Mercy Nursing Annual Report - Mercy Medical Center Dubuque

2 0 1 1 MERC Y NURSING ANNUAL REPORT
EXCELLENCE IN
Caring
Int
roduct
ion
Mercy Medical Center is a great organization and highly regarded
for top-notch nursing care. At Mercy, we passionately believe that
excellent patient outcomes are largely dependent on strong nurses,
and we constantly strive to raise the bar on our already high standards.
Our nurses embrace the critical role they play on the care team and
in shaping a culture of collaboration, innovation and shared
leadership.
Kay Takes, VP of Patient Care Services, CNO
In the end, the primary driver for all Mercy nurses is to serve in a
manner that generates the best possible experience for our patients.
Through the efforts of many, we work to cultivate a thriving
environment for patient care, learning, changing and modeling
evidence-based improvement.
In this annual report, we are pleased to highlight the many ways that our nurses make a difference at Mercy. We begin
each year with a clear statement of our objectives, which serve to advance the organization’s mission and nursing vision.
By year’s end, I am awed and inspired by the cumulative accomplishments of our committed team and the pervasive
leadership responsible for meeting and exceeding our performance goals.
It is with pride and gratitude that we present the 2011 Mercy Nursing Annual Report and I look forward to continuing
Mercy’s Magnet tradition in 2012 and beyond.
It is both a privilege and a source of pride for me to be associated with all the great nurses at Mercy. I’m continually
impressed by the knowledge, skills, and attitudes on display every day. What I see starts with compassionate care
and competent practice, of course, but also includes such qualities as teamwork, innovation, resilience, and the
continued pursuit of excellence. Hardly a day goes by that I don’t hear from our patients and their families about
how much they appreciate our nurses, an appreciation I share and echo.
– Russell M. Knight, President and CEO
M E R C Y N U R S I N G V I S I O N S TAT E M E N T
As a Magnet organization, our Nursing Vision is to fulfill the commitment of our patient/family-centered
Caring Model and Mercy’s Mission by actualizing a thriving culture of nursing excellence. We embrace
continuous innovation, development, inclusiveness, leadership and teamwork in achieving desired
outcomes in all dimensions of performance.
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Caring
T HROU G H T R AN SFORMAT IO N A L LEA DERSHIP
RECOGNITION: NURSES WEEK 2011
The Nurses Week luncheon is anticipated each year, as
members of the RN Retention & Recruitment Committee
transform the Francis Auditorium into a restaurant-like
atmosphere to celebrate and recognize Mercy nurses.
Blessing of t
he Hands
“
Remember you are special and have been called to ministry. I anoint your hands for service, look
at them… The heart in these hands has made a difference in the lives of others. May all those you
touch know God’s love and may that love be a source of strength for you.
“As usual the R&R Committee outdid themselves!
Nurse’s Week was a great pick-me-up and lots of
fun! Great job!”
– SHELLY KLINKHAMMER, RN
”We would like to join Mercy in recognizing the
outstanding Nurses that assist our Physicians in
providing quality health care in the hospital
setting each day. On behalf of the Physicians
of Medical Associates, please extend our
appreciation to your staff during Mercy's
National Nurses Week celebration.”
– JOHN TALLENT, CEO
MEDICAL ASSOCIATES CLINIC
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”
RECOGNITION: NURSING AWARDS
2011 Rita Trenkle BSN
Completion Scholarship
Winner
2011 Connie Noel Award
Winner
2011 Ott Family
Excellence in Surgical
Nursing Award Winner
The Mercy Medical Center Great Catch Award recognizes associates who encounter a situation that
could harm a patient and take immediate action to
prevent the event from occurring. It is among
Mercy’s many patient safety initiatives.
The Salute to Excellence Award recognizes Mercy
employees for actions demonstrating excellence in
care or service.
Carol Handke, RN
Mercy Dyersville
Shelly Klinkhammer, RN
Performance Improvement
Jean Tauke, RN
Operating Room
> Great Catch Award RN Recipients:
-
Angela Trenkamp, RN, Mercy Dyersville
Kevin Krug, RN, Surgical Services Unit
Jill Petersen, RN, Operating Room
Mary Demeyer, RN, Operating Room
Steve O’Brien, RN, Operating Room
> Salute to Excellence Award RN
Recipients:
-
Robert Krapfl, RN, Emergency Department
Jane Boge, RN, Operating Room
Janet Clemen, RN, Mercy Dyersville
Kevin Krug, RN, Surgical Services
Norma Gross, RN, Mercy Homecare
Cheryl Husemann, RN, Psychiatric Services
Susan Ruden, RN, Psychiatric Services
Marjorie Coleman, RN, Emergency Department
The Connie Noel Award is given annually to a Mercy
associate who is honest, caring, a humanitarian,
an advocate for all people including those with less
influence and control, has an ability to bring out the
best in others, is enthusiastic, has a positive attitude
and sense of humor, and has an intuitive sense of
people’s needs and problems.
The Ott Family Excellence in Surgical Nursing
Award annually recognizes a Mercy registered nurse
for excellence in surgical nursing.
The Rita Trenkle BSN Completion Scholarship is
awarded annually to a Mercy nurse who is pursuing
a BSN degree.
The 100 Great Iowa Nurses program, sponsored by
the Iowa Nurses Association, the Iowa Nurses Foundation, the Iowa Hospital Association and the University
of Iowa College of Nursing, annually recognizes 100
outstanding Iowa nurses whose courage, competence
and commitment to patients and the nursing
profession stand out above all others.
> Connie Noel Award RN Nominees:
-
Sue Engelbrecht, RN, Mercy Dyersville
Shelly Klinkhammer, RN, Performance Improvement
Nancy Merges, RN, Surgical Services
Barb Otting, RN, Mercy Homecare
Bonnie Steines, RN, Rehab/Skilled Services
Sara Uthe, RN, Cardiac Medical
2011 100 Great Iowa Nurses:
Lee Ann Krapfl, RN, Ambulatory Services;
Cheryl Husemann, RN Psychiatric Services; and
Barb Keough, RN, Mercy Homecare
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RECOGNITION: RN PROFESSIONAL ACHIEVEMENT
The Mercy Medical Center RN Professional Achievement
(RNPA) Model was developed to recognize registered
nurses who go above & beyond to advance the Nursing
Vision and their own professional practice.
“I found that participating in the RNPA Model was a
very rewarding experience. It is nice to get acknowledged for the things that I am already doing.”
- HEATHER WUEBKER, RN
“RNPA helped me to be a more involved and better
informed nurse.”
The RNPA Model has three tiers of achievement
beyond the basic expectation of the RN role and
points are awarded in five categories of activity:
- Mercy Nurse as Leader
- Mercy Nurse in Professional Development
- Mercy Nurse in Quality and Evidence-Based
Improvement
- Mercy Nurse as Teacher
- Mercy Nurse and the Community
- DARCY GLASKER, RN
The model encourages RN's to engage in activities
which elevate professional practice, consistent
with the Forces of Magnetism.
