Recognized Excellence, Designated Magnet VUMC Nursing December 2010

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


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


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.


• 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



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



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


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


Mea

n Sc

ale

Enough People Available to Accomplish Necessary Workload

Best in Class

VUMC

RN

0 20 40 60 80 100


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


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


Perc

ent

Yes

Nurse Participation in Hospital Affairs

VUMC AMC 90th1

1.5

2

2.5

3

3.5

4

20082010


Mea

n S

cale

Good Communication Among Work Group

Best in Class

VUMC

RN

0 20 40 60 80 100


Percent Favorable

Opportunity to Participate in Decisions

Best in Class

VUMC

RN

0 20 40 60 80 100


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


Mea

n S

cale

Satisfied with Involvement in Decisions

2005 2007 20091

2

3

4

5


Mea

n S

cale

Decisional Involvement Scale

2007 20091

2

3

4

5

2.262.09

2.74 2.67

ActualPreferred


Mea

n S

cale

Collaborative Decision Making

Work Group Values Diversity

2005 2007 20091

2

3

4

5

Series 1


Mea

n S

cale

Striving toReach the

top

Documents

Recognized Excellence, Designated Magnet VUMC Nursing December 2010