Nursing’s Annual Report

2008

We are MagnetTM!

Who We Are

Beacon Award for Critical Care ExcellenceWe are the only Intensive Care Unit in Montana and Wyoming to win this national award.

What does it mean?Winning this award demonstrates quantitative

success when measured against evidence-based national criteria for recruitment and retention, education, training and mentoring, research and evidence-based practice, patient outcomes, leadership and organizational ethics and a healing environment.

Receiving this award is a tribute to the entire critical care team including the staff who work in the ICU, the ICU leadership team who have helped guide the team in the right direction, and our collaboration with the intensivists.

Who We Are

Tina Molvig, RN, Greta Beam, RN, Sue Blaskovich, RN, and Billings Clinic CEO Nicholas Wolter, MD

Lu Byrd, RNBillings Clinic Vice President of Hospital Operations and CNO

Nurses at the Heart of Patient CareAs a physician who joined the Billings Clinic in 1982 to practice Pulmonary and Critical Care Medicine, it has been a great pleasure and an honor to work with our nursing staff, both during those years of practice, and more recently as an administrator. We have a fabulous tradition of nursing excellence at Billings Clinic and the daily care delivered to our patients and their families is done with clinical excellence, compassion, and true Personal Service Excellence (PSE). As the years have passed and as we have been asked to provide more definitive measures related to quality and patient safety, we now find our Billings Clinic nurses in leadership positions helping us deliver evidence-based care. This allows us to achieve the highest marks on national measures of safety and quality in areas such as cardiac and diabetes outcomes, hospital infection rates, methicillen-resistant Staphylococcus aureus infection reduction, and others. Receiving Magnet designation and the Beacon Award for critical care excellence are other examples of the outstanding performance of nurses here at the Billings Clinic. Billings Clinic nursing makes all the difference.

From the time I decided to be a nurse through this moment, I can’t imagine a different choice for myself. The profession of nursing remains a true commitment and passion for me. As the

Vice President of Hospital Operations and the Chief Nursing Officer (CNO) for Billings Clinic, I am proud to be part of this dedicated nursing team. Located in Billings, Montana, Billings Clinic is an integrated, multi-specialty physician group practice serving the patients of eastern Montana and northern Wyoming. Driven by a vision to be best in nation in quality, safety and service, Billings Clinic’s commitment to the role of nursing is well established and was the driver to achieve Magnet™ status and establish the 14 forces as our commitment to nursing excellence.

This annual report covers a time of significant growth for this organization. Demands for clinical space were at a premium. Three new patient care areas were part of an unfolding master facility plan. Nursing involvement in designing space, which included evidence-based concepts of patient-centered care, helped align the architectural design of our

new inpatient cancer care unit, surgery center and comprehensive cancer center.

Focusing on quality care is an important commitment of our vision and obviously a true passion of the nurse. One of our major clinical accomplishments is the drastic reduction in transmission of hospital acquired MRSA infections (see the article on page 2). Improvement of this magnitude can only be accomplished by a committed team that continues to forge forward despite all barriers.

Fortunately for all of our patients, our nurses’ commitment to our vision and their desire to provide the best quality of care for the patient cannot be underestimated. I hope you will enjoy this glimpse into the world of nursing at Billings Clinic. Like so many of the nursing staff here, I am proud to say I am a nurse and sincerely grateful to say I am a Billings Clinic nurse!

Enjoy.

Chief Nursing Officer

Billings Clinic’s total service area comprises 40 counties in eastern Montana and northern Wyoming and covers approximately 121,000 square miles. Billings Clinic branch locations include:

We are a MagnetTM Health Care OrganizationBillings Clinic is recognized internationally for nursing excellence with the Magnet™ award from the American Nurses Credentialing Center (ANCC). Billings Clinic has a system-

wide Magnet designation and is the only Magnet designated health care organization in Montana and Wyoming.

What does it mean?Magnet designation is nursing’s highest honor. The standards set by ANCC far exceed the expectations of our Joint Commission accreditation. Often referred to as “the gold standard” for nursing, our Magnet designation is truly valued by nursing as a tangible acknowledgement and recognition of the care that is provided at Billings Clinic.

About Billings ClinicBased in Billings, Montana, Billings Clinic is a community governed, not-for-profit multi-specialty group practice integrated with a 272-bed hospital, long-term care facility, and over 3,500 employees, including 238 physicians, 67 nonphysician providers which includes 24 nurse practitioners, and 843 registered nurses.

