JCMC Nursing Annual Report - Mountain States Health Alliance

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JCMC Nursing Annual Report - Mountain States Health Alliance

Celebrating Strengths That Nursing Brings to Patient-Centered Care.

Johnson City

Medical Center

2009

Nursing Annual Report


From the Chief Nursing Officer

It is with great

pleasure that I am

writing to you as the

chief nursing officer

to acknowledge the

nursing excellence

evidenced at Johnson

City Medical Center.

Being the first hospital

in Tennessee to

achieve Magnet status

and redesignation

has provided us with an opportunity to focus on our

success as a Magnet organization by “Celebrating the

Strengths That Nursing Brings to Patient-Centered

Care.” These strengths are the key to excellence and

our overall success at Johnson City Medical Center

( JCMC). The strengths cross all Magnet forces and

provided the basis for our redesignation success and

the evidence that our nursing staff is continuously

identifying new ways to improve how patient care is

delivered.

The exemplars identified by the Magnet Site

appraisers included our strategic plan to eliminate

travel nurses with the onboarding of 120 new grads

and the hiring of 10.6 FTEs of support in clinical

resource nurses and educational roles to support

the transition of the new grads. The projected cost

savings for elimination of contract labor, an 84-hour

cardiovascular option, an Emergency Department

weekend staffing option, the use of i-choice

scheduling options and nursing role definitions have

been estimated at $7.2 million. We also exceeded

Magnet expectations in disseminating quality

data throughout the organization. Our personal

Blueprint cards, based on our four pillars of quality,

Magnet cited as an exemplar for communicating

quality data to all team members. We exceeded

Magnet expectations in providing adequate resources

for consultation and access to nursing expertise to

nurses at all levels in the organization and fiscal

allocations for affiliated schools and colleges of

nursing based on the identification of needs within

the nursing program to meet the goals for health care

in the region. They commended the examples offered

that demonstrate how nurses are used in promotional

materials, brochures, advertisements, newspaper

articles, television and radio advertisements, direct

mailings, educational booklets, pamphlets and

community activities. JCMC was congratulated on

providing resources that include tuition support,

scholarships and flex time to attend school, and

demonstrating support to nurses, financially, to

attend different conferences or symposiums.

With our Magnet redesignation, it will truly be

a year to celebrate our excellence. ANCC honors

all the newly designated and redesignated Magnet

organizations at the National Magnet Conference

each year. We look forward to receiving this honor

at the 2010 ANCC National Magnet Conference

in Phoenix, Oct. 13-15, 2010, at the Phoenix

Convention Center.

We also realized a successful Joint Commission

survey and achieved, for a second time, the TNCPE

Governor’s Award for Excellence.

Over the past five years, our organization

has made significant investments in improving

recruitment and retention. RN recruitment, turnover

and retention are now blueprint measures for the

CNO and her nursing leaders. We now have 150

students enrolled in our scholarship program who

will be employed at the completion of their RN

program. We are developing LPN to RN and LPN

to BSN programs. We have also implemented a

JCMC Nurse Retention Committee. With these new

initiatives and dedicated resources, our recruitment

numbers have shown an increase for this year.

In addition, to recognize and financially reward

excellence at the bedside, the “BEST” Nurse (Bedside

Excellence Shining Through) Clinical Advancement

Program at Johnson City Medical Center is the spirit

and practice of caring for patients, families and the

community through leadership, knowledge and

compassion. We believe that nursing is both an art

and a science incorporating multiple realms of care

including the physical, developmental, emotional,

social, psychological, cultural and spiritual. Nursing

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exemplifies the highest degrees of accountability,

integrity and honesty in all relationships with

patients, families, colleagues and community. The

nurse is a patient advocate committed to upholding

the American Nurses Association’s Code of Ethics

for Nurses and other professional and regulatory

standards of nursing practice and patient care. The

program supports nursing practice by assisting

the retention of experienced, motivated bedside

nurses in direct patient care by acknowledging their

professional development. We now have 250 BEST

nurses at JCMC.

Many accomplishments, advances, contributions

and innovations have been mentioned in the

preceding paragraphs and will be expanded upon

throughout the Annual Report. I applaud the efforts

that have been undertaken that substantiate the

achievement of Magnet redesignation.

I am very proud of our nursing staff for

their professional contributions, as well as their

commitment to our patients, Johnson City Medical

Center and our community.

Congratulations on a year of excellence. This

certainly is a time to celebrate our strengths.

Inside

Contents

Congratulations from Senior Leadership............4

New Magnet Model.................................................5

Magnet Redesignation.............................................6

Transformational Leadership.................................8

Structural Empowerment.................................... 10

Exemplary Professional Practice......................... 14

New Knowledge, Innovation

and Improvement.................................................. 18

Imperical Quality Outcomes.............................. 21

Niswonger Children’s Hospital.......................... 23

Years of Service....................................................... 24

Pressure Ulcers....................................................... 26

Turnover.................................................................. 26

Rapid Response...................................................... 27

Pat Niday, VP, CNO

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A Message from the CEO

This was a year of

accolades for nurses at

JCMC and Quillen

Rehabilitation Hospital.

