2010 Patient Care Services Annual Report - Huron Valley-Sinai ...

Letter from the VP of Patient Care ServicesYou can feel the difference when you enter HVSH. I believe what sets us apart fromother organizations is the collaboration and teamwork by the entire team. It takesevery person coming together in a respectful and collaborative way to achieve ourcare outcomes that are meeting and exceeding the national benchmarks at this “smallcommunity hospital in the apple orchard”.The awards and achievements we have earned and the recognition we have enjoyedin 2010 are reflective of our quality outcomes. These include the following:We were named by the Leapfrog Group, the nation's premier quality ranking agency, as one of onlyfour hospitals in Michigan and one of only 65 hospitals nationally to achieve “Top Hospital” status. TheLeapfrog hospital survey is the gold standard for comparing hospitals’ performance on the nationalstandards of safety, quality, and efficiency. This designation was enjoyed by less than 2% of hospitalsnationally.Forbes magazine reported that HVSH was designated by HealthGrades, a hospital rating company, asbeing among the best hospitals in the country based on our low complication and mortality rates for avariety of procedures placing us in the top 5% of hospitals nationwide.Additionally, we are certified as a Primary Stroke Center by the Joint Commission; and accredited as aChest Pain Center by the Society of Chest Pain Centers.The Detroit Medical Center (including HVSH) was recognized for the fourth consecutive year as one ofthe nation's "Most Wired" hospitals.The achievement I continue to be most proud of is our Designation as a Magnet hospital from the AmericanNurses Credentialing Center, the highest honor that can be bestowed on Nursing. Magnet designation is animportant acknowledgment of nurses' worth, and a seal of approval of quality patient care. Only 5% of allhospitals in the U.S. have attained this honor.These awards and designations do not occur by accident; they are achieved as a result of hard work and dedicationby the entire team and I congratulate you on another great year of achievements.It is with pride that I share the 2010 HVSH Patient Care Services annual report, depicting the many facets ofexcellence taking place at HVSH everyday.Respectfully;Bette R. Fitz RN BSN, MBA NEA-BCVice PresidentPatient Care Services1

Letter from the VP of Patient Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Mission, Vision, Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3NURSING LEADERSHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Structural Empowerment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Professional Nurse Council. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Quality Council. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Magnet Council. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Evidenced Based Practice Council. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Patient Care Associate Council. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12CONSULTATION AND RESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15NEW KNOWLEDGE, INNOVATIONS and IMPROVEMENTS. . . . . . . . . . . . 17NURSING CLINICAL QUALITY INDICATORS . . . . . . . . . . . . . . . . . . . . . . . 19CLINICAL TRANSFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21EXEMPLARY PROFESSIONAL PRACTICENurse of the Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Patient Care Associate of the Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Physician Partner of the Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Nightingale Award Winner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26COMMUNITY INVOLVEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28PROFESSIONAL DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29CertificationsTable of ContentsSHARING OUR KNOWLEDGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Code of Ethics for Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Nurses’ Bill of Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Nursing Leadership Team 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342

***********************************************************HVSH Nursing Mission, Vision and Values***********************************************************Mission: To provide evidence based, cost-effective care resulting in quality patient outcomes andpatient and staff satisfaction.Vision: To be the leader in our community in providing quality service and cost-effective health care.Values: RespectCompassion Integrity Autonomy Relationships AccountabilityBeliefs Nurses are respected and are essential members of the healthcare team. Collaboration is expected among the healthcare team members Patients and families are partners in care We are united in our quest to provide comprehensive care, comfort and compassion to patients, families,coworkers and our community. Evidence based Practice is the foundation of Nursing Education and Care Delivery Relationship with self, each other and our patients/families are essential aspects to our professionalmodel of care**Revised and endorsed by the Professional Nurse Council December 2008_________________________________________________________________________________Nursing’s professional practicemodel at HVSH is rooted in KristenSwanson’s theory of caring.1. Maintaining belief-believing in persons and theircapacity to make it through events and transitions andfind meaning.2. Knowing-striving to understand an event as it hasmeaning in the life of the other3. Being with-being emotionally present to the other.4. Doing for-doing for the other what they would dofor themselves if it were possible.5. Enabling/informing-guiding the other’s passagethrough life transitions and unfamiliar events.Everything we do centers around thepatient, family and our communityThe trunk represents ourProfessional Practice model which isbased on our Values.Respect (for self and others; for resources)CompassionIntegrityAccountabilityAutonomyRelationshipsThe Fruit of our labors are Outcomes (depicted as Apples). These include Trust, Satisfactionof patients, staff and physicians; Professional Growth including professional certification;Quality; Collaboration in all of our relationships; and Practice Excellence (using evidencedbased practice and research as a foundation of our practice), to name just a few.3

Nursing Leadership is also provided by our Clinical Managers –Each one is responsible for the day-to-day operations of their unit and accountable on a 24 hour basis.They function as individual “CEO’s” of their units and are the back bone of the organization.Tina Coo RN, BSNIntensive Care Unit/ Intermediate Care/ 3 WTina has a Bachelor’s of Science in Nursingand is a member of the AmericanAssociation of Critical Care Nurses.Michelle Ming RN, BSN, ONC2 West Med/SurgMichelle holds a Bachelor’s of Science inNursing. She is a member of NationalAssociation of Orthopedic Nurses, MichiganOrganization of Nurse Executives, and OUAlumni Association. She is currentlyattending a MSN program at FerrisUniversity.Linda Habitz RN, BSN, CNORDirector Surgery/Endoscopy andPre-Admission testingLinda holds a Bachelor of Science inNursing, She is a certified OR nurse and amember of Association of Peri-OperativeRegistered Nurses.Nancy Briody RN, BSNCardiac Cath Lab and/InterventionalRadiologyNancy holds a Bachelor of Science inNursing. She is currently attending theDMC Leadership Academy and will take theexam for nurse executive certification inApril.Maureen Heathman RN, BSN3 East Med/Surg/ HemodialysisMaureen holds a Bachelor’s of Science in Nursing,and is a certified oncology nurse and is chemotherapycertified. She is also ACLS certified and is an ACLSinstructor.Kathleen Goll RN, BSN, MSA, ONC, NE-BC2East TelemetryKathy has both her Bachelor’s degree and Master’s ofScience in Nursing. She is professionally certified as anOrthopedic nurse and a Nurse Executive.Janet Tucker RN, BSN, MSN, MBA, NE-BCEmergency ServicesJanet holds a Bachelor of Science in Nursing, a Master ofBusiness Administration, and a Master of Science inNursing. She is a board certified nurse executive, BLS-C,ACLS, TNCC, BDLS, ABLS, IANCICI and a board memberof Baker College.Monica Walker RN, BSNPre-op/Post Anesthesia UnitsMonica holds a Bachelor of Science inNursing. She is a member of AmericanSociety of Peri-Anesthesia Nurses, and iscurrently preparing to take the nurseexecutive certification exam.Rob O’Connor RN, ADNCardiology/ Cardiopulmonary Rehab ServicesRob is currently enrolled in a Bachelor of Sciencein Nursing program at Oakland University and willgraduate in the fall of 2011.Administrative Supervisors – are anotherimportant leadership resource to our staff; theyserve as the on-site administrative resource for theentire hospital on the off shifts, week ends andholidays. Not pictured: Julie Richie RN BSN, Alicja KorenekRN BSN and Linda Simons RN ADNAngie Diana LisaCusick RN ADN Bowman RN BSN Hurley RN BSNA complete list of the HVSH Nursing Leadership team can be found on 345

Structural EmpowermentA basic belief at HVSH is that the quality of any decision improves when it involves keystakeholders. HVSH has always had a form of shared decision making also known as sharedgovernance. The shared decision making model is utilized for issues in the Clinical PracticeEnvironment. Decisions regarding the clinical practice environment are made by the direct caregivers involved. The Professional Nurse Council (PNC) slogan is “if it touches Practice, itbelongs to PNC”. The HVSH Shared Governance model has the Professional Nursing Councilat the apex with representatives from each nursing unit/department as well as representativesfrom the Advance Practice Nurses, and leadership.Nursing Shared Governance (Shared decision making) ModelProfessionalNurseCouncilQuality CouncilUnit Practice Councils(UPC)Magnet CouncilEvidence Based Practice and Research Council is open to all nursingstaff and is the foundation for Nursing at HVSHEach unit has a unit practice council composed minimally of the unit representatives to thePNC, Quality and Magnet councils. All unit staff nurses are encouraged to become involvedin their UPCs and unit practice issues discussed at these meetings. There is a monthlyEvidence Based Practice and Research Council that all staff nurses are encouraged to attend.The council encourages and assists nurses to utilize current research findings to resolveclinical practice issues. Kate McLean, HVSH PNC chair served as the HVSH representativeon the system level PNC for the Detroit Medical Center where issues that impact all hospitalsare discussed and decided.6

