2015 Nursing Annual Report

2015 Nursing Annual Report
Dear Friends,
Throughout 2015, MedStar Southern Maryland Hospital Center (MSMHC) demonstrated steady progress on its journey to
becoming a high-reliability organization. With this inaugural edition of the MedStar Southern Maryland Hospital Nursing
Annual Report—the first since our merger with MedStar Health—I’m pleased to recognize the contributions that the
MSMHC nursing team has been making on this journey.
Table of Contents:
Page 1
Letter from Pat Scalfari, MSN, RN, ACNS-BC, NEA-BC - CNO
Page 2 - 7
Highest Quality & Safety
Page 8 - 9
Best Place to Work
Page 10 - 13
Best Patient Experience
Page 14 - 15
Market Leadership
Page 16 - 17
Fiscal Strength
As a team, our nurses demonstrated continuous improvement in several critical areas in 2015, including providing our
patients with the safest, highest quality care; creating a “best place to work” culture; ensuring patients have the best
experience possible; demonstrating the skills and commitment that maintain market leadership; and using the technical and
procedural tools that help us remain fiscally strong.
Nurses play key roles in our drive to achieve high reliability, and their efforts are producing outstanding results. In 2015, for
the first time in the history of MSMHC, the Joint Commission recognized us for overall progress in our quality measures.
Through a partnership with the Notre Dame University of Maryland, we supported 21 scholars with a BSN education on
MSMHC’s campus, and moved closer to our goal of ensuring that 80% of our nurses earn bachelor’s degrees by 2020.
Nurses also contributed to MSMHC’s market leadership and fiscal strength: we could not have opened our state-of-the-art
hybrid cardiac catherization lab, nor introduced robotics surgery, without our nurses’ expertise. Our nurses’ participation in
MedStar’s system supply chain initiatives and their innovative work with EMR contributed to MSMHC’s fiscal well being.
To continue the momentum, we introduced new nursing councils in 2015, both at the corporate and local levels. Although
our patient experience scores have consistently improved, we reinvigorated our efforts to raise scores even higher by
establishing a Data Dashboard that captures and measures the nursing-driven components that enhance patient experience.
It is with much enthusiasm that I invite you to review this report. It is one means in which we proudly recognize the ways
in which MSMHC nursing professionals are making a difference on our ongoing journey to become a high-reliability
organization and provide the best possible care to our community. I am honored to be practicing nursing here with each and
every one of you.
Kindest regards,
Cover Photo, from left to right: Karen Dunlap, RN, Brenda Hill, BSN, RN, Pat Frasier, RN, Dvika Kandhai, BSN, RN,
Shannon Holton, RN, Mary Ann Lucero-Pierce, BSN, RN
Pat Scalfari, MSN, RN, ACNS-BC, NEA-BC
Chief Nursing Officer, MedStar Southern Maryland Hospital Center
Highest Quality & Safety
Our Hospital-Wide Commitment to Becoming a
High-Reliability Organization
At MSMHC, we know that quality and safety go hand in hand.
Developing and applying effective solutions to healthcare’s most
critical safety and quality problems is key to achieving High-Reliability
Organization (HRO) status.
Infection Prevention HeRO Recognition Banquet to honor our work on ICU CLABSI reduction.
Pictured from left to right: Janice Pineda, MSN, RN, David Mayer, MD, Vice President of Medical
Affairs, MedStar Health, Renee Sicheri, MSN, RN, Rebecca Cook, BSN, RN, and Faye Goode, MSN, RN
In 2015, our ongoing commitment to a patient-first philosophy
moved us significantly closer to our goal. Today, all MSMHC
associates have been trained in HRO, and the nursing team has
entered “Phase 2” of our journey. We’re realigning processes to
reflect what we’ve learned over the past year; reviewing safety events
and improving our responses with more efficient approaches and
thorough documentation; and assessing our skills and effectiveness
as individuals as well as a team. MSMHC is still early in its journey to
transform our hospital into an HRO, but we’re encouraged by our
substantial progress as we find even more ways to improve care for our
patients and create a workplace culture in which we can all thrive.
•Cumulative performance of at
least 95 percent across reported
accountability measures;
•Performance of at least 95 percent
on each accountability measure
with at least 30 denominator cases;
and
•A composite rate of 95 percent or greater in one or more core
measure set(s), and a performance rate of 95 percent or greater on
applicable individual accountability measures within the set(s).
Nationwide, only 1,043 hospitals earned recognition from the Joint
Commission this year, and the knowledge and training of our nursing
team were integral to MSMHC’s accomplishment.
