NURSING
Practice
& Progress
Reporting on Excellence in Nursing at UW Hospital and Clinics
Winter 2012-2013 • Volume 11: Issue 3
aNNUaL RePORT
2 013 Magnet Strong
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Table of Contents As the Magnet journey continues at UW Hospital and Clinics, the 2013 Nursing Annual Report provides a snapshot of the remarkable accomplishments and initiatives from July 2012 – June 2013 that support our pursuit of re-designation, as they relate to the Magnet model.
Transformational Leadership
Pages 4-7
Today’s health care environment is changing. Unlike yesterday’s leadership requirement for stabilization and growth, today’s leaders must transform their organization’s values, beliefs, and behaviors. The intent is no longer to just solve problems, fix systems and empower staff, but to actually transform the organizations to meet the future. Reformation calls for new ideas and innovations.
Structural Empowerment
Pages 8-13
Solid structures and processes provide an innovative environment where professional practice flourishes and where the mission, vision and values come to life to achieve the outcomes believed to be important for the organization.
Exemplary Professional Practice
Pages 14-16
The true essence of a Magnet organization stems from exemplary professional practice within nursing. This entails a comprehensive understanding of the role of nursing; the application of that role with patients, families, communities, and the interdisciplinary team; and the application of new knowledge and evidence. The goal of this component is more than the establishment of strong professional practice; it is what that professional practice can achieve.
New Knowledge, Innovation and Improvements
Pages 17
Magnet organizations have an ethical and professional responsibility to contribute to patient care, the organization, and the profession in terms of new knowledge, innovations, and improvements.
Empirical Outcomes
Pages 18-23
The question for the future is not “What you do?” or “How you do it?” but rather, “What differences have you made?” Outcomes need to be categorized in terms of clinical outcomes related to nursing; workforce outcomes; patient and consumer outcomes; and organizational outcomes. Quantitative benchmarks should be established. These outcomes will represent the “report card” of a Magnet-recognized organization, and a simple way of demonstrating excellence.
* Source for all model components: Magnet Recognition Program® Model at nursecredentialing.org/magnetmodel.aspx
Seeing the Beauty in What We Do One morning last week I came into the kitchen to make a pot of coffee and spied a note my daughter had left me that said, “Have a beautiful day.” I was touched by the note and how differently it made me feel from someone simply saying “Have a good day.” I wasn’t going to just have a good day, I was going to have a beautiful day. On my drive to work the crisp aqua blue sky glistened as a back drop for the red, yellow and orange fall leaves. A father was walking on the sidewalk, carrying his son on his shoulders, and both were laughing with joy. Many folks were pedaling energetically on their bikes, taking in the cool fall air. The beauty of the day was all around me. I felt energized and inspired. That afternoon Chris Green, Chief Medical Officer and I were making our weekly patient rounds on the units, during which time my spirits were lifted even higher by the beauty of what I saw and heard. A team of colleagues was at a patient’s bedside collectively discussing the plan of care for her discharge, when one of the doctors gently reached for her hand and asked if the plan sounded good to the patient. I heard firsthand from a patient how extraordinary he felt the care was, from each and every person and how he especially looked forward to the night respiratory therapist and their late night chats. I saw a family member who received a hug and was comforted by a nurse after her mother had been admitted to palliative care. I also observed a nurse practitioner peek her head out of the staff lounge and motion to an environmental worker to come in with the rest of the staff to enjoy the potluck lunch they were having. I was in awe at that moment by the incredible beauty of the expression of human connectedness. While our technologies and clinical acumen are amazing, we can never underestimate the difference we can make in another individual’s life through our gentle words, a hug or a warm smile. As you read this issue of Practice and Progress, I hope you too are enveloped in the beauty of this organization and the efforts of all our team members. There is so much good work occurring in our midst. The annual report is merely a snap shot of the myriad of talent and commitment to our patients and their families. I sincerely thank you for all you do. Have a beautiful day!
Beth Houlahan, MSN, RN, CENP Senior Vice President Nursing and Patient Care Services Chief Nursing Officer
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Transformational Leadership
FY13 Nursing Strategic Goals UW Health Strategic Plan Goals Best Work and Academic Environment UW Health is healthcare’s best work and academic environment.
UWHC Nursing Service Goals
UWHC Nursing Service Selected Initiatives
Develop each clinical practice area to reflect the concepts of a healthy work and practice environment.
• Healthy Work Environment
Deliver exemplary professional practice and transformational leadership that empowers clinicians and is characterized by collaborative governance, participative decision-making and a commitment to professional development.
• Council accountability
• Safe Patient Handling • Leader Rounding • Magnet sustainability • Bedside computers
Support innovative patient care and enhance the effectiveness of professional practice within patient care services by optimizing the power and potential of technology and informatics.
Quality Distinction UW Health truly provides outstanding patient care, is clearly distinguished as a leader in quality and patient safety, and is recognized for its stewardship of health care resources.
Deliver outstanding patient and family centered care across the continuum that is:
• Bariatric Center of Excellence
• superior in quality and safety
• Hand hygiene
• evidence-based
• Intentional Rounding
• culturally congruent
• PSA project
• extraordinary in service delivery
• Teachback
• fiscally responsible
•C LABSI maintenance improvement
Clinical Model of Care UW Health implements a state-of-the-art organization wide model of care that will be recognized for
Nurture a spirit of inquiry and continual innovation that leads to evidence-based practice, knowledge-expanding research and the translation of research into practice, and the constant improvement of patient care.
•R esearch/Evidence Based Practice
Collaborate with the UW-Madison School of Nursing and instill a culture that advances education, professional development and research for clinical disciplines.
•C ertification/professional development (BSN)
• Superior, interdisciplinary team-based care •E xcellent clinical outcomes • Innovation • Academic excellence •H igh demand and/or market strength (both locally and regionally)
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Fully implement the components of the Interdisciplinary Model of Care (interprofessional collaborative practice) across the continuum to improve patient access, interdisciplinary communications, collaboration, patient outcomes and satisfaction.
• Bedside report
• Scholarly forums monthly •C ollaboration with the School of Nursing
• Academic EHR • Simulation Lab • Complex care management • Dyads • Increase access in clinics • IPOC/IMOC • Decrease readmissions • Throughput
Transformational Leadership
Integration UW Health functions as though it is a single clinical enterprise. 3
Transformational Leadership
Leadership Rounding for Patients and Staff By Deb Segertsten A transformational leader is one who can positively influence, inspire and motivate others through example and articulation of vision and challenging goals. Staff often feel trust, admiration, loyalty and respect for a transformational leader because the leader offers more than self-gain—he/she provides staff with an inspiring mission and vision and gives them a sense of identity. The leader is a role model for ethical behavior and instills pride in the work being done and pride in the team. The transformational leader pays attention to each person as an individual, listens to concerns and provides empathy and support. Communication is open, respectful and therefore, trust is developed. Through trusting relationships, the leader can inspire and motivate others to maintain high standards and expectations, maintain accountability and build healthy work cultures. Staff members who have a transformational leader are willing to invest more in their daily work, professional development, and have greater commitment to their patients, their unit and the organization. They have a sense of ownership, pride and engagement.
Daily leadership rounds for staff offer the ability to build relationships of trust, demonstrate visibility, teach, and model respect in communication and interactions. The transformational leader has the skills and ability to create a shared vision of success, inspire alignment, energize the team into action with initiatives, teach from the heart, and hold people accountable for behaviors and performance. When the leader is mindfully present with staff on rounds, the leader listens and can better understand barriers and concerns expressed by the individual or group. Trust is built when the leader follows through on issues brought to their attention during leader rounds. When staff is listened to and shown that they are valued, they feel their work is worthwhile and has purpose. This in turn leads to greater engagement, commitment and self-motivation – it also develops the leadership around you.
Daily leadership rounds for patients offer the ability to hear directly from the patient and family their perception of care they have received. It offers patients the ability to provide feedback and for the leader to learn what is working well and where opportunities for improvement may exist. Leaders can then use the patient feedback for staff recognition, to build on positive behaviors, or for crucial conversations to facilitate change. A stronger sense of pride is felt by the team and the individual because they trust and recognize that the leader understands the work they do and the challenges that they may face on a daily basis related to patient care. Transformational leadership skills are used in all communication and interactions with staff and patients during rounds. Leadership rounding ties the organizational vision to strategies to improve patient outcomes and satisfaction as well as sustaining staff satisfaction and engagement.
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Transformational Leadership
UW Health at The American Center By Sheryl Butts and Deb Dalsing
Summer 2015 It’s not every day that nurses expect to be asked to help build a hospital. But when The American Center (TAC) opens in August 2015, many UW Health nurses will be able to say they had a hand in just that! Staff from D6/5 and B6/4—representing both medical and surgical staff—became involved during the initial stages of this project by helping define the current state of practice and workflows. As direct care nurses, their involvement helped identify duplications, inefficiencies and opportunities for workspace redesign. Their continued involvement has provided details needed to ensure that the design would be truly patient- and familycentered, and also provide the support needed for staff caring for those patients. Because it wasn’t possible to have every staff member attend the planning sessions, feedback and ideas were solicited from both units. More than 100 suggestions were made and provided to the work group to ensure that they were taken into consideration with the design. Following is a list of some of those suggestions that have been incorporated into the design: • Larger door openings to patient rooms and bathrooms •B athrooms large enough to accommodate a wheelchair, patient and staff • Sinks in the patient bathrooms • Easy access staff sinks in patient rooms • Pharmacy room sink
Build it and they will…decide Decisions on the physical layout of the patient room and bathroom were made easier after true-to-scale mockups were constructed of different room designs. The life-size mockups of patient rooms were put together with heavy-duty cardboard in red, white and blue in the unfinished space on the 6th floor of AFCH, which gave staff an opportunity to see the actual size and layout of the rooms and experiment with patient and staff flow. The model rooms were also used when making decisions on lighting, which was left up to direct care nurses given the importance of patient room lighting in providing care to patients. To date, an incredible amount of work has been done by countless people throughout the organization. As the project moves forward, nursing staff will continue to be involved to ensure that the end result is a new facility truly focused on providing the best care possible in a patient- and familycentered environment.
• Computers in each room • L arge family area with sleeping accommodations • D ocumentation counters with computer outside each room • Designated lactation rooms • Utility room on each unit • Nightlights in patient rooms Access to clean linens and supplies inside each patient room was another request from nursing staff. The nurse server was designed with that in mind and direct care nurses made the decision on the actual content.
