Recognized Excellence, Designated Magnet VUMC Nursing December 2010
Dec 19, 2015
Recognized Excellence, Designated MagnetVUMC Nursing
December 2010
Clinical Workforce
Lou Kaelin, Robin Mutz & Vicki Thompson
Clinical Workforce
Staffing and Scheduling2010 Goal Accomplishments
Analysis of supplemental staffing needs for inpatient and outpatient areas.
Improve satisfaction and retention of the maturing workforce.
Develop and implement subspecialty nursing fellowship.
Established Medical Assistant positions in the Clinical Resource Center.
Float Pool Tier 3 Proposal
Completed 14 FOCUS Groups and gathered data that will be evaluated to obtain: - Best practices regarding flexible staffing - Identified organizational barriers to flexible staffing Pilot program in Women’s Patient Care Center started in July 2010. -4 participants-Have been placed in L&D, 4East and Clinic-To be completed in September 2011- Next cohort scheduled to begin in January 2012
NDNQI Data 2010Practice Environment Scale “Adequate Resources”
CWC Impact on NDNQI scores has been accomplished by:1) Implementation of PRN Tiers - March 20062) Standardized Scheduling Process – July 20043) VandyWorks Implementations Go Live– July 20064) VandyWorks Implementations (ED, Procedural) 2009 -2010
Vanderbilt Comparison
2007 2008 2010 Magnet Academic Medical Centers
Adequate Resources
2.78 2.83 2.85 2.84 2.79
Safety and Scheduling2010 Goals Accomplishments
Monitor data on maximum work hours per week.
Addition of Certification Tracking to VandyWorks with alerts sent to staff and managers.
Reviewed data for over 60 hours/week work
Updated the Patient Care Services Scheduling Process Policy (CL 20-06.25).
Track 19 certifications (8208 employees) in VandyWorks
Track 10 professional licensures (3701 employees) in VandyWorks
Updated License, Registration and Certification Verificaton/ Reverification Policy (CL 20-06.02)
Schedule Period CN RN CP MR Paramedic
4.11.10 to 5.22.10 1 1 1 4 0
5.23.10 to 7.03.10 0 0 1 4 0
7.04.10 to 8.14.10 1 1 1 0 0
8.15.10 to 9.25.10 0 2 2 1 0
9.26.10 to 11.06.10 0 0 0 2 1
2011 GoalsPillar Goal :
Growth and Finance
Nursing Strategic Plan:Vanderbilt Personalized Patient
Health Care Mode
Steps to accomplish Measurements for success
Ensure that nursing work efforts include a coordinated plan to standardize staffing and scheduling practices and policies to support evidence based care
Review 2010 NDNQI VUMC Organizational Data Identify trends that relate to staffing and scheduling Make recommendations to NEB for workforce improvement based on analysis of NDNQI scores
Educate CWC and Managers on Staffing Templates and benchmarking data.
Complete literature review on the use of acuity tools in the current healthcare environment.
Review VUMC policies as needed and make recommendations to HR and NEB.
NDNQI Practice Environment Score “Adequate Resources will Continue to increase.
NDNQI RN “Plans for Next Year” will be at benchmark.
Will complete a gap analysis related to best practice acuity tools and requirements that match VUMC practice.
2011 GoalsPillar Goal:
People
Nursing Strategic Plan:Transformational Leadership and
Professional Development
Steps to accomplish Measurements for success
Work with Leaders and Staff to understand and promote flexible staffing strategies that balance the needs of the patients and quality of work life for the staff.
Continue Focus Group Sessions across the organization to understand best practices for flexible staffing currently used at VUMC.
Literature review regarding best practice flexible staffing options.
Monitor current internal and external literature related to staffing and scheduling.
Compiled index of best practices.
Analysis and make recommendations to NEB regarding flexible staffing options, best practices and barriers.
Turnover data of nurses 50 years and older
2011 GoalsPillar Goal:
People
Nursing Strategic Plan:Transformational Leadership and
Professional Development
Steps to accomplish Measurements for success
Inform Leaders and others of health care reform changes and legislation that has an impact on workforce strategy and management.
VUMC Clinical Workforce Committee will contribute to the body of knowledge of best practices in nursing workforce.
Inform NEB on the current trends in the literature and legislative actions that affect staffing and scheduling
Identify opportunities to present the work of the committee both internally and externally
Update to NEB and VUMC NLB annually and as needed.
