MARCH ● APRIL ● 2013

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Compiled by| Jordan Colwell, MHA, BSN, RN

Contact| Jordan Colwell, MHA, BSN, RN

P 308.630.1450E Jordan.Colwell@rwmc.net

4021 Avenue B Scottsbluff NE 69361

rwhs.org

Find us on Facebook/RegionalWest

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Letter from the Editor 4

A Message from Shirley 5

Professional Developement 7

Linda Rock 8

Skin Care Note 9

Safety Sense 10

Breakfast with Shirley 12

Shooting Star Award 13

Lean Six Sigma 14

Shared Governance Updates 17

RCU to Close 22

Table of Contents

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Hello and welcome to the March/April edition of the Magnetic Times.

The past two months have been extremely busy for patient services shared governance councils. The council I would like to draw your attention to is Quality and Safety. This council led by Chair Liz Ossian, Chair-Elect Christy Jay, and Management Advisor Margo Ferguson have worked tirelessly for the past year on the new Nursing Peer Review Committee policy. The purpose of policy 718.0.06 is to ensure quality performance of direct nursing care to patients is measured and has a positive outcome. Some of the goals from policy 718.0.06 are to improve quality of care provided by individual nurses, identify system process issues, and enhance the practice of nursing and promote nursing as a profession. As an organization striving to become a High Reliability Organization, what

better way to identify if processes or practices need to be improved in order to achieve our overall goal.

In the upcoming months, this council will be looking for volunteers from all nursing disciplines to become members of the Nursing peer review committee. If you have an interest in guiding, coaching, and mentoring your fellow colleagues, please contact:

Liz Ossian at Elizabeth.Ossian@rwmc.net Christy Jay at Christy.Jay@rwmc.net Margo Ferguson at Margo.Ferguson@rwmc.net.

Please join me in congratulating this council on a job well done!

Yours,F. Jordan ColwellF. JORDAN COLWELL, MHA, BSN, RNSurvey Preparedness/Magnet Coordinator

Jordan Colwell

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Nursing Peer Review Nursing peer review has been in development at Regional West Medical Center for about a year. The old process, which involved having the Risk Manager, CNO, and a Clinical Nurse Specialist review cases to see if standard of care was met by nursing, has been revamped. The change is driven by a desire to have nurses who are currently practicing in a similar setting make the standard of care determination and any recommendations for improvement if they are indicated.

The process is educational, collegial, confidential, and non-punitive. It weaves together 1. looking for ways to improve quality, performance improvement, and 2. best practice by monitoring nursing practice performance at Regional West Medical Center. It encourages nurses to identify system process issues so they can be addressed. The goal of nursing peer review is to improve nursing care provided, and to enhance the practice of nursing at Regional West and as a profession.

The Nursing Peer Review Committee will meet monthly to review cases that have been referred by nurses, physicians, case managers, any member of the health care team, risk management, or quality resource staff. The committee is also working to develop triggers that would cause a case to automatically be reviewed. An example might be a patient who was not identified to be a fall risk, but fell. The review would look to see if the patient suffered an event that caused an unexpected fall, or was the screening inadequate to determine the patient was a fall risk? If the screening was inadequate, was it because the screening tool is not adequate, or the patient’s condition changed but they were not rescreened? Having nurses who are actually using the tools and doing the work can help identify changes that can make our patients safer. Ultimately, that is our purpose.

Shirley KnodelSHIRLE Y KNODEL, MS RNChief Nursing Office VP of Patient Care

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Save the Date Eager nurses answering Questions during the Joint Commission fair.

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F. Jordan Colwell, MHA, BSN, RN

SPECIALT Y CERTIFICATIONS

In December 2012 I officially graduated with my Master of Science degree in Health Care Administration.

I chose this degree of study because I would like to one day be a Chief Operations Officer and then Chief Executive Officer of a health care facility. I have always had a passion for health care and started off as a phlebotomist in a laboratory during high school, then as a Certified Nursing Assistant during college, and finally became a Registered Nurse.

