2008 Nursing Annual Report - Delnor Hospital

of Nursing at Delnor
2008 Nursing Annual Report

Art + Science

Contents
Alpa Thaker, RNC, MSN
Letter: The Art + Science
of Nursing at Delnor......................... 2
Shared Decision Making
Accomplishments 2008 ...................... 3
Delnor Receives
Magnet Re-Designation.................... 4–5
Largest Expansion in
Delnor History Focuses
on Patient-Centered Care .................. 6 –7
E-Learning =
Easy, Efficient Education..................... 8
L.E.A.P. into
Evidence-Based Medicine.................... 9
Teamwork Reduces
Patient Infection Rates. ................. 10–11
Delivering Safer
Narcotics ................................. 11
The Best Practice of
Bedside Reporting ...................... 12–13
Music to Her Ears....................... 14–15
Healing in a Heartbeat................... 16–17
Measures of Clinical
Excellence............................. 18–20
Nursing Professional
Practice Awards ........................... 21
Hospitalists and Nurses
Have Strong Bond....................... 22–23
On the Horizon. ........................... 24
2008 Nursing Annual Report
1

Art + Science
“At Delnor, the
Art of Nursing
sometimes seems
an inherent
quality, evident
in the high
level of caring
demonstrated
by the nurses we
recruit into our
organization.”
Lore Bogolin, RN, MSN
Chief Nursing Officer and
Vice President of Patient
Care Services
Dear Colleagues:
We are pleased to share our 2008
Delnor Hospital Nursing Annual
Report with you. Its success stories
and data alike chronicle the journey our
nursing staff and their clinical partners
have taken this year in the pursuit of
service excellence and quality of care.
Our annual report theme, “The Art and
Science of Nursing,” is a title that represents
the importance of both high-tech and hightouch
in the nursing profession. At Delnor, the
Art of Nursing sometimes seems an inherent
quality, evident in the high level of caring
demonstrated by nurses in our organization.
And the Science of Nursing is equally demonstrated
by those Delnor nurses who pursue
the advanced technology and research necessary
to impact clinical outcomes.
One demonstration of the marriage of Art
and Science within our organization is our new
patient bed tower, which opened to patients
this summer. This new 52-bed private room
addition was designed with the Planetree philosophy
of patient-centered care in mind. From
its décor to its technology, everything about
the addition focuses on healing and wellness,
not only for patients and their family members,
but also for the nurses who work on the new
units each and every day.
In the weeks following the grand opening
of the addition, Delnor was named the first
Patient-Centered Planetree Hospital in
Illinois, and only the third to receive Magnet
Re-Designation by the American Nursing
Association. It is a rare hospital that can boast
about so many achievements, all in the same
year! Many thanks to our Board of Directors,
Chief Executive Officer Craig Livermore and
President Tom Wright for their ongoing support
of our nursing profession.
Even as we look back with pride at the
accolades of our staff in 2008, we look forward
to a new year of dedication to the patients that
we serve.
Lore Bogolin, RN, MSN
Chief Nursing Officer and
Vice President of Patient Care Services
2008 Nursing Annual Report
2

Shared Decision Making
Coordinating Council 2009
Shared Decision Making Accomplishments 2008:
The 2008 accomplishments of our five Shared
• Revised Joint Commission “Red Team”
• Developed new Continuing Nursing Education
Decision Making Councils (SDM) are many.
readiness
(CNE) policy
Key highlights include:
• Collaborated with evidence-based medicine
• Collaborated with human resources department
• Developed bedside reporting process that allows
initiatives
to provide preceptor differential bonus and to
RN-to-RN handoff
• Developed the Planetree Care Partner Program
develop certification and degree bonus program
• Expansion of methicillin-resistant staphylococcus
aureus (MRSA) protocol screening to include all
inpatients
• Enhanced Hand Hygiene Policy, Isolation
Observation Studies and Project Zero
• Planned Nurses Week activities and celebration
led by our SDM Councils
• Assisted with the successful Planetree
Designation process (Care Partner Program,
Open Medical Record Policy and Patient Plan
of Care)
• Implemented e-learning system (Healthstream)
• Participated in the application and site visit
required to become an Accreditation Provider
for contact hours through The American Nurses
Credentialing Center
• Provided input on hospital dress code revisions
• Restructured the SDM Newsletter
• Actively participated in the Magnet Re-Designation
process
2008 Nursing Annual Report
3

2008 Nursing Annual Report
4
Delnor Receives
Magnet Re-Designation
Susan Herrmann, RN, MSN, Director of Professional Practice
and Magnet Project Coordinator; Lore Bogolin, RN, MSN, Chief
Nursing Officer and Vice President of Patient Care Services
This fall, Delnor nurses discovered
a truth in the old adage: sometimes
it is better the second time
around. In September 2008, a group
of nursing leadership huddled in a
crowded conference room awaiting
a call from the American Nursing
Association’s Magnet credentialing
center. Even though the moment
was months in the making, when the
phone rang the response was not
anti-climatic. The room erupted into
applause and tears as the conversation
was played out loud on speaker
phone: Delnor had received redesignation
as a Magnet hospital
for another four years.
Delnor was the first non-academic medical
center in Illinois to receive Magnet designation
in 2003 and now joins Rush University Health
System and Children’s Memorial of Chicago
on a short list of organizations that have had
the prestigious designation reconfirmed for
another four years.
The Magnet Recognition Program ®
was developed by the American Nurses
Credentialing Center (ANCC) to recognize
healthcare organizations that provide nursing
excellence. A subsidiary of the American
Nursing Association, the ANCC is the world’s
largest nursing credentialing organization.

