Download the 2011 Nursing Annual Report - Jersey City Medical ...

“ 

We ” 

are the light 

in institutional 

darkness, and in this 

model we get to return 

to the light of our 

humanity. 

Jean Watson

Table of Contents 

A Message From Joseph Scott . . . . . . . . . . . . .2 

A Message From Rita Smith . . . . . . . . . . . . . . .3 

Professional Nursing Leaders . . . . . . . . . . . . . .4 

Emergency Department . . . . . . . . . . . . . . . . .6 

Trauma Division . . . . . . . . . . . . . . . . . . . . . . .7 

Critical Care Division . . . . . . . . . . . . . . . . . . .8 

Cardiac Catheterization Laboratory . . . . . . . .10 

Perioperative Services . . . . . . . . . . . . . . . . . .11 

Medical Surgical Division . . . . . . . . . . . . . . .12 

Maternal Child Health . . . . . . . . . . . . . . . . . .15 

Neonatal Intensive Care Unit . . . . . . . . . . . . .16 

Behavioral Health . . . . . . . . . . . . . . . . . . . . .17 

Stroke Program . . . . . . . . . . . . . . . . . . . . . . .18 

Wound Care & Fall Prevention . . . . . . . . . . . .20 

Infection Control . . . . . . . . . . . . . . . . . . . . . .21 

Palliative Care . . . . . . . . . . . . . . . . . . . . . . .22 

Renal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 

Editors: 

Michele Lopez Vicki DeChirico Tara Mazzone 

MSN, RN, CEN MSN, RN, CIC MSN, RN 

1 

Case Management . . . . . . . . . . . . . . . . . . . .23 

Employee Health Services . . . . . . . . . . . . . . .24 

The Educational Center for 

Professional Development . . . . . . . . . . . . . . .26 

Community . . . . . . . . . . . . . . . . . . . . . . . . . .27 

Nursing Informatics . . . . . . . . . . . . . . . . . . . .28 

Nursing Finance . . . . . . . . . . . . . . . . . . . . . .28 

Risk Management . . . . . . . . . . . . . . . . . . . . .29 

Clinical Ladder Program . . . . . . . . . . . . . . . .30 

Certified Registered Nurses . . . . . . . . . . . . . .31 

Nurse Excellence Awards 2011 . . . . . . . . . . .32 

The DAISY Award . . . . . . . . . . . . . . . . . . . . .33 

Quality and Safety Council . . . . . . . . . . . . . .34 

Staff Satisfaction and Retention Council . . . . .34 

Nursing Research Council . . . . . . . . . . . . . . .35 

Professional Practice Council . . . . . . . . . . . . .36 

Liberty Health Patient Engagement . . . . . . . . .37 

The Voice of the Customer . . . . . . . . . . . . . . .38

A Message From Joseph Scott 

Every year, Jersey City 

Medical Center gets better 

and better. This is the direct 

result of the collaborative 

effort of our entire staff that 

focuses every day on our 

Mission of “Enhancing Life”. 

This year we have many 

accomplishments to 

celebrate. This recognition is 

the result of our focus on our 

four Pillars of Safety, Quality, 

Satisfaction for our Patients, Employees and Physicians 

and the Economic Health of our Organization. These 

recognitions can only be accomplished when everyone 

works together and focuses on our vision of being in the 

Top 10% nationally. Our nursing staff plays an integral 

role in achieving many of these recognitions. 

For an unprecedented two consecutive years in 

2010 and 2011, Jersey City Medical Center has been 

voted by Castle Connolly and Inside New Jersey-Star 

Ledger as the “Number One Hospital” for its size. This 

award is voted on by physicians throughout the state. 

We were also rated number one in all clinical categories 

during this period. 

Health care consumers had the opportunity to vote 

on their hospital experience, rating hospitals in four 

areas for their overall quality, best doctors, best nurses 

and best image including reputation. This award 

presented by the National Research Corporation’s 

Consumer Choice is given annually to one hospital in 

each of approximately 300 markets around the country. 

We now join the select few who have achieved this 

prestigious status. 

Our Primary Stroke Center continued to thrive in 

2011 and received the American Heart/American 

Stroke Association’s "Get With the Guidelines ® -Stroke 

(GWTG-Stroke) Silver Performance Achievement Award” 

for excellence in stroke care. The award recognizes the 

hospital's success in providing a high level of stroke care 

by ensuring that patients receive treatment according to 

nationally accepted standards and recommendations. 

As a Primary Stroke Center, the hospital has developed 

a comprehensive system for rapid diagnosis and treatment 

of stroke patients. 

The American Heart Association also supported our 

efforts to encourage healthy lifestyles and to create a 

culture of physical activity in the workplace. Proudly, we 

received the “2011 Gold Fit Friendly Company Award”. 

Acknowledging our commitment to the safety and 

well being of our community, we were honored as the 

“Organization of the Year” by both the Jersey City 

Rotary Club and the Hudson County Chamber of Commerce. 

The hospital was recognized for our outreach 

programs to the community including health fairs, 

screenings, free dental clinics, first aid training, senior 

citizen fall prevention programs, youth bike safety and 

infant car seat inspection programs and many other 

educational programs. Our Mission of “Enhancing Life” 

is evident as we care for our community through many 

programs that are nurse driven. 

Jersey City Medical Center is one of just 10 hospitals 

and health care systems throughout the U.S. to be 

honored with the “CEO Cancer Gold Standard” for our 

efforts in reducing the risk of cancer for employees and 

their families through healthy lifestyle choices, by 

encouraging early detection through cancer screenings, 

and by ensuring access to quality treatment. 

Just one of three organizations in New Jersey to be 

selected, Jersey City Medical Center was honored in 

2011 as Modern Healthcare Magazine’s “100 Best 

Places to Work in Healthcare”. This distinction is based 

on polices and procedures, benefits and demographics, 

and the random responses of employees to questions 

concerning such areas as leadership and planning, 

culture and communication, role satisfaction, working 

environment, training and development, salary and 

benefits, and overall satisfaction. 

I am very proud and humbled to be a member of 

our organization and grateful that we have a nursing 

staff that focuses on achieving so much for our patients 

and community. The commitment and skill of our nursing 

staff is evident by our success. I look forward to a 

prosperous and successful 2012. 

2 

Sincerely, 

Joseph F. Scott, FACHE, 

President & CEO, Liberty Health/ 

Jersey City Medical Center

A Message From Rita Smith 

In 2011, with the strong support and leadership 

of nurses, Jersey City Medical Center achieved great 

success with quality and safety initiatives. It is our 

vision to be in the top decile nationally for quality 

and safety, and over the past year we have made 

significant progress toward that goal. The Quality 

and Safety Nursing Council along with the 

Performance Improvement Department set very 

aggressive targets in all quality and safety indicators. 

Through the efforts of this council and the work of all 

of our nurses and physicians, we were able to 

achieve 100% compliance with all core measures and 

either met or exceeded the target in 22 of 26 safety 

initiatives. Thanks to the great work done by our 

Clinical Nurse Leaders, Nurse Managers, Charge 

Nurses and Staff, we successfully implemented many 

initiatives impacting quality and safety, including 

Early Warning Scoring System (EWSS) as part of daily 

assessments to reduce failure to rescue, central line 

associated blood stream infections (CLABSI) and 

catheter associated urinary tract infections (CAUTI) 

and acute respiratory distress syndrome (ARDS) and 

delerium protocols. In addition we continued 

strengthening many other previously implemented 

initiatives to reduce falls and pressure ulcers and 

deaths from sepsis. Nurses are working 

collaboratively with physicians to ensure the best 

outcomes for our patients and our results are 

impressive. 

In recognition of extraordinary clinical skills and 

compassionate nursing care, more than 100 nurses 

were nominated for the DAISY award, originally 

created by the family of Patrick Barnes, a patient 

diagnosed with a Disease that Attacks the Immune 

System to honor the dedication and excellence 

demonstrated by nurses. 

This past year was also a time of growth in 

shared governance with a strengthening of our 

nursing councils, from Unit Practice Councils (UPCs) 

to general nursing councils. Many topics for 

improvement were identified in UPCs and 

3 

collaborative activity 

between individual 

nursing units and other 

departments resulted in 

process improvement in 

patient flow, support 

system changes and staff 

and patient satisfaction. A 

focus on communication 

between nurses and 

physicians and nurses and 

patients resulted in routine interdisciplinary meetings 

between surgeons and nurses; restructuring the role 

of Discharge Nurses; and redesigning the role the 

Charge Nurses in the Critical Care and Neonatal 

Intensive Care Unit. The Transforming Care at the 

Bedside (TCAB) initiative, in its third year on our 

surgical unit continues as a strong force in 

developing teamwork and transformational 

leadership of staff nurses in the pursuit of safe and 

effective care and nurse engagement. 

At Jersey City Medical Center we recognize that 

nurses are at the heart of patient care and that 

nurses are uniquely capable of assessing the need 

for improvement and leading change. We have the 

skills to communicate, organize, evaluate and 

implement and we understand the concept of 

teamwork. Nurses will continue to lead change in 

the institution, focus on improvement in all areas 

affecting patients. We are very proud of the 

progress made in the area of quality and safety in 

2011 and we will lead the challenge in 2012 as we 

improve our patient engagement outcomes. 

Sincerely, 

Rita Smith, DNP, RN, CNO, NEA-BC 

Senior Vice President of Patient Care Services 

Chief Nursing Officer

Professional Nursing Leaders 

Nursing Leadership 2011 

Rita Smith, DNP, RN, CNO, NEA-BC 

Senior Vice President Patient Care Services 

Brenda Hall, MS, RN, NE-BC 

Senior Vice President of Safety, Quality and Regulatory Affairs 

Cheryl Owens, MSN, RN CNOR ...............................Director of Nursing 

Susan Lanning, BSN, RN .....................Director of Community Outreach 

Elenita Ajose, BSN, RN 

Nurse Manager 6 West and Renal 

Therese Boruta, BSN, RN 

Clinical Informatics 

Selena Bray, BSN, RN-C 

Nurse Manager 5 West 

Ellen Brummer, MS, RN 

Employee Health Services 

Karen Caldas, MSN, RN-BC 

Clinical Risk Management 

Winnie Cherubin, MSN, RN, CNL, WCC 


Clare Cinelli, BSN, RN 

Nurse Manager 7 East and 7 West 

Vicki DeChirico, MSN, RN, CIC 

Infection Control Coordinator 

Marissa Fisher, BSN, RN 

Injury Prevention Coordinator 

Claudia Garzon-Rivera, MSN, RN, CNL, CCRN 

Clinical Nurse Leader 

Kerry Genese, BSN, RN 


Jennifer Jones, MSN, RN CNL 

Trauma Program Coordinator 

Janice Kozzi, MSN, RN CNL 


Mabel LaForgia, MSN, RN, CNL, CCRN 


Kelly Loo, BSN, RN, CGRNA 

Nurse Manager Endoscopy, Same Day Surgery, PACU, and PAT 

Michele Lopez, MSN, RN, CEN 

Director of Stroke Program Services & 

Educational Center for Professional Development 

4 

Fadia Mastrovich, BSN, RN 

Director Clinical Documentation & Coding Integrity 

Rachele Mattaliano, RN-C, CLNC 

Quality Management Specialist 

Tara Mazzone, MSN, RN 

Nurse Manager Newborn Intensive Care Nursery 

Nancy Pain, APN, RN-C 

Pain and Palliative Care Nurse 

Kim Palestis, RN, CEN 

Assistant Nurse Manager, Emergency Department 

Margaret Petrucelli, BSN, RN 

Wound and Falls Program Coordinator 

Rafael Portales, RN 


Lillian Reyes, RN 

Nurse Manager Maternal Child Health 

Bonnie Rosenzweig, BSN, RN, CRRN 

Quality Management Specialist 

Marilyn Sarnatora, MS, RN, BC 

Nurse Manager 6 East and 5 East 

Larissa Semenoff, BSN, RN, CNOR 

Nurse Manager Cardiac Catheterization Laboratory and 

Interventional Radiology 

Kelly Sietsma, BSN, RN 

Stroke Program Coordinator 

Cristina Simeone, BSN, RN 

Nurse Manager of the Critical Care Units, Cardiac Stepdown 

and Critical Care Stepdown 

Christine Wade, MSN, RN, CEN 

Nurse Manager Emergency Department

Professional Nursing Leaders 

Advanced Practice Nurses: 

Almanzor, Mary Lou NP Department of Medicine 

Babich, Jessica NP Department of Medicine 

Brophy, Shannon E. NP Department of Medicine 

Brun, France CRNA Department of Anesthesia 

Cahill, Sharon L. NP Department of Emergency Medicine 

Campbell, Shanna CRNA Department of Anesthesia 

Canning, Mark A. NP Department of Psychiatry 

Cogan, Michael CRNA Department of Anesthesia 

Cottle, Suzanne CRNA Department of Anesthesia 

De Belen, Donna-Vivian CRNA Department of Anesthesia 

DiBrita, Franca NP Department of Medicine 

Drattler-Gold, Florence A. NP Department of Emergency Medicine 

Duhart-Ball, Debra CRNA Department of Anesthesia 

Duncan, Keesha CRNA Department of Anesthesia 

Espinosa, Benedicta CRNA Department of Anesthesia 

Fox, Adrian F. NP Department of Psychiatry 

Glover, Nicole NP Department of Medicine 

Jeffers, Yana NP Department of Emergency Medicine 

Klingelhofer, Elizabeth A. NP Department of Emergency Medicine 

Levy, Marina CRNA Department of Anesthesia 

Lucas, Alfredo F. CRNA Department of Anesthesia 

Makowski, Rachel NP Department of Medicine 

Manchery, Jessymol NP Department of Medicine 

Marquet, Judith R. NP Department of Psychiatry 

McCarthy, Jayne T. NP Department of Emergency Medicine 

McDonnell, Shannon M. CRNA Department of Anesthesia 

McGovern, Maryann E. NP Department of Medicine 

Meller, Heather A. NP Department of Surgery 

Pain, Nancy NP Department of Medicine 

Park, Seongae NP Department of Medicine 

Petropoulos, Lisa NP Department of Orthopedics 

Prendergass, Fred J. CRNA Department of Anesthesia 

Pritsiolas, Kristine NP Department of Emergency Medicine 

Rallakis, Nicholas CRNA Department of Anesthesia 

Rathbun, David CRNA Department of Anesthesia 

Scarinci, Eileen G. NP Department of Medicine 

Stralkus, Jan NP Department of Emergency Medicine 

Taylor, Bethany L. CRNA Department of Anesthesia 

Uysal, Alisa CRNA Department of Anesthesia 

Zadel, Janis L. NP Department of Medicine 

Zamber-Costello, Lisa M. NP Department of Emergency Medicine 

Nurse Educators: 

Cris Amato, BSN, RN, CEN, MICN 

Elizabeth Corshu, MS, RN 

Michelle L. Dickerson, BSN, RNC-NIC 

Maura Donohue, BSN, RN 

Randa Francis, BSN, RN, CNM, WHCNP-BC, MSN 

Nicole Sardinas, MSN, RN CCRN 

Emma Toussaint, BSN, RN 

5 

Assistant Directors of Nursing: 

Valerie Brown MSN, RN, CNOR 

Catherine Cutone, MS, BSN, RN, CPHQ, CPMSM 

Lori Horton, MSN, RN 

Dan Huq, MS, BS, RN 

Charmaine Ifill, RN 

Robin Maher, BSN, RN 

Vince Obode, MSN, RN 

Fe Saquibal, BSN, RN 

Jessica Walsh, MSN, RN APN-C

Emergency Department 

Once again the Emergency Department (ED) has seen 

an unprecedented number of patients, treating almost 

85,000 patients including 1,202 traumas. This represents an 

increase of 5,000 visits from 2010. Despite the increase in 

volume, the ED team diligently worked to reduce the left 

without being seen (LWOBS) rate to below 1.5% and the 

door to stretcher time was reduced to less than 15 minutes. 