Greg Purell, RN assisting NICHE patient
MSMHC Achieves NICHE Level 3 Designation
MSMHC Earns Joint Commission Top Performer
Status on Six Quality Measures
In 2015—for the first time in our history—MSMHC was recognized by
the Joint Commission as a Top Performer in its Key Quality Measures®
Program. We were honored for our achievements on six sets of
accountability measures reported in 2014: heart attack, heart failure,
stroke, pneumonia, surgical care, and perinatal care.
Page 2 - 2015 Nursing Annual Report
To be named a Top Performer,
hospitals must achieve:
Nurses Improving Care of Health System Elders (NICHE) is a national
program providing education, resources, and practices to improve
geriatric nursing care. In 2015, MSMHC launched several initiatives and
met the criteria to achieve the third of four levels of the NICHE process.
Initiatives included making all patient rooms senior friendly by the
end of 2016, with environmental changes such as improved lighting
and doorframes painted in contrasting colors so those with low vision
can identify bathrooms. Nurses and CNAs supported MSMHC’s early
mobility program by keeping older patients as ambulatory as possible
during the day to prevent functional decline. Nurses also started
collecting data in 2015, which will be used to evaluate the success of
the mobility program. MSMHC started the NICHE program on units
1 East and 4 East. We will be implementing the program on all units in
the hospital and NICHE implementation will be completed in 2016.
NICHE-related efforts are part of MSMHC’s longstanding commitment
to exemplary care for elder patients. All CNAs are encouraged to
complete Geriatric Patient Care Associate (GPCA) training, and
MSMHC has a dedicated team of geriatric resource program nurses
(GRNs), who model NICHE’s nursing practices.
Highest Quality & Safety - Page 3
Highest Quality & Safety
Nursing Councils Provide Support, Education, and
Innovative Ideas
Our Nursing Collaborative Governance Coordinating Council
(NCGCC), Nursing Quality & Safety Council (NQSC), and Nursing
Practice Council (NPC) have distinct roles to support and enable
collaboration among our nursing professionals.
The NCGCC oversees the NQSC and NPC and is integral to their
operations. Comprised of the chief nursing officer and nurse leaders,
the NCGCC facilitates communications and collaboration between
the NQSC and NPC, and guides them toward the goals outlined in the
nursing strategic plan. The NCGCC also reduces potentially redundant
activities among nursing councils and departments.
The NQSC designs, implements, and evaluates the entity-level nursing
safety and improvement program; measures patient outcomes
sensitive to nursing intervention; and promotes improvement of
patient safety and clinical outcomes.
In 2015, the NQSC celebrated its inaugural year of first-rate initiatives,
starting with hand hygiene compliance. The council launched a video
on hand-washing techniques and a quarterly competition to recognize
the unit with the highest percentage of compliance. Hand hygiene
has now increased significantly hospital-wide. The NQSC’s second
initiative, “Back to You,” featured massage, exercises, safe lifting
techniques, equipment, and prizes to promote back health and back
injury prevention while caring for patients. The council’s third initiative,
“Armed Against CLABSI,” launches in 2016, and will increase CLABSI
awareness and identify unit-specific clinical champions.
Page 4 - 2015 Nursing Annual Report
The NPC develops and reviews MSMHC’s nursing standards of care
and contributes to policies and procedures that support the exemplary
professional practices that are critical to excellent nursing care.
In 2015, the NPC researched the use of whiteboards as a tool for
communicating, facilitating patient discharges, and supporting patient
care. The council proposed a pilot study in which whiteboards will
be installed in each room on certain units, updated after each nurse’s
shift, and provide pertinent information, such as the patient’s treatment
goals and anticipated discharge date, for easy reference by the patient,
family, and staff. The pilot was approved for 2016, and the NPC will
provide oversight and present results at its conclusion.
2015 Nursing Collaborative Governance Members, from left to right: Laura Shwartze, BSN, RN,
Kim Elliot, MSN, RN, Jacquie Payne-Borden, PHD, RN, Monique Dillard, MSN, RN, Lisa Douglas,
BSN, RN, Ellena Arellano, BSN, RN, Karol Edwards, MSN, RN, Aldene Doyle, BSN, RN, Luis Corpin,
MSN, RN, Janice Pineda, MSN, RN, Christine Galvez, MSN, RN, seated: Pat Scalfari, MSN, RN
Hand Hygiene Compliance Improves as Units
Compete for Recognition
According to the World Health Organization proper hand-washing
techniques can save lives. That’s one reason why the Nursing Quality
& Safety Council chose hand hygiene compliance as its first initiative.
In April 2015, the council launched an intranet video called “Wash
It Off,” choreographed to a popular song and featuring associates
who demonstrated hand-washing techniques that reduce the risk of
infection. A second event was held on May 5—to celebrate International
Hand Hygiene Day.