“We are so proud of this outcome because
it recognizes our sustainability,” says Chief
Nursing Officer Lore Bogolin, RN, MSN. “Earning
Magnet re-designation meant going above and
beyond the work that Delnor accomplished four
years ago. That speaks to our ongoing commitment
to nursing excellence.”
Hospital president Tom Wright agrees.
“The culture of nursing excellence at Delnor
continues to elevate the level of patient care
that we provide to the communities we serve,
and has been the driving force behind our
consistently stellar marks in patient, physician
and employee satisfaction.”
As Sue Herrmann, RN, MSN, Delnor’s
Director of Professional Practice and Magnet
Project Coordinator knows, every time an
organization applies for Magnet status the
experience is unique. Organizations that have
achieved Magnet in prior years are not guaranteed
approval in future attempts.
“I believe that re-designation is even
more stringent; it becomes more challenging
to score high marks in the areas of innovation,
creativity and outcomes because they
expect a higher level of performance once you
have achieved Magnet an initial time,” says
Herrmann.
“At the same time, I think that re-designation
is even weightier than getting Magnet
status the first time around,” says Herrmann.
“It shows that you have maintained a culture of
excellence, and that it has permeated the organization,
not just during the Magnet application
process, but every day and at every turn.”
The process of Magnet re-designation
application was a collective effort by more
than 50 Delnor staff members, including a
writing team of 25. “The way we approached
the application process was much like we
approach patient care everyday at Delnor,”
says Bogolin. “We did so systematically,
thoroughly, and as a team. The resulting
re-designation is an honor shared by all of
our nurses and the many patient care staff
at Delnor who come together each day to
provide our patients with an exemplary level
of care.”
Recognizing quality patient care, nursing
excellence and innovations in professional
nursing practice, the Magnet Recognition
Program provides consumers with the ultimate
benchmark to measure the quality of care that
they can expect to receive.
“Earning and maintaining Magnet status
should be a sign to our patients that they
are being cared for in a facility honored for
its nursing excellence, and that they should
expect to receive the highest level of care
every time they are with us,” says Herrmann. n
“Earning Magnet
re-designation
meant going above
and beyond the
work that Delnor
accomplished four
years ago. That
speaks to our
ongoing commitment
to nursing
excellence.”
Lore Bogolin, RN, MSN
Chief Nursing Officer and
Vice President of Patient
Care Services
Re-Designation
2008 Nursing Annual Report
5

Largest Expansion in Delnor History
Focuses on Patient-Centered Care
2008 Nursing Annual Report
6
After nearly two years of planning
and construction, Delnor opened
its largest addition in the hospital’s
history in July, 2008. The three-story,
100,000-square-foot expansion adds
52 new patient beds to the hospital.
“As the population of our service area has
grown, so has the demand for medical care,”
says Roger Harris, Chairman of Delnor’s Board
of Directors, noting that Delnor’s average daily
census during the past five years has risen by
nearly 40 percent.
As part of Delnor’s commitment to caring
for the whole patient, the addition was built
after painstaking research into best practices
in hospital design and patient comfort. This
fall, Delnor became the first hospital in Illinois
and only one of six in the nation to receive
a Patient-Centered Hospital Designation by
Planetree, a non-profit organization devoted
to helping hospitals provide patient/familycentered
care within a healing environment.
With Planetree principles in mind, creating
a space that was healing to the mind, body
and spirit became the chief intent during the
planning and construction of the new addition.
All patient rooms are private and
feature natural lighting, beautiful furnishings,
a large bathroom, and a sleeper-sofa for
family members.
Research shows that patients in private
rooms heal faster, and are more at ease in
space that feels less clinical and more like
home,” says Lore Bogolin, RN, MSN, Delnor’s
Chief Nursing Officer. “Simply put, attention to
patient comfort is good medicine.” The addition
also includes other innovative features for
patients and their families, including lounges
with fireplaces, balconies, water features, skylights,
a full kitchen and wireless Internet.
The expansion also includes the latest in
medical technology and equipment, such as
an advanced nurse call system that will send
alarm notification to a nurse’s portable phone
when a patient has an immediate need; barcode
scanners to verify medications; special
lift systems that make it safer for nurses to
move patients from bed to chair to bathroom;
and an electronic board on each medical unit
that lists patient preferences and information. n

