Page 1

Nursing Excellence FY2019 NURSING ANNUAL REPORT


Mission To extend the healing ministry of Jesus Christ.

Core Values DIGNITY Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. INTEGRITY Honesty, justice, and consistency in all relationships. EXCELLENCE High standards of service and performance. COMPASSION Service in a spirit of empathy, love, and concern. STEWARDSHIP Wise and just use of talents and resources in a collaborative manner.

Vision CHRISTUS Health, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God’s healing presence and love.


REPORT Editor-in-Chief Mona Gaw, MPA, MSN, RN, NEA-BC, FACHE, CPHQ, LSSBB Contributors Stephen Botha, LSSBB Deborah Chelette, MHA, BSN, RN Geertje De Jong, MPA, RN Jason Lee, MSN-NI, RN Tami Hurley MSN, APRN, ACNS-BC Jamie Maddox, MSN/Ed., HACP, RN Gary Miller, MSEd, BA, BSN, RN-BC Cathy Newman, MSN, RN, NEA-BC Anitha Sanderson, MSN, RN Advisor Shelly Welch, MBA, BSN, RN, NEA-BC The information and opinions expressed in this newsletter are those of the contributor and do not necessarily reflect the opinions of CHRISTUS Trinity Mother Frances Health System. Layout & Design: Gary D. Miller


CONTENTS 4 6 8 10 12 14 16 18 20 22 24 26

Chief Nursing Officer Message Transformational Leadership Structural Empowerment DAISY Award Winners BEE Award Winners Nursing Hall of Fame Centers of Excellence NICU Expansion Exemplary Professional Practice Empirical Outcomes New Knowledge & Innovation Key Accomplishments Across the System


CNO Shelly Welch, MBA, BSN, RN, NEA-BC Chief Nursing Officer | CHRISTUS Mother Frances Hospital—Tyler As we reflect on our accomplishments for the fiscal year 2019, I would like to sincerely thank all our nurses and unit technicians who work hand-in-hand each day to provide excellent care for our patients. Today, we are 1,760 nurses in all and I am humbled by your daily contributions to live our mission of extending the healing ministry of Jesus Christ. This year has been focused on Zero Harm initiatives across CHRISTUS Health as a system. We continue to strive as a nursing team to collaborate with the multidisciplinary team in order to decrease and eliminate preventable harm. Our shared governance councils have been instrumental in the approval process of new supplies and equipment following evidence-based practice (EBP). One example I would like to emphasize is the use of external catheters to decrease our catheter associated urinary tract infections (CAUTI). Through our shared governance councils, every clinical area has adopted external catheters – especially our critical care units. In an effort to decrease and eliminate falls with injury, CHRISTUS Mother Frances Hospital-Tyler collaborated with the Zero Harm Committee to make falls one of the organizational priorities for this year. Multidisciplinary efforts are underway to engage every Associate to prevent patient falls. To further improve awareness of hospital-acquired pressure injury rates, the Pressure Ulcer Prevention (PUP) study team has completed its quarterly prevalence and incidence studies in the different clinical areas.


As a proponent of safe, effective, and efficient patient care, I listened to our nurses who shared barriers they were experiencing with the medication administration workflow. I reached out to our Process Improvement and Pharmacy teams who willingly supported improvement efforts. Today, I am happy to hear positive feedback about the changes implemented. Lastly, I encourage you to continue being involved in your unit based councils (UBCs). Each one of you is equipped with the knowledge, skills, and abilities to bring sustainable change at the unit level. Your active engagement and commitment to excellence is integral to ensuring the best outcomes for our patients.


designation, June 2021. At this time, we are seeking American Nurses Credentialing Center (ANCC) Magnet stories from our Associates, which demonstrate passion, dedication and care for our patients, captures -recognized organizations will serve as the fount of knowledge and expertise for the delivery of nursing care work flow enhancements created and implemented by front line caregivers, and use of technology or best globally. They will be solidly grounded in core Magnet principles, flexible, and constantly striving for discovery practices to improve work environments and outcomes. and innovation. They will lead the reformation of health The ANCC Magnet® Model (below) is comprised of five care; the discipline of nursing; and care of the patient, components: family, and community.  Empirical Outcomes Magnet Vision:

Why Magnet?