2010 Council Representatives and their accomplishmentsProfessional Nursing Council (PNC)The Professional Nurse Council (PNC) represents professional nurses and serves to promote shared decisionmaking in the pursuit of excellence in nursing practice/care. PNC members represent peers by initiating andmanaging positive change and by participating in the shared decision making process as it effects the practice andprofessional development of the nursing staff members.Kate McLean, RN, BSN 2 East Chair Lynne Arnaut, RN, BSN OR Chair ElectMelissa Mayes RN, BSN Past Chair CCTC/VAT Patrick Hamill, RN, ADN Interventional Rad/Card.Pam Loszewski RN, ADN ICU Jeannie Kinderman, RN, ADN Cardiopulmonary/RehabGeri Koby RN, BSN Administrative Liaison Bernice Bowles RN, ADN EDMolly Kowalski, RN, BSN PAT Lori Fairbanks, RN, ADN MCOUMary Krist RN, ADN 2 West Pat Kampmann-Bush, RN, BSBA PACULois Larson RN, MSN APN MS/CC Gina Amara, RN, ADN Float PoolLizabeth Knoll, RN,ADN 3 East Surita Sieben RN, BSN MagnetRosama Mathai, RN, ADN 3 West Marlene Rankin RN, BSN Clin TransLinda Woodford, RN, Diploma Peds Kathleen Goll, RN, BSN, MSA Clin. Mgr. 2EDebra Kraft RN, BSN CCN Erin Bragg, RN, ADN HBCBette Fitz RN, BSN, MBA VP PCS Chris LaFee-Fedorko RN, BSN POCUBack L-R: Surita Sieben, Bernice Bowles, Lori Fairbanks, Jeanne Kinderman, Linda Woodford, Patrick Hamill, Kathy Goll, Melissa Mayes,Gina Amari Middle Row: Rose Mathai, Karen Emler, Marlene Rankin, Erin Bragg, Lois Larson, Liz Knoll, Pam Loszewski, Mary Krist,Front Row: Kate McLean, Lynne Arnaut, Pat Kampmann-Bush, and Bette FitzPNC 2010 Accomplishments included: Updated HVSH PNC Web Site Sponsored Physician Partner of the Year Program Creation of meaningful bulletin boards for nursing reflecting the business of PNC Support of all EMR transitions, new functionality, and Go-Lives Support growth and development of Unit Practice Councils Collaboration with DMC-wide Nursing Leadership via quarterly forums (Chair reporting back tocouncil) HVSH PNC member serves as DMC Critical Care System Committee Member8

Quality CouncilThe Quality Council is chaired by a staff nurse and facilitated by the Magnet program manager and includesstaff RNs from all inpatient and outpatient nursing areas. The QC develops and monitors Nursing SensitiveIndicators for each nursing unit and implements action plans in response to data from the National Databaseof Nursing Quality Indicators (NDNQI) and other measures to achieve continuous improvement. They alsocoordinate Performance Improvement projects in collaboration with other disciplines.Dolly Shaffer RN, BSN CCTC Chair Surita Dexter, RN, BSN Magnet/Epidem FacilitatorKelly Hughes, RN, BSN Cath Lab Ann Ward, RN, BSN EDTracey Beach RN, ADN Cardiopulmonary Diana Clafton RN, ADN 3 EastMonica Walker, RN, BSN Clin. Mgr. PACU/POCU Kathy Coram RN BSN ORDeb Pierson, RN, ADN ICU Debbie Brennan RN, BSEd HBCRenita Milburn RN, ADN 2 West Diana LaBumbard, APN, MSN Med SurgMolly Kowalski RN, BSN PAT Kathryn Scanio RN, ADN PedsBarb Sterling, RN, ADN POCU Amy LaBarge RN ADN CCNGail Ridley RN, ADN 2 East Shawn Priebe, RN, ADN MCOUToni Norman RN, ADN 3 West Cathy Grant RN, BSN Adm. Dir. Cancer/Quality/EpiBette Fitz RN, BSN, MBA VP PCS Karen Moore CRNA Admin Dir Perioperative SrvcBack L-R: Bette Fitz, Diana Clafton, Cathy Grant, Kelly Hughes, Ann Ward, Diana Labumbard, Dolly ShafferMiddle Row: Toni Norman, Kathy Scanio, Karen Moore, Monica Walker, Surita Sieben, Gail Ridley, Tracey BeachFront Row: Shawn Priebe, Amy LaBarge, Deb Pierson, and Debbie BrennanQuality 2010 Accomplishments included: Developed the nursing quality dash board and review monthly to increase staff understanding of metrics Increased participation of hospital units/members Increased knowledgebase of members related to quality Structured unit reporting template to organize report outs Created a hospital wide pre-procedure checklist to ensure that patients are prepared for procedures Supported staff in achieving “at mean” or better in all aggregate quality nursing sensitive indicators in2010 (metrics can be seen starting on page 20)9

Magnet Champion CouncilThe Magnet Champions Council is facilitated by the Magnet Program Manager, Surita Sieben, and hasstaff RNs representative of all inpatient and outpatient nursing areas. They are responsible fordeveloping the Magnet components within HVSH; developing communication plans to includePosters/bulletin board /newsletters/ presentations; facilitate identifying and gathering sources of evidencefor Magnet document submission and provide regular and ongoing communication of the magnetinitiative efforts within all levels of HVSH.Surita Sieben RN, BSN Facilitator Kathy Bricker RN,ADN 2 EastTrish Barrowcliff RN ADN 3 East Rob O’Connor RN, ADN CardiopulmonaryDiana LaBumbard APN M/S-CC Carol Devore RN, BSN CCTCPat Clark APN, DNP Crit. Care Kristina Cerda RN,BSN 2 WestDenise Dybas RN, ADN 3 West Renee Freese RN,BSN PedsCarol Conte RN, ADN ED Linda Adams RN, Diploma HBCJennifer Martin RN, BSN PACU Karen Baruzzini RN,BSN MCOUDeborah Plotzke RN,BSN ICU Elaine Hunter RN, Diploma ORBette Fitz RN, BSN,MBAVP PCSBack L-R: Diana Labumbard, Pat Clark, Linda Adams, Kristina Cerda, Renee Freese, Deb Plotzke, Surita Sieben, Karen Baruzzini,Jennifer Martin, Denise Dybas Front L-R: Trish Barrowcliff, Carol Conte, Rob O’Connor, Carol Devore and Elaine Hunter.Magnet 2010 AccomplishmentsPresented Nursing Grand Rounds in January and December 2010 to share information from the national magnetconferenceBegan education efforts of nursing staff to understand the new ANCC Magnet ModelRestructured Quality and Magnet councils to align with new Magnet ModelCelebrated HVSH’s Magnet designation by raising a Magnet flag outside of HVSH and sponsored magnet pinsfor all nurses and badge pulls for non-nursing employeesMagnet Council manned an information table at the Community Open House Harvest Bash in SeptemberParticipated in the development of the Michigan Magnet Coalition with Magnet representatives attending first alldaymeeting/education program in Grand RapidsIntegrated Unit Practice Councils to provide regular magnet updateFive Magnet Council members attended the National magnet conference where HVSH was recognized as a firsttime designated hospital (see page 33)10

Evidence Based Practice CouncilThe EBP Council is co-chaired by APNs Linda Miller and Diana Labumbard and is open to all staff nurses who areinterested in investigating a best practice or beginning a research project. Evidence based nurse practice is theprocess by which nurses make clinical decisions using research evidence, clinical expertise and patient preference.Evidence Based Practice 2010 AccomplishmentsDeveloped a communication plan to include posters/bulletin board presentationsOrganized and hosted a highly successful Evidence Based Practice Poster day where 34 nurses shared 27 posterson relevant topics of interest to nurses at HVSH who were able to earn continuing education credit for reviewingthe poster presentations. The list of posters and presenters can be found on page 31.Several posters were also shared at DMC poster day in Detroit and again at the Circle of Influence meetingallowing additional nurses to earn CEs for viewing.Developed annual nursing education related to how Evidence based practice differs from research or performanceimprovement initiatives.11

