Transformational Leadership - TL01
TL 1: Describe and demonstrate how nursing's mission, vision, values and strategic and quality plans reflect the organization's current and anticipated priorities.
Mission, Vision and Values:
Penrose-St. Francis Health Services (PSFHS) Nursing Services' Mission, Vision, and Value statements represent our beliefs. Their content also demonstrates our commitment to patients, our communities, and other associates. These statements are the foundation for our organization's strategic planning and priority setting. The table below demonstrates the alignment of our mission, vision, and values throughout Centura Health, PSFHS, and PSFHS Nursing Services.
Mission Values Vision
Centura Health &
We extend the healing
ministry of Christ by
caring for those who are
ill and by nurturing the health of the people in
Centura Health will fulfill a
covenant of caring for our
communities with excellence
and integrity to become their
partner for life.
Centura Health &
We extend the healing
ministry of Christ by
caring for those who are ill
and by nurturing the
health of the people in
PSFHS Nursing is the
recognized leader in
dedicated to excellence in
nursing practice; balanced with
the concern for the well being
of the care giver.
PSFHS Nursing Vision PSFHS Nursing Leadership Team created our nursing vision. This team is inclusive of: the Chief Nursing Officer, the Vice President of Nursing, the Director of Patient Care Services at Penrose, the Directors of Peri-Operative Services, the Director of Clinical Effectiveness, and the Director of Professional Resources. This group of senior nursing leaders utilizes an annual retreat process to review our vision, evaluate progress toward that vision, and assess need for change. In 2010, we adopted a Relationship-Based Care philosophy at the Centura Health Nursing level. This change prompted PSFHS Nursing Services to replace our previous model ("patient-family centered care"), with "relationship based care" in our vision statement.
Centura Health 2020 (TL1-1) Strategic planning at the Centura Health corporate level involves leadership representation from each Centura facility. In 2009, Gary Campbell, the Centura Health President and CEO, established structures for communication and led Centura to create Centura 2020, our strategic plan to transform health care in Colorado and fulfill our mission during the next 10 years. Campbell sent emails and electronic surveys to gather input from all Centura associates, prior to finalizing Centura Health 2020. The following three paragraphs, quoted from the plan's introduction, provide a summary of Centura Health 2020:
Strengthening the Foundation: From small, day-to-day actions to the way we collaborate as a team, this commitment to safety and service is more than just good health care; it is a natural expression of the compassion and caring that is central to Centura Health. Strengthening our foundation also means providing our associates and physicians with the proper tools to reach their full potential and care for our patients.
Creating Systems of Care: We serve more communities and people in Colorado than any other health care provider, but in order to truly unlock the power of our system we must begin to view our organization less as individual facilities and more as a network of care that works together. We will focus our initial efforts on three key service lines, and by 2020, Centura Health will be the statewide leader in: Trauma services, Cardiovascular care and Neurosciences (stroke and spine).
Moving Upstream: There is nothing more compassionate, more effective, and more rewarding than to be part of a team that supports wellness rather than just treats illness. "Moving upstream" means helping our patients learn to make smarter choices about their health, by promoting wellness and preventative care, and providing the education and support they need to think differently about health care.
In 2012, Centura Health 2020 shifted from system wide objectives to delivering value for the community. Using crowd-sourcing, Centura Health is seeking associate input into all 2020 focus areas. The use of crowd-sourcing demonstrates the ongoing commitment to align the strategic plan with all entities and all levels and settings of our associates. (TL1-2, TL1-3)
The schematic attached provides a quick overview of the structures and processes for continuing our transformation via Centura Health 2020. (TL1-4)
Centura Health Nursing Strategic Plan Chief Nursing Officers across Centura comprise the membership of the Centura CNO Council. Ann Kjosa BSN, MBA/MHM, RN, FACHE, CNO for PSFHS is an active member of this group. The Centura CNO Council is responsible for the creation of Centura Health's centralized Nursing Strategic Planning across our healthcare system. The Centura Health Nursing Strategic Plan is a structure for evaluating nursing practices and generating annual nursing goals that are consistent with the goals of both our organization as well as individual entities. The schematic attached to our 2010 - 2014 Centura Health Nursing Strategic Plan is in alignment with Centura Health 2020. (TL1-5)
PSFHS Nursing Strategic Plan (TL1-6) The Nursing Strategic Plan is also aligned with the Centura Health Nursing Strategic Plan. The structure for professional nursing practice, communication, and collaboration at PSFHS is presented in our PSFHS Nursing Professional Practice Model (PPM); which we have named the "Circle of Excellence." Six primary elements guide our practice, and they are: Nursing Vision, Relationship Based Care, Standards of Practice, Quality of Care, Guiding Principles, and Shared Decision Making. These structures support the implementation of our strategic plan and continuous quality improvement by displaying the physical interactions and intersections that make up the elements of nursing practice at PSFHS.
Our Shared Decision Making structure delineates council purposes and each council defines goals and tactics to implement the nursing strategic plan to achieve targeted outcomes. Within our Shared Decision Making structure, several councils are charged with quality and patient safety. Some of these are:
The Nursing Leadership Council functions as a decision making body, evaluating the practice of nursing and making recommendations in regard to delivery of direct patient care services across the continuum. Core membership consists of directors or other representatives from Nursing, Respiratory Care, Care Management, Human Resources, Infection Control, Patient Safety/Risk Management, Educational Resources, Perioperative Services, Out-Patient Services, and Information Services. Laboratory, Radiology, and Pharmacy are also included in the council as needed.
Nursing Practice Council (NPC) revises and supports standards of nursing practice through effective communication with clinical nursing staff. NPC goals for FY2012 focused on peer review to improve the quality of care, the implementation of relationship based care, and improving patient satisfaction.
Nursing Quality Council (NQC) supports the mission, vision, values, and the strategic plans of the hospital by addressing key nursing issues each fiscal year. In FY2013, for example, the NQC has targeted and identified a series of strategic objectives which compliment those of the organization writ large.
Penrose-St. Francis Health Services Quality Plans:
PSFHS Organizational Performance Improvement and Patient Safety/Risk Management Plan Penrose-St. Francis Health Services (PSFHS) is dedicated to improving systems and outcomes through continuous quality/performance improvement. Organizational quality/performance is linked to our mission and core values. Our energy and convictions focus on "excellence and quality service" as the heart of what we do, and how we do it. Our goal is a system-wide process that improves organizational quality/performance with improved patient safety and cost savings. Innovation and creativity are central themes of this effort. Although regulatory requirements must be met, the motivation behind our process development is our desire to continuously improve the services that we deliver to our customers. A collaborative, cross-departmental effort to maximize patient safety, produce positive outcomes, increase customer satisfaction, and cost effectiveness drives our improvement efforts. We evaluate results in order to constantly improve our services and streamline our systems via the Clinical Effectiveness Committee.
While everyone is responsible for quality, multiple committees and councils provide a structure and process for the ongoing evaluation of quality metrics and continuous quality improvement practices. The following examples highlight this focused self-evaluation:
The Clinical Effectiveness Committee (CEC) is a leadership committee that has been organized by the Community Board. The CEC's responsibility is the ongoing oversight of safety improvement activities via periodic reports from parties that are accountable for the implementation of quality and patient safety efforts. The committee is comprised of: members of the Community Board, Senior Administration, Medical Staff, Quality Improvement, Nursing leaders, as well as clinical ancillary department leaders.
The Quality Patient Safety Committee (QPSC) is responsible for setting specific quality/performance goals each year based on these priorities. When reviewing and setting goals, the QPSC, will consider emerging needs such as those identified through data collection and assessment, unanticipated adverse occurrences affecting patients, changing regulatory requirements, significant patient and staff needs, changes in the environment of care, or changes in the community. The CEC membership includes nursing representation.
Nurses serve on organization wide interdisciplinary committees charged with quality and patient safety including:
• Infection Control
• Accreditation Readiness Group (ARG)
• Red Rules
• Rapid Response Team (RRT) and Code Blue
PSFHS Nursing Quality Goals are defined in our Nursing Strategic Plan and then individualized at the unit, department, and council levels. Annually, each nursing unit writes a "Plan for Provision of Care" which states the organizational performance improvement methodology and quality indicators. An example of the quality indicators from Penrose 9 (Surgical) is presented below.
"The 9th Floor will meet The Joint Commission Standards, National Patient Safety Goals, and CMS indicators. All occurrence reports are reviewed by the Clinical Manager or her designee. Physician and associate satisfaction is monitored annually. Patient satisfaction (HCAHPS) is monitored monthly.
The 9th Floor quality indicators include: pain assessment and reassessment, pressure ulcer prevention, hand hygiene compliance, fall prevention, 24/48 hour discontinuation of antibiotics, medication reconciliation completeness, and hand-off communication. 9th floor FOCUS PDCA is the Shift - to -Shift (Hand-off) report."
In addition, nursing quality goals are integrated into individual associate Performance Feedback and Development plans. By aligning our strategic plan goals at the corporate, organization, unit, and individual levels we create a synergistic focus.
Strategic and Quality Plan Reflect the Organization's Current and Anticipated Strategic Priorities:
The Centura Nursing Council Strategic Plan for FY2013 documents the Organizational Strategic Priorities, Objectives, Metrics, and Initiatives for nursing services related to each priority. Centura Health 2020 continues to evolve; current language includes the "Second Curve", "Getting Different", and "Getting Better." This terminology builds and focuses our strategic
Examples of How Nursing Reflects Organization Current and Anticipated Priorities:
Linking Organization Priority with Nursing Strategic Plan and PSFHS Nursing Practice Council
• Centura Health Priority: Maximize Revenue Capture from VBP
• Centura Health and PSFHS Nursing Strategic Plan Initiative: Integrate strategies to reduce pressure ulcers and injury falls with post acute care through Improve Peer Accountability.
• PSFHS Nursing Practice Council Goal: Promote professional development, increase individual and team accountability and strengthen the professional nursing culture through formal unit level nursing peer review in all clinical nursing service areas.
Linking Nursing Mission, Vision, Values, Strategic and Quality Plans with Organizational Priorities -Examples
Priority Actions that Reflect Organization's Priorities
Implementing evidence based practices that reduce risk
of healthcare acquired infections.
A philosophy of relationship-based care is included in our nursing
vision. Many "Magnet Moments" stories reflect actions indicative
of relationship-based care. This monthly document is sent to all
board members and associates and is posted on units.*
Velda Baker BSN, CGRN, GI Lab Penrose Hospital writes "We received a heads up from a physician's office that we were going to be taking care of a patient with ALS who was dependent on a ventilator. We called the husband ahead of time to discuss the patient's needs, equipment and medications. When the patient arrived, the Respiratory Therapist was ready to meet the patient. We had a Hoyer lift ready to transfer the patient to the bed. We had meds and history already entered into the record so we did not need to take time to do that. Our planning ahead allowed us time to focus on reducing the patient and family anxiety and not feel rushed. As planned the surgeon came in to assess and remove a skin tag - the OR brought the necessary supplies to us quickly. The GI procedure went well! The patient and family were helpful, actively involved and appreciative of our actions. Watching how the patient's husband cared for her made me feel grateful to be part of coordinating her care at Penrose. The care he gave his wife was a calling and burden, and to be able to lighten that burden just a little was a privilege."
PH GI Lab HCAHPS Top Box results for June 2012 reflect patient perception of staff respect and compassion:
• Overall Rating 91
• Responsiveness 84
• Keeping you informed 90
• Treat you as whole person 97
PSFHS nursing improved in all categories of Press Ganey Scores and is scheduled to participate in the annual Press Ganey in April 2013. (Overall Score 2011=68.2; Overall Score 2012=72.9)
Graphics are displayed on all units and best practices implemented. PSFHS nurses participated in several Centura Health Nursing Pilot Projects to evaluate outcomes of best practices and validity of assessment tool. Penrose Hospital reports Injury Falls per 1000 Patient Days for 3Q2012 Mean 0.70 improved from 1Q2012 Mean 1.11.
The PSFHS 2010-2014 Nursing Strategic and Quality Plan and goals are attainable, measurable and meaningful. As we progress toward our strategic and quality goals, annual reviews promote revisions based on new priorities. For example, Patient Safety Goals are always a priority and as new patient safety goals are anticipated and then disseminated, PSFHS nursing will add these priorities and related goals to our plan.
When PSFHS closed our inpatient behavioral health unit, we anticipated a possible impact on emergency department services. PSFHS leaders had been collaborating with community agencies and leaders to identify options for continuing care of patients with psychiatric illness. PSFHS' relationships with three inpatient psychiatric facilities have provided continuing inpatient treatment to patients with psychiatric illness. Our emergency departments will continue to provide emergency services and disposition planning for these patients. PSFHS expanded outpatient services to meet the continued outpatient needs of our patients.
Our anticipated priorities are to minimize the potential for delays with disposition and throughput of patients served in the emergency rooms, reduce readmissions related to congestive heart failure, and improving our Value Based Purchasing rating.
Nursing Actions that Reflect Organization's Anticipated Priorities:
Priority Nursing Actions
Quality of Care Nursing services expanded the shared decision making structure with a Nursing Quality Council and Nursing Staffing Council in late 2011. As the focus on quality and on adequate staffing increases these councils are providing opportunities for direct care nurses to actively analyze data and take actions to improve.*
Concern for the
well being of
The PSFHS Nursing Quality Council investigated the literature and approved napping during breaks in FY2012.
Excellence Closing our inpatient behavioral health unit in 2011 led to an increase in emergency room time for patients waiting for inpatient admissions and/or an increase in inpatient admissions with co-morbid psychiatric illness to medical-surgical floors. Active planning to meet patient, nurse and organization needs is continuing. In 2012 PSFHS nursing and security services revised mandatory training to improve patient and associate safety through actions to reduce and/or contain aggressive patient behaviors. Non violent crisis intervention training was taught to all security staff, emergency departments, urgent cares and charge nurses on select floors.†
The Professional Practice Model: Nursing Guiding Principles identifies the importance of Interdisciplinary Collaboration. As PSFHS moves closer to implementation of Computerized Physician Order Entry (CPOE), workflow meetings, training schedules and order set implementation required strong interdisciplinary collaboration.‡
Nursing mission, vision, values and strategic and quality plans reflect the organizations current and anticipated priorities. Structures and processes across multiple levels and multidisciplinary oriented promote a collaborative approach to achieve strategic and quality goals. Led by Centura Health, our PSFHS Governing Board and the Standards of Nursing Practice we align goals to fulfill our mission. Metrics are identified in plans and national benchmarks ensure accurate evaluation of progress and outcomes. A continuous process of evaluation of our internal operations and outcomes and ongoing scanning of our external environment for healthcare needs, changes, new technology and regulations keeps PSFHS focused on excellence. A final attachment demonstrates the integration between our PSFHS Nursing Vision, PSFHS Nursing Professional Practice Model and Organizational/Nursing Quality Metrics which demonstrate excellence. The professional poster was displayed at the annual American Nurses Association National Conference in February 2013. (TL1-11)
Transformational Leadership - TL02
TL 2 Describe and demonstrate how nurses at every level - CNO, nurse administrators, and direct-care nurses - advocate for resources, including fiscal and technology resources to support unit/division goals.
Standard 14: Resource Utilization. The nurse administrator considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing and other services. (American Nurses Association (2009). Nursing Administration: Scope and Standards of Practice. Silver Spring, MD: Nursebooks.org)
The Nursing Strategic Plan and individual unit Plans for Provision of Care identify nursing division and unit goals, as well as staffing resources to meet goals. The PSFHS annual budget documents financial resources planned for the year including staffing, capital, supply, and technology budgets. The Strategic Plan and Nursing Services Budget are the two top level structures for fiscal and technology resource planning to meet unit/division goals.
Decision making for fiscal and technology resources occurs on multiple levels depending on the request. As a member of the Senior Leadership Team, the CNO participates with PSFHS senior leaders as well as PSFHS nursing senior leaders in planning for the allocation of resources. Additional structures that provide opportunities for nurses to advocate for resources include nursing councils, staff meetings, manager meetings, director meetings, and multiple interdisciplinary specialty committees.
Annual Fiscal Planning:
The annual budget is developed by the organization's Finance Department based upon historical, trended data, and strategic/operational goals. Senior nursing leaders and clinical nurse managers participate in an annual review and revision of their unit budget which includes: capital expense requests, staffing changes, equipment, as well as other needs.
Chief Nursing Officer:
One of the primary duties of the Chief Nursing Officer is the continual management of resources that are to be utilized by direct care nurses. Kate McCord, CNO, is able to advocate for the maintenance, expansion, and procurement of resources through her active participation on strategic, fiduciary, and quality committees. The strategic planning process including development of metrics guides the review and request for resources to achieve these goals for the organization and for nursing services.
CNO Advocacy - Capnography:
Patient safety is the primary goal for nursing and the organization as a whole. Our Nursing Professional Practice Model expects nursing to use evidence based practices to improve patient care and outcomes. When the High Risk Medication Team at Centura Health provided recommendations for safe patient care, we took action to evaluate the recommendations, literature, and the relevant PSFHS standards of practice.
Background/Purpose Our commitment to patient safety and recommendations from Centura Health Clinical Effectiveness Group (CEG) led to an evaluation of our standards of care and current practice at PSFHS related to the monitoring of patients on Patient Controlled Analgesia (PCA) or those who are receiving conscious sedation. In February 2011, the Centura Health CEG group made the following recommendations:
"All patients on PCA should be monitored with continuous pulse oximetry. Continuous pulse oximetry should not be discontinued until the patient is off of PCA. Again, caregivers must be mindful of the limitations associated with pulse oximetry monitoring, especially when the patient is on supplemental oxygen. Pulse oximetry should not replace routine, direct observation of the patient's respiratory status.
Although it would be idea and best practice to provide capnography monitoring for high risk patients, the High Risk Medication team recognizes this level of monitoring may not currently be possible in our facilities." (TL2-1,TL2-2)
The American Society of Anesthesiologists reviewed their capnographical standards and created new policies that went into effect July 1, 2011. In order to meet these new standards, McCord and the other participants reviewed the existing procedures and noted that a material upgrade was required. (TL2-3)
Kate McCord, MSN, RN, NEA-BC, CNO
Evelyn Angeles, RN, CVU
Pamela Assid, Cin. Mgr. SFMC ED, Interim PH ED
Patrick Ballard, Dir. Finance
Lonnie Cramer, Adm. Dir. OR
Diane DeMasters, Cin. Mgr. GI
Mike Eglinton, Cardio Tech
Calvin Eisenach, Mgr. Pharmacy, SFMC
Todd Farina, Cin. Coord. PH ED
Ingrid Fenlon, RN, CVU
Jeff Oram-Smith, MD, CMO
Methods/Approaches In July 2011, the Chief Nursing Officer established an inter-professional team to evaluate the literature and Centura Health recommendations regarding use of Pulse Oximetry with all patients on PCA and monitoring all patients receiving conscious sedation with capnography. The team reviewed literature, current policies and identified current capacity to meet the recommendations. (TL2-4, TL2-5)
Per the PSFHS structure, we obtained quotes to meet the needs of the entire organization to include the following units:
Inpatient Imaging: Ultrasound Cardiac Diagnostics
Cath Lab Radiation Oncology Labor and Delivery
Radiation Diagnostics Outpatient areas Urgent Care
In September 2012, capital requests were approved and submitted to Supply Chain for processing. McCord then compiled the data and presented the CFO with requests for new equipment.