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Transformational Leadership
The Intersection of Cultural Congruence and the Magnet Model By Tracey Abitz, MSN, RN, CTN-B Global issues in nursing and health care are overarching concepts in the new Magnet model. This is important with the diversification of our nation and calls out the importance in cultural congruence in practice. If we take a closer look at some of the Magnet components and the intent behind them, we can further look at the intersection of cultural congruence and the Magnet model and what we have done at UWHC to live those components. At UWHC, the phrase cultural congruence is preferred over cultural competence because “competence” to many denotes an endpoint or checklist of achieving something that once complete is done. Cultural congruence, however, is an ongoing journey that is ever changing. It is vital that we continue to develop our knowledge and skill set in meeting the individualized needs of our patients and families. Through selfawareness and reflection on our practice we can continue to grow as practitioners and leaders. Transformational leadership speaks to nursing’s mission, vision, values and strategic plan. There is an emphasis on the transformational leader helping to lead people in order to meet the demands of the future. If we think of the changing face of the nation, cultural congruence is an important component for any leader to keep at the forefront. The Pew Research Center has predicted that by 2050 Whites will be a minority. The racial/ethnic composition of the U.S. in 2050 will be Whites 47 percent, Hispanics 29 percent, Blacks 13 percent and Asians 9 percent. (1) One of the goals in UWHC’s Nursing Strategic Plan is to deliver outstanding patient- and family-centered care
across the continuum that is superior in quality and safety, evidence-based, culturally congruent, extraordinary in service delivery and financially responsible. The importance of cultural congruence in practice is clearly stated as a priority. Structural empowerment focuses on professional engagement and participation in councils, committees and task forces, as well as involvement in professional organizations. Our collaborative governance structure was key when looking at cultural congruence. Our Nursing Advancement and Recognition Councils chose the Purnell Model as the best and most inclusive theoretical framework for cultural congruence in nursing practice at UWHC, after comparing and contrasting the nursing theoretical models that existed from a literature search. Nursing leadership has also been supportive of the interdisciplinary cultural congruence/diversity resource group that promotes diversity and cultural congruence at UWHC. They disseminate new knowledge to others, promote inclusivity and interdisciplinary collaboration, and translate the new knowledge into their practice thereby, strengthening their ability as a practitioner to provide better patient- and familycentered care. Nurses have used the resources provided in this group to continue to develop their practice. Sharing of stories and examining them through the lens of the Purnell model has helped to evolve their practice in culturally congruent care. Many nurses have referenced the U-Connect web page for additional information about diversity and have used it to raise their awareness and education about various components as they relate to the Purnell model and patient care. Professional development is another component that falls under structural empowerment. There was a conscious effort to include the Purnell model and objectives related to the Purnell model in ongoing education, orientation, clinical grand rounds, performance evaluations and our advancement program. Lastly, several staff members have become part of the Wisconsin Chapter or Transcultural Nursing Society as they have participated in the development activities that started in the UWHC nursing department. Exemplary Professional Practice is highlighted by our Nursing Professional Practice Model and the Purnell Model when we look specifically at cultural congruence. Our Professional Practice Model has the patient, family and community at the center. Purnell’s Model looks at the person, family, community and global society.
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Transformational Leadership
There are 12 domains to the Purnell Model that include: overview/heritage, communication, family roles and organization, workforce issues, biocultural ecology, highrisk behaviors, nutrition, pregnancy, death rituals, spirituality, health care practices and health care practitioners. All of the domains have several components under them to consider when providing care to patients and families. Both of the models speak to the health care practitioners and the importance of self-awareness and reflection on ones’ practice. Interdisciplinary relationships have continued to evolve with
nursing’s leadership of the cultural congruence/diversity resource group and nursing has influenced the adoption of the Purnell model by social work and nutrition services as well. Clearly, there is a distinct connection between cultural congruence and the Magnet Model. And as Magnet’s journey of continuous improvement moves forward, so will our journey of ongoing learning and improvement in culturally congruent, patient- and family-centered care and outcomes.
(1) http://thesocietypages.org/socimages/2012/11/14/u-s-racialethnic-demographics-1960-today-and-2050/
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structural empowerment
DAISY Award: A Perfect Fit for Magnet By Dennise Lavrenz, MBA, RN As a Magnet organization, appreciating nurses for their contributions to patient care helps enhance the image of nursing at UWHC and provide meaningful recognition. In order to accomplish this, UWHC adopted a more frequent, structured approach to recognizing nurses by partnering with the DAISY Foundation through the Nursing Recognition Council. The award was established, by the Barnes family in memory of J. Patrick Barnes, who died at age 33 of complications from idiopathic thrombocytopenic Purpura (ITP). Having been touched by the remarkable care demonstrated by nurses during Patrick’s illness, the Barnes family made it their mission to recognize exceptional nurses with the DAISY Award, which stands for “diseases attacking the immune system.” Since the inception of the award in July 2012 through June 2013, the Nursing Recognition Council has reviewed 91 nominations, which speaks (and shows) volumes to the quality of care and the impact UWHC nurses have on patients and families every day. During the first half of the year, 33 nominations were submitted, which grew to 58 nominations during the second half of the year, showing an increase of 76 percent. Additionally, the percentage of nominations coming from patients and families (as opposed to nominations from colleagues), increased dramatically over this first year from 45 percent to 92 percent. The number of units/areas being recognized also expanded—18 units were represented in the first half of FY13, which grew to 29 units in the second half of FY13—accounting for a 61 percent increase. Due to this overwhelming response, the presentations of awards transitioned from bimonthly to monthly in FY14.
Based on this small sampling of heartfelt nominations from patients and families, it’s easy to understand why:
“ It is pretty amazing what one nurse’s skill, knowledge, compassion, confidence; exceptional care can ensure a good outcome. She was in a zone and throughout her care delivery, explained every move and encouraged my wife to keep communicating and making sure she was okay.” “ She is always kind, warm and caring. I will always remember the compassion she has for patients and her passion for her job!”
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“ There is no place like home and we were able to get there because of her excellent, top notch nursing care. We are so grateful that simply saying “thank you” was not enough; this nomination is not enough; we will never forget our nurse for providing remarkable care, clinical excellence, and extraordinary compassion. She is a role model for nurses.” The DAISY Award has allowed us to tie our mission, vision and values into a program that recognizes nurses for these traits, and allows us to celebrate the compassionate caring of these extraordinary nurses…demonstrating why the DAISY Award is a perfect fit for UWHC’s healthy work environment and Magnet culture.
The
Award
DAISY
Celebrating past Daisy Award recipients and their remarkable care, clinical skills and compassion in nursing.
Gail Hettrick, BSN, RN, OCN Infusion Center July 2012
Marcy Holtz, BSN, RN Gyn, Urol, Plastic & Otorlaryn September 2012
Ashley Fenske, MSN, RN Gyn, Urol, Plastic & Otolaryn November 2012
Noreen Hogan, BSN, RN Infusion Center January 2013
Chrystina Schroeder, BSN, RN General Medical/Surgical Pediatrics, AFCH March 2013
Sarah Johnson, BSN, RN, CCRN B4/4 Rehabilitation May 2013
uwhealth.org/daisyaward
ND-35560-13
DAISY Award recipients from July 2012 to May 2013
Structural Empowerment
Caring for Our Community By Susan Collings, Senior Executive Assistant
Nursing Food Drive Proves Successful It all began in 2011when two nurse managers from Heart, Vascular and Thoracic approached Beth Houlahan, MSN, RN, CENP, Senior Vice President Patient Care Services and Chief Nursing Officer, about promoting a food drive. Dave Dwyer, MSN, RN, NE-BC, and Nikki Cagle, MS, RN, CNML, wanted to help children and families during the summer months when the nutritional supports available through the school system are not available. So they issued a challenge at the Nursing and Patient Care Services Leadership Council to see which unit/clinic/area could collect the most food and money. The operating room team led by Trish Parrell, RN and Jeff Fenne, BSN, RN, CNOR, came in first in 2011. In 2012, the HVT team was the top contributor and in 2013, nursing administration dominated! The most impressive and important result was the amount of food and money donated by nurses, respiratory therapists and clinical nutritionists for the children and their families in the Madison/Dane County area. As a team, UWHC collected 2,487 pounds of food and $9,628, which amounts to 30,851 meals donated to Second Harvest Food Bank, MOMs Food Pantry and River Food Pantry over the last three years. This activity is certainly consistent with our Professional Practice Model where we highlight “community” in the center of all that we do. What an amazing accomplishment for our community!
Nursing Food Drive Success The annual Nursing and Patient Care Services Food Drive was held June 3-20 and the results are astounding!
Food donations: 7,367 meals donated to local pantries, with nursing administration leading the pack! Place
Division
# Meals
1
Nursing Administration
2,731
2
Pediatric Clinics
1,223
3 4
HVT
1,170
Medical Nursing
804
5
Operating Rooms
503
6
Ambulatory Float Staff
453
7
ED
258
8
Surgical/Psych Nursing
225
Total
7,367
Pounds of food donated: 966 (336 from the emergency department alone!)
Case donations: $971 to the River Food Pantry $970 to Middleton Outreach Ministry (MOM) $50 to Second Harvest $200 to a local food pantry from the pediatric clinic’s pay for performance money Thanks to everyone who participated. Your efforts in giving back to our community are inspiring.
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Structural Empowerment
Increasing Nurse Manager Certifications By Sue Rees, DNP, RN, CPHQ, CENP As a Magnet ® organization, UWHC leadership understands the importance of professional certification for bedside nurses, and has strived over recent years to encourage those nurses to become certified. At the same time, the certifications of nurse managers have been viewed as equally important and also influential for direct care nurses. The nurse manager certification rate was 33 percent (21 of 64) in July 2012 with just one nurse manager certified in nursing management/administration and the remaining managers certified in a clinical specialty. In the annual learning needs assessment, nurse managers identified a desire for information and support regarding nurse leader certification. It was desired to have nurse managers serve as role models for nursing staff and benefit from the fruits of knowledge that would be obtained both initially to prepare for the certification, as well as the ongoing knowledge needed to maintain certification. In order to see an increase in nurse manager certification rates, a process was created to facilitate certification and make it as convenient as possible for nurse managers. The process included: •C reation of a nurse manager certification preparation course utilizing content experts from within the organization as the instructors for the course. •D eveloping extensive at-your-fingertip resources on how to study, how to register, how to form study groups, etc. •P roviding one-on-one coaching as well as proctored practice sessions. •U tilizing frequent methods of communication to keep the enthusiasm and momentum going. •P ublicly recognizing those who took the certification examination and passed. In late October 2012, two nursing leaders determined that the organization should offer a course to prepare nurse managers to obtain either the Certified Nurse Manager Leader (CNML) certification offered by the American Organization of Nurse Executives (AONE) or the Nurse Executive certification (NEBC) offered by the American Nurses Credentialing Center (ANCC). The content was reviewed for each certification and the information was categorized into the following six major overlapping areas:
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1. Performance improvement
4. Change management
2. Financial management
5. Technology
3. Strategic management
6. Human resources
It was determined that the organization had the in-house expertise to lead the course and therefore, divided the content areas among five content experts.
