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November 1, 2013

Help Create a Cancer-Free World Cancer Prevention Study (CPS-3) In the past few weeks I hope that you’ve been hearing about the enrollment for the Cancer Prevention Study-3 or CPS-3. We are participating along with Castle Family Health Center and Golden Valley Health Centers as host sites for enrollment in this historic cancer study. An estimated 300,000 men and women between the ages of 30 and 65 will participate in this study. Our goal in Merced County is to enroll over 200 participants.

By participating in this study, we honor all of those who have fought the battle, and do our part to create a future free from the fear of cancer.

I am honored that the Mercy Medical Center campus will serve as an enrollment site for this important study. On November 14 and 16, you are invited along with your family, friends, and local community members to begin your participation.

Please consider registering for this important study. Talk to your family, your friends, and your neighbors about CPS-3. If they can’t come to one of the Mercy sites, then encourage them to participate at one of the other company sites.


To register, go to :


Halloween Fun at the Mercy Outpatient Center

Participation in CPS-3 is a commitment that begins on November 14th or 16th with a questionnaire, waist measurement, and blood draw. Every few years, for the next 20-30 years, the American Cancer Society will mail another survey to the home of study participants. These surveys will allow participants to update their lifestyle, environmental, and medical information. According to the American Cancer Society, what we learn in this study will reshape the impact of cancer on all of our lives. There are so many people who have been touched by this terrible disease. Most of us know a friend, a relative, or co-worker who has battled cancer.



Living Spirituality THOUGHT: As we get closer to the holidays, shopping is on many people’s minds. For many, buying things is an opportunity to nurture your true self, to make important choices, to express your "wild side," and to exercise control. To help you make shopping a richer and deeper spiritual experience, try this spiritual practice the next time you hit the stores. Rosa Smith and Lillian Sanchez taking us around the world for some Halloween spirit. If anyone else has pictures of staff that were in the Halloween spirit, send them to lindsey. gallagher@dignityhealth for inclusion in the next issue.

PRACTICE: As you cross the threshold of the store, state your intention to shop well, to stay alert, and to find the best possible gifts for those you love and cherish.

Employee of the Month Brigid Ferrari, MSW Social Worker


National Healthcare Quality Week October 20-26

by Kelly Bitonio and Susie Brooks

Brigid has been a social worker at Mercy for the past 2 years. She exemplifies humankindness each and every day she works. Brigid is a warm and compassionate person who is always willing to go the extra mile for our patients. One such example of her excellence in care was when Brigid coordinated the transport of a very high risk patient from our hospital to a hospital in Seattle, Washington. The patient had to be flown by commercial airline and she needed portable suction and high flow O2. Brigid worked with great compassion to assist this terminal patient in granting her final wishes to die at home with her family. While it took the efforts of our entire team, it was under Brigid’s leadership on this case that the patient was able to be flown to Seattle to be near her family, who would care for her until she passed away.

Operation Christmas Child

Your Quality team from left: Dr. Rob Streeter, Susan Rutherford, Linda Silva, Kelly Bitonio, Nancy Hollingsworth, Tanya Herje and Dennis McCabe. Not pictured is Edith Reyna.

The Quality Department is a “behind-the-scenes” unit that strives for excellence in ensuring that Mercy Medical Center provides the absolute best care it can to its customers. There are many ways in which the Quality Team interacts and supports the clinical units. You can look forward to new HealthStream educational modules and MeasureVention involvement where staff members interact with the Quality Team to ensure we are meeting our reportable goals, and performance improvement teams. Meet the team on the next page

by Janice Wilkerson, Director of Missoin Integration

I would like to invite you to put a smile on the face of a less fortunate child. “Operation Christmas Child” is a project of Samaritan’s Purse and is a ministry outreach to children all over the world that live in some of the most poverty stricken environments. Shoeboxes are filled with items for a boy or girl in a specific age range. Many of our departments have chosen this as their “Christmas Sharing” project or you can participate on your own. Shoeboxes along with instruction sheets are now available for pick up and due back by November 22. If you are interested give me a call at 5645007 or email me at: For more information about this project, go to and you will find some of the most heart warming stories from children around the world that have received a shoebox. It’s hard to believe a shoebox can change a person’s life, yet it has.


