variability occurs in their preparation, content, and methods.2, 4

Information and communication theories have relevance to this specialized form of medical communication. Claude E. Shannon‘s unidirectional Mathematical Theory of Communication, stated that all communication involves 3 steps: coding a

Figure 1: 65% of sentinel events, reported to The Joint Commission,

include communication failures among their root causes1

message at its source, transmitting the message through a communications channel, and decoding the message at its destination.7 Later, Osgood and Schramm developed a Circular Model, which expanded the communication process to include a feedback system: an encoder sends a message to a decoder, who interprets the message and then encodes a message back to the sender; the sender decodes and interprets that message, resulting in a continuing process of interaction.8 (Figure2) No wonder taped reports without interaction with the actual caregiver were so risky! We were not able to verify our understanding of the information we just received.

Charles Berger addressed the use of communication as a tool to cope with the need to reduce uncertainty in his Uncertainty Reduction Theory. This theory describes how communication strategies are used in social situations to decrease

Figure 2: Communication Model

The Osgood & Schramm Circular Model

high degrees of uncertainty that interfere with behavior prediction.9 Patient transfers and complex care create UNCERTAINTY. Communication is what humans use to reduce uncertainty. Effective communication reduces uncertainty to acceptable levels, while poor communication increases uncertainty and can create anxiety.

Handoff communication is intended to facilitate safe, effective care. However, studies examining the handoff process have documented that the process is variable, unstructured, and prone to error. 2,

3, 4 Studies also support that failures can lead to adverse patient outcomes.5 Intern interviews, using a technique to identify and describe near misses and adverse events resulting from poor sign-outs, uncovered the following error categories:

• Content omission, such as omission of active medical problems, medications, and test results

• Failure-prone communication processes, such as multiple sign-outs

Caregivers and patients are affected by the quality of information provided during handoff communication. Problematic handoffs may lead to frustration, anxiety, and uncertainty among caregivers, and, worse, caregivers may not even know they have incomplete information. This can decrease satisfaction and confi dence among patients and can lead to poor treatment decisions that may compromise the quality and safety of care. 2, 6

Given the complexity of handoff communication and its effect on patient care, The Joint Commission added a requirement to the National Patient Safety Goal: Improve the effectiveness of communication among caregivers. This requirement

asks organizations to “Implement a standardized approach to ‘hand off’ communication, including an opportunity to ask and respond to questions.”10

I m p l e m e n t a t i o n expectations include using a process that is interactive and up-to-date, limits interruptions, and includes an opportunity for the receiver to review relevant historical data.11 What is interesting about this requirement is that it mandates a “standardized approach” not a form or checklist. Although, forms and checklists can

be effective tools, they are often too constraining to address every type of handoff.

Any approach to handoff communication should be applicable to professionals with varying levels of training and knowledge, including developing professionals who are learning standards and care processes. A fl exible approach should be adaptable to the end-user, supporting the novice’s need for thorough handoffs, while allowing experts to “solve problems and make clinical decisions using fewer items of information.”12 We must fi rst identify the critical information to be included in every handoff and then develop a means of packaging this information in a manner that is predictable. (Figure 3) You have to start somewhere. Decide on your approach, set the expectation and watch the improvement happen!

REFERENCES1. Joint Commission on Accreditation of Healthcare

Organizations. Root Causes of Sentinel Events. Retrieved October 2007, from http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8F-E8AF6571E372/0/root_cause_se.jpg

2. Arora, V., Johnson, J., Lovinger, D., Humphrey, H. J., & Meltzer, D. O. (2005). Education and training: communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 14, 401-407.

3. Frank, G., Lawless, S. T., & Steinberg, T. H. (2005). Improving physician communication through an automated, integrated sign-out system. J Healthcare Information Management 19, 68-74.

4. Solet, D. J., Norvell, J. M., Rutan, G. H., Rutan, G. H., & Frankel, R. M. (2005). Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 80, 1094-1099.

5. Horwitz, L. I., Krumholz, H. M., Green, M. L., & Huot, S. J. (2006). Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med 166, 1173-1177.

6. Hohenhaus, S., Powel, S., & Hohenhaus, J. T. (2006). Enhancing patient safety during hand-offs: standardized communication and teamwork using the “SBAR” method. AJN 106, 72A-72C.

7. Shannon, C. E. (1948). A mathematical theory of communication. The Bell System Technical Journal 27, 379-423, 623-656.

8. Schramm, W. (1954). How communication works. In W. Schramm (Ed.), The process and effects of mass communication. Urbana, IL: University of Illinois Press.

9. Berger, C. R., & Bradac, J. J. (1985). Language and social knowledge: the social psychology of language: uncertainty in interpersonal relations. London: Edward Arnold.

10. Joint Commission on Accreditation of Healthcare Organizations. (2007). 2007 Hospital/Critical Access Hospital National Patient Safety Goals. Retrieved September 1, 2006, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_hap_cah_npsgs.htm

11. Joint Commission on Accreditation of Healthcare Organizations. (2006). FAQs for the 2006 National Patient Safety Goals. Retrieved September 1, 2006, from http://www.jointcommission.org/NR/rdonlyres/25E48E23-6946-43E4-916C-65E116960FD5/0/06_npsg_faq2.pdf

12. Hawkins, R., Gaglione, M. M., LaDuca, T., Leung, C., Sample, L., Gliva-McConvey, G., Liston, W., De Champlain, A., & Ciccone, A. (2004). Assessment of patient management skills and clinical skills of practising doctors using computer-based case simulations and standardised patients. Medical Education 38, 958-968.

Figure 3: Examples of Handoff Approaches

Just Go Nuts:N: NameU: Unique (pain mgmt, critical labs)T: TubesS: Safety (fall risks, med rec.)

Ticket to RideRequired whenever patients leave their roomChecklists for tests, procedures and observationsBased on air-traffi c controllers hand off

SBAR: START:S: Situation S: SituationB: Background T: Therapies, treatmentsA: Assessment A: Anticipated CourseR: Recommendations R: Reconciliation T: Transfer

Gina Moore

The Critical Link to Safer Care


Kathy Schmidt RN, MS, CPHQ

Delaware Association for Healthcare Quality

President

Kathy received her Bachelors of Science in Nursing degree from Delaware State College in 1983 and a Masters of Science in Human Resource Management fro Wilmington College in 1990. She has been a Certifi ed Professional in Healthcare Quality since 2001.

She has an extensive clinical nursing background that includes emergency and critical care, psychiatric and infusion therapy nursing. She has held positions in Nursing Management and as an Infection Control Practitioner and Performance Improvement Specialist prior to joining the staff of Nemours/A. I. duPont Hospital for Children in 2006. In her role of a Performance Improvement and Patient Safety Lead Coordinator she has oversight for all of the Nemours Children’s Clinics throughout the Delaware Valley as well as the Ambulatory Care Clinics and General Pediatrics located at A. I. duPont Hospital for Children.

Kathy has 10 years of Performance Management and Patient Safety experience and maintained certifi cation as a Quality Improvement Profession since 2001. She is an active member of the Leadership Council with the National Association for Healthcare Quality and is the current President of the Delaware Association for Healthcare Quality. She is has worked with the Delaware Alliance for Excellence as a trained Baldridge Examiner for the Quality Award process in Delaware.

Kathy can be reached by e-mail at [email protected] or by phone 302-293-9543 or through the DAHQ website. www.DAHQ.org

In September 2008 the National Association for Healthcare Quality (NAHQ) will hold the 33rd Annual Educational Conference. This year’s theme “Collaboration: The Spark Behind Quality” is a fi tting reminder that commitment, participation and teamwork involving all healthcare practitioners and support systems are required to ensure the highest quality and safest care to all patients. How often do we hear “Quality is everyone’s job?” We design work process and systems that support our quality mission but it is the Quality Improvement and Patient Safety Professionals that are our the true leaders, experts and often our cheerleaders that drive the improvement initiatives that impact patient outcomes, reduce healthcare related injury and error and move our organizations towards greatness.