The achievement of

redesignation as a

Magnet Hospital for

Nursing in 2009 was

confirmation of the

excellence of nursing and

nurses at these hospitals. Many people worked long,

hard hours to write the application that told our

story about nursing and its accomplishments. We

continued to make significant strides in improving

the quality of patient care, including the aspects

of patient care that are so dependent on nursing

expertise, such as preventing falls and pressure ulcers,

decreasing the rate of infections and preventing

ventilator-associated pneumonia. This excellence

was recognized by the Magnet examiners and in the

granting of redesignation.

We also received an excellent report from our

Joint Commission survey, with no requirements

for improvement in nursing cited. What a truly

outstanding accomplishment! And if those

accomplishments weren’t enough, nurses contributed

significantly to the winning of the prestigious

Tennessee Center for Performance Excellence Award

after a site visit to our facilities in November 2009.

Many other accomplishments are presented in this

Annual Report for Nursing. Nurses are making major

contributions to the improvement of patient care

and safety in our hospitals, and their efforts are being

recognized. As we navigate the uncertain future of

healthcare reform, it is very clear to me that nurses are

ready to take a significant leadership role in designing

a system that works for our patients and communities

and actually improves health and wellness and the

ability of people to have better lives.

I am very proud of every nurse who has contributed

to the successes of the past year. Congratulations

on this wonderful year of achievement, and I am

privileged to work with you and support you in your

efforts.

Candace Jennings, senior VP, CEO

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New Magnet Model

Global Issues in Nursing and Health Care

Structural

Empowerment

Transformational

Leadership

Empirical

Outcomes

New Knowledge,

Innovations &

Improvements

Exemplary

Professional

Practice

Transformational Leadership:

The CNO in a Magnet organization is a knowledgeable transformational leader who develops a strong vision

and well-articulated philosophy, professional practice model and strategic and quality plans in leading nursing

services.

Structural Empowerment:

Magnet structural environments are generally flat, flexible and decentralized. Nurses throughout the

organization are involved in self-governance and decision-making structure and processes that establish

practice and address issues of concern.

Exemplary Professional Practice:

A professional practice model is the overreaching conceptual framework for nurses, nursing care and

interdisciplinary patient care. It depicts how nurses practice, collaborate, communicate and develop

professionally to provide the highest quality of care for those served by the organization.

New Knowledge, Innovations and Improvements:

Magnet organizations integrate evidence-based practice and research into clinical and operational processes.

Nurses are educated about evidence-based practice and research, which enables them to explore the safest and

best practices and to generate new knowledge.

Empirical Outcomes:

Nursing makes an essential contribution to patient, nursing workforce and community outcomes. The

measurement of quality outcomes is imperative and directly related to nursing leadership and clinical practice

in Magnet organizations.

American Nurses Credentialing Center. (2008). Application Manual Magnet Recognition Program.

Silver Springs, MD: Author.

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Magnet Redesignation

When Johnson City Medical Center was named

a Magnet Hospital by the American Nurses

Credentialing Center in 2005, it was the first

hospital in the state to receive that prized distinction.

Since that time, only Vanderbilt Medical Center

in Nashville has also received the honor of being

recognized as one of the state’s top places for a nurse

to work.

On Wednesday, Nov. 18, 2009, JCMC achieved

Magnet designation for a second time.

“The commission on Magnet was very impressed

with the great work done at Johnson City Medical

Center and Quillen Rehabilitation Hospital, and as

a result of some outstanding work, the Commission

voted unanimously to redesignate Johnson City

Medical Center as a Magnet organization,”

said Karen Drenkard, director of the Magnet

Recognition Program. “When you reach the level

that redesignation demonstrates, it shows such

commitment, and it’s very, very difficult to have

sustained effort toward quality. The excellence in

patient care that was demonstrated at Johnson City

Medical Center makes the community very fortunate

to have such a team.”

The ANCC is the arm of the American Nurses

Association, and Magnet status is the ANCC’s

highest honor. It is also considered one of the

highest possible levels of achievement for a medical

facility on any level. The award is bestowed only

after criteria from a book of standards are in place,

evidence is gathered to support the claim, review of

written responses is complete and an on-site, threeday

visit by a team of Magnet appraisers has taken

place. A Magnet hospital is the gold standard in

patient care and the highest honor of excellence, and

only around 2 percent of the 6,000 hospitals in the

United States have earned the title.

As the news was delivered to more than 100 nurses

and administrators gathered together inside

Niswonger Children’s Hospital, President and CEO

Dennis Vonderfecht said he was again filled with

pride for the work of the nurses inside the hospital.

“We are very honored. This is truly exciting knowing

we were the first hospital in the state to receive the

designation in 2005, and to know we are now the

only hospital in Tennessee to earn the redesignation.

The nursing staff at Johnson City Medical Center

truly is bringing loving care to each and every one of

its patients,” Vonderfecht said.

Candace Jennings, MSHA senior vice president of

Tennessee operations and a registered nurse, said,

“This is a reflection of something we already know,

and that is our nurses are wonderful and make The

MSHA Difference.”

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Transformational Leadership

(Forces of Magnetism: Quality of Nursing Leadership, Management Style)

Global Issues in Nursing and Health Care

Structural

Empowerment

Transformational

Leadership

Empirical

Outcomes

New Knowledge,

Innovations &

Improvements

Exemplary

Professional

Practice

Transformational leadership describes nurses who are

knowledgeable, strong risk-takers who follow a wellarticulated,

strategic philosophy in the day-to-day

operations of nursing services. Nurses, at all levels of

the organization, convey a strong sense of advocacy,

vision and support for the nursing staff and for the

patient.