 Transformational Leadership

To achieve Magnet recognition, organizations provide evidence of nursing professional development programs and progress above benchmark (exceeding a comparison group) performance for RN satisfaction and patient outcomes.

 Structural Empowerment  Exemplary Professional Practice  New Knowledge, Innovations, and Improvements


Where are we on our Magnet Journey? recognition is a cultural transformation focused programs/magnet/magnet-model/ on professional development of nurses and excellent outcomes. As an organization, we are pursuing programs/magnet/history/ our first re-



transformational LEADERSHIP Nursing Leadership Council Chair: Kent Andries, BSN, RN


Review National Database of Nursing Quality Indicators (NDNQI) nurse satisfaction survey scores


Promote professional growth through succession planning


Review quality data including NDNQI and core measures


Determine and communicate leadership educational needs

Co-Chair: Brenna Stidham, MBA-HCM, BSN, RN, ONC Facilitator: Gary D. Miller, MSEd, BA, BSN, RN-BC The Nursing Leadership Council provides a venue for leadership collaboration that promotes effective operational management of nursing staff. The Council helps ensure appropriate material and human resources to meet patient care requirements are available and supports excellent nurse satisfaction through shared best practices. The charge of the Nursing Leadership Council includes: 


Review turnover data as related to staffing effectiveness

Accomplishments of the Nursing Leadership Council during FY2019 include: 

Review best practices for improving fiscal and human resource accountability and develop and implement Performance Improvement (PI) projects

Standardization of bedside shift report auditing by clinical leaders


Supporting development of annual education requirements


Share and implement related best practices



Facilitate and support shared governance structure

Planning and team building to foster nursing leadership collaboration



Leading the Charge: Charge Nurse Forums Chair: Shelly Welch, MBA, BSN, RN, NEA-BC Facilitator: Donna Jackson, MSN, RN-BC Charge Nurse Forums occur each quarter to foster communication between Nursing Leadership and Charge Nurses. The forums also serve as a way to provide important updates to front line leaders on key topics. February 2019 Highlights: 

Review unit-based data for patient outcomes and unit progress


Review Optix targets


Participate in Fierce Conversation for Frontline Leaders

June 2019 Highlights: 

Review risk event trends within the health system


Discuss new products: external and internal catheter devices


Ornelas and Emergency Care Center (ECC) electronic patient handoff pilot


Review role expectations regarding Leader Rounding and support decreasing charting burden

The interactive group nature of the class is good. I liked being able to address our CNO one on one and hear updates directly from her as well as other nursing leaders.

Communication skills are essential. Successful projects and programs, strategies and initiatives, partnerships and relationships all require collaboration and buy-in that is only accomplished through clear, ongoing conversations. Between January-May 2019, leaders across the organization participated in the Fierce Conversation Training program, facilitated by Talent Management. During the five-session program, participants learn the Fierce Conversation model as a tool to forge meaningful connections and spark whole-hearted execution. These conversations techniques are the foundation for healthy cultures and the cornerstone of great leadership. FY2019 NURSING ANNUAL REPORT


structural EMPOWERMENT Shared Governance Structure

FY19 Council Leadership Ambulatory Care Practice

CHRISTUS Mother Frances Hospital-Tyler is

Chair: Sherry Whiteside, RN

committed to the advancement of nursing shared

Advanced Practice Clinicians

governance. The purpose of the shared

Chair: Eva Blight DNP, PNP-BC,

governance councils is to provide a structure


in which clinical nurses have autonomy in practice and decision-making ability related to both clinical and professional practice decisions, and to ensure a high level of professional performance by all nursing and interdisciplinary team members.

