Nursing Annual Report - UNM Hospitals - University of New Mexico

Designated February 8, 2010!
2 0 1 0 N u r s i n g A n n u a l R e p o r t
O u r N u r s i n g F u t u r e

ANNUAL NURSING REPORT 2010 — From the CNO
A Welcome from Chief Nursing Officer Sheena Ferguson
Dear Nursing Colleagues,
This annual report is an update of another very successful year for nursing! As always,
we review the contributions by our profession around the professional triad of
education, research, and practice. Again this year we’ve done much toward our goals,
and most exciting, our goals are in complete synchronization with the Institute of
Medicine: Future of Nursing recommendations!
• The numbers of our staff working to advance on their next degree: “BSN in ‘10” ‐ 80% of nurses will have their
BSN by 2020; we are above 50%!
• Prepare nurses to lead: MSN required for Unit Directors by 2014
• Double the number of nurses with a doctorate (PhD or DNP in Nursing)
• UNMH has two nurses in the BSN to PhD program
• UNMH has our first nurse practitioners completing their DNP
• Our internal database for tracking education and certification: Nurse Recognition Website
• Our High School program, to share what a career in Nursing offers.
The numbers of staff working to advance our practice:
• The Pathways to Excellence and Magnet Champions are leading us to real Shared Governance!
• This supports our goal of practicing at the top of our Scope of Practice
• New Mexico has one of the leading Nurse Practice Acts for autonomy in the country
• Nurse‐managed protocols are evidence of what nurses can contribute to Core Measures & Quality
• Our Nurse Residency just learned we are accredited by CCNE — the third in the country! ☺
• Our Nurse Fellowship for Nurse Practitioners is in development
• Our RN Supervisors are changing the Patient Care Environment with their Leadership!
The numbers of staff working to advance our profession:
• Our Transforming Care At the Bedside (TCAB) conference went citywide last year
• PDSAs are improving patient care (example: 4West Insulin Administration project)
• PDSAs are improving patient satisfaction (example: L&D with their coping with labor pain project)
In This Report
In This Report
2
Page
Page
Welcome from the CNO 2
People 4
Service 10
Quality 12
Finance 35
Growth 36
• PDSAs are enhancing patient safety (example:
PICU with their central line management project)
• The Ethics Course was a huge success, and we are
following up with a Publication Workshop
• These are State‐of‐the‐Science Workshops:
Evidence‐based
• This summer/fall look forward to a workshop on
Preventing Falls and one on Plan of Care.
Wow, that’s a lot for a year!
Best,
Sheena Ferguson, MSN, RN, CCRNr, CNS
Chief Nursing Officer, University of New Mexico Hospitals
smferguson@salud.unm.edu ♥

Evidence-Based Nursing Practice
ANNUAL NURSING REPORT 2010 — EVIDENCE-BASED NURSING
Nicole Weimer, MSN, RN Nurse Residency Program
“Unless we are making progress in our nursing every year, every month, every week, take my
word for it — we are going back.” ~ Florence Nightingale
Since our last annual report many things have happened with the Nursing Research Council at
UNMH. We took a step back and reviewed the difference between Evidence Based Practice (EBP)
and Nursing Research to a full‐on set educational rollout. This rollout included:
• PICO— how to write an evidence‐based question
• Magnet and Pathway — how they relate to EBP and Nursing Research
• Nursing databases and search engines
• UNM HRRC overview
• PDSA — how do I do one?
• Publication opportunities for nurses
“Honestly, the council has definitely helped me! I’ve learned a lot from the presentations and
continue to get valuable information from every meeting.” ~ Member, Nursing Research Council
The Nursing Research council helped with Hospital Workers Week to provide Nursing Research
and Evidence Based Practice with CNEs. We ended up awarding over 60 CNEs in two days. These
sessions included:
• Defining the question and evidence‐ based journey
• Hydration in the post‐surgical patient
• Magnet journey
• Databases and search engines
• Pain
• HRRB overview
• Consent and how to complete an application for research
• IRB consultations onsite
There were 31 PDSA boards on display.
We joined with clinical education to provide a portion of their Nurse Educator Foundation series on
evidence‐ based practice.
Our institution held the Second Annual Transforming Care at the Bedside Conference. The Nursing
Research Council had both speakers and poster presenters that were accepted to this conference.
We would like to invite everyone to attend our meetings and join in our efforts to make evidencebased
practice the preferred method of practice here at UNMH.
"Let whoever is in charge keep this simple question in her head ‐ (not, how can I always do this
right thing myself, but) how can I provide for the right thing to be always done?"
~ Florence Nightingale ♥
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ANNUAL NURSING REPORT 2010 — PEOPLE
People
2010 Nurse Star Performers
Standards in Action Winners are Star Performers
Given to employees who consistently “set the standard” in one of the Standards of Performance. ♥
Name Area For Standard:
Carla Nelson, RN Pediatric PACU Ownership
Sandra Donohoe, RN Interventional Radiology Positive Attitude
Vicki Paustian, RN UPC Continuing Care Fiscal Responsibility
Cara Davenport, RN General Pediatrics Unit Knowledge & Expertise
Deborah Minke, RN 5 South Neuroscience Knowledge & Expertise
Dianne Erickson, RN Behavioral Health OP Services Knowledge & Expertise
The Five Pillars of Excellence
UNMH has adopted “Five Pillars” as a simple way to remember
the Joint Operating Plan. The pillars help define the road map to
pursue our common purpose and mission. They give us:
• A way to focus our efforts
• Help in prioritizing our main initiatives
Star Performer Vicki Paustian
• Help in making decisions
receives a plaque at a July 2010
• Alignment so we are all moving
in the same direction
Management Coffee presentation
• Reminder of key points in the JOP
Pillars are for People, Service, Quality, Finance and Growth. You’ll find the following information to be
categorized into these pillars. ♥
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People • Service • Quality • Finance • Growth

