News and Views Summer 2015

views A Publication of the

Department of Nursing and

Patient Care Services

Summer 2015 University of Maryland Medical Center

news

This Act included a $19 billion program encouraging the expansion of technology and its applications

to health care (Ball et al., 2011). When considering possible applications for telemedicine, one cannot overlook the potential that exists in the intensive care unit. Life-threatening events in the critically ill do not follow a 9-to-5 schedule, and immediate treatment is crucial to achieving positive outcomes (Gajic & Afessa, 2009).

Creating an environment that optimizes resources, observation, and treatment has been the hallmark of intensive care units over the last six decades. Dating back to the days of Florence Nightingale, it has been a priority to group the most vulnerable patient populations together to allow for

increased vigilance (Munro, 2010). The care of critically ill patients in a specialized manner by specialized physicians and critical care intensivists has been proven to provide the safest and highest quality of care. Unfortunately, there is a shortage in the number of intensivists in the U.S., with the highest number practicing in urban and metropolitan areas (Halpern, Pastores, & Greenstein, 2004). Therefore, many critical care patients in rural areas do not receive the benefits of having this specialized care. However, with the growth of biomedical and information technologies, innovative ideas like the tele-ICU have been able to bring experienced critical care teams to hospitals and patients, no matter where they are located.

continued on page 14.

Lisa Rowen’s Rounds: In Different, Not Indifferent


Have you ever noticed that when you are receiving your annual job performance appraisal, you focus on and even perseverate on the feedback you consider negative? This is human nature. Most people remember negative feedback or events more strongly and in more detail than those that were positive. This may be due to the fact that our brains process positive and negative information in different hemispheres. Because negative emotions generally involve more thinking, we process this information more thoroughly than positive emotions. Consequently, we tend to ruminate about unpleasant or negative events, information, and feelings more than happy or positive ones.1

I will admit I have been contemplating a comment recently made to me by a patient: she said the nursing care she received here was “indifferent.” I cannot stop thinking about this comment, how she must have felt as a patient and how it made me feel as a nursing leader.

If you look up the word indifferent you will find this meaning:• having no particular interest or concern, apathetic;• having no marked feeling for or against;• not mastering one way or the other, unimportant, immaterial; and,• being neither good nor bad but mediocre.

Mediocre? Is our nursing care mediocre? It’s difficult for me to believe this. I see and hear about amazing care here every day. Sadly, I also see and know of pockets of nursing care that are sub-optimal, apathetic, and

Innovations and Leadership in Tele-ICU NursingAnita Witzke, MS, RN, Director of University of Maryland eCare

The concept of telemedicine originated nearly 50 years ago with the National Aeronautics and Space Administration’s (NASA) use of satellite applications to provide medical care to individuals in isolated areas of the U.S., where it was difficult to access them using traditional means (Bashshur & Shannon, 2009). The 1990s saw a significant increase in the use of health information technology (HIT), and since then it has grown exponentially due to the American Recovery and Reinvestment Act passed by President Obama in 2009.

Lisa Rowen, DNSc, RN, CENP, FAAN, Senior Vice President of Patient Care Services and Chief Nursing Officer

In This Issue

Innovations in Tele-ICU Nursing

Lisa Rowen’s Rounds

The Relationship of Unprofessional Behaviors and Burnout

Achievements

Message from New AACN President

Portfolio Patient Numbers — What the Wristband Has to Tell You

Integrating Teambuilding, Yoga, and Reiki for Staff Well-being

Improving Therapist Productivity

Advocating for Advanced Practice Nursing

Spotlight on Pharmacy

2015 Student Nurse Residency Program

Certification Corner

Pre-visit Planning in Ambulatory Clinics

Publications and Presentations

STC Respiratory: A Gear in the Machine

Food Drive for the Hungry

Clinical Practice Update

1

1

3

4

5

7

10

11

12

15

16

18

19

20

21

23

24

Scope of PublicationThe scope of NEWS & VIEWS is to provide clinical and professional nursing and patient care services practice topics that focus on inpatient, procedural, and ambulatory areas.

Submission GuidelinesSend completed articles via e-mail to [email protected] Please follow the guidelines provided below.

1. Font – Times New Roman – 12 pt. black only.2. Length – Maximum three double spaced typed pages.3. Include name, position title, credentials, and practice

area for all writers and anyone named in the article.4. Authors must proofread the article for spelling, grammar,

and punctuation before submitting.5. Provide photos and embedded images in separate .jpg files.6. Submit trend data in graphic format with labeled axes.7. References must be numbered consecutively and

provided at the end of the article.8. Editor will seek expert review of articles to verify and

validate content.9. Articles will be accepted based on appropriateness of

content and availability of space in each issue. 10. Articles that do not meet the above guidelines will be

returned to the author(s) for revision and resubmission.

Editor-in-ChiefCarolyn Guinn, MSN, RNMagnet Director, Clinical Practice & Professional Development

Managing EditorSusan Santos Carey, MS Lead, Operations Clinical Practice and Professional Development

Editorial BoardLisa Rowen, DNSc, RN, CENP, FAANSenior Vice President of Patient Care Services and Chief Nursing Officer

Suzanne LeiterExecutive Assistant to the Senior Vice President of Patient Care Services and Chief Nursing Officer

Greg Raymond, MS, MBA, RNDirector, Nursing and Patient Care ServicesClinical Practice and Professional Development, Neuroscience and Behavioral Health

Chris LindsleyDirector, Communication ServicesUniversity of Maryland Medical System

Anne HaddadPublications EditorUniversity of Maryland Medical System ISSUE

Winter 2016Spring 2016

Summer 2016

DUE DATE

January 4, 2016May 2, 2016July 11, 2016

Find news&views online at http://umm.edu/professionals/nursing/newsletter and on the UMMC INSIDER at http://intra.umms.org/ummc/nursing/cppd/excellence/publications/news-and-views

NEWS & VIEWS is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center.

Displaying CredentialsThe UMMC standard for displaying of credentials is based on the ANCC Guidelines.

The preferred order is:• highest earned degree (can list more than one if

in different fields)• licensure• state designations or requirements• national certifications and honors• other recognitions

Nurses with two or more nursing degrees (MSN, BSN) should only list their highest nursing degree, along with other degrees obtained. Example: Betty Smith, MSN, MBA, RN.

Why this order: The education degree comes first because it is a “permanent” credential, meaning it cannot be taken away except under extreme circumstances. The next two credentials (licensure and state designations/requirements) are required for you to practice. National certification is sometimes voluntary. Awards, honors, and other recognitions are always voluntary.

If you would like additional information, please visit http://www.nursecredentialing.com and search using the word “credentials.”

Summer 20152

Corporate ComplianceKallie A. Smith, Corporate Compliance Analyst, UMMS Corporate Compliance and Business Ethics Group

In each issue, the Medical Center Compliance Program provides a short Frequently Asked Question (FAQ) for News & Views. We are looking for new ways to reach out to employees to raise awareness of compliance issues. Please let us know what you think, or suggest topics by emailing [email protected] or [email protected].

Compliance FAQ Q: “I wonder if I should check for authorization before discussing her condition

with this visitor…”

A: Yes, you should. No matter how busy or inconvenient, discussing patient information with unauthorized individuals is a HIPAA violation! Be sure to ask the patient if it is alright to discuss their information in front of a visitor. If the patient is not cognizant, check the chart for authorization and any passcode required before providing an update.

Due to organization focus on Epic Portfolio, there will not be a Fall issue.

views&news3

Examining the relationship of unprofessional behaviors and burnout in trauma nurses through research Paul Thurman, MS, RN, ACPNC, CCNS, CCRN; Kathryn Von Rueden, MS, RN, CNS-BC, FCCM; and the Shock Trauma Nursing Research Council

Unprofessional behaviors and co-worker conflict are types of workplace violence that are more recognized as problems in the health care workplace. Unprofessional behaviors in hospitals can impact staff retention, team performance, and the safety of patient care delivery. A previous study of trauma nurses at UMMC suggested that burnout and compassion fatigue were related to poor co-worker relationships in nurses caring for trauma patients. To better understand this relationship, the R Adams Cowley Shock Trauma Nursing Research Council recently conducted a survey, which included the Survey of Unprofessional Behaviors: Triggers, Responses, Impacts, and the Professional Quality of Life Survey (ProQOL). The ProQOL instrument measures burnout, compassion fatigue, and compassion satisfaction.

The survey included nurses, unlicensed assistive personnel (UAPs), unit secretaries, and technicians. Of 550 surveys distributed, 262 (48%) were returned. After removing surveys with incomplete data, 235 were available for analysis. Most respondents were female (85%), white (80%), between the ages of 18 and 30 years (44%), and single (40%). Staff nurses were the most common type of respondent (60%) and practiced in critical care. Fourteen percent were unlicensed assistive personnel. Most respondents had a baccalaureate degree (63%) and worked between 32 and 40 hours per week (82%).

All types of unprofessional behaviors (conflict, condescending language, passive aggressiveness, etc.) were reported to be experienced weekly or daily by 26% to 45% of respondents, except for physical violence, which 86% reported never experiencing. When asked about the triggers of unprofessional behavior (chronic system issues, lack of co-worker competence, lack of teamwork, etc.), 25% to 60% of respondents reported these occurring weekly or daily. Less than 20% of nurses and UAPs completely agreed that they responded effectively to unprofessional behaviors. For example, when staff experienced unprofessional behaviors, they reported that they did not do another’s work to avoid the behavior, they notified the manager, and/or addressed the behavior with the individual. Most respondents (67%) completely disagreed with the statement that they did not report deteriorating patient conditions to a provider acting unprofessionally. Between 15% to 25% of respondents completely disagreed with statements about reasons for not addressing unprofessional behaviors, such as “not comfortable addressing,” “avoidance due to fear,” and “nothing changes when addressed.” Between 30% and 41% completely agreed that unprofessional behavior negatively impacted morale and job satisfaction, and takes an emotional toll.

Linear regression was used to examine the relationship of the total burnout score with unprofessional behaviors, individual characteristics, and social support. Each of these factors individually were significantly related to burnout score; however, when taken together, only the type and frequency of triggers of unprofessional behaviors and the impact of the unprofessional behaviors were independent predictors of burnout. The type and

frequency of triggers of unprofessional behaviors and the impact of the unprofessional behaviors remained significant predictors of burnout score even when social support and respondent characteristics such as age, education, and practice area were included in the model. The final regression model with the above factors explained 28% of the variation in burnout (adjusted R2 = 0.28). The relatively large amount of explained variance suggests it is a good predictive model.

