nursing annual report - ssmhealth.com nurses/2016...nursing annual report. ... strategic direction...

IN OUR HANDS

Nursing Annual Report

Table of Contents

CNO/VP Nursing Welcome Letter ...................................................................................................................................................................... 1

SSM Health Mission, Vision and Values ........................................................................................................................................................2

Nursing Professional Practice Model...............................................................................................................................................................3

1. Transformational Leadership ...................................................................................................................................................................4

Mission Possible .............................................................................................................................................................................................................4

TeamSTEPPS ....................................................................................................................................................................................................................4

Rising Leaders .................................................................................................................................................................................................................4

2. Structural Empowerment ...............................................................................................................................................................................5

Jill Fine Lighthouse Nursing Excellence Awards ..........................................................................................................................5

Mission in Motion Award .......................................................................................................................................................................................7

DePaul NL2020 Scholarship Recipients ................................................................................................................................................7

Professional Nursing Organization Membership ...........................................................................................................................8

Certifications Earned ................................................................................................................................................................................................9

Futures Program ..........................................................................................................................................................................................................11

3. Exemplary Professional Practice ......................................................................................................................................................... 12

Shared Governance .................................................................................................................................................................................................. 12

Moment of Silence ..................................................................................................................................................................................................... 12

Table of Contents (continued)

4. Exemplary Professional Practice ......................................................................................................................................................... 13

Inpatient Value Stream Accomplishments ....................................................................................................................................... 13

Statistics: Hospitalist — Number of Avoidable Days/Month ............................................................................................. 13

Focus on Wound Care ...........................................................................................................................................................................................14

Statistics: Hospital-aquired Pressure Ulcers (HAPUs) ............................................................................................................14

Statistics: Falls with Injury with BHS ........................................................................................................................................................14

The DAISY Award .......................................................................................................................................................................................................14

External Recognition of our Clinical Excellence .......................................................................................................................... 15

1

CNO Nursing Welcome Letter

Dear Nursing Colleagues:

It is my privilege to present the 2016 SSM Health DePaul Hospital

Nursing Annual Report. The magnitude of our nursing staff’s

accomplishments this past year is admirable. Congratulations on

a successful 2016!

Throughout the year, our caring and compassionate nurses

delivered exceptional care to our patients and families,

while demonstrating their commitment to high patient safety

and quality standards. Additionally, our nurses are committed

to advancing the nursing profession through inquiry,

evidence-based practice and excellent patient outcomes.

Nurses at DePaul Hospital embody passion as transformational leaders,

grounded in exceptional professional practice, shared governance

and sound decision-making at both the entity and the unit level.

They inspire knowledge acquisition and innovation at all levels

of the organization.

Nursing’s continued dedication to enhancing our LEAN journey

to reduce repetition and redundancy in the workplace, along with

our commitment to place our patients as our top priority,

ensure we as a nursing body emulate our Mission to provide

exceptional care.

It is through our nurses’ compassionate hearts, knowledgeable minds

and skilled hands that our patients perceive us. I am honored and

privileged to work with such incredible and compassionate nurses.

Warmly,

Shelly Cordum, MSNR, RN, CENP

SSM Health DePaul Hospital – St. Louis

2

SSM Health Mission, Vision and Values

SSM Health Mission, Vision and Values

Mission

Through our exceptional health care services, we reveal the healing presence of God.

Vision

Through our participation in the healing ministry of Jesus Christ, communities, especially those that are economically, physically and socially marginalized, will experience improved health in mind, body, spirit and environment within the financial limits of the system.

Values

Respect We respect life at all stages and promote the dignity and well-being of every person.

Compassion We reveal the healing presence of God through compassionate care focused on the fullness of the person.

Excellence We provide exceptional care and service through employees and physicians dedicated to our Mission.

Community We cultivate relationships that inspire service and promote justice in our organization and throughout our communities, with special concern for the poor and marginalized.

Stewardship We use our financial, human and natural resources responsibly and care for the environment.

Strategic Direction for NursingProfessional Nursing Practice at SSM Health creates an innovative environment for

the achievement of exceptional outcomes while advancing and contributing to the profession. We partner with patients, families, providers and each other,

using practices that are restorative, supportive and promotive in nature. SSM Health is the preferred partner for care across the health continuum.