Julie Brown, RN
Patient-Centered
7

Education
“This allows nurses
to engage in new
learning when
their concentration
is the highest
and materials are
at hand, making
the process easier
for everyone.”
Susan Herrmann, RN, MSN
Director of Professional
Practice and Magnet Project
Coordinator
E-Learning =
Easy, Efficient Education
Over the past year, many changes
to traditional nursing education
have taken place at Delnor. One of
the innovative and creative ways our
nurses now learn is through the electronic
system Healthstream.
Healthstream is a new system that has
placed mandatory learning units such as
policy revisions, national patient safety goals
and annual safety courses into e-learning
modules. Other voluntary modules are available
for those who wish to enroll in a course
and complete them at their leisure. The system
can be accessed internally via the hospital
employee portal or externally through an
Internet web address.
The result has been increased efficiency,
scheduling and convenience. Delnor nurses are
able to pace their continuing education, and
complete it at a time that is most convenient for
them. Leaders can take advantage of improved
attendance tracking, report functionality, ability
to perform needs assessment and surveys, and
competency testing.
“Frequently you hear nurses say that they
sat at home in their sweats or PJ’s, drinking
coffee and doing their learning modules,” says
Sue Herrmann, RN, MSN, Delnor’s Director
of Professional Practice and Magnet Project
Coordinator. “This allows them to engage in
new learning when their concentration is the
highest and materials are at hand, making the
process a win-win for everyone.” n
2008 Nursing Annual Report
8
C e r t i f i c at i o n s
a n d D e g r e e s 2 0 0 8 :
Life-long learning and continual
education is embraced and supported
at Delnor. Congratulations to the
following Delnor Nurses who have
accomplished certifications and
degrees in this fiscal year.
Master in Science
Pat Rogers
Kim Thomas
Marcie Fedderson
Brian Poynor
Theresa Sweetman
Certified Healthcare
Financial Professional
Karin Podolski
Medical-Surgical
Certification
Bethanie Akers
Amy English
Lisa Kramer
Fonda Rowe
Case Management
Dawn Wigstone
Jeannine Harvell
Elizabeth Cranford
Susan Melton
Gina Malamos
Certified Pediatric
Nurse
Irene Saucedo
Home Care Coding
Specialist-Diagnosis
Delores Mayo
Informatics
Certification
Jean Blazey

“At Delnor, we
want our patients
to know that their
care adheres to
the most current
quality and safety
guidelines, developed
through
extensive research
of best practices.”
Sue Beck-Sheridan, RN, MSN,
Quality Informatics Analyst
L.E.A.P. into
Evidence-Based Medicine
In the past year, Evidence-Based
Medicine (EBM) has been a strategic
focus for Delnor Nurses. The
acronym L.E.A.P. translates into
Letting Evidence Advance Practice,
and serves as a reminder that the
principle impacts our nursing practice
at every turn. Our commitment to
evidence-based practice is part of the
promise we make to our patients that
the care they receive will be based
on the most current clinical standards
available. “We want our patients to
know that their care adheres to the
most current quality and safety guidelines,
developed through extensive
research of best practices,” says Sue
Beck-Sheridan, RN, MSN, Quality
Informatics Analyst.
This commitment has also driven change in
the way we deliver patient care. Most recently
a team from Nursing, Quality and Education
collaborated to manage the changes made
in patient order sets. “A standardized template
was developed that helped us understand the
reasons behind each change,” says Beck-
Sheridan. “We have learned that when the
reason is clear, it is easier to get everyone to
buy into it.”
Once the standardized approach to order
set was developed, communication and
education were provided on its use. “This
supports the hospital clinician and physician,
and provides stability for successful implementation
and utilization,” says Beck-Sheridan.
The team used Employee Portal Nursing
update meetings, Physician Portal meetings,
unit-based bulletin boards, staff educators and
one-on-one sessions to reach all of the nursing
staff. “The third Tuesday of each month has
been designated as the day all new order sets
or computerized screen changes are released.
This allows staff to be prepared,” says Beck-
Sheridan. “Overall, the change has been great
for everyone...being on the cusp of innovation,
research and practice is exciting.” n
L.E.A.P. into EBM
2008 Nursing Annual Report
9

