A Message From - MedStar Health Message From ... Maureen P. McCausland, DNSc, ... Lea Ann Carranza, BSN, RN; Heather Guy, RN; and Ashley O’Neil, BSN, RN, ... National Magnet Conference

Raising the Bar2015 Nursing Annual Report

A Message From ... Maureen P. McCausland, DNSc, RN, FAANSenior Vice President and Chief Nursing Officer, MedStar Health

As chief nursing officer of MedStar Health, I welcome any and every opportunity to celebrate and recognize the invaluable work of our nurses. I am therefore honored by the invitation to share the MedStar St. Mary’s Hospital Nursing Annual Report, which features the many achievements and contributions of extraordinary nurses.

It is with immense pride that I congratulate the professional nurses at MedStar St. Mary’s for an outstanding year. Each of you demonstrates a deep commitment to our patients and their families, while pursuing the highest levels of quality and safest possible care. Your success is particularly noteworthy this year in light of significant changes impacting our industry, system and your organization.

I am proud of our collaboration on a system and entity level to smoothly navigate the new dynamics of an evolving healthcare environment - within your hospital and beyond. From your quality and safety efforts and the creation of the MedStar St. Mary’s Nursing Professional Practice Model, to your engagement on MedStar Nursing Councils and involvement in unprecedented opportunities to redesign care delivery across MedStar, our partnership embodies systemness at its best and underscores the strength of our system as the leading healthcare provider in the Maryland and Washington, D.C., region.

As a testament to your strong performance, MedStar St. Mary’s was recognized as part of The Joint Commission’s 2015 annual report, “America’s Hospitals: Improving Quality and Safety,” for attaining and sustaining excellence in accountability measure performance for a variety of quality care metrics. This validation from the leading accreditor of healthcare organizations showcases the unwavering commitment of all MedStar St. Mary’s clinicians, including nurses, to our patients and their care.

As we approach MedStar 2020 and look to the future of health care and our system, I am reassured that MedStar, and our patients and their families, are in the best of hands with our nurses at MedStar St. Mary’s Hospital. Your tenacious protection of our mission and vision is commendable and evident in the anecdotes shared within this Nursing Annual Report. Notably, the report provides only a snapshot of the remarkable efforts of MedStar St. Mary’s Hospital nurses, with whom it is a privilege to practice. Thank you for your unwavering commitment to the purpose and meaning of our profession, and to the care and healing of our patients and families.

1 2015 NURSING ANNUAL REPORT

Pictured above are our hospital nursing council representatives alongside Dr. McCausland (center). From left, Sara Oliver, BSN, RN; Becky Bjerke, RN-BC, CMSRN; Regina Steele, BSN, RN, CNOR; Linda Miedzinski, BSN, RN; Jamie Miller, RN; Robin Garrahan, RN; Amanda Dyson, BSN, RN, PCCN; and Heather Swan-Jones, BSN, RN. Not pictured: Nicole DiMauro, BSN, RN.

New Nursing Leadership

In 2015, Lea Ann Carranza, BSN, RN; Heather Guy, RN; and Ashley O’Neil, BSN, RN, PCCN, were promoted to charge nurses in Telemetry. Kathleen Keister, BSN, RN, joined Jane Lawing, MS, BSN, RN, as an education specialist in Organizational Learning & Research (OLR) to support the educational needs of all clinical and support departments. Kristen McVerry, BSN, RN, joined the OLR team as nurse educator to support the expansive educational needs of all nurses in the organization. In addition, Pamela Barnard, MSN, RN-BC, began her role as assistant director of OLR, guiding the learning and development of all associates. All registered nurses in OLR have bedside nursing experience, which lends a level of credibility to their work — enhancing career development and providing best practice learning opportunities for associates hospital-wide.

National Magnet Conference Promotes Innovation

Seven MedStar St. Mary’s Hospital (MSMH)nurses, pictured right, networked with more than 8,000 nurses, nursing executives and healthcare professionals from the world’s best hospitals at this year’s National Magnet Conference, held Oct. 7-9, 2015. The theme of the conference, “Inspiring Nurses with World-Class Innovation,” allowed attendees to gain insight into the newest advances in nursing quality improvements from Magnet-recognized hospitals. MSMH nurses who attended the conference in Atlanta, Georgia serve on the Magnet Champion Committee, the Magnet Steering Committee and Nursing Shared Governance Councils.

Transformational Leadership


Cheryl Wyatt, CRNP (left) and Kathleen McClanahan, CRNP (right)

Advance Practice Nurse Practitioners

Cheryl Wyatt, CRNP, makes a difference every day by truly connecting with her patients. This was evidenced in 2015 by her diagnosis of Ehrler-Danlos syndrome in a 3-year-old patient. This diagnosis is rarely made in the Emergency Department and is often mistaken for child abuse. Because of the connection she made with the patient and family, Cheryl was able to avoid bias, make the diagnosis and arrange the specialty care required for the patient to achieve optimal health.

