EXECUTIVE CAREER FIELD (ECF) PERFORMANCE APPRAISALVETERANS HEALTH ADMINISTRATION (VHA) NURSE III Manager/Assistant Nurse Manager/Nursing Coordinator

IMPORTANT: For additional information, see VHA Handbook 5013, Part 1, Appendix F.PERFORMANCE PLAN AND APPRAISAL OF

EMPLOYEE’S NAME (Last, First, Middle Initial)Deitz, Lora R

PAY LEVEL SALARY

III

POSITION TITLE AND NUMBER

5 West Nurse Manager xxx-xx-6212

ADMINISTRATION/OFFICE

637LOCATION

NURSING SERVICE

DATE ASSIGNED PRESENT POSITION

October 12, 2010PERIOD COVERED BY THIS APPRAISAL

FROM 10/01/2012 TO 07/30/13SECTION A - PERFORMANCE PLANIdentify the critical and non-critical elements and performance standards for the position to be rated. Critical elements (i.e., those elements which contribute towards accomplishing organizational goals and objectives and are of such importance that unacceptable performance of them would result in unacceptable performance in the position) are to be identified with an asterisk. Each position must have at least one critical element. Performance standards are statements of the individual's expectations and organizational expectations or requirements established by management for each element. There are usually three to five performance standards for each element. Attach Performance Plan, typed on plain bond paper.PERFORMANCE PLAN COMMUNICATEDDATE COMMUNICATED SIGNATURE OF RATER SIGNATURE OF EMPLOYEE

CHANGES TO PERFORMANCE PLANAttach changes to Performance Plan, typed on plain bond paper. Changes may be recorded anytime during the rating period. Communication of changes must be documented.DATE COMMUNICATED SIGNATURE OF RATER SIGNATURE OF EMPLOYEE

SECTION B - PROGRESS REVIEWAt least one progress review is required during the appraisal year. Employee must be informed of his/her level of performance as measured against the performance plan.A performance review was conducted and discussed, and the employee’s performance as of this date:

Is considered Fully Successful or better.Needs improvement to be Fully Successful or better.

SIGNATURE OF RATER DATE

COMMENTS

.

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SECTION C-1 - ACTUAL ACHIEVEMENTIndicate the single, overall level of achievement that best describes the employee’s performance for each ELEMENT shown in Section A. Do not indicate achievement for each individual standard. Specific achievement must be provided in Section C-2 for each element where a level of achievement other than Fully Successful has been assigned.* Denotes Non-Critical Element LEVELS OF ACHIEVEMENT

ELEMENTS(Use the same keyword description for each element as in Section A) EXCEPTIONAL FULLY

SUCCESSFUL

LESS THANFULLYSUCCESSFUL

#1 Leading Change (15%)

#2 Leading People (15%)

#3 Business Acumen (10%)

#4 Building Coalitions (10%)*

#5 Results Driven (50%) SECTION C-2 - SPECIFIC ACHIEVEMENTDescribe specific achievement(s) for each element where a level of achievement other than Fully Successful has been assigned in Section C-1. Attach descriptions of achievements, typed on plain bond paper.

SECTION D - SUMMARY RATING LEVELUsing achievement levels assigned in Section C-1 and the criteria described below, check the rating which describes the employee’s performance during the covered period.PERFORMANCE RATING

OUTSTANDING - Achievement levels for all elements are designated as Exceptional. EXCELLENT - Achievement levels for all critical elements are designated as Exceptional. Achievement

levels for non-critical elements are designated as at least Fully Successful. Some, but not all, non-critical elements may be designated as Exceptional.

FULLY SUCCESSFUL - The achievement level for at least one critical element is designated as Fully Successful. Achievement levels for other critical and non-critical elements are designated as at least Fully Successful or higher. MINIMALLY SATISFACTORY - Achievement levels for all critical elements are designated as at least Fully Successful.

UNSATISFACTORY - The achievement level(s) of one (or more) critical elements(s) is (are) designated as Less Than Fully Successful.

Check here if multiple summary ratings are not applicableNurse lll Nurse Manager S Element #51. PRACTICE DIMENSION (Practice, Ethics, Resource Utilization)a. Provides leadership in the application of the nursing process to patient care, organizational processes and/or systems, improving outcomes at the program or service level.b. Provides leadership in identifying and addressing ethical issues that impact patients and staff, including initiating and participating in ethics consultations.c. Manages program resources (financial, human, material or information) to facilitate safe, effective and efficient care.