ANNUAL NURSING REPORT 2010 — PEOPLE
2010 Nurse Employees of the Month
January 2010
PEOPLE: Ulla Jaramillo, RN, Nursing Supervisor,
Behavioral Health
SERVICE: Priscilla Landon, RN, NBICU
FINANCE: Monica Vickery, RN Case Manager
February 2010
PEOPLE: Susan Byrd, RN, Outpatient RN
Supervisor
SERVICE: Helena Dunn, RN, Mother Baby Unit
March 2010
GROWTH: Karen Maher, RN, Labor & Delivery
April 2010
GROWTH: Rachel Hunt, RN, Neuroscience ICU
May 2010
SERVICE: Cheryl Swart, RN, Utilization
Management
GROWTH: Janet LaBrecque, RN, L&D
June 2010
QUALITY: Alana Vanmalden, RN, NBICU
SERVICE: Cristi Cnare, RN Supervisor, 7 South
Critical Care
August 2010
PEOPLE: Eric Peterson, RN, Inpatient Director UPC
SERVICE: Beth Beazley, RN, Trauma/Surgical ICU
QUALITY: Sheila Garcia, RN, Southeast Heights Clinic
FINANCE: Aisha Jones, APN, Urgent Care
September 2010
PEOPLE: Michael Servilla, Nurse Practitioner,
NE Heights Clinic
GROWTH: Rhonda Davis, RN, Medical/Cardiac ICUPC
October 2010
PEOPLE: Linda Murphy, RN Case Manager
QUALITY: Roseann Jacks, RN, NBICU
FINANCE: Chris Abeyta, RN Supervisor,
Neurosciences ICU
November 2010
QUALITY: Celia Andrews, RN, TSICU
FINANCE: ML Johnston, RN, Patient Education
December 2010
SERVICE: Stephanie Andrews, RN, Mother Baby Unit
QUALITY: Gloria Sharp, RN Supervisor, MHC
GROWTH: Sue McReynolds, RN, Clinical Educator ♥
July 2010
PEOPLE: Kathryn Browne, RN, Mother Baby Unit
FINANCE: Nicole Moret, RN, MHC
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ANNUAL NURSING REPORT 2010 — PEOPLE
Ambulatory Nursing – Not Easy Stuff!
Oftentimes nurses in the ambulatory setting are put in situations where their expertise makes the difference
in whether or not patients are admitted to the hospital, or preventing an admission
altogether. “Never underestimate what an ambulatory nurse can do, and how well they do it,” says
Bridget Murphy of the 1209 Clinic. “In our fast‐paced setting, we don’t have time to bring new nurses
up to speed. We rely on their experience, critical thinking, and quick decision‐making skills.”
Ambulatory nurses find themselves giving an array of medications from nebulizers to intravenous
meds, and helping the Medical Assistants when questions arise. Working in an ambulatory setting
demands a team approach, and all team members rely upon one another to give the best care to our
patients. Nurses in these settings will triage phone calls, triage patients in the clinic, and serve as the
patients’ guide to long‐term preventive health care, which will be ever more important as health care
reform approaches. “Working in Family Practice requires that the nurse knows a bit of everything
from pregnancy to geriatrics. A good ambulatory nurse knows the right questions to ask, so that the
proper disposition can be assigned to the patients.” Skye Sego, RN – Family Practice. ♥
“What is the Trauma Support Program?”
The American College of Surgeons recognizes four levels of Trauma Care.
Level IV: This facility will attempt to stabilize and utilize EMS and Aero Medical services
to transfer its Trauma patients to definitive care.
Level III: Can range from a small community hospital all the way to a large metropolitan
full‐service hospital. Size doesn’t always denote depth of resources to meet the needs of
the acute trauma patient. The Level III facility may be able to keep and treat a select
portion of its trauma patients.
Level II: Is a full‐service community hospital with a scope of resources to provide 24/7/365 care.
This will include a broad cadre of surgical specialists, and inpatient facilities to meet the diagnostic
and therapeutic needs of the acute, major‐mechanism trauma patient (receives ACS Accreditation).
Level I: There are very stringent distinctions between the Level II and New Mexico’s only Level I
Trauma Center: UNMH. Not only do we meet the 24/7/365 provision of an ED Trauma Room, but
provide access to a staffed OR, with a variety of “in‐ house” trauma and surgical specialties. We
also maintain ready access to the latest non‐invasive and interventional diagnostic and therapeutic
facilities. All of these resources result in the trauma patient receiving advanced, skilled management —
from the ED to the OR, and to the ICU, SAC and floor units.
Additionally a Level I center is charged with conducting ongoing trauma research, best accomplished by
an affiliation with an Academic Medical Center. It also must provide data and quality management. ♥
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Trauma Support Program
ANNUAL NURSING REPORT 2010 — PEOPLE
The Trauma Support Program is staffed by a group of licensed and
non‐licensed health care providers. Our Trauma Nurse Coordinators,
Debra Platt, RN and Richard Danner, RN audit in excess of 2,400
moderate/major trauma cases per year — reviewing each chart,
and entering up to 135 QA filter items into a database. These chart
reviews look for mechanisms of injury, injury patterns, procedural
interventions, complications etc., and are abstracted, which receive
a variety of National & International recognizable “codes.” In turn,
the TSP Registrar, Betty Jordan reviews the data entries and adds
codes and data points into the system. From this database, we provide reports to UNMH/HSC customers
(research/educational applications) plus periodically download into NM DOH and National Trauma data
collection networks.
Our Injury Prevention Program is titled “The Best Trauma We Can Treat Is The One We Prevent.”
Helen Sisneros is UNMH’s certified injury Prevention Specialist. She works closely with several UNM/
UNMH coalitions, NM DOH and statewide groups to take the Injury Prevention message to New Mexico’s
citizens, both young and old alike. ♥
Nursing Education Council
The purpose of the Nursing Education Council is to promote, facilitate, and plan
professional development by setting and maintaining educational practice standards.
The Council addresses identified educational issues and reviews and advises on staff
development activities based on nursing practice, education standards, and
regulatory requirements.
During 2010 the Nursing Education Council has participated in several activities which demonstrated
progress toward achievement of goals. A couple of education referrals have been made using a
newly developed form. After review, the Council recommended education plans based on unique
needs. A process for a standardized educational response to hospital–wide education was written.
The online competency process was examined. A recommendation for several patient safety issues
to be covered in annual unit clinical competencies was adopted by the
Nurse Executive Council. The orientation process was reviewed and the
charter is being revised.
The Nursing Education Council expects to build on these successes during
2011.
Janet Renn‐Nelson (Co‐Chair)
Joan Deis (Co‐Chair)
Cynde Tagg (Executive Director Mentor) ♥
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ANNUAL NURSING REPORT 2010 — PEOPLE
NBICU/ICN — More than Just Patient Care
It is very difficult to describe what the NBICU and ICN does in any
sort of “common language” outside of medicine. When you tell
people what you do, you get one of two responses; either “You
must love working with all those babies” or “that must be so hard.”
The fact is both are true, but those statements give a very limited
view of what we do every day.
Because there is no way to define the job, I will describe one of
the things we do that has nothing to do with patient care, but has
everything to do with taking care of the whole family. Starting five
years ago, one of the nurses in the unit had got caught up in the card
making craze that had hit the crafting world. She thought it would be
nice to make Christmas cards for the families and maybe include the
footprints of the baby on the card. After talking to her a few more of
us decided to take a picture of each baby and put it on the card also. That first year we scrambled around to
make 30 cards and, enlisting the help of the staff, we were able to complete all the cards for Christmas Day.
Wrapped up with some homemade blankets, a candy cane, and some
ribbon, we left the packages at each bedside. As Christmas day came and
the parents started to filter in, they saw their gifts and began to open the
cards. Some parents cried, most smiled and all of them left that day
clutching that simple piece of paper like it was gold.
The medical part of what we do is very important, but the greatest
impact is often in the small gestures we make to families who are
struggling through the toughest experience they will go through. Yes,
we do love taking care of the babies and it is a hard job, but every day
we get to see how amazing people can be, and how loving, giving, and
compassionate they are to one another. ♥
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PDSA Status Summary — Carrie Tingley Inpatient Unit
ANNUAL NURSING REPORT 2010 — PEOPLE
PDSA Status Summary Outcome
The pediatric rehabilitation
population experienced a fall
prevalence rate of 2.34 per
1,000 patient days for 2010.
The breakout for this year
looked at monitored patients
versus un‐monitored patients
who fell.
In December 2009 a video
monitoring system, which consisted
of digital cameras
mounted in five designated
patient rooms, and a centrally
located monitor was purchased
and installed.
The objectives of this video
monitoring system were to afford
continuous visual observation
of patients by remote
staff; as well as determine the
need for dedicated room sitters.
Implementation of the
video monitoring system has
been a success.
• Continue to
monitor fall rate
by breaking out monitored
versus unmonitored
data.
• Consider adding additional
cameras on unit.
• Present and
educate other UNMH
Nursing
Departments on the
benefits of the video
monitoring system
versus sitter usage.
• Publish data since
there is little
research completed in
this area.
NO. PATIENTS FALLS FALL RATE
TOTAL 4,055 9 2.22
MONITORED 1,066 2 1.88
UNMONITORED 2,989 7 2.34
Cost savings related to sitter usage is equivalent to
6.7 FTEs resulting in a savings of $328K.
Fall Rate reduction comparing monitored versus
unmonitored area is a 31% reduction.
Administrative Supervisors
The Administrative Supervisor Group had a productive year that resulted in a
positive leadership change. With a new Executive Director and newly designated
Manager, the hardwiring of processes and procedures had a great impact. Our
Pathways to Excellence
representation in hospital activities continues to grow. In addition to daily assignments,
each Administrative Supervisor has branched out and attends various committees within the nursing
department structure.
We take pride that the entire hospital is our assignment. As we share information and ideas, we can
make a better environment for all. We hope our continued support of growth activities will indicate the
need for continuous learning and quality improvement for all nursing staff. The Admin Supervisors will be
participating in their first ever PDSA projects and working to develop a set of guiding quality indicators
to improve their very unique practice. ♥
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ANNUAL NURSING REPORT 2010 — SERVICE
Maternity & Family Planning (M&FP)
Neighborhood Clinics Celebrate 40 Years!
January 2010 Celebration Brings Staff from Past &
Present Together, Serves Communities
The Maternity and Family Planning (M&FP) Clinics, formerly known as
M&I, are a means of bringing women’s health services into neighborhood
clinics. Patients are seen by highly qualified nurse midwives,
nurse practitioners, medical assistants and lab technicians who are all
bilingual and provide culturally sensitive services for our patients. The
services provided at the clinics encompass comprehensive women’s
health care such as annual exams, family planning, prenatal care and a
broad spectrum of diagnostic, educational, and consultation services.
In addition to the health care and education, a social worker is available to counsel and refer
patients to social services that may be needed. A community health worker/promotora rotates
her time between the four clinics, working with patients individually to provide information on
insurance/payment options that are available through the UNMH system, and Emergency Medical
Services for Aliens (EMSA). The M&FP clinics also offer childbirth classes in Spanish that prepare
patients for the delivery of their child, the importance of breastfeeding, family planning methods,
and the father’s role in the delivery room. ♥
UNMH Serves Through St. Baldrick’s Events
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The St. Baldrick's Foundation raises funds for childhood
cancer research by hosting worldwide head‐shaving
events, where volunteers shave their heads in public to
show solidarity with the children who typically lose their
hair during treatments. In 2010, there were two St.
Baldrick’s events — one where UNMH Lifeguard staff
shaved their heads as part of the St. Patrick’s day local
area firefighters and EMS
community, and the May
event in the UNMH Plaza. ♥

