About Saint Joseph Mercy Health System

About Saint Joseph Mercy Health System . . . . . . . . . . . . . . . . . . . . . . . . 2

Letter from Joyce Young . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Professional Practice Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Pathways to Excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Nursing Strategic Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Nursing Quality, Safety, and Engagement Results . . . . . . . . . . . . . . . . . 7

Transformational Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Structural Empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Exemplary Professional Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

New Knowledge, Research & Improvements . . . . . . . . . . . . . . . . . . . . 22

Awards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

About Saint Joseph Mercy Health SystemAt Saint Joseph Mercy Health System, compassionate, patient-centered care is designed to treat the mind, body and spirit. Consisting of five award-winning hospitals and affiliated health centers serving southeast Michigan, we provide remarkable care close to home using leading-edge technology for patients and their families.

Our highly skilled nurses and physicians have made SJMHS a national leader in cancer care, neuroscience, orthopedics, bariatric surgery, senior services, robotic surgery, and neonatal care. Our hospital ministries have received many accolades, including Truven 100 Top Hospitals, Governor’s Award of Excellence as well as HealthGrades America’s 100 Best Hospitals Award, Distinguished Hospital Award for Clinical Excellence, Outstanding Patient Experience and Patient Safety Excellence.

BY THE NUMBERS

4,246 Nurses across SJMHS hospitals

2.9 Million outpatient visits 265,107 ER visits

74,747 Inpatient Discharges

6,464 babies born 102,147 older adults 5,784 less fortunate persons received charity care

2,862 skilling nursing visits

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On behalf of a grateful health system, I would like to congratulate all of our nursing colleagues for providing truly remarkable care experiences that our patients have come to expect and appreciate.

Everything we do is rooted in our heritage as a faith-based organization and our strong commitment to improving the health of the communities we serve. We thank the Sisters of Mercy for their love and caring for this community for well over 100 years.

Nursing care is anchored in our Mission, “We serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.” The core of our Nursing Professional Practice model calls each of us to strive to improve nursing excellence, professional practice and shared governance through innovation, teamwork, compassion and leadership.

We focus on “People-Centered Care” in support and alignment with our strategic plan and framework. Putting people first is a hallmark of our continued commitment to ensuring the outstanding patient experience - in the midst of a rapidly changing health care industry.

In addition, we focus on enhancing the nurse experience through improved engagement and satisfaction. Their dedication, expertise and innovative ideas are contributing to enhanced care throughout our five- hospital system. The support of nursing professional practice through increased tuition reimbursement is a result of your input and passion for learning.

We know that our nurses’ compassionate, healing touch literally transforms health status for the bet-ter. Families are better informed and comforted; communities are healthier, and best of all our patients trust us as their health partner for life.

We thank our many highly engaged nursing teams and our interdisciplinary team partners for the care they provide. Through nursing leadership, nursing excellence and nursing professional development, we will continue to be national leaders in transforming the way in which we work, think and live.

By Joyce Young, RN, PhD, CEMP Chief Nursing Officer, Saint Joseph Mercy Health System

Meet the Chief Nursing Officers of SJMHS - Kathy Brubaker, RN, St . Joe’s Chelsea: Joyce Young, PhD, RN, Regional Chief Nursing Officer / St . Joe’s

Ann Arbor; Sharon Blanche, RN, St . Joseph Mercy Livingston; Amber Flynn, RN, St . Mary Mercy Livonia; and Doug Dascenzo, RN, St . Joseph Mercy Oakland .

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Our nurses ‘ commitment to compassionate and transforming, healing care is vital to fulfilling our mission, vision and values. A Professional Practice Model (PPM) helps depict the essence of nursing practice and its relationship to the mission, vision, values, and strategic priorities of Saint Joseph Mercy Health System.

In 2016, nurses at SJMHS developed our Professional Practice Model (at right) to symbolize our strength and ability to adapt and grow in a dynamic health care environment. Rooted in our Core Values and strengthened by the philosophy of relationship-based care, the following examples are some of the fruits of nursing excellence:

• Evidence-Based Practices – Nurses and colleagues in the Women and Children’s Services have been transforming our practices around supporting new mothers and their babies through the Baby-Friendly initiative, a strategy launched by the World Health Organization with the goal of improving nutrition and health of children. This initiative involves ten practices that support informed feeding choices. For instance, mothers are encouraged and supported to initiate breastfeeding within one hour of delivery, as evidence shows that breastfeeding has lasting effects on a person well beyond their infancy.

• Professional Development – Leveraging the size of our health system, best practices in nurse education, development, and empowerment are being shared and implemented across the region. Based on feedback from nurses and other colleagues, a substantial increase was added to the tuition reimbursement provided to colleagues pursuing further academic courses. In addition, this past year saw the full implementation of a Clinical Advancement Program and Nurse Residency Program in all the Health Ministries in our region.

• Interdisciplinary Care – Interdisciplinary teams are now documenting patient-centered goals of care into the medical record through the deployment of Interprofessional Plans of Care (IPOCs). This interprofessional team, responsible for the patient’s care, strives to communicate common goals and coordinate their care towards these goals. In particular, IPOCs support nurses’ critical thinking skills and selection of appropriate nursing interventions for their patients.

• Advocacy – This past year, Joyce Young, SJMHS Regional Chief Nursing Officer, along with Advanced Practice Registered Nurses (APRNs) from across our region travelled to Lansing to advocate for increased APRN scope of practice. As a result of this and numerous other nurse–supported initiatives, House Bill 5400, which allowed Nurse Practitioners, Nurse Midwives, and Clinical Nurse Specialists to prescribe nonscheduled prescription drugs, physical therapy, speech therapy, and order restraints, passed. This is a great accomplishment for the State of Michigan to increased access to care for its residents.