HPDM: Technical, Interpersonal Effectiveness, Customer Service, Flexibility/Adaptability, Creative Thinking. Personal Mastery, Systems Thinking and Organizational stewardshipComments:Please refer to attached:Additional Attachment to VA FORM 3482e, JUN 2011ECF Performance Plan for F Y 2012Nurse llI Nurse Manager

.

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2. PROFESSIONAL DEVELOPMENT (Education/Career Development, Performance)a. Implements an educational plan to meet changing programs or service needs for self and others. Maintains knowledge of current techniques, trends and professional issues.b. Uses professional standards of care and proactive to evaluate programs and/or service activities.

HPDM: Technical, Personal Mastery, Interpersonal Effectiveness, Customer Service, Flexibility/Adaptability, Creative Thinking and Systems ThinkingComments:Please refer to attached:Additional Attachment to VA FORM 3482e, JUN 2011ECF Performance Plan for F Y 2012Nurse llI Nurse Manager

.

3. COLLABORATION DIMENSION (Collaboration, Collegiality)a. Uses group process to identify, analyze, and resolve care problems.b. Coaches colleagues in team building. Makes sustained contributions to health care by sharing expertise in and/or external to the Medical Center.

HPDM: Personal Mastery, Interpersonal Effectiveness, Customer Service, Flexibility/Adaptability, Creative Thinking Systems ThinkingComments:Please refer to attached:Additional Attachment to VA FORM 3482e, JUN 2011ECF Performance Plan for F Y 2012Nurse llI Nurse Manager

4. SCIENTIFIC INQUIRY DIMENSION (Quality of Care, Research)a. Initiates interdisciplinary projects to improve organizational performance.b. Collaborates with others in research activities to improve care.

HPDM: Technical, Personal Mastery, Interpersonal Effectiveness, Customer Service, Flexibility/Adaptability, and Creative ThinkingComments: Please refer to attached:Additional Attachment to VA FORM 3482e, JUN 2011ECF Performance Plan for F Y 2012Nurse llI Nurse Manager

This section may also be used to describe significant accomplishments not otherwise described in the appraisal, to comment on the executive's potential for higher level positions, and/or to document VHA Personal Development Plans. Attach Narrative Summary, typed on plain bond paper.

SECTION F - INITIAL RATINGRATING SIGNATURE OF RATER DATE

SECTION G - EXECUTIVE REVIEW

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REVIEW

I do I do not request higher level review. I do I do not wish to provide a written response. The ECF Participant should attach the written response

to this formSIGNATURE OF EMPLOYEE DATE

SECTION H - HIGHER LEVEL REVIEW (Optional)

ACTION

Concur with rating. Do not concur with rating - Recommend rating of Select.....

BASIS FOR RATING CHANGE

SIGNATURE AND TITLE OF REVIEWER DATE

SECTION H-1 NURSE EXECUTIVE REVIEWACTION

Concur with rating. Do not concur with rating - Recommend rating of Select.....

BASIS FOR RATING CHANGE

SIGNATURE AND TITLE OF NURSE EXECUTIVE DATE

SECTION I – FINAL RATINGRATING SIGNATURE OF APPROVING OFFICIAL DATE

VA FORM 3482e, JUN 2003 7 VA FORM 3482e, JUN 2003 8

Element #1 Leading Change: VISN 6 VAMC Score Card for Element #1 leading change rated Outstanding.

Nurse Deitz has exemplary ability to bring about strategic change, both within and outside the organization to meet organizational goals. Nurse Deitz exhibits the ability to establish an organizational vision and to implement it in a continuously changing environment.

Nurse Deitz develops new insights into situations; questions conventional approaches, encourages new ideas and innovations; designs and implements new or cutting edge programs/processes.Nurse Deitz’s external awareness, flexibility, resilience, strategic thinking, and vision are demonstrated throughout this proficiency.

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Identified: AES (All Employee Survey) Outcomes:#49 Managers in my facility are risk-takers. They encourage employees to take risks and be innovative.#50 The glue that holds my facility together is commitment to innovation and development. There is an emphasis on being first.# 58 My facility emphasizes competitive actions and achievement. Measurable goals are important.