Teamwork
Karen Rhodes, PharmD
and Scott Helm, MD
2008 Nursing Annual Report
10

Teamwork Reduces
Patient Infection Rates
At Delnor, our nurses are committed
to working with our physicians
and staff to decrease patient infection
rates. That commitment has led to a
number of specific initiatives, which
include protocols specific to MRSA
infection, new policies related to hand
hygiene and administration of antibiotics
prior to surgery.
Administering antibiotics prior to surgery
was a joint effort made possible by a team of
nurses, physicians and pharmaceutical staff.
“We determined that there was an opportunity
to reduce post-operative surgical infections
by making sure patients were given the appropriate
antibiotic, and at the right length and
time,” says Karen Rhodes, PharmD, Director
of Pharmacy. “The challenge was that all physicians
had their own order set, and everyone
was doing things differently.”
Working with a team of nurses, Rhodes
and anesthesiologist Scott Helm, MD, PhD,
developed a standard protocol for the
administration of antibiotics to all Delnor
surgical patients. “The process of getting
everyone on board and educating them was
a long one,” says Rhodes. “But in the last
six months we have finally received the results
we were looking for, and have significantly
reduced post-operative infection.”
“The process we developed involves the
pre-operative nurses, the nurse anesthetist,
and the surgical operative team,” says Dr.
Helm. “It is testament to the culture at Delnor
that we were able to bring nurses and physicians
together to work collaboratively on this
project for the good of the patient.”
Helm explains that he took accountability
for making certain that all physicians agreed
regarding which antibiotics to give, and when
to give them. “Before we addressed this
together, it was not a defined process,” he
says. “Now we have several checkpoints
along the way to make certain that antibiotics
are delivered prior to incision. In the past,
that happened only 50–60 percent of the time.
Now we are at 95 percent.” n
Members of the Narcotic Safety Team:
Lynn Skelton, RN, CIC; Steven Lewis, MD
and Marjie Schoolfield, BSN, OCN, ONC, CNRN
D e l i v e r i n g S a f e r
Narcotics
The Narcotic Safety Team (NARCS), is a subcommittee
of the Medical Safety Team, formed in
response to the Save 5 Million Lives From Harm
campaign. In 2008, the team composed of Scott
Helm, MD, Karen Rhodes, PharmD, Dee Dodd,
RN, BSN, and Linda Steffens, RN, BSN, CCRN,
was challenged to reduce the risk of patient harm
from high-risk narcotics and sedatives.
Extensive research indicated that different narcotics
and sedatives were to blame for adverse respiratory
reactions, but that most often the culprit
was Dilaudid. The team launched an education
campaign for both nurses and physicians to inform
them of the findings, created signage promoting
Dilaudid safety and developed an analgesic
equivalency tool for nurses.
Future initiatives will include the development
of standardized patient-controlled analgesia
(PCA) forms, and potentially the addition of risk
factor assessment and screening for obstructive
sleep apnea.
2008 Nursing Annual Report
11

The Best Practice of Bedside Reporting
Last fall, Delnor nurses were
charged with the challenge of
improving the end-of-shift-handoff
reporting process at the patient bedside.
By streamlining and improving the
system, we hoped to improve patient
safety, outcomes, increase efficiency
and ensure greater accountability.
Members of our Shared Decision Making
(SDM) Practice Council formed a smaller
task team of nurses led by Christine Gish,
RN, BSN to conduct research and a literature
review of best practices in this area. It was
during that research that we discovered the
concept of bedside reporting; a philosophy
that fit with Delnor’s Planetree patient-centered
care nursing practices. “With the patient at
the center of everything we do, the concept
of giving the end-of-shift report at the bedside
to the new nurse who is responsible for that
patient’s care, and involving the patient in the
plan of care by sharing information as a team
just made sense,” says Gish.
The team developed a process for bedside
reporting that could be initiated in five
minutes or less, and included the completion
of the Situation, Background, Assessment and
Recommendation (SBAR). Currently the initiative
is being followed on all Delnor’s medicalsurgical
units, as well as pediatrics, NewLife
Maternity and post-anesthesia recovery.
While goals have been met, establishing the
process has been challenging. “Barriers had
to be overcome,” says Gish. “We have had to
become more comfortable talking about the
patient in front of the patient, which is something
that we have not done in the past. We
have also learned to hold each other accountable
for continuing the process.”
As a result of bedside reporting, positive
change has occurred in the patient/nurse
relationship. “Because of bedside reporting
the patient now knows when the change in
shift is occurring and can connect with their
new care giver almost immediately,” says
Gish. “And bedside reporting has enhanced
patient satisfaction results (Press-Ganey and
HCAHPS), indicating that increased communication
with our patients has increased their
overall satisfaction.” n
The Bedside Reporting Checklist
2008 Nursing Annual Report
12
• Conduct a focused assessment,
asking the reason for admission/transfer
• Monitor intake and output
• Check and address pain medication level
and pain medication
• Examine dressing and tubes
• Review pending or out-of-the-ordinary
tests and/or results
• Discuss the plan for upcoming shift
(testing, goals, etc.)
• Review discharge plans to date

Becky Shields, RN, BSN; Nikki Corken
with baby Kelsey Corken; Laura Jahn, RN
Bedside Reporting
13