Pat Niday, VP and CNO, conveys a strong and

supportive role as our chief nursing officer at Johnson

City Medical Center. Under the CNO’s scope of

practice, Pat has direct-line authority responsibilities

and matrix responsibilities where nursing is practiced

at JCMC. Pat is the leader with the development

of our MSHA Nursing Strategic Plan that outlines

strategies for optimizing outcomes through improved

clinical processes, enhancing financial performance

and creating a safe environment for patients and

caregivers. Promoting patient safety, quality nursing

care, and patient and nursing satisfaction are major

components in ensuring Patient-Centered Care,

positive patient outcomes and integrity in everything

we do.

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Results from the 2009 NDNQI RN Satisfaction Survey demonstrate an increase in Nursing Management

T-Scores over this past year. Our nursing leaders, Pat Niday and Candace Jennings, RN, senior vice president/

CEO of Washington County Operations, serve as strong and visible leaders for the front-line team members

of JCMC. Pat and Candace attend the newly restructured Nursing Retention Committee, which is

co-chaired by front-line nurses and the manager of Human Resources.

Johnson City Medical Center

Nursing Management T-Scores

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Structural Empowerment

(Forces of Magnetism: Organizational Structure, Personnel Policies and Programs, Community and the

Healthcare Organization, Image of Nursing, Professional Development)

Structural

Empowerment

Global Issues in Nursing and Health Care

Transformational

Leadership

Empirical

Outcomes

New Knowledge,

Innovations &

Improvements

Exemplary

Professional

Practice

Magnet nurses throughout Johnson City Medical

Center and Quillen Rehab Hospital are involved

in self-governance, decision-making structures,

processes that establish standards of practice, address

issues of concern and information dissemination.

The front-line team member is the central core to

our Shared Governance structure. Nurses and other

care providers contribute through multidisciplinary

partnerships throughout the organization to improve

patient outcomes and the health of the communities

they serve.

Unit-based councils are the functioning units or

the “worker bees” that give and receive information.

The flow of information is bidirectional and

horizontal between and among professional nurses

at the bedside, the leadership team and the CNO.

Nurses extend their support and commitment to the

professional growth of nursing through these shared

governance councils, professional organizations and

community service.

BEST Nurse Program

The BEST Nurse Clinical Advancement Program is based on the Synergy Model and Jean Watson’s Theory

of Human Caring. The BEST (Bedside Excellence Shining Through) Nurse Clinical Advancement Program

was developed by and for bedside nurses at MSHA. The BEST Nurse program recognizes the value of the

clinical bedside nurse by evaluating the following eight characteristics: clinical judgment, advocacy and moral

agency, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitator

of learning. The BEST nurse exhibits knowledge-seeking behaviors and takes advantage of educational

opportunities that enhance optimal evidence-based care.

The BEST program supports nursing practice by facilitating the retention of experienced, motivated bedside

nurses by supporting their professional development, diversity in field of practice and clinical excellence at

the bedside. Nurses achieve points in the BEST program that translate into a higher level in the program

and an increase in wages. Points are earned for professional education, teaching, volunteering and preceptor

achievements. For each level achieved, the nurse receives a percentage increase in base pay. After a successful

6-month introductory period, nurses can apply to the program, where the applications are peer reviewed

by a panel of BEST nurses. Since August 2008, 33% of 750 eligible RNs have participated in the program,

compared to 3-5% participation in the previous program.

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NDNQI Scores

The NDNQI RN Satisfaction Survey measures different aspects of the nurse’s satisfaction with his/her work.

Included here are graphs depicting RN-RN Interactions, Decision Making and Professional Development.

All of these characteristics showed an improvement from 2008 to 2009.

RN-RN Interactions

RN-RN Interactions is the combination of scores related to the following comments: Nursing personnel pitch

in and help each other when things get in a rush, it is hard for new nurses to feel “at home” on the unit, there is

a good deal of teamwork among nursing personnel, the nurses on our unit support each other.

Johnson City Medical Center

Rn-Rn Interactions T-Scores

Decision Making

Decision Making is the combination of scores related to the following comments: There is ample opportunity

for nursing staff to participate in administrative decision-making processes, they can count on nursing

administrators to back them up, nursing administrators generally consult with the staff on daily problems.

Johnson City Medical Center

Decision Making T-Scores

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Professional Development

Professional Development is the combination of scores related to the following comments: They have career

development opportunities, they have access to regional and national conferences, they have opportunities for

advancement, they have clinical nurse specialists who provide patient care consultations.

Johnson City Medical Center

Professional Development T-Scores

Volunteering Enhances Image of Nursing in the Community

Magnet nurses contribute to the organization and

community and are recognized for their positive

effect on patients and families. Nurses who volunteer

enhance the image of nursing in the community. The

exemplar written by Candy Mink, RN, expresses in

her own words her volunteering experience during

the RAM (Remote Area Medical) event held in

Wise, Va. Candy is a registered nurse at Quillen

Rehabilitation Hospital.

“Volunteering to work the RAM event was

something I had wanted to do for several years.

When I registered for the event, I was not sure what

I would be assigned to do because I registered as a

volunteer after all the nursing positions had been

filled.

“Driving to the location (Wise County Fairgrounds)

at 5:30 a.m. was the beginning of the day’s adventure.

Soon after turning onto the small, two-lane road

leading into the site, the traffic stopped. There was

bumper-to-bumper traffic heading to the fairground.

