Sparrow Nurses | 2016 Nurses Annual Reportsparrowannualreport.org/Nursing-Annual-Report-2016.pdf2016 Sparrow Nurses Annual Report Table of Contents Sparrow Nursing Leadership Sparrow

Sparrow Nurses | 2016 Nurses Annual Report 1Sparrow Nurses | 2016 Nurses Annual Report

2016 Sparrow Nurses Annual ReportTable of Contents

Sparrow Nursing Leadership Sparrow Leadership 2015

Professional Practice Component Sparrow Nurses Provide Patient-Centered Care

Transformational Leadership Sparrow Nurses Display Transformational Leadership

Care Delivery System Sparrow Nurses Deliver Evidence-Based, Individualized Care

Collaborative Practice Sparrow Nurses Collaborate to Streamline Care Delivery

Professional Growth Sparrow Nurses are Committed to Professional Growth and Development

The Process Component Sparrow Nurses Demonstrate Attention to Professional Practice Processes

The Primary Outcomes Component Sparrow Nurses Follow the Sparrow Way to Achieve Primary Outcomes

The Strategic Outcomes Component Sparrow Nurses Strive to be National Leaders in Quality and Patient Experience

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Solange Ngantchui, RN Intermediate Medical Care, Sparrow Hospital

Wendy Embs, BSN, RN Emergency Department, Sparrow Clinton Hospital

Sparrow Nurses | 2016 Nurses Annual Report4

VICE PRESIDENT OF NURSING, SPARROW HOSPITALChristine Jodoin, MSN, RN, NE-BC

CHIEF NURSING OFFICER, SPARROW IONIA HOSPITALLinda Reetz, MBA, BSN, RN, NE-BC

CHIEF NURSING OFFICER, SPARROW CLINTON HOSPITALBeth Anne Daugherty, MPH, BSN, RN, CRRN

CHIEF NURSING OFFICER & COO, SPARROW CARSON HOSPITALBarbara McQuillan, MSA, BSN, RN

CHIEF NURSING OFFICER, SPARROW SPECIALTY HOSPITAL Tina Gross, MSN, BAS, RN, SANE

and occurs one nurse and one patient, family, or community at a time. The encounter between a nurse and patient forms a fundamental bond that defines, not only nursing as a profession, but each individual nurse as a provider of care. Nursing practice drives value, and nurses have a direct and intimate influence on the quality, safety, and costs of patient-centered care.

Nursing is a practice discipline

The value that nurses bring to our reforming healthcare system is essential.

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“SENIOR VICE PRESIDENT AND CHIEF NURSING OFFICER, Mary Lou Wesley, MSN, RN

Sparrow’s Nursing leadership would like to thank all of our academic partners, especially Michigan State University and Lansing Community College. A special thank you to our Nursing union partners: Michigan Nurses Association (PECSH-MNA); International Union of Electronic, Electrical, Salaried, Machine-Furniture Workers-Communications Workers of America AFL-CIO, CLC Local 84444 (IEU); and Healthcare Michigan Service Employees’ International Union, Nursing Unit (SEIU).


Kisha Naval, RN (left); Surgical Specialties, Sparrow Hospital Ed Ash, BA, BSN, CCRN (right); ICU, Sparrow Hospital

Professional Practice ComponentSparrow Nurses Provide Patient-Centered Care

Transformational Model of Professional PracticeThe Transformational Model of Professional Practice highlights the distinguishing principles of a Sparrow Nurse and how that role relates with Patients, the community, and the entire Sparrow team. This model emphasizes critical thinking, accountability, and individualized Patient care. Sparrow Nurses continually review their professional practice processes to ensure that their leadership, care delivery, collaboration, and professional development efforts meet the needs of each Patient and focus on high Patient experience and quality outcomes. The model does not just outline and guide the professional Nurse, but rather defines what that professional Nurse can achieve.

Ashely Sweet, BSN, RN-BC, PCCN (left); Nursing Education and Practice, Sparrow Hospital

Abby Scott, BSN, RN, (right); Medical Surgical, Sparrow Hospital

Anita Moller, BSN, RN, CNOR; Surgery, Sparrow Hospital


Sparrow Nurses are empowered to take ownership for their practice; this is the basis for accountable Nursing care and the achievement of primary and strategic outcomes.