ANNUAL NURSING REPORT 2010 —SERVICE
Many nurses participated
in this large community health
event in January 2010.
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ANNUAL NURSING REPORT 2010 — QUALITY
What is National Data for Nursing Quality Indicators (NDNQI) and
How Does it Relate to the Magnet Recognition Program?
Magnet requires data from many different areas within an institution; however they do not specify which
database a facility must use to report this data. Some requirements exist for benchmarking — that is why
so many hospitals choose to join NDNQI. What is unique about NDNQI is that they are the only national
database that collects nursing data at the unit level. This allows hospitals not only to compare themselves
to other hospitals in regard to nursing quality indicators, but also to other ‘like’ units in the nation
participating in database.
Participating in NDNQI is completely voluntary and provides a hospital with an opportunity to be part of a
nursing database that specifically aims to help nurses refine their care and processes within their practice.
New facilities join regularly so this is a very dynamic database that allows nurses to closely monitor how
their nursing care compares to other facilities. This, in turn, provides multiple opportunities for better
quality and improved patient outcomes. What are the NDNQI Indicators? Patient Falls; Patient Falls with
Injury; Pressure Ulcers: community‐acquired, hospital‐acquired, unit‐acquired; Skill Mix; Nursing Hours
per Patient Day; RN Surveys: Job Satisfaction — Practice Environment; RN Education and Certification;
Pediatric Pain Assessment Cycle; Pediatric IV Infiltration Rate; Psychiatric Patient Assault
Rate; Restraints Prevalence; Nurse Turnover; and Healthcare‐associated Infections:
VAP — ventilator‐associated pneumonia; CLABSI — central line–associated blood stream
infection; and CAUTI — catheter‐associated urinary tract infection. ♥
What’s New in the ED?
The Emergency Department is hard at it with some
of the best AMI Core Measures in the country.
Pneumonia Core Measures are at 94% and the staff
members are currently working toward a Chest Pain
Center Accreditation.
The ED also offers monthly review courses for the
CEN exam, and constantly looks at new ways to
improve communication including a system called
“Vocera Communication,” a hands‐free ‘voice
command’ communication wireless system.
2010 also ushered in a brand‐new onsite adult
urgent care center that is staffed by NPs and PAs.
Way to go UNMH ED! ♥
In the Excellence Spotlight
The Lifeguard Staff has a 100%
certification rate! Their team also gave
some national presentations for 2010:
• “When Good Teams Go Wrong,” by
Kevin Schitoskey, RN, CFRN, CMTE @
the Air Medical Transport
Conference.
• State EMS Conference Presenters
Jennifer Stafford, RN, CEN and
Kevin Schitoskey, RN, CFRN, CMTE
for the 2010 conference. ♥
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ANNUAL NURSING REPORT 2010 — QUALITY
Quality
Blood Stream Infections per 1,000 Central Line Days
50th Percentile (median) comparison
2010
AMC
UNMH
1Q 2Q 3Q 4Q
Compared to the 50th Percentile (Median) for
Academic Medical Centers (AMC), UNMH was:
First Quarter: Lower Than
Second Quarter: Higher Than
Third Quarter: Lower Than
Fourth Quarter: Higher Than
The ICU units use a blood stream infection (BSI) checklist during the insertion of a central line. Use of the
checklist is good but can be improved for consistency of excellent patient care. Documentation occurs in the
patient’s electronic medical record (EMR). All supplies are bundled so they are readily available when the
procedure begins. UNMH is participating in the New Mexico state (BSI) collaborative in order to decrease
infections and learn best practices. One area of opportunity is to determine the best practice when clean the
ports prior to use. ♥
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ANNUAL NURSING REPORT 2010 — QUALITY
Total Nursing Unit Turnover Rate as % of Employed FTEs
% Separated Number of RN and APRN Staff
50th Percentile (median) comparison
2010
AMC
UNMH
1Q 2Q 3Q 4Q
Compared to the 50th Percentile (Median) for Academic Medical Centers (AMC),
UNMH was:
First Quarter: Higher Than
Second Quarter: Lower Than
Third Quarter: Higher Than
Fourth Quarter: Lower Than
RN Education
% BSN
50th Percentile (median) comparison
2010
Compared to the 50th
Percentile (Median) for
Academic Medical Centers
(AMC), UNMH was:
LOWER than the Median for all
four quarters . . .
AMC
UNMH
BUT CHECK OUT our Cert Rate
on the next page!
1Q 2Q 3Q 4Q
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ANNUAL NURSING REPORT 2010 — QUALITY
We are HIGHER THAN the Median for all four quarters compared to all other
AMC’S that participate in the NDNQI!
Percent of RNs with National Certification
50th Percentile (median) comparison
2010
AMC
UNMH
1Q 2Q 3Q 4Q
UNMH Identified Best Practices
• Core Measures
> Door to catheter
> Asthma
> Restraints
• Cleanliness of Facilities
• Environment of Care and Emergency Management Plans
• Patient Rights-New Patient Centered Consent
• Medication Reconciliation Process
• Advanced Directives
• Leaders
> Commitment to mission at all levels
> Strategic plan shared with community
• Frontline Staff
> Ownership of goals/mission
• Electronic Medical Record ♥
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ANNUAL NURSING REPORT 2010 — QUALITY
•
Ventilator Associated Pneumonias per 1,000 Ventilator Days
50th Percentile (median) comparison
2010
.
AMC
UNMH
1Q 2Q 3Q 4Q
Compared to the 50th Percentile (Median) for Ventilator
Associated Pneumonia (VAPS), UNMH was:
LOWER than, in all four quarters! WAY TO GO UNMH!
At UNMH, we follow the national ventilator associated pneumonia (VAP) care bundle. This includes such
practices as elevating the head of the bed 30 degrees, routine oral care with chorohexadine, turning the
patient every 2 hours, decreasing the number of times the ventilator circuit is disconnected which reduces
the opportunities for infections to begin, using the VAP checklist in the EMR for documentation, and
“sedation vacation” for the patient to assess for the earliest opportunity to extubate the patient. ♥
Using our Nursing Recognition Website, with well over 51%
of our nurses reporting, we have a 41% certification rate!
Way to go UNMH Nurses!
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ANNUAL NURSING REPORT 2010 — QUALITY
Injury Falls per 1,000 Patient Days
50th Percentile (median) comparison
2010
AMC
UNMH
1Q 2Q 3Q 4Q
Compared to the 50th Percentile (Median) for Injury Falls, UNMH was:
LOWER THAN in the first quarter, and HIGHER THAN for all other quarters.
WHAT DOES THIS MEAN?
UNMH formed a Falls Task Force via the Medical/ Surgical shared governance group to evaluate and
standardize the fall with injury definition. Prior to this task force there was inconsistency with reporting
falls with injury. Through increased education, there was increased awareness, which resulted in increased
correct reporting. We are having patients self‐report falls by providing this education to them.
A new fall scale has been implemented and associated interventions are in process of being changed.
Documentation will occur in the EMR once that module is built and added. ♥
In June 2010, CEO Steve McKernan,
ED Carolyn Green and Unit Director
Michele Wafer celebrate receiving
an award from the DOH Infant
Immunization Program, honoring
the Best Hospitals in NM in 2010
for immunizing infants.
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ANNUAL NURSING REPORT 2010 — QUALITY
Inpatient Burn, Wound & Ostomy Services
The mission, vision, and core values of the Burn, Wound & Ostomy Services (BWOS) are consistent with
those of the institution and nursing division. BWOS aims to provide high‐quality care and education to
the customers of University of New Mexico Hospitals (UNMH). Relevance and efficiency are key to
achieving these goals. More than 7,960 patients were seen with 10,133 nurse encounters. BWOS are inhouse
seven days a week from 0700 – 1730.
Accomplishments in 2010 include: four RNs obtaining National Certification in wound care, developing
yearly competency for Burn, Wound & Ostomy Team members and continuing the Skin Champion
program (over 50 Skin Champions, with education provided, incentives – CAP points, and data entry
quarterly to NDNQI).
Teaching Services: Nursing Students: 54 total – 5 UNM Capstone students (96 hours each for clinical
time), CNM students, Carrington Students, UNM (Albuquerque & Valencia); UNMH Staff Nurses – six
total, Burn Pod – three staff and one supervisor; Float Pool – two staff; Nurse Tech students – four;
WOCN student from Emory University (96 hours); In‐Servicing: nine wound vac in‐services; Nurse Tech
classes – two/year; 4West comps – two days; Nurse Resident program – three/year.
Future plans for Inpatient Wound Care Team:
• First annual Wound Care Fair
• National Certification in Wound Vac Therapy
• RN/PT wound care team combine product committee
• Outreach – Outpatient Ostomy teaching
• Standing orders for wound care
• Inpatient wound care team website
• Boot Camp meeting for New Residents of General
Surgery & Orthopedics
• Ostomy certification
• Start RN to BSN programs
• Inreach – MHC
~ Linda Bailie, RN, Inpatient Unit Director
Burn, Wound & Ostomy Services ♥
The Inpatient Burn & Wound unit has
four new Nationally Certified Wound Nurses.
Our thanks and congratulations go to Cresta
Nicola, Karen Brown, Kim Gordon and Sarah
Cole, who are Wound Care Certified (WCC)!
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2010 PICC & Sedation Team Nursing Report
ANNUAL NURSING REPORT 2010 — QUALITY
The mission, vision, and core values of the PICC & Sedation Team (PST) are consistent with those of the
institution and nursing division. PST aims to provide high‐quality care and education to the customers of
University of New Mexico Hospitals (UNMH). Relevance and efficiency are key to achieving these goals.
PST, a dual‐role team, has five Registered Nurses (RNs), (4.20 FTEs), Three RNs are .9 and two RNs
are .75. All five are ADN‐prepared: one has another bachelor degree; one has Medical/Surgical National
Certification; and one has a paramedic license. PST is in house seven days a week, 0700 – 1630.
In 2010, the PST team inserted 672 PICC lines and performed 506 procedural sedations. Additionally,
six PICC removal classes were taught (to more than 50 registrants) and central line care in‐services were
given to six inpatient units, two nursing student groups, and three nurse residence new hire groups.
Accomplishments this year include writing Central Vascular Line Care Guidelines (passing through PP&G
committee) to align with the National Patient Safety Goals (NPSG.07.04.01) and implementing guidelines
with RN on‐line competencies.
Additionally, the Sedation Team added the Burn Pod to the list of new sedation areas.
Future plans include all five RNs obtaining their National Certification in Vascular Access‐Board Certified
(VA‐BC) credentials and encouraging them to return to school for their BSN. Additionally, the team is
writing guidelines and implementing new state‐of‐art ultrasound for PICC placement – to eliminate
x‐rays to those insertions that qualify – which will increase usage time and throughput time. New
ultrasound will be the main focus of study for PDSA. Other plans are to develop a website to showcase
who we are and what we do.
~ Linda Bailie, RN, Inpatient Unit Director
PICC & Procedural Sedation Team ♥
Training Top 125
UNM Hospitals has again been honored by Training magazine as
one of the top 125 training organizations in the country that excels
at human capital development, and training and development.
The annual Training Top 125 list is the only report that ranks
companies’ excellence in employer‐sponsored training and
development programs. This recognition is testament to the quality
of — and importance the organization places on — the education offered
to employees at UNM Hospitals.
Five educational services divisions — Computer Learning and Technologies, Clinical Education,
Frontline Education, Behavioral Health Education, and Organizational & Professional Development —
provide valuable, useful information in classes and trainings to UNM Hospitals employees. ♥
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ANNUAL NURSING REPORT 2010 — QUALITY
UNMH Quality Outcomes Department
Professionals Helping Professionals
for Better Quality Outcomes
Thanks to ED Cathy Jaco and her team of dedicated
professionals whose continuous efforts to improve
quality help our staff provide exceptional care.
A Continued Commitment to Quality
Serving more than 450,000 patients annually, UNM Health Systems nursing services provide the kind of
professional commitment to quality nursing that patients expect from a large Trauma I hospital.
We have a culture of local accountability for performance and performance improvement in the context of
organization‐wide values and priorities. The nursing division alone has a rich history of placing an emphasis
on system support for patient and staff safety — with contributions from nurses including: Patient Safety
Committee, Nursing Quality and Peer Review, Medication Safety Committee, Patient Safety Service Team,
Patient Safety Improvement Corps, and the Hospital Quality Committee.
With a commitment to quality, the Executive Director of Quality Outcomes Management is a Mastersprepared
nurse supporting an environment in which high‐quality nursing care is provided. Throughout the
year, frontline nurses have actively participated in a number of patient safety projects. ♥
Mountain West Winner of NurseWeek’s 2010 Nursing Excellence Award for
Advancing & Leading the Profession: Sheena Ferguson, RN, MSN, CCRN, CNS
Sheena Ferguson is passionate about nursing, education, students and
reflecting the legacy of Florence Nightingale. She has empowered nurses to
influence practice change and continues to contribute to the hospital’s Magnet
journey by supporting all nurses to practice autonomously and establish
a shared‐governance model of leadership.
Sheena is a nurse’s nurse. She usually is wearing scrubs so she can stop at a
moment’s notice and provide patient care. She was chosen as CNO in 2008,
over others with more experience. But Sheena has the respect of the
bedside nurses, and she challenges the boundaries of nursing practice. ♥
20

