Organizational Overview - OO1
OO1 A description of the applicant organization in terms of: Mission, Vision, Values, History, Geographical Location, Services Provided, Number of licensed beds, Total RN full-time equivalents, Populations Served. Including: an ethic profile of the nursing staff, client population, and the community served.
The information provided below describes our organization in terms of our longstanding relationship to our community, how our staff is representative of that community, and the ways in which we perceive our care services.
Penrose St. Francis Health Services are a part of Centura Health, Colorado's largest healthcare system. As such, we share the same mission, vision, and values as we relate to fellow associates and serve our communities.
Our Mission Statement:
"We extend the healing ministry of Christ by caring for those who are ill and by nurturing the health of the people in our communities"
Our mission guides us in all that we do. We strive to provide compassionate care to all of our patients and to extend our reach to underserved communities. We attempt to emulate Christ through our commitment to treating the person and not the symptoms.
The Vision Statement of Centura health and PSFHS is:
"To fulfill a covenant of caring for our communities to become their partner for life."
In order to help achieve this vision in both scale and scope, Centura Health developed a planning document entitled Centura 2020. This visionary design provides three thematic directives which will enable us to lead into the next decade and beyond. They are provided below:
Strengthening the Foundation Our commitment to safety and service is more than just good health care; it is a natural expression of compassion and caring. Both of which are central to Centura Health. Strengthening our foundation also means providing our associates and physicians with the proper tools to reach their full potential in order to continue to provide exceptional care for our patients.
Creating Systems of Care We serve more communities and people in Colorado than any other health care provider. In order to truly unlock the power of our system, however, 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 in neurosciences.
Moving Upstream We believe that 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 they need to think differently about their health.
o Compassion: We will be Sensitive and Responsive to Persons in Need
* Honor the individuality of each person.
* Treat each person with dignity, taking the time to be present, to listen, to explain and to understand.
* Create a caring environment that exudes humanity, humility, grace and love.
o Respect: We will Respect all Persons and Honor the Christian Identity, Heritage, and Missions of our Sponsoring Organizations
* Encourage and value the contributions of each person, and make each feel supported, reassured and empowered.
* Listen well, communicate openly and honestly, and encourage others to do the same.
* Treat others as we would like to be treated ourselves, relating so well with them that they actively seek to associate with us.
o Integrity: We will be Honest and Direct and will Respect our Commitments
* Foster trust by being truthful, empathetic and consistent.
* Be authentic and courageous, aligning what we are thinking, saying, feeling, and doing.
* Be responsible for and follow through on the commitments we make.
o Spirituality: We will Acknowledge the Central Role of Spirituality in Facilitating Mental, Physical, and Emotional Health
* Add meaning and purpose to the lives of our associates, physicians, and partners.
* Celebrate the role of spirituality in healing for each individual.
* Serve each other and our communities in harmony with the inclusiveness, wholeness and touch that characterized Christ's healing ministry.
o Stewardship: We will Respectfully Manage our Natural, Human, and Financial Resources
* Seek ways to appropriately utilize resources, allowing us to become more effective and productive.
* Act responsibly, taking only those actions that align with our mission.
* Be accountable to the organization and to each other for our actions and the outcomes they produce.
o Imagination: We will be Creative and Innovative in all we do
* Look beyond the challenges of the present and envision what is possible.
* Cultivate and reward innovation and risk taking.
* Embrace continuous learning and positive technological advancement.
o Excellence: We will Strive to Exceed the Clinical Quality, Customer Service, and Cost Performance Expectations of our Customers
* Put forth our personal and professional best, providing the highest quality of care of which we are capable.
* Commit ourselves to continuous improvement, seeking to set the recognized performance standards within our industry.
* Deliver a superior experience for all of our customers, sensing their needs and exceeding their expectations.
Both Colorado Springs and PSFHS owe their longevity and vitality to the Pikes Peak Gold Rush and to endemic tuberculosis. This relationship between a community and its health care providers is one that is demonstrably unique. PSFHS is a fusion of two religious healthcare systems which both served the Pikes Peak Region for over a century. Penrose Hospital, which was run by the Sisters of Charity as well as the St. Francis healing centers which were run by the Sisters of St. Francis of Perpetual Adoration. The two organizations came together in 1990 to better serve the community, although both have a storied past. In order to understand the long standing importance of these two organizations, one must understand the community's unique relationship with healthcare.
Tuberculosis Tuberculosis, Consumption, the White Plague - no matter the designation - it was the rapid spread of the disease in the late 19th century which made Colorado Springs famous as a city of health. Due to the region's dry climate, clean air, and altitude (as well as a successful marketing campaign) - physicians the world over recommended that patients who were suffering from the disease head to Colorado Springs to recuperate. Tuberculosis remains a cultural centerpiece for the town, as those with the means uprooted their lives and moved to this community, infusing the puritanical resort town with culture, an international flair, and an urgent need for health care.
St. Francis Health Center The St. Francis health organization was the first hospital in Colorado Springs. The infirmary was founded in 1887 (that is 126 years ago) by the Sisters of St. Francis of Perpetual Adoration and a physician for the Midland Railroad Company, in order to provide care for railroad workers. Colorado Springs was the ideal location due to its proximity to Denver (the major western railroad hub outside of California) and because of Colorado Springs' relationship with the railroads (it was founded by a railroad magnate). The community was excited to receive the new hospital as it had relied upon unaffiliated practitioners and charlatans since its founding in 1871. The care focus of St. Francis Health Center remained on trauma throughout its independent history. Due to this intention, St. Francis brought the region's first level II trauma facility, Flight for Life, and a hospital owned and operated ambulatory service.
Penrose Hospital Originally founded in 1890 as the Glockner Sanatorium, its goal was palliative care. Shortly after the hospital's creation, ownership was given to the Sisters of Charity, a large religious order based in Ohio. Colorado Springs experienced rapid and continual population growth from 1900-1919; as a result, the Sisters changed the hospital's focus to deal with acute care. This led to the creation of the "Glockner Training School for Nurses" in 1903 (a school which developed nurses for seventy five years and was later incorporated into the University of Colorado system). Further growth came in 1939 when Spencer Penrose, a local magnate who was one of the few who "struck it rich" during the mineral rush, donated large amounts of capital for a facility dedicated to cancer care. When Penrose died, his widow Julie continued to support the hospital and it was renamed in her honor.
