the Nursing Annual Report

2014-2015 NURSING ANNUAL REPORT
TABLE OF CONTENTS
01 Message from the Chief Nursing Officer
02 Nursing at Memorial Hermann Memorial City Medical Center
07 Transformational Leadership
08 Structural Empowerment
19 Exemplary Professional Practice
25 New Knowledge, Innovations and Improvements
31 Empirical Outcomes
Message from the Chief Nursing Officer
I always welcome the opportunity to feature and talk about our professional nurses here at Memorial
Hermann Memorial City Medical Center. There is so much to be proud of at our hospital.
The passion and compassion evident in the care our nurses deliver every day at Memorial Hermann
Memorial City is truly amazing. Having earned designation as a Magnet® hospital in 2009, and in the
process of undergoing redesignation in 2015, it is clear that our nurses have made the commitment to
sustain the highest excellence in nursing practice.
We consistently challenge ourselves to do more for our patients and more for our community. Our nurses
are furthering their professional education, achieving new certifications and participating in Professional
Nurse Development councils across the facility, all with the goal of serving our patients better while
advancing their careers as registered nurses.
Our nurses continue to have a voice in their professional practice. Their voices are heard through our
unit-based councils and facility-wide shared governance councils. With their focused and enlightened
perspective from the bedside, they frequently bring new ideas and improvements forward. Many of their
ideas have been implemented hospital-wide.
At Memorial Hermann Memorial City, our nurses’ hearts and hands often work outside the hospital walls
as they take personal time to volunteer for the community. Our nurses partner with and mentor students
pursuing a career in health care. They’re developing our future and shaping the healthcare workforce.
Whether you’re an experienced nurse, a new graduate, a nursing student or an individual who is
considering nursing as a potential career choice, I think you’ll be impressed by what it means to be a
Memorial Hermann Memorial City nurse.
As we are focused on creating our future in our efforts to improve and refine the clinical care
and services we provide to every patient and family member, I invite you to learn more about our
accomplishments highlighted in this report. We’re so very excited to share our clinical results, our
accomplishments and our commitment to our profession with you. Please drop me a note to let me
know what you think at [email protected].
Dan Kelly, M.B.A., B.S.N., RN
Vice President, Chief Nursing Officer
MEMORIAL HERMANN MEMORIAL CITY MEDICAL CENTER
1
“It was a nurse who held
me, aided me, saved me,
helped me, taught me,
inspired me.” – Unknown
2
Nursing at
Memorial Hermann
Memorial City
Medical Center
The Nursing Mission: to advance the health of our
community by partnering with patients, families and
physicians to provide patient-centered, quality care, in a
collaborative environment while promoting growth and
operational excellence.
The Nursing Vision: to promote trusting partnerships that
deliver the best patient experience, through the selection,
development, and retention of the highest performing
nurses, while creating systems that achieve consistency
and excellence in patient care.
The Nursing Pledge: As a nurse at Memorial Hermann
Memorial City Medical Center, I believe in making a positive
difference for those I serve through compassionate,
innovative, and evidence-based nursing care.
Nursing Strategies
• Provide highly reliable, customer-centered nursing
care with a focus on service excellence, quality and safe
clinical practice
• Enhance the professional image of nursing
• Partner with physicians to improve patient care outcomes
• Drive high-quality outcomes by protecting, promoting,
and optimizing the health and wellbeing of the patients
we serve
• Advance the professional growth of nurses to expand
our service to the community
• Optimize and demonstrate fiscal responsibility
3
Our Mission: to advance
the health of our
community by partnering
with patients, families,
and physicians to provide
patient-centered, quality
care, in a collaborative
environment while
promoting growth and
operational excellence.
The Nursing MVP
(Mission, Vision and Pledge)
As a professional nurse at
Memorial Hermann Memorial City Medical Center
My Nursing Pledge: As a nurse at Memorial Hermann
Memorial City Medical Center I believe in making a
positive difference for those I serve through compassionate,
innovative, and evidenced-based nursing care.
Pillar:
Patients
Pillar:
People
Pillar:
Physicians
Pillar:
Quality & Safety
Pillar:
Growth
Pillar:
Operational
Excellence
Provide highly
reliable, customercentered nursing
care with a focus on
service excellence,
quality, and safe
clinical practice.
Enhance the
professional image
of nursing.
Partner with
physicians to
improve patient care
outcomes.
Drive high quality
outcomes by protecting,
promoting, and
optimizing the
health and
wellbeing of the
patients we serve.
Advance the
professional growth
of nurses to expand
our services to the
community.
Optimize and
demonstrate fiscal
responsibility
Nursing Goals:
Nursing Goals:
Create an
environment that
inspires professional
development
through internal and
external educational
opportunities.
Increase employee
retention through
best practices in staffing.
Nursing Goals:
Enhance and utilize
a culture that
maximizes customer
experience through
hourly rounding,
leadership rounding,
bedside report and
accountability.
Reduce readmission
through effective
communication and
education of patients
and families from
admission to discharge.
Nursing Goals:
Hire and retain a
diverse, caring,
compassionate,
connected, and
committed staff
through shared
governance.
Improve
interdisciplinary
collaboration as
the coordinator of
the patient’s care.
Advance health
with a passion and
inspiration for
patient and family
centered care.
Nursing Goals:
Achieve effective,
high quality,
nurse-physician
communication.
Promote a positive
culture for
nurse-physician
relationships.
Engage
physicians in the
implementation
of evidence-based
practice to ensure
high quality patient
outcomes.
Utilize evidence
based practice and
research in all
patient care areas.
Eliminate serious
safety events, falls
with injury, and
hospital acquired
infections.
Utilize data
to drive process
improvement.
Memorial Hermann Memorial City nurses demonstrate
excellence by emulating the core values of quality
patient care, continuous improvement, partnerships,
and professional development and growth. This allows
them to elevate the professional image of nursing as
reflected in increased accountability, leadership and
fiscal responsibility.
Since 2009, Memorial Hermann Memorial City has
been designated by the ANCC’s Magnet Recognition
Program®. Ultimately, Magnet designation is reflective
of nursing care and quality and is considered the
highest level of recognition the profession can receive.
4
Our Vision: to promote
trusting partnerships that
deliver the best patient
experience through the
selection, development,
and retention of the
highest-performing nurses,
while creating systems
that achieve consistency
and excellence in
patient care.
Promote academic
partnerships and
improved talent
acquisition processes.
Pursue new patient
populations through
the creation and
expansion of services.
Dan Kelly
Vice President and
Chief Nursing Officer
Nursing Goals:
Optimize supply
costs and improve
resource utilization
to ensure the right
supplies and
equipment are
available for the
right patient at the
right time.
Standardize care
and improve
efficiency in patient
flow using current
technology.