“RNPA is a great opportunity for nurses here at Mercy.
This program not only encourages nurses to volunteer
outside of the workplace but also recognizes all of their
hard work and dedication that they provide throughout
the year.”
Nurses who successfully completed an RNPA
portfolio in 2011 included:
- BROOKE LYONS, RN
“The RNPA model provides an opportunity to be
recognized for your commitment to advancing nursing
practice at Mercy. Through involvement and continued
learning in multiple areas: leadership, professional
development, quality, teaching and community service,
Mercy provides many opportunities and support for this
RN recognition.”
- DEB MUELLER, RN
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TIER II:
Jessica Severson
TIER III:
Jolene Bagge
Donna Cota
Peggy Driscoll
Cheryl Husemann
Brooke Lyons
Virginia McDonough
Nancy McEowen
Candy Meyer
Ann Miesen
Deb Mueller
Polly O’Connor
Stephenie Stephens
Jean Tauke
Darcy Glasker
Marie Trannel
Stacie Vaassen
Courtney Veach
Heather Wuebker
TIER IV:
Mary Birch
Rosalie Jahn
Linda Otting
Susan Ruden
LEADERSHIP: SHARED GOVERANCE
At Mercy Medical Center, direct care nurses are empowered
through shared governance to be the key decision makers
regarding nursing practice and the practice environment.
PRACTICE &
STANDARDS
PERFORMANCE
IMPROVEMENT
EDUCATION
PATIENT CARE SERVICES
LEADERSHIP
Jane Myers (Leader)
Angela Lauer (Leader)
Peggy Driscoll (Leader)
Kay Takes (Leader)
Ann Hosch, Homecare
Donna Kluesner, Emer. Room
Cindy McDermott, Ambulatory
Janet Clendenen, Recovery Rm.
Marian Arthofer, Oper. Room
Megan Heiderscheit, Psych
Darcy Glasker, Medical
Michelle Arensdorf, Cardiology
Teri Reevs, Cardiac Med.
Janice Weydert, Intensive Care
Elaine Thier, Cardiac Pul. Rehab
Vickie Connolly, Rehab/Skilled
Jenny Grau, Surgical Svcs.
Jessi Thompson, Float Pool
Jolene Bagge, Dyersville Acute
Barb Hess, Oakcrest
Deb Rea, Coach
Angel Keller, Homecare
Kari Ernst, Emer. Room
Margaret Landolt, Ambulatory
Kris Richey, Recovery Rm.
Jessica Menard, Oper. Room
Ann Schroeder, Psych
Heather Demaio, Medical
Cindy Rowley, Cardiac Med.
Sandy Tegeler, Intensive Care
Elaine Thier, Cardiac Pul. Rehab
Edna Scherbring, Rehab/Skilled
Kali Blocklinger, Surgical Svcs.
Abby Naber, Float Pool
Deb Oberbroeckling, Dyersville
Acute
Carmen Reinert, Oakcrest
Jane Flynn, Consultant
Sandy Kass, Consultant
Lynn McCubbin, Coach
Megan Staner, Homecare
Rita Schmitt, Emer. Room
Sarah Gravel, Ambulatory
Marie Trannel, Recovery Rm.
Cindy Donovan, Oper. Room
Brooke Lyons, Psych
Stephanie Gilbert, Medical
Kathy Kalb, Cardiology
Sara Uthe, Cardiac Med.
Marcia Ambrosy, Intensive Care
Julie Heins Reber, Cardiac Pul.
Rehab
Courtney Veach, Rehab/Skilled
Ann Vandermillen, Rehab/Skilled
Stephenie Stephens, Surgical
Services
Laura Kinsella, Maternal Child
Shelly Meyer, Dyersville Acute
Gayla Boice, Oakcrest
Bruce Schmidt, Coach
Carol Alexander, Periop. Svcs.
Lavern Bird, Mercy Dyersville
Jack Kampf, Pharmacy
Barb Keough, Homecare
Lynn McCubbin, Performance
Improvement & Social Services
Louann Mottet, Medical & CCT
Alice Prochaska, Emer. Room
Deb Rea, Systems & Support
Sally Roy, Psych
Joan Runde, Surgical Svcs.
Bruce Schmidt, Clin/Prof Devel.
Liz Tippet, Maternal/Child Svcs.
Bob Wethal, Critical/Cardiac Svcs.
Dawn Wold, Rehab/Skilled
Jane Myers/Peggy Driscoll, CCT
Education Representative
Carol Dietzel, House Supervisor
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LEADERSHIP: IMPACT PLANNING
Impact planning is conducted on all nursing units on an
annual basis to improve the experience of our patients and
the engagement of the members of our care teams.
IMPROVING THE CARE OF THE AUTISTIC PATIENT
Carol Alexander and associates from Peri-operative
Services noted an increase in the number of children with
autism having a surgical procedure. The team decided to
look at how they could better serve the needs of autistic
kids using the Mercy Model of Caring as their guide:
- Knowing the patient - How does the child with autism
view his or her surgical experience?
- Facilitating care for the patient - How can we facilitate
an experience that does not feel threatening to the
autistic patient/family and gets them more involved in
their care?
Staff members participated in an educational program
entitled, “Meeting the Needs of the Surgical Patient With
Autism”.
Their increased sensitivity resulted in the following
outcomes:
- Improved staff knowledge of specific challenges faced
by autistic children and families in the healthcare
setting
- Identification of specific visual support aides for
patients, including a visual aid book provided by
Alyson Beytien, Behavioral Specialist, for use in the
peri-operative area
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- Greater staff knowledge of simple ways to improve
the experience of the autistic patient in areas that
are especially difficult for them, such as:
- Putting a gown on over their clothing when
changing their clothes.
- Having family accompany them into the operating
room, or having family in attendance in the
recovery room immediately after the procedure.
- Providing photos of the preoperative area and
operating rooms prior to the patient’s admission.
LEADERSHIP: MANAGEMENT ROUNDS
Understanding the perspectives of patients and associates
is key to a manager’s effectiveness.
ROUNDING FOR INSIGHT
In 2011, all directors in Patient Care Services
committed to conducting and documenting
weekly patient and staff rounds. Feedback is
solicited from associates on topics like communication, staffing and teamwork, and from patients
on their perceptions of pain management, staff
response times, and noise on the nursing unit.
Often, patient and staff feedback is positive and
complimentary. They also provide valuable input,
which has led to improvements like purchasing
new equipment, changing the format of a shift
huddle, and using the white board more consistently during hand-offs in patient care.
The nursing staff on 3 West shared with Louann
Mottet during staff rounds that while they were
happy to have computers in each patient's room,
they did get fatigued from having to stand to
document their care. With this feedback, Louann
and the 3 West team decided to purchase chairs
for each patient room so clinicians can now sit
at the bedside to chart.