The reason I chose to become a nurse is because I knew that I needed to see how to take care of patients before I get into administration. These experiences will help me make the tough decisions once I become a hospital administrator. Since the majority of the workforce in health care facilities are nurses, I needed to immerse myself in the trenches.

I also serve my country in the 34th Aeromedical Evacuation Squadron out of Peterson Air Force Base Colorado Springs, Colo. There I serve as a First Lieutenant

and flight nurse on the C-130 Hercules Airplanes. For me, there is nothing more humbling then to help our wounded warriors get back to the United States from abroad with great nursing care.

The one piece of advice I'd give a new nurse is to take the time to learn as much as possible from your preceptor. Remember to ask your preceptor the tough questions and know that one day you will be asked to be a preceptor to support the future of nursing.

I chose to be a nurse because I had my daughter at a young age so I knew that I needed a career choice that would be financially stable, but would also be rewarding and fulfilling.

I am a 1992 Alliance High graduate, a 1997 UNMC graduate, and completed the Wound, Ostomy, and Continence Nurse (WOCN) program in 2012.

I worked from 1995 to 1997 as a CNA in a nursing facility, from 1998 to 2003 as a staff nurse on an adult post-surgical unit, from 2003 to 2009 as Unit Manager of an adult post-surgical unit, and since 2009 as a wound care nurse in the acute care and outpatient wound clinic.

I am nationally certified as a CWOCN-Certified Wound, Ostomy and Continence Nurse. My training was in Atlanta, Ga. from Sept. 9 to Nov. 16, 2012. My clinicals included: in-patient acute care, outpatient wound center with a burn unit (with immediate surgical intervention as the surgery center was literally across a walkway), and the Atlanta

Children’s Hospital. I am grateful for the experience and educational opportunity I was given.

I feel I am blessed to have this position in nursing. There are so many different opportunities in nursing. Since the start of my nursing career, I have been part of the skin team at Regional West. I find wounds, ostomies, and wound vacs fascinating. Each day I am at work I have the chance to teach and assist patients during their visit. I love the fact that each day is different so I feel I learn something new every day. I truly can’t see myself doing anything else.

Some advice I would give a new nursing graduate just starting out is to learn the basics first and create a solid foundation. Become a well-rounded nurse before you specialize. Organizational skills are a must. Take in every experience as a learning opportunity. Remember we are here for the patients and are in the position to make patients more comfortable and educate them during their time with us.

Rachelle Noe, BSN, RN, CWOCN

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Linda Rock, executive director of Prairie Haven Hospice, was elected vice-chair of the National Hospice and Palliative Care Organization (NHPCO) and began her term in January at the organization’s first 2013 national meeting.

Rock has represented the Central Plains Geographic Area on the NHPCO board of directors for six years and has served in a variety of leadership capacities. As vice-chair she will continue to serve on the executive committee. In addition, she will chair the Public Policy committee and also serve on the board of the Hospice Action Network.

“I want to recognize Linda Rock, our incoming board vice chair. I look forward to hearing her bold voice this year, especially on behalf of the many important issues affecting small and rural providers,” said Ron Fried, NHPCO Board Chair.

The National Hospice and Palliative Care Organization is the largest nonprofit leadership organization representing hospice and palliative care programs and professionals

in the United States. The organization is committed to improving end of life care and expanding access to hospice care with the goal of profoundly enhancing quality of life for people dying in America and their loved ones.

Rock joined Regional West Medical Center as coordinator of Hospice Services in 1986 and became the executive director of Prairie Haven Hospice in Scottsbluff in 1997. She has served on the Regional West Medical Center Bioethics Committee and is past chairperson of the Scotts Bluff County End of Life Care Coalition. She holds a bachelor’s degree in Sociology and Psychology from Central Michigan University, Mt. Pleasant, Mich.

