empowered - Deaconess Health System

Transcription

Excellence
EMPOWERED
by
pulling the pieces together
N u r s i n g A nn u a l R e p o r t | 2 0 1 1
Magnet
Model
Dear Nursing Staff,
Professional
Practice Model
Congratulations to
Deaconess Nurses
Transformational
Leadership
Leadership
Chart
for another year of
progress toward
national recognition
for nursing excellence.
This report will
highlight another year
of accomplishments
by Deaconess
nurse leaders at
all levels that help
position Deaconess
Hospital and Health
System for recognition as a leader in safe,
compassionate, high-quality health care.
Structural
Empowerment
These achievements are due to the leadership
shown by many of you through the unit-based
councils, the Nursing Shared Governance
Councils, Healthy Work Environment teams,
interdisciplinary teams (e.g., Stroke Team),
core care teams and other nurse-led initiatives
in which the difference nurses make results in
great patient care. Because of these results,
we also had a “perfect” accreditation HFAP
survey, with no nursing deficiencies noted.
Exemplary
Professional Practice
New Knowledge,
Innovations & Improvements
This is our fourth nursing annual report.
It covers many Deaconess nursing
contributions, including:
• “hardwiring” efficient and effective
use of EPIC
• improving core measures and NDNQI nurse
sensitive indicators
• maintaining a strong position with skin care
management, and
• making important improvements in patient
satisfaction across a number of nursing units.
We achieved these goals while opening a
new tower at Deaconess Gateway Hospital,
expanding the Gateway ED, expanding
the Deaconess Hospital ED and ORs, and
remodeling the new unit 4800 ICU that’s
scheduled to open in June of 2012.
From Your
Family To Ours
The VHA RetuRN to Care Collaborative Teams
that began work in 2010 continue to show
their commitment to patient-centered care by
enhancing our care delivery process for every
patient as we meet their individual care needs
during hospitalization. All medical surgical
units and several ICUs across campuses have
integrated this structure into their units. The
remaining ICUs have incorporated many of
the actions central to RetuRN to Care within
their unit structures. In addition, the work
of the Healthy Work Environment teams
continues to help build highly effective teams
across nursing units.
2 | Deaconess Health System
The Emergency Department nurses at both
campuses took a lead role in developing a
standard of care for sexual assault patients,
with a number of the nurses stepping forward
to obtain their Sexual Assault Nurse Examiner
certification in 2010. This year they have done
significant work to ensure that we provide
best practice in the care of these vulnerable
patients—while expanding their expertise to
also care for child victims.
The new Professional Development Program
for RNs rolled out at the end of 2010, and
this year we’ve already recognized more
than 13 nurses through this program. Other
improvements to the program continue,
and increased participation is evident. The
SG Education Council continues to lead this
initiative.
Trauma Services had a very successful
re-accreditation survey. The nursing
leadership and staff who were involved were
critical to such a strong survey, as were the
other interdisciplinary team members who
emphasized to the surveyors our team-based,
high-quality, patient-centered care for trauma
patients and their families.
It will be apparent to all who read this report
that Deaconess nurses are moving forward
with an aggressive nursing-excellence
agenda. I encourage you to read this
report in detail. It will make you proud and
even more determined to accomplish as
much as possible in 2012 in the interest of
extraordinary patient care.
On behalf of Deaconess nurses, I would like to
thank the Board of Directors and Linda White,
President and CEO, for their ongoing support
of nursing excellence and their continued
loyalty and support of our pursuit of Magnet
recognition. We will submit our documents by
August 1, 2012.
Let’s go for the gold and accomplish the
goal of Magnet 2013.
Sincerely,
Cherona J. Hajewski, MSN, RN, NEA, BC
Vice President and
Chief Nursing Officer,
Deaconess Hospital
EXEMPLARY PROFESSIONAL PRACTICE ............................................................. 36
NEW KNOWLEDGE, INNOVATIONS & IMPROVEMENTS ................................... 42
FROM YOUR FAMILY TO OURS ................................................................................45
Deaconess Health System
pulling the pieces together
Licensed beds at Deaconess Gateway Hospital
(excluding ancillary areas)
Licensed beds at Deaconess Cross Pointe
Deaconess Hospital Campus Surgery Cases
Gateway Campus Surgery Cases
From Your
Family To Ours
323
158
60
4,180
3,842
Licensed beds at Deaconess Hospital
(301 acute-care beds)
Transformational
Leadership
STRUCTURAL EMPOWERMENT ................................................................................10
Leadership
Chart
LEADERSHIP ChART ..................................................................................................... 8
Structural
Empowerment
Transformational Leadership ....................................................................... 6
Exemplary
PROFESSIONAL PRACTICE MODEL ......................................................................... 5
New Knowledge,
MAGNET MODEL ............................................................................................................ 4
Professional
Practice Model
Magnet
Model
Table of Contents
2011 Nursing Annual Report | 3
Magnet
Model
The Magnet Model
Professional
Practice Model
ES IN NURSING & HEAL
U
S
S
TH
AL I
CA
B
O
RE
GL
Structural
Transformational
Leadership
Empowerment
Transformational
Leadership
Empirical
Outcomes
Exemplary
Professional
Practice
Leadership
Chart
New Knowlege,
Innovations &
Improvements
Structural
Empowerment
Exemplary
The Magnet Model consists of five components, including
the sources of evidence from each component. They include:
Transformational Leadership; Structural Empowerment; Exemplary
Professional Practice; New Knowledge, Innovations & Improvements.
New Knowledge,
Transformational Leadership:
Focuses on leadership within the organization and their actions to influence
change, values, behaviors, vision and
beliefs. To achieve this goal, leaders must
be strong communicators and good
listeners while supporting future practices.
Structural Empowerment:
The involvement of nurses at every level
making the best decisions with the most
optimal outcome—from the bedside to
the CNO. Nurses are valued at Deaconess,
and we recognize them for their achievements both within the system and
community-wide.
From Your
Family To Ours
Exemplary Professional Practice:
The essence of Magnet nurses and a
Magnet organization! The goal of this
component is to guide practice by using
a strong model that focuses on collaboration, communication, nursing practice
and professional development to provide
the highest quality care to patients.
Another key point to this component is
a strong shared governance, which is
vital to the success of the organization.
With the integration of the Professional
Practice Model of Nursing along with the
Professional Development Program, the
leaders of today are making way for the
leaders of the future.
New Knowledge, Innovations and
Improvements: Evidence-based practice
provides our patients with the safest
and best practices while generating new
knowledge. To be successful, Deaconess
must continually build on the current
knowledge base by using existing
evidence while applying new evidence to
achieve optimal outcomes.
Empirical Outcomes: From excellent
nursing care at the bedside, and by having
proper structures in place, we continue to
see growth and improvement in patient
satisfaction and outcomes.
LPN
PCA
Tech
CA
Physician
Case Manager
Quality Analyst
Social Worker
Chaplain
Admin
Interdisciplinary Team:
EN
T
PATIENT
E
M
UA
TE
IM
Interdisciplinary Care Plan Coordination
Integrate & Coordinate Interdisciplinary Activities
Manage Length of Stay and Utilization
PL
Outcome: Evidence-Based
Practice Care Resulting in Best
Outcomes.
DEACONESS FIRST
Fantastic People
Increasing quality
Resulting in growth
Superior service
CNO/Leadership
Professional Development
Accountability
Community Service
Nursing Shared
Governance/Unit Based
Council
EBP / Research
Shared Decision
Making
Autonomy
Best Patient Outcomes
Code of Ethics
RN Retention
Innovation
Patient Satisfaction
T
Vision/Values
Deaconess Nursing Professional Practice Model aligns with the
Magnet Model. Our model is patient-focused, evidence-based
and utilizes the expertise of the interdisciplinary team; all are
components of professional practice. It also demonstrates the
support the organization gives us to achieve excellence in nursing.
Our Professional Practice Model (PPM)
• Integration of a patient-focused care
delivery system delineates nurses’
authority and accountability for clinical
decision-making and outcomes.
• Demonstrates a collegial and collaborative relationship between nursing
and the interdisciplinary team.
• Reflects the Nursing Process and the
Nurse Practice Act, which is foundational to clinical decision-making.
• Displays the infrastructure of support
provided by organizational and nursing
leadership.
• Reflects the professional values that
Deaconess nurses hold regarding
their practice: evidence-based
patient care, working relationships,
work environment, professional
development, and recognition of the
contributions they provide at the
bedside.
• Demonstrates the embracement and
application of the Code of Ethics for
Nurses as nursing practice and
interdisciplinary care is enveloped in a
caring and healing environment.
Magnet
Model
Leadership
Chart
Pharmacy
PT, OT, ST
Resp. Therapy
Dietician
Lab/Rad
Structural
Empowerment
RN
Exemplary
Evid
enc
e-B
a
New Knowledge,
DIAGNOSE
P
ASSE
SS
Inte
rdi
sci
pl
m
Tea
tice
rac
dP
se
LAN
y
ar
in
Care Delivery
From Your
Family To Ours
Patient Need
ealing Environment
nd H
ga
rin
Ca
PATIENT-FOCUSED
CARE DELIVERY
AL
EV
ng and Healing Env
iron
Cari
me
nt
ealing Enviro
and H
nme
g
n
i
r
nt
Ca
Transformational
Leadership
Professional
Practice Model
Professional
Practice
Model
PROFESSIONAL PRACTICE MODEL OF NURSING
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Structural
Empowerment
Exemplary
New Knowledge,
From Your
Family To Ours
Transformational
Leadership
Focuses on leaders within the organization and their actions
to influence change, values, behaviors, vision and beliefs.
To achieve this goal, leaders must be strong communicators
and good listeners while supporting future practices.
• Reimbursement for nursing degrees
exceeded $196,000 during 2011.
Continuing Education
Opportunities for
Deaconess Nurses
Deaconess provided continuing nursing
education, with 74 activities, classes and
seminars offered throughout 2011.
• Deaconess nurses earned up to 372.2
contact hours.
• 2,097 attendees took advantage of
the programs that were offered at
Deaconess last year.
• 1,378 of these were nurses from
Deaconess and the Tri-State area.
Deaconess Nurses in
Professional Organizations
As of September 25, 2011, according
to the professional development
survey, there were 270 nurses who hold
membership in a professional organization. Deaconess is proud to have several
nurses holding offices in local chapters of
professional nursing organizations.
Deaconess Leadership Training
from Novice to Expert
Deaconess nurses are supported every
day in the growth and development of
professional nursing at all levels. Many
nurses, from staff nurses to nursing
leaders, attend leadership training with
Deaconess’ support, including:
• VHA Nursing Leadership Institute and
IHA Management Institute Leadership
training
• Southwest IONE Annual Leadership
Conference
• Strategic Planning Day
• Lean Six Sigma Training
• Deaconess Leadership Annual
Conference
Certified Nurses at Deaconess
Magnet
Model
From Your
Family To Ours
According to the Professional Development Survey taken by nurses in fall 2011, 349
nurses currently hold specialty certifications in the health system. Many more are
actively pursuing certifications. This number has continued to grow throughout the
years thanks to the encouragement and assistance provided by Deaconess.
Professional
Practice Model
According to our current nursing
professional development survey,
BSN-prepared nurses have increased to
437, and MSN-prepared nurses to 54 and
1 DNP. There are 167 nurses pursuing
BSN degrees and 98 pursuing MSN
degrees. Seventy-five percent of our
leadership team has a BSN or higher, with
the other 25% to complete their BSN or
higher in 2012.
Transformational
Leadership
• In 2011 Deaconess paid more than
$41,000 for first-time voluntary nursing
certifications.
Leadership
Chart
Deaconess Nurses Achieving
Advanced Degrees
We are proud of our Deaconess nurses
and all their levels of education and
achievement! Deaconess nurses continue
to seek out opportunities to further their
education and advance their degrees.
Structural
Empowerment
eaconess recognizes the important
relationship between education
and improved patient outcomes. The
organization supports nurses’ pursuit of
continuing education through seminars,
advanced degrees, classes, certifications
and professional organizations.
Exemplary
D
New Knowledge,
Highlights for 2011
Cheron
Magnet
Model
MSN, RN
Patient C
Vice Pres
Kathy Clodfelter
MSN, RN, CHS, NE-BC
Critical Care &
Trauma Services Director,
Magnet Program Director
BSN, RN, MBA, NE-BC
Patient Care Services
Director (DGH)
Darla Bush
April
Winkleman
Michelle
Decorrevant
RN
Cardiovascular ICU
Manager (DH)
RN
Medical Surgical ICU
Manager (DGH)
Erin Smith
Belle McCool
Christa Wolf
Structural
Empowerment
BSN, RN
Adult Mental Health Unit
Manager (DH)
DNP, RN, NE-BC
Peds Trauma, Trauma &
Cardiovascular Surgical
ICUs Manager (DH)
BSN, RN, CNRN
Neuro ICU & Neuro
Science Manager
(Gateway)
Kristi Spencer
Lanney Avis
Debra Wilson
BSN, RN
Child/Adolescent Services
Manager (Cross Pointe)
BSN, MS, RN, NE-BC, CCRN
Neuro Medical Surgical
ICU & Neuro Care Center
Manager (DH)
MSN, RN, OCN
Surgery Oncology
Manager (DGH)
Amanda
Elikofer
Sara Holzmeyer
Transformational
Leadership
Jill Buttry
MSN, RN
Deaconess Cross Pointe
Psych Mental Health
Administrator
Leadership
Chart
Professional
Practice Model
Cheryl Reitman
RN
Adult Services Manager
(Cross Pointe)
Exemplary
BSN, RN
Trauma Program Manager
(DH)
BSN, RN, CMSRN
Orthopedics Manager
(DGH)
New Knowledge,
Karen Fox
Staci Chambers
BSN, RN, CCRN
Cath Lab, CVSS &
Non-Invasive Cardiology
Manager (DH)
BSN, RN, CMSRN
General Medical Telemetry
Manager (DGH)
ADONs
Paula Yarbrough
From Your
Family To Ours
BSN, RN, CPN,
NE-BC
Pediatrics and PICU
Manager (DGH)
Call Center Nurses
ADONs
Radiology Nurses
Chancellor Center
na Hajewski
MSN, RN-BC, NE-BC,
CNRN
Employee Education &
Health Science Library
Manager
Lynn Lingafelter
RN, BHS, MBA
Emergency & Surgical
Services Director
Sara Goedde
Ellen Wathen
Marlene Waller
BSN, RN
Cardiovascular Care
Center Manager (DH)
PhD, RN
Magnet Recognition
Program, EBP & Nursing
Research Program Coord.
