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Strategic Planning (1)

Strategic Planning

Source of Evidence 1

Describe and demonstrate how nursing’s mission, vision, values, and strategic and quality

plans reflect the organization’s current and anticipated strategic priorities.

Context for Vanderbilt Nursing Mission, Vision, Values and Strategic Plans

Vanderbilt is a complex academic medical center. The detail about the organizational

structure is comprehensively reviewed in Organizational Overview 1 however, there are some

important organizational relationships to consider related to alignment of mission, vision and

strategic and quality plans. Vanderbilt University Medical Center is comprised of four entities.

These include Vanderbilt University Hospital, The Monroe Carell Junior Children’s Hospital,

Vanderbilt Psychiatric Hospital and the Vanderbilt Medical Group and Clinics and all are part of

the Vanderbilt Magnet designation. The Chief Executive Nursing Officer provides leadership for

the provision of nursing care across all of these entities. Thus, the nursing mission, vision and

strategic plan must be relevant in each of the entities. An extremely important strategic alliance

is with the Vanderbilt Medical Group which is the physician practice portion of the organization.

Alignment of physician and nursing professions within each entity is critical to maximizing

patient outcomes.

This source of evidence demonstrates the alignment of the nursing mission, vision,

values and strategic plan within the context of the broader organization and within the

Vanderbilt Medical Group. The CEOs of the entities described above as well as the Executive

Chief Nurse report as peers to the to the Vice Chancellor of Health Affairs and thus have equal

influence over the organization’s strategic and quality plans.

Nursing and the Organization Vision and Mission Alignment

Vanderbilt provides us a stimulating, intellectually rich and supportive environment to

develop the science and art of nursing and to bring the full potential of nursing practice to bear

on patients and families. The mission, vision and values of nursing are driven by the philosophy

of nursing represented in Table TL 1-1 as well as the principles set forth in the Vanderbilt

Nursing Bylaws Table TL 1-2. (Complete copy of Nursing Bylaws in OO 3). The content of these

foundational documents ensure that nursing is clear in its focus for strategic planning and

integrates within a complex organization. Fully grounded in a deep understanding of, and

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commitment to the discipline of nursing, the profession of nursing at Vanderbilt is leading the

way in innovation and excellence. To that end, the nursing vision, mission and values have been

developed and then integrated into the strategic vision and planning for Vanderbilt University

Medical Center.

The CNO is engaged and involved in the planning process for the system and brings the

message of professional nursing to the executive table. Likewise nurses across the organization

in all roles and all settings are part of the planning and implementation of this strategic vision as

they are included in many of the planning and implementation teams. (Committee information

in OO 15) It is this process of matrix decision making and inclusion of all disclilpines in clinical

testing of new ideas and processes to improve patient care that makes Vanderbilt a system that

continues to grow, and strive to meet all aspects of its mission and vision.

Table TL 1-3 demonstrates the relationship between the University mission statement,

the Medical Center mission statement, The Vanderbilt Medical Group and the nursing mission

statements. The process of strategic planning for nursing and the organization is reviewed in

TL3.

Table TL 1 – 1: Philosophy of Nursing

PHILOSOPHY OF NURSING

VANDERBILT UNIVERSITY MEDICAL CENTER

We believe that the provision of highly skilled and specialized nursing care is essential to the

fulfillment of Vanderbilt University Medical Center’s mission of improving health care outcomes

through quality in patient care, education and research. Nursing embraces the responsibility to

provide patient centered, high quality, and cost effective nursing care for all patients and their

families.

We believe nursing is an applied art and science with the focus of professional practice being to

assist individuals, families and communities in achieving optimum health and well-being. This

assistance includes preventive health care, education, facilitating recovery and continued

support through illness, disability, or death. Professional nurses collaborate with physicians and

other disciplines to deliver coordinated and comprehensive patient care. This collaborative care

takes place in a variety of settings.

We are guided by a philosophy that recognizes the inherent worth, dignity and uniqueness of

every individual. We promote participation of patients and significant others in decisions

regarding the patients’ health care and work toward their optimal level of wellness.

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We are committed to providing an environment that continually seeks to improve delivery of

patient care, facilitates rapid changes in practice, and encourages flexibility throughout all

levels of care providers. We believe in the concept of Shared Governance whereby staff

participates in decisions affecting nursing practice and the clinical work environment. We

believe in the enhancement of an environment that fosters effective communication at all

levels, provides recognition of nursing staff for excellence in clinical practice and promotes the

recruitment and retention of clinically competent staff. We support the roles of nurses in

advanced practice as clinical experts and resources for the enhancement of patient care

throughout the care continuum.

We believe that research is a vital component for the advancement of evidenced-based clinical

practice. Systematic evaluation of the effectiveness of nursing practice contributes to the

improvement of patient care and the expansion of nursing knowledge. Excellence in nursing

practice is enhanced by creating an environment that provides opportunities for advanced

nursing education as well as stimulating personal and professional growth. We seek to foster

innovation by working collaboratively with other disciplines to develop new models of clinical

practice to improve quality patient outcomes.

We believe that the future of the profession rests upon developing collaborative models

between nursing service and nursing education. Nursing facilitates the education of patients,

families, nursing peers, colleagues from other disciplines and students of the various health

professions. Each nurse serves as a role model of quality professional practice.

We are accountable for our practice in accordance with recognized professional standards and

ethical codes. We accept the challenge of providing high quality nursing care as a member of

the total health care team in a complex and dynamic health care environment.

Table TL 1-2: Nursing Bylaws Preamble - below

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Preamble to the Nursing Bylaws

The nursing staff of VUMC is responsible for the nursing care administered to our patients, with the

Board of Trust having the ultimate authority. In order to effectively fulfill this obligation, the nursing

staff conforms with the Bylaws, which are formulated upon the following principles:

1. All patients are entitled to safe, effective, evidence-based nursing care.

2. Nursing care of the patient is enhanced by use of an evidence-based care delivery system

tailored to the uniqueness of each patient and provider.

3. The continuing measurement, evaluation, and improvement of nursing practice are essential to

the provision of safe, effective, evidence-based nursing care.

4. The patient is best served by the nursing staff’s collaboration with other hospital staff,

participation in educational and research programs, and use of evidenced based practice.

5. All nursing staff is accountable for our mission of continuous quality improvement, patient

safety, customer satisfaction, and cost effective, evidence-based, value added care.

6. Patients are best served in a healthcare environment that fosters learning, stimulates

professional growth and promotes nursing research and innovation in nursing practice.

Table TL 1-3: University, Medical Center and Nursing missions, vision and values

Vanderbilt University

Mission

Vanderbilt Medical

Center Mission

The Vanderbilt

Medical Group and

Clinics

Vanderbilt Nursing

Mission, Vision and

Values

Vanderbilt University is a

center for scholarly

research, informed and

creative teaching, and

service to the community

and society at large.

Vanderbilt will uphold the

highest standards and be a

leader in:

 the quest for new

knowledge through

scholarship,

dissemination of

knowledge through

teaching and outreach,

 Creative

Vanderbilt University

Medical Center

(VUMC) is a

comprehensive

healthcare facility

dedicated to patient

care, research, and

biomedical education.

Its reputation for

excellence in each of

these areas has made

Vanderbilt a major

patient referral center

for the Mid-South.

Each year, people

throughout Tennessee

and the Southeast

MISSION

The Mission of

VMG is to improve

the health of the

people in the

communities we

serve through

evidence-based

personalized

compassionate care

research, ad

education.

VISION

The Vision of VMG

is to shape the

future of

MISSION

Advance health and

wellness through

excellence in nursing

care, education, and

research throughout the

lifespan and across the

continuum of care.

VISION

To be the national leader

in nursing practice,

education and research

in all nursing roles,

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experimentation of

ideas and concepts.

In pursuit of these goals,

Vanderbilt values most

highly

 Intellectual freedom

that supports open

inquiry, equality,

compassion, and

excellence in all

endeavors.

choose Vanderbilt for

their health care

needs, not only

because of its

excellence in medical

science, but also

because the faculty

and staff are

dedicated to treating

patients with dignity

and compassion.

Vanderbilt's mission is

to advance health and

wellness through

preeminent programs

in patient care,

education, and

research.

healthcare through

discovery and

innovation.

VALUES

We make those we

serve our highest

priority.

We respect privacy

and confidentiality

We communicate

effectively with our

patients and

colleagues

We conduct

ourselves

professionally, with

respect and

compassion.

We have a sense of

ownership for the

health of our

communities

We have a high

commitment to our

colleagues

specialties, and settings.

VALUES

We value:

 patient safety and

quality

 Having strong

interdisciplinary

collaboration and

communication.

 having effective

shared decision

making

 and support a

continuous learning

environment.

 providing meaningful

rewards and

recognition

 highly specialized

nursing care and

influencing the

nursing practice

 patient and family

centered care

 improving the health

of the community

through outreach,

research and

wellness initiatives.

Behavioral Alignment of Nursing and the Organization

An important part of the foundation for Vanderbilt that aligns nursing and all disciplines

is the Vanderbilt Medical Center Credo. The credo translates the mission and vision into

foundational behaviors for all faculty and staff. It is commonly referred to as describing “It’s

Who We Are”. Regardless of the role at Vanderbilt, all faculty, staff, nursing and other

disciplines, are held accountable through performance management for demonstrating

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behaviors described by the credo. The credo provides consistency, accountability and a shared

understanding of behaviors that optimize patient outcomes and staff satisfaction. The Credo is

presented in Table TL 1-4.

Table TL 1 – 4: VUMC Credo

Vanderbilt University Medical Center Credo

 We provide excellence in healthcare, research and education.

 We treat others as we wish to be treated.

 We continuously evaluate and improve our performance

I make those I serve my highest priority:

• promote the health and well being of all patients who seek care at Vanderbilt

• support trainees in all of their academic endeavors

• respect colleagues and those we serve who differ by gender, race, religion, culture,

national origin, mental and physical abilities and sexual orientation and treat them with

dignity, respect and compassion

• recognize that every member of the Vanderbilt team makes important contributions

• ensure that all team members understand overall team goals and their roles

• answer questions posed by patients, trainees or staff to ensure understanding and

facilitate learning

I have a sense of ownership:

• take any concern (real, perceived, big, or small) seriously and seek resolution or

understanding - ask for help if the concern is beyond ability or scope of authority

• approach those who appear to need help or be lost and assist/direct them

appropriately

• clean up litter, debris and spills promptly or notify the best resource to keep the

medical center environment clean and safe

• remain conscious of the enormous cost of health care, teaching and research and

optimize resources while delivering exemplary service

I conduct myself professionally:

• recognize the increasing diversity of our community and broaden my knowledge of the

cultures of the individuals we serve

• adhere to department and medical center policies such as smoking, attendance and

dress code

• refrain from loud talk and excessive noises - a quiet environment is important to heal,

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learn and work

• discuss internal issues only with those who need to know and refrain from criticizing

Vanderbilt in the workplace and in the community

• continue to learn and seek new knowledge to enhance my skills and ability to serve

• strive to maintain personal well-being and balance of work and personal life

I respect privacy and confidentiality:

• only engage in conversations regarding patients according to Vanderbilt policies and

regulatory requirements

• discuss confidential matters in a private area

• keep written/electronic information out of the view of others

• knock prior to entering a patient’s room, identify myself, and ask permission to enter

• utilize doors/curtains/blankets as appropriate to ensure privacy and explain to the

patient why I am doing this, ask permission prior to removing garments or blankets

I communicate effectively:

• introduce myself to patients/families/visitors, colleagues

• wear my ID badge where it can be easily seen

• smile, make eye contact, greet others, and speak in ways that are easily understood

and show concern and interest; actively listen

• recognize that body language and tone of voice are important parts of communication

• listen and respond to dissatisfied patients, families, visitors and/or colleagues

• remain calm when confronted with or responding to pressure situations

I am committed to my colleagues:

• treat colleagues with dignity, respect and compassion; value and respect differences in

background, experience, culture, religion, and ethnicity

• contribute to my work group in positive ways and continuously support the efforts of

others

• view all colleagues as equally important members of the Vanderbilt team, regardless

of job, role or title

• promote interdepartmental cooperation

• recognize and encourage positive behaviors

• provide private constructive feedback for inappropriate behaviors

Alignment of Strategic Planning

The strategic planning process for nursing is described in TL 3. This section responds to

the question of how the nursing strategic plan reflects the organization’s current and

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anticipated strategic priorities. The most recent nursing strategic planning process was

completed in May of 2010. The organizational pillar goals, the Vanderbilt Medical Group’s

strategic plan and the known information related to healthcare reform provided the context

and foundation for the nursing strategic plan. On completion of the draft nursing strategic plan,

Marilyn Dubree, the Executive Chief Nursing Officer met with the CEO’s of the Vanderbilt

Medical Group, Vanderbilt University Hospital, Monroe Carell Junior Children’s Hospital, the

Vice Chancellor of Health Affairs and the Dean of the Vanderbilt School of Nursing to ensure

they perceived the nursing strategic plan aligned with those entities plans and that the strategic

plan was relevant to the future of the Medical Center.

Several tables are presented that demonstrate alignment of the Vanderbilt Nursing

Strategic plan with the organization. Table TL 1-5 demonstrates the alignment of Vanderbilt

Medical Group Strategies and Nursing Strategies. (Nursing Strategic Plan in OO 3)

Table TL 1 -5: Alignment of Goals and Strategic Plans Fiscal Year 2010

VMG Strategies Nursing Strategies

Continuously improve patient outcomes using

evidence-based medicine: and innovative,

reliable, coordinated care practices.

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.

Promote wellness and disease-prevention in

our communities.

Provide an exceptional personalized patient

experience through family-centered care and

value creation.

Transform the way in which health care is

delivered across the continuum in order to

ensure highly reliable personalized care, taking

advantage of the capabilities and unique

contributions of the entire care delivery team.

Be the healthcare employer of choice. Create a leadership model that will provide

current and future leaders the environments,

tools, evidence and skill development to be

innovative and transformational during a time

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of health care reform and transition.

The Strategic Plan for Nursing outlines goals that support each strategy. Strategies and

supporting goals are outlined in Table TL 1-6. The crosswalk of the alignment of these goals

with the VMG strategic goals is presented in Table TL 1-7.

Table TL 1 – 6: Nursing Strategies and Goals

Nursing Strategies and Goals

I. Vanderbilt Personalized Patient Care Model

1 Statement of Strategy: Transform the way in which health care is delivered across the

continuum in order to ensure highly reliable personalized care, taking advantage of the

capabilities and unique contributions of the entire care delivery team.

GOALS

1.1 Determine what brings value to patients, makes a difference and creates breakthroughs

1.2 Understand the impact of who brings the right skill set and resources to achieve a

personalized healthcare model

1.3 Understand and design systems to maximize the benefit and utilize the full talents of the

healthcare team

II. Evidenced Based Practice and Effective Processes

2 Statement of Strategy: 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.

GOALS

2.1 Establish/create nursing infrastructure dedicated to driving the cycle of EBP

2.2 Develop and implement core training systems for evidenced based practice processes

targeted to role requirements

2.3 Ensure the alignment of evidenced based practice with internal and external benchmarking

and quality improvement priorities

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2.4 Complete gap analysis for evidenced based practice and create a work plan for moving

forward

2.5 Disseminate and publish; broadcast to mark what is being accomplished in evidenced based

practice

III. Transformational Leadership and Professional Development

3 Statement of Strategy: Create a leadership model that will provide current and future

leaders the environments, tools, evidence and skill development to be innovative and

transformational during a time of health care reform and transition.

GOALS

3.1 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).

3.2 Develop a recruitment and retention philosophy that supports flexible standard and

consistent requirements for leadership practice.

3.3 Provide organizational learning opportunities for the individual leaders and leadership

teams to learn together and obtain or create tools to meet their desired objectives

3.4 Define the leadership model that is transformational and flexible with leadership

competencies and a menu of tools

Table TL 1 - 7: Cross walk of alignment of VMG strategic goals and Nursing Strategic Goals

Vanderbilt Medical Group Strategic Goals Nursing Strategic Goals

Clinical Growth & Capacity

Establish clinical service capacity,

infrastructure, and desired growth in support

of VUMC goals.

Operational Efficiency

Achieve optimal service and care coordination

by improving the operational efficiency and

effectiveness of the Vanderbilt clinics through

1.2 Understand the impact of who brings the

right skill set and resources to achieve a

personalized healthcare model

1.3 Understand and design systems to

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the design and implementation of a consistent

and measureable operational platform that

meets patient/family expectations, simplifies

work processes for physicians and staff,

supports future growth, and creates an

environment of innovation.

maximize the benefit and utilize the full

talents of the healthcare team

2.4 Complete gap analysis for evidenced

based practice and create a work plan for

moving forward

Continuous Improvement of Outcomes

Demonstrate continuous improvement of

patient outcomes through the use of

evidence-based medicine and quality and

safety science best practice

2.3 Ensure the alignment of evidenced based

practice with internal and external

benchmarking and quality improvement

priorities

Development & Training

Improve team effectiveness, care, and service

outcomes in patient care through

organizational development and training

programs targeted to leadership

development, support staff education, clinical

team training, and orientation.

2.2 Develop and implement core training

systems for evidenced based practice

processes targeted to role requirements

3.1 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).

3.3 Provide organizational learning

opportunities for the individual leaders and

leadership teams to learn together and obtain

or create tools to meet their desired

objectives

Maximize Value

Maximize the value of VMG to the

organization (internally), locally, and

nationally.

1.1 Determine what brings value to patients,

makes a difference and creates

breakthroughs

2.5 Disseminate and publish; broadcast to

mark what is being accomplished in evidenced

based practice

Management & Governance

Align management and governance of the

2.1 Establish/create nursing infrastructure

dedicated to driving the cycle of EBP

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VMG/TVC for execution of the strategic plan

and the meet the interests of the VUMC in the

transformation of practice.

3.2 Develop a recruitment and retention

philosophy that supports flexible standard and

consistent requirements for leadership

practice.

3.4 Define the leadership model that is

transformational and flexible with leadership

competencies and a menu of tools

We have adopted an approach to operations based on the five pillars of people, service,

quality, finance and innovation. Annually, the organization develops pillar goals to guide

operational focus for the coming year. A Blueprint for Quality that has been collaboratively

developed for the entire organization and the Nursing Quality Performance Plan guide the

creation of the annual quality pillar goals which are represented in Table TL 1-8. Both of these

documents are available in Organizational Overview – Question 3. Table TL1-8 represents our

approach to annual 5 pillar goal establishment and the crosswalk of organizational pillar goals

and nursing pillar goals.

Table TL 1 – 8: Crosswalk of organizational pillar goal targets with nursing pillar goals

2011 Organizational Pillar Goals 2011 Nursing Pillar Goals

People

 Retention at 18 months after hire – 67.5%

 Overall turnover (all employees) – 11.5%

People

 Retention at 18 months after hire – 67.5%

 Overall turnover (all employees) – 11.5%

 Nursing Turnover – 11.8%

Service Pillar (Patient Satisfaction)

 Overall Quality of Care – perform at 95

percentile

 Overall Teamwork between doctors,

providers, nurses and staff – perform at 95

percentile

 Patient engagement – perform at 95

percentile

 Improve VMG access to level of 60% of

Service Pillar (Patient Satisfaction)

 Overall Quality of Care – perform at 95

percentile

 Overall Teamwork between doctors,

providers, nurses and staff – perform at 95

percentile

 Patient engagement – perform at 95

percentile

 Improve VMG access to level of 60% of

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new patients being seen within 15 days of

requesting appointment

new patients being seen within 15 days of

requesting appointment

Quality

 Observed to expected mortality at 0.70

 15% reduction in healthcare acquired

infections (SIR score of 1.11) as

measured by the sum of Central line

acquired blood steam infections,

ventilator acquired pneumonia,

catheter associated urinary tract

infections

 15% reduction in preventable

healthcare adverse events as

measured by the sum of falls, pressure

ulcers, medication errors.

 Improve intra-professional

communications within and across all

care settings during transfer ad

transitions of care and during

procedures

 Design and establish a coherent quality

improvement learning system with

defined tools and methods to foster

continuous learning for continuous

improvement

 Achieve top performance in clinical

programs

o Stroke – 91%

o Pneumonia – 90%

o Heart failure – 95%

o SCIP – 94%

o OPPS – 94%

o Acute MI – monitor

o Diabetes – to be developed

o Pediatric asthma – TBD

Quality

 Observed to expected mortality at 0.70

Healthcare Acquired Infections

 Central line acquired blood steam

infections SIR score of 1.31

 Ventilator acquired pneumonia SIR

score of 1.24

 Catheter associated urinary tract

infection SIR score of 0.63

 Surgical site infection SIR score of 1.09

 Hand hygiene – 90%compliance

Preventable healthcare adverse events

 Pressure ulcers per 1000 patient days –

0.86

 Falls per 1000 patient days – 3.00

 Medication errors per 1000 patient

days – 3.81.

Intra-professional communications

 Design standardized process and tools

for handovers and spread to 3 areas

Design and establish a coherent quality

improvement learning system with defined

tools and methods to foster continuous

learning for continuous improvement

 Develop prototype of standardization

process for admission and discharge

medication reconciliation

Achieve top performance in clinical programs

o Stroke – 91%

o Pneumonia – 90%

o Heart failure – 95%

o SCIP – 94%

o OPPS – 94%

o Acute MI – monitor

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o Diabetes

–

to be developed

Pediatric asthma – TBD

Finance and Growth

 Results of operations - $106.4 million

 Discharges – 55,360

 Ambulatory visits – 1,557,302

 Surgical procedures – 47,472

 Cost per discharge - $16,288

 Cost per visit - $489

Finance and Growth

 Results of operations - $106.4 million

 Discharges – 55,360

 Ambulatory visits – 1,557,302

 Surgical procedures – 47,472

 Cost per discharge - $16,288

Cost per visit - $489

Innovation

 Warfarin– proof of concept

 MyHealth@VU – results of proof of

concept

 Achieve reduction in growth of Vanderbilt

Health Plan costs – results of proof of

concept

 Diagnostic Management team – results of

proof of concept

 Integration of pharmacogenomic

information into clinical decision support

infrastructures

 Presentation of genomic data to

individuals

Innovation

Warfarin

 Improve over baseline INR in-range by

20% (outpatient coumadin clinic)

MyHealth@VU

 Improve to 65% the number of

patients with blood pressure in control

without adversely affecting satisfaction

scores (VMG nurse managed patients

through MyHealth@VU)

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Strategic Planning

Source of Evidence 2

Describe and demonstrate how nurses at every level – CNO, nurse administrators, and direct-

care nurses – advocate for resources, including fiscal and technology resources, to support

unit/division goals.

There are a multitude of ways nurses at all levels influence access to resources to meet

unit and department goals. Starting at the staff level, all staff have direct access to nurse

managers as well as through Unit Board meetings, staff meetings, unit based quality and service

meetings. Managers practice leader rounding intentionally asking “Do you have the tools to do

your job” and “What resource or systems problems exist that are barriers to effective patient

care”. Leaders are expected to actively access required resources and/or to remove identified

barriers to support patient care. Staff nurses also sit on organization wide committees and

councils providing feedback to managers and administrators in nursing and from across the

Medical Center.

Managers meet with the administrator responsible for their area regularly both one and

one and with their peers. During these group meetings common resource issues are identified

and accountability for access resources defined. Inpatient managers have access to the Medical

Economics Outcomes Committee where supply purchases are considered. This committee

organizes trials for new supplies and supply replacement and equipment.

Nursing administrators and executives are actively involved in creating and prioritizing

the capital list for all entities each year. Nursing leaders are responsible for demonstrating need

and return on investment for new items that are not replacement items. Managers and

administrators work closely with Clinical Engineering leadership to be certain critical equipment

is replaced according to the life cycle and maintenance and repair requirements of the

equipment is followed. [TL2-Exhibit A-1–VUH capital list with leaders] Nursing administrators

play a pivotal role in establishing IT priorities. Nurses at all levels participate in design shops and

regular meetings to advocate and influence nursing IT development and purchasing plans that

support the role of the professional nurse and optimize patient outcomes.

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Examples

IT Design Shops

Information technology annual planning process – Although there has been a long

history of end users being involved in the IT decision making, there had not been a structured

process for nursing input. This sometimes resulted in the lack of alignment between IT priorities

and outputs and organizational goals. The current process has been perfected over the last 5

years. It has put the operational planning process team members with a strong nursing voice in

the driver seat for IT prioritization. The process results in a shared vision, clear priorities and

measurable outcomes. The process also includes quarterly check in as objectives and priorities

change over the year.