Chair –Elect: Katie Storrs MS,

PA-C Clinical Informatics Advisory Chair: Stephen Hall, BSN, RN Co-Chair: Lauren Clark, BS, RD Nursing Leadership Chair: Kent Andries, BSN, RN

Council Charge and Accountability 

8 

Co-Chair: Brenna Stidham,

Advanced Practice Council: Enhance Advanced Practice Providers’ professional practice,


review standards for Advanced Practice Providers and address practice related issues.

Practice & Professionalism

Ambulatory Care Practice Council: Focus on CHRISTUS Trinity Clinic practice and operations.

Chair: Roxie Cochran, RN Chair-Elect: Ashton Crawford,

RN 

Clinical Informatics Council: Multi-organizational; addresses informatics decisions ensuring consistency and maximization across CHRISTUS ministries using Epic.



Staffing Committee Chair: Eric Vogt, BSN, RN, CCRN,

Nurse Excellence Steering Committee: Decision making; resource allocation; ensure


information is disseminated; barrier removal; address attendance concerns.

Chair-Elect: Monica Harris, MBA,

BSN, RN Practice and Professionalism Council: Focus on Nursing practice and professional


development. Chair: Brenda Seaton, BSN, RN, 

Staffing Committee: Focus on issues affecting staffing and how staffing affects quality,


work place satisfaction, and is a State-mandated committee.

Chair-Elect: Maria Hartnauer,


Outcomes Council: Focus on quality and Nurse-Sensitive Indicators (NSIs).


Unit Tech (UT) Council: Focus on practice and standardization of UT work.


Unit Based Councils : Focus on the work environment, retention and outcomes at the unit

BSN, RN Unit Technician



Chair: Lindsay Courtney Co-Chair: Shirley Hickman


Direct care nurses with Bachelor of Science in Nursing (BSN) degrees are well-prepared to meet the demands placed on today's nurse. BSN nurses are valued for their skills in critical thinking, leadership, case

40% ADN

management, and health promotion, and for their ability to practice across a variety of inpatient and outpatient settings. Professional nursing certifications contribute to optimal patient safety and outcomes, while helping advance professional and

58% BSN

personal growth by nurses. CHRISTUS Trinity Mother Frances supports nurses furthering their education through a tuition reimbursement program, and establishing partnerships with academic organizations who offer discounts and other incentives for enrolled students. A one-time bonus is available for nurses seeking a professional certification, and live and computer-based review courses are available to help prep nurses to sit for the certification exam.


Nurse Leaders with Advanced Degrees

26% 37%

Certified Clinical Nurses

Certified Nurse Leaders Reference: Demographic Data Collection Tool (DDCT), June 2019



d a i s y awa r d f o r nursing The DAISY Award is a nationwide program that rewards and celebrates the extraordinary clinical skill and compassionate care delivered by nurses every day. CHRISTUS Trinity Mother Frances is proud to be a DAISY Award Hospital Partner, recognizing one of our nurses with this special honor every month. DAISY Award honorees personify the mission of CHRISTUS Trinity Mother Frances to enhance community health through service with compassion, excellence and efficiency. These nurses consistently demonstrate excellence through their clinical expertise and extraordinary compassionate care, and they are recognized as outstanding role models in our nursing community. 10 FY2019 DAISY Award Recipients: July 2018: Ben Christopher, BSN, RN, ECC, CHRISTUS Mother Frances Hospital-Tyler

January 2019: Amanda Couch, LVN CHRISTUS Trinity Clinic OB-GYN

August 2018: Miranda Royman, RN, 5 Ornelas, CHRISTUS Mother Frances Hospital-Tyler

February 2019: Taylor Yancey, RN, 3 Dawson, CHRISTUS Mother Frances Hospital-Tyler

September 2018: Bridget Harrigan, BSN, RN 5 Ornelas, CHRISTUS Mother Frances Hospital-

March 2019: Hailey Granzin, BSN, RN, LPOHH 3 CVICU, CHRISTUS Mother Frances Hospital-Tyler

Tyler October 2018: Megan Heath, BSN, RN, CMSRN, 4 Dawson, CHRISTUS Mother Frances Hospital-