Who are these nurses, these quality professionals? When did we decide we needed them? Where have we been and where are we going?

Kathy Schmidt

Lighting the Spark for Healthcare QualityIn 1847 the American Medical Association

(AMA) was founded in part because there was a need to correct the poor quality of medicine and to create oversight for medical training that was disorganized and in the hands of propriety and for-profi t institutions. The 1910 “Report to the Carnegie Foundation” by Abraham Flexner documented the failing state of medical schools and hospitals in the United States. It was the same year that Ernest Codman of Boston’s Massachusetts General Hospital introduced the ideas of tracking patient care and outcomes. By the year 1952 the American College of Physicians, the American Hospital Association, and the Canadian Medical Association joined the American College of Surgeons to form the Joint Commission on Accreditation of Hospitals. Since the inception of the accreditation process we have witnessed the growth and development of the quality management and patient safety specialty fi eld. Since the fi rst efforts to monitor the effectiveness of care we have witnessed the evolution of quality improvement efforts beginning with the fi rst set of minimum standards, auditing requirements, quality assurance methodologies, the expansion of regulatory standards and practice guidelines. This was followed by the use of some of the fi rst quality assessment and continuous quality improvement methodologies. Today accredited healthcare organizations strive to comply with the current Joint Commission expectation that each organization designs and implements strategies that maintain a constant state of survey readiness.

Over the past several decades we have seen many changes within the accrediting organization known today as the Joint Commission. A number of factors have impacted development of the Joint Commission regulations and standards. These include but are not limited to the establishment of state and federal regulations and standards, the Center for Medicaid and Medicare (CMS), the Professional Standards Review Organization (PSRO) and Peer Review Organizations (PROs), liability litigation and underwriter demands. The Institute of Medicine (IOM) reports, “To Err is Human” (2000) and “Crossing the Quality Chasm” (2001) clearly identifi ed major gaps related to quality and patient safety within the healthcare systems in this country. Analysis of Joint Commission reportable events lead to the development the National Patient Safety Goals and the performance expectations related to these goals. These standards are designed to promote ongoing organizational risk assessment, implementation of processes and programs designed to reduce patient and staff safety risks, prevent error and injury and to improve the effi ciency, effectiveness and quality of patient care.

What does all this have to do with the Quality Improvement and Patient Safety Professionals of today? Ours is a parallel history; a history of necessity, change, evolution, standardization, adaptation, increased regulation, learning, and more change! Some of the ideal characteristics of the quality improvement professional include clinical expertise, knowledge of quality management and improvement methodology, data analysis, project management and facilitation skills and potentially the most important; dedication, commitment and tenacity. Just as the quality improvement and patient safety arena has evolved so to have quality improvement practitioners. Initial skills have been learned, applied and mastered only to later be abandoned based on newer, more current theory and evidence for new skills and methodologies.

The evolution of the Healthcare Quality Professional has been essential in meeting the challenges and demands of our healthcare systems. In earlier days there were very few available educational opportunities for the nurse or practitioner who moved into the quality improvement work arena. Though we are fortunate today to have a variety of educational opportunities and resources some of the most important factors that will affect one’s success in the quality improvement and patient safety fi eld are a well documented clinical background, exposure to quality improvement activities in clinical practice and a clear understanding that despite completion of formalized education in quality management and improvement theory and methodology it is the on the job training that is necessary and invaluable. Therefore, it is the acceptance of responsibility and commitment of all seasoned quality professionals that is essential to teach, mentor, guide and support all practitioners entering the practice of quality improvement and patient safety.

One of the most highly recognized and comprehensive organizations supporting the fi eld of Quality Management and Patient Safety and the Quality Professional is the National Association for

Healthcare Quality (NAHQ). Established in 1976, the mission of NAHQ is to empower healthcare quality professionals from every specialty by providing vital research, education, networking, certifi cation, professional practice resources, and a strong voice for healthcare quality. It is a dynamic, interactive resource for healthcare quality practitioners.

NAHQ has established affi liations at local and state levels by supporting qualifi ed state organizations. The organization provides educational resources, materials, networking opportunities, and organizational management guidelines and support for each affi liated state organization. In addition, NAHQ has established Communities of Practice, publishes the research based Journal for Healthcare Quality and is the fi rst and sole provider of the esteemed Certifi ed Professional in Healthcare Quality (CPHQ) credential through it’s certifying arm, the Healthcare Quality Certifi cation Board. Current NAHQ membership includes 5,000 individuals and 100 organizational memberships.

The Delaware Association for Healthcare Quality (DAHQ) was established in 1982 and has remained affi liated with NAHQ since 1986. Our state organization is comprised of healthcare professionals from a variety of practice arenas throughout Delaware. The “Spark” that fuels collaboration and teamwork is clearly visible in the commitment of the membership of DAHQ. Our state organization continues to grow and through sound structure, annual strategic planning, alignment of mission and vision with NAHQ, DAHQ will remain sustainable for the future. The Education Committee of DAHQ plans and executes an annual educational conference for our members and all healthcare professionals throughout the region. DAHQ has been successful in establishing partnerships with other quality organizations in Delaware and are currently evaluating the possibilities of establishing a state-wide patient safety coalition.

As we move forward in our quality improvement and patient safety initiatives, as we establish the state of constant survey readiness in our healthcare organizations there are few things to consider. In a recent interview with Mark Chassin, the current President of the Joint Commission, he stated that “In the coming years, the healthcare quality professional will be among the most valuable resources that hospitals and other healthcare organizations have. The most effective organizations will invest in the development of these professionals, place them in central roles in the organization, and equip them with appropriate resources for achieving their most critical strategic goals in quality and patient safety. DAHQ welcomes all practitioners and we invite all practitioners from all settings including acute care, long term care, rehabilitation and behavioral health care, ambulatory care offi ces and surgery centers and insurers to consider attending the next DAHQ general meeting. Practitioners from Risk Management, Infection Control, Care Management, Offi ce Managers and staff from all levels are welcome! Together we collaborate, plan and establish our expertise and create partnerships with other organizations that will provide the framework for initiatives that support the safest and highest quality of care to all citizens and visitors in Delaware.

Mark your calendars and remember to celebrate the 2008 Healthcare Quality Week scheduled October 19th–25th, 2008. It is an opportunity to showcase the work that you do and to recognize all that your dedicated Healthcare Quality Professionals do to improve the quality of healthcare delivery, improve patient outcomes and provide error proof safety systems in your organizations. So it is true—Quality and Patient Safety is Everyone’s Job! So I say to you, you are the “Spark” that shines, that illuminates the excellence in everything you do for every patient, family member or friend that you care for. On behalf on the Delaware Association for Healthcare Quality, we thank you!

Reference(s)1. Harrington L, White SV. Interview with a quality leader:

Mark Chassin, new president of the Joint Commission, J Healthc Qual., 2008; 30: 25-29.

2. Luce JM, Bindman AB, Lee PR. A brief history of health care quality assessment and improvement in the Untied Sates, West J Med., 1994; 160:263-268.

3. The Proud History of DAHQ. From the archived fi les of the Delaware Association for Healthcare Quality. Accessed July 1, 2008.

4. The National Association for Healthcare Quality. The CPHQ page. Available at www.nahq.org. Accessed June 30, 2008.

5. The National Association for Healthcare Quality. The 2007 annual report. Available at www.nahq.org/about/. Accessed July 2, 2008.