Patient Care Associate (PCA) CouncilThe HVSH Patient Care Associate Council represents care givers who are working as Patient Care Associates, andserves to promote shared decision making in the pursuit of excellent patient care. PCA Council members representtheir peers by initiating and managing positive change and by participating in the shared decision making process asit effects the practice and educational development of PCAs. The group is facilitated by Jo-Ann Smith NursingDirectorJohn Corey 2 WestErie Aeilts PACU, Chair/ DMC PCA council repSandra Southerland Vascular Access Team, Co-chairSandy Matusik Marie Carls Observation UnitTara Hagel 2 EastHeather Nelson 3 EastJo-Ann Smith Nursing Director – facilitatorMichelle Aeilts Emergency ServicesRonda Broden ICUCathy Benton Harris Birthing CenterRita Gilbreath 3 WestL-R Back row: Tara Hagel, John Corey, Eric Aeilts, Sandy Southerland, Sandy Matusik, Michelle AeiltsFront Row: Heather Nelson, Rita Gilbreath, Cathy Benton, Ronda Broden, and Jo-Ann Smith RNPCA Council AccomplishmentsEstablished a routine meeting date and identified representatives from all unitsEstablished PCA Council bylaws to provide structure to the councilElected first Chair (Eric Aeilts) and Co-chair (Sandy Southerland)Established a conference line for any interested PCAs to be able to call in and participateParticipated in planning PCA week celebration activities which included an on-site speaker andrecognition tea for department PCAs of the year acknowledged in 2010ED Tech title was implemented for PCAs working in the ED to be more consistent with the standard inthe communityCouncil supported implementation of PCA certification review course and testingCouncil reps participated in recommendations for room furnishings and configurations for new unit inRSC areaCouncil reviewed the bladder scanner and approved the education process for mandatory competencies12

Shared decision making and staff involvement is highly valued at HVSH. In addition to staff involvement in thevarious councils and committees, RNs come together at the annual nursing strategic alignment retreat.The Nursing Strategic Alignment Retreat was held February 10 th atEdgewood Country Club. 64 nurses attended. The annual retreat isconducted as an opportunity for development and to learn from each otheras well as to set strategic alignment ofannual goals for nursing. All members ofthe PNC, Magnet and Quality councils aswell as Nursing Leadership including alleducators, APNs, managers and directorsare invited. 6.1 CEs were earned byattendees. Nurses presenting at the retreatincluded: Kelly Haren and KateMcLean on Patient satisfaction surveyresults, Greg Bozimowski on writing forBecky Muldoon RNFront: Denise Dybas, Jennifer MartinBack: Karen Emler, Pam Lozsewskipublishing, Linda Schulz and Paula Cunningham on evidenced basedpractice, Surita Sieben on Magnet changes, and Becky Muldoon on FamilyPresence during emergencies.Private Room Renovation PlansStaff has been actively involved in planning for the renovationof the vacated space in the Regional Specialty Center due tobegin construction in early 2011. Floor plans were draftedand posted, available 24 hours per day for staff review and forstaff input. Life sized space was taped off in the RSC showingroom dimensions and location and size of doorways, sinks,etc. Furniture and equipment was located into the space sothat all staff could physically try out the space. Staff frommultiple departments toured the area bringing wheel chairsand IV poles and other equipment to make an assessment ofthe functionality of the space. Several excellent suggestionswere made and incorporated into plans as a result of thiseffort. In July several staff (Kim Miller PCA, Jen BogarRN, Marlene Rankin RN, Michelle Ming RN, and KathyGoll RN) flew to the Indiana Hill Rom showroom to review furniture options and call light integration.National Database of Nursing Quality Indicators(NDNQI) RN satisfaction surveyHVSH is interested in the satisfaction level of our RNs and staff is asked to complete the NDNQI RN satisfactionsurvey annually. In 2010, 75% of the staff nurses house wide completed the survey. Two measures of RNsatisfaction include the Job enjoyment T-score which is a compilation of responses from several differentindicators and the second relates to the RNs intention to remain on the same unit next year. As can be seen in thetables below, HVSH has experienced a steady improvement in these 2 indicators and are above the mean in both.13

In fact, in every category (nurse’s participation in hospital affairs, quality of care, nurse manager ability andsupport of staff, staffing adequacy, and collegial nurse-physician relationships) HVSH nurse satisfaction levelsexceed both the national overall mean as well as the mean for Magnet facilities participating in the survey.Implementation of theHospira “Smart Pump”!HVSH was the first DMC hospital to implement thenew Hospira smart pump devices in June. They arecalled “smart pumps” because they come withcomputerized drug libraries and other technology thatassists staff in ensuring that they are administeringthe correct dose and within the hospital policy for thelimits allowed in specific departments. The pumpshave different allowed limits for drugs administeredto different types of patients; for instance, in the adultmedical units vs. the pediatric unit. Because of thenew pump technology, a complete changeover of IVtubing products was necessary as part of theconversion. This allowed us to changeover to newKate McLean RN and Lynne Arnaut RN with new smart pump tubing that is non-DEHP tubing. DEHP is theplasticizer that has been recently associated withvarious health risks, thus improving safety to our patients. The new tubing is much more pliable making it moreprone to kinking and setting off the pump occlusion alarms. Nursing is actively working to achieve improvedpatient safety while controlling noise associated with alarms.Medication Safety has been paramount at HVSH. Besides implementation of the new smart pumps, HVSH boasts100% bar code medication scanning technology and also 100% compliance with electronic documentation ofpatient medications upon admission. This helps to ensure that the healthcare team is knowledgeable of all medsthat may impact the patient’s medical course.14

Consultation and Resources –HVSH has many specialized nursing resources available to support patient care…Patricia Clark DNP, RN, ACNP-BC, ACNS-BC,CCRN Pat is doctoral prepared, certified in CriticalCare Nursing (CCRN) as well as being a boardcertified Clinical Specialist in Medical- SurgicalNursing, board certified Acute Care NursePractitioner and an Advance Cardiac Life Support(ACLS) provider and instructor. She is a member ofthe American Association of Critical Care Nurses andof Sigma Theta Tau International.Lois E. Larson, RN, MSN Clinical NurseSpecialist – Lois serves as the Advanced PracticeNursing resource for Med Surg and Critical Care.Lois co-coordinates the ACLS course of which she isa certified instructor. She is chairperson of the CodeBlue Committee and a member of AmericanAssociation of Critical Care Nurses and of SigmaTheta Tau.Top to bottom: Greg Bozimowski, Nicole Hawkins, DianaLabumbard, Pat Clark, Deb Johnson, Linda Miller and Lois LarsonDiana LaBumbard RN, MSN, APN-BC, CCRNClinical Nurse Specialist -Diana is the ClinicalNurse Specialist for Med Surg and Critical Care. Sheis certified in Critical Care Nursing (CCRN) as wellas being a board certified Acute Care NursePractitioner. Diana is a member of the DMC Centerfor Clinical Research and is co-chair of ourEvidence-Based Practice Committee. She is amember of the American Association of Critical CareNurses (AACN) and National Nursing PracticeNetwork for Evidence-Based Practice. She is a RedCross Disaster Prepared Nurse. She serves on theRN-AIM Board as the Region 7 Liaison to theNursing Excellence in Practice State Council for2008-2010.Linda Miller RN, MSN, WHNP, IBCLC- Linda isa certified Women’s Health Nurse Practitioner as well as an International Board Certified Lactation Consultant.Linda does Nurse Practitioner case management for the community health breast and cervical cancer screeningprogram. Linda is a member of the American Academy of Nurse Practitioners, Association of Women’s Healthand Obstetric and Neonatal Nurses, Maternal Newborn Nurse Professionals of Southeastern Michigan,Southeastern Childbirth Education Association, Michigan Association of Lactation Consultants and Sigma ThetaTau. Linda serves as co-chair of the Evidence Based Practice council.Greg Bozimowski CRNA, MS, BSN – Greg is a Certified Registered Nurse Anesthetist and Manager of theHVSH Anesthesia Pain Service as well as Assistant professor- University of Detroit Mercy Graduate Program ofNurse Anesthesiology. Greg conducted a research project on “Patient Perceptions of Pain Management: AComparison of Real Time Assessment of Patient Education and Satisfaction and Registered Nurse Perceptions”which he submitted for publication in spring 2011.Deborah Johnson MSN, APRN, Board Certified Family Nurse Practitioner, Certified Diabetic Educator(CDE) is the Occupational Health Services Nurse Practitioner. Deb has been very involved with assisting withWomen’s Health Breast and Cervical Cancer Control Program, for underinsured women in Oakland County.Nicole Hawkins RN, BSN, BSBS, MSN, FNP-BC Nicole is a certified Family Nurse Practitioner and providesLIP house coverage to address patient issues that arise on the afternoon shift.15