While providing quality adult inpatient medical care, Kathleen McClanahan, CRNP, maintains her reputation for having an excellent rapport with patients, families and physicians. Her friendly nature and unique ability to relate to various situations provide a greater level of comfort for patients who might feel nervous or uneasy in the hospital. Hired in 2009 as the first Nurse Practitioner hospitalist at MSMH, she continues to meet the highest standards in bedside care for patients in Telemetry and Medical/Surgical/Pediatrics.

High Reliability Organization 2.0 — Safety Coaches

Ten registered nurses, four of whom are pictured below, are trained front-line safety coaches, who observe the performance of a group or individuals to determine if their observed practice meets MSMH desired safety behaviors. Coaches provide real-time feedback to reinforce good practices and correct unsafe practices. In 2015, safety coaches gave mostly positive feedback at a ratio of 5:1, offering reinforcement whenever they see colleagues or co-workers using best practices. Monthly observations are entered into the MedStar Health database and are used to guide improvement efforts.

2015 NURSING ANNUAL REPORT 3

Pictured from left to right, Jane Lawing, MS, BSN, RN; Kristen McVerry, BSN, RN; Ashley O’Neil, BSN, RN, PCCN; Heather Guy, RN;

Kathleen Keister, BSN, RN; Pamela Barnard, MSN, RN-BC. Not pictured Lea Ann Carranza, BSN, RN.

Pictured below from left to right, Ashley O’Neil, BSN, RN, PCCN; Cathy Humphries, RN, CHPN; Gay Brittan; Jan Watson; Alicia Gronseth; Jane Lawing, MS, BSN, RN; and Mary Cantwell, RN.

Leadership Southern Maryland

Director of Hospice and Palliative Care for MSMH, Teresa Brannigan, MSN, BSN, RN, is

networking with more than 30 other local leaders through her participation in Leadership Southern Maryland (LSM). In October 2015, she began

the nine-month course, which includes an extensive

curriculum with opportunities to tour local facilities and experience work being done across multiple industries. LSM’s mission to educate and inspire a diverse group of current and emerging leaders creates collaborations and partnerships that impact the community needs of Calvert, Charles and St. Mary’s counties. Through her participation, Teresa is strengthening her knowledge and partnerships, which will assist her in expanding services in the community and sharing the work of hospice throughout the Tri-County area.

Interdisciplinary Model of Care (IMOC)

IMOC is an innovative model designed to provide safe, high-quality and efficient patient care. A diverse group of MedStar leaders, providers and associates - including Carla Cavanaugh, BSBA, RN; Kathy Franzen, BSN, RN; Kathleen McClanahan, CRNP; Jill Maxwell, BSN, RN; Cathy Fenwick, BSN, RN; and Anita Wetzel, RN - joined together for two days in the fall of 2015 to create the continuum-based IMOC. As a result, six strategic themes emerged: role clarity, care coordination, relationship-based care, patient and family engagement, information sharing and organizational support. Their innovative ideas will help propel MedStar to become the premier diversified and integrated healthcare network.

RL Solutions

At MedStar St. Mary’s Hospital, RL Solutions Event Reporting software supports the High Reliability Organization journey by promoting a culture of safety and open reporting,

while putting the power of reducing patient risk in associates’ hands. Utilizing RL Solutions to compile incident, risk and infection control data; quickly identify trends; and produce comprehensive reports helps prevent incidents before they happen. Demonstrated engagement in sustaining a safe and reliable culture and improving outcomes is evidenced by a 41percent increase in authored RL Solutions entries for FY 2015. Entries include “lifesaver” events and “good catches,” which are used to celebrate Patient Safety Heroes.

Nursing Mentors

Ann Byrne, BSN, RN, CHPN, along with other members of the Professional Development and Educational Council, played an instrumental role in redeveloping the MedStar St. Mary’s Hospital Nursing Mentor Program. On Sept. 8, 2015, the program was presented to a group of nursing graduates, UHC Cohort 3, who were assigned RN mentors. Mentoring nurses participate in the development of their peers by providing information, advice and support, while assisting with knowledge transfer and professional growth. The program pairs nurses from different departments and helps to bridge the gap between theory and nursing practice. Mentoring is one of the greatest gifts nurses can give to each other and a wonderful way to share knowledge, experience and expertise throughout our organization.