Sparrow Nurses Act as Transformational Leaders

» Serve as champions for Patient experience and quality improvement initiatives

» Participate in the Professional Advancement System

» Contribute to Nursing Strategic Planning » Serve as Charge Nurses » Take part in shared decision-making, including

unit-based and hospital-wide Nursing Councils » Mentor peers

» Teach Charge Nurse Development Workshops » Participate in Aspiring Nurse Leader Programs » Serve as preceptors » Serve as clinical mentors on the Dedicated

Education Unit » Chair councils and committees » Participate in secession planning » Take part in evidence-based practice fellowships

Transformational LeadershipSparrow Nurses Display Transformational Leadership

Nikki Pierson, BSN, RN; Nursing Administration, Sparrow Hospital

Sparrow Nurses | 2016 Nurses Annual Report 9

Shared GovernanceShared governance has been identified as leading to higher caregiver and Patient satisfaction, better Patient safety, shorter lengths of stay and improved quality outcomes. It is one of the core components of Nursing at Sparrow. This decision-making structure empowers nurses by ensuring that those at the point of care control and influence their professional practice. The Nursing Council structure includes Unit-Based Councils, Service Lines, Quality, Professional Development, Practice, Research, and Leadership Councils. Nurse participation at Council and Committee levels ensure that Nurses have a voice in the decisions that impact the work they do each day.

Ashley Liniger, BSN, RN Intermediate Float, Sparrow Hospital

Kisha Naval, RN Surgical Specialties, Sparrow Hospital

Ashley Sweet, BSN, RN-NC, PCCN Nursing Education and Practice, Sparrow Hospital

Sparrow Ionia Hospital: Surgery Department Unit-Based Council

In October 2016, the Surgery Department had the rare opportunity to care for a pediatric Patient, which is not the typical surgical population at SIH. The standard of care is to have two licensed providers at the head of the bed for post-operative recovery. Due to the infrequency and unfamiliarity of taking care of pediatric Patients, Justin Thomas, RN, took ownership and accountability and made the recommendation at a UBC meeting for all nurses to obtain Pediatric Advanced Life Support (PALS) certification. Kim Dora, RN, took the initiative to request a PALS class for all surgery Nurses to attend together. In December 2016, eight of 10 registered nurses (RNs) from the Surgery Department obtained their PALS certification, including the Manager, Amanda Martin, BSN, RN. This exemplifies ownership and accountability of direct care Nurses.


Sparrow’s Commitment

Every action we take is meant to reflect the highest standard of safe practice for the most optimal outcome. We demonstrate this operationally in our bundles of care/protocols and our communication. An example of this commitment is the October 2015 launching of the Sparrow Oral Care Project in which all Patients admitted to the hospital now receive

an improved set of oral health care supplies and education to improve oral hygiene and reduce cases of hospital-acquired pneumonia (HAP) at Sparrow Hospital. Nationally, HAP is associated with increased lengths of stay, increased care costs and poorer Patient outcomes. The program was sparked by the evidence-based practice work of Sparrow Nurses

Mary-Kathryn Medei, Brooke Wood, and Chastity Warren and brought to fruition through the generous support of the Delta Dental and Sparrow Foundations. Thanks to the efforts of many, we are helping improve the health of the people of the mid-Michigan region.

Sparrow Nurses are getting national attention for improving the pediatric care delivery environment.

Sparrow Nurses are committed to identifying and implementing new evidence to improve nursing care. We subscribe to national and state initiatives to perfect our practice: The Institute for Healthcare Improvement, The Advisory Board Company, Michigan Hospital Association Keystone initiative and much more.