A Toyland Holiday Saturday, December 7, 2013 Yosemite Hall (Commerce Bldg) Merced Fairgrounds 6:30pm - 11:30pm • • • •

Bring a toy to donate to Kops for Kids Catered by España’s Photobooth Employees are free and can purchase one guest ticket for $5.00

November 1, 2013

Quality article continued...

by Kelly Bitonio, MHA, BSN, BC-NEA - Senior Director of Care Management

Please meet the team: Dr. Rob Streeter - Vice President of Medical Affairs, who coordinates Quality initiatives with the medical staff, hospital boards and senior leadership. Kelly Bitonio - Senior Director of Care Management, who ensures data and quality issues are addressed throughout the hospital. Reporting Area of responsibility: • Utilization Review/ Case Management • Mortality • Readmissions • Organ Donation Dennis McCabe, RN – Quality Facilitator: Develops meaningful, actionable and evidenced based metrics for internal and external reporting • Manages data flow between Mercy Medical Center and our partners like Joint Commission, Medicare, and MIDAS • Serves as a technical resource for MIDAS, iVOS, and Crimson tools • Trains staff on quality process and tools • Conducts concurrent quality audits on the 5th and 7th floors Nancy Hollingsworth, RN – Peer Review: • Prepares clinical case reviews and behavioral concerns regarding Physicians for evaluation by their Peers. • Works with Multidisciplinary Peer Review Committee of dedicated Physician representatives from our various specialty Departments who review cases and work together to promote and continue excellence in patient care at Mercy Medical Center • Coordinates Committee outcomes and suggestions to improve patient care and

satisfaction, as well as to recognize exemplary care. Linda Silva, RN – Public Reporting Liaison: • Conducts concurrent quality audits on the 4th Floor for Core measures: CHF, PNA, vaccines, CVA, VTE, SCIP, and AMI • Works with Readmission Team • Staff education • Midas and Joint Commission reporting • Stroke • Leapfrog Hospital Recognition Program survey – Recently received an “A” status. Edith Reyna, RN - Quality Facilitator: • Surgical Care Improvement Project (SCIP) • Venous Thromboembolism (VTE) prevention • Lead MeasureVentionist • Works with Readmission Team and Cancer Center community outreach. • Conducts concurrent audits and retrospective audits on the 6th Floor and OR. Susan Rutherford, RN – Quality Facilitator: • Conducts concurrent and retrospective audits for ED and ICU metrics • ED throughput • Outpatient AMI, stroke, pain management, and sepsis • Facilitates the ED Quality Council Tanya Herje – Quality Technician • Administrative Support for Quality and Risk Management • Administrative Support for Code Blue & Patient Safety Committees • Coordinates reports for the Quality Management Committee • iVOS System Assistant Administrator and Technical Support

You can find most of the facilitators on the floors reviewing charts and speaking to Nurses and Physicians for compliance with Core Measures. Together, this team has over 200 years experience in healthcare. The team’s main objective is to incorporate quality in every aspect of patient care from pre-admission to discharge and to make this the hospital you choose for your medical needs. We are always seeking staff members to get involved in making improvements in the organization. Please do not hesitate to contact any member of your Quality Team if you’d like to volunteer.

Employee Scholarships made available by the Volunteers of Mercy! ATTENTION HOSPITAL PERSONNEL

The Mercy Hospital Volunteers will be awarding scholarships to two employees in the amount of $500 each. You must be a Mercy Hospital employee working in a healthcare field and studying in a healthcare field. You need to earn 12 units, but this may be done in several semesters. Scholarship applications are available from our Volunteer Advisor, Janice Wilkerson, or at the Volunteer Desks in the Main Hospital Lobby or Pavilion Lobby. Application Deadline is Friday, November 29, 2013.

November 1, 2013


November 3-9, 2013 Please join our staff in observing National Medical Staff Services Awareness Week on November 3-9, 2013. In 1992, President George Bush issued a proclamation designating the first week of November as “National Medical Staff Services Awareness Week,” to acknowledge and thank medical services professionals (MSPs) for playing “an important role in our nation’s healthcare system.”

