Nursing Annual Report - SSM Health · During January and February of 2016, we educated more than 80...

IN OUR HANDS

Nursing Annual Report

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Welcome Letter .....................................................................................................................................................................................................................................................1

SSM Health Mission, Vision and Values ................................................................................................................................................................................2

Nursing Vision — Professional Practice Model ...........................................................................................................................................................3

1. Transformational Leadership ................................................................................................................................................................................. 4

Leading from the Bedside ............................................................................................................................................................................................................4

Nursing Mentorship ...........................................................................................................................................................................................................................4

Nurse-Driven Practice ......................................................................................................................................................................................................................5

Care for Caregivers ........................................................................................................................................................................................................................5-6

Emergency Department — Ready for Change ....................................................................................................................................................7

2. Structural Empowerment ........................................................................................................................................................................................................8

Inter-Professional Decision Making — Driving Change .................................................................................................................................8

Nursing Workforce Overview .................................................................................................................................................................................................9

Degrees Earned .......................................................................................................................................................................................................................................9

Professional Organizations..........................................................................................................................................................................................................9

Certifications ..............................................................................................................................................................................................................................................9

Honors and Awards ...........................................................................................................................................................................................................................10

NLNL 2020 Scholarships ....................................................................................................................................................................................................10

Daisy Award Winners .............................................................................................................................................................................................................10

Spotlight on Scholarship Recipients .................................................................................................................................................................................11

National Nurses Week Awards.............................................................................................................................................................................................. 12

Great Catch Winners ............................................................................................................................................................................................................... 13

Futures ............................................................................................................................................................................................................................................................14

Value of Community and Growing Tomorrow's Nurses ............................................................................................................................14

Accomplishments for 2016 Entity Nurse Practice Council .................................................................................................................... 15

Professional Poster Presentations ............................................................................................................................................................................. 15-16

Table of Contents

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Table of Contents (continued)

3. Exemplary Professional Practice ................................................................................................................................................................................ 17

Professional Practice Model — Finding the Characteristics Within ........................................................................................17-18

Impacting National Safety Goals 2016 ........................................................................................................................................................................19

SSM Health St. Clare Hospital ICU Central Line Safety ......................................................................................................................19

Medication Safety Improvement .....................................................................................................................................................................................20

Medication Scanning Rates ...................................................................................................................................................................................................20

Simulation Education to Enhance Understanding .........................................................................................................................................21

Patient-Centered Care .................................................................................................................................................................................................................22

Evidence-Based Practice ..........................................................................................................................................................................................................23

4. New Knowledge, Innovation and Improvements ..............................................................................................................................24

Stroke Gold Plus Achievement Award with Target Stroke Honor Roll Elite Plus ...........................................................24

Clinical Data Outcomes ................................................................................................................................................................................................................25

2016 Patient Satisfaction Scores ...............................................................................................................................................................................25-26

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CNO/VP Nursing Welcome Letter

Dear Nurses,

The presence of a nurse or caregiver at a family’s time of need is invaluable. A gentle smile, a calming touch, a word of kindness. These simple acts are inherent within the nurses at SSM Health St. Clare Hospital. Our team of nurses is consistently present for patients and for each other. I am inspired by the dedication, passion and commitment I witness during my rounding, Daisy Award presentations, Great Catch recognitions, patient letters of satisfaction and the highest quality outcomes. I am honored to be part of such a highly engaged team. And I am committed to maintaining a work environment where nurses thrive and aspirations can be achieved.

Our nurses are well-positioned to lead change and advance patient care, in part, because we challenge them to continue their education and to have a strong voice in their own practice. We are committed to growing our nurses into the leaders of tomorrow.

The Mission of SSM Health is alive inside the caring hands of each of our nurses. Every day, SSM Health St. Clare Hospital nurses make a difference in the lives of our patients, the community and each other.

The Nursing Annual Report is designed to highlight some of the many accomplishments of the previous year. As we look back, I challenge you to look towards the future, a future I know is safe in your hands. I thank you for choosing to practice at SSM Health St. Clare Hospital, and I will continue to serve you on our journey to excellence.