Poster presentation at local and/or state level
NURSING DIVERSITY
Nicole Herndon & Laura Kelley
Nursing Diversity
PURPOSE:
To cultivate an inclusive culture encompassing respect and valuing individual uniqueness at all levels of Nursing within
Vanderbilt University Medical Center.
DEFINITION:
Diversity is defined as a broad spectrum of demographic attributes and philosophical perspectives that encompasses
respecting and valuing each individual’s uniqueness at all levels of nursing within Vanderbilt University Medical Center.
GOAL 2010 ACCOMPLISHMENT GOAL 2011Goal 1: Be unified in our voice and message as ambassadors for diversity at Vanderbilt as well as finding new ways to improve our reputation in the community to attract a diverse workforce.
• Continue to collaborate with Recruitment on diversity recruitment.
• Metro Nashville Partnership School Career Exploration Fair.
Completed a review of possible opportunities to collaborate with LDI, EAD, and Nursing Education.
Participated in the 2010 Metro Partnership School Career Exploration Fair.
• 139 schools• 4000 (plus students)
Goal 1: Be unified in our voice and message as ambassadors for diversity at Vanderbilt while finding new ways to highlight nursing’s commitment to diversity and a diverse workforce.
• Plan a Diversity Job Fair for Vanderbilt’s employees.
• Explore the possibility of developing a Diversity Recruitment Plan.
GOAL 2010 ACCOMPLISHMENT GOAL 2011Goal 1: Partner with the office of Client and Community Relations to participate in the 2011 Metro Partnership School Career Exploration Fair.
GOAL 2010 ACCOMPLISHMENT GOAL 2011
Goal 2: Find new ways to increase visibility and awareness of resources available at Vanderbilt concerning our efforts to encourage diversity in our workforce.
10 weeks of Nursing Alerts for diversity programs and resources (religious groups-Pastoral Care).
Updated website to include minority nurse associations and added three websites devoted to diversity and cultural awareness.
Collaborated with Nurse Wellness on the Mature Nurses Workforce.
Goal 2: Identify diversity training opportunities within current and new venues.
• Hearts & Minds • VUMC Orientation• Nurse Residents
• Generate a twice a year diversity newsletter -- “Nursing Diversity NewsPepper”
GOAL 2010 ACCOMPLISHMENT GOAL 2011
Completed four sessions of “Diversity in Healthcare” and Cultural Competence/Awareness.
Goal 2: Identify diversity training opportunities within current and new venues.
• Hearts & Minds • VUMC Orientation• Nurse Residents
GOAL 2010 ACCOMPLISHMENT GOAL 2011Goal 3: Develop a diversity training program for leadership so that they are more sensitive to:
• Diversity issues in hiring practices.
• Respect and treatment of the diversity in their employees.
CNO Diversity Breakfast.
Developed a draft for Nursing Diversity Education Pilot.
On-line Diversity Survey for Managers and Assistant Managers.
In collaboration with EAD completed three diversity training sessions.
Goal 3: Integrate diversity into mission and strategic goals based on best practices.
Driver Diagram Analysis for Diversity.Benchmark with institutions that have demonstrated best practices around diversity initiatives. Implementation of the Diversity Education Pilot.
First 2 Years Retention& Recruitment
Julie Foss & Debianne Peterman
F2YRR
PURPOSE
To assess, develop and implement effective strategies, program and processes for recruitment, selection, orientation and support for nurses during their first two years of employment at Vanderbilt University Medical Center.
Goals 2010 Accomplishments
Use shared governance process to gather feedback and share information to achieve F2YRR goals, include VPH
• Committee members volunteered to attend Staff Council meetings to hear issues and obtain feedback on proposed strategies:
o Buddy Systemo Transfer Processo Need to add routine reporting of
Staff Council feedback to F2YRR monthly agendas
• Debbie Arnow – Children’s Hospital• Ro Wallace – VPH• Julie Foss – VMG• Donna Ruth - VUH
Goals Accomplishments
• Maintain or improve selection/hiring process of new RN’s, including right person to the right area/job.
• Conduct assessment of managers who currently use targeted selection and peer interviewing – determine educational needs.
• Improve internal transfer process – review current policy and create career development process to help guide nurses requesting transfers.
Assessment was completed – 50% of managers reported that peer interviewing was not being utilized.
Added Tammy Key to committee.Dropped the registration fee. Education sessions offered onsite at unit when requested.