ANNUAL NURSING REPORT 2010 — QUALITY
Dr. Kendall Rogers and Rosa Matonti presented this poster at the International Hospital Diabetes Meeting in
San Diego, October 2010. Later it was presented at the TCAB conference in October 2010. Rosa and the staff
of 4W have been invaluable in creating a much smoother process of blood glucose measurement, insulin
administration, and meal delivery. This was a lot of hard work for all involved, but the patient outcomes
speak for themselves! This project will continue to make great patient improvements for our diabetic
population. The National Association of Public Hospitals & Health Systems went on to award Rosa & 4W
with and Honorable Mention Recipient for the 2011 NAPH Safety Award! Thanks 4West and all involved! ♥
UNMH Employees: Be Wise. . . Get Immunized!
Tis the season to be flu-LESS! UNMH Flu Shot Clinic 2010
On Tuesdays and Thursdays through October 2010, UNMH offered a free shot clinic
for influenza for all UNM Health Science Center Employees/Providers/Staff. Coming
off of a huge flu year in 2009, UNMH was prepared to meet the needs of staff and
patients for the 2010 season. ♥
21

ANNUAL NURSING REPORT 2010 — QUALITY
College of Nursing News
Education: In 2010 UNM College of Nursing admitted 96 students into the basic and accelerated BSN
program. It takes students 15 months (or four terms) to complete the Bachelor’s of Science in Nursing
program. Each term, 63 students were individually precepted at UNM Hospitals. Eighteen nursing staff
served as Master Clinicians teaching College of Nursing undergraduate students at the hospital.
Practice: Dr. K. Ann Caudell, Associate Professor at the UNM College of Nursing is now in a half‐time
position at UNMH, working as the diabetic nurse practitioner. It is a consultation position for which she
will be contacted to manage newly diagnosed or chronic diabetics of patients hospitalized at UNMH for
a variety of problems. The diabetic nurse practitioner will work closely with the diabetic nurse educator
in a team approach to improve health outcomes of diabetic patients admitted to UNMH.
Alumni: The first annual breakfast for College of Nursing alumni working for UNM Hospitals was held in
June 2010. Many graduates came to the event to meet Dean Ridenour and the leadership team from the
College, as well as enjoy a wonderful meal with fellow alumni.
The New Mexico Center for Nursing Excellence honored Sheena Ferguson, UNMH chief nursing officer
and UNM College of Nursing alumna at their award ceremony in October (see following page). ♥
University of New Mexico Hospitals 2010 Vital Statistics
• Inpatient Beds: 620
• Inpatient Days: 151,059
• Inpatient Discharges: 27,479 — down 2%
• Average Daily Census: 414
• Emergency Dept (ED) Visits: 58,685 — down 16%
• Pediatric ED Visits: 19,189 — down 10%
• Total ED Visits: 77,874 — down 15%
• Total Ambulatory Visits: 456,171 — down 34%
(Clinics Only)
• Total Number of Births: 3,538 — down 7%
• Busiest Month for Births: 357 — (August)
• Main Operating Room Cases: 8,612 — up 2% ♥
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ANNUAL NURSING REPORT 2010 — QUALITY
UNM Hospitals Nominates 37 for NM Nursing Excellence Awards; is Honored with
Three Awardees
Awards are presented by the New Mexico Center for Nursing Excellence. The
program presents awards in 21 Nursing Excellence categories. The following
UNMH nurses were award recipients: UNM Hospitals honored its nominees with
reception tea in October 2010.
UNM Hospitals is proud to announce that three of our nurses were honorees this year:
• For Excellence in Practice in Behavioral Health, MHC Dual Diagnosis Clinic nurse Leslie Kern was honored.
• For Excellence in Practice in Peri‐Operative, PACU nurse Vonda Temple was honored.
• For Excellence in Leadership for Nurse Executive Leadership, CNO Sheena Ferguson was honored.
UNMH is proud and honored to have these exceptional nurses as a part of our community! Nominees included:
a
• Mary Bachmann
• Karen‐ Lynn Fiato
• Mina Khazee
• Sylvia Price
• Theresa Bacon
• Crystal Frantz
• Annette Licht
• Lorraine Ramirez
• Gayle Benintendi
• Yvonne Gabaldon
• Jim Little
• Justine Sanchez
• Mary Blessing
• Sheryl Gordon
• Kyria Lopez
• Martha Snow
• Laura Bluhm
• Susan Grohman
• Kathy Lopez‐Bushnell
• Vonda Temple
• Sandy Critchfield
• Connie Tabet Hardy
• Bridgette Love
• James Verzi
• Sara Daykin
• Rochelle Hedin
• Deborah Markee
• Nicole Weimer ♥
• Margaret Edwards
• Deborah Hedrick
• Alethea Martinez
• Chris Esquivel
• Ulla Jaramillo
• Jennie Montano
• Sheena Ferguson
• Marina Kasen
• Devona Myrick
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ANNUAL NURSING REPORT 2010 — QUALITY
Nursing Recognition Website
STRUCTURAL EMPOWERMENT:
In November 2010, UNMH rolled out the Recognizing our Professional Achievements,
Nursing Recognition Website. The Magnet realizing our autonomous nursing practice, and
Champions, along with the Pathway to Excellence
Committee of Nurses, recognized that
a determined focus on the growth of our Shared
Governance — this is the future of nursing at UNMH!
during our collection process for Pathway to
Excellence written submission our Shared Governance was
in need of overhaul, and we were missing an important
opportunity to capture professional achievements of nursing
peers on‐line.
In the past, whenever our CNO wanted to get some statistical
information regarding how many BSNs any one unit had, how
many were in school, who was certified, etc., the UDs were
scrambling to get in touch with their staff to get this updated
information. Unfortunately, we knew that the collected information
likely was not reflecting the complete certification status,
and/or the education status, but we were also missing opportunities to recognize our nursing peers
who have published, presented or were active in community service. With this gap in recognition, the
Magnet Champions, together with the Magnet Program Manager, created a database that would not
only capture all of this incredible talent, but would in fact serve as a professional portfolio that the
individual nurse would be in control of creating and updating.
Our CNO, Sheena Ferguson liked this idea so much that she agreed that each nurse should keep track
of their professional data; and that this could serve as part of the written submission for CAP and
during our annual reviews. So we rolled out the website with the help of IT and the support of our
nurses, and received tremendous support from the nurses entering their information. Based on
feedback we received, we created a ‘Privacy’ button on this website, so that any nurse entering his
or her professional credentials could check that box and hide the profile from the intranet. We also
made sure that this website is only available on our intranet, and we have limited access to the
database for maintenance and improvements.
So far, more than 1,275 nurses have entered professional information! We have also learned that this
database could be a best practice, as this type of data is often needed for national benchmarking
statistics, Magnet, and Pathway — and there is no state that keeps a current database with this kind
of statistical information. When we do use this database for any kind of statistical reporting, there will
never be any kind of identifiers attached to the data. Most of the data that will be extremely important
to identify includes BSN rate, certification rate, and publication rates. The opportunity to recognize
one another on an intranet venue has resulted in a great sense of pride for the nurses at UNMH who
saw a missed opportunity for recognition. Way to go UNMHNurses!
Internal Link: https://hospitals.health.unm.edu/intranet7/apps/nurse_achievements/index.cfm
External Link (accessible from home): https://hospitals.unm.edu/
24
intranet7/apps/nurse_achievements/index.cfm ♥

