organizational overview transformational leadership · safety event rate continue to decline, with...

Organizational Overview

TRANSFORMATIONAL LEADERSHIP

OO3 – Copies of the most recent:

Annual reports (nursing and organization)

o Link to Exhibit OO3.1 2015 Medical Center Annual Report

o Link to Exhibit OO3.2 2015 Nursing Annual Report

Quality plans and Patient safety plano Link to Exhibit OO3.3 2016 Medical Center & Nursing Quality and Patient

Safety Plan

Strategic plans for the organization and nursing serviceso Link to Exhibit OO3.4 Medical Center Strategic Framework & Core

Strategieso Link to Exhibit OO3.5 Nursing Strategic Framework

o Link to Exhibit OO3.6 Nursing Strategic Plan

7.19.16 jlm

OO3 Advocate BroMenn Medical Center 1

https://s3.amazonaws.com/media.cloversites.com/76/765e631d-7f21-48fb-a63e-54d8e764d772/documents/OO3_Exhibit_OO3.2_2015_Nursing_Annual_Report.pdf

2015 Annual Report

Advocate BroMenn Medical CenterNormal, Illinois

Exhibit OO3.1

As I reflect back on 2015, I think about the many wonderful accomplishments we achieved by working together to strengthen our health care ministry and better serve our community. These accomplishments are evidence of your continued dedication, support and passion for making a difference. Although we continue to face significant challenges and changes in the health care landscape, we are blessed to be part of Advocate Health Care. Our strong, dynamic, innovate system is leading the way nationally as we build new partnerships, improve patient safety and ultimately transform the way health care is delivered. It is truly an exciting time to be in health care.

This annual report shares many of the improvements and significant accomplishments from 2015. In addition, I wanted to highlight just a few of our many accomplishments from this past year:

• BroMenn was designated as a Primary Stroke Center by the Illinois Department of Public Health.• Our cardiovascular team was awarded the Mission: Lifeline Gold Plus Award for STEMI Care from

the American Heart Association.• BroMenn again received the Platinum Plus Achievement Award, the highest recognition for MI

Patient Care from the American College of Cardiology and the American Heart Association.• BroMenn was one of only 35 hospitals in Illinois recognized by the March of Dimes for reducing

the number of elective deliveries performed before 39 completed weeks of pregnancy.• BroMenn received a $250,000 gift from State Farm to expand our Graduate Medical Education

program’s Family Health Clinic and add mental health resources to the Emergency Department.• Our Graduate Medical Education family medicine residency program celebrated its 10th year.

In addition to these great achievements, one of the most significant accomplishments was the progress on our journey to become the safest place for our patients. In 2015, we saw our serious safety event rate continue to decline, with a reduction of over 40%. At the same time, we experienced continued improvement in our patient satisfaction scores and our health outcomes increased, allowing us to achieve results near the top for all Advocate sites. Finally, for the first time in 2015, our associate engagement results rose above the 90th percentile, placing us in the top 10% across the country.

In our quest to achieve the Advocate Experience and become the “safest and best place for patients to heal, physicians to practice and associates to work”, I am delighted to say that 2015 was a year of great movement on this journey.

Thank you for all your continued contributions to our health care ministry and your unwavering commitment to our community. It is truly an honor and privilege to serve with so many talented individuals. Thank you for another amazing and blessed year!

Colleen Kannaday, FACHEPresident

Message from the president

• Recognized among America’s Best Hospitals for Obstetrics byWomen’s Certified, Inc. (Jan)

• Earned 4 star HCAHPS rating from Center for Medicare andMedicaid Services (April)

• Received Greenhealth Emerald Award from Practice Greenhealth(May)

• Received 2015 Gold Plus Stroke Award and Target: Honor Rollrecognition from the American Heart Association (May)

• Designated Mission: Lifeline Gold Plus Receiving Center by theAmerican Heart Association (May)

• Recognized for 100 years of service to the community by Mayor ofNormal (July)

• Earned 4-star HCAHPS rating from Center for Medicare andMedicaid Services (Oct)

• Earned ISO 9001 Certification

• Contributed to the $783 million total in community benefits byAdvocate Health Care

2015 Accolades

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2020 Strategies Key Result Areas Measure Target Actual

ADVOCATE EXPERIENCE

SAFETY Serious Safety Event Rate -20% -36.9%

Safety Event Reporting Rate 3.5 5.5

QUALITY Health Outcomes Score 100 116

SERVICE

Patient Engagement 75 60

Associate Engagement 80 >90

Physician Engagement 75 79

ACCESS AND AFFORDABILITY

GROWTH Net Revenue Growth (% vs prior yr) 3.38% 3.25%

FUNDING OUR FUTURE

System Operating Margin 3.84% 5.96%

Hospital Cost per Discharge $8,016 $7,701

Medical Group Cost per Visit $114.42 $116.05

Philanthropy (000) $29,000 $29,358

ADVOCATECARE COORDINATED CARE AdvocateCare Index 100 87

2015 AHC System Report Card

2

2015 Site (BroMenn Medical Center) Report Card

2020 Strategies Key Result Areas Measure Target Actual

ADVOCATE EXPERIENCE

SAFETY Serious Safety Event Rate -20% -47.2%

Safety Event Reporting Rate 3.5 6.7

QUALITY Health Outcomes Score 100 113

SERVICE

Patient Engagement 75 67

Associate Engagement 80 >90

Physician Engagement 75 51


GROWTH Net Revenue Growth (% vs prior yr) 2.82% 3.12%

FUNDING OUR FUTURE

Operating Margin -5.27% -4.84%

Hospital Cost per Discharge $6,548 $6,513

Philanthropy (000) $2,000 $5,046

ADVOCATECARE COORDINATED CARE AdvocateCare Index 100 99

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SafetyAs Advocate Health Care continued its journey to zero patient harm, BroMenn Medical Center reached two important milestones in its development as a High Reliability Organization (HRO). These were the establishment of a Physician Safety Champion Program and the introduction of High Reliability Units (HRU’s).

Dr. Jim McCriskin, Advocate Heart Institute, led the development of the Physician Safety Champion Program. The goal was to enlist the services and commitment of select physicians to act as safety champions for the rest of the medical staff. Sixteen physicians have been trained in HRO principles.

Obstetrics was the first unit to become a High Reliability Unit. This involved additional staff training in problem identification and safety methods. Ten associates volunteered to be Safety Coaches who identify opportunities for improvement and potential safety issues on the unit. Staff from Radiology and the Progressive Care Unit followed Obstetrics in HRU training. All three units saw a significant increase in safety reporting following their training.

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QualityThe Intensive Care Unit (ICU) connected to Advocate Health Care’s Electronic ICU, or eICU, in the spring of 2015. Offsite monitoring by physicians and specially trained nurses via an eICU provides an additional layer of safety and “another set of eyes” for our most acutely ill patients.

The Stroke Collaborative Practice team improved internal processes and worked with the area’s emergency management system on reducing the symptom onset to hospital door time. At the same time, multiple education sessions on the sign and symptoms of stroke were provided to the community by our stroke coordinator and neurology advanced practice nurse. This work resulted in a reduction of 74 minutes (43%) from symptom onset to door time since 2013.

The Advocate System converted food purchases of some meats to antibiotic free meats in an effort to add another layer to our microbial stewardship program. All ground beef and some turkey are now antibiotic free.

A new Professional Practice Model (PPM) was introduced to the nursing discipline throughout Advocate. Locally, an implementation group of nurse leaders and bedside nurses met monthly to develop activities focusing on the integration and adoption of the model in all areas of the hospital where nurses practice.

5

ServiceAdvocate BroMenn Medical Center partnered with the McLean County Health Department, the McLean County for Human Services and the Woodford County Health Department to offer Mental Health First Aid training to the community. In just over a year’s time, more than 200 community members have been trained in how to identify the signs and symptoms of mental illness and connect those in crisis with the appropriate care.

Community outreach for cardiovascular health continued as a focus for BroMenn Medical Center in 2015. This included special programming in February for Heart Month, signature sponsorship for the McLean County Heart Walk, installation of an upgraded blood pressure kiosk at the Eastland Mall for public use and continued sponsorship of Young Hearts for Life, a free cardiac screening program for conditions that cause sudden cardiac death. We also partnered with the Town of Normal to provide cardiac screenings for Normal firefighters, an occupation that has been found to be at risk for cardiac disease. As a result, forty-nine firefighters returned to BroMenn Medical Center for additional testing and/or treatment.

• 181,778 lives touched through community events

• 989 health professional students educated

• 2,217 staff hours at community health events

• 1,569 staff hours serving community boards

6

GrowthPhysicians with Advocate Heart Institute, in cooperation with the cardiopulmonary services at Advocate BroMenn Medical Center, opened a Vein Center to treat individuals with venous disease. Free vein screenings were conducted to introduce the program to the community.

Palliative Care (or Supportive Care) Services continued to grow in 2015. Plans are underway to develop the program in concert with the Advocate system program. Three individuals will trained to bring Respecting Choices Advanced Care Planning to this area.

Ultrasound/sonography services were added at the Advocate BroMenn Outpatient Center, providing greater access to patients in our service area.

Partners broke ground for The Center for Integrated Wellness located adjacent to the Advocate BroMenn Outpatient Center. The Center will house the Advocate BroMenn Health & Fitness Center, McLean County Orthopedics and Method Sports Performance with an opening scheduled for late summer 2016.

The Obstetrics department delivered a record number of babies (168) in July, surpassing the previous record of 156.

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Funding Our FutureDuring the Annual Associate Giving Campaign, associates donated $73,000 to the Advocate Charitable Foundation. This included contributions to the Reach Out and Read program, the Nursing Excellence fund and the Associate Crisis/Helping Hands fund.

2015 by the Numbers

Admissions: 8,958

Patient days: 34,758

ER Visits: 32,255

Babies born: 1,685

Inpatient surgeries: 1,901

Outpatient surgeries: 3,287

Total surgeries: 5,188

Total outpatient visits: 130,631

Coordinated CareThe length of stay (LOS) for medical and surgical patients was low compared to industry standards. The results placed the hospital above the 90th percentile nationally.

Work continues on the development and implementation of a supportive care program to improve cross-continuum coordination of care for high utilizers.

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2020 Strategies KRAs 2016 Measure 2016 Target

ADVOCATE EXPERIENCE

SAFETY Serious Safety Event Rate -50%

QUALITY Health Outcomes Index 100

SERVICE

Patient Loyalty Score* 80

Associate Engagement %tile >80th

Physician Engagement %tile 75th


GROWTH Net Revenue Growth 7.31%

FUNDING OUR FUTURE

Operating Margin 3.0%

AdvocateCare Margin (PMPM)** $49.24

Hospital Cost per Discharge $7,866

Medical Group Cost per Visit $122.60

Philanthropy (000) $30,500

COORDINATED CARE 100

2016 AHC System KRA Targets

ADVOCATECARE® ADVOCATECARE® Index

On the Horizon

*New calculation**New measure

2020 Strategies KRAs 2016 Measure 2016 Target

ADVOCATE EXPERIENCE

SAFETY Serious Safety Event Rate -50%QUALITY Health Outcomes Index 100

SERVICEPatient Loyalty Score* 75

Associate Engagement %tile 80th

Physician Engagement %tile 75th


GROWTH Net Revenue Growth 1.33%

FUNDING OUR FUTURE

Operating Margin -4.09%AdvocateCare Margin (PMPM)** $4.00

Hospital Cost per Discharge $6,419Philanthropy (000) $2000

COORDINATED CARE 100

2016 Site (BroMenn Medical Center) KRA Targets

ADVOCATECARE® ADVOCATECARE® Index

1304 Franklin AvenueNormal, IL 61761309.454.1400advocatehealth.com/bromenn

The Advocate Nurse Empower. Serve. Thrive.

NursingAnnual Report

2015

Exhibit OO3.2

I am pleased and honored to present the Advocate BroMenn Medical Center 2015 Nursing Annual Report. In the following pages, you will find accomplishments that are both impressive and impactful, emphasizing advances in patient-centered care, professional growth

and development, and compassion for our community.

In 2015, we continued to sharpen our focus on eliminating healthcare associated conditions such as infections, pressure ulcers and falls. A commitment to the elevation of nursing professional practice was demonstrated through increased professional certifications, clinical ladder advancement, and achievement of advanced degrees. We focused on the continued pursuit of excellence and I am proud of our nurses and interdisciplinary partners who have led initiatives to improve the patient experience and clinical outcomes by incorporating evidence-based practice into the care they provide to our patients and their families.

These accomplishments represent the impact of a strong infrastructure, processes and outcomes that support our ongoing Magnet journey, a formal, recognized measure of organizational excellence. This report aligns accomplishments with the Magnet model components of Transformational Leadership, Structural Empowerment, Exemplary Professional Practice, and New Knowledge, Innovations, and Improvements. As we move forward in 2016, we will continue to strengthen participation of front-line associates in shared governance, identify best practices for our patients, and bring up more High-Reliability Units as we journey to become a High Reliability organization. We will continue to encourage and support professional development and growth in an effort to enhance patient care and our profession practice.

Nurses play a vital role in improving the quality of life for the patients we serve in a challenging health care environment, while consistently delivering safe, high quality nursing care. We elevate the practice of nursing through empowerment, autonomy, nursing education and the implementation of evidence based nursing best practice. Please take time to celebrate our outstanding achievements in 2015! It is a privilege to serve as your Chief Nursing Executive. I would like to thank our dedicated team of nurses and interdisciplinary partners for the outstanding work you do.

Sincerely,

Laurie Round, RN, BSN, MS, NEA-BC Vice President and Chief Nurse Executive

About Advocate BroMenn Medical CenterAdvocate BroMenn Medical Center is a 221-bed, full-service, teaching hospital dedicated to serving our patients, their families, and our community. BroMenn Medical Center is designated as a Level II Trauma Center and a Level II Nursery; and is accredited as a primary stroke center, a chest pain center and STEMI receiving center.

2015 Awards • Recognized among America’s Best

Hospitals for Obstetrics by Women’sCertified, Inc. (Jan)

• Earned 4 star HCAHPS rating from Centerfor Medicare and Medicaid Services(April)

• Received Greenhealth Emerald Awardfrom Practice Greenhealth (May)

• Received 2015 Gold Plus Stroke Awardand Target: Honor Roll recognition fromthe American Heart Association (May)

• Designated Mission: Lifeline Gold PlusReceiving Center by the American HeartAssociation (May)

• Recognized for 100 years of service tothe community by Mayor of Normal(July)

• Earned 4-star HCAHPS rating fromCenter for Medicare and MedicaidServices (Oct)

Nursing by the Numbers

Total Number of Nurses 431

Nurse Turnover Rate 11.93%

Nurse Vacancy Rate 5.62%

Nurse Tenure Average 11.72 years

New Nurse Hires in 2015 66

Percentage of BSN Prepared Nurses 60.3%

Percentage of MSN Prepared Nurses 9.6%

Percentage of Nurses with BSN or higher degrees 70%

Number of nurses currently enrolled in school 46

Nursing by the Numbers

Nursing by the Numbers 1Nursing Strategic Map 2Transformational Leadership 3

Structural Empowerment 10Exemplary Professional Practice 24New Knowledge, Innovation and Improvements 34

Table of Contents:

The Advocate Nurseis skilled in the art of healing and

serves as the face of patient care.