Rock is a member of the Nebraska Hospice and Palliative Care Partnership, and served as president of the Nebraska Hospice Association from 1996 to 2000. In 2005, she was awarded the Nebraska Hospice and Palliative Care Partnership Shining Star Award, and in 2012 she received the Nebraska Hospice and Palliative Care Association’s State Impact Award.

Linda Rock Named Vice Chair of the National Hospice and Palliative Care Organization

Linda Rock Director of Prarie Haven Hopsice

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Continued from page 8.

NEW-NEW-NEW

New ace-wraps-Velcro on each end. No more metal clips.

Calmoseptine and Silvasorb gel is now in the Meds pyxis.

There is a wound nurse available Monday through Friday. Call, page, text, refer, consult.

New KCI negative pressure wound vac therapy machines coming soon. It has the ability to instill antibiotic therapy.

Save the Date: Wound Care Conference at the Harms Center on Tues., October 10 from 7:30 a.m. to 5 p.m. The conference offers CEUs and many vendors with hands-on training. More information to come!!!

———————————————————————————————

Did you know coding can only document two things out of a record that are not written by the licensed medical provider? One is the staging of pressure ulcers.

Wound staging affects the Diagnosis Related Group (DRG) and how the hospital is paid.

Each patient is assigned a DRG based on his or her principle diagnosis, which then determines what the relative weight (RW) for the case will be.

For hospital reimbursement the RW is multiplied by our DRG base amount and that is how much Regional West is paid, regardless if the patient is here four days or 40 days (there are a few exceptions).

Example #1: An 80 year old female comes in with pneumonia and a pressure ulcer on her coccyx.

DRG-195 Simple Pneumonia and Pleurisy without CC/MCC

RW-0.7078

Average length of stay projected: 3.5 days

Reimbursement: $4954.60 (even if she is here two weeks)

Example #2: An 80 year old female comes in with pneumonia and has a documented Stage III pressure ulcer on her coccyx (this is the same patient, just different documentation).

DRG-193 Simple Pneumonia and Pleurisy with MCC

RW-1.4893

Average Length of Stay projected: 6.3 days

Reimbursement: $10,425.10 (same patient just two words added)

Please notify the wound care nurses when your patient is admitted to Regional West with a stageable wound so it can be documented appropriately in the progress notes.

** It should be noted these wounds need to be documented upon admission to each unit or it is presumed that we, Regional West Medical Center, caused the wound and therefore will not be reimbursed!

By Rachelle Noe, RN

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Have you ever thought about why we act the way we do? Why we respond the way we do? It’s culture. We all have a ‘culture’ and each separate group we are involved with has a ‘culture.’ Groups like the church you attend, your family compared to the family next door, and each school classroom. All are groups that have their own ‘culture.’ Culture is what we value and believe to be important. We hear this word a lot in the safety realm, about how we are trying to “change the culture.” To help us understand this word better, let’s take a look at the dictionary definition.

The World Dictionary1 defines culture as:

• The behaviors and beliefs characteristic of a particular social, ethnic, or age group: the youth culture; the drug culture.

• The total of the inherited ideas, beliefs, values, and knowledge, which constitute the shared bases of social action.

1 bit.ly/XLFJOt

• The total range of activities and ideas of a group of people with shared traditions, which are transmitted and reinforced by members of the group: such as the Mayan culture.

I look at this definition and see behaviors, beliefs, values, inherited ideas, and knowledge, all which are transmitted and reinforced by group members.

We don’t think of Regional West Health Services and its entities as having a culture, but we do. Each entity, Regional West Medical Center, Regional West Physicians Clinic, Foundation, RCI, Hospice, etc. as well as each department within those entities, has its own set of values and beliefs—culture.

Each area reinforces those values and beliefs with its members and newcomers. These values and beliefs drive how we behave which in turn, drives what we produce—our outcomes. For example, if we value our lunch break that behavior translates into making sure everyone gets their lunch break. If we value and believe that patient satisfaction is

Susan BackerSUSAN BACKER, MSN, APRN‑CNS, ACNS‑BCPatient Safety Officer/CNS

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important, then we will be friendly to patients and visitors and go out of our way to see that their needs are met to the best of our ability.