Similarly, logistic regression was used to examine the relationship of unprofessional behavior factors, individual characteristics, social support, and burnout score to staff intention to leave or transfer to another unit. The final predictive model with all factors predicted almost 30% to 40% of a person’s intent to leave or transfer (Cox & Snell R2=.29, Naglekerke R2=.40). Every increase in either type or frequency of unprofessional behaviors increased the odds of the intention to transfer or leave by 14% after controlling for other sections of the unprofessional behaviors survey, practice setting, education, age, and social support. Every point increase in the perception of the impact of unprofessional behaviors score increased the odds for an intention to transfer or leave by 18%.

Healthy work environments (HWE) are essential to providing excellent patient outcomes. The tenets of HWEs are skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and


It was hypothesized that increasing type and frequency of unprofessional behaviors would be related to higher

amounts of burnout; however, the study did not support this hypothesis. The study did find that the type and frequency of triggers of unprofessional behavior were related to burnout. It is important to note that this suggests that organizations that ameliorate triggers of unprofessional behavior may experience less staff burnout. The study also showed that staff retention may improve with amelioration of triggers of unprofessional behavior because type and frequency of unprofessional behaviors predicted intent to leave or transfer, especially for staff working in the intensive care unit.

Summer 20154

Raymond Appointed to Maryland State Board of Nursing

For the first time in at least a decade, a UMMC nurse serves on the Maryland State Board of Nursing, now that Governor Larry Hogan has appointed Greg Raymond, MS, MBA, RN, the Medical Center’s director of nursing and patient care services for clinical practice and professional development, neuroscience, and behavioral health.

Raymond is also a faculty associate for Health Services, Leadership and Management at the University of Maryland School of Nursing. He will be one of 13 professional and lay members, while also continuing to serve in his job at UMMC. His board term will expire on June 30, 2018. Maryland law requires

that one board member “be a nurse administrator with, at least, a master’s degree in nursing administration, business administration, business management, education, or public health,” and Raymond was chosen to fill this slot.

“We applaud Governor Hogan for appointing Greg to the Board of Nursing,” said Lisa Rowen, DNSc, RN, CENP, FAAN, senior vice president for patient care services and chief nursing officer. “It was a competitive process, and I’m sure there were many exemplary nurses from around the state who were considered. His appointment is an honor for him, and also an honor for the Medical Center.”

The board’s mission is to advance safe, high-quality health care across the state through licensure, certification, education, and discipline of the licensees, certificate holders, and educational programs under its jurisdiction.

The jurisdiction includes approximately 330,000 professionals, including: registered nurses, licensed practical nurses, nurse anesthetists, nurse midwives, nurse practitioners, nursing assistants, medication technicians, and electrologists.

Raymond first came to UMMC in August of 2006 as a nurse manager of the Surgical Intensive Care Unit. He led the unit through challenges that included development of care-model changes in the event of a flu epidemic. In 2010, he

was promoted to a position as director of nursing and patient care services for neuroscience and behavioral health. In 2012, his director duties expanded to cover the Department of Clinical Practice and Professional Development for all nurses at UMMC. In addition to his usual duties, he leads many hospital-wide initiatives, such as the professional advancement model for nurses. He also co-chairs UMNursing, an academic-practice partnership between UMMC and the University of Maryland School of Nursing. The co-chair of the partnership is Karen Kauffman, PhD, CRNP, RN, FAAN, associate professor and chair, Department of Family and Community Health at the UM School of Nursing.

“We are all very proud to see Greg receive this very important appointment,” said Jeffrey A. Rivest, former president and chief executive officer of UMMC.

“Greg is admired throughout the Medical Center as both an excellent nurse and an excellent administrator.”

“I’m deeply honored to serve on the Board of Nursing,” Raymond said. “I look forward to participating with the same passion for excellence that drives our own culture at the Medical Center. Serving on a board that affects safety and quality statewide is an opportunity to join with others who are advancing the practice of nursing.”

Achievements

Maryland Hospitals for a Healthy Environment Recognizes One of our Own

On June 1, at the Maryland Hospital Association’s annual meeting at the Four Seasons hotel in Baltimore, four Maryland hospitals/health systems were honored by Maryland Hospitals for a Healthy Environment (MD H2D) as environmental “Trailblazers” for their recent innovative achievements. Additionally, MD H2E honored two health care professionals for their dedication to environmental health and

sustainability, one of whom was our own Justin Graves, MS, RN, sustainability manager for UMMC. All winners serve as models for those seeking to reduce their environmental footprint and raise the bar on improved results.

Joan Plisko, director of MD H2E, presented the award of Environmental Health in Nursing to Justin and commented: “Justin Graves, MS, RN, University of Maryland Medical Center,

is a nationally recognized sustainability manager, skilled in collaboration and sharing best management practices. Justin chairs the hospital green team, spearheaded programs in waste reduction and healthy foods, and has identified opportunities to change hospital purchasing programs that save money and reduce environmental impact.”

The winners will be sharing their success stories and lessons learned at the MD H2E Trailblazer event, scheduled for October 23, 2015 at Johns Hopkins Bayview Medical Center. Congratulations to Justin!

“Having great confidence in your dedication to public service, it is my pleasure to appoint you a member of the State Board of Nursing,” the letter from Governor Hogan to Raymond reads. “Thank you for making this

strong personal and professional commitment to serve the best interests of our citizens.”


views&news5

Courageous Care – An Inspirational Theme from the New President of AACN

On July 1, 2015, Karen McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN, lead clinical nurse specialist at the R Adams Cowley Shock Trauma Center, became the 46th president of the American Association of Critical-Care Nurses (AACN). This is the largest specialty nursing organization in the world, with over 104,000 members and representing the interests of nurses who care for acutely and critically ill patients. The association is dedicated to creating a health care system driven by the needs of patients and their families, where acute and critical care nurses make their optimal contribution.

On May 20, 2015, at the AACN National Teaching Institute, McQuillan unveiled AACN’s theme for her presidential year — Courageous Care — reminding nurses that courage is facing their fears to do what they know is right, even when it’s not easy. For nurses, it means doing what is necessary to provide the best possible care for their patients and their families. In her address, McQuillan emphasized the unique ability nurses have to make a lasting difference in the lives of their patients and their families. She encouraged the 8,000 nurses present to never lose sight of the power and the triumph that comes with their unique practice — tending to the needs of patients and their families at the most vulnerable times of their lives.

McQuillan highlighted how nurses show courage daily. Courageous Care is

demonstrated each time nurses step up to advocate for their patients, challenge the way they have always done things, gain knowledge to care for complex patients, or have a difficult conversation with a colleague who has lost their passion for nursing. Courageous Care is also demonstrated when nurses recognize their own needs and take the time to renew and recharge.

McQuillan explained that this is a tumultuous time in health care; change is rapid and rampant. Nurses are delivering Courageous Care 24/7, she said, so who better to drive the needed changes in health care. She challenged all the nurses in the audience to define nursing so that others understand their unique work. She emphasized that nurses must work to reshape the very face of health care and to re-imagine the way health care is delivered. In closing, McQuillan reminded nurses that they perform the greatest job in the world with compassion, conviction, and — above all else — courage.

Achievements, continued from page 4.

Andrea M. Smith, DNP, CRNP, FNP-BC, was the recent recipient of Sigma Theta Tau International’s (STTI) “DNP Rising Star of Nursing Research” award at the 27th Annual STTI Research Congress in Puerto Rico.

Smith was nominated by faculty at the University of Maryland School of Nursing, from which she earned her

doctorate in May 2015 and a master’s degree in 2010.

Smith is the Medical Center’s nurse practitioner clinical program manager for the Emergency Department, Psych Emergency Services, and the Prep Center, a position she recently accepted. She began her career at UMMC in 2006, first as a nurse and eventually as a nurse practitioner in the ED, and then as a senior leader in the UM Center for Performance Innovation, where she led many teams on process and quality improvements across the Medical Center.

STTI selected Smith’s abstract from more than 900 that were submitted. At the international conference, which drew nursing scholars from around the world, she presented her doctoral work, “Creating a Culture of Teamwork through the Use of the TeamSTEPPS Framework.”

Smith is also an alumna of Washburn University in Topeka, Kansas, where she earned her BSN in 2005.

DNP Rising Star of Nursing Research

Summer 20156

Lisa Rowen’s Rounds, continued from page 1.

‘‘ ‘‘should not define who we are as nurses. I’ve heard from many of you in the past year about the care you’ve received here as a patient. In some instances, our nursing care did not meet your expectations; in fact, you were disappointed and saddened that we did not live up to the excellence you hoped to receive.

We all hear a lot about the patient experience and patient satisfaction. If we consider a construct that our patients are guests in our home (our hospital), how would we rate? How kind and respectful are we? How well do we communicate with our guest? How courteous are we? Are we quiet at night? Is the guest bathroom clean? Are we there for our guest when they require our help or explanations, and, if so, how quickly do we lend a hand? How well do we, the host family members, communicate with each other about plans for our guest?

Patients can and should expect incredible hospitality, care, and empathy from nurses and everyone who works at the Medical Center. It’s easy to make excuses and point fingers about why this sometimes does not happen. I’d like us to consider the things we have some control over and greatly influence as nurses. Patient satisfaction is a critical nurse-sensitive quality indicator, which means that patient satisfaction is dependent on nurses and the quality of nursing care.

You may be reading this and thinking, “Why isn’t she addressing all of the other non-nursing issues that impact patient care?” I hope you believe that the myriad of issues that affect the patient experience are being addressed. But you and I can’t stop there — we need to look within ourselves and our profession to understand what nurses can do to improve the care delivered by nurses and nursing staff to our patients at this Medical Center. And we need to do this without offering up explanations, rationalizations, and justifications.

Rank the following items in order, from most to least important, if you were a patient:

Nurses always treated me with courtesy and respect.

Nurses always listened carefully to me.

Nurses always explained things in a way I could understand.

I always received help as soon as I wanted it for going to the bathroom or using a bedpan.

My pain was always well controlled.

Nurses always explained the medicines they gave me.

Nurses always explained the side effects of the medicines they gave me.

Nurses gave me information in writing about the symptoms or health problems to look out for after I left the hospital.

Nurses always took my preferences and those of my family or caregiver into account in decision-making.

My room and bathroom were always kept clean.

The area around my room was quiet at night.

After I was discharged, I had a good understanding of the things I was responsible for in managing my health.

When I was discharged, I clearly understood the purpose for taking each of my medications.

What were your numbers one, two, and three? It’s hard to rank these items, right? If I were a patient, I would want and expect each one of them. If my loved one was a patient, I would assertively advocate for all of them. They are reasonable expectations from a patient’s perspective. and when all are combined, they define our vision for nursing and patient care services: Privileged to Care, Passion for Excellence.

Can we be content to provide some of these items, but not all, to our patients? I can only answer that with questions: Are we okay being indifferent? Are we okay being mediocre?