Outcomes These requests were approved thanks to the clear advocacy and leadership of the CNO. The standards of care that had been established by the American Society of Anesthesiologists were met and the CO2 levels of patients can now be monitored in a more efficient way.
VP of Nursing, Directors of Nursing, Nurse Administrators:
The culture of advocacy within the nursing staff at PSFHS is prevalent. Nurses at all levels are encouraged to pursue ideas and innovations that would promote efficiency and effectiveness. The actions of our Nurse Administrators are evidence of this.
Nursing partnered with Finance, Therapies and Supply Chain to improve our ability to meet the needs of bariatric patients cared for on the Penrose Hospital floors. The goal was to increase our bariatric equipment to improve patient and nurse safety as well as respect for the unique needs of our patients. The Sleeper Chair/Bari Equipment Task Force included representatives from all provider partners. (TL2-6)(TL2-7)
The VP of Nursing at Penrose responded to the requests from direct care nurses and managers for more equipment. Sleeper chairs and bariatric equipment were limited, shared and often not easily available on the floors. The Bariatric Unit has adequate equipment that it shares with units in the east tower, however, the west tower requested easier and timely access to equipment. The team completed an inventory of equipment and found gaps. She requested input from all floors on current needs and each unit responded with specific needs for bedside commodes, sleeper chairs and recliners. Finance provided a budget of $60,000. The VP identified the needs and collaborated with Supply Chain and the Vendor to obtain the equipment within the budget. Equipment was ordered and arrived in summer 2012. (TL2-8)
The 11th Floor Inpatient Oncology Unit identified the need to replace the whiteboards in patient rooms. The boards were difficult to clean and many of them look dingy. Other facilities include more information on their patient whiteboards, helping the patients, families, and staff to have easy access to basic information related to the patient's plan of care. The 11th Floor's whiteboards had only the patient's room number, phone number, patient's name, RN name, and CNA name. A literature search was conducted to identify the key components that should be included; however, research on use of whiteboards is limited. (TL2-9)
The Clinical Manager, Carolyn Cusic, gathered multiple samples of whiteboards from the internet and from catalogs. UPC members evaluated the options. A paper trial of 2 different styles of whiteboards was done in May 2012. During the trial period, each template was used for one week and filled out during the change of shift. The charge nurses rounded with patients and obtained feedback regarding whether the information was completed, and if not, what was missing. The nursing staff was also asked to complete a feedback tool at the end of their shift. This tool asked for information regarding: how many patients they had cared for, how many patients had the whiteboard information completed, what was a benefit of the whiteboard information during their shift, what barriers existed to filling out the information, and any additional comments. (TL2-10, TL2-11)
After the trial period, the results were discussed at the UPC and staff meetings. The project then moved into the ordering phase. The Clinical Manager searched for companies that had the desired product as well as a contract with Centura Health. Quotes were reviewed with the CNO who had supported nursing's decision. The selected produce required Supply Chain to establish a new contract. (TL2-12)
After the whiteboards were installed, the UPC and charge nurses are responsible for developing a peer review/audit tool to ensure that the whiteboards are being utilized each shift. The clinical manager will also be rounding with patients to gather patient response to the boards. HCAHPS results will also be followed to evaluate whether the whiteboards have an impact on patient satisfaction scores.
Advanced Practice Nurses, advocated by the Director of Professional Resources:
The number of Clinical Nurse Specialist positions within PSFHS, have been increasing under the leadership of our CNO. Pain, Palliative Care, Critical Care and Birth Center CNS's were employed during the 2005-2006 period. In 2010, a Medical Surgical CNS and a Nurse Practitioner/Educator for medical surgical nursing were added to the overall number of Advanced Practice Nursing specialties practicing at PSFHS. In 2012, an additional Nurse Practitioner was hired to provide support at SFMC for pain and palliative care. Nursing Service goals that are focused on improving patient quality and safety, as well as increasing the percentage of certified nurses are supported through these Clinical Nurse Specialist positions.
Direct Care Nurses:
Volunteer Grants Every fall our PSFHS Volunteer Department seeks applications for the annual volunteer grants. Direct care nurses and managers collaborate to identify needs focusing on patient safety and satisfaction. We all look forward to this time as this is always an opportunity to advocate for needed resources that we had not anticipated or been approved in the annual budgeting process. For example in 2011 the Volunteer Association gave out approximately $225,000 in the form of grants and pledges. Nursing units received DinaMap Vital Sign machines, a mechanical lift, a hyper/hypothermia machine, wireless fatal monitors, and specialty chairs. (TL2-13)
Direct Care Nurse Advocacy for Resources through Rounding "Do you have the equipment to do your job?" is a regular rounding question. Nurse leaders round on all nursing staff and directly seek input into resource needs. Mackenzie Mudd BS, MSN, RN, Clinical Nurse Manager posts a sheet asking for needs; she states "it really works well - sometimes staff needs tape or thermometers or notebooks. I respond quickly by ordering and delivering the resources staff have requested." Nursing quality goals require adequate resources to effectively and efficiently practice nursing.
Direct Care Advocacy for budget revisions to support Council Chairs A proposal was submitted to and approved by the Nursing Leadership Management Council to allocate funds from the Nursing Administration budget instead of unit level budgets to pay for time for nursing council chair work. (TL2-14)
Direct Care Nurse Advocacy for unit equipment PH 4 nurses identify their requests for equipment during staff meetings. The Clinical Manager supports staff requests within the unit budget. When staff asked about wall mounted manual BP cuffs, the manager reminded them they had voted "no" during prior meetings. However, at the current time nurses would like this change; pricing is being obtained. (TL2-15)
Nurse Educator Advocate for Resources:
Paid Time for Nurses, advocated by Nurse Educator One Nursing Division Goal is "to retain 90% of ASCENT New Graduate nurses at one year." The ASCENT program is our nurse residency program and begins with a one day a week for six weeks education, training, simulation and support time in parallel with unit orientation. Diana Patterson BSN, RN, Nurse Educator and ASCENT Coordinator received immediate financial support for the program. Following the first ASCENT cohorts, she requested a 6 month follow up session for these new graduate nurses. Diana stated "the research literature clearly identifies high risk times and recommends strategies to improve retention of this vulnerable group of professionals. The feedback from the graduates of the ASCENT program also included comments about wanting an opportunity to reconnect following initial orientation. We created a half day which included education, time to process learning and their experience transitioning from college students to mentees to professional nurses, and time to meet with nursing leaders. I met with the CNO and Nursing Councils (Leadership, Management and Education) to share the evidence and request paid time for these new associates. It worked well and at one year we had over 90% retention! We paid for the day and met our division goal!" (TL2-16) This example demonstrates one of a myriad of ways that nurses advocate for resources within our organization.
In addition, the Education Department requested and received a ceiling mounted LCD projector in the classroom. Not only does this make is easier for education presenters and orientation, we now have equipment to loan out for staff meetings or other uses.
From: Patterson, Diana Sent: Monday, January 07, 2013 12:12 PM
To: Nussdorfer, Debra; Caton, Cynthia J; Lyons, Joy; Varnes, Kristin; Randazzo, Victoria; Strauch, Joan; Anic, Sonja; Spitzer, Olinda P; Quirk, Stefanie Cc: Clark, Jill; Creech, Kathy; Lezon, Sandra Subject: Education LCD Projector
Good news-we finally got the ceiling mounted LCD projector installed in the Alpine/Cascade classrooms. There is a wall mount cord and remote for the LCD to your laptop……please be sure to leave in the basket when you finish using the equipment. Additionally, we will be able to loan out our older LCD as needed for other locations/meetings. Let us know in advance if that equipment is needed. Diana Patterson, RN, BSN, MA, Nurse Educator
Ensuring adequate resources to provide quality nursing care is a leadership responsibility. Our nursing leaders advocate for a variety of resources including fiscal and technology resources. The nursing strategic plan and goals require we have equipment for patient safety such as the capnography and bariatric equipment discussed. Partnering with direct care nurses to identify needs, we seek items through our annual volunteer grants. Nursing goals focus on quality and elimination of hospital acquired infections. By advocating increasing our advanced nurses on staff, we are able to expand education and role modeling to improve nursing practices.
Budget planning actively occurs in the spring each year. However, we know that changes will occur during the year that may require additional resources. Nursing leaders collaborate with finance and other senior organizational leaders to prioritize to obtain critical resources. When staffing hours are over the budget, the clinical manager prepares a variance report to indicate the rationale for the increased hours. The variance process validates the experience that sometimes additional resources, unplanned, are needed.
Transformational Leadership - TL03
TL 3 The strategic planning structure(s) and process(es) used by nursing to improve the healthcare system's: Effectiveness and Efficiency.
Strategic Planning Structure and Process:
PSFHS has a well defined structure and process for strategic planning which creates alignment of goals from the Centura Health corporate level through Nursing Services at PSFHS. Centura Health establishes the foundation and priorities through a strategic plan known as Centura Health 2020. The Centura Health 2020 goals and priorities cascade through the Centura Health Chief Nurses, Senior Nurses at PSFHS and nursing associates within PSFHS. The Professional Practice Model at PSFHS defines the elements required for professional nursing practice which contributes to excellence in patient, nurse and organizational outcomes.
Centura Health 2020:
Centura Health 2020 provides the foundation for strategic planning throughout Centura Health. Developed by Centura Health leaders in conjunction with input from associates, the plan promotes long term and short term goal setting. (TL3-1)
Centura Health Nursing Strategic Plan:
Chief Nursing Officers across Centura Health comprise the membership in the Centura CNO Council which is responsible for developing and evaluating the Centura Health Nursing Strategic Plan. These CNO's determine nursing goals in alignment with Centura Health 2020 and review organization and system progress toward goals quarterly. (TL3-2)
PSFHS Nursing Strategic Plan and Goals:
The Nursing Strategic Plan for PSFHS is in alignment with the Centura Health Plan. Each summer, Nursing Councils review progress toward annual goals and identify goals for the following fiscal year. In the early fall, PSFHS Senior Nursing Leaders meet to evaluate progress toward strategic plan goals, review the Centura Health Nursing Strategic Plan and design the PSFHS Plan and Goals for the fiscal year. (TL3-3, TL3-4) This Draft Plan is reviewed/revised at the Nursing Leadership Council and then the Nursing Leadership Management Council meeting prior to final approval. The strategic and quality goals include targets for efficiency and effectiveness. This process includes nurses from all levels and all settings in annual evaluation of strategic plan outcomes and determination of goals and tactics for the next year. (TL3-5, TL3-6)
In late fall, PSFHS Nursing creates the Nursing Annual Report to celebrate and recognize the PSFHS achievements and progress toward goals. This is published in the winter/spring and disseminated throughout Centura Health, physician colleagues and community partners. (TL3-7)
The Nursing Councils and Interdisciplinary Committees provide the structures for ongoing plan implementation and evaluation. Functions of each council and goals align with the Nursing Strategic Plan Goals. All Nursing Councils report to the Nursing Leadership Council which monitors progress toward goals and makes decisions and recommendations as needed.
Summary of Structures and Process for Strategic and Quality Plans:
The table below outlines the structure and process for developing and evaluating our PSFHS Nursing Strategic and Quality Plan:
Centura Health LeadershipCentura Health Strategic Plan was designed and included input from all settings and levels of staff throughout the Centura Health system.
Centura Chief Nursing Officer CouncilCentura Health CNO Council sets nursing quality goals, evaluates progress toward goals and revises strategic and quality plans as needed.
PSFHS Senior Nursing LeadersPSFHS senior nursing leaders review and draft a revised strategic and quality plan annually based on the Centura Health Nursing Strategic Plan
PSFHS Shared Decision Making Nursing Councils PSFHS Governing Board, PSFHS Clinical Effectiveness (CEC) and Quality Patient Safety (QPSQ) Committees Interdisciplinary Quality Committees Nursing Units
Nursing Dashboards/Graphs provide Data for Strategic Planning:
The design of nursing dashboards focused performance on key indicators by units in order to improve effectiveness and/or efficiency. Dashboards include color codes and specific targets to improve comprehension and utilization. Posted on units the data is easily visible and communicates progress as well as areas needing improvement. Nurses are able to use this information to evaluate and adjust practices that lead to improved outcomes.
The Site Coordinator for the National Database of Nursing Quality Indicators (NDNQI) provides quarterly unit level graphs to each unit practice council and clinical manager. (TL3-8)
Performance Feedback and Development Plan (PFD) Promotes Goal Alignment across All Nursing Levels and Settings:
All associates have a PFD plan which identifies specific goals for each individual and requests that each employee document needed actions to achieve said goals. For nurses, their goals must be in alignment with the larger strategic plan. By aligning goals throughout all levels and all settings we focus our energy and resources on these priorities. Each level or setting contributes to the overall organizational goals from their unique perspective. For example Rose Ann Moore, RN, Director of Patient Care Services at Penrose has a goal stating "Improve performance on the HCAHPS survey for the Department of Nursing for the category "overall rating of the hospital" as measured by percentile ranking of top box score for the period FY2013." The Clinical Managers who report to her have a similar goal with a unit based scope. Individual nursing staff has a similar goal with a focus on particular questions in the HCAHPS survey. By cascading goals through the PFD process we are focused on building synergy to achieve the Values Based Purchasing measures for PSFHS and Centura Health.
Performance Improvement Process Provides a Structure and Process to Improve Effectiveness and Efficiency:
The Performance Management Process and Plan-Do-Check-Act (PDCA) structure promote improvement in both efficiencies and effectiveness. The use of a standardized format for performance improvement projects provides clear direction and goal setting that improve the efficiency and effectiveness of the process. While some practice changes are small and do not require a defined plan, we are committed to improving outcomes through evidence based practices that are developed, implemented and evaluated best through a standardized process. At the Centura Health level, clinical quality evidence based teams design toolkits for implementation of evidence based practices. In the fall of 2012, Catheter Associated Urinary Tract Infection (CAUTI) toolkit was used by PSFHS nursing to change and improve our practice. (TL3-9) Monitoring for effectiveness is occurring through bedside shift report, quarterly peer review and outcome results.
Nursing Councils Provide a Structure for Goal Setting and Outcome Monitoring:
Nursing Staffing Council PSFHS uses sitters primarily in two situations. All patients who are admitted on a mental health hold at risk for injury to self or others require constant observation in the hospital. When these patients are on a floor, a sitter is required since constant observation is not available through routine nurse staffing and assignments. The second type of patient that may need a sitter is someone who is confused and at risk for inadvertent self harm. Often times these are patient with dementia and agitation or patients in detoxification from alcohol or drugs. In both cases, added staff is needed. By adding 1:1 staff unit productivity is negatively impacted. The clinical managers and senior nursing leaders resolved one part of this challenge in 2011. At that time, PSFHS contracted for an agency for sitters to observe patients on a mental health hold. The costs for these sitters were shifted off the unit budget. As nursing evaluated the effectiveness of these contract sitters, they noted difficulty with scheduling and ongoing questions about their competency. The contract was discontinued and we use internal staff for this service. However we continue to keep a separate cost center for these hours. Units continue to provide sitters for confused, agitated, safety risk patients and this does impact staffing and the budget. Following a literature review, review of our use of sitters and dialogue with staff, the Nursing Staffing Council made a recommendation to the Medical Executive Committee that sitters be ordered based on nursing orders in lieu of physician orders. The Committee agreed. This process was implemented at the end of 2012 and will be evaluated during 2013. Evaluation data will include sitter hours and patient safety outcomes.
Interdisciplinary Committees Provide a Structure for Goal Setting based on Strategic Plans:
Critical Values Committee Ensuring regulatory readiness and compliance is a foundational goal for the organization and the nursing department. The Joint Commission National Patient Safety Goal Requirement 2C addresses the timeliness of reporting critical test results. The Chief Nursing Officer initiated an interdisciplinary committee to review and analyze compliance with the PSFHS Critical Value Notification Policy (TL3-10)
The policy guideline states "Critical tests/results will be communicated to the practitioner in a timely manner in order to facilitate the patient treatment decisions." PSFHS defined critical tests and critical results and established logs, reports and monitors to improve efficiency and effectiveness of reporting. The committee has identified and resolved problematic issues related to communication and nursing documentation during the last year. The goal remains to provide timely results to providers and prevent any unnecessary delays in patient treatment. The graph below demonstrates the improvement in outcomes.
Clinical Managers participate in strategic planning through their membership in the Nursing Leadership Management Council. In addition, clinical managers partner with unit physicians and/or medical directors to evaluate the effectiveness and efficiency of their specialty unit. In the Emergency Department, Pam Assid, MSN, RN, NEA-BC, CEN, CPEN, Clinical Manager actively collaborates with Michael Roshon, MD, Medical Director of the ED in planning to meet ED patient needs. This interdisciplinary collaboration is essential in this fast growing ED. The Nursing Strategic plan identifies goals related to staffing productivity and patient satisfaction. By drilling down to a unit level, clinical managers are able to expand their planning and interventions unique to their unit to achieve goals. Expanding the staff budget requires the clinical manager to demonstrate need and her ability to effectively manage a budget. Assid and Roshon evaluated the metrics in the ED and drafted a strategic plan proposal to improve patient satisfaction and reduce wait times. They sought information from the literature as well as comparable hospitals. The Strategic ED Plan is discussed in detail in TL 3 EO.
Transport Partners with Nursing to Improve Efficiency - 2011-2012:
The Transport Team is responsive and innovative. A new supervisor joined the team and has partnered with nursing staff to reduce the amount of time nurses need to leave the unit. Nursing has not formally tracked time off the unit but certainly can talk about the trips to obtain telemetry equipment or locate beds or take patients to their car at discharge. Transporters identified these areas, adjusted scheduling and expanded hours as they expanded their services to take these tasks from nursing.
Transport Team Goal: Provide quality customer services and assist in patient care activities to keep nurses at the bedside
DateTransport Expanded Roles
August 1, 2011Telemetry equipment transport between floors and telemetry unit
January 3, 2012Clean up, organization and monitoring use of Gala Room. This large room in the basement was filled with scrap and unusable furniture and equipment. Now the Gala Room provides needed storage for easy access to beds and space for meetings/education.
