Professional Practice Contents

  • Exemplary Professional Practice - EP01

    Professional Practice Model

    EP 1 Describe and demonstrate how nurses develop, apply, evaluate, adapt, and modify the Professional Practice Model.

    "Our Professional Practice Model (PPM), named the Circle of Excellence, identifies our Nursing Vision, our organization's Mission and Core Values, and the importance of caring for the mind, body and spirit of our patients, families, and our nurses. Our PPM includes our belief in the value of shared decision making by our nursing staff and the principles that guide the care we deliver everyday. It also emphasizes the quality of our practice and the use of evidence-based practice to achieve the best outcomes for patients. With plenty of input from our nurses we designed an illustration to help introduce the model to all associates in the organization. PSFHS Nursing is a professional, quality driven health care discipline. We Are Extraordinary!"

    From our PSFHS Nursing Annual Report (Distributed May, 2011)

    The current schematic of our Professional Practice Model: Circle of Excellence is depicted below. The attachment includes descriptions of the core elements and our strategic nursing goals.  Every nurse and every nursing unit was provided a copy of the schematic and descriptions. (EP1-1)

    PPMThe History of our Professional Practice Model - Develop, Apply, Evaluate and Modify:

    The formal development of our professional practice model began in 2007.  Two members of the PSFHS Magnet Committee started the process by researching nursing theorists, evaluating their different contributions, and the differing conceptual frameworks. These committee members then presented their findings to a group of nurses from all settings and levels. After discussing the theorists' positions, and reflecting upon our background as a faith based institution of healing, PSFHS selected Florence Nightingale and Patricia Benner as the theoretical guides for our nursing practice.

    Our nurses were compelled to select Florence Nightingale as we recognized the congruence between our nursing vision and her concepts. Nightingale's vision and legacy of compassion, advocacy, participating in research, seeking evidence to develop best practices, importance of nursing education, and her recognition of the role of the environment in healing spoke to nurses at PSFHS.

    Our commitment to quality and to expert nursing practice led us to the work of Dr. Patricia Benner. We are inspired by her attention to the development of the clinical nurse and by her work regarding the continuum of professional development, which ranges from novice to expert. In 2011, several of our nurses had the opportunity to meet with her in Denver. Benner took the opportunity to challenge us to advance nursing professionalism; she also highlighted the importance both formal education and experience to build expert nurses.  We apply our model and choice of Dr. Benner through development and implementation of our evidence based Nurse Residency Program, ASCENT (Autonomy, Safety, Competence, Evidence Based Practice, Nursing Excellence and Transition to Practice) which was discussed in SE8.  (EP1-2)

    In 2008 we evaluated and modified our Shared Decision Making structures. Expanding and clarifying the structures and expectations for shared decision making led to additional council development across all settings. At this same time, Centura Health and PSFHS Human Resources were implementing Insights, a tool for self assessment. Insights uses colors to discuss different styles and strengths in individuals. Our nursing leadership identified the need for every "color," every strength, and diversified representation to build a strong nursing service.  The decision was clear - design a graphic to include the four primary colors and talk about our commitment to honoring diversity. The diagram and vision was shared with all staff through the Shared Decision Making structures. Application of this early professional practice model schematic occurred through the council structure, performance improvement processes, and organization commitment to self care; including our free fitness center access and Employee Assistance Program.

    In 2009 PSFHS nursing evaluated our model/schematic. PSFHS nurses had completed our first NDNQI RN Survey with the Practice Environment Scale, and although our response rate was low, we used this data to help evaluate our Professional Practice Model. The results from the survey pointed out a need to improve nurse participation in hospital affairs and to improve staffing resources. In contrast, our nurses identified RN-Physician relationships as a strength. (EP1-3)

    In 2010, a Professional Practice Model team, which included nurses from all levels, accepted the challenge to evaluate and modify the current schematic representing our conceptual framework for nursing and expand the depiction of how we practice, collaborate, communicate, and professionally develop to provide expert, quality care. Rose Ann Moore RN, PPM Design Team Chair states "we struggled in our early efforts to develop our PPM but it didn't take long to discover we weren't just looking for 'one thing' but many pieces and parts that really reflect, represent and speak of PSFHS Nursing as a professional, quality driven healthcare discipline." 

    We believe that our commitment to the Magnet Journey provided the impetus to address the structure of our Professional Practice Model. It also inspired us to truly reflect on our professional nursing practice, to examine our strengths, integrate our nursing standards, and adapt our schematic to reflect the broader aspects of our nursing practice within PSFHS. Following this contemplation, the model was dramatically adapted to address the complex needs of our nursing practice. The Design Team incorporated multifaceted aspects of daily professional interactions and motivations. These adaptations led to the current PPM, our "Circle of Excellence" displayed on page one of this source of evidence.

    To build awareness, understanding, and application of our modified model, all nurses and units were given copies of the revised model, a description of each element and the 2010 nursing goals.  In addition, we provided education on the ANA Nursing Scope and Standards of Practice as well as on the Code of Ethics for Nurses. Information on the model is included in our organization's education offerings; the model is visible through our nursing intranet and it is discussed in our nursing newsletter. (EP1-4) Some units have framed and posted the PPM for everyone to see. Note cards with the model schematic are used for thank you notes and recognition of individual staff, linking individual nursing practice with our PPM.

    The Nursing Leadership and Management Councils identified gaps in understanding and applying nursing standards and relationship-based care (RBC). In 2010, the Chief Nursing Officer purchased the book, Relationship-Based Care (Koloroutis, 2004) and the ANA Nursing Scope and Standards for every unit. The members of the Nursing Management Council took turns educating their colleagues on each standard including giving specific examples of how we apply the standards.  (EP1-5)

    In 2011, the Professional Development Council provided education on RBC, available for all nurses in all settings and levels.  Hospital wide nursing orientation was revised and now begins with an overview of our Professional Practice Model, a review of ANA Nursing Scope, the Standards of Practice, and the ANA Code of Ethics for Nursing.  (EP1-6)

    Professional Practice Model Application - Cardiac Service Line at St. Francis Medical Center:

    In October 2011, St. Francis Medical Center formed a partnership with Colorado Springs Cardiology. Cardiologists Paul Sherry and Pam Taylor with Nurse Practitioner Linda Nath moved their practice to SFMC so they could administer care on a full time basis. At this time SFMC did not have a dedicated cardiac unit, nor were there formally trained cardiac nurses and staffing standards. SFMC 5 South Medical was the unit selected for the new patient population.

    Staff education was a primary focus to prepare for the new cardiac service line. Shortly before the partnership was formed, a clinical educator was hired to support the medical, surgical, and critical care units. Before preparing a curriculum, a review of the competencies and education of the current staff was completed. To meet the patient care needs a "cardiac core group" was established. Nurses selected for this group had previous cardiac education or experience. Requirements included ACLS and EKG courses. Those who were interested in joining the cardiac core group were offered both courses. Stephanie Quirk MSN, NP educator, held a four week EKG class with a fifth class on percutaneous interventions. The fifth class included staff from the Cardiovascular Unit (CVU, Penrose Hospital) with detailed education about heart catheterization and angioplasty.  The final component of training included "field trips" to either the Vascular Center of Colorado (VCC) and/or the aforementioned Cardiovascular Unit.  The 5S
    Medical Clinical Manager frequently met with the nursing leadership of the VCC and of the CVU to better understand and learn about the needs of this patient population. By December, the cardiac core group consisted of ten nurses.  (EP1-7EP1-8)

    Generally, a cardiac unit has a higher staffing standard than a general medical unit. This is due to the time and labor intensive care required by nurses in this specialized setting. Working with the VCC, we were able to get a schedule of the procedures for the following day. The night shift charge RN would then assign "the cardiac nurse" fewer patients (generally 2-3), in anticipation of admitting a "post-cath" patient later in the shift. This was a staffing challenge in the early stages. Another challenge was receiving patients who had an intervention. Initially only patients who underwent a diagnostic heart catheterization were admitted to 5 S. Patients who had a stent placed, required a sheath removal, and closer monitoring were sent to the Intensive Care Unit (ICU); although technically they were did not require intensive care. This created some frustration with the cardiologists. Frequent communication about the progress of staff training and competencies helped the group to better understand the reasons for admitting their patients to a more intensive care environment. Six months after the cardiology partnership was formed, the 5 S team began to admit the interventional post-cath patients.

    The cardiologists were also instrumental in staff education. What began as a simple request for an in-service briefing at a staff meeting became a day long, hospital-wide cardiac symposium. During Nurses Week 2012, a cardiac colloquium was held in the North Care auditorium. Speakers included Dr. Paul Sherry, Dr. Pam Taylor, and Chris Simpfendorfer, MD. The event included presentations of all the cardiac services newly offered in the facility. Attendees were able to view images of actual echocardiograms, heart caths, and EKGs through PowerPoint presentations. The program was a tremendous success with the attendance of 80 nurses from the organization. Attendees were also awarded CEs. (EP1-9)

    As the volume of cardiac patients increased, the staff became more comfortable and excited with caring for the population. The initial thought of caring for a post-cath patient was unknown and intimidating for the staff. They wanted to provide excellent care, yet the staff felt that they did not have the knowledge or skills to do so. Looking back, the direct care nurses realize how far they have come and what they have achieved. Not only are they better able to care for cardiac patients, but an improvement was also demonstrated in nationally reported data. The data for The Centers for Medicare and Medicaid's Core Measures for acute MI and CHF improved significantly. The experience also improved the staff's skills in caring for non-cardiac patients. The nurses are able to identify changes in EKGs, lab values, and have overall improved patient care on the unit.

    Staff education continues with EKG and PCI courses offered throughout the year for new hires. Opportunities to gain more experience in the CVU or VCC are also available.  In January 2013, a formal program of "floating" to the CVU will be reviewed in cooperation with the CVU manager and staff. Additionally, order sets created specifically for the CVU will be reviewed for implementation on 5S. PSFHS will also plan another cardiac symposium or similar educational offering for staff in 2013.

    This exemplar describes the real world application of the PPM through professional development, relationship based care, interdisciplinary practice, staff input into staffing/scheduling, and actions to ensure competencies with standards of care. 

    Professional Practice Model - Adaptation, Application, and Evaluation by Penrose Emergency Department:

    Penrose Hospital Emergency Department Unit Practice Council (UPC) adapted andapplied the Professional Practice Model schematic to improve nursing's awareness, utilization, and evaluation of the model within this specialty service. Keeping the patient and family in the center, ED nursing is focusing on relationship-based care.  The ED UPC has integrated both process and outcome goals within their schematic, to include peer review and specialty certification. One Emergency Department RN reported improved collaboration and collegial respect during the year stating that, "even the doctors are 'managing up' the nursing staff to our patients."


    The PH ED evaluated their application of the PPM through the following metrics:


    Baseline 2Q2011



    Patient Satisfaction: Quick evaluation upon arrival to ED




    Patient Satisfaction: Quick response to requests




    Patient Satisfaction: Courtesy and Respect of staff




    % of RNs with BSN or Higher



    Increased  9%

    % of RNs with specialty certification



    Decreased with turnover of several certified nurses

    SFMC 5N Unit Practice Council - Adapt Model, Modify Practice, Evaluate:

    Patient falls were a performance improvement area for SFMC 5N Surgical in the last quarter of 2010. One charge nurse and the chair of the UPC lead the development of bulletin boards that were positioned to be visible every time an associate used the elevator. The intent was to increase awareness, educate, and demonstrate a commitment to improving clinical outcomes on the unit. By adapting the model schematic to include specific nursing practices, these nurses were championing consistent evidence based practices. In addition the board included education from subgroups working on the unit or nurses representing the unit in interdisciplinary committees. While the nurses did not keep minutes of all their activities, they demonstrated their project via photos and in the quantified reduction in falls via the NDNQI Fall Report. Adaption of the model, modification of nursing practices through education and awareness were effective. The reduction in falls is their evaluative outcome.

    PSFHS Nursing Organization - Evaluation and Modification of the Professional Practice Model:

    The evaluation, adaptation, and modification of our model at the organization level are ongoing procedure. In 2010-2011, we evaluated our model using the following five structures/processes:

    1. Decisional Involvement Scale The Nursing Management Council and Nurse Practice Council members all identified interest in increasing shared decision making in the development of practice standards, selection of RN's for hire on the unit, and scheduling/unit coverage decisions. (EP1-10) Based upon this feedback, nursing services modified the following practices:

    a. Inclusion of direct care RN's in interview and selection process of colleagues
    b. Nursing Practice Guidelines reviewed and revised by clinical nurses through the Nursing Practice Council
    c. Nursing Practice Council goals revised to increase peer review and effective application of relationship-based care

    2. The Annual Nursing Report displays progress towards goals and highlights successes with evidence based practices, clinical outcomes, practice changes, internal experts, and community collaboration.

    3. The RN Practice Environment Scale (NDNQI RN Survey) is another tool to support the evaluation of our PPM. While questions and results do not directly tie into all elements of our PPM, they provide a proxy measure for analysis as displayed in the table below: (EP1-11)

    Professional Practice Model: Elements

    NDNQI RN Survey (2009 to 2011)

    Shared Decision Making

    Participation in Hospital Affairs ratings increased overall at Penrose and SFMC as well as on 63% of our units.

    Relationship Based Care and Care Delivery Systems

    Staffing and Resource Adequacy improved overall and on 69% of our individual units. Staffing and resource adequacy impact all areas of nursing practice as well as our ability to achieve our goals. In the context of relationship-based care, nurses report increased opportunities to form relationships with colleagues and with patients and families when adequate resources are available.

    Guiding Principles

    The 2011 results on "Nurse Manager Ability, Leadership, and Support of Nurses" improved significantly at SFMC.   "Collegial Nurse-Physician Relations" ratings are among the highest on our surveys recognizing the value we place on professional respect and collaboration to provide quality care.

    Quality of Care

    Quality of Care ratings increased overall at both hospitals.

    4. NDNQI, Infection Control, Patient Safety and Clinical Effectiveness reports provide feedback on the Quality of Care element of our PPM.

    a. Multiple committees review and act on quality data. 
    b. Goals are set through our strategic plan and oversight occurs at the nursing leadership council and through the nursing directors meetings.
    c. In 2011 a Nursing Quality Council was established.

    5. HCAHPS Patient Perception Results from this survey provide evaluative feedback on implementation of relationship based care and quality indicators. Improvements in patient satisfaction are reported in detail in EP35EO

     Formal evaluation of the PPM continues to occur through the structures and processes listed in the table below:

    Professional Practice Model: Elements


    Vision and Values

    Associate Engagement and RN Satisfaction Surveys, Rounding

    Shared Decision Making

    Annual evaluation of council progress toward goals, RN Satisfaction/Engagement Surveys

    Care Delivery Systems/Relationship Based Care

    Nursing Unit Practice Councils, Annual unit provision of care plan, peer review, Patient Perception feedback via HCAHPS, DAISY nominations, staff satisfaction surveys

    Guiding Principles

    Clinical Advancement Program, Professional Development Council

    Quality of Care

    NDNQI, Infection Control Committee, Restraint Committee, Falls Committee, Nursing Quality and Patient Safety Committee

    Standards of Professional Practice

    EBP and Research through SDM Councils, Nursing Quality, Patient Safety Committee, Ethics Council

    Adaptation and modification will occur subsequent to evaluation through our Shared Decision Making structures. 


    Our Professional Practice Model (PPM) was developed by nurses at all levels in our organization. The core elements are consistent throughout our system and they reflect the organization's mission and vision as well as our nursing standards. Relationship-based care supports our focus on patients and families, as well as highlighting the goal of creating a healthy work environment for ourselves and our colleagues. We know the work environment impacts patient safety and quality. As nurses apply the PPM they are critically evaluating and adapting it to meet unit specific goals. This innovative strategy brings the PPM alive, aligns goals and actions and values the expertise of nurses providing direct care.

    Finally, we know that patient feedback provides a way to demonstrate the application and evaluation of our Professional Practice Model. When a family member takes time to write a thank you note, we feel honored. The following thank you note demonstrates our focus on our patients and families who are centered in our Professional Practice Model:  

    To the doctors, nurses, administrative and support staff of the ICU unit of Penrose-St. Francis Hospital.

    Our brother, Richard Carlson, was taken to the emergency room in the early afternoon of July 22nd. He had suffered a massive vascular aneurysm and was immediately taken to the ICU and placed in room 2013 on life support.
    Richard's brothers and one sister live in different states. The first news of his condition, and our first contact with the hospital came from Chaplain Theresa later in the afternoon. She verified that she was talking to the correct person, explained the situation with compassion, asked and answered questions, explained what to expect and that he wasn't alone, and then shared a prayer.
    The next call came from Dr. McFarland of the emergency room and he professionally, but kindly explained Ricks condition and prognosis, and he let us know he was in the ICU. Dr. Wyes from ICU explained that Rick was essentially brain dead and may have less than 48 hours to live.  Ricks niece, Michelle, whom lives in Castle Rock, arrived at the hospital Friday morning. We all arrived from out of state Friday evening.
    Ricks attending nurses, Nia, Coleen and Amy informed us of his condition, what was being done to keep him comfortable and they also answered all our questions. Dr. Lee continued to keep us all informed and updated.
    We stayed all night until our brother passed away early Saturday afternoon. We feel strongly compelled to offer these words of thanks for the professional and compassionate care you not only offered our brother but also the attention and care you gave our family. We understand that you serve patients with dire needs everyday and see grieving families on a routine basis. At no time did any of us sense with anyone we came into contact with that this was another routine day for them. All the staff graciously gave us personal attention that showed us a deep passion for the care of others.

  • Exemplary Professional Practice - EP01EO

    Professional Practice Model

    EP1EO The result of applying the Professional Practice Model. Include two examples related to nursing practice, collaboration, communication or professional development activities.

    Mother-Baby Unit - Developing a Culture of Breastfeeding (2010-2012):

    The application of the Professional Practice Model in SFMC's Mom/Baby Unit is described and demonstrated below. Making changes in nursing practice to increase breastfeeding initiation required the implementation of evidence based practice, interdisciplinary collaboration, education initiatives, and ongoing communication. The collaboration between the lactation experts and direct care nurses resulted in improved patient outcomes and achievement of the performance improvement project team goals.

    Background/Purpose The Mom/Baby Unit identified a performance improvement project based on evidence presented by Dr. Marianne Neifert and the "Can Do 5 project for Colorado," the American Academy of Pediatrics, Breastfeeding and Human Lactation by Jan Riordan, and The Joint Commission's Perinatal Quality Measure. The "Can Do 5 project" outlines five practices that support breastfeeding. The team goal was to change practices to include these elements that encourage breastfeeding and to receive a Colorado Can Do 5! B.E.S.T (Breastfeeding Excellence Starts Today) Award as a result. The five elements are:

    1. Help mothers initiate breastfeeding within one hour of birth.
    2. Give newborn infants no food or drink other than breast milk, unless medically indicated.
    3. Practice "rooming in" - allow mothers and infants to remain together 24 hours a day.
    4. Give no pacifiers or artificial nipples to breastfeeding infants.
    5. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

    Goal: To increase the initiation rate of breastfeedking mothers through application of the Professional Practice Model (staff and patient education, collaboration, and practice changes) and to achieve the Colorado Can Do! B.E.S.T. (Breastfeeding Excellence Starts Today) Award.

    staff and patient education, collaboration, and practice changes, and to achieve the Colorado Can Do! B.E.S.T. (Breastfeeding Excellence Starts Today) Award.

    Methods/Approaches The SFMC Mom/Baby nurses initiated a standardized performance improvement project starting in the fall of 2010 with the outcome measured through breastfeeding initiation rates at SFMC. The attached Plan Do Check Act form outlines the projectThe SFMC Mom/Baby nurses initiated a standardized performance improvement project as outlined in the attached PDCA. (EP1EO-1)

    Collaboration and Evidence Based Practices

    PSFHS Lactation Consultants and PostPartum/ MomBaby Unit nurses attend the Centura Lactation Consultant Meetings where nurses collaborate on increasing breastfeeding in alignment with the "Can Do 5" project.  This cross organizational team reviewed current status at their organizations and discussed best practices.  The team agreed one of the modifiable obstacles to initiation and continuation of breast feeding was the commercial promotion of infant formula through distribution in hospital discharge packets.  The Team sent a letter to senior leadership recommending the discontinuance of distribution of free formula products, a change of practice. (EP1EO-2

    Interdisciplinary Collaboration

    The proposal was discussed in the Physician Section Meetings, Birth Center Staff Meetings, as well as with Central Supply Staff.  In September 2010, the discharge bags which included free infant formula were discontinued. By discontinuing the long standing practice of distributing free formula products and promotional items the Mom/Baby Unit at St. Francis Medical Center sent a clear health promotion message to our patients in support of breast feeding. The change was based on clinical research by The American Academy of Breastfeeding Medicine, The American Academy of Pediatrics, and many others.


    SFMC Birth Center Lactation Consultants, Clinical Nurse Specialists, Nurse Educators, Nursing Staff, and Managers partnered to provide staff education as well as to analyze the impact of this practice change.  (EP1EO-2b)

    • Designed Poster "No Pacifiers"
    • Designed teaching handout regarding formula supplementation
    • Provided staff education and added breastfeeding skills to annual competency demonstration

    Jolene Bedford, MSN, RN, IBCLC,ION,LAMAZE
    Amy Furfari, BSN, RN IBCLC,LCCE
    Lou Ann Cox, BSN, RN, MaED
    Centura Health Lactation Specialists
    Mom Baby Direct Care Nurses

    Outcomes Increased breastfeeding initiation rates are demonstrated in the graph below following the nursing practice changes.

    Dissemination of Practice Change The unit's nurses created a poster and presented their evidence based practice implementation at the 4th Annual Centura Health Evidence-Based Practice, Research and Innovation Conference on November 11, 2011 in Denver and at the Sigma Theta Tau Xi Phi Research Conference on November 4, 2011.  (EP1EO-3)

    Awards Achieving their goal, the unit was honored and recognized for their nursing practice changes and outcomes. In January 2012, SFMC's Mom/Baby Unit received the International Board of Lactation Consultant Award. (EP1EO-4)  Further highlighting the effectiveness of this procedural change, in August 2012, the Mom/Baby Unit was awarded the Colorado Can Do 5! B.E.S.T (Breastfeeding Excellence Starts Today) Award. (EP1EO-5)

    Summary The nurses applied the elements of the Professional Practice Model including nursing practice changes, communication, collaboration, and professional development. By using the lactation internal experts, the group made significant changes in practice to improve breast feeding initiation rates and succeeded.

    2:  Penrose 7 Orthopedic/Neurological Unit - Improving Pain Management and Nursing Satisfaction:

    Background/Purpose PH 7 Surgical primarily serves orthopedic patients. Using a modified team approach, nurses and certified nursing assistants provide 24/7 nursing care; physical and occupational health therapists provide related therapies during the day. Physician colleagues working on this unit are known leaders; Dr. Stephen Myers recently served as Chief of Medical Staff and Dr. David Matthews serves as the Orthopedic Section Chief. 

    Patients treated on this unit have often been in pain from joint and back related problems for a significant period of time. Managing their post operative pain within the context of chronic pain is challenging. In order to mitigate this challenge, the Pain Service Nurse provides the unit with a daily consultation. Despite the recognizable leadership and the targeted pain briefings, patient satisfaction with pain management and nursing satisfaction needed improvement.  Collaborative methods were introduced to improve patient and nurse satisfaction.    

    Methods and Approaches PH 7 Surgical nurses identified a need for additional education related to orthopedic patients and improved partnerships between nurses and physicians. Audrey Simpson RN, Clinical Manager collaborated with David Matthews MD, Orthopedic Medical Director to identify and plan opportunities to meet educational and relationship building needs. Based upon a unit goal to improve pain management, the unit leaders scheduled education directly related to orthopedic surgery and pain management. In addition, the charge nurses, manager, and physicians met to collaboratively identify unit strengths and quality improvement goals. (EP1EO-6) Using educational strategies, nurses and physicians have partnered to improve services and outcomes on this unit. The table below depicts the education/meeting schedule: 

    Date Topic Speaker
    January 28,2011 Improving Patient Satisfaction Laurie Kennedy, VP Customer Experience
    April 11, 2011 Anticoagulation teaching  Lynne Wahl RN
    May 9, 2011 Infection in orthopedic patient  John Redfern MD
    June 13, 2011 New approach approaches for hip and knee surgeries Stephen Myers MD
    August 16, 2011 Physician and Charge RN Meeting: Improving Collaboration and Practice (EP1EO-8) David Matthews MD
    November 10, 2011 Pre-emptive Pain Management (EP1EO-7) Dan Chatelain RN
    January 23, 2012 Compartment syndrome and preparing to call the physician.
    Patient safety and when to call the Rapid Response Team (EP1EO-9)
    Eric Jepson MD, Olinda Spitzer RN
    March 13, 2012 Effective pain management to improve patient satisfaction  Dan Chatelain  RN












    Audrey Simpson, MSN, RN, Clinical Manager
    David Mathews, MD
    Steven Myers, MD
    Eric Jepson, MD   
    PH 7 Direct care nurses participated in education   
    Olinda Spitzer, MSN, CNS, CCRN
    Dan Chatelain, MSN, RN-BC
    Laurie Kennedy, VP Customer Experience
    John Redfern, MD
    Terry Frymire, RN
    Earnestine Nichols, RN
    JeriAnn Cline, RN
    Carlos Johnson, RN
    Kris Williams, RN

    Outcome - Patient Report on Pain Management The improvement of patient perception of our pain management process (as measured by our HCAHPS), indicates growth on two pain related questions. The results demonstrated that patients perceived an improvement in both areas in the latter half of 2011, with slight decrease noted in early in 2012. Ongoing monitoring will continue to measure continued growth in both pain related areas.  In addition, PH 7 continues to prioritize this nurse sensitive indicator.

    The goal to improve patient satisfaction related to pain was met.


    Outcome - Clinical Nurse Report on Partnership and Engagement (Press Ganey Survey) In March 2012, PH 7 clinical nurses completed the Press Ganey Staff Survey. The results demonstrate improvement in four areas following the education/meeting intervention. In both "System/Leadership" and "My Work" categories, clinical nurse mean scores outperformed the HealthStream Database mean.  Our goal to improve nurse satisfaction was met.

    Implications A collaborative multidisciplinary team approach to orthopedic patient care improves outcomes for both patients and staff.  Using focused educational strategies based upon direct care nurse requests provided learning opportunities and time to build relationships. Our Professional Practice Model includes elements of interdisciplinary collaboration, relationship based care, professional development and shared decision making. Applying each of these PPM elements resulted in improved patient and staff outcomes.

  • Exemplary Professional Practice - EP02

    Professional Practice Model

    EP 2 Describe and demonstrate how nurses investigate, develop, implement, and systematically evaluate standards of practice and standards of care.

    The guidelines in ANA Nursing: Scope and Standards of Practice outline the expectations of the professional nursing role. These standards define, guide, and direct professional practice across our organization. Standards reflect the priorities of our profession.

    Standards of practice and care are a primary element in our professional practice model. Visually situated between our nursing vision and quality, these standards describe the responsibilities for which nurses are accountable. The ANA Scope and Standards of Practice for Nursing Administration and the ANA Scope and Standards of Practice for Nursing provide the foundation for nursing practice at all levels and settings. In addition, nurses serving on specialty units are accountable to know and implement relevant specialty standards.   Each standard provides measurement criteria for implementation and evaluation processes.
    The major standards of the ANA Scope and Standards of Practice for Nursing are outlined below:

    Standards of Practice Standards of Professional Practice
    Assessment Quality of Practice
    Diagnosis Education
    Outcome Identification Professional Practice Evaluation
    Planning Collegiality
    Coordination of Care Ethics
    Evaluation Research
      Research Utilization

    Centura Health:

    The CNO is an active member of the Centura CNO Joint Council.  One example of CNO action related to standards of care is Relationship Based Practice (RBC). Through the strategic planning process this senior leadership group established RBC as our standard of practice and guiding philosophy of care. In 2012, Centura Health contracted with Creative HEALTH MANAGEMENT to provide a five day workshop to educate participants on RBC, promote in depth investigation of RBC and the development of processes for RBC implementation in each facility. PSFHS sent five nurses to conference and they eagerly shared an overview with the Nurse Practice Council upon return.  (EP2-1)

    Interdisciplinary Forums:

    The Nursing Leaders participate in the following groups to investigate, develop, implement and evaluate standards of practice and care. 

    • Interdisciplinary Policy Committee provides oversight for all interdisciplinary clinical policies in the organization. Committee members are responsible for obtaining input from their colleagues, ensuring current evidence is integrated and communicating changes to all impacted associates. Centura Health is in process of standardizing policies across the organization. The CNO, a clinical nurse manager and administrative support person meet regularly to provide a voice for PSFHS standards of practice and care.  (EP2-2)

    • Clinical Effectiveness Committee and Infection Control Committee review outcome data reflective of our development and implementation of standards. The attached minutes from Infection Prevention and Control demonstrate the review of data outcomes related to implementation and evaluation of standards as well as review of specific standards of care and policies. (EP2-3)

    • The Medical Executive Committee provides oversight and leadership to the process for clinical care, including investigating and acting on breaches in standards of care and establishing standards for clinical competence and credentialing/privileging medical staff members. The CNO reviews and recommends action on all advance practice applications and reapplications.  (EP2-4)

    Nursing Councils and Committees:

    Participation from nurses at all levels on councils and committees afford the structure and process for developing, implementing and systematically evaluating standards of care.  During nursing orientation, all nurses are informed of PSFHS expectation to practice based upon these national standards.  In addition, unit level orientation includes demonstration of competence with standardized nursing practices. (EP2-5)

    The Nursing Practice Council is accountable to investigate, develop, implement and systematically evaluate all Nursing Guidelines. Each guideline is based upon current evidence based practices and reviewed at least every three years.  Nurses who use these guidelines the most frequently assume responsibility for maintaining a working knowledge of new practices or approaches. The process includes a review of current literature, including the use of the Mosby's Mobile Dictionary of Medicine Application for evidence based practices. Revisions and updates are completed by the Unit Practice Council; they are also reviewed and approved by the Nursing Practice Council and then forwarded to the Chief Nursing Officer for final review and inclusion in the online database.  (EP2-6)

    Individual Unit Practice Councils with Clinical Managers are accountable for nursing practices which are specific to that unit. Guidelines are monitored and reviewed at least every three years; more frequently if changes in practice are identified through evidence based practice committees.  In all situations, the lead nurse reviewing the guidelines and policies is accountable to ensure adequate investigation of current practice, relevant research, and evidence based practices as part of the process to evaluate and revise methods. In February 2011, the PH Critical Care Unit Practice Council discussed their plan to review and revise policies based on the American Association of Critical Care (AACN) Nursing standards.  The UPC decided all members would investigate critical care relevant AACN standards of practice and care in preparation for developing and implementing practice changes within the unit. (EP2-7)

    The Nursing Leadership Management Council investigated and systematically evaluated PSFHS implementation of the Nursing Administration ANA Scope and Standards of Practice (2009). Each nurse member of the council reviewed the standards and measurement criteria, investigated our current practices to evaluate implementation of each standard, and led a presentation to council members to promote understanding, awareness, and accountability for standards. The attached table demonstrates the process used in the council. (EP2-8)

    As PSFHS focused on reducing Catheter Associated Urinary Tract Infections, nurses participated with the Centura Health CAUTI Evidence Based Practice team to investigate, develop and implement standards of practice. Evaluation of the effectiveness of these standards occurs through the monitoring of quality improvement data at the hospital and unit levels. In addition, the PSFHS Nursing Quality and Unit Practice Councils follow up to ensure we are achieving positive outcomes and take action such as re-education or peer review depending on the gap assessment.  (EP2-9)


    The electronic medical record facilitates the implementation of standards of care. At PSFHS, Standards of Care are the minimum care that patients receive regardless of their unit. Embedded in our EMR are specific standards of care for different patient ages as well as individual needs.  This structure facilitates access and increases nurses' use of evidence-based assessments, interventions, and teaching for specific patient needs. Fall assessments and interventions are evidence-based and included in the EMR. Nurses are able to revise the frequency of nursing interventions and add standards of care to the EMR based on patient needs. In addition, standard changes are made within Meditech for all providers when indicated. (EP2-10)

    Hospital and nursing policies are available online for easy access. Nurses can access these policies from any computer.  In addition access to professional journals is available online and through the Webb Library.  Professional journals and professional organization information may stimulate added investigation of our standards as well as suggest revisions to nursing practice. 

    The Peanut Ball: 

    Labor and Delivery - Investigating and Evaluating Standards of Care Our culture encourages nurses' curiosity and embraces ideas nurses bring from credible external sources.  For example, a nurse on Labor and Delivery shared the "Peanut Ball" practice she had used at a prior hospital.  The peanut ball is a peanut shaped exercise ball to aid in labor and delivery.  She reported a research study complete at her hospital with 200 patients demonstrated the use of this ball reduced labor time and c-sections. SFMC L & D nurses decided they would like to investigate this practice. Currently L&D uses hospital pillows to increase pelvic diameter and allow more room for the fetus to descend. (EP2-11)

    Bedside Report:

    PH 9 Surgical - Developing, Implementing and Evaluating Standard of Practice Nursing shift report is a structure and process to implement and evaluate nursing standards of care.  The following exemplar describes and demonstrates PH 9 Surgical Unit Practice Councils process to implement Bedside Shift Report (BSR).  In 2011, the PSFHS Nursing Practice Council (NPC) began discussing Bedside Shift Report (BSR) as a standard of practice.  Two inpatient units were successfully piloting BSR and shared their strategies for implementation.  Professional nursing journals spoke of the benefits of BSR including patient safety, patient participation in treatment planning, patient satisfaction and increased nursing accountability. Each of these identified benefits aligned directly with the nursing strategic plan and the NPC goals. Articles were distributed and discussed in council meetings at the organization and unit levels and units began to pilot various structures to implement the change in standard of care. 

    • February 2011. PH 9 Unit Practice Council planned implementation of BSR.  A standard for greeting patients/families had recently been implemented and was the agreed upon structure for bedside introductions - AIDET (Acknowledge, Introduce, Duration, Explain and Thank).  The chair of the UPC volunteered to draft a script to use with input from all nurses.

    • October 2011. The UPC defined and implemented the structure and process for BSR calling it "Transition of Care." (EP2-12) The team agreed to make adjustments as they implemented the new process.

    • January 2012. The UPC identified inconsistency in BSR practice and the team sent out a survey to all nurses seeking feedback. Initial feedback reported BSR was "too time consuming, don't like it and stupid." The UPC members designed a form and offered to pair up with nurses to provide peer support and review for the change in practice.  (EP2-13)

    • June 2012. The clinical manager shared information on BSR obtained from a literature review and reinforced the importance and expectation of BSR.

    • July 2012.  Sue McDonald, RN stated "Just days into BSR Theresa and I were rounding on our patients. From the moment we entered our patient' room the patient couldn't have been more thankful for the care he received through the night.  He spoke highly of Theresa.  It was then I realized the Transition of Care was as much as positive, rewarding part of nursing to the staff as it is to the patients."

    SFMC ED:

    Implementing and Evaluating Standards of Care for Stroke Patients The standards of care for stroke patients who are evaluated and treated in the emergency room include:

    • A dysphagia screen prior to admission and before the administration of oral medication

    • Baseline neurologic assessment using NIH guidelines

    • tPA vital sign and neurological checks every fifteen minutes

    The nurses formed a team to evaluate the practice and to make improvements if needed. The team included 6 ED charge nurses, the clinical manager, and a clinical coordinator. A review of practice identified the ED physician responsible for completing the baseline neurologic assessment. Following this initial review, further patient information is provided by nurses who are certified in the National Institute of Health Stroke Scale (NIHSS). The NIHSS is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. This tool helps evaluate the acuity of stroke patients and it aids in determining appropriate treatment.   Staff nurses identified a deficit in understanding and competence with the NIH Stroke neurologic baseline assessment process. Some staff was unable to perform a dysphagia screen. The stroke coordinator provided evidenced based materials to support standards of care implementation.  The ED team proceeded to correct shortcomings by providing training on both procedures. Charge nurses became identified as resources for staff and auditors to provide immediate feedback on any documentation gaps. The ED Manager developed a spreadsheet to support tracking and systematic evaluation. The Quality Improvement template is attached.  (EP2-14)

    Outcomes improved following the evaluation of care and education standards. Dyphagia Screening in the ED improved from 84% to 85.2%; and the baseline NIH score improved from 64% to 81.2%. Further, the tPA Vital signs reached 100%.


    The standards of nursing practice and care are continually being examined and revised by our nurses at all levels. We employ standardized methods for nurses, at the unit through organizational levels, to investigate, develop, implement, and evaluate every aspect of care at PSFHS. This is demonstrated by the above examples, which include nursing participation at senior through unit level in ensuring our standards of practice and care are followed and improve clinical outcomes.

  • Exemplary Professional Practice - EP03

    Professional Practice Model

    EP 3 The structures (s) and process (s) that include direct-care nurse involvement in tracking and analyzing nurse satisfaction or engagement data.

    Our nursing professional practice model includes expectations for both relationship-based care and shared decision making. These expectations are demonstrated through direct care involvement in tracking and analyzing nurse satisfaction data. As professional nurses, we are also expected to take appropriate actions to improve our work environment.

    Structures and Processes for Tracking and Analyzing Satisfaction Data:

    PSFHS is committed to associate satisfaction and engagement. In order to objectively quantify information related to nurse morale, PSFHS utilizes two nationally recognized and respected tools: the Press Ganey Partnership Survey and the National Database of Nursing Quality Indicators RN Survey (NDNQI).

    Centura Health, PSFHS' overarching healthcare network, sets expectations for administering the Press Ganey survey at regular intervals. As an organization, we encourage all associates to complete the survey and we provide easy access through an online link sent directly to each individual's mailbox. (EP3-1) During the survey period, leaders are provided with ongoing updates on the percentage of associates in each area who have completed the questionnaire. This ongoing monitoring allows leaders to elicit real-time feedback on any problems accessing the survey or questions that may emerge. One of the most frequent concerns is related to confidentiality. We assure associates of confidentiality every year, and at the same time we also seek ongoing feedback between survey periods.

    In addition, the nursing department elects to complete the NDNQI complete with the Practice Environment Scale at least every two years. This data is reported to the Colorado Hospital Association and is published for comparison with other hospitals.  The first year of participation was 2009, and the response rate was low. Leadership worked to raise awareness so that this issue could be addressed. In 2011, our response rate more than doubled; which increases our ability to effectively analyze and develop action plans to address results. PSFHS is scheduled to complete the survey in April 2013. The Nursing Practice Council will "host" the survey as they champion participation on their units. NPC members have requested handouts to give to staff and they plan to encourage colleagues during shift huddles.  (EP3-2)

    Nurse Involvement:

    All nursing satisfaction data is provided in report formats and presented to nursing leaders. This data is then reviewed during unit staff meetings so that unit results can be discussed with direct care nurses. Our process includes a review of the data as well as analysis for trends, areas of strength, and areas of opportunities. The easy to read format of the data provides data points at multiple levels and it includes a summary of the top ten strengths and top ten opportunities identified through the vendor's statistical process. (EP3-3)

    Since the survey data is broken down by unit, direct care nurses participate in analyzing the results in their Unit Practice Council meetings. We develop action plans in response to data analysis at the organizational, department, and unit levels. While alignment is important in setting goals, the primary focus is on units selecting areas they identify as critical. We then acknowledge unit strengths and focus ongoing efforts to improve areas of weaknesses.

    General Leadership Meeting The General Leadership includes senior nursing leaders and nursing managers.  This group reviews the overall Press Ganey Associate Survey results and identifies trends, strengths and opportunities.  As an organization, all associates contribute to creating an environment for engagement and satisfaction.  Nursing leaders not only review their department and units, they also participate in organization level reviews and action planning, such as Listening Sessions open to all associates. (EP3- 4EP3-5)

    The Associate Satisfaction Committee provides the data review, analysis, and action planning based upon survey outcomes. This committee includes nurses and associates from all departments.  They do not keep minutes but meet, take action and review Press Ganey outcomes. In addition, this group plans picnics and other activities for PSFHS associates.  In 2010, the Associate Satisfaction Team provided an update on their progress and sought additional feedback through a "Zoomerang" survey. The Penrose Pulse, a weekly newsletter informed associates of the survey, actions taken following the survey, and the resulting improvements to the overall organization. To improve communication of important information, an opportunity identified through the survey, the associate satisfaction team identified seven ways to communicate information; all seven methods have been implemented. The request for recognizing excellent performance led to the development of a pay for performance structure which was implemented. It has resulted in associate payouts every year since its inception. (EP3-6EP3-7)

    PH Critical Care Unit Practice Council reviewed and analyzed the results from the nursing Press Ganey Satisfaction/Engagment survey. In November 2010, they identified two areas to improve and determined tactics to support improvement. Staffing/retention and nurse recognition/appreciation were target areas. Over the next few months the UPC in collaboration with unit nurse colleagues and the clinical manager implemented changes in scheduling/on-call and created a recognition committee. (EP3-8) The Press Ganey results in 2012 for PH CCU reflect improvement in both areas - adequate resources increased by 1.5 and recognition by 1.9 respectively.

    The Nursing Practice Council analyzes and tracks nurse satisfaction data. Council members identified four target areas to analyze and identified actions to improve. The decision was made to delay application for Magnet and focus on improving these ratings during FY2012. The Press Ganey Survey taken in April 2012 demonstrated improvements and led to the decision to apply for Magnet Recognition. (EP3-9)

    The Magnet Champions (Direct Care Nurses) analyze and track nursing satisfaction survey results. In June 2011 they decided to highlight and challenge nurses related to their participation in shared decision making and their recognition and appreciation of one another. They published a newsletter encouraging nurses to nominate peers for DAISY and highlighting strengths. (EP3-10)


    Direct Care Nurses participate in tracking and analyzing satisfaction data in their individual work unit as well as at the organizational level through the Nursing Practice Council. By using the reports provided by Press Ganey, nurses are able to celebrate strengths and prioritize opportunities for improvement. Press Ganey reports provide data on changes from prior surveys, a practice that promotes trending analysis. Clinical Managers partnering with direct care nurses determine actions to create an environment for positive patient outcomes and increasing nurse engagement and satisfaction. Results of our 2012 survey discussed in EP3EO demonstrate an improved rating in all categories following these actions.

  • Exemplary Professional Practice - EP03EO

    Professional Practice Model

    EP3EO That nurse satisfaction or engagement aggregated at the organizational or unit level outperforms the mean, median, or other benchmark statistic of the national database used. Include participation rates, analysis, and evaluation of the data

    Image removed.

    The most recent PSFHS Press Ganey Partnership Report was completed in April, 2012. Registered Nurse participation totaled 687 with a 65% participation rate. Press Ganey provides seven primary categories for analysis and evaluation. Each category is depicted in the graph above.


    The report provided by Press Ganey, Inc. reflects the ratings from only the registered nurses.  PSFHS Nursing Services selected the FTEs 2001-3000 Peer Group as our national benchmark. There are over 722 workgroups within this peer comparison group. The data is presented by major categories: System/Leadership, Resources, Teamwork, Direct Management, Our Organization, Our Work and My Work. The data table in the graph reports the mean score for each category.

    Press Ganey separates the categories into Employee Satisfaction and Employee Engagement.

    • Employee Satisfaction includes: System/Leadership, Resources, Teamwork, Direct Management

    • Employee Engagement includes: Our Organization, Our Work, My Work


    The data depicted in the graph above demonstrates PSFHS registered nurses outperformed the national benchmark in all seven categories demonstrating both nurse satisfaction and nurse engagement in the areas of measurement. PSFHS registered nurses outperformed the national registered nurse benchmark in 100% of the categories.

  • Exemplary Professional Practice - EP04

    Care Delivery System

    EP 4 That the structure (s) and process (es) of the Care Delivery System involve the patient and-or his or her support system in the planning and delivery of care. Provide at least two (2) examples of a plan of care that included patient and/or family member involvement.

    Care Delivery on Intensive Care (ICU) "On October 24, 2011, my grandfather, Walt Hanson, was emergently transferred from dialysis on the 5th floor to the ICU where he was placed in Colleen's capable hands. During the next few hours, 20 of his loved ones, ranging from his bride of 65 years down to his 2-month-old great-grandson, gathered around his bed to offer our last expressions of love as he slipped from this world into the next. Throughout our vigil, Colleen was ever-present, quietly tending to both his needs and the needs of my family. Whether she was helping to ease his pain with medication or moistening his mouth and lips with a sponge, her tender care was noticed and appreciated. It was the little details - a kind word, a gentle touch, a hug, a tissue, a glass of water - these are the small things that mattered so much". - Thank you letter from family members

    Care Delivery in preoperative area One family nominated a perioperative nurse for a DAISY award stating, "Gina Wamble RN made my mother feel calm and relaxed before her surgery. She explained everything to my mom, me and my sisters. I really liked her. My family liked her as well (2011)" 

    Our Professional Practice Model guides our nursing practice; this includes the expectation of unit designed, "Care Delivery Models" to provide excellent patient care based upon the needs of the patients and their families. During the last five years our philosophy of care has evolved from "patient centered care" to "patient/family centered care" to our current standard of "relationship-based care." Our Professional Practice Model presents the patient, family, and community in the center of the figure to symbolize the role of the three in how our organization approaches holistic care. To further emphasize the importance that our organization places upon the bonds formed in healing, the aforementioned center of our PPM is surrounded by elements of relationship-based care; something which directly speaks to the incorporation of family members into healthcare decisions. Our nursing vision, "PSFHS Nursing is the recognized leader in relationship-based care dedicated to excellence in nursing practice balanced with concern for the well being of the caregiver" drives our focus on self awareness/care, building positive collaborative relationships with our colleagues, and strengthening our partnerships with patients and family members during the treatment process. 

    The ANA Nursing Scope and Standards of Practice (2004) describes a competent level of nursing care demonstrated through the nursing process.  The initial nursing assessment with our patients set the stage for patient and family involvement in care planning and in the delivery of care.  Admissions to inpatient care may come through the emergency rooms, physician's office, or through post-operative rehabilitation. Preplanned admissions provide an opportunity for planning care through processes such as our class for patients planning joint surgery, or classes for patients who are exploring and/or planning bariatric surgery. The clear expectation throughout the standards is that nurses involve the patient and family in all steps of nursing practice.

    Nursing associates also care for those in outpatient areas. These areas include such units as the Wound Clinic, Urgent Care, and the Cancer Center. Each service/unit selects a care delivery system to meet the needs of the patient population that they serve. Inpatient units document a Provision of Care plan that identifies the types of health care associates delivering care and the overall staffing plan. (EP4-1)

    Patient Rights and Interdisciplinary Policies:

    Patients have the right to participate in all areas of their care plan including areas of: treatment, care decisions, and discharge. The Plan for Providing Patient Care IDPC P-02-b (EP4-2) states:

     B.  PATIENT'S RIGHTS AND RESPONSIBILITIES: Penrose-St. Francis Health Services (PSFHS) supports the philosophy that all patients should understand and participate in their health care decisions. PSFHS encourages the patient to express their spiritual beliefs and cultural practices and is committed to the promoting the highest ethical standards of medical care. 

    We recognize the value of family support and participation in treatment for both the patient and their family/support system. We ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences. Visiting, however, may be limited due to specific and justified clinical restrictions (if it is critical to patient well-being). (EP4-3)

    Patient teaching is a crucial element of professional practice. The process is designed to enable patients and their support structures to: assume responsibility for self-care, successfully participate in the management of chronic health problems, continue to recover from acute illness, and adopt positive health behaviors. Patient and family teaching is provided based upon the needs and plan of care. For example, when our soon to be new parents anticipate labor and delivery, we encourage their participation in multiple education classes as one method to provide information and partner with the "parents" in planning and delivery of care.  (EP4-4)

    Supporting the Involvement of the Patient/Support System: 

    Patient/Family Resources

    • Many inpatient rooms provide sleeper chairs for family members to rest while they stay with the patient. While we have defined visiting hours, family members are encouraged and allowed to visit including spending the night when this is consistent with patient and family wishes. When patients are in semi-private rooms, to support privacy and rest, we do not allow overnight guests. The nurses on PH 4 are quick to talk about how they provide meal coupons or other comforts when needed to support family overnight stays.
    • The John Zay House, a property which belongs to PSFHS and is located immediately adjacent to Penrose Hospital, provides rooms and kitchen facilities for out of town families to stay close to the patient.
    • The Ronald McDonald room at SFMC allows families to be close and find some quiet time, food, or a shower without having to leave the hospital.
    • The Patient Handbook, provided upon admission provides information to promote patient/family participation.

    Staff Resources

    Staff Resources Staff education improves knowledge and competency. During "Education Days" in 2010, the Professional Development Council presented a simulation of patient/family centered care. In 2011, 5 nurses participated in a weeklong conference on relationship based care and have shared their new knowledge with their colleagues.  Demonstrating nursing commitment to patient and family participation in care is their third goal related to Relationship Based Care. The 2012 Nursing Practice Goals include:

    1. 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.

    2. Outperform national benchmark in nurse sensitive HCAHPS categories: Pain Management, Nurse Communication, Discharge Information, Responsiveness, Medication education and Quietness at Night.

    3. Improve relationship-based care as part of our Professional Practice Model. 

    • Our Nurse Case Managers are skilled in disposition planning and in the coordination of care across multiple settings. Partnering with patients and families, the case managers seek to meet patient/family preferences as they arrange for placement, home health, or follow up outpatient appointments to facilitate a continuity of care.

    • During the past two years we have expanded case management service by assigning a case manager nurse to serve in the emergency department seven days a week. The role of these nurses is to assist with complex discharge planning for patients who do not need inpatient care. The case manager focuses on identifying needs and options as they involve the patient and family in discharge planning. (EP4-5)

    • Clinical nurse experts in palliative care, pain management, and wound care assess patient and family needs partner to provide opportunities for patient involvement in planning and delivery of care. Ginny Davis, RN, MSN our Palliative Care Clinical Nurse Specialist, meets with patients and families to discuss their preferences as she involves them in planning their care; including advanced directives and palliative care strategies when appropriate. (EP4-6)

    Bedside Report provides opportunities to involve the patient and family in their care. As nurses transfer the responsibility and accountability for nursing care at shift change, they meet briefly with each patient/family to do introductions, identify priorities or individual needs, and assess patient safety.

    Hourly rounding with patients, the response and follow up to pain management interventions, planning the eventual discharge, medication administration, and patient teaching all provide opportunities for collaboration, clarification, and dialogue as our nurses partner with patients and their families.  


    The Plan of Care is one tool to guide interdisciplinary care of patients. Recognizing care planning is an ongoing process that requires effective and efficient documentation; we continue to evaluate and revise the structure for documenting the Plan of Care. When we implemented our electronic medical record system in 2008 we used an interdisciplinary care plan. In 2011, we revised the documentation to reduce redundancy and demonstrate the fluidity of care planning. As each discipline evaluated outcomes or identified additional care needs, interventions were completed, revised and added. Ongoing revisions to the system were based on feedback from nurses. These revisions improved efficiency and were a large step toward standardization. At the same time, nurses know that care based upon standards must also allow an element of customization, so that each patient and family can receive individualized care. Our organization's motivation to balance standardization, individualization, and efficiency led to a procedural change in 2011. The KOIN (Knowledge of patient education and of the plan of care, Orders, Intervention and documented patient tasks, and Notes) process was the result of that procedural change. (EP4-7EP4-8EP4-9) details the nurse led the KOIN development and implementation process.

    Plan of Care Including Patient/Support System Involvement:

    Our care planning process is ongoing and is best reflected in the documentation of specific interventions. Identified as one of our standards of care, and individualized to meet unique patient and family needs, care planning shares a vital link with patient/family satisfaction. The following examples provide evidence of patient and family involvement in planning and delivering care across our system:

    1. Pediatric patients and their parents are involved in care planning and delivery at an age appropriate level. The following page shows how we include the parents in education with a focus on safety and security. 

    NOTE: In addition the initial assessment identified the parents' need for assistance completing an application for Medicaid. You will notice that the attending nurse requested a social work referral to meet this treatment need. (EP4-10

    2. Oncology Inpatient involved in delivery of care. The following care plan interventions reflect patient involvement in care delivery through dialogue with a chaplain. Additionally, it demonstrates the contributions of family members as family planning in incorporated with regards to the patient's post discharge care:The Case Manager RN documents the following in the patient interventions reflecting collaboration with the patients' daughter in planning for discharge. (EP4-11)

    3. NICU Baby. Mom expressed her desire to breastfeed. The care planning intervention attached identifies support for the new mother's involvement in the delivery of care. (EP4-12)

    4. Infusion Center.  Two Infusion Center nurses shared the following example of relationship based care (EP4-13)

    5. PH Critical Care Unit  Halos for Heroes Program sponsored by the PSFHS Foundation receives letters of recognition and donations in recognition of excellent care.  The Foundation celebrates these associates in front of their colleagues and leaders with a plaque, photo and reading of the letter. In 2011 Colleen Eisman RN was honored. The letter clearly demonstrates nursing inclusion and honoring family participation in this patient's care.   (EP4-14)

    6. Penrose 5 Renal/Diabetic Unit Practice Council implemented consistent, standardized bedside shift report (BSR). These were standardized because broad based evidence supports the claim that BSRs improve safety, communication, and the building of collegial relationships. A nurse who works in the unit Anna George, RN writes of the role that BSRs play in care planning:

    "BSR supports relationship based care as we introduce ourselves to the patient and family, collaborate on the plan of care for the shift, and clarify expectations among staff and patients.  Patients contribute to the nurse-to-nurse report and often remind us of pertinent information to pass on. BSR promotes positive communication between the two nurses, and supports self care through a clear transition of responsibility as well as providing information for the oncoming nurse to plan for their shift and effectively manage time without adding unnecessary stress." 

    The graph below reflects the improvement in "nurse listening" as rated by patients through our HCAHPS process. Bedside Report is a strategy to actively include patients and family members in care planning:



    Our nursing associates consistently demonstrate a partnership with patients, families and health care providers to provide exemplary care. This care is guided by best practices, which include patient and family involvement in the planning and delivery of care. Defined in our professional practice model and in our nursing standards of care, it is our hearts and minds that establish relationships, which are focused first on our patients. The stories and copies of documentation detailed in this source of evidence describe and demonstrate the effective use of our relationship based care model to involve the patient and family members in care planning and delivery.
    Involving patients in their planning and delivery of care can occur regardless of the age of the patient.

  • Exemplary Professional Practice - EP05

    Care Delivery System

    EP 5 How nurses use the Care Delivery System (s) to make patient care assignments that ensure continuity, quality and effectiveness of care within and across services and settings.

    A letter from a grateful family:

    "Nancy, you made a very deep impression as you cared for my father with such loving respect, dignity and grace. My mother and the rest of our family will always be grateful that you were my father's nurse, until he passed on October 20, 2010.  You are exceptional and the true epitome of the nursing profession.

    If I could share a little bit of our story… My father was 93 when he passed away.  He was a husband, a father of 9 adult children, grandfather of 17 and great-grandfather of 15; and is survived by a family of 60 people and many other friends and relatives.   On Sunday, October 17, my father was rushed from his home in Black Forest to St. Francis Medical Center.  He was treated in the Emergency Department and then transferred to the 5th floor of the hospital.  While on the 5th floor, he was primarily under the care of Nancy Cookson, RN.  She would enter his room with a smile and say her name.  While my father was quite alert and very conversational until the day he passed, Nancy would gently take his frail hand to begin her monitoring.  My father had very little strength and Nancy would lovingly help him to sit up so that she could place the stethoscope on his back.  On Monday, the 18th, all 9 children arrived from around the country.  Nancy could not have been more accommodating as she stepped around all of us to care for Dad.  Knowing he saw all his children, Dad's health began to decline and he allowed himself to begin to pass from this life to the next. All the while, Nancy remained respectful and focused on Dad's care and comfort and continued to treat Dad with dignity throughout the day. 

    Nancy, your care was touching to our family, as you could not have known what a tremendous man Dad was.  I remember the moment you turned Dad to his side to help ease his breathing and carefully caressed his back with baby powder to help him feel a little better.  You continued to soothe him as you monitored him and you treated all of us with care as we struggled through our grief.  You had infinite patience with all of us (my mom, my 8 other siblings, their spouses, and 2 grandchildren) as we crowded in Dad's room.  The family of my father, Francis E. Billiard, will always be grateful that you were the angel placed in my father's care. You are our hero."    

    Nursing's Role in the Care Delivery System:

    Our Nursing Professional Practice Model places the patient and family in the center of care, primary in our mind, as we deliver care. While relationship-based care provides the foundation for nursing care delivery, each unit operationalizes this priority differently. Acute care medical surgical units use modified team nursing with a charge nurse on each shift, with support provided by additional nurses and certified nursing assistants (CNA). A unit secretary serves for specific periods of the day and may also provide CNA services if competent in that role. Each RN and CNA is assigned to specific patients/family with assignments based on patient acuity, staff competency and prior assignments to support continuity of care. Specialty areas such as ICU, Labor and Delivery, Post Partum, perioperative services, and the Emergency Department utilize a primary care model in accordance to specialty nursing standards of care.

    Interdisciplinary Practices, Patient Assessment  Internal Policy number IDP A-04-m (EP5-1) states that, "An initial assessment shall be performed to determine the patient's immediate and emerging needs to direct appropriate assignment of care in the organization." Decisions regarding patient care assignments begin with patient placement on a unit/service with competent staff to meet the patients' acuity and treatment needs. The ultimate goal in making patient care assignments is to provide the highest quality of care to achieve the most optimal patient outcomes. Patient care assignments are based upon our commitment to quality and safety for our patients. The nursing staff is responsible for the coordination of treatment, medications, diagnostic testing, and implementation of the nursing process. Each member of the nursing staff is assigned clinical responsibilities based on educational preparation, licensing laws and regulations, and an assessment of current competencies.

    The Plan for Provision of Care is another structure that supports continuity and quality of patient care practices. PSFHS' plan for the provision of patient care is a policy that defines all areas where care is delivered. This policy refers to individual unit's provision of care plans that specify staffing guidelines for each patient care area. Every unit's provision of care plan department has defined populations served, hours of operation, services provided, staffing information, and the competencies that RNs and other staff need in order to care for the specific population in the individual unit or department. Following are excerpts from this policy, which address patient care assignments:

           K.  Utilization of Patient Care Areas:

    1.  Patients are admitted on the order of a medical staff member. All bed placement needs are the responsibility of the Bed Control Staff or the PSFHS Administrative Nursing Managers.  The bed control and administrative nursing managers work collaboratively with the physicians, physician's office staff, Patient Access, and the Emergency Departments to determine appropriate placement of all patients being admitted into our facilities. The Bed Control Staff and the Administrative Managers work collaboratively with the Clinical Nurse Managers or designees to place patients in the appropriate setting and to ensure the units have the required competencies to meet the needs of the patients.

    The provision of one level of care to patients throughout the PSFHS organization: Whenever a patient must be held in temporary bed location such as ED, PACU, etc., while awaiting an inpatient bed assignment (e.g. Intensive Care, Med/Surg), the nursing care will be adjusted to meet the needs of the patient.

