Our Pathway to Excellence

OUR

pathway

TO

excellence Januar y • Februar y 2015

Compiled by | Jacqulyn Robison, BSN, RN, GRN Contact | Jacqulyn Robison BSN, RN, GRN P 308.630.1450 E Jacqulyn.Robison@rwmc.net 4021 Avenue B Scottsbluff NE 69361

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Table of Contents A Note e Frrom the Editor

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onal Development.

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Breakffast with Shirley

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Skin Note

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ual Nourishment .

Intellectu

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ucing Mr. Robot Introdu

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d Governance Updates .

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Nurse Re esidency & Clinical Coach Programs .

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Patient Satisfaction Scores The background for patient satisfaction scoring in health care is to make sure that we are providing reputable care that is of the best quality. The push for this is to ensure our patients that we care about their stay and the care that they receive. Otherwise, why would we be here in the first place? Most people who go through nursing school have the notion that they want to make a difference in the lives of their patients and ensure that they are well taken care of.

Jacqulyn Robison Jacqulyn Robison, BSN, RN, GRN Survey Preparedness/Magnet Coordinator

As an organization and as a team, we are providing the quality of care that could be termed as excellent. We now have to remember to remind our patients about this. Sometimes it can be difficult to find that common line of medicine and customer service at the same time. It seems like an odd concept, but if you think about it, don’t you want to receive medical care that you are happy about? It comes down to treating others the way you want to be treated. If we are able to convey this to our patients with a genuinely positive attitude, it helps build rapport and increases the bond between nurse and patient. The same could be said for any other health care worker in the hospital.

When looking at what we can do to treat our patients the way we would want to be treated, there are seven ways that we can improve the rapport and communication that happens between the health care worker and the patient: 1. Provide your patients with information they can understand.

2. Respect your patients’ opinions and be genuine with the communication you use.

3. Allow your patients to have adequate time with you.

4. Incorporate patients in the decision-making process of their care.

5. Start with a good introduction using AIDET when making your rounds.

6. Show empathy.

7. Get to know patients as people and realize that they have their own perspective and experience.

Investing in practicing these qualities is something that each of us already do, but now we must acknowledge them as part of our daily work habits so we can influence our patients in a positive way. We want them to know we care about their stay and the quality of care that they receive. We also want them to know that if they have any issues, we want to address them and make things right before they are discharged. That is a part of upholding our organization’s Standards of Behavior with integrity and compassion.

Remember that word of mouth advertising is the most powerful form of marketing and it is free. We want our patient population to continue noticing that we are improving and striving for excellent, quality care. This will make our organization and the community an ongoing credible place that serves to meet the needs of our patients.

We ask – always – What is in the best interest of the patient?

– Regional West’s Value Statement Respectfully,

Jacqulyn Robison

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Susan Backer SUSAN BACKER, MSN, APRN-CNS, ACNS-BC Patient Safety Officer/Clinical Nurse Specialist

2015 is all about working together as a TEAM— MyCRU— cooperative, respectful, unified. Our CRU toolkit has five tones to reduce power distance and manage authority gradient to make it easier for people to speak up when something doesn’t seem right; and five tools designed to prevent human error. These tools are: 1. Maintain situational awareness 2. Lead the team 3. Communicate clearly 4. Think critically 5. Speak up for safety The tools are simple, and all have been used by everyone at some time or another. In a way, safety and reliability are taking the best practices done by some of us once in a while and making them habits done by all of us every time.

The first tool in this toolkit is maintaining Situational Awareness. Situational awareness is the ability to identify, process, and understand the critical elements of information about what is happening to the team with regards to the mission or goal. Simply—it’s knowing what is going on around you. Situational awareness is required for efficient and effective team performance throughout the shift or during a critical event, such as cardiopulmonary arrest, OB emergency, or child abduction.

We work in teams in all these situations, so to be effective as a team we need to perform as a team. To do this we must all be on the same page; knowing the goal, the individual tasks that must be performed, and team members’ roles and responsibilities. Situational awareness and team performance requires the ability to anticipate and predict the needs of other team members, and adapt to task demands efficiently. We can’t do that unless we’re all on the same page and are aware of what’s going on around us.

