11 May 20193rd Quarter 2019

BY DEBORAH BURTON, SENIOR VICE PRESIDENT, CHIEF NURSING OFFICER

From the Desk of Deb BurtonThis issue of Best in the West highlights our extraordinary nursing clinical practice andquality. Once upon a time, being Best in the West for nursing care and practice was aninspiration and an aspiration. Now we have arrived, and our work has shifted towardcontinuous quality improvement. How do we know we’re the Best in the West? Consider justa few examples of breathtaking nursing clinical performance evidence:

Maternal Death Rates• Last year, despite over 71,000 deliveries across Providence St. Joseph Health, we had

only ONE maternal death. Absolutely amazing and wholly unprecedented.

Healthcare-Associated Infections and Serious Safety EventsAs a system, we achieved Outstanding-level performance in 2018 for reducing Healthcare-Associated Infections andSerious Safety Event rates. Nearly all the included metrics are “nurse sensitive”—that is, they directly reflect thequality of nursing care being provided. To illustrate:

• In 2012, our system-level inpatient Cather Associated Urinary Tract Infection (CAUTI) rate was 1.58 cases per1000 catheter days; our Central Line Associated Blood Stream Infection (CLABSI) rate was 1.39 cases per 1000central line days.

• As of June 2019: Our system level CAUTI rate dropped to 0.93 cases per 1000 catheter days; our CLABSI ratedecreased to 0.51 cases per 1000 central line days. Both achievements far surpass what is statistically predictedfor the volume and acuity of our hospitalized patient population.

Sepsis• In 2018, PSJH had over 770 fewer deaths from sepsis than would be statistically expected for our size, acuity

and patient population.

Malnutrition• Also in 2018, we detected and treated over 40,000 hospitalized patients for malnutrition.

Magnet & Pathway to Excellence• Ten years ago, PSJH had four Magnet facilities and none with Pathway to Excellence designation (**the program

didn’t exist yet). By the end of 2019, PSJH expects to have 15 Magnet designated facilities, and six with Pathwayto Excellence designation. And we have many more in the cue—2020 will be a banner nursing excellence year!

So how is this all possible? Largely it is because we are engaged, compassionate, competent, vigilant, well-educated,accountable and passionate about delivering the best care possible. And we do all of this as a very, very large nursingcommunity. About 40,000 of us to be exact! We are spread across seven states, four time zones, and over a third ofthe geography of the entire United States. We are in remote critical access hospitals; large, urban quaternaryhospitals; vast networks of community-based and home health agencies; over 900 ambulatory settings; and muchmore. We are deeply blessed with extraordinary teams of care coordinators, expert consultants, nurse scientists,nurse educators, mentors, advanced practice nurses of every kind, and nurse leaders and executives who drive andlead us forward---all in the name of the best care possible for our patients. And the secret sauce? We learn from eachother and we all improve together because what is best for our patients doesn’t vary.

Thank you for staying on this improvement journey together. We just keep getting better!

22 3rd Quarter 2019

In October 2019, the annual ANCC Magnet Conference will be held in Orlando, Florida. More than 10,000 nursesare expected to attend this year’s conference. Below are a few photos of PSJH nurses at previous conferences.

ANCC Magnet designation "is the highest and most prestigious credential a healthcare organization can achievefor nursing excellence and quality patient care" (2019 Magnet Application Manual). The Magnet and associatedPathways to Excellence designation processes are valuable to help healthcare organizations identify and improvenursing structures and processes. This can lead to enhanced patient care outcomes, improved nursingsatisfaction, and increased nurse retention.

Magnet re-designation occurs every four years and requires stories and outcomes about transformationalleadership, structural empowerment, exemplary professional practice and new knowledge and innovationinvolving nurses within the ministry. With each re-designation the bar is raised to achieve higher standards ofpatient care with excellent outcomes. This is in line with our Providence St. Joseph Health mission and values.One PSJH ministry, Providence St. Patrick Hospital (Missoula, MT), will be recognized for a re-designation duringthis year’s Magnet conference.