Organizations that obtain the designation must
consistently outperform national benchmarks
regarding nursing and patient satisfaction
scores and nursing-sensitive indicators including
Catheter-Associated Urinary Tract Infection (CAUTI),
Hospital-Acquired Pressure Ulcers Stage II (HAPU
Stage II and Above), Central Line-Associated
Bloodstream Infections (CLABSI) and Patient Falls.
Research supports that Magnet facilities foster
an environment conducive to achieving improved
patient safety outcomes.
MEMORIAL HERMANN MEMORIAL CITY MEDICAL CENTER
NURSING ORGANIZATIONAL CHART
Paul O’Sullivan, CEO
Dan Kelly, Vice President, CNO
Office of Designations
Magnet & Baldrige Coach
Mary Poe
Sr. Admin. Director,
Women’s & Children’s
Karen Childs
Mary Poe
Sr. Admin. Director,
Critical Care
Patricia Howell
Sr. Admin. Director,
Med/Surg
Maryellen McGlothlin
Sr. Admin. Director,
Nursing Services
Vacant
Sr. Admin. Director,
Emergency Services Adult
Harold Engle
Director, MFM/OB Special
Care, OBED L&D
Lynneece Rooney
Director, MICU/SICU
Margie Witt
Director, 6M/7M
Mila Goldstein
OAs
Patricia Howell
Manager, ED
Melanie Aluotto
Director, Dialysis
Margie Witt
Manager, 6M
Olu Funke
Float Pool
Harold Engle
Emergency Services
Pediatric ED
Manager, MICU
Dora Barrows
Manager, 7M
Vacant
Director, CRM
Shayla Preston
Manager, CDU
Chauntelle Long
Manager, SICU
Prince Balason
Director, 5E/7E
Barbara Thomas
Director, Volunteer Services
Bailey Curtis
Director, Neurosciences
Angela Dever
Manager, 5E
Purisma “Dolly” Vingco
Manager, Chaplaincy Services
Rick Chandler
Manager, IMCU
Pamela Mare
Manager, 7E
Elizabeth Bench
Project Manager, Magnet
Nadia Saiphoo
Manager, Neuro ICU
Jason Hayes
Director, 6E
Maria Jardiolin
Educators
Maryellen McGlothlin
Manager, Labor & Delivery
Jennifer Johnson
Manager, Family Life Center
Robin Gray
Manager, NICU, Pediatrics
Kevin Hart
Updated 5/21 /2015
Using components of the Magnet Model (on right),
our nursing leaders and clinical nurses transform
practice through empowerment of our staff and
use of our shared governance model to evaluate
and implement evidence-based interventions.
These innovations raise the bar on quality for nurses
at the bedside, creating an exemplary practice
environment for generating new knowledge
and improvements. As a result, excellence in
patient outcomes is achieved and supported by
empirical findings.
Program Specialist,
Emergency Management
Mike Barron
Manager, 6E
Jenneta Manning
MAGNET MODEL
s in Nursing & Healt
hC
Issue
l
a
are
b
o
l
G
Structural
Empowerment
Transformational
Leadership
Empirical
Outcomes
Exemplary
Professional
Practice
New Knowledge,
Innovations, &
Improvements
5
Senior Nurse Leaders at
Memorial Hermann Memorial City
Dan Kelly, M.B.A., B.S.N., RN
Vice President and
Chief Nursing Officer
Harold Engle, M.B.A., B.S.N., RN, CCRN-K
Senior Administrative Director,
Emergency Services
Karen Childs, M.S.N., B.S.N., RN-OB
Senior Administrative Director,
Women’s & Children’s
Mary Poe, M.S.N., B.S.N., RNC
Office of Designation,
Magnet & Baldridge
Maryellen McGlothlin, B.S.N., RN, NE-BC
Senior Administrative Director,
Medical/Surgical Services
Patti Howell, M.B.A., B.S.N., RN, CCRN-K
Senior Administrative Director,
Critical Care
Transformational
Leadership
In 2014, Memorial Hermann Memorial City nurses were
empowered to advocate for both fiscal and technology
resources. The process involves nurse leaders rounding
with direct care nurses monthly and asking each of
them, “Do you have the basic tools and equipment
to do your job?” This had an enormous impact in
improving the clinical nursing environment across the
Memorial Hermann Memorial City campus.
Nursing leaders at all levels of a
Magnet-recognized organization must
demonstrate advocacy and support on
behalf of staff and patients to transform
values, beliefs and behaviors.
The CNO must be strategically positioned within the
organization to effectively influence other executive
stakeholders, including the board of directors/trustees.
Nursing’s mission, vision, values and strategic plan
must align with the organization’s priorities to improve
performance, wherever nursing is practiced. Mechanisms
must be implemented for evidence-based practice to
evolve and for innovation to flourish. As a result, nurses
throughout the organization should perceive their voices
are heard, their input is valued, and their practice is
supported.
– A New Model for ANCC’s
Magnet Recognition Program, 2014
As an example, Administrative Director of Medical
Surgical Services Maryellen McGlothlin, B.S.N., RN,
rounded on several medical surgical units. On one of
these units, McGlothlin met with a direct care nurse who
requested a microwave, a refrigerator, and a workstation
on wheels (WOW). This request was documented using
the Spotlight Report. Requests from medical surgical
nurses on the 7 East/Cardiology unit Stoplight Report
included an additional BP machine, two microwave
ovens, a refrigerator, lockers, backboards, thermometers
and bedside commodes.
Stoplight Report
The Stoplight Report is a tool used to document the direct
care nurses’ needs for fiscal and technology resources.
This helps to transform the clinical work environment in
practical ways, which is in line with the Memorial Hermann
Memorial City Nursing Strategic Plan that directly impacts
quality, safety, patients, operational excellence, people,
physicians and growth. The Stoplight Report is reviewed
each month with the direct care nurses.
As a result of this collaboration, all of the nurse requests
were granted. Additional WOWs were also purchased
so that direct care nurses could continue to improve on
developing personal and professional technology skills and
continue to provide best nursing practices.
7
Structural
Empowerment
The second of the five Magnet model components,
Structural Empowerment, is integral to ensuring
that nurses have the tools they need to be
the central part of the patient care decisionmaking process. The ANCC describes Structural
Empowerment as follows:
Solid structures and processes developed by influential
leadership provide an innovative environment where strong
professional practice flourishes and where the mission, vision,
and values come to life to achieve the outcomes believed to
be important for the organization. Further strengthening
practice are the strong relationships and partnerships
developed among all types of community organizations to
improve patient outcomes and the health of the communities
they serve. This is accomplished through the organization’s
strategic plan, structure, systems, policies and programs.
Staff needs to be developed, directed and empowered to
find the best way to accomplish the organizational goals and
achieve desired outcomes. This may be accomplished through
a variety of structures and programs; as one size does not fit all.