Rather than being indifferent, I believe we need to find, in different ways, the connection with our patients to communicate our care, compassion, and high standards for nursing practice. Our current approach is usually but not always kind, caring, empathetic, and excellent. This is the simple yet difficult truth about our nursing care. We are good most of the time. We need to be excellent all of the time. What does this involve? The answers are in our patients’ voices.

These are their expectations of us:

Don’t tell me that you are tired — I’d rather be working than confined to this bed.

Don’t blame your colleague for something that didn’t go well for my care.

Apologize and explain without making excuses.

Please call me by my name, not a term of endearment.

Make eye contact with me — I’m frightened.

I can hear you when you talk with each other; it’s hard to listen to your plans for this weekend when I have to be here.

I worry when you get your information about my plan of care from me instead of the team.

All I want to know is that you care about me as a person.

All of these comments, directly from our patients, speak to their need and desire for the human connection in health care and from their nurses. Offering this connection and compassion to our patients is in our DNA. Offering it with every patient interaction will distinguish the patient experience in many positive ways … in different ways.

Reference1. Nass, C. and Yen, C. (2012). The Man Who Lied to His Laptop: What We Can Learn

about Ourselves from Our Machines. Penguin Publishing Group.

views&news7

Unlocking the Mysteries of Portfolio Patient Numbers and What the Wristband Has to Tell You Sarah Waters, BA, MPhil, Internal Communications Director

The tight link between clinical and registration/scheduling/billing functions in Portfolio, the Medical Center’s electronic medical record system, has implications far beyond what this article can explain. But understanding one consequence of that link – the many patient numbers in Portfolio – will make the transition easier for nurses and Patient Care Services (PCS) staff. The article below explains the four main numbers in the patient’s record, what they represent, how they are used in Portfolio, and where you will see them. Once you understand them, you will never have to worry about them again.

There are four kinds of numbers to be aware of in Portfolio: ◗ the medical record number (MRN); ◗ the contact serial number (CSN); ◗ the hospital account record number (HAR); and, ◗ the trauma number (TR — which is trauma-specific).*

*Only patients who received care in the Shock Trauma Center will have a trauma number.

Before we begin, it’s important to understand that when we move to Portfolio, patient look-up will not be as prevalent as it is today. Clinical applications in Portfolio provide short lists of relevant patients to choose from for every workflow. This feature makes the need for patient look-up fairly rare.

Portfolio’s integration of clinical, registration, and billing functions will impact many workflows for UMMC nurses and PCS staff. Getting a handle on the variety of numbers Portfolio uses to track patient information means taking a giant step toward understanding this new, integrated tool.

The medical record number (MRN) identifies a patient by facility. The MRN is useful, but somewhat tricky in Portfolio. The same patient seen at two different UMMS hospitals has two different MRNs. On the other hand, there are multiple MRNs in use across the University of Maryland Medical System, some of them identical. Use the MRN in reporting issues or looking up a patient, but be sure to always combine it with a second identifier, such as the patient’s name.

The contact serial number (CSN) is the easiest patient identifier to use. The patient’s primary contact serial number (CSN#) is the only unique identifier for him/her in the Portfolio system. You just have to understand one thing: during a patient’s inpatient stay, each visit to a procedural area will generate an additional CSN. Luckily, the primary CSN will not change. It can be distinguished from “non-primary” CSN numbers because it is given upon admission and appears on the patient’s wristband after the characters “CSN#.” (See graphic on page 8.) Use the CSN to look up a patient if you need to. (See tip box on pages 8-9). But only use the primary CSN.

The hospital account record number (HAR) is purely a hospital billing number in Portfolio. It is used to gather all charges related to a particular hospital stay, clinic visit, or series of clinic visits onto a single bill. Most nurses and other clinicians won’t use the HAR, but they will see it in the record and on the wristband, so it’s useful to understand its meaning.

The trauma number (TR) indicates that the patient is receiving care related to whatever event led to an admission to the Shock Trauma Center (e.g. car accident). Even if a patient comes in for surgery several months after his/her accident, if the care is related to the accident, you will see his/her TR number.


Summer 20158

Type of Number Definition Who uses it and how? Where does it appear?

Medical record number (MRN)

The medical record number identifies a patient by facility.

There are three types of MRN numbers in Portfolio:1. The Facility MRN 2. The Quadramed Enterprise patient

Identifier 3. The Portfolio Enterprise MRN, which is

system assigned and the one you see between brackets that look like this: < >

Facility-specific MRNs will continue to be assigned based on legacy formats.

Clinical users:The MRN is used for patient look-up and/or to report a problem:Just keep in mind: A patient can have many MRNs. One patient can have many identities. Here’s an example:• MRN without leading zeroes for

a particular facility• MRN for the Quadramed System• MRN for Epic Enterprise ID

One patient can have many identities. An MRN search will find every identity for every patient that contains the number searched. Always use the MRN with another patient identifier.

Display of MRN is context based: It depends on your login department.

If you are logged in to a UM rehab department, for example, you will see the facility specific UM rehab MRN.

If you are logged in to a UMMC department, and you look up a St. Joseph patient who has never been seen at UMMC, a Portfolio number called the Enterprise MRN will display in <> brackets.

Contact serial number (CSN)

The CSN is a unique identifier to identify each patient contact or “encounter.” An encounter in Portfolio can be a hospital admission, office visit, or a procedure a patient undergoes while in the hospital. The three most important aspects of the CSN for nurses/PCS staff to understand: 1. A patient will normally have multiple

CSNs. 2. The primary CSN (the CSN given at

admission) is the only CSN number that inpatient nurses/PCS staff need to pay attention to. The primary CSN appears on the patient’s wristband.

3. In clinical workflows, the patient can be found on the patient list associated with the module. If needed, use the primary CSN for patient look-up.

Clinical users:Used for dictation.Associates patients with specific encounters.

Access/Registration users:Used to differentiate between encounters when communicating with other users.

Third-party system users:• CSN is used by third-party

systems to tie encounters from Portfolio to encounters in other systems.

• The CSN is also used as a scanning identifier.

• Registration• Patient station*• Labels/wristbands• Chart• Dictation/scanning• Ancillary systems• Patient headers• Reports• Columns

* The Patient Station is used by both clinicians and patient access staff (PAS). It shows the many encounters, HARs, and MRNs for one patient.

Although you will rarely have to look up a patient in Portfolio, since short lists of your patients appear in every clinical module, the most direct way do it is to type in “csn.[ TYPE PRIMARY CSN# HERE]” You can use this method wherever a search box appears, even if the search box is asking for the patient’s name and/or MRN. Typing “csn.[TYPE PRIMARY CSN# HERE]” yields information about the one, unique patient you are seeking.

Caution: the CSN has to be entered perfectly.Example: csn.5001006756

Portfolio Patient Numbers, continued from page 7.

PATIENT LOOK-UP: THE SECRET TO TAKING THE EASY ROUTE


views&news9

Type of Number Definition Who uses it and how? Where does it appear?

Hospital account record number (HAR)

The HAR is a billing number used to group all charges related to a hospital claim. It is a financial identifier linking the patient’s encounter to his/her hospital account. Where STAR or Meditech have account numbers that also serve as visit numbers (same number serves two purposes), Portfolio has one Hospital Account Number, under which several contacts, procedures, and a hospital admission can fall.

PAS/Registration users:The HAR is used by PAS staff and others during registration/scheduling.

Billing users:Used to group charges related to a claim using the HAR.

• Registration• Billing Scenarios• Account Maintenance• HDM Coding System• Midas System

Trauma number (TR)

The trauma number indicates that a patient is receiving continued care related to an injury or illness that led to a Shock Trauma Center admission. The TR is tied to the Shock Trauma episode of care. Subsequently, single or multiple encounters in trauma could be linked to a Shock Trauma episode of care.

PAS/Registration users:A TR is assigned upon admission to the Shock Trauma Center.

Clinical users:• Trauma Registry needs the

Trauma Number• Cerner Blood Bank • FormFast System

• Patient Wristband (but only if patient is getting care as the result of some event that led to an admission into the Shock Trauma Center.)

• Trauma Registry needs the Trauma Number

• Cerner Blood Bank • Form Fast System

Portfolio Patient Numbers, continued from page 8.

PATIENT LOOK-UP: THE SECRET TO TAKING THE EASY ROUTE

Three identical 3D barcodes used for BCMA, repeated in different areas of the wristband in case one location is easier to scan than the others.

The Account Number here is actually the Hospital Account Record number (HAR), which is important only for billing purposes. Do not try looking up a patient by his or her HAR. Use csn.[Primary CSN] or MRN + a second identifier.

2D barcode identifies patient exactly as 3D barcodes do. Use 2D for glucometer scanning, even during downtime.

TR# shows that this patient is now in your area getting care related to whatever caused them to be admitted to the Shock Trauma Center.

Primary CSN; (use csn.5001006796 to look up this patient)

MRN identifies facility

How to read the Portfolio-generated wristband

Summer 201510

PATIENT CARE SERVICES | REHABILITATION

Peace, Harmony, and Kinship: Integrating Teambuilding, Yoga, and Reiki as a Resource for Staff Well-beingDiana Johnson, MS, PT; Carly Funk, DPT, PT; Katherine Frampton, MS, OTR/L; and Alyson Greenberg, rehabilitation aide

It is well-known that health care workers are susceptible to burnout, which can affect patient care.1 Being aware of this, the Department of Rehabilitation Services has created an outlet to help reduce stress and promote teamwork among staff. The Peace, Harmony, and Kinship (PHK) workgroup was developed in June 2014. The mission of PHK is to facilitate team-building among staff by creating opportunities for them to bond through various activities.

It is a multidisciplinary collaboration under the oversight of Diana Johnson, MS, PT, director of rehabilitation services. She also provides oversight and support to clinical nutrition and respiratory care services. Carly Funk, DPT, PT; Alyson Greenberg, rehabilitation aide, registered yoga instructor and Reiki Master; and Katherine Frampton, MS, OTR/L, lead the rehab PHK group and work to promote well-being by providing monthly sessions for the staff to engage in holistic health and wellness activities.

The concept of PHK was developed after a yoga session was offered to the rehabilitation leadership staff at its annual retreat. The aspects of team-building and overall well-being were so well received that Funk, Frampton, Greenberg, and Johnson felt it would be beneficial to offer this experience to all staff within the department. National Rehabilitation Week in September of 2014 provided a great opportunity to initiate a department-wide team-building activity. Staff participated in a challenge called The Golf Ball Drop. They were divided randomly into teams and instructed to work together using limited resources to create a structure that would catch a golf ball dropped from chair height. This activity fostered relationship-building among rehabilitation staff (assigned to different work areas/service lines) who may not normally see one another on a daily basis. The collaboration among staff was evident and they learned to work together using creativity to solve a common problem. This type of skill is frequently required of our therapists when working with other disciplines on the patient care units. From here, PHK expanded to offer additional activities.