“The Mercy nurses are not only distinguished by their abilty to think critically and the great compassion
they have for their patients but by their persistent dedication to excellence in all aspects of caring for the
sick. The Magnet award reflects their outstanding capability to transform care."
– Dr. Hendrik Schultz, MD, Medical Director, Mercy Hospitalist Service
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WORKPLACE COMMUNICATION
Making sure everyone is on the same page and takes
ownership in the success of their department is the idea
behind change-of-shift huddles.
WOULD yOU CARE TO HUDDLE?
In 2011, several nursing units incorporated huddles as a routine method of intradepartmental communication; and
twice-daily staffing huddles were added to improve direct care staffing across the organization. While huddles were a big
change, nurses and all patient care associates agree they have been successful in:
- Improving communication and teamwork
- Resolving issues quickly and efficiently
- Identifying environmental break/fix issues and safety
concerns and assigning accountability for resolution
- Educating and informing staff on new processes
- Ensuring best patient outcomes by a renewed focus on
performance improvement indicators
- Meeting fiscal obligations by review and discussion of
productivity each shift
- Giving recognition to staff by sharing patient
and staff-to-staff compliments
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WORKPLACE COMMUNICATION
Mercy’s RN Retention & Recruitment (R&R) Committee
members understand the importance of a healthy work
environment in retaining and recruiting great nurses.
In 2011, the R&R Committee equipped all
associates with a creative way to stop disrespect
in its tracks and to cultivate a thriving workplace
where excellent care (of patients and of each
other) is the focus. The result was a clear set of
directions on how to respond when disrespect is
happening.
MERCy EMPLOyEES’ OBLIGATION IN ENSURING
RESPECT IN THE WORKPLACE
1
2
3
Follow the Mercy Guiding Behaviors (and supportive
statements) & the Trinity Health Code of Conduct.
Be accountable for your own behavior.
Speak up. Hold each other accountable. Call a Code
Purple when disrespect is happening/on the verge of
happening.
When disrespectful, disruptive behavior doesn’t stop
when respectfully confronted (including a Code
Purple), report it.
“Just a quick note to thank all of you for your help and professionalism during my recent surgery.
I appreciate all of your hard work in making it a success! I wanted to share my gratefulness with each
of you. Sometimes we go to work and complete our task at hand. Everyday you go to work and make
a difference in someone’s health. This is a true gift! So please accept my simple, yet heartfelt thanks for
all you do each day in your profession.”
– 2011 Mercy Medical Center Patient
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Caring
T HROU G H ST RU C T U R A L EMP O WERMEN T
WHAT WE LOOK LIKE
Mercy is comprised of nurses from across the spectrum of
the novice to expert continuum. We value the fresh insights
and enthusiasm of our newest nurses, and the wisdom and
experience of our most tenured associates.
>
>
>
Total number of
registered nurses
449
Average age
46 yrs.
BREAKDOWN OF RN’S
By AGE
TOTAL NUMBER OF RN’S
By EMPLOyMENT STATUS
<25 = 33 RN’s (8%)
26-35 = 94 RN’s (21%)
36-45 = 69 RN’s (15%)
46-55 = 123 RN’s (27%)
56 – 65 = 118 RN’s (26%)
>65 = 12 RN’s (3%)
(Direct care only)
Full time = 244 (64%)
Part time = 104 (27%
PRN = 36 (9%)
Average years
of service
TOTAL NUMBER OF
NEWLy HIRED RN’S
19
>
Total number of
direct care RN’s
384/86%
of all RNs
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TOTAL NUMBER OF RN’S WHO
SEPARATED FROM MERCy
(Direct care only) = 46
A.D.N. = 17 (37%)
Diploma = 1 (2%)
BSN = 27 (59%)
MSN = 1 (2%)
(Direct care only) = 27
< 1 year = 3 (11%)
1-5 years = 12 (44%)
6-10 years = 1 (4%)
11-20 years = 2 (8%)
>20 years = 9 (33%)
PRECEPTOR STEERING COMMITTEE
Each year, Mercy’s Preceptor Steering Committee hosts an
Annual Preceptor Business Meeting, promoting recognition
and continuing education for our nurse educators.
Our nurses passionately serve as adjunct faculty, preceptors and mentors to students and new nurses throughout the
year. We have approximately 75 formal preceptors who support new nurses throughout their orientation process, and
nurses who serve as preceptors for college practicums and for our Summer Preview to Nursing Interns.
NURSE PRECEPTORS:
Surgical Services
Natalee Berg
Jenny Grau
Linda Heitkamp
Diane Lahr
Lisa Lambe
Cindy Murguia
Melissa Osterhaus
Peri-Operative Services
Mary Birch
Deb Didesch
Fran Fagan
Diane Nie
Jean Tauke
Grace Pins
Heather Wuebker
Marie Trannel
Polly O’Connor
Homecare
Ann Hosch
Kim Gorman
Dawn Noel
Emergency Department
Jeff Baker
Katie Harris
Donna Kluesner
Rita Schmitt
Kris Wegmann
Psychiatric Services
Susan Ruden
Stacie Vaassen
Cheryl Husemann
Linda Otting
Rosalie Jahn
Ann Schroeder
Joyce McDermott
Medical/Oncology
Julie Feldman
Virginia Hinman
Angela Weber
Candy Meyer
Peggy Driscoll
Jan Theisen
Julie Oberbroeckling
Dyersville-Acute/Oakcrest
Bagge, Jolene
Carol Handke
Barbara Hess
Rehab/Skilled
Katie Bauer
Paula Tschudi
Courtney Veach
Jennifer Steil
Diane Manemann
Mary Beth Hinz
Jackie Bierman
ICU/CMU/Cardiology/
Cardiac Rehab
Betty Buss
Mark Zelinskas
Mary Ann Hartke
Jeanne Duggan
Barb Hinz
Brenda Werner
Marcia Ambrosy
Elaine Thier
Bev Uthe
Maternal/Child & Peds
Donna Cota
Cory Denlinger
Connie Gabrielson
Laura Kinsella
Nancy Hanson
Sue Herrig
Colleen McDermott
Rhonda Wernimont
Marilyn Bruck
STAFFING RESOURCE POOL
Understanding the importance of optimal financial performance while ensuring appropriate nurse to patient ratios is a high priority
for Mercy nurses.
In order to most effectively staff nursing units across the organization, charge nurses meet in huddles twice daily to discuss patient
activity and anticipated staffing needs. In addition, we created a Staffing Resource Pool to provide RN coverage for scheduling gaps
known in advance.
The Resource Pool is in addition to the Float Pool, which provides coverage for ‘day-of’ needs due to increased census and
unanticipated staff vacancies. We have grown our Float Pool to 11 RN’s and 9 CNA’s, and our Resource Pool to 4 RN’s.
