Providence Little Company of Mary Torrance: 2011 Nursing Report

We are NURSES of

2011 Nursing ReportThis is Our Journey to Excellence: Charting the Course to Magnet

P R O V I D E N C E

ContentsMessage from CNO 3

Message from CE 4

Transformational Leadership 5

Structural Empowerment 7

Exemplary Professional Practice 23

New Knowledge, Innovations and Improvement 26

Empirical Outcomes 30

Friends of Nursing (Philanthropy) 34

One Ministry Committed to Excellence:Inspired by our heritage, we work together to deliver excellent health care in the communities we serve.

2011 Nursing Annual Report 3

As nurses of Providence Little Company of Mary Medical Center Torrance (PLCMMCT), we have the ongoing opportunity to “make visible a healing presence” for every patient in our care. This fourth edition of our Nursing Annual Report beautifully reflects our continued commitment to link compassionate care with clinical excellence. Together, we strive for discovery and innovations as we build the systems, structures and processes that advance both the art and science of caring for others.

As we journey toward ANCC Magnet Designation, we celebrate the exceptional work of our Shared Governance (SG) coordinating councils and teams. This past year, the councils presented their achievements through four nursing congress sessions. For the first time, two of the congress sessions were “mobile” sessions making it possible for staff, regardless of their shifts, to share in the great teamwork and outcomes. More than 500 employees participated in the congress sessions reflecting our highest participation to date.

There is much to share on our meaningful journey and this annual report reflects the depth of work including our nursing strategic plan, as well as the goals and successes of the Professional Practice, Clinical Practice, Technology and Informatics, Research and Education and Quality and Safety councils. The amount of work completed by these Shared Governance councils is impressive, including many first-time achievements such as: the National Daisy Award for nursing excellence, the implementation of Patient and Family-Centered Care as a professional practice/patient care delivery model and the improved access to our Nursing Policies and Standards as we moved from printed manuals to the intranet site. Other firsts include the addition of patient and family advocates to the Patient and Family Advisory Council, CAMIS 6.0 deployment, new KRONOS nursing workforce scheduling system, full deployment of electronic team collaboration sites and a number of evidence-based practice changes using our Rosswurm and Larrabee EBP tool. Together, we also shared an exceptional National Certification Nurses Day celebration where more than 70 nurses were recognized for their specialty certifications in practice. The 13 Unit-Based Councils (UBCs) had tremendous advancements as well, and their SMART goals were strongly articulated. More than 150 nurses are participating in various Shared Governance councils throughout the organization. This type of nurse engagement is what drives our organization’s outcomes to continually improve. Thank You!

As 2011 came to a close, I made the important decision to respond to the call for a different way to serve Providence as a member of the Southern California regional team. After 25 years as a nurse leader at Providence Little Company of Mary Medical Center Torrance, it was my privilege to serve with each of you as my nurse colleagues in caring for the health care needs in our community. It has been my great professional privilege to pass the baton forward to our new Chief Nurse Executive, Jessica Rivas RN, MSN. Jessica is a passionate, expert nurse leader who will take our organization forward to achieve our goal of excellent patient care and ANCC Magnet designation no later than 2014.

As nurses of Providence we will keep a steadfast commitment to our patients and families who are relying on us to “know them, care for them and easy their way.” Thank you for being a part of the sacred calling at Providence Little Company of Mary. The joy of our work is truly in our journey to pursue excellence in all we do for our patients, their families and this beloved fellowship called nursing.

Providence Little Company of Mary Medical Center Torrance

Message from our CNO

Kathy Harren, RN, MHA, MSNc

Our Nursing VisionProvidence nurses embrace their

heritage of compassion, courage,

and leading-edge care as a steadfast,

sacred presence in protecting and

easing the way for those in need.

4 Providence Little Company of Mary Medical Center Torrance

Each day, I encounter the nurses at Providence Little Company of Mary Medical Center Torrance living and breathing the Mission and spirit of our Founding Sisters. Our nurses are genuinely dedicated to compassion in caring for the patients who entrust us with their lives.

Providence Little Company of Mary Medical Center Torrance nurses also are committed to continued excellence, as reflected in our pursuit of Magnet designation. I take great pride in our unit-based nursing initiatives and the participation of our nurses in decisions that strengthen the care we deliver to patients and their families.

We know that 2011 was a challenging year across the nation for health care organizations. The hard work and commitment of our nursing team helped ensure that Providence Little Company of Mary Medical Center Torrance remained a strong and vibrant force in the community and enabled us to continue serving those who came through our doors. Through the contributions of our nurses, we delivered nearly 3,000 babies, cared for more than 20,000 people who come here with acute conditions and successfully managed 65,000 emergency room visits. I am proud of our accomplishments and look forward to continuing our journey together.

Providence Little Company of Mary Medical Center Torrance

Liz DunneMessage from our CE

RespectAll people have been created in the image

of God. Genesis 1:27We welcome the

uniqueness and honor the dignity of every person

We communicate openly and we act with integrity

We develop the talents and abilities of one another

As People of Providence, we reveal God's love for all,especially the poor and vulnerable, through our compassionate service.

CompassionJesus taught

and healed with compassion for all.

Matthew 4:24We reach out to people

in need and give comfort as Jesus did

We nurture the spiritual, physical and emotional

well-being of one another and those we serveWe embrace those who are suffering

JusticeThis is what the Lord requires of you: act

with justice, love with kindness and walk humbly with your God. Micah 6:8We believe everyone

has a right to the basic goods of the earth

We strive to remove the causes of oppression

We join with others to work for the common good and to advocate

for social justice

ExcellenceMuch will be

expected of those who are entrusted with much. Luke 12:48

We set the highest standards for ourselves and for our ministry

We strive to transform conditions for a better

tomorrow while serving the needs of today

We celebrate and encourage the contributions

of one another

StewardshipThe earth is the Lord’s and all that is in it. Psalm 24:1

We believe that everything entrusted to us is for the common good

We strive to care wisely for our people, our

resources and our earthWe seek simplicity in our

lives and in our work


transformational leadership

Innovation-Informatics: Nurses are involved with evaluation and allocation of technology and information systems, and participate in architecture and space design to support practice.

Nursing Accessibility to Electronic Information: Nursing staff have access to PLCMMCT nursing information, resources and documents.New Knowledge Dissemination: Nurses disseminate and generate knowledge through nursing research to internal and external audiences.Evidence-Based Practice/Nursing Research: Infrastructure and resources are in place to support the advancement of evidence-based practices.

Nursing Division Strategic Plan Summaryph&s Core strategy One Ministry Committed to Excellence: Inspired by our heritage, we work together to deliver excellent health care in the communities we serve.

Nursing Mission Through collaboration, excellence and innovation,

Providence Little Company of Mary Medical Center Torrance nurses embrace life-long learning, respect

diversity and make visible a compassionate and healing presence for each patient and family in our care.

Nursing ValuesMaking a Difference

QualityCompassion

CaringAdvocacy

Nursing Division Strategic Priorities Goals

Transformational Leadership

Professional Advancement: Leaders are visionary risk-takers who engage in life-long learning to maintain competencyAdvocacy and Influence: Nurse leaders engage in succession planning, leadership development and mentoring services. Visibility, Accessibility and Communication: Nurse leaders must be visible, accessible and approachable. Magnet Recognition: Strong leadership team and interdisciplinary collaboration to achieve

Magnet designation by 2014 and maintain enculturation of Magnet.