RN, CEN
Emergency Services
Manager
(DH and DGH)
Patty Laird
Lois Welden
Libby Ketchem
MSN, RN, OCN, NE-BC
Surgical Medical Care
Center & Lift Team
Manager (DH)
MSN, RN
Advanced Practice
Nursing, Primary Stroke
Center Coord., Lead CNS
MS, RN, NE-BC
Wound Care Center,
PACU, SDCC & Pretesting
Manager (DH and DGH)
Erin Fuhrer
Sally Finley
MSN, RN, ONC,
NE-BC
Ortho Medical Care
Center Manager (DH)
RN
Case Management
Services Manager
Laticia
Gunderson
Sonja Frisby
Leigh Ann
Gamble
MSN, RN, NE-BC
Home Care, Hospice &
HME Manager
Angela Stroud
Vicki Jasper
RN, CMSRN
OP Chemo, Oncology/
Pulmonary & General
Med-Surg Manager (DH)
RN, CHPN
Home Services Clinical
Manager
Diana McDaniel
MSN, RN, CASC
Pain Management Manager
(DGH and West-Side
Clinic)
New Knowledge,
BSN, RN, NE-BC
Dialysis & Cardiac
Renal Care Center
Manager (DH)
RN, BSN, CNOR
Surgery Deparmtnet
Manager (DH and DGH)
Transformational
Leadership
Linda Cason
Leadership
Chart
MSN, RN, NE-BC
Med-Surg & Specialty
Services Director
Structural
Empowerment
Kay Vaught
Exemplary
Care Services
sident, CNO
Professional
Practice Model
Magnet
Model
N, NEA-BC
Jennifer Kirby
From Your
Family To Ours
RN, CMSRN
IV Therapy, WOCNs and
Resource Team Manager
(DH)
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Structural
Empowerment
Exemplary
New Knowledge,
Structural
Empowerment
From Your
Family To Ours
Structural empowerment means the involvement of nurses at every level,
making the best decisions with the most optimal outcome—from the
bedside to the CNO. Nurses are valued at Deaconess, and we recognize
them for their achievements, both within the system and community-wide.
Claire Bennett, BSN, RN
Gateway Surgery Oncology
Staff Nurse, Magnet Specialist
Sara Holzmeyer, BSN, RN,
CMSRN
Manager of Gateway Ortho
Jill Buttry, MSN, RN, CNS
Critical Care and Trauma
Director, Magnet Director
Genny Kamer, BSN, RN, CCRN
CVSICU Staff Nurse,
Magnet Specialist
Karen Fox, BSN, RN, CCRN
Manager of CVSS/Cath Lab
Andrea Klotz, BSN, RN
Med/Surg 5200 Staff Nurse,
Education/PDP Council Chair
for 2012
Melody Littrell
Education Specialist,
Writing Team
Marian Schneider, RN
CVSICU Staff Nurse, Image of
Nursing Council Chair for 2012
Michelle Stoll, MSN, RN
Clinical Educator at Gateway
Ellen Wathen, PhD, RN-BC
EE&D, Magnet Document Writer
• Honoring the Past; Creating the Future
• Baltimore, Maryland — October 2011
• There are currently 393 international
Magnet facilities across the globe
• There are currently 12 facilities in Indiana,
with the first one designated in 2003.
• This is just the tip of the iceberg of what is
available at a Magnet conference. Shared
governance chairs, liaisons, leadership
and staff nurses brought home many
ideas, so find them and ask questions!
Feedback
“After returning from the Magnet
conference, I realized that this journey
is one that uses all our strengths as an
organization collectively to meet the
challenge of staying on the path that’s
going in the right direction.”
Michelle Stoll, MSN, RN—
Clinical Educator at Deaconess Gateway
“I learned we are well on our way to
achieving Magnet. We need to recognize
each other and the great things we do
every day!”
Claire Bennett, BSN, RN—
Surgery Oncology Gateway
“Improving work environments and
decreasing patient load by one patient
decreases mortality rates. Decreasing
the patient load in an unhealthy work
environment shows no change in
mortality rates.”
Sara Holzmeyer, BSN, RN, CMSRN—
Manager, DGH Ortho
“I really took away the big picture that
nursing isn’t just my perception of my
patients on my unit. The profession and
passion that drives it is so much bigger
than that. Every day there are so many
nurses just like my Deaconess colleagues
and myself who are doing our best to care
for others and improve the way we do so
to better serve everyone.”
Andrea Klotz, BSN, RN—Med/Surg 5200
After hearing a session on resiliency
training for stress reduction, I saw that
educational intervention increased patient
satisfaction and teamwork, resulting in
a huge impact on their organization and
promoting excellence in care, leadership,
integrity, respect, collegiality and a
healthy work environment.
Marian Schneider, RN, CVSICU
New Knowledge,
• Nurses traveled from as far as the
Netherlands, China, Finland and New
Zealand, with Australia being the
farthest away!
Exemplary
Structural
Empowerment
• More than 7,500 national and
international nurses in attendance
• Attended sessions on Falls, HAPU, Restraint
and Sitter Usage, Care Delivery Models
(such as Jean Watson’s Theory of Caring),
Healthy Work Environment and documentation writing/submission workshops.
Magnet
Model
Leadership
Chart
Highlights
From Your
Family To Ours
Cherona Hajewski, MSN, RN,
NEA-BC
Chief Nursing Officer
Betty Nelson, BSN, RN, BC
Heart Hospital Staff Nurse,
Quality and Safety Council
Chair for 2012
Professional
Practice Model
Attendees
Transformational
Leadership
Magnet Conference | 2012
Magnet
Model
The Journey from
Novice to Expert
Professional
Practice Model
W
Transformational
Leadership
e are excited to join with these nurses as we pave the way for them from Novice
to Expert. Katie Burnett in Human Resources has done an excellent job assisting
our managers in finding new graduates to add to our excellent nursing staff. These
nurses will begin their journey as new nurses in our organization.
Leadership
Chart
Structural
Empowerment
University of Southern Indiana
Vincennes University
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IVY Tech Community College
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Exemplary
•
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New Knowledge,
•
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Lindsey Adcock, BSN—DGH Neuro ICU
Lindsey Cobb, BSN—DGH Neuro ICU
Theresa Adler Richardson, BSN—Surgery
Ashley Aufman, BSN—DGH Pediatrics
Erica Berning, BSN—DGH Neuroscience
Abby Buck, BSN—DGH Ortho
Samantha Chambers, BSN—DH Trauma/
CVSICU/Peds Trauma
Melinda Clark, BSN—Wound Care Clinic
Chantal Dash, BSN—DH Emergency
Michelle Ferguson, BSN—DGH Ortho
Kristin Fischer, BSN—Resource Team
Ashly Guth, BSN—DGH Surgery Oncology
Alysha Hall, BSN—DH CRCC
Laura Hall, BSN—DH SMCC
Jessica Harper, BSN—The Heart Hospital
Amber Lang, BSN—DGH Surgery Oncology
Avery Lebowitz, BSN—DH Trauma/CVSICU/
Peds Trauma
JaeWon Lee, BSN—DH CVCC
Katie Lindsey, BSN—DH Emergency
Elizabeth Kramer, BSN—DH SMCC
Stuart Love, BSN—The Heart Hospital
Samantha White, BSN—DH OPCC
Lissa Wilkey, BSN— DH OPCC
Amanda Wilson, BSN—DH SMCC
Courtney Woods, BSN—DGH Ortho
Allison Vick, BSN—DGH Surgery Oncology
Brandy Waninger, BSN—
DGH General Med/Tele
Dawn Rogers, BSN—DH Trauma/
CVSICU/Peds Trauma
Lauren Meneghetti, BSN—DGH Surgery
Oncology
Kayle Neurenburn, BSN—DH NCC
Andrea Schnur BSN—DH CVCC
Brett Schipley, BSN—DH CVICU
Peter Sieg, BSN—DH CVCC
Katelyn Russell, BSN—DGH MSICU
Shawna Haywood, BSN—DH OPCC
University Of Evansville
From Your
Family To Ours
• Ashtin Collins, BSN—DH/DGH Surgery
• Courtney Dauby, BSN—DH Trauma/
CVSICU/Peds Trauma
• Jordan Dawson, BSN—DH NMSICU
• Brianne Denning, BSN—DH CVCC
• Ann Dodge, BSN—DGH Neuroscience
• Olivia Edens, BSN—DGH Ortho
• Amanda Malone, BSN—DH NMSICU
• Morgan Roos, BSN—DH CRCC
• Bryanne Hartman, ASN—DGH Emergency
• Casey Dittmer, ASN—
• Nicole Fischer, ASN—DGH MSICU
• Heather Keller, ASN—DH CRCC
• Anna Villian, ASN—DH OMCC
• Elizabeth Walker, ASN—DH NCC
• Jamie Long, ASN—DGH General Med/Tele
• Amber Becker, ASN—DH OMCC
• Donna Datkamp, ASN—DH Med/Surg 5200
• Crystal Smith, ASN—DH OMCC
• Amber Townsend, ASN—DH Med/Surg 5200
• Jodi Sullenger, ASN—DH SMCC
• Tiffany Summers, ASN—
• April Schaefer, ASN—DH CVCC
• Jamie Webb, ASN—
• Jessica McCord, ASN—DH CVCC
• Mindy Lutz, ASN—DH OPCC
• Ellen Kramer, ASN—
• Krista Hollingsworth, ASN—DGH Ortho
• Terra Delano, ASN—DH OMCC
Henderson Community College
• Sarah Brown, ASN—DH NMSICU
• Paige Perry, ASN—DH SMCC
Wabash Valley
Community College
•
•
•
•
•
Kathryn Adams, ASN—DH CRCC
Dennis (Chad) Griffin, ASN—DH CVICU
Stacey Rafferty, ASN—The Heart Hospital
Taelor Johnson, ASN—DH OMCC
Kathryn Adams, ASN—DH CRCC
Hope College
• Janette Zandstra, BSN—DH Trauma/
CVSICU/Peds Trauma
IECC
• Jessica Clodfelter, ASN—DH OPCC
Frontier Community College
• Lori Esmon, ASN—DH Med/Surg 5200
University of Indiana
• Maegan Reeves, BSN—DGH MSICU
Maryville University
• Amanda Schmeltz, BSN—DH Trauma/
CVSICU/Peds Trauma
Murray State University
• Brittany Clemmons, BSN—
• Katherine Faver—USI
• Jennifer Schwartz —USI
Adjunct Faculty
Deaconess nurses have the honor to participate as adjunct faculty at many of our
Tri-State nursing programs to provide expert education to our many upcoming bright
stars of nursing.
Magnet
Model
Exemplary
University of Southern Indiana
• Cherona Hajewski, MSN, RN, NEA-BC
• Edith Hoehn, BSN, RN, CVRN
• Diana Everley, BSN, RN-BC, CNRN
• Linda Ogle, BSN, RN, CCRN
• Debra Norman, RN, BS, MHA
• Tonya Krieg, BSN, RN, OCN, CMSRN
• Erin Georges, BSN, RN, CCRN
• Paula West, MSN, RN, CNS
• Teresa Price, BSN, RN, CNRN
New Knowledge,
IVY Tech Community College
• Cynthia Hodge, MSN, RN, OCN
• Leslie Kirkwood, MSN, RN, CCRN
Henderson Community College
• Jill Rector, RN
• Janet Ziegler BSN, RN, CMSRN
From Your
Family To Ours
University of Evansville
• Linda Cason, MSN, RN-BC,
NE-BC, CNRN
• Ellen Wathen, PhD, RN-BC
• Jean Hunt, MSN, CVRN, RN-BC
• Jane Rauscher, MSN, RN, CPNP
• Denise McDowell, MSN, RN, CPNP
• Joan Fedor-Bassemier, MSN, RN
• Cynthia Schaefer, MSN, RN
• Jerrilee Lamar, PhD, RN, CNE
• Diana McDaniel, MSN, RN
Professional
Practice Model
• Sarah McQuay—IVY Tech
Transformational
Leadership
• Cassie Eckerle—USI
Leadership
Chart
Deaconess Hospital would like to congratulate the winners of the Nursing Scholarship
Awards. Each scholarship is valued at $7,000. These scholarships go to local nursing
students throughout the Tri-State. If the nursing student accepts the scholarship, he or
she commits to working two years at Deaconess as a nurse after graduation.