“After arriving and registering in, I was given a name

badge that read ‘support staff.’ In other words, do

whatever needed to be done.

“The number of volunteers was amazing, and

they were from all walks of life. Volunteers were

needed for everything from emptying trash cans to

performing surgery. I met people who had traveled

from Oregon and Michigan just to volunteer at this

event.

“The services provided were huge. There were

medical services, mammograms, bone density tests,

pap tests, vision care with eyeglasses, and dental care

from cleaning, fillings, X-rays and extractions to

oral surgery. There were pharmacy services, social

services, and a tent with free clothes and toys. There

were many teaching activities, and free samples with

educational literature.

“The patients were the primary concern for the event,

and all were very grateful for the care they received.

They were either uninsured or under-insured and

continued

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unable to afford health care. It seemed the biggest

need for the majority of the patients was for dental

care. Patients waited in long, hot lines for hours for

dental services. The tents for the dental services were

full of rows and rows of dental chairs and they were

all filled with patients. As soon as one person got up,

another was waiting to take their place.

“One of my duties as support staff was to escort

patients from one area to another area. Another task

was to take a patient’s place in line while they either

had to have a restroom break or go to a different area

for a different service. I didn’t do any actual nursing

duties, but I worked side by side with students,

secretaries, housewives, nurses and even a hospital

CEO in assisting the patients to obtain the care they

needed.

“What I learned from this experience is that there are

people in our own back yards in dire need of health

care. These people each have their own stories to tell.

Often the look on their faces is a glimpse into their

life struggles.

“Another thing I learned is that the world is still full

of good people. People are willing to give days at a

time out of their schedule to volunteer and in some

way be a help to another person.

“At the end of the day, I was hot, tired and dirty, but

grateful for the experience. The things I learned that

day were things that could not be learned from a

classroom or a book.”

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Exemplary Professional Practice

(Forces of Magnetism: Professional Models of Care, Consultation and Resources, Autonomy, Nurses as

Teachers, Interdisciplinary Relations, Quality of Care: Ethics, Patient Safety and

Quality Infrastructure, Quality Improvement)

Transformational

Leadership

Global Issues in Nursing and Health Care

Structural

Empowerment

Empirical

Outcomes

New Knowledge,

Innovations &

Improvements

Exemplary

Professional

Practice

A professional practice model is the overarching

conceptual framework for nurses, nursing care and

interdisciplinary relationships. It is a schematic

description of a system or theory that depicts how

nurses practice, collaborate, communicate and

develop professionally to provide the highest quality

of care for those served by the organization.

Candace Jennings, senior VP, CEO, and Pat Niday,

VP, CNO, as part of their roles and responsibilities,

are to ensure that adequate resources for consultation

and access to nursing experts are available to all levels

of nurses in the organization. Whenever the need

for this resource arises, filling that need is discussed

at various council meetings with the stakeholders

involved. The discussion also includes identification

and availability of the individual who is best suited

for the task required. The clinical resource nurses

and clinical educators are an asset to Johnson City

Medical Center. Nurses in this capacity work various

shifts, helping with classroom instruction as well

as bedside demonstration, providing guidance and

support to the front-line nursing team.

National Nursing Conference Involvement

Poster abstracts and podium presentations at national

nursing conferences are rewarding both to the nurse

presenting and the conference attendees. Applying

to present a poster or podium presentation is very

competitive. Some national conferences receive up

to 1,600 poster abstract or podium presentation

submissions from nurses all over the country. It

is believed and supported by our nursing leaders

that nurses at all levels grow professionally through

attending local and national conferences. National

conferences serve as meeting places for nurses all

over the country to network, provide support and

guidance, and to experience “like” opportunities for

improvements or celebrations. The following list

includes our nurses who have presented at national

conferences:

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Lisa Anderson, RN, MSN, CCRN, CCNS, APN

Physical Violence Against Nurses

National Association of Clinical Nurse Specialists

(NACNS)

Portland, Ore.

Beverly Gugliotta, RN, Nursing Quality Facilitator

Jeannette Clark, RN, Nurse Manager

Quillen Rehab Hospital

Falls Reduction at Quillen Rehabilitation Hospital

National Database of Nursing Quality Indicators

(NDNQI) Conference

New Orleans

Millie Wykoff, RN, Apache Coordinator

Lisa Boghozian, RN, MSN, ICU Clinical Educator

JCMC ICU Outcomes

Society for Critical Care Medicine Conference

Miami

Millie Wykoff, RN, Apache Coordinator

JCMC ICU Outcomes Data

Cerner Presentation

Kansas City, Mo

Cathy Ivory, RN, MSN, Corporate Director of

Women’s Health

Presentation: Healthcare IT and Perinatal Safety:

Friends or Foes?

Cerner Health Conference Women’s Health Track

Kansas City, Mo

Cathy Ivory, RN, MSN, Corporate Director of

Women’s Health

Presentation: CPOE: Challenges and Opportunities

AWHONN Informatics Breakfast

San Diego

Cathy Ivory, RN, MSN, Corporate Director of

Women’s Health

Presentation: Healthcare IT and Perinatal Safety:

Friends or Foes?

AWHONN

San Diego

Cathy Ivory, RN, MSN, Corporate Director of

Women’s Health

Presentation: Technology and Evidence-Based

Practice

FL/GA/AL/TN AWHONN Conference

Atlanta

Patricia Niday, RN, Ed.D.