Construction in the Diagnostic Unit was completed and this 

additional space assisted the department in improving 

patient throughput in the ED. The Diagnostic Unit serves as 

a treatment area for patients admitted to “observation” 

status and for patients waiting for results of their diagnostic 

exams. 

Representation on the Clinical Ladder from the ED 

remains strong. Five nurses have contributed valuable 

projects impacting outcomes in the ED. Recruitment for new 

members to the Clinical Ladder is ongoing and welcomed 

by the leadership. 

The nursing staff continues to set goals and achieve 

great accomplishments. Three ED nurses, Doreesha 

Armstrong, RN, Shkeirra Lucas, BSN, RN and Michelle 

Lopez, BSN, RN were nominated for awards presented at the 

“Tenth Annual Nurse Excellence Awards” ceremony. The 

“Anita Sommers ED Nurse Award” is granted annually to the 

Emergency Department Nurse who demonstrates continued 

outstanding achievement in leadership, serves as a model 

patient advocate and has the highest standards of clinical 

practice skills. Voted by her peers, Mary Verrinder RN, CEN 

the ED Charge Nurse deservingly was the recipient of the 

“Anita Sommers Award”. 

Nancy Chiocchi MSN, RN, PhD-C was selected by the 

Senior Rocks organization as New Jersey's "Hero Among 

Us" and was honored at the half time activities of the Red 

Bulls' season closer at the Red Bull Arena in Harrison, NJ on 

October 20, 2011. The award was part of the Red Bulls / 

Seniors Rock sponsored "Nurse Appreciation Night.” 

Nancy was selected as a shining example of a healthcare 

professional from among many submissions from New Jersey 

hospitals. 

6 

The Golden Stethoscope Club was established to 

recognize ED nurses who successfully passed the Certification 

in Nursing Exam (CEN). In 2012, the CEN exam will be hosted 

right here in JCMC and the department is proud to expand 

the number of nurses certified in this demanding specialty. 

Our ED Nurse Preceptors have again taken on the 

challenge of fully training 7 new graduate RNs who have all 

successfully transitioned into their new role. The 

comprehensive orientation process in the ED has been a 

successful model and is continually reevaluated to meet the 

needs of nurses new to the profession or new to the 

specialty of emergency nursing. Proudly, the ED staff 

turnover rate is less than 1%. Collegial support has a 

demonstrated impact on staff retention. Nurse Educator Cris 

Amato, BSN, RN, CEN, MICN and Nancy Chiocchi MSN, RN, 

PhD-C, created a support group for new graduate nurses 

called Registered Nurses’ Anonymous. This forum provides 

a safe and confidential environment to discuss their 

experiences as new graduates, examine best practices and 

common pitfalls in nursing, and design communication 

techniques to empower nurses and build healthy 

relationships with their peers. 

Caring for our community extends beyond our campus 

and the doors of the ED. Members of the ED staff have 

signed up to mentor a child in the Big Brothers/Big Sisters 

program sponsored by our neighboring Boys and Girls Club. 

Staff showed their support and participated in the 

Alzheimer’s Walk of Hudson County. During the holiday 

season the spirit of giving was inspirational as a family was 

“adopted” from the Women’s Rising Shelter. Gifts were 

collected and donated to a deserving family, hoping to ease 

their hardship and share 

our holiday spirit. Over 

200 coats were collected 

during the annual coat 

drive and distributed to 

those in need. 

In review, 2011 was 

both a challenging and 

rewarding year for the ED 

and the team looks 

forward to more exciting 

accomplishments in 2012!

Trauma Division 

The Trauma Service 

Division treated over 1000 

patients this year: a new 

record! This year brought 

several new programs to 

the Trauma Center. We 

initiated a program to 

screen patients for alcohol 

abuse and offer them the 

help they might need. This 

Screening, Brief 

Intervention, and Referral to 

Treatment program (SBIRT) 

evaluates each trauma 

patient by a multidisciplinary team, and offers them referrals 

to alcohol treatment. We also received a grant from the 

New Jersey Department of Health and Human Services 

(NJDHHS) Mental Health Division to begin a Family 

Assistance Support Team (F.A.S.T.); a volunteer-based 

program that helps the family members of trauma victims 

navigate the acute crisis phase of trauma. A Trauma Core 

Nurse Team was developed in the ED, consisting of nurses 

who have a primary interest in caring for trauma patients and 

who are committed to improving outcomes for our subset of 

patients. 

The Injury Prevention Program continues to thrive under 

the direction of Marissa Fisher, BSN, RN. The permanent car 

seat inspection station has checked and/or replaced well 

7 

over 1000 seats since it’s inception in 2009. Marissa has 

developed strong relationships with the Jersey City Public 

Schools and educates grammar school children on 

pedestrian safety, booster seat safety, and helmet use. This 

year, Injury Prevention has teamed up with local new 

mothers’ groups to teach car seat safety. Marissa continues 

to be the Safe Kids Hudson County Coordinator, with JCMC 

as its lead agency. 

Sherry Algoo-Maier, RN again successfully submitted our 

center’s data to the National Trauma Data Bank. She 

obtained Trauma Registry Certification this year. Thanks to 

the excellent documentation efforts of the trauma team, and 

the precise data collection efforts of our Trauma 

Administrative Assistant, Wilfredo Beyo, we are among the 

top hospitals in the nation for data completeness. For 2011, 

our Trauma Center has a penetrating injury rate of 24%, 

which is almost 3 times the national average. The acuity of 

our sickest patients is also higher than the national average, 

based on the standardized Injury Severity Score. 

We continue to bring Trauma Nursing Education to Jersey 

City Medical Center through monthly lectures on topics 

tailored to the care of patients in our hospital. Additionally, 

Marissa and Jennifer became Trauma Nurse Core Course 

(TNCC) Instructors, and have started offering classes on-site. 

This year has been extremely busy for the Trauma Staff 

who has been preparing for our upcoming American College 

of Surgeons Trauma Center Reverification in 2012. 

Port Authority Heros of 9/11 Trauma Center — 2011 Trauma Score Card

Critical Care Division 

The Critical Care Division has seen an expansion in the 

scope and breadth of their practice. Their evidenced based 

practices were adopted by multiple units to improve the 

quality of care and establish a safe patient environment. All 

Critical Care Units were united to form a Division under one 

manager. Additionally, the Charge Nurse Team was 

developed to enhance patient care, improve patient flow, 

and promote professional growth. The team consists of our 

former bedside Critical Care nurses from ICU and CCU. The 

Charge Nurses maintain a perspective of the operations and 

needs of all the units, fostering teamwork across the entire 

division. 

Rapid Response/ Code Blue 

The Rapid Response Team (RRT) is part of the “100,000 

Lives Campaign” whose goal is to prevent deaths through 

early intervention in patients who are clinically deteriorating 

or employees and visitors that may develop sudden illness 

while on the premises. In 2011, the emphasis on Rapid 

Response was team building and the use of the Early 

Warning Scoring System (EWSS). The team building 

sessions included nurses from different specialties, medical 

residents, respiratory therapists, patient care technicians 

and unit clerks. During these sessions, the EWSS was 

introduced. The EWSS is a color-coded scoring graph that 

encompasses a range of normal vital signs to abnormal 

findings that alert the practitioner to reassess the patient or 

call for a RRT intervention. The premise of the EWSS is to 

detect early deterioration before the patient 

decompensates. Before introducing the EWSS to all units, 

the EWSS tool was piloted on the 6 West Medical/Surgical 

unit, and feedback from staff has been very instrumental in 

making the EWSS meaningful. The use of this tool has 

increased our RRT calls throughout all units and has 

decreased code blues outside the Critical Care Division and 

the Emergency Department. Our RRT consists of the Medical 

Resident on days (MON) and the Medical Resident on nights 

(MON), the Critical Care RN, the Respiratory Therapist, and 

the patient’s primary team. Mid year, we introduced the role 

of the Critical Care charge Nurses whose primary role was to 

respond to RRT calls. Having the consistent Critical Care RRT 

nurse has facilitated the development of the RRT and has 

influenced a change in culture that empowers anyone to 

activate the RRT if the need arises. 

Severe Sepsis/ Septic Shock Protocol 

Success with Severe Sepsis and Septic Shock Campaign 

has sustained in 2011. Collaboration between the 

Rate 

8 

Emergency Department, Critical Care, Pharmacy, Laboratory, 

Respiratory Therapy and Infection Control continue to 

ensure quality patient outcomes. Prior to implementation of 

the Surviving Sepsis Campaign, baseline mortality rates were 

48%. The Institute of Healthcare Improvement (IHI) 

recommends reducing the baseline mortality rate for severe 

sepsis and septic shock by 25% and sustaining it for 5 years. 

The Critical Care nursing staff has been essential in 

advocating for the use of sepsis order sets and nursing 

pathways. This collaborative approach has led to 28% annual 

mortality rate for 2011. In 2012, efforts will continue as new 

strategic goals are implemented such as reducing overall 

LOS with patients admitted with the diagnosis of Sepsis. In 

addition, monthly collaborative meetings will occur to 

maintain a multidisciplinary approach. 

1.00 

0.90 

0.80 

0.70 

0.60 

0.50 

0.40 

0.30 

0.20 

0.10 

0.00 

Ventilator Associated Pneumonias per 1000 Ventilator Days 

1Q11 2Q11 3Q11 4Q11 

JCMC 0.00 0.00 0.88 0.69 

Ventilator Associated Pneumonias (VAP), Central Line 

Associated Blood Stream Infections (CLABSI), and 

Catheter Associated Urinary Tract Infection (CAUTI). 

Critical Care Division nurses are empowered to advocate 

for patients and implement evidence based practice at the 

point of care. This is evident due to the divisions’ continued 

efforts to decrease ventilator associated pneumonias (VAP), 

central line associated blood stream infections (CLABSI), and 

catheter associated urinary tract infection (CAUTI). The 

Critical Care division continues to maintain rates below the 

National Healthcare Safety Network (NHSN) benchmark for 

(Continued on page 9)

Critical Care Division 

(Continued from page 8) 

these indicators year to date. During 2011, the process was 

standardized with the development of the Oral Care Policy 

and the Central Venous Catheter Policy. In addition, a new 

hand-off Plan of Care Tool was developed for nursing staff 

which includes each of the bundles. The tool is used during 

interdisciplinary rounding to promote discussion and 

collaboration regarding VAP, CLABSI, and CAUTI prevention. 

In 2010 – 2011 the critical care division achieved 12 

consecutive months without a ventilator associated 

pneumonia (VAP). With in the last year, we have enhanced 

the bundles. We have revised the insulin drip protocol and 

added chlorhexidine mouth washes every 12 hours, as well 

as sedation awakening/spontaneous breathing trials. We 

also contribute our success to the ongoing collaboration and 

teamwork among the critical care team. Our staff nurses are 

empowered to endorse evidence based practice and strive 

continuously to improve patient outcomes. 

Critical Care Committee 

The Critical Care Committee consists of members of the 

multidisciplinary team. It is chaired by Dr. Rao Mikkilineni 

and Co-Chaired by Claudia Garzon-Rivera, Clinical Nurse 

Leader for the Critical Care Division. The team has been 

involved in the development of initiatives that enhance our 

goal to improve quality care and decrease mortality. Some 

of the current initiatives are the use of the Acute Respiratory 

Distress Syndrome (ARDS) protocol, Confusion Assessment 

Method (CAM)-ICU screening tool, Sepsis bundles, 

Ventilator Associated Pneumonias (VAP), Central Line 

Associated Blood Stream Infections (CLABSI), and Catheter 

Associated Urinary Tract Infection (CAUTI) protocols and 

Rate 

9 

increase usage of the Rapid Response Team. In addition to 

the initiatives, the committee continues to strive for optimal 

quality care by revising and developing guidelines and 

policies that assist in providing evidence-based care. One of 

the most recent policies to be updated was the admission 

and discharge criteria for the Critical Care Division. All 

physician services collaborated on one criteria for Medical, 

Surgical, Trauma, CCU, Cardiothoracic and Step-down 

patients. Development of this policy could not have been 

accomplished without the collaboration and shared vision of 

the interdisciplinary team. 

1.00 

0.90 

0.80 

0.70 

0.60 

0.50 

0.40 

0.30 

0.20 

0.10 

0.00 

Central Line Associated Blood Stream Infections per 1000 Central 

Line Days 

1Q11 2Q11 3Q11 4Q11 

JCMC 0.00 0.00 0.00 0.00 

Rate per 1,000 discharges 

45.0 

40.0 

35.0 

30.0 

25.0 

20.0 

15.0 

10.0 

5.0 

RRT calls per 1000 discharges 

0.0 

Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 

RRT calls per 1000 discharges 16.1 29.8 25.4 32.2 37.3 23.8 36.3 34.1 33.2 38.1 33.8 28.1

Cardiac Catheterization Laboratory 

Each year more than 

1000 procedures are 

performed in the Cardiac 

Catheterization 

Laboratory at the Jersey 

City Medical Center. 