• Formed subcommittee• Identified “hills, skills, and will.”• Created a new Transfer Process
algorithm.• Vetted algorithm to NEB, NAB,
Managers and Recruiters.• Developed operational processes
within NE&PD to manage 2011 Pilot.
Goals 2010 Accomplishments
• Retain 87% of new nurses during their first two years at VUMC.
• Implement Preceptor Nurse Alerts! And provide ongoing educational updates.
• Committee will review general onboarding rounding tool that has been created and determine need to revise current Nursing Rounding 30-90-180 day tool.
• Explore the pilot of the “Buddy System” implemented on 7N and determine feasibility of rolling that system out to all units/departments
• Implemented the Preceptor Dish Nurse Alerts!
• Now offer ongoing development of preceptors beyond initial course. 149 preceptors have attended since 7/1/10.
• Updated Nursing’s 30-90-180 day rounding tool.
• Reviewed results from 7N.
• Currently conducting pilots on L&D and MICU.
• Created evaluation tool for pilot units for both the Mentor and “Buddy.”
NURSING STRATEGIC PLAN F2YRR GOALS MEASUREMENT STRATEGIES
TRANSFORMATIONAL LEADERSHIP AND PROFESSIONAL DEVELOPMENT(Provide current and future healthcare leaders and care providers the environment, tools, evidence and skill development to lead during a time of healthcare reform and transition.)
EVIDENCE-BASED PRACTICE AND EFFECTIVE PROCESSES(Lead nation in producing evidence that will drive nursing practice, recognizing and legitimizing the evolution of knowledge in a rapidly changing environment. Create passion and discipline for the translation of evidence into practice that will optimize patient outcomes.)
Increase the use of Peer Interviewing throughout the enterprise.
Currently only 50% of inpatient managers report using Peer Interviewing.
Threshold Target Reach 60% 75% 90%
DIS* Peer Intervewing subscaleCurrent 1.75 – 2.82Threshold Target Reach 2.0 2.5 3.0
Next Year Compliance:% of hires used peer interviewing
*DIS = Decisional Involvement Scale
• Partner with LD & SG Committees to develop curriculum for Nursing leaders specific to peer interviewing.
o Literature review peer interviewingo List Serv surveyo Identify managers who have
completed Targeted Selection (December Managers Meeting)
• Strategize with nursing leaders to develop rollout plan for education of staff on peer interviewing techniques.
• Meet with managers’ Council (Dec. 2010) – identify barriers. Identify Managers who have completed Targeted Selection.
• Follow-up on barriers identified by managers.
• Develop calendar identifying slots for each unit to place staff for PI education.
• Offer PI education session during AprilFest 2011.
• Develop compliance survey to send out to managers quarterly.
PEER INTERVIEWING
NURSING STRATEGIC PLAN F2YRR GOALS MEASUREMENT STRATEGIES
TRANSFORMATIONAL LEADERSHIP AND PROFESSIONAL DEVELOPMENT(Provide current and future healthcare leaders and care providers the environment, tools, evidence and skill development to lead during a time of healthcare reform and transition.)
EVIDENCE-BASED PRACTICE AND EFFECTIVE PROCESSES(Lead nation in producing evidence that will drive nursing practice, recognizing and legitimizing the evolution of knowledge in a rapidly changing environment. Create passion and discipline for the translation of evidence into practice that will optimize patient outcomes.)
Rollout Buddy System strategy across inpatient units as best practice strategy for assisting with enculturation of new nurses.
2 units are currently using a Buddy System strategy.
Threshold Target Reach 25% 50% 75% (Inpatient units)
• Partner with Leader Development and Shared Governance Committees to develop curriculum for (inpatient) nursing leaders specific to the Buddy System. • Outline “must haves” for successful implementation.
• Complete evaluation of pilot units.
• Present pilot results to nursing leadership.
• Develop rollout plan with nursing leaders and educators.
• Develop compliance survey to send out to managers quarterly.
• Begin to develop strategies for implementation in ambulatory, procedural, ED, and Perioperative areas.
• Implement process in Children’s Hospital & VPH, ED’s
• Begin thinking about rolling out for other roles (Manager, CP, MR, PCT).
BUDDY SYSTEM FOR NEW NURSES
NURSING STRATEGIC PLAN F2YRR GOALS MEASUREMENT STRATEGIES
TRANSFORMATIONAL LEADERSHIP AND PROFESSIONAL DEVELOPMENT(Provide current and future healthcare leaders and care providers the environment, tools, evidence and skill development to lead during a time of healthcare reform and transition.)