Monthly PHK sessions were created to provide staff with an opportunity to recharge and take a break from the hectic work day. Each monthly session is tailored to the needs of the staff, most often including gentle Reiki, yoga, and healthy snacks. PHK has also incorporated the resources of the Integrative Care Team

to offer a sound healing therapy session. Most recently, PHK sessions have expanded to include staff from clinical nutrition and respiratory care services. Jennifer Sauers, DPT, a physical therapist, says “The PHK events are a very valuable resource for me. I have attended four events over the past several months and I always leave feeling relaxed, refreshed, and ready to take on the rest of my day. Not to mention that there are always great snacks to munch on and great people to catch up with! Alyson, Katie, and Carly always ensure that everyone feels comfortable, adapting the yoga sessions to fit all skill levels and abilities. In this fast-paced, busy environment, having an outlet to relieve stress is very important, and I’ve found the PHK events to be just the right thing for me.” April 2015 was National Occupational Therapy (OT) month and PHK collaborated with UMMC occupational therapists to offer specific events to meet the needs of the occupational therapists. This included a team-building activity to create an OT Month Quilt expressing each individual’s definition of occupational therapy. Each staff member was asked to create a panel using craft supplies and all panels were strung together to create one quilt. This activity fostered creativity, unity, and time for staff to come together for a social lunch hour. April’s monthly PHK session was also tailored to support OT month and included chair yoga. Chair yoga was an opportunity for staff to relax, as well as learn new techniques that could be used in patient care. Research shows that chair yoga can reduce blood pressure and the physiological and psychological markers of stress.2 Staff found this to be true by helping alleviate the stress of the day and encourage mindfulness. Mindfulness is the practice of being aware and observing one’s own thoughts and emotions and staying present in the moment.3 “This is a great group!! I have learned many simple and effective techniques that can be easily completed while at work to bring my mind and body to peace and harmony. Some of the sessions I have attended include chair yoga and the OT month team-building activity. I’m grateful to have this opportunity in the workplace,” says Amandeep Kaur, OTR/L, occupational therapist.

The PHK activities have been successful and overall feedback has been positive. The group has provided resources and various opportunities for staff to collaborate and take time to improve overall well-being. PHK continues to grow and adapt new activities to the needs of staff so that all are better equipped to handle the challenges of this fast-paced academic medical center.

References1. Hartfiel, N., Havenhand, J., Khalsa, SB., et al. (2011). The effectiveness of yoga for the

improvement of well-being and resilience to stress in the workplace. Scandinavian Journal of Work, Environment & Health, 37 (1), 70-76.

2. Melville, G., Chang, D., Colagiuri, B., et al. (2012). Fifteen minutes of chair-based yoga postures or guided meditation performed in the office can elicit a relaxation response. Evidence-Based Complementary and Alternative Medicine, 2012, ID 501986.

3. Bishop, S., Lau, M., Shapiro, S., et al. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11 (3), 230-241.

views&news11

Using Lean Principles and Transformational Leadership to Improve Therapist ProductivityDiana Johnson, MS, PT; Kristie Snedeker, DPT; Michael Swoboda, MPT, OCS; Cheryl Zalieckas, OTR/L; Rachel Dorsey, MS, OTR/L; Cassandra Nohe, PT, DPT; Paige Smith, MA, CCC-SLP; and Renuka Roche, PhD, MS, OTR/L

When working to earn degrees in occupational therapy (OT), physical therapy (PT), and speech-language pathology (SLP), the focus is on skill acquisition and learning to apply entry-level knowledge. Novice clinicians entering the workforce quickly recognize the need to be accountable for management of administrative functions as well as clinical decision making. Meeting the organization’s productivity standard is one administrative function that can be challenging to novice and experienced clinicians alike (Malone, 2010). Even so, the management of productivity and the need to maximize efficiency is inescapable, because these concepts are both linked to cost containment (Kovacek, 2012).

The Department of Rehabilitation Services at UMMC is generally divided into inpatient (IP) or outpatient (OP) multidisciplinary divisions. Historically, UMMC used relative value units (RVU), cost per workload unit (CPWU), and hours per workload unit (HPWU) to measure productivity and efficiency; however, therapists expressed that these targets were irrelevant to daily practice. In an effort to make the productivity targets more meaningful, therapists were given a choice of meeting one of two targets: (1) numbers of patients treated, or (2) percentage of time spent performing billable patient care. Even so, compliance with meeting targets was only 16%. With increasing demands for services and an inability to add more staff, rehabilitation (rehab) leaders devised a plan to improve productivity.

METHODS

Getting Organized — The rehab department engaged in a benchmarking process and determined that productivity standards should be reset, giving consideration to therapist role and population served. One of two metrics was assigned to each therapist; (1) percentage of billable time primarily assigned to OP therapists, or (2) number of patients seen primarily assigned to IP therapists. A productivity task force (PTF), made up of front-line therapists, was assembled and charged with examining practices around productivity. Assistance was sought from the UM Center for Performance Innovation who worked with the PTF to teach them the principles of Lean, a quality improvement philosophy originated by the Toyota Motor Company (Wojtys, Schley, Overgaard, & Agbabian, 2009). Specific barriers to success were identified. Next, the group created visible productivity tools for therapists to use daily. Buy-in and participation were secured from leaders and front-line staff.

Applying the Knowledge — The PTF identified three key areas for improvement: communication, equipment management, and time spent for lunch breaks. A standardized hand-off communication methodology, which the team called the 4Ps, was instituted across the IP areas. The PTF improved equipment management by using the 5S Process, a Lean methodology of organizing and standardizing work spaces (Holden, 2011). The time spent for lunch breaks was found to be variable throughout the department; therefore, expectations were clarified and a daily tracking tool was created.

Next, team productivity tracking boards were installed, which enabled therapists to track daily individual and team outcomes. Comment space allowed staff to list productivity barriers. Outcomes from each team were transferred to a centrally located leadership audit board. Leaders used this information to monitor team progress and respond to staff needs.

Accountability and Support — Rehabilitation leaders worked to transform the environment by paving the way for culture change, securing staff, and executive buy-in, establishing accountability measures, and building employee support models. Levin and Gottlieb (2009) stated, “Culture develops and evolves slowly over time. It is simply not realistic to think it can be changed quickly.” (p. 45) Understanding that transforming the culture would be a challenge, the human resources (HR) department at UMMC was asked to help. HR observed therapists in their work environments and provided education to staff on time management and barrier recognition. HR representatives were available for private and team coaching as needed.

Therapists then began to understand how to take control of problem resolution in order to maximize productivity. Without exception, there was an expectation that both staff and leaders would be committed to the process. Coaching, role modeling, and performance management were implemented for those having difficulty. A culture of open communication was established so staff could question processes and make suggestions.

Results — When comparing FY12 to FY13, compliance with meeting productivity targets increased from 16% to 77%. The improvement was sustained and in FY14, department compliance was 73%. Two-tailed paired t-tests revealed statistically significant improvement in efficiency and productivity for IP therapists as more patient encounters occurred while taking less time.

Efficiencies gained for the IP division equated to having 3.2 additional full-time therapists on staff. Unfortunately, there were no statistically significant differences in the mean efficiency or billable hours for the OP division.

In FY13, leaders addressed 21 barriers to improving productivity identified by staff. Therapists’ attitudes toward the productivity initiative softened and several who had been resistant to the process reported feeling more satisfied at the end of their shifts. During FY13, eight therapists were placed


Summer 201512

Advocating for Advanced Practice NursingMary Ellen Connolly, MSN, CPNP, Nurse Practitioner Pediatric Surgery, University of Maryland Medical Center

In October 2015, nurse practitioners (NPs) in Maryland will be joining a growing number of their counterparts nationwide who are employed in states with legislation that promotes full practice for NPs. A recent review analyzed the impact of nurse practitioners on health outcomes and demonstrated a strong relationship between full practice authority for advanced practice nurses (APNs) and decreased re-hospitalization rates for patients receiving medical assistance (Oliver, Pennington, Revelle, & Rantz, 2014). The authors also noted that residents in nursing homes in full practice authority states were less likely to require hospitalization. Better overall health outcomes were reported in states with APN full-practice legislation in place.

A large majority of Maryland legislators recognized the benefit of full practice authority for NPs and supported the Nurse Practitioner Full Practice Authority Act of 2015, signed into law by Governor Hogan in May of this year. Maryland now joins 20 other states and the District of Columbia in allowing NPs to practice to the full scope of their education and training. Maryland’s new regulation also complies with the 2011 Institute of Medicine (IOM) report that recommends advanced practice nurses practice to the full extent of their training and education with no barriers to practice. This piece of legislation will go into effect October 2015 with the following changes: (1) NPs will no longer be required to name a physician with whom they will collaborate, and (2) provides for an 18-month mentorship period for a new graduate NP. Previous requirements that a NP be a registered nurse who has completed a masters or doctoral program in nursing, as well as clinical hours in advanced practice, and pass a national certification examination in order to practice, remain the same.

What’s so good about this? Many states limit prescriptive authority, and require physician oversight or supervision, which limits the NP scope of practice. These barriers or limitations on practice occur despite evidence that demonstrates improved outcomes when the NP is allowed to practice to the full extent of his or her training and education. In these states, as in Maryland, prior to 2010, there is a need for a collaborative agreement. This document could be 20 pages in length and requires the nurse practitioner to identify a physician or physician group with whom they practice, and in some states, who will supervise their advanced nursing practice. As physicians move medical practices, these agreements need to be revised, causing the NP work or license to be challenged. Seeking Board of Nursing approval for the initial agreement and any subsequent changes takes many weeks. Additionally, insurance companies can attempt to put constraints on NP practice based on physician panels. Even since 2010, the state of Maryland’s attestation process was considered a barrier to practice. Although it streamlined the collaborative agreement process, the legislation was interpreted to require approval by the MBON, which was done only monthly, often slowing the NPs’ employment onboarding and readiness to practice. Maryland practitioners look forward to a more streamlined process, thanks to these legislative changes.

Of final importance to all nurses, patients and physicians is the provision that will mandate that new graduate nurse

practitioners name an experienced NP or physician to act as a mentor for the first 18 months of his or her practice. Even nurse practitioners who move to Maryland will require a mentor for 18 months. The mentorship process is welcomed by nursing organizations throughout the state and will be seen as a benefit to the new graduate nurse practitioner. The mentorship role is familiar to nurses who routinely participate in an orientation process with a preceptor after graduation from undergraduate studies. The new NP will be well positioned to transition from expert nurse to novice provider and should be eager to work in a state that promotes such supportive mentoring in the context of a full practice environment.