– A New Model for ANCC’s
Magnet Recognition Program, 2014
9
STRUCT U R AL EM POW E R M E NT
Memorial Hermann Memorial City Medical Center
Shared Governance Councils Structure
Professional
Nursing
Development
Council
Nursing
Research
and EvidenceBased Practice
Council
Nursing
Leadership
Council
Nurse
Staffing
Effectiveness
Council
Unit-Based
Councils
Magnet
Champs
Nursing
Quality
Council
Professional
Nursing
Practice
Council
Revised 4/16/2015
Nursing Shared Governance Council
Our Shared Governance councils, which are nurse-driven,
support and demonstrate structural empowerment.
Each council has a chair and a co-chair who are
appointed or elected by the council members, who
are bedside care nurses. Each council is guided by a
specific mission and accountabilities, as described in
the Memorial Hermann Memorial City nursing bylaws,
which allows them to focus on different aspects related
to improving nurse practices.
12
10
• Professional Development Council
Mission:
• Define educational needs, structures, and
processes as they pertain to building a culture of
nursing excellence that attracts and retains quality
nurses, and develops rewards and recognition.
• Collaborate with Human Resources to determine
the structures and processes to recruit and retain
quality nurses.
• Develop in partnership with clinical nurse educators
to provide unit-based education and incentives
related to new knowledge and nurse recruitment,
retention, reward and recognition.
• Develop and guide formal and informal reward and
recognition of nurses.
• Participate in planning the annual Nurses Week,
Certified Nurses Day™, and other nurse-related
celebrations.
• Promote nurses’ individual accountability and team
ownership of retaining best nurses..
STRUCTUR AL EM POW ERM ENT
• Professional Practice Council
Mission:
• Support and implement the standards of the
nursing practice.
• Define the roles and responsibilities of patient care
support staff.
• Evaluate and implement evidence-based practices.
• Incorporate nursing research findings into clinical
practice as appropriate.
• Participate in the improvement of patient care
and safety.
• Participate in the improvement of employee safety
and address multidisciplinary issues that impact
patient care areas.
• Participate in the review and recommendation of
products and equipment brought into the patient
care areas.
• Review and approve applications and make
recommendations for clinical ladder advancement.
• Nursing Quality Council
Mission:
• Define structures and implement nursing quality
improvement programs.
• Collaborate in nursing continuing education and
patient education programs.
• Support evidence-based clinical practice, nursing
outcomes, and empirical outcomes.
• Integrate nursing performance improvement
programs with the hospital quality improvement
system (Six Sigma).
• Evaluate the effectiveness of the quality
improvement programs and make
recommendations to appropriate departments,
committees, and organizations.
• Assess and reassess both patient education and
nursing continuing education as it relates to quality
of care.
• Promote, facilitate, and evaluate the use of
evidence-based nursing practices on unit.
• Research and Evidence-Based Practice
Mission: Research and Evidence-Based Practice
(EBP) are essential to providing excellent nursing
care. Nurses define problems and use a process
where they improve their knowledge and skills
to affect positive clinical changes and outcomes.
A Research and EBP culture requires a structured
collaborative approach from nurses at all levels, as
well as an interdisciplinary problem-solving approach.
Use of Research and EBP in nursing is essential
to patient-centered care and safety, efficiency,
timeliness, equity and excellence.
• Nurse Staffing Council
Mission:
• Positively impact and address staffing-related
issues that affect the safety and quality of patient
care and nurse practices.
• Return the control of nursing practice back to those
having direct patient care, and return autonomy to
the workplace.
• Review risk indicator for nursing dynamics (e.g.,
staffing grids, actual staffing data, recruitment and
retention).
• Determine how correlation data (e.g., fall data)
applies to patient care and ascertains if there is a
correlation or not.
• Review staffing policies and accept input from all
areas of the hospital to ensure the needs of our
patients are being met.
• Provide direct care nurse input and
recommendations to the Nurse Staffing Plan to
ensure that we comply with the Texas Nursing Safe
Staffing Law (Senate Bill 476).
• Review skill mix and nurse characteristics with staff
to ensure that quality care is available on all shifts
and units.
11
STRUCT U R AL EM POW E R M E NT
DAISY Award
DAISY is an acronym for Disease Attacking the
Immune System. The DAISY Foundation was formed
in November 1999, by the family of J. Patrick Barnes,
to honor the exceptional nurses who cared for
J. Patrick until his death at age 33 from complications
of idiopathic thrombocytopenic purpura.
The DAISY Award recognizes one nurse each month
for going above and beyond to deliver exceptional
patient care. The Memorial Hermann Memorial City
DAISY Program recognizes extraordinary nurses who
have been nominated for their compassion and clinical
skills provided to patients and families.
