Carol Dwyer Chris Slaughter. 50th percentile NDNQI. Jan-16 Plans in place. 80th percentile May-15 (Hospital target)

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1 PEOPLE People A: Work Place Satisfaction and Quality of Life 1. Conduct annual RN satisfaction survey with focus on nursing practice scale. 2. Develop effective strategies and skills for powerful Nurse Leader/Physician communication. 3. Implement unit-based plans to address NDNQI results. 4. Nursing Work Life Council to focus on retention, reward and recognition using Advisory Board materials. Chris Slaughter Physician Council D Goulson/C Dwyer Directors and Managers Melanie Sanguigni Debbie Kitchen Oct-15 50th percentile NDNQI Oct-15 Document Published Jan-16 Plans in place Sep-15 Education provided Meet or exceed the 5. Conduct Staff Satisfaction Survey. Human Resources 80th percentile May-15 (Hospital target) Structural Empowerment 7.4 Workforce-Focused 1. Continue RN to BSN strategy. Sep-15 80% by Revise nursling link on Turnover Rate <10% website by using social media. Jason Yount Jan-15 Vacancy Rate < 7% People B: Recruitment and Retention 3. Evaluate hiring practices (Predeployment Pool) to optimize our image of quick turn around. James Brown Jan-16 Plan developed 4. Evaluate effectiveness of RN Residency program as recruitment and retention tool. Rose Patrick Oct-15 Results published 5. Implement retention best practices at unit level for units above 10% turnover rate. Two practices implemented Reduce voluntary turnover to 8% (Hospital target) James Brown Oct Develop a SAGE or Back to Work Program for implementation. Rose Patrick Oct-15 Five RNs enrolled 7. Develop plan to attract BSN RNs. Rose Patrick Sep-15 Plan developed Structural Empowerment 7.4 Workforce - Focused

2 PEOPLE People C: Reward and Recognition Growing number of 1. Expand formal reward and recognition opportunities. candidates in each Dec-15 category Examples DAISY Award given DAISY Award Melanie Sanguigni Quarterly every month in 2015 Aspiring Nurse Leader KONL Award Heart of Saint Joseph Award Tim Holbrook Quarterly Nurse of the Year Awards Debbie Kitchen May Showcase quarterly associate accomplishments in nursing newsletter. Karen Cooper Quarterly 4 issues published 3. Pursue Beacon Award in ICU- South/CTVU/NICU/CCU Carole Adam T Powers/G Ross Dec-15 Draft ready 4. Plan and celebrate Nurses Week. Nursing Work Life Council Positive feedback from staff May-15 (Survey Monkey) 5. Promote Professional Advancement System. Faith Reynolds Sep-15 Campaign launched Structural Empowerment 7.4 Workforce - Focused 1. Continue to develop and evaluate Professional Practice Model to further empower staff in decision-making and autonomy in practice and council and unitbased levels. Jun-15

3 PEOPLE People D: Professional Development 2. Develop various means for professional growth e.g. journal clubs, legislative activities, authorship and speakers bureau. Faith Reynolds Dec-15 Log of activities 3. Equip, support and promote bedside nurses participation in research grant writing and poster presentation. Trudy Gochette Dec-15 Report Exemplary Professional Practice 7.4 Workforce - Focused 4. Develop plan in collaboration with EKU to integrate Nursing Research activities into staff roles/develop joint appointment. Trudy Gochette Dec-15 Plan developed 5. Develop roles for MSN and doctoral level nurses, including CNS expansion. Two positions developed and Dec-15 enacted 6. Establish formal nursing peer review process to evaluate practice. Chris Slaughter Director Mar-16 Process in place People E: Develop Extraordinary Management Team 1. Develop competencies for Nurse Managers using AONE standards for Nurse Executives and annually assess compliance. Apr-15 AONE standards 2. Conduct activities to support leadership growth throughout the year based on Manager Development Plan. Transformational Nurse Manager Sep-15 Program developed 3. Develop formal mentoring program for future nurse leaders: "Aspiring Nurse Leaders." Two sessions per Jan-16 year Transformational Leadership 7.4 Workforce - Focused