The prioritization occurs in “Design Shops” which are held in the Center for Better

Health. These design shops depend on large groups of multiple levels of employees coming

together. The participants work in small groups reporting out progress to the larger group. The

recommendations and decisions in the day(s) of Design Shops are iterative and continually

draw on the experts in the field to inform IT of needs, desired outcomes and priorities. The final

output of the Design Shops is a “Swim Lane” document that creates timelines and deliverables

for each project. The document is used by users to evaluate the progress of the IT teams. [TL2-

Exhibit B-1-2010 Design Shop –Patient Engagement, TL2-Exhibit B-2-Heart Failure Teaching

Record]

In one of the early design shops several nursing related IT projects were identified.

 The need was identified to standardize admission and shift skin assessments to be

consistent with national guidelines. As a result of this, changes were made to the

electronic order entry system and the nursing documentation system. The changes were

piloted for staff feedback and then rolled out across the enterprise in the spring and

summer of 2009.

 Ventilator acquired pneumonia (VAP) and compliance with the VAP bundle were

problematic in the nursing ICU’s. The participants in the design shop recognized the

opportunity for IT to provide reminders and feedback loops for nurses to improve

compliance with the bundles. As a result of the design shop both the electronic order

entry system and the nursing documentation system were improved.

In addition, nurses were provided with a dashboard that is constantly open on clinical

work stations for the patients on the unit. Each part of the bundle has a red, yellow and green

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indicator flag for each patient. Red means the task in the bundle is not complete and overdue

for a particular on a patient. Yellow means that it is nearing time for a particular task to be

completed. If the steps in the bundle are complete, the task box is green. Through the use of

the VAP dashboard as a reminder and flag to nurses regarding what is due, over- due and

complete on their patients, the VAP standardized infection ratios (SIR) fell from 2.59 in MCJH in

February of 2008 to a SIR of 0.7 in July of 2010 and in the adult hospital the Sir went from 2.23

to 1.75 in the same time frames referenced.

 Nurses identified at the design shop that the electronic medical record made it difficult

to see all of the information necessary to care for the patients efficiently. Nurses stated

they could not easily read the patient story and understand what had happened, was

happening and was going to happen to a patient. As a result of this identification, the

Overview of Patient Care (OPC) was developed which aggregates all necessary

information for the nurse in one location.

Although the pilot was well received, changes were made to “de-clutter” the overview

to make it easier to read. In addition, a charge nurse snapshot was developed to include all of

the information charge nurses need to make appropriate assignments on patients. The

overview of patient care has had broad adoption across the inpatient organization and has

been adopted as a useful tool for physicians as well as nurses.

 Based on feedback at a design shop that nurses needed more alerts and reminders, a

screen saver was developed for all clinical work stations which displays visual reminders

and alerts for nursing staff when there are new orders for a patient, new lab results or

interventions are necessary.

Accessibility to Human Resources at Off-Campus Site

Opening of the 100 Oaks outpatient campus provided many challenges for Janice Smith,

RN, MS, the Chief Administrative Officer and the Nursing leader at 100 Oaks. She became aware

that the human resource needs of the 1,000 employees at that campus would be difficult to

manage with Human Resource (HR) functions only available approximately 6 miles away. Both

managers and employees have many human resource department needs including recruitment,

position changes, hiring, termination, and employee relations issues. These functions have

traditionally been spread across many departments in HR. Janice set a goal to provide as much

on site HR consultation as possible. Janice worked with Veronica Burns, the Director of Human

Resources to develop a new title of HR generalist. This HR employee would be able to manage a

wide variety of issues as opposed to the traditionally highly specialized staff in Vanderbilt’s HR

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Department. Janice successfully worked with David Posch, the CEO of the VMG and the

Vanderbilt Clinics to secure funding for the position. The position was funded through VMG but

dually reports to Janice and HR leadership. The position was filled and HR service began in

October of 2009. [TL2-Exhibit C-1-HR Generalist Job Description]

Resources to Change Practice

Kathy Burns, MSN, RN, a clinical nurse specialist in the CVICU became aware of research

related to improved neurological survival for out of hospital arrest patients when their body

temperature is cooled for 24 hours. Kathy partnered with the Medical Director of the CVICU,

John McPherson and developed a program proposal for this effort. She worked through the

Medical Economics and Outcomes Committee to complete trials of the necessary cooling

equipment.

Kathy discovered interest for this technology across other ICU’s. She began to work

through the Institutional Critical Care Committee to develop the necessary justification for the

devices. She worked with purchasing and with the vendor of the selected device to develop a

quote for the technology. Through the capital prioritization process in the Vanderbilt Heart and

Vascular Institute, funds were secured for this device.

To date, 38 of the 79 patients or 48.1% who were “out of hospital arrests” survived and

are neurologically intact. This is compared to a historical 25-30% survival rate in un-cooled

cardiac arrest victims admitted alive to hospital, with a lower rate of good neurologic outcome

despite survival. [TL2-Exhibit D-1-Cooling Release, TL2-Exhibit D-2-Hypothermia]

IT Leadership for Nursing

VUMC has been listed as one of the “most wired” hospitals and health system in the

country. There is a large informatics team that develops and implements healthcare

technologies that enhance the delivery of patient care. Our Executive CNO, Marilyn Dubree

MSN, RN, NE- BC, recognized the need for a nursing leader in informatics applications within

the healthcare system. She observed that technology was beginning to define nursing practice

and noted it would either enhance or detract from the professional role of the nurse depending

on the implementation and use. Marilyn recognized that the science of the application of

technology to nursing practice in a healthcare system required a knowledgeable and dedicated

resource.

Marilyn created a position to oversee clinical applications of technology and enhance

the practice of nursing. The position created the nursing informatics bridge between the

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hospital and the clinics. The person selected for this position would articulate a strategy to

ensure that nursing needs were met in an ever increasing highly automated environment.

Deborah Ariosto, RN, MSN, PhD(c) (doctoral candidate in Nursing) joined Vanderbilt as the

Director of Patient Care Informatics on November 5, 2008. Since her arrival, she has completed

the assessment of nursing informatics systems and processes and begun to influence change in

the system.

Deborah has been very active. Since she began in her role she has worked with staff and

leaders to standardize and simplify pain documentation. She has developed a new method,

system and tool for documenting patient education for heart failure patients. She directs

changes to the nursing documentation system through simplification and standardization.

Deborah as created the QERI-Ops group which is charged with quality, education, research and

informatics initiatives with the strategic planning and operational structures of Vanderbilt

nursing.

Capital Budget

As part of the budget process annually, all of the entities submit the prioritized list of

the capital needs in their area. These are generally submitted in the major Capital Category

(>$100,000), routine capital (<$100,000 but >$50,000) and discretionary (<$50,000). The

Vanderbilt Heart and Vascular Institute spans the continuum of care and includes operations

and nursing in the following areas:

 5 Inpatient units

 1 on campus clinic for cardiology, vascular and cardiac surgery (50,000 visits)

 14 off campus clinics (20,000 visits)

 Non-invasive diagnostic testing s on campus and off including nuclear cardiology,

Cardiac MRI, Echosonography, stress testing, autonomic function testing, vascular

testing

 Cardiac Catheterization labs

 Electrophysiology labs

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VHVI does not have a capital allocation. Capital must be submitted to both the VMG and

VUH because VHVI operations sit both in VUH and the VMG and both of these entities have

their own capital allocations.

The diversity of services provided in the Heart Institute makes capital submission to two

different entities challenging every year. Robin Steaban RN, MSN is responsible for operations

and nursing in VHVI and is responsible for capital submission. She has created an Operations

Council within VHVI. The Council is the operating decision making body of VHVI for all things

that are within the budget and the recommending body for all things outside of the budget. All

of the Medical Directors, their associated nursing manager partners and VHVI administrators

are voting members of the Council. Robin works through this structure to have physician and

nursing leaders prioritize the capital list for VHVI based on programmatic priorities and clinical

need. Nursing leaders and physicians have equal voice in the process. [TL2-Exhibit-E-1-

Operations Council Minutes]

Robin then takes the capital needs to both the VMG and VUH and works with the

administrative teams at that level to prioritize VHVI needs against others in the organization.

Robin is able to work with all administrators to agree what capital should be purchased with

consideration of the entire organization in mind. She is present for the capital negotiations and

is able to advocate for the needs within VHVI based on return on investment, patient safety and

quality risk, potential impact to the business for unplanned failure. This participation in the

organization wide process allows Robin to communicate with VHVI Medical Directors, Nursing

Managers and Administrators why capital decision were made. The process builds trust in the

organization and keeps staff and faculty connected to organizational priorities outside of VHVI.

[TL2-Exhibit-E-2-Five year Capital Plan]

“Vanderbilt Shockers”

Dawn Sabine, RN, BSN is a nurse in the Vanderbilt Heart and Vascular Institute. She

works as a specialty nurse with arrhythmia patients. There is a significant population of patients

with CIEDs (cardiac implantable electronic devices). Dawn is the expert in caring for these

patients. She recognized that although this therapy is life saving, it is also a life altering

experience. Patients must make modifications to their lives once they have had a CIED placed.

She recognized CIED patients needed additional support. Dawn researched what other

institutions were doing and developed a proposal for a CIED support group for patients and

families. She advocated with leadership in VHVI for the funding and clerical support to manage

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these support groups. In 2007, the support for the group was successfully budgeted and Dawn

held the first meeting of the “Vanderbilt Shockers”.

The group typically has 80-100 people in attendance. She has worked on behalf of the

patients to advocate for resources for the meetings that takes place 3-4 times per year. These

resources include speakers, space, recruiting volunteers as well as monetary resources.

The group has remained active and has been positively reviewed in a patient feedback

tools. By increasing patient education and allowing for greater access to health care providers,

patients have an opportunity to learn from experts as well as other patients about how to

adjust their lives to accommodate and thrive with an ICD.

Dawn has just started an advisory board that meets on a periodic basis on behalf of the

other ICD patients. The advisory board makes suggestions as to future topics, speakers and if

needed, will contact new patients who are having trouble or would like to speak with another

patient with an ICD. [TL2-Exhibit F-1-Invitation]

Can I help you find your way?

Tom Conner, RN, Manager of the Medical Center East PACU reported that staff noted

many lost visitors and families outside of the PACU wandering the halls. At times, they have

inadvertently entered the operating rooms. Staff consistently offers to assist people who

appear lost. Numerous times when a patient is in route to the OR the gurney is stopped so the

Anesthesia personnel can provide directions. Guest Services did not seem to be an option for

the 3

floor. In lieu of Guest Services, Tim contacted Julie Bulger in volunteer services. In

cooperation with Beth Pittman of Guest Services, there will soon be a volunteer on the 3

floor

scouting lost people in 2 hour time blocks.

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Strategic Planning

Source of Evidence 3

Describe and demonstrate the strategic planning structure(s) and process(es) used by nursing

to improve the healthcare system’s: 1) effectiveness and 2) efficiency.

Our strategic planning efforts are multi-tiered and multi-focused. The foundation for all

planning efforts is the VUMC organizational plan. The plan is created annually at the most

senior executive levels of the organization and sets the direction of VUMC. There are entity and

Institute strategic planning efforts that produce plans consistent with the overall VUMC

strategic planning but specific to the entity or Institute. In addition, there is a specific strategic

planning process for nursing within the organization that is lead by Marilyn Dubree, MSN, RN,

NE-BC, Executive Chief Nursing Officer.

Each of these plans cascade off of the VUMC. In addition, each of these plans is heavily

influenced if not lead by nursing leaders. Nurses across the organization contribute and

influence the strategic plans of the organization, entities and Institutes. The following will

describe efforts related to VUMC, Vanderbilt entity and institute strategic planning efforts and

the structures and processes that provide nurses at every level an opportunity to influence

these plans to improve the effectiveness and efficiency of the healthcare system.

Vanderbilt Nursing Strategic Planning Structure and Process

In 2008 many changes were occurring in our nursing leadership. The organization had

grown to the extent that a more robust nursing leadership structure was required. In that year

Marilyn added several positions that reported to her as she moved into the Executive Chief

Nursing Officer role. Those positions included a CNO for VUH and for the Vanderbilt Medical

Group in addition to the existing CNO of Monroe Carell Junior Children’s Hospital. In October of

2008, Marilyn Dubree, the Executive Chief Nursing Officer (ECNO) convened all nursing

administrators for a several day retreat. The goal of that retreat was to solidify the leadership

infrastructure for nursing as well as the charters for the nursing leadership structures. Another

deliverable of the retreat was a draft mission and vision statements for nursing.

Marilyn gave all nursing administrative leaders (the Nursing Administrative Board i.e.,

NAB) an opportunity to review the organizational documents related to the mission and vision

of the organization. She then asked all to participate in a dialogue about the content of these

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documents and how they should inform the development of a nursing vision and mission. After

much discussion, a list of agreed upon thoughts was created.

The Nursing Executive Board (NEB) members then left the NAB retreat armed with what

they had heard from all nursing administrators. They began the work of crafting the mission

and vision statements for nursing. Each member of NEB worked privately and then joined with

the entire NEB group to share their ideas and collaborate on the final draft of a mission and

vision statement. After 2 hours, the draft was presented to the larger NAB. The document was

fully endorsed and has become the Vision and Mission of nursing at Vanderbilt University

Medical Center.

Several more workshops and retreats focusing on the development of the nursing

strategic plan were held in the months that followed. Consistent with the roles of Boards in the

Nursing Bylaws, Marilyn worked closely with the members of the strategically focused Nursing

Executive Board (NEB) through the strategic planning process. In April of 2009, the NEB worked

with Marilyn to identify three strategic priorities based on a review of internal and external

priorities for nursing.

Through June and July of 2009, Marilyn reviewed the three strategic priorities with the

Vice Chancellor, the Deputy Vice Chancellor and CEO of Vanderbilt Hospitals and Clinics and the

CEO’s of the VMG and Clinic, the Children’s Hospital and Vanderbilt University Hospital. In

addition, Marilyn reviewed the three strategies with managers of the Medical Center and at the

Staff Nurse Councils. Feeling confident about the direction of the strategic plan, Marilyn

convened an NEB retreat in the November of 2009 to begin to plan the tactics to attain the

strategic priorities.

Throughout 2010, the Be the Best teams have begun to focus on the beginning

implementation of the nursing strategic initiatives.

The Development and review process of the strategic plan is shown in Chart TL 3 – 1.

Chart TL 3 - 1: Process for Development of Current Nursing Strategic Plan

Structure: NAB Function: Inform

development of Mission and

Vision

Structure: NEB

Function: Draft Mission and

Vision for Nursing

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Vanderbilt University Medical Center Planning

Structure: VUMC Nursing

Managers

Functions: Endorse /

recommend changes to

Nursing Strategic Plan

Statements

Structure: Vice Chancellor,

Deputy Vice Chancellor, Entity

CEO’s

Functions: Endorse /

recommend changes to the

Nursing Strategic Plan

Statements

Structure: Staff Nurse Councils

Functions: Endorse /

recommend changes to the

Nursing Strategic Plan

Statements

Structure: NEB

Function: Draft Strategic Plan

Priority Statements

Structure: NEB

Function: Draft Strategic Plan

Tactics

Structure: Administrative Affairs

Function: Final Approval of

Strategic Plan

Structure: Be the Best Task

Forces

Function: Implement tactics to

achieve Nursing Strategic Plan

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VUMC executives support an annual planning process that is build around the five pillars

of performance used by Vanderbilt to guide organizational direction and focus. The pillars and

the 2011 goals are represented in Table TL 3 – 1.

Table TL 3 - 1: Vanderbilt University Medical Center Pillar Goals

People

Service Quality

Growth and

Finance

Innovation

We nurture a

caring, culturally

sensitive, and

professional

atmosphere as

continuously

invest

in the individual

and

collective

aspirations

of our people

Collegiality is a

central

characteristic

of our culture

and

defines how we

serve our

patients,

those we teach,

and the local

and worldwide

community

We relentlessly

pursue and

measure

ourselves against

the highest

quality

performance in

all

areas, from

patient

care to

scholarship

We invest our

resources in a

manner that

supports

our long-term

obligation to

society;

to achieve local,

national and

worldwide

impact in

improving health

We seek

excellence

and leadership

we advance our

systems of care,

educational

practices and our

commitment to

discovery

2011 Goals:

New hire

retention

After 18 months

to 67.5%

Turnover

Medical Center

12.0%

Nursing 12.5%

2011 Goals:

Improvement in

access

60% new

patients seen

within

15 days

Improve patient

satisfaction

with:

Overall quality of

care

Overall

teamwork

between

2011 Goals:

Mortality rate

Improve to .70 of

expected

Indicators

Improve

Standardized

Infection Ratio to

1.11

Reduce adverse

events

to 7.67/1000

patient days

Achieve top

performance

2011 Goals:

Volumes meet

or exceed

budget for:

Hospital

discharges

55,085

Ambulatory visits

1,541,883

Surgical

operations

47,236

Achieve Medical

Center

Financial Targets

2011 Goals:

Demonstrate

results from

innovation

projects

Personalized

Medicine

Systems of Care

Value Based Care

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doctors,

providers, nurses

and staff

Patient

engagement

in clinical

programs

Improve reliable

system

design and

communication

Develop quality

improvement

learning system

VUMC results of

operation

VUMC cash

savings

Cost per Visit

Cost per

Discharge

The structure used to develop and approve the pillar goals is demonstrated in Chart TL 3 - 2.

Chart TL 3 - 2: Figure Demonstrating structure and function for Vanderbilt University medical

Center Annual Pillar Goals

Structure: Board of Trust

Nursing membership: Chief Executive Nursing

Office is a member

Function: Approve Annual Pillar Goals

Structure: Medical Center Administrative Affairs

Nursing membership: Chief Executive Nursing

Office is a member

Function: Develop Annual Pillar Goals

Structure: VUMC Committees and Councils

(Examples: Quality Council, Compensation

Committee, Elevate Steering)

Nursing Membership: Nurses at all levels of

leadership - (Examples: Nursing managers,

nursing administrators, quality consultants

Function: Inform and recommend

illar

oals

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Strategic Planning (3)

Each Pillar is assigned to member of the Administrative Affairs team. The members of the

Administrative Affairs team include:

 Vice Chancellor of Health Affairs

 CEO of Vanderbilt University Hospital

 CEO of Monroe Carrel Children’s Hospital

 CEO of the Vanderbilt Medical Group - Service Pillar

 Associate Vice Chancellor of health Affairs, Chief Strategic and Information Officer –

Innovation Pillar

 Deputy Vice Chancellor of Health Affairs and CEO of Vanderbilt hospitals and Clinics –

Quality Pillar

 Assoc. Vice Chancellor for Health Affairs & Chief Admin Officer

 Associate Vice Chancellor of health Affairs and Senior Vice President of Finance –

Finance Pillar

 Chief Executive Nursing Officer – People Pillar

These leaders then work through teams and committees focused on each pillar to

recommend goals for the coming year using historical performance data, external

benchmarking data and knowledge of organizational capability and capacity.

For 2011 pillar goal development, Marilyn Dubree, MSN, RN, NE-BC Executive CNO was

assigned to the people pillar. Marilyn was assisted by human resources experts in the

organization to identify strengths, weaknesses, opportunities and threats related to employees

and employment in healthcare in the Middle Tennessee region. Human Resources provided

knowledge of the regional human resource market supply and demand, compensation trends

and opportunities. The 2010 performance against VUMC goals for turnover and retention in the

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first 18 months and the outcomes of the employee satisfaction survey were used to drive goal

development.

Through her work as the Executive CNO, Marilyn Dubree is responsible for the largest

subset of the workforce at VUMC. Throughout the year she works within the nursing structures

inclusive of the Nursing Executive Board and the Nursing leadership Board to optimize

performance in the people pillar. Marilyn has always focused on optimizing human

performance and thus organizational effectiveness and efficiency. To that end, Marilyn

developed approaches to comprehensively address human resource issues within nursing. This

effort, started several years ago is called “Be the Best, Keep the Best”. This is a nursing

approach led by Marilyn Dubree to select the right people, foster growth, address quality of

work life issues, and create the culture that retains the right people. Under the umbrella of the

Be the Best effort are several task forces. The task forces that make up that Be the Best team

are represented in Table TL 3-4.

Table TL 3 - 2: Be the Best Task Forces and Purpose

Be the Best, Keep the Best

Task Force

Task Force Purpose

First Two Years Retention &

Recruitment

To assess, develop and implement effective strategies,

programs and processes for recruitment, selection,

orientation and support for nurses during their first two

years of employment at Vanderbilt University Medical

Center.

Clinical Work Force To identify, plan, recommend, and implement strategies

that:

 Ensure resources and processes are in place to

appropriately deploy staff to meet organization,

unit/clinic goals of quality patient care and staff

satisfaction.

 Promote and foster a dynamic staff and leader

partnership that promotes collaboration and

innovative problem solving of ongoing staff challenges

due to daily demand, new programs and overall

growth.

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Strategic Planning (3)

Diversity To cultivate an inclusive culture encompassing respect and

valuing individual uniqueness at all levels of Nursing

within Vanderbilt Medical Center

Leadership Development To identify, recommend, plan, and implement strategies

that will create an environment for nursing leaders that:

 Supports excellence in clinical practice and customer

service

 Enhances the work environment for staff and

leadership

 Promotes professional and personal development of

staff

 Fosters a workplace of participation and collaboration

Nurse Wellness

 Develop programs and services based on the identified

needs of nurses

 Advocate for the health & wellness of nurses

 Evaluate programs and services based on indicators of

success

 Serve in an advisory capacity to the Nurse Wellness

Program

Service improvement 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.

Shared Governance

 To evaluate and monitor the establishment of

purposeful shared decision-making structure within All

nursing patient care areas.

 To promote and foster a dynamic staff-leader

partnership that promotes collaboration, shared

decision-making and accountability for improving the

quality of care, safety, and enhancing work-life

All of the membership of these task forces includes nursing managers and/or are lead by

nursing managers. For all groups there is a high level of engagement of staff nurses and

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frontline leaders. These groups report their work, collaborate and inform Marilyn in monthly

“Be the Best” meetings. [TL3-Exhibit A-1-Be the Best Steering Committee Meeting Minutes] Be

the Best taskforce chairs share an annual report with all nursing leaders. The reports include

yearend accomplishments and proposed goals for the coming year. The nursing leaders at large

have an opportunity to influence the goals for the coming year at this meeting. Through this

work, Marilyn is fully knowledgeable and constantly engaged in understanding and managing

human resource issues, interventions and tactics that drive performance toward human

resource goal attainment. The “Be the Best” work informs her in a way that uniquely positions

her to lead the organization wide human resource goal development.

Accomplishments of these task forces listed in Table TL 3 -5 demonstrate how planning

has impacted efficiency and effectiveness within nursing.

Table TL 3 - 3: Accomplishments of Be the Best Keep the Best task Forces, 2009

Be the Best, Keep the Best

Task Force

Task Force Accomplishments

First Two Years Retention &

Recruitment

 Set process in place to use peer interviewing for

placement of nurse residents

 Revised nurse preceptor workshop based on focus

groups and implemented monthly as “Preceptor 1:

essential skills for the preceptor”

 Developed plan for ongoing preceptor training – has

implemented: “Preceptor 2: communication skills for

the preceptor”

 Offered unit based preceptor courses

 Orientation and on-boarding of experienced nurses –

did a survey of experienced nurses who were within

their first 2 years of employment at VMC; CNO

breakfast w/ same population; complete a gap analysis

from feedback

Clinical Work Force

 Improved nursing understanding of the need to take a

break by creating break buddy system on 7 RW,

creating charge nurse incentives n PCCU to encourage

nurses taking a break and Kay Stobaugh presenting

take a break success at April Fest

 VMG Nursing Administration approved a policy for

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Ambulatory Areas to Post Shifts and Fill with Available

Nurses from Other Areas. Staff are able to see needs

posted on the Nursing webpage and orientation plan

created to guide managers to ensure demonstration of

clinical competence of float nurses

 System implemented for tracking of BLS certification in

Vandyworks (scheduling system) that alerts nurse and

manager near due date.

Diversity

 Aprilfest 2009 Three one hour Cultural Workshops

 Completed 7 One-Hour Cultural Workshops including

Lines of Communication: Interpreter Services at

Vanderbilt Dignity and Respect: Showing our Patients

Cultural Sensitivity, Generational Differences and

Healthcare Disparities for the Hispanic Patient.