Structural
Empowerment
Scholarship Winners for May 2011
Magnet
Model
Professional
Practice Model
Community Service
Programs & Contributions
O
ur community says thank you to Deaconess nurses for all the community programs
you have participated in.
Transformational
Leadership
• Deaconess Day of Caring at
Eastland Mall
• National Night Out
• Multiple stroke screenings throughout
the community
• EVSC blood pressure screenings
• Day of Dance
• Doctor’s Day
• Allure: An Evening for Women
Leadership
Chart
• Memorial Baptist Church health fair
• Employer health fairs at Toyota, Mead
Johnson and Vectren
• Buehler’s/IGA blood glucose screenings
• Race for the Cure
• Frog Follies
• Vanderburgh County 4-H Fair
• West Side Nut Club Fall Festival
• Go Red for Women’s Health at several
community events
• Community 1st Health Fair
Structural
Empowerment
Deaconess nurses logged more than 150 volunteer hours for Deaconess Community
Advocate Nurses (CAN). The Resource Center with Becca Scott created many new
opportunities last year for Deaconess nurses at any level to participate in.
Exemplary
New Knowledge,
From Your
Family To Ours
100%
80%
Attendance
40%
Pass R ate
20%
0%
2010
Magnet
Model
Professional
Practice Model
Structural
Empowerment
60%
2011
Year
Critical Care Challenge
A few of the nurses from the 2010 CCRN drive participated in the AACN Critical Care
Challenge with Tri-State schools of nursing and hospitals and won the trophy for 2011.
• Jason May, BSN, RN, CCRN—
DH Trauma ICU
• Josh Johnson, BSN, RN, CCRN—
DGH Neuro ICU
• Linda Ogle, BSN, RN, CCRN—
DH Cardiovascular Surgical ICU
• Travis Wilcox, RN, CCRN—
DH Cardiovascular ICU
• Craig Mims, RN, CCRN—
The Heart Hospital
• Christin Wallace, BSN, RN, CCRN—
DH Neuro/MedSurg ICU
• Tami Weisshaupt, RN, CCRN
(Alternate)—The Heart Hospital
“I was proud to represent
Deaconess. The team members
were only a sample of what the
ICUs at Deaconess Hospital and
Deaconess Gateway Hospital
have to offer! Bringing home the
trophy this year brought a sense
of pride and respect across all
the critical care areas. Being a
critical care nurse is a humbling
experience, knowing that many
decisions you make can greatly
affect a patient.”
— Josh Johnson, BSN, RN, CCRN
Exemplary
Percentage
CCRN Drive Results
Transformational
Leadership
The second group had an 89% pass
rate, and the evaluations regarding
the changes were all positive. We are
awaiting approval for our 2012 proposal
for a repeat “Exam Cram” review course
with Deborah Tuggle and two additional
review sessions in which applicants
practice test questions as a group.
New Knowledge,
The evaluations were reviewed by CCRN
drive committee members, who decided
that we should change our strategy based
on feedback from the nurses. The second
group started their session in February
2011 and had 23 RNs who participated.
We offered 16 hours of review sessions
that were taught by CCRN- or
MSN-prepared instructors who hosted
a two-day “Exam Cram” by national
speaker Deborah Tuggle, MSN, RN, CCNS,
an instructor from Louisville, Kentucky.
From Your
Family To Ours
In May 2010 we started our first CCRN
drive for critical care. There were 19
RNs who participated. Each participant
attended four eight-hour review sessions
for a total of 32 hours of review time.
The review sessions were taught by
Deaconess educators and staff members.
The CCRN pass rate for that group
was 50%.
Leadership
Chart
Critical Care Certification Drive
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Image of Nursing Council
Structural
Empowerment
NEA-BC
Exemplary
Kathy Clodfelter, BSN, RN,
NE-BC, MBA
Director of Patient Care
Services—DGH
Magnet, Critical Care,
Trauma Director
Diane Wallace, RN
SDSS/PAT—DH
Vicki Martin Berntson, BSN,
RN, CMSRN
SMCC—DH
Margaret Anderson, RN
Med/Surg Neur ICU—DH
Kim Mastison, RN, CMSRN
Neuro—DGH
Melinda Byers, RN
CRCC—DH
Jackie Spears, RN
SDSS/PAT/PACU—DGH
Sarah Joyce, BSN, RN
OMCC—DH
Jamie Browning, RN
Ortho—DGH
Leah Bucherl, RN
CVSS—DH
Valerie Wills, BSN, RN
Pediatrics and PICU—DGH
Cindi Lemen, RN, CCM
Case Management
Brian Miller, RN
Cath Lab—DH
Edna Fletcher, RN, RN-BC
Cross Pointe Adult
Teresa Whitledge, RN, CNOR
Surgery Department—
DGH/DH
Rachel Wire, RN
Emergency Department
New Knowledge,
Melissa Jassim, BSN, RN
CVCC—DH
Russell Kirby, RN, CEN
Emergency Department—DH
Rachel Roy, BSN, RN
CVICU—DH
Jean Hunt, MSN, CVRN,
RN-BC
Employee Education &
Development
Charla Buttram, RN
IV Therapy—DH
Ashley Robb, RN
Neuro Care Center—DH
Carolyn Putnam, RN, CMSRN
SMCC—DH
Peggy Huey, RN
Adult Mental Health Unit—DH
From Your
Family To Ours
Lisa Williams, RN
Procedure Center
April McBride, RN
Home Care/Hospice
Katie Burnett
Human Resources
Nurse Recruiter
Michelle Almon, BSN, RN
Endoscopy—DH/DGH
Nursing Excellence
Nancy Aud, RN, CMSRN
General Med-Tele—DH
Renee Bower, RN
Med/Surg 5200—DH
Magnet Specialist/Surgery
Oncology
Kara Donnetta, RN
Endoscopy—DH/DGH
Promote the professional
image and practice of nursing
at Deaconess Health System
• Promoted certifications
• Deaconess Health System offered to
pay for all initial certification exam fees
prior to exam
• Presented AIDET communication
information, which has been
implemented across Deaconess Health
System nursing units
• Supported “Zero Tolerance” policy,
protecting employees from abusive
work-related behaviors
• Council chair participated on the
physician loyalty team to help improve
communication with medical staff
National Nurses’ Day 2011
Image of Nursing Council members participated on the Nurses’ Day/Nurse of the Year
subcommittee and helped plan Nurses’ Day and the Nurse of Year Ceremony for 2011.
These were two very successful events this year.
• The lobbies of both Deaconess Hospital
and Deaconess Gateway Hospital were
decorated with unit posters displaying
RN pictures and artwork created by
hospital employees’ children.
• For National Nurse’s Day, Deaconess
Foundation funded the nationally
renowned speaker Liz Jazweic, RN, for
two inspirational presentations that
were “live-fed” to the Gateway campus
concurrently.
• WIKY radio station interviewed
Cherona Hajewski, MSN, RN, NEA-BC,
VP Patient Care Services and CNO,
regarding efforts at Deaconess to
convey their appreciation of excellent
care given by each Deaconess nurse.
• Johnson Hall became an elegant
destination for nurses to mingle with
colleagues. The wonderful food and
decorations planned by the subcommittee and Deaconess Catering Services
impressed everyone in attendance.
Music added ambience, and the
continuous slide show of Deaconess
nurses captivated the audience.
All Deaconess nurses had their names
placed in a drawing for chances
to win prizes, and each Deaconess
nurse received a complimentary cup
inscribed: “Excellent Care, Excellent
Nurses. Thank you for being a DH
nurse.” This was an inaugural event, and
word quickly spread that this was the
event to attend.
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Medical information was well received,
and nurses who participated gained
personal satisfaction at this much-needed
community event.
Improve nurse-to-physician
communication and collegiality
• Provided communication exercises for
council members
Leadership
Chart
• Distributed disease-specific pamphlets
according to test results
Structural
Empowerment
• Provided resources for follow-up
• Promoted advancement of formal
education beyond the diploma/associate
degree nurse (ADN) level by encouraging
tuition reimbursement programs and the
privilege to self-schedule work hours,
enabling nurses to return to the classroom
Exemplary
Participate in the Community
First Day at C.K. Newsome Center
• Counseled 125 participants about their
abnormal test results
New Knowledge,
The Image Council worked with Deaconess Resource Center to promote the positive
perception of nursing throughout the Tri-State by establishing a Deaconess Day of
Caring in April 2011. Many nurses provided stroke education, nutrition and exercise
information, and alcohol and depression screenings.
From Your
Family To Ours
Promoting Nursing
Magnet
Model
2011 Nurses of the Year
Professional
Practice Model
Advancement of the Profession Award
Betty Nelson, BSN, BC-RN — The Heart Hospital
Transformational
Leadership
Betty encourages, motivates and inspires co-workers, assisting in their
professional development. She is instrumental in encouraging active
participation from co-workers in the improvement of quality on her
unit enlisting co-workers to engage in making needed change. Her
attitude is contagiously positive, and her compassion is sincere.
Community Service Award
Cathy Wagner, BSN, RN — Deaconess Home Health
Leadership
Chart
Cathy is a liaison for referrals and marketing in the region, an online
USI instructor in tele-health monitoring, a community CPR instructor,
and a volunteer at local health fairs and blood pressure clinics at
assisted-living facilities.
Excellence in Clinical Practice Award
Kim Brace, RN, CMSRN — Surgical Medical Care Center
Structural
Empowerment
Kim is an expert nurse in the care of surgical and trauma patients.
She has excellent critical thinking skills and is able to see the whole
patient from vital signs, lab results and her head-to-toe assessments.
She is thorough and efficient in her care but also demonstrates
compassion toward her patients and their families.
Leadership Award
Exemplary
Michael Aders, RN — CVSICU
Michael encourages staff to participate, updates us on plans,
asks for feedback, relays information to the team, and explains
rationale for decisions. As two units merge and learn new skill sets,
surroundings and co-workers, Michael is paving the way for positive
change. He is a beacon of professionalism, courtesy and respect.
Mentorship Award
Jennifer Ramsey, BSN, RN, CCRN — CVSICU
New Knowledge,
Jennifer is an amazing source of knowledge and skill in the field
of critical care. She is tireless in her efforts to drive for clinical
excellence. She can always be counted on to teach others the proper
methods of patient care.
Florence Nightingale InPatient Award
Tonya Kreig, BSN, RN, OCN — Surgical Oncology Gateway
Tonya exemplifies the Deaconess credo by volunteering her time
promoting cancer awareness and education. She consistently
encourages and inspires those around her. She is very caring,
compassionate and sympathetic, taking the best possible care of her
patients and their families.
From Your
Family To Ours
Florence Nightingale OutPatient Award
Laura Benkert, BSN, RN — Procedure Center Deaconess Clinic
Laura is a bright example of the type of nurse and individual we
all hope to work with and to have care for our loved ones during
difficult times, which can occur while receiving health care. When
Laura finishes with a patient, they know that a nurse who truly loves
her job cared for them.
Anne Ainsworth
Joseph Fields
Noni Roberts
C. Danielle Alderson
Shirley Gubler
Dawn Rowley
Janie Arington
Tammy Hildebrandt
Kirby Russell
Nancy Ash
Elizabeth Ivy
Mary Beth Schitter
Graceanna Austin
Sarah Joyce
Michelle Sharp
Teri Bassett
Denise Kohut
Kymber Baumholzer
Gigi Kozinski
Heather
Stonecipher-Short
Patricia Bender
Tonya Krieg
Laura Benkert
Melanie Mahone
Kathy Beyer
Ashley Mellott
Jill Boles
Tara M. Moore
Kim Brace
Sallie Moseley
Kristina Brown
Sara Mossberger
Shawn Brown
Betty Nelson
Kathy Clevidence
Vena Owen
Angie Cox
Kari Pawlak
Rebecca Deig
Whitney Porter
Jill DeShields
Carolyn Putnam
Shauna Dilger
Jennifer R. Ramsey
Amber Dillon
Jill Rector
Michael Clint Sheffer
Mindy Shoulders
Libby Sisk
Chris Smith
Sarah E. Smith
Amy Stott
Kelsie Tarter
Cindy Ulrich
Cathy Wagner
Christin Wallace
Rachael Waninger
April Winkleman
Magnet
Model
From Your
Family To Ours
New Knowledge,
Janet Ziegler
Professional
Practice Model
Gail Riedford
Transformational
Leadership
Briana Elpers
Leadership
Chart
Michael Aders
Structural
Empowerment
Sixty nominations were received for Nurse of the Year awards. We would like to
congratulate and say thank you to the following nurses for all their hard work and
dedication to Deaconess, our patients and their fellow staff.