The Results A total of 28 nurse managers attended one of two nurse manager certification courses held in late 2012 and early 2013. Fifteen of the 28 course attendees (53.6 percent) passed a certification exam (12 CNML; 3 NE-BC). Fifteen of 16 (94 percent) who took the exam passed on the first attempt. An overall increase in the percentage of nurse managers who were certified went from 33 percent (21 of 64) as of July 1, 2012 to 50 percent (33 of 66) as of September 1, 2013. Note: Three of the nurse managers who were certified in 2012 are no longer in those positions (one retirement, one resignation, one promotion). Also of significance is the increase from one nursing management certification as of July 1, 2012 (1 NE-BC and 0 CNML), to 16 (4 NE-BC and 12 CNML) as of September 1, 2013.
Structural Empowerment
New Certifications for Professional Nurses and Clinical Nutritionists in FY13 Congratulations to the 97 professional nurses and nutritionists who were newly certified or re-certified during FY13! Mary Anderson, CPEN
Constance Gilkey, CNML
Angela Kurth, PCCN
Therese Quinn, CBCN
Joanne Anderson, CNML
Michele Glynn, RN-BC
Jacqueline Lakosky, COCN
Sheri Rembert, CDE
Ann Arnold, RN-BC
Nancy Gondzur, CNML
Matthew Lakosky, CMSRN
Barbara Rider, CMSRN
Allison Baus, OCN
Katie Greer, PCCN
Diane Larson, NE-BC
Stefania Sani, CPAN
Colleen Becker, CCTN
Amy Haen, OCN
Kelly Lawler, CAPA
Deborah Segersten, CNML
Cassie Bendall, CEN
Lindsay Haskins, CSR
Kristine Leahy-Gross, CPHQ
Sherry Siekert, CNML
Troy Betts, RN-BC
Brenda Herron, RN-BC
Carey Lee, CAPA
Jennifer Simpson, CMSRN
Cheryl Bingham, RN-BC
Kelly Hibray, RN-BC
Nelda Lemmenes, NE-BC
Anne Skar, CNOR
Deanna Blanchard, RN-BC
Matthew Hickel, RN-BC
Ashley Limmex, OCN
Priscilla Smith, CNOR
Becky Borchert, CPHQ
Joseph Hilgers, CNOR
Adrienne Luber-Heller, CMSRN
Kimberly Snyder , CAPA
Stanley Breunig, CNRN
Anne Hoeft, CCRN
Andrea McKenna, PCCN
Elise Spencer, CCRN
Angela Brown, CMSRN
Elise, Janssen, CCRN
Wanda Meeteer, CPHON
Briana Swanson, PCCN
Becky Brunker, PCCN
John Juno, CEN
Nicole Mendolla, OCN
Rachel Taylor, CMSRN
Michelle Bucey, CMSRN
Nikki Karlen, CMSRN
Sarah Miner, RN-BC
Nanette Thompson, CNOR
Rachael Buss, RN-BC
Alazda Kaun, CNRN
Amy Mliner, CPN
Susan Tipple, CNML
Jeanette Cagle, CNML
Ann Keenan, CPAN
Deborah Morningstar, CCRN
Cassandra Vanderwall, CDE
Yinqiu Chen, CMSRN
Diane Kelley, ANP-BC
Jamie Mowry, CCRN
Jennifer Weigel, RN-BC
Kevin Colwin, CCRN
Erin Kennedy, CNRN
Claire Negus, PCCN
Valerie Welsh, CNML
Deborah Dalsing, CNML
Christie King, CMSRN
Sandra Niemi, PCCN
Kimberley Williamson, ACNP-BC
Joyce Despain, RN-BC
Deanna Klenz, CPAN
Erin O’Fallon, CPN
Lindsey Woodworth, CCRN
Sara Eckerman, CNOR
Morgan Kraut, CMSRN
Sheri Pauer, CEN
Malinee Yindee, CDE
Brianna Eull, RN-BC
Hilary Krieger, CMSRN
Judith Payne, AOCN
Janet Zechel, CNML
Stephanie Feltes, CCRN
Barbara Kroll, CMSRN
Kelly Peroutka, CNML
Colleen Foley, ACNS-BC
Sara Kupcho, CCRN
Vickie Porter, CDN
Sarah Freiburger, OCN
Karen Kurt, ONC
Katrina Pycha-Holst, CMSRN
CEN. . ............ Certified Emergency Nurse
CRNI. . ........... Certified RN Infusion
CENP. . .......... Cert in Executive Nsg Practice
CSPHP. . ........ Cert Safe Pt Handling Prof
ACNP-BC...... Acute Care Nurse Practitioner
CFRN. . .......... Certified Flight RN
CTN-B.......... Cert Transcultural Nurse-Basic
ACNS-BC...... Adult Health Clinical Nurse
CLC. . ............ Certified Lactation Counselor
CWOCN........... Cert Wound, Ostomy, Continence Nurse
ACRN.. .......... AIDS Cert Registered Nurse
CMSRN......... Certified Medical-Surgical RN
CWON.. ......... Cert Wound and Ostomy Nurse
AE-C............ Asthma Educator-Certified
CNSC.. .......... Cert Nutr Support Clinician
OCN............. Oncology Certified Nurse
AHN-BC........ Advanced Holistic Nurse
CORLN. . ........ Cert Otorhinolaryngology Nurse
PCCN.. .......... Progressive Care Cert Nurse
ANP-BC........ Adult Nurse Practitioner
CPEN. . .......... Certified Peds Emergency Nurse
RN-BC.......... Ambulatory Care Nurse Certification
AOCNS......... Adv Onc Clin Nurse Spec
CPHON......... Certified Peds Hem/Onc Nurse
RN-BC CV..... RN, Cardiac/Vascular Nurse
CCRN........... Cert Critical Care Nurse
CPHQ........... Cert Prof-Healthcare Quality
RN-BC IN...... RN, Informatics
CCTC. . .......... Cert Clinical Transplant Coord
CPN.. ............ Certified Pediatric Nurse
RN-BC GER... Gerontological Nurse Cert
CCTN. . .......... Cert Clinical Transplant Nurse
CPNP-PC...... Cert Ped Nrs Prac Primary Care
RNC-NIC....... Neonatal Intensive Care Nursing
Certification Descriptions
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structural empowerment
Professional Growth and Recognition through Advancement By Sarah Brzozowski, BSN, RN, MBA develop an increased awareness that allows him/her to see the incredible work he/she is doing, how that work ties into the nursing service and the organization’s goals, and identify areas for continued growth. The NCAP is structured as a peer review processes, which provides another opportunity for professional development. Nurses that apply to the program are reviewed by a group of peers and provided with feedback both during the process (prior to an interview if an interview is necessary) and also at the end of the process. This feedback includes areas where the review team felt the nurse was exemplar, as well as opportunities for continued professional development. Recognition for the nurses’ positive effect on patients and families is another aspect of Magnet’s Structural Empowerment, and a key component of the NCAP. Nurses who advance through the program receive personal, peer and organizational recognition for their excellence and professional practice in the following ways: Development of the Nursing Clinical Advancement Program (NCAP) at UWHC began in August 2006 with the formation of the Nursing Advancement Council. The Council was given two charges:
1. Design a program that would reward nurses at UWHC for staying in the mainstream of direct patient care; and
2. Recognize professional nurses for their achievements and professional contributions to patients, families, UWHC and the profession of nursing. Recognizing nurses for the incredible work they do and providing an opportunity for continued professional development, are key components of the NCAP. Magnet describes these concepts under the “Structural Empowerment” component, which encourages organizations to develop structures that empower nursing autonomy, clinical excellence and professional fulfillment. Professional nurses are lifelong learners and the NCAP provides UWHC nurses with an opportunity to continue learning and developing professionally through self-reflection and peer review. Embedded within the NCAP are the key drivers of nursing practice at UWHC (e.g. care delivery, cultural congruency, evidence-based practice, research, the nursing service and organization’s missions, visions and values). To advance through the program, nurses must take the time to reflect on their practice. By taking this time to self-reflect, a nurse will 12
• Congratulatory letter from the Nursing Advancement Council • Certificate of Achievement signed by nursing leadership • Acknowledgement in In Brief and the NCAP page on U-Connect • Unit recognition (“Blazing Trails” flier in break area listing name/s of nurses who’ve advanced)
Blazing Trails in professional nursing
Congratulations Aeron Adams in Psychiatry, for achieving advancement to the Proficient Level through the Nursing Clinical Advancement Program!
• Nurses Week celebration • Monetary bonus uconnect.wisc.edu
The NCAP provides an opportunity for nurses to develop professionally and obtain recognition for the incredible work they are doing. Valerie Mack, BSN, RN, CEN, CPEN, a recent applicant to the program states, “It is nice to advance through the program, but I must say, the journey has been the best part. It gave me the opportunity to reflect on where I have been and set sights on where I want to be. After 34 plus years in the profession it is humbling to realize that I am not always the expert.”
Structural Empowerment
Clinical Leadership Institute By Marilyn Haynes-Brokopp, MS, RN-BC The Clinical Leadership Institute (CLI) was developed to introduce an academic-practice partnership designed to expand nurses’ and other providers’ self-knowledge, skills and competencies in leadership. The collaborative addresses the FY10-FY14 UWHC Nursing and Patient Care Services Strategic Goal to: “Collaborate with the UW-Madison School of Nursing and other academic programs to create a culture that advances education, professional development and research for clinical disciplines.” It also supports the recruitment, retention and development of nursing/patient care services leaders in clinical practice and clinical management. The CLI recognizes the challenges of developing contemporary nurse leaders despite faculty shortages and limited faculty experience in health care administration. Additionally, as a Magnet-designated organization, the collaborative supports a lifelong learning culture that includes professional/interprofessional collaboration, role development, career advancement and academic achievement. This project acknowledges that opportunities for clinical leadership development need to occur throughout one’s professional career.
Aspiring leaders
Emerging leaders
Operational leaders
Strategic leaders
Leadership learning opportunities are designed to ground future leaders in the knowledge, skills, and abilities essential to success. The program recognizes the unique needs of: • Emerging leaders (new managers) • Operational managers (middle level managers with some leadership experience) •S trategic leaders (experienced middle and upper level managers aspiring vice presidential and/or higher levels of leadership (Wolf, 2006) The collaborative is currently concluding its sixth successful year in meeting the strategic goals established at the inception of the program.
The core elements of the CLI experience include: 1. Core Curriculum: Collaborative Leadership, RWJ Turning Point Initiative 2. Crucial Conversations 3. Individualized Development Plan 4. Collaborative Interprofessional Project 5. Mentoring and Coaching
“ Today, the need for leaders is too great to leave their emergence to chance.” – Institute of Medicine Report, 1988
6. Commitment to Leadership Development The interprofessional collaborative project undertaken by each scholar furthers research efforts to create and test collegial working relationships to ensure that patient care is comprehensive, coordinated, and monitored through quality improvement models. The six scholar interprofessional cohorts have included nurses, nutritionists, social workers, chaplains, respiratory therapists, SoN faculty and an information scientist. In 2013, the cohort expanded to include nurses from the UW Medical Foundation. Since the inception of the CLI in 2008, a total of 60 scholars have completed the program, with an additional 10 currently enrolled. All scholars remain employed at UWHC/SoN with the exception of one relocation and one retirement. Two UWHC nurses were promoted to manager positions, and one was recently promoted to a director position. Three UWHC nurses are enrolled or have completed Master’s programs, and three are enrolled in or have completed doctoral programs. These impressive facts demonstrate the level of commitment these scholars have to continuous learning, professional growth, and UWHC/SoN.