Talking over coffee at a mentor breakfast are, left to right, Ashley Songy, RN; Ann Byrne, BSN, RN, CHPN (mentor); Jen Alvey, BSN, RN, VA-BC (mentor); and Carolyn Davis, RN.

Felicia Deese, RN; Kedija Duncan, RN Lauren Hall, RN

Center Left to Right: Kathleen Brauner, RN; Mary Day, RN, CHPN; and Michele White, BSN, RN Andrew Hollopeter, BSN, RN

PATIENT SAFETY HEROES NAMEDThis year, three remarkable registered nurses were celebrated as Patient Safety Heroes. Nominated by their peers, Patient Safety Heroes are selected quarterly by the Patient Safety Council. Congratulations and thank you all!

2015 MEDSTAR HEALTH TOP GOOD CATCH NOMINEEMSMH Patient Safety Heroes are eligible to be nominated for a corporate-level award, which recognizes the Top Good Catch among all MedStar Health entities. Congratulations!

2015 DAISY AWARDSThe not-for-profit DAISY Foundation was established by the family of J. Patrick Barnes. The care he and his family received from nurses inspired this means of recognizing outstanding nurses who make a profound difference. St. Mary’s Hospital Foundation honors Daisy award winners twice a year.

JEAN WATSON AWARD WINNERS During Nurses Week celebrations, MSMH nursing leadership honored three individuals who exemplify Jean Watson’s Caring Model in their everyday interactions. This model emphasizes patient-centered care and the humanistic aspects of nursing combined with scientific knowledge.

JOSIE KING FOUNDATION HERO AWARDMSMH presented its first Josie King Foundation Hero Award at our annual Nurses’ Dinner in May. The Hero Award is given to someone who works hard to create a culture of patient safety by listening to the patient and their family and encouraging them to speak up and ask questions. This includes looking for near misses and fixing them before they potentially harm a patient. The Josie King Foundation was created by Sorrel King, whose 18-month- old daughter, Josie, died from medical errors in 2001. Sorrel King was a special guest speaker during our 2015 Nurses’ Week celebration and is pictured to the right of our Hero Award winner.

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Emergency Department Behavioral Health Team, represented by Renese Wagy, RN (center)

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3Tyla Countiss, RN (second from right)

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Teresa Waldron, BSN, RN (second from left)

Ashley McAfee, RN, CCM


Structural Empowerment

“Stand Tall to Prevent Falls” Campaign

The Telemetry Shared Governance Council held a “Stand Tall to Prevent Falls” campaign designed to reduce the number of patient falls this year and renew its commitment to patient safety. Under the leadership of chairpersons, Ashley O’Neil, BSN, RN, PCCN, and Lauren Tygrett, BSN, RN, the campaign raised awareness about new safety measures and gained commitment from associates to renew fall prevention efforts. As a result, falls decreased from 40 to 35 and falls with injury dropped more than half, from 15 to seven, since last year. Safety improvements achieved include adding a gait belt and chair alarm to patients’ rooms; establishing a red rule requiring patients with a MORSE score of 45 or greater to not be left unattended in the restroom; adding fall kits throughout the unit; and using red magnets on the unit assignment board to quickly identify fall risk patients.

Emergency Department (ED) Professional Development Council

Members of the ED Professional Development Council, led by Michele White, BSN, RN, and Kristen Davis, BSN, RN, (pictured left) took on the responsibility of ensuring ED associate competency this year. The team developed four separate competency/education days attended by more than 95 percent of the ED staff. The group used recommendations from the Emergency Nurses Association to develop its competency plan. The education effort was received very positively by participating associates.


Domestic Violence Program

MSMH’s grant-funded domestic violence program, one of 11 in Maryland, is in its second year of providing care, education and

resources for victims living with abuse. By caring about the personal safety of others and providing mandatory screening, hundreds of domestic violence victims have been recognized and assisted since the program began. Full-time program coordinator, Yvonne Dawkins, RN, FNE, A/P, follows up on all

positive screens and is available when forensic examinations and evidence-worthy photography is warranted to document

injuries. Yvonne was recognized with the 2015 Corporate Friendship Award by the Southern Maryland Center for Family Advocacy. She serves as a bridge to law enforcement, the judicial system and counseling services in the community and serves on the county family violence council.

Nurse Residency Program

The University HealthSystem Consortium/American Association of Colleges of Nursing New to Practice (NTP) Post-Baccalaureate Nurse Residency Program is designed to enhance retention of the NTP nurses and expedite their transition to competent, professional nurses. In 2015, MSMH conducted two cohorts with a total of 23 NTP nurses, some of whom are pictured below.

