Nursing Annual Report - UNM Hospitals - University of New Mexico

INTRODUCTIONPage 3From Our Chief Nursing OfficerDear Nursing Colleagues,Another year has flown by! Is anyone else as surprised as I am that we are already intoϮϬϭϯĂŶĚĐŽŵƉůĞƟŶŐŽƵƌĂŶŶƵĂůƌĞƉŽƌƚĨŽƌĂůĞŶĚĂƌzĞĂƌϮϬϭϮ͍ dŚŝƐĂŶŶƵĂůƌĞƉŽƌƚŝƐĂŶƵƉĚĂƚĞŽĨĂŶŽƚŚĞƌǀ ĞƌLJƐƵĐĐĞƐƐĨƵůLJĞĂƌĨŽƌŶƵƌƐŝŶŐĂƚĂĐƌŝƟĐĂůƟŵĞŝŶŚĞĂůƚŚĐĂƌĞ͊ Ɛǁ ĞƌĞǀ ŝĞǁ ƚŚĞĐŽŶƚƌŝďƵƟŽŶƐďLJŽƵƌƉƌŽĨĞƐƐŝŽŶĂƌŽƵŶĚƚŚĞƚƌŝĂĚŽĨĞĚƵĐĂƟŽŶ͕ ƌĞƐĞĂƌĐŚ͕ ĂŶĚƉƌĂĐƟĐĞ͕ ŝƚŝƐƉƌĞƩ LJĐůĞĂƌƚŚĂƚǁ ĞĂƌĞƚŚŝŶŬŝŶŐĂďŽƵƚŽƵƌƉƌĂĐƟĐĞŝŶŶĞǁ ǁ ĂLJƐ͘ ŐĂŝŶƚŚŝƐLJĞĂƌǁ Ğ͛ ǀ ĞĚŽŶĞŵƵĐŚƚŽǁ ĂƌĚŽƵƌŐŽĂůƐ͕ ĂŶĚŵŽƐƚĞdžĐŝƟŶŐ͕ ŽƵƌŐŽĂůƐĂƌĞŝŶĐŽŵƉůĞƚĞƐLJŶĐŚƌŽŶŝnjĂƟŽŶǁ ŝƚŚƚŚĞ/ŶƐƟƚƵƚĞŽĨD ĞĚŝĐŝŶĞ͗ &ƵƚƵƌĞŽĨE ƵƌƐŝŶŐƌĞĐŽŵŵĞŶĚĂƟŽŶƐ͘CNO Sheena FergusonIn Our Efforts to Enhance ĚƵĐĂƟŽŶ KƉƉŽƌƚƵŶŝƟĞƐĨŽƌ^ƚĂīNursing Pipeline͗ ŽŶŐƌĂƚƵůĂƟŽŶƐƚŽϭϴŽĨŽƵƌWdƐĂŶĚD Ɛǁ ŚŽĐŽŵƉůĞƚĞĚƚŚĞŝƌ͘ ͘ E ͘ ŝŶĞĐĞŵďĞƌŽƌD ĂLJĂŶĚĂƌĞǁ ŽƌŬŝŶŐŽŶŶƵƌƐŝŶŐƉŽƐŝƟŽŶƐ͊ D ŽƐƚĂƌĞĂůƌĞĂĚLJĞŶƌŽůůĞĚŝŶ^E ƉƌŽŐƌĂŵƐ͘ “BSN in ‘10” - 80% of nurses will have their BSN by 2020. Approximately 58% of our staff are working toward theirBSN or higher degree! We are following the progress on each unit, and the trend is excellent!Prepare nurses to lead͗ hE D , ŝƐĂƚƚŚĞϳ ϱƚŚƉĞƌĐĞŶƟůĞŶĂƟŽŶĂůůLJĨŽƌŶƵƌƐĞƐǁ ŝƚŚĂŵĂƐƚĞƌƐŽƌĚŽĐƚŽƌĂƚĞ͘ ůůŽĨŽƵƌUDs have a BSN or a bridge to MSN. The MSN is required for Unit Directors by 2014. UNMH is exceeding MagnetĞdžƉĞĐƚĂƟŽŶƐǁ ŝƚŚƚŚŝƐƌĞƋƵŝƌĞŵĞŶƚ͘ dŚŝƌƚLJŽĨŽƵƌƐƚĂī ĐŽŵƉůĞƚĞĚƚŚĞŝƌ^E ŽƌD ^E ƚŚŝƐƉĂƐƚLJĞĂƌ͖ Ɛŝdžǁ ŝƚŚƚŚĞŝƌE W͊Double the number of nurses with a doctorate (PhD or DNP in Nursing). We have three staff members that wereaccepted into a PhD program in 2012! A UNMH cohort of eight is planned to start a DNP in several programs this^ƵŵŵĞƌϮϬϭϯ͘ ŽŶŐƌĂƚƵůĂƟŽŶƐ͊ WĂƌƟĐŝƉĂƚĞŝŶ>ŝĨĞůŽŶŐ>ĞĂƌŶŝŶŐ͗ t ĞŚĂǀ ĞŝŶĐƌĞĂƐĞĚŽƵƌdƵŝƟŽŶZĞŝŵďƵƌƐĞŵĞŶƚďƵĚŐĞƚƚŽũƵƐƚƐŚŽƌƚŽĨΨϭŵŝůůŝŽŶ͘ ůŝŶŝĐĂůĚƵĐĂƟŽŶŝƐůĞĂĚŝŶŐƚŚĞǁ ĂLJǁ ŝƚŚĂƐƐĞƐƐŵĞŶƚŽĨĞĚƵĐĂƟŽŶĂůƉƌŽŐƌĂŵŝŵƉĂĐƚƚŚƌŽƵŐŚŽŶůŝŶĞǀ ŝĂ^t E

SPOTLIGHT Page 6Why Do I Work at UNMH?Why do I work at UNMH? I definitely felt a sense ofexcitement when I interviewed here five years ago — it'sthat intangible—'something' that only teachinghospitals possess. This energy is what drew meto this facility--and it has made me stay. Thingsare always changing for nurses here, fromcomputer systems, to evidence-basedƉƌĂĐƟĐĞƐ͕ ƚŽƚŚĞWĂƚŚǁ ĂLJƐƚŽdžĐĞůůĞŶĐĞprogram. And when things change, theyƌĞŵĂŝŶĚLJŶĂŵŝĐĂŶĚĞdžĐŝƟŶŐ͕ ǁ ŝƚŚŶĞǁ ůĞĂƌŶŝŶŐŽƉƉŽƌƚƵŶŝƟĞƐĨŽƵŶĚĞǀ ĞƌLJǁ ŚĞƌĞ͘And a big change /Ζǀ ĞŶŽƟĐĞĚƐŝŶĐĞĂƌƌŝǀ ŝŶŐŚĞƌĞŝƐƚŚĞƐŚŝŌŝŶĞŵƉŚĂƐŝƐƚŽŐĞƚŽƵƌŶƵƌƐĞƐŶĂƟŽŶĂůůLJĐĞƌƟĮ ĞĚ͘ ƐŝĚĞĨƌŽŵƚŚĞƐƚŝŶƉĂLJ͕ ĐĞƌƟĮ ĐĂƟŽŶŵĞĂŶƐwe are personally invested in the nursing profession. HavingďĞĞŶĐĞƌƟĮ ĞĚŝŶƚǁ ŽĚŝī ĞƌĞŶƚĂƌĞĂƐŝŶƚŚĞƉĂƐƚ͕ /ĂůƌĞĂĚLJƵŶĚĞƌƐƚŽŽĚŚŽǁ ƉƌĞƐƟŐŝŽƵƐĐĞƌƟĮ ĐĂƟŽŶǁ ĂƐ͘ t ŚĞŶ/Į ŶĂůůLJI knew I had done the right thing, because I set anĞdžĂŵƉůĞĨŽƌŽƚŚĞƌŶƵƌƐĞƐƚŽƉƵƌƐƵĞĐĞƌƟĮ ĐĂƟŽŶĂŶĚďĞƩ ĞƌƚŚĞŝƌĐůŝŶŝĐĂůƉƌĂĐƟĐĞƐ͘UNMH also is invested in our nursingprofession. We offer classes to prepare for“And when thingsĐĞƌƟĮ ĐĂƟŽŶŝŶĐĞƌƚĂŝŶƐƉĞĐŝĂůƟĞƐ͕ ĂŶĚĂůůŽǁ change, they remain ŽƵƌŶƵƌƐĞƐƟŵĞƚŽĂƩ ĞŶĚƚŚĞŵ͘ &ŽƌƚŚŽƐĞĚLJŶĂŵŝĐĂŶĚĞdžĐŝƟŶŐ͕ ƐƉĞĐŝĂůƟĞƐǁ ŝƚŚŽƵƚĂŶLJĐůĂƐƐĞƐ͕ ŵŽƟǀ ĂƚĞĚwith new learningŽƉƉŽƌƚƵŶŝƟĞƐ͘ ͘ ͘ ͟ƐƚƵĚŝĞĚĨŽƌĂŶĚƌĞĐĞŝǀ ĞĚŵLJĐĞƌƟĮ ĐĂƟŽŶŝŶŵďƵůĂƚŽƌLJĂƌĞ͕ nurses have made their own resources andshared them with other staff that seekĐĞƌƟĮ ĐĂƟŽŶ͘ t ĞĂůƐŽŽī ĞƌƟŵĞƚŽŐŽƚŽĐŽŶǀ ĞŶƟŽŶƐ͕ ƐĞŵŝŶĂƌƐ͕ ĂŶĚƚŽĂƩ ĞŶĚŚĞĂůƚŚ-relatedclasses that benefit ourselvesĂŶĚŽƵƌƉĂƟĞŶƚƉŽƉƵůĂƟŽŶ͘ Who wouldn't want to beemployed by a facility that sovalues their nurses?Terry Norvell, RN-BC BSN, MSOP Nursing Float Pool RNĞƌƟĮ ĐĂƟŽŶŽƵŶƚƐ͊ E ƵƌƐĞ͛ Ɛ^ƚŽƌLJĞŝŶŐŶĂƟŽŶĂůůLJĐĞƌƟĮ ĞĚdemonstrates the high level ofĚĞĚŝĐĂƟŽŶ/ŚĂǀ ĞĨŽƌƚŚĞƉƌŽĨĞƐƐŝŽŶŽĨnursing.As a leader it is important to encourageexcellence from my staff, andďĞŝŶŐĐĞƌƟĮ ĞĚƐĞƚƐĂŶĞdžĂŵƉůĞĨŽƌthem to follow — it shows myemployers, co-workers, and evenƉĂƟĞŶƚƐƚŚĂƚ/ĂŵĐŽŵŵŝƩ ĞĚƚŽďĞŝŶŐhighly educated and qualified as aprofessional nurse, which enables meƚŽƉƌŽǀ ŝĚĞĞdžĐĞůůĞŶƚƉĂƟĞŶƚĐĂƌĞ͘ĞŝŶŐĐĞƌƟĮ ĞĚŚĂƐŽƉĞŶĞĚĚŽŽƌƐĨŽƌme both personally and professionallyĂůůŽǁ ŝŶŐƉƌŽŵŽƟŽŶƐ͕ ĚŽĐƚŽƌĂůƐĐŚŽŽůacceptance, and personal growth andƐĂƟƐĨĂĐƟŽŶ͘ /ĞŶĐŽƵƌĂŐĞĞǀ ĞƌLJŶƵƌƐĞƚŽƉƵƌƐƵĞŶĂƟŽŶĂůĐĞƌƟĮ ĐĂƟŽŶ͘Meaghan M. White, MSN, RN, CENRN Supervisor/ŶƚĞƌǀ ĞŶƟŽŶĂůZĂĚŝŽůŽŐLJ;/Z

SPOTLIGHTPage 7Shaping Our CultureOver the last few years, we have worked hard as anŽƌŐĂŶŝnjĂƟŽŶƚŽŝŵƉƌŽǀ ĞŽƵƌ^ŚĂƌĞĚ' Žǀ ĞƌŶĂŶĐĞĐŽƵŶĐŝůƐ͕ both at the hospital and unit levels. When we startedlooking seriously at our path to Magnet, we decided to startǁ ŝƚŚWĂƚŚǁ ĂLJƚŽdžĐĞůůĞŶĐĞĚĞƐŝŐŶĂƟŽŶ— and we did it inƐŝdžŵŽŶƚŚƐ͘ dŚĞŝŶĨŽƌŵĂƟŽŶǁ ĞŐĂƚŚĞƌĞĚĂďŽƵƚŽƵƌĐƵůƚƵƌĞand our Shared Governance revealed that we needed tostep it up.Many leaders and staff shared that they felt that SharedGovernance wasn’t working for myriad reasons — most ofwhich stemmed from not really understanding the process,ŽƌŚŽǁ ƚŽĚŽŝƚ͘ dŚŝƐŝŶĨŽƌŵĂƟŽŶǁ ĂƐƐŚĂƌĞĚǁ ŝƚŚŶƵƌƐŝŶŐleadership, and the Magnet Program Manager startedleading in-ƐĞƌǀ ŝĐĞƐŽŶŚŽǁ ƚŽŝŵƉůĞŵĞŶƚĞī ĞĐƟǀ Ğ^ŚĂƌĞĚGovernance. Even though this helped, the MagnetŚĂŵƉŝŽŶƐƐƟůůĨĞůƚůŝŬĞǁ ĞĐŽƵůĚĚŽďĞƩ Ğƌ͕ ƐŽŝŶϮϬϭϯǁ Ğwill offer Shared Governanceclasses throughout the year aspart of our basic infrastructure.“Everyone thinksof changing theworld, but noone thinks ofchanging himself.”We also started focusing onLeo Tolstoyother things we believed wouldimprove the culture, including making sure nurses andůĞĂĚĞƌƐŬŶĞǁ ƚŚĞŝƌE ĂƟŽŶĂůĂƚĂĨŽƌE ƵƌƐŝŶŐY ƵĂůŝƚLJIndicators (NDNQI). We have been offering a class forthe last two years, every other month. Everyone whotakes this class has shared that they “loved” it and feltthey can make a difference now on their units.We also updated our Magnet /PTE website to includean ‘Events Calendar’ and we started working on a PeerReview Process for RN staff at the bedside. We’ve donea lot over the last few years, and plan to keep growing.What Shapes Our Culture?Five Pillars of ExcellencehE D , ŽƐƉŝƚĂůƐďĂƐĞƐŝƚƐĐƵůƚƵƌĞŝŶŝƟĂƟǀ ĞƐŽŶ&ŝǀ ĞWŝůůĂƌƐŽĨdžĐĞůůĞŶĐĞ͘ dŚĞƐĞƉŝůůĂƌƐĂƌĞƚŚĞĨŽƵŶĚĂƟŽŶƐĨŽƌƐĞƫ ŶŐĐůĞĂƌŐŽĂůƐĂŶĚĚŝƌĞĐƟŽŶĨŽƌŽƵƌƐĞƌǀ ŝĐĞƐĂŶĚŽƉĞƌĂƟŽŶĂůĞdžĐĞůůĞŶĐĞ͘ dŚŝƐŚĞůƉƐƵƐĐŽŶƟŶƵĂůůLJĨŽĐƵƐĂŶĚƉƌŽǀ ŝĚĞĐŽŶƐŝƐƚĞŶĐLJ͘ dŚĞŵŽĚĞůŚĞůƉƐƵƐƉƌŝŽƌŝƟnjĞŐŽĂůƐĂŶĚŽƌŐĂŶͲize them in a way that is applied system-wide. The PillarsĂůƐŽƉƌŽǀ ŝĚĞĂĨƌĂŵĞǁ ŽƌŬĨŽƌƚŚĞĞǀ ĂůƵĂƟŽŶƉƌŽĐĞƐƐ͘ Timely and efficient service ͻdžĐĞĞĚƌĞŐƵůĂƟŽŶƐWŝůůĂƌŽƌĚĞƌŝƐŝŵƉŽƌƚĂŶƚ͕ ďĞĐĂƵƐĞǁ ĞĮ ƌƐƚŶĞĞĚĐŽŵŵŝƩ ĞĚ͕ Plan, Do, Study, Act • Easy-to-use processesengaged People (employees and leaders). This leads toimprovements in Service and an increase in Quality of FINANCE: UNM Hospitals will maintain a healthy financialcare. Improved Finances and Growth follow if the first ƐƚƌƵĐƚƵƌĞƚŚĂƚĂůůŽǁ ƐƵƐƚŽĐŽŶƟŶƵĞƚŽƉƌŽǀ ŝĚĞŚŝŐŚ-qualitythree Pillars are the primary focus.ŚĞĂůƚŚĐĂƌĞƚŽŽƵƌƉĂƟĞŶƚƐ͘ PEOPLE: UNM Hospitals values its employees andƌĞĐŽŐŶŝnjĞƐƚŚĂƚƐƵĐĐĞƐƐĨŽƌŽƵƌŽƌŐĂŶŝnjĂƟŽŶŝƐƚŚĞƌĞƐƵůƚof all of us working together with a common goal to pro-ǀ ŝĚĞƚŚĞĮ ŶĞƐƚŚĞĂůƚŚĐĂƌĞƚŽŽƵƌƉĂƟĞŶƚƐ͘ t Ğǁ ŝůůƐƚƌŝǀ ĞƚŽĂƩ ƌĂĐƚĂŶĚŵĂŝŶƚĂŝŶƚŚĞďĞƐƚǁ ŽƌŬĨŽƌĐĞ͘ SERVICE: hE D , ŽƐƉŝƚĂůƐ͛ ƉĂƟĞŶƚƐĂŶĚĨĂŵŝůŝĞƐǁ ŝůůďĞtreated with respect, compassion, and friendliness whilereceiving the finest, high-quality healthcare. We wantthe following as a result of our services: Compassion for others • Good outcomes Good experiences • Treated with respect ZĞƐƉĞĐƚŽĨƟŵĞ͕ ĐŚŽŝĐĞ͕ ĂŶĚŽƉŝŶŝŽŶƐQUALITY: Quality guides our decision-making at all levelsŽĨŽƉĞƌĂƟŽŶƐƚŚƌŽƵŐŚŽƵƚƚŚĞŽƌŐĂŶŝnjĂƟŽŶ͘ t Ğǁ ŝůůŵŽŶŝͲƚŽƌĂŶĚĐŽŶƟŶƵŽƵƐůLJŝŵƉƌŽǀ ĞƚŚĞƋƵĂůŝƚLJŽĨƉĂƟĞŶƚĐĂƌĞ͘ Good clinical outcomes • Error-freeBalanced budgetE ĞƚŝŶĐŽŵĞƚŚĂƚƐƵƉƉŽƌƚƐŽƌŐĂŶŝnjĂƟŽŶĂůŐƌŽǁ ƚŚ͕ ĞƋƵŝƉŵĞŶƚĂŶĚĨĂĐŝůŝƟĞƐ&ŝŶĂŶĐŝĂůůLJƐŽƵŶĚĨŽƌĐŽŵƉĞŶƐĂƟŽŶĂŶĚƐƵƉƉůŝĞƐGROWTH: hE D , ŽƐƉŝƚĂůƐǁ ŝůůŐƌŽǁ ƚŽƐŽůǀ ĞƚŚĞƉĂƟĞŶƚcare, medical workforce, and academic needs of NM.Medical research – advances in diagnosis, care andtreatmentSignature programs – ƐƉĞĐŝĂůŝnjĞĚĐĂƌĞƚŚĂƚƐŽŵĞƟŵĞƐmakes us the sole providerGrowth in volume & capacity to meet growth in need.

