UMMC Nursing Newsletter by UMMS

July 2012 Volume 1, Issue 6

UMMC Nursing Newsletter Healthcare Associated Infections (HAIs) According to the CDC and Healthy People 2020 objectives, nearly 3 out of every 4 HAIs in the acute care hospital setting are a result of one of the following 4 categories of infections, listed in order of prevalence: 1. Catheter-associated urinary tract infections (CAUTIs) 2. Surgical site infections (SSIs) 3. Bloodstream infections—including CLABSIs 4. Pneumonia—including ventilator-associated pneumonia or VAP HAIs are the most common complication of hospital care. Studies indicate that adherence to appropriate prevention strategies can lead to a 70 percent reduction in certain HAIs. The financial benefit of using these prevention practices is estimated to be $25 billion to $31.5 billion savings in healthcare costs. Factors leading to HAIs include: • Use and maintenance of medical devices, such as catheters and ventilators • Complications following surgical procedures • Transmission of infection between patients and health care workers Downloaded from www.healthypeople.gov on July 13, 2012

How are we working to prevent and reduce HAIs at UMMC? Continuing to Promote Compliance with Hand Hygiene! The overall hand hygiene rate for UMMC has increased 15% to 80% since March.

Congrats to C5E and C7E/W on achieving 100% compliance! 4 units achieved our goal of at least 90% overall: ο Gudelsky 8 ο Trauma Acute care; ο Multi Trauma IMC ο North 8/North 9

The most improved discipline is Radiology Technologists who improved from 33% in May to 76% in June (43% improvement)! The disciplines with the highest hand hygiene rates are Rehab Therapy and Nursing at 88%!

Unit based staff achieving 100% compliance included: ο Nursing on N8/N9, 10E, 13 E/W, C5E, C4E, C7E/C7W, C6W, C8, Weinberg 5, 4STA, NTCC MTIMC, MTCC, STCC, PICU ο Physicians on N8/N9, 10E, SICU ο Patient Care Techs on C5E, C6W, C8, 4STA ο Nutrition & Food services C9E ο House keeping & Hospitality Services on Weinberg 5 ο Rehabilitative Therapy on Multi Trauma Critical Care 1

How are we working to prevent and reduce HAIs? (con’t)

Focus on CLABSI Focus on CAUTI How did our patients fair in FY12?

How did our patients fair in FY12?

There were 89 fewer catheter associated blood stream infections in ALL patients at UMMC.

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ICUs saw a 19% reduction in CLABSIs IMC rates decreased by 62% Acute Care unit rates dropped 50%

This translates to: • 11 lives saved (based on the mortality rate of such infections) • $2 million avoided in costs to treat centralline infection. • 356 more hospitalization days available to all other patients needing care. What can you do to sustain this great work?

Prevention Tips • •

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Strict adherence to the central line checklist protocol during insertion of central line. Place Biopatch completely over exit site. Central line hub should be approximately 1 cm from exit site to allow Biopatch to be placed completely around exit site. Biopatch should be changed every 7 days, or more often if saturated. Hemodialysis catheters should only be used for dialysis and only accessed by trained staff Careful attentiveness to central line dressings, insuring that the dressing is clean, dry, intact and dated. Assess daily if central line is necessary and promptly remove any central line that is not necessary. All IV lines should be scrubbed with alcohol for 15 seconds prior to access. Consistent hand hygiene prior to each entry into a patient room as well as upon exiting. Hand hygiene should always be performed immediately prior to an aseptic procedure. Reminding your colleagues is advocating for our patients. Adherence to hand hygiene is fairly good upon exiting patient rooms, but we need to be reminded to do the same

There were 14% fewer catheter-associated urinary tract infections in the ICUs in FY12.

13 patient care units are participating in the “On the Cusp- Stop CAUTI” Collaborative which provides guidance ideas for implementing best practices as well as a means to learn from other institutions, what has worked for them.

Prevention Tips • • • • • • •

Use indwelling catheters only when medically necessary Use aseptic technique insertion technique with appropriate hand hygiene and gloves Properly secure catheters after insertion to prevent movement and urethral traction Maintain a sterile closed drainage system Maintain good hygiene at the catheter urethral interface Maintain unobstructed urine flow Maintain drainage bag below level of bladder at all times

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Remove catheters as soon as no longer needed!