Fun Fact: PSJH has 11 Magnet designated ministries and 4 Pathways designated ministries!

PSJH Ministries with Magnet Designation: Providence Alaska Medical Center (Alaska) Providence Holy Cross Medical Center (California) Providence Little Company of Mary Medical Center - Torrance (California) PSJH Mission Hospital (California) St. Joseph Hospital - Orange (California) Hoag Memorial Hospital Presbyterian (California) St. Jude Medical Center (California) St. Patrick Hospital (Montana) Providence Portland Medical Center (Oregon) Providence St. Vincent Medical Center (Oregon) Providence St. Peter Hospital (Washington)

ANCC CORNER

PSJH Ministries with Pathways to Excellence Designation: Covenant Health Medical Center & Children's Hospital (Texas) Providence Center for Medically-Fragile Children (Oregon) Providence Centralia Hospital (Washington) Swedish Ballard (Washington)

Coming Soon! ANCC National Magnet Conference (October 10-12, 2019)

33 3rd Quarter 2019

The Role of Nurse Quality Specialist at the Swedish Neuroscience InstituteQuality is an emerging area of professional nursing practice. In line with the national call for health systems toconsistently deliver reliable and safe care, many schools of nursing are beginning to offer master of nursingprograms in quality and patient safety.

BEYOND THE BEDSIDE

At Swedish Neuroscience Institute, we are fortunate to have Nurse QualitySpecialist Sarah Hopkins, MN, RN, CNOR, CPHQ, CPHRM, NE-BC. The qualitynurse role has been a key figure in transitioning from tracking pureoutcome data to implementing new processes to elevate the quality of careprovided to every neuroscience patient in both outpatient and inpatientsettings. Ms. Hopkins manages teams to bring the science of clinicalpractice to an industry-leading standard. She is a quarterback and designsstrategies to enhance collaboration across a highly-matrixed organization.

Nurse quality specialists often collaborate with executive operational and medical leadership when designingprograms to optimize patient-centered care and the patient experience. These individuals stay current withnational standards of best practice clinical care, regulatory and accreditation standards, as well as innovativereimbursement models associated with high performance. Nurses who are passionate about improving clinicalcare and transforming healthcare would find this specialty fascinating and highly-rewarding.-------------This article was co-authored by Sarah Hopkins, RN, and Akshal Patel, MD, at the Swedish Neuroscience Institute.Sarah is a University of Providence RN-to-BSN alumni and recent University of Washington-Bothell graduate witha Master of Nursing in administrative leadership.

The nurse quality specialist supports the understanding, integration andapplication of quality programing in healthcare settings. Nurse qualityspecialists promote the highest-attainable quality through assessment ofpatient outcomes, identification of opportunities for improvement, anddevelopment of recommendations aimed to increase the likelihood ofdesired health outcomes. They often lead the development andimplementation of initiatives by collaborating with interdisciplinary teams.

UPDATES FROM THE UNIVERSITY OF PROVIDENCE

University of Providence RN to BSN Completion ProgramThe University of Providence RN to BSN program celebrated 10 years of over 900 graduates in May 2019! Thisprogram continues to offer PSJH caregivers a direct link to a values-based nursing program that provides high-quality, individualized instruction. With the unique model of synchronous class time and a required, one-dayImmersion Program, students are connected to faculty and fellow students in a positive environment to enhancetheir learning experience.

For more information about the RN to BSN program, please visit the website.You can also contact nursing@uprovidence.edu or call 406-791-5258 to speak to a program counselor.