EVIDENCE-BASED PRACTICE AND EFFECTIVE PROCESSES(Lead nation in producing evidence that will drive nursing practice, recognizing and legitmizing the evolution of knowledge in a rapidly changing environment. Create passion and discipline for the translation of evidence into practice that will optimize patient outcomes.)
Decrease turnover (nurses leaving VUMC)
Pillar Goals for turnoverThreshold Target Reach 12.5% 12% 11.5%
Partner with Leader Development and Shared Governance Committees to develop education for nursing.
Leaders: - Best practice - Creating environment that promotes career explorationStaff: on transfer process itself
• Finalize Transfer Process algorithm.
• Develop assessment questionnaire.
• Develop optional shadowing experience model.
• Provide career counseling through Nursing Education and Professional Development.
• Conduct pilot of Transfer Process.
• Evaluate pilot and share results.
TRANSFER PROCESS
Leader Development
Betty Sue Minton & Robin Steaban
2010 Goal: Develop recommendations for span of control
Accomplishments• Defined variables in that influence
span of control• Completed focus groups to identify
the work of the management team across the organization
• Consolidated and reviewed the data from the focus groups identifying the work that is transformational.
• Reconciled data with the behavioral rating scale.
Ongoing• Make a recommendation regarding
leadership team roles and responsibilities that are consistent with span of control.
• Quantify the work by area and develop leadership team models.
• Examine impact of span of control on outcome metrics such as turnover, staff satisfaction , NDNQI PES sores, financial performance, etc.
2011 Goal:Define the leadership model that is transformational and flexible with leadership competencies and a menu of tools.
2010 Goal: Implement manager behavioral rating tool consistent with job description.Develop scoring templates for other leader roles.
Accomplishments• Behavioral Rating scale was finalized
and implemented • Survey has been completed and will
be distributed in Dec. to evaluate the use of the tool at mid-year conversations.
Ongoing• Evaluate the use of the manager 5
point behavioral rating scale - revise and improve
• Complete performance assessment rating scale for assistant managers and charge nurses.
2011 Goal:Develop transformational leaders who can create and transform programs/products/environments to meet the patient population needs and VUMC organizational goals (People, Quality, Safety, Finances, Growth, and Innovation).
2010 Goal: Collaborate with HR and Recruitment related to strategies for recruiting and retaining managers
Accomplishments• On hold
Ongoing• Create a plan to begin this work
following implementation of behavioral rating scale.
2011 Goal:
2010 Goal: Develop collaborative working relationship with others in the organization, creating leader development opportunities
Accomplishments• Have a connection through
Workplace Learning collaborative to stay abreast of leader development opportunities
• Terry Minnen presented update on elevate and how it aligns with the efforts this group is overseeing.
Ongoing• Create a plan to begin this work
following implementation of behavioral rating scale.
• Map organizational learning opportunities to 5 point rating tool to assist managers to identify resources that will help them be successful
2011 Goal:Provide organizational learning opportunities for individual leaders and leadership teams to learn together and obtain or create tools to meet their desired objectives.
Maturing Workforce
Adrienne Ames & Susie Lyons
Maturing Workforce
• New focus for 2010• Conducted Gap Analysis• Phases of Maturing and Retirement• Identified targets for improvement• Retired Nurses Group
NURSING STRATEGIC PLAN MATURING
WORKFORCE GOALS
MEASUREMENT STRATEGIES
TRANSFORMATIONAL LEADERSHIP AND PROFESSIONAL DEVELOPMENTProvide current and future healthcare leaders and care providers the environment, tools, evidence and skill development to lead during a time of healthcare reform and transition.
Goal 1: Develop transformational leaders who can create and transform environments to meet patient population needs and VUMC organization goals. (People)Goal 2: Develop a recruitment and retention philosophy that supports flexible standard and consistent requirement for leadership practice.Goal 3: Provide organization learning opportunities for individual leaders and leadership teams to learn together and obtain or create tools to meet their desired objectives.
Create workplace that values and respects the contributions and expertise of the maturing worker and creates opportunities to strengthen the organizations commitment to and the retention of a maturing workforce.
Analyze workforce demographics and establish baseline metrics in various age groups of 50+ Turnover Satisfaction
o NDNQIo Employee
survey
Measure activity on Mature Workforce web site.