TRANSFORMATIONAL LEADERSHIPPage 8Developing a Strategic PlanFor many years, the NursingDivision has worked together withthe UNM College of Nursing todevelop and implement ourNursing Strategic Plan — using the, ^ƚŚƌĞĞƉĂƌƚŵŝƐƐŝŽŶŽĨWƌĂĐƟĐĞ͕ ĚƵĐĂƟŽŶ͕ ĂŶĚZĞƐĞĂƌĐŚ͘ dŚŝƐ:ŽŝŶƚK ƉĞƌĂƟŶŐWůĂŶŝƐďĂƐĞĚon the HSC Core Values, Missionand Vision.WƌĂĐƟĐĞ͗ :ŽŝŶƚƉĂƌƟĐŝƉĂƟŽŶŝŶthe Advanced Nurse Council;maximizing nurse intern & externƉƌŽŐƌĂŵƐ͖ ĂƩ ƌĂĐƚΘƌĞƚĂŝŶƚŚĞbest and brightest RNS; NurseZĞƐŝĚĞŶĐLJWƌŽŐƌĂŵĂĐĐƌĞĚŝƚĂƟŽŶfor new nurses; provide high-ƋƵĂůŝƚLJŚĞĂůƚŚĐĂƌĞƚŽE D ĐŝƟnjĞŶƐand visitors.ĚƵĐĂƟŽŶ͗ integrate academic andĐůŝŶŝĐĂůĞĚƵĐĂƟŽŶ͖ ƉƌĞƉĂƌĞŶƵƌƐĞƐǀ ŝĂ^E ƉƌĞƉĂƌĂƟŽŶĂŶĚŶĂƟŽŶĂůĐĞƌƟĮ ĐĂƟŽŶƐ͖ ŝŶƚĞŐƌĂƚĞĂĐĂĚĞŵŝĐĂŶĚĐůŝŶŝĐĂůĞĚƵĐĂƟŽŶ͖ ƉƌĞƉĂƌĞgraduate-level management andĐůŝŶŝĐĂůŶƵƌƐŝŶŐƐƚĂī ͖ ĐŽŶƟŶƵĞƚŽrefine the Master Clinician/MasterTeacher model.Research: ƐƚĂďůŝƐŚĐŽůůĂďŽƌĂƟǀ Ğͬ joint research endeavors such asmanuscript review, projects forNursing Excellence state-wideĐŽƵŶĐŝůƉĂƌƟĐŝƉĂƟŽŶ͕ ĂŶĚƐƵƉƉŽƌƚthe UNMH research RN interns,etc.; TCAB ConferenceƉĂƌƟĐŝƉĂƟŽŶĂŶĚE D ĞŶƚĞƌforE ƵƌƐŝŶŐdžĐĞůůĞŶĐĞƉĂƌƟĐŝƉĂƟŽŶ͘“Both Magnet & PTE offerƌĞĂůŝƐƟĐƌŽĂĚŵĂƉƐƚŽimproving the nurse workenvironment which inturn, improves ouroutcomes and decreasesour employee turnover.”Magnet ProgramD ĂŶĂŐĞƌĚƌŝĞŶŶĞ&ƵŐĞƩ ͕ RN BSN MBA“The five MagnetComponents, as you know,ĂƌĞdƌĂŶƐĨŽƌŵĂƟŽŶĂůLeadership, StructuralEmpowerment, ExemplaryWƌŽĨĞƐƐŝŽŶĂůWƌĂĐƟĐĞ͕ E Ğǁ

TRANSFORMATIONAL LEADERSHIPPage 9Building Nursing Leaders—Nurse Management CouncilThe Nurse ManagementCouncil (NMC) facilitatesĐŽŵŵƵŶŝĐĂƟŽŶĂŵŽŶŐthe different units/areaswithin UNMH, supportsmanagement andůĞĂĚĞƌƐŚŝƉŝŶŝƟĂƟǀ ĞƐĂŶĚŝŵƉůĞŵĞŶƚƐĂĐƟŽŶplans based on targetedŝŶŝƟĂƟǀ ĞƐ͘The council is comprised ofŝŶƉĂƟĞŶƚĂŶĚŽƵƚƉĂƟĞŶƚunit directors whorepresent their differentareas in decision-makingprocesses for the targetedĂĐƟŽŶƉůĂŶƐ͘In 2012, NMC worked withHR to standardize the unitemployee files so that allareas have the sameĞŵƉůŽLJĞĞŝŶĨŽƌŵĂƟŽŶŝŶthe files. NMC also devel-ŽƉĞĚĂŶĞĚƵĐĂƟŽŶĂŶĚFAQ on the ProfessionalHealthcare (CINHC) calledLeadership EmpoweredK ƌŐĂŶŝnjĂƟŽŶƐ͘ Along the same lines, theUNM Leadership Academy(UNMLA) enrolled its firstclass in 2012 and includesƚŚƌĞĞŶƵƌƐĞĞdžĞĐƵƟǀ ĞƐ͘The purpose of the UNMLAis to develop the healthƐLJƐƚĞŵƐ͛ ŶĞdžƚŐĞŶĞƌĂƟŽŶ/ĚĞŶƟƚLJ' ƵŝĚĞůŝŶĞforstaff to assist the RNƐƵƉĞƌǀ ŝƐŽƌƐŝŶĞĚƵĐĂƟŶŐand holding staffaccountable to thehospital standards forprofessional appearance.The final products for bothŽĨƚŚĞƐĞŝŶŝƟĂƟǀ ĞƐǁ ĞƌĞthen communicated to thedifferent areas viaŵĞĞƟŶŐƐ͕ ĞŵĂŝůƐ͕ handouts.E ƵƌƐĞdžĞĐƵƟǀ ĞŽƵŶĐŝů—E ͗ dƌĂŶƐĨŽƌŵŝŶŐWƌĂĐƟĐĞThe NEC is where UNMHospitals’ top nursingĞdžĞĐƵƟǀ ĞƐŐĂƚŚĞƌƐĞǀ ĞƌĂůƟŵĞƐĞĂĐŚŵŽŶƚŚ͘In 2012, five of ourĞdžĞĐƵƟǀ ĞŶƵƌƐĞůĞĂĚĞƌƐǁ ĞƌĞĐŚŽƐĞŶƚŽƉĂƌƟĐŝƉĂƚĞin a three-day intensiveleadership trainingsponsored by California/ŶƐƟƚƵƚĞĨŽƌE ƵƌƐŝŶŐĂŶĚof clinical leaders, supporta networking forum toďƵŝůĚĐŽůůĂďŽƌĂƟŽŶ͕ ƉƌŽŵŽƚĞĞdžĞĐƵƟǀ ĞůĞĂĚĞƌskill development, advanceengagement betweenhealth systemcomponents, and supportĞdžĞĐƵƟŽŶĂŐĂŝŶƐƚŽƌŐĂŶŝnjĂƟŽŶĂůŝŶŝƟĂƟǀ ĞƐ.“The depth andbreadth in whichthe individual RNengages in thetotal scope ofŶƵƌƐŝŶŐƉƌĂĐƟĐĞis dependent onƚŚĞŝƌĞĚƵĐĂƟŽŶ͕ experience, role,ĂŶĚƚŚĞƉŽƉƵůĂƟŽŶserved.”~ ANA 2010, asquoted by CNOSheena Ferguson.Helping Leaders Grow—K ƌŐĂŶŝnjĂƟŽŶĂůĂŶĚWƌŽĨĞƐƐŝŽŶĂůĞǀ ĞůŽƉŵĞŶƚ;K WOPD offers several venuesand classes for aspiringnew leaders, or leaders inŽƵƌŽƌŐĂŶŝnjĂƟŽŶǁ ŚŽĂƌĞlooking to develop orpolish their skills. Forexample, in the MentoringProgram, experiencedleaders are paired withnewer leaders to increasetheir job success andƚƌĂŶƐŝƟŽŶƚŽĂŶĞǁ leadership role.The Up and Comers Programfocuses on staff withŚŝŐŚƉŽƚĞŶƟĂůĨŽƌůĞĂĚĞƌͲƐŚŝƉ͕ ĂŶĚƌĞƋƵŝƌĞƐƉĂƌƟĐŝͲƉĂƟŽŶŝŶŵĞĞƟŶŐƐĂŶĚmentoring partnerships.OPD also offers Leadership>ĞĂƌŶŝŶŐŽŵŵƵŶŝƟĞƐ͕ where specific managementteams learn about leadershipskills together.Stone Soup is also aLeadership LearningCommunity, but for theĞŶƟƌĞŽƌŐĂŶŝnjĂƟŽŶƚŽĂƩ ĞŶĚŵŽŶƚŚůLJŵĞĞƟŶŐƐ͕ ďĂƐĞĚŽŶvarious topics of interest.

MAGNET/PATHWAY TO EXCELLENCEPage 10First Annual UNMH Magnet/PTE ConferenceRequirements for the MagnetComponent StructuralEmpowerment (SE) focuses onĂŶŽƌŐĂŶŝnjĂƟŽŶĂůƐƚƌƵĐƚƵƌĞƚŚĂƚis decentralized, with nursesƉĂƌƟĐŝƉĂƟŶŐŝŶĚĞĐŝƐŝŽŶ-makingat all levels. The emphasis is placedon establishing standards ofƉƌĂĐƟĐĞĂŶĚĂĚĚƌĞƐƐŝŶŐŽƚŚĞƌissues of concern.There is a commitment toProfessional Development,Teaching, and CommunityInvolvement.With that in mind, in April 2012,our first Magnet/PTE SpringConference was held,where we featurednurses and otherprofessionals toƐŚĂƌĞŝŶĨŽƌŵĂƟŽŶand processes thatwould serve toŝĚĞŶƟĨLJĨŽƌŽƵƌŶƵƌƐĞƐhow to be involved indecision-makingthrough SharedGovernance, addressƉƌĂĐƟĐĞŝƐƐƵĞƐĂŶĚŚŝŐŚůŝŐŚƚƚŚĞteaching role of nurses, as well asfeaturing a project that involvedour community. This program wassold out and also well received.PATHWAY TO EXCELLENCE REDESIGNATION (PTE)t ĞƌĞĐĞŶƚůLJƐƵďŵŝƩ ĞĚŽƵƌWdre-ĚĞƐŝŐŶĂƟŽŶƉĂƉĞƌǁ ŽƌŬ͕ ĂŶĚĞdžƉĞĐƚto hear in a few months if we haveƉĂƐƐĞĚƚŚĞǁ ƌŝƩ ĞŶƉŽƌƟŽŶ͘ Once we do, nurses at all levels willbe invited to take a survey to verifyŽƵƌǁ ƌŝƩ ĞŶƐƵďŵŝƐƐŝŽŶ͘ /Ĩǁ ĞĚŽǁ Ğůůon our survey, including at least a 51%response rate, we are re-designated!“It is with great pridethat I thank the staff nursesŽŶŽƵƌWdŽŵŵŝƩ ĞĞĨŽƌtheir diligent work on thisĚŽĐƵŵĞŶƚ͘ ͘ ͘ ͟ ͞ ĚĚŝƟŽŶĂůthanks to [others] for theirquick responses andŝŶǀ ĂůƵĂďůĞĐŽŶƚƌŝďƵƟŽŶƐ͘ ͟ΕĚƌŝĞŶŶĞ&ƵŐĞƩ ͕ ZE ^E D Magnet Program Manager

STRUCTURAL EMPOWERMENTPage 11ůŝŶŝĐĂůĚƵĐĂƟŽŶ ĞƉĂƌƚŵĞŶƚThe nurse educators ŝŶůŝŶŝĐĂůĚƵĐĂƟŽŶŵĞƚŽƵƌƉƌŝŵĂƌLJŐŽĂůŽĨƉƌŽǀ ŝĚŝŶŐƐƵƉĞƌŝŽƌĂŶĚƉĞƌƟŶĞŶƚĞĚƵĐĂƟŽŶƚŽŚĞĂůƚŚĐĂƌĞƐƚĂī ͕ ƌĞƐƵůƟŶŐŝŶŝŵƉƌŽǀ ĞĚƉĂƟĞŶƚŽƵƚĐŽŵĞƐ͘ ĞŶŶĞƌ͛ ƐŵŽĚĞůŽĨƐƚĂī ĚĞǀ ĞůŽƉͲŵĞŶƚŝƐƵƐĞĚƚŽĚĞƐŝŐŶĞĚƵĐĂƟŽŶĂůƉƌŽŐƌĂŵƐ͘WƌŽŐƌĞƐƐŝǀ ĞĞĚƵĐĂƟŽŶwas offered for a widevariety of courses developed to address thelearning needs of novice and experienced staff:life support, pediatrics, women’s health, newborn,ambulatory, neuroscience, trauma, emergency,medical-surgical, oncology, pain, end-of-life, cardi-ĂĐƌŚLJƚŚŵƐ͕ ĐĞƌƟĮ ĐĂƟŽŶƉƌĞƉĂƌĂƟŽŶ͕ ƉƌĞĐĞƉƟŶŐ͕ ƐƵƉĞƌǀ ŝƐŝŶŐ͕ ĞĚƵĐĂƟŶŐ͕ ĂŶĚĚĞůĞŐĂƟŶŐ͘ Our efforts were rewarded with this sampling ofpost-course comments. “I will use the skills IůĞĂƌŶĞĚƚŽĚĂLJƚŽĂƐƐĞƐƐŵLJƉĂƟĞŶƚďĞĨŽƌĞĐĂůůŝŶŐƚŚĞĚŽĐƚŽƌƚŽƐƵŐŐĞƐƚĚŝĂŐŶŽƐƟĐƚĞƐƚƐ͘ ͟ ͞ dŚĞŝŶƐƚƌƵĐƚŽƌ͛ ƐŬŶŽǁ ůĞĚŐĞĂŶĚĞdžƉĞƌƟƐĞŝƐŝŶǀ ĂůƵͲĂďůĞƚŽŽƵƌŽƌŐĂŶŝnjĂƟŽŶ͘ ͟ ͞ /ĂŵƐŽŐůĂĚ/ǁ ĂƐĂďůĞƚŽďĞŚŝƌĞĚďLJĂŚŽƐƉŝƚĂůƚŚĂƚǀ ĂůƵĞƐĞĚƵĐĂƟŽŶ͊ ͟ And, “The class was well organized and theinstructors helpful.”/ŶϮϬϭϮ͕ ůŝŶŝĐĂůĚƵĐĂƟŽŶĂŶĚŐƵĞƐƚ/ŶƐƚƌƵĐƚŽƌƐƉƌŽǀ ŝĚĞĚ͗1,056 Classes215 Different Courses11,718 ůĂƐƐƩ ĞŶĚĞĞƐ 13% increase71 E Ğǁ E ĂƉƉůŝĐĂƟŽŶƐ ^ƵďŵŝƩ ĞĚ26,766.32 Contact Hours Awarded 12% increase5,884 Online self study modules Completed314 E ƵƌƐĞƐĂƩ ĞŶĚĞĚ New Hire classes232 hŶůŝĐĞŶƐĞĚƐƐŝƐƟǀ ĞWĞƌƐŽŶŶĞů;hWƐĂƩ ĞŶĚĞĚ2,972 Nursing, Medical Assistant,Paramedics and EMTSNew Hire classesPlaced through 10Academic ProgramsdŚĞůŝŶŝĐĂůĚƵĐĂƟŽŶĞƉĂƌƚŵĞŶƚŚĂƐϭϰŐŝŌĞĚNurse Educators and 3 skilled Support Staff: 10 Nurses are Master’s prepared & several haveƐƉĞĐŝĂůƚLJĐĞƌƟĮ ĐĂƟŽŶ͘ K ŶĞŝƐďŽĂƌĚĐĞƌƟĮ ĞĚŝŶNursing Professional Development 7 enrolled in school, pursuing nursing-related degrees Irene Zamora presented at the 2012 NMNA ConferenceDepartment Accomplishments for 2012: ĚƵĐĂƟŽŶƐƵƉƉŽƌƚĨŽƌƌĞǀ ŝƚĂůŝnjĂƟŽŶŽĨƚŚĞĂƌĚŝŽǀ ĂƐĐƵůĂƌ^ƵƌŐĞƌLJWƌŽŐƌĂŵ D ĂŝŶƚĞŶĂŶĐĞŽĨŽƵƌ͗ ^ƚƌŽŬĞ͕ , ĞĂƌƚ&ĂŝůƵƌĞ͕ dƌĂƵŵĂ͕ ĂŶĚWĂƟĞŶƚĞŶƚĞƌĞĚD ĞĚŝĐĂů, ŽŵĞWƌŽŐƌĂŵƐ WƵƌƐƵŝƚŽĨĂďLJ&ƌŝĞŶĚůLJĂŶĚD ĂŐŶĞƚĞƐŝŐŶĂƟŽŶƐ /ŶŶŽǀ ĂƟŽŶƉƌŽŐƌĞƐƐǁ ĂƐŵĂĚĞďLJŚŝƌŝŶŐD ĂŶĚĂ>Žǁ ŚŽĚĞƐŝŐŶĞĚƚŚĞƐĞǁ Ğď-basedĞĚƵĐĂƟŽŶĂůƉƌŽŐƌĂŵƐ͗ ĂƐŝĐƌƌŚLJƚŚŵŝĂ͕ &ĞƚĂůD ŽŶŝƚŽƌŝŶŐΘ' ƌƟĨĂĐƚZĞĐŽŐŶŝƟŽŶ A computer-ďĂƐĞĚĞůĞĐƚƌŽŶŝĐĞǀ ĂůƵĂƟŽŶǁ ĂƐƵƐĞĚƐƵĐĐĞƐƐĨƵůůLJĂŌĞƌĂůĂƌŐĞĐŽŶĨĞƌĞŶĐĞ dŚĞƵŶŝǀ ĞƌƐĂůůLJĂƉƉůŝĐĂďůĞƉŽƌƟŽŶŽĨƚŚĞŽŵƉĞƚĞŶĐLJ-ĂƐĞĚK ƌŝĞŶƚĂƟŽŶŬůĞƚǁ ĂƐƌĞǁ ƌŝƩ ĞŶ dŚĞE D E ƵƌƐĞƐƐƐŽĐŝĂƟŽŶ;E D E ƌĞŶĞǁ ĞĚƚŚĞƉƉƌŽǀ ĞĚWƌŽǀ ŝĚĞƌƐƚĂƚƵƐĨŽƌůŝŶŝĐĂůĚƵĐĂƟŽŶƚŽƉƌŽǀ ŝĚĞĐŽŶƟŶƵŝŶŐŶƵƌƐŝŶŐĞĚƵĐĂƟŽŶ