Gayl Hubler RN earned her BSN from Madonna University. Gayl serves as educator in ourEmergency Services Department and Cardiac Observation Unit. Gayl is certified in EmergencyNursing. She is a member of the Emergency Nursing Association. She is an instructor for ourtrauma nursing core course (TNCC), BLS and ACLS classes. She is also a tremendous resourcerelated to emergency preparedness and stroke and heart attack patients.Shelly Killebrew RN, BSN, CNOR serves as the educator for Perioperative Services. She has herADN from Henry Ford Community College and her BSN from Madonna University. She is aCertified Operating Room Nurse and a member of the Association of Operating Room Nurses.Shelly has been very involved in Surginet (the electronic medical record in the OR) as well as thekeystone surgery initiative.Penny McPhee RN BSN, MLS has been with the DMC for 43 years. She is a diploma graduateof Grace School of Nursing, earned her Bachelors of Science in Nursing from Mercy College ofDetroit and her Masters in Library Science from Wayne State University. She is a certified BLSand ACLS instructor and is responsible for new hire orientation and mandatory education for medsurg staff.Jennifer Palace RN ADN, BSN is a graduate from Oakland Community College with an ADNand earned her Bachelors of Science in Nursing at the University of Detroit- Mercy. She ispresently pursuing her Masters degree in Nursing Education at Oakland University.Linda Bell RN, BSN Clinical Transformation Director - Linda leads the ClinicalTransformation department at HVSH and represents HVSH at the system level for clinicaltransformation issues including new upgrades, programs and data mining and distribution. Lindacoordinates the activities of the clinical transformation super users throughout the hospital acrossall disciplines to ensure that all departments remain current. She is a member of Sigma Theta Tau,National Honor Society of Nursing.Dan Keehner RN, BSN, MSN, ACM Director, Clinical Resource Management – Dan is anAccredited Case Manager and leads the Care Resource management and access managementdepartments. These departments ensure proper bed placement of newly admitted patients andassesses and arranges for home care and other discharge dispositions and needs.Paul Reichert RN, BSNNurse Recruiter is availableto assist with interviewing,job placement, and HR policyand procedure guidance.Surita Sieben RN, BSNMagnet Program Manager andEpidemiology assists withcompliance with infectioncontrol practices and serves asour Magnet expert.16

“get it”.New Knowledge, Innovation and ImprovementsPatient Safety and QualityHVSH is committed to enhancing collaboration amongst all healthcare teammembers to improve the patient care experience and reduce errors. In September,Karen Moore Administrative Director for perioperative services madearrangements to bring national speaker and aviation consultant for ABC Newsand World Report, John Nance, to speak on the topic of patient safety andquality. All staff, physicians and board members were invited to attend thepresentation and for those unable to attend, a video was made for later viewing.Reading of the book “Why Hospitals Should Fly” was mandatory for the boardand senior leadership team to help provide support to staff in dealing withdifficult situations. John Nance toured the Operating room the next daymeeting several staff and having the opportunity to observe a minimallyinvasive robotic surgery case. Later he commented that many hospitals heconsults with think they have ingrained the principles he prescribes but in realitythey haven’t. He said that after observing the HVSH OR he felt that our staff and physicians trulyThe Perioperative areas continue to participate with the Surgery Keystone initiatives which is a quality and patientsafety collaborative led by the Michigan Health and Hospital Association. Hospitals across all of Michigan shareinformation regularly to learn from each other various ways to implement known best practices to enhance thequality and safety of the surgical experience.Some of the results of these initiatives include:100% compliance with all 8 of the orthopedic surgery measures (prophylactic antibiotic given within 1 hourbefore surgery, correct antibiotic selected, antibiotic discontinued within 24 hours of surgery, hair removal isclipped and not shaved, Foley is discontinued within 24 hours of surgery, patient temperature is within normalrange following surgery, DVT preventive measures are ordered and administered within the proper timeframe.)Teamwork and communication scores on Safety and Attitude Questionnaire were at or above benchmark andimproved over previous results. This tool measures staff perception of quality, how comfortable they feelreporting concerns, how confident they are that their concerns are taken seriously and other factors.Keystone Surgery initiative measures compliance with briefings before each surgical case and debriefingsfollowing each case to provide an opportunity for the team to ensure that they are all on the same page beforesurgery and to review anything that could be improved upon for future cases. HVSH compliance with presurgicalbriefings is improved from 88% to 98% exceeding the current 93% Keystone benchmark. Debriefingsimproved from 60% to 88% but shy of the 91% benchmark.Shelley Killebrew RN, Laura Kern RN, John Nance, Karen Moore CRNA, Mark Kamil MD17

Minimally Invasive Robotic SurgeryIn May, HVSH purchased our first daVinci robot to support our patients and surgeons who prefer the roboticsurgery option for GYN and urology patients among others. Robotic surgery is the least invasive alternative toboth open surgery and laparoscopy. HVSH performed our first daVinci surgery on May 27 th ! A speciallydesignated OR team consisting of Rebecca Webb RN (robotic charge nurse), Renee Pullen RN, Janine GulichST, Sue Padot ST, Alex Robertson CST, Anne Stus CRNA and Annette Cope CRNA were the initial team ofstaff identified to ensure success with this new modality. Members were sent to Ohio State University Hospital,Harper Hospital and Oakwood Hospital for training prior to completing the first case. Additional staff consistingof Roberta Nebus RN, Michelle Williams RN, Lindsay Flatt RN, Bernhardt Witzke CSA, Crystal Reed ST,and Zina Talia ST were sent for training at OSU in July.The team celebrated the first robotic surgery, performed by Dr. Ethan Goldstein on a member of his office staff!The robot consists of 2 major sections; one is the arms with instruments that are positioned in the patient and the other is aremote console where the physician can sit comfortably controlling the movement of the instruments without needing to beleaning over the patient physically.The first ever HVSH robotics case was celebrated with commemorative bottles of champagne.L-R: Rebecca Webb RN, Lynn Torossian HVSH President, Dr. Goldstein and Anne Stus CRNAThe team was introduced and honored at theCommunity open house in September.L-R: Rebecca Webb RN, Renee Pullen RN, AlexRobertson ST, Dr. Tina Schuster, Dr. Ethan Goldstein,Sue Padot ST, Michelle Nosal CRNA, Anne Stus CRNA,Annette Cope CRNA and Dr. David Cantor18

Nursing Clinical Quality IndicatorsThere are specific quality measures that are recognized nationally as being nursing sensitive; in other words,nursing can have a profound impact on whether certain events happen with patients. These include: patient falls,urinary tract infections, central line associated blood stream infections, ventilator associated pneumonia, pressureulcers, and others. HVSH participates in the National Database of Nursing Quality Indicators (NDNQI) whichcompares data on nursing quality indicators quarterly from over 1200 hospitals nationally. The graphs that followdemonstrate that nursing at HVSH is doing a great job at protecting our patients and delivering quality patientcare. This is a time that LESS is BETTER!Falls - Not all falls can be prevented, but witheach fall the nurse needs to ask “what can beTotal Patient Falls per 1000 Patient Daysdone to prevent that from occurring again?” Did4 quarter Roll up average compared to NDNQI Mean Q4-09 - Q3-10the slippers play a part; was there not enough5light to see; was the call light within reach to call4for help when needed; were belongings located3close enough to avoid overreaching, etc. Fall2rates will vary by the type of patients and type ofcare delivered. For instance, ICU patients are1generally not up and out of bed, so the expected 0fall occurrence rate is much less than for a unit2 East 2 West 3 East ICUwhere patients are ambulatory. As can be seenby the graph, the average rate of falls at HVSHHVSH NDNQI Meanfor the aggregated past 4 quarters has been less than the mean rate reported by NDNQI.Pressure Ulcers – Pressure ulcers occur as aresult of the combination of suboptimal healthstatus with immobility causing long duration ofpressure on bony prominences, or skin damagefrom shearing effects such as may occur inpulling a patient up in bed against the sheets.Some patients may come to the hospital withpressure ulcers already formed. Our goal is toprevent pressure ulcer formation while the patientis hospitalized and to improve the status ofexisting pressure ulcers. Patients are thoroughlyassessed when they come to the hospital for thepresence of pressure ulcers. HVSH measures86420% of surveyed patients withUnit Acquired Pressure Ulcers4 quarter roll up average compared to NDNQI Mean Q4-09 - Q3-102 East 2 West 3 East ICUHVSHNDNQI Meanthe prevalence of unit acquired pressure ulcers and compares that measure to the national mean from NDNQI.For the aggregated past 4 quarters, HVSH has compared favorably.Door to EKG time - In the EmergencyDepartment, the time from when a patient arrivesinto the ED to when they have their EKGcompleted is critical for a cardiac patient. TheAmerican Heart Association has set the target at 10minutes. At HVSH, our average time consistentlyruns well below that target ranging from an averageof 1-3 minutes! Our processes are such that mostpatients are brought directly back to a bed in theemergency department upon arrival.1086420Average time in ED from Door to EKGAHA target = 10 minutesAHA TargetJan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec19