Wayne Laramie | Vice President Nursing SSM Health St. Clare Hospital

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Mission

Through our exceptional health care services, we reveal the healing presence of God.

Vision

Through our participation in the healing ministry of Jesus Christ, communities, especially those that are economically, physically and socially marginalized, will experience improved health in mind, body, spirit and environment within the financial limits of the system.

Values

Respect We respect life at all stages and promote the dignity and well-being of every person.

Compassion We reveal the healing presence of God through compassionate care focused on the fullness of the person.

Excellence We provide exceptional care and service through employees and physicians dedicated to our Mission.

Community We cultivate relationships that inspire service and promote justice in our organization and throughout our communities, with special concern for the poor and marginalized.

Stewardship We use our financial, human and natural resources responsibly and care for the environment.

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SSM Health Mission, Vision and Values

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Strategic Direction for NursingProfessional Nursing Practice at SSM Health creates an innovative environment for

the achievement of exceptional outcomes while advancing and contributing to the profession. We partner with patients, families, providers and each other,

using practices that are restorative, supportive and promotive in nature. SSM Health is the preferred partner for care across the health continuum.

Our Miss

ion: Through our exceptional health care services, we reveal the healing presence of God.

Shar

ed Leadership • Relationship-Based Care

Nursing Professional Practice Model

EXCEPTIONAL Experience • People • Value

I am aleader

I am anadvocate

I amaccountable

I am apartner

I am aprofessional

I am an SSM Health Nurse

Patient and

Family

Sacred Trust

Our

Valu

es: C

ompassion • Respect • Excellence • Stewardship • Comm

unity

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Nursing Vision

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1. Transformational Leadership

Leading from the BedsideThe strategic focus at SSM Health St. Clare Hospital is to ensure nurses see and know the outcomes of events and near misses they report through the event management system. This allows team members to know their voices can make positive change for our practice environment, our outcomes and the safety of our patients. It also enhances their understanding of patient outcomes and the utilization of the event system.

Bedside team members are then invited to attend No Harm. This centralized, biweekly meeting brings together team members from the entire hospital to discuss outcomes directly related to patient safety and review events that occurred within the previous two weeks. Ten RNs and ten ancillary department team members participate in the meetings. Attending bedside nurses are able to provide input that deepens discussion of the process, clarifies translation and enhances understanding of the focus needed. It was a No Harm group that discovered the fall policy did not mention current practice; as

a result, our Nurse Practice Council reviewed and added input on best practices related to falls.

Additionally, the Campus Executive Team is now taking Great Catch and Stop the Line Awards celebrations to the recipient's department.

This enhances team spirit and creates awareness within the department of the outcome of reported events. Throughout 2016,

we celebrated 50 RN events with team members from various departments housewide.

Nursing Mentorship Katy Bushart, RN, joined SSM Health six years ago as a staff nurse on 5 South at St. Clare Hospital, completing her orientation and education through the Futures program. She quickly rose to Preceptor for the unit and helped support the Infusion Suite. In 2013, Katy accepted the CSN position where she helped 5 South reach high levels of employee and

patient satisfaction, as well as ensured quality and safe care for patients.

Her ability to lead her team daily while focusing on patient care and patient safety was a natural fit for leadership. Katy is able to

convey a strong sense of advocacy for our patients and their safety while balancing the support needed from the staff through the daily

workflow. Katy shows creative communication skills, is considered a role model for other nurses and is easily accessible for support of team

members. Katy was promoted to Team Leader of the 2 North Orthopedics and Concierge/DTA teams

in July 2016.

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Transformational Leadership

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Nurse-Driven PracticeDuring senior leader rounding, Anne Janson, RN, a nurse on 2N Ortho, voiced concern regarding an adequate availability of gait belts for patient care. A quick survey of the stock on hand showed few plastic gait belts available. The Physical Therapy department provided their own and cleaned them between patients. On some floors, belts were assigned to patient rooms, but many patients had no belt available. With focus on patient safety and preventing patient falls, Anne advocated for a change.