The council and MSMHC continue to reinforce hand hygiene practices
with a friendly competition. Each quarter, the unit or department with
Beverly Francis, CNA, 3 East
the highest percentage of hand hygiene compliance is awarded a
trophy. The Infection Prevention and Quality and Risk departments,
assisted by a cadre of trained undercover observers, help determine
the winners. The first unit to win the award was 4 East, followed by
OR/PACU. But even more important: hand hygiene compliance
has increased hospital-wide, from 89% to 92%, since the program’s
inception.
Using MOST to Manage Critical Situations in
Obstetrics
MedStar Obstetrical Safety Training (MOST), our system-wide training
program, helps obstetrics nurses improve their emergency response
by standardizing healthcare communications. MOST promotes
patient safety and high reliability, and improves the way healthcare
professionals function as a team.
As a result of MOST preparation in 2015, MSMHC obstetrics nurses
increased their use of critical language at key times during emergency
situations to bridge communication gaps and enhance their collective
skills. By educating nurses on the proper use of Situation, Background,
Assessment, and Recommendation (SBAR), MOST is helping
our teams better manage critical situations and achieve
safer patient outcomes.
Highest Quality & Safety - Page 5
Highest Quality & Safety
Nurses Use RL Solutions to Build Unit-Wide Safety
Culture
Dr. Taylor, Dr. Nair, Kim Bushein, RN, Tara Mclane, BSN, RN, Julie Gato, BSN, RN
Daily Safety Huddles - A 15-Minute Call to Support
24-Hour Safety
A short phone call that occurs every weekday morning at 8:45 is
helping to keep MSMHC patients, staff, and visitors safe and secure,
around the clock. All department leaders participate in the daily safety
huddle to make each other aware of any safety-related matters that
occurred over the previous 24 hours, or are anticipated that day. They
cover a lot of topics in just a few minutes, including medical issues and
Page 6 - 2015 Nursing Annual Report
Mabvuto Mayaya, RN
good catches, bed availability, and admission or staffing concerns. If
there are new policies, the Education Department will discuss them.
If a technology update will impact EMR, IT will alert the group. If a
construction project is starting, Facilities will announce it.
In 2015, adjustments were made to the format to make calls even more
helpful. One change is that the on-call administrator now announces
the day’s visitor wristband color, which will help associates to ensure
that visitors have checked in at the desk.
The nursing team is using system data in daily safety huddles to
identify patients at risk and find areas for process improvements. For
example, when a nurse reports a fall, it prompts a safety huddle to
identify contributing factors and interventions that can avoid another
fall. RL Solutions can also provide data to support recommended
initiatives, such as the need for bed alarms that was recently addressed
at MSMHC, and shorten the distance from identifying a safety concern
to resolving it.
Core Measures Guide Nurses in Best Practices
Compliance
The Joint Commission, Centers for Medicare and Medicaid Services
(CMS), and a number of healthcare plan and provider organizations
collaborated to develop a set of quality measures—i.e., standardized
best practices—against which MSMHC and other hospitals assess
patient care. These core measures provide a consistent, industrywide unit of measurement to evaluate improvements, especially in
Venous Thromboembolism - VTE
Pts who receive VTE within 24 hrs admission/surgery or who have
documentation why none given
ICU admission VTE prophylaxis
Pts with anticoag overlap
Pts received unfractionated heparin w/ dosages/platelet count
Warfarin therapy discharge instructions
Hospital acquired VTE
Immunization -IMM
Influenza vaccine compliance
Stroke (NEW 2014)
VTE Prophylaxis documentation
Antithrombotic therapy at discharge
Ischemic pts with atrial fibrillation who are prescribed anticoagulation
therapy at discharge
Acute ischemic stroke pts who arrive w/in 2 hrs of time last known well
and whom IV TPA was initiated w/in 3 hrs of times last known
Ischemic stroke pts admin. antithrombotic therapy by day 2
Ischemic stroke pts with LDL>=100mg or LDL not measured or who were
on a lipid lowering meds prior to arrival are prescribed statin meds.


