January 6, 2012Transporters enforced the "high fall risk patients must be transported via cart" rule per policy, hoping to assist in lowering hospital fall rates.
March 1, 2012All Bed Movement. Transporters now deliver patient beds (including specialty beds) to nursing units and the OR which reduces the wait time for beds and eliminates the need for surgery CNA's to retrieve beds.
March 21, 2012Expanded hours - Patient Transport became a 24/7 operation. Transporters are now available to assist nursing staff during the night.
May 29, 2012Expanded telemetry equipment transport to 24/7.
September 2012Developed a new CNA role within the department. CNA Transporters are now available to assist in transports that require a higher skill set, such as transporting patients that require more than 6 liters of oxygen, and confused patients.
November 20, 2012Transport patients being discharged home from the unit to checkout and their car
2012 Patient Transport numbers
Total number of transports = 53,023
Total number of beds moved = 8,924 (10 months)
Total number of new telemetry units = 2,967 (6 months)
Total number of discharges = 647 (6 weeks)
To estimate the improved efficiency for nurses we can estimate time and costs associated with all these changes. Discharges, telemetry equipment and beds can easily take ten to fifteen minutes each; totaling over 4000 hours per year at Penrose Hospital provided by transport instead of nursing.
PSFHS Nursing Services build a strategic plan through a shared decision making process with strong leadership from Centura Health and Chief Nursing Officers. Goal setting in alignment with the strategic plan at council and individual levels uses synergy to improve the likelihood of achieving improved efficiencies and effectiveness. Standardized toolkits and performance improvement processes promote continuity and collaboration. Ongoing evaluation as well as quarterly reviews of the strategic plan maintain the focus and allow for deliberate changes or adjustments if necessary.
- PSFHS Nursing Leadership Council review, revise and approve the annual strategic and quality plan.
- All Nursing Councils evaluate and develop annual goals in alignment with the PSFHS Nursing Services Strategic and Quality Plan and Goals.
- Unit Practice Councils collaborate with nursing clinical managers to design and implement unit specific goals in alignment with PSFHS Nursing Services Strategic and Quality Plan.
- The PSFHS Board is accountable for the PSFHS Quality and Patient Safety Plan.
- The PSFHS Organizational Performance Improvement and Patient Safety/Risk Management Plan is reviewed, revised and approved annually.
- The Clinical Effectiveness and Patient Safety/Risk Management Committees provide oversight for implementation of the plan.
- Multiple interdisciplinary quality committees comprised of nursing, medicine, pharmacy, therapies, cardiology and other disciplines regularly monitor and take actions related to quality goals.
- Each committee has a specific focus area and members are selected based on expertise in that clinical area. Committee examples include: Falls, Restraints, Critical Values, Medication Use, Code Blue/RRT, Red Rules, Pressure Ulcer Prevention, and Infection Control. These Committees report to the Clinical Effectiveness Committee.
- Nursing Councils review reports from these committees based on council goals and take actions to improve quality of nursing practice and patient outcomes. Nursing Councils may also refer issues to any quality or practice committee.
- Nursing Units set quality, effectiveness and efficiency goals formally each year as documented in the Unit Plan for Provision of Care.
- These goals are consistent with overall nursing goals and target appropriate areas on the unit.
- In addition nursing units use the standardized Plan-Do-Check-Act structure and process for performance improvement activities.
Transformational Leadership - TL03EO
TL 3 EO: The outcome(s) that resulted from the planning described in TL 3.
SFMC Emergency Department Strategic Plan Implementation and Outcomes
Purpose and Background:
The Nursing Strategic Goals 2010-2014 (TL3EO-1) included
• Improving HCAHPS Patient Perception Scores
• Nursing Units meet year end productivity standards
In alignment with these organization and nursing goals the SFMC Emergency Department took action to improve HCAHPS Scores and to meet the expectation of effective, efficient care. Aware of the difficulty with meeting productivity standards with current budget, the Clinical Nurse Manager partnered with colleagues, analyzed trends and created a proposal to change staffing (productivity) that would impact effectiveness and efficiency.
When the Emergency Department moved with the entire hospital into a new building in late 2008, we did not know what our volumes, acuity and case mix would be or when we might see an increase in utilization. Providing quality patient care, meeting national standards for triage and wait times, ensuring adequate numbers of competent staff and achieving high patient satisfaction ratings were our goals.
The initial productivity standard for SFMC ED was developed based on estimated patient acuity and the fact the SFMC would open with a Level 4 Trauma designation. While these estimates were based on the best data available at the time, by 2010 we had two years of collected data that indicate that the initial acuity estimates were low and that the resulting productivity standard of 2.55 is insufficient.
Pam Assid, MSN, RN, CEN, NEA-BC, Clinical Manager and Michael Roshon, MD/PhD, Emergency Services Physician Director prepared an proposal to demonstrate the SFMC ED productivity standard was set too low. They researched multiple national databases, literature, and statistics to design a proposal. (TL3EO-2) Comparisons with other Centura ED's were included. Input from ED associates and leadership as well as SFMC Administration were included in the plan.
Data collected and analyzed included:
• Acuity indicators
• Admission rates: Increased from prior to move of 4 - 6% to 15.5%
• Emergency Nurses Association recommends triage based on Emergency Severity Index. Our data show SFMC ED is a high acuity ED with rating similar to Penrose Hospital ED and less low acuity patients than the national average. From 2008 to 2010 there has been a 14.5% increase in higher acuity patients (based on patient charge data). The shift in patient acuity from low to medium acuity increases the ED workload and extends the length of stay in the ED from 2.5 hours to 3-4 hours.
• Volume indicators
• SFMC ED has increased volume of patients by 40% from 2008 to 2010 which places additional stress on staff since the physical plant has not changed.
• Process improvement initiatives have been ongoing to improve patient flow. Staffing patterns have been adjusted to meet the demands of volume and patient flow. Other evidence based process improvements implemented include:
• Rapid Medical Examination. Every patient is triaged and treatment for lower acuity patients is overseen by a physician's assistant and ED Tech. The length of stay goal is 60 minutes for this population. This approach does not include nursing treatment and therefore limits the number of patients who can successfully be treated via rapid medical examination. Increasing staffing would extend the scope to a Fast Track and allow us to service double or more the number of patients.
• Greeter Mode. The ED initiated this process in late 2009 resulting in an improvement in door to triage time. However increasing patient volume has outpaced staffing during peak times and negatively impacted our door to triage time.
• Improvement of cycle times with focus on triage efficiency, bed turnover time and laboratory cycle times has supported strong ED throughput times in comparison to national averages.
• Additional responsibilities assigned to the ED
• Responds to all in-house code blues including those in two adjacent provider buildings
• Responds to all stroke alerts
• Responder role for obstetric hemorrhage
• Assists with IV starts, splinting for all inpatient units
• Responds to all pediatric rapid responses and backs up intensive care response to adult rapid response calls
• As a certified trauma facility the ED has increased communication needs with pre-hospital providers
• Staffing impact. The ED nurse call in goal is 5% but increased to 11.2% which impacts staff satisfaction.
• Comparison of ED metrics across Centura. Volume/Capacity standard is equal to St. Anthony Central Emergency Department. However, the Productivity standard is the second to lowest in our system. St. Anthony Central has a 2.91 productivity standard compared to SFMC at 2.55 productivity standard.
Pam Assid, RN Clinical Manager and Michael Roshon, MD, ED Medical Director also analyzed hourly patient flow against nursing and provider staffing. Since SFMC ED opened in 2008, Front Range Emergency Service Physicians (FRES) increased staffing by 22% and at the time of the proposal were preparing for another 42% increase in physician/physician assistant providers. Nurse staffing increased 28% and the proposal requested an additional increase of 35%.
The proposal requested a productivity standard change to be equal to St. Anthony Central standard. The additional staffing was targeted to add a Fast Track area and to improve triage efficiency and effectiveness.
Pam Assid, MSN, RN, CEN, NEA-BC, Clinical Manager
Michael Roshon, MD/PhD, Emergency Services Physician Director
SFMC Emergency Department nurses, techs and associates
Nate Olson, CEO, SFMC
Becky Kahl RN, Interim VP of Nursing, SFMC
Danny Reeves, PSFHS CFO
Centura Corporate Leadership
The PSFHS Chief Financial Officer and the SFMC CEO supported the proposal and presented it to Centura Corporate. Centura Corporate immediately approved the change in productivity standard and made the change effective immediately; approval was retrospective to beginning of current pay period. This was quite an accomplishment as there were 12 other cost centers requesting similar adjustments.
Additional Staffing and resulting outcomes are outlined below.
1) SFMC ED added a Fast Track area adjacent to triage, to reduce wait times and improve patient throughput. By staffing a fast track area we created a 3 bed unit with efficient outturn to care for many of the charge level 4 patients resulting in decreased wait time and improved services. These 3 rooms essentially function as 6 rooms because of the faster throughput. This significantly alleviated the ED stress resulting from an inverted volume: capacity ratio. Outcomes: Patients who "left without being seen" steadily declined from 1.7% in Jul-Dec 2011 to 1.2 (a 30% improvement).
2) Provider at triage. By adequately staffing the Fast Track area, a physician assistant (PA) or physician is present in the triage area to assist with triage, and to reduce the door to provider time as well as total throughput time.Outcomes: Total throughput times dropped from 147.2 minutes average for Jul - Dec 2010 to 144.2 minutes as we implemented staffing and practice changes. This improvement occurred even with an 8% increase in the volume of patients.
3) Improved triage efficiency to reduce door to doctor times with the goal of improving patient satisfaction. The Fast Track team is able to double as a second triage team when needed. Outcomes: Time to triage for Jan-Jun 2011 was 16.7 min average. After we increased staff following approval for a standard increase, our times to triage evaluation decreased to 14.8 min average (12% improvement). This improvement occurred in the context of an 8% growth in ED volumes.
4) Patient Satisfaction Outcomes: The following HCAHPS ratings demonstrate improvement from the 48th percentile in February 2011 (which existed prior to staffing and practice changes) to scoring at 93-99th percentile after those changes. The following graph depicts the initial decrease associated with the implementation of the changes and the increased and sustained satisfaction as changes in practice are integrated.
Significance of Results:
The strong collaborative relationship between physicians and nursing evidenced in this proposal is based on a shared commitment to quality and safety. Physician and nursing leaders aligned staffing processes so by the time of hiring and orienting, resource allocation minimizes gaps on both sides.
Analyzing trended data, reviewing standards of practice, and collaborating across disciplines, this process used data in budget formulation, staffing implementation, monitoring and evaluation. Our organization and professional commitment to effectiveness and efficiency is demonstrated through this major Emergency Services project, led by the Clinical Nurse Manager and Physician partner.
Plans to continue to monitor efficiency, effectiveness and satisfaction in the ED include
• Door to triage time
• Left Without Being Seen
• Patient Satisfaction
Transformational Leadership - TL04
Advocacy and Influence
TL 4 Describe and demonstrate the process(es) that enable the CNO to influence organization-wide changes.
The Vice President (VP) of Patient Care Services/Chief Nursing Officer is a registered nurse with a Master's degree and at least a BSN. The position description states this person "has 24-hour responsibility and accountability for planning, organizing, directing, controlling and evaluating nursing services across the health care continuum by working with other administrative team members to provide administrative direction and oversight. The VP exercises final authority over all associates providing nursing care, regardless of reporting structure. Authority and responsibility for developing organization-wide patient care programs, policies, and procedures that describe how patients' nursing care needs or needs of patient populations receiving nursing care treatment and services (are assessed, evaluated, and met) and, for establishing standards of nursing practice and standards of care." (TL4-1)
Within Penrose St. Francis Health Services (PSFHS) the CNO is a member of the senior management team, attends the Medical Executive Meetings as well as the PSFHS Board Meetings. (TL4-2)
In addition, the CNO is seen as an expert nurse and knowledgeable leader, representing nurses at the Centura Corporate and Centura South State through participation in multiple councils, committees and specialty work teams. By chairing and participating in many nursing and interdisciplinary teams, the CNO influences, advocates and leads changes throughout the organization. The following is a list of regular council/committee assignments which is in review by the new CNO. In addition, work groups are created for specific projects and lengths of time and not included in the table.
Centura Nursing Council CNC
South State Executive SOAR
Centura Professional Development Council
PSFHS Nursing Leadership Council
PSFHS Nursing Leadership Management Council
CSI - Nursing Peer Review
PSFHS Patient Safety committee
PSFHS Bariatric Team
PSFHS ED Security
PSFHS Bio-Ethics Committee
PSFHS ED Leadership
PSFHS Interdisciplinary Patient Education Committee
PSFHS Clinical Effectiveness
PSFHS Credentialing Committee
PSFHS Medical Executive Committee
PSFHS Nursing Directors Committee
PSFHS Interdisciplinary Pain Committee
PSFHS Interdisciplinary Policy Committee
PSFHS Trauma Section and Peer Review
PSFHS Emergency Dept Section & Peer
PSFHS Obstetrics/Gynecological Section & Peer Review
PSFHS Surgical Section & Peer Review
PSFHS GI Section & Peer Review
PSFHS Anesthesia Section & Peer Review
PSFHS Red Rules Committee
PSFHS STEMI/Cardiac benchmark
PSFHS Stroke Committee
PSFHS Entity Implementation Team
PSFHS Accreditation Readiness Group
Multiple factors and processes enable the CNO to advocate for and influence organization-wide changes; her participation in interdisciplinary committees and work groups, her clinical and leadership expertise, relationships with staff across the organization and her absolute dedication to excellence in patient care.
The following two exemplars demonstrate her leadership and influence on organization wide changes.
PSFHS Certified as Primary Stroke Center - July 2011:
In 2010 our stroke program leadership shifted from the Director of Rehabilitation to the Chief Nursing Officer. The CNO expanded the stroke program team by adding representatives from the designated stroke inpatient units. Continuing program members included the Chief Medical Officer, Stroke Medical Director, the Stroke Program Coordinator, a clinical nurse, a physician, a representative of clinical effectiveness team, neurological support (both local and advanced), and Emergency Medical Services/Fire Department. This team, under the leadership of the CNO and the Stroke Coordinator, was charged with creating an effective multi-disciplinary structure for the creation of policies, procedures, and quality improvement initiatives to guide us to achieve our goal of becoming a The Joint Commission (TJC) Stroke Center of Excellence.
In December 2010, the Stroke Program Coordinator resigned. The Stroke Nurse accepted the interim coordinator position, but her tenure with the program was short and she focused on abstracting data and supporting the process to achieve Primary Stroke Center certification. A mock survey with external consultants was scheduled and completed in December 2010. Mock surveyors toured both hospitals; they completed individual tracers, reviewed the performance improvement plan, and they examined staff human resources files for education and competencies. The Joint Commission Primary Stroke Center Certification Mock Survey Report (January 2011) provided the following recommendations:
The CNO immediately increased her time and leadership with the Stroke Program in preparation for TJC Survey scheduled in April 2011. Weekly meetings with the Interim Stroke Coordinator and frequent meetings with the Interprofessional Stroke Clinical Effectiveness Team focused on implementing the recommendations from the Mock Stroke Survey with strong emphasis on reviewing all stroke patient records and staff adherence to protocols. Nursing services in the EDs, Intensive Care/Critical Care Units, Medical "stroke" designated floors, imaging, pharmacy, human resources, education, physicians, and therapies collaborated to ensure excellent patient care and a successful survey. (TL4-3)
The CNO is a champion of excellence in patient care. Her expertise as a nurse and leader are well respected at all levels and across all disciplines and departments. Using multiple strategies and collegial relationships, she helped set the vision, coached the stroke coordinator, and linked all levels of staff from pre-hospital through rehabilitation to create a structure and process based upon empirical evidence and the standards of the American Heart Association and Joint Commission to achieve the distinction as a Stroke Center of Excellence. The Chief Nursing Officer as leader and champion of the stroke program and supervisor of the Stroke Coordinator led the team to meet the requirements of The Joint Commission Stroke Center of Excellence. The journey required strong communication and collaboration across our organization including the two main hospitals and urgent care facilities. Medical, nursing, pharmacy, therapy, rehabilitation and imaging staff were primary participants in the program. (TL4-4)
Project Red - Congestive Heart Failure (CHF) Team:
The Project Red Interdisciplinary Team was established in 2011 to improve/reduce readmissions of patients with CHF. The CNO as well as other nurses participated in this team. In February 2012 the CNO initiated a subgroup "CHF" to review and analyze current data and make recommendations for actions to increase our compliance on CHF Core Measures. Working in collaboration with clinical effectiveness, informatics, nursing, physicians, education and case management the team met monthly.
Actions Taken between February 2012 and September 2012 include:
Alan Henley, Outreach Pharmacy Manager
Phyllis Burton, BSN, RN, PCCN, Clinical Manager, CVU
Helen Graham, PhD, RNC, Clinical Manager, Cardiac Rehabilitation
Brenda Molencamp, BSN, RN, NE-BC, Clinical Manager, PH 4 Medical
Mackenzie Mudd, MSN, RN, Clinical Manager, SFMC 5 S Medical
Jeff Oram-Smith, MD, Chief Medical Officer
Tamra Renzelman, Director Case Management
Kelli Saucerman, MSN, RN, CQPS, Director Clinical Effectiveness
Sharon Pletcher, RN, Cardiac Rehabilitation
Lynanne Plummer, System Analyst
Kate McCord, MSN, RN, NEA-BC, Chief Nursing Officer
Ramona Beal, BSN, RN, Clinical Informatics
Sylvia Kurko, BSN, MBA, Education Coordinator
By September 2012, documentation of overall discharge instructions improved from 58% in January 2012 to 74% in October. Through her participation on this committee, a direct care nurse designed a research proposal as a strategy to advance the overall Project Red Committee goal on reducing readmissions of heart failure patients. (TL4-9)
Our CNO is able to create and influence change through the organization by demonstrating collaborative, patient care focused leadership. Her participation in councils and committees, including those at the Centura level, allow her to effectively direct the evolution of healthcare practice at PSFHS. Nowhere is this more evident than with the example of our recognition as a Stroke Center of Excellence. The CNO's direct participation in coordinating and leading a multidisciplinary team allowed PSFHS to earn that distinction.