Hardwire exit interview of retired nurse Monitor, report trends and address
issuesInvolve nurses in Retired Nurses group Creating engaging agenda and activities Inform participants of Vanderbilt
initiatives and progress.Create and make available tools and information of interest to maturing population. Planning for retirement toolkit Job flexibility and job redesign options
Increase awareness of maturing worker to nursing management. Collaborate with Clinical Workforce
regarding flexibility and job design Increase volume of information and
tools on website
Create Advisory Group of senior employees Collaborate with each BTB committee to
determine needs from this population. Follow-up on suggestions/barriers
identified by group.
Nurse Wellness
Susan Hernandez & Diane Johnson
Goal 2010 AccomplishmentSupport the Wellness needs of a Multigenerational Nursing Staff
• Partnership with Health Plus to achieve 79% Nursing participation in Go for the Gold Wellness Program. Increased participation this year by 136 nurses.
• Partnership with Health Plus to Promote the Vanderbilt Farmers Market
• Partnership with Vanderbilt Child and Family Center to promote 2 back-up care options for adults and children: the Sitter Service and Parents in a Pinch.
• Increased nurse participation in the Wellness Commodores program
Goal 2010 AccomplishmentAdvocate for the Health and Wellness of Nurses by providing communication and education
Serve in an Advisory capacity to the Nurse Wellness Program
Promotion of Personal Safety• VUPD offered monthly self defense classes
from January to May. • The annual campus safety walk was not
conducted this year. Support of Healthy Behaviors• Flu shots -2008, 2,525 2009, 3,278-33% increase H1N1-2,215Provided Targeted Messages• Nurse Wellness Nurse Alerts subscribers
increased by 13% in 2010
Innovation• Hey Florence
Advocated• Work/Life Connections-EAP increased
psychological support services to nurses including support for those who suffered loss from the floods.
• Increased presence of Nurse Wellness Program/EAP to off site staff
2011 GoalsStrategic Goal Goal Action Plan Measurement
EBP and Effective Processes
Increase the percentage of nurses with a healthy BMI in an effort to decrease cost of care to the organization
• Spread awareness of current condition
• Identify unit based Wellness Commodores
• Educate nurses on ways to improve BMI
• Promote use of Health and Wellness programs offered by Vanderbilt
Percentage of nurses with healthy BMI. (will follow CDC guidelines)
Strategic Goal Goal Action Plan MeasurementEBP and Effective Processes/ Transformational Leadership
Achieve cultural change in an effort to decrease violence in the workplace
3 year phased plan• Year 1-Awareness
Campaign and education
• Year 1-Identify legislation and policy related to workplace violence
• Year 2- Creation of protocols/strategies to help
• Year 3-Implement identified strategies and measure effectiveness
• Pre and Post Survey of knowledge
• Leaders development of innovative strategies to address workplace violence
• Decrease in occurrence of workplace violence
2011 Goals
Strategic Goal Goal Action Plan MeasurementEBP and Effective Processes
Recommend needs and themes for future education and/or intervention
• Identify Wellness Commodores for units
• Support NWP participation in new leader orientation
• Support weekly rounds of NWP
• Support injury prevention efforts
• Increase # of Wellness Commodores across the organization
• Pre and post tests after educational offerings
• Increased use of NWP
• Increased compliance with use of Smooth Moves equipment
• Decreased patient handling injuries
2011 Goals
Shared Governance
Laura Beth Brown & Connie Ford
Goals 2010 Accomplishments
Work with Administrative Directors, Managers, and Staff to strengthen shared decision-making and accountability in improving the quality of care, safety and enhancing work life. Transformational leadership and professional development (provide current and future healthcare leaders and care providers the environment, tools, evidence and skill development to lead during a time of healthcare reform and transition)
Monitoring and Evaluation of Shared Governance
• Implementation of SG Dashboard to monitoro SG website utilization o SG Nurse Alerts
• Consideration of SG dashboard for the unit level
All SG workshop offerings now in LMS for registration. Evaluation of educational portfolio to determine methods for steamlining information and promoting shared governance across the enterprise
Developed 3 Dimensional Approach (Pilot in Adult and Children's Hospitals)
• Shared Decision Making Data• Employee Satisfaction• Elevate Coaching and Rounding
Continue to meet individually with areas as needed
Goals AccomplishmentsWork with Administrative Directors, Managers, and Staff to sustain a purposeful shared decision-making structure and process Evidence-based practice and effective processes(lead the nation in producing evidence that will drive nursing practice, recognizing and legitimizing the evolution of knowledge in a rapidly changing environment. Create passion and discipline for the translation of evidence into practice that will optimize patient outcomes.)