Billings Clinic offers 35 specialty services, including our Level II Emergency & Trauma Center, Cancer Center, Family Birth Center, Orthopedics and Sports Medicine Center, Cardiovascular Services, Neurosciences, Women’s and Children’s Services, Surgery, Psychiatric Services and Primary Care.

Innovative technology that improves patient care, safety and access, including a Clinical Information System with one electronic medical record in all clinic and hospital locations.

Eastern Montana Telemedicine Network operates 35 sites offering specialty physician care and education to over 8,700 people a year.

Billings Clinic MedFlight advanced life support fixed-wing aircraft service averages 700 flights per year, transporting critically ill or injured patients from rural communities.

Our Family Birth Center provides family-centered care in beautiful birth suites and a Level IIIa NICU. Nearly 1,300 babies are born here each year.

Our Research Center has 25 to 50 ongoing clinical trials per year for conditions such as Alzheimer’s disease, diabetes, high cholesterol, multiple sclerosis, osteoporosis, Parkinson’s disease and hypertension.

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Serving Our Region

Billings Clinic CodyBillings Clinic ColumbusBillings Clinic HeightsBillings Clinic Miles City

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Billings Clinic Red LodgeBillings Clinic WestBozeman OB/GYN

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Nicholas Wolter, MDBillings Clinic CEO

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Health care-associated Methicillin-resistant Staph aureus (MRSA) Infections 4th Quarter 2008 (October, November, December)

Incidence Rate = # cases / patient days X 1,000Case is defined as health care-associated infection.

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2008 MRSA Elimination AccomplishmentsElimination of MRSA Using the Positive Deviance Approach

A multi-pronged intervention was implemented in spring of 2006 through 2008 consisting of active MRSA surveillance testing, contact precautions for colonized and infected patients, hand hygiene promotion, environmental cleaning, and using the positive deviance approach to social and cultural change.

Billings Clinic achieved an 84 percent reduction (p=0.001) in healthcare-associated (HA) MRSA infections from January 1, 2005 through December 31, 2008.

Infection control nurses work directly with the CDC to build the first transfer of clinical microbiology data across a secure electronic network for the purpose of calculating a surrogate, objective measure (clinical incidence density of our MRSA clinical culture data).

Billings Clinic was selected to present the MRSA prevalence study as a podium presentation at the 2008 ANCC National Magnet Conference in October.

Billings Clinic and its beta site partners were selected to present the entire PD/MRSA elimination experience as a

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Patient Safety with CAT’itude - The Critical Assessment TeamThe Critical Assessment Team (CAT) consists of an ICU registered nurse and a respiratory therapist who assist nursing staff in early identification of potential problems that could lead to an arrest. Based on research, most patients show signs up to eight hours before they arrest. These signs include change in blood pressure, heart rate, respiratory rate, level of consciousness and temperature. When staff notice selected signs, they initiate the CAT.

Expected outcomes of the team include:

Staff consultation and support system

Teaching tool to enhance skills, improve relationships, and inspire confidence

Improved nurse retention

Support nurses who need help with difficult decision making

Mentor novice nurses

New challenges for the seasoned ICU nurse

Improved outcomes

Decrease transfers to higher levels of care

Improved satisfaction of nurses, physicians and patients

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A Culture of SafetyThe Quality Council is committed to reviewing and assessing the quality of nursing practice at Billings Clinic. It is composed of bedside nurses and nursing leaders and is led by Vice President of Hospital Operations and CNO Lu Byrd, RN.

Quality at Billings Clinic:

Our vision is to be the best in the nation in quality, safety and service by 2010.

Our quality goal is to strive to deliver the right care for each patient the first time and every time.

Nurses and other health care providers directly and profoundly affect Billings Clinic patients, families and ultimately our community.

Quality Council focuses on both national and organizational patient safety and quality issues.

In September 2008, the professional development department implemented a new three-week long CNA training program to assist in filling vacancies. Attendees of the CNA classes have thus far had a 100 percent pass rate and Billings Clinic has benefited from a 100 percent retention rate of these new CNAs.

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Nursing, Quality and Research

Number of Nationally Certified Nurses at Billings Clinic.

Since initiation of the CAT, failure to rescucitate and CPR calls outside the ICU and emergency department have decreased to one or two per month. Patient transfers to a higher level of care have decreased from over 30 per month to less than 10 per month.

From January 1, 2005 to December 31, 2008 Billings Clinic had an 84 percent reduction in health care-associated MRSA infections.

learning lab at the Institute for Healthcare Improvement’s (IHI) national forum in December 2008.