Aug 2015
Sep 2015
Total
Positive
Positive
Positive
Positive
Positive
79.5
78.5
74.7
80.3
77.7
HCAHPS: Did everything to help your pain
HCAHPS: Drs explained things understandably
76.1
75.2
81.3
78.2
77.9
HCAHPS: Drs listened carefully to you
79.1
78.1
81.3
81.8
80.1
100%
100%
100%
100%
100%
100%
0%
FY16 Jul
NA
FY16 Jul
100%
98%
100%
100%
100%
100%
0%
FY16 Aug
NA
FY16 Aug
100%
100%
63%
100%
86%
60%
99%
95%
98%
97%
MSMHC Hand Hygiene Complance Rate Hospital
Wide
100%
90%
80%
Oct 26, 2015
70%
60%
50%
40%
30%
20%
10%
0%
Rate
0
55.1
54.9
Number
61.4
63.7
Rate
HCAHPS: Nurses explained things understandably
74.8
72.7
77.0
66.7
72.6
HCAHPS: Quiet around room at night
59.1
52.4
58.0
55.3
55.0
HCAHPS: Rate hospital
72.5
54.0
58.7
50.6
54.7
HCAHPS: Received info re: symptoms to look for
90.6
89.0
94.3
88.9
90.8
HCAHPS: Room kept clean during stay
72.3
62.7
70.3
65.9
66.0
HCAHPS: Staff described med side effects
50.0
55.9
50.0
51.0
52.7
HCAHPS: Staff took preferences into account
44.8
27.3
32.7
32.5
30.4
HCAHPS: Talked about help you would need
85.0
84.9
86.7
77.2
83.5
HCAHPS: Told what medicine was for
77.5
72.1
76.0
84.0
76.8
HCAHPS: Treated w/courtesy/respect by Drs
86.9
87.7
88.3
83.9
86.9
HCAHPS: Treated w/courtesy/respect by Nurses
85.6
78.7
83.3
83.1
81.3
HCAHPS: Understood managing of health
53.4
43.3
45.4
48.8
45.4
HCAHPS: Understood purpose of medications
61.8
52.9
53.2
58.0
54.3
HCAHPS: Would recommend hospital to family
75.0
55.6
64.2
54.1
58.1
IP: Received follow up after leaving hospital
76.9
82.3
81.1
67.1
77.9
IP: Staff taking action for safety
79.1
76.3
72.2
70.4
73.4
Green - score is equal to or greater than the NRC Average
©2015 National Research Corporation
Yellow - score is less than the NRC Average
10.0
MSMHC ICU-Central Line-Associated Bloodstream
Infection Rate per 1,000 Catheter Days
8.0
25
20
15
4
4.0
2.0
2
2.0
0.0
0
14-Jul 14-Aug 14-Sep 14-Oct 14-Nov 14-Dec 15-Jan 15-Feb 15-Mar 15-Apr 15-May 15-Jun 15-Jul 15-Aug 15-Sep
Number
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
14Oct
14Nov
14Dec
15Jan
Feb15
0.0
0.0
0.0
0.0
Mar15
Apr15
May15
Jun15
Jul15
Aug15
Sep15
4
4
3
6
2
2
6
1
2
5
2
3
3
5
4
8.7
9.36
6.7
13
4.65
4.1
11.8
1.9
3.55
9.01
3.83
5.67
5.63
10.44
8.24
Goal = < 0.9
8.0
4.0
0.0
Sep
14
10.0
6
0.0
Aug14
8
Goal = < 0.9
0.0
5
Jul14
MSMHC Non-ICU Central Line-Associated Bloodstream
Infection Rate per 1,000 Catheter Days
10
6.0
Rate
30
10
0.0
10
6
4
2
0.0
Number
Rate
0
8
6.0
Rate
71.1
67.3
Count
66.3
70.5
40
35
5
57.1
75.2
45
10
MD Goal
67.2
63.9
50
Goal = < 7.0
15
% of Compliance
52.9
70.9
100%
100%
FY16 Aug
0%
56%
NP
0%
17%
44%
25
62.3
68.2
100%
30
63.0
75.8
95%
100%
20
69.3
64.5
25%
95%
MSMHC C. difficule Lab ID Event Rate per 10,000 Patient Days
HCAHPS: Got help as soon as wanted
HCAHPS: Nurses listened carefully to you
75%
96%
95%
94%
99%
99%
97%
FY14
FY15
FY16 Jul
N/A
0%
0%
N/A
43%
45%
N/A
100%
NP
N/A
0%
0%
N/A
26%
30%
N/A
56%
56%
** DELMARVA GOAL-96% **
HCAHPS: Help going to bathroom as soon as wanted
HCAHPS: Pain well controlled during stay
FY16 Aug
Number
Jul 2015
FY16 Jul
Count
NRC Average
FY15
97%
97%
98%
100%
91%
4%
FY15
95%
FY15
99%
97%
88%
INFECTION PREVENTION QUALITY INDICATORS
HCAHPS - Patient Perception of Care Survey Results
Catalyst Trend by Questions - Southern Maryland Hospital IP-A Overall
FY14
89%
92%
96%
100%
83%
5%
FY14
96%
FY14
96%
95%
98%
Stroke Education
Patients who were assessed for rehab services
Perinatal
Elective Delivery >37 <39 weeks (low rate good)
C-section rate (low rate good)
Antenatal Steroids for preterm newborns
BSI in newborns
Exclusive Breast feeding
Exclusive Breast feeding due to Mothers choice


Rate
RL Solutions, an incident reporting and feedback system, is helping
nurses identify and follow up on safety concerns and create a safer
environment at MSMHC. Safety-related events are logged into the
system and addressed by the appropriate individual or department.