STRUCTURAL EMPOWERMENTPage 12SHARED GOVERNANCE GROWTHYou spoke up, and the We heard you andMagnet Champions offered workshops, andlistened. 2012 has seen several one-on-onetremendous growth in ŝŶƐƚƌƵĐƟŽŶƐĞƐƐŝŽŶƐǁ ŝƚŚour Shared Governance our Magnet Program(SG) Councils. Many of Manager.you have shared with theWe also added SG classesMagnet Champions andto start in 2013, and tothe Magnet ProgramďĞŽī ĞƌĞĚƐĞǀ ĞƌĂůƟŵĞƐManager that youper year, from thereneeded helpforward.understanding theprocess.“Shared Governance isĂŶŽƌŐĂŶŝnjĂƟŽŶĂůŵŽĚĞůthat provides a structurefor shared decisionmakingamong profes-ƐŝŽŶĂůƐĂďŽƵƚƉƌĂĐƟĐĞΘclinical outcomes.”~ 2011. Hess, Robert &Swihart, D. SharedGovernance: What itCan Mean for Nurses.Nurse.comE ƵƌƐĞĚƵĐĂƟŽŶŽƵŶĐŝůdŚĞƉƵƌƉŽƐĞŽĨƚŚĞE ƵƌƐŝŶŐĚƵĐĂƟŽŶŽƵŶĐŝůŝƐƚŽƉƌŽŵŽƚĞ͕ ĨĂĐŝůŝƚĂƚĞ͕ ĂŶĚƉůĂŶƉƌŽĨĞƐƐŝŽŶĂůĚĞǀ ĞůŽƉŵĞŶƚďLJƐĞƫ ŶŐĂŶĚŵĂŝŶƚĂŝŶŝŶŐĞĚƵĐĂƟŽŶĂůƉƌĂĐƟĐĞƐƚĂŶĚĂƌĚƐ͘ dŚĞŽƵŶĐŝůĂĚĚƌĞƐƐĞƐŝĚĞŶƟĮ ĞĚůĞĂƌŶŝŶŐŶĞĞĚƐĂŶĚƌĞĐŽŵŵĞŶĚƐĂŶĞĚƵĐĂƟŽŶĂůĂƉƉƌŽĂĐŚĂŶĚͬ ŽƌŵĞƚŚŽĚŽůŽŐŝĞƐ͘ dŚĞƐĞƌĞĐŽŵŵĞŶĚĂƟŽŶƐĂƌĞďƌŽƵŐŚƚƚŽƚŚĞE ƵƌƐĞdžĞĐƵƟǀ ĞŽŵŵŝƩ ĞĞĨŽƌĂƉƉƌŽǀ Ăů͘ƵƌŝŶŐϮϬϭϮ͕ ƚŚĞE ƵƌƐŝŶŐĚƵĐĂƟŽŶŽƵŶĐŝůƌĞǀ ŝĞǁ ĞĚĂŶƵŵďĞƌŽĨƌĞĨĞƌƌĂůƐ͘ ĚƵĐĂƟŽŶŚĂƐďĞĞŶƐƵĐĐĞƐƐĨƵůůLJimplemented on the topics listed (See accompanying table).ĚĚŝƟŽŶĂůďƵƐŝŶĞƐƐĐŽŶĚƵĐƚĞĚŝŶϮϬϭϮŝŶĐůƵĚĞĚĂƐŝŐŶŝĮ ĐĂŶƚƌĞǀ ŝƐŝŽŶƚŽƚŚĞŽƵŶĐŝů͛ ƐĐŚĂƌƚĞƌ͕ ĞůĞĐƟŽŶŽĨĂŶĞǁ ĐŽ-chair,and the welcoming of new members.RN Co-Chairs: Joan Deis & Jim EffingerED RN Sponsor: Mary BlessingĚƵĐĂƟŽŶ^ƵĐĐĞƐƐĨƵůůLJŝŵƉůĞŵĞŶƚĞĚŽŶ͗AccuveinDispatch WipesCidex UseBlood Bank SlipsOxivir wipes^ŬŝŶŶƟƐĞƉŝƐWƌŽĐĞĚƵƌĞǁ ŝƚŚŚůŽƌŚĞdžŝĚŝŶĞ&ĞĞĚŝŶŐdƵďĞ/ŶƐĞƌƟŽŶGlucometerNew Needle for InsulinD ĞƉŝůĞdž^ŬŝŶhůĐĞƌWƌĞǀ ĞŶƟŽŶƐŝĸ ĐƵůƚŝƌǁ ĂLJdĞĂŵ;ZdĐƟǀ ĂƟŽŶCuros caps

STRUCTURAL EMPOWERMENTPage 13NURSE PRACTICE COUNCILdŚĞE ƵƌƐĞWƌĂĐƟĐĞŽƵŶĐŝů(NPC) has worked hard tomake it easier for youto make the necessaryƉƌĂĐƟĐĞĐŚĂŶŐĞƐŶƵƌƐĞƐsee as vital to theirƉƌĂĐƟĐĞ͘ In 2012 the NPC added anew ‘referral form’ thatyou can submit for helpƌĞŐĂƌĚŝŶŐĂŶĞǁ ƉƌĂĐƟĐĞidea. This can be found onthe Magnet intranet underthe link ‘SharedGovernance.’The goal of the NPC is to“define, implement andmaintain standards ofbest EBP nursing.”If you want to learn moreabout the NPC, check outtheir Charter and Roster,and contact them to findout about joining theircouncil. Get involved: youwill make a difference!SHARED GOVERNANCEMODEL DEPICTIONNPC—Referral Form—New in 2012!This story can fit 100-150 words.dŚĞƐƵďũĞĐƚŵĂƩ ĞƌƚŚĂƚĂƉƉĞĂƌƐŝŶŶĞǁ ƐůĞƩ ĞƌƐŝƐvirtually endless. Youcan include stories thatfocus on current tech-ŶŽůŽŐŝĞƐŽƌŝŶŶŽǀ ĂƟŽŶƐin your field.You may also want tonote business or economictrends, or makeƉƌĞĚŝĐƟŽŶƐĨŽƌLJŽƵƌĐƵƐͲtomers or clients./ĨƚŚĞŶĞǁ ƐůĞƩ ĞƌŝƐĚŝƐͲtributed internally, youmight comment uponnew procedures or im-The NPC’sCombined ReferralForm—Sample of acompleted form.Look for this on theMagnet link ‘SharedGovernance’Go to the Magnet UNMH Intranet and select the link ‘Shared Governance’ŚƩ ƉƐ͗ ͬ ͬ ŚŽƐƉŝƚĂůƐ͘ ŚĞĂůƚŚ͘ ƵŶŵ͘ ĞĚƵͬ ŝŶƚƌĂŶĞƚͬ ŵƌƉͬ ƐŚĂƌĞĚͺ ŐŽǀ ͘ ƐŚƚŵů— to find this form

STRUCTURAL EMPOWERMENTPage 14PEER REVIEW (PR) FOR THE STAFF RNIn a medicine cup– WZŝƐƚŚĞǁ ĂLJZE Ɛ͞ ƐLJƐƚĞŵĂƟĐĂůůLJassess, monitor, and make judgments about the qualityof nurse care as measured against professionalƐƚĂŶĚĂƌĚƐŽĨƉƌĂĐƟĐĞ͘ ͟ According to the ANA Code of Ethics, nurses are to lookĨŽƌƉĂƟĞŶƚƐĂĨĞƚLJŝƐƐƵĞƐ͕ ĂƐǁ ĞůůĂƐďĞĚŝƌĞĐƚůLJinvolved in PR processes. For Haag-Heitman andGeorge (2011), the purposes of Peer Review include theĞǀ ĂůƵĂƟŽŶŽĨďŽƚŚƚŚĞƋƵĂůŝƚLJĂŶĚƚŚĞƋƵĂŶƟƚLJŽĨĐĂƌĞ͕ ĐŽŶƐŝĚĞƌĂƟŽŶŽĨƚŚĞƐƚƌĞŶŐƚŚƐĂŶĚǁ ĞĂŬŶĞƐƐĞƐŽĨƚŚĂƚcare, and follow-ƚŚƌŽƵŐŚǁ ŝƚŚƉƌĂĐƟĐĞĂĚũƵƐƚŵĞŶƚƐǁ ŚĞƌĞĐŽŶĐĞƌŶƐĂƌŝƐĞĂŶĚŽƉƟŵĂůĐĂƌĞŝƐŶŽƚĂƩ ĂŝŶĞĚ͘WZƉƌŽǀ ŝĚĞƐƚŚĞƉĞƌĨĞĐƚƐĞƫ ŶŐĨŽƌŶƵƌƐĞƐƚŽďĞĞŵƉŽǁ ĞƌĞĚĂŶĚĂƵƚŽŶŽŵŽƵƐ͕ ĂŶĚƚĂŬĞĂŶĂĐƟǀ ĞƌŽůĞŝŶdecision-making and quality assessment of care, whichĚŝƌĞĐƚůLJƌĞůĂƚĞƐƚŽďŽƚŚŽƵƚĐŽŵĞƐ͕ ĂŶĚƉĂƟĞŶƚƉĞƌĐĞƉƟŽŶŽĨƚŚĞĐĂƌĞƌĞĐĞŝǀ ĞĚ͘The journey toward StaffNurse Peer Review (SNPR)at UNMH began when theMagnet Program Managerand two RNs met to discussthe issue in Spring 2011.Phase I of the process beganwith a required class, whichtook place in August.In the class, RNs learned about the SNPR process anddeveloped their own tools for PR on their units. For theŶĞdžƚϯŵŽŶƚŚƐƚŚŽƐĞǁ ŚŽĂƩ ĞŶĚĞĚƚŚĞĐůĂƐƐǁ ŽƵůĚĂƐŬĂnurse peer to review them, using the tool developed.As Phase I of the program was evaluated in early 2012,it was determined that we needed to develop an actualPR Taskforce, and become familiar with a newly availableresource: Peer Review in Nursing, a book by Haag-Heitmanand George.Working together in groups, the Taskforce, under theleadership of the Magnet Program Manager constructeda curriculum outline that would educate RNs and LeadersͻĐŽŶƟŶƵĞĚ͕ ƉĂŐĞϭϱPeer Review Phase I and Phase II Timeline͞ WĞĞƌZĞǀ ŝĞǁ ƉůĂLJƐĂŶĞƐƐĞŶƟĂůrole in ensuring quality outcomes,ĨŽƐƚĞƌŝŶŐƉƌĂĐƟĐĞĚĞǀ ĞůŽƉŵĞŶƚ͕ and maintaining professionalautonomy.”May 2011AugustSeptemberMarch 2012MayMagnet Program Manager and 2 staff RNs meetPhase I Staff Nurse Peer Review ClassWĂƌƟĐŝƉĂŶƚ^ƚĂī ZE ƐďĞŐŝŶϯŵŽŶƚŚ-PR on UnitsZĞĐĂƉŵĞĞƟŶŐ- Phase I results evaluatedPhase II begins with PR Taskforce development~ Haag-Heitman & George,2011 p19SeptemberTaskforce meets, begins Curriculum developmentDecember Basic class outline complete, 1st class– May 2013

STRUCTURAL EMPOWERMENTPage 15PEER REVIEW ĐŽŶƟŶƵĞĚabout the SNPR process, how to engage in PR, and thesignificance of Shared Governance, which serves as theĐŽŽƌĚŝŶĂƟŶŐĨƌĂŵĞǁ ŽƌŬĂŶĚŽƉĞƌĂƟŽŶĂůŐƵŝĚĂŶĐĞĂŶĚĐŽŶƚƌŽůof the process.Plans include the ƉĂƌƟĐŝƉĂƟŽŶŽĨƚŚƌĞĞ͚ ďĞƚĂƵŶŝƚƐ͛ ĨŽƌƚŚĞ/ŵƉůĞŵĞŶƚĂƟŽŶŽĨWŚĂƐĞ//͘ K ŶĞƚŽƚǁ ŽŶƵƌƐĞƐ͕ ƚŚĞh͕ ĂŶĚƚŚĞhŶŝƚŝƌĞĐƚŽƌǁ ŝůůĂƩ ĞŶĚƚŚĞĐůĂƐƐŝŶD ĂLJ͕ ϮϬϭϯ͕ ĂŶĚĚŝƐƐĞŵŝŶĂƚĞƚŚĞŝŶĨŽƌŵĂƟŽŶƚŽƚŚĞŝƌƵŶŝƚƉĞĞƌƐ͘ &ŽƌƚŚĞŶĞdžƚϲŵŽŶƚŚƐ͕ ĂůůŶƵƌƐĞƐĨƌŽŵƚŚĞƐĞƵŶŝƚƐǁ ŝůůƉĂƌƟĐŝƉĂƚĞŝŶƚŚĞ^E WZƉƌŽĐĞƐƐ͕ ƵƐŝŶŐthe tools developed in class, and through their Unit SG to reviewĞĂĐŚŽƚŚĞƌŽŶƋƵĂůŝƚLJĂŶĚƉƌĂĐƟĐĞĨŽĐƵƐĞĚŝŶŝƟĂƟǀ ĞƐ͘ ƐWŚĂƐĞ//ƚĂŬĞƐƉůĂĐĞ͕ ŽŶŐŽŝŶŐĞǀ ĂůƵĂƟŽŶĂŶĚƵƉĚĂƚĞŽĨƚŚĞƉƌŽŐƌĂŵǁ ŝůůĐŽŶƟŶƵĞ͘ /ƚŝƐĂŶƟĐŝƉĂƚĞĚƚŚĂƚĂƐǁ ĞůĞĂƌŶĂďŽƵƚwhat works and what needs adjustment, and more nurses takethe other classes offered in late 2013, we will be prepared to rollŽƵƚƚŚĞƉƌŽĐĞƐƐƚŽŶƵƌƐĞƐĂĐƌŽƐƐƚŚĞŽƌŐĂŶŝnjĂƟŽŶŝŶϮϬϭϰ͘ Basic Principles of Peer Review:A peer is someone of the samerankWĞĞƌZĞǀ ŝĞǁ ŝƐƉƌĂĐƟĐĞ-focused&ĞĞĚďĂĐŬŝƐƟŵĞůLJ͕ ƌŽƵƟŶĞ͕ ĂŶĚĂĐŽŶƟŶƵŽƵƐĞdžƉĞĐƚĂƟŽŶWĞĞƌZĞǀ ŝĞǁ ĨŽƐƚĞƌƐĂĐŽŶƟŶƵͲŽƵƐůĞĂƌŶŝŶŐĐƵůƚƵƌĞŽĨƉĂƟĞŶƚƐĂĨĞƚLJĂŶĚďĞƐƚƉƌĂĐƟĐĞFeedback is not anonymousFeedback incorporates thenurse’s developmental stageƐǁ ĞƐƚƌŝǀ ĞƚŽǁ ĂƌĚD ĂŐŶĞƚZĞĐŽŐŶŝƟŽŶ, and consider theŝŵƉůŝĐĂƟŽŶƐŽĨWϮϬ- ͞ dŚĂƚŶƵƌƐĞƐĂƚĂůůůĞǀ ĞůƐƌŽƵƟŶĞůLJƵƐĞself-appraisal performance review and peer review,” we as staffnurses need to embrace this concept and find our way toward abest ƉƌĂĐƟĐĞ͘ The Peer Review classes that start in 2013 will get nurses andƚŚĞŝƌƌĞƐƉĞĐƟǀ ĞƵŶŝƚƐƐƚĂƌƚĞĚŽŶĐŽŶĐĞƉƚƵĂůŝnjŝŶŐŚŽǁ ^ƚĂī E ƵƌƐĞPeer Review can work for them.~ Haag-Heitman & George, 2011“Reengagement and ownership ofthe quality of one’s work is thecenter piece of both obtaining andsustaining the quality and value ofthe work.”~ Haag-Heitman & George, 2011Peer Review Benefits:^ƟŵƵůĂƚĞƐprofessional growth;Provides for an increase in clinicalknowledge; andKeeps skills updated