Care Delivery SystemSparrow Nurses Deliver Evidence-Based, Individualized Care

Callie O’Keefe, BSN, RNC-INC; Neonatal ICU, Sparrow Hospital


Jamie Dykeman, BSN, RN; Pediatrics, Sparrow Hospital

Nationally, the increased use of technology to monitor Patients also has led to a rise in false and nuisance alarms that aren’t related to the Patient’s condition, but instead are caused by the monitoring equipment. Frequent alarms cause fatigue, distract from alarms that are significant to the Patient’s condition and pull attention away from the Patient. Through the Center for Innovation and Research, a collaboration between Sparrow and Michigan State University, Nurse Researchers sought to determine if measures effective in reducing alarm fatigue for adult Patients would also work for infants. As a result, Sparrow’s Regional Neonatal Intensive Care Unit (RNICU) experienced a 50 percent reduction in false and nuisance alarms. The research team presented its

findings at several academic and medical conferences in the fall of 2015, including the prestigious Vermont Oxford Network annual neonatal quality forum in Chicago.

Ismaila Lasisi, BSN, RN Nursing, Sparrow Specialty Hospital


Many examples of collaborative practice can be found in action on the 6th floor of Sparrow Hospital where highly specialized inpatient rehabilitative care is provided for Patients with physically disabling conditions due to stroke, head injury, arthritis, amputation, spinal cord injury, or other musculoskeletal and nervous system disorders. These rehabilitation services are strengthened by the joint venture between Sparrow Hospital and Mary Free Bed Rehabilitation Hospital which was solidified in 2015.

Here, Nurses collaborate with the Patient and their family as well as providers, therapists, and discharge planners to systematically create individualized care plans to maximize each Patient’s functional abilities.

Patient-centered care is essential to the Patient experience and our care delivery model. Sparrow Nurses team with their peer professionals (Physicians, Physical Therapists, Occupational Therapists, Speech Therapists, Respiratory Therapists, Social Workers and many ancillary services) in caring for our Patients.

Collaborative PracticeSparrow Nurses Collaborate to Streamline Care DeliveryAnita Moller, BSN, RN, CNOR (left); Surgery, Sparrow HospitalMegan Kiest, RN (middle); Emergency Department, Sparrow Hospital

Alex Gill, MD (right); RPGY-2 EM Resident, Sparrow Hospital

Kerrie Pasini, RN IT Analytics, Sparrow Hospital


Ann Wilson, MSN, RN, CHPN; Hospice House, Sparrow Hospital


Sparrow Nurses are committed to professional growth and development as an essential component to attain nursing excellence and to provide the highest standards and best practices of Patient-centered care. The pursuit of higher levels of formal education among Nurses has been shown in research to have an impact on Patient quality care and safety outcomes. Sparrow strongly supports Nurses pursuing higher education and provides opportunities and incentives for doing so. Sparrow Nurses advance their expertise through formal education in a variety of specialties. For example, some Sparrow Nurses are master’s degree

Nurse Practitioners, Clinical Nurse Specialists, Clinical Nurse Leaders, Nurse Anesthetists, Nurse Educators and Nurse Administrators. Sparrow also has doctorate-prepared Nurses in some areas. To help ensure that we have the workforce needed to keep up with the changing demands of healthcare, Sparrow has created cohorts to help Sparrow Nurses grow into new roles such as the Clinical Nurse Leader and the Neonatal Nurse Practitioners. Laura Sykes, a 2015 Neonatal Nurse Practitioner graduate who has worked for 13 years in Sparrow’s RNICU noted, “I felt I was ready to contribute to the unit I love in a new way.”

An organizational approach to learning and development, with a focus on innovation and creativity, is essential to attain nursing excellence. Sparrow focuses on the professional development of Nurses in all roles across the health care system.

Sparrow Carson

Sparrow Clinton

Sparrow Hospital

Sparrow Ionia

Sparrow Specialty

PERCENTAGE OF NURSES PREPARED AS BSNs OR HIGHER

0% 50% 100%

17%

37%

44%

51%

35%

Professional DevelopmentSparrow Nurses are Committed to Professional Growth and Development

Amilia Mendoza, BS; Nursing Administration, Sparrow Hospital


Sparrow Nurses Take Part in Growth Opportunities

» Professional Advancement System » Attend Workshops (Examples):

» Charge Nurse Development » Pain Symposium » Preceptor Development » Nursing Research Day

» Professional Organization Involvement » LEAN Training » Aspiring Nurse Leader Program » Evidence-Based Practice Fellowships » Attend Conferences » Certification Exams

Rachel Justice, BSN, RN, CMSRN (left) Nursing Education and Practice, Sparrow Hospital