The Delaware Nurses Association is proud to announce its new job site. Delaware Nurse Jobs helps employers target nurses in our state. By advertising on our website, employers will increase effi ciency through direct access to the most qualifi ed members of the nursing community.

It’s fast and easy! Pay and submit your job information all in one transaction. Your job will be posted within 5 working days and sent via listserv to all of our members. If you have any questions, please contact Sarah Carmody at [email protected].

Click on the logo to go directly to the job-posting page.

Organization Affi liate ProgramNow only $199

The Delaware Nurses Association is offering is organization affi liate program for only $199 until December 31st*. The purpose of the program is to create a formal relationship with other nursing and healthcare organizations. Together we can:

• Strengthen nursing and healthcare in Delaware through education, knowledge and information dissemination;

• Provide opportunities for networking with other nurses and healthcare organizations;

• Support learning and the professional development of nurses; • Provide a greater voice for the nursing profession and healthcare in the

legislative arena-both locally and nationally.Visit www.denurses.org for more information and to download the application.*After December 31, 2008, the annual cost will be $250.

Nurse Leader Bayhealth Medical Center Kim ColeMarianne FoardLana GordineerJoyce HillPam JamesKaren KellyKaren PalmerCarol Ritter-Soots-Finalist Brandywine School DistrictBeth Mattey-Finalist Christiana CareArlene Bincsik-Finalist Suzanne HeathBonne OsgoodPenny Seiple Dover Surgical CenterHolly Gebhart Nemours/duPont Hospital for ChildrenDaryl Miller-FinalistCathleen Rossi-McLaughlin

Community-Based Bayhealth Medical CenterRhonda Owens-Finalist DE Dept. of EducationRebecca King-Finalist University of DelawareEvelyn Hayes-Finalist

Nurse Educator Bayhealth Medical CenterKimberly ColeShila HaydenLinda Thoma Christiana CareWendy Wintersgill-Finalist DE Dept of EducationLinda Wolfe-Finalist University of Delaware Karen Avino-FinalistKathleen Brewer-Smyth-Finalist

Acute Care Bayhealth Medical CenterPaulette BarberaGinny Bliszcz Michelle CammisaKimberly Cole-FinalistSusan ConleyDawn Culp-FinalistMisty CunninghamMarianne FoardMaria GasperettiLana GordineerJohn GossmanShila HaydenJoyce HillBarbara HolmanMichele JusticeAlana KingLisa LaudemanRhonda OwensBrenda SharpLinda Thoma Christiana CareMelanie ChichesterMaria Thomas Nemours/duPont Hospital for ChildrenChristine EckrichTaryn Pariag-FinalistMary Sawin-FinalistJoella Slowik

New Graduate Bayhealth Medical CenterNicole BellSarah KinnardLisa LaudemanPaul Pahren-Finalist Christiana CareGeoffrey RandoRachel Ray-Finalist Nemours/duPont Hospital for ChildrenJacqueline Sce-FinalistJenn Thurm-Finalist

Advanced Practice Bayhealth Medical CenterAndrea Holecek-Finalist Correctional Medical ServicesJean Binkley-Finalist

*No applications were submitted for long-term care.

Delaware Excellence in Nursing Practice

AwardsCongratulations to the nominees and fi nalists of the Delaware

Excellence in Nursing Practice Awards.The awards ceremony will be held July 17, 2008 at the Modern Maturity

Center in Dover, Delaware. To purchase individual tickets or for sponsorship information, please visit our website at www.denurses.org, under store.


Hematology / Oncology and Bone Marrow Transplant Unit at Christiana Hospital. Previous nursing experience includes staff nurse and Nurse Manager in Pediatrics at Christiana Care. She is a member of the Oncology Nursing Society, the Delaware Diamonds Oncology Nursing Society, American Organization of Nurse Executives, Delaware Organization of Nurse Executives and the Omicron Gamma Chapter of Sigma Theta Tau Nursing Honor Society. Elizabeth can be reached at [email protected] or at her offi ce at (302) 733-6213.

Diane P. Talarek, RN, MA, CNA is the Senior Vice President, Patient Care Services & CNO for Christiana Care Health System for the past 15 years. Diane reports to the Executive Vice President and Chief Operating Offi cer, this position oversee the daily operation of the Department of Nursing.

She received her Bachelor of Science from Farleigh Dickinson University in New Jersey in 1972 and a Master of Art from New York University in New York in 1976.

Diane is a member of the following healthcare organizations: American Organization of Nurse Executives (AONE), Delaware Organization of Nurse Executives (DONE) serving as the President, a member of the American Nurses Association and the Delaware Nurses Association, serves on the New Castle County Vocational Technical School District Advisory Committee, and is on the Visiting Committee of the University of Delaware College of Health Sciences. Diane is also a Fellow from the Johnson & Johnson Wharton Fellows Program in Management for Nurse Executives for the Wharton School & Leonard Davis Institute of Health Economics of the University of Pennsylvania.

Three members of the nominating committee, one from each county

Please visit www.denurses.org under the “about” tab for more information about the positions and for the consent to run form.

The following individuals have consented to run:

ANA At-Large Alternate-Marianne Foard, RN, MS-Bayhealth Medical Center

Exper ience: 24 years of nursing experience; c u r r e n t l y m a n a g i n g professional recruitment for the second largest healthcare organization in DE; proven results maintaining vacancy rate < 3% and executing programs to improve retention. Developed Apprentice program focusing on recruitment, retention and relations in nursing. Various publications in nursing magazines; Editor of Vital Signs of Nursing; Received 2008 State of Delaware award for outstanding contribution for Advisory Council on Career and Technical Education; Finalist, Nurse of the Year, Nursing Spectrum 2007; nominee Delaware State Nurses Association Nurse of the Year 2008

“ I believe in our profession, igniting the passion, leading the way, shifting the paradigm from what has always been to reaching new heights and discovering roads less traveled. What a fantastic journey to nursing excellence.”

Betty Stone-Alternate DelegateElizabeth Stone earned her Diploma in Nursing from

St. Francis Hospital School of Nursing, her BSN from Wilmington University and her MS in Human Resource Management and MS in Health Care Administration from Wilmington University. She is Oncology Certifi ed and is currently working as the Nurse Manager of the

The benefi ts of being a DNA leader can be both personal and professional, and can provide you with skills that can be applied to many areas of your life. Here are just a few to think about:

• Increase your opportunities to mentor, to be mentored, to gain peer recognition and to share your expertise and ideas;

• Enhance your development as an individual and as a professional through strengthened communication and organizational skills;

• Be on the cutting edge of a new and better health care for our state; and

• Develop marketable campaign skills while articulating your views, engaging with a diverse membership and speaking publicly.

We know you have the ability to be a leader; what better way to serve your profession than to become active in your state nurses association. The Delaware Nurses Association (DNA) represents nurses and nursing in Delaware through action, service, education and leadership.

Open positions for 2008 Election:Three ANA at-large alternates Treasurer

Marianne Foard

Diane Talarek

Upcoming Conferences

APN Update-FallOctober 13, 2008

Sands Hotel and Conference CenterRehoboth Beach, DE

DNA Fall ConferenceNovember 7, 2008

Cavalier Country ClubNewark, DE


Group’s fi rst pitch

David’s fi rst pitch

Sarah and David

Penny welcoming

Bonnie, Wendy, and Daryl

David singing

Wendy’s fi rst pitch

Wendy and David

Nurses Week


Spring ConferenceSpring Conference


Please Distribute Poster. Thank You!


by Nancy D. Rubino, EdD, RNC

Nancy D. Rubino, EdD, RNC, Professor of Nursing at Wesley College served as president of the Delaware Nurses Association from 2002-2004 and as delegate to the American Nurses Association House of Delegates from 2002 –2005. She currently is co-chair of the DNA Continuing Education Committee. Dr. Rubino is nationally certifi ed as a pediatric nurse, child care health consultant trainer, and ELNEC—Pediatric Palliative Care Trainer. Dr. Rubino coordinates a mentoring program for senior nursing students at Wesley College.