- Expand the Stroke Clinical Effectiveness Team
- Conduct a concurrent review of all in-house stroke patients
- Engage clinical staff in unit/departmental performance assessment and improvement
- Ensure staff files include qualifications and competency of staff including required education hours (Human Resources)
- Improve clinical documentation and adherence to established protocols
- Revise physician order sets (Medicine, Emergency, Neurology)
- Collaboration with Centura Health Task Force to implement evidence based practices (TL4-5)
- Education via online module for nursing
- Cardiovascular Unit Pilot with pharmacy students (TL4-6)
- Review and determine patient education handout (TL4-7)
- Documentation process revised (TL4-8)
Transformational Leadership - TL04EO
Advocacy and Influence
TL 4 EO Describe and demonstrate one CNO influenced organization wide change.
TITLE — Improving the Patient Experience at Penrose-St. Francis Health Services (PSFHS)
Background and Purpose:
Nursing and healthcare professionals have focused on delivering an excellence patient experience for many years. Over the past few years, PSFHS and its C-Level officers have prioritized patient satisfaction related to our commitment to excellence, improving market share, and the federal decision to link reimbursement to patient satisfaction ratings.
In February 2011, Gary Campbell, president and CEO of Centura Health sent a message titled "The patient experience: whose job is it?" His message highlighted the Centura Health expectation that all associates impact the patient experience, promoted a patient satisfaction summit, and introduced the role of patient satisfaction in Values Based Purchasing. The message was clear: Centura Health has improved in overall Patient Satisfaction ratings and has room for more improvement. (TL4EO-1)
PSFHS set the goal to improve the overall patient experience as measured through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national standardized survey. The HCAHPS is one of the domains used to measure performance improvement for Value-Based Purchasing reimbursements. For FY2013 HCAHPS results hold a 30% weight. Eight composite ratings are used to establish the floor, threshold and ultimately determine the overall points.
In the context of national changes, reimbursement repercussions, and Centura Health's goal, PSFHS identified patient satisfaction as a priority. The overall goal is to improve our HCAHPS ratings which will impact the VBP rating.
Methods and Approaches:
In 2011, PSFHS developed and filled a senior leadership position, Vice President of Customer Services. Laurie Kennedy accepted this role, initiated a Patient Experience Committee and invited interested associates from across the organization to get involved. Many of the same people who initially joined this committee remain members today. In December 2011, Ann Kjosa, BSN, MSN/MHM, FACHE, VP of Nursing accepted leadership of this committee and the priority organizational performance improvement project. (TL4EO-2, TL4EO-3)
From conversations in the committee and a review of available StuderGroup materials three priority areas emerged and committee members self selected to work in one of the three groups.
1. Patient Communication The AIDET (Acknowledge-Introduce-Duration-Explain-Thank) patient communication process from the StuderGroup was selected for implementation across the organization. An implementation plan was developed and a "train-the-trainers" model was selected. Trainers received instruction prior to accepting assignments to scheduled AIDET training. The AIDET group and Patient Experience Committee identified nursing associates as the priority group for training due to the frequency of nursing-patient interactions. Classes were offered both within and outside of staff meetings. By the end of 2012, 881 associates had completed the AIDET training. In January 2013, per Ann Kjosa, BSN, MBA/MHM, FACHE, CNO and Jim Humphrey, VP of Human Resources, AIDET training became a mandatory training for all PSFHS associates. (TL4EO-4)
2. Service Recovery Recognizing that there will always be incidences of frustration or delays in patient care, this team focused on developing a structure and process to follow after a mistake. The PSFHS values guide this process as associates apologize, take responsibility for mistakes or inconveniences and strive to solve the problem. The program was designed by our Service Recovery team. The referral to the Patient Representatives is always an option, but ideally we prefer to solve the problem quickly or to satisfy the patient/family without needing to make a referral. Our goals are to build loyalty with our services and to empower all of our associates to use common sense to assist in taking care of patients and their families. Creating and maintaining a Service Recovery ToolBox in multiple areas has cost less than $1000 in the past year. In addition, a map of Penrose Hospital was designed and is available to provide directions to families and visitors to Penrose Hospital. A comparable map for SFMC had been designed at an earlier date. (TL4EO-5, TL4EO-6)
3. Creation of an Expectation of Customer Service Among Associates The third team focused on our organizational culture, our mission, vision, values, and our journey to Magnet Recognition. The AIDET education and Service Recovery Programs provide tools and behavioral expectations for all associates, however, this group identified the need for a holistic approach by focusing on the culture. The goal of this group is to support the Patient Experience Committee to integrate various strategies that improve our culture and patient experience with our overall mission, vision, values, and organizational goals. One of the first tactics for this group included an expert external review or mini-experience of our customer service at Penrose Hospital. We recruited four leaders in local organizations recognized for excellence in customer services. We accompanied these people through a tour of the hospital and observed actions, behaviors, and the environment. The feedback from this team was shared with our senior leaders and our nursing department. (TL4EO-7)
As the multidisciplinary team continued to meet additional organizational practices were improved or revised.
Room Service was initiated at Penrose Hospital PH 11 piloted the process beginning in March, 2012. As the practice change was implemented on other floors, a Room Service Task Force composed of dietary associates, nurses, unit secretaries, and interns met to identify and resolve the challenges with the new practice. In addition, a consultant met with dietary to provide recommendations on food temperature challenges. Menu revisions were made to include larger font, different languages, and inserts on directions for specific diets. The delivery process between dietary, nursing, and patients were reviewed, revised, and monitored. Although Nutrition Services does not have a specific question on our HCAPHS survey, there is no question that food service plays a role in patient satisfaction. An internal audit and survey tool is being used by the Nutrition Services department to ensure timely feedback and patient input is received, reviewed and appropriate changes implemented. (TL4EO-8, TL4EO-9)
Human Resources Implemented a Supervisory 101 Class requirement for manager and supervisor new hires; also available for any manager or supervisor.
Nursing Practice Council (NPC) Goals Two of the three goals identified by this council direct the actions and evaluation of practice for nursing. Patient satisfaction with nursing services is identified as a primary goal. The second goal, relationship based care, is the approach we use within PSFHS to create a healing, healthy environment for staff, patients, volunteers, physicians, families, and visitors. In August 2012, NPC reviewed HCAHPS ratings on nurse sensitive indicators. On 8 of 11 questions, PSFHS outperformed the database mean. (TL4EO-10)
Relationship Based Care (RBC) RBC is a primary element of our PSFHS Professional Practice Model. Practices based on RBC are woven throughout our organization. In January 2013, Kjosa and the Magnet Coordinator presented RBC to the General Leadership Meeting. Partnering with Marketing, we created and are distributing a video that portrays associates, volunteers, and physicians "Making a Difference" throughout our facilities. (TL4EO-11) The following are examples of RBC throughout the organization:
i. Phyllis Burton, BSN, RN, PCCN, Clinical Manager of the Cardiovascular Unit is passionate about RBC and eagerly recruiting associates from across the organization to collaborate as we intentionally grow our RBC culture. This team is currently working on video clips that demonstrate positive and negative staff behaviors in the workplace that impact our culture of excellence and patient experience. (TL4EO-12)
ii. Diane Villavicencio, BSN, RN, Assistant Nurse Manager at SFMC ED is leading the Magnet Champions to create a "Masterpiece Theatre" that will create synergy with the RBC organizational team and Patient Experience Committee.
iii. The Volunteer Department participated in AIDET training soon after the nurses began. In addition, they are integrating principles from RBC in their training. (TL4EO-13)
iv. NICU Unit cared for a record number of patients in July, August, and September 2012. SFMC collaborated to care for patients and families during this high census period. Nurses from Labor and Delivery as well as Mom Baby Unit helped based on their competencies. Staff adjusted schedules to ensure all our patients received excellent care. Dietary, Facilities and Environmental Services associates quickly accommodated are patients/families (TL4EO-14)
Performance Feedback and Development Process (PFD) Every associate has a goal related to patient satisfaction on their PFD. The Patient Experience Committee is multidisciplinary and reflects the commitment to lead, coach and educate each discipline and department in strategies to improve the patient experience.
Andy Barton, Penrose-St. Francis Foundation, Director
Tami Charles, Manager, Nutrition Services, Penrose Hospital
Charlene Coffin, Manager, Psychiatric Emergency Treatment Team
Heather Graves, Director, Volunteer Services
Kathy Guy, BSN, MSHA, NE-BC, Director, Professional Resources
Kim Hassell, Manager, Penrose Environmental Services
Frank Hennessy, Manager, Business Development
Mike Herbst, Manager, Plant Operations
Becky Morland, BSN, RN, Manager, Urgent Cares
Gina Nygaard, Manager, Radiation Services
Kathy Parham, BSN, RN, Patient Representative
Janet Reedy, Manager, Human Resources
Brian Sarpy, Director, Support Services
Patricia Wilfong-Mager, RN, PH 4 Medical
Jill Woodford, Marketing
Deb Nussdorfer, BSN, MSN, RN, NE-BC
Ann Kjosa, BSN, MBS/MHM, RN, FACHE
The National Research Corporation awarded PSFHS the Consumer Choice Award Each year, National Research honors those hospitals whose consumers rate as having the best quality and image, based on our nationally syndicated Market Insights/Ticker study of over 250,000 households. This is the seventeenth year of the award. On Monday, October 22nd, National Research announced that Penrose-St. Francis, as well as 296 other facilities, has been chosen as Consumer Choice Award winners in the top 300 markets across the country. The announcement appeared in Modern Healthcare magazine.
The Better Business Bureau of Southern Colorado (BBB) recognized Penrose-St. Francis Health Services at the "Night of Excellence" gala for our outstanding customer service practices.PSFHS successfully completed an internal audit to assess the effectiveness of our customer service processes. This was followed by a visit and extensive interview of associates by members of the evaluation team. The evaluation team is made of independent quality assurance professionals. This comprehensive program was created in 1995 to recognize companies that exemplify excellent customer service. (TL4EO-15, TL4EO-16)
The HCAHPS Survey Dimensions have improved The VBP analysis reports an improvement from the baseline scores (April - December 2010) to 2012. PSFHS improved in all eight domains to achieve an overall VBP HCAHPS Domain Score of 65%. (TL4EO-17)
The organizational goal to improve the patient experience as measured through patient reports on the HCAHPS has been met.
The leadership of the Chief Nursing Officer through the multidisciplinary Patient Experience Council has led to organizational improvement. Members in the council come from all levels and all settings to promote and lead change in both their areas and throughout the hospital. This exemplar represents both the leadership of our Chief Nursing Officer and the culture of excellence through collaboration evident throughout the organization.
Transformational Leadership - TL05
TL 5 How nurse leaders guide the transition during periods of planned or unplanned change.
For us who nurse, our nursing is a thing which, unless you are making progressevery year, every month, every week, take my word for it, we are going back. - Florence Nightingale
All nurses are leaders who act autonomously as well as collaboratively to guide transitions during periods of planned and unplanned change. The American Nurses Association (ANA) Nursing Standards of Professional Performance (2004) encompasses the full range of nursing practice and describes responsibilities for which nurses are accountable. Standards inclusive of collaboration, resource utilization, ethics, and leadership guide direct nurses to "exhibit creativity and flexibility through times of change," to "engage in teamwork as a team player and a team builder," be available to "serve in key roles," protect "organizational resources," and "partner with others to effect change and generate positive outcomes."
Our Professional Practice Model, (which features our philosophy of Relationship-Based Care) challenges us to lead by honoring the relationships with our patients, families, colleagues, and ourselves. An interdisciplinary structure evidenced through many committees, work groups, and councils provides a framework for collaboration across disciplines. Changes, planned or unplanned, within Penrose-St. Francis Health Services (PSFHS) are initiated and directed from multiple levels. The structure to guide change is dependent upon the breadth and extent of that change. Within the PSFHS structure, councils and committees exist at the Centura level, the PSFHS organizational level, as well as at the unit / department level.
The Centura Joint Council is made up of all Centura Chief Nursing Officers (CNO) and Chief Medical Officers (CMO). This Council guides clinical decision making in order to build consistency and standardization across our system. This team is currently leading the planned change for safe, effective, and efficient medication reconciliation along with the implementation of computerized order entry. This is to be accomplished through the application of regulatory standards, and collaboration with multiple parties, including: information technology, medical staff, and direct care nursing.
The Senior Leadership Team for PSFHS, including our Chief Nursing Officer, determines need for large scale organization change based upon the assessment of the clinical, financial, quality, and human resource environments. When the organization planned to open a new hospital in 2008, leaders from across the organization (including nursing leaders) met in order to develop action plans that were focused on building, preparing, and occupying a new facility.
Nursing Directors A primary structure for major changes that directly involve nursing is the Nursing Senior Leadership Team. This team is comprised of: the Chief Nursing Officer, the Vice President of Nursing, the Director of Peri-Operative Services at Penrose, the Director of Peri-Operative Services at SFMC, the Director of Professional Resources, and the Director of Clinical Effectiveness. Focused on data driven decision making and supporting a shared decision making structure, this team seeks appropriate information and it delegates or supports decision making at the appropriate level or council.
Shared Decision Making and Interdisciplinary Collaboration Our Shared Decision Making councils take leadership roles based upon each group's scope of authority. The Nursing Leadership Management Council provides oversight and makes decisions related to change. (TL5-1)
The Nursing Practice Council (NPC) and the Unit Practice Councils (UPC) are leading the planned change for expansion of nursing peer review. As individual UPC's design pilot structures and processes for peer review at the unit level, the NPC has supported the project through education and opportunities to share learning. The attached NPC minutes demonstrate decision making related to peer review, telemetry education and policy. (TL5-2)
The Cardiovascular Unit Practice Council is committed to excellence in patient care and relationship based care. The council identified an opportunity to improve nursing - physician communication. A subgroup of nurses from the council invited the physician group to meet and outline strengths and opportunities. The CVU nurses are following up with brief visits to the physician office to strengthen communication and relationships. (TL5-3)
Interdisciplinary Teams. Collaboration is an essential piece of most changes, either planned or unplanned. Our organizational structure of multidisciplinary committees facilitates dialogue and action while reducing potential bureaucratic challenges. More importantly, our culture of collaboration to meet patient needs has led the Inpatient Rehabilitation Unit to work with the Dietary department to pilot and then change the procedure to having dietary associates deliver trays rather than relying upon nurses to deliver them. A interdisciplinary group of trauma, physicians, nurses, ED technicians and physician assistants set up meetings to review trauma program and outcomes, anticipating needs to "redesign" trauma flow and procedures. (TL5-4)
Education Department Education and training are often part key elements of transitions. Implementing a revised Fall Prevention Program required the creation of a new LEARN module for all staff. Sylvia Kurko BSN, MBA, RN, Education Coordinator crafted a new module based on input from the Falls Committee.
Centura Health Process for Major Planned Change - Values Impact Analysis:
Centura Health established a process called, Values Impact Analysis (VIA), based on our commitment to the values of stewardship, imagination, spirituality, compassion, integrity, respect, and excellence. This process is used in the decision making process within Centura Health, and it is a dynamic and rigorous procedure which assists us in making conscientious decisions that are respectful of our stakeholders. This tool is designed to use Centura's Core Values in a consistent way so that we can be accountable to our sponsors and community for values driven decisions. When the Senior Leadership team made the decision to close one of our buildings, assisting current occupants to find space was a key priority. Several agencies chose to move into other PSFHS buildings. However, the inpatient psychiatric unit could not move into another building without significant remodeling to a space. With space and financial limitations, many options for this service were explored. Consistent with our values and process for key decisions, a VIA was held with an external facilitator. The results of the VIA guided the Senior Executive Team to reach a decision that was viable, reasonable, and in line with our guiding principles. Senior Leadership provided ongoing communication to all associates on the process to close the aging St. Francis Health Center (SFHC). Committed to demonstrating Relationship-Based Care, Human Resources and Nursing Leadership worked together to focus on retaining excellent associates until the facility was closed. During this process, the commitment to provide quality patient care and in assisting nursing staff with the uncertainty and financial stress were priorities. The former was accomplished by keeping the facility functional and supported until its closing while the latter was achieved by offering a retention bonus and alternate positions to nursing staff. (TL5-5)
Processes Demonstrated through Exemplars:
The following examples demonstrate processes based on our mission, vision and values. Building on strengths and using partnerships and unique expertise has facilitated successful negotiation of change in PSFHS.
Planned and Unplanned Change - Closing Inpatient Psychiatric Services
Unplanned Change - Nurse Manager Vacancies
Planned and Unplanned Change - Closing Inpatient Psychiatric Services:
In 2010 PSFHS took a hard look at our inpatient psychiatric services. The building the services were located in was closing and up for sale; moving the unit would take significant financial resources. Using our organizational structure and process, Values in Action, we held multiple discussions involving community members, Board member, physicians, inpatient unit leaders and senior administrative/clinical leaders. The decision to close the unit was finally made. Talking Points keep staff informed of the process of change. (TL5-6)
The implementation process included the following priorities:
1. Maintaining quality and safe care until unit closed
i. Inpatient staff were offered significant bonuses to remain on staff. (TL5-7)
ii. Opportunities to continue employment post unit closure with Centura Health were identified
2. Identifying options for inpatient psychiatric care in our community
i. Established contracts with two other local psychiatric facilities providing these services to provide beds for patients who might need inpatient psychiatric care
3. Identifying additional resources in nearby communities
i. Centura Health provides inpatient psychiatric services in a sister facility in Denver
ii. Other inpatient psychiatric hospitals in the Denver metro area
iii. Pueblo has a hospital that provides inpatient psychiatric services
4. Anticipating and planning for changes in our emergency departments since immediate transfer to impatient treatment may take longer without our own local facility
i. Developed job descriptions for Behavioral Health RNs and Mental Health Workers within the Emergency Department at Penrose Hospital, determined staffing and scheduling needs and requested appropriate budget.
ii. Revised reporting and oversight structure so behavioral health nurses and mental health workers assigned to the ED report through the ED nursing structure.
iii. Interviews and hiring decisions for ED positions were conducted by ED Management and ED staff. Three nurses and four mental health workers hired.
iv. Psychiatric Emergency Triage Team (PETT) expertise available to direct and support immediate patient care in the Psychiatric ED pod
v. Modified license with the State Division of Behavioral Health 2765 to include designation as a 72hr Evaluation and Treatment facility.
5. Psychiatric coverage and contracts with physicians Julie Sanford, MD the staff psychiatrist on our former inpatient psychiatric unit contracted with PSFHS to provide inpatient and Emergency Department psychiatric consultation services and oversight to PETT staff. Due to the limited demand for "in-house" psychiatric consultation services within the PSFHS system, PSFHS arranged to share a portion of her time with one of our community partners to provide psychiatric consultation services to PSFHS referred patients hospitalized in their inpatient psychiatric facility.