Structural Empowerment

Image of Nursing: Nurses are perceived as essential team members and are integral to the delivery of excellent patient care.Collaborative Decision-Making: Structures and processes enable nurses to actively participate in organizational decision making and

effectively influence system-wide processes.Education Development: Support, recognize and improve continuous education among staff membersCommitment to Community Involvement: Support and recognize the participation of nurses at all levels in service to the community,

continue to establish partnership with community.Nursing Excellence: Nurses are celebrated and recognized through multiple media in the organization, the nursing and healthcare community.Advancement of Nursing Practice: Utilize infrastructures and resources to support

workforce development and advancement of nursing practice.Academic Affiliations: Collaboration with our academic colleagues to develop/teach the next generation of healthcare professionals.Professional Advancement: Provide opportunities through structures and processes that enable professional and career advancement.

Exemplary Professional

Practice

Professional Practice Model: Professional nurses are accountable for excellent practice through continuity of care as well as for providing individualized and interdisciplinary patient- and family-centered care.

Healthy Practice Environment: Exceed median of national/or comparative benchmark on nursing satisfaction targets three out of four quarters annually.

MD Satisfaction: Exceed median of national/or comparative benchmark on nursing satisfaction targets three out of four quarters annually.Patient and Family Satisfaction: Exceed median of national/or comparative benchmark on nursing satisfaction targets three out of four

quarters annually.OE/Six Sigma Projects: Nurses are actively involved in Operational Excellence (OE) (performance improvement) activities at all levels.Performance Appraisal Process: Create opportunities for ongoing performance evaluation through informal/formal avenues in order to

create a culture of accountability.Nursing-HR Partnership: Nurses and HR collaborate to improve recruitment and retention of nurses.Monitoring and Reporting: Quality data is collected and disseminated through various processes and structures in collaboration with

Department of Performance Improvement (PI) and nursing leadership.Interdisciplinary Collaboration: Healthcare team members are observed in collaborative and healthy working relationships that achieve

positive patient outcomes. Nursing Outcomes: Nurse-sensitive outcomes are monitored, evaluated and improved on an ongoing basis.

New Knowledge, Innovation and Improvements

2007-2014


transformational leadership

Nurse Leaders Participate in State, National and International Education

Amy Dugan, adn, rn �� International Association for Human Caring Annual Conference, poster presentation, “Transitioning with a Caring Touch”, San Antonio, TX

Kathy Harren, mha, rn

�� UCLA MSN and BSN students presentation, “Health Policy and Contemporary Impact Issues for Nurse Leaders”, Los Angeles, CA�� California State University Dominquez Hills: MEPN students presentation, “Contemporary Impact Issues for Nurse Leaders”, Carson, CA�� Collaborative Alliance for Nursing Outcomes (CALNOC) Annual state-wide program: podium presentation, “Regional and National Forces Shaping CALNOC’s Strategic Evolution”, Long Beach, CA

Melissa Punnoose, msn, rn

�� International Association for Human Caring Annual Conference, poster presentation “Using Simulation to Promote Compassionate Care at the End of Life”, San Antonio, TX

Sue Revero, msn, rn, ccrn

�� International Meeting on Simulation in Healthcare, podium presentation: “Simulation to Advance Quality and Safety”, New Orleans, LA

In 2011, recognized as experts in their field, our nurses gave the following presentations around the world:

Heidi Traxler, msn, rn

�� International Meeting on Simulation in Healthcare, podium presentation: “Simulation to Advance Quality and Safety”, New Orleans, LA�� Providence Excellence Conference, podium presentation: “Leveraging Technology to Reduce Mortality using Simulation”, Seattle, WA�� California Institute for Nursing & Health Care (CINHC) Level 1 Course: Co Facilitator Torrance, CA September 6-7, 2011 Providence Little Company of Mary, Torrance�� CINHC Debriefing Course: Co-facilitator September 20, 2011 Long Beach City College�� Southern California Healthstream User Group Meeting poster “Implementing A Simulation Program”, Torrance, CA


Our Shared Governance Model

Our Journey to

Structural Empowerment

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ShAREd gOvERNANCE

COORdINATINg COuNCIL

CLINICAL PRACTICE

TEChNOLOgy & INFORMATICS

RESEARCh& EduCATION

PROFESSIONAL PRACTICE

quALITy & SAFETy

uNIT-bASEd

COuNCILS(ubC)

unit-based

councils(ubc)

uNIT-bASEd

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Q U A L I T YC A R I N G

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M A K I N G A D I F F E R E N C ENuRSE MANAgEMENt COuNCIL

N u r S E E x E c u t i V E c o u N c i l


struCtural empowerment

Shared governance Big 5 Councils’ Main Accomplishments

Professional Practice Council�� Researched and developed the framework of the RN Professional Portfolio. �� Participated in the Professional Nurse Excellence Nomination Selection Committee and Award/Ceremony Planning Committee.�� Hosted a successful National Certified Nurses Day celebration breakfast on March 18th.�� Rolled out the National Daisy Award during 1st Quarter 2011. Hosted four quarterly award presentations honoring four outstanding compassionate nurses. The President of Daisy Award, Bonnie Barnes, presented the 2nd quarter award. �� Started the “Busy Beads” project (jewelry made solely by the council members) and began selling the beads in the Gift Shop. All sales go back to the organization.

Clinical Practice Council�� Developed the 1st Phase plan to roll out the Professional Practice Model of Patient- and Family-Centered Care. �� Hosted a Magnet Professional Practice Model Education and Awareness Day in June. �� Reviewed nursing policies and reduced redundancies. �� Finalized location of all nursing policies. Identified two sources: Lippincott and PLCMMCT intranet site. �� Active advocates for patients and families by involvement with Patient and Family Advisory Council and attendance at Patient- and Family-Centered Conference in July. �� Revised and finalized "Talking the Talk" elevator speech of the Professional Practice Model.

Providence Little Company of Mary Medical Center

Torrance nurses continue to look for creative ways

to give back to the community. One example is the

“Busy Beads” project that raised funds to benefit

at-risk women and children. Chris Farnham, RN,

had an idea to make beaded bracelets and lanyards

not only for certified nurses, but also to sell in the

Gift Shop. Professional Council members eagerly

volunteered their time to learn how to make the

beautiful beaded creations and went on to raise

more than $1,500. Their work on these items

further signifies the spirit our nurses have to give

back to the community both on and off the job.



Technology and Informatics�� California Advanced Medical Information System (CAMIS): Members served Core Trainers and as Super Users to promote a successful implementation on June 1, 2011. Collected input from staff post go-live in regard to CAMIS concerns for submission to CAMIS Educator.�� KRONOS Workforce Manager: Representation from Technology and Informatics Council to launch Part 1 of KRONOS. Educated staff at Magnet Congress in regard to utilizing existing features of KRONOS.�� Team Collaboration Sites (TCS): The council has committed to work on optimization of the TCS sites. This will begin by gathering staff input at Magnet Congress to determine what staff would find valuable on these sites.

Quality and Safety�� Designed the first mobile Congress: Educated more than 90 staff in the first mobile Congress regarding Nurse Sensitive Indicators (NSI), HCAHPS.�� Designed poster of puzzle pieces to incorporate the NSI and how it leads to Family-Centered Care.�� Educated staff members on data analysis, databases (e.g. CalNoc, NDNQI, NHSN, etc.) and each unit’s NSIs (included two Mobile Unit Education Tours in June and October).�� Identified, provided guidance and made recommendations to areas where the quality indicators were not performing at the benchmark.�� Assisted with Pressure Ulcer Reduction Campaign – Inspect 2 Prevent. Together with our WOCN (Wound Care Specialist), the council educated staff members house-wide on “inspect and prevent” to improve quality outcomes.

