nursing annual report

NURSING ANNUAL REPORT

2015

Dear Colleagues, I am excited to share the 2015 UCHealth Nursing Annual Report with you. Over the past year, UCHealth has continued to provide the very best care, putting patients first and living our mission of improving lives throughout the Rocky Mountain region. Our nurses, staff and providers have led new safety initiatives and innovations in care while continuing to deliver the highest quality outcomes. As always, we have maintained our focus on creating exceptional experiences for our patients and their families, even as we expand to care for even more residents in the communities we serve. The Nursing Annual Report showcases the outstanding accomplishments that our nurses throughout Colorado are making. In this report, you will see examples of how we introduced new, innovative technology while maintaining our constant focus on caring for our patients and families. You will also read about how our nurses stand out as partners with the communities we serve and how members of our interprofessional team live out the UCHealth Standards of Excellence to continue our tradition of being the health care leaders in Colorado and beyond. I value the ongoing contributions of the nurses at UCHealth. As we continue to progress and grow in the future, we are creating a lasting culture of excellence in health care of which I am very proud. I would like to personally thank the nursing teams throughout UCHealth for contributing to our vision of transforming health care. Sincerely,

Elizabeth B. Concordia UCHealth President and CEO

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A Message from our CNOs At UCHealth, our nurses are at the forefront of an everchanging health care environment. They are leaders—shaping the future of professional nursing practice in providing exemplary care to the patients and families throughout Colorado. Our nurses are agents of change—ensuring that their contributions are opportunities for professional growth that is critically evaluated and evidence-based. Our focus on patient- and family-centered care is a shared culture and we emphasize personal accountability in providing the best quality and service available. Health care today is rapidly changing and our nurses remain steadfast in leading change by influencing the future of patient care innovations across the country. Throughout this report, you will learn more about our commitment to providing evidence-based care using our Standards of Excellence, shared decision-making, evidence-based innovations, and our goals to set the new standard in quality and patient experience. We are moving forward as a system to use UEXCEL as the Nursing Clinical Practice and Credentialing Model. This model supports nurses to promote role model and expert status while remaining clinicians— thus upholding our conviction that clinical excellence is of highest priority. As your CNOs, we realize that as we have come together, the scope of our global mission has taken on a whole new life, yet our core values of each collective organization remain the same—collectively, we are dedicated to improve lives through excellence in patient care, adopting new technology, improving goals for education, embracing innovation, and using research and evidence-based practice to propel us as leaders in health care. Carolyn L. Sanders PhD, RN NEA-BC, FACHE Chief Nurse Executive, University of Colorado Health Chief Nursing Officer & Sr. Vice President of Patient Services

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Ryan Rohman, MSN, RN, NMF Vice President and Chief Nursing Officer UCHealth - Medical Center of the Rockies

Kay J. Miller MS, RN, NE-BC, CENP Chief Nursing Officer UCHealth - Memorial Hospital

Donna Poduska MS, RN, NE-BC, NEA-BC Chief Nursing Officer UCHealth - Poudre Valley Hospital

Cathleen Ehrenfeucht, MS, RN Vice President of Nursing and Associate Chief Nursing Officer UCHealth - University of Colorado Hospital

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receives the recognition they deserve for a job well done. She is constantly and selflessly recognizing her peers. She truly meets the definition of a transformation leader through her strengths as an advocate. Amber is a supporter of staff and patients, and exhibits strong leadership qualities. These qualities include being visible, accessible, and an effective communicator.

Structural Empowerment

Transformational Leadership Unit Councils lead changes to improve patient care: There are over 100 RNs who serve as active members of our Shared Leadership Committees. At the center of the MCR Shared Leadership structure are our Unit Councils. These Unit Councils consist of staff nurses who are motivated to create improvements in staff engagement, patient satisfaction and overall quality of care. Unit Council accomplishments this year include: electronic communication boards, placed on all units to provide timely, accurate communication and updates; trial of nurse-driven C-diff testing and isolation protocol; and development of an enhanced controlled-stimulation protocol for traumatic brain injury patients.

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Spotlight Magnet RN: Amber Sansone, Surgical Trauma Unit Amber Sansone, BSN, exhibits characteristics of a transformational leader on a Amber Sansone, RN daily basis. She has built strong, trusting relationships with the staff. While Amber is officially a day shift Nurse Coordinator, she has been known to come in during night shift and weekends to be visible to all our staff. She ensures that staff

Nurses are empowered and supported to plan and participate in community outreach events focused on improving the health of the community. This year, another successful Teddy Bear Hospital was held at MCR. The event, planned by staff nurses and leaders in the Emergency Department, provided an experiential education for children, their stuffed friends, and families. Approximately 600 children attended the Teddy Bear Hospital this year. Nurse leaders in the Cardiovascular Service Line participated in a wellnessfocused event during the Horsetooth Half Marathon in the summer, which provided heart healthy information and snacks for attendees. Spotlight Magnet RN: Carrie Guffey, Mother and Family Unit Carrie Guffey, BSN, is a mentor to new graduates and a resource Carrie Guffey, RN to new nurses. She is patient, has a vast knowledge of her specialty, and always has a positive attitude. Carrie was a part of the triage Rapid Improvement Event and was the point person on rolling out the “Triage Transition nurse”, known as “T and T.” The trial run of the “T and T” nurse has now become a permanent position thanks to Carrie’s hard work in implementing this role on the unit. Carrie is committed to continuing her education and recently completed her BSN. She has encouraged many of the department’s staff to make the commitment to further their education and has been a great role model on how to balance work, family, and school.

Nurses at MCR work collaboratively and lead improvements in assuring that the patient experience focuses on patient- and family-centered care and assuring high-quality outcomes in nurse sensitive indicators. In collaboration with the Senior Director of Patient Experience, nurses participated in implementation of three tactics focused on improving the patient experience. These were: refocus on use of MAIDET as our key communication tool, consistent leader rounding with staff, and purposeful patient rounding on all nursing units. In addition, Commitment Conversations were initiated to assure that improvements that were implemented are providing the intended results of a positive patient experience. Medical Center of the Rockies Communication with Nurses

She helps MCR achieve the absolute highest quality of patient care every single day she is here.

New Knowledge Innovations and Improvements This year, the nurses at MCR participated in initiatives to decrease the rate of patient falls. Several areas significantly decreased the rate of unassisted falls, and fall, with injury, resulting in improved quality. Several initiatives, both in critical care and medical surgical areas, were implemented to prevent hospital-acquired pressure ulcers. An innovative, nurse-driven protocol was implemented, focusing on earlier extubation from the ventilator for post-operative heart surgery patients, has resulted in a decrease of delirium and total hours of restraint use in the critical care units.