The Advocate Nurse brings years of research,

education and experience to patients.

They are the center of clinical innovation

and the heart and soul of Advocate Health Care.

The Advocate Nurseis part of a diverse community

of proud, dedicated individuals who

Empower. Serve. Thrive.

Message from the Chief Nursing Executive

Brand Promise

1

2 3

The Strategic Map represents Advocate BroMenn Medical Center’s established nursing priorities from 2013-2016. Additional details related to these priorities are found throughout this report.

Nursing Strategic Map Transformational Leadership

“I am proud to be an Advocate nurse because excellence is the standard of care and safety is a priority. I am grateful for Advocate’s commitment to ongoing education with the tuition reimbursement program. With this assistance, I am working toward reaching my goal of earning my BSN.”

– Toni Winks, RN-BC

Clearly define Care Delivery

Model

Clearly define roles/responsibilities

across all related disciplines

Interdisciplinary collaboration and role optimization through

clinical growth and expertise

Identify target populations and multi-disciplinary

strategies by population

Improve access to and communication

of patient health information

Identify strategic non-traditional partnerships

Identify interventions that promote

coordinated care across the continuum

Efficiently manage resources

Free nurses from non-nursing tasks to increase time

with patients

Leverage technology to support

nursing practice

Expect professionals to be competent,

accountable

Foster a commitment to lifelong learning,

mentoring and clinical expertise

Professional responsibility for

communication and a healthy work environment

Increase percentage of certifications

and higher degrees

Provide consistent evidence-based

practice based on the nursing process

Add the voice of the patient to

conversations and decision-making

Utilize FTEs effectively within

and across departments

Standardize supplies/storage

Implement tools and support for professional

development; define professional image

Implement the Nursing Professional

Practice Model

1

2

3

4

5

Fostering a healing environment that is patient and family centered, ensuring patient safety and quality

through the elevation of professional nursing practice.

Partner with Patients and

Coordinate Care Across the Continuum

Fiscal Responsibility

Build an Accountable, Empowered

Nursing Culture

A B C D

Develop Nurses as Leaders

Who Practice at the Top of

Their Licenses

A culture of Shared Governance that empowers RNs to use their clinical knowledge and expertise to impact decisions regarding their professional practice in

the delivery of nursing care guided by compassion and patient centeredness.

Achieve Magnet Designation

Our Magnet JourneyThe Magnet Program recognizes health care organizations for quality patient care, nursing excellence, and innovations in professional nursing practice. Magnet designation is the highest national and international recognition granted to health care organizations for combined nursing and organizational excellence.

The nurses at BroMenn Medical Center were hard at work in 2015 preparing the Magnet application. Five work groups were formed with nurses from across the hospital to gather evidence and write examples of how BroMenn nurses meet and exceed the Magnet standards.

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Front row – Jenny Messier, Stephanie Moore and Laurel Mode. Back row – Logan Frederick, Theresa Bailey, Janet Sutter, Donna Schweitzer and Amanda Parrish. Not pictured – Heather Jackson, Rachel Koerner, Meg Noreiko, Tami Olson and Melissa Reidy.

L-R – Jenny Messier, Teresa Gimbert, Wendy Woith, Trayce Bartley, Todd McCartney and Pam Bierbaum. Not pictured – Crystal Bricker, Denise Hammer, Janet Hood, Michael Mandrell and Heather Meece.

Front row – Penny Rathbun and Lori Harper. Second row – Jenny Messier, Shelly Yoder, Barb Hancock, Stephanie Wollenberg and Victoria Steinkoenig. Back row – Dana Robbins, Jo Samara, Chrissy Jennings and Jennifer Ringsby. Not pictured – Renee Donaldson and Kristin Remmers.

Front row – Mark Lareau, Jenny Messier and Jennifer Steinhausen. Back row – Mike Mueller, Peggy Watkins, Linda Wahl, Stacy Barclay, Ann Frederick, Angela Turner and Ra’Net Bye. Not pictured – Teresa Novy, Kristin Peterson and Laurie Round.

Magnet Work Groups

• Exemplary Professional Practice I

• Exemplary Professional Practice II

• New Knowledge and Innovations

• Structural Empowerment

• Transformational Leadership

Front row – Alicia Allen, Lori Ritter and Jenny Messier. Back row – Kristi Wolfe and Toni Winks. Not pictured – Aaron Barclay, Lisa Gossmeyer, Angela Harrison, Susan Kaufman, Shelly Malin, Yvonne Rees, Cindy Schaumburg and Sonia Vercler.

Transformational LeadershipTransformational Leadership

New Knowledge and Innovations

Structural Empowerment

Transformational Leadership

Exemplary Professional Practice II

Exemplary Professional Practice I

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Advocate Health Care Professional Practice ModelThe implementation of our new Professional Practice Model (PPM), began in 2014 with its introduction to the Nurse Practice Council (NPC) at the September 2014 NPC meeting. Members agreed to read and discuss Joanne Duffey’s book, Quality Caring in Nursing and Health Systems. Over the next year. NPC members read one to two chapters per month and discussed the material at each meeting. Shelly Malin, endowed professor from Illinois State University’s Mennonite College of Nursing, led the monthly discussions. By June 2015, NPC was ready to develop a housewide implementation plan.

The Professional Practice Integration workgroup (consisting primarily of clinical nurses) developed the implementation plan. It began with educating nurses about the theorist, the Advocate PPM and how their nursing practice reflects quality and caring. The August/September 2015 Quarterly Education sessions were dedicated to the Quality Caring Model and PPM. Next, a monthly activity was planned to reinforce the model. The next step was to identify the caring factors that exist in each unit.

Our VisionTo be a faith based system providing the safest environment and best health outcomes,

while building lifelong relationships with those we serve.

Our RoleThe Advocate Nurse transforms care delivery throughout the patient and family journey,

creating the safest environment and resulting in the best health outcomes.

THE ADVOCATE NURSE 2020

Advocate Experience

1. Establish culture of accountability at all levels of nursing

2. Implement Advance Practice Clinician strategy

3. Standardize Nursing Practice around interdisciplinary plans of care

4. Develop consistent, evidence- based educational platform to support patient outcomes

Access & Affordability

1. Develop cost-effective care delivery model utilizing lean

2. Develop integrated workforce management strategy evidence based practices

AdvocateCare

1. Implement acute care component of care management model

2. Enhance team-based approach to care delivery

3. Optimize EHR

Transformational Nursing Leadership

1. Create a professional practice environment based on Magnet principles2. Define the core competencies and professional development standards of the Advocate Nurse3. Strengthen succession planning and leadership development

Magnet CoordinatorJenny Messier, BSN, RN, ACM began her role as Magnet Program Coordinator in June 2014. In this role, she

• provides education to nurses about Magnet Recognition

• facilitates Magnet workgroups

• serves as a resource for the Shared Governance Councils

• assesses Magnet readiness

• verifies that all of the stringent Magnet requirements are met.

In 2015, Jenny focused on assuring that BroMenn Medical Center outperformed the required metrics for nursing sensitive indicators, patient satisfaction, RN satisfaction, and preparing the documentation required for Magnet recognition. She also assisted with the implementation of the new Advocate Professional Practice Model at BroMenn. Through her work, key nursing initiatives such as Shared Governance, Peer Review, Nursing Professional Development and the Magnet application was prepared for Spring 2016 submission.

The Nursing Strategic Plan was developed by the System Chief Nurse Executive and the Chief Nurse Executives of the sites to lead nursing to 2020. September – NPC members worked with their units

to identify, through words and phrases, the daily activities of the nurse that reflect the caring factors of our nursing theorist. These words were used to create

“word clouds” to be displayed on each unit.

October – The workgroup held a toothbrush drive in response to community oral health needs. Over 1500 toothbrushes were collected and distributed through the emergency departments at BroMenn Medical Center, Eureka Hospital and other local agencies.


AdvocateNurse

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PATIENT, FAMILY AND

COMMUNITY

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GROWTH

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The Advocate Nurse Professional Practice Model

November – Nursing Practice Council “hit the road” with cake and badge cards.

Emily Anderson, ICU

Bet Atkins, Nursing Resource Pool

Stacy Barclay, Nursing Office

Betty Benedino, Quality

Tiffany Boyd, Emergency

Leslie Carter, Emergency

Heidi Castleman, Mental Health

Colleen Chandler, Nursing Resource Pool

Brittney Decroix, Mental Health

Katie Denney, Nursing Resource Pool

Codee Delagrange, 6W Surgical

Maggie Durbin, Mother Baby

Stefanie Esme, Emergency

Lindsey Etheridge, Progressive Care

Scott Farquhar, Nursing Resource Pool

Stephanie Fuller, ICU

Jeannie Gaddis, Cardiovascular Care Unit

Nichelle Gavin, Quality

Angie Harrison, 6W Surgical

Kim Helgeson, Acute Rehab

Susan Henkel, Quality

Sheron Howard, Cardiovascular Care Unit

Julie Hyland, Acute Rehab

Ashley Johnson, Mental Health

Dayna Krowlek, Acute Rehab

Mark Lareau, Quality

Kevin Lee, 6W Surgical

Amy Loveless, Quality

Patti Mayer, Medical Oncology Specialty Unit

Jodi McCombs, Emergency

Beni McNaught, Progressive Care

Angela Miller, Medical Oncology Specialty Unit

Cindy Mounce, 6W Surgical

Marilyn Nelson, Emergency

Amanda Parrish, Acute Rehab

Jason Pate, ICU

Ariel Pearson; Acute Rehab

Carolyn Peden, Medical Oncology Specialty Unit

Kristin Remmers, Medical Oncology Specialty Unit

Angie Robbins, Mental Health

Melanie Salisbury, ICU

Amy Short, Nursing Office

Jessica Sinks, Cardiovascular Care Unit

Christine Stauter; Social Work

Jillian Stiles, Cardiovascular Care Unit

John Titus, Quality

Lori Troyer, Mother Baby

Clara Veal, ICU

Linda Wahl, Quality

Peggy Watkins, Nursing Office

Lisa Wetzel, 6W Surgical

Suzanne Wilcox, Nursing Office

Toni Winks, Mental Health

Courtney Yoder, ICU

Kacie Zielsdorf, Mental Health

Shelly Zobrist, Quality

The layered cake was a representation of the relationship of our nursing theory and our professional practice model. The bottom layer of the cake represented the theory or “base” for our practice. The top layer represented our professional practice model. NPC members brought their peers this sweet treat along with badge cards with the eight caring factors.

In December each department was challenged by NPC to participate in at least one “pay it forward” activity during the month. Activities ranged from recognizing and giving “treats” to other departments, to adopting families for Christmas. Hundreds of “pay it forwards” happened during the month.

Nurses across Advocate BroMenn Medical Center exemplify the caring behaviors and model the professional practice model every day, in every encounter. The model has truly given a name and a depiction of the way that our nurses care for our patients, for each other and for our organization.


Next came the monthly Caring Awards. The Caring Award started in the Mother Baby Unit but was then implemented across all nursing units. The goal is to recognize a peer for their caring behaviors. It is intended to let each nurse reflect on who consistently displays caring behaviors and to recognize them within the department. Caring Award winners were:

98

10 11

Structural Empowerment

“I am proud to work at Advocate BroMenn Medical Center because of the beliefs and values instilled in the culture that create a positive work environment in which to provide excellent care to the community.”

– Rebekka Prokup BSN, RN

Nursing Practice Council and Unit Shared GovernanceThe Nursing Practice Council (NPC) at Advocate BroMenn Medical Center has accountability for establishing and maintaining the standards of nursing practice. Nurses come together to share best practices and to problem-solve the challenges that come with working in a complex health care environment. Council participants include clinical nurses who chair their Unit Shared Governance Councils, nurse educators, and nurse leaders from across the organization.

SharedGovernance

Shared Governance Highlights

Pain Management

• Same Day Surgery continued to identify opioid tolerant patients pre-operatively, in an effort to pre-operatively evaluate effectiveness of interventions to better control pain of the patient.

• 6W Surgical established a pain order set to achieve better pain control as measured by patient satisfaction scores.

Patient Experience

• Same Day Surgery determined the impact on patient perception of nursing IV insertion skills.

• Mental Health Unit implemented hourly rounding to decrease falls and keep those who are at risk for self-harm safe.

• Progressive Care Unit created an educational brochure for patients to take home in their stroke education folders, along with a “Mediterranean diet grocery shopping list.”

• Medical Oncology Specialty Unit created a file system for patient education materials on the most frequently seen diagnosis and (new) medications.

• Same Day Surgery began actively warming (Bair Huggers and Foil caps) patients prior to surgery if they had a temperature equal to or below 36.5 degrees Celsius. Data showed a significant increase in patients going to surgery warm, staying warmer during surgery and meeting criteria of a temperature of 36.5 degrees Celsius or above upon arrival to PACU.

Improvement of Work Flow

• Same Day Surgery redesigned the layout of patient rooms with the goal of making RN movements more efficient and reducing instances of being in patients’ family members’ space.

Clinical Outcomes

• Emergency Department identified the need to evaluate low risk chest pain patients in the ED and then collaborated with multiple disciplines to create early morning openings for stress testing of ED patients. This resulted in earlier discharge from the ED when tests are negative.

• Mother Baby Unit implemented EBP changes with a newborn hypoglycemia protocol, delayed bathing, immersion baths and transcutaneous bilirubin monitoring.

• Wound Healing Clinic collaborated with physicians on chart review to ensure everything possible is being done to heal their patients’ wounds in the shortest amount of time.

Professional Development

• Neuroscience Nursing Grand Rounds – Progressive Care Unit assembled Neuroscience Nursing Grand Rounds to expand the neuroscience knowledge among nurses throughout the hospital.

• Acute Rehab improved assessment of their patients’ functional outcomes through professional development activities.

• Medical Oncology Specialty Unit utilized resources and reimbursement through the professional development program to encourage peers to attend more conferences, thus obtaining more CE’s.