Unplanned change added on December 31, 2010 resulting in abrupt unit closure
On December 31, 2010 a flood occurred in St. Francis Health Center where the inpatient psychiatric unit was located. Unable to effectively contain the flood in the building and on the inpatient psychiatric unit, evacuation plans were quickly made and implemented. Penrose Hospital 10th floor did not currently have patients and the decision was made to use this space, with safety the first priority. The nursing leadership from the inpatient psychiatric unit notified PSFHS Senior Leadership and resources were identified. The immediate transfer of these patients required interdisciplinary collaboration including environmental services, security, external transport services, dietary, registration, laboratory, medical records, nursing, physicians and pharmacy. The decision to maintain a 1:1 staff to patient ratio for patient safety was made.
During the immediate following days, safety and facilities determined repairs would be extensive and in the context of plans to close the unit the following quarter, senior leadership moved to immediately close the unit. Nursing staff and psychiatrists made arrangements to discharge or transfer the patients temporarily treated on Penrose 10 to alternative facilities. (TL5-8, TL5-9)
All current nursing staff was provided work in areas of competency until they accepted other positions, retired or resigned.
Psychiatric - Emergency Department Collaborative Meeting A Psychiatric - Emergency Department Collaborative Meeting had been established prior to the closure of the Inpatient Psychiatric Unit. Meeting frequency increased following the closure decision to plan, implement and evaluate the closure. This meeting continues with a primary focus on psychiatric patient triage and emergency treatment in the emergency departments at PSFHS.
Since closing the inpatient psychiatric unit several challenges have been identified and continue to be on this committee agenda for monitoring, analysis, action and evaluation. In August 2011, the ED Policy and Evaluation of Psychiatric and Chemically Dependent Patients in the Emergency Department was revised. (TL5-10, TL5-11, TL5-12)
PSFHS remains committed to serving behavioral health patients in our community. We provide emergency evaluations and outpatient treatment. We coordinate inpatient services with both local and regional resources. Since closing PSFHS Inpatient Psychiatric Services we have been able to refer over 60% of our ED psychiatric triaged patients to local facilities. We continue to provide outpatient psychiatric services within our community.
Summary Closing our inpatient psychiatric unit included both a planned and unplanned changes. The values of PSFHS were evident from the beginning as we partnered within our community to make a decision to close and then throughout the process of closure as staff were actively involved and recognized for their commitment to this service through bonuses and opportunities to continue within PSFHS and Centura Health. Patient safety was paramount and especially evident during the evacuation of the unit during the flood. Interdisciplinary collaboration was required and demonstrated as we continued to serve inpatients in an alternate setting until appropriate clinical dispositions were coordinated. Nurse leaders from charge nurses through the Chief Nursing Officer facilitated a safe transition for staff and for our patients. The Clinical Effectiveness Committee maintains oversight of changes during this time. (TL5-13)
Unplanned Change - Nurse Manager Vacancies:
Changes in nursing leadership impact nursing services at the unit, management and organization level. In the summer/fall of 2012 PSFHS lost three clinical nurse managers on medical surgical units. Senior nursing leaders and current clinical nurse managers quickly partnered to develop and implement immediate short term and longer term strategies to meet the needs of the organization.
Penrose Hospital The Director of Patient Care Services at Penrose oversees seven units with a total of six clinical nurse managers. The loss of two of these six clinical nurse managers required immediate action.
PH 5 Medical/Renal/Diabetic. The clinical manager resigned in March 2012. Several internal nurses applied. Consistent with our Talent Management process and succession planning focus, teams of staff nurses, educators and clinical managers interviewed the applicants. One nurse was selected and agreed to be the Interim Clinical Manager. When she left in September 2012 to accept a staff nurse position in the emergency department, the process was repeated. During the time for applications and interviews, permanent charge nurses on the unit accepted "point" responsibilities to maintain coverage of necessary clinical manager roles. (TL5-14)
These charge nurses identified specific meetings and represented their unit at these meetings. Schedules and assignments were adjusted to ensure patient safety and adequate staffing. The Director of Patient Care Services provided support and guidance to these nurses through frequent rounding and oncall availability. On December 26, 2012 a nurse transferred from the Cardiovascular Unit and accepted the Clinical Manager position.
PH 7 Surgical (Orthopedic/Neurological). The clinical nurse manager accepted a nurse educator position within PSFHS in September 2012. The Director of Patient Care Services at Penrose identified "point" charge nurses to assume daily leadership and represent the unit at specific meetings. In addition, Peggy Plylar, Clinical Nurse Specialist and Joint/Spine Program Coordinator agreed to provide additional clinical support as needed via frequent rounds and informal consultation. A new clinical manager is scheduled to orient in February 2013. (TL5-15)
St. Francis Medical Center (SFMC) The third clinical nurse manager who left was from a post surgical unit at SFMC. The VP of Nursing met with the staff and made frequent rounds on the unit to provide support and to answer questions. SFMC has two units on one floor that serve medical patients and post operative patients. Each unit had a clinical nurse manager and charge nurses. When the post op clinical nurse manager left, the clinical manager of the medical unit accepted responsibility for both units. This leadership role was initially temporary but upon further discussion with the VP of Nursing, the clinical manager accepted permanent leadership for both units. She chose to hire a full time business support person in lieu of adding additional clinical leadership, stating "we have strong charge nurses and I do not want to place another layer of unit leadership that is not necessary. I will mentor and coach our charge nurses as they continue to grow professionally." (TL5-16)
Summary The loss of three clinical managers in less than three months challenged the nursing leaders to guide nursing services during these transitions. Prior to these unplanned changes PSFHS Nursing Services had developed a permanent charge nurse role with additional responsibilities. Some clinical nurse managers chose to restructure staffing and scheduling to include these roles. Other clinical nurse managers chose to implement an assistant nurse manager position. The decisions were made based on unit needs, budgeting, preferences of leaders and available staff. The assistant nurse manager and the permanent charge nurse positions expanded the succession planning process for nursing services.
When three clinical nurse managers unexpectedly left their roles, nursing leaders partnered to identify and implement strategies to meet the immediate needs for unit level leadership and continue our planning for succession planning. While unplanned leadership vacancies are challenging, nurses on each of the units demonstrated leadership skills that served the unit and their own professional development in the short term and we anticipate in the long term. Nurse leaders increased visibility, informal coaching, specific individual assignments in alignment with individual nurse strengths and publicly recognized the units for successful transitions.
Transformational Leadership - TL06
Advocacy and Influence
TL 6 How the organization supports: leadership development, performance management, mentoring activities, succession planning for nurse leaders.
"I have been supported throughout my career when leadership suggested or allowed me to develop new roles with increasing responsibility and diversity such as taking on supervisory responsibility, starting a Nutritional Support Team, chairing various committees and finally becoming Nurse Scientist based on my passion for research."
-Rochelle Salmore, MSN, RN, NE-BC, Nurse Scientist
"The registered nurse provides leadership in the professional practice setting and the profession." (ANA Standard of Professional Performance 15)
"For us who nurse, our nursing is a thing which, unless you are making progress every year, every month, every week, take my word for it, we are going back."
Florence Nightingale, 1872
Nurses serve an essential role in PSFHS, both within the facility walls and in our community. At PSFHS we believe that every nurse is a leader. Our commitment to excellence and our organizational priority for talent management provide the foundation for the professional development of nurses. A framework for leadership development and performance management is present within the formal organizational structure. Succession planning is evident in our talent management program with increasing movement to formalize its structures and processes. A review of many current nursing leaders demonstrates active leadership development as well as advancement. In addition to our CNO, both the Director of Patient Care Services at Penrose as well as our Director of Clinical Effectiveness/Infection Control/Patient Safety has consistently advanced their nursing careers within PSFHS. Coaching and mentoring activities are present at all nursing levels and they support the practice of excellence and achievement of each individual's professional goals.
Leadership Development Institute The Learning and Leadership Department at Centura designs and evaluates leadership training and education across our heath care system. New Leader Orientation is held twice a year. (TL6-1) The Leadership Development Institute (LDI) provides training and opportunities for networking across the Centura organization. Based upon author Quint Studer's Hardwiring Excellence, the purpose of LDI is to improve the performance of individual leaders as well as contributing to organizational consistency. Senior leaders, directors, and managers all participate in LDI. Recent Centura LDI priorities are presented in the table below, and it demonstrates the consistent commitment to leadership development:
• 2008: Targeted Selection, Courageous Conversations
• 2009: Centura Health 2020 Vision
• 2010: Talent Management
• 2011: Healthcare Reform
In 2011 and 2012 the South State Centura Health Group has focused on expanding transformational leadership using music, theatre and arts to inspire and teach. Using Shakespeare's The Tempest, a British Company called OLIVIER MYTHODRAMA taught leadership principles in January 2013. (TL6-2) Additional training for leaders is available online through multiple modules on LEARN, our online learning system.
Conferences Participation in professional nursing leadership conferences promotes leadership development. In 2011, the CNO, the Director of Clinical Effectiveness, and the Director of Patient Care Services at Penrose attended the Institute for Healthcare Improvement National Conference. The exiting CNO serves on the Board of Directors for the Colorado Organization of Nurse Leaders (CONL) and promotes, through direct request and paid expenses, nursing director participation in this professional organization's annual conference. (TL6-3)
Professional Organizations Leadership development also occurs while serving in professional nursing organizations. Kathy Guy, Director of Professional Resources recalling her development as president of the local oncology nursing association stated that, "many of the nurses on the oncology unit participate - we adjust scheduling to support their attendance and they are quick to bring ideas back to the unit." Currently three direct care nurses are serving in officer positions for the Pikes Peak Oncology Nursing Society.
Coaching Advanced Leadership Coaching, commonly known as "Executive Coaching," is a learning accelerator. Centura employs a cadre of certified coaches who employ methods that help leaders lead effectively (Centura also retains the ability to recruit a coach from outside of the organization, if the situation warrants such a maneuver). Nursing directors and managers use this service for their leadership development. Melissa Williamson, Clinical Manager states, "I learned how to integrate leadership expectations into my style - scripting doesn't work for me, but with coaching I found ways to become more effective communicating and leading our unit associates. 5th floor also used my coach for focused training for all of us. Our satisfaction scores improved and clinical outcomes are better!" This example strongly demonstrates how the organization supports the development of nursing leaders through multiple forms of support systems. By utilizing a variety of approaches through coaching, our young nursing leaders are better prepared to lead. (TL6-4)
Centura Professional Development Council The membership of the Centura Professional Development Council (CPDC) includes professional development nursing leaders from all internal organizations. The council's stated purpose is, "to use learning to accelerate the accomplishment of enterprise educational priorities." Council functions include discussions on knowledge management, strategy, educational design, technology, consultation, measurement, and excellence. The Chief Nursing Officer's Council requested that the CPDC design a formal learning program for assistant managers, supervisors, and frontline nurses to support continued leadership development. In order to accomplish this task, a core group of nurse leaders explored options and the literature and selected the American Organization of Nurse Executive leadership's core competencies and QSEN as our conceptual framework. The Leadership Excellence Accountability Professionalism - LEAP- program was designed and three cohorts have completed the 20 hours of class work plus additional study. Using expertise from across our system and encouraging networking, LEAP faculty and participants have come from all Centura facilities. Approximately thirty frontline nurse leaders at PSFHS have completed LEAP. Gwen Thompson, RN wrote the following as she completed the LEAP program, "The nurse leader needs to facilitate the learning growth of the staff by having available resources. In my opinion, the main focus of the nurse leader is "high quality patient care". This involves all nursing staff. The staff should be empowered with skill, knowledge and great guidance from the nurse leader. With high quality patient care the nurse leader and the staff shines in the glory of excellence." The LEAP program and its implementation will be discussed in greater detail in SE5EO as we evaluate the effectiveness of this program. (TL6-5)
Council/Committee Leadership Interdisciplinary and Centura Health organization committee structures provide opportunities for leadership development through participation, networking, stretch assignments, and informal coaching. As the educator for the Birth Center, Candace Garko, MSN, RNC, C-EFM actively networked with other educators and clinical nurse specialists across the system. Her people centered leadership demonstrated her competence in communication and led to her role as Chair of the Clinical Effectiveness Group (CEG) for all Centura Birth Centers. Chairing this committee allowed her to continue to develop her leadership skills and it gave her the opportunity to make a difference with patient outcomes. She has since been promoted to be the Clinical Manager of the Labor and Delivery Unit. (TL6-6)
Education Requirements for Positions All nursing leader roles state educational requirements. The CNO and Director level positions require advanced graduate training. The Clinical Manager position requires a bachelor in nursing degree. While exceptions have been made in the past for these positions, the expectation has been the individual enroll and complete education to meet requirements. The system supports continuing education with tuition reimbursement and flexible scheduling. Rose Ann Moore, Director of Patient Care Services at Penrose accepted her position knowing she would be returning to school to achieve her MSN, "I had so much to learn the first couple years, and then I earned my Nurse Executive certification while working on my masters. I appreciate the opportunity and the mentoring I have received from Kate (CNO)" [her emphasis]. Several clinical managers are completing their BSN programs. Becky Morland, RN Clinical Manager of Urgent Care states "I learned a lot in my BSN program and had the chance to integrate my experiences with my education." A recently hired clinical manager is completing his BSN in May 2013 which will result in a 100% nursing leadership team with a BSN or higher degree.
Clinical Coordinator/Assistant Nurse Position The Clinical Coordinator role provided experiential leadership development. Nurses interested in management positions have used this role to grow into managerial opportunities. The Clinical Coordinator role has provided opportunities for nurses to advance their career with close support from Clinical Managers. Brenda Molencamp, RN who had been identified as a "star" by her manager was promoted to Clinical Coordinator, where she was mentored and promoted to Clinical Manager. The Assistant Manager title recently replaced the Clinical Coordinator title.
Nancy Marts, Clinical Coordinator writes "Six weeks of interim clinical manager is approaching six months. As the Clinical Coordinator I had some idea of the manager role, and filling in for a short time seemed reasonable. But as I approach six months and our manager is just beginning to return to work, I am reflecting on these past months. Prior to this experience I was going through the paces of my work and admit my passion for nursing had waned. I had never really thought about seeking a promotion. Supported, coached and encouraged by our VP of Nursing, manager colleagues in the system and Human Resources, I have grown professionally. My skills are better, I have initiated changes on our unit, and successfully helped resolve conflicts and staff performance problems. But more importantly I have learned to trust my judgment and make independent decisions. Today I can say my passion is back. My confidence has grown significantly and I am committed to my professional growth. Coaching and mentoring made a difference for me and I will offer the same to my nursing colleagues. This has been a great growth opportunity." (Nov., 2010)
Retreats combine education, training, evaluation, and networking which in turn support leadership development. The CNO leads an annual Directors of Nursing retreat focused on evaluating and revising the strategic plan for nursing. In 2009, the Directors created a nursing annual report, which detailed information presented at this retreat, in a calendar format. This report combined photos, metrics, and Florence Nightingale quotes; it was distributed internally and externally so that interested parties who were not in attendance could benefit from the leadership retreat as well. The Directors have continued this process nursing annual reports. Further, the Directors host an educational and inspirational retreat annually for nursing managers and have periodically included supervisors and charge nurses. These activities are held off campus, and they encourage time for reflection and relationship building, both being consistent with our professional practice model. (TL6-7)
Professional Journals and Library Resources Library resources are readily available onsite and online for professional practice and leadership development. The CNO subscribes to Nursing Management for every clinical manager and emails pertinent articles to nurses to keep them informed and to challenge standards and practices. (TL6-8)
Our "Standards of Practice," and the "Code of Ethics for Nursing," hold us accountable to evaluate our nursing practices in relation to the standards, guidelines, and regulatory requirements. We are responsible for assessing and improving our own competences and are accountable to our colleagues for our practice.
Annual performance appraisals provide an opportunity to set goals, clarify expectations, reinforce a job well done, initiate change, and foster a healthy working relationship between the nurse and the manager. Structured through Human Resources, the appraisal process includes a self assessment as well as evaluation by both peers and supervisors. A recent change to the process strengthens goal alignment with organizational metrics and it increases the frequency of evaluation. Leaders were provided education and coaching to implement the new model. (TL6- 9)
Peer Review, credentialing, and privileging are additional structures for performance management and they are discussed at length in the Structural Empowerment section's documentation.
The Essentials of Nurse Manager Orientation (ENMO), a one year online program that was specifically developed for nurse managers by the American Association of Critical Care Nurses and the American Organization of Nurse Executives, provides education to new nurse managers. Three new managers completed the online program in 2010-2011 and reported that "it really helped [me] to learn while I was doing" (emphasis added). In 2012-2013 additional new managers and assistant nurse managers are enrolling in the program. Licensing costs of $400 per person are paid for by PSFHS. (TL6-10)
As members of the Advisory Board, we can access articles, reports, online toolkits, as well as arrange for onsite education. In the spring of 2010, The Advisory Board presented two half day trainings sessions that were attended by multiple levels of nurses. In 2012, The Advisory Board presented to CNO's, nursing directors and managers across Centura Health, including McCord, Varnes, Moore, Molencamp, Saucerman, Kraft, Robertson, Mudd, McPike and Cusic. (TL6-11)
Our nursing leadership has strong interpersonal skills, but they may be challenged when troubled employees do not respond to supervision. Our relationship with the Employee Assistance Program (EAP) includes monthly EAP Frontline Supervisor newsletters and specific training upon request. It is through this tool that supervisors can seek guidance to reach employees who are at risk.
Clinical manager and Charge Nurse "rounding" with associates provides opportunities to develop relationships, identify nurse needs, unit needs, provide recognition, provide feedback, encourage recognition of others, and to clarify expectations. Rounding provides a standard process for ongoing performance management. Additional tools for performance management are available on line or through classes. (TL6-12, TL6-13, TL6-14)
The CNO requires those who directly report to her, to provide her with an annual portfolio. The Cardiovascular Unit and Critical Care Unit also use a portfolio structure for performance assessment. This structure encourages nurses to develop portfolio skills which also enhance their career planning. The portfolio structure has expanded, and it is now required for all nurses who apply to the Clinical Advancement Program.
The Clinical Effectiveness Analysts gather data and provide graphics that show unit, department, and hospital level performances on quality indicators. The nurse sensitive quality indicators, which are patient satisfaction and associate engagement, are primary outcome performance management tools. PSFHS uses this data to monitor and track performance management trends across our system.
Emerging HealthCare Leaders is an intensive program through the University of Colorado, Colorado Springs College of Business. In 2012, six PSFHS leaders including three nurses completed this program. One summer 2012 cohort proposed a project to improve teamwork. (TL6-15)
All new nursing associates are paired with a nurse preceptor on the assigned unit. While the relationship is focused on orientation and is time limited, ongoing informal relationships naturally develop and support professional development for both parties. Nurses may select a mentor informally or formally at any stage in their career. The importance of this relationship is demonstrated by Kate Peterson BSN, RN when she speaks of her mentor, "She is a retired nurse and does not work within our system. I meet with her or sometimes call her to talk about my career challenges and successes. I count on her perspective." The mentor / protégé relationship is crucial to creating professional bonds which span conventional institutional barriers.