Because the tool tracks and compiles data about each event, it
provides critical information about the type of events occurring and
how long it takes to close them, and identifies trends to prevent future
incidents. The system also recognizes individuals who make good
catches and prevent errors from happening.
MSMHC Quarterly Core Measures Data-FY14, FY15 & FY16
Delmarva

0
14-Jul 14-Aug 14-Sep 14-Oct 14-Nov 14-Dec 15-Jan 15-Feb 15-Mar 15-Apr 15-May 15-Jun 15-Jul 15-Aug 15-Sep
1
0
0
0
1
2
0
0
1
0
0
1
2
2
1
1.8
0.0
0.0
0.0
2.0
3.9
0.0
0.0
2.1
0.0
0.0
2.2
3.6
3.8
2.1
µ - Warning: n-size is under 30!
Page 1 of 1
cardiology, orthopedics, and five other clinical areas considered to
be the core set of medical practices. Because core measures are tied
to federal reimbursements and must be reported, they also promote
transparency; the public knows which hospitals are in compliance and
can track their year-to-date performance.
At MSMHC, these guidelines are helping to improve patient outcomes,
decrease the length of hospital stays, and reduce readmissions. Each
nursing unit addresses core measures during daily multi-disciplinary
rounding. As an additional motivator, unit-based teams compete
informally to have the highest compliance scores.
Highest Quality & Safety - Page 7
Best Place to Work
Today, the nurses who comprised the program’s first cohort are not
only enjoying new career opportunities at MSMHC, but also using their
improved competency and critical thinking skills to provide better
patient care. In addition, several nurses are now taking advantage of
MSMHC’s graduate-level tuition reimbursement program to pursue
their master’s degrees. The second cohort of 22 nurses graduates in
May 2016; the third cohort starts in August.
Nursing Promotions from Within
MedStar Southern Maryland Hospital Center believes in promoting
outstanding individuals into roles with greater impact and
responsibility. In 2015, three nurses received significant promotions
that have broadened their capabilities and career options, and
introduced new avenues for growth in the future.
Pat Scalfari, MSN, RN-CNO, presents Christopher Bowling, RN with a scholarship in MSMHC’s RN
to BSN Program
RN to BSN Program Benefits Patients as well
as Nurses
In accordance with The Future of Nursing Report from the Institute
of Medicine (IOM) MSMHC encourages all nurses to advance their
education. To support our nurses who are interested in earning
their bachelor’s degree, MSMHC is allowing them to apply for full
scholarships to Notre Dame of Maryland’s RN to BSN Program. The
program bridges the educational requirement from current RNs to
BSNs and offers convenient weekly classes at MSMHC. To qualify,
nurses must meet academic and MSMHC criteria and remain at the
hospital as full-time employees for a specified time.
Page 8 - 2015 Nursing Annual Report
Karen Elliot, MHA, RN, was promoted from Director of Nursing to
Senior Director of Nursing. Karen oversees the inpatient medical
surgical units and ICU/CCU, directs staffing, bed management, and
the nursing supervisors. She has previously served as Nursing Director
of 1E and 1W; prior to joining MSMHC she was a Nurse Manager at
MedStar Franklin Square Medical Center; and Assistant Manager of
Emergency Services at MedStar Washington Hospital Center.
Angela Sykes, BSN, RN, was promoted from Interim Director to Nursing
Director of 1E/1W. In 2008, Angela started her nursing career at our
hospital as an LPN. She then undertook the challenging—and ultimately
successful—goal of earning her RN designation (2009) and BSN (2013),
and will complete her master’s in nursing this year.
Dominique Stuckey, MSN, RNC-OB, C-EFM, was promoted from
Nursing Director of Labor & Delivery to Nursing Director of the
Women’s & Newborn Center. She oversees daily operations of the
Labor and Delivery Unit, Mom and Baby Unit, Special Care Nursery,
Antenatal Testing Unit, and Lactation Services.
Reception Honors Nurses on the Road to
GRN Certification
For many nurses and CNAs, Gerontology Resource Program Nurse
(GRN) certification provides knowledge they can use every day to
care for the needs of older patients. GRN training focuses on geriatric
issues such as falls and confusion, and emphasizes care strategies that
promote patient mobility and discourage the use of restrictive devices.
In May 2015, MSMHC held a ceremony to award nurses and CNAs
who have completed the prerequisite training towards achieving GRN
certification. This year, they’ll have the opportunity to sit for the GRN
exam and earn national certification, and MedStar is sponsoring review
courses to help them prepare.
