Location: Conference Room 1-2. Co-chair: Co-chair since:

Transcription

1 SMH Nursing Mission: Deliver leading edge patient care, research and education by utilizing SMH Nursing s Professional Practice Model as a guide. SMH Nursing Vision: Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. EPP Meeting Minutes Meeting: Exemplary Professional Practice Date & Time: Monday April 3, Page 1 of 10 Purpose: Ensure the demonstration of exemplary nursing practice with patients, families, communities, and the interdisciplinary team at SMUCLA by: upholding the PPM; creating structures that ensure access to information, resources, and support; cultivate a culture of safety; equip nursing staff with a comprehensive understanding of the role of nursing. Location: Conference Room 1-2 Chair: Chair since: Danielle Greenacre, RN, BSN, CNII, CCRN Since April 2016 Co-chair: Co-chair since: Heather Dodge, RN, BSN, CNII Since April 2016 Electronic sign in be sure to scan in your badge or ask one of the admins for assistance. You need to have a sub if you cannot attend. Topic Person reporting Action Summary PPM EPP Element Next step Owned by Items status (mark one with x) Review Minutes and General Announcements (20 mins) 12:00-12:20 Heather Dodge, Yesenia Valle, Mary Lawanson- Nichols Review Minutes and General Announcements Review EPP council minutes from last meeting including progress on outstanding business. Introduction of new members. Call for co-chair nominees hdodge@mednet.ucla.edu Call for volunteers for the Magnet Anniversary Celebration June 15, 2017 Sepsis Updates new documentation tool will be huddled on each unit Nurses Week is May 6-12 please nominate your fellow colleagues by April 7 th. 1 st Approved: Betty Lee 2 nd Approved: Kristin Sy 1,2,3,4,5,6 1,2,3,4,5,6 Goal: Members will check if their names are spelled correctly, input credentials, and add Month/Year of joining EPP. Goal: Members to return folders in a box Goal: Make sure everyone checks in for attendance. Goal: Co-chair will be voted on in May for a one-year term starting in July Goal: Respond to Yesenia with your interest in volunteering in June Standing Item In-Progress Complete Dashboard Data Review (20 mins) 12:25-12:45 Ksenia Kurnakova Magnet Outcomes Hospital Dashboard updates Review UCLA SM Overall Audit Dashboard Demonstration of Unit-specific Quick Trend Report from Press Ganey Website Nurse-sensitive clinical indicators: 1. Falls and Falls with Injury 2. HAPU stages 2 and above 3,4,5,6 Goal: Identify the progress of our hospital Standing Item In-Progress

2 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 2 of 10 Topic Person reporting Action Summary PPM EPP Element Next step Owned by Items status (mark one with x) Complete

3 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 3 of 10 Magnet Outcomes Hospital Dashboard updates Review UCLA SM Overall Audit Dashboard Demonstration of Unit-specific Quick Trend Report from Press Ganey Website Nurse-sensitive clinical indicators: 1. Falls and Falls with Injury 2. HAPU stages 2 and above 3. Central Line Associated Bloodstream Infections (CLABSI) 4. Catheter Association Urinary tract infections (CAUTI) 5. Patient satisfaction data MOVERS (see for more info) MOVERS: Essentially MOVERS outlines pillars of quality and outcomes and helps identify gaps and how our system identifies priorities. We look at our outcomes, gaps where we are not doing well and that becomes a priority. Experience, falls, readmission rates, etc. What we do in MOVERS realigns what we do systemwide and in our health system. We are approaching the end of fiscal year and new goals will be rolled out. For us our max points is 30 and we are at 21 we are doing well however our red areas are RN/MD rounding and Discharge and opportunities in patient safety CLABSI, Falls into opportunity in patient safety and our MOVERS Scorecard. 1,2,3,4,5,6 Mortality (part of movers framework): Sepsis: We are doing better we are at 61.5% in February our goal is 41.3%. The national average is 33.3%. Our baseline from 2016 was 27%. Experience (part of movers framework): Pain: What could interfere with our pain scores?? Higher census, seasonal cycles, new residents, nurses, chronic pain, delivery inconsistency. From Jan March top 3 performing units are ED 4NW, 3NW. National average for pain is 71% - SM UCLA 72.4%. Safety (part of movers framework): CAUTI: We had spike in December however lately we are doing well. CLABSI our trend

4 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 4 of 10 is increasing - we had 3 cases in February and 7 cases in January. RNs: Please change HD dressings to keep lines clean. Best practices: Our goal is to increase CHG compliance February we are at 76.1% Falls: We had a spike in January of 20 falls and as of February we had 9 falls we want to be in single digits. Half of falls occurred from the bed meaning the patient trying to get out of bed. Injuries we had 1 minor injury in February and had 1 visitor injured.