 Focusing on leadership development for diversity

leaders participated in “Attitudes Toward

Differences” workshops, completed Diversity gap

analysis of current practices and training for

leadership, developed a Diversity Web Site, developed

on-line Diversity Toolkit

Leadership Development

 Developed behavioral rating tool to be used for

formative and annual evaluation of managers. The tool

clarifies the expectation of the competent, proficient

and expert manager and will help standardize

performance within established nursing manager

competencies

Nurse Wellness

 Implemented Traveling Nurse Wellness Fair during

nurses week

 Implemented “refresh rooms” in the critical care

towers to assist nursing in self-care activities during

work hours

 Held an art retreat for high performing nurses

 Completed Safety Walk to identify unsafe areas on

campus where nurses need to walk when traveling to

and from work locations

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Strategic Planning (3)

 Increased the number of self-defense classes in 2009

 Created and implemented “Flu Jail” to encourage flu

shots

 211 new nurse case referrals to the Nurse Wellness

Specialist/EAP

 Rounds made by NW Specialist to over 1000 nurses

during Nurses Week

Service improvement See TL3 EO

Shared Governance

 Assisted Clinics transitioning to 100 Oaks to use

Shared Governance systems and processes for

transition planning

 Launched VCH Float Pool and planning for a virtual

unit board

 Verified staff involvement in Critical Care Tower

transition planning.

 Shared Governance overview added to new program

aimed at developing leadership capability in Asst

Managers and Charge Nurses (“S3”)

The goals of these committees for 2010 calendar year are listed here that demonstrate a

continued focus on effectiveness and efficiency within nursing.

Table TL 3 – 4: 2010 Goals for Be the Best Keep the Best Task Forces

2010 Goals

–

Be the Best task Forces

First Two Years Retention & Recruitment

 Use shared governance process to gather feedback and share information to achieve F2YRR

goals, include VPH

 Improve communication between hiring official and recruiter throughout recruitment

process to on boarding

 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

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Strategic Planning (3)

 Improve internal transfer process – review current policy and create career development

process to help guide nurses requesting transfers

 Retain 87% of new nurses during their first two years at VMC

 Implement Preceptor Nurse Alerts! and provide ongoing educational updates

 Committee will review general on-boarding rounding tool that has been created and

determine need to revise current Nursing Rounding 30-90-180 tool

 Complete assessment of educational needs of leadership teams in regards to retention and

socialization at the local level

 Explore the pilot of the “Buddy System” implemented on 7N and determine feasibility of

rolling that system out to all units/departments

Clinical Workforce

 Complete analysis of supplemental staffing needs for in/out patient areas

– Complete focus groups with in/out patient areas to assess need

– Review best practice and complete literature search

– Make recommendations for change in current process

 Partner with Nurse Wellness Committee to educate and encourage breaks for staff

– Complete a literature search

– Pilot analysis of two units/clinics for times of no breaks/ no lunch

– Decrease no lunch Kronos punches by 25%

– Create a tool kit for managers and staff for education on importance of breaks

 Implement education plan and formalize policy for floating nurses to OP areas

– Introduce floating option, educate on policy and process at VMG Managers Council

– Update Nursing Website for links to posted needs

 Develop and Implement Subspecialty Nursing Fellowship

– Identify pilot area/ unit

– Create fellowship program as a gateway to subspecialty nursing

– Pilot fellowship will be designed and implemented in 2010

 Add additional certifications for VandyWorks tracking and alerts

– ACLS, PALS, NRP, PEARS, and EOR

– Implement policy recommendations on certification expiration

– Attend Unit Boards to share information and Best Practice

 Safety and Staffing

– Make recommendations for change in Schedule Process policy to support maximum

work hours per week

– Monitor data for rule enforcement of scheduled hours greater than hours per policy

– Review data with Workforce Planning Committee

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Strategic Planning (3)

 Partner with other Be-the-Best Committees to improve satisfaction and strengthen the

retention of the experienced nurse

Nursing Diversity

 Develop Diversity Ambassador Program Continue to collaborate with Recruitment on

diversity recruitment

 MNPS Career Exploration Fair

 Cultural Presentations for:

 Martin Luther King Celebration

 Aprilfest

 Nurses’ Week 2010

 Employee Celebration Month

 Oktoberfest

 Develop communication plan to advertise diversity website

 Develop plan to increase number of subscribers to nurse alerts for diversity

 Continue updates to website

 Develop Cultural Awareness presentations for Medical Center Orientation and Nursing

Orientation

 Support B-T-B Committees (Wellness, Leader Development and R2YR committees) in

advisory capacity

 Participate in Black History Month Highlighting Nursing

 Develop celebration months for other cultures

 Collaborate with LDI, ODC and Nursing Education in an advisory capacity for development

of leadership support

 Implement recommendations from Diversity Gap Analysis.

 Develop on-line diversity training

 Develop diversity training for leadership

Leader Development

 Analyze current leader span of control at Vanderbilt

 Compare staff satisfaction and turnover data and consider whether a correlation exists with

manager span of control

 Compare Vanderbilt span of control with national statistics

 Define specific performance behaviors related to job description evaluation scoring

 Develop and implement communication plan

 Collaborate with HR and Recruitment related to strategies for recruiting and retaining

managers

Transformational Leadership

Strategic Planning (3)

 Collaborate with organizational initiatives focused on leadership assessment and

development

 Develop collaborative working relationship with others in organization who are creating

leader development opportunities

 Evaluate and revise existing leader orientation pathways

Nurse Wellness

 Wellness Fair in 2010

 Continue collaboration with Clinical Workforce, Diversity and Career Development re:

Maturing Workforce

 Finalization of guidelines for Refresh Room

 Additional performances of “Hey Florence”

 Art Retreat for managers to reward high performers

 Encore performance of Hey Florence

 Compete plans for Refresh Rooms

 Annual safety walk

 Wellness Fair 2010

 Continue partnerships with Professional Behavior Task Force, Occupational Health, and

VPD

 Expand use of “Flu Jail” to encourage flu shots 2010

 Increase self-defense classes to 1 per month

 Improve Nurse Wellness page on website

 Collaborate on ideas to increase presence of Nurse Wellness Program/EAP and other

resources to off-site staff

 Continued website development

 Increase communication about Nurse Wellness Program/EAP services to OHO and other off-

site staff

 Encourage staff participation in Nurse Alerts

Shared Governance

 Fall 2009 – Total Inpatient assessment (qualitative and quantitative).

 Revamping of SG website and addition of “SharedGovernASK”

 Partner with VMG training and development leaders

 Bylaws Convention

 Virtual Unit Boards

 Dissemination of inpatient Unit Board assessment data

 Next Nursing Staff Summit

 Partnership with other BTB Committees

Transformational Leadership

Strategic Planning (3)

 Shared Governance Traveling Fair

 Coordination with Nursing Leader Development using SG as foundation in building leaders

 Coordination with Nursing Research Committee in evaluating effectiveness of Shared

Governance

 Coordination with NEB in developing future nursing org structure

 Coordination with either Retention Committee or Mature Workforce Committee regarding

experienced nurse data and action plan

[TL3-Exhibit-A-2-Be the Best 2009 Annual Report]

Entity Planning Structures and Processes and Nursing Effectiveness and Efficiency

Each entity (VUH, VCH, VPH, Clinics) has planning processes annually as well. There is a

great amount of nursing influence in these planning processes. The evidence in this section

demonstrates the nursing influence in all entities.

Annually, Larry Goldberg, the CEO of Vanderbilt University Hospital (VUH) leads a

planning effort with the VUH team. Among others, the VUH planning team includes, Pam Jones,

RN, MSN the CNO of VUH, Nancy Feistritzer, RN, MSN the Associate Director of Perioperative

Services, and Robin Steaban, RN, MSN Administrator for Operations and Nursing in the

Vanderbilt Heart and Vascular Institute. These nursing leaders develop the VUH plan with other

non-nursing leaders. A full review of the year end 2010 VUH Operating plan is provided. In

addition, Robin Steaban leads the development of the VHVI operating plan. Examples of some

operating plan elements that have improved efficiency and effectiveness are in the Table TL 3-7

below.

TL 3 – 7: Examples of VUH Operating Plan Examples

FY 2010 Goal Responsible

Person

Impact on Efficiency and Effectiveness

Goal was to decrease

infant mortality by

predicting high risk

Robin Mutz RN,

MBA

Administrative

Improved efficiency of utilization of ultrasound

machines. Center for Women’s Health consolidated and

moved 3 clinics to the One Hundred Oaks location in Feb.

08. At that time we were operating 3 ultrasound

Transformational Leadership

Strategic Planning (3)

pregnancies. This

required increasing the

utilization of

ultrasonography for

early identification of

high risk infants in the

face of fixed resources.

Director,

Women’s

Health

machines at less than 50% capacity. Through redesign

efforts, we smoothed the template for each machine,

evened the schedule for each machine and gave the

sonographers daily targets for numbers of completed

scans (33 is the goal). We also adopted a philosophy of

“just say yes” whenever they were asked to do a scan.

Through the efforts, we are now at 98% increase over

the same month last year. The graph is attached.

Implement Central

telemetry monitoring

for 9 North, TVC

observation and 15

Robin Steaban

RN, MSN,

Administrator

New telemetry equipment implemented and

Central monitoring expanded to include 9 North, 7

RW, ED. This improves the monitoring accuracy

within the organization by centralizing observation

Transformational Leadership

Strategic Planning (3)

beds in the ED VHVI of cardiac rhythms to highly trained sta

f. It also

consolidated the human resources to one area. .

The telemetry tech pool was large enough to cover

all unexpected call outs with telemetry techs

instead of nurses as was the norm in the

decentralized model.

Integrate Vascular

patient population into

the VHVI inpatient bed

allocation and service

Robin Steaban

RN, MSN,

Administrator,

VHVI

Vascular patients integrated into VHIV consolidating

vascular patient with nursing experts in CV care.

Nurses focused only on CV patients and working

with the same MD teams everyday are able to more

effectively care for patients and ensure patients

move through the system with accuracy and

efficiency.

Develop Quality

Council leading to

development of a

forum for review of

near misses and

failures in the

Vanderbilt heart and

Vascular Institute

Robin Steaban,

RN. MSN

Administrator

VHVI and

Brittany

Cunningham,

RN, MSN,

Quality

Consultant,

VHVI

Development of ImPaCT

–

Improving Patient Care

Together – See full story below

VUH leaders also meet monthly to review and influence Informatics priorities.

“IMPACT” in Vanderbilt Heart and Vascular Institute (VHVI) – In Support of the Quality Pillar

Goal

In 2009, VHVI chartered a Quality Council. The Council membership includes all nursing

managers, VHVI Medical Directors and Administrators and is focused on meeting the quality

Pillar goals developed by the organization. While the Council has proven to be an effective

forum for quality improvement planning, outcome review and tactical planning, the need was

identified to develop a system and process to learn more quickly from near misses and harm to

Transformational Leadership

Strategic Planning (3)

patients. This is consistent with literature on Highly Reliable Organizations where one

characteristic is pre-occupation with failure.

The idea was to create a forum to improve the timely and effective review of cases so

early correction in systems and processes could be made to prevent harm in other patients.

Robin Steaban, RN, MSN, the administrator for VHVI, supported the efforts of Brittany

Cunningham, RN, MSN, VHVI Quality Consultant Jeff Boord MD, the Quality Director and Tom

DiSalvo MD, the Quality Medical Director for VHVI, as the idea of a team that met regularly to

focus on near misses and harm was envisioned and eventually created. Through the work of

this team Managers, Medical Directors and Administrators gathered and chartered the group

which eventually became known as ImPaCT or Improving Patient Care Together.

The goal of the ImPaCT effort was to craft a sustainable management process for CQI for

all clinical operational units of the Vanderbilt Heart and Vascular Institute. It was the aim to

create a safe environment where incidents could be shared and learned from. The work was

based on the belief that continuous quality improvement (CQI) in health care systems

necessitates an approach to review of:

 Care delivery processes

 Systems

 Group and individual performances

 Incidents

 Outcomes

VHVI leadership believed a robust process should be:

 Multidisciplinary

 Occur in “real-time”

 Provide detailed review and discussion of care processes, performance and outcomes

 Generate actionable rapid cycle improvement opportunities

A standing interdisciplinary biweekly managerial forum (ImPaCT- “Improving Patient

Care Together”) of quality medical directors, key clinical physicians and nurses, nursing unit

Transformational Leadership

Strategic Planning (3)

managers, hospital administrators and quality consultants was developed. The meeting

follows a standing structured agenda:

 All mortalities since last meeting

 Morbidity including “major misses” and major adverse events

 Rapid response team calls

 Out of ICU “codes”

 Events reported by staff in our institutional incident reporting system

 Events or issues brought forward by any clinician or unit manager

 Interval progress on ongoing rapid cycle improvement projects

ImPaCT acts as the interchange for quality and safety information and provides the following

functions.

 Adverse events and patient safety issues are discussed in a confidential forum that

promotes Problem solving and accountability but avoids blame

 ImPaCT can identify events that merit root cause analysis, and also follow up on the

findings

 ImPaCT coordinates communication and process improvement efforts with other

departments

 ImPaCT develops and prioritizes quality improvement initiatives

The forum allows the exchange of information between many groups looking at near

misses and errors. It provides a forum for closing the loop on issues raised in other forums as

the members are operationally and clinically focused. A graphic of the information flow

between teams is depicted below.

Transformational Leadership

Strategic Planning (3)

In the first year various types of issues have been brought to this forum. The issues

identified that required action were categorized and quantified below:

Table TL 3 – 8: Issues Requiring Action

Topics Contribution (N) Percent

Handoff and Communication 13 28%

Medicine Administration 10 22%

Equipment 7 15%

Transport of Patients 5 11%

Education back to staff (i.e. M & M) 4 9%

Risk Management Cases 3 7%

Blood administration 2 4%

Vascular Surgery Integration 2 4%

The examples of Quality projects that resulted for the IMPACT review include:

 Development of ICU “transport time out” to improve safety of patient transport

 Development of standardized nurse report form for patients transferred in from an

outside facility

Transformational Leadership

Strategic Planning (3)

 Implementation of a rapid nurse debriefing process to identify and capture key data

related to patient falls

 Implementation of a handoff process for patients with an indwelling vascular sheath

after catheterization

 Training on communication of adverse outcomes and errors for unit nurse managers

In conclusion, a multidisciplinary, structured, regularly scheduled meeting of physician

and nursing leaders, unit managers, and administrators is a critical component of performance

management and improvement. This forum not only facilitates learning and collaboration

between clinical areas, but also creates a culture of safety and enhances communication.

[TL3-Exhibit-B-1-QCO ImPact Conference Poster]

Revision of Operating Room Case Cart Operations and Supply Management

Lead by Nancye Feistritzer RN, MSN, Associate Hospital Director, Perioperative Services

In November 2009, we opened a new Critical Care Tower which included 141

New acute-care inpatient rooms and 12 new state-of-the are operating rooms, and is the most

significant increase in adult inpatient hospital rooms at VUMC since it’s opening in 1980. In

order to support the opening of the Tower, VUMC’s Medical Center Support Services (MCSS)

worked with a logistics consultant to redesign the current state of materials management and

case cart delivery as it services the preoperative environment.

Findings from the original assessment were divided into two broad categories: Case

Management operations and Supply Operations. Through extensive interviews, observation of

current operations and data analysis, teams focused recommendations on these categories in

three (3) areas:

1. People

Training staff and managers to develop and use standard policies, operating and

reporting procedures

2. Process

Transformational Leadership

Strategic Planning (3)

Streamlining current operations to be more efficient and produce more consistent

results

3. Technology

Realigning technology to better support current and future processes. In addition,

multidisciplinary teams worked with MCSS to design and construct a new offsite

Case Cart Operations Center. The new Case Cart Operations Center was built in

Briley Park and was put into operation in November 2009. This facility replaced the

majority of the current Central Supply, freeing up valuable storage space at VUH for

a large percentage of the cases currently performed. With few exceptions, case carts

will be processed at the CCOC. Case carts fall into one of three categories:

 Scheduled elective and add-on case carts delivered multiple times per

day

 Specialized pre-built trauma supply totes and VUH pre-built instrument

cart, maintained at VUH and replaced by CCOC as used

 POD specific “specialty” carts, managed at par levels and replenished

daily

Carts that are not case specific but are managed through the Central Supply staff (e.g.

isolation carts) continue to be managed via the VUH Central Supply.

Improvements

The following areas were identified during the assessment phase, redesigned and

implemented during the course of the entire project.

Case Management/Perioperative Improvements:

 Established Preference Card Maintenance policy and SOP. In addition created charter

for Preference Card Review Group which will meet regularly to establish standards and

approve changes.

 Established Weekly, Monthly and Quarterly OR Management Reporting. Scheduling

Accuracy as well as other performance metrics established and placed on OR Dashboard

Transformational Leadership

Strategic Planning (3)

 Established standard scheduling policies and SOP and it relates to the CCOC

 Reviewed and presented case “add-on” procedures and management of surgical block

time. Presented data findings to leadership to aid in operational decisions, i.e. case

block release times

 Created specialty supply and room stock carts to eliminate inventory in multiple bulk

locations. (12) Specialty supply carts were created for key service lines and placed in

strategic locations. Carts containing basic room stock were also created and placed in

each room. These carts are replenished daily and reduce duplicate inventory as well as

reduce clinical involvement in supply chain functions.

Perioperative IT Improvements:

 Implemented requirements for all non-emergent appointment requests through

STARform interface

 Reviewed and made suggestions for standard reason codes

Case Cart Process Improvements:

 Established standard “home” locations for all instrument trays

 Established standard case cart build SOP

 Established supply “stay/go”, identifying which supplies remain at VUMC and which

move to the CCOC freeing up much needed support space at VUMC

 Establish a policy and SOP for communication between Central Supply and OR for

missing supplies and instrument trays on case carts

 Establish policy and SOP for communicating missing supplies, instruments and other

items on Preference Card

Case Cart Information Technology Improvements:

 Revised use of PMM Pick Ticket to support Point-of-Use technology and preference card

clean-up

Transformational Leadership

Strategic Planning (3)

 Prepared operations for Point-of-Use Technology

 Established surgical instruments “stay/go” list indentifying instrument sets thatshould

stay and be processed at VUMC and sets that should be moved and be processed at the

CCOC

Instrument Processing Improvements:

 Established a policy and SOP for more strategic use of Censitrac to support off-site case

cart operations

 Established a policy and SOP for determining instrument processing priority

 Realigned shift schedules to more align with the needs of the medical center

 Establish policy and SOP for identifying tray processing location

 Establish a policy and SOP for identifying critical (show stopper) instruments for each

instrument tray

 Implemented quality control measures to ensure all instruments are sterilized

Instrument Processing Information Technology Improvements:

 Realigned instrument scan points

 Established management reporting for KPIs

 Rolled out interface between Censitrac and ORMIS schedule

In conclusion, the design and creation of the Case Cart Operations Center brought

together interdisciplinary team of nursing leaders, front line nursing staff, administrators,

physicians, and front line support staff to review, change and create new procedures and

protocols that allowed case cart operations to be moved offsite.

Some production statistics:

Transformational Leadership

Strategic Planning (3)

 Case carts processed: 2,100/month

 Instruments processed: 420,000/month

 Case cart supplies picked: 70,000/month

[TL3-Exhibit-C-1-Case Cart Current Performance]

Transformational Leadership

Strategic Planning (3)

Transformational Leadership

Strategic Planning (3 EO)

Strategic Planning

Source of Evidence 3 EO

Describe and demonstrate the outcome(s) that resulted from the planning described in TL 3.

Strategic planning and operational planning drive Vanderbilt nursing’s agenda each year.

Below are three examples of outcomes that have resulted from planning. They include; Nurse

Residency, Door to Balloon SWAT team and MyHealth@Vanderbilt.

Strategic Planning for Needed Nursing Resources - VUMC Nurse Residency Program

Background

We have had significant growth in patient volumes over the past five years. As the Nursing

Executive Board and other hospital leaders engaged in a strategic planning process for the

Critical Care Tower it became evident that there would need to be a more robust mechanism

for attracting and retaining qualified nurses to meet the increased capacity. After one and a

half years of planning, the consolidated VUMC Nurse Residency Program (NRP) was launched in

July 2008 by the Department of Nursing Education and Professional Development as part of a

strategic approach to recruitment and retention of staff. The program was designed to meet

the strategic need of recruitment by standardizing the application, interviewing, hiring, and on

boarding process. The new program was marketed through the Vanderbilt Nursing website

(see Figure TL 3 EO – 1 below). The strategic need of retention was addressed by developing a

program to help novice nurses successfully transition from the student nurse role to the

professional nurse role, increasing satisfaction and decreasing the turnover rate of those new

graduates.

The program at VUMC, is affiliated with the University HealthSystem Consortium (UHC) and

the American Association of Colleges of Nursing’s Post-Baccalaureate Nurse Residency

Program. The residency is a year-long program, which consists of orientation specific to

graduate nurses, as well as seven-weeks of core and track orientation during a rotational phase,

followed by a match to a permanent unit. Once matched, the program co-leaders mentor the

new nurses and lead eight monthly facilitated workshops conducted during the first year of

employment. Additional details of the NRP are outlined on our Nursing website at

www.vanderbiltnursing .com with a direct link:

http://www.mc.vanderbilt.edu/root/vumc.php?site=vanderbiltnursing&doc=9935

Transformational Leadership

Strategic Planning (3 EO)

Participants

The planning committee for creating the consolidated NRP was diverse with nurse

educators, and managers who represented all inpatient nursing areas of VUMC and nurse

recruiters and administrators from Nursing Recruitment and Human Resources. The members

of the Residency Planning Committee included the following:

Table TL 3 EO – 1: Residency Planning Committee Members

Debbie Arnow, MSN, RN, NE-BC

Director Clinical Education and Professional Development

–

Children’s Hospital

James Barnett, MSN, RN Nurse Educator

–

NCU

Richard Benoit, MSN, RN Nurse Educator

–

SICU

Cindy Brown, RN, MSN MCE OR Director

Ed Dennis, MSN, RN Nurse Educator

–

Burn Unit

Tracey Fargo, BSN, RN Nurse Recruiter

–

Elizabeth Fritz, MSN, RN Nurse Educator

–

Labor & Delivery

Kara Gordon, MSN, RN Nurse Educator

–

MICU

Todd Griner, MSN, RN, NEA-BC Manager

–

10S

Rachael Hamilton, BA Administrative Manager

–

Nursing Education and

Professional Development

Beth Hodge, MSN, RN Nurse Educator

–

3 and 5/6 RW

Collette Judd Recruiter

–

Erin Kuhn, MSN, RN Nurse Educator

–

Perioperative Services

Anya Lockert-Young Recruiter

–

Lori Martin, BSN, RN Nurse Educator

–

VUH ED

Leanna Miller, MSN, RN Nurse Educator

–

Trauma

Amy Moore, BSN, RN 3, CEN,

EMT, IV

Flight Nurse - LifeFlight

Nancy Moore

–

RN 7RW

Christy Mullen, BSN, RN Nurse Educator

–

NED VCH

Rosalyn Norris HR Recruitment

Cathy Ollom, MSN, RN Nurse Educator

–

Oncology

Terry Owens Program Coordinator

–

Nursing Education and Professional

Development

Shelly Padgett, BSN, RN Nurse Educator

–

Cardiology

Debianne Peterman, Ph.D., MSN, Director

–

Nursing

Transformational Leadership

Strategic Planning (3 EO)

RNC-NIC, NE-BS Education and Professional Development

Sheryl Redlin-Frazier, BSN, RN Nurse Educator/Assistant Nurse Manager, 4 E

Laurel Roberts, BSN, RN Administrative Director

–

VCH

Donna Ruth, MSN, RN Nurse Educator

–

Labor & Delivery

Teresa Simpson, BSN, RN Nurse Educator

–

CVICU

Sherri Stringfellow Art Director - Nursing Education and Professional

Development

Martha White, MSN, RN Nurse Educator

–

9N & 9S

Bridgette Willette Director HR Recruitment

Chris Wilson, MSN, RN-BC Director Clinical Education and Professional

Development - Nursing Education and Development

Sandra Winfield Recruiter

–

Methods and Approach

The committee reviewed historical data that identified a turnover rate for first-year

nurses that was typically very high and very expensive to the medical center (35-55%) and

developed a program with the hypothesis that the turnover rate of this population would be

reduced by employing a standardized nurse residency strategy. Working with HR and assigning

one Nurse Recruiter (Tracey Fargo, BSN, RN) who would serve as the recruitment liaison for this

program helped to organize the marketing and recruitment efforts.