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PRECEPTOR STEERING COMMITTEE
Mercy is committed to offering a quality experience for
nursing students at all levels of the educational continuum.
Our goal is to partner with our colleagues in academia so
that nursing students achieve their highest potential.
EDUCATING OUR FUTURE NURSES
Almost 500 student nurses from the University of
Dubuque, Clarke University, Northeast Iowa Community
College and Southwest Technical College participated in
106 clinical rotations on the day and evening shifts across
a variety of nursing units at Mercy – Dubuque and
Dyersville in 2011. Students are key stakeholders in
Mercy’s nursing organization, and we appreciate hearing
from them.
“I was really impressed with the facility and
the people working here.”
“Staff was helpful, professional, and interested
in teaching.”
“I felt very welcomed and the nursing staff
took time to explain things to me. They were
interested in helping me learn.”
CARING FOR OUR COMMUNITy
On Easter Monday, RN’s from Mercy-Dubuque delivered 45
boxes of goods to the Dubuque Rescue Mission along with a
check for over $1,600. RN’s from Mercy-Dyersville delivered
over $150 and boxes of items for the St. Francis Xavier School
in Dyersville. The Caring for Our Community campaign is
sponsored annually by Mercy Nursing and coordinated by the
Magnet Sparklers.
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RECOGNITION: CERTIFIED NURSES
We are proud of the near 100 Mercy nurses who obtained or
maintained national board certification in 27 different areas
of specialization in 2011.
Certified Nurse Operating Room (CNOR) Carol Alexander | Mary Birch | Jane Boge | Deb Didesch | Mary Dietzel | Audrey Golden | Mary
Knapp | Doris Ries | Diane Schroeder | Pam Sweeney | Jean Tauke | Certified Registered Nurse First Assistant (CRNFA) Deb Didesch |
Certified Wound, Ostomy, and Continence Nurse (CWOCN) Lee Ann Krapfl | Shirley Zurcher | Certified Post Anesthesia Nurse (CPAN)
Beth Brown | Deb Mueller | Marie Trannel | Certification in Critical Care Nursing (CCRN) Edith Cornett | Janice Weydert | Bonnie Gorrell
| Barbara Hinz | Janis Scherrman | Susan Schneider | Sandy Tegeler | Judy Thorpe | Robert Wethal | Jill Ballantine | Certified Rehabilitation Registered Nurse (CRRN) Mary Beth Hinz | Bonnie Steines | Certified Hospice and Palliative Nurse (CHPN) Edna Scherbring |
Registered Nurse Board Certified – Nursing Professional Development (RN-BC) Bruce Schmidt | Nurse Executive Advanced – Board Certified
(NEA-BC) Kay Takes | Lavern Bird | Sally Roy-Boynton | Certified Medical-Surgical Nurse (CMSRN) | Natalee Berg | Orthopedic Nurse
Certified (ONC) Julie Beecher | Diane Lahr | Stephenie Stephens | Registered Nurse Board Certified – Gerontology (RN-BC) Ann Grogan
| Deb Hocking | Marilyn Heinisch | Registered Nurse Board Certified – Adult Psychiatric and Mental Health (RN-BC) Michele Cornish |
Cheryl Husemann | Gina Gross | Rosalie Jahn | Gary Jobgen | Joyce McDermott | Virginia McDonough | Linda Otting | Susan Ruden |
Ann Schroeder | Mary Beth Turnis | Stacie Vaassen | Shelly Klinkhammer | Adult Psychiatric and Mental Health Clinical Nurse Specialist
– Advanced (MHCNS-BC) Sally Roy-Boynton | Oncology Certified Nurse (OCN) Louann Mottet | Certified Emergency Nurse (CEN) Sue
Houselog | Angela Lauer | Certified Professional In Healthcare Quality (CPHQ) Ann Burds | Certified Infection Control (CIC) Ann Burds
| Certified Professional in Healthcare Risk Management (CPHRM) Jacquie Brunssen | Certified Case Manager (CCM) Cathy Weber |
Bobbie Reimer | Certified Advance Practice Nurse (APN) Jennifer Johnson | Katie Wiederholt | Sarah Thibadeau | Tassie Carter | Anne
Glasker | Connie Wessels | Jan Geertsema | Megan Carter | Sue Houselog | Certification in Electronic Fetal Monitoring (C-EFM) Marilyn
Bruck | Lori Burrows | Carol Dean | Margie Gross | Brenda Huseman | Kristina Ihrig | Tara Lynch | Kimberly Maring | Colleen McDermott
| Tiffany Roling | Mary Vize-Hubanks | Rhonda Wernimont | Katie Wiederholt | Susan Herrig | International Board Certified Lactation
Consultant (IBCLC) Kathy Murphy | Jayne Schuster | Annie Havner | Registered Nurse Certification – High Risk Newborn (RNC-NIC)
Janet Knabel | Candace Miller | Registered Nurse Certification – Low Risk Newborn (RNC-LRN) Jayne Schuster | Vickie Weber | Registered
Nurse Certification – Inpatient Obstetrics (RNC-OB) Julie Tressel | Rhonda Wernimont | Marilyn Bruck | Colleen McDermott | LeeAnne Sindt
| Jolene Beebe | Susan Herrig | Jane Flynn | Advanced Certified Alcohol and Drug Counselor (ACADC) Connie Kelly
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SHARED GOVERNANCE
A new graphic of Mercy’s nursing shared governance
structure was unveiled in 2011, more clearly depicting the
relationship between area (unit-based) and central teams.
MERCY NURSING SHARED GOVERANCE STRUCTURE
The Annual Nursing Shared Governance Business
Meeting topped off a very successful and productive
2011. The meeting included a presentation of highlights
from each of the shared governance central teams and
member recognition. Kay Takes provided an overview of
the recommendations from the Institute of Medicine
(IOM)/Robert Wood Johnson (RWJ) Future of Nursing
Report; and Kristen Swanson offered the keynote
address, describing the development of her mid-level
caring theory (which provides the foundation for the
Mercy Model of Caring) and how it has evolved in
relation to changes in nursing practice. Mercy associates
heard Dr. Swanson speak and many commented it was
one of the best presentations they had ever heard. As one
of the participants shared, “It was an honor to be able to
attend this workshop and hear Kristen Swanson speak.
I think it humbles us and brings it all together,…. It is
why we do what we do.”
2011 SHARED GOVERANCE TIMELINE OF EVENTS:
JANUARY
Mercy Nursing’s
1st Courage in
Innovation
Evidence-Based
Practice Summit
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FEBRUARY
Shared
Governance
Focus Groups
share findings
with ACTs
MARCH
Certified Nurse’s
Day Celebration
in the Mercy
Certified
Nurses Lounge
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APRIL
Over 80 Nurses
Attend RN
Professional
Practice
Symposium
SEPTEMBER
Tailgating and
Trivia at the
Courage In
Innovation
Kick-Off
OCTOBER
Administration
of the Annual
NDNQI RN
Satisfaction
Survey
NOVEMBER
Selection of
new 2012
Shared
Governance
Leaders
DECEMBER
Shared
Governance
Orientation and
Annual Business
Meeting
CONTINUING EDUCATION
Many nurses model our commitment to continuous
education as evidenced by their enrollment in formal
nursing educational programs.