Exemplary
Nurse of the Year Nominees
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Nursing Practice Council
Structural
Empowerment
Cherona Hajewski, MSN, RN, NEA-BC
Exemplary
Magnet Program, Critical Care, and
Trauma Program Director
Karen Jochim, RN, CCRN
CVSICU/Trauma/Peds Trauma
Rachel Roy, BSN, RN, CCRN
CVICU (2900)
Jennifer Palmer, BSN, RN, CMSRN
EE &D
Nancy Lutz, RN, SMCC—DH
Kim Mastison, RN, Ortho—DH
New Knowledge,
Melissa Dotson, BSN, RN
Neuro/MSICU (3900)
Jan Woehler, RN—CRCC Outgoing
Meghan Smith, RN—CRCC New Rep
Peggy Huey, RN—Adult Mental Health
Carol Scarafia, RN, CMSRN—OMCC
Barbara Wade, RN, OCN, CHPN
OPCC (5100)—DH
Camella Mack, RN
Med/Surg (5200) Outgoing—DH
Heather Powell, RN, CMSRN
Med/Surg (5200) Outgoing—DH
From Your
Family To Ours
Renee Bowyer, RN—Med/Surg
(5200)—DH
Peggy Hutchinson, RN—ADON—DH
Leah Cox, RN—Case Management
Lois Weldon, MSN, RN, CNS
Clinical Nurse Specialist
Surgery Department—DH/DGH
Edna Fletcher, RN—Cross Pointe
Nikki Nixon, RN—CVCC—DH
Jennifer Reeves, RN
CVCC—DH
Linda Broerman, MSN, RN
Pain Management
Brenda Jost, RN—Procedure Center
Haley Lemkuhler, RN
CVCC Outgoing—DH
Tonya Vaupel, MSN, RN
Quality Innovation and Improvement
Amy Brown, RN, RCIS, Cath Lab—DH
Reagan Robbins, RN
Radiology—DH/DGH
Janet Thompson, RN—CVSS—DH
Karen Fleck, RN, CDE
Diabetes Educator
Dande Osborne, BSN, RN, CEN
Debbie Austill, BSN, RN
Endoscopy—DH/DGH
Brittany Clemons, BSN, RN
General Med/Tele—DGH
Kelly Memmer, RN—MSICU—DGH
Josh Johnson, BSN, RN, CCRN
Neuro ICU—DGH
Jacqueline Spears, MSN, RN
PACU—DGH
Emily Low, RN, CPN
Aaron Stoll, BSN, RN, CHPN
Surgery Oncology—DGH
Beverly Johnson, RN
Home Care Services
Paula Payne, BSN, RN—IV
Therapy—DH
Genevieve Kamer, BSN, RN, CCRN
Magnet Specialist
Magnet Specialist
Tara Moore, BSN, RN, CPAN
PACU—DH
Linsdey Morris, RN, CLN, CPHRM
Safety and Risk Management
Patty Leggett, BSN, RN, CMSRN, CCRN
SSDS/Pre-Testing—DH
Paula Snodgrass, RN, CWOCN, CMSRN
Wound Care Services
Amanda Elikofer, BSN, RN
Manager Trauma Services
Candice Alderson, RN
DGH Surgery Oncology
Michelle Stoll, MSN, RN
DGH Clinical Educator
Vicki Rausch, BSN, RN CMSRN
Team Leader, Neuroscience Unit—DGH
Cathy Basham, RN
Neuroscience Unit—DGH
Valerie Wills, BSN, RN—Pediatrics &
PICU—DGH
Ellen Wathen, RN-BC, PhD.
EE& D, Nursing Excellence,
Document Writer
Mellodee Montgomery, MT, MA, RN, CIC
Infection Control
Aprile Sandefur, RN—Infection Control
Packy Fairless, RN, MSN—
Internal Audit
Michelle Schymik, PharmD—Pharmacy
Outcome goals are to reduce complications with both peripheral and central
line access through monitoring and
performance standards. The achievements of this group include global
education, improvement in communication across campuses, improvement
In August 2011 the Heart/Gateway IV
Therapy Team was formed to support
the need for additional IV services at the
Gateway campus. A preliminary pilot
study on phlebitis was completed at the
Gateway campus to measure IV therapy
performance and has provided baseline
data for a future project to evaluate
the primary causes of phlebitis defined
in our care practices. This information
will provide a framework to improve IV
practices globally.
Deaconess Gateway Hospital Phlebitis Study
Initial
60%
40%
September
20%
November
October
Oncology
Departments
Med Tele
Ortho
Neuro
Neuro ICU
Med ICU
0.00
Reforming of Standards of
Documentation Team
• Their focus: Top five EPIC flowsheets
that are most commonly used.
• A laminated, color-coded tool was
developed.
• These were reviewed and standards
developed by staff nurses, management
and education department nurses.
• Posters of Standards of Documentation
at Skills Day for all RNs and PCAs.
Magnet
Model
New Knowledge,
August
From Your
Family To Ours
Percentage
80%
Professional
Practice Model
in care and maintenance of central lines,
and improvement of IV standards for
documentation in EPIC. A monthly review
and update of policies were implemented
November 2011 to sustain quality and
to align with the current standards. The
future educational goal is a standardized
process to disseminate those updates and
standards into the culture of caring at
Deaconess Hospital through the Shared
Governance of Nursing Practice Council.
Transformational
Leadership
The Intravenous Quality Collaborative
(IVQC) is an interdisciplinary team with a
mission to improve the quality of intravenous (IV) therapy via assessment of
educational needs, collaboration across
campuses and disciplines, provision
of adequate IV therapy resources, and
coordination of IV therapy services. The
purpose of the IVQC is to improve patient
outcomes by decreasing complications
through early vascular access assessment,
appropriate IV device placement, vein
preservation and staff nurse education.
The Centers for Disease Control and
Infusion Nurse Standards of Practice
guide Deaconess IV practices and the role
of the IVQC team.
Leadership
Chart
IV Quality Collaborative
Team Development
Structural
Empowerment
The Practice Council promotes continuous improvement in the quality and delivery of
patient care through supported evidence-based practice by actively identifying and
incorporating evidence-based research into all nursing polices.
Exemplary
Promoting Quality
Professional
Practice Model
• Policies now reviewed for changes in
practice by groups at the direct care
level: Pediatrics Core Team, ICU Core
Team, Oncology, IV Collaboration Team
and delegated to members of Practice.
Transformational
Leadership
• Any changes to practice reflected
in new skills or updated skills from
Mosby’s are reviewed and discussed.
• Some policies are not accepted into
practice because our Deaconess
practice is more stringent or specific
than the practice that is described in
Mosby’s—upholding our Deaconess
standards.
Leadership
Chart
mOSBY’S uSAGE rEPORT
Structural
Empowerment
# of Generic Logins
Magnet
Model
Mosby’s Review of
Nursing Skills Defined
1600
1400
1200
1000
800
600
400
200
0
1/11 2/11 3/11 4/11 5/11 6/11 7/11 8/11 9/11 10/11
Exemplary
Top Five mOSBY’S Skills Visited
(January–December 2011)
New Knowledge,
591
639
Medication
administration of
ivp and iv drips
at Deaconess
Dyspnea:
Positioning the
patient (pediatric)
234
From Your
Family To Ours
Blood products:
administering
201
950
Ring removal
Postmortem care
Clamping of Foley after
1000cc output evidencebased? Carol Scarafia, RN,
CMSRN, and Patsy
Fraisier, RN, OCN, CHPN,
CMSRN–OMCC
No evidence to support
this practice after
collaboration with
physicians and literature
review.
Updated in Mosby’s, and
Practice Change Flyers
sent out to units.
Life Vest (Wearable
Cardioverter Defibrillator)
Lynn Schnautz, MSN,
RN,CCRN,CCNS,NP-C –
The Heart Hospital
Presentation of information
to ask that guidelines for
usage be inserted into
Mosby’s.
Motion accepted to accept
to add into Mosby’s skills;
Practice Change Flyer sent
to all units.
Patient Safety: IV fluids
are to be on pump for
pre-procedure
Rachel Greene, MSN, RN
OR presentation regarding
Holding Area with IVs
infusing only by IV pump.
Motion made and accepted
to add into Mosby skills;
Practice Change Flyer sent
to all units.
No current P&P for
extravasation other than
chemo or vasopressors.
Lana Roth, RN–IV Therapy
Researched and
presented additions to
the extravasation skill in
Mosby’s.
to add Mosby skill,
information to UBC, and
Web inservice to educate
staff.
Procedure for
replacement or
reinsertion of catheter
with patients with healed
suprapubic catheter.
Patsy Frasier, RN, OCN,
CMSRN–OMCC
Problem researched
and brought by OMCC
to Practice Council for
insertion into Mosby’s.
to add into Mosby’s skills.
Information sent to UBC,
and Practice Council Flyers
sent to all units.
IV access guidelines for
chronic renal patient with
fistulas.
In collaboration with
nephrologists: New
guidelines for preservation
of patient veins that are at
risk for hemodialysis.
Practice Council Flyer sent
to all nurse managers.
New pain pumps to be
used for joint replacement,
general surgery, bariatric
surgery or rib fractures.
Amanda Eilkofer, BSN, RN–
Manager, Trauma Services
Presentation of information
regarding pain pumps
On-Q Bloc with SelectA-Flow and On-Q pain
buster.
Information to UBC and
Practice Council Flyer sent
to all managers.
What is evidence-based
practice for how blood
cultures should be
collected? Venipuncture is
recommended method for
obtaining blood cultures.
Reviewed Mosby’s and lab
protocol, blood cultures
from central lines to be
paired with venous sample.
Arterial lines are not
recommended.
to add into Mosby’s,
Information to taken to
UBC, and Practice Change
Flyers sent to all managers.
Practice in current
policy different than
what is recommended in
Micromedex around IV
use of Versed.
Josh Johnson, BSN, RN,
CCRN–Neuro ICU DGH
Presentation of researched
problem and brought the
issue of IV Versed usage
and recommendations to
be made.
Discussed and accepted to
change Versed from IVP
to IM only on patients in
medical surgical units.
Transformational
Leadership
Skill updated in Mosby’s
and website linked
regarding Heimlich valves.
Leadership
Chart
Presentation of Heimlich
valves: No information
currently in Mosby’s.
Structural
Empowerment
Heimlich Valves
Sallie Mosely, BSN, RN
The Heart Hospital
Exemplary
OUTCOME
New Knowledge,
PROCESS
From Your
Family To Ours
STRUCTURE
Professional
Practice Model
Magnet
Model
Examples of nurses owning
their practice
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Quality and Safety Council
Chair:
Chair Elect:
Liaison:
Structural
Empowerment
Clerical Support:
Director for CC, Trauma,
Magnet Program
Exemplary
CNAA, NEA-BC
Magnet Specialist/ Surgery
Oncology—DGH
April Watters, RN
Radiology
Sonja Marx, BSN, RN
Endoscopy—DH/DGH
New Knowledge,
Kelly Stead, RN
Surgery Outgoing—DH/DGH
Misty Adye, RN
Surgery Outgoing—DH/DGH
Surgery Incoming—DH/DGH
Jackie Badar, RN
Cath Lab—DH
Svetlana Squier, BSN, RN
CVSICU/Trauma/Peds
Trauma—DH
Julia Ellington, RN, CMSRN
PAT/SDCC—DGH
Jackie Spears, RN
PACU—DGH
Lisa Rickey, BSN, RN
CVCC—DH
Lucinda Mathew, RN, CCRN
CVICU—DH
Nancy Robinson, RN
IV Therapy—DH
Nancy Ash, BSN, RN, CMSRN
SMCC—DH
Rachel Finch, RN
Aaron Stoll, BSN, RN, CHPN
Sheila Ferrell, RN
MSICU—DGH
Cathy Merrick, RN-BC, CCRN
Neuro/MSICU—DH
April Donaldson, RN
CRCC—DH
Kim Liberman, RN, OCN,
CHPN
OPCC—DH
Andrea Klotz, RN
Med/Surg (5200)—DH
Mary Ann Niemeier, RN, CM
Home Services/Hospice
Libby Payne, MSN, RN
Employee Education
Mellodee Montgomery, MT,
RN, MA, CIC
Infection Control
Lindsey Morris, RN, CLN,
CPHRM
Risk Management
Erin Fuhrer, BSN, RN, OCN,
NE-BC
Fall Team Member
Jenny Cissell, BS, RN, CDE
Diabetes Educator
Lisa Hirsch, BSN, RN
Procedure Center/Endoscopy
From Your
Family To Ours
Peggy Huey, RN
Amanda Blanton, BSN, RN,
WOCN, CFCN
Wound Care/Skin Team
Edna Fletcher, RN-BC
Cross Point Adult Incoming
Nursing Excellence/EE&D
Crystal Sensmeier, BSN, RN
PACU—DH
Randi Sylvester, ADN, RN
Cross Point CHAD
Lois Welden, MSN, RN
Linda Neville, ADN, RN
PAT/SDCC—DH
Patsy Frasier, RN, ONC,
CMSRN
OMCC—DH
Kim Burk, RN
Restraint Team/Neuro
ICU—DGH
Juanita Little, ADN, RN
Cardiovascular Short
Stay—DH
• Display made for the Patient Safety Fair
in fall 2011.
Better
• Some units used Safety Huddle to
address SCIP measures, especially
Foley Days
scip all-or-none bundle
DH and DGH
Magnet
Model
Professional
Practice Model
Education and understanding of SCIP measures
• Reviewed SCIP measures monthly and
• Educated staff members on SCIP
discussed barriers/improvements.
measures through PowerPoint and
games for retention of knowledge.
• Information shared across units
regarding checklists to use by the
• Invited quality improvement owner
nurses for improving treatment and
Lori Mercer to educate and identify
documentation standards.
problem areas.
Transformational
Leadership
Promoting Safety
Leadership
Chart
100%
90%
80%
70%
60%
7/09 10/09 1/10
Goal
4/10
7/10 10/10
Mean
1/11
4/11
7/11
UCL
LCL
scip all-or-none bundle
Better
Exemplary
Actual
4/09
The Heart Hospital
120%
100%
80%
60%
40%
20%
0%
10/08 1/09
Actual
4/09
7/09 10/09 1/10
Goal
4/10
7/10 10/10
Mean
1/11
UCL
4/11
7/11
LCL
Improving skin assessment and documentation
• What wounds need WOCN consults?