TCAB 2010—TRANSFORMING CARE AT THE BEDSIDE
Our 2010 TCAB conference was a hit! This year
we took it statewide, and had over 160 participants.
We had guest speakers from area hospitals, and
anticipate that this will become one of the best
state‐wide conferences for nursing around, if it
isn’t already.
We held this conference at the Marriott Pyramid
and offered 6 CEUs for nurses. It was an opportunity
for nurses in New Mexico to disseminate best
practices and learn not only what their peers are
doing at UNMH, but from other hospitals in our
state. We had 12 presentations, two of them from
an area hospital in Albuquerque. Discussion topics
included how we accomplished our Pathway to
Excellence award, rounding in the pediatric ER,
Coping with Labor (pain), Lean Methodology in
the ER, Crew Resource Management in the OR,
and End‐of‐Life Moral Distress in the ICUs, just
to name a few!
This is a great opportunity to not only share best
practices, but to get our nurses involved in
important decisions affecting our practice,
ANNUAL NURSING REPORT 2010 — QUALITY
including generating interest and
inclination in nursing research.
The better we become as nurses,
in articulating what we do, why
we do it, how we do it, and how
hospitals can support us, the better able we are
able to control our practice as nurses. Autonomous
nursing practice if vital for better patient outcomes
and for decreasing our RN Turnover. ♥
In the Excellence Spotlight!
Jo Anne Wright, RN, MSN, CNS, BC Peds
In her career, Jo Anne has been a speaker at
numerous conferences, teaching school nurses
and other staff how to care for students with
tracheostomies; attending conferences talking
about ethical issues with dependent babies on
ventilators; presenting at a Pediatric ENT
seminar; and speaking at the National
Congress last fall where Jo Anne received a
standing ovation after her presentation!
Wow, thanks Jo Anne! ♥
25

ANNUAL NURSING REPORT 2010 — QUALITY
Magnet Journey — The 5 Components of Magnet — Encompass the 14 Forces of
Magnetism
In January 2011, UNMH began their
Magnet data collection. In December 2010,
we announced our Magnet Data collectors
who are RN Liaisons for various units/clinics
and departments. They will be instrumental in
helping to guide units in recognizing their best
practices, as well as helping them fine‐tune
and further implement changes they see as
necessary to improve their units/clinics. The RN
Liaisons can be found on the Magnet Website
under the link ‘Magnet Data Collectors.’ We
have also posted their bios, the hospital‐wide
data collection calendar, and what areas each
data collector will serve.
If we believe that a determined focus on our
practice can help us constantly improve our
patient outcomes, as well as create New Knowledge,
Innovations & Improvements
(the research component of Magnet), we can
truly transform our units, and our practice, to
be the hospital with the best patient care —
and the evidence to back it up!
Magnet designation is an achievement that will
ask more of us at every level, but the returns
and rewards will be evident with decreased RN
turnover, more job satisfaction and better
patient outcomes. Magnet offers a great blueprint
for achieving these outcomes, but only if
we all embrace this journey of excellence! ♥
26
Prior to 2005, Magnet required organizations to write a total
of 155 Sources of Evidence, (SOEs) taken from the 14 Forces
of Magnet. Over the years, based on feedback from Magnet
facilities, the ANCC consolidated the 14 Forces into concepts,
known as the 5 Components of Magnet—Transformational
Leadership, Structural Empowerment, Exemplary Professional
Practice, New Knowledge, Innovations & Improvements and
Empirical Outcomes. Now there are 88 SOEs, a much more
manageable achievement. Magnet seeks to find the best
nursing care in an organization, so when we attempt to achieve
this designation, we are in essence stating, ‘we give the best
patient care and we have the evidence to back it up.’ Magnet is
no easy endeavor, it will ask more of us at every level, but the
rewards by far outweigh this dedicated commitment. ♥

Pathway to Excellence Designation: Journey Onward to Magnet!
How does this Award Propel Us Forward for Patient Excellence & to Our Magnet Journey?
The Pathway to Excellence award has been invaluable in providing a roadmap to our
continued Magnet Journey. Nurses at UNMH realize that achieving Magnet status is more about the
journey, and less about the award. That is not to say we don’t want and deserve this nursing
excellence award, but the Magnet Champions and the nurses that are learning about this process are
finding that our Pathway to Excellence journey really provided us with invaluable information about many things.
Our Shared Governance throughout UNMH was not where we needed it to be. We discovered that although
UNMH rolled out Shared Governance in 2004, there was still a lot of misinformation out there, and
mistrust. Armed with this information, we have Magnet classes that are taught every fourth (4th) Tuesday from
3‐5PM through OPD, titled ‘Supporting a Magnet Organization.’ In this class we talk about the journey, and what
the dedicated and determined focus on nursing can mean to the organization, not just nursing.
We also identified best practice tips for revitalizing Shared Governance, as well as what Shared Governance
really is, and what it aims to accomplish. The Magnet Program Manager is also consistently meeting with Shared
Governance Councils throughout the organization, helping to disseminate the most successful practices of Shared
Governance, and how to make it realistically work on any unit.
Some of the most important things for Shared Governance include:
• Have a Shared Governance Charter that clearly defines your mission, vision and goals for your unit. We have
Charter templates on the Magnet website under the link ‘Shared Governance.’ In the charter, be detailed
about when you will meet, where, and the time frame. Most SG councils prefer 90‐minute meetings as
opposed to an hour. Also reveal in your charter who is the Chair is and Co‐Chair, and what timeframe they will
serve. For large units that want to include everyone, sometimes it is easier to pick a council that represents
your ‘Quorum’ so that this quorum always meets, regardless of the availability of other staff members who
show up. Now you have a committed group of people who agree to meet for the term — 6 months, one year,
etc., and they agree to poll their peers, and be the voice for their peers.
• Have a pre‐agenda meeting with your management partner. Too many times staff were sharing that their
SG meetings were ‘gripe sessions.’ Creating an agenda ahead of time with your management partner can
prevent this from happening.
• Set time‐lines, goals and due dates for projects, and
keep minutes that reflect the decisions you make.
That way your peers know you are meeting, and it
is making a difference.
• Post your minutes in your break‐rooms, and if you
would like, on our Magnet Website. If we can show the
benefits to our peers of staff and management coming
together to make a functional SG, we can also share
the importance of involvement — for without SG, we
essentially give up a lot of our voice at the bedside.
• Understand the SG Model. This is also posted on the
website, and delineates what decisions are a part of
the purview of SG. Specifically, in SG, our purview should
be — practice, education, quality & research.
Questions? Contact Adrienne Fugett at afugett@salud.unm.edu. ♥
ANNUAL NURSING REPORT 2010 — QUALITY
27

ANNUAL NURSING REPORT 2010 — QUALITY
BATCAVE Achievements for 2010-2011
• People: The BATCAVE has outstanding employees
and outstanding volunteers serving approximately
2600 employees/year for BLS, ACLS‐NP, ACLS‐R,
PALS‐NP, PALS‐R and NRP. Additionally, the BAT‐
CAVE provides simulation services for the
SOM (Emergency Medicine, Anesthesia, Pediatrics/
Neonatology, Internal Medicine, Family Practice
and GME). We coordinate and conduct the New
Intern Mega Fest for approximately 120 new
residents annually. We also provide numerous
consultations on a daily basis.
• Diversity: We are involved with the hospital’s Project Diversity
(nursing and health sciences pipeline) for middle and high school
students, and Office of Diversity pipeline on the HSC side.
• Service: In addition to CTC and simulation services, we provide Rural
Health Education Outreach (RHEO) via monthly webinars to
healthcare providers around the state, around the country, and now
internationally. We held a fantastically successful First Annual NM
Simulation Symposium in December 2010.
We also provide Train‐the‐Trainer courses (now profession‐specific),
mini‐sabbaticals with rural Pediatricians/Neonatologists, and a
national anesthesia credentialing program.
We have established a BATCAVE Research program collaborating
anesthesia, the Nurse Residency Program, and Project Diversity.
• Quality: We have instituted qualitative evaluations for our
simulation programs and RHEO. We are actively participating
in the Magnet journey, and a customer satisfaction survey is
coming soon.
• Growth: RHEO, Project Diversity, Anesthesia Credentialing,
Tours, Simulation Use (ultrasound guided central line
placement), and ACLS‐NP/PALS‐NP courses for the new interns.
• Financial: Grants, Simulation Symposium, Research Grants, RHEO. ♥
28