Research and Education Council�� Supported staff in utilizing EBSCO database effectively, teaching the following via Congresses, printed handouts and information tables�� Incorporated EBP into Department-based Competencies. �� Reviewed and revised Nursing Research Strategic Plan.�� Assisted the Education staff in research proposal (using PICOT template) for Simulation Project with new graduate RNs.�� Two R&E Council members attended the Providence Holy Cross Medical Center Research and EBP annual conference with two of our posters displayed and two information tables.�� Four R&E Council members attended the UCLA Annual Research and EBP conference�� Collected four Rosswurm and Larrabee Worksheets summarizing details of successfully implemented EBP Practice Changes at PLCMMCT.�� Initial support and planning for Carol Glenn’s wound care project, which has since been approved by the IRB members and the study will continue through 2012.



Surgery/PACU/SDS/GI Goal: By August 2011, the skin of 75 percent of patients will be assessed using the “Pressure Ulcer Prevention Assessment Tool”Results: From August 2011- December 2011, we maintained a 75% and above compliance in the use of the “Pressure Ulcer Assessment Tool” in the peri-operative Areas. Goal: Improve peri-operative ranking in the large Press Ganey database by at least 10 points each quarter. The overall goal is to achieve and maintain a ranking of greater than 80 by January 2014.Results: The planning phase started in 3rd Q 2011. The development and implementation phases will take place in 2012 – it will be our UBC’s main focus in 2012.

Women’s HealthGoal: Increase women’s health patient satisfaction, as reflected in the HCAHPS top box results (12 month average) for the “Pain Management” composite roll-up score to a top box of 78%, by the end of 2011.Results: We have met our goal of 78% for three out of the last six months of 2011. We plan on continuing this goal of 78% throughout May of 2012.

ICUGoal: 1. To increase the number of CCRN, CSC & CMC certified nurses in the ICU by 5% (about three RNs), by December 31, 2011. 2. ICU Quarterly nursing communication scores will be greater than 50% in the “always” category of HCAHPS Survey.

unit-Based Councils’ 2011 Achievements

3. Staff will have increased knowledge regarding ICU and nursing policies as evidenced by post-test results at quarterly staff meetings.Results: Certification - From January 1, 2011, to December 10, 2011, nine nurses achieved new CCRN/CSC certification, which increased our unit to 44%, or a 15.3% increase. Communication score - As of the third quarter ending September 30, 2011, ICU received four HCAHPS surveys which showed overall nursing communication scores to be greater than 50% in the “always” category. There were four indicator questions with two questions resulting in 100%ICU Policy - “Policies of the Month” were selected by UBC members throughout the year and were posted in the lounge for staff to review. A post- test was given at the ICU October staff meeting for the five POMs from May to September. All questions turned were answered correctly.

Case ManagementGoal: Create Care Management Handoff communication form by October 2011.Results: Created Care Management Handoff Communication form and guidelines for use.Goal: Develop Care Management Recognition Program poster by October 2011. Results: Developed Care Management Recognition Program “I Care” poster, nominating cards and written process.

4th Med CardGoal: Increase morale on 4th Med-Card, by end of 2011, by 50% based on the survey results.Results: There was an increase greater than 50% of staff that felt the morale on the unit had improved.

Elizabeth

Bruner, RN,

RN Quality

Specialist, at

Providence

Home Health,

helped lead

the development of the Unit-

Based Council for Home Health.

Elizabeth was transferred to

the department from Labor and

Delivery where she also participated

in the Unit-Based Council (UBC).

This enabled her to quickly put

her experience in the Labor and

Delivery UBC to work to help Home

Health establish its first UBC.

Elected chair, Elizabeth worked

with the team to establish goals:

�� educate the staff regarding the UBC

�� motivate participation in the UBC

�� focus the unit specific indicators to decrease re-hospitalizations, and

�� improve pain management.

After educating the clinical staff

about the UBC, a charter was

created and work began.

The UBC continues to help empower

clinicians with shared decision-making

related to practice, competency, work

environment and patient safety. Over

the long term, UBC participation

will increase staff confidence,

encourage good communication,

increase accountability and

improve processes and quality

outcomes within the department.



EDGoal: Increase ED’s Press Ganey score to 70% in three months, 80% in six months and 90% in nine months starting May 2011Results: Press Ganey scores greater than 70% for two consecutive months in fall 2011.Goal: Increase ED’s numbers of certified nurses and numbers of nurses in school (more than five) by December 2011. Results: Currently four CENs and greater than 15 total number of RNs in school for advanced education by December 2011.

1st SurgicalGoal: Four RNs from 1st Surgical to become Med/Surg certified in 2011.Results: Ludy Chang, Aldrin DeSantos, Mark Motio and Lety Vega became Med/Surg certified in 2011.Goal: Increase personnel baseline knowledge on 1st Surgical unit on proper Continuous Passive Motion (CPM) use by 80% by November 31, 2011.Results: CPM poster board was created and displayed at the Magnet Congress November 2011. 100% of the participants stated gaining knowledge on proper CPM use.Goal: Improve employee morale and teamwork on 1st Surgical by 1% by January 2012. Baseline data are 80%.Results: In the 2011 Employee Opinion Survey, 81% of 1st Surgical employees agreed with the statement “I feel I am part of a team.”

Children ServicesGoal: Increase knowledge of the Peds and NICU staff of Magnet process by 10% by November 2011.Results: Using Survey Monkey, the data indicated that staff showed an improvement of knowledge on Magnet of about 13%. Goal: Increase in morale of team members by 10% by November 2011.Results: There has been a range of 6-12% increase based on a survey that contained eight questions.

AOUGoal: AOU to develop and adapt a standard Room Readiness Checklist by December 2011.Results: Results showed we performed better than our baseline study in 2010. Poster created.

Angio-RecoveryAngio-Recovery Goal: Uncomplicated A-line pulls will be achieved in 90% of Angio-Recovery patients at year end 2011. Results: From third quarter 2011 data, our uncomplicated A-line pulls have reach over 90%Cath Lab Goal: Safe RN to MD hand-off report will be done in 100% of angiogram patients by the year end 2011.Results: From third quarter 2011 data, our RN to MD safe hand-off report is between 85%-99%.

4th Med OncGoal: Decrease foley catheter usage by 60% by December 2011.Results: Decreased number of device days by more than 60% (from 141 in May to 41 in December 2011).Goal: Improve responsiveness of staff to call lights 15% by December 2011. Results: “Call button help soon as wanted” reached 100% from December 2011 HCAHPS score (top box national benchmark: 63%).



Emergency DepartmentAs one of the Emergency Department’s Unit-Based Council (UBC)’s SMART goals, the department partnered with security to ensure the safety of patients, families and employees during the daily Emergency Department operation. This effort in collaboration and improvement of work environment was captured by ADVANCE for Nurses (January 17th 2011 issue) as the cover story for the issue.

Surgery DepartmentThe surgery department at Providence Little Company of Mary Medical Center Torrance began utilizing the World Health Organization (WHO) Surgical Safety checklist, a successful research project that has proven to cut death rates in half and non-fatal complications by one-third in facilities that have used it.

After implementation of the WHO Surgical Safety checklist, our compliance rate improved significantly from 53% in 2010 to 97% in 2011.

This notable improvement led to our surgical team’s selection as one of the top finalists for ADVANCE for Nurses’ “2011 Best Nursing Team” contest.