The same holds true with safety. If we value keeping patients safe, the environment safe, and each other safe, then our actions and behaviors will reflect that. We will:

• Keep an eye out for things in the environment that are safety hazards and report what needs to be fixed.

• Help co-workers with lifting or provide just-in-time coaching before they use improper lifting techniques.

• Take measures to keep patients from falling.

• Communicate clearly with other health care providers.

• Foam in and foam out, every time.

• Round with purpose.

• Uses two patient identifiers on admission, prior to tests, treatments, medications, and procedures.

• Use job aides so we don’t miss a step in a process.

• Seek help from others when we don’t know.

• Verify information when something just doesn’t seem right or make sense.

• Watch out for each other and step in before a mistake occurs.

• Speak up for safety.

• AND THE LIST GOES ON……

Data from our cause analysis program shows the number one System Failure Mode that contributes to errors in our hospital is Culture and it is defined as:

The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance. (HPI (2006). Common Cause Analysis. System Failure Mode: Culture)

My challenge to you is this – Let’s all work together to change our mindset and set the expectation that we will do what it takes, practice the tools we have learned (STAR, Job Aides, SBAR, 3-Way Repeat Back, Validate and Verify, Speak Up for Safety, etc.) to provide the safest care possible to all our patients. Their lives depend on it.

Together we can make a difference!

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Employee Breakfast | February 26

Attending: Mary Coon, Kendra Vera, Jen Hooton, Amy Henke, Amber Gomez, Nina Grubbs, Amber Sandine, Sandy Hebbert

Questions, Concerns, etc.:

• Shirley explained to the group that our target goal to be ready to submit our application for Magnet designation is December 31, 2015.

• In regards to report times; what are the actual times nurses need to be present to get face-to-face report before going out and working? Nursing Leadership to standardize the practice so everyone knows how early they can clock in and need to show up for working the floors.

• A question was asked about the float pool and if it was full. Shirley explained that Sarah Shannon will be hiring more staff into the float pool. We are looking at hiring new graduates into the float pool with float pool RNs functioning as preceptors in order to supplement our number of preceptors.

• Shirley gave an update regarding the rumors of RCU closing.

• A question was asked about holiday pay, specifically, “Why, if someone is required to work the day shift of Christmas Eve, or the Friday of Thanksgiving, are they not paid holiday pay?” Shirley explained each of the six designated holidays are paid for the day of the holiday and in recognition of the night shift staff having to work, the night before the

holiday is paid. Example being Christmas Eve night shift and Christmas Day shift. She explained separate from pay practice policies, each floor’s unit practice councils or staffing committees decide on how to schedule staff.

• A second question was raised regarding why staff members are paid time and a quarter for holiday pay instead of time and one half. Shirley looked for the policy on holiday pay but was not able to pull it up in a timely manner, so asked the staff member to have this conversation with an HR representative. Post meeting note, this policy is not on the campus homepage so Shirley contacted HR to request this be addressed as well as a meeting with the staff nurse to review the policy.

• A question was asked about how policies and procedures are updated and the need for accuracy. An example was given of a procedure that has the steps out of sequence. Shirley explained the process of procedure updating utilizing Mosby’s on line subscription, but we need staff nurses on the committee to ensure we do have the right steps and in the correct sequence. This staff member graciously agreed to be part of the policy and procedure committee to help with this (Thank you Jen!).

• A nurse asked if the Pediatric Unit would ever get a new unit. Shirley discussed she is working with David Griffiths of the possibility of turning the north wing of the RCU into the pediatric unit. It would require remodeling and will require sprinklers, etc. so we want to get cost estimates and consider it as part of the budget process. It would not happen quickly but we will begin the process.