Policy and legislation advocacy are part of our nursing responsibility. Carmel McComiskey, DNP, CRNP, FAANP, director of NPs and PAs at UMMC, supports full practice authority and the removal of the attestation process. She says, “This legislation streamlines the licensing requirement in Maryland but does not change our scope of practice. It is even more important now for hospitals to understand the importance of APRN education, accreditation, certification, and education in order to assure that NPs have the appropriate education and license to care for each specific patient population.” The NP community at UMMC is grateful to the Nurse Practitioner Association of Maryland (NPAM), the Maryland Nurses Association (MNA), and the Maryland Academy of Advanced Practice Clinicians (MAAPC), who worked together to advocate for the Nurse Practitioner Full Practice Authority Act. Shannon Idzik, DNP, CRNP, FAANP, a member of the NPAM legislative committee, an associate professor and an assistant dean, Doctor of Nursing Practice Program at the University of Maryland School of Nursing, and a practicing nurse in the UMMC Emergency Department and PREP Center, reports that the team “focused on strategies such as building relationships with legislators at fundraisers, and attending Nurses Lobby Night.” She shared that the group developed strong sponsorship of the bill in the House of Delegates. When the bill was up for a vote, the alliance garnered grass-roots support from its members who contacted legislators with phone call and emails. Reflecting on this experience, Idzik believes the success of the passage of the Nurse Practitioner Full Practice Authority Act can be related to years of hard work advocating for nurse practitioners. She also notes that The Affordable Care Act has made increasing the numbers of primary care providers and improving access to health care a key focus


views&news

Advocating for Advanced Practice Nursing, continued from page 12.

for legislators. Maryland lawmakers recognized that the NP is able to meet the growing health care needs of the people.

Idzik encourages nurses who are novices in the advocacy arena to get involved. A first step is joining a nursing organization and volunteering for committee work. Nursing organizations are always looking for new members and leaders with new ideas. MNA sponsors an annual Nurses Lobby Night in Annapolis. This is a great way to meet face-to-face with legislators who welcome your visit. At Lobby Night, the MNA helps guide discussions with elected officials through the development of talking points. This assists in providing a focus for local meetings. Information to register for Nurses Lobby Night will appear on the MNA website in early 2016.

At the organizational level, there are also opportunities to get involved in advocacy work. Claudia Handley, MS, MBA, RN, manager of STC Multi-Trauma IMC/Critical Care 5, is chair of the legislative committee at UMMC. The committee is made up of nurses, physicians, social workers, and APNs, who focus on legislative actions surrounding trauma care. The group meets

every other week during the Maryland legislative session and reviews proposed legislation. Several committee members have given testimony to the legislature voicing their support or concerns related to proposed bills. The legislative committee is interested in expanding the focus of this group beyond trauma legislation. An educational session is being planned for late summer and meetings will begin again in the fall to prepare for the upcoming legislative session. For more information, contact Handley at [email protected]. In addition, if you are a nurse considering further education to become a nurse practitioner, now may be the time to pursue your studies and practice in a state that supports full practice for NPs.

ReferencesThe Institute of Medicine. (2011). The future of nursing: Leading change, advancing

health. Washington, DC: The National Academies Press. Practice NursingKingdon, J., W. (1995). Agendas, alternatives, and public policies. New York: Harper

Collins College Publishers.Oliver, G., Pennington, Revelle, S., Rantz, M. (2014) Impact of nurse practitioners on

health outcomes of Medicare and Medicaid patients. Nursing Outlook. 62, 440-447.

13

Summer 201514

The University of Maryland Medical System (UMMS) has met these challenges with the opening of University of Maryland eCare in April of 2013. eCare is a tele-ICU care delivery model that brings together experts in critical care and technology. This tele-ICU program utilizes two-way sophisticated audiovisual equipment and smart software to provide collaborative patient care. The central monitoring location of the tele-ICU is the “COR,” or central operations room. UM eCare is one of over 60 CORs in the U.S. and is located in the Paca-Pratt building on the downtown campus of UMMC. This COR is an associated care partner with 11 other hospitals (12 ICUs) throughout the state of Maryland, of which five are part of the University of Maryland Medical System: UMMC Midtown Campus; University of Maryland’s Shore Medical Centers at Chestertown, Dorchester, Easton; and Charles Regional. It is staffed 24/7 with experienced critical care nurses and data coordinators and, from 7 pm to 7 am, with a board-certified critical care intensivist.

Tele-ICU nursing is a subspecialty of critical care nursing that is still in its infancy. The American Association of Critical-Care Nurses (AACN) has been a leader in establishing both guidelines and recommendations for this nursing specialty, urging the development of solid research evidence to continue to develop the

practice (AACN, 2013). The rapidly changing and diverse nature of tele-ICU nursing practice requires nurses to be experienced, deft, and collaborative in order to create the finest environments and models for advancing the practice. (AACN, 2013)

ReferencesAmerican Association of Critical Care Nurses (2013). Tele-ICU Nursing Practice

Guidelines. Retrieved from http://www.aacn.org/wd/practice/docs/ tele-icu-guidelines.pdf

American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf McEwen, M., & Wills, E.M. (2011). Theoretical basis for nursing, (3rd. ed.). Phila

Ball, M. J., Douglas, J. V., Hinton Walker, P., DuLong, D., Gugerty, B., Hannah, K. J., Troseth, M. R. (Eds.). (2011). Nursing informatics: Where technology and caring meet (4th ed.). London, England: Springer-Verlag.

Bashshur, R. L., Shannon, G. W. (2009). History of telemedicine. New Rochelle, NY: Mary Ann Liebert.

Gajic, O., Afessa, B. (2009). Physician staffing models and patient safety in the ICU. American College of Chest Physicians, 135, 1038-1044.

Halpern, N. A., Pastores, S. M., Greenstein, R. J. (2004). Critical care medicine in the United States 1985-2000: An analysis of bed numbers, use, and costs. Critical Care Medicine, 32, 1254-1258.

Munro, C. L. (2010). The lady with the lamp illustrates critical care today. American Journal of Critical Care, 19(4), 35-317.

Tele-ICU Nursing, continued from page 1.

Anita Witzke, MS, RN, Director of UM eCare, and Elaine Comeau, RN, MS, FACHE, Chief Nursing Executive, H2H Philips Healthcare

Witzke Receives Philips Healthcare’s eXcellence in Innovative Leadership Award

In June of 2015, Anita Witzke, MSN, RN, director of UM eCare, was recognized as an innovative leader in the advancement of tele-ICU nursing.

Her national efforts were acknowledged during the Philips Spring Leadership meeting in Chicago, where she received the eXcellence in Innovative Leadership Award for her cutting-edge work in establishing the COR Connections Webinar Series. This initiative has brought the tele-ICU nursing community together to collaborate on practice, discuss key issues, and find creative solutions to shared concerns. Text taken directly from the awards program described the reasons why Witzke received this year’s award. She “exudes authentic leadership qualities through her dedication to care transformation and collaboration with her tele-health partners. Her work has not only strengthened the tele-ICU nursing community but has been instrumental in advancing practice through leadership and scholarship. The AACN (2006) defines scholarship in nursing as discovery, teaching, applications, and integration, and Anita’s efforts have certainly reflected that principle. She is truly a pioneering spirit and a wonderful asset to the UM eCare program and the national tele-ICU nursing community.”

The COR Connections Webinar Series began on the premise that the majority of tele-ICU CORs had little to no exposure or contact with other CORs in the U.S. A preliminary outreach survey to nationwide CORs demonstrated this to

be true, with 81% of responses confirming that they “very rarely” to “never” had contact with other CORs. Therefore, the first COR Connections Webinar was developed to close that communication and collaboration gap. Currently, 17 tele-ICU CORs from across the U.S. communicate via webinar on a bi-monthly basis. To date, five webinars have been conducted at various times and with various structures from organized content to open-forum formats. Topics have included: demographical data sharing, relationship building strategies and successes, workflow practices, shared success stories and innovations, and interest in establishing a professional network. The most recent growth in this webinar connection has been focused on the possibility of establishing a more formal collaborative platform or network through the AACN.

views&news15

The Rising Cost of Medications Ryan G. D’Angelo, PharmD, PGY-2 Pharmaco-therapy Resident, University of Maryland Medical Center, University of Maryland School of Pharmacy

Medication costs are often the largest components of a hospital system’s pharmacy budget and are continuing to increase more quickly than other health care costs.1 During the 2014 fiscal year, hospital prescription medication costs exceeded $29 million, accounting for more than 8% of total pharmacy expenditures, a nearly 5% increase from the prior year.2 As hospital systems succumb to more and more drug shortages, increasing generic medication costs, and increased time and resources spent managing shortages, the trend becomes more frightening.

Unfortunately, not just new “blockbuster” medications are making a fiscal impact; the price of nitroprusside and isoproterenol, two cardiovascular medications that have been on the market for quite some time, rose 512% and 212%, respectively, when the rights were purchased by Valeant Pharmaceutics International.3 At the University of Maryland Medical Center (UMMC), efforts have been underway to decrease the overall cost of drugs while ensuring patients receive appropriate therapy and care.

There are many proposed theories as to why medication costs are skyrocketing at such a swift pace. Multiple sectors within the commercial and pharmaceutical industry are likely responsible; new highly demanded medications, changes in wholesale distribution channels, and drug shortages seem to be the likely culprits.3,4,5 Also, with the recent implementation of the Affordable Care Act (ACA), more people are becoming consumers of medications, which increases demand and ultimately the price point. Drug shortages are also playing a large role in the rising cost of medications. There were 267 drug shortages reported by the American Society of Health-System Pharmacists

(ASHP) during 2011. Indirect costs of drug shortages are also increasing as more nurses, pharmacists, and pharmacy technicians are spending more time managing issues related to the shortages.1,6 According to ASHP, these costs have been estimated to be near $215 million.

Newer pharmaceutical agents being produced for cancer, hepatitis C virus (HCV), and drugs belonging to the orphan drug class are also driving up medication costs. In 2012, 11 new oncology agents were approved by the U.S. Food and Drug Administration (FDA). Each of these agents cost more than $100,000 each year.7 Even older chemotherapy agents, such as imatinib, are experiencing increased costs. Imatinib was originally developed to treat chronic myelogenous leukemia (CML). In 2001, the drug cost $30,000 per year; however, in 2014, the cost increased threefold to $90,000.7 In 2013, the FDA approved sofosbuvir for the treatment of HCV, which was thought to be a major breakthrough in the infectious disease world. When it was brought to market, each tablet of sofosbuvir cost $1,000, or $84,000 for a 12-week treatment course, making it the top selling medication in terms of expenditure in less than a year.5,8 New pipeline medications expected to hit the market soon will likely follow suit, further increasing medication costs. Hospitals will have to carefully review formulary additions and policies to ensure costs are controlled while still providing patients with the most up-to-date and effective therapies.

