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March/April 2019


Difference A bimonthly newsletter for CHI St. Joseph Health Team Members

Raquel Webb Ordination, Pg. 3 New Emergency Code System, Pg. 4 Foundation Update, Pg. 8

Physician Spotlight Spotlight Physician Dear CHI St. Joseph Health team members, By now, you all should be involved on some level with the Integrated Work Plan (IWP) and huddle board process that was rolled out in early February. As you’ll recall, this process is being utilized across the CHI Texas Division in order to improve quality and efficiency within our hospitals and clinics. While this particular process is new for our organization, the concept of constantly striving for improvement isn’t foreign to us at all. Our team has a firm understanding of process improvement and has been doing this well before I arrived at CHI St. Joseph Health. We are simply building on the foundation that you all started.

Theron Park, President and CEO

Although the process may be challenging initially, I am proud of the hard work that has been put into making this part of your daily routines across our system. That hard work has already begun paying off. And over the next couple of months, all of our departments should have the IWP process fully implemented. As we continue our focus on the FY19 strategic plan, specifically improving our patient experience, employee engagement and quality metrics, it has been uplifting to see team members embracing the IWP and huddle board process and find wins at the unit and department levels. These are all opportunities to improve our organization. Even better, the IWP has allowed you all to identify ways to correct issues on your own, without having to escalate them to the tier two huddle. Just with our pilot teams, we have seen new processes created that are directly impacting employee satisfaction and patient experience. While change can be uncomfortable, it also creates opportunity for growth and success. I’d like to thank each of you for your willingness to step out of your comfort zone and grow with me. Your enthusiasm for making this new format part of your daily routine and the commitment you continue to show to it are what fuels our Mission day in and day out. Warmest regards,

Theron Park President and CEO

We are pleased to announce Elizabeth Suarez, M.D., as a member of the May 2018 graduating class of The Institute for Functional Medicine (IFM) Certified Practitioners. As an IFM Certified Practitioner of The Institute of Functional Medicine’s Certification Program (IFMCP), Dr. Suarez is uniquely trained in the Functional Medicine model to identify and treat the root causes of chronic diseases. Of total healthcare costs in the United States, an estimated 86% are spent on chronic conditions. Often, healthcare treats acute conditions; however, chronic and lifestyle-related diseases are often not successfully treated using the same approach. Functional Medicine is an innovative approach to medical care, with an emphasis on the way environmental and lifestyle choices interact with a patient’s genes. Functional Medicine uses the latest medical research to develop personalized care for each patient, based on his or her unique environment, lifestyle, and genes. The result is a dynamic and effective way to address chronic disease.

PERFORMANCE EXCELLENCE THROUGH AN INTEGRATED WORK PLAN: UPDATES We are thrilled to see many of our front line staff excited to incorporate huddle boards and employ the Lean tools into their daily work. Throughout the last couple of months, the Performance Excellence (PE) team has worked hard to assess almost all the huddle boards across the system. To further help leaders and team members understand how to use the huddle board to improve a process within your department, we send out weekly messages and resources. Our local PE team will continue to coach departments and units. In addition, our Senior Leadership Team has begun to conduct Huddle Effectiveness Rounding Opportunity (HERO) to provide real time feedback on each department’s huddle board. This is the time to be proud of the hard work you and your team have done to have great huddle boards! As we mentioned before, we are excited to see so many great ideas on the huddle boards being implemented. KEEP THE IDEAS COMING! What Makes a Good FLD? As a reminder, a front line driver (FLD) is a measurable action that front line team members can influence to help drive key performance indicator (KPI) measures. A good FLD: • Aligns with the KPI • Is within the control of the front line staff within the department to impact • Is a process measure, not an outcome • Can be measured daily

KPI and FLD Metrics Both the KPI and FLD should have a numerical goal so you can track improvement and attainment of your goal. Some examples are below: • KPI: Reduce specimen mislabeling to 0.01/CPT; FLD: Reduce extra tubes by 50% • KPI: Shift rating ≥ 8; FLD: Daily task completion rate ≥ 90% • KPI: Room Cleanliness HCAHPS score ≥ 75th%; FLD: 98% adherence to standard work