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Structural Empowerment
Nursing Accomplishments: May – July 2013 Appointments Francois, M. (August, 2013). Appointed to the NATCO Executive Committee. Rees, S. (August, 2013). Elected to WONE (Wisconsin Organization of Nurse Executives) Board of Directors for 2014-2106. Stevens, L. (May, 2013). Appointed Chair, Exam Committee, Association of Safe Patient Handling Professionals.
Publications Rees, S. & Houlahan, B. (2013). The CNO scorecard: A tool and process for ensuring focus on the right metrics. Nurse Leader, 11(3), 44-47. Stevens, L., Rees, S., Lamb, K., & Dalsing, D. (2013). Creating a culture of safety for safe patient handling. Orthopaedic Nursing, 32(3), 155-164.
Presentations Rich, A., Kingston, M., Dugan, B., Cucchi, M., Kielich, R., & Stevens, L. (2013, May). Ask the experts. Podium presentation at the Association of Safe Patient Handling Professionals, Inc. An Uplifting Experience - Networking with SPH Experts, Pewaukee, WI. Stevens, L. (2013, May). Performance improvement for optimal outcomes. Podium presentation at Infusion Nursing Society, Charlotte, NC.
Williams Black, L. (July, 2013). Member, Continuing Education Committee. National Association of Pediatric Nurse Practitioners (NAPNAP). Williams Black, L. (July, 2013). Member, Review Panel for Continuing Education Modules. National Certification Corporation.
Awards Williams Black, L. (September, 2013). Distinguished Alumnus Award. Trinity College of Nursing and Health Sciences.
Degree Completions Hattenhauer, L. R. (December 2012). Doctor of Nursing Practice, University of Minnesota-Twin Cities, Minneapolis, MN. Hawkinson, A. L. (May 2013). Master of Science in Nursing, Edgewood College, Madison, WI.
Strayer, A. (2013, July). Practical anatomy of the apine, spinal cord, and peripheral nerves; Pain management after spinal fusion. Podium presentations at Spine review: A Comprehensive Approach for Neurosurgeons, Orthopedic Surgeons, and Nurses, Cleveland, OH.
Kiger, T. (June, 2013). Master of Science in Nursing, Walden University, Minneapolis, MN.
Strayer, A. (2013, April). Prevention and management of complications following acute spinal cord injury. Podium presentation at the American Association of Neurological Surgeons Annual Meeting, New Orleans, LA.
Myers, W. (May, 2013). Master of Science in Nursing, Edgewood College, Madison, WI.
Zupanc, T & Lukas, P. (2013, July). Recognizing nursing assistants: Planning the nursing assistant educational series. Poster presentation at Association for Nursing Professional Development Annual Convention 2013, Dallas, TX.
Leahy-Gross, K. M. (May 2013). Master of Science in Nursing, Edgewood College, Madison, WI.
O’Leary, M. E. (May, 2013). Master of Science in Nursing Administration, Edgewood College, Madison, WI. Pavek, K.U. (May, 2013). Master of Science in Nursing, Concordia University, Mequon, WI. Webber, M. M. (May, 2013). Master of Science in Nursing, Clarke University, Dubuque, IA.
To submit an accomplishment for the next issue, use the Nursing Accomplishments Submission button on the Nursing page on U-Connect. 14
Exemplary Professional Practice
Physician-Nurse Manager Dyads By Sue Rees, DNP, RN, CPHQ, CENP Current conditions in health care demand simultaneous improvements in clinical quality and reductions in health care costs. The relentless pressure to optimize value (value = quality + satisfaction / costs), requires a new model of leadership: one that combines clinical knowledge and decision making with management skills.
Engaged frontline teams, high-quality care Leaders must be able to engage frontline teams in continuous improvements toward better patient experience, improved clinical care and reduced waste, while simultaneously creating a work environment that fosters collaboration and enhances professional satisfaction. In response to the need for a new model of physician-administrative leadership (dyads) at the frontlines of care, UW Health is committed to creating an ongoing professional development program for physician-nurse management teams, to ensure these dyads have the necessary skills and knowledge to lead teams as they improve care processes to achieve the highest value care for patients and their caregivers. UWHC has recently initiated inpatient, unit-based, physiciannurse manager clinical partnerships to help advance our strategic goals. Our organization strives to achieve quality care that is safe, timely, efficient, effective, equitable and patient centered. The role of the physician–nurse manager leadership dyad is to build a local clinical environment that seeks to enhance the entire patient care experience. We began this work by creating a shared understanding of the roles, responsibilities and accountabilities of these leadership dyads. The initial focus will be on measures identified on the UW Health Improvement Scorecard, including performance on the HCAHPS patient experience survey.
Role of the inpatient unit leadership dyad The overarching goal of the physician–nurse manager leadership dyad is to:
Examples of measures that dyadswill address Better Care: Enhancing patient experience and engaging patients in their care. •H CAHPS (Communication with Doctors, Communication with Nurses and Pain Management)
Better Health: • Hand Hygiene • CLABSI • CAUTI • National Hospital Quality Score
Lower Costs: 30-day, All-Cause, Re-admissions • Medical • Surgical The dyads will also promote UWHC’s Interdisciplinary Model of Care (IMOC) and Patient Family Centered Care (PFCC).
•c reate a clinical unit that promotes continuous learning and collaborative relationships in support of the ideal patient experience; •d eliver the highest quality and safest care, and the most efficient use of our resources. The shared accountability model allows for more effective communication, problem-solving, and execution of change.
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Exemplary Professional Practice
Coordinated Transitions of Care (C-TraC) By Maria Brenny-Fitzpatrick and Kris Leahy-Gross Transitions of care occur each time a patient moves from one health care provider or health setting to another. These transitions are the most vulnerable phases of care for patients and may result in errors and poor outcomes. Transitional care programs have been shown to improve care while bridging care between providers and health care settings. An evidence-based practice transitional care model, Coordinated Transitions of Care (C-TraC), was implemented on July 29, 2013 at UWHC and has been shown to be successful among patients with high-risk conditions (Kind et al., 2012). The C-TraC model is a low-resource, telephonebased, protocol-driven program designed to reduce 30-day re-hospitalizations and improve care transitions of patients. Patients enrolled in the C-TraC program are at least 65 years old and discharged home or to an assisted-living facility. They have been assessed as having a high risk of re-admission and receive a post-discharge telephone call and/or in-home nurse practitioner visit 48-72 hours after discharge. The needs of the patient determine the frequency of follow-up phone calls and home visits. Patients are followed for 30 days post-discharge and receive a thorough medication review and ongoing follow-up for any health care issues with the goal of avoiding re-admission.
The C-TraC program elements consist of: •A transitional care nurse and a nurse practitioner who together with the interdisciplinary health care team, identify hospitalized patients who meet criteria for the program. •D etermining which C-TraC patients are in the moderate or high-risk category. -M oderate-risk patients receive a telephone call 48-72 hours after discharge, then weekly. -H igh-risk patients may receive an in-home nurse practitioner visit 24-48 hours after discharge. •D etermining whether a repeat home visit is needed, then a weekly telephone call thereafter, based on the needs of the patient. • G iving all C-TraC patients a discharge plan containing three “red flag” signs or symptoms they should watch for when returning home. •T he follow-up phone call program, which is available to eligible patients at no cost (however, the NP visit may be charged to the patient). The transitional care program is a component of UWHC’s professional practice framework through seamless transitions of care as it spans the concepts of leadership, clinical practice and professional development. The C-TraC program facilitates care across the continuum with the primary goals of: 16
•E ducating and empowering the patient/caregiver in medication management •E ducating the patient and/or caregiver regarding “red flags” or warning symptoms •E nsuring the patient has medical follow-up with a primary care provider •E nsuring the patient and/or caregiver know whom to contact if questions arise Since the program’s inception in July 2013, 49 patients enrolled in the program (as of September 2013). The roll-out of the program has been coordinated with support from the General Medicine and Hospitalist services on F6/5 and D4/4. Five patients have re-admitted within 30 days for a readmit rate of 10.2 percent compared to the FY 13 65y/o and older readmit rate of 12.7 percent. The C-TraC re-admit rate is 20 percent lower than the overall FY 13 rate.
Kind, A.J., Jensen, L., Barczi, S., Bridges, A., Kordahl, R., Smith, M.A., & Asthana, S. (2012). Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Affairs, 31(12), 2659-2668. doi: 10.1377/hlthaff.2012.0366
Exemplary Professional Practice
Nursing Involvement in the Interdisciplinary Model of Care By Ann Malec, MS, RN, ACNP and Anne Mork, MSN, RN
Background
IMOC rounds should include the attending physician or designee, primary nurse or designee, and the patient and/or family. Other pertinent members of the interdisciplinary team (ie. pharmacy, social work, OT, PT, case manager, RT, etc.), are also highly encouraged to attend.
2. Discussion regarding the daily plan of care 3. Discussion regarding the plan for the stay including key elements required for a seamless transition to the next level of care and long-term goals. The plan for the day and plan for the stay is posted in each patient’s room and updated during daily rounds.
4. Comprehensive discharge planning Beth Houlahan, MSN, RN, CENP, Senior Vice President Patient Care Services, Chief Nursing Officer, and Chris Green, MD, Chief Medical Officer, appointed physician and nurse leaders to facilitate implementation of the core IMOC concepts. In addition, an interdisciplinary advisory committee with patients and family member representatives meets monthly to evaluate unit progress and make additional recommendations. The advisory committee has staff nurse representation to promote RN participation in the IMOC implementation.
Phases of Implementation: IMOC pilot An IMOC pilot was initiated on F6/5 (General Medicine), in January 2013. Key nursing and physician leaders partnered with interdisciplinary team members to facilitate a culture change from rounding on patients in an independent, fragmented, non-patient-centered manner, to rounding as a cohesive, interprofessional team at the bedside with patients and families.
Pla
ion
c a ti
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RN
ers re Team Memb a al C
A d dit
1. Interdisciplinary presence: Daily participants in
du
MD
ing Patient and Family
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At UWHC, all inpatient units have been charged to incorporate the following IMOC principles during daily bedside rounds:
nn
i ng
a Ev
The interdisciplinary model of care (IMOC) project was initiated to strengthen the partnership with patients, families and health care providers to ensure excellent communication, collaboration and coordination of the plan of care.