You may have noticed that the UMMC pharmacy department and hospital administration have made an effort to evaluate rising costs of certain medications. We are reviewing certain high-cost medications, such as intravenous acetaminophen and erythropoietin, and implementing appropriate restrictions while maintaining patient care and safety in an effort to compensate skyrocketing medication costs. During the last year, over 30 medications have seen significant cost increases, some with greater than 1000% increases. Policies regarding cost-effective medication use have been implemented to assist with fiscal responsibility and optimizing patient care. Pharmacists

and medical staff within the hospital system are also taking responsibility to manage medication therapy with cost effectiveness in mind, while also providing optimal patient care. The policies and recommendations being put forth are likely to save the Medical Center several million dollars each year while ensuring UMMC provides the most effective and safest care possible.

With such a vast landscape of factors affecting medication prices, it is unrealistic to expect significant changes in medication prices in the near future. Identifying factors such as drug utilization, policies and protocols, and drug use optimization may be effective at reducing the burden of expanding medication budgets. Each member of a health care system has the responsibility to impact medication use in a positive way. More prudent assessment of patient requirements for medications, especially high-cost medications, and appropriateness of therapy can reduce the financial burden that face all hospitals.

References1. ASHP Expert Panel on Medication Cost Management.

ASHP guidelines on medication cost management strategies for hospitals and health systems. Am J Health Syst Pharm. 2008 Jul 15;65(14):1368-84.

2. Schumock GT, Li EC, Suda KJ, Wiest MD, Stubbings J, Matusiak LM, Hunkler RJ, Vermeulen LC. National trends in prescription drug expenditures and projections for 2015. Am J Health Syst Pharm. 2015 May 1;72(9):717-36.

3. Shinkman, R. Drug company business practices drive up hospital costs. http://www.fiercehealthfinance.com/story/drug-company-business-practices-drive-hospital-costs/2015-04-28. Published April 28, 2015. Accessed July 7, 2015.

4. Caramenico, A. Drug shortages force increased hospital costs, medication errors. http://www.fiercehealthcare.com/story/drug-shortages-force-increased-hospital-costs-medication-errors/2013-03-25. Published March 25, 2013. Accessed July 7, 2015.

5. Drug costs projected to rise in hospitals, other settings. http://www.pharmacist.com/drug-costs-projected-rise-hospitals-other-settings. Published July 1, 2015. Accessed July 7, 2015.

6. Weinstock M. Keeping pharmacy costs in check. Hosp Health Netw. 2012 Jun;86(6):59, 57.

7. Kantarjian H, Rajkumar SV. Why are cancer drugs so expensive in the United States, and what are the solutions? Mayo Clin Proc. 2015 Apr;90(4):500-4.

8. Linas BP, Barter DM, Morgan JR, Pho MT, Leff JA, Schackman BR, Horsburgh CR, Assoumou SA, Salomon JA, Weinstein MC, Freedberg KA, Kim AY. The cost-effectiveness of sofosbuvir-based regimens for treatment of hepatitis C virus genotype 2 or 3 infection. Ann Intern Med. 2015 May 5;162(9):619-29.

Spotlight on Pharmacy

Summer 201516

2015 Student Nurse Residency Program Cyndy Ronald, BA, Manager, SON Partnership Programs

The University of Maryland Medical Center’s (UMMC) Student Nurse Residency Program has just completed its ninth year. This highly competitive program has been a valuable recruitment tool for top new graduate nurses at the Medical Center – over 70% of last year’s residents have been hired as new graduate nurses, many of whom have already started here this past summer. The summer internship places students entering their senior year of nursing school on units ranging from acute to critical care in a variety of specialties. While here, they work one-on-one with a nurse preceptor (three 12-hour shifts/week), attend bi-weekly education sessions, complete journals, and develop an evidence-based poster, which they presented in the Weinberg Atrium on August 6th and 7th.

The interview process was changed this year to a group format. The students were given an article to review one week prior to their interview, along with the rubric for scoring for the group assessment. There were no more than eight students per group and one facilitator. Two individuals from Clinical Practice and Professional Development (CPPD) observed and scored the students. After this group discussion, the students were then taken to the computer lab, where they were given a writing prompt and had 30 minutes to respond.

The scores for both assessments, along with their resume and letters of recommendation (two from instructors or faculty were required), were used to select the students. We had 120 students take part in the process and selected 45 students from 12 different BSN schools.

The students started on June 1st and many shared the same emotions of excitement, anxiety, apprehension, and insecurity. Through their sessions with mentors from CPPD, and reports from preceptors and journal entries, we are happy to report that that each resident learned a great deal during the ten weeks and increased his/her skills and confidence toward becoming a competent, safe, and compassionate nurse. The students could not say enough good things about their time here. The units, preceptors, senior leadership, and others whom the students interacted with embraced them, supported them, and offered multiple opportunities for learning. Because of this incredible experience, the students feel they are well on their way to transitioning from student to new graduate nurse, and will emulate the positive professional behaviors they witnessed.

We are extremely proud of this group of student nurse residents. Following are some excerpts from their last journal entries speaking to the UMMC culture and their experiences. Next to their name is the unit on which they did their residency and the school of nursing they are attending. continued on page 17.

views&news17

Brenna Nave, PICUEast Carolina UniversityIt’s hard to put into words how grateful I am for this experience. I spent my summer working with the sickest of kids. I spent my summer comforting crying parents. I spent my summer cradling a crying baby at 3 am. I spent my summer waking up at 5 am and getting home at 8:30 pm. But I also spent my summer watching kids walk out the PICU with a smile on their faces. I spent my summer watching parents cry tears of joy when we tell them their child will be going home. I spent my summer playing with kids who feel much better than they did the day before. I spent my summer leaving work feeling accomplished and rewarded for the job I had done. I was able to change so many peoples’ lives, and for that I am grateful.

Gianna Marchini, 13 E/WNotre Dame University of MarylandAs I sit here and reflect on the past nine weeks, I cannot help but feel a sense of immense pride and accomplishment. I have had such a rewarding and educational experience on 13 E/W. I know that I have laid a very solid foundation for myself as a future nurse. With the help of my preceptor, Kate, I was able to go from shy and timid to confident and assertive. It still perplexes me that an experience so short in time has provided me with a vast amount of knowledge that will stay with me throughout my career as a nurse. I know there is still so much more to learn about the profession I have chosen to dedicate my life to; but this experience reinforces the fact that every minute will be absolutely worthwhile.

Rachel Smith, NeuroCare ICU University of MarylandI really appreciate my time as a SNR and my time spent on the unit. I’m so thankful to have worked with such experienced and friendly nurses, helpful techs, knowledgeable respiratory therapists, and proficient LIPs. They have all taught me so much in the past two and half months — more than I could have possibly learned from my textbooks or a clinical experience. This experience has also reinforced my decision to change careers and become a nurse. When I transitioned into this career, my greatest fear was the actual skill part of nursing; I knew that I could handle the coursework but I was worried that I would be all thumbs. Thanks to this experience, I now feel more competent in the clinical practice.

Kira Graham, L&DUniversity of MarylandI would not trade the experience that I had this summer for anything. I have learned so much about myself in these few weeks. I always wondered whether I had what it took to be a nurse, and now I know I have what it takes. The fear and uncertainty is still there every time I clock in, but having a little more confidence and a whole bunch more knowledge quells some of those jitters. I am so thankful to each and every person who has taught me this summer, from my preceptor, to the staff on the unit, the organizers of this program, and yes, even the patients! Nursing is such an oxymoron of a profession, because it is exhausting yet so rewarding. Like Florence Nightingale said herself, “Nursing is one of the fine arts.” I had almost said, “the finest of fine arts.”

Maxine Cruz-am, CPCUStevenson UniversityDeath is inevitable for everyone. We all must live and we must die. We are taught that health care exists to alleviate symptoms, cure disease, and to improve a person’s physical and emotional well-being throughout life. Nurses walk with their patients every step of the way. What I learned from this experience was that care and respect does not stop when the patient passes away. We, as nurses, are given the privilege of caring for the body once the soul has left. We, as nurses, are given the privilege of caring for who is left: spouses, children, family, and friends. Death is not symbolic of how health care failed, but more so, it is a symbol of the work that needs to be done. One can use death as a catalyst to seek the best evidence-based practice, to seek further education into disease processes, treatment and prevention, and to gain more of an appreciation for human beings, in general. Nursing, in a way, transcends death.

Brittany Schuetzle, MICUUniversity of MarylandThe people we are surrounded by in our work environment have great power over our career experiences. The primary reason I will be able to reflect back on this summer program so positively is the staff on the MICU. Every nurse I encountered was very supportive with regard to my learning. My preceptor was patient and allowed me to take my time to think through things and practice skills that I had little experience with. In a lot of ways this experience has felt like riding a bike; I was initially very overwhelmed but I am now feeling more secure with my training wheels and looking forward to when they come off!

Student Nurse Residency Program, continued from page 16.

Left to right: Henry Inegbenosun, Morgan Dunlow, Brittany Schuetzle, Alena Antonova, and Jane Joo

Left to right: Jill Archibald and Diana Owen

Summer 201518

Certification Corner

Professional Organizations — A Great Way To Impact Your FuturePeggy Torr, BSN, RN, OCN, Senior Clinical Nurse I, UMMC Greenebaum Cancer Center

The Oncology Nursing Society (ONS) is a professional association of over 35,000 members dedicated to excellence in oncology nursing and cancer care. The Baltimore chapter has been in existence for over 32 years and has over 600 members from the greater Baltimore region of Maryland. Our members, on a local and national level, are administrators, researchers, educators, editors, publishers, advanced practitioners, and clinical staff nurses, all with the single goal of providing the best and safest care possible to this unique patient population. We come from varied practice settings, which include almost every medical institution, physician office, and pharmaceutical company throughout the region.

Since its official incorporation in 1975, ONS has become a leader in cancer care. It has grown to include more than 225 local chapters and advocates for oncology nurses at the national level. The Greater Baltimore Chapter of ONS (GBCONS) aligns with the national organization’s mission by planning and executing educational programs, which support evidence-based practice. This year, the programs committee planned for five dinner programs and a half-day of learning and networking. The 2015 Symposium, held on February 28th in partnership with the Leukemia & Lymphoma Society, provided our members with contact hours, an opportunity to personally sign on to our legislative efforts, and networking opportunities with survivorship coordinators at area hospitals.