Healthcare Associated Central Line Blood Stream Infections (BSI) andVentilator associated pneumonia (VAP) rates are two measures closely monitored in our ICU. HVSHparticipates in the Keystone ICU collaborative sponsored by the Michigan Health and Hospital Association(MHA) where actions known to prevent these types of infections are “bundled” and implemented on our patients.HVSH continues to be very proud of our outstanding BSI and VAP rates in the ICU – both have been zero for thepast 12 months! This outperforms the Michigan Keystone rate, the NDNQI mean and the CDC NationalHealthcare Safety Network (NHSN) rate at the 25 th percentile! HVSH was acknowledged in the ConsumerReports magazine in March 2010 for our zero central line blood stream infection rate..Ventilator Associated Pneumonia in the ICUcompared to NDNQI Mean3.002.001.000.00Q1 Q2 Q3 Q4 Q1 Q2 Q3HVSH 2.41 2.22 0.00 0.00 0.00 0.00 0.00NDNQI Mean 2.38 1.94 2.17 1.86 1.92 1.74 1.79ICU Central Line Associated Blood StreamInfections Compared to NDNQI Mean2.001.000.00Q1 Q2 Q3 Q4 Q1 Q2 Q3HVSH 0.00 0.00 0.00 0.00 0.00 0.00 0.00NDNQI Mean 1.38 1.29 1.76 1.50 1.15 1.04 0.84Catheter Associated Urinary Tract Infectionscompared to NDNQI Mean4.003.002.001.000.00Q1 Q2 Q3 Q4 Q1 Q2 Q3HVSH 0.00 2.99 0.00 0.00 0.00 1.42 0.00NDNQI Mean 2.12 2.64 2.39 2.47 2.08 2.01 2.08Catheter Associated Urinary Tract Infections(CAUTI)Patients in the ICU frequently have a Foley catheter.Due to their weakened state, ICU patients can bepredisposed to various infections so measures taken toprevent infections are critical. As can be seen in theaccompanying chart, HVSH’s ICU has outperformed thenational mean reported from NDNQI.Peripheral IV infiltration rate –The nursing sensitive indicator used in the pedatricunit is the percent of peripheral IV site infiltrations.HVSH’s Pediatric unit boasts a zero infiltration ratefor more than a year, far outperforming the nationalmean.% of Pediatric Peripheral IV sites with Infiltrationcompared to NDNQI mean1.510.50Q1 Q2 Q3 Q4 Q1 Q2 Q3HVSH 0 0 0 0 0 0 0NDNQI Mean 0.35 1.18 0.18 0.72 1.08 0.84 0.3120

All of these elements were launched simultaneously known as the “Big Bang” implementation; it was a major stepin HVSH’s EMR journey.2010 brought HVSH on line with Electronic Physician/ Resident/ MLP ( mid- level provider) “Powernotes”which provides immediate communication in the EMR to clinicians with History & Physicals, progress notes,consults, discharge summary, operative notes and brief Incident notes. This provides improvements in thetiming that documentation is available to clinicians to drive Clinical decisions as they do not need to wait fordictation, transcription and to be sent to CIS, which can take several days in some cases. Also, this provides amajor improvement in legibility, which has always been an issue with physician's documentation.In December, HVSH was recognized as passing the EMR Leapfrog Certification, meeting criteria necessary forPatient Safety. This was one of many patient safety and quality criteria that HVSH needed to meet to be namedone of four hospitals in Michigan with this prestigious Leapfrog designation.“Meaningful use” – As a result of the Stimulus Bill known as the American Recovery and Reinvestment Act of2009 (ARRA) significant funding from the federal government will be available in 2011 for meeting the identifiedcriteria. HVSH’s electronic medical record was enhanced and HVSH is currently meeting all identifiedMeaningful use criteria as defined by CMS (Center for Medicaid/Medicare Services)The DMC/HVSH was awarded a HIMSS level 6 for our EMR system. From the chart below, you can see that lessthan 3% of the Nation’s hospitals have achieved this level of electronic medical record penetration andsophistication.Other major initiatives in 2010 included implementation of our first multidisciplinary Powerplan along with aSepsis alert. This allows the computer to look at data documented in EMR that may indicate a patient isdeveloping sepsis (a major infection) and sends a communication to the HVSH Rapid Response team alertingthem to go and assess the patient. If the patient is confirmed to be in initial stages of Sepsis, an EMR power planis initiated and early intervention utilizing best practice standards occurs, thus reducing patient mortality ratessignificantly. This is just one of many enhancements and EMR improvements implemented this past year.22

A key satisfier for our Physicians was the development of an Mpage to view their patient’s information from theiriPhone and access to Citrix and CIS (Clinical information system) from the iPad. Remote access to patientinformation is important to continuity of care and the critical communication clinicians require. Several “Mpages”or summaries in the EMR were implemented which help pull information from a variety of places within apatient’s chart to one place to “help tell the patient story”. These Mpages have links that allow the clinician tolook further if more information is needed.The team strived to make the upgrades fun by sponsoring a Funky WOW (wireless on wheels) contest where staffwere encouraged to decorate their WOWs. Pictured below are some of the entries.Shelly DaleMelanie Brandenburg, Marlene Rankin,Martina Delaney, Deb SilvermanThe winner: “Life’s a Beach with EMR”Tera Neirath, Pauline Gaffney, Diana LaBumbard, LizKnoll, Louise Calhoun and Petri BuriSurgiNet, the Operating room version of the EMR was implemented inNovember 2009, and continued on through 2010, resulting in 100%medication scanning in the OR. HVSH was the first Hospital of all Cernerclients to attempt bar code medication scanning in an OR setting to continueour goal of providing the safest/ highest quality care for our patients.Jennifer Dumortier OR staff nurse, made a presentation on how the HVSHOR nurses adopted medication scanning in the OR at the national Cernerclient conference in October 2010.Jennifer Dumortier RNAt that same conference, Linda Bell, RN Clinical Transformation Director atHVSH presented on the Mpages we have developed at HVSH and the DMC.The Emergency Department summary Mpage, designed by Dr. Chris Heberer,Emergency Department Chief has been a significant satisfier for clinicians toreduce the time it takes to view the story of what occurred in the Emergencyvisit.Linda Bell RN23

Exemplary Professional PracticeHVSH 2010 Nurse of the YearLaura Lewellen RN was selected as HVSH Nurse of the Yearfrom among the 14 unit level nurses of the year (shown below).Laura has been with HVSH and the DMC for 21 years. Sheearned her BSN from the University of Michigan. In October2009, Laura achieved certification from the International Boardof Certified Lactation Consultants. She is an active member ofher department’s unit practice council and participates in theareas of breast feeding education and assistance, postpartumdepression screening, perinatal loss and shaken baby education.Laura is also active in her community in her volunteer ministry“Buddy Break” assisting in providing respite care for familiesof special needs children. Laura was honored at the 2010 HVSHHarvest Bash Community Picnic in September.Laura Lewellen RN, BSN, IBCLCHBC/Peds/CCNLouise Calhoun RN Chibuzor Ndukwe RN Kathryn McLean RN Renita Milburn RN3 East 3 West 2 East 2 WestJulie Skidmore RN Patricia Ratka RN Jeanie Kinderman RN Tracey Zacks RNICU Cath Lab Cardiopulm./ Card. Rehab CCTC/IVRT/SWCMichelle Elkin RN Karen Calvo RN Rebecca Muldoon RN Lyndsey Flatt RN Valerie Austin RNFloat Pool MCOU Emergency Dept. OR/ENDO/PAT PACU/POCU24

HVSH 2010 Patient Care Associate of the YearPetri Buri 3 EastMed/Surg (3W, 2W , 3E)The Patient Care Associate Award of Excellence ispresented to the PCA that best exemplifies the characteristicsof competency, caring and outstanding customer service.Petri Buri from 3 East was selected as the 2010 HVSH PCAof the year. Petri has worked on 3 East for the past 4 years.He is currently taking his prerequisites to enter the PAprogram. Petri was acknowledged at a system-wideceremony on Central campus and again during theCommunity Open house in September. Comments from hisnomination included: “Always professional…courteous…respectful” “Can anticipate care in advance” “He always follows through with a task and neverhesitates to help anyone.” “He is quiet and doesn’t talk about personal issues orproblems in front of patients/family ever. He isrespectful to all employees. “Petri is always dressed professional” “In emergency situations he is calm, quick andknowledgeable” “I can remember I offered to walk a patient upon meeting them. Petri was already in there and scheduled a time towalk. The patient wanted to walk with Petri and not me! His patients ask for him by name even when he is off” “I cannot recall Petri having a “bad day”. I think he has only all good days.” “He is extremely hard working and I rarely see him sitting; he’s always busy helping” “I know I am going to have a good night with great supportive PCA care when he is assigned to my patients. Thisallows me to in turn, be a better RN and frees up my time to work closer with patients.”In addition, Petri successfully completed national PCA certification in April.Other department winners included:Valerie FettermanEmergencyDepartmentColeen CharbonneauMCOUCritical Care(ICU/2E /MCOU )Sandy Southerland VATAmbulatory Services(CCTC/FloatPool/ Cardiopulm)Heather DewanHBCTina MeadorPACUPerioperativeCongratulations to the following staff who graduated from nursing school in 2010:Rochelle Holmes RN 3 East earned her ADN from Delta CollegeZhana Bondar RN 2 West earned her ADN from Oakland County Community CollegeKalyn Cookingham RN 2 West earned her ADN from Oakland County Community CollegeDhou Vue RN 3 East earned her ADN from Oakland County Community CollegeLauren Pierowich RN HBC earned her ADN from Oakland County Community CollegeMarie Kaye RN 2 East earned her BSN from Oakland UniversityMaha Hasan RN 2 East earned her BSN from Wayne State UniversityJessica Epley RN 2 East earned her ADN from Oakland County Community CollegeKelsey Horek RN 2 East earned her BSN from Oakland University25