Photo: Sarah Hopkins, RN

44 3rd Quarter 2019

Certified Nurse Midwives (CNMs)Excerpts from an Interview with Kelly McKittrick, MSN, CNM, ARNP from Swedish Issaquah

ADVANCED PRACTICE CORNER

Q: What makes CNMs unique from other advancedpractice nurses?A: Only CNM/advance practice nurses provide 24hour, 7 days a week, 365 days a year care. This makesmidwifery a very intense and sometimes exhaustingjob. But caring for families throughout this importanttime of life is very rewarding. We see our patients 7to 12 times during the 30 weeks they receive prenatalcare, and at least twice more in the following 8weeks. This allows for very special, and sometimesintense, relationships with our patients. Wefrequently see repeat clients, either for pregnancycare or for gynecology care in the years that follow.

Another unique aspect of midwifery is that we offercare in a group setting. CenteringPregnancy is anevidence-based model of care that many midwives,including the Swedish Issaquah midwifery group,offer as an option for prenatal care. Centering atIssaquah includes 9 prenatal group sessions wherewe sit together for 2 hours with a group of soon-to-be mothers and partners. During this time, momshave a quick, 5-minute “belly check” and then thegroup has 1.5 hours to ask questions and discuss anyconcerns related to their pregnancies and birth. Thisformat allows me, as the care provider, to answerquestions once (rather than during each individualappointment) and allows patients to learn from otherpatients. Centering is an evidence-based practice thatnot only creates life-long friendships for new parents,but it better prepares them for what to expect duringtheir birth. It’s also a lot more fun!

Q: Tell us about yourself.A: I have been a midwife for about 8 years. In 2014, I washired by Swedish Issaquah to start their midwifery programalongside a small group of peers. Our clinic opened with 2midwives and, today, we have grown to 6 FTE midwives plusseveral per-diem midwives. As a team, we manageapproximately 35-45 births per month including all prenatal,delivery, and postpartum care.

Q: Why did you choose to become a CNM?A: Unlike many CNMs, I did not previously work as a nurse.In fact, I spent 14 years teaching science and health tomiddle- and high-school students prior to nursing school. Ialways felt it was my calling to be a nurse midwife so I wentback to nursing school at the University of Washington andgraduated with my master’s degree at the age of 40.

Q: What is the process and training required for CNMs?A: All CNMs are nurses first. After completing a Bachelor ofScience degree in Nursing (BSN), CNMs complete anadvanced degree in nursing practice. This additionaleducation can be either a master’s degree or a Doctorate inNursing Practice (DNP) and the programs provide a mix ofclassroom education and hands-on experience. Followinggraduation, CNMs take a board certification exam andcomplete any additional requirements to become a licensedCNM in their state of practice.

Q: Tell us a little more about what it’s like to be a CNM.A: It’s interesting because midwifery is the one of the oldestprofessions. However, it’s often still considered weird, odd,or “hippie” by many patients. In reality, our care is equally assafe for low-risk patients and can sometimes be moreeffective because we create strong relationships with ourpatients. Overall, midwives have lower cesarean sectionrates than obstetricians.

Midwives meet women where they are. Our philosophy is tobe women-centered and we spend a lot of time getting toknow each patient so they can be in charge of their owncare. We have 30 minute appointments (new appointmentsare longer) so we can spend more time with our patientsproviding education and ensuring we can answer theirquestions. The midwifery philosophy of pregnancy and birthis that this is a normal, healthy part of life and our teamworks with each mom to meet their individual goals.

Article continued on next page…

55 3rd Quarter 2019

CMC is now using the lessons learned and best practices gleaned from PLCM and PSJMC to reduce Foleyinsertions in the ED with the aim of reducing the overall CAUTI infections at CMC. The cross-regioncollaboration facilitated by the CAUTI CLIC has kept our patients safer and helped reduce our system wide ratesof preventable harm.

If you are interested in joining a clinical collaborative focused on CAUTI, CLABSI, or C.diff, please reach out to Sara Morris.

Reducing CAUTIs through System-wide CollaborationCONTINUOUS QUALITY IMPROVEMENT

Q: What do you enjoy most about being a CNM?A: Centering is one of my favorite parts of my job because it benefits everyone. Hospital nurses love centeringbecause the patients are so well-prepared for their births. Patients love it because they build relationships withpeers and feel more educated which makes them better-equipped to handle any situation that may arise at thehospital. I love it because it's so fulfilling to watch each group grow from strangers to friends while sharingtheir prenatal care. It's almost a rite of passage in a way that families need as they grow.

