Letter from Maria Vezina, EdD, RN, NEA-BC, Chief Nursing Officer and Vice President

Similar documents
CLABSI Prevention Hardwiring Improvement

Leveraging the Accountable Care Unit Model to create a culture of Shared Accountability

Value Based Purchasing

CAMDEN CLARK MEDICAL CENTER:

HIMSS Nicholas E. Davies Award of Excellence Case Study Nebraska Medicine October 10, 2017

Harm Across the Board Reporting: How your Hospital Can Get There

Strategies to Reduce Readmissions, Sepsis, and Health-Care Associated Infections

Kentucky Sepsis Summit. August 2016

CAUTI Reduction A Clinton Memorial Presentation

HCAHPS. Presented by: Bill Sexton. Proudly recognized as one of the Nation s Top 100 Critical Access Hospitals - ivantage Health Analytics

SPECIAL SESSION: Creating Academic Service Partnerships for Education, Practice and Research

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

Improving HCAHPS with a Culture of Quiet St. Francis Hospital (Puget Sound)

Creating A Niche: Medical-Surgical Nurses Role in Succesful Program Development (Oral)

Expert Caring. Innovation. Lifelong Learning. Quality Achievement. Empowered Leaders. Annual Report Exhibit OO3.b

Quality Management Report 2017 Q2

Quality Measure Indicators +Throughput Metrics + Automated Dashboard = Innovation to Improve Quality Goals

UI Health Hospital Dashboard September 7, 2017

Worth a Thousand Words: Telling a Story with Data

The presentation will begin shortly.

Goal Statement: Achieve reduction in CAUTI events by review and implementation of best practices for utilization and management.

UNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD

Telligen. Making BIG Changes Attainable with Affinity Group Outreach June 3, 2016

MEDICAID ACCELERATED EXCHANGE (MAX) SERIES ACCELERATE TRANSFORMATION AND LASTING CHANGE

Using the BaldrigeCriteria to Achieve High Reliability

Failure to Maintain: Missed Care and Hospital-Acquired Pneumonia

L19: Improving Transitions from the Hospital to Post Acute Care Settings

University of Illinois Hospital and Clinics Dashboard May 2018

Nurse Driven Foley Removal Protocol. Cathy Moore, MSN, ACNS-BC, CCRN 2009

Quality and Safety. Why Quality and Safety? Why Quality and Safety? Leadership Development Institute

UPMC Passavant POLICY MANUAL

The Case for Optimal Staffing: A Call to Action

UNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD

Global Nursing Perspectives and Professionalism

PSI-15 Lafayette General Health 2017 Nicholas E. Davies Enterprise Award of Excellence

Health Care Systems - A National Perspective Erica Preston-Roedder, MSPH PhD

The CAUTI Can-Can. Hennepin County Medical Center August Caitlin Eccles-Radtke, MD Infectious Disease and CAUTI Prevention Champion

Thursday, October 11, 2012 Gaylord Opryland Resort and Convention Center Nashville, TN

The Triple Aim. Productivity: Digging Deep Enough 11/4/2013. quality and satisfaction); Improving the health of populations; and

Electronic Physician Documentation: Increased Satisfaction

TRANSLATING CARINGTHEORY INTO PRACTICE

Raising the Bar On Infusion Safety: A Patient Safety Program at Baylor Scott & White Health Improving Infusion Pump Safety: A Systematic Approach

Ayrshire and Arran NHS Board

Executing a Patient Experience Measurement Initiative

Tina Nelson, MBA, BSN Lisa Stepp, BSN, RN Rebecca Fyffe, BSN, RN Jessica Coughenour, LPN

Improving Pain Center Processes utilizing a Lean Team Approach

Creating Data-driven Strategies to Improve Hospital Outcomes

To Dip or Not To Dip

Session 183, March 7, 2018 Sue Murphy, RN, BSN, MS, Chief Experience Officer, UChicago Medicine

HSAG the QIN-QIO NHQCC II and CDI Initiative Kick-off

Improvements & Sustained Change through the Implementation of High Reliability Units

Celebrating our Successes 2014

MemorialCare Orange Coast: Using Innovative Technology to Improve Efficacy of Patient Repositioning

Translating Evidence to Safer Care

Three C s of Change in the Value-Based Economy: Competency, Culture and Compensation. April 4, :45 5:00 pm

CAUTI reduction at Mayo Clinic

Unifying Real-Time Mobile Rounds with Follow Up Care Calls to Improve Patient Experience and Outcomes

Completing the Specialty Practice Assessment Tool: Guide for Behavioral Health Organizations and Divisions

AGENDA. Introduction and Executive Leadership Year in Review Environment of Care Report and Policy Approvals

Nurse Link. Special Edition: Professional Practice Model. LUHS Nursing Professional Practice Model. Nursing Attributes

Creating a Culture of Quality and Safety Gordon C. Hunt, MD, MBA Sr. Vice President & Chief Medical Officer, Sutter Health

Preventing Health Care Associated Infections. PJ Brennan, MD Chief Medical Officer University of Pennsylvania Health System August 16, 2011.