Presentation: Achieving Clinical Excellence:

Putting Evidence into Practice

Tennessee Hospital Association 2009 Nursing and

Quality Leadership Summit

Nashville, Tenn.

Lisa Carter, RN, MSN

Presentation: Retinopathy of Prematurity

Tennessee Hospital Association 2009 Nursing and

Quality Leadership Summit

Nashville, Tenn.

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RN-MD Interactions

RN-MD Interactions have been tracked for the past five years through NDNQI. Results continue to

demonstrate high satisfaction with our nurses and physicians. JCMC is a teaching hospital for many colleges

that train nurses, physicians, allied healthcare team members and pharmacy students. Students at all levels

of learning form relationships with team members and develop communication skills and interactions that

provide them with positive learning experiences. Nurses have a direct line to the physician during rounds,

communicating and reciprocating needs and concerns regarding patient care. Physicians and nurses need

reliable processes, transparency and effective communication in order to provide the best care to our patients.

Johnson City Medical Center

RN-MD Interactions T-Scores

Autonomy

Autonomy t-scores demonstrated an increase from 2008 to 2009. Nursing leadership believes the changes

to the practice, quality and research councils in addition to the stabilization of nursing leadership has had

a positive impact on the autonomy of our nurses. The Shared Governance councils facilitate autonomy by

offering opportunities for direct care, advanced practice, nurse leaders, nurses in non-traditional roles and

other clinical disciplines, to bring forward practice issues into a forum that helps them identify opportunities

and assists in implementation of action plans. The councils also function to facilitate team member education

regarding the importance of small tests of change, Plan-Do-Check-Act Model of Performance Improvement,

use of evidence-based clinical practice and literature search.

Johnson City Medical Center

Autonomy T-Scores

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Exemplary Professional Practice in Action

Exemplary Professional Practice is the manner

in which our nurses provide Patient-Centered

Care every day (Professional Model of Care). It

embodies the relationships among nursing and other

disciplines. Follow a nurse as she displays Exemplary

Professional Practice:

Katie, Mr. Richards’ nurse for the day, enters his room

with a knock on the door and a smile on her face.

“Hello Mr. Richards, my name is Katie, and I will

be your nurse today.” Katie examines Mr. Richards

and explains what the plan for the day will be. She

tells him that she will be coming in to check on him

approximately every hour, and to ring his call light if

he needs anything before she returns. Before exiting

his room, she asks “How well is your pain managed?”

Mr. Richards does admit that his pain level is a 5.

Katie explains that he has medication available that

will manage his pain and that she will return shortly

with his medication (Autonomy).

Later in the morning, Katie sees Mr. Richards’

physician in the alcove. She approaches to round with

the physician (Interdisciplinary Relationship). When

they enter the room, the physician explains test

results and some new medications that he will order

for Mr. Richards. Katie mentions to the physician

that Mr. Richards is not eating well, and requests

a consult for the dietitian to assist Mr. Richards in

finding a more palatable diet. The physician agrees

and writes the consult (Consultation and Resources).

As midday approaches, the physical therapy assistant

presents on the unit. He has worked with Mr.

Richards to increase the distance Mr. Richards can

ambulate. The physical therapy assistant sees Katie

in the alcove charting and he asks how Mr. Richards

is doing. She tells him that Mr. Richards is up in

the chair and ready to ambulate (Interdisciplinary

Relationship). Katie assists the PTA with ambulating

Mr. Richards in the hallway, and as they return and

assist him into bed, Katie notices some redness to

Mr. Richards’ backside. Katie calls the wound care

nurse to evaluate Mr. Richards’ skin and bed surface

and give input on other interventions that could be

used to prevent further pressure to Mr. Richards’ skin

(Autonomy and Consultation and Resources).

Now that Mr. Richards is settled in his bed, it is

time for Katie to administer his new medications.

She reviews each medication with Mr. Richards as

she scans the barcode in MAK. She explains what

the medications are for and how they will help him

(Nurses as Teachers).

As Katie is finishing her shift, Mr. Richards thanks

her for the care she has provided him today. He tells

her how her care has made a difference and that he

feels he is one step closer to returning to wellness.

As Katie steps back and watches Mr. Richards

enjoy his dinner meal (after some adjustments by

the dietitian), with a manageable pain level (after

administration of his PRN medications during the

day), and with a pressure-relieving bed surface (after

discussion with the wound care nurse), she feels

proud to know the impact her exemplary professional

practice has made on her patient.

The true essence of a Magnet organization stems

from exemplary professional practice within nursing.

This entails a comprehensive understanding of

the role of nursing; the application of that role

with patients, families, communities and the

interdisciplinary team; and the application of new

knowledge and evidence. The goal of this component

is more than the establishment of strong professional

practice; it is what that professional practice can

achieve.

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New Knowledge, Innovation and Improvement

(Forces of Magnetism: Quality of Care: Research and Evidence-Based Practice, Quality Improvement)

Global Issues in Nursing and Health Care

Structural

Empowerment

Transformational

Leadership

Empirical

Outcomes

Exemplary

Professional

Practice

New Knowledge,

Innovations &

Improvements

Research Conference

In June 2009, the Nursing Research Council held its

4th annual research conference. As an annual event,

we have the opportunity to invite researchers from

all disciplines to participate and share their original

research in podium presentations or as posters. Our

presenters come from our own organization, and

as far away as Lexington, Ky. We have also had the

good fortune of hearing Dr. Mona Baharestani,

Ph.D., APN, CWOCN, CWS, noted expert in the

prevention and care of wounds and pressure ulcers,

as our keynote speaker at the 3rd annual conference.