HVSH 2010 Physician Partner of the YearThe 2010 Physician Partner of the Year was awarded to Dr. Sam George at the AnnualMedical staff meeting inOctober. Since 2002 it has beena tradition to honor a physicianpartner of the year – selectedby the nursing staff based oncharacteristics such ascollaboration, respect, patientadvocacy, willingness to teach,patient care excellence andL-R: Karen Haneline RN, Pat Kampmann-Bush RN, Janet Hoover RN, Dr. Sam George,Kathy Brooks-Fava CRNA, Kaumea Dato CRNAcommunication. Nominationsfor Dr. George cited his respectfor nursing, his collaborativenature, his calm demeanor in a crisis, and how he takes the time to teach after the situation isresolved. Several nominations were received this year from all areas of practice. Otherphysicians deserving honorable mention include: Dr. Binesh Patel from the ED, Dr. Dhanjalintensivist, Dr. Jamie Taweel Internal Medicine and Dr. Larry Mac Donald pulmonologist.2010 Nightingale Winner –Advanced Practice CategoryPat Clark DNP - was selected as 2010 Nightingale Winner in theAdvanced Practice Category. The Nightingale awards are cosponsoredby Oakland University and hospital systems throughoutMichigan. Nominations are submitted from all over the State andare scored on several categories including professionalachievements, community service and participation in professionalorganizations. Pat was honored at a dinner at the San Marino Clubduring Nurse's week in May with about 800 in attendance. This is atremendous honor and is well deserved by Pat for her outstandingperformance as an advanced practice nurse.Patricia Clark DNPIn 2010 Pat’s poster abstract titled, Using Nurse-Driven Protocols to Effectively ManageElectrolyte Imbalance and Stress Hyperglycemia in Critically Ill Patients, was accepted forpresentation at the 2010 National Magnet Conference. Her poster was selected from among the1600 posters submitted.We celebrate the milestone of retirement with the following nurses…Geri Koby RN, BSN, NE-BC Administrative Director Women’s and Children Services at HVSH since 1986.Geri retired at the end of October. Under Geri’s leadership, the Harris Birthing Center progressively implementedevidence based best practices and achieved patient satisfaction scores in the 99 th percentile.Kimberly Wojnarski RN retired most recently from 3 East. She hired on with the DMC in 1976 at GraceHospital as Nurse Associate and then as staff nurse. She came to HVSH 2/10/1986.Leigh Sowles RN hired on at the DMC at Grace Hospital in 1980 and came to the HBC in 1986Sharon Shulick RN retired from 2 East this year and has been with HVSH since 1986Connie Demar RN retired from the recovery room and had been with HVSH since 1986Geri, Kim, Leigh, Sharon and Connie were all HVSH nurses since we opened our doors in 1986!Sheila Potter RN from 3 West retired after 15 years of service with HVSH. She hired in 9-11-1995Dot Kempf RN began 9/10/1990 as a Staff Nurse in Pediatrics and retired from Customer Service in March 2010.26

DAISY is an acronym for "Diseases Attacking the ImmuneSystem” This is a national award program formed by thefamily of J. Patrick Barnes who died at age 33, ofcomplications of an immune disease. Pat's family initiatedthe DAISY award program to memorialize their son byrecognizing "unsung nursing heroes who work at the bedside". The DAISY award program was kicked off atHVSH October 1 st with cake and Cinnabons. The Cinnabons are a tradition at the DAISY award presentations.Nurses are nominated by patients and their families for thecompassion and caring they exhibit toward their patients. Thisprogram has been endorsed by Magnet and the ANCC. Afterreviewing the program ourPNC council felt that it wassomething that they would liketo implement. The program iscompletely coordinated by ourProfessional Nurse Counciland they will award the firstrecipient in early 2011. TheGet Well Network isL-R: Surita Seiben, Bette Fitz, Lynn Arnautunderwriting the expenses tothis program for our first year. Patients can nominate a nurse using the GetPat Kampmann-Bush serving upCinnabons at the DAISY KickoffWell Network on the TVs in their rooms or by completing a paper form.By December we already had over 100 nominations. More informationabout the DAISY foundation can b e found at www.DAISYfoundation.orgEmployee of the MonthThe following staff members from Patient Care Services were acknowledged in 2010 asEmployees of the month:Chris Bergman Lori Durbin Frank Quinn RN Judy Moore RNPCA ICU Nursing Office Coordinator Cath Lab IMCUIn Remembrance of…Markie Saghaiepour RN of 2 West for 22 years, who lost her battle with cancer on September 30 th .Markie had been with HVSH since 1988. Markie was a wonderful, compassionate, therapeuticnurse. Her expertise in homeopathy and alternative medicine went beyond the traditional nursingrole. Her knowledge and wisdom extended to her patients and to anyone who sought her advice fortheir family member,friend and even pets.27

Community InvolvementHVSH nurses are committed to our community, participating in activities that support the community. Some ofthe events in 2010 included:Big shot program –our annual free community flu shot clinic, offered October 28 th in the Krieger center forcommunity members who were interested in receiving the influenza vaccine. 125 people were immunized and thefollowing nurses helped support this event; Penny McPhee RN, Diana LaBumbard RN, Tracy Abbo RN andMichelle Ming RN.Harvest Bash Community Picnic- was held September 12 th offering family fun,games, hospital tours and health information about stroke, heart attacks and otherconditions as well as health screenings including prostate cancer screening, bloodpressure and body fat analysis among others. The event was staffed by many HVSHemployees including: Kathy Goll RN, Shelley Killebrew RN, Lisa Frantti RN, Tina CooRN, Tobe Unaegbu RN, Autumn Galleher UC, Linda Bell RN, Linda Habitz RN, KarenMoore RN, Bette Fitz RN, Tracy Abbo RN, Paul Reichert RN, Lisa Weiss RN, KellyHojnacki RN, Jo-Ann Smith RN, Karen Emler RN, Gayl Hubler RN, Diana LabumbardRN, Deb Kraft RN, Beth Leon RN, Rob O’Conner RN (pictured left), Janet Tucker,Lois Larson, Linda Miller RN and Geri Koby RN.Emergency Services, Community health and Laboratory Services worker togetherto support the Fire Fighter Challenge, a competition between local fire fighters fromWalled Lake and Commerce Township in a pilot program to enhance fire fighter health. The firefighters attendeda 12 week class related to healthy living and personal training. HVSH provided body fat analysis and baseline labtests to measure their success.Carol Devore RN took part in the Jewish Community Centers Book Fair that was sponsored by HVSH inNovember. Carol served as the medical expert for an author who was presenting a book she had written on herexperience with ovarian cancer and genetics. Carol had a table with information related to ovarian cancer and ourCharach cancer treatment center.Diana Bowman RN, Karen Emler RN, Janet Tucker RN and Gayl Hubler RN sponsoreda mitten tree to collect children's mittens, hats and scarves. Over 150 articles were donated toDolsen Elementary School in New Hudson (South Lyon School District) to help the manyfamilies that are struggling and don't have the resources to providefor these very much needed items.For more than 13 years, since her son was in the 6 th grade, GailMcCarthy RN in the Emergency Department has collected usedprinter cartridges from around the hospital to pass on to HighlandMiddle School who then turns them into a recycling company in exchange forcomputer or camera equipment, PE equipment and otherneeded items.Every year several nurses support the Annual Women’s Expo held in Novi to sharehealth information about multiple women’s issues. Pictured right are Beth Leon RNand Debra Kraft RN, just two of the many nurses that volunteer their time at thisworthwhile event.Carol Devore RN and Melissa Mayes RN from the Charach Cancer Treatment Center provided educationalinformation on self breast exams, breast cancer, the importance of early detection and regular mammogramsduring the “Ladies Night Out” event in Milford.Bike 4 Breast Cancer –a fund raising bike event held at Kensington Metro Park in Milford. The event included76 participants and raised funds for Sister Hope Retreat and Five Points of Light. Breast Cancer Awareness andeducational information was provided on behalf of the Sinai Center for Women with an RN in attendance toanswer questions.28