GBCONS values recognition for the hard work and professional achievements of our members. We make announcements at all chapter meetings, as well as include a section of newsworthy accomplishments in the newsletter. This includes initial oncology certifications, graduations, presentations, awards, and publications. In 2014, GBCONS was awarded the much coveted ONS Chapter Excellence Award, which highlights the accomplishments of a chapter’s members.

The chapter conducts an annual OCN (oncology certified nurse) review course taught by chapter members. We support continuing education in oncology nursing by awarding an educational grant at each membership meeting, an annual grant to pay for the registration of two members at the annual National Oncology Congress, and a grant to pay for the successful completion of the initial oncology certification testing. This chapter has received awards for having the greatest number of certified nurses in a chapter.

The chapter supports the community by collecting for a designated non-profit at each of its chapter meetings. It also hosts an annual fund-raising event that increases awareness of oncology nursing while

raising funds for the local charities that support our cancer patients. We also provide support to the ONS Foundation, which provides scholarships to registered nurses who are interested in and committed to oncology nursing to continue their education by pursuing bachelor’s and master’s degrees in nursing.

Our board meets four times a year. We are proud to say that at this time, out of the 14 members in chapter leadership, UMMC nurses hold five of these positions. Our president, Trisha Kendall, MS, RN, OCN, is coming to the end of her two-year presidency. Kendall is passionate about and writes the Advocacy Corner for The Harbor Herald (GBCON’s newsletter), encouraging our chapter nurses to get involved by participating in Capitol Hill lobbying days and meetings with congress, and representing GBCONS at committee hearings in Annapolis. It was Nancy Corbitt, BSN, RN, OCN, CRNI, senior clinical nurse II, who had the pleasure of passing the torch mentoring Kendall. During her presidency from 2011-2013, Corbitt was instrumental in the chapter’s


The Harbor Herald is the newsletter of the Greater Baltimore Chapter of ONS.

views&news19

web page development and greatly increasing both certification and active membership. Nancy is now the program’s chair, which is no easy task considering the pharmaceutical regulatory guidelines continue to restrict this industry’s ability to support continuing education offerings. Lisa Malick, MS, RN, OCN, senior clinical nurse I, is on the Continuing Education Committee and works tirelessly to help the chapter in offering CEU

programs. Lisa strongly supports staying current with the latest developments in oncology, and believes “the pursuit of lifelong learning is vital to a successful oncology nursing career.”

The author of this article, Peggy Torr, BSN, RN, OCN, holds a position as a director at large. She has also had the privilege of being entrusted as the editor of The Harbor Herald. This has been a wonderful challenge with some big shoes to fill. GBCONS is a dynamic

group that encourages, supports, and mentors its members to continue to meet the challenges of the very changing oncology climate.

We invite you to like us on Facebook: https://www.facebook.com/page/Greater-Baltimore-Chapter-Oncology-Nursing

Certification Corner, continued from page 18.

Pre-Visit Planning in the Ambulatory ClinicsJacqueline Rodriguez, BSN, RN

In a busy multi-specialty medical clinic, it is no easy task to be proactive and predict the needs of patients so that the clinic is adequately prepared to receive them. Unprepared patients may have their appointment delayed or arrive without background information due to an inefficient pre-visit planning process. University Health Center (UHC) implemented a robust pre-visit planning process as a means to enhance preparedness of staff, providers, and patients.

After an appointment is made and several days pass before a patient is seen in the clinic, this is valuable time that can be used to prepare for the patient’s visit and ensure that all of their needs will be met.

Through intensive observations and data evaluation, gaps contributing to clinic preparedness and patient’s readiness were identified as follows: ◗ communication between schedulers and staff; ◗ no standard process evaluating the needs of staff; ◗ lack of employee empowerment; ◗ no use of electronic tools; ◗ patient gathering own records; and, ◗ MD review process delaying scheduling of appointments.

UHC introduced a new scheduling role of a pre-visit planner (PVP) to address several of these gaps for the rheumatology, gastroenterology, and internal medicine clinics. By utilizing

reporting features from EPIC, the PVP proactively works with patients to ensure that their follow-up lab tests have been completed before their next visit to UHC. One of the PVPs, Candice Westbrook, assists patients in gathering vital records that are needed if they are new to the clinic. They also collaborate directly with physicians to ensure that all elements needed for appropriate scheduling have been obtained. This allows the PVP to immediately schedule the appointment for the patient without delay and concurrently complete the review process with the physician, thus increasing patient and provider satisfaction.

Communication improvements included scheduling scripting, which allows the scheduler to identify the special needs of patients, such as those who are stretcher bound or who are at an increased risk of fall due to the use of a wheelchair or other assistive device. Lead clinical staff members utilize this information through the electronic medical record and disseminate it during huddles to ensure that the clinic is prepared for patients that may have special needs during their visit.

Significant improvements in workflow and patient satisfaction have occurred in primarily two areas. The first is how long it takes to schedule the initial clinic appointment. Originally, it took from 14 to 30 days before the first appointment could be made. Now, when the patient calls in, the appointment is scheduled immediately. The second area of improvement was related to the preparedness and completion rate of labs and/or imaging for follow-up patient appointments. Prior to the intervention, the rate of completion for labs and/or imaging was about 80%. With the assistance of the PVP, this number rose to 96%, allowing patient and provider to have a more meaningful follow-up visit.

AMBULATORY SERVICES

Summer 201520

Peer-reviewed Publications and Presentations Notifications of Acceptance: January — June 2015

Publications

Makic, M, Rauen, C, Jones K, Fisk, A. (2015). Continuing to challenge practice to be evidence based. Critical Care Nurse, 35(2), 39-50.

Schofield, D. & McComisky, C. (2015). Postgraduate nurse practitioner critical care fellowship: Design, implementation, and outcomes at a tertiary medical center. Journal for Nurse Practitioners, 11(3), e19-26.

Presentations

Bothe, L., Figert, L., Heikes, K., James, V., Motely, J., Wingo, E. (2015, March). Building and sustaining a culture of excellence in hand hygiene practices: An inter-professional collaborative approach. Poster presentation at the Maryland Patient Safety Conference, Baltimore, MD.

Mandella, C. Rigdon, A., Stanek, G., Anderson, S. (2015, March). Partnering with our patients: Documenting patient education with “Ask Me 4.” Oral presentation before the Epic Nursing Advisory Council, Verona, WI.

Mignano, L., Gulati, J., Miner, M., Cafeo, C., Brown, T., Frank, G., Ramirez, J., Lanthan, V., Rowen, L. (2015, March). Routinizing HIV diagnosis and linkage to care in urban populations. Poster presentation at the Society of Hospital Medicine’s Annual Meeting, National Harbor, MD.

Miner, L., Migano, J., Cafeo, C., Gulati, M., Brown, T., Lathan, V., Chance, G., Rowen, L. (2015, May). Transitions in care for persons living with HIV accessing the acute care setting. Poster presentation at the 6th Annual National Nursing Research Symposium, Stanford, CA.

Miner, L., Migano, J., Cafeo, C., Gulati, M., Brown, T., Borkoski, R., Lathan, V., Chance, G., Rowen, L. (2015, June). Increasing access to HIV care through institutional policy in the acute care setting. Poster presentation at the 2015 National Summit on MCV and HIV Diagnosis, Prevention, and Access to Care, Arlington, VA.

Murter, A., Rowen, L., Cafeo, C., Menefee, L., Huffman, G., Spann, C.J., Couser, J., Gregg, D., Gulati, M., Hendricks, S. (2015). An interdisciplinary response to improve patient and staff safety following a devas-tating fire in an inpatient room. Poster pre-sentation at the Maryland Patient Safety Conference, Baltimore, MD.

Noll, C. & Doyle, K. (2015, March). Behavioral emergency response team: Implementing a performance improvement strategy to address workplace violence. Poster presentation at the 2015 Maryland Annual Patient Safety Conference, Baltimore, MD.

Noll, C. & Doyle, K. (2015, October). Mitigating workplace violence by implementing the behavioral emergency response team (BERT). Poster presentation at the 2015 ANCC National Magnet Conference, Atlanta, GA.

Noll, C., Falck, Z., Sadtler, K. (2015, October). Recovery-founded interventions in a psychiatric emergency department results in a near restraint free environment for patients: It is possible! Podium presentation at the 2015 American Psychiatric Nurses Association National Conference, Orlando, FL.

Noll, C. & Audia, D. (2015, October). The Ebola response support team: Integrating interdepartmental efforts to assist patients, families, and staff in crisis. Poster presentation at the 2015 American Psychiatric Nurses Association National Conference, Orlando, FL.

Rowen, L., Murter, A., Cafeo, T. (2015, April). Igniting change after a devastating fire in an inpatient room. Oral presentation at the Annual Conference of the American Organization of Nurse Executives 47th Annual Meeting, Phoenix, AZ.

Simone, S. & Tumulty, J. (2015, May). Ain’t got no rhythm: Sudden cardiac arrest in children and adolescents. Oral presentation at the AACN National Teaching Institute, San Diego, CA.

Simone, S. & Tumulty, J. (2015, May). Sudden cardiac arrest in children and adolescents. Oral presentation at the National Association of Pediatric Nurse Practitioners Chesapeake Chapter Conference, Mount Washington, MD

Stronski, A., Williams, D., Meyer, J. (2015, October). The CAUTI crew: A story of nurse-driven CAUTI reduction initiative. Poster presentation at the 2015 ANCC National Magnet Conference, Atlanta, GA.

Tauber, A., Nandwani, V., McCarthy, P., Herr, D. (2015, February). Nutrition practice patterns in adult ECMO patients: Results of an international study. Poster presentation at the Clinical Nutrition Week, Long Beach, CA.

Tumulty, J. (2015, May). Alarm identification and response simulation (AIRS) study. Oral presentation at the AACN National Teaching Institute, San Diego, CA.

Tumulty, J. & Simone, S. (2015, March). Synaptic overload: Case studies in refractory status epilepticus. Oral presentation at the National Association of Pediatric Nurse Practitioners National Conference, Las Vegas, NV.

Congratulations and thank you to all UMMC PCS staff that

have gone above and beyond to advance professional practice

and science!

If you are a PCS employee submitting scholarly work outside

the UMMC organization, let us know if your submission was accepted

and get recognized!

Contact [email protected] for more information.

views&news21

STC Respiratory: A Gear in the MachineJames Huff, BS, RRT, and Maria Madden, BS, RRT-ACCS

The Shock Trauma Center is a fast-paced and professionally demanding area that relies on all gears turning in unison to achieve optimal patient outcomes. Respiratory therapy is an important gear in this machine. Our staff engages in patient care through multiple different therapist-driven pathways and protocols to decrease ventilator days and respiratory complications.