Communication with Nurses – HCAHPS

Unassisted Patient Falls Per 1,000 Patient Days

82.8

Percent of “Strongly Agree” Answers by Patients Surveyed

MEDICAL CENTER OF THE ROCKIES

Exemplary Professional Practice

Hospital

82.6

Mean

50th Pctl

82.4

10th Pctl 75th Pctl

25th Pctl 90th Pctl

0.80

82.2 82

0.60

81.8 81.6

0.40

81.4

0.20

81.2

0.00

81 80.8 Q1-2015

Q2-2015

Q3-2015

Q4-2015

Spotlight Magnet RN: Sarah Sifrit, Operating Room As the Operating Room evening shift Nurse Coordinator, Sarah Sifrit, BSN, dedicates many hours each week to assure Sarah Sifrit, RN appropriate staffing is in place for the upcoming scheduled procedures. Sarah strives to make the department work together seamlessly. She effectively responds to the needs of the staff, surgeons, anesthesia providers, and above all, the needs of the patients we serve. Sarah brings cohesiveness to the team that is essential for the department. She is an excellent resource for all aspects of the Operating Room. Sarah is dedicated to lifelong learning and uses every opportunity available to further herself in her role.

-0.20 -0.40 -0.60 -0.80 -1.00

Q1

Q2 Q3 2014

Q4

Q1

Q2 Q3 2015

Q4

Spotlight Magnet RN: Robin Lueck, GI Lab Robin Lueck, MS, RN, possesses several attributes that make her stand out as an exceptional, innovative nurse. As the EHR Robin Lueck, RN Specialist in the MCR GI Lab, Robin was instrumental in EPIC documentation changes to pain assessment, procedural assessment and discharge documentation. Her leadership in this

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area has resulted in her being universally recognized both by staff and physicians as the ‘go-to’ person for computer questions. Robin earned her Master’s degree in Nursing in Informatics, in 2013. Robin’s initiative to learn and teach the specialty software used in the GI Lab has improved workflow for nurses and technicians, saving both time and money. Robin is also the moderate sedation Subject Matter Expert for the northern region. She assisted in researching evidencebased practices and rewriting moderate sedation policies to provide the highest standard of safety for patients.

HIGHLIGHTS National Recognitions: In 2015, MCR was again acknowledged for excellence in patient satisfaction through the Exemplary Service Overall Best Performer Award and the HCAHPS Best Performer Overall Rating; both awards were given by Avatar International, the patient satisfaction survey vendor selected by the organization to measure our patient experience. MCR also made significant improvement in the overall ranking for the University Health Consortium (UHC) database, moving from 56th to 7th in Quality and Accountability for 2015. The Joint Commission completed the triennial survey of MCR in August 2015 with no major findings by the surveyors, resulting in accreditation for another three years.

That night, an overwhelming number of the hot team employees responded to the page. Hot team members were called in to care for the patient and showed up immediately ready to provide patient care. The ED staff did an extraordinary job of preparing for the potential Ebola patient by moving patients out of rooms adjacent to the determined Ebola area and gathering all supplies needed. Environmental Services did a phenomenal job with room preparation. Exceptional coordination and communication occurred between the nursing supervisors, command center participants, physicians, ancillary departments, EMS and leadership team. Everyone did their job to the best of their ability and we were able to safely and effectively provide quality care to the patient.

Capacity Enhancements: As the inpatient census at MCR continues to increase, the need to grow our inpatient bed capacity became a priority focus in 2015. Nurses participated in the planning and design for additional rooms to increase the number of beds on the four medical and surgical units. Two inpatient beds were added to each of the four medical and surgical units. The rooms opened in July. The additional beds were quickly utilized and additional options for patient placement needed to be addressed. In early December, the Clinical Decision Unit, an observation and post-procedure monitoring area, was opened. The unit, staffed Monday through Saturday with two RNs, provides additional space to support patient recovery.

Preparation Pays Off:

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April 1, 2015 was the first day as interim VP/CNO for Ryan Rohman. The day would be unusually exciting as Emergency Medical Services responded to a call about a patient that had recently visited Sierra Leone and was experiencing Ebola-like symptoms. It was decided that the patient would come to MCR for their initial care before being transferred to University Hospital. It was not an April Fool’s Day joke. Approximately 75 interdisciplinary staff members had gone through extensive training to be on our Ebola hot team.

“I couldn’t be more excited about working in the CDU. As this unit starts to fully operate, the vision for great care for patients who need a short term stay has started to come to fruition, and I’m honored to be a part of it. I truly believe the CDU will be a wonderful addition to MCR,” Emily Young, CDU, RN.

Jerre Johnson, BSN, creates metrics, dashboards, reports and drill down data that provides staff and physicians with information that influences change in the care of patients. As the Cardiovascular Clinical Quality Specialist for Jerre Johnson, RN the northern region, Jerre helps to develop strong cardiovascular patient care through accurate data analysis and process improvement.

MCR’s Cardiovascular Services received the Platinum level award from Get with the Guidelines, the National Cardiovascular Data Registry in 2013 and in 2014. Jerre’s work with the Door to Balloon committee is testament to the power of data to outcomes management. Jerre is our watchdog on cardiovascular processes. She is a patient advocate, and excellent staff resource with a wealth of knowledge on the history of the organization’s programs, as well as new initiatives.

What are MCR’s Door to Balloon Time for STEMIs? – 2015 Annualized Median D2B = 41 minutes (Avg = 43 min) MCR D2B time (minutes)

100

1Q-15 (7/7) 100% PCI < 90 min Median = 49 min Avg = 48 min


System Goal = 60 min


Stretch Goal = 30 min


80 60 40 20

9/1 9/5 9/1 4 9/2 2 10 /11 11 /4 11 /9 11 /20 11 /29 12 /2 12 /11 12 /14

0 1/5 1/1 7 2/1 0 3/1 8 4/4 4/2 8 6/1 5 6/1 9 6/2 8 7/2 3 8/4 8/1 9 8/3 0

D2B Time (in minutes)

120

National Goal = 90 min


Spotlight Magnet RN Empirical Outcomes: Jerre Johnson, Clinical Quality

Retired Denver Broncos’ quarterback Peyton Manning visits with the nursing staff at Medical Center of the Rockies.

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• Examination of pros and cons of different learning formats • Comparisons of popular nursing programs (contact information, program attributes, tuition costs) • Information and links to nursing scholarships (i.e., Memorial Foundation Nursing Scholarship) and grants • Federal and private student loan information • UCHealth tuition assistance policy

Transformational Leadership Clinical Nurse Forges the Way to Eliminating RN to BSN Barriers Michelle Massie, Wound Ostomy Nurse, started out as an Associate’s Degree Nurse. Since then she obtained her Baccalaureate, and has now been awarded Masters status. Over this time she experienced many barriers to these achievements. For her MSN capstone she explored evidence-based practice related to the personal and professional barriers that prevent nurses from pursuing a higher education degree. The result of this project is an RN to BSN Resource Binder that addresses ways to overcome these obstacles. Nurses lead very busy lives. The binder saves nurses from having to do their own research and assists them to make informed choices and select the school that best fits their personalized needs. The information in the resource binder includes the following:

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• Establishing a support system • Goal setting • Time management strategies • Computer software and hardware recommendations • Free software training links • Comparisons of online and local brick-and-mortar school programs

The RN to BSN Resource Binder is an excellent tool that provides nurses with alternatives and will be kept current as new resources are identified. The RN to BSN Resource binder is located in Clinical Education at Memorial Central, and may be checked out. In the future, this resource will be available on the UCHealth intranet site, The Source. We thank Michelle Massie for her hard work and for making her research available to all employees.

