SM Nursing Mission : Deliver leading-edge patient care, research and education by utilizing SMH Nursing’s Professional Practice Model as a guide.
SM Nursing Vision : Through the Art of Nursing, we strive to heal humankind, one patient at a time, by delivering care that is grounded on the Relationship-based Care Model. Page 5 of 6
Meeting: / Exemplary Professional Practice / Date Time: / Monday, July 11, 2016 @ 1200-1500Purpose: / Ensure the demonstration of exemplary nursing practice with patients, families, communities, and the interdisciplinary team at SMUCLA by: upholding the PPM; creating structures that ensure access to information, resources, and support; cultivate a culture of safety; equip nursing staff with a comprehensive understanding of the role of nursing. / Location: / Conference Room 1-2
Chair:
Chair since: / Danielle Greenacre, RN, BSN, CNII
Since April 2016 / Co-chair:
Co-chair since: / Heather Dodge, RN, BSN, CNII
Since April 2016
Electronic sign in – be sure to scan in your badge or ask one of the admins for assistance. You need to have a sub if you cannot attend.
Topic / Person reporting / Action Summary / PPM / Next step / Owned by / Items status
(mark one with x) /
EPP Element /
Review Minutes and General Announcements
(5 mins)
12:15-12:20 / Heather Dodge (filling in for Danielle Greenacre) / · Review EPP council minutes from last meeting including progress on outstanding business. Minutes approved as reviewed by council.
· Introduction of new members.
· Review of expectations:
Consistent attendance by assigned reps every month – Members will utilize their badge to sign in during meeting
Approve: Diane Shao
Announcement of new EPP members: Pete Zimak joins Peer Review, Eusonne Joy Deloslado and Robert Yeranosyan join Infection Prevention and Stephanie Hines takes over lead for EPP UD Mentor. EPP Council also announces that SM UCLA is officially magnet designated.
Leah Korkis accepts role as “Nursing Practice Outcomes & Magnet Coordinator.” / Goal: Members will check if their names are spelled correctly, input credentials, and add Month/Year of joining EPP.
Goal: Members to return folders in a box
Goal: Make sure everyone checks in for attendance. / Standing Item
In-Progress
Complete X
Dashboard Data Review
(10 mins)
12:20-12:30 / Ksenia Kurnakova / Magnet Outcomes
· Hospital Dashboard updates
· Review UCLA SM Overall Audit Dashboard
· Demonstration of Unit-specific Quick Trend Report from Press Ganey Website
· Nurse-sensitive clinical indicators:
1. Falls and Falls with Injury
2. HAPU stages 2 and above
3. Central Line Associated Bloodstream Infections (CLABSI)
4. Catheter Association Urinary tract infections (CAUTI)
5. Patient satisfaction data
In June, we had 3 cases of CLABSI (SIR=1.06, benchmark=1.00) and no cases of CAUTI (SIR=0.00, benchmark=1.00). Additionally, there were 16 inpatient falls with 2 resulting in minor injuries. No HAPU’s were identified.In FY16, we improved and sustained patient experience scores on Nurse Communication and Pain domains. Discharge is likely to be the area of focus in FY17 / 3,4,5,6 / Goal: Identify the progress of our hospital. / Standing Item
1,2,3,4,5,6 / In-Progress
Complete X
Subcommittee Rounds
(115 mins)
12:30 -14:25 / Subgroup Leads / Perform Floor Audits.
1. Pain
One of the most common complaints through Press Ganey patient feedback reports are painful phlebotomy PIV sticks and nursing PIV sticks.
Pain subcommittee continues to provide feedback to Yan in IT to improve automated pain system audits so pain group members do not have to enter audits manually.
Pain subcommittee focuses primarily on documenting pain however would like to address and focus on creating a standard of practice for documentation as a whole.
New PCA/PCEA policy being worked on
2. Infection Prevention
Mary Lawanson-Nichols presented mini-causals for CLABSI in ICU.
Infection prevention team has compiled CLABSI audit data – once compliance data is > 95% IP team will revise questions. Compiled data is as follows: In June 87 charts were audited. For ”CVC dressings were changed within 7 days” we were 100% compliant; for “curos caps in place on unused ports” we were 86% compliant, and for CHG bath treatment performed within the last 3 days we were 92% compliant.