• One nurse asked about the different pay grades for nurses with associate degrees vs. nurses with bachelor degrees, and wanted to know why we don’t pay nurses with bachelor degrees more. Shirley explained this is a problem with nursing as a profession. Nursing needs to make a decision about entry into practice requirements in relation to licensure. Shirley also explained the clinical ladder, which is managed by the Professional Practice Council, is being reviewed again to focus more on continuing education and certifications and less on tasks. Please give your feedback to the Professional Practice Council.

Shooting Star Department Nomination

Award: Honorable Mention

Recently, the entire staff of 2 West was recognized by a patient because, as the patient said, “You can’t pick one! They were all great.” This patient went on to praise the professionalism and the feeling of safety she had

during her stay thanks to the staff of 2 West. Congratulations to the staff and support staff of 2 West on being recognized by a patient for outstanding care. I’d say you definitely exceeded her expectations!

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What is Lean Six Sigma? That question is being asked frequently around Regional West Health Services.

It is a process improvement method that focuses on reducing variation and eliminating waste. The central focus and drive used is the “Voice of the Customer”. We are looking for ways to reduce complexity and use an integrated team approach to problem solving. This means that a project team will include front line staff who perform the process on a regular basis. They will help find the variation and waste and design new processes which are usable and timely. A control plan is developed after improvements are put into place so that the process can be managed and not slip back into inefficiency.

One current project that exemplifies this method is the “Direct Admit Patient Flow” project. Kim Meininger brought together a team comprised of RWMC and RWPC staff. Its goal is to clarify the roles of

clinic nurse, floor nurse and admissions staff when patients from the clinics are admitted to the hospital. As a team, a flow was developed that utilized the work flow already established in the Transfer Center. These improvements ensure a timely admit for our patients. The patient will now be escorted to their hospital room by the clinic nurse and the admission department will meet them at the room so that their family members are not separated from them during the admission process. This will also allow for the clinic nurse and hospital nurse to have a face-to-face handoff which ensures a high level of safety and quality for the patient. It is a process change that truly puts our patients and their families first but also assists our staff to do their work more efficiently. Be looking for more examples of Lean Six Sigma projects going on throughout the Regional West Health Services system!

Lean Six Sigma at Regional West Martha StrickerMARTHA STRICKER, BSN, RNLean Six Sigma | Community Health Manager

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Order to Direct Admitreceived from Health Care

Provider

Office Nurse callsTransfer Center at

x1577

Transfer centercoordinates callbetween House

Supervisor, OfficeNurse and ReceivingUnit Charge Nurse

Office Nurserefers to House

SupervisorTransfer Sheetfor appropriate

data

While on call,House Supervisor/

Charge Nurseconfirms Unitassignment

House Supervisoravailable?

Transfer centerincludes approopriate

receiving Unit andupdates House

Supervisor whenavailable

Charge Nurseassigns bed

Unit Nursereceived SBAR

form from ChargeNurse

Office nurse donewith call; prepsNextGen SBARreport to go with

patient

Transfer Center contactsMain Admissions at x1388 to notify of admit

and room number

Patient Escorted toAppropriate Unitby Office Nurse

Office Nurse andUnit Nurse hold a

face to faceHandoff

Admission –Assign staff to go

to room andcomplete bed side

admissionEstimated time of

arrival??

Behaviorial Health– call directly from

RWPC; no useTransfer Center

Women’s Center –Do not use

Transfer Center forOB patients due tobeing pre-admitted

NO

YES

Direct AdmitComplete

Admission processcomplete so that

nursing may begincharting

While on call,Office Nurse giveHandoff (SBAR)to Receiving Unit

Charge Nurse

For an emergencysurgery, each RWPC

site will utilize anindividualized

process

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Shared Governance Council Updates January 2013Coordinating Council (CC) New Business

Public Relations: Begin working with Marketing to develop a Brand for Shared Governance that can be used for recruitment, projects, web design, publications, etc. Magnet Fair: Coordinating Council will be assisting with planning the Magnet Fair. New Council: CC approved the formation of a new council to address/support resource management as it relates to nursing.RN Satisfaction Survey: The survey will be reviewed at the February meeting.