The ASCENT, new graduate nurse residency program, provides a unique form of group mentoring. Research demonstrates that nurses who are mentored have improved retention and personal satisfaction. Our ASCENT program provides transition strategies, from school-to-work which includes a group mentoring component called, "Tales from the Bedside". Facilitated by an experienced nurse who has a master's degree in counseling, this group meets weekly to provide emotional support and transition assistance. This group format promotes multiple relationships that continue well beyond the formal scope of the ASCENT Program. Participants consistently provide positive feedback when they evaluate this process with the sentiments of "more time please" and gratitude. New nurses praise this program for providing a safe place to share their vulnerabilities and challenges as they transition to the units. In this group time, they receive and offer support, encourage, guide one another, and begin the socialization process into professional nursing.
Audrey Simpson MSN, RN moved from a Charge Nurse position to being an Interim Clinical Manager and then to the Clinical Manager of the Orthopedic Unit. She recently completed her MSN program. Simpson enjoyed a particularly important mentor/protégé experience as Kate McCord, CNO agreed to serve as her mentor.
I chose Kate McCord, our chief nursing officer as my practicum mentor. My goals were to identify strategies to improve pain management on our orthopedic/neurological post-operative unit and to build a relationship with my chief nursing officer. During our regularly scheduled meetings over a three month period, Kate allowed me to think outside the box and look deeper for answers. She used probing questions to help me discover my weaknesses and to build on my strengths. While I met my goals related to my pain management project, my growth in understanding leadership styles and applying new behaviors is most significant. I prepared and presented education on pain management which helped build my confidence. I now have a closer relationship with my mentor. I learned we all have a job to do in this life, and until you walk in another person shoes, there is no room for judgments. Kate's expectations are high; so are mine. I thought about how I present myself and the impact that has on staff…. how to be clear with my expectations, how to listen, how to work collaboratively for a common goal and how to encourage growth. I do believe collaboration increases productivity, maintains motivation, and stimulates creativity and risk taking. I was able to work closely with seventh floor unit practice council to improve pain management. Preparing for my meetings with Kate taught me to plan ahead and organize my research. I am applying these principles and transforming my behavior to help create a strong, effective team. (TL6-16)
This example is illustrative of the leadership skills and values that can be exchanged via the mentor/protégé relationship. This formal social framework is vitally important to the creation and maintenance of nursing's cultural makeup at PSFHS, and how that framework positively affects the goals of the hospital.
Mackenzie Mudd MSN, RN shares how much the mentoring process has helped her throughout her career:
As a new graduate nurse eleven years ago, I entered Penrose Hospital lacking any previous experience. Through the years I advanced quickly to charge nurse and then Clinical Coordinator. My experience may have not occurred without the encouragement, leadership, and mentorship of two nurses, Lynne Wahl and Melissa Williamson.
Lynne helped me develop critical thinking and leadership skills, encouraging me think through a problem or situation. She taught me how to accurately assess patients, set priorities, and create a plan of care based on the circumstances. She taught me how to hold my emotions together when I would rather cry or scream. She supported me through my first Code Blue and my first patient death with compassion and understanding. I applied what I had learned from Lynne and soon progressed to the charge nurse role.
My clinical manager took notice of my drive and commitment as a staff and charge nurse, and offered me a Clinical Coordinator position. For three years Melissa taught me leadership and management skills that I never had imagined existed, being in a non-management position. There are many elements in a healthcare organization that, when involved with direct patient care, go unnoticed. She has taught me the concepts of budget, productivity, and staffing, but she has more importantly, has taught me how to have compassion and understanding with the staff, coworkers, patients, and family members. I have learned how to effectively solve an issue between conflicting staff members, or talk with a distressed family member. Melissa has allowed me to be a part of a management team and I participated in all meetings with her. She has taught me how to be fair, maintain a high standard of integrity in the role, and work hard for what you believe in. She has given me more responsibilities and encourages me to address diffcult situations when they arise. She has also allowed me to express new and inventive ideas to improve patient satisfaction or staff morale through posters, presentations, or various activities.
In 2011, Mudd was promoted to Clinical Manager and earned her Master's Degree in Nursing. These examples provide direct evidence to support the idea that advocacy and influence are attended to in the PSFHS mentoring program. The camaraderie and shared experiences help shape what would otherwise be a version of an antiquated master/apprentice relationship into a modern and professional link that is focused upon the needs of the patient and community.
Our nursing department's commitment to the profession of nursing and to our expert nurses leads to succession planning within our system. Nurses begin their career with us in different developmental stages. Building education, training, support, and other interventions to stimulate lifelong learning begins with orientation and it is ongoing through performance appraisals and individual learning plans.
Our succession planning process includes:
o Identification of essential formal nurse leader positions
o Identification of "star" associates with potential and an interest in advancement
o Provision of formal leadership development training and experiences
o System opportunities for leadership activities, within small groups or across system ventures
o Continuous scanning of the environment for opportunities for growth, high potential leaders, and plans for when nurses inevitably leave the organization
Essential formal nurse leader positions include: the CNO, the Vice President of Nursing, Directors, Clinical Managers, Administrative Managers, Assistant Nurse Managers, and Charge Nurses. PSFHS also has additional positions that provide nursing leadership in specialty areas, including program coordinators and educators.
The Nursing Leadership Team discusses leadership development and succession planning during the annual strategic planning retreat. Kate McCord, CNO requests that each nursing leader identify individuals who have demonstrated skills and interest in advancing to formal nursing leadership roles. Recognizing the presence of expertise and interest outside direct scope, the directors have challenged the managers to perform the same exercise and commit to provide specialized education, training, coaching and mentoring for those individuals.
PSFHS has a strong tradition of promoting within whenever possible. Leadership development structures and processes support continuing education to prepare associates for promotions. Centura recently hired a new VP of Human Resources based on her expertise in Talent Management. This VP has committed to making education and succession planning precedence. Collaborating with the Learning and Leadership Department, Talent Management is a high priority strategy and is depicted.
The nursing department recognizes the essential role of the clinical nurse manager to support direct nursing care with our patients. Managers meet with their directors regularly to discuss interests in career advancement, exploring options within the system, and taking actions to further develop leadership skills. Due to this type of advanced career planning the pace of advancement can be significant. For example, Kathy Guy the Director of Professional Resources started at PSFHS as a Clinical Manager with the Oncology Unit and advanced to a director role within 5 years.
When charge or relief charge positions open, the manager strives to hire from within the unit for these leadership positions. In order to successfully fill charge positions from the unit, direct care nurses need to be identified early for leadership interest, their leadership potential, formal education, or specific project work encouraged to assess readiness for promotions. One informal tool used to make these determinations is through observation of nurse participation in committees, councils and leadership of small practice changes. Clinical Managers encourage nurses interested in advancement to participate in our LEAP program. Over 30 charge nurses from PSFHS have participated in the LEAP program, returning with new ideas and skills.
Opportunities to "try" nurse manager roles occur when a manager leaves the unit as an interim manager is appointed to supervise. Todd Farina RN, Clinical Coordinator at Penrose Emergency Room accepted an Interim Clinical Manager role when the ED manager resigned. A BSN is required for manager positions, and Todd used this opportunity, and his ambition, to return to school for his BSN. In 2013 Todd accepted the Assistant Nurse Manager position at Urgent Care. (TL6-17)
Chairing a Nursing Council provides another forum for succession planning. In 2010, Lynne Wahl, RN nominated a nurse to transition into the chair position Lynne was leaving. Lynne called her and noted her passion, energy and demonstrated professional commitment through her participation in nursing associations and by obtaining her certification. Lynne met with her prior to the nomination to share her observations, to offer support, and to provide coaching to encourage her to accept the nomination. Cheryl Imlay, RN accepted the nomination and the Chair position stating "I really appreciated Lynne's leadership and her confidence in my ability to take this role. I know I can count on her to help if I need it. I am so excited about this opportunity to grow professionally." The Magnet Coordinator provides coaching and mentoring at least monthly to the Nurse Practice Council Chair.
Kelly Ledbetter, RN has expanded her responsibilities and departmental oversight over the last several years. Ledbetter has prepared for continued advancement through active participation in multiple cross system committees including: the Surgical Care Improvement Project, Peri-Operative Clinical Excellence, Universal Protocol Development, and with revising the Handoff Communication protocols. In 2011, she was invited to attend the organization's Patient Safety Committee when her department was identified with risk issues, and she has now become a permanent member of that Committee.
In 2009 Ledbetter assumed responsibility for 50% more areas in the SFMC Peri-Operative department due to the sudden resignation of another clinical manager. Ledbetter assumed leadership of PACU, Pre-Admit Testing, GI Lab, and Pre-Op, meeting with the Charge Nurses to establish a reorganization plan. In 2010 she assumed nursing leadership of the Women's Surgical Center, which was integrated into PSFHS. Ledbetter had to orient the staff quickly, order supplies, ensure this OR met TJC requirements and standardize processes to be consistent with PSFHS. Due to her leadership and clinical expertise, Ledbetter is a member of the Centura Peri-Operative Clinical Effectiveness Group. In this group, she ensures that we are on the cutting edge of clinical practice and reviews all contracts to ensure standardization and compliance across Centura. Through her efforts, several contracts have been analyzed and "switched" to ensure sound financial practices. In 2012 Kelly was promoted to Director of Perioperative Services at SFMC.
Chief Nursing Officer Succession Planning In 2011 high level nurse leadership planning was broadened, developed, and implemented within Centura by the creation of a Nurse Executive Residency Program for Centura Health associates. This new and innovative program is intended to prepare a pipeline of internal candidates for future Nurse Executive positions within Centura Health. This program is intended for nurse leaders who aspire to become a Nurse Executive at some stage of their career. The residency program is one year in length. This is a precepted, experiential program with required classroom time, online assignments, and a culmination project. Two PSFHS senior nurses are participating in this program. (TL6-18, TL6-19)
Nurse Leadership in Other Departments Working for the Director of Integrated Services, Chris Hildebrant, RN is currently the Director of Women's Services for Centura facilities in Southern Colorado. Hildebrant began her career with PSFHS in 1986 and has held a variety of leadership positions including: the Director of Business Development Outreach Services for PSFHS, the Director of the Health Learning Center, and the Director of the Employee Assistance Program. While Hildebrant loves the challenges of leadership, she always speaks from her core as a nurse practitioner with a focus upon meeting patient needs with high quality care and total caring strategies. (TL6-20)
Kelli Saucerman, RN advanced her career through direct care nursing positions and into management. She is currently the Director of Clinical Effectiveness, Infection Control, and Patient Safety/Risk Management. Reporting directly to the Chief Medical Officer, she leads an interdisciplinary, multi-level group of professionals whose goal is achieving various accreditation and high quality ratings from multiple sources.
Diana Patterson, RN began her nursing career as a civilian and then she transitioned into the military. Teaching patients and families, she stated "I loved watching the light bulb go off and watching people start to apply what they had learned." Moving around in the service did not slow her career progression, "I volunteered to teach childbirth classes and found a great need on the base, with many young pregnant women, for education and support. Reviewing the materials I noticed it had not been updated. I reviewed the literature and improved the program. Returning to the states, I once again volunteered - this time to teach Lamaze classes. Soon I was working on Post Partum and then Labor and Delivery. Then I took time off to raise my children." Diana returned to nursing through Medical Surgical Care. "My manager asked me where I wanted to be in 5 years - I want to teach at the bedside or classes or students." Using every opportunity she could she became a unit preceptor and to pursue her teaching goals she became an adjunct clinical faculty. "One day Jackie (my previous manager) saw me and told me about a position in the hospital Human Resources/Education Department. She encouraged me to apply and here I am 9 years later, continuing to teach and to learn and grow professionally." Diana states "it takes courage and openness to be willing to go through doors that open. I will always do that."
The above examples are drawn from a widely different group of nurses. Their stories and specifics are certainly different, yet the unifying elements in these narratives is that talent is managed within the PSFHS and that nurses are encourages, and empowered to pursue wherever their career goals lead them.
Centura, Penrose-St. Francis Health Services, and our Nursing Department are committed to excellence in service and leadership. This commitment begins with strong evidence based performance management structures and with consistent, fair processes for all of our associates. Leadership Development opportunities exist and are taken advantage of by nurses in all settings and all career levels. Mentoring and coaching are available in both formal and informal ways and have led to improvement in leadership skills and promotions. Succession Planning begins with performance management, organizational planning for succession and strong leadership development opportunities.
In 2013 Rose Ann Moore was promoted to the VP of Nursing at Penrose. (TL6-21) Rose Ann Moore, MSN, RN, NE-BC, VP of Nursing, Penrose responds to congratulations from the Chairman of the Board:
From: "Moore, Rose Ann" Date: January 22, 2013, 4:01:59 MST
To: Mason Smith , Chairman of the Board
Subject: Re: Talking Points: PSF Employs Talent Management Principles to Restructure Executive Team
Mason, thank you so much for your message and support. I'm not sure if you know that I began working at Penrose in 1981 as a graduate nurse making $6.99 per hour and have worked at Penrose my entire nursing career - my promotion is very surreal.
This new role is so important to me especially because I am one of just a handful of staff that worked side -by -side with Sister Myra (and other wonderful leaders of the Penrose system) and am able to share those experiences with our newer associates to keep her vision alive.
Know that I do not take my new role and responsibilities lightly and I promise to continue to learn, grow and do my best everyday for the patients, families and our staff.
Please share this with the board and thank you again.
Transformational Leadership - TL07
Advocacy and Influence
TL 7 How nurse leaders value, encourage, recognize/reward and implement innovation.
Selecting Florence Nightingale as one of our nursing theorists to guide our nursing practice sets the stage for innovation. Her ongoing commitments to quality, creating healing environments, empirically measuring outcomes, and to spirituality are truly consistent with our nursing vision.
Our Structure and Our Culture:
As a member of Catholic Health Initiatives and Centura Health, our opportunities to share ideas, to challenge one another, to seek changes to improve patient care, as well as our work environment are available through committee participation, online sharing, and through conference attendance. Our long term strategic plan, Centura 2020 provides a compelling and inspiring vision of our future. A key element of Centura 2020 is the expansion of health initiatives and innovations outside of the hospital walls. Rural health initiatives, women's health programs, and integrated health structures are being developed by a team of interdisciplinary professionals led by Chris Freeman, MSN, RN, NP. Freeman, a valued leader in PSFHS, leads through innovation. Her role and responsibilities encourage her to be creative and resourceful as she partners within the community to implement innovative practices to meet needs.
Our Professional Practice Model and our Shared Decision Making Model provide visual structures and processes for nurses to officially pursue innovations to improve clinical outcomes and the practice environment. Our Guiding Principles within our Professional Practice Model includes the following elements: Accountability, Autonomy, Competence, Honoring Diversity, and Recognition. These principles challenge and encourage us both individually and collectively to seek the best strategies to improve our professional practice and work environment.
Nurse Leaders Value and Recognize Innovation:
Nurse leaders create an environment for innovation by encouraging participation in teams to identify opportunities to improve outcomes, ensuring access to literature and journals to stimulate thinking and by being visible and accessible. Some nurses choose to share an idea in private where the risk appears less and PSFHS nurse leaders are always available for these discussion. When Jane Allin-Cloutte RN was considering options for furthering her education, she met individually with the CNO to explore her ideas. This dialogue led to more than her choosing to return to school. Her passion for creating a healing environment, nursing practice and gardening led to the beautiful Healing Garden in the Penrose Courtyard.
Healing Garden When you walk through Penrose Hospital, you will have the opportunity to see our Healing Garden. The center courtyard, initially planted with some trees and drought resistant greenery was redesigned in 2010-2012. One nurse, dedicated to healing and health for all, combined her passion for nursing and for gardening. Jane-Allin Cloutte RN stated "Some days I thought it would never happen. I did my research, called on gardening friends, met with hospital administration multiple times, designed a plan and then got the approval. I was so excited to help make a difference for our associates and our patients." Marketing encouraged Jane-Allin as they printed articles to recruit volunteers to help with the program she was implementing. Our nursing leaders recognized and rewarded her innovation with an article in our monthly newsletter and page in our nursing annual report which included her photo and story. We are all grateful for her passion, determination and her ability to implement the Healing Garden. (TL7-1)
Nurse Leaders Encourage Innovation:
Conferences Providing conferences and retreats that allow for "thinking time" and speakers who challenge nurses to innovate, such as Tim Porter-O'Grady is an effective strategy to encourage innovation. A group of Penrose Critical Care Nurses and their Clinical Manager recently decided to adopt the "Porter-O'Grady" idea. The UPC Chair states "We are requiring everyone on our unit to be involved in a committee or workgroup." The Clinical Manager demonstrates her support for this through inclusion on the evaluation. An excerpt from the January 2013 minutes is below:
Quality Metrics Ongoing monitoring of nurse sensitive quality indicators encourages us to identify opportunities for improvement. When the Cardiovascular Unit noticed patients falling more frequently, they closely observed patients and examined the context of the falls. A staff nurse stated "We noticed patients were falling as they pulled on the oxygen tubing, and brainstormed options. We tried longer tubing, which meant coordinating with supply chain to obtain the product. It worked, falls decreased and the other units recognized and applauded our actions."
In 2012 the Centura Nursing Practice Council (CNPC) decided to promote innovations to reduce falls. Louise Wilson, BSN, RN, PH 8 Rehabilitation designed and implemented a pilot toilet training program and fall prevention bundle on the unit. Supported by the Clinical Manager the unit reduced falls and was identified as a leader in the CNPC project. (TL7-2)
Nurse Leaders Recognize/Reward Innovation:
The Annual Seton Awards for Nursing Excellence are designed and decided by a team of nurses representing a variety of levels and settings. In 2012, the team identified a new category for awards, "Innovator". Eight nursing associates were nominated in this category and each one demonstrated innovative thinking and actions that improved our nursing services and organization. One nurse was selected for the award and received a plaque and flowers. Each nominee received a certificate of recognition and was announced at the annual Seton Awards Dinner. A brief review of each applicant is attached. (TL7-3, TL7-4)
One Person, One Time The implementation of innovations is governed by the depth and breadth of the change. With a commitment to actively involve persons who are most affected by a change in the entire process, we use our system called "Plan-Do-Check-Act." This is done to ensure that quality improvement remains the focus and that there is a structure and process in place to support innovation. Other innovations are implemented through a small pilot project or one patient, in what are essentially, one time actions. When Wendy Lowery, RN pushed a confused isolated patient to the nursing station so she could monitor her closely, intervene to reduce patient anxiety, and to provide appropriate stimulation, she noticed the patient seemed calmer. Bringing two patients to the same spot added companionship. In short order, the "Social Club" was established for patient support and it was recognized by The Joint Commission during a site visit as a "Best Practice." As you tour our hospital you will notice the respectful caring of these patients in the "Social Club".