Structural Empowerment Employees Empowered to Improve The 2015 Employee Giving Campaign at Memorial Hospital was simply amazing this year! Our employees have given over $124,714 in one-time, recurring, and PTO donations this year. This is an increase of over $41,000 compared to the previous campaign. In fact we enjoyed over one hundred more participants that last year. A 5% increase! In 2001, the Memorial Hospital Foundation was created to support the programs and services of Memorial Hospital. All of the donations received are invested in programs, services and employees at UCHealth Memorial Hospital. This year, employees in 147 departments participated in the biggest campaign yet. These funds are used in a variety of ways: • Employee Assistance Program. An average of twenty grants are provided to UCHealth Memorial Hospital employees in crisis each year. • Employee Education. Scholarships are offered to Employee continuing education to improve patient care and outcomes and pursuit of higher degrees

Our employees are dedicated to helping their coworkers and our community.

Exemplary Professional Practice Nursing Scholarship Program The Excellence in Nursing Scholarship Program at Memorial Hospital is offered twice each year to employees pursuing nursing degrees. This program was initially funded by the Memorial Hospital Auxiliary (MHA). When the MHA disbanded in 2014, they donated their remaining funds to jump start the Excellence in Nursing Scholarship Program. Funding is also supplemented by employee specified contributions to the Memorial Foundation through the Employee Giving Campaign. To date, the $2,500 scholarship has been awarded to ten employees pursuing nursing education. The National Institute of Medicine will require that 80 percent of nurses within the hospital environment hold a baccalaureate degree or higher by 2020. Currently, over 60 percent of Memorial Hospital nurses hold a higher degree in nursing education. In fact, Memorial Hospital is ahead of the game, as the national average is only about 50 percent for advanced nursing degrees. We are proud of our employees, and the strides that they undertake to pursue education and to transform that knowledge into delivering excellent service to our patients and customers.

New Knowledge Innovations and Improvements Forensic Nurse Examiner Team Leads the Way Since 1995, Memorial Hospital has housed the only Sexual Assault Nurse Examiner (SANE) program for sexual assault victims living in El Paso and Teller counties. The largest and most comprehensive in the state with 24-hour in-house services, our program sits within the Emergency Department (ED), with its own suite of rooms to accommodate the patient population we serve in privacy and comfort, but with ready access to additional services. In addition to sexual assault victims, Forensic Nurse Examiners (FNEs) care for several other patient populations. These patient populations include, but are not limited to victims of: intimate partner violence (IPV), strangulation, child abuse, elder abuse, physical assault, human trafficking and trauma. From 2007 to 2014, the FNE Program at Memorial has increased in patient volume by 486 percent. This is largely due to having an FNE presence at all times, something that is very unique in hospital systems, nationally. Research has shown that violence is a health care epidemic. By providing trauma-informed forensic health care to patients, we are the leaders on the path to what will surely become a standard of practice in the future.

MEMORIAL HOSPITAL

• Women’s/Maternal Care. Mother and Baby Services, and needs related to the care of infant and pediatric patients. • Sometimes special equipment is required to improve a patient’s experience or outcomes, and the Memorial Hospital Foundation is able to assist in filling these needs. • Wellness and community outreach, to include trauma and emergency services. • Chronic disease management. Cardiovascular, Cancer, and Oncology Services, and rehabilitation.

Memorial Hospital is also home to the Colorado SANE/ SAFE Project. The primary purpose of this project is to provide statewide SANE/SAFE education, clinical training, and technical assistance to all of the programs in the state, based on the International Association of Forensic Nurses (IAFN) SANE Education Guidelines. Not all communities have access or support for SANE/ SAFE programs. This project trains facilities and providers without programs, in addition to training multidisciplinary Sexual Assault Response Teams (SART). Through the use of web-based and live training we are able to assist SANEs and other medical professionals in maintaining the skills necessary to care for the sexually assaulted patient and to run sustainable programs.

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MEMORIAL HOSPITAL

Memorial Hospital Patient Volume 2007-2015 2000 1800 1600 1400 1200 1000 800 600 400 200 0 2007

2008 2009 2010 2011 2012 2013 2014 2015

Memorial was selected as one of three sites nationally to be featured in the upcoming SANE Program Development and Operation Guide Project due to our progressive clinical and education programs. To assist nurses and other community leaders in developing, strengthening and sustaining SANE programs, the Office for Victims of Crime (OVC), in collaboration with other federal partners, and a diverse group of subject matter experts, will revise and enhance the current SANE Development and Operation Guide (Guide) to include advances in forensic nursing practice, forensic science and criminal justice, since its first publication in 1999 and transform the Guide into a Web-based, interactive format. An informed, effective response to sexual violence in America transcends the criminal justice system and needs to incorporate many disciplines, including the health care sector. Providing sensitive and evidencedinformed health care to victims is critically important in the aftermath of a sexual assault, and the OVC is committed to promoting the development and sustainability of Sexual Assault Nurse Examiner (SANE) programs throughout the U.S., which represent a best practice in providing this care.

HIGHLIGHTS National Recognition: In 2015, Memorial Hospital received recognition from The International Board of Lactation Consultant

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Examiners® (IBLCE®) and International Lactation Consultant Association® (ILCA®) for excellence in lactation care. Decalie Brown, President of ILCA, shares with us, “This recognition highlights the efforts being made by maternity facilities all across the world to help mothers get off to a good start with breastfeeding and to support them in reaching their goals. IBLCE is the leading internationally recognized lactation certification in the world, and IBLCE certificants are highly skilled in helping mothers with the questions and concerns that can arise. They are also an important part of the overall maternal and child health team by assuring that evidence-based policies and practices are in place to help mothers succeed with breastfeeding.” IBLCE certified personnel focus on preventive care during pregnancy and beyond. Assessment is necessary to determine any assistance needed to overcome obstacles to successful breast feeding practices and baby growth. Certificants are an essential part of the Maternal/Baby health care team. US News & World Report has ranked Memorial Hospital in the top four Best Hospitals of Colorado, and as High Performing in the areas of Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Hip Replacement. In the 26th annual report from US News & World Report, almost 5,000 hospitals are assessed to quantify the care provided to patients with complex health care concerns. George Hayes, President and CEO of Memorial Hospital, says, “This recognition is a tribute to our dedicated and expert nurses, physicians, and staff members who are constantly focused on providing the very best care to patients.”