Integrating Quality Into Your CDI Program: The Case for All-Payer Review

TOP 10 IDEAS TO INVOLVE ALL STAFF IN ADVANCING EXCELLENCE

Reducing Hospital Readmissions: Home Care as the Solution

What s Right in Healthcare. Covenant Health Knoxville, Tennessee

Winning at Care Coordination Using Data-Driven Partnerships

Using Appreciative Inquiry to SOAR through Strategic Planning

LESSONS LEARNED IN LENGTH OF STAY (LOS)

North Carolina Division of Medical Assistance

CONGRATULATIONS! MGH Site Visit: November 6-9, The Site Visit what to expect. You ve got this!

Influence of Patient Flow on Quality Care

FHA Call to Action: Eliminating Infection-Related Ventilator-Associated Complications IVAC Bi-Monthly Webinar #2 May 3, 2018

Session 92AB Improving Patient Experience and Outcomes Using Real-Time Care Rounding Technology

Taming Length of Stay Challenges Through Analytics

Advancing Accountability for Improving HCAHPS at Ingalls

Relational Coordination: An Imperative Influencing our Capacity to Reach the Core

REPORT OUT TEMPLATE. Please refer to the C.A.R.E bylaws and other program material for additional information.

Solution Title: Reduction Nurse Sensitive Conditions: Utilizing an Observational and Retrospective Review Methodology

Figure 1. Massachusetts Statewide Aggregate Hospital Acquired Infection Data Summary. Infection Rate* Denominator Count*

Key Steps in Creating & Sustaining Excellence

Engaging Residents and Families in HAIs/CAUTI Prevention. Presenters

Managing Healthcare Payment Opportunity Fundamentals CENTER FOR INDUSTRY TRANSFORMATION

Improve the Efficiency and Service of the Emergency Room at North Side Hospital

Columbus Regional Hospital Pressure Ulcer Prevention

Laguna Honda Lean Transformation. Laguna Honda Strategic Performance Management November 2017

Executive Summary MEDICARE FEE-FOR-SERVICE (FFS) HOSPITAL READMISSIONS: QUARTER 4 (Q4) 2012 Q STATE OF CALIFORNIA

Lynn Ives, MSN, RN-BC; Jessie Reich, MSN, RN, ANP-BC, CMSRN. Disclosure. Learning Objectives. The speakers have no conflicts of interest to disclose

Alaina Tellson, PhD, RN-BC, NE-BC

Eliminating Catheter-Associated Urinary Tract Infections: Implementing a Quality Improvement Project

Follow Up on Bedside Reporting. IHI Expedition Improving Your HCAHPS Scores Through Patient Centered Care. Today s Topics

The Cleveland Clinic Experience

Medicare Value Based Purchasing Overview

PATIENT CARE SERVICES REPORT Submitted to the Joint Conference Committee, November 2017

What are the Barriers and Facilitators to Nurses Utilization of a Nurse Driven Protocol for Indwelling Urinary Catheter Removal?

Using HCAHPS Survey Custom Questions to Drive Staff Engagement

The speakers have no conflict of interest to disclose. Inspired to Get Certified: Validation of Expertise for Psychiatric Mental Health Nurses

Value-Based Purchasing: A Rural Hospital Perspective

EXPERIENCE OF NH HOSPITALS: FALLS DATA NH FALLS RISK REDUCTION TASK FORCE ANNUAL DATA MEETING MARCH 7, 2017 PRESENTED BY: ANNE DIEFENDORF FOUNDATION

BEDSIDE REGISTRATION CAPE CANAVERAL HOSPITAL

Transcription:

Welcome

Letter from Maria Vezina, EdD, RN, NEA-BC, Chief Nursing Officer and Vice President Mount Sinai St. Luke s: Nursing at its Best I am privileged to be the Executive Nurse Leader for Mount Sinai St. Luke s. I witness a community of nursing staff who are committed to giving excellent care always to the patients and families we serve. My goals as a transformational nurse leader are fourfold: Collaborate with all members of the health care team, executive leaders, clinical champions and union members to develop strong partnerships to set common goals for support of our staff and their environment of care and to assist their professional growth and development as clinical leaders who are second to none. Exercise prudent financial practices to enhance the growth and development of Mount Sinai St. Luke s as a Center of Excellence. Advance the professional practice of nursing to embrace the 21st century s strategies for health care delivery that produce safe and quality patient care. Lead the patient care experience by engaging staff to initiate Relationship Centered Care as a Professional Practice Model that focuses on the patient and family as our priority at all times in their continuum of care. Celebrating nursing excellence has been an exciting experience in my tenure to date as the Chief Nursing Officer. Not to mention the countless experiences I have had personally with nursing staff who are committed to providing excellent care always! To create and sustain nursing excellence, it is critical to have a commitment to transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation, continual performance improvement and empirical outcomes focused on quality and patient safety. At Mount Sinai St. Luke s, the team spirit is extraordinary, executive team talent is unparalleled, the commitment to the West Harlem community is palpable, and the journey to develop into a Center of Excellence within the Mount Sinai Health System has begun with a sense of urgency, purpose, and excitement. Mount Sinai Nursing Mission: To advance nursing through unrivaled education, research and clinical care to provide exceptional experiences and outcomes to patients locally and globally. Mount Sinai Nursing Vision: To continue to grow and challenge convention through a pioneering spirit of inquiry, advancements in nursing practice and research, transformational leadership, and collaborative approach to providing exceptional patient and family relationship-centered care.

Transformational Leadership: Providing a strong mission, vision, and forward thinking to guide a professional nursing practice with a collaborative sense of advocacy and support to provide exceptional care to the patients and families we serve. Nursing Leadership Team & New Nurse Leaders - 215 AGREEMENT Between New York State Nurses Association and Mount Sinai St. Luke s and Mount Sinai West January 1, 215 - December 31, 218 Nurse Leaders Joined in 215 Survey 215 - Quote from Hospital Administration As with any survey, there were findings that we will have to correct, and there are always opportunities for us to improve. Nevertheless, your months of hard work and preparation went regularly and repeatedly noticed by the surveyors. Many of our units were described as spotless and sparkling; some of our physicians and nurses were declared awesome, amazing, and rock stars; our split flow model in the Emergency Department was deemed a fabulous job; and our infection control team was proclaimed awesome, amazing, and high reliability at its best. Metabolic and Bariatric Surgery Comprehensive Center Survey October 215

Structural Empowerment: Structures and processes are in place to empower nurses to participate in decision making, establish standards of practice, and advocate for lifelong learning and recognition. The Nurse Executive (NEC) is accountable for ongoing communication with each standing committee on issues related to professional practice and patient care. Nurse empowerment is fostered through committee participation in developing and reviewing evidenced-based practice, policies, standards of care, documentation and clinical procedures, recognition, retention and patient education. These issues guide nursing practice and are brought forward to the NEC. The Mount Sinai St. Luke s and Mount Sinai Roosevelt: Department of Nursing Shared Decision Making/Nursing Practice and Quality Structure. VP Clinical Operations Ambulatory Services TBD VP System Clinical Operations, Mount Sinai Heart Beth Oliver Director Peri-Operative Services Leah Borenstein Chief Nursing Officers Maria Vezina, MSSL Judy Miranda, MSR Nursing Quality Michelle Dunn Director Nursing Executive Co Judy Miranda and Maria Vezina Nursing Practice s Practice/ Policy/ Clinical Guidelines/ Procedures Co Chair Grace Phelan SLR & Jeannine Bernstein SLR Nursing Pharmacy Co Chaired Jeanine Bernstein & Karen Falk MSSL, Irina Usherenko & Jennifer Jaromahum, RN, MSR Peer Review Chaired & Co Mike McDougal & Susan Ranalli MSSL, Bernice Emmanuelli & LaShawn Jemison, MSR Nursing Evidence Based Practice/ Nursing Research Cochaired by Natalia Cineas, MSSL & Wendy O Brien, MSR Nursing Recognition and Retention Maureen Stone MSSL, Francine Pasadino, MSR and ADD Grace Phelan, SLR Nursing QI Michelle Dunn (SLR) Patient/ Family/ Education Co Chaired by Judith Nierenberg SLR & Kathleen Arcidiacono MSR Safe Patient Handling Jennifer Jaromahum, MSR and ADD & Yvonne Guariglia, SLR Pain Cochaired by Jennifer Jaromahum, ( MSR) Dr. Jung Kim, (SLR) & Susan Ranalli (MSSL) Falls Prevention Michelle L. Dunn, SLR Skin Integrity Co Chaired by Lisa Webb & Dr. John Lantis MSR and ADD Rosalyn Beswick & Dr. Carl Braun MSSL NP Practice Council Rosalyn Beswick, MSSL & TBD Nursing Leadership Meeting Unit Staff Meeting 2 18 16 14 12 1 8 6 4 2 Percent of Nurses with Professional Certification 8 7 6 5 4 3 2 1 Percent of Nurses with BSN or Higher QTR 1 215 QTR 2 215 QTR 3 215 QTR 4 215 QTR 1 215 QTR 2 215 QTR 3 215 QTR 4 215 215 Falls Prevention Awareness Week Take a Stand to Prevent Falls Student Affiliations