New nursing graduates with undergraduate and graduate degrees embark on a journey in their professional career as a nurse. High school graduates begin employment or pursuit of a college education. Excitement and enthusiasm exudes as these graduates aspire for successful futures. Accompanying the excitement is uncertainty as to who will be the guide in this venture. Enter the mentor, defi ned as “a wise and trusted teacher, guide, and friend” (Webster, 2002). Mentoring is an essential thread in the nursing profession. The mentoring continuum begins as a student nurse and carries over to the practicing nurse. The mentoring continuum is dynamic just as mentoring is a process that brings benefi ts to both parties and spans over our professional career and even our lifetime. The American Nurses Association (ANA) identifi ed the development of mentoring programs as an essential mechanism to address the nursing shortage. ANA recognizes mentoring as a key role in nursing recruitment and retention (Blakeney, 2005). Mentoring provides opportunities to share knowledge and wisdom gleaned from experiences. Mentoring can mold future leaders in the nursing profession.

Identifying a mentorMentors are all around you in school, work,

nursing organizations, and community groups. Preparation for fi nding a nurse mentor begins with defi ning what you want to learn. Also consider the

following mentor characteristics: knowledgeable, honest, trustworthy, emotionally secure, mature, and willing to share (Marino and Sisler, 1999).

Finding a MentorFinding a mentor requires establishment of

networks with other nurses. Opportunities are available through participation in the Delaware Nurses Association, ANA, and other professional nursing organizations. Join a committee. Participate in continuing education conferences.

Developing Mentoring Qualities Tau Beta Chapter of Sigma Theta Tau International

invites nurses to develop their mentoring skills at an upcoming conference. Nurses Mentoring Nurses: Success Stories and Train Wrecks—Friday, October 17, 2008 from 8:00 a.m.–1:00 p.m. at the Duncan Center in Dover, Delaware. Nancy Sharts-Hopko, PhD, RN, FAAN, Professor in the College of Nursing at Villanova University and Director of the Doctoral Program will share how the construct of mentorship signifi cantly infl uences career development. Guided by Dr. Sharts-Hopko and other experienced mentors:

Take advantage of a mentoring experience. Create personal toolkits for effective mentoring.Then take that experience and “pay it forward,”

share with the next nurse. Nurses Mentoring Nurses is important in

improving the work environment in nursing and the health care culture, as well as in nursing recruitment and retention (Nursing’s Agenda for the Future, 2002).

Nurses Mentoring Nurses can make a difference in professional knowledge, growth, and development.

Nurses Mentoring Nurses directs the future of professional nursing.

References:American Nurses Association (2002). Nursing’s Agenda

for the Future.Blakeney, B. (2005). “The Importance of Mentoring.”

Imprint. November/December 2005: 41-43.Marino, D., Sisler, L. (Revised 1999). Guidelines for

District Mentorship Projects: Florida Nurses Association.

For information regarding participation in

the Delaware Nurses Association, contact Sarah

Carmody, Executive Director at 302-998-3141

or [email protected].

For information regarding the Mentoring

Workshop on Friday, October 17, 2008, contact

Nancy Rubino at 302-736-2550 or email

[email protected].

Nancy Rubino

Nurses Mentoring Nurses

important to prevent accidental poisonings and abuse. We look forward to holding additional events.”

A special thank you goes out to the Newark Senior Center, the Newark Police Department, DNA members, the Offi ce of Controlled Substances, DNREC, the Delaware Board of Pharmacy and the DuPont Company.

The Delaware Nurses Association’s environmental task force Nurses Healing Our Planet collected over 10 gallons of pharmaceuticals and countless inhalers, liquid medications, ointments and pet medicine at its one-day medicine take-back event held at the Newark Senior Center on April 18, 2008.

All pharmaceuticals brought in were disposed of in an environmentally safe manner. In addition, all medicine boxes, containers and plastic bags collected at this event were recycled.

“The event was a huge success,” says Michelle Lauer, RN, chair of the NHOP task force. “The amount of drugs collected documents the need for this type event in the community on an ongoing basis. Despite the short advertising lead time and only 4 hours to collect, we received over 43,000 pills.” She also adds, “People want to do the right thing and dispose of their unused pills in an environmentally safe manner. I’m glad we could help to facilitate this. Not only does it keep them from being fl ushed down the toilet and ending up in our water supplies, but getting these medications out of households is

Delaware Nurses Association Sponsors Successful “Medicine Cabinet Clean-Out Day”


Jane Lucas earned her BSN from Neumann College and her MS in Health Administration from St. Joseph’s University, Philadelphia, PA. She is a Registered Nurse with experience in Utilization Management and Performance Improvement for hospitals and third party payors. Currently, Jane is a Project Manager at Quality Insights of Delaware, the quality improvement organization contracted by the Centers for Medicare & Medicaid Services (CMS). She is a member of the Delaware Association for Healthcare Quality and an associate member of the Association for Professionals in Infection Control and Epidemiology. Jane can be reached by e-mail at [email protected] or at her offi ce at (302) 478-3600.

Quint Studer, author of Hardwiring Excellence1, was described by a colleague as a Fire Starter. “A Fire Starter is a person who keeps the true essence of the organization alive and fl ourishing. Fire Starters ignite the fl ame that guides and supports the organization.”2 The colleague explained that in early civilization, Fire Starters were people who kept the fl ame alive and without them, others would perish.

There are many Fire Starters in the Delaware healthcare community. From the C-suite to the front line, health care providers strive to deliver high quality care to people at a time when they are most vulnerable. For the past fi ve years, my colleagues at Quality Insights of Delaware and I have had the opportunity to facilitate statewide initiatives that promote Medicare’s quality improvement priorities. We have met many Fire Starters across the health care continuum—hospitals, nursing homes, home health agencies, and physician offi ces. The projects they managed ranged from improving clinical measures, to introducing the concept of organizational culture change, to implementing health information technology, including electronic medical records, telemedicine, and bar-coding at the point of care.

While each health care setting is unique, the commitment to quality improvement was apparent during the Quality Insights’ recruiting process in 2005. Because literature describes the support of Senior Leaders in quality improvement efforts as paramount to their success3, Quality Insights met with Senior Administrators from the various settings to outline the projects and elicit their support.

Delaware health care providers responded to the challenges presented and struggled against competing priorities to achieve success within their organizations and, in many instances, surpass national benchmarks.

In hospitals, Quality Insights met with the Quality Improvement Directors to provide resources and technical assistance for the Centers for Medicare & Medicaid Services (CMS) Core Measures. Adherence to evidence-based guidelines defi ned in the core measures has proven to improve outcomes and promote safety.

The clinical topics include Acute Myocardial Infarction, Heart Failure, Pneumonia, and the Surgical Care Improvement Project. The most recent data posted on Hospital Compare, the CMS website of publicly reported data, shows that AMI care in Delaware has improved dramatically, with 98% of patients receiving Aspirin at arrival and 95% of patients receiving ACE inhibitor for left ventricular systolic dysfunction.

The pneumonia vaccination rate is 78%—up from a rate of 47% in 2004. Approximately 12% more of Delaware’s MI, HF, and pneumonia patients are receiving all of the “appropriate care” treatment while in the hospital.

Delaware hospitals also participated in workshops and teleconferences hosted by Quality Insights and shared project barriers, solutions, and successful implementation strategies that improved clinical outcomes and sustained the gains.