ProfessionalCertificationsProfessional DevelopmentProfessional Certification is achieved followingsuccessful completion of a national certifying exam.HVSH celebrates the contribution of board certifiednurses to the advancement of nursing professionalism andto higher standards and better outcomes in patient health.In fact, the American Association of Critical Care Nurses(AACN) has linked certification to fewer medical errors, increased job satisfaction, and greater professionalconfidence among nurses. HVSH has focused resources and support to assist staff in reviewing for variouscertification exams. Nurses were honored on March 19 th National Certified Nurses DayThe following HVSH Nurses have achieved Professional CertificationBoard CertifiedAntony, Molly MSNC, ONCAttar, Cathy RNCBass, Sharon RNCBiondo-Smith Matt MSNCCalvo, Karen CVNEClark, Patricia ACNP, ACNS, CCRNCunningham, Paula MSNC, ONCCurl, Teri CNORDepompolo, Darla MSNCDevore, Carol OCNDrake, Linda CNOREmler, Karen NE-BCEngle, Barbara GNC, OCN, MSNCFagnani, Layne GNCFambrough, Debra RNCFitz, Bette NEA-BCGoll, Kathleen ONC NE-BCHabitz, Linda CNORHelm, Elizabeth CCRNHojnacki, Kelly NE-BCHolmes, Kristine RNCHubler, Gayl CENHunter, Elaine CNORHurley, Lisa CENJackson, Pat CCRNJohnson, Deborah CFNPKern, Laura CGRNKillebrew, Shelley CNORKobBoard CertifiedLaBumbard, Diana ACNP, CCRNLeon, Elizabeth NE-BCLewellen, Laura IBCLCLingham, Roberta GNCLoszewski, Pamela CCRNMayes, Melissa OCNMcAvoy, Kari ONC, MSCMiller, Linda IBCLC, WHCNPMing, Michelle ONCMiron, Roberta RNCNdukwe, Chibu MSNCNorman, Toni MSNCO'Brien-Reno, Julie CENPawloski, Lisa OCNPierson, Deborah MSCPlotzke, Deb CCRNShaffer, Dolly OCNSkidmore, Julie CCRNSmith, Jo-Ann NE-BCSmolyn, Sharon RNCSutton-Jones, Sara SANE, FNETucker, Janet NE-BCVanOmen, Patty OCN, CBCNWetzel, Sally OCNWilliams, Denise GNCWithrow, Gail OCNWoodford, Linda RNCWright, Dana RNCZehely, Geri NE -BC , Rebecca CDECBCN Certified Breast Patient Navigator IBCLC International Board Certified Lactation ConsultantCDE Certified Diabetic Education MSNC Certified Med-Surg NurseCEN Certified Emergency Nurse NE Certified Nurse ExecutiveCFNP Certified Family Nurse Practitioner NEA Certified Nurse Executive AdvancedCGRN Certified Gastroenterology Nurse OCN Oncology Certified NurseCNOR Certified OR Nurse ONC Orthopedic Nurse CertificationCVNE Certified Cardiac Vascular Nurse RNC Certified inpatient OB, pediatrics or NICUFNE Forensic Nurse Examiner SANE Sexual Assault Nurse ExaminerGNC Certified Geriatric Nurse WHCNP Women’s Health Certified Nurse Practitioner“It was alot of hard work and I’m so glad the hospital promotes nursing excellence. I was happy to learn thehospital offered a review class and would pay for the exam, it was a great help. ..” Julie O’Brien Reno29

PCA Certification - The first ever PCA certification class was offered at the DMC March30th and again August 31 st with on-site testing.Congratulations to the 8 HVSH PCAs that successfully passed the exam.Kim Miller Gigel Petibota Petri Buri Gina VanderburgCatherine Weir Sandi Pitcock Heather Nelson Vicky RubinoSharing our knowledgeMagnet organizations are expected to share their knowledge with others.The following are examples of sharing knowledge.Greg Bozimowski CRNA has written an article entitled "Patient perceptions of pain management therapy: Acomparison of real time assessment of patient education and satisfaction and registered nurse perceptions" whichhas been accepted for publication in Pain Management Nursing to be published in spring 2011.Tracy Abbo RN submitted an article on customer service (Eye-to-Eye) for publication to Nursing Spectrum.Becky Muldoon RN from the Emergency Department presented “Family Presence during emergencyprocedures” to the group attending the statewide annual RN-AIM conference in Lansing September 23&24.Carol Devore RN presented a poster authored by her, Dolly Shaffer RN and Melissa Mayes RN entitled:“Improved patient education outcomes through development of the care coordinator role in an outpatientoncology center” at the 2010 International Cancer Patient Education Conference in San Diego from October 24ththrough the 27th. This is a collaborative effort between the Cancer Patient Education Network (CPEN), AmericanAssociation of Cancer Education (AACE) and the International Association of Cancer Education (IACE).Carol also presented 2 posters developed by Patti Van Omen RN and Chrisie Deming RN entitled “Sentinellymph node biopsy” and “Breast care nurse navigation” at the same conference.Diana LaBumbard APN had a poster at the Wayne State College of Nursing Research Day on GeriatricResource Curriculum and nurses attitudes and increase knowledge from participating in core curriculum courses.Diana also submitted (2) posters “Alliance for The Ages: Geriatric Interdisciplinary Teamwork is Central toQuality Care and Improved Outcomes for our hospitalized Elders.” Our Journey to Geriatric Certification:Improving Patient Outcomes, Patient Satisfaction, and Nurse/Physician Satisfaction.” to the 13 th annual nationalNICHE conference April 21- 23 in Baltimore, Maryland and to the National 2010 Conference on GeriatricEvidence-Based Practice June 24, 2010 in New Jersey and to the Gerontological Advanced Practice NurseAssociation National Conference held September 23, 2010 in Albuquerque, NM. “Alliance for the Ages” postertook first place at these most recent 2 conferences and will be published in the journal Geriatric Nurse.Jen Dumortier RN and Linda Bell RN presented at the annual national Cerner conference in October. Jendiscussed caremobile and the scanning process/ benefits and issues. (also see page 24 for more)Tuesday Teas – in March, Laura Kern certified endoscopy RN delivered a presentation on colorectal cancer tohelp increase awareness. March is designated as National Colorectal Cancer Awareness month.HVSH is participating in the Michigan Magnet Coalition which is composed of all 13 Magnet designatedhospitals in Michigan. Surita Sieben is on the steering committee of this newly formed group. The goal is toshare information amongst hospitals as well as to join together to conduct a group research project. The groupmet for the first time in October 2010. Attendees from HVSH included: Carol Devore, Cathy Grant, ShellyKillibrew, Surita Sieben and Bette Fitz. Pat Clark DNP represents HVSH on the Research subcommittee.30

EBP poster day sponsored by the EBP council was offered during Nurse’s week. 27 Posters authored by 34different nurses were on display for staff to obtain CE by viewing posters and completing CE requirements. Manyposters were also displayed again in August for the Circle of Influence meeting held at HVSH. See list below.Poster TitleBreast NavigationNoise in the Recovery Room: SHHHH!!!!Have you cleaned your stethoscope todayEffects of Comfort Care RoundsSBAR: Effective communication improves patient outcomes.Preventing Post-op Complications-How Evidenced –Based Nursing Practice leads to positive OutcomesGeriatric AssessmentEvidence about Surgical patient skin antisepsis: Chloraprep vs. Beta dine and Dura prep.Stop Smoking in the ORA Feeding Care Map for ELBW InfantsDVT ProphylaxisHyperbili Kids; Treatment and The Effects On The Jaundiced Neonate In The Pediatric UnitOur Journey to Geriatric Certification: Improving Patient Outcome, Patient Satisfaction, and Nurse/PhysicianSatisfactionAlliance for the Ages: Geriatric Interdisciplinary Teamwork is Central to Quality Care and ImprovedOutcomes for our Hospitalized EldersThe Cardio-protective Importance of Beta BlockersColorectal cancer screeningNeeds of the amazing newborn: what does the evidence tell us?Quality Initiatives: What Does It All Mean?Non pharmaceutical pain management of the newbornUtilization of patient acuity tool preoperativelyPrevention of metabolic derangements in critically ill patients with standardized protocolsTo swab or not to swab."Antioxidants and Radiation Therapy: Controversy of Use During Treatment”Is premedication needed for the ERCP patient allergic to IV iodine?Complications in Obstetric Anesthesia: the Nursing's Role to Anticipate, Recognize, and RespondIs medication the only treatment for depression?Focus: Eye to Eye Initiative in HBCAuthor(s)Chrissie Deming andPat Van Omen CCTCKaren Haneline PACUDebra Elkins – 3 WBarb Engle andNicole Regan – 3 EDiana Clafton – 3 EPaula Cunningham 2WDenise Williams 2WAmy Wilenius andTina Miceli, SurgicalServicesLinda Drake - ORJudy Nash - CCNMolly Anthony 3WLinda WoodfordLinda Schultz PedsLynn Etters,Reva Klar, DianaLaBumbard, MSCCLynn Etters, DianaLaBumbard, MSCCTeresa Morgan RN PACUPatrick Wozny, RN(EMU Grad Student)Linda Miller, HBCDeb Brennan - HBCDeb Kraft - CCNPat Lucas – Pre-opPam Loszewski, RNPat Clark, DNP - ICUCharlotte FenwickDenise O'Neill PATCarol DeVore CCTCLisa Chadderdon andDeb Wilkinson EndoLinda Miller HBCPat Patrello andLaura Lewellen HBCDeb Brennan - HBCStudent placements at HVSHcontinue to rise…TOTAL CLINICAL PLACEMENTS AT HVSH25Numer ofClinicalGroups201510511 12 15 18242302007-2008 2008-2009 2009-2010FALL 11 15 24WINTER 12 18 2331