The Safety Attitude Questionnaire Begins on Monday The Safety Attitude Questionnaire (SAQ) will be made available in a variety of formats between Nov. 4 and Dec. 6. Our SAQ lead, Mika Grisham, and your manager/director will have all the information you need to participate. This important survey helps Dignity Health assess the beliefs and attitudes about safety among our 30,000 clinical employees. Those beliefs and attitudes are a proven indicator of the likelihood for errors and injuries. We urge all employees to be candid in providing your assessments of the safety culture in your work area and to be active participants in the follow up for your work group. This survey should take about 10 minutes to complete, and all of your responses will be kept strictly confidential. In January, reports summarizing overall patterns of our responses will be shared with our hospital leadership and other key constituent groups.

In February these results will be shared with you in department meetings. Be sure to ask about your department’s results. By learning the department’s strengths and weaknesses, we can all share in the mission of improving patient outcomes. A word about confidentiality: Pascal Metrics, the company administering the survey, has assured us that it will protect the confidentiality of all responses. The survey will be hosted on a Pascal Metrics server, completely separate from Dignity Health. All responses will be maintained in a password protected data base. Responses will be reported in the aggregate only (no individual responses). Group results will only be reported for groups of more than five.

What role do these professionals play? They are the people behind the scenes who make certain the credentials of all practitioners who are caring for patients are correct and have been verified. MSPs are experts in provider credentialing and privileging, medical staff organization, accreditation and regulatory compliance, and provider relations in the diverse healthcare industry. They credential and monitor ongoing competence of the physicians and other practitioners who provide patient care services in hospitals, managed care organizations, and other healthcare settings. The American Medical AssociationOrganized Medical Staff Section also recognizes the medical services profession in a resolution that formally acknowledges “the importance and value of medical services professionals to the healthcare organization and its physician members, and recognizes their contribution and dedication in preserving quality patient care.” MSPs are a vital part of the community’s healthcare team. They are dedicated to making certain that all patients receive care from practitioners who are properly educated, licensed, and trained in their specialty.

November 1, 2013

JUST FOR NURSES Last Week’s Winners

Tip of the Week: Purpose of Core Measures

No winners

by Linda Silva, RN, Quality Public Reporting Liaison

Core Measures are evidencebased criteria of care for specific conditions such as Stroke (STK), Heart Failure (HF), Pneumonia (PNA), Immunizations (IMM), Acute Myocardial Infarction (AMI), Surgical Care Improvement Project (SCIP), and Venous Thromboembolism (VTE). Our hospital reports our performance on the Core Measures to the Joint Commission (TJC) and The Centers for Medicare and Medicaid Services (CMS). The results submitted to these organizations affect TJC accreditation and CMS reimbursement for care. Not only do they affect the accreditation and reimbursement of our healthcare organization but also these measures reflect evidence-based guidelines for successful patient outcomes. By facilitating our organization’s compliance with Cores Measures, we are providing and promoting quality patient care. Core Measures and Value-based Purchasing The Hospital Value-Based Purchasing (Hospital VBP) program links a portion of Inpatient Prospective Payment System (IPPS) hospitals' payment from CMS to performance on a set of quality measures. The Hospital VBP Total Performance Score (TPS) for FY 2013 has two components: • •

Core Measures includes 12 clinical measures and accounts for 70% of the TPS. Hospital Consumer Assessment of Hospital and Provider Services (HCAHPS) results accounts for 30% of the TPS.

What Does the HCAHPS Survey Ask?

Answer to last Week’s Question:

The HCAHPS survey asks the patient 18 questions to rate care on eight key topics:

The value of our work is enhanced by evidenced-based care. Which metric (outcome or process) most accurately reflects our adherence to evidencebased practices?

1. 2. 3. 4. 5. 6. 7.

Communication with doctors Communication with nurses Responsiveness of hospital staff Pain management Communication about medicines Discharge information Cleanliness of the hospital environment 8. Quietness of the hospital environment As of October 2012, under CMS's Value-Based Purchasing (VBP) plan, Medicare: • •

Withholds 1% of its payments to hospitals which perform poorly on HCAHPS measures. Places withheld funds into a pool to be distributed as bonuses to hospitals which score above average on several measures.

Now this does not seem like a lot but it really can add up to a lot of money. Our organization provides us with protocols and checklists that we utilize for our benefit and for the benefit of our patients. Our role as nurses is to document timely and be an advocate for your patients. Thank you for all that you do. It is really appreciated.

ANSWER: Outcome

Below is a question from last issue’s “Tip of the Week”. The first day and night shift RN to respond to lindsey.gallagher@dignityhealth. org with the correct answer will receive a Mercy Medal from Greg Rouleau, CNO.