There are four specific Situational Awareness tools in the MyCRU toolkit: • Anticipatory thinking • Call-Out • Cross Monitoring • STEP – Status of the patient, Team members, Environment, and Progress toward the goal The first three tools are not new to us, so I’m going to focus on the fourth tool, STEP. This tool is one of the tools from TeamSTEPPs, developed by the Agency for Healthcare Research and Quality (AHRQ) for patient safety and working effectively as a team. The STEP process is a mnemonic tool that can help monitor the situation and the overall environment. The STEP process involves ongoing monitoring of the: - continued to page 6

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Status of the patient

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nvironment The environment directly affects the quality of care delivered. Is the In a health care setting, the most obvious element of the situation needed equipment present? Is there enough staff to tend to all the requiring constant monitoring is your patient’s status. Even minor patients? The environment can change quickly and dramatically, and changes in the patient’s vital signs may require dramatic changes in teams must be able to adapt to the dynamic nature of the situation. the team’s actions and the urgency of its response. When assessing patient status, consider the following: When assessing the environment, consider the • Patient’s history following: • Vital signs •Facility information • Medications •Administrative information • Physical exam •Human Resources • Plan of care “Individual •Triage acuity • Psychosocial condition (e.g., patient’s commitment •Equipment status stress level)

Team Members You should also be aware of team members’ status, to include the following: • Fatigue level • Workload • Task performance • Skill level • Stress level

to a group effort—

that is what makes

Progress Toward Goal

By monitoring progress toward the team’s established and agreed-upon goals, team members a company work, will be able to alert the team when strategies or the plan of care may need to be reconsidered or revised a society work, or when additional resources are needed. When a civilization work.” assessing progress, team members need to consider – Vince Lombardi the following: •Status of the team’s patients Health care providers are just as prone to •Goal of the team human error as the general population. Teams that recognize and •Tasks/actions completed or that need to maintain an awareness of their individual team members’ functioning be done are more likely to lend support or assistance. Observing the actions • Continued appropriateness of the plan of fellow team members is a safety mechanism that can be used to lessen error before the patient is harmed.

Goals were established and agreed on at the team meeting. What has changed and how does our goal have to be modified?

a team work,

STEP tool taken from TeamSTEPPS 06.1/Situation Monitoring http://www.usuhs.mil/cerps/TeamSTEPPS.html; Healthcare Performance Improvement. (2012). Collegial Interactive Teams: Skills for Health Care. CIT Handbook.

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Skin Care Notes

Rachelle Noe Rachelle Noe, RN Wound Care Nurse

Celebration note!!!! Our wound clinic patient visit numbers have consistently grown over the past four years. We see a variety of patients from two days old to 102 years old.

• In 2011, we had 3,147 patient visits • In 2012, we had 3,383 patient visits • In 2013, we had 3,429 patient visits • In 2014, we had 3,955 patient visits Total Contact Casting (TCC) The most recent treatment that we utilize in our wound clinic is Total Contact Casting (TCC), a gold standard procedure used to heal difficult wounds to the plantar aspect of the foot, such as diabetic foot ulcers. We use Cutimed DeltaCast from BNS Medical. This is a synthetic rigid lightweight, strong casting material that is applied to offload the site of the wound and promote healing at faster rate. By applying this fitted, non-removable cast around the affected leg, the whole cast is in contact with the foot and part of the leg, hence the name. Dr. Willats and Dr. Walsh have utilized this treatment successfully for the past eight months.

Who needs a TCC? People who have diabetes often have trouble with their feet. Part of the problem is that the loss of feeling in their feet makes it hard to tell if they have a blister or sore. If the little sores aren’t taken care of, they can get worse and turn into non-healing ulcers.

The only way to heal these ulcers is to offload at the site of the ulcer at all times. These patients will then need special inserts or shoes to prevent the wound from returning. If the patient goes back to wearing the same shoes, then the wound will return.

The primary reason for treating diabetic foot ulcers with total contact casting is because it offloads completely and limits the use of the foot with the ulcer. Diabetic patients who already have diabetic neuropathy are at the greatest risk for ulcers since the loss of protective sensation in their limbs prevents early detection of any injuries to their feet. The peripheral neuropathy may also cause foot deformities by paralyzing the muscles of the foot, causing clawing of the toes and producing bony prominences that are subject to pressure from shoes. Fractures can develop without the patient’s awareness, resulting in a condition known as Charcot foot.

The Total Contact Casting procedure Total contact casting is done by molding a cast over the entire surface of the foot and part of the leg. A dressing of soft foam is placed on the ulcer, and the whole foot is wrapped in a

protective dressing prior to the application of the cast. The cast, which follows the contours of the foot, is designed to distribute the weight evenly over the entire weight-bearing surface of the foot. This results in offloading of pressure from the ulcer and the bony prominences of the foot.