Nursing Grand RoundsProviding opportunity for professional continuing education credit is a priority at HVSH. Thefollowing programs were offered for our nurses through our Nursing Grand Rounds1/13/10 2009 Magnet Conference Update1/20/10 The Undertaking: Good Death, Grief,funerals on mortals and mortality2/17/10 The Undertaking: Good Death, Grief,funerals on dying3/15/10 Hearing Communication needs for the deaf3/17/10 The Undertaking: Good Death, Grief,funerals on Grief4/21/10 The Undertaking: Good Death, Grief,funerals on Faith and Wonder5/12/10 Hand Hygiene - Dr. Gordon5/ 19/10 The Undertaking: Good Death, Grief,funerals on funerals5/26/10 Elder Care6/9/10 Hand Hygiene - Dr. Gordon7/14/10 Mobility presented by Hill Rom7/28/10 Care of the Islamic Muslim patient8/30/10 Understanding and Respecting theobservance of Jewish Holidays9/8/10 Influenza Update9/17/10 Applying Principles of Bioethics to ClinicalDecisions10/13/10 Understanding Family Dynamics11/11/10 Adult Immunizations12/09/10 Lessons from the 2010 Magnet ConferenceAttendance to the National Magnet Conference in Phoenix Arizona– All nurses interested inattending the October 2010 Magnet NationalConference were invited to submit a letter ofinterest. HVSH was specially recognized at theconference as one of the Magnet hospitalsdesignated within the past year. To celebrate thisspecial honor, Lynn Torossian, HVSH Presidentaccompanied Bette Fitz VP PCS, the nursingdirectors and others representing the managers,APNs/educators and staff nurses. Attendees couldparticipate in more than 100 different educationalsessions over a course of 3 days to learn about bestpatient care practices nationally.Pat Clark presented her poster abstract titled, UsingNurse-Driven Protocols to Effectively ManageElectrolyte Imbalance and Stress Hyperglycemia inCritically Ill Patients, Her poster was selected fromamong the 1600 posters submitted. Otherssubmitting from HVSH: Linda Miller (Verifyfeelings, Offer help - Perinatal Adjustment SupportServices), Tracy Abbo (Eye-to-Eye) and GaylBack Row L-R: Jo-Ann Smith, Pat Clark, Carol Conte, DollyShaffer, Bette Fitz, Trish Barrowcliff, Barb Engle, Kelly Hojnacki,Geri Koby, Lynn Torossian, Surita Sieben, Monica Walker, CathyGrant and Karen EmlerHubler (Stroke care using telecommunication andthe electronic medical record)Patricia Clark DNP32

Code of Ethics for Nurses1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity,worth, and uniqueness of every individual, unrestricted by considerations of social or economic status,personal attributes, or the nature of health problems.2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.4. The nurse is responsible and accountable for individual nursing practice and determines the appropriatedelegation of tasks consistent with the nurse’s obligation to provide optimum patient care.5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity andsafety, to maintain competence, and to continue personal and professional growth.6. The nurse participates in establishing, maintaining and improving health care environments and conditions ofemployment conducive to the provision of quality health care and consistent with the values of the professionthrough individual and collective action.7. The nurse participates in the advancement of the profession through contributions to practice, education,administration, and knowledge development.8. The nurse collaborates with other health professionals and the public in promoting community, national, andinternational efforts to meet health needs.9. The profession of nursing, as represented by associations and their members, is responsible for articulatingnursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.___________________________________________________________________________________________Nurses' Bill of Rights1. Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receivenursing care.2. Nurses have the right to practice in environments that allow them to act in accordance with professionalstandards and legally authorized scopes of practice.3. Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance withthe Code of Ethics for Nurses and its interpretive statements.4. Nurses have the right to freely and openly advocate for themselves and their patients, without fear ofretribution.5. Nurses have the right to fair compensation for their work, consistent with their knowledge, experience, andprofessional responsibilities.6. Nurses have the right to a work environment that is safe for themselves and their patients.7. Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, inall practice settings.~Adopted by the ANA Board of Directors: June 26, 2001~Disclaimer: that this is an ANA consensus but "does not necessarily reflect the rights embodied in state and federal law".33

2011 Nursing Leadership TeamVice President Patient Care Services, Chief Nurse ExecutiveBette Fitz RN, BSN, MBA, NEA-BC, FABCAdministrative DirectorsCathy Grant RN, BSNKelly Hojnacki RN, BSN, MSA NE-BCKaren Moore, CRNA, MSDirectorsKaren Emler RN, BSN NE-BCJo-Ann Smith RN, BSN, MSN NE-BCBeth Leon RN, BSN, MSA, NE-BCLinda Habitz RN, BSN, CNORClinical ManagersMichelle Ming RN, BSN, MSN, ONCKathleen Goll RN, BSN, MSA, ONC, NE-BCTina Coo RN, BSNMaureen Heathman RN, BSNVacantJanet Tucker RN, BSN, MSN, MBA, NE-BCRobert O’Connor RN, ADNNancy Briody RN, BSNMonica Walker RN, BSNCancer Services, Quality, Epidemiology and ComplianceMed/Surg, Critical CareSurgical and Anesthesia ServicesEmergency Service, Cardiac ObservationNursing OperationsWomen’s and Children’s ServicesSurgery/Endoscopy/Pre-Admission testing2 West Orthopedics/Neuro2 East TelemetryIntensive Care/IMCU and 3 West Med/Surg3 East Oncology/Med/Surg and HemodialysisHarris Birthing Center/Post PartumEmergency ServicesCardiology/Rehab ServicesCath Lab/Interventional RadiologyPre-op/Post Anesthesia UnitsPain Service ManagerNurse RecruiterGreg Bozimowski CRNA, MS Paul Reichert, RN, BSN HR GeneralistClinical Transformation DirectorMagnet Recognition Program Manager,Linda Bell RN, BSN epidemiology Surita Sieben RN, BSNCustomer Services/ Friends and FamilyTracy Abbo RN, BSNAdministrative SupervisorsDiana Bowman, RN, BSNAngela Cusick, RN, ADNJulie Richey, RN, BSNAdvanced Practice NursesLois Larson, RN, BSN, MSN,Pat Clark RN DNP, ACNP-BC, ACNS-BC, CCRNDiana LaBumbard, RN, MSN, APN-BCDeborah Johnson, RN, MSN, FNP-BCLinda Miller, RN, MSN, IBCLC, WHNPEducatorsGayl Hubler, RN, BSN, CENShelley Killebrew, RN, BSNPenny McPhee, RN, BSN, MLSJennifer Palace, RN, BSNProfessional Nurse CouncilLynne Arnaut RN, BSN – ChairPatricia Kampmann-Bush RN, BSBS Chair ElectKate McLean, RN, BSN -PNC Past ChairDirector, Clinical Resource ManagementDan Keehner RN, BSN, MSN, ACMLinda Simons, RN, ADNAlicia Koroenek, RN, BSNLisa Hurley, RN, BSNMed/Surg Critical CareCritical CareMed/Surg Critical CareOccupational Health ServicesWomen’s and Children’s ServicesEmergency Service, Cardiac ObservationSurgical ServicesGeneral NursingGeneral NursingStaff Nurse ORStaff Nurse PACUStaff Nurse 2 East34

For more information please visit us at : http://www.hvsh.org/nursingHuron Valley Sinai Hospital1 William Carls DriveCommerce Township, MI 4838235