Nurse Practice Council members

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Structural EmpowermentStructural Empowerment

Professional Development

Clinical Ladder Success through Excellence in Practice (STEPS)The STEPs program is Advocate’s professional development program for full and part-time Registered Nurses who provide direct patient care. The program recognizes nurses who exemplify professional practice and clinical skill in their areas of expertise. In 2015, ten deserving nurses were promoted to Nurse Clinician III (NCIII) status within the STEPs program. Promotion to NCIII requires completion of an application, peer reviews, completion of 15 contact hours of continuing education, a written case study and presentation of the study to the Clinical Career Advancement Board. Congratulations to these deserving nurses who were promoted in 2015:

Emily Ruedi Emergency Dept

Ashley Johnson Mental Health

Diane Crouch Medical Oncology Specialty Unit

Cindy Wells Progressive Care Unit

Emily Wall Emergency Dept

Lindsey Zummallen Progressive Care Unit

Sarah Magee Progressive Care Unit

Paula Dapkus Progressive Care Unit

Lori Troyer Mother Baby Unit

Professional Certified Registered NursesAdvocate Health Care and Advocate BroMenn Medical Center support continuous professional development including the attainment of professional nursing certification in one’s area of specialty. Certification signifies the licensed professional has mastered a body of knowledge and acquired skills to meet certain predetermined standards specified by that profession for specialty practice. Advocate Health Care’s Education Assistance Program provides reimbursement for review courses and materials, as well as examination fees following successful completion of a certification.

“Nurses validate their mastery of skills, knowledge and abilities through certification and meet ongoing learning and practice requirements through recertification. Patients and families, employers and nurses all benefit from certification.”

– American Association of Critical Care Nurses

Nurses at BroMenn Medical Center with Magnet-Recognized Certifications

ACM (Accredited Case Manager)

• Brandie Anderton, Care Management• Tena Bliss, Care Management, new Nov 2015• Lisa Crane, Care Management, new Oct 2015• Nichele Gavin, Care Management• Susan Henkel, Care Management• Jenny Messier, Magnet• Jeff Smith, Care Management, new Feb 2015• Cindy VanDusen, Care Management, new Nov 2015• Laura Wiley, Care Management, new Sept 2015• Shelly Zobrist, Care Management, new Oct 2015

ACNS-BC (Adult Clinical Nurse Specialist)

• Victoria Steinkoenig, Clinical Education

AGCNS-BC (Adult Gerontology Clinical Nurse Specialist)

• Candice White, Nursing Resource Pool

CAPA (Certified Ambulatory Perianesthesia Nurse)

• Corinn Desmond, Same Day Surgery

CCNS (Critical Care Clinical Nurse Specialist)

• Donna Schweitzer, Clinical Education

CCRN – Adult (Critical Care Registered Nurse)

• Grace Fisher, Cardiology• Michael Mandrell, Emergency Dept• Bridget McClusky, Intensive Care• Michael Mueller, Cardiopulmonary Service Line• Marilyn Nelson, Emergency Dept• Emyli Quain, Cardiovascular Care Unit• Mindy Ruan, Emergency Dept• Donna Schweitzer, Clinical Education• Marissa Smith, Intensive Care• Megan Threm, Cardiovascular Care Unit• Suzanne Wilcox, Nursing Resource Pool

CCRN – Pediatrics (Critical Care Registered Nurse)

• Michael Mandrell, Emergency Dept

CCTN (Certified Clinical Transplant Nurse)

• Shannon Hurliman, Nursing Resource Pool

CDE (Certified Diabetes Educator)

• Linda Avery, Diabetes

CEN (Certified Emergency Nurse)

• Penny Boser, Emergency Dept• Kathy Brown, Nursing Office• Leslie Carter, Emergency Dept, new Aug 2015• Mike Kelly, Emergency Dept• Michael Mandrell, Emergency Dept

• Marilyn Nelson, Emergency Dept• Amber Painter, Emergency Dept, new Feb 2015• Lori Ritter, Emergency Dept• Mindy Ruan, Emergency Dept• Emily Ruedi, Emergency Dept• Jennifer Toohill, Emergency Dept

CGRN (Certified Gastrointestinal RN)

• Cheryl Hart, Same Day Services• Betty Kaupp, Post Anesthesia Care Unit• Yvonne Rees, Same Day Services• Sonia Vercler, Perioperative Services

CHPN (Certified Hospice & Palliative Nurse)

• Gay Shoot, Palliative Care, new July 2015

CHRN (Certified Hyperbaric Registered Nurse)

• Melanie Evelsizer, Wound Healing • Jennifer Perry, Wound Healing• Missy Smith, Wound Healing

CIC (Certified in Infection Control)

• Pam Bierbaum, Quality

CNM (Certified Nurse Midwife)

• Peggy Jacobs, Mother Baby Unit

CNOR (Certified Nurse Operating Room)

• Crystal Bricker, Operating Room• Barbara Hancock, Operating Room• Cindy Hauk, Materials Management• Michael Hoeft, Operating Room, new Jan 2015• Laura McCartney, Operating Room• Todd McCartney, Surgical Services, new Mar 2015• Meg Noreiko, Operating Room, new Jan 2015• Rayford Rattley, Operating Room, new Apr 2015• Nicole (Niki) Tracy, Operating Room, new Jan 2015

CPAN (Certified Post Anesthesia Nurse)

• Betty Kaupp, Post Anesthesia Care Unit, new Apr 2015• Heather Meece, Post Anesthesia Care Unit,

new Apr 2015

CPEN (Certified Pediatric Emergency Nurse)


CPHQ (Certified Professional in Healthcare Quality)

• Ann Frederick, Quality• Tami Olson, Quality• Cindy Schaumburg, Quality

CPN (Certified Pediatric Nurse)


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CPPS (Certified Professional in Patient Safety)

• Kristie Wolfe, Patient Safety

CRN (Certified Radiology Nurse)

• Janet Sutter, Radiology

CRRN (Certified Rehabilitation RN)

• Dayna Krowlek, Acute Rehab – new July 2015• Amanda Parrish, Acute Rehab – new July 2015

CWCN (Certified Wound Care Nurse)

• Linda Bergren, Wound/Ostomy

CWOCN (Certified Wound, Ostomy, Continence Nurse)

• Becky Hatfield, Wound/Ostomy

CWON (Certified Wound Ostomy Nurse)

• Linda Bergren, Wound/Ostomy

FNP-BC (Family Nurse Practitioner)

• Miranda Gonzalez, Mother Baby Unit

GCNS-BS (Gerontological Clinical Nurse Specialist)

• Candice White, Nursing Resource Pool

IBCLC (International Board Certified Lactation Consultant)

• Lucinda Edgren-Gebhardt, Mother Baby Unit

NEA-BC (Nurse Executive Advanced)

• Laurie Round, Chief Nurse Executive

NE-BC (Nurse Executive)

• Lori Harper, Nursing Practice• Stephanie Moore, Critical Care/Emergency Svcs

NP-C (Family Nurse Practitioner)

• Miranda Gonzalez, Mother Baby Unit• Rachael Hudgins, Mother Baby Unit

OCN (Oncology Certified Nurse)

• Jeanne Aden, Medical Oncology Specialty Unit• Patty Omahana, Cardiovascular Care Unit

ONC (Orthopedic Nurse Certified)

• Angie Le, 6W Surgical, new Oct 2015• Cindy Wells, Progressive Care Unit

PCCN (Progressive Care Certified Nurse)

• Bet Atkins, Nursing Resource Pool

RN-BC (Gerontological Nurse)

• Teresa Novy, Wound/Ostomy

RN-BC (Medical/Surgical Registered Nurse)

• Jennifer Abraham, Medical Oncology Specialty Unit• Donna Anderson, Medical Oncology Specialty Unit• Gayle Guffey, Quality

• Kristin Remmers, Medical Oncology Specialty Unit, new Nov. 2015

• Angie Schoon, Cath Lab

RN-BC (Nursing Professional Development)

• Alicia Allen, Medical/Surgical• Dana Robbins, Clinical Education

RN-BC (Psychiatric & Mental Health Nurse)

• Patricia Kruse, Mental Health• Sara Purfield, Mental Health• Margaret (Peggy) Vanhorn, Mental Health• Toni Winks, Mental Health

RNC-LRN (Low Risk Neonatal Nursing)

• Linda Baer, Mother Baby Unit• Michelle Braun, Mother Baby Unit, new Sept 2015• Lisa Gilmore-Riess, Mother Baby Unit• Angela Philpott, Mother Baby Unit• Lori Troyer, Mother Baby Unit, new Sept 2015

RNC-MNN (Maternal Newborn Nursing)

• Brenda Drury, Mother Baby Unit• Susan Kaufman, Mother Baby Unit• Kathy Macy, Mother Baby Unit• Joan Yoder, Mother Baby Unit

RNC-NIC (Neonatal Intensive Care Nursing)

• Denise Hammer, Mother Baby Unit

RNC-OB (Inpatient Obstetric Nursing)

• Jessica Baker, Mother Baby Unit• Lucinda Edgren-Gebhardt, Mother Baby Unit• Melissa Eskridge, Mother Baby Unit• Mary Finley, Mother Baby Unit• Ann Groonwald, Mother Baby Unit• Peggy Jacobs, Mother Baby Unit• Lori Pearson, Mother Baby Unit• Keli Sidebottom, Mother Baby Unit• Susan Wilkins, Mother Baby Unit• Stephanie Wollenberg, Mother Baby Unit

SANE-A (Sexual Assault Nurse Examiner-Adult)

• Tammy Vandegraft, Emergency Dept

SCRN (Certified Stroke Registered Nurse)

• Victoria Steinkoenig, Clinical Education

WCC (Wound Care Certified)

• Teresa Novy, Wound/Ostomy

2015 Summer InternsFor the past 16 years Advocate BroMenn Medical Center has offered a paid internship program for student nurses who are entering their last year of nursing school. These students work side-by-side with a preceptor, gaining valuable hands-on experience.

Front row left to right – Ashley Segerstrom, Taylor Orr, Cami Westfall, and Luke Bachtold. Back row, left to right – Katilyn Ramey, Alyssa Polen, Melanie Anderson and Nicole Nonnemacher.

Reward and Recognition

2015 Certified Nurses DayMarch 19th is Certified Nurses Day each year. A Certified Nurse has taken an additional exam that demonstrates their expertise in their area of specialty. We celebrated with a Certified Nurses Day breakfast.

2015 Nurses’ Week Highlights

Nurses Week (May 6-12) is a time to acknowledge and recognize our nurses for the service that they provide for patients, families and the community. Nurses Week 2015 began with an ice cream social hosted by Nurse Practice Council.

Chaplains performed a Blessing of the Hands in our nursing units and in the Chapel for our caregivers. The Shared Governance councils displayed their work in a poster session held in the hospital lobby for employees and the public to see.

On May 11th the nurses were treated to a pancake breakfast. Nursing directors and managers served as cooks and servers. A great time was had by all!

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Our Nursing Excellence Awards were presented to four very deserving nurses.

Nursing Story Awards were presented for the third year. Mary Ann Bottles, Addiction Recovery,

“The Influence of Mildred”

Jasmine Harris, Mother Baby Unit, “Receiving Quality Care”

Teresa Novy, Wound/Ostomy, “A Story of a Life Time”

Peggy Watkins, Nursing Office, “A day in the life”

Susan Zobrist, Advocate Eureka Hospital, “Illuminating the Way”

Patient Advocacy

Clinical Care Mentoring

Leadership

Chrissy Jennings, BSN, RN, Mental Health Unit

Amanda Parrish, BSN, RN, CCRN, Acute Rehab Unit Crystal Bricker, BSN, RN, CNOR, Operating Room

Heather Jackson, Mother Baby Unit


New Graduates: Nurse ResidencyFor new graduate nurses at Advocate BroMenn Medical Center the end of orientation is only the beginning of ongoing support and mentoring through the Nurse Residency Program. The Nurse Residency program is a one-year program that begins the month following the conclusion of the new graduate nurses’ unit orientation. Colleen Ewen, BSN, MBA, RN, Clinical Development Specialist, leads the Nurse Residency program and its monthly four-hour sessions. These sessions are devoted to educational/professional development topics such as lab values, respiratory and rapid response codes. They also provide the opportunity to debrief, network with peers, discuss the transition into the health care environment, provide support, and address concerns or difficult situations.

Mentoring: Laurie Round, MS, BSN, RN, NEA-BC, Vice-President, Patient Services and Chief Nursing Executive, recognized that the first year nurse turnover rate was higher than expected. She identified an additional level of support for new graduate nurses: a formalized mentoring program. Laurie, together with the nursing directors, identified potential mentors. Those identified were experienced nurses who demonstrated interest in nurturing and supporting new graduate nurses. The goal of the program was to connect new graduate nurses to experienced nurses outside of their direct practice area. This would afford them the opportunity to discuss personal needs and concerns, develop a broader network, feel connected to other nurses in the organization, and allow them to learn about other areas of practice. The potential mentors met with Laurie in November 2015 to discuss their interest and support for the program. The mentors enthusiastically endorsed the program and agreed to serve in this capacity. The program will begin in 2016.

“I enjoyed hearing the things others struggled with and where they succeeded. This helped me feel like I wasn’t the only one still finding my way!”

– Nurse resident

Patient Safety Award

Whitney ButikoferEach year Advocate Health Care recognizes Patient Safety Award Winners from each site. In early 2015, the 2014 BroMenn Medical Center Patient Safety Award Winner, Whitney Butikofer, was honored. Whitney, a new nursing graduate, used a questioning attitude when a patient she was caring for started to exhibit signs of severe sepsis. Concerned with the patient’s deteriorating condition, Whitney used ARCC to escalate her concerns. As a result of her persistence, the patient received earlier treatment and recovered successfully with the best outcome possible.

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Nursing’s Value LeadersFour nurses were honored this year as Quarterly Value Leaders because of their display of one or more of our five core values: Compassion, Equality, Excellence, Partnership and Stewardship.

Community Partnership

Compassion

Teri Hill & Julie Lemons Palliative Care & Intensive CareJulie and Teri spent many hours with a patient, helping her arrive at a decision about withdrawing care as she faced end stage respiratory disease. They thoroughly explored the possibilities with her, making sure that she felt in control over her situation and was at peace with her decision. In the end, the patient trusted that she would be kept comfortable and had a peaceful death.

Equality

Sherri Pearson, Emergency DepartmentSherri advised perioperative leaders and connected them with a pediatric abuse clinic who could provide more appropriate and comprehensive care for a patient that was thought to be a victim of abuse. Sherri’s willingness to collaborate with perioperative leaders allowed for the patient’s rights to be protected and [for her] to receive the psychological and physical care she deserved.

Compassion

Tena Bliss, Quality Resource ManagementTena assisted a patient in obtaining authorization for a medication and when the patient was unable to find a ride back to the hospital pharmacy for her medication, Tena made arrangements to pick up the medication and personally deliver it to the patient’s home. She recognized the importance of the medication being available to the patient and even followed up several days later to discuss pick-up of further doses with the patient.

AHA Heart WalkAs the presenting sponsor for this year’s event, Advocate BroMenn Medical Center was very proud of the amazing turnout of our associates, their families, and friends at the 2015 McLean County Heart Walk! Our goal was to have 240 registered walkers, and we had 255. We raised in excess of $24,000, an increase over the 2014 total.