Residency Program Eases Transition for New-toPractice Nurses
By providing our new-to-practice nurses with both education and
support, the Vizient/American Association of Colleges of Nursing
Nurse Residency Program (NRP) is moving MSMHC closer to being
a Best Place to Work. Our nursing team and nursing administration
work with the NRP to help new-to-practice registered nurses with
baccalaureate degrees make the transition from advanced beginners
to competent professionals. In 2015, our inaugural cohort of nine
nurses graduated from the 12-month NRP, and we welcomed a second
cohort of seven nurses.
New nurses in the nurse residency program, back row: Verna LaFleur, PhD, RN, Program Facilitator,
Jasmine Atwater, BSN, RN, Beatrice Kauemou, BSN, RN, Dr. Alawode, MD, Nancy O’Rourke, BSN,
RN, Jessica Koster, BSN, RN, Ashley Siemonh, BSN, RN, Brianna Dozier, BSN, RN, Jacqeline PayneBorden, PhD, RN, Program Coordinator, front row: Lielte Estifanos, BSN, RN, Ida Hometowou, BSN,
RN, Koudjo Elitsa, BSN, RN
MSMHC’s first NRP covered an array of interactive topics, including
ethics, leadership, and delegation. It culminated with “Patient Safety:
Effectiveness of Remote Telesitters vs. Face-to-Face Sitters,” an
evidence-based project to enhance patient care and outcomes. Results
indicate that remote telesitters improve the psycho-social aspects of
patient hospital stays, directly contributing to patient satisfaction.
Best Place to Work - Page 9
Best Patient Experience
4 East earns #1 in key patient experience metrics
2 West earns #1 in patient satisfaction for quarter 2
Nursing associates showcase their talents in AIDET Video
EMR Team members: Teresa Waldron, RN, Shelly Martin, RN, Alie
Kamara, BSN, RN
EMR Team member: Tina Gray, RN
Patient Experience Council Initiatives Receive
Enthusiastic Support
AIDET Video Showcases the Hidden Talents of
MSMHC Staff
Providing Patients with Customized Care—Quickly,
and Under Budget
2015 was a good year for the Patient Experience Council: it introduced
successful initiatives that attracted substantial support and wide
participation. One initiative introduced the SPIRIT Award, honoring
one associate each month who demonstrates “above and beyond”
performance. Next, the council agreed to choose one philosophy
or theme per quarter to hardwire into our hospital practices and
professional behavior. First choice: AIDET—Acknowledge, Introduce,
Duration, Explanation, Thank you.
Now playing on the intranet: “AIDET,” the blockbuster music video.
In 2015, the Patient Experience Council, with the help of associates
throughout MSMHC, produced “AIDET” to underscore its importance
and remind us to use it in our interactions with patients and visitors.
One of our most impressive accomplishments in 2015 was our fast
implementation of Plan of Care software in the EMR system. The
module tailors care to each patient’s unique problem and aligns it
with specific goals. For example, if a patient has a high risk of falls, the
software alerts nurses to start fall-prevention care, including explaining
the risk to the patient, goals they’re working toward, and interventions
they’re taking, such as providing yellow socks, noting the risk on the
bracelet ID, and ensuring the way to bathroom is obstacle free.
But the most powerful initiative was to invite one patient each quarter
to speak at a council meeting. It’s an opportunity for the patient to
ask questions and for the council to fully understand how well we’re
meeting our objectives of care. This year, the council will use these
and upcoming dialogues to explore more innovative approaches to
improve patient experience.
Page 10 - 2015 Nursing Annual Report
Marketing and the HCAHPS Steering Committee took the lead, but
the video was a hospital-wide effort. Starting with the melody from the
song, “Happy,” the team revised the lyrics to emphasize the meaning
behind AIDET (i.e., Acknowledge, Introduce, Duration, Explanation,
Thank you) and its role in delivering high-quality care and improving
communication with our patients. The video also highlights the
distinctive dance moves and perfect pitch of several associates. Cast
and viewers agree: the production will enjoy a long run at MSMHC.
Directors are presenting it in staff meetings, and it will also be
incorporated into our staff orientation program.
When the Plan of Care was initiated in January 2015, there were 97
different plans available to patients, and the vendor anticipated a
three-month process. However, Nursing Informatics and the vendor
developed an efficient approach to teach nurses about the software,
and the nurses then created a Plan of Care with each of their patients—
all in just five weeks. Not only did they complete the project in record
time, but their quick work also saved MSMHC $6,000.
Teresita Domagas, BSN, RN, 2 East
Post-visit Phone Calls Ensure Continued Care
At MSMHC, our connection with patients doesn’t end when they leave
the hospital. To ease the transition from in-patient status to home,
MedStar uses a call management system to assist nursing to perform
post discharge calls to patients. Nurses attempt to call patients on the
first or second day after discharge to answer any questions they have
and check on their status. For example, has the patient picked up his
or her medications from the pharmacy? Does he or she understand all
discharge instructions?