From January 2005 through September 2008, the range of cost avoidance is calculated to be $800,000 to $1,216,000 by preventing 34 healthcare-associated infections at Billings Clinic (using $38,000 in attributable costs for a MRSA infection (2005/2006 Billings Clinic data).

Billings Clinic hosted a Plexus site visit where our story was captured. This story will be published by the Plexus Institute in their Emerging Series publication.

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Nursing, Quality and Research

Nursing Education Benefits from The Classic 25th Anniversary

Billings Clinic Foundation raised an estimated $940,000 from the 2008 Classic to support excellence in health care education, including the Friends of Nursing endowment.

Classic festivities included a women’s golf scramble, open golf and sporting clays, in addition to the gala event featuring comedian Martin Short.

Hundreds of volunteers from Billings Clinic and the community helped organize the event, doing everything from making decorations to serving food.

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Director of Patient Safety and Infection Control Nancy Iversen, RN, and the MRSA team conduct an improvisational session to stress

MRSA infection prevention and safety.

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Med/Surg Length of Stay by Fiscal Year

Stroke CertificationBillings Clinic is certified as a Primary Stroke Center by The Joint Commission.

Nursing had a key role in attaining and maintaining the certification through:

Registered nurse stroke care manager rounds with physician

Concurrent medical record reviews and interventions to guide evidenced-based practice

Dysphagia screening by trained nurses

Medication reconciliation

Discharge education specific to stroke and risk factor modification

Outcomes:

Improved dysphagia screening process with decreased risk for aspiration

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Billings Clinic is the only accredited Chest Pain Center in our region by the Society of Chest Pain Centers. Nursing had a major role in attaining and maintaining the accreditation.

Nursing has been instrumental in quarterly reviews between Billings Clinic and EMS.

Nursing collects data with feedback to physicians and nursing that measures Chest Pain Center pathway compliance (NSTEMI data collection).

Nursing has worked diligently on clock synchronization for accurate time reporting for STEMI patients (process improvement).

Nursing has developed flow charting of patients from EMS call to emergency department.

Nursing has developed flow charting of patients from the emergency department through triage care.

Total Hip and Knee CertificationBillings Clinic received disease-specific certifications from The Joint Commission in 2008 for:

Joint Replacement – Hip

Joint Replacement – Knee

Nursing had a significant role in attaining and maintaining the certification.

Nursing care of patient is one key element a surveyor utilizes to certify quality of program.

Surveyors interview staff nurses to assess overall professionalism, knowledge, and confidence.

Individualized care plans were supported by demonstration and accurate documentation.

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Nursing, Quality and ResearchNursing, Quality and Research

Patients reported, “When she walks in the door, she makes me feel like I am her only patient.”

Nurses played a key role in pain control, allowing patient to optimize rehab activities and ensure safe discharge to home.

Outcomes:

Nursing “owns” part of deep vein thrombosis prophylaxis ensuring that sequential compression device placement occurs within 24 hours post operatively.

Future nurse-driven process will be related to standardizing discharge education for all patients.

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Operational ExcellenceIn 2008, Billings Clinic added the Operational Excellence department to foster an environment of sustained change in transforming health care delivery processes by:

Improving patient outcomes and satisfaction

Analyzing processes from start to finish

Eliminating errors and variations from the expected clinical and business outcomes, and

Eliminating waste and inefficiencies.

2008 Nursing Op Ex Projects:

Medical/surgical length of stay

Inpatient surgical discharge time

Emergency department length of stay

Cath lab cycle time

SameDay Care patient cycle time

Endoscopy flow and productivity

Inpatient adult psychiatric unit productivity enhancement

Inpatient critical care unit productivity enhancement

Admitting coordination

Lab point of care documentation

Women’s and Children’s maternity financial counseling

Dialysis inventory event

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Length of stay has decreased through the efforts of the length of stay and through-put Op Ex projects as noted in the graph above.Surgical Care Improvement Project core measurements

indicate positive outcomes are directly related to the measures in the chart.

Patients arriving at Billings Clinic’s Emergency & Trauma Center are greeted by staff who expedite their care to the appropriate care station.

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Restrained Patients(Inpatient Medical, Inpatient Surgical, ATU)

Nursing, Quality and Research Nursing, Quality and Research

Blaseg, K, RN, MSN, OCN, BC. “Cancer Survivorship.” Big Sky Oncology Nursing Society Annual Conference. Billings, MT. October 4, 2008

Iversen, N, RN, CIC. “Unleashing Solutions to MRSA Prevention Using Positive Deviance Approach.” Institute for Health Improvement (IHI). Nashville, TN. December 8, 2008

Zinnecker, P, RN, BAN, MSN, CCRN. “Throughput: Success.” VHA CCIN Collaborative. April 2007

Pam Zinnecker, RN, and Carol Blackwell, RN. ICU Research Study at Poster Sessions at NDNQI

Pam Zinnecker, RN. “Patient Safety with CAT’itude,” for a National VHA webinar about rapid response teams.