Music + Medicine
Stephanie Kleba, MT-BC, NICU-MT
with patient Elida Ortiz
14

Music to Her Ears
Aurora resident Elida Ortiz has
struggled with fibromyalgia pain
for years. Due to allergies to pain
medication, there are not many things
that provide her with relief from her
unrelenting discomfort—with the
exception of the music therapy program
she has discovered at Delnor. “I
am so grateful for it,” she says. “I have
been able to learn to relax a bit, and
during those times the pain almost
disappears.”
The Music and Medicine at Delnor program
is led by certified music therapist Stephanie
Kleba, MT-BC, NICU-MT. “Music is my heart,”
she says. “It is a wonderful feeling to be able
to connect with patients and help reduce their
pain by doing something that I love to do.”
Kleba has been a music therapist since
1990 and has spent her career in healthcare.
She began her college education specializing
in music with a minor in psychology, eventually
combining the two. Since then, she completed
her board certification in music therapy.
“When I am hospitalized, the first thing that
I do is ask for Stephanie,” says Ortiz. “She
knows my struggle and always seems to be
able to get me through it.”
Ortiz links her fibromyalgia to growing up
in Texas across the street from a pesticide
plant. “I was always sick,” she remembers.
“But back then, I had to walk many miles just
to get to school, and the exercise helped.
Today, I am limited in what I am able to do
physically.”
That is where music comes in. The music
therapy sessions that Ortiz experiences at
Delnor include relaxation and calming techniques,
as well as music individually chosen
for her. “Stephanie gave me a New Age CD
recording recently that was just perfect,” says
Ortiz. “It is amazing how the music can help
you handle the pain so much better than you
would have been able to otherwise.” n
“It is amazing how
the music can help
you handle the
pain so much
better than you
would have been
able to otherwise.”
Elida Ortiz
Music & Medicine patient
2008 Nursing Annual Report
15

Healing in a Heartbeat
“I was diagnosed while I was still
five minutes away from Delnor.
They were already waiting for
me in the cardiac catherization
lab when I arrived.”
Rick Muno, cardiac patient
“Eight years prior I had suffered
a heart attack, was brought to
Delnor and had a stent inserted,
so I knew what the pain was.”
Rick Muno, cardiac patient
Elburn resident Rick Muno had
just returned from a game of
golf in May 2008 when he began to
experience chest pain. “Eight years
prior I had suffered a heart attack,
was brought to Delnor and had a
stent inserted, so I knew what the
pain was,” he says.
Thankfully, his wife Kathy, who is a Delnor
pharmacist, knew as well. She called 911,
administered aspirin and prepared her
husband for transport. When the paramedics
arrived, they started him on an EKG heart
monitor in route, and also began nitroglycerin
treatment. “I was diagnosed while I was still
five minutes away from Delnor,” says Muno.
“They were already waiting for me in the cardiac
catherization lab when I arrived.”
The speed in which Delnor emergency
room nurses and staff were able to treat
Muno was life saving. “It was just 16 minutes
from that 911 call until I was in the cardiac
catherization lab,” he says. “They first did an
angiogram to diagnose which part of the heart
was involved, and then they completed the
angioplasty and put an additional stent in. In a
matter of 90 minutes, the whole thing
was done.”
The efficiency of Muno’s treatment also
left his heart healthier than it might have been
otherwise. “Because my case was handled so
quickly, I was told that there was no residual
damage to my heart,” he says.
Muno left Delnor’s Critical Care Unit in just
three days, although he returned two weeks
later for an additional stent. “They realized that
I needed follow-up in another area, so I came
back in again for an additional procedure,”
he remembers.
He says he looks back on the experience
with gratitude for his nurses and physicians.
“I can’t think of one that I wouldn’t say was
lovely,” says Muno. “They knew their jobs, and
did them in a spectacular fashion.” n
2008 Nursing Annual Report
16

Rick Muno, cardiac patient
Cardiac Cath Lab
17

Measures of Clinical Excellence
Quality at Delnor is defined as
demonstrated improvement in the
lives of our patients and community,
resulting from measurable and continual
progress of healthcare services
that aim to be safe, effective, patientcentered,
timely, efficient and equitable.
In order to meet these objectives, Delnor
nursing staff and leadership participate in
a plethora of performance improvement
and quality initiatives, and are committed
to achieving exceptional quality outcomes.
“We strive to make improvements, raise the
bar and seek the best,” says Lore Bogolin,
RN, MSN, Delnor’s Chief Nursing Officer.
Delnor measures clinical excellence through
benchmarks and comparison data at local,
regional and/or national levels. The Illinois
Hospital Association, Institute for HealthCare
Improvement, and the Center for Disease
Control are a few of the organizations that
analyze and assess our performance based
on results and outcomes.
Hospital Acquired Pressure
Ulcers (HAPU)
At Delnor, the evidence-based Braden Scale
has been used to assess patients’ skin since
2004. Our diligence in conducting these skin
assessments upon admission and at every
shift, combined with perfected processes and
systems, has resulted in sustainability of HAPU
outcomes well below national benchmarks.
To maintain these stellar results, Delnor
Wound and Skin Team members conduct
monthly randomized checks and participate
in quarterly prevalence studies. Monthly and
quarterly results are posted and shared in our
transparent environment.
Falls
Delnor uses the Hendrich ii Fall risk model
for adult patient populations and the Graf-PiF
scale for pediatric populations, both evidencebased
assessment tools that assess each
patient at each nursing shift for risk of falls.
Standard safety measures are in place for
Hospital Acquired
Pressure Ulcers
FY 08
Delnor
National
Fall Rate Index
NDNQI Comparison
FY 08 Delnor National
Falls with
Injury Rate
FY 08 Delnor National
Hand Hygiene
Nursing Staff
FY 06 – FY 08
Pneumonia
Vaccination Rate
FY 08
Delnor
Others
2008 Nursing Annual Report
11.0%
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
2.81
Delnor
Critical Care
9.90
National
Comparison
2.06
Delnor
Med-Surg
4.80
National
Comparison
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
1.44 1.38
Delnor
Critical Care
National
Comparison
2.18
Delnor
Med-Surg
3.88
National
Comparison
1.25
1.00
0.75
0.50
0.25
0.00
0
Delnor
Critical Care
0.28
National
Comparison
0.58
Delnor
Med-Surg
1.04
National
Comparison
100%
80%
60%
40%
20%
0%
88.0%
92.0% 91.6%
FY 06 FY 07 FY 08
100%
80%
60%
40%
20%
0%
99%
Delnor
78%
National
75%
Illinois
18