A tt e n d
a t m e nt & Tre luation
“Interdisciplinary relationships” are an integral part of the exemplary professional practice component of the Magnet model. Magnet organizations are charged to support structures that provide all members of the health care team to make “essential and meaningful contributions in the achievement of clinical outcomes.”
P ri
r ma
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Specific strategies were utilized to lead the interdisciplinary teamwork such as engaging front line staff, empowering nurses to initiate patient presentations during rounds, and creating standardized checklists and teaching tools. The strategies and findings of the IMOC pilot were used to expand IMOC to establish house-wide rollout plans. Physician and nurse manager leadership dyads have been key to engaging staff and reinforcing IMOC principals at the unit level. In addition, nursing unit council members and nurse champions have played an important role in sustaining initial IMOC efforts.
Summary Collaborative, interdisciplinary relationships are critical to creating and sustaining high quality, safe and satisfying practice environments. The presence and active participation of the nurse during IMOC rounds brings relevant information to the attention of the entire team. The nurse has a unique opportunity to coordinate care, present vital information, support families and promote overall positive patient outcomes.
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exemplary Professional Practice
University of Wisconsin Hospital and Clinics
Nursing Professional Practice Model
IP
NA
H
lit
PM y EN
e ol alth Vi s la b Po ion LE orativ licy Aary AD e Pa dvocates ER rtnership s SH
n ti o uiry abi t lec Ref f Inq oun LO c it o Spir nd Ac V E E a my LD
Autono
The PPM graphic needs little explanation. The “Patient,” “Family,” and “Community” are at the center of our nursing practice as depicted in the model, which also represents the importance of relationships and responsibilities of the professional nurse at UWHC.
Patient Family Community
PROFESSIO
The Nursing Advancement Council began important work in 2011 to develop a new Nursing Professional Practice Model (PPM). Their tireless work included input and feedback from nurses across the organization, to ensure that the model would reflect the essence of nursing practice at UWHC. The model was approved in the fall of 2012.
NICAL PRACTICE
a c h i n g a n d P ro m otio lth Te n Hea Clinical Expertise x E e m p l a r y C a re
Co nti n of KTran uou no sfe s wl r ed ge
By Gwen Klinkner, MS, RN, APRN, BC-ADM, CDE
CLI
s les ns am itio S e a n s a re C Tr of
Living the Professional Practice Model at UWHC
C
T
The model’s framework includes three domains – Leadership, Clinical Innovation Practice, and Professional Development – linked by three “bridges” or concepts – Innovation, Continuous Transfer of Knowledge and Seamless Transitions in Care, which span across the domains. Each domain is further defined by three critical characteristics. Nurses at UWHC are living our PPM every day. This is becoming more apparent as we share our reflections and stories about why the model’s domains and bridges are meaningful to each of us. Earlier this year, some of our nurses who received Nursing Excellence Awards reflected on various components of the model:
Leadership
Innovation
“Leadership at UWHC shows itself in many ways. All opinions are valued and you’re encouraged to collaborate and be involved as much as possible.”
“Innovation is important in providing effective and exemplary care. We need to take evidence-based practices and implement them in new, fresh ways.”
—Tracy Zastrow, RN nurse clinician, central float
—Suzanne Purvis, DNP, RN, GCNS-BC clinical nurse specialist, nursing practice innovation
seamless Transitions of Care “Each person here is an essential part of the team. We have to coordination with other specialties to make sure we are providing the best care. We also empower patients by informing them of what to expect and encouraging them to ask questions.” —Patricia Marsh, BSN, RN, CPN, ONC nurse clinician, pediatric specialties clinic, AFCH
The work of the Advancement Council did not stop in 2012when the model was approved; council members have continued to identify creative strategies to share the model. For example, a video featuring Nichole Blazel, BSN, RN, nurse clinician, F6/6, to highlight each domain and bridge of the model and explain how each of them relates to nursing practice at UWHC. This video has been shared with councils and is available on the PPM page of U-Connect. The Advancement Council is also asking nurses to submit stories that describe how the model applies to their practices. As these stories are heard, nurses will be able to celebrate and consider possibilities for strengthening the care we provide collectively.
To learn more about the UWHC Nursing Professional Practice Model, view the video and retrieve reference materials, visit U-Connect. 18
Exemplary Professional Practice
Plain Language and Teach-back: By Cindy Leeder, MS, RN, ACNS-BS
Tools of Magnet Exemplary Professional Practice Have you made the connection between Magnet exemplary professional (EP) practice and the teach-back with plain language method yet? I’m guessing you have, but do you know about its link to our Magnet documents and Nursing Professional Practice Model (PPM)?
Here are a few quotes: •E P4: “That the structure(s) and process(es) of the Care Delivery System involve the patient and/or his or her support system in the planning and delivery of care…” •E P25: “How the organization identifies and addresses disparities in the management of the health care needs of diverse patient populations. Include the role of the nurse.” • EP26: “How nurses use resources to meet the unique and individual needs of patients and families.” •E P35EO: “…Provide analysis and evaluation of data and resultant action plans related to patient satisfaction with nursing addressing four of the following... education...” • PPM: “Empower patients through education and care planning.” By using the plain language and the teach-back method to educate patients and family members, we are able to increase our understanding of the learner, their situation and their understanding of the information provided. We are also better able to understand the needs of individual patients, families, patient populations, the disparities in management of health care needs of diverse patient populations, and patient satisfaction. Further, the use of teach-back with plain language empowers patients and their support systems to be directly involved in the planning and delivery of their own care. This proactive caregiver/patient dynamic ultimately increases patient engagement which is associated with lower costs and better health outcomes. Additionally, engaged and empowered patients are also more likely to keep their appointments, follow care instructions, take prescribed medications and practice preventative care. So, the next time you are discussing a topic with a patient and their family while you are beginning to get to know them, enjoy the journey that you all are embarking upon. As you use the tools of plain language and teach-back, you’re engaging in exemplary professional practice!
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Exemplary Professional Practice
Reducing Central Line Infections: A 15-Second Solution By Linda Stevens, DNP, RN-BC, CPHQ, CSPHP In 2012, when UWHC switched to a new needless connector called Microclave, the change in practice required for the new equipment inadvertently led to an increase in central line associated blood stream infections (CLABSI). By September 2012,31 infections were recorded for the third quarter, which was nearly twice as many as the previous quarter.
Recruitment of CLABSI champions was also completed during these educational sessions. The CLABSI champions will provide unit-based leadership for maintaining central lines and provide data on how we are doing with all aspects of central line maintenance.
These infections are expensive and preventable. We, as UWHC nurses, are committed to delivering exemplary care and knew we could do better for our patients and families.
Figure 1: Needleless Connector after Scrubbing with Alcohol Wipe
Using Kotter’s change model, our first step was to increase awareness of the problem and create a sense of urgency. Communication was distributed throughout the organization to increase awareness and identify the probable cause of the problem. To help staff “see” the need for a change in practice, we introduced a poster that featured a picture of the amount of bacteria left on the connecter with various amounts of scrubbing (Figure 1). This helped to communicate why it is important to scrub for at least 15 seconds.
A swipe with a wipe doesn’t cut it. Scrub must last 15 seconds!
15 seconds = ABCs
20
Central Line-Associated Blood Stream Infection (CLABSI) Occurences and Rate 16
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The nurse leaders worked together to check off 1,020 staff in a week and a half. It was exciting to see the CLABSI rate drop from 31 in September 2012 to seven in October 2012…and even better when that number reduced to three CLABSIs in November 2012. In order to sustain the change, we needed to continue the CLABSI reduction efforts. In addition to scrubbing the “hub” (needleless connector), other steps of line maintenance also needed attention, so we did not let up on educating all inpatient nurses on line maintenance in educational sessions in July 2013.
Figure 2: Overall Central Line Associated Blood Stream Infection Rate and Occurrence
CLABSI Occurences
Our team then set the goal to eliminate CLABSIs. We needed to ensure that everyone who used the needless connectors knew what a 15-second scrub felt like and why it was important. We developed a “SWAT” team of nurse leaders who signed up for shifts during a two-week period. Each unit had a staff list and the nurse leaders rounded on assigned locations and observed staff members scrubbing for 15 seconds using a checklist. The staff members who completed the observations found nurses to be engaged and understanding of the need to monitor the practice. Many of the observed staff indicated surprise at how long 15 seconds really was, and did not recall the content during the original education on the new product. We found that 15 seconds was approximately the time it takes to sing a verse of the ABCs.
New Knowledge, Innovations and Improvements
Medical Students Shadow Nurses By Sue Rees, DNP, RN, CPHQ, CENP
Early Collaboration Proves Beneficial The Nurse Residency Program at UWHC has been in place since 2004 and is one of only 11 programs in the nation accredited by the Commission on Collegiate Nursing Education (CCNE). The 12-month program is designed to help nurses move confidently into practice following graduation from a baccalaureate program. As part of the program, nurse residents are expected to complete an evidence-based practice project. For Megan LeClair-Netzel, BSN, RN, that meant demonstrating the Magnet domain of New Knowledge, Innovations and Improvements through her project titled “Advancing Interdisciplinary Collaboration: Medical Students Shadowing Nurses.”
LeClair-Netzel started by posing this PICO question: • Population: Among medical students, • Intervention: how does partnering with a nurse, • Comparison: compared with no partnering, • O utcome: influence attitude towards nursing practice and the profession of nursing? In March of 2013, LeClair-Netzel proudly represented UWHC at the UHC Nurse Residency conference in San Diego where she was one of five selected to do a podium presentation on her project from a pool of 115 abstracts. At the time of the presentation, LeClair-Netzel was a nurse clinician in the Trauma and Life Support Center (TLC), a medical/surgical ICU site she selected for implementation of her project,
which involved a four-hour “partnering” experience for firstand second-year medical students from UWSMPH, with a registered nurse (RN) on TLC at UWHC. The sample for the “partnering” experience included 11 medical students. A survey was completed pre- and postpartnering experience along with four open-ended questions. An additional 12 first- and second-year students completed the survey once, without the partnering experience. The results revealed a statistically significant change of attitude (p=0.04) toward positive nurse-physician collaboration when comparing pre-partnering and post-partnering total scores, and a statistically significant change in attitude between the non-partnering group and the partnering group (p<0.01). These findings highlight the need for increased interprofessional educational opportunities within academic curricula and demonstrate that this intervention may help to improve patient outcomes and health care team communication. LeClair-Netzel not only represented UWHC and the Nurse Residency Program as a Magnet nurse, but also is hoping to add to nursing literature by publishing her findings. LeClairNetzel is currently a staff nurse in the Post-Anesthesia Care Unit and is pursuing an MSN to DNP education at the University of Wisconsin-Madison.