Tyler November 2018: Emily Tekell, BSN, RN, The Birth Center, CHRISTUS Mother Frances Hospital-Tyler December 2018: Sierra Arnold, RN, LPOHH 3 CVICU, CHRISTUS Mother Frances Louis and Peaches Owen Heart Hospital-Tyler


April 2019: Decarlton Wooten, RN, 4 Dawson, CHRISTUS Mother Frances Hospital-Tyler May 2019: Lorie Bonin, BSN, RN, 6 Ornelas, CHRISTUS Mother Frances Hospital-Tyler June 2019: Rhoda Bullington, RN, 4 Ornelas NeuroMedical, CHRISTUS Mother Frances Hospital-Tyler

Ben Christopher, BSN, RN

Miranda Royman, RN

Bridget Harrigan, BSN, RN

Megan Heath, BSN, RN, CMSRN

Emily Tekell, BSN, RN

Sierra Arnold, RN 11

Amanda Couch, LVN

Taylor Yancey, RN

Hailey Granzin, BSN, RN

Decarlton Wooten, RN

Lorie Bonin, BSN, RN

Rhoda Bullington, RN


‘BEE’ING The Being Extraordinary Every day (BEE) Award was launched in 2019 as a way to honor Unit Technicians (UT)/ Patient Care Technicians (PCT) who support the role of the nurse to deliver extraordinary patient care. Just as the daisy cannot bloom without the support of the bee, nurses need the outstanding teamwork provided by UTs/ PCTs in order to flourish. 12

1st Quarter BEE Awardee: Lauren Rachelle, Unit Technician LPOHH 3 CVICU, CHRISTUS Mother Frances Hospital-Tyler

The BEE Award nominee portrays a positive presence at CHRISTUS Trinity Mother Frances Health System. They are respectful, anticipate needs, share information, promote teamwork, and foster an environment of safety. Moreover, the UT/PCT exemplifies the mission of extending the healing ministry of Jesus Christ.

2nd Quarter BEE Awardee: Lois McGowan, Unit Technician 4 Ornelas, CHRISTUS Mother Frances Hospital-


2019 Unit Technician Appreciation Week


LININGS In July 2018, the Medical-Surgical Intensive Care Unit at CHRISTUS Mother Frances Hospital - Tyler received the American Association of Critical-Care Nurses (AACN), Beacon Award for Excellence, silver level. The Beacon Award for Excellence – a significant milestone on the path to exceptional patient care and healthy work environments; recognizes unit caregivers who successfully improve patient outcomes and align practices with AACN’s six Healthy Work Environment Standards. Units that achieve this three-year, three-level award with a gold, silver or bronze designation meet national criteria consistent with the Magnet® Recognition program, the Malcolm Baldrige National Quality Award, and the National Quality Healthcare Award. “The Medical-Surgical Intensive Care Unit at CHRISTUS Mother Frances Hospital - Tyler has achieved this honor by focusing on providing safe, effective, compassionate care to our patients and their families,” said Shelly Welch, MBA, BSN, RN, NEA-BC, Chief Nursing Officer of CHRISTUS Mother Frances Hospital - Tyler. “Our efforts are focused toward the vision of CHRISTUS Health to be a leader, a partner

and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God's healing presence and love.” In June 2019, the Cardiac Intensive Care Unit at the CHRISTUS Trinity Mother Frances Louis and Peaches Owen Heart Hospital -Tyler obtained its first AACN Beacon Award, silver level. “This award is an indication of a prolonged period of exceptional quality at CHRISTUS Trinity Mother Frances Health System,” said Jason Proctor, President, CHRISTUS Mother Frances Hospital - Tyler and the CHRISTUS Trinity Mother Frances Louis and Peaches Owen Heart Hospital - Tyler. The silver level Beacon Award for Excellence earned by the MedicalSurgical Intensive Care Unit and Cardiac Intensive Care Unit fosters learning and effective systems to achieve optimal patient care following evidence-based Beacon Award for Excellence criteria: Leadership