Cancer & Prestige Penrose was led into the modern era of medical research by Henri Coutard, a world famous physician brought to head the hospital in 1941 through the patronage of Julie Penrose. Coutard was trained in the best oncology schools in the world and he revolutionized the treatment of cancer in the interwar period through the invention of the Coutard Cancer Therapy. He later became the head of the Curie Institute at the University of Paris. Under Coutard's leadership, Penrose became a world class cancer hospital in terms of research and outcomes. Patients from all around the world came to Penrose Hospital for cancer treatment. Following Coutard's retirement in 1949, the hospital was led by his protégé Juan del Regato. Regato made Penrose Hospital the first training center dedicated to radiology treatment in the United States. ( OO1-1 )
Unification & Centura Health As previously mentioned, St. Francis and Penrose hospitals combined in 1990. The sharing of the healthcare responsibilities made the overall care of the community more efficient and better prepared to remain a force for health in Colorado. The merger was so successful that another was sought. In 1995, Centura Health was formed through a merger between the Sisters of Charity and Porter Adventist Hospital in Denver (our sister facility and a Magnet institution). Now, Centura Health is part of the nationwide Catholic Health Initiatives and the Adventist Health System. Since 1995, PSFHS has continued to be the premier healthcare facility in the Pikes Peak Region. Our nurses, physicians, and support staff are exemplary and we have been recognized as one of the 50 Best Hospitals in the Nation for 5 years in a row.
Geographically, the city is spread over approximately 190 square miles with a dry climate that is considered to be "semi-arid." Our two facilities are based in Colorado Springs, Colorado. Colorado Springs is located on the Colorado High Plains, roughly 60 miles south of Denver. The city is nestled next to the foothills of the Rocky Mountains (and most prominently Pikes Peak) to the west, Monument Hill to the north, Cheyenne Mountain to the south, and to the east by plains. This provides the city with a "pocket climate" of milder temperatures than the surrounding areas. Our older of the two facilities, Penrose Hospital, is located in what is known as the "Old North End," a Victorian neighborhood slightly north of downtown Colorado Springs. It serves the population-heavy urban areas of the south and western parts of town. St. Francis Medical Center is on the east side of town where it services the suburban and rural areas near and on the plains near the northern and eastern parts of the area.
Penrose-St. Francis is a part of Centura Health, Colorado's leading healthcare provider with a coordinated statewide network including 13 hospitals, seven senior living communities, medical clinics, Flight for Life, and home care and hospice services. The outstanding physicians and staff who lead the charge enhance this supportive network. And with a full range of emergency, medical and surgical services, Penrose-St. Francis distinguishes itself with outstanding clinical specialties and skilled healthcare professionals to provide the best possible care. PSFHS provides a wide variety of general and specialized services through our facilities.
Breast Cancer CenterOccupational Medicine
Bariatric Weight LossPediatric Care
Behavioral HealthRehabilitation Services
Cancer CenterSleep Disorders
Critical Care UnitSurgical Services
Emergency/TraumaTotal Joint and Spine Center
GI Lab, Heart Vascular CenterUrgent Care
Health Learning CenterVascular and Vein Care
Laboratory/Pathology ServicesWound Clinic
Minimally-Invasive Robotic Assisted Surgery
Additional services are provided through resources dedicated to our community. These include: Ask-A-Nurse, classes, programs, and the option for the creation of a personalized web page to facilitate communication between family and friends of patients.
Beds, RNs, and Additional Information:
• 2,520 associates
• Total RN FTEs = 799.61
• 781 affiliated physicians
• 522 licensed beds (Penrose Hospital = 364 Beds, St. Francis Medical Center = 158 Beds)
• 21,810 annual admissions*
• 88,176 annual emergency department visits*
• $120 million in uncompensated and charity care provided annually*
* For the fiscal year ended June 30, 2012
Colorado Springs is currently the 41st largest city in the country by population (bigger than Miami, Oakland, Cleveland, Cincinnati, Minneapolis, and New Orleans) and it is one of the fastest growing communities in the country. The main industry of Colorado Springs is the military, as we have five military bases in or near the city. Therefore, our population includes a large number of military members and their dependants. For the ethnic breakdown of populations served over period, please see graphs under "Community Served."
Provided below are the ethnic profiles of our nursing staff, our client population, and of the community we have served:
Nursing staff Our nursing staff is largely representative of our community with two exceptions; the first being that our nursing staff is largely female (92% to the approximately 52% of women in the community) and that the number of Hispanic nurses is underrepresented by roughly 5%. The following data demonstrates the ethnic makeup of our staff; while the section on "client population" will show how our staff is a microcosm of Colorado Springs.
Faith Community Nurses, Clinic Nurses, and Case Managers
Gender Breakdown of Other RNs (group consisting of Direct Care Nurses, Nurse Navigators, and Weekend Nurses / Float Pool) by Population
Ethnic Breakdown of Other RNs
According to the United States Census Bureau, the demographics of Colorado Springs are as follows (Data from 2011):
Organizational Overview - OO2
OO2 The current CNO's job description and curriculum vitae
The following is a link to the job description of our Vice President of Patient Care Services/Chief Nursing Officer: ( OO2-1 )
Our long time CNO, Kate McCord retired in 2012. She was replaced in December 2012 by Ann Kjosa who left for a promotion in March 2013. Currently Rose Ann Moore, MSN, RN, NE-BC, VP of Nursing for Penrose is serving as Interim CNO while we search for a CNO. Since all three have served as our CNO during the application period, their vitarum are provided below.
Kate McCord: ( OO2-2 )
Ann Kjosa: ( OO2-3 )
Rose Ann Moore: ( OO2-3 )
Organizational Overview - OO3
OO3 Copies of the most recent annual reports, quality and strategic plans for the organization and nursing services. These can be formal documents or less formal methods used to inform the staff of activities related to the strategic plan. (TL1)
PSFHS assesses our progress towards the long term strategic plans every year. This plan is comprehensive and it addresses issues of budgetary importance, service quality, among many others. The following link provides our most recent annual report and the second link provides our long term strategic plan.