Unit Board Assessments (qualitative and quantitative).:• Outpatient CY2010• Inpatient CY2011
Gap Analysis of 2009 Inpatient Assessment Data continues with dissemination of information completed to all groups in May
Operationalized Clinical Dispute Resolution Panel• On-going education-nine RN3s, RN4s, APNs trained in
March• Panel to be deployed as needed• Evaluate process following panel meetings
Comprehensive review of VUMC SG nursing leadership structure
• NEB, NAB, and entity NLBs Jan – April• Completed Review of Committee/Council/Board
Charters and • Produced flying saucer graphic of our nursing
enterprise Successful Bylaws Convention November 16, 2010
• 4 Substantive Amendments recommended by the Boards, Councils, Committees and delegate retreat representatives
• The composition of the Unit Clinic Boards includes Administrative Directors
• The addition of the Entity Nursing Leadership Board to our Bylaws and established Medical Center Nursing Leadership Board
• The Shared Governance Committee becomes a Standing Committee of the Nursing Staff Bylaws.
Goals AccomplishmentsWork with Administrative Directors, Managers, and Staff to sustain a purposeful shared decision-making structure and process Evidence-based practice and effective processes(lead the nation in producing evidence that will drive nursing practice, recognizing and legitimizing the evolution of knowledge in a rapidly changing environment. Create passion and discipline for the translation of evidence into practice that will optimize patient outcomes.)
Agenda Crashers!!
• 6 NEB Meetings
• 1 NAB Meeting
• 8 ECNO Face to Face Meetings
• Entity NLBS
• 4 Staff Council Meetings
• 2 Staff Council Cabinet Meetings
Nursing Strategic Plan SGTF Goals SGTF Tactics to accomplish
Transformational leadership and professional development (provide current and future healthcare leaders and care providers the environment, tools, evidence and skill development to lead during a time of healthcare reform and transition)
Measurable:I have the opportunity to participate in decisions made by the person I report to that affect my work environmentTh 68% T 69% R 71%
I feel free to go to a higher boss than the person I report to for discussing any problems that are bothering meTh 56% T 59% R 62%
Turnover RateTh 12% T 11% R 10%
Goal:Work with Organizational Leaders, Managers, and Staff to build and optimize shared decision-making and accountability in improving the quality of care, safety and enhancing work life.
Goal : Understand and design systems to maximize the benefit and utilize the full talents of the health care team.
• Gap Analysis • Pilot • Pre and Post Measurement
Partner with Organizational Development Specialist to create 3 Dimensional Approach
• Elevate-coaching• HR-Satisfaction• SG-decision making
Monitoring and Evaluation of Work
• Dashboard Implementation• Turnover Analysis
Collaborate with Leader Development Task Force on leadership initiative
• Health of the Unit
Nursing Strategic Plan SGTF Goals SGTF Tactics to accomplishEvidence-based practice and effective processes(lead the nation in producing evidence that will drive nursing practice, recognizing and legitimizing the evolution of knowledge in a rapidly changing environment. Create passion and discipline for the translation of evidence into practice that will optimize patient outcomes.)
Measurable:Improve Outpatient Unit Board Chair Election process:Th 65% T 75% R 80%
Improve Outpatient participation in survey process: Th 425 T 500 R 600
I have the opportunity to participate in decisions made by the person I report to that affect my work environmentRN Th 68% T 69% R 71%LPN Th 64% T 69% R 71%
GOAL :Work with Organizational Leaders to expand shared decision-making structure and process
Develop and Implement Pilot 3 Dimensional Approach {Adult and Children's Hospitals}
• Shared Decision Making Data
• Employee Satisfaction• Elevate Coaching and
Rounding
Gap Analysis of Data
Unit Board Assessments (qualitative and quantitative).:
• Outpatient CY2010• Inpatient CY2011
OperationalizeClinical Dispute Resolution Panel
• On-going education• Deploy panel as needed• Evaluate process following
panel meetings
Nursing Strategic Plan SGTF Goals SGTF Tactics to accomplishEvidence-based practice and effective processes(lead the nation in producing evidence that will drive nursing practice, recognizing and legitimizing the evolution of knowledge in a rapidly changing environment. Create passion and discipline for the translation of evidence into practice that will optimize patient outcomes.)