Nurses’ Community Involvement4H

Sonia Vercler, Surgical Services

ALS Walk

Chris Waters, Medical Oncology Specialty Unit

Alzheimer’s Walk

Christine Hammond, Operating Room

Sam Munk, Medical Oncology Specialty Unit

Melanie Walker, Nursing Office

American Diabetes Association

Linda Avery, Diabetes

Ellen McComb, Same Day Surgery – walk

Stacy Thomas, Cardiovascular Care Unit – walk

American Heart Association

Mike Mueller, Cardiopulmonary Service Line

Peggy Jacobs, Mother Baby Unit

American Heart Association Heart Walk

Alicia Allen, Medical/Surgical

Theresa Bailey, Medical Oncology Specialty Unit/ Pediatrics/Infusion

Aaron Barclay, Emergency Dept

Stacy Barclay, Nursing Operations

Trayce Bartley, Surgical Services

Kimberly Crutcher, Cardiopulmonary Service Line

Conni Cunliffe, Mental Health

Diane Forrest, Preadmission Testing

Bev Glendon, Cardiopulmonary Service Line

Lisa Gossmeyer, Quality

Lori Harper, Nursing Practice

Heidi Heite, Cardiopulmonary Service Line

Jen Kjeldgaard, Cardiovascular Care Unit

Rebekah Lavicka, Cardiopulmonary Service Line

Laura McCartney, Operating Room

Todd McCartney, Surgical Services – co-chair

Stephanie Moore, Critical Care/Emergency Svcs

Michael Mueller, Cardiopulmonary Service Line – committee and walk

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American Heart Association Heart Walk...continued

Sam Munk, Medical Oncology Specialty Unit

Kathy Ott, Nursing Office

Kristin Peterson, Progressive Care Unit

Dana Robbins, Clinical Education

Laurie Round, Chief Nurse Executive

Marie Smith, Cardiovascular Care Unit

Tori Steinkoenig, Clinical Education

Angela Turner, Surgical/Rehab

Tammy Vandegraft, Emergency Dept


Suzanne Wilcox, Nursing Office

Laura Wiley, Care Management

Stephanie Wollenberg, Mother Baby Unit

Shelly Yoder, Critical Care

Bloomington/Normal Community Campus Committee

Tammy Vandegraft, Emergency Dept

BLS, CPR, PALS Instructors

Le Ann Galbraith, Emergency Dept - PALS

Tami Olson, Quality Resource Management – BLS, CPR

Tammy Vandegraft, Emergency Dept. – CPR

Brain Health Fair

Stephanie Moore, Critical Care/Emergency


Victoria Steinkoenig, Clinical Education

BroMenn Delegate Church Association

Jo Samara, Information Systems – executive committee

Boys/Girls Club

Patricia Kruse, Mental Health

Buddy Walk

Shelly Yoder, Cardiovascular Care Unit/Intensive Care

Carlock Fire Protection

Mark Lareau, Quality – Trustee

Car Seat Checks

Sara Mounce, Mother Baby Unit

Chase for Champions


Christie Clinic Run

Jeffrey Smith, Care Management

Church Volunteer

Michelle Braun, Mother Baby Unit – church camp nurse

Patricia Kruse, Mental Health Unit – Blood Pressure checks and blood drives

Nanci Liniger, Same Day Services – Blood Drive, health education

Ellen McComb, Same Day Services – Health care fair

Nicole McDonald, Nursing Office – church camp nurse

Teresa Novy, Wound/Ostomy – wellness committee

Peggy Watkins, Nursing Office – church camp

Cindy Wells, 6W Surgical – Health fair

Michael Zobrist, Nursing Office – mission trips, Team 224 Co-Founder/ Co-President and Chairman of the Board


Community Health Care Clinic

Jo Samara, Information Systems, President of the Board 2012-2014, Executive Committee, Resource Development

Community Health Fairs

Kelsey Anderson, Nursing Resource Pool – John Warner Health Fair

Carrie Alexander, Emergency Dept

Linda Avery, Diabetes

Crystal Battaglia, Medical Oncology Specialty Unit

Lisa Bova, Progressive Care Unit – flu clinic

Tonia Cannon, Mother Baby Unit

Conni Cunliffe, Mental Health

Julie Cuppini, Quality

Karen Dodd, Cardiopulmonary Service Line

Lucinda Edgren-Gebhardt, Mother Baby Unit – Baby Expo

Melanie Evelsizer, Wound Healing Center

Bev Glendon, Cardiopulmonary Service Line – Concerns of the Heart committee member

Miranda Gonzalez, Mother Baby Unit

Denise Hammer, Mother Baby Unit – Ridgeview Pre-K Health Fair

Heidi Heite, Cardiopulmonary Service Line

Teresa Hogan, Nursing Office

Kelly Johnson, Emergency Dept – BP screens

Jessica Lee, Wound Healing

Claire Mojica, 6W Surgical

Bryan Nally, Operating Room

Tami Olson, Quality

Amanda Parrish, Acute Rehab – Brain Matters, Concerns of the Heart

Kristin Peterson, Progressive Care Unit – Concerns of the

Heart, Senior Expo, John Warner Health Fair

Sharon Plante, Mother Baby Unit

Kaley Rinkenberger, Mother Baby Unit

Jodi Robbins, Operating Room – ISU fair, community flu clinic

Keli Sidebottom, Mother Baby Unit – Baby Expo

Tori Steinkoenig, Clinical Education

Natasha Wattleworth, Clinical Informatics – Bloomington Jr. High

Chris Waters, Medical Oncology Specialty Unit – flu clinics

Easter Seals

Theresa Bailey, Medical Oncology Specialty Unit/Peds/ Infusion


Stacy Thomas, Cardiovascular Care Unit

Stephanie Wollenberg, Mother Baby Unit – walk

Eighth Grade Career Day

Barb Hancock, Operating Room

Emergency Management Systems

Laurel Mode, Quality – EMS education, disaster preparedness drills

Faith Community Nursing/Health Ministries


Julie Cuppini, Quality

Becky Hatfield, Wound/Ostomy


Marilyn Nelson, Emergency Dept

Jo Samara, Information Systems


Illinois State University-Mennonite College of Nursing

Ann Frederick, Quality

LeRoy High School Academic Week


March of Dimes

Theresa Bailey, Medical Oncology Specialty Unit/ Peds/Infusion

Brenda Drury, Mother Baby Unit

Ann Groonwald, Mother Baby Unit


Peggy Jacobs, Mother Baby Unit

Susan Kaufman, Mother Baby Unit


Stephanie Wollenberg, Mother Baby Unit – Steering Committee (walk & auction)

Michael Collins Walk


Missy Hardesty, Critical Care

Jen Kjelgaard, Critical Care

Todd McCartney, Surgical Services

Stephanie Moore, Critical Care/Emergency

Courtney Yoder, Critical Care

Midwest Food Bank volunteer

Lori Harper – Nursing Practice

NAMI Walk

Brittney Decroix, Mental Health

Mary Ann Kirchner, Quality

New Life Pregnancy Center

Nichele Gavin, Care Managementet Therapy


Paula Dapkus, Progressive Care Unit

Lauren Evans, Operating Room

Pray for the Cure

Susan Henkel, Care Management – Committee

Jenny Messier, Magnet

Race for the Cure

Theresa Bailey, Medical Oncology Specialty Unit/Peds/ InfusionSusan Henkel, Care ManagementJoy Kusturin, Nursing Resource PoolLaurie Round, Chief Nurse Executive

Region 2 EMS Meeting



Relay for Life

Alicia Allen, Medical/Surgical

Stephanie Anderson, Nursing Resource Pool



Corinn Desmond, Same Day Surgery


Taylor Greico, Same Day Surgery

Susan Henkel, Care Management

Shelly Jimenez, Cardiovascular Care Unit/Intensive Care

Jessica Miller, Medical Oncology Specialty Unit

Julie Morton, Medical Oncology Specialty Unit

Sally Ohmart, Preadmission Testing

Kristin Remmers, Medical Oncology Specialty Unit

Emily Ruedi, Emergency Dept

Red Cross

Laura Deisher, Cardiovascular Care Unit


Kathy Ott, Nursing Office

Darla Schwertfeger, Operating Room


Right to Life March


Safe Harbor

Theresa Bailey, Medical Oncology Specialty Unit – meals

Jessica Miller, Medical Oncology Specialty Unitl

Jessica Lee, Wound Healing Center

St. Jude

Lindsay Kaiser, Emergency Dept – B/N to Peoria run

State Stroke Advisory Task Force


Stroke Education

Jennifer Steinhausen, Quality

Jenny Messier, Magnet

Tami Olson, Quality

Kristin Peterson, Progressive Care Unit – State Farm, Country Companies, Senior Center, Chase for Champions Committee, B/N EMS, State Stroke Advisory Task Force, MCHD, Eureka College Reagan Run, Eureka Jr. High

Victoria Steinkoenig, Clinical Education – State Farm, Senior Center, Chase for the Champions, B/N EMS, MCHD, Eureka College Reagan Run, Eureka Jr. High

United Way

Aaron Barclay, Emergency Dept

Ann Frederick, Quality – Chair


Todd McCartney, Operating Room

Stephanie Wollenberg, Mother Baby Unit

Women’s Health Night

Melanie Evelsizer, Wound Healing Center

Young Hearts for Life


Theresa Bailey, Medical Oncology Specialty Unit/ Pediatrics/Infusion

Stacy Barclay, Nursing Operations

Tonia Cannon, Mother Baby Unit

Leslie Carter, Emergency Dept

Joelle Felumlee, Post Anesthesia Care Unit

Miranda Gonzalez, Mother Baby Unit

Denise Hammer, Mother Baby Unit

Susan Kaufman, Mother Baby Unit

Karen King, Nursing Resource Pool

Jen Kjeldgaard, Cardiovascular Care Unit

Kelly Krise-Evans, Nursing Resource Pool

Patricia Kruse, Mental Health Unit

Joy Kusturin, Nursing Resource Pool

Emyli Quain, Cardiovascular Care Unit

Keli Sidebottom, Mother Baby Unit

Jessica Sinks, Cardiovascular Care Unit

Stacy Thomas, Cardiovascular Care Unit

Shelly Yoder, Critical Care


Academic Partnerships

Shelly Malin, PhD, RN, NEA-BC, and Wendy Woith, PhD, RN, FAAN, shared the Advocate BroMenn Endowed Professor role. The Professorship is focused on excellence in nursing, research, and EBP (evidence-based practice). Dr. Malin led the implementation of the professional practice model, based on Joanne Duffy’s Quality Caring Model, and guided leadership development through her work with the Nursing Practice Council. Dr. Woith mentored nurses in the development and execution of research and evidence-based practice projects. She partnered with Trayce Bartley, MS, RN, director, Perioperative Services, to implement a Nursing Research Council. Both Dr. Malin and Dr. Woith served on the Advocate Health Care Research Council and actively participated on the annual Nursing Research Symposium planning committee.

Springfield Nurse Advocacy Day

On April 29, 2015, nurses from Advocate BroMenn Medical Center joined 60 other direct-care Advocate nurses at the State Capitol in Springfield. Crystal Bricker, Kristin Remmers, Brenda Drury, Denise Hammer, Ron Bartlett and Jane Patterson had the opportunity to talk with legislators and Governor Rauner about critical issues that impact their profession and their patients, including the Nurse Practice Act, mandated nurse to patient ratios, and the Nurse Licensure compact.

Legislative Forum

The Nurse Advocacy Council representatives from Advocate BroMenn Medical Center and Advocate Eureka Hospital hosted the 5th Annual Legislative Forum for associates and volunteers in September. Co-hosting the event were Nurse Advocacy Council members Ron Bartlett, MSN, RN, nurse manager, Eureka Hospital and Stephanie L. Moore, RN, MSN, NE-BC, director, Emergency Department and Critical Care Services). Clinical nurses directed health care-related and general questions to five panelists via pre-recorded video. Legislators at the event were Representatives Tom Bennett, Keith Sommer, Dan Brady and Bill Mitchell, and State Senator Jason Barickman. Following the formal presentation, legislators remained to discuss with nurses other concerns for today’s health care professionals.

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Exemplary Professional Practice

“I am proud to work for Advocate BroMenn Medical Center because of the high standard of nursing professionalism. I really like the fact that Advocate wants all nurses to have the same training so other RN’s and patients can expect the same nursing care throughout their experience with us.”

– Yvonne Rees, RN

Quality of Care and Improvement In support of Advocate Health Care’s vision to be a faith-based system providing the safest environment and best health outcomes, the core value of excellence is fundamental. Excellence is seen as empowering people to continually improve the outcomes of service, to advance quality, and to increase innovation and openness to new ideas.

ISO 9001 CertificationOur safety and quality goals by the end of the decade are to eliminate all serious safety events, and to consistently achieve top decile performance in our health outcomes and service. The achievement of these ambitious goals relies on Advocate BroMenn Medical Center becoming a highly reliable organization. This is a journey involving a transformation of culture, leadership, and process. BroMenn Medical Center’s Quality Management System (QMS) is the framework for quality improvement used by nursing and others within the hospital to enhance process reliability through Consistency of Service, Customer Satisfaction, and Continual Improvement.

Three C’s:

• Consistency of Service

• Customer Satisfaction

• Continual Improvement

This framework, which is outlined within the ISO 9001 standards, aids us in our pursuit of excellence and helps us to achieve the Advocate Experience outcomes of “Safety, Quality and Service Always.” BroMenn Medical Center was recognized along with six other hospitals within the Advocate system for the strength of its Quality Management System, as demonstrated through the achievement of ISO 9001 certification.

Safety and Health Outcomes OverallAdvocate Health Care utilizes a systematic approach to achieving and sustaining excellence which is supported through the use of a balanced scorecard. Within the Safety & Quality Scorecard, a number of safety/quality outcomes and nursing-sensitive metrics were tracked in 2015, including serious safety events, the safety event reporting rate, unassisted falls, inpatient core measure performance, and a variety of infection prevention statistics. All of the safety and quality measures are aggregated into an overall Safety & Quality Health Outcomes Composite Score. During 2015, BroMenn Medical Center’s Health Outcomes Composite score exceeded goal nine of twelve months.

Safety event reporting, including “near miss” and “good catch” events, increased in 2015 from 3.5 events/patient day to 6.7 events/patient day. Near miss and good catch events are events that are caught and corrected before reaching the patient and/or before patient harm occurs. Near miss and good catch reporting gives us the opportunity as providers to proactively improve our processes, thereby reducing the risk of harm to patients. In 2015, as a result of process improvements made over the course of the year, BroMenn Medical Center’s serious safety event rate (SSER) declined by 47.2%.

These patient safety metrics and our Health Outcomes Composite score were impacted substantially by several nursing-sensitive metrics included in and impacting these measures.