Identified: Nurse Deitz empowers staff and leads changeOutcome: Multiple PI projects (examples)

Coagulation Study by Chris Sherman and Travis D’Albor (Nursing Research Council wants staff to pursue research project)

“Wipe It Wipe It Good” by Teri Allstaedt, JB Stephenson, and Gus York (Nursing Research Council wants staff to pursue research project)

Paper conservation project by Megan Tarrer (Nurse Deitz nominated Ms. Tarrer for “Caught Conserving Award”) Care Path Development and Revision Team by Deb Bulsiewicz and Donna Adams White Boards Bedside Reporting Interdisciplinary Rounding at Bedside Huddles Quiet Time

Unplanned leave: Addresses with staff the importance of being here to meet the Veterans needs and to support their colleagues. Verbal discussions as needed when absenteeism increases per individualOutcome: Nurse Manager Team decreased unplanned leave by 5%

Interdisciplinary Rounds at BedsideIdentified: The VA initiative of Veteran Centered Care and the interdisciplinary rounding taking place in the 5 West conference room was noted to last 45 minutes to 1.5 hours, Monday through Friday. Nurses were taken away from the bedside and the Veterans for 10-20 minutes. It was noted that there was lack of collaboration and discussion with the Veteran and family in the rounding and put the Veteran at a disadvantage and possibly increasing length of stay. Planning: Change of practice: Interdisciplinary Bedside Veteran Centered Care rounds. Implementation: Facilitated education of staff on 5 West in collaboration with Ms. Morris, CNL in new process of bedside interdisciplinary rounding. Nurse Deitz communicates that Bedside Interdisciplinary Rounding are an expectation of the Primary RN, Social Worker, PCC, Dietician, Utilization Review RN, CNL and other interdisciplinary partners who need to attend. Implemented in March 2012. Outcome:(1) Bedside interdisciplinary rounds were initiated on the 5W surgical unit. Interdisciplinary rounding now focuses on

Veteran and family allowing for conversation in the patient’s room. Significant contributions discussed include evaluation of diet, pain, ambulation, surgical wounds/drains, financial and/or home needs, lodging, length of stay and anticipated discharge date, discharge needs related to dialysis and CLC admittance and inter-facility transfers.

(2) Interdisciplinary rounds now only last for 30- 45 minutes if unit is at full capacity.(3) These SHEP outcome scores help to substantiate the change in practice. 5 West continues to include the Veteran in

decisions related to their care as evidenced by the SHEP score “Shared Decision Making”

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5 W SHEP Patient Satisfaction Survey Month “Shared Decision” Making

5WFebruary 2012 81.5%March 2012 87.2%April 2012 81.3%May 2012 81.1%June 2012 87.1%

CGVAMC 76.5%National 78.2%

(4) Goal for FY12 ALOS <4.98 for Med-Surg

Average length of stay (ALOS) on 5 west is 3.08, decreased by one (1) day.

Month 5 WestAverage Length of Stay (Days)

Number of Discharges/Month

May 2012 3.2 154June 2012 2.98 159July 2012 5.52 87August 2012 3.42 189September 2012 4.66 94

Updates for 5 West Nurse Deitz understands the necessity for effective communication. She has been composing the “Updates for 5 West” for 2 years now. She writes these newsletters as one way of communicating important information to the staff. The newsletter is sent as an attachment via email so that staff might access at a later time if needed. It is also printed in hard copy for those that prefer this method. Nurse Deitz offers many resources in the newsletter and she and staff will often refer to it as a resource. Nurse Deitz communicates to the staff that all communication from her is required reading by all and their professional responsibility to stay abreast of information offered. The staff is also encouraged to give information to share in the updates. The staff on the unit can state that communication is positive, effective and continuing.Outcome: Improved communication and staff utilizes the newsletter as a resource for information.

HUDDLE Identified need for instrument for daily communication between shifts. Planning: Discussed with Iva Morris CNL need for 5 minute morning “huddles”. Ms. Morris presented the Researched literature and evidence based practice on communication in acute care. Development of a “Morning 5 minute Huddle” which occurs daily at 0730 and includes day and night shift. This occurs in the 5 west conference room. IMPLEMENTATION: Implemented on 2/22-12 and has become a sustainable part of weekly morning routine under the leadership of the CNL and professional expectation of Nurse Deitz, Manager. Staff educations occurred for “21” days and discussion detailed expectation that all staff on shifts must attend huddle. Huddle would last for “5” minutes at 0730, all staff on day and night shift is to attend. Information presented is unit information or education. Outcome: Evaluation of the morning huddle has allowed for a daily period of time for educational offerings, unit, facility and/or procedural concerns.