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New Knowledge, Innovations and Improvements
Innovation and Improvement Exemplars By Sue Berns, MSN, RN A commitment to continued innovation and improvement is a hallmark of UWHC nurses, who contribute new knowledge through research and evidence-based care to advance the profession. Following are several exemplars of innovations in nursing practice at UWHC.
with the most recent data showing 136 monthly page views to the Workspace. Feedback has also been exceedingly positive, with the greatest benefit being that nurses who weren’t able to attend meetings in the past, can now be actively involved.
Burn Wound atlas: a Picture guide to Healing When nurse resident Courtney Roth, RSN, RN, began an evidence-based practice (EBP) project with Luke Markus, BSN, RN, nurse clinician, they identified an opportunity to improve patient education and potentially reduce patient anxiety, through the use of burn wound pictures to supplement other educational materials. Picture Guide
to Burn Healing
Virtual Resource group UWHC has a number of nursing resource groups, which are comprised mainly of direct care nurses and facilitated primarily by clinical nurse specialists (CNS). Resource nurses enhance their knowledge related to a particular clinical topic, and serve as unit-based experts and consultants to their peers. Until last year, all resource groups were scheduled regularly as inperson meetings. With 15 resource groups, this added up to a considerable commitment of staff hours. In 2012, Dawn Berndt, MS, RN, CRNI, CNS for infusion therapy, participated in the UWHC Clinical Leadership Institute (CLI), which required the development and implementation of a leadership project. Berndt took that opportunity to explore and measure the potential success of a virtual resource group that met online vs. an in-person meeting. Berndt recruited 12 nurses and others interested in joining an Infusion Pump Resource Nurse (IPRN) Resource Group, which would meet online only. She then developed a Workspace web page on U-Connect—a collaborative online space for work teams and committees to share information and communicate— to post resource materials and “host” the meetings every other month. Instead of scheduling the meetings on a set day and time, group members were/are notified of the meeting agenda by e-mail and are free to access and respond to agenda items at any time during the month. Engagement continues to grow strong—the group has garnered 100 percent participation and active involvement, 22
Roth worked on her project during the first half of 2011. During this time, she conducted a literature review and assessed the evidence on the topic, assembled photographs of various types of burn wounds and created a draft guide titled “Burn Wound Atlas.” When Roth left her position in the Burn Unit, Markus assumed responsibility for the project. In Spring 2012, UWHC marketing and public affairs assisted Markus with the creation of a professional design and layout. The final version—a binder containing 28 laminated color photographs and brief descriptions of burn wounds in various stages of healing, post-graft wounds and compression garments—was complete by mid-2012. The guide has been well-received and is used by unit staff in a variety of ways: nurses use it as a pictorial guide to enhance their patient education; preceptors and the CNS unit use it to educate new staff; and staff also have used it in burn prevention programs. Markus presented the project at the 2011 Midwest Burn Conference and presented a poster at the 2013 UWHC Nursing Poster Fair. This project has improved practice through the development of a new resource to support patient/ family education.
New Knowledge, Innovations and Improvements
Improving the transition of pediatric patients to adult care with HealthLink A major issue in pediatrics is the preparation of children and adolescents with chronic illnesses, for the eventual transition to adult health care settings. Abigail Roth, BSN, RN, CPHON, nurse clinician in the Pediatric Sickle Cell Clinic, became interested in how best to prepare patients with sickle cell disease to transition to adult providers. She found little specific literature on the topic, but was aware that the Pediatric Hematology Clinic had developed extensive transition guidelines. Roth convened a workgroup including a nurse practitioner, clinical nurse specialist, attending physician and social worker. Using the hematology guidelines as a template, they adapted the content to reflect the unique needs of patients with sickle cell disease. Initially, Roth used a paper version of the guidelines, but this method did not provide easy access to other members of the team. Roth realized that the UWHC electronic health record (EHR) system (Health Link), allowed the creation of “smart sets,” user-customizable content that could be inserted into any note. She created smart sets for each age group along with the age-appropriate content and education to be covered, from age 2 through 19. At every visit, she checked off material that was successfully covered with the patient and his/her parent. Roth presented her innovation as part of a Clinical Grand Rounds in October 2012. This has improved nursing practice through standardizing the process of transition, facilitating the tracking of the transition preparation process over time, and enabling efficient communication of progress to other members of the care team.
interested in transitioning to pediatric care. The program was named LEAP--Learning and Education from Adult to Pediatric—and consists of a one-day educational workshop including lectures, resource materials, video review, case scenario written exercises and a medication quiz. Following the workshop, prospective candidates must complete an eight-hour shadowing experience on one of the AFCH units and submit a written “reflection” responding to several structured questions. The preceptor they shadow during the observation completes an assessment of the candidate’s potential aptitude for pediatric nursing and managers interview candidates using a structured interview guide. Participation in LEAP is voluntary and successful completion enables candidates to apply for appropriate pediatric care positions. For adult general care nurses with at least one year of recent inpatient experience, participation in LEAP will waive the requirement of one year of pediatric experience. For adult ICU nurses with one year of recent critical care experience, LEAP participation will waive the requirement of one year of pediatric critical care experience. Successful completion of the program does not guarantee a position, but it is required in order to be considered. Three LEAP workshops were offered in early 2013 and attended by 25 participants. Nurse managers have found LEAP to be a highly valuable process that has allowed them to identify candidates with strong potential to become excellent pediatric nurses. This project has improved nursing practice by creating a process for potential pediatric nurses to learn about the specialty and be assessed for their likelihood of success.
LEAP: A new way to access potential pediatric nursing candidates Traditionally, the American Family Children’s Hospital (AFCH), has required pediatric experience when hiring experienced nurses. With the AFCH expansion to add inpatient beds and a new Neonatal Intensive Care Unit, Barbara Byrne, DNP, RN, PNP-BC, director of pediatric nursing and clinical services, realized that an innovative solution was needed to ensure that a sufficient number of nurses could be hired without compromising the quality of pediatric care. Byrne was aware that UWHC adult care nurses who had requested to transfer to AFCH, were frustrated when they were rejected due to lack of pediatric experience. At the time, it was unclear how AFCH leadership would evaluate whether pediatrics would be a good fit for a candidate or how candidates could self-assess their suitability. Byrne’s innovation, in collaboration with pediatric nursing leadership, was to develop a brief, educational program and observation experience for UWHC adult inpatient nurses 23
New Knowledge, Innovations and Improvements
Embracing a Changing Health Care Environment By Élise Arsenault Knudsen, MS, RN, ACNS-BC
Through Evidence-Based Practice Training The International Council of Nurses has emphasized that “in an era of evidencebased practice and knowledge driven health care...nurses have a professional obligation to society to provide care that is constantly reviewed, researched and validated”*. Not surprising, UWHC nurses are rising to the occasion to meet this challenge. During the last fiscal year, 75 nurses in a variety of roles completed eight interactive, evidence-based practice (EBP) workshops. The resource nurses delved into implementation science during the four-hour workshops that provided theory and strategies to promote an evidence-based approach to implementing practice changes. Additionally, 38 clinical nurse specialists and nursing education specialists have undergone training to become EBP coaches, who are ready and willing to answer questions and help with EBP projects. Across the organization, nurses are exploring clinical questions and working toward improving their practice and patient outcomes. Here are just a few of the questions that were explored this year: • I n patients who have external fixators, what is the best way to perform pin site care to prevent infection? • I n hospitalized patients, how does calculating insulin dosage (based on carbohydrates eaten), improve blood glucose control? • I n adult patients, which site is better to administer intramuscular injections – the ventrogluteal or the dorsogluteal? To support the process of answering these questions and all EBP projects, an online EBP project toolkit and accompanying EBP project plan were created, which are available within the Evidence-based Practice Project Workspace page on U-Connect. The Nursing Practice Guideline Committee also is supporting evidence-based nursing care through the implementation of a new guideline titled, “Strategies to Support Self-Management
24
in Chronic Conditions.” Additional information can be found on the newly updated Nursing Practice Guidelines web page on U-Connect. It is no secret that health care is in the midst of major changes, and nursing will have to change with it. As we advocate to maintain the essence of nursing, while providing the most current, effective and efficient care, nurses are showcasing their agility, innovation and intellect to solve complex problems. Supported by the growth of the EBP Program for Nursing, our nurses are coupling theses skills with an enriched knowledge of the EBP process and resources to advance the profession of nursing, and improve the care and outcomes of our patients, families and community.
* Varnell, G., Haas, B., Duke, G., & Hudson, K. (2008). Effect of an educational intervention on attitudes toward and implementation of evidence-based practice. Worldviews on Evidence-based Nursing, 5(4), 172-181. doi:10.1111 /j.1741-6787.2008.00137.
New Knowledge, Innovations and Improvements
Building a Nursing Research Program at UWHC By Judith K. Payne, PhD, RN, AOCN The domain of nursing research has grown in depth over the past several decades. There are many roles and activities for nursing within research, ranging from independent researcher, member of a research team, performing data collection, data analysis and dissemination. Research is the foundation of practice—seeking knowledge to provide the best care. It a process of inquiry to seek or search, a systematic, controlled investigation of presumed relationships among variables. Therefore, nursing research is the scientific investigation of phenomena, generating new knowledge about a phenomenon or validating existing knowledge. Initial charges for building a nursing research program began with an analysis of the current status of nursing research at UWHC. Key priority goals were identified, which included creating an infrastructure for the Nursing Research Office to promote, educate, and facilitate research projects; and create a culture of scholarly inquiry at UWHC.
Infrastructure and Processes for Conducting Nursing Research at UWHC •C reated a conceptual framework, philosophy, and mission for nursing research • Developed a Nursing Research web page on U-Connect •C reated a notice of intent-to-submit form, which must be submitted to the Program Director of Nursing Research at UWHC for approval prior to conducting research
submitting a research proposal. A U-Connect Workspace page was developed with plans to create an external internet-based UWHC Nursing Research web site in early 2014. Four nurse faculty members from the UW-Madison School of Nursing have been appointed Nurse Scholars in 2013, which has resulted in increased collaboration between UWHC and the School of Nursing. Our Professional Practice Model illuminates the value we place on new knowledge and innovations. The Nursing Research Council completed a descriptive survey research study on IV initiation practices at UWHC, which was presented at the Annual Poster Fair and at a monthly Scholarly Forum. The principal investigator and team members are preparing a manuscript for submission to the American Journal of Nursing. The Nursing Research Office and the Nursing Research Council are vital elements of our Nursing Professional Practice Model. Our Nursing Research Council is comprised of inpatient and outpatient nurse clinicians, clinical nurse specialists and nursing education specialists. The Nursing Research Council charges for 2014 are: •p romote the spirit of inquiry in UWHC nurses, to further initiate research studies and to develop evidence-based practice projects; • s upport research conducted by UWHC nurses, UW-Madison School of Nursing researchers and others;
•D eveloped three- and five-year strategic plans to guide nursing research at UWHC
•d evelop mechanisms to promote the dissemination and utilization of research and other evidence to UWHC nurses;
• I dentified nurse-related indicators and designed a nursing research dashboard
•c ontribute to the development of evidence-based nursingrelated standards, nursing practice guidelines, and polices.