Recognized for Advancements in Safety



RNs Who Completed BSN or MSN in 2011Jennifer Massimo, MSN (NICU)Jinsook Lee, BSN, RN (AOU) Joann Bernier, BSN (ED)Lindsey Yuen, RN, MSN, FNP (1st Surg)Lori Bischoff, RN, BSNRobbie Lee, BSN, RN (4th Med Onc)Rosely Werner, BSN, RN (AOU) Sachiko Tatsuno, BSN (Women’s Health)Samantha Ryan, BSN (ED)Sara Kranke, BSN (ED)Rachel Bruce-Carothers, MSN in Nursing Leadership (4th Med Card mgr)Kathy Sliff, MSN (ICU) Beena Philipose, BSN (ICU)

Affiliate Nursing Instructors Melissa Punnoose, MSN, RN, Los Angeles Harbor CollegeKaren Walter, BSN, RN, El Camino College and Cerritos CollegeLinda Scott, BSN, RN , El Camino College and Los Angeles Harbor CollegePaula Grimaud, RN, Mount St Mary’s CollegeJoan Gahan, MSN, RN, El Camino CollegeLinda Mason, MSN, RN, Cal State University Dominguez HillsSue Endicott, MSN, RN, El Camino College

Newly Graduated RN Residency ProgramProvidence Little Company of Mary continues to provide and improve our award winning comprehensive, evidence-based Newly Graduated RN Residency Program. The retention rate for the 34 new grads hired in 2011 is 100%.

Specialty Residency ProgramsProvidence Little Company of Mary offers specialty training programs for advancing the clinical practice of experienced registered nurses. Seventeen RNs completed specialty training in the ICU, ED and/or OR.

Our Academic Nursing PartnersProvidence Little Company of Mary continues to maintain strong affiliate relationships with both undergraduate and graduate nursing programs. Every day of the week, as many as 100 RN students help provide direct patient care.

2011 StudentsCal State university dominguez 30Cal State university Los Angeles 20Cal State university Long beach 4Cal State university Fullerton 4uCLA 10Mount St Mary’s College 20El Camino College 120Los Angeles harbor College 120Loma Linda university 1West Coast university 1

We are committed to nursing students being successful in their final semester preceptorship experience and in their graduate program rotations at Providence Little Company of Mary.

Advancing Education

Providence Little Company of Mary Medical Center Torranceis committed to supporting nurses at

all levels in professional advancement

and continued formal education.



Providence Little Company of Mary Medical Center Torrance Nurse Excellence Annual Celebration

Campus Awards & RecognitionWinners in RedCritical Care NursingYoung Cho, bsn, rnMaria Victoria Liwanag, bsn, rnKaren Lofstrom, adn, rnAmy Polvani, bsn, rnSherry Samson, bsn, rn-icu

Womens & Childrens HealthMarie Halls, diploma, rnTracy Hall, bsn, rnBlanca Landman, adn, rnElisabeth Rios, bsn, rn

Advanced Medical Surgical NursingJeremy Bounds, adn, rnAldrin Delos Santos, bsn, rnRainbow Stephens, bsn, rnCasey Vastano, bsn, rnSuh Young, adn, rn

Ambulatory Care + Distinct Sub SpecialtyJean Bunten, adn, rnSherry Kim, adn, rnJennifer Lastimosa, adn, rnLucy McRae, bsn, rnSarah Park, diploma, rnMelissa Punnoose, msn, rnCynthia Rohrer, adn, rn

Honoring Excellence

Rookies1st medical surgical/oncology Jeni Varghese, rnaou Gina Scachetti, msn, rnemergency department Sara Sarhangian, adn, rniCu Tracee Suntharaphat, bsn, rnmedical Cardiology Jayna Kwon, rn surgical Jennifer Sabbagh, adn, rn or Emma Schwab, rnpost partum Jessica Sharman, bsn, rntCC/tCu Hyo Shim Yang, rn

Friends of NursingStephanie Crane patient relations Coordinator

David Dinh paCs manager

Andrea Flores Clinical informatics/translation leader

Dr. Denise IshimaruSalvador Jimenez imagining paCs administrator

Danny Le Cardiac paCs administrator

Richard Partyka education program Coordinator

Dr. Elliot SumiJulian Villaescusa or support tech

Humanitarian AwardJo Ann Birdsong, rnRita Wadhwani, msn, rn



AORNKum Cho, rnChristine Constable, rnDiane Dragotto, rnSheli Hicks, rnArlene Howe, rnCara Lazarus, rnCindy McDonald, rnSusan Medlicott, rn

ASPANChris Disario, rnMary Olszewski, rnJeanna Peshl-Amaro, rnAWhONN Susan Balou, rnNi-Wei Chu, bsn, rn, Linda Mason, rn, rnc-obAudrey Stempel, bsn, rn, rnc-ob, mnnSachiko Tatsuno, rn

California Society for Cardiac Rehabilitation (CSCR)Yvonne Hashimoto, bsn, rnDebbie Lawlor, adn, rnEstela Uchima, bsn, rn

ENANikki Durepo, rnRuth Jeffery, rnCourtney Kosnik, rnMelanie Marriot, rnLori Mullenhour, rn, cenSara Sarhangian, rn

AACNJennifer Bee, rnAphiradee Chaiweerathai, rn

AACN, Sigma Theta Tau and ACNLJulie Baker, rnRachel Bruce-Carothers, msn, rnMaria Chan, rnKelene Degrell, rnMaritess Dignadice, rnNEllen Liu, rnMelissa Garth, rnJennifer Herz, rnMelanie Marriot, rnMichael Mizuta, rnLori Mullenhour, rnCatrice Nakamura, rnRosemarie Navarro, rnAndie Nordstrom, rnGem Oga, rnTheresa Parks, rnKimberly Patel, rnRachel Rolince, rnSherry Samson, rnEvelyn Sanchez, rnLeona Sandrik, rn Maria Luisa Santonil, rnJulian Schiesser, rnKathy Sliff, rnTracee Suntharaphat, rnKimberley Thach, rnYani Thomas, rn

California and Professional Organization Positions and Memberships



Statewide Awards & RecognitionAssociation of California Nurse Leadersbest Practice – Clinical Nursing Carol Glenn, bsn, rn, cwocn

best Practice-Education Heidi Traxler, msn, rn

Catholic Health Care Leadership Life Time Achievement award (finalist)Kathy Harren, mha, rn

NurseWeek/Nursing Spectrum, Nursing Excellence Finalist - Community ServiceRita Wadhwani, msn, cns, rn

California and Professional Organization Positions and Memberships (cont.)Oncology Nursing Society MembersSameena Adamjee, rn, ocnKerry Blazevich, rnEleanore Bley, rnMaria Britton, rnChristine Canceran, rn, ocnJulia Farfan, rnLuningning Floresca, rnVisesh Mohan, rnCasey Vastano, rn, ocn

Ellen gorbunoff, msn, rn-bc

��Association of California Nurse Leaders, Nurse Leadership Development Team Chair

Patti hamaguchi, msn, rn

��Association of California Nurse Leaders, Voice of Nurse Leadership Team

geri harmon, bs, rn, cde

��Association of California Nurse Leaders��American Association of Diabetes Educators��Coastal Area of Southern California Diabetes Educators Association, President Advisor & Board Member

Kathy harren, mha, rn

��CALNOC Board of Directors Founding member ��California Hospital Assessment and Reporting Taskforce (CHART) Board member��California Institute for Nursing and Health Care (CINHC): Board member ��California Action Coalition (CAC) IOM Future of Nursing Council member��Association of California Nurse Leaders (ACNL) Health Policy Committee member

derlyn hudson, msn, rn, cde

��American Association of Diabetes Educators�� Coastal Area of Southern California Diabetes Educators Association - Secretary�� Coastal Area of Southern California Diabetes Educators Association Board Member

Maria Sibal, bsn, rn-bc, cde, ocn

�� American Association of Diabetes Educators�� Coastal Area of Southern California Diabetes Educators Association