Structures and Systems; Appropriate Staffing and Staff Engagement; Effective Communication, Knowledge Management, Learning and Development; Evidence-based Practice and Processes; and Outcome Measurement. FY2019 NURSING ANNUAL REPORT


two-thousand nineteen

nursing hall of


Nurse of the Year (Clinic) Casie Cobern, LVN

As part of the 2019 National Nurses Week, CHRISTUS Mother Frances Hospital –Tyler held nominations for the inaugural Nursing Hall of Fame to recognize nurses within 14

the organization who demonstrate nursing excellence as part of their daily practice. Nominations were submitted by peers, reviewed by a selection committee, and peers voted

Structural Empowerment Role Model of the Year Julie Blakely, BSN, RN, CNOR

for the following categories: Nurse of the Year, Advanced Practice Nurse of the Year, Rookie of the Year, Transformational Leader of the Year and Structural Empowerment Role Model of the Year. Recipients were announced during a special ceremony held on May 9, 2019. Structural Empowerment Role Model of the Year Melanie Miller, BSN, RNC-MNN FY2019 NURSING ANNUAL REPORT

Rookie of the Year (Clinic) Mallorie Farmer, LVN

Rookie of the Year (Hospital)

Nurse of the Year (Hospital)

Kaley Cooper, BSN, RN

Ashley Turman, BSN, RN


Structural Empowerment Role Model of the Year James Garland, MSN, RN, CNOR

Structural Empowerment Role Model of the Year Maria Stewart, BSN, RN, CMSRN, CCRN

Structural Empowerment Role Model of the Year Maria Hartnauer, BSN, RN

Structural Empowerment Role Model of the Year

Structural Empowerment Role Model of the Year Cheryl Henderson, MSN, RN, APRN, FNP-BC

Transformational Leader of the Year Tarah Thornton, RN, ONC, CCRN Celeste Fisher, BSN, RN, CPPS

Advanced Practice Nurse of the Year Brandi Holcomb, MSN, APRN, AGACNP- BC, CCRN


HEART The CHRISTUS Trinity Mother Frances Louis and Peaches Owen Heart Hospital - Tyler is recognized as the first recipient of the HeartCARE Center: National Distinction of Excellence by the American College of Cardiology (ACC) based on a demonstrated commitment to comprehensive, high-quality culture and cardiovascular care through accreditations and ongoing registry reporting. 16

earn the HeartCARE Center designation, including participation in at least two ACC Accreditation Services programs, NCDR registries and targeted quality improvement campaigns designed to help hospitals and institutions close gaps in guideline-based care. Previous designations and certifications include the Chest Pain Center with Primary PCI and Resuscitation Accreditation by ACC Accreditation Services.

“ACC Accreditation Services is proud to award CHRISTUS “To be named the first Mother Frances ever HeartCARE Center Hospital - Tyler the by the ACC is a nation’s first ever tremendous honor and HeartCARE Center: achievement for health National Distinction of care in this region. This is Excellence an outstanding designation,” said recognition for the Phillip Levy, MD, FACC, tremendous effort and chair of the ACC passion that our Accreditation Management Board. “CHRISTUS Mother physicians, advanced practice providers, the amazing Frances Hospital is a shining example of what the ACC nursing teams and all of our support services on the is looking for in all HeartCARE Centers—a desire to be heart care team put into ensuring our patients receive the best!” the highest levels of faith-based care when they visit our facilities,” Chris Glenney, FACHE, CEO of In order to obtain this prestigious recognition, CHRISTUS Trinity Mother Frances Louis and Peaches CHRISTUS Trinity Mother Frances Health System, said. Owen Heart Hospital - Tyler met a set of criteria to


Earning certification from The Joint Commission (TJC), the American Heart Association/American Stroke Association, the American College of Cardiology, Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, American Association of Cardiovascular and Pulmonary Rehabilitation and the Commission on Cancer signifies many things, with none larger than a devotion to patient safety. The certification standards set the framework for a program that provides access to the broad scope of care services required to diagnose, treat, rehabilitate, support and educate. CHRISTUS Mother Frances Hospital - Tyler certified and accredited programs include the following:


Advanced Hip and Knee Replacement

Comprehensive Stroke


1st in the state of Texas and fifth in the Nation


Only Comprehensive Stroke Center in East Texas


Treat approximately 1,000 joint replacement patients annually


Treat approximately 1,350 stroke patients annually

Bariatric Surgery 

Designed to help patient not only lose weight but to gain health


Treat approximately 500 patients annually


Highest level of cardiac certification by TJC and the American Heart Association

Hip Fracture 

Includes all patients with a hip fracture over the age of 50


Treat approximately 700 hip fracture patients annually

Spine Surgery 

Cervical, thoracic, and lumbar surgeries ranging from simple discectomies to complex multiple level fusions


Treat approximately 1,000 spine cases annually

Cancer 

Accredited by the Commission on Cancer


Measures the quality of care and outcomes for cancer patients


Treat approximately 2,200 patients annually FY2019 NURSING ANNUAL REPORT

care On May 8, 2019, CHRISTUS Mother Frances Hospital-Tyler celebrated the ribbon cutting and the Grand Opening of the Lucy and John Carr Neonatal Intensive Care Unit (NICU). The 18

renovations to the NICU include the addition of 16 new patient beds, family-friendly amenities, cameras where families can see their child from home when they have to leave the NICU, new Epic bedside electronic communication



work areas for Associates, ip-down bed for the family to stay the night, and other cosmetic upgrades.



Associates from LPOHH 4 worked together to support the mobility needs of one of their patients who had severe obesity. After 139 days of intense care the patient was ready to be discharged, but there was a problem with his ability to access his home. The Associates took it upon themselves to build him a wheelchair accessible ramp on their days off to support the patient returning home.



exemplary professional PRACTICE Transition to Practice CHRISTUS Trinity Mother Frances Health System moves to HealthStream® Nurse Residency Pathway program Newly Licensed Nurses (NLN) are the largest source for nursing recruitment. Trends in Tyler are mirroring national recruitment statistics. Challenges facing NLN in their post-graduation environment are psychological, emotional and adapting to the routine of employment to the work environment.


More specifically, the challenges can be seen in these areas: professional socialization, struggling in role as novice to advanced beginner while measuring self against competent preceptors and peers, knowledge deficits about policies, procedures/skills and nursing theory, and use of delegation skills. Many evidence-based practice (EBP) studies have demonstrated the effectiveness of NLN and Intensive Care, and Pediatrics are also available. specialty residency program. Each of these specialty residencies provide clinical In October 2018, CHRISTUS Trinity Mother Frances and professional skills to the nurse to help enhance launched the HealthStream® Nurse Residency their practice during the first year post-graduation. Pathway as part of an enterprise-wide standardized Overall, residencies assist healthcare organizations program. The Residency Pathway is a year-long align with the Texas Board of Nursing requirement model, with an emphasis on clinical intensive weekly of providing education to adequately care for for seven weeks and then moving to a monthly patients. Furthermore, residencies are a great professional topic format. Knowledge assessments recruiting tool for new Associates as we strive to and confidence surveys are part of the pathway to attract the best nurses to care for patients. provide baseline and trending data for clinical References: progression. The first cohort will complete in October 2019 and a fourth cohort will begin the Texas Board of Nurses. (2019). Nursing Practice Act; same month. Texas Administrative Code 217.11. ® In addition to the HealthStream Nurse Residency Parsh, B. (2013) Benefits of residency programs for Pathway model, service line specific programs for new graduates. Nursing 2013. 43:12, p. 64. Cardiac, Maternal Child, Perioperative, Neonatal


Vizient Cohort S

HealthStream Cohort 1

(December 2017 Graduates)

(August 2018 Graduates)


Transition Residency (May 2018 Graduates)



HealthStream Cohort 2 (December 2018 Graduates)


HealthStream ® Nurse Residency Pathway Cohort 1 Graduates 21


empirical OUTCOMES Nurse-Sensitive Indicators (NSIs) are measures and indicators that reflect the structure, processes and outcomes of nursing care .These measures reflect the impact of nursing care. NSIs are measures of the outcomes related to the structures and processes that drive nursing care. (American Nurses Association [ANA], 2004).