Tracey conducted onsite visits to local schools of nursing and sent out email marketing

blasts to schools around the country at the time that we posted the NRP positions. We created

an introductory video and placed all information on the Nursing website. A series of town hall

meetings were conducted to inform current VUMC staff of the changes we were making to the

hiring process for graduate nurses. We set up one portal of entry for all of the applications to

enter into the system and created and built an NRP-specific database that allows us to send out

standardized communication to all candidates during each phase of the inquiry, application,

interviewing, and hiring process.

An example of the marketing approach to this project through the website can be seen in G

raph TL 3 EO - 1 below.

Transformational Leadership

Strategic Planning (3 EO)

Graph TL 3 EO – 1: Nursing Website Nursing Residency Program

Outcomes

The strategic objective of attracting qualified applicants has been successfully achieved.

The [TL3EO-Exhibit A-1-Nurse Residency Summary Report] shows the number of applicants for

each cohort. We have been able to attract a diverse group of graduate nurses from thirty-nine

(39) states plus DC with a 176 different nursing programs represented. Our average GPA is 3.43

(on a 4.0 scale) with each cohort. The percentage of graduates with BSN degrees has increased

since the initiation of this program and our average now is at 80%. Our retention rate of these

new graduates has improved significantly as indicated by the table below.

Table TL 3 EO – 2: Retention Rates of Nurse Residents

Cohort

3 months

6 months 9 months 12 months

>12 mos.

and < 24

mos.

Summer 2008

100%

97.1% 96% 91%

85%

Winter 2009

100%

98.8% 95% 92%

92%

Transformational Leadership

Strategic Planning (3 EO)

Evaluation:

It is clear from the data above that this program achieved both strategic objectives of

recruiting a ready supply of highly qualified nursing staff and retaining those nurses at VUMC.

Door to Balloon Time SWAT Team

Purpose/Background

The goal established by the American Heart Association/American College of Cardiology

for patients experiencing an acute MI was to have the culprit artery opened and blood flow

restored to the heart within 90 minutes of patient presentation to the ED. There has been a

long standing collaborative effort between the ED and the cardiac cath lab to achieve that goal.

In 2008, the Chest Pain Center Committee identified the need to improve the door-to-balloon

time for patients experiencing ST elevation myocardial infarction (STEMI), particularly in

regards to the interval from activation of the cath lab until the patient arrived to the lab.

During off hours (evenings and weekends), a call team responded from outside of the

hospital with a 30 minute maximum response time and this was identified as the primary

limiting factor to improvement. Some staff members lived in a range that allowed them to

respond to a page for an acute MI and be on site within 30 minutes but not faster. The patient

could not be moved to the cath lab without staff. This fact delayed the actual intervention time

because staff reported to Vanderbilt, went to the lab to prepare the area and then retrieved

the patient. The median time the patient was moved from the Emergency Department to the

Cath lab was 37 minutes. This left only 52 minutes for the patient to be prepped, the MD to

gain arterial access, complete a diagnostic cath and re-vascularize the culprit vessel. The

interval time of patient arrival to transport to the cath lab needed to be shortened.

Methods

The CVICU Manager met with charge nurses of the CVICU to develop a plan for the

charge nurse to be involved in the care of acute MI patients. The plan developed was for the

charge nurse to respond to a “STEMI Alert” page by going to the ED. Once there, the patient

would be prepped and the ED nurse, cardiac fellow and CVICU nurse would transfer the patient

to the cath lab and prepare them for the procedure by getting the patient on the cath table,

connect the patient to the defibrillator pads, connect cath lab monitoring equipment and

provide care until the cath lab team arrived. The roles and responsibilities of the ED staff and

the cardiac fellow were also more clearly determined.

Transformational Leadership

Strategic Planning (3 EO)

Once requirements and resources identified (CVICU Charge Nurse), protocols were

developed. The team identified training needs of the CVICU charge nurse as response/cardiac

catheterization environment. The CVICU Charge nurse would have to work in an environment

where they were unfamiliar. There were competency requirements established and formal

training and competence validation. A medication box was developed in collaboration with the

pharmacy for administration of emergency meds during time the CVICU nurse would be in the

lab. In addition, a fully implementable contingency plan had to be developed in case the charge

nurse was unable to leave the CVICU because of acuity or other situation.

After implementation, the median transfer time decreased to 30 minutes and has been

sustained.

Table TL 3 EO – 3: Participants

Jeannie Byrd, MSN, RN, NE-BC CVICU Manager

Janice Sisco, BSN, RN ED Manager

Laura Zelenak, RN, Cardiac Catheterization Lab Manager

Tiffany Richmond, RN Cardiac Catheterization Lab Assistant Manager

Carol Parsons, RN Cardiology Case Manager

Brittany Cunningham, RN, MSN Quality Consultant

Kathy Burns, Med, RN, CCRN CVICU Clinical Nurse Specialist

Dan Johnson, Dph Clinical Pharmacist

Michelle Hasselblad, BSN, RN Director, Cardiac OR and Catheterization Lab

David Zhao, MD Cardiac Catheterization Lab Medical Director

Thomas DiSalvo,MD VHVI Quality Director

The workgroup implemented this change for of the D2B Swat Team in January 2008 and

the evaluation follows.

Evaluation

There is an analysis of every STEMI patient coming through the ED. Interval

measurements were established for each segment of time dependent care. Median time of

transfer decreased from 37 minutes to 30 minutes. This has been sustained since the

implementation of the process. [TL3EO-Exhibit B-1-D2B Swat Team Policy, TL3EO-Exhibit B-2-

CPC Meeting Minutes]

Transformational Leadership

Strategic Planning (3 EO)

My HealthCareTeam@Vanderbilt

Purpose/Background

A study was done through the electronic medical record that demonstrated a large

number of patients with hypertension, diabetes, and/or heart failure whose conditions were

not under control. Vanderbilt set a goal to improve the health of this population and to try to

prevent costly ED visits and hospitalizations that could be avoided by improving primary care

access and follow-up. [TL3EO-Exhibit C-1-Summary Presentation]

VUMC provided an innovation grant to create a “medical home” within our primary care

practices to care for patients with hypertension, diabetes and/or heart failure in a manner that

would get their chronic conditions under control and try to reduce morbidity and mortality and

prevent unnecessary emergency visits and hospitalizations. The medical home would make use

of RN “care coordinators” to implement evidence-based, protocol-based individualized care

plans.

Methods/Approach

An interdisciplinary group took several months putting together the proposal for the

project. They researched the evidence for reducing mortality and morbidity of the three chronic

conditions by providing close follow-up, coaching, goal setting and behavior modification by

registered nurses working with the primary providers to develop individualized evidence-based

care plans for each patient. The project was then funded.

The specialists, for example the heart failure nurse practitioner, Connie Lewis, RN were

engaged to write care protocols. A dashboard was built to show the progress and care needs of

the patients. Care plans were developed and placed in into StarPanel, the EMR system. RN Care

Coordinators were hired. Data definitions (defined what “being in control” and “at target”

means) were developed. Measures were built into the EMR.

A system to stratify patients was created and the team began enrolling patients.

The primary care practices’ patients were stratified by co-morbidity, and patients were enrolled

in the proof of concept project, so far involving 3 primary care physicians, their care teams, and

2 RN care coordinators.

Transformational Leadership

Strategic Planning (3 EO)

Table TL 3 EO – 4: Participants

Jim Jirjis, MD, MBA Primary Care physician, Lead, Main Campus

Ralf Habermann, MD Primary Care Physician

Jim Powers, MD Primary Care Physician

Bill Gregg, MD Primary Care Physician, Informatics

Pete Powell, MD, MBA Primary Care Physician, Lead, Williamson Co.

Racy Peters, RN, MSN VMG Associate Director, Operations

Betty Akers, BS Business Administrative Director, Primary Care, Operations

Pat Covington, BSN, RN, CRRN Clinic Manager, Operations

Anne Hurd, RN Clinic Nurse

Julie Scott, BSN, RN Manager, Center for Disease Prevention, Care Coordination

Management

Sharon Mullins, RN Health Information Systems Project Manager 2, Project

Manager

Joan Peterson, RN, CCM, CDE Care Coordinator

Rebecca Bumm, RN Care Coordinator

Collin Mothupi Quality Value Analyst

Outcomes/Impact

The data demonstrates the program and nursing interventions are improving patient’s

control of chronic conditions. There is insufficient data at this time to determine whether

incidence of ED visits or hospitalizations is affected. [TL3EO-Exhibit D-1-MHTAV Work Plan]

Hypertension control improved after the intervention from the MyHealth@Vanderbilt team.

Graph TL 3 EO – 2: Hypertension Measure

Hypertension Measure

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Basel ine 2-Jun 14-Jun 28-Jun 14-Jul 27-Jul 2-Aug 8-Aug 16-Aug

IC + IT OOC

Transformational Leadership

Strategic Planning (3 EO)

Graph TL 3 EO – 3: Diabetes Measure

Diabetes Control improved after intervention from the MyHealth@Vanderbilt Team

Graph TL 3 EO – 4: CHF Measure

Control of HF improved after MyHealth@Vanderbilt team interventions

Diabetes Measure

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 2-Jun 14-Jun 28-Jun 14-Jul 27-Jul 2-Aug 8-Aug 16-Aug

IC + IT OOC

CHF Measure

10%

20%

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Basel ine 2-Jun 14-Jun 28-Jun 14-Jul 27-Jul 2-Aug 8-Aug 16-Aug

IC + IT OOC

Transformational Leadership

Strategic Planning (3 EO)

Graph TL 3 EO – 5: CHF Measure

CHF Measure

10%

20%

30%

40%

50%

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Baseline 2-Jun 14-Jun 28-Jun 14-Jul 27-Jul 2-Aug 8-Aug 16-Aug

IC + IT OOC

Transformational Leadership

Advocacy and Influence (4)

Advocacy and Influence

Source of Evidence 4

Describe and demonstrate the process(es) that enable the CNO to influence organization-

wide changes.

Marilyn Dubree transitioned from the Chief Nursing Officer to the Executive Chief

Nursing Officer (ECNO) in 2007. The organization had grown tremendously by virtue of the

addition of the Monroe Carell Junior Children’s Hospital, extraordinary growth in the outpatient

business and clinics, and the planned expansion of the University Hospital. The increase in the

size and complexity of the organization was diluting the role of the CNO simply due to the

diversity and demands one person had to attend to.

The executive leaders recognized the critical need to have Marilyn represent nursing at

the executive level. She was, and remains, well respected by the executive team. Marilyn

demonstrated that she was a valuable partner in the strategic decision making of the

organization and a driving force behind quality, patient, and employee satisfaction. Marilyn also

needed to be able to maintain the equal partnership of nursing with MD’s at the executive

level.

The executive leaders of the Medical Center actively supported and encouraged Marilyn

to restructure nursing leadership so she could fulfill the role and demands of the Chief

Executive Nurse. To that end, Marilyn transitioned to the Executive Chief Nurse and the added

Chief Nursing Officers for Vanderbilt University Hospital, Monroe Carell Junior Children’s

Hospital, the Vanderbilt Medical Group and the Vanderbilt Psychiatric Hospital.

The change positioned the role of the Chief Executive Nurse to partner with the Chief

Executive Officers in the clinical entities. The ECNO reports, as do the CEO’s of the clinical

entities to Dr. Wright Pinson, MBA, MD the Deputy Vice Chancellor for Health Affairs and the CE

of the Hospitals and Clinics. She is equally positioned to influence organizational change as are

the CEO’s.

Intentionally written into the job description of the ECNO are requirements to

participate in Executive teams and influence organizational change. The job summary (complete

job description provided in OO 2) states; “As a member of the VMC executive team, the CNO

supports and facilitates an interdisciplinary team approach to the delivery of care. This includes

creating a nursing environment in which collaboration is valued and excellence in clinical care,

Transformational Leadership

Advocacy and Influence (4)

education, and research is promoted and achieved. The CNO ensures the continued

advancement of the profession of Nursing at VMC.”

Key function number thee requires the ECNO to “participate in the planning,

implementation, and evaluation of clinical programs and services, assuring appropriate

resources for the delivery of care”. Key function four requires the ECNO to “Serve as the senior

spokesperson for Nursing, advising senior leadership of VMC and individual entities, institutes

and other affiliated institutions, (including the medical staff) by providing input about the

implications of decisions and change on the quality of patient care, on nursing practice, and on

nursing care providers.”

To enable Marilyn to influence organization wide change, the position of ECNO in

strategically placed on key committees within the structure. Table TL 4-1 describes the

organization wide teams where the ECNO is either an active participant or leader of the team.

Table TL 4- 1: Organization wide committees and forums where the Chief Executive Nurse is

an active participant

Committee Purpose

Clinical Enterprise

Executive Committee

The purpose of the Clinical

Enterprise Executive Committee is

to bring together leadership of

the Clinical Enterprise to address

strategic and operational topics

focused on PCC/Institute updates,

patient care operational issues,

and review of performance

alignment of common

infrastructure.

Influenced decision for VUMC

to be a tobacco free campus

which will be launched in

November, 2010

Administrative Affairs The purpose of Administrative

Affairs is to bring together key

clinical enterprise leadership and

medical center leadership to

address strategic and financial

topics focused on the clinical

enterprise.

Influences the agenda creation

for Leadership Assembly and

the alignment of such with the

strategic initiatives

With other Executives, defined

participants in executive and

leader incentive programs

Transformational Leadership

Advocacy and Influence (4)

Proposed and gained approval

for changes to NP

compensation

Medical Center Medical

Board

The broad, but not all-inclusive

purpose of the Medical Center

Medical Board is to represent and

act on behalf of the Medical Staff

while serving as the principal

committee to which all standing

and special committees report.

Influenced the decision to

support a policy allowing

families being present in

pediatric codes

Executive Committee of

the Medical Center

Medical Board

The purpose of the Executive

Committee is to affect a high

degree of communication

between the Medical Staff and

Medical Center administration

and to scrutinize and evaluate, on

a continuing basis, patient care in

terms of quality, convenience,

comfort and efficiency. It shall

make recommendations to the

Medical Center Medical Board

regarding the quality of overall

medical care rendered to patients

treated at the Medical Center.

Participates in decision related

to MD suspension

Quality and Safety

Steering Committee

Purpose is to align and

monitor contributions to the Pillar

Goals, manage projects and

improvement assignments, and

coordinate the readiness of

quality assurance, and regulatory

and accreditation improvement

Processes.

Approves quality plan and

quality goals.

Participated in decisions related

to the evolution of Medical

Director roles in quality

Quality and Safety Purpose is to guide and assist

executive leaders, the medical

Approves quality reports and

provides direction for quality

Transformational Leadership

Advocacy and Influence (4)

Council center board, and the board of

trust in fulfilling their

responsibility to oversee safety,

quality, and effectiveness of care.

initiatives

Information, Privacy

and Security Executive

Committee

The purpose of the Information,

Privacy and Security Executive

Committee is to regularly assess

the operating and computing

environment to identify risk

factors and define safeguards

against intentional or

unintentional disclosure of

Protected Health Information

(PHI), person-identifiable, or other

confidential or proprietary

information created, used, or

maintained by Vanderbilt.

Determines consequences for

individuals who breach

confidentiality

Determines use of social media

in clinical areas and on clinical

work stations.

Executive Faculty

Committee

Monthly meeting for the chairs of

all the SOM and SON to purpose is

to share information for the good

of the enterprise. Communication

and dialogue among the academic

leaders.

Provides updates regarding

clinical enterprise nursing issues

Clinical Enterprise

Group

“The purpose of CEG is to obtain

input, alignment, and ratification

of strategies with Department

Chairs and faculty on strategic

plans, capital plans, operating

budgets, public policy position

and other key items. This forum

also allows for information

sharing on various improvement

efforts in quality, services and

other areas. The financials are

Provides updates on the people

pillar performance and directs

clinical chairs on methods to

improve faculty performance

related to patient satisfaction

Transformational Leadership

Advocacy and Influence (4)

reviewed in detail monthly

identifying and discussing

variances based on budget.”

Human Resource Policy

Committee

The Human Resource Policy Sub-

committee is made up of

designated management

representatives from the major

areas of the University. Each

member of the committee is to

provide operational expertise on

how staff human resource policies

would impact their areas. The

role of this working committee is

to review recommended changes

to existing HR policies or to make

recommendations on the

development of new HR policies.

Once a policy reaches the

consensus of the members of the

policy sub-committee, the policy

is advanced to Policy Advisory

Board, comprised of senior level

executives or their designees for

review and approval.

Voting member that reviews

recruiting and hiring policy,

smoking, FLSA policiess (work

hours policy)

Clinic Redesign

Executive Committee

The purpose of the Clinic Redesign

Executive Committee is to support

and assist the clinics in designing

and implementing operational

models that improve access,

service, and evidence-based

delivery of quality healthcare

services for our patients. The

strategy is to: Redesign and

Approves nursing role changes

requiring evidenced based role

changes (triage nurses)

Transformational Leadership

Advocacy and Influence (4)

implement common/measurable

foundations for access operations

redesign and implement

common/measurable foundations

for clinical operations, and

support operations training and

development goals of VMG.

Organizational

Compensation

Committee

The purpose of the Organizational

Compensation Committee is to

address organizational concerns

about compensation and benefits.

Directs reviews for critical

nursing and other clinical roles

for market equity. Makes

recommendations related to

salary changes

[TL4-Exhibit A-1-CEEC Meeting Minutes Feb 2010, TL4-Exhibit A-2-CEEC Meeting Minutes Aug 2010, TL4-

Exhibit A-3-CEEC Nursing Presentation, TL4-Exhibit A-4-CEEC Nurse Residency Presentation] Other

minutes

are available upon request unless they are proprietary.

Table TL 4 – 2: Identifies the organization wide committees over which that Marilyn, as the

ECNO serves as the Executive Sponsor

Committee Purpose

Medical Center Staff

Advisory Committee

The purpose of the Medical Center

Staff Advisory Committee is to act

as an advisory group with both

administration and staff on

problems and policies that affect

the medical center and the people

it serves; to facilitate

communication between medical

center staff and administration on

all levels, including but not

necessarily limited to, Vanderbilt

University Hospital, Vanderbilt

University Medical School,

Vanderbilt University School of

Nursing, The Vanderbilt Clinic, and

Held retreat for group to create

charter purpose for this all staff

committee and how they need

to be effective in providdng and

receiving feedback. Employee

communitcation vehicle. Hold

quarterly meeting for chair and

executive te team.

Transformational Leadership

Advocacy and Influence (4)

medical center administration,

and to maintain effective

communication among staff

employees of Vanderbilt

University Medical Center.

Leadership Assembly The purpose of the Leadership

Assembly is for those medical

center leaders accountable for

pillar goal outcomes, to gather

quarterly with the Vice Chancellor

and other executive leadership.

These Leadership Assemblies

include the quarterly Elevate Pillar

Update as well as stimulating

leadership topics relevant to

sustaining a culture of excellence

and service.

Staff and Faculty

Satisfaction Survey

The purpose of the Staff/Faculty

(Community) Satisfaction Survey is

to utilize the tool drive employee

satisfaction and results across all

pillars organization-wide. The data

itself is shared with the staff and

actions are communicated based

on feedback.

Executive sponsor and thus

coordinates all work with the

vendor including contracting,

revisions to questions, action

plans and goals, time of

surveying

Patient Family Advisory

Council

The purpose of the Patient Family

Advisory Council is to offer

innovative ways for patients to

receive healthcare, become

healthy and stay healthy. This

council plans and evaluates

services, programs, policies, and

teaching materials.

Executive Sponsor attending

monthly meeting sharing and

hearing feedback. Work

influenced position on tobacco

free campus, patient education

work

Transformational Leadership

Advocacy and Influence (4 EO)

Advocacy and Influence

Source of Evidence 4 EO

Describe and demonstrate one (1) CNO-influenced organization-wide change.

Purpose/Background

VandyWorks

The Staffing Task Force was formed in 2001 as a request of the Chief Nursing Officer,

Marilyn Dubree, MSN, RN, NE-BC, to ensure that Vanderbilt Hospital and Clinics have the

appropriate staff resources properly deployed to provide consistent, safe, quality care. Through

the work of this group, it was determined that an electronic tool was required to achieve this

goal. A return on investment (ROI) was completed to quantify organizational benefit of an

automated tool.

The Staffing Task Force surveyed VUMC nurses to understand their unique staffing

requirements. Over an 18 month period, 13 vendors were evaluated to find the best product to

achieve our organizational goals. Workbrain (VandyWorks) was chosen as the best match due

to their track record of innovation and flexibility in retail and transportation markets.

Workbrain was willing to partner to develop a unique healthcare solution that goes beyond

basic staffing and scheduling and incorporates quality, safety and the ability to expand.

The initial cost of the Workbrain program outlay was $300,000. Ongoing support of the

project was an additional cost of the project. Functional and technical teams were created to

continue implementation and support of the work. Marilyn Dubree, MSN, RN, NE-BC, CNO,

advocated for the capital dollars and ongoing operating budget to support this project. (More

information is provided about VandyWorks in EP 8, 9, 11 & 12)

CATS

As the Medical Center continued to grow, Marilyn Dubree, CNO, helped to lobby for a

better way to monitor the nursing staff licensure, certification, education and experience.

Prior to an electronic system, each unit kept paper records to track the information on their

staff. The process was not consistent and it was challenging to have information readily

available during surveys by the state and JCAHO. Nursing leadership partnered with Human

Resources to make suggestions on the design of a program to fill this need. Marilyn presented

the proposal for the required capital outlay and ongoing operating budget to the board and

received approval.

Transformational Leadership

Advocacy and Influence (4 EO)

The Credentials Application Tracking System (CATS) was initially created to track nursing

licensure and certifications in 2005. Vanderbilt Medical Center identified that a single tracking

tool would be optimal so that a repository of information would be available for collecting data

on certification and licensure for nursing. A single tool would assist in monitoring license and

certification compliance for all staff as well as store years of experience used for salary equity

reviews among our current employees. Prior to CATS there was a gap in the system as this

information was not stored in any electronic or useable format.

Vanderbilt partnered with Infoworks, the computer software company used to write an

electronic evaluation program for Vanderbilt that is still in use (VPES). Infoworks was asked to

write a program to track licensure and certification for our professional nursing staff. The initial

cost of CATS was $60.00. In 2006 nursing was the primary user. In 2008, pharmacy technicians

were added. In 2009 licensure for Rehabilitation (PT/OT), Respiratory Therapist, Radiology

Technologists, Pharmacists, Laboratory Technologists, and Dietary/ Nutrition were added. In

2010, anesthesia technicians were added. In addition, all entry level positions in patient care

support, service support, and nutritional support were added. Case managers and Utilization

Management were also added to round out the clinical enterprise. The total cost of CATS to

date has been approximately $230.000 for the programming plus the additional support

supplied by HR to manage the program.

Methods/Approach:

VandyWorks

The Staffing Task Force (now Clinical Workforce Committee), under the direction of

Marilyn Dubree, MSN, RN, NE-BC, CNO, worked with Human Resource to write a clinical policy

on the “Schedule Process” for all the Medical Center staff. The policy included schedule length,

maximum hours of work and gave general parameters for vacation, holiday and personal day

scheduling that should be used for areas to write their own unit specific policies. (Reference

policy Patient Care Services: Scheduling Process, CL 20-06.25 – provided in EP 9) These unit

specific policies are reviewed by the Clinical Workforce Committee to ensure they were

consistent with the clinical operation policy.

Initially VandyWorks was piloted in two units 9N and 9S. The manager, assistant

managers, charge nurses and staff were given extensive training on how to use the program.

There were many focus session groups to gain knowledge on how the system needed to work

and how to make the work of the charge nurse easier to manage staffing. Using this pilot

information, the rollout process was planned. The VandyWorks team would meet with each

area and give a demonstration and discuss the setup process. The staff on the units were

involved in the process from the beginning and offered feedback. Unit specific rules were in

Transformational Leadership

Advocacy and Influence (4 EO)

place to provide consistency, fairness, and safe staffing decisions. Ongoing training was given

as new capability is added to the system. The team now has a full time RN educator who is able

to provide a clinical focus to the work.

After the implementation of the system in in-patient areas in both the adult and

pediatric hospitals, the focus has changed to meet the needs of the outpatient and procedural

areas. This work is ongoing. For some out-patient areas the VandyWorks system has not

matched the unique staffing requirements and partial shift times. These areas are brought on

line to use the request off function that allows tracking of leaves and to receive alerts for

certification and licensure via the CATS information.