4 PEOPLE 4. Create sustainable funding for degree attainment at Bachelor's (Clinical Educators, Nurse Managers), Master's (Managers, Directors, Clinical Educators/Specialists) and Doctorate levels. (See D.5.) May-15 Plan established 5. Provide a Nurse Manager certification review course. Director Jan-16 Course conducted People F: Impact on Health of Our Community 1. Lobby legislators and others to influence state funding to promote local health initiatives. Jan-16 Report published 2. Participate in Fayette County Flu clinics. Shawntal Garr Oct-15 Report 3. Promote Nursing profession in schools and wide array of community events. Rose Patrick Jan-15 Report 4. Create scholarships for high school students. Di Boyer Mar-15 Report 5. Participate in minority professional associations. Peggie Brooks Oct-15 Report 6. Develop and implement Diversity Recruitment Plan with HR. James Brown Jan-15 Plan developed Structural Empowerment 7.4 Workforce - Focused People G: Nurse/Physician Partnerships 1. Appoint Physician Unit Champions. Nurse Managers Oct-15 Monthly report 2. Formalize Physician/RN rounding on patients. Med-Surg Director Oct-15 Report 3. Brainstorm Nurse-Physician Collaboration ideas at Nursing Work Life Council. Melanie Sanguigni Oct-15 Med Exec Report Transformational Leadership 7.4 Workforce - Focused

5 QUALITY Quality A. Interdisciplinary Approach to Care 1. Participate in Length of Stay Team initiatives with Intensivists. 2. Standardize MEWS in Med- Surg Units. Jeana Cavenee Faith Reynolds Debbie Kitchen Jun-15 Dec Expand Critical Care Rounds. Chris Slaughter Oct Partner with Medical Staff on Consents and Order Sets. Aug-15 Reduction in Code Blue rates outside the ICUs Exemplary Professional Practice 7.1 Healthcare Quality B: Practice Excellence 1. Promote Professional Advancement System Rose Patrick Increase National 2. Develop plan to increase National Certifications. Faith Reynolds Certifications to 20% Jan-15 by 12/16 3.Conduct quarterly mock codes in all Service areas. Advance Practice Forum Chris Slaughter Log reflects mock Jan-16 codes conducted 4. Evaluate effectiveness of RN Residency program as recruitment and retention tool. Rose Patrick Oct-15 Results published Exemplary Professional Practice 7.1 Healthcare Quality C: Care Practices/ Models of Care 1. Define in writing our Patient Centered Care Model and develop educational plan to disseminate and assimilate into practice. Dec-15 Document ready New Knowledge, Innovations and Improvements 7.1 Healthcare

6 QUALITY Quality D: Patient Safety 1. Conduct AHRQ Safety Culture Survey. 2. Develop action plan based on results of AHRQ survey. Apr-15 70% participation rate Aug-15 Plans enacted 3. Conduct ISMP Survey Report validation of Medication Safety assessment. Marla Whitaker Dec-16 practices 4. Develop action plan based on results of ISMP assessment. Marla Whitaker Jan-16 Plans enacted Exemplary Professional Practice 7.1 Healthcare 5. Implement evidence based practices related to health literacy for staff and patients. Rose Patrick May-16 Materials ready 1. Implement evidence-based practices to reduce catheter associated urinary tract infections (CAUTI). Carole Adam Meet or exceed Jul-15 national mean 2. Implement evidence-based practices to reduce central line associated blood stream infections (CLABSI). Chris Slaughter Meet or exceed Aug-15 national mean Quality E: Evidence-Based Practices for Nursing Sensitive Indicators and Empirical 3. Implement evidence-based practices to reduce patient falls. Debbie Kitchen Meet or exceed Jul-15 national mean 4. Implement evidence-based practices to reduce Pressure Ulcers. Jeana Cavenee Meet or exceed Aug-15 national mean 5. Implement evidence-based practices to reduce restraint usage. Tricia Powers Sep-15 Achieve top decile New Knowledge, Innovations and Improvements 7.1 Healthcare 6. Develop and disseminate quarterly summary scorecard for Nursing Sensitive Indicators. Chris Slaughter Ongoing Timely distribution 7. Implement early mobility concepts in Critical Care. Chris Slaughter Aug-15 Reduction in Length of Stay in Critical Care. 8. Implement evidence-based practices to improve Core Measures (Immunizations, VTE, Stroke, SCIP). Carole Adam Chris Robb Lesly Arrasmith Aug-15 Meet or exceed 95th percentile

7 QUALITY Quality F: Leading Practices at National Level 1. Participate in national initiatives e.g. IHI, HEN, and CRMP. Chris Slaughter Dec Conduct benchmark activities with NDNQI and Magnet Hospitals. Ongoing 3. Create robust mechanism to prepare for the Triennial Joint Commission Survey and Accreditation Readiness. Dana Stephens Meet or exceed national mean Implementation of three (3) best practices Ongoing Successful survey New Knowledge, Innovations and Improvements Empirical 7.1 Healthcare Quality G: Electronic Medical Record 1. Continue development of standard order sets/nurse driven protocols. Maria Fera Perioperative Orders Dec-16 Completed 2. Redesign Nursing Informatics Committee. Janie Fergus Jun-16 High participation 3. Participate fully in EMR Process optimization plan. ALL Jun-16 improvements logged New Knowledge, Innovations and Improvements Empirical 7.1 Healthcare