21 Days for Change: Identified: Nurse Deitz recognized amount of changes on unit. Knowing even positive changes can be a source of stress she implemented the “21 Day Promise”. She promised to staff that any further changes would be given a minimum of 21 days to implement or more if needed.Outcome: The “21 Day Rule” has become culture on the unit and changes are more controlled leading to decreased stress and improved morale. As indicated by comments received, and it becoming a part of the “language” on the unit.

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Element #2 Leading People: VISN 6 VAMC Score Card for Element #2 Leading People rated Outstanding.

Nurse Deitz demonstrates the ability to lead people toward meeting the organization’s vision, mission, and goals. She fosters the development of others, facilitates cooperation and teamwork, and supports constructive resolution of conflicts.

AESOutcomes:#25 New practices and ways of doing business are encouraged in my work group#28 Employees in my work group are protected from health and safety hazards#36 Supervisors/team leaders understand and support employee family/personal life responsibilities in my work group#38 I have a lot to say about what happens on my job#43 Members in my work group are able to bring up problems and tough issues

Patient Experience Team - LeaderOutcome: Assisting nursing and other departments to implement use of Press Ganey Patient Satisfaction Tool

Recognizes and rewards staff members for outstanding performance.Nurse Deitz has recommended 1 RNs for Special Advancement for Achievement of BSN Degree.Nurse Deitz has recommended 2 LPNs for Special Advancement for Achievement of Certification in LPN-IV.One nursing assistant was chosen to attend MAHEC’s annual WNC Nursing Assistant Conference on Wednesday, October 11, 2012 5 Nurses completed preceptor program this year 1 Nurse is in school for their RN-BSN, this nurse has told Nurse Deitz that through her positive encouragement he has chosen to go back to school and is interested in management. 1 LPN is finishing his ADN program by the end of this year.1 LPN is going back for her RN and should complete within 2 years. There are 2 CNAs taking pre-requisites for nursing school.1 Nurse has decided to pursue the CNL Master’s program and thanked Nurse Deitz for her encouragement to proceed.Outcome: Staff recognition improves morale and fosters the desire to keep learning.

Identified: Proficiency completion re-organized and instructed and guided staff on how to give inputOutcome: Proficiencies on time, less than 90 days

Conflict ManagementIdentified: Need for supportive courses and worked with LRC to bring this course to CGVAMC for guidance for transformational leadershipOutcome: Completed course “Managing Talented People with Bad Attitudes” and several other managers participated

Identified: Staff members building tension in regards to differences of opinionImplemented: Nurse Deitz brought both staff members together and encouraged civil discussion between the twoOutcome: Through constructive intervention and guidance, the two were able to resolve their differences and come up with a plan of how to address issues if future concerns arise. Both remain amicable and are holding true to their plan

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Unit PI ProjectsNURSING SERVICE UNIT LEVEL PI PROJECTS FY 2012Yellow fill is a potential research project per Research Council and Research DeptKey Staff/Leaders

P: Project Name/Problem Description/Goal D: Actions to Improve/Change Pre-project Data S/A: Progress

Lora Deitz, Iva Morris

Improve Communication. Problem: Veteran satisfaction and staff satisfaction scores indicate issues with communication. Goal: improve veteran and staff satisfaction with regard to communication by 20% by 3Q 2012.

Nurse manager newsletter 1Q 2012. Bedside reporting Sept 2011. Daily huddles Feb 2012. Whiteboards in pt rooms March 2012.

RN overall satisfaction: 2011=3.0, with NM: 2011=2.0; Veteran satisfaction: Dec=67

RN overall satisfaction: 2012=3.7; with NM: 2012=2.8; Veteran satisfaction: Jan=89, Feb=100, Mar=97, June=84, Aug=85, Sep=94 GOAL ACHIEVED - continuing

Lora Deitz

PCA Documentation. Problem: PCA documentation inadequate. Goal: improve PCA documentation compliance to 100% by Feb 2012.

Bedside reporting implemented. Clinical Nurse Leader reviews PCA documentation daily. Provides F2F education with staff. This increased compliance ultimately improving pt safety.

Compliance in Sept 2011 < 90%.