Carol Sukimoto, adn, rn

�� California Society for Cardiac Rehabilitation (CSCR), Executive Board member and Education & Research Chair.�� California Society for Pulmonary Rehabilitation (CSPR)�� American Association of Cardiovascular and Pulmonary Rehabilitation.

heidi Traxler, msn, rn

�� Association of California Nurse Leaders�� Society for Simulation in Healthcare�� International Nursing Association for Clinical Simulation and Learning�� California Statewide Simulation Alliance Steering Committee�� California Simulation Alliance Research Committee�� Southern California Simulation Collaborative Operating Committee�� Southern California Simulation Collaborative (SCSC) Co-chair

Lindsey yuen, msn, np, rn

�� American Academy of Nurse Practitioners�� American Nurses Association

Sue Revero, msn, rn, ccrn

�� Association of California Nurse Leaders, Voice of Nursing Leadership Team�� Association of Critical Care Nurses �� California Institute for Nursing and Health Care, Centralized Clinical Placement System Advisory Board



Sara Abuddyhea, acmSameena Adamjee, ocnCindy Allen, ccmLisa Amour, cohnEmily Anderson, ccrnNino Arlene, cen, cpenNicole Artiano, cmsrnMarianne Ayala, chpnJeong (Lori) Bang, pccnShannon Bell, cnorLori Bishoff, rnc-nic Mary Jo Bongard, ccmAlison Bonk, ocn Rachel Bruce-Carothers, ccrnJean Bunten, cgrnErin Cameron, cenAnke Campanella, cphqChristine Canceran, ocnDee Dee Chaiweerathai, ccrnMaria Chan, ccrnLudy Chang, cmsrnNi-Wei Chu, cnmRaeann Colburn, rnc-ob Christine Constable, cnorGinaya Crooks, ccrnMaryjane Dacanay, cmsrnJean Dahdah, rnc-nic Emma Delacerna, acmLori Delgado, rnc-nic Aldrin Delos Santos, cmsrnJune Delrosario, ccrn

Sheri DeMaagd, cenKathy Demar, ccrnValerie Deverman, rnc-nic Claudette Dorsey, cnorDiane Dragotto, cnorMaria Eclevia, cmsrnMarie Fischer, rnc-nic, ne-bcTeri Fox, rnc-nic Caroline Gallego, rnc-obCarol Glenn, cwonMila Glodoveza, ccrnEllen Gorbunoff, bcJoan Gahan, rnc-ob Hilary Gray, rnc-nic, rnc mnbPaula Grimaud, rnc-ob, cnmJodi Hadden, ccrnGeri Harmon, cde Sue Herbert, rn-cJennifer Herz, ccrnArlene Howe, cnorDebbie Harder, rnc-pedsDebbie Hudson, rnc-pedsDerlyn Hudson, cdeMarie Hynes, ccrnRuth Jeffery, cenSally Jenkins, rnc-nic Michael Jongsma, ne bcRebecca Keeton, rnc-Mae Keltner, cohn-s, cm

Bonnie Kerber-Louvet, cenMichelle Kershaw, ccrnMadonna Kielty, rnc-nicJane Lindner, rnc-nic Ellen Liu, ccrnApril Marones, rnc-mnn, ibclcJoanne Masalle, phnLinda Mason, rnc-obMelanie Marriott, cenSher Mc Gann, cohnLynette McCoy, rnc-nicCindy McDonald, cnorJoan McIntosh, cphqSusan Medlicott, rn-cToni Meek, rnc-ob Michael Mizuta, ccrnBethany Mota, pccnMarc Motio, cmsrnCatrice Nakamura, ccrnRose Navarro, csc, cmc, ccrnGloria Noell, ccm, hcqm, cpum, cmacEden Oblepias, rn, ccrn Gem Oca, ccrnMary Olszweski, cpanMichelle Owens, rnc-nicNicha Panich, rnc-nicKim Patel, ccrnJeanna Peshl-Amaro, cpanFereshteh Pirayesh, cnm

Victoria Pniel, rnc-nicMelissa Punnoose, rn-bc Stacy Quintana, ccrnSue Revero, ccrnJessica Rivas, cenpEmma Schwab, cnorCecile (Maria) Sibal, ocn, cde Jillian Schiesser, ccrn Jodie Senter, rnc-icNancy Skifstrom, cgrnKathy Sliff, ccrnMarilyn Cejka Steinberg, rn-bc, nnp-bcAudrey Stempel, rnc-ob, rnc mnnLilia Stephenson, rnc-ob, npEllie Tamargo, ccrnIris Tamashiro, rnc-ob, npYani Thomas, ccrnCasey Vastano, ocnLety Vega, cmsrnCorazon Villacarlos, rnc-mnnRita Wadhwani, rnc-nicJulie Walker, rnc-nic Cathy Wassenberg, rn-cNicole Weber, rnc-mnnMary Black Williams, rnc-ob, fnp-bcCarol Yokoyama, rnc-nicSue Yoon, ccrn

Certified Nurses contribute to better patient outcomes through national board certification in their specialty. Certification affirms advanced knowledge, skill, and practice to meet the challenges of modern nursing.

Excellence Through Certification



The DAISY Award is a nationwide program that celebrates the extraordinary clinical skills and compassionate care given by nurses. A DAISY Nurse is one who always goes above and beyond, is sensitive to patients’ needs, is positive and professional, listens not only with his or her ears but with his or her heart as well. The DAISY award was developed by the Daisy Foundation, which was formed in 2000 by the family of J. Patrick Barnes who died at age 33 of complications of Idiopathic Thrombocytopenic Purpura (ITP), an auto-immune disease. DAISY gets its name from the acronym for Diseases Attacking the Immune System and was created by Tena Barnes, the patient’s widow and co-founder of the DAISY Foundation.

Providence Little Company of Mary Medical Center Torrance is proud to be a DAISY Award Hospital Partner recognizing one of our nurses with this special honor every quarter. Patients, nurses, physicians, visitors and employees can nominate that very special and deserving nurse.

Honoring Our DAISY Nurses

”

daisy honoree 1st quarter 2011

debbie Nowak, RN - First Surgical

debbie goes the extra mile for her patients. For instance, she cared for a patient who was in medical, social and spiritual crisis. She spent a lot of time sitting bedside and listening to the patient and would go and purchase flowers for this patient to encourage her. Each day, debbie goes above and beyond her call of duty treating her patients as if they are her family. She is an example of a truly compassionate, caring and committed nurse.

daisy honoree 2nd quarter 2011

Annie Flores, RN - Angio RecoveryAnnie exhibits compassion and outstanding daily care for patients and their families and serves as a role model. For instance, the husband of an Angiocenter nurse was suddenly stricken with Acute Myeloid Leukemia (AML). The nurse and her husband had two small children. during her off hours, Annie drove the family to the hospital, provided emotional support and comforted them while the husband underwent treatment. during the treatments, Annie never left the side her co-worker; she prayed with her and provided food, financial help, safety, childcare, emotional and spiritual support. In addition to helping this co-worker and her family, Annie has also helped many families who have come to PLCMMCT including a teenager from the Philippines who had a heart problem. Annie stands out in her quiet compassionate nature and demonstrates compassion every day.