These nurses met monthly in didactic seminars to develop effective decision-making skills and clinical nursing leadership roles, strengthen their commitment to the nursing profession, formulate individual career plans, and incorporate research-based evidence into their practice. The Nurse Residency incorporates collaboration from multiple disciplines, leaders and other peers in order to make the program a success. This year, NTP nurses were able to choose mentors to aid in their professional transition. With cohorts starting every six months, MSMH will continue to support and nurture these NTP nurses to become clinically sound, competent, empowered and committed MedStar nurses.

Pictured from left to right, Gina Russell, BSN, RN, CPEN; Cindy Dean, BSN, RN, CNOR; Mary Sullivan, BSN, RN, CEN; and Amanda Dyson, BSN, RN, PCCN, represent many MSMH nurses who are Raising the Bar by receiving national board certification in their area of specialty.


Relationship-Based Care

Women’s Health & Family Birthing Center’s Professional Development Council is educating associates on the Relationship-Based Care Model for Transforming Practice. Author Mary Koloroutis designed this model with three crucial relationships in mind: care provider’s relationship with patients and families, their relationship with self, and their relationship with colleagues. The model teaches care providers to maintain the patient and family as their central focus. A care provider’s relationship with self is nurtured by self-knowing and self-care. Their relationship with colleagues is maintained through respect and affirmation of each other’s unique scope of practice and contribution. By adopting this model of care, MSMH aims to promote positive outcomes in clinical safety and quality, patient and family satisfaction, and physician and staff satisfaction.

HSCRC recipients pictured front row, left to right: Shirley Tumang, BSN, RN; Valerie McKay, RN; Holly Adams, BSN, RN; Shonna Gardner Wagaman, RN; Shemeka Robinson, BSN, RN, FNE-A; and Kristen McVerry, BSN, RN. Pictured back row, left to right: Yvonne Dawkins, RN, FNE, A/P; Ashley O’Neil, BSN, RN, PCCN; Stephanie Angle, RN; and Jennifer Alvey, BSN, RN, VA-BC.

Not pictured: Lisa Ellie, RN; Shannon Farrell, RN; Meghan Freeman, RN; Jessica Maguire, RN; Kara Ridgell, BSN, RN; Pamela Riley, BSN, RN, PCCN; Kathleen Sullivan, RN; and Mary Sullivan, BSN, RN, CEN.

BSN Breakdown CY15 as of 12/31/15

47%45%

6% 2%

Diploma 7 out of 407 Nurses

Associate’s 195 out of 407 Nurses

Associate’sBachelor’s

Master’s Diploma

Bachelor’s 182 out of 407 Nurses

Master’s & PhD 23 out of 407 Nurses


Tuition Support Awards

This year, a record 18 nurses received grant funds from the Health Services Cost Review Commission (HSCRC) to assist them in returning to school to further their education. Since its inception at MSMH in 2003, 70 nurses have been awarded tuition support through the HSCRC Nursing Excellence Grant.

SPIRIT AWARD WINNERS

SPIRIT Awards are given to associates who have been empowered to transform their professional practice to a higher level of performance. Nominated by their peers, SPIRIT winners are selected monthly and then become eligible to be selected as Associate of the Year.

The five registered nurses pictured are among the winners for 2015 and represent the SPIRIT within MedStar St. Mary’s Hospital.

Congratulations to all winners and keep up the exemplary work!

PATTI SCHMIDT, RN, HONORED AS PEABODY AWARD RECIPIENT

The Peabody Award of Excellence is presented to the Associate of the Year for outstanding performance.

Well respected by providers, patients and her peers, Patti displays a generosity of SPIRIT as a Telemetry nurse, helping patients through critical moments in their life with skill and understanding. She believes nursing is a calling and has embodied this sentiment for more than 12 years at MedStar St. Mary’s.

The Peabody Award is named for Elinor Peabody, a former hospital Auxiliary member who was a tremendous role model for the community.

Kara Ridgell, BSN, RN

Nicole Hanson, RN

Shelley Morgan, RN

Michelle Fleming, BSN, RN

Katherine Vachalek, BSN, RN

From left: Kay D’Esposito, Auxiliary President, Patti Schmidt, RN, and Christine Wray, President of MedStar St. Mary’s Hospital, at the 2015 Associate Service Awards Banquet.


Professional Practice

RN Clinical Ladder

More than 71 registered nurses participated in the clinical ladder program in 2015. The RN Clinical Ladder is designed to assist nurses with professional growth, development and engagement through a variety of creative and quality activities and projects that benefit patients and hospital associates. Supported by the Nursing Professional Development & Education Council, the RN Clinical Ladder program accepted 20 new applicants to the ladder, and eight of whom raised the bar by advancing to the highest level (RNIV). The four nurses pictured above, left to right, Ann Byrne, BSN, RN, CHPN; Stacey Corrick, BSN, RN, CNOR; Dee Dee Johnson, BSN, RNC-OB; and Gina Russell, BSN, RN, CPEN, have already reached the top of the RN clinical ladder and set an excellent example for others working to Raise the Bar.