One hundred percent of Delaware hospitals also signed on for the Institute for Healthcare Improvement (IHI) 5 Million Lives Campaign whose goal is to protect patients from 5 million incidents of medical harm. The Campaign began in December, 2006 and will end December, 2008. Quality Insights is a node for the campaign and, as a node, has secured national speakers for Delaware healthcare providers.

A national effort to reduce avoidable acute care re-hospitalizations was a major focus of home health agency initiatives. Hospitalizations can create

unnecessary fi nancial and emotional burdens for patients and their families, and can negatively impact the health care delivery system. Currently, 1 in 4 home health patient episodes will result in a hospitalization.4 Approximately eighteen months into the project, CMS realized that re-hospitalization rates were impacted by many external factors, such as hospital discharge planning, communication of critical information to the next provider, a patient-centered approach to care, and the importance of medication reconciliation across settings. In January, 2007, CMS launched a national campaign supported by LANEs (local area networks of excellence). As the Delaware LANE, Quality Insights recruited 100% of Delaware home health agencies and disseminated many educational resources and Best Practice Intervention packages. Delaware Home Health Agencies have achieved an improvement in the rate of re-hospitalization of 40% above the CMS target.

Quality Insights also invited providers across settings to improve care coordination by sponsoring the Transitions of Care Collaborative in October, 2007. Research has documented that when patients are most vulnerable and their informal caregivers are often overwhelmed, systems of care fail patients by not ensuring that: (1) the critical elements of the care plan developed in one setting are transferred to the next; and (2) the essential steps that need to take place before and after transfer are executed.By default, facilitation of successful care transitions becomes the responsibility of patients and their caregivers, who often do not possess the necessary health care self-management skills or confi dence to assume this role.5 The Collaborative is designed to address the critical elements in care coordination.

Culture change was a major theme of the nursing home quality improvement initiatives outlined by CMS over the past three years. Quality Insights provided technical assistance for initiatives such as employee and resident satisfaction surveys, target-setting using health information technology, and certifi ed nursing assistant turnover rates. Clinical topics related to quality of care included pressure ulcer prevention, restraint reduction, and pain management.

In an effort to improve the organizational culture of Delaware nursing homes and promote transformational

change in workplace practices, care practices, and resident environment, Quality Insights hosted the Person-Directed Care Collaborative in October, 2005. Ten nursing homes elected to participate in the Collaborative and became the early adopters of the principles of person-directed care.

Nationally, in September, 2006, key stakeholders launched “Advancing Excellence in America’s Nursing Homes.” This is a two-year campaign for which Quality Insights is a LANE.

"Electronic medical records are a cornerstone tool for improving quality and safety in health care. Doctors should have all of the information about all of their patients all of the time. Only a computer and an EMR can do that work," George Halvorson, chairman and CEO of the nonprofi t Kaiser Foundation Health Plan and Hospitals, said in Kaiser's May 5 statement.6

Quality Insights of Delaware has supported physician practices with implementation of electronic medical records over the past three years. Dr. Ed Sobel, Director of Quality Improvement at Quality Insights of Delaware, has chronicled his experiences in EMR implementation in our quarterly news journal, Quality Time.

The accomplishments of the Delaware provider community validate the commitment of both organizational leaders and individual practitioners to safety and quality in health care. You are the Fire Starters.

References1. Studer, Quint. Hardwiring Excellence. Richardson, D.,

ed. Gulf Breeze, FL: Fire Starter Publishing; 2003:19.2. What is a fi re starter: Studer Group Website: www.

studergroup.com3. Bradley, E et al, The roles of senior management in

quality improvement efforts: what are the key components: Journal of Healthcare Management 2003; 48

4. Home Health Quality Improvement National Campaign website: http://www.homehealthquality.org/hh/

5. An interdisciplinary team approach to improving transitions across to improving transitions across sites of geriatric care. Care Transitions Website: http://www.caretransitions.org/documents/manual/pdf.

6. Kaiser Permanente completes rollout of electronic medical records. East Bay Business Times Website: http://eastbay.bizjournals.com/eastbay/

Jane Lucas

Lighting the Quality Flame


A review of current literature reveals that medication mistakes are the most common type of health care error.2 The National Coordinating Council for Medication Error Reporting and Prevention defi nes a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.”3(p21) The Institute of Medicine (IOM) Committee on Identifying and Preventing Medication Errors estimates “that on average, a hospital patient is subject to at least one medication error per day, with considerable variation in error rates across facilities.”1(p1) The Institute for Healthcare Improvement (IHI) reports “experience from hundreds of organizations has shown that poor communication of medical information at transition points is responsible for as many as 50 percent of all medication errors and up to 20 percent of adverse drug events in the hospital.”4

In 2005, the Joint Commission (TJC) launched a national campaign “urging Americans to ‘Speak Up’ to avoid medication mistakes” and to carry a medication list.2 Also, in an effort to improve patient safety, the Joint Commission introduced evidenced-based National Patient Safety Goals (NPSGs) in 2003 for accredited organizations. Goal #8 of the 2008 NPSGs calls for organizations to “accurately and completely reconcile medications across the continuum of care.”5 The Institute for Healthcare Improvement (IHI) defi nes medication reconciliation as “the process of creating the most accurate list possible of all medications a patient is taking-including drug name, dosage, frequency, and route-and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital.”4

Health care professionals must encourage patients to be involved, to play an active role in their health care and to speak up when something is amiss. As organizations focus on more accurate and complete medication reconciliation for patient safety, consumers need to become involved by maintaining a list of their medications with the help of a patient-owned medication form. A medication form provides a mechanism to have relevant patient medication information available at the point of entry into the healthcare system. The form involves the consumer in the self-management of their medication history, facilitates patient-provider communication and fosters a partnership. Knowledgeable and educated patients are better able to help prevent errors.

Christiana Care Health System adapted the concepts of the Joint Commission Speak-up campaign for their organizational guide for patient safety, including advice for helping patients prevent medication errors, encouraging patients to maintain a list of their current medications and by providing a tool called “My Medication List” for their patients, visitors and staff.6 “My Medication List,” a patient-owned medication form developed as a statewide initiative by Christiana Care Health System in collaboration with Quality Insights of Delaware, provides the consumer with a cognitive aid utilizing a standard format. The form allows the consumer to record important information about their medications, eliminates reliance on memory for medication recall and emphasizes the value of keeping a current list with them at all times. Patient-provider communication is enhanced when standardized forms are used to help in the accurate documentation and sharing of pertinent medication information. Written directions and visual prompts on the medication form help ensure that patients’ critical medication information is obtained. Maintaining a current list of medications including prescription, over-the-counter (OTC) drugs, vitamins, and herbal supplements and taking the list to all visits to a hospital, health care provider, pharmacist or doctor can help make patients health care safer.

Nurses have a vital role and are in the best position to discuss safety with their patients and to reinforce and promote the use of a medication form to improve patient safety. According to the IOM Committee on Identifying and Preventing Medication Errors, “in any given week, more than four of fi ve U.S. adults take at least one medication (prescription or over-the-counter (OTC) drug, vitamin/mineral, or herbal supplement), and almost a third take at least fi ve different medications.”1(p1) The more information patients have about their medications the better able they will be to use them properly. Educating consumers about the potential for medication errors, and providing practical tools and advice on what consumers can do to make processes safer, encourages participation and leads to effective partnerships and improved systems with less chance for error.