Information was gathered on gait belts and costs for both reusable plastic belts and disposable cloth versions. After talking with the 2N staff about the reusable plastic versus disposable cloth and the prices, the staff decided to try the disposable cloth gait belts. The unit received a trial case. The staff loved having the softness of the cloth, as well as having them available when needed. They were stocked on the floor. Before long, the team reached out to other inpatient areas of the hospital. Now, these gait belts are stocked in each middle pass-through of every inpatient department (with the exception of Family Birthplace).

This is an example of an idea and/or concern brought forward by a staff nurse to a member of the leadership team. The concern was taken seriously, options were explored and staff input was solicited, culminating in a better end result for patients housewide.

Care for CaregiversRelationship-based care is focused on creating relationships with the patients, families and other caregivers associated with the patient. This is a very rewarding model of nursing care that enables nurses to understand the patient and their needs. Delivering personalized care means nurses feel a stronger connection to their patient. Nurses are tied to them emotionally — feeling all their emotions with them. The Care for the Caregiver program was developed to provide an additional level of support for staff while working during stressful times.

During January and February of 2016, we educated more than 80 leaders, including Clinical Support Nurses, in Tier Two support. Several Tier Two educated nursing staff members helped provide Tier One education to the entire SSM Health St. Clare Hospital employee base.

Throughout 2016, we have held quarterly Tier Two training and education meetings and have provided information about EAP, resilience and mindfulness for our Tier Two trained leaders. Along with this we have provided tangible support for our caregivers by means of the Lavender Cart. When a team or department has had a particularly rough day, this cart is delivered to bring some comfort. It includes snacks, candy and water for the team to share. Between February and October, we had 22 individual referrals, several team referrals and used the Lavender Cart more than 40 times. To measure the program’s success, we used the Agency for Health Care Research Quality Safety Survey results for the questions on the following page.

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30% 40% 50%

2015 – 39%

2016 – 46%

2015 – 50%

2016 – 46%

Did you receive support from anyone within our healthcare organization?

PERCENT ANSWERING YES

PERCENT ANSWERING NO

0% 20%

2015 – 18.7%

2016 – 19%

Within the past year, did a patient safety event cause you anxiety, depression or concern about your ability to do your job?

PERCENT ANSWERING YES

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Of those who answered YES to the above question, we asked the following:


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Emergency Department — Ready for Change SSM Health St. Clare Hospital started its LEAN Journey in 2016, and the Emergency Department was identified as the starting point. The ED was chosen because its staff is highly engaged and ready for change. The purpose of LEAN is to establish standard work on a process in order to reduce waste and variability. The journey began in November 2016 with the first Rapid Improvement Event (RIE) — Disposition to Discharge. With the help of a multidisciplinary team throughout the hospital, the ED was able to decrease its disposition to discharge times from an average of 46 minutes to 23 minutes. During the event, adding value from the customer's perspective was a focus. This was done by including an emergency room patient in the process, hearing what from the standard work process didn't work for them and learning what kinds of changes would add value from their perspective. Their feedback was taken into consideration when developing the new standard work from the ED discharge process. The ED has completed two RIEs, each showing positive results on ED metrics.

Disposition to Discharge Time

50%0% 100%

BEFORE LEAN implementation

AFTER LEAN changes

46 minutes

23 minutes

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Structural Empowerment

2. Structural Empowerment

Inter-Professional Decision Making — Driving ChangeThe SSM Health St. Clare Throughput Team identified an opportunity to modify the Cardiac Cath Lab (CCL) patient care flow. The goal is to decrease hold times of admitted patients. The original process involved multiple phone calls and handoffs. This inefficiency and other barriers created delays on patient placement and throughput, affecting the patient experience. Challenges included designing a daily communication process to identify patient placement needs, identifying defined touchpoints between staff and developing appropriate information to be communicated between the Administrative Supervisor, the CCL Clinical Support Nurse and the 4 North Clinical Support Nurse. This would make the transfer of patients more timely and safe.

A team, including nursing staff from the 4th floor and CCL, was created to develop a more efficient transfer process, with a goal of reducing times by 50 percent. These outcomes were monitored for 60 days, during which both CSNs and the Administrative Supervisor noticed duplicate work.