Compliance 2Q 2012 = 100% GOAL ACHIEVED - continuing

Megan Tarrer, Chris Williams, Georgiana Hogan, and Teri AllstaedtLora Deitz

Provide ambient environment for veterans on 5W. Problem: inadequate rest and sustained exposure to chaotic environment affects timely healing. Goal: improve pt satisfaction r/t noise by 20% by March 2012.

Decrease noise on the unit 24/7 = keeping overall noise level to minimum. Scheduled "Quiet Time" during 2p-4p = very little noise and low lights. Every staff member required to hold everyone on unit accountable to noise reduction and quiet time. Signage in and out of pt rooms, brochures, inservices, newsletters, and emails educating and promoting this program were completed.

Noise level on Press-Ganey Dec= 66%.

Noise level PG Jan=75%, Feb=85%, Mar=81%, June=60%, Sep=58% GOAL ACHIEVED - continuing - June/Sep low will monitor…

Chris Sherman, Travis D'Albor, Leigh Ann Highsmith (educator)Lora Deitz

Decrease critical PTTs. Problem: increase in critical PTTs and drastic fluctuations in PTTs cause pts to receive more medication and perhaps the incorrect dose of heparin. Goal: decrease critical PTTs by 50% by April 2012.

Standardize drawing of specimens and require stat stickers on all PTTs when pts are on heparin gtts. Education provided to staff about heparin/argatroban and proper lab drawing. Importance of timely draws reinforced. Accountability by requisition duplication. One to lab and one to coag team.

5-West % of all critical PTTs in the facility: Sept 27.5, Oct 60.9, and Nov 42. % PTTs drawn on 5W that were critical: Sept 1.0, Oct 2.5 ,Nov 2.5

5-West % of all critical PTTs in the facility: Jan 13.2, Feb 9.1, Mar 62.5, Apr 0. % PTTs drawn on 5W that were critical: Jan 0.5, Feb 0.1, Mar 1.1, Apr 0.0 GOAL ACHIEVED - continuing

Mike Antonucci identified problem , Lora Deitz, Natalie Parce, Dan Kinnaird

Medication Timing for Most Therapeutic Effect. Problem: timing of medications was causing sub-therapeutic blood levels. Goal: change medication times that are congruent with achieving constant blood levels. This change be implemented house wide by 3Q 2012.

Medication times are changing house wide to allow for constant blood levels of meds to be present in pts avoiding peaks and valleys. Medication MCM revision.

Meds with recommended time intervals were being given at intervals not recommended -allowing for peaks and valleys in blood levels.

Medications times changed house wide May 2012. Medication MCM revised. GOAL ACHIEVED - continuing

Teri Allstaedt, JB Stevenson, Gus York, Iva Morris, Lora Deitz and Pam AlexanderLora Deitz

Wipe, Wipe it Good-To Keep Us Healthy and At Work. Problem: patients and staff are infected by contaminated surfaces. Goal: reduce unapproved leave use by 20%, MRSA transmission to 0 and MRSA infection rate to 0 by Sept 12.

Institute a "wipe before you start" program for 5W. Staff will wipe surfaces before starting their shifts (phones, COWs, computers, desks, any surface). A pamphlet and poster have been designed. Routine cleaning assignments are being made for unit staff.

Over the last 9 Qs, 5W has had an average loss of 1.7 FTTE/Q due to unplanned leave use. The MRSA transmission rate for Oct/Nov for 5W was 1.6 and MRSA infection rate was 1.5. Pending data: baseline ATP test swab by RUHOF.

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Self SchedulingIdentified: Nurse Deitz acknowledges the “shared schedule” is a great staff satisfier.Implementation: Nurse Deitz supports the self-scheduling system she and her unit council developed to meet the needs of the unit. This in turn increases employee morale by providing the flexibility to achieve work/life balance. Attendance has much improved and employees work together to meet the needs of the unit. The employees draft the schedule, Mike Antonucci completes the schedule, and Nurse Deitz receives a schedule to post that usually requires little to no changes needed. Outcome: The outcome is a schedule that meets the needs of the unit, increases staff satisfaction, and decreases the need for overtime. Staff satisfaction with schedule decreases call-ins. Nurse Manager Team decreased unplanned leave by 5%. Shared schedule for staff satisfaction and meeting the needs of the unit to maximize bed capacity