Simulation Training & Education Lab (SiTEL) Collaboration

In 2015, operating room associates began participating in quarterly mock Code Blue exercises in collaboration with a team from MedStar SiTEL. The impressive equipment includes a mannequin fully connected to simulators and complete with a variety of cardiac rhythms, chest movement and even blinking eyelids. The SiTEL team leads associates through scenarios to prepare for participation in an actual Code Blue situation in the operating room. One surgical technician stated that the expert, real-time and in-person feedback was very helpful in honing skills and bolstering confidence.

New Sepsis Guidelines

The continued increase in mortality rate for sepsis across the United States prompted new Centers for Medicare & Medicaid Services sepsis guidelines, supporting the idea that early recognition is the key to saving lives. Patty Hall, BSN, RN, and Jennifer Alvey, BSN, RN, VA-BC, joined together in assisting MSMH in moving in the right direction to meet the new guidelines. This has been a collaborative effort between many departments within the hospital to make necessary changes in order to meet the new guidelines and continue to Raise the Bar in saving lives at MSMH.


Associate Safety – Violence Against Healthcare Workers

Fifteen new Crisis Prevention Institute (CPI) instructors are trained and ready to respond as a result of discussion from a MSMH Safety/Security meeting. Occupational Health Nurse, Susan McCallum, BSN, RN, noted an increase associate injuries to during Code Greens – Emergency Response to Combative People. Further research showed a decrease in the number of CPI trained staff responding to Code Greens. As a result, a CPI Instructor Course was held at MSMH in October 2015 and OLR increased the number of CPI classes offered at the hospital, which are shown in the three photos to the right.

Improving Ambulation with Physical Therapy

In 2015, Intensive Care Center (ICC) nurses began using physical therapy to increase ambulation with their patients. Using evidence-based practice, they realized increased ambulation would improve a patient’s physical and mental healing. Physical therapists were included in the multidisciplinary rounds in the ICC and became an integral part of the ambulation effort, which began in fall 2014. Since then, ICC patients requiring some assistance — a walker, two-person assist or self-ambulated, as well as patients on a ventilator — are benefitting from increased ambulation practices.

Nursing Shared Governance Open House

More than 70 associates attended a Nursing Shared Governance Open House held by the Shared Governance Coordinating Council on Dec. 2, 2015. As shown in the photos below, attendees enjoyed a Dr. Seuss-themed event with games and prizes and learned about shared governance and why it is important to participate. The open house introduced them to the purpose and activities of each of the MSMH Central Nursing Councils and helped recruit new members, including four nurses, to the Nursing Informatics Council, the Evidence-Based Practice and Research Council, and the Professional Development & Education Council.


Improving Nursing Clinical Practice Guidelines

The MedStar Nurse Practice Innovation Council works to develop and implement evidence-based MedStar Nursing Clinical Practice Guidelines into nursing practice at all MedStar entities. Following the 2015 appointment of Amanda Dyson, BSN, RN, PCCN, to the council, six clinical practice guidelines were incorporated into nursing practice at MSMH. The new guidelines include Care of the Adult Patient Suffering from Morbid Obesity; Nurse-to-Nurse Bedside Change of Shift Report; Nursing Care of Hospitalized Adult Patients with a Non-Tunneled Central Line; Prevention of Catheter Associated Urinary Tract Infections (CAUTI); Prevention of Falls among Hospitalized Adult Patients; and Prevention and Treatment of Pressure Ulcers in Hospitalized Adults.

Nursing Professional Practice Model (PPM)

In December 2014, MedStar St. Mary’s Hospital’s Nursing Professional Practice Model (PPM) was approved by members of the MSMH Nursing Shared Governance Councils. With a nautical compass design, the model serves as a symbolic representation of our waterfront community, as well as a navigational instrument to guide professional, relationship-based nursing practice every day. During the Magnet Countdown Celebration on Oct. 22, 2015, full-sized posters of the PPM were distributed to each of the clinical nursing units. Nurses were asked to sign their unit’s poster, reaffirming their commitment to form a relationship with the patient and their family and always keep them first. The signed posters will be framed and hung on each unit as a visual reminder of this commitment for nurses.

Care Coordination/Population Health

Interdisciplinary approaches to seamless patient care transitions are being accomplished by nurses across the continuum. Inpatient case managers and Health Connections’ outpatient care coordinators work hand-in-hand to assist patients in returning safely home following their hospital visit. These registered nurses educate and empower patients to better manage their chronic conditions and recovery at home. They also help coordinate patient recovery in partnership with the patient’s primary care physician and specialists involved in their plan of care. In addition, community partners and neighboring care coordinators participate in regular meetings to review best practices, discuss challenging situations and celebrate improvements in care transitions, which allows MSMH to better serve Southern Maryland residents.