Q: What advice would you give to someone interested in becoming a CNM?A: If you have an interest in caring for women, go for it! Midwifery is an incredible, intense, and highly-rewarding job. Just don’t do it for the hours because babies like to come at night

Q: Is there anything else you would like to share?A: A common misconception is that midwives are just for pregnant women. However, we are trained asprimary care providers (PCP) so we take care of all women, including teens and women nearing menopause. Infact, I recently saw an 85-year old patient because her PCP wasn’t available that day. Even people who aren’tpregnant need a little extra TLC and patients often appreciate our longer visits and individualized approach totheir care.

The CAUTI Collaborative Learning and Improvement Community(CLIC) is a system-wide group of infection prevention caregiversand nurses focused on reducing CAUTI events across ourorganization. The CAUTI CLIC is a forum to share challenges, bestpractices, and drive change in our health system on everythingfrom updates in our electronic health record, changes toprotocol, to the types of products we purchase. At a recentCAUTI CLIC meeting Lynette Kingsberry from Covenant MedicalCenter (CMC) shared a number of interventions her facility hasimplemented to reduce CAUTI infections, including a three day

Product Training Assessment involving observations on Foley Maintenance and Insertion Practices, with one ofour vendor partners, BARD. BARD clinical representatives shared their observation findings with the team atCMC and suggestions for improvement. One of the findings of note was that 37% of Foleys at CMC are insertedin the ED, and the BARD clinical educator recommended reaching out to Providence Little Company of Mary(PLCM), who had recently implemented a “Foley Free ED” program to reduce CAUTI infections. Fellow CAUTICLIC member Rebecca Clarkson at PLCM was eager to share the Foley Free ED strategies implemented in herfacility and connected Lynette to another CAUTI CLIC member at Providence St. Joseph Medical Center (PSJMC)in Burbank, Silva Ohanian, who had also recently implemented the same program in her facility with greatsuccess.

Article continued from previous page…

66 3rd Quarter 2019

PSJH NURSING HIGHLIGHTS

Regional Spotlight on Nursing: Texas & New MexicoEach issue of Best in the West highlights the accomplishments of PSJH nurses in one region or service area within ourorganization. Continue reading to learn more about recent nursing achievements in the Texas / New Mexico region.

The Texas/New Mexico region serves a 62 county area with approximately 1.1 million people. This population is

supported by Covenant’s tertiary care facility, a separately-licensed children’s hospital, 3 smaller community

hospitals, a long-term care facility, the community’s only behavioral health unit, a cancer center, hospice, 2 busy

medical groups, and clinics throughout the region. Covenant School of Nursing and Covenant School of

Radiography graduate more than 140 new healthcare workers each year.

Excellence in Caregiver Engagement:

Nursing response rate was 92% with the majority (67%) of health, safety, and environment scores above the

90th percentile

RN vacancy rate decreased from 7.5% to a low of 3.7%

12 of the “Great 25 Nurses” on the South Plains were Covenant nurses

Strong participation in the Clinical Academy with recent development of a regional steering council

Implementation of Covenant Culture 99, a program for nurses to recognize those non-nursing caregivers who

support and enhance nursing care

Implementation of extensive caregiver safety programs and training to improve security in the ED

Excellence in Nursing:

Covenant Medical Center (CMC) submitted its Magnet document in June 2019

Beacon Award designation achieved by MICU and Oncology/Stem Cell units in 2019

The Palliative Care Unit, the Bariatric Unit, and Stem Cell Unit recently received re-accreditation as a Center

of Excellence by The Joint Commission.