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Ask providers to order the catheter removal protocol so that you can act immediately when catheter can be removed Do not change indwelling catheters or urinary drainage bags at arbitrary fixed intervals Use reminder systems to target opportunities to remove catheter Use external or condom style catheters, if appropriate, for men Use portable ultrasound bladder scans to detect residual urine amounts, and minimize the need to catheterize Obtain fresh urine specimen for urinalysis and urine culture. Do not obtain specimen from foley drainage bag.

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What’s New @ UMMC? Professional Advancement Model Degree Requirement Changes Please review the following changes to the degree requirements for Senior Clinical Nurse I and II. If you have questions, please speak with your manager or email professionaladvancement@umm.edu for assistance. Professional Advancement Model Changes to Academic Basic Requirements for Senior Clinical Nurse I Application (June 12, 2012) *Current Staff holding the Senior Clinical Nurse I title will not be affected As of July 1, 2012 As of January 1, 2013 As of July 1, 2013 (July & Oct. application cy(Jan & April application cles-2012) cycles-2013) Degree Current nurses on the payroll Must hold a BSN, or be Applicants must have Requirewith an AA/AS or diploma enrolled in a BSN program evidence of a conferred ments degree: must sign a (BSN must be conferred by BSN in their application commitment contract with July 1, 2015). For applicants manager to enroll in a BSN in a RN to MS program, a program with graduation date BSN degree must be by July 1, 2015. obtained by July 1, 2017 for programs that confer. Evidence of enrollment must be submitted with application. Please refer to http://intra.umm.edu/ummc/advancement/index.htm for additional requirements Basic Requirements for Senior Clinical Nurse II Application Current requirements As of July 1, 2012 As of July 1, 2013 -Bachelor degree or enrollment Must have a BSN degree. Must have a BSN on a program for nurses on the degree. payroll before July 1, 2007. -Bachelor degree can be on any field through June 2012. -Must have at a BSN after July 1, 2012. Please refer to http://intra.umm.edu/ummc/advancement/index.htm for additional requirements Degree Requirements

Clinical Practice Update July 11th: Changes made to Quality Dashboard • • • • •

Dashboard will have stoplight-like icons indicating whether documentation is complete, coming due, or incomplete Hover over the icon for additional information Interactive - Click on the icon to open the document to be completed More than one view- select the view that is meaningful for your needs Starts Isolation status is easy to see July 17th

What’s New @ UMMC? From Clinical Practice Update July 16th: Labraotory Process Changes The Laboratory of the Pathology Department now has new instrumentation that requires a change in Blood Tubes. We will be using pale green gel tubes for many chemistries.

Clinical Practice Council Updates: Rapid Response Team Updates (RRT) updates: clarification for ambulatory settings. • RRT does not have a provider with the team for calls, therefore they cannot respond to ambulatory calls (Scope of Practice issue) • Code Team does have a provider, and will respond to code calls in ambulatory areas within the hospital building. • Off-site ambulatory settings must call 911 for emergency response.

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One can infuse multiple units/types of blood products through one tubing as long as it is flushed between products with saline. No more than 2-4 products and no longer than a 4 hour hang time per tubing. • Examples include: • 1 unit of RBCs + 1 unit of platelets • 2 units of RBCs + 2 units of platelets • 3 units of FFP New Blood Product sticker to be introduced. Sticker will have information regarding the time a product left the blood bank – intent is for the infusor to know how long they have before product must be infused.

Blood Transfusions • Transfusion form errors continue. Blood bank looking at Typenex band with barcode for lab use. • Blood products expire (for purposes of reStat-Lock for Cancer Center PICC patients issuing) when product reaches a certain tem• Patients with PICCs placed outside of UMMC perature, usually <15 minutes. The 30 minute without sutures require a Stat-Lock device for rule is a myth! securement. • Blood products issued for a specific patients • Until a UMMC decision about Stat-Lock decan be infused within a four hour window vices is made, product will be made available from time of dispense. If you have not started for Cancer Center patient’s whose PICCs lack the product within the 30 minute window, sutures. then it may be more prudent to hold a blood product rather Policy than return it to blood Revisions are bank where it will be in process wasted. 4