New ED Throughput Leads to Improved Patient Satisfaction: Memorial Hospital Central has been researching methods to reduce the number of patients who leave without being seen (LWBS) and improving the throughput process in the Emergency Department (ED). A Process Improvement (PI) team was tasked with these efforts, and they began to make changes

care to patients.”

Not only did the ED accept this challenge, they embraced it and were very excited about trialing something new. The old processes were preventing our patients from the best experience possible and all disciplines were eager to be a part of positive change. As a result, a physician was placed in ED Intake during peak times. This drastically decreased significant

measures (LWBS rate and door to provider time). Positive patient feedback was immediate. ED employees have also been very happy with the new process; and the positive momentum has continued, encouraging other process improvements. Physicians, nurses, patient care technicians, and patient access all have taken ownership of the new process and feel that this has positively affected their work flow in addition to the patient experience. We saw dramatic and immediate improvement after initiating these changes. Our initial goal for LWBS was less than 2 percent. We were averaging 4 percent, but had days as high as 12 percent. After the new process was implemented our LWBS rates dropped below 1 percent, and have remained there. The average Door to Provider wait was 23 minutes from January through July 2015. That average wait time dropped to less than ten minutes after the new process was initiated in August 2015. Prior to August 2015, the FY2015 data for the question, “Given my medical condition, I did not have to wait too long” moved. This is just one of the many teams that illustrate how staff engagement and empowerment continue to drive our facilities to positive change and improvement.

Dec

Nov

Oct

Sept

Dec

Nov

Oct

Sept

Aug

Jul

Jun

May

Apr

Mar

Feb

Jan

0%

Jul

1%

Jun

2%

Linear (MHC)

May

3%

Apr

4%

MHC

Mar

5%

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

Feb

Linear (MHC)

Jan

MHC

Door to Provider (Min)

Aug

LWBS (%) 6%

MEMORIAL HOSPITAL

in August 2015. The team goal was to make substantial changes that were sustainable to the entire department and would positively affect the experience of our ED patients. Clinical staff members, physicians, and leadership were engaged and involved in planning meetings, piloting new “This recognition is a processes, tribute to our dedicated and critical and expert nurses, conversations about what physicians, and staff the new model members who are would look constantly focused on like and how it providing the very best would work.

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Zero CAUTI for the calendar year 2015

Zero CLABSI for the calendar year 2015

MCR

PVH

MCR

PVH

Medical Ortho Neuro Spine Rehab

Cardiac Medical Neuro Med Surg Ortho Pediatrics Plus

Cardiac Medical Ortho Neuro Spine PCU Rehab Surgical Trauma

Cardiac ICU Medical Neuro Med Surg NICU Oncology Ortho Pediatrics Plus Surgical

Memorial 3C Acute Care North MHC Digestive Med MHC Inpt Oncology MHC Renal Peds PICU

UCH ACE Birth Center CPCU Rehab Unit

UCHealth Nursing Education for the calendar year 2015 MSN/DNP/PhD 4%

ADN 14%

Memorial 3C ICU Central MHC Inpt Oncology MHC-Renal Ortho/Spine Peds PICU Stroke Surgical/Trauma

UCH Birth Center Ortho Neurosciences Women’s Care Center

2015 UCHealth System Fiscal Year Average Daily Census (ADC) (July 1, 2014-June 30, 2015)

BSN 82%

1,063

Poudre Valley Hospital University of Colorado Hospital

University of Colorado Hospital is the only organization in Colorado with this accreditation!

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UCH’s 4th designation announcement at the ANCC Magnet Conference 2015

Medical Center of the Rockies SICU (Gold) & CICU (Silver) University of Colorado Hospital Neuro ICU (Silver)

Medical Center of the Rockies (2*) Poudre Valley Hospital (4*) University of Colorado Hospital (4*)

Poudre Valley Hospital Family Medicine Center Primary Care University of Colorado Hospital Ambulatory Services

Medical Center of the Rockies Memorial Hospital Poudre Valley Hospital University of Colorado Hospital

Medical Center of the Rockies Memorial Hospital Poudre Valley Hospital University of Colorado Hospital

Poudre Valley Hospital University of Colorado Hospital

Certified Baby-Friendly®

Top 10 Hospitals in Colorado Medical Center of the Rockies Poudre Valley Hospital

Medical Center of the Rockies (#7) Memorial Hospital (#4) Poudre Valley Hospital (#4) University of Colorado Hospital (#1)

American College of Surgeons Burn Center of Excellence

The Joint Commission Inpatient Diabetes Care Certification Poudre Valley Hospital University of Colorado Hospital

University of Colorado Hospital

University of Colorado Hospital

Medical Center of the Rockies

*designations

100 Top Hospital by Truven Health Analytics Poudre Valley Hospital

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Transformational Leadership Poudre Valley Hospital clinical nurses’ roles, as well as nursing leaders’ roles, model transformational leadership. Spotlight Magnet RNs: Lydia Baldwin and Suza Ault In 2015, the nurse leaders of PVH and MCR identified a new recognition, the Magnet Nurse Leader Award. These Lydia Baldwin, RN awards are based on the concepts of Transformational Leadership: Idealized Influence, Inspirational Motivation, Intellectual Stimulation and Individualized Consideration. The three recipients of the Magnet Suza Ault, RN Nurse Leader Awards were selected based on their consistent and exemplary implementation of these characteristics in our organizations. The PVH Nurse Leader Awards for 2015 were presented to Lydia Baldwin, MSN, CCRN, nurse manager, ICU, and Suza Ault, BA, RN, BSN, NE-BC, nurse manager of Cardiac Rehab. Spotlight Magnet RN: Heather Roth The 2015 PVH Magnet Nurse for Transformational

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Leadership is Heather Roth, BSN, NSN. Heather commits to leading by example in her practice as the nurse coordinator on the Surgical Unit at PVH, and she does it with a kind of humbleness that Heather Roth, RN is so sincere and graceful, that it actually demands attention. Heather epitomizes the gold standard of advocacy for both patients and staff. She takes to heart our vision, mission, and values by exemplifying her personal leadership mission to improve lives. As a leader, Heather has been involved in LEAN and Rapid Improvement Events, most notably a RIE that focused on staffing on the Surgical Unit with the subsequent Intensity Index outcome. When nurses were adapting to a new matrix, Heather championed the Intensity Index – a guide to gauging patient complexity so as to better assign patients to nurses in a more fair, safe, and manageable way. After directly affecting care at the bedside at PVH, she went on to present this project and represent PVH in Florida at the Academy of Medical-Surgical Nurses.