Healing of ulcers using total contact casts takes approximately six to eight weeks, during which the cast is replaced on a weekly basis. The cast is removed when complete healing is achieved, after which it is recommended that the diabetic patient wear specially designed shoes.

Advantages Even when the best care is given, healing may be delayed if the ulcer is subjected to constant pressure while walking. Total contact casting provides optimal wound healing conditions and also prevents the development of new ulcers.

Precautions Patients who are selected for TCC must be properly informed and give consent, as this treatment will impose limitations on freedom of movement. Walking may be done with the aid of a cane or crutch and a cast shoe is applied in order to avoid exerting any pressure on the affected foot and to prevent any fall-related injuries. The cast should remain dry, so the patient is advised to take sponge baths instead of showers or demonstrate that they can appropriately protect the cast while showering.

We have seen great success with Total Contact Casting!!

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Introducing Mr. Robot

THE NEWEST MEMBER OF OUR STROKE CARE TEAM Linda Fowler, MSN, RN Clinical Coordinator, ICU/CCU Alice Fillingham, MSN, APRN-NP Clinical Coordinator, ER We have a new stroke care team member at Regional West Medical Center – a robot. The robot is a telemedicine service provided by Swedish Hospital in Englewood Colo. The Stroke Alert team, including pre-hospital care, emergency physicians and nurses, radiology/CT, pharmacy, lab, and transfer care, join with the robot to save brain cells. The addition brings a stroke certified neurologist to the bedside of a Regional West Medical Center patient having a stroke within minutes. Tele-stroke systems are recommended by the American Stroke Association to provide improved stroke care for patients.

So let’s meet the robot. He/she lives in the Emergency Department (ED). We have yet to name the robot, so for now we will call it “the robot.”

A patient arrives at the Emergency Department either by ambulance or walk-in and presents to triage. The nurse or EMS triages the patient as meeting the criteria for stroke team activation.

The ER physician evaluates the patient and he or she is rapidly escorted to radiology to receive a CT

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scan to rule out a brain hemorrhage. Meanwhile, a call is placed to the tele-stroke network and the robot brought to the patient. Introductions are made. The ED provider and the neurologist team up to provide outstanding patient care. The stroke neurologist is able to control the robot from a laptop computer. A bedside exam and interview is conducted. The neurologist controls the robot remotely – zoom in, zoom out, turn to speak with providers or family members in the room, and request information and assistance. The robot has a stethoscope and private phone attached, and can even zoom close enough to evaluate subtle eye movements. The Regional West physician and the neurologist then determine the plan of care.

There is an opportunity to improve initial stroke care for the hospitalized patient. Stroke (FAST) criteria is being added to Rapid Response criteria.

A rapid response is called for a patient exhibiting stroke-like symptoms. The primary physician will also be called and a stroke activation page will be sent out. This alerts our CT department to clear the CT table for a patient presenting with strokelike symptoms. The robot will join the patient in CT or in the ICU depending on the time to CT. The goal of therapy is to determine if the patient is having a stroke, and if he or she meets criteria for a clot buster (thrombolytic) and rapid administration of

the medication within 60 minutes, or preferably less. Thirty thousand brain cells die each second during a stroke; this makes early intervention imperative. Time is brain!

To prepare for the addition of tele-neurology at Regional West, multi-disciplinary teams worked to review current stoke order sets, adapt documentation tools to Regional West Medical Center, develop flowcharts, and revise and update stroke alert procedures. The stroke team from Swedish Hospital provided an introductory education session for staff and providers. Three in-situ simulations were held to look at and revise processes for initial stroke care. Ten disciplines and over 45 people were involved in the simulations. Some tools were developed to monitor what we do and how to follow the patient throughout the hospital stay. Patients requiring a stay on the Acute Rehab Unit can receive care at a CARF stroke certified center right here at Regional West.

•http://www.strokeassociation.org/STROKEORG/WarningSigns/Stroke-Warning-Signs-and-Symptoms_UCM_308528_SubHomePage.jsp •http://www.ncbi.nlm.nih.gov/pubmed/23212458 •http://www.activase.com/telestroke/what-is-telestroke •http://www.thecni.org/ •http://www.activase.com/telestroke/telestroke-networks-map Switzer, J. A., Demaerschalk, B. M., Xie, J. Fan, L., & Wu, E.Q. (2013). Cost-effectiveness of hub and spoke telestroke networks for management of acute ischemic stroke from the hospitals’ perspectives. Circulation – Cardiovascular Quality Outcomes, 6(1):18 – 25.