    The charge nurse may consult with other nurses or bed placement in making decisions regarding patient placements. One structure to support this process is the Capacity Optimization Meeting, which occurs Monday-Friday at Penrose Hospital. Attended by the charge nurse from each unit, admissions, discharges, open beds, and staffing is reviewed. This meeting supports planning for the day and it is important for resource allocation. When the hospital is full to capacity, nursing leadership calls an urgent capacity meeting in order to set priorities, facilitate discharges, and plan for admissions from the OR and ED.  (EP5-2)

    Role of Documentation:

    Nursing documentation is an essential component in the communication process. This element directly impacts continuity of information, the quality of care, and patient outcomes (effectiveness of care). The use of our electronic medical record system (Meditech) supports communication across our system to improve the continuity of care, and it provides data for the evaluation of the effectiveness of care within and across services and settings.

    An important part of the Care Delivery System is the role nurses play in the monitoring of plans of care. An example is when patients who are receiving specialized wound care transfer to the outpatient Wound Clinic, the clinic nurses can review the inpatient plan of care interventions and outcomes as they continue care in an outpatient setting.  (EP5-3)

    Inpatient Services - Charge Nurses Describe Patient Care Assignments:

    The charge nurse from the previous shift makes the assignments for the next shift.  The patient acuity, continuity of care for the patient, and the skills of the nurse are taken into consideration when assigning patients.  The patients can request to have or not have a particular staff member care for them. The nurse can also request to care or not care for a patient. 

    Assignments that allow the same patient and nurse to work together are usually preferable to both parties; the mechanics of twelve hour shifts, however, decrease the frequency of a nurse's ability to partner in care over several days. On the other hand, the twelve hour shifts that are in place in most of our inpatient units allow for longer period of time for the nurse and patient to work together during a day and decrease the number of nurses that a patient/family works with during a twenty-four hour period. We recognize the value of continuity, and all units strive to assign the same nurse to the same patient when possible. The charge nurse may review the schedule from the prior day to assign the same nurse to the same patients, whenever possible.  (EP5-4)

    In helping to maintain documentation so that continuity can be achieved, each unit maintains a staffing matrix, commonly referred to as the "grid." The grid is a guideline for the number of staff needed and includes the charge nurse who generally does not take patients, except on the night shift.  The patients are then divided among the remaining staff (scheduled or "floated in") for that shift based on matching the skills of nurses with patient needs. Patients requiring specialty care are assigned to nurses who are proficient in that specialty. For example, intensive care nurses require special training prior to being assigned a post operative open heart patient. Certified nursing assistants are assigned to a group of patients or on some units to a nurse. The grid is maintained by the manager of each unit.  

    Even when all considerations are taken into account, there are instances when changes in a patient's condition result in need to change assignment or for staff to require help with their assignment. The charge nurse or other staff members, who may have more time assist the nurse, attend to the patient's care. Extra staff may have to be called in to accommodate an influx of admitted patients or due to changes in patient acuity. Nurses relieve each other for breaks and for additional support as demonstrated by the following quote:

    Krista Leisure RN, Float Pool wrote to share her experience on 11th floor.  "After report I realized how busy I was going to be and felt overwhelmed. I was assigned six patients and had to complete an admission assessment, assess and intervene with a patient who had a fever and another patient was reporting pain and her anxiety was increasing. Thankfully the charge nurse recognized my need even before I could ask for help. She jumped in to help me.  She is a strong team player and exemplary charge nurse."

    Inpatient Oncology Unit:

    The real-world implementation of the Care Delivery System requires clinicians who are willing to work together and to learn from one another to guarantee patient outcomes. The Oncology unit ensures only chemotherapy certified nurses administer chemotherapy.  (EP5-5)  The following story, from a nurse in the inpatient Oncology Unit, demonstrates the continuity, quality, and effectiveness of continual teamwork within our Care Delivery System:

    "My name is Carolyn Cusic, RN and I work on the oncology unit. We care for oncology patients who have any medical or surgical issues, as well as for chemotherapy. One patient had a radical vulvectomy with skin grafting that had dressing changes that were time consuming, meticulous, and had to be done several times per day. I was assigned to her and her graft was not taking well. I rounded with the doctor and observed him do the dressing change to make sure I knew exactly what to do. I took care of that patient for 3 consecutive days and the surgeon commented that my consistent wound care made a difference. Since then I have taught many of my colleagues to care for the unique needs of these patients." 

    Care Delivery Models: 

    Nurses strive for continuity of care through consistent patient assignments, individualized care plans, and effective handoff communication. Case Managers and Social Workers serve all patients by providing referrals and through the coordination of discharge planning in order to meet patient needs. Regardless of the patient assignment, teamwork is essential as revealed by the following example of nurses ensuring quality and the effectiveness of care:

    "I was working the floor one evening and had 4 patients and awaiting my 5th patient.  It was close to 1700, I hadn't passed out my 1700 meds yet. I was in the middle of giving one patient a blood transfusion when I got a call from the CNA telling me that I had another patient vomiting. Moments later, I got another call telling me that my Direct Admit patient was here and was in excruciating pain. A scary feeling crept up, and suddenly I felt extremely overwhelmed. I had spiked the blood and had a few more minutes to wait to make sure this patient was safe. The Charge nurse, Carolyn had passed on to the other nurses that I might need help. One of my teammates, a nurse, Sara V, looked at the Direct Admit patient's orders and came to me and told me that she had time to access the new patient's Infusa Port, start the IV fluids and initiate the PCA pain pump.  I knew that the patient was in pain, and relief swept over me. I was ever so grateful to Sara. Another nurse, Gail came to me and told me that she had time to do the "Admission" documentation for my new patient. I was astounded. I finished with what needed to be done with the blood and headed straight to the patient that was vomiting.  The patient stated that she was actually feeling a bit better, but I gave her an antiemetic and made sure she was cared for.  I was able to pass out my evening meds knowing that my new patient was in capable, caring hands with Sara and Gail. I then went to my new patient, completed the physical assessment and documentation knowing that all the patients' needs had been cared for. This is a reflection of caring leadership and teamwork, and the bottom line is that all the patients' needs were met in a timely manner. I am blessed and proud to work with such a caring and wonderful group of health care providers. You all are the BEST!" - Helen Ray RN BSN. Charge Nurse 11th Floor Oncology

    Perioperative Services:

    Surgery The Assistant Nurse Managers make daily assignments based on service lines. The aforementioned staffing matrix, the grid, identifies who is in what service at what time. Some nurses are competent in three service lines.  (EP5-6)

    All PACU as well as OPS pts are supported by all the PACU/OPS nurses.  There is a 2:1 ratio that is maintained in PACU and a 4:1 pre/post ratio is maintained in the OPS unit.  The number of patients assigned to a nurse is dependent on patient acuity. There may be some slight variation in staff assignments if we have someone just off of orientation that may need additional collegial support.

    Post Anesthesia Care Unit (PACU) Registered nurses accept the care of patients post operatively when they enter PACU. All RN's are competent to provide recovery care for all patients. While all are competent, some nurses have greater experience with certain procedures and may be assigned those patients first. For example, at SFMC, cesarean sections are usually done in the birth center. However, if a c-section is completed in surgery, some PACU nurses have more experience with this population and will take this assignment. If all PACU nurses are currently recovering a patient and a new patient arrives, the nurse with the lower acuity patient will take on the new patient. PSFHS addresses continuity of care, quality, and effectiveness by keeping the same nurse with the patient for their entire time in PACU. This decreases the chance of errors and it improves patient satisfaction. Patients on ventilators following surgery are transferred directly from surgery to intensive care in order to reduce the number of times equipment needs to be set up; this in turn improves patient safety and quality of care.

    Penrose Intensive Care/Critical Care Unit:

    The table and assignment sheet displayed demonstrate the practice to ensure patients admitted to Critical Care post open heart surgery are assigned to competent nurses.  ICU nurses need to demonstrate competency prior to this assignment. An example is provided below. It is demonstrative of the deliberate placement of particular skill sets with patients who are in need. Be sure to note the matrix identifying the ICU staff skills and how it relates to the daily need of the unit


    Pediatric Unit and Neonatal Intensive Care Unit:

    Pediatric patients and families receive care from an all RN staff. The Neonatal Intensive Care Unit (NICU) provides total patient care in a partnership between nurses and neonatal nurse practitioners. This improves patient outcomes as there exists a continuity of care between direct and advanced nurse practitioners.

    Nurse Case Managers:

    Case Managers are experienced nurses who assist in care planning and utilization review with insurers as they coordinate care across the system, facilitate with complex discharge planning, arrange specialized care as needed and effectively communicate patient information across the continuum of care.  (EP5-7)

    Infusion Center:

    Some patients verbalize a preference for a specific nurse.  The infusion center strives to respect patient wishes. (EP5-8)

    Nurse Counselor on the Inpatient Rehabilitation Center:

    Moving through a major transition in life such as a traumatic brain injury, stroke or serious accident resulting in paralysis can be eased through the services of a nurse counselor.  She works one or two days a week and is available for follow up contacts during a patient (and family) rehab process.  (EP5-9)

    Emergency Department:

    Our emergency department's nurses triage all patients and provide care based upon patient need.  As we are committed to providing privacy and safety for patients with mental health and substance abuse needs, our Penrose Emergency room includes an area next to the main emergency room with locked access. These patients are assigned to both emergency room nurses and psychiatric nurses during their ED stay. This collaborative practice provides quality care for patients with primarily behavioral health needs. Supported by internal experts, the Psychiatric Emergency Treatment Team evaluates patients for mental health holds or emergency commitment and coordinates appropriate discharge placement or referrals.   Ensuring staff are clear about their roles in the ED improves patient flow and safety.  (EP5-10)

    Efficacy and Effectiveness Review Process:

    1. Nurse sensitive quality indicators
    2. Patient Satisfaction
    3. Nursing Satisfaction
    4. Cost/Productivity

    For example, 5N Surgical at SFMC assigns patients based on acuity, proximity, and matches with staff preferences and competency. One night nurse received a DAISY award in part based upon comments from her colleagues:

    "Kandy recently took care of a patient who had "fired" several nurses. Kandy was very successful in taking care of this patient. She spoke of how anxious the patient was about her pain resulting in frequent requests. Kandy was calm and reassuring with this patient.  Kandy is a great example of how to be positive with patients and staff and is always ready to lend a helping hand."  (EP5-11)

    The effectiveness of the care delivery model, relationship based care and modified team nursing, is evident in considering these four factors.

    1. Nurse sensitive quality indicators - fall rates and zero use of restraints provide evidence of quality of care and effectiveness.

    2. Patient Satisfaction ratings provide data to support effectiveness of the care delivery model and patient assignment process.


    3. Nursing Satisfaction as reported by the Practice Environment Scale shows improvement in all three areas from 2009 to 2011.


    4. Cost/Productivity is always a challenge especially in light of the treatment of extended recovery patients. However, this unit averages 94-96% with a targeted goal of 100%.


    Pikes Peak Hospice and Palliative Care and PSFHS have a strong working partnership at the business level and the carelevel.  The attached letter shares the positive and grateful perspective on caring for patients across multiple settings.  (EP5-12)


    Nursing demonstrates a commitment to high quality and safe patient care through care assignments that facilitate continuity across shifts and settings. Quality and effective care occurs through appropriate patient placement for services and patient assignments which match the acuity and clinical needs to expert, competent nurses. Throughout our facilities and units, our nurse leaders maintain knowledge of the expertise of their nurses and they apply that expertise in the targeted clinical setting. Nurses use the Care Delivery System to ensure quality patient outcomes by keeping a diligent watch over the ever changing patient landscape.

  • Exemplary Professional Practice - EP06

    Care Delivery System

    EP 6 How regulatory and professional standards are incorporated into the Care Delivery System (s).

    Each nursing unit creates a Provision of Care plan describing that unit's structure, process to meet the unique needs of patients, the types of health care workers providing nursing care, staffing, scheduling plans, and quality outcome priorities. This document is reviewed annually and is revised as needed. Guiding the scope and goals of these documents are regulatory and professional standards. In order to demonstrate the process by which these standards are incorporated into our Care Delivery System, we must define regulatory standards, our professional standards, and our Care Delivery System. 

    Regulatory Standards:

    Nursing practice within the state of Colorado is regulated at the federal, state, and local levels. Nationally, there are no less than fifteen executive agencies which enforce regulations in the health care field.  These agencies interpret legislation and provide hospitals around the country with ever evolving standards. At the state level, the Colorado Nurse Practice Act determines the scope of nursing practice and defines the boundaries for the delegation of authority. The delivery of care methodology at Penrose-St. Francis Health Services is consistent with state and national standards of nursing practice, the underlying philosophy of the Division of Nursing, and national accrediting bodies.  For example our RNs and LPNs function within the limits of the Colorado Nurse Practice Act and  Certified Nursing Assistants, Mental Health Workers, and ED Techs function by delegation from the Registered Nurse as described in their in our policy.  (EP6-1)

    Professional Standards:

    The American Nurses Association, the foremost organization for professional nursing standards in the USA, has prolifically produced definitions and classifications for scopes and standards of nursing practice. PSFHS uses these guidelines in every nursing department. In units of specialized care, the professional recommendations of professional nursing organizations are also employed. For example, in our Birth Center, Association of Women's Health, Obstetric and Neonatal Nurses provides professional standards to guide this specialty practice.   In the fall of 2011, the Centura Health statewide OB Meditech Sub Group requested changes to OB interventions to address regulatory changes.  (EP6-2

    Care Delivery System (CDS): 

    The care delivery system at PSFHS is integrated with our professional practice model and is based on relationship-based care. The overall system for care delivery on the inpatient medical and surgical units is a modified total and team based patient care.   Nurses on these units are responsible for patient care to their assignment patients for the shift.  Certified nursing assistants provide patient care in collaboration with several nurses.  The Critical Care/Intensive Care units provide total patient care.  Staffing and scheduling assignments are based on nurse competency and patient needs and our relationship based care philosophy.

    How Regulatory Standards are Incorporated into Care Delivery:

    Once new regulations and standards come into effect, PSFHS integrates the changes. Individual units are responsible for designing their own care processes within the confines of overarching regulations and standards. Changes to procedures also occur due to shifts in accepted medical practices. New literature frequently emerges detailing the connection between lower nurse to patient ratios and the resulting: improvements to patient outcomes, the reduction of medication errors, and increases in patient satisfaction. Our CNO or other nursing leaders routinely forward information to clinical managers regarding these studies and determines ways we can implement such measures.  (EP6-3) The following is a segmented demonstration of how regulations and standards are implemented into the PSFHS care delivery system.

    Colorado Nurse Practice Act

    • The Colorado Nurse Practice Act is available online from all computers used by nurses.  This enables nurses to be able to access the most updated legislation at will and for them to be able to quickly locate relevant material within the Act.  The Act is also linked through the PSFHS Professional Nursing Intranet site.
    • The Clinical Manager is accountable to complete primary verification of licenses for all nurses.
    • Continuing education is not currently required as a condition to renew licenses, however, PSFHS nursing units identify specific continuing education requirements. (EP6-4)
    • Grounds for discipline is reviewed in the context of decision making to report a nurse to the State Board of Nursing.  (EP6-5)
    • Implementation of models of care: Virtually every nurse action that falls within organizational rules is a form of the implementation of the CNPA. For example, LPNs are used in the medical surgical areas; the scope of practice and rules of delegation created by the CNPA ensure the care delivered by LPNs and CNAs are followed.

    Regulations from Agencies

    • We incorporate the results of a variety of regulatory agencies into our care delivery system. These regulatory agencies include The Joint Commission, Centers for Medicare and Medicaid, Occupational Safety and Health Administration and others. In addition nurses participate in committees and work groups that evaluate practice compliance with regulations. Nursing senior leadership and clinical managers are standing members of the Accreditation Readiness Group (ARG). When new information is available from regulatory agencies, ARG members are informed and expected to review policies for needed changes and communicate requirements to direct care nurses at the unit level.   

    • Ongoing audits and monitoring of care delivery is reviewed at unit and department level for compliance with regulations.

    • Nurses work in multiple areas related to quality and regulatory compliance at PSFHS.  Heidi Baird, MSN, RN is the Regulatory Coordinator for PSFHS.  Revenue integrity includes multiple nurses who serve as clinical auditors.  Within Clinical Effectiveness, nurses in infection prevention, patient safety and risk management are expert resources to clinical nursing leadership and practitioners to support a care delivery system that meets regulations. For example, infection prevention nurses make rounds and provide education and direction to reduce risk of infection transmission.  (EP6-6)

    • Evaluation of models of care: Unit staffing matrixes are utilized in all inpatient units; these matrixes are developed based on current national standards of practice and internal patient care delivery systems. Further evaluation occurs through the examination and analysis of staffing data and nursing quality indicator data. 


    • Direct care nurses are educated about other regulatory documents through three venues: Heidi Baird MSN, RN (our Regulatory Readiness Coordinator), unit rounding, and formalized education. Each nursing unit is presented with detailed regulations coupled with learning tools to understand those regulations. Further, each nurse is given pocket guides and other quick reference tools that address regulations and how those regulations affect their practice.  (EP6-7)


    • The Joint Commission identifies the need for an organization to determine and implement timeframes for reassessment of the effectiveness of pain medication.  The PSFHS policy was been reviewed and revised to clarify requirements to meet this regulation.  In addition the functionality of the electronic medical record has been revised to automatically notify the nurse of the time the reassessment is required.  (EP6-8)

    How Professional Standards are Incorporated into Care Delivery:

    Staffing Since Colorado does not have mandated staffing ratios, we rely upon the various professional standards that are advocated by professional nursing organizations. Based on national trends and professional organizations' recommendations/standards, PSFHS maintains staffing ratios to best meet patient care delivery & safety concerns. The following data presents different PSFHS nursing units, the patient to nurse ratio, and the organization whose standards were adopted to meet said ratios:

    i. 4:1 ratio of patient to nurses in pediatrics (AAP)
    ii. 4:1 mom-baby couplet ratio (ACOG/AWOHNN)
    iii. 4:1-2:1 ratios in NICU depending on patient acuity (AAP)
    iv. 2:1-1:1 Labor & Delivery ratios (ACOG/AWOHNN)
    v. 2:1-1:2 intensive care patient ratios (AACN)
    vi. 4:1-7:1 patient ratios in medical-surgical areas
    vii. 1:1 patient ratios in OR and for patients undergoing moderate sedation
    viii. 4:1 patient ratios in ED (ENA)
    ix. 2:1-1:1 patient ratios in post anesthesia care units depending on acuity (ASPAN)

    In addition nurse staffing is analyzed through nursing hours per patient day and our inpatient units are benchmarked through a national database.  Regardless of professional organization standards and national benchmarks, the charge nurses on each unit are supported to adjust staffing based on acuity and patient safety needs. 

    Restraint Use Regulatory agencies, professional nursing standards and the Code of Ethics for Nurses address use of restraints.  Ensuring patient dignity, respecting patient rights, providing patient safety through ongoing assessment, individual interventions and reassessments form the basis for use of restraints.  PSFHS discontinued the use of vest restraints two years ago.  We use specialty "mesh" beds and soft wrist restraints when needed on our medical surgical and intensive care units.  Our polices reflect the regulatory requirements and monitoring for compliance occurs through audits, shift reports and trending use for reporting and benchmarking through a national database. (EP6-9)

    Professional Standards and Code of Ethics:

    Our professional standards of practice and code of ethics hold nurses accountable to practice with compassion and respect for human dignity. The ANA Code of Ethics for Nurses, Provision 2 states "the nurses' primary commitment is to the patient".   The nature of nursing practice has an inherently personal component as evidenced in the story below.  Passes for a patient to leave the premises during an acute inpatient hospitalization are restricted for safety and regulatory reasons. (EP6-10)

    In this situation, nursing advocated for the patient and coordinated a special pass for this dying man:

    PH 5 Renal/Diabetic We've all heard that man's best friend is his dog.  Michael was a long-term dialysis patient that we had been treating for many years.  Michael was a 3 times a week dialysis patient that had made the decision to stop dialysis after battling kidney failure for many years. This decision was a difficult one, which obviously affected Michael and his wife, but also the staff of my floor whom had cared for Michael. But after making this tough decision Michael had one wish- to see his dog "Gizmo" just one more time in his own home.

    I worked the 7p-7a shift and was just getting off of work when I saw my manager looking through policy. This is when I learned about Michael's final wish. My manager was determined to make this happen and was looking through policies and regulations. I told Melissa that I would go with Michael and that I would have him back within the 3-hour window his doctor had given us. So we lifted Michael into a wheelchair, wheeled him to his daughter's minivan, and were off on our road trip to Michael's house!

    Ten minutes later we arrived at Michael's house and found his family, and little Gizmo, waiting for him outside.  I will never forget the look on Michael's face when he got to hold his dog again. There were tears in his eyes, which as you can imagine, caused the rest of us to tear up! Michael spent the next few hours sitting on his back patio with his little dog Gizmo in his lap. Michael died a few days later but not without having his final wish fulfilled.  An experience that many of us will be talking about for many years to come and one that I am thankful to have been a part of… Lori Bird, RN (November, 2010)


    The legal and regulatory guidance contained within the Colorado Nurse Practice Act makes up the backbone of overall nurse practice at PSFHS. This connection can be easily identified through just a cursory examination of our internal policies and procedures. Additionally, the standards of professional organizations provide us with a professional framework and best practices to improve outcomes.  Both are crucial to the efficient operation of our hospitals and both are routinely incorporated, examined, developed, and implemented in our nursing units by our nurses.  Regulatory standards from multiple agencies are incorporated into the Care Delivery System through policy, demonstrated through practice and monitored through audits, rounding and external agency surveys.

  • Exemplary Professional Practice - EP07

    Care Delivery System

    EP 7 The structure (s) and process (es) used to engage internal experts and external consultants to improve care in the practice setting.

    We know that we are better as a team then as individuals; during Nurses Week 2012, we celebrated these community relationships during a program entitled "Nurses Connected!" Relationship based care encourages the building of effective, positive relationships among the entire healthcare team to achieve the best outcomes for our patients and families as well as to create a healthy work environment for us all.

    Internal Experts:

    Structures for internal experts to improve care PSFHS employs Clinical Nurse Specialists, Nurse Practitioners, and other nurse experts throughout the organization. PSFHS recognizes the value of employing experts who support patient care through direct contact or through consultation to the healthcare team. In addition these experts provide education and mentoring as well as advance nursing practice through EBP implementation and research. For formal nurse internal experts, position descriptions identify responsibilities of advance practice nurses and "resource" nurses.  (EP7-1)

    Process for using internal experts Internal experts are accessible on the units, through education classes, via phone or email. In addition, nurse consultations may be ordered through our electronic health record.  Nurses or physicians may seek consultation through formal means such as orders or informal calls. Many internal experts carry pagers or phones to improve timeliness of response.

    The following positions/disciplines provide internal expert consultation:

    • Clinical Nurse Specialists
    • Pain, Palliative Care
    • Intensive Care, Medical Surgical
    • Oncology
    • Lactation Specialists
    • PICC/VAT Nurses
    • Informatics Nurses
    • Stroke Coordinator
    • Diabetic Educators
    • Therapy Specialists
    • Nurse Practitioners
    • Spiritual Care Team
    • Code Teams
    • Rapid Response Teams    Psychiatric Emergency Triage Team
    • Skin Wound and Burn nurses
    • Ethics Consultants
    • Finance and Revenue Integrity
    • Values Based Analysis
    • Security
    • Nurse Navigators in the Cancer Center
    • Pharmacy
    • Infection Control Preventionists
    • Patient Safety/Risk Management
    • Trauma

    Internal Nursing Experts:

    Daily interdisciplinary rounds on our Intensive Care Unit improves communication and patient care planning. Physicians, nurses, respiratory therapy, spiritual care, palliative care clinical nurse specialist, dietary, physical therapy, case managers, and other team members review the patient's progress toward goals and makes revisions based upon changing patient needs. Rounds address current, potential, and upcoming issues including discharge planning. They also provide a venue for education. Evidence based practices and recent research are discussed and integrated into treatment plans to improve patient outcomes. The Palliative Care CNS provides treatment recommendations and follows up with family members when indicated.

    Infection Prevention nurses make daily rounds as well as respond to calls or pages.  After reviewing lab results each morning, they follow up as indicated on each unit.  In addition, they stay current on evidence based practices which are discussed in the multidisciplinary Infection Control Committee.  When a research study included issues with infection control, the primary investigator sought consultation with IP who contacted the Centers for Disease Control and Prevention.  (EP7-2)

    Nurse Navigators in the Cancer Center coordinate care, provide support and education to patients and families.  Nurses on the inpatient oncology unit refer patients to these experts and can call them with any questions on services.  (EP7-3)

    Pain Nurse Specialist rounds on Pain Service patients Monday-Friday mornings.  During this time, the nurse rounds on patients, consult with physicians and nurses to improve patient pain management. In addition, the Pain Specialist provides monthly education to nurses on evidence based practices, new medications and case consultation.  The PSFHS Values Based Purchasing Model reports outcome improvement from 70.2% to 73.3% Top Box Pain Management. (HCAHPS report through HealthStream).  (EP7-4)

    Wound Care Nurse Specialists provide direct patient care on all units, educate nurses and physicians and serve outpatients through the Wound Clinic. They can be accessed by phone, pager or consultation order through the electronic record. Pressure Ulcer prevalence is impacted by the expert education and consultation these nurses provide.   (EP7-5)

    Patient and family health teaching is integral in all care plans. Nurses coordinate with experts to provide detailed education around diabetes, dietary requirements, or other individual needs.  A diabetic educator nurse meets with those in the inpatient units and they are available for outpatient services following discharge. The nurses on our Mom/Baby unit partner with lactation nurse specialists to support effective lactation. In both situations, the assigned unit nurse requests services from other nurses to improve the quality and effectiveness of care during the inpatient stay and post discharge.  Following nursing practice changes implemented on the Mom Baby Unit, the breastfeeding initiation rate has improved from 81% in summer of 2010 to 94.5% in December 2012.  (EP7-6)

    The Behavioral Health Psychiatric Emergency Triage Team (PETT) are available 24 hours per day for consultation when patients are seen in the emergency departments at Penrose Hospital and St. Francis Medical Center and are determined to have a psychiatric illness or a chemical dependency problem. In addition, these evaluators will consult with staff regarding behavioral health patient needs on the unit. 

    Trauma Nurses Lenora Kraft, RN, PH 9 Surgical was recognized for her leadership in improving trauma services on the 9th floor. This was accomplished by connecting the trauma staff with nurses throughout the organization. By reaching out to other nurses the policies and nurse expertise can be more nuanced and prepared. "The trauma staffs are the experts. We can call them anytime. Trauma education had been offered in the Emergency Department but frequently nursing staff from the floors couldn't attend. The trauma staff agreed to offer similar education focused on post surgical trauma care management to the floors. We host this monthly on 9 and invite all the floor nurses to attend. We also send nurses to our annual Trauma Symposium for professional development." 

    PSFHS employs an internal process that allows for the rapid sharing of internal expertise across different units when needed. The following examples demonstrate consolation and cooperation across our health system that speaks directly to positive patient outcomes:

    Nurses in Labor and Delivery partner with ICU nurses "In 2011 we had a pre-term patient admitted to LD who was suffering from a severe asthma attack. This patient ended up being treated in ICU after a couple of days on the LD unit. This required continuous fetal monitoring by an obstetric nurse in the ICU. I was assigned to this patient on the day she delivered.  An attempt at extubating had been made, but the patient failed this trial. There were consultations between the intensive care doctor and perinatologist on several occasions that morning. The patient was delivered via cesarean section at 1300.  As an L&D nurse, not an ICU nurse, the ventilator made me very nervous just as the electronic fetal monitor made the ICU nurses nervous. We were able to work together in our expert roles for the good of the patient. We shared our experience with each other which resulted in a good outcome for the patient and baby."   Nancy Steele RNC-OB    (EP7-7)

    GI Lab When SFMC decided to open a GI Lab, nurses from SFMC engaged the Penrose GI nurse experts for training in patient care, nursing standards, equipment and patient flow. Vicki Jack Blue, RN, SFMC, GI Lab coordinator stated "it really helped to train at Penrose prior to opening our lab. The nurses are experts and I can continue to contact them if I have questions." 

    Nursing Educators provide and coordinate the initial new nurse orientation and other professional development opportunities.  Education Department, Unit Educators and Clinical Nurse Specialists partner to provide education to support nursing practice. CNS's assist at the bedside as well, in order to address competency issues or to provide support for challenging situations. All educators can be accessed through phone, email, or during unit rounding.  Education provided by these educators in 2012 is demonstrating an improvement in "Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2".  Our baseline data for the Values Based Purchasing Model was obtained Apr-Dec 2010 with a 80% compliance with this measure.  Following the education in 2012, our FY2013 Year to Date performance is 88.38%, an improvement of over 8% in outcomes based on an improvement in nursing practice.

    The Nurse Scientist provides expertise to nurses interested in EBP implementation and nursing research.  She is a member of the Nursing EBP/Research Council and is also contacted through emails and phone calls.  When two professionals contacted the IRB about submitting a research study that will invite nurses to participate as research subject, the IRB Coordinator immediately called the Nurse Scientist and referred these professionals to her for assistance with study proposal and implementation. (EP7-8)

    Administrative Manager staffs the hospital on evenings, nights, weekends and holidays.  Making rounds, they assist and consult on a full range of patient care issues.  Challenging or complex issues, death and donor situations, staffing challenges and other situations are effectively managed with their expertise. The Administrative Manager can be accessed through phone or pager. (EP7-9)

    Departmental Resources:

    Spiritual Care staff are available 24/7 making unit and patient rounds, and offering the expertise in counseling and spiritual support.  Nurses can access a chaplain through a phone call, pager or during rounds.  Spiritual Care respond to all Code Blues in the hospital and are thus immediately available in these crisis times.

    Clinical pharmacists are assigned to each floor and provide education and consultation during rounds. In addition, nurses call pharmacy with questions and concerns regarding medications and side effects and receive timely responses.  The clinical pharmacists also provide anticoagulant and antibiotic consultations to physicians.

    Dieticians provide expertise on patient nutritional needs.  Dieticians round on units and are also available by phone or pager for patient care questions. 

    Therapies are available by phone or order consultation. Therapists are assigned specific patients and units where they provide direct patient care as well as respond to nursing or physician questions.  PH8 Rehab therapists provided education to all nursing staff related to stroke patient positioning in 2012. 

    The Rapid Response is accessed through a phone call and immediately available to nursing or any patient/family member.  Designed to assist in the treatment of a deteriorating patient on medical/surgical floors, these nurses provide phone consultation as well as immediate response to the patient room.  Nurses from PSFHS participated in a research study on the use of Rapid Response Teams; results will be evaluated for possible nursing practice changes in 2013. (EP7-10)

    External Experts:

    Structures for external experts to improve care The utilization of external experts occurs through a contracting process. Identification of specific needs and an examination of internal resources occurs first.  Nursing leaders work in collaboration with the CNO and Chief Financial Officer to approve budgeting money and ensure the selection process and contracting meet requirements.

    Processes for external experts to improve care Our relationships with Centura Health and Catholic Health Initiatives provide expertise to support changes within our practice. Within the formal evidence based practice/quality structures in Centura Health, our associates participate in practice areas.  For example, the Birth Center Clinical Effectiveness Group was co-chaired by our Clinical Nurses Specialist, Candace Garko, RN. Olinda Spitzer RN, CNS, participates in intensive care clinical teams. By engaging in these teams we have both shared our internal clinical experts and gained through external expertise.  The recent catheter associated urinary tract infection practices, for example, have been revised -including the development of toolkits that will facilitate the implementation of evidence based practices.

    The following narratives provide examples of engaging with external experts to support professional development and practice changes. In each of these cases our goals focused on changing structures and processes to improve patient care outcomes. 

    Nursing Professional Development in Research The EBP/Nursing Research Council engaged external experts in order to promote the development of our nursing research structure and process. (EP7-11

    PSFHS contracted (2009-2011) with Janet Houser, PhD. For facilitation and advice in the development of a EBP/Research Nursing Council.  Dr. Houser met with Council members and interested nurses, providing education and examples of structures and processes to use as we advanced our EBP/Research program. At the time of her consultation non-Ph.D nurses were not participating in any nursing research.  During the last two years our nursing practice has improved to include nursing research at unit and national levels as well as multiple EBP projects including implementation of bedside shift report, hourly rounding, pain management strategies and hospital acquired infection prevention.  (EP7-12)

    Deb Kenny PhD, RN, FAAN from the University of Colorado's nurse department, participates in the PSFHS Professional Development Council and the EBP/Research Council. Dr. Kenny provides formal and informal education, coaching and mentoring. Rochelle Salmore, MSN, RN stated that, "I appreciate Deb's help with clarifying our PICO question for the pilot project on chronic pain patients."  Dr. Kenny also assisted Deb Nussdorfer, MSN, RN, NE-BC with data analysis on a 2012 Green Zone Research project which increased nursing time with patients. Further implementation and study is planned in 2013.

    Nursing Professional Development in Leadership Nursing leader retreats have included presentations from external experts. When the nursing leadership team identified needs for education and professional development for nursing leaders, we sought outside experts in that field. In the past three years we have engaged expertise related to shared decision making, relationships, leadership skills, and building a healthy work environment. Jill Clark, BABS, Executive Administrative Assistant has been instrumental in coordinating contracts with these people in order to meet the educational goals set by the leadership team. The following are some of the experts brought in to engage and educate nurse leaders:

    • Judith Briles, DBA, MBA
    • Dale Smith Thomas, CEO, "WINNERS BY CHOICE"
    • Tim Porter-O'Grady, DM, EdD, ScD(h), APRN, FAAN
    • Vicki George, PhD, RN  (EP7-13)
    • Laurie Kennedy, Director of Learning and Leadership, Centura Health
    • Kathleen Bartholomew, RN, MN  (EP7-14)

    The utilization of external experts in order to promote professional development among nurses has been successful. This is evidenced by the promotion rate among internal nurses. In the past two years, nine of eleven clinical manager positions have been filled through internal nurse promotion (SFMC 5S Medical/Cardiac, Labor and Delivery, NICU, Float Pool, PH ED, PH 11 Oncology, SFMC 5N Surgical, PH 5, Infusion Center).  The improvement in nursing satisfaction ratings can partially be attributed to improvements in nursing leadership.  The Press Ganey Associate Survey RN results in 2012 demonstrated "Direct Management" outperformed the national benchmark (PSFHS 72.9 vs.  HSTM 67.8).


    Our organization actively seeks the input of both internal and external experts. Internally, our nurses informally seek the expertise of those who understand a specific problem. Our formal relationship with Centura Health and with Catholic Health Initiatives increases this pool of internal experts immensely. Externally, experts are sought who provide education and consultation. Speakers and presenters are brought in by PSFHS to address specific gaps ranging from motivation to professional development. Experts are sought and utilized by nurses at all levels and settings at PSFHS to improve care in the practice setting.

  • Exemplary Professional Practice - EP07EO

    Care Delivery System

    EP 7 EO Two improvements in the practice setting that occurred as a result of the use of internal experts or external consultants.

    Internal Experts - Palliative Care:

    Background/Purpose In 2006, Centura Health made the decision to provide palliative care within their facilities. Nurse leaders from Centura facilities served on several committees (including clinical, marketing, education, and finance) to develop the components of a hospital-based palliative care program. In 2007, PSFHS hired a full-time Palliative Care Advanced Practice Nurse (APN) to develop and implement palliative care at our hospitals. In 2009, Penrose Community closed and patients were transferred to the newly constructed St. Francis Medical Center (SFMC).  

    The Palliative Program expanded in 2011-2012. The goal was to increase palliative care consultations and the presence of  advance directives or medical durable power of attorney documents on critically ill patient medical records.

    Methods/Approaches Centura Health adopted an APN led palliative care model. Implementation of the model at PSFHS has the aforementioned Advanced Practice Nurse (Ginny Davis, RN) leading the team, which is designed to be comprised of a part-time Medical Director, a social worker, and a chaplain. PSFHS's full-time APN was the only member of the palliative care team for a number of years. A part-time medical director was added in 2010, but resigned her position within 9 months due to issues unrelated to the program. A part-time (0.5 FTE) social worker was added to the team in 2011, and was increased to 0.8 FTE in 2012. In addition to the palliative care team, chaplains assigned to each unit provide additional spiritual support. In 2012, a second full time advanced practice nurse was added to the Palliative Care/Pain team.

    The palliative care program initially started in the intensive care unit of Penrose Main Hospital and quickly expanded to the medical units as patients were transferred out of the ICU. Palliative care service was limited in the program's initial years, due to the realities of having a single APN to cover two hospitals. As a result, palliative care was provided through a process which was initiated through a written consult. When the new St. Francis Medical Center was opened, palliative care continued responding to written consults; however, with the hiring of a part-time social worker, the palliative care team started to focus on expanding the services at St. Francis by attending interdisciplinary patient rounds, providing education, and communicating consistently with the case managers to identify appropriate patient referrals. Palliative care consults have continued to increase at both hospitals.

    Education Palliative care education is provided through participation in ICU daily rounds, formal consultation, and during all ASCENT New Graduate Nurse Residency Programs. In addition, palliative care participation in the Ethics Committee provides informal education opportunities and collaboration. The Ethics Committee identifies a decrease in Ethics Consultation requests with the increasing presence and expertise of Palliative Care Nurses.  The Palliative Care Nurse provides education to the Ethics Committee.  ( EP7EO-1 )

    Volunteer Program The "No One Dies Alone" program was initiated in late 2009 to provide companions for patients who are dying in our facilities. Our Chief Nursing Officer charged the Palliative Care Team with the development and implementation of this program. Our palliative care advanced practice nurse, in collaboration with spiritual care and the volunteer service designed this program after a similar one in Oregon. In 2010-2011 the palliative care nurse mentored the volunteers so they could take on increased responsibility for the program. In 2012, the leadership for "No One Dies Alone" was transferred to the Volunteer Department. The Penrose-St. Francis Volunteer No One Dies Alone Program received the Colorado Association of Healthcare Auxilians/Volunteers Recognition Award (CAHAV) 2012 Recognition Award at the annual CAHAV Convention. PSFHS received a plaque as well as a $500 award to honor this program.  Any member hospital in the state of Colorado has the opportunity to submit their program for recognition and only one award is given annually.  ( EP7EO-2 )

    The Volunteer NODA Program provides volunteers to sit with a patient around the clock when they have been identified as being within approximately 72 hours of death. This program is particularly directed towards those who do not have any family available to be with them. The volunteers will take shifts to be with these patients. They may play soft music, sing, read, hold their hand, or sit quietly and just be present with them at that time. There is no other program like this currently in the state of Colorado.

    Advance Care Planning The Palliative Care Clinical Nurse Specialist introduced the goal to improve presence of advanced directives on medical records to the Critical Care committee and trauma group who agreed to do the pilot. An audit tool was created and used and continues to be use during interdisciplinary ICU rounds.  (EP7EO-3 )


    1. Centura Health nursing leaders in initial program development 
    2. Virginia Davis, MSN, CNS, APRN, Palliative Care Nurse at PSFHS 
    3. Kate McCord, MSN, RN, NE-BC Chief Nursing Officer, PSFHS 
    4. Inpatient unit associates at Penrose Hospital and St. Francis Medical Center 
    5. Nurse Case Managers 
    6. Nurses and physicians throughout PSFHS (primarily serving in Intensive Care, Critical Care, Medical and Surgical Units)


    Outcomes reviewed in PSFHS Ethics Committee Meeting. ( NK7EO-4 )

    1. Increasing utilization of palliative care consults supports our goal to provide patient and family education on palliative care, end of life options, and emotional support designed to facilitate patient/family choice. Further, this type of care is used to collaborate with other healthcare providers in treatment care planning and delivery. The graph below depicts a trend of increasing referrals to palliative care from both hospitals. Between 2010 and 2011, overall consultations increased 22%, meeting the goal to increase consultations.


    2. The graph below demonstrates the increasing consult focus on goals of care, advance care planning and hospice. Advance Care Planning has increased 45% over three years. Goals of Care and Hospice Discussions have increased 17%-18%.


    3. The growth of the palliative care program has resulted in increasing referrals to hospice and palliative care services at home, specialty residential treatment, and skilled nursing facilities.  Discharge to residential facilities increased 29% over three years and discharge home or to a skilled nursing facility with palliative care increased 60%.


    4. Increasing presence of Medical Durable Power of Attorney or Proxy Decision Maker forms for patients.

    The Palliative Care team is focused on increasing the number of vented, sedated, unstable, and confused patients that have a Medical Durable Power of Attorney or Proxy Decision Maker form on their chart by day five of their hospitalization. Although patients/families are asked about whether they have a Medical Durable Power of Attorney (MDPOA) form, most patients in the ICU do not. Colorado law outlines a process of designating a Proxy decision maker if there is not a MDPOA. There are times when vented/unstable/confused patients take a serious and quick turn for the worse, requiring a legal decision maker to address code status, intubation, etc. When there is not already a designated MDPOA/Proxy, then precious time is wasted in trying to identify who is to make these life and death decisions. The palliative care team decided to address these situations by developing this pilot program in order to identify legal decision makers early in the ICU stay, in order to ensure that there was a clear, legal decision maker should important decisions need to be made. 

    The pilot program was initiated in July 2011. At that time 18% of patients in ICU who were unstable or on vent had a documented MDPOA/Proxy by day five of their ICU stay. In March 2012, over 80% of the ICU patients who are vented/unstable have a documented MDPOA/Proxy by day five of their ICU stay. The pilot program increased the percent of unstable/vented ICU patients with a MDPOA/Proxy from 18% to 80% demonstrating a significant change in practice. The goal to increase presence of MDPOA or advanced directives on critically ill patients was met.  


    The Palliative Care Program and consultation provide a strategy to introduce patient/family and healthcare providers to the benefits of palliative and hospice care, including the range of expertise and resources available. In addition, consults can support advance care planning to include an exploration of treatment alternatives. Consultation helps illuminate the range of treatment care options available and in so doing, enables the patient and family to make an informed choice about whether to pursue extraordinary means to extend life or use other care resources.  In addition, palliative care services demonstrate our commitment to the ANA Code of Ethics for Nurses as we practice with compassion and respect for every individual and support the right to self determination as we secure informed consent from our patients.

    Using a multidisciplinary approach, palliative care collaborates with other providers to promote quality of life and patient choice as we integrate the psychological and spiritual aspect of care with the physical health needs.

    During the last three years this internal expert advanced practice nurse and the Palliative Care Program has met the program goals:

    Increased the number of referrals

    Increased the disposition of patients to include hospice and palliative care services

    Expanded number vented/unstable ICU patients who have a MDPOA/Proxy Decision Maker

    Initiated No One Dies Alone program including training volunteers to lead the program


    External Consultants and Construction - Penrose Emergency Services

    PH Emergency Department (PH ED): Consultant Recommendations and Construction Remodeling Promotes ED Practice Changes (Greeter Mode and Vertical Treatment) and Improved Outcomes


    In 2011 Blue Jay Consulting was hired to evaluate and make recommendations to improve Penrose Emergency Services.  After speaking with multiple staff members and spending time throughout each shift observing, the consultants reported the department was functioning at an "acceptable level" with adequate bed capacity for current volume but the "flow through the department was not always streamlined".  Blue Jay Consulting identified the need for change based on the entire process and with clear staff involvement and accountability.   ( EP7EO-5 )

    The measurable goal for the PH ED based on recommendations from the Blue Jay Consulting Group were to improve throughput as measured by times between 
    • Receive to triage 
    • Receive to treatment 
    • Receive to physician

    Methods and Strategies:

    Prior to Blue Jay Consulting nursing staff were actively involved with the PH ED Construction Remodel project. In 2011 and 2012 the Penrose Hospital Emergency Department completed a major multi-year remodeling project. The staff collaborated with the construction and safety teams to ensure patient and staff safety during the remodel.  Blue prints were designed with staff input with a focus on patient flow, adequate storage and communication flow. The construction remodel was in alignment with PH ED practice and performance improvement planning to address the recommendations made by Blue Jay Consulting.  ( EP7EO-6)

    In July 2012, the PH ED had a Grand Re-Opening Day.  While the department did not change locations, it had undergone a complete remodel and facelift. The changes included an increase from 27 to 31 private room beds and a unique pod design to improve efficiency.  ( EP7EO-7 )

    The final remodeling phase included two designs based on provider input that supported two major practice changes: Greeter Mode and Vertical Treatment.

    A Performance Improvement Committee was created to change practices based on Blue Jay Consulting Recommendations. This team met frequently as they evaluated their practices and processes and used the construction changes to improve patient throughput.

    Greeter Mode In January 2012 PH ED often had more patients in the waiting room than was the department goal, and physicians were available in the treatment rooms for patient assessment. An interdisciplinary committee of ED providers and the Interim ED Clinical Manager met to examine the current triage process and take action to improve patient flow.  The remodeling included a major change with the entrance and check in desk.  Prior to the remodel, patients were greeted and checked in through a small slot in a window.  Now a desk area was open to the entrance door and to the waiting room. 

    The Interim ED Clinical Manager was a member of the Blue Jay Consulting Group and therefore, was in position to help the ED make the recommended changes.   He described a "pull to full" process that began at the greeter desk.  We revised our staff assignments and locations and placed a nurse and patient access representative at the greeter desk.  Now patients are greeted, given a visual ESI assessment by the RN at the Greeter Desk and if a room is open, the patient is brought directly to a treatment room. 

    The ESI assessment consists of giving an acuity priority (scale of 1-5) and documenting the chief complaint, and immediately be brought to a room to have the intake assessment completed by the RN in the back. This process was put in place to increase the speed in which patients are brought to a room, seen by a provider, care started and ultimately shorten their overall length of stay. Reducing the time to triage, to room, to provider assessment would lead to better patient throughput and shorter wait times for all patients.

    The Process Improvement committee met twice and they designed the process changes and communicated directions via e-mail, shift huddle, and information sheets the week prior to implementation. On February 7, 2012, Greeter Mode was implemented. Nursing staff did not require training since the procedures and assessments remained the same and the process change had been clearly communicated.  ( EP7EO-8 )

    As staff became more comfortable with the process, "Greeter Mode" was used throughout the day whenever rooms were open.  The ED instituted the assignment "ESI RN" as the nurse assigned to the Greeter Desk and responsible for assigning a chief complaint and priority to the patient and arranging for a room assignment.  When the ED gets busy, the ESI RN assists with triage.   However, the ESI RN is remains available at all times to greet patients walking in the door, determine their priority and answer questions as needed. 

    The Greeter Mode was also meant to provide a safer and friendlier environment when a patient and family enter our ED.  Photos demonstrate our "Greeter Desk" and "Vertical Treatment Area" post remodeling. The remodeling has allowed and supported the practice changes.  

    Fast Track/Vertical Treatment In 2012 Penrose Hospital Emergency Department instituted a committee to review their "fast Track" policies. Fast track was the process of seeing patients with a low acuity in a separate part of the ED or even in the hallways of the ED.  The goal of Fast Track was to treat patients in timely manner based on their acuity and improve overall throughput through the ED. In Fast Track, patients are usually seen by a Physician Assistant (PA).  Prior to the remodel completion, the lack of designated space and lack of assigned provider led to inconsistency with Fast Track policies.  Many of these lower acuity patients were waiting hours to be seen while higher acuity patients were prioritized and seen sooner. Both the nurses and the waiting patients were discouraged and frustrated with this process.  

    The remodeling project included a designated space for lower acuity patient treatment. An interdisciplinary team met to plan the opening of the new "Vertical Treatment" area.  Vertical Treatment was chosen as the name as it was decided that anyone who was able to sit vertically would have potential to be treated in this area. The definition of low acuity was thus widened to include anyone who did not need continuous monitoring and that the RN and PA working in that area felt they could serve. The Vertical Treatment area is opened during the day around 10:00 AM and remains open until the PA shift ends at 9:00 PM. If patient census is low, the charge nurse makes the decision to delay opening Vertical Treatment.  PH ED designed and drafted an algorithm and process for VT patients to support the practice change.   (EP7EO-9 , EP7EO-10 , EP7EO-11 )

    Once we opened Vertical Treatment we saw an immediate decrease in our waiting room numbers and length of wait for our patients. We also changed our practice and initiated use of the waiting room for Vertical Treatment patients waiting for procedures.  By using the waiting room as a second place for these patients to wait for procedures we are able to have more than 4 patients in this area at one time. We can have a few in the waiting room waiting for imaging while other patients are seen and treatments are ordered or initiated. 


    Jack Sharon, MD Rachel Locker, Physician Assistant
    Tim Hurtado, MD Gary Howard, Interim ED Manager
    Will Stewart, MSN, RN, CEN Clinical Manager Jennifer Apodaca, Registration
    Susie Valdovinos, ASN, RN, CEN Jalean Makedonsky, BSN, RN, CEN
    Sharon Cerrone, BSN, CEN Assistant Nurse Manager Kristin Thompson, ASN,RN
    Falecia Rader, RN Lisa Montijo, RN 
    Sheri Lasater, Patient Access Kerry Mullane, BSN, RN, CEN
    Pam Assid, MSN, RN, CEN Linda Simpleman, RN
    Kelly Bruggerman, RN Todd Farina,BSN, RN
    Cyndi Souleret, RN Justin Lark, RN
    Carson Murray, CCT Jeremy Gianzero, RN
    Brian Foltz, CCT Cheryl Imlay, RN, CEN, CFRN



    The goal was to improve throughput as measured by times between

    • Receive to triage 
    • Receive to treatment room 
    • Receive to physician

    Evaluation/Analysis The time from when a patient enters the ED until the patient is triaged did not decline following the Greeter Mode practice but did decline following implementation of Vertical Treatment.  PH ED will continue to monitor and evaluate the improvement (reduction in time to triage) following implementation of both practice changes.  GOAL MET. 

    Evaluation/Analysis  The time from patient arrival to time placed in treatment room declined following implementation of Greeter Mode.  The time decrease is a 50% reduction.  GOAL IS MET. 

    Evaluation/Analysis :  The time from patient arrival to time seen by a physician declined following implementation of Greeter Mode and again following implementation of Vertical Treatment. GOAL MET.

    Additional Positive Outcomes related to Consultant, Construction and Practice Changes in PH ED.  PH ED noticed that following implementation of Greeter Mode and VT process that both the Left Without Being Seen metric improved (decreased) and the Patient Satisfaction with Timely Evaluation improved (increased) as demonstrated in the graphs below.  


    Clinical Implications:

    Timely treatment in the emergency room is essential for patient safety, clinical outcomes and patient satisfaction.  The priority is given to high acuity patients which can result in delays in treatment for patients with lower acuity. 

    The recommendations provided by Blue Jay Consulting and the completion of a construction project in the PH ED provided an opportunity to implement practice changes that made a difference.  The goals to improve throughput time were met in all three categories. The bonus outcomes included improvement in left without being seen numbers and improvement in patient satisfaction. Nurses partnering with other professionals serving in PH ED accomplished great results.

  • Exemplary Professional Practice - EP08

    Staffing, Scheduling, and Budgeting Processes

    EP 8  How nurses use trended data to formulate the staffing plan and acquire necessary resources to assure consistent application of the Care Delivery System (s).

    Penrose St. Francis Health Services is committed to providing care of the highest quality to our patients. Nursing service areas are staffed with highly skilled and competent registered nurses, licensed practical nurses, and certified nursing assistants. The Care Delivery Plan is based on our philosophy - Relationship Based Care - and implemented through a variety of staffing plans in each area to meet patient needs. Care Delivery Plans include interdisciplinary, total patient care and modified team nursing.   

    Nurses Use Trended Data to Formulate Staffing Plan:

    Each unit maintains a Plan for the Provision of Care which describes the populations served, unique needs of each patient/ family, patient safety, quality improvement focus, staffing plan, and educational requirements for all unit staff.

    Every nursing unit reviews and revises their Provision of Care Plan at least annually. The Policy on the Plan for Provision of Care is included in OO11. This structure defines the staffing plan for the unit and is based upon the review of the prior year's data including: census information, productivity reports, observation patient hours, incident report trends, quality data and staff feedback. 

    Trended data is available in both short and long term formats. Census reports, productivity reports, and anticipated admissions/discharges are readily available online and may also be posted on units. Census trends as well as anticipated changes in the unit populations are considered when the annual unit staffing plans are developed.

    Clinical nurse managers develop staffing plans based on their assessment of the trended data and discussion with direct care nurses and nursing directors. Consultation with the finance department on prior years' expenditures, current budget, and actual-to-budget nursing costs provides a valuable perspective. Comparing our staffing to external sources, like data from the National Database of Nursing Quality Indicators (NDNQI) for example, on patient care hours, staff satisfaction, and hospital acquired conditions provides national benchmarks for analysis.

    The finance department presents a preliminary budget plan which includes staffing to Senior Nursing Leaders and Clinical Nurse Managers on an annual basis. The draft is based on historical census data, staffing trends, as well as projections of any anticipated changes (unit closures or expansions). The Clinical Nurse Manager meets with Finance to review the draft and identify any changes. The Directors meet with their Clinical Nurse Managers to review the budget and to discuss any variances. The Chief Nursing Officer reviews all unit staffing plans annually with a focus on staffing, satisfaction, and quality indicators. All Clinical Nurse Managers receive training and ad hoc support from Finance on accessing and utilizing reports. The NDNQI Site Coordinator provides quarterly reports on all reported quality indicators to each clinical nurse manager.

    The Critical Care Unit uses registered nurses to provide care with minimal support from certified nursing assistants. The graph below demonstrates this care delivery system with PSFHS' "RN hours per patient day" significantly above NDNQI National Non-Magnet Hospital benchmark across the previous eight quarters:


    The next piece of graphic evidence displays the NDNQI percentage of RN hours supplied by agency staff. Penrose Hospital uses experienced critical care traveler nurses, when needed, to ensure necessary resources. The blue column indicates higher than national benchmarks for agency staffing during several quarters in the last two years: 

    While a trend of using agency/travelers may raise concerns, our analysis shows that as a military community, turnover is often related to deployments and changes in duty stations. In fact, 36% of the nurses working in Penrose Critical Care have worked here for more than 10 years.

    SFMC 5 N Surgical demonstrates use of trended data to address staffing needs. This unit viewed trended data that compared staffing with patient falls and they took that data and based staffing changes off of their conclusions. In order to reduce the number of patient falls, the unit implemented increased staffing during the first quarter of 2011. As the data establishes, the increased staffing directly correlates with the lower number of patient falls. This kind of real-world data analysis and resulting policy reactions is a goal of every nursing unit at PSFHS. 



    Nurses Use Trended Data to Acquire Necessary Resources:

    The ANA Nursing: Scope and Standards (2004), guides our approach to professional standards. Standard 14 of the guide states that, "the registered nurse considers factors related to safety, effectiveness, cost and impact on practice in the planning and delivery of nursing services." This standard holds nurses accountable for ensuring adequate resources for the delivery of patient care.

    Each unit establishes a core schedule based on unit specific staff matrixes.  Staff is scheduled to "core" unit staffing which is the number of RNs, CNAs and Unit Secretaries needed for each shift on that specific unit based on projected average daily patient census. The patient census is reviewed each shift by a unit clinical nurse manager and/or charge nurse. Staffing is adjusted as needed to meet census and patient needs. Nursing supervisors are on duty when nurse clinical nurse managers are not onsite and through rounding they provide support to acquire necessary resources. Clinical Managers have 24/7 responsibility and may be called at home when unexpected fluctuations in patient census or needs occur. Staffing ratios serve as a guideline only for considering necessary resources.

    PSFHS utilizes the AtStaff scheduling system for the scheduling process. Individual nursing units and departments determine the shifts of work based on the unit's hours of operation, the patient population and the required work load of staff. Most inpatient units comprise two 12-hour shifts to provide 24-hour nursing coverage. Some nursing areas have multiple shifts of four, six, eight or ten hours.  The Emergency Departments and the PreOperative Department utilize multiple overlapping shifts to provide increased staffing coverage during peak times when there are more patients in the department ( EP8-1 ). Some units use a "weekend option" nurse to improve coverage and support individual nurse preferences.

    Short Term Options Several options exist to acquire necessary manning resources in the short term:

    • PSFHS Float pool

    Quarter 1 2012 - 8627 hours 
    Quarter 2 2012 - 6707 hours 
    Quarter 3 2012 - 6772 hours 
    Quarter 4 2012 - 6149 hours

    • Centura Health Regional Float Pool - rarely used but available

    • Extra shifts for current staff including considering options to use a different staff mix

    • Approval of unscheduled bonus pay

    • Calling in staff on-call several units maintain on on-call schedule for census increases or sick calls ( EP8- 2 )

    When nurses are "floated" to meet manning needs on a different unit, ensuring competence is critical. As a result, our float nurses serve areas of personal expertise, for example surgical nurses float to surgical units. Very seldom do nurses from critical care, emergency services, or surgery float to another unit. Labor and Delivery (LD) maintains its' own per diem nurses to maintain adequate coverage for vacations or sick calls.   AWHONN has a position statement which requires external fetal monitoring training and on-going education for any staff who applies a fetal monitor (EFM) to a patient, much less interprets the data from it.  It is a Centura standard that all LD RNs be certified in EFM through NCC.  Labor and Delivery nurses are also required to complete ACLS.   LD nurses will float to NICU to be "helping hands" or to Mom-Baby to take an assignment.  ( EP8-3 )

    Long Term Options Our intent is to reach and maintain consistent staffing with our own competent, mission oriented associates. One nursing goal is that "contract labor will be less than 1.5% net revenue." However, patient safety is our priority and some vacancies have been temporarily filled with agency nurse travelers. These nurses bring experiences, new ideas, and diversity to our environment. If census increase trends continue, additional FTE may be recruited and hired. PSFHS uses a Director Workforce Council of interdepartmental leaders to review requests for additional FTE's. This process promotes creativity as well as validates collaboration in decision making. ( EP8-4 )

    The use of "sitters" in PSFHS supports adequate staffing. Sitters are personnel who stay by patients who are or may be unstable. Patients who are being held on a mental health hold (M-1) and who are admitted to an inpatient medical/surgical floor are assigned a sitter to heighten surveillance and to subsequently ensure patient safety. Certified nursing assistants may be assigned as a sitter or specially trained staff in the Float Pool may be assigned. By assigning additional associates, nurse hours are freed to pursue direct care. Sitter policies delineate the responsibilities of this position. The goal is to assign a sitter without creating shortages in overall unit staff.  In FY2012 PSFHS spent over $150,000 on contract agency and staff to stay with patients on a mental health hold. 

    PSFHS Float Pool:

    The Float Pool at PSF provides an option for nurses who want more flexibility in their schedules. The Float Pool pays a higher rate per hour, but does not provide associates benefits, including health insurance or vacation time. 

    In 2012, the float pool revised their scheduling process based on input from direct-care nurses and clinical nurse managers. Increased weekend hours and clear parameters for number of float pool staff that may sign up for a shift occurred to reduce call off and improve hospital coverage.  ( EP8-5 )  Anecdotal comments indicate improvement though metrics do not demonstrate significant changes in these two areas.  


    Nurses use trended data to formulate the staffing plan for their unit.  Variations in staffing plans include staggered shifts, length of shifts and on call schedules.  The staffing plan is formulated annually and each unit schedules a "core staff" based on the annual plan.  Adjustments are made based on census, patient needs, sick calls and other unanticipated situations.   Staff acquire necessary resources to ensure consistent application of relationship based care and the unit care delivery system.  Float pools, contract agency and use of our on call staff provide the necessary resources for patient care.  Clinical managers and nursing administrative managers collaborate with direct care nurses in this process however; these defined nursing leaders remain accountable to provide necessary resources.