all patients, but specific interventions are
placed into the plan of care based on findings
from that assessment. Patients identified as
at-risk for falls have a blue band placed on
their wrist, which serves as a communication
tool to other interdisciplinary team members
who interact with them to ensure that safety
measures are seamless.
Hand Hygiene
Hand hygiene standards at Delnor follow the
guidelines that have been set by the Centers
for Disease Control and Prevention (CDC) and
continue to be a national patient safety goal
as set by The Joint Commission. As a result,
Delnor conducts hand hygiene observations
on all units and shifts, which include observations
from nursing, physicians, and support
personnel. Those observations include giving
immediate feedback by thanking and praising
those who have followed proper precautions,
and also sharing missed opportunities.
Delnor’s Nursing Shared Decision Making
(SDM) council members also conduct monthly
observations to monitor compliance, and
share monthly results of those surveys. By
being open to giving and receiving feedback,
coupled with the hospital-wide initiative Project
Zero, which strives to eliminate patient infection,
hand hygiene results are reaching marks
of success that translate to better care for
our patients.
Pneumococcal Vaccination Rate
The Centers for Medicare and Medicaid
Services, The Joint Commission and the
Hospital Quality Alliance require that hospitals
report the number of inpatients that receive the
pneumonia vaccine. Providing eligible patients
with the vaccination helps prevent or lower the
risk of pneumonia and its complications.
Delnor goes above the minimum requirement
to screen and assess all patients who
would benefit from receiving the pneumococcal
vaccine. We have established a proven
sustained process that ensures patients
receive the vaccine prior to discharge, and for
four years running have maintained a vaccination
rate of greater than 99 percent. In
addition, we provide patients with a record of
this vaccination that can be shared with their
primary physician.
Decision to Incision
One quality measure in our NewLife Maternity
Center is our Decision to Incision for emergency
cesarean sections. The mark of
excellence is 30 minutes from the time the
continued on next page
100%
80%
60%
40%
20%
0%
50
40
30
20
10
0
100%
80%
60%
40%
20%
0%
Decision to Incision
Percent Compliance
FY 08
89%
1st Qtr.
08
84%
2nd Qtr.
08
92%
3rd Qtr.
08
92%
4th Qtr.
08
Average Minutes
to Emergency C-Section
FY 08
23.25
1st Qtr.
08
21.85 22.00
2nd Qtr.
08
3rd Qtr.
08
20.00
4th Qtr.
08
Patient in OR for C-Section
15 Minutes or Less
FY 08
78%
1st Qtr.
08
87%
2nd Qtr.
08
100%
3rd Qtr.
08
92%
4th Qtr.
08
Quality
2008 Nursing Annual Report
19