2011 MERCy RN GRADUATES
MERCy RN’S CURRENTLy ENROLLED
Bachelor of Science
In Nursing Degree
Bachelor of Science In
Nursing Degree
Master of Science
In Nursing Degree
Jill Ballantine
Alex Bushman
Betty Buss
Jacquie Fleming
Brenda Husemann
Barb Keough
Heidi Klein
Danielle Miller
Ashley Stoffel
Megan Staner
Sara Bechen
Erica Berlage
Tiffany Brehm
Emily Capesius
Wendy Christopherson
Lori Dalberg
Heather DeMaio
Deb Didesch
Tracy Frank
Marilyn Gaber
Carol Handke
Elly Hinders
Dustin Husemann
Jessica Kennedy
Julie Klar
Shelly Klein
Mandy Krafel
Jill Ballantine
Leslie Bunting
Betty Buss
Kelsy Clemens
Kari Ernst
Emily Kirschbaum
Melissa Lux
Brooke Lyons
Joyce McDermott
Joann Pregler
Deb Rea
Teri Reeves
Edna Scherbring
Master of Science
In Nursing Degree
Jackie Bierman
Megan Carter
Tassie Carter
Jennifer Grau
Sue Houselog
Jennifer Johnson
Melissa Klinkkammer
Sarah Thibadeau
> Total amount of tuition
support
$167,673
>
Chelse Krueger
Jessica Ludescher
Kim Maring
Elizabeth Meyer
Tina Oberfoell
Diane Ramirez
Sara RamsdellGoffinett
Candace Raymond
Brittny Redfearn
Jodi Roeth
Joan Runde
Sarah Schiesl
Dana Stangl
Amy Warner
Aaron Williams
RN’s received
63
reimbursement through
Mercy’s tuition support
program
Car ing Thr ough S tr uct ur a l Em po werm ent
| 15
CONTINUING EDUCATION
Nursing Grand Rounds, the RN Professional Practice
Symposium and the RN Professional Practice Fair
exemplify our committment to the ongoing development
of our nursing team.
NURSING GRAND ROUNDS
System Overload: CHF/CMU
ADDITIONAL EDUCATION
Nursing Grand Rounds, sponsored
by the Shared Governance Central
Education Team, promote a “nurses
teaching nurses” format to support
ongoing education on clinically
relevant topics.
Cindy Rowley
Sara Uthe
The Central Education Team also
led popular annual educational
offerings including the Mercy
Medical Center RN Professional
Practice Symposium and the RN
Professional Practice Fair. And in
the fall, several of Mercy’s pain
resource nurses attended a day-long
conference in Waterloo entitled,
“Kicking the Pain”.
“Staying Green”: Managing Pain
Using a Multi-Modal Approach/PACU
The Evolving Role of the
Expert ECT Nurse/Psych. Services
Joyce McDermott
Linda Otting
Nancy McEowen
Beth Brown
Nancy McEowen
Jessica Severson
Marilyn Heinisch
Michelle Ertz
Kathy Schwager
Carol Dietzel
Gretchen Johnson
Mike Lehmkuhl
Raising Concern: Recognizing
Drug-Seeking Behaviors/DyersvilleAcute
Shelly Meyer
Jolene Bagge
Mercy Caring Model: A Backdrop
for Therapeutic Communication/
Interdisciplinary Rounds
Sally Roy-Boynton
Joseph Gianino
Nancy Diehm
Extreme ED: Senior Specialty
to Pediatric Trauma/ER
Rita Schmitt
Bobbie Reimer
Kari Ernst
Donna Kluesner
16
| Caring Thr ough S t r uct ur a l Empo we r me nt
>
52
124
Nursing educational programs
sponsored free of charge by Mercy on
different dates
Caring
THROUGH EXEMPLARY PROFESSIONAL PRACTICE
PROFESSIONAL PRACTICE MODEL
The Nursing Professional Practice Model, refined in 2011,
provides the conceptual framework for nursing at Mercy.
> At the center of our focus is
Caring for Patient, Family and
Community, guided by the principles outlined in the Mercy Model
of Caring.
>
In providing patient-centered
care, we assume individual and
organizational accountability to
meet or exceed standards of care
and behavior
>
We are supported by a strong
infrastructure and a commitment
to Nursing Excellence and
Nursing Well-Being.
>
Nursing exists at Mercy to fulfill
the Mission, Values & Strategies
of the organization as a whole.
Car ing Thr ough Ex e mpla r y Pr o f essio nal P ractice
| 17
CARE DELIVERy MODEL
Mercy Nursing endorses a Collaborative Care Delivery
Model, valuing the contribution of every single member
of the care team in providing exceptional care to our
patients and families.
Collaborative practice is especially visible in the interdisciplinary and
patient rounding that occurs on most of our nursing units. Every day,
members of the multidisciplinary care teams meet on 3 West, 4 West, and
on the Cardiac Medical Unit in interdisciplinary rounds to collaborate on
the plans of each patient on the unit and to discuss how we can assist
them in moving effectively through their stay. Patient rounds occur after
interdisciplinary rounds and involve the primary nurse, the charge nurse
or clinical leader, the pharmacist, the hospitalist and the patient, and
serve to clarify the patient’s goals and our plans for meeting them.
Practice has evolved over the years, from functional to team to primary
nursing. A collaborative practice model incorporates the perspectives of
the entire care team in achieving the best outcomes for our patients.
COLLABORATIVE CARE IN THE
EMERGENCy DEPARTMENT
Recognizing and meeting the needs of the
patients we serve is the primary goal of Mercy
Nursing. While the care we provide in the
Emergency Department (ED) is second to none,
it became clear to us that we could do more
to offer a smooth transition for patients
discharged from our ER to the next level of care.
We wanted to make sure our patients had the
best opportunity for success by providing
needed resources and support. Bobbi Reimer,
RN, joined Mercy as our ER case manager in
December 2010, and collaborates with the care
team (including the patient), identifying and
facilitating the discharge planning process.
The ER presents a wonderful opportunity to
assess the patient’s situation and assist
in a way that could prevent a future
readmission to the hospital. Activities include
arranging for needed medical equipment,
setting a patient up on Lifeline or Meals on
Wheels, bathing and transportation assistance,
or coordinating a referral to Hospice or
Homecare. Bobbi also assists the care team
with important utilization review activities.