• Identify who is at highest risk for skin
breakdown.
• What is a proper turn? 40 degrees is
• Detailed education on documentation
of skin on admission to hospital and
after transfer to unit.
• Require documentation on LDAs:
size, blanchable vs nonblanchable,
description of wound.
evidence-based.
• Report of skin breakdown from
prevalence and incidence days along
with MRN #’s for staff to take back
to the unit to determine causes and
breakdown in communication.
New Knowledge,
10/08 1/09
From Your
Family To Ours
40%
Structural
Empowerment
50%
• Removal of old mattresses
• Mepilex dressing implementation across
all campuses
• Skin Team members have developed
many informational binders and posters
to improve skin care education based
on clinical area
Exemplary
Includes 2000,
2100, 2900, 3900
• They plan to continue to research
further skin improvements and evaluate
usage of current products
% of Surveyed Patients with Hospital-Acquired Pressure Ulcers
All Adult Critical-Care Units
8.00
Percentage
Structural
Empowerment
Deaconess Hospital
10.00
• Monthly skin prevalence and incidence
to screen every patient
6.00
4.00
2.00
0.00
Includes MSICU,
Neuro ICU
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
3Q11
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
Hospital Adult Critical Care Median
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
12.50
0.00
0.00
7.14
5.00
4.17
Mean
9.25
7.66
7.71
7.26
7.55
7.16
6.39
6.67
Mean
9.25
7.66
7.71
7.26
7.55
7.16
6.39
6.67
Deaconess Hospital
All Adult Med-Surg Units
3.50
New Knowledge,
Includes OMCC,
SMCC, OPCC,
NCCU, 5200
3.00
2.50
Percentage
Leadership
Chart
• Skin Team education of specific skin
issues, including tears, yeast, pressure
ulcers, fungating tumors, etc., along
with treatment guidelines
Percentage
Transformational
Leadership
This year has been a year of growth in
many ways for the Skin Care Team. They
have not only seen growth in the team
itself, but they have also been involved in
major changes regarding skin/wound care
at Deaconess.
Percentage
Professional
Practice Model
Team Leads: Paula Snodgrass, BSN, RN, WOCN; and
Amanda Blanton, BSN, RN, WOCN, CFCN
Liaison: Jennifer Kirby, RN—Manager,
Resource Team, IV Therapy, Wound Care
2.00
1.50
1.00
0.50
0.00
Includes MCRU, Ortho,
Neuro, SurgOnc
12.00
10.00
8.00
6.00
4.00
2.00
0.00
3Q11
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
Hospital Adult Step-Down Median
0.00
2.44
2.44
0.00
0.00
2.44
0.00
0.00
Hospital Adult Med-Surg Median
0.00
0.00
12.50
1.61
0.00
7.14
5.00
4.17
Mean
3.06
2.78
2.54
2.43
2.64
2.63
2.25
2.20
Mean
3.06
2.78
2.54
2.43
2.64
2.63
2.25
2.20
Deaconess Hospital
All Step-Down Units
5.00
Percentage
Magnet
Model
Skin Team Subcommittee
Includes CVCC,
NTCA, CRCC
4.00
3.00
2.00
1.00
From Your
Family To Ours
0.00
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
0.00
0.00
2.86
0.00
0.00
0.00
0.00
0.00
Mean
4.59
4.38
3.77
3.99
4.06
3.83
3.39
3.29
Fall Team is now an interdisciplinary team with members from direct care nurses, managers,
laboratory staff, pharmacy staff, physical medicine staff, employee education department,
with consultation of University of Evansville nursing faculty to ensure all areas of the hospital
identify falls as a priority. The Fall Team has been working very hard this year to improve
patient safety regarding falls. The team identifies monthly unit fall rates and discusses
where problem areas are as well as who is doing well. The Fall Team encourages unit-based
participation and the use of evidence-based interventions to keep our patients safe.
• Implementation of Fall Trophy to
highlight those making strides to improve
fall rates
• Evaluation of hourly rounding and
effectiveness
• Implementation of management hourly
rounding with staff, patients and family
• Evaluation of current fall prevention
strategies
• Discovery of new interventions that are
evidence-based practice
• Many new practice changes to come
in 2012, with inclusion of all Deaconess
employees utilizing an interdisciplinary
approach to preventing falls
Includes 2000,
2100, 2900, 3900
Total Falls per 1,000 Patient Days
All Adult Critical Care Units
2.50
Total Falls per
Patient Day
Falls per 1,000
Patient Days
Deaconess Hospital
All Adult Critical Care Units
2.00
1.50
1.00
0.50
0.00
Includes MSICU,
Neuro ICU
3.00
2.50
2.00
1.50
1.00
0.50
0.00
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
4Q09
1Q10
3Q10
4Q10
1Q11
2Q11
3Q11
0.83
0.96
0.00
0.00
0.43
1.91
1.94
0.47
2.41
1.09
1.15
1.21
1.39
1.26
1.17
1.46
Mean
1.33
1.36
1.28
1.28
1.19
1.19
1.21
1.19
Mean
1.33
1.36
1.28
1.28
1.19
1.19
1.21
1.19
Includes OMCC,
SMCC, OPCC,
NCCU, 5200
Total Falls per
Patient Day
Total Falls per
Patient Day
Deaconess Hospital
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
2Q10
Includes MCRU,
Ortho, Neuro,
SurgOnc
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
4Q09
1Q10
2Q10
3Q10
4Q10
2Q11
3Q11
5.66
4.66
3.45
4.43
5.60
5.05
3.86
6.31
1.76
4.77
4.42
4.24
3.79
3.76
3.35
5.66
Mean
3.88
3.78
3.78
3.71
3.76
3.57
3.59
3.55
Mean
3.88
3.78
3.78
3.71
3.76
3.57
3.59
3.55
3Q11
1Q11
Includes CVCC,
NTCA, CRCC
6.00
5.00
4.00
3.00
2.00
1.00
0.00
4Q09
1Q10
3Q10
4Q10
1Q11
2Q11
3Q11
3.73
2.92
5.32
2.92
5.02
3.08
2.91
3.73
Mean
3.39
3.27
3.29
3.38
3.31
3.29
3.20
3.16
2Q10
Professional
Practice Model
From Your
Family To Ours
Total Falls per
Patient Day
Deaconess Hospital
All Step-Down Units
Transformational
Leadership
DH Staff Lead: Jennifer Palmer, BSN, RN, CMSRN—EE&D
Gateway Staff Lead: Amber Schenck, BSN, RN, CMSRN—DGH General Medical Telemetry
Liaisons: Erin Fuhrer, BSN, RN, ONC—Manager, OMCC; and
Theresa Price, BSN, RN, CNRN—Resource Team
Leadership
Chart
Fall Team Subcommittee
Structural
Empowerment
• Assisting in hardwiring effective hourly
rounding with the Six P’s across all units.
Exemplary
• Maintaining line of sight with patients
during bathroom assistance.
New Knowledge,
• Fall boards with safety huddles as the focus
being implemented across campuses.
Magnet
Model
Fall Prevention Initiatives
Transformational
Leadership
Restraint Team
Gateway Staff Lead: Kim Burk, BSN, RN—Gateway Neuro ICU
Liaisons: Christa Wolf, BSN, RN, CNRN—Manager, Gateway Neuro and Neuro ICU; and
Belle McCool, DNP, RN, NE-BC—Manager, Trauma, CVSICU and Peds Trauma
Clerical Support: Dawn Wall—Medical Executive Secretary
Leadership
Chart
• Policy revisions to meet regulatory
guidelines
The Restraint Team monitors and
implements changes regarding restraint
usage, documentation and policies to
meet HFAP and CMS regulatory standards.
Structural
Empowerment
• Best practice link to add care plan
every time RN documents in med/surg
restraint flowsheet
• Evaluation of restraint documentation
to meet regulatory guidelines
• Updated restraint audits to ensure
practices being followed correctly
• Changes made to documentation
flowsheets to ensure best practice
followed
• Restraint audits are done by
management or designated person to
ensure accuracy and follow-up
Exemplary
Deaconess Hospital
Percent of Patients with Physical Restraints (Limb and Vest)
New Knowledge,
Includes 2000,
2100, 2900, 3900
25.00
20.00
15.00
10.00
5.00
0.00
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
21.59
5.00
17.14
7.14
21.59
0.00
11.54
17.14
Mean
19.62
18.58
18.27
18.77
17.22
18.23
17.71
17.00
3Q11
Percent of Patients with Physical Restraints (Limb and Vest)
From Your
Family To Ours
Percentage
Professional
Practice Model
November: Neuroscience and Neuro ICU from Gateway
have been working diligently to decrease falls and
improve safety awareness through education of staff,
families and patients, along with implementation of
new products to decrease falls.
Percentage
Magnet
Model
Fall Trophy Winners for 2011
October: Cardiovascular Renal Care Center attributes
improved fall numbers to management’s rounding with
RNs and PCAs to ensure proper hourly rounding. PCAs
also educated on not leaving patients unattended in
the restroom, since this is the most common place for
falls to occur.
Includes MSICU,
Neuro ICU
25.00
20.00
15.00
10.00
5.00
0.00
4Q09
1Q10
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
14.29
14.29
12.50
0.00
18.18
12.70
5.00
0.00
Mean
19.62
18.58
18.27
18.77
17.22
18.23
17.71
17.00
• Evaluation of pilot program initiated on
CVCC with education done throughout
the organization.
• Plan for 2012 is to transition hall pass to
EPIC for printing so that information is
pulled directly from the medical record.
Unit-based Quality Improvement
Projects Presented at Quality Council
April Waters, RN—
Radiology Department
(DH/DGH)
Rounding program for Radiology placed nephrostomy tubes, abcess drains,
kyphoplasty’s, patient teaching port-a-caths.
Nancy Robinson,
RN—IV Therapy
(DH)
IV team now rounding on all PICCs daily to decrease # of occlusions and decrease
usage of Activase. New hubs with clear casings to ensure proper flushing of
ports. Improving insertion at bedside with ultrasound guidance and over-the-wire
exchange procedure.
Sonja Marx, BSN,
RN—Endoscopy
(DH/DGH)
Time-out audits with site verifications. Changed cleaning product to increase
turnaround time. Improved medication scanning from 25–50% to 100%. All RNs to
have PALS training.
Lucinda Mathew,
RN, CCRN—CVICU
(DH)
After education and posting of checklist: Staff are now doing bedside safety
checks at change of shift to include turning, skin/dressing check, restraint/fall
risk, lines/drips/LDAs, MAR review, order review, room cleanliness.
Kim Liberman, RN,
OCN, CHPN—OPCC
(DH)
Created communication tree to improve communication scores through direct
communication. Implemented Lunch Buddies to improve lunch free of patients
from 12%. Implemented patient satisfaction team. Unit-based Race for the Cure
and monthly OPCC “Team Nights”
Aaron Stoll, BSN,
RN, CHPN—Surgery
Oncology (DGH)
Four Eyes in Four Hours initiated in June 2011. Two nurses visualize and document
patient’s skin assessment within four hours of admission.
Kim Burk, RN—
Neuro ICU (DGH)
Created education pamphlets for bedside procedures and involving patient/
families with care conferences starting with subarachnoid patients.
April Donaldson,
RN—CRCC (DH)
CRCC developed Renal Skills Day for nursing staff to improve patient satisfaction,
quality measures and renal competencies.
Rachel Finch, RN—
General Med/Tele
(DGH)
Staff developed simple handouts to assist with nurse/patient education. Staff also
developed a comfort box that has several different items such as contact lens
cases, crossword puzzles, etc.
Jackie Badar, RN—
Cath Lab (DH)
Cath lab is measuring Response to patient arrival. Cath lab staff educating on
arrival time of staff and how it affects the Cath lab turn around. Educated on
Radial access and TR bands.
Lisa Rickey, BSN,
RN—CVCC (DH)
Staff implemented bedside care conferences with social work, case management,
charge RN, RN, manager, patient and family. Also presented on interventions put
in place for fall prevention.
Lisa Hirsch, BSN,
RN—Deaconess
Procedure Center
(DH)
The Procedure Center has been 100% compliant with hospital outpatient
procedure (HOP) quality measures for the last 12 months. They also perform
audits on 10% of their moderate sedation and handoff. They also provide patient
call-backs on 100% of their patients.
Magnet
Model
Professional
Practice Model
Transformational
Leadership
• Revisions to DHS handoff in EPIC to
ensure patient care is streamlined for
effective handoff communication.
Leadership
Chart
• Involvement of families in bedside report
when able to ensure continuity of care.
Structural
Empowerment
• Team revised hospital P&P 40-74
Handoff Communication Tools “SBAR
and Hall Pass” after evaluation of tools
and changes made to increase patient
safety.
Exemplary
Handoff Communication Team ensures
a safe and effective handoff of clinical
information across the health system.
• Development and implementation of
bedside shift reporting in all inpatient
nonpsychiatric units.