RN Satisfaction – NDNQI
Delnor
Nurses
Comparison in
Magnet Facilities
Annual Percent
Turnover –
Registered Nurses
MD Satisfaction
with Nursing
Patient Satisfaction
Emergency Department
Same Day Surgery
FY 08
FY 05 – FY 08
FY 08
Inpatient
4%
30%
100%
100%
3%
2%
1%
25%
20%
15%
10%
5%
15.5%
18.0%
11.7%
11.7%
98% 99.0% 98.5%
99.1%
98.2%
98.9%
96%
94%
92%
90%
88%
86%
84%
82%
98%
96%
94%
92%
90%
88%
86%
84%
82%
0%
0%
80%
80%
Nurse Participation in
Hospital Affairs
Nursing Foundations for
Quality of Care
Nurse Manager Ability of
Leadership and Support
Staffing and Resource
Adequacy
Collegial Nurse-
Physician Relationships
Mean Practice
Environment Scale Scores
FY 05 FY 06 FY 07 FY 08
Responsiveness to
Patient/Family Needs
Nursing Staff’s Care and
Treatment of Patients
Nursing’s Assessment and
Monitoring of Patients
Nursing’s Collaboration
with Physicians
Adequacy of Nurse
Staffing Levels
FY 06 FY 07 FY 08
2008 Nursing Annual Report
decision is made to a cesarean section.
A continued performance-improvement
process change, led by nursing, focused on
having Delnor patients requiring a cesarean
section in the operating room in 15 minutes
or less. This year, our average time was 22
minutes, which improved two minutes over last
year’s performance. Currently case reviews
are conducted on any patient experience that
falls outside of the 30-minute range.
RN Satisfaction
Nursing satisfaction results at Delnor are
reflective of a Magnet culture. Delnor nurses
are engaged and autonomous in their practice,
which is evidenced by a 91-percent survey
response rate, and above the national norm
results as compared to other Magnet facilities.
Delnor nurses review these results, use them
to create action plans for improvement and
take ownership for creating environments that
are satisfying for their team members.
Physician Satisfaction
Delnor physician satisfaction is measured
quarterly and annually by Professional
Research Consultants (PRC). The results of
the 2008 survey indicate that physicians place
Delnor nurses in the 98th percentile for quality
of overall nursing care. They also rated our
nursing staff’s responsiveness to patient/family
needs at the 99th percentile. Delnor nurses
consistently score in the excellent percentile
ranking in the national data base for PRC,
which speaks to the collaborative relationships
between nurses and our medical staff.
Patient Satisfaction
The staff at Delnor strives to always deliver
high-quality care. In the past year, we have
continued to achieve some of the highest
patient satisfaction scores in the nation.
Results from our 2008 patient satisfaction
survey show Delnor ranks in the top
10 percent of U.S. hospitals for patient
satisfaction. Our emergency care ranked
in the top 2 percent of hospitals nationally,
and Same Day Surgery ranked in the 84th
percentile. This year our inpatient scores
were combined with Hospital Consumer
Assessment of Healthcare Providers and
Systems (HCAHPS) data, which placed
Delnor in the 91st percentile overall. n
20

Nursing Professional Practice Awards
The Professional Practice Award is
a prestigious honor awarded quarterly
to a Delnor staff nurse who has
exemplified the forces of Magnet in
their everyday work. Recipients of the
award are passionate about nursing,
respected by their peer group and
committed to seeking challenges
that elevate the practice of nursing.
The Shared Decision Making (SDM)
Management Council sponsors this award,
and sends out a call for nominations on a
quarterly basis. Nomination narratives can
be submitted by leaders, staff or peers, and
each is read and scored by members of the
Council. After the difficult process of choosing
an award winner is complete, the honoree is
revealed and celebrated.
Each Professional Practice Award winner
is recognized with a certificate plaque, flowers
and the invitation to attend the next annual
Magnet Conference, as well as with a portrait
that is displayed in the Delnor awards
hallway. Announcements are also distributed
in the SDM quarterly newsletter, hospital
newsletter, through internal emails and at
announcements made at education forums.
This year our winners include Dawn Olson
(Information Systems Analyst), Dawn Stanley
(NewLife Maternity Center), Lisa Janeway
(Information Systems Analyst) and Joanne
Heidorn (Endoscopy).
Dawn Olson
Dawn was instrumental in helping to launch
the Bedside Medication Verification (BMV) process
at Delnor, serving as leader of the computer,
technology and direct user aspects of the project.
She continues to embrace the ways in which
technology can positively impact bedside nursing
through her involvement in the Medication
Transformation Team (a group that looks at ways
to improve medication delivery through technology
enhancement).
Dawn Stanley
Dawn found herself interested in the answer to
a question she had regarding newborn care. That
one question compelled her to work on a research
project alongside two master’s-prepared nurses
in NewLife Maternity at Delnor. While Dawn is
working to complete her BSN, she never thought
she would be involved in research. “What I
discovered is that writing the research application
and performing data collection has been a
great experience and not nearly as intimidating
as I thought it would be,” she says. Dawn now
encourages others to follow in her footsteps.
Lisa Janeway
When Lisa’s name was announced as a Professional
Practice Award winner at a celebration,
she was the only one shocked in disbelief. Lisa
was nominated by her leader for outstanding work
as clinical IT analyst for the Emergency Department
Module (EDM) of the Meditech system.
She coordinated demonstrations of the new
system enhancements, worked closely with ED
physicians and ED departmental staff, and coordinated
efforts with an outside consulting group.
All of these efforts enhanced customer service in
the ED, and exemplified Magnet-level excellence.
Joanne Heidorn
Joanne was asked to join a task team charged
with standardizing Delnor policy and procedure
regarding conscious sedation. She spent hours
researching standards, guidelines and best
practices, and brought fresh ideas, sugges-
tions and sample templates to each meeting.
In the end, she took the lead in merging existing
forms to create a standardized format for all
departments that met all current standards and
workflow practices.
Each of our Professional Practice Award winners
brings passion, energy and commitment
to her area of nursing. Each upholds the forces
of Magnet in her everyday work and excels at
making Delnor a better place for all nurses
to practice.
2008 Professional Practice Award Winners
Recognition
2008 Nursing Annual Report
21