STRUCTURAL EMPOWERMENTPage 16Nurse Residency Program Accredited by the CCNE!dŚĞŽŵŵŝƐƐŝŽŶŽŶŽůůĞŐŝĂƚĞE ƵƌƐŝŶŐĚƵĐĂƟŽŶ(CCNE) has accredited nine nurse residency sites in theUnited States. We are very proud to say that UNMPost-baccalaureate Nurse Residency is one of thosesites! Being accredited by CCNE makes an importantstatement to the health care community about the wayǁ ĞŚĞůƉďƵŝůĚƚŚĞĨŽƵŶĚĂƟŽŶŽĨǁ ŚŝĐŚŶĞǁ ŶƵƌƐĞƐďĞŐŝŶƚŚĞŝƌƉƌĂĐƟĐĞ͘ /ƚŝƐƌĞĐŽŐŶŝƟŽŶŽĨƚŚĞŚŝŐŚƋƵĂůŝƚLJof our program and the value of the program by ourŝŶƐƟƚƵƟŽŶ͘ Since we began our program over a decade ago wehave seen an increase in the number of baccalaureatepreparednurses in our hospital and a significantincrease in nurses returning to school to obtainadvanced degrees.Requirement for admission to the post baccalaureateŶƵƌƐĞƌĞƐŝĚĞŶĐLJƉƌŽŐƌĂŵŝŶĐůƵĚĞƐŐƌĂĚƵĂƟŽŶĨƌŽŵĂŶaccredited basic BSN program or master’s level entryŝŶƚŽƉƌĂĐƟĐĞƉƌŽŐƌĂŵǁ ŝƚŚŝŶƚŚĞƉĂƐƚϲŵŽŶƚŚƐĂŶĚZE ůŝĐĞŶƐƵƌĞ͕ ŽƌŐƌĂĚƵĂƚĞŶƵƌƐĞƉĞƌŵŝƚƚŽƉƌĂĐƟĐĞ͕ ŝƐƐƵĞĚfrom the State of New Mexico; and a willingness tocommit to the one-year Residency Program. NurseZĞƐŝĚĞŶƚƐĂƌĞƌĞƋƵŝƌĞĚƚŽǁ ŽƌŬĨƵůůƟŵĞ͕ ĂƩ ĞŶĚďŽƚŚŐĞŶĞƌĂůŶĞǁ ŐƌĂĚƵĂƚĞŽƌŝĞŶƚĂƟŽŶĂŶĚŵŽŶƚŚůLJspecialized learning events.The program Director and nurse educators are responsiblefor planning the program and developing learningexperiences to support quality, evidence based,ƉĂƟĞŶƚ-centered care delivered by a member of theinterdisciplinary team. The Director communicates withresidents and clinical units, rounds on the units, andƐĞƌǀ ĞƐŽŶƚŚĞƵŶĚĞƌŐƌĂĚƵĂƚĞĐŽŵŵŝƩ ĞĞĂƚhE D ŽůůĞŐĞŽĨE ƵƌƐŝŶŐ͕ ǁ ŚŝĐŚŚĞůƉƐƐŽůŝĚŝĨLJƚŚĞƌĞůĂƟŽŶƐŚŝƉďĞƚǁ ĞĞŶthe college and hospital.K ƵƌŶƵƌƐĞĞĚƵĐĂƚŽƌƐŝĚĞŶƟĨLJĞĚƵĐĂƟŽŶĂůŶĞĞĚƐĂŶĚŝƐƐƵĞƐof the residents and work with the director to establishƌĞƐƉŽŶƐŝǀ ĞĞĚƵĐĂƟŽŶĂůƉůĂŶƐ͘ dŚĞŶƵƌƐĞĞĚƵĐĂƚŽƌƐĚĞǀ ĞůŽƉƚŚĞĂƉƉƌŽƉƌŝĂƚĞĞĚƵĐĂƟŽŶĂůĐƵƌƌŝĐƵůĂ͕ ĨŽƌŵƵůĂƚĞƚĞĂĐŚŝŶŐŽƵƚůŝŶĞƐ͕ ĂŶĚĚĞƚĞƌŵŝŶĞĂƉƉƌŽƉƌŝĂƚĞŝŶƐƚƌƵĐƟŽŶĂůŵĞƚŚŽĚͲŽůŽŐŝĞƐƵƟůŝnjŝŶŐĂĚƵůƚůĞĂƌŶŝŶŐƉƌŝŶĐŝƉůĞƐĂƐĂƉƉƌŽƉƌŝĂƚĞƚŽŵĞĞƚƚŚĞŽǀ ĞƌĂůůŐŽĂůƐĂŶĚŽďũĞĐƟǀ ĞƐŽĨƚŚĞƉƌŽŐƌĂŵ͘ dŚĞLJĂůƐŽƐĞƌǀ ĞĂƐĞĚƵĐĂƟŽŶĂůƌĞƐŽƵƌĐĞƐĂŶĚƌŽůĞŵŽĚĞůƐ͘ ~ Mary Blessing, MSN RN, ED Nurse Residency ProgramOur Goals for the Program are:dŽƐƵƉƉŽƌƚƚŚĞƚƌĂŶƐŝƟŽŶĨƌŽŵĂĚǀ ĂŶĐĞĚďĞŐŝŶŶĞƌƚŽĐŽŵƉĞƚĞŶƚƉƌŽĨĞƐƐŝŽŶĂůŶƵƌƐĞŝŶƚŚĞĮ ƌƐƚLJĞĂƌŽĨƉƌĂĐƟĐĞdŽĚĞǀ ĞůŽƉĞī ĞĐƟǀ ĞĚĞĐŝƐŝŽŶ-making skills related to clinical judgment and performanceTo provide clinical nursing leadership at the point of careTo strengthen commitment to nursing as a professional career choiceTo formulate a 1-year individual development plan related to new clinical rolldŽŝŶĐŽƌƉŽƌĂƚĞƌĞƐĞĂƌĐŚďĂƐĞĚĞǀ ŝĚĞŶĐĞůŝŶŬĞĚƚŽŽƵƚĐŽŵĞƐŝŶƚŽƉƌĂĐƟĐĞdŽƌĞĐŽŐŶŝnjĞƌĞƚĞŶƟŽŶĂƐĂŶŝŶĚŝĐĂƚŽƌŽĨƐĂƟƐĨĂĐƟŽŶTo support the Associate Degree New Graduate Nurse

STRUCTURAL EMPOWERMENTPage 17From the Desk of HSC Library Nursing Research SupportIngrid Hendrix is the Nursing ServicesLibrarian and is available to help nursesŝŶƚŚĞŚŽƐƉŝƚĂůĂŶĚĐůŝŶŝĐƐǁ ŝƚŚƋƵĞƐƟŽŶƐĂďŽƵƚůŝƚĞƌĂƚƵƌĞƐĞĂƌĐŚĞƐ͕ ƐĞůĞĐƟŶŐƚŚĞbest database for a topic, finding full-textĂƌƟĐůĞƐ͕ ĂŶĚĂŶLJƚŚŝŶŐĞůƐĞƌĞůĂƚĞĚƚŽĮ ŶĚŝŶŐŝŶĨŽƌŵĂƟŽŶĨŽƌƉĂƉĞƌƐŽƌƉƌŽũĞĐƚƐ͘She is available to work one-on-one to helpnavigate through the array of resourcesaccessible through the library and toprovide literature searches for nursesworking on their PDSA projects or otherresearch endeavors.Ingrid is involved in a number of CNEofferings through the hospital, such asthe PDSA series, the Nurse EducatorĐůĂƐƐĞƐĂŶĚƚŚĞE ƵƌƐŝŶŐWƵďůŝĐĂƟŽŶt ŽƌŬƐŚŽƉƐ͘ /ŶĂĚĚŝƟŽŶƚŽƉƌŽǀ ŝĚŝŶŐůŝƚĞƌĂƚƵƌĞƐĞĂƌĐŚŝŶŐŝŶƐƚƌƵĐƟŽŶƚŚƌŽƵŐŚthose classes, she also provides anŽƌŝĞŶƚĂƟŽŶƚŽůŝďƌĂƌLJƌĞƐŽƵƌĐĞƐƚŽĂůůnew nurse residents.A Nursing Resources Guide has beendesigned for clinicians, students, andfaculty — ǀ ŝƐŝƚŚƩ Ɖ͗ ͬ ͬlibguides.health.unm.edu/content.php?pid=191251.Ingrid Hendrix, MILS, AHIPReach Ingrid at ihendrix@salud.unm.edu or askingrid@salud.unm.eduƚŽƐĞƚƵƉĂŶĂƉƉŽŝŶƚŵĞŶƚŽƌũƵƐƚĂƐŬƋƵĞƐƟŽŶƐǀ ŝĂĞŵĂŝů͘Evidence-ĂƐĞĚWƌĂĐƟĐĞŚĂŵƉŝŽŶƐ– since July 2012ǁ ĞƌĞƌĞĐƌƵŝƚĞĚĂŶĚ͕ ŝŶ:ƵůLJ͕ ϮϬϭϮ͕ ƚŚĞŐƌŽƵƉďĞŐĂŶŵĞĞƟŶŐŽŶĂŵŽŶƚŚůLJďĂƐŝƐ͘ ĚƵĐĂƟŽŶǁ ĂƐƉƌŽǀ ŝĚĞĚĂƐŶĞĞĚĞĚ͕ ĂůŽŶŐǁ ŝƚŚĂĚĚŝƟŽŶĂůƐƵƉƉŽƌƚ͘dŚƌŽƵŐŚĂƐŬŝŶŐƉĞƌƟŶĞŶƚƉƌĂĐƟĐĞƋƵĞƐƟŽŶƐ͕ ůŝƚĞƌĂƚƵƌĞƐĞĂƌĐŚĞƐ͕ ĂŶĚŝŵƉůĞŵĞŶƟŶŐŶĞǁ ƉƌĂĐƟĐĞƐ͕ ƐŽŵĞŽĨƚŚĞƉƌŽũĞĐƚƐŚĂǀ ĞƌĞƐƵůƚĞĚŝŶƉĞŶĚŝŶŐƉŽůŝĐLJͬ ƉƌĂĐƟĐĞĐŚĂŶŐĞƐ͘With encouragement from CNO Sheena Ferguson,Nicole Weimer, MSN, RN, Nurse Educator for the NurseResidency program, put together a plan to providecompensated hours for staff nurses to spend workingon PDSA/Evidence-Based Projects on their units.ŌĞƌƌĞĐĞŝǀ ŝŶŐĂƉƉƌŽǀ ĂůƚŽŝŶŝƟĂƚĞƚŚĞƚƌŝĂůƉƌŽŐƌĂŵ͕ ZE Ɛǁ ĞƌĞŝŶǀ ŝƚĞĚƚŽĂƉƉůLJ͘ ƉƉůŝĐĂƟŽŶƐǁ ĞƌĞƌĞǀ ŝĞǁ ĞĚby program leaders, and seven candidates were chosen,ƌĞƉƌĞƐĞŶƟŶŐĂǀ ĂƌŝĞƚLJŽĨƵŶŝƚƐ͘ dǁ ŽŵŽƌĞƉĂƌƟĐŝƉĂŶƚƐ^Ğǀ ĞƌĂůƉĂƌƟĐŝƉĂŶƚƐǁ ĞƌĞŝŶƐƉŝƌĞĚƚŽĐŽŵƉůĞƚĞƚŚĞŝƌŝŶŝƟĂůproject and move on to another topic. This program hasprovided a unique opportunity for UNMH nurses tocontribute to the body of nursing knowledge and research.Billie Babb, RN: PICU—Primary Nurse Project,^ƚĞƌŶĂůWƌĞĐĂƵƟŽŶƐ͕ ĂŶĚĂŶŽƚŚĞƌdŽŽůĞǀ ĂůƵĂƟŽŶTerri Gibson, RN: OP,FP-Live Fit Family ChallengeJonathan Olp, RN: TSICU- ŽŵďĂƟŶŐD ĂůŶƵƚƌŝƟŽŶJessamy Phillips, RN: 4W- MSOC, CAUTI, RSI medsAndrea Rhodes, RN: NBICU-Kangaroo Care, CLABSI^ĂďƌĞĞŶĂ^ƚƌĂƩ ŽŶ, RN: NSICU-CAUTI

EXEMPLARY PROFESSIONAL PRACTICEPage 18WƌĂĐƟĐĞD ŽĚĞůdƌĂŶƐůĂƚĞƐK ƵƌWƌĂĐƟĐĞŝŶƚŽĐƚƵĂůĂƌĞCOMPASS OF CAREOUR CARE DELIVERY MODELUNMH Compass of Care Delivery ModelPatientOutcomesHaving a model allows us toǀ ĂůŝĚĂƚĞƉĂƟĞŶƚŶĞĞĚƐĂŶĚexamine our competenceas a profession tomeet those needsInterventionsRight interventionRight timeRight reasonNursingDirects anddelegates patientcare based on rolesUAPsAssists in patient careProfessionalismEducationResearchPracticePatientFamilyCommunityCOMMUNICATIONDiagnosesPlan for CareInterdisciplinaryTeam MemberCollaborationwith nursing forcommonpatient goals.AssessmentChief ConcernHistory & PhysicalNursing DatabaseModel Highlights:WĂƟĞŶƚ͕ &ĂŵŝůLJ͕ ĂŶĚCommunity is CentralE ƵƌƐŝŶŐĐƟǀ ŝƚLJŝƐ͗ ProfessionallyDrivenDemonstrates RoleCompetence andInterdisciplinarydĞĂŵŽůůĂďŽƌĂƟŽŶt ŚĂƚŝƐĂWƌĂĐƟĐĞD ŽĚĞůĂŶĚt ŚLJŽt ĞE ĞĞĚK ŶĞ͍ƉƌĂĐƟĐĞŵŽĚĞů͕ in short, is a model of ƚŽŽƵƌƉŽƉƵůĂƟŽŶ͘ /ƚĞŶĐŽŵƉĂƐƐĞƐŽƵƌcare that provides a framework for what mission, vision, and values.UNMH nurses believe about nursingBy consistently reviewing our model,ƉƌĂĐƟĐĞ͘ /ƚŝƐƚŽďĞƵƐĞĚĂƐĂŐƵŝĚĞƚŚĂƚand applying the ĞŶŶĞƌĂŶĚE ŝŐŚƟŶŐĂůĞdirects and describes ŚŽǁ ǁ ĞƉƌĂĐƟĐĞ͕ concepts, we believe we can and doďLJŝĚĞŶƟĨLJŝŶŐŬĞLJĞůĞŵĞŶƚƐŽĨŽƵƌachieve ƚŚĞďĞƐƚƉĂƟĞŶƚŽƵƚĐŽŵĞƐ͘ ƉƌŽĨĞƐƐŝŽŶĂůƉƌĂĐƟĐĞ͘ ĂƐĞĚŽŶŽƵƌŬŶŽǁ ůĞĚŐĞŽĨƚŚĞƉĂƟĞŶƚ͛ ƐWƌŽĨĞƐƐŝŽŶĂůWƌĂĐƟĐĞD ŽĚĞůƐŚŽƵůĚ needs and the plan of care, our goal is forĞŶƐƵƌĞƚŚĂƚŽƵƌŶƵƌƐŝŶŐƉƌĂĐƟĐĞŝƐ ƚŚĞƉĂƟĞŶƚƚŽƐĂĨĞůLJƉƌŽŐƌĞƐƐƚŚƌŽƵŐŚconsistent throughout UNMH-across all the hospital stay without any preventableƐĞƫ ŶŐƐ͕ ĂŐĞŐƌŽƵƉƐ͕ ĂŶĚŶƵƌƐĞĞdžƉĞƌŝĞŶĐĞ ĐŽŵƉůŝĐĂƟŽŶƐŽƌĚĞůĂLJƐ͘ ĐĂƌĞŵŽĚĞůŝƐůĞǀ ĞůƐ͘ /ƚƐĞƌǀ ĞƐĂƐĂ͚ ŐƵŝĚĞĨŽƌƉƌĂĐƟĐĞ͛ Žƌ ŶĞĐĞƐƐĂƌLJĨŽƌƵƐƚŽďĞĂďůĞƚŽĂƌƟĐƵůĂƚĞa ‘checklist’ for the most basic of what we our process for the best outcomes.believe as nurses and what is importantCare is: ƉĂƟĞŶƚoutcomesdriven.The Model is: ŽŶƟŐƵŽƵƐŽŶƟŶƵŽƵƐModified to fitƉĂƟĞŶƚƐ͛ ŶĞĞĚƐ͘Nursing Process: AssessmentDiagnosis/Plan ofCare/ŶƚĞƌǀ ĞŶƟŽŶWĂƟĞŶƚK ƵƚĐŽŵĞƐĂŶĚǀ ĂůƵĂƟŽŶ