Danielle Hartig, BSN, RN, PCCN (middle) Neuro Sciences, Sparrow Hospital

Elizabeth Leskovar, MSN, RN, AGCNS-BC (right) Nursing Education and Practice, Sparrow Hospital

Kelly Husted, RN; Infusion Center, Sparrow Carson Hospital

Sparrow Carson

Sparrow Clinton

Sparrow Hospital

Sparrow Ionia

Sparrow Specialty

PERCENTAGE OF NURSES WHO HOLD NATIONAL CERTIFICATION

0% 50% 100%

8%

10%

10%

26%

13%


To accomplish desired outcomes, targeting and improving professional practice processes is key. For example, at the nationally accredited Breast Clinic at the Sparrow Cancer Center, a multi-disciplinary team pioneered a program to streamline the healthcare process for women whose mammograms indicate a need for further testing. Aided by a comprehensive action plan, Patients now go from diagnosis to treatment much faster. By putting the needs of the Patient first, Sparrow’s Breast Health Nurse Navigator

Sharon Cosgrove, RN, ONC, received the 2015 inaugural Excellence in Nursing Award from Modern Healthcare, a nationally recognized leader in health care business news, research, and data.

Nursing excellence requires Sparrow Nurses to reflect on the processes used in delivering patient care. In accordance with the Sparrow Way, Sparrow Nurses engage in purposeful critical thinking and decision-making in order to combine the unique needs of each patient with evidence-based best practices.

Process ComponentSparrow Nurses Demonstrate Attention to Professional Practice Processes

Mary McClain, BSN, RN; Emergency Department, Sparrow Carson Hospital

Sharon Cosgrove, BBA, RN, OCN; Cancer Center, Sparrow Hospital


Sherri Forell, RN Sparrow Specialty Hospital

Isru Megerssa, RN (left); Emergency Department, Sparrow Hospital

Labresha Olds, RN (middle); Orthopedics, Sparrow HospitalTeresa Miller, RN Medical Surgical, Sparrow Clinton Hospital


Primary outcome exemplars:Sparrow Clinton Hospital: Patient Experience

» Patient Experience: Centers for Medicare and Medicaid Services Five-Star rating in Patient experience based on outcomes of its Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)

» PRC scores increased significantly, with Nurse-driven indicators leading the way. Overall quality moved to 89.7 percentile.

» Fall rate decreased from 4.2 to 1.67. Nursing was the champion for this initiative.

Sparrow Ionia Hospital: Patient SatisfactionSurgical Services Patient Satisfaction scores have improved from 62 percent (excellent) to 70 percent.

As Nurses, we take seriously our role in ensuring only the best outcomes through the Sparrow Way: Defining, documenting, deploying and adhering to patient-centered, evidence-based, best practices (clinical, service and leadership) to reduce unjustified process variation throughout Sparrow and consistently deliver national benchmark level outcomes. Having a strong structure and process is the first step, but Sparrow seeks clear evidence that a difference has been made.

Primary OutcomesSparrow Nurses Follow the Sparrow Way to Achieve Primary Outcomes

Mark Keane, BSN, RN; Central Sterile Supply, Sparrow Hospital


Sparrow Hospital: Patient-Centered CareTo improve health outcomes for mothers and babies in the Greater Lansing area, Sparrow Hospital worked hard to earn “Baby-Friendly” designation, which signifies excellence in providing evidence-based, Patient-centered maternity care that promotes best practices in infant feeding and mother/baby bonding. Only six hospitals in Michigan and 245 in the United States hold the Baby-Friendly designation. Being Baby-Friendly is another way that Sparrow is improving the health of the people in our communities by providing quality, compassionate care to everyone, every time.

(“Baby-Friendly” and its logo are registered with the US Committee for UNICEF.)

Sparrow Carson Hospital: Infection PreventionThe Centers for Disease Control and Prevention (CDC) estimates that 10 percent, or 2 million, patients a year acquire hospital-associated infections. In the USA, the most frequent type of infection hospital wide is urinary tract infections (36 percent) followed by surgical site infections (20 percent). In 2015, Sparrow Carson City Hospital kept all Patient free of Foley catheter related urinary tract infections and maintained a very low surgical site infection rate well below the goal of less than 1 percent of patients.