The Administrative Supervisor and 4 North CSN used morning rounds to create a tentative plan for placement regarding CCL cases, discharges and nursing-skill mix. The process was streamlined to add daily communication between the CCL CSN and the 4 North CSN to encourage early planning for possible placements and strengthen the cohesiveness across units. It was found that having the right people and clinical expertise in place decreased the number of phone calls from six to just two.

This helped ensure an appropriate nurse-skill mix and bed placement for the patient. At the time of intervention and decision for admission, the CCL CSN should call the 4 North CSN as a “heads up” to begin planning. After admission orders are entered, the CCL notifies the 4 North CSN of patient acuity, gives the 15 minute notification time and receives the inpatient room number. The 4th floor CSN then notifies the Administrative Supervisor and appropriate receiving RN. A face-to-face handoff is then given bedside to the receiving nurse.

After the first 30 days, an average time of 49 minutes was observed. That was reduced to 29 minutes by the end of the 60 day trial. The staff provided positive feedback regarding the new process, and it was quickly decided that this new process would move from trial phase to implementation.

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The working relationship between CCL and 4 North has improved communication and created trust.

Holly Zweifel | CSN | 4 North

Honors and Awards

NLNL 2020 Scholarships

SSM Health St. Clare awarded support to nurses in completing BSN degrees and obtaining certification.

BSN Scholarship

C. Angel Bailey Jennifer Braciszowski

Jeannie Hall Lauren Hartman

Joseph Pilger Certifications

Melisa Robert Maureen Duetman

Alexandra Roberts Laurencia Klipfel

Laurie White Christen Werkmeister

Katie Youngblood Lisa Wilson

Daisy Award Winners

January Amanda Gordon ER

Kathie Holmes 2 North

February Jessica Patton 5 South

March Adrienne Mann 5 North

April Kelly Tarpeo 4 South

May Beth Marler 2 North

June Natalie Crandall 3 IMCU

July Oscar Ramirez 5 South

August Kim Hammond 3 IMCU

September Don Cao 3 ICU

October Brittany Seper 5 North

November Elizabeth Vogel 4 South

December Amanda G’Sell ICU

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Brittany Seper Oscar Ramirez

Kim HammondDon Cao

Daisy Award Winners


NLNL 2020 Award Winners

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NLNL 2020 Banquet

Spotlight on Scholarship Recipients

Lisa Wilson | Certification I am a 4 South Neuro CSN. My career began at SSM Health St. Clare Hospital in 2010. Prior to moving to Missouri, I was living in Florida. My husband and I made the decision to rejoin our family. I remember entering SSM Health St. Clare for my interview and thinking this is not like any other hospital. SSM Health St. Clare has a magical feel to it. The overall culture is filled with compassion, and I knew this is where I wanted to be. In 2015, I challenged myself to study for my Certified Neuro RN certification. With almost a year of endless hours of self-studying and much encouragement by my team leader Jill and my family, I am excited to say I passed the exam! The vast amount of information I have been exposed to has increased my knowledge and given

me a greater understanding to the complex neuro system. SSM Health St. Clare has recently been designated as a Level 1 Stroke Center and is now Magnet Status bound. The growth and expansion is proof we are engaged to deliver excellence. The scholarship program only validates our commitment to continue delivering exceptional health care. I plan to continue my education and strengthen my skills so I can provide the finest care to our patients.

Jeannie Hall | BSN Scholarship

I have been with SSM Health since 2012; however, SSM Health entered my life prior through personal experience. SSM Health had an impact on me during the most difficult time that I had ever experienced in my life. I was in nursing school, and I made a decision that when I graduated, I wanted to be a part of the SSM Health family. So that is exactly what I did. I am currently a CSN on the 4 North Cardiac Unit. Previously I have been a RN and CSN on 5 North Medical/Surgical unit and an RN on 4 South Neuro unit. All of which have been wonderful experiences and allowed me to grow as a nurse. I am currently pursuing my BSN, and the NLNL 2020 scholarship will assist me in reaching

my goal. I am very thankful to have the opportunity to continue with my education. And I feel blessed to work for a corporation that supports me on that journey. Once I have completed my BSN, I plan to continue on with my master's degree. With this scholarship, you have invested in me, I plan to continue my career here at SSM Health St. Clare and use this education to serve SSM Health and its patients.