Why Chart and Action Item Log The Why Chart is used to track the barriers to performance of the FLD. Once a trend is identified, the action item log is used to record the interventions put in place to remove that barrier. Notate the date the intervention began on the Run Chart to see the impact on the FLD. If you need assistance at any point or have additional questions, reach out to: Katie Spiegelhauer, Director, Performance Excellence and Improvement, at



Raquel Webb

Chaplain and Manager of Spiritual Care Ordained from First Baptist Church Chaplain and Manager of Spiritual Care at CHI St. Joseph Health, Raquel Webb, knew from a very young age that she was called by God to do vocational ministry, and at a young age, she made a commitment to devote her life to Jesus and to respond to her calling to serve. Over the course of her life, the way in which she has felt called to serve has changed; initially Raquel was committed to evangelism and spent her time in discipleship, mission trips and church involvement. Eventually, she applied for a Clinical Pastoral Education internship, and her experience was life-changing. Raquel knew that she was meant to minister in the hospital setting. “When I encounter individuals in the hospital, I feel deep compassion to respond and minister to them. I believe this is not automatic, but a deep moving caused by God’s Spirit within me…” Raquel said. She joined CHI St. Joseph Health in August of 2018, and in December of 2018, she was promoted to the position of Raquel Webb with Sister Penny Dunn and Sister Nancy Ferguson manager of the Spiritual Care Department. Raquel supervises seven other chaplains and manages the provisions of spiritual care for our clinics and hospitals throughout the Brazos Valley. “Chaplaincy is an opportunity to minister to many who might never step foot in a church, but my encounter with this in a hospital room or a staff meeting might make a difference in their lives and in their understanding of who God is.” On Sunday, March 24, Raquel became the first woman to be Ordained from First Baptist Church in Bryan, a role we at CHI St. Joseph Health are proud of her for undertaking.


Four CHI St. Joseph Health Hospitals Receive TMF Hospital Quality Improvement Award CHI St. Joseph Health hospitals received TMF Hospital Quality Improvement Gold and Bronze awards. Burleson Hospital earned the Gold Award, while Regional, Grimes and Bellville earned Bronze Awards. Sponsored by the TMF® Health Quality Institute and hospital associations in several states, the award recognizes hospitals in Arkansas, Missouri, Oklahoma and Texas that have undertaken quality initiatives to improve outcomes in patient care and improve their performance on specific national quality measures. This program was established in 2004 as a non-competitive recognition program designed to identify exemplary outcomes achieved by hospitals. The 2018 TMF Hospital Quality Improvement Award program is based on achievements in 2016-17. Our hospitals performed quality initiatives aimed at improving outcomes in patient care. To earn gold recognition, Burleson Hospital reported at least one measure set for Inpatient and Outpatient Quality Reporting and attaining a 20-percent relative improvement for readmissions or a readmissions rate of 5 percent or less. Burleson was one of 557 hospitals earning this honor. Our bronze-winning hospitals reported at least one measure set for IQR and OQR programs and attained a 10-percent improvement in readmissions or a rate of 5 percent or less. Grimes, Bellville and Regional were among 51 hospitals earning this honor. Please join us in congratulating our team on earning these accolades.

The American College of Surgeons’ Commission on Cancer reaccredited the CHI St. Joseph Health cancer program last month, recognizing the health system’s commitment to providing comprehensive, high-quality, patient-centered care and its continued work towards improving the care and outcomes of patients with cancer in the Brazos Valley.

Join us in congratulating our team at CHI St. Joseph Health Cancer Center!