12
2014/2015 DAISY Winners
• Anton DeGuzman, A.D.N., RN, 7M
• Ian Binns, B.S.N., RN, 7M
• Tiffany Hatch, B.S.N., RN, CDU
• Sophie Harris, B.S.N., RN, NICU
• Nhu Do, B.S.N., RN, 7E
• Alberto Galvan, B.S.N., RN, MICU
• Ihechi Nwachokwu, B.S.N., RN, 7M
• Roselyn Flauta, B.S.N., RN, SICU
• Trinh Linh, B.S.N., RN, 7M
• Laura Wueste, A.P.R.N., RN
• Marisa Ehrich, RN, FLC
STRUCTUR AL EMPOW ERM ENT
COMMITMENT TO PROFESSIONAL DEVELOPMENT
CURRENT CERTIFICATIONS FOR NURSING BY SPECIALITY
Certified Case Manager
Jennifer Johnson, CCM
Kathleen Nipper Johnson, CCM
American Case
Management Certification
Stephanie Campbell, ACMA
Karen Charba, ACMA
Sharon Humphreys, ACMA
Deborah Tarner, ACMA
Fellow American Academy
of Case Management
Certification
Elaine Cavenall, FAACM
Rossanny Cerino, FAACM
Joanna Davidson, FAACM
Marietta Guinhin, FAACM
Sharon Humphreys, FAACM
Abeni Jones, FAACM
Leilani McCarthy, FAACM
Gail McNeal, FAACM
Judy Roberson, FAACM
Shelia Rougeaux, FAACM
Certified Diabetes
Educator
Nadia Saiphoo, CDE
Gail Llewellyn, CDE
Certified Nurse Midwife
Lynneece Rooney, CNM
Certified Emergency Nurse
Melanie Aluotto, CEN
Kara Edwards, CEN
Lauren Ivanhoe, CEN
Steven Talbot, CEN
Marcie Woodard, CEN
Certified in Infection
Control Certified Nurse
Manager Leader
Helen Nielsen, CNML
Margie Witt, CNML
Certified Low Risk Newborn
Jocelyn Guzman, RNC-LRN
Certified Neonatal
ICU Nurse
Roxanne Cabori, RNC-NIC
Sophie Harris, RNC-NIC
Kevin Hart, RNC-NIC
Karen Parthum, RNC-NIC
Cathy Singer, RNC-NIC
Amy Theall, RNC-NIC
Certified Nurse Executive
Annette Conley, NE-BC
Louise Hernandez, NE-BC
Daphney Jacques, NE-BC
Maryellen McGlothlin,
NE-BC
Certified Advanced
Nurse Executive
Bernadette Pollard, NEA-BC
Certified Nurse
Operating Room
Jennifer Amedio, CNOR
Anjanette Bryant, CNOR
Rebecca Burt, CNOR
William Coakley, CNOR
Denise Collins, CNOR
Constance Curtis, CNOR
Nathalie Desinor, CNOR
Ann From, CNOR
Deborah Lucas, CNOR
Dina Roane, CNOR
Bernita Russo, CNOR
Barbara Sparks, CNOR
Adoracion Tangalin, CNOR
Certified Orthopedic Nurse
Maria-Belen Jardiolin, ONC
Joseph Galvan, ONC
Jenneta Manning, ONC
Thelma Redondiez, ONC
Certified Wound, Ostomy
and Continence Nurse
Barbara Kebodeaux, CWON
Nnenna Nelson, CWON
Larry Ong, WCC
Critical Care Registered Nurse
Clinton Alsup, CCRN
Jennifer Amedio CCRN
Tammera Averette, CCRN
Brenda Borhary, CCRN
Laurie Brumley, CCRN
Marian Buado, CCRN
Jeanne Caneda, CCRN
Nelia Collado, CCRN
Margaret Conner, CCRN
Irene DeLeon, CCRN
Nida Dumantay, CCRN
Soyna Gaines CCRN
Michael Garcia, CCRN
Hilaria Gascon, CCRN
Katharine Hicks CCRN
Linda Holifield, CCRN
Andronico Inocenio, CCRN
Daphney Jacques, CCRN
Trudy La, CCRN
Maria Luz, CCRN
Robert Malinsky, CCRN
Jacquelyn Marchman, CCRN
Irene Martin, CCRN
Mariam Namakar, CCRN
Ibrahim Noubani, CCRN
Barbara Paredes, CCRN
Paige Percoski, CCRN
Suzy Robinson, CCRN
Diane Stephenson, CCRN
Jean Talosi, CCRN
Joseliza Tan, CCRN
Rubylyn Toquero, CCRN
Vicki Trask, CCRN
Lisa Verbeke, CCRN
Yu Wang, CCRN
Felisa Wong, CCRN
Amy Wriht, CCRN
Critical Care Registered
Nurse-Knowledge
Harold Engle, CCRN-K
Patty Howell, CCRN-K
Cardio-Vascular
Certified Nursing
Maria Meneses, CVCRN
Certified Bariatric Nurse
Debbie Cook, CBN
Suzanne Hovis, CBN
Trudy Ivins, CBN
Laura Moreno, CBN
Caroline Wesgona, CBN
Certified
Gastroenterology Nurse
Josefina Bernstein, CGN
Staci Norman, CGN
Vicki Norman, CGN
Cary Yeary, CGN
Certified Medical Surgical
Registered Nurse
Ida Aristizabel, CMSRN
Martha Awotwe, CMSRN
Liz Bench, CMSRN
Monica Climaco, CMSRN
Charlotte Elizondo, CMSRN
Mureal Escano, CMSRN
Staci Forcade, CMSRN
Maria Hurtado, CMSRN
Maria Lapat, CMSRN
Maudheler Lewis, CMSRN
Carla Mondelli, CMSRN
Isioma Okoye, CMSRN
Alana Pollard, CMSRN
Jenn Rivas, CMSRN
Olofunke Taiwo, CMSRN
Barbara Thomas, CMSRN
Purisima Vingco, CMSRN
Maria Wilson, CMSRN
13
STRUCT U R AL EM POW E R M E NT
COMMITMENT TO PROFESSIONAL DEVELOPMENT
CURRENT CERTIFICATIONS FOR NURSING BY SPECIALITY
Healthcare Quality
Debbie Garbade, CPHQ
Certified Patient
Safety Officer
Debbie Garbade, CPSO
Certified Healthcare
Risk Management
Ellen Davis, CPHRM
Debbie Garbade, CPHRM
Certified Neuroscience
Registered Nurse
Nelia Collado, CNRN
Guoqing Fan, CNRN
Amy Lewis, CNRN
Maryann Mendoza, CNRN
Paige Percoski, CNRN
Perianesthesia Certified
Registered Nurse
Vivien Swaren, CPAN
Stroke Certified
Registered Nurse
Angela Dever, SCRN
Paige Percoski, SCRN
Electronic Fetal Monitoring
Leah Burnitt, EFM
Angela Fraizer, EFM
Jennifer Johnson, EFM
Kystal Wilkins, EFM
Barbara Wilson, EFM
14
Certified Obstetric
Registered Nurse
Kathy Armitage, RNC-OB
Leah Burnitt, RNC-OB
Lucia Champange, RNC-OB
Karen Childs, RNC-OB
Brandy Duffy, RNC-OB
Angela Frazier, RNC-OB
Veronica Gaston, RNC-OB
Robin Gray, RNC-OB
Bridget Ikejimba, RNC-OB
Jennifer Johnson, RNC-OB
Margo Makowski, RNC-OB
Jennifer Maiorana, RNC-OB
Shean Manickchan, RNC-OB
Gail Matejka, RNC-OB
Teena Middleton, RNC-OB
Jennifer Rocha, RNC-OB
Lynneece Rooney, RNC-OB
Barbara Wilson, RNC-OB
Certified Hospice and
Palliative Care
Corrine Ferchak, CHPN
Tracie Meeks, CHPN
Certified Breastfeeding
Counselor
Lucia Champange, CBC
International Board
Certified Lactation
Consultant
Aida Alinsub IBCLC
Susan Boehning IBCLC
Rebecca Ovbiaele IBCLC
Heather Sanderson IBCLC
Leslie Trevino IBCLC
Evelyne Volny IBCLC
Certified Lactation
Counselor
Foluke Akinola, CLC
Maternal Newborn Nursing
Amor Ballestero, RNC-MNN
Mimoza Duraj, RNC-MNN
Irma Garza, RNC-MNN
Erica Huckaby, RNC-MNN
Lucy Langley, RNC-MNN
Rebecca Ovbiaele,
RNC-MNN
Memusa Paez-Cabangon,
RNC-MNN
Mary Poe, RNC-MNN
Oncology Certified Nurse
Arrian Amini, OCN
Jessica Burgess, OCN
Maritess Castilan, OCN
Constance Curtis, ONC
Karen Davin, OCN
Nancy Evans, OCN
Anton De Guzman, OCN
Mila Goldstein, OCN
Certified Cardiac
Rehabilitation Professional
Donna McFadyen-Taylor,
CCRP
Certified Pediatric Nurse
Holly Beck, CPN
Jan Davis, CPN
Jody Duncan, CPN
Penny Kakoolaki, CPN
Lisamma Kurian, CPN
Josephine Larbi, CPN
Jessica Oliveira, CPN
Cecilia Pangandoyon, CPN
Aimee Strech, CPN
Association of
Pediatric Hematology/
Oncology Nurses
Ashlyn Ward, APHON
Certified Pediatric
Hematology/
Oncology Nurse
Mary Higan, CPHON
Trauma Nurse
Certification
Claire Lasiewski, TNCC
STRUCTUR AL EM POW ERM ENT
Certified Nurses Day TM Celebration
Charge Nurse Academy
Memorial Hermann Memorial City promotes leadership
at the point of care and enhances competencies at all
levels. Memorial Hermann Memorial City knows that
charge nurses play a pivotal role in providing leadership,
and are vital to the overall improvement of patient
outcomes and effective management of the nursing
unit. The Charge Nurse Academy curriculum includes
healthcare economics/finance, effective communication,
conflict management, resource management and
self-development.