Collaboration
Anitha Nallari, MD and
Audrey Eggleston, RN, BSN
22

Hospitalists and Nurses
Have Strong Bond
Delnor nurses are accustomed to
spending a majority of their day
in direct contact with their inpatients.
The only other group of medical
professionals that can say the same
is Delnor hospitalists. These physicians
are dedicated to caring for the
patients admitted to the hospital by
other Delnor physicians.
The primary focus of hospitalists is hospitalbased
care and medicine. The term hospitalist
was first used in a 1996 New England Journal
of Medicine article to describe physicians
committed solely to patient care, teaching,
research and leadership related to hospital
care. Delnor hospitalists, like Anitha Nallari,
MD, help manage patients through the
continuum of hospital care, often admitting
patients to inpatient units, following them as
necessary into critical care or other areas,
and organizing post-acute care.
“Working with Delnor nurses has always
been a pleasurable and educational experience,”
says Dr. Nallari. “We really work as a
team, and because of that we learn a lot from
each other.”
Delnor nurse Audrey Eggleston, RN, BSN
agrees. “If I have a question about a patient
I know that I can go to Dr. Nallari for guidance,”
she says. “As a hospitalist, she is always
accessible, and that means seamless care
for the patient.”
And because of their close partnership with
nurses, hospitalists at Delnor are often the first
to experience patient feedback about nursing
at Delnor. “Without a doubt, Delnor nurses give
patients and their families a caring hospital
experience,” she says. “I have seen evidence
of this time and again. I receive feedback
everyday from patients about the quality of care
that nurses are providing, and it makes me
proud to be part of Delnor. It is not the same
story everywhere else.”
Dr. Nallari says that Delnor nurses and
physicians alike have the goal of high patient
satisfaction in mind. “Even for the patients that
aren’t mine, I try to be on-hand to help, or to be
a bridge for them until we can get in touch with
their own doctor. We all do the very best that
we can for the patient.” n
“Without a doubt,
Delnor nurses give
patients and their
families a caring
hospital experience.
I have seen
evidence of this
time and again.
I receive feedback
everyday from
patients about the
quality of care
that nurses are
providing, and it
makes me proud
to be part of
Delnor. It is not
the same story
everywhere else.”
Anitha Nallari, MD
2008 Nursing Annual Report
23

Moving Forward
2009 studies
t o i n c l u d e :
• Retention strategies for
new nursing grads
• Clinical aggression
• Mock Trauma Code Study
• Heathcare literacy
• Perception of quality
On the Horizon
The Magnet vision of nursing
research promotes the development
of nurse researchers who
provide bedside care. The Delnor
Nursing Research Council (NRC) is
committed to helping bedside nurses
engage in research to support their
practice and add to the worldwide
body of nursing knowledge.
In 2008, the NRC focused time and energy
in reformatting the application used in the
development of a research protocol, and
implementing a simplified checklist of steps
to be taken with available resources and mentors.
This checklist was chosen as an exemplar
by Magnet surveyors during Delnor’s recent
successful Magnet Re-Designation process.
“The use of the protocol and checklist
makes the transition to the actual research
application streamlined and less threatening
for first-time researchers,” says Sue Herrmann,
RN, MSN, Delnor’s Director of Professional
Practice and Magnet Project Coordinator.
The NRC bylaws and research fellowship
applications were also revised this year to
encourage nurses novice in research experience
to take part.
Evidence-based practice and accelerating
quality initiatives continue to demand that
nurses assimilate a great amount of information
quickly and efficiently. Delnor’s Shared
Decision Making (SDM) leadership recognizes
this challenge and has launched an
on-going project to seek strategies to manage
innovation. These include managing the way
information is shared with nurses, with an eye
toward increased use of methods such as the
Delnor employee portal, and the e-learning
system Healthstream. n
24

MEMBERS OF NURSING LEADERSHIP
Lore Bogolin, RN, MSN
Chief Nursing Officer and Vice
President of Patient Care Services
Linda Bauer, RN, MHA, CNOR
Director of Surgical Services
Debra Dyrek, RN, MS, CNAA, BC
Director of Nursing Resource
Team and Nursing Supervisors
Diane Coluzzi, RN, BSN, CCM
Director of Case Management
Regina Fraiya, RN, MSN, CPNP
Director of Maternal Child/
Pediatrics, Adolescents
Susan Herrmann, RN, MSN
Director of Professional Practice
and Magnet Project Coordinator
Pat Liska, RN, MSEd, BSN
Director of Education
Ann-Louise Pinkawa, RN, MBA
Director of Rehabilitation Services,
Cardiac and Pulmonary Rehab,
Psychology Services, Diabetes
Management, Aquatic and Senior
Exercise Programs
Patricia Rogers, RN, MS
Executive Director of Emergency,
Trauma and Critical Care Patient
Care Center
Judy Smith, RN
Director of Service Excellence
Kathy Tedesco, RN, MS, MBA
Executive Director Home Health Care,
IV Therapy, Outpatient Infusion
Center, Pharmacy and Rehab Services

Pictured on Cover:
Alpa Thaker, RNC, MSN
Designated a
Magnet Nursing
Hospital by the
American Nurses
Association.
DELNOR HOSPITAL
300 Randall Road
Geneva, Illinois 60134
630/208-3000
www.delnor.com
© 2008 Delnor Hospital