In 2015, our post-visit calls were especially timely: a few prompted the
nurse to ask the patient to return to MSMHC for evaluation. Nurses
continue to strive to meet the benchmarks for call attempts and
completions: with a goal of calling 100% of the discharged patients,
and completing 80% of those calls. It’s one more way nurses ensure
care is continued as patients re-enter the community.
Best Patient Experience - Page 11
Best Patient Experience
Monitoring Care in Coordination with the
MedStar Way
nine nursing-driven initiatives. Each month, the tool shows where
benchmarks were exceeded, met, or missed, and where performance
has or has not improved, and monitors how well we function as a team
and support the MedStar Way.
Even before Southern Maryland Hospital Center joined MedStar,
both organizations shared a similar vision: to serve our patients, our
associates, and our community. Now that we’re part of MedStar’s
network, MSMHC is demonstrating steady improvement in our patient
experience scores—thanks largely to the dedication of our nurses.
In 2015, we’re proud that our nursing team demonstrated consistently
outstanding performance in bedside shift reports, physician and RN
collaborative rounding, shift huddles, and coordinating plans of care
with in-room communication boards. In the upcoming years, the
Dashboard will continue to guide us in our ongoing efforts to improve
patient care. Going forward nursing will be focusing a lot of effort in
establishing a method to connect with our patients post discharge.
But we know we can do better. So, in 2015, we created a Nursing Data
Dashboard to measure the nursing activities and interdisciplinary
collaboration that enhance patient experience. The Dashboard
provides a visual, at-a-glance representation of our compliance with
2015 MSMHC NURSING DATA DASHBOARD
Jan
Feb
March
April
May
June
Hourly Rounding
N/A
70%
80%
68%
103%
94%
76%
99%
83%
84%
89%
94%
>90
Bedside Shift
91%
98%
100%
109%
143%
147%
100%
100%
100%
100%
100%
100%
100
MD/RN Round
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
>90
Shift Huddle
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
99%
100
Leader rounding iPad
N/A
48%
51%
56%
60%
62%
70.5%
67%
71%
70%
70%
68%
>70
Communication Board
N/A
97%
99%
99%
97%
98%
94%
97%
98%
96%
93%
98%
>90
D/C Calls Attempted
100%
100%
100%
100%
100%
N/A
92%
87%
100%
96%
98%
91%
100
D/C Calls Connected
N/A
N/A
N/A
N/A
N/A
N/A
50%
47%
56%
60%
60%
49%
>80
No Pass Zone
N/A
N/A
N/A
N/A
N/A
N/A
76%
91%
80%
100%
97%
99%
>95
Page 12 - 2015 Nursing Annual Report
July
Aug
Sept
Oct
Nov
Dec
Benchmark
iPad Rounding Provides Critical Data to Enhance
Patient Experience
Multi-Disciplinary Rounding:
How We’re Improving on Success
Gathering and documenting data on each patient’s needs is now much
more efficient with iPad rounding. By displaying detailed questions,
such as whether a patient is experiencing side effects from medication,
iPads help nurses address patients’ immediate and potential health
concerns while they’re still in the hospital. The iPad’s EMR interface
provides nurses with up-to-the-minute clinical information, and
its connection to other departments streamlines communications
between teams. After the technology was deployed in 2015, patients
responded enthusiastically, thanking nurses for quick responses to
their concerns. What’s next? MSMHC is exploring options to implement
phone apps, so patients can easily access discharge instructions and
other information from home.
The nursing team at MSMHC is always exploring new ways to keep
patients updated about their plans of care and provide timely answers
to their questions. As part of this effort, multi-disciplinary rounding with
physicians from our Georgetown and MDICS hospitalists has been one
of our success stories. But we knew we could make it better. In 2015,
we worked with the hospitalists to streamline our approach, make it
more meaningful for patients, and hardwire it with informative content.
Kristin Gajda, MSN, RN
Today, a nurse, physician, and case manager, frequently joined by one
or two colleagues from the Quality or Education departments, round
together to visit every patient. These multi-disciplinary rounds are
an opportunity to review the patient’s daily care plan, discuss quality
measures and discharge plans, and address any other concern that the
patient might have. Patient feedback ensures we’re on the right track.
This year, we’ll videotape rounds for new hires, so they can see what a
meaningful and effective round looks like.
Best Patient Experience - Page 13
Market Leadership
Enhancing the Pre-operative Assessment Process
Pre-operative planning reduces patient stress, minimizes cancellations,
and produces better surgical outcomes. Throughout 2015, MSMHC
continued to improve the efficiency of pre-operative assessments and
successfully close the loop on communications. By streamlining the
operative process we substantially reduced the number of canceled
surgeries.