Our Miss

ion: Through our exceptional health care services, we reveal the healing presence of God.

Shar

ed Leadership • Relationship-Based Care

Nursing Professional Practice Model

EXCEPTIONAL Experience • People • Value

I am aleader

I am anadvocate

I amaccountable

I am apartner

I am aprofessional

I am an SSM Health Nurse

Patient and

Family

Sacred Trust

Our V

alues

: Compassio

n • Respect • Excellence • Stewardship • Community

3

Nursing Professional Practice Model

4

Transformational Leadership

1. Transformational Leadership

Mission PossibleSSM Health DePaul Hospital’s lean journey started in February 2015 with our campus executive leadership joining forces to identify opportunities for improving patient throughput and satisfaction. With their guidance, two distinct areas of focus were determined: the current practices in the ED and inpatient units related to patient throughput. Each month, multi-disciplinary teams are established to strategize process improvements for each of the focus areas using lean tools. Engaging front line staff and using consistent methodology creates a culture ready for change.

After two years, more than 158 staff and 72 leaders have been involved in process improvement events.

While throughput challenges remain a concern, because of lean process improvement efforts our patients are being seen sooner by an ED provider, are waiting less time for an inpatient bed, and are being discharged in a more timely manner from both the ED and the inpatient units.

Other positive outcomes from lean process improvements have been increased staff engagement and improved communication among multi-disciplinary teams.

TeamSTEPPSIn 2016, the nursing leaders and staff at DePaul Hospital embraced a patient safety initiative known as TeamSTEPPS®, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety. TeamSTEPPS® is an evidence-based teamwork system focused on optimizing patient care by improving communication and teamwork among health care professionals, including front line staff. TeamSTEPPS® addresses and promotes the delivery of high-quality interdepartmental communication and handoffs. In 2016, training of all inpatient units was completed as well 60 percent of all employed physicians. Techniques such as huddles, briefs, debriefs, SBAR, “CUS” words and “stop the line” behaviors have become part of the everyday culture of safety at DePaul Hospital.

Rising LeadersIn 2016, we identified three nurses as high performers with tremendous leadership potential. Ashlynn Rushing, Katie Collings and Chris Engelbart were nominated and accepted into SSM Health’s Rising Leaders program. This program is designed to enhance and further develop natural leadership qualities. Ashlynn feels that this program has enabled her to be more self-aware of how she is as a person and how she can use those skills and qualities to become a better leader.

5

Structural Empowerment

See our additional honorees on following page.

Patient Care

Heather Nannie

3 South

Leadership, Coaching and Mentoring

Eileen Pierron

Emergency Department

2. Structural Empowerment

Jill Fine Lighthouse Nursing Excellence AwardsThe award was established in honor of Jill Fine, who began working at DePaul Hospital in 1979 as a staff nurse in the ICU. From 1979 through 2013, she continued to work at DePaul Hospital as a nurse clinician, nurse manager, director and clinical educator in the critical care areas. She was a compassionate nurse, expert educator, supportive colleague and superb mentor to many.

The lighthouse was chosen as the symbol to represent this award because of Jill’s long-time love of lighthouses. Jill and her husband spent many vacations driving up and down different coastlines visiting and photographing lighthouses all over the United States. A lighthouse symbolizes various things such as overcoming challenges and adversity or guidance. Jill’s light was always shining — even through clouds and fog.

2016 Award Winners: Patient Care | Leadership, Coaching and Mentoring

6


Rising Star

Michelle Reese

6 North

Tori Puder 6 South

Innovation and Evidence-Based Practice

Cindy Bauer 2S, 7N, 7S

Jill Fine Lighthouse Nursing Excellence Awards

2016 Award Winners: Rising Star | Innovation and Evidence-Based Practice

7


Mission in Motion

Julie Meyer, RN Endoscopy

Mission in Motion Award

Julie Meyer consistently displays care and compassion for patients and their families and is a great patient advocate who exemplifies SSM Health’s Mission. Just one example is when she encountered a patient whose glasses were beyond repair. Because the patient could not afford new glasses, Julie worked with an eye doctor’s office to secure a new pair of glasses for the patient for under $10.