In addition to more effectively meeting patient
needs upon discharge from the ER, we also
saw the patient’s time in the ER as ideal in
collecting a more comprehensive medication
history and reconciling the medications with
those ordered for the patent’s inpatient stay.
With these needs in mind, we added
pharmacists to the core clinical team in the
ER. Pharmacists collaborate with physicians,
nurses and patients to improve the quality of
care and the care experience.
18
| Caring Thr ough Ex e mpla r y Pr o f essio na l Pr a ct ice
SENIOR EMERGENCy DEPARTMENT
Mercy implemented the first Senior Emergency
Department in the state of Iowa and the only one in
the tri-state area on April 4th, 2011.
The Senior ED focuses on the unique needs of patients
who are 65 and older, and includes screening and
follow-up related to a patient’s ability to perform
activities of daily living, cognition, depression, fall risk,
risks related to medications, and the patient’s home
environment.
“What I feel is most important is that nurses and
physicians are not just focusing on the patient’s
chief complaint, but are looking at the patient as
a whole and working with patients and their
families to better identify the needs of the patient.”
– ALICE PROCHASKA, Director of the Emergency
Department and leader of the Senior ED initiative
> Outpatient Visits/Day to
ER for patients >65 years
JANUARy - NOVEMBER 2010
JANUARy - NOVEMBER 2011
9.2
9.6
> ER Admissions/Day
for patients >65 years
JANUARy - NOVEMBER 2010
JANUARy - NOVEMBER 2011
6.2
6.7
> ER Patient Satisfaction
Overall Assessment
APRIL 1 - JUNE 30, 2010
APRIL 1 - JUNE 30, 2011
JULy - SEPTEMBER 2011
88.1
88.1
91.8
> ER Patient Satisfaction
Likelihood to Recomend
Since the inception of the Senior ED
patient satisfaction ranks in the
top decile of
performance nationally.
APRIL 1 - JUNE 30, 2010
APRIL 1 - JUNE 30, 2011
JULy - SEPTEMBER 2011
87.8
89.0
92.2
Car ing Thr ough Ex e mpla r y Pr o f essio nal P ractice
| 19
EXCELLENT CLINICAL OUTCOMES
Mercy has had continued success in reducing both
central line infections and ventilator pneumonias in 2011.
KEy FACTORS TO THIS SUCCESS
- Adoption of evidence based practices from sources
such as the Institute for Healthcare Improvement
- Policy development, education and performance
monitoring through shared governance teams.
- Ongoing leadership of multidisciplinary teams
dedicated to infection prevention in both central
lines and for patients on ventilators. These include
directors, clinical educators and staff representatives.
- Engagement of all caregivers in assuring best
practices are consistently observed on an every day,
every shift basis.
- Trial and adoption of new technologies to enhance
care delivery
Mercy Central Line Associated Bloodstream
Infections (CLABSI) Trends
Mercy Ventilator Associated Pneumonia (VAP) Trends
6
16
14
5
Rate/1000 line days
VAP/1000 Vent Days
12
10
8
6
4
3
2
4
1
2
0
0
2007
2008
2009
2010
[1 case each in 2010 & 2011]
2011
Mercy ICU VAP Rate
Trinity Health Target
20
| Caring Thr ough Ex e mpla r y Pr o f essio na l Pr a ct ice
2008
2009
Mercy ICU CLABSI Rate
Mercy All Units CLABI Rate
2010
2011
PERFORMANCE IMPROVEMENT
Mercy’s work on sepsis prevention is part of a larger Trinity
Health collaborative whose purpose is to achieve consistent
delivery of the safest, highest quality and most efficient
care for every patient with sepsis, every time.
SEPSIS PREVENTION
As part of the Trinity Health community of caregivers,
our local Sepsis Prevention Team’s objectives were to:
- Implement the most current evidence-based guidelines
for sepsis identification and management
- Utilize standardized tools and processes for the early
recognition of severe sepsis
- Deploy severe sepsis resuscitation and management
bundles in a timely manner
As a result of the work of this dedicated team,
we achieved the following results:
13%
10%
8%
Decrease in the number of patients
needing medication to maintain
blood pressure
Increase in the use of central venous
pressure (CVP) monitoring
Increase in the number of patients
receiving fluid boluses as defined by
standards
A reduction in median time of
antibiotic administration from
300 to
64
minutes
COMMITTED TO A CULTURE OF SAFETy
Nurses and members of the multidisciplinary team came together every
three weeks in 2011 to focus on fostering a culture of safety for our patients
and our caregivers. Staff in all clinical areas received results of the Culture of
Safety survey, administered in the spring, and developed action plans based
on the unique issues experienced in their unit-based cultures. 373 RN’s
attended a Culture of Safety presentation at the RN Professional Practice
Fair in September and October.
Continued work using Duke University tools on improving our Culture
of Safety, including efforts in the areas of fatigue management, stress
recognition and learning from defects are planned for 2012 and beyond.
Topics discussed at the RN
Professional Practice Fair:
- Communication openness
- Teamwork
- Non-punitive response to errors
- Patient hand-offs/transitions
- Stress recognition
- Burnout
Car ing Thr ough Ex e mpla r y Pr o f essio nal P ractice
| 21
COMPLIANT DOCUMENTATION
Consistent with our Vision, Mercy nurses are committed
to achieving desired outcomes in all dimensions of
performance.
IMPROVING THE ACCURACy OF CLINICAL DOCUMENTATION
The nurses in the Performance Improvement Department are constantly upgrading their nursing practice to position
Mercy for success in a world of increasing regulation and payment reform. The clinical documentation specialists in
our PI Department perform concurrent review of clinical documentation to ensure that our charting is compliant with
applicable rules and accurately represents the complexity of the patient’s condition and treatment.
Compliance Documentation Total Reviews
By Clinical Documentation Specialists | January 2011 - December 2011
400
300
200
100
0
Jan
334
>
Feb
349
Mar
411
Apr
395
May
427
June
359
July
361
Aug
375
Sept
389
Oct
367
Nov
348
The clinical documentation specialists played a
crucial role in the organization’s overall success in 2011,
with a financial impact of over
$1million
22
Dec
361
| Caring Thr ough Ex e mpla r y Pr o f essio na l Pr a ct ice
Caring
T HROU G H N EW KNO WLE DG E & IN NOVAT IO N
EVIDENCE-BASED IMPROVEMENT
As stated in Mercy's Nursing Vision, we embrace new
knowledge and innovation because we are committed to
raising the bar on our already high performance. Advancing
nursing practice and the practice environment requires that
we seek out new and innovative ways of doing things.
SPACE DESIGN
Staff involvement and evidence-based design
are key elements in planning for new facilities
at Mercy. A staff team has been involved every
step of the way in designing the new Intensive
Care and Cardiovascular Units at Mercy, in
addition to planning for an OR/Ambulatory
Services Unit expansion, Maternal & Child
Service Unit upgrade, and Homecare relocation.