CLINICAL EDUCATION Annual Nursing Report - 2010
ANNUAL NURSING REPORT 2010 — QUALITY
The mission, vision, and core values of the Clinical Education (CE) department are consistent with those
of the institution and nursing division. CE staff aim to provide high‐quality education, contain costs, and
enhance participant experience which will positively impact the patient/family experience. Relevance and
efficiency are key. Clinical Education has 14 staff (10.95 FTE’s). Twelve are talented nurse educators, eight
Master’s prepared. Several possess specialty certifications; one is board certified in Nursing Professional
Development. The educators in Clinical Education use Benner’s model of staff development to design
educational programs. Novices and nurses new to University Hospital are required to attend general
orientation and foundational clinical classes relevant to a particular area; e.g., pediatrics. Experienced
nurses may choose from a wide variety of intermediate and advanced courses, including certification
preparatory classes, specifically designed to meet ongoing educational needs. Instruction in precepting,
supervising, delegating, and educating is provided for nursing staff for those branching out into new roles.
In 2010, Clinical Education offered 862 classes, 120 types. Basic and advanced instruction was offered
for a wide variety of courses: pediatrics, women’s health, newborn, ambulatory, neuroscience, trauma,
emergency, medical‐surgical, oncology, pain, end‐of‐life, cardiac rhythms, certification preparation,
precepting, supervising, and delegating. Registrants totaled more than 10,000 and over 22,000 Continuing
Nursing Education (CNE) units were available. Almost 1,200 students from eight academic programs were
placed for clinical experiences throughout the year.
Several accomplishments in the past year are noteworthy. Clinical Education staff worked with OPD and
CLT staff to establish an “orientation week” which provides a cohesive beginning for new nurses. A strong
relationship with staff in these departments has been established as well as with those in the Simulation
Center. The Patient Centered Medical Home educational initiative has been launched and now offered by
CE to new ambulatory nurses. CE maintains a website to provide department contact and course offering
Information. The department has expanded office hours to better meet customer’s needs.
Course participants universally provided constructive feedback and expressed appreciation for educational
opportunities. For example, a unit‐based educator shared that a student reported “she absolutely loved
the multidisciplinary class she took; she was able to snag a 1:1 septic patient today to care for and is very
happy to be applying what she learned in the class to an actual patient so soon after the class; thanks for
being so good at what you do!”
Future plans for Clinical Education staff include several ambitious projects. The identification and provision
of educational programs to underserved specialties is one. Another is ensuring patient safety‐related instructional
needs are addressed proactively. CE would like to provide CNEs for self‐study modules and OPD
classes. The outcomes of instruction will be studied to determine its impact and appropriate timing. ♥
Some of our Clinical Nurse Educators, summer 2010
29

ANNUAL NURSING REPORT 2010 — QUALITY
Structural Empowerment — Nurse Recognition Website
Using our new Nurse Recognition Website, the following nurses are listed as having a new nursing certification
either in 2010, or 2011. To date, we have approximately 1,281 nurses who have entered their professional credentials
to this website. That is statistically significant to report the following information:
• BSN Rate: we are at 52 %, including our Nursing Leadership, & our APNs. Our BSN staff rate is approximately
45%, with 80% of our nurses reporting on our Nurse Recognition website!
• MSN Rate: 8.2%
• BSN & Certification Rate: 19%
• Certification Rate: 41%
• Published Rate: 2%
• Presentation Rate: 4% This includes nurses who have presented at a
state or national conference.
• Community Service Rate: 6%
• Percentage of Nurses Belonging to a Professional Organization: 20%
Belonging to a professional organization is a great way to stay current in nursing issues as well as contribute to
our profession, and learn from our nursing peers! This is completed degrees only, not those who are in school
with a pending degree completion date. ♥
30
Certified Nurses ‐ Studies indicate that nurses who are certified are
quicker at initiating early interventions and have more control over
their practice; better communication; fewer adverse events and
patient errors; more satisfaction and better pay. Board certification
of nurses plays an increasingly important role in the assurance of
high standards of care of patients and their loved ones. ♥
NAME DESCRIPTION ABBR
Courtney D Beach Certified Ambulatory Perianesthesia Nurse CAPA
Kathy Lopez‐Bushnell Family Nurse Practitioner FNP‐BC
Jill Dykhuis Progressive Care Certified Nurse PCCN
Colette McWhorter Certified Critical Care RN CCRN
Dora G Flores‐Burns Certified Registered Rehab Nurse CRRN
Jolene E Enslin Certified Critical Care RN CCRN
Gwendolyn I Barnhart Cardiac Vascular Nursing RN‐BC
Cyrillie J Cadman Certified Critical Care RN CCRN
Sherry L Reeder Certified Case Manager CCM
Karen Maher Inpatient Obstetric Nursing RNC, INPT
Bridgette Love Certified Infection Control CIC
Meghan J Schleyer Maternal Newborn Nursing RNC, MN
Rebecca D Hodges Maternal Newborn Nursing RNC, MN
Kristina Johnson Ambulatory Care Nurse RN‐BC
Julie A Lott Certified Pediatric Nurse RN‐BC
Lori Bunjes Certified Critical Care RN CCRN
Rebecca M Gallegos Certified Pediatric Nurse RN‐BC
• continued, next page

ANNUAL NURSING REPORT 2010 — QUALITY
NAME DESCRIPTION ABBR
Monica R Vickery Certified Case Manager CCM
Lisa A Quinones Certified Pediatric Nurse RN‐BC
Lezlie M Garcia Vascular Access ‐ Board Certified VA‐BC
Rosa Matonti Certified Diabetes Educator CDE
Jennifer S Trujillo Registered Cardiovascular Invasive Specialist RCIS
David Bommarito Certified Critical Care RN CCRN
Tara Fletcher Certified Post Anesthesia Nurse CPAN
Katherine A Chavez Advanced Oncology Certified Nurse AOCN
Stephanie A Sayre Certified Critical Care RN CCRN
Lizabeth L Gober Certified Hospice and Palliative Nurse CHPN
Elizabeth Lytle Certified Wound Care Nurse CWCN
Adriana M Gonzales Certified Pediatric Nurse CPN, RN‐BC
Julie N Sanchez Ambulatory Care Nurse RN‐BC
Jamie L Gunderson Neonatal Intensive Care Nursing RNC, NIC
Mary P Perez Certified Critical Care RN CCRN
Mayka Archuleta Certified Critical Care RN CCRN
Claudine R Olivas Inpatient Obstetric Nursing RNC, INPT
Theresa Bacon Certified Nurse Educator CNE
Tandi Harper Certified Case Manager CCM
Carla M Metzner Certified Case Manager CCM
Brenda Mobley‐Claman Progressive Care Certified Nurse PCCN
Andrew Leyba Psychiatric & Mental Health Nurse RN‐BC
Ann Zolin Ambulatory Care Nurse RN‐BC
Betsy L Noel Low Risk Neonatal Nursing RNC, LRC
Fernando Martinez Certified Pediatric Nurse RN‐BC
Melissa A Lopez Certified Critical Care RN CCRN
Terri Mathews Certified Emergency Nurse CEN
Richard S Noice Oncology Certified Nurse OCN
Sarah Skinner Clinical Nurse Specialist in Adult Health ACNS‐BC
Amy N Lewis Certified Pediatric Nurse CPN, RN‐BC
Joan L Deis Board Certified Nursing Professional Development RN‐BC
Casey O'Hara Certified Post Anesthesia Nurse CPAN
Irene V Zamora Certified Pain Management RNC, PM
Lena M Celestine Ambulatory Care Nurse RN‐BC
Sabrina K Hamel‐Green Internationally Board Cert Lactation Consultant IBCLC
Sharon L Williard Internationally Board Cert Lactation Consultant IBCLC
Marlene Jaramillo Progressive Care Certified Nurse PCCN
Deborah Atencio Certified Pediatric Nurse RN‐BC
Cheryl D Swart Case Manager ‐ Accredited ACM
Sabrina L Parks Bent Acute Care Nurse Practitioner ACNP
Theresa Bacon Certified Pediatric Nurse CPN, RN‐BC
Cresta D Nicola Certified Wound Care Nurse CWCN
Karen Brown Certified Wound Care Nurse CWCN
Veronica Rael Certified OR Nurse CNOR
Amanda T Holbrook Inpatient Obstetric Nursing RNC, INPT
Sarah J Cole Certified Wound Care Nurse CWCN
• continued, next page
31