As of March 1, CHI St. Joseph Health facilities started announcing emergencies using a set of “plainlanguage” emergency codes in place of the color-based codes previously used. “Plain-language” codes typically use a phrase to identify the type of emergency, the code itself and the location of the emergency to relay information about the emergency to staff, emergency responders and guests. These codes are standardized across the Texas division and will reduce errors, align CHI St. Joseph Health with the national safety recommendations, increase transparency of communications and safety protocols, promote safety and reduce confusion to those working in multiple facilities. CHI St. Joseph Health’s staff, emergency responders and guests will be able to act appropriately and effectively based on the information received through the plain language emergency announcement. Codes are now organized into four categories: • Security • Facility • Weather • Medical Codes blue, green and pink will remain response codes, and they were deemed universal. The new codes will be called in a three part statement: 1. Alert category 2. Specific code description 3. Location of emergency Example: Facility alert, power outage, bed tower. Each team member will receive a new badge with information that can be referenced in the event of an emergency. Managers for Regional Hospital and South College Station campus will get new badges for their teams at safety huddle. New hires will go to security to get their badges.

The Cancer Center received three commendation standards for meeting and exceeding the recommendations set by the Commission on Cancer. The Commission on Cancer offers many benefits including structured care models; accountability and quality improvement measures; extensive data to use for quality improvement, administration and research; data analysis; public awareness; and recruiting. There are also numerous patient and community benefits including reputable and verified standards of care, collaborative efforts to provide cancer prevention and cancer screening events, and greater exposure to clinical research studies and trials. CHI St. Joseph Health is the only health facility in the Brazos Valley to be accredited by the American College of Surgeon’s Commission on Cancer.

New Emergency Code System

About TMF: TMF Health Quality Institute focuses on improving lives by improving the quality of health care through contracts with federal, state and local governments, as well as private organizations. For more than 45 years, TMF has helped health care providers and practitioners in a variety of settings improve care for their patients.

Team members were assigned second quarter education in the learning hub to review the new system and then should have signed an attestation form stating that they had completed the review. Please contact Kristen Christian at with questions.


“One of the neat things about APWAP is they have made themselves available to us,” said Amy DiLeo, palliative care registrar. “If we have an emergency situation with one of our patients and feel that pet therapy may be beneficial, we are able to call and get a pet here the same day or the next day. We are looking forward to growing that relationship in 2019.” Who We Serve Patients in the palliative care unit are prime candidates to receive visits from the pet therapy dogs.

Aggieland Pets With A Purpose and CHI St. Joseph Health volunteer Kit Darling and her dog, Daschle, with team members Penelope Hamilton and Amy DiLeo of our Palliative Care Unit.

Palliative Care & Pet Therapy

For our patients who are injured, ill or recovering from surgery, the hospital can be a disorienting experience. Away from the familiarity of home, many are in need of comforting. Enter the Caring Canines Pet Therapy Program. Offered in partnership with Aggieland Pets With A Purpose (APWAP), the program is designed to connect patients with the outside world and provide comfort and companionship during their hospital stay. “When we bring pets in to visit our patients, we see them smile. The experience takes them away from their burdens,” says Lacy Genovese, R.N., M.S., W.C.C., registered nurse in our palliative care department. “The pets remind the patients that there is still joy. The animals bring peace and comfort, and the effects extend beyond the moments spent with them.” The partnership between CHI St. Joseph Health Regional Hospital volunteer services and APWAP began years ago and has been reestablished with new vigor during the past year. Together, we share the responsibilities of identifying who is in need of pet therapy and which specially trained animals and owners can provide proper support. Under the direction of President Kit Darling, APWAP boasts a network of dogs of various sizes, shapes and breeds, 5 ensuring that there is something for everyone.

“We take a very holistic approach to patient care, paying attention to the clinical aspects of care as well as the psychosocial elements,” Amy said. “Being able to provide pet therapy is something that we feel is very positive for our entire department. It strengthens us as a team.” The benefits of pet therapy may extend into other areas of the hospital as well, including the critical care unit (CCU) and oncology. How Pets Help Pets in the therapy program boost patients’ spirits by offering a little bit of relaxation during a time of turmoil. They can also inspire patients to keep going with confidence at a time when they may feel hopeless. “When you come in with a pet, you can feel the instantaneous relief in a person. There is hope and joy,” Lacy said. “When a patient has something to look forward to, mental outlook improves, which can definitely affect physical healing.”