  • Exemplary Professional Practice - EP09

    Staffing, Scheduling, and Budgeting Processes

    EP 9 Describe and demonstrate how direct-care nurses participate in staffing and scheduling processes

    Excellence in patient care requires adequate and competent staff to deliver safe, evidence based nursing care based on our professional practice model. At PSFHS nurses at all levels are empowered to participate in staffing and scheduling processes to meet patient needs. In the context of relationship-based care, these decisions include consideration for competency, continuity, and nurse preferences.

    Each unit details their staffing plan in the Unit Provision for Care and Staffing Plan. Reviewed and revised annually, the clinical manager is responsible for creating a staffing plan using input from staff, recommendations from professional nursing organizations, and budget parameters.  This unit staffing plan provides guideline for the fiscal year. Staffing projections and total full time-equivalent requirements are established in conjunction with the annual budget and the PSFHS approved Premier Staffing Standards. Key target ratios, hours per unit of work, staff mix and nonproductive factors are identified using historical data trends.

    Direct Care Nurse Involvement in Staffing Decisions:

    Interviewing for Open Nursing Positions and staffing decisions involves the input and involvement from nurses across the unit. Staffing activities also include recruiting, interviewing, selecting, and orienting adequate staff for the unit. The manager holds responsibility for this process and collaborates with Human Resources and the Nurse Recruiter to meet the staffing demand. During the last three years, nursing services has expanded the interviewing and selection process to include peer interviewers, a process that has improved nurse satisfaction. In 2012, there was a series of open manager positions which tested this time intensive staffing involvement. The Clinical Nurse Manager on Ph 5 Medical departed in the spring, and interviews to fill the position included team efforts organized by Clinical Nurse Managers. For several of the positions, there were a significant number of internal nurses who had applied for open positions. One nurse accepted an Interim Clinical Nurse Manager position. When she left to take a position in another area of the hospital, the process was once again implemented and team interviews were set up with two clinical nurses. At this point in time, three clinical nurse manager positions were open. The schedule attached demonstrates the interviewing process. Ultimately the outcomes were positive as quality personnel were hired and promoted. This process also proved itself to be a success, as it was implemented and re-implemented over a short period of time. This process reflects one way direct care nurses participate in staffing decisions. ( EP9-1)

    Making Patient Assignments:

    The charge nurse is responsible for making patient assignments. Input from direct-care nurses regarding their assigned patient's status and accompanying care plans, provide essential information for making assignments for the next shift. In addition, new nurse assignments are made based upon the recommendations of preceptors when considering orientation status. ( EP9-2 )

    SFMC Labor and Delivery Unit - New Training Program:

    The Labor and Delivery Unit rarely has nurse openings and usually fills positions with experienced nurses. In 2012, the nursing team decided to offer a training program for three open positions. Forty-two nurses applied for the training program. The Clinical Nurse Manager and Assistant Nurse Manager did an initial application screen and identified 21 potential candidates.  All staff were invited to interview the candidates with the requirement that they would need to interview all of the potential transfers in order to be part of the interview team. Sixteen interviews were scheduled on one day and they were completed by three clinical nurses and the two managers. Each candidate was asked the same questions and given a tour and information on the unit.

    Candace Garko, RN, Clinical Nurse Manager writes of the experience:

     "At the end of the day we ranked the candidates.  We all had roughly 6 candidates that stood out to us and only 3 positions. We each ranked our top 3. Among the 5 of us who were interviewing, we had 6 great candidates. We then discussed each of those 6 listing pros and cons.  Then we assigned points to our individual 3 favorites, our top getting 5 pts, our second getting 4 pts and our 3rd getting 3 pts.  This resulted in a clear top 3 candidates for the 5 of us.  The end result was neither one of my top 3 choices, nor Melody's (Assistant Nurse Manager) but it was the top 3 of our group. I was thrilled to have their feedback and their buy-in for the candidates of our new training program. In addition we have eight bedside practitioners who volunteered to help teach the didactic portion of the training program.  We are all excited to be able to grow our own again and will never forget that once upon a time, someone had to take this chance on each one of us."

    Direct Care Nurse Involvement in Scheduling:

    Throughout the year, schedules are developed and produced in four-week cycles for each unit. Units use a variety of scheduling models directed to meet the needs of the patients and staff on that unit. Within budgeting parameters and PSF human resource policies, individual units set their own criteria for scheduling including shift length, rotation patterns, holiday staffing and call off priorities are determined by unit staff. Staff participates in the scheduling process by stating their preferences, requesting time off, volunteering for extra shifts, and by creating the schedule for the unit. The core schedule is based on the staffing plan and census projections. Clinical Managers are responsible for ensuring adequate resources to meet the unit needs.  The clinical manager contacts the Staffing Office for additional staff as needed.

    Flexible scheduling opportunities exist on all units and benefit all nurses. Many PSF nurses prefer 12 hour shifts, though some request 8 hour shifts or less. While the expectation is to work the number of hours hired for (including weekend and holiday shifts), nurse requests for time off are able to be respected due to this process.

    Day-to-day scheduling decisions are made by the clinical manager in collaboration with the charge nurse. These decisions are based on patient needs including: current census, acuity, discharge planning, anticipated admissions, and nursing staff/care requirements. Nursing staff requirements include the levels of expertise of staff scheduled, work schedules, availability, and the presence of staff orienting. The intent is to match the staff with the unit needs and in the context of the core staffing plan. Charge nurses are taught to assess needs and make reasonable decisions for scheduling. Talking with team nurses, the admitting department, and the emergency department helps the charge nurse be aware of the entire situation. The staff scheduled may need to be adjusted up or down based on this assessment. 

    Reducing scheduled staff Decisions to reduce staff from the planned schedule are made by the manager or charge nurse. Ensuring adequate staff to meet current and anticipated patient needs is essential. Minimum staffing levels or staff expertise requirements are set on each unit. If the workload is less than anticipated, staff may be floated to another unit if he/she is competent or called off based on procedures listed in the unit call off system. 

    Additional Staff Needed When additional staff is needed, there are several options.  The manager or charge nurse may negotiate schedule changes with available staff, contact the staffing office (for available pool staff, float options, or agency staff), or approve overtime pay including unscheduled bonus pay. Adjusting skill mixes of nurses and certified nursing assistants is another possibility. In some situations, collaboration with other units and the admitting office results in other units accepting admissions, the creation of a temporary discharge "lounge," or sharing the services of a unit secretary. When the hospital is full, a Capacity meeting is called.  This meeting includes managers, charge nurses and directors who are charged to "make room." Identifying discharges and contacting physicians for discharge orders and transferring patients from high intensity care to lower levels of care are two strategies to resolve the capacity challenge. A decision to divert is made with great care.

    PSFHS scheduling and staffing system encourages flexibility and aims to promote the balance between work and personal life for our nurses. Our nurses can also take advantage of full-time, part-time and weekend staffing opportunities. The internal float pool allows nurses to express greater autonomy by self-selecting desired shifts and improving control over their schedules.

    A key aspect of nurse involvement in developing and maintaining schedules is developing an acceptable process for the allocation of vacations. This seems elementary yet it is vitally important to morale and the smooth running of a nursing unit. With regards to time off, the following story describes how a unit developed an in-house policy for counteracting scheduling needs with time off:

     "Our manager asked our UPC to discuss vacation scheduling. Historically, vacation requests were granted based on seniority, and we have many nurses who have worked in this department for 20 or more years.  Our newer nurses were left with limited vacation choices. The UPC met and we discussed options, asked other units how they did vacation scheduling and talked with our nursing team. We came up with a plan that included a lottery system. Our manager approved and we will start this in January. Our manager had confidence in us and we appreciated the opportunity to create a new process." Gina Wamble, RNC, Chair ( EP9-3 )

    Self Scheduling:

    Self scheduling processes have been tried by several units, resulting in varying levels of success. The following are two examples of the process. What makes unit sized scheduling a valuable part of our overall scheduling process is how each individual entity can act as a laboratory where ideas are tested. Ideas that work can be spread throughout the system, while ideas that do not work can be either modified or let go.

    SFMC PostPartum Mom Baby Unit  In August 2012 the UPC explored self scheduling.  They team was focused on ensuring everyone had input into the process. Current schedulers provided informtion and they sought ideas from the NICU who was using self scheduling.  ( EP9-6 )

    Cardiovascular Unit (CVU) The Cardiovascular Unit is proud of their participation in staffing and scheduling.

    The Cardiovascular Unit transitioned to a new clinical manager in January 2012. Phyllis Burton, BSN, RN, PCCN had experience as a charge nurse on a busy cardiovascular unit at another hospital. She initially observed and asked questions related to patient care, staffing, scheduling, safety, and staff preferences. She identified a complex staffing schedule that included multiple shift lengths with varying start and end times and unit secretary coverage that did not meet unit needs. Weekend coverage included a component of seniority that resulted in new staff assigned to more weekends than other staff.  Burton stated, "I watched the Monday-Thursday day charge leave at 1530 and the other nurses having to shift assignments to cover the charge role. This jeopardized patient safety." Transition gaps and shifting patient assignments raised concerns for patient safety.  

    The Clinical Manager reviewed the turnover rates on CVU and the length of tenure of the current nursing staff. First year turnover for nurses was 18.8% (7/11/2012-3/31/2012). Voluntary turnover for the unit 5/1/2011-4/30/2012 is 31.25% (this category includes transfers within the organization as well as nurses moving with military spouses). Most of the nurses had about three years of experience with only a few with more than five years. The manager recognized that retention improves teamwork, multidisciplinary collaboration, and supports professional development and competence. She sought ways to improve staff satisfaction, retention and patient safety. 

    The manager completed a literature review and identified self scheduling as an evidence based strategy she planned on pursuing to meet unit goals:

     "I have had the opportunity in the past to do self scheduling and was surprised that this unit had not started this process. From the articles I read, it was noted that self-scheduling can be challenging and time consuming for a manager or staffing committees to organize, however it can greatly improve staff satisfaction. I realized that CVU is a busy Cardiac unit with admissions and discharges occurring throughout the day and evening, so I understood the need for 2 unit secretary positions. The opportunity came about for a change when the 3pm to 11pm unit secretary transferred to a different unit. I asked the remaining unit secretaries if they would be willing to work a new schedule which would entail working 12 hour shifts. They were willing to try, so we implemented a 06-1830 and 10 -2230 hours for unit secretaries. The next challenge I had was talking to the Charge Nurse that worked Monday thru Thursday 0600-1530. This particular nurse made the decision that she would not be able to work 12 hour shifts a nd was able to find another job within the Penrose St. Francis Health System."

    The manager discussed unit goals with the UPC and the Charge Nurses. When the day charge nurse left, some relief charge nurses voiced lack of confidence in the charge role and requested time and support to develop their competence and confidence. Within a month, nurses' competence and confidence grew and they easily accepted charge nurse responsibilities.   

    By creating a weekend schedule that required all staff to work a weekend every three weeks per month the manager demonstrated that this improved coverage and provided fair scheduling for all nurses. She discussed with the staff the hope that this change would also improve retention of the newer nurses on the unit.

    A Staffing Committee was created to develop the rules and guidelines for self-scheduling on CVU. These committee members shared the responsibility of reviewing and revising the schedule as needed during the transition to self scheduling. ( EP9-4 )

    The August schedule was the first self schedule for the C.N.A.'s and Monitor Telemetry Technicians on the 0700 to 1930 shift. The C.N.A.'s and MTT's were split into two groups, A and B. Group A had first access to schedule choices and group B were designated "movers" with their self selected schedule first to be adjusted to meet staffing parameters. The two groups rotate with each schedule period. Guidelines for process, designed by the Staffing Committee are posted and include number, type of staff and weekend requirements. The nurses initiated self scheduling in September. ( EP9-5 )

    Outcome - Nurse Satisfaction In reviewing the RN satisfaction data through Press Ganey Staff Survey in 2010 (blue) and 2012 (red) staff satisfaction has improved in all areas. The 2012 survey was completed following informal and staff meeting discussion on staffing, but prior to implementation of self scheduling. Nursing staff will complete the Press Ganey Staff Survey in spring 2013 which will provide additional outcome data.  

    Blue Column=2010; Red Column=2012

    Outcome - Patient Safety Patient falls have decreased through this process of shared decision making related to staffing and scheduling. The unit will continue to monitor and evaluate falls as well as other patient safety quality indicators through the implementation of self scheduling and shift change process.


    The new clinical nurse manager actively sought staff participation in evaluating current scheduling process, reviewed literature for best practices and promoted shared decision making to design and implement a change in the scheduling structure and process. Initial outcomes are positive.  The UPC requested feedback on self scheduling from staff.   The results of this survey:

      Yes, Continue No
    RN: Day Shift 84% 15%
    RN: Night Shift 50% 50%
    CNA: Day Shift 77% 22%
    CNA: Night Shift 100% 0

    Monitoring of outcomes related to staff satisfaction and patient safety will continue in 2013.  In addition, the annual turnover rates will be examined in 2013.

    Cardiovascular Unit nurse participation in staffing and scheduling analysis, design and evaluation demonstrates consistency with our Professional Practice Model. It has yielded initial positive outcomes.


    Nurses participate in the development of their staffing plans and scheduling processes. The incorporation of nurse input and participation is crucial to maintaining nurse morale throughout the organization. As such, important decisions regarding nurses' time are left to flexible policies and procedures that respect the individual nurse, their units, and quality patient outcomes. 

  • Exemplary Professional Practice - EP10

    Staffing, Scheduling, and Budgeting Processes

    EP10 How nurses develop, implement, and evaluate action plans related to unit-based staff recruitment and retention.

    The above insert recognizes the long term nursing associates who provide a strong foundation for professional nursing practice at PSFHS.  Each year we celebrate longevity with an Employee Recognition Event including dinner, dancing, skits and awards.  Over 35% of our registered nurses have worked at PSFHS for ten or more years.

    Penrose-St. Francis (PSFHS) works in partnership with other Centura Health facilities in major projects, program development, and evaluation related to recruitment and retention. During the last 1-3 years, major retention and recruitment projects included: establishing a Centura Professional Development Committee, creating and initiating the ASCENT Program, revising the Preceptor Program, and designing frontline nurse leadership educational programs. The Centura Health framework allows facilities to share resources and expertise during times of change.

    A PSFHS Recruitment and Retention Committee, chaired by a nursing director, meet as needed.  Committee members include representatives from several nursing units, human resources, a float pool manager, and recruitment staff from Centura Health. Currently, PSFHS has a Nurse Recruiter who is managing engagement efforts based on identified vacancies and hiring needs.   During the first quarter of 2012, he filled 212 vacancies which include internal transfers. He completes screening interviews on approximately one hundred applicants each month. Neonatal Intensive Care, two medical units, PH Critical Care and SF Emergency Services have been the top users of our nurse recruiter.

    Salary and benefit packages, transfer policies, scholarships, tuition reimbursement, and professional development opportunities are additional structures to support recruitment and retention. The nursing department's Shared Decision Making (SDM) structure promotes control over nursing practice, accountability, and best practices. Multiple research reports identify the value of SDM for recognition, satisfaction, and retention.

    Human Resources provide reports to nursing leaders on turnover and vacancy. While unit managers know this information as they track their associates, the reports provide an opportunity to analyze larger trends and to develop relevant action plans. The results from the annual Press Ganey Associate Survey also provide unit level information of perceived areas of strengths and weaknesses. In analyzing this information, managers (in collaboration with the director and the unit associates) can prioritize areas to improve, develop, and implement action plans. By taking action to improve both the work environment, teamwork retention, and recruitment can be enhanced.

    Retention in SFMC's PostPartum Unit includes 61% of RN's who have worked there for over 5 years. The RN Satisfaction measured by Press Ganey Survey was 70.7% for 2012 as nurses rated adequate resources, participation in decision making, meaningful work, quality care, and more as being positive aspects of their work environment and practices. There were only four (4) nurses hired in 2012 due to the lack of turnover.  

    Across PSFHS Clinical Nurses identify teamwork as a strength and strategy for retention and recruitment.  This is evident in the individual stories shared below:

    •  PH 7 Surgical-Ortho : This example circles Yun hui Yi's, RN story from her days as a CNA/Unit Secretary. Beginning on intensive care, she moved to the orthopedic unit and continues to "belong" with this team. From adjusting schedules to accommodate her school to hugs and appreciation, both units' associates retained and recruited her. The evaluation of their actions to this individual nurse is positive as she says "I love this crew. I have a lot to learn but what more could I ask for?"  ( EP10-1 )

    •  NICU :  Michelle Coffy, RN traveled to Colorado from a large NICU at a Children's hospital in Ohio. She made the move with the hopes of obtaining a position in Denver at one of the larger NICU's:

    "From day one, I was shocked at how beautiful and inviting SFMC's NICU was. I was amazed that each infant had his/her own room. I came from a unit with very small bed spaces that where designed for 8 infants per open room. This didn't leave much room when you factor in equipment, monitors, parents, etc. 
    From the moment I walked in the door I felt welcomed and appreciated by all staff. All of the nervousness about starting a new job 1500 miles from home with knowing no one but my husband disappeared. At the end of my travel assignment, I realized that I could fulfill my dream of both working in a Level III NICU and enjoying the thought of coming to work at the same time. I accepted a permanent position after my travel assignment ended and have plans on working here until retirement."

    Intensive Care Unit (ICU) Nurse Training Program - Developing, Implementing, and Evaluating Staff Action Plans for ICU:

    The Intensive Care Unit and assigned Clinical Nurse Specialist designed an orientation program to recruit nurses to ICU. Training led and coordinated by the Clinical Nurse Specialist is 3-6 months long. Since the ICU Training Program was implemented in 2007, 63% of the nurses continue to work in our intensive care units. Of the nurses who have left, one nurse moved into a manager position and another nurse transferred after three years on ICU to the PICC team. Since the training program's initiation, only 7 of the 36 ICU trainee nurses have left our system. ( EP10-2 )

    In 2012 both recruitment and retention was challenging for PH ICU.  The nurse manager and assistant manager have collaborated with Human Resources and received support from the CNO as the ICU team has sought to develop a strong, consistent team.  Several actions were implemented in January 2013 to improve staffing including contracts with traveler nurses, nurse recruiter actions and scheduling another ICU training program.  Progress will be evaluated in 2013. ( EP10-3 , EP10-4 )

    Informal Recruitment of a Clinical Nurse Manager:

    When a vacancy occurs and nurses within a unit know the best possible candidate for the position, informal recruitment activities may occur prior to any official job announcement. The following is an example from Nancy Steele, RN, SFMC Labor and Delivery Unit:

    "The three of us were scheduled to volunteer for the Medical Tent at the Women's Golf event (spring, 2011). I was scheduled to work with Kate, our Chief Nursing Officer while Amelia and Gwendy were working with Nate, our Chief Executive Officer at SFMC. Our manager had recently left and we knew who we wanted to take that position. Although we did not want to lose our Clinical Nurse Specialist, we knew she would be great in the manager role.  So we decided to take this informal opportunity to share our position and rationale for recommending our CNS to our leaders. I was initially nervous talking with our CNO and figuring out how to bring this issue up.  But I did. I asked her what the plans were for the position. She asked ME about my thoughts, opinions and suggestions. So I told her who and why!  She listened and eventually our choice - our CNS - was offered and accepted the position. It is great! She knows and is passionate about Labor and Delivery, recognizes the excellence in our nurses and always challenges us to use evidence based practices.  In summary, we had a plan, implemented it and the outcome was perfect!" 

    Pediatric Unit - Developing, Implementing and Evaluating an Action Plan for Unit Recruitment and Retention:

    During the fall of 2010, the Pediatric Unit Practice Council developed a Float Orientation Class for both RNs & CNAs. The objective was to improve the knowledge base and comfort level of those staff that floated to pediatrics. Topics included: pediatric unit specific routines, documentation, drug and dosage calculation, and a review of our most common pediatric diagnoses. A follow up 2-4 hr individual unit orientation was also offered. One of the members of the Pediatric Unit Practice Council wrote that:

    "Our initial hope was to build a roster of staff nurses that we could call and schedule during our high census winter months. We had a great turnout for both the class and the unit orientation. But when it came to calling and asking these associates to work, they were unavailable. The consensus from the pediatrics nursing staff was that most of the participants came to the class to increase their paycheck, and perhaps learn about pediatrics but without an actual commitment or intent to work on our pediatric unit."

    In the fall of 2011, the Pediatric Unit nurses offered a 4-8 hour individual orientation to PSFHS nurses interested in floating to pediatrics. These nurses came with the understanding that they would have to commit to working at least one day on our schedule if needed.  This method was much more successful in recruiting staff. "We now have a roster of nurses who have floated here and are fairly comfortable working on our unit. When we need extra help, we contact them prior to calling the staffing office." ( EP10-5 )  

    Penrose Hospital Surgery Staffing Council - Developing a Plan for Unit Based Recruitment and Retention:

    PH Surgery's Press Ganey Staff Partnership and Engagement Scores fell in September 2010 and continued to decline in April 2012. In late 2011, a new Director was hired. Upon her hire, Kristin Varnes, RN, Director assessed the workforce issues and identified a need to improve staffing and scheduling processes, recruitment, retention, and staff accountability. Nursing associates working in our surgery department established a Surgery Staffing Council in the middle of 2012, upon the direction of the Director of Perioperative Services at Penrose. The Council's charter delineates clear goals and objectives; it also provides the initial structure for staff participation and leadership in workforce processes. Varnes recruited staff members, provided clear responsibilities for the council chair person, and drafted a Change of Schedule/Service Line Request Form. When discussing the changes made under her tenure as director, Varnes states that:

    "Our nursing associates in surgery have the skills and opportunities to transform the current processes. My goal is for us to be fair and transparent with the decision making process and outcomes for all of our associates. I will support this council to use evidence based practices and nursing standards as the foundation of their process. Competent staff at the right place and right time is critical to our surgery success."

    A major objective of the newly formed Surgery Staffing Council is to improve staff partnership and engagement so that nursing associates feel as though they are fully immersed and involved in their professional lives.  The Press Ganey Associate Engagement Survey scheduled in April 2013, will provide measurable feedback for analysis by this council.  ( EP10-6 )

    Penrose PreOperative/Outpatient Surgery (PH PreOp) - Developing, Implementing, and Evaluating a Retention and Recruitment Plan:

    Background Penrose PreOp has a strong record of experienced nurses who stay with the unit. The average number of years of nursing experience for the nurses in the unit is 32. Combined, the nurses have a total of 681 years of nursing experience (the unit is composed of 21 nurses).  Prompting the development and implementation of a formal retention/recruitment plan was the opening of two positions. One of which was due to retirement and the other was the result of a resignation.

    Methods & Retention In 2011, Gina Wamble RN, Chair of the UPC, built on the unit strength of retention by creating a display board for the unit. Each nurse responded to "Why we Love Being Nurses" and these quotes were posted. To illustrate the longevity of nursing careers in the unit, one nurse celebrated 50 years of nursing with her team during this process. The team honored her with a party, a hat, and a poster with her biography written on it.

    The clinical manager responded to questions and complaints about summer vacation scheduling by asking the Unit Practice Council to evaluate the issue, seek input from colleagues and propose a change in vacation scheduling. Given the high retention rate, nurses with seniority were scheduled on the preferred shift (days) and given first option for time off. Nurses who had been working for 5-10 years were assigned evenings and had less choice for vacation times. The UPC sought input and designed a new lottery based system.  It was implemented in 2012. (EP10-7 )

    Recruitment In an effort to recruit internally, the UPC designed a Recruitment Flyer and distributed it to all nurses in our system through the Nursing Practice Council. The Clinical Manager recognized the continued challenge with recruitment and contracted with a traveler over the winter holidays (2011-2012) for three months to improve staffing, support holiday time off and maintain patient safety.

    Gina Wamble, BSN, RN-BC, Chair of Unit Practice Council 
    Jennifer Graham, BSN, RN 
    Rosemary Calderaro, RN 
    Margaret Loucks, BSN,RN 
    Teri Geanetta, RN 
    Diane DeMasters, BSN, RN, CGRN, Clinical Nurse Manager

    Outcomes - Retention The UPC designed a lottery system to afford every nurse an opportunity to have first choice of summer vacation time. Each nurse placed her name in a box and the clinical manager pulled names. Nurses with the lowest numbers will have first choice for summer vacation this year and nurses with the larger numbers will have first choice next year. Everyone has an equal opportunity to request summer time off, based on the number assigned to their name. Not surprisingly, anecdotal comments from nurses who have seniority are less favorable than those who are "newer" on the team. Turnover will be evaluated in 2013.

    Outcomes - Recruitment Two nurses were hired and began orientation January 12, 2012. There are no current vacancies on the perioperative unit since January 2012.

    Recruitment Flyer:


    Unit Practice Councils and Unit Staff Meetings provide structures to assess staffing status, unit needs and work environments. During these meetings, associates are encouraged to identify strengths and to resolve issues related to clinical practice and operations. These meetings lead to the development of collegial relationships that not only reinforce the desire to stay with PSFHS but also contribute to nurses working to "cover" one another to accommodate individual situations. Within council and staff meetings, nurses welcome new associates, say goodbye to those leaving, and celebrate personal and professional successes including: certification, return to school, new babies, marriages, and birthdays. This recognition, which is entirely nurse led and developed, helps retain and recruit nurses. We prize our work culture.

    When there are challenges to retention and recruitment, these same unit level teams partner with their managers and use Human Resource expertise to develop and implement actions plans.  The examples demonstrate the effectiveness of this structure and process in the perioperative service and the continuing revisions made to improve intensive care unit staffing.  The Pediatric Unit developed and implemented a floating orientation to recruit nurses during high census season and when the first run was ineffective, they revised their plan and enjoyed the success in the next year.  Turnover, vacancy and staff satisfaction ratings provide evaluative feedback for unit based actions.

  • Exemplary Professional Practice - EP11

    Staffing, Scheduling, and Budgeting Processes

    EP 11 Describe and demonstrate how guidelines such as the ANA Principles of Nurse Staffing (ANA, 2005), standards for scheduling, delegation, and from nursing specialty organizations and/or state-mandated requirements are incorporated into staffing and scheduling processes.

    Structure and Process:

    PSFHS knows the importance and value of ensuring adequate nurse staffing so that we can provide high quality and safe patient care.

    The state of Colorado does not mandate staffing ratios nor does it recommend staffing/ scheduling guidelines. As a result, we utilize professional standards as our staffing and scheduling procedures evolve. Adequate staffing and scheduling trends are developed, implemented, and evaluated by nurses on all levels. PSFHS uses several tactics to routinely evaluate our staffing plans for effectiveness, efficiency, and safety.  These tactics include:

    • Examining turnover and vacancy rates 
    • Nurse satisfaction data 
    • Patient and family satisfaction via HCAHPS 
    • Temporary staffing hours and units 
    • NDNQI quarterly staffing reports 
    • Work related injuries

    The Professional Practice Model provides broad guidance to most realms of nursing decisions and actions, to include staffing. Our vision for excellence in nursing practice requires that we ensure adequate staffing. Our relationship-based care philosophy directs us to plan, decide, and evaluate nurse scheduling in the context of our relationships with patients and colleagues as well as caring for ourselves. The analysis of trends and the budgeting processes previously discussed, require the integration of solid business processes with quality care for our patients and families. In addition, PSFHS' commitment to associate health and well being align with the element of self-care in RBC.

    Several shared decision making councils provide structures for the review of staffing data and the analysis of possible relationships to nurse sensitive quality indicators. Two structural examples include the PSFHS Nursing Staffing Council and the Penrose Surgery Staffing Council.

    The ANA Standard 14 (Resource Utilization) of the Professional Performance for Nursing Administration Practice states that, "the nurse administrator considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing and other services." Staffing and scheduling are performed using census trends, professional organization guidelines, national benchmarks (when available), and professional nursing judgment informed through experience. The Chief Nursing Officer advocates for staffing levels and necessary budgetary modifications to support each unit's staffing plan (which is found in each unit's Plan for Provision of Care). These plans are reviewed annually and changes are made if indicated.

    The two attached policies provide a broad structure for staffing and scheduling processes: EP11-1 Staffing/Scheduling Guidelines and EP11-2 the Plan for the Provision of Care.

    Applying Professional Nursing Standards:

    Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) AWHONN's staffing guidelines are principle based. In September 2010, AWHONN published their new Perinatal staffing guidelines. This revision was based on changes in patient population and how those changes influence individual needs. These guidelines serve as a foundation for planning adequate nursing staff, and they recommend a decrease in the number of patients assigned to each nurse. In addition, the AWHONN guidelines include post-anesthesia recovery recommendations accompanied by relevant standards from the American Society of Peri-Anesthesia Nurses. The Birth Center Provision of Care demonstrates integration of AWHONN standards into the unit staffing and scheduling plan. (EP11-3 )

    Applying ANA Safe Staffing Principles:

    ANA's Principles for Nurse Staffing provides recommendations on appropriate staffing and it requires nurses to be an integral part development of the nurse staffing plan as well as the overall decision-making process. The following nine sections are direct responses to the principles presented in the ANA Safe Nurse Staffing standards. These responses are designed to demonstrate how these recommendations are integrated in our staffing and scheduling processes.

    1. Appropriate staffing levels for a patient care unit reflects analysis of individual and aggregate patient needs .

    The staffing grid identifies the personnel plan for the unit and is based upon census-data trends, budget parameters, a case mix of patients, staff competencies, roles, and national benchmarks through NDNQI. Decisions on scheduling are made each shift and are based on patient census, assigned staff, anticipated discharges, admissions, staff competency, and available support staff. The charge nurse makes shift decisions and has a variety of resources available to help. 

    The Pediatric Unit census reflects a seasonal fluctuation. There are times that the unit may have only two or three patients. While one nurse may competently care for two to three pediatric patients, the possibility of an emergency or need to take a patient for a test has led the unit to always schedule at least two RN's each shift. Cell phones and locator buttons worn by all nursing staff provide immediate communication; when direct emergency care is required, however, the close presence of nurses is essential. ( EP11-4 )

    2. There is a critical need either to retire or seriously question the usefulness of the concept of nursing hours per patient day (NHPPD).

    While we agree with this principle, we do use NDNQI for broad staffing comparisons against a current national benchmark. In addition, the Nursing Staffing Council is reviewing current research on using an Admission Discharge Transfer (ADT) formula to assist with staffing decisions. ( EP11-5 )

    The graph below depicts our quarterly comparison of NHPPD against a national benchmark. As you can see, both Penrose Hospital and SFMC have improved nursing hours during the last 18 months and are close to or above the national benchmark mean for Non-Magnet Hospitals.

    3. Unit functions necessary to support delivery of quality patient care also must be considered in determining staffing levels.

    Transport staff have increased their hours at Penrose Hospital twice in the last year to provide 24/7 support to nurses during shift change, obtaining telemetry equipment and, most importantly, providing off shift coverage for transporting patients from the ED to tests and nursing units. With the opening of the Penrose Pavilion, Patient Transport is now responsible for moving patients to that building when needed. ( EP11-6 )

    4. The specific needs of various patient populations should determine the appropriate clinical competencies required of the nurse practicing in that area .

    All nurses are required to complete mandatory training and demonstrate annual competencies based on service unit/area and patient population. CVU requires training above and beyond the regular medical surgical unit.

    CVU RN's must be ACLS certified within the first 6 months of hire. Nurses must have passed a basic EKG course, 12 lead EKG class, Angioplasty class, and Pacemaker class within the first year. Nurses must also maintain 10 CEU's per year unless certified. New graduates are given a longer period to orient, due to the complexities on this unit. New Graduates also will have a reduced number of patients, and assignments are based on experience and patient acuity. RN's participate in Code Blues as the recorders. Nurses on this unit must learn to how to care for Chest tubes, Blake tubes, internal and external pacing wires, Cardiac drips such as; Nitroglycerin, Dopamine, Dobutamine, Cardene, Heparin, Integrillin, etc. Nurses attend a 2 - 3 hour skills review once a year, this covers, Glucometer testing, Hover mats, tanscutaneous pacing, chest tube management and proper removal, central line management, performing a 12 lead EKG, CAUTI, and Code Blue for example. ( EP11-7 )

    5. Registered nurses must have nursing management support and representation at both the operational and executive level.

    The CNO is a member of the senior team at the executive level. The VP, Directors and Clinical Managers examine staffing and scheduling issues through routine reports, informal rounding and observation on units and represent nursing operational needs through collaboration with other departments, formal budget requests, and expressed rationale when not meeting productivity standards. Charge nurses making shift staffing decisions have access to the Clinical Nurse Manager, Staffing Office, and/or Administrative Nurse Managers for operational representation. (EP11-8 )

    The Nursing Staffing Council includes representation from executive level associates through direct care nursing levels as well as from multiple settings. This membership promotes communication and effective representation of nursing staff resource needs. The annual report for this council is attached.  ( EP11-9 )

    6. Clinical support from experienced RNs should be readily available to those RNs with less proficiency.

    New graduate nurses or nurses in training who transfer to a different unit receive clinical support from experienced RN's. The below example demonstrates the structure in which ANA regulations are implemented in a real scenario:

    In the spring of 2012, the clinical manager of Penrose's 5th floor Renal/Diabetic unit resigned. Within ninety days, five additional nurses left the unit. The interim clinical manager hired five new graduate nurses and they began the ASCENT New Graduate Nurse Residency Program and unit orientation. Our orientation program is twelve weeks long and it includes reduced patient assignments to new graduate nurses to promote transition, the development of competencies, and patient safety. The unit's targeted staff patient ratio is 1:5. Yvette Grijalva, RN, Interim Manager stated

    "I discussed my concern for patient safety and proposed capping our census during the orientation period. Our Director agreed and we reduced our maximum unit census to 21 patients. At the same time, we began a transition to private rooms. The new graduates finished orientation and all staff appreciated the ability to maintain a staffing ratio during this time. We are back to full capacity now."

    Our commitment to the ANA Principles on Safe Staffing is evident in this example.  Fifth floor nurses must demonstrate clinical competencies with renal/diabetic patients. The need to orient five new graduate nurses to the unit and the patient population required that experienced nurses be available for support and education to the less proficient nurses. The Clinical Manager and Nursing Director decreased the maximum unit census to allow adequate time for new nurse orientation and to maintain an acceptable staff to patient ratio which allowed for expert nurse availability to the new graduates. In addition, Mary Jane Nickell RN, an expert day shift nurse agreed to work a different schedule in support of the new graduate nurses assigned to night shift.  ( EP11-10 )

    7. Organizational policy should reflect an organizational climate that values registered nurses and other employees as strategic assets and exhibits a true commitment to filling budgeted positions in a timely manner.

    RNs provide direct clinical care, coordinate care, educate, manage, and lead within PSFHS. One way we demonstrate the value of our RN's is financially; PSFHS provides incentive payments for time serving in committees or on councils, participating in conferences, educating colleagues, and participating in quality initiatives. Some nurses prefer to attend meetings during a work day and will work with the clinical nurse manager to coordinate schedules to support this preference. Other nurses prefer to schedule a day off to attend council meetings. In either case the nurse is paid for time and their preference is met as much as possible.  Nurses who choose to present at professional nursing or inter-professional conferences are paid for their time and they are reimbursed for registration and travel needs.  ( EP11-11 )

    Human Resources provide support and coordination to fill open budgets through the timely posting of positions, screening applicants, and supporting interviewing processes as needed. In addition, some positions are advertised through professional journals as we seek to balance our goal for internal promotions and succession planning with experienced nurses from external organizations. Finally, contract staff serves in a variety of settings and levels when an immediate need is present. Penrose Hospital Emergency Services was managed by a contracted Clinical Nurse Manager with an internal nurse serving as the Assistant Nurse Manager for over a year. This structure meets immediate needs and maintains the option for internal advancement.  ( EP11-12 ) 
    In June 2012, PSFHS hired a Nurse Recruiter. During the first quarter of FY2013 he has filled 132 positions in PSFHS with a 33 day time-to-fill average . Recruiting nurses to the Neonatal Intensive Care Unit has been a top priority, as this unit continues to expand past previous censuses and has experienced the loss of several nurses. The graph below demonstrates the upward trend of total RN hours required in the Neonatal Intensive Care Unit in 2012: 

    8. All institutions should have documented competencies for nursing staff, including agency or supplemental and traveling RNs, for those activities that they have been authorized to perform.  ( EP11-13 )

    The Nursing Plan of Care P-02-b and the Staffing/Scheduling Policy states process to evaluate competency.  Snapshot taken from P-02-b is displayed below.

    a. The competency of all nursing staff members will be evaluated through mechanisms such as:

     • Licensure/certification 
     • Orientation 
     • Observation 
     • Cross-Training 
     • Annual performance appraisal 
     • Unit-based peer review 
     • Annual skills review    
     • In-service on equipment and procedures 
         • Other mechanisms as defined in Interdisciplinary Practice C-02-a 
     • Other mechanisms as defined in unit-specific policies

    b. Competency will be evaluated using Guidelines for Care/Practices for PSF Nursing

    All nurses participate in hospital and unit based orientation that includes competency check off lists, both hospital and unit specific. RN's who float to another unit receive a unit orientation.  RN's that belong to the Float Pool receive additional orientation to the units to which they routinely float. Travelers complete the same orientation checklist as RN's. Float Pool nurses are evaluated by units in which they work with evaluation data sent to the Staffing Office for any needed follow up or education. ( EP11-14 , EP11-15 )

    Specialty Certification is required in some areas for specific tasks.  Oncology requires chemo certification. Carolyn Cusic, BSN, RN, Clinical Manager states: "Currently, the nurses are required to complete competency checklists yearly.  Some of the nurses renew their certification independently and others have not.  Our policy does not indicate it is required.  Deborah Richardson , DNP, CNS, OCN and I are working on reviewing our current policy in comparison to other Centura facilities and the ONS guidelines to make sure we are following practice guidelines." The Clinical Manager tracks education, certification, preceptor status and chemotherapy certification status on all nurses to assist with scheduling and assignments.  ( EP11-16 )

    9. Organizational policies should recognize the myriad needs of both patients and nursing staff . 

    PSFHS' commitment to Relationship Based Care reinforces consideration for patient and nursing staff needs. Many clinical, nursing and human resource policies recognize and honor the needs of patients and staff. For example, Human Resource policies protect staff rights, support staff needs during illness, demonstrate compliance with regulatory requirements, include a shift differential for nights/on-call/holidays, define overtime, breaks, meals, and create regulations that promote a violence free workplace. Each of these HR policies impacts scheduling and staffing. The Overtime, Breaks and Meal policy is attached to represent one way to consider staff needs in scheduling.  ( EP11-17 )

    The "Care of Prisoners" Policy establishes guidelines for securely managing the care of patients who are hospitalized while under arrest or in the custody of law enforcement. The policy states "law enforcement will identify the security rules to be used for each patient. These rules must consider the security of all involved while allowing for appropriate medical care of the patient." ( EP11-18 )

    Applying the Colorado Nurse Practice Act - Delegation of nursing tasks:

    The Colorado Nurse Practice Act regulates acts of delegation. The scope of practice for RN's and LPN's is defined and focuses on oversight and accountability.

    Policy D-02-b: Delegation of Tasks by the Registered Nurse defines delegation and states the approved PSFHS Practices. Delegation is reviewed in nursing orientation and the policy provides an ongoing reference. The Nursing Policy I-01-b LPN: Administration of IV Therapy Guideline defines the parameters of delegation related to IV therapy.  ( EP11-19 , EP11-20 )

    PH 9 is one unit that routinely schedules LPN's as part of their staffing matrix. The Charge nurse provides oversight for LPN practice to ensure she practices within her scope of practice.  If the patient needs blood or IV push medications, the charge nurses is readily available to provide this treatment intervention for patients assigned to the LPN.  ( EP11-21 )


    In addition to using professional organization staffing standards, each unit develops their unique scheduling plan that addresses the specific needs of their patient population, the structure of the unit, and the preferences of staff. Experienced, knowledgeable shift charge nurses use their knowledge of individual patient needs, individual nurse/CNA competencies, and the effectiveness of teamwork assigned to the current shift. In making shift time decisions regarding staffing, charge nurses err on the side of caution as one or two high need patients or admissions/discharges impact the workflow on the team and may affect patient safety.

    While we do not use a formal acuity system, adequate staffing for each shift is achieved by relying on unit data, chart reviews, and experienced charge nurses. Patient safety is our priority and when nurses are out sick or we are unable to fill in an emergent vacancy, teamwork is evident as nurses prioritize to ensure patient safety. The Nursing Staffing Council, implemented in 2011, is evolving and we anticipate that this council will provide strong leadership across the organization regarding staffing and scheduling in clinical care areas.

  • Exemplary Professional Practice - EP12

    Staffing, Scheduling, and Budgeting Processes

    EP 12 How nurses analyze data to guide decisions regarding unit and department budget formulation, implementation, monitoring and evaluation.

    Budget Formulation:

    Budget development, implementation, monitoring, and evaluation are ongoing processes at PSFHS. We operate on a fiscal year from July 1 to June 30 which requires an annual budget be submitted for approval in early spring each year. The Chief Nursing Officer is a member of the senior leadership team and is accountable for the nursing services budget. PSFHS receives final approval for the annual budget from Centura Health. As a value oriented business, PSFHS' commitment is to be fiscally sound and to be good stewards of our limited resources. 

    The annual budget is developed in the spring and is based on the prior year's budget and census projections. New physicians and services that have been added during the year are factored into establishing the next annual budget. The Chief Financial Officer provides a draft of the departmental and unit budgets to the Chief Nursing Officer for review and revision. Unit budget drafts are shared with the directors and clinical nurse managers. 

    The Clinical Nurse Managers, Directors, and our CNO review the budget drafts provided by the CFO. To formulate the budget, these nursing leaders review the prior year's finances and staffing reports; including Vision and Cost Comparison reports, "AtStaff" reports, nursing turnover and agency use data. New programs, or expansions, are factored into the budget when they are anticipated. These nursing leaders provide guidance in all aspects of budgeting for the units they manage. Directors coach managers to identify staffing mix options, analyze over or under budget months, anticipate seasonal fluctuations, and consider cross unit collaboration. Finance staff provide an annual training manual and is available for support.  ( EP12-1 , EP12-2 )

    Capital Budget At least annually, the Chief Financial Officer seeks requests for the capital budget. The request must include item descriptions, an estimated dollar amount, and any additional comments in support of the request. The CFO also asks for a priority rating of items from the directors and managers to assist senior leadership in making decisions. Capital budget formulation is based in part on needs that have been identified by unit associates. ( EP12-3 )  PSFHS has an annual tradition called the "Mud Bowl." Senior leaders, directors and managers meet to review and prioritize capital expenses that have not been approved.  ( EP12-4 )

    Nursing Leadership Management Council Nursing leaders also review equipment and contract budget issues related to nursing. Standardization across Centura Health can be both a quality and cost issue. When Centura Health proposed new compression materials, the Nursing Leadership Management Council saw the demonstration of the product as they considered budget issues.  ( EP12-5 )

    Budget Implementation:

    Resources for staffing are allocated based upon the agreed operational targets within the budget. While senior nurse leaders and clinical managers are responsible for the budget, active participation from direct care nurses is essential in implementing and monitoring the staffing allowances.  

    Implementation and monitoring of the unit budget occurs on a daily basis relative to staffing.  Managers review productivity reports every pay period, or more often if a census is fluctuating significantly. If orientation numbers are above the norm or if there appears to be a significant use of patient sitters further budget analysis occurs. While the Staffing Grid provides the budget target, the charge nurse or clinical manager may deviate from the grid in order to meet unit and patient needs.  When units do not achieve productivity targets, they are required to create a Productivity Variance Report that makes unit leaders address shortcomings and to create plans to correct deficiencies. The managers post the productivity reports and they discuss the findings monthly with their unit associates. ( EP12-6 , EP12-7 )

    Equipment During regular rounding, the manager asks nursing associates the general question, "what equipment or resources do you need to do your job?" On SFMC 5S, the Clinical Coordinator posts a "Needs List" and seeks input during staff meetings on "needs." When items are within the budget, as they usually are, she quickly purchases them. She states "Usually people need small things - another stapler, new BP cuff, a white board - my job is to get these things quickly so we can practice without delays due to small needs."   ( EP12-8 )

    Penrose Hospital Conversion to Private Rooms Penrose Hospital has mix of private and semi-private rooms. Semi-private rooms reduce space for patients, equipment and visitors and negatively impact both patient and nurse satisfaction.  In 2012 PSFHS seriously evaluated the options to move to private rooms without reducing total beds and revenue. In fact, PH 5 did change to private rooms in the spring. Nurses, construction, revenue, bed management and facilities met multiple times to consider budget and space issues.  ( EP12-9 )

    Nurse Practitioners In 2012 the Chief Nursing Officer sought and received funding which was not budgeted, in order to pay for the education of the Neonatal Nurse Practitioners so that they could take courses towards earning prescriptive authority.  Using money from the Tuition Reimbursement fund and nursing administration fund, she arranged to directly pay Regis University for their education. The policy requires a reimbursement process for tuition however, she was able to advocate for this exception.   ( EP12-10 )

    Budget Monitoring and Evaluation:

    Finance provides multiple tools for budget monitoring and evaluation. All nursing leaders have immediate access to staffing reports and specific revenue and expense information through online access to reports. The Staffing Office provides specific reports upon request as well. In addition, hospital acquired infections, falls, and occurrence reports are available to promote the quality and cost evaluation process.

    Performance Feedback and Development Annual goals for all nurses at each level include a focus on unit productivity. Examples of goals and tactics include:

    Vice President of Nursing - Stewardship- Maintain productivity for the roll up of nursing at 100% for the fiscal year.

    Clinical manager - "CVU and telemetry will meet productivity expectations by reducing the amount of overtime by 40% by talking with staff that has more than 15 minutes of overtime for their shift, and by replacing terminated staff within one month to decrease the need for overtime from scheduled staff members."

    RN - Unit will average 100% productivity. I will complete at least 70% of my shifts without overtime."

    Nursing Directors Senior nursing leaders consider impact on budget from multiple areas.  Discussions in one of their meetings in 2011 included the expectation that directors help managers meet productivity, review of agency and traveler nurse use and evaluation of the impact of designing and implementing a new position-permanent charge nurse.  ( EP12-11 )

    Unit Staff Meetings Ensuring that nurses have accurate and current information on budgeting may occur through staff meetings. The Wound Clinic Manager provides data on budgeting to promote nurse participation in analyzing and evaluating related data. Budgeting decisions occur at multiple levels. The following communication was sent to wound clinic nurses via a wound clinic newsletter in December 2011. The data is relevant to their plans to relocate and to the selection of new beds designed to support quality skin care:

    Education The budget process at both the unit and departmental levels requires knowledge of budget structures as well as monitoring and evaluation strategies. While the Finance Department is easily accessible for 1:1 discussion, they also provide small group and larger group education.  During the LEAP series provided at PSFHS in the fall of 2012, nurses requested an overview of the hospital budget.  During LEAP Day 2, budgeting, staffing and productivity are discussed and include handouts to promote understanding and application. In response to the nurses request, Finance presented an overview of hospital budgeting. Following up with this request two additional educational opportunities are scheduled spring 2013. ( EP12-12 , EP12-13 , EP12-14 )            


    Nurses use several tools to analyze fiscal data and to guide budgetary decisions. Each unit reviews their historical monetary output and combines it with projected needs to formulate that unit's budget for the coming fiscal year. These unit budgets are implemented through the CNO, nurse leadership, and our organization's leadership. Throughout the year, that approved budget is monitored continuously and the accuracy of the projection is evaluated.

  • Exemplary Professional Practice - EP13

    Interdisciplinary Care

    EP 13 Describe and demonstrate how nurses have assumed leadership roles in interdisciplinary collaboration.

    Nurses at all levels are actively involved in interdisciplinary collaboration and they are leaders throughout the organization. One of the guiding principles of our Professional Practice Model is Interdisciplinary Collaboration, which is also congruent with ANA's nursing standards of professional performance.

    The nursing philosophy is Relationship Based Care which is one primary element in our Professional Practice Model. At PSFHS we know it takes a team with strong relationships across the spectrum of disciplines, departments, and settings to provide excellent care and to achieve quality outcomes. Nurses at all levels are valued for their leadership skills within nursing and for their expertise at championing interdisciplinary collaboration.

    Leadership by the Chief Nursing Officer and Senior Nursing Leaders:

    Nurses lead the following interdisciplinary teams:

    • The Patient Experience Committee, discussed in length in TL 4 EO, is an interdisciplinary team led by the Chief Nursing Officer
    • The Director of Clinical Effectiveness, Infection Control and Patient Safety Risk Management is a credentialed, certified nurse

    • Interdisciplinary Policy Committee is led by the Chief Nursing Officer

    • The Ethics Committee includes internal associates as well as members from other organizations and from the community is chaired by the Chief Nursing Officer

    Nursing Leaders :

    • Entity Implementation Team (EIT) is chaired by Ramona Beal, BSN, RN, Clinical Informatics Manager. Meeting monthly, this team supports the change management process to ensure effective implementation transitions. Changes may be related to but not exclusive of the electronic health record, clinical effectiveness groups, or corporate project improvement teams  (EIT Tracking form)
    •  The Stroke Team is led by the Stroke Coordinator/Stroke Nurse

    • Peggy Plylar, MSN, RN, CRRN is the Coordinator for the Spine and Joint Program
    •  The PSFHS Pain Committee is chaired by Dan Chatelain, MS, RNC

    •  Heidi Baird, MSN, RN, Regulatory Coordinator chairs the Accreditation Readiness Group

    •  Phyllis Burton, BSN, RN, PCCN, Clinical Manager, Cardiovascular Unit champions Relationship Based Care, disseminating the concepts and practices initiated in nursing throughout the organization

    •  While the Infection Control Committee is chaired by a physician, the Infection Preventionist nurses assume a strong leadership role in this committee

    •  Theresa Lutze, BSN, RN, Clinical Manager, Inpatient Rehabilitation Unit is known for her interdisciplinary collaboration and leadership on the unit ( EP13-1 )

    Leadership by Direct Care Nurses:

    • Dana Justus, BSN, RN, Cardiovascular Unit Nurse chairs the interdisciplinary Falls Committee with coaching from Rose Ann Moore, MSN, RN, NE-BC, Director of Patient Care Services at Penrose
    • On patient care units, interdisciplinary rounds are led by a nurse or nurse case manager.  This interdisciplinary team rounds daily as they review patient status and make changes as needed in the plan of care ( EP13-2 )

    Leadership by Nurses in Positions Outside of the Nursing Department:

    • Jean Barnes, BSN, RN, Director of Information Technology (IT) leads the IT team in collaboration with all disciplines to ensure availability of effective IT throughout the organization
    •  Sylvia Kurko, BSN, MBA, RN, Education Coordinator develops and assigns online learning modules for interdisciplinary education throughout PSFHS

    •  Heidi Bouwens, BSN, RN and Sherry Gray, BSN, RN are the two occupational health nurses who have led the implementation of influenza vaccinations. 

    • Bonnie King, BSN, RN, Trauma Manager coordinates the trauma team readiness for trauma certification as she facilitates education across the organization, participates in interdisciplinary rounds on trauma patients, and monitors quality effectiveness and performance improvements.

    Exemplar - Influenza Vaccinations:

    Nursing leaders were instrumental in our fall 2012 Influenza Vaccination Initiative. Each year our Chief Nursing Officer and Medical Director partner to promote influenza vaccination.  Messages to all Centura Health associates related to mandatory vaccinations began in February 2012. The Colorado Department of Public Health and Environment (CDPHE) proposed legislation to require mandatory flu vaccination for all health care providers. Anticipating that the legislation would pass, Centura Health informed associates that we would adjust our policies to be inclusive of all associates.  ( EP13-3 )  The Influenza Vaccination policy was revised at the corporate level and became effective 8/7/2012. ( EP13-4 )

    Implementation of the Revised Policy involved interdisciplinary collaboration by Nursing Leaders, Human Resources, Occupational Health, Infection Control Committee, Medical Staff Services, the Volunteer Department, and department directors. Occupational Health Nurses coordinated access to the vaccine, flu clinics, as well as tracking all associates to ensure compliance. Human Resources provided required forms and the process for associates who refused to comply with the policy.

    Tracking compliance with the vaccination was a challenge and required IT support as tracking occurred for associates, physicians, volunteers, and contractors. Each group had differing tracking systems that required oversight to ensure we were in compliance with the regulations.

    Tactic to Promote Vaccination

    • Information including flu clinics was posted on the website. ( EP13-5 )
    •  Frequent communication through emails and the weekly newsletter

    •  Bulletin board information in all elevators

    •  Flu Clinics coordinated by Occupational Health with additional nurse support giving vaccinations

    •  Clinical Managers and Nursing Administrative Managers (Supervisors) vaccinated associates during staff meetings or during the shift

    • Occupational Health nurses attended staff meetings across the organization to give vaccinations

    •  Deadline for vaccination or declination established and enforced

      Outcomes We accomplished our goal with a 98% vaccination rate. Two percent of associates obtained approved exemptions. Nursing leadership in all settings and at all levels led to strong interdisciplinary collaboration and successful compliance with mandatory influenza vaccinations.

      Exemplar - Aquapheresis on PH 5 Renal/Diabetic Unit:

      The following exemplar demonstrates interdisciplinary collaboration to introduce a new product and services.   The Clinical Manager on PH 5 took a leadership role, simultaneously coaching direct care nurses to become active participants and leaders in identifying challenges and solutions. Nurses from informatics, revenue integrity, direct care, PICC Team, and professionals from marketing, medical staff, and pharmacy collaborated to design a program based on a physician group suggestion.

      Background/Purpose Heart failure continues to be a national concern. PSFHS established an interdisciplinary team to consider treatment options based on literature. PH 5 Medical (Renal/Diabetic) includes a Dialysis Unit staffed through a contract between PSFHS and Liberty Dialysis. PH 5 nurses provide all care except dialysis to patients on the unit. The team, including physicians, nurses, clinical informatics, revenue integrity, pharmacy, medical staff services, and Liberty Dialysis staff identified an opportunity to expand services for patients with heart failure through an aquapheresis/ultrafiltration process.

       The ultrafiltration process is able to remove 2-4 liters of fluid in a single treatment without a hypotensive effect due to the ability to keep a plasma refilling rate proportional to the fluid removal rate (Rosenthal, 2004). In addition, the process allows sodium to move freely through the membrane keeping the concentrations equal and protecting the electrolyte balance (Streets & Vickers, 2012). In comparison, diuretic treatment causes a much larger potassium loss with a lower sodium loss leading to a potentially dangerous electrolyte imbalance (Streets & Vickers).  The ability to filter sodium at a higher rate may allow for improved renal function and perfusion, though this effect needs further evaluation (Streets & Vickers). One review of literature indicated that, while ultrafiltration may not improve renal function, it did not cause an increased deterioration of renal function either when compared with diuretic use (Kazory & Ross, 2009).

       The process of ultrafiltration has been shown to reduce inpatient stays by two days, improve heart failure classification, and even improve the patient's responsiveness to oral treatments (Rosenthal, 2004). Because of the costs associated with heart failure, the desire to cut down on admissions / readmissions, and the goal to provide the highest standard of care with improved outcomes and patient satisfaction, the nephrology team at Penrose, led by Jesse Flaxenburg, MD began looking at aquapheresis as a possibility for high risk and diuretic resistant heart failure patients.

        Methods/Approaches A benefit of the ultrafiltration program is the ease of implementation concerning a location and equipment. The hospital is able to perform catheter access either through the PICC team or interventional radiology depending on the physician's order and appropriateness for the patient. The dialysis is currently located on the fifth floor with dialysis equipment already available for use in an ultrafiltration process. Dialysis nurses are available and already trained in the ultrafiltration process with 5 th floor nurses who are experienced in caring for individuals receiving ultrafiltration for renal dysfuction. Standards of care in the aquapheresis process include monitoring vital signs, labs, edema and weight changes, maintenance of the catheter, intake and output, and continued education of the patient regarding ultrafiltration and heart failure management. A heparin infusion protocol has been developed specifically for the aquapheresis patient and a standing order set is available for the treatment process.

      The aquapheresis program was initially introduced by Flaxenburg and supported by his partners: Drs. Yuan, Hockensmith, Devault, Ross, and Fox. The clinical managers for the 5 th floor are promoting the program to senior nursing leadership. This program has been reviewed and supported by Rose Ann Moore, MSN as well as exiting CNO, Kate McCord. The nephrology team has worked in collaboration with the cardiology team, pharmacy, clinical informatics and revenue integrity to design this program.

      The aquapharesis process will be performed by the dialysis nurses who work for Liberty Dialysis and contract with Penrose Hospital. Care of the patient will be assumed by the nurses on the 5 th floor. Initial education efforts have been undertaken by Mary Jane Nickell RN, direct care nurse on PH 5 Medical. Formalized education will be performed under the guidance of Liberty Dialysis with a floor nurse liason, Meredith Lauber MS, BSN.


      Melissa Williamson BSN, RN; Yvette Grijalva BSN, RNC; Rob Hollenback, RN Clinical Managers

      Meredith Lauber MS,BSN, Direct Care

      Mary Jane Nickell, RN, Direct Care

      Ramona Beal BSN, RN, Informatics

      Rose Ann Moore MSN, RN, NE-BC, Director

      Dr. Flaxenberg

      Holly Beatty BSN, BSBA, RN, Revenue Integrity

      Mike Force, PharmD, Director of Pharamacy

      Angie Schroeder, Liberty Dialysis

      Alison Schlang, PharmD, Pharmacy

      Nancetta Wescott, Medical Staff Services

      Richard Fatziner, Liberty Dialysis

      Jeannie Fox, RN, PICC Team

      Outcomes The following outcomes have resulted from this interdisciplinary process.

      1. Approved physician order set
      2. Tracking system
      3. Costing structure
      4. Documentation structure and process
      5. Contract revisions and amendments
      6. Initial education planning

      Implementation of the project is pending, and may be delayed until late spring following other major organizational changes scheduled in March and April 2013. ( EP13-6 , EP13-7 , EP13-8 , EP13-9 )


      American Heart Association. (2006). Heart disease and stroke statistics. Dallas, TX.

      Kazory, A. & Ross, E. A. (2009). Ultrafiltration for decompensated heart failure: Renal implications. BMJ , 2-15. doi:10.1136/hrt.2008.160218

      O'Connell,  J. (2000). The economic burden of heart failure. Clinical Cardiology, 23 , 6-10.

      Peterangelo, M. (2008). Incorporating aquapheresis into the hospital setting: A practical approach. Progress in Cardiovascular Nursing, 168-172.

      Rosenthal, K. (2004). Case study: Using ultrafiltration to manage CHF. Nursing Management , 41-46.

      Streets, K. W. & Vickers, S. H. (2012). Is this patient with heart failure a candidate for ultrafiltration? Nursing , 30-36.

    • Exemplary Professional Practice - EP14

      Interdisciplinary Care

      EP 14 Describe and demonstrate how the organization ensures the participation of nurses at all levels in interdisciplinary activities to develop policy and standards of care.

      Nurses at all levels at Penrose-St. Francis Health Services (PSFHS), lead and participate in the development of policies and standards of care through a variety of formal and informal procedures. Structures and process have been designed and are in place to ensure nurses' involvement and/or leadership in policy and standards of care. 