Professional Practice Model The Fruits of Nursing Excellence

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All of our health ministries across SJMHS are committed to excellence in nursing practice. Our journey to Magnet is a vehicle to portray nursing excellence. In 2016, St. Mary Mercy Livonia led the way by becoming the first SJMHS hospital to obtain Pathways to Excellence certification. The designation is assessed and processed through the ANCC which recognizes hospitals where nurses excel through meeting 12 Practice Standards essential to an ideal practice environment. This process includes submitting a document that provides examples of how our hospital achieves each of the 12 practice standards with narratives, graphs and charts. Each standard reflects the foundational elements for safe patient care, quality outcomes and a positive environment for delivering quality nursing services.

As part of their Pathways to Excellence journey, nursing staff in SMML developed their model of nursing care. This model aligns with and is part of the SJMHS PPM. Their model positions them well and continues to develop as they progress in their journey towards nursing excellence.

Our SJMHS journey of nursing excellence has proven to strengthen communication and accountability among colleagues, while providing systems that support evidenced - based practice. This will increase nursing satisfaction and retention, leading to sustained positive patient outcomes.

1 Nurses control the practice of nursing

2 Work environment is safe and healthy

3 Patient care and practice concerns are addressed

4 Orientation prepares nurses for the work environment

5 The CNO participates at all levels of the organization

6 Professional development

7 Equitable compensation

8 Nursing achievements are recognized

9 A balanced lifestyle is encouraged

10 Collaborative relationships are valued and supported

11 Nurse managers are competent and accountable

12 Use of evidence-based practices and quality programs

Nursing Strategic PlanPathways to ExcellenceSt. Mary Mercy Livonia

Pathway to Excellence12 Practice Standards

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Saint Joseph Mercy Health System will leverage the leadership strength of our nurses to advance synergistic relationships and ensure the consistent delivery of the highest quality, safest, and most effective care experience for every patient, every day, every site. We will build a people-centered approach to achieve the Triple Aim – better care, better health and lower cost.

Our nurses are guided by the following behaviors:

• We support each other in serving our patients and communities• We communicate openly, honestly, respectfully and directly• We are fully present• We are all accountable• We trust and assume goodness of intentions• We are continuous learners.

People Centered: Improve the experience of care• Focus on factors that most significantly influence the patient experience• Enhance the nurse experience; engagement and satisfaction:• Strengthen and hardwire evidence-based practices: purposeful hourly rounds; nurse leader rounds; handoffs; patient ambulation; etc.• Primary measure: HCAHPS

Engaged Colleagues: Develop a workforce to transform care • Talent acquisition: Provide high quality onboarding for new hires/ maximize the Nurse Residency Program• Performance management: Develop and retain high performers• Talent development: Continue BSN strategy. Encourage and increase certifications across the region

• Primary measure: Press Ganey Engagement & Safety Survey; vacancy/turn-over

Operational Excellence: Build on our strengths to deliver operational excellence• Demonstrate excellence in practice through pursuance and attainment of nationally recognized

nursing excellence programs• Further develop the nursing infrastructure to reduce overall administrative overhead, variation, and streamlines/strengthens rapid dissemination of best practices in education, development; research, and policy• Deploy Kronos Analytics across all sites and standardize staffing management

• Primary measure: Nursing Sensitive Indicators, Productivity report, Kronos Analytics

Leadership: Strengthen and expand the ministry of Catholic health care in our communities• Create a culture of engaged nurse leaders (at all levels) – evidenced by participation in professional activities, councils, & Advocacy.

• Primary measure: Magnet standard compliance and achievement

Stewardship: Improve quality and safety outcomes through redesign• Drive High Performance/Achieve Top Outcome Performance• Leverage technology to gain eficiencies• Implement standardized staffing management, methodologies, acuity, productivity management, and grow our profile workforce

• Primary measure: GPA, NDNQI, staffing effectiveness assessment/ Productivity Report

Nursing Strategic Plan

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Nursing Quality, Safety, and Engagement Results

SJMHS Nurses have demonstrated excellence in many ways and it is reflected in our 2016-17 data . Nurses kept patient safety a top priority through the reduction of Hospital-Acquired infections in our hospitals, and provided compassionate care and a listening ear as evidenced by patients’ feedback on their communication with nurses . These remarkable feats are possible because we have engaged nurses that exemplify leadership at the bedside and continuous learning, as reflected through our most recent nurse engagement survey results .

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An Increase in Patient Acuity Leads to Creating Progressive Care UnitsSt. Joseph Mercy Ann Arbor

BackgroundAs health care and technology continue to evolve, there has been an acuity increase in our patient population. This change in patient intensity of care need became more evident when we looked at the constraints in availability of Intermediate Care (IMC) beds. While the Medical-Surgical beds had an average daily occupancy of 86%, occupancy for IMC beds is often higher than 95%.

The inadequate IMC bed capacity negatively affected timely inpatient throughput and created frequent patient transfers. This impacted the care teams’ ability to provide consistent care and created an additional workload for nurses and physicians. Patient transfers require additional hand-offs and add 3.5 hours of non-value added work.

Moreover, frequent transfers and throughput issues impact patients. Transfers can lead to increased length of stay,

communication breakdown, and longer wait times in the Emergency Department. Patients and their families have commented on transfers, “I wish my father hadn’t been moved from one floor to another - this made him really confused. I understand why it was done, but I want to recommend trying not to move the elderly when possible.”

An interdisciplinary group reviewed best practices for managing IMC needs such as staffing models and acuity tools. They also reviewed the current patient placement policy and literature to determine a plausible solution. In addition, they consulted with peers in Trinity Health regarding acuity adaptable units.

Purpose/GoalTo shift IMC capacity across additional patient care units, creating true Progressive Care Units where patients will progress from IMC acuity at admission to a general medicine bed care and subsequent discharge, all within the same room and unit.