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National Nurses Week AwardsRecipients were nominated for awards by their peers, and winners were selected by committee. Awards were presented at the 2nd Annual National Nurses Week breakfast on May 9, 2016.

Rookie of the Year | Brittany Schulte | 4 South

Mentor/Clinical Coach of the Year

Allison Hacay | 5 North

Nursing Practice and Professionalism

Lisa Wilson | 4 South

Essential Partner | Terrie Boucher | IHT

Lifetime Achievement Award | Mary Fischer

above: 4 South

NLNL 2020 Scholarship celebration

right:5 South Daisy Award winner

Kim Hammond and her team

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0 5 10 15 20 25 30

2015 – 24 students

2016 – 29 students

Senior Nursing Students Mentored in 2016

SSM Health St. Clare Hospital Number of Senior Practicum Students

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Futures Graduation 2016 In 2016, SSM Health St. Clare Hospital hosted its largest Futures graduation since the program’s inception. These graduates are quickly becoming leaders in the organization.

Value of Community and Growing Tomorrow's NursesSSM Health St. Clare Hospital's value of community is demonstrated every day by the collaboration between departments and work towards patient safety and satisfaction goals. Along with patient-focused care, we also offer many opportunities for the future of nursing to continue to grow.

We enhance the nursing student experience by allowing senior students to work with our staff on the floors. Transformational leadership is something we strive for at SSM Health St. Clare. In this program, it is evidenced through the senior students’ time within our facility and with our staff. That time with our staff totals more than 90 hours per student.


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Accomplishments for 2016 Entity Nurse Practice Council • Developed and approved new council charter

• Standards Nurse Practice Council highlights and updates sent to staff and IP to procedure center transfer process

• Johns Hopkins Evidence-Based Model education and utilization on the units for projects

• Updated REDA and an approval process to become a system policy

• Professional Practice Model roll-out completed with roving rounds throughout the hospital

• Revised APIC position paper and conducted gap analysis | Gap analysis reviewed at the regional level

• Nursing Symposium input and unit participation with posters

• Continuous improvement on preventing CAUTIs and CLABSIs | Using infection prevention champions for education

Professional Presentations

Nursing Symposium SSM Health St. Clare Hospital

Decreasing Pressure Ulcers in an Inpatient Setting: Turn Team (5 North)

• ECG-Guided PICC Line Placement | Sally Merkel

• Standardization of Neonatal Crash Carts | Michelle Hudson

• Implementing the Donna Wright Competency Assessment Model | Sharon Rector

• Touching Lives…Healing Hearts…Giving Hope | Melanie Schwob


right:

Melanie Schwob at the 2016 Nursing Symposium

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Professional Presentations (continued)

Emergency Nursing 2016 Conference Los Angeles, California

Decreasing Blood Culture Contamination in the Emergency Room

| SSM Health St. Clare Hospital's Emergency Department Blood Contamination Team

A big congratulations goes out to this team, that was selected by the Institute for Emergency Nursing Research to present at the conference last September. The efforts of this team have been recognized as a best practice and recently earned them an Exceptional Performance Award for Exceptional Financial Performance and Growth. The new collection process they implemented showed immediate results. The average blood contamination rate in 2014 was 2.54 percent. From implementation in April through October 2015, the contamination rate dropped to 0.99 percent. The national benchmark for blood culture contamination is 2.5 percent . The average cost savings per contamination ranges from $5,000 to $10,000.

The team was selected to present from among a large number of project abstracts submitted by organizations around the country. We are very proud that this best practice was recognized by a national group of their peers. Way to go team!


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3. Exemplary Professional Practice

Professional Practice Model — Finding the Characteristics WithinIn 2016, the Nursing Professional Practice Model was rolled out to the nurses at SSM Health St. Clare. The Entity Practice Council came together and developed a plan to reach all nurses during Nurses Week 2016. They created a poster and developed a rounding schedule. This two-fold plan enabled the team effort to reach every nurse and helped each nurse realize the ways they exemplify the Professional Practice Model each day.