      Providing bedside care is a complex task; it involves multiple disciplines and processes that cross organizational boundaries. Successful strategies to affect the delivery of health care require the integration of all disciplines involved in a patient's care delivery. 

      In order to promote and support participation of all nurses, meetings are scheduled in advance and direct care nurses coordinate with their Clinical Manager, so they are free to attend meetings.  Nurses are paid for their time in meetings, writing, or researching evidence to support policies and standards of care.

      Clinical Nurse Specialists and Nurse Educators provide expert knowledge into policies and standards of care specific to their specialty areas.

      Interdisciplinary Practice Development - Approval and Communication:

      The procedure for finding and selecting evidence based practices is also one for finding, appraising, and aggregating resources as the basis for effective practices. Evidence based practice is the basis for all Interdisciplinary Practices. Staff with appropriate clinical knowledge and expertise, participate in the development of interdisciplinary practices through committees. These committees are designed to forge trans-disciplinary bonds in order to further patient care. Formal review/approval mechanisms are in place to appropriately control the implementation of such practices. ( EP14-1 )

      Interdisciplinary Committees:

      Interdisciplinary Policy Committee (IDPC) The IDPC meets monthly and is chaired by the Chief Nursing Officer. The committee includes a direct care nurse and director level nurse. Representatives from all disciplines review and revise policies on a systematic basis. When new evidence is available or new practices are being considered or implemented, this committee leads the policy and standard of care development for all interdisciplinary practices. (EP14-2 )

      Exemplar - IDPC IDP V-01-b Vacuum Assisted Closure Device (VAC) for Wounds and Open Abdominal System Vacuum Assisted Closure ( EP14-3 )

      This Interdisciplinary policy was reviewed and revised in 2011. The resident experts, the Wound Nurses, were active participants in this process as demonstrated in the attached minutes and policy review. ( EP14-4 , EP14-5 )              

      Exemplar - IDP Blood Culture Draw The review and revisions to the Blood Culture Draw policy and the accompanying standard of care, was assigned to Lynn Plummer-Plunkett RN, Infection Preventionist.  Plummer-Plunkett sent the policy draft revision to nursing, physicians, pharmacy, infection control and education for input prior to approval at the Interdisciplinary Policy Committee. ( EP14-6 )  
      Exemplar - Interdisciplinary Pain Committee Centura Health is in the process of developing standardized polices and standardized order sets. As we move closer to implementing Computerized Provider Order Entry, standardized order sets play an important role in our electronic medical record program (Meditech). A Centura Health Multidisciplinary Team reviews and approves all standardized order sets.

      In 2012, Alison Schlang, PharmD, BCPS, Penrose Pharmacy Clinical Manager participated in the Centura Pharmacy Clinical Team. The Patient Controlled Analgesia (PCA) order set was reviewed and revised based on clinical expertise and examination of all Centura Health PCA order sets. Schlang brought the recommendations to PSFHS for review using the interdisciplinary Pain Committee as well as the Anesthesia Section and Pharmacy/Therapeutics/ Dietary Committee. Each PSFHS committee approved the changes prior to final Centura Clinical Content Steering Committee approval. In December 2012, education on changes was provided via flyers to physicians and in-service education to all nurses. ( EP14-7 , EP14-8 , EP14-9 )

      Nursing Shared Decision Making Councils:

      The Nursing Practice Council (NPC) reviews and revises all nursing standards of care. When a standard may benefit from interdisciplinary collaboration, nurses seek feedback from other disciplines. Most recently, the NPC discussed the use of the "Carpujects" syringe system. The nursing team recognized the value of pharmacy and supply chain expertise in this discussion and decided to contact both of these areas for further information. In addition, our Values Analysis nurse, Michelle Stephens, searches literature for evidence based conclusions for use upon request. (EP14-10 )

      Laser Safety in Perioperative Services:

      Purpose/Background The Penrose surgical nursing team stays current with the Association of Preoperative Registered Nurses' standards and evidence based practices. The AORN Journal (May, 2012) outlined and provided a continuing education offering on "Practices for Laser Safety" (pp.  612-627). Eleven practices for laser safety were recommended. Prior to these recommendations, the policy for laser safety had not been updated since October of 2008. The senior leaders in surgical services identified a need for realigning policies in a comprehensive and multidisciplinary laser safety program.

      Methods/Approaches Cindy Caton, RN, Clinical Perioperative Educator, reviewed the current policies and had sought input from both Centura Health and her PSFHS nurse colleagues. She used the AORN policy/procedure template to initiate a draft policy for altering the existing procedures at PSFHS in a comprehensive way. In addition, she sought expertise from the Clinical Effectiveness/Regulatory Department and the PSFHS Safety Program. The policy was reviewed, revised, and approved by an interdisciplinary group comprised of medicine, nursing, quality, patient safety, risk management, regulatory, perioperative leadership, and safety. ( EP14-11 )

      Caton created a Laser Safety presentation based upon AORN's Recommended Practices and she placed it, along with an exam, on LEARN (online learning system at PSFHS) for the entire staff.  Training was mandatory and is required for all new surgical staff during orientation. ( EP14-12 )

      Cindy Caton, BSN, RN, CNOR, Perioperative Unit Educator 
      Kristin Varnes, MSN, RN, Director of Perioperative Services, Penrose Hospital 
      Kate McCord, MSN, RN, NE-BC, Chief Nursing Officer 
      Heidi Baird, MSN, RN, Regulatory Coordinator 
      David Linebaugh, Manager, Environmental Health and Safety 
      Jeff Oram-Smith, MD, Chief Medical Officer 
      Kelli Saucerman, MSN, RN, CPSQ, Director of Clinical Effectiveness 
      All perioperative staff required to complete new training and comply with changes in policy

      Outcomes The revisions to our Laser Safety Program and the related education materials were made to ensure compliance with the American National Standards Institute's (ANSI) requirements. All staff completed mandatory training. These standards of care and revised policy are also being implemented in our surgical services at SFMC. A review of physician credentialing and the accompanying need for laser safety training is in process. ( EP14-13 )


      Interdisciplinary collaboration is a fundamental expectation at PSFHS. The organization's values of respect, imagination, and stewardship promote identification and the use of a variety of perspectives and expertise to create a healthy work environment and to deliver effective, safe patient care.  Within our Professional Practice Model, the elements of Relationship Based Care, Standards of Care, and Interdisciplinary Collaboration guide the culture of our practices. Nurses at all levels have expertise and knowledge necessary to develop policies and standards of care and are accountable as professionals to participate in our organizational structure.

    • Exemplary Professional Practice - EP15

      Interdisciplinary Care

      EP 15 Describe and demonstrate interdisciplinary collaboration using continuous quality and process improvement.

      Within PSFHS, we believe that a system-wide process to improve organizational quality and performance will result in improved patient safety, excellent quality care and cost savings. We also believe that an interdisciplinary environment is the most effective climate to achieve those goals. As a result, a collaborative and cross-departmental effort drives our improvement actions. 

      The following section describes our structures and processes which contribute to quality improvement, as well as a series of examples which demonstrate the effectiveness of said processes.

      Quality Improvement Structures:

      The PSFHS Performance Improvement/Patient Safety/Risk Management Plan states that

       "PSFHS is dedicated to improving systems and outcomes, a process known as continuous quality /performance improvement…. A collaborative, cross-department 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."

      Everyone at PSFHS is responsible for implementing the Quality and Patient Safety program through the establishment of mechanisms that support effective responses to actual occurrences, ongoing proactive reduction in medical/health care errors, and the integration of patient safety priorities into the design and/or continuous improvement of all relevant organization processes.

      A key element of our Performance Improvement Plan is what we call the FOCUS-PDCA Model. This Model is the adopted methodology used to improve performance through interdisciplinary performance improvement teams. In addition, we use rapid decision making and Six Sigma improvement methodology for system improvement.  Below is the explanation of the FOCUS-PDCA acronym:

      F ind a process to improve

      O rganize a team that knows the process

      C larify current knowledge about the process

      U nderstand the cause of process variation

      S elect the process improvement

      P lan the improvement

      D o the improvement-by piloting or trials

      C heck the results through data collection

      A ct to make more changes or implement the change

      Centura Health has prioritized the implementation of evidence-based practices across our organization. Interdisciplinary teams, including wide representation from PSFHS, target clinical practices to improve patient safety, quality, and outcomes. Clinical Effectiveness Groups (CEGS) are systematic, interdisciplinary teams across Centura that lead the implementation of best practices and seek to reduce unnecessary variation to improve care. The CEGS are in continuous evolution and revision as we set priorities, identify new evidence, target problem areas to improve practice across Centura Health.  ( EP15-1 )

      Quality Improvement Processes

      PSFHS currently uses two interdisciplinary committees to lead quality improvement activities across PSFHS:

      1. Clinical Effectiveness Committee (CEC) is a leadership committee that is responsible for ongoing oversight of safety improvement activities. It does this via periodic reports from individuals or groups accountable for implementation of quality and patient safety efforts at PSFHS. The committee is comprised of members of the Community Board, Senior Administration, Medical Staff, Quality Improvement, Nursing leaders, and clinical ancillary department leaders. These leaders meet monthly to:

      • Approve annual priorities for quality improvement and patient safety activities in the organization. 
      • Review data/recommendations from the Quality/Patient Safety Sub-Committee 
      • Review quality indicator data 
      • Remove barriers to improvement including financial and cultural barriers. 
      • Review the organizations results from TJC and other regulatory agencies site visits. 
      • Assess the adequacy of the allocation of human, information, physical, and financial resources in support of their identified performance improvement and patient safety improvement priorities. ( EP15-2 )

      2. Quality/Patient Safety Committee (QPSC) is concerned with the improvement of quality and patient safety improvement efforts. The QPSC is an organization-wide multidisciplinary committee with representation from departments with the responsibility for aspects of patient and employee safety. The QPSC responsibilities include the following:

      • Provide a system for overall evaluation of the quality of care in the organization. 
      • Develop and prioritize the annual goals for the organization-wide quality and patient  safety program and recommend goals to CEC. 
      • Oversees the comprehensive quality and patient safety program to reduce adverse health events and monitors occurrences of patient safety issues; develops mechanisms to ensure that safety issues are identified and communicated. 
      • Coordinates and oversees data collection, analysis, reporting (internal and external), improvement, and follow-up activities related to quality and patient safety. 
      • Provides interpretation and recommends policies/practices related to quality and patient safety, in accordance with external regulatory requirements. 
      • Proactively educates site-responsible individuals regarding quality and patient safety issues, regulatory requirements, and new statutes/guidelines. 
      • Serves as a resource for quality and patient safety/regulatory issues and for the regulatory component of accrediting agencies. Assists with monitoring programs to ensure compliance with external regulatory requirements.

      In addition, these committees can create "sub-committees" made up of multidisciplinary members to address specific quality issues within our hospital system.  Examples of current sub-committees are Fall Prevention and Pain Management.

      Policies, Procedures, and Protocol PSFHS' protocols reinforce interdisciplinary collaboration.  Throughout our protocols there are references to multidisciplinary instructions. This type of collaboration is fundamental to practice at PSFHS, as implied by the regularity of complimentary cross-notations. The screenshot below is an example of these cross-referential protocols and it demonstrates a clear link between a regular medical instruction and nursing specific standards: 

      Interdisciplinary Collaboration at Unit/Service Line Levels:

      SFMC Radiology Care Diane Kirkbride, RN works in the SFMC Radiology Department. She set up a nursing office and radiology care unit at SFMC. She has designed a radiology orientation packet and process for per diem radiology nurses as well as a nurse reference handbook. Her commitment to quality and ensuring competency has led to an IV competency for radiology ultrasound/CT Scan/Nuclear Medicine technicians including venipuncture, documentation, and IV infusion pump problem solving. Moving to patient needs she has partnered to create a procedure information manual for patients to review while in the radiology waiting area. 

      Kirkbride has collaborated with her radiology colleagues to set up a room and develop a standardized process for bronchoscopy exams. As the service expands to provide outpatient exams, coordination with other departments is essential. Kirkbride has collaborated with a wide variety of health care workers from many disciplines and departments, including: central scheduling, pulmonary department, pulmonologists, outpatient office staff, radiology, nursing, and cardiodiagnostics.

      Effective and efficient use of space, coordination across departments and settings is essential for patient, physician and staff satisfaction. In addition, having rooms available for timely scheduling improves patient care.  Challenges with ultrasound guided biopsies and drainage procedures led the interdisciplinary to design and successfully implement a FOCUS-PDCA performance improvement project.  ( EP15-2b )

      Cardiovascular Unit The following story demonstrates the commitment of our associates for continued quality improvement. Dee Dills is a C.N.A. on the Cardiovascular Unit. She started noticing that many of our post Coronary Artery Bypass Graft patients were having increased amounts of diarrhea; some patients up to 5 times a day on the 3rd or 4th post operative day. This was affecting their recovery in many ways. Patients were more tired and would not get up and walk, they were less likely to go for a walk because of the embarrassment of having diarrhea while walking. Patients were also more likely to get skin breakdown due to the frequent episodes of diarrhea, not to mention the threat of dehydration. Dills noted this significant change with our CABG patients and talked with Olinda Spitzer RN, CNS who represented the CVU and ICU.  Spitzer wondered if there was a change in prescribed medications. She investigated and found that patients were being started on colchicine 1.2mg BID in the ICU. When patients transferred to the CVU they were started on Colace and MOM to prevent constipation from the pain medications. Spitzer spoke with Melissa Temmert, RN and they discovered that the amount of the drug being ordered exceed the maximum dose that should be given in a week. Further investigation by Spitzer found that the reason this population of patients were being given this medication was due to a clinical study which found that patients were less likely to have complications from inflammation leading to atrial fibrillation. Spizer notified John Mehall, MD, Cardio Thoracic Surgeon, of the  side effects this medication was having on the CABG patients.  Dr. Mehall decreased the amount of colchicine and discontinued Colace. Patients are doing better, with decreased diarrhea and atrial fibrillation post operatively. ( EP15-3 )

      Traumatic Brain Injury Team (TBI Team) The TBI Team is a multidisciplinary group which includes members from Trauma Services and Neurosurgery. The team is focused on increasing the implementation of evidence based practices for patients with severe traumatic brain injuries. The TBI team was organized as a response to our trauma review, when the American College of Surgeons (ACS) recommended that PSFHS refine and standardize our emergent neurosurgical care. 

      The TBI team took the lead to implement recommendations based upon the review and best practices. The team identified standards of practice to use in implementing and evaluating our practice. These guidelines included were representative of the following organizations:

      • American Association of Neurological Surgeons   
      • American College of Surgeons Committee on Trauma 
      • National Trauma Data Bank standards

      We implemented quarterly Trauma Neurosurgical Peer review to provide a forum for peer review of trauma cases.

      The Intensive Care Unit TBI team was created to implement and evaluate consistent practices and improve efficiency with TBI care. This group also serves as expert resources for colleagues who are practicing to patients with traumatic brain injuries.  PSFHS had approved order sets available, however physician use was inconsistent.  ICU treats a limited number of TBI patients so the team set the goal to standardize practice to improve quality and outcomes. As a result, an algorithm was developed to assist the RN at the bedside with difficult decisions ( EP15-4 )  

      In order to further adjust for the lack of experience by health providers, an interdisciplinary education program was established. This group sought to review evidence based practices and to provide assistance in the development of systematic traumatic brain injury protocols. The following examines several highlights of this educational program:

      Education and Professional Development Activities

      • Monthly case reviews and presentations occurred monthly in summer 2011 which is our busiest TBI season. Interdisciplinary staff participated in these educational opportunities.  

      • May 9, 2011- Dr. Murk-Emergent TBI Case Presentations to include drain management 
      • June 10, 2011- Dr Brown- Emergent TBI Case Presentations ( EP15-6 ) 
      • July 15, 2011- Sara Westerhaus, PA-C (Neurosurg PA) - Brain A&P ( EP15-7 )

      • The trauma department initiated quarterly intracranial pressure monitoring education for nursing associates.  
      • Integra Neurosciences has provided education on best practices and use of specific TBI products twice in 2011. 
      • Associates on the rehabilitation unit provide ongoing education to ICU and two postoperative units regarding the use of cognitive scoring tools and management of dynamic behavioral patterns.

      TBI Team Participants include :

      Bonnie King, BSN, RN, Trauma Coordinator/Educator 
      Wendy Erickson, BSN, RN Trauma Coordinator 
      Olinda Spitzer, MSN, RN, CNS, CCRN 
      Robin Tillman, RN, CCRN 
      Patty Morse, RN, CCRN 
      Carmen Ramirez, RN 
      Lisa Larson, RN 
      Daniele Francis RN 
      Patti Townsell RN 
      Peggy Hendricks, RN 
      Dayle Thornton, RN 
      Michael Visolosky RN (St. Mary Corwin Hospital) 
      Tonya Kurtz, RN 
      Melinda Rivera, RN 
      Neurotrauma Physician Peer Review Committee 

      TBI Team Outcomes The interdisciplinary team has demonstrated improved communication and collaboration among disciplines leading to use of a standardized order set and ongoing peer review. Focused educational activities were well attended.  The TBI team reports that the staff is able to articulate an understanding of the importance of using evidence based practices to improve outcomes for not only our severe TBI patients but all patients. The following are a series of TBI case studies which emphasize the interdisciplinary nature and effectiveness of our program.

      1. Bonnie Bellman, RN in the Penrose Hospital ICU was taking care of a patient with severe TBI. Her enhanced assessment skills identified subtle papillary changes. She immediately notified the physician and assertively recommended a repeat CT of the head. The CT of the head revealed an acutely developing hemorrhage.  Ms. Bellman received accolades in neurological peer review for her excellent practice which resulted in an improved patient outcome.     

      2. XXXXXXXXXXXXXXXXX a young woman was treated following an accident resulting in severe TBI, including bilateral epidural hematomas. She received two emergent craniotomies and experiences multiple challenging treatment course changes on ICU.  She was transferred to inpatient acute rehabilitation and then to outpatient rehabilitation with focus on cognitive skills.  Dr. XXXXXXXXX states "when I'm old and sitting on my front porch, this is one of the cases that makes it all worthwhile- it is so great to see a patient with a very poor prognosis improve." Below is a clip from a progress note, and it indicates critical care nursing assessment and follow up:


      3. XXXXXXXXXXXXXXXXXXXX a Patient treated in ICU and Acute Inpatient Rehabilitation for large Subdural Hematoma and C-spine fracture with emergent craniotomy, evacuation of hematoma and bone flap removal.  Documentation from his medical record reflects nursing assessment consistent with algorithm.


      Inpatient Rehabilitation Unit Our interdisciplinary collaboration is transparent enough that they are recognized by our patient population. The following is a thank you letter from a family member recognizing interdisciplinary collaboration to improve our process to support the family.  

      Penrose Cancer Center is the only National Community Cancer Center Program (NCCCP) in the state. NCCCP is a designation program of the National Cancer Institute (NCI) designed to foster excellence in community based cancer programs like our own. Their 2011 Annual Report presents Penrose's excellence in clinical trials, multidisciplinary care, care navigation, outreach to underserved populations in Southeastern Colorado, and support for survivorship. This outside recognition is demonstrative of the levels of interdisciplinary care in our organization.

      Thoracic Oncology Program A multidisciplinary conference strategy promotes better cancer outcomes.  A nurse navigator, linked to each multidisciplinary program, is responsible for working directly with patients to assist them with prompt and accurate diagnostic evaluation and treatment.    Two oncology nurses assist with prompt navigation of patients and families through the diagnosis and treatment phase of their illness.  The navigators help coordinate follow up of nodules suspicious for lung cancer through the Pulmonary Nodule Clinic.  In second quarter 2011, 66 patients were navigated through the process, with a total of 302 patients being followed. The navigation process reduced the time of first contact to treatment from 45 days in 2009 to 20 days in late 2011 .

      20092010Jan-Jun 2011Jul-Sept 2011

      First Contact to Diagnosis (Days)1816189

      Diagnosis to Treatment (Days)27191511

      First Contact to Treatment (Days)45352320

      Head and Neck Oncology In 2011, Penrose Cancer Center added a nurse navigator to the Head and Neck program with the goals of improving the experience for patients/families, assisting with the coordination of complex care, and to improve patient outcomes. In many cancer centers, delays in starting treatment may be 30 to 60 days in order to accomplish the various consultations and preparations required for therapy for oropharynx cancer. In 2011 the interval between referral and initiation of therapy was approximately 15 days. Average weight loss during therapy was 5.5% of baseline weight, which outperformed our program goal of limiting weight loss to 10% of total weight.  Only 13% of patients required hospitalization and a mere 8% of patients sought emergency room treatment. 

      Cardiac Rehabilitation Program Reviewing the literature and examining the program experience, clinicians identified an opportunity to improve the identification and treatment of patient depression.  The team of physicians, nurses, dieticians, psychologists and exercise physiologists developed a FOCUS-PDCA to address this concern.  They are using the Dartmouth Questionnaire and PHQ-9 as evidenced based instruments to improve identification and have established treatment referral processes. Beginning this program in fall 2012, outcome results are pending. ( EP15-5 )

      PSFHS Perioperative Services: Surgery  

      We are committed to providing the absolute best health care to our community. One of the most important services we provide is inpatient and outpatient surgery. The operating room is the "workshop" for our surgeons, and it must run well for our organization to be successful. While we have a great staff and successfully perform hundreds of surgeries each month, with the help of consultants, we identified and took actions towards improvement in our OR efficiency at both Penrose and SFMC.  This will be measured by the achievement of the highest standards for on-time first-case starts, block time utilization, and turnover times among many other metrics.

      In November 2010, PSFHS contracted with H*Works, an Advisory Board Company, bring some of the best practices from around the country to increase OR efficiency at both Penrose Hospital and St. Francis Medical Center.  Kate McCord, PSF Chief Nursing Officer and Jamie Smith, PSF Chief Operating Officer are co-executive sponsors of the project.  The project leads are Gayle Eward, interim director of Perioperative Services at Penrose Hospital, and Kelly Ledbetter, clinical manager of the OR at SFMC. (EP15-9)

      The consultants provided recommendations and the interdisciplinary team in the OR's identified and implemented changes to meet goals.  Changes were across the board for associates and physicians working in the OR's.  (EP15-10)  

      1. Clear concise direction on physician block utilization and awards/penalties for using/not using the block time as outlined in OR committee.  Surgeons and Nurses were provided specific guidelines for scheduling.  (EP15-11)
      2. Created a dashboard to focus on outcomes and promote visual ongoing monitoring of metrics for all staff.  Dashboard includes Turnover time, % of first case starts on time, Cost per minutes, Surgeon & Anesthesia arrival time
      3. OR incentive to all OR staff for meeting the above metrics.  (EP15-12)

      We implemented an OR Staff Incentive Plan. Associates in Perioperative Services at PSFHS are in a unique position to directly and seismically impact the financial performance of the OR. From first case start times, to turnover, and supply cost per case. This incentive plan is aimed at providing a budget positive incentive to associates based on improving defined performance.  Metrics for the Incentive Plan include:

      • OR Supply Cost per Unit of Service to be measured and reported monthly
      • OR Turnover
      • OR First Case Start 

      Practice Changes made:

      1. Designed tools to streamline preadmission testing and registration.  This allowed scheduler to determine readiness for appointment, in office or on the phone.  (EP15-13)
      2. Created and implemented process flow changes to reduce morning of surgery delays. (EP15-14)
      3. Physician revisions to improve block scheduling and on time starts including requiring physicians and anesthesiologists to "card in" 15 minutes prior to surgery schedule.
      4. PreOp Nurses in collaboration with physicians and marketing designed a patient education brochure. (EP15-15, EP15-16)
      5. PH OR staff revised schedule to arrive fifteen minutes earlier and reduce time for morning report/assignments.
      6. PH OR UPC identified and is implementing changes to improve efficiency. (EP15-17)

       Outcomes established include three target goals.  The graphs below demonstrate improvements in efficiency in both the Penrose and SFMC Operating Rooms.



      Penrose: % First Case starts have improved from 50% to 64-68%; Turnover times have improved (reduced) from 34 minutes to 30-31 minutes.


      Supply costs at both hospitals have been reduced though have not reached final target goal. 


      Quality care and patient safety are priorities for all PSFHS providers.  Partnering across departments and disciplines at unit, service and organizational levels has improved empirical outcomes as well as patient satisfaction. Our commitment to identifying best practices stretches beyond disciplinary boundaries and as a result, we are recognized as a leading health organization

    • Exemplary Professional Practice - EP16

      Interdisciplinary Care

      EP16 Interdisciplinary collaboration across multiple settings to ensure the continuum of care

      PSFHS professionals are dedicated to interdisciplinary collaboration within our system and external to our organization; with the goal of supporting patients in selecting their care settings and achieving quality outcomes. Within the hospital, patients may transfer across units or departments and receive the same optimum level of care. Within the organization, we provide inpatient and outpatient services in several physical locations. Outside of the organization, we collaborate with other hospitals, senior resources, skilled nursing facilities, healthcare professional offices, clinics, hospice, home health, and other programs to assist patients in improving or sustaining their health status. This section is to provide evidence of PSFHS' interdisciplinary cooperation and the guarantee of care which is the result of such cooperation.  

      Structures and Processes:

      Our organization's strategic plan states our priority for collaboration across multiple settings. It specifically identifies three strategic categories for collaboration:

      • Strengthening the Foundation 
      • Creating Systems of Care 
      • "Moving Upstream"

      As members of Centura Health, we participate in targeted service lines including: Cardiovascular Care, Neurosciences (Stroke) Services, Cancer Center, and Trauma Services. These services transcend one discipline and one department, challenging all associates to form relationships and partnerships with our patients, families, and colleagues. Service line directors build communication links and facilitate sharing of best practices. For example, our Stroke Center of Excellence is built on collaboration beginning with pre-hospital services through the emergency departments, primary stroke units, and acute rehabilitation services, or outpatient therapy programs. All along the patient's path, physicians, nurses, therapists, imaging, and other healthcare associates partner to provide the most effective, efficient level of care for the individual patient.

      PSFHS' committees, task forces, councils, and project teams provide venues for interdisciplinary collaboration. Some of these committees may also include members from the community, such the Ethics Committee which is not only comprised of physician representatives, nursing professionals, hospice, and a case management associate, but also a Deacon from the Catholic diocese, a community attorney, and other outside experts.

      Clinical practice and performance improvement teams are interdisciplinary based upon expertise and authority. The Director of Clinical Effectiveness, Kelli Saucerman, RN, promotes the expertise of infection preventionists, patient safety/risk managers, and clinical effectiveness staff to lead or participate in quality improvement groups across the organization. The Infection Control Committee membership includes representation from multiple disciplines, departments and settings with the unified goal of reducing hospital borne infections through control measures like hand washing.

      The Nursing Professional Practice Model: Circle of Excellence includes interdisciplinary collaboration and nursing accountability in accordance with the ANA Nursing Scope and Standards of Practice. The nurse coordinates care delivery and relationship based care, including building respectful relationships with colleagues in care planning and delivery. 

      The interdisciplinary care planning policy's ( EP16-1 ) purpose is, "To define a standardized process for planning and communicating the patient plan of care within and between all disciplines involved in the care of the patient." It is the policy of PSFHS that:

      A. All patients admitted to an acute inpatient facility will have an interdisciplinary and individualized plan of care supported by documentation within the Electronic Medical Record (EMR).

      B. The interdisciplinary and individualized patient plan of care is constituted of: the Licensed Independent Practitioner's (LIP) orders, interventions selected specific to the patient, the notes and other documentation contained within the EMR, and the healthcare professional's knowledge.

      C. All disciplines will provide care based on the interdisciplinary plan of care and contribute information to the overall medical record.

      Cancer Center:

      Clinical Research Nurses, Nurse Patient Navigators, social workers, and inpatient nurses collaborate and coordinate within the system and community to provide comprehensive care to patients and families. Working with Rocky Mountain Cancer Center, PSFHS Infusion Center, laboratories, pharmacies, and primary investigators from across the nation, our clinical research nurses and navigators keep communication flowing to meet patient and family needs through an interdisciplinary approach. ( EP16-2 , EP16-3 )

      Christine Smith, RN, OCN, Clinical Research Coordinator shares an example of multidisciplinary collaboration across multiple settings:

      "Prior to enrolling this patient in a clinical trial, we communicated with the Rocky Mountain Cancer Center, oncologist and laboratory.  Two nurses met with the patient and family to provide initial teaching and a referral to social work. The social worker followed this couple through many months, providing supportive counseling, community referrals for their family and assistance with SSDI applications. In addition, we provided information on Integrative Therapies classes. When we experienced treatment delays, I communicated with two physicians (Doctors from the University of Maryland School of Medicine and NYU School of Medicine). Ongoing interdisciplinary collaboration continued through his course of treatment and included:

      a. Rocky Mountain Cancer Center 
      b. Oncologist and Nurse Practitioner 
      c. Pharmacies that prepare and then distribute medication to ensure patient received trial medications 
      d. Laboratory 
      e. Infusion Nursing in Penrose Hospital 
      f. Research primary investigators in Maryland and New York 
      g. Penrose Clinical Trials team 
      h. Community referrals and assistance 
      i. Thoracic Nurse Navigator 
      j. Social Work 
      k. Penrose Inpatient Oncology unit during inpatient treatment" 

      This story is indicative of the kind of multidisciplinary work employed by PSFHS. This couple received care along the continuum spectrum including support from a wide variety of specialties. 

      Oncology - Patient:

      Caring for a patient with Acute Lymphoid Leukemia (ALL) requires collaboration across multiple settings to ensure that the patient is receiving the best possible care. This piece of evidence is concerned with the care of a patient suffering from ALL. When this patient left the hospital with a new diagnosis of ALL our oncology services partnered with him to plan, provide for, and to evaluate his care. The healthcare providers and plan of care were interdisciplinary and they included: his physician, laboratory, blood bank, surgical services, infusion center, clinical trials research, pharmacy, radiology care unit and patient navigation. Nursing takes the lead as they coordinate his care between the various parties and the nurse in charge at all of the units he uses. After two years, he continues his participation in the clinical trials and receives care from the same group of professionals. ( EP16-5 )

      Medical Services:

      Our nurse case managers and social workers work collaboratively with the patient, their family, and the interdisciplinary healthcare provider team to facilitate a continuity of care across settings and to support patient preferences. A gentleman with end stage chronic obstructive pulmonary disease was admitted multiple times to our facilities. Various providers provided treatment and had been able to support a continuity of care between the emergency rooms, inpatient units, and outpatient providers. His choice is to live at home and he has been clear he is not interested in nursing facilities. Supporting his discharge preferences has required coordination with:

      • His Primary Care Physician's office 
      • HCBS 
      • Nurse Finders Home Health Care 
      • Palliative Care 
      • Hospice 
      • Judicial system/Court 
      • Attorney 
      • Advanced Medical Solutions 
      • Home oxygen services 
      • Laboratory testing and pulmonary treatments

      In addition, we have facilitated his purchase of durable medical equipment at reduced costs through Silver Key, a community senior service. In the context of his increasing disability and continued medical needs, we have assisted him to obtain Medicaid coverage. ( EP16-6 )

      Emergency Transfer - Nurse Planning:

      Patients may be admitted for stabilization prior to a transfer if medically indicated. In November 2011, a patient was admitted to SFMC ICU via the Emergency Department. This patient was critically ill, unstable, and had history of organ transplant. The patient's response to initial treatment interventions and multiple consultations resulted in a grim prognosis. This patient did not have any form of advanced directive and the patient refused any information related to creating one. Recognizing the need for specialized treatment, the physician, case manager, and nurses coordinated a transfer plan. Based on the patient's clinical status, a nurse and respiratory therapist accompanied the vented patient to a specialized treatment facility in Denver. ( EP16-7 )

      Meditech - Our Electronic Medical Record System:

      In December, 2008 PSFHS implemented Meditech, the standardized documentation system selected by Centura Health. During the past four years, our system has undergone many changes and we stand poised to add the Computerized Provider Order Entry (CPOE) element in April, 2013. Documentation templates and Meditech functionality have improved via features such as auto fills and links between modules. The ability to visualize trends in vital signs or laboratory results, access to see imaging, and links to physician office systems improve the continuity of care across multiple settings. As health care providers have digitized tools to identify areas of concern and records are easily identified and accessed. Individual patient records are accessible throughout the Centura Health system, so prior to a patient arriving from another Centura Health facility, we are able to see their status and current treatment. ( EP16-8 )


      PSFHS utilizes a comprehensive system of care in order to ensure that patients are able to receive care throughout their lives. This system is multidisciplinary in nature and it encompasses health and care services from both within and outside of our organization. Patients can expect to receive physical care from nurses and physicians of virtually any specialty, spiritual care from community leaders, and additional care from other experts ranging from attorneys to those who provide financial services.

    • Exemplary Professional Practice - EP17

      Interdisciplinary Care

      EP17 Describe and demonstrate interdisciplinary collaboration to ensure that information systems and technology used for clinical care monitoring, documentation, and communication are integrated and evaluated.


      Centura Health Gary Campbell, president and CEO of the Centura Health system, has a goal for our integrated electronic health records. He envisions one documentation system, requiring interdisciplinary collaboration, which will effectively integrate information processes to improve clinical care monitoring, documentation, and communication.  

      August 2011 Centura Health will be known as a health care system that achieves the highest standards in patient safety and quality care, in great part, through a fully integrated EHR system. Every record of a patient's or resident's health care is available in one place-the computer closest to the clinician. Through an ever-growing database of clinical results and information, our medical professionals determine the best in evidence-based care and achieve superior results. Through the collaborative effort it took to build this fully integrated EHR system, and through increased patient care collaboration throughout our system, Centura Health has created the most closely knit team of medical experts to be found anywhere in the country. Is it a bold vision? Yes; and by consistently working toward it, we will achieve widespread impact and lasting value for those we serve!      Gary Campbell 

      In order to ensure adequate nursing and clinical leadership in information technology, the Centura Chief Nursing Officer employed a Chief Nursing Informatics at the corporate level who supports and leads the Clinical Informatics Managers throughout the Centura system. ( EP17-1 )

      As we continue forward with enhancing the EHR integration and expansion, the ongoing evaluation, structures, and processes have been revised. The primary groups at the Centura Health level responsible for this interdisciplinary leadership include:

      • Administrative Support Centers (ASC) 
      • Clinical Informatics 
      • Evidence Based Practice Group and Entity Implementation Teams (EIT)  ( EP17-2 ) 
      • Information Technology

      An example from the Emergency Department ASC reflects changes made to improve the electronic medical record. Todd Farina BSN, RN, Penrose Emergency Room is an expert nursing representative on this ASC. Improving, evaluating and integrating technology for clinical care is the primary function of this ASC.  In October 2011, the ED Module (EDM) integrated several changes to improve clinical care monitoring. ( EP17- 3 )

      Centura Health Values Analysis (CHVA) an interdisciplinary group, identifies technology options available through our contracting system as well new technologies that may improve clinical care monitoring.  Michelle Stephens, BSN, RN, represents PSFHS on this team.

      Penrose-St. Francis Health Services PSFHS has a history with using information systems technologies. As technology has evolved and the need for further integration of systems was identified, PSFHS examined available technology in light of our evolving clinical needs. Physicians, nurses, IT, finance, and others participated in this journey during the 2000s, implementing a electronic medical record (Meditech) in December 2009. From 2007-2009, two full time nurses plus several part time nurses from PSFHS participated in Meditech system design and testing with interdisciplinary representatives from across Centura Health.

      Entity Implementation Team at PSFHS is a standing multi-disciplinary entity oversight committee accountable for receiving and operationalizing corporate projects. Changes may be related to, but not exclusive of, the electronic health record (Meditech), clinical effectiveness teams, or process improvement teams. This team provides an efficient and effective system for managing change and reducing redundancy of efforts. This multi-disciplinary team ensures that information systems and technology use for clinical care monitoring, documentation and communication is evaluated and integrated.  ( EP17-4 )

      Primary Staff Expert Leaders for Information Systems and Technology

      Jeanne Barnes, BSN, RN is the PSFHS Director of Information Systems. As a nurse and IT specialist, she has expertise in understanding clinical requirements and effective use of technology to achieve those requirements. In this capacity, Barnes makes decisions on hardware purchasing, distribution and maintenance for PSFHS. Further, she is actively involved in the evaluation of technological purchases, to ensure that they continue to assist direct care health workers and that the technological programs do not become a liability. Barnes participates in the Nursing Leadership Council as needed to seek input and discuss technology options to support nursing practice. ( EP17-5 )

      Ramona Beal, BSN, RN is the PSFHS Clinical Informatics Manager. She chairs our Entity Implementation Team (EIT) and partners with clinical informatists across Centura Health. As we move forward with Computerized Provider Order Entry (CPOE), her role includes collaboration with trainers for all associates and physicians, as well as resolving workflow issues identified by interdisciplinary teams. ( EP17-6 )


      Meditech Technology can help clinicians make better decisions at the point of care. A quick look at the patient record shows isolation state, code status, recent medications, lab values, and past assessments. "Pop Ups" and various colors are used to highlight safety issues, critical labs or remind clinicians of needed interventions. 

      Our Clinical Informatics Team works to ensure that clinical care monitoring with electronic health records (EHR) is an ever improving process. Their experience in clinical practice, their passion for using technology to improve care, and their motivation to grow professionally is evident from the years of planning Meditech implementation, the ongoing review of system use, software module revisions (including streamlining assessment screens), and reducing redundant data entry. PSFHS' clinical informaticists are active partners with other Centura Informaticists in designing systems that will work across our organization and in building consistency in data collection fostering stronger data analysis. 

      Meditech updates and revisions improve the integration and communication of information systems and technology used for clinical care monitoring, documentation, and communication are integrated and evaluated.

      • Meditech automatically sends immunization data to the Colorado Immunization Information System enabling providers to obtain information on immunizations previously given to patients by other providers participating in the registry.

      • In order to provide clinicians with a more complete picture of a patient's medical record, vital sign information obtained from clinic and hospital visits are augmented by vital sign information collected in a patient's home.

      • Real time scanning improves access of all clinicians to documentation in current record as well as in prior admissions. The Ethics Consultants requested electronic access to Advance Directives and medical records initiated scanning so all providers can quickly see patient preferences. ( EP17-7 )

      • Centura Rehab team requested changes in documentation to improve interdisciplinary communication. ( EP17-8 )

      •  Meditech In-Patient CPOE PSFHS is preparing to "Go Live" with Computerized Provider Order Entry (CPOE) in April 2013. During the last two years, order sets have been standardized and revisions in technology as well as clinical practice processes have occurred. This project is currently our most complex, interdisciplinary process to improve the integration of technology used for clinical care monitoring, documentation and communication. During the prior two years, Clinical Informaticists across Centura Health have worked with information technology, physicians and other clinicians to evaluate the system and roll out implementation across each facility.  Revisions in documentation in preparation for Go Live are in process. ( EP17-9 )

      • Care Continuity is a downtime system that provides access to clinical information during a scheduled or unscheduled Meditech downtime.  All healthcare providers require access to critical patient data throughout a Meditech downtime.  The process was designed by IT with input from all disciplines to ensure patient safety.  (EP17-10 )

      • ICU Physiological Monitor Interface integrates ICU monitors with Meditech documentation systems, reducing duplicative documentation and streamlining workflow. The interface improves access to real time patient status for all providers regardless of location which assists with treatment decision making.  ( EP17-11 )

      Bar Code Medication Administration (BCMA) PSFHS implemented BCMA in 2010 following graph provides data over a two year Centura Health wide process to evaluate and pilot technology. The collaboration of pharmacy, information technology and nursing led to successful implementation and meeting our BCMA Scan Rates to improve patient safety and meet Meaningful Use requirements. In addition as our Bar Code Scan rates have improved our admission medication errors have decreased from 0.22 to 0.16 in two years (Oct 2010-Oct 2012). 

      Centura's Future in Interdisciplinary Information Systems Centura has established four working groups that are charged with ensuring that we stay ahead of the "curve" in information systems. ( EP17-12 ) This is an interdisciplinary endeavor as each group is made up of specialized associates, as the following list describes:

      • Group 1 (visionary group) Made up of leaders and those with IS/IT expertise 
      • Group 2 (users) Those who use different systems and identify needs and innovations 
      • Group 3 (financing) Those with direct knowledge of system costs and available funds 
      • Group 4 (overview) Working closely with Group 2, this is made up of clinicians


      Centura Health and PSFHS have structures and processes that ensure information technology and systems are evaluated and integrated through interdisciplinary collaboration.  Clinical care, documentation and communication is improved through our ongoing improvements in our electronic health record and patient education materials. As we implement CPOE we are confident patient safety and quality care will continue to improve.

    • Exemplary Professional Practice - EP18

      Interdisciplinary Care

      EP 18 Describe and demonstrate interdisciplinary collaboration to develop, implement, and evaluate a comprehensive set of patient education programs and resources within the organization.

      Patients and families receiving treatment through Penrose St. Francis Health Services can expect a holistic approach to their care, collaboration among disciplines involved in treatment, and education provided at a level to enhance understanding, informed consent, and active participation in their treatment.

      Structure and Process:

      The hospital provides patient education and training based on each patient's needs and abilities (The Joint Commission, 2010). 

      PSFHS provides services to a wide variety of patients which requires a comprehensive education program and resources in a variety of formats for ease of access and individualization. The PSFHS Patient Education Committee (PEC) is an interdisciplinary committee comprised of members from inpatient and outpatient services. The Chief Nursing Officer chairs the committee which meets quarterly or as needed. The PEC Guidelines for Practice state, "The interdisciplinary Patient/Family Education Committee will plan and support the provision and coordination of inpatient and outpatient and family educational activities, including the approval of internally developed materials used for patient education such as booklets, brochures, videos, and teaching sheets.  Educational materials that are developed by the Penrose St. Francis Health Services (PSFHS) staff will also be approved by the medical director of a department or service or by the Director of Medical Education." ( EP18-1 )

      The PEC membership includes: 
      Kate McCord, RN, Chief Nursing Officer 
      Rose Ann Moore RN, Director Patient Care Services at Penrose 
      Larry Benner, Respiratory Therapy 
      Jean Baumann, RN, Diabetic Educator 
      Andi McDonough, PT, Manager Outpatient Rehabilitation 
      Lynn Plummer, RN, Clinical Effectiveness 
      Jolene Bedford, Family Education 
      Judy DeGroot, RN, Cancer Center Lead Navigator 
      Tamra Renzelman SW, Director Case Management 
      Sharon Fletcher RN, Cardiology 
      Jeanne Barnes, Director Information Technology 
      Ginger Karbousky RN, Patient Representative 
      Alison Schlang, Pharmacy

      The development, implementation, and evaluation of patient education occurs at the individual patient level, unit, department and service line levels; with coordination of  development and evaluation of materials and resources used throughout our organization occurring through the PEC. In general, PSFHS approves the use of patient education materials available through national professional and disease specific organizations. The expectation is that professionals will stay current and use appropriate professional resources. 

      The nursing standards include Health Teaching and Health Promotion (Standard 5B, ANA Nursing Scope and Standards of Practice). PSFHS' professional nurses employ multiple strategies including teaching and the evaluation of pedagogical approaches in order to promote health and a safe environment for patients. Recognizing the interdisciplinary nature of patient care, collaboration and coordination with all disciplines regarding patient education is essential for quality care.

      A relationship based care philosophy requires a well-designed and well-delivered patient education program to improve patients' ability to participate both in their treatment as well as to increase adherence to prescribed treatment after discharge. Recognizing the varying learning styles and abilities in our diverse population, we use verbal, written, and visual modalities to assist with learning.


      Centura Health develops contracts to meet facility needs for some patient education materials and resources.   For example in 2009, The Patient Channel was identified as a source of patient education materials and alternate method for teaching. Other hospitals in the Centura system reported a positive evaluation of this technology. In 2011, PSFHS implemented the Patient Channel. ( EP18-2 )

      Micromedix CareNotes is the preferred intranet source for patient education. Centura Health purchased this service several years ago for all facilities to use. Available at all computer stations, providers may look up topics specific to patient treatment plan, customize and print for discussion with patient as well as for patient reading and review post teaching. The Micromedix CareNote application is easy for all clinicians to access and includes unbiased, peer-reviewed content that is updated regularly. Recently changes were implemented in Meditech that now support a direct link between Micromedix and documentation of teaching; this link automatically brings a copy of the teaching materials use into the electronic health record.

      In 2011, PSFHS obtained access to the Mosby Software Suite which includes patient teaching materials as well as access to evidence based practices. These practices expand nursing knowledge and they may be relevant to patient teaching.

      Interdisciplinary Unit Rounds provides a structure to identify and evaluate education needs for individual patients. It also allows educators to gauge the effectiveness of their current tools, which promotes an evolving educational approach.

      Specific diseases or health needs are usually met through our use of materials from specialty professional organizations, such as The National Cancer Center. Specialty nurses and educators implement and evaluate patient education programs. Examples of these teaching specialty areas include:

      • Diabetes 
      • Stroke 
      • Congestive Heart Failure 
      • Birth Center Classes including Family Education 
      • Cancer Center classes 
      • Smoking Cessation

      Centura Health's Quality and Evidence Based Practices Committee develops and evaluates specific educational materials. These materials are reviewed by PSFHS PEC to determine a customized implementation processes. In the March 2012 PEC meeting, Kathy Specht, RN, Case Manager presented a Centura Health approved booklet for Congestive Heart Failure education.  The PEC reviewed this educational material and planned for its intervention. (EP18-3 )

      Joint Care:

      PSFHS has historically provided joint classes prior to surgery, which was usually led by a physical therapist. The classes focused on specific limitations and the therapy process following total joint procedures. In 2010, Kim Booton, Case Manager presented a draft to revise the class.  The PEC reviewed Booton's material in November 2010, and made several recommendations. ( EP18-4 ).  In 2011, a Joint and Spine Coordinator was hired and took over the coordination of educational materials. She evaluated current educational materials as well as recent research related to joint patient care. An educational booklet was developed to address joint issues in collaboration with case management, physical therapy, occupational therapy, nursing, physicians, and marketing. Photos of our surgery rooms as well as of our therapists demonstrating physical therapy exercises and safety limitations were included in this new offering. In March 2012, the PEC evaluated the material and approved the booklet.  The booklet was implemented and patients verbally report it is helpful. ( EP18-5 )

      Stroke Education:

      Patients admitted with ischemic, transient ischemic attacks, or hemorrhagic stroke received inconsistent education in prior to 2010. The Interdisciplinary Stroke Committee identified the need to improve stroke education, and as a result they implemented quality improvement strategies to develop evidence based stroke education materials. Additionally, they sought to standardize the education materials across our system and effectively use technology to facilitate the implementation of the practice. The stroke coordinator met with staff nurses to educate them on rationale for change and the process for stroke teaching. Further, the coordinator obtained materials from the American Heart Association for all stroke care units and initiated audits with feedback to evaluate the effectiveness of these strategies. ( EP18-6 )

      Elevator Boards:

      The use of bulletin boards in elevators at Penrose Hospital presents educational materials in colorful, quick view formats. The Clinical Effectiveness staff, which includes representatives from Patient Safety and Infection Control, use professional organization materials such as information on hand hygiene and influenza vaccination from the Centers for Disease to educate all people within Penrose Hospital. These materials reinforce quality and safety initiatives within PSFHS as they serve as a reminder of best practices. At the same time, community members and visitors receive evidence based education to promote their health and safety. In November 2010, our Clinical Effectiveness staff presented a poster at the 3rd Annual Centura Health Evidence-Based Practice, Research and Innovation Conference in Denver. ( EP18-7 )

      Rehab Buddy Library:

      The inpatient rehabilitation unit is composed of nursing, medical, occupational therapy, physical therapy, speech therapy, language therapy, spiritual care, counseling, psychology, and volunteer associates who partner to provide education to patients and families. Using evidence based practices, the team designed pathways for specific diagnosis, to include educational support. An example of this educational support is the Rehab Buddy program. The Rehab Buddy program was funded through a grant, and its financial backing went towards the development of a library on the unit.  The "Buddy Team" asked for materials and ideas from all disciplines and they had incorporated concepts that they found useful when they were rehab patients. PSFHS constructed the area and donated computers per Rehab Buddy request.  The unit's medical director approves all resources used for patient education.. This Rehab Buddy Library is located in the center of the Rehab Unit for easy access.

      Bariatric Education:

      Bariatric Education materials were drafted by the Bariatric Coordinator in collaboration with surgeons.   Approved by the PEC, this material is disseminated through the Penrose-St. Francis Health Services website and can easily be updated as needed.  ( EP18-8 , EP18-9 )

      Family Education Department:

      The Family Education Department at St. Francis Medical Center is an invaluable asset to the Penrose St. Francis System. This department is made up of ten instructors, all of whom are certified in their area of expertise. Some instructors work in multiple areas, and their multidisciplinary backgrounds support education across the continuum of care and multiple settings.  They are led by Jolene Bedford RNC, MSN, LCCE, IBCLC who also manages the Lactation Center at SFMC.   

      The instructors provide classes for families that include: Prematurity Prevention, Child Birth Preparation, Labor Skills Refresher, Breastfeeding, Baby Care, Infant / Child CPR, Car Seats, Sibling Classes, Infant Massage, and more. Support groups are offered to aid families with breastfeeding and adjustment to parenthood after discharge. The Family Education Department also includes "The Fertility Care Center of Colorado Springs" - a natural family planning program that supports our catholic mission and core values.

      Most of the classes provided are after-hours. This is to allow for the schedules of working adults. This is important because the family education instructors, and the services they provide, are often the first exposure that many expectant parents have to the Penrose St. Francis System. The feedback from parents and staff is positive and indicates the classes are meaningful and that they provide needed education. The Family Education Department has experienced challenges, however, recruiting competent and certified instructors and has had an open position for two years. In order to account for this ongoing problem, the Family Education Department has initiated several strategies to ensure continuation of the program with competent instructors.

      1. Maintained close contact with the Lamaze Certification Program in Denver to facilitate student teaching opportunities when a candidate lives in the Colorado Springs area. 
      2. Offered current qualified RN staff the opportunity and support to obtain certification with tuition assistance.  
      3. Begun revision of curriculum in 2013 to shorten some classes from two sessions to one so that the same staffing levels can be maintained while doubling the number of people who could take a class.   
      4. Purchased an online Childbirth Class that includes an optional opportunity for attendance at a one evening skills class with a certified instructor to practice what they have learned at home. This class will begin in January 2013 (EP18-10 )

      All Birth Center Education is provided to meet patient and family needs by certified interdisciplinary professionals. All education content is based upon the standards from the following professional organizations:

      • American Congress of Obstetricians and Gynecologists 
      • International Childbirth Education Association 
      • Lamaze International 
      • The American Board of Family Medicine 
      • International Lactation Consultant Association 
      • American Academy of Pediatrics 
      • American Dietetic Association 
      • March of Dimes 
      • American Heart Association 
      • National Highway Traffic Safety Administration 
      • Crieghton Model for Fertility Care

      Unit Patient Education "Easy Access" Resources:

      The photos below demonstrate displays, books and computer access present in the central areas of the units. This promotes patient education and encourages independent research.




      The above examples demonstrate that Patient Education at PSFHS is an interdisciplinary responsibility supported from the unit to organizational levels. These programs are designed to meet unique patient and family needs. The use of Centura Health's contracted online resources and other technological tools promotes current evidence based education. Using innovative strategies, such as the Elevator Boards, we expand our education to broad safety and wellness initiatives that may benefit all who enter PSFHS. 

      Through oversight and approval processes, the Patient Education Committee promotes the development, implementation, and evaluation of internally established educational resources when professional materials do not meet our patient/family needs. This interdisciplinary committee promotes current, evidence based, as well as a comprehensive set of patient education programs and resources throughout PSFHS.

    • Exemplary Professional Practice - EP19

      Accountability, Competence, and Autonomy

      EP 19 Describe and demonstrate that nurses have ready access to, and routinely use, current literature, professional standards and other data sources to support autonomous practice.

      Registered nurses are licensed and authorized by the state to practice nursing within the profession's designated scope. Our Professional Practice Model provides the structure to support autonomous nursing practice through the inclusion of nursing standards and interdisciplinary collaboration. 

      Nursing orientation sets the expectations of nursing practice within PSFHS. All new nursing associates are oriented to our Professional Practice Model (PPM), which includes the stated expectation of accountability to the ANA Scope and Standards of Nursing Practice and Performance and the ANA Code of Ethics for Nurses. Using our PPM as a point of reference, discussions of evidence-based practices and access to current literature is included.  In addition, unit nursing preceptors show new nurses how to access professional standards and other data sources to support autonomous action. 

      PSFHS has multiple structures and processes that provide ready access to current literature, professional standards and other data sources that support autonomous nursing practice.

      Structures and Use of Written Data Resources:

      •Nurses and nursing councils regularly forward professional articles to colleagues for review, discussion, and consideration for practice. ( EP19-1 , EP19-2 )

      •PSFHS Nursing Services subscribes to the Journal of Nursing Management for all managers.

      •Individual units and the PSFHS Library subscribe to professional journals which are available in break rooms and digitally. In addition, some articles are posted on bulletin boards or copied and placed in resource notebooks on the unit. Individual nurses share their personal subscriptions with nursing colleagues to improve nursing practice. Managers highlight access to these articles on white boards by the nursing stations.

      •Vendors provide handouts and flyers, posted on units or by products to support autonomous practice. Cheryl Rudolph, RN, Wound Care states "the vendor for new ostomy wafers was very helpful. He trained staff for two days and left literature to help answer questions."  In addition, some vendors leave DVD's for staff education and training.

      •Written resources available on units vary depending upon the specific group's needs. For example, some units have a Pain Management Manual or educational brochures, the results of a collaborative effort between nursing and pharmacy. In addition, pharmacy sends ISMP Medication alerts and adds comments when information is especially relevant to nursing units.  ( EP19-3 )

      •Nursing Newsletters support autonomous practice by providing information on new policies, summaries of current nursing articles and educational opportunities. ( EP19-4 )

      •Wound Care Nurses and Unit Based Skin Experts created a Pressure Ulcer/Wound Care Resource Book with information and photos to promote increased nurse competency and autonomy. Some areas have used a poster with tear-off sheets to support education on wound V.A.C. for patients and families.

      •The Stroke Manual is available on all our stroke units including emergency departments. The manual includes current evidence based literature and references as well as relevant policies and procedures. The below vignette is evidence of the effectiveness of this particular data source: ( EP19-5 )

      November 2010 Chris Williams, RN, 7th floor .  "I was assessing my post op patient; she was alert and oriented. I left the room to gather some items for her care and upon return she was not responding. I immediately called the charge nurse, clinical nurse manager, and our Rapid Response Team. Audrey Simpson, our manager, had just received a new stroke alert protocol on responding to possible stroke in patients on our inpatient units. She pulled this off her desk and we used it to guide our interventions. The patient went for a CT scan and then transferred to Critical Care Unit and is doing well.  What timing! Great nursing expertise - timely response from everyone - and a new protocol that came at just the right time. Thank you to Susan Baker PhD, for leading our Stroke Program." 

      Structures and Use of Online Data Resources:

      •Demonstrating our continued commitment to evidence based practices (EBP) and easy access to literature to support autonomous practice, Centura information technology collaborated with clinicians to plan and implement several software projects; a good example of which is the implementation of Mosby's Nursing Consult. The Mosby Implementation Team included nurses from each Centura organization. In 2011, Mosby Consult was set into place through our nursing preceptors who were led by team leader and PSFHS Nurse Educator, Diana Patterson, RN.

      Mosby's Nursing Consult, Nursing Skills, and the associated Nursing Index are readily available from all workstations. These products offer nursing-specific tools that enhance patient care and nursing education by allowing quick access to evidence-based practices, procedure videos or diagrams and journals. Mosby is accessed by associates who simply click on the Mosby icon on the desktops of clinical workstations. The resource is also available to all associates on My Virtual Workplace which provides access from home. ( EP19-6 )

      The following is a brief testimonial of the ease of access and utility of this product:

      Pat Wilfong-Major RN, PH 4 states "I use Mosby to look things up all the time.  I had questions about a rash on my patient and as I tried to recall all I know about Stevens-Johnson syndrome; I remembered I can (and did) look up information from my computer!  Another nurse asked about Sjogrens Disease - I showed her how to get the latest information and evidence based nursing practice on Mosby. I love it!"

      In 2012, following input from nurses, Centura Health approved the use of "Mosby Clinical Procedures" for nursing guidelines. ( EP19-7 )

      •Meditech, our electronic medical record system, is used every day for documentation, assessment, and treatment planning. Embedded in Meditech are multiple data sources to support nursing practice; including information about medications, standards of care, and pop up reminders or cautions. For example as we implement evidence based practices, we design the electronic medical record documentation to prompt for these practices. When we changed our Fall Assessment process, we revised the documentation to clearly guide the nurse through the agreed upon standard of care related to fall risk interventions. Designing technology is one way to support autonomous practice.  ( EP19-8 ) 

      •All nursing workstations provide access to the internet and links to the current PSFHS Interdisciplinary Policies and Nursing Guidelines. One physician wrote this letter of support about Evelyn Angeles, RN, Cardiovascular Unit which demonstrates the overall efficiency of this particular device:

       "Evelyn stands out even among a group of highly talented nursing staff for her knowledge base and her clinical acumen. Evelyn frequently has already prepared a differentiated diagnosis for her patient problems before the physician has even seen the patient on the floor. In one instance of a patient who was eventually found to have a pheochromocytoma, Evelyn had already suggested that diagnosis in her notes based on a computer search of the patient's symptoms . Her clinical awareness and acumen are therefore greatly appreciated by the entire physician staff." 1/2012 William Barry, MD (emphasis added) ( EP19-9 )

      •The Nursing Intranet available from work and home includes links to resources including: the Colorado Nurse Practice Act, various nursing standards, evidence based practice tutorials, and library resources. ( EP19-10 )

      •Risk Management provides an online occurrence reporting structure to improve both reporting and tracking which allows for the continuous monitoring, evaluating, as well as immediate action by the risk management nurses to support quality care.

      •"Facts & Comparisons Online," the online version of the Drug Facts and Comparisons Reference Manual, is available on the Centura Health network. The online version includes daily updates providing real-time access to the most comprehensive and in-depth drug reference available. Detailed product information on more than 22,000 prescription drug products is provided. Pill identification with the interactive Drug Identifier tool is included along with modules that support patient counseling initiatives. Also available is the Cancer Chemotherapy Manual which is invaluable to our Oncology associates. The link to Facts and Comparison can be found under the Reference Tab in My Virtual Workplace. For nurses' convenience, no separate log in is required if accessing via the Centura Health network. 

      •All associates have access to My Virtual Workplace and the Centura Health Reference Tab, which provides multiple resources including:

       • 2009 H1N1 Flu Site 
       • ADA Nutrition Care Website 
       • CDC Isolation Precautions 
       • Facts and Comparisons 
       • Hazardous Pharmaceutical Disposal 
       • MicroMedex 
       • Zynx Health

      •MicroMedex has several applications which support search functionality; including results that provide a complete picture of all available information about a drug or condition on a single screen. In addition, MicroMedex has tools for calculating dosing, analyzing laboratory values, identifying antidotes, IV compatibility, drug identification with images, comprehensive drug interaction checking, and Tox & Drug Product Lookup for quick substance identification.