Measurable:Complete SG Education Portfolio redesign
Improve participation and communication via web portal: Average page views/month Th 200 T 350 R 500
Improve to .70 of expected mortality rate
GOAL :Work with Organizational Leaders to expand shared decision-making structure and process
Nursing Bylaws to BOT for approval
Redesign SG Education Portfolio Initiate development SG/Board Basics modules for online learning via LMSPartner with Education Experts and BTB Chairs on combined learning experiences that include staff nurses.
Plan/execute Bylaws Convention• Implement approved SG
structure for VUMC Nursing leadership boards
• Ensure alignment across the enterprise
• Understand the impact and coordinate skill set with the work
o Organizational Development Leader position
Collaborate with Nursing Research and CCI on Quality Initiatives
• Implement standing agenda item for UB’s related to system quality initiative
Service Improvement
Brent Lemonds & Todd Reimer
Service Improvement
PURPOSE
To identify and resolve issues hindering/preventing faculty and staff from doing their bedside duties that ultimately impacts meeting the needs of our patients and their families.
Major Accomplishments
• Mapped all Measureable Outcomes to Pillars and Nursing Goals
• Food Service• Using CCI Consultant to Implement Lean Principles to
Performance Improvement – Scores went Up !!
• EVS & Patient Transportation• Continued results improvement• Implemented Teletracking for Dashboard results
SERVICE IMPROVEMENT COMMITTEE
SEMI-ANNUAL REPORT
Brent LemondsTodd Reimer
GOALS ACCOMPLISHMENTS ONGOING WORKMaintain Scorecard, Reporting Track Metrics, and Facilitate Course Corrections as a Team
2009- Established Service Agreements with all service areas between service departments and nursing areas.
Establish New Metric for Admitting ? Early morning admitting times
Communicate with Manager's Council
2010 -Teletracker in place. Steady improvement noted in Patient Transport. Meeting metrics in Linen Services, Information Systems, Supplies/Equipment, Bed Delivery.
Establish New Metric for Bed Management ? Patient fall off queue in three days
2009 Identified responsibilities between units and service areas for equipment/area cleaning
Requested CCI Consult for Nutrition Services 6/2010 due to no progress toward meeting metricsPoint of Use System installation to improve supply distribution.
Patient Transport SubcommitteeAccomplishments• Hired Additional Staff• Increased Patients Transported by
Patient Transport to 81% of discharges to home.
• 75% of transports are completed within 35 minutes
• Average transport time is 28 minutes
Service Standard• Patient will be ready for transport
when transporter arrives for patient– (Service – overall teamwork;
Quality of Care)• Patient Transport will complete all
transports within 35 minutes – (Service, Quality of Care)
• Decrease the number of Bed Transport Tracking, increase stretcher transports.– (Service – improve efficiency,
Overall Teamwork, VUMC Results of Operations)
Environment SubcommitteeAccomplishments• Average response time is 27 minutes.• Average cleaning time 34 minutes.• The turn around time from when the
patient is discharged till the room is ready has been an average of 61 minutes.
Service Standard• Turnaround time completed
within 90 minutes during peak hours of 1-8 pm.– Service – meeting volumes,
Quality of Care• Isolation rooms will be completed
within 2 hours from central dispatch notification– Service, Quality of Care, Meeting
Volumes
Nutrition Services
Accomplishments• Lean Management Improvements• Metrics went “green” on
scorecard
Service Standard• Meal Rounds. Visit 7% of the
patient Population.• Service – Patient Satisfaction
• Food is rated excellent 19% of the time.• Service – Patient Satisfaction
• Test Tray scores will be at 90% or better.• Service - Quality
• At your Request Service Trays will be delivered to patient within 44 minutes.• Service - Timeliness
Materials Management
Accomplishments• Preparing to implement Point of
Use
• Linen services preparing to provide manager statistics through on-line portal
Service Standards• Turn around time for supplies 20
minutes 90% of the time. • Linen items available on each unit
98% of the time.