Structural Empowerment Poudre Valley Hospital has strong structures and processes in place for nurses to continue to grow in their profession. • The North UCHealth Nursing Scholarship continues with the 2nd Annual Family Fun Walk and Run. The scholarship provided $6,500 to nurses at PVH and MCR to continue their formal education in nursing. The PVH recipients for 2015 are: Gwen Crist, RN, Emergency Room, PVH; Jaimie Dirks, RN, SAC/PACU/ ODSC, PVH; Rhonda Fisher, BSN, Clinical Nurse Educator, Operating Room, PVH; Cindy McCauley, RN, Clinical Educator, Women and Family Services and Pediatrics; Janele Peterson, RN, Women’s Care. PVH; Riley Mulligan, BSN, Float Pool. Poudre Valley Hospital has supported all nurses to return to school to advance their formal education. In 2015, many nurses completed their higher education that they worked hard to achieve.

80

Year End 2014

Year End 2015

70

Percentage

60 50 40 30 20 10 0 Associate Diploma Bachelor of Masters of Degree RN Degree RN Nursing Nursing

Spotlight Magnet RN: Michelle Zheng The 2015 PVH Magnet Nurse for Structural Empowerment is Michelle Zheng, BSN, RN-C, EFM. Michelle is an active participant Michelle Zheng, RN on the Birthing Center Quality and Practice Council. She is an accomplished Obstetric nurse certified in Electronic Fetal Monitoring and Impatient Obstetrics. Michelle was one of the first nurses to become part of the “GO Team.” The “GO Team” was developed to support the patient care needs in the Women and Children’s Service line between PVH and MCR. Michelle promotes nursing, and partners with our community in Northern Colorado by sharing her talents and skills. Michelle speaks Chinese and has completed the requirements to become an official interpreter in Mandarin Chinese. Michelle is very active in the Chinese community and is a liaison for their birthing experience, promoting culturally competent care. Michelle coordinates a women’s group for the Chinese community and assists members to locate physicians for themselves and their families.

Exemplary Professional Practice Highly engaged, clinical nurses are empowered to identify opportunities for meeting the unique and individual needs of patients and families, using the resources available to them at the hospital. Since January 2015, a workgroup from the Nurse Practice Council and Clinical Nurses met to evaluate the current professional practice model and shared

leadership model of PVH. The PVH Nursing Mission and Nursing Philosophy were also reviewed and evaluated. The statements continue to drive nursing at Poudre Valley Hospital. Mission Statement To provide quality, compassionate care that focuses on the strengths of patients and families; assisting patients to regain or maintain health, live with disabilities or die with dignity and comfort.

POUDRE VALLEY HOSPITAL

Percent of Highest Nursing Degrees Year End 2014 - 2015

Nursing Philosophy Statement The nursing staff is committed to providing quality patient- and familyProfessional Practice and centered Shared Leadership Model care through collaborative partnerships among health care providers, patients and families. The Coordinating Council governs the quest for excellence in evidencebased nursing practice, focusing on the domains of Quality, Education, Advocacy, Community and Professionalism. The outcome of the yearlong process was the development of a new shared leadership process at PVH. This workgroup, consisting of nurses at all levels included, CJ Bang, Kathy Brown, Jane JostesWanek, Charis Kee, Cindy McCauley, Cheryl Milner, Casey Newth, Donna Poduska, Sarah Watson, and Jill Zamzow. The new shared leadership model consists of unit-based councils and a coordinating council with membership comprised of clinical nurses. The new model incorporates the Professional Practice Model and Care Delivery Model. It started January 1, 2016.

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Spotlight Magnet RN: Melinda Tafoya The 2015 PVH Magnet Nurse for Exemplary Professional Practice is Melinda Tafoya, BSN. Melinda is able to create a culture for all Melinda Tafoya, RN staff working on the unit to feel supported, and part of the team. Melinda took on the responsibility to be the lead on improving the workflow of charge RNs and how workflow could be adjusted to be efficient and easier. Melinda also created tip sheets and handouts that she provided for charge RNs as well. Melinda is the type of leader who sets standards for all nurses to strive toward: honesty, kindheartedness and clinical expertise. She doesn’t take herself too seriously and genuinely cares about the patients, families, unit and organization she works for.

New Knowledge Innovations and Improvements Innovation in nursing practice occurs daily at Poudre Valley Hospital. Nurses have autonomy within their scope of nursing practice to be able to respond to patients’ needs. • In the fall of 2015, the nurses on the PVH Medical Unit began a pilot using an early warning system to identify clinically deteriorating patients. The goal of the early warning system is to identify patients on the Sepsis continuum. Sepsis Coordinator Elise McKnight, BSN, managed the pilot from October 26 through December 24, 2015.

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Spotlight Magnet RN: Page Peters The 2015 PVH Magnet Nurse for New Knowledge Innovations and Improvement is Page Peters, BSN, IBCLC. Her ability to increase Page Peters, RN breastfeeding success rates empowers moms, and is also at the heart of public health and preventing readmissions. Within the past two years, Page Peters, RN, BSN, IBCLC experienced a new mom with Theca Lutein Cysts, and was able to

assist this mom into exclusive breastfeeding status when no other health professional was able and allowed the mom to continue breastfeeding through the first two years of the infant’s life. Page’s research and case study into Theca Lutein Cysts and the effect on Lactogenesis II was important enough to the field of lactation that she was requested to speak at International Lactation Consultant Association (ILCA) 2014 in Arizona. It was Page’s knowledge that provided new knowledge for impacting not only UC Health Northern Colorado WeeSteps Program but programs throughout the United States.

Empirical Outcomes: Clinical nurses continue to impact patient outcomes and improve nursing care. • The PVH Nursing Quality committee took the lead to review and report clinical outcomes including: – Catheter Associated Urinary Tract Infections – Patient Falls with Injury – Hospital Acquired Pressure Ulcer, Stage II and above – Catheter Associated Blood Stream Infections A portion of each Nursing Quality meeting was the sharing of outcome and best practices on the clinical units. Clinical nurses were able to network and determine best practices for their patient population. Spotlight Magnet RN: Katrina Rice The 2015 PVH Magnet Nurse for Empirical Outcomes is Katrina Rice, BSN. In 2014, she started a project on the Oncology Katrina Rice, RN Inpatient Unit here at PVH. The project’s goal was to reduce the amount of central line associated bloodstream infections. Between 2011 and the first quarter of 2014, there were seven CLABSI infections on the Oncology Unit. One hundred percent of the seven patients were neutropenic. To meet the goal of reducing CLABSI’s, Katrina implemented the following measures on Oncology: All central lines are required to have neutral pressure caps (Neutron caps)

Number of CLABSI

2

Hospital

Mean

10th Pctl

50th Pctl

0.80

75th Pctl

25th Pctl 90th Pctl

0.60

1 0

Percent of Surveyed Patients with Hospital Acquired Pressure Ulcers Stage II and Above

Q1 2014

0

0

0

0

0

0

0

Q2 2014

Q3 2014

Q4 2014

Q1 2015

Q2 2015

Q3 2015

Q4 2015

0.40 0.20 0.00

placed on them, all neutropenic patients, or expected to be neutropenic patients, will be given daily CHG baths and staff were educated on central line care and meticulous IV maintenance. Katrina did all the research, data collection, monitoring and tracking the data of all the neutropenic patients admitted to Oncology. From April 2014 to the end of December 2015, Oncology has been CLABSI free! Decreasing CLABSI infections decreases mortality rates, shortens length of stay and saves millions of health care dollars.