EXEMPLARY PROFESSIONAL PRACTICEPage 19COMPASS of CARE DELIVERY MODEL - The ProcessOur delivery model focuses on ƉĂƟĞŶƚoutcomes, believing that the nurse,through his/her assessment, creates thecare plan, and collaborates and delegateswith the team members so that the properŝŶƚĞƌǀ ĞŶƟŽŶƐĐĂŶďĞĚLJŶĂŵŝĐ— just asƚŚĞŶĞĞĚƐŽĨƚŚĞƉĂƟĞŶƚĂƌĞĂůƐŽ͘ The Nursing Process can be applied to allƐĞƫ ŶŐƐ͗ ĐƵƚĞĐĂƌĞ͕ ŚƌŽŶŝĐĐĂƌĞ͕ Behavioral Health, and Community Health,ŝŶĐůƵĚĞƐƚŚĞĐŽŶƟŶƵŝƚLJŽĨĐĂƌĞĂŶĚĐĂƌĞacross the lifespan of individuals. It is acomprehensive and problem-solving approach,not unlike methods used byother disciplines-allowing us tocommunicate Ğī ĞĐƟǀ ĞůLJǁ ŝƚŚŽƚŚĞƌteam members.These processes allow for theŝĚĞŶƟĮ ĐĂƟŽŶŽĨƚŚĞĂĐƟǀ ĞĂŶĚƉŽƚĞŶƟĂůƉƌŽďůĞŵƐƚŚĞƉĂƟĞŶƚŶĞĞĚƐĂĚĚƌĞƐƐĞĚin their plan of care. At the end of theƐŚŝŌ͕ ƚŚĞŶƵƌƐĞĂĚũƵƐƚƐƚŚĞƉůĂŶŽĨĐĂƌĞďĂƐĞĚŽŶƚŚĞƉĂƟĞŶƚ͛ ƐƌĞƐƉŽŶƐĞ͘ /ŶƚŚŝƐway, environment, nurse competency,ĂŶĚƉĂƟĞŶƚŶĞĞĚƐĂƌĞĂĚĚƌĞƐƐĞĚ͘Staff and Leadersattempt to put CCMModel togetherfrom memory.NIGHTINGALE-UNMH Care Model TheoristAlong with the Nursing Process, the UNMHCompass of Care Model is also based on the^LJƐƚĞŵĂƟĐΘ, ŽůŝƐƟĐĂƉƉƌŽĂĐŚŽĨĐĂƌĞƚŚĂƚ&ůŽƌĞŶĐĞE ŝŐŚƟŶŐĂůĞŝŶƚƌŽĚƵĐĞĚŝŶƚŚĞϭϴϲϬ͛ Ɛ͘E ŝŐŚƟŶŐĂůĞĚĞǀ ĞůŽƉĞĚƚŚĞŝĚĞĂŽĨŶƵƌƐŝŶŐĂƐĂĚŝƐƟŶĐƚƐĐŝĞŶĐĞ͘ dŚŝƐŐŝǀ ĞƐŶƵƌƐŝŶŐĂƉƌĂĐƟĐĞmilieu of Engagement, Accountability, andŽŵŵƵŶŝĐĂƟŽŶ͘ This also allows evidenceďĂƐĞĚƉƌĂĐƟĐĞ͕ĐŽŶƐŝƐƟŶŐŽĨĂProfessionalapproach that includes, ĚƵĐĂƟŽŶ͕ ZĞƐĞĂƌĐŚ͕ and WƌĂĐƟĐĞ͘I did it,but it isnot easy!&ůŽƌĞŶĐĞƐĂǁ ƚŚĞƉĂƟĞŶƚĂƐŵŽƌĞƚŚĂŶĂĚŝƐĞĂƐĞƐƚĂƚĞŽƌĐŽŶĚŝƟŽŶ͘ ^ŚĞǁ ĂƐconcerned about all needs– physical, spiritual,ĞŵŽƟŽŶĂů͕ ĞŶǀ ŝƌŽŶŵĞŶƚĂů͕ ĚŝĞƚĂƌLJ͕ ĂŶĚƌĞŚĂďŝůŝƚĂƟŽŶ͘ E ƵƌƐŝŶŐĐĂƌĞƉƵƚƐƚŚĞƉĂƟĞŶƚŝŶƚŚĞďĞƐƚĐŽŶĚŝƟŽŶĨŽƌƌĞĐŽǀ ĞƌLJ͕ ĂŶĚƚŽĚĂLJƚŚĞƐĞŶĞĞĚƐĂƌĞĞǀ ĞŶŵŽƌĞĐƌŝƟĐĂůĐŽŶĐĞƌŶŝŶŐƚŚĞƉĂƟĞŶƚƐŝŶŽƵƌŚŽƐƉŝƚĂůƐ͘BENNER—UNMH Care Model— Professional ModelBenner discusses how nurses develop fromNovice to Expert. We have to recognizeŽƵƌĞdžƉĞƌƟƐĞ͕ ĂŶĚƐĞĞŬŽƵƌŽǁ ŶŶƵƌƐŝŶŐconsultants.Benner’s Stages of Clinical Competence:Stage 1:Beginner: no experienceStage 2: Advanced Beginner: marginallyacceptable performance, some experience.Stage 3: Competent: on the job 2-3 years,lacks speed/efficiency, some skill mastery.Stage 4: WƌŽĮ ĐŝĞŶƚ͗ ƉĞƌĐĞŝǀ ĞƐƐŝƚƵĂƟŽŶƐĂƐwhole, which improves decision-making.We trust that the engagement via SharedGovernance and professionalism results inownership and autonomy ŝŶƉĂƟĞŶƚ-focusedcare.

EXEMPLARY PROFESSIONAL PRACTICEPage 20Liz Gober RN Supervisor, Pediatric Hospice Program (Mariposa)Each year dozens of nurses are nominated for NewMexico Nursing Excellence Awards. In 2012, 50 UNMHnurses were nominated in several categories, and fouresteemed nurses were named winners. (See page 22).>ŝnj' ŽďĞƌǁ ĂƐĨĞĂƚƵƌĞĚŝŶĂŶĞǁ ƐƉĂƉĞƌĂƌƟĐůĞŝŶƚŚĞValencia County News-ƵůůĞƟŶĂŌĞƌǁ ŝŶŶŝŶŐƚŚĞE D E ƵƌƐŝŶŐdžĐĞůůĞŶĐĞĂǁ ĂƌĚ͘ dŚĞĂƌƟĐůĞďLJ:ƵůŝĂD ͘ ĞŶĚŝŶŐͲer, News-ƵůůĞƟŶ^ƚĂī t ƌŝƚĞƌ͕ ǁ ĂƐƉƵďůŝƐŚĞĚŽŶĞĐĞŵďĞƌ5, 2012. Excerpts from the lengthy writeup:“Gober is credited with developing the pediatric hospiceprogram for University of New Mexico Children’s Hospitaland is now Mariposa’s RN Supervisor.A nurse for 36 years, graduated from the University ofNew Mexico in 1976 with a Bachelor of Science degreeŝŶŶƵƌƐŝŶŐ͕ ĂŶĚďĞĐĂŵĞĐĞƌƟĮ ĞĚĂƐĂE ĞŽŶĂƚĂůE ƵƌƐĞWƌĂĐƟƟŽŶĞƌŝŶϭϵϴϯ͘͞ /ŚĂĚŶŽĞdžƉĞĐƚĂƟŽŶƚŽďĞŶŽŵŝŶĂƚĞĚŽƌƚŽǁ ŝŶ͕ ͞ ' ŽďĞƌsaid, “I was just doing the right thing. This is the most diffi-ĐƵůƚƟŵĞŝŶĂĐŚŝůĚ͛ ƐůŝĨĞ͘ t ĞũƵƐƚƵƐĞƚŚĞƐŬŝůůƐǁ ĞŚĂǀ ĞƚŽŵĂŬĞƚŚĞƉĂƟĞŶƚ͛ ƐůŝĨĞƚŚĞďĞƐƚǁ ĞĐĂŶ͘ ͟ She also works with hospice agenciesoutside Mariposa Program’s 60-mileƌĂĚŝƵƐƚŚĂƚŽŶůLJƚĂŬĞĂĚƵůƚƉĂƟĞŶƚƐ͕ to train staff, and collaborates withstaff from local agencies so childrencan receive hospice in their homeĐŽŵŵƵŶŝƟĞƐ͘ ' ŽďĞƌĂůƐŽŝŶƐƟƚƵƚĞĚĂprogram that allows providers fromthroughout New Mexico to contact atoll-free number to obtain answersregarding care of children with endof-lifeissues.“ I’ve beenable to dowhat I dobecause ofthe supportof thehospital . . .”L.Gober, RNMariposaƌLJƐƚĂů&ƌĂŶƚnj͕ ƚŚĞD ĂƌŝƉŽƐĂdžĞĐƵƟǀ ĞŝƌĞĐƚŽƌŽĨĂƐĞManagement, nominated Gober for the award. “She isdedicated to providing compassionate quality care toƉĞĚŝĂƚƌŝĐƉĂƟĞŶƚƐĂŶĚƚŚĞŝƌĨĂŵŝůŝĞƐ͕ ͟ Frantz said in apress release.Pediatric Hospice: UNM Mariposa Program (UNM Hospitals website)Mariposa means ͞ ƵƩ ĞƌŇLJ͟ in Spanish.We do not expect children to have life-ůŝŵŝƟŶŐŵĞĚŝĐĂůĐŽŶĚŝƟŽŶƐ͘ But tragically, some do. The Mariposa Program of UNM Children’sHospital is designed to assist families facing such a challenge. Mariposaoffers comprehensive, compassionate care for infants, children andĂĚŽůĞƐĐĞŶƚƐǁ ŝƚŚůŝĨĞůŝŵŝƟŶŐĐŽŶĚŝƟŽŶƐ͘dŚĞƉƌŽŐƌĂŵƐĞƌǀ ĞƐŶŽƚŽŶůLJƚŚĞĐŚŝůĚ͕ ďƵƚƐƵƉƉŽƌƚƐƚŚĞĞŶƟƌĞĨĂŵŝůLJ͕ including parents and siblings. An individualized plan of care is designedƚŽŵĞĞƚƚŚĞƐƉĞĐŝĮ ĐŶĞĞĚƐ͕ ŚŽƉĞƐĂŶĚŐŽĂůƐŽĨĞĂĐŚƉĂƟĞŶƚĂŶĚŚŝƐŽƌher family. The plan addresses the medical, nursing, psychosocial, andƐƉŝƌŝƚƵĂůŶĞĞĚƐŽĨƚŚĞƉĂƟĞŶƚĂŶĚĨĂŵŝůLJ͕ ĂŶĚŝƐĐĂƌƌŝĞĚŽƵƚďLJĂƚĞĂŵŽĨhighly trained professionals.The Mariposa Program emphasizes quality of life rather than lengthŽĨůŝĨĞ͕ ĂŶĚƵƐĞƐǁ ŚĂƚĞǀ ĞƌƟŵĞŝƐĂǀ ĂŝůĂďůĞƚŽƉƌŽǀ ŝĚĞƐƉŝƌŝƚƵĂůĂŶĚĞŵŽƟŽŶĂůƐƵƉƉŽƌƚƚŽƚŚĞƉĂƟĞŶƚĂŶĚĨĂŵŝůLJ͘The dying child deserves always tobe treated first as a child, andsecondarily as a dying person."~ Kathleen W. Faulkner,Hospice Care for Children

EXEMPLARY PROFESSIONAL PRACTICEPage 21Over 50 RNs Collaborate with Medical TeamsThe Care Management Department at UNM Hospitalshas more than 50 Registered Nurses who work inĐŽůůĂďŽƌĂƟŽŶǁ ŝƚŚƚŚĞŵĞĚŝĐĂůƚĞĂŵƐƚŽĐĂƌĞĨŽƌŽƵƌƉĂƟĞŶƚƐďŽƚŚǁ ŝƚŚŝŶƚŚĞŚŽƐƉŝƚĂůĂŶĚƚŚƌŽƵŐŚŽƵƚƚŚĞcommunity. These teams include Doctors, NurseWƌĂĐƟƟŽŶĞƌƐ͕ ^ŽĐŝĂůt ŽƌŬĞƌƐ͕ ŽƚŚĞƌE ƵƌƐĞƐĂŶĚĂǁ ŚŽůĞvariety of other professionals.K ƵƌŶƵƌƐĞƐĚŽhƟůŝnjĂƟŽŶZĞǀ ŝĞǁ ͕ Discharge Planning,dƌĂŶƐŝƟŽŶƐŽĨĂƌĞ͕ ĂƌĞŽŽƌĚŝŶĂƟŽŶĂŶĚŽƚŚĞƌĂƐĞD ĂŶĂŐĞŵĞŶƚƌĞƐƉŽŶƐŝďŝůŝƟĞƐ͘ ǀ ĞƌLJƉĂƟĞŶƚŝŶƚŚĞhospital is reviewed by a Nurse Case Manager on aƌĞŐƵůĂƌďĂƐŝƐ͘ ǀ ĞƌLJƉĂƟĞŶƚǁ ŝƚŚĂƉƌŝŵĂƌLJĐĂƌĞƉƌŽǀ ŝĚĞƌat one of the UNM Clinics has a Nurse Case Manager tohelp coordinate care needs.2012 Case Management TeamAccomplishments44,401 hƟůŝnjĂƟŽŶƌĞǀ ŝĞǁ ƐĐŽŵƉůĞƚĞĚďLJZE D Ɛnecessary to maintain compliance andmaximize reimbursement.18,626 WŽƚĞŶƟĂůůLJĂǀ ŽŝĚĞĚǀ ŝƐŝƚƐ͘9,421 WŽƚĞŶƟĂůĂǀ ŽŝĚĂďůĞŝŶƉĂƟĞŶƚĚĂLJƐŝĚĞŶƟĮ ĞĚ͘1,412 hE D ĂƌĞ/ŶƉĂƟĞŶƚĚĂLJƐƐĂǀ ĞĚďLJƚƌĂŶƐŝƟŽŶŝŶŐƚŽůŽǁ Ğƌ-ůĞǀ ĞůĐĂƌĞƵƟůŝnjŝŶŐĐŽŶƚƌĂĐƚĞĚĨĂĐŝůŝƟĞƐ͘These clinics include but are not limited to:●2ACC Clinics●Medicine Faculty Clinic●Senior Health Clinic●4ACC Clinics●Medicine Specialty Clinic●Westside Clinic●5ACC Clinics●Northeast Heights Clinic●●●ĂƌƌŝĞdŝŶŐůĞLJK ƵƚƉĂƟĞŶƚFamily Medicine ClinicManaged Care Clinic●●●Pediatric ClinicSoutheast Heights ClinicSouthwest Mesa ClinicMonica Vickery, MSN, RN-BC, CCM,RNC-MNNRN Case ManagerCare Management ServicesCheck out ourMagnet EventsCalendar linkto find outwhat’s goingon in nursing!Get involved!