Element #3 Business Acumen: VISN 6 VAMC Score Card for Element #3 Business Acumen rated Outstanding.Identified: need to decrease Unplanned Leave in Nursing ServiceOutcome: Nursing Service reached goal of 5% reduction

1Q 2Q 3Q 4Q$0

$500,000

$1,000,000

$1,500,000

$2,000,000

Nursing Service Unplanned Leave Reduction

FY 11 amount spentFY 12 amount spent5% reduction target

Sala

ry D

olla

rs

Source: C. Griffin/NM attendance reviewand average salary information for nursingfrom Fiscal

OR5%

PACU3%

ED4%

PC11%

Spec Clinic6%

CVL/ENDO3%

1E4%

1W/MHC2%SICU

5%MICU

8%

3E6%

5W7%

4W (5E)10%

CLC-16%

Hospice4%

CLC-212%

SWAT5%

Total Hours Unplanned Leave Nursing Service by Ward/Unit 2010 - 3 Q 2012

Source: C. Griffin/NM attendance review

Identified: Nurse Deitz recognized the need for more supply omnicellsOutcome: She collaborated with Logistics and more supply Omnicells are to be ordered for improved supply management and cost containment

Unplanned leave: Addresses with staff the importance of being here to meet the Veterans needs and to support their colleagues. Verbal discussions as needed when absenteeism increases per individualOutcome: Nurse Manager Team decreased unplanned leave by 5%

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Identified: Need to decrease overtimeOutcome: Decreased overtime as noted in Nursing Budget per Mr. Przestrzelski

Turning off Auto Print in All WardsIdentified: Nurse Deitz provided resources, time, contacts, and guidance to Ms.Tarrer for increasing efficiency when Ms. Tarrer recognized a computer system function that had become obsolete. This function was not only no longer needed, but was also a threat to patient safety and security, complicated the work load of nursing and ward staff, and was costing the hospital at least $20,000 yearly in office supplies. Outcome: As of September, 5 West, 4 West, 3 East, 1 East, MICU, and SICU have adopted this change.  In paper alone, this change is expected to save the hospital about $20,000 per year.  When factoring in the amount saved on printer supplies and maintenance, decreased shredding and recycling, and decreased ordering charges for office supplies, the savings are even more remarkable.

Staffing MethodologyIdentified: Need to address Staffing Methodology 2012. Met with staff representatives and developed proposalOutcome: Completed Staffing Methodology and given to Leadership

Element #4 Building Coalitions: VISN 6 VAMC Score Card for Element #4 Coalitions rated Exceeds Fully Successful.

Shared GovernanceIdentified: Nurse Deitz recognizes the importance of active participation and leadership in the collaboration of nursing councils, work groups, and meetings to improve Veteran care for both the 5 West staff.Intervention:Nurse Practice Council: Chair, Sabrina Thomas, RN and nurse manager representative Nurse DeitzQuality Council: Iva Morris, CNL representative whose focus is on quality outcomesTechnology and Informatics Travis D’Albor, RN representativeResearch Council: 5 West is recruiting for a representative and Travis D’Albor is interested in research and John Byrd might commit to Technology and Informatics.Nursing Professional Development: Mike Antonucci, RN representativeLPN Council: Kathy Vuyovich and Chris Williams representativesACLS Instructor: Nurse DeitzBCLS Instructor: Nurse DeitzNurse Manager’s Meeting: Nurse Deitz Nursing Administration Committee: Nurse DeitzPatient Experience Team: Nurse Deitz, ChairCare Delivery Model Workgroup: Sabrina Thomas, RN, Iva Morris, CNL and Nurse DeitzOutcome: Staff involvement improves patient outcomes and staff satisfaction as nurses take ownership of their practice.

New Units Design TeamIdentified: In 2011, 5 West moved into the new unit. The unit was a great satisfier for the Veterans and staff. As with any new construction, there were areas for improvement and change.Intervention: Nurse Deitz ask the staff to give feedback on any issues found. Ms. Hogan, staff nurse came to the forefront and actively engaged in this process and developed a PowerPoint to present. Nurse Deitz arranged for Ms. Hogan to be invited to a planned meeting with Mr. Przestrzelski, CNE, the engineers, achitectural team, and other key members of the build team. Outcome: The findings from Ms. Hogan and Nurse Deitz were presented and performance improvement changes were implemented. Nurse Deitz continued as a member of the team and was given the opportunity to help with the changes for the 4W unit that could be made and new designs for the future 5E and 4E units. This is an example of the Magnet® component for “New Knowledge, Innovations and Improvements.” Source of evidence (SOE) “nurses participation in architecture and space design to support practice”.Nurse Deitz also assisted the previous 5E nurse manager in her move to the new 4W unit.