4Th quARTER

�� 1st runner up: Tammy Majik, 4th Medical Cardiology�� 2nd runner up: Rosely Werner, AOU�� 3rd runner up: Juliet Phillips, 1st Surgical

3Rd quARTER

�� 1st runner up: Jen Tran, AOU�� 2nd runner up: Gina Scachetti, AOU�� 3rd runner up: Gary Carnes, AOU

2Nd quARTER

�� 1st runner up: Wendy Pestano, Endoscopy�� 2nd runner up: Christine Canceran, 4th Med Oncology�� 3rd runner up: Debbie Harder, Pediatrics

1ST quARTER

�� 1st runner up: Rea Ricafort, AOU �� 2nd runner up: Joan Tierney, SDS�� 3rd runner up: Tammy Majik, 4th Med-Card

daisy honoree 3rd quarter 2011

Ketty Scaroni, RN Women’s healthKetty is a PM charge nurse who is always upbeat and encouraging to her team. One night she heard that a patient’s baby was not doing well in NICu and went to pray for the baby. days later we received news from the mom that the baby was doing better. The patient was very grateful for Ketty’s extra touch.

This is just one example of how Ketty goes above and beyond every night she works. When the hospital is busy, Ketty is the peace in the midst of the storm. her famous words are, “It’s OK, we can do it.” She is never upset, negative or discouraging and is a walking example of all of our core values.

daisy honoree 4th quarter 2011

Claudia Olvera LopezClaudia goes over and beyond with all of her patients. She is extremely passionate in her care for all of the hospice patients. For instance, we had a very young gentleman who was at TCu for end-of-life care. She took excellent care of him and provided compassionate care and support to his 21-year-old daughter and wife. She took extra time to explain to the daughter what was happening and reassured her that her father was no longer suffering. Claudia is an excellent RN and cares for patients like they are family.

Runner Up



Our Nurse Volunteers Making a Positive Impact

Living Our Mission

breast Cancer Awareness Fair: Leah glavan, RN, worked with a local girl Scout to help her earn her gold Award

and provide education to women about breast cancer. The girl Scout wanted to hold a breast Cancer Awareness Fair

at the scout center in honor of her grandfather whom she had lost to stomach cancer a few year prior and went to Leah for help. Working with the Providence Women's

Imaging Center, the girl Scout received fun and educational materials to hand out. Leah attended the event to support the scout, passing out Advance directive information and

provided information about the form. The event was educational and helped everyone learn while demonstrating

that the nurses at PLCMMCT not only give during their work hours but also after hours to help the community.

Leah Glavan, RN (1st Surgical)

As People of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.

PLCMMCT Simulation Program�� Medical supply donation to clinic in India.

Cynthia Rohrer ADN, RN�� Gaitors Walking Club

Leona Sandrik, RN (4th Med Card)�� Venice Family Clinic in Santa Monica

Carol Sukimoto ADN, RN�� Gaitors Walking Club�� Speaker at one event for 2011.

Jo Birdsong, RN (ED)�� Humanitarianism missions to Haiti in January and July 2011

Darcie Bohl BSN, RN�� Gaitors Walking Club

Connie Chung RN (PACU) �� Torrance Mission Health Center�� Medical mission with her church to rural China.

Valerie Deverman, NICU RN�� No One Dies Alone” (NODA) �� TrinityCare Hospice

Geri Harmon, BSN,RN,CDE�� Speaker: Type 2 Diabetes: Basics and Beyond community lecture, March/April 2011�� Speaker: Teledyne Diabetes lecture, May 2011�� Speaker: Diabetes Awareness Day, November 2011�� Diabetes screening and Speaker for community lecture, November 2011

Yvonne Hashimoto BSN, RN�� Teaches CPR for friends and family, community classes.

Derlyn Hudson, MSN, RN (CDE)�� Speaker: Cardiopulmonary Diabetes community lecture, February 2011�� Ambassador for African American Initiatives in the Los Angeles Area

Maria Liwanag (Victoria) RN (PACU)�� Global Community Outreach: Medical mission to the Philippines.

Bonnie Louvet, RN (ED)�� No One Dies Alone (NODA), St Lawrence Martyr Church�� Community High School volunteer/fund-raising



Relay for Life in 2011: Approximately 60 PLCMMCT employees attended the Relay for Life including 40 medical oncology nurses. The local event requires participants to walk for

24-hours at a nearby park. Together with millions of others across the globe, PLCMMCT nurses participated in a life-changing event that helps communities celebrate the lives of people who have battled cancer, remember loved ones lost, and fight back against the disease.

PLCMMCT employees, including medical oncology nurses

Manhattan beach hometown Fair 5K Race: PLCMMCT nurses helped out at the annual Manhattan beach hometown Fair 5K race. In 2011, three RNs, two techs and dr. baldridge from the ER, set up a “mini ER” at the finish line to provide wound care,

start Ivs for those requiring rehydration, and offered moral support to participants. As appropriate, the team sent them to PLCMMT for additional care if required.

Chris Farnham, RN (ED) and other ED nurses

PLCMMCT Simulation Program�� Medical supply donation to clinic in India.

Cynthia Rohrer ADN, RN�� Gaitors Walking Club

Leona Sandrik, RN (4th Med Card)�� Venice Family Clinic in Santa Monica

Carol Sukimoto ADN, RN�� Gaitors Walking Club�� Speaker at one event for 2011.



For the first time in its history, the 2013 Rose Parade will feature a float recognizing nurses and the nursing profession. In honor of the nurses at Providence Little Company of Mary Medical Center Torrance (PLCMMCT), funds are being raised to support this float.

An initial contribution was made in the nurses of PLCMMCT. To continue to support the nursing float, PLCMMCT nurses sold baskets created by nurses from each unit. The baskets were then displayed and sold, raising more than $3,000 for the Rose Parade Nurses Float. The check was handed over at an event attended by four Tournament of Roses Committee members, more than 150 nurses, countless employees and executive leaders.

Nursing Profession to be Honored at Rose Parade


Our Journey to

Exemplary Professional Practice

Our Nursing Professional Practice Model

The Patient- and Family-Centered Care Professional Practice Model is aligned with our nursing mission, vision and values which sets the professional standards for all nurses. The five components of this model are compassion, communication, collaboration, professional advancement and quality care. These are the components of our practice which we use every day in caring for our patients and their families.

NuRSINg MISSIONThrough collaboration, excellence and innovation, Providence Little Company of Mary Medical Center Torrance nurses embrace life-long learning, respect diversity and make visible a compassionate and healing presence for each patient and family in our care.

NuRSINg vISIONProvidence nurses embrace their heritage of compassion, courage, and leading-edge care as a steadfast, sacred presence in protecting and easing the way for those in need.

NuRSINg vALuES Making a DifferenceQualityCompassionCaringAdvocacy

“Providence Nurses are here to give you and your family a helping hand.”

PATI

ENT A

ND FAMILY-CENTERED CARE

HEA

LTHFUL CARING ENVIRONMEN

T


exemplary professional praCtiCe

In 2011, 99% of our 511 direct care provider nurses took the national NDNQI (National Database of Nursing Quality Indicators) RN satisfaction survey. We used the Practice of Environment Scale survey tool, which reflected the voice of nursing on priority areas that impact their practices.