ImplementationTo implement this solution, two units, 4 North and 11 East, increased their capacity for IMC patients. This change included an adjustment of the two units’ nurse-to-patient ratio, additional training and education to meet the needs of the patient population. Nurses were hired and oriented to meet the new nurse ratios. An educational and orientation plan was developed, which included cross-training the nurses in existing Progressive Care Units. The staff and their unit-based councils also developed acuity tools to help them create optimal staff assignments.

TeamNurses, leaders and physicians.

OutcomeImplementation of the Progressive Care Unit expansion began in April 2016 and positive results were immediately seen in throughput times. IMC bed utilization decreased from 95% to 88% within four months. The number of admitted patients held in the EOC, Emergency Department, and PACU also saw a decrease. Finally, the average number of patients transferred decreased by 65% after expansion.

Next Steps Continue to closely monitor the changing needs of the patient population and make improvements.

Transformational Leadership

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Figure 1. Patients Held in EOC, Emergency Department and PACU Decreased

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Unit Councils Help Nurses Improve Patient CareSt. Joseph Mercy Chelsea

BackgroundExemplary nursing practice is evidenced in Magnet organizations through the involvement of nurses at all levels of the organization. Nurses assume leadership roles at the bedside, on their units and through participation in inter-professional teams.

Purpose/GoalProvide a forum for nurses to network in order to improve patient care.

ImplementationNursing councils were implemented in 2010 beginning with the Nurse Practice Council, Nurse Education & Development Council, Relationship–Based Council and the Nurse Operations Council. The council structure provided a forum for nurses to network, dialogue about multiple aspects of nursing care within the organization and make decisions which impacted daily nursing practice.

Subsequently, Unit Councils in all inpatient areas were formed in June 2016, allowing for clinical nurses to have shared leadership at the unit level. The unit councils are led by clinical nurses practicing at the bedside and mentored by the nurse directors.

TeamNurses

OutcomeUnit Councils give clinical nurses an opportunity to look at quality of care issues, current nursing practices and trending of nurse-sensitive indicators for their specific unit, as well as collaborate with other health care

professionals to improve quality patient outcomes. All Unit Councils report their work back to the Nursing Practice & Education Council on a monthly basis.

Next Steps As Unit Councils grow, it is anticipated that more nurses will become involved in research, community outreach, and decision making.


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Off Shift Assistant Nurse Managers Improve SafetySt. Mary Mercy Livonia

BackgroundLimited front-line nurse leadership/management support during the afternoon and evening shifts of the Medical Surgical Units left charge nurses with the added responsibility of handling patient assignments. The added workload hindered their core efforts to assist nursing staff with patient/family issues.

Purpose/GoalIncrease of nursing leadership/management support during off-shift hours; to improve safety and satisfaction.

ImplementationWith the identification of a soft, but compelling ROI in late 2016, nursing leadership added six assistant nurse managers to the Inpatient Nursing Leadership Team. To prepare the assistant nurse managers for their new roles, nurse managers created an orientation program. After approximately six weeks of orientation, the assistant nurse managers began working the afternoon/midnight shifts in January 2017.

The assistant nurse managers initiated a 9 p.m. safety huddle. They meet with the shift administrator (who is scheduled for the night) to discuss throughput and staffing issues that may arise during the shift.

TeamMary Nelson (2 South), assistant nurse manager; Laura Kehler (4 West), assistant nurse manager; Danielle Dandachi (3 East/ICU), assistant nurse manager; Stephanie Tucker (5 East/Rehab), assistant nurse manager; Rob Krupp (4 East), assistant nurse manager; and Kelly Pollack (3 South), assistant nurse manager.

OutcomeStaff and patient safety have improved through the addition of the assistant nurse managers to the inpatient nursing units. The care provided by the nursing staff has improved and nurses are now able to immediately resolve urgent issues. Staff engagement has improved and the staff feels supported. Nurse leader rounding has also been positively impacted, especially with the new admits.

Next Steps Continue to monitor the staff’s needs and continuously improve patient care and safety; ultimately to improve the experience of care for both the patent sand nurses.


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Bariatric Surgery can Improve Weight Loss and Health Issues St. Joseph Mercy Livingston

BackgroundIn 2014, 30.7% of adults in Michigan were obese, according to the Centers for Disease Control and Prevention (CDC). During 2012 – 2014, 36.9% of adults in Livingston County were obese, according to the CDC.

Bariatric surgery can be an option for patients who have failed non-surgical weight loss options. Patients considered for surgery must have a body mass index (BMI) of more than 40 or a BMI of more than 35 with significant comorbidities. Comorbidities may include any one or more of the following: high blood pressure, diabetes, obstructive sleep apnea, heart disease, acid reflux, and other weight-related medical problems

Purpose/GoalTo improve weight loss and improve or resolve obesity-related health issues.

ImplementationAfter nearly a year of planning and preparation, the first bariatric surgery was performed at Saint Joseph Mercy Livingston Hospital on January 17, 2017. The Sleeve Gastrectomy will be the primary procedure performed.

TeamSurgeons, nurses, project coordinators, inventory coordinators, surgical technologists, anesthesia and other personnel.

OutcomeBariatric surgery significantly improves weight loss, obesity-related health issues, life expectancy. Patients have seen significant improvements in type 2 diabetes, hypertension, sleep apnea and hyperlipidemia.

Next Steps Saint Joseph Mercy Livingston is striving to become a Bariatric Center of Excellence.

Structural Empowerment

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Preserving Eyes Eligible for TransplantsSt. Joseph Mercy Ann Arbor

BackgroundSt. Joseph Mercy Ann Arbor is one of the largest sources of organ donation in southeast Michigan. This is particularly true for eye donation, which many patients rely on to regain their sight. In order for the donated eyes to be viable for transplantation, they must be preserved within a few hours of a donor’s death. Realizing this need within the community, nurses at St. Joe’s Ann Arbor partnered with Eversight Michigan, the local eye bank, to increase the number of donated eyes eligible for transplantation.