Question The question: what does CLIP stand for?

November 1, 2013

Stroke is the No. 1 cause of preventable disability worldwide.

Asia, Russia and Eastern Europe have the highest rates of stroke mortality and disability.‡

Stroke is the No. 4 cause of death in the U.S.†

In China, stroke rates are growing from the aging population and from high rates of smoking and hypertension.‡

1 in 6 people will have a stroke in their lifetime.1

Stroke Deaths (per 100,000)

15 million people experience a stroke each year. 6 million of them do not survive.2

Every six seconds someone dies from a stroke, worldwide.3

1 Minute =

240-480 120-240 60-120 30-60 0-30 No Data Anthony, 2011.

Stroke is largely preventable, treatable and beatable. Learn more at No Low-Risk Lifestyle Behaviors and All-Cause Mortality: Findings from the National Health and Nutrition Examination Survey III Mortality Study Ford ES, Zhao G, Tsai J, Li C. Am J Public Health. 2011 Oct;101(10):1922-9. Anthony, 2011. 1 Bushnell, C.D. (2008). Stroke and the female brain. Nature Clinical Practice Neurology 4(1), 22-33 2 World Health Organization (2004). Atlas of Heart Disease and Stroke 3 International Cardiovascular Disease Statistics (2007 Update). A publication of the American Heart Association †

©2013, American Heart Association 9/13DS7245

e k o r t S d n E o t r e Togeth

Together to End StrokeTM Stroke is the No. 2 cause of death worldwide and the No. 4 cause of death in the U.S.1-3 Yet studies show that Americans do not rank stroke as a leading health concern.4 With the generous help of Covidien, the American Heart Association and American Stroke Association have launched Together to End Stroke™ to help spread the word that stroke is preventable, treatable and beatable.

Here are some fun and easy ways to spread F.A.S.T.: Download and share the F.A.S.T. mobile app • Tell five friends and family members to download the F.A.S.T. mobile app at

On World Stroke Day, October 29, the American Stroke Association needs your help. You can help us increase awareness by reaching out to your colleagues, families and friends and educating them about stroke. This resource page provides some ideas to help you get started. With your help, together we can end stroke!

• Challenge a high school class, sports team, or community organization to see how many people they can get to download the F.A.S.T. mobile app.

Honor a stroke hero • Is your stroke hero a doctor, EMT, caregiver, survivor or even yourself? • If you or your loved one has had a personal experience with stroke, share your post-stroke tips for daily living on #WhatWorksWednesdays by submitting your 2-3 minute video to Alexson Calahan at

Start by Spreading F.A.S.T. Help people learn the F.A.S.T. stroke warning signs

When someone is having a stroke, they need immediate treatment to save their life and improve their chances of recovery. But the very first step is recognizing that someone is having a stroke. The simple acronym, F.A.S.T. helps you remember the most common signs and symptoms of a stroke.

• Post the F.A.S.T. flyer or infographic throughout your community, office, school or favorite coffeehouse, or share it with family and friends. • Email five family members or friends the “Spot a Stroke F.A.S.T.” PSAs or “What is F.A.S.T.” email. • Use the F.A.S.T. Community Presentation to share stroke with your class, colleagues, community group or organization. • Download the F.A.S.T. Coloring Sheet and make it a family activity to color with your children, nieces or nephews, or consider distributing the coloring sheets to a neighboring daycare center.

Go to to access resources for F.A.S.T. and World Stroke Day

Download the F.A.S.T. Mobile App here!

1. World Health Organization. (n.d.). Retrieved from 2. Centers for Disease Control and Prevention (CDC). Prevalence and most common causes of disability among adults–United States, 2005. MMWR Morb Mortal Wkly Rep. 2009; 58:421– 426. 3. Chiuve, Stephanie E. et al. Primary Prevention of Stroke by Healthy Lifestyle. Circulation. 2008; 118:947-954. 4. Gorelick, P.B. Primary prevention of stroke. Impact of healthy lifestyle. Circulation. 2008; 118:904–6 ©2013, American Heart Association. Also known as the Heart Fund. 4/13DS6691


Mercy Inroads Nov. 1, 2013  
Mercy Inroads Nov. 1, 2013  

First Issue for November 2013