Satisfaction Survey

The profile of those who responded were:�� 94% Female�� 42 years in average age�� 54% practiced nursing for more than 10 years�� 43% Associate degree�� 48% Baccalaureate degree�� 5% Master’s degree and higher�� 15% nurses with national certifications

4.18

4.02

4.06

3.9

3.95

4

4.05

4.1

4.15

4.2

PLCMMCT National Magnet

Staff Level Adjusted Shift to Shift

4.94

4.87

4.92

4.82

4.84

4.86

4.88

4.9

4.92

4.94

4.96


Orientation Adequacy

�� Nurses agreed that staffing level adjustments are done appropriately shift-to-shift

�� Nurses received adequate orientation (outperform the national average)

0.37

0.31 0.31

0.28

0.29

0.3

0.31

0.32

0.33

0.34

0.35

0.36

0.37

0.38


Mean Change Over Past Year

�� Improvement of quality of care:

Our Strengths

Key findings:

Survey CategoriesNational

Benchmark PLCMMCT

Score

Nurse Participation in Hospital Affairs 2.84 2.86

Nursing Foundations for Quality of Care 3.08 3.05

Collegial Nurse-Physician Relationship 2.94 2.87


exemplary professional praCtiCe

InpatientIn 2011, our Ministry initiated a plan to improve Patient Experience/Patient Satisfaction including the formation of an HCAPS steering committee to focus on results. By the end of 2011, PLCMMCT outperformed more than 50 percent of the hospitals across the country on two of the eight HCAHPS measures. Our effort to improve Patient Experience/Patient Satisfaction continues in 2012 with the adoption of standard work for key nursing communication pieces like white boards, bed shift hand-off and hourly rounding. In addition PLCMMCT will continue to strengthen how nurses and others show more gratitude to employees and for nurse leaders to round on patients and their direct reports to strengthen patient care and nurse accountability.

Some Highlights for our Inpatient Team’s Accomplishments:�� Rate the Hospital: 72%�� Communication with Nurses: 75%�� 4th quarter improvements:

o Rate the Hospital: 78% o Communication with Nurses: 79% o Hospital Environment: 63% o Discharge Information: 85%

2011 Trends for Inpatient

Emergency DepartmentOur emergency team has one of the highest volumes in Providence and their mean score is 59%, demonstrating that a majority of patients rate ED care as very good. The graph below depicts part of the 2011 and the 2012 overall rating score as of March 2012.

together We Achieve Higher Standards


• Search for best-evidence through a literature review.

• Critique and weigh evidence.

• Synthesize best-evidence.

• Assess feasibility, benefits and risk.

• Define proposed change.

• Identify needed resources.

• Plan implementation process.

• Define outcomes

• Pilot study demonstration

• Evaluate process and outcome.

• Decide to adapt, adopt, or reject practice change.

• Use standardized language based on Nursing Classification Systems (ex: NANDA).

• Identify potential interventions and activities.

• Select outcomes indicators.

• Communicate recommended change to stakeholders.

• Present staff in-service education on change in practice.

• Integrate into standards of practice.

• Monitor process and outcomes.

• Include stakeholders (individuals or groups affected by change).

• Collect internal data about current practice.

• Compare internal data with external data.

Our Journey toNew Knowledge, innovations and

improvement

assess need for change in practice

link problem, intervention and outcomes

synthesize best evidence

design practice change

implement and evaluate change in practice

integrate and maintain change in practice

Assess Link Synthesize Design Implement & Evaluate Integrate & Maintain

Our Conceptual Model for Translating Nursing Evidence into Clincal PracticeRosswurm & Larrabee Model


new knowledge, innovations and improvement

The Nursing Institute encompasses programs and support systems to enhance the quality of nursing practice that will grow and advance our nursing workforce. Our goal is to consistently attract and retain dynamic, committed nurses to give great patient care in the is exciting, thriving workplace.

Our Vision StatementTo inspire men and women to excel in both the

art and science of nursing with compassion,

commitment, and the spirit of inquiry.

Simulation Program(ISAQS) (Unihealth Grant funding):�� Training of faculty at Center for Advanced Perinatal Education at Stanford University�� Dinner and simulation demo for administration, physician leaders and other key leaders to introduce simulation and ISAQS�� Held 20 ISAQS sessions in ED and Periop areas�� About 200 RNs, techs, and RTs attended�� 41 MDs attended�� Metrics: Decrease sepsis mortality in the ED by increased utilization of the Severe Sepsis protocol (11.1% reduction)�� Increased utilization of the WHO Surgical Safety checklist in the OR (in the OR consistently 100% except for one month)

ISAQS practice changes�� Sepsis order set, the abxs should be listed in order of priority �� Suggestion to put laminated copy of the sepsis orders at the bedside in ED �� Since there is only one Broselow laryngoscope handle, we should have fresh batteries stocked right next to the handle in the top drawer �� Removed pediatric intubation tray that sat on top of Broselow cart �� Need laminated color coded pediatric broselow guide put in chart for pediatric patients coming straight up from surgery. ED notify peds for emergency admits and peds RN brings laminated broselow sheet to OR.�� Laminated code blue phone number in each OR

Simulation to Advance Quality and Safety (SAQS): WH SAQS focused on Pre-eclampsia and an OR scenario focused on the WHO surgical safety checklist and disruptive behavior.

Project Smartie:2 new grad programs

NODA28 volunteers attended NODA training in the simlab

TCC/TCUSimulation Skills Training - All of the RNs from TCC/TCU attended and focused on IV starts, CL dressing changes, blood cultures and the hospira pump.

the Schneider Institute for Nursing



transforming Care through Evidence-Based Practice and technology

Technology and Informaticsspecial thanks to Camis smart team members:1st Surgical: Letty vega, Leah glavan, and Lindsay yuen; AOU: Rea Ricafort; 4th Med Card: John Flynn; 4th Med Onc/Heritage: Sharon Aaron and visesh Mohan; ICU: Stacy quintana and Andrea Nordstrom; SDS: Andrea Reed; Education: Karen Walter; TCC: Joan McIntosh

Evidence-Based PracticeProfessional Health Care Providers at PLCMMCT searched the EBSCO Research Database over 2,500 times in 2011 ensuring that the care delivered reflected the latest clinical guidelines. In addition, the team used 1,700 research articles, including 120 Cochrane Systematic reviews, the highest level of research supporting clinical practice in patient care and reviewed an additional 750 clinical guidelines and patient education information articles.

�� California Advanced Medical Information System (CAMIS): Technology and Informatics Council members served as Core Trainers and as Super Users to promote a successful implementation on June 1, 2011. Collected input from staff post go live in regards to CAMIS concerns for submission to CAMIS Educator.



�� Technology and Informatics Council members contributed to launching part one of KRONOS Workforce Manager. Council members also educated staff at Magnet Congress in regards to utilizing existing features of KRONOS.

�� Pyxis automated medication management system went live on 1st Surgical in December. Turnaround times for getting medications has greatly decreased.


Our Journey toEmpirical outcomes

Making a Profound Difference in Our Quality of Care


empiriCal outComes

Embracing Best Practice to Reduce Readmissions for Congestive Heart Failure

Celebrating Outcomes

Healthy HeartHabits

f i r s t e d i t i o n

2011 Calendar

1.170.97

0.99

0.69 0.77

1.13

0.66

1.00

1.64

0.43

0.790.70

1.12

0.90

0.0

0.4

0.8

1.2

1.6

2.0

Jan -Dec 2010

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTD Total

PLCMMCT CHF Readmission O/E - PHS Objective to Date

O/E Ratio Target

In April 2010 we developed a heart failure program to reduce Congestive Heart Failure (CHF) readmissions using evidence-based information and recommendations from the Institute for Healthcare Improvement and American Heart Association. �� In 2011, we saw a 30% decrease in the rate of O/E readmissions within 30 days.

How We Did ItWe held regular CHF committee meetings that involved a CHF champion. As a result, our heart failure patients received education from admission to discharge by the bedside nurse and the heart failure navigator. We scheduled a physician appointment within seven days from discharge, as well as a home health RN visit. We provided each of our patients with a “Healthy Heart Habits” calendar and an action plan, a scale for those that could not afford it as well as a medication box and an education video to take home. Our heart failure navigator followed up with each patient to review education including diet, weight management, medication compliance, and reminded patients of their physician appointment. High-risk patients were called weekly for two months or until stable. If the patient was noncompliant or high risk, a case manager was assigned to follow the patient until they were stable. �� Core measure for Heart Failure has been 100% compliance for four quarters.