SolutionA representative from Eversight Michigan spoke to nurses on St. Joe’s Nurse Practice Council about eye donation and tissue recovery. Nurses reviewed the current policy for post-mortem care and made revisions to ensure proper preservation of the organs.

Changes included:• Flushing eyes with saline after death. • Closing eyes with paper tape. • Elevating the head of the patient to reduce swelling. • Placing ice over the eyes.

OutcomeSince the changes were implemented, the number of donors receiving eye care has increased. This has been particularly effective on11 East and MICU, who have provided eye care to 100% of the donors. The percentage of eyes from donors continue to increase. In 2016, there were 29 donor patients from St. Joe’s Ann Arbor. With the appropriate care/practice change, 48 people received the gift of sight out of the generosity of these donors (a 40% increase).

Next Steps The process improvements have been so successful that Eversight has invited SJMHS to make a presentation at its national meeting and its global meeting in China. Eversight is seeking to replicate this partnership with other hospitals to further provide the gift of sight to more people in need.

This success reflects on the Core Values of our organization - Reverence, Commitment to Those Who are Poor, Justice, Stewardship, and Integrity. It further showcases St. Joe’s commitment to relationship-based care, shared governance, and nursing excellence – the foundations of the Nursing Professional Practice Model – through compassion and community outreach.


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Nurse Residents Contribute to Care St. Mary Mercy Livonia

BackgroundThe first cohort of St. Mary Mercy’s Nurse Residents graduated on June 15, 2017.

Purpose/GoalTo celebrate the nurse residency graduates, ease onboarding of new nurses, and improve care and live our mission.

ImplementationThe nurse residents completed their residency program and were recognized at the graduation ceremony. The day ended with the popular activity of escaping from a break-out room. The break-out room was developed by the nursing education task force. The nurse residents used critical thought to solve the clues which were related to the topics they learned throughout the year. The graduates successfully escaped from the room within the one-hour time limit.

The graduates presented five quality projects to leadership during the graduation celebration.

OutcomeThe graduates were celebrated and they contributed to improving patient care by developing research questions.

Left to right: Latrice Fountain (ICU), Kelsey Daniels (2 South), Katelyn Moss (3 South), Renee Marcarian (4 East), Kevin Oeftering (4 East), Patty Pokrandt (Education), Kevin Essex (Emergency Center), Lauri Sak (Outpatient Surgical Center), Amber Stinson (ICU), Daniel Modes (4 East), Alexandra Brandt (3 South), Corey Bedra (3 South).

Students: Lauri Sak, Latrice Fountain

To live out our mission and core values, the graduating residents assembled 100 clean birthing kits for Global Health Charities. These kits will be delivered to underdeveloped countries and will help to ensure that mother and baby have a clean birth.

Next Steps Project abstracts will be submitted to the National Nurse Residency Conference next spring. Many of the residents plan to continue to develop their leadership skills and display their professionalism by serving on nursing councils, shared governance and taking on charge nurse roles. Some of the residents are dedicated to obtaining additional certification and pursuing further academic education.


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Initial Stroke Care Gets FasterSt. Joseph Mercy Ann Arbor

BackgroundThe Joint Commission requires Primary Stroke Centers to provide Alteplase, or tissue plasminogen activator (tPA), within 60 minutes of arrival to the Emergency Department (ED) in at least 50% of all cases. In the critical-acute stroke workup phase that occurs in the ED, the most important things to know and/or do, are: • What is the time last known well? Is this time within the last four hours?• Obtain a stat blood glucose to rule out a stroke mimic.• Obtain a stat head CT without contrast to assess for intracranial bleeding.• Complete a focal neurological exam using a standardized stroke assessment.• Assess candidacy for tPA by reviewing the inclusion-exclusion criteria.

In 2014, prior to the change in the Joint Commission’s expectations, our door-to-drug times remained far below 50%. We had to improve to align with the rest of the country and meet the Joint Commission’s new requirements.

Purpose/GoalTo provide Alteplase within 60 minutes of arrival to the ED in 50% or more of eligible ischemic stroke patients that present within four hours of last known well.

Implementation• EMS takes patient to the CT scanner as a priority after pre

notifying the ED that the patient is showing stroke symptoms. • Priority overhead page in the ED to converge to the ED CT

scanner to identify the patient and expedite the scan.• Inclusion of EMS provider on Stroke Collaborative Practice

Team. • Bi-annual training on mixing and hanging tPA by registered

nurses.• Updated acute tPA stroke packets.• ED nurse assigned to review and provide feedback to

clinicians on all TPA cases. • Created a FirstNet tracking icon for visual reminder to use

the stroke packets.

TeamED registered nurses, ED physicians, radiology technicians and physicians, clerks, assistants, laboratory staff and EMS providers.

OutcomeDoor-to-drug times are at or exceeding 50% within 60 minutes; the national average is about 80%. Door-to-drug times of only 22 minutes have occurred this year. Saint Joseph Mercy Health will receive the Target Stroke recognition from the American Stroke Association this year.

Next Steps Meet or exceed the national level and shift focus for door-to-drug times to within 45 minutes.

Students: Lauri Sak, Latrice Fountain

Exemplary Professional Practice

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Addressing Alarm Fatigue in Cardiac Telemetry Monitoring St. Joseph Mercy Ann Arbor

In a world of increasing medical technology, patients frequently endure unnecessary monitoring and the monitor’s alarm system. Many of these alarms do not contribute to a change in patient’s plan of care, but do contribute to a work environment in which clinicians responding to such alarms have become desensitized to its message. This is known as alarm fatigue.