5 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 5 of 10 Topic Person reporting Action Summary PPM EPP Element Next step Owned by Items status (mark one with x) Introduction to Tableau (15 mins) 12:45-13:00 Summer Gupta Summer will present on the new Tableau (pronounced Tablo Dashboard and its purpose at SMUCA Works with sepsis team if your unit receives a fallout letter. Your CNS will approach you with the case if you were the RN. 60% of sepsis cases come through the ED We have created a new dashboard called Tableau. We will only give some nurses access. For now total # of cases by month of sepsis, severe sepsis and septic shock combined. In Jan we had 205 cases at SM Hospital. Out of 205 patients 184 had sepsis, severe sepsis, septic shock on admission. Look at Jan out of 205 cases - we had 45 patients that had septic shock and 38% of them died ( mortality rate). The tableau will break the numbers down into sepsis severe sepsis and septic shock and the Tableau can break the cases into unit and patient details. However keep in mind the unit may not represent where the patient became septic. For January looking at our 205 cases the LOS index was 1.2 (we want to be < 1.0) These cases are staying longer than we want them to. In January we had a.93 mortality index. We are below 1.0 which is good however we are too close. Sepsis tool compliance rate for ED is 95% of the time and RN needs to assess within 1 hr. Sepsis compliance for SM UCLA hospital is 42% of the time in January. 20 cases a month are reviewed For Questions: us: sepsis@mednet.ucla.edu 1,2,3,4,5,6 Goal: Understand how we are assessed on our sepsis interventions from a quality standpoint Standing Item In-Progress 3,4,5,6 Complete Subcommittee Rounds (90 mins) 13:00-14:30 Subgroup Leads Perform Floor Audits. 1. Pain - Elizabeth Mejia from 5NW will be new pain lead. Goal: Subcommittees (Pain, IP, and Falls) will perform floor audits to identify areas of improvement. Standing Item In-Progress

6 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 6 of 10 Topic Person reporting Action Summary PPM EPP Element Next step Owned by Items status (mark one with x) Group continues to utilize new pain audit tool Pet therapy is not easy assessable: Group to determine barriers. Pain Committee to be restructured - Yesenia to f/u with David about restructuring group. National average for pain is 71% - SM UCLA 72.4%. 2. Infection Prevention - Huddle topic CLABSI/CHG ask your leadership about huddle message. CHG for everyone blue only on contradicted or patient s allergic to aloe vera or CHG packets. Educate co-workers on CLABSI, CHG, and that RNs can change HD lines (dressings). Changes implemented in CC for dropdown sepsis assessment. Questions: Contact Mary Lawanson-Nichols. 3. Fall Prevention - New IPO improving patient outcomes class w/ simulations rolling out in May. Bathroom fall sign will be in all bathrooms hospital wide. Fall team rounded and did audits on 4MN & 5NW and noticed that most fall risk patients did not have armbands on. Remember to keep your patients safe - armband, bed alarm, declutter room! Data from rounds: Armband on: 40% of time, Fall sign on door: 100 % of time on 4MN and 0% of time on 5NW. Safety precautions in place: 75%, Bed connection available: 100%, Wall and Bed connections attached; 80%, Alarm Activated: 67%, Patient understands fall risk plan: 85% of the time. 1,2,3,4,5,6 Complete 4. Peer Review - Post op patient had Que pump -MD placed order for on Que pump to be dc d RN dc d pump when order was prompted. Issue: MD dissatisfied with how pump was dc d. There was also minimal communication between RN and MD about plan of care for patient. Group will get policy in place and help promote clearer communication between MD & RN on plan for patient. Subcommittee Report-back (30 min) Subgroup Leads Expectations for each meeting s documentation: 1,3,4,6 Standing Item

7 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 7 of 10 Topic Person reporting Action Summary PPM EPP Element Next step Owned by Items status (mark one with x) 14:30-15:00 a) Each subcommittee is to report-back progress on their interventions using hospital-wide dashboards and FOCUS- PDCA s. b) Each subgroup leader to fill out bullet point worksheet and give to co-chair upon returning from rounds. Goal: Subcommittees will share what they have learned from audits and their steps going forward. In-Progress 1,2,3,4,5,6 Complete Next Meeting: Monday May 1, 2017 from 12-3pm in Conference Room 1 & 2. 3,4,5,6 1,3,4,6 Parking Lot: Focus PDCAs 1. PPM 2. Care Delivery System 3. Interdisciplinary Care 4. Accountability, Competence, & Autonomy 5. Ethics, Privacy, Security, & Confidentiality 6. Culture of Safety & Quality of Care

8 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 8 of 10 Development, implementation and evaluation of the PPM Create partnerships with patients and families; incorporate standards/guidelines into the care delivery; Evaluate organizations standards; use internal/external experts to improve clinical setting Provide leadership opportunities in collaborative interdisciplinary activities Provide resources to support decision making in autonomous nursing practice; perform nursing peer case reviews, support and promote nurse autonomy Encourage use of available resources to address ethical issues Evaluate and improve workplace safety; involve nurses in facilitywide proactive risk assessment and error management; review, action-plan, and evaluate patient safety data and patient safety goals; monitor clinical indicators and patient experience data. 1. Patient, Family, Community 2. Relationship-Based Care Model 3. Leader 4. Scientist 5. Transferor of Knowledge 6. Practitioner Patient and family centered care. A. Caring and healing practice environment B. Responsibility for relationship and decision making C. Work allocation & patient assignment D. Communication with health care team E. Leadership/Management F. System improvements. A self-directed decision maker, focused on the improvement of quality and safety outcomes for patients or patient populations. Conducts research and quality improvement initiatives through EBP FO- CUS-PDCA. Guide colleagues, patients and family members through the learning process and document the outcomes of educational program. Provide quality care to patients throughout the lifespan.