Clinical Practice Council Updates: Pre-Spiked IV Fluids The APIC Safe Injection Practices Position Statement (April 2010) asserts that IV bags cannot be spiked greater than 1 hour prior to use. If not using “APIC Requires a 1-hour limit from within the completing preparation (eg, spiking hour, then an IV bag) until beginning DONOT administration of the immediate-use pre-spike for patients. Rationale: 1-hour limit is IV Fluids! expected to preclude microbial population increase when accidental contamination of such drugs occurs with small quantities of microorganisms.” Central Line Dressing Kits • All inclusive kit with Biopatch is required. • Discussed whether to have 2 separate Central Line kits with 4 mm Biopatch vs 7 mm Biopatch. (decided to have 1 kit and pull the larger patch when needed) • Request for larger occlusive dressing to cover infusion ports. • Request for infant/neonate kit that would lack CHG swab.

Peritoneal Dialysis Documentation Form • Some units use paper flowsheet. Some units prefer including in I&O page • Group voted to have form available for use and to create education on standardization of documentation once form is available • Follow up required Unit to Unit Transfer FormProposed and approved to add MRSA swab for patients transferring out of ICUs • Proposed and approved to add statement regarding medications to be transported with patient upon transfer .

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Proposed and Approved Changes to PAL • Eliminate tasks & items that are not used • Add nursing tasks CIC determined important communication items • Change times to 12 hour blocks to correspond to most unit scheduling patterns

Additional Governance Council Updates • •

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Clinical Information Council (CIC) Welcomed new CIC members from the disbanded PowerUsers Group. CIC members are tasked to submit 10 Inpatient Chart Audits per month for Order Management. Results will be evaluated every quarter to determine next steps Encouraged council members to be proactive about asking co-workers to set up access to RL solutions for Event reporting. Reminded staff of the new Patient-Family Education icon which allows for easy printing of hand-outs for patient teaching.

Newsletter Updates If you have news or updates, then please send your information by the 7th of each month to: amurter@umm.edu or tfronczek@umm.edu Newsletter Editorial Board Allison Murter Christine Provance Susan Carey Trisha Fronczek

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Staff Nurse Council (SNC) Discussed “Font” size on medication labels, elevator outage concerns for safe transport of patients, and medication safety. Discuss concerns regarding improper use of dispatch (bleach cleaner), Members need to reinforce proper use on their units. Diana MacFarlane and Melissa Custer shared the outcomes from a recent RIE (Rapid Improvement Event) for mislabeled and misidentified specimens. To be presented at CPC. Reviewed FY12Q3 Nursing Sensitive Quality Indicator outcomes.

Congratulations Newly Certified RNs! Michelle Garwood; Peds ED: Certified Pediatric Emergency Nurse (CPEN) • Bernadette Schuetz, Peds ED: Certified Pediatric Emergency Nurse (CPEN) • Deborah A. Smith RN-BC, SCNI Center for Diabetes and Endocrinology: Ambulatory Care Nursing Send your certification news to: certification@umm.edu •

Governance Council Updates: • •

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Clinical Education Council Melanie Matthews was elected the FY13 Chair Elect. Gastric residual volumes increased to 500mL for adult population. New enteral nutrition guidelines to go live in October post marathon education (August/September). NDNQI pressure ulcer education modules #1 and #2 will be required of all staff as part of August Marathon activities.

Patient & Family Education Council Updates Discussed development of PICO for the council EBP project by completing the EBP Question Development tool. Elected Ann Rigdon for Chair-Elect for the next fiscal year. Discussed objectives and activities related to Nursing Strategic Goals Determined that the council has met objectives from previous fiscal year. Discussed potential focus areas for the upcoming fiscal year.

Nursing Research Council • •

Meetings Canceled for June 2012 Nurse Coordinating Council Magnet Champion Subgroup Medication Process Improvement Subgroup

Reviewed UMMC Trifold template. All printing issues have been corrected. Reminder that all that nursing publications & presentations must go through the department’s director and through a scientific overview by Pat Woltz. It also allows tracking submissions, acceptances, and presentations.

Professional Advancement Council Updates • • •

Change in BSN requirements for PAM for SCN I. (see page 2) New e-mail address for Professional Advancement for inquiries or requests. professionaladvancement@umm.edu Reviewed portfolio submission and successful promotion data across UMMC. Targeted areas needing professional development support.