Most of our presentations and posters come from

local nurse researchers from Mountain States Health

Alliance and other organizations in our region.

Our goal is to not only showcase the research being

conducted in our area, but to also give our local

nursing community the opportunity to network

with nurse researchers. This networking opportunity

encourages collaboration and partnerships to help

generate and use evidence to improve practice and

the quality of care delivered. As we currently plan our

5th annual nursing research conference, we hope to

continue to see the interest and enthusiasm that has

been evident in increasing attendance.

Chest Pain Center/ Emergency Department Nurse Liaison Position

One of the entries for the Quality Awards Banquet

was the submission by Rebecca Pullon, RN, and

Lori Kelley, RN, to improve proper utilization of the

Chest Pain Center while decreasing ED wait times

and limiting unnecessary inpatient admissions for

low-risk cardiac patients. The plan was to implement

a Chest Pain Center/Emergency Department

Nurse Liaison. This nurse would assess, educate and

assist with the evaluation of criteria for inpatient or

observed care.

A 90-day pilot study was implemented with the

CPC/ED Nurse Liaison based in the ED. Improved

ED wait times and reduced inpatient admissions

for low-risk cardiac patients were identified. This

has led to greater patient satisfaction and decreased

healthcare costs to the patient.

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Falls Prevention Program:

Decision Making by Front-Line Nurses

FALL RISK

Direct-care nurses were asked to use the Hendrich

and Morse fall risk tools on each of their patients for

a two-week period trial in 2008. From their input,

the Morse risk assessment tool was determined to

be most appropriate for our nursing practice. The

Hendrich fall risk assessment tool received a mean

rating of 2.66 out of 4.00 on a Likert scale, while the

Morse tool received a mean score of 3.27.

On July 27, 2009, the new Fall Prevention Program

using the Morse fall risk tool was implemented. This

was a very comprehensive undertaking regarding

the change of policy, forms and practice throughout

MSHA. Using the yellow armband with “Fall

Risk” inscribed on the band was adopted by our

organization as the method of identifying patients at

high risk for falls.

Nationally recognized as the color for high fall

risk patients, the yellow armband is just one of

the colored armbands that identify patients with

special needs. The adoption of a uniform colorcoded

armband system by MSHA in July 2009

presents a clearly defined practice for identifying and

communicating patient risk factors, or special needs,

by standardizing the use of color-coded armbands

to support safe patient care based upon the patient’s

assessed needs and wishes.

JOHNSON CITY MEDICAL CENTER

PATIENT FALL RATES

Rate = falls per patient days x 1000

4.00

3.50

3.00

2.50

2.00

2010

1.50

2009

1.00

2008

0.50

0.00

JAN FEB MAR APR MAY JUN JUL

AUG SEP

OCT

NOV

DEC

New Fall Program

started July 27, 2009

2008

2009

2010

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

2010 3.59 3.16

2009 3.37 3.00 2.48 3.04 3.29 2.85 3.55 1.98 3.79 2.89 3.75 2.74

2008 3.30 2.44 2.02 1.59 2.23 2.46 3.39 1.89 2.57 2.60 2.31 3.27

Aquapheresis

A new treatment for congestive heart failure

was made available to our patient population in

2009. Aquapheresis, a pump that filters blood and

removes only water and sodium, was purchased in

2009 with the first utilization starting in August

2009. Congestive heart failure patients are able to

get out of bed during this therapy, which is much

more comfortable for them. Most patients receive

the treatment for 3 days, with most seeing a drastic

weight loss between 15 and 30 pounds in 3 days.

Patients have been able remove their bipap apparatus

or oxygen therapy after the aquapheresis treatment.

Swelling is dramatically decreased in all areas so

patients who have had severe pain secondary to

swelling are able to mobilize more freely.

19

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Quality Awards 2009

Individual Award Winner: Katie Rice, RNC

Holding the Gains: Operational Effectiveness

After implementation of Centricity Perinatal (CPN),

missed charges were dramatically reduced and charges

generated by CPN were found to be consistently

correct when nursing documentation was correct and

complete. Nurses in the Center for Women’s Health

continually monitored for correct capture of patient

charges. The nurse caring for the patient must verify

and sign the electronically generated charge form prior

to submitting it, and as a double-check the clerical

associate who entered charges notified the CPN

system administrator if anything seemed unusual. In

addition, a review of all available charts for a 5-week

period was conducted 2.5 years after implementation

of CPN charge capture to verify that gains were indeed

being held as well as we perceived. Over the past two

years, CPN has correctly captured 100% of patient

charges when nursing documentation is correct and

complete, and nursing staff is consistently reviewing

charges and ensuring accuracy before submission of

charges. This method of charge capture, which started

with the Obstetrics unit at JCMC, has been expanded

to the OB units at JCSH, SSH and IPMC.