      •The Webb Library provides professional journals, reference books, and professional publications for onsite perusal or check out. The librarian supports clinicians' pursuit of documentation by performing literature searches upon request. Associates and physicians can look for a particular book or journal before going to the library as well as search online for literature. We encourage nurses to use the journal full text option to review their professional journals each month. Education on the use of the library and the websites is provided at orientation, during Nurses Week and by the members of the EBP Nursing Council to units or individuals.

      Access to the library and full text professional journals is available on all workstations. In addition, support and assistance for literature reviews is readily available through the Nursing EBP/Research Council and/or the library. The Chief Nursing Officer and other senior nursing leaders seek literature reviews directly through the library.  Many other nurses contact members of the Council for assistance. 

      •The Nursing EBP/Research and Nursing Professional Development Council forward literature summaries, articles, and informative links to nurses. For example, as the managers and directors focus on creating a healthy work environment, relevant information is sent to them. As the Pain Resource Nurses continue to seek evidence based practices and current literature to improve pain management, the nursing councils provide literature to support this goal. ( EP19-11 ) Further, the Pain Clinical Nurse Specialist teaches a monthly class based upon literature and discusses potential applications.

      •As members of the advisory board we have online and presentation access to materials to support nursing practice. These materials including toolkits support nursing autonomy through education and guidelines. ( EP19-12 )

      Unit Examples Demonstrating Use of Resources to Support Autonomy:

      Bariatric and Back Unit Megan Bishop, RN recently joined PSFHS nursing and writes "autonomy and nurse-physician relationships are why I really enjoy working on this unit." Order sets related to pain and use of patient controlled analgesia (PCA)/epidurals support autonomous practice. The order sets provide options to adjust PCA/Epidurals based on nursing assessment, order bowel medications as needed, treat common epidural side effects without calling a physician, selecting best option to maintain blood pressures, and options to treat hypertension.  The order sets support nursing practice, recognize the importance of a nursing assessment and validate critical thinking. ( EP19-13 )  In addition, two physicians call each night to check on their patients and obtain report/answer questions from the nurses. As a night nurse, Bishop states "the doctors are attentive to my report, respond quickly to questions and I feel heard. In addition this nightly call helps me be prepare and anticipate any needs our patients may have that night."

      Neonatal Intensive Care Unit III Infant Driven Feeding The Sheridan statistics indicated our infant weight gain was below the Vermont Oxford numbers. The NICU III interdisciplinary Developmental Care Committee reviewed the literature for evidence based practices to improve our infant growth scores. Nursing research demonstrates that feeding preterm infants requires specific skills and decision making related to how and when to feed the infant.  Our committee work is based on several references including the Synactive Theory of Development (Heidelise Als) which provides a framework for understanding the behavior of premature infants. Based on literature and professional standards, the Committee developed a mandatory education program to revise our nursing practice to infant driven feeding. The education class included:

       • Recognition of infant cues for feeding with numbers assigned to various cues and readiness indicated by adding the scores (scoring was already in place in infant developmental literature) 
       • Infant positioning with normal developmental positions 
       • Use of  developmental positioning aids 
       • Methods to secure endotracheal tubes that also utilized understanding of developmental positioning (i.e. very low birth weight infants less than 1,000 gms, to be positioned with head mid-line for 48 hrs to protect brain perfusion and decrease chances of IVH) 
         ( EP19-14 )

      Cardiovascular, Medical, Surgical Units The Nursing Practice Council members identified a need for education and information on telemetry.  Telemetry techs work from CVU and provide remote telemetry monitoring throughout Penrose Hospital. While education was provided and is easily available online, the Clinical Nurse Specialist on CVU created an EKG card for nurses throughout the system. This visual resource improves nurses ability to communicate effectively with the telemetry techs as well as the physicians.  ( EP19-15 ) 
      SFMC PreOperative Services Milissa Chenosis, RN, noted the many different ways physicians were performing the same procedure or block. Different equipment, timing, and placements by each physician were impacting the autonomy and efficiency of the assisting nurses. Chenosis created a procedure book with photos, lists and details for each physician and procedure. Now available on the unit, each nurse feels more prepared to participate in the procedure. This resource, specially designed by nurses for nurses, improves autonomy and efficiency in SFMC PreOp.  Chenosis' colleagues nominated her for a Seton Award for Nursing Excellence in 2012 for her innovative work in the PreOperative unit. ( EP19-16 )


      Nurses at PSFHS are supported to practice autonomously through easy access to current literature, professional standards and other data sources. The advances in technology continue to improve access to professional literature, policies and nursing clinical procedures, standards and tip sheets. Our nurses routinely use this easy access to educate themselves and their patients, review procedures, or to evaluate and change practices.

    • Exemplary Professional Practice - EP20

      Accountability, Competence, and Autonomy

      EP20 That nurses at all levels routinely use self appraisal performance review and peer review, including annual goal setting, for the assurance of competence and professional development

      Nursing takes a whole life to learn. We must make progress every year. - Florence Nightingale, 1897

      Our Nursing Professional Practice Model references the ANA Nursing Scope and Standards of Practice and Performance and the ANA Code of Ethics for Nurses with regards to competence and professional development. Below are several samples of the ANA guidelines which govern our nursing practice:

      "The registered nurse evaluates one's own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules and regulations.  The registered nurse interacts with and contributes to the professional development of peers and colleagues."(ANA Nursing Scope and Standards of Practice, 2004)

      "The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth." (ANA Code of Ethics for Nurses, 2001)

      "The registered nurse attains knowledge and competency that reflects current nursing practice." (ANA Nursing Scope and Standards of Practice, 2004)

      Our Shared Decision Making (SDM) Councilor Model provides one structure for ongoing appraisal of nursing competence that promotes peer review. Peer Review is a professional responsibility that promotes professional development and facilitates nursing competence. The SDM Charter begins with the following:

      "Shared decision making is based on the belief that healthcare professionals working at the bedside or closely with patients are in the best position to make decisions relating to clinical practice. It provides a framework whereby clinical staff and management can work collaboratively to develop a professional model of care." The Nursing Leadership Council is charged to "model professionalism and peer review." The Nursing Peer Review Council function is nursing peer review. One Nursing Practice Council goal is to "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." 

      As an organization, PSFHS fully believes in the following consideration which is quoted from our Associate Principals, "the employee performance appraisal process as an important part of giving and receiving feedback to promote employee associate growth." Management is responsible for conducting thorough and timely performance evaluations with associates who report directly to them. Established standardized performance evaluation tools and competency checklists support the process. 

      Performance Appraisal Process - Performance Feedback and Development (PFD):

      A formal performance appraisal process approved by Centura Health provides the structure for evaluations. While 90 day, mid-year, and annual evaluations are required appraisal intervals, ongoing evaluation and feedback occurs throughout the year. Each individual associate is responsible for completing all mandatory education, in-services, and training. As associates prepare for the formal performance appraisal, they self evaluate their completion of education and are expected to reflect upon prior year goals, performance and consider goals for the next year. A dialogue between the associate and the manager focuses on the self and manager's evaluation of performance and the setting/pursuit of annual goals.  

      There are three main components of the PFD that contribute to overall ratings.

      Section One - Performance Plan Goals and Results

      Section Two-Behavior Expectation

      Section Three - Individual Development Plan

      The Annual Goal Setting process starts with the organizational goals and priorities and the senior nursing leaders.  Goals are "cascaded" to each level of nursing and individualized based on areas of responsibility and accountability.  The following example demonstrates this process

      VP of Nursing  Assistant Nurse Manager  Direct Care Nurse
      Improve performance on the HCAHPS Survey for the Department of Nursing at PH and FM for the category "overall rating of the hospital: as measured by percentiale ranking of top box score for the period June 1, 2012 through May 31, 2013  My units will contribute to the overall HCAHPS scores by receiving a score of 80 in the following categories, courtesy and respect, waiting time and delays in care average for fiscal year 13. To improve the overall rating of the hospital stay on HCAHPS socres by focusing on nursing communication, discharge information and using the AIDET process

      Some nursing areas formalize the self evaluation and preparation process through the use of a portfolio. The Cardiovascular and Intensive Care nurses create a portfolio which includes an updated resume, community services, education, presentations, and other highlights of professional practice. 

      The Chief Nursing Officer requires a portfolio from all nursing directors for their annual performance appraisal and goal setting. In addition, the directors of nursing meet twice a month with the CNO, which provides ongoing opportunities for peer review. 

      The Chief Nursing Officers of Centura meet monthly. One of the goals of this meeting is to review the nursing services goal statuses from each organization. This practice facilitates accountability and peer review within the Centura Health system writ large.

      PH 4 Medical - Direct Care Nurse- Performance Appraisal and Peer Evaluation:

      In 2012, the manager and unit staff discussed and implemented a formal peer evaluation process. This system was designed to be inclusive of performance over an annual period and that a nurse would be reviewed by four people - two peers and two supervisors. ( EP20-1 , EP20-2 , EP20-3 )

      Excerpt from Direct Care RN Performance Evaluation: Annual Goal Setting and Self Evaluation

      Category: Performance Goal.   CVU will maintain HCAPS score of 83% for the question H30 "What number would you give this hospital?"

      Measurement: I will ask 100% of my patient it we are meeting their expectations and what can I do to make their stay better.

      Employee Rating: Exceeds expectations

      Comments:  Always meet this goal daily. I have also received Halo for Heroes Award this year.

      Employee Manager Rating: Exceeds expectations.

      Manager Comments: CVU exceeded this year with our HCHAP scores, this is due to your leadership with UPC to get relationship based care in place this year. Your leadership to guide staff to perform hourly rounding, bedside reporting and to discuss the plan of care with patients and their families is why CVU was so successful

      Peer Review - Clinical Managers:

      In 2012, six Clinical Managers developed a plan for Clinical Manager Peer Review.  This plan is goal oriented, and the Clinical Manager Peer Review is designed to meet the following targets:

      • To increase our self awareness 
      • To increase our collaboration 
      • To  strengthen our foundation by knowledge sharing 
      • To increase mentoring 
      • To increase accountability

      In alignment with the ANA Nursing Administration Scope and Standards of Practice (2009) and our Professional Practice Model, the team identified the following procedural outline for the implementation of Manager Peer Review:

      • Value added/Professional Development:

      • Align with the Performance Feedback and Development process using a standardized rating system 
      • Review our core values 
      • Structure with defined tool that also supports focused dialogue and integrates standards 
      • Participation in committees and meetings will be one standard 
      • Knowledge sharing is expected as part of the process 
      • Review coverage for other units including interaction time 
      • Do not want to mirror our job descriptions 
      • Interdepartmental problem solving will be a required standard 
      • Communication 
      • Education for self and facilitation of education for staff 
      • Self care 
      • Manager and staff recognition

      • Process for feedback:

      • Focus will be on professional development not performance evaluation 
      • Confidential; individual reports will not be shared with directors 
      • Face to face feedback by reviewer


      Diane DeMasters, BSN, RN, CGRN, Chair 
      Mackenzie Mudd, MSN, BA, RN 
      Jennifer Trahan, BSN, RN 
      April McPike, BSN, RN 
      Carolyn Cusic, BSN, RN, OCN 
      Pam Assid, MSN, RN, CEN, NEA-BC 


      In November of 2012, the Nursing Management Council approved the above outline structure and they set April 2013 as the initiation date of this new process. This model of professional development review will be a quarterly requirement. The attachments demonstrate their process and include a completed Clinical Manager Performance Appraisal including annual goal setting, self evaluation and peer review. ( EP20-4 , EP20-5 , EP20-6 , EP20-7 )

      Peer Review - Shared Decision Making Model:

      1. The Nursing Evidence Based Practice/Research Council completes peer reviews on all conference poster and presentation abstracts prior to submission. Draft posters and presentations are peer reviewed and approved by the EBP Council prior to recommending to the Nursing Leadership Council. All peer reviewed abstracts that have been submitted have been accepted for national or regional conference presentations during the last two years. ( EP20-8EP20-9 )

      2. Nursing Peer Review/Clinical Scene Investigation (CSI) is part of our Shared Decision Making structure. This council provides the structure for a nursing case peer review. Chaired by a direct care registered nurse, members include nursing representation from multiple settings. Other representatives to this council include: a nursing manager, someone at the director level, patient safety/risk management nurse, and a clinical effectiveness nurse. Nurses from other areas are invited or consulted as needed. Individual nurses who are subject to this council receive positive and corrective feedback on their nursing practice and are assigned actions to improve their standard of care. System and unit level issues, such as Fentanyl patch use, transferring from PACU to units, over-sedation of geriatric patients, and other issues are identified and resolved through education, process changes, and ad hoc work team interventions. CSI is focused on improving nursing competence and professional development at an individual and system level. In order to increase the effectiveness of the process, documentation from Nursing Peer Review is confidential. Nurses and their managers are notified of outcomes of peer review and any recommendations. Any potential disciplinary decisions are made by management. ( EP20-10 , EP20-11 )

      Unit Based Peer Review:

      1. Cheryl Imlay RN, CEN, CFRN and Chair of the Nursing Practice Council states that:

      "it is OUR nursing practice and professionalism and as such we should give our colleagues feedback on their performance. I know when I observe a colleague at work and share my observations, I learn something too. When I brought this topic up in our Council meeting, there were a lot of comments and questions. But overall we all agreed that we want to continue to expand peer review activities."

      Imlay attended the Magnet Conference in October 2010 and attended selected presentations to expand her knowledge of peer review. Imlay used information from these presentations in discussions and education that she facilitated within the Nursing Practice Council. ( EP20-12 , EP20-13 )

      2. Robin Tillman RN, CCRN, Critical Care shares her perspective on the long term goals of Unit Based Peer Review, "we have created a new format to use for performance appraisals this year. We have decided to do this anonymously and eventually to grow into becoming more open and direct with one another." 

      3. Informally, there are forms of this type of peer review on a daily basis in nursing units. Several Practice Council nurses noted the informal peer review that occurs during shift to shift handoff. The following is a direct care nurse's perspective on how the processes are similar in scope:

      "We look at the documentation, ask about specific interventions and effectiveness, discuss possible alternatives and clarify treatment goals.  I know patient needs are different for each shift, but some practice is essential regardless of the shift - like making sure the patient is getting adequate rest - so handoff is another way of doing peer review" -- Mary Castle BSN, RN, 4th floor. 

      4. The Cardiovascular Unit Nursing Practice Council initiated peer reviews of nurses and certified nursing assistants in 2010. The UPC Cardiovascular Unit is proud of their Unit Practice Council initiative on shift handoff at the bedside noting that:

      "This gives us a chance to check IV's, oxygenation, pain level, and more. At the same time we can check the documentation for congruence and assess progress toward goals. Bedside handoff also encourages patient participation. We are working to be more consistent with this process. In addition we designed a peer review form for nurses and one for our certified nursing assistants. Peer Review helps us to grow professionally and it checks to make sure our practice is within or better than standards!"

      5. The Intensive Care/Critical Care Units and the Emergency Department have designed a form for documenting peer review feedback on competence and professional development. It is to be used in these units' annual performance appraisal process.

      System Nursing Peer Review:

      The Clinical Advancement Program (CAP) was designed by direct care nurses, a clinical nurse specialist and a nurse manager representative. The Clinical Advancement Peer Review Board is comprised of direct care nurses and a management/senior leader representative. Initiated in 2010, all applications for CAP are peer reviewed by the CAP Board. In addition all applications require a peer review by a unit practice council member prior to submission.  The CAP is designed to encourage and recognize individual nurse competence, professional development, and contributions to the nursing profession at PSFHS.

      Excerpt from CAP 2012 Overview - REVIEW COMMITTEE    The CAP Peer Review Board will review all applications and award points for qualifying activities.  The CAP Peer Review Board will make recommendations to the Chief Nursing Officer for appointment to a CAP level.   The Chief Nursing Officer will formally sign CAP appointments

      Nurses Week awards for excellence in nursing practice are made through a peer review process. Nurses and certified nursing assistants are recommended by their colleagues for Nurses Week awards. The committee that reviews the applications is composed of direct care nurse peers. This peer review process recognizes nurses for competence and professionalism as observed and evaluated by their peers.  ( EP20-14 )

      Using the Unit-based Skin Resource Nurse structure unit nurses, in collaboration with the Wound Clinic Nurse Manager, designed and implemented nursing peer review that focused on improving pressure ulcer prevention. Quarterly pressure ulcer prevalence surveys are completed by this team. In addition, the Unit Based Skin Resource Nurses meet quarterly for education to increase their competence with the prevalence survey and their professional knowledge/skills to support their colleagues' professional development. The Unit Based Skin Resource Nurses are subject to annual peer review during a prevalence study to ensure competence.

      The Pressure Ulcer Peer Review team meets monthly to provide peer review on referred cases. Direct care nurses along with wound care nurses both participate in these referred reviews. The Pressure Ulcer Nursing Peer Review assures competency and provides direction for professional development.  

      Direct Care and Nurse Manager Goal Setting, Self Evaluation and Peer Review were discussed earlier in EP20 with attachments to demonstrate practice. The following attachments demonstrate annual goal setting, self evaluation and peer review for other levels of nursing practice. 

      VP of Nursing- Annual Goal Setting and Self Evaluation and Nurse Executive Peer Review ( EP20-15 ) 
      Advanced Practice Nurse- Annual Goal Setting and Self Evaluation ( EP20-16 ) 
      APN Peer Evaluation occurs in the context of Privileging 
      Charge Nurse Annual Goal Setting and Self Evaluation ( EP20-17 ) 
      Charge Nurse Peer Review ( EP20-18 ) 
      Assistant Nurse Manager Peer Review ( EP20-19 ) 
      Assistant Nurse Manager Goal Setting and Self Evaluation ( EP20-20 )

      Interviewing and Selecting New Associates:

      Targeted Selection is the process for interviewing and selecting new associates.  Recognizing the importance of "culture fit", nurse managers incorporate peers in formal interviews of applicants and informal tours of the unit. "Culture Fit" includes congruence with organization values, location, colleagues, and work responsibilities. Providing an opportunity for peers to talk about daily activities, standards of care, and work responsibilities promotes realistic thinking in potential hires. Direct care nurses ask questions and complete the scoring guideline and they share their input with managers. While managers make the final hiring decision, most rely on the feedback given from peers in this process.


      Nurses use peer review as part of the formal performance appraisal process as well as during daily work.  Peer Review for competence and professional development is structured at the unit levels as well as at nursing department levels as described above.

      Nurses of all levels routinely use annual goal setting, peer review and self appraisals of their performance. Through the structures that govern annual performance review, nurses objectively review their goals and practice with their managers. They regularly set professional goals and they pursue those goals with the support of their units and the organization.  This process of performance review assures competence and professional development. 

    • Exemplary Professional Practice - EP21

      Accountability, Competence, and Autonomy

      EP 21 Describe and demonstrate the structures and processes that support shared leadership/participative decision-making and promote nursing autonomy.

      What would Kate (Chief Nursing Officer) do?

      "We were caring for a patient who had a balloon pump and was critically ill. In the process of coordinating a transfer out of state, we were able to move the patient to a fixed wing aircraft. Unfortunately, the flight nurses reported he was no longer stable and requested we readmit to PSFHS. Our procedures direct critically ill patients through the ED prior to admission, yet I knew the ICU staff were familiar with the patient and technology he needed. Directly admitting to ICU was in the patient's best interest and as I stopped and reflected " What would Kate do? (Our CNO)", I knew she too would support nursing autonomy and decision making to meet the patients' needs . A call to the ICU Clinical Manager resulted in the response of, "Absolutely, bring the patient directly to us." The nurses collaborated to accept an admission from the ED and PACU at the same time they readmitted this man who had just been discharged. I was proud of our ability to truly focus and meet this man's needs." Jean Paulsen, RN, Night Administrative Manager (emphasis added)

      The Professional Practice Model (PPM) at PSFHS fosters an environment of care that recognizes the expertise of nurses at the bedside and places the authority and accountability for the care of patients with our direct care nurses. In our PPM the patient is center, surrounded by nursing practice based on relationship based care, shared decision making, nurse autonomy, accountability, evidence, and standards.

      The Nursing Standards of Professional Performance hold us accountable to systematically enhance the quality and effectiveness of nursing practice and to lead professional practice in our healthcare setting. Shared leadership and decision making are tools to lead, evaluate, design, and implement effective nursing practice.

      A healthy work environment demonstrating teamwork, respect, opportunities for education, manager coaching, and recognition all promote a culture of shared leadership and nursing autonomy. Results from Press Ganey staff satisfaction during the last several years demonstrate improvement in these areas. The following graph demonstrates the improvement of autonomy and decision making, as the red bar on the graph represents the most recent results from 2012:

      Promote Shared Leadership/Participative Decision Making:

      The shared decision making structure, which is composed of nursing councils and interdisciplinary committees, requires the participation of direct care nurses. Unit level council meetings are scheduled at varying times based on member scheduling preferences. Some nurses choose to participate on a day off and others attend during a working shift. Nurses are paid for their participation time. Organization level nursing councils are scheduled on the fourth Tuesday of every month and rotate between SFMC and PH. Call in participation is available. ( EP21-1 )

      Recognizing the need for education, coaching, and mentoring in developing a strong shared decision making process, PSFHS provides educational opportunities that are open to all nursing staff. Tim Porter-O'Grady, the healthcare speaker, presented during a daylong conference in 2011 and 2012 to nursing crowds of over 150 each time.   ( EP21-2 )

      The Nursing Practice Council creates an annual report which consists of all of the Unit Practice Council's goals, accomplishments, and plans for the next year. This report demonstrates some of the outcomes of shared leadership/participative decision making and recognizes the value of nurses. A key element of the Annual Nursing Report is the highlighting of accomplishments from various nursing councils. ( EP21-3 )

      Labor and Delivery The SFMC Labor and Delivery Code Team identified an opportunity to support nurse autonomy and efficient nursing practice.  A patient with malignant hyperthermia is at high risk and immediate action is required.  The nurses created reference charts, reference book and a cart complete with essential equipment.  (EP21-4 )

      PH Critical Care Unit In January 2012, Patty Morse RN, CCRN, Chair of the CCU Unit Practice Council, brought in a new picture board that showed the ICU's model for Shared Governance.  The Unit Practice Council with the support of the Clinical Manager decided all ICU staff is required to participate in shared decision making.   Each committee commitment will be for 18-24 months and staff may be members on more than one committee.  Members are required to attend and are responsible to schedule themselves off the unit to facilitate attendance.  The UPC is working on having call in conference meetings to ease attendance.  The UPC encouraged staff to select a committee that "you are passionate about or that aligns with your professional goals".  The Clinical Manager agreed to include committee participation on annual performance goals and evaluation.  ( EP21-5 )

      ASCENT Nurse Residency Program and Staffing The ASCENT, new graduate residency program encourages nurses to openly identify challenges and strategies for a successful transition from student nurse to advancing novice nurses. "Tales from the Bedside," a demonstrative tool facilitated by the nurse educator provides a time each week to review experiences and to provide peer support during this transition. "Tales from the Bedside" examples are confidential unless the group decides to take action outside of their cohort. 

      The 2012 Fall ASCENT cohort identified specific challenges and suggested solutions for issues related to unit staffing. The facilitator supported their advocacy and provided information and access to the Nursing Shared Decision Making structure. The Co-Chair of the Nursing Staffing Council placed their questions and suggestions on the Council agenda for discussion. Following the council meeting the Council Co-Chair provided feedback to the ASCENT nurses stating two issues were currently being worked on, one issue will be referred to the Nursing Practice Council and other issues will be investigated. The ASCENT nurses have the name and contact information for the Council Co-Chair for further discussion.  ( EP21-6 )

      One nurse took time to thank the ASCENT Nurse Coordinator for her assistance with staffing questions and her overall assistance. Her email is displayed below at it resonates with themes of nurse autonomy and decision making:

      "From: XXXXX Sent: Friday, November 02, 2012   To: Patterson, Diana 
      Hi, Diana, I wanted to thank you for the way you interacted with our ASCENT cohort and handled our concerns about staffing/safety. Tales from the bedside was extremely valuable, not only for the shared experiences with other new graduates, but also because of the proactive approach you took with the things we brought to your attention. Choosing to share the staffing obstacles from my floor was a hard choice to make because I was not sure how it was going to be received, but you created an environment that made it safe to discuss things of that nature. I never imagined that a resolution would be sought. The issue was handled in such a satisfying, professional, solution-focused way. You not only listened to our concerns, but you helped us brainstorm solutions, and you took our concerns to the right place (the staffing committee). You also gave us access to the people involved in the committee, and shared your communication with that committee, all the while letting us know what your actions would be and protecting our confidentiality. I know that these issues are complicated and cannot be solved overnight, but it is so encouraging to know that the staffing committee exists, and to see that its leadership is open to input and is actively working on solutions. I am so thankful that you listened, included us, gave us future direction, and provided us with hope and a voice. I'm committed to the patients, the nursing profession, and Penrose Hospital. Thank you so much for handling the situation the way you did.  The amount of effort you put into the ASCENT program resonated with us, and I'm thankful for the experience."


      Clinical nurses in all areas are leaders and their participation in committees, councils, and task forces are vital to their professional development. In order to further this goal, PSFHS provides opportunities to nurses to use their expertise and to expand their leadership skills to improve patient outcomes. When they assume the role of a chair or co-chair, we provide support through coaching, mentoring, administrative support, as well as access to information relevant to the meetings.

      Structures and Processes that Promote Nursing Autonomy:

      Position Description Nurses are oriented to the Professional Practice Model (PPM) including the expectation of practice autonomy within our legal scope of practice. The Guiding Principles in the PPM include autonomy, competence, accountability, professional development, and interdisciplinary collaboration. In fact, all of these principles are embedded in our nursing standards and position descriptions.

      The RN Job Description includes "Teamwork and Collaboration:  Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care."

      The CNO Job Description includes "Serves as a change agent, assisting others in understanding the importance, necessity, impact and process of change through active involvement in decision making and coaching of others.  Supports an environment of shared decision making." 

      Interdisciplinary Rounds Staff nurses continuously exercise independent professional judgment as they provide patient centered care. Penrose Hospital Critical Care Unit does Interdisciplinary Rounds Monday through Friday mornings. The charge nurse, palliative care nurse, case manager nurse, and assigned patient nurse actively participate in rounds that evaluate patient status and review/revise plans of care. ( EP21-7 )

      The Clinical Advancement Program (CAP) promotes and rewards nursing autonomy. The CAP application requires nurse submit an exemplar of their nursing practice. The exemplar fosters reflection on nursing practice and recognition by CAP Peers who read the exemplar and reward to the nurses as they achieve CAP levels. The attached exemplar demonstrates nursing autonomy. ( EP21-8 )

      Access to Resources Easy access to online resources including medical literature, nursing literature, patient education materials, and evidence based practices all promote nursing autonomy. Any nurse may request a literature search and that search will be supported by the nursing evidence based practice/research council and our resident medical librarian. Many nurses access online resources to enhance their knowledge of specific conditions, diagnostic tests, and current evidence based treatment options. Ben Barton BSN, RN, OCN on PH 11 Oncology states that, "I use my phone to access information on medications or patient conditions frequently. I can also easily access Mosby or MicroMedix from my workstation." ( EP21-9 ) 

      Education Nurses are accountable for their practice and they are expected to demonstrate competence at all levels. Strong clinical judgment provides a foundation for autonomous practice. Education opportunities, in-services, access to professional journals, and opportunities to ask questions increase nursing competence. 

      Certification Increasing nurse specialty certification builds confidence and expert credibility. The Clinical Nurse Specialist on SF L & D promoted the use of standardized language between nurses and physicians related to electronic fetal monitoring (EFM). Providing education and requiring nurses to become EFM certified has improved nursing confidence and interprofessional communication. ( EP21-10 )

      Clinical Nurse Specialists (CNS) CNSs model nursing autonomy as they assess and treat patients/families, collaborate, and share current evidence based practices with colleagues. For example Dan Chatelain MSN, RN-BC is the Pain Nurse Specialist. Chairing the organization Pain Committee, an interprofessional committee, provides clinical nurses the opportunity to learn and to observe nursing autonomy. Chatelain does not have prescriptive authority, but based on his expertise, history of positive outcomes, and his collegial relationships with physicians, the Medical Executive Committee approved an intensive Pain Protocol to support nursing autonomy. 

      PH Cardiovascular Unit (CVU):

      The CVU Unit Practice Council assumed leadership of the unit staff meetings in late 2010. Supported by the Clinical Nurse Manager, the Unit Practice Council identifies a staff meeting facilitator each month and then supports them in the meeting. This process provides opportunities for shared leadership and integrates clinical and unit priorities for CVU. ( EP21-11 )

      PH 4 Medical:

      PH 4 Medical nursing associates represent nursing on a variety of shared decision making committees and resource staff meetings as displayed on the displayedunit bulletin board. The nurses of this unit represent the following areas and awards:

      • Pain Resource Nurses 
      • Skin Resource Nurses 
      • Safety Committee/Safety Monitor 
      • Nurse (System) Practice Council 
      • Unit Practice Council 
      • Magnet Champions 
      • Infection Control 
      • DAISY Awards 
      • Meditech SuperUsers

      Nurses usually self select participation and are paid for their time. Reports from various areas are integrated into unit staff meetings

      SFMC 5S Medical - Developing a Cardiac Service Line:

      In October 2011, the St. Francis Medical Center formed a partnership with Colorado Springs Cardiology. Prior to this arrangement, SFMC did not have a dedicated cardiac unit nor were there formally trained cardiac nurses and the accompanying staffing standards. SFMC 5S Medical was identified to care for the new patient population.

      Ensuring knowledgeable and competent nursing staff was the first priority. Stefanie Quirk RN, Educator was a recent addition to SFMC; with her primary focus being on the education of the following units: Intensive Care, 5N Surgical, and 5S Medical. Quirk supported a review of competencies and educational needs related to cardiac patients. Nurses with previous cardiac education, certification or experience created a "cardiac care core group." Two main requirements were designated as basic necessities in order to care for cardiac patients; they were a current competency with Advanced Cardiac Life Support as well as the completion of an electrocardiogram (EKG) class. PSFHS offered both courses for nurses that were interested. Quirk held a four week EKG class with a fifth class on percutaneous interventions. The fifth class included staff from the vascular center, with detailed education about heart catheterization and angioplasty. The final component of training included spending time with either the Vascular Center of Colorado (VCC) and/or the Cardio Vascular Unit (CVU) at Penrose Hospital. By December, the cardiac core group consisted of ten nurses who had completed all aspects of the course.

      Initially only patients who underwent a diagnostic heart catheterization were admitted to 5S Medical. Patients who had a stent placed, required a sheath removal, and/or closer monitoring were sent to the Intensive Care Unit (ICU). The cardiologists expressed frustration with this process. Frequent communication about the progress of staff training and competencies helped the cardiologist group understand the reason for admitting their patients to a higher level of care. Within six months, interventional post catheter patients were being admitted to 5S Medical instead of ICU. 

      The cardiologists were supportive of nursing education. What began as a simple request for an in-service at a staff meeting became a day long, hospital-wide cardiac symposium during Nurses Week 2012. Three cardiologists spoke to over 80 nurses from across the organization. 

      Collaboration between nurses and physicians (as well as accessible continuing education opportunities) developed a competent nursing staff to care for the expanded cardiac patient population. In addition, the unit's compliance with Core Measures for acute MI and CHF improved significantly.

      Staff education continues with EKG and PCI courses offered throughout the year for new hires and opportunities to gain more experience in the CVU or VCC are available. In January 2013, a formal program of floating to the CVU will be reviewed in cooperation with the CVU manager and staff. Additionally, order sets created specifically for the CVU will be reviewed for the application on 5S Medical. Planning for another cardiac symposium is scheduled. ( EP21-12 )

      Expanding cardiac services and nursing autonomy on SFMC 5S Medical has been successful due to shared leadership, participative decision making, and professional development.

      Nursing Orders:

      The electronic medical record supports the implementation of professional standards and nursing orders. The nursing assessment guides the selection of interventions required for individual patient treatment. The nurse adds these interventions via a Standard of Practice selection and then adds additional interventions as needed. The changing frequency of interventions is done based upon nursing judgment and physician orders.

      Our Wound Care nurses are recognized for their expertise, clinical judgment, and responsiveness. Valuing these nurses, our system supported their autonomous practice through changes in ordering process. 

      Shared Expertise/Collegial Support for Nursing Autonomy:

      •  PH 9 Surgical The Rapid Response Team (RRT) supports nurse autonomy. Critical Care Unit nurses serve on this team and respond quickly to calls from nurse colleagues on other units.  A nurse on PH 9 reports following her "intuition" as she stopped the oxygen to assess potential oxygen needs for discharge later that morning. She elected, however, to keep the telemetry on the patient. She was called back from lunch by her charge nurse. Telemetry had called and the patient was experiencing ventricular tachycardia. The nurses called a RRT and the patient coded on the way to Critical Care.  ( EP21-13 )

      •  PH GI Lab On Saturday morning January 7, 2012, Dr. Lukasz Kawalczyk performed a procedure on a patient in the GI lab under Propofol sedation. The patient had a history of alcohol abuse. The procedure went well. Since the patient had screened positive for obstructive sleep apnea, per our policy, he was to remain in recovery for 2 hours. After 15 minutes in our recovery area, the patient became restless and he began asking for pain medication. Per post-operative orders, the patient was given Fentanyl for pain. He continued to ask for more pain medications reporting that the pain in his abdomen was unchanged. He reported nausea and dry heaves. The patient was repositioned several times and he was provided with warm blankets. He became more restless and his dry heaves increased in intensity. Kawalzcyk called the nurse on 5th floor in order to review the patient's history and current orders, including questioning the current status of his alcohol withdrawal protocol orders. Given the extended time in recovery, his withdrawal symptoms were increasing. Within five minutes Linda Mueller RN, from 5th floor came to the GI Lab to further assess the patient and to administer Ativan per withdrawal protocol. The patient's condition improved and he recovered in the GI Lab without incident. This interdisciplinary collaboration between specialized nurses is evidence of nurse autonomy and the effectiveness of education procedures.

      •  SFMC 5N Surgical One RN actively participated in the Pressure Ulcer Peer Review team and  she promoted the use of evidence based practices to prevent pressure ulcers on patients admitted to SFMC 5S. As she planned her retirement, she identified and educated her replacement, briefly demonstrated in email below:

      •  Emergency Services : Patient Perspective Patient report to Kathy Parham RN, Patient Representative about the SFMC Emergency Department:

      "The nurses here are awesome.  You can't ask for better care.  And I want to give high praise for the care I received in the ER from RN.  I filled out a yellow card on her already, but I want your administrator to pay special attention to this compliment:  I honestly don't think I would be here today if it wasn't for her. I was having a stroke, but didn't have the 'usual' stroke signs. The doctor was going to send me home, but Linaye gently pushed and persuaded the doctor to do an MRI. She picked up on something he didn't. Who knows what would have happened to me had I just gone home? And I want the physician to receive kudos too, for listening to the nurse; not all doctors would do that. That represented real teamwork to me. You have awesome people in that ER and here on this floor."   Summer 2011.

      Physician's Perspective:

      The following is a letter from Timothy Murphy, MD that he wrote to the Clinical Nurse Manager on PH 11 Oncology in recognition of nursing actions:

      From: Murphy, Timothy J MD       Sent: Thursday, January 13, 2011 11:17 AM 
      To: Guy, Kathy               Subject: kudos 
      Kathy, just want to make sure I relayed this to you. I want to personally recognize a few of your nurses for an event that happened yesterday. Mr XXXXXXX met a quick XXXXXXX demise in his room when he started with massive hemoptysis around 4:00 pm.  This was an unavoidable consequence of his XXXXXXXXX cancer and the location of the mass abutting his pulmonary artery.  
      I want to personally thank Karen and Chelsea for their outstanding actions at the bedside. They were calm, cool, and collected. They stabilized the situation in the most professional manner for that kind of situation that I have been part of in my 17 years as a physician. The patient's daughter was in the room and they helped her tremendously.  There was a third RN who came in and helped . She handled the daughter's grief very well, the chaplain was on the scene almost immediately. 
      Being an ex-Army guy, I know good leadership when I see it.  These nurses proved their metal to me (as if I needed any proof).  I believe their actions reflect your leadership.  tim


      PSFHS supports shared leadership/participative leadership and nursing autonomy through multiple structures and processes. Formal nursing shared decision making structures, education, coaching, recognition of successes, and our Professional Practice Model set expectations and provide the support for nurses to progress to their full professional scope as they advance nursing practice and patient outcomes at PSFHS. The Press Ganey Survey RN results demonstrate improvements in our culture and work environment and they provide solid evidence that we value professional nursing practice.

    • Exemplary Professional Practice - EP22

      Accountability, Competence, and Autonomy

      EP22 That nurses are accountable to resolve issues related to patient care or operational issues

      Our Chief Nursing Officer holds high expectations of all nursing associates as evidenced in her article in the monthly nursing newsletter, The Learning Connection :

      Accountability by Kate McCord MSN, RN, NEA-BC, Chief Nursing Officer

      It is in the month of July that we celebrate our country's independence. May we never take our freedom for granted. But as it is with any freedom, so comes responsibility and accountability. Such is the case with our profession of nursing.

      Nursing has its freedom. We are free to practice our profession; to innovate and design new healthcare practices through nursing research; to influence positive patient outcomes; and to lead healthcare reform by making a more efficient and accessible healthcare system for all levels of society. However, there is a professional accountability that applies to everyone involved in healthcare.  

      Accountability is a legal obligation; in healthcare it is also an ethical and moral responsibility. The American Nursing Association (ANA) states in its Code that the nurse will assume accountability for nursing judgment and actions. A professional nurse has the responsibility to practice within his/her scope of care calling upon his/her knowledge and skills to make decisions in the best interest of the patient. The nurse is then accountable for the decisions that were made in these situations. It is through this accountability that the nurse may be called upon to explain, justify and defend these decisions.

      Although accountability is often defined as an individual or departmental responsibility to perform in a certain way, accountability may also be dictated or implied by law, regulations and professional standards---such is the case in nursing. At times it may seem that accountability is a big price to pay in order to practice nursing. But I suppose the same could be said about freedom-but would we have it any other way? Have a safe and happy 4th of July-Independence Day!

      Penrose St. Francis Health Services' (PSFHS) nursing and interdisciplinary practice guidelines, job descriptions, policies, and procedures support nurses to practice autonomously. Further, the organization's nursing culture acts in accordance with the Colorado Nurse Practice Act, the ANA Standards of Practice and Professional Performance , and the ANA Code of Ethics for Nurses .  

      Within the ANA Standards of Professional Performance are two standards that highlight nursing accountability to resolve problems. "Standard 14: Resource Utilization" describes the role of nursing to consider factors related to safety, effectiveness and cost in delivering nursing services. "Standard 15: Leadership" holds nursing accountable for the coordination of care, the creation of a healthy work environment, and engagement in teamwork.

      The leadership structure is inclusive of directors, supervisors, managers, and charge nurses. All of whom provide support for problem solving in the direct care setting. Policies identify specific incidents that require notification or reporting; a nursing leader and an Administrator On-Call are always available to discuss issues, facilitate decision making, and to support the resolution of issues related to patient care or operations. Within formal and informal supervision, nurses are held accountable to resolve issues related to patient care and to operations. One Clinical Manager stated that:

      "I expect them to solve their problems and to come to me when they need support, direction, or assistance. The charge nurses are great at managing admissions, including working with the emergency room and bed control to resolve bed space operational issues, collaborating with the staffing office to obtain adequate staff, and consistently maintaining the focus on safety."

      Position Descriptions:

      All nursing position summaries identify leadership and management responsibilities focused on patient care and operational issues. The following are two examples which demonstrate the breadth of this policy:

      The RN position summary states that the nurse: "Assumes responsibility and accountability for facilitating, communicating, and collaborating with both the healthcare team, and the patient/family to identify and meet the physical, emotional, and spiritual needs of the patient. Promotes the optimal health, well being and safety of the patient through use of the nursing process and in accordance with patient care standards, guidelines and the State Nurse Practice Act. Demonstrates personal accountability for relationship-based care, organizational mission, and core values. The Clinical Manager position summary states that the manager: Manages the human, physical, and financial resources to deliver optimal quality care to patients on their units.  Directs activities for maximum efficiency integrating the mission, values and goals of PSFHS.


      Recognizing the importance of education and information to support problem resolution, Charge Nurse education and training has expanded in the last 2 years to include multiple opportunities to build skills and confidence in problem solving, interpersonal communication, and coaching. In 2010, a two day charge nurse conference included topics such as delegation, scope of practice, conflict management, problem solving, legal implications, and exposition on the professional practice model for issue resolution. Continuing the focus on accountability a conference for clinical managers was held in the fall of 2010 and 2011.  ( EP22-1 , EP22-2 )

      LEAP, an educational program designed for frontline nursing leadership was developed in collaboration with other Centura organizations. First offered in 2010, the program continues to evolve to meet changing managerial and accountable needs. Recently, the Centura Nursing Professional Development Council recommended that this training be required for all assistant nurse managers. The Centura Chief Nursing Officer Council supported this proposal.  Attendance for the program in the fall of 2012 was great. ( EP22-3 )

      Shared Decision Making Councils:

      The Shared Decision Making Council structure and purpose support issue resolution.

      The Nursing Management Council's (NMC) functions include: 

      • Provide a forum for discussion of management concerns, issues, problems that may need action, decisions or referrals to another level in the organization 
      • Review reports from other system councils and act on those that require decisions 
      • Network with peers on management issues 
      • Review information from other departments that affect nursing units and nursing practice 
      • Discuss organization wide decisions and changes that impact PSFHS and PSFHS nursing

      The attached minutes demonstrate problem resolution discussions regarding policy, on-call requirements, contracts related to reducing turnover and missing items. ( EP22-4 )

      The following are several examples of nurse accountability for the resolution of issues related to patient care through councils or committees:

      SFMC Mom Baby Unit Practice Council identified and resolved both practice and staffing issues. Teamwork, use of evidence based practices, focus on patient comfort, education/teaching sheets and revising the plan of care were strategies used to resolve operational and patient care issues.  ( EP22-5 )

      The Nursing Practice Council and Transport Jerry Hospador, Transport Supervisor at Penrose Hospital notified his manager and the chief nursing officer of concerns with patient comfort during transport, the Chief Nursing Officer immediately supported his perceptions and directed him to the Nursing Practice Council for discussion. During the fall of 2012, the Nurse Practice Council discussed his concerns and collaborated with Hospador to "get the message" of Elevator Etiquette to all associates. ( EP22-6 )

      Nursing Professional Development Council (PDC) The Centura Health Professional Development Council and the Centura CNO group requested input on the Mosby product.  Mosby proposed to improve our EBP through access to journals, literature and ability to quickly look up information on diseases, treatments, side effects of medications and patient teaching tools.  PSFHS offered to pilot the program as an avenue to identify and resolve potential operational problems.  The PSFHS PDC provided oversight for this process. ( EP22-7 )

      Individual Professional Nurse Actions:

      PH 11 Oncology Unit In order to demonstrate the active resolution of patient care and operational issues for her unit, Debbie Arseneau RN, Case Management, Oncology Unit writes that:

      "Barb was the patient's nurse for the day. She was completing discharge paperwork and preparing instructions for the patient to be discharged home. She knew the patient had been admitted for a pulmonary embolus and the patients INR was currently sub-therapeutic. She had an order from the physician to give a large dose of Coumadin before the patient was discharged home but no instructions for different Coumadin dosing when the patient was at home. Based on her knowledge of the importance of maintaining an appropriate INR level and regulating the Coumadin dosage, she alerted the case manager that a follow up INR was not scheduled for the patient the next day. The case manger subsequently called the physician and arrangements were appropriately made for a follow up INR the next day." (Fall. 2010)

      Benjamin M Barton RN documents in Meditech his clinical autonomy and respect for the patient's needs:


      Ben Barton, RN on the Oncology unit noticed the vacutainer blood collection tubes sitting in the sun in the medication room.  He wondered if this would affect the performance of the tubes and validity of testing results.  He contacted our PSFHS lab and their response was not definitive.  He contacted the supplier with his question.  He spoke with the supplier via phone and they sent literature to confirm their verbal response.  In fact sunlight, light and temperature do negatively impact the blood collection tubes.   He relocated the tubes in the medication room and notified his colleagues.  His manager has agreed to follow up with her colleagues. ( EP22-8 )

      Emergency Services Kelly Rivera, RN in Penrose Emergency Services took action to resolve a patient issue and received recognition and gratitude from the patient and family via the Halo for Heroes Awards. The family stated,

      "Kelly you noticed my wife, Judith, was not acting normal so you stopped her from being released from the Emergency Department at Penrose Hospital. You called the doctor back and he ordered a CT Scan. The CT scan showed cranial bleeding. Kelly, your attention to patients' needs probably saved my wife's life. How can you thank someone for something like that? You are our angel." (May, 2011, Mr. Donald Diaz)

      Jalean Makedonsky, RN, submitted a special project with her Clinical Advancement Program application.  She recalled a time in 2012 when she and her current colleagues were tentative about using hypothermia in post cardiac arrest patients.  She elected to do research the policies and equipment and designed a quick brochure for use the next time.  ( EP22-9 )

      Interdisciplinary Team Actions:

      The Rapid Response Team is available for immediate consultation and response to support nurses in resolving patient care issues. Nurses evaluate one another and the form depicted below reflects appreciation for the responding nurse.

      Rapid Response Code Blue Committee     This interdisciplinary committee identifies and resolves both operational and patient care issues.  The attached minutes demonstrate the following actions:

       -Inclusion of RRT education in Patient Handbook to support patient education 
       -Collaboration with Supply Chain on carts and supplies 
       -Revision to staff education on PH 8 Rehab   ( EP22-10 )

      Relationship Based Care:

      Our patient representatives are nurses and they are always eager to promote patient satisfaction and to resolve any problems. While they are most often are called to address a patient complaint, they also make rounds and look for opportunities to recognize excellent care in our associates. The following story was printed and disbursed across our organization including board members describing a unique moment that was provided by a patient representative:

      Patient Grievances:

      When the hospital received a written complaint from a patient, the Patient Representatives were notified. Our Grievance Process requires timely action and clear tracking of problems. The patient representative notified the clinical manager who took immediate action including providing a response to the patient via phone call and email correspondence. The result was a satisfied patient as evident in the patient final response to the manager shown below:  

      While our goal is to absolutely satisfy our patients and their families, we realize there are times that we cannot prevent delays or cancelled appointments or transfer timing. Patients and families are usually feeling vulnerable and we may need to do provide some "extra" attention to ease them through a dissatisfying situation. To empower our nurses, the Patient Experience Committee, a multidisciplinary committee chaired by Ann Kjosa, VP of Nursing at SFMC, created a service recovery toolkit. This toolkit includes instructions for tracking and is located on every unit. Nurses are encouraged to use gift certificates or other items if needed for service recovery when other strategies have been unsuccessful. Distributed to all managers in April 2012, initial feedback from staff nurses has been positive. 


      The "Can Do" attitude and actions recognized in this letter from a physician colleague demonstrate the culture promoted and supported throughout our organization through formal committees and councils and through individual expertise and professionalism. 

      From: []      Sent: Wed, May 04, 2011 9:20 AM 
      To: McCord, Kate                                                          Cc: Walsh, Peter; Olson, Nathan

      I'm writing today to pass on some much deserved but past due compliments to two pre-operative nurses at St. Francis Medical Center.  Indeed, Jane Hutson and Milissa Chesonis are two of the most outstanding nurses I have had the honor of being affiliated with over the past twenty years.  They continue to represent the finest nursing has to offer and serve as terrific examples to nurses throughout our entire hospital.  Exposure to Jane and Milissa should be mandatory for all of the nursing students passing through St. Francis. 
      Two weeks ago, we received early morning word that our coagulation machine was broken at St. Francis and therefore, we would not have the ability to obtain pre-operative PT/PTT/INR's without drawing the labs and then sending them via courier to Penrose Main and awaiting the results.  Milissa immediately recognized the impact of this and, rather than remaining passive, she scanned the charts for the day's surgery schedule and made note of the patients who would need coagulation studies.  Amazingly, Milissa then contacted one of our late morning total joint patients via telephone and politely asked if, on his way up to St. Francis, he could stop at the Penrose Main laboratory and have his coagulation studies done.  She then called the lab and explained the situation to them and relayed our patient's name.  The lab expedited our pre-operative patient who then made his way to St. Francis.  When he arrived, his coag studies were waiting for us.  This is truly way above and beyond the call of duty, but frankl       y only represents one of many examples I could list of Milissa's usual extraordinary efforts.  Her clinical acumen is unparalleled and she consistently knows the details of her assigned patients medical histories.  She is fantastically efficient and exhibits professionalism that is beyond reproach.  Milissa's ability to anticipate patient's needs is uncanny.  She is to be commended. 
      In addition, Jane Hutson sets the bar extraordinarily high in the pre-operative area, and her nurses respond accordingly.  She asks NOTHING of anyone that she would not immediately do herself, and she knows no job description; that is, she will happily perform any task as long as it is in her patients best interest.  We frequently ask Jane to perform the unexpectedly impossible task and she always succeeds.  Jane communicates more clearly, directly and effectively than any nurse I have ever worked with and I say this even though she sometimes needs to tell me some things I would rather not hear! 
      Just as importantly as everything noted above, Jane and Melissa are the consummate professionals and unfailingly perform all of their duties respectfully, courteously and with smiles on their faces.  Our patients always note their ability to place everyone at ease. 
      Please pass along my appreciation for the great care Jane and Milissa continually give.  They truly represent the very best that St. Francis Medical Center has to offer. 
      Sincerely, Joe Slavoski

      The ultimate structure for resolving patient care and operational issues is evident in the professionalism of our nurses. Leadership, Shared Decision Making, Interdisciplinary practices, and policies support our nurses as they focus on quality care for patients/families and on actions that create and maintain a healing environment. PSFHS nurses practice autonomously and are accountable to resolve issues. They demonstrate their expertise, seek consultation, collaborate with others, and work with supervisors to meet patient care needs, improve operations, and maintain regulatory compliance. More importantly, the focus on patient safety and patient satisfaction demonstrates nurses' commitment to our nursing vision and professional practice model.

    • Exemplary Professional Practice - EP23

      Ethics, Privacy, Security, and Confidentiality

      EP 23 How nurses uses available resources, such as the ANA Code of Ethics for Nurses (American Nurses Association, 2001b), to address complex ethical issues.  Provide examples from different practice settings.

      Nursing encompasses an art, a humanistic orientation, a feeling for the value of the individual, and an intuitive sense of ethics, and of the appropriateness of action taken.
      -Myrtle Aydelotte

      Multiple structures and processes within PSFHS support nurses to use available resources to address complex ethical issues.

      Mission, Vision, and Core Values:

      Professional nursing practice occurs in the context of the PSFHS Mission, Vision and Core Values.  Our PSFHS Mission directs us to practice with compassion and respect for all people respecting the uniqueness of each person. Our Vision includes a covenant of caring with excellence and integrity. 

      Penrose-St. Francis Health Services is a faith based institution, sponsored by Catholic Health Initiatives (CHI), one of the largest non-profit health care systems in the United States. Based in Denver, CHI was founded in 1995, by twelve congregations of religious women, including the Sisters of St. Francis of Colorado Springs. The mission of Catholic Health Initiatives is to nurture the healing ministry of the Church by bringing it new life, energy, and viability in the 21st century. Fidelity to the Gospel urges us to emphasize human dignity and social justice as we move toward the creation of healthier communities. CHI's core values: reverence, integrity, compassion, and excellence all define the organization and serve as its' guiding principles. These Catholic beliefs and values are the roots, or anchors from which all activities, decisions and behaviors follow.

      Ethical and Religious Directives for Catholic Health Services:

      While offering services to all persons in need, some parameters are required to ensure the integrity of the values and principles that ground Catholic health ministry. In essence, we hold ourselves to higher ethical standards than secular institutions. The Ethical and Religious Directives for Catholic Health Care Services issued from the Unites States Conference of Catholic Bishops reaffirm the standards of behavior in health care that flow from the Church's teachings about the dignity of the human person. These moral directives provide authoritative guidance on certain issues that face Catholic health care today. As a Catholic health care system we adhere to these guidelines. For example, we do not perform abortions or sterilizations at our facilities.

      Code of Ethics from Nurses:

      Combined with our professional obligation to uphold the ANA Code of Ethics for Nurses, our nursing practice is grounded in respect, compassion, integrity, and competence. Coupled with the guidelines from the Ethical and Religious Directives for Catholic Health Care Services by the National Council of Bishops, our guidelines are grounded in ethical, legal, and moral constructs. These Ethical Religious Directives (ERDs) guide our clinicians in their care-giving. (EP23-1EP23-2

      Professional Practice Model - Circle of Excellence:

      Our Nursing Professional Practice Model, entitled the "Circle of Excellence" illustrates our commitment to mission, vision, values, and ethical practice. PSFHS' Mission and Vision frame our model, and our holistic nursing practice elements and values encircle daily nursing practice.  The patient, family, and community are in the center, surrounded by our defined essential elements of professional and excellent practice. The American Nurses' Association's Code of Ethics for Nurses (2001) provides a framework describing the goals, values, and obligations of the nursing professional. The Code is explicitly identified within our Professional Practice Model. Woven throughout the model are statements focused upon the essences of competence, collaboration, integrity, promotion of efforts to meet health needs, advocacy, and quality. A relationship-based care philosophy emphasizes our commitment to honor and promote healing and healthy relationships. Nurses have an obligation to protect patients and the public. A number of organizational policies guide associates on important ethical issues such as corporate compliance, conflicts of interest, standards of performance, professional behavior, and reporting requirements.

      Patient Rights:

      Patient Rights and ethics intersect to promote a fair health care system and they provide patients with an avenue to address any problems and to encourage active patient/family participation in care. The Patients Rights #21 states that the "patient has the right to participate in decision-making regarding ethical issues, personal values, or beliefs." Patient/family/surrogate decision-maker (legal representative) shall be informed of how to gain access to the Ethics Committee and the process for ethical issues resolution, which includes an ethics consult. An Ethics Committee brochure is visible and available on all units. 

      PSFHS Ethics Committee/Ethics Consultation:

      PSFHS' Ethics Committee is an interdisciplinary work group charged with assisting leadership in ensuring consistency between mission, values, organizational behaviors, and clinical practice. This committee includes members from our community, physicians, PSFHS nursing, case management, and spiritual care. The Ethics Committee oversees the ethics consultation service that provides information, education, and/or consultation about ethical problems twenty-four hours a day, seven days a week. We recognize that the care of patients can be clinically and ethically complex and often these inquiries reassure team members as to whether or not they are appropriately proceeding through challenging and nuanced situations. Education and training for our ethics consultants occurs during monthly meetings and through regular participation in conferences. The Ethics Consultation team is comprised of registered nurses, chaplains, and physicians who meet regularly to review their practice and meet when complex ethical consultations are requested. Ethics Consultation requests come from across the system and from multiple persons. The presence of palliative care on our intensive care services has resulted in fewer requests from these units, however, consults related to end of life issues remain the most frequent reason for consultation.

      Nurses, case managers, and physicians requested improved access to consultant documentation. Prior to the fall of 2012, consultants documented a note in the physician progress notes. If providers were off the unit or off site, however, they were unable to access the document. Ethics consultants across Centura Health requested and designed an intervention to be added to Meditech.  In November 2012, this intervention became "live." 

      Ethics Committee - Exemplars:

      The following are examples of the Ethical Committee's participation in assisting decision making among clinicians.

      - The objectivity of the ethics consultants can especially help when the patient, family, physician, nurse, and others have differing opinions and hopes. I recall a 90 year old man who was admitted after nearly dying at his birthday party. Even though his life was saved, the patient remained on life support. While this man had requested and documented a desire to die naturally and not to be resuscitated, his family panicked and called for help. The family requested that we remove life support and the physician agreed.  The Ethics Consultant arrived and supported extubation.

      - A skydiver was presumed dead after a fall with a failed parachute. The neurosurgeon requested the apnea test be performed which included turning off the vent to assess patient respiratory effort.  The Ethics Committee in collaboration with physician experts developed an Apnea Testing Protocol to reduce the risk associated with test.

      - A woman after open heart surgery needed a permanent pacemaker to survive. A temporary pacemaker was in place and the patient decided that she wanted the pacemaker turned off so she could die. The cardiovascular surgeon insisted she was not competent to make this decision and ordered her sedated with anxiolytics. The RN upheld the patient's right to make her decision and advocated for her. The Ethics Consultant was contacted and after significant discussion with the patient and all providers, the patient's wishes were followed.   

      Hiring Process, Orientation, and Education:

      Using a Targeted Selection process for interviewing and hiring new associates provides opportunities to articulate our standards for ethical and social conduct. This process includes specific questions which allow the manager and peer interviewers to assess applicant responses for ethical behaviors.

      Centralized ethics education occurs through new employee orientation, annual mandatory refresher courses, with special training for new graduate nurses, and associates involved with research. All new nurses are oriented to the ANA Code of Ethics and Ethics Consultation during orientation.

      Additional educational and ethical instructional programs are integrated into palliative care, behavior management, and cultural sensitivity programs. In 2010-2011 Grand Rounds presentations expanded the focus on ethics, bringing in external expert Deb Bennett-Woods EdD, FACHE from Regis University. She gave a presentation entitled, "Ethics and Resources at the Margins of Life: Health Care for the Oldest of the Old, the Youngest of the Young and The Sickest of the Sick."  (EP23-3)  Recording the presentation has allowed us to share the learning with our nursing colleagues. She returned in September 2011 to speak on "Unexpected Ethical Challenges of Nanotechnology on Health." In addition, Grand Rounds featured the "Jehovah Witness Patient and Bloodless Care" which helped inform caregivers of differing religious considerations. (EP23-4)

      A tradition of Nurses Week at PSFHS is the offering of educational activities. In addition, a nurse ethics consultant provides overview and case examples on ethical practice, ethics consultation, and the ANA Code of Ethics to participants in the new graduate nurse program. (EP23-5) In addition, the monthly nursing newsletter heightens awareness of ethics through periodic articles. (EP23-6)

      Letter from Family in Story to the left

      Business Ethics and Integrity:

      Centura Health/PSFHS is committed to high standards of business ethics and integrity that reflect our heritage and values. The Integrity Standards is a resource that provides general guidance to assist in complying with applicable laws. Further, it is helpful in fostering an environment that promotes and encourages values-based business practices and high standards for ethical behavior. Mandatory education on Corporate Responsibility is provided through an online educational module. 

      The Integrity Standards include:

      1. Foster an Ethical Culture
      2. Protect our Assets
      3. Adhere to Regulatory Compliance
      4. Avoid Conflicts of Interest
      5. Protect Confidential Information
      6. Provide Quality Care

      Additional Resources to Support Nurses:

      Resources available to all nurses to support ethical nursing practice include: the Ethics Committee, Ethics Consultants, Chaplains, Spiritual Care, Faith Community Nurses, Clinical Nurse Specialist in Pain, Clinical Nurse Specialist in Palliative Care, Psychiatric Emergency Treatment Team, Nursing Administration/PSF Administration, Peer Review, Patient Representatives and interdisciplinary policies. Consultation with ethics consultants, spiritual care associates, and nursing administration is available 24/7. The current edition of Ethical & Religious Directives is available on the PSFHS Nursing Intranet and in 2012 this tool was made available on "My Virtual Workplace" (our intranet) on the Reference tab to all associates and physicians. 