EXEMPLARY PROFESSIONAL PRACTICEPage 22EXEMPLARY PROFESSIONAL PRACTICE—GROUNDING CONCEPTS FOR NURSESThe Magnet Component,Exemplary ProfessionalWƌĂĐƟĐĞ;Whas the mostĞdžƉĞĐƚĞĚĚĂƚĂĐŽůůĞĐƟŽŶwhen compared to theother components. WithEP there is an emphasis onnurses understanding theirCare Model, NurseAutonomy, WorkplaceAdvocacy and clearĞdžƉĞĐƚĂƟŽŶƐĂďŽƵƚŚŽǁ we will achieve and besupported in our efforts toprovide quality nursingcare. There are manywonderful conceptswithin all the MagnetComponents, but thisŽŶĞŝŶƉĂƌƟĐƵůĂƌƌĞĂůůLJencompasses the bigpicture of nurses inhealthcare, and howĐŽůůĂďŽƌĂƟŽŶŝƐƚŚĞŵŽƐƚĞī ĞĐƟǀ Ğ͕ ĂŶĚĞdžƉĞĐƚĞĚway, to improve outcomesĨŽƌƚŚĞƉĂƟĞŶƚƐǁ ĞƐĞƌǀ Ğ͘ ĞĐŽŵĞĨĂŵŝůŝĂƌǁ ŝƚŚƚŚŝƐand the other components, as a way to improveyour outcomes and build up interdisciplinaryĐŽůůĂďŽƌĂƟŽŶ͘ “The Pathway to Excellence ® Program recognizesŚĞĂůƚŚĐĂƌĞŽƌŐĂŶŝnjĂƟŽŶƐĨŽƌƉŽƐŝƟǀ ĞƉƌĂĐƟĐĞenvironments where nurses excel. To qualify,ŽƌŐĂŶŝnjĂƟŽŶƐŵĞĞƚϭϮƉƌĂĐƟĐĞƐƚĂŶĚĂƌĚƐĞƐƐĞŶƟĂůƚŽĂŶŝĚĞĂůŶƵƌƐŝŶŐƉƌĂĐƟĐĞĞŶǀ ŝƌŽŶŵĞŶƚ͘ E ƵƌƐĞƐƚƌƵƐƚthat Pathway-ĚĞƐŝŐŶĂƚĞĚŝŶƐƟƚƵƟŽŶƐƌĞƐƉĞĐƚƚŚĞŝƌĐŽŶƚƌŝďƵƟŽŶƐ͕ ƐƵƉƉŽƌƚƉƌŽĨĞƐƐŝŽŶĂůĚĞǀ ĞůŽƉŵĞŶƚĂŶĚŶƵƌƚƵƌĞŽƉƟŵĂůǁ ŽƌŬƐĞƫ ŶŐƐ͘Εǁ ǁ ǁ ͘ ŶƵƌƐĞĐƌĞĚĞŶƟĂůŝŶŐ͘ ŽƌŐhE D , ĞůĞďƌĂƚĞƐŶŶƵĂůĞƌƟĮ ĞĚE ƵƌƐĞƐĂLJThe leadership at UNMH valuesƐƉĞĐŝĂůƚLJĞƌƟĮ ĐĂƟŽŶĨŽƌE ƵƌƐĞƐ͘ Many classes are offered on a yearlybasis that review material for aǀ ĂƌŝĞƚLJŽĨĐĞƌƟĮ ĐĂƟŽŶƐ— includingƌŝƟĐĂůĂƌĞE ƵƌƐŝŶŐ͕ ŵďƵůĂƚŽƌLJCare, Progressive Care, EmergencyNurse, and others.Along with cake and networkingŽƉƉŽƌƚƵŶŝƟĞƐ͕ ĂƐƉĞĐŝĂůƐůŝĚĞƐŚŽǁ ŝƐĐŽŵƉŝůĞĚ͕ ŚŝŐŚůŝŐŚƟŶŐǁ ŚĂƚĞƌƟĮ ĞĚE ƵƌƐĞƐŚĂǀ ĞƚŽsay about the benefits theyĞŶĐŽƵŶƚĞƌĂƐĂĐĞƌƟĮ ĞĚZE ͘ t ĞĂůƐŽŚĂǀ ĞĂĐĞůĞďƌĂƟŽŶĂŶŶƵĂůůLJthat honors those nurses who areĐĞƌƟĮ ĞĚ͕ ĂŶĚǁ ĞŵĂŬĞĂǀ ĂŝůĂďůĞŝŶĨŽƌŵĂƟŽŶĨŽƌƚŚŽƐĞǁ ŚŽĂƌĞĐŽŶƐŝĚĞƌŝŶŐĐĞƌƟĮ ĐĂƟŽŶŝŶƚŚĞĨƵƚƵƌĞ͘

EXEMPLARY PROFESSIONAL PRACTICEUNMH Eyewitness News 4 HEALTH FAIRFor many, especiallythose in rural NewMexico, the KOBHealth Fair is theonly opportunityannually to getbaseline healthnumbers, vaccinesand basic healthŝŶĨŽƌŵĂƟŽŶ͘ Each year at the end of January, UNM Hospitals sponsorsthe Eyewitness News 4 Health Fair. This large vendorevent at the Manuel Lujan building on the NM Fairgrounds;yWK ͊ E Ğǁ D ĞdžŝĐŽŝƐǀ ŝƐŝƚĞĚďLJƚŚŽƵƐĂŶĚƐŽĨĐŝƟnjĞŶƐfrom around the state.For UNMH, it’s a once-a-year opportunity to bringĂƩ ĞŶƟŽŶƚŽƚŚĞŵĂŶLJŚĞĂůƚŚƐĞƌǀ ŝĐĞƐŽī ĞƌĞĚ͘ D ŽƌĞƚŚĂŶ20 departments — ŝŶĐůƵĚŝŶŐWĞĚŝĂƚƌŝĐŵĞƌŐĞŶĐLJ͕ E ĂƟǀ ĞAmerican Health Services, Orthopedics, Senior Health,WĂƟĞŶƚ&ŝŶĂŶĐŝĂů^Ğƌǀ ŝĐĞƐ͕ ĞŚĂǀ ŝŽƌĂů, ĞĂůƚŚ͕ D Θ&W͕ Trauma Support, Neuroscience, and many more— wereŽŶŚĂŶĚƚŽƉƌŽǀ ŝĚĞŝŶĨŽƌŵĂƟŽŶŽŶŚĞĂůƚŚĐĂƌĞ͘ĚĚŝƟŽŶĂůůLJŶƵƌƐĞƐĂŶĚŶƵƌƐŝŶŐƐƚƵĚĞŶƚƐƉƌŽǀ ŝĚĞĚŇƵƐŚŽƚƐand height, weight, body fat and blood pressure readings.Feria de Salud&ŽƌƐĞǀ ĞƌĂůLJĞĂƌƐhE D , ŚĂƐƉĂƌƟĐŝƉĂƚĞĚŝŶƚŚŝƐĨƌĞĞĚĂLJŽĨŚĞĂůƚŚĂƚƚŚĞE ĂƟŽŶĂůHispanic Cultural Center in southwestAlbuquerque.The one-day event brings healthcareƐĞƌǀ ŝĐĞƐĂŶĚŝŶĨŽƌŵĂƟŽŶƚŽĐŽŵŵƵŶŝƚLJmembers. Blood pressure and bodyĨĂƚĐŚĞĐŬƐ͕ ĂƐǁ ĞůůĂƐŝŶĨŽƌŵĂƟŽŶŽŶŵĂƚĞƌŶŝƚLJ͕ ƐůĞĞƉ͕ ƉĂƟĞŶƚĮ ŶĂŶĐŝĂůĂŶĚorthopedic services, have been sharedǁ ŝƚŚŚƵŶĚƌĞĚƐŽĨŚĂƉƉLJĂƩ ĞŶĚĞĞƐ͘

EXEMPLARY PROFESSIONAL PRACTICEPage 24New Mexico Nursing Excellence AwardsThe New Mexico Center for NursingExcellence holds an annual New MexicoNursing Excellence Awards program. Nursesfrom around the state are nominated in 20specialty categories for their exemplarywork.The awards are celebrated at a banquet,held each October, where more that 800ĂƩ ĞŶĚƚŽůĞĂƌŶƚŚĞǁ ŝŶŶĞƌƐ͛ ŶĂŵĞƐ͘ UNMH holds a special nominees teaduring the week of the NMNE awardbanquet for UNMH nominees , tohonor and thank them for sharingƚŚĞŝƌƐƉĞĐŝĂůŐŝŌƐĂƚhE D , ͘ In 2012 UNMH fielded 67 nominees, andfour Exemplary Nurses were awarded:Lizabeth Gober - Homecare/HospiceStephanie Sanderson - ƌŝƟĐĂůĂƌĞEric Peterson - džĞĐƵƟǀ Ğ>ĞĂĚĞƌƐŚŝƉTerri Gibson – Community Serviceh E D , ŝƐƐŽŚŽŶŽƌĞĚƚŽŚĂǀ ĞƚŚĞƐĞŚŝŐŚůLJƐŬŝůůĞĚ͕ ĐŽŵƉĂƐƐŝŽŶĂƚĞŶƵƌƐĞƐŚĞƌĞƚŽƐŚĂƌĞƚŚĞŝƌĞdžƉĞƌƟƐĞĂŶĚĐĂƌĞǁ ŝƚŚŽƵƌƉĂƟĞŶƚs!2012 NomineesIngrid Alvarado-SaenzShirley ArchuletaDiane BachichaTheresa BaconTracy BaslerCourtney BeachMeghan BlackHillary BleaMary BlessingKerri BrozenaCatherine BryanSusan ChampionDawn CheshireStephanie CoburnTeresa CoffeyKathleen CrispMarsha DeatonAna DiehlKaren EllingboeGrace FrancoDenise GarciaTanya GgbarneyMary GibsonTerri GibsonCindy GillespieLizabeth GoberBecky GonzalesDeborah Gonzales>LJŶĞƩ Ğ' ŽŶnjĂůĞƐCarolyn GreenRaymond GriffinHeather HowardY ƵĞŶƟŶ:ŽŶĞƐJodee KeithJoseph KimKori KindredVeronica LopezSocorro Lopez-MazonBarbara MacmillanEmily Maner:ŽĂŶD ĂƌƟŶĞnj-MaguireLisa McGuireGwynne McMurryBeth MullerToyin OladejiEric PetersonRazvan PredaFelicia PughEarl RedwineKayla RosenAndrea RostelStephanie SandersonHurbina SandovalAlison SchumannJennifer SearcyPatricia SeeberE ĂƟǀ ŝĚĂĚ^ŝůǀ ĂElaine StackCynde TaggVera TorresKimberly Ann ValerioWalter ViersJonathan WexlerůŝĐĞt ŚŝƩEve WohlertSharilyn WoloschukToni Wood

EXEMPLARY PROFESSIONAL PRACTICEPage 25DAISY AWARDS STARTED JANUARY 2012As many of you know,the DAISY stands for͞ ŝƐĞĂƐĞƐĂƩ ĂĐŬŝŶŐƚŚĞimmune system.”This award was started bythe Patrick Barnes Family,whose son died at the ageof 33 from ‘idiopathicthrombocytopeniapurpura’ aka ITP.Because Patrick’s familywere so grateful for thenursing care, and so inspiredby Patrick’s nurses,the family started thisaward in the late ‘90’s,in order to recognizeexemplary nurses.Check out or ‘DAISY’ linkon the Magnet intranetpage to learn more aboutthis wonderful award, andĐŽŶƐŝĚĞƌŶŽŵŝŶĂƟŶŐŽŶĞof your peers.Encourage doctors,ĨĂŵŝůŝĞƐ͕ ĂŶĚƉĂƟĞŶƚƐto nominate as well!2012 DAISY WINNERS—CONGRATULATIONS AND THANK YOU!1/12 Andrea Solano—Peds Clinic2/12 Reta King—L&D3/12 Valerie Barboa— PICU4/12 Joseph Montoya—5S5/12 Mackenzie Lake—NSICU6/12 Teresa Keppler— Peds Clinic7/12 Melanie Costales—Mind Clinic8/12 Kristen Hanrahan— NICU9/12 Donna Mulroy—5S10/12 Kathy Dolan-Cox—FPC11/12 Sue Tobin UD—Peds Clinic12/12 Rhonda Davis—MICU

NEW KNOWLEDGE, INNOVATION & IMPROVEMENTSPage 26TCAB–Transforming Care at the BedsideThe 4th Annual TCAB Symposium was held on October26, 2012, at the Embassy Suites Hotel. Over 125 guestsĂƩ ĞŶĚĞĚ͘ dŚĞƌĞǁ ĞƌĞĞŝŐŚƚƉƌĞƐĞŶƚĂƟŽŶƐďLJE ƵƌƐĞƐĂŶĚother Health Professionals. Also, 21 Posters wereǀ ŝĞǁ ĞĚ͕ ƉƌĞƐĞŶƟŶŐŝŶĐŽůŽƌĨƵůĂŶĚĚĞƐĐƌŝƉƟǀ ĞƚĞƌŵƐŽƚŚĞƌWŝŶŝƟĂƟǀ ĞƐƚĂŬŝŶŐƉůĂĐĞ͘ Sheena Ferguson,UNMH CNO, started the day by reminding us of thecurrent Triple Aim affect: we are trying to see moreƉĂƟĞŶƚƐ͕ ŝŶĐƌĞĂƐĞŽƵƌƋƵĂůŝƚLJ͕ ĂŶĚĚŽĂůůŽĨƚŚĂƚŵŽƌĞefficiently.Returning Key NoteSpeaker ƌ͘ WĞĚƌŽƩ LJinformed us about theǀ ĂƌŝŽƵƐǁ ĂLJƐƉĂƟĞŶƚƐƵƐĞto cope with their illnessand how we might thenapproach them with ourcare giving and teach inways more beneficial toƚŚĞƉĂƟĞŶƚƐ͘ *TCAB 2012 Presenters ƫ ƚƵĚĞƐdŽǁ ĂƌĚ, ŽŵĞůĞƐƐ͗ ŶŝŶǀ ĞŶƚŽƌLJŽĨĞdžŝƐƟŶŐĂƫ ƚƵĚĞƐƚŽǁ ĂƌĚŚŽŵĞůĞƐƐŶĞƐƐĂŵŽŶŐZE Ɛand Student Nurses- Noah Bankhurst, KristenD ĂƌƟŶĞnj͕ :ŽZĂĞdĂLJůŽƌ(UNM College of Nursing) D ƵůƟĚŝƐĐŝƉůŝŶĂƌLJƉƉƌŽĂĐŚƚŽĞĐƌĞĂƐŝŶŐhŶƉůĂŶŶĞĚdžƚƵďĂƟŽŶƐŝŶƚŚĞWĞĚŝĂƚƌŝĐ/h–Marian Daigle, RN BSN WƐLJĐŚŝĂƚƌŝĐD ĞŶƚĂů, ĞĂůƚŚĚǀ ĂŶĐĞĚWƌĂĐƟĐĞE ƵƌƐĞin An Emergency Department– Eric Peterson, RN ƌŝƟĐĂů, ĂŶĚŽī -ŽůůĂďŽƌĂƟǀ ĞƉƉƌŽĂĐŚƚŽdžƚĞƌŶĂůVentricular Drain Management between the NSICUand IR– Todd Christensen, RN BSN, Meaghan White,RN MSN, CEN, Deirdre Kearney, RN MSN Oral Versed vs IV Versed in Adult Procedural^ĞĚĂƟŽŶ—Courtney Beach, RN BSN ĸ ĐĂĐLJŽĨƚŚĞ/ŶƐƵůŝŶWƵŵƉǀ ƐD ƵůƟƉůĞĂŝůLJ/ŶũĞĐƟŽŶƐŝŶz ŽƵƚŚϵ-18 years old with Type I DiabetesMellitus: A Literature Review – Michelle Treme, RNBSN, CEN ŽŵďĂƟŶŐD ĂůŶƵƚƌŝƟŽŶǁ ŝƚŚW– Jonathan Olp, RNBSN, BS, MS, CCRN, Crystal Sanchez, RN BSN, CCRN. D ƵůƟĚŝƐĐŝƉůŝŶĂƌLJƉƉƌŽĂĐŚŝŶWƌĞǀ ĞŶƟŶŐWƌĞƐƐƵƌĞhůĐĞƌƐ͗ E ƵƌƐŝŶŐ͕ WdŽůůĂďŽƌĂƟŽŶ– Karen Brown, RNWCC, Jassmine Safier, RN, Linda Halvorson, RN, CCRN,Sunny Chirieleison, PT, Rachael Brown, RN, ChandraBlunt, Project Coordinator.***