From angioplasty to stent 

placement, TEE (Trans 

Esophageal 

Echocardiogram), NIPS 

(Non Invasive Program 

Stimulation) to 

implantable defibrillators 

and implants including the biventricular pacemaker for 

treatment of congestive heart failure, patients are receiving 

top quality care. The cath lab team is available 24 hours a 

day, seven days a week to manage any cardiac emergency. 

The most sudden heart attacks are treated with emergency 

angioplasty. The time between a patient’s arrival at the 

Emergency Department and emergency angioplasty known 

as the “Door to Balloon Time” is very critical to the outcome 

and survival of the patient. The Code Heart team at Jersey 

City Medical Center takes its door to balloon time very 

seriously. The team responded to 49 Code hearts, met 100% 

door to balloon time within 90 minutes for seven 

consecutive months. 

The number of cath lab staff has grown tremendously to 

accomplish the ultimate goal of delivering the safest and 

highest quality care. Each member of the cath lab staff has a 

strong work ethic and takes pride in his or her contribution 

10 

to the goal of the department. To keep abreast of the latest 

technologies and treatment modalities of this rapidly 

growing field, the staff attended several national conferences 

such as the Coronary Research Technology Conference held 

in Washington DC, The VIVA Conference in Las Vegas, and 

Complex Coronary Cases in New York. 

The staff actively participates in the Clinical Ladder 

Program. They participated in community health fairs 

educating attendees about heart disease prevention and 

complications. They extended their assistance internationally 

during the flood disaster in the Philippines by organizing a 

clothing and food drive. They also joined in the Second 

Annual Research 

Symposium with a poster 

presentation titled 

“Bringing Research 

Findings to the Cardiac 

Cath Lab- the Role of 

Everyone in the 

Department”. The cath 

lab staff is also 

anticipating the 

expansion of the 

Electrophysiology 

Program for 2012. In 

preparation for the new 

program, the staff attended a series of educational sessions 

for the new procedures. Collectively, the staff of the cardiac 

cath lab looks forward to providing this high-tech procedure 

to members of our community.

Perioperative Services 

The Endoscopy Department had a very busy year and 

was in-line with the organization’s strategic initiatives to be 

the number one provider of gastrointestinal services in 

Hudson County. We added two additional services which 

includes EUS (endoscopic ultrasound studies) and pelvic 

floor studies. EUS is a highly specialized endoscopy 

procedure that involves the passing of a thin tube with an 

ultrasound tip that emits sound waves through the mouth 

down into the first portion of the small intestine. These 

sound waves are then recaptured by the probe and 

converted into black and white images for interpretation. 

The procedure is mainly performed on an out-patient basis 

and has both diagnostic and therapeutic capabilities. EUS 

allows for a very detailed imaging and 

analysis of the pancreas as well as 

detecting those conditions or diseases 

of the pancreas which includes the 

staging of pancreatic masses or 

tumors, pancreatic cysts, and chronic 

and acute pancreatitis. Additionally, 

EUS gives the gastroenterologist the 

ability to remove a tissue sample with 

the use of a deep fine needle biopsy 

for the early diagnosis and treatment 

of pancreatic cancer and gives 

gastroenterologists the ability to 

examine the pancreas and biliary 

system while diagnosing and staging 

cancers and other abnormalities. 

According to the National Cancer 

Institute, in 2011 it is estimated that 

44,000 men and women will be 

diagnosed with pancreatic cancer with 

about 37,000 of them resulting in 

death. Incorporating EUS will improve 

access and quality care to the 

uninsured/underinsured as well as to 

11 

those patients of Hudson County that have pancreatic cancer 

or any other pancreatic condition or disease. The addition of 

EUS is in accordance with the organization’s strategic plan, 

initiatives, mission, and vision which are focused on serving 

and enhancing the health, wellness, and quality of life for the 

community. 

In an effort to incorporate and bring colon cancer 

awareness to the community, the endoscopy department 

held their annual GI awareness day in March 2011 with a 

record high turn-out from staff and visitors. The GI physicians 

participated in the Madeline Fiadini Foundation for cancer 

prevention. This foundation pays for colon cancer screenings 

for those individuals who meet criteria. 

Same Day Surgery 

The staff of same Day Surgery in conjunction with the 

operating room has been working on improving 7:30 A.M. 

start times in the OR which will improve physician 

satisfaction and OR efficiencies. 

Pre-Admission Testing (PAT) 

PAT has opened their doors to employees for routine 

blood work in an effort to improve employee satisfaction. 

They have also expanded services to provide follow-up 

PKU’s (phenol-ketonuria) for discharged neonates. 

PACU 

Congratulations go out to Gina Sequio Manaois PACU 

RN who passed her specialty certification in the area of post 

anesthesia (CPAN).

Medical Surgical Division 

5 East 

November 2011 marked the one year anniversary of the 

Observation Unit on 5 East. The purpose of the Observation 

Unit is to manage patients who are not well enough to be 

discharged or who need further diagnostic exams and 

treatment for a short period of time. Staff members on 5 

East are skilled in the rapid diagnostics and rapid 

interventions required for these patients to assist the medical 

team in making an informed decision about the course of 

the patient’s treatment plan. Utilizing 5 East in this manner 

has allowed the Emergency Department to improve their 

patient flow. Additionally, Observation avoids unnecessary 

and costly admissions. As of this time, the unit has been 

operating at a 100% occupancy rate and overflow 

admissions to Observation are then cared for on other 

nursing units. 

We are proud to celebrate Shaun Barcavages, BSN, RN 

in his efforts and commitment for caring for the community 

beyond our immediate borders. A true testament to 

“Enhancing Life”, Shaun participated in “Project Hope” 

where he worked with local and international physicians 

caring for post-op adult and pediatric patients who required 

surgical intervention for injuries sustained in the earthquake 

in Haiti. 

6 West: 

Over the past year, the 6 West nursing staff and its 

support group have embarked on a significant endeavor in 

providing the best care possible. What makes 6 West a 

special place to work? Each of our highly trained staff 

possesses a broad range of clinical knowledge, background 

and expertise in providing and delivering safe and reliable 

patient care. The various service lines include Epilepsy, Brain 

Mapping, Surgery (Trauma, General, Orthopedic, 

Neurological, Gynecological, Cardiothoracic, Bariatric, 

Podiatry, and Spine), and Detox. 

Recently post operative patients with a significant 

cardiac history or complex medical history who have been 

considered “high risk” surgical candidates have been 

admitted to 6 West and have safely been monitored through 

the use of remote telemetry. The staff is proud to meet the 

increasing demands of complex patients. 

Staff members continue to remain active in their Unit 

Practice Council (UPC). Meetings are held monthly and 

attendees share their ideas, solutions and suggestions on 

how to continuously improve patient care and safety. A 

highlight of 2011 was the UPC’s improvement in 

communication with their multidisciplinary team, particularly 

between the nurses, physicians, residents and surgeons. 

Designated as a Pilot Innovation unit for Transforming 

Care at the Bedside (TCAB), 6 West remains committed to a 

culture of change. They aim to improve quality of care, 

12 

patient safety and the patient and family experience through 

the role and interaction of the nurse and patient care 

technician on the medical surgical unit. TCAB is unique in 

that it takes a reverse approach to problem solving, with 

change being driven by the front line staff. The objectives of 

TCAB are to immerse and engage staff, improve care 

delivery and processes, eliminate waste and foster an 

environment of teamwork. 

Six West has had several TCAB meetings this year, and 

in each meeting the staff tackles a small issue with care 

delivery. The change is rapid cycle with quick trials and 

evaluations of ideas (see graph on page 13). One nurse trials 

one idea for process improvement and evaluates. If the idea 

works, it is tested on a larger scale (one shift for example). 

With continued success, it is implemented as a policy. If the 

idea does not work, the staff meets again to brainstorm and 

discuss. 

Since embracing TCAB in 2009, significant changes have 

been made to impact outcomes on 6 West. Bedside 

reporting has been a key improvement made on the unit 

because it has increased the time spent with the patient. 

Beside reporting has increased transferring accountability 

about the patient’s care and improving communication with 

the patient and their families about the plan of care. This 

improvement of communication is reflected in the increase in 

patient satisfaction score to 85% at the end of the year. 

Using the “Surgical Triad” of pain management, bowel 

regimen (hydration/ambulation) and core measures, namely 

the Surgical Care Improvement Project (SCIP), the outcomes 

were stellar. The SCIP core measures were 100% and this 

has been attributed to concurrent monitoring of care and 

providing real time feedback from nurses, physicians and the 

Performance Improvement Specialist. 




Clinical improvements on the unit continued last year. 

The staff standardized the nurse-to-nurse hand off 

communication tool and report process on the unit. A daily 

communication board was created to provide updates and 

Appropriate Care Score 



100 

95 

90 

85 

80 

75 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

2010 100 100 100 91 100 100 92 95 95 96 91 85 

2011 100 100 98 100 100 100 100 100 100 100 100 100 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Acute Myocardial Infarction 

2010 2011 


2010 93 100 94 100 88 92 100 93 94 82 92 100 

2011 100 90 100 100 95 100 100 100 100 100 100 100 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Pneumonia 


Congestive Heart Failure 



2010 100 100 100 100 100 100 100 100 100 100 100 100 

2011 100 100 100 100 100 100 100 100 100 100 100 100 

13 

key information to the patients and families. The Quality 

and Safety Committee began a pilot of the Early Warning 

Scoring System (EWSS) on 6 West. The purpose of the EWSS 

is early identification of a change in a patient’s condition and 

to provide early intervention(s). Additionally, 6 West created 

a “Rapid Response Box” to assist in emergency care and 

during their increased activations of the Rapid Response 

Team (RRT). Through nurse driven endeavors, the staff was 

involved in the creation and implementation of the foley 

catheter removal protocol to reduce the incidence of urinary 

track infections. 

Staff involvement remains critical to the satisfaction of 

the staff and the improvements seen on the unit. Nurses 

continue to serve as Magnet champions, share chairmanship 

of TCAB, precept Nurse Residents and actively participate in 

various councils. The accomplishments of the unit are many, 

and the staff acknowledges the support and collaboration of 

all of the other disciplines. 

6 East: 

The staff on 6 East is diligent in their quest to deliver 

quality care for patients with cardiac disorders and other 

serious conditions requiring telemetry monitoring. Patients 

admitted with congestive heart failure (CHF) are often 

admitted to 6 East and they present their own unique 

challenges because of the nature of their chronic condition. 

Congestive heart failure has frequent exacerbations and 

patients require readmissions to the hospital. Recognizing 

the need for in-depth patient and family education to reduce 

readmissions and improve the patient’s quality of life, the 

staff has designed a comprehensive education program. 

The goal of the patient education is to empower patients to 

manage their disease process through symptom 

management and compliance with medications and lifestyle 

modifications. Staff members use the “Teach Back” method 

of learning and distribute the “Living with CHF: A Guide to a 

Healthy Heart” booklets. 




A multi-disciplinary team has been established to 

expand this education to our partners in the community, 

particularly staff at skilled nursing facilities. Educating other 

health care practitioners about the CHF and how to 

intervene early in the patient’s care has proven to reduce the 

number of readmissions we have due to exacerbations or 

complications from CHF. 

Proudly the staff of 6 East can celebrate achieving 100% 

in compliance for the Congestive Heart Failure Core 

Measure for the entire year. 

7 East and 7 West 

Collectively 7 East and 7 West have many 

accomplishments to highlight. Unit based leadership 

continued to grow and the charge nurse role was expanded 

to include the 3pm-11pm shift. Astrid Latar, RN is the 

Charge Nurse on 7 East and Anita Williams, RN is the 

Charge Nurse on 7 West. The nursing staff was busy 

orienting fourteen new nurses to their units and have 

proudly assisted them in acclimating to our mission, vision 

and values. Four Nurse Residents spent fourteen weeks 

being mentored by the staff of 7 East and 7 West. The 

Nurse Residents learned how to transition from a graduate 

nurse to the role of bedside nurse under the guidance and 

direction of our staff. A positive experience for all, the Nurse 

Residents were offered positions of employment and have 

joined our organization. 

A new program called the “Patient Care Technician 

(PCT) of the Day” was implemented to engage our PCTs in 

efforts to prevent patient falls. The “PCT of the Day” assures 

that the falling star is in place outside the patient room if the 

patient is on the “Falls Prevention Program”. The PCT of the 

Day ensures that the patients at risk for falls are identified on 

the assignment board. This teamwork approach to 

preventing falls is another example of instituting best 

practices to promote patient safety. 

Staff on 7 East participated in the National Database for 

Nursing Quality Indicator (NDNQI) pain management study 

called “Dissemination and Implementation of Evidence- 

14 

Rate 

6.00 

5.00 

4.00 

3.00 

2.00 

1.00 

0.00 

Percent of Patients with Physical Restraints (Limb and Vest) 

1Q11 2Q11 3Q11 4Q11 

6 East - 6150 0.00 0.00 3.57 0.00 

6 West - 6155 0.00 0.00 2.94 2.94 

7 East - 6045 0.00 0.00 0.00 2.78 

7 West - 6135 0.00 0.00 0.00 5.41 

Based Methods to Measure and Improve Pain Outcomes”. 

The purpose of the NDNQI Pain Prevalence study is to 

assess and improve pain management practices and has 100 

participants nation-wide. Nurses have gone through training 

and have collected data about pain care and outcomes in 

selected units at Jersey City Medical Center. Patients were 

interviewed on two particular dates for phase 1 and phase 2 

of the study. Astrid Latar, RN was on the team that 

interviewed the patients and collected data. NDNQI 

researchers will use the data submitted to develop a set of 

pain quality indicators and develop a web-based tool to help 

nursing units improve pain care using clinical practice 

guidelines. The data submitted to NDNQI also allows 

Jersey City Medical Center to benchmark against other 

participating institutions. 

End of life care services are provided on 7 West through 

our Hospice Program which is lead by our Palliative Care 

team. Through the generosity of Compassionate Care 

Hospice, furniture was donated. Volunteers from Goldman 

Sachs painted and wall papered the room. The room is a 

comfortable environment for patients and their loved ones 

during a difficult time. 

The staff had many educational milestones to celebrate. 

Four nurses completed their BSN and one nurse completed 

an MSN. Seven nurses renewed their Chemotherapy and 

Biotherapy Provider Certification. 

Members of the Medical Surgical division are preparing 

to embark on the electronic medical record implementation. 

Several staff members are on workgroups designing the 

product and making decisions about the content and 

workflow. 