DePaul NL2020 Scholarship Recepients:

Anne Green BSN Kathy Furlong VA-BC

Mariann Dinello CCDS Certification Leslie Lawrey BSN

Cynthia White CCDS Certification Ruby Smith SCRN

Jennifer Dawson BSN

SSM Health DePaul Hospital NL2020 Scholarship Recipients

8


Professional Nursing Organization Membership

MONL ANA AONE NAON AACN Other

Cindy Bauer • AANN

Amanda Ben •Christian Boyce •LuAnn Connor •Sue Denningham •Cindy Duggins •Stacie Estes-Collins •Whitney Fugate •Jennifer Geno •Robin Gilder • •Lindsay Griggs •Amanda Gruen • AWHONN

Kiyoko Guthrie •Veronica Harlston •Mary Kelly •Laura Klaus •Sam Kohler •Erin Krupinski •Macy Marsonette • •Meredith Masin •Stacy Miller •Shannon Olson •Nancy Roach •Ashlynn McQuiggan •Nikita Schellhardt • ENA

Erin Spees •Jason Stacey • • •Kathleen Waeckerle •Rachel Walker •Katherine Wurm •

9


Continues on following page.

Certifications Earned In March 2016, we celebrated 83 certified nurses.

Lisa Boyle ONC Nancy Roach CCRN-E, CNML

Mary Connelly ONC Larry VanHook ONS

Lisa Hughes ONC Andrea Coster ONS

Angela LeMarr ONC Pat Finch ONS

Erica Melton ONC Ruth Kiambuthi ONS

Gwen Oteh ONC Tammy Gierer ONS

Yolanda Parker ONC Lea Anne Banholzer RNC-EFM, inpatient OB

Mary Reedy ONC Dianna Battcoletti IBCLC

Emily Brame ONC Shannon Dexter IBCLC

Amber Childress ONC Terry Markel RNC-EFM

Robin Gilder ONC Lynn Baker CNOR

Lauren Gumm ONC Michelle Brown CAPA

Rhianna Juge ONC Andrea Coster CNOR

Laura Kramer ONC Nina Dotson CNOR

Lauren Weinreis ONC Sharry Johns CNOR

Sarah Wolf ONC Karen Lightfoot CNOR

Christine Heady CWOCN Junietta Shough CNOR

Amanda Barich ONS Della Smith CNOR

Debbie Bohne OCN Bob Streb CNOR

Julie Buie ONS Carl Glenn CNOR

10


Certifications Earned (continued) In March 2016, we celebrated 83 certified nurses.

Maureen Flachs CHTP Nancy Goewert CAPA

Dana Foley CDE Mary Kelly CNOR

Peggy Guilfoy ONS Patty Scott SGNA

Dawn Montgomery OCN Karen Tucker CNOR

Mary O’Neil CHTP, CHTI Javier Turkieltaub CNOR

Saydi Rempfer ONS Don Davis CNOR

April Schulte CWONVictoria Horowitz-Denger

CNOR

Jason Stacey NE-BC Carol Tipton CNOR

Sharon Todd HPCN, CPM Stephanie Walsh CNOR

Christie Tress ONS Uma Konala CCRN

Mark Wagner AVA Ryan Rozycki CCRN

Denise Waitulavich ONS Melissa Weldon CCRN

Lloyd Ferguson ONS Michelle Belgeri CCRN

Michelle Fortner ONS Jared Holten CCRN

Machelle Hunter ONS Sharon Millsap RNBC

David Langford ONS Eileen Thompson Med/Surg

Tracy Robinson ONS Nancy Jackson CNRN, SCRN

Jill Vahey ONS Johanna Armstrong CNL

Katie Wurm ONS Lis Neise CEN

Kathe Russo TNS Amanda Gruen RNC-EFM

11


Futures

The future of nursing relies on the nurses who are entering the field from nursing schools. It is our strong commitment to the successful transition of these nurses from the school to the hospital setting that makes the Futures program successful at SSM Health. The Futures program was developed in June of 2010 and grew from the need to hire a number of new graduate nurses.

In 2016, SSM Health DePaul Hospital hired 108 Futures graduate nurses.