June Estock, RN, MSN, CPHQGail Faraone, RN, CCM, MSN

Nichole Cunningham, RN, CCM, BSN

June Estock earned her BSN from the University of Delaware and her MSN from Wilmington University. She is a Certifi ed Professional in Healthcare Quality and has experience in Women’s Health, Ne on a t a l I n t en s i v e Care, Case/Peer Review, Patient Safety and Hea lthca re Qua l it y. June is a member of the Delaware Association for Healthcare Quality and served on the board from 2007-2008. She received the Gold Level of Unsurpassed Excellence Award in 2002 from Christiana Care Health System, participated in the 2005-2006 Patient Safety Improvement Corp, an AHRQ/VA partnership and completed the TeamSTEPPS Train-the-trainer course in 2006. June is currently working as a Senior Operational Excellence Consultant supporting process improvement projects at Christiana Care Health System. She can be reached by email at [email protected] or her offi ce at (302) 733-4165.

Gail Faraone earned her Diploma in Nursing from the Kings County Hospital School of N u r s i n g a t K i n g s C o u n t y H o s p i t a l Brooklyn, New York, her BSN from Widener University and her MSN in Leadership from Wilmington University. She is certifi ed in Case Management and is past President of the Case Management Society of America Delaware Chapter from 2005-2007 and currently a member of Delaware Association for Healthcare Quality. Gail has over 35 years experience in Nursing including Pediatric Emergency, Cardiac Nursing, Case Management and Performance Improvement. Gail received Excellence in Professional Nursing Practice Award in 1993 from Christiana Care and participated in the 2005-2006 Patient Safety Improvement Corp, an AHRQ/VA partnership. She is currently working as a Project Manager in the Patient Safety and Accreditation Department at Christiana Care Health System. Gail can be reached by email [email protected] or (302) 733-5432.

Nichole Cunningham earned her BSN from Immaculata University. She is a Certifi ed Case Manager and has over 10 years experience in nursing including Cardiac, Trauma, and Case Management. She is currently working as an Accreditation & P e r f o r m a n c e Improvement Coordinator at Christiana Care Health System with a focus on medication safety. Nichole can be reached by email [email protected] or (302) 733-6858.

In today’s health care environment, patients need to understand the implications and benefi ts of becoming involved with their own care and medication safety. Current literature supports the involvement of patients in their health care decisions to improve the quality and safety of care. Research has shown that patients who are involved in their own care have better outcomes.1(p163)

Engaging patients as part of the health care team for improving safety and quality in health care requires patients to assume a new role.7(p190) Centers for Medicare and Medicaid researched patient safety messages aimed for consumers and concluded that messages work best if they “advocate a collaborative doctor-patient relationship, specify action to be taken and clearly indicate how that action can be taken.”7(p191) Providing practical tools for patients, such as a medication form, helps to facilitate their involvement as contributing members of the healthcare team.8 The National Patient Safety Foundation (NPSF), the Agency for Healthcare Research and Quality (AHRQ), the Institute for Safe Medication Practices (ISMP), the Joint Commission and state-based patient safety coalitions are some of a number of organizations that have “sponsored educational activities to assist patients and their families in becoming more involved in their care.”7(p191)

The use of “My Medication List” at Christiana Care Health System augments organizational, state and national medication reconciliation and patient safety efforts. During development and implementation of “My Medication List’ patients welcomed practical advice on how they could self-manage their medication history and healthcare providers welcomed efforts that made it easier to engage patients in medication safety.

Our goal as nurses is to promote a patient-owned medication form so that the form will increasingly and consistently be used by consumers and asked for by healthcare providers in a collaborative effort to prevent medication errors and improve patient safety.

Nurses play an integral part in promoting the use of a patient-owned medication form and advising consumers to keep a current medication list with them at all times. As healthcare providers we must review each patient’s list of medications to ensure medication reconciliation at all transitions in care. Collaboration among healthcare professionals and patients is imperative for medication safety and the prevention of patient harm.

A detachable “My Medication List” is provided in this issue. Please use this medication form to track your medications or give it to a patient, family member or friend. Providers can order “My Medication List,” customized with their logo if desired, via SMARTworks, an online document ordering company, by calling 302-369-7205.

References

1. Aspden P, Wolcott JA, Bootman J L, Cronenwett LR. eds. Preventing Medication Errors. Washington, DC: National Academy Press; 2007.

2. Speak UP: New National Campaign Offers Americans Tips To Prevent Medication Mistakes. The Joint Commission (TJC). Published 2005. http://www.jointcommission.org/MewsRoom/PressKits/MedicationMistakes/news. Assessed April 10, 2008.

3. Meadows M. Strategies to reduce medication errors. FDA Consumer. 2003; 37(3): 20-27.

4. Institute for Healthcare Improvement (IHI). Reconcile Medications at All Transition Points. http://www.ihi.org/IHI/Topic/PatientSafety/MedicationSystems/Changes/Reconcile. Accessed April 3, 2008.

5. Joint Commission. 2008 Comprehensive Accreditation Manual for Hospitals: The Offi cial Handbook (CAMH). Oakbrook Terrace, Ill: Joint Commission Resources; 2008.

6. Christiana Care Heath System. Speak-up Patient Safety Guide. Wilmington: Author; 2006.

7. Aspden P, Corrigan JM, Wolcott J, & Erickson SM. eds. Patient Safety; Achieving a New Standard for Care.Washington, DC: National Academy Press; 2004.

8. Entwistle VA, Mello MM, & Brennan TA. Advising patients about patient safety: Current initiatives risk shifting responsibility. Jt Comm J Qual Patient Saf. 2005; 31(9), 483-493.

June Estock

Gail Faraone

Nichole Cunningham

“My Medication List”


List all prescriptions, over-the-counter medicines, vitamins, herbs,dietary supplements, oxygen, inhalers and homeopathic remedies.

Universal Medication Form: You can help make your health care safer by keeping this listcurrent. Complete this form and keep it in your wallet. Bring this form with you to any visit toa hospital, healthcare provider, pharmacist or doctor. For copies of this form or a pocket-sizeversion visit our web site at www.christianacare.org or call (302) 623-CARE or 800-693-CARE.

Medication Name/ Dose When ReasonDate Started (mg, drops, etc.) Taken for Taking

My Medication ListName ___________________________________________________________

Doctor _______________________________Phone _____________________

Pharmacy_____________________________Phone _____________________

My Medication List

Universal Medication Form: You can help make your health care safer by keeping this listcurrent. Complete this form and keep it in your wallet. Bring this form with you to any visit toa hospital, healthcare provider, pharmacist or doctor. For copies of this form or a pocket-sizeversion visit our web site at www.christianacare.org or call (302) 623-CARE or 800-693-CARE.

Medication Name/ Dose When ReasonDate Started (mg, drops, etc.) Taken for Taking

Allergies and reactions (please describe):

Date last received the following:

Pneumonia Vaccine Flu Vaccine

Hepatitis Vaccine Tetanus

Other: Other:

(Continued)


Gale Moore Bucher, RN MSN

Gale Moore Bucher earned her BSN and MSN from the University of Delaware. She has worked in critical care, nursing education, and home care for over 28 years. Gale is the Performance Management Coordinator at Christiana Care Visiting Nurse Association, New Castle, Delaware. Her responsibilities include performance improvement and accreditation. She is also a surveyor for the Commission on Collegiate Nursing Education, a national accreditation agency, and an adjunct instructor for the University of Delaware’s Department of Nursing in the College of Health Sciences. Gale can be reached by e-mail at [email protected] or by phone (302) 327-5341. The over 65 age group in Delaware is expected

to increase 133.8% from 2000 to 2030.1 According to the U.S. Bureau of Census, in 1996 only 4.5% of adults over age 65 lived within institutional settings in the United States.2 Home health care needs and demand is on its way up!