9 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 9 of 10 EPP Council Members Infection Prevention Emergency Department: Kayla Reynolds, RN, BSN, CNII, CEN (Member since June 2014, Infection Prevention Lead) 4CW: Mary Lawanson-Nichols, MSN, CCRN, CNS (Member since 2013, Infection Prevention Mentor) 4CW: Danielle Greenacre, RN, BSN, CNII, CCRN (Member since November 2013, EPP Chair) 5NW: Rosalie A. Silva, RN-BC, BA, CNIII (Member since August 2013) PACU/PTU: Michelle Dixon, RN, BSN, ANI, CPAN (Member since June 2015) IOF: Robert Yeranosyan, RN, BSN (Member since July 2016) Float Pool: Eusonne Joy Deloslado, RN, BSN (Member since July 2016) Peds 6NW: Tali Leitner, MSN, CPN, BSN, RN (Member since December 2015) 4NW: Margaret Cabreros, RN, BSN, PHN CN II 4SW: Rachel Villasenor, RN, OCN, CNIII IR: Anne Cagney, credentials? 3NW: Meghann Lilley,RN, MSN, CNL, PHN 6NW:Heather Garcia RN MSN (member since March 2017 Pain 3NW: Yuki Arai, RN II BSN (member since June 2016) Acute/Chronic: Irma Tan (credentials, Pain Mentor) 4SW: Kristin Sy, RN, BSN (Member since July 2015) 4NW: Anna Nichik, RN, BSN (Member since July 2014-Pain Lead) 4MN: Heather Dodge, RN, BSN (Member since December EPP Co-Chair) 6NW: Diane Kui, BSN, MSN, CPN, CNII (Member since September 2013) Administration: Ksenia Kurnakova, MPH, Senior Analyst (Member since November 2013) PACU/PTU: Clara Chavez, RN, CNII (Member since August 2012) IR/Cardiac Cath Lab: Sandra Losasso, RN III BSN (member since June 2016) 4SW: Aimee Xillahermosa, RN ANI, (member since Feb 2017) 4NW: Kristin Sy, RN, BSN, CN II (member since Feb 2017) IOF: Jennifer Miraflor RN CNIII (member since Feb 2017) 5MN; Francis Glenn Santoyo RN BSN CNII (member since Feb 2017) 4MN; Kristian Del Rosario RN-BC BSN AN II (member since Feb 2017) L&D; Alison Lingard RN (member since March 2017) 5NW: Elizabeth Mejia RN MSN (member since March 2017) Peer Review 5MN: Michelle Thong, RN, BSN, CNII,PCCN (Member since June 2014, Peer Review Lead) NICU: Stephanie Hines, RN, MSN, CCRN (Member since July 2016) Peer Review Mentor) 2MN: Diane Shao, RN, ADN, ANI, (Member since 2012) 2MN: Susan Nolan, RN, BSN, CNIII (Member since 2012) 4CWICU: Susan Lim, RN, BSN, CNIII, CCRN (Member since October 2016) 2SWW: Denise Scalercio-Ribeiro, RN, AND, BA, MA, RNC-NIC, CNIII (Member since 2013) 5NW: Anila Ladak, RN, MSN, CNS (Member since start of EPP)

10 SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship based Care Model. Page 10 of 10 Operating Room: Kim Young S., RN, BSN, CNII, MSN, CNOR (Member since July 2014) Resource/Float Pool: Nicole Pfiester RN II, BSN Quality: Sharron Hickey, RN, BSN, PHN, Quality Management Specialist (Member since September 2014) ED: Pete Zimak, credentials? (Member since July 2016) Nursing Admin: Yesenia Valle RN, BSN, OCN, Interim Magnet Coordinator (Member since March 2017) Falls 4MN: Betty Lee, RN, MN, CNS, CMSRN (Member since start of EPP, Falls Lead) 4MN: James Fernando, RN, BSN (Member since 2016) Physical Medicine: Trena Carpenter, PT (Member since start of EPP) 4NW: Margaret Cabreros, RN II, BSN, PHN (Member since 2016) 5NW: Christina Richner RN, BSN, RN-BC, CN II (Member since May 2015) 5MN: Jamie Hughes credentials? (Member since September 2015) Quality: Anet Sinanyan, BS, MHA, CPHQ, Sr Patient Safety Specialist (Member since 2012) Quality: Nathaniel Lacasse credentials?, Quality Management Specialist (Member since May 2015) IOF: Philip Tu, RN, MSN, MBA, ANII (Member since 2015) Administration: David Bailey, MSN, RN, MBA, CCRN-CMC, NEA, BC, Interim Director of Nursing (Member since November 2013, Falls Mentor) 3NW: Sinval DePaula RN (Member since July 2016) IOF: Ayumi Sawa RN, MSN (member since March 2017)