Congratulations to Daisy Award Winners Helen Im, RN 

on 7 East who was nominated by a peer and to Manan 

Parikh, RN on 7 West who was nominated by a patient’s 

family. Your achievements are recognized by all of us!

Maternal Child Health 

In 2011, the patient volume of the Maternal Child Health 

(MCHD) Department has increased by 6% as it continues to 

support the pregnancies and births of women and infants 

throughout Hudson County. The 5 bed triage area 

evaluated over 4900 patients and averaged a total of 1800 

deliveries, including 25 sets of multiples. 

The MCH staff of obstetricians, registered nurses, 

obstetrical residents and technicians go through ongoing 

education and training to provide the highest level of care 

for women during this very sensitive time in their lives. With 

the Antepartum Testing Unit averaging more than 35 patient 

visits per day, the perinatologist is committed to providing 

excellent care to women whose pregnancies are at risk. 

The MCH team is also dedicated to educating their 

patients about child birth and breastfeeding and offers both 

Breastfeeding and Child Birth Education classes monthly to 

expecting parents. A multidisciplinary task force lead by 

April Major the Certified Lactation Consultant, and 

consisting of staff 

nurses, managers, educators, obstetricians, pediatricians, 

neonatologists and a social service representative has been 

designated to drive and support our mission in attaining 

“Baby Friendly” status which increases awareness and 

promotes the importance of breast feeding. The entire 

maternity department including L&D, Postpartum, Newborn 

Nursery and NICU will go through an educational process in 

2012 that aims to develop key processes in Baby Friendly 

such as increasing breastfeeding rates during the first hour 

of life. 

15 

The nurses of Labor and Delivery have done a 

phenomenal job with their transition to electronic monitoring 

and documentation since April 26, 2011 when the GE 

Perinatal Clinical Information System (Centricity) went live in 

it’s first stage. Since then, Elizabeth Jardines the Centricity 

coordinator is preparing to lead the division through its 

second and third phase of implementation. The projected 

“go live” date for the second implementation is in June 

2012, when the postpartum staff will transition from paper to 

100% Electronic Medical Record (EMR). The third and final 

stages will extend Centricty throughout the entire 

department including Newborn Nursery and NICU. 

Two thousand eleven has also been a year of change for 

this division with the addition of Lillian Reyes, RN as OB 

Nurse Manger and Randa Francis, CNM, WHCNP, as the 

Nurse Educator. Together, they have been committed to 

improving outcomes and quality care through staff education 

and development. 

The MCHD is proud to report a 100% compliance in its 

safety initiative of putting a “hard stop” in the electronic 

documentation for elective inductions of labor in gestations 

less than 39 weeks. Dr. 

Bimonte leads this 

initiative with OB 

Quality Management 

Specialist Rachele 

Dalalian, RNC. 

During the latter 

part of the year, the 

MCHD team began 

the process of 

becoming Hudson 

County’s first perinatal 

simulation lab, with 

the use of a high 

fidelity doll that can 

simulate human 

obstetrical and neonatal scenarios. The plan is to integrate 

the lab with the EMS simulation center and allow for 

physicians and nurses to simulate high risk scenarios. This 

will help to decrease maternal and infant mortality and 

improve outcomes, while also improving interdisciplinary 

teamwork and communication. Through Randa’s vision, the 

dedicated support of Tara Mazzone, Michelle Dickerson, 

Lillian Reyes, Mario Pozo and the committed leadership of 

Dr. Alsheikh and Dr. Bimonte, we are looking forward to 

opening the Perinatal Simulation Lab very soon!

Neonatal Intensive Care Unit 

Two thousand eleven was an exciting year for the 

Neonatal Intensive Care Unit. The healthcare team cared 

for 468 babies, received 29 critical infants from 

surrounding hospitals and began to open up services to 

community admissions after installing a central 

monitoring system that can be used inside of the isolation 

rooms. In addition to the ‘baby boom’, the NICU also 

treated some of the tiniest and sickest patients in the 

region, some as premature as 23 weeks gestation and 

weighing 500 grams. 

This year there was a focus on developmental care for 

the neonates. As new research becomes available that the 

care delivered early on can affect the rest of the baby's 

life, the NICU team is adopting techniques such as 

positioning, comfort measures and minimizing noxious 

stimuli that enhance life right from the beginning. The 

nurses, respiratory, speech, occupational and physical 

therapists participated in a "Premie for a Day" program 

which emphasized the importance of developmental care 

and taught the healthcare providers techniques and tools to 

implement this type of care. Moving also in that direction, 

the NICU is promoting breastfeeding and the use of 

breastmilk. There are two breast-pumping rooms, lactation 

support and education to the parents on the importance of 

human milk, especially to the sick neonate. Breastmilk 

provides the perfect nutrition, passes immunities from 

mother to baby and allows the mother to be the vital 

participant in care as she should be! 

The unit held its annual NICU Graduate Halloween Party 

at the end of October. Every year, children who once were 

NICU patients come back to Jersey City Medical Center to 

celebrate their developmental accomplishments and 

reconnect with their favorite nurses and doctors. The team is 

always excited to see their favorite patients too and to see 

how far they have come since their isolette days. 

NICU received many accolades for its excellent nurses! 

Evelyn Cha and Kwan On Sa won Daisy Awards, which are 

presented for mentoring and leadership in nursing. Jocelyn 

16 

DelaCruz Torres received the 

Exemplary Professional Practice 

award and was nominated in the 

category of New Knowledge 

Innovations & Improvements. 

Odalys Bridson received several 

nominations in the area of 

Exemplary Professional Practice, as did Evelyn Cha. Kwan On 

Sa was nominated for Transformational Leadership and 

Rossana Vales for New Knowledge Innovations & 

Improvements. Mary Daley was nominated for the Structural 

Empowerment award and Michelle Dickerson received the 

New Knowledge Innovations & Improvements Award. 

This year, we celebrated the accomplishments of eight 

of our nurses as they retired. Evelyn Cha, Lydia Francisco, 

Rebecca Samanyaphon, Beatriz Balatbat, Milagros Mahiya, 

Milagros Chia, Erlinda Asuncion and Chona Punzalang 

dedicated their time and nursing expertise for several 

decades in the NICU and improved the health of countless 

patients. We will miss them! 

Two thousand eleven also welcomed a new nurse 

manager, Tara Mazzone, MSN, RN and a new educator 

Michelle Dickerson, BSN, RNC and began a reemphasis on 

education and promotion of evidenced based knowledge 

among the nurses. The unit started a journal club to share 

current research and strengthened their participation in unit 

based councils such at the Unit Practice Council, Infection 

Control and Development Care Committee. These 

committees, among others, help to foster teamwork, nurse 

participation and further our commitment as a Magnet 

organization.

Behavioral Health 

5 West 

In 2011 the Behavioral Health Unit, better known as 5 

West, cared for an increased volume of patients. With an 

interdisciplinary team approach, they managed to decrease 

the length of stay to 8.5 days, reduce the incidence of falls 

by 59% and decrease confinement episodes (seclusion & 

restraint) by 44 incidents. All of these accomplishments are 

attributed to hard work and 

great teamwork across all 

disciplines. 

Many of the nursing staff 

members on 5 West were 

involved in hospital-wide 

committees which help 

contribute to the many 

successes of the unit. Sally 

Kufczynski, RN and Diane 

Black, PCT are active 

members of the Falls 

Committee. Pamela 

Santiago, RN and Barbara 

Pangilinan RN conduct a 

quarterly restraint prevalence 

study hospital wide. David 

Forshtay RN participates in 

the Research Council. Sheila 

Ragoonanan RN chairs the Quality & Safety Council and 

Marlene Paredes RN is a member of the Professional 

Practice Committee. Blythe Johnson RN and Letitia 

Fernandes RN are both active participants and hold 

positions of chair and co-chairs respectively on the Staff 

Satisfaction Council. All of these nurses are active members 

of the hospital’s Clinical Ladder Program and make 

significant contributions to patient care and the overall 

operation of the unit. 

The staff’s hard work and dedication have lead to many 

of them receiving various rewards and recognition in the 

hospital. Blythe Johnson RN and Pamela Santiago RN both 

won the Daisy Award in 2011. Barbara Pangilinan RN won 

the Nursing Structural Empowerment Award. Delia Alvarez, 

PCT and Babitha Babu RN were both named Employee of 

the Month. Many other staff members have also received 

recognition during the hospital’s quarterly Patient 

Satisfaction Ceremony. 

The staff is truly thankful to be part of such a great 

organization and they all look forward to contributing to the 

overall success of Jersey City Medical Center in 2012. 

17 

Outpatient Behavioral Health 

The Outpatient Behavioral Health Services continues to 

focus on providing the highest quality of behavioral health 

care to residents of Hudson County. Our adult and children’s 

services are always looking for innovative ways to expand 

the services based on the changing needs of the community. 

Our Integrated Case Management Services Team was able 

to secure housing for 9 homeless individuals in 

December through housing vouchers provided by 

the Division of Mental Health and Addictions 

Services. As we are aware that recovery is made 

much more difficult when one is homeless, we 

continually look for housing resources for our 

consumers. Our Child and Adolescent Services 

continue to surpass expectations and generate 

revenue that assists in our ability to continue funding 

new services. They are currently developing a day 

program for children and adolescents that are on 

Home Instruction from school due to mental health 

and behavioral issues. We will be able to assess and 

stabilize these issues and return the student to 

school to 

continue their 

education. 

This will 

potentially 

keep these 

students from 

being classified 

as Special 

Education 

students, 

affecting their 

future and 

recovery in 

many ways. 

The Psychiatric 

Emergency 

Screening 

Center’s 

Mobile Crisis 

Service and the Traumatic Loss Coalition continue to 

respond to traumatic events in the community in an effort to 

provide support in the aftermath of an event and helping to 

prevent long term affects through psychoeducation and 

referrals to supportive services as necessary. In the coming 

year, Behavioral Health Services will continue to respond to 

the needs of the community and has plans to expand our 

Adult Outpatient Services through a satellite office.

Stroke Program 

Embracing the mission of “Enhancing Life”, the Primary 

Stroke Center at Jersey City Medical Center continued to 

improve the quality of care provided to patients suffering a 

stroke or transient ischemic attack (TIA). Led by Michele 

Lopez, MSN, RN, CEN, Director of Stroke Program Services, 

Kelly Sietsma, BSN, CCRN Stroke Program Coordinator, Dr. 

Musaid Kahn, the Medical Director of the Stroke Program, 

this team has met the objectives outlined by the Department 

of Health and Human 

Services to maintain 

certification as a Primary 

Stroke Center. The 

benefits of the Stroke 

Program are evident. 

Comprehensive 

multidisciplinary care from 

various healthcare 

professionals is rendered 

daily during the patient’s 

hospitalization. Using a 

team approach and an 

inclusive group of 

consults, the care is 

planned through the 

acute phase of a stroke 

while designing an 

individualized 

rehabilitation program. 

Evidenced based care is coordinated with the 

Neurologists, Hospitalists, Residents, Advanced Practice 

Nurses, Staff Nurses, Therapists, Case Managers and 

Ancillary Staff. The plan of care is designed and 

implemented through standardized physician order sets and 

nursing documentation tools. Best practices adapted from 

the American Heart and Stroke Association are incorporated 

into each patient’s individualized plan of care. 

In 2011 the volume of patients diagnosed with stroke 

and TIA remained steady, treating nearly 400 patients with a 

confirmed diagnosis of stroke/TIA. Members of the Stroke 

Response Team are defined as the Emergency Department 

Physicians, Emergency Department Nursing Staff, Residents, 

Neurologists and the Rapid Response Team joined Kelly and 

Michele in responding to 116 “Code Stroke” activations 

from the Emergency Department and 10 “Rapid Response- 

Code Stroke” activations for inpatients. 

Collectively in 2011, there were 9 patients who met the 

criteria and received thrombolytic therapy, representing a 

18 

significant increase in our use of this medical treatment to 

treat ischemic stroke as compared to previous years. This rise 

in the use of thrombolytic therapy can be attributed to the 

increased awareness of stroke by the community, prompt 

recognition and expedited transport of patients by our 

Emergency Medical Services (EMS) personnel, increased 

knowledge of the Nursing, Physician and Resident Staff and 

the rapid interpretation of results from our Laboratory and 

Radiology departments. 

The quality of stroke 

care is quantified in core 

measures. With the 

assistance of the Quality 

Management Specialists, 

particularly Rachele 

Dalalian, RN-C, CLNC; we 

were successful in 

achieving 100% in all 

seven of the stroke core 

measures for the entire 

year. Rachele is valuable 

member of the team and 

manages our stroke 

patient database. 

Additionally, the 

Stroke Program received 

the “Get With the 

Guidelines-Stroke Silver Achievement Award®” for 

successfully incorporating evidence-based standards of care 

in clinical practice aimed at providing high quality care to 

stroke patients. The award is in conjunction with the 

“American Heart Association’s Get With the Guidelines® 

(GWTG) Program”. This distinction provided many 

celebration opportunities including being listed as part of a 

“Get With the Guidelines®” advertisement that appeared in 

the “America’s Best Hospitals” issue of US News & World 

Report. The achievements of the Stroke Program were also 

highlighted at the Jersey City Medical Center “Quality Expo 

Fair” in March claiming 1st Prize for featured poster 

presentation and station. 

Award winning care extends beyond the immediate 

parameters of Jersey City Medical Center. Stroke care often 

begins with the activation of EMS when 9-1-1 is called. 

Michele, Kelly and Dr. Wang, the Medical Director of EMS, 

designed an education program for our EMS professionals 

focusing on the rapid dispatch, recognition, treatment and 


Stroke Program 


transport of stroke patients. Education also focused on the 

atypical signs and symptoms of stroke which may be seen in 

the pre-hospital setting. 

Employee education is fundamental for the success and 

continued designation as a Primary Stroke Center. 

Employees attended unit based inservices, completed 

module testing and attended the Annual Competency 

Program for healthcare providers. The Stroke Program 

leadership implemented a Continuing Education series for 

our Residents and Physicians. Information about the stroke 

program and stroke related health topics was relayed to the 

hospital staff and the community through the “Spotlight on 

Stroke Newsletter”. 

Annually, May is designated as “Stroke Awareness 

Month” and there were many events aimed at raising 

awareness and educating our employees and the 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Stroke 


19 

community. During the “Stroke Awareness Day” in the 

cafeteria stroke prevention literature was distributed to our 

employees and guests. Dr. Khan was the featured speaker at 

the May “Dinner with the Doctor” program held at the 

Chandelier Restaurant in Bayonne, NJ. The session was 

well attended by members of our community. Additionally, 

Michele was interviewed for a “Stroke Prevention and 

Recognition” segment for a local radio station and 

contributed to multiple newspaper articles. 