•O btained a statistical software package (SPSS) to help facilitate data analysis for nursing research •C ontinued to host an Annual Poster Fair. The 2013 Annual Poster Fair resulted in 78 posters being displayed by nurses from UWHC, WMS Middleton Veterans Hospital and the UW-Madison School of Nursing. Plans for next year include hosting a first-time ever, city-wide Annual Poster Fair, including St. Mary’s Hospital, Meriter Hospital (now joined with Unity Point Health), and Select Hospital for abstract submission
Mentoring and Consultant Services Additional goals included developing monthly Scholarly Forums containing educational content on a variety of topics such as, describing how to critique a research article, critical components of a research study, and explaining processes and procedures required in 25
Empirical Outcomes
Patient Satisfaction By Linda Stevens, DNP, RN-BC, CPHQ, CSPHP At the center of the Nursing Professional Practice model is the patient, family and community. Assuring a positive patient experience by providing a culture of patient- and family-centered care is one of the organizational strategic goals. Patient satisfaction for the inpatient units is collected by Press Ganey™ and measured using surveys mailed to patients after discharge. We have selected the Press Ganey™ academic medical center (AMC) 50th percentile score as the benchmark we aim for with all of our adult and pediatric inpatient units.
How Well Nurses Kept You Informed 100
“Educational” Domain
90
Thirteen of 19 units, or 68 percent, outperformed the Press Ganey™ AMC 50th percentile score for education. The adult survey states, “How well nurses kept you informed” and the pediatric survey states “Degree to which nurses kept you informed using language you could understand.”
80
Percent Very Good
70 60 50 40 30 20 10 0 CY2011 Q1
CY2011 Q2
CY2011 Q3
CY2011 Q4
D6/6
CY2012 Q1
CY2012 Q2
CY2012 Q3
CY2012 Q4
Press Ganey AMC 50th Percentile Score
Friendliness/Courtesy of the Nurses 100
“Courtesy and Respect from Nurses” Domain
80 70
Percent Very Good
Thirteen of 19 units, or 68 percent, outperformed the Press Ganey™ AMC 50th percentile score for courtesy and respect. The adult and pediatric survey statement is “Friendliness/ courtesy of the nurses.”
90
60 50 40 30 20 10 0 CY2011 Q1
CY2011 Q2
D6/6
26
CY2011 Q3
CY2011 Q4
CY2012 Q1
CY2012 Q2
CY2012 Q3
Press Ganey AMC 50th Percentile Score
CY2012 Q4
Empirical Outcomes
During Council Day 2013, the Nursing Quality Excellence Award for Outstanding Achievement in the category of Inpatient Staff Engagement Performance Excellence was presented to the Clinical and Translational Research Core (D6/6), demonstrating how engaged staff can positively affect patient satisfaction (see graphs).
Amount of Attention Paid to Your Special or Personal Needs 100
“Careful Listening by Nurses” Domain
80 70
Percent Very Good
Fourteen of 19 units, or 74 percent, outperformed the Press Ganey™ AMC 50th percentile score for careful listening. The adult survey statement is “Amount of attention paid to your special or personal needs,” and the pediatric survey statement is “Amount of attention paid to you and your child’s special or personal needs.”
90
60 50 40 30 20 10 0 CY2011 Q1
CY2011 Q2
CY2011 Q3
D6/6
CY2011 Q4
CY2012 Q1
CY2012 Q2
CY2012 Q3
CY2012 Q4
Press Ganey AMC 50th Percentile Score
Promptness in Responding to the Call Button 100
“Response Time” Domain
90
Thirteen of 19, or 68 percent, outperformed the Press Ganey™ AMC 50th percentile score for response time. The adult and pediatric statement is “Promptness in responding to the call button.”
80
Percent Very Good
70 60 50 40
Each unit continues to develop action plans to assure ongoing improvement in patient satisfaction.
30 20 10 0 CY2011 Q1
CY2011 Q2
D6/6
CY2011 Q3
CY2011 Q4
CY2012 Q1
CY2012 Q2
CY2012 Q3
CY2012 Q4
Press Ganey AMC 50th Percentile Score
27
Empirical Outcomes
The Power to Save Lives By Michelle Schmitz
Hand Hygiene Efforts Pay Off Several efforts targeted at improving hand hygiene compliance continued throughout FY13…and they paid off! Through various educational and awareness messages— including a monthly “awards presentation” of the “#1 in Hand Hygiene!” trophies and certificates for the top performing unit/ area and discipline—we achieved the organizational goal of 82 percent for hand hygiene compliance in August 2012, and consistently surpassed it to present day. For FY14, the bar has been set higher to 90 percent. Hand hygiene posters featuring staff and faculty from a variety of units and disciplines continued to influence behavior and positively affect compliance.
power to save lives
i have the So do YOU
It only takes 15 seconds to save lives. perform hand hygiene every time you enter and exit a patient room.
•E ducation was provided for all radiology nursing staff on how to complete restraint documentation. •E ducation was provided for nurses and nursing assistants on proper restraint application, documentation and restraint orders through the use of flyers and annual review. •E ducation was provided to physician groups on their role in the restraint ordering process.
The percent of patients in physical restraints ranged between 2.3 percent and 6.2 percent based upon one-day prevalence studies conducted monthly (Figure 1).
You have the power. please do Your part.
ND-29564-12
The Power To Stop Infections Is In Your Hands
• The copy forward feature was reinstated.
•D etermined that one reason for the increase in restraint usage was the lack of good restraint alternatives. A literature search was completed, and a new mitt was trialed on D6/4 (Neurology), F8/4 (Neuro ICU), and TLC. Upon successful completion of the trial, the mitt was approved by product council, and will replace the current mitt starting in FY14.
Ann White
ND-29564-12 hand hygiene 8.5 x 11.indd 6
•T he restraint flow sheet was modified with the goal of following current nursing workflow and simplifying documentation. A line was also added to prompt nurses to obtain an order prior to applications of restraints.
•R estraint documentation compliance added to the unit-based scorecards for increased visibility.
Manager, Surgical Services
The Power To Stop Infections Is In Your Hands
trying to improve the restraint program. Here is a list of what has transpired during the past year:
4/13/12 7:48 AM
Planned continuous improvements for the restraint program in FY14 include:
Overall Hand Hygiene Compliance 100%
•M onitoring unit trends and those units consistently above the national benchmark
90% 80%
•P roviding education on restraint alternatives and restraint documentation
70% 60% 50%
• Changing monitoring and documentation requirement for elbow
40% 30%
Figure 1: Restraint Prevalence June 2011 to June 2013
20% 10%
Percent of Patients with Physical Restraint
0% Jul-12
Aug-12
Sep-12
Oct-12
Overall UWHC Compliance
Nov-12
Dec-12
Jan-13
UWHC Goal 82%
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Compliance Trendline
7%
6%
5%
Monitoring Restraints for Patient and Staff Safety By Brooke Anderson, MSN, RN and Linda Stevens, DNP, RN-BC, CPHQ, CSPHP
4%
3%
2%
1%
28
Overall Nursing-One Day Prevalence
Trendline Restraint Prevalence
Jun-13
Apr-13
Mar-13
Feb-13
Jan-13
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
0%
To assure both patient and staff safety, the use of physical restraints is monitored very closely. The Safety Resources Nurses have been busy monitoring restraint use and are continually
Empirical Outcomes
Pressure Ulcers Trend Downward in FY13 By Deb Johnson, MS, RN, CWOCN; Jill Monfre, PhD, RN, CWOCN; Jackie Lakosky, BSN, RN, CWON; and Ginny Luger, BSN, RN-C
Teamwork, training and documentation credited with success Wound, skin, ostomy and continence care at UWHC is led by an experienced team of certified clinical nurse specialists (CNS), and nurse clinicians. The Wound/Skin Team CNS provides leadership for the Resources in Skin Care (RISC) nurses, which is comprised of direct care nurses from UWHC and AFCH who are given additional education and training specific to wound and skin care. This education includes pressure ulcer (PU) prevention, identification and treatment. The RISC nurses also collect monthly UWHC/AFCH Pressure Ulcer Prevalence and Incidence (P & I) data. The Wound/Skin Team in collaboration with the RISC nurses, have been instrumental in leading efforts to decrease the number of UWHC/AFCH hospital acquired PUs.
Below is a sampling of efforts that took place in FY13: •W orked with nursing leadership and RISC nurses on select units (TLC, D4/5) to improve PU admission assessment and documentation. •E mergency Department (ED) documentation has been modified to include PUs present on admission to the ED.
•A ctively supported UWHC/AFCH safe patient handling initiatives including, increased use of lift devices, turning devices and repositioning equipment as these decrease patient skin microtrauma and optimize PU prevention. •A dded question to Nursing Admission Assessment: Does this patient have a pressure ulcer? Yes or No • AFCH uses the Braden Q to assess Pediatric Patient PU Risk •A ssessment/Review of wound care dressings currently used at UWHC/AFCH •A ssessment/Review of current rental specialty beds used at UWHC/AFCH Overall, pressure ulcer prevalence and incidence is trending downward for FY13 (Figure1).
Planned initiatives for FY14 include: • Complete assessment/review of UWHC Wound Care Formulary •C ontinue process for obtaining an integrated pressure redistribution mattress/frame system for all critical care patients •A ssess/Review and make recommendations for new mattress/frames at UW Health at The American Center •P articipate in rental specialty bed/vendor fair to decide optimal specialty support mattress surfaces for UWHC/AFCH patients (includes Bariatric and Low air loss)
•U WHC inpatient mattresses have been standardized to a pressure redistribution surface with pump.
• Update the U-Connect Wound/Skin/Continence/Ostomy site
• Bariatric waffle cushions were added to the CS inventory. •S tandard and bariatric waffle cushions are pre-filled to reduce chance of manual under/over inflation.
5%
10% 9%
7%
3%
6% 5% 2%
4%
Pressure Ulcer Incidence
4%
8%
3% 1%
2% 1%
Prevalence
Jun-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Oct-12
0%
Sep-12
0%
Aug-12
• I nitiated Wound and Skin CNS review of coded Stage 3 and 4 pressure ulcers before data submission to external reporting agencies, assuring data accuracy.
Pressure Ulcer Prevalence and Incidence 11%
Jul-12
•W orked with the inpatient rehabilitation program (B4/4) leadership team and staff to assure all nurses are skilled in PU identification, assessment and documentation. A member of the Wound/Skin Team does weekly patient rounds with B4/4 staff and the B4/4 unit CNS to assure proper PU assessment and documentation.
Figure 1
Pressure Ulcer Prevalence
•O n P & I day, the RISC nurse contacts a member of the Wound/Skin Team if there are new areas of skin breakdown and also notes this during patient assessment/data collection. The Wound/Skin Team member assesses the patient to assure wound etiology is properly identified with the correct documentation.