Our respiratory therapists excel in the Neurotrauma Critical Care Unit by liberating spinal cord patients from the ventilator via the secretion clearance and bronchodilator pathway (SCABDAP), as well as employing a generous amount of tender loving care.

Kara Vogt, RRT, said that “We spend a lot of time caring for these patients during their long stay here at Shock Trauma. We are their cheerleader, coach, friend, and family; that big push to help cross that finish line; or a shoulder to lean on when it gets really hard. The happiness on a patient’s face when they hear their own voice makes every minute worth it.”

The SCABDAP has been such a great success that other units, including the Lung Rescue Unit, have begun to apply the evaluative process for their patient populations.

Our respiratory therapists are depended upon for many inter-hospital transfers of Maryland’s most critical patients. Therapists using the skills and knowledge of airway pressure release ventilation (APRV) and

other lung protective/recruitment methods are able to stabilize and improve a patient’s pulmonary status before reaching the hospital. We are currently partnering with ExpressCare and Lewis Rubinson, MD, PhD, director, Critical Care Resuscitation

Unit (CCRU), to trial and evaluate new transport ventilators.

Respiratory therapists are making strides in research and setting the bar in respiratory care through a strong partnership with our interdisciplinary partners. Multiple research abstracts have been submitted, as well as education opportunities, because of this relationship. A quarterly lecture series provided by different physicians is working to fine-tune the respiratory therapist’s relationship with the team and is helping to develop very well-rounded respiratory therapy support.

Our respiratory therapists continue to grow and develop to stay ahead of the ever changing world of trauma and strive to embody the UMMC mission of “We Heal, We Teach, We Discover, We Care.”

PATIENT CARE SERVICES | RESPIRATORY

Kara Vogt, RRT

Unprofessional Behaviors, continued from page 3.

authentic leadership. Contrary to these tenets, unprofessional behavior is deleterious to HWEs. Unprofessional behaviors are everyone’s business and responsibility, from the bedside staff, nurses and UAPs, to providers and leadership. Leadership should commit to reducing the perceived triggers of unprofessional behavior, such as identifying and correcting system issues that are chronic or unresolved. Each individual must address unprofessional behavior, calling it by name and not tolerating it as a passive bystander. Staff should commit to improving competence and teamwork, and be introspective about their own behavior.

Although the majority of respondents completely disagreed with the statement that they “do not report deteriorating

patient conditions to an unprofessional provider,” that still leaves instances where changes in patient conditions go unreported. As clinical staff, we can shape our work environment to ensure that unprofessional behavior is not tolerated and that no patient deterioration goes unreported. By shaping our environment, not only are patients protected, but individuals may alter their intentions to transfer or leave.

If you are experiencing unprofessional behaviors or know someone who is, say something, take action, or ask for help. Our patients are counting on us.

Summer 201522

on non-punitive performance improvement plans and all were successful in making improvement. No staff turnover was linked with the productivity initiative.

DISCUSSION

Department-Level Improvement — Department success was attributed to use of an evidence-based practice approach, the involvement of therapists at the front line (PTF), subject matter experts from the departments of HR and Innovation, and the consistent involvement of rehabilitation leaders. The aforementioned factors are considered important to making long-lasting change (Stubblefield, 2005; Levin & Gottlieb, 2009).

Initially, implementing the 4Ps communication system, the 5S Process for organizing equipment, and adding clarity regarding lunch breaks were considered to be effective changes. Over time, the communication process and the changes around the lunch break were sustained. For some therapists, as much as 45 minutes were recovered each shift. That time was used for patient care.

The prospect of change and concern about not meeting the productivity expectations created negativity and distractions within the department at the onset of this project. Prior to implementing the productivity initiative, the practice of disclosing individual productivity outcomes was taboo. With time and investment in the process, staff realized productivity did not require secrecy. This process encouraged open discussion of successes and challenges. An important piece to consider regarding the success achieved was the desire by leadership to hold themselves accountable for supporting the staff. Leadership also took a firm stance by communicating that meeting productivity was an expectation, not a suggestion. Anecdotally, teamwork and individual accountability improved. Staff realized that what previously seemed impossible could be accomplished.

Making Productivity Meaningful at the Leadership Level —The lessons learned at UMMC could assist other rehabilitation leaders in justifying the need to examine performance metrics and selecting them based on the role of the clinician and the facility’s level of care. For example, RVUs are common productivity metrics found in hospital rehabilitation departments, however, they may not be effective in measuring productivity for IP service lines within that department. For rehabilitation at UMMC, it was more important for therapists in the IP division to thoughtfully prioritize their caseloads and interventions in order to see more patients as opposed to applying multiple interventions that would lead to longer treatment sessions. This supports our goal of moving patients safely and efficiently along the care continuum. The recovery equivalent of 3.2 therapists back into patient care pleased executives as rehabilitation leaders were able to rescind a request previously made for additional staff.

Limitations — As a result of engaging in a phased approach, the true impetus for the increase in staff productivity and efficiency was unclear. There was no specific measure to assure quality was not decreased as a result of the work, although it should

be noted that there were no anecdotal increases in customer complaints or noticeable changes in therapist competency scores. The lack of statistically significant positive outcomes in the OP division suggests the need to conduct Lean work that is more specific to OP.

Conclusion — Faced with non-compliance in meeting productivity targets and increasing demand from providers for therapy intervention, rehabilitation department leaders were compelled to develop a methodology for increasing productivity. The department of rehabilitation services at UMMC was able to establish new guidelines and processes that yielded improvements in the IP division. This was accomplished by conducting a thorough assessment of baseline department operations and outcomes, utilizing the Lean principles, setting new expectations, engaging experts from other departments (Innovation and HR), securing staff buy-in and having leadership committed to making positive change. In the end, IP therapists were able to see more patients, with fewer FTEs on staff, and in less time. The improvement has proved to be sustainable and is consistent with the Triple Aim of Healthcare, which speaks to three things:

◗ improving the patient experience; ◗ better overall health management of populations; and, ◗ reducing the per-capita costs related to health care.

(Magnan, Fisher, Kindig, Isham, Wood, Eustis, Backstrom & Leitz, 2012). Areas for further IP study could include examining the links between rehabilitation productivity, hospital length of stay, and insurance payment denials. Improvement in the OP division was statistically insignificant and more study is warranted in this area. Lessons learned may be valuable to practitioners in any therapy setting. Metrics that do not drive customer satisfaction and enhance processes, while maintaining quality and safety, may not be as useful (Magnan et. al., 2012).

The full-length version of this article has been accepted for publication in the Journal for Healthcare Quality.

Special thanks to Krystal Lighty, MSPT, COMPT, inpatient rehab manager; Gregory Mesa, PT, MSPT, outpatient and pediatric rehabilitation manager; the UM Center for Performance Innovation; the department of Human Resources; and the senior therapists in Rehabilitation Services for their contributions to this important work.

ReferencesHolden, R. (2011). Lean Thinking in Emergency Departments: A Critical Review. Annals

of Emergency Medicine, 57(3), 265-278.Kovacek, P. (2012). New Productivity: A Manager’s Perspective. Advance for Physical

Therapy & Rehab Medicine, 13(12), 7.Levin, I. & Gottlieb, J. (2009). Realigning Organization Culture for Optimal Performance:

Six Principles & Eight Practices. Organizational Development Journal, 27(4), 31-46.Magnan, S., Fisher, E., Kindig, D., Isham, G., Wood, D., Eustis, M., Backstrom, C., & Leitz, S.

(2012). Achieving Accountability for Health and Health Care. Minnesota Medicine, 37-39.Malone, D. (2010). The New Demands of Acute Care: Are We Ready? Physical Therapy,

90 (10). 1370 372.Stubblefield, A. (2005). The Baptist Health Care Journey to Excellence: Creating a

Culture that WOWs!. New Jersey, United States of America: John Wiley & Sons, Inc.Wojtys, E., Schley, L., Overgaard, K, & Agbabian, J. (2009). Applying Lean Techniques to

Improve the Patient Scheduling Process. Journal of Healthcare Quality, 31(3). 10-16.

Improving Therapist Productivity, continued from page 11.

views&news23

PATIENT CARE SERVICES | NUTRITION

Food Drive for the Hungry: A Medical System Nutrition CollaborationAccording to the Maryland Food Bank, there are more than 770,000 Marylanders in need of food. For the past eight years during National Nutrition Month, a team of nutrition colleagues from across the medical system has sponsored a food drive to help feed the hungry.

In 2007, Ellen Loreck, MS, RD, LDN, director, clinical nutrition services, initiated the March food drive at UMMC and it has since expanded to include other system hospitals. When selecting a cause, feeding the hungry was a natural choice for a team of food and nutrition professionals who are passionate about promoting healthy nutrition for everyone. Each hospital representative sets up his or her own process for collecting food and funds. This year, our Medical System team jointly collected 1,507 pounds of food and also raised $3,032. Between food collected and dollars raised, we provided the equivalent of 10,352 meals for hungry Marylanders. In addition, after the recent events in west Baltimore, we were able to direct $1,000 raised at the Medical Center to support our community. We look forward to continuing our annual March food drive in support of our UMMC mission to promote health and wellness outside of our walls.

Medical System nutrition team:

Denise Lichaa, RD, LDNClinical DietitianUniversity of Maryland Rehabilitation and Orthopaedic Institute

Hilary Hosford, RD, LDNClinical Nutrition and Patient Services ManagerUpper Chesapeake Health

Samantha Hauswirth, RD, LDN, CNSCClinical Nutrition ManagerUMMC Midtown Campus

Donna Morris-Snoussi, MS, RD, LDNClinical Nutrition ManagerMt. Washington Pediatric Hospital

Megan Larson, MS, RD, LDNClinical Nutrition ManagerBaltimore Washington Medical Center

Courtland BuhrRetail Services ManagerUniversity of Maryland Medical Center

Left to right: Courtland Buhr, Retail Services Manager, Food and Hospitality Services, UMMC; Beth Wedekind, Events Manager, Maryland Food Bank; and Ellen Loreck, MS, RD, LDN

Clinical Practice Update

22 South Greene StreetBaltimore, Maryland 21201www.umm.edu

The text for the nurse foley removal protocol has been updated in Powerchart to reflect the revisions in the foley indications.

Please remember to remove the foley catheter as soon as no longer necessary.

Thank you for all of your efforts in preventing CAUTIs.

Infection Prevention Team

Added criteria to define “frequent urinary output” will populate when chosen

REGULATORY BUNDLE REVISIONS to FOLEY INDICATIONS

Urinary retention and failed bladder scanner protocol (straight cath 3 times)

Open sacral / perineal wounds AND incontinence with wound care or soft

tissue consult required

News and Views Summer 2015

Documents

Transcript of News and Views Summer 2015