Nurse-Sensitive Indicators (NSIs) These measures include restraint use, patient falls with or without injury, hospital-acquired pressure injuries (HAPI), hospital-acquired infections (HAIs), such as central line-associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), and measures of the nursing work environment, including nurse turnover rates, skill mix and paid hours per patient day, which measure the intensity of nursing care, as identified by the ANA. Magnet-recognized organizations are in a key position to advance nursing science, learning and discovery. Reference:



CHRISTUS Mother Frances Hospital-Tyler Nursing Excellence Scorecard


Reference: National Database of Nursing Quality Indicators (NDNQI)


new knowledge & INNOVATION Disseminating Evidence-Based Practice (EBP)

Leveraging Academic Partnerships Tami Hurley MSN, APRN, ACNS-BC (CTMFHS) & Beth Neidlinger, MSN, RN, CENP (CGSHS)

Know Your Role: Task Cards & Simulation Based Training for Malignant Hyperthermia

STEMI: The Inside of the Outhouse

Julie Blakeley, BSN, RN, CNOR

2019 ACC Quality Summit, New Orleans, La.

Jamie Moore, RN, AACC, CCCC

2018 Magnet Conference, Denver, Co.

2019 AORN Conference, Nashville, Tenn.

Using Different Types of Media Tools to Communicate with Nurses

Quality Improvement of Antibiotic Standardization in Inborn Infants

Promoting a Life of Joy and Dignity for Medical Fragile Children

Jason Lee, BSN, RN

Jamie Morrison, BSN, RNC-NIC and Tiffany Taylor, MD

Molly Brown, BSN, RN, Chelsea Hawkins, ADN, RN, Oleta Huitt, ADN, RN, and Celeste Fisher, BSN, RN, CPPS, 2018 PediHOPE Conference, League City, Tex.


2018 ANIA Annual Conference, Orlando, Fl.

2018 Vermont Oxford Network Conference, Chicago, Ill.

Process Improvement for Medication Access Gemba Walk #1: Meds Missing During Med Pass Nursing, Pharmacy and Performance Improvement collaborated to address the high volume of medications not available during med pass. Actions Taken:  4 Teams, 12 Gemba Walks, 4 Projects  Define a standard stock list for the on-site Pyxis location.  Adjust minimum par levels to eliminate stock-outs.  Add twice-daily “cart fill” process to ensure new orders for patient-specific drugs are on-hand when needed.  Educate nurses to look for meds in all possible locations (Pyxis, pneumatic tubes) FY2019 NURSING ANNUAL REPORT

Outcomes: Following a three-month staged rollout across CTMFHS, Med Messages for 30 days were analyzed.  23% fewer requests by nurses for meds already on the floor.  68% fewer requests by nurses for meds missing from Pyxis.  46% fewer Med Messages to Pharmacy.  3.53 nurse FTE efficiency (based on 10 minutes saved per instance).

Nurse Residency EBP Projects As part of the Nurse Residency program, each cohort presents evidence-based practice (EBP) projects to clinical leadership at the conclusion of the residency program. Residents choose subjects that they believe will impact care delivery at CHRISTUS Mother Frances Hospital—Tyler. The residents start with a "spirit of inquiry" to develop their project theme. Ellen Fineout-Overholt PhD, RN, FNAP, FAAN, the Dowdy Distinguished Professor at University of Texas at Tyler, introduces the residents to EBP theories and concepts to prepare them for their project. Projects are developed over the ďŹ nal months of their residency, culminating in the presentation of their EBP posters. Awards are given for best posters and the residents provide a poster presentation on their project. Several examples of award winning posters are showcased here. 25 The following posters are highlights of the top poster presentations chosen by peers and clinical leaders during FY2019: Bereavement Education in Perinatal Areas Beatriz Colunga BSN, RN; Kim Jongsma BSN, RN; Sarah Ragsdale BSN, RN; Alexis Smith RN; Sydnie Shope BSN, RN Preventing Hospital Acquired Anemia with Push-Pull Lab Collection Method Jessie Dejong BSN, RN; Allison Hamman BSN, RN; Daniel Holland BSN, RN; Michael Leatherwood BSN, RN; Amber Robertson BSN, RN; Shelby Sims BSN, RN; Madison Thrasher Smith BSN, RN StatLock Foley Securement Device vs. Current Practice Shaylee Fennell, BSN, RN, Jayme Harris, BSN, RN, Maribel Pliego, BSN, RN, Erin Gilbert, RN