-0.20

The following graphs represent the clinical outcomes for Poudre Valley Hospital from Quarter 1, 2014 to Quarter 4, 2015.

0.60

Injury Falls Per 1,000 Patient Days Hospital

Mean

50th Pctl

0.80

10th Pctl 75th Pctl

25th Pctl 90th Pctl

-0.40 -0.60

Q1

Q2 Q3 2014

Q4

Q1

Q2 Q3 2015

Q4


Poudre Valley Hospital - Oncology Unit Number of Central Line Blood Stream Infections Quarter 1, 2014 to Quarter 4, 2015

Central Line Associated Blood Stream Infections per 1000 Central Line Days Hospital

Mean

50th Pctl

0.80

10th Pctl 75th Pctl

25th Pctl 90th Pctl

0.40 0.20 0.00 -0.20 -0.40

0.60

-0.60

0.40

Q1

Q2 Q3 2014

Q4

Q1

Q2 Q3 2015

Q4

0.20 0.00

Catheter Associated Urinary Tract Infections per 1000 Catheter Days*

-0.20

Hospital

-0.40 0.80

-0.60 -0.80

Q1

Q2 Q3 2014

Q4

Q1

Q2 Q3 2015

Q4

Mean

50th Pctl

10th Pctl 75th Pctl

25th Pctl 90th Pctl

0.60 0.40 0.20 0.00 -0.20 -0.40 -0.60

2015 Q1

2015 Q2

2015 Q3

2015 Q4

*Only 2015 data available due to the changes in the benchmark.

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HIGHLIGHTS Poudre Valley Hospital Nursing Leaders and Clinical Nurses continue to strive to improve and be the best in patient care. Nurse sensitive indicators, patient experiences and nurse engagement are several ways to monitor health care improvement. Below are several other 2015 highlights that identify best practices at Poudre Valley Hospital.

Bariatric Program Re-Accreditation: In January 2015, the PVH Bariatric program achieved Comprehensive Center with Adolescent Accreditation from the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). This program has held accreditation since 2005. To be accredited, the bariatric unit, located on the PVH Surgical Unit, must perform a specific number of surgeries with high-quality patient outcomes. The adolescent accreditation that PVH received with its Comprehensive Center designation means that PVH meets specific criteria to serve the unique needs of adolescent patients. Lynelle Diede, BSN is the manager of the bariatric program and coordinated the accreditation program at PVH.

and security led by nursing have been planning the changes throughout 2015. The input includes the physical environment including room layout, furniture, equipment set-up, and lighting. The nurses are also taking the lead on the changes in nursing practice when all patients are located in their own rooms. Demolition began in June 2015 and construction on the new individual rooms started in September. The NICU project is scheduled to finish by late fall, 2016.

New Freestanding Emergency Room: Nurses also took the lead when the Emergency Department at Poudre Valley Hospital expanded to include a new freestanding ER located in southwest Fort Collins. The new Harmony ER opened October 28, 2015. The Emergency Department provides patient access to an emergency care in an area where the population of the city continues to grow. The new Emergency Department provides the same high-level care as the ED located at PVH.

Neonatal Intensive Care Unit – Expansion:

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In the spring of 2015, the oldest wing of Poudre Valley Hospital was separated from the Hospital brick-by-brick in preparation for demolition. The bricks were removed, saved and sold by the PVH/MCR Foundation with proceeds going to the Neonatal Intensive Care Unit. As changes occur with the new building, the NICU is expanding. The current space for the NICU is not enough to accommodate the patient census throughout the year. The average daily census is about 15 but the census can climb as high as 29 babies. Clinical Director Laura Hall explained that the space does not currently work for the population growth and families. A team of architects, physicians, pharmacists, therapists,

In November 2015, the new facility saw approximately 700 walk-in patients, 22 patients arrived by ambulance while two patients were brought to the ER by local police. The average patient wait time was seven minutes. UCHealth’s Sexual Assault Nurse Examiner (SANE) program at Medical Center of the Rockies expanded to provide a second location for victims at the new PVH Harmony ER.

1. Increase satisfaction for the patient’s experience

Population Health Care Manager/Transitional Care Case Managers:


work to assure that there are no gaps in care from patients discharged from PVH returning to the FMC clinic. Jen Nolte and Andrea Hooley, along with Pam Boehm, work with the staff and Family Practice Residents to impact patient care. The main goals include:

SANE nurses provide adult and pediatric medical examinations for sexual assaults using compassionate methods. The medical exam treats injuries, tests for pregnancy, addresses sexually transmitted diseases, and collects forensic evidence for future or current use. Patients also receive counseling resources.

2. Provide patient education 3. Reduce readmissions

Transitional Care Case Managers and the Population Health Care Manager, are new roles for health care, and three nurses at PVH have been leading the path for patients at Poudre Valley Hospital. Pam Boehm MSN, CENP, has a new role as Population Health Manager with the Family Medicine Center (FMC). Pam, along with Marcia Snook, RN, FMC Practice Manager, have worked to develop this role during the past year. Jennifer Nolte BSN, and Andrea Hooley, BSN, work as Transitional Care Case Managers. All of these nurses

These nurses work daily to assist the physicians and Family Practice Residents with patient’s plan of care and patient discharges. This may include patient and family education, prescription medication management, and working with the patient to remove any barriers for follow-up care. It is important for the patient to access care at the appropriate level. These nurses have decreased all FMC patient hospital readmissions since the start of the program.

FMC 30-day Hospital Readmission Rate 70 60 50 40 30 20 10 Dec-15

Nov-15

Oct-15

Sep-15

Aug-15

Jul-15

Jun-15

May-15

Apr-15

Mar-15

Feb-15

Jan-15

Dec-14

Nov-14

Oct-14

Sep-14

Aug-14

Jul-14

Jun-14

May-14

0

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the education for the 11th floor nurses on how to use the new tool for every patient on every shift. Prior to Beth’s research on acuity tools, only 3.78 percent of BMT/ONC nurses were using the previous acuity tool. After the tool revision and educational intervention, 91 percent of nurses Are you using the new population specific patient acuity tool? reported using the acuity tool. 5% She also found 4% that the nurses thought the 91% acuity tool was more relevant and easier to use.

Transformational Leadership What’s your Number? Development of a Specific Acuity Tool for Oncology/ Medical Surgical ONC and BMT Patients After years of frustration working without a patient population-specific acuity tool on the BMT/ONC unit, the leadership team engaged Beth (Joy) Prabhakar BSN, RN, to research whether there was an acuity tool that was standardized and population specific, to improve staffing considerations when patient acuity for individual nurse assignments were high. Beth engaged the Health Sciences Librarian in a literature search and found a tool from Ohio State University that was validated. Beth modified and adapted pieces from the validated tool for the current tool to meet the 11th floor needs. Changes included keeping the current 3-6 range acuity score on the current tool, and adding a 2nd numeric indicator that would highlight the patient’s “nursing care intensive level.”