Cancer Care & Infusion Services Nurses Patty Svecz, RN, OCN and Teresa Gould, RN, OCN

Health Connections Care Coordinators, pictured left to right: Kathy Franzen, BSN, RN; Stephanie Angle, RN; Christine Taylor, RN; Holly Adams, BSN, RN; Jill Maxwell, BSN, RN.


Pictured from left to right: March of Dimes representatives Tina Cavucci and Jennifer Abell; Women’s Health & Family Birthing Center associates Lisa Hulvey and Kathy Whitecotten; and Robert Imhoff, president and CEO of Maryland Patient Safety Center.

Code Lullaby

MedStar Obstetrical Safety Training (MOST) results from November 2014 indicated MSMH would benefit from a policy to address imminent deliveries occurring outside of the Women’s Health & Family Birthing Center (WH&FBC). Beginning in January 2015, Nurses from the WH&FBC and the Emergency Department (ED) worked together to develop the Code Lullaby policy, researching best practices and how similar policies had been implemented in other facilities. In addition to the policy, Code Lullaby response bags were also created for both the WH&FBC and the ED. Education was completed for nursing and medical staff from both departments and Code Lullaby went live in December 2015. This new program has been well received by all associates.

Quarter 1 Quarter 2 Quarter 3 Quarter 4237 Inpatient Falls with Injury Rate 2.08 1.66 0.38 0.43 < 0.60236 Nursing Turnover 1.29 0.46 1.55 4.23 < 16.80

591 Overall Inpatient Nursing Care - Nurses Listened Carefully to You 84.60 82.40 86.50 87.20 > 75.70

592 Overall Inpatient Nursing Care - Treated With Courtesy & Respect by Nurses 91.70 95.80 93.10 92.70 > 85.50

593 Overall Inpatient Nursing Care - Nurses Explained Things Understandably 81.10 86.10 84.10 88.70 > 74.80

594 Overall ED Nursing Care - Nurses Listened Carefully to You 78.60 82.60 76.60 79.20 > 76.80

595 Overall ED Nursing Care - Treated With Courtesy and Respect by Nurses 82.70 85.80 80.40 85.30 > 82.50

596 Overall ED Nursing Care - Nurses Explained Things Understandably 80.10 76.90 77.00 79.00 > 75.10

81 Physical Restraint Events - Acute Care 0.12 0.00 0.69 0.67 < 0.837 CHF - Discharge Instructions RETIRED RETIRED RETIRED RETIRED ≥ 96.00

184 Rate of Height of Bed (HOB) Elevation 95.15 97.16 89.18 95.42 ≥ 96.00191 Rate of Ventilator Associated Pneumonia 0.00 0.00 0.00 0.00 < 0.16472 Oral Care of Ventilator Patients 87.21 96.30 88.16 68.89 > 90.00190 Rate of Indwelling Urinary Catheter-Associated UTIs 0.00 6.45 0.00 0.00 0.00407 Central Lines Bloodstream Infections in the ICC 0.00 0.00 0.00 0.00 0.00181 Critical Care - Patients with Hospital Acquired Pressure Ulcers as Reported to NDNQI 0.00 33.33 0.00 0.00 < 3.92

387 Telemetry - Patients with Hospital Acquired Pressure Ulcers as Reported to NDNQI 4.55 0.00 8.70 4.76 < 1.08

388 Med Surgical - Patients with Hospital Acquired Pressure Ulcers as Reported to NDNQI 0.00 3.70 0.00 0.00 < 1.72

170 Hospice - Caregiver Confidence in Doing What was Needed to Take Care of Patient 73.90 78.30 93.80 No Data > 72.20

169 Hospice Emotional Support to Family Prior to Patient's Death 93.50 96.70 96.70 No Data > 94.70

459 Hospital Wide Hand Hygiene Compliance 93.03 95.21 94.61 95.13 ≥ 95.00

404 Inpatient Complaints 0.72 0.31 0.61 0.39 < 0.77

405 Outpatient Complaints 0.03 0.02 0.02 0.03 < 0.10406 ED Patient Complaints 0.19 0.13 0.18 0.03 < 0.21619 Stroke - Dysphasia Screening - Overall 96.97 96.97 100.00 96.67 ≥ 96.00

620 Stroke - Education - Overall 96.67 100.00 96.88 86.21 ≥ 96.00

Indicator NameIndicator #

Nurse Sensitive Indicators - Stoplight ChartBenchmarkFY 2015


Hospital Awarded 39 Weeks Recognition Banner

On June 11, 2015, MedStar St. Mary’s Hospital received the 39 Weeks Recognition banner sponsored by the Maryland Patient Safety Center and Maryland Department of Health & Mental Hygiene in partnership with the March of Dimes Maryland National Capital Chapter. This banner represents MedStar St. Mary’s Hospital’s dedication to the reduction of early elective deliveries and the commitment to providing the best care for mothers and babies. The banner was awarded during the Maryland Patient Safety Center Conference held in Ellicott City, Maryland.