900
800
500
700
400
600
500
300
400
200
300
200
100
0
BSN
MSN
Total RN Count
Total RN Count
Staff Count BSN/MSN
Certified Nurses Day is a national day to honor and
recognize the important achievement of nursing
specialty and subspecialty certification. Certification
is a milestone of personal excellence along the
professional journey.
Memorial City Nursing Education Trend
600
100
FY2013 Q1 FY2013 Q2 FY2013 Q3 FY2014 Q1 FY2014 Q3 FY2014 Q4 FY2015 Q1
363
372
358
324
393
430
502
19
20
14
9
17
32
25
599
613
605
516
667
752
781
0
*No data for FY13 Q4 or FY14 Q2
15
STRUCT U R AL EM POW E R M E NT
Nurse Practitioners
Insertion of PICC Lines and Dressing Changes
Memorial Hermann Memorial City has employed
advanced practice registered nurses (APRNs) since
2011. Their hard work, attention to detail, and patientcentered care has resulted in the cardiovascular program
receiving a three-star rating from the Society of Thoracic
Surgery. This award has elevated the Memorial Hermann
Heart & Vascular Institute-Memorial City cardiovascular
program to the top 8% of cardiovascular surgery
programs in the United States. The APRNs had a direct
impact on achieving this award based on meeting 100%
compliance with the required medications at discharge,
a decrease in the length of stay by two full days, a
decrease in readmission rates, and an overall increase in
patient satisfaction and consulting physician satisfaction
with the cardiovascular surgery service at the Institute.
Memorial Hermann Memorial City leadership promotes,
encourages, and supports the active participation of all
nursing staff in professional nursing organizations.
The Memorial Hermann Memorial City Peripherally
Inserted Central Catheter (PICC) team nurses attend the
Infusion Nurse Society (INS) and Association for Vascular
Access (AVA) chapter meetings. Through participation
in these professional nursing organizations, the
importance of avoiding hospital-acquired conditions,
particularly CLABSIs, is emphasized. Dora Li, M.S.N.,
RN, CRNI VA-BC, attended the Association for Vascular
Access Annual Scientific Meeting and returned to the
organization with a plan to provide more intensive
education for direct care nurses in dealing with access,
maintenance, and care of central lines.
In February 2014, the PICC team collaborated with
critical care educators to develop an educational
program for the Intensive Care Unit (ICU) nursing staff
that defined the interventions required for the proper
use, maintenance and care of central lines in order to
decrease the risk of CLABSIs. Best practice guidelines
from the American Association of Critical-Care Nurses
(AACN), the INS and AVA were used to develop the
educational program.
The education included instruction on maintenance
of central lines, causes of occlusions, dressing
change techniques, directions regarding medications
and adverse reactions. The educational offering was
held during the ICU annual competencies in March
2014, and included various teaching methodologies:
explanation, discussion, handouts, questions and
answers, and return demonstration. All nurses
employed by SICU, MICU, IMCU and Neuro ICU
received this education.
16
STRUCTUR AL EM POW ERM ENT
In the fourth quarter of 2013, the CLABSI rate in
all ICUs (SICU, MICU, IMCU, Neuro ICU) was 3.28.
After implementation of these interventions, in the
second and third quarter of 2014, the CLABSI rate
in all ICUs decreased to 2.5.
instructor contacts Maryellen McGlothlin, B.S.N., RN,
the administrative director of Med/Surg at Memorial
Hermann Memorial City, several months prior to the
start of the upcoming semester and identifies the
number of preceptors needed. At the same time the
school will submit a clinical placement request form.
McGlothlin sends an email to all nursing managers and
directors to ask if there is willingness to precept a
HBU management student. The resources allocated by
Memorial Hermann Memorial City include approximately
120 hours of nursing leadership time for precepting an
RN management clinical practicum. Additional resources
allocated include the use of a conference room for the
student’s weekly pre- and post-conference with the
nursing instructor.
Affiliations with Schools of Nursing
Memorial Hermann Memorial City is committed to
the health of the community and participating in and
supporting nursing’s involvement in education and
community projects. The nursing strategic plan promotes
growth through academic partnerships and improved
talent acquisitions. One objective within the strategic
plan is to support growth and nursing leadership
while advancing the professional growth of nurses to
expand our services to the community.
To support this nursing goal, resources are allocated for
affiliations with schools of nursing during the budgeting
process. Key initiatives are discussed with nursing
leaders to determine what resources, human and
financial, are needed. Each school of nursing affiliation
starts with a student affiliation agreement between
Memorial Hermann Memorial City and the school entity.
Clinical and leadership preceptors are needed for
nursing students from many nursing schools. Houston
Baptist University (HBU) partners with Memorial
Hermann Memorial City for their senior management
student clinical rotations. The HBU lead nursing
Nursing students are assigned to specific nursing
leadership who volunteer their time to teach and mentor.
Nursing leaders participate in each student’s review
and reinforce skills that support current nursing
strategic initiatives. One of the initiatives is customer
service: enhancing and utilizing a culture that
maximizes customer experience as it relates to effective
communication and education.
17
“Quality is never an accident.
It is always the result of
deliberate intent guided by
sincere effort, intelligent
direction and skillful execution.
It represents the wisest choice
among many alternatives.”