Cardiac telemetry monitoring, for example, has a plethora of alarms that require multiple phone calls to resolve. Oftentimes, these alarms do not change treatment course for patients, but they contribute to a perception of increased workload. As a result, patient safety outcomes are at risk when true alarms that do result in an intervention are not responded to appropriately or in a timely fashion.

In June 2015, new evidence-based ECG alarm parameters were developed by Trinity Health, in response to the Joint Commission’s 2014 National Patient Safety Goal of “Improving the safety of clinical alarm systems.” The Joint Commission (TJC) charge health systems with making alarm safety a priority by identifying the most important alarms, establishing policies and procedures for managing those alarms, and educating clinicians about the importance of alarm system management.

In July 2015, St. Joe’s Ann Arbor and Livingston reduced the number of alarms that did not result in a nursing intervention (Table 1). During fall 2015 a Post Alarm Change survey was completed by staff indicating that the alarm changes resulted in an increased sensitivity to alarms, and a decrease in alarm fatigue.

January 2016, all RNs completed two Healthstream modules for alarm management education titled “Alarm Management-ANCC” and “SJMHS Do Your Part: Be Alarm Smart”.

Since the changes of the default alarm settings, including priority alarms “Leads Off and Low/Dead Battery” becoming red alarms, the number of leads off and low/dead battery alarms has decreased by nearly 50%. In Summer 2017, an additional Healthstream module was added to increase education and awareness of adjusting alarm parameters to prevent alarm fatigue.

Through the collaborative work of many nurses, leaders, and physicians a plan was developed and implemented to address Alarm Fatigue. Proactive work on safe alarm management will continue as we seek to provide Remarkable Care to all our patients.


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Innovations Improve the Patient ExperienceSt. Joseph Mercy Chelsea

BackgroundTo improve the patient experience, the Innovative Concepts for Surgery Committee was formed in January of 2015. Patients were having a difficult time finding their way to the Surgery Department. Patients were also experiencing stress and confusion about the surgical process.

Purpose/GoalTo improve the patient’s surgical experience.

ImplementationIn a Gemba event, the new surgery committee team members completed a “walk-through” of the hospital and grounds to experience “finding their way” as a patient. They noted where additional signs were necessary. The committee updated the website for the Surgery Department and Endoscopy/Pain Clinic (located in a separate building). Other enhancements included a new video, new photos, website, patient packet and a new wayfinding map with door-to-door instructions.

An informational and instructional video showing the journey from pre-op, to post-op, to admission into the hospital and finally discharge to their home.

Team Representatives from Marketing, Clinical Informatics, Patient Experience Advisory Council, surgery, SAM administrator and registered nurses.

Outcome Improved signage was installed in the hospital and on the grounds clearly directing patients to the Surgery Department. Improvements were made to the campus map. The website pages and patient information packets for the Surgery Department and Endoscopy/Pain Clinic were updated and enhanced.

A video of the patient’s surgical experience was created and posted to the website. The video and website can be seen, at: www.stjoeschelsea.org/surgeryexpectations.

Next Steps Add a pre-surgical questionnaire to the website - allowing patients to email it via a secure mailbox to the surgery nurse. The committee is also exploring ways to use technology to update patients and their family with information regarding their surgery.


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Fetal Heart Rate Now Dictates Mother’s Pushing in Labor St. Joseph Mercy Oakland

BackgroundThe Labor & Delivery Team has worked diligently this year to improve the safe delivery of newborns while focusing on the second stage of labor. The second stage of labor is defined as the interval between complete cervical dilation and delivery.

The second stage of labor is the most physiologically stressful time for the fetus. Although most fetuses can tolerate some fetal heart rate decelerations during pushing, others enter the second stage of labor with less physiologic reserve. Variable and late decelerations occurring with every one to two contractions in the 30 minutes prior to birth are associated with lower one- and five-minute Apgar scores, more cases of arterial blood pH < 7.2 and more

admissions to the Neonatal Intensive Care Unit when compared with decelerations occurring less frequently.

Purpose/GoalTo increase the use of modified pushing to > 95% compliance.

ImplementationThrough peer mentoring and auditing, Labor & Delivery registered nurses were trained to use continuous fetal monitoring data to guide maternal pushing efforts and minimize risks. The baseline Fetal Heart Rate (FHR) should always be identified between contractions. Labor & Delivery nurses temporarily suspend maternal pushing efforts to allow the fetus to recover to baseline when the FHR is indeterminate or abnormal. Maternal pushing efforts then resume to one push every other or every third contraction to help maintain normal FHR characteristics.

Nurses no longer initiate pushing with a mother simply because her cervix is dilated at 10 cm – they now wait until the mother feels the natural urge to push.

Mothers are supported to push in a more natural, spontaneous way. Mothers are no longer instructed to hold their breath while counting to 10 and repeating two more times with each contraction.

Team Nurse Champions: Michelle Carter, PPSN/CNL and Laura Weidle, CAP, RN

Outcome The goal to increase usage of modified pushing > 95% compliance was achieved.

Next Steps Expand these teachings into the new obstetrics residency program.


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Hypoglycemic Episodes Decrease with Apple ProtocolSt. Joseph Mercy Oakland

BackgroundNursing staff on 6 South Neurology recognized there was a variation in the time from blood glucose check to correctional insulin administration. This was largely caused by the pharmacy standard medication administration time and the standard meal delivery time.

Current practice consisted of the PCA completing blood glucose checks at 0500, 1100, 1600 and 2100 hours. Scheduled insulin administration times were 0630, 1130, 1630 and 2100 hours. Patients order their own trays

according to their preferences.

Purpose/GoalDecrease hypoglycemic episodes by developing a process to obtain blood glucose within 30 minutes of meal delivery and insulin administration.