Sparrow Specialty Hospital: Patient EducationWith more than 29 million diabetic Americans, Sparrow Specialty Hospital has taken an important step towards improving the health of the Sparrow Community by improving the diabetes education average from all disciplines to reach 94 percent of patients prior to discharge. Diabetes education is designed to empower patients to self-manage their care in order to reach their goals and has been shown to significantly improve outcomes among people with the condition.

Tammy Kimmel, RN, Infusion Center, Sparrow Carson Hospital

Adam Dobbrastine, RN Emergency Department, Sparrow Ionia Hospital


Strategic outcomes: A year of growthIoniaIn June 2015, Sparrow celebrated the grand opening of new Sparrow Ionia Hospital, the first new hospital in the mid-Michigan region in decades. The all-new, state-of-the-art critical access hospital features 18 private inpatient rooms and also offers outpatient services including a Chemotherapy and Infusion Lab, General and Fluoroscopy Radiology, Nuclear Medicine, CT, Digital Mammography, Ultrasound and Bone Density, an Emergency Department with private Patient rooms, a Surgery Department with two operating rooms, a cafeteria and a community education center.

CarsonIn February 2015, Carson Health became Sparrow Carson Hospital and joins Sparrow Clinton Hospital and Sparrow Ionia Hospital as partners in our mission to provide the very best care, as close to home as possible. By aligning our services, our technology and our resources, we can meet the growing needs of Patients throughout our expanding region and improve local access to health care services. Carson, founded in 1936, includes a 61-bed acute care hospital with 16 Physician practices and an impressive list of inpatient and outpatient programs.

Sparrow Specialty HospitalSparrow Specialty Hospital (SSH) cares for medically complex and critically ill Patients who need intense, highly technical, extended medical care. In February 2015, SSH relocated to the 8th Floor of the Sparrow Hospital Tower to further improve the care coordination. SSH is able to improve the Patient experience by offering increased access to specialty services and ancillary support such as Neurology, Orthopedics, Cardiology and more while helping the health system ensure that all Patients receive the appropriate level of care.

The mission and vision of Sparrow Nursing directly reflects and supports the strategic priorities of the hospital. Sparrow’s vision is to be recognized as a national leader in quality and Patient experience. Our nursing mission – to provide high-quality Nursing care utilizing the Transformational Model of Professional Practice – enables Sparrow to be successful in both mission and vision.

Strategic OutcomesSparrow Nurses Strive to be National Leaders in Quality and Patient Experience


Emmanuel Ijere, MSN, CCRN; Critical Care Float Team, Sparrow Hospital

ClintonSparrow Clinton Hospital earned the Joint Commission’s Gold Seal of Approval® for Critical Access Hospital Accreditation by demonstrating continuous compliance with its performance standards. The Gold Seal of Approval® is a symbol of quality that reflects an organization’s commitment to providing safe and effective Patient care.

Sparrow HospitalIn January 2015, a new unit opened on the 7th floor of the Sparrow Hospital Tower. The 30-bed unit adds Patient space to the hospital and features all private rooms. A generous donation from the Sparrow Service Auxiliary funded a multi-purpose meeting space on the brand new Surgical/Medical unit.

Choua Yang, RN Orthopedics, Sparrow Hospital

Karmen Warner, BSN, RN Emergency Department, Sparrow Hospital



In June 2014, Sparrow Hospital was re-designated for another 4 years as a Magnet Hospital that exemplifies Nursing Excellence. The standard to achieve this designation and recognition is very high; only about 6% of Hospitals nationwide obtain Magnet Designation and only about 2.5% of hospitals obtain re-designation as a Magnet Hospital. This elite designation is one of the ways in which nurses at Sparrow are nationally recognized for quality and the patient experience.

1215 E. Michigan Avenue Lansing, Michigan 48912 Sparrow.org

Magnet status is awarded to only about 6 percent of hospitals.

Documents

Sparrow Nurses | 2016 Nurses Annual Reportsparrowannualreport.org/Nursing-Annual-Report-2016.pdf2016 Sparrow Nurses Annual Report Table of Contents Sparrow Nursing Leadership Sparrow