12
Exemplary
Professional
Practice
The professional nursing team at Memorial Hermann
Memorial City is committed to providing the safest
quality care for our patients and families, and
that means taking advantage of every possible
opportunity to learn and share best practices
with their colleagues. This commitment to both
the art and science of nursing is what transforms
someone with a gift of caring for others into a
nurse of Exemplary Professional Practice.
As the third of five Magnet model components
for nursing, Exemplary Professional Practice is
defined as follows:
The true essence of a Magnet organization stems from
exemplary professional practice within nursing. This entails
a comprehensive understanding of the role of nursing; the
application of that role with patients, families, communities,
and the interdisciplinary team; and the application of new
knowledge and evidence. The goal of this Component is more
than the establishment of strong professional practice; it is
what that professional practice can achieve.
–A New Model for ANCC’s
Magnet Recognition Program, 2014
19
EXEMPL ARY PROFES SI O NA L P R ACTI CE
Fall Project
One of Memorial Hermann Memorial City’s safety initiatives
is to prevent patient falls. A hospital fall team was created
to develop best practices for fall prevention. The best
practices include: the use of the Post Fall Investigation
Tool, patients wearing yellow arm bands and yellow
socks to alert staff and family members, along with the
use of a fall sign on patient room doors. In addition, all
patient rooms display a “Please Call Stop a Fall” sign.
The Cardiology unit (7E) was chosen to be the pilot.
The goal was to decrease patient falls on the unit by
50 percent. The falls team used Define, Measure,
Analyze, Improve and Control (DMAIC) methodology
to identify critical factors leading to injurious falls, and
implemented targeted solutions to address the critical
factors. Periodic meetings of the fall team were held
and team members reported the following:
Define: Identified process issues of variation in
assessing presence of secondary diagnosis and
history of falls, patients unaware of falls risk levels,
subjectivity resulting in variation of interventions
selected, confusion on definitions of some interventions
(assistive devices, hip protectors, non-slip floor mats),
20
interventions selected on variance report either not in
use or not applicable, variations in reports.
Measure: Streamlined data collection process, implemented
new post-fall huddle tool, identified 28 contributing
factors. High priority factors: nurses not having completed
priorities, not rounding with purpose, staff not recognizing
patients in or out of the room, desensitization from treating
all patients at risk for fall. Completing high priority factors
resulted in a more accurate assessment and education of
fall risk. Memorial Hermann Memorial City also identified
patient education needs through interviewing patients and
their nurses.
Analyze: Implementation of robust data collection:
medication, call light response time, call light behaviors,
and change in condition. Through this analysis, Memorial
Hermann Memorial City found the following root causes
of falls on the Cardiology unit:
• Gender – males are injured more often than
females (66%)
• Lack of assistance – most falls with injury are
unassisted (93%)
• Bathroom-related activity prior to fall – injuries
related to the bathroom (54%)
EXEMP L ARY P RO FES S IO NA L PR ACTICE
• Inconsistent patient education about bed alarms –
patients interviewed said they were not educated on
falls (64%)
• Bed alarm not on – patients injured did not have
bed alarm on (54%)
• Not calling for help – patients with injuries had
called for help (0%)
• Staffing – fall injury rate correlates with vacancy rate;
the higher the vacancy rate, the higher the fall rate
and Safety Metrics indicate that the most consistent
injuries to RN staff over the past two years have been trips,
falls, and injuries related to patient handling and needle
sticks. As part of our process, these injuries are tracked
in our SafetyNet reporting system, which enables the
employee’s supervisor to complete an injury investigation.
The intent and focus of the Workplace Safety Initiative at
Memorial Hermann Memorial City has been to develop
a culture where direct care staff is mindful of their
actions at all times and they are empowered to speak up
about safety concerns. The percent of RN injury related to
needle sticks in April – June 2013 was 27.27%. Memorial
Hermann Memorial City’s goal was to increase workplace
safety for nurses by reducing the percentage of RN
injuries related to needle sticks.
Improve: Fall team met and identified 22 targeted
solutions to address 16 root causes. A robust improvement
plan was developed and implemented.
Control: Continued safety audits are performed to ensure
appropriate interventions are in place (bed/chair alarms
on, arm bands, white board communication, door tags).
Monthly monitoring of Fall with Injury Rate and Total Falls
Rate is communicated in a timely manner. Full support
and buy-in has been obtained with all stakeholders.
Through the utilization of the Professional Practice
Council, the Leadership Council, Education Resource
Specialists and direct care nursing, Memorial Hermann
Memorial City took the following steps to ensure direct
care nurse safety to prevent needle sticks. The suggestion
was to increase the use of Vacutainer® access devices
throughout the hospital. This new practice was taken to
the hospital Professional Practice Council. The Council
found that the Vacutainers® were not stocked on all the
Workplace Safety for Nursing
In July 2014, Memorial Hermann Health System announced
a renewed focus and prioritizing of employee safety.
Memorial Hermann Memorial City Occupational Health
RN Needle Stick Injuries
30.00%
I
n
t
e
r
v
e
n
t
i
o
n
Percent
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
% RN Injury related to
needle sticks
April - June
2013 (Q4 FY
2013)
27.27%
August 2013 Feb. 2014
April - June
2014 (Q4 FY
2014)
July - Dec.
2014 (Q1 &
Q2 FY 2015)
14.28%
8.75%
21
EXEMPL ARY PROFES SI O NA L P R ACTI CE
The intervention was effective and the percent of RN
injuries related to needle sticks was decreased from
27.27% to 8.75% by the fourth quarter of 2014.
Rapid Response Team
units and that the staff was not consistently trained
to use them. The Council agreed these items and
education needed to be available to all direct care staff.
The Professional Practice Council decided to take the
recommendation to the Leadership Council to add to
the unit’s PLR and determine education needs of staff.
The Rapid Response Team (RRT) was activated during
the second quarter of 2013. The dedicated RRT has
decreased the number of codes called and the number
of times physicians and nurses were pulled from their
unit to address codes. The goal was to increase the
number of RRT calls and reduce the number of codes
called. In February 2014, the RRT department was 75%
staffed and their duties included reviewing the code
blue responses, and assisting with patient assessments
and emergency interventions. In March 2014, the RRT
nurses began attending staff meetings to introduce
themselves and explain how they could partner with
direct care nurses: educating, starting IVs, assessing
septic patients, and designing and conducting mock
codes. By the fourth quarter of 2014, the number of
RRT calls had increased to 202 and the number of
codes had decreased to 7.
Rapid Response Team Activations and Number of Codes
Number of Activations/Codes
250
150
100
50
0
Codes
RRTs
22
Intervention
200
Q1-2013
6
80
Q2-2013
23
76
Q3-2013
20
113
Q4-2013
20
100
Q1-2014
13
111
Q2-2014
14
106
Q3-2014
13
171
Q4-2014
7
202
27
New Knowledge,
Innovations and
Improvements
Magnet-recognized organizations integrate
evidence-based practice and research into
clinical and operational processes.