New Knowledge,
Team Lead: Lisa Hensley, MSN, RN—DH CVCC
Team Lead Elect: Genevieve Kamer, RN, BSN, CCRN CVSICU/Trauma/Peds Trauma
Liaisons: Paula Yarbrough, BSN, RN, NE-BC, CPN—Manager, DGH Pediatrics; and
Patty Laird, MSN, RN, OCN—Manager, SMCC
Clerical Support: Lavonna Armstrong—Executive Secretary Surgical Services
From Your
Family To Ours
Handoff Communication Team
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Education & Professional
Development Council
Chair:
Structural
Empowerment
Exemplary
Magnet,Trauma & Critical Care
Director
NEA-BC
Surgery Department—
DH/DGH
Emily Dawson, RN Endoscopy—DH/DGH
New Knowledge,
Lynne Belcher, RN
Cath Lab—DH
From Your
Family To Ours
Svetlana Squier, BSN, RN
CVSICU—DH
Alice Haire, RN
Radiology
Mary Dawn Weaver, RN, CLNC
CVSS New Rep—DH
Donna Cobb, MSN, RN, CCRN,
CNRN
Trauma/Peds Trauma
Angelea McEllhiney, RN, CPN
Kimberly Pixley, RN
Amy Pierce, RN
PACU—DH
Darlene Wolf, RN, CMSRN
Same Day Surgery—DH
Hannah Ison, MSN, RN, CMSRN
OMCC—DH
Myra Taber, BSN, RN
Same Day Surgery—DGH
Jill Graul, RN
Case Management
Kirby Dewig, RN
CVCC New Rep—DH
Sharon Dunville, MSN, RN,
OCN, CMSRN
OPCC—DH
Lisa Relleke, RN, CMSRN
IV Therapy—DH
Craig Meyer, BSN, RN
SMCC—DH
Vicke Rauch, RN
Neuroscience—DGH
Angie Cox, MSN, RN,
CCRN, CNRN
Neuro/MSICU (3900)—DGH
Patricia Bender, BSN, RN,
CMSRN
Emergency Department—DH
Aaron Stoll, BSN, RN,
CHPN
Jill Rector, RN
CRCC—DH
Peggy Huey, RN
Edna Fletcher, RN-BC
Cross Pointe Adult
Teri Bassett, BSN, RN
Home Care/Hospice
Amy Stott, RN
Deaconess OP Procedure
Center/Endoscopy
Mary Ann Allen, BSN, RN
EE&D
Brielle McKinney, BSN,
RN,CMSRN
Diabetes Center
Rachel Greene, MSN, RN,
CAPA PACU, SDCC,
Pre-testing, GI, Pain
Genevieve Kamer, BSN, RN,
CCRN
Magnet Specialist
Magnet Specialist
EE&D, Document Writer
The hard work of the PDP committee
has paid off; as of December 2011, 13 RNs
have achieved PDP recognition. All three
levels were represented, and a pinning
ceremony in December recognized 12
of those 13 participants, with the last
participant recognized a week later. PDP
has become a major topic across nursing.
According to a fall 2012 nursing survey,
there are as many as 200 nurses interested in participating in the PDP. The PDP
committee has taken several comments
regarding the PDP and will update the
PDP program to include this feedback.
Magnet
Model
Professional
Practice Model
From Your
Family To Ours
Increase Nursing Specialty
Certifications by promoting certifications
throughout the year as one of six cores of the
Professional Development Program.
• Information was provided from EE&D,
Human Resources and the Deaconess
P&P regarding the process for taking a
certification and the payment.
• Promoted the annual recognition
luncheon for all nurses who received a
certification or higher degree.
• A nurse with three specialty certifications presented on what encouraged her
to obtain certifications and the value in
being certified.
Transformational
Leadership
Implement a Professional
Development Program (PDP) to
replace our past career ladder. This has
given nurses the opportunity to grow
as professionals and be well-developed
within the many areas of nursing. The PDP
committee educated staff in late 2010
and the beginning of 2011 on a variety
of topics that directly relate to PDP
cores and electives. After education was
complete, implementation and publicity
around PDP was started.
• For two months, weekly information
tables in high-traffic areas of the
hospitals provided information to nurses.
• Nursing Excellence and Deaconess.com
websites were updated to include
ambassadors’ contact information and
the PDP program so nurses can access
the program from work or at home.
Leadership
Chart
Increase nurse knowledge to help
nurses pursue advanced nursing degrees
through an education fair to provide
information for nurses who want to go back
to school.
• In April 2011, a half-day education fair was
offered at both Deaconess Hospital and
Deaconess Gateway for nurses only.
• Information and representatives were
available for a variety of programs
(Associates, BSN, BS, MSN, DNP, etc.)
• Eight different programs were
represented, as well as Deaconess
Human Resources, to discuss tuition
reimbursement.
• Sixty-two evaluations were received,
which showed that RNs had an increase in
knowledge about obtaining an advanced
nursing degree and available resources.
Structural
Empowerment
• Certification questions, barriers and
benefits were discussed as a council.
• Educated members about upcoming
opportunities for review courses and
materials.
Exemplary
The Education and Professional Development
Council monitors and evaluates the educational needs of nursing staff and helps
plan, implement and evaluate educational
programs as needed by direct-care nurses.
New Knowledge,
Promoting Development
Magnet
Model
Professional
Practice Model
Participants for 2012
T
he following participants went above and beyond to achieve their professional
development recognition. Each participant must participate in at least four of the
six cores to participate and also provide evidence of at least 40 electives.
The Core Areas are:
Transformational
Leadership
• Quality Data Collection: Applicant actively participates
in quality data collection at the unit or hospital level.
• Example of Excellence: Applicant serves as a role
model who demonstrates and exhibits service
excellence behaviors to impact patient satisfaction.
• Continuing Education: Applicant must complete
twenty continuing education hours from an
accredited nursing-related program or source.
Leadership
Chart
• Certifications: Applicant holds a specialty
certification by a national professional nursing
organization in which credentials are obtained.
• BSN or BS with major in nursing
• Membership in professional nursing organization
The Electives include:
The opportunity to obtain more
than 280 different points in
electives, with areas ranging from
publications, mentorship, advanced
educational levels, community
service, writing or updating policies
and procedures, advanced certifications, presentations on evidencebased practices, Journal Clubs,
committees, providing inservices
for staff, and more.
Please congratulate these
nurses for taking a leap into the
frontier of PDP and achieving this
accomplishment.
Structural
Empowerment
Bronze Level (4 Cores and 40 Electives)
Afsaneh Hahn, BSN, RN
Exemplary
•
•
•
•
RN at Deaconess for 12 years
Works in surgery
Earned her BSN from USI
Involved in her unit quality data project
involving the Hemocue/Istat
• Led a journal club for her unit
• Reviewed and revised several policies
• Member of the Medical Surgical-Neurological
Conference planning committee
Meros-Ann Fortney, BSN, RN, CNOR
New Knowledge,
• Works in surgery
• Obtained her BSN in the Philippines and
started working for Deaconess in 2006.
• Certified Operating Room Nurse (CNOR)
• Member of the Philippines Nursing Association
of Indiana
• Pursuing her MSN at USI in the Nursing
Education Program
• Volunteered her time to work at health fairs
and participated in screenings at local schools.
Dawn Rowley, RN, CCRN
From Your
Family To Ours
• Deaconess nurse for nine years
• Member of the American Association of Critical
Care Nurses
• Participated in quality data collection and
contributed to educating other RNs, both on
her unit and throughout critical care
• Course instructor for ICU competencies,
participates in ICU Competency day and
planning the “CCRN Exam Cram”
• Presented at Patient Care Circle
• Nominated by her peers for Nurse of the Year
Angela Sawyer, BSN, RN, CCRN
• With Deaconess for 11 years
• Works in Critical Care
• Member of the American Association of
Critical Care Nurses
• Helps with the IOPA Regional Collaborative
• Member of Sigma Theta Tau International
Honor Society of Nursing
• Tracked data to improve quality of care for
trauma patients through using audits to
identify risks of DVT and C-Spines clearance
• Developed a research project on Mepilex dressing • Presented at Patient Care Circle
Pamela Leatherland, BSN, RN, CMSRN
• Works on Surgical Medical Care Center (SMCC)
• Member of the Academy of Medical Surgical
Nurses and serves as the co-chair of recruitment
and membership for the local chapter.
• Part of the research project on SMCC unit,
which involved the use of chewing gum in
surgery patients.
• Member of Research Council and her
Unit-Based Council
• Volunteered as a nurse at the Southern Indiana
Classic Marathon
Valerie Wills, BSN, RN
• Graduated from USI with her BSN in 2009.
• Enrolled in the master’s program at Frontier
School of Midwifery
• Works on the Gateway pediatric unit
• Preceptor
• Member of the Nursing Shared Governance
Image council
• Member of Sigma Theta Ta Honor Society of
Nursing
• Reviewed and revised a policy
• Volunteered in the community
• Began her career with Deaconess in 1973
• Currently works in Same Day Surgery at
Deaconess Hospital
• Longstanding history of being involved and
making a difference at Deaconess
Gold Level (6 Cores and 65 Electives)
Donna Cobb, MSN, RN, CCRN,
Peds CCRN, CNRN
• First Deaconess RN to be recognized in
Deaconess Professional Development Program.
• Works in Pediatric Trauma
• Received her BSN and MSN from the University
of Evansville
• Holds certifications in both Critical Care
Registered Nurse and Certified Neuroscience
Registered Nurse
• Member of the American Association of
Critical-Care Nurses
• Taught numerous classes for nurses, participated in unit level journal club, and has written
articles for the nursing newsletter.
• Researched and developed a new policy about
caring for patients in a barbiturate coma.
• Significant part of the PDP committee and
assisted in developing and encouraging other
RNs with this program.
Janie Arington, MSN, RN
Linda Martin, BSN, RN, CMSRN
• Has been with Deaconess for 11 years
• Works on the Surgical Medical Care Center
(SMCC)
• Very involved on her unit and throughout
Deaconess
• Maintained her CMSRN (Certified Medical
Surgical RN)
Nurses and involved as a part of the Education
Committee of the local chapter
• Has demonstrated leadership by being a super
trainer on various processes, equipment,
quality improvement projects and inservices.
• Conducted journal clubs
• Preceptor for new nurses
• Assists with SNIP class; presented at the
CMSRN review course and presented once at
Patient Care Circle
• Reviewed nine hospital policies
• Participated in nursing community service
Magnet
Model
From Your
Family To Ours
• Obtained her MSN and changed roles from a
cardiac staff RN to working a split between
administration and urology as a Certified
• Obtained her MSN from Liberty University,
where she completed the Adult Care Critical
RN track.
• Submitted an article for publication
• Active in many groups, including the CAUTI
Research Committee, Education Council and
the PDP Committee, and she was a champion
for the CVSS’s Unit-Based Council.
• Gave a presentation to the Research Council
on physician-assisted suicide.
• Member of American Association of Critical
Care Nurses
• Nominated for Nurse of the Year this year
Professional
Practice Model
• Graduate of the Deaconess School of Nursing
• Has worked at Deaconess for more than 35
years, since 1973
• Works in surgery
• Super trainer for flash sterilization
• Reviewed several policies and revised a total of
three in this past year
• Involved in the Tri-State’s chapter of the
Association of Perioperative Registered
Nurses. Teresa served as the president from
2009 to 2010.
• Chairperson of several committees
Transformational
Leadership
Leadership
Chart
Darlene Wolf, RN, CMSRN
Nurses (AMSN)
• Involved in starting our local AMSN chapter in
Evansville last year and is serving as president
• Member and ambassador for the Professional
Development Program
Structural
Empowerment
• First Deaconess RN to submit a Professional
Development Portfolio.
• Started at Deaconess Hospital Emergency
Department in 2005
• Member of the Emergency Nurses Association. • Attended the 2010 ANCC National Magnet
Conference
• 2011 Research Council chair
• Chair of the Emergency Department’s
Unit-Based Council
• Completed extensive research on early
detection of sepsis and treatment guidelines
resulting in articles, inservices and presenting
at the Clarian Health Nursing Research
Conference
Exemplary
Kristina Brown, BSN, RN
New Knowledge,
Silver Level (5 Cores and 55 Electives)
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Research and EvidenceBased Practice Council
Structural
Empowerment
Exemplary
New Knowledge,
Surgery—DH/DGH
Krista Price, RN
OMCC—DH
Susan Alka, RN, CCRN
PACU—DH
Lori McDonald, RN
OPCC—DH
Japhia Leach, RN
CVCC—DH
Rachel Greene MSN, RN, CAPA
PACU, SDCC, Pre-testing, GI, Pain
Matt Gibson, RN, CRNI
IV Therapy—THH
Maria Alsop, RN
Med/Surg 5200—DH
Pam Leatherland, BSN, RN, CMSRN
SMCC—DH
Heather White, BSN, RN
Home Care Services
Amanda Sollman, BSN, RN
Amy Stott, RN
Deaconess OP Procedure Center/Endoscopy
Heather Weir, RN
Ortho—DGH
Lydia Rutherford, RN
Wound Services
Chasity Archer, RN
Neuro MSICU—DH
Cindy Head, RD, CDE
Diabetes Center
Danette Culver, BSN, RN
NICU— DGH
Chris Politano, OT
Physical Medicine
Janet Ziegler, BSN, RN
CRCC—DH
Monica Corcoran, MLIS
Health Science Library
From Your
Family To Ours
212th Degree: Our Healthy
Work Environment Initiative
Poster Presentation at Clarian
Nursing Research Conference
Indianapolis, IN
Kristina Brown, BSN, RN;
Dande Osborne BSN, RN—
Emergency Department; and
Libby Payne, MSN, RN—EE&D
Stopping Sepsis in Its tracks
Poster Presentation USI Nursing
Research Conference and Clarian
Nursing Research Conference
Indianapolis, IN
Kristina Brown, BSN, RN
Court Is in Session
Poster Presentation at USI Nursing
Research Conference
Lois Welden, MSN, RN—
Nursing Services
Blood Conservation:
Reduction of lab draws and
transfusion guidelines
Poster presentation at Clarian
Nursing Research Conference as well
as published in Nursing Leadership
Matt Gibson, BSN, RN—
IV Therapy—THH
Nursing Clinical Series
Dane Strongvein to provide
education on IV therapy
Deaconess Nursing Newsletters
and two online publications for IV
therapy
Ellen Wathen, PhD,
RN-BC—EE&D
Template: A Tool for
New-Nurse Orientation/
Fellowship Program
USI Nursing Research Conference
Angela Cox, MSN, RN, CNRN,
CCRN; and Noni Roberts, RN,
CCRN
Multidisciplinary Rounding:
Don’t Be a Missing Piece of
the Puzzle
Dr. Belle McCool, DNP, MSN,
RN—Manager, CVSICU/
Trauma/Peds Trauma
DNP Capstone Project:
Transforming Nurse Manager
Skills to Create and Sustain
Healthy Work Environments
Edith Hoehn, BSN, RN;
Jennifer Palmer, BSN, RN,
CMSRN; and Carol Scarfia, RN,
CMSRN
Evidence-Based Policy and
Procedures: Making Online
System Your Own
Clarian Nursing Research
Conference Indianapolis, IN
How many evidence-based practice opportunities were available last year?