12

Exemplary Professional Practice

3. Exemplary Professional Practice

Shared GovernanceThe entity-based Nursing Practice Council (NPC) at SSM Health DePaul Hospital is a very active and engaged group of nurses, focused on promoting best practices and the highest levels of care possible for our patients. At their monthly meetings, the unit-based practice councils discuss new ideas and how to best provide exceptional care. Those new ideas, including new products and processes, are taken forward to the entity council to discuss for consideration of possible house-wide implementation. The group also receives updates from many different departments that collaborate in the care of our patients and help make decisions that affect patient care. To help improve communication among their group, a DePaul NPC Share Point site was created. All members can access the site at any time and retrieve information to share with nursing staff on their units. We thank the DePaul NPC members for their dedication to their practice and ensuring our patients receive high-quality care.

Moment of SilenceThe Code Blue / Rapid Response Teams rolled out the “Moment of Silence” initiative in 2016. When a patient passes away after a resuscitation attempt, someone on the code / rapid response team initiates a moment of silence out of respect for the patient who died. This practice has existed for decades and initiating it at DePaul Hospital fits perfectly with our Mission and Values.

13

New Knowledge, Innovation and Improvements

4. New Knowledge, Innovation and Improvements

Inpatient Value Stream AccomplishmentsThrough lean process improvement work, we implemented Exceptional Patient Care Rounds (EPCR) on four telemetry units. Standardizing the EPCR process with hospitalists, nurses, pharmacists and case managers has improved the coordination of care for our patients. With better communication among the health care team, patients are experiencing a more timely discharge from order placed to leaving the hospital. (On average 2.5 hour improvement). Avoidable days for patients admitted to hospitalists also have decreased significantly from an initial 118 days per month to less than 50 days per month. Staff nurses and CSNs play a vital role in the coordination and success of EPCR on their units. Together with other multidisciplinary departments, they continue to review the current EPCR process for additional improvement opportunities that can encompass more patients and improve overall patient satisfaction. Hospitalist — Number of Avoidable Days/Month

10

30

50

70

90

110

130

JanDecNovOctSepAugJulJunMayinitial118 72 87 51 75 35 39 29 43 30

Series 1

Hospitalist — Number of Avoidable Days/Month

14


DP — Falls with Injury with BHS

0

1

2

3

4

5

Oct Nov DecSepAugJulJunMayAprMarFebJan

2016

Linear (IP only)

Nu

mb

er

of

Fa

lls

IP & OP

Falls with Injury with BHS for SSM Health DePaul Hospital in 2016

Focus on Wound Care In 2016, nursing focused on optimum wound care, pressure ulcer prevention and proper wound documentation. Activities throughout the year included multiple educational offerings for registered nurses and clinical partners, near real-time retrospective feedback by wound nurses and wound champions, and daily audit of documentation with feedback to caregivers regarding opportunities for improvement. This additional focus resulted in improved documentation compliance and understanding of optimum wound care, as well as a marked decrease in the HAPU rate for the year.

Month J F M A M J J A S O N D

Total 9 3 3 6 3 2 3 2 3 1 1 3

QTR 15 11 8 5

Hospital-aquired Pressure Ulcers (HAPUs) for SSM Health DePaul Hospital in 2016

15


Evidence-Based Practice

Amanda Meyer MSN, RN, diabetes educator, completed a poster presentation at the 2016 Annual Nursing Research Congress on Education Intervention to Improve Inpatient Glycemic Management.

The purpose of this study was to develop and test an educational intervention designed to improve the management of acute inpatients with Diabetes Type 1 or Type 2 and reduce the occurrence of hypoglycemic events in the same population. An evaluation of data by a Glycemic Management Team (GMT) using the Hypoglycemic Event Analysis Tool (HEAT) revealed an opportunity to reduce the number of inpatient hypoglycemic events. There were significant reductions in the percent of use of home medication regimen (insulin) continued during hospitalization, the use of basal heavy regimens, the use of sulfonylureas and improvement in the timing of the meal and insulin administration. Education provided to nursing staff and to physicians can reduce hypoglycemic events in an acute inpatient setting. This project was important because hypoglycemia is a safety concern and we want to prevent it from happening in the hospital if at all possible.

nursing annual report - ssmhealth.com nurses/2016...nursing annual report. ... strategic direction...

Documents