Michele, Kelly and Dr. Khan remain committed to the 

high caliber of care provided to patients diagnosed with 

stroke, offering the best acute care and rehabilitation 

services. Aside from award winning care, the most cherished 

reward is the establishment of relationships with patients and 

families during such an adverse time and knowing we 

“Enhanced” their life. 


2010 63 100 75 73 85 79 83 70 100 82 100 100 

2011 100 100 100 100 100 100 100 100 100 100 100 100

Wound Care & Fall Prevention 

Wound prevention 

is a national safety 

initiative and continues 

to be a focus area 

throughout Jersey City 

Medical Center. The 

staff devotes a great 

deal of time caring for 

our patients to ensure 

quality outcomes and 

continues to perform 

quarterly prevalence 

studies measured by 

the clinical ladder 

participants. 

Assessments are completed on every patient and 

charts are reviewed to ensure consistency with the 

National Data base of Nursing Quality Indicators. 

(NDNQI) The NDNQI data shows a national mean of 

2.57 in the adult medical-surgical units. The Jersey 

City Medical Center shows an average of 0.89 for the last 

eight quarters. The adult critical care mean is 7.46 and the 

Jersey City Medical Center was 4.16 over the last eight 

quarters. A prevalence study is a snap shot of time in one 

day per quarter which depicts a quick view of the wounds in 

our hospital. We compare ourselves to NDNQI which is a 

national data base and also Hill-Rom’s data base. 

Falls Rate for 2011 

Unit Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec. 2011 Year Total 

7 W Patient Care Days 986 880 952 917 916 805 897 849 871 974 891 893 10831 

7 W/# falls 7 4 2 4 1 9 10 8 9 6 4 2 66 

Rate 7.1 4.55 2.1 4.36 1.09 11.18 11.15 9.42 10.33 6.16 4.49 2.24 6.09 

7 E Patient Care Days 976 885 953 911 882 750 828 834 806 908 879 838 9700 

7 E/# falls 6 4 4 5 6 11 7 4 5 7 7 4 70 

Rate 6.15 4.52 4.2 5.49 6.8 14.67 8.45 4.8 6.2 7.71 7.96 4.77 7.21 


6 W /#falls 8 7 2 1 1 2 3 5 1 4 3 1 38 

Rate 8.86 9.16 2.29 1.25 1.28 2.43 3.58 6.26 1.25 4.31 3.76 1.14 3.81 

6 E Patient Care Days 1000 911 978 868 812 772 817 838 839 924 890 890 10539 

6 E/#falls 6 3 3 3 0 2 5 3 4 1 3 2 35 

Rate 6 3.29 3.07 3.46 0 2.59 6.12 3.58 4.77 1.08 3.37 2.25 3.32 

ICU Patient Care Days 434 377 413 397 361 395 423 383 368 449 398 441 4539 

ICU /#falls 0 0 0 0 0 0 2 0 0 1 0 0 3 

Rate 0 0 0 0 0 0 4.73 0 0 2.23 0 0 0.65 

CCU Patient Care Days 285 268 246 223 240 245 240 239 228 289 251 275 3029 

CCU /#falls 0 0 1 0 0 1 1 0 1 0 0 0 4 

Rate 0 0 4.07 0 0 4.08 4.17 0 4.39 0 0 1.32 

0 

CSD Patient Care Days 233 223 173 161 174 185 182 175 175 210 162 219 2272 

CSD /#falls 0 1 0 1 1 1 0 0 1 0 1 1 7 

Rate 0 4.48 0 6.21 5.74 5.41 0 0 5.71 0 6.18 4.57 3.08 

4 OB Patient Care Days 113 343 428 884 

4 OB/Falls 1 0 1 2 

Rate 8.85 0 2.34 2.26 


5 W/#falls 6 8 10 4 4 4 2 1 1 5 2 4 51 

Rate 5.94 9.49 9.38 4.38 4.09 4.21 2.15 1.03 1.02 5.17 2.32 4.58 4.49 

Sub Total 

Days 4817 4066 4589 4276 4166 3974 4226 4117 4087 4794 4610 4862 52584 

Falls 27 19 12 14 9 26 28 20 21 20 18 11 225 

Rate 5.61 4.67 2.61 3.27 2.16 6.54 6.63 4.86 5.14 4.17 3.9 2.26 4.28 

Rate 

0.00 

1Q11 2Q11 3Q11 4Q11 

6 East - 6150 0.00 0.00 0.00 0.00 

6 West - 6155 3.23 0.00 5.00 6.25 

7 East - 6045 0.00 3.70 0.00 3.33 

7 West - 6135 3.33 3.70 3.85 0.00 

20 

Percent of Patients Surveyed with Hospital Acquired Pressure 

Ulcers 

7.00 

6.00 

5.00 

4.00 

3.00 

2.00 

1.00 

Skin in pressure areas can break down in as little as four 

hours and our nurses are diligent in monitoring these areas. 

Wound assessment and staging are part of the annual RN 

competency and ensure that all nurses remain proficient and 

focus on wound care. In addition, all nurses are continuously 

educated on the factors that influence wound healing such 

as proper nutrition, exercise, positioning and overall health 

and well being. Although there are challenges in keeping 

our patients ulcer-free, our 

nursing staff remains focused 

in preventing wounds. 

Preventing falls is 

another a major initiative at 

Jersey City Medical Center. 

Our interdisciplinary team 

has diligently worked to 

reduce the fall rate in 2011, 

especially in Behavioral 

Health. The fall rate of 10.27 

in 2010 decreased to a rate 

of 4.49 in 2011 and some 

months as low as 2.16 by 

implementing a new drug 

regimen in specific age 

groups and increasing PCT 

support. We have seen 

dramatic improvement in 

Behavioral Health and will 

continue to assist other 

departments to reduce falls 

throughout the hospital.

Infection Control 

The mission of the infection control program and the 

Jersey City Medical Center’s Strategic Plan are closely 

aligned. Preventing healthcare- associated infections (HAIs), 

represent one of the major safety initiatives of an infection 

control program. Infection control must be the responsibility 

of all hospital personnel. All healthcare providers, in 

21 

partnership with the medical staff, are accountable for the 

safety, health and well being of all patients, visitors and 

healthcare workers. This can be achieved through 

multidisciplinary collaboration to promote safe infection 

control practices and observing all regulatory standards and 

guidelines. The staff of the Jersey City Medical Center is 

empowered to bring best practices to the point of care. By 

doing so, we not only provide quality patient care and 

reduce the potential harm to our patients; it contributes to 

the economic health of the organization by reducing 

morbidity and mortality. 

Successful implementation of the various collaboratives 

in the critical care areas has generated positive quality 

outcomes. Evidence-based protocols or “bundles” for 

central line and foley catheter insertions are in place and 

followed by all members the healthcare team. Observing 

staff awareness and reviewing these infections reported 

through the Whole System Measure score card, has 

prompted administration to include central line associated 

blood stream infection (CLABSI) and catheter associated 

urinary tract infection (CAUTI) best practice bundles in the 

2012 Strategic Plan. In addition, Improving Individual Patient 

Care by Reducing Healthcare-Associated Infections (HAIs) is 

a quality initiative led by the Healthcare Quality Strategies, 

Inc. Participating in this initiative and applying prevention 

strategies to prevent healthcare-associated infections such 

as CLABSIs and CAUTIs, allows us to provide quality patient 

care and improve patient outcomes. 

Infection Indicator Goal Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 

VAP 

( MICU, SICU, CCU only) 

BSI 

(Hospital-wide) 

Catheter Related UTI 

(Hospital-wide) 

0 

0 

0 

Cases 0 0 0 0 0 0 1 0 0 1 0 0 

Vent. Days 336 296 258 238 228 283 214 260 247 291 281 283 

Rate 0.00 0.00 0.00 0.00 0.00 0.00 4.67 0.00 0.00 3.44 0.00 0.00 

Cases 0 0 0 0 0 0 1 0 2 0 0 0 

Line Days 1138 986 1,020 1015 875 1,016 976 879 890 1112 1031 1217 

Rate 0.00 0.00 0.00 0.00 0.00 0.00 1.02 0.00 2.25 0.00 0.00 0.00 

UTI 3 0 0 0 1 0 0 1 5 0 0 2 

Foley Cath Days 1057 1075 736 996 984 989 931 982 1104 1471 1135 1168 

Rate 2.84 0.00 0.00 0.00 1.02 0.00 0.00 1.02 4.53 0.00 0.00 1.71

Palliative Care 

The past year has been 

full of challenges and 

accomplishments for 

Palliative Care. Dr. Michel 

Riesner and Dr. David Flores 

continue to be an integral 

members of Palliative Care. 

Nancy Pain, APN was joined 

by Pam Saporita, Licensed 

Clinical Social Worker, which 

enhanced our ability to 

present a multidisciplinary 

approach to the services we 

offer patients and their families. We are impacting more 

patients and families then ever before by staying committed 

to our mission and vision. 

Our nurse practitioner Nancy Pain is a founding 

member of The New Jersey Palliative Care Advance Practice 

Nurse Consortium (NJ PCAC) This is a group of 22 nurse 

practitioners from 15 hospitals throughout the state of New 

Jersey. The NJ PCAC provides a formal organizational 

structure for the advancement of the professional practice of 

palliative care services across the State of NJ. 

We continue to actively participate in the New Jersey 

Hospital Association (NJHA) to stay on the forefront of 

advances in palliative care. The NJHA has been responsible 

for legislation that has resulted in Provider Orders for Life 

Sustaining Measures (POLST) being into passed into law. 

Renal 

The Jersey City Medical Center’s Renal Dialysis 

division has their own measure of success when it 

comes to patient safety. Recently, five clinical ladder 

nurses were recognized for their commitment to 

patient safety. They were awarded the “5 Diamonds of 

Safety Status” from the Quality Insights Renal Network 

(QIRN). The staff was honored for their diligent work in 

providing patient focused care on infection control 

measures such as hand washing, medication 

reconciliation, flu vaccination, stenosis surveillance and 

emergency preparedness. Jointly working with the 

QIRN, the staff developed programs to assist the 

dialysis facilities and patients to have a raised 

awareness about safety and to build a network of best 

practices related to renal care. They established a 

culture of safety and values that foster high quality 

22 

This legislation made New Jersey one of the 

few states in the country to have completed 

this task. POLST is an opportunity for 

patients and families to fully participate in 

health care decision making. 

The Bereavement Support Group that 

was implemented in 2010 has proved to be 

a essential addition to the services JCMC 

offers to the community. On the third 

Wednesday of each month we open our 

doors to grieving families. The success of 

this group is in large part due to the 

dedication of Chris Amato, RN, David 

Kaplan, LCSW and Pam Saporita, LCSW, who all facilitate the 

monthly meetings. 

The Joint Commission has launched an advanced 

certification in palliative care. Our goal for 2012 is to apply 

for and achieve this advanced certification. Over 1500 

hospitals in the United States today have a palliative care 

team. In addition, the Joint Commission recognizes the 

importance of palliative care and the overall quality of care 

represents a giant step forward for this field. Certification of 

our palliative care program at JCMC will insure that we 

continue to meet a high standard of care to help individual 

patients with serious illness. Achieving advance certification 

in Palliative Care aligns with our pillars of clinical quality, 

satisfaction and economic health, and will ultimately improve 

the standing of our hospital in the community. 

care. The Renal Dialysis staff’s participation in this 

endeavor reinforced their mission and vision to deliver 

the highest quality of patient care to our patients in this 

community.

Case Management 

Although case managers 

have always focused on 

reducing the length of stay and 

avoiding clinical denials the 

outcomes have improved and 

leveled off in the past 2 years. 

Other projects have received 

increased focus and the 

department has again had 

successful outcomes. 

Readmission Reduction has 

been a primary goal and in 

2011 we increased our efforts outside the hospital walls to 

engage multiple community agencies and nursing centers, in 

our efforts to reduce 

readmissions back into the 

hospital. These 

partnerships have been 

significant in helping to 

reduce our overall 

readmission rate by 30%. 

Sharing "the right 

information at the right 

time" and collaborating on 

benchmark readmission 

tools has been the 

cornerstone of the 

program’s success 

In addition, the evolving role of Case Management in the 

Emergency Department has not only impacted the readmission 

rate but has assisted in a 30% reduction of 

clinical admission denials. Nurses trained to 

utilize nationally recognized criteria 

recommend and guide patients to the 

"right" level of care including discharge if 

appropriate. Case Managers are integral 

members of the health care team and lead 

efficient patient flow throughout the 

hospital which results in the best care 

possible at the right cost. 

Month and 

Year 

23 

Percentage 

15.00% 

13.00% 

11.00% 

9.00% 

7.00% 

5.00% 

OBGyn & 

NB Disch 

DRGs 

YTD 

2010 

Readmission Reduction Project 

2011 

Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 

2011 14.70% 10.87% 11.86% 10.17% 8.45% 9.21% 9.61% 9.52% 9.28% 10.84% 9.63% 8.93% 7.78% 

Table 1. Overall Inpatient Discharges and Readmission (All MS-DRGs), JCMC 2011 

Other 

DRGs 

Total INP 

Discharges 

Overall 

Cases With 

Readmissi 

30 Day 

Readmissi 

on 

30 Day 

Readmissi 

on Rate 

on 1 

YTD 2010 14.70% 

Jan-11 401 1,242 1,643 245 135 10.87% 

Feb-11 341 1,172 1,513 344 139 11.86% 

Mar-11 372 1,308 1,680 329 133 10.17% 

Apr-11 284 1,231 1,515 303 104 8.45% 

May-11 350 1,173 1,523 200 108 9.21% 

Jun-11 354 1,093 1,447 288 105 9.61% 

Jul-11 358 1,156 1,514 282 110 9.52% 

Aug-11 415 1,132 1,547 233 105 9.28% 

Sep-11 368 1,061 1,429 217 115 10.84% 

Oct-11 320 1,121 1,441 243 108 9.63% 

Nov-11 296 1,142 1,438 225 102 8.93% 

Dec-11 331 1,221 1,552 302 95 7.78% 

YTD Total 4,190 14,052 18,242 3,211 1,359 9.67% 

Legend 

1 OB & NB Primary Disch MS-DRGs Excluded 

2 HF Cases/Discharges Includes MS-DRGs 291 - 293 

3 Sep 2008 Readmissions covered those admitted in Aug 08 and discharged in Sep 08


The Employee Health Team, comprised of a group of 

dedicated professionals; Dr. Chalapathy Narisety, Medical 

Director, Ellen Brummer, MS, RN, Jessica Babich, MSN, RN, 

APN-C and Zorida Khan Department Secretary provide 

multifaceted health care services. Our dedicated members 

of Employee Health Services provide preventive health care, 

health maintenance, health education programs and 

counseling services. They are diligent in promoting a safe 

work environment for healthcare workers through infection 

control surveillance. Additionally 

they evaluate, monitor and treat 

work related injuries and promote 

early return to work using a case 

management model. 