Unassisted FallsThe Fall Prevention Committee continues to oversee the falls prevention program at BroMenn Medical Center. In addition to clinical nurse representation from all departments, the committee includes the therapies, pharmacy, risk management, patient safety and radiology. In response to a number of falls initiatives implemented this year, and the weekly auditing of falls program compliance, BroMenn Medical Center’s unassisted falls rate continued to decline in 2015 and achieved 84th percentile performance nationally by the end of the year.

Inpatient Core Measure CompositeCore measures evaluate the extent to which evidence-based care is provided to inpatients within the hospital. Core measures evaluated in 2015 included influenza immunization, four stroke care measures, and five venous thromboembolism prevention measures. Core measure performance demonstrated sustained improvement from the beginning to the end of the year, meeting goal eight of twelve months.

Infection Prevention CompositeMeasures within the infection prevention composite included central line bloodstream infections (CLABSI), catheter associated urinary tract infections (CAUTI) and four surgical site infections. In 2015 there were no CLABSIs, representing 112 months without an ICU CLABSI and 34 months without a non-ICU CLABSI. Although urinary catheter device days were reduced by 14% in 2015, seven CAUTIs were unable to be prevented, and there were six surgical site infections. There were no ventilator associated events in 2015.

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Individualized Plan of Care and Pain ManagementIn addition to metrics tracked on the Safety & Quality Scorecard, the nursing units monitored a variety of metrics applicable to all nursing areas and several departments as well as diagnosis-specific metrics. Of note, considerable improvement was noted over the course of the year in individualization of the plan of care. Patient satisfaction with pain management hovered around the 75th percentile and ended the year at the 88th percentile.

High Reliability UnitsIn 2015, Advocate BroMenn Medical Center continued moving forward in the systemwide journey to eliminate unintended serious patient harm by the year 2020 by becoming a High Reliability Organization (HRO).

Focus of training shifted to front line associates through development of High Reliability Units (HRUs). A HRU is a patient care unit focused on eliminating serious preventable harm through an enhanced culture of safety at the unit level. This involves an intensive three-month focus on error prevention techniques to strengthen individual performance and incorporate high reliability principles to improve systems and processes. The first HRU was the Mother-Baby Unit, followed by the Progressive Care Unit and Radiology.

Mother-Baby Unit Safety Coachs – Katie Brown, Susan Kaufman, Jaime Carpenter, Justine Lee and Racheal Keighin. Not pictured – Jessica Baker, Amanda Huber, Hillary Watkins, Katie Thomas, Janice Westpfahl and Caitlin Wilson.

Progressive Care Unit Safety Coaches – Samantha Correll, Sarah Smithson, Stacy Carden, Sarah Magee and Samantha Stover. Not pictured – Lindsey Etheridge.

Led by Brenda Downen, Radiology Safety Coaches are Virgil Foreman, Kari Gattung, David Honegger, Lori Sherman, Janet Sutter, and Edie Weber.

The Mother Baby Unit, Progressive Care, and Radiology saw increases in reporting rates of 152%, 67%, and 127%, respectively, following the three-month HRU education. All HRUs initiated at least one process/quality improvement project focused on improving a unit safety concern. Units planning for an HRU rollout in 2016 include Intensive Care, Cardiovascular Care, Medical Oncology Specialty Unit, Peds and Infusion, Perioperative Services, and 6W Surgical.

2015 Key Process/Quality Improvement Achievements

• Standardization of the direct admission process through policy revision.

• Implementation of Advocate system dysphagia recommendations.

• Improvement in early identification and treatment of sepsis.

• Implementation of tele-psychiatry and standing order treatment set for behavioral health patients in the Emergency Department.

• Establishment of a Safe Patient Handling Program.

• Management of patients receiving TAPP blocks for post-procedure pain management.

• Revision of the surgical counts policy to ensure process standardization and alignment with best practices.

• Additional resources and process changes for PICC line management.

Stroke CareThis year the Stroke Collaborative Practice Team, including representation from nursing, medical management, pharmacy, therapies, radiology, laboratory, dietary, social work and others, demonstrated remarkable outcomes achieved through sequential process improvements made over time. Through the efforts of this group, stroke patients consistently receive high quality, evidence-based care. Time to treatment with TPA meets best practice guidelines nationally, providing patients the best opportunity for improvement of symptoms.

In addition, as a result of the Stroke Collaborative Practice team’s work with the area’s emergency management system, time from symptom onset to door has been reduced by 74 minutes (43%) since 2013.

Exemplary Professional PracticeExemplary Professional Practice

Back – Thomas Grobelny, Dr. Herman Dick. Front – Kristin Peterson, Victoria Steinkoenig, Dr. Sunil Chauhan.

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Nurse Experts Sharing Their Expertise

In late 2013, the Heart Failure Nurse role was established to provide patients with education to not only understand how to manage, but also how to accept their diagnosis. Beka Lavicka, RN, BSN, CHSN has been the primary nurse in this position since its implementation. Beka moved into this role after working as a summer nursing intern and a staff nurse on the Medical Oncology Specialty Unit.

The heart failure nurse receives referrals on, as well as seeks out, inpatients that have a primary diagnosis of heart failure. The nurse

• rounds on inpatients and provides them with the tools and education that they need to assume an active role in managing their heart failure.

• reviews what heart failure means, signs and symptoms to monitor for and report, and importance of medication and dietary compliance.

• works with patients who have been readmitted to identify what further assistance or education they need to help them succeed when they transition back home.

• collaborates with the patient’s multidisciplinary care team to address the patient’s needs both while in the hospital as well as at discharge.

• makes multiple discharge calls (within 2-3 days of discharge, again at 5-7 days post discharge, and then weekly for one month) to prevent readmission.

• troubleshoots potential issues with the patient and contacts home health or the patient’s primary care nurse if needed.

It’s a beautiful thing when a career and a passion come together.

Supportive Care Program

Throughout 2015 a group of palliative nurse clinicians and hospital leaders worked to create a new model of care that would expand the inpatient palliative care program beyond the inpatient hospital stay. The new model was designed to have the palliative care nurse follow up with the patient after discharge to reduce barriers to care. The target population for the program is patients with complex medical needs who may be suffering from uncontrolled chronic symptoms and encountering barriers to care.

The Supportive Care Program is an 8-week program designed to support patients through transitions of care by:

• facilitating the development of personal goals around symptom management

• achieving functional recovery

• teaching self-management skills

• removing barriers

• integrating community and health resources in the care plan

The model is based on 4 fundamental elements of care, as established by Dr. Eric Coleman, a known expert in successful care transitions. The program starts while the patient is in the hospital. Within one week of discharge, an in-home visit occurs and

a nurse attends a post-discharge provider office visit. The majority of patient interaction after the first week is by telephone. Desired outcomes for the program are:

• Patient is knowledgeable about medications and has a solid administration process.

• Patient maintains a record keeping system that ensures continuity of care across providers and settings.

• Patient is aware of and uses appropriate community and health care resources.

• Patient has established an Advanced Plan of Care.

• Patient has made life style changes to achieve optimum state of health.

• Patient is knowledgeable about indications that their condition is worsening and how to respond.

The program rolled out as a pilot in Spring 2016 with patients of Advocate Medical Group – Family Medicine, Normal. Once the program demonstrates a solid process and shows individual patient success, the pilot will extend to additional physician practices.


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Infection Prevention and Control Program Public health challenges continued in 2015. Following the Ebola scare of 2014, there was heightened awareness of risks related to travel as well as those related to failures in applying proper isolation and PPE usage promptly at the time of presentation. The infection prevention program addressed issues surrounding two mumps epidemics in the community, and preparation of the Emergency Department, local physician offices and urgent care staff for responding to ZIKA concerns and testing processes. This was in addition to maintaining the necessary preparation for Ebola.

As a result of the travel related threats and other community concerns, employee safety was a focus. Training highlighting the consistent need for travel assessment and implementation of empiric precautions was critical and reinforcement essential. Practices including proper PPE use and hand hygiene as well as management/cleaning of devices were identified as key pieces of the culture of safety. These practices will remain a focus for 2016 and use of our Be Safe behaviors will be leveraged to embed infection control practices into the culture.

A more defined methodology for internal consultations using a risk assessment approach to assess situations and processes was initiated in 2015. Risk assessments were completed on:

• Radiology vaginal probes

• TEE Scopes

• Lab storage

• Fan use

• Dialysis storage

• Acute Rehab isolation practices

• Breath call cleaning

• Equipment cleaning and management related to storage

Sterilization, high level disinfection, and cleaning continue to represent critical processes that are key for overall patient safety. Current processes were considered exemplary when reviewed by DNV during the Fall 2015 survey.

We continued our journey to ensure there is clear separation of clean and dirty in all situations. Staff awareness and understanding of this principle increased considerably this year, and the level of engagement was outstanding.

We completed an organizational wide assessment of the 18 DNV Managing Infection Risk (MIR) standards culminating in a DNV Gap Assessment in August. The program found to be largely ready for certification.

Interdisciplinary Partnership

Stroke ProgramStroke Community EducationAdvocate BroMenn Medical Center has been a certified primary stroke center since 2007. One of the requirements for maintaining this status is to provide education to the community on stroke recognition, calling 911 when symptoms arise, risk factors and treatment options. In addition to this certification requirement, community education also aligns with the nursing strategic plan.

Stroke continues to remain one of the leading causes of disability. The overarching goal of educating the community on stroke is to improve health knowledge.

The stroke team at BroMenn Medical Center takes a multifaceted approach to education. The team partners with members of Community Wellness to access various venues in order to capture the largest audiences. These venues range from baseball games to health fairs to local businesses.

One of the new education venues for 2015 was education for junior high schools. According to recent stroke literature, targeting this age group has proven successful. With this in mind, members of the Stroke Team – Nancy Allen, RN, MSN, Chief Nurse Executive and Nursing Director at Eureka Hospital; Kristin Peterson, RN, MSN, Stroke Coordinator; Victoria Steinkoenig, MSN, RN, CNS-BC, SCRN Inpatient Neurology Advance Practice Nurse; and Jennifer Steinhausen, RN, BSN, Stroke Quality Care Coordinator provided an interactive education to the 5th grade class at Eureka Junior High School. The training incorporated an overview of stroke, how to recognize someone having a stroke and what to do. The stroke team provided real life situations that a stroke patient may experience and had the kids simulate what it is like to have a disability that stroke victims live with after a stroke. At the conclusion of the junior high education, each student was provided with a packet to share with their family on what was learned about stroke.

As with every education effort, it is important to measure the success of the education. The stroke team measured their success through pre and post-tests at education events but more importantly by the amount of time from when a patient first experienced symptoms to when they arrived at the hospital.

Since focusing community education efforts, the stroke team has seen an average of a 70-minute decrease in symptom onset to door time from 2014 to 2015, which ultimately leads to decreasing the rate of disability from stroke.

Given these positive results, Kristin Peterson and Victoria Steinkoenig were accepted to present a poster at the International Stroke Conference in Los Angeles California in February 2016.


Tele-PsychiatryTele-psychiatry was implemented at Advocate BroMenn Medical Center in the Spring of 2015. An outstanding relationship has been developed between BroMenn and the tele-psychiatry staff at Advocate Christ Medical Center. These services have provided consultation to our Emergency Department associates, physicians and patients and have allowed us to either discharge patients to a recovery-focused setting or to start proactive treatment while in the ED. The Tele-Psych machine moves to multiple nursing units to meet our patients’ needs. It’s a fascinating and proactive way to wholistically care for our patients! Patients on our Medical-Surgical Units have received assistance for the development of coping skills strategies and/or for additional behavioral health emotional-focused support.

eICUAdvocate Health Care’s eICU provides increased monitoring of intensive care unit patients through continuous remote surveillance of real time patient data by ICU nurses and physicians located in Oak Brook, IL. The eICU program is clinically proven to reduce severity adjusted mortality and length of stay in the ICU. The eICU is not designed to alter nurse-to-patient ratios or replace on-site nurses or physicians. It adds a layer of care, virtually, a “second set of eyes” watching over the patient to provide support to the nurse and enhance care provided at the bedside. The eICU team proactively assesses and notifies our team on-site with changes noted in patient condition. This program was implemented at Advocate BroMenn Medical Center in Spring 2015.

Hospital Elder Life Program (HELP)In an effort to help decrease hospital induced patient delirium—a mental state in which one is confused and not able to speak or think clearly—the Hospital Elder Life Program (HELP) was developed and initiated on the Medical Oncology Specialty Unit (MOSU) in January 2015. Delirium and functional decline are common results of hospitalization in the elderly population and can lead to increased length of stay, the inability for a patient to return to their home setting, and a higher risk for falls.

The HELP program was initiated at BroMenn Medical Center by Laurie Round, RN, BSN, MS, NEA-BC. Current leads on the project are Stacy Barclay RN, BSN and Theresa Bailey, RN, MSN. What makes HELP so special and successful is its partnership between nursing and volunteers. Nursing assesses the needs and screenings of the patients, and the interactions are carried out by specially-trained volunteers. These interactions take place in intervals throughout the day and include cognitive stimulation, physical exercise, feeding assistance, and social interaction.

To date, HELP volunteers have provided care to 421 patients. We have received an enormous amount of positive patient/family feedback regarding the program, and many volunteers have been able to fulfill their requirements for health degrees they are interested in pursuing. The program is truly a win-win for all involved by offering a way to get volunteers more involved and providing optimal care to our patients.

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Cardiac Collaborative and Awards

Advocate BroMenn Medical Center’s Cardiac Collaborative Team, led by Dr. Beth Tumilty and Bev Glendon RN, BSN, Chest Pain Center Coordinator, remains strong in “sustaining the gain.” Overall heart attack care is above the 90th percentile nationally. In 2015 the hospital again was awarded the Platinum Achievement Award for ACTION Registry Get with the Guidelines and Mission Lifeline STEMI Receiving Center—Gold Plus. The recognitions are for heart attack care. The care also reflects the work done with outlying hospitals to get STEMI (serious heart attack) patients to the cath lab to open a blocked artery within 120 minutes of arrival to the outlying hospital. These awards are sponsored by the American College of Cardiology and the American Heart Association. And, of course, BroMenn Medical Center is still an accredited Chest Pain Center with PCI (Percutaneous Coronary Intervention).

Even though our heart attack care is above the 90th percentile, the Cardiac Collaborative always strives for improvement. Early activation of the Code STEMI is key. The sooner the arrival of the Cath Lab team, the quicker the patient can get to the Cath Lab to save heart muscle. In the first 6 months of 2015, 67% of the Code STEMIs from the field were activated from the field. This improved to 90% in the last 6 months of 2015. Through case reviews, education is provided to both EMS (ambulance personnel) and the ED staff on both calling the Code STEMI from the field and immediately activating the Code STEMI team once the ED is notified.

The Cardiac Collaborative team focuses on care elements other than heart attack:

• Reduction in Acute Kidney Injury: By adding documentation prompts proposed by nursing and through education, the cath lab at BroMenn Medical Center is now greater than the 90th percentile in avoiding acute kidney injury in patients exposed to contrast.