Implementation• All patients who receive correctional insulin have an “apple” icon posted outside the bedroom door. • The registered nurse (RN) informs the PCA in report that the patient is an “apple blood sugar.” The RN coordinates

the blood sugar check time with the PCA.• The RN educates the patient and family about the apple blood sugar procedure.• Dietary delivers the tray to bedside table.• The dietary staff presses the dietary light and an alert is sent to the PCA’s and RN’s phones.• The blood sugar is checked, if not already done.• The RN checks the blood sugar result and administers the appropriate amount of insulin.• The RN gives the food tray to the patient.

Team Two leadership students from U of M Flint, registered nurse manager.

Outcome Reduced the average time from blood glucose check to insulin administration by 23 minutes over the past year and decreased hypoglycemic episodes by 18%.

Next Steps Continue to audit monthly, reinforce process measures and provide support to other patient care units as this process is replicated elsewhere.


2019

Busy Fingers and Hands St. Joseph Mercy Livonia

BackgroundFor Nurses’ Week this year, the 3 South Shared Governance Committee brainstormed creative fund raising activities that would fund “Alternatives to Go Cart” for the unit. This cart is designed to keep confused, elderly patients busy with various interactive, diversional activities. The activities are an effort to distract and prevent patients from pulling out IV lines, Nasograstric tubes and falling.

The patient population on the 3 South unit is older than 65 years old and susceptible to delirium, or already has

baseline dementia. A new environment for these patients can be very scary and can cause anxiety.

Purpose/GoalTo distract and aid in preventing elderly and confused patients from pulling out IV lines, Nasograstric tubes and falling.

ImplementationCreate a cart with large print word searches and crossword puzzles, coloring books, stuffed animals for comfort, various small plastic loops to keep hands and fingers busy, and “Busy Blankets.”

Team Karen Isles, Jeanette Marron, Shared Governance Committee.

Outcome As a department, 3 South Staff raised more than $500 towards the creation of the “Alternatives to Go Cart.”

Next Steps This effort will be ongoing and supported by Karen Isles who will make the Busy Blankets. Patients and families will be able to take home the Busy Blankets upon discharge. The T- shirt sales will continue.


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Clinicians Partner with IT Staff to Improve CareSt. Joseph Mercy Oakland

BackgroundAn electronic hand disinfection monitoring system (Hill-Rom) was installed in the new South Tower addition in 2014. The hand hygiene compliance scores were low (67% in April 2016) on 4 South, despite efforts to improve.

Known high-performers were experiencing large fluctuations in hand washing compliance scores depending

on room assignments. It was discovered that most staff members experienced dead or dying batteries in theirReal-TimeLocation System (RTLS) tracking badges.

Purpose/GoalTo achieve greater than 90% hand hygiene compliance; 100% functional RTLS badges; and 100% functional sensors (wall dispenser, ceiling tracker) in all rooms and corridors.

ImplementationDaily huddles with 4 South staff revealed IT problems with RTLS. Hand hygiene compliance and infection rates were reviewed during the huddles.

Bad batteries in RTLS badges were identified and changed. Wall dispenser sensors were repaired to accurately capture badges and record hand hygiene compliance.

Team Registered nurse manager; registered nurses; PCAs; Patient Safety Team; HUCs; nurse externs; Robert Jones, senior director; TIS; and Centrax staff.

Outcome Standard work was developed by IT to perform maintenance on RTLS tracking. Hand hygiene compliance scores increased by an average of 12%. In October 2016, hand hygiene compliance score was 88%. Staff morale and engagement increased as they understood the significance of higher hand hygiene compliance. Hospital-acquired MRSA bacteremia decreased as hand hygiene compliance increased.

Next Steps Continue to improve hand hygiene compliance.

New Knowlege, Research and Improvements

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Technology Makes Patient Hand-Offs Safer St. Joseph Mercy Oakland

BackgroundInpatient nursing and medical staffs frequently noted that admitted patients received from the Emergency Department (ED) were often arriving without adequately planning for patient needs or proper regard for the appropriate unit based on presenting conditions.

When an admitted patient was determined to be ready for transfer following bed assignment, the “Ready to Move” function in Teletracking was utilized to initiate notification to the medical-surgical unit of an imminent admission. Once notification was received, the inpatient nurse was allotted 15 minutes to review the ED record online and call with questions. Sometimes the patient would arrive sicker than reflected on the record; or arrive to an inappropriate

unit necessitating the Rapid Response Team (RRT) within two hours of arrival.

Purpose/GoalTo improve the quality, safety and efficiency of patient hand-offs from the ED to participating medical-surgical units.

ImplementationJabber video applications were installed on iPads affixed to goose-neck stands to facilitate virtual face-to-face hand-offs at the patient’s bedside from the ED to the inpatient unit. The use of this technology was integrated into a clearly defined procedure for hand-offs originating in the ED, including a tool to guide the exchange of critical information.

The success of the pilot was determined by the following: • Positive key stakeholder feedback including patient and sending and receiving nurses; • Decreased number of voice reports with “inadequate or poor hand-off” identified as the root cause; and• Decreased number of RRT events within two hours of patient arrival to the inpatient unit.

Team Direct care nurses, leaders from the ED and 4 South, a medical-surgical inpatient unit, CNS, logistics manager and IT.

Outcome Patients presented to the appropriate receiving inpatient unit in a timely manner and in the same condition as reported/observed without the element of surprise. The patients’ comfort and confidence in the hand-off process was increased as they became active participants.

Next Steps Continue to improve patient safety.

2017 AwardsNew Knowlege, Research and Improvements

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Numerous organizations have recognized our hospitals with awards and citations for remarkable

quality, patient safety and satisfaction. These awards underscore our commitment to providing the

highest caliber care in the nation.