21

Beth completed 83 trials on the old and the new tools, then presented her findings to the 11th floor Shared Leadership Council the BOOM (Bone Marrow and Oncology Operations Meeting) and to the med-surg managers. After she received feedback, she adjusted the acuity tool and completed 43 more trials. After further adjustments, she prepared a new roll-out and

Yes No Unknown

Structural Empowerment A Quality Improvement Project Improving Rates of Hepatitis B Vaccinations through a Nurse-Driven Protocol The Center for Disease Control (CDC) and Kidney Disease: Improving Global Outcomes (KIDIGO) recommends that patients with chronic kidney disease stages III or IV receive the Hep B vaccination. This course is given in three separate vaccinations over a 6-month period. Before the nurse driven protocol created by Michelle Jonjak, BSN, RN, CCRN, Charge Nurse of the Multispecialty Surgery Clinic, was created for her Level III credentialing project, there was no automatic way to remind patients or providers when the next vaccination was due, therefore many patients were not receiving the full course of shots to protect them. Not receiving all three shots can lead to worsening immune problems in this already vulnerable population. In the initial phase of the project, Michelle worked with the Epic team to send staff a message two weeks before the each subsequent injection for the patient. This message prompted the nurse or MA to call the patient to schedule an appointment. This process was backed up by the team to track all patients who start the vaccine course on a spreadsheet, on the clinic’s shared

The Hepatitis B Vaccination Protocol was approved in July 2014. The new process entails orders for the vaccine placed by the providers, the RN/MA sends electronic reminders to the patients for the next vaccine and appointment, and the team is still keeping up the spreadsheet to ensure patient compliance and accuracy of data. Hepatitis B Vaccinations N = 79 injections total First Dose

9

Second Dose

Third Dose

8 7 6 5 4 3 2 1 Jul-15

Jun-15

Apr-15

May-15

Mar-15

Jan-15

Feb-15

Dec-14

Oct-14

Nov-14

Sep-14

Jul-14

Aug-14

Jun-14

May-14

0

Exemplary Professional Practice Cardio and Vascular Center (CVC) Chronic Disease Management (CDM) Team Drives Care Delivery Using a Quality Measure Performance Dashboard

of care for patients with heart failure. The CDM team has aligned with organizational goals and strategically implemented quality improvement strategies using a systemic approach. CDM meets monthly and uses a quality performance dashboard to track data. Interprofessional collaboration has played a vital role in the improvement of quality measures to ensure minimized variance and improved care, as well as safety for patients with HF. From fiscal year 2013 (FY2013) through fiscal year 2015 (FY2015) the CDM team focused on six quality metrics and improved overall performance from 33 percent to be 67 percent of metrics at or above the national benchmark (NB) (source HF-GWTG®). Three clinical metrics focused on evidence-based care directed to measure left ventricular function and based on those results to prescribe ACEI/ARB and an evidence-based beta-blocker at time of discharge. Prescription of discharge medications improved from below the NB in FY2013 to above the NB in FY2015. Three additional quality metrics focused on care transitions. One metric targeted discharge instructions and showed an improvement by 8 percent, but remained no different than the NB. Two quality metrics focused on care post discharge. Follow up (FU) visits within seven days or less improved by 9 percent from FY2013 to FY2015 and remains above the national benchmark. A FU visit within 72 hours of discharge remains below the NB, but has improved from FY13 to FY15 by 11 percent.

UNIVERSITY OF COLORADO HOSPITAL

drive. All clinical team members were able to update the spreadsheet. While the data collection continued, Michelle continued to revise the protocol, present education for the clinic team members, and finalize the protocol.

CVC Quality Dashboard

Source Heart Failure HF-1 Discharge Instructions HF-2 Eval of LVS function HF-3 ACEI or ARB for LVSD ACHF-01: Evidence based BB prescribed at DC ACHF-02: Post Discharge Appointment ACHF-06: Post DC eval for HF patients (72h)

Health care reform has drawn attention to national improvement efforts to improve care transitions for patients with heart failure. Chronic Disease Management (CDM) teams are vital to move health care delivery forward, in order to improve health and health care for patients and chronic disease populations. The CVC team was motivated by a national quality initiative to improve the quality and transitions

FY 13

HF-GWTG 89.9% HF-GWTG 100% HF-GWTG 84.9% HF-GWTG 84.9% HF-GWTG 54.7% HF-GWTG

FY 14

Top 50th Percentile Nat’l FY 15 Benchmark

92.7% 99.4% 96.9% 89.2% 61.4% 23.5%

96.2% 99.0% 97.8% 92.2% 63.3% 29.7%

96.6% 98.2% 95.1% 90.5% 58.9% 38.4%

New Knowledge Innovations and Improvements Post-Op Nausea and Vomiting Aromatherapy Project Debra Malone, BSN, RN, CAPA, Charge Nurse in the

22


ambulatory pre/post anesthesia unit, focused her Level IV credentialing project on a complimentary alternative for post-operative nausea and vomiting (PONV). Nausea and vomiting are familiar patient problems in the PACU. They can lead to an array of post-op problems and cause the patient to have increased anxiety and dissatisfaction with their hospital experience. Current practice at the time of the project was to have patients sniff an isopropyl alcohol prep pad as an aromatherapy to decrease the sensation of nausea. Deb introduced QueaseEASE as an alternative product that was developed by a certified registered nurse anesthetist (CRNA) to help treat the PONV. This product is made of essential oils known for their nausea suppressing effects. Its ingredients are natural and include peppermint, ginger, and spearmint. Lavender is added as an anti-anxiety intervention. The patients were all treated with traditional treatment modalities. All the patients received aromatherapy as a complimentary modality. During the time between November 2014 to March 2015, 50 patients with PONV received isopropyl alcohol to inhale and the next 50 patients with PONV received QueaseEASE to inhale. QueaseEASE pads lasted for 8 hours while an isopropyl pad dried out in about one hour. During the post-operative follow up phone calls, patients were asked the helpfulness of the aromatherapy in reducing their PONV using a 1-5 Nurse Satisfaction of Alcohol Prep Pad vs. QueaseEASE for Management of PONV Alcohol Prep Pad

QueaseEASE

Alcohol Prep Pad

QueaseEASE

16 14 12 10 8 6 4 2 0

1

2

3

4

5

Patient Satisfaction of Aromatherapy for PONV (1 being least helpful & 5 extremely helpful)

scale (with 1 being least helpful and 5 extremely helpful). Patients and nurses were more satisfied with the QueaseEASE product in managing PONV.