Old BusinessShared Governance Model: Continuing review of current Shared Governance Model and what updates are needed as Shared Governance at Regional West evolves.

Nurse/Physician Council (NPC)New Business

Dr. Sorensen will be speaking at their February meeting (Feb. 21 at 7 a.m.)

Old BusinessRecruitment: The council is working hard to recruit new members. Katie Metz, PA-C has joined the council.

Projects and StatusCurrently looking for a small project to embark on that will ensure success as the council is regrouping and gaining new membership.

Considering work on a Provider ID book for each department that provides a photo and identifying information for providers. Working with Amy Potts in the Medical Staff Office to recognize Physicians on Physicians Day, which is March 30.Also looking at how the council can support the HEO transition.

Quality and Safety Council (QSC)New Business

Working on recruitment of new members.Old Business

Liz has been working with the UPC Chairs on 2nd and 3rd floors related to hand hygiene and interventions.

Projects and StatusRecommendation for Nursing Peer Review has been sent to Shirley for review. Next steps for the project include the selection of committee members and developing an education plan.

Professional Practice Council (PPC)New Business Low Census Nurses Day Awards Social Media Position Statement Hospital Dress-code policy 205-0-02Old Business Clinical Ladder has been updated and is available on f:drive and Campus Home Page

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Projects & StatusLow-Census: Recommendations will be made about the following issues so that the directors who have been working to finalize the low-census policy can complete the project. We will address the following three issues: how long a nurse has to be ‘on-call’ must be to count it when low-censused, what should the minimum ‘call-in’ time be when you have been placed on-call and then are called-in, and should low-census on-calls always count as ‘on-call’ or not.Nurses Day Awards: Will set up publicity and deadlines for this year’s awards.Social Media Position Statement: Articles have been shared the council about the benefits and pit-falls of Social Media in health care. Possibly will need a work session specifically scheduled to finalize a position statement.Hospital Dress-code policy 205-0-02 Review: policy is due for review and per request of Susan Backer we will briefly review today, with plan for thorough review in February.

Care and Practice Council (CPC) New Business

Clinical Value Analysis has requested a recommendation statement regarding the discontinuation of the use of Pall filters for blood transfusion. The committee will be looking at the recommendations from the Blood Bank as well as literature as it relates to nursing practice and blood transfusion. In addition, a recommendation to a multidisciplinary convene to make the final determination was made. There are many stakeholders who should be given the opportunity to weigh in on the recommendation that will be taken to Clinical Value Analysis. We will identify members from the council to participate in the multidisciplinary discussion as it relates to nursing practice as well as providing an overview of the discussion during the council meeting.

Old BusinessCare and Practice Council Retreat took place on January 9. The purpose for the retreat was to focus on the Falls Prevention Program and make significant progress toward completion. We had excellent attendance from council members and the work objectives were achieved. We will be evaluating of the usefulness of the retreat.

Projects and StatusFall Prevention Program: Due to contract issues, the council will be looking at alternate risk assessment tools for use at Regional West. Once the evidence has been reviewed, the council will make a recommendation regarding the risk assessment tool which appears to be the best fit for Regional West Medical Center. The council will continue work on the project as soon as a risk assessment tool is identified, presented to leadership, and agreed upon.

Evidence-Based Practice Council (EBPC)New Business

Possible work day for fatigue literature review.Old Business

EBP has taken on the fatigue project.EBP council survey has been distributed.

Projects and StatusFatigue recommendation: Literature review is complete. Articles have been gathered. Council will be dividing articles by level of evidence today and distributing articles to members to review for literature review summary table. Possible work day to follow to compile all articles in the summary table. Council will decide on goal date for recommendation.EBP Survey: Surveys have been distributed to many units. Many surveys have been returned. Emailed surveys did not have high return rate. We still need surveys from 2nd and 3rd floor. Plan is to distribute at next staff meeting. Data collected will be compiled in spreadsheet format.