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Kim Meininger Kim Meininger, BSN, RN Nurse Education Coordinator

Nurse Residency and Clinical Coach Programs Regional West Medical Center now has 34 newly graduated nurses participating in the Nurse Residency Program. The topics reviewed since the program began in October include: transition shock, effective communication skills with delegation and supervision, conflict management, and emotional intelligence. Part of the transition of a new graduate nurse from student to professional role involves learning effective communication skills. Communication in nursepatient relationships is an important part of daily nursing practice, as well as communication among other team members. Ineffective communication or poor communication typically leads to areas of conflict, so it is important for the new graduate nurses to develop conflict resolution skills to improve teamwork and productivity and increase patient and nurse satisfaction.

We have been applying stress management and conflict resolution skills in patient scenarios of caring for difficult and angry patients, disruptive nurse and/or physician behavior, plus dealing with ‘toxic personalities’ in the workplace by first

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identifying their own type of conflict style which includes: 1. Withdrawal or avoiding 2. Forcing or competitive 3. Smoothing or accommodating 4. Compromising 5. Confronting By understanding your own view point of how you typically respond or approach conflict allows you to better achieve the overall goal of conflict, which is collaborating and preventing the conflict from re-occurring. Conflict resolution is about finding the third perspective between “your” opinion and “their” opinion. This middle ground is where all perspectives are respected, honored, and considered. The goal of conflict is for all parties to create a ‘common’ goal in problem-solving, which in turn can lead to better relationships.

Learning the delegation process has been the most challenging topic in our class and simulation labs. It will take time for each new nurse to be effective with delegation. The new graduate nurses identified several barriers with learning and applying the delegation process, in that it is difficult to delegate to someone older than you, it is difficult to delegate to an unlicensed staff member when not knowing their

level of competency, and learning each role’s scope of practice. We have reviewed Nebraska’s state board of nursing delegation standards and have practiced these four steps in delegating: 1. Assessment and planning 2. Effective communication 3. Surveillance and supervision 4. Evaluation and feedback The delegation process must be a ‘closed loop’ process. When delegating a task, the RN must continue to survey and indirectly supervise the delegated event and then evaluate the patient’s outcome and provide feedback to the individual to whom the task was delegated. ‘Delegation is the transfer of responsibility for the performance of a task from one individual to another while maintaining accountability for the patient’s outcome’ (2012, NCSBN). The graduate nurses have worked hard on applying different tasks in which they can delegate and to whom they can delegate.

The final topic discussed in the December class was related to emotional intelligence in the workplace. Emotional intelligence is defined as an individual’s ability to monitor one’s own and others’ emotions or having the ability to identify, use, understand, and manage emotions in a

Catharine Houstoun Catharine Houstoun is now a Certified Lactation Consultant. Congratulation Catharine!

Why did you become a nurse?

I have always known that I wanted to become some kind of care provider. My mother is a nurse, and I spent many summers working at her home health agency in Colorado.

After I graduated from Colorado State University, the accelerated nursing program at Front Range Community College just fell in to place for me, and I never looked back. I have worked on the Pediatric Unit at Regional West for eight years now, and I truly enjoy my patients and coworkers every day.

What are you hobbies?

We have two young boys, so we enjoy doing anything and everything when we are together. We love to visit the Riverside Zoo and take small trips around the area.

positive way. We typically hear about our level of Intelligence Quotient (IQ), but when people have a high amount of emotional intelligence (EQ), it allows them to be more empathetic, relieve stress, and overcome challenges in a better and healthier way. The greater ability we have to apply EQ in the workplace or develop self-management skills, the better we can prevent escalating conflict between co-workers and/or difficult patient behaviors.

Why did you decide to go on for your certification?

The first hours and days after a baby is born are a very vulnerable time in a mother’s life. I think it is very important to have a great interaction with staff in those days, and I want to make a difference. I want breastfeeding mothers to know that someone believes in them, and although the breastfeeding process is not always an easy one, it is such a beneficial thing to do for yourself and your baby.

What is your background?

I have a wonderful husband and have been married for eight years. We have two active little boys; William, five years old, and Carter, who is almost two years old.