Charge Nurse Subgroup Updates

The Charge Nurse Next Charge Nurse Workshop Manual has moved! Date: August 17, 2012 Check the Time: 8:00 a.m. - 4:30 p.m. Clinical Staff Resource Location: Paca Pratt Lower Level, Room 5. sidelink of the New Please register in HealthStream. Nursing Intranet Recruitment of New Members Charge nurses play a key role at UMMC in providing leadership, safety and excellent care. The role of the charge nurse is vital for unit operations and management of unit work systems and processes. The Charge Nurse Council is recruiting new members. Next Meeting scheduled for Tuesday, August 14 8:00 a.m. - 9:00 a.m. Room T1R14. Each unit or division is encouraged to have representation. For additional information, contact Stacey Trotman, SCNII, RN, CNC Chairperson x 8-2807 or StaceyTrotman@umm.edu

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Medication Oversight Committee Subcutaneous Insulin double check pilot to begin. ICUs are included in pilot. PPE for hazardous medication administration guidelines are being developed. Timeline for deployment begin developed. TBA. Excessive nebulizer withdrawals from Onmicell discussed. Group to observe and develop action plan to limit. TJC has now indicated that anyone can have access to medication rooms as long as individuals are identified and included in hospital policy. UMMC meets these requirements via revisions/ approvals of policy.

DASH 3000/4000/5000 Unexpected Loss of Custom Automatic BP Measurement Cycling If you currently use the Custom Auto NBP Measurement Cycling feature in conjunction with Automatic View On Alarm and/or View Other Beds options, GE recommends that you stop using the Custom Auto NBP Measurement feature and use the Auto NBP function instead. To discontinue use of the Custom Auto NBP Measurement Cycling, turn-off the feature by: 1. Select the NBP parameter window label and select SETUP SERIES A. To stop one of the defined series, select the SERIES OFF B. To stop measurements for one of the defined series, select REPEAT OFF Effective June 26, 2012 Argatroban Infusion Bag Change The pharmacy department has converted infusion bags of argatroban to 50mg/50mL vials for direct infusion. This change was made in response to high drug waste expenditures. Please note that the final concentration has not changed, as both the compounded IV bags and the new vials are 1mg per mL. The pumps have been updated to accept the new volume (additionally, the 250 mL drip entry will be removed next pump upgrade). Hydromorphone Shortage Hydromorphone 2mg IV syringes are on national shortage. Once your omnicell is depleted, the 2mg syringes will be replaced with 2mg injection vials and ampules. August/September Marathon Training Sessions: New and Old Trainers WELCOME! Sign up via Healthstream. Search “education marathon trainer the trainer” July 17 8am-10am or 1pm-3pm; July 19 8am-10am or 1pm-3pm July 20 8am-10am or 1pm-3pm July 23 8am-10am or 1pm-3pm July 24 8am-10am or 1pm-3pm July 26 4pm-6pm Topics: Pressure Ulcer Prevention and Assessment; Blood Product Administration Enteral Nutrition Guideline Changes; CAUTI Improvement Strategies Environment of Care Rounds; Scope of Practice; New Products Required on-line modules to complete marathon education: www.nursingquality.org/ ndnqipressureulcertraining Complete Module 1 - Pressure Ulcer Staging Test; Complete Module 2 Wound Type Identification Test. Attach a copy of test results to each person's marathon summary form. Time to complete both modules ~ 30 minutes Questions: dhuffer@umm.edu

Overview of the PICC Team Service

The PICC team offers a comprehensive service that includes triage, insertion & f/u chest x-ray. In FY11, the UMMC PICC Team placed over 1600 PICC single & double lumen power injectable PICC lines at the bedside. Indications for PICC Lines: Short and long term IV meds, Chemotherapy & TPN Guidelines: Platelets > 50,000, INR < 2, Creatinine <2, Negative blood cultures for at least 48 hours Contraindications: Patients receiving hemodialysis/ Renal Failure; Upper extremity limitations like: contractures, skin wounds, rash, phlebitis, infiltration; History of current upper extremity, jugular, or central venous thrombus; Recent pacemaker insertion with new leads.

FAQ’s about PICC lines •

A PICC is a peripherally inserted central catheter that is inserted in the upper extremity & threaded into the central venous system. • The tip is located in the SVC, or cavoatrial junction. • The line may remain in place as long as needed without complications. • My patient has a fever? Call IR (8-7490)for consult BEFORE removal How to get a PICC ordered in Powerchart • Please have provider order: PICC insertion and confirmation careset