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Night-Shift Council (NSC)New Business

Will be working on Charter, Mission, and Vision statements at the next meeting scheduled for January 30.

Projects and StatusWill determine what project to undertake.Shared Governance

February 2013Coordinating Council (CC)New Business

Public Relations -The Brand for Shared Governance will be revealed at the March council meeting with the Magnet Fair flyers as the first activity to use the new Marketing/PR materials.Magnet Fair-Coordinating Council will be assisting with planning the Magnet Fair. New Council-CC approved the formation of a new council to address/support resource management as it relates to nursing. Shirley and David Griffiths will meet with Nursing Directors on March 12, to discuss purpose, structure and membership. Following the March 12 meeting, Shirley and Jordan will coordinate a workgroup to begin developing the structure and functions of the council. Members for the workgroup have been identified and will be invited to participate. RN Satisfaction Survey-Susan Backer presented the facility overview data for the survey. Shirley discussed two areas of opportunities for Shared Governance involvement with idea of engaging in activities to raise awareness with the goal of improving satisfaction (satisfaction scores).

Old BusinessShared Governance Model-Continuing review of current Shared Governance Model and what updates are needed as Shared Governance at RWMC evolves.

Nurse/Physician Council (NPC)New Business

Dr. Sorensen presented on National Healthcare Reform and what potential impact RWMC might see. Currently, the organization is looking as ways "to do better". An important focus for all staff at RWMC is correcting misuse through the Safety Culture Initiative.

Old BusinessPhysician's Day is March 30. The council continues work on Physician's Day activities. There will be banners and the council asks that staff sign as a note of their appreciation.

Projects & StatusThe council continues to explore projects.Quality & Safety Council (QSC)

New Business Poster for Magnet Fair for Nursing Peer Review (NPR)

Old BusinessPeer Review Committee Policy was approved by the Policy/Procedure committee this month.

Projects & StatusPeer Review - Members worked this month on developing educational morsels (talking points) for educating staff members on peer review. This includes “What is NPR?” “What does nursing peer review involve for the nurse who is on the NPRC?” and “What does NPR mean for the nurse whose care is under review?” We hope this will help us while recruiting nurses to be on the committee itself as well as prepare nurses for being “called to appear.” Hand Hygiene–Backburner, but need to move forward because this is part of 2013 Core Measures. Condition Help–Backburner

► Continued to page 20

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Professional Practice Council (PPC)New Business

RN Job Description: We have invited Jane Wisniewski to be present at our meeting to help us review/revise the current generic RN job description.

Old BusinessNurses Day Awards: Jordan Colwell has sent out mass emails with nomination information to management staff and Marketing has posted information out on the Campus Home Page. Deadline for applications was March 18. PPC members will review the applications at the March meeting. Winners will be announced this year in April in their respective departments with a cake, plaque and management staff and announced to the general public on 3rd of May, at the Magnet Fair.

Projects & StatusSocial Media Position Statement: The Social Media ‘workday’ was cancelled. A new date will be selected; the goal is to have this completed by April.Hospital Dress-code policy 205-0-02 Review: This was tabled last month due to time constraints. The current policy will be reviewed today, and a response sent to Sue Backer if there are any critical changes that need to be made, with plan for a complete revision to be made after the Uniform Pilot Study is completed.Low Census Recommendations (completed at Jan. meeting and sent to Sarah Shannon): How many hours does a nurse have to be home on-call to count it as on-call time? ‘On-call’ will count if the staff is home for one-third of their scheduled shift (i.e. 4 hours for a 12 hour shift). What is the minimum ‘call-in’ time once you have been called to come into work? Call response time for emergency access staff continues to be 20 minutes. All other nursing unit call-in response time will be 30 minutes.; Should

low-census on-call always count as on-call (regardless of days scheduled to work)? As long as the staff has been home on-call the minimum required hours (one-third of their scheduled shift) the on-call will always count (regardless of the days scheduled to work).