Mark Anderson, a local mental health counselor, was our presenter on emotional intelligence.

He has taught many classes about EQ in the workplace and presented tools to the staff on how we can better manage patients who may be exhibiting difficult behaviors such as anger, fear, non-compliancy, or manipulation.

care in Quality Improvement practices. This will include understanding the responsibilities of the RN in health care reform and CMS core measures, as well as understanding legalities within our documentation responsibilities.

During the January 2015 class we will begin reviewing our objectives towards patient centered

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January 27 Attending: Attending: Connie Morrill, Shannon Hultengren, Mike Jackson, Debbie Van Noy, Chris Micheels, John Seiler II, Cody McCellan, Stephan Sanchez, Cory Quevedo, Chloe Liebsock, and Shirley Knodel

During this breakfast there were many concerns with the changes in Regional West’s organization and direction. Shirley was able to answer questions with the staff on the changes that reflect the Pediatrics Unit and staffing models.

There was talk in the community that the Peds floor is closing, however, just like in the game of telephone, things get miscommunicated. The LPNs will be transitioning to working eight-hour shifts to help meet the needs of the inpatient floors and during busy peaks. This will help out when surgical patients are coming and admissions are taking place, and also ensuring that the nursing staff is taking their meal break without feeling rushed.

The Pediatric Unit will be combining with the Float Pool and working effectively in broadening their skills in adult care with pediatric care being their primary focus when the census increases in this area. The float pool nurses will also have the chance to get trained in pediatric care which will be beneficial to all nursing departments in the hospital. There will be some changes in staffing ratios, which Shirley was very clear on. She shared with the staff that hospitals across the nation are looking at ways to be cost-effective in their staffing that will provide safety for patients but also look at acuity for nursing.

That is when we touched on how the Care & Practice Council for Shared Governance will be initiating a staffing committee during the month of February.

There were other questions regarding the process of Peer Evaluations and how this works. When peer evaluations are done, they have two or three nurses evaluate each other, which seemed that the result could be skewed if both or all nurses put positive affirmations on the evaluation. This is a concern with nurses who are doing a great job but see different results when evaluation time rolls around. The new Nursing Business Partner in the HR department will help bridge this gap and make the process a little easier for nursing staff to understand when evaluations on done.

Intellectual Nourishment “If you don’t like something, change it. If you can’t change it, change your attitude.”

– Maya Angelou

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Shared Governance Update

Coordinating Council

Care & Practice Council

Coordinating Council went over updates from each council.

After updates and discussion from council members, Chair Michelle Powell went over parliamentary procedure and how to incorporate it within council meetings. She also did a thorough job in showing the members where to find documents for collecting, taking notes, and for running a meeting during Shared Governance.

The intake and output (I&O) presentation is just about ready for approval from the Education Department.

This will help provide reminders to nursing and nursing support staff on how to document intakes and outputs, as well as daily weights, in patient charts. The goal is to see consistency in the charting for all of the nursing departments. After completion of the I&O presentation, their next goal is to start research on a Nursing Staffing committee and nurse retention.

Quality & Safety Council This council has been working on the health care worker fatigue project. After completing the research on evidencebased practice in health care worker fatigue and shift work, they began the outline that will help the plan of putting together an educational program move forward.

This will be placed on Swank as mandatory education for all staff who perform shift work.

Professional Practice Council They have been working on changing the name of Magnet Nursing Awards and Magnetic Times since the vision is to start pursuing Pathway to Excellence Accreditation under the ANCC. They have been taking name suggestions from the frontline staff nurses and will vote on a name. The color-coded uniform project will be finalized as well and the second communication plan announcing the dress code expectations will be released. This council had the LPNs and CNAs vote for their scrub color choices. This will go into effect August 1. Goals for this council will be to work on the Nurse’s Week celebration in May and then they will eventually work on revising the nursing dress code policy to reflect the color-coded scrubs.

Nurse/Finance Council This council has been working on the recycling project to “Go Green.” They are taking this project to Gering recycling and Regional West will paid for our recyclables instead of paying someone to take current recycling away. The reusable blood pressure cuffs have been circulated and are in use. The biggest concern is to not throw these away and so some education has to be implemented to remind staff that some cuffs are reusable and need to be saved while the disposable cuffs for patients in isolation rooms are to be thrown away. Once the nursing floors are able to start reusing Oxygen saturation sensors, it will be a $300,000 savings.

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