Nurse Leaders Implement Innovation:
Unit Peer Review Sending nurses to the Magnet Conference recognized and rewarded individuals for their motivation to improve nursing through innovation and evidence. In November 2010, Cheryl Imlay, RN, came back with a passion for Peer Review which has been implemented through the Nursing Shared Decision Making Councils. Each unit has selected a different focus and process for peer review. On the ICU, nurses provide formal peer evaluation feedback annually. The Penrose PeriOp UPC have identified implementation of relationship based care for unit level peer review. The PostPartum/MomBaby Unit reviewed IV's and are moving onto other nursing practice. The Skin Resource nurses are using data from the prevalence study to provide peer review. While senior nursing leaders have discussed standardizing the process, they have supported the unit innovations as they implement and grow professionally in the practice of peer review. In July 2012 the NPC approved Unit Peer Review Guidelines. (TL7-5)
DAISY Program Michelle Wolf, RN, returned with a passion for the DAISY Program. The DAISY Award is a nationwide program whose aim is to recognize extraordinary nurses who help people on a daily basis. When the Magnet Champions asked to implement the DAISY program at PSFHS, they created a proposal including outlining the amount of funds that would be required. Since money and other resources impact the process of innovation, the implementation of the DAISY Award needed to have appropriate approval. The Magnet Champion Chair presented the program and the specific plans PSFHS would use to implement and evaluate the program to the Nursing Leadership/Management Council. The Council approved the funding for the program for one year and requested a review of goals prior to making a decision to continue the program. (TL7-6) In addition, paid time to begin the program was provided by nursing administration. This is a prime example of how innovation is valued, encouraged and implemented by nurse leaders. PSFHS nurses were seeking more recognition and when one was presented by direct care nurses it was approved with all of the appropriate funding. (TL7-7)
Daffodil Award The PSFHS Rewards and Recognition committee has grown and expanded programs during the last several years. "Halo's for Heroes," a recognition program through the PSFHS Foundation, honors associates regularly through public presentations. The nursing newsletter and the hospital newsletter showcase associate stories and photos to demonstrate the value of nursing our associates. When we implemented the DAISY Recognition Program for nurses our certified nursing assistants asked if they are included. The DAISY Program is set up for registered nurses at PSFHS and throughout the country. However, the nurses on the Cardiovascular Unit (CVU) designed the Daffodil Award for their nursing colleagues. CVU agreed to share this innovative reward with nursing on all units and the Magnet Champions decided they will maintain the DAISY program and each unit can implement the Daffodil program as they choose. (TL7-8) The Daffodil Award was valued and encouraged by nursing leaders and has been implemented on several units.
Resolve through Sharing (RTS) - Perinatal Bereavement The loss of a fetus is usually a sad time for the family as well as the associates. Recognizing the impact of fetal demise, several nurses on the Birth Center sought evidence based options to support affected families during this time. The nurses located a program called "Resolve through Sharing," which is a bereavement program that provides a comprehensive approach for the caring for families whose babies died during pregnancy or shortly after birth. PSFHS sent our nurses for training and supported implementation of this innovation. These nurses expanded the options by also collaborating with administration and regulatory bodies to create a cemetery and remembrance place on hospital grounds for these babies. In 2012 we provided support through this program to thirty eight families. The following story describes the unit's response to patients during trying times:
Brook Poe, RN, stated " I have never worked at any other hospital, but things that I hear from patients and other nurses regarding other hospital's care of women with fetal loss, leads me to believe that we at our birth center at SFMC really makes the care of these families a huge priority. We all really work hard and do our best to support these families and help them through this very difficult time. We use the philosophy of RTS Bereavement Services that began over 25 years ago. This is an evidence base practice. Our whole hospital goes the extra mile too. Rosemary Partridge RN told me about a mother who had an early loss with a D&C. After the patient went home she called pastoral care and really wanted to see her baby. Rosemary called the physician who took time to place the baby's remains in a way that would be recognizable to the mother."
The patient's well being is at the core of our Professional Practice Model and our hospital mission. By addressing the spiritual needs of these affected families our nurses truly demonstrate the value that leadership places upon their innovative ideas. (TL7-9)
Video As the Magnet Journey progressed the Magnet Steering Committee supported the request by Magnet Champions to create a video of excellence. The PSFHS Marketing Department created the "I make a difference" video which has been shown to the PSFHS Board Members, PSFHS General Leadership Team and is now spreading throughout the hospital. The video recognizes the role of each individual at PSFHS to create an environment of excellence. (Video available at site visit)
Press Ganey Staff Survey:
The nursing services results of the Press Ganey Staff Survey demonstrate improvement in "opportunity to create and innovate" from 2010 to 2012. These results provide evidence of nurse leaders valuing, encouraging and recognizing innovation.
Individual and group innovations are valued at PSFHS. Our vision for excellence in nursing practice balanced with the concern for the caregiver, guides the actions of nurse leaders as they value, encourage, recognize and reward innovations. Implementing new practices in patient care and nursing recognition makes a difference in our culture, environment and outcomes.
Transformational Leadership - TL08
Visibility, Accessibility and Communication
TL 8 The various methods by which the CNO is visible and accesses direct-care nurses.
In order to be a dynamic, transformational leader, the Chief Nursing Officer at Penrose-St. Francis Health Services has developed both formal and informal structures to facilitate her visibility and accessibility.
Structures and Processes for CNO Visibility:
Committees, Rounds, Disaster Leadership A challenge to CNO visibility in our organization is our physical and geographic separation into multiple facilities. Kate McCord, MSN, RN, NEA-BC, Chief Nursing Officer and Vice President of Patient Care values personal connections with direct care nurses and strives to be visible throughout the organization. As a committee chair or participant, making rounds, leading during disaster drills, and through organization Town Hall meetings, McCord's presentation as a strong nursing and organizational leader is professional and dynamic. She communicates organization and nursing goals clearly, seeks input from others and demonstrates collaboration to provide excellent care. Direct care nurses see expertise and professionalism while they experience her heart.
Pat Wilfong-Mager, RN says "I used to work nights and I couldn't believe how often I would see Kate making rounds at night."
When we were moving patients to accommodate residents from a nursing home who were evacuating due to fire, one nurse commented, "She was right on the unit, helping us move patients, reassuring the patients and staff this would be a smooth transition."
Mary Nott, RN states "the day that the shootings occurred at the New Life Church in Colorado Springs, Kate was at the hospital, along with the rest of us, caring for not only the immediate family, but the community supporting this family as well. Her presence on that day gave me strength at the time. But I also saw Kate in a different light. She has remained compassionate and truly caring for patients and their families as well as those of us giving "direct" patient care. I have developed a great deal of respect for Kate and hope she continues to lead us into the future!"
Nursing Newsletters The front page of our monthly nursing newsletter, The Learning Connection (TLC) includes an article from McCord. Frequently her topics are educational or inspirational; her words reach out to every nurse in every setting. In July 2011, McCord spoke about Professionalism. (TL8-1)
The Nursing Annual Report provides comprehensive information, with regards to all aspects of nursing, to the organization. This report provides data that covers all of the achievements and challenges of the previous year as well as goals for the next year. The Chief Nursing Officer writes an introduction in the beginning of each annual report. The CNO is also visible and accesses direct care nurses through her introduction in our Nursing Annual Report. (TL8-2)
Nurses Week McCord is particularly visible during Nurses Week celebrations. She is known for sharing her special chocolate chip cookies with nurses and teaches a well attended class while dressed in traditional nurses' "whites." Modeling the role of nursing as teachers and demonstrating her commitment to professional development, McCord provides education during Nurses Week, hosts tea, and presents at our annual Seton Awards for Nursing Excellence. (TL8-3)
Leadership Retreats Are held annually, provide another forum for our CNO to speak directly with direct care nurses. A Charge Nurse/Manager retreat titled, "Our Image Our Choice" began with education and laughter with our CNO.
Structures and Processes for CNO Access to Direct Care Nurses:
The monthly "Tea with Kate" provided McCord with an opportunity to access direct care nurses. McCord stated that, "this is a time to build relationships with PSFHS nurses. We can talk about anything - interests, families, dreams or nursing at PSFHS, innovations, goals. I love this one-on-one time." Nursing associates are selected randomly during their birth month and invited to tea. (TL8-4)
The "Tea with Kate" program is considered to be a great success by those nurses who attend. The visibility of McCord and her attentiveness is well noted. Below is a grateful email to Jill Clark, Executive Assistant to CNO, from a nurse who was selected to attend a tea session:
Dear Jill, I would like to take this opportunity to thank you for the invitation to the tea last month. I was honored to be invited. Wow! To think that Kate would take the time from her busy schedule to sit with some of us nurses, and just talk with us was a wonderful thing. I was envisioning a large type gathering with us all sitting stiffly in rows; however the setting for the tea was small and intimate. There were several round tables, pretty flowers, teapots and the neatest little sandwiches and snacks! It was just like a real tea party!
Kate took that opportunity to have each of us introduce ourselves, tell where we work, and ask what all was new in our departments. A couple of people took this time to bring up concerns, which I noticed Kate was writing down. She really listened to us. At first we were a little shy about talking, but gradually we began to feel more comfortable, as we realized she really wanted to hear what we were saying! I even got to know a couple of the nurses sitting at my table, which was an added bonus!
Kate also let us know of some upcoming things going on at the hospital, and was able to answer questions some of us asked her about the hospital and our individual departments. It was a nice exchange of information.
Again, thanks for the invitation, and for making us feel so special! It makes me feel good to know my CNO cares about me, and takes the time to show this. Kate is a wonderful person, and I was happy to get to know her better through this nice gathering. I am honored to work for a nurse who cares for her staff and all the patients at her hospital the way Kate does. -Gina Wamble, RNC, Outpatient Surgery, Penrose
This leadership strategy demonstrates relationship based care, boosts morale and provides a direct link between the organization's CNO and those nurses who provide daily care for our patients.
Welcoming New Graduate Nurses - ASCENT Graduation Ann Kjosa, BSN, MBA/MHM, FACHE, CNO spoke with the ASCENT graduating class in November 2012, as she assumed the CNO position. Traditionally the CNO provides the congratulatory, inspirational presentation to the graduates. (TL8-5)
Recognizing Direct Care Nurse Achievements and Honors Using opportunities to personally and publically recognize nurses McCord attends the "Halo's for Heroes" awards, gives the DAISY Awards to direct care nurses and congratulates all nurses achieving specialty certification. McCord attends community awards recognizing nurses including the annual Nightingale Awards and the El Paso County Medical Society Excellence in Professional Nursing Awards. Bridget Town, RNC, responded to McCord's congratulations with a letter thanking her for her advocacy and support when she moved to Colorado and joined PSFHS 11 years ago. (TL8-6)
Via email McCord recognizes excellence in wound care and the national dissemination of our outcomes:
From: McCord, Kate CNO Sent: Saturday, October 08, 2011 To: Bennett, Dorothy E. (Wound Care RN)
Dorothy, Thank you for representing all of us at the National Conference in New Orleans. I am so proud of all of the wound nurses and for the outcomes that you all continue to achieve. Great job!! Kate
Email provides a forum to access all direct care nurses Emails recognize successes or challenges as well as share information. When a critical care nurse passed away, McCord wrote an email expressing her sadness and sharing information. (TL8-7).
"Talking Points" sent via email and often posted on the units are another strategy to access direct care nurses. Changes in Nursing Leadership are formally disseminated through "Talking Points" (TL8-8).
The ability to digitally present information to as wide or as narrow of an audience is utilized by McCord on a daily basis. This enables her to directly reach out to every single direct care nurse whenever contact is needed, and she provides her phone number in these communiqués so that nurses have several options to ask questions.
Chair of PSFHS Ethics Committee & Ethics Consultant Kate McCord, CNO was the Chair of the Medical Bioethics Committee until December 2012 when she resigned from PSFHS. Continuing her education towards a doctorate in Bioethics, McCord led our organization in living the Code of Ethics for Nurses and applying bioethical principles in our clinical practice. In addition, McCord took calls as an Ethics Consultant each month, responding to nurse, physician, or family requests for consultation. Responding to calls for an ethics consultant allows Kate to access, support and professionally develop direct care nurses in challenging situations. Confidential Ethics Committee Minutes, October, 2012 available at site visit.
Shared Decision Making Chairs from all nursing councils are members of the Nursing Leadership Council. These meetings provide both an opportunity to be visible and to access direct care nurses. In addition practice issues that are brought to the CNO attention are appropriately referred to the Nurse Practice Council for discussion, decision and action. The referral action demonstrates CNO valuing of the shared decision making structure and the expertise of direct care nurses. (TL8-9)
Our CNO's passion for nursing excellence includes seeking opinions before decisions and maintaining open communication with associates. While Press Ganey Associate Engagement ratings reflect nursing feedback on all senior leaders, we believe McCord's actions contributed to increased ratings by nurses to questions related communication from senior leaders.
Press Ganey Employee Engagement Survey results demonstrate improved ratings from nurses in the category "Systems and Leadership" from 2010 to 2012.
Red Bar Reflects increased ratings from 2010 to 2012
The CNO is visible and accesses direct care nurses through participation in formal meetings, informal conversations at "tea" or through rounding, teaching, consulting, celebrations during Nurses Week/award ceremonies, electronic communications, and print media. The emails from staff demonstrate the gratitude direct care nurses have for her visibility and accessibility during routine times and during times of crisis.
Transformational Leadership - TL09
Visibility, Accessibility and Communication
TL 9 The various methods by which direct-care nurses access nurse leaders.
A walk through any of our facilities shows how accessible nurse leaders are to direct-care nurses. Nurse Managers may be seen in the nursing station talking with unit nurses or answering a page from their unit while they are participating in a meeting. Assistant Nurse Managers may be filling a charge nurse role for a shift, co-leading a staff meeting, or supporting the Unit Practice Council. The Chief Nursing Officer and other senior nursing leaders may be rounding on units/services, responding to emails from direct care nurses, discussing practice issues and ideas in committees, or meeting one-on-one in their offices. All nursing leaders have open door policies, they freely provide their cell phone numbers, and they all have organizational email access. The structures that support CNO visibility also promote direct care access to all nursing leaders. We believe that bi-directional communication among all levels of professional nurses improves both nursing practice as well as patient outcomes.
The overarching responsibility for Nurse Managers is that they have 24/7 accountability for their assigned unit. For additional support, they maintain a network of assistance among them. For example, Nurse Managers cover for one another during vacation or other absences from the workplace (such as conferences, vacations, etc). As a general rule, direct care nurses are quick to recognize the support from the unit clinical manager, as demonstrated by this testimonial:
"Theresa is always available. I can go into her office with a question or seek her help with a challenging patient situation and I know she will listen and join me on the unit if I need her. Patient care is her priority. We all count on her leadership." (Judy Crenshaw, RN, Inpatient Rehabilitation).
Our nursing administrative managers are on-site making rounds and they are available by pager or cell phone to nurses within the facilities during evenings, nights and weekends. These managers respond to all calls as well as make continuous rounds throughout the house to provide support and be readily accessible to direct care nurses. (TL9-1)
Nursing leaders are also accessible to direct care staff. A member of nursing leadership is present in our facilities at all times. Specific clinical managers or directors may be out of the facilities during the night and weekends but are available by phone or email.
Scheduled formal meetings:
Nursing Leaders participate in unit and organizational committee and council meetings, which provides a forum for communication between nursing leaders and direct care nurses. Shared Decision Making Nursing Councils, as well as various other committees, provide opportunities for direct care nurses to access nursing leaders. Wendy Lowery, RN, Chair of Nursing Peer Review wrote the following in support of leadership accessibility:
"I remember when I was asked to be on the Nursing Peer Review Council. I accepted and was excited but nervous as I had not served on a nursing council. Unsure of what I was getting into, I went to the first meeting. There were only a few staff nurses; the rest of the members were manager and director level nurses. I recognized some members from around the hospital but was uncertain as to their role. At my first meeting I was elected co-chair of the council. I was nervous and overwhelmed! I did not have experience co-chairing a council and especially a big council involving managers and directors. I took my responsibility seriously and worked side by side with the chair and learned many things. This was a new nursing council so there were many details we needed to be work out. Everyone made me feel comfortable, answered questions and shared ideas. I listened and learned. I became a better resource person for my colleagues as I learned who to call for certain things and who had answers if we had questions on policies, nursing practice or risk management."
The Nursing Staffing Council is another example of nursing leader accessibility. The attached charter identifies the member roles for nurses within this council. (TL9-2)
The Nursing Professional Development Council members from all levels and settings identify and take actions to enhance professional development of all nurses. Discussion in this forum enhances ideas as well as builds a partnership with a local university. (TL9-3)
Staff meetings provide direct access to nurse leaders on a more intimate scale. PH 10 opened in January 2011. Rose Ann Moore MSN, RN, ND-BC, Director and Brenda Molencamp, BSN, RN, NE-BC, Clinical Manager participated in a staff meeting on Penrose 10 Observation Unit which included a dialogue about staffing, equipment and expectations. (TL9-4)
It is important, now more than ever, for all nursing work stations have access to digital communication. Nurses can easily write an email to any leader as well as read new communications. Evelyn Angeles, BSN, RN, CCRN, works on the Cardiovascular Unit. The PSFHS Certification Policy states certification pay is paid for the certification appropriate to the assigned unit. Since Angeles' certification is in Critical Care she anticipated being denied certification pay for her work on a step down unit. Angeles states:
"I emailed Rose Ann Moore, Director of Patient Care Services and listed my reasons why I think my CCRN certification is very applicable to CVU and I should be able to retain my certification pay. I also spoke with her and offered to present my case to a panel of nurse leaders. I emailed her again and attached an article an AACN publication that support CCRN certification for progressive care units, noting that both ICU and progressive care nurses have similar preparation. Rose Ann met with other Nursing Directors, presented my reasons and the article to support my case. I know that the evidence I provided to support my request made a difference. The nursing directors made the decision to continue my certification pay. Our nurse leaders do listen to staff nurses especially if when we provide evidence based information." (TL9-5)
Jamie Rushford, BSN, RN, OCN recently joined the PH 11 Oncology Unit. She used email to communicate with the Clinical Manager regarding scheduling and teaching. The attached email also demonstrates easy access to the Clinical Manager who responded on a Saturday. Timely response demonstrates the manager's attentiveness to this new employee and welcoming attitude. (TL9-6)
One nurse took time at the end of her first shift as a charge nurse to recognize her colleagues. Not only did she thank them during her shift, she wrote an email to nurse leaders, copying the shift colleagues, to recognize the support she received. (TL9-7)
What these examples illustrate is the type of important and candid discussions that nurses have with the members of their leadership. The topics of these communications relate to a wide variety of subjects, matters of policy, and the quality connections made between levels of the nursing staff. All are important examples of the accessibility of nurse leadership in PSFHS.