Every nurse who came to the in-service received a cookie thanks to the efforts of Donna Robinson, Director of Critical Care, Cardiac, and Neuro Nursing, who hand-baked 500 of them in her home kitchen. Her effort was prompted by the belief that “our nurses deserve more than store-bought cookies. It's important that we show them the care they show each other and our patients every day.”

In addition to the roving education by their peers, nurses received reminders of the Practice Model in the form of Inspire Coins. Decisions regarding how the coins would be utilized was left in the hands of the Practice Council for each unit. The coins served as reminders of the Professional Practice Model we live out each day. Some nurses kept the small tokens in their pockets as reminders of the characteristics they strive to exemplify.

All units provided time to have each team member sign a large poster of the Professional Practice Model as demonstration of their commitment to living it out daily.

Exemplary Professional Practice

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I am accountable when I question orders to do what is best for my patient.

I was a partner when I was able to connect with a deaf patient and calm him down when no other nurse on the floor could. His demeanor changed dramatically.

I am a professional when I attend continuing education, like the Neurosciences Summit in May.

I am an advocate when I do not let lab draw multiple times from my patient…draw multiple tubes at one time.

I am a professional by utilizing what I have learned in my Futures classes to care for my patients.

I am accountable when I research my patients condition if I am unfamiliar with it. I want to make sure I am educated on all my patients' conditions.

I am an advocate when I call the physician because my patient's pain is uncontrolled. I want to ensure my patients are comfortable, pain-free and content.

I am a partner when I help my co-workers out! My co-workers are a partner when they help me with my patients.


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Strategic Direction for NursingProfessional Nursing Practice at SSM Health creates an innovative environment for

the achievement of exceptional outcomes while advancing and contributing to the profession. We partner with patients, families, providers and each other,

using practices that are restorative, supportive and promotive in nature. SSM Health is the preferred partner for care across the health continuum.

Our Miss

ion: Through our exceptional health care services, we reveal the healing presence of God.

Shar

ed Leadership • Relationship-Based Care

Nursing Professional Practice Model

EXCEPTIONAL Experience • People • Value

I am aleader

I am anadvocate

I amaccountable

I am apartner

I am aprofessional

I am an SSM Health Nurse

Patient and

Family

Sacred Trust

Our

Valu

es: C

ompassion • Respect • Excellence • Stewardship • Comm

unity

Impacting National Safety Goals 2016 The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. With newly developed champion roles at SSM Health St. Clare Hospital, the ICU was able to create a work plan to reduce their central line infections, which improved patient safety.

SSM Health St. Clare Hospital ICU Central Line Safety

2015 Seven line infections per 1000 line days | Yearly rate 2.23 per 1000 line days

2016 One line infection per 1000 line days | Yearly rate 0.45 per 1000 line days

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Dec NovOctSepAugJulJunMayAprMarFebJanDec2015 2016 2016

ICU

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(per 1,000 catherer days)

(per 1,000 catherer days)

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Dec NovOctSepAugJulJunMayAprMarFebJanDec2015 2016 2016

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Medication Safety Improvement In January of 2016, SSM Health St. Clare nursing departments saw an improvement opportunity to increase the use of the Guardrails ® System — the system used during IV medication administration. The system allows preset limits in order to enhance patient safety with medications administered. In collaboration with the pharmacy department, daily outliers were sent out for follow up.

The start date for interventions was scheduled for mid-January 2016 because improved compliance for Guardrails was needed quickly. Interventions included nursing team leaders speaking with nursing staff and educational huddles, as well as signs placed throughout nursing areas for understanding of patient safety. Clinical support nurses also provided staff with real-time education. Bedside RNs and pharmacy worked together to identify opportunities for improvement of the library if a medication or dosage was missing. With the multiple means for interventions, our goal of greater than 95 percent usage was exceeded in March 2016 and maintained throughout the rest of the year.

Medication Scanning Rates Using Medication Safely | Scanning compliance overall rate for 2016

Total administrations of medications | 1,133,546

Patient identification bands not scanned | 22,247

98%

MedicationScanning Rate 98%


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Guardrails® Infusions

90

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JanDec NovOctSepAugJulJunMayAprMarFebJan

SSM Health St. Clare Hospital

2016 2016 2017

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Enhanced Communication and Simulation Education Implemented to Improve OB Hemorrhage ResponseThe leading cause of preventable death among OB patients is hemorrhage. Following ACOG and the California Collaborative, SSM Health implemented the Massive Transfusion Protocol into OB units to improve our health care response to obstetric hemorrhage.