3. Fall Prevention
July fall prevention subcommittee data as follows for 4NW and 5MN (new bed cables):
Armband on: 66%, Fall sign on door: 86%, Safety precautions in place: 91%, Bed connection available 91%, Wall and bed connection attached 77% (100% of beds audited on 4NW; bed cable installation on 5MN not completed), Alarm activated 30.5%, Patient’s understands fall risk plan 100%, Door open 84%
Discussed new questions added to “post-fall” huddle form, to help track patient refusals of fall precautions.
“Falls Promise” flyer discussed. This flyer will be used for high risk patient “teach back” and will be a reinforcement tool.
Bathroom Fall Sign
All RN/CP will enroll in “improving patient outcomes” class. RNs earn 4.5 hours of CEUs after completing on line evaluation.
Avasure (tele-sitting) approved to roll-out.
“CAM” (5NW, 5MN, ICU use this tool)
New Bed connections and wall cables in place. New transport process “gurney only” rolled out– beds to be left in rooms to make sure bed alarm cables stay intact.
4. Peer Review
Michele reviewed ED meeting etiquette and subgroup binders.
Subcommittee received feedback regarding follow-up letter. Kim had one-on-one meeting to discuss group recommendations.
A case regarding the care of a patient at end-of-life was reviewed. Pain management was concerned relating to appropriate pain assessment and delayed intervention. / 3,4,5,6 / 1. Vascular access committee is in progress working on protocol utilizing “JTip.”
Yan to implement changes to automated audit system.
EPP pain members will discuss at next EPP meeting on August 1st with David Bailey & Jill Scherrey
Health System pain committee is working on revising policy
More data to be compiled; questions will be revised when compliance is greater than 95%. IP team will revise Care Connect question to include “port” on CVCs. Questions for ED/IR/OR and PACU coming.
Fall prevention team will continue to collect data and perform audits to track our success on fall prevention.
Pending availability on forms portal. Betty Lee will f/u.
David Bailey to f/u with color copies to be available for the “My Care Folder.”
Betty Lee will f/u with pre/post fall rates for 4SW (pilot unit)
RNs/CP to enroll.
Guidelines and IT/ISS need to be established.
Need MD collaboration; David Bailey to f/u.
Continue to use “gurney only” rule
Case follow-up letter will now have all participants to assure that recipients know that the group has received the same recommendations.
If a patient at the end of their life isn’t able to verbalize their pain using the 0-10 pain scale, the next best pain scale is PAINAD.
For this case the Peer Review team will follow-up with pharmacy on availability of meds; RNs needs of education on pain documentation; change of shift communication (break relief as well) needs to be better; pharmacy will be added to committee, and end-of-life order set to be implemented. / Standing Item
1,3,4,6 / In-Progress X
Complete
Subcommittee Report-back
(30 min)
14:25-14:55 / Subgroup Leads / Expectations for each meeting’s documentation:
a) Each subcommittee is to report back progress on their interventions using hospital-wide dashboards and FOCUS PDCA’s. (See action summary above for each subcommittee).
b) Each subgroup leader to fill out bullet point worksheet and give to co-chair upon returning from rounds. / 5 / Goal: Subcommittees will share what they have learned from audits and their steps going forward. / Standing Item
In-Progress
1,2,3,4,5,6 / Complete X
Next Meeting: Next meeting will be held Monday August 1, 2016 from 12-3pm in Conference 1 & 2. / Parking Lot: Overview of New My Care Folders and Focus PDCAs
/ 1. PPM / 2. Care Delivery System / 3. Interdisciplinary Care / 4. Accountability, Competence, & Autonomy / 5. Ethics, Privacy, Security, & Confidentiality / 6. Culture of Safety & Quality of Care
Development, implementation and evaluation of the PPM / Create partnerships with patients and families; incorporate standards/guidelines into the care delivery; Evaluate organizations standards; use internal/external experts to improve clinical setting / Provide leadership opportunities in collaborative interdisciplinary activities / Provide resources to support decision making in autonomous nursing practice; perform nursing peer case reviews, support and promote nurse autonomy / Encourage use of available resources to address ethical issues / Evaluate and improve workplace safety; involve nurses in facility-wide proactive risk assessment and error management; review, action-plan, and evaluate patient safety data and patient safety goals; monitor clinical indicators and patient experience data.
/ 1. Patient, Family, Community / 2. Relationship-Based Care Model / 3. Leader / 4. Scientist / 5. Transferor of Knowledge / 6. Practitioner
Patient and family centered care. / Dr. Watson’s theory of human caring and Dr. Swanson’s five caring processes. / A self-directed decision maker, focused on the improvement of quality and safety outcomes for patients or patient populations. / Conducts research and quality improvement initiatives through EBP FOCUS-PDCA. / Guide colleagues, patients and family members through the learning process and document the outcomes of educational program. / Provide quality care to patients throughout the lifespan.