ANNUAL NURSING REPORT 2010 — QUALITY
NAME DESCRIPTION ABBR
Renee F Lewis Neonatal Intensive Care Nursing RNC, NIC
Valli Aran Certified Med‐Surg Nurse CMSRN
Alicia K Ortiz‐Briggs Certified Med‐Surg Nurse CMSRN
Mary Anne Wisnewski Certified Med‐Surg Nurse CMSRN
Amy Baker Certified Pediatric Nurse RN‐BC
Jae‐in Cho Certified OR Nurse CNOR
Kathy M Trujillo Case Manager ‐ Accredited ACM
Arlenda C Thompson Certified Pediatric Nurse RN‐BC
Heather A Howard Adult Nurse Practitioner ANP‐BC
Katie B Jaksha Neonatal Intensive Care Nursing RNC, NIC
Stefanie L Garber Inpatient Obstetric Nursing RNC, INPT
Megan D Sanders Low Risk Neonatal Nursing RNC, LRC
Elizabeth E Williams Certified Critical Care RN CCRN
Ryan D Matson Certified Pediatric Nurse RN‐BC
Mahshid Roohi Pediatric Nurse PractitionerPediatric Nurse Practitioner PNP‐BC
Vanessa Johnson Certified Pediatric Nurse CPN, RN‐BC
Sandra Kincaid Acute Care Nurse Practitioner ACNP
Max M Parker Progressive Care Certified Nurse PCCN
Marissa A Gibson Oncology Certified Nurse OCN
Colleen Johnson Inpatient Obstetric Nursing RNC, INPT
Terry L Norvell Ambulatory Care Nurse RN‐BC
Doug E Walker Progressive Care Certified Nurse PCCN
Krista N Burns Progressive Care Certified Nurse PCCN
Julia Silva Certified Pediatric Nurse RN‐BC
Christopher K Kramar Certified Critical Care RN CCRN
Maria A Mallory Certified Pediatric Nurse CPN, RN‐BC
Rosa M Garcia Certified Pediatric Nurse CPN, RN‐BC
Chad Fluhman Certified Critical Care RN CCRN
Marisa C Hassemer Certified Pediatric Nurse RN‐BC
Pamela Lantz Certified Pediatric Nurse RN‐BC
Caroline L Paxson Maternal Newborn Nursing RNC, MN
Rochelle E Hedin Certified Pediatric Nurse RN‐BC
Amanda D Blea Certified Critical Care RN CCRN
Victoria N Rios Certified Pediatric Nurse RN‐BC
Nicolas R Schoenfeld Certified Critical Care RN CCRN
Lisa Jung Certified Pediatric Hematology Oncology Nurse CPHON
Lindsay A Endean Certified Pediatric Nurse RN‐BC
Monica J Herrera Certified Pediatric Nurse RN‐BC
Cynthia D Chavez Certified Post Anesthesia Nurse CPAN
Gregory Cantwell Certified Critical Care RN CCRN
Holly L Markham Certified Critical Care RN CCRN
Kirah S Smith Orthopedic Nurse Certification ONC
Jane Penrod Clinical Nurse Specialist in Adult Psychiatric & Mental Health PMHCNS‐BC
Jamie Lang Certified Pediatric Nurse RN‐BC
Kevin F McFarlane Certified Emergency Nurse CEN
Gwendolyn Charlee Progressive Care Certified Nurse PCCN
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• continued, next page

ANNUAL NURSING REPORT 2010 — QUALITY
NAME DESCRIPTION ABBR
Brandon Kennedy Certified Pediatric Nurse CPN, RN‐BC
Eva Hamill Certified Critical Care RN CCRN
Grant P Chanin Certified Emergency Nurse CEN
Jennifer L Aguirre Certified Pediatric Nurse RN‐BC
Myla M Sapienz Inpatient Obstetric Nursing RNC, INPT
Michael W Keleher Registered Cardiovascular Invasive Specialist RCIS
Tonya T Nguyen Ambulatory Care Nurse RN‐BC
Jennifer M Lowrie Certified Pediatric Nurse RN‐BC
Jill E Frankel Inpatient Obstetric Nursing RNC, INPT
Lisa J Normand Certified Pediatric Nurse RN‐BC
Andrea C Durfee Certified Pediatric Nurse RN‐BC
Lynn Leninger Certified Professional Util Review CPUR
Ryan M Lopez Certified Emergency Nurse CEN
Marion H Stewart Certified Pediatric Nurse RN‐BC
Pamela Lantz Certified Critical Care RN CCRN ♥
The UNMH Magnet website contains information about our Magnet journey,
our Pathway to Excellence designation, and many other shared governance
and nursing topics. Visit https://hospitals.health.unm.edu/intranet/mrp/
index.shtml for more.
33

ANNUAL NURSING REPORT 2010 — QUALITY
Exemplary Professional Practice: UNMH Nurse Residency Program
In an effort to address aspects of the nursing shortage and augment expertise
of new graduate nurses entering the workforce, University HealthSystem
Consortium (UHC) and the American Association of Colleges of Nursing (AACN)
joined forces to create the UHC/AACN Nurse Residency Program. The
post‐baccalaureate program based on Dreyfus’ model of skill acquisition, was
created to assist the new graduates’ transition into their first professional role.
The program includes seminars based on a standardized curriculum, evidence
based practice classes, clinical experiences under the guidance of a preceptor
and access to nurse resident educators who provide support and guidance in
role development. Essential elements of the program include a core curriculum
used throughout the residency year
The objectives of the program are to:
• Make the transition from beginner to competent professional nurse
in the clinical environment
• Develop effective decision making skills related to clinical judgment
Top to bottom:
and performance
Mary Blessing, Nicole
Weimer. Not pictured:
• Provide clinical leadership at the bedside
Donna Winn & Andrea
• Strengthen commitment to nursing as a professional career choice
de Chadenedes.
• Formulate an individual development plan
• Incorporate research‐based evidence linked to practice outcomes into the care provided
243 baccalaureate‐ prepared new graduate nurses and 205 associate degree graduates have completed
the residency program since 2002. Additionally 51 baccalaureate prepared nurses have continued their
education to the graduate degree level and 30 associate degree nurses have enrolled in a RN‐BSN
program. One nurse resident has completed a PhD program and one is currently enrolled in the
BSN‐PhD program.
One year retention of residents is 94% compared to 95.5% retention for all UHC/AACN sites for the
same time period. Five year retention is 90%. The most common reason for leaving is relocating out
of the area.
We applied for Post‐Baccalaureate Nurse Residency Program accreditation through the Commission on
Collegiate Nursing Education (CCNE) and had our site visit October 2010. The on‐site evaluation team
provided us with excellent feedback and as a result we submitted further information to CCNE. The
team report and our response was considered by the Residency Accreditation Committee in March 2010
and their recommendation will be considered by the CCNE Board at its meeting on April 14, 2011.
We will know their decision within 30 days of the meeting!
~ Mary Blessing RN ♥
34

ANNUAL NURSING REPORT 2010 — FINANCE
Finance
Working Mother Magazine Names UNM Hospitals
to Best Companies for Hourly Workers List
List Highlights Best Practices & Sets Benchmarks
Part of a pioneering group of honorees, UNM Hospitals has been named to the first‐ever Working
Mother Best Companies for Hourly Workers list. Honoring companies that believe in offering familyfriendly
programs like flextime, training and benefits to all employees, the Best Companies for Hourly
Workers is an adjunct to the renowned Best Companies program, setting a new standard for best
practices among companies whose workforce consists of more than 50% hourly workers.
“Particularly in this era of severe cost‐cutting measures, companies tend to overlook the long‐term
value of family‐friendly benefits — but we find these programs increase productivity and decrease
turnover at all job levels,” said Carol Evans, President, Working Mother Media. “Our Working Mother
Best Companies for Hourly Workers are leading the way for innovative and responsible employee
practices, and we urge others to follow their strong example.”
For UNM Hospitals and 100% of this year’s Best Companies for Hourly Workers winners, that example
includes offering hourly workers benefits such as health insurance and company‐matching 401(k), as
well as paid vacation and sick days, tuition assistance and flexible
spending accounts.
“We’re honored to be a part of this inaugural list,” says UNM
Hospitals CEO Steve McKernan, “because we know our hourly
employees are a strong and integral part of our 24/7 workforce.
Staff members at UNM Hospitals are our greatest asset in
providing all members of our community with accessible,
quality healthcare.” ♥
CEO Steve McKernan holds the
trophy UNMH recently received from
Working Mother magazine. UNMH
was one of six organizations in the
nation named Best Company for
Hourly Workers for 2010.
35

ANNUAL NURSING REPORT 2010 — GROWTH
Patient Centered Medical Home
Patient Centered Medical Home is a way
to provide comprehensive, integrated
primary care for children, youth and
Growth adults that is based on the relationship
between the patient and the primary
care provider, and is intended to improve the patient’s overall health.
The National Center for Quality Assurance states, “The Patient Centered Medical Home” is a healthcare
setting that facilitates partnerships between individual patients and their personal physicians and, when
appropriate, the patient’s family. Care is facilitated by registries, information technology, health
information exchange and other means to assure that patients get the indicated care when and
where they need and want it in a culturally and linguistically appropriate manner.”
What are the Core Expectations Developed by UNMH for this Model?
1. Personal Provider: Ongoing relationship with primary care provider trained to provide initial,
continuous and all inclusive care.
2. Provider Directed Medical Practice: Primary care provider leads a team of health care individuals
who collectively partner with the patient to provide comprehensive care. Additionally, each team
member will work at the capacity of their scope of practice.
3. Whole Person Orientation: Focus on whole person, the physical, mental and social person, from
birth to death, for preventive, acute and chronic care needs.
4. Care is Coordinated and/or Integrated: Care is coordinated across the entire health care system
and patient’s community to assure patients receive the indicated care when and where they need
and want it and is culturally and linguistically appropriate.
5. Quality and Safety: Decisions are made based on evidence‐ based medicine, focus is on patientcentered
outcomes that are defined by a care planning process, and patients are involved in the
continuous performance measurement and improvement processes.
6. Enhanced Access: Care is available through open scheduling, expanded hours and electronic
options to communicate with providers and practice staff.
7. Cost Effective: Payment reform is needed in addition to providing well organized, coordinated,
integrated care based on continuous relationships.
36