• EBP Basic Course was offered six times.
• EBP Intermediate Course was offered four times.
• Court Is In Session was offered once at Gateway. It was duplicated in fall 2010 and is
planned to be presented at Medical Surgical Neurological Conference in 2012.
• Council members encouraged and given opportunities to attend research
conferences and events.
What do we see in the future for
nursing research at Deaconess?
Magnet
Model
From Your
Family To Ours
Ellen Wathen is our charter member of the
Improvement Science Research Network.
It facilitates research projects in multiple
hospitals to move research findings into
practice sooner. Members from all over the
U.S. have the opportunity to collaborate on
research and share information on studies
they are participating in.
Professional
Practice Model
Janet Zigler, BSN, RN, CMSRN;
Kaye Cates, BSN, RN, CMSRN;
Jill Rector, RN; Roxie Sullivan,
RN, CMSRN; and Jeanette
Woehler, RN, CMSRN, CRCC
Transformational
Leadership
Poster Presentation at USI Nursing
Research Conference
Leadership
Chart
Wound Care Planning Guide
Structural
Empowerment
Heather White, BSN, RN
Home Care Services
Exemplary
Nursing Research and Evidence-Based presenters for 2011
New Knowledge,
Promoting Research
Deaconess Hospital was chosen last fall
as one of five hospitals in the U.S. to
participate in a study. Ellen will continue
to apply for additional studies as they are
presented.
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Structural
Empowerment
Exemplary
New Knowledge,
Exemplary
From Your
Family To Ours
The goal of this component is to guide practice by using a strong
model that focuses on collaboration, communication, nursing practice
and professional development to provide the highest quality of care to
patients. Another key point to this component is a strong shared
governance, which is vital to the success of the organization.
Healthy Work Environment
Conference
Deaconess held an eight-hour workshop,
Healthy Work Environment: Helping
You Help Your Unit. The workshop
was developed to help Deaconess
nurses understand what Healthy Work
Environment can do for them and their
units, and it offered tools for implementation. The workshop was attended by
more than 75 nurses from Deaconess
Hospital, Deaconess Gateway Hospital
and Deaconess Cross Pointe.
VHA RetuRN to Care
SMCC used the RetuRN to care model,
which is composed of three crucial
relationships: the relationship with the
patient and family; the relationship with
self; and the relationship with co-workers.
The model is surrounded by a framework
of leadership, teamwork, professional
practice, patient care delivery, resourcedriven practice, and outcomes.
SMCC began this process in April 2008.
They attended three face-to-face
meetings conducted by VHA over the
course of the first year. These meetings
included presentations from other
facilities and reviews of best practices.
The team conducted weekly meetings
and developed an action plan.
This process has helped in the implementation of hourly rounding and preventive
measures such as turning patients and
offering to take patients to the bathroom
to prevent falls. SMCC’s patient satisfaction and HCAHPS scores have steadily
had an upward trend. They currently meet
about every other week to continue their
RetuRN to care initiative.
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Structural
Empowerment
• Currently, more than 70% of the
inpatient nursing units at Deaconess
Hospital have implemented HWE
elements, and more than 50% of those
have initiated full HWE programs that
include a staff contract.
Good-to-Great Grants
There were several Good-to-Great
Grants awarded by the Foundation
to nursing units and ancillary departments to improve patient and staff
satisfaction. Keep coming up with great
ideas and moving forward on innovations to improve our work environment
no matter where we work. Staff who are
motivated and excited about coming to
work are more satisfied, which can lead to
improved patient satisfaction.
Exemplary
Many HWE champions worked hard last
year to share HWE standards across
the units at Deaconess Hospital and
Deaconess Gateway Hospital. Improving
the work environment has helped improve
RN satisfaction scores overall. There
have been significant improvements
in several units that have implemented
these standards. Many of these units
had RN satisfaction above the mean in
various different areas: RN-RN, RN-MD,
professional status, decision making and
autonomy, to name a few.
10 Tips of Skilled Communication
The committee developed a 10 Tips of
Skilled Communication poster that will
be posted throughout both campuses
soon. The Ten Tips were created by the
HWE steering committee as they read and
discussed the book Crucial Conversations
along with many other great resources
on good communication. The journal club
discussion was held at the meetings to
discuss Crucial Conversations to better help
the committee understand communication
techniques to bring to the nursing units.
New Knowledge,
Healthy Work Environment
Steering Team
Chair: Kathy Bell, BSN, RN—Neuro MSICU
until April 2011
Chair-Elect: Melissa Jassim, BSN, RN—
CVCC, assumed chair position April 2011
Liaison: Cherona Hajewski
From Your
Family To Ours
Improving Decisions and
Outcomes
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Value-Based Purchasing
The value-based purchasing (VBP) program
was implemented by the Centers for Medicare
and Medicaid Services to promote higher
quality care. The program is built on inpatient
quality reporting measures, including 12
clinical measures (heart attack, pneumonia,
heart failure and SCIP core measures) and
eight patient experience measures (HCAHPS
survey). The goal is to move from a “pay for
service” model to a “pay for performance”
model and reward better value, patient
outcomes and innovation.
Leadership
Chart
All-or-None Bundle scores show the percent
of patients who receive all indicated care as
established by core measures. For example,
the heart failure All-or-None Bundle score
shows the percent of patients hospitalized
with a heart failure diagnosis who have the
following completed and documented:
Better
If any of these items are indicated but not
completed and documented, the patient
doesn’t meet the heart failure All-or-None
Bundle. This means staff nurses must follow
documentation guidelines and practices
to ensure core measures are met, engage
with families to provide an excellent patient
experience, and use our metrics to allow us
to improve daily care.
HCAHPS Overall Rating—%9’s and 10’s
DH and DGH
Structural
Empowerment
90%
85%
80%
75%
70%
65%
60%
55%
50%
•Discharge instructions (including activity,
diet, follow-up, medications, symptom
worsening and weight monitoring)
provided to patient
• Ejection fraction documented
• ACEI or ARB prescribed for LVEF
dysfunction or contraindication
documented by provider
• Cessation counseling completed for
patients who are smokers
Better
95%
90%
85%
80%
75%
70%
65%
60%
10/08 1/09
4/09
7/09 10/09 1/10
Actual
Exemplary
Better
4/10
7/10 10/10
Mean
1/11
4/11
UCL
7/11
55%
100%
100%
90%
90%
80%
80%
70%
70%
60%
60%
4/09
New Knowledge,
Better
7/09 10/09 1/10
Goal
4/10
7/10 10/10
Mean
1/11
4/11
7/11
UCL
120%
100%
80%
80%
60%
60%
40%
40%
20%
20%
4/10 7/10 10/10 1/11
Mean
UCL
From Your
Family To Ours
Better
4/11
0%
7/11
LCL
4/09
7/09 10/09 1/10
Goal
10/08 1/09 4/09
Actual
7/09 10/09 1/10
Goal
Pneumonia All-or-None Bundle
DH and DGH
110%
100%
90%
80%
70%
60%
10/08 1/09
Actual
4/09
7/09 10/09 1/10
Goal
4/10
Mean
5/10
8/10
11/10
2/11
5/11
UCL
8/11
LCL
4/10
Mean
7/10 10/10
1/11
4/11
7/11
UCL
LCL
Heart Failure All-or-None Bundle
THH
Better
120%
2/10
Mean
Actual
100%
7/09 10/09 1/10
Goal
10/08 1/09
LCL
Heart Failure All-or-None Bundle
DH and DGH
10/08 1/09 4/09
Actual
8/09 11/09
Heart Attack All-or-None Bundle
THH
Better
110%
Actual
5/09
Actual
Heart Attack All-or-None Bundle
DH and DGH
10/08 1/09
11/08 2/09
LCL
110%
0%
HCAHPS Overall Rating—%9’s and 10’s
THH
7/10 10/10
1/11
UCL
4/11
7/11
LCL
4/10 7/10 10/10 1/11
Mean
UCL
4/11
7/11
LCL
Hypoglycemic Response
The diabetes clinicians at Deaconess
Hospital have taken the initiative to
improve our treatment for hypoglycemic
episodes. Over the last year, they have
changed the hypoglycemia policy/
protocol and education. This included
treatment options, identification of
response time, documentation, and
timely relay of information to RNs to treat
effectively.
The diabetes clinicians utilized pocket
cards that many units have attached to
computers on the units and/or posted
in pantries. This was developed to help
staff identify signs and symptoms;
treat, observe, re-treat if necessary; and
become familiar with guidelines regarding
hypoglycemia. The goal for treatment
is less than 20 minutes. This includes
identification of hypoglycemia (blood
glucose less than 70mg/dl), completed
treatments, and re-checks of bedside
blood glucose (BBG).
The clinicians educated on appropriate
treatment and monitoring of blood sugars
after a hypoglycemic episode. Blood
sugars tend to drop after a period of
time, post-treatment. The pocket cards
describe how often blood sugars must be
monitored after an initial hypoglycemic
episode. Managers now get reports on
time-to-treatment, blood sugar re-checks
and the percentage of staff using the
hypoglycemia protocol correctly.
Hypoglycemic Response Time
Initial BBG, Treatment-to-Recheck BBG
120
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
80
60
January 2011
November 2011
40
20
M
C
IC
U
IC
NM
C
CV
U
NC
C
CR
CC
O
PC
52 C
00
M
S
CV
CC
SM
CC
M
O
ed
M
CC
/T
Su ele
rg
D
/O GH
nc
Ne
DG
ur
o
H
IC
U
Ne DG
ur H
o
O DG
rt
ho H
DG
M
H
SI
CU
He
D
ar
t H GH
os
pi
ta
l
Goal for treatment: 20 minutes
M
U
IC
SI
a
CV
Tr
a
um
CU
0
From Your
Family To Ours
Response Time (min)
100
Structural
Empowerment
One of Behavioral Service’s Deaconess
Hospital goals is to continue to
improve RN satisfaction rates
by providing more education,
promoting autonomy and
strengthening communication
between all disciplines of the
health system. As we approach
the upcoming year, we’ll continue
to work as an integrated team to
improve patient outcomes and
staff satisfaction.
Exemplary
Services
They continue to make patient and
staff safety a priority and have recently
received approval for additional security
cameras. Other upcoming improvements
include additional security staff to Cross
Pointe throughout the night-time hours
and the recent implementation of the
badge scanning system. They are excited
about these improvements, as safety
is essential in providing a therapeutic
environment for those they serve.
New Knowledge,
Deaconess Cross Pointe Behavioral
The behavioral health units are proud
of the accomplishments of 2011 and are
looking forward to 2012. They continue to
strive to lower their number of restraints
and increase the education of staff. The
staff of Deaconess Cross Pointe’s Adult
Unit, Child and Adolescent Unit and 4200
Unit float within the three behavioral
health departments. Each unit works very
well together to meet patients’ needs and
aid in their successful recovery.
Leadership
Chart
Structural
Empowerment
One strategy in initiating the CAUTI
prevention project was to embed the
CAUTI evidence-based care practices
within the electronic health record (EHR)
to assist in driving evidence-based care
practices. By using clinical decision
support features of the EHR, it would
assist in driving and sustaining evidencebased care delivery and documentation.
We are seeing positive results in performance and surveillance outcomes.
• Significant improvement shown in
documentation practice for both ICU
and non-ICU units.
• Non-ICU units demonstrated the
greatest improvement by the third
quarter of the study.
• Significant improvement shown in
census with catheters and criteria on
non-ICU units versus ICU units.
• Both ICU and non-ICU demonstrated
significant improvement in care
practices and documentation.
Each unit has taken ownership and
performs monthly prevalence studies.
Prevalent outcomes showed that:
Exemplary
A major emphasis of the CAUTI
Preventive Bundle is to limit the duration
of an indwelling catheter. Currently, the
incidence of CAUTI show a constant
downward trend. Obviously, staff are
making a conscious effort to help keep
our patients safe from a CAUTI by
adhering to catheter care practices. A big
thank you to all staff who are making a
difference in this area!
• Within the first six months, care
practices increased from 56% to 93%.