CATS

When every staff member is hired, our HR tracking system, PeopleSoft automatically

loads their hiring information into CATS (unit, job code, etc). This is done by department

numbers. Then licensure, certification, education and years of experience are gathered by their

department and entered into CATS. This data follows the employee throughout their

employment at Vanderbilt even thought they may change positions. When staffs transfer to

new areas, PeopleSoft automatically makes those changes.

The department administrator (PAF responsible) and the department manager have

assigned access to CATS based on their job role in the People Soft system. Either of these two

responsible persons can delegate up to two department assistants per area to help assist in

data entry. The department manager has the overall responsibility of keeping this data up to

date in the system.

Licensure and other information can be updated as needed (expiration times).

Managers are also required to check the data annually at evaluation time. CATS is interfaced

with VPES which is our electronic evaluation system. When a manager is doing the staff

evaluation, an automatic notification comes up about reviewing CATS. The manager is then

linked directly into that staff member’s CATS database to be able to review their information.

All staff also have a “read only” capability for their CATS information. The system is set-up in

such a way that no one (manager, supervisor, etc.) can change or update their own

information, their one-up must do that. That is one of the many safe guards of the system.

New capabilities added this year include a date stamp for primary source verification

(State Website) and pop up messaging to remind managers or designees to enter additional

information related to certification and licensure for Advanced Practice Nurses and Emergency

Medical Personnel. The changes will improve complete documentation in the system.

Transformational Leadership

Advocacy and Influence (4 EO)

The system uses a stop light monitoring system:

 Green- information is current

 Yellow- information will expire at the end of the current month

 Red- information has expired and needs updated

This allows the manager or designees to see at a glance when staff information needs updates.

In addition, managers of the various areas can run reports for their specific units from

any information located in CATS. They can do years of experience, licensure expirations,

certification expirations, and many others. This provides a unique flexibility to the managers.

CATS administrators have the flexibility of adding additional licenses and certification

when needed. This flexibility in the programming has allowed Vanderbilt the ability to manage

the information required as new areas/departments have been added to the system over time.

Evaluation/ Outcomes:

VandyWorks

VandyWorks is used for reporting and tracking productive and non-productive hours (in-

services, sick, vacation, FMLA, etc). It is also able to track staff that clock in early for their shifts

or out late when leaving. Bi-weekly rollup reports are sent to the administrative leaders

showing hours and dollars associated with these costs so that the managers can manage these

hours to a minimum. Managers can run drill down reports that specifically identify staff that

are on the reports. Working to reduce the “in early” hours are a direct cost savings to the

Medical Center by managing incidental overtime. Managing these hours along with reducing

the hours needed to create and maintain a schedule for the units has been the ROI needed for

this project.

Staff satisfaction with the system has been positive. They are able to access their

schedule, make time off or swap shift requests from any computer. Feedback supports that it

makes the schedule process fair and allows easy access. Feedback indicates there is a high

learning curve but after the learning curve the system is user friendly and provides them with

the information they need.

The VandyWorks technical team has been able to add new alerts to the system by

pulling data from CATS in relation to nurse licensure. One example is nurse licensure compact

information. The system can look at the employee’s address and send an alert message when

the state of residency does not match the license entered into the system. This alert

information is validated monthly to ensure that staff licensure is correct to meet compact

Transformational Leadership

Advocacy and Influence (4 EO)

requirements. When staffs are identified, the unit/department manager is notified to follow up

for compliance and update the system or note approved variance from the rules written for the

VandyWorks system.

CATS

The CATS database has the ability to send the license and certification information to

the VandyWorks program, allowing for reminders of upcoming expirations for staff and their

leaders. For licensed staff using the VandyWorks system, if their license has expired in the CATS

system they are unable to be scheduled until this is updated. Recent updates in VandyWorks

can also project out for scheduling six weeks in advance and color code staff who have a license

that will expire in the future.

The CATS team partnered with the Resuscitation Department which provides

certification for VUMC staff for BLS, ACLS, PALS, etc. They now enter the new certification

expiration dates into the CATS system for each all Vanderbilt staff members attending. This

gives very accurate records for these certifications in the system. It has allowed the team to

run reports and identify how many staff members have expiring certifications and will need

training. This data allows the Resuscitation Department to more accurately plan on the number

of classes needed for each of the certifications required.

The CATS system has also been able to communicate with the Vanderbilt Performance

Evaluation System (VPES). Through this communication information is available during the

evaluations related to the employee’s status of required licensure and certification. RN

licensure and BLS information is uploaded from the CATS data. The CATS system integration

into VPES allows managers to easily and efficiently complete primary source verification for

licensure at the time of the annual evaluation.

The years of experience data in CATS is used by HR to determine salary for current staff

comparison. Using regression analysis, HR can determine cost when implementing market

adjustments with this data. This has been a significant improvement and time saver over prior

years saving time and dollars.

The CATS database has been invaluable during state and JCAHO visits. Reports are

easily pulled that detail all licensed personnel, type of licenses and tracking of expiration dates.

The system can also be used to track all required certifications for the different professions.

Each unit/department has designated staff that can access and maintain each group’s data for

their staff and run reports.

Transformational Leadership

Advocacy and Influence (4 EO)

Summary

Marilyn Dubree’s ability to actualize her vision of automated systems for scheduling and

tracking of required human resource licensure and other compliance data for nursing has had

far reaching and positive effects on the organization. The systems designed for nursing are now

used throughout the organization. The human resource transaction systems are now

organization wide and allow the organization to:

 Accurately and efficiently track licensure and competency status for individual staff

 Ensure required licensure and certification through automated reminders for staff and

managers

 Improve efficiency of verification of licensure requirements

 Use years of experience data for equity reviews for the implementation of market and

other organization wide adjustments as well as for individual reviews

 Improve the ability of staff to participate in creating work life balance by participating in

the scheduling process

 Examine human resource utilization to improve efficiency (example: timeout report)

[TL4EO-Exhibit A-1-VandyWorks Advisory Minutes Sept 10, TL4EO-Exhibit A-2-VW Project Team

Minutes Sept 2010, TL4EO-Exhibit A-3-News You Can Use Sept 2010, TL4EO-Exhibit A-4-

VandyWorks Alert]

Graph TL 4 EO – 1: CATS Screenshot

Transformational Leadership

Advocacy and Influence (4 EO)

“In their own words”

Salary and Compensation Comparisons From Human Resources

“Prior to CATS, the HR Office of Compensation had attempted several methods for

determining salary, with limited success, if an RN had x number of years of experience for

current staff and new hires. Our goal was to use the full pay range for individuals in the RN title

considering their years of nursing experience and their last performance evaluation score across

the organization, not just within a specific unit. Any attempt at data collection was via an Excel

Spreadsheet requiring a manual update each time the data was requested as well as the

logistical challenges of obtaining this information from each unit across the Clinical Enterprise.

When determining new hire salary rates, Recruitment did not have up-to-date information for

comparing against similar individuals within the organization beyond the unit level resulting in

inconsistent salary offers and creating bidding wars among hiring managers for the same

applicant. And, Compensation could not easily determine a cost estimate for a nursing market

adjustment.

With the creation of CATS, we now have a mechanism for capturing years of experience

that have greatly improved our processes. Years of experience data in CATS updates

automatically so that once the data is entered, it automatically adds the years without requiring

any additional work from the manager. We have the ability to pull RN data for the entire

Clinical Enterprise to compare individuals across entities and units with the same years of

experience and performance evaluation scores. Data is provided to Recruitment so that salaries

can be determined for new hires without disrupting salary equity with current staff, and reduces

bidding wars among hiring officials from different departments. Compensation has used the

data from CATS to conduct organizational wide salary equity reviews, and cost projections for

market adjustments. This process is invaluable for cost projections of widespread populations

such as nursing or entry level staff, each group with 2500+ employees. This method of reviewing

salaries for nurses has also been applied to Pharmacy Technicians, Rehab, Respiratory,

Radiology, Labs, and Dietitians. Information is power, and we have provided this invaluable

data and system to our managers, recruiters and compensation teams for evaluation and use of

efficient and effective methods to perform daily functions of their job.”

Leslee Hughes, MA, PHR, Manager, Compensation Human Resources

“The ability of VandyWorks and CATS to communicate is a huge win. Prior to this, the educator

or assistant manager manually tracked pending expirations and emailed staff. With this current

capability, the manager, administrative assistant and staff member receive an email beginning

90 days prior to expirations allowing plenty of opportunity for scheduling and completion of the

needed task. In addition, the nurse is automatically removed from the schedule in VandyWorks

if they fail to renew their nursing license prior to the expiration date.”

Debbie Shinkle, RN, BSN, MHA, M Ed, Manager, VCH 6A/B, Pediatric Hematology & Oncology

Transformational Leadership

Advocacy and Influence (4 EO)

“Having CATS and VandyWorks interfaced is helpful with automatic notices about license

expiration. This interface is also helpful with alerting staff about pending certification

expirations (BLS or ACLS). It gives a 90 day and 30 day alert.”

Julie Foss, MSN, RN, NE-BC, Manager, MICU VUH

“The reports allow us to track prior to expiration dates and provide staff with ample time to

renew their license and certification to meet their job requirements. Having staff removed if

their license is expired helps as a last and final warning to both the manager and the staff

member.”

Richard Corcoran, BSN, MSHA, RN, Manager, 9 North, Surgical Step down, VUH

“CATS has been valuable to the pharmacy to help us maintain updated information on licensure

status of our staff. The notification features are a great motivator to our staff to process

needed paperwork in situations where renewals may not be as timely as desired.”

Mark Sullivan, PharmD, Director, VUH Pharmacy

“The CATS database has provided us in the Respiratory Care Department with several

advantages:

1. We are now able to easily generate a custom report with all of our staff’s licenses,

expiration dates and special endorsements. This has been very helpful specifically when

we had our recent TN State Department of Health inspection and they requested a list of

all RTs, with license numbers, expirations dates and ABG endorsements. It only took a

minute to generate this from the CATS database.

2. The CATS database provides us with a quick visual of the status of all our staff with

regard to special certifications, i.e. Fundamentals of Critical Care Support (FCCS), ACLS,

PALS, BCLS training.

3. The CATS database also assists us with tracking years of experience so we can be

assured we are maintaining pay equity with all of our staff.

Anna Ambrose, RRT, MHA, Administrative Director, Respiratory Care VUH

“CATS have been helpful to me in tracking the renewals. One less spreadsheet I have to keep. It

automatically emails employees reminding them of their expiration date. One less email I have

to send. I can then update the system when they have renewed their license.”

Cindy Johnson, Pharmacy

Transformational Leadership

Advocacy and Influence (4 EO)

“It has been helpful to me in tracking renewals and reminding staff by the automatic emails. It

is very helpful!”

Rhonda Tully, CRA, MBA, Administrative Director, Department of Radiology

Transformational Leadership

Advocacy and Influence (5)

Advocacy and Influence

Source of Evidence 5

Describe and demonstrate how nurse leaders guide the transition during periods of planned

or unplanned change.

Vanderbilt is a system that has as one hallmark, the ability to plan and execute on

change. The drive to constantly improve, innovate and lead in patient care delivery

effectiveness and efficiency creates a culture where change is expected. The environment

attracts those who find change intellectually and professionally rewarding. Whether change is

“top down” or initiated from staff, nursing leadership is always at the heart of the change

planning, implementation and evaluation processes.

The Shared Governance model at Vanderbilt provides a strong structure to engage all

levels of nursing in the change opportunity. The structured described in OO 11 and SE 1, is our

vehicle for shared decision making, provision of feedback, and evaluation of change

effectiveness. Leaders use the rich dialogue of shared governance collaborative teams and

structures at all levels to recognize the need for change, test change ideas, to refine plans for

change, implement and evaluate change.

As change ideas emerge, the Nursing Executive Board places the change ideas against

the strategic direction for nursing, testing the congruency with over arching objectives. The

Nursing Administrative Boards which are both organization wide and entity specific are the

vehicle for accountability of clearly planning change across the organization. Nursing Leadership

Boards implement changes and use their area and Units Boards for rapid cycle improvement,

evaluation and feedback of real and proposed change.

Nursing leaders participate in enterprise wide committees and help those teams pace

the rate of change as nursing seems to be the common denominator impacted by all

organizational change. The collaborative nature of nursing with all disciplines positions nursing

leaders to be involved in designing change throughout the organization.

Three examples of how nursing leaders manage planned and unplanned change are described

below.

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Critical Care Nurse Practitioner Program

Purpose/Background

Patient volumes have been on a steady increase at VUMC. The strategic plan for the

organization included the addition of a new Critical Care Tower with 3 critical care units

opening in November of 2009. These units would accommodate increases in the Surgical

Intensive Care Unit (SICU), Medical Intensive Care Unit (MICU) and Neuro Intensive Care Unit

(NICU). As planning occurred for these expanded units, it was recognized that additional nurses

in advanced practice roles would be need to provide comprehensive, team based critical care to

the increased patient populations. This need was further reinforced by the unplanned reduction

of resident hours due to training program restrictions.

Pam Jones MSN, RN, the Chief Nursing Officer for VUH, was the executive leader for this

project. Other team members included Dr. Lee Parmley (Executive Medical Director for Critical

Care), Dr. Allen Kaiser (Chief of Staff – VUH), Clare Thomson-Smith, RN, APN, JD (Director,

Center for Advanced Practice Nursing and Allied Health), Devin Carr, RN, MSN (Administrative

Director) and Deeanne Moore (APN – NICU).

The need for a systematic plan and approach to this was identified as a goal for the CNO

during the annual goal setting process in July of 2008. A multidisciplinary group of leaders was

put together to assess this need and develop a standardized model. A roadmap for decision

making was developed and presented to the CEO on 8/25/2008. [TL5-Exhibit A-1-ICU APN

Coverage Plan Development]

The project team conducted a site visit to Duke University Medical Center which had

been identified as a best practice site for the use of advanced practice nurses in critical care.

Clare Thomson-Smith, Director for the Center for Advanced Practice Nursing and Allied Health,

also conducted telephone interviews with other experts in the utilization of advanced practice

nurses to assess best practice.

A model was developed in collaboration with the ICU Medical Directors and other

appropriate faculty members and presented to administration for approval. [TL5-Exhibit A-2-

ICU APN Critical Care Model] This model included the addition of advanced practice nurses at a

ratio of one (1) APN to eight (8) patients. The numbers of APNs hired allocated per unit varied

depending on the resident coverage. The appropriate number of APNs were placed in the

budget and hired in a staggered manner in preparation for the opening of the Critical Care

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Tower. The staffing compliment was determined and put into the budget for the fiscal year,

2009-2010 which began on July 1, 2009.

In addition to the model development, the physician leaders of MICU developed an

extensive training program to ensure competency for the MICU APNs. Historically, the MICU

did not utilize APNs at all and Dr. Art Wheeler, Medical Director of the MICU, embraced the

concept with academic enthusiasm. The curriculum is attached. [TL5-Exhibit A-3-MICU NP Core

Curriculum]

Meal Break Time Keeping Unplanned Change

In November, 2009, Vanderbilt University Medical Center attorneys were notified of a

class action lawsuit that had been filed against Vanderbilt by a former nurse. The nurse alleged

that Vanderbilt had not compensated her and other of Vanderbilt employees for missed meal

breaks. We learned this was a common occurrence that was happening throughout the

country.

The situation was that the time and attendance system at Vanderbilt (Kronos) was

programmed to deduct 30 minutes from the total time an employee was clocked into work as

an automatic deduction for a meal break. If an employee missed the meal break, the employee

should self-correct by cancelling the meal break deduction or reporting the missed meal break.

Reporting the missed break allows the time-keeper to cancel the deduction. The lawsuit

alleged that employees who did not get a meal break due to work responsibilities were not

always compensated for that time. The lawsuit was based on the Federal Labor Standards Act,

which requires that employees be paid for all hours worked, including meal breaks missed by

employees or meal breaks that were interrupted in such a way that the employees were not

able to fully enjoy their meal breaks.

The person involved in the lawsuit was the Executive Nursing Officer and became the

Executive leader responsible for managing the situation. Since the allegations in the lawsuit also

related to non-nurses, David Posch, the CEO of the Vanderbilt Medical Group, became Marilyn

Dubree’s Executive partner.

The actions taken to resolve the matter included:

 Increase all supervisor , manager and leader understanding of and ability to comply

with the federal regulations and Vanderbilt University Policies on meal breaks

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 Correct any error that had occurred in compensation

 Clarify the rationale for the automatic meal break deduction in the time and attendance

system

 Reinforce the expectation that all staff take regular breaks

 Maintain a process of time keeping that is efficient and effective for staff and the

organization

An Executive Committee was formed to manage this situation with far reaching

implications to the organization. The Committee included:

 Marilyn Dubree, RN, MSN, NE-BC, Executive Chief Nursing Officer

 David Posch, MS, CEO Vanderbilt Clinic and Executive Director Vanderbilt Medical Group

 Lynn Webb, PhD, Assistant Vice Chancellor for Health Affairs

 John Manning, Assoc. VC for Health Affairs and Chief Admin Officer and Sr. Associate

Dean for Operations and Admin, SOM

 Wright Pinson, Deputy Vice Chancellor for Health Affairs and CEO of the Hospitals and

Clinics

An Education and Communication Committee was also formed and included:

 Susan Mezger, CCP, SPHR, Director, Human Resources

 Terri Minnen, Senior Consultant, M.Ed.

 Pam Brown, Director, Organizational Effectiveness Team

 Debora Shiflett, Director, VUMC Financial Training

 Karen Anne Rye, Assistant Director, Enterprise Wide Functions

 Debianne Peterman, Ph.D., MSN, RNC-NIC, NE-BC, Director, NE & PD

 John Callison, Senior Deputy General Counsel

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 James Floyd, Associate General Counsel

 Veronica Burns, Senior Director, Human Resources

 Nannette Vaughan, Manager, Department of Employee Relations

 Payroll office and Management Information Systems

Action Steps

The first action was to review the Vanderbilt policies and understand if the policies were

consistent with Federal requirements. The policies were reviewed and, while the policies were

consistent, some revisions were made to clarify any ambiguities.

The second step was to investigate if Vanderbilt was following the stated policies. To

that end, hundreds of supervisors, managers and timekeepers were interviewed to assess their

practices related to time keeping and meal breaks. This was accomplished with the assistance

of external legal manpower. The assessments found that there was variation in the

administration of time keeping related to time and attendance. At this point, Vanderbilt

recognized that there was potential for error in payment to employees and began to action

plan.

Based on the principle for doing the right thing for employees, planning was focused on

communication, education, and identifying error in payment. A team of human resource,

training and financial experts was assembled to take the next steps. A process was designed to

inventory the number of staff who might not have been paid accurately. The process that was

developed was a survey methodology.

The survey was developed with the intent that it would be made available to all current

and former staff using the Kronos system for time keeping in the last two years. The survey was

developed to provide each staff member the following employee-specific information: total

number of meal breaks that were deducted from their pay for the previous two years and the

number of meal breaks that were credited back (logged as “no meal break”) in the Kronos

system. With that information, staff members were asked to declare the number of meal

breaks they missed and were not compensated for in the two year period. [TL5-Exhibit B-1-Staff

Training]

Vanderbilt’s intention was to do the right thing for employees trusting in the honesty of

employees to self-report accurately. As a result of Vanderbilt’s program of education and self-

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correction (including voluntarily paying staff for all reported meal breaks missed); the lawsuit

was dismissed at an early stage.

Communication and education for this entire effort was daunting. A detailed training

plan is provided for review. [TL5-Exhibit B-2-Training and Communication Plan]

Training/Education

Managers and supervisors were first trained in required sessions. [TL5-Exhibit B-3-

Manager Training]

The objectives of the supervisor training were to:

 Define the supervisor’s responsibility and accountability for:

o Reconciling and approving payroll data

o Overseeing the timekeeping function

o Monitoring of trends and practices within department

o Communication process of policy and procedures to staff

 Identify the correct procedure for reviewing and approving time records when a staff

member has not been able to take an uninterrupted meal break during work hours.

 List examples of best practice to create an environment where staffs routinely take an

uninterrupted meal break.

After leaders were trained and aware of the plan, the training effort turned to staff. There

were multiple sessions at various times in order to provide sessions for those working different

shifts.

The training objectives were to:

 Define an “uninterrupted meal break.”

 Identify the correct processes to follow to cancel an automatic meal deduction in

Kronos.

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 List the steps required to ensure that the Kronos time record is accurate.

Once the training was complete, staff began taking the survey. Vanderbilt provided a

helpline for those needing assistance with their survey information. In addition, staff was able

to go to dedicated computer rooms during the survey period in case they did not have easy

access to a computer nor needed additional assistance. After the survey was closed, it was

recognized that some staff who did not participate in the survey wanted to be included. The

survey was reopened to staff who had not taken the survey initially.

Once staff had declared the meal breaks for which they believed they should be paid,

letters were written to staff with an explanation of the compensation they would receive. They

were paid the average rate of pay for the two year period for the hours they reported as not

paid.

A helpline and frequently asked questions website were developed for ongoing support

to staff, supervisors, managers and leaders. The Executive Leadership team continues to meet

once a week with additional meetings at least twice a month to monitor progress of the effort.

Summary

This entire event caused Vanderbilt to learn about an opportunity for improvement. The

event created recognition of the need for ongoing and predictable education related to time

keeping. In addition, it created a model for managing meal breaks that is now being extended

to other employees who do not use the Kronos system. The event tested the organization’s

ability. Never before had such an extensive institution-wide education effort been executed in

such a short time frame. Perhaps, most importantly, the event tested Vanderbilt’s commitment

to employees and for defining the “right thing to do” approach to providing fair treatment to its

most precious resource - Vanderbilt staff.

Measureable outcomes include:

 Policy was revised (provided for review)

 Hundreds of managers, supervisors and timekeepers interviewed

 Approximately 1,600 managers, supervisors, administrators were trained

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 Approximately 10,000 employees using Kronos were trained (40 sessions which

provided 24,700 available seats)

 7217 employees responded to the survey

 2,782employees were compensated for missed meal breaks

VUMC H1N1 Pandemic Response

When the outbreak of H1N1 began in April 2009, through an interdisciplinary approach

VUMC was ready to respond. On the weekend of the initial outbreak the Chief Medical Officer

& Associate Vice Chancellor for Clinical Affairs, Chief Hospital Epidemiologist, and VUMC

Emergency Preparedness Coordinator kept in close contact by phone on the developing health

emergency. On Sunday, April 26

, the decision was made by this group to have an Executive

Briefing early Monday morning due to the extent of the developing H1N1 outbreak. The VUMC

Emergency Preparedness Coordinator , Pam Hoffner, RN, MSN was also in contact with the

Regional Hospital Coordinator and requested a TN Department of Health (TDH) Hospital

Advisory Committee conference call on Monday to ensure all TN hospitals were updated on the

situation, communication lines were established, and to ensure a well coordinated response to

the health emergency.

At the first Executive Briefing, it was decided a gap analysis of the VUMC Contagious

Pathogen Plan needed to be completed to ensure readiness for a bio health emergency

response. A Vanderbilt University representative would be included in all executive level

meetings to ensure the University response plan was in place. There were a series of daily

Executive Briefings and Operational meetings over the next several days which where chaired

by Executive Nursing Leaders in collaboration with the VUMC Emergency Preparedness

Coordinator, and Executive and Senior Medical Leadership. The VUMV Emergency

Preparedness Coordinator and Director of Infection Control attended frequent TDH conference

calls and conference calls with the Regional Hospital Coordinator.

The Monroe Carell Junior Children’s Hospital at Vanderbilt received their first suspected

H1N1 Influenza patient. With the arrival of the first patient, the decision was made to increase

surveillance activity to include virtually all ports of entry into the Medical Center. A partial

activation of the Emergency Operations Center (EOC) allowed for a succinct interdisciplinary

response to the health emergency. Executive briefings were conducted on a daily basis.

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The Contagious Pathogen Plan gap analysis performed by the VUMC Emergency

Preparedness Coordinator in collaboration with the Executive Chief Nursing Officer revealed

gaps in HR, Triage, Surge Capacity, Education, Vaccine and Antiviral Allocation/Distribution, and

Ethics. To remedy these areas of vulnerability, six interdisciplinary pandemic planning teams

were formed to address each gap. A chair (from senior leadership) was assigned to each team

and the majority of team meetings were facilitated by the VUMC Emergency Preparedness

Coordinator. The teams were given a series of tasks to rectify the gaps and these were to be

completed within a designated time frame set by the Chief Medical Officer & Associate Vice

Chancellor for Clinical Affairs.