Re-designation as a Primary Stoke Center occurred in February of this year

Grace Medical Center was recognized with an Outstanding Patient Experience Award

17 Covenant nurses were invited to present their research and evidence-based practice initiatives at the

Sigma Theta Tau International Research Congress in Canada this August

Covenant School of Nursing was ranked #17 of the 200 programs in Texas, achieving a 99% NCLEX pass rate

Excellence in Patient Care Delivery:

Commitment to the Fall Bundle has resulted in a 50% decrease in fall rates for 2019

The Walking Warrior program supporting early ambulation has been implemented regionally

Clinical nurses have endorsed our Commit to Sit initiative to enhance patient experience

S7 Bariatric Unit and S8 Urology Unit were recognized as Zero Harm Heroes for CAUTI/CLABSI

Care Management provided leadership for our Med-to-Bed program implementation

Regional Telesitter program implemented this year with CMC as the Hub site

Covenant Plainview was the first to launch the Telestroke program

Two APRNs were added to compliment the Trauma team’s delivery of care

Web Cam system for virtual visitation in the NICU was implemented in April

As the Chief Nurse Executive for the Texas/New Mexico region, I’m beyond honored to work alongside some of the

most compassionate and dedicated nursing professionals who are truly committed to our healing Mission.

Karen Baggerly, RN, CNE

77 3rd Quarter 2019

Simplified Nursing Documentation in EpicRecent Care Plan Updates

The Care Plan tells the patient’s unique story, reflects their progress, and serves to coordinate care. The most recent 2019 Epic updates brought new features that streamline nursing documentation, including:

1. Care Plans now include universal goals that applyto all patients!

2. Caregivers only add the relevant goals that apply to the specific patient. Each goal includes its own easily-adjusted expected end date.

3. New goals for comorbidities are available. This is best used for those problems being actively managed, but that are not the primary reason for admission.

“NEED TO KNOW” NURSING INFORMATION

The above enhancements help to reduce the care planning documentation burden for staff whiletelling the patient’s interdisciplinary story and meeting regulatory requirements.

For full “Tips and Tricks” related to Care Planning, please refer to the Epic Learning Resources.

88 3rd Quarter 2019

Recap: 10th Annual Distinguished Nursing Lectureship On May 9, Amy Berman, RN, FAAN, LHD, presented theannual Providence St. Joseph Health Nursing Lectureship.

RECAP OF RECENT EVENTS

Ms. Berman, a national advocate for improving care ofolder adults, spoke with Debbie Burton, SVP / ChiefNursing Officer, about the Hartford Foundation’scollaboration with the Institute for HealthcareImprovement to create a national network of Age-Friendly Health Systems.

Watch the 2019 Nurse Lectureship...

New Fellowships Available from the PSJH Clinical AcademyHome Health/Hospice Residency Program

The Clinical Academy launched the Home Health/Hospice nursing residency and fellowship in June 2019. Thisprogram assists new nurses and experienced nurses who are new to specialty to work in Home Health or Hospiceor a combination of both. Lessons cover topics such as an introduction to home care, unique regulatoryrequirements for both Home Health and Hospice, palliative care, end-of-life, medication management, casemanagement, and pediatric/geriatric considerations.

If you would like more information, please contact: Melani.Mangum-Williams@providence.org orShay.Bradshaw-Scharbach@providence.org

PACU Residency Program

The Clinical Academy launched the Post-Anesthesia Care Unit (PACU) nursing residency and fellowship inJune. Similar to our other residencies, this program assists new and experienced nurses who are entering thePACU specialty. The program is based on the American Society of PeriAnesthesia Nurses (ASPAN) Standards andGuidelines and focuses on training nurses who are responsible for patient care during the Phase I and Phase IIrecovery time frame. In recognition of the hiring patterns for this specialty area, this curriculum is designed foruse with 1-2 learners but can be adapted and used for larger cohorts as well.

