Kelsey Archibald, RN, 6A Mary Barkhymer, MSN, MHA, RN, CNOR, Administration Renee Carolan, Program Mgr, Service Excellence Ann Ciak, Ph.D., School of Nursing Jackie Drahos, RN, ICU/IMC Joyce Doody, RN, Nurse Recruiter Traci Fick, RN, Emergency Department Veronica Findley, RN, Care Management Kathy Fowler, RN, Quality Project Manager Sharon Fritzley, RN, Quality Project Manager Diana Fox, RN, 3B Lisa Graczyk, RN, Harmar Outpatient Jessica Graff, RN, 5A Carlyn Goodrich, RN, 5B Ruth Harris, RN, 4B Amy Haugh, Library Tanya Hoebel, RN, 3B Marjorie Jacobs, RN, Care Management Kathy Kline, RN, Lawrenceville Family Health Center Gina Koch, RN, 6B Lisa Lehman, RN, 6A/Magnet Cheryl Lenhart, RN, Nursing Administration Kim Lopes, RN, Emergency Department Darcy Green Lutz, RN, Emergency Department Dawn Pajerski, RN, 3B Megan Rupp, RN, 5B Rose Scalo, RN, HBC Kristen Schmidt, RN, Informatics Janine Sharer, RN, Informatics Karen Soltez, RN, Perianesthesia Colleen Sunday, RN, Nursing Education Barbara VanEtten, RN, 4A/4B Dawn Vocke, RN, Operating Room Karen Weimer, CNRP, Nurse Practitioners Aimee Wilson, RN, Care Management Jay Wright, RN, Perianesthesia Anna Kalafut, RN, Nursing Education
Nurse Division Leadership Council Minutes Approval of Minutes November 20, Minutes approved as typed. 2012 Supply Chain - Ryan Beaver Ryan Beaver came to speak about supplies from Central Supply as well as epro, etc. Reviewed how to service our patients by servicing better and more streamlined. Jason Smith QA Analyst, is available to answer any questions about where the orders are, questions regarding epro, etc. Will add items to par as you request. Do not want the units to run out of items. Arrangements for items that need to be donated to Global Links need to go through Ryan Beaver s office. His staff will be able to assist with these donations. Spoke to the group about cost reduction and how to use items in the most cost effective way. If needing to contact Ryan Beaver please use his cell phone. Will have the Business Assistants meet with Ryan Beaver since they do the ordering on the units. Asked if the link to order specialty beds could be put on the desk top Ryan Beaver is going to check on this.
computers to help streamline the ordering. Professional Practice Council Karen Soltez Clinical Practice Council Jackie Morgan/Kelsey Archibald Nursing Reports Goal is for every chair and co-chair come to the meeting, if they cannot attend then a staff nurse must come to the meeting. The mentors are not to give the information Finalized the computer etiquette. The final design was turned over to Renee Carolan for final draft and distribution. Subgroups were developed for each goal in the Strategic Plan and were asked to develop action plans. December meeting will be Wednesday, December 19 th. Collected 120 items for Kerr Elementary Delivered 512 cards for hero s Will begin preparation for the NDNQI survey and unit based SOAR. Approved the Council s 2013 mission, vision, and goals Informatics demonstrated how to access patient education Developed subcommittee to review the progress of standardizing the process for unit based policies. If a unit does not have unit based policies their representative should
let the Council know that. Informatics to adjust bar scan compliance to reflect new goal of 95% compliance Nursing Operations Council Mary Jo Klebine/Diana Fox Nursing Education, Research & Evidence Based Practice Council Ruth Harris/Jessica Lindenberger New co-chair with Chrissy Huey, 6B Lisa Lehman gave an update on Magnet and the NDNQI survey Were able to resolve the issues with getting patients to CT timely thanks to Radiology attending the meeting. Working on cytology specimens being missed or cancelled. Diana Fox will work with Dr. Gup for clarity. Continue to work on the ambulation policy Kim Klamut will work with PCT to educate them on proper weight entry into the computer. Cathy Pieper from Pharmacy is also available to come to staff meetings to talk to nurses and PCT to get this straightened out. Retiming of medications has resulted in a lot of Risk Master entries. More to come on this. Nurse Talk has become a big discussion. Usage and functionality has been brought up. Over the past 30 days out of 685 nurses there were only 85 nurses who utilized the nurse talk. The majority Suggestion was made to have the business assistant print the Nurse Talk every Friday.