Team Award Winner: Lisa Carter, MSN, RN, Nurse

Manager of PICU

Renee’ Lowe, RN, Nurse Manager of NICU

Jill Naylor, RN, Assistant Clinical Leader of NICU

Dr. William Devoe, MD, Neonatologist

Retinopathy of prematurity is a condition affecting

premature infants in which blood vessels in the eye

begin to grow abnormally. In 2006, the overall NICU

rate was found to be 75%. We have since decreased

this rate to 24%, and the rate for severe ROP dropped

from 14.3% to 2%. To ensure continued success with

the ROP protocol, specific elements are monitored

monthly by nursing and respiratory staff. The

results from these monitors show that the staff have

consistently maintained compliance rates at 94% or

greater with following the ROP protocol. We have

continued to see drastic reductions in the number of

infants diagnosed with severe ROP (stage 3 or greater),

and have continued to see fewer infants requiring

surgical interventions. Only two infants have needed

treatment in the last 12 months. The rate for severe

ROP has dropped from our initial rate of 14.3% to 2%,

which is well below the national average. The rates for

any stage of ROP have dropped from 75% to 24%.

20


Empirical Quality Outcomes

(Forces of Magnetism: Quality of Care)

Global Issues in Nursing and Health Care

Structural

Empowerment

Transformational

Leadership

Empirical

Outcomes

New Knowledge,

Innovations &

Improvements

Exemplary

Professional

Practice

Nursing Excellence: Empirical Outcomes

During our celebration of nursing excellence

and Magnet redesignation, we discussed the

components of the new Magnet nursing excellence

model. Empirical outcomes are a common thread

throughout the Magnet model for nursing excellence.

These outcomes are the identified endpoints for each

aspect of the model using measurable quantitative

data, as well as qualitative data. They are based on

using existing evidence as well as generating that

evidence. We discussed two models for using the

evidence and one model for generating the evidence.

We were reminded that research occurs in all practice

arenas including administration, clinical, education

and research. We must evaluate the evidence

and its impact on healthcare resources, patient/

participant preferences and actions, level of evidence,

and settings and circumstances. Clinical or area

expertise is needed to integrate all the information to

determine if the evidence fits our environment.

When evidence is generated, practice, theory and

education are part of a continuous cycle to support

our practice and contribute to nursing’s body of

knowledge. There are internal and external factors

that affect how evidence is used, and both research

and non-research evidence should be included. Using

the evidence or generating the evidence both will

lead to quality outcomes in all areas of practice. This

will result in improved quality and a continuation of

nursing excellence at Johnson City Medical Center.

21

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MSHA receives TNCPE Excellence Award for second time

Mountain States Health Alliance was formally

recognized as the recipient of the 2009 Excellence

Award at the Annual Conference of the Tennessee

Center for Performance Excellence (TNCPE) in

Nashville, Tenn. MSHA previously received this

recognition in 2005, thus making MSHA the only

healthcare organization in Tennessee to receive this

recognition twice.

“A large number of our leadership attended the

events of the conference, which featured past

Baldrige National Quality Award recipient speakers,

as well as several of our team who have been involved

in helping lead MSHA’s quality journey,” said MSHA

President and CEO Dennis Vonderfecht.

Vonderfecht and MSHA Vice President of Quality

Tamera Fields both presented at the conference,

sharing the healthcare system’s model for quality

delivery of health care and its performance

improvement process.

2009

Excellence Award

22


Niswonger Children’s Hospital Opening

The dream has finally become a reality. After

nearly five years of fundraising, community support

and steady construction, Niswonger Children’s

Hospital opened March 3, 2009. The $36 million,

69-bed hospital for children admitted patients

approximately one year ago.

“This is truly a great and momentous day for our

region,” said Dennis Vonderfecht, president and

CEO of MSHA. “With the opening of Niswonger

Children’s Hospital and its associated Children’s

Emergency Department, the Tri-Cities joins the

other four metropolitan areas of Tennessee in

having a full-service children’s hospital.” Niswonger

Children’s Hospital is named after lead donors Scott

and Nikki Niswonger of Greeneville, Tenn., who

gave $10 million toward the construction.

Using natural light to provide feelings of comfort

and healing, the main entrance lobby and threestory

glass atrium-lined hallways provide bountiful

light. The stained glass kite gallery suspended from

the ceiling provides a calming environment to the

patients and families. Direct care nurses’ feedback

was crucial to the design and work flow of the patient

care provision areas in the new Niswonger Children’s

Hospital for efficient delivery of patient care. Directcare

nursing team members were involved in all of

the renovation and refurbishment projects for the

patient care units. Women’s and Children’s nursing

team members participated on multiple teams in the

design of the new Niswonger Children’s Hospital.

23

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Years of Service

Donna Ledbetter

Donna Ledbetter, RN, ONC,

director of the Ortho/Neuro/

Trauma SSU, is very dedicated

to the development and

advancement of the nursing

profession. As a team member

of MSHA for 40 years,

Donna’s devotion to Patient-

Centered Care is well-known by all team members at

JCMC. She is a nurse with high integrity, regarded

by her peers as kind and accessible, and a strong

patient and nursing advocate. She exudes grace and

a soft-spoken manner in which her experienced

voice is heard and respected. Donna is a member of

the American Association of Critical Care Nurses

and the Advisory Council for the Surgical Tech and

Cardiovascular Technician Program at Northeast

State Technical Community College. She is a

member of the American College of Healthcare

Executives and an American Heart Association

Board Member. She was certified as an orthopedic

nurse in 2007, and is a member of the National

Association of Orthopaedic Nurses (NAON). Other

memberships include the North East Tennessee

Organization of Nurse Executives (NETONE),

TONE, Tennessee Hospital Association (THA)

and Tennessee Nurses Association. She received the

Nurse of Distinction Clinical Award from TNA

in 2005. Donna’s knowledge, devotion to Patient-

Centered Care and advocacy to the profession of

nursing truly exemplify The MSHA Difference.