According to ACOG and the California Collaborative, three pieces must be in place to prevent maternal death from OB hemorrhage. The first is early recognition, which includes ongoing risk factor assessment and cumulative quantification of blood loss. The second piece is the response to hemorrhage, which includes easy and available access to uterotonics, a hemorrhage cart and blood product replacement. And the final piece is active management of the third stage of labor.

Several areas for improvement were identified. In assessing our process, it was determined that maternal hemorrhage risk factors were not being assessed regularly, and blood loss was being estimated instead of quantified. It also was determined that blood loss was often underestimated and inaccurate. The third stage of labor was being managed well by giving oxytocin and having uterotonics available.

Response to hemorrhage held multiple opportunities for improvement.

• Clarification was needed for the staff regarding which blood products to order, which labs to draw and at what intervals — this is especially important in emergency situations.

• Communication between the blood bank and the unit also could be improved.

• It was time consuming to keep placing individual orders because an emergent infusion order set was not available.

Following ACOG and the California Collaborative recommendations to implement a Massive Transfusion Protocol, an order set was created so that the nurse only needs to click one order to activate the right combination of blood products, IV fluids, uterotonics and the drawing of appropriate labs at the appropriate times. Staff were educated on the weighing of all blood loss during delivery and up to 4 hours post-delivery for accuracy and recognition of the cumulative amount. The patient’s


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risk factors are routinely calculated before and after delivery and entered in Epic. The risk assessments are visually available for all staff and are part of the time-out process. The physicians, nurses, techs and lab personnel were all educated to facilitate communication between teams during a hemorrhage emergency. The blood bank has an improved process for working to get massive amounts of blood products ready. In October, all staff went through an OB maternal hemorrhage simulation based on recognizing a massive hemorrhage and activating the Massive Transfusion Protocol.

Patient-Centered Care The exceptional care nurses provide their patients is exemplified in the letters we receive from both the patients themselves and their loved ones. These letters reaffirm for our nurses the value of the patient-centered care and healing relationship they are engaged in daily.

November 11, 2016

The dawn of a new day came. My husband and I were anxious to see Mom. We arrived at the hospital to news that she was struggling with coming out of sedation, and it was concerning. Doctors were very busy with evaluation, Shea, her nurse was a constant presence. We were allowed and welcomed in her room. The family could only pace. At one point Shea and I just sat on the couch. I wept, openly. Shea did not move or say anything. She gave me time to work through my fear and handed me tissues. After I was stronger, she shared her own family story of navigating a sick parent.

The presence of the nursing staff as we were exiting her room was profound. Many reached out their hands, or offered whispered words of support. Coincidence? Possibly. But, we are a faith-filled family and know that God knows when we need Him the most. The nurses and doctors who were with us those horrible, worried hours were comforting to our family. God put those people on that shift, during that time for a reason!

120+ hours passed. We came, we went, we cried, we yelled, we prayed. The staff just kept smiling and saying, "she just needs time." We kept telling each other, "she just needs time," but we still sat and watched, yelled and cried. The nurses were so welcoming and open, I often felt like I knew them my entire life. They continued to answer questions, explain vitals, and speak openly about small progress that was being made, but always

respecting our emotions.


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Evidence-Based Practice October 31, 2016, SSM Health St. Clare Hospital rolled out the Hester Davis Fall Risk Program. This is an evidenced-based assessment tool for falls. The program helps nursing anticipate a patient’s fall risk and create a personalized plan to help prevent falls while in the inpatient setting. The program goes beyond the traditional model that was followed and incorporates the patient’s medications, cognitive state and mobility. The program now categorizes patients into high, medium and low fall risk categories. Each risk category has suggested interventions to prevent an injury from occurring due to a fall.