• Management of the Low Risk Chest Pain Patient: A patient who comes to the ED with chest pain may not have initial test results that demonstrate a possible cardiac event. Therefore, many patients are kept for observation for further testing. It is important to review patient care processes in order to decrease delays in ED throughput and enhance patient satisfaction. More on this in 2016, but in January 2015 the average length of stay (LOS) was 29.1 hours and towards the end of 2015 the average LOS was as low as 19 hours with a goal of less than 16 hours.

The Cardiac Collaborative will continue to work diligently in 2016 as we prepare for Chest Pain Center with PCI re-accreditation, now sponsored by both the American College of Cardiology and the Society of Cardiovascular Patient Care.

Realizing that the national goal is to decrease heart disease as the number one cause of death in the U.S., it is important to educate the community on early recognition of signs and symptoms of a possible heart attack and the importance of calling 9-1-1. Community education is done at senior events, Women’s Health Night and local business events, to name a few. The cardiac team also plays a part in organizing the annual “Concerns of the Heart.” In 2015 physicians spoke on the effects of sleep apnea on heart disease, including congestive heart failure.

Critical Care CollaborativeCurrent Initiatives/Recent Accomplishments:

• RRT/Code Blue System Report

• Review of readmission rates for COPD

• Intraossious IV insertion

• Review of system telemetry policy

• STOP BANG – BroMenn group developed and implemented a process, participating in and awaiting development of a system policy.

• eICU is in operation

• Sepsis (June focus):

May Sepsis Data reviewed

Template for physician sepsis documentation is being created

Reviewed the BroMenn site sepsis workgroup

Reviewed Sepsis dashboard

Reviewed Sepsis policy – Plan group to review/revise.

Antibiotics – pharmacy will specify which antibiotics can go together and which will need to start first.

Behavioral Health Collaborative Along with the implementation of tele-psychiatry, the group completed the following.

• Implemented a new and innovative fall protocol for inpatient population. An approximate 40% reduction in patient falls has resulted.

• To provide both associate and patient safety, a panic button was installed in the ICU for associate and patient safety.

• Collaboration by nursing staff from multiple units for standardization of care for behavioral health patients.

• A psychiatric ED order set was revised and implemented.

• Through CNE support, an outside consultant was used to provide mental health education to staff from ED, ICU, MHU, CVCU and Public Safety.

BroMenn remains committed to providing services to those patients that present with Behavioral

Health needs. We look forward to the remodel of our Inpatient Psychiatric Unit and to the relocation of one of the Advocate Medical Group outpatient clinics to the Advocate BroMenn Outpatient Center. Another focus is implementation of Tele-psychiatry at Advocate Eureka Hospital by the end of 2016.

Surgical Collaborative The goal of Advocate BroMenn Medical Center’s Surgical Collaborative Team was to achieve top decile patient health outcomes and satisfaction. During 2015, the Collaborative focused on developing the Quality Management Oversight Committee (QMOC) measurement reporting structure, creating a sedation documentation audit process, preventing surgical site infections (SSI), and realigning the Ambulatory Patient Experience Committee.

Highlights from the year include development and approval for quality measures reported to QMOC, development and implementation of SSI prevention bundles, using evidence based practice guidelines to reduce SSI occurrences and training to frontline Perioperative Services staff by the Ambulatory Patient Experience Committee on how to help drive improvement of patient experience results.

OB/Nursery Collaborative 2015The OB/Nursery Collaborative was established in 2015 and focused on the following initiatives:

• In order for associates and physicians to more easily identify new associates, the collaborative developed a process to communicate and post a biographical form and picture of each new associate.

• The Critical Safeguards Checklist used by the OR was revised for OB to facilitate the Time Out process.

• Start times of the scheduled morning c-sections were monitored and the group worked with physicians to minimize late starts.

• Developed a process for physicians to refer families to the Atrium Pharmacy for Tdap vaccination and flu vaccination. Patient education materials were posted to encourage vaccinations.

• Developed drills and simulations for high risk events that include the 24/7 obstetrician and anesthesia.


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I am proud to work at Advocate because we are a health ministry that merges faith with technology to provide optimal outcomes.

– Rayford Rattley, BSN, RN, CNOR

New Knowledge, Innovation and Improvements

Advocate Research Symposium Nineteen nurses from Advocate BroMenn Medical Center attended the 3rd Annual Advocate Health Care Nursing Research Symposium, Collaborating to Advance the Profession, held at Advocate Sherman Hospital on April 22, 2015. Seventy abstracts were submitted for podium and poster presentations; 40 were accepted. Two of the abstracts accepted for poster presentations were from BroMenn Medical Center.

Becky Hatfield RN, MSN, CWOCN; Alicia Allen, RN, MSN, BC; Linda Bergren, RN, WOCN; and Teresa Novy, RN-BC, MSN presented a poster entitled Quality Improvement: Eliminate Hospital Acquired Pressure Ulcers. This poster showcased work of the Skin Care Committee and their ongoing efforts to decrease hospital acquired pressure ulcers. The poster was also presented at the NPUAP Conference in February of 2015, and the WOCN conference in June of 2015.

Yvonne Rees, RN, CGRN, Pam Bierbaum, RN, BSN, and Ara Peterson, RN, MSN, of the Perioperative Shared Governance committee, presented their poster, Minimizing Preoperative Heat Loss. Their poster described development and implementation of an evidence-based practice project to increase and

maintain temperatures of 36 degrees Celsius at the patient’s first intraoperative temperature check following post-anesthesia induction and again within fifteen minutes of arriving in PACU. The project was created following safety reports of three patient’s arriving in PACU with temperatures below 36 degrees Celcius, placing them outside the acceptable range in the SCIP protocol and increasing their risk for surgical site infections. For patients whose temperatures were 36.5 or below preoperatively, Same Day Services staff applied active warming blankets (Bair Huggers) to prevent redistribution of body heat to the periphery and Thermoflect caps on all patient’s going to surgery to reduce heat loss through the scalp.

Shelly Malin, PhD, RN, Advocate BroMenn Endowed Chair, presented the plenary session on JoAnne Duffy’s Quality Caring Model when the guest speaker, JoAnne Duffy, fell ill and was unable to attend the conference. The program planning committee and symposium participants responded positively to Dr. Malin’s presentation, and her expertise on the model led to an interesting discussion session on use of the model to undergird Advocate Health Care’s Professional Practice Model.

National Mother-Baby Conference 2015The MBU Shared Governance group was challenged with formulating a plan to reduce OB maternal and newborn Falls. The interventions identified by the staff were simple to implement and supplemented the fall prevention measures already in place. These measures are continually evaluated with reporting and review at the monthly shared governance meetings. There has been a significant decrease in falls in 2015. Brenda Drury developed and presented a poster on this topic to the National Mother-Baby Conference in Orlando, Florida in September 2015.

Wound Care Nurses

In 2015, the Wound Department was honored to display a poster at the Nation Pressure Ulcer Advisory Panel (NPUAP) in February, 2015 in Orlando, FL and in June at the Wound Ostomy Continence Nurse (WOCN) National conference in San Antonio, TX. Both presentations showcased the work completed by the Skin Care Committee in their ongoing efforts to decrease HAPU at Advocate BroMenn Medical Center.

Nursing education is always a priority for this department. In 2015 this department identified the need for nursing staff education emphasizing the differentiation between pressure ulcers and other types of skin injuries in the buttocks/coccyx area. Education regarding Incontinence Associated Dermatitis (IAD), Moisture Associated Dermatitis (MAD), and intertriginous dermatitis and how these are different and require different treatment plans from pressure ulcers. Helping bedside nurses recognize skin injury and to identify correct etiology is important to wound care practice and patient outcomes.

A significant practice change throughout the Advocate system took place in 2015. The bedside nurse now determines if a wound is a pressure ulcer, and if this pressure ulcer is partial versus full thickness during their assessment of all pressure skin injuries. The bedside nurse then stages the partial thickness PU as stage 1 or stage 2. The staging of all full thickness pressure ulcers is now provided by the Wound/Ostomy Nurse. This provides consistency of documentation and streamlines the process.

The Wound Ostomy Department continued educating the nursing staff about relevant practice issues. A collaborative continuing education program was presented in October in cooperation with the Advocate BroMenn Center for Wound Healing and Hyperbaric Medicine. This program provided 18 local nurses with updated information premiering current treatment for lower leg ulcers. As care moves to the community, external partnerships continue to be a priority for the wound care team. We see the education of nurses in all local care settings and the staff at the Center for Wound Healing and Hyperbaric Medicine as our wingman for the continued care of our wound and ostomy patients after they are discharged from our facility.

Teresa Novy, MSN, RN-BC, Wound Ostomy

Brenda Drury, MSN, RNC, Mother Baby Unit

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I would like to acknowledge and thank the Advocate Charitable Foundation and their generous donors for making this annual report possible.

The multitude of opportunities to elevate nursing professional practice are afforded to Advocate BroMenn Nurses by charitable donors who believe in the advancement of nursing practice, which ultimately impacts patient care. After all, the patient is in the center of all that we do.

– Laurie Round, Chief Nurse Executive

1304 Franklin Avenue Normal, IL 61761 309.454.1400

advocatehealth.com/bromenn

06/16 MC 0918

“To know even one life has breathed easier because you have lived. This is to have succeeded.”

— Ralph Waldo Emerson

The Advocate Nurse Empower. Serve. Thrive.

2016 Quality & Patient Safety Plan

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Integrated Quality and Patient Safety Plan 2016

I. Philosophy and Framework In support of Advocate’s vision to be a faith-based system providing the safest environment and best health outcomes while building lifelong relationships with the people we serve, the core value of excellence is fundamental. Excellence at Advocate Health Care is defined as empowering people to continually improve the outcomes of our service, to advance quality, and to increase innovation and openness to new ideas.

In support of a systematic approach to achieve and sustain excellence, Advocate Health Care utilizes a balanced scorecard involving six Key Result Areas (KRA’s):

Safety Quality Service Growth Funding Our Future Coordinated Care

Advocate lives our MVP through the Advocate Experience, with our commitment to create the safest and best place for our patients, associates and physicians – always. The Advocate Experience is: An experience without harm – Safety An experience of excellence – Quality An experience of engagement and trust – Service Always

II. Quality Management System

Quality Policy: The Advocate Health Care quality policy is: Safety, Quality and Service Always through Continual Improvement. The leadership and associates of Advocate Health Care execute our quality policy through our quality management system and a commitment to continual improvement to enhance patient safety, health outcomes, operational excellence, and patient satisfaction. Quality and Patient Safety Plans are maintained by the sites to provide operational framework.

Advocate Health Care is committed to evidence-based performance improvement using a holistic approach to problem solving. The organization is steeped in a culture of continual improvement to enhance patient safety, health outcomes, service and operational excellence from the patient’s perspective. Accountability for performance is addressed through an objective leadership evaluation system in which management performance objectives directly align to KRA performance.

Performance improvement initiatives are driven by performance gaps as measured by KRA’s and opportunities identified by leadership. Advocate’s measurement philosophy is supported by a robust business intelligence environment:

Responsible leadership demands familiarity with and rigorous use of data

Exhibit OO3.3 ABMC


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Processes are in place to accurately and consistently obtain a balanced set of measures thatmonitor health outcomes, customer satisfaction, functional status, and resource utilizationthat ultimately supports a culture of accountability

Data driven decisions are made that assist in identifying opportunities and correspondingimprovement strategies

ISO 9001 is the foundation for performance improvement for Advocate. The ISO foundation includes a wholistic approach to performance improvement methods that includes PDSA as the core performance improvement approach and includes the Change Acceleration Process (CAP), Lean and Six Sigma tools and methodologies. The Change Acceleration Process is a change model designed to increase the success and accelerate the implementation of organizational change efforts. It addresses how to create a shared need for the change; understand and deal with resistance from key stakeholders; and build an effective strategy and communication plan for the change. Lean Six Sigma is a business process philosophy that focuses on the customer and increasing value and improving quality, safety and productivity. Recognizing the complementary nature of the two methodologies, Advocate uses a blended approach of Lean and Six Sigma concurrently, utilizing different tools to address specific improvement problems along a value stream and/or project.

The 2016 KRAs are listed in the 2016 Balanced Scorecard posted on the intranet.

A. Quality Management System Oversight and Structure

The Advocate Health Care Board of Directors oversees the business management functions of the Advocate System. There is two way communication and interaction between the Board and Advocate system senior leadership and the site Governing Councils. The system ISO 9001 Quality Management Review Committee interacts and is accountable to these two groups. The Medical Executive Committees at each hospital report to the site Governing Councils. The site Quality Management Oversight Committees report to the site Governing Councils and to the system Quality Management Oversight Committee. The system and site Quality Management Oversight Committees provide leadership and resources to support the quality management system objectives.

For the purposes of quality review, improved patient outcomes and reduction in morbidity and

mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee

will designate specific site committees to provide professional and peer self-evaluation of the

adequacy of patient care. These may include but are not limited to:

Patient Safety Committees

Health Outcomes Committees

Morbidity and Mortality Committees

Peer Review Committees

Cause Analysis Committees

The system and each hospital have a Quality Management Representative. The site Quality Management Representatives report site information to the system Quality Management Representative.


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The Advocate Health Care Quality Manual provides an overview of the Quality Management System. Results from the quality management system audits, corrective and preventive actions will be reviewed and acted upon by the Quality Management Review Committees at the site and system level.

B. Quality Management System Metrics The following are required to be reported to the Quality Management Oversight Committee:

Results of Quality Management System (QMS) audits Patient feedback Process performance and product conformity Status of preventive and corrective actions Follow-up actions from previous management reviews Changes that could affect the QMS, and Recommendations for improvement.

Additional data may also be submitted.

III. Patient Safety Program

The goal of Advocate’s patient safety program is to eliminate all events of serious harm within

the system by December 31, 2020, with a target of achieving an 80% reduction in the rate of

serious events between 2013 and 2017.

In 2012, a strategic plan for patient safety was completed and implementation initiated. This plan

maps out a multi-year plan for achieving high reliability in care delivery across Advocate. The

development of the plan involved the collective efforts of key executive leaders from across the

system, site and system patient safety leaders as content experts together with input from front

line associates and physicians. The strategic plan outlines four key strategies, including:

1. Establish patient safety as the foundation of care

2. Teach leaders how to lead to safety

3. Empower the front line to address safety issues

4. Engage patients and families in patient safety

The strategic plan will serve as the primary roadmap for operational work in patient safety for the

system in the near future. In 2015, the focus of the patient safety program included:

1. Transition from a primary focus on leadership to a focus on safety at the front line through

the creation of High Reliability Units (HRUs). HRUs will be clinical departments in which there

is a focused training effort in high reliability healthcare, training on error prevention

techniques, coaching to integrate the techniques into front line clinical work, and front-line

problem solving with issues that impact the safety of care delivered.