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Element #5 Results Driven: VISN 6 VAMC Score Card for Element #5 Results Driven rated Exceeds Fully Successful.

Safe and Effective (identify two)

# Adm vs indicated swab rate FY Comparison

Prevalence rate of MRSA on adm to unit

# discharge swabs done vs indicated

Rate of MRSA transmission per 1000 BDOC

Rate of infection per 1000 BDOC

Unit 2011 2012 Unit 2011 2012 Unit 2011 2012 Unit 2011 2012 Unit 2011 2012

5 west88.70

% 85.70% 5 west 9.1 10.4 5 west 88% 88% 5 west 2.4 1.6 5 west 0.17 0

MRSA Transmission rate down in 2012 from 2.4 to 1.6 Rate of infection per 1000 BDOC down in 2012 from 0.17 to 0

CLABSI and CAUTI:EVALUATION: Outcome Data

(1) CLABSI - 1 Reported CLABSI reported July 2012Reported to 5 West reported CLABSI and prevention measures during Huddle. Reinforced education and need to adhere to Central line bundle sheets.

(2) CAUTI DATA - No reported CAUTI on 5 West March 2012 to present(3) NDNQI DATA – No reported CLABI or CAUTI since its inception.

Patient Centered Care (identify two)(Scores prior to November 2011 are not to be considered, units are mixed and Press Ganey first implemented)Noise Level in and Around RoomAmbience TeamThrough the unit council Nurse Deitz ask Megan Tarrer, RN if she would be interested in organizing a team of the other new nurses to research ways to decrease noise and incorporate quiet time. Ms. Tarrer and her team of three other new nurses started the “Ambience Team” and the unit now has quiet time from 2-4 pm daily, a practice that has become a growing trend among the nation’s top hospitals. The “Quiet Time” educational pamphlet for patient education in regards to and how it aids in the healing process is given to veterans. Posters are on all patient whiteboards about “Quiet Time”. The news of “Quiet Time” has spread throughout the other med/surg units and 3 East has adopted a quiet time as well.Outcome: The patients and staff make an effort to encourage “Quiet Time” to aid in the recovery of the veterans. It has improved patient and staff satisfaction. The Press Ganey Scores have been sustainable above the mean since the inception of “Quiet Time”. Nurse Deitz is awaiting the new decibel readers she requested to arrive any time now to gather audible data.

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Cleanliness of Hospital EnvironmentIdentified: Nurse Deitz reviewed Press Ganey results in January 2012 for the question “Room Cleanliness”. Intervention: She noted the score below the mean at 82.1 %. Nurse Deitz has worked closely with FMS this year to maintain cleanliness on the unit for the veteran’s safety and satisfaction. There are daily rounds completed by Nurse Deitz for cleanliness of unit and weekly rounds with a staff member and an FMS supervisor. Ms. Deitz continues to address the environmental concerns and follows up with FMS leadership as needed.Outcome: Sustained greater than mean from January to October 2012

Efficiency

Lost Time and Claims RateThere were 72 lost time claims for FY’12 at CGVAMC with an incident rate of 4.8

5 West Acute Care Observed Minus Expected Length of Stay (OMELOS)

June 2011 June 2012

Patients Discharges Patients Discharges549 150 474 159

LOS 3.77 2.981132

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Turning off Auto Print in All WardsIdentified: Nurse Deitz provided resources, time, contacts, and guidance to Ms.Tarrer for increasing efficiency when Ms. Tarrer recognized a computer system function that had become obsolete. This function was not only no longer needed, but was also a threat to patient safety and security, complicated the work load of nursing and ward staff, and was costing the hospital at least $20,000 yearly in office supplies. Outcome: As of September, 5 West, 4 West, 3 East, 1 East, MICU, and SICU have adopted this change.  In paper alone, this change is expected to save the hospital about $20,000 per year.  When factoring in the amount saved on printer supplies and maintenance, decreased shredding and recycling, and decreased ordering charges for office supplies, the savings are even more remarkable

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