Technology is necessary for home health agencies to meet the needs of patients with increasingly complex medical and social needs. Telecommunications advances have made it possible for home care to be a major player in preventing emergent care and unplanned acute care hospitalization (ACH); technology, in various forms, is being used worldwide. Britain’s National Department of Health recently initiated a $60 million (USD), two-year telemonitoring program for medically complex patients.3 This program and others like it are helping organizations and governments cope with the increasing pressure placed on medical services by a rapidly aging population.

Technology can provide information to identify a patient’s decline in condition. Telecommunications technology used to improve health is known as Telehealth. Decline in health addressed through timely intervention can prevent emergent care or unplanned hospitalization.

What is Telehealth?Telehealth includes telephonic communication,

telemonitoring, and teletriage to facilitate a timely response to urgent and emergent care needs. The telemonitor, a device placed in the home to transmit vital signs and other information via a telephone line or internet, is used to communicate with a health care provider. The telephone is used to contact the patient and have a dialogue about the patient’s symptoms. Teletriage is the use of telemonitoring information to plan an action addressing the patient’s needs. Telemonitoring provides trend information on declines that previously went unrecognized. A secondary use of the technology is to manage nursing resources effectively by providing visits when clinically indicated rather than scheduling in advance. Christiana Care Visiting Nurse Association (VNA) has improved home health care by implementing this technology.

How did VNA get started?The VNA joined Honeywell’s HomMed National

Telehealth Value Study in July 2005 as one of 32 home health agencies. VNA had no experience with telemonitors and was selected based on patient census, regional location and type of agency (non-profi t, for profi t, hospital-based, etc.).4 VNA’s leadership believed participation in the study would help assess effectiveness in patient care.

Sharon Charles, RN, supervisor and leader of the pilot, found that deploying 25 monitors throughout Kent and Sussex Counties required major planning as a small number of monitors effects every area of clinical and offi ce staff functioning. A new central station nurse as well as equipment moving logistics and infection control procedures had to be added. In addition, a condition of the study was adherence to a prescribed visit pattern. Therefore, the team must rely on daily transmitted patient data to manage care rather than more frequent visits. Sharon then ensured staff scheduling was fl exible in order to cover urgent care visits.

Gale Moore Bucher

Using Technology to Meet 21st Century Home Health Needs

Telehealth is used to empower patients to become experts on their symptoms. Agencies employing telehealth use tools such as weight and symptom diaries so patients can accurately identify when they are feeling worse and to gain an understanding of the meaning of symptoms.5 The nurse’s role shifts from instructor to coach as (s)he assists them with healthy lifestyle changes. Faye Collins, RN, our fi rst “tele nurse,” reported that her method of care is now focused on proactive patient education on self management from the fi rst visit. Faye devotes time teaching patients to identify changes in dyspnea or fatigue. She discusses symptom trends with her patients allowing them to understand the positive effect of adhering to a medical regimen. Daily use of the telemonitor provides an interactive tool to practice self monitoring that eventually becomes a habit.

The Telehealth Value Study required random selection of Medicare patients. The ACH rate for 83 randomized patients was 10 percent compared with the Center for Medicare Services’ risk-adjusted predicted rate of 28 percent.6 Following the study, VNA expanded from 25 to 100 monitors statewide. The patient population focus also shifted. Kent and Sussex Counties targeted high risk patients for hospitalization rather than random Medicare patients for telehealth. In New Castle County, high risk patients receiving telehealth have heart failure, post cardiac surgery, other cardiac, or chronic pulmonary diagnosis. The purpose of telehealth is aimed at providing additional support to our most vulnerable patients.

How does Telehealth work?At VNA, Medicare patients receiving home care

are provided with an in-home telemonitor as an adjunct to nursing visits. Patients receive training on how to transmit vital signs, pulse oximetry and weight measurement. Data is transmitted daily, via telephone to a central monitoring station where the patient’s clinical status is evaluated by a nurse. In addition, the patient is instructed to answer “yes/no” to 1-5 individualized questions regarding symptoms. For example, “Are your ankles more swollen today,” and “Are you more short of breath today?” Visits are front-loaded, meaning 60 percent of visits are completed within the fi rst two weeks of the home care episode. Frontloading has been effective in reducing ACH for patients with heart failure. A study published by Joanne Rogers, et. al, reported rehospitalization decreased by more than half (39.4 percent to 16 percent) for patients with heart failure, with fewer total visits (15.5 vs. 9.5).7 Frontloading allows instruction on self monitoring to be completed early in the episode and facilitates medical stabilization following hospitalization. Nursing visits are eventually weaned to every other week, and patients are encouraged to purchase a scale and blood pressure cuff to continue self monitoring after telemonitoring is discontinued.

What impact is Telehealth having on our patients?

Consider this patient’s telehealth experience. Mr. S. an 80-year-old gentleman, was admitted to VNA following hospital discharge for exacerbation of heart failure and pneumonia. Mr. S. also has a history of chronic obstructive pulmonary disease and is oxygen dependent. Mr. S. told the nurse he takes his medicines when he begins to feel bad. The home care nurse instructed him on medication management and to keep a daily diary of telemonitor information. The diary provided feedback to help Mr. S. understand the effect of medications and diet on symptoms. When the heart rate suddenly increased and Mr. S. reported worsening shortness of breath via telemonitor, a home visit was scheduled. The nurse identifi ed and communicated an irregular heart rhythm to the physician. An ECG showed that Mr. S. was in atrial fi brillation and a cardioversion was scheduled. Mr. S. returned to normal sinus rhythm following the cardioversion and was stable for a couple of weeks when the telemonitor showed a high heart rate and cardioversion was required again. When the patient reverted to atrial fi brillation a third time, the patient was scheduled for an ablation and diuretic medication was changed to prn due to the possibility that fl uid/electrolyte imbalance was contributing to atrial fi brillation. Telemonitor alerts were adjusted to make sure that any weight gain would cue the central station nurse due to the high risk for heart failure. For Mr. S., telehealth was used to identify the dysrhythmia early, avoiding clinical deterioration to more serious conditions such as syncope or a fall with injury. Telehealth effectively

facilitated appropriate medical interventions without hospitalization. Because of the positive outcomes during the two previous episodes of dysrhythmia, the cardiologist was confi dent that the patient could safety remain at home using telehealth.

Cheryl Alexander, RN, central station nurse, acknowledges the value of telehealth in helping patients with heart failure associate changes in pulse oximetry and weight gain with declining condition. Cheryl found that patients with advanced heart failure compensate for dyspnea by decreasing activity and the decline often goes unrecognized. When the telehealth patient sees a weight gain of 2 lbs. and a lower pulse oximetry reading, s/he recognizes this as a critical sign and as a result becomes proactive in managing their care.

Home care nurses are able to use telehealth to effi ciently identify and meet urgent care needs. As a result, fewer patients require ACH. For medically fragile patients, this means more frequent medical intervention, such as medication dose changes, as clinical information is communicated timely to the physician. Early intervention is key in reducing ACH and sparing further deterioration and suffering. Since 2005, over 1500 VNA patients have participated in telehealth. Fifty-nine patients surveyed during 2007 and 2008 related that they felt more in control of their chronic disease and that their physician was more involved in the care they received at home.

In 2007, VNA Medicare patients with telehealth care were compared with non-telehealth care patients:

• A primary home care diagnosis of heart failure required acute care hospitalization for any reason at 34.9 percent (N=126) compared with non-telehealth patients at 40.3 percent (N=253).

• The average case mix weight, a measure of disease and functional severity, were equivalent for patients in the telehealth and non-telehealth groups.

• Telehealth patients showed 64.4 percent improvement in self medication management at discharge compared with non-telehealth improvement of 50 percent.