Exemplary Professional Practice: An overarching conceptual framework for nurses, nursing care, and interdisciplinary patient care delivery guided by our professional practice model: Relationship Centered Care. Care Delivery Model: Modified Primary Nursing Professional Practice Model: Relationship Centered Care ANA Standards Professional Nursing Practice MS Nursing Philosophy Professional Nursing Performance MSHS Relationship Centered Care (MSHSRCC) Professional Practice Model Relationship Based Care Mount Sinai Health System Relationship Centered Care (MSHSRCC) Care of: Patient/Family Self Clinician Colleagues Care Team Members Community (Local - Global) Relationship Centered Care Tenets of Modified Primary Nursing Nurse Patient Relationship Accountability Autonomy Continuity Collaboration Outcome Dimensions Quality Safety Patient Falls Prevention Champion Program Interdisciplinary Patient Communication Screen The Mount Sinai Health System Relationship Centered Care (MSHSRCC) Tenets of Relationship Centered Care Relationship Centered Care (RCC) is the Professional Practice Model for the Mount Sinai Health System Nursing Departments. A Professional Practice Model is an overarching conceptual framework for nurses, nursing care and interdisciplinary patient care. RCC is represented by the schematic description above showing how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality care for those served by the organization. The tenets of RCC include: Admission Welcome Bedside Shift Report Purposeful Hourly Rounding HELP AM/PM Care 5 Minute Sit Down Medication Review MD/RN Unit Collaboration (Unit Dyads) Discharge Wrap-Up

New Knowledge, Innovation, and Improvements: Integration of evidence-based practice, continual performance improvement such as Lean and research into clinical and operational processes. PEOC The Patient Operations (PEOC) is an interdisciplinary group of health care professionals focused on improving the patient experience through collaboration and engagement of staff, patients, family members, and the community. The priority goal of PEOC is to guarantee Excellent Care Always for ALL patients through the delivery of relationship centered care and standardization of work. LEAN Management Lean management is an approach to running an organization that supports the concept of continuous improvement, a long-term approach to work that systematically seeks to achieve small, incremental changes in processes in order to improve efficiency and quality. Lean emphasizes value added work and seeks to eliminate non value added work through purposeful design. 215 True North Metrics Mount Sinai St. Luke s: Patient Cycle Lean (Process Improvement) Follow-Up - Surveys - Compliments & Complaints - TBD: Comprehensive Service Recovery Program Support Respect for Patients Engaged Employees Respect for Each Other Recovery Evidence-Based Practice - Staff Recognition - Patient Amenities Management - Domain Teams - Dyads Relationship Centered Care (Practice Improvement) Patient Operations (PEOC) 16 12 Clinical Outcome 15 CAUTI Reduction of 53% in First 7 Months of 215! Quality and Safety 1. Readmission Rate 2. Mortality Rate 3. PSI-9 w/ CAUTI and Falls 4. Dollars for Patient Harm Ambulatory Care and Population Health 1. Excess Medial Revenue 2. Avoidable Admissions and ED Visits 3. New Primary Care Patients Patient 1. Overall Rating Score 2. 3rd Next Available Appt. 3. Admission Decision to Departure Staff Vitality 1. Composite Press Ganey Score 2. Participation in Staff Education 3. Use of Non-Productive Time Financial Stewardship 1. Net Operating Surplus 2. Overtime 3. Volume Growth Opportunities 4. Length of Stay 8 4 Jan - July 214 Jan - July 215 Financial Outcome $47,432 $57,45 CAUTIs Jan - July 214 Jan - July 215 Cost to treat CAUTI Product Cost ROI 7 7 Month ROI $34,222 $43,634 $26,621