• The number of catheter insertions
showed a downward trend from 29% of
census at baseline to 25% six months
post-implementation. Furthermore,
sustained decrease in overall catheter
insertions continued a year later to 20%.
New Knowledge,
Deaconess Hospital
Catheter-Associated Urinary Tract Infections per 1,000 Catheter Days
2.50
Includes
2000, 2100,
2900, 3900
2.50
2.00
1.50
1.00
0.50
0.00
Includes MSICU,
Neuro MISICU
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
Percentage
Transformational
Leadership
Using the Electronic Health Record to Drive Evidence-Based CAUTI Care Practices
2.00
1.50
1.00
0.50
0.00
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
0.44
0.51
1.21
0.00
0.51
0.00
1.24
0.00
0.00
0.00
0.00
0.00
Mean
2.17
2.29
2.03
2.08
2.05
1.95
Mean
2.17
2.29
2.03
2.08
2.05
1.95
From Your
Family To Ours
Deaconess Hospital
All Adult Step-Down Units
3.00
Includes
NTCA
Percentage
Professional
Practice Model
CAUTI Project Update
Percentage
Magnet
Model
ANCC Accredited Nursing Skills Competency Program
A new American Nurses Credentialing
Congratulations to those who participated
in Deaconess’ first ANCC-accredited
Center (ANCC) Accredited Nursing
Skills competency program was brought
Nursing Skills Competency Program.
to Deaconess so that nursing staff at
Jessica Barnes, RN
Myra Taber, RN
Deaconess Hospital and Deaconess
Mary Beth Schitter, RN
Mary Correll, RN
Gateway Hospital medical surgical floors
Jacquelyn Dixon, RN Carmella Mach, RN
were more comfortable and competent in
Jennifer Wright, RN
Megan Jahn, BSN,
RN, CMSRN
the application and care of Wound V.A.C
Nancy Ash, RN
Linda Martin, RN
therapy. Nurses are able to transition
Tracie Johnson, RN
Amanda Nosko, RN Destiny Smith, RN
patients from the hospital Wound V.A.C
Amber Schenk, BSN, Bill Chapman, RN
system to the home care Wound V.A.C
RN, CMSRN
system.
2.50
2.00
1.50
1.00
0.50
0.00
2Q11
3Q11
0.00
0.00
Mean
2.50
1.97
2.50
4Q10
1Q11
2Q11
3Q11
0.00
1.05
1.65
0.00
0.51
0.00
Mean
1.08
1.30
1.13
1.18
.098
1.31
Central Line Associated Blood Stream Infections per 1,000 Central Line Days
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
0.00
0.00
0.00
0.00
0.00
0.00
Mean
1.66
1.97
1.64
1.63
1.56
1.93
Deaconess Hospital
Ventilator-Associated Pneumonias per 1,000 Ventilator Days
2.50
2.50
2.00
1.50
1.00
Includes
2000, 2100,
2900, 3900
0.50
0.00
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
2.75
0.00
0.00
0.00
0.00
0.00
Mean
1.08
1.30
1.13
1.18
0.98
1.31
Percentage
Percentage
3.00
Includes
MSICU,
Neuro ICU
0.50
0.00
2.00
1.50
1.00
0.50
0.00
2Q10
3Q10
4Q10
1Q11
2Q11
3Q11
1.34
0.00
0.00
0.00
0.00
0.00
Mean
1.66
1.97
1.64
1.63
1.56
1.93
2Q10
3Q11
0.00
0.00
Mean
0.00
0.00
Exemplary
Includes
NTCA
Percentage
Deaconess Hospital
Central Line Associated Blood Stream Infection per 1,000 Central Line Days
All Step-Down Units
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
Emergency Department Sexual Assault Nurse Examiner (SANE) Program
Several of our Emergency Department
nurses were able to attend advanced
education in the forensic examination and
care of sexual assault victims.
• The basis of our SANE program is the
belief that sexual assault victims have
the right to immediate, compassionate
and comprehensive medical/legal
evaluation and treatment by a specially
trained professional.
• The services of trained, experienced
SANE practitioners help preserve
the victim’s dignity, enhance forensic
medical evidence collection and
increase the prosecution of sex
offenders.
Magnet
Model
Leadership
Chart
3Q10
1.50
1.00
Structural
Empowerment
Includes
MSICU,
Neuro ICU
2Q10
2.00
• Since the development of the
Deaconess Health System SANE
program, staff members have treated
more than 150 victims of sexual assault.
Adult/Adolescent SANE
Barbara Dewitt, RN—DH
Vicki Wright, RN—DH
Shawn Brown, RN, TNS—DH
Jessica Hahn, BSN, RN—DH
Monica Larue, RN, CMSRN—DH
Tamara Conrey, RN—DGH
Amy Dodson, RN—DGH
Rachel Wire, RN—DH
Amanda Payne, RN—DGH
Patty Bender, RN, CMSRN—DH
Pediatric and Adult/Adolescent SANE
Kathalene Keller, BSN, RN, CEN
New Knowledge,
1.80
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
Ventilator-Associated Pneumonias per 1,000 Ventilator Days
Percentage
Includes
2000, 2100,
2900, 3900
Percentage
Deaconess Hospital
Central Line Associated Blood Stream Infection per 1,000 Central Line Days
Professional
Practice Model
The Ventilator Associated Pneumonia
Bundle is now in EPIC. Review of literature
and evidence-based practice has helped
ensure patients receive the best care
possible while in the ICU. The CCC Team
will continue to keep these issues on our
radar to keep us striving for excellence.
From Your
Family To Ours
The original Central Line Prevention
Bundle was developed through the
Critical Care Core (CCC) Team. This
project is now being managed by the
IV Quality Collaborative Team, and staff
from both departments continue to do
amazing work regarding prevention of
blood stream infection rates.
Transformational
Leadership
Critical Care Core Team
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Structural
Empowerment
Exemplary
New Knowledge,
New Knowledge
and Innovation
From Your
Family To Ours
Evidence-based practice provides our patients with the safest and best
practices while generating new knowledge. To be successful, Deaconess
must continually build on its knowledge base by using existing evidence
while applying new evidence to achieve optimal outcomes.
Expanded Emergency Department
While the kick-off for this project involved
working a Saturday, it was an opportunity
to celebrate the history and closeness
of the department. Music played the
entire day; the more experienced staff
members shared pieces of “preserved
history” such as handwritten preferences
cards. When lunch time rolled around,
everyone stopped working and ate
barbeque together. The team turned a
day that could have been drudgery into a
celebration.
Expanded Surgery Suites
New Unit 4800 Under Construction
Magnet
Model
Professional
Practice Model
From Your
Family To Ours
OR Expansion Build Out
In April 2011, DH Surgery completed phase
I of a four-phase building project. Phase I
involved removal of one existing OR suite to
allow for expansion of the center core and
three new OR suites. This project coincided
with go-live of the new electronic health
record for OR. To ensure each of these
projects started smoothly, each member
of the surgery team pulled together. Team
leaders, center core staff and staff volunteers cleaned shelving, reorganized stock
and revamped the department.
Transformational
Leadership
4800 Addition: Cardiovascular Surgical ICU and Trauma Merge
has presented a challenge to everyone.
In fall 2010, following the strategic
A unified 4800 Unit-Based Council
building and remodeling plan for
was formed to represent everyone’s
Deaconess Hospital, the decision was
interests. An education plan for all staff
made to combine Trauma Intensive
was developed to promote advanced
Care, Cardiovascular Thoracic Surgical
learning, competencies and proficiency.
Intensive Care and Pediatric Trauma into
A Healthy Work Environment committee
one unit on the fourth floor. The new
was implemented to continue good
Unit 4800 will include a 22-bed intensive
collaboration, communication and team
care and step-down area. The projected
building. It’s the goal of the 4800 staff to
opening for the unit is May 2012.
provide compassionate, quality care to
Nurses from all three areas were actively
all patients, matching the expertise of the
involved in the design and development
staff to the needs of patients.
of the unit. Merging three different staffs
Leadership
Chart
Over the last year, staff rose to the
challenge of working in and around the
construction site with no disruption
of service to patients and visitors. The
investment in the Emergency Department
shows the value and commitment
Deaconess Health System places on
emergency services.
Structural
Empowerment
pleasing for patients, visitors and staff.
Exemplary
Emergency Department Expansion
2011 was an exciting year for the
Emergency Department at Deaconess
Hospital, with the addition of 5000
square feet of space. Staff were closely
involved in design and workflow change,
including relocation of security, triage,
visitor lounge, patient registration/
financial counseling and the six-room
treatment area and waiting area. The ED
is now full of light, open and aesthetically
New Knowledge,
Promoting the Future
Magnet
Model
Professional
Practice Model
OpTime
Since 2008, Deaconess’ goal to increase
continuity of care across the health
system has been met through spreading
EPIC across all departments. O.R.,
EPIC, I.S., Risk Management, Quality
Improvement, physicians and representatives from all nursing teams were involved
in the process. All nursing departments
across the health system are now charting
in EPIC so that all patient information
is available to all health care providers
within the health system.
OR staff attended classes earlier this year
for EPIC documentation education, implementation and evaluation. The real-time
documentation of the surgery record has
not changed but is now available to all
caregivers at the time of procedure.
Transformational
Leadership
Leadership
Chart
Deaconess is the first hospital in Indiana to reach HIMSS Stage 7
This ultimately improves performance,
A health care organization’s goal with
patient safety and patient care quality.
its EHR is to reach HIMSS Stage 7, the
Stage 7 hospitals are truly paperless.
highest stage of an environment in which
paper charts are no longer used in delivDeaconess was awarded Stage 7 status
ering patient care. According to HIMSS,
November 10, 2011. Deaconess was the
stage 7 health care organizations support
first health care organization in Indiana to
the true sharing and use of patient data.
earn this award!
Structural
Empowerment
Palliative Care Consult Team
Palliative care focuses on providing
specialized medical care to help relieve
patients’ pain and stress during a serious
illness, regardless of the diagnosis. The
goal is to improve quality of life for both
the patient and the family at any age
and at any stage in a serious illness and
to reduce readmissions and ICU stays.
Services can be provided together with
curative treatment.
Exemplary
New Knowledge,
After years of research into palliative care
and its impact on our health care system,
Deaconess approved the palliative care
service line in November 2010. In August
2011, Deaconess Palliative Care Services
started with the inpatient consult team,
which consists of physicians, nurses,
social workers, pharmacists, chaplains
and therapists. The team meets daily and
From Your
Family To Ours
rounds on palliative care patients in the
hospital.
In the four months since palliative care
has started, they have been consulted
on 180 patients. Of those 180 patients,
they have collaborated with other
disciplines to provide 55 hospice referrals,
54 different consulting physicians, and 98
ICU days saved.
The Palliative Care Service Team will
present a day of education to nursing
staff across both Deaconess campuses.
Palliative and End-of-Life Nursing Care:
Connecting the Pieces will provide
Deaconess nursing staff the education
and tools to care for chronically ill
patients and their families throughout
their disease process.
Magnet
Model
Thank You
Deaconess would like to say thank you for all the
wonderful things that nursing services and ancillary staff
accomplished last year. Here are just a few of your major
accomplishments in 2011. Congratulations!
•HFAP Survey with Accreditation—May 2011
Leadership
Chart
From Your
Family To Ours
•American College of Surgeons Level II
Trauma Reverification—Fall 2011
Transformational
Leadership
Professional
Practice Model
Units throughout the organization do
things that go above and beyond the
call of duty on a daily basis. Deaconess
has some of the most amazing, caring,
compassionate and considerate
employees in the Tri-State. Thanks to
everyone for the things you do each time
you walk through the doors!
Structural
Empowerment
The unit has had some of its own
struggles and growing pains during the
year. Opening at the end of 2010 with 12
beds, census quickly increased. The unit
pulled together as a team during this
time. Many staff members worked extra
hours to help their co-workers during
their time of need. Many patients and
families have been through the sixth floor
of Gateway over the past year. They have
touched the lives of the staff in ways
some never imagined.
Exemplary
Throughout the past year, many units at
Deaconess have gone above and beyond
to provide the best care to their patients
and families. Many new units have
opened, and many are in the process of
remodeling and expanding. The Surgery
Oncology unit at Gateway recently
celebrated its first birthday!
New Knowledge,
Surgery Oncology Gateway
•Primary Stroke Center Survey and
Designation—March 2011
•Top 100 Places to Work
Magnet
Model
Professional
Practice Model
Transformational
Leadership
Leadership
Chart
Structural
Empowerment
Exemplary
New Knowledge,
From Your
Family To Ours
Front Cover Design
The design on the front cover is our new Magnet
motto for 2012. All units were invited to submit
ideas for the motto. Once ideas were submitted,
a complete list of ideas was sent out to each
unit manager to post on the unit. Feedback was
welcomed, and each unit was encouraged to
submit their top vote for the Magnet Motto.
At the end of the competition there was a
three-way tie. The Magnet Writing Team looked
at each motto and decided they liked the way
two of them sounded together. Thus our Magnet
Motto was born!
Thanks to all units that participated, and
congratulations to Deaconess Hospital
Emergency Department and Michael Hart in
Public Relations for helping pull together a great
motto for our Magnet journey!
Deaconess Hospital
600 Mary Street • Evansville, IN
812-450-5000
4011 Gateway Boulevard • Newburgh, IN
812-842-2000
Deaconess Cross PointE
7200 E. Indiana Street • Evansville, IN
812-476-7200
800-947-6789

empowered - Deaconess Health System

Transcription

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