2. Engagement of the front line in safety efforts through implementation of a Safety Coach and

Physician Champion program

3. Launch of the system simulation program focused on in-situ simulated learning, along with

establishing the first hospital-based simulation lab.


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1. Completion of the high reliability leader training series.

2. Greater focus on the integration of the Advocate Experience through the development of a

Leader tool box for safety, quality and service.

3. Initiation of actions to address items on the Safety Top Ten list.

4. Improved reporting of patient safety events.

5. Establishing a baseline for Advocate’s hospital Serious Safety Event Rate.

6. Full standardization of the RCA process throughout the system.

7. Realignment of the patient safety reporting structure across the system to enable safety

standard work.

8. Implementation of the updated version of the Cause Analysis Database (CAD 2.0) for the

collection and utilization of system causal data.

9. Improved focus and utilization of Advocate’s Just Culture Decision Matrix.

In 2016, the focus of the patient safety program as outlined in the strategic plan strategies and

tactics will include:

1. Launch the front line High Reliability Units (HRU) with all clinical departments at Advocate

hospitals across the system. The HRU initiative will appoint and train a team of safety coaches

in each clinical department, training in high reliability principles, coaching techniques and the

PDSA model for front line problem solving.

2. Expand the front line approach to include the medical staff, through launch of the Physician

Safety Champion program. Physician safety champions, as partners to the safety coaches, will

serve to influence the culture of the medical staff in Advocate towards high reliability.

3. Continued development of the system simulation program through in-situ simulations focused

on high risk areas as identified by the Serious Safety Event Rate, opening of the first hospital-

based simulation center at Illinois Masonic Medical Center, and acquisition of funds and

planning for three additional hospital-based simulation labs.

4. Pilot of the Cognitive Bias and Diagnostic Error program throughout all Emergency

Departments across the system

5. Refreshing the Patient Safety Strategic Plan to identify strategies and tactics to guide safety

efforts between 2016 and 2020.

Classifying and Measuring Patient Harm

Advocate utilizes the Serious Safety Event Rate (SSER), through Healthcare Performance

Improvement (HPI) as the foundational measure of patient harm within the system. The SSER

classifies patient harm according to severity (severe, moderate or minimal) and duration

(temporary or permanent), using standardized definitions. The methodology used also

classifies near miss events based on the type of barrier that prevented the event from reaching

the patient. The SSER will serve as a key metric for the advancement of Advocate toward a

culture of high reliability.


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In 2013 Advocate revised the medical staff peer review process in order to align peer review

cases classified as a patient safety event with key reporting metrics. As such, the SSER will

include cases identified as a patient safety event by the peer review process and determined to

be a serious safety event through application of harm classification.

AHRQ Culture of Safety Survey

Advocate Health Care participates annually in the AHRQ Culture of Safety Survey for associates.

This survey serves as a key metric for the movement towards high reliability facilitated by the

strategic plan. It is the expectation that Advocate sites will implement unit/department based

action planning to facilitate advancement of the culture.

A. Patient Safety Program Oversight and Structure

Advocate’s patient safety program is endorsed by the Advocate Board of Directors. The Health

Outcomes Committee of the Board is the safety and clinical oversight committee of the Board.

Advocate’s Health Outcomes Council oversees the system-wide safety and clinical performance

improvement projects and initiatives. The Health Outcomes Council reports to Advocate's Quality

Management Oversight Committee.

For the purposes of quality review, improved patient outcomes and reduction in morbidity and

mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee

will designate specific site committees to provide professional and peer self-evaluation of the

adequacy of patient care. These may include but are not limited to:

Patient Safety Committees

Health Outcomes Committees

Morbidity and Mortality Committees

Peer Review Committees

Cause Analysis Committees

Patient Safety Team

A corporate patient safety department supports system-wide safety initiatives, reports, data,

education and consultation. Strategic collaboration occurs to enhance this work, including but

not limited to:

The risk management department collaborates with patient safety to reduce and eliminate

actual and potential risk factors that may impact the safety of care provided to our patients.

The center for health information services (CHIS) oversees system-wide clinical data

measurement, reporting, analytics and provides public data expertise.

The department of quality management and regulatory collaborates to integrate safety with

Advocate’s ISO 9001 Quality Management System, and into the Advocate Experience.


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The patient experience department collaborates to integrate safety into the Advocate

Experience.

All sites of care within Advocate Health Care have identified safety leaders that report directly to

the system safety department. Additionally, each site has a committee that guides clinical safety

and quality initiatives. Together, leaders at the system and site collaborate on key strategies,

programs and tactics that enhance the safety of the system.

B. Patient Safety System Metrics

A variety of metrics are used in the patient safety program. The majority are included in either

the 2016 Balanced Scorecard or the Safety & Quality Close. Both dashboards are distributed to

sites monthly.

The following are key patient safety metrics for 2016 reported on the Safety & Quality Close and

reported to the Quality Management Oversight Committee:

Safety Event Reporting Rate

AHRQ Culture of Safety Survey Results

Serious Safety Event Rate Change

RCA Aging

OSHA Employee Injury Rate

Unassisted Falls Percentile

V. Authorities and Structures that Support Quality and Patient Safety

at Advocate BroMenn Medical Center

The Advocate Healthcare (AHC) Board of Directors assumes ultimate accountability for the quality

and safety of the patient care and services provided at Advocate’s hospitals and for providing the

leadership and resources to support system quality management objectives. While oversight of the

system Quality and Patient Safety Program is provided by the AHC Board of Directors, the Advocate

BroMenn and Eureka Governing Council guides the direction of Advocate BroMenn Medical

Center’s (BroMenn) quality and patient safety program, and has delegated functional responsibility

to Administration, the BroMenn Quality Management Oversight Council (QMOC), and the Executive

Committee of the Medical Staff for implementation and maintenance of the scope of activities

addressed in this plan. Authority for the activities included in this plan is further delineated in the

Medical Staff Bylaws/Rules and Regulations, a variety of hospital committee and council charters,

and at times, hospital policy and procedure. As noted within the BroMenn QMOC charter,

BroMenn’s QMOC together with the AHC System ISO 9001 QMOC, are responsible for the quality of

patient care delivered at BroMenn and for providing the leadership and resources necessary to

support the hospital’s quality management objectives.


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The organization structure and reporting of activities addressed in this plan are illustrated within

the BroMenn Quality Management Committee Structure diagram and the Quality Management

Reporting Plan, which have been included as attachments to this document. The Quality

Management Committee Structure is reviewed, and the Quality Management Reporting Plan is

prepared annually, outlining information to be reported to the BroMenn QMOC each calendar year.

A listing of performance improvement priorities is developed in conjunction with the AHC KRA

structure, and a year-end review is completed annually to evaluate effectiveness of the quality

management system.

V. Attachments

BroMenn Quality Management Committee Structure

BroMenn Quality Management Oversight Reporting Structure

UNCONTROLLED WHEN PRINTED

Document Metadata

Document name: Quality-Patient Safety Integrated PlanOriginal Location: /Advocate Health Care/Advocate

BroMenn (BMC)/QualityManagement/Management Plan

Created on: 05/01/2015Published on: 04/05/2016Last Review on: 03/17/2016Next Review on: 03/17/2017Creator: Schaumburg, Cynthia

Quality Management StaffCommittee: BMC Policy CommitteeOwner: Frederick, Ann

Other Title (Not on List)Manager: BENEDINO, ELIZABETH

Other Title (Not on List)Author(s): Frederick, Ann

Other Title (Not on List)Approver(s): Round, Laurie

Other Title (Not on List)Publisher Schaumburg, Cynthia

Quality Management Staff

Custom Meta Data:Review Cycle 1 year

UNCONTROLLED WHEN PRINTED

Medical Executive

Committee

BROM Quality Management

Oversight Council

Medical Staff

Committees

- Medical Care

Evaluation

- Medical Staff

Committees

(Function Specific)

Medical Staff

Departments

DATE:

02-29-2016

Advocate Health Care

Board of Directors

Critical Processes *

- Accreditation

- Advocate Experience

- Document Control

- QMS Auditing

- Clinical Data Management

- Infection Prevention

- Patient Safety

- Physical Environment

- Utilization Management

- Nursing Practice

QM7 Functions

BROM Governing Council

* multidisciplinary

representation

System ISO 9001

Quality Management

Oversight Council

ADVOCATE BROMENN MEDICAL CENTER

QUALITY MANAGEMENT OVERSIGHT

BROM Executive Team

Hospital Service Lines and

Collaborative Practice Teams

Exhibit OO3.3 Advocate BroMenn Medical Center 1

ABMC QMOC

2016 Reporting Plan

QMOC

Reporting

2016

Jan 25

2016

Feb 22

2016

Apr 4

2016

May 23

2016

Jun 27

2016

Jul 25

2016

Aug 22

2016

Sep 26

2016

Oct 24

Internal-External Audit Findings Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg

QMOC Dashboard Frederick Frederick Frederick Frederick Frederick Frederick Frederick Frederick Frederick

CAPA Logs & Reviews Frederick Frederick Frederick Frederick Frederick Frederick Frederick Frederick Frederick

RCA Reviews Wolfe Wolfe Wolfe Wolfe Wolfe Wolfe Wolfe Wolfe Wolfe

SR1 Threats to Safety/Pt Safety Wolfe Wolfe

SR2 Medication Management Pinneke Pinneke

SR2 Pharmacy Services Pinneke Pinneke

SR3 Operative & Invasive Procedures (Surgical, OB, Cath) Bartley Harper

Mueller

Bartley Harper

Mueller

SR4 Anesthesia / Moderate Sedation Bartley Bartley

SR5 Blood & Blood Components Durdle Durdle

SR6 Restraint Use / Seclusion Moore

SR7 Pain Management Harper Harper

SR8 Infection Prevention & HAIs Bierbaum

SR9 Utilization Management Frederick Frederick

SR10 Patient Flow (Quarterly)Bartley Moore Bartley Moore Bartley Moore

SR11 Customer Satisfaction (Quarterly) Donaldson Donaldson Donaldson

SR12 Discrepant Pathology Durdle Durdle

SR13 Unanticipated Deaths (Quarterly) Frederick Frederick Frederick Frederick

SR14 Adverse Events / Near Misses Wolfe Wolfe

SR15 Readmissions (Quarterly) Frederick Frederick Frederick Frederick

SR15 Unplanned Returns to OR Bartley Bartley

SR16 Critical Processes - Therapies & Safe Handling (in

February)

Vogel Vogel

SR16 Critical Processes - Spiritual Care Ward Ward

SR16 Critical Processes - Wound Healing Center Brown Brown

SR16 Critical Processes - Cardiac Services Mueller Mueller

SR16 Critical Processes - Stroke Care Peterson Peterson

Bartley

Moore

Donaldson

Moore

Bierbaum

2016

Dec 5

Schaumburg

Frederick

Frederick

Wolfe


ABMC QMOC

2016 Reporting Plan

QMOC

Reporting

2016

Jan 25

2016

Feb 22

2016

Apr 4

2016

May 23

2016

Jun 27

2016

Jul 25

2016

Aug 22

2016

Sep 26

2016

Oct 24

SR16 Critical Processes - Nursing Services/Nursing Sensitive

Indicators/Magnet

Harper Harper

CR16 Critical Processes - Lab Services Durdle Durdle

CR16 Critical Processes - Beh Health Mgmt Donaldson

CR16 Critical Processes - Staff Mgmt Coletta

CR16 Critical Processes - Contracted Services Meissner

CR16 Critical Processes - Radiology Downen

CR16 Critical Processes - Food, EVS, Linen Mellon

CR16 Critical Processes - Health Info Mgmt Sweeney Sweeney

SR17 Medical Records Delinquency Sweeney Sweeney

SR18 Physical Environment (Quarterly) Bassett Bassett Bassett

MI2.SR3 Radiation Badges Downen

TO2.SR2 Death Notification/Organ Donation Harper Harper

IC1.SR4 OSHA Illness & Injury Rates Coletta

SM7.SR4b Performance Distribution Rates Coletta

SM7.SR6 CBT Completion / Staff Turnover Coletta

Other Quality Plans Review & Research Projects Update Lareau Bartley Lareau Bartley

Date: September 2015

Revised: November 2015

Revised: February 2016 (Leadership Changes Noted)

Coletta

Bassett

Downen

Coletta

Coletta

Meissner

Downen

Mellon

2016

Dec 5

Donaldson

Coletta


Advocate VisionTo be a faith-based system providing the safest environment and best health outcomes, while

building lifelong relationships with the people we serve.

Our ContributionTo be the leading regional medical center in Central Illinois

Strong Physician Engagement

AdvocateExperience

Safety

Quality

Service

Access andAffordability

Growth

Funding Our Future

AdvocateCare

Coordinated Care

Vision

Strategies

Key Result

Areas

Core ABMC

Strategies

Foundation

ABMC’s

Contribution

Strengthen wellness and

prevention platform

Optimize in network care

throughout the Advocate

network

Create a comprehensive

supportive care network

Position service lines to optimize

care delivery across the continuum

Strengthen regional expansion

strategy in Central Illinois

Design a consumer facing strategy

to position ABMC in retail services

Advance ABMC as safe,

Highly Reliable

Organization

Consistently provide

superior quality outcomes

Deliver an extraordinary

experience for patients,

physicians and associates

Advocate BroMenn Medical Center 2016-2019 Strategic FrameworkExhibit OO3.4

Strong Physician Engagement

AdvocateExperience

Safety, Quality, Service

Access and Affordability

Growth, Funding Our Future

AdvocateCare

Coordinated Care

Strategies

Key Result

Areas

Core ABMC

Strategies

Foundation

Strengthen wellness and prevention

platform

• Plan and implement launch of the

Center for Integrated Wellness

• Expand direct to employer client base

Optimize in network care throughout

Advocate network

• Meet or exceed in-network care

coordination target

• Develop plan with Advocate

Children’s Hospital to keep pediatric

care within Advocate

• Grow attributed lives in risk based

contracts

Create a comprehensive supportive

care network

• Advance coordination of care through

Advocate Post Acute Network

• Meet or exceed Advocate at Home

capture rate

• Develop palliative care program

identifying most appropriate setting for

patients

Position service lines to optimize care delivery across the

continuum

• Expand access to key services throughout Central Illinois

(cardiovascular, neurosciences, orthopedics, mother/baby)

• Recruit and retain PCP’s and key specialists to support

market share growth

• Position ambulatory platform to support movement to

outpatient arena

Strengthen regional expansion strategy in Central Illinois

• Collaborate with Advocate Health Care to identify expansion

opportunities

• Optimize AMG, and aligned PCP footprint to maximize

patient access

• Build and sustain new community partnerships

Design a consumer facing strategy to position ABMC in

the delivery of retail services

• Implement ambulatory care plans for immediate care

inclusive of launch of new AOS site

• Develop and implement telehealth plans for strategic

services to delver to ABMC and Critical Access Hospital

markets

• Coordinate system based consumer e Health strategy to

implement in central Illinois

Advance ABMC as a safe, Highly

Reliable Organization

• Full engagement with Medical Staff

in leadership of HRO journey

• Increase safety event reporting and

eliminate serious safety events

• Sustain DNV/ISO 9001 full

accreditation

Consistently provide superior

quality outcomes

• Achieve Magnet designation

• Meet or exceed targets for all

Advocate health outcome

measures

• Sustain MIR accreditation

Deliver an extraordinary experience

for patients, physicians and

associates

• Achieve 75th percentile/Meet or

exceed targets for patient and

physician engagement

• Achieve top decile performance in

Associate engagement

Continue to strengthen physician partnerships – primary, specialist and sub-specialist

• Implement strategies to enhance the relationship with aligned, employed and independent physicians

• Increase the base of aligned primary care physicians

Core ABMC Strategies

Nursing Strategic Map: 2013-2016

Clearly Define

Roles/Responsibilities

Across all

Related Disciplines

Provide consistent

evidence-based practice

based on the

nursing process

Increase Percentage

of Certifications

and Higher Degrees

Efficiently Manage

Resources

Free Nurses from

non-nursing tasks to

increase time

with patients

Foster a

Commitment to

Lifelong Learning,

Mentoring and

Clinical expertise

Professional

Responsibility for

Communication and a

healthy work environment

Identify Target

Populations and

Multi-Disciplinary

Strategies by Population

Identify Strategic

Non-Traditional

Partnerships

Improve Access to

and Communication

of Patient

Health Information

Implement Tools

and Support

for Professional

Development, Define

Professional Image

Add the Voice of

the Patient to

Conversations and

Decision-Making

Identify Interventions

that Promote

Coordinated Care

Across the Continuum

Clearly Define

Care Delivery

Model

Leverage technology

to support

nursing practice

Utilize FTEs

Effectively Within

and Across

Departments

Standardize

Supplies/Storage

Expect professionals

to be competent,

accountable

1

2

3

4

5

Interdisciplinary

Collaboration and

role optimization

through Clinical

Growth and Expertise.