The partially activated EOC remained operational along with the daily Executive

Briefings for a total of nine days at which time H1N1 Influenza activity in the state of TN

stabilized. During this time, it became apparent there was a need for a medical director to be

assigned to the Department of Emergency and an appointment was made by the Chief Medical

Officer & Associate Vice Chancellor for Clinical Affairs.

The need for a Pandemic Tabletop Exercise for Executive and Senior Medical Leadership

to test the newly revised Contagious Pathogen was entertained by the VUMC Emergency

Preparedness Coordinator and Executive and Senior Medical Leadership agreed this would be

an excellent educational method to utilize to train senior leadership about pandemic planning.

A decision was then made to hold the exercise in early September.

During the months of May, June, July, and August the Pandemic Planning Teams

continued their work until their task lists were completed. Periodic updates were given to

Executive Leadership by the VUMC Emergency Preparedness Coordinator and the newly

appointed Medical Director for the Department of Emergency Preparedness.

The increased surveillance efforts continued at VUMC throughout the summer months

and H1N1 Influenza was elevated to a pandemic by the World Health Organization (WHO) in

the month of June. During the months of July and early August the VUMC Emergency

Preparedness Coordinator served as a liaison and consultant to Vanderbilt University in their

pandemic planning efforts with their start-up of the fall semester. She also assisted the

Director of Student Health, Dr. Hanson, in obtaining a Memorandum of Understanding (MOU)

with CVS pharmacy in an effort to streamline the filling of antiviral prescriptions in order to

streamline patient throughput in the Student Health Clinic.

The Labor Day weekend proved to be the start of the second wave of the H1N1

Pandemic for Children’s Hospital. It hit with a vengeance that allowed us to test our plan. This

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was followed by an outbreak on the VU campus side. The other metro hospitals didn’t

experience a large second wave of H1N1 like VUMC.

A multidisciplined H1N1 Steering Committee comprised of senior leadership was formed

at the request of the VUMC Emergency Preparedness Coordinator to establish a mechanism to

handle the second wave of the pandemic. This proved to be a good forum to coordinate the

second wave response efforts and minimally disrupted hospital operations. A weekly

conference call was also conducted with the University side and was attended by the VUMC

Emergency Preparedness Coordinator.

In early September an H1N1 Pandemic Exercise was conducted and attended by 106

faculty and staff members who included a large portion Executive and Senior Medical

Leadership along with VU Executive Leadership and key Medical Center departments. The main

objective of the exercise was to educate senior leaders and key departments about the newly

revised Contagious Pathogen Plan and the pandemic planning process. This exercise was

planned and facilitated by the VUMC Emergency Preparedness Coordinator.

Following the exercise, the VUMC Emergency Preparedness Coordinator was utilized as

a consultant for pandemic preparedness initiatives in several medical center departments and

divisions. Faculty and staff were also assigned to a mandatory online inservice on the VUMC

Contagious Pathogen Plan and Pandemic Planning. The VUMC Emergency Preparedness

Coordinator was an active participant in the development of this inservice in collaboration with

the pandemic planning education team, infection control, and the Chief Hospital

Epidemiologist.

During the fall and winter months, the adult side of VUMC experienced a few surges in

H1N1 influenza cases that primarily affected the MICU. The H1N1 Steering Committee and VU

conference calls continued to meet on a weekly basis and H1N1 issues were addressed on a

weekly basis in this forum some of which included: weekly surveillance reports on flu activity

and N-95 mask usage, antiviral distribution, H1N1 vaccination distribution, education of

patients and visitors, and ECMO issues. At the beginning of December H1N1 surveillance

reports indicated a marked decrease in disease activity in TN and at VUMC. At this time a

decision was made by the H1N1 Steering Committee members to decrease meeting frequency

to bi-weekly. In early January, the flu surveillance systems continued to indicate very little

H1N1 activity and the decision was made to discontinue the H1N1 Steering Committee with the

understanding to resume the meetings if activity started to increase.

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At this time the VUMC Emergency Preparedness Coordinator continues to monitor

H1N1 activity in collaboration with Infection Control and the Chief Hospital Epidemiologist and

the pandemic planning process continues at the medical center.

In summary, the success of VUMC’s and Vanderbilt University’s response plans was

due, in large part, to a exceptional degree of interdisciplinary collaboration within Vanderbilt as

well as extensive external communication and collaboration at the local, state and national

levels.

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Advocacy and Influence

Source of Evidence 7

Describe and demonstrate how nurse leaders value, encourage, recognize/reward, and

implement innovation.

Examples and methods of valuing, encouraging, recognizing and rewarding innovation

are found across the organization. The following are some of those examples.

Table TL 7 – 1: Examples

Recognition and

reward through

the Center for

Frontline

Leadership.

Through the Center for Front Line Leadership program, Vanderbilt Nursing

invests in training aspiring leaders into the field. Since 2006, Vanderbilt has

partnered with the Advisory Board to make the Center for Frontline Nursing

Leadership program available to Vanderbilt nurses.At the end of the

program, all participants are honored by presentation of their projects to

the Nursing Administrative Baird members. [TL7-Exhibit A-1-CFNL

Graduation Jan 2010]

The Future of Nursing Leadership Award was initiated in 2007 to recognize

the incredible impact of frontline nurses who have completed the Advisory

Board Academies’ Center for Frontline Nursing Leadership. Tanika Wilson,

RN, BSN, Assistant Manager PCCU was recognized for her work on “Drip

Double Check reduced medication Errors” in 2009. Debra Grimes, RN,

Charge Nurse in Women’s Health was recognized for her work in “Creating

an Acuity Based Staffing Model” in 2008. Both of these award winners are

highlighted on the Vanderbilt Nursing Web site. The web site provides

videos of each of these award winners.

http://www.mc.vanderbilt.edu/root/vumc.php?site=vanderbiltnursing&doc=18887

Annual Nursing

Awards

Every year nurses from across the VUMC system nominate the best and the

brightest for recognition at Vanderbilt. The nurses to be awarded are

selected by a committee. The nominees and the award winners are

recognized annually at a presentation ceremony during Nurses week.

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Information about these nurses remains posted on the Vanderbilt Nursing

Website. The 2010 award winners are listed below.

Spirit of Nursing Award:

Elliott Douglass, RN, BSN, WOCN

Monroe Carell Jr. Children's Hospital at Vanderbilt

What is the essence or heart of nursing at Vanderbilt? Several moving and

inspirational pieces were submitted, but the nursing council selected a

poem, submitted by Elliott Douglass, R.N., the wound ostomy and

continence nurse at Monroe Carell Jr. Children's Hospital at Vanderbilt.

Douglass, who spent most of her 13 years in nursing working with adult

patients at Vanderbilt University Hospital, says coming to work at Children’s

Hospital three years ago brought her love of nursing full-circle. It is a life-

long passion that began at the age of 3, when she developed epiglottitis and

nearly suffocated. She says James O’Neill, M.D., then chairman of Surgery in

Pediatrics, saved her life, and her experience in the critical care unit at

Children’s left a deep impression on her. Poetry has been another passion

for Douglass. “In high school, the boys would ask me to write poems they

could use to give to their girlfriends,” Elliott says with a laugh. Her love of

poetry and nursing blend nicely in the winning essay for the Children’s

Hospital “Spirit of Nursing” contest.

The Rebecca Clark Culpepper Award:

Jan Malone, RN, BSN

Interim Nurse Educator/Charge Nurse, Monroe Carell Jr. Children's

Hospital at Vanderbilt

The Rebecca Clark Culpepper award is given jointly by Vanderbilt School of

Nursing and Vanderbilt Medical Center Nursing to honor Becky’s many

contributions to both areas. The recipient can be a nurse at VUMC or faculty

at VUSN. The recipient of this award exhibits mentorship of fellow nursing

staff, faculty or students and actively promotes of the nursing profession.

There is a commitment to professional development at all levels.

In December 2009, Jan accepted the Interim Nurse Educator position for the

Pediatric Surgery and Adolescent Unit. Jan had agreed to support the unit in

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this role as temporary position while the regular Educator is out on

maternity leave. During her short time in this role, she has been active in

attending clinical practice and policy meetings. She actively seeks out

evidence based research, collaborates with the management team, and

seeks staff input to support her recommendations. In addition to this new

role, Jan is an active member in the Society of Pediatric Nursing and has

recruited many new members into the organization. Recently, Jan was

confirmed as the new Vice President for the Middle Tennessee Chapter of

Pediatric Nursing. She attended the National Society Pediatric Nursing

Conference in Orlando, Florida this May.

In her Interim Nurse Educator role, Jan assigns preceptors to orient new

staff, pediatric nurse residents, and nursing practicum students and also

coaches and mentors the preceptors and helps them individualize plans to

meet the needs of the new staff members and students.

Jan encompasses the true spirit of nursing through her passionate

commitment to elevate the nursing profession and her commitment to her

colleagues. This is demonstrated through her quest to engage others to join

nursing organizations and seek continuing education opportunities that

advance nursing practice and organizational standards.

Vanderbilt School of Nursing Faculty Award:

Clare Thomson-Smith, JD, MSN, RN, FAANP

Assistant Professor of Nursing

Director, Center for Advanced Practice Nursing and Allied Health

This award is given to the Vanderbilt School of Nursing faculty (nurse or non-

nurse) who has made the greatest contribution to the field of nursing.

Clare Thomson-Smith serves as a role model, advocate and a mentor at the

School of Nursing, the Medical Center and the Tennessee Nurses

Association. She contributes to the academic mission of the school by

facilitating courses for the much-in-demand Health Systems Management

program of study – teaching students from around the country who are or

will become nurse administrators and leaders for health systems throughout

the country. As director of CAPNAH which is dedicated to supporting existing

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and emerging practices, she and her team have made significant strides in

mentoring advanced practice nurses and allied health professionals into the

profession and the VUMC culture with a robust array of activities and

professional development opportunities.

She has used her J.D. degree to become an advocate for policy development

related to advanced practice nursing. She serves as chair of government

affairs and health policy committee for the Tennessee Nurses Association

and can navigate the often challenging and ever-changing landscape of

health care legislation in the state. She voluntarily contributes her time to

these efforts to support the role of advanced practice nursing because she

believes in the important role that advanced practice nursing plays in health

care delivery – throughout Vanderbilt, the state and the country. Thomson-

Smith is widely viewed as an expert in her field and was recently selected as

a 2010 Fellow of the American Academy of Nurse Practitioners, recognized

for her outstanding contributions to health care through clinical practice,

research, education or policy.

Advanced Practice Nurse of the Year Award:

Kimberly Huffman, RN, MSN, PNP

Pediatric Otolaryngology

Kimberly is the Vanderbilt Children’s Hospital resource for the Pediatric

Otolaryngology service. She provides continuity of patient care by

participating in daily team rounds and attending rounds, evaluating

consultations in the ER and with inpatients, and facilitating preoperative and

postoperative care of patients. Although Kimberly joined the Peds ENT team

in 2008, her knowledge and clinical skills are well beyond expected for her

years of training. Kimberly confidently assists in patient management and

instructs residents how to care for common pediatric otolaryngology

problems. She is a huge resource for ensuring proper multidisciplinary care

of pediatric patients. She maintains open lines of communication with the

Pediatricians, Peds GI, Peds Pulmonary, PICU, NICU and ER. In addition to

these duties, Kimberly serves at the tracheotomy resource for Children’s.

She provides education to nurses, patients and families and ensures that the

necessary equipment and supplies are available prior to discharge. In fact,

she is often contacted to serve as a tracheotomy resource for patients not

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treated by the Otolaryngology service. In addition, she has developed the

website for the Peds ENT department and her efforts there are decidedly

centered on patient understanding and care.

Kimberly has created and implemented several new evidence-based practice

(EBP) order sets for the Peds ENT service (including postop cleft lip, postop

cleft palate). She was also instrumental in developing a Children’s hospital-

wide, standardized post-tracheotomy order set. Kimberly also serves on the

Nursing Research Committee.

Kimberly is an integral part of the Pediatric Otolaryngology team. She is a

patient advocate, and provides seamless continuity of care from the clinic

and OR to the hospital. She educates residents and nurses on a daily basis

and is a Children’s-hospital wide resource for tracheotomy patients. Through

her collaborative efforts with other services, Peds ENT patients receive the

best care possible.

Staff/Unit/Department Educator of the Year Award:

Kara Gordon, RN, MSN, Nurse Educator

Vanderbilt University Hospital Medical Intensive Care Unit

The recipient of this award demonstrates participation in and models lifelong

learning and positively reflects the image of nursing. Education is Kara’s

passion. She is a positive, knowledgeable, cheerful and caring person. Kara’s

main focus is providing the staff with the tools needed to deliver excellent

patient care. She fulfills this challenging task while remaining positive and

helpful.

All aspects of Kara’s work are based on evidence. She models and promotes

evidence-based nursing practice, while coaching the staff in obtaining and

using evidence. She also collaborates with the EBL librarians in obtaining

needed information and utilizes critical care research from the National

Teaching Institute. Through the utilization and sharing of evidence, Kara is

able to influence nursing practice on the unit and organizationally.

Kara plays a leadership role in both unit and organizational initiatives,

including, but not limited to, blood stream infections, Pressure Ulcer

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Prevention, nurse resident education, HINI, bariatric equipment and the

work around the Critical Care Tower. Helping to maintain a calm

environment when anxiety was very high supported the staff to focus on

safe patient care. Kara has been a leader in the work around the Critical Care

Tower. She was instrumental in developing the education provided to all

critical care nurses prior to the move and opening.

Kara is an advocate and support for the staff in regard to professional and

personal educational goals. She mentors staff in studying for and taking the

Critical Care RN certification exams and helps them obtain study materials.

Kara encourages staff to become certified in CVVHD for our renal

population. She works with graduate students and also took a refresher

pathophysiology course recently at Vanderbilt. Kara encourages staff to

continue their education whether it is graduate work or other.

Kara is a valued role model and colleague to the staff of the MICU and many

others throughout the Medical Center and also a great friend.

Julie Foss, RN, MSN, NE-BC

Nurse Manager, Medical Intensive Care Unit

Julie has been the manager in the MICU for 21 years and some of the staff

has been with her the entire time! Her hard work, dedication and nurturing

spirit have helped to create the awesome work environment in the MICU

today. MICU staff believes she is one of the finest leaders. Julie is a role

model for shared governance. She sets a tone of enthusiasm and inclusion.

Each staff member knows their comments and ideas are valued. Through

unit board, staff meetings, frequent emails, Friday communication, rounding

and general visibility, staff are able to provide feedback and stay informed

about the Medical Center and MICU.

Julie recognizes other departments’ contributions to patient care and urges

the staff to show appreciation to those who support patient care. Recently

she shared how a member of our Environmental Services team went above

and beyond the call of duty to help with a challenging patient. As a result,

we were able to celebrate and honor the ES staff member. She co-chairs the

Retention and First Two Years Retention Committee for Be the Best. She is

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also active in HED Advisory, UTI Advisory, Falls Prevention, Handiworks, VAP

Dashboard, and Rapid Response. Julie helped lead efforts in transitioning to

the new Critical Care Tower.

Julie treats all people with respect and compassion. She lives the Credo and

is positive and inspires the staff to do the same.

Licensed Practical Nurse of the Year Award:

Arthur Thompson, LPN

Neurology Clinic

Our staff fondly refers to Arthur as "Mr. Vanderbilt.” Over Arthur’s thirty-

five years at the Vanderbilt University Medical Center, he has been in the

forefront of many great activities that have helped to make this institution

the place is it today, through Nursing. Some things Arthur has been a part of

are: the first Unit/Clinic Board in our clinic (and is presently the Unit Board

Chairperson); a leader in feeding the staff and the patients’ family members

on Thanksgiving Day in the Neurology units; advocating for the LPN name

badge change; a member of the original Nursing Staff Council, and

instrumental in the need to expand and develop a clinic nurse council to

better represent the outpatient nurses.

Although for many years, Arthur has been a mainstay in the Stroke division

of the Neurology Clinic, he is also a part of the Movement and Headache

team in the Neurology Clinic. Arthur continues to be an alternate for VMG’s

Nursing Staff Council as well as alternate for the Nursing Staff Bylaws

Convention Delegate.

This year Arthur Thompson has been appointed to the Tennessee State

Board of Nursing, and he is one of only three licensed practical nurses on

this important board. This appointment honors the role of the LPN and

instills pride for all Vanderbilt Nurses. Arthur is the type of nurse that makes

Vanderbilt Nurses stand out and his work contributes to making us a Magnet

designated organization. Arthur is a good friend to both patients and staff.

Research and Evidence Based Practice Award:

Donna Christensen, RN, BS

Evidence Based Medicine Specialist,

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Case Management Department

In Donna’s role as an EBM Specialist, she meets the criteria for this award

many times over on a daily basis. Since 2008 Donna has served as a leader

on the Nursing Research Committee to build resources that support staff to

access nursing literature, conduct critical analysis and make practice

recommendations.

Donna supports many nurses in their quest through individual consultation

and the development of web-based EBP tools. One example is the “Got a

Question” tab on the Nursing Research web site. Nurses or any member of

the team can post a clinical question and receive a summary of the evidence

available to answer the question. The traffic in this activity is very high and

Donna has a personal commitment to provide high quality answers. A large

number of nurses have benefited from Donna’s extra efforts and thus

supporting quality patient care. Donna does work with the research staff in

the Eskind Biomedical Library on the complex questions, but screens each

one herself. Donna is a role model on providing feedback and presenting

her opinion.

Donna compiled all of the Research website links and for the search tips

section. This has given any nurse at Vanderbilt access to many resources

which provide evidence to support or improve patient care. Donna’s

greatest contributions may not lay within the realm of research itself, but

her evaluation of the implementation process. This evaluation process is

critical for us to continue to improve nursing practice at Vanderbilt as well as

move the science of nursing forward. Donna has been a leader in the efforts

to move Vanderbilt nursing to a higher level of evidence-based practice. Her

contributions to the Nursing Research Committee are invaluable and

showcase only a portion of Donna’s dedicated work

Team Award:

Monroe Carell Jr. Children's Hospital at Vanderbilt

Perioperative Services Guatemala Mission Team September 2009

Each year throughout the Medical Center, different individuals and teams

travel the U.S. and the world on medical missions. Several teams have gone

to Guatemala and we salute all of those teams and individuals. The

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particular team being recognized by this award is the Guatemala Team of

September 2009.

The success of this team’s hard work is measured in the quality of the lives

changed; specifically the children of Guatemala. From the 96 patients

screened to the 51 who received surgical care, this team had a direct impact

on the quality of life for many. Surgical outcomes were measured by clinical

data, but cannot compare to the emotional well-being. The clinical

outcomes are followed by both The Shalom Foundation and individual

physicians at Vanderbilt. They were also able to follow-up on past surgical

patients and bring that news back to other staff from previous mission trips.

The team demonstrated a strong sense of inquiry in preparation for the trip

by packing all necessary equipment and supplies and taking into account

cultural aspects as well. Coloring books and candy were mixed in with

surgical drapes and scalpels. Spanish translation of teaching materials was

instrumental to the team’s success. None of this could have been

accomplished without research and team coordination.

The interpersonal communication skills team members honed have

improved “hand overs” here at Vanderbilt. In addition, team members

reported they got back to the basics of nursing, through having to “make

do” and be creative. Working with the staff from the local hospital was

rewarding for the team and enhanced learning on both sides. Their

welcoming attitudes taught the Vanderbilt team a lesson in

inclusiveness. The team faced challenges and overcame many obstacles.

However, it was worth it to see the smiles and to receive the handshakes

and the hugs. Changing lives in a different country means changed lives back

here at Vanderbilt.

Rosamond Gabrielson Staff Nurse of the Year Award for Monroe Carell Jr.

Children's Hospital at Vanderbilt, Vanderbilt Medical Group, Vanderbilt

Psychiatric Hospital, and Vanderbilt University Hospital

Lisa Foust, RN, Vanderbilt Medical Group, Vanderbilt Health One Hundred

Oaks

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Lisa Foust has defined the model for "team approach." Her colleagues

respect and admire her. They turn to her for patient care advice routinely.

Lisa treats every patient as her own, and leaves nothing for the next person

to finish. Lisa's friendly and confident demeanor immediately establishes a

good rapport with patients. But what she offers our patients is far more than

a great first impression. To them, she is a reliable and loyal advocate who

inspires trust and confidence. She is central to their success in blood

pressure management, weight loss, dietary and exercise compliance, and

lipid management, as she is integral to the follow-up on these patients both

in clinic and in the interim between clinic visits.

Lisa has been integral to the success of the Vanderbilt Heart Preventive

Cardiology program. In only two short years Lisa has become so

knowledgeable about management of cardiovascular risk factors that she is

able to anticipate the next step (e.g. changes in medications) and prepare

for it, and she frequently makes pertinent suggestions for patient care and is

able to integrate complicated factors like cost, likelihood of patient

compliance, side effects, and/or drug-drug interactions into her decision

making suggestions. Lisa has promoted preventive cardiovascular health,

women's health, and Vanderbilt, and she continues to self-educate. She

attends evening Vanderbilt Lipid Club journal club meetings regularly and

she served as a host at several OHO opening events to promote the new

clinic. She has also been critical in helping design and implement a free

(daily!) heart health screening program for women at OHO (this program

could serve 500-1000 women per year).

Lisa makes many contacts with other RNs and practitioners to constantly

stay involved in what is going on in preventative medicine. Lisa is also the

frontline contact for the preventative program's involvement with the lipid

management practice. She works with that team's NP, MDs and research

team to ensure that patients who qualify for new and ongoing research

studies are entered and have assistance.

Lisa Foust is the absolute epitome of nursing. She is an incredible and loyal

colleague. She is a patient advocate, and her leadership style is organized

and thorough. Her impeccable work ethic, leadership, thoughtful approach

to patient care, and contribution to Vanderbilt deserve not only recognition,

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but great reward.

5 Pillar Leader

Award

Two nurse leaders this year were honored by the entire organization as 5

Pillar Leaders. All leaders serving VUMC are eligible with the exception of

executive leadership guided by the following criteria:

 Nominees in a leadership position for at least one year.

 Nominees must be in good standing and nominations must be

supported by “one up” leader.

 Nominations may be made by any faculty or staff member. Self-

nominations are not accepted.

 Nominees must demonstrate consistent practices that impact

success across the five pillars and demonstrate consistent Credo

behavior

The following excerpt was taken from the Reporter and written by Paul

Govern

9/25/2009 - Several staff and faculty who do consistently outstanding work

were honored last week at Vanderbilt University Medical Center's

Leadership Assembly at Langford Auditorium.

Donna Williams, MSN, R.N. NEA-BC, an administrative director with

Operative Services, was presented with the Five Pillar Leader Award for

superior

All-around leader Donna Williams, R.N., received a Five Pillar Leader Award.

(photo by Susan Urmy)

Performance across VUMC's management “pillars” — employee satisfaction

and retention, service, quality, finance and innovation — and for upholding

the VUMC Credo.

The award was presented by John Brock III, M.D., surgeon-in-chief at the

Monroe Carell Jr. Children's Hospital at Vanderbilt.

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“Donna Williams is simply the best of the best. She makes everyone around

her better. There's no greater honor for someone like me than to work with

someone like Donna,” Brock said.

December, 2009 Karen Hughart, M.S.N., R.N., director of Systems Support

Services, was presented with the Five Pillar Leader Award, which recognizes

superior performance across the Medical Center's management “pillars” —

service, quality, finance, people and innovation.

Karen Hughart, M.S.N., R.N.

As director of Systems Support Services, Hughart has aided clinical

information technology implementation at VUMC. Over many years, she and

her staff have had a hand in Vanderbilt's growth as a clinical information

technology powerhouse.

“Karen's dedication to her staff is remarkable,” the award nomination

stated. “She never fails to demonstrate respect and consideration for others.

She is known to many seasoned Vanderbilt nurses as 'the best manager I

ever had.' … Karen embraces the sense of ownership that is key to the

Vanderbilt Credo.”

Reward and

recognize

System

Vanderbilt offers a method for leaders to reward and recognize staff

through the Reward and recognize System. The system is an electronic one-

stop shop for rewards and recognition! This year the system was open to

colleagues who can now more easily recognize each other with Life

Occasions E-cards or Performance E-cards to simply say “congratulations on

the new baby” or “thank you for your efforts”.

RECOGNIZE awards will be issued by award givers through

MyVUMCRecognition in the form of points. Points can be saved or spent in

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our Universal Rewards Mall which offers over 5,000 merchandise items and

numerous gift cards.