Truven100 Top HospitalsSt. Joseph Mercy Ann Arbor

St. Joseph Mercy Livingston

Everest Award (for 5+ years 100 Top Hospitals)St. Joseph Mercy Ann Arbor

Governor’s Fitness AwardOutstanding Healthy WorkplaceSaint Joseph Mercy Health System

Hospitals and Health NetworksMost Wired HospitalSt. Joseph Mercy Oakland

St. Mary Mercy Livonia

NYU College of NursingNICHE Designation for Elder CareSt. Joseph Mercy Ann Arbor

St. Joseph Mercy Chelsea

St. Mary Mercy Livonia

Michigan Breast-Feeding Friendly WorkplaceSt. Joseph Mercy Oakland

Pathway to ExcellenceSt. Mary Mercy Livonia

Guardian of Excellence AwardSt. Joseph Mercy Chelsea

HealthGrades Award for Patient Safety ExcellenceSt. Joseph Mercy Chelsea

Midas Platinum Quality AwardSt. Joseph Mercy Chelsea

2017 Awards

Governor’s Award of Excellence for its Extended Care CollaborativeSt Joseph Mercy Ann Arbor

HealthGrades Award for Outstanding Patient ExperienceSt. Joseph Mercy Ann Arbor

St. Joseph Mercy Chelsea

Blue Cross Blue Shield MichiganBlue Distinction Centers of ExcellenceSt. Joseph Mercy Ann Arbor – Maternity

Nurse.orgBest Hospitals for Nursing ListSt. Joseph Mercy Ann Arbor Leapfrog Patient Safety “A” GradesSt. Joseph Mercy ChelseaSt. Joseph Mercy LivingstonSt. Joseph Mercy OaklandSt. Mary Mercy Livonia

Double 5-Star Rating from CMSSt. Joseph Mercy Chelsea

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2017 Nursing Awards & Scholarships

St. Joseph Mercy Ann ArborDaisy Award WinnersChristopher Anderson, 2 North / SICUMelisa Whisenant, 5 NorthMichael Colombino, PACUKatie Bryant, MICULindsey Wallace, 9 EastRenee Bazzelle, 1 EastGail Spring, 5 EastMissy Taylor, Labor & DeliveryKristy Ward, NRP / STAT TeamSandra Halquist, 10 EastAnita Berendt, 4 EastJianyi Lin, 4 NorthEmily Pasola

Outstanding RN AwardRobin OliverTammy CummingsCaitlyn BeamMelanie GreenleafBarbara YoungMercedes BakianPatricia Lawrence Kearsten Lizak Alyssa AdamsDanielle Sawyer Carla SallSarah SampsonJenn Loria Sarah Hendren Kellie Lewis Sarah Impola Cherie EgedyJamie FarmerSeiwa DouglasRachael HendersonSusan MyersKevin MarchildonErika LeoneAnne KellyDawn Martin Washington OslerElise NapierJulia BurkJanis PfeifferVita Pouget

Anne CaidRuth Cooke Jeremy Zahn Marsha HoffmanTe Hua Fa (Frances) Connie VedrodeAmie Baker Heather GibsonElizabeth SukeiAndrea McHenrySarah PerkinsMichele MongeStacey LyonsKaren Sedgwick Angie AminiBecky HiggsCarla Mackey

MHA Keystone Center Patient Safety & Quality Leadership AwardPat Posa

Nightengale NominationOdette Naughton

Helen Berg ScholarshipShelly Clark, Canton Surgery, Lisa Cummins, Outpatient OncologyRobin Oliver, 1 EastLisa Paul, 4 EastJill Pittman, EDEllyn Tindall, 2 East

Julie MacDonald Nursing ScholarshipEmily Naquin, ICPRBeth Scott, RadiologyTuomy ScholarshipChelsea DeLuca, 9 EastJordan Judge, SSU/EOCGabriela Wilson, 2 East

St. Joseph Mercy ChelseaDaisy Award WinnersLeslie Beaupre, BHSVeronica Ibeson, EastKara Fagnani, HPCarrie Kostanko, WestAutumn Munsell, WestSherry Vogel, BHS

CAP NursesPatti Acton, ICUAmanda Adams, Endo/PainMary Bottomley, WestJill Brown, BHSSusan Burris, Endo/PainBarbara Collins, ERNicole Corbell, BHSShannon Daniels, BHSBarb Grace, InfusionMarcia Hutter, SurgeryLynn Keezer, WestCarrie Kostanko, WestEstelle Marshall, EastCynthia Milks, ICUAutumn Munsell, WestKim Pilon, Endo/PainLindsey Quinn, Endo/PainJanet Sexton, ICUJill Secord, HPHollie Shaw, HPHadley Spensley, Endo/PainSusanne Shelhart, EastTeresa Taylor, SurgeryEden VandenBosch, WestSherry Vogel, BHS

St. Mary Mercy LivoniaDaisy WinnersGayle Jaloszynski, ORLarry Philpot, Pre/Post OpPaula Wingett, Birthing CenterHannah Cavicchio, Stepdown UnitJennifer Conley, PM & RDorota Kaliszczak, Behavioral Health Medicine UnitDarcy Morris , ICU / CCUHami Chaboya, ICU / CCUAmanda Riebling , Emergency Room

Nurse of the YearMichelle BenderDarlene O’DonnellNicole JosephJohn CunninghamJulie LeoZeinab KhaterSusan O’Connor

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Shelley LechnarTheresa CastagnaJanice CouchIoana OrtanPenny DinesKelly Busha Nightengale NominationLisa Graski Heart of Nursing ScholarshipDenise Parrish, Birthing CenterCheryl Soraghan, EndoscopyMichele Winn, Pre/Post Op

St. Joseph Mercy LivingstonDaisy Award WinnersLynn Rivas, EOCDebbie Fulton, 2 SouthKim Bannon, Emergency Services