of the people wanted to know why they cannot access it from home. Will explore putting it on the desktop. Actively planning for the Research Forum scheduled for Mat 24, 2013 Reviewed Council s goals and strategic planning. New Nursing Research Fellowship class begins January 24, 2013 with 8 new projects Professional Development Council Darcy Lutz/Jess Wilson Jess Wilson from 3B will be the new co-chair. 16 new employees, 8 RNs and 8 NAs Approved three new professional contributions Reviewed educational presentation from National ENA conference by Kaela Funtal and Jess Lindenberger. This and all education brought back from conferences will be posted on Share Point. Discussed retention activities. Voted and finalized the goals and strategic plan for 2013 Nursing Quality Council Megan Rupp/ Amy Haugh gave a presentation on Introduction to Literature Searching. Megan Rupp has taken the Chair position. Continue to look for a cochair. Distributed the template for the
Quality bulletin boards and getting these up on each unit. Updates DCOI Update Janine Sharer We will be going live in the ED with Power note, Dragon, and Depart on 12/13/12 SMH Informatics team will be rounding and supporting WPICs erecord go-live on 1/14/13 The System is working on having the initial dysphagia screening for the inpatient units being tasked SMH Informatics is encouraging nurses to use order sentences in the Meds by History Theater in the Round 11/28/12 on Nursing Documentation Patient Satisfaction - Renee Carolan After the first of the year Renee will be doing roving inservices with a Studer webinar on AIDET and Communication about Medication. Each inpatient area should be putting great focus on Frontline Leadership Rounding, Whiteboard Communication, and AIDET. The Patient Experience Steering Council will be refocusing their efforts on re-launching AIDET and it will begin with this webinar. Press Ganey called today and they are evaluating the patient satisfaction data for our ED. At this time it looks like they will also receive the Journey to High When nurses are having trouble with scanning and do not see the medication on the chart the nurse must call IS immediately so they can look into it. Renee Carolan will know more this week.
Performance Award, as the ASU has. Performance Improvement Report Nursing Performance Improvement Report Sharon Fritzley 34% of falls were related to incorrect falls assessment. 27% non-compliance with using the call light and asking for assistance 19% staff not putting on the bed alarm Injury rate for November were below benchmark Trialed the Liko mechanical patient lifts on 6B, ICU and ED. Looking for safety coaches for each unit. 8 hospital acquired and 7 unit acquired pressure ulcers Replaced the quilted pads with the purple pads and will use the draw sheet to lift the patient Nursing Performance Improvement No CLABS Infection Control Sue DiNucci CAUTI only 1 this is way below benchmark VAP none CDI infections increased over last 3 months. November had 4, patient days are down from October MRSA 2 and both were surgical site infections Surgical site increased in November, 5 inpatient and 2 outpatient Hand hygiene compliance 73% highest we have been
Secret Shoppers - outpatient 100% in all areas. Inpatient areas were 93%. Looking at another group to do secret shopper such as Lab, Respiratory to help us be more objective. Issues: Glove box dispensers have been approved and ordered. CAUTI reviewed the definition of CAUTI change. Will be seeing an increase in CAUTI due to the new definition. Reports Available on Share Point Nursing Recruitment Coordinator Report Total Open Requisitions 51 Professional Staff Nurse 33 FT/FFT/WE 15 (includes advanced level CRNP, UD, Clinician, NI, SON) PT 2 Tier I/Tier II - 16 PCT 18 FT/FFT 9 PT 2 Casual 7 Pending Requisitions for approval - 22 Remember to let HR know when staff certify or recertify CPR. Both components, written and skills must be taken and passed. Exempt employees (i.e., clinician, UD, CM do not get LCD, they either have to take PTO or work Please see report on share point Nurse Interns will be interviewing.