For more information, please contact: Julia.Parazin@providence.org

Local and Regional Nursing NewslettersWe would like to feature your local and regional nursing newsletters in future editions of the Best in the WestNewsletter. Please send copies of nursing-related newsletters to Nursingnewsletter@providence.org

COMING SOON! A SNEAK PEEK OF SEVERAL TOPICS FEATURED IN OUR NEXT EDITION

PSJH Nursing Presentations at National Clinical ConferencesWe have recently changed our process for collecting PSJH nursing research achievements. The Nursing ResearchProgram is now gathering data on scholarly publications, poster presentations, and clinical studies using theRedcap database. Please use this link to submit nursing research highlights from your region!

CLINICAL ACADEMY UPDATES

99 3rd Quarter 2019

False. Based on current literature and best practice, NSAID (including Toradol during Cesarean delivery) should not be used for intrapartum or postpartum pain in patients with elevated blood pressure.Evidence: Recent research demonstrates that NSAIDs can cause an increase in blood pressure. This can exacerbate gestational hypertension leading to extended length of hospital stay and increased interventions. There is evidence that in patients with gestational hypertension or preeclampsia (as well as other circumstances), use of NSAIDs can further increase hypertension. This may be associated with volume expansion and fluid mobilization that are common during the postpartum period. New guidelines from the California Maternal Quality Care Collaborative, ACOG, and others recommend caution when using NSAIDs in this patient population.

ReferencesGhuman, N., Rheiner, J., Tendler, B. E. & White, W. B. (2009). Hypertension in the Postpartum Woman: Clinical Update for the Hypertension Specialist. The Journal of Clinical Hypertension, 11, 726–733.Mustafa, R., Ahmed, S., Gupta, A., & Venuto, R. C. (2012). A Comprehensive Review of Hypertension in Pregnancy. Journal of Pregnancy, 2012, Article ID 105918. doi:10.1155/2012/105918Wasden, S. W., Ragsdale, E. S., Chasen, S. T., & Skupski, D.W. (2014). Impact of non-steroidal anti-inflammatory drugs on hypertensive disorders of pregnancy. Pregnancy Hypertens. 4(4):259-63. doi: 10.1016/j.preghy.2014.06.001. Epub 2014 Jul 11.ACOG Committee Opinion No. 623. (2015). Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. ACOG, Task Force on Hypertension in Pregnancy. (2013). Hypertension in pregnancy- Practice guide. Washington DC: ACOG. California Maternal Quality Care Collaborative (CMQCC) Preeclampsia Toolkit. Retrieved from: https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit

True or False?

Use of NSAIDs for pain is safe for intrapartum and

postpartum patients.

Nursing MythbustersChallenging Traditional Practices not Supported by Evidence

Nursing Research and Clinical Scholarship News

HIGHLIGHTS FROM THE Q3 NURSING RESEARCH NEWSLETTER

In spring 2019, the University of Providence added aSenior Seminar class to its RN-BSN curriculum. Theclass incorporates competencies from previoussemesters including evidence-based practice, quality,safety, and leadership.

The class allows student groups to complete a smallchange project on one of their units. The studentgroups formulate a PICOT question and conduct aliterature search and synthesis before deciding on asmall test of change. The change is implemented onone unit and tested using the PDSA methodology.Data from the change is collected and analyzed.Students perform a gap analysis and providerecommendations for future PDSA cycles. Theproject is then summarized in a poster format andpresented to their peers.

Small test of change projects for Spring Semester2019 included:• Teaching nurses about music listening

interventions• Reducing distractions and interruptions during

medication administration• Aseptic vs sterile technique in wound care• Reducing blood draw labeling errors• Identifying Knowledge Gaps in CHG bathing• The effect of education on nurses’ knowledge of

ICough• Standardized reporting from hospital to home

health

The University of Providence hopes to share theamazing work of the students in future editions ofthis newsletter.

Interested in reading more articles about Nursing Research and Clinical Scholarship?Check out the complete Q3 Newsletter here.

RN-to-BSN Senior Seminar Projects

Nursing Best in the West is a quarterly email newsletter for nurses in all regions across the PSJH organization. To submit an announcement or news item, or be added to the distribution list, please email

Nursingnewsletter@providence.org.