Credo Award The Credo Award recognizes staff and faculty who exemplify the Medical

Center's standards for service and all-around professionalism, while the Five

Pillar Leader Award goes to those who exemplify Medical Center leadership

standards. Awards are bestowed each quarter.

The Credo Award went to Edie Vaughn, R.N., staff nurse (on 9 South)

Edie Vaughn, R.N.

“'Edie spoils everyone she comes into contact with. She's such a joy to work

with and to watch her welcome every patient with her smile.’ … ‘Edie brings

warmth, laughter and insight to our workplace. Edie has been walking the

Vanderbilt Credo every moment of every day long before the Credo was even

published.'”

Orientation

Buddy System

Alaina Knight, staff nurse on 7 North was awarded the opportunity to

present a poster on the buddy system she helped develop on her unit at the

American Heart Association Quality forum. Expenses for the trip were paid.

[TL7-Exhibit B-1-Buddy System Poster-ONSITE] Alaina noted that when

nurses came out of orientation, they still needed support. They did not

always have the chance to experience or become competent in rare but

necessary care 7 north nurse are called to deliver. Alaina devised the “Buddy

System” for nurses out of orientation. After the RN is out of the typically 6

weeks of orientation the new nurse is paired with an experienced nurse. The

experienced nurse and the new nurse have assignments close together

geographically. The experienced nurse gets report form the new nurse and

checks on the new nurse every two hours. The experienced nurse is

responsible for monitoring, supporting, coaching the new nurse and stands

ready to assist in any moment. This was received with great reviews by staff.

The idea has been formalized in other units.

Nursing stress

management in

The PEDS ED has seen a tremendous amount of growth in the past 5 years

now seeing approximately 60,000 children annually. With growth comes an

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the Pediatric ED increase in the number of traumatic injuries, newly diagnosed cancers or

other diseases, and deaths. The management team has been committed to

come in for every death for the past 2 years. Upon arrival, the management

team will assist the family, staff, and lead debriefings for the team. This

support has led to an increased awareness in staff for the need to “take care

of themselves” emotionally and physically given the stress factors of the job.

There have been many informal and formal debriefing for the team.

Gregg Horn, a staff nurse (who is now a Charge Nurse) was very passionate

about proactively managing the level of staff stress. He developed a stress

survey to get a baseline for the level of stress that the staff was

experiencing. His work and the support of the management team led to

more formal debriefing and an increase in visibility of EAP in the PED on an

ongoing basis. EAP now makes monthly rounds in the department for day

and night shifts to assist with the stress levels of the staff. This is in addition

to the debriefings that occur after an event.

The post survey results were very positive. The work has been transforming

how nurse manage stress. [TL7-Exhibit C-1-VCH ED Stress Project]

Daily shift to

shift staffing

report earns

Leann Grimes

Recognition

It can be difficult to plan the right staffing for a unit. It is especially difficult

when varying patient acuity requires many different nurses to patient ratios

all in the same shift. This is true in the OB/GYN inpatient unit which provides

care for post partum, ante-partum and GYN ONC patients. The AWOHNN

guidelines are used for staffing and to determine the nurse to patient ratios.

Even more difficult than creating the budget is managing the unit day to day

to ensure the appropriate care is provided within the budgetary plans.

Leann Grimes, charge nurse developed a daily management tool used by the

charge nurses to make the assignments based on acuity of the patients. The

tools tell the charge nurse how many nurses are needed and how to

balance assignments. The tool has been in use since 2008 and is extremely

effective. The Advisory Board recognized Leann for her work through a

Future of Nursing Award. Leann was recognized in the Frontline Leader

graduation and on the Vanderbilt Nursing Web site. [TL7-Exhibit D-1-Staffing

Sheet]

Vanderbilt

Professional

This program is fully reviewed in EP20. VPNPP is the professional

advancement program for clinical nurses at Vanderbilt. It is the way nurses

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Practice

Program

are recognized for their excellence n nursing through promotion that allows

them to stay at the bedside. Both pay and title change as nurse’s advance in

this program.

Evaluation

recognition

All performance evaluations at Vanderbilt are performance based. Annually,

employees have an opportunity to be recognized for contributions above

the norm in the evaluation process. The evaluation rating scale is a 1-5

scale. A score of three is considered competent and meeting the expectation

of the job. A score of 4 is considered proficient and a score of 5 is considered

excellent and expert performance. Criteria established for level 4 and 5

include more leadership such as coaching and mentoring. It also includes

broadening influence in the organization through sharing of expertise. The

salary adjustments are consistent with the level of performance varying for

each staff member based on their evaluation score. See OO 17 for more

detail.

= Exploring

Executive

Excellence:

Building the

Legacy and

recognizing

future leaders

Among managers, there are some who will be the future of nursing. They

are among the best. In an attempt to recognized their talent and invest in

succession planning, a program has been developed to do just that. The

program for nurses stems from a focus on recruitment, retention, and

ongoing development of nursing leaders of as part of our Be the Best (BTB).

In November, 2008, the Director of Nursing Education and Professional

Development brought together a small subset of our BTB committees to

discuss what type of mentoring or coaching program VUMC should develop

for current or potential nursing leaders. Nurse managers had been

encouraged to pursue additional education and achieve certification but had

not been provided with formal mentoring. In addition, the majority of

nurses were pursuing advanced education in a clinical track with few

pursuing a leadership track.

Planning began in November 2009. The following committees and

departments had representation on this committee:

- Recruitment and Second Year Retention

- Leader Development

- Diversity

- Nursing Education and Professional Development

In addition, a few managers to participate on this planning committee to

provide their ideas and feedback about what a mentoring program include.

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100

The committee determined the focus of a leader mentoring program should

be the development of nurse managers in preparation for administrative

roles. The objectives were to:

1. Ignite a passion for nursing leadership.

2. Attract talent to the Nursing leadership role.

3. Create an environment where emerging Nursing leaders recognize

that leading nurses is satisfying work and where nurses feel invited to

explore career opportunities.

4. Help nurses learn and apply the art and science of nursing leadership.

5. Transform a nurse’s passion for clinical excellence with individual

patients to a passion for creating environments for all nurses to

practice clinical excellence.

The work was informed by similar work at St. Barnabas Health System and

their willingness to share their program details.

The program launched September 7, 2010 and will annually offer 6

managers time, exposure and experience with members of the Nursing

Executive Board..

The pilot program will run for one year (September 2010 – September

2011). During the year long program participants will be required to meet

with each mentor for at least one hour. The participants are provided with a

portfolio of the Executives strengths as well as their own strengths

determined through the use of “Strengths Finders”. During that session the

participant should ask questions and will spend some time after each

meeting reflecting on several questions. (Provided TL7 – Peterman). The

participants are able to negotiate a more formal and long term mentoring

relationship with an Executive if they wish.

A formal evaluation has been designed for the pilot program.

[TL7-Exhibit E-1-E3 Overview, TL7-Exhibit E-2-E3 Mentoring Schedule, TL7-

Exhibit E-3-E3 Questions Example]

Interdisciplinary rounding and plan of care development in the CVICU recognized through

national presentations

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101

The following is an account of innovation that was recognized through presentations at national

meetings.

Table TL 7 – 2: Participants

Kathy Burns, MSN, RN CVICU Clinical Nurse Specialist

Jeannie Byrd, MSN, RN, NE-BC CVICU Manager

Kirk Krokosky, RN, CCRN CVICU Resource Nurse

Tonya Beattie, BSN, RN2, CCRN CVICU Staff Nurse

Jillian Russell, BSN, RN CVICU Staff Nurse

Brian Widmar, MSN, RN, APN,

CCRN

Cardiac Surgery Nurse Practitioner

April Kapu, MSN, RN, APN Cardiac Surgery Nurse Practitioner

Dr. John McPherson CVICU Medical Director

Dr. Chad Wagner CVICU Medical Director

Dr. Lee Parmley Director, Division of Critical Care/Department of

Anesthesiology

Anna Ambrose, RRT, MHA Administrative Director: Respiratory Therapy

Dan Johnson, Dph CVICU Clinical Pharmacist

Robin Steaban, MSN, RN Administration of Operations and Nursing/Vanderbilt Heart

and Vascular Institute

CVICU Unit Board

CVICU Staff

CAUSE/REASON FOR CHANGE:

An individualized plan of care was present in the patient record, but it was

compartmentalized into specialty notes, diagnosis-specific clinical pathways, and current order

sets.

This process frequently resulted in:

 Missed or delayed communications and verbal relay errors

 Care intervention and progression delays

 Suboptimal utilization of the specialty expertise offered by team members

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102

 Lack of understanding of the reasons for ordered interventions – resulting in reduced

ability to apply prioritization and critical thinking skills while implementing and

evaluating care outcomes

 Conflicting orders

 Lack of patient and family understanding of the plan of care

 Patient and family concerns that, with so many people involved, care coordination was

not occurring

HOW WAS IT DONE

This process has been ongoing over the last two years with constant review and

enhancements.

Phase I:

A “blank” interdisciplinary plan of care form was created with columns for initiation

dates, patient goals, evaluation codes (examples: met, continued, revised, discontinued) and

signatures. His approach and form originated in a hospital-wide, interdisciplinary committee

whose objective was to improve the creation (and evidence) of an individualized,

multidisciplinary plan of care. The CVICU agreed to be one of the pilot units. The form’s purpose

was to supplement, not duplicate, the goals presence on the diagnosis-specific clinical

pathways and to identify and track one to three of the patient’s priority, individualized goals.

In the CVICU, the form was primarily used to document individualized blood pressure, cardiac

output, incentive spirometry, activity, or nutrition goals set for the patient.

All members of the interdisciplinary team were asked to contribute to the form. It

quickly became a nursing-only form as other disciplines began rebelling against having to

“double document” their goals. Despite its failure as a document that was completed by the

interdisciplinary team, the CVICU nursing leadership team recognized that use of this tool

succeeded in demonstrating that individualized goals were being established by the team and

that goal prioritization was occurring.

The primary failures were:

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 Completing the form was not part of workflow. It was a separate work task. The form

was completed after the rounding and care planning process occurred because

completion was a performance expectation – not because the tool was a valued,

working document. The “real” care information was still in scribbles on the white

board, in the parameters written sideways in the margins of the nurse’s worksheet

during rounds, or in information jotted on a strip of “stuck down” silk tape during OR –

ICU handover reports.

 The tool did not include a comprehensive plan of care.

 The form directed that information be documented in “measureable goal” verbiage.

Nurses who are caring for patients with complex, multi-system, changing needs do not

actually think in complete goal statements. So, “the plans” are usually target parameters

and interventions. For example: Providing adequate nutrition is a goal for all patients.

Increasing tube feeding to a target of 75mL/hour without evidence of gastric distension,

diarrhea, or aspiration makes the generic nutrition goal measureable and individualized.

The working “goal” for the busy nurse is actually the intervention to “increase tube

feeding rate to 75 mL/hour as tolerated”. The rest is known. Repetitive documentation

of this information for all patients is considered to be academic and without true value.

It detracts and reduces compliance.

PHASE II:

The underlying objective of the quality initiative was to improve interdisciplinary care

planning, to ensure that plans of care were comprehensive and clearly communicated, and to

ensure that progress toward meeting goals was timely and ongoing.

Therefore, Phase II of this project expanded to include:

1) Restructuring of the Rounding/Plan of Care development process in the CVICU. This

included redesign and standardization of the rounding format to achieve effectiveness and

efficiency. All members of the team should have opportunity to contribute, but this

needed to be accomplished without concurrently extending rounding time. Designing this

process was challenging because the CVICU is a mixed CCU/Cardiac and Vascular Surgery

unit with two rounding teams: One lead by rotating Intensivists with consistent NP/PA

providers and one lead by rotating Cardiologists with rotating Residents. [TL7-Exhibit F-1-

CVICU Rounds Pocket Card]

2) Redesign of the Plan of Care form to include: [TL7-Exhibit F-2-Plan of Care (Instructions)]

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104

a) Designated, labeled spaces for multi-system/multi-focus goals and interventions

b) Checkboxes for select quality focuses to reduce oversights (Examples: DVT prophylaxis

ordered, bowel regime ordered, and daily review of need for lines/tubes done)

c) Dedicated space to indicate the patient’s status on the clinical pathway so that there

would not be a need for multiple record entries to complete goal achievement

documentation. The clinical pathway still provides the foundation for the plan of care.

The form is used for individualization of the plan when a diagnosis specific pathway is

present; it provides the complete plan of care when a pathway is not available.

d) Removal of the requirement to document the plan in formal, measureable goal form.

3) A process design that ensured that the bedside nurses would be active participants in

multidisciplinary care planning and not just data reporters and recorders. Bedside nurses

assess and evaluate progress or regression from pathway and goal achievement on an

ongoing basis. It is nonsensical, nonproductive, and professionally-demoralizing to exclude

nurses from this process during physician-led rounds. [TL7-Exhibit-F-3-CVICU RN Handover

Report]

4) Redesign and standardization of the unit’s RN-RN handover form to provide more structure

and consistency for information transfer. This became integrated into the overall project

because a better system for information transition was needed to help the newer nurses

feel better prepared (and thus more confident) for their role in rounds and to help to focus

the “ramblers”. AM rounds start immediately after change of shift. Any nurse can feel

unready to provide comprehensive information about a new patient and his/her needs

when they have just assumed care and have not yet completed a full assessment.

5) An initial RN-RN handover tool was drafted by the CVICU CNS by combining features from

forms originally created by staff nurses for personal use and from forms created by RN

preceptors to help their new orientees get organized, ask the right questions, and provide

the right information during handover reports. The handover form was/is two pages. Page

one is an ongoing record of the patient’s invasive lines and significant procedures. It is

designed to provide quick access to key information (without repeatedly searching the

record) and to assist with comprehensive reporting on complex patients. Page two is

designed for transition of current assessment and order information. A new page two is

used for each handover. Form use was endorsed by the CVICU Unit Board and peer

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105

education and coaching was provided. After several months of use, a page two revision was

spearheaded by a staff nurse. Input from all CVICU nurses was solicited by the staff leader.

More preprinted, circle, or fill in the blank options were added. Checklists for select, staff-

identified, high risk handover details were incorporated. The revised form was approved for

implementation by Unit Board.

Key elements of the expanded process included better preparation by nurses to

participate in rounds (new RN-RN handover forms), incorporation of plan of care

documentation into the workflow process, a more comprehensive, multidisciplinary plan of

care (new plan of care form and new, standardized, expanded rounding team and format), and

a summation. At the end of rounds, the nurse reads back the plan of care. This ensures that

nothing has been missed or misinterpreted. Because we are a University hospital, rounds are

teaching opportunities. This results in suggestions and discussions that may be generalized.

The read-back helps to ensure that the nurse, the person who is responsible for implementing

and coordinating the plan, is clear.

OUTCOME:

This very important, but complex improvement initiative was started two years ago.

Parts are hardwired and require little ongoing support, but it is still (and may always be) in

evolution and improvement mode. The rounding and plan of care development processes are

firmly implanted with the cardiac and vascular surgery patients, but the rounding format is not

as consistent with the cardiology patients. The Residents on the Cardiology service rotate

monthly and process success relies heavily on the Cardiologist leader, how long the Residents

have been on service, and the confidence/assertiveness of the staff nurse participant. Pre-

service meetings have begun with the Cardiology Residents. Expectations for the rounding

process and plan of care development are now part of their unit orientation. Laminated pocket

cards describing the process and delineating role responsibilities for rounding and plan of care

development are available.

Part of the initiative is to consistently involve the patient and family in rounds and plan

of care development. Patient and family inclusion is increasing, but is still variable and quite

dependent on the Attending Physician or Intensivist who is leading the rounds.

Nurses are now consistent participants in AM rounds. If they do not join the rounding

team, the team seeks them out. A comprehensive plan of care is consistently documented

during morning rounds. During the abbreviated evening rounds, the plan of care is evaluated

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106

and, if needed, modified. Although goal achievement and plan modification are now

consistently discussed, documentation of the evening revisions on the plan of care form

remains an improvement opportunity.

The new plan of care is initiated immediately after rounds. Previously, key aspects of the

plan were unknown until orders were entered and reviewed. Discussion of the plan of care

(including consult input) includes resolution of conflicting orders. The process is also assisting

with intervention sequencing and prioritization.

An unexpected outcome of this process has been the identification of some behavioral,

delay patterns with specific nurses. Example: When the plan includes removal of lines or

catheters and the plan is read back to the team, repetitive intervention delays become evident.

These delays are being recognized and reported.

EVALUATION

 Direct observation of the rounding process

 Audit of the Plan of Care Forms

 Feedback (solicited and unsolicited) from the Nurses, Physicians, Residents, Nurse

Practitioners, and other team members

INFORMATION SHARING

 Processes and forms were shared with other Vanderbilt ICUs at the Institutional Critical

Care Committee

 Poster presentation at the 2010 ACCA Cardiovascular Administrators' Leadership

Conference in Atlanta, Georgia

 Presentation at the UHC Cardiovascular Council meeting in the Fall of 2009 at Duke

University

[TL7-Exhibit-F-4-Poster-ONSITE]

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Visibility, Accessibility, and Communication

Source of Evidence 10

Describe and demonstrate how nurse leaders use input from direct care nurses to improve

the work environment and patient care.

There are multiple ways nursing leaders have access to staff nurses and respond to

information from them to improve the environment nurses work in and the resulting patient

care. Through staff meetings, unit boards, leader rounding, staff nurse councils leaders learn

what barriers exist to patient care and ideas staff have t improve equipment, systems and

processes. The following demonstrates the request and the leader and organizational response.

Table TL 10 – 1: Request/Response

Input from Nurse(s) Leader Response

Vital Signs changes

Jon Coomer, the manager of the psychiatrics VITA/Adult 3 unit gathered

information from staff related to work flow issue. Some of the feedback

given was that all patients were required to have vital signs at 6 a.m.

regardless of their clinical condition. This was a concern to patients and

staff and added little clinical advantage. The MD’s did not round until 9

a.m. so the vital signs were not relevant from 6 a.m. for clinical decision

making and often had to be repeated. A group of staff redesigned shift

responsibilities to allow the day shift to absorb this work. [TL10-Exhibit-A-

1-VITA Daily Schedule] Both staff and patients verbalized appreciation for

the change and it has had no noted affect on management of patient’s

clinical issues.

Myelosupression

preceptor

improvement

A nurse on the myelosuppression noted the need for improvement in the

orientation program. The Manager supported her efforts to improve the

orientation through guidance, coaching and mentoring. The manager

used the opportunity to help the nurse develop new skills and to meet

the needs of the unit. The nurse convened a preceptor group to review

the orientation of new hires. The group surveyed staff about their

perceptions of orientation and then informally surveyed the preceptors.

From these experiences, there were several suggestions for

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improvement in orientation. Those included: Development of an

orientation checklist, teaching sheets of common medications and

procedures, list of frequently used phone numbers; 10 rules for all 11

North staff. [TL10-Exhibit-B-1-Meeting Minutes]

Targeting clinical

growth in the

Neonatal intensive

care unit

The NICU staf

s were concerned that they were not getting assigned to

the right patients for them to get exposure and gain experience in clinical

areas where they needed development. A spreadsheet exsisted that

identified which nurses were competent in which skills and this was to be

used as a guide for the charge nurses in making assignments. In a

complex 76 bed unit, charge nurses found the use of the tool difficult and

nurses were still not assigned to patients that would allow them to learn

new skills. In a charge nurse meeting they identified that a white board

could be placed in the charge nurse office with the necessary skills listed

at the top. Staff would be encouraged to write their names in the column

where they needed experience. [TL10-Exhibit C-1-Charge Board Photos,

TL10-Exhibit C-2-Mentorship Charge Meeting] Charge nurses could “at a

glance” know who needed what experience and make assignments

accordingly. Staff nurses have expressed greater satisfaction in getting

assignments that help build their skill since this change took place.

Bone Marrow

transplants and

discharge needs

A staff nurse on the Myelosuppression unit was concerned that patients

were not being prepared adequately and consistently for discharge. The

staff nurse discussed her concerns with the casemanager and the

management team. The manager supported the staff member through

coaching and mentoring to meet the developmental needs of the staff as

she developed a discharge checklist. After a trial use of the checklist on

her own patients, she found she was able to identify discharge issues

earlier allowing early intervention. The manager used this small test of

change by one nurse to improve the discharge process for all patients.

In-services are in progress (October, 2010) for all staff to begin to use the

form. [TL10-Exhibit-D-1-Discharge Checklist]

Staffing Changes 11

North

The staffing rations on 11 North which is a hematology unit were

decreased several years ago because so much chemotherapy was

delivered as an outpatient. However, staff began to verbalize that the

acuity was changing on the unit and in particular, the night workload was

difficult to manage. The manager and finance officer were able to

demonstrate the need and the 12hours of RN coverage was added per

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day to the staffing template. [TL10-Exhibit

-1-Staff Meeting Minutes]

100 Oaks Women’s

Health Shift

Changes

Patient Care Technicians in the 100 Oaks Women’s Clinic requested 10

hour work days instead of 8 hours work days. This would allow them to

work 4 days a week instead of 5. After reviewing the request, the

manager determined that the needs of the clinic would be well served by

providing a schedule with 9 hour shifts and a ½ day on Friday. The Friday

is split with some staff working in the a.m. and some in the p.m. After a

pilot, the decision was made that the shift change was advantageous to

the work place and to staff. The change has now been fully implemented.

[TL10-Exhibit F-1-PCT 9 Hr Staffing Template]

Clinic Scheduling Stephanie Nelson, RN, Clinical Nurse Coordinator recognized patient flow

was hampered by the way patients were scheduled on Dr. Kaufman’s

template for urodynamic testing. Often these patients were new to the

practice and needed to be seen by Dr. Kaufman prior to their test being

performed. Stephanie requested that Dr. Kaufman’s template be

changed to reflect his actual practice pattern instead of 45 minutes after

actual testing occurred. There was also a need recognized for a special

procedure slot for new medication Dr. Kaufman was administering. The

procedure needed to be done in the treatment room with a sonesta

chair. This required that the team collaborate to accomplish this

complicated scheduling. Stephanie spoke with Gail Bauer and Leslie

Denton the manager of the area and they worked to have the

Macroplastique appointment placed on the schedule at 1300 to allow for

procedure to be done while the last UDS was being accomplished in

adjacent room without interference. The scheduling change also allowed

the staff to ensure all of the proper equipment for special procedure was

in place in the early am for procedure to be done @ 1300.

Development of

Standard roll-out

process in the ED

During Karin League’s, BSN, RN masters program in Health systems

management through the Vanderbilt University School of Nursing, she

had the opportunity to complete 210 practicum hours with Brent

Lemonds, RN. Brent is the Administrative Director for Emergency Services

and provided Karin with the opportunity to observe the challenges of

leadership in a large, fast paced, high risk area that experiences change

at a phenomenal pace.

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Karin had a passion and interest in quality. She chose a practicum

project that would fit with the department’s need for change

management tools around quality, evidence-based practice, and process

improvement. Brent and Karin worked together to develop the Standard

Rollout Process tool. The tool is based on multiple theories including

Lewin’s theory of Change, Stetler Model Theory, and Roger’s Diffusion of

Innovation. Other evidence included in the development included human

factors studies and the use of tested tools such as PDSA, Gap analysis,

and SWOT analysis.

The resulting product was designed to assist teams to clearly define

their goal for change, cultivate the stakeholders involved, develop an

action plan with a timeline and clear accountability, communicate the

plan effectively, and utilize PDSA cycles for improvement and

sustainability.

Under Brent’s leadership, the Emergency Department and VCH

PACU/Holding have utilized this tool for the past year. There are several

examples of its use at

http://www.mc.vanderbilt.edu/root/vumc.php?site=adulted&doc=25041

[TL10-Exhibit G-1-Standard Rollout Presentation, TL10-Exhibit G-2-

Standard Rollout Process]

Hand washing

Foam in the PACU

In the PACU, it is difficult to have foam to wash hands with close to the

patient because there are no walls between patients, to mount hand

washing foam. If someone comes to the bedside to see the patient, there

is a distance that they must walk to get to the foam. At the request of

the nurses, Betty Sue Minton, RN, MSN placed foam on the wall behind

the patient slot, but to get to it, you had to come into the slot and reach

behind the patient to foam your hands. Therefore, the foam on the wall

behind the patient was difficult for physicians to use.