8 SERVICE 1. Serve in leadership capacity on Service Excellence Committee and coordinate activities within Nursing. HCAHPS 50th Ongoing percentile 2. Coach Leadership Team in Service A: Leadership Practices best practices, skills and techniques to achieve Patient Experience Goals. KentuckyOne Coaches HCAHPS 50th Aug-15 percentile Transformational Leadership 3. Educate/Validate Management Team on Coaching for Performance. KentuckyOne Coaches HCAHPS 50th Aug-15 percentile NDNQI Nurse 4. Standardize Huddle Board in all departments. Kelly Roggenkamp Satisfaction Dec-15 50th percentile 3. Customer Focus 7.2 Customer-Focused Service B: Bedside Practices 1. Implement RN Discharge Phone Calls to Patients. Carole Adam Lesly Arrasmith 100% attempt rate; Sep-15 80% connect rate 2. Incorporate Communication Bundle into new hire orientation with validation of competency. Rose Patrick Orientation updated and added to RN Core Competency Sep-15 Checklist 3. Standardize White Boards for communication with patient/family. Lesly Arrasmith Rounds validate 90% Jul-15 usage Structural Empowerment 4. Implement bedside shift report in all units. Carole Adam Lesly Arrasmith Sep-15 HCAHPS Nurse Communication Domain demonstrates improvement quarter to quarter 5. Develop document describing Rounds validate service expectations. Jul-15 practices in place 3. Customer Focus 7.2 Customer-Focused

9 SERVICE 1. Engage physician partners in achieving HCAHPS results. Pat Alagia, M.D. Dec-15 Physician Communication HCAHPS results improve quarter to quarter Service C: Collaborative Relationships 2. Serve in leadership capacity on Service Excellence Committee and coordinate activities within Nursing. HCAHPS 50th Ongoing percentile 3. Develop Patient/Family Advisory Councils. 4. Engage ancillary departments in achieving HCAHPS results via bi-monthly combined Patient. Lynnette RauvolaBouta Kent Savage Three active Councils Inpatient, ED, Jan-16 Outpatient Call bells HCAHPS results improve quarter to Jul-15 quarter Structural Empowerment 3. Customer Focus 7.2 Customer-Focused 5. Pursue empathy training and Literature review Patient-Centered Care Model. Jul-15 completed Service D: Responsiveness to Customers 1. Optimize Domain Champion Teams for all HCAHPS Domains and ED Patient Experience Team. Combined Patient Experience Sep-15 Committee Reporting 2. Manage Performance Improvement Plans on all units to ensure achievement and maintenance of HCAHPS results. Ellen Stotts Combined Patient Experience Oct-15 Committee Reporting Structural Empowerment 3. Customer Focus 7.2 Customer-Focused

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11 Resources Resources A: Optimize Length of Stay to Maximize Revenue GOAL Department / STRATEGIC of Nursing Strategic PRIORITY Plan 1. Utilize Queuing Theory in Throughput optimizing patient flow. Jeana Cavenee Jan-16 Dashboard 2. Develop effective Standardized Nursing Care Plans. Maria Fera Jan-16 80% Utilization Rate New model Exemplary Professional 2. Strategic Planning 3. Redesign Care Coordination. David Joos Jan-16 operationalized Practice 7.3 Financial & Market 4. Create team approach to length of stay via the Hospitalists' engagement. Jeana Cavenee Jul-15 Quarterly reports 5. Design new models of care delivery. Directors Jan-16 Units Operational Resources B: Optimize FTEs per Adjusted Occupied Beds 1. Implement operational tactics for census-smoothing. Manager, Staffing & Scheduling Oct-15 Bi-weekly productivity at 98% or better 2. Managers to complete Bi-weekly productivity Productivity Training. Jul-15 at 98% or better Resources C: Achieve Budget Productivity Target by Department 3. Implement Sitter Algorithm to reduce patient safety hours (inhouse safety sitter program). 4. Introduce web scheduling and flexible staffing ( hours). Manager, Staffing & Scheduling Manager, Staffing & Scheduling Bi-weekly productivity Nov-15 at 98% or better Reduce overtime and call in costs over FY Dec Structural Empowerment 3. Customer Focus 7.2 Customer-Focused 5. Validate Manager use of Daily Bi-weekly productivity Hours Log. Directors Oct-15 at 98% or better 6. Cyclic Scheduling introduced. Manager, Staffing & Scheduling Dec-15 Bi-weekly productivity at 98% or better

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