Summer Inters for 2013 interviewing and selection process will begin in January. The program is 10 weeks, May 20-July 27, 2013 Employee Health Report Two exposures for November. One splash and one needle stick. Both on same unit Nursing Injuries six nursing injuries, one injury to surgical tech One Blood born pathogen exposure Please see report on share point CNO System Report Mary Barkhymer Fire in Natrona heights Nursing Administration Changes CNO Update 1. UPMC Health Plan priority strategies 2. UPMC Health Plan for culture competency care The message is to decrease admissions. Will be looking at decreasing readmissions, decreasing LOS. Will be looking at OBS patients and delivery of care. There will be a lot of information about this in the very near future. Round Robin Multispecialty clinics, Radiology, UPP Derm, Woman s Care, etc were completely affected with the fire. Changes in coordinator: Ginny Hudak is retiring on Jan 4 th. Will be recruiting for her replacement
Hired Jennifer Pernesky a Professional Nurse with ICU experience from Passavant. Please welcome Jennifer. Tanya Hoebel - this is her last Nursing Leadership meeting. Please wish her well. Dawn Pajerski has agreed to be the interim UD. Reviewed a recent situation where a patient became unhappy that he had to go to a NH and he reacted he was going to bring a gun in and kill the doctor. In light of recent events, everyone got upset and someone called 911. The first line of defense is to call Security. Any patient who makes a threat the patient should be seen by psychiatry. Will have a debriefing on this incident. The procedure is to call Security and call the Unit Director and that person is to come to the floor immediately. We will never tell someone not to call the police but Security should be the ones to make the decision to call the police. Peer Review Models L Lehman Last week showed module 1 2 and 3. Need all 3 modules to be considered competent at Peer Review. Will repeat the 3 modules this week. Jackie Drahos Working on improving RN to MD communication as well as white board
communication. Encouraging staff to introduce themselves to the MDs Jess Graff 5A Ethics - went to Children s to look at their Ethics Committee. We are doing a very good job. We are working closely with the Ethics Consortium program and are planning a Theater in the Round regarding Ethics. Much more to follow.. Waiting for scores from Press Ganey on Adopt a Room. Staff is assigned a room and they must stop in to see the patient, make sure it is tidied up, etc. We will be looking to see if this will help increase our patient satisfaction scores. Strategy for NDNQI Once a month we are sending out emails to staff regarding classes, etc. that they can attend within the system. Lisa Lehman will send out key words to use in the communication. Colleen Sunday Trying to recruit interest in the Waynesburg cohort for BSN and MSN need at least 10 people in order to have a cohort on site. CPR dates are going out today for 2013. Will be offered twice a month
Kathy Kline Flu culture education is out Health Centers have been doing fund raising to buy gifts for needy families for Christmas. The Ladies Auxiliary donated $1,000 for gift cards for families of Health Center. Very busy with behavioral health project. Has shown a decrease in depression screening rates Have a few positions open, RN, NA and front desk. Kelsey Archibald Gina Koch Lisa Graczyk Looking at new sites for Lawrenceville Family Health Center. Working with Radiology Department to help streamline patients going down for x rays. The process fax the assignment sheet to Radiology and they call the nurse directly when they are ready for the patient. This is working very well. Blitz on customer service and service recovery. Will do Studer video taping in January. Have been mixing up the skill mix on days. Have increased the NA by one and down a nurse. This is working very well and the patients are happy. Had our annual DOH survey on Friday. Received one citation. Sited for spraying the throat before an
endoscopy with a medication order. Amy Haugh Kim Lopes Talked about hand hygiene, will go around with the hand machine that registers how clean your hands are. For hands to be considered clean it must be below 200 Library putting together a list of all the things they can do for nurses who want to get their certification and the information available and help them. Literature searching help is available in the library and distributed a flyer with the days and times available. Went live today with monitors, will be a significant work flow adjustment. The Emergency Department hosted a CEN review in November and had 22 participants. Remind staff about the NEDOC plan when we go to a 5 or 6 so they know what is needed from them. Jay Wright Ronnie Findley The metal detector has been ordered and we are redesigning the waiting area to accommodate it. Sent email about American Red Cross and collecting money for Hurricane Sandy victims. Will be having a risk assessment team which will focus on medication
rescheduling MDs asked for heart failure improvement team readmissions Respectfully submitted, If you have any topics for the Winter Quality Series please let Ronnie know. Beth Wislie Administrative Coordinator