Nurse Sensitive Indicators

Nurse Sensitive Indicators are used to determine the level of care provided by nurses. These nurse-controlled measurements can impact the quality and safety of a patient’s stay. We are proud to share the quarterly results below, which are continuously monitored and provided to nurses as a means to measure progress and celebrate great nursing care.

Knowledge, Innovations &Improvements

Behavioral Health — Emergency Department Collaboration

Valuable feedback received on a 2015 MedStar Associate Survey resulted in better teamwork and efficiency in moving patients between Behavioral Health and the Emergency Department (ED). Nursing associates noted issues in patient handoff and turnaround time for arrival of patients to Behavioral Health (BH). Following the survey, they participated in action planning, which resulted in the implementation of new patient handoff procedures in October 2015. Now all Behavioral Health nurses, including Erika Humphreys, RN, and Alyssa Bogacki, MS, RN, who are pictured above, go to the ED to escort patients back to BH, allowing ED nurses to remain in their unit.

Nursing Research, Alive and Well at MSMH

New research is underway by the Nursing Research Council (NRC), following approval from the Institutional Review Board (IRB) on May 15, 2015. The research focuses on activities related to the study protocol: “The effect of horizontal violence education on the turnover rates for new graduate registered nurses in a rural community hospital.” Through this study, the council will determine how educating new graduate registered nurses about horizontal violence and how to manage it, if encountered, will affect their decisions to remain at MSMH during their first year of employment. This exciting research is scheduled to be completed by May 2016.

CareMobile Compliance

Nurses hospital-wide are helping to improve patient safety with the use of CareMobile scanning for medications and patients. With a score at 92 percent, MSMH exceeded internal CareMobile compliance benchmarks for 2015. First introduced in the hospital’s Emergency Department in 2014, CareMobile devices provide added safety through positive patient identification and bedside documentation of medications administered to patients.


Rounding with iPads

Clinical associates are using hospital iPads while rounding with patients to help ensure patients experience the best stay possible at MSMH. Introduced in October 2015, this new technology affords nurses the ability to better communicate on behalf of patients. Nurses can instantly send kudos to caregivers and emails to departments regarding a patient’s questions or concerns. Also, patient feedback is documented immediately during rounding through a series of 10 questions, ranging from their Plan of Care and responsiveness of caregivers to their level of pain and any concerns with medication side effects.

PACU/ASC Cross-Training

Nurses in the Perioperative Department, Ambulatory Surgery Center (ASC) and Post Anesthesia Care Unit (PACU) have merged to create a perianesthesia team of nurses. These nurses care for the surgical patient in the preoperative interview, the admission phase and the first and second stage recovery areas. As part of the merger, ASC nurses attended a didactic class, became Advanced Cardiac Life Support certified and began duties as second recovery nurses in order to work in all perianesthesia areas. As a team, perianesthesia nurses move within the continuum of care to meet the ever-changing needs of their patients.

RN Educational Needs Assessment

During summer 2015, 170 registered nurses participated in an RN Educational Needs Assessment survey. Supported by Organizational Learning & Research and the Nursing Professional Development & Education Council, the survey allowed registered nurses in all positions and departments to identify areas in which additional learning opportunities would provide benefit. Several topics were identified as areas of interest for associates to increase their learning experience. Associates were offered opportunities to address the identified areas, as well as a variety of activities to enhance their knowledge and improve their practice.

Clostridium Difficile (C. diff) Testing Procedures

Nurses are following established protocol to better identify when to test patients for C. diff. Infection Preventionist Patty Hall, BSN, RN, spearheaded the project and found a person can be colonized with C. diff and not have an active infection. She used her findings and evidence-based practice to help establish the protocol. In addition, Patty collaborated with Environmental Services regarding the proper cleaning of C. diff rooms to prevent spreading the infection. An Adenosine Triphosphate (ATP) monitoring system is being used on each C. diff room to assure proper cleaning has occurred.