      The Department of Missions and Ministry:

      Chaplains, priests, pastoral care staff, and volunteers are available twenty-four hours a day. They also make rounds on units, visiting patients/families upon request, and they offer spiritual services when needed. We are especially proud of our on-campus Certified Pastoral Education program and interns. Our associates seek counsel from spiritual care as well as the EAP as needed.

      Resources for Ethically Distressing Situations:

      When our associates experience morally distressing situations, they have a variety of resources they can choose from to help them cope with their troubles. A key resource of this type is our Employee Assistance Program (EAP). When the Labor and Delivery Team experienced multiple deaths, the manager identified signs of stress in her staff. Collaborating with another nurse manager to help cover the unit, an EAP counselor provided education, debriefing, and team support to reduce stress and to support effective management of this trauma. Staff voiced appreciation to the EAP and to the manager and were able to manage the stress related to these losses without sick calls or resignations.

      In 2012 associates in SFMC's Emergency Department experienced the tragic loss of a baby. One of the chaplain interns arrived at the ED to provide support to the family and to the unit staff. The ED Clinical Manager wrote a "Note of Appreciation" to the Director (Spiritual Care) which is attached. These actions helped to bolster a sense of worth and to console all parties. (EP23-7)

      Clinical Nurse Specialists (CNS) in Pain Management and Palliative Care promote best interdisciplinary practices to support quality of life for our patients. Consultation with patients, families, and caregivers always includes advocacy for patients, for nurse autonomy, and for integrative health care. Hosting an ELNEC Palliative Care Conference in 2010, our Palliative Care CNS shared her expertise with people from across our state and region.

      Professionals have reporting requirements related to abuse. The Social Work team provides support and guidance when needed.

      Expanded education on ethical issues is available to all. Annually, a Fall Ethics Conference is held in the fall. In early 2012, an Ethics Associate Program was designed and offered to interested Centura Health associates. Provided by respected Catholic Health Initiative ethicists Carl Middleton and Lois Lane, the program provides an opportunity to learn more about the Catholic tradition in health care or simply becoming more comfortable in dealing with difficult issues in practice. (EP23-8)(EP23-9)

      Leadership Resources Directors and managers are readily available to discuss ethical and compliance concerns. Human Resources are available for any related issues such as fair treatment, payroll, and disciplinary issues. The Corporate Responsibility and Privacy Officer can be contacted directly via phone or email. In addition, the Integrity Helpline is available 24/7 and may be used anonymously.


      RN's in SFMC's perioperative service prepare for women's surgery with an open eye for potential ethical questions. In 2010 and 2011 the nurses called for ethics consultations on surgeries involving use of intrauterine devices, dilation, and curettage procedures in the presence of signs of pregnancy. The nurses identify these complex ethical challenges as the woman is being prepared for surgery. While the Ethical Consultants respond immediately, surgery is delayed until reviewed and approved. In general, the Ethics Consultants provide consultation to all involved, however, in situations clearly regulated by the Ethical and Religious Directives, the consultants make the decision to approve or halt a procedure. The Chief Nursing Officer and Chief Medical Officer meet with the physician obstetric section regularly to promote open discussion as well as clarification regarding our ethical consultation process and outcomes.

      PSFHS participation in donor activities is regulated through strict policies and procedures.  Only specially trained staff may ask patients and families about donations.  In some situations, ethics consultants must be called prior to action. 

      Organ Donation

      The NICU Clinical Manager contacted the on call ethics consultant on XXXXXX, requesting consultation on potential infant organ donation. The consultant reviewed the clinical record, policy on organ donation and the Ethical and Religious Directives and met with two other ethics consultants. Copies of the policies on Brain Death and Organ Donation were reviewed with the clinical manager. Actions required in these policies were occurring and scheduled. The consultant refocused on the infants family and clinical staff. The nursing staff had rearranged patients to provide an empty room next to the infant for family and visitor use. Family members and friends were using the room for breaks and easy access to visit the baby. Nursing staff provided education and support, respecting the family's desire to stay close. Chaplains checked in with the family, who declined spiritual care support from our chaplains. The clinical manager and nursing staff supported one another as they moved through the two days of process to assess for brain death. 
      Although the current policy was appropriate in providing procedures to follow, our policy did not specifically address determination of brain death in infants.  Pediatricians and neonatologists determined brain death and were involved with the process for organ donation. When the Ethics Consultant reviewed the policies, she suggested the addition of a separate section for determining brain death in pediatrics and infants. National guidelines and literature were searched to gather evidence based guidelines for determining brain death in this population. The policy has now been revised to include the process for determining infant and pediatric brain death. The revised 2012 Ethics Committee Charter now includes a focus on education of Spiritual Care and Managers about recognizing and counseling for moral distress of staff members during difficult care situations.

      Resources - Teamwork:

      The NICU Clinical Manager sent the following email to the Chief Nursing Officer and VP of Nursing at SFMC. 

      Hi Kate and Ann,

      I wanted to share with you an amazing experience that I think should be published somewhere!  On Monday morning I was asking Dr. Mike Muench some questions about the procedure that was to take place on XXXXXXXXXXX   We, in the NICU, were preparing for the possibility of getting a 24 week twin. While conversing with Dr. Muench he stated that he wouldn't be able to do this procedure the same way that he had done the last one. I had asked if I could help get anything, or do anything and he gave me a list. I then called Kelly Ledbetter, told her the plan, she immediately began calling Penrose Main OR to find the needed equipment.

      On Tuesday morning, Donna Hogan and I began working on making sure we had all of the equipment, which was not an easy venture. With Ann and Kristin's (PH OR Director), help we were able to call not only Porter Hospital in Denver, but Memorial Hospital in Colorado Springs, who graciously sent some crucially needed supplies. I would like to recognize Karen Smoczyk from PH OR for her exemplary team work, her helpfulness, and her professionalism; we couldn't have done it without her.

      Additionally, I would like to recognize the entire team that was involved in this process.  The entire NICU team, which included respiratory therapy, nursing, nurse practitioners, and Dr. Prado, the Labor and Delivery team, nursing and CST, and the OR from both PH and SFMC. The procedure performed by Dr. Muench, one of two MFM's in the State of Colorado who could perform this surgery, saved a baby's life.

      While watching this procedure take place, it only reinforced why I love working here and what an amazing place and people we are surrounded by!   April McPike BSN, RNC-C-EFM

      The physician sent a follow up email to notify clinicians of outcome and his gratitude.


      Very Important Persons (VIPs):

      Our nurses' knowledge, skill, and commitment to the Code of Ethics influence the delivery of patient care. The perception is that VIPs can negatively affect the quality of care due to them receiving unethical "special treatment." This is not a problem at PSFHS. Our attitude towards VIPs is simple as demonstrated by the following quote, "I don't care if she is a VIP. On our unit we treat everyone with respect and compassion. We are committed to excellence - and VIP does not make a difference."


      Healthcare environments breed ethical dilemmas. Differing considerations for the quality and dignity of life have the potential of placing nurses in difficult positions. To confront these potential disturbances, our nurses act through several different modes. Among these is the Ethics Committee, which has significant nurse membership. This committee examines situations and it makes recommendations based on what is best for the patient and our organization's values. It is this group which developed our "Ethics Development Plan 2011-2016," a five year plan designed to make our ethical directives some of the most comprehensive in the industry. (EP23-10

    • Exemplary Professional Practice - EP24

      EP24 Request- Please provide description and substantiating evidence to demonstrate how nurses have resolved issues related to patient security.


      There are two major forms of security issues within the healthcare field. These fields are physical and information security. We believe that all associates are responsible for the security of our installations, patients, and information infrastructure. The importance of nurse interaction with security cannot be overstated as it is the nurses who have the most direct contact with patients and they are aware of the familial situations. Additionally, nurses maintain information databases which contain vast amounts of patient information. The following are high points which demonstrate our organization and our nurses' commitment to patient security.

      • PSFHS contracts its security to G4S Secure Solutions (formerly known as the Wackenhut Corporation) which provides protective services for patients, visitors, and associates. Security officers are available 24 hrs/7 days a week and can be accessed by calling an internal number. Security officers patrol the hospital grounds and internal facility regularly, and they respond to all Code Greens (violent behavior or call for security) within minutes.

      • Valet services promote patient and visitor safety. The associate parking garage at SFMC is locked and requires card access.

      • Data security is of the highest importance to our patients and our associates. When Centura associates leave the workforce their access to IT is discontinued. Passwords are required to access information technology; these network passwords require strong construction and timely regular changes. Centura Health IT also monitors access to patient records and can identify questionable access.  If a staff member wants to review their own patient record, they are required to follow the process of all patients.  Access to internet sites is limited and Centura email is encrypted. In the event of data loss, Centura Health takes immediate action. Nurses using computers for patient care are required to lock or secure the computer prior to leaving the area.  This nursing action secures patient information.  ( EP24-5 , EP24-6 , EP24-7 )

      • Badge access limits access to areas within the hospital for all associates and visitors.  All associates, volunteers, physicians and vendors are required to wear badges.  All associates are expected to query people without visible identification badges.  Nurses question unknown people who attempt to enter the nursing stations and direct unauthorized people to leave.

      These security organization security practices are established to reduce patient, family and staff worry or anxiety about their safety.  These are external safeguards in place to protect people.  Nurses are active participants in ensuring accurate badges are worn, codes are called when needed and unauthorized access to patients and patient care areas is reduced.

      In addition, nurses resolve issues related to patient security through specific actions for especially vulnerable patient populations.

      Organ/Tissue Donation and Recovery

      Penrose St. Francis Healthcare facilities will identify potential organ/tissue donors and refer to Donor Alliance in a timely manner. Only trained designator requestors will approach the next of kin to assure discretion and sensitivity to the circumstances, beliefs, and desires of the families of potential donors. PSFHS holds required training to ensure requestors are knowledgeable of all policies related to organ donation requests.  Patients and families can be secure in the knowledge that we follow clear protocols.  Nurses and chaplain staff comprise our Designated Requestor List. ( EP24-R1 , EP24-R2 )

      Patient Security for Infants and Children

      The HUGS/PEDS infant and Pediatric Security System provides an effective deterrent against the abduction of infants/children. The system consists of tamper-proof tags and receivers that define the safe areas in the hospital and alert hospital personnel whenever a breach of boundaries has occurred. Nurses are responsible for applying a HUGS tag to the infant as soon as possible after birth and to children under age 5 or children at risk for elopement during the admission process.  The banding process (HUGS) and the use of unique photo identification badge for pediatric and birth center associates provide patient security. ( EP24-R3 )       

      The Code Pink policy outlines the procedure for a missing child or adult within the PSFHS facilities. Nurses are usually the ones who observe a missing patient and call the Code Pink. ( EP24-R4 )

      The Security Department evaluates possible vulnerabilities with the Code Pink procedures through regular Code Pink drills. The After Action Reports are confidential but indicate the importance of nurse's role in securing patients.  Excerpts of three reports are attached that demonstrate nurse action in resolving issues related to patient security. ( EP24-R5 )

      Locked Doors to Improve Patient Security for Infants and Children

      In the fall of 2010 a SFMC 3rd Floor Security Plan was drafted and implemented in 2011. The attached report details plans to improve security through additional locked doors.  By limiting access to these units through locked doors or associate badging, the responsibility for nurses to implement, monitor and approve access increases. ( EP24-R6 )

      The Post Partum Mom Baby Unit Practice Council identified and resolved issues related to patient security. The Mom Baby unit has a locked door for patient security.  The UPC requested a phone for guests to call after hours with link to nurse for accessing the unit.  This was approved.  ( EP24-R7 )

      Psychiatric Patients in the Emergency Room

      In 2011, an interprofessional team met weekly to review security and safety for psychiatric patients treated in the emergency room.   Since the ED remodel included a separate section for psychiatric patients and the PSFHS inpatient behavioral health unit was closed, the team met to identify risks and opportunities for patient care.  Issues resolved by these nurses, physicians and security staff include:

      1. Access to unit for nursing staff, physicians; door locks 
      2. Visitor policies 
      3. Security of patient belongings including possible weapons; patient searches and use of lockers 
      4. Observation and monitoring patients by nursing, security 
      EP24-R8 , EP24-9 )


      Nurses resolve issues related to patient security by establishing and implementing policies and procedures in collaboration with facilities, security and patient representatives.  Psychiatric patients, dying patients and children are high risk for security issues.  The examples above highlight the strategies nurses have used to improve patient security.

    • Exemplary Professional Practice - EP25

      Diversity and Workplace Advocacy

      EP25 Describe and demonstrate how the organization identifies and addresses disparities in the management of the healthcare needs of diverse patient populations. Include the role of the nurse.

      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.  (PSFHS Mission)


      Our Mission Statement provides our organization with guidance and direction. Our Mission is congruent with the Nursing Social Policy Statement, the ANA Nursing Scope and Standards, and the Code of Ethics for Nurses.  These documents hold us accountable to demonstrate respect for human dignity and responsibility to our community.

      In essence, we look to fulfill the goals and expectations of our long term plan, Centura 2020. This plan has three clearly stated goals which are based upon our mission and values and are directly applicable to disenfranchised members of our community:

      Build Systems of Care: We will transcend the four walls of our facilities to create true systems of care that connect our facilities together in a seamless network of excellence delivering health services across the full continuum of need. We will extend the notion of hospital-based "Centers of Excellence" to create coordinated "Systems of Excellence" that connect various care delivery settings and allow us to reach out to the communities we serve.

      Move "Up Stream" to Manage HealthWe will devote increasing resources and attention to that portion of our mission statement that calls us to improve the health of the people in our communities. This means we will expand the scope of our services beyond traditional "sick care" to truly manage health in accordance with our health model. (EP25-1)

      Strengthen the Foundation: We have a tremendous foundation of health care facilities and organizations and a large group of highly committed, mission-centered professionals who share in our ministry. This foundation must evolve with the times to ensure the continued viability and effectiveness of our ministry. To strengthen our foundation, we must continually find ways to improve. A strong foundation will fuel our transformation, allowing us to build systems of care and move "up stream." (emphasis added)

      Clearly, the elements of continual improvement, evolution of methodology, and the devotion of resources to the community at large demonstrate a dedication to providing care for the underserved members of the populace.

      How Organization Identifies Needs:

      Community Benefit Plan Our community is growing more diverse every year. Due to the large military presence in Colorado Springs and the increasing population of those from Hispanic backgrounds, PSFHS knows that it must help reach out to these, and other groups' specific needs.  In order to work from a well informed position, and to ensure our non-profit status, PSFHS commissioned a study of the population of southern Colorado in order to identify and anticipate the community's needs. The Community Benefit Plan identified the following problems in order of their impact on the community:

      1. Children in Crisis Due to Violence
      2. Failure to Meet the Needs of the Mentally/Behaviorally Ill
      3. Lack of Access to Health Systems
      4. Lack of Systems to Approach Preventative Care
      5. Obesity Rate
      6. Oral Health
      7. High Incidences of Melanoma

      Statistically, at risk children are facing high rates of violence at all ages and El Paso County's teenage suicide rate is unconscionably high. As a result both of our facilities have pursued ways to improve the community through the creation of opportunities directed at reducing this crisis. SFMC, whose location is suburban and which enjoys a pediatric focus, its strategies include: creating partnerships with local school districts, increase breastfeeding, education programs, and to create job opportunities for teens. Penrose Hospital, in keeping with the challenges of being an urban healthcare hub has adopted the following strategies with the goal of improving the mental health status of El Paso County: depression screenings for teens, increase community awareness, decrease the use of alcohol among teens, and to improve access to health care for underserved populations. (EP25-2EP25-3EP25-4)

      Internationally, our associates actively seek ways to help people in medically underserved regions. Over the last few years, individuals and groups indentified needs and travelled to Haiti, Peru, East Asia, and Central Asia. The specific care provided in these trips will be discussed in "How Organization Addresses Diverse Needs." 

      Collecting Demographic Data The weekly associate newsletter published a brief article on the value and reason for collecting demographic data.  Registration and nurses collect demographic data that provides information on a wide range of disparities across the nation and promotes research action.  (EP25-5)

      Centura Health Management Council has charted a course for us to be more proactive, coordinated, and results-oriented. We made the commitment to focus our community health improvement efforts on obesity. Sixty percent of our community health programming will be devoted to reducing the growth of obesity among Coloradans, with a special emphasis on childhood obesity. By focusing most of our efforts on a single health condition, we plan to make a much greater impact than by our past practice of spreading our efforts widely among a plethora of independent programs. Yet, this approach will undoubtedly produce considerable backlash as our funding of community health programming follows our focus. Those Centura Health associates and stakeholders with strong commitments to addressing other community health issues will probably assail our focused approach. Our commitment to be more results-oriented and to use metrics to gauge our progress will help us to determine relatively quickly whether this focused approach is demonstrating the benefits we envision.

      The Office of Patient Representatives The Office of Patient Representatives is overseen by the Chief Medical Officer. The group is comprised of three full time patient representatives. These nurses have both clinical and patient representative experience and provide services throughout the PSFHS organization. 

      Nurses Role in Identifying Needs:

      The Community Benefit Plan and needs assessment was written by a committee which compiled data, wrote the report, and created strategies for addressing community issues. Cynthia Wacker, RN was a key member of this committee. She participated in the development of the report and she states that, "As a nurse, it was important to see the many healthcare challenges of El Paso County. Being able to participate in identifying needs, and how to concentrate on fixing them spoke to why I became a nurse in the first place."

      Nursing standards of practice and professional performance provide a structure for identifying diverse patient needs. The individualized care plan provides the structure for collaboration and communication with the patient, family and health team to meet patient needs. Nurse ethical practice provisions clearly state the obligation of nurses to collaborate not only with other health professionals but also with the public at-large in promoting community, national, and international efforts to meet health needs. Nurse participation in Centura Health, PSFHS and community committees provide opportunities to collaborate to identify health needs.

      Penrose-St. Francis Neighborhood Nurse Centers staffed by Faith Community Nurses are located throughout our community. Through partnerships with multiple community agencies who serve a diverse population, the nurses identify and coordinate to facilitate patient access to resources.  (EP25-6)

      How Organization Addresses Diverse Needs:

      The Centura Health Advocacy function, led by the Senior Vice President, Strategic Integration, is responsible for providing associates with information, support and leadership in relation to health care management issues and legislation. Centura Health is highly involved in advocacy efforts to improve Colorado's health care quality, access, and affordability. We participate in health care-related meetings, committees, task forces, and coalitions throughout the state; further, our advocacy shares Centura's positions on all healthcare-related bills. Our position on each is guided by Centura's mission, vision, values, and strategic goals. We believe that all Centura associates should be aware of the big issues in health care and the impact they have on the communities we serve.  A website is accessible to all associates, which provides the latest information and suggestions on actions associates can take. The weekly Corporate Communication email is sent to all associates and includes information on healthcare advocacy issues. Additional information is available on's Advocacy page. (EP25-7)

      PSFHS Foundation provides financial assistance to patients. This program is in keeping with our religious heritage and it seeks to lighten the burden on those whose access to care is limited. (EP25-8)

      Locations of Facilities PSFHS services are available in multiple sites including two Urgent Care Centers in mountain communities west of Colorado Springs.

      Nurses Role in Addressing Needs:

      Nurses address disparities in the management of healthcare needs of diverse patient populations through individualized treatment, community services and partnerships within the community.

      Individualized treatment All patient care is relationship based and involves establishing an individualized treatment plan for all patients. Case Managers and unit nurses provide vouchers for transportation when a patient is unable to arrange for transportation at discharge. 

      Nurses collaborate with other departments to ensure we have equipment and resources readily available such as Cyracom translator phones, bariatric beds and chairs, Braille signage, interpreters, and education materials in various languages. 

      Case Manager Nurses provide discharge support especially in complex patient/family situations.

      Through Neighborhood Nurse Centers, Faith Community Nurses (FCN) facilitate access and coordinate referrals to meet the needs of a disparate population. (EP25-9) FCN programs have been discussed and demonstrated in SE11.

      Penrose Cancer Center The Cancer Center provides outreach services and education to increase awareness of cancer prevention, screening and early detection. As part of our mission of care, meeting the spiritual needs of the community is just as important as providing physical and emotional healing. We are especially committed to meeting the cultural, ethnic, and religious needs of high-risk groups. As proof of our promise, Penrose Cancer Center specializes in providing services to Spanish-speaking patients through JUNTAS and to African American women through the ANGEL Network. ANGEL stands for African-American Women Nurturing and Giving Each other Life. The Angel Network is dedicated to promoting wellness and empowering women though health education. Its mission is to reduce cancer health disparities by offering early detection screening and health education.  

      ANGEL Network Even though the ANGEL Network does not exclude anyone interested in fighting cancer health inequities, most of these women are supporters of our efforts to get the word out to the African American community about early detection and screening for cancer.  They originally came together to focus on breast health issues in 2001.  Carolyn Kalaski developed a program to teach volunteers from all ethnicities and walks of life about seven different cancers: breast, cervical, ovarian, testicular, prostate, colorectal, and skin.  After training they are certified to talk about these cancers, on a basic level, and refer people to other resources for further information.  This program is called (CAARE) Cancer Awareness Advocate and Resource Educator.  Last year we certified eight community advocates through CAARE. (EP25-10)

      Prostate Screening PCC volunteer physicians and personnel, in collaboration with Peak Vista Clinic, Rocky Mountain Cancer Centers, the Man to Man Support Group, and Memorial Health System, led an annual free prostate cancer screening event in September 2011. A total of 133 patients, approximately 50% of whom had no insurance or access to routine health care, received prostate cancer screening with PSA testing and DRE (digital rectal examination). A total of 45 were found to have an abnormal DRE, and 10 were found to have an abnormal PSA. To date, a number of patients have been referred for urologic evaluation, and at least one patient has been diagnosed with cancer.

      Patient Navigators "Patient navigation" in cancer care refers to the assistance offered to healthcare consumers (patients, survivors, families, and caregivers) to help them access and then chart a course through the healthcare system and overcome any barriers to quality care. Navigators help their patients move through the complexities of the healthcare system - getting them more timely treatment, more information about treatment options and preventive behaviors.   Examples of navigation services include:

      • Arranging various forms of financial support; arranging for transportation to and childcare during scheduled diagnosis and treatment appointments
      • Identifying and scheduling appointments with culturally sensitive caregivers
      • Coordinating care among providers (such as screening clinics, diagnosis centers, and treatment facilities);  arranging for translation/interpretation services
      • Ensuring coordination of services among medical personnel;
      • Ensuring that medical records are available at each scheduled appointment;
      • Coordinating other services to overcome access barriers encountered during the cancer care process.
      • Linking patients and families with appropriate follow-up services

      Evidence shows that in addition to unequal access to health care, racial/ethnic minorities and underserved populations do not always receive timely, appropriate advice and care when confronted with a cancer diagnosis. Patient navigators can make the difference between someone from an underserved population becoming a cancer survivor or a cancer death.

      Community Partnerships:

      SET Family Medical Clinic (Service, Empowerment, and Transformation) is a clinic which treats the homeless and destitute in our community. The clinic managed 8,048 visits in FY10 which was almost double 4,855 visits in FY09 (2010 is the most recent annual data available). Among the 3,060 patients receiving care, 32 percent were children under age 18 and over 85 percent of the families are living below the federal poverty line. When patients are asked where they would go for care if it were not for SET, 38% state "nowhere." Several PSFHS nurses volunteer at the SET Clinic each week. In addition, PSFHS is a major sponsor for SET Clinics.

      SET Service The Comprehensive Healthcare Re-entry Program (CHRP) in Colorado Springs is in the third year of a CHI grant which supported the establishment of a healthcare program that includes a mental health care for ex-offenders returning to live in our community. The CHRP is a collaborative project with other faith-based organizations. All services are provided to support successful re-entry and to curb the recidivism rate. In FY10, CHRP enrolled and provided services to more than 1,000 clients and reported a 6 percent recidivism rate compared to the State of Colorado's rate of 56 percent. Since its inception, the CHRP Program greatly exceeded goals, serving a much larger population than initially anticipated. To help cover costs of the popularity of this program, grants have been sought through outside parties. (EP25-11)

      Psychiatric/Behavioral Care With the closing of our in house psychiatric care unit in 2011, PSFHS had to make additional external partnerships to continue to serve those who were experiencing crises. As a result, PSFHS contracted with Cedar Springs and Aspen Pointe (two local for-profit mental health facilities) to provide care for the indigent at the expense of our organization. Further, we re-organized and streamlined our emergency departments to address mental health concerns while leaving open avenues for taking patients to our partners in the field. (EP25-12)

      Centura Health Global Health Initiatives:

      Our Global Health Initiatives (GHI) increased significantly during the past fiscal year. Projects have taken place in six countries around the globe...Belize, Haiti, Nepal, Peru, Rwanda, and Vietnam. Nearly 50 physicians across Centura have been involved in these projects, as well as 10 residents/medical students/physician assistants, 63 nurses, and over 100 allied health professionals. In addition to the regularly scheduled projects, a number of our physicians and nurses went to Haiti in response to the devastating earthquake in January. As a result of these efforts, nearly 250 surgeries were performed (not counting those in Haiti) and about 7,500 outpatients were seen in community health clinics. These efforts (patient care including but not limited to: cleft palate surgeries, de-worming, sanitation, and education) were supported by grants of $320,000. Additionally, $307,240 in contributions were received for GHI projects along with $81,646 in general donations. Donations of medical supplies and equipment were in excess of $500,000.


      Our mission statement above provides a firm foundation for our organization. Assessment of community needs, developing services independently and through community partnerships and living our ethical principles ensures we identify and address disparities and manage the healthcare of a diverse patient population. Nurses within the Penrose Cancer Center and Mission Outreach Faith Community Nurses demonstrate a leadership role in obtaining grants and developing partnerships to address disparities in healthcare.

    • Exemplary Professional Practice - EP26

      Diversity and Workplace Advocacy

      EP 26 How nurses use resources to meet the unique and individual needs of patients and families

      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.  (PSFHS Mission Statement)

       "Our Labor and Delivery patient was Spanish speaking. I used the translator phone for much of our communication, and the education sheets and paperwork is available in Spanish. But when I offered her the menu to choose her own foods, I found out we did not have copy in Spanish. I used my computer and translated it for her. She was so pleased and grateful.  It was a great shift!" Kristin Wright, RN

      Our Code of Ethics for Nurses states that, "The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual."  We believe all patients and families have individual needs that are worthwhile and deserving of attention. Our commitment to Relationship Based Care and our Nursing Professional Practice Model places the patient, family and community at the center of our practice. 

      In addition, regulatory requirements and Patient Rights require PSFHS to make accommodations for those with differing communication needs.

      A variety of PSFH policies guide nursing and interdisciplinary practices to meet the unique and individual needs of patients and families. While we believe each person has individual needs, some unique situations present challenges to our nurses. 

      Individual care planning is the heart of the process for meeting the unique needs of patients and families. Beginning with assessment, the nurse quickly identifies any needs that require immediate intervention. The assessment process is adjusted and accommodations made to facilitate an accurate assessment of the patient's needs while in the hospital as well as for discharge planning. For example, translator phones are readily available in all areas for patients who speak a language other than English. Interpreters are also called to assist when needed. (EP26-1

      The following list provides a few broad examples of our nurses providing individualized care to patients through flexibility, education, and patience.
      • Inpatient rooms frequently include a sleeper chair for families that choose to stay overnight with their loved one
      • Fertility assistance in accordance to our Catholic mission (EP26-2)
      • A grieving widow who was treated for physical and emotional wounds (EP26-3)
      • Rehab Buddies attended an off Broadway show to demonstrate quality of life (EP26-4)
      • PSFHS Offers Pet Rehab services with volunteer dogs. This gives patients something to look forward to and it reduces patient stress (EP26-5)

      Use of Resources to Provide Care:

      Like all of our units, Penrose's rehabilitation group provides individual care to patients on a daily basis. The following story, told by Theresa Lutze BSN, RN, is important as it demonstrates the willingness to go beyond normal standards of care for a patient who is experiencing trouble during recovery:

       "A patient with a traumatic brain injury was admitted to our inpatient rehab unit. While this is not a rare occurrence, the patient's agitation, confusion, and sensitivity to stimuli was higher than many other patients. We did the evidence based practices that are usually helpful - reducing stimuli, consistent assignments, use of medication, predictable schedule. However, his unpredictable, aggressive behaviors continued to escalate. We are truly committed to patient centered safe care, and we are committed to a safe work environment. He began to assault associates on the unit.  Finally in desperation I asked if we could build a separate area on our unit that would safely allow him space to move and participate in therapies, yet contain his actions and limit access to other patients and associates. I received immediate support from my Director and our CNO. I contacted Facility Management and within the day, a wall was built which met patient and associate needs. We continued therapies safely until he was rea dy for discharge."

      Integrative Therapies are offered in order to treat the patient as a whole unit.  Patients and their caregivers have opportunities to try integrative therapy modalities.

      Organ and Tissue Donation PSFHS is associated with the Donor Alliance Organ Procurement Organization and follows its rules and regulations. The Donor Resource Team is comprised of representatives from Penrose Hospital, SFMC, Donor Alliance, and Rocky Mountain Lions Eye Bank. This organization reviews our donation processes, identifies education needs, recommends changes in practices, and monitors our compliance with reporting requirements. Jean Paulsen RN, our donor champion, and Chair of the Donor Resource Team states that:

       "In the years I have been involved with organ/tissue donation at PSFHS, I have consistently observed compassion, integrity, supportive care, and dedication in many associates. Our associates are genuinely concerned for our patients and their families. Spiritual Care associates are always available to support the families and the healthcare team. As a tribute to the patient and family, we fly the Donate Life flag for 5-7 days following donor death. Families have requested prayer time, pictures, and memory sharing at the flag pole. I recall one night a group of friends of the donor requested to meet at 3am to raise the Donor Flag and remember their friend. It was an incredible honor for all involved to see the flag and share stories."

      In 2010, PSFHS donors provided kidneys, hearts, livers, and a pancreas in addition to 35 tissue donations and 42 eye/cornea donations. Recognizing the potential stress during these situations, nursing consults with spiritual care and may also seek Ethics Consultations. (EP26-6)

      In September 2011, Penrose Hospital was presented the Ending the Wait award in appreciation for their extraordinary efforts in organ and tissue donations. Penrose was awarded for our commitment to honoring patient and family wishes for Donation after Circulatory Death.

      Each year the Donor Alliance has a float in the Rose Bowl Parade. In 2012 a patient family who recovered in our Intensive Care Unit was honored on this Rose Bowl Donor Alliance Float.

      Organ and tissue donation is a personal decision for donors, for recipients, as well as all of their families. Our dedication to providing resources to supporting this unique personalized care decision goes through our nurses and it helps countless people. 

      Inpatient Rehabilitation Unit:

      Recognizing the unique needs of patients and families who have experienced a stroke, traumatic brain injury, or other life changing event this unit enhanced services beyond medicine, nursing, therapies, spiritual care, and psychological testing to include the following:

      Vision Clinic is scheduled weekly to provide Inpatient Rehabilitation patients with visual deficits an opportunity for assessment by a Behavioral or Neuro optometrist and prescription for remedial exercises, adaptive equipment, and/or environmental adaptations to enable improved visual skills, function and safety.

      Nurse Counselor A psychiatric nurse serves patients and families, offering supportive counseling, education, grief work, and referrals for continued outpatient care. In addition, she supports the volunteers who serve as Rehab Buddies. She skillfully pairs patients with a buddy volunteer (former patient) and in that role has inspired and nurtured the buddies as well as the patients. A Rehab Buddy states that, "Connie (our nurse counselor) has a way of making each of us feel valued. She shows tremendous love for each of us and always says just the right thing."

      Other Available Resources for the unique Needs of Patients and Families:

      Nursing Specialists are a key aspect to the Case Management team, who are primarily responsible for facilitating discharge planning. It is comprised of nurses and social workers who work in collaboration with the patient/family and physician. The duties of this team include referrals, appointments, and communication between parties to promote a continuity of care across multiple settings. This team also provides vouchers for medications when needed, and maintains a clothes closet at our various facilities. A list of low cost referrals is maintained and shared with the nursing department to provide patient and family choice as we respect their socio-economic situation.

      Lactation nurse specialists support breastfeeding mothers both in the hospital and following discharge. This certified and experienced team sees patients and they provide a unique service for new mothers. Further, PSFHS has been a "Mother's Milk Depot Station" for over 25 years. Our lactation nurses collect breast milk and distribute it to patients across southern Colorado. (EP26-7)

      Associate Campaigns are performed annually in order to raise capital for philanthropic endeavors. In 2009, we raised a record-breaking $365,000 through our associate campaign.  This is the most ever raised in the history of the campaign (which goes over twenty years), and it should be mentioned that this was during a time of severe economic downturn. If there was ever a testimony to our associates believing in our mission, this is it. They knew even more people would need assistance, and they reached deeper and farther in order to provide for the community's needs. We were also pleased that 38% of our associates gave, far exceeding the national average of 30% for this type of campaign. Most of the funds raised through the campaign were directed by the donor to our Sisters of St. Francis Associate Assistance Program and our Sisters of Charity Patient Assistance Program. Over $50,000 was also directed to purchase digital mammography equipment at Penrose Hospital. This quality and quantity of giving speaks volumes to the generosity, caring and service of our associates to others in need.

      With funds raised from last year's campaign, we were able to provide assistance this year to over 1,100 people who experienced unforeseen crisis or unanticipated hardship. Through our patient and associate assistance programs, we were able to provide crucial financial assistance and make life-changing differences for people. A few examples include: providing time for rehabilitation to an associate who was attacked and severely injured by burglars, emergency travel for an associate who lost a parent, and financially supporting increased independent living to a paralyzed patient in need of a wheelchair ramp.

      The John Zay Guest House is a "Home Away From Home" for patients of the Penrose-St. Francis Health Services Hospitals. Patients and family members who live farther than 30 miles from the hospital are welcomed guests in this warm and inviting two-story home, nestled in the safe, residential area known as the Old North End. The John Zay Guest House is directly across from Penrose Hospital. The home is handicap accessible and features 11 comfortable, private suites, several common living areas, a full-service kitchen, a dining room, a laundry room on each floor, and wireless internet access. All guests must be referred by a Penrose-St. Francis Health Services physician, nurse, case manager, or chaplain and must be able to care for themselves or have a care giver accompany them. We operate on a first-come, first-served basis. There is no predetermined room rate but a donation, if the family is able, is requested to continue to provide services to those we serve.

      The 12,000 square foot John Zay Guest House was built for Penrose-St. Francis Health Services in 2008 by HBA Cares and Vanatage Homes Corporation in partnership with Penrose-St.Francis Health Foundation.  The project began with an anonymous donation, followed by donations from the Hospital's associates and individual room donors. The construction was completed by more than 100 allied tradespeople donating their time and skills while supplies were provided by several construction companies donating supplies, labor, money, and talent to the building of "The House That Love Built."  This guest house was named in honor of John Zay who worked as a cancer floor chaplain at Penrose Hospital for over 14 years. The ministry he loved is gratefully continued in this wonderful home.

      Pikes Peak Hospice moved into a unit at Penrose Hospital so that the two organizations could provide services to patients and families under a single roof. While we are not providing direct care for these patients and families, we do honor and value their unique needs. Prior to Pikes Peak Hospice's move into our facility, our Infection Control Committee established a safe process for Pet Therapy and home pet visits to Hospice Patients. (EP26-21)

      The Ronald McDonald Family Room is located in the St. Francis Medical Center. We are proud to be the home of Colorado's second Ronald McDonald Family Room, which opened in 2009 and provides families a respite within the hospital. Open 365 days a year, 12 hours a day, the Family Room is manned 100% by volunteers.  Just steps away from their child, families can rest and regain their strength.   Healthy, nutritious foods and beverages are available to them at no cost.  They can access email and the internet via computers, shower, watch TV, do laundry and check out materials from a resource library.  In addition, siblings of hospitalized children can play in the playroom.

      "Since the SFMC Family Room opened in Nov. 2009, it has served over 1011 families and 4012 guests," says Jill Woodford a family room volunteer and RMHSC board member. "The other day, I ran into a parent whose child was in the NICU last fall and had been in the Family Room during my shift.  We both remembered each other and I found out that his baby is doing much better and out of the NICU.  He was so complimentary of the hospital staff and the role that the Family Room played in helping his family cope with a sick child."   


      Nurses provide individualized care through the careful stewardship of PSFHS' resources. They help create and maintain individual care plans and then they help in executing those plans. Individualized care is supported by our supplementary services. The John Zay Guest House, the Ronald McDonald House, and the NICU transport vehicle all address specific and unique concerns of patients and families. All of which are addressed through the interventions of our caring nurses. 


      EP26-8 Admission of Patients A-02-f
      EP26-9 Assessment (Patient) A-04-m
      EP26-10 Educational Needs of Hospitalized Children  E-01-m
      EP26-11 Hospice Care H-03-c
      EP26-12 Palliative Care P-01-a
      EP26-13 Interpreters I-05-a
      EP26-14 Organ and Tissue Donation O-03-k
      EP26-15 Pet Visitation P-03-c
      EP26-16 Pregnant Patients P-04-a
      EP26-17 Prisoners (Treatment of) P-03-a
      EP26-18 Sexual Assault Victims S-01r
      EP26-19 Sight Impaired (Care of Patient) S-02-1 (4)
      EP26-20 Suicide (Care of Individual with Suicidial Tendencies S-03-e

    • Exemplary Professional Practice - EP27

      Diversity and Workplace Advocacy

      EP27 How the organization promotes a non-discriminatory climate for patients

      At PSFHS we begin all of our meetings with a reflection. The following reflection was shared in our Centura Health Newsletter

      "May I become at all times, both now and forever
      A protector for those without protection
      A guide for those who have lost their way
      A ship for those with oceans to cross
      A bridge for those with rivers to cross
      A sanctuary for those in danger
      A lamp for those without light
      A place of refuge for those who lack shelter
      And of service to those in need."

      -- the Dalai Lama, Nov. 6, 2000


      The mission and vision of Penrose St. Francis Health Services (PSFHS) sets the expectation of a non-discriminatory climate.

      Our Mission 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 Vision Centura Health will fulfill a covenant of caring for our communities with excellence and integrity to become their partner for life.

      Advancing this expectation are our core values; which state:

      "Respect for all persons…..Compassion by honoring the individuality of each person….Excellence through delivering a superior experience for all our customers, sensing their needs and exceeding their expectations."

      PSFHS fosters an environment of acceptance which encompasses individual differences and anticipates the unique needs of patients, associates, visitors, physicians, and volunteers. The hospital buildings are accessible to persons with disabilities and provide services to facilitate communication with non-English speaking individuals, deaf /hearing impaired persons, and others with special communication needs. 

      It is the policy of PSFHS to provide services to all people regardless of race, color, age, national origin, gender, religion, marital, or disability status. This non-discrimination policy applies to all hospital facilities and programs.

      Our Professional Practice Model refers to the ANA Nursing Code of Ethics as a guide for our nursing practice; the first provision in the Code states that:

      "The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems."

      Our choice to provide Relationship-based care directs us to listen to and partner with our patients and families in providing care and in honoring the individual's beliefs, values, and needs. 

      SHARE, an acronym integrating our mission, vision, values is the outline for our Share a Compliment/Share a Concern Cards found throughout the organization.  Anyone can complete a card which is routed through leadership and to the individual associate.

      • Sense people's needs before they ask
      • Help each other out
      • Acknowledge people's feelings
      • Respect the dignity and privacy of others
      • Explain what is happening
      • Reaching new milestones of clinical quality
      • Pursuing an agenda of social justice

      Regulatory, legal, and accrediting agencies require a non-discriminatory climate. Patients at PSFHS are entitled to all the rights afforded to them under local, state, and federal laws. These laws are also supported by additional hospital policies which are oriented towards protecting more rights of the individual. The "Patient Rights" posted in all treatment areas, as well as on the Hospital Admission Agreement form, state clearly that, "We treat everyone with dignity and respect". (EP27-1

      Leadership Catholic Health Initiatives strongly believes in its vision of Catholic health care as a vibrant ministry that is ready to provide compassionate care of the body, mind, and spirit through the 21st century and beyond. This is the same pioneer spirit that first led congregations of religious women to carry out the healing ministry of Jesus hundreds of years ago in the founding of care oriented religious orders. The organization is committed to:

      Creating new ministries that build healthy communities

       The Catholic community is renowned for its history of helping to heal those who have nowhere else to turn. For more than 100 years, Catholic Health Initiatives and Adventist Health System have held rich traditions in accomplishing sacred work that cares for the whole person, regardless of one's ability to pay. The Centura Health Mission and Ministry department enhances our faith-based calling by providing these services.

      Equal Opportunity Employer The Equal Opportunity statement is the foundation of our hiring process and establishes the expectation that all PSFHS associates will not engage in discriminatory practices or sexual harassment. The dimensions of diversity are visible through race, ethnicity, gender, age, abilities, values, experiences, skills, religion and more. PSFHS nursing demographic report state 12% of our nursing associates are minorities. Men comprise 7% of direct care nurses. This points to the type of non-discriminatory climate that PSFHS has created, and this climate is enjoyed by our diverse patient population. (EP27-2)

      Volunteers Our volunteer program includes over 600 people ranging in age from fourteen to ninety-four. Our teen program has approximately one hundred youth volunteers. In 2011, volunteers provided almost 100,000 hours of service in all patient and non-patient areas. Volunteers transport patients, assist in pharmacies, manage the gift shop, oversee the John Zay Guest House, offer spiritual support, provide clerical support, and more. This diverse group of people is required to complete specialized training and demonstrate PSFHS's commitment to a nondiscriminatory culture and honoring of diversity before they can begin volunteering.  

       Resources We provide a range of services at multiple locations, creating easy access to needed care. Ensuring that we have adequate equipment to serve our patients requires both long term planning and the short term shifting of resources when needed. Our Bariatric Center of Excellence has specialized beds, wheel chairs, and equipment. When bariatric patients are receiving services in a separate area equipment is made readily available. In addition, the Cancer Conference Rooms, normally used for meetings of associates as well as community members, includes bariatric seating.

      All units have access to mesh beds and low boy beds to improve patient safety and use least restrictive options to reduce patient falls.

      The Pediatric Unit includes age appropriate furniture and displays. In order to support families who wish to stay with their children, we provide sleeping chairs in all pediatric rooms. In addition, the Ronald McDonald room within the Birth Center provides showers, kitchen facilities, relaxation options, and computer access for families; all of which support those who are visiting their infants and children.


      Penrose St. Francis takes reasonable steps to ensure that patients and family members have meaningful access and an equal opportunity to participate in our services, activities, and programs. We recognize that many disabilities may not be visible to us, so upon initial contact we will ask what assistance or accommodation that person may need. Common accommodations offered include printed material in alternative formats such as large print, audio cassette, Braille, computer disk, TTY relay service, language interpreters, pictographs, accessible exam rooms, call lights operated by body pressure, and lift devices.

      Admission of Patients Our Patient Admission Criteria (EP27-3) details the scope of care for each unit and outlines appropriate types of admissions for that unit. While all inpatient units are competent to provide safe nursing care to patients, we strive to admit patients to the most appropriate specialty unit.

      During the admission process, each patient receives a copy of the Hospital Admission Agreement which has the Patient Rights and Responsibilities printed on the reverse side. These Rights include detailed information on our Patient Grievance Process (EP27-4). In addition, the Patient Rights are posted on all units and they are included in our Patient Guide, which is a handbook provided to all patients upon admission. (EP27-5)

      Educational needs of hospitalized children We have practices in place to provide educational services to children who are hospitalized for a particular amount of time. The specifics are documented in the policy referenced in EP26. Recently, we have not had to implement this policy as the stays of our pediatric patients have been short.

      Staff Education and Training Part of any comprehensive diversity program is to ensure that the staff is educated to issues of culturally competent care and non-discrimination. This training begins in General Orientation, and additional programs are available that are designed to support associates'' abilities to provide cultural competent and sensitive care to our diverse patient population. Introducing new staff to the mission and core values of the organization and fostering a climate sensitive to diversity and nondiscrimination is one of the main goals of orientation. Components of the orientation program include: a discussion about culturally competent care, diversity, employee rights, patient rights, and confidentiality. All new associates are required to attend the general orientation and it is offered every other week.

      Annually, competencies for nursing associates include validation of age specific skills for assessing and treating individuals from varying age groups. Since 2010, there has been a mandatory online education module assigned to all associates entitled "Our Responsibility. Ask and Listen." This education is designed to support the ongoing development of the sensitivity in our corporate culture and the result is a kinder place for all patients.

      Relationship Based Care/philosophy of care Meeting the diverse needs of patients and their families is accomplished by providing individualized care at the bedside. This is inclusive of:  taking special considerations for age, taking additional precautions for the potential of increased falls, skin breakdown, through availability of specialty meals (e.g., vegetarian, kosher), and through pastoral care services. Marie Manthey, author of Relationship-Based Care states that, "There must be a relationship with the patient to know their strengths, weaknesses, hopes and fears…our challenge is to balance task with relationship." The nursing process that guides care occurs in the context of relationships with our colleagues, our patients/families, and through ourselves. The following examples demonstrate the realities of our philosophy of care and how it relates to maintaining a non-discriminatory climate for patients:

      Velda Baker BSN, CGRN, GI Lab Penrose Main "We received a heads up from a GI Dr.'s office that we were going to be caring for 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 she 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." 

      Meeting Special Language Needs PSF provides the majority of patient education and information in two languages that comprise the largest percentage of patient population: English and Spanish. Interpreter services are available for all languages 24hr/7day by telephone or in person to assure timely and competent communications between patients, PSF associates, and physicians. (EP27-6) PSFHS maintains a list of multi-lingual employees who are willing to assist with translation. The following are two examples of our active utilization of solutions to special language needs:

      Kathy Parham, Patient Representative, 10/2010. I received a voice mail from a somewhat agitated man who could speak only Spanish. Several minutes later, the same man called back, only this time he got me "live." I know basic Spanish, but could not communicate well with him. I couldn't discern if he was trying to communicate a medical emergency, but I could tell he was anxious and frustrated. Because I knew it would be impossible for me to communicate with him without the CyraCom language interpretation phone which would take a few minutes to set up, I asked him in Spanish to "wait" and then I ran over to Nutrition Services, knowing there are bilingual associates who work there. 

      Joel Castellon graciously agreed to give up his break time to assist our caller. He came to my office where the man was still on the line, and calmly interpreted the callers' needs to me, and my answers. Because of Joel's willingness to help, we were able to serve this man expediently. (Joel never had to know details of this man's needs - he simply explained who I am and what I would do to help. I was able to set up a CyraCom phone call with him and help him access the resources he needed.) My goal was to respond quickly to this man, help him understand that I will help and to allow me the extra time to arrange for appropriate interpretation resources.

      Spiritual Care Information The attached (EP27-7) screen shot shows the easy access all clinical associates have to information on various spiritual/faith beliefs. By reviewing information related to patients' faith traditions, clinicians can elicit additional information and promote respectful actions through an individualized treatment plan.

      Another demonstration of our known expertise in ensuring a discrimination free workplace came from the widespread publication of an article contributed to by a PSFHS associate. This article was published on the healthcare website,, and the article was entitled, "Fair Care: Nurses Ensure Oncology Services Meet Needs of LGBT Community" (July 25, 2011, EP27-8). This piece featured Judy DeGroot RN, MSN of our Cancer Center. The following is a quotation from the article:

      Clinical implications of training

      Training like that at HHC can be a boon for LGBT patients with cancer, once staff knows the appropriate questions to ask. For example, a transgender patient who has had her breasts removed still will need cancer screenings.

      "Although they may disassociate with those body parts after surgery, there is still some breast tissue left," said Judy De Groot, RN, MSN, AOCN, facilitator of the Oncology Nursing Society's Gay Lesbian Bisexual Transgender Focus Group and lead nurse navigator at Penrose Cancer Center in Colorado Springs, Colo.

      "Likewise, men who transition still have a prostate, so staff must make sure to perform a thorough checkup."

      Practice what you preach

      Although sensitivity training is important for staff, facilities must openly practice what they preach to staff. De Groot has been helping facilities do just that through her lectures at the society's annual meetings. She has held three different educational sessions during the past several years that address the LGBT population and the issues it faces.

      The sessions were as basic as providing an overview of terminology such as gay, lesbian, queer and transsexual, and as complicated as discussing some of the legal documents LGBT patients need to have in place to ensure their wishes are met, such as medical power of attorney, living wills and power of attorney.

      "Who has the right to make the decisions must be in writing, otherwise insurance forms and any kind of legal thing will default to family," De Groot said.

      The sessions also provided tips oncology nurses could take back to their facilities on being more "gay friendly." The tips include putting a rainbow sticker in their window, offering magazines that address LGBT issues in the waiting room, printing brochures that feature same-sex and multiethnic couples and families, and including more information - such as "partnered" not just single or married - on intake forms. "I would consistently ask an Nurse Practioner I knew to add 'partnered' to her intake form," De Groot said. "I would always change it to say 'partnered,' and after about a year she just made the change.


      Our programs and services reflect the organizational commitment to meeting patient care needs in a manner that is non-discriminatory, respectful, and sensitive to diversity.  This commitment is powerfully illustrated through several stories.

      Caring for a Hindu Patient Theresa Gregoire, a well loved chaplain, shared the following story of caring: "As the ED staff was trying to save the life of a woman, they called me to come down to be with her husband and son. After repeated resuscitation efforts, she died. Her husband and son were clearly sad and as we talked about the next steps, they quickly said she needs to come home before going to the funeral home. We talked about their faith traditions and they explained that for Hindu's the family grieves for the person who has died in their own home. I called many funeral homes before finding one that would carry the patient's body to the home for a couple hours and then take her to the funeral home. Grateful this was possible I shared the information with the husband and son. Then I was asked who would bathe her before she left the hospital.  This is not something we usually do so I tried to understand their need. In the Hindu culture the woman must be bathed by women before she goes home. Of course the husband and son were men. I remember how busy the ED was that night. We called Megan, a flight nurse on standby, and she quickly agreed to help me bathe this woman. The ICU nursing staff provided bathing supplies to us. What an incredible honor - a sacred moment - a blessing. We prayed as we gently bathed and prepared her for her family. The family came to our PSFHS Memorial Service and spoke again of how grateful they are for our care and for washing her body and for our help during this difficult time. It brought tears to my eyes.This really is who we are at Penrose St. Francis." 


      The mission, vision, and values of PSFHS hold us each accountable to promote a non-discriminatory climate for our patients and their families. Beginning with orientation and through ongoing training, associates are kept informed of expectations and available resources to meet unique needs.

    • Exemplary Professional Practice - EP28

      Diversity and Workplace Advocacy

      EP 28 The organizational structure (s) and process (es) that are in place to identify and manage problems related to incompetent, unsafe, or unprofessional conduct.

      Centura Health's Mission, Vision and Core Values create the expectation of compassionate, professional, and expert care. A detailed orientation to our Core Values in orientation sets clear expectations for professional conduct. (EP28-1 )

      Our PSFHS Nursing Professional Practice Model drives us to provide high quality care based on evidence and standards as well as using a relationship-based care philosophy. The ANA Code of Ethics for Nurses makes explicit our accountability to a standard of conduct which precludes prejudicial actions, harassment, threatening behavior, and it requires collaboration with professional boundaries. Within the Code of Ethics we are obligated to address impaired practice to protect patients, the public, and our profession. 

      The ANA Nursing Administration: Scope and Standard of Practice, Standard 10 holds nursing leadership accountable to establish a supportive, healthy work environment to include mentoring, modeling expert practice, and providing feedback to colleagues.

      Effective January 1, 2009, The Joint Commission added a leadership standard that addresses disruptive and inappropriate behaviors. Hospitals are now required to have a code of conduct that defines acceptable, disruptive, and inappropriate behaviors and leaders are required to implement a process for managing disruptive and inappropriate behaviors.

      Nurses at PSFHS practice within the rules established by the Colorado State Board of Nursing.  The Nurse Practice Act established policies and it also defines the scope of practice for nurses within PSFHS. Nurse licensure is checked at least annually by clinical managers with support from the nursing staffing office. 

      Our effort to create a culture of safety, excellence, and professionalism is integrated in all of our structures and processes. In addition, PSFHS has designed processes to identify and manage problems related to incompetent, unsafe, or unprofessional conduct.


      All nursing associates participate in two days of organization orientation prior to nursing specific and unit orientation. New associate orientation includes an overview of mission and ministry, cultural diversity, patient safety topics, and corporate responsibility requirements.  The overall strategic plan is highlighted. In addition, all new associates are required to sign the Centura Standards of Behavior form.

      An orientation to SHARE, an acronym displayed below, includes a self assessment which also state expectations for specific behaviors:

      S     sense 
      H     help 
      A      acknowledge 
      R     respect 
      E     explain

      Centura Health Integrity Standards are reviewed and a corresponding handbook is distributed to new associates which reinforces our duty to act in a manner that is consistent with Centura Health's mission and core values. In addition, the standards introduce our Corporate Responsibility Program, which includes regulatory requirements. (EP28-2 )  The Integrity Helpline is accessible via email or our website and is a place to report any situation that threatens our values, assets and/or our reputation. ( EP28-3 )

      Nursing Orientation:

      The general orientation is followed by a specific nursing orientation for new RNs, LPNs, and CNAs. Nursing orientation includes classroom based education, online modules, and competency skill demonstrations. Following classroom orientation, the nursing staff is assigned a unit preceptor for specific unit orientation, which has been designed through regulatory requirements and direct care nurse planning. Nurses also receive education to the electronic medical record system. Nurses are educated, trained, and evaluated for competency throughout the orientation period by their preceptor and manager. ( EP28-4 )

      Nursing Competency:

      Following orientation, nurses are continued to be evaluated for competency through two primary strategies: annual competency review and nursing peer review.

      Annual Competency reviews are a standard of the profession. All associates participate in an ongoing competency assessment program which begins pre-hire and is continuous throughout the period of employment. The interdisciplinary policy ( EP28-5 ) documents the process for competency assessment, including identification of core competencies that are applicable to all nursing associates and requirements for at least an annual evaluation of all job-required competencies.  ( EP28-6 )

      In addition, as new practices or revised practices are implemented, competency checklists are used to assess current competency. In 2012, we revised our practices related to prevention of catheter associated urinary tract infections. Every associate was required to complete an online education module and demonstrate competency. Every new associate is required to do the same with this specific skill.

      Nursing Peer Review processes include the following:

      • Nursing Council: Clinical Scene Investigation This nursing peer review council evaluates cases for standards of nursing practice. Nurses demonstrating questionable practices or practices which are outside of our standards receive follow up action which may include education through discipline.

      • Practice audits Patient records are audited on various practices which result in feedback to the team and/or individual clinicians. These audits focus on documentation of standards of care.

      • Unit level peer review Each unit practice council identifies areas of practice for peer review which include direct observation and feedback. For example, each unit has identified Hand Hygiene Champions that observe and provide immediate feedback on hand hygiene compliance. 

      • The Clinical Advancement Program requires the applicant manager and a peer provide a review of professional conduct. ( EP28-7 )


      Associate policies and the medical staff bylaws include expectations of competence and professionalism as well as formalized steps to take when problems are identified.  

      •  IDP c-03-k Conflict Management PSFHS recognizes that conflict occurs at all levels and that it may be related to professional, competent, or unsafe behaviors. Organizational structures provide a forum for professional dialogue to address concerns including: Chain of Command processes, leadership/management meetings, individual supervision, and medical department meetings.  When these structures do not provide sufficient dialogue or action to resolve a disagreement, Conflict Management identifies processes to resolve disputes between members of PSFHS. ( EP28-8 )

      •  Drug Free Workplace As part of our responsibility to our patients, the public and associates, Centura has implemented a policy to ensure that a safe environment exists on Centura premises and facilities. Centura complies with the federal Drug-Free Workplace Act and seeks to establish a work environment that is free from the negative effects of drug and/or alcohol abuse. Centura prohibits all drug use and/or possession that violate state and/or federal law. ( EP28-9 )

      •  IDP P-07-c Code of Conduct In 2009, PSFHS created the Penrose-St. Francis Health Service Code of Conduct. The purpose of this Code is to emphasize the necessity for all individuals working in PSFHS to treat others with respect, courtesy, dignity, and to conduct themselves in a professional manner. Additionally, this policy protects individuals from behavior that does not meet these standards. Part 1, "PSF Code of Professional Conduct" is applicable to the entire PSFHS community of health professionals and associates. Part 2, "Disruptive Conduct Policy for Medical Staff" applies specifically to the members of the medical staff. We know that professional and collaborative behavior is essential to patient safety and that it improves the work environment. The Chief Medical Officer and the Chair of the Clinical Effectiveness Committee have provided relevant literature to the committee and facilitated conversations to enhance the professional relationships between physicians and nurses.    ( EP28-10 )

      •  Just Culture Management of incompetent, unsafe, or unprofessional conduct is based upon regulatory requirements, human resources' procedures, and medical staff bylaws. Our focus is on performance improvement, not punishment.

      •  Human Resource Policy, Corrective Action When disciplinary action is indicated, our policies provide guidance for corrective action based upon a commitment to administer equitable and consistent progressive discipline according to policy. Associates of Penrose-St. Francis Health Services are expected to maintain high standards of performance and behavior in the workplace and demonstrate respect for others to ensure quality patient care and professionalism towards everyone. When an associate fails to meet these standards in any way, Management has the responsibility to take decisive, positive, and timely action to correct the problem. ( EP28-11 )

      •  IDP L-03-m Licensing Board (Reporting) The procedure for reporting to the licensing board complies with the professional licensing board on reporting conduct that constitutes grounds for discipline. A thorough investigation of any event is completed by the manager with the assistance of the Patient Safety/Risk Management Department. Each potentially reportable event is reviewed by a committee which includes at least three directors: Human Resources, Clinical Effectiveness, and Patient Safety Risk Management. Legal counsel is available if needed. ( EP28-12 , EP28-13 )

      •  Alternative Dispute Resolution encourages conflict resolution among associates and provides a formal mechanism for attempting to resolve problems. ( EP28-14 )

      National Database of Nursing Quality Indicators Survey:

      PSFHS nurses completed the NDNQI Practice Environment Scale in 2009 and 2011. One component, the "Collegial Nurse-Physician Relations" provides a tool to identify any problems in these relationships which are essential to quality care. Collegial Nurse-Physician Relations is defined as the positive work relationships between nurses and physicians. The overall rating for this area is based on nurse responses to three questions:

      • Physicians and nurses have good working relationships.

      • A lot of team work between nurses and physicians.

      • Collaboration (joint practice) between nurses and physicians.

      Our sample size in 2009 was 23% which increased in 2011 to 48%. Several units provided adequate sample sizes and are used to demonstrate positive responses on the collegial nurse-physician relations component. Nurses from a variety of units rated nurse-physician relationships above non-magnet hospital means, as the table below demonstrates:

      Unit Unit Mean Non-Magnet Benchmark
      PH 11 Oncology 3.07 2.94
      PH 8 Rehabilitation 3.1 3.0
      PH 5 Medical 3.13 2.94
      PH 4 Medical 3.06 2.94
      PH Cardiovascular 3.09 2.95
      SFMC Labor and Delivery 3.06 3.03

      Surveillance Systems:

      An ongoing surveillance and reporting system facilitates identification of problems.  Monitoring occurs through:

      • Patient representative rounding and responding to calls 
      • Patient Safety and Quality systems including quality metrics, peer review, root cause analysis, and occurrence reporting 
      • Patient satisfaction ratings 
      • Associate surveys (NDNQI Practice Environment Scale and Press Ganey) 
      • Ethics consultations 
      • Integrity Hotline 
      • Pandora Committee for medication diversion

      When problems are identified through any of these systems they may be handled through actions by Human Resources, organization leaders (including managers), peer review for medical staff, the clinical effectiveness committee, and the patient safety committee. 