This has been an exciting year! 

The theme for 2011 was “Watching 

Your Back.” In conjunction with the 

vendor RoMedics, Liberty Health 

created a healthy ergonomic 

environment by implementing a 

“Safe Patient Handling Program”. 

Various lifts and transfer devices 

were purchased throughout the 

hospital to prevent work related 

injuries and maintain patient safety. 

Staff received online and hands on training on the process, 

equipment and the policy for the program. 

Musculoskeletal disorders (MSDs) have become endemic 

to hospital workers and cost millions of dollars in workrelated 

to injuries. Daily repetitive movements, 

repositioning, lifting and lateral movements of patients puts 

the health care worker at risk for MSDs. Recognizing the toll 

of MSDs, it was imperative for us protect our employees 

from preventable injuries. 

Jersey City Medical Center partnered with Prevent, Inc. 

for the successful integration of sustainable safe handling 

practices with a “Get a Lift!” program. The “Get a Lift!” 

integrates the use of the handling equipment for proper 

lifting, transferring and repositioning of the patients. The 

goal of the program is to promote safety and comfort of the 

patients, prevent injuries among health care providers and 

reduce absent time from work because of work related 

injuries and to help recruit and retain quality staff. 

Nationally, the program has maintained a greater than 70 

percent reduction in the number of employee injuries. 

On the LibertyHealth Intranet all staff can access the 

“Safe Patient Handling Program” information including the 

policy, the decision guide for equipment selection and 

complete the online learning module. In the near future a 

video demonstration will be available. From an educational 

perspective, a brochure about our program was developed 

24 

for the patients and their families. Our documentation tools 

were modified to identify patients that need a specific type 

of lift. A sticker is then placed on the ID band denoting that 

the patient needs a lift so everyone that cares for the patient 

is aware. The Safe Patient Handling Committee chaired by 

Ellen Brummer will continue to evaluate the program and 

look at any work related injuries sustained and develop 

initiatives to keep our patients and employees injury free. 

Employee health ensures a safe 

environment by determining the 

physical and emotional suitability of 

job applicants on pre-employment 

physicals. Employees are monitored 

for immunity titers to infectious 

diseases and vaccinations are 

administered when necessary. 

Annually Employee Health Services 

conducts tuberculosis (TB) 

surveillance through tuberculin skin 

testing and maintains a respiratory 

protection program through the 

Occupational Safety Health 

Administration medical evaluation 

and N95 respirator fit testing. 

Additionally Employee Health Services promotes and 

protects our health through the flu vaccine program. A flu 

campaign was organized with Flu cart visits to individual 

units encouraging staff to receive their flu shots. Flu shots 

were also available in the cafeteria and at the employee 

picnic. This year the Tdap vaccine was offered to high risk 

groups of employees. Moving forward the goal is to screen 

all employees for this vaccine. 

Employee Health Services participated in this year’s 

Wellness Fair. Lipid and prostate specific antigen screenings 

were conducted. Education and counseling were also 

provided. 

The Sharps Committee led by Jessica Babich is 

comprised of staff members that review sharp injuries, assess 

equipment, and evaluate new products to protect staff. The 

committee created an Employee Blood/Body Fluid Post 

Exposure Resource Guide, which goes on the back of the 

employee I.D. card, and is now distributed during 

orientation. 

Both Ellen and Jessica are members of the American 

Association of Occupational Health Nurses (AAOHN). This 

association provides updates and trends on what is occuring 

in the occupational health arena. We look forward to their 

continued contribution to maintain a safe patient and 

employee environment! 




25

The Educational Center for 

Professional Development 

Jersey City Medical Center’s philosophy of excellence in 

patient care is achieved through our strong commitment and 

leadership of the staff in the Educational Center for 

Professional Development. Nursing education fosters 

professional development, which in turn directly expands the 

professional practice of the nursing staff by bridging 

evidence based practices and clinical application at the 

bedside. The outcome of the quality education programs 

offered is safe, competent, holistic, care grounded in nursing 

theory and the latest research. 

The Nurse Educators continued to serve as liaisons for 

the various nursing councils, committees, and support 

meetings. Proud to be working with front line staff, the Nurse 

Educators assist in advocating for change in nursing practice, 

provide feedback regarding quality and safety concerns and 

investigate new products and technology. 

In 2011, the department’s momentum was in full 

acceleration developing and coordinating numerous 

programs and hospital wide initiatives. The General 

Educators provided training programs for RNs, Patient Care 

Technicians, Nursing Residents and members of the 

community. There were a total of twenty- five educational 

conferences offered this past year. A high priority is placed 

on encouraging staff nurses to become empowered leaders 

and strengthen their management and clinical skills. As a 

result of the educational needs assessment survey, the 

education seminars are tailored to meet the employees’ 

request. Examples of courses offered this past year included 

the: “Charge Nurse Leadership Series, Rescue and 

Recognition of the Decompensating Patient, The Art of 

Mentoring Nurses into Professional Practice, 12 Lead EKG 

Course, Wound Care Essentials, Nursing Preceptor Course 

and Advanced Stethoscope Skills Course”. 

June marked the celebration of nursing as the Nurse 

Educators collaborated with staff nurses to plan the Magnet 

Fair. The theme,“The Journey to Magnet Re-designation” 

was the setting to showcase our examples of 

Transformational Leadership, Structural Empowerment, 

Exemplary Professional Practice, New Knowledge, 

Innovations and Improvements and to demonstrate how all 

of these practices and efforts lead to improved Empirical 

Outcomes. A fun-filled day was enjoyed by the attendees 

and rejuvenated our staff about the mission, vision and 

values of our organization as well. A team approach was 

utilized to orchestrate the various educational stations at the 

26 

fair. The team consisted of magnet champions, clinical 

ladder nurses, staff nurses, educators, nurse managers, 

nursing students and clinical nurse leaders. 

In October, The Educational Center for Professional 

Development hosted the “Tenth Annual Nurse Excellence 

Awards”. Over forty nominations were received honoring 

the achievements of our staff who represent the core values 

of Magnet. The event highlighted the role and impact that 

all nurses will have on the profession of nursing, particularly 

in reference to the “Institute of Medicine’s report on the 

Future of Nursing”. 

Relationships were strengthened with various colleges, 

universities, and allied health schools of technology. The 

education department coordinated thirty- seven 

undergraduate and graduate clinical rotations. In an effort to 

increase employee’s enrollment in college partnerships and 

program development continued with Drexel University 

Online, the University of Medicine and Dentistry of New 

Jersey, New Jersey City University, Seton Hall University, 

University of Phoenix and Walden University. 

The Nurse Educators look forward to supporting our 

nursing and allied health staff through innovative programs 

and the use of an electronic learning management system 

called MC Strategies. Set to debut in 2012, technology 

based learning will bring cutting edge information to 

evidence- based best practices right to the front lines of care 

delivery. Stay tuned…we are sure you will be engaged in 

new methods of learning!

Community 

In 2011, we continued to reinforce our mission of 

Enhancing Life to the community and increased our 

educational outreach. Director of Community Outreach and 

Corporate Liaison Susan Lanning, BSN, RN, is accelerating 

the popular “Dinner with the Doctor” series, not only in 

Jersey City, but also in neighboring areas. Topics have 

included “Heart Health, Breast Cancer Detection and 

Treatments, Epilepsy, Pulmonary Diseases, Diabetes, 

Innovative Treatments and Procedures in 

Cardiothoracic Surgery, Spinal Issues and 

Stroke Prevention”. Community 

attendance at these hour long sessions 

now averages between 85 – 100 people. 

The feedback has been positive and we 

plan to expand our reach beyond 

Hudson County. 

We also “took our show on the road” 

with a presentation by our lead 

cardiologist, Dr. Mary Abed about heart 

health. The seminar was held in the 

Jersey City Waterfront area but was also 

telecast to offices in Dallas, Chicago and 

San Diego. 

In November, we collaborated with 

The Liberty Science Center for the first 

time, and held a Women’s Health 

Symposium featuring a panel of expert physicians in the area 

of women’s health. Some of the topics included Heart 

Health, Osteoporosis and Breast Cancer Detection and 

Treatment Options. Sixty professional women from the 

community attended this interactive educational session. 

27 

Susan continues to work with Waterfront Corporations. 

She works closely with their health centers to assist 

collaboration with Jersey City Medical Center and physician 

referrals. This year, three additional financial institutions 

have partnered with Jersey City Medical Center and some of 

their employees are now utilizing our facility and physicians. 

We also reach out to our community through various 

support groups. Interest and 

participation in our groups continues to 

grow, which demonstrates the 

community’s need for these services. 

Our newest group is the Caring Heart, 

which is facilitated by a grateful patient 

who underwent successful 

Cardiothoracic Surgery at JCMC. 

Susan and the LibertyHealth 

Foundation are committed to 

improving the economic health of the 

hospital and raise money for important 

projects. For example, there are many 

areas where expansion is required in 

order to serve our community 

effectively. Some of these projects are 

several million dollars. In 2011, our 

Emergency Department saw a record 

85,000 patients in a space that was 

built for 50,000 patients. The Emergency Room expansion is 

projected to cost $22,000,000. Financial efforts are a critical 

focus so that we can accommodate our growing community 

while maintaining the highest quality of healthcare, and 

continue our Mission of Enhancing Life.

Nursing Informatics 

This year was one of tremendous growth for Nursing 

Informatics at Jersey City Medical Center. The informatics 

team have been tailoring an electronic medical record (EMR) 

system to fit the needs of the 

entire organization. With EMR 

implementation, the team has 

been working on 

computerized physician order 

entry (CPOE), interfacing with 

pharmacy for accurate drug 

administration and billing and 

nursing documentation. EMRs 

will streamline care delivery, 

Nursing Finance 

In 2011 the nursing department continued to deliver quality patient 

care while maintaining, and in some cases, lowering unit costs. In the 

inpatient medical surgical units, patients stayed a total of 3,354 less days 

in comparison to 2010. The units were able to maintain patient hours to 

8 hours. There was an increase of 744 cases on the 5 East Observation 

unit in 2011. 

The Maternal Child Health Division was able to reduce their hours 

per patient day from 12.5 to 11.6 while continuing to deliver healthy 

newborns and caring for the region’s sick and premature neonates. 

The Emergency Department saw an increase of 4,989 visits in 2011; 

treating a total of 84,846 patients. The department lowered its costs per 

treatment from $112 to $107 per visit and improving productivity. 

The Operating Room performed virtually the same amount of cases 

in 2011 as in 2010 totaling over 5,700 surgeries. However, they were 

able to reduce their cost over $750,000. 

28 

give providers the information they need to provide quality 

care and provide safety mechanisms such as ‘hard stops’. 

Hard stops will be put in place to remind caregivers to 

perform certain assessments or 

interventions that are 

imperative to care before they 

are able to move forward in 

order entry and/or 

documentation. This ensures 

that documentation and 

interventions are thorough and 

adhere to policies, making care 

safer for all of our patients. 

The Critical Care Division also decreased operating costs by close to $1,000,000 by implementing various process 

improvements. Through the collaborative efforts of our multi-disciplinary teams, the economic status of Jersey City Medical 

Center has improved and fosters continued growth.

Risk Management 

January 2011 marked 

one year since the Risk 

Management Department 

transitioned from paper to 

electronic incident reporting 

through rL Solutions. There has 

been a noticeable increase in 

the number of incident reports 

submitted. In 2008, the Risk 

Management Department 

received a mere 987 incident 

reports. That number has steadily increased to over 

3,000 incident reports in 2011 (Figure 1). 

Patient events are reported, investigated, tracked 

and trended to ensure that practice issues are 

addressed and system issues are managed to allow 

staff to continue to provide the highest quality of care. 

Safety and security concerns account for the majority of 

incident reports submitted, followed by skin integrity 

and falls (Figure 2). Of particular importance is the 

tracking of severity levels to determine near misses vs. 

actual harm. Analyzing near miss events allows the Risk 

(Figure 1) 

Management Department to proactively manage potential 

risk issues before an adverse event occurs. In the last two 

quarters of 2011, 75% of all incident reports submitted were 

near miss and no harm events (Figure 3). As incident reports 

are analyzed, practice issues and system issues arise that are 

addressed through a root cause analysis (RCA). Staff 

participation in this process allows the Adverse Event Team 

to critically identify the people, process, policy and system 

factors that lead to an adverse outcome and can prevent a 

similar incident from occurring. In 2011, forty two RCAs were 

conducted. Action plans were developed and responsibility 

was assigned for implementation of the plans and ongoing 

monitoring. 

(Figure 2) 

29 

The Risk Management Department works collaboratively 

with all members of the organization to reduce risk to 

stakeholders at the strategic and operational level. The 

department’s mission is to share knowledge and resources 

across disciplines to ensure a culture of safety and risk 

reduction. The vision of the Risk Management Department is 

structured to align with the organization’s strategic goals and 

objectives. To this end, the department’s vision is to create a 

culture in which safety is a priority and interventions are 

tailored to ensure limited risk, reduced litigation and foster 

an environment in which patients and staff feel secure and 

protected. The Risk Management Department supports the 

Liberty Health values of trust, accountability, communication, 

excellence and teamwork by integrating ethics, integrity, 

creativity and expertise into our interactions with internal 

and external customers. 

(Figure 3)

Clinical Ladder Program 

The Differentiated Practice Program provides a structure 

for the development of clinical excellence in patient care 

based on increasing expertise in the following areas: 

Professional Development 

Clinical Expertise 

Community Involvement 

Leadership 

The goal of this program is to recognize and reward 

professional nurses who develop clinical excellence, 

encourage professional growth, provide exceptional patient 

care, enhance recruitment and retention of nurses, and 

enhance patient satisfaction. 

