2019 NURSING ANNUAL REPORTSentara Leigh Hospital

TABLE OF CONTENTS

Message from CNE 2

Quality and Patient Sensitive Measures 3

Professional Development 4-5

Professional Practice 6-7

Healthy Work Environment 8-9

Scholarly Dissemination 10

Community Outreach 11

Jennifer Kreiser

MS, BSN, RN, NE-BC

Nurse Executive

Sentara Leigh Hospital

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A MESSAGE FROM OUR CNE

Dear Sentara Leigh Hospital Nursing Team,It is my pleasure to present the 2019 Nursing Annual Report. You will find a compilation of our accomplishments over the past year. Some highlights include:

• 2018 & 2019 by IBM Watson Health 100 Top Hospitals

• 2018 & 2019 IBM Watson Everest Award winner

• 2019 America's 100 Best Hospitals by Healthgrades

• Improved nursing professionalism through BSN growth

• Improved length of stay

• Decreased readmissions

• Improved ED patient flow

• Achieved top 20% patient experience goal

• Achieved top 25% MOT engagement index

It is a testament to your dedication and professionalism that we have accomplished so much in the current context. While 2019 brought many new challenges, you faced them all with grace and resolve. You have embodied the Magnet Culture of Exemplary Professional Practice, Structural Empowerment, New Knowledge and Innovation and Transformational Leadership. As we continue on our Magnet journey and continue our growth in quality and patient experience, I am proud to be a part of such an exemplary team.

Sincerely,

Jennifer Kreiser, MS, BSN, RN, NE-BCNurse Executive, Sentara Leigh Hospital

QUALITY AND PATIENT SENSITIVE MEASURES

HAI, HAPI, Falls, Patient Experience3

Goal Q1 Q2 Q3 Year EndAchieve 4 of 5 Clinical Appropriateness and Sustainability goals • Meet readmissions target of 13.0% or less

13.7 13.313.0

12.9%

• Meet mortality ratio target of 0.81 or less 0.92 0.81 0.68 0.91• Meet LOS ratio target of 1.07 or less 1.16 1.10 1.09 1.10• Achieve 50% patients Treated & Released from ED within 120 minutes 47% 51% 52.0 53%• Achieve 40% patients Treated & Admitted from ED within 240 minutes. **At least one of the two Flow goals must be met. 23% 33% 42.0 46%• Reduce sepsis mortality to less than 9.5% 11.0 9.3 7.3 8.6%Meet or exceed SLH Employee Engagement Index (5.28) 2.5% for Hospital, 2.5% for unit 4.25 4.25Meet Turnover target of 12.1% or less 2.5% for Hospital, 2.5% for unit 4.4% 8.0 12.5%Meet or exceed SLH Customer Experience goal (81.0) 5% for Hospital, 5% for unit 83.7 83.1 81.5 83.4Meet OSHA Incident Case Rate target of 5.9% or less 2.5% for Hospital, 2.5% for unit 5.2 4.7 5.1 6.3%Meet 4 of 6 Nurse Sensitive Measures (if individual unit performance is improved from last year, ½ credit is given even if hospital does not meet)• CAUTI: Limit 8 SCK- I see threshold at 9

1 1 2 5

• CLABSI: Limit 2 SCK- Improvement over prior year performance of 5 0 3 3 4• CDI: Limit 38 SCK- I see threshold at 28 8 15 19 28• Falls with Injury: Limit 30 2 7 16 22• HAPI: Limit 26 2 5 5 12• Hand Hygiene – target >95% 98 97 98 98

PROFESSIONAL DEVELOPMENT

BSN Rates, Certifications, Transition to Practice Programs, NRP, ED Internship, Periop 1014

Nursing Professional Development is celebrated annually during Nurse’s Week through a pinning ceremony. Above are the names of the 2019 nurses recognized.

PROFESSIONAL DEVELOPMENT

BSN Rates, Certifications, Transition to Practice Programs, NRP, ED Internship, Periop 101

Certification validates a nurse's knowledge, skills, and abilities in a defined role and clinical area of practice, based on predetermined standards. Certified nurses practice at the top of their scope and are committed to delivering excellent patient care. To empower RNs to become certified, Jennifer Kreiser financially covers all nursing certification exams through a combination of pre-paid testing codes and reimbursements.

If you are interested in becoming certified, please email Tess Bilyeu (tescherm@sentara.com).

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SLH Certified Nurses were celebrated at our Annual Certified Nurse Breakfast hosted by the Magnet Champions on Certified Nurses Day.