St. Joseph Mercy OaklandDaisy Award WinnersLisa Slowinski, PACULauren Johnson, 4 SouthKatherine Mosier, 5 SouthSandi Elgert, 2 SouthKathryn Bradley, Mother / BabyChristopher Reynolds, 3 SouthVirginia Allen, 2 South AICU Nursing AwardsJacob Allen - Promise of NursingAmanda Toyzan – PracticeHeidi Warrington – Research & InnovationBecky Alsup – EducationPam Wietecha – LeadershipLaura Kerby – LegacyNancy Flynn – LegacyMichele Rausch - Quality & InnovationFaith Community Nursing – TeamHal Learman, Friend of Nursing-Care TeamFabian Fregoli - Friend of Nursing Physician Caritas Awards4 South, EVS, 3G, 2G, 6 South, CDU, 7 South, ASC, 5 South, 3 South Nightengale NominationsLaura Wiedle (runner up)Amanda ToyzanAlice Holmes Virginia Denomme ScholarshipAndrea Woolcox, 6 South Kitty Paulus ScholarshipJoanne Pavlinac, ED Barbary Burley Scholarship, EDRachel Doyle, ED

Magnet ChampionsSt. Joseph Mercy Ann ArborAmanda Bontemps, SurgeryAmanda Norfleet, 4 East Rehab

Augustina Obi, 6 North MICULeslie Beaster, 3200 Ldr/PBethany L. Roth, Emerg. Observation CenterBrekke E. Crisovan, Short Stay UnitChelsea R. LawlerCynthia Allison, 3200 Ldr/PCynthia L. Behe, Pain InstituteDanielle Suhy, 3200 Ldr/PDawn M. Day, 1 East PsychiatricDawn M. Nehring, 4 NorthDeborah Cross, 6 East CICU/PICUDenise Hoffman, Patient Care ServicesDonna Johnson, Canton Urgent CareEileen V. Newton, Clinical InformaticsElizabeth A. Stierle, 2 North PCUElizabeth J. VanAllen, 6 North PCUElizabeth M. Engle, 2 North SICUJanice L. Molnar, 10 East ACE UniteJean L. Forsythe, 5 East OrthopedicsJennifer A. Hoover, 6 East CICU/PCUJennifer Dunn, Patient Care ServicesKaren L. Hammang, Emergency Dept.Kate Spangler, 5 NorthKathryn L Hoffman, Nursing AdministrationKatie E. Schwark, 5 NorthKelly C. Chizick, 9 East Medical PCUKristy J. Raab, 5 East OrthoLane B. Judge, Emergency CenterLauren B. Osiwala, 6 East CICU PCULauren S. KurtzLisa E. Cummins, O/P Oncology ClinicLisa Friedman, EEDLori A. Spring, EOCMary C. Roelant, 7 East Cardiac PCUMary L. Bishop, 3200 Ldr/PMelissa N. Woldt, 11 East Onc MedicineMichelle Amstutz, 3200 Ldr/PPatricia Buslawski, 3 North Mother_BabyPatricia D. Lawrence, 3 East Med/SurgRachael E. Eisenmann, 2 East Surg PCURachel L. Vandercook, 8 East SurgeryRebecca Kanak, 3200 Ldr/PSandra K. Heinz, ACE Unit 10 East Sheila A. Lynn, 4 NorthStephan J. Bodnar, 6 North MICUStephanie A. Lyons, Emergency CenterTamara Stokes, 3 North Mother_BabyYvonne Reed, Patient Care ServicesAmy LaPere, 5 East Ortho

St. Joseph Mercy ChelseaAndrea Smilowski, IP Head PainAnn McShane, IP Head PainAshley N. Frost, IP West Med/Surg/RehabBecky L. Reynolds, IP East Med/SurgBridget Barrer, IP Behavioral HealthChasidy Federoff, IP Behavioral HealthChristina Claucherty, IP Head PainClara L. Haller, Case ManagementHadley Spensley, Endo/PainHeidi Roberts, Home Care

Hillary D. McCalla, EmergencyJan Sexton, IC CCUJennifer Etue, EmergencyJoan Harvey, IP Head PainJoan Tucker, IP East Med/SurgKathy Brubaker, Patient Care ServicesLori Pritchett, Infusion ClinicLori Williams, IC CCULynn Keezer, IP West Med/Surg/RehabMelissa Edson, SurgeryPat Parr, EducationPatricia Jansa, EmergencyRachel A. Rang, SurgerySally C. Flack, IP West Med/Surg/RehabSherry Vogel, IP Behavioral HealthSue Shelhart, IP East Med/Surg

St. Joseph Mercy LivingstonJan Foran, EducationLisa Smith, 2 SouthJanna Wallace, Emergency CenterDawn Langdon-Paff. 2 South

St. Joseph Mercy OaklandDeborah Pietras, ASCDebra Clancy, NRPAnne Slee, Nursing EducationAnita Barksdale, Nursing EducationJennifer Glass, Nursing EducationKeith Yater, Nursing EducationJona Piazza-Chair, QualityJo Ann Pavlinac, Senior EDKim Weltyk, Pre-OpJames Woods, 2 South ICULynn Boomer, Research

St. Mary Mercy LivoniaJeff Renaud, Nursing EducationPatty Pokrandt, Nursing EducationDiane Gale, Nursing EducationLauren Bailey, Nursing EducationKaren Piotrowski, Med/SurgicalKathy Wagner, 5 EastJulie Rutkowski Yvonne Avery, Nurse ManagerGwen Mc Bride Kim Ayler, Nurse ManagerTashira Winston, EducationFiona Jubenville, PerioperativeSusan Montgomery, Sterile Processing,Kathy Borromeo, Operating Room Larry Philpot, Pre/Post & PatDebbie Ainsworth Pamela Wrigley Karen Bostick, EC/Critical CareDustin Deriemacker, Emergency CenterSandra Elliot, Special Care UnitKatie Schneider, 3 East Pam McCullough, Behavioral Health

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