Nurses are educated about evidence-based practice
and research, enabling them to appropriately explore the
safest and best practices for their patients and practice
environment while gaining new knowledge.
As the fourth of a five-component Magnet model,
New Knowledge, Innovation and Improvements is defined
as below:
Innovations in patient care, nursing, and the practice
environment are the hallmark of organizations receiving
Magnet recognition. Establishing new ways of achieving
high-quality, effective, and efficient care is the outcome
of transformational leadership, empowering structures and
processes, and exemplary professional practice in nursing.
–A New Model for ANCC’s
Magnet Recognition Program, 2014
25
N EW KN OW L EDG E, I NNOVATI O NS A ND I M P ROV E MENTS
Journal Clubs
Memorial Hermann Memorial City’s nurse-driven effort
to integrate best practices into the clinical environment
involved evaluating existing nursing practices through
Journal Clubs. Journal Clubs encourage nurses to review
evidence-based literature that may have an impact on
existing clinical practices.
A hospital-wide Journal Club was created by Pediatric
Nurse Educator Jessica Oliviera, B.S.N., RN, CPN,
to foster an evidence-based learning environment for
Memorial Hermann Memorial City nurses. A hospital-wide
presentation was given on the importance and benefits
of Journal Clubs. This served to support and encourage
the direct care nurses that attended to start individual
unit-based Journal Clubs. After attending the Journal Club
presentation, Amor Ballestro, B.S.N., RNC-LRN, charge
nurse in the Family Life Center, used the Journal Club’s
new knowledge as a platform for evaluating kangaroo
care at birth for full-term infants in the newborn nursery.
Kangaroo care is skin-to-skin contact with mother and
baby immediately after birth. The Journal Club provided
the necessary structure that enabled the nursery nurses
to evaluate the validity of kangaroo care for full-term
infants. This helped them to develop new knowledge and
skills, as they were already familiar with the importance
and necessity of providing kangaroo care in preterm
infants, but were not sure of its benefits or a needed
practice in full-term infants.
The process that Ballestro conducted included a
literature search that provided an article for the nursery
nurses to review via the Nursery Journal Club: Walters,
M., Boggs, K., Ludington-Hoe, S., Price, K., & Morrison,
B. (2007). Kangaroo Care at Birth for Full Term Infants
– A Pilot Study. MCN American Journal Maternal Child
Nursing. 2007 Nov-Dec; 32(6): 375-381.
26
The Nursery Journal Club met and reviewed the article,
and discussed their current practice compared to
the best practice identified in the article’s use of
kangaroo care for full-term babies. In addition, Ballestro
provided an article for the nursery nurses to review:
Cong, X., Ludington-Hoe, S., Vazquez, V., Zhang, D., &
Zaffetti, S. (2013). Ergonomic Procedure for Heel Sticks
in Kangaroo Care (Skin-to-Skin) Position. Neonatal
Network, 2013; 32(5):353-357. After a review of the
evidence, the recommendation was made to incorporate
kangaroo care into newborn nursery practice.
Surgical Attire Policy and Procedure
Many of the nursing policies and procedures that guide
nursing practice at Memorial Hermann Memorial City
originate at a Memorial Hermann system level to ensure
consistency in nursing practice across the system.
The System and Entity Policy, Procedure and Guideline
(PP&G) process is set up to enable all staff to have access
to approved PP&Gs and to facilitate consistency in
the development and management of PP&Gs. When
a question, concern, or issue arises with an existing
nursing practice, and there is a PP&G involved, the item
is brought to the attention of the document owner who
is the Chief or Director responsible for owning a particular
policy, procedure, or clinical guideline, and for its periodic
review or update. The document owner assigns content
experts to review the issues and revise or write the
policy or procedure. Throughout the review process,
the policy is sent and reviewed by the PP&G committee
as well as stakeholders, which are interdisciplinary
healthcare providers (i.e., Critical Care Council, Med-Surg
Council, Physician Committees, Pharmacy), to ensure
the written information reflects their input and is accurate
and evidence- based.
For example, a Surgical Site Infection (SSI) task
force was created with the intention of eliminating SSIs
at Memorial Hermann Memorial City. The task force
consisted of a hospital-wide multidisciplinary team that
In June of 2013, a hospitalwide Journal Club was created
by Pediatric Nurse Educator
Jessica Oliviera, B.S.N., RN,
CPN, to foster an evidencebased learning environment for
Memorial Hermann Memorial
City nurses.
N EW KN OW L EDG E, I NNOVATI O NS A ND I M P ROV E MENTS
was championed by our former Chief Operating Officer,
Jim Witt, M.B.A., B.S.N., RN. The task force adopted the
Pathway to Zero Surgical Site Infections created by Dr.
Waleed at Kaiser Sunnyside Medical Center in Clackamas,
Oregon. The first item in this pathway is Operating Room
(OR) attire. The task force assigned Annette Conley,
M.H.A., B.S.N., RN, director of Inpatient Perioperative
Services; Shanna Harris, M.H.A., MT (ASCP), Six Sigma
Master Black Belt; and Karen DeKay, manager of Infection
Prevention, to lead the work on developing a surgical
attire policy and procedure. Annette Conley was assigned
to be the document owner.
The team performed a literature review and decided to use
the Association of Perioperative Registered Nurses (AORN)
guidelines in developing their policy and procedure. The
team, led by Conley, worked on the policy and procedure,
asking for input from all affected areas. They presented
the Development Plan and Education and Communication
Plan to the Memorial Hermann Memorial City PP&G
committee and, with the approval of the committee,
proceeded in finishing the policy and procedure. The
policy and procedure was completed and published.
28
Catheter-Associated Urinary Tract
Infections (CAUTIs)
The Memorial Hermann Memorial City nurse-led CAUTI
champion team implemented new knowledge collected
from evidence-based best practice and national
guidelines to reduce CAUTIs within our facility. CAUTI
numbers were collected, with data tracked for decreasing
the incidence of CAUTIs without successful improvement,
despite being below the national data average. In
November 2013, the pre-data showed that an average
of 3.5 CAUTIs occurred per month. The nurses saw
this as an opportunity to improve on the quality of
patient care and improved health outcomes with the
new knowledge by introducing new insertion techniques
and reconsidering whether patients truly required urinary
catheters. Their goal was to reduce the incidence of CAUTIs
as measured by the average number of CAUTIs/month.
Memorial Hermann Memorial City developed a task
force of point-of-care CAUTI champs supported by project
leader Maryellen McGlothlin. She was appointed to this
position based on her extensive nursing experience in the
acute care environment, and direct responsibility for five
NEW K NOWLEDG E, INNOVATIO NS AND IM PROVEM ENTS
medical surgical units at the hospital. The CAUTI champs
were selected based on a volunteer basis.