“I was excited to be part of designing the
new unit, it was important to have the
staff input to ensure we build a great place
to work.”
– JEANNE DUGGAN, RN, Intensive Care Unit
Car ing Thr ough New K no wledge & Innova tion
| 23
COURAGE IN INNOVATION
Mercy Nursing’s Courage in Innovation Initiative is
intended to promote research and evidence-based
improvement at the nursing unit level.
Courage projects, led by Shared Governance Area Coordinating Teams, have yielded evidence-based improvements in
nursing practice and the practice environment for the past 10 years. In 2011, the Shared Governance Central Coordinating Team facilitated our first Courage in Innovation Evidence Based Practice Summit, where teams shared the results
of their research/evidence-based practice changes. Due to the passionate work of our Courage teams, we are constantly
challenging why we do what we do in order to improve the care our patients receive.
COURAGE IN INNOVATION PROJECTS
(1st Place) The Pitfalls of “Power Pit”: A
Comparison of High vs. Low Dose Oxytocin
(Pitocin) in the Induction of Labor
Rural Health Nurse: Evaluation of Competence
in an Emerging Specialty
Maternal Child Services: Marilyn Bruck BSN, RN; Katie Wiederholt
MSN, RN; Liz Tippet MSN, RN Mercy Mecial Center - Dyersville: Beth Neyen; Carol Handke; Lavern
Bird; Deb Oberbroeckling; Mari Vorwald; Barb Hess; Gayla Boice; Diane
Schroeder; Janet Clemen; Jolene Bagge; Ann Grogan; Heather Ries
(2nd Place) Working Hard for the Money
Screening & Brief Intervention Referral to Treatment
Rehab/Skilled Unit: Jackie Bierman BSN, RN; Joann Pregler BSN, RN;
Courtney Veach BSN, RN; Heather Ries MSN, RN-BC; Vickie Connolly RN
Emergency Department: Kari Ernst RN, BSN; Sue Houselog RN, BSN; Rita
Schmitt RN, BSN; Alice Prochaska RN, BSN; Donna Kluesner RN, BSN
(3rd Place) A “Seated” Affair: Bringing Nurses
and Patients Closer Together
Improving Support of Evidence-Based
Practice at the Bedside
Medical Unit: Peggy Driscoll BSN, RN; Heather Ries MSN, RN-BC;
Darcy Timmerman BSN, RN; Louann Mottet MSN, RN, OCN
Intensive Care Unit/Cardiac Medical Unit: Marcia Ambrosy BSN, RN;
Judy Thorpe RN, CCRN; Amy Cherne MSN, RN; Robert Wethal BSN, RN,
CCRN; Sandy Tegeler BSN, RN, CCRN; Janice Weydert RN, CCRN
(People’s Choice) Let’s Get Dressed Up
Ambulatory Services Unit: Ann Miesen BSN, RN; Fedia yaklich RN;
Laura Runde BSN, RN; LeeAnn Krapfl BSN, RN, CWOCN; Heather
Wuebker BSN, RN
Extreme Makeover – SSU Edition. Identifying and
Reconciling Selected Nursing Practice Deviations
on a Post-Surgical Unit
Surgical Services Unit: Stephenie Stephens BS, RN, ONC; Heather
Ries MSN, RN; Jennifer Grau MSN, RN; Joan Runde BS, RN; Marie
Wiederholt MSN, RN
Electroconvulsive Therapy (ECT):
Measuring Quality of Life Outcomes
Psychiatric Services Unit: Virginia McDonough RN-BC; Martha Ring
RN; Joyce McDermott BSN, RN-BC; Ann Schroeder RN-BC; Nancy
McEowen BSN; Sally Roy-Boynton DBA, MSN, PMHCNS-BC; Linda
Otting BSN, RN-BC; Karen Fulwood DNP, FNP-BC, PMHNP-BC
24
| Caring Thr ough Ne w K no wle dge & Inno v a t io n
Is My Client at Risk? Evaluating Factors
for Post Surgical Wound Deterioration (PSWD)
Mercy Homecare: Lois Homewood RN; Barbara Keough MGS, RN;
Gloria Knepper RN; Ruth Lucas MSN, RN; Julie Reicher RN; Melissa
Klinkkammer BSN, RN; Shirley Zurcher BSN, RN, CWOCN
Policing Traffic in the Operating Room
Operating Room: Marian Arthofer BSN, RN; Doris Ries BSN, RN;
Michelle Ertz BSN, RN; Jenny Flynn-Kelley BSN, RN; Diane Nie RN;
Carol Alexander BS, RN; Stacey Heitkamp BSN, RN
The Fear Factor: Anxiety in the PACU
PACU: Polly Kaiser RN, BSN; Marie Trannel RN, CPAN; Deb Mueller RN,
CPAN; Beth Brown RN, BSN, CPAN
TECHNOLOGy INNOVATION
Since the implementation of our clinical information system
in February of 2006, nurses have played an instrumental role
in expanding and improving clinical technology at Mercy.
TECHNOLOGy UPGRADES
Computers at the Bedside:
With overwhelming feedback from direct care nurses,
computers on mobile carts (versus devices fixed on walls)
were purchased for all patient rooms, making documentation at the bedside easier for caregivers.
hard to use. With their input, new carts were purchased,
making the electronic chart much easier to read on the
computer screen and the carts/computers better from an
ergonomic perspective. The new carts have since been
purchased for Ambulatory Services, PACU and other
nursing units in the hospital.
iNet:
iNet was implemented in late summer and provided caregivers with the long awaited functionality of bringing
data from monitors and other devices automatically into
the patient’s electronic record. Bonnie Gorrell, a nurse in
our Intensive Care Unit stated, “We had seven patients
with two balloon pumps; all our vitals are flowing into
the chart. This is amazing.”
CareAdmin:
With Nursing Bundle III came the implementation of
CareAdmin, which replaced CareMobile on most nursing
units. CareAdmin allows the nurse access to the entire
medical record during medication administration and
eliminates many of the technical issues encountered with
the hand held device.
Surginet:
Surginet was implemented on April 30, 2011, providing
electronic scheduling, documenting, reporting, and
supply information for the surgery department. When
planning for the Surginet implementation, OR nurses
identified their computer carts/laptops were extremely
“I had the opportunity to experience your nursing care as not only a family member but as a nurse. The
members of this family all agree that mom & dad had very excellent care. The compassion that was
shown when mom passed was something that not everyone sees. We saw it as a family and can't express
our thanks enough. Your staff went above and beyond what we expected.”