Incidence
29
Empirical Outcomes
CAUTI Project at UWHC By Suzanne Purvis, DNP,RN, GCNS-BC and John Marx, MPH In 2011, the CAUTI rate was noted to be 4.2 CAUTIs per 1000 indwelling catheter days. NDNQI® reports showed CAUTI rates above the benchmarks and verbal reports from nurses during CNS rounding indicated a wide disparity in beliefs about how best to manage indwelling urinary catheters and when they should be discontinued. The CAUTI team consisting of nursing, quality, infection control and physician leadership, determined the following goals: • Reduce CAUTI rates at UWHC •R educe the number and duration of use of indwelling urinary catheters on all inpatient units
Methods employed in this project included: •A one-month concurrent review of all patients with indwelling urinary catheters on one medical unit (D4/6) and one surgical unit (F4/6) to evaluate current practice. These were performed in collaboration between the clinical nurse specialists and physicians on the team. •R eview of all positive urine culture results by the infection control practitioner, along with determination if the patient had a symptomatic or asymptomatic bacteremic CAUTI, as defined by the most current National Healthcare Safety Network (NHSN) criteria for CAUTI. •C ollaboration between the CNS for geriatrics, the unitbased CNS, surgeons, and nursing staff on F4/6 to collect and analyze data on urinary retention in the post-operative patients, with the goal being the removal of indwelling urinary catheters by post-operative day (POD) 1. •M odification of the existing Catheter Removal and Bladder Management protocols, standardization of the protocols on all inpatient units, and linkage of the protocols to provider orders in Health Link. •C reation of an icon in HealthLink to identify patients with an indwelling urinary catheter as well as evidence of the protocols in use. •E ducation of CAUTI champions including 63 clinical nurses, 13 nurse managers, and 12 CNSs. •P rovision by infection control of regular updates on the monthly data including catheter utilization and CAUTI rates. CAUTI rates were added to each unit’s quality scorecard every month. •D iscussions about indwelling urinary catheter management were added to the daily Interdisciplinary Model of Care (IMOC) Rounds.
30
Outcomes With more prompt removal of catheters, overall measures of indwelling urinary catheter use declined dramatically. When compared by service, sharp declines in urinary catheter days on surgical services were prominent. Overall device utilization (urinary catheter days/patient days), likewise declined each year, most notably from 0.27 in 2011 to 0.23 in 2012. For patients with a urinary catheter, this represented a 50 percent reduction in mean catheter dwell time (total catheter hours/ total number of catheterized patients), which declined from 182 catheter hours per catheterized patient in 2011 to 91 catheter hours per catheterized patient in 2012. With reductions in urinary catheter duration—the main modifiable risk factor for CAUTI—overall CAUTI rates likewise decreased in each successive intervention year, from 4.2 infections per 1,000 Foley days in 2011 to 3.1 through August 2013. Caveat: A substantial change in CAUTI definition in January 2013 renders direct comparison of CAUTI rates to previous years invalid, although device utilization calculations are unaffected.
2013-2014 Plans Interventions for the second phase of the CAUTI project include: •P oint prevalence to include monitoring of proper indwelling urinary catheter management • I nventory of equipment with goal of standardizing catheter configurations stocked on units •P ilot in TLC and on F4/6 of new protocol for insertion of indwelling urinary catheters • Implementation of new protocol in OR •A udit of patients with indwelling urinary catheters transferred out of IMCs • Addition of Foley catheter care to HealthLink documentation.
Empirical Outcomes
Urinary Catheter-Days by Service 4000 3750 3500 3250 3000
Catheter-Days
2750 2500 2250 2000 1750 1500 1250 1000 750 500 250
2011
Burn
Med Tx
Ped Crit Care
Plastic Surg
Rehab Med
Pall Care
Fam Med
Surg Crit Care
Liver Tx
Card Surg
Thorac Surg
Cardiol
Renal Tx
Vasc Surg
Gyn
Urol
Trauma Surg
Orth Surg
Gen Med (6)
Hosp (4)
Crit Care
Gen Surg
Neurosurg
0
2012
Catheter-Associated Urinary Tract Infection vs. Urinary Catheter Utilization Jan 2011 - August 2013 .27
.27
.27
.26
.25
6.0
.27
.28
.28
.28 .26
.26
CAUTI definition changed in January 2013
.27 .25
6.1
.25
.25 .24
.24 .23
.22
.23
.23
.22
4.8
4.4
.23 .21
3.7
3.7
3.6
3.7
2.3
2.2
2011
CAUTI Rate = 4.2 Device Utilization = .27 Catheter Hours/Cathed Patient = 182
2012
CAUTI Rate = 3.5 Device Utilization = .23 Catheter Hours/Cathed Patient = 91
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
CAUTI Rate per 1,000 Urinary Catheter-Days
.23 .21
5.2
3.5 3.2
3.1
3.0 2.5
2.1
.22
.22
3.7 3.7 3.6
3.6
3.3
3.0
.22
4.2 4.2
4.1
Jan Feb Mar Apr May Jun
.22
5.1
4.5
3.2
.24 .22
2.4
2.3
2.2
2013 (Jan-Aug)
CAUTI Rate = 3.1 Device Utilization = .22
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Jul Aug
Device Utilization (Urinary Catheter-Days/Patient-Days) 31
Empirical Outcomes
SMART Program By Brooke Anderson, MSN, RN, and Linda Stevens, DNP, RN-BC, CPHQ, CSPHP
Reducing Patient Handling Injuries and Costs Patient handling injuries result from the manual lifting of patients—costly, yet preventable events. The Safe Patient Handling Taskforce formed in 2009 has helped develop and implement the evidence-based Safe Movement and Repositioning Techniques (SMART) Program at UWHC. The SMART program includes state-of-the-art equipment, education and training for frontline staff. The purpose is to decrease the cost and severity of injuries associated with patient handling by improving workplace safety and creating a culture of safe patient handling and mobility. As of June 2013, the SMART program has been implemented within 13 inpatient units. In addition, components of the program are in place in Hemodialysis, the Operating Room, Radiology, the Cardiac Catheterization Lab and Radiotherapy Clinic. Since implementing the program, patient handling-related injuries have declined organization-wide, from 187 injuries related to patient handling in FY12 to 164 injuries in FY13. There has also been a 32 percent decrease in lost days of work related to patient handling injuries from 2,010 days in FY12 to 1,361 days in FY13. This indicates a decrease in the severity of staff injuries from patient handling duties. The cost of safe patient handling injuries has decreased from more than $1 million in FY12 to $440,844* in FY13. This represents a 57 percent reduction in costs in just one year (Figure 1).
After-injury results indicated that the most common contributing factors were: appropriate equipment not available on the unit; staff did not know equipment was available or how to use it; or nursing staff felt the equipment was not needed. These common causes were used to develop a “tips and tricks” handouts and content was incorporated into some units annual review content.
Additional accomplishments of SMART in FY13 include: • I ntroduction of new equipment (Sara Stedy, Hoversling, Sage Turn and Reposition System) • I nitiation of a sling trial to begin standardizing the use of slings • In-services on safe patient handling for multiple units • D evelopment of a pediatric safe patient handling algorithm •A ssessment of HoverMatt use and subsequent addition of canisters •E limination of mattress pads on inpatient units (except for trauma and pediatrics), to encourage the use of safe patient handling equipment •C reation of in-service videos for the HoverMatt, HoverSling, and Ceiling lift • Publication of the safe patient handling equipment guide • Submission of budget requests for additional equipment for FY14 • Production of the ceiling lift replacement plan • Distribution of a quarterly SMART newsletter to all champions • Creation of a post-injury, follow-up database
Direct Injury Cost Related to Patient Handling by Fiscal Year
Figure 1 – Direct Injury Costs Related to Patient Handling
$1,600,000
$1,400,000
* D ata compiled by Lorna Knapp RN, COHN-S. Not all claims closed at time of publication.
$1,200,000
$1,000,000
$800,000
$600,000
$400,000
$200,000
$FY10
32
FY11
FY12
FY13
Empirical Outcomes
Inpatient Fall Prevention By Linda Stevens, DNP, RN-BC, CPHQ, CSPHP Nurses at UWHC have been making efforts to prevent patient falls and injuries for many years. Patient falls are reported through the patient safety net and all reported falls are evaluated by a clinical nurse specialist in quality and safety. Common causes of falls are evaluated through the collection of data and examining factors such as time of day, day of week, number of days after admission, medications, activity prior to the fall, gender and age. Multiple initiatives and collaboration with all team members are required in the inpatient setting to prevent falls. An interdisciplinary work group was formed and determined that the first step was to assure appropriate identification for patients at risk for falling. Since nursing staff complete the risk assessment for fall prevention, initial focus was placed on educating nurses on fall risk assessment and interventions required for patients at both standard and high fall risk.
Increase awareness, decrease falls To elevate the importance of fall prevention, increased and frequent communication about falls and fall prevention was initiated. Daily fall prevention messages are sent to nurse leaders regarding patients who have fallen, audits of patients with correct visual communication of fall risk, and fall risk
assessments completed on transfer between units. A weekly message was also initiated to allow each unit to post “days without a fall.” Units with significant improvements receive a visit from senior nursing leadership—all inpatient units experienced a record “four consecutive days without a fall” this past year. Learning from our falls has been an additional focus in FY13. To look for common causes of falls, unit leadership was asked to complete a “Post-Fall Analysis” after each fall involving the patient and staff members who were present at the time of the fall. The most significant finding from the reviews identified that for about 90 percent of the falls, a contributing factor was either the patient or the staff member over estimating the patient’s functional ability. This finding will drive further work on fall prevention in the coming year, and highlights the need to partner with patients and families in fall prevention efforts. In addition, many units developed a unit-specific action plan to prevent falls. The number of falls decreased slightly in FY13 to 385 with a rate of 2.50 falls per 1,000 patient days (Table 1). The number of patients injured when falling increased to 126 or 0.82 injury falls per patient day. There were 113 minor injuries, eight moderate injuries and five major injuries.
Table 1: Number of Inpatient Falls and Fall Rates Fiscal Year
Number of Falls
Blended Patient Days
Fall Rate per 1000 Blended Patient Days
2011
403
145,121
2.78
2012
407
147,998
2.75
2013
385
154,000
2.50
Total Patient Injury Falls Per 1000 Blended Patient Days
Total Patient Falls Per 1000 Blended Patient Days
1.60
3.50
1.40
3.00
1.20
2.50
1.00
2.00
0.80 1.50 0.60 1.00
0.40
0.50
0.20
Trendline Injury Fall Rate
Fall Rate
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Injury Fall Rate
Jul-12
0.00
0.00
Trendline Fall Rate
Mean based upon 24 data points Upper Control Limit (UCL) +2 Standard deviations from fall rate mean Lower Control Limit (LCL) -2 Standard deviations from fall rate mean 33
t e n Mag d u o Pr
ND-37505-13