�� QSP YTD Thru Oct 2011

Cases 451Readmissions 79Readmission Rate 17.52%Expected Readmission Rate 20.79%CHF Readmission O/E 0.842011 CHF Readmission O/E Target 1.06


empiriCal outComes

L&D, Mother/BabyThe L&D and Postpartum Unit-Based Council led by Raeann Colburn, RN, worked diligently to improve the assessment and reassessment of pain in patients with cesarean sections. They created a video to educate all staff on hourly rounding, white boards, and pain assessments. As a result pain assessments improved 20% from 80% in Q4 2010 to 96% in Q4 2011.

Improving Patient Hand-Off CommunicationBreakdowns in patient ‘hand-off ’ communication continue to be a leading cause of preventable patient harm. Hospital hand-offs occur upon admission, at shift changes, before and after procedures, at transfer and discharge. Evidence clearly demonstrates that hospital hand-offs are high-risk, high frequency events where critical information must be transferred completely and accurately with a narrow margin for error in an environment that, in many ways, either allows or promotes failure. In 2011, nursing leaders developed a customized handoff checklist to enhance the accuracy of each handoff. As a result hand-off communication improved in the following departments from Q4 2010 to Q4 2011: �� Angio Recovery/Cath Lab RN to MD (prior to procedure) - remained the same at 100%�� Same Day Surgery RN to RN – 76%�� GI Lab RN to RN – 84%�� Recovery Room RN to RN – 100%

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11PLCMMCT 75.61 80.00 82.32 86.18 89.00 96.00

0.0010.0020.0030.0040.0050.0060.0070.0080.0090.00

100.00

% P

ain

Ass

essm

ents

Co

nd

uct

ed

L&D Pain Assessment

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11PLCMMCT 0.00 100.00 90.00 85.00 97.00 100.00

0.0010.0020.0030.0040.0050.0060.0070.0080.0090.00

100.00

% R

N-M

D H

ando

ff C

ompl

ete

ARU Cath Lab RN MD Handoff

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11PLCMMCT 0.00 0.00 26.00 58.64 100.00 76.27

0.0010.0020.0030.0040.0050.0060.0070.0080.0090.00

100.00

%RN

-RN

Han

doff

Com

plet

e

SDS RN-RN Handoff

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11PLCMMCT 0.00 0.00 83.00 57.00 54.00 84.00

0.0010.0020.0030.0040.0050.0060.0070.0080.0090.00

100.00

% R

N-R

N H

ando

ff C

ompl

ete

GI RN-RN Handoff

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11

PLCMMCT 0.00 0.00 88.00 100.00 99.00 100.00

0.0010.0020.0030.0040.0050.0060.0070.0080.0090.00

100.00

% R

N-R

N H

ando

ff C

ompl

ete

PARR RN-RN Handoff


empiriCal outComes

Emergency DepartmentTimeliness and appropriate amount of IV fluids are key in reducing sepsis mortality. The ED RNs focus on improving IV fluid documentation showed a 58% increase from Q4 2010 to Q4 2011. This increased focus assisted in reducing sepsis OE (observed/expected) mortality from 1.11 YTD 2010 to 1.00 YTD 2011, a 10% reduction.

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11

PLCMMCT 0.00 55.00 64.00 72.00 74.00 87.00

0.0010.0020.0030.0040.0050.0060.0070.0080.0090.00

100.00

% IV

F D

ocu

men

ted

ED Sepsis IV Fluid Doc'd

Preventing Patient Falls on the RiseIn addition to unit rounding for fall signs and bed alarms, Falls Council and nursing leadership meet each month to discuss continuous improvement. A pilot program called CareView sets up an invisible perimeter around a patient’s bed and will trigger an alarm to the nursing station if the patient breaks the invisible plane. CareView has had great success in other hospitals and we hope to capitalize on this innovative solution to prevent patient falls.

Fall rates decreased on the following units from Q4 2010 to Q4 2011:�� ICU – 26%�� 1st Surg – 70.8%�� 4MC – 7.3%

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11

NDNQI Mean 1.45 1.43 1.41 1.36 1.38 1.37

CalNoc Mean 1.09 1.15 0.97 1.12 1.06 1.16

PLCMMCT 0.96 1.36 1.33 0.48 0.52 0.00

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60Fa

ll ra

te p

/100

0 p

t. d

ays

ICU Falls

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11

NDNQI Mean 2.79 3.03 2.90 2.74 2.74 2.67

CalNoc Mean 3.19 3.29 3.19 3.05 3.14 3.11

PLCMMCT 1.98 2.33 1.66 2.31 2.48 0.68

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

Fall

rate

p/1

000

pt.

day

s

1st Surg Falls

Q3'10 Q4'10 Q1'11 Q2'11 Q3'11 Q4'11

NDNQI Mean 4.01 4.09 3.90 3.86 3.99 3.85

CalNoc Mean 3.19 3.29 3.19 3.05 3.14 3.11

PLCMMCT 1.37 2.33 3.64 2.74 4.03 2.16

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

Fall

rate

p/1

000

pt.

day

s

4MC Falls


philanthropy and friends of nursing

At Providence Little Company of Mary, the words philanthropy and nursing have become permanent partners in advancing patient care. Motivated by the nursing shortage, Providence Little Company of Mary Foundation has developed deep relationships with individuals, foundations and corporations to help advance the life-giving work of nursing. Generous benefactors have supported registered nurses at all levels of professional practice with gifts of more than $8 million in the past five years. In 2005, George and Virginia “Ginnie” Schneider, exemplary partners in philanthropy, led the way with a $3 million endowment to create the George W. and Virginia Schneider institute for Nursing. Within a year, the work of the Institute expanded to include Providence Little Company of Mary Medical Center San Pedro. The goal of the Institute was clear: “to inspire men and women to excel in the art and science of nursing with compassion, commitment and the spirit of inquiry.” What we didn’t realize at the time was just how much the Institute would inspire the generosity of others.

In 2011, we recognized the incredible contributions of the Schneider family by awarding Ginnie with the 2011 Mary Potter Humanitarian Award. This award honors an individual who reflects the spirit of Venerable Mary Potter, Foundress of the Sisters of Little Company of Mary, through their professional and personal accomplishments. A life devoted to humanitarian concerns, making a visible and positive difference to humanity by nature of works, deeds, example and being are the qualities of Mary Potter recognized in the recipient of this award. Ginnie dedicated her time, personal talents and philanthropic support to Providence Little Company of Mary for over half a century, and is unparalleled in her efforts to make the Sisters’ vision of Catholic healthcare a reality in the South Bay. She was an active member of the Volunteer Auxiliary in Torrance, taking special care of the hospital’s gift shop until moving to Oregon in June 2011. She also served as a Eucharistic Minister, as well as a charter member of Mary Potter and Company, a social service and fund-raising group. It is with deep gratitude that we take this opportunity to thank George, Ginnie and all our generous Friends of Nursing for their compassion, commitment and leadership.

Blessed Are the givers

The goal of The George W. and Virginia Schneider Institute was clear:to inspire men and women to excel in the

art and science of nursing with compassion,

commitment and the spirit of inquiry.


Thank Youvirginia “ginnie” Schneider

Providence Little Company of Mary Medical Center Torrance4101 Torrance Boulevard

Torrance, CA 90503310-540-7676

www.providence.org/torrance

Providence Little Company of Mary Torrance: 2011 Nursing Report

Documents

nursing excellence

nursing congress sessions

nursing annual report

nursing policies

nursing strategic plan

clinical practice

safety councils

familycentered care