Equipment SubcommitteeAccomplishments Service Standard
• Delivery of product after request made to Service Center within 20 minutes 95% of the time.– Service – Teamwork– Finance - Volumes
• Delivery of owned specialty bed after call is placed to the Service Center within 30 minutes (if beds are available) 90% of the time.– Service – Quality of Care
ED Registration, Admitting, Bed Management
Accomplishments• Met previous metrics• Determining New Metrics
Service Standards• Phone calls answered by
designated response 88% of the time.
• Calls requiring transfer will follow protocol 88% of the time.
Evaluation
Nancy Wells
Overall Goal
Recruit and retain excellent professional nurses
Annual RN Turnover
2005-06 2006-07 2007-08 2008-09 2009-100
2
4
6
8
10
12
14
16
18
Perc
ent o
f Tur
nove
r
NationalBenchmark
Data SourcesSource Date SampleStaff Satisfaction Survey Fall 2009 2358Unit Board Assessment Fall 2009 503NDNQI RN Satisfaction Survey Summer 2010 2288
Job Plans for Next Year
Job Plans VUMC 2010 AMC
Remain in direct care at hospital
90 88
Direct care at a different hospital
4 5
Leave direct care 4 4
Change careers 1 1
Retire 0 1
NDNQI RN Survey 2010
Nurse Residency Recruitment
Summer 2008 Winter 2009 Summer 2009 Winter 2010 Summer 20100
50
100
150
200
250
191
117 114129
160
Num
ber o
f Rec
ruits
Nurse Resident RetentionDuration of Employment Retention
12 months 90%18 months 80%
Developing Leaders
• Frontline Leadership Academy– Staff and charge nurse development
• S3 – Charge nurse development
• E3 – Manger development
Nurse Manager Ability
VUMC AMC 90th1
1.5
2
2.5
3
3.5
4
20082010
NDNQI RN Satisfaction Survey 2010
Mea
n Sc
ale
Recognition for a Job Well Done
Best in Class
VUMC
RN
0 20 40 60 80 100
Staff Satisfaction Survey 2009
Percent Favorable
Staffing & Resource Advocacy
VUMC AMC 90th1
1.5
2
2.5
3
3.5
4
20082010
NDNQI RN Satisfaction Survey 2010
Mea
n Sc
ale
Enough People Available to Accomplish Necessary Workload
Best in Class
VUMC
RN
0 20 40 60 80 100
Staff Satisfaction Survey 2009
Percent Favorable
Change in Overtime Worked
VUMC 2010 AMC
-0.5
-0.4
-0.3
-0.2
-0.1
0
0.1
0.2
0.3
0.4
0.5
Series 1
NDNQI RN Satisfaction Survey 2010
Mea
n Sc
ale
Use of EAP Program by Nurses
00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-100
50
100
150
200
250
300
350
6676
107
135 138
198218 228
211
292
Num
ber o
f Con
sults
Had Enough People to Lift/Move
2010 AMC 90th 0
20
40
60
80
100
NDNQI RN Satisfaction Survey 2010
Perc
ent
Yes
Nurse Participation in Hospital Affairs
VUMC AMC 90th1
1.5
2
2.5
3
3.5
4
20082010
NDNQI RN Satisfaction Survey 2010
Mea
n S
cale
Good Communication Among Work Group
Best in Class
VUMC
RN
0 20 40 60 80 100
Staff Satisfaction Survey 2009
Percent Favorable
Opportunity to Participate in Decisions
Best in Class
VUMC
RN
0 20 40 60 80 100
Staff Satisfaction Survey 2009
Percent Favorable
Inpatient Unit Board Assessments
Year Unit Interviews
Surveys Completed
All Nurses2003 38 982 5272005 44 586 4082007 39 662 4512009 39 790 503
Percent of Units with Unit Boards
2003 2005 2007 20090
20
40
60
80
100
68
97 95 97
Unit Board Assessments 2003 - 09
Perc
ent
Group Cohesion Over Time
2003 2005 2007 20091
2
3
4
5
6
7
Unit Board Assessments 2003 - 09
Mea
n S
cale
Satisfied with Involvement in Decisions
2005 2007 20091
2
3
4
5
Unit Board Assessments 2003 - 2009
Mea
n S
cale
Decisional Involvement Scale
2007 20091
2
3
4
5
2.262.09
2.74 2.67
ActualPreferred
Unit Board Assessments 2007 - 09
Mea
n S
cale
Collaborative Decision Making
Work Group Values Diversity
2005 2007 20091
2
3
4
5
Series 1
Unit Board Assessments 2003 - 2009
Mea
n S
cale
Striving toReach the
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