      Pandora Drug diversion represents a patient safety hazard. We focus on reducing diversion through multiple strategies. Manager, colleague relationships, and supervision processes promote early recognition and intervention. EAP resources, easily accessible associate benefit can help associates maintain or return to positive self care actions. In addition, Pandora, our software application and committee name for identifying and documenting drug diversion, is a structure and process for monitoring drug administration within our organization. Chaired by our pharmacy director, committee members include two pharmacist managers, nursing leadership representatives, Chief Medical Officer, and a Patient Safety/Risk Management nurse. These parties meet monthly to analyze "Anomalous Usage Reports," which may indicate missing drugs. When a report identifies possible drug diversion, additional data is collected including record reviews by the Patient Safety/Risk Management nurse. Reasonable suspicion triggers a drug screen in accordance with policy. ( EP28-15 )

      Integrity Hotline All Centura Health facilities have access to the "Integrity Hotline." This provides associates an avenue to report cases of: fraud, waste, abuse, incompetency, theft, or any kind of situation in which patient safety is compromised. This hotline allows associates to report anonymously if they choose to. 

      Education on performance, behavioral expectations, and standards begin in orientation. All organizational leaders complete "Courageous Conversations" training as part of new hire training. This exercise promotes clear communication, associate accountability, and direct management of disruptive or incompetent behaviors. The table below identifies a sample of education offered during the last several years:

      Education Date Participants
      Silence Kills  2009  All Preceptors
      Creating a Collaborative Workplace  2009  Charge Nurses, Managers, Directors, Supervisors 
      Drug Free Workplace  2010  Mandatory-directors, managers
      Dementia:  Recognizing Dementia and Communication Strategies for Healthcare Providers   2010  Primarily nursing associates 
      Art of Coaching  2010  Primarily nursing associates
      Creating a Healthy Work Environment  2010  Primarily nursing associates
      Be the Change  2010  Nursing Directors, Managers
      Appreciative Inquiry  2011  Primarily nursing associates 
      Relationship-Based Care: Supporting The Impaired Provider  2011  Primarily nursing associates
      Dealing with Difficult Situations  2011  Primarily nursing associates
      Leadership Excellence Accountability Professionalism (LEAP)  2011  Primarily nursing associates
      Diversion/Tampering by DEA Staff  2011  Mandatory-nursing directors, managers 
      Grand Rounds: Disruptive Physician Behavior  2011  Primarily physicians 
      Bullying Behavior at Work  2012  Interdisciplinary and departmental
      Leadership Excellence Accountability Professionalism (LEAP) 2012   Primarily nursing associates

      Employee Assistance Program (EAP) The EAP sends out quarterly newsletters that provide additional education through situational question and answer scenarios. This encourages managers to identify and manage problems related to potential incompetent, unsafe, or unprofessional conduct. ( EP28-16 )

      Performance Feedback and Development (PFD):

      All associates participate in the PFD plan. Our performance evaluation process includes evaluation of professional behaviors and competence. Both the self assessment and supervisor assessment includes an annual review of standards of behavior. The PFD review of standards of behavior comprises a percent of the final report. The final report determines any pay increases. 


      Our vision is that Centura Health will fulfill a covenant of care for our communities with excellence and integrity to become their healthcare partner for life. Our actions are based on our mission, vision, and our seven core values that are in alignment with our professional and ethical standards. PSFHS has created structures and processes to hold our associates, volunteers, and medical staff accountable for their professional actions. 

      In February 2011, Centura Health's Vice President of Employee Relations testified in front of the House Health and Environment Committee which helped move the committee to pass HB1148 Disclosure of Health Worker Employment Information. He said the following when asking for this piece of additional legislation be passed so that patients could be afforded some extra protection:

      "As a large employer, we have seen time and again the challenges related to reporting incidences of drug diversion, patient abuse, and drug/alcohol policy violation. Often times, a violation of this nature may not rise to the level of criminal prosecution, which presents significant reporting challenges.

      We are currently prohibited from notifying prospective employers about drug diversion, patient abuse, and drug/alcohol policy violations. That means our hands are tied when perpetrators seek employment elsewhere. We can't legally notify another facility of the dangerous incidence(s) that occurred while the individual was employed by us, which is frightening. We simply cannot afford to have someone impaired by drugs working in a facility, which is why we are so thoughtful in producing our drug and alcohol policies.  Health care entities regularly deal with life and death situations, which is why it is imperative that we do everything we can to ensure we are providing the safest patient experience possible. HB1148 is critical to increasing patient safety and ensuring that all health care employers hire associates without a history of drug diversion, patient abuse or drug policy violation."

      PSFHS is committed to safe, high quality, expert, compassionate care to our patients. We are committed to creating a healthy work environment for our patients.  We have clear policies and education that supports identification and management of problems related to incompetent, unsafe, or unprofessional behaviors.

    • Exemplary Professional Practice - EP29

      Diversity and Workplace Advocacy

      EP29 The organization's workplace advocacy initiatives for: caregiver stress, diversity, rights, and confidentiality

      Centura Health's Culture of Health Vision Statement Our associates and their well-being are our most precious asset. Centura Health is committed to engaging our associates into a culture of optimal health that: Integrates the physical, spiritual and emotional well-being of associates; Inspires positive, sustainable lifestyles; Creates a meaningful and supportive environment; Extends to families and communities.

      From a PSFHS Associate (2012) "In September of last year, my son was in a serious car accident in Texas. He was taken to the hospital at around 8 pm and was in surgery until 6 am the following morning. I was obviously beyond overwhelmed and scared. I was so very grateful that he was alive - but worried because he was alone in Texas - and I didn't know how I was going to get to him.  I came into work the morning after the accident - and went to the Foundation to ask for help - there was no way I could just "stay" in Colorado. That night, at around 11pm my son called and said "Mom, I think I need you here." It was all I could do not to jump in the car and far as the tank of gas would get me. After a few days I received a phone call from the Foundation. The woman I spoke to told me she had a check for me - not just to cover the expense of travel there and back, but meals and a room for 15 days. As anyone with a child knows, no matter how old they are they are still your "baby." And, thanks to the Associate Assistance Program, I was able to be with my son during a very difficult and scary time. I will never be able to express how much it meant to me to be able to be with him and without the funds provided I truly don't think it would have been possible."

      The organization's commitment to workplace advocacy initiatives begins with our leadership.  Margaret Sabin, CEO is a strong advocate of wellness and self care, as evidenced through her leading of Fitness Boot Camps, promotion of our Strive Program (wellness) including the "black shirt" award, and initiating the Healthy Neighborhood Project. At PSFHS, we enjoy a wide variety of programs that are designed to enhance the work environment and quality of life for associates and patients.  ( EP29-1 )

      In addition, the PSFHS Nursing Vision statement promotes a culture of positive relationships and self care "PSFHS Nursing is a recognized leader in relationship based care dedicated to excellence balanced with concern for the well being of the caregiver."

      This chapter will describe the structures and processes of our workplace programs in the four major categories identified in the source of evidence: caregiver stress, diversity, rights, and confidentiality.

      Caregiver Stress Initiatives:

      Code You, A Centura Health Program Code You is Centura Health's new associate wellness initiative. We believe that having associates taking responsibility for their own health is an important part of the Centura mission. Code You is about being true to one's own health. It is an overarching initiative that encompasses the physical, spiritual, and emotional well-being of associates, so associates and clinicians can fulfill the mission of extending the healing ministry of Christ to others. Code You also supports one of the key tenets of the 2020 strategy - "Moving Upstream to Manage Health." ( EP29-2 )

      The Code You program also sponsors lunch and learns on topics such as sun-safety/skin protection, managing stress during the holidays, managing finances, inexpensive gift ideas, managing tension in the workplace and coping with grief. Handouts and webinars provide education. Code You recently introduced a new online tool to support Centura Health Associates in their wellness journey. The online tool is available to all associates (full-time, part-time or PRN status). The site provides relevant health information via interesting articles, informative videos and innovative online tools to help keep associates and their families healthy and happy ( EP29-3 )

      Workplace Accommodations for Nursing Mothers Giving birth is usually an exciting time for new parents. At the same time, some of these new mothers are returning to work and want to continue to nurse. All facilities provide a room in close proximity to the work area of a nursing associate in order for the associate to express milk in private. We provide reasonable, unpaid break time or permit an associate to use paid break time, meal time, or both to allow the associate to express breast milk for her nursing child or to nurse her baby. ( EP29-4 )

      Associate Campaign In 1982, the Penrose-St. Francis Associate Campaign began as an effort to help build the Ambulatory Care Center on the Penrose Hospital campus, an $8 million dollar project. Since then, the Associate Campaign has become an annual tradition, helping support Penrose-St. Francis patients, staff, and projects through times of need.   The 30th Annual Associate Campaign kicked off on April 19th, 2012.  The theme of the campaign, "Lend a Hand… Touch a Life" acknowledges the profound impact employees of the hospital make through their giving.  For seven weeks, over 130 staff volunteers worked tirelessly to ensure success. They met with co-workers, attended department staff meetings, and came in on off hours to ensure that all employees had the opportunity to participate. The goal set by these volunteers was an ambitious $320,000.  

      The campaign successfully concluded on June 6th when a final gift put the total raised over our goal. Since then, additional gifts have raised that amount to a remarkable $323,000. With 971 employees contributing, the average gift of $332 speaks volumes about the generosity of our staff and their dedication to the mission of our hospitals. Not only did the amount raised this year far exceed the national average for employee campaigns in hospitals of similar size (by $53,000), the 38% participation in giving was once again above the national average for hospitals of any size.  

      This success means a great deal. The Associate Campaign is the only funding source for the Sisters of St. Francis Associate Assistance Fund at Penrose-St. Francis. Through this employee financial assistance program, over 500 Penrose-St. Francis staff members received support of $179,000 for unforeseen financial crises during last fiscal year alone. 

      Beyond supporting fellow employees, staff donors gave a significant amount in support of our patients. Financial assistance for patients can be one of the most valuable tools in bridging the gap between hospital and home for patients experiencing severe financial crises. Covering expenses ranging from durable medical equipment to home modifications such as wheel chair ramps, the Sisters of Charity Patient Assistance Fund helps insure that our patients have a soft landing once they leave the hospital.  In Fiscal Year 2012, 111 patients received $149,490 in financial assistance.  ( EP29-5 )

      Scheduling For most of our nursing associates, having some control over work schedules is a primary issue in work-life balance. The Attendance Policy outlines the process for reporting for scheduled duty on time. All units have established scheduling guidelines and provide completed schedules in advance.  Processes for requesting time off and calling in sick are enforced.  At the same time, if a nurse offers to work overtime or stay late, her schedule can be adjusted to provide a shift off later or options to come in late to meet both the nurse and the unit needs. ( EP29-6 )

      Employee Assistance Program (EAP) PSFHS offers an Employee Assistance Program (EAP) for all associates. Providing high quality, confidential EAP services is a benefit that demonstrates care and concern for the well being of our associates. Associate confidentiality is strictly maintained. The EAP is available to assist employees and their families in finding solutions to emotional and psychological problems that may be affecting their mental health or their work. The EAP covers a wide range of issues from stress management to depression, substance abuse and financial counseling. There are a number of ways that EAP can assist employees, including phone assessment and referral, individual assessments, and by providing eight free sessions with a therapist. Services provided through EAP include:

      •  Counseling  and Crisis Counseling services 
      •  Resource and referral services : Materials are available on the web site and professional referrals are available regarding legal, financial and life topics, as well as, the free use of self inventory tests and more than 2,000 legal and financial forms. 
      •  Legal and financial services : Each associate is eligible for one free consultation with an attorney per legal matter and one consultation with a financial counselor or certified public accountant. If services are needed after the consultation, a discount will be offered. 
      •  Supervisor classes and tools : Many services are available specifically for those in supervisory roles, including management consultations, team building exercises, trauma intervention, drug free workplace tools and educational workshops. 
      •  Front line employee newsletter : This monthly newsletter offers education and advice to employees on safety and wellness. ( EP29-7 ) 
      • The following table provides totals for EAP services in 2011 and 2012. These events include: legal referrals, financial services, consultations, benefit fairs, and various workshops - among others. 

        Number of Events (In Hours) Number of Associates who Participated
      2011 209.5 837
      2012 156.66 511

      Better Bites PSFHS initiated a "Better Bites" Program to help associates and consumers identify healthy menu choices. Liebert et al (2012) states "The Better Bites program, a hospital cafeteria nutrition intervention strategy, was developed by combining evidence-based practices with hospital-specific formative research, including key informant interviews, the Nutrition Environment Measures Study in Restaurants, hospital employee surveys, and nutrition services staff surveys. The primary program components are pricing manipulation and marketing to promote delicious, affordable, and healthy foods to hospital employees and other cafeteria patrons. The pricing manipulation component includes decreasing the price of the healthy items and increasing the price of the unhealthy items using a 35% price differential. Point-of-purchase marketing highlights taste, cost, and health benefits of the healthy items. The program aims to increase purchases of healthy foods and decrease purchases of unhealthy foods, while maintaining revenue neutrality.

      The intent of the Better Bites program is to change the worksite culture of hospital cafeterias to one that promotes employee health and wellness. Aligning this program into existing organizational efforts to promote healthy worksite behaviors (employee wellness programs) elevates the Better Bites program to a systemic change toward a comprehensive approach to health." PSFHS is proud of Tami Charles, Nutrition Services Manager and her collaborative work in implementing this program.  Charles is a co-author of the quoted publication. ( EP29-8 )

      STRIVE is our organization's fitness program. The connection between exercise and stress relief is well established. STRIVE is designed to get associates interested in physical fitness while being flexible enough for members to incorporate it into their routine. There are in-house gyms at both PH and SFMC that are available 24 hours a day for associate use. In addition to the standard self initiated gym activities there are instructor led courses available ranging from aerobics to belly dancing as well as classes that focus on nutrition and preventative health. Further, there are other Wellness Programs offered through STRIVE; including courses which are designed to help manage the stresses of a work/life balance. ( EP29-9 , EP29-10 , EP29-11 )

      WOW! (Wellness on Wheels) The Strive Team stated that "our nursing floor staff gives and sacrifices so much to give quality patient care. It's time to balance this care with the wellness of the associate."  Based on research and feedback from another hospital, Strive designed the WOW! Program. ( EP29-12 )

      The Strive Team piloted a wellness on wheels program and offered the opportunity to all units in Penrose Hospital. The Cardiovascular Unit (CVU) eagerly volunteered for the pilot and the program was offered for 8 weeks beginning September 27, 2011. WOW was intended to increase participation in health, fitness, and wellness amongst hospital associates. CVU associates engaged in 5-10 minutes "revitalize and energize with STRIVE" breaks once a week for 8 weeks. These energizing fitness and wellness breaks consisted of flexibility/stretching, strength training, energizing sequences, meditation/relaxation, and Zumba. ( EP29-13 )

      After eight weeks, participants completed a survey. Of the 86 associates on CVU, 55 participated in at least one WOW session. The average number of participants at each session was 16.25.  The survey responses were positive. Associates were satisfied with instructors, session time, handouts and varying programs. Of the twenty-one participants who responded to the survey, 81% reported an increase in energy, 86% bonded with their coworkers and 100% reported making behavior changes based on participating in WOW. ( EP29-14 )

      The WOW program was consistent with our overall organization goal of "moving upstream" to promote wellness and aligned with our nursing services focus on relationship based care including self and others.  The Strive associates recognized their nursing partners and offered this "gift" to them.

      Diversity Initiatives:

      Equal Opportunity Employer PSFHS is proud to be an Equal Opportunity Employer (EOE). We respect the dignity and diversity of individual work force members. We also recognize the value of diversity in our organization and employ a workforce that is as diverse as the communities and people we serve. It is our policy to comply with applicable federal, state and local laws governing Equal Employment Opportunity (EEO). PSFHS also adheres to the principles of the Americans with Disabilities Act Amendments Act (ADAAA). It is our policy to provide equal employment opportunity for persons with disabilities in full compliance with federal, state, and local laws, such as the Americans with Disabilities Act Amendments Act. We do not discriminate against qualified job applicants and associates with known physical or mental disabilities in any employment practice, including, but not limited to: recruitment, hiring, education, training, promotion, compensation, participation in social or recreational functions, use of PSFHS facilities, transfer, discipline, layoff, recall, and termination.

      As a faith based and mission focused organization, PSFHS practices the ideals defined by Christian/Catholic values. These values are visible in all hiring and employment practices.  Recruiting and interviewing practices reflect a nondiscriminatory format, following Title VII laws. PSFHS demonstrates our commitment to diversity through EOE disclaimers in all recruiting ads and within the application process on our web page.  ( EP29-15 , EP29-16 )

      Recruitment of Minorities Our Nurse population is more representative than the community of Colorado Springs writ large. For detailed documentation of the ethnic makeup of our nursing staff, patient population, and our community see OO1.

      Diversity Training and Cultural Competency Training in the importance of understanding the diversity of our patient population and provision of culturally competent care is annually required. 

      Shared Decision Making encourages expression of diverse opinions. We are committed to achieving diversity within our nursing team including all levels of nursing associates. We view differences as opportunities to grow.  One element of the nursing professional practice model specifically included "honoring diversity".

      Novice Nurses One area we promote is the hiring of new graduate nurses, using our nurse residency program to encourage progression from novice to beginner nurse.  Our community includes schools of nursing at the ASN, BSN, MSN, and doctoral level. While some hospitals have chosen to exclude new graduates and ASN graduates, we employ both of these groups.

      Generational Diversity PSFHS recognizes that the current workforce is made up of workers of multiple generations. Sometimes differing generational priorities and values can lead to interpersonal conflict. In order to mitigate these potential problems, we offer webinars which provide skills in recognizing these differences. ( EP29-17)

      SHARE is the customer loyalty training program that is introduced to each associate at orientation. SHARE is a set of behaviors that are the foundation of the Centura culture and they embody our mission, vision, and values. SHARE stands for:

      S ense people's needs before they ask 
      H elp each other out 
      A cknowledge people's feelings 
      R espect the dignity and privacy of others 
      E xplain what is happening

      SHARE cards are a tool to recognize associates who have assistant customers through this process. The attached SHARE cards express patient gratitude towards their nurses. ( EP29-18 , EP29-19 )

      Relationship Based Care PSFHS nursing integrated the principles of relationship based care in 2011.  In 2012, we began to educate PSFHS associates on these principles which are aligned with our core values and mission statement.

      Rights Initiatives:

      PSFHS respects the rights of staff without compromising patient care. Quality patient care and related health services are the primary functions of Centura and all its facilities. The foundation for quality patient care in this safe environment is contained in the policies and practices of human resources, employee health safety and environmental employee safety. Centura respects the religious, ethical, and cultural beliefs of its associates but cannot allow the quality or availability of patient care services to be compromised. In the event that a job assignment, task, or responsibility conflicts with a staff member's cultural values, ethics, or religious beliefs, and the associate requests to not participate in an aspect of patient care, an attempt will be made to provide reasonable accommodation without negatively impacting patient care. Examples of the types of procedures which may qualify for such accommodation include blood transfusions, abortion procedures, reproductive sterilization, and the withdrawal of life-support measures. ( EP29-20 )

      Human Resource Support The Human Resources Department also hosts a website on our internal associate portal, "My Virtual Workplace" with additional information about associate rights and benefits including a list of phone numbers for easy access. Human Resource staff are located in both main hospital facilities. ( EP29-21 )

      For persons seeking employment with PSFHS, the recruitment website includes references to Applicant Rights as well as PSFHS' adherence to federal law regarding employee rights such as the Americans with Disabilities Act, Drug-Free Workplace, Family Medical Leave Act, Equal Employment Opportunity and E-Verify/Right to Work. In 2012, Centura Health began transition of all Policies from Meditech Forms to the Policy-Tech Policy Management System. All associates have been oriented to the process to access policies and this is covered in new hire orientation.

      Leave of Absence In accordance with the Family and Medical Leave Act of 1993, associates may take medical or family leave for their own health or to care for other family members. We recognize that associates sometimes need to be absent for reasons other than medical or familial, and that some leaves are beneficial to both the associate and Centura Health. Associates are allowed 30 days of personal or educational leave per year. Other leaves supported include jury duty, voting time off, military leave, and bereavement leave. ( EP29-22 )

      Alternative Dispute Resolution (ADR) Centura has established an Alternative Dispute Resolution (ADR) policy to help associates and supervisors resolve conflicts that go beyond the kinds of misunderstandings that normally can be settled by simply talking things through. Alternative dispute resolution can take place when an associate does not have adequate resolution through informal discussions with their supervisor/manager. In ADR, the employee fills out an ADR response form with a statement of the problem or issue. The appeal is then directed to the department head. If the associate does not agree with the response of the department head, the appeal is submitted to the vice president or administrator. If the associate does not agree with that response, the next appeal progresses to the ADR committee which includes the facility CEO. Further disagreements proceed to mediation. The mediation process is limited to disputes, claims or controversies that a court of law would be authorized to have jurisdiction over. The mediator's decision is final for both the associate and Centura Health.

      Fair and Just Culture and Red Rules A Fair and Just Culture is a one where errors are treated as learning opportunities. This initiative endeavors to create an atmosphere of trust in which associates are encouraged or even rewarded for providing essential safety related information. This culture also delineates acceptable and unacceptable behavior. Red Rules are procedures or practices that are critical to safe patient care. A Red Rule is something that should be done every time it is indicated within a particular process of caring for a patient, except in rare and extenuating circumstances. An example of Red Rules adopted includes two identifiers for patients. Healthcare providers are accountable for maintaining the Red Rule standards. Accountability will be maintained through self reporting, investigation of adverse events, peer referral, rounding, observation audits and/or patient complaints.

      Employee Health Safety PSFHS strives to provide a safe working environment for our associates. The ANA Bill of Rights for Nurses states "Nurses have a right to a work environment that is safe for themselves and their patients." PSFHS agrees that this right is applicable to all our associates. Safety practices are discussed further in EP30. 

      Confidentiality Initiatives:

      PSFHS is often in the position of providing healthcare to our associates. Associates receiving care have the same right to confidentiality as any other patient. PSFHS is in compliance with government laws and regulations associated with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Any violation of HIPAA will follow the provisions of Sanctions for Workforce Privacy and Security Violations.

      Treating confidential information in an appropriate manner is a requirement not only of the law but also to ensure the trust of and maintain respect for all of our customers, patients, residents, physicians, associates, and/or business partners. Centura associates uses discretion when accessing and discussing any confidential information. (EP29-23 )

      Suddenly Losing Our Expert (Salmore, 2012). JW was a well known, respected and loved clinical nurse specialist. When she became ill and suddenly deteriorated, her manager wondered how to maintain confidentiality and at the same time respect and honor the strong relationships JW and many colleagues shared. A dying unresponsive colleague cannot sign a release or tell you it is okay to share with others.  The manager and the many nurses who are caring for JW walk a fine line. Despite privacy and confidentiality regulations word spreads through the hospital during her last day and many associates stop by her room to say goodbye. During the memorial service many others who did not know she was dying ask why they were not informed. They too wanted to honor her and say goodbye.  We use the memorial service to do just that. The clinical manager published this story in Nursing2012.  (EP29-24 )

    • Exemplary Professional Practice - EP30

      Culture of Safety

      EP 30  The structure (s) and process (es) used by the organization to improve workplace safety for nurses, based on standards such as ANA's Safe Patient Handling and Movement

      The PSFHS Nursing Vision, " PSFHS Nursing is the recognized leader in relationship-based care dedicated to excellence in nursing practice balanced with the concern for the well being of the care giver demonstrates a primary commitment to workplace safety for nurses.

      PSFHS uses multiple structures and processes to improve workplace safety for nurses based upon: professional nursing standards of practice, the Code of Ethics for Nurses, Occupational Safety and Health Administration (OSHA) guidelines, our relationship based care philosophy, and the American Association of Critical Nurses - Healthy Workplace initiative. Safety is the primary concern for our organization, and the emphasis that is placed on safety demonstrates our commitment to creating an environment where our staff is able to provide care and patients can receive quality care in a safe climate. This section will detail the structures, processes, and standards utilized by PSFHS' nurses to ensure a safe work environment.

      Planning for Safety:

      PSFHS reviews the previous year's safety trials and successes while preparing the annual Safety Management Plan. The primary purpose of this plan is to identify of potential risks in the hospital and then to make aggressive strategies to correct those risks. In addition, the Occupational Health Standards purpose is "to create a safe working environment for all associates…"  ( EP30-1 , EP30-2 ) 


      New Hire Orientation Workplace safety begins prior to hire. All associates must complete screenings for tuberculosis, illicit drugs, as well as an immunization review. Physical requirements for each nursing position are detailed in the job description which the associate signs indicating their willingness and capacity to meet these requirements. New associates meet the occupational health staff during orientation as they complete these requirements and are given the necessary immunizations. ( EP30-3 )

      During orientation, workplace safety polices are introduced including: general safety, emergency procedures, potential job related hazards, hazard prevention, action to take in case of injury, and reporting procedures. Disaster Preparedness begins at orientation when all new associates complete ICS100 training. In addition, infection prevention education is provided based in part on area and scope of work. ( EP30-4 )

      Also during new hire orientation, basic infection and exposure procedures are presented by the Occupational Health Unit. They go over follow up testing, documentation, and follow-ups that may be necessary in the event of an accidental endangerment through hazardous contact or staff injury.

      Annual Safety Education While annual safety education is based in part on regulatory requirements and quality initiatives, expanded education occurs in the context of environmental changes. For example, in 2011 an added safety module was designed by an interdisciplinary team from safety, security, and nursing. Recent increases in violence including a shooting at a local church, led to the decision to add a training course on identifying and avoiding a shooter with hostile intent.  (EP30-5 )

      Department of Occupational Health:

      Our Occupational Health Department is divided into two sections: direction from Centura Health's Occupational Health and our local Occupational Health Department (who initializes health plans). Nurses from PSFHS meet regularly with the Centura Occupational Health Nurses to review guidelines and to suggest improvements.

      Locally, our Occupational Health Nurses perform the following tasks in support of healthy work environments: teach a section in new associate orientation, file/process workplace safety claims, administer the FMLA, advocate for ergonomics, and appoint unit safety monitors.

      The PSFHS Department of Occupational Health is comprised of two full time nurses and one support person. Reorganization of this staff has recently resulted in a reporting structure to Centura Physician Health Group. 

      Annual Respirator Fit Testing We ensure the safety of our nurses through the strict implementation of safety standards. The OSHA Respiratory Protection Standard 29 CFR1910.134 was formalized in 2012. In an effort to assist departments with meeting OSHA requirements, our internal Occupational Health unit decided that fit testing of associates would be done on annual basis. Centura Centers for Occupational Medicine (CCOM) will be providing fit testing clinics on site during each March. Penrose St. Francis will have a PAPR training station available for all associates who are currently working in a PAPR only department.

      In 2006, the CDC recommended that all healthcare workers receive a onetime dose of the Tdap vaccine in replacement of their Td vaccine in order to help reduce the amount of pertussis in our community. Occupational Health offers the Tdap vaccine to all associates who have not yet been vaccinated. The vaccine is made available during the fit testing clinics in March. ( EP30-6 )

      Influenza Immunizations Our Occupational Health unit provides annual influenza vaccinations to all associates. Each year this team has expanded outreach to increase vaccination rates through the following:

      • Provide vaccine to supervisors to vaccinate their staff on nights and weekends 
      • Provide vaccine to managers to vaccinate their staff during their assigned shift 
      • Roving cart through units and attendance at staff meetings to provide easy access to vaccinations 
      • Flu Clinics staffed with additional nurses who volunteer their time 
      • Scheduled office hours

      In 2010-2011 the Infection Control Committee initiated strong dialogue on mandatory vaccination for all healthcare workers. In 2012 a mandatory requirement was implemented. Our organization had been gradually increasing the percent of associates receiving vaccinations and had provided education through newsletters and visits to staff meeting. Denny Weber, MD Infection Control Committee Chair, is a strong advocate for vaccinations and is available to meet with teams and individuals who have questions and concerns. 

      Occupational health also coordinates matters of Workman's Compensation. The Centura Centers for Occupational Medicine provide support through drug testing, compensation, and wellness/preventative health screenings. If a nurse is hurt on the job, they will be able to recuperate and receive needed assistance through these occupational health offerings. ( EP30-7 )

      The PSFHS Environment of Care (EOC) Committee:

      The EOC Committee is chaired by our Chief Operating Officer. It is an interdisciplinary committee that meets monthly to provide leadership and oversight. The following areas are under the EOC Committee's purview: life/fire safety, infection control, materials management, compliance, the safety management program, the medical equipment program, security, and employee health. The EOC Committee is the main structure that oversees all aspects of employee safety. It is from the EOC that standards are interpreted, and that responding policies and structures are developed. Subjects that have been reviewed by the EOC in recent years include: radiation safety policies, laser safety, and chemotherapy safeties. Members of the EoC perform monthly inspections, prepared by the company called READINESS ROUNDS. These observations check for safety issues in nursing units. Discrepancies are noted and corrected. Further, they are charted over time for analysis and presented to the hospital leadership. The Safety Performance Indicators demonstrate knowledge and action follow up on reports for FY2012. ( EP30-8 )

      Safe Patient Handling:

      Transport and Nursing The CNO, the Director of Patient Care, and the Transport Clinical Manager have received requests to increase transport staff duties to include the assisting of patients to move from bed to wheelchair/gurney and back. This concern originated from the realistic fear of back injuries from nurse personnel. In order to facilitate this change, and to thereby make the workplace safer for nurses, the Clinical Manager researched job duties and applicable job standards from the Advisory Board Company and the National Association of Healthcare Transport Management. She spoke with several national leaders about job requirements and training.  A cost benefit analysis was completed as we considered providing certified nursing assistant training to all transport staff which would meet competency for transfers.

      Multiple meetings occurred with patient transport staff to discuss the upcoming change and how it could impact staff. We also established a Task Force that was inclusive of: patient transport staff, nursing, Human Resources, and Occupational Health. This Task Force's responsibility was to examine potential new job requirements, job descriptions, physical examinations for transport staff, and the consequences of failing a physical. We met with Occupational Therapy to evaluate job tasks and plan the appropriate physical. Training was developed and provided for the safe handling of patients, AIDET, light transport equipment maintenance, and the cleaning of the equipment.

      We designed a second job description for transport staff which included patient handling and equipment cleaning, and offered employees the option to remain in current position or apply for new position at a slight salary increase.  ( EP30-9 )

      Lifting Technology and Policies A key element in moving or transferring patients is the available equipment, type of transfer/lifting capacity of patient and available staff. This is a difficult and potentially dangerous task; a task that is further complicated by the fact that as patients are getting larger, the median age of nurses is getting older. In order to provide an option that would allow for easier movement of patients, PSFHS started to pursue lifting systems that would decrease the chance of nurse injury and thereby increase workplace safety overall.

      During the completion of the St. Francis Medical Center (whose doors opened in 2008), lift systems were integrated into patient rooms. This contributed to a culture that used the available systems. While similar systems have been available at Penrose Hospital for a considerable time, their use was always limited by the fact that the equipment was centrally located and difficult to obtain in a timely manner. Instead, many units would rely on "team lifts" to move a patient when needed. This added an additional difficulty to the integration of lifting technology; specifically, a cultural shift towards using all resources available to medical staff to reduce injury.

      In 2010 the Occupational Health Nurses requested and received a volunteer department grant to purchase Hover Mat equipment.  A "Hover Mat" team met in April to plan implementation and education.  ( EP30-10 , EP30-11 )  While some units used this equipment and purchased additional equipment, use remained inconsistent.   PSFHS completed a gap analysis provided by Catholic Health Initiatives in 2011. ( EP30-12 )

      In March 2012 the Nursing Management Council met with a vendor to consider a program. In June 2011 the Interdisciplinary Policy Committee approved a Safe Patient Handling Policy.   ( EP30-13 )  The graph below does not demonstrate improvement in injuries.  However, with the new policy approved and hover mats available on units the Safe Patient Handling Program will be further implemented in 2013. The first step identified is completing the unit level assessment and needs assessment. ( EP30-14 )

      Fatigue Management:

      Policies have also been introduced that govern "power naps" for nurses in a variety of settings. This progressive policy shift was pursued in order to ensure vigilance and attentiveness for those who work 12 hour shifts, and particularly those who work the night shift. Physiologically, people who work nights experience more fatigue than those who work during day shifts. By encouraging nurses to take brief naps during breaks, we seek to increase nurse safety. The Nursing Staffing Council cited the following in their 2012 annual report.

      i. Combating nursing fatigue based on literature review and evidence 
      ii. No more than 4, 12 hour shifts in a row w/o manager approval 
      iii. Extended  on-call response time to 45 minutes 
      iv. Okay to take a nap as your lunch.

      In addition the Nursing Practice Council has distributed articles for review related to fatigue and work hours. ( EP30-15 )


      Workplace safety through security is provided for in an organizational Security Management Plan, which is created annually following a review of the previous year's incidences and responses. ( EP30-16 ) Incidents that are reviewed include: auto-accidents, assaults, theft, restraints, unsecured doors, and work orders.

      Safety is also supported through 24/7 security personnel in the facilities and parking lots. In the parking areas are valet staff that provide oversight to on and offsite parking. Our security personnel train for a variety of potential incidences and they provide immediate "real world" response to violent patients or other incidents.

      Name Badges All PSFHS associates are required to wear name badges while "on duty." This is to ensure sound identification and so that only authorized personnel have access to secured areas within the facility.

      Violence in the Workplace Code "Greens" are calls for security and/or the emerging threat of violence in the hospital. When announced, security crews rush to establish a presence at the scene of the disturbance to protect people and property. Our security personnel contact the Colorado Springs Police Department, when necessary, and they maintain crucial lines of communication during periods of emergency. When the CSPD is in the building, and after they have left, our security members continue to look after PSFHS' associates. This is something that was noted in November 2012: 

      Further securities policies that we have in place work to ensure nurse safety through:

      Searching of Associates / Patients / Visitors for illicit drugs and weapons ( EP30-17 )

      Name Badge Identification ( EP30-18 )

      Lockdown Procedures ( EP30-19 )

      Violence Free Workplace ( EP30-20 )

      Safe Patient Handling ( EP30-21 )


      Nursing safety is a priority of our organization. As such, we have numerous policies and structures that provide for a safe workplace. Resources from planning, technology, manpower, and our leadership are directed towards efforts of improving workplace safety for nurses from a wide variety of threats.

    • Exemplary Professional Practice - EP30EO

      Culture of Safety

      EP30EO Two workplace safety improvements for nurses that resulted from EP30

      Reducing Blood and Body Fluid Exposures

      Background/Purpose PSFHS is committed to the safety of our associates. Occupational Health monitors exposures and examines factors that contribute to incidents. Reviews of trends, frequencies, equipment, or other similarities are explored and actions taken to reduce risk and to improve outcomes.

      In 2009, PSFHS had 85 total exposures to blood and body fluids with a cost of $42,000 in post exposure laboratory testing. From January 1, 2010 to June 30, 2010 there was a 74% increase in the number of exposures. Several service areas were identified as high risk including: labor and delivery, laboratory, emergency departments, and operating rooms. In 2010, accidents resulting from the use of insulin syringes and butterfly needles were the cause of the most exposures.

      In addition to increased exposures and costs, PSFHS identified an increase in source positive (blood borne infection) patients. In all of 2009, PSFHS had 8 patients who were source positive; in the first half of 2010, there were 15 source positive patients. This resulted in an increased risk to our associates' health.

      Our goal was to reduce the number of blood and body fluid exposures.


      Occupational Health presented the data of exposures to the Nursing Leadership Council, PSFHS Interdisciplinary Infection Control Committee, and to the Environment of Care Committee.  ( EP30EO-1 , EP30EO-2 )

      Once the problem was identified and data on exposures presented the PSFHS Occupational Health and Worker's Compensation Nurses collaborated to enhance education, design competencies for high risk areas, and to collaborate with the Centura Statewide Occupational Health Nurse Council in implementing best practices.  

      • Educational posters were developed and placed in staff break areas  ( EP30EO-3 ) 
      • Occupational Health designed and presented information on statistics, cost/health impact of exposures, and requirements for use of personal protective equipment to all nursing associates during their required annual Nursing Skill Review. All Nurses were required to complete questions after reviewing the storyboard.  ( EP30EO-4 ) 
      • Occupational Health nurses notified clinical managers each time an exposure occurred in their department and requested documentation of investigation and follow up actions. 
      • Areas of high risk and reported exposures created action plans to prevent future incidents. The following are two examples of the resulting policies:

      o Nursing leaders on one unit developed retraining/education and competency demonstration process used with all nursing staff to reduce exposure to blood or body fluids during insulin administration ( EP30EO-5 )  
      o Labor and Delivery nursing leaders educated and held nursing staff accountable for use of personal protective equipment during labor and delivery following a reported increase of exposures

      Recognizing the target goal is zero exposures, occupational health nursing in collaboration with risk management nursing established a goal to decrease the number of total exposures by 25% within one year, and overall reduce registered nurse exposures.


      Heidi Bouwens, BSN, RN, Occupational Health Nurse 
      Sherry Gray, RN, Worker's Compensation Nurse 
      Jane Dodder, BSN, RN, Patient Safety/Risk Management 
      PHFHS Nursing Leadership Council including Chief Nursing Officer, Directors, Nursing Managers, Education 
      Infection Control Committee (medicine, nursing, pharmacy, infection prevention, clinical effectiveness, facilities)

      Outcomes / Results As a result of our efforts we saw a 40% reduction in the number of exposures from January 1, 2011 to June 30, 2011.  While our overall target is to reduce exposures to zero, the goal for this project was a 25% reduction which was met and surpassed. The goal to reduce RN exposures was met.   

      Clinical Implications Taking actions to improve workplace safety is a regulatory requirement as well as ethical necessity. A collaborative strategy based on education, awareness, and competency was effective. Our PSFHS Occupational Health nurses designed a professional poster to disseminate the structure, process and outcomes of this project throughout Catholic Health Initiatives. All nursing breakrooms and units displayed the poster.  Nurse Managers follow up with each individual following an exposure and the use of a competency checklist, led to a reduction in exposures and improvement in workplace safety for nurses.


      Centura Occupational Health Exposure of Associates to Blood and Other Potentially Infectious Materials Policy 

      CDC. NIOSH alert: preventing needlestick injuries in health care settings. Cincinnati, OH: Department of Health and Human Services, CDC, 1999; DHHS publication no. (NIOSH) 2000-108.

      Improving Workplace Safety for Nurses and Associates: Reducing Code Greens and Staff Injuries

      Improving Workplace Safety for Nurses and Associates — Reducing Code Greens and Staff Injuries

      Background Our community has provided inpatient psychiatric services in both private stand-alone facilities and hospital-based settings for close to 40 years. In addition, the community has been host to a number of facilities that care for alcohol and substance abuse and psychiatric patients in an outpatient setting. Similarly to the cities across the nation, Colorado Springs has had many of these facilities close due to hospital downsizing and limited funding which leaves a vulnerable population without access to care. 

      In 2009 our hospital leaders were discussing what to do with an aging building as well as the services offered there. One of the services in this facility was our 23 bed Inpatient Psychiatric Unit. This unit provided mental health services to our community as well as to soldiers and airmen from nearby military installations. It was a difficult decision to close the inpatient psychiatric unit and our leaders assured the community that contracts were signed with private mental health services to help serve this patient population. On December 30, 2010 the water pipes on the 5th floor of that building froze and as the pipes began to thaw early the next morning, thousands of gallons of water saturated one floor after another. This required a full evacuation of our psychiatric patients to the main hospital. The move was swift and successful thanks to the help of a dedicated a behavioral health team who came in from home to provide one-to-one care for each of the patients. It took three days to discharge each of those patients to a safe setting from the hospital and then the unit was closed permanently, four months early.

      An inpatient medical unit at the main hospital was designated to care for all "behavioral" patients needing admission for medical needs who were unable to be discharged or transferred to another facility. Despite additional training for the emergency department it was not long before the EDs were inundated with behavioral health patients and the inpatient medical surgical units were overwhelmed by the care needed by this population.

      Rose Ann Moore, MSN, RN, NE-BC, Director of Patient Care Services at Penrose identified a need to improve nurse safety by addressing the care of agitated and violent hospitalized patients. As a strong nursing leader she was "in place" as a member of interdisciplinary committees and nursing committees that focus on safety in our workplace.

      The goals for the project was to reduce nurse injuries in the category "Struck by Coworker or Patient."


      Literature Review We conducted a literature search of current practices in emergency departments and inpatient settings. After reviews of over 60 abstracts and articles, 19 works that addressed the successes and failures of care with behavioral health patients in hospital settings were selected.

      The trends noted in the care of patients with high-risk for agitation, aggression, and violence included identification of "triggers" for behavioral emergencies. Some of the newest evidence and best practices place an emphasis on clinical algorithms. These algorithms are a set of instructions that assess the patient for danger to themselves and others; they also provide a framework to help decide whether a hold is necessary, they assist in determining medical care needs, and if a psychiatric evaluation would be useful (White, 2010). A psychiatric evaluation and standing orders are helpful to clinicians when making objective decisions related to placement and clinical interventions (White, 2010).  ( EP30EO-6 )

      Assess PSFHS Data and Trends Within PSFHS, we have identified "Code Greens" as the call for assistance with a violent person. The organization collects a variety of information related to aggressive and violent episodes. Most data related to Code Greens is collected by the Security department. PSFHS has the following three reports to evaluate and analyze practice and outcomes.

      Code Green & Patient Physical Contact (PPCT) Report tracks all Code Green assistance calls for our three facilities for FY 2011 (July 2010-June 2011). This report identifies dates, facilities, times, a reference number, class, category, and specific locations. Each call is linked to a "drilldown" of information documented by Security officers who respond to each Code Green call. This drilldown includes a narrative from the staff about the incident. 

      Code Green Patient Safety/Security Trend Report tracks all Code Greens and PPCT called in the organization/facility/month and categorizes each code called into one of six categories (failure to respond to verbal command, combative, aggressive/violent, threatening, danger to self/others, and miscellaneous).  There is the ability to manipulate the data into a variety of graphs for trending by month, by quarter, etc.  

      PSF Patient Watch is a report produced by Security that tracks ED visits, mental health holds, emergency commitment holds, and psychiatric diagnosis.

      Analysis of Data FY 2011:

      In 2011, there were 50 Code Green calls from inpatient units at Penrose and SFMC. The majority of the Code Green calls are from Penrose Hospital. On average, there are four codes called per month and the primary specified reason for Code Green is Aggressive/Violent behavior demonstrated (13 of 37). An additional 13 did not specify a reason.

      Three units stood out among all nursing units, two of which are general medical units in addition to our main ICU for calling the most Code Greens. A drilldown was completed, and graphs were created to show data from target units. 4 West Medical showed a downward trend in Code calls for FY 2011; FM 5 South Medical showed an upward trend of Code call in FY 2011.

      FY2011 includes July 2010 through June 2011.


      Code Green Debriefing Report documents information about the Code Alert to use as a learning opportunity, to prevent future code calls, and ultimately to prevent injury to patient and staff.  After a review of our debriefing responses, it was discovered that there was only a 28% (14) return of debriefing forms and they are inaccurately filled out. We identified this as an opportunity for improvement.  ( EP30EO-7 , EP30EO-8 )

      A Failure Mode Effects Analysis (FMEA) was used to review the code alert process. A FMEA is a process/tool to improve patient and staff safety. It proactively identifies failures by identifying how a process is carried out, analyzes the steps, identifies variables, documents the process results, critical issues, and safety concerns. The following  areas were a focus 1) patient behavior, 2) sounding alarms, 3) staff response, and 4) staff follow-up /code cancellation; the FMEA team met nine times to complete the process. The identified shortcomings included failures to: identify warning signs, to de-escalate the situation, articulate handoff communication, rapidly call the code alert, failures in training, and in irregular respondents.  ( EP30EO-9 )

      A survey was developed and distributed to collect additional information from the hospital's frontline caregivers related to current practice and knowledge in care and management of violent/agitated patients. Eight questions were developed and the survey was emailed to all RNs, LPNs, and CNAs. The survey began June 28th and was open for 3 weeks to accommodate the July 4th holiday. A spreadsheet was developed to export data for displaying summaries and graphs of results.  

      Fifty responses (20% return rate) were examined.

      1- Reason Code Called- Aggressive/Violent Behavior (63%) 
      2- Treatment prior to Code Call- Verbal de-escalation (54%) 
      3- How recognize potential aggression- escalating behavior demonstrated (38%) 
      4- SBARQ used (54%) 
      5- Adequate Education (68%) 
      6- Experience with this population (58% <5>

      Education and Training:

      The decision was made to provide learning opportunities to the two inpatient medical units. The Clinical Nurse Specialist for these two units provided input to the Director of Patient Care Services at Penrose regarding educational strategies. Handouts of the presentation were created in a variety of formats and some had additional note-taking space. Flyers, checklists, sign-in rosters, and a pre and post test were developed to measure the participants' knowledge before and after the presentation.  ( EP30EO-10 , EP30EO-11 , EP30EO-12 )

      Practice and Policy Changes Identified:

      Based on a review of the literature, completion of the FEMA project, analysis of data, and the results from the survey, recommendations for revisions to the hospital's practice in the care and management of the agitated/violent patient hospitalized on medical and surgical units were identified. Recommended best practices and a re-emphasis on existing practice include: understanding terminology associated with this patient population, better identification of patients at high risk for a behavioral emergency, identification of causes and triggers to aggressive and violent behavior from a patient or family member, and interventions to prevent behavior emergencies. Having the knowledge of the many interventions that have been proven to be successful in mitigating a behavioral emergency is important and will reduce the chances of injury to patients and care providers.

      The Code Green debriefing form has been revised and is used to analyze and improve our practices. ( EP30EO-13 ) This form provides the structure for continuous process improvement through the analysis of every code green. The literature supports additional practices that have proven to be effective in the care of this population; these include: Behavioral Emergency Response Teams (BERT) where subject matter expert RNs and MSW's respond to every Code Green to reassure, reorient, support patient and care providers and are the primary communicators with the attending physician. They also obtain medical orders for re-control, and they teach communication strategies with unit teams to include how to address delusions, hallucinations, delirium, withdrawal, dementia, etc. They serve as consultants, skilled in addressing belligerent behaviors and threatening actions. (Loucks, Rutledge, Hatch and Morrison, 2010).  In PSFHS we have a Psychiatric Emergency Triage Team that serves in this capacity. (EP30EO-14 )

      Nonviolent Physical Crisis Intervention Training PSFHS selected and implemented a new training program that teaches communication, decision-making, problem solving, de-escalation techniques, and safe responses to disruptive/assaultive behavior.  Eight staff members completed a five day instructor training class and PSFHS schedules three classes per month for training. ( EP30EO-15 , EP30EO-16 , EP30EO-17 ) 

      Policy Revisions Based on quality improvement project and education and training plan the policy was revised. (EP30EO-18 )


      Rose Ann Moore, MSN, RN, NE-BC, Director of Patient Care Services, Penrose 
      Kelli Saucerman, MSN, RN, CQPS, Director of Clinical Effectiveness, Infection Control, Patient Safety and Risk Management 
      Melissa Williamson, BSN, RN, Clinical Manager, Penrose 5 Medical 
      Brenda Molencamp, BSN, RN, NE-BC, Clinical Manager, Penrose 4 Medical 
      Mackenzie Mudd, MSN, RN, Clinical Coordinator, Penrose 5 Medical 
      Brian Sarpy, Director of Support Services 
      Heidi Baird, MSN, RN, Regulatory Readiness Coordinator 
      PH 5 Medical Unit Nursing Staff, Penrose 
      PH 4 Medical Unit Nursing Staff, Penrose 
      PH 5 Medical Unit Nursing Staff, SFMC 
      Nonviolent Crisis Intervention Educators 
      Emergency Department and Urgent Care Staff 
      Security Staff 
      Administrative Nursing Managers/Supervisors 
      All staff who completed the CPI Nonviolent Crisis Intervention Training


      Code Green Alerts per Quarter The graph below displays the trend prior to the interventions which occurred in Jan-Mar 2012.  The following quarter, Apr-Jun 2012 demonstrates a decrease, however, most of the quarters in 2011 are similar. We will continue to monitor this metric. 

      Goal Outcome While we are uncertain of the impact of interventions on calling Code Greens, we are certain that we have seen a reduction in  "Struck by Fellow Worker/Patient." The graph below demonstrates the Pre Intervention, Intervention, and Improvement Post Intervention incidents in this category.

      The goal of the project was to improve workplace safety for nurses as measured by a reduction in "Struck by Fellow Worker/Patient" category.  During calendar year 2011 ten incidents reports; in calendar year 2012 7 incidents reported.  The graph displays the decreasing incidents during calendar year 2012.  The goal was met.

      Loucks, J., Rutledge, D.N., Hatch, B., & Morrision, V. (2010). Rapid response team for 
      behavioral emergencies, Journal of the American Psychiatric Nurses Association, 16(2), 92-100. 
      White, A. (2010) Managing behavior emergencies: Striving toward evidence-based 
      practice, Journal of Emergency Nursing, September 2010, 36(5), 455-459.

    • Exemplary Professional Practice - EP31

      Culture of Safety

      EP 31 How the organization uses a facility-wide approach for proactive risk assessment and error management

       "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." ( ANA Code of Ethics for Nurses , 2001)

      PSFHS supports an organizational wide approach to proactive risk assessment and error management. Daily evaluation of the practice environment occurs both informally and formally at all levels and in all settings. Commitment and action to patient, associate, visitor, and physician safety is the responsibility of every associate and department.  This culture of safety is created through an infrastructure of performance improvement, patient safety and evidence based practice interdisciplinary committees and councils.

      Risk Management Plan:

      PSFHS uses an organization wide policy that describes our proactive risk assessment and error management, known as the "Organizational Performance Improvement and Patient Safety/Risk Management Plan." ( EP31-1 ) The following excerpts demonstrate the widespread responsibility for patient safety.

      Facility Wide Approach "Patient safety is a collaborative effort between all departments and disciplines."

      Proactive Risk Assessment "Every eighteen months, a proactive risk assessment on at least one high-risk process will be conducted utilizing the Failure Mode Effects Analysis (FMEA).  The Joint Commission information about sentinel events and risks will determine priorities for selection" In 2012 PSFHS completed a FMEA on Code Greens and took actions to improve safety. This is discussed in detail in EP30EO.

      Error Management In order to mitigate safety errors, PSFHS uses the following to assess and manage risk:

        Risk Identification :  The collection of information about patient care occurrences and other situations presenting a potential loss to the system 
        Risk Analysis:   The evaluation of past experience and current exposure in order to assure appropriate remedial and preventative measures have been taken. 
        Risk Control :  Respond to areas assessed as having significant risk to decrease the likelihood of an occurrence.

        Sentinel Events/Critical Issues :  Intense analysis of sentinel events or critical issues, as defined by TJC, will be conducted by the Chief Medical Officer, Chief Nursing Officer, Patient Safety/Risk Management and the Clinical Effectiveness Department with involved parties and departments.

      Occurrence Reporting System:

      PSFHS employs a robust online reporting system which promotes follow up, reporting and trending.  The formal occurrence reporting structure and process encourage all associates to document all errors as a method to facilitate ongoing monitoring, evaluation, and action planning to reduce future errors. Every associate has access to a Pocket Guide that includes relevant information on occurrence reporting (see below). In addition the Sentinel Reporting structure provides guidelines for immediate notification and action in the case of a potential sentinel or critical event.  ( EP31-2 )

      Patient Safety Committee:

      The Patient Safety Risk Management nurses are available by phone for questions or consultation. In addition they review occurrence reports daily to identify any opportunity to reduce risk immediately or follow through with required reporting.  These nurses participate on the t Patient Safety Committee that meets twice a month to examine data for trends, to determine educational needs, to investigate individual and system issues, as well as to take action based on our Just Culture policy includes the Patient Safety staff, CNO, CMO, Director of Clinical Effectiveness, Director of Pharmacy and other senior nursing leaders.  Minutes from these meetings are confidential.

      Clinical Risk Management Incentive Plan (CRMIP):

      PSFHS participates in an annual Clinical Risk Management Incentive Plan. The CRMIP is a voluntary program for participants in Catholic Health Initiatives' consolidated insurance program. This structure and process offers facilities an opportunity to earn a financial incentive by achieving exemplary outcomes and by implementing initiatives that reduce or eliminate harm to patients/employees in our healthcare setting. 

      In FY12, PSFHS selected three performance improvement projects for the CRMIP. These projects were: Hand Hygiene, Central Line Associated Bloodstream Infection, and a Pressure Ulcer initiative. These programs resulted in improved outcomes for our patients and more than a $145,000.00 rebate on our insurance assessment. ( EP31-3 )

      For FY13, PSFHS' Quality and Patient Safety Committee identified the following four priorities for the CRMIP:

      Red Rules Goal is a 50% decrease in the number of mislabeled specimens. Strategies identified include a new Associate Accountability policy, education via online LEARN module and a new video and continuing our Red Rules/Just Culture structure and process.

      Reducing Medication Errors In 2012, nursing reported thirteen medication errors related to pharmacy Pyxis restocking and nurse standard of practice. The goal is to have a 50% reduction in Pyxis stocking errors.

      Disaster Preparation and Response In 2012, the Colorado Springs Community was faced with a catastrophic fire.  Penrose Hospital was on a pre-evacuation order while we were providing space for residents of Mount St. Francis nursing home and the 40+ nuns residing at Mount St. Francis Retreat Center. The goal is to modify our external disaster plan, review supplies, and equipments needed for a disaster and to renew our MOU documents.

      Reducing patient harm by eliminating retained surgical items (RSI) Analysis of a sentinel event related to a retained surgical item identified an immediate need for process improvement. Initial strategies in processes include review/revision of policies, re-education of staff/surgeons on surgical counts, and the reinforcement of the "time out" process. The Goal is zero (0) retained surgical items. ( EP31-4 , EP31-5 )

      Interprofessional Collaboration for Risk Assessment and Error Management:

      1. Mass Transfusion Protocol (MTP) 

      Background and Purpose The urgent provision of blood for life threatening hemorrhages requires a rapid, focused approach as excessive blood loss can jeopardize the survival of patients.  It is vital that staff within the emergency department understand the pathophysiological consequences of massive blood loss in trauma, and that they are familiar with when and how to administer blood components in trauma resuscitation.

      A standardized Mass Transfusion Protocol was initially prompted by the Trauma Medical Director, Roger Nagy, MD in January 2011. He specifically proposed changes to the blood shipment quantities and timing. This was based on extensive research done and the positive outcomes that have been seen in contemporary wartime practices. 
      Methods and Approaches With the prospect of a practice change, the trauma department decided to examine the components of the previous policy and procedure. Since this practice is high stress and low frequency, the team dissected the steps to the most intricate detail to ensure both patient safety and staff competence.

      Meetings were conducted with all relevant departments to review roles and to identify challenges. Staff was interviewed in the ED, ICU, OR, Blood Bank, Pathology, Lab, Pharmacy, Registration, PBX, IT, Anesthesia, and Trauma Surgery. Ideas on how to improve the efficiency and the effectiveness of the process were identified and an operational outline drafted.  ( EP31-6 )

      The participants knew the "recipe" (blood components and timing) for a successful MTP practice and the importance of training and practice.   A review of the literature and best practices supported our current procedure. The most challenging aspect of this policy reform was choreographing the operations of this intensive event. Effective communication was the key element across this continuum. 

      Leadership and Communication In order to make communication efforts more efficient, this MTP group eliminated the PBX operator from the "phone tree." The operator was seen as a redundancy and they could contribute to life threatening errors since they had been passing on clinical information. The primary RN assigned to the patient would initiate and take responsibility for the MTP process. After a physician order, this RN would refer to an algorithm that clearly defined the necessary actions. The algorithm was color coded to designate the roles of the RN, Blood Bank, and Pharmacy during a MTP process.

      The Trauma Department created a large tablet as a visual cue for the entire team. The tablet defines the blood components and quantities and includes a place to write (in red) times to anticipate next product arrival. Often, the MTP is initiated in the ED. The patient is then moved swiftly to the OR and then to ICU. This large tablet follows the patient to each unit until the termination of the MTP. These patients are always in a critical, unstable condition, with multiple procedures and diagnostics happening simultaneously in conjunction with the MTP process. The use of the tablet improves communication and reduces staff stress across the continuum of care. Once the patient moves from the ED to the OR, the anesthesiologist and circulating RN can refer immediately to the MTP tablet and know exactly what products have been given and when next products will arrive.  ( EP31-7 below image )


      The only units that have exposure to the MTP are the ED, OR, and ICU. An identical setup was created in each area. A large rolling white board (made by Dan Harmon, RN, PH ICU) was built for the MTP tablet so that it could be easily moved with the patient. A MTP checklist, red markers, and paper documentation for process were all attached to the tablet. The goal was to have easy access to needed items and standardize the set up across all areas.

      Documentation We identified a place in the electronic medical records for blood bank documentation. Standardized blood bank documentation assists with tracking and monitoring and it improves the staff's ability to perform quality audits. Previously, staff could not determine whether the protocol was initiated or if the patient had received blood products. 

      Transfusion Alert A "Transfusion Alert" was designed and initiated. The Blood Bank determines and initiates alerts as needed. The alert is an overhead audio announcement to hospital staff that an MTP is in progress. It also requests that staff not disturb Blood Bank for routine matters until a "Transfusion Alert All Clear" is paged.

      Education Beginning in June 2011, the Trauma Nurse Educator and Blood Bank Lead Technologist provided mandatory education to all staff in the ED, OR, PACU, and the ICU. Trauma Surgeons and Anesthesiologists were also required to undergo formal training on the new procedures. Education included a review of policy and practice changes as well as use of the Level 1 Rapid Infuser. The ED, ICU, and OR all participate in MTP Drills to evaluate changes and to promote competency. MTP and Level I Rapid Infuser training is also a component of the annual required unit skills review.

      Ongoing Monitoring The Trauma Department and the Blood Bank do collaborative audits about the blood usage and the operational aspects monthly. After each MTP is identified, the Trauma Educator conducts debriefings with available staff for feedback. The Critical Care, ED, and Trauma Department continue to collaborate to ensure that we are evaluating our practices based on standards and improving practice based on current evidence. ( EP31-8 )

      Bonnie King BSN, RN, Trauma Educator 
      Roger Nagy MD, Trauma Medical Director 
      Jody Wallace RN, Trauma Coordinator 
      Wendy Erickson, RN, Trauma Coordinator 
      Anne Wardrop, RN, South State Trauma Director 
      Kacie Puderbaugh, Blood Bank 
      Lynn Schutz, Blood Bank 
      David Newton, MD, Pathology 
      Alison Schlang, PharmD, BCPS, Pharmacy 
      Mike Force, R.PH., Pharmacy 
      Dan Harmon, RN, Critical Care Unit 
      Emergency Room Staff (Nurses, Techs, Support) 
      Critical Care Nursing Staff 
      Operating Room Nursing Staff

      Outcomes and Clinical Implications Practice and policy improvements are actively in use in both hospitals.  The following list identifies specific changes made in 2011.