– 2011 Mercy Medical Center Patient
Car ing Thr ough New K no wledge & Innova tion
| 25
Caring
A S EVIDEN CE D BY E MPIRICA L O U T C O MES
EXCELLENCE IN CLINICAL PERFORMANCE
Mercy RN Engagement 2010-2011
[National Database of Nursing Quality Indicators (NDNQI)]
100
90
84
80
70
Percent Positive
69
76
72
60
62
50
40
80
79
83
63
92
30
76
64
61
32
87
20
10
0
Outcome
Q1/10
Q1/11
Nat HC Norm
Organizational
Effectiveness
76
79
72
64
80
76
Mercy Patient Care Services RN Engagement
Recognition/Career
Advancement
61
83
69
Supervisory
Management
32
63
62
Mercy RN National Certification and BSN Preparation
2010 (N=576) compared to 2011 (N=616) [HR Solutions]
100%
90%
17
16
10
Coworker Performance/
Cooperation
87
92
84
191
200
179
13
175
166
80%
150
Percent
60%
53
59
60
57
50%
40%
Number of RNs
70%
125
100
87
75
30%
20%
29
25
31
30
Mercy 2010
17
53
29
2010 Norm
16
59
25
Mercy 2011
10
60
31
2011 Norm
13
57
30
72
72
50
10%
25
0%
Actively disengaged
Ambivalent
Actively engaged
26
| Caring As Evide nce d By Empir ica l Out co me s
2010 Actual
2011 Goal
2011 Actual
Certification
72
87
72
BSN
166
179
191
EXCELLENCE IN CLINICAL PERFORMANCE
Mercy Medical Center Patient Satisfaction
Nurses Treated you With Courtesy & Respect
96
94
94
94
92
91
81
90
89
88
Score
88
86
85
86
83
84
84
84
83
84
Jan-Mar 10
86
83
Apr-Jun 10
88
84
Jul-Sep 10
94
84
Oct-Dec 10
91
84
Jan-Mar 11
94
83
Apr-Jun 11
91
84
84
82
80
78
76
Mercy
All PG Mean
Jul-Sep 11
89
85
Mercy Medical Center Patient Satisfaction
Call Button Help as Soon as you Wanted it
66
65
64
64
63
62
62
61
Score
61
60
61
62
62
62
61
61
58
58
57
56
54
52
Mercy
All PG Mean
Jan-Mar 10
61
61
Apr-Jun 10
62
61
Jul-Sep 10
58
62
Oct-Dec 10
57
61
Jan-Mar 11
65
61
Apr-Jun 11
64
62
Jul-Sep 11
62
63
Mercy Medical Center Patient Satisfaction
Nurses Listened Carefully to you
90
86
85
85
85
81
80
80
75
72
73
73
76
73
73
74
Jan-Mar 10
80
72
Apr-Jun 10
76
73
Jul-Sep 10
86
73
Oct-Dec 10
80
73
Jan-Mar 11
81
73
Apr-Jun 11
85
73
Jul-Sep 11
85
74
Score
80
76
70
65
Mercy
All PG Mean
SOURCE: Press Ganey (PG) Patient Satisfaction Survey
Car ing A s Ev idenced By Em pir ica l Outcom es
| 27
EXCELLENCE IN CLINICAL PERFORMANCE
Mercy Medical Center Patient Satisfaction
Pain Well Controlled
80
70
75
72
71
70
70
62
62
63
62
62
62
63
Jan-Mar 10
69
62
Apr-Jun 10
71
62
Jul-Sep 10
70
63
Oct-Dec 10
70
62
Jan-Mar 11
75
62
Apr-Jun 11
68
62
Jul-Sep 11
72
63
69
68
60
Score
50
40
30
20
10
0
Mercy
All PG Mean
Mercy Medical Center Patient Satisfaction
Nurses Explained in a Way you Understand
84
83
83
81
82
80
80
77
78
Score
76
75
75
74
81
70
73
72
72
72
72
72
Apr-Jun 10
77
72
Jul-Sep 10
83
72
Oct-Dec 10
75
72
Jan-Mar 11
80
72
Apr-Jun 11
81
72
71
68
66
64
Mercy
All PG Mean
Jan-Mar 10
75
71
Jul-Sep 11
83
73
Mercy Medical Center Patient Satisfaction
Staff Did Everything Possible to Control Pain
88
87
86
84
85
87
85
84
82
82
Score
81
80
78
78
76
74
77
77
77
77
77
Apr-Jun 10
85
77
Jul-Sep 10
87
77
Oct-Dec 10
81
77
Jan-Mar 11
87
77
Apr-Jun 11
82
77
76
72
70
Mercy
All PG Mean
28
Jan-Mar 10
85
76
| Caring As Evide nce d By Empir ica l Out co me s
Jul-Sep 11
84
78
SOURCE: Press Ganey (PG) Patient Satisfaction Survey
EXCELLENCE IN CLINICAL PERFORMANCE
Our performance on core clinical indicators consistently
ranks among top hospitals as shown on the Trinity Health
clinical dashboard.
AMI
PCI within 90 minutes
100%
CHF
Discharge Instructions
94%
SCIP
Antibiotic w/in 1 Hour
Antibiotic Selection
Antibiotic dc’d in 24 Hours
Post Operative Glucose (Cardiac)
Treatment Ordered to Prevent Blood Clots (VTE 1)
Treatment Received to Prevent Blood Clots w/in 24 Hours (VTE 2)
Beta Blocker Prior to Arrival
Urinary Catheter Removal
98%
99%
98%
97%
98%
97%
96%
99%
Pneumonia
Blood Culture in ED Before 1st Antibiotic
Antibiotic Selection for Pneumonia
100%
100%
Peri-Natal Patient Safety
Elective Delivery Prior to 39 Weeks
Hepatitis B Vaccine for Newborns
Injury to Neonate ratio
Electronic Fetal Monitoring Certification
0%
100%
3.85
54%
Patient Safety
Falls with Injury/1000 Patient Days
Pressure Ulcer Prevalence Rate
ICU VAP/1000 Ventilator Days
ICU BSI/1000 Central Line Days
Severity Adjusted Mortality Ratio
Medication Reconciliation Rate
Readmission Rate Medicare
Readmission Rate CHF
% SRE’s Reported in 5 Days
0.0
0.6%
0.0
0.0
0.79
71%
13%
20.2%
100%
Patient Satisfaction
Overall Perception of Safety
Overall Patient Satisfaction
Pain Management
Communication with Nurses
Communication with Doctors
Discharge Instructions
ER Likelihood to Recommend
Nursing Rolling Annual Turnover
Clinical Weighted Grade Point Average
67%
75.1%
73.3%
82.9%
85.3%
90.7%
90.7%
9.2%
3.7
Green = Targeted or exceptional levels of performance
Yellow = Above the median in performance
Red = Below the median in performance
Excellent care
Taken from the December Trinity Health Clinical Dashboard representing Clinical Performance from July through December 2011
Car ing A s Ev idenced By Em pir ica l Outcom es
| 29
2 0 1 1 MERC Y NURSING ANNUAL REPORT
250 Mercy Drive Dubuque, IA 52001 | 563.589.8000