MedStar Southern Maryland Hospital Center’s Cath Lab
Linda Black, RN, and Dorel Marks, RN
Nurses, medical staff, and anesthesiologists collaborated to
develop criteria that identify the patients who should meet with
anesthesiologists before their pre-op appointments. As a result, the
number of pre-op visits has been reduced and nurses have more
time to prepare patient data. On the day of surgery, more patients are
now fully informed, have received medical clearance, and have made
arrangements for post-op recovery. The nursing team is striving to
improve the assessment process even further, committing to a goal of
calling patients a minimum of 72 hours before their surgery dates.
Hybrid Cath Lab Improves Cardiac Services—and
Convenience
which treats irregular heartbeats, no longer require a commute to
Washington or Baltimore.
Nursing Support is Critical for Successful RobotAssisted Surgery
When MSMHC opened its hybrid catheterization lab a few years ago,
patients gained immediate access to an expanded range of healthcare
services, right in their neighborhood. Combining high-definition
imaging with specialized equipment and intervention capabilities
helps surgeons and interventional cardiologists coordinate approaches
to complex health problems. Services such as electrophysiology,
In 2015, the lab continued to streamline processes, allowing nurses
to monitor patients even more carefully and with a greater focus on
safety. This year and beyond, MSMHC interventional physicians will
continue to rely on nurses’ critical skills and ongoing training for
support.
Use of robot-assisted surgery is growing exponentially in the
healthcare field. Because this exciting technology is minimally invasive
and improves precision, it can reduce patients’ pain and shorten
hospital stays. It also provides opportunities for increased collaboration
between nurses and surgeons. With tools such as the da Vinci robot,
MSMHC has the technology to meet the increasing need and provide
patients with the most advanced healthcare available.
Page 14 - 2015 Nursing Annual Report
Josephine Gloria, Surgical Tech, and Ann Cunningham, RN
Robot-assisted surgery, however, requires highly trained surgeons with
exceptional professional knowledge and refined skills. The support
team must be just as specialized as the surgeons, and participate in
ongoing education programs and frequent simulations to keep their
skills current. At MSMHC, robot-assisted surgery is benefitting many
patients, as well as the nurses who care for them. This past year, more
MSMHC nurses opted to strengthen their career opportunities with
specialized training.
Market Leadership - Page 15
Fiscal Strength
Streamlined Supply Chain Means More Time for
Patients, Less for Paperwork
Visibility Boards Monitor Patient Safety
Around the Clock
IMPPACT software standardizes and automates businesses processes
and information sharing across the MedStar network. In 2015,
IMPPACT was a key factor in helping the MSMHC nursing team
increase efficiency by managing its supply budget.
Whether you’re in a hallway, a nurses’ station, or the ED, you can check
on a patient’s status: just look up at a visibility board. MSMHC was the
first hospital in MedStar’s network to use visibility boards, and they’ve
quickly become a valuable tool for supporting safe, effective care.
IMPPACT improves the accuracy of each transaction by showing where
supplies are delivered and the quantity available in each department,
as well as usage, pricing, and other data. Because the system also
reduces paperwork, nurses have more time available to serve patients.
The boards not only provide 24-hour visibility, they also collect patient
data. They access real-time information from the EMR, environmental
services, and other hospital systems to monitor clinical measures, and
use color and icons to display a room’s layout, availability, and status.
This provides real time communication to the health care team to
help improve patient outcomes. The visibility board displays real time
clinical and safety alerts that flow from the patient’s electronic medical
record.
By centralizing and standardizing supplies throughout MSMHC and
the MedStar network, IMPPACT not only manages supply cost and
demand, it also coordinates with our sister hospitals so we can obtain
specific products if the need arises. In addition, IMPPACT’s supply
chain model improves resource alignment with clinical service areas.
In the long term, it will contribute to MSMHC’s fiscal strength by
supporting market growth and sustainability.
Page 16 - 2015 Nursing Annual Report
Nursing Retention is Improving at MSMHC
Turnover rates at MSMHC have averaged about 16%. But turnover is
more than a number: it has far-reaching consequences. For the nursing
department, attrition means new nurses must be recruited, trained,
and allowed time to be orientated and become productive. Retention
is important, as the financial cost of losing a single nurse has been
calculated to equal up to twice the nurse’s annual salary.
MSMHC continues to pay close attention to key statistics involving
nurse vacancy and turnover. We are working diligently to fill
vacant positions quickly by improving initiatives to recruit nurses.
Nurses who choose to pursue a career with MSMHC have access
to generous associate benefits, opportunities to further education,
and the possibility of career advancement within the organization.
There’s another benefit to our improved retention: increased nurse
satisfaction, which can have a positive impact on our patient’s
experience with their care.
Fiscal Strength - Page 17
MedStarSouthernMaryland.org
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Clinton, MD 20735
301-868-8000 PHONE