Our Differentiated Practice Program, also known as the 

Clinical Ladder Program, is based on the research of Patricia 

Benner, PhD, RN. Benner’s classic work, From Novice to 

Expert, describes the attributes of professional nurses as 

they gain experience and education. 

In the Clinical Ladder, there are 5 recognized levels of 

nursing practice. They are: novice, advanced beginner, 

competent, proficient and expert. 

Members of the Clinical Ladder program continue to 

make significant contributions to the practice of nursing. In 

2011, 73 nurses participated in the Clinical Ladder Program. 

A sample of the projects included: 

“Preventing Catheter Related Blood Stream 

Infections” 

“Code Stroke Orientation for Emergency 

Department Nurses” 

“Revision of the Cardiac Catherization Pre-op 

Checklist” 

“Bereavement Counseling for the Community” 

“Capsule Endoscopy” 

“Electronic Medical Record Charting in the OB 

Division” 

“Comparing and Contrasting the NICU Nursing 

Practice Benchmarks Vs the Oxford Network” 

“Developing a Sharing Network Orientation Manual 

for Nurses” 

“PACU Employee and Family Satisfaction Plan” 

“Wound Care Assessment” 

“Diabetic Education for the Psychiatric Patient 

Population” 

“RSV Sampling in the Pediatric Population” 

“CHF Teaching to Decrease Re-admissions of 

Patients” 

“Tracking and Trending of OR Cases” 

“Post Discharge Phone Calls to Improve Patient 

Satisfaction” 

“Monitoring Blood Transfusion Compliance” 

“Preventing Transmission of Infection Among 

Renal Patients” 

30 

The clinical ladder members, through their diligent work, 

directly impact the quality of nursing care provided at JCMC, 

the outcomes of our patients and the community we serve as 

well as the practice of their fellow colleagues. 

Clinical Ladder 

LEVEL 1 

Alcantara, Rino 

Alegre, Prescila 

Aristone, Christina 

Bahadur, Dhaneesha 

Bahadur, Evelyn 

Bautista, Analyn 

Bernardo, Maria 

Bryant, Yvette 

Das, Minimol 

Fernandes, Letitia 

Forshtay, David 

Giron, Anna 

John Lewis, Marie 

Kufczynski, Sally 

Lopez, Joelina 

Lucas, Shkeirra 

McLendon, Sharon 

Odimma, Kelechi 

Pagaduan, James 

Ragoonanan, Sheila 

Rances, Edna 

Ryan, Tara 

Sun, Jung Ahn 

Vallo, Aurea 

Villaflor, Pamela 


LEVEL 2 

Alvarado, Evelyn 

Alves, Laura 

Appadurai, Lakshmanan 

Bridson, Odalys 

Calero, Coleen 

Campenella, Elise 

Chang, Chi Yuan 

Chou, Corine 

Clouglher Cynthia 

Dela-Cruz Torres, Jocelyn 

DiRubba, Andrea 

Dumo, Lilia 

Espejo, Shirley 

Gonzales, Rosemarie 

Herrada, Deana 

Hernandez, Melissa 

Jean, Marie 

Johnson, Blythe 

Kyung-Suk, Kim 

Labutong, Maribel 

Ligon, Lorna 

Lim, Alegria 

Manuel, Emily 

Marasigan, Josefina 

Massa, Melissa 

Meglioranza, Connie 

Ordonio-Red, Evelyn 

Paredes, Marlene 

Pajel, Ophelia 

Pangilinan, Barbara 

Peterson, Janet 

Quiambao, Cherrielyn 

Rosana, Lily 

Sprawks, Magdalena 

Vales, Rossana 

Vicente, Jasmine 

Villaflor, Sonia 

Yannaccone, Debbie 

Ziemak, Karla 


LEVEL 3 

Aguirre, Lita 

Blanco, Amelia 

Cagas, Evangeline 

Daley, Mary 

Gelicame, Venerando 

O’ Donnell, Regina 

Pitao, Isabelita 

Santiago, Pamela

Certified Registered Nurses 

Nursing Leadership 

Rita Smith NEA-BC 

Brenda Hall NE-BC 

Cheryl Owens CNOR 

Emergency Department 

Aguilera, Connie CEN 

Amato, Chris CEN 

Aristone, Tina CEN 

Bernardo, Mary CEN 

Isaacson, Dana CEN 

Nierstedt, Pat CEN 

Palestis, Kim CEN 

Rin, Jorge CEN, CCRN 

Ryan, Tara CEN 

Vassallo, Christina CEN 

Verrinder, Mary CEN 

Wade, Chris CEN 

Waga, Chris CEN 

PACU 

Aguirre, Lita CPAN 

Mangubat, Maluz CPAN 

Sequio-Manaois, Gina CPAN 

Uy-Villa, Maryann CPAN 

Cardiac Catherization Lab 

Herrada, Deanna CCRN 

Lakshmanan, Appadurai RNC 

O'Donnell, Regina CCRN 

Pilgrim, Terrence CCRN 

Quiambao, Cherrielyn CCRN 

Semenoff, Larissa CNOR 

Psychiatriac Mental Health Services 

Bray, Selina RN-BC 

Jensen, Veronica RN-BC 

Merluza, Rosita RNC 

Pangilinan, Barbara RN-BC 

Paredes, Marlene RN-BC 

Santiago, Pamela RN-BC 

Labor and Delivery 

Aborde, Cielo RNC-MNN 

Chang, Chi-Yuan NCC 

DiRubba, Andrea NCC 

Edwin, Jarsley RNC-MNN 

Ferdinand, Helen NCC 

Francis, Randa NCC 

Reyes, Lillian RNC 

Medical-Surgical and Telemetry 

Abrams, Hermella (6E) RN-BC, RNC 

Atienza, Lucrecia (6E) CPAN 

Beating, Sara(6E) RNC 

Blanco, Amelia (6W) RNC 

Cancanindin-Carino, Virginia (6E) CPAN 

Candalla, Olivia (6W) RNC 

Chin, Joycinth (7W) RNC 

Corpuz, LuzMarilou (6E) RNC 

Corral, Arlene (6E) RNC 

DeLeon, Luzviminda (6E) RNC 

Dequia, Susan RN-BC 

Devera, Vicky (6E) RNC 

Gonzalez, Rosemary (6E) RNC 

Jean, Marie (7W) RNC 

Labutong, Maribel (6E) RNC 

Meglioranza, Concordia (6W) RNC 

Mones, Shirley (6E) RNC, CMSRN 

Palces, Trijidia (6W) RNC 

Pagaduan, James (7W) RNC 

Palugod, Bella (6E) RNC 

Patel, Anitaben (7W) RNC 

Platero, Jenina (6E) RNC 

Ryan-Giglio, Bernadette (6W) RNC 

Sarnatora, Marilyn (6E) RNC 

Tangalin, Rolondo (6E) RNC 

Tothova, Judita (6E) RNC 

Vallo, Aurea (6E) RNC 

Vergara, Leonida (6W) RNC 

NICU 

Anthony-Garnett, Gwen NCC 

Bridson, Odalys RNC 

Chacko, Lucy RNC 

Dickerson, Michelle RNC 

Daley, Mary NCC 

Fant, Denise NCC 

Mantilla, Marianita NCC, CCRN 

Moss, Paula NCC, RNC 

Omay, Juni RNC 

Rebustes, Roselita NCC 

Samson, Lucila NCC, RNC 

Sia, Concepcion NCC 

Vales, Rossana CPN 

Operating Room 

Cabalfin, Senen CNOR 

Coles, Gwendolyn CNOR 

DiBello, Patricia CNOR 

Dumo, Lilia CNOR 

Ebanks, Vikki CNOR 

Gonzales, Susan CNOR 

Loo, Kelly Ann CGRN 

Manuel, Emily CNOR 

McCorkle, Dianna CNOR 

Reyes, Ramona CNOR 

Santos, Zedith CNOR 

Weaver, David CNOR 

Zimmerman, Jacqueline CNOR 

Renal 

Bondoc, Nerissa CNN 

Corpuz, Rolando RN-BC 

Espejo, Shirley CNN 

Gelicame, Venerando CNN 

Marasigan, Josefina CNN 

Pitao, Isabelita CNN 

Rada, Marguerite CNN 

31 

Critical Care 

Briggs, Julia CCRN 

Calusin-Caballar, Liberty CCRN 

Chlougher, Cynthia CCRN 

Cotha, Prema CCRN 

David, Lisa CCRN 

Gagarin, Flordeliza CCRN 

Gamo, Marlene CCRN 

Garzon-Rivera, Claudia CCRN 

Jones, Doreen RNC 

Kirschenbaum, Diana CCRN 

LaForgia, Mabel CCRN, CNL 

Lusara, Marcelina CCRN 

Maniar, Reshma CCRN 

Melendez, Julia CCRN 

Narvaez, Nena CCRN 

Norton, Lea CCRN 

Rajaram, Calowtie CCRN 

Redondo, Mary CCRN 

Sardinas, Nicole CCRN 

Seu, Myeung CCRN 

Terry, Geraldine CCRN 

Wolf-Cavanagh, Beverly CCRN 

Zaorski, Michele CCRN, CSC 

Float RN 

Rabara, Norma RNC 

Outpatient Clinic 

Pajel, Ophelia WCC 

Rios, Eufemia RNC 

Post Partum and Newborn Nursery 

Aborde, Cielo RNC 

Glover, Marie NCC 

Major, April CMNN 

Watco, Marlyn NCC 

Infection Control 

DeChirico, Vicki CIC 

Mary Plaskon CIC 

Stroke 

Lopez, Michele CEN 

Performance Improvement 

Rosenzweig, Bonnie CRRN 

Dalalian, Rachele RNC, CLNC 

Endoscopy 

Ligon, Illuminada RNC 

Same Day Service 

Shah, Kokila RNC 

Assistant Director of Nursing 

Goel, Puspha CNOR 

Walsh, Jessica ACNP 

Risk Management 

Caldas, Karen RNC

Nurse Excellence Awards 2011 

In the words of Aristotle, “Excellence is an art won by training and habituation. We do not act rightly because we have 

virtue or excellence. But rather we have those because we acted rightly. We are what we repeatedly do. Excellence, then, is 

not an act but a habit.” 

In 2011, 40 nominations were submitted for nurses who consistently demonstrated excellence. The everyday habits and 

actions of the nominees and recipients of the awards are clear examples of excellence. The awards presented were based on 

the principles of Magnet that each nurse exemplified. The nominees and winners of the 2011 Nurse Excellence Awards are: 

Exemplary Professional Practice 

Winner: 

Jocelyn Dela Cruz Torres, NICU 

Nominees: 

Odalys Bridson, NICU 

Kim Suk Kyung, 7East 

Prema Cotha, ICU 

Evelyn Cha, NICU 

Doreesha Armstrong, ED 

Appaduria Lakshmanan, Cardiac 

Cath/ED 

Alfreda Holte, ICU 

Transformational Leadership 

Winner: 

Geraldine Terry, ICU 

Nominees: 

Myeung Seu, ICU 

Prema Cotha, ICU 

Kwan On Sa, NICU 

Strutural Empowerment 

Winner: 

Barbara Pangilinan, Psych 

Nominees: 

Christine Pangilinan, ICU 

Mary Daley, NICU 

Cynthia Cloughler, ICU 

Regina O’Donnell, Cardiac Cath 

Shkierra Lucas, ED 

Nelly Idrobo-Campos, ICU 

Michele Lopez, Stroke Coordinator 

32 

New Knowledge Innovations & 

Improvements 

Winner: 

Michelle Dickerson, NICU Educator 

Nominees: 

Doreesha Armstrong, ED 

Jocelyn Dela Cruz Torres, NICU 

Janice Kozzi, CNL 

Alfreda Holte, ICU 

Rossana Vales, NICU 

Nelly Idrobo-Campos, ICU 

Empirical Outcomes 

Winner: 

Deborah Hall, L&D 

Nominees: 

Shkierra Lucas, ED 

Michelle Dickerson, NICU Educator 

Arlene Ramos, CCU 

Mabel Laforgia, CNL 

During our Nursing Excellence Awards ceremony, we welcomed Edna Campus PhD, RN, NEA-BC as our keynote speaker. 

Edna is a professor and specialty director of the DNP program leadership track at Rutgers University. She has also held many 

leadership positions and has been involved in many initiatives such as Transforming Care at the Bedside (TCAB) and 

Campaign for Action on the Future of Nursing: Leading Change advancing Health Institute of Medicine Report. She is a 

perfect example of nursing excellence and we were honored to have her as part of our program!

The DAISY Award 

The DAISY Award is a nationwide program that rewards and celebrates the extraordinary clinical skills and compassionate 

care given by nurses everyday. The DAISY Foundation was established in 2000 by J. Patrick Barnes’ family after he was 

diagnosed with a Disease that Attacks the Immune System (DAISY). Patrick’s family was awestruck by the quality nursing care 

and compassion that Patrick and his family received. 

The DAISY Foundation was created by Patrick’s family. Its goal is to recognize extraordinary nurses everywhere who make 

an enormous difference in the lives of so many people. Late in 2010, the Quality & Safety Nursing Council started awarding 

nurses who also exemplify delivery of high quality and safe patient care. All nominees receive a DAISY pin and a DAISY 

nomination certificate. The DAISY winner receives a special winner pin and the “Healers Touch” sculpture. To honor the nurse 

recipient, the DAISY banner is displayed in the winner’s unit for one month. The winner’s unit also receives Cinnabons, the 

sweet treat once enjoyed by J. Patrick Barnes. 

From October 2010 to December 2011, the Quality and Safety Council have recognized over 100 DAISY nominees. We 

are very proud that the majority of our nominations come from patients and/or their family members. 

Congratulations to our DAISY Award Winners! 