How Animals Heal At the end of a long, hard day, nothing is quite as comforting as coming home to a wagging tail and fuzzy cuddle. Not only do pets offer emotional support through unconditional love, they can also boost physical health. According to the Centers for Disease Control and Prevention, people who own a pet may enjoy: • Companionship to combat loneliness • Lower blood pressure • Reduced cholesterol Plus, having a pet can inspire you to get outside and get moving, taking walks with your animal to whittle your waistline and improve cardiovascular health. You may even make new friends at the dog park who can join you during your daily workouts.

Kristie Force, RN, Selected as Daisy Award Winner for December We are pleased to announce that Kristie Force, a Registered Nurse who serves on the Critical Care Unit in the CHI St. Joseph Health Regional Hospital, has been selected as the Regional Hospital DAISY Award winner for the month of December. Kristie was nominated by a patient’s wife for going above and beyond when providing care for the patient and for ensuring that his wife was taken care of as well. “….Kristie had a listening hear, answers to my numerous questions, and a calming voice. I don’t know St. Joseph’s mission statement, but if it were molded around her, patients would receive superior care at every encounter,” the patient’s wife said.

The DAISY Award is an international award program that honors and celebrates the extraordinary and compassionate care that nurses provide to their patients each day. CHI St. Joseph Health team members can be nominated by patients, family members or colleagues, and nominations can be sent via, or nomination forms can be found at nurses stations. Please share the nomination process with your colleagues and patients and congratulate Kristie Force for her achievement!

2019 Legacy Awards CHI St. Joseph Health leadership presented the Legacy Award on Feb. 28 to three retired members of our team for their commitment to Franciscan values and for continuing the legacy of our founders, the Sisters of St. Francis of Sylvania, Ohio. Award recipients Drs. Alan and Ralph Young and RN Mari Szabo were recognized in a special ceremony held in the Regional Hospital Tower Lobby. They each received a plaque, which is now on display in Regional Hospital near the Legacy Tree, commemorating the core values of the Sisters of St. Francis of Sylvania, Ohio. Our award recipients were nominated by their peers for their commitment to the Sisters’ core values of Tenderness, Humility, Selflessness and Reverence for all Creation.

2019 Legacy Award Honorees

Ralph Young, MD retired Urologist Alan Young, MD retired Urologist Mari Szabo, RN retired from Medical Staff Services


CHI St. Joseph Health

Foundation Update The CHI St. Joseph Health Foundation has recently identified several initiatives, with direction from the Strategy Council and CEO Theron Park: Purchase of a 3D Mammography machine for the South College Station Imaging Center – Early detection of breast cancer saves lives. As part of our commitment to our Mission and the health of women across the Brazos Valley, the Foundation will fund $451,000 to purchase this piece of equipment. Purchase of a Da Vinci XI Surgical Robot for the Operating Room at Regional Hospital – This unit will complement our existing Da Vinci, which has the highest utilization of any Da Vinci unit in Texas Division facilities. This purchase will complement our Mission, allowing us to offer less invasive surgical treatment and faster healing while decreasing readmissions.

Cutting-Edge Pediatric Emergency Standards Provide Fast, Coordinated, Precise Treatment on CHI St Joseph Health AirMed 12

Launch of our employee giving campaign – Team members are encouraged to contribute to the campaign with a designation through payroll. They will have the ability to designate funds to support education, mission integration, physical plant improvements and other initiatives. The campaign will launch soon.

When it comes to treating children in medical emergencies, emergency providers must commonly make a series of quick calculations in order to treat their youngest patients.