While the CNO's main office is located at Penrose Hospital, she makes rounds at both hospitals, particularly during holidays or off shifts. One nurse from SFMC wrote the CNO an email detailing the successes on the unit, championing Magnet and acknowledging the CNO had rounded at night but this nurse had missed seeing her. The CNO responded via email as well and shared her expectation that PSFHS sends nurses to the Magnet conference. (TL9-8)
Office/Open Door Access:
The CNO's door is always open and she is quick to reprioritize to meet changing needs. To illustrate, one nurse shared her experience:
"Recently I was upset and very emotional regarding my position at Penrose-St. Francis with some of the problems and frustrations I was experiencing in creating a new program. As a direct report to Kate for several years, I feel very comfortable going to her for guidance and direction as well as comfort. She is always there for me, regardless of the reason. I share the highlights of my job and the difficulties. She listens intently, provides possible remedies, and takes any required action. In this particular incident, Kate was in her office as I approached, saw my expression, closed the door and asked "what is wrong and what can I do." I spoke very frankly and within a few minutes, she relieved my anxiety and re-energized my commitment to my endeavors. At the close of the session, I received a big hug. I feel so very privileged to have a CNO who cares deeply for staff, colleagues, and patients that she will stop immediately to help a person in stress. Penrose-St. Francis is fortunate to have such an outstanding CNO. (signed) A Grateful RN"
The VP of Nursing at Penrose is accessible to direct care nurses through her open door policy and scheduled meetings. In addition, she rounds on Penrose Units multiple times a week, and is always present on units for celebrations, honors, and challenges. A screenshot of her schedule demonstrates her accessibility. (TL9-9)
Direct care nurses are able to contact nurse leaders in a variety of ways. Nurse leaders frequently make rounds through nursing units, in order to make contact with direct care nurses and to develop relationships with them. Direct care nurses participate in councils and committees, providing a formal route to advocating change openly with leadership. Further, our "open-door" policies allow for direct care nurses to contact any nurse leader either in person or through a phone call or email.
Most importantly, this narrative demonstrates accessibility that both creates a culture and leads to collaboration and results.
Transformational Leadership - TL10
Visibility, Accessibility and Communication
TL 10 Describe and demonstrate how nurse leaders use input from direct-care nurses to improve the work environment and patient care.
Nursing leaders at Penrose-St. Francis Health Services (PSFHS) recognize and value the expertise of our professional direct-care nurses. There are a variety of structures and processes that provide opportunities for nurse leaders to seek, listen, act on and support direct care nurse ideas for improvements for both the work environment as well as patient care.
We expect our nurse leaders to obtain and act upon input from our direct care nurses. Position descriptions for clinical managers and for directors include essential functions such as:
• promoting an engaged workforce
• fostering an environment to achieve high associate satisfaction and the retention of staff
• a collaborative work culture
• providing an environment in which staff are motivated to meet both personal and professional goals
• requirements for effective interpersonal skills
• maximizing quality, productivity and efficiency (TL10-1)
While some structures are formal, our nurse leaders' commitment to ongoing communication and accessibility to our nursing associates, promotes collaborative dialogue and decision making.
Formal Structures for Direct Care Input for Improvement:
Nursing Shared Decision Making (SDM) The SDM process occurs through formally structured nursing councils. Unit Practice Councils (UPC), which are closest to the bedside, provide a primary forum for direct-care nurse decision making as well as a forum to investigate actions that improve the work environment and patient care. Nursing managers support UPC activities through coaching, access to resources, and access to information. These UPC's provide representatives to the organization's Nursing Practice Council as well as to other committees throughout PSFHS. Chairs of all hospital nursing councils participate in the Nursing Leadership/Management Council (NLM/NMC) which promotes communication and accessibility to resources. The attached minutes reflect the reports from council chairs as well as wide breadth of topics relevant to nurses at all levels and in all settings. (TL10-2)
Unit Practice Councils (UPC) In fall of 2010, the 4th floor Unit Practice Council decided to automatically order low boy beds for all patients admitted with orders for alcohol detoxification to reduce the number of falls in this patient population. The nursing manager used the input of the UPC to coordinate the availability and access to low boy beds. The graph below depicts the significant decrease in falls following this particular change in procedure.
SFMC Post Partum Mom Baby Unit In July 2012 the Unit Practice Council reviewed the status of breast feeding pumps. Twenty two rooms had a secure breast pump, twelve rooms did not have a breast pump. The unit kept four "floaters pumps" available. However when the census is high, finding a pump was challenging. The nurses identified the challenges of having breast pumps secured in some rooms and therefore not available in other rooms. Mothers were not assigned to a room based on locations of breast pumps so this created extra effort to unsecure and move the pumps based on mother's location. In addition, the nurses reported the location of the secured pumps were difficult to move into place to support comfortable use for the new moms. Unfortunately, prior experience with the breast pumps being left unsecured in rooms had resulted in loss of equipment. (TL10-3)
The UPC shared their concerns with their manager and they requested a breast pump for each patient room. During "Appetizers with Ann", an informal open house meeting with the VP of Nursing, the nurses shared their challenge and request with Ann. Ann met with the Clinical Manager and approved purchase of additional breast pumps. In January 2013, the pumps arrived and were placed in rooms. This has proven to be a great patient satisfier as well. New moms no longer have to wait for a breast pump to be found as it is available for use throughout their stay. This is another step as we continue to promote breastfeeding support to our patients as we move towards Baby-Friendly Recognition.
Space and decorating decisions are always challenging in organizations To expand medical surgical services, we moved the pediatric unit to a different floor in 2010. Direct care nurses requested age appropriate art work in lieu of the abstract art they had initially received. The decision of the direct care nurses to pursue more age appropriate art improved the work environment for all parties. When you tour the unit you will notice the animals on the walls and ceilings.
Infection Control Committee Hand Hygiene is a priority. The infection control committee and specifically our nurse leaders sought input and feedback from all associates on strategies to improve compliance. When the cardiovascular units requested that hand sanitizer dispensers be placed outside of every patient door, the equipment was ordered and hung. When nurses reported chapped hands from one cleanser, additional ones were ordered and piloted until one was selected as the product least likely to result in complaints, or chapped hands. Currently the Nursing Quality Safety Council and Nursing Practice Council are championing to improve hand hygiene on units. Moving from "secret" off unit observations to direct care peer review has resulted in improved hand hygiene. The graph below demonstrates improvement with direct care peer review observations on individual units. The blue line reflects Infection Prevention monitoring; the green line represents Hand Hygiene Champion monitoring and demonstrate improvement. The ratio of complete hand hygiene to total observations accompanies each month marker. Actions taken by direct care nurses through their participation in a nursing council, and supported by nursing leaders have improved compliance with hand hygiene. (TL10-4)
Collaboration between Transport and Nursing Patient diagnostic testing occurs on a 24/7 basis, however, when possible we allow patients to sleep at night and schedule tests starting first thing in the morning. This coincides with report and shift change on most units, and it is especially critical when an RN must accompany a patient outside of their unit for changes in clinical status. Nurses from many units voiced concern for maintaining patient safety in the context of many priorities. The Transport Manager listened, discussed with transport staff and revised transport procedures to support nursing in delivering quality patient care.
National Nurses Week The activities of National Nurses Week are coordinated by a group of nursing managers, educators, and direct care nurses. One of the activities is a series of educational opportunities. The request for these educational opportunities comes from the suggestions of direct care nurses each year. We offer both contact and continuing education hours on topics that have been suggested by direct care nurses. In 2011 for example, a number of requests for additional education focused on infection prevention, disasters and interpersonal skills. As a result, these topics were included in the schedule. (TL10-5)
Unit Staff Meetings In 2011, the GI staff had a "brainstorming" session to address the following issues: procedure room turnaround time, patient/family satisfaction, physician satisfaction, and employee satisfaction. Patients' families wait in a room at the end of a long hall until the patient is in recovery. Walking to the waiting room to escort family members back took up a lot of time between cases. The GI staff requested that an unused conference room next to the recovery room be converted into a space for family waiting, to improve family access to staff. The GI Manager supported the project and enabled a smooth transition to the new layout. The feedback following the change has been positive from all parties. In addition, the data from the HCAHPS reports demonstrate that this change that was prompted by the direct care nurses led to a positive change in the work environment.
Measuring Direct Care Nurses' Perceptions of Leaders:
Work Environment/Patient Care PSFHS uses two methodological instruments to measure how direct care nurses perceive the many elements of their work environment, to include leaders listening and supporting their ideas.
One of these methods is to measure the effectiveness of our nurse leaders by using data provided by direct care nurse input. This data is provided by the results from nursing on the "Press Ganey Associate Survey." In addition when we receive results from the survey, nurse leaders meet with direct care nurses to examine, analyze, and take actions that both celebrate the successes as well as work to improve the professional practice environment.
The 2012 Press Ganey Satisfaction Survey results from nurses in the category entitled "My Work," demonstrate consistent improvement from 2010. Nursing literature consistently reports improved outcomes when nurses are actively engaged and making decisions related to their professional practice and work environment. Educational opportunities for nurses also provide skills to identify and pursue practice and environmental changes.
Question 2010 2012 Oppurtunity to create/innovate 66.6 71.6 Makes good use of my skills/abilities 77.7 80.9 Feelings of accomplishment 76.6 81.7 Given oppurtunities for education 70.7 75.1
As you can see, the data indicates an increase on average of 4.5% across each category over the two year period. This demonstrates that PSFHS nurses perceive that their input is valuable to nursing leaders and the organization as a whole. The Press Ganey survey is administered every one- two years and we review the results of the organization as a whole as well as by units, supervisors and profession. By selecting responses from only registered nurses, we are able to examine our successes from the perspective of our direct care nurses.
PSFHS' commitment to best practices and best outcomes is reflected in our efforts to take actions based on direct care nurse expertise. Direct care nurses have excellent ideas for improvement, and with support and resources from nurse leaders in implementing those ideas, we improve patient care and the work environment. Our nurses view themselves as an integral part of the healthcare team, seeking to partner in all performance improvement initiatives, from simple projects to large architectural commitments. The transformational leadership style of PSFHS is reinforced as these partnerships across all nursing levels result in an effective process of change. TL 10 EO will provide additional examples of nurse leaders' use of direct care nurse ideas to improve patient care and the work environment.
Transformational Leadership - TL10EO
Visibility, Accessibility and Communication
TL 10 EO Describe and demonstrate changes in the work environment and patient care based on input from the direct-care nurses.
1. Penrose Community Urgent Care (PCUC): Improving Patient Satisfaction Changes in the Work Environment and Changes in Patient Care
Purpose and Background:
PCUC staff monitors and evaluates the time from patient arrival to triage and physician assessments. In addition, the team reviews patient satisfaction with services. In reviewing their data for early 2011, they identified opportunities to improve. Door to triage time had increased in the first quarter and although it had appeared to be improving, the staff questioned their efficiency. Time from patient arrival to physician contact was at a record high of 90 minutes in February. Patient Satisfaction with timeliness was below 50%, HCAHPS Top Box Rating.
The goal for the project was to reduce Door to Triage Time and improve Patient Satisfaction Ratings.
The PCUC's Unit Practice Council formed a process improvement team and developed a performance improvement plan using the standardized Plan-Do-Check-Act format. The UPC identified their current process and determined that several steps could be completed concurrently rather than sequentially. In addition, the team requested a window be installed in the triage reception area in order to improve communication. The manager approved and facilitated the addition of window. The UPC revised nursing practice from a separate triage to the direct admission to the room; the team educated their colleagues and implemented changes in July 2011. PCUC continued to collect daily data, promote standardization of practice, and evaluate outcomes over the next two quarters. ( TL10EO-1 )
Rebecca Morland RN, Clinical Manager
Anne Shepard RN
Peggy Myers RN
Sloan Farris RN
Katie Conway RN
Mary Lou smith RN
Dan Jones RN
Donna Baker RN
The timeliness data and patient satisfaction immediately improved and has sustained improvement. Goals were met.
1. Time from patient arrival to triage decreased following intervention.
2. Time from patient arrival to being seen by a physician decreased following the changes in environment and practice.
3. Patient Satisfaction with timely staff response improved following intervention.
Significance of Results:
Direct care nursing staff participation in evaluating their own practice and reviewing patient satisfaction, led to practice changes. These changes were highlighted by restructuring the initial triage nursing practice and their work environment change via an added window. Both changes have led to reductions in patient wait times and improved patient satisfaction. The Clinical Nurse Manager listened to direct care nurse ideas and provided support through her participation on the performance improvement team and accessing resources to add a window.
TL 10 EO: Describe and demonstrate changes in the work environment and patient care based on input from the direct-care nurses.
2. The Peripheral Inserted Central Catheter (PICC) Team Takes the Lead to Reduce Central Line Bloodstream Infections: Changing Patient Care through Collaboration between PICC and Critical Care Nurses
Purpose and Background:
Despite the implementation of a peripheral inserted central catheter (PICC) team, dissemination of practice guidelines on vascular access care and education about proper vascular access dressing changes, central line associated blood stream infections (CLABSI) persisted at PSFHS. From October 2005 - June 2009 Penrose Hospital Critical Care unit reported CLABSI rates that outperformed the National Health and Safety Network (NHSN) national benchmarks. The following year, from October 2009 to June 2010, the Critical Care Unit experienced an increase in CLABSI. An interdisciplinary team formed and revised nursing practices, implemented use of new evidence based products, and expanded nursing education. These practice changes included a strict focus on hand hygiene, the use of a Central Line Insertion Practice sheet (with ongoing monitoring for practice compliance), education of staff during annual skills review, the use of maximal barrier precautions at insertion, and chlorhexidine skin antisepsis. CLABSI rates slowly decreased and the rates again outperformed the national benchmark. However, in 2011 Penrose Critical Care Unit reported a rate almost double that of the national benchmark and the Central Line Committee took immediate action. The goal is to reduce central line infections in Intensive Care.
Methods and Approaches:
In June 2011, the PICC nurses proposed a practice change to the Central Line Committee to reduce CLABSI infection rates. The PICC nurses drafted a Process Improvement Plan with support from the Chair of the Nursing EBP/Research Council (PDCA, Proposal to pilot an Early Vascular Access and Care Intervention in the Penrose Critical Care Unit for 3 months). The proposal requested to pilot an Early Vascular Access Team to ensure that each patient receives venous access that is appropriate to the patients' plan of care and to implement evidence-based interventions to reduce the risk for CLABSI's and other vascular access associated complications. The goal for the project was to Reduce Central Line Infections. ( TL10EO-2 )
The Practice Guideline selected for use in changing nursing practice to reduce central line associated bloodstream infection is available through the Agency for Healthcare Research and Quality, National Guideline Clearinghouse. The Penrose-St. Francis PICC nurses established an Early Vascular Access trial that took place from September 6, 2011 to December 6, 2011 in the Penrose Hospital Critical Care Unit. During the trial, a Vascular Access Team (VAT) monitored the access site of each patient Monday through Saturday and made recommendations for discontinuation, site modification, and PICC line insertion based on CDC and APIC national evidence based practice standards for the care of central lines.
The Early Vascular Access Team agreed to the following accountabilities in Penrose Critical Care Unit:
• Monitoring all PIV sites, Central Lines & PICC Lines for infections and complications
• Changing all Central Line and PICC Line dressings weekly and as needed to ensure protocol was followed
• Request nursing staff attempt no more than 2 peripheral IV sticks during the hours of 0800-1800 M-F prior to calling a PICC nurse
• Educate staff on CDC and APIC guidelines, care of central lines and the devastating aspect's of CLABSI's
The PICC nurses participated in interdisciplinary rounds in the Critical Care Unit and provided 1:1 education as needed. During this time the need for additional FTE support was identified. In December 2011, the Director of Professional Resources proposed and received approval for an addition 0.5 FTE nurse in the PICC service.
The pilot project shifted the responsibility of central line maintenance from that of routine nursing care to a collaborative interdepartmental approach of shared responsibility between staff nurses and PICC nurses. The PICC team was accountable to the Central Line Committee and the PSFHS Quality and Patient Safety Committee. (TL10EO-3 )
Jeannie Fox, RN, PICC Services
Rita Ellson, RN, PICC Services
Jeri Bari, RN, PICC Services
Dawn Ingram, RN, PICC Services
Kathy Guy BSN, MSHA, RN, NE-BC, Director of Professional Resources
Rochelle Salmore, MSN, RN, NE-BC, Nursing EBP/Research Council Chair
Daniele Lakin, RN, CCRN, Intensive Care Unit
Jennifer Robertson, RN, PH Critical Care Unit, Clinical Manager
Kate McCord, MSN, RN, NEA-BC, Chief Nursing Officer
Penrose Hospital Critical Care Nurses
During the Trial Period (September 6, 2011 to December 6, 2011) there were ZERO CLABSI's in the Critical Care Unit. The initial goal was met.
The PICC team working in collaboration with Penrose Critical Care nurses designed a professional nursing practice poster. Daniele Lakin, RN, CCRN in Critical Care disseminated the project and outcomes through a poster presentation at Catholic Health Initiatives Patient Safety, Quality and Risk National Conference and Centura Health Annual EBP Conference in 2012. ( TL10EO-4 )
Based on the initial outcomes and the accompanying assessment of outcomes on other inpatient units, PSFHS is expanding the services throughout both hospitals. The Director of Professional Resources requested an additional 2.0 FTE to create a Vascular Access Team which will include the current PICC nurses. The Director Workforce Council approved the request and these nurses are completing orientation. ( TL10EO-5 ) Reducing CLABSI is essential for patient safety, provider satisfaction, regulatory requirements and reimbursement. Ongoing monitoring of infections will occur through the Central Line Committee.
Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; David Classen, MD, MS; Kathleen M. Arias, MS, CIC; Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; David P. Calfee, MD, MS; Susan E. Coffin, MD, MPH; Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Keith S. Kaye, MD; Michael Klompas, MD; Evelyn Lo, MD; Lindsay Nicolle, MD; David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS; Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH. (2008). "A compendium of strategies to prevent healthcare-associated infections in acute care hospitals." Infection Control and Hospital Epidemiology , 29(S1), S22-S30.
Yokee, D.S. & Classen, D. (2008) Introduction: improving patient safety through infection control: a New Healthcare imperative. Infection Control and Hospital Epidemiology, 29(S1), S3-S11.