Pam Zinnecker, RN, and Aileen Rogers, RN. Prevention of Central Line Associated Blood Stream Infections: A national satellite/TV broadcast for VHA.

Poster Presentations Zinnecker, P, RN, BAN, MSN, CCRN, and Blackwell, C, RN, CCRN. “Examination of Skin Lesions on Admission to the ICU.” ANCC Magnet Conference. Atlanta, GA. October 2007

Zinnecker, P, RN, BAN, MSN, CCRN, and Blackwell, C, RN, CCRN. “Examination of Skin Lesions on Admission to the ICU.” NDNQI. February 2008

National CollaborationsKaryl Blaseg, RN. Karyl has worked with the Oncology Nursing Society (ONS) to develop and organize the annual Institutes of Learning (IOL) conferences for 2006, 2007 and 2008.

PublicationsZulkowski, K, DNS, RN, CWS and Gray-Leach, K, RN, BSN, CWCN, COCN. “Staging Pressure Ulcers: What’s the Buzz in Wound Care?” The American Journal of Nursing. January 2009. 109(1):27-30.

Zulkowski, K, DNS, RN, CWS and Zinnecker, P, RN, BAN, MSN, CCRN, Blackwell, C, RN, CCRN, Sutphin, L, RN, BSN, CCRN, Horman, M, RN, BSN, Thompson, D, RN BSN, CCRN, and Quest, R, RN, BSN. “Examination of Skin Lesions on Admission to the ICU.” World Council of Enterostomal Therapists Journal. January/March 2007.27:(1):22-23.

Presentations Iversen, N, RN, CIC, Mellgren, J, MT, (ASCP, CIC). “Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) Colonization: A Patient and Employee Study in a 270-Bed Regional Hospital.” ANCC Magnet Conference. Salt Lake City, UT. October 2008

Gray-Leach, K, RN, BSN, CWCN, COCN. “Time is Ticking: Pressure Ulcer Prevention is the BOMB!“ Montana Nurses Association. September 25, 2008

Nursing Research Council and Research ActivitiesThe Nursing Research Council created an independent nursing research policy to guide and support nurse-led research at Billings Clinic. All nursing research conducted at Billings Clinic is now monitored through the Nursing Research Council.

Membership includes nursing leadership, as well as a representative from each nursing department, Center for Clinical Translational Research, Montana State University – Billings campus, and Billings Clinic library. The director of the Institutional Review Board is an adjunct member.

A Nursing Research Council intranet site was created for general information about the Nursing Research Council and as source for conducting nursing research at Billings Clinic.

Billings Clinic and Montana State University-Billings College of Nursing are planning collaborative opportunities for further development of nursing research and mentorship, enhanced evidence-based practice, and expanded cooperation in education for current and future nurses using the Magnet model.

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Technological AdvancesOptiLink and Nursing Compass

In 2008, Billings Clinic began working toward implementation of a system to centralize and streamline the scheduling and staffing process. This system also provides the integration of a standardized patient acuity system for the patients we care for every day. This system will also:

Allow us to manage staffing needs for today and tomorrow while also planning for the future.

Allow us to assign acuity levels that have been tailored to our units using input from our direct-care staff.

Allow organization leaders to access accurate and timely data regarding nursing quality indicators, patient acuity and census and staffing productivity by creating an interface between these applications.

This system will be implemented across the patient care units within the hospital. System implementation began in late 2008, with full implementation expected in 2009.

Restraint use at Billings ClinicIn 2006, the decision was made by nursing leadership to move toward a restraint limited patient care environment at Billings Clinic. The following nursing initiatives drove the results in the graph below:

diversion tactics

circadian rhythms

personal safety attendants

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Nursing Research Council Members Jane Scharff, MN, RN, MSU-B, Campus Director College of Nursing, Kerry Nichols, BSN, RN, and Kristen Klebe, BSN, RN, discuss current literature for their research project.

Billings Clinic nurses boarded the bus for Salt Lake City to take part in the 2008 ANCC International Conference, Defining Excellence: Magnet. Over 5,000 nurses from 21 countries were represented. Celeste Dimon, Billings Clinic Director of Women’s and Children’s Services and Magnet leader, said, “We are learning how to take nursing excellence to the next level and continue our journey of extraordinary care for our patients.”