Care & Practice Council (CPC) New Business

The council has scheduled a workday on Wednesday, March 27, to finish development of the Fall Prevention Program. Upon conclusion of the workday the council will begin to solicit feedback on the ease of understanding and use from end-users as well as additional reviews and approvals prior to pilot, house-wide education and go-live.

Old BusinessFall Prevention Program: The council reviewed the evidence related to alternate fall risk assessment tools for use at RWMC. The council's recommendation regarding the risk assessment tool which is the best fit for RWMC continues to be the H2M. The recommendation was discussed and evidence provided to support the recommendation.

Projects & StatusApproval has been given to sign the contract and move forward with the implementation of the H2M as the fall risk assessment tool at RWMC. The Council will continues to work on the project including policy and procedure development, job aid development, education planning and go-live planning.

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Evidence Based Practice Council (EBPC)New Business

Review EBP Toolkit on homepageOld Business

Journal ClubFatigue RecommendationEBP Survey

Projects & StatusFatigue recommendation: Continue the review of literature. Original search terms did not produce the high quality evidence needed. Many of the articles have been level six or seven. Research studies in references of these articles will be pulled to review. Originally the council wanted to have a recommendation at this meeting. Will not have a recommendation at this meeting.EBP Survey: Much of the data has been compiled. Will distribute surveys to 2nd and 3rd floor at education days in April.Journal Club: In the planning phase.

Night-Shift Council (NSC)New Business

The council made revisions to the mission and vision statement. The council continues to work on growing the membership. Each member was asked to bring a "buddy" to the March meeting as a recruitment activity.

Projects & StatusThe council had selected its first project. The council will be working with Lori Miller in Food Service to look at the night food cart and how the food offerings can be improved for employees working the night shift.

Top: Dr. Sorensen speaking to the Nurse/Physician Council. Bottom: Night Shift Council members.

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Regional West Medical Center to Close Skilled Nursing Unit

Regional West Health Services announced the upcoming closure of its Restorative Care Unit (RCU). The unit, which opened 26 years ago to provide short-term skilled nursing, is closing due to declining usage and the need for major renovations to comply with new skilled nursing regulations. The last patients will be admitted to the RCU on March 30 and the unit will officially close on April 15.

Hospital President and CEO Todd Sorensen, MD, MS, expressed regret that the decision had to be made.

“For the past several years, we have been researching the best and most cost-effective way to upgrade the unit to meet new standards and codes in order to continue skilled nursing care at Regional West, but new regulations, increasing costs, changes in health care reimbursement, and the availability of skilled nursing care at other local facilities have eliminated that option,” said Sorensen.

“We are committed to the needs of the many of patients who require a period of skilled nursing care before returning to their homes, so we have been carefully researching options for partnering with local long-term care facilities to provide that continuum of care for our patients,” he said.

All employees of Regional West Medical Center’s RCU have been informed of the unit’s closure and all have been guaranteed employment in other departments or in the float pool. Most employees have accepted positions within the Medical Center.

The inpatient dialysis unit and offices located on the east wing will remain open in their current location.

The Restorative Care Unit opened in September 1987 to provide skilled nursing care for hospitalized but non-acute patients. Throughout the years, many dedicated nurses, aides, and other employees have provided compassionate rehabilitative and restorative care for thousands of patients who were healing, but not quite ready to return to their homes following hospitalization. The RCU provided a vital link in the continuum of care.

“The RCU has a well-deserved reputation for providing personalized care to help patients prepare to return to their homes. I am personally grateful to all of the employees–past and present–who cared for our RCU patients and helped them regain their strength and their ability to return home,” said Sorensen.

Skilled Nursing Unit to CloseBy Joanne Krieg, Marketing and Public Relations Department