Implement the

Nursing Professional

Practice Model

Develop Nurses as Leaders

Who Practice at the Top of Their

Licenses


Build an Accountable, Empowered

Nursing Culture

Partner with Patients and

Coordinate Care Across the Continuum

A B D C

Fostering a healing environment

that is patient and family centered,

ensuring patient safety and quality

through the elevation of

professional nursing practice.

Achieve Magnet Designation – ABMC Achieve Pathways to Excellence Designation – AEH

Culture of Shared Governance that empowers RNs to use their clinical knowledge and expertise to impact decisions regarding their professional practice in the delivery of nursing care guided by compassion and patient centeredness.


Advocate BroMenn Nursing Strategic Plan June 2015 – December 2016

1 Updated 6.5.15, 2.4.16, 7.2016

System/ABMC Strategy

System Nursing Strategy/ Goal

ABMC Nursing Strategic Priority

Objectives Tactics Accomplished 2015

2016 Plan due date

Leader(s) Notes


Develop effective and efficient care delivery model.

Develop nurses as leaders who practice at the top of their licenses

Clearly define Care Delivery Model

1) Nursing leaders & associatesattended the AdvocateNursing Summit to discusskey elements of theAdvocate Care DeliveryModel.

2) Clearly define our caredelivery model.

3) Focus on delegated role &delegating with respect.

4) Explore utilizing CrucialConversations as a part ofthe education

5) Increase consistencybetween units for start times & care delivery expectations

1) Completed4/23/15

2)

3)

4)

5) Done withworkforceoptimization

2) Dec2016

3) Dec2016

4) Dec2016

2) Lori Harper

3) TheresaBailey, managers

4) LoriHarper/ Deb Block

2) continue to work on

3) continue to work onacross all areas. Recommend working on with onboarding. Develop nurse to tech hand-off for consistency with people who float. Tech training. Techs to coach training for half day. Coach training quarterly. Educate on RN consistency of follow-up on incomplete delegation tasks.

4) OR has sent frontlineleaders. IONL fellowship had some training. IONL charge nurse education (4 webinars & one in person day). Deb Block could integrate CC skills into other training prn. Going to have some online options in the future (late spring). Charge nurse & clinical coordinator meetings.

Exhibit OO3.6 ABMC


2 Updated 6.5.15, 2.4.16, 7.2016

Operational Excellence

Create an empowered workforce to lead in designing & providing the highest quality & most efficient care to patients/clients across the continuum.


Clearly define roles/responsibilities across all related disciplines

1) Clearly define the role ofnursing & the RN.

2) Establish an expectation ofacceptance of delegation fortechs

3) Focus on support services

1) Completedwith PPM,theAdvocatenurse. Sept2015.

2) Above

3) Dec2016

3) ReneeDonaldson

3) MDT AE team



Increase percentage of certifications & higher degrees

1) 2015 Manager AMS goals toincrease the number of newnurses with certificationestablished.

2) 80% BSN Action Planestablished. Ongoingmonitoring of progression.

3) ISU Event for NursingSystems Masters’ Program

4) New certification flash mobcelebration implementation

5) Develop annual recognitionprocess for attaining higherdegrees (BSN or higher)

6) Re-evaluate use of APRNswithin the hospital. Look attuition support.

1) Initiated1/1/15

2)

3) Completed6/26/15

4) Started4/30/15

5)

6)

1) ongoing

2) ongoing

4) ongoing

5) Nursesweek

6) continue

1) LaurieRound

2) LoriHarper

4) LoriHarper

5) KristinPeterson

6) AaronBarclay

5) Kristin P has the namesof those who completed before.

6) Discussion in CNEcounsel & within HR. Considering sending to APN school only if need within Advocate. Explore clinical options for APN students to reduce amount of time needed away from work. Expand options for APN practice (Med-Surg?). ED implemented the use of APNs.


3 Updated 6.5.15, 2.4.16, 7.2016



Provide consistent evidence-based practice based on the nursing process

1) Establish the Nursing EBP/Research Council.

2) Continue to build the EBP foundation at NPC

3) Utilize EBP with role development process

4) Establish expectations of EBP Projects for Shared Governance

5) Establish partnership process with Quality for EBP Projects.

6) Develop a documentation tool for EBP projects – simple & complex

7) New 2016 - Enhance communication of Research & EBP within Sharepoint

8) New 2016-Provide additional population based education (Bridges out of Poverty Feb)

1) Feb 2015. 2) 3) SG

workshop 2015

4) complete

1) Completed May 2016 2) Continue 3) Complete 5) Completed with Research Council 6) Research Council completed 7)Rolled out May 2016 8) Completed Spring 2016

1)Trayce Bartley 2) Lori Harper 3)Lori Harper 4)Lori Harper 5) Ann Frederick 6) Trayce Bartley 7)Laurie Round 8)Director; Bridges -Renee

3) doing in ED with techs watching psych patients. 2017 SG workshop 4) 2015 SG annual reports

Population Health

Standardize nursing practice around interdisciplinary plans of care.


Interdisciplinary collaboration and role optimization through clinical growth and expertise

1) Develop handoff process between disciplines.

2) Develop a patient-centered mindset for all

1) 2) 3)

1) Completed July 2016 2)continue 3)ongoing

1)Aaron Barclay 2)Renee Donaldson

2) weave into MDT AE; Assuring hours match patient needs


4 Updated 6.5.15, 2.4.16, 7.2016

3) Consider ways to includesupport departments withPPM education

4) Leverage system work todevelop collaboration i.e.,Diabetes Management &Dysphagia Care

5) Rehab Stroke Lab Simulation6) Neuro Intervention

Taskforce/ Neuro Sciences7) Multidisciplinary report on

MOSU8) Nurse physician Rounding9) Supportive Care

Collaboration10) Collaboratives

4)done

5) continue.Dec 2016

6)Dec 20167) Dec 2016

8) Dec 20169)Implemented May 2016 10)ongoing

3)LoriHarper

5)Alicia Allen

6) StephanieMoore

7)Alicia Allen

8)Alicia Allen9) AliciaAllen 10) directors

10)bimonthly meetings


Partner with patients and coordinate care across the continuum

Improve access to the communication of patient health information

1) Implement the readmissionrisk tool & process

2) Medication Reconciliationprocess

3) Doctor First Implementation

1) 6/24/15done

2)EDPharmacist added Nov 2015

3)inprogress

2)StevePinneke 3)StevePinneke

2. Pharmacy in ED helpful.



Identify strategic non-traditional partnerships

1) Complex Care Program2) New- Managed Medicaid

patients

1)continue2) initiate

1)Alicia Allen2)LaurieRound/Stephanie Moore/ Aaron Barclay

2)Working on access tocare.


5 Updated 6.5.15, 2.4.16, 7.2016

Operational Excellence Create & sustain

a culture of patient/client centered care system-wide

that results in best in class

service outcomes.


Add the voice of the patient to conversations and decision-making

1) Multi-disciplinary teamrounding to include patients& families

2) Implement a PatientAdvisory Council

1) Above

2)Dec 2016 2)Directors

2)Hospital EngagementNetwork initiatives– Pt Advocacy, Family members calling RRTs, …..; Alicia discussed reaching out to Palliative Care donors for patient advisory; Need a process for how to pull patients into focus groups; “Real time listening posts”, further develop leadership rounding; consider training some volunteers.

Population Health


Identify target populations and multi-disciplinary strategies by population

1) See above tactics2) Diabetes3) Dysphagia4) Tele-psych5) Behavioral Health patient

standard of care6) Spine Class7) Neonatology

4) Implemented

6)completedSept 2015

2)completed Apr 2016 3)completeOct 2015

5)Dec 2016

7)Fall 2016

2) LoriHarper 3)LoriHarper 4) ReneeDonaldson 5)ReneeDonaldson 6)KristinPeterson 7) StephWollenberg

Population Health

Design & implement a system-wide standard approach to care coordination


Identify interventions that promote coordinated care across the continuum

1) Implement ED Social Work2) Expand the Post-Acute

Network3) Continue quarterly SNF

meetings.4) Complex Care Program

1) CM 2015 1)SW 2016-completed 2)ongoing3)Ongoing4)continue5) Dec 2016

1)SusanHenkel 2)AnnFrederick 3)BrandiAnderson 4)Alicia Allen


6 Updated 6.5.15, 2.4.16, 7.2016

that will provide for patient smooth transition across the continuum.

5) Chemotherapystandardization

5)TheresaBailey


Build & support efficient & effective patient-centered care sites. Curb nursing labor cost growth.


Efficiently manage resources

1) Implement FlexibleWorkforce Optimization

2) Transition to centralizedscheduling

3) Implement Nurse ResidencyProgram

4) Enhance bed meetingutilization

3) done Sept2015 4) done 2015

1)ongoing2) done May2016

1)StacyBarclay 2)StacyBarclay 3)LoriHarper 4)StacyBarclay


Utilize information technology as an enabler to achieve best in class patient/client quality & safety outcomes and to reduce operational costs.


Leverage technology to support nursing practice

1) Tele-psych implementation2) eICU implementation3) Doctor First implementation4) Readmission Risk Tool

implementation5) Sepsis Lighthouse Project6) New monitors on 5 & 67) Electronic tissue tracking8) New 2016 – ICU suicide

documentation accessible totechs

9) Vein Finders

1)done2)done3)done4)done

7)done

9)completedSept 2015

10)completed Oct 2015

5) in process7/2016 6) done

8) Dec 2016

3)StevePinneke

5)StephanieMoore

8)StephanieMoore


7 Updated 6.5.15, 2.4.16, 7.2016

10) Bladder scanners 11) CVCU beds

11)completed



Free nurses from non-nursing tasks to increase time with patients

1) LEAN/Time-in-motion studies/PI projects to evaluate opportunity

1)ongoing



Utilize FTEs effectively within and across departments

1) See above



Standardize supplies/storage

1) OR supplies 2) Cath lab supplies 3) SDS Room Redesign

3)done July 2015

1) 2 bin in 2016. Done. 2)Dec 2016

1)Trayce Bartley 2)Mike Mueller 3)Soni Vercler


Create the Advanced Practice Clinician Model that supports the Advocate Health Care business strategy. Clearly define the role, required competencies

Build an accountable, empowered nursing culture

Expect professionals to be competent, accountable

1) Maintain competency expectations.

2) Implement High-Solid-Low process

2)done

1)ongoing 1)Directors


8 Updated 6.5.15, 2.4.16, 7.2016

and experience to efficient & effective operations.


Create an innovative, evidence-based, centralized clinical education approach that fosters engagement in achievement of strategic outcomes across the continuum. Create a consistent evidence-based education and practice platform to provide the highest quality & safest care for our patients/clients across the continuum.


Foster a commitment to lifelong learning, mentoring and clinical expertise

1) Implement CoachingProgram – for 2016, makingexpectation to completewhen moving from NCI toNCII. Have all nurses attendover the course of 2 years.

2) 2015 Nursing ProfessionalDevelopment Plan

3) HRL Training for frontlinestaff

1)done

2)done

3)inprogress 7/2016

1)LoriHarper

3)KristieWolfe

1)all nurses to go throughcoaching program; have some nurses come through in 2016 even if not planning for them to be coaches. Have another 15% of nurses to go through the coach program.


9 Updated 6.5.15, 2.4.16, 7.2016



Professional responsibility for communication and a healthy work environment

1) Implement chain ofcommand policy.

2) AACN Healthy WorkEnvironment Survey

3) Improve RN AssociateSatisfaction/EngagementResults to outperformnational benchmarks

4) ENA workplace violencesurvey

1)done

2)done

3)done

4)doneOperational Excellence

Define the core competencies & professional development standards of the Advocate Nurse.


Implement tools and support for professional development; define professional image

1) Establish a professionaldress code

1) 1) Dec 2016 1)Laurie Round/ Stephanie Wollenberg


Create a professional practice environment across Advocate.


Implement the Nursing Professional Practice Model

1) Develop education & roll-outstrategy

1)started 1)ongoing 1)LoriHarper


Strengthen nursing leader succession, planning & leadership development across the system.

1) Utilize the calibrationprocess to identify potentialindividuals for advancement

2) Identify opportunities tomove people to frontlineleadership

3) Evaluate opportunities forcross-training.

1)ongoing

2)ongoing

3)ongoing

4) ongoing

1)Leaders

2)leaders

3)leaders

4)leaders

1)Moving people to chargenurse role; purposeful charge nurse orientation; GI specialty head SDS; Chrissy’s role based on associate satisfaction 3)Crosstrain to cath lab &xray


10 Updated 6.5.15, 2.4.16, 7.2016

4) Evaluate resource needs forsuccession planning

5) Provide individuals withopportunities to partner onprojects.

5)ongoing5)leaders 4)advocate talent

management 5)many opportunities given & available.


Achieve Magnet Designation

organizational overview transformational leadership · safety event rate continue to decline, with...

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