EPP Council Members
Infection Prevention
Emergency Department: Kayla Reynolds, RN, BSN, CNII, CEN (Member since June 2014, Infection Prevention Lead)
4CW: Mary Lawanson-Nichols, MSN, CCRN, CNS (Member since 2013, Infection Prevention Mentor)
4CW: Danielle Greenacre, RN, BSN, CNII (Member since November 2013, EPP Chair)
5NW: Rosalie A. Silva, RN-BC, BA, CNIII (Member since August 2013)
5MN: Patty Sheehan¸ RN, MN, CNS (Member since the start of EPP)
PACU/PTU: Michelle Dixon, RN, BSN, ANI, CPAN (Member since June 2015)
Resource Team: Mary Ellen Blakley, RN, MS, ANII (Member since November 2013)
Infection Prevention: Alisa Trout, RN, BSN (Member since July 2015)
Infection Prevention: Mary Claire Horkay credentials? (Member since July 2015)
IOF: Robert Yeranosyan, RN, BSN (Member since July 2016)
Float Pool: Eusonne Joy Deloslado, RN, BSN (Member since July 2016)
Unit?: Tali Leitner, MSN, CPN, BSN, RN (Member since December 2015)
Pain
3NW: Yuki Arai, RN II BSN (member since June 2016)
Acute/Chronic: Irma Tan (credentials, Pain Mentor)
4SW: Kristin Sy, RN, BSN (Member since July 2015)
4NW: Anna Nichik, RN, BSN (Member since July 2014-Pain Lead)
4MN: Heather Dodge, RN, BSN (Member since December 2014 - EPP Co-Chair)
5MN: Darya Ratliff, RN (Member since November 2013)
6NW: Diane Kui, BSN, MSN, CPN, CNII (Member since September 2013)
Administration: Ksenia Kurnakova, MPH, Senior Analyst (Member since November 2013)
PACU/PTU: Clara Chavez, RN, CNII (Member since August 2012)
IR/Cardiac Cath Lab: Sandra Losasso, RN III BSN (member since June 2016)
Peer Review
2SWW: Denise Scalercio-Ribeiro, RN, AND, BA, MA, RNC-NIC, CNIII (Member since 2013, Peer Review Clinical Nurse Lead)
Administration: Leah Korkis, RN, MSN, CNII, Magnet Coordinator (Member since September 2013, Peer Review Admin Mentor)
5NW: Anila Ladak, RN, MSN, CNS (Member since start of EPP, Peer Review CNS Mentor)
NICU: Stephanie Hines, RN, MSN, CCRN (Member since July 2016)
2MN: Diane Shao, RN, ADN, ANI, (Member since 2012)
2MN: Susan Nolan, RN, BSN, CNIII (Member since 2012)
Operating Room: Kim Young S., RN, BSN, CNII, MSN, CNOR (Member since July 2014)
Resource/Float Pool: Nicole Pfiester RN II, BSN
Quality: Sharron Hickey, RN, BSN, PHN, Quality Management Specialist (Member since September 2014)
ED: Pete Zimak, credentials? (Member since July 2016)
Falls
4MN: Betty Lee, RN, MN, CNS, CMSRN (Member since start of EPP, Falls Lead)
4MN: James Fernando, RN, BSN (Member since 2016)
Physical Medicine: Trena Carpenter, PT (Member since start of EPP)
4NW: Margaret Cabreros, RN II, BSN, PHN (Member since 2016)
5NW: Christina Richner RN, BSN, RN-BC, CN II (Member since May 2015)
5MN: Jamie Hughes credentials? (Member since September 2015)
Quality: Anet Sinanyan, BS, MHA, CPHQ, Sr Patient Safety Specialist (Member since 2012)
Quality: Nathaniel Lacasse credentials?, Quality Management Specialist (Member since May 2015)
IOF: Philip Tu, RN, MSN, MBA, ANII (Member since 2015)
Administration: David Bailey, MSN, RN, MBA, CCRN-CMC, NEA, BC, Interim Director of Nursing (Member since November 2013, Falls Mentor)
3NW: Sinval DePaula RN (Member since July 2016)
This document is located on the Nursing shared drive. To access it, go to the W drive, open SMH Nursing Leadership folder and click on Agenda-Minutes Template.