Exemplary Professional Practice

Patient Experience...the Journey Continues!

2021 continued to be a challenge for our entire team as COVID continued to rage throughout our community, however, we were able to maintain our patient satisfaction scores at a consistent level. Our “Overall Rate Hospital” category for 2021 was 62.4%.

Although our score decreased by 4.1 percentage points from the previous year, the 62.4% score for Mercy was a positive accomplishment. We were able to achieve this by working together as an entire team and working diligently to ensure that we were communicating with our patients during their admission and their families via telephone or Ipad. Through our continued discharge phone call process this year, 6,067 patients were reached. During most of the year, although challenged with constraints on visitation, we were still able to work together to find ways to communicate. Purposeful patient rounding efforts still occurred with 2,983 being completed. In 2022, we look forward to to renewing and re-igniting our passion to deliver excellent care to our patients! 6 West Unit receives Most Improved in Patient Satisfaction Award

The Wound and Ostomy Nurses

The Wound and Ostomy Advisors focused on pressure injury prevention education through empowerment of the bedside RN and nurse’s aide by actively participating in the following activities: • Wound care education classes were redesigned to give system-wide education, develop competencies and empowerment regarding staff RNs’ ability to identify and treat pressure injuries, more importantly, prevent them from occurring. • A system-wide assessment of patients’ risk factors were completed with an outcome of identifying equipment and surfaces that are required and purchased. This aids CH nurses and helps in the battle against pressure injuries. • System-wide education and roll out of a simplified incontinence associated dermatitis and skin tear protocol to not only empower nurses but provide state-of-the-art care for their patients. • Real-time staff education at the bedside utilizing innovative and state-of-the-art equipment to assist in pressure injury reduction and patient comfort such as; seated positioners, heel offloading boots and surfaces. • Re-design the methodology of prevalence and incidence of pressure injuries ensuring data collection and benchmarking against national and international standards as well as reducing unnecessary nurse labor. • Plan, support and continue the journey to becoming recognized as a system in excellence in both wound and skin prevention and care.

Mercy Hospital Clinical Education

The Clinical Education team at MHB had a very busy year and underwent a complete change of staff. Education/Rounding topics that were provided in 2021 for the RN’s/ NA’s/ITA’s included: • TPA rounding points • Carpuject education • TPN-Lipid filter updates and rounding • Stroke case scenario education at huddles • Commonly misused abbreviations in documentation- rounding topic • Secondary IV tubing education • Heparin aPTT protocol changes and complete Heparin Education • Telemetry lead placement and tips- rounding topic • Charge nurse education on Epic Dashboards • Charge nurse education on code cart checks • Curos Cap rounding topic • Massimo education • Cleaning of glucometers • Covid equipment cleaning protocol education • Restraints

Exemplary Professional Practice

Quality and Patient Safety

Efforts in place to improve Patient Safety by continuously educating our staff about safe care practices, encouraging staff to have a questioning attitude, use of “Safety Alerts”, and recognizing and learning from our staff when they prevent a harm event. Each month we recognize any associate or clinician at Mercy Hospital who have “spoken up” through our “Great Catch Program”. Below are the Mercy Hospital winners of a “Great Catch” for 2021. Each winner receives a “Great Catch” certificate and pin. The Midas Occurrence Reporting system is used to identify a “Great Catch”.

Shannon Balus (6E), Erica Chevalier-Slisz (ITA), Alicia Courtney (Pharmacy), Tina Swan (ED), Laurie Belge (GI/MAPU), Jerome Tallington (NA), Rachel Weber (Pharmacy), Tammy Smith (Environmental Services), Jillian Owens (Pharmacy), Tara Graham (Infection Control) and Renee Puleo (Pharmacy)

Joint Commission Hospital Accreditation- A very successful Joint Commission hospital survey was completed 9/21- 9/24/2021. At the end of the survey, there were 26 citations received, all standard level citations with no condition level citations. Joint Commission accreditation provides valuable reassurance that we are providing safe, high quality care to our patients. This was a Mercy Hospital (including all off sites) team accomplishment that everyone was well prepared for! It was recognized that all of our nurses, staff and physicians demonstrate their commitment every day to medical excellence and patient-centered care. The Joint Commission’s team of surveyors recognized and praised everyone with words like, “engaged”, “knowledgeable”, “professional” and “dedicated”.