Improving Pain Management

The Medical/Surgical/Pediatrics (MSP) department showed significant improvement in pain management from FY14 to FY15, according to scores from National Research Corporation (NRC) Picker. For the question, “During this hospital stay, how often did the staff do everything they could to help you with your pain?” MSP’s score increased 8.7 points, ranking in the 95th percentile compared to NRC Picker Magnet hospitals. For the question “During this hospital stay how often was your pain well controlled?” MSP ranked in the 83rd percentile compared to NRC Picker Magnet hospitals. An overall Pain Composite ranking in the 91st percentile compared to NRC Picker Magnet hospitals indicates MSP’s strong nursing focus on pain management.

Charge Nurse, Erica Buckler, RN, FNE-A, rounds with patients using an iPad in the Women’s Health & Family Birthing Center.


Wound Care

Efforts to reduce hospital-acquired pressure ulcers proved successful in 2015. By yearend, the combined total number for the three departments indicated in the chart above declined from 10 to three. This improvement is attributed to the Skin Protection Committee’s focus in five key areas: adding turning clocks inside patient rooms; wound care policy re-enforcement; promoting associate involvement with the Skin Protection Committee; ongoing nurse education; and identifying and documenting pressure ulcers that are present on admission. In addition, choices for specialty bed surfaces are now documented in IVIEW software. This update reflects a more accurate picture of nursing interventions implemented to prevent skin breakdown.

Neuro-Tele Initiative

Three additional nurses are trained to assist with the telemedicine program — a collaboration with MedStar Washington Hospital Center’s Stroke Neurologists and MedStar Georgetown University Hospital. Ashley Borden, BSN, RN; Hayley Cain, BSN, RN; and Jessy May, BSN, RN, use their skills to support the program, which is designed to enhance communication during consultations between referring and consulting hospital physicians. Increasing the number of nurses trained to work with the telemedicine program ensures appropriately trained staff for weekly coverage.

Rehabilitation and the Cancer Patient

Cancer rehabilitation is a process that helps cancer patients obtain their maximal physical, social, psychological and vocational functioning within the limits created by the disease and its resulting treatment. Cancer Care & Infusion Services patients who are currently on active

chemotherapy are now completing a form, called the Psychosocial Distress Screen. Information from the form is used to gauge whether patients need a referral for rehabilitation services or a social worker. Working in conjunction with Rehabilitation Medicine, a therapist evaluates the patient to determine if services are needed and also the type — physical, occupational or speech — and duration of therapy. Plans are in place to expand the use of the Psychosocial Distress Screen to include follow-up patients who have completed treatment. The goal is to improve the patient’s daily function and quality of life.

Disposable Visitor Wristbands

When a nurse shared concerns about visitors’ badges not being placed in the proper container, potentially contaminating clean badges, the Patient and Family Advisory Council for Quality and Safety (PFACQS) listened. Infection Preventionist Patty Hall, BSN, RN, identified that numerous hospitals in the area and across the nation use disposable wristbands. In December 2015, MSMH began using the disposable wristbands, which are more sanitary and more convenient for visitors. In addition, the color-coded bands provide an added safety feature to better identify hospital visitors during their stay.

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Hospital-Acquired Pressure Ulcers 2015by Department

TelemetryMed/Surg/PedsIntensive Care Center

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


Featured on the Cover...These registered nurses represent the many MedStar St. Mary’s nurses who are Raising the Bar in 2015 by advancing themselves through education to become even better caregivers. Through their exceptional level of competency, skill and knowledge in their field, many nurses are pursing or have received educational level or advanced degrees, certification in one or more specialty areas, and/or specific training that allows colleagues to help each other continue to improve.

Pictured, front row from left to right: Kathy Vachalek, BSN, RN, Women’s Health & Family Birthing Center; Teresa Gould, RN, ONC, Cancer Care & Infusion Services; Justine Reimer, BSN, RN, CNOR, Perioperative Services; Carina Morrison, BSN, RN-BC, Medical/Surgical/Pediatrics.

Pictured, back row left to right: Lindsay Canter, RN, Behavioral Health; Ashley, O’Neil, BSN, RN, PCCN, Telemetry; Brittany Szaks, BSN, RN, Emergency Department; Nancy Sperbeck, RN, DN, CHPN, Hospice & Palliative Care; Temeria Wilcox, BSN, RN, Nursing Resources.

Special thanks to College of Southern Maryland (CSM), for allowing us to use their facilities to capture this

photo. Many of our nurses begin their nursing journey through CSM.

MedStarStMarys.org

25500 Point Lookout RoadLeonardtown, MD 20650301-475-6226 PHONE

A Message From - MedStar Health Message From ... Maureen P. McCausland, DNSc, ... Lea Ann Carranza, BSN, RN; Heather Guy, RN; and Ashley O’Neil, BSN, RN, ... National Magnet Conference

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