PROFESSIONAL PRACTICE

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0% 20% 40% 60% 80% 100%

2014 YE

2015 YE

2016 YE

2017 YE

2018 YE

2019

34.1%

23.8%

18.9%

19.5%

17.4%

16.4%

14.3%

21.3%

25.9%

22.8%

19.6%

17.0%

51.6%

54.9%

55.2%

57.7%

63.1%

66.6%

Non-BSN Degree

Non-BSN w/Contract

BSN or Higher Degree

Leigh RN Education 6-Year Trend

BSN 2018All Nurses

BSN 2019All Nurses

BaselineCount

Total RNs

Baseline % Count

Total RNs BSN Goal % YTD

457 725 63.0% 467 703 1% 66.4%

CERTS 2018All Nurses

CERTS 2019All Nurses

BaselineCount

Total RNs

Baseline % Count

Total RNs

Cert Goal % TYD

174 725 24.0% 179 703 1% 25.5%

CERTS 2018All Eligible Nurses

CERTS 2019All Eligible Nurses

BaselineCount

Total RNs

Baseline % Count

Total RNs

Baseline % % TYD

174 524 33.2% 179 534 1% 33.5%

PROFESSIONAL PRACTICE

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Our Nurse Executive is…

Our Nurse Leaders are…

Clinical Nurses at SLH were asked what they thought of their leadership. This is what they said…

HEALTHY WORK ENVIRONMENTExemplary Professional Practice Nurse Excellence Awards

Recognizing excellence in practice and leadership in 8 distinct specialties. The Nurse Excellence Awards are hosted by the Magnet Champions and are presented to SLH staff members that exemplify our commitment to excellence and quality. Nominations are submitted by peers and leaders, reviewed by an expert panel and selected based on individual’s commitment to excellence, participation in achieving quality outcomes and contributions to the overall SLH team. Awards are presented at an annual banquet during Nurses Week.

2019 Nurse Excellence Award Winners

Biz Gieselman: Becca Cooper

Experienced: Chi Guyon

Leader: Lisa Hart

LPN: Nick Best

NCP/Tech: Mary Cherry

Novice: Kayla Barrett

Preceptor: Chris LaPietra

Interprofessional Team: Endoscopy

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HEALTHY WORK ENVIRONMENT

Nursing Satisfaction, Retention, MOT Engagement, Magnet, Beacon, NICHE, DAISY

What is The DAISY Award?

The DAISY Award is an international program that rewards and celebrates the extraordinary compassionate and skillful care given by nurses every day. Sentara Leigh Hospital is proud to be a DAISY Award Partner, recognizing one of our nurses with this special honor every quarter. To find out more about the program, including the growing list of Partners, please go to www.DAISYfoundation.org.

2019 Winners:1Q19: Angie Isaacs2Q19: Antionette Kelley3Q19: Victoria Gumapas4Q2019: Jessica Schafer

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SCHOLARLY DISSEMINATION

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PublicationsMo./Year Author/Authors Subject Title Journal NameJune 2019 Melissa Pilat Exploring the Lived Experiences of Staff Nurses Transitioning to

the Nurse Manager RoleThe Journal of Nursing Administration

May 2, 2019 Iza Hester Tick Tock Tick Tock Says the Critical Clock 2019 Vizient/AACN Nurse Residency Program NewsletterPodium PresentationsJune 2019 Marybeth Baber, Co-presenter Sentara Team: Always Cleaning June 2019Poster PresentationsJanuary 31, 2019February 1, 2019

Lisa Scheels LEANing in to Manage Infection Risk: Applying LEAN Concepts to Reduce Contamination Events in Central Sterile Services

VHHA Annual Safety Summit

March 13 & 14,2019

Iza Nadine Hester Tick Tock, Tick Tock, Says the Critical Clock 2018 National Vizient/ANCC Nurse Residency Program Annual Conference, Bonita Springs Florida

May 1, 2019 Nerizza Murido Leveraging the Inter-Professional Approach to Reduce Venous Thromboembolism Rates on a Medicine Inpatient Unit

Sentara Nursing Leadership Symposium, Marriot City Center, Newport News, VA

May 17, 2019 Nerizza Murido Leveraging the Inter-Professional Approach to Reduce Venous Thromboembolism Rates on a Medicine Inpatient Unit

VONEL Spring Conference at Glen Allen, VA

May 17, 2019 Deborah Smith, Janice Olicia, Taylor Adams

Clinically Indicated IV Replacement versus Replacement Based on Dwell Time

VONEL Spring Conference at Glen Allen, VA

October 18, 2019 Janice Olicia Clinically Indicated IV Replacement versus Replacement Based on Dwell Time

VONEL Fall Conference at Fredericksburg Hospitality House Hotel and Conf Center

October 18, 2019 Krista Fotland Implementation of Enhanced Recovery After Surgery (ERAS)–Guiding Colorectal Patients Down the Right Path

VONEL Fall Conference at Fredericksburg Hospitality House Hotel and Conf Center* 1st place winner

November 1, 2019 Janice Olicia Clinically Indicated IV Replacement versus Replacement Based on Dwell Time

Sentara Unit Coordinator Symposium – Great wolf lodge

COMMUNITY OUTREACH

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In 2019 SLH Nurses participated in a variety of community outreach initiatives. These initiatives include but are not limited to:• Backpack and school supply donation to United Way for Ingleside Elementary• Community Health Fair & Flu Drive where 400+ vaccines were administered• Hosted American Red Cross blood donation drives• Collaboration with Kennedy’s Angel Gowns for infant loss• Southeastern Food Bank donation• YWCA sponsorship• Old Dominion University- Women’s Initiative Network Mentorship Program

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