Falls Data: MHB improved fall rate 2021 (2.03) compared to 2020 (2.25) and target met for 2021 (2.28). MHB was the only Catholic Health site to meet their 2021 target. Many initiatives are in place to prevent and reduce patient falls, including: chair and bed alarms; AVA sitter; purposeful rounding; chairs in patient rooms mounted to wall to prevent clutter and tripping hazard; “Stop Signs” in ceiling tiles on several units to create a visual reminder to call for help; 3-Zone bed project on 6E; and weekly “Wipe-Out Wednesday” huddle for managers to review all falls from the week and opportunities for improvement/lessons learned to prevent falls across the units.

Infection Prevention & Control Team

In 2021, Infection Prevention & Control focused on “getting back to basics”. The Covid pandemic flipped all of our worlds upside down and we realized that many of our basic infection control practices were forgotten or had changed since early 2020. The IC Team started concentrating on education with all staff; nurses, nurses’ aides, providers and ancillary staff all needed to be brought up-to-date on what our practices should be in the hospital (all while learning to live in a world with Covid-19). Our main focuses were isolation precautions, cleaning reusable equipment, CLABSI and C diff prevention. Epic allowed us to communicate with the care team directly so we were able to educate on the spot which was different than how we used to practice; it was a great change. The staff seems very engaged and work with us so well to address everyday Infection Prevention & Control issues.

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Tara Graham, IC Coordinator “Great Catch Winner”

Highlights from 2021 include: • 3-star top rating with Society of Thoracic Surgeons (STS) for CABG only from July 2018 through June 2021 • Mission Lifeline Get With The Guidelines (GWTG) – (Coronary Artery Disease) 2021 Gold

Award for NSTEMI (Heart Attack Care) • Application in process to reapply for Blue Center of Distinction 2022 • Secured RFP for Cardiac Cath Lab upgrade with Phillips equipment • Syngo upgrade was completed with enhanced remote reading capability for physicians • Epiphany upgrade completed. (Physicians can now view ECG wave forms in Epic and ECG’s are available in HEALTHeLINK and Epic Care Link.

Neuroscience/ Stroke Services

Mercy Hospital is a Joint Commission accredited Comprehensive Stroke Center (CSC)—this is the highest level of stroke care that can be provided to patients and their community. We will be having our recertification survey this year. In the two years since our last survey, we have implemented stroke neurology and neurocritical care telemedicine consults to our system of care. Our neurologists and neurocritical care intensivists can now assist in consults, assessments and treatment recommendations to manage care for patients at all acute Catholic Health sites throughout the system. Our Viz AI app, which processes all the stroke imaging for our stroke patients and sends immediate imaging results directly to the providers’ phones, partnered with our telemedicine access, further enhances quality care. This technology allows for increased communication for our teams, immediate access to imaging, earlier discussions between team members as well as earlier interventions, transfers and overall improved outcomes for our patients. For the ninth consecutive year, our CSC has achieved the American Heart, American Stroke Association Get With the Guidelines Stroke Gold Plus with Honor Roll Elite and Target: Type 2 Diabetes Honor Roll award. This is the highest achievement level in quality awards in this category. This a testament to the quality care our nurses, providers and healthcare teams provide to our stroke patients every day. This is a tremendous achievement and it should be noted that this award has been achieved by our nurses, providers, imagining team, and direct care staff throughout the pandemic.

PNA Research Summary

Since our last annual review, our stroke department had submitted several nursing led research abstracts to the International Stroke Conference as well as the Western New York chapter of the Professional Nurses Association. With our transition to Epic as our electronic medical record, there were areas of opportunity identified for nursing documentation of posterior stroke symptoms. Our stroke coordinator and neuroscience nurse care coordinator worked with the Epic team to build and educate nurses on this specific neuro check flow sheet in order for the nurses to document and take credit for their neuro assessments in their entirety. This allowed the providers and nurses caring for the patient to identify changes in posterior stroke symptoms and follow the patients’ progress more closely. There was also a submission by the neuroscience research coordinator and a neurology Nurse Practitioner that was focused on a barber shop project that provided blood pressure checks in underserved areas to assist in the education and identification of high blood pressure for high risk populations and provided referrals to primary care providers for blood pressure management. This allowed for education on signs and symptoms associated with high blood pressure, stroke risk factors and coordinating care for management of these risk factors by health care professionals. The neurocritical care nurse practitioner team provided an abstract in which they created an acuity assessment tool that tracked patient acuity and outcomes with the number of providers to optimize neurocritical care provider care based on the piloted model. The research identified multiple areas in which nursing care, education and interventions directly impact the patients they care for.

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