ANNUAL NURSING REPORT 2010 — GROWTH
How Do We Plan to Implement the Patient Centered Medical Home?
Overview of Implementation Plan
Phase I
June 2009-July 2010
Phase II
July 2010-July 2011
Phase III
July 2011-July 2012
Infrastructure &
Design
Design the basic PCMH
Infrastructure & begin
implementation at UNMH
Primary Care Sites.
Enhance Infrastructure and
refine /expand design.
Complete all stages
of design.
Implementation
Trial & validate components
of the PCMH model at one
primary care site. Make
recommendations for
implementation at other
sites.
Use recommendations
from trial to implement
processes within at least
50% of Primary care sites.
Complete implementation
in all adult Primary Care
practices.
Integration
Begin engagement of
Primary care residents in
the PCMH.
Develop outreach
programs with specialties,
the School of Nursing, the
School of Medicine and
the Primary Care residency
programs.
Fully integrate the PCMH
model into specialties,
school of nursing, medical
school and residency
programs.
Funding
Initiate exploration of
funding opportunities.
Continue pursuing
various funding
options.
Aggressively pursue
state and federal funding
opportunities.
PCMH
Recognition
Obtain NCQA level 1
recognition for adult
primary care.
Obtain level I recognition
for Pediatrics.
Obtain NCQA level II recognition
for applicable sites.
Obtain NCQA levels II or III
recognition for applicable
sites.
37

ANNUAL NURSING REPORT 2010 — GROWTH
What Have We Accomplished?
Core Expectations
Identifiable
Leadership
Team Based Care
Population Risk
Stratification and
Management
Phase I
• Participated on Implementation Team
• Completed Transformed leadership “Readiness to Change”
• Submitted NCQA application Level I
• Trialed Planned Visit
• Developed Standing Orders
• Piloted team based care in 3 clinics
• Defining roles and responsibilities of all team members
• In the process of Proposing team model
• Defined Chronic Disease Guidelines 5 key conditions
• Piloted Motivational Interviewing training
• Provided diabetes foot check training
• Patient panels reviewed by all providers and are current
• Defined Problem List & populate historical info.
• Problem List active with plan to keep current
• Developed Registry
• Registry reports given to providers
• Developing Mutual Goal Plan tool
assessment.
Integrated Care
Management
Enhanced Access to Care
Inclusion of Patient and
Families
Cost Effective
Integration of Health
Information
Technology
• Wrote protocol for patient “No Show”
• Writing protocol for patients being discharge to outpatient care
• Continuing to track third available
• Identified advanced access principles and guidelines
• Patient Advisory Board formating in all clinics
• Piloted Krames patient educational software
• Plan to educate patients on rollout plan
• Beginning to develop staffing analysis
• Submitted PQRI
• Explored funding opportunities, submitted proposals accordingly
• Submitted BCBS proposal
• Will define financial indicators and quality dashboard
• Developed inpatient to outpatient electronic notification system
• Tested electronic MSummary pages
• Developing algorithms for Condition Management page
38

ANNUAL NURSING REPORT 2010 — GROWTH
What Do We Plan to Do in Phases II and III to Implement PCMH?
Phase II
• Select one provider leader each clinic
• NCQA application Level II & III
• Create staffing model
• Implement standing orders
• Implement team based care in all clinics
• Refine roles & responsibilities of team members
• Utilize Registry data to improve patient outcomes
• Automate mutual goal plan & implement use in all clinics
• Provide Motivational Interviewing training at clinics
• Develop mechanisms for tracking consults and diagnostic referrals
• Integrate PCMH Care Management Services
• Define for patient after‐hours phone access
• Define global access standards
• Define standard & measurement of language
services for English proficiency
• Roll out patient education plan for each clinic
• Implement modified LEAN training principles
• Refine PCO to include clinic “Home” and PCP
• Optimize “Health Maintenance Module”
• Create mechanism to score cardiovascular risk
• Implement M pages
• Create Integrated Care Management tool
Phase III
• Continuously evaluate process,
structure and practice performance
data and share results with
providers and staff
• Develop forum for various team
to share best practices
• Develop Outcomes Dashboard to
aid providers with population
management
• Develop a network to share health
information with outside facilities
• Schedule based on patient’s request
• Offer E‐Visits
• Build Patient Portal
• Have a patient Wellness Conference
• Develop PCMH Newsletter
• Offer web‐based education for
Self‐Management
• Continue to monitor cost effectiveness
• Implement Cerner scheduling
• Program email field with auto
appointment reminder
• Implement Patient Portal
• Enhance E‐prescribing
• Enhance registration, include patient
vision and language preference in
Cerner
• continued, next page
39

ANNUAL NURSING REPORT 2010 — GROWTH
What Do We Expect after We Have Implemented the Patient Centered Medical Home
initiative?
1. We expect that patients with chronic health issues will have improved clinical outcomes such as
improved blood pressure, diabetes indicators etc.
2. We expect to partner with our patients and encourage their self‐management skills.
3. We expect that access will be somewhat improved in that when patients call the
primary care clinics they will be able to get an appointment with their primary care provider or team
member when they want the appointment.
4. We expect the quality of care provided to our patients to be considerably improved and patients
will report their satisfaction with our medical homes by scoring us higher in our patient satisfaction
surveys (in the 90% range).
5. We expect staff and providers will be more satisfied with their jobs, staff will be working at the top of
their licenses/certificates and will enjoy developing a lasting relationship with their patients. Providers
will find their clinic practice less burdened with non‐provider tasks which will encourage them to stay
in family practice.
6. We expect medical students and residents to enter and stay in family practice. ♥
Eight UNMH Clinics and 50+ UNMHSC Providers Receive First NCQA Level 1 PCMH
Recognition in NM
In August 2010 the National Committee for Quality Assurance (NCQA) recognized UNMH with their
Physician Practice Connections — Patient‐Centered Medical Home Level 1 Recognition. These clinics:
• Primary Care Family Health, 1209 University NE
• Primary Care Family Health, Westside
• Primary Care Family Health, 2400 Tucker NE
• Primary Care Family Health, Northeast Heights
• Primary Care Family Health, Southeast Heights
• Primary Care General Medicine Clinic
• Primary Care Medicine Faculty Clinic
• Primary Care Senior Health Clinic
along with more than 50 physician partners, were named to the
group’s clinician directory, intended to help individuals find doctors who have demonstrated that they
meet important standards of care. Visit http://recognition.ncqa.org/ to see all of the Level 1 designees
(and note that UNMH is the only listing for NM!). ♥
40

New Knowledge, Innovation & Improvements: Initiation of Large-Volume IV Pumps
We began the search for replacements of our large
volume IV pumps three years ago with a goal of
improved patient safety and the ability to advance
the pump’s functionality looking toward electronic
documentation. Our current pumps had reached
their end of life and we were unable to obtain
replacement parts for them. Yvonne Tanuz‐Trujillo,
Value Analysis Facilitator, was very instrumental in
collating this data for our organization.
ANNUAL NURSING REPORT 2010 — GROWTH
A multidisciplinary task force was formed and met with Alaris®, Hospira®, and B. Braun® Medical to review
their safety features and their ability to connect to the Cerner system. One company stood out as having no
FDA recalls on IV pumps in history, and as having the safest pump on the market. B. Braun Medical has been
our business partner for many years with a good history of responsive customer service and great pricing for
the organization — we have used their pumps, tubing and IV fluids for the last 18 years. We chose their
newest product called Infusomat Space infusion system. These pumps have been used in Europe for more
than 10 years with a good safety history.
A drug library is a list of IV medications sorted by patient types called clinical care areas (CCAs) such as
critical care/ ED, SAC, obstetrics, peds, etc., which makes it easier for the nursing staff to find their most
frequently used medications on the pumps. Pharmacy compiled the drug library list adding the highest risk
and most frequently used IV medications. Expert UNMH nurses from the different care areas reviewed the
lists for accuracy to ensure contents of libraries are reflective of current clinical practice. Once the lists were
reviewed, the drug library was loaded on the 1500 pumps.
Mandatory training for all nurses who use the pumps took place over a one week period in November 2010.
Classes were held around the clock to allow for night shift nurses to take classes during their regularly
scheduled shifts. B. Braun product educators taught 1,460 nurses how to use the new pumps, with 440 of
those nurses trained on the night shift. Thanks so much to Clinical Education staff: Sue McReynolds, Joan
Deis, and Melanie Duran for their ongoing support of this educational process!
On November 9, 2010, more than 50 individuals formed four teams to switch out current IV pumps for the
new Space pumps while keeping all patients safe. Team members from the Nursing Division included Lisa
Sena, Susan Harrison‐Salt, Joanna Garcia, Felicia Pugh, Terry Young, Tina Gonzales, Zach Pickett, Carissa Silva,
Jeff Sillivent, Stephanie Hess, Paula Stulce, Theresa Wunsch, Jaclyn Trujeque, Jassmine Safier, Steve
Trammel, and Karen Lermuseaux. From Clinical Engineering: Shasta Carrol‐Sonnabend, Tim Suchla, Raul
Corona, and Gwen Brogdon; backed up by Darren Shotwell, Eddie Bachicha, and Hector Sanchez. From
Materials Management: Ted Schreier, Thomas Yarbrough, Robert Brittenham, and Mary Legler, backed up by
Art Luna and Jim Shepherd. UNMH staff that helped the pump deployment teams at the last minute: Larry
Lucero, Food and Nutritional Services, and Housekeeping Services to include Victoria Rodriguez, Hermelinda
Gonzalez, Irma Gonzalez, Darlenys Acosta and Leslie Moon, to whom we are very grateful for their help!
B. Braun nurse educators were in house 24 hours a day during the week following the pump deployment.
There were available by phone to answer questions the nursing staff had to ensure safe patient care. They
shared recurring issues, which were shared with UDs. Since the training was mandatory they could spend
their time refining the nurses’ knowledge for troubleshooting issues. Then,
123 UNMH nurses were trained as pump champions — now onsite nurses
who will train new staff upon hire or transfer and help with questions.
Congratulations to all in this very successful equipment conversion! ♥