Infection Prevention and Control professionals, Nancy Iversen, RN, CIC, and Jennifer Mellgren, MT, CIC, were invited to present the results of a methicillin-resistant Staphylococcus aureus (MRSA) prevalence study and the successful work that has been done applying the Positive Deviance approach for eliminating transmission of MRSA at Billings Clinic.

Billings Clinic received MagnetTM in August, 2006.

28 Nurses Attend Magnet™ Conference

In 2006, Billings Clinic moved toward a restraint limited patient care environment.

bed chair alarms

protective mitts

hourly patient rounds

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Billings Clinic Surgery CenterThe new 29,000 square foot Billings Clinic Surgery Center opened in February 2009 and was designed with quality care, safety and the patient experience at its core. With all aspects of care provided on one level, there is a seamless flow for patients and their families. Cross-trained nurses can inform patients what to expect during each step of their care.

Features of the Surgery Center include:

Integration with Billings Clinic’s electronic medical record and digital imaging system

Five active operating rooms with capacity to expand to eight

Medical equipment is organized on an overhead boom system, giving care providers 360-degree access to the patient

Dedicated room for pain management treatment

14 pre-operation areas with walls for privacy

10 patient recovery areas for immediate post-operative care, with 14 additional areas for the remainder of the recovery stay

On-site radiology

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Surgery Center nurses Heather Bearcloud, RN, and Vicki Hert, RN

NICU Moves to Level IIIa StatusBillings Clinic’s neonatal intensive care unit (NICU) recently moved from level II+ to level IIIa status.

Neonatologist Nadine C. Seger, MD, arrived in September 2008. Average daily census increased from 2.4 to 6.8 in first six months.

Staff attended educational days in June 2008, July 2008, and February 2009 with Presbyterian-St. Luke’s (PSL) in Denver.

75 percent of NICU nurses are certified.

90 percent of NICU nurses are credentialed.

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Neonatal Intensive Care Nurse Gwen Felstet, RN, cares for newborns with special needs in our Level IIIa NICU at Billings Clinic Family Birth Center.

Building Our Future Building Our Future

Comprehensive Cancer CenterBillings Clinic provides care in a new comprehensive outpatient Cancer Center.

Clinical care areas were designed with evidence-based nursing involvement from design through construction.

A regional cancer patient survey was completed to ensure patient care areas would meet and exceed the expectations of patients and families.

The most advanced technology has been incorporated into the center, from provider and nursing tablets for electronic documentation to state-of-the-art radiation oncology and infusion center equipment.

Oncology specific education is provided to all staff through an orientation and annual competency program.

The cancer program supports nationally-recognized best practice through support programs like patient care navigation and cancer research, led by cancer nurses.

Eight patient navigators work to ensure seamless and coordinated care between the physicians, the diagnostic tests and the cancer treatments, while offering education, support, and guidance to help patients and families cope with their challenges.

Billings Clinic has 21 Oncology Certified Nurses (OCN or AOCN), making up 42 percent of oncology nurses.

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Cancer Care Navigators (L-R) Chris Kuehl, RN; Emily Tesar, RN; Linda Dukart, RN; Deb Hofer, RN; Mary Lou Simmons, RN; Pat Mahana, RN; Deb White, RN; Linda Allen, RN

Connie Anderson, RN, uses one of the new bedside computer tablets to record a patient’s vital signs into his electronic medical record. Computer tablets in each room help nurses spend more time with their patients while delivering more efficient patient care.

Inpatient Cancer Care Unit As part of our vision for comprehensive cancer care Billings Clinic opened a new inpatient cancer care unit in February 2009. The unit and each patient room is designed using evidence-based practice and participation from the oncology staff and leadership to include many features that support patient safety, service and quality. This new unit features:

26 private patient rooms with specific clinical, patient and family zones

Advanced medical technology includes:

Patient lifts

Electronic bedside reporting with automatic data transfers

Hands-free nurse/patient communication

Patient nourishment centers located throughout the unit

An exercise room to enhance stress reduction and minimize complications related to being sedentary during extended hospital stays

Private family consultation rooms

An education and resource center to provide disease-specific information and access to online support groups

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In the Fall of 2009, the Neonatal Transport Flight program will be initiated. Six NICU registered nurses will be the “pilot crew” for this new program. Educational sessions, with assistance from PSL in Denver, have been conducted over the past several months.

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