key accomplishments


NUMBERS The Clinical Education Services Department supports training and professional development needs across the health system. From New Nurse and Unit Technician Orientation to monthly resuscitation skills validations, the department supports Associates with achieving clinical excellence.

FY2019 Clinical Education Highlights 

CNE Individual Activities: 101


CNE Nurse Attendees: 1,421


CPR Live Skills Check Offs: 1,285


Childbirth Class Attendees: 1,974


Nurse Residency Pathway : 133


New Nurse Orientation: 420


Skills Fair Attendees: 1,448


Unit Tech Orientation: 133


CHRISTUS Trinity Clinic 

In 2018, the American Medical Group Association (AMGA) presented CHRSITUS Trinity Clinicl (CTC) with the 2018 Acclaim Award, which recognizes safe, effective, patientcentered care.


CHRISTUS Population Health Department and CTC collaborated to provide care to Tyler Independent School District employees and their dependents. To date, Chapel Hill Independent School District has contracted with CTC to provide video visit services.


The Ambulatory Care Practice Council (ACPC) was organized to foster shared governance among CTC Associates.


The Advanced Practice Council (APC) convened to ensure advanced practice clinicians have a venue to collaborate from an inpatient and outpatient care perspective.


Ambulatory nursing Associates actively participated in the 2019 National Nurses Week celebration and supported their peers during the inaugural Nursing Excellence awards.


CHRISTUS Mother Frances Hospital—Jacksonville 

Patient experience scores finished in the 90th percentile rank for FY2019, and recognized as above target by CHRISTUS Health as Industry Leader


Twenty-four Nurse Associates received DAISY nominations


Two RNs completed BSN degree


One Unit Technician in ED completed her BSN and now works in the ED


Two LVNs completed Associate Degree in Nursing (ADN) Grow Our Own Program and are working in Inpatient Unit


Three RNs enrolled in BSN programs; Four RNs enrolled in Nurse Practitioner programs


Three RNs received specialty certifications; one RN received CNOR certification

CHRISTUS Mother Frances Hospital—Sulphur Springs 

Received Primary Stroke certification through The Joint Commission


Two RNs received DAISY Awards


Two RNs completed BSN degree


Two RNs received specialty certifications


Patient experience scores increased from 65.4% to 69.4% for ED and from 64.5% to 75.5% for inpatient post implementation of nursing leadership rounding and hourly rounding


Bedside nursing turnover rate decreased to <6%


Handwashing compliance increased from 78.6% to 89%

CHRISTUS Mother Frances Hospital—Winnsboro 

Patient experience for the Emergency Care Center above target for the entire year


Two RNs completed their BSN degree


Twenty-two Associates received DAISY nominations


Three Unit Technicians received the BEE nominations


Zero CLABSI, zero Hospital acquired pressure ulcers


Nine months without a CAUTI


Hand Hygiene improved to being above system target for the year




Mission: To extend the healing ministry of Jesus Christ


Profile for Jason Lee, MSN-NI, RN

CHRISTUS Trinity Mother Frances Health System Nursing Annual Report 2018-2019  

CHRISTUS Trinity Mother Frances Health System Nursing Annual Report 2018-2019

CHRISTUS Trinity Mother Frances Health System Nursing Annual Report 2018-2019  

CHRISTUS Trinity Mother Frances Health System Nursing Annual Report 2018-2019


Recommendations could not be loaded

Recommendations could not be loaded

Recommendations could not be loaded

Recommendations could not be loaded