Team members can pass contact information along to Foundation Director Chuck Konderla at 979-774-2167 or

Handtevy Pediatric Emergency Standards, a system used by CHI St. Joseph Health AirMed 12 for the last five years, supports quality care by our emergency team by streamlining dosing for pediatric patients. Before AirMed 12 adopted the Handtevy standards, the air medical team used a system still commonly used by many first responders. “What we would do is pull out this piece of equipment called the Broselow Tape,” said Billy Rice, Flight Paramedic for AirMed 12. “You lay this out next to the child, and then, depending on their height, you would get a standard dosage and equipment recommendations.” This system, said Rice, works best when the patient is lying on a bed. It doesn’t work quite as well in certain emergency situations, such as when a child is trapped inside a car. The recommended dosage also required some quick calculation on the part of first responders, as the unit of measurement used for medication can differ from the unit of measurement used on the Broselow Tape. And often the Broselow system was actually different than the protocols used.


Developed by a pediatric emergency medicine physician and EMS Medical Director, Dr. Peter Antevy, the Handtevy standards rely only on the patient’s age to determine drug dosing and equipment sizing. It also calculates that dosing, based on our individual protocols, for each and every drug carried on our helicopter – all in a handy app. “Because we did some work on the front end, not only does the app know all the dosages our medical director wants us to use. It also knows the concentration of the medication stocked on our helicopter,” said Rice. “Now when we go to the patient, I start a new patient, enter the information, and it gives me all the data I need with no math.” In addition to offering greater accuracy in treatment of pediatric patients, Rice said the Handtevy system also alleviates stress for first responders in an emergency, as they are assessing their young patients and determining a course of treatment. Rice also points out that, as more EMS systems across the Brazos Valley integrate the Handtevy system into their protocols, more pediatric patients will benefit from seamless and continuous treatment, streamlining their move toward definitive, hospital-based care.

The Foundation is actively solidifying relationships and reconnecting with established donors with one-on-one dinners, small gatherings or hosted events. The team encourages team members to offer to put families and patients in touch with the Foundation when they are very enthusiastic about the care they have received.

Mammogram Mondays CHI St. Joseph Health has begun hosting “Mammogram Mondays,” monthly events for team members, focused around women’s health. Held at the CHI St. Joseph Health Diagnostic Imaging Center in Bryan on the fourth Monday of each month, these events are an opportunity for team members to receive their mammogram in a comfortable environment, while enjoying refreshments and fellowship with their colleagues. The goals of these events are to align our actions with our Living Our Mission Metrics by increasing employee engagement scores and to help employees prioritize their own health by making mammograms accessible. The events have been a success, with numerous employees receiving mammograms. Several attendees have commented that their managers allowed them to take time off of work in order to attend the event. As an organization, we are thankful to have leaders who prioritize the health of team members, and we hope leaders continue to allow and encourage their team members to attend. All eligible team members will receive an invitation by email, and a limited number of spots are available on a first come, first served basis. Moving forward, we are looking at ways to use this model to make healthcare more convenient and accessible to our community partners.


Heart Month

In&the News Our Community


Denise Stackhouse, EMS Training Coordinator, speaking at the Hard Hats for Little Heads Program at Reed Arena.

Denise Stackhouse spoke to over 3,000 kids on the importance of helmet safety.

Team members across CHI St. Joseph Health wearing red in support of the American Heart Association and Go Red for Women on Friday, February 1, to raise awareness of cardiovascular disease.

Cindy Emola, nurse navigator with the cardiovascular team at CHI St. Joseph Health Regional Hospital, joined First News at Four to discuss some early signs that you might be having a heart attack, including chest discomfort, shortness of breath, discomfort in other areas of the upper body, and more.

Nurse practitioner Wendy Seneff on KBTX discussing self-care management and how it helps keep heart patients out of the ER.

Dr. Mark Floyd accepting the game ball at the Texas A&M Women’s Basketball BTHO Breast Cancer game on February 14th.


Dr. Neal Spears discussing heart disease in children along with signs, symptoms and treatments. 10

50 Men Who Can Cook We are proud Top Chef sponsors of College Station ISD Education Foundation Annual 50 Men Who Can Cook event. Team members including Chuck Konderla, Thomas Salzer, MD, Matthew Propst, MD and Thomas Campbell, MD were all chefs.

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Difference March and April  

Difference March and April