NEW KNOWLEDGE, INNOVATION & IMPROVEMENTSPage 27dϮϬϭϮWŽƐƚĞƌWƌĞƐĞŶƚĂƟŽŶƐE ĂƐŽͬ ŽƌĂů' ĂƐƚƌŝĐĂŶĚ/ŶƚĞƐƟŶĂů&ĞĞůŝŶŐ*Code Management and Crash Cart ItemsWƌĞŽƉĞƌĂƟǀ ĞdŽƚĂů:ŽŝŶƚZĞƉůĂĐĞŵĞŶƚůĂƐƐTurn That Thing off!Geraldine Guerra-Sandoval, RN MSN, EDGeraldine Guerra-Sandoval, RN MSN, EDRachel Brown, RN BSNMelinda Song, RNLive Fit Family (Teen) ChallengeTerri Gibson RN-BC MSN, Patricia McCarty, RN BSN,CDE, Jennie McCary, MS, LD, RD*WŽƌƚĐĐĞƐƐ͗ t ŚĞŶŽƌƌĞĐƚWŽƐŝƟŽŶ dĂŶLJĂ' ŐďĂƌŶĞLJ͕ ZE ^E ͕ ΘE ĂƟǀ ĂĚ^ŝůǀ Ă͕ D ^͕ A.D.N.ŝƐŶŽƚĂĐŚŝĞǀ ĞĚŽŶƚŚĞϭƐƚĂƩ ĞŵƉƚ*Ăůů>ŝŐŚƚZĞĚƵĐƟŽŶ͛ Ɛ/ŶŇƵĞŶĐĞŽŶ, , WƐ^ĐŽƌĞ ƌŝƐƟŶĂƌĞ͕ ZE ^E ͕ WE ΘƌĐĞůŝĂZĂŵŽƐ͕ ZE ^E/ŵƉůĞŵĞŶƟŶŐWĨŽƌƚŚĞZĞĚƵĐƟŽŶŽĨ, /ŶĨĞĐƟŽŶƐ Diane Bachicha, RN BSN & Dierdre Kearney, RN BSN^ƉĞĐŝĮ ĐĂůůLJD ĞŶŝŶŐŝƟƐǁ ŚĞŶK ďƚĂŝŶŝŶŐ^&ŝŶƚŚĞE /hZĞĚƵĐŝŶŐƚŚĞZŝƐŬŽĨĞǀ ĞůŽƉŝŶŐ, /ŶĨĞĐƟŽŶƐ͕ ĐŚĞŵŝĐĂůŽƌ Angela Alberson, RN, Diane Bachicha, RN BSN &ŝŶĨĞĐƟŽƵƐƌͬ ƚŵĞŶŝŶŐŝƟƐĨƌŽŵ>ƵŵďĂƌΘͬ ŽƌƌĂŶŝĂůĐĐĞƐƐ Claudia Tchiloyans, RNE ƵƌƐŝŶŐE K t ͕ , Žǁ ŶƵƌƐŝŶŐƌŽƵŶĚƐŝŵƉƌŽǀ ĞƐĂƟƐĨĂĐƟŽŶƐĐŽƌĞƐGary McNeil, RN ANDOur Icky Campaign: A Hand Hygiene Improvement Plan Martha Andaloza, RN-BC BSN, PCCN,/ŵƉƌŽǀ ŝŶŐŽŵŵƵŶŝĐĂƟŽŶŵŽŶŐƐƚW/h^ƚĂī ^ƚƌŽŬĞŽĐƵŵĞŶƚĂƟŽŶ͕ Į ůůŝŶŐŝŶƚŚĞŐĂƉƐRachel Rivera, RN BSN CPN CCRNMarian Kelly, RN Deirdre Kearney, RN MSN*dŝŵĞůůŽĐĂƟŽŶĨŽƌ&ƌĞƋƵĞŶƚE ƵƌƐŝŶŐdĂƐŬƐŝŶĂD ĞƚƌŽƉŽůŝƚĂŶ Kate Hicks, RN BSN, CENEmergency DepartmentdŚĞD ŝƐĐŽŶĐĞƉƟŽŶƐ^ƵƌƌŽƵŶĚŝŶŐK ƌŐĂŶŽŶĂƟŽŶŝŶE DĂƌƌŝĞƌƐƚŽdƌĞĂƚŵĞŶƚĨŽƌD ŝůĂŐƌŽůŝŶŝĐWĂƟĞŶƚƐIvy Gosselin, Janae Cave, Tammy Jackson (UNM CON)Victoria Barner, Rachel Montoya, TeeJay Secatero,Viviana Skaggs, Eve Wohlert, RN & Geoff Shuster(UNM CON)WƌĞǀ ĞŶƟŶŐ^ŚĂŬĞŶĂďLJ^LJŶĚƌŽŵĞ Jayme Robertson RN-BC BSN, Donna Garcia Hoffman,ǁ ŝƚŚWĂƌĞŶƚĂůĚƵĐĂƟŽŶRN-BC, & Kathy Lopez-Bushnell, RN-BC, EdD, MPH,CTSCdŚĞĞī ĞĐƚƐŽŶŚŝůĚƌĞŶ͛ ƐΘĚŽůĞƐĐĞŶƚƐ͛ ĨƵŶĐƟŽŶĂůƐƐĞƐƐŵĞŶƚ Art Brambila, PhD, & Becky Gonzales, RN ADN^ĞĐŽŶĚĂƌLJƚŽ/ŵƉůĞŵĞŶƚĂƟŽŶŽĨŝĂůĞĐƟĐĂůĞŚĂǀ ŝŽƌĂůdŚĞƌĂƉLJ/ŶƚĞƌǀ ĞŶƟŽŶdŚĞ^ƚĂŶĚĂƌĚŝnjĂƟŽŶŽĨZŝƐŬWƌŽƚŽĐŽůŝŶĐƵƚĞŚŝůĚĂŶĚĚŽůĞƐͲcent Psychiatric HospitalDawn Cheshire, RN^ŚĂƌĞĚ' Žǀ ĞƌŶĂŶĐĞ/ŶŝƟĂƟǀ Ğ͗ ZĞƐŝůŝĞŶĐLJĂŶĚ^ƚƌĞŶŐƚŚďĂƐĞĚ Garry Wolfe, MA, CTRS &Integrated Acute Care ProgrammingDawn Cheshire, RN ADNΎĞŶŽƚĞƐĂWŽƐƚĞƌƚŚĂƚǁ ĂƐĂǁ ĂƌĚĞĚĂƉƌŝnjĞĨŽƌďĞƐƚƌĞƉƌĞƐĞŶƟŶŐĂŽŶĨĞƌĞŶĐĞK ďũĞĐƟǀ Ğ– see page 26.

NEW KNOWLEDGE, INNOVATION & IMPROVEMENTSPage 28Healthy Hands Resource SquadGoal: Increase overall hand hygiene compliancefrom 76% for 2011 to at least 85% for 2012.Forming the Team: Ŷ/ŶĨĞĐƟŽŶŽŶƚƌŽůůŝĂŝƐŽŶƚĞĂŵǁ ĂƐĐƌĞĂƚĞĚŝŶƐƉƌŝŶŐŽĨϮϬϭϮ͕ ŵĞĞƟŶŐD ĂLJϭϳ ͕ ϮϬϭϮ͕ ǁ ŝƚŚϯϴĂƩ ĞŶĚĞĞƐ͘ /ƚŶŽǁ ŵĞĞƚƐĞǀ ĞƌLJƚǁ ŽŵŽŶƚŚƐ͘ ^ƋƵĂĚŵĞŵďĞƌƐĂƌĞĨƌŽŵŶƵƌƐŝŶŐƵŶŝƚƐ͕ /ŶƉĂƟĞŶƚΘK ƵƚƉĂƟĞŶƚK ZƐ͕ ŵďƵůĂƚŽƌLJĂƌĞĂƐĂŶĚZĂĚŝŽůŽŐLJ͘Establishing Measures: Hand Hygiene surveillanceƌĞƐƵůƚƐĂƌĞƵƐĞĚĂƐƋƵĂŶƟƚĂƟǀ ĞŵĞĂƐƵƌĞƐ͘ ƐŽĨ:ƵŶĞϮϬϭϮĂůů, , K ďƐĞƌǀ ĂƟŽŶƐǁ ĞƌĞƚĂŬĞŶŽǀ ĞƌďLJZĞƐŽƵƌĐĞSquad members and their designees and emailed and/or faxed into Epidemiology monthly. This is aggregatedĂŶĚƉƌĞƐĞŶƚĞĚƚŽƚŚĞ/ŶĨĞĐƟŽŶŽŶƚƌŽůŽŵŵŝƩ ĞĞĂƚĞǀ ĞƌLJŵĞĞƟŶŐ͘ WƌŽŐƌĞƐƐŝǀ ĞƐƚĂƟĐƐĂŶĚgraphs are provided tostaff to enhanceĐŽŵŵƵŶŝĐĂƟŽŶĂŶĚprovide feedback./ŵƉůĞŵĞŶƟŶŐĂŶĚSpreading Changes:HHRS have developedŝŶƚĞƌǀ ĞŶƟŽŶƐďĂƐĞĚŽŶfour areas of need:ĚƵĐĂƟŽŶ;ďŽƚŚƉĂƟĞŶƚƐĂŶĚƐƚĂī ͕ D ŽƟǀ ĂƟŽŶ͕ Product Availability, &Policy/Accountability.Nursing “NOW” - 4E-TSICU Quality ProjectStaff RNs on 4E (TSICU) recognized:Problem: WŽŽƌWĂƟĞŶƚ͕ E ƵƌƐĞ͕ ĂŶĚWŚLJƐŝĐŝĂŶĐŽŵŵƵŶŝĐĂƟŽŶƌĞƐƵůƟŶŐŝŶƉĂƟĞŶƚĚŝƐƐĂƟƐĨĂĐƟŽŶĂŶĚůŽǁ WƌĞƐƐ' ĂŶĞLJƐĐŽƌĞƐ.In October of 2011, they presented theƉƌŽďůĞŵĂŶĚŶĞĞĚĨŽƌĂƐŽůƵƟŽŶƚŽƚŚĞ4-East SG Team, which began the process ofbrainstorming, to develop a plan to be usedǁ ŚŝůĞƌŽƵŶĚŝŶŐŽŶƉĂƟĞŶƚƐ-ĞŶƟƚůĞĚ͕ E ƵƌƐŝŶŐNOW. ͞ E K t ͟ ŝƐĂŶĂĐƌŽŶLJŵĨŽƌƉĂƟĞŶƚNeeds, OďũĞĐƟǀ ĞƐ͕ ĂŶĚWorries.The process ŝŶĐůƵĚĞĚŶƵƌƐĞƐƐƚĂƌƟŶŐĂŶĚĞŶĚŝŶŐĞĂĐŚƐŚŝŌďLJĂĚĚƌĞƐƐŝŶŐƚŚĞE ƵƌƐŝŶŐE K t ͛ Ɛǁ ŝƚŚĞĂĐŚƉĂƟĞŶƚĂŶĚĞƐƚĂďůŝƐŚŝŶŐĂĐŽŵŵƵŶŝĐĂƟŽŶͬ ƌĞůĂƟŽŶƐŚŝƉƉƌŽĐĞƐƐŝŶĐŽŶũƵŶĐƟŽŶǁ ŝƚŚǁ ƌŝƟŶŐƚŚĞƉĂƟĞŶƚ͛ ƐŐŽĂůƐŽŶƚŚĞŝƌƌŽŽŵ͛ ƐĚƌLJĞƌĂƐĞďŽĂƌĚ͘ LJĚĞƚĞƌŵŝŶŝŶŐŶĞĞĚƐ͕ ŽďũĞĐƟǀ ĞƐ͕ Θǁ ŽƌƌŝĞƐĂƚƚŚĞƐƚĂƌƚŽĨĞĂĐŚƐŚŝŌ͕ ƚŚĞƉĂƟĞŶƚŝƐĂďůĞƚŽ͗(1) Have immediate needs addressed;(2) dĂŬĞĂŶĂĐƟǀ ĞƉĂƌƚŝŶƚŚĞŝƌĐĂƌĞ͖ (3) Determine their own Goals; and(4) Be able to voice their concerns.Also, the nursing staff will be able to:Demonstrate consistency in care by each nurse usingƐŝŵŝůĂƌƉŚƌĂƐĞƐĂŶĚĂĐƟŽŶƐ͖ Θ;Ϯ/ŶĐƌĞĂƐĞƚŚĞŶƵƌƐŝŶŐƌĞůĂƚĞĚƐĂƟƐĨĂĐƟŽŶƐĐŽƌĞƐ͘ dŚĞƉƌŽũĞĐƚǁ ĂƐĚŝƐĐƵƐƐĞĚĂƚ^' ŵĞĞƟŶŐƐ, and the staffwere educated. Pre- and post-ƉĂƟĞŶƚĐĂůůůŝŐŚƚƵƐĞĂŶĚƉĂƟĞŶƚƐĂƟƐĨĂĐƟŽŶƐĐŽƌĞƐǁ ĞƌĞĂŶĂůLJnjĞĚƚŚƌŽƵŐŚWƌĞƐƐ' ĂŶĞLJ͘ ŶŽƟĐĞĂďůĞŝŵƉƌŽǀ ĞŵĞŶƚŝŶƐĐŽƌĞƐǁ ĂƐobtained almost immediately, and has been trackedcarefully since ŝŵƉůĞŵĞŶƚĂƟŽŶ͘ ^ƉĞĐŝĮ ĐĂůůLJ͕ ƉĂƟĞŶƚƐĂƟƐĨĂĐƟŽŶƐĐŽƌĞƐƌŽƐĞĨƌŽŵϳ ϯ͘ ϰƚŽϴϱ͘ ϳ ŝŶŽŶĞŵŽŶƚŚ͘

NEW KNOWLEDGE, INNOVATION & IMPROVEMENTSPage 29MAGNET FAIR—The Fun started in 2011!Nurse’s Week takes place annually atUNMH and Thursday of that week iscause for Magnet Journey/PathwaysƚŽdžĐĞůůĞŶĐĞ;WdĞĚƵĐĂƟŽŶĂŶĚĐĞůĞďƌĂƟŽŶ͘ K Ŷ May 10 th , 2012, theMagnet Champions held their 2ndAnnual Magnet Fair in 4ACC honoringNurse’s Day!Popcorn, prizes, custom UH Magnetpin and bake sale were a part of theĞdžĐŝƟŶŐĞdžŚŝďŝƟŽŶ͘ dŚĞ&Ăŝƌǁ ĂƐĂŐƌĞĂƚsuccess in 2011 & 2012, and worth theĂƩ ĞŶĚĂŶĐĞĂŶĚĞŶŐĂŐĞŵĞŶƚŽĨĂůůhE D , ^ƚĂī ͘ Ʃ ĞŶĚĞĞƐĐŚĞĐŬĞĚŝŶĨŽƌĂ“Passport’ and took the table top tour,ůĂƐƟŶŐũƵƐƚϮϱ-30 minutes.It was a great opportunityto learn about UNMH bestŶƵƌƐŝŶŐƉƌĂĐƟĐĞƐ͘ E ƵƌƐĞƐand other Departments areencouraged to present theirlatest projects and shareƚŚĞŝƌƉƌĂĐƟĐĞƐ͘ dŚŽƐĞƐƵďŵŝƫ ŶŐƉŽƐƚĞƌƐĂƌĞŝŶǀ ŝƚĞĚƚŽbe present for 1-2 hours, to talk aboutƚŚĞŝƌƉŽƐƚĞƌƉƌŽũĞĐƚǁ ŝƚŚĂƩ ĞŶĚĞĞƐ͘ Topics include those related to MagnetModel Components and the PTEWƌĂĐƟĐĞ^ƚĂŶĚĂƌĚƐ͘ ůůĂƩ ĞŶĚĞĞƐĂƌĞeligible for the many prizes available.

NEW KNOWLEDGE, INNOVATION & IMPROVEMENTSPage 30Nursing Research Council, aka “NRC”According to Nicole Weimer, RN, MSN-NRC Chair,there are ĨŽƵƌƉƌŝŵĂƌLJŽďũĞĐƟǀ ĞƐfor the NursingResearch Council:1. To promote Knowledge on Nursing Research,W͕ ĂŶĚY ƵĂůŝƚLJ/ŶŝƟĂƟǀ ĞƐ;Y /ŐůŽďĂůůLJĂŶĚĂƚUNMH.2. To educate on how to ŝŶŝƟĂƚĞ͕ ĞdžƉĂŶĚĂŶĚŐƌŽǁ nursing research, EBP, and QI at UNMH.3. To Collaborate with all councils within the HSC,ƚŽƐƚĂŶĚĂƌĚŝnjĞ͕ ŝŵƉůĞŵĞŶƚ͕ ĂŶĚƉƌŽǀ ŝĚĞďĞƩ ĞƌƉĂƟĞŶƚĐĂƌĞĂŶĚŽƵƚĐŽŵĞƐ͘, Žǁ ĂŶE ƵƌƐĞƐWĂƌƟĐŝƉĂƚĞŝŶƚŚĞE Z͍A few ideas● Present your work at Nursing Research Rounds2 nd Thurs. 11-11:30 a.m. BBRP Pavilion● Join the NRC-2 nd Thursday, 11:30-1 p.m. BBRP Pavilion● Implement a Research Council on your unit● Educate yourself through the classes offered● Present your work at the nursing research rounds● Implement a research council on your unit● Implement a Journal Club● /ŶŝƟĂƚĞĂŶĞǀ ŝĚĞŶĐĞ-based or quality project● Be a mentor4. dŽĐŽŵŵƵŶŝĐĂƚĞǁ ŝƚŚƚŚĞŝŶƐƟƚƵƟŽŶandĐŽůůĂďŽƌĂƟŶŐďŽĚŝĞƐƚŚĞŐŽĂůƐ͕ Į ŶĚŝŶŐƐ͕ ĂŶĚneeds of nursing research at the bedside,procedural areas and clinics.^ƵƉƉŽƌƟŶŐE

EMPIRICAL OUTCOMESPage 31NDNQIBlood Stream Infections per 1,000 Central Line Days50th Percentile (median) comparison2012AMCUNMH1Q '11 2Q '11 3Q '11 4Q '11 1Q '12 2Q '12 3Q '12 4Q '12ĐĂĚĞŵŝĐD ĞĚŝĐĂůĞŶƚĞƌƐ;D ƌĞƉƌĞƐĞŶƚƐŶĂƟŽŶĂůĐŽŵƉĂƌĂƟǀ ĞŝŶĨŽƌŵĂƟŽŶĨŽƌŚŽƐƉŝƚĂůƐƚŚĂƚƉĂƌƟĐŝƉĂƚĞŝŶƚŚŝƐƉĂƌƟĐƵůĂƌŝŶĚŝĐĂƚŽƌ͘ ƐƚŚĞŐƌĂƉŚƐŝŶĚŝĐĂƚĞ͕ hE D , ĐŽŵƉĂƌĞƐĨŽƌƚŚĞĨŽůůŽǁ ŝŶŐϮϬϭϮƋƵĂƌƚĞƌƐ͗1st Quarter:>Žǁ ĞƌƚŚĂŶƚŚĞŵĞĚŝĂŶ;ϱϬƚŚƉĞƌĐĞŶƟůĞ2nd Quarter: Higher than the median3rd Quarter:4th Quarter:Lower than the medianHigher than the medianWhat is NDNQ? And Should We Be Higher or Lower Than The Median?E ĂƟŽŶĂůĂƚĂďĂƐĞĨŽƌNursing Quality Indicators(NDNQI) is a researchdatabase that focuses onthe quality of nursing care.This database is verypowerful because it allowyou to compare “like”units to “like” units. Thisallows for example, ICUnurses to compare theiroutcomes to other ICU’sƚŚƌŽƵŐŚŽƵƚƚŚĞŶĂƟŽŶ͘ Depending on theMake sure you knowthe parameters expectedfor each indicatoryou evaluate.For example, for bloodƐƚƌĞĂŵŝŶĨĞĐƟŽŶƐ;^/you would want to be“Lower” than themedian, not higher.Higher would indicatethat you have a higherrate of BSI’s. Want tolearn more?Your UD receivesquarterly reports onyour unit indicators, soask for them. Or contactCarolyn Green, ED at:cgreen@salud.unm.edufor your unit report.t ĞĂůƐŽŽī ĞƌŝŶĨŽƌŵĂƟǀ Ğclasses for NDNQI everyother month. Check outour Magnet EventsCalendar for class dates.“It is moreimportant thanever to be able toevaluate nursingperformance onkey indicators inlight of the CMSpolicy on nonreimbursementfor“hospital acquiredĐŽŶĚŝƟŽŶƐĂŶĚpay for qualityŝŶŝƟĂƟǀ ĞƐ͘ ͟indicator, you may want tobe higher or lower.NDNQI Website:www.nursingquality.org