Empirical Outcomes: Demonstration of quality outcomes made by nurses as an essential contribution to patient care, nursing workforce, and organizational and consumer outcomes. Purposeful Hourly Rounding (PHR): The goal of Mount Sinai St. Luke s is to provide excellent care to every patient, every day, every shift. An important part of providing patients with excellent care and service is purposeful hourly rounding. RNs and nursing assistants round on patients every hour. During rounding, the nursing staff checks on patient well-being, monitors comfort and pain, assists the patient to change positions, and assists with trips to the bathroom. Hourly rounding is now a part of the culture at Mount Sinai St. Luke s. 9 8 7 6 5 4 3 2 1 Mount Sinai St. Luke s All Units PHR Training Starts 71.3 74.9 7.9 72 54.9 57.1 59.4 56.9 Q1 214 Q2 214 Q3 214 Q4 214 Percentile Rank Comm w/ Nurses Comm w/ Nurses 76.3 59.2 77.7 81 59.7 69.6 Q1 215 Q2 215 Q3 215 Percentile Rank Response of Hosp Staff Response of Hosp Staff Nursing Unit Quality Boards Clark 9 Falls Reduction Initiative CAUTI Bath Basin Elimination: The Nurses Role Bath Basin Elimination: Removing the bath basin to reduce catheter-associated urinary tract infection in critically ill patients Natalia Cineas, DNP, RN, NEA-BC, Senior Director of Nursing, New York, NY Rosalyn Beswick, RN, MSN ANP-BC CWOCN, Wound Ostomy Manager Maria Vezina, EdD, RN, NEA-BC Number of Falls in 215: Geriatric Psychiatry 14 12 1 8 6 4 2 Purpose The purpose of this study was to compare the effectiveness of two methods of patient bathing and incontinence care on overall cost and patient outcomes for catheter-associated urinary tract infections (CAUTI) in critically ill patients. Results There were 22 CAUTIs in the 214 time period and 9 CAUTIs in the 215. This represents a 59% reduction in CAUTI. Return-on-investment (ROI) was calculated by using the differences in supply costs associated with each bathing process as well as the cost avoidance attributed to CAUTI reduction. ROI for the 12-month intervention period was $33,234. Background Methods Healthcare-associated infections (HAI) are CAUTI rates were measured for a 12-month period on all common, costly, and associated with significant hospital units (214) to provide a baseline measure. morbidity and mortality. Prevention strategies The 214 standard of care in the general care units was are often underutilized, particularly for CAUTI. once-daily bathing with soap, water, peri-spray and reusable CAUTI rates by hospital are now publically bath basins; incontinence care was performed as needed using available and the Centers for Medicare and the same supplies. Medicaid Services (CMS) will no longer In January 215 a new bathing and incontinence care protocol reimburse hospitals for the additional costs of was implemented where all basins were eliminated and caring for patients who develop CAUTI. A growing replaced by a one-time use packaged bathing product. body of evidence supports that the removal of Product cost and CAUTI were measured for a 12-month period reusable bath basins can reduce CAUTI. (January December, 215). 3. Conclusion 2.5 2. The use of the new bathing and 1.5 incontinence care protocol will continue 1. throughout the hospital, with ongoing.5 tracking of compliance, clinical. Q1 Q2 Q3 Q4 outcomes and cost. These findings add 214 215 to the emerging body of evidence Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec supporting the benefit of basin 214 Catheter Days 1,21 1,211 1,63 1,276 999 1,56 1,95 1,121 1,146 1,15 1,76 987 # of CAUTI 2 3 3 4 1 2 2 2 3 elimination on HAI reduction and the 214 CAUTI Rate 1.7 2.5. 2.4 4..9 1.8 1.8. 1.8. 3. associated economic benefits. 215 Catheter Days 916 71 961 697 714 681 886 822 54 883 866 15 # of CAUTI 2 1 2 1 1 1 1 215 CAUTI Rate 2.2. 1. 2.9. 1.5 1.1.. 1.1 1.2. CAUTI Rate The removal of the basin has been shown to reduce risk factors for UTIs 1. 1. Stone S, et al., Removal of bath basins to reduce catheter-associated urinary tract infections. Poster presented at APIC 21, New Orleans, LA, July 21. 2. Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs), APIC, 28; 5, 4 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Nursing Annual Report Department of Nursing Copyright 216