30 Plus Years of Service

Linda Allen

Lana Renfro

Brenda Campbell

Delores “Ann” Wilson

Mitchell Hathaway

Martha K. Smith

Pat Looney

Mary Farrington

Karen Adkins

Connie Hatcher

Vickie Torbett

Pamela Kubisiak

Uta Lewey

Richard Blevins

Carolyn “Charlie” Wishon

Harriet Fitzgerald

40 years

38 years

38 years

38 years

37 years

36 years

36 years

35 years

35 years

35 years

34 years

34 years

34 years

34 years

34 years

34 years

Cassandra Moore

Mary “Peep” Adams

Teresa Bailey

Connie Jessee

Ernestine Hatcher

Patrick Kiernan

Treva Williams

Sharon Johnson

Donna Rice

Wilmetta Collie

Sharon Jarrett

Amy Belcher

Victoria Privette

Loreta “Sue” Clark

Beverly Gugliotta

33 years

33 years

33 years

32 years

32 years

32 years

32 years

32 years

32 years

31 years

31 years

30 years

30 years

30 years

30 years

24


Georgita Washington

On Dec. 19, 2009, Georgita

Tolbert Washington, Ph.D.,

RN-BC, MSN, CCRN,

received her doctor of

philosophy in nursing

from East Tennessee State

University in Johnson City,

Tenn. A native of Charleston,

S.C., she received her bachelor of science in nursing

from Clemson University and her master of science

in nursing from the Medical University of South

Carolina.

Dr. Washington’s dissertation research, titled,

“Effects of Anxiety-Reducing Interventions on

Performance Anxiety in Graduate Nurses,” was

conducted to determine the best methods of

reducing anxiety in those newly graduated from

nursing school. This would hopefully facilitate

their transition from student to professional nurse,

helping to contribute to strategies to ease the nursing

shortage. She plans on further research in this

area to facilitate the retention of new nurses to the

profession and to Mountain States Health Alliance.

Georgita is a 10-year team member at Mountain

States Health Alliance and is currently the director of

nursing education for Johnson City Medical Center.

She has a clinical background of 26 years in critical

care nursing, with 18 as a critical care clinical nurse

specialist. Her role at MSHA also includes chair of

the nursing research council, which is very active in

mentoring new researchers.

25

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N u m b e r o f H o s p ita l A c q u ire d P re s s u re U lc e rs

30

20

10

0

3Q

08

4Q

08

1Q

09

2Q

09

3Q

09

4Q

09

1Q

10

Stage I 7 21 13 6 6 12 3

Stage II 20 18 16 18 11 5 14

Stage III 10 2 0 3 0 1 0

Stage IV 1 0 0 0 0 0 0

2Q

10

3Q

10

Stage I

Stage II

Stage III

Stage IV

DTI

Unstageable

Indeterminate

The prevention of hospital-acquired pressure ulcers

is a constant priority at JCMC. The skin care team

and wound care nurses are available to assist bedside

nurses with treatments, education and appropriate

selection of wound care dressings and specialty

beds. Quarterly pressure ulcer prevalence surveys are

Pressure Ulcers

conducted by a group of nurses educated in pressure

ulcer assessment with validation from the wound

care experts. Tracking of in-house specialty beds has

been enhanced over the past year to determine the

right bed for the right patient at the right time for

prevention and treatment of pressure ulcers.

Turnover

26


Percentage of Non-ICU Code Blue Occurence 2009

45

40

35

30

25

Percentage

20

Actual

Target

15

10

5

0

Jan Feb March April May June July Aug Sept Oct Nov Dec

January - December

Rapid Response Team

One of our quality care initiatives, started in 2005

and continuing today, was the development of the

Rapid Response Team. Opportunities were identified

to bring critical care expertise, RNs and respiratory

therapists to the bedside of patients whose condition

was deteriorating or uncertain. There is a large

amount of variability in both quality of care and the

safety of patients in health care today. This variability

is evident in hospital mortality rates. There are

three main systemic issues that contribute to the

problem such as failures in planning (assessment,

treatments, goals), failure to communicate (patient

to staff, staff to staff, staff to physician), and failure

to recognize deteriorating patient condition. These

fundamental problems can often lead to a failure

to rescue. Establishing rapid response teams stands

to impact this problem by identifying unstable

patients and those patients likely to suffer cardiac or

respiratory arrest. If identified in a timely fashion,

their unnecessary deaths can often be prevented.

Successful

Joint Commission Survey at

JCMC/QRH/Woodridge !!!

27

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Patient -Centered Care

10 Guiding Principles

Care is based on continuous healing relationships.

The patient is the source of control for their care.

Care is customized and reflects patient needs, values and choices.

Families and friends of the patient are considered an essential part of the care team.

All Team Members are considered as caregivers.

Care is provided in a healing environment of comfort, peace and support.

Knowledge and information are shared freely between and among patients, care

partners, physicians and other caregivers.

Transparency is the rule in the care of the patient.

Patient safety is a visible priority.

All caregivers cooperate with one another through a common focus on the best interest

and personal goals of the patient.

400 N. State of Franklin Road

Johnson City, TN 37604

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