• Telehealth improvement in dyspnea was 72.4 percent compared with non-telehealth patient group improvement of 59.5 percent. This improvement in outcomes for the telehealth patient group is attributed to prompt detection of abnormalities and intervention.

Who pays?Currently, telemonitoring is not reimbursable

by Medicare or third party payers in our area. At VNA, Medicare patients were selected to participate in telemonitoring due to the prospective payment for home care. VNA implemented telemonitoring as a care management strategy to position the agency for Pay for Performance and to improve utilization of nursing resources.

The effi cacy of telehealth for managed care companies was demonstrated by VNA. Three managed care Medicaid patients were selected for telehealth due to frequent hospitalizations. Two of the patients had heart failure and one patient had hypertension, diabetes, and depression. These patients had a combined total of 12 hospitalizations (85 hospital days) 12 months prior to telehealth. The patients received telehealth for varying lengths of time depending on individual needs: 48 weeks, 15 weeks, and 6 weeks. During telehealth, there was just one hospitalization (12 hospital days). The number of nursing visits per week pre-telehealth averaged 1.75 to 3 per week, and decreased from 0.65 to 1.30 per week during telehealth. VNA has used telehealth to manage care and fi scal resources effectively for high-risk patients. Managed care organizations can benefi t from collaborating with home care agencies using telehealth.

Top 10 StrategiesJule Holt, RN, branch manager and telehealth

program leader, has found that benefi ts of telehealth are maximized using the following strategies:

1. Start small to identify barriers and bridge gaps in communication between the central station nurse and team.

2. Establish a team of clinicians dedicated to the program. Include therapists on the team in order to meet needs for activity and therapeutic exercise. Make education a priority—insure the team is knowledgeable about nationally recognized standards of care and agency

continued on page 19


Delaware Nurses Association/American Nurses AssociationMembership Application

____________________________________________________________________________________________________ Name Credentials ____________________________________________________________________________________________________ Home Phone Work Phone ____________________________________________________________________________________________________ Home Email Work Email ____________________________________________________________________________________________________ Mailing Address ____________________________________________________________________________________________________ City, State, Zip ____________________________________________________________________________________________________ RN License # State ____________________________________________________________________________________________________ Employer/Address ____________________________________________________________________________________________________ Position/Title

Permission to print name in the Reporter as a new member? ❑ Yes ❑ No

___________________________________________________________________________________________________ School ___________________________________________________________________________________________________ Highest level of education

Return form to:Delaware Nurses AssociationOrchard Commons Complex

5586 Kirkwood HighwayWilmington, DE 19808

Membership Category (check one box)

Full Membership Dues ❑ Employed – Full-time❑ Employed – Part-time$229 per year, $19.59 monthly, electronically

Reduced Membership Dues❑ Not Employed❑ Full-time Student❑ New graduate from basic nursing education program, within 6 months after graduation (fi rst

membership year only)❑ 62 years of age or over and not earning more than Social Security allows$114.50 per year, $10.04 monthly, electronically

Special Membership Dues❑ 62 years of age or older and not employed$57.25 per year, $5.27 monthly, electronically

Dual Membership❑ RN holding membership in ANA through another state A copy of ANA membership card must accompany your application.$95.00 per year–State Only Membership $149.00

Methods of Payment❑ Full Annual Payment: Cash, Bank Card or Check made payable to the American Nurses Association❑ Electronic Withdrawal: Monthly electronic withdrawal from checking account (Authorization form on

ANA application—includes $6 service charge) _____________________________________________________________________________________________________ Visa/MC Number Expiration

AuthorizationThis is to authorize ANA to withdraw 1/12 of my annual dues from my checking account each month on or after the 15th day of each month, which is designated and maintained as shown by the enclosed check for the fi rst month’s payment. ANA is authorized to change the amount by giving the undersign thirty (30) days written notice. The undersign may cancel this authorization upon receipt by ANA of written notifi cation of termination twenty (20) days prior to deduction date as designated above.

_____________________________________________________________________________________________________ Signature for EDPP authorization

Apply online at www.denurses.org

Using Technology to Meet 21st...continued from page 18

expectations for management of patients with cardiopulmonary disease. Emphasize the need to address depression and psychosocial needs as these can be barriers to learning and self management.

3. Focus on at-risk patients to impact agency ACH rates.

4. Utilize a prescribed visit pattern and frontload visits to help patients become knowledgeable about identifying and reporting worsening symptoms early in the episode of care.

5. Utilize interactive patient education tools such as Quality Insights of Pennsylvania’s Heart Failure Patient Self-Care Workbook available from www.medQIC.org.8

6. Provide patients with a written emergency care plan. A patient friendly emergency care plan can be individualized and is available for use from www.medQIC.org.9 Caution patients that the telemonitor is not an emergency device and that a plan is needed to seek emergent care. Algorithms for addressing declines in telemonitoring are also available.

7. Communicate and collaborate with physicians and hospitals. Eliciting input from Mitch Saltzberg, MD FACC, and Lynne Bouffard, CFNP, DNP, the physician and nurse leaders from Christiana Care hospitals’ heart failure program was helpful in development of the program. A VNA telehealth nurse attends weekly rounds at the hospital’s heart failure unit, providing an opportunity to conference on shared patients and exchange information on what home care has to offer when they leave the hospital. VNA refers patients at discharge to the Christiana Care Heart Failure Telemonitoring Program, a telephonic case management service, for ongoing follow-up and support.

8. Provide a nurse to monitor the central station during weekends and holidays. These are times when home care patients are most vulnerable.

9. Evaluate program effectiveness through record review and case conferencing of hospitalized patients in order to utilize the full potential of telehealth technology. Look back for lessons learned and look ahead to revise the plan of care when the patient resumes home care. Analyze the current model/processes for optimal patient care management. Hold staff accountable for practicing according to protocols.

10. Collaborate with other home health agencies that have implemented telehealth. Nationwide, agencies have provided invaluable information on workfl ow processes, equipment selection, and understanding clinical outcomes.

Nurses who are knowledgeable about disease management and supported with adequate resources and technology can use telehealth to meet home healthcare needs well into the future. VNA telehealth nurses fi nd satisfaction in combining skill with technology to help patients manage their illness in the comfort of home and avoid the emotional trauma of hospitalization.

Clinical outcomes were provided through Strategic HealthCare Programs LLC, and record review.

References1. U.S. Census Bureau. Changes in total population and

population 65 and older by state: 2000 to 2030. Washington, DC: April 2005. Available at: http://www.census.gov/population/projections/PressTab4.xls. Accessed May 31, 2008.

2. U.S. Census Bureau. Population projections of the United States by age, sex, race, and Hispanic origin: 1995-2050, current population reports. Washington, D.C.: February 2006: No. P25-1130.

3. U.K. Department of Health. Government launches national debate on the future of care and support. National News. 12 May 2008. Available from: http://nds.coi.gov.uk. Accessed May 31, 2008.

4 & 6. Kevich M, Guiden M, Bucher GM. Telehealth reduces hospitalizations: creates secondary improvements for other quality measures. The Remington Report. 2007: July/August: 55-58.

5. Eastwood CA, Travis L, Morgenstern T, Donaho E. Weight and symptom diary for self-monitoring in heart failure clinic patients. Journal of Cardiovascular Nursing. 2007: 22: 382-389.

7. Rogers J, Perlic M, Madigan E. The effect of frontloading visits on patient outcomes. Home Healthcare Nurse. 2007: 25: 103-109.

8 & 9. Center for Medicare and Medicaid Services. Medicare Quality Improvement Community page. Available at: http://medqic.org/dcs/ContentServer?cid=11719745

83965&pagename=Medqic%2FMQTools%2FToolTempl

ate&c=MQTools. Accessed June 2, 2008.

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