      • Revised policy and practice based on literature and staff input across multiple departments 
      • Created an algorithm ( EP31-9 ) 
      • Created the large MTP tablet and process for use 
      • Established a Massive Transfusion Alert to be called by Blood Bank 
      • Revised documentation in Meditech for the MTP

      The use of a massive transfusion protocol and alert standardized the process for responding to a life threatening emergency and guides all healthcare providers which minimizes confusion, improves communication and the treatment process for the patient.  Per literature, a formal MTP such as the one we have developed has shown to decrease patient mortality and reduce the amount of blood product waste.


      Duchesne, et al.  (2010). Damage control resuscitation:  the new face of damage control.  Journal of Trauma, 69,4. 
      Nunez et al.  (2010) Creation, implementation, and maturation of a massive transfusion protocol for the exsanguinating trauma patient.  Journal of Trauma, 68, 6.

      2. Disaster Training

      Preparing for and responding to disasters requires close collaboration between all departments.  Senior Nurse Leaders, Clinical Nurse Managers and direct care nurses participate in disaster drills and the evaluation of structures, processes, and outcomes.  Several of these nurse leaders have completed national training with the Federal Emergency Management Agency. In the summer of 2012, Colorado Springs was faced with a real disaster in the "Waldo Canyon Fire." This fire quickly spread from nearby mountain communities into suburbs of the city. Ultimately, the fire would result in the deaths of two people, the loss of nearly 350 homes, millions of dollars in damage, and numerous medical emergencies resulting from smoke inhalation and heat stroke.

      Incident Command System and Process The Waldo Canyon Fire started on June 23, 2012 at approximately 12:00.  On June 26 the fire was pushed into northwest Colorado Springs ultimately destroying 246 homes.  Over 22,000 residents were ordered to evacuate, some with little to no warning.

      In the immediate path of the fire was Mount St. Francis Nursing Facility and Nunnery.  PSFHS agreed to accept the remaining fifty plus patients and over twenty nuns who were under immediate threat of fire and smoke.  On June 26 at 7PM patients began arriving to Penrose Hospital and the nuns were delivered to the old shuttered Penrose Community Hospital building where rooms and beds were made available.  Over three days the long term care patients were transferred to local long term care facilities.

      PSFHS immediately activated Incident Command System (ICS) when the fire erupted and overtook the northwest section of the city.  The immediate objectives were established and included:

      • Contact all associates to determine their safety and availability for work 
      • Prepare for receiving mass casualty patients created from the fire 
      • Prepare for possible evacuation of Penrose Hospital to St. Mary Corwin in Pueblo

      The Incident Command System leadership included:

      • Lorin Schroeder, PSFHS Safety Officer, Incident Command 
      • Johnny Rea, Marketing, Public Information 
      • David Linebaugh, PSFHS Manager, Safety Officer 
      • Kate McCord, Chief Nursing Officer, Operations Section Chief 
      • Danny Reeves, Chief Financial Officer, Finance/Administration Section Chief

      PSFHS Incident Command was able to communicate with the city and the county Emergency Operations Center to obtain real time situational reports.

      Challenges, Lessons Learned and Opportunities for Improvement

      • Nursing Review

      o Patients arrived via bus and needed assistance to enter the building and then soon needed bathrooms, food, drinks and oxygen tanks

      ED, transport and other staff assisted nursing leadership with care

      o Some patients were designated to go to other facilities but buses brought all to Penrose and then redistribution occurred several hours later 
      o Patients initially arrived without medical records or staff

      Nursing staff at PSFHS immediately initiated needed care until records arrived 
      Nursing and Pharmacy coordinated to obtain needed medication

      o Five hours after patient arrived, some staff from Mount St. Francis were available to assume care

      • Overall areas to improve

      o Time to contact associates.  Consider automated communication system. 
      o Little communication to PSFHS from multiple extended care facilities ordered to evacuate.  Meet to plan for future needs. 
      o Evacuation of Penrose Hospital needs further planning and signed agreements with receiver facilities

      Care of PSFHS Associates

      • Associates affected by the fire were offered accommodations at the shuttered Penrose Community Hospital building. 
      • EAP staff were immediately available 
      • Communications with staff occurred formally through daily Talking Points via email as well as through manager face to face or phone contact with affected staff 
      • Financial assistance through the PSFHS Foundation

      Care of our Community

      • Associates were allowed to take two paid days to volunteer with Fire Clean up.  Over a 20 day period 117 PSFHS associates volunteered. 

      EP31-10 , EP31-11 , EP31-12 )

      Partnering - Nursing, Pharmacy and IT:

      The in-house Pharmacy receives and forwards the ISMP Newsletter to nursing units each month.  When articles present information that is especially timely or relevant to our organization, the pharmacist includes a comment to highlight information for nursing.  This process helps our nurses to be aware of changes in best practices and it is illustrative of our organization's commitment to proactive risk assessment and error management.  The following is a good example of this process in action: 

      To improve patient safety and reduce risk associated with maximum medication dosages, changes were implemented in Meditech to support pharmacy and nursing practice.  ( EP31-13 )


      PSFHS uses expertise from across the facility for proactive risk assessment and error management. Creating a safe environment is a shared responsibility and every associate is accountable to take action including reporting issues to improve our environment. The formal structures through performance improvement and patient safety maintain oversight and prompt actions when needed.  Our culture of safety is the foundation for risk assessment and mitigation.

    • Exemplary Professional Practice - EP32

      Culture of Safety

      EP 32 Describe and demonstrate the nursing structure and process that support a culture of patient safety

      Patient safety is the crux of PSFHS' daily operations. Nurses create and ensure a climate of patient safety through several structures and operational keystones.

      Structures for Patient Safety Risk Management Plan:

      Our nursing standards and organizational mission sets the stage for a culture of safety. ANA Nursing Standard 18 for Professional Performance states that, "The RN considers factors related to safety, effectiveness, cost and impact on practice in the planning and delivery of nursing services." In June 2011, the Centura Health CEO wrote the following that connects our mission to the need for a safe healing environment, "To extend the healing ministry of Christ means, in part, to provide the safest place for patients and residents to heal." 

      A culture of patient safety requires strong leadership, vigilance, teamwork, and communication.  By implementing evidence based practices and effectively using our technology to alert us to risks, we can continually improve patient safety. PSFHS practices within a culture of non-punitive reporting. This encourages openness and honesty in the disclosure of mistakes. This combined with our investigation of risk model (which examines areas proactively and retrospectively) contributes to the improvement of patient safety.

      Our Board of Directors charges PSFHS to take actions that monitor and improve patient safety. The Chairman of the Board routinely attends the Institute of Health Conference which develops Board member knowledge of quality and patient safety concepts, initiatives and national priorities. The Board selects initiatives that will improve quality/patient safety within PSFHS. Hand hygiene compliance is a priority action. In 2012, the Board established a subcommittee and directed these members to focus on quality and patient safety issues. The Board has direct oversight of quality/patient safety within PSFHS and receives updates at each Board meeting. The Board delegates operations to other quality/patient safety committees within PSFHS as outlined in the Quality/Patient Safety Plan. (EP32-1 )

      Patient safety is a collaborative effort between all departments and disciplines to establish the plans, processes, and mechanisms for PSFHS patient safety activities. The Patient Safety Officer and Director of Clinical Effectiveness along with the Patient Safety/Risk Management Committee are responsible for safety plan oversight. The plan is derived from priorities set by our organization's strategic plans, Centura Health Quality plan, Risk Management incentive plans, IHI initiatives, National Patient safety goals, culture of safety surveys, regulatory reporting requirements, and other patient safety initiatives. 

      Below is a flow chart which represents the quality and patient safety structure of PSFHS. The PSFHS Clinical Effectiveness Committee provides system leadership for oversight, monitoring and direction of performance improvement actions to continuously improve quality and build a culture of safety. The attached minutes from the Clinical Effectiveness Committee demonstrate board oversight and review and analysis of quality/patient safety data. ( EP32-2 , EP32-3 )

      Environment of Care Plan:

      Our Environment of Care Management Plan establishes and maintains a physically safe environment for our patients and associates. Further, it provides for adequate orientation/training and manages staff activities to help reduce the risk of injuries. This plan, based on standards from multiple regulatory bodies, and multidisciplinary committees provides a structure and a systematic organization-wide approach to improving the performance of safety, fire, security, medical equipment, utility systems, hazardous material, and waste management.  ( EP32-4 )

      Processes to Support a Culture of Patient Safety:

      Safety and Surveillance Rounds Our organization performs formal safety/hazardous surveillance rounds twice a year. These rounds are conducted by a multidisciplinary team including safety, security, bioengineering, infection control RN, regulatory readiness RN, facilities and the fire marshal. The findings are entered into an electronic database and tracked to ensure timely corrections.

      Safety Monitors PSFHS encourages associates to be active participants in creating and maintaining a safe culture. Each unit/department has identified a safety monitor who champions safety by sharing knowledge learned from quarterly training. These monitors improve safety by doing monthly area rounds and by encouraging colleagues to report safety hazards immediately. The fall 2012 meeting included fire safety, access to online MSDS in case of accidental exposures, review of annual plans, policy revisions and safety monitor rounding. ( EP32-5 , EP32-6 )

      Culture of Safety Survey At PSFHS we know Patient Safety is everyone's business; Penrose Hospital associates are visibly reminded of this commitment by the banner hanging by the dining room. The Chief Medical Officer, the Chief Nursing Officer, and the Director of Clinical Effectiveness encourage the organization in the monitoring and improvement of the quality/safety of all services provided by PSFHS. In 2009 and 2011 associates took the AHRQ culture of safety survey. This survey allows associates to give input into the current culture of safety within PSFHS and make suggestions for improving the culture of safety. Two key elements of improvement were identified from the 2009 survey: Nurse/Physician communication and Handoff communication. The Clinical Effectiveness Committee has focused on Nurse/Physician communication during the last year and an interdisciplinary group meets as needed to review handoff communication. The results from the 2011 survey identified several areas of strength:

      • When a lot of work needs to be done quickly, we work together as a team to get the work done. 
      • People support one another in this unit. 
      • We are actively doing things to improve patient safety. 
      • Teamwork within units

      The low number of responses to this survey limits the value and applicability to the survey.  While we continue to do this survey, actions to create and sustain a culture of safety come from other committees, data analysis and observations/informal dialogue.

      Interdisciplinary Committee Work:

      Nursing participates on several multidisciplinary committees charged with patient safety.

      • The Infection Control Committee meets every two months. A recent priority focus has been on influenza vaccinations for all health care providers and staff within our hospitals.  For the 2012-2013 flu season, we required everyone to be vaccinated or provide proof of reason for non-vaccination. All associates with adequate proof for non-vaccination are required to wear a mask while providing care during influenza season.

      • The Clinical Effectiveness Council meets monthly. Quality and patient safety are the priorities for this committee. One primary focus during the last year has included nurse/physician communication. Building on our commitment to relationship based care,  TLC (Nursing Newsletter) included a series of articles on a "Culture of Respect".  The evidence on building a culture of safety is clear - relationships and communication make a difference. ( EP32-7 ,EP32-8 )

      Nursing Services Safety Initiatives:

      Patient safety and quality care are goals that are strongly integrated into all aspects of patient care at PSFHS. Providing quality care requires that we also take actions to create an environment that ensures patient safety from admission to post-discharge. The cultivation of associates who believe in our culture of safety begins upon hiring. Orientation includes education and training on standard precautions, hand hygiene, and fall prevention. The first day of the new graduate nurse ASCENT program includes training entitled "Creating a Culture of Safety".  ( EP32-9 )

      Unit Based Resource Nurses Nursing has identified unit based resource nurses with specialty focuses in skin care, pressure ulcer prevention, and pain management. These nurses participate in professional development and in-service opportunities as well as monitor and analyze nurse sensitive quality indicators.  The implementation of pressure ulcer prevention standards improves patient safety by reducing the risk of pressure ulcers. 

      Hand Hygiene Champions In March 2012, we implemented a Hand Hygiene Champion program to improve compliance with hand hygiene. ( EP32-10 )  Nursing staff across the organization observe, provide feedback and analyze trends related to unit compliance with hand hygiene. Observations include watching nurses, physicians, dietary, and other healthcare providers wash their hands upon entering and leaving patient rooms. These reports are reviewed in the Patient Safety Committee and Clinical Effectiveness Committee. The Hand Hygiene Champions are improving this essential patient safety goal. The Infection Preventionists continue to monitor and provide feedback primarily in Intensive Care and Emergency Room locations.


      Nursing Bedside Shift Report (BSR) and Handoffs Nursing uses two structured processes that promote accurate communication during transition times. The SBARQ format is integrated into all communications at handoff times or when contacting a physician or licensed independent practitioner.

      Bedside rounding promotes patient and family involvement in treatment as well as patient safety, as the off going and oncoming nurses check lines, medication, drips and other pertinent individual patient treatments. The Nursing Practice Council has identified BSR as a standard of practice.  Council members have reviewed the literature, trialed different processes and shared best practice. Currently the council is considering a standardized format for all units. ( EP32-11 )

      Huddles Many nursing units "huddle" at shift change (and as needed throughout the shift) to communicate high risk and potential patient safety issues.  The team identifies priorities and needed actions to take to reduce patient safety risk. These actions include: increased rounding, "sitting," shifting assignments, and staffing.

      Chart checks Concurrent chart review is conducted to ensure that complete and timely documentation pertaining to patient care is completed in accordance with all regulatory requirements. Prior to the end of a nursing shift, each nurse reviews physician orders to ensure that they have been transcribed properly and that interventions have been implemented in a timely manner. This standardized process reduces the risk of missed orders or delays in the implementation of treatments.

      Physician Order Process The physician order, transcription, and implementation processes have multiple built in safeguards for patient safety. All medication orders are transcribed by pharmacy and then checked by nursing. 

      Infection Prevention Practitioners The nurse plays a critical role in preventing and controlling infectious diseases. Infection Prevention Practitioners (IP) perform rounds on units so that they can answer questions and provide education as needed. New hires receive orientation from the IP. Through continuous surveillance and through the investigation of incidents of hospital infections, the IPs can: initiate actions, obtain needed equipment, and provide education in order to promote a safe hospital environment. Evidence based practices guide isolation precautions and nursing interventions to reduce infection risk. 


      The newsletter of the Environment of Care Committee is titled, The Environment of Care. The role of this internal publication is to disseminate questions raised during EOC rounds. This newsletter often includes photos to enhance associate understanding of safety risks and expectations. 

      A second publication that is designed to address our culture of caring is the Nurse Advise-ERR. The goal of this newsletter is to educate nurses about updates to safe medication practices. It is distributed to all practice areas monthly. 


      Effective use of our electronic medical records system promotes patient safety. Multiple revisions to the medication reconciliation application, initiated by collaborative requests from nurses and physicians have contributed to a slight improvement in associate confidence in the system. However, this critical patient safety issue is complex and we continue to make modifications in the application in order to improve effectiveness and efficiency. Progress towards a computerized physician order entry is ongoing with scheduled implementation in April 2013.

      Education, Training, and Competency:

      Annual mandatory training for all associates is assigned through our HealthStream system. Per policy, associates are suspended if they have not completed the training by the due date and the associate cannot return to work until their mandatory training is complete. During annual nursing skills review, certain topics are selected based on needs assessment for additional training. For example, in 2012 nursing associates completed demonstrations of the following procedures: isolation precautions, appropriate swabbing for MRSA, and hand hygiene. At another simulation station, nursing associates demonstrated hand hygiene and patient identification requirements. 

      Nonviolent Crisis Intervention training provides designated associates with the tools to manage an aggressive patient. Keeping patients, associates, and visitors safe in our facility requires strong interpersonal skills as well as training in self protection. Taught by a certified inter-professional team, direct care PSFHS associates (nurses, CNAs, critical care technicians, etc.) are taught strategies to reduce the risk of violence and aggression. Our commitment is to always use the least amount of force necessary and to provide associates with the skills to deescalate situations. Identified associates are required to complete the training as well as an annual refresher.

      Examples of mandatory annual training modules related to patient safety include:

      • PSF Safety Extravaganza and Emergency Preparedness 
      • PSF Fie and Life Safety 
      • PSF Electrical Safety 
      • PSF Safety Control 
      • PSF Hazard Communication 
      • National Patient Safety Goals 
      • PSF HIPAA Review for Safety 
      • PSF Identifying Patient Abuse and Neglect

      Additional education and training is designed and provided to meet specific patient needs such as stroke education and fall prevention.  ( EP32-12 )

      Quality and Patient Safety - Surgical Services at PSFHS:

      Nursing associates working in PSFHS Surgical Services are led by two nursing directors.  These nursing directors are committed to collaboration within our organization as well as across Centura Health to achieve the best clinical outcomes. 

      Reducing Number of Flash Sterilizations:

      Nursing Practice Standards from the Association of Perioperative Registered Nurses recommend completely avoiding the use of flash sterilization, except in emergencies. In 2010, the PSFHS Operating Room and the Sterile Processing staff improved patient safety through the reduction in flash sterilization. The Centura Perioperative Quality Team proposed a revised Flash Policy.  PSFHS surgical services had examined the current flash policy and metrics and concurrently identified a goal to reduce the number of flash cycles and to eliminate implant flashing altogether. The charge nurses in the OR collaborated with the Sterile Processing team to change practices. New items were purchased which have led to a decrease in flash sterilizations. The graph depicted below provides a clear view of our successful practice change to improve patient safety through the implementation of nursing standards and interdisciplinary collaboration: 

      In 2011 H*WORKS CONSULTANTS stated that a 5% flash sterilization rate is the national benchmark. Discussed in the Infection Control Meeting in January 2011, PSFHS adopted 5% as our goal. ( EP32-13 )

      In March of 2011, SFMC started to track their flash sterilization demonstrating a 7% flashing, above our goal of 5%. We examined the flashing data for trends and identified high flash rates related to dental cases and oral surgery. In an effort to reduce this flash sterilization, the Director met with the staff from the dental and oral surgery office. Instrumentation was purchased to allow these surgeons to do back to back cases without having to flash the instruments. Not only did this help for patient safety, but the physician satisfaction was extremely positive. The following timetable illustrates the chronology of the flash sterilization reform:

      Spring/Summer 2011

      Dental Instruments Purchased

      Oral Surgery Instruments Purchased

      Ocular Instruments Purchsed for two pediatric surgeons


      • Orthopedic instrumentation was also purchased that was being routinely flashed. 
      • Education occurred on the care and handling of wrapped instruments to reduce   incidence of holes in the wrappers. 
      • Vendor representatives from orthopedic companies were informed we would not flash and they needed to bring adequate instrumentation for the day. We required instrumentation be in the Operating Room twenty-four hours in advance of scheduled surgery to allow for proper processing.

      By setting a goal, purchasing needed equipment, defining limits, through teamwork and partnering with vendors, our flash rate has decreased significantly and continues to outperform our goal. Since the purchase of the instrumentation, and the diligence that is placed on making sure that we do not have to flash, our flash rate in 2012 has been under 5%. Teamwork improved patient safety and satisfaction of staff and physicians.

      The red line represents the goal of 5% flashing or less. Reduction in flashing percentages is demonstrated in October 2011 and the goal was achieved by December 2011 with sustained improvement evident in 2012.

      SFMC ED Blood Culture Collection Process Improvement Using the standardized FOCUS PDCA process, SFMC ED describes and demonstrates a reduction in contamination of blood cultures/false positive rates.

      Find a Process to Improve

      • False positive blood cultures causes several thousands of dollars in unnecessary admissions and other expenses 
      • Nationally, the benchmark is a 3% contamination rate throughout a hospital 
      • PSFHS overall reported a false positive percent of 3% 
      • SFMC Emergency Department (ED) had the highest contamination rates

      Organize a Team

      Team Leader: Kim Dumont, RN

      Physician Advisor: Michael Roshon MD

      Team members :

      • Alese Bagby, RN 
      • Tiffany Romero, RN 
      • Diane Villavicencio, RN 
      • Mary Gronberg, RN 
      • Tim Snell, EMT 
      • Ayesha Johnson, Lab Tech

      Clarify Current Knowledge

      • Staff varied in their methods of collecting blood cultures 
      • Staff lacked knowledge of the rate of false positives from the ED collected specimens nor the implications of those false positives

      Understand Process Variation

      • Staff were drawing off pre-existing devices (e.g., EMS lines) 
      • Staff were unaware that chlora-prep needed to fully dry before venipuncture 
      • Staff would re-contaminate the area when palpating and not realize it


      • Correct knowledge deficits

      o Each ED preceptor were trained on proper technique 
      o Each preceptor then taught every staff member how to properly collect blood cultures

      ? Proper prep techniques 
      ? Proper fill techniques of the bottles 
      ? Avoiding using pre-existing devices 
      ? Avoiding re-palpating the site or properly prepping the gloved finger prior to re-palpating site to avoided cross-contamination

      • Have each staff member signed off as being competent by the trained preceptors through 1-on-1 lecture & demonstration


      • Staff were informed they needed to be educated on the proper technique and then observed by the trained preceptors over a 6 week time period


      • Given the small sample size at SFMC ED (about 30-40 blood cultures monthly), our goal was to decrease from 10-12% to 5-6% monthly 
      • Nov 2011: 10-12% 
      • Dec  2011:  5-6% (with only half the staff trained) 
      • Jan-Feb 2012: 2-3% rate 
      • Sept-Oct 2012: 0% rate


      • This continues to be a work in progress for the preceptor team 
      • Microbiology will continue to forward the false positives to ED management for trending and dissemination to team leader and rest of staff



      PSFHS creates a culture of safety based on our mission and values.  The Professional Practice Model for Nursing provides the structural foundation for nursing's participation in this process and includes shared decision making, standards of practice and strong quality improvement processes.  Partnering with our disciplines and departments nursing demonstrated safety improvements in the OR and in the ED.  Using peer review, nurses have improved compliance with hand hygiene on their units.  Finally, as we continue to "live" relationship based care we are confident communication and teamwork will continue to grow which are essential to a culture of safety.

    • Exemplary Professional Practice - EP32EO

      Culture of Safety

      EP32EO That nursing sensitive indicator data aggregated at the organization or unit level outperform the mean, median, or other benchmark statistic of the national database used. Provide analysis and evaluation of data released to patient falls, nosocomial pressure ulcer prevalence/incidence, and two of the following: Blood stream infections, Urinary tract infections, Ventilator associated pneumonia, Restraint use, Pediatric IV infections, Other specialty specific nationally benchmarked indicators

      PSFHS is a participant in the National Database for Nursing Quality Indicators (NDNQI). We report and nationally benchmark: patient falls, nosocomial pressure ulcers (Hospital Acquired Pressure Ulcers- (HAPU), Catheter Associated Blood Stream Infections (CLABSI), Catheter Associated Urinary Tract Infections (CAUTI), Ventilator-Associated Pneumonia (VAP), restraint use prevalence, and pediatric intravenous infiltrations. PSFHS reports outcomes for all of the nursing-sensitive indicators for each of the inpatient acute care units with the exception of ventilator-associated pneumonia which is reported only in the Intensive Care Unit. Patients requiring ventilator assistance are only treated in the Intensive Care Unit. 

      In addition, PSFHS is enrolled with the National Healthcare Safety Network (NHSN), an internet-based surveillance system for patient care and healthcare associated infections. Using NHSN guidelines we report and benchmark VAP, CAUTI and CLABSI.

      Indicators that will be presented include:

      Falls, at the unit level 
      Pediatric IV Infiltration, at the organization level 
      Hospital Acquired Pressure Ulcers (HAPU), at the unit level 
      Restraint Prevalence, at the unit level

      Falls per 1000 Patient Days:

      • Benchmark: NDNQI Non Magnet Mean; Over 1100 hospitals reporting 
      • Penrose - 9 units reporting 
      • SFMC - 3 units reporting

      Data Analysis and Evaluation of Total Falls

      • PSFHS reports on all eleven eligible units and has outperformed the national benchmark over 50% of the last eight quarters on four of eleven or 36% of the units.  
      • An additional two units outperformed 50% of the last eight quarters. 
      • PSFHS Interdisciplinary Falls Committee has drilled down to review each fall with focus on use of sedation, risk scores, age and fall in the context of elimination. 
      • PSFHS Falls Committee has led the implementation of evidence based practices to reduce falls including the following practices

      o Fall Assessment via Johns Hopkins instrument.  Centura Health is transitioning to use of the Heinrich Fall Assessment 
      o Use of bed alarms 
      o Use of low boy beds 
      o Hourly rounding 
      o Yellow gowns for patient at risk of falls

      The PSFHS Fall Committee continues to research and pilot practices to reduce the incidence of patient falls. PSFHS has recently applied for a grant to purchase the Fall Prevention Video Monitoring System.  ( EP32EO-1 )

      Pediatric IV with Infiltration - Pediatric Unit and Neonatal Intensive Care Unit III:

      • Benchmark: NDNQI Non Magnet Mean; Over 200 hospitals reporting 
      • Penrose - Does not have a Pediatric or Neonatal Intensive Care Unit 
      • SFMC - 2 units reporting


      Data Analysis The Pediatric Unit and Neonatal Intensive Care Unit III use evidence based practices to prevent the occurrence of intravenous site infiltrations. Prevalence is monitored, benchmarked and analyzed through the structure and process of the National Database of Nursing Quality Indicators. A unit level data review of 4Q10 indicates one NICU patient had an IV infiltration. The Clinical Manager facilitated review by the nurses. There have been zero pediatric IV infiltrations on the Pediatric Unit during the last eight quarters and no repeat IV infiltrations on the NICU.

      Data Evaluation Combined, both units have outperformed the national benchmark seven of eight quarters or 88% of the time during the last two years.

      Restraint Prevalence:

      • Benchmark: NDNQI Non Magnet Mean; Over 1100 hospitals reporting 
      • Penrose - 9 units reporting 
      • SFMC - 3 units reporting



      Data Analysis Our units consistently utilize evidence based practices and they follow internal policies for the usage of restraints. As a result, our patient outcomes are better and the individual units achieve distinction in minimizing the use of restraints.

      Data Evaluation 13 out of the 14 reporting PSFHS units outperform the benchmark by a wide margin. On average the restraint benchmark is outperformed 88% of the time.

      Hospital Acquired Pressure Ulcers:

      • Benchmark: NDNQI Non Magnet Mean; Over 1100 hospitals reporting 
      • Penrose - 9 units reporting 
      • SFMC - 3 units reporting

       Data Analysis Hospital Acquired Pressure Ulcers are directly linked to lower quality care and they require increased hospital expense. As a result, they are actively striven against at PSFHS. The above data demonstrates unit quality above expected outcomes 2/3 of the time.

      Data Evaluation PSFHS units outperform the benchmark for Hospital Acquired Pressure Ulcers 66 percent of the time

    • Exemplary Professional Practice - EP33

      Quality Care Monitoring and Improvement

      EP 33 Describe and demonstrate the structure(s) and process(es) used by the organization to allocate and/or reallocate resources to monitor and improve the quality of nursing, and total patient care. The nurse has responsibility for ensuring the coordination of care among other disciplines and support staff.

      Penrose St. Francis Health Services (PSFHS) actively and routinely provides resources to improve the quality of nurses as well as the care they provide. Furthermore, the organization recognizes that the nurse is the "hub" of the healthcare system and that nurses' behavior in that capacity includes nothing less than the coordination of patient care. PSFHS supports this requirement through the allocation of resources.    

      Professional Leadership:

      PSFHS is dedicated to improving systems and outcomes in a process known as continuous quality/performance improvement. Organizational quality and performance is linked to our mission and core values. . A collaborative, cross-department effort to maximize patient safety, produce positive outcomes, increase customer satisfaction, and cost effectiveness drives our improvement efforts.

      PSFHS is committed to the delivery of quality patient care as measured and monitored by patient perception, patient satisfaction, nursing sensitive quality outcomes, regulatory conclusions, accrediting body reviews, external ratings, and quality outcomes. Several of the external ratings include those that are required by the Centers for Medicare and Medicaid, The Joint Commission, the Colorado Hospital Association, as well as the State of Colorado. The Clinical Effectiveness Department, directed by Kelli Saucerman MSN, RN, CQPS and overseen by the Board and the Chief Medical Officer, facilitates the development of an annual PSFHS Quality and Patient Safety Plan.

      Quality of nursing and total patient care relies on leadership to set organizational goals and expectations. It also requires all associates to take actions within their scope of practice to meet said goals. 

      ANA Nursing Scope and Standards of Nursing Practice , ANA Code of Ethics for Nurses, and the PSFHS Registered Nurse Position Description:

      Our Professional Practice Model is the driving force for nursing care at PSFHS. Additionally, it is designed to be in alignment with our organizational mission and vision. The American Nurses Association's Scope and Standards of Nursing Practice state that, "the registered nurse coordinates care delivery."(Standard 6) Furthermore, Standard 9 of the same document states that, "The RN consistently, appropriately and systematically enhances the quality and effectiveness of nursing practice through communication,  documentation, initiation of change, creativity, innovation, participation in quality improvement (QI), evidence based practice (EBP), and research processes."

      The ANA Code of Ethics for Nurses states, "The nurse is responsible and accountable for individual nursing practice and determines the appropriate tasks consistent with the nurse's obligation to provide optimum patient care." 

      The PSFHS Registered Nurses (RN) Position Summary asserts the RN:

      "Assumes responsibility and accountability for facilitating, communicating, and collaborating with both the healthcare team, and the patient's family to identify and meet the physical, emotional and spiritual needs of the patient. Promotes the optimal health, well being and safety of the patient through use of the nursing process and in accordance with patient care standards, guidelines and the State Nurse Practice Act."

      Annual Budget Process:

      The annual budget development and approval structure/process is used to allocate resources for nursing. The CNO and senior nursing leaders direct the development of the Nursing Budget, which is a significant portion of the overall budget. The Chief Financial Officer provides the draft annual nursing budget based upon historical financial performance and projected changes in clinical unit census. Senior nursing leaders review and request revisions based on dialogue with Clinical Managers. In turn, the Clinical Managers request input from direct care nurses and other colleagues throughout the budget development process. The annual budget provides the foundation and structure related to annual planning to include: staffing, supplies, education, and equipment. 

      Councils and Committees:

      Diverse structures of interprofessional councils provide a formal framework for monitoring quality of care and identifying resource needs. Guided by the "Organizational Performance Improvement and Safety/Risk Management Plan" as well as the Nursing Quality Goals, associates are responsible for participation in quality care monitoring. In addition, every associate is invested in making suggestions for improvements anywhere in our organization.  Formally, nurses working in Clinical Effectiveness, Infection Control, and Patient Safety/Risk Management provide data collection, practice consultation, trend analysis as well as serve on multiple committees to support provider analysis of data and action planning.   

      Our Shared Decision Making councilor structure affords opportunities to monitor and improve patient care. For example, the Nursing Practice Council has reviewed NDNQI quarterly reports, and patient satisfaction. The Nursing Leadership Management Council reviews fall data, as this remains a priority nurse sensitive quality indicator. In 2011, nursing expanded our Shared Decision Making Councils by adding two councils. The Nursing Quality and Patient Safety Council and the Nursing Staffing Council provide two additional formal structures that are designed to review patient care and staffing resources. ( EP33-1 , EP33-2 )

      Standards of Care - Stroke Units:

      Each unit provides care for their specific patient population. This division is based upon the Provision of Care/Staffing Plan, which is developed at least annually. When PSFHS identified the need to improve care for patients with cardiovascular accidents, which was among the initial steps towards becoming a Stroke Center of Excellence, nursing staff and managers recommended designating the Cardiovascular Unit and 4th floor at Penrose Hospital as "stroke units." Medical 5S became the designated "stroke unit" for SFMC. The staff of these units are required to complete additional education and to earn certifications in the National Institute of Health (NIH) Stroke Scale. By identifying specific stroke units, we were able to allocate funds to support needed education. These moves directly improve patient care and the quality of nursing. The Clinical Nurse Managers pay for nurses on these units to maintain their certification.

      Standards of Care - Safety for Patients at Risk for Harmful Behavior:

      Patients admitted on a mental health hold require constant supervision for their safety and the safety of others. When these patients are mobile or when they are admitted to a medical-surgical unit, a staff member is assigned to monitor them. Historically, floors were assigning a certified nursing assistant which left the unit "short staffed." PSFHS has designed a "sitter" position in order to fix this shortcoming. The "sitter" position, however, negatively impacted the unit budget. The senior nursing leaders met with finance to find an alternative solution. We now have a separate cost center for adjusting these hours out of the unit budget. This reallocation of resources supports direct nursing care of all patients while maintaining the important budgetary goals. In FY12 we reallocated resources to provide "sitters" for patients on a M1 hold; over $150,000 came from a budget separate from the unit staff budget.

      Shared Decision Making - Telemetry at Penrose Hospital:

      Background and Purpose PSFHS provides telemetry monitoring through a remote process.  Penrose Hospital has remote telemetry monitoring stations staffed with qualified telemetry technician or cardiovascular nurses.  Over the last several years the number of acutely ill patient requiring telemetry monitoring has grown.  Ensuring adequate telemetry equipment and telemetry trained staff has been a challenge.

      In January 2012 a new Clinical Manager was hired for the Cardiovascular Unit. As she observed and evaluated the unit functioning she identified the need to further evaluate the effectiveness and impact on patient safety via remote telemetry monitoring.  Shortly after her arrival, a patient event reinforced her decision to further examine telemetry monitoring.  

      Methods and Approaches A telemetry task force comprised of direct care and clinical nurse managers and telemetry technicians was established to evaluate and improve our telemetry monitoring system.  Included in this dialogue are ensuring we have or obtain the necessary resources to monitor and improve patient safety.   ( EP33-3 )

      Comprehensive Evaluation and Improvements:

      Equipment The Penrose Critical Care and the Bariatric and Back Unit (BBU) both have telemetry dashboards (which monitor and display cardiac rhythms) in patient rooms. In addition, the nursing station in the Critical Care Unit has a board for monitoring telemetry in Critical Care.   The Cardiovascular Unit provides remote telemetry monitoring for all floors/units at Penrose Hospital including a "second set of eyes" on the Critical Care and BBU monitors at PH. SFMC ICU monitors their patients.  Currently, Penrose has a G.E. system that is 7-10 years old and the server memory is approaching maximum limits. New G.E. equipment that is more durable including moisture resistance for use in showers/bathrooms is currently being installed.  The monitor boxes have both EKG and Sp02 capability. The current monitoring capacity is for 128, and the upgrade will increase our capacity to 165 remote monitors, the largest in Centura Health.

      Telemetry equipment is kept in the telemetry area on the CVU.  In spring 2012 the transport team agreed to obtain the monitors from telemetry, and transport to the unit for nursing application to patients.  Once the monitor is placed on patient, the nurse needs to verify with the monitor technician the box number and the rhythm is confirmed.  When patients are discharged or telemetry is discontinued equipment must be cleaned and readied for the next patients. Transport picks up and returns telemetry units to CVU. ( EP33-4 )

      Telemetry is ordered on 80% of patient admitted through the emergency room. The ED will take patients to their room, and if telemetry is ordered, the nurse has about 15 minutes to get that patient on the monitor.   Remote telemetry monitors display real time rhythms.  Because of the sedation / OSA policy, all patients that come from the PACU are required to have a monitor in place prior to leaving this area.  ( EP33-5 )

      In some areas of Penrose Hospital monitoring of patients through remote telemetry is not possible due to technology gaps.  In these situations, if necessary, nurses accompany patients to their destination.  Portable telemetry equipment is available and used as needed.   Areas with technology gaps are being rewired to improve patient safety throughout the facility. 

      Telemetry Technicians/Staffing The initial focus was on number of Telemetry Technicians in relation to number of telemetry patients.  The research and evidence based practice literature did not provide a ratio of Telemetry Technicians to Telemetry Patients.  The Clinical Manager requested an immediate increase in staffing which was approved by the Chief Nursing Officer.  Telemetry Technician staffing increased from 2 per shift to 3 per shifts per seventy plus telemetry patients.  The Clinical Manager established a ratio of 1 Telemetry Technician to 35-40 Telemetry Patients.  

      In 2012, PSFHS established a new position, the Lead Monitor Technician (LMT) person. This role collaborates with Bio Med to make sure all equipment is identified and repaired if needed.  In addition, the LMT works with the CVU business support person to ensure adequate supplies are ordered and available. ( EP33-6 )

      Communication between Telemetry Technician and Unit/Floor Nurse A Telemetry Flow chart was developed by Evelyn Angeles with input from the Telemetry Technicians in 2011 and revised in 2012 based on the Telemetry Task Force recommendations.  This is a visual cue for all staff to help them follow the proper sequence of actions when caring for a patient on telemetry.  Additionally, an EKG Quick Reference with color coded dots depicting urgency of actions is laminated and posted on all units.  ( EP33 -7 , EP33-8 )

      Telemetry Monitoring Station Currently, the telemetry room is an open area linked with the unit medication room.  With the increase in monitors, the Clinical Manager has requested the telemetry room be closed to improve privacy and quiet and reduce interruptions and distractions in the med room. 

      Staff Competency Two advance practice nurses teach the mandatory telemetry class for all telemetry technicians. The class is four hours each week for four weeks.  The telemetry technicians on CVU take the same class and are required to pass the same test that the nurses take on CVU.   Every May, all telemetry technicians and nurses take an EKG interpretation exam and must score 90% or better.   Some Telemetry Technicians are cross trained to be certified nursing assistants which improves staffing coverage and improves teamwork.

      In February 2012, the ASCENT New Graduate Residency education was revised to include "When Telemetry Calls". A Cardiovascular nurse teaches the class and supports the educators with a mock code blue simulation during ASCENT.   ( EP33-9 )

      Policy The Policy states the purpose of telemetry and pulse oximetry monitoring is: To define a safe process in telemetry or continuous pulse oximetry for all our acute inpatient units. ( EP33-10 )  Education on the policy and practice changes was provided online and at staff meetings. ( EP33-11 )

      Participants Telemetry Task Force

      Phyllis Burton, BSN, RN, PCCN, Clinical Manager 
      Sherry McNabb, Monitor Technician II 
      Evelyn Angeles, BSN, RN, CCRN, Charge Nurse, Cardiovascular Unit 
      Jennifer Trahan, BSN, RN, Clinical Manager, PACU 
      Mike Eglinton, Cardio Technician, VCC 
      Kristen Waughtel, RN, 9th flr 
      Brenda Molencamp, BSN, RN, NE-BC, Clinical Manager, PH 4 Medical 
      Lenora Kraft, BSN, RN, Clinical Manager, PH 9 Surgical 
      Nicole Mason, RN, PH 7 Orthopedic/Neurologic 
      Diane DeMasters, BSN, RN, NE-BC, Clinical Manager, GI Lab 
      Jennifer Robertson, BSN, RN, CNML, Clinical Manager, Critical Care Unit 
      Transport Supervisor, Jerry Hospador 
      Nursing Leadership Management Council ( EP33-12 )


      • Changes to policy discussed at the meetings were submitted to the policy committee.  The two most significant changes were the telemetry flow chart for uniformity of times when monitor tech places calls for arrhythmias or pulse oximetry changes, and placing telemetry within a timeframe upon admission. Revised policy published April 2012 with all RN's required to sign that they have read it. 
      • Development of a laminated quick EKG arrhythmia with intervention chart for all units 
      • Reinstate lecture "When Tele Calls" in ASCENT Residency program. 
      • Developed a telemetry checklist orientation so all RNs will experience the telemetry room during their orientation.(EP33-13 ) 
      • Updating equipment - new server and teleoximetry units purchased.

      There have been no sentinel events since the algorithm has changes.

      • The Telemetry Technicians are more proactive and are able to clearly  define their role 
      • Suggestion for change in algorithm for notification of oxygen saturation from 90% to 85%.  Many patients easily live with 85%.  The 90% notification was creating many unnecessary calls. 
      • The Telemetry Technicians will be forming their own Unit Practice Council, called Tele Practice Council.

      Reallocating Transport Resources to Support Quality Patient Care:

      The transport team, part of nursing services, includes both employees and volunteers. These people are truly team players and during the last two years have made many changes to improve the quality of nursing and total patient care.  Historically, PSFHS nurses have been taken off the units to obtain telemetry equipment, to accompany patients to procedures when transport was not scheduled and to assist patients with check out at discharge.  Transport has increased hours and responsibilities to include all of these tasks!  This reallocation is a nurse satisfier and has allowed nurses to stay at the bedside. ( EP33-14 )

      Ensuring Coordination of Care among Other Disciplines and Support Staff:

      • The Registered Nurse position description apportions 60% of essential functions to Patient and Family Centered Care, and Leadership/Professionalism. The coordination of care based on the patients' needs and preferences along with unit delegation, effective use of time, and teamwork are included in these two areas. 

      • Case Management nurses are assigned to each unit in order to provide utilization management and discharge planning services, as needed, for patients. Partnering with patients, nurses, and other healthcare providers, the care management nurse teams coordinate care across different settings to meet patient needs. Case Management is also assigned to the emergency department to assist with complex disposition planning and coordination with external providers at discharge from the ED. The graph below depicts patient perception of coordination of care at SFMC Emergency Department as monitored through HCAHPS: 


      • According to their position dscription, Cancer Center Nurse Navigators are required to "Demonstrate the knowledge, skill and coordination to provide nursing care and guidance to the cancer patient from first contact and throughout follow-up, serving as an essential link between patients and all other care providers." ( EP33-15 )  Below is a thank you letter from a patient, and it is revealing of the amount of time and care our Cancer Center nurses provide:

      Dear Dennis (Bruens), I have tried to call you a couple of times recently, but haven't connected and I didn't leave a message. I wanted to talk to you about this marvelous nurse navigator program. Lori is wonderful. My husband and I have been fighting cancer for ten years now, so we feel like we know the ropes . . . and even for us Lori is a tremendous help. 
      I can only imagine what it would have been like to have had someone like Lori at the beginning of our journey when we were baffled and scared and confused. Heck, we're still baffled and scared and confused. 
      This is a truly great program . . . I don't know how to emphasize enough how valuable it is. So, thank you for Lori Dagostino, RN Patient Navigator. . . and I'm sure we will meet or talk at some point in our journey.             Darice Zimmermann, Colorado Springs, CO


      PSFHS associates are committed to providing the highest quality of care. Collaboration and teamwork among all associates is an expectation based upon our mission statement and position descriptions. We are proud to say that the evidence supports that these expectations are reflective of reality. Nursing practice, based on our Professional Practice Model is focused on providing quality through relationship-based care and effective and efficient care delivery models. Our quality structure and our shared decision making structures enable allocation and reallocation of resources to improve the quality of nrusing care and the total patient care. Nurses provide coordination of care through individual care planning such as our case managers and nurse navigators. Nurses also coordinate care and allocation of resources through participation in councils and committees.  The practice and resource changes related to telemetry are ongoing but intial staffing changes, policy changes and new equipment will continue to improve safety for our patients. The transport team is an excellent example of reallocation of resources that is increasing nurse time at the bedside and nurse satisfaction.

    • Exemplary Professional Practice - EP34

      Quality Care Monitoring and Improvement

      EP34 How nurse leaders ensure the dissemination of comprehensive quality data to direct care nurses

      The amount of data and information available in healthcare continues to grow. Reporting requirements, the growth of evidence based practices, information technologies, and the complexity of systems have led to both an abundance of data as well as the challenge of processing data into meaningful information. The commitment to quality and excellence is present in our direct care nurses. Creating structures and processes to improve their awareness and understanding of quality data is necessary to support the professional practice standards that evaluate and improve performance and outcomes.

      The Nursing Strategic Plan outlines our nursing goals and defines the quality metrics that we use to evaluate our practice and outcomes. The strategic nursing plan quality metrics include: HCAHPS, Hospital Acquired Infections, patient falls, Pressure Ulcers, VBP, Percent BSN, Readmissions, Nursing Turnover, and Nursing Satisfaction. To achieve our goals, nurses at all levels need to: be aware of our objectives, participate in assessments, be active in interventions, and they need to engage in the evaluation of nursing practice. This nursing process begins with nurse leaders' dissemination of comprehensive quality data to direct care nurses.

      Structures for Dissemination:

      Clinical Effectiveness Department Quality data is obtained, collated, trended, and disseminated at multiple levels. The PSFHS Clinical Effectiveness department provides expertise through all of these processes. Led by Kelli Saucerman, MSN, RN, CQPS, Director this team of nurses supports the hospital and the nursing department structures with quality data. At the Centura Health level, quality data is also abstracted from data warehouses, reports, and monitoring systems and then disseminated to associates for monitoring and evaluation.

      The nurses working in this department abstract data from records so that they can analyze trends from occurrence reporting; using this information, they are also able to monitor infections and hospital acquired conditions. Reporting to multiple internal and external bodies requires structures to obtain, gather, and organize data in order to meet requirements. These experts are both detailed and flexible as they strive to convert data into formats that are easy to access and use to evaluate performance measures. The attachment demonstrates one report provided to the Critical Care Committee. ( EP34-1 )

      National Database for Nursing Quality Indicators (NDNQI):

      PSFHS participation in the National Database for Nursing Quality Indicators (NDNQI) and other national benchmark databases promotes comparison of PSFHS outcomes with like facilities.  The NDNQI Site Coordinator disseminates quarterly data to units, interdisciplinary committees, nursing councils, and senior nursing leaders. Formats include tables and graphs with supporting analysis if requested. ( EP34-2 , EP34-3 )

      HCAHPS :

      The Healthstream vendor provides data on patient perception of services. The results of all patient satisfaction and HCAHPS quality data is disseminated at all levels. Clinical managers have access to HCAHPS data on a shared drive; a business support person obtains the data from HealthStream and creates unit level and organization level tables each month. The Patient Experience Committee and all unit practice councils/unit staff meetings review HCAHPS quality data. The attached HCAHPS report on Maternity provides a quick look at the table, targets and graphs provided by leaders to clinical nurse managers and direct care nurses. ( EP34-4 )

      Shared Decision Making Councils:

      Shared Decision Making Councils provide a structure for the dissemination of quality data.  Nursing Shared Decision Making Councils include nurses from all levels and settings. Nursing quality is integrated in all councils. 

      The Nursing Quality and Patient Safety Council serves as one primary forum for the dissemination of quality data. In addition, these nurses provide data to other direct care nurses through the Nursing Practice Council, boards on individual units, and through the Unit Practice Councils. ( EP34-5 )

      The Professional Development Council monitors, analyzes, and takes action related to the overall percent of BSN trained nurses as well as with the percent of certified nurses based on the organization's goals. ( EP34-6 )

      The EBP/Research Council promotes and supports the dissemination of quality data via professional posters. By coaching and assisting direct care nurses to create a poster of a QI project to display internally and/or at conferences, nurses grow in their capacity to interpret data and effectively use a quality improvement process. 

      Unit Practice Councils and Unit Staff Meetings include regular review of quality metrics. 

      Interdisciplinary Committees:

      Specific interdisciplinary and/or nursing committees are identified as "quality" committees and these groups receive standardized quality data for analysis and action.

      The Falls Committee disseminates quality data in meetings (which include direct care nurses) and provides unit level reports for view. ( EP34-7 )

      The Infection Control Committee is inclusive of direct care nurses and it reviews all infection data and discusses actions to improve performance. ( EP34-8 )

      The Medication Use Committee disseminates quality data related to Bar Code Medication Administration Scanning and Medication errors. 

      The Patient Experience Committee receives quality data and it disseminates HCAHPS data to direct care nurses and all staff.

      Processes for Dissemination:

      The overall process for dissemination includes several factors:

      1. Data is disseminated based on goal areas and is therefore relevant and meaningful 
      2. Data is presented in a variety of formats to improve understanding and use 
      3. Experts are available to assist in interpreting data 
      4. Many of the databases collecting data have the ability to organize and sort data in different ways to improve analysis and usefulness

      Increasing Awareness and Understanding of Quality Data:

      Katrina Roy, BSN, RN provided a presentation to the LEAP class on quality data and various presentation styles. Her storyboard was also shared with the Nursing Leadership Management Council upon their request. Nursing orientation includes a review of quality data of nursing practices and clinical outcomes. Orientation sets the expectation that direct care nurses are accountable for knowing and using quality data in evaluating their practice and outcomes.  ( EP34-9 )

      Staff Meetings/Unit Displays Staff meetings on all units include a section devoted to quality data review, analysis, and action. In addition, nursing units have bulletin boards, newsletters, and other displays to enhance dissemination of quality data to direct care nurses. Data includes patient satisfaction, nurse sensitive quality indicators, and metrics relevant to unit performance improvement projects.  ( EP34-10 )

      Print and Intranet TLC (nursing newsletter) is published monthly and disseminated to all nurses at all levels. This publication includes information to promote direct care participation in quality data review and analysis.  ( EP34-11 )

      Nursing Annual Report This annual report provides an opportunity to highlight quality improvement from the previous year. ( EP34-12 )

      Core Measures The nurses in Clinical Effectiveness designed a colorful brochure describing the Core Measures. The information is a collection of facts from The Joint Commission and CMS which reinforces what new nurses hear in orientation. The brochure provides a quick reminder or reference for staff. Although physicians write the orders, nurses are in an essential position to implement or question orders. In addition, staff receives quality indicator data on core measures in their clinical area. The brochure and the data promote knowledge, action and accountability. (EP34- 13 )

      Exemplar - Falls:

      Reducing falls (and falls with injuries) has been a priority for PSFHS. An interdisciplinary Fall Committee, chaired by a direct care nurse, meets regularly to review quality data, "dig deeper," organize and analyze data from different perspectives, and to identity best practices. This active committee evaluated the Johns Hopkins Fall Assessment, piloted it, and then trained the nursing staff.  Recently as part of Centura Health, PSFHS piloted the Heinrich II Fall Risk Model.  The Centura Nursing Practice Council voted to proceed with changing to this evidence based tool in 2013.   ( EP34-14 )

      During the last two years, units across PSFHS have tried and shared their successes and failures with different interventions.  The following list includes practices implemented:

      1. PH 11 - Hourly rounding and bedside report 
      2. PH 7 - New beds with new alarms 
      3. PH Critical Care - using mesh beds and alarms 
      4. PH 4 - piloted Heinrich II, hourly rounds, tried red sox for high fall risk patients 
      5. PH 5 - Fall Prevention Volunteer Position (innovation) 
      6. PH CVU - alarms on all at night, safety huddles, bedside shift report 
      7. SFMC 5N - daily huddles to identify high risk, ongoing education, post fall assessment  ( EP34-15 ) 
      8. PH 8 Rehab - all patients on alarms upon admission and continues at night for length of staff, toileting schedule when indicated, low boy beds, chair and be alarms 
      9. Trauma Services - education in the community on fall prevention 
      10. SFMC 5S - unit fall committee  ( EP34-16 ) 
      11. PH ED- bed alarms, yellow sox, mesh beds, low boy beds, family education 
      12. PH 5 - new gurneys with alarms

      The PSFHS Falls Committee provides reports to all units each month.  The attachment provides an example of the report that is disseminated. ( EP34-17 )

      PSFHS continues to reduce patient falls and patient falls with injuries.  Several units are demonstrating positive outcomes including PH 4 Medical, BBU, PH 8 Rehabilitation, and SFMC 5 Surgical. Our overall quality data shown below demonstrates improvement with continued need for evaluation, practice changes and benchmarking.  



      Nurse leaders ensure the dissemination of comprehensive quality data to direct-care nurses through multiple structures including interdisciplinary committees and nursing councils. Each unit displays their quality data on bulletin boards or in books and discusses at staff and unit practice council meetings. Actions are taken based on evaluation of quality data to improve outcomes.  The use of dashboards, tables and graphs as well as disseminating the rationale for the quality data promotes direct nurse participation - and leadership - to improve the quality of care.

    • Exemplary Professional Practice - EP35

      Quality Care Monitoring and Improvement

      EP 35 The structure (s) and process (es) used to identify significant findings and trends in overall patient satisfaction with nursing as compared to benchmarked sources.

      "If I hired people to take care of me, I would hire exactly the people who care for me here! They are present for me in every way - physical, emotional and spiritual. Amazing." - Inpatient Rehabilitation Patient, March 2011

      Penrose-St. Francis Health Services (PSFHS) identifies Patient Satisfaction as a priority for all associates and volunteers. Our goal is to deliver quality patient clinical care that exceeds national benchmarks in an environment that is relationship based and patient centered. It is our belief that this combination enhances patient satisfaction. Patient satisfaction is not simply represented by the numbers, but also in the impact on patient health, familial relationships, as well as on our intangible spirit.

      Expectations and Rewards for Patient Satisfaction:

      Values Based Purchasing In 2011, the Centers for Medicare and Medicaid Services (CMS) released its "Hospital Value-Based Purchasing Final Rule" (HBVP). While implementation of the entirety of this rule is ongoing, one focus that is on patient satisfaction. In order to maximize revenue, organizations need to achieve defined target goals. The results of our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey determine a percent of our HVBP reimbursement. In order to prevent any appearance of impropriety PSFHS contracts with an outside company, HEALTHSTREAM, to administer the HCAHPS survey. HEALTHSTREAM presents PSFHS' outcomes as well as provides benchmark data.

      Centura Associate Reward for Excellence (C.A.R.E.) In 2010, Centura Health established an annual C.A.R.E. program to reward associates system-wide for demonstrated excellence. Consistent with the 2020 Strategic Plan, "Strengthen the Foundation" key initiative, C.A.R.E. establishes and communicates annual goals to associates and promotes teamwork across the organization. The goals for FY2011 focused on meeting financial and patient satisfaction targets. The attached document demonstrates the achievement of these goals and success of this program for FY2011. ( EP35-1 )


      Recognition Awards at the organizational level may be planned with clear selection processes or they may occur in honor of special actions and accomplishments. In January 2012, the Bariatric/Back Unit (BBU) was honored for raising their HCAHPS scores by 44 points in one quarter. ( EP35-2 )

      While HCAHPS is a standardized process to identify significant findings and trends in patient satisfaction, other processes are also valuable. SHARE Cards are available throughout the hospital and provide a way for patients to directly recognize their healthcare providers. The DAISY Award is another venue for direct recognition within the institution. In addition, patients write letters or respond to other requests for feedback. This information is always shared with the recipients. ( EP35-3 )

      Online and social media is monitored through our Marketing Department. Patient satisfaction feedback often comes to our attention within this medium. For example, a CaringBridge comment praised the team on PH 11 Oncology. ( EP35-4 )

      Structure and Process to Identify Significant Findings and Trends:

      The Patient Experience Council initiated in 2011 began with this idea "Our ultimate goal is to improve our patient's perception about the quality of care they receive in our facilities.  In order the Patient Experience Council to do it's job, it has to become a "Community" that is working together to create a desired future that is distinct form the past.  What we will work in is not decided yet, it will emerge from the collective wisdom, gifts and strengths and capacity of the Patient Experience Council Community" ( EP35-5 ) 

      The Patient Experience Committee reviews findings and trends for HCAHPS results and has led the AIDET Training, implemented a Service Recovery Toolkit and disseminated customer service best practices.  ( EP35-6 )

      Nursing Services:

      The Chief Nursing Officer is accountable through the Performance Feedback and Development (PFD) process for patient satisfaction with nurse sensitive categories. As part of the PFD process this goal from the CNO is delegated to the Directors, Clinical Managers, and to the direct care nursing staff. 

      Clinical Managers regularly review the HCAHPS results within staff meetings and at unit practice councils. Results are posted on unit bulletin boards to promote awareness and provide visual cues of trends. Across inpatient nursing, units have implemented proven strategies to improve patient satisfaction including: bedside shift reports, AIDET, engaging patients/families in the care process, discharge planning, patient education, and hourly rounding.  In addition each area identifies, implements, and evaluates strategies in order to improve results in targeted areas relevant to their practice.

      Penrose Hospital 11 Oncology:

      The team on PH 11 examines and discusses HCAHPS results and links actions to patient satisfaction as they review their goals and accomplishments. PH 11 staff meetings review findings and trends during each staff meeting and post results on a unit bulletin board.  ( EP35-7 ) The 11th Floor Bulletin (attached) demonstrates a review of HCAHPS results and discussion of nursing actions that impact patient satisfaction.  ( EP35-8 )

      Penrose Hospital PreOperative/Same Day Surgery:

      Our hospital system uses HCAHPS to assess and evaluate patient satisfaction with services. Pre Operative/Same Day Surgery generally receives high marks for patient satisfaction. However, the survey process is outsourced so we do not have the opportunity to directly engage with patients about their surgery, follow up, or to provide them with an opportunity to ask questions.

      Our Performance Improvement process, Plan-Do-Check-Act (PDCA), is a standardized procedure for initiating quality improvement projects. In March 2011, the Preoperative nursing team at Penrose identified one of their roles in improving patient satisfaction. They targeted improving the patient experience by getting patients to surgery on time, rounding, and making follow up phone calls. By reallocating CNA resources to support hourly rounding, revising the admitting nurse responsibility to include communication with patients about surgery delays, and by initiating follow up call backs, the team reported and sustained improved "Top Box" scores on their overall rating (HCHAPS). 



      Godden, B. (2010). "Postoperative phone calls: Is there another way". Journal of PeriAnesthesia Nursing, 25 (6), 405-408.

      PH 4 Medical- Unit Practice Council:

      The PH 4 Medical UPC identified an opportunity to improve patients rating of pain satisfaction.  In May 2012 the group reviewed specific Healthstream reports regarding pain "Clarify Knowledge of the process" and "Understand Variation".  Healthstream also provides a "Select Improvement Strategy" report which guided their decision making for interventions to take to improve the patients perceptions of pain management.  The attached minutes outline the multiple strategies the team implemented in June 2012. ( EP35-9 )

      The UPC monitored the patient satisfaction findings and trends related to pain management and were pleased to note the improvements which are continuing. 

      SFMC Labor and Delivery The LD team reviews HCAHPS in staff meetings. ( EP35-10 )

      Available Resources:

      PSFHS  utilizes Healthstream (national vendor) to complete patient satisfaction surveys and provide reports.  Healthstream allows us to run a variety of reports with different factors which allows analysis of data. In addition PSFHS may choose to review findings via means or medians and can identify the impact of specific questions on overall patient satisfaction. This process allows for in depth analysis of trends which is particularly useful when units are struggling with ratings.  PSFHS provides access to HEALTHSTREAM to all senior leaders, directors, and managers.  

      PSFHS finance regularly compiles reports that include dashboards and spreadsheets to facilitate review, analysis, and action planning. These conclusions are based on significant findings and/or trends in data. The reports are accessible to interested associates through our shared drive. Additional reports are available through the Healthstream Online Report builder.  ( EP35-11 )


      PSFHS uses our shared decision making structure including unit practice councils and unit staff meetings as primary structures to identify significant findings and trends in overall patient satisfaction as compared to benchmark sources.  The Healthstream vendor ensures standardization of the survey process and provides national benchmarks. In addition the report building through Healthstream allows nurses to do in depth reviews and data analysis.  Patient satisfaction is an organizational goal reflected through strategic planning, included in our Performance Appraisal Process and rewarded in multiple ways. 

    • Exemplary Professional Practice - EP35EO

      EP35EO Request- Please demonstrate that patient satisfaction data aggregated at the organization or unit level outperform the mean, median or other benchmark statistic of the national database used for the measure of Careful listening by nurses.

      The graph below demonstrates the organizational level mean results of "Careful Listening by Nurses" outperforms the national database  benchmark mean five of eight quarters or 63% of the time.