In January 2014, the CAUTI champs held their first
meeting in which they reviewed current national legislation,
financial impact and adverse patient outcomes data.
Group discussion resulted in recommendations to reduce
CAUTIs at Memorial Hermann Memorial City.
In March 2014, the infection prevention specialists
(Shaunte Walton, M.S., MB (ASCP), CIC; and
Julia Thomas, MAOM, MT (ASCP)) presented data
to the CAUTI champs that showed current national
CAUTI data and highlighted the fact that Memorial
Hermann Memorial City was below the national
average. Recommendations were made to collaborate
with C.R. Bard, Inc., a company that manufactures
medical devices.
In April 2014, the Bard representatives performed
an insertion gap analysis in the Main Operating Room
(MOR), Emergency Department (ED), Labor and Delivery
(L&D), and the Medical Intensive Care Unit (MICU)
that showed significant improvement was needed
with insertion techniques. This new knowledge led to
a facility-wide awareness and improvement in nursing
practice with each Foley catheter insertion. The CAUTI
champs created a universal poster that was used in
each unit to present the new urinary catheter insertion
guidelines focusing on new knowledge. This new
knowledge included using a two-person/nurse insertion
team, having a valid reason for a urinary catheter
insertion, committed use of the catheter stat lock and
securement device, using best practices with catheter
and peri-care, and proper drainage bag placement.
This project continued through May 2014 when the
CAUTI team reviewed evidence-based literature and
focused on the following article: Parry, M. F., Grant, B.,
& Sestovic, M. (2013). Major article: Successful
reduction in catheter-associated urinary tract infections:
Focus on nurse-directed catheter removal. AJIC:
American Journal of Infection Control, 411178-1181.
doi:10.1016/j.ajic.2013.03.296.
This was used as a source of best practices that integrated
new knowledge with improving clinical practices.
In June 2014, this new insertion technique knowledge
was incorporated by the nurses and implemented
facility-wide as a best-practice change for insertion.
This also fulfilled a key focus of the 2014 National
Patient Safety Goal - NPSG.07.06.01: to use proven
guidelines to prevent infections of the urinary tract that
are caused by catheters.
The clinical nurse practice changes that were implemented
included:
• using best practices to ensure that there is a need
and indication for a urinary catheter
• using stat lock and green safety clip on catheter
• adhering to safe urinary catheter care and peri-care
• obtaining urine samples using the needleless
sampling port
• ensuring proper catheter bag placement
• providing patient and family education
To scrutinize the necessity of inserting a urinary cathether,
nurses employed the HOUDINI acronym: Hematuria,
Obstruction, Urological surgery, Decubitus ulcer(s),
Immobile, No Code, and Input and Output (I&O). This led
to a significant decrease in CAUTIs as well as decreased
the use of urinary catheters at Memorial Hermann
Memorial City. By the end of June 2014, all nursing
practice changes were effectively in place.
29
Empirical
Outcomes
Today’s Magnet recognition process primarily
focuses on structure and processes, with an
assumption that good outcomes will follow.
Currently, outcomes are not specified, and are
minimally weighted. There are no quantitative
outcome requirements for ANCC Magnet
Recognition. Recently lacking were benchmark
data that would allow comparisons with best
practices. This area is where the greatest
changes need to occur. Data of this caliber
will spur needed changes.
In the future, having a strong structure and processes are the
first steps. In other words, the question for the future is not
“What do you do?” or “How do you do it?” but rather, “What
difference have you made?” Magnet-recognized organizations
are in a unique position to become pioneers of the future and
to demonstrate solutions to numerous problems inherent in our
healthcare systems today. They may do this in a variety of ways
through innovative structure and various processes, and they
ought to be recognized, not penalized, for their inventiveness.
Outcomes need to be categorized in terms of clinical outcomes
related to nursing, workforce outcomes, patient and consumer
outcomes, and organizational outcomes. When possible,
outcomes data that the organization already collects should be
utilized. Quantitative benchmarks should be established. These
outcomes will represent the “report card” of a Magnet-recognized
organization, and a simple way of demonstrating excellence.
–A New Model for ANCC’s
Magnet Recognition Program, 2014
31
EMP IRI C AL OU TC OM E S
Nursing-Sensitive Clinical Indicators
We benchmark our performance against the American Nurses Association (ANA)
National Database of Nursing Quality Indicators (NDNQI).
Injury Falls Per 1,000 Patient Days
0.60
0.40
0.20
0.03
0.00
-0.20
-0.09
-0.11
-0.11
-0.40
-0.31
-0.28
-0.80
-0.28
-0.34
-0.43
-0.50
-0.60
2013 Q2
Hospital
2013 Q3
Mean
2013 Q4
10th Pctl
-0.09
2014 Q1
25th Pctl
2014 Q2
2014 Q3
50th Pctl
2014 Q4
2015 Q1
75th Pctl
90th Pctl
Central Line Associated Blood Stream Infections per 1000 Central Line Days
0.60
0.40
0.20
-0.20
0.06
0.05
0.00
0.00
-0.11
-0.14
-0.40
-0.60
Hospital
32
-0.34
-0.37
2013 Q2
2013 Q3
Mean
2013 Q4
10th Pctl
-0.19
2014 Q1
25th Pctl
2014 Q2
2014 Q3
50th Pctl
2014 Q4
75th Pctl
2015 Q1
90th Pctl
EMP IRICA L OU TCOM ES
Nursing-Sensitive Clinical Indicators
We benchmark our performance against the American Nurses Association (ANA)
National Database of Nursing Quality Indicators (NDNQI).
Percent of Surveyed Patients with Hospital-Acquired Pressure Ulcers Stage II and Above
1.00
0.80
0.84
0.60
0.40
0.20
0.09
0.00
-0.07
-0.20
-0.28
-0.31
2013 Q3
2013 Q4
-0.40
-0.60
2013 Q2
Hospital
Mean
10th Pctl
-0.10
-0.18
-0.33
2014 Q1
2014 Q2
25th Pctl
2014 Q3
50th Pctl
2014 Q4
75th Pctl
2015 Q1
90th Pctl
Catheter-Associated Urinary Tract Infections per 1000 Catheter Days <=2014
0.80
0.60
0.40
0.20
0.00
-0.20
-0.40
-0.31
-0.15
-0.24
-0.20
2013 Q3
2013 Q4
-0.04
-0.03
2014 Q3
2014 Q4
-0.24
-0.60
-0.80
2013 Q2
Hospital
Mean
10th Pctl
2014 Q1
25th Pctl
2014 Q2
50th Pctl
75th Pctl
90th Pctl
33
921 Gessner
Houston, TX 77024
memorialhermann.org
713.222.CARE (2273)
4408157