EMPIRICAL OUTCOMESPage 32NDNQITotal Falls per 1,000 Patient Days50th Percentile (median) comparison2012AMCUNMH1Q '11 2Q '11 3Q '11 4Q '11 1Q '12 2Q '12 3Q '12 4Q '12ĐĂĚĞŵŝĐD ĞĚŝĐĂůĞŶƚĞƌƐ;D ƌĞƉƌĞƐĞŶƚƐŶĂƟŽŶĂůĐŽŵƉĂƌĂƟǀ ĞŝŶĨŽƌŵĂƟŽŶĨŽƌŚŽƐƉŝƚĂůƐƚŚĂƚƉĂƌƟĐŝƉĂƚĞŝŶƚŚŝƐƉĂƌƟĐƵůĂƌŝŶĚŝĐĂƚŽƌ͘ ƐƚŚĞŐƌĂƉŚƐŝŶĚŝĐĂƚĞĨŽƌϮϬϭϮ͕ hE D , ĐŽŵƉĂƌĞƐĨŽƌƚŚĞĨŽůůŽǁ ŝŶŐϮϬϭϮƋƵĂƌƚĞƌƐ͗1st Quarter:, ŝŐŚĞƌƚŚĂŶƚŚĞŵĞĚŝĂŶ;ϱϬƚŚƉĞƌĐĞŶƟůĞ2nd Quarter: Same as the median3rd Quarter: Higher than the median4th Quarter: Higher than the medianWhat Does Magnet Look For?Be familiar withyour unit’sƉĂƌƟĐƵůĂƌŽƵƚĐŽŵĞƐ͘ Remember, theabove-ŵĞŶƟŽŶĞĚgraph is the totalŽƌŐĂŶŝnjĂƟŽŶ.“The American NursesƌĞĚĞŶƟĂůŝŶŐĞŶƚĞƌ;E ΠD ĂŐŶĞƚZĞĐŽŐŶŝƟŽŶWƌŽŐƌĂŵΠƌĞƋƵŝƌĞƐĚĂƚĂĐŽůůĞĐƟŽŶŽĨnursing-ƐĞŶƐŝƟǀ ĞŽƵƚĐŽŵĞƐĂƚthe unit-level that comparesƉĞƌĨŽƌŵĂŶĐĞĂŐĂŝŶƐƚĂŶĂƟŽŶĂůbenchmark database.” ~www.nursingquality.orgThis is right in line with ourdesire to implement real-ƟŵĞpeer review. This is where weown our outcomes.But more importantly, knowingwhat our indicators are is theŵŽƐƚĞī ĞĐƟǀ Ğǁ ĂLJĨŽƌŶƵƌƐĞƐto improve their own care.CNO Sheena Ferguson servesĐĂŬĞĂƚƚŚĞĞƌƟĮ ĞĚE ƵƌƐĞƐĂLJĞůĞďƌĂƟŽŶ͘ 2012 Healthcare Workers WeekTeddy Bear Hospital. What a blast!

EMPIRICAL OUTCOMESPage 33NDNQIInjury Falls per 1,000 Patient Days50th Percentile (median) comparison2012AMCUNMH1Q '11 2Q '11 3Q '11 4Q '11 1Q '12 2Q '12 3Q '12 4Q '12ĐĂĚĞŵŝĐD ĞĚŝĐĂůĞŶƚĞƌƐ;D ƌĞƉƌĞƐĞŶƚƐŶĂƟŽŶĂůĐŽŵƉĂƌĂƟǀ ĞŝŶĨŽƌŵĂƟŽŶĨŽƌŚŽƐƉŝƚĂůƐƚŚĂƚƉĂƌƟĐŝƉĂƚĞŝŶƚŚŝƐƉĂƌƟĐƵůĂƌŝŶĚŝĐĂƚŽƌ͘ ƐƚŚĞŐƌĂƉŚƐŝŶĚŝĐĂƚĞ͕ hE D , ĐŽŵƉĂƌĞƐĨŽƌƚŚĞĨŽůůŽǁ ŝŶŐϮϬϭϮƋƵĂƌƚĞƌƐ͗1st Quarter:2nd Quarter:3rd Quarter:4th Quarter:, ŝŐŚĞƌƚŚĂŶƚŚĞŵĞĚŝĂŶ;ϱϬƚŚƉĞƌĐĞŶƟůĞHigher than the medianHigher than the medianHigher as the medianCheck out our Job Enjoyment T-ScoresĨƌŽŵŽƵƌZE :Žď^ĂƟƐĨĂĐƟŽŶ^Ƶƌǀ ĞLJ—slightly above or right at the median.Good Job UNMH!T-^ĐŽƌĞƐ͗ фϰϬсĞdžƚƌĞŵĞůLJĚŝƐƐĂƟƐĮ ĞĚ͖ ϰϬ-ϲϬсŵŽĚĞƌĂƚĞůLJƐĂƟƐĮ ĞĚ͖ хϲϬсĞdžƚƌĞŵĞůLJƐĂƟƐĮ ĞĚ

EMPIRICAL OUTCOMESPage 34NDNQIVentilator Associated Pneumonias per 1,000 Ventilator Days50th Percentile (median) comparison2012AMCUNMH1Q '11 2Q '11 3Q '11 4Q '11 1Q '12 2Q '12 3Q '12 4Q '12ĐĂĚĞŵŝĐD ĞĚŝĐĂůĞŶƚĞƌƐ;D ƌĞƉƌĞƐĞŶƚƐŶĂƟŽŶĂůĐŽŵƉĂƌĂƟǀ ĞŝŶĨŽƌŵĂƟŽŶĨŽƌŚŽƐƉŝƚĂůƐƚŚĂƚƉĂƌƟĐŝƉĂƚĞŝŶƚŚŝƐƉĂƌƟĐƵůĂƌŝŶĚŝĐĂƚŽƌ͘ ƐƚŚĞŐƌĂƉŚƐŝŶĚŝĐĂƚĞ͕ hE D , ĐŽŵƉĂƌĞƐĨŽƌƚŚĞĨŽůůŽǁ ŝŶŐϮϬϭϮƋƵĂƌƚĞƌƐ͗1st Quarter:, ŝŐŚĞƌƚŚĂŶƚŚĞŵĞĚŝĂŶ;ϱϬƚŚƉĞƌĐĞŶƟůĞ2nd Quarter: Lower than the median3rd Quarter:4th Quarter:Lower than the medianSame as the medianPercent of Surveyed Patients with Hospital Acquired Pressure Ulcers50th Percentile (median) comparison2012AMCUNMH1Q '11 2Q '11 3Q '11 4Q '11 1Q '12 2Q '12 3Q '12 4Q '12ĐĂĚĞŵŝĐD ĞĚŝĐĂůĞŶƚĞƌƐ;D ƌĞƉƌĞƐĞŶƚƐŶĂƟŽŶĂůĐŽŵƉĂƌĂƟǀ ĞŝŶĨŽƌŵĂƟŽŶĨŽƌŚŽƐƉŝƚĂůƐƚŚĂƚƉĂƌƟĐŝƉĂƚĞŝŶƚŚŝƐƉĂƌƟĐƵůĂƌŝŶĚŝĐĂƚŽƌ͘ ƐƚŚĞŐƌĂƉŚƐŝŶĚŝĐĂƚĞ͕ hE D , ĐŽŵƉĂƌĞƐĨŽƌƚŚĞĨŽůůŽǁ ŝŶŐϮϬϭϮƋƵĂƌƚĞƌƐ͗1st Quarter: , ŝŐŚĞƌƚŚĂŶƚŚĞŵĞĚŝĂŶ;ϱϬƚŚƉĞƌĐĞŶƟůĞ2nd Quarter: Higher than the median3rd Quarter: Higher than the median4th Quarter: Same as the medianCheck out our Annual NDNQI ReportŽŶƚŚĞD ĂŐŶĞƚƉĂŐĞƟƚůĞĚ“NDNQI Annual Report—Indicators”

EMPIRICAL OUTCOMESPage 35WĂƟĞŶƚK ƵƚĐŽŵĞƐŝŶƚŚĞŵďƵůĂƚŽƌLJ^Ğƫ ŶŐAs we end our Annual Nursing Report for 2012 let’s look at where healthcare reform is taking us, and how ourŵďƵůĂƚŽƌLJŶƵƌƐĞƐĂƌĞ͕ ĂŶĚŚĂǀ ĞďĞĞŶ͕ ĂŚƵŐĞƉĂƌƚŝŶŝŵƉƌŽǀ ŝŶŐŽƵƌƉĂƟĞŶƚŽƵƚĐŽŵĞƐ͘ LJĨŽĐƵƐŝŶŐŽŶƉƌĞǀ ĞŶƚĂͲƟǀ Ğ͕ ƋƵĂůŝƚLJĐĂƌĞ͕ ŶƵƌƐĞƐŝŶƚŚĞĂŵďƵůĂƚŽƌLJƐĞƫ ŶŐĂƌĞŝŶĂƵŶŝƋƵĞƉŽƐŝƟŽŶƚŽŚĞůƉƉĂƟĞŶƚƐĂĚĚƌĞƐƐŚĞĂůƚŚĐĂƌĞĐŽŶĐĞƌŶƐďĞĨŽƌĞƚŚĞLJŶĞĞĚƚŽǀ ŝƐŝƚĂŶĂĐƵƚĞĐĂƌĞƐĞƫ ŶŐ͘ dŚĞƌŽůĞŽĨƚŚĞĂŵďƵůĂƚŽƌLJŶƵƌƐĞǁ ŝůůďĞŵŽƌĞƐŝŐŶŝĮ ĐĂŶƚĂƐƉĂƟĞŶƚƐǁ ŝůůƌĞƋƵŝƌĞĞdžƚĞŶƐŝǀ ĞŶĂǀ ŝŐĂƟŽŶĂĐƌŽƐƐƚŚĞĐĂƌĞĐŽŶƟŶƵƵŵ͘ t ŝƚŚŵŽƌĞŚĞĂůƚŚĐĂƌĞƚĂŬŝŶŐƉůĂĐĞŽƵƚͲƐŝĚĞŽĨƚŚĞŚŽƐƉŝƚĂůƐĞƫ ŶŐ͕ ĂŵďƵůĂƚŽƌLJŶƵƌƐĞƐǁ ŝůůŶĞĞĚƚŽďĞƵƟůŝnjĞĚƚŽƚŚĞŚŝŐŚĞƐƚĞdžƚĞŶƚŽĨƚŚĞŝƌĞĚƵĐĂƟŽŶ͕ ůŝĐĞŶƐƵƌĞĂŶĚĐĞƌƟĮ ĐĂƟŽŶ͘ ĚĚŝƟŽŶĂůůLJ͕ ŵďƵůĂƚŽƌLJE ƵƌƐŝŶŐ^Ğƌǀ ŝĐĞƐĞŵƉůŽLJƐĚǀ ĂŶĐĞĚWƌĂĐƟĐĞE ƵƌƐĞƐ;WE Ɛǁ ŚŽƉƌŽǀ ŝĚĞĂǀ ĂƐƚĂŵŽƵŶƚŽĨĐůŝŶŝĐĂůƐĞƌǀ ŝĐĞƐŝŶĐůŝŶŝĐƐĞƫ ŶŐƐ͘ ƵƌƌĞŶƚůLJǁ ĞŚĂǀ ĞϯϬAPNs ƐĞĞŝŶŐƉĂƟĞŶƚƐĂƚĂmajority of our clinic sites. Check out what our Ambulatory Nursing Division has been up to!AMBULATORY NURSING SERVICESCONTINUED CHANGE, GROWTH AND SUSTAINABILITY - 2012K Ƶƌ, ĞĂƌƚ&ĂŝůƵƌĞƉƌŽŐƌĂŵƌĞĐĞŝǀ ĞĚƚŚĞϮϬϭϮ' ŽůĚWůƵƐĐŚŝĞǀ ĞŵĞŶƚĨƌŽŵƚŚĞŵĞƌŝĐĂŶ, ĞĂƌƚƐƐŽĐŝĂƟŽŶĨŽƌGet With The Guidelines ĂŶĚd:ĞƌƟĮ ĐĂƟŽŶĨŽƌŽƵƌ, ĞĂƌƚ&ĂŝůƵƌĞƉƌŽŐƌĂŵ͘, ĞĂƌƚ&ĂŝůƵƌĞůŝŶŝĐƐƚĂī ƉĂƌƟĐŝƉĂƚĞĚŝŶ&ĞƌŝĂĚĞ^ĂůƵĚ-A Day of Free Health Care and theKOB Health Fair Annual health fair.The 70 clinics in ambulatory are home to approximately 150 registered nurses.ŵďƵůĂƚŽƌLJE ƵƌƐŝŶŐ^Ğƌǀ ŝĐĞƐƐƵďŵŝƩ ĞĚƌĞƐĞĂƌĐŚĂďƐƚƌĂĐƚƐĨŽƌƚŚĞdƌĂŶƐĨŽƌŵŝŶŐĂƌĞĂƚƚŚĞĞĚƐŝĚĞŽŶĨĞƌĞŶĐĞƐĞĐƵƌŝŶŐĂƉŽĚŝƵŵƉƌĞƐĞŶƚĂƟŽŶ͕ ĂƉŽƐƚĞƌƉƌĞƐĞŶƚĂƟŽŶĂĐĐĞƉƚĞĚƚŽƚŚĞ^ŽĐŝĞƚLJĨŽƌ' ĂƐƚƌŽĞŶƚĞƌŽůŽŐLJE ƵƌƐŝŶŐ͕ ĂŶĚĂ&ŝƌƐƚWůĂĐĞǁ ĂƌĚĨŽƌ/ŵƉƌŽǀ ŝŶŐƚŚĞY ƵĂůŝƚLJĂŶĚ^ĂĨĞƚLJŽĨWĂƟĞŶƚĐĂƌĞ͘K ƵƌƌĂƚĞŽĨŶƵƌƐĞƐŽďƚĂŝŶŝŶŐ^E ͕ D ^E ĂŶĚĐĞƌƟĮ ĐĂƟŽŶƐŝƐŽŶƚŚĞƌŝƐĞ͘ϮϬϭϮ>E ͬ >Y /WƐĞƐƐŝŽŶƐĨŽƌŵďƵůĂƚŽƌLJŝŶĐůƵĚĞĚK ZŽŽƌĚŝŶĂƟŽŶ͕ ' /WƌŽĐĞĚƵƌĂů&ůŽǁ ͕ ĂŶĚZĞĨĞƌƌĂůƐManagement.K ĐĐƵƉĂƟŽŶĂů, ĞĂůƚŚƉƌŽǀ ŝĚĞĚŽǀ ĞƌƐŝŐŚƚŽĨƚŚĞ&ůƵ^ŚŽƚŝŶŝƟĂƟǀ ĞĂŶĚƌĞĂĐŚĞĚĂϲϴй ĞŵƉůŽLJĞĞǀ ĂĐĐŝŶĂƟŽŶƌĂƚĞ͘hE D , ŽƐƉŝƚĂůƐWƌŝŵĂƌLJĂƌĞĐůŝŶŝĐƐ͕ ƌĞĐŽŐŶŝnjĞĚďLJE Y ĂƐWĂƟĞŶƚĞŶƚĞƌĞĚD ĞĚŝĐĂů, ŽŵĞƐ͕ ĐŽŶƟŶƵĞƚŽĐŚĂŶŐĞĂŶĚĞdžƉĂŶĚƚŚĞƌŽůĞŽĨŶƵƌƐŝŶŐŝŶƚŚĞWƌŝŵĂƌLJĂƌĞ^Ğƫ ŶŐ͘ƐƚĞĂŵůĞĂĚĞƌ͕ ƚŚĞŶƵƌƐĞƐƌŽůĞŝƐƚŚĂƚŽĨĚŝƌĞĐƟŶŐĂŶĚƐƵƉƉŽƌƟŶŐĂŵƵůƟĚŝƐĐŝƉůŝŶĂƌLJƚĞĂŵŝŶƉƌŽǀ ŝĚŝŶŐĂŶĚĐŽŽƌĚŝŶĂƟŶŐƚŚĞĐĂƌĞŽĨƚĞĂŵƉĂƟĞŶƚƐ͘dŚĞŶƵƌƐĞŝƐĂĐĐŽƵŶƚĂďůĞĨŽƌĞŶƐƵƌŝŶŐƚŚĞĐŽŵƉůĞƟŽŶŽĨƉƌĞǀ ĞŶƟǀ ĞĂŶĚŬĞLJĐŽŶĚŝƟŽŶďĞŶĐŚŵĂƌŬƐ͘dŚĞŶƵƌƐĞĂĐƟǀ ĞůLJĂƐƐŝƐƚƐƉĂƟĞŶƚƐŝŶŝĚĞŶƟĨLJŝŶŐĂƩ ĂŝŶĂďůĞƐĞůĨ-management goals.