HIGHLIGHTS Once again in 2015, US News & World Report rated UCH as the #1 hospital in Colorado and the #1 hospital in the Denver Metro area. Numerous nurses received the honor of awards and nominations for their dedication and commitment to high quality patient care:

Nightingale Award – 33 nominations, 5 finalists: • Recipient: Lindsey McMenimen, RN, BMT Infusion Center

12 10

Magnet Nurse of the Year Award – 44 nominations:

8

• 8 Recipients:

6 4

Clinical Practice:

2

– Transformational Leadership: Mike Metcalf, RN, Rehabilitation Medicine – Exemplary Professional Practice: Stephanie Nelson, RN, Orthopedics Unit

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23

Patient Satisfaction of Alcohol Prep Pad vs. QueaseEASE for Management of PONV

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3

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5

Nurse Satisfaction of Aromatherapy for PONV (1 being least helpful & 5 extremely helpful)

Non-traditional Practice: – Exemplary Professional Practice: Staci Aden, RN, Pulmonary Unit – New Knowledge, Innovations and Improvements: Michelle Ballou, RN, Pre-Operative and Post-Anesthesia Care Units – Structural Empowerment: Kathy Foss, RN, MSN, Professional Resources – Transformational Leadership: Jamie Nordhagen, RN, Oncology/BMT and the Oncology/Medicine/Gynecologic Oncology Units

Daisy Award – 31 Nominations: • 6 Recipients: – Erin Butzen, RN, BIC – Tammy Switzer, BMT Nurse Practitioner – Jodi Ecklund, RN, CTICU – Gwen King, RN, Cancer Infusion Center – Becky Hutchison, RN, Outpatient Cancer Center – Danielle Justice, RN, MDSS

National Award Recipient: Colleen McIlvennan, DNP, ANP-BC, was awarded the 2015 Heart Failure Society of America (HFSA) Nursing Research Award at the organization’s 19th Scientific Assembly in National Harbor, Md., Sept. 26-29.

UEXCEL: 65 nurses submitted a credentialing portfolio: – Level III (63) – Level IV (2)

Post Graduate Nurse Residency Program Earns Reaccreditation: On June 1, 2015 an announcement was made that UCH’s Graduate Nurse Residency Program had received a five-year reaccreditation from the Commission on Collegiate Nursing Education (CCNE). The program, initially accredited in 2010, is the first in the nation to earn this five-year accreditation. Our program, led by Mandy Moorer, BSN, RN, CCRN, has allowed UCH to provide a quality experience in the graduate nurse transition from a novice

to a competent and professional expert nurse. The accredited program has attracted more than 1400 nurses since its “home grown” early beginnings in 2002. Today, graduate nurses make up at least 50 percent of the hospital’s nursing staff, making it a major “feeder” for nursing positions at UCH. Carolyn Sanders PhD, RN, NEA-BC, FAAN joined GNRP Coordinator Mandy Moorer BSN, RN, CCRN and Professional Resources Director JoAnn DelMonte MS, RN in celebrating the program’s achievement.

SUCCESS! IHQSE Team Opens CARE Clinic: An interprofessional team joined forces to create and open the CARE (Clinical Assessment & Rapid Evaluation) clinic at the UCH Cancer Center. This new clinic provides prompt support for cancer patients struggling with treatment symptoms when the clinic schedules are full. It aims to relieve pressure and assist with capacity on busy clinic schedules, ED visits, and inpatient units when patients seek treatment of symptom management. Mary Jane LaRoche is a provider in the clinic; her focus is to provide access to expedited and appropriate care, without the patient and family waiting.


– Structural Empowerment: David Ricke, RN, Neuro ICU New Knowledge, Innovations and Improvements: Vicki Slat-Vasquez, RN, Cancer Center Infusion Center

The clinic uses two exam rooms in the Infusion Center and is open five days a week from 9 a.m.-5 p.m. So far, the emphasis of early response and ease of access for patient symptom management has assisted with improved recovery times, decreased hospitalizations, and keeping patients on schedule for their therapies. Three nurses and a pharmacist developed and led the idea for the CARE clinic:

Left to right: Adam Poust, pharmacy; Sarah Eppers, Infusion Center practice manager; Nicole Giles, Infusion Center clinical nurse; Mary Jane LaRoche, medical oncology nurse practitioner; Whitney Herter, physician assistant

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New Burn Center: The UCH Burn Center expansion and remodeling project was completed on June 26, 2015. Integrated outpatient and inpatient treatments are all on the 3rd floor of the critical care wing (CCW) in the Anschutz Inpatient Pavilion (AIP). “We now have created a true Burn Center,” said Nurse Manager Mary Holden BSN, RN. An integrated unit strengthens our Burn Center’s status as the only ABA-verified service in Colorado.

The successful rollout of the Alaris pump integration project was the result of an interdisciplinary The expansion, team approach which coupled with included Bedside a process Here are some of the members of the new Burn Center’s team. Left to right: Emily Scott, RN Super Users, improvement social worker; Rance Beasley, burn technician; Kimberlee Lamoth, staff nurse; Mandy Nursing Leadership, project through Seader, staff nurse; Camy Bell, advanced practice nurse; Mary Holden, nurse manager; Linda Staubli, former nurse educator; Darcie Lubbe, physical therapist; Laura Madsen, Clinical Informatics, the Institute for outreach coordinator; Katie Winkleman, staff nurse (now clinical educator) Pharmacy, Medication Healthcare Quality, Safety, Biomed, Epic Trainers and IT. Deb Bonnes MS, Safety and Efficiency (IHQSE) which revamped RN, from Clinical Informatics was the Nursing Lead scheduling, expanded nursing responsibility, and for the project and states that working alongside increased patient access, has the new outpatient bedside nurses from throughout the UCHealth system, clinic volume “booming,” Holden said. On day one, to standardize workflows and improve patient safety clinic providers saw 19 patients (up from eight to 10 through innovation, was the most gratifying part of on a normal day in the AOP space). These changes the project. mean better care for burn patients and better communication between inpatient and outpatient The new Pump Integration technology was rolled out services. The team has also noticed that they have a to the Northern Colorado campus on February 9th, better opportunity to see burn survivors now, as they 2016 and the Southern Colorado campus on April come to the same floor for their outpatient treatments. 12th, 2016. The Burn Center leadership added a new advanced Infusion Pump Integration Results practice nurse, Kathryn Moser, ANP-BC, to the team. Overall administration compliance: 91%

UCH Pumps it Up!

25

populated by the provider’s order to decrease manual pump programming errors. Medication administration data is also automatically sent back to the Epic EHR for the nurse to review and validate. This new process reduces the risk of manual pump programming errors and ensures timely documentation. Preliminary data on SI events shows a decrease in manual pump programming errors for infusions.

On Tuesday November 10th, 2015 UCH joined a small number of hospitals that have successfully tethered two powerful technologies in a major patient safety effort. The Alaris smart infusion pumps are now fully integrated with the Epic EHR. Patient-specific medication orders are sent wirelessly by RNs from the MAR to the Alaris pumps through a barcode supported process. The pumps are then auto-

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Patient ID Capture Compliance

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Guardrails Compliance