All nurses, outpatient and inpatient — even in the Emergency Department — have been educated on the new assessment tool. Each unit is prepared with tools for success, including new fall signs to replace the leaves signs outside the room, new communication tools for fall mats used at the bedside and new signs to be placed near the bathroom to enhance communication with ancillary departments.

Along with the communication tools, new educational tools have been employed to enhance patient and family understanding of assessments and interventions. The education tools demonstrate skills the patient and family can transition for home use post discharge.

While this new assessment program has quickly become embedded in our practice, it is important to keep in mind that the program is based on evidence and remains an avenue to further develop evidence and suggest changes, thereby keeping our nurses actively involved in evidence-based nursing care as a hospital.


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4. New Knowledge, Innovation and Improvements

Stroke Gold Plus Achievement Award with Target Stroke Honor Roll Elite PlusSSM Health St. Clare Hospital has received the American Heart Association/American Stroke Association's Get With The Guidelines®— Stroke Gold Plus Achievement Award with Target Stroke Honor Roll Elite Plus. The award recognizes the hospital's commitment and success in ensuring that stroke patients receive the most appropriate treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence. Many of these coordinations are conducted by nursing.

To receive the Gold Plus Quality Achievement Award, hospitals must achieve 85 percent or higher adherence to all Get With The Guidelines® — Stroke achievement indicators for two or more consecutive 12-month periods and achieved 75 percent or higher compliance with five of eight Get With The Guidelines® — Stroke quality measures.

To qualify for the Target Stroke Honor Roll Elite Plus, hospitals must meet quality measures developed to reduce the time between the patient's arrival at the hospital and treatment with the clot-buster tissue plasminogen activator (tPA), the only drug approved by the US Food and Drug Administration to treat ischemic strokes. If given intravenously within the first three hours after the onset of stroke symptoms, tPA has been shown to significantly reduce the effects of a stroke and lessen the chance of permanent disability. SSM Health St. Clare earned the award by meeting specific quality achievement measures for the diagnosis and treatment of stroke patients at a set level for a designated period.

"This is the highest level of the award, and recognizes every member of the stroke team," says Maureen Bell, stroke program coordinator. "When dealing with stroke, time is brain, and this award

New Knowledge, Innovation and Improvements

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St. Clare Hospital Emergency DepartmentPress Ganey Scores — Mean Scores of Patient Satisfaction

60

80

100

Dec NovOctSepAugJulJunMayAprMarFebJan2016 2016

rate trend

25


is just verification of the strength of the team at SSM Health St. Clare Hospital to provide fast, safe, exceptional care to each stroke patient we see." These quality measures are designed to help hospital teams provide the most up-to-date, evidence-based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients.

Clinical Data OutcomesBenchmarking against the NDNQI hospital comparison groups, SSM Health St. Clare Hospital has clinically superior outcomes in the four key clinical areas.

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HCAHPS Survey — Rate Hospital 9-10Percentage of patients who gave their hospital a rating of 9 or 10 on a scale of 0 (lowest) to 10 (highest)

60%

80%

100%

Dec NovOctSepAugJulJunMayAprMarFebJan2016 2016

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SSM Health St. Clare Hospital Nursing Quality Indicators Inpatient Quality Benchmarks

benchmarks met = ✓ not met = ✗ 2N 3 ICU 3 IMCU 4N/4S 5N 5S

Falls with Injury ✓ ✓ ✓ ✓ ✓ ✓

Percent HAPU 2+ ✓ ✓ ✓ ✓ ✓ ✓

CLABSI ✓ ✗ ✓ ✓ ✓ ✓

CAUTI >=2015 ✓ ✗ ✓ ✓ ✓ ✓

a Q1 2016

Q2 2016

Q3 2016

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HCAHPS Rate Hospital 9-10

overall satisfaction rate 77.6% 80.1% 83.3% 81.2%

percentile rank 74 83 90 84

patients treated 392 351 406 367

Recommend Hospital




Communication with Nurses




Responsiveness of Staff

overall satisfaction rate 60.7% 68.3% 70.7% 66%



Communication with Doctors

overall satisfaction rate 79.8% 81.9% 85.3% 83%



Pain Management




Care Transition




2016 Patient Satisfaction Scores

26


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