Betty Sue knew that each PACU slot had a bedside table that is usually at

the foot of the stretcher and that would be a good place for the foam to

be located. A nurse could foam their hands before they went into the

slot to see the patient and then again as you were leaving the slot. Plant

Ops built a round flat surface that attaches to the side of the bedside

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table. The hand washing foam is mounted on the round surface. It takes

up no room on the top of the bedside table, so it is still very usable for

patients and the staff. [TL10-Exhibit H-1-PACU Hand Foam]

ECMO

Improvement

ECMO Specialist (made up of RN’s and RRT’s) work very well

collaboratively and during a PM&I (Quality Review meeting) the team

members pick patients to present. We review every patient that goes on

ECMO. The center does a large volume of ECMO patients and thus,

reviews up to 6 patients in one session. The team members are given

guidelines to present. This gives the team members the opportunity to

express their concerns and also hear what the physicians were thinking

during this process. It has led to multiple open discussions and changes

including the one below.

Daphne Hardison, RN became the manager in January 2009 and had

noted some process issues and inconsistency in the way prime blood was

“treated”/buffered. The ECMO circuit was usually primed with 2 units

PRBC’s. The blood product was buffered so when patients go on ECMO

and are exposed to the blood it not only is anticoagulated but has

electrolytes and gasses in a range to prevent the heart from going into a

stun picture. The team had different ideas on how to make this the

correct gas and what is acceptable. Because the protocols requested a

physician order, Daphne required all team members to go to the

physician and get an order instead of just adding different medications.

ECMO is not utilized by all physicians every day; therefore there was

even more inconsistency with the physician orders than when the

specialist did their own thing. Many team members felt it very difficult to

get the orders during the intense time of ECMO Cannulation and

requested a solution of some sort to include a protocol. Daphne took

this back to the group and facilitated a discussion where a decisions was

made to create a protocol that came from our director’s (surgical and

medical) that allowed the team members to treat the circuit gas

appropriately and independently. This has not only led to the ECMO

Specialist independence but the physicians are not expected to come up

with answers during a code situation. [TL10-Exhibit I-1-ECMO WIZ Order

Guidelines, TL10-Exhibit I-2-Minutes Medical Director, TL10-Exhibit I-3-

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Team Meeting Minutes Aug 2010

]

9 North and pill

splitters

When Richard Corcoran, RN, MSN manger of 9 North first came to 9

North two years ago the first step he did was round on all employees to

get to know them and identify any areas they felt needing improving

rapidly. Two items came up repeatedly – pill splitters, and pill crushers.

Nurses stated that they never were available and hunting them was a big

time waster. Within 2 weeks Richard had a pill splitter and a pill crusher

attached to each Work Station on Wheels. The pill splitters have

remained and are replaced as needed. On 9 North pill crushers moved

to the top of each unit supply care for infection control reasons this past

January. These replaced the smaller individual crushers in use prior to

that time. [TL10-Exhibit J-1-Unit Board Minutes]

“In her Own Words” – Story by Anisha Fuller, Manager 4 East, OB/GYN

“In April of this year, one of the night shift nurses, Amy Suddeath, sent me an email

stating that she had taken the initiative to investigate some cost saving measures that could be

taken in our department. I have attached her initial email, for your review.”

EMAIL FROM AMY SUDDEATH

–

APRIL 27, 2010

“Anisha,

For the past 3 years, I have complained about what a dumping ground our nurse servers are.

I know that they are intended to be helpful to staff but they are so randomly stocked that I think

we spend more time going from server to server hoping to find something than we would spend

just going to the main cell. I get so frustrated with them that it has become by personal mission

to clean them out approximately every 6 weeks or so. After cleaning them out several times, I

decided it would be really interesting to see just how much the items being stuffed in the servers

(and rarely used because no one knew they were there) were actually costing our unit in

restocking charges. I cleaned out the servers and returned everything to the main cell. Six

weeks later I cleaned them out again. I wrote down everything I returned to the cell and

contacted Karen Sterbutzel, Supply Chain Director. She provided me with a price list for every

item stocked on our cell. I used the list I had prepared from my "six week cleanup" and

computed the cost of all the items I had returned to stock just that one time. The total cost of

those items was $110.00. If every six weeks that same amount was returned to the cell, the

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annual cos

would be $952.00. I don't think a lot of our staff realize that every time they stick

something in the nurse servers, that missing item has to be restocked on the cell to maintain

par. Our patients are not paying for us to maintain par, the unit pays. Therefore, if everyone

would return items to the cell when they aren't used, the unit could save approximately

$1000.00 per year.

Here is a list with prices for some of the most frequently "dumped" items:

Specipan $0.38/ea

Pitchers $0.29/ea

Socks $0.66/ea

Bath wipes $1.42/ea

Catheter kits $ 1.88/ea

BP cuffs $2.94/ea

Bedpan $0.63/ea

Soap $0.22/ea

Shampoo $0.22/ea

Toothpaste $0.22/ea

Bath basin $0.39

I realize that we do sometimes use these things if we are lucky enough to find them when we

need them, but how often do we just go to the cell instead of wasting time looking in the

servers?

Just this past weekend, I was looking for Tucks pads in the servers and found probably 10

bags of items that looked like they were gathered in preparation to set up empty rooms. That is

a great way to be prepared especially when things are as busy as they have been lately.

However, in almost every bag I noticed that there was shampoo, toothpaste, a toothbrush,

tissue, deodorant, blue or brown socks, and a package of bath wipes. Most of our patients don't

need any of those things because they usually bring all of those things with them. If you add up

the cost of all of those items it is $4.08 per patient. If you estimate that we admit 8 patients per

day, that same setup would cost our unit $32.64/day or $11,913.60/yr! That's almost

$12,000.00 a year the unit could save just by giving those items out on a request only basis. I

have worked at other facilities where a "room setup package" was charged to the patient on

admission and extra items were also charged when requested. I don't see Vanderbilt ever doing

that but we could definitely be more conservative with those items instead of including them

with every room setup.

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One last thing, during one of my server cleanouts I found 25 BP cuffs. Some were still

wrapped and were returnable to the cell. Most were unwrapped and there was no way to tell if

they were used, from an isolation patient's room, or were defective and just stuffed in the server

for convenience. I ended up throwing away all of the unwrapped ones for patient safety. BP

cuffs are $1.94/ea and were the most frequently dumped item. If staff could discard them when

they are worn out and only remove them from the cell when they are replacing old ones, lots of

money could be saved.

My point in this project is to make all staff aware that it is really important to return things to

the cell if they aren't going to use them. The unit is charged for every item that sits in the

servers unused. I know we all get busy and sometimes don't have time to do the most cost

effective thing. Would a box, placed at each nurses station to put unused items in, be helpful?

Maybe our volunteers could help us with restocking those items? Any other suggestions?

I think that we all do our best in using our resources wisely, but sometimes need a little

motivation to improve. I hope everyone finds this information informative and helpful. I have a

price list of every item on our cell, so if anyone is curious about how much something cost I

would be happy to let you know.”

Thanks!

Amy Suddeath, RN

“In summary, she had noticed that many of the non-chargeable supplies were being

haphazardly stored in the cabinets (nurse servers) throughout the unit. This practice was

causing costly clutter, and resulted in inaccurate par levels in the unit storage room.

Amy made the suggestion that we create specific storage locations among the existing servers,

and formally organize what is placed in them. I thought it was a great idea, and supported her

taking it to our Unit Board meeting. She was put on the agenda, and presented her findings to

the department. Everyone was in agreement that we could better organize how we store

supplies, and they voted to adopt Amy’s suggestion.

Together, the staff decided which cabinets would be best suited for centralizing linens

and supplies. Five cabinets were designated for this purpose. Labels were made, and the

cabinets were organized to one standard. Since then, the staff have maintained how the

servers are utilized. Amy still does her six-week “round-up,” but she finds less and less clutter

each time.

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I have helped support her project by encouraging her to present to Unit Board, and

endorsing her project in that forum. Empowering her to take action on something she identified

as a problem has added to an atmosphere of staff empowerment and recognition for innovative

ideas. I facilitated the coordination of support needed to initiate the organization of her project,

and have continued to do so. Amy has drafted several emails to the staff, and asked that I send

them out on her behalf. This shows that I support her efforts, and request that others do, as

well.

It has not been a long-standing project, but it will be interesting to see if our non-

chargeable costs to the unit decrease over time. I applaud Amy’s drive and persistence, and am

proud to be her manager. She’s a great member of the team. Incidentally, Amy received her

RN3 while working on this project.”

“In Her Own Words”

Submitted by Christine Kennedy, MSN, RN, Administrative Director, Adult Medicine –

September 7, 2010

“At Vanderbilt University Medical Center, an interdisciplinary team, the Pain

Management Task Force, has been working on improving pain management assessment and

reassessment with a particular focus on streamlining documentation in our charting system

Horizon Expert Documentation (HED). One specific objective was to provide direction to the staff

to choose and use one pain scale appropriate to the patient. After our Pain Management

Guidelines were updated in November, 2009, the Pain Management task force had been

working with staff to get their input as to how we could improve our documentation format

related to assessment and reassessment of pain.

During focus groups with staff, it was identified that not all staff understood which pain

scales should be used for patients who were “able to self report” versus those patients who

were “unable to self-report”. For example, some staff members were using the Wong-Baker

Faces scale for patients who were “unable to self report”. By definition, the Wong-Baker Faces

scale is to be used for a patient who is able to self report. This scale is typically used by a child or

someone who prefers to point to a face rather than using the numeric rating scale (NRS). One

change made in a release that took place on July 19, 2010 was to differentiate the scales for

patients “able to self report” from those patients who are “unable to self report”. Patients who

are “unable to self report” are typically non-verbal patients who cannot communicate their

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needs. In order to identify if patients are in pain, staff observe physiological or behavioral cues

to determine if the patient is in pain. The following scales: FLAAC, NIPS, NPASS, and PAIN AD,

are summative scales used at Vanderbilt for patients who are “unable to self report”. There are

some patients for whom we cannot use any of these summative scales and for these patients

the nurses describe physiological or behavioral cues to try to determine if patients are in pain.

After the July 19 release of changes in HED, our system support staff and educators

rounded on staff to help explain the rationale for these changes. In general this change was well

accepted and during rounding with staff this was generally seen as improvement.

There was one concern identified. It was identified by users/staff that due to the change

in format, there was no longer an option listed under the pain assessment drop down boxes for

patients who cannot self-report pain. This was identified by staff, communicated through the

HED Advisory committee and forwarded to the Pain Management Task force. A solution was

identified by the Pain Management Task Force and vetted with staff. The solution was to add

two descriptors, one each under behavioral cues and physiological cues. The purpose of adding

these options was to allow the nurse an indicator for behavioral and physiologic cues that

suggests the patient is not in pain. This can be used for the shift assessment as well as for

reassessment after interventions.

Deborah Ariosto, MSN, RN, Director of Patient Care Informatics was instrumental in

helping to facilitate conversations and devise the redesign released on July 19, as well as the

additional simple solution. With the help of Nancy Rudge with HED, the additional changes

requested by the staff were released to the organization on August 31, 2010. We appreciated

the feedback from our clinical staff and appreciated the quick response from informatics and

system support staff for implementing this small but important change. At this time, the

feedback from this change is that it has addressed the concern identified by the staff.”

[TL10-Exhibit K-1-Pain TF Meeting Minutes, TL10-Exhibit K-2-Pain Management HED Screen

Update, TL10-Exhibit K-3-Pain Documentation Revision]

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Visibility, Accessibility, and Communication

Source of Evidence 10 EO

Describe and demonstrate changes in the work environment based on input from the direct-

care nurses.

Transition from Systems Support Specialist to Clinical Application Specialist

Purpose/ Background

The use of informatics systems has become extremely important for nurses to

accomplish patient care. Vanderbilt develops many of the informatics tools nurses use and the

pace of change is great. For many years, the System Support Department of Informatics which

supports end users in the clinical areas has reported to the Executive Chief Nursing Officer. The

role of the “Systems Support Specialists” (SSS) on that team has largely focused on

implementation of new systems. After implementing two large-scale, complex clinical nursing

applications back to back, our institution realized there was a problem. User feedback from

nurses indicated the Systems Support Department is great at implementation of systems, but

not as accessible as they would like for ongoing support. A goal was established by the team to

allow Systems Support to respond in real-time to increasing regulatory requirements without

additional FTE’s and to increase user independence and proficiency in all clinical computer

systems. The hypothesis was that user-based versus centralized support will increase overall

institutional satisfaction with systems support services. This plan that responded to needs of

nurses began the transition of Systems Support Specialist to Clinical Application Specialist.

The project was based on the following information.

• User feedback was that Systems Support provided great support for implementation of

systems but there was dissatisfaction with accessibility for ongoing support.

• Ever increasing regulatory requirements and scrutiny by regulatory bodies required

users to be able to meet documentation requirements and use systems to leverage their

understanding of the patient status and patient needs. Users must be knowledgeable of

the most effective use of tools and processes, and there needed to be iterative

enhancement to those tools and processes for documentation

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• The increasing size and complexity of the organization created a need for new support

strategies.

• SSS staff needed an opportunity to expand their skills and leadership abilities.

• Customers should become less reliant on SSS and be able to use all informatics systems

more effectively and independently.

• SSS must demonstrate the success of informatics system from a user’s perspective as

well as a systems perspective.

Table TL 10 EO – 1: Participants

Karen Hughart, RN, MSN Director of Systems Support Services

Gwen Holder, RN, MSN Assistant Director of Systems Support Services

Sara Seaman, RN, BSN Clinical Applications Specialist for Adult Neurology/Epilepsy & Neuro

ICU

Lillian McGehee, RN,

MSN

CAPS for Adult Surgical ICU, Surgical Step-down, & General Surgery

unit

Ron Reed, RN, ADN CAPS representative for VCH covering general surgery floors for

young/adolescent as well as medical infant to adolescent

Tom Mack, RN, BSN CAPS Representative for adult medicine floors and Medical ICU

Lisa Grunwald RN, ADN CAPS Neonatal Intensive Care Unit

Valerie Kibler, RN, NP CAPS representative for adult colorectal, urology, orthopedic, and

general surgery units

Sara Winters RN, BSN Clinical Application Support Team Lead

Approach/Methods

The first step in developing a plan for area based Systems Support Specialists was unit

selection. CAPS would be assigned to a unit or group of units that complement one another.

Variables influencing the development of CAPS assignments to units or “pods” included the

following:

 “sister” units (same management) would be grouped together

 patient flow from ICU to step down/general care floor should be considered in the

groupings

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 acuity, number of staff, number of patients, geography should be considered

Once assignments were made, the teams began to move toward implementation.

Clinical Application Specialists (formerly Systems Support Specialists) met with unit leadership

to establish relationships, expectations, desired outcomes, and boundaries. They introduced

the idea of Clinical Application Specialists to staff nurses and used that time for information

sharing and to begin to build relationships with nursing staff.

The next phase was an observation phase. During this time, CAPS observed workflow in

their assigned areas and were oriented to the unit practices. They gathered information via a

survey focusing on current use and knowledge of clinical applications. This information was

used to prioritize education efforts.

The survey yielded information on:

 Nursing documentation systems including medication bar-coding

 Application downtime procedures

 Electronic Medical Record

 Provider order entry system

[TL10 EO- Exhibit A-1-Computer Applications Support Survey]

The next phase of implementation was the identification of priorities and ongoing

support. The CAPS assessed educational and work process simplification needs of the staff to:

 Identify opportunities to leverage existing tools to help meet clinical and

operational objectives.

 Identify potential systems enhancements that would make the tools more

effective/efficient

 Prioritize needs and develop a plan to address priority needs

 Implement the plan

 Evaluate and revise objectives and strategies on an ongoing basis

 Provide support on the units

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 Answer questions about computer applications during daytime hours

 Explain computer related processes

 Troubleshoot computer problems as they happen

 Follow up on issues that arise

 Decrease the time between questions and answers

 Engage in problem solving alongside staff and follow through to resolution

It was recognized that there was a need for on- going learning for the CAPS. Learning

needs were met through collaboration across CAPS in CAPS meetings that were held every two

weeks. This provided an opportunity to share information and trends they had observed on

CAPS units. The meetings provided a forum for preliminary review of tools developed in

response to education requests, suggestions, and issues experienced by nursing staff with

clinical applications. CAPS met with unit leadership and unit boards to discuss ongoing work

and priorities or obtain feedback. [TL10EO-Exhibit A-2-CAPS Overview]

Outcomes

A goal of the project was to have CAPS staff on the unit 80-90% of the time of their

worked hours in order to be available to staff when the questions arise.

From November 15 – December 15, 2009 CAPS spent 481 man hours on the units. There

were a total of 6 CAPS representatives covering 18 units/pods. These 6 CAPS employees worked

a mixture of 30 – 40 hours per week.

The initial goal was that CAPS would spend 80-90% of work time on the units.

Initial Outcome – CAPS time spent on units:

• Average for all areas = 68%

• VCH = 66%

• VUH = 63%

• Round wing = 75%

Based on the initial results the goal was modified to 60-70% of work time spent on units. This

was found to meets the needs of the users on the units as well as SSS central office work

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The areas where the CAPS provided assistance included:

• Hardware Issues

• Implementation Support

• Staff Orientation

• Management Team Efficiency

• Troubleshooting

• Problem Resolution

• Project Preparation

• Quality Improvement

Examples of improvements made based on presence of the CAPS are described here.

Hardware

• On the 8

floor of Children's Hospital a need was recognized Workstations on

Wheels (WOWs) were in demand for multiple groups. Reorganizing existing WOWs

to place scanners on machines used by nurses who give meds improved overall

satisfaction, maintained hardware for all groups and did not affect unit budget.

• On the round wing units more wireless scanners were needed to replace tethered

scanners when large numbers of isolation patients were on the unit. Following

intensive care unit moves to the critical care tower (with all new equipment) our

CAPS person was able to negotiate two “new” wireless scanners from the “old” ICU

space at no cost.

Implementations

• Children's hospital reported “quick and painless rollout of Falls Risk and Braden Q

Indicators”

• Tamper resistant printers and pharmacy upgrades were supported

• Large scale efforts to streamline the three ICU moves to critical care tower, including

testing of all hardware functionality, printing capability, and behind the scenes

changes for location compatibility primarily conducted by the 3 ICU CAPS

representatives

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• Plan of care rollout for the 8th floor of Children’s hospital in two weeks time

educating over 100 staff in coordination with the educator

Staff Education and Orientation

• 20 or more new staff in Children's hospital received on-on-one review of technology

tools available to them, followed by requests from seasoned staff to also participate

in learning experience

• Mini lunch education sessions on 9 south for discussion of downtime process

improvement

• Training on unit specific applications such as pre-orders and plan of care at time of

need.

• Encouraging StarPanel use in NICU by customizing views for staff and illustrating

features available to them

• Assisted physicians on MICU to gather information and links to allow viewing of

IMPAX images from home

Management Team Efficiency

• Detailed assistance to leadership team for retrieving and searching for quality

safety measures on patient records, including those that are discharged, and

chart audit reviews

• Charge nurses on MICU were taught how to most proficiently access “fix it now”

reports

• 9 north charge nurses had white board indicators customized to assist in

managing quality care goals

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Trouble Shooting/Problem Solving

• Directly taking calls during daytime hours to reduce wait time on calls to the help

desk – following up with help desk to manage data collection and trends of issues

• From routine CAPS rounding learned that SICU had certain lab screens they are

accustomed to seeing that were not displaying correctly after the move to the

Critical Care Tower. Through detailed follow u p discovered that certain screens in

HEO were “hard coded” to the 3N/C location only. Resulted in thorough evaluation

and reconfiguration of three similar instances.

Project Preparation and Quality Improvement

• Anticipating needs of NICU leadership and staff for implementation of Admin-Rx

during 2010

• Improvement of Admin-Rx scan rates following embedded CAPs representative on

Round Wing (Table 1 below)

Empowering nurses with suggestions for HED improvements to take ideas to HED advisory

committee. Several have been approved!

Table TL 10 EO – 2: Admin RX Scan Rate Trend

Admin RX Scan Rate Trend

Month S34 total

February 73%

March 84%

April 96%

May 97%

June 99%

Next Steps

• Expanding CAPS role to more areas in the medical center

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• Continuing to manage expectations with controlled growth of the program

• Ongoing efforts to maintain quality initiatives housewide with direct impact support

• Submitted abstract to ANIA 10/08 - Sara Winters RN BSN and Valerie Kibler RN NP

[TL10EO-Exhibit A-3-CAPS Outcomes]

CVICU Ultrasound Guided Peripheral IV Insertion

Purpose and background

The CVICU staff, leadership and medical directors were interested in reducing the rate

and the risk of central line infections. This work was initiated by Kirk Krokosky, RN who was a

night shift staff member in the CVICU at the time. They observed that some patients received

central lines because peripheral access was not possible. They hypothesized that if they could

eliminate or delay the need for central line catheters they would reduce the central line

infection rate. On a parallel course, they wanted to improve the quality of peripheral

intravenous access and patient comfort while obtaining said access.

The two primary reasons to pursue this project were:

 to reduce the number of central line associated blood stream infections (CLABSI) by

decreasing the need for or delay the placement of central lines most commonly PICC

lines.

 To improve success of peripheral IV insertion in patients that were considered “difficult

sticks” related to obesity, edema, known poor quality veins.

Methods/Approach

 An intensive analysis was done on BSI cases that occurred during a five month period

(July-November 2008, n=7 cases).

 It was found that medical cardiology patients who acquired BSI were all related to the

presence of a peripherally inserted central catheter (PICC).

 Based on this analysis, in early 2009, all staff were re-educated on care and

maintenance of central venous catheters, including PICC lines.

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 As a parallel course, a process to find an alternative to inserting PICC lines in patients

previously identified as non-peripheral intravenous (IV) access candidates was pursued.

These candidates were determined by the presence of:

o Edema

o Obesity

o Unsuitable or poor quality veins

o History of multiple attempts

o A review of literature revealed that ultrasound guided venous access technique

has been used with success by physicians in the emergency department setting.

 A competency based protocol for nursing insertion of ultrasound guided peripheral IV

access was developed.

 The data demonstrated a significant reduction in PICC usage (Figure 2) and a subsequent

decrease in BSI rates.

[TL10EO-Exhibit B-1-Ultrasound Guided IV Insertion Policy, TL10EO-Exhibit B-2-Ultrasound

Guided IV Manual, TL10EO-Exhibit B-3-QCOR Ultrasound Poster-ONSITE]

Table TL 10 EO – 3: Participants

Kirk Krokosky BS, RN,CCRN Developed project, conducted in-services

Jeannie Bryd, MSN,RN Project oversight

Kathleen Burns Med, RN Assisted with development & provided guidance on in-services

and data collection.

Lee Parmley, MD project oversight, collaboration at the provider level with the

Vascular Access Group

John McPherson, MD project oversight, collaboration at the provider level with the

Vascular Access Group

Chad Wagner, MD project oversight, collaboration at the provider level with the

Vascular Access Group

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The CVICU Collaborative

Committee

provided data review, support and endorsement of the project

Staff nurses of the CVICU

Outcomes

The table below compares success rates of lines placed traditionally (no ultrasound) vs.

those placed with ultrasound guidance. Most noteworthy is the success rate on first attempt of

64% [with ultrasound] up from 27% (without ultrasound). As for PICC insertions the top graph

in figure 2 shows a dramatic decrease in PICC insertions in the first four months of the live

project (Jan- April 2010). Graph 3 shows an encouraging trend downward in the number of

blood stream infections.

Table TL 10 EO – 4: Success Rate with ultrasound vs. no ultrasound

Traditional Peripheral IV Technique

Attempts 1 2 3 4 5

# of Patients 6 6 6 0 4

Success rate 27% 27% 27% 0% 18%

Ultrasound Guided Insertion Technique

Attempts 1 2 3 >3

# of Patients 21 9 3 0

Success rate 64% 27% 10%

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Graph TL 10 EO – 1: Decrease in PICC Lines Inserted

Graph TL 10 EO – 2: Blood Stream Infection Rates

Nov Jan 09 Mar May July Sep Nov Jan 10 Mar

Blood Stream Infection (BSI) Rates

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Summary

The CVICU has seen a significant reduction in PICC line usage and subsequent reduction

in CLABSI rates as a result of the implementation of ultrasound guided peripheral IV insertion.

The project has been a success and the area is moving forward to train more staff in the

technique. To date there have been no major complications related to the technique. The

CVICU staffs have been asked to place lines in other units and currently the Burn Unit is

developing its own program based on our materials and data. The use of ultrasound guided

technology by specially trained nurses has increased the success rate of obtaining peripheral IV

access. As a result, the reduced need for or at least delayed placement of central access was

achieved. This reduction has brought about a downward trend in BSI rates.