January 2011 Kwan On Sa-NICU 

February 2011 Gina McDonald-SDS 

March 2011 Corrine Chou-Critical Care Division-Step Down 

April 2011 Mary John Mannamkery-5 East Med/Surg 

May 2011 Lisa William-Peace-Critical Care Division 

June 2011 Blythe Johnson-ACC Out-Patient Psych 

July 2011 Erin Salmond-Critical Care Division 

August 2011 Lorna Candido-Critical Care Division 

September 2011-Helen Im-7 East 

October 2011 Evelyn Cha-NICU 

November 2011 Manan Parkih-7 West 

December 2011 Pamela Santiago-5 West Psych 

33

Quality & Safety Council 

The Quality and Safety Council is comprised of nursing representatives from the Medical- 

Surgical, Telemetry, Psychiatry Units, Cardiac Catheterization Laboratory, Same Day Services, 

Post Anesthesia Care Unit, and the Critical Care Division. The council is chaired by Claudia 

Garzon-Rivera, Clinical Nurse Leader for the Critical Care Division. The council is also co-chaired 

by Erin Salmond, Critical Care Charge RN. The purpose of the Quality & Safety Council is to 

review patient safety and clinical quality initiatives and assist in providing evidence based action 

plans to obtain best patient outcomes. The council has contributed to several initiatives and 

assisted in developing quality-safety related policies. The council is a forum for the reporting of 

quality and safety outcomes and encourages input from all members. This council also 

promotes the collaboration between the Clinical Ladder Nurses and the Key Clinical Process 

Council team leaders in order to combine efforts to achieve the organization’s goals. Some 

highlights from the Quality & Safety Council efforts include: 

Assisted in the development and promotion of the Early Warning Scoring System (EWSS). Assisted in developing a EWSS 

policy to standardized reassessment of patients and early Rapid Response Team (RRT) calls. 

Assisted in the revision of the following policies: “The Executing Verbal and Telephone Orders, Arterial Line, Oral Care for 

Ventilator Patients, Fecal Management, and the High Alert Double Check Medication”. 

Approved the “Insertion and Maintenance of Central Venous Catheter, Nursing Management of Hemodynamic Lines” 

policies and the Critical Care Interdisciplinary Plan of Care/Hand off Tool, and Remicade pre-administration checklist. 

Members participated in the prospective, randomized, controlled, multi-center study to determine the complication rate 

for peripheral intravenous catheters secured by two Federal Drug Administration approved devices. 

Members contributed to the Quality Management Department to determine benchmarks for Acute Respiratory Distress 

Syndrome (ARDS) protocol, Central Line Bloodstream Infection, Glucose Control Values, Codes outside of the Critical 

Care and Emergency Department , rapid response team (RRT) calls, Ventilator Associated Pneumonias (VAP), rates, and 

sepsis mortality. 

Members collaborated with the Nursing Research Council, the Research Fun Fair and Research Symposium, to promote 

quality care by presenting evidence-based care initiatives, such as during the Central Line Associated Blood Stream 

Infections (CLABSI), ventilator associated pneumonias (VAP), Sepsis initiative, Early Warning Scoring System (EWSS)/RRT, 

Wound Prevention, Crutch Walking, Falls Prevention, and Delirium Prevention. 

Staff Satisfaction and Retention Council 

The Staff Satisfaction and Retention Council are key in 

creating a work environment that encourages professional and 

personal growth and satisfaction at the Jersey City Medical 

Center. Members of the council plan events which are both fun 

and educational. Planning Nurses’ Week and the Cultural- 

Diversity Day festivities are a highlight of this council. In addition, 

the council members work diligently assessing the nurse 

satisfaction survey results to meet the needs of the nursing 

personnel and promote nurse retention. 

34

Nursing Research Council 

In 2011, the Nursing Research Council continued its 

efforts to foster staff member knowledge and skill in 

evidence-based practice through educational offerings as 

well as direct involvement in nursing research studies. 

In May 2011, the Nursing Research Council, in 

collaboration with the Quality and Safety Nursing Council, 

sponsored the 2nd annual “Research Fun Fair” to enhance 

learning of the research process through games and 

interactive methods. The theme of the fair was “Teaching 

our Patients using Evidence Base Practice”. This year, the 

councils invited visitors and community members to learn 

about different evidence-based topics in health care, as well 

as offered free health screening to those in attendance. The 

event was a success with over 150 JCMC employees and 

community members in attendance! 

In August, a presentation was given to the nursing staff 

on “Overcoming the Barriers to Evidence-Based Practice/ 

Nurse Reference Center Tutorial”. The nurse reference 

center (NRC), available to the nursing staff since 2008, is a 

comprehensive reference tool designed to provide clinical 

tools directly at point of care. This resource offers the best 

available and most recent clinical evidence from thousands 

of full text documents. This point of care database assists the 

nursing staff to deliver the best possible care by reviewing 

the latest evidence-based summaries and clinical information 

for a patient’s condition. Jersey City Medical Center nurses 

35 

utilize the database for patient education, journal articles, 

care sheets and free continuing education. Monthly usage 

reports demonstrate that over 1000 searches and 150 

sessions are done every month. 

In November, the council successfully launched the 

2nd annual “Nursing Research Symposium” with the 

theme of “Improving Quality at the Bedside”. Published 

doctorial speakers from clinical and academic settings 

shared their experiences with published research and staff 

nurses from Jersey City Medical Center and other facilities 

showcased nursing research through poster presentations. 

In attendance were clinical staff nurses from six academic 

hospitals, five of which have received the Magnet 

designation award. 

The Research Council is proud of all the nurses who 

have been working hard to develope and participate in 

various nursing research projects. Current Research studies 

approved by JCMC Institutional Review Board (IRB) in 2011 

include: 

“NDNQI: Dissemination and Implementation of 

Evidence-Based Methods to Measure and Improve Pain 

Outcomes” 

“Multi-site Retrospective Chart Review of Heart Failure 

(HF) Patients Readmitted with 30 days of Discharge” 

“A Prospective, Randomized Controlled, Multicenter 

Study to Determine the Complication Rate of Peripheral 

Intravenous Catheters Secured by StatLock® as 

compared to Tegaderm® 

“The Quality of Life in Outpatient Renal Dialysis Patient 

with Hemoglobin Less then 12g/dl in Outpatient 

Settings in NJ” 

“Frontline Nurse Manager Study” 

2012, promises to be an exiting year as the Research 

Council continues to foster nursing research and 

implementation of best practices.

Professional Practice Council 

The Professional Practice 

Council ensures accountability 

to the nursing practice at 

Jersey City Medical Center. 

The council provides a forum 

for discussion, referral, and 

decision making regarding 

practice and patient care 

issues. Members are 

empowered by the 

organization to carry out their 

decisions related to defining, 

promoting and evaluating 

practice. Members include at 

least one front line nursing representative from each unit. 

Each Professional Practice Council member has a 

responsibility to communicate nursing practice issues at the 

meeting, contribute to meeting discussions and share 

council information. Meetings are monthly unless otherwise 

scheduled. 

Some of the highlights of the Professional Practice 

Council in 2011 include the following: 

Members of the council organized a successful 

Community Blood Drive in spring 2011, with 

participation of 63 registered volunteer donors. 

Continuous collaboration with the Policy Committee in 

reviewing, revising, and approving policies and 

guidelines where nursing care is delivered in accordance 

with current national standards. Notable policies include 

“Drawing Blood Cultures”, “Medication Reconciliation”, 

“High Alert Medication Double Check” and “Safe 

Patient Handling”. 

36 

Organized a Transport Task Force which reviewed 

concerns brought to the council that led to the revision 

of the Ticket to Ride and overall of transport process. 

Partnered with other disciplines to improve clinical 

outcomes such as: 

■ Respiratory Department – blood gas requisition 

compliance in the STAR system and oxygen travel 

kit stickers 

■ Blood Bank – ensuring 100% completion of the 

blood transfusion slips 

■ Pharmacy Department- reviewed several medication 

order forms and policies such as the Warfarin 

Treatment Plan, Epoetin Alfa order form and ID 

approval process 

■ Security Department- handling of wandering 

patients 

■ Medicine- Medical Resident coverage stickers were 

created 

The council is in charge of the process for selection of 

Nurse Excellence Winners every year. 

Members of the council made a quilt- “Quilt of Caring 

Hearts” that was displayed at the Magnet Conference 

Art and Gallery in Baltimore, Maryland last fall. 

The goal for the Professional Practice Council for 2012 is 

to continue to collaborate with other professionals in the 

discussions, evaluation and change of practice issues using 

evidence based practice as our guide.

Liberty Health Patient Engagement 

Patient engagement is a strategic priority for Jersey City 

Medical Center. Our goal is to achieve satisfaction scores in 

the 90 percentile nationally for three consecutive quarters. 

To achieve this goal, the Jersey City Medical Center is 

required to meet and exceed our customer’s expectations, 

provide excellent service and deliver superior care 

experiences. A customer is defined as a patient, family 

member, visitor, employee and/ or a Licensed Independent 

Practitioner (LIP). Success of this initiative combines patient, 

employee and physician engagement. 

The mission of Patient, Employee and Physician 

Engagement is customer loyalty. Jersey City Medical Center 

is committed to providing care that is respectful of and 

responsive to individual patient preferences. We ensure that 

the patient’s, physician’s and employee’s needs and 

expectations are fulfilled. 

Several key initiatives of 2011 included hourly rounding, 

discharge phone calls, call bell illumination response time, 

thank you cards, rewards and recognition have continued 

throughout the year. We have encouraged the distribution of 

WOW cards to fellow employees. 

A new program called Patient Advocate Day was 

launched in 2011. This is a full day with Senior Leadership 

and each Department Director/ Manager to review Press 

Ganey /HCAHPS scores. The discussion covered the 

following: 

Patient Comments on surveys 

Trends 

Unit analysis 

Issues / Barriers / Successes 

Resource allocation 

Support teams 

Evening and night shift staff 

360 reviews 

Communication of upcoming events and follow-up with 

results 

The atmosphere in the room during Patient Advocate 

Day is one of non-threatening, educational and information 

exchange between the Department Leaders and the Senior 

Management. 

During Patient Advocate Day round table discussions, 

the senior leaders made sure they clarified each department 

head’s role in the Patient Engagement Program. They 

reviewed and planned to fulfill leadership roles with teams 

(walk in their shoes – what would YOU do?) and expressed 

personal commitment to patient engagement. They also 

expressed expectations, examined follow-up tools and 

leader/support roles in follow-up campaigns to support 

job-specific implementation of action plans. 

37 

In 2011 we developed / adopted a rounding plan based 

on the Studer Model. 

The Vice Presidents and Directors now round on staff in 

an effort to: 

■ Capture systems that are working well, to sustain 

measurable results. 

■ Highlight individual staff and physicians so they can 

be both complimented by supervisors and 

managed up to senior leaders. 

■ Identify systems needing improvement and identify 

tool and equipment needs. 

■ Help the organization identify chronic issues that 

have been missed. 

■ Provide information for consistent reward and 

recognition. We also find that what gets 

documented in health care gets done. If rounding 

doesn’t get documented, it will fall behind those 

things that do. 

Reduction of Lost and Stolen property was another 

major improvement effort we launched in 2011. 

Developed a complaint management system

The Voice of the Customer 

Our vision at the Jersey City Medical Center is to 

achieve the top ten percentile in each of our four pillars: 

patient safety, clinical quality, engagement (satisfaction), and 

economic health. This year we completely revised and 

renamed one of our four pillars from Satisfaction to 

Engagement. Jersey City Medical Center has implemented 

several new patient, physician and staff satisfaction initiatives 

during the past four years. Driven by the principle that the 

most effective method of understanding how we can 

improve our patient, employee and physician satisfaction is 

by listening carefully and engaging the people we serve. 

These efforts have resulted in the hospital being named by 

Modern Healthcare Magazine as one of the “top 100 places 

to work nationally in healthcare”. In addition we obtained 

the “Top Hospital” under 350 beds by Castle Connolly which 

is rated by physicians throughout New Jersey for two 

consecutive years. In 2011, the hospital was chosen by 

consumers for the “Consumer Choice Award” by the 

National Opinion Research Center in the Hudson County 

area. 

At Jersey City Medical Center we call our program of 

listening “The Voice of the Customer”. The “Voice of the 

Customer” represents the collective efforts our leadership 

has instituted to increase customer satisfaction. At Jersey 

City Medical Center our customers include our patients, their 

families, the community, physicians, clergy and over 2,000 

employees. 

During the last three years, hourly rounding on the 

nursing units has become an important avenue to involve 

multi-disciplinary team members in planning our patient’s 

care, identifying patient specific needs increasing our 

patients’ involvement in their care, assessing pain, managing 

safety concerns and addressing basic satisfaction issues. 

Service recovery is vital and employees can now access 

information on the LibertyHealth Jersey City Medical Center 

intranet. The intranet provides service recovery scripts 

which provide step-by-step instructions for patient 

encounters. Senior Management also conducts evening 

and night rounds and random patient rounding, thus 

providing another tool in hearing directly from staff, families 

38 

and patients about our strengths and areas in which we did 

not meet all of their expectations. The hospital has 

instituted an electronic suggestion box and also developed a 

President’s Council composed of members of many career 

paths, including nursing. Due to our combined efforts, 

Jersey City Medical Center has dramatically increased 

physician satisfaction, nurse satisfaction and overall staff 

satisfaction from 2008 to 2011. Leadership also values the 

feedback from all our employees and seeks ideas and 

suggestions from the annual employee surveys and physician 

surveys. We continue to seek guidance from Press Ganey to 

increase our patient satisfaction and learn how to re-commit 

ourselves to becoming a leader in healthcare satisfaction. 

Our Chief Nursing Officer, Rita Smith, RN, DNP, along 

with the Chief Medial Officer Ken Garay, MD and our 

President/CEO Joe Scott, FACHE, host a monthly “Breakfast 

or Lunch at the Brownstone” (a local restaurant) with our 

attending physicians to hear their ideas and concerns related 

to patient care and discuss the physician’s role in patient 

satisfaction. 

Jersey City Medical Center holds an annual community 

meeting each November. This meeting is a special time for 

the public to address the hospital Board of Trustees and 

Administration with concerns, comments and questions. 

Following a brief introduction, a slide show illustrates our 

programs and objectives. Most important is the dialogue 

period between community members, community leaders, 

former patients and the hospital leadership. This is a forum 

for our leadership to listen to the voice of our customers, the 

members of our community. 

We also conduct health fairs, safety and trauma 

prevention events, and a monthly community program called 

“Dinner with the Doctor”. This year we are sending direct 

mail surveys to selected individuals in Jersey City and 

surrounding towns. As we continue to listen and respond to 

the “Voice of the Customer” we will continue to adapt our 

practices as we become one of the nation’s premier hospitals 

for patient, employee, community and physician 

engagement/satisfaction. We are well underway!

“I was impressed 

with the nursing care 

my child received. 

The nurses provided 

excellent care” 

“The nurses really explained 

my treatment plan and that put 

me at ease” 

“The staff was exceptional, especially the nurses and 

the physicians who cared for me” 

“Not only did your staff provide great care to me, they 

extended that care to my family and visitors” 

“The nursing staff gave me hope. Thank you for 

being there for me” 

“We appreciate and 

are grateful for all 

the support and care 

you gave us and our 

baby”

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