Recent Annual Report OO3-1
Centura 2020 Strategic Plan OO3-2
A written review of nursing activities, care quality, and progress towards long term goals is completed annually. Further, strategic goals for nursing and specific units are completed yearly as well.
Recent Nursing Annual Report OO3-3
Method to Inform Staff of Strategic Goals:
The following is a handout used to inform nursing staff of strategic goals: OO3-6
Organizational Overview - OO4
OO4 A budget summary for the most recent fiscal year, actual to budget, for nursing education, conference attendance and research. (TL2, EP12)
Nursing's budget for education is embedded both in each unit's budget and in the nursing administration's overall budget. The Clinical Manager will request education funds for the upcoming year during the budget process. Nursing time for conferences, if paid, is sometimes included in the non-productive category. This allocation is inconsistent, depending on the individual entering information into the timekeeping system. There is no category in the current timekeeping system to differentiate between paid conference attendance, mandatory education classes, meeting time, or special unit projects, all of which are included in "non-productive" category.
The PSFHS Foundation has three groups, ICU, Birth Center and Wound who have scholarships established by donors for which these staff may apply.
The Nursing Administration budget funds education for the CNO, Nursing Directors and special educational events throughout the year.
Education Approval Committee The Education Approval Committee has recently been established to provide a formal review process for nursing staff who wish to attend conferences and receive reimbursement of expenses related to attendance at educational offerings/conferences. Recommendations for approval or disapproval of funds will be based on the application (requires a report back from conference) and established criteria. (OO4-1)
Nursing Research The Nurse Scientist position was not established until August 2012; therefore this is an unbudgeted position. Individual nursing research and EBP implementation hours were allocated to the nursing unit's individual budgets and non-productive hours.
Organizational Overview - OO5
OO5 The administrative and nursing organizational chart (s). Describe the CNO's structural and operational relationships to all areas where nursing is practiced. (TL4)
CNO Structural and Operational Relationships to Nursing Areas:
The CNO is accountable for all nursing practice throughout the PSFHS organization. At both of our facilities there is a Vice President of Nursing who is responsible for operational issues related to nursing; both of whom report directly to the CNO. Structurally, the CNO delegates responsibility over individual nursing units to Directors and Managers who oversee more specific operations. The nursing leaders in these individual units report directly to the CNO. These units include sections which do not usually provide direct care to patients (Patient Representatives, for example).
Organizational Overview - OO6
OO6 A table of nurse executives, nurse managers, and supervisors and their: credentials, Earned Professional Certifications, Professional organizational membership, activities, and offices held, Professional development programs and formal education attended during the 24 months prior to documentation submission. (TL6)
Leadership Table: OO6-1
Organizational Overview - OO8
OO8 The policies and procedures that govern/guide professional development programs, such as tuition reimbursement, access to web based education, and participation in local, regional, national, and international conferences/meetings. (SE3, SE4, SE5)
Tuition Reimbursement / Continuing Education:
OO8-1 Continuing Nurse Education
OO8-2 Competency (Staff)
OO8-3 Guidelines for Tuition
Access to Web-Based Education:
OO8-4 Corporate Responsibility Training and Education
OO8-5 Required Learning and Education
OO8-6 Centura-Wide LEARN Module Approval Process
OO8-7 Mosby's Clinical Procedures
OO8-8 Travel and Business Expense Reimbursement
Organizational Overview - OO9
OO9 The assessment for the continuing education needs of nurses at all levels and settings and the related implementation plan. (SE5)
Our patients and their families are served by associates who are knowledgeable in all areas mandated by The Joint Commission (TJC), Centers for Medicaid and Medicare Services (CMS), the Occupational Safety and Health Administration (OSHA), other regulatory agencies, and as required by our organization for improvement of organizational and individual performances. Required education and training is outlined in our internal regulation IDP E-01-f. (OO9-1) This direction is reviewed annually by both the Centura Professional Development Council and the Centura Quality/ Regulatory department. The PSFHS Shared Decision Making councils also review the plan for required education and they are able to make revisions to the plan. This is done to ensure that PSFHS can fulfill its commitment to providing high quality care. In addition, regulatory agencies may change their requirements throughout the year, which leads to revisions in our education instructions.
Every year our education plans are reviewed and re-developed by: the Nursing Professional Development Council, nursing educators, our education department, and the unit practice councils. The value of individual unit education planning cannot be overstated, as they are focused outlooks which serve to promote professional development and competence to meet the needs of our community. The continuing assessment and implementation plans and processes will be examined below.
All levels and settings of nursing services are involved in the assessment of educational needs; either through direct participation or through unit representation and unit level committees/councils.
The Education Department participates on the PDC and collects data from a variety of sources every year. Emails are sent to the following groups requesting their assessment of needs based on their specialty and focus:
• Patient Safety and Risk Management
• Clinical Effectiveness
• Infection Prevention
• Occupational Health
• Clinical Managers and Directors related to performance appraisals, unit quality issues
• Quality Committees such as Falls, Code Blue, Restraints, Pressure Ulcer Prevention
• Nursing Councils including: Leadership, Management, Quality, Nursing Peer Review, and Evidence based practice
In 2010-2011, the PDC initiated a focused self assessment for our nursing leaders and managers. This self assessment tool identified educational needs and led to planning for education in 2011 and 2012. (OO9-2) During the last 6-8 years this group of nursing leaders has participated in Centura wide education through our Leadership Development Institute. This formalized educational opportunity offers 2-4 focused learning days each year with follow up coaching and support at the facility level.
Our commitment to shared decision making holds the unit practice councils accountable for identifying unit level needs and seeking educational support to meet those needs. Clinical Nurse Specialists are the expert educators available on most units. In addition, some units have identified an expert nurse educator or assistant nurse manager to facilitate unit level education in collaboration with the unit practice councils. The PSFHS Education Department provides leadership and coordination with mandatory education and other educational opportunities upon request.
The education needs assessment is a dynamic tool which reflects current and emerging educational requirements. The needs assessment guides the planning and providing education and training throughout the year and it is guided by our policy regarding the competency of our clinical staff. (OO9-3)
Individualizing Continuing Education Needs for Nurses:
Performance Feedback and Development Structure and Process (PFD) The PFD structure and process was implemented in 2011 and requires all individuals to identify a "Development Goal," as well as tactics to achieve that goal. By individualizing this process nurses have the opportunity to clearly identify and discuss their career plans and educational needs with their supervisor. The supervisor provides support to the nurses through this discussion during goal setting and goal monitoring throughout the year. For example, as frontline nurses spoke of their desire to assume leadership positions, clinical managers recommended and paid for their participation in Leadership Excellence Accountability Professionalism (LEAP) classes. The Chief Nursing Officer uses the PFD process to identify and plan for the evolving educational needs of nursing staff.
New clinical managers have the opportunity to participate in an online 40 hour continuing education course. Entitled, "Essentials of Nurse Manager Orientation" (ENMO) this course was made available through a contract PSFHS has established with the American Organization of Nurse Executives (AONE). Feedback on this module, from nurse managers has been positive.
Nursing Leadership Self Assessment: Fall 2010 (n=17) In late 2010, all Nursing Directors, Clinical Managers, and Assistant Managers were asked to complete a self assessment and to identify any continuing education needs. A significant majority of nurse leaders identified themselves as competent or proficient in all of the following areas:
1. Financial Management
2. Human Resources
3. Performance Improvement
4. Foundational Thinking Skills
6. Strategic Planning
7. Relationship Management
9. Shared Governance
11. Career Planning
12. Personal Journey Disciplines
13. Reflective Practice
Educational Implementation Plan A key element of a personalized educational plan is in providing access to a selection of varied learning experiences. As such, PSFHS has provided the following educational courses and seminars for nurses during the past two years:
• Accountable Care Organizations provided by Jackie Driscoll in General Leadership meeting (Winter 2011) and during Nurses Week (2011). Keith Humble, Finance, individual education upon request
• Tim Porter-O'Grady Conference 2011 and 2012
• 1:1 education on Office applications by Jill Clark, Administrative Assistant
• Certification preparation class in Denver, reimbursed by PSFHS
• Certification Study Group
• Relationship Based Care focus in nursing meetings
• Nursing Conferences upon request
• Essential of Nurse Manager Orientation forty hour online class available upon request
• E-Learning via LEARN
• Patient Satisfaction Surveys at Centura Health
• Adjusting to Change to Achieve Excellence
• Personal Accountability Through Integrity
• Spirituality in the Workplace
• Kronos Time Keeper for New Managers
• STARS for New Managers
• Leader Evaluation Manager (LEM) for New Managers
• Success Factors for New Managers
• Alternative Dispute Process
• Associate Leave
• Americans with Disabilities Act
• Understanding Discrimination and Sexual Harassment
• Rounding for Outcomes
• Employee Thank You Notes
• AIDET - Five Fundamentals of Patient Communications
• Journey of a Claim
• Introduction to Commercial Insurance
• Introductions to Regulatory Insurance
• Healthcare Finance Overview for Leaders
• Centura Financial Basics for Leaders
• CEN Giving Praise and Recognition to Motivate Others
The attachment contains a table of the various educational programs and their provisional outcomes. (OO9-4)
Needs Assessment for Direct Care Nurses The structure and process of PFD offers an individualized opportunity to identify needs and to design an implementation plan. In the context of the IOM: Future of Nursing Plan, nurses are to be focusing on certification in their specialty area and returning to school to complete a BSN or MSN. As the organization moves toward the 80% BSN by 2020 national nursing goal, our implementation plan includes:
• Increasing tuition reimbursement
• Contracting with schools of nursing to offer discounted tuition
• Partnering with local schools to promote easy transitions from associate to baccalaureate programs
• Educational Fairs to connect nurses with schools
Clinical Managers identified the need for leadership education for charge nurses based upon their discussions and observations of charge nurse practices. The LEAP program is available several times a year to meet this need.
Each Unit Practice Council collaborates with the clinical managers and clinical experts to meet identified needs every year, with help from the Educational Task Force. (OO9-5) While the annual Medical Surgical Skills review process identifies education and skills needs based on performance metrics, occurrences, new policies and procedures, as well as mandatory regulatory learning, the Unit Practice Councils identify and meet educational needs through a variety of formats. For example, the Neonatal Nurse Practitioners provide ongoing education through lunch hour meetings. The trauma nurses provide unit based monthly education to direct care nurses and to other interested staff.
Conferences and Nursing Retreats:
The Nursing Department hosts annual nursing retreats for nurse leaders. These retreats alternate between clinical managers and charge nurses with clinical managers. The learning retreats provide education on topics identified by participant nurses as well as the Nursing Leadership Council. PSFHS also hosts conferences based upon nurse suggestions. Tim Porter-O'Grady presented in 2011 and 2012. In 2010 and 2012 PSFHS co-hosted an Evidence based practice conference for our Centura Health colleagues. An annual Trauma Conference brings in national, regional, and local speakers each spring.
The educational needs assessment for all levels of nursing associates is a dynamic process supported by our shared decision making culture and focus on safe, effective, evidence based care. Our nursing service uses a systematic procedure, through the nursing councilor structure, to provide effective, timely and efficient learning experiences to nurses of all levels and settings. These are designed to enhance excellence in nursing practice and lead to nursing satisfaction, professional development, as well as positive clinical outcomes.
The presence of multiple committees that are focused on quality results in continuous improvements in practice. These are based on evidence and they result in continuing education and/or in-service education. Our educational needs assessment, planning, and our provision of education is strongly supported through the following internal structures:
• Performance Feedback and Development Structure and Process
• Shared decision making structures and process
• Available metrics to monitor performance
• Nursing peer review
• Expert clinical nurse specialists
• Collaboration between the education department and nursing
• Interdisciplinary collaboration
• EBP committees across Centura Health
• Culture of Safety
• Professional Practice Model
• Commitment to professional nursing practice and our scope and standards of practice
Organizational Overview - OO10
OO10 A list of the continuing education programs (classroom and or electronic) and the number of nurses completing each during the last 24 months. Do not include orientation activities or in-service education. Include programs covering the each of the following topics: Research (including protection of human subjects), Evidence-based practice, Application of Ethical Principles, ANA Bill of Rights for Nurses (2001a), Professional standards of practice and performance, cultural competence, data and information analysis competencies, quality improvement, leadership, Nurse Practice Act, Patient privacy/security/confidentiality, and regulatory requirements.
OO10-1: List of education programs complete with number of completing nurses.
Organizational Overview - OO11
Exemplary Professional Practice
OO11 Describe the Professional Practice Model and the Care Delivery System in use in the organization. The Professional Practice Model is a schematic description of a theory, phenomenon, or system that depicts how nurses practice, collaborate, communicate, and develop professionally. A Care delivery system delineates nurses' authority and accountability for clinical decision making and outcomes. If possible, provide a depiction of each model. (EP1, EP1EO, EP2, EP3, EP4, EP5, EP6, EP7, EP12)
Professional Practice Model:
Our Professional Practice Model (PPM) provides a comprehensive view of the components of professional practice and it is aligned with Centura Health's values and Penrose St. Francis Health Services' nursing vision. The PPM frame work provides a structure for achieving clinical outcomes and a healthy work environment. Our PPM is titled the "Circle of Excellence." It is made up of said circle supported on either side by our organization's mission and vision. Bordering the Circle of Excellence are the needs of the patient: physical, spiritual, and psychosocial; while the circle itself is composed of our values (respect, excellence, compassion, stewardship, spirituality, integrity, and imagination). Centered within the structure is the heart of our mission, which is our focus on patients, families, and our community.
The complex part of the PPM is color coded to represent the relationships of the categories. Yellow represents our "Concern for Caregivers." This classification is made up of our guiding principles for nursing practice (competence, accountability, autonomy, professional development, inter disciplinary practice, community involvement, valuing diversity, and recognition) as well as our vision for nursing care at PSFHS.
The red class originates below our crux and it is called "Excellence in Nursing Practice." This group is composed of Shared Decision Making and our Standards of Professional Practice. We rely on Shared Decision Making in leadership and management through the incorporation of nursing councils which draw from nurses at all levels and settings. Unit practice is supported by evidence based results, continuing education, and nursing peer review. Whereas the Standards of Professional Practice support nursing decision making and standardization of care. As such, PSFHS' nurses practice in compliance with the ANA Code of Ethics, the Colorado Nurse Practice Act, the ANA Nursing Scope and Standards of Practice, among others. Furthermore, this is where our chosen nursing theorists are incorporated into clinical support.
Finally, the green section is representative of our commitment to "Outstanding Patient Care." The subdivisions of this category are "Quality of Care," "Relationship Based Care," and our "Care Delivery Systems." Quality of care is measured through patient satisfaction, nurse satisfaction, nurse engagement, and through outside certifiers such as The Joint Commission or the Centers for Medicare & Medicade Services. Relationship based care is composed of the care provider's relationship with patients/families, themselves, and with their collegues. Our care delivery systems are unit designed to maintain flexibility and focus. Nurses in each practice setting are accountable to create delivery models that are representative of their specific care and of the Circle of Excellence.
Care Delivery System:
Our Care Delivery System is made up of unit specific and unit designed Care Delivery Models. This approach was taken to ensure that patients receive care that is unique to their needs and not "pigeon-holed" into general practice scenarios. Units design their models off of the characteristics listed above in the PPM. Relationship based care, evidence based practice, shared decision making, and a culture of accountability exist in all of our nursing units as a result. Providing oversight over individual unit models the CNO acts as our organization's senior nursing leader. She has the responsibility for the evolution and maintenance of unit care models. Unit managers report to her in matters regarding the Care Delivery system.
An element of all unit based Care Delivery Models is the incorporation of regulatory standards. For example, the Colorado Nurse Practice Act delineates nurses' authority in the clinical setting and it establishes a framework for clinical decision making, both of which are standards that we follow. The process of creating a standardized level of care across units is described in EP4, 5, 6, and 7. Each unit creates a Plan for the Provision of Care which details population served, care delivery system and staffing. (OO11-4)
In many areas, the KOIN system is used. KOIN stands for Knowledge, Orders, Interventions, and Notes. This process is explained in the attachment: OO11-1.
Organizational Overview - OO12
Exemplary Professional Practice
OO12 Unit based, nationally benchmarked Nurse Satisfaction or engagement data for a 2-year period to include data from at least 2 survey cycles. If available, include the levels of statistical significance as compared to the benchmark. Include a graphic display of the data that clearly identifies benchmarks. (EP3)
Labor and Delivery:
Organizational Overview - OO13
Exemplary Professional Practice
OO13 For U.S. Applicants, case mix index information, by unit, service, or product line, for each of the two 1-year periods immediately preceding the submission of written documentation. IF this is not feasible, explain why. (EP8)
FY 2011 FY 2012 CMI CMI CARDIAC 1.9061 1.8712 ENT 0.8830 0.8734 GENMED 1.0730 1.0804 GENSURG 2.7217 2.6706 GYN 1.0358 1.0682 NEONATOLOGY 2.7642 2.7547 NEUROLOGY 1.0939 1.0349 NEUROSURG 2.9144 2.9969 NEWBORN 0.1643 0.1655 OBSTETRICS 0.6423 0.6576 ONCOLOGY 1.6598 1.7074 OPHTHALMOLOGY 0.8841 0.8959 ORTHO 1.9763 1.9692 OTHER TRAUMA 1.1895 1.0243 PSYCH 0.8715 0.9023 REHAB 1.2525 1.3096 SPINE 2.4632 2.5223 THORACICSURG 3.1845 3.0198 UROLOGY 1.3862 1.3770 VASCULAR 2.0475 2.0922 TOTAL 1.4467 1.4797
Organizational Overview - OO14
Exemplary Professional Practice
OO14 The actual to budgeted direct nursing care hours/patient day or hours worked per workload index by unit for each of the two 1-year periods immediately preceding the submission of written documentation. (EP11)
Nursing Care Hours/Patient Day (HPPD) - Direct Care Nursing (RN, LPN, CNA)
Units FY 2011 Actual HPPD FY 2011 Budgeted HPPD FY 2012 Actual HPPD FY 2013 Budgeted HPPD PH 4 Medical 7.37 8.98 7.82 7.22 PH 5 Medical 8.22 9.32 8.48 7.60 PH 10 Medical Not Open Not Open SFMC 5S Medical 7.82 10.25 8.41 8.16 PH 11 Oncology 7.67 4.33 7.95 6.25 PH 7 Surgical 7.93 7.99 8.01 7.74 PH 9 Surgical 7.87 8.29 8.26 7.43 SFMC 5N Surgical 8.62 10.25 9.50 8.10 Cardiovascular Unit 8.36 11.83 9.51 10.73 Bariatric Back Unit 11.30 12.27 11.48 12.24 PH 8 Rehab 7.79 7 7.82 7.37 PH Critical Care 15.98 12.27 15.11 15.70 SF Critical Care 18.77 21.76 19.53 24.58 SFMC NICU 11.07 12.88 10.84 10.1 SFMC Pediatrics 12.1 16.6 13.39 11.16
Organizational Overview - OO15
Exemplary Professional Practice
OO15 A table of the interdisciplinary committees and task forces at the organizational level, a description of each one's purpose, and guidelines for decision making. Include nurse membership and role on committee. Indicate each nurse's work unit and roles in the organization. (EP13, EP14, EP16)
Table of Interdisciplinary committees and task forces: OO15-1
Organizational Overview - OO16
Exemplary Professional Practice
OO16 Access to the state's Nurse Practice Act. It is sufficient to provide the web address of this document after validating that the most current version of the act is available on the web site. If this is not the case, provide a hard copy of the most current version of the act.
The following link provides access to the most recent revision of the Colorado Nurse Practice Act:
This version was amended in the 2010 legislative session and the amendments came into law in 2011.
Organizational Overview - OO17
Exemplary Professional Practice
OO17 Performance appraisal tools, if used, and all associated peer evaluation tools for staff nurses and nurse leaders. Include frequency of evaluation. If the organization uses multiple versions of these tools, provide a representative sample for all levels of nurses. (EP20).
Centura Health Annual Appraisal Method:
PSFHS appraises the performance of its associates annually. This is done through a mandated structure from our umbrella organization, Centura Health, as well as through our local policies. Centura's annual review structure requires at least four formal conversations between an associate and their supervisor over the course of a year. During the first conversation, a plan for the associate's performance and growth is established; the other conversations as well as the results of those discussions, all flow from that initial plan. The following flowchart details this proce dure:
The final section mentions Centura's "pay for performance" initiative. This is a process which provides a financial incentive for an associate's stable and continual adherence to our values coupled with achieving the personal goals established in "Conversation 1." This process is mandatory for all associates, to include direct care nurses and nurse leadership. The following attachment is Centura Health's standard template example of this Performance Appraisal Tool. ( OO17-1 ) All nursing associates use the same performance appraisal tool. Goals are developed and evaluated each year. The Nursing Strategic Plan and Organizational Priorities set the stage for identification of goals and then each level of nursing sets goals in that priority relevant to their unit, department and role.
PSFHS Nurse Performance Evaluation and Peer Review:
Nursing Peer Review tools vary by level and in some units. The attached Peer Review tools represent our current Peer Review for Evaluation structure.
1. All Associate Performance Appraisal ( OO17-1 )
2. VP of Nursing ( OO17-2 )
3. Nurse Executive Peer Review ( OO17-3 )
4. Clinical Manager ( OO17-4 )
5. Nurse Practitioner ( OO17-5 )
6. Assistant Nurse Manager ( OO17-6 )
7. Charge RN ( OO17-7 )
8. Direct Care RN ( OO17-8 )
Organizational Overview - OO18
Exemplary Professional Practice
OO18 A description of the process by which the CNO or their designee participates in credentialing, privileging, and evaluating advanced practice nurses. Include the frequency of re-privileging.
The "Allied Health Professionals Policy" identified three categories of practitioners, with Advance Practice Nurses represented as the first tier. Advance Practice Nurses (APN) work within PSFHS as employees and/or as members of the Allied Health Professional Staff. The Allied Health Professionals Policy within the medical staff bylaws, rules, and regulations delineates the structure and process for APNs who are permitted to provide patient care services in the hospital. We at PSFHS follow the ANA guidelines for credentialing and privileging advanced practice nurses. PSFHS employs APN's who care for patients in the following areas:
• Neonatal Nurse Practitioners in the NICU III
• Clinical Nurse Specialists in Pain and Palliative Care Services
• Nurse Practitioners in Urgent Care
Credentialing Advanced Practice Nurses:
According to the ANA, credentialing is "the process of assessing and validating the qualifications of a licensed independent practitioner to provide patient care services." When we credential an APN, it is a formal acknowledgement of their competence in caring for members of our community. This recognition is not given lightly.
Privileging Advanced Practice Nurses:
Privileges to provide care exist within a framework of explicit responsibilities. These privileges dictate which procedures and the scenarios in which they can be performed.
Processes for Credentialing and Privileging:
Applications for initial and continuing credentialing require two to three documented peer reviews. In order to meet this requirement, two of our APN's are members of the PSFHS Medical Staff Credentials Committee. These two APN's review and make recommendations on all APN applications for credentialing, privileging, and re-privileging.
Historically, the Chief Nursing Officer also reviewed and signed off on all APN applications in addition to the two aforementioned APN Credential Committee members. In December 2012, Ann Kjosa, BSN, MBA/MHM, RN, FACHE accepted the Chief Nursing Officer position. Kjosa reviewed the most recent Allied Health Professionals Policy (January 2012) and following a meeting with the Manager of the Medical Staff Office, she has elected to continue the CNO's active involvement in the process. The policy requires peer review, which occurs through the application and the review processes, by APN Credential Committee members. Per Policy, the Department Chair prepares the written report regarding whether the applicant has satisfied all of the qualifications for the scope of practice or clinical privileges requested.
Evaluating Advanced Practice Nurses:
The evaluation of APNs occurs through a review process headed by the CNO. It also includes peer review from other APNs in the Medical Staff Credentials Committee.
Further evaluation of APN's practice is evaluated through the standardized "Centura Health Performance Feedback and Development" (PFD). Clinical Nurse Managers or Nursing Directors, in addition to the Chief Nursing Officer, provide oversight of their employment performance.
Re-privileging Process & Frequency:
Although the formal re-privileging process occurs every two years (or when the scope of practice changes), evaluation of advanced practice nurses' practice is an ongoing process. All Advanced Practice Nurses employed by PSFHS complete an annual performance appraisal review with their direct supervisor.
Organizational Overview - OO19
Exemplary Professional Practice
OO19 The organization's policies and procedures that address patient ethical issues/needs. Describe the leadership of nurses in developing and participating in these programs. (EP23)
Ethical considerations are complex and difficult. When competing opinions of the "good" clash, crises may very well follow. In order to mitigate these potential scenarios, PSFHS relies upon the guidance provided by ethical sources like the ANA's Code of Ethics for Nurses. Since we are a religious institution, we are careful to follow the healthcare guidelines of Catholicism which are provided by the Unites States Conference of Catholic Bishops. In order to mitigate any ethical problems, our organization has structures which address different possible outcomes.
Nurses lead participation in implementing these ethical directives by driving our Ethics Committee. This committee reviews problematic scenarios in order to provide appropriate ethical directions which are in line with our mission, values, and vision.
Currently, the chair of the Ethics Committee is our Vice President of Mission Integration, Larry Seidl who replaced our outgoing CNO in late 2012. Other active nurses on the committee are: Rochelle Salmore, MSN, RN, NEA-BC, Eileen Hurd BSN, RN, and Brenda Molencamp BSN, RN, NE-BC. This committee includes members from our community, physicians, nursing, case management, and spiritual care. Education and training for our ethics consultants occurs during monthly meetings and through regular participation in conferences.
OO19-1 Ethics Advisory Council
OO19-3 Ethical Practice
OO19-4 Patient's Right to Request Confidential Communications
OO19-5 Patient's Right to Request Privacy
OO19-6 Breach of Unsecured PHI and Mitigation of Harm
OO19-7 General Use and Disclosure of PHI
OO19-8 Inquiries and Complaints Concerning Patient Privacy
OO19-9 Limiting Use of Disclosure of PHI to Minimum
OO19-10 Notice of Privacy Practice
OO19-11 Patient Authorization for Use of Disclosure of PHI
OO19-12 Patient Right to Request Access to their PHI
OO19-13 Patient Right to Request an Accounting of Disclosure of their PHI
OO19-14 Patient Right to Request an Amendment to their PHI
OO19-15 Personal Representatives Action on Behalf of Patients and PHI
OO19-16 Verbal Disclosure of PHI to Family and Friends
OO19-17 Palliative Care Policy
OO19-18 Spiritual Care Services Policy
Organizational Overview - OO20
Exemplary Professional Practice
OO20 The policies and procedures that permit and encourage nurses to confidentially express their concerns about their professional practice environment without retribution (EP28)
OO20-1 Staff Rights Policy
OO20-2 Inquires and Complaints Concerning Patient Privacy
OO20-3 Alternative Dispute Resolution
OO20-4 Corporate Responsibility Training and Education
OO20-5 Violence-Free Workplace
OO20-6 Sexual and Other Harassment Policy
OO20-7 Professional Conduct
OO20-8 Conflict Management
Organizational Overview - OO21
Exemplary Professional Practice
OO21 The policies and procedures that address the identification and management of problems related to incompetent, unsafe, or unprofessional practice or conduct. (EP28)
OO21-1 Associate Performance Policy
OO21-2 Drug Free Workplace Policy
OO21-3 Excluded Persons Policy
OO21-5 Licensure, Registration, and Certification Policy
OO21-6 Sexual and Other Harassment Policy
OO21-7 Violence Free Workplace Policy
OO21-8 Professional Conduct Policy
OO21-9 Competency Policy
OO21-10 Red Rules Policy
OO21-11 Patient Safety Accountability Policy
Organizational Overview - OO22
Exemplary Professional Practice
OO22 The policies and procedures regarding interdisciplinary conflict. (EP29)
OO22-1 Associate Performance Policy
OO22-2 Standards of Behavior Policy
OO22-3 Conflict Management Policy
OO22-4 Interdisciplinary Care & Conferences Policy
OO22-5 Ethical Considerations Policy
Organizational Overview - OO23
OO 23 Request - Please provide 8 quarters of data for CLABSI and CAUTI for all units.
The graphs below provide data on the following units.
Cardiovascular Unit (CVU)
Bariatric Back Unit (BBU)
PH 10 Medical
PH 4 Medical
PH 5 Medical
SFMC 5S Medical
PH 11 Oncology
PH 9 Surgical
PH 7 Surgical/Ortho
SFMC 5N Surgical
PH 8 Rehab
Labor and Delivery
Organizational Overview - OO24
Exemplary Professional Practice
OO24 Nursing sensitive indicator data related to nurse work related injuries such as needle sticks, musculoskeletal injuries, and exposures. (EP5, EP15, EP30)
The departments of Occupational Health and of Workman's Compensation track, report, analyze, and lead actions to promote a safe work environment. The following graphs including comments provide an overview of the work related injuries of nurses.
1. Total Nurse Injuries Reported The total of PSFHS Nurse Work Related Injuries reported in the two year time period are 227.
2. Calendar Days Lost related to Reported Work Injury have decreased 28% over one year.
3. Nurse Work Related Injuries are displayed in three primary categories below. Patient Handling injuries are the lowest percentage of injuries in these three categories. The costs for these injuries is 51% of total injury expenses and 39% of calendar days work lost.
4. Reported Exposures Injuries related to exposure comprise 30% of the nurse reported injuries. Nurse injuries related to exposures are depicted in four categories. Needlesticks represent the largest number of exposures, costing $6745.
5. Patient Handling injuries represent 22% of nurse injuries. Patient handling injuries are shown in three categories: Lifting, Push or Pull, and Hold or Carry. Patient lifting injuries account for 50% of the overall patient handling injuries. Lift equipment is available in both inpatient hospital buildings. In addition, the Occupational Health nurses requested and received funds to purchase Hover Mat equipment through the Volunteer Grant program in 2010. The Emergency Room agreed to "pilot" the use of the Hover Mats with a primary focus on orthopedic patients. In 2011, PSFHS hosted a Lift Fair with multiple vendors showcasing products for trial. Hover mats remained the consistent choice of products for nurses. Many units have purchased hover mats; however, the use of hover mats by nursing staff remains inconsistent.
Struck/Injured by Fellow Worker or Patient:
Ten (10) of eighteen (18) or 56%, of the reported injuries in this category occurred in the Emergency Departments. The overall expenses for the 18 injuries totaled $4756. The implementation of our education module, "Nonviolent Crisis Intervention Training" occurred in January 2012 with its primary focus being on staff whose units are prone to aggressive patient behavior. This training resulted in a decrease in reported injuries over the course of the year.
6. Injuries by Unit The following are itemized injuries, over time, by nursing units
Creating and maintaining a culture of safety in our healthcare environment is an organizational priority. Leadership and accountability at all levels are essential to improve safe care for patients and a safe work environment for all associates. PSFHS will further discuss our culture, structure, and processes that improve workplace safety for nurses in Exemplary Professional Practice, Culture of Safety.
Organizational Overview - OO25
Exemplary Professional Practice
OO25 A description of the infrastructure, the organizational committees, and decision making bodies specifically designed to oversee the quality of patient care (EP33).
Infrastructure for Patient Care Quality Oversight:
The highlighted portions of the attachment describe the structure, organizational committees, and the decision making bodies which are designated to oversee quality patient care: OO25-1
Organizational Overview - OO26
Exemplary Professional Practice
OO26 Patient satisfaction data at the unit level by measure for a 2 year period, including statistical levels of significance. Include a graphic display of the data that clearly identifies benchmarks. (EP35)
PSFHS uses the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) to obtain patient satisfaction data. Two data sets of questions were asked. The first, consisting of:
This question set was asked of the following units: Penrose Hospital (PH) 4, PH 5, St. Francis Medical Center (SFMC) 5S, PH7, PH9, SFMC 5N, PH11, CVU, BBU, SFMC Maternity, and SFMC Pediatrics.
The second question set consisted of the following questions:
This question set was asked of the following units: PH Pre-Op, SFMC Pre-Op, PH8, PH ED, SFMC ED, and PH GI Lab.
The following are graphic representations of patient responses to these questions over a two year period. The information is presented from each nursing unit by HCAHPS question.
PH Pre Op:
SFMC Pre Op:
PH GI Lab:
- How often did the nurses treat you with courtesy/respect?
- How often did nurses listen carefully?
- How often did you receive assistance with bathroom needs as soon as you wanted?
- Before giving you a new medication, did the staff inform you of what the medication was for?
- How often did the nurses treat you with courtesy/respect?
- How quick were the staff to respond to the patient's requests?
- Was the staff doing everything they could to help with pain?
- Was there clear communication by the patient care staff?
Organizational Overview - OO27
New Knowledge, Innovations, and Improvements
OO27 The institution's policies, procedures (including institutional review board) and processes that protect the rights of participants in research. (NK2)
OO27-1 Use and Disclosure of PHI for Research Policy
OO27-2 Institutional Review Board Policy
OO27-3 Nursing Research Policy
OO27-4 Patient Rights and Responsibilities
Organizational Overview - OO28
New Knowledge, Innovations, and Improvements
OO28 The credentials or related experience of all external experts and other resources used to develop and or improve the infrastructures, capacities, and processes for evidenced based practice and research. (NK4, NK4EO)
Internal and External Experts
• Deborah Kenny, PhD, RN, FAAN, Associate Dean Research, University of Colorado, Colorado Springs, CO (OO28-4)
• Janet Houser PhD, RN, Abacus Systems, Consultant for Nursing Organizations
• Susan Baker, PhD, RN, Director Stroke Program, member IRB
• Catherine Kleiner, PhD, RN, CNS, National Director of Nursing Research, Clinical Services Group, Catholic Health Initiatives
Centura Health associates who have acted as resources include:
• Cynthia Oster PhD, MBA, APRN, CNS-BC, ANP Nurse Scientist Clinical Nurse Specialist - Critical Care and Cardiovascular Services, Porter Adventist Hospitals
• Kathy Bradley, DBP, RN, NEA-BC, Director Performance and Practice Innovation, Porter Adventist Hospitals
• Darcy Copeland , RN, PhD, Nurse Scientist and Housewide Educator, St. Anthony Hospital
• Dick Maxwell, RN,MLS, Medical Library Coordinator, Harley E. Rice Medical Library, Porter Adventist Hospital
New Positions at PSFHS
• Rochelle Salmore, MSN, RN, NE-BC, Nurse Scientist
• Kristina Slanc, MLIS, Medical Librarian
National and state conference attendance by various staff representatives provided many opportunities to gain new knowledge about evidence-based practices from 2009 through 2013 include:
• Annual EBP and Research Conferences, Porter Adventist Hospitals, Denver
• Annual EBP and Research Conferences, University of Colorado, Denver
• Annual National CHI Quality and Safety
• American Association Cardiovascular Pulmonary Rehabilitation Annual Conference
• American College of Cardiology) Annual Meeting
• American Nurses Association
• American Public Health Association
• Association of Women's Health, Obstetrics and Neonatal Nursing
• Emergency Cardiovascular Care
• National Cardiovascular Data Registry
• National NTI
• National Association of Women's Health Obstetrics and Neonatal Nurses
• National Consortium of Breast Centers
• 20th National Evidence-Based Practice conference, University of Iowa
• National ENA
• Preventative Cardiovascular Nurses Association Regional Meeting
• Rocky Mountain Cardiovascular Regional Annual Meeting
• Pikes Peak Oncology Nurses Society
• Rocky Mountain Gastroenterology Nurses and Associates
• Annual Trauma Conference
• National Wound Ostomy Continence Nurses
• NDNQI Quality Improvement
• Wound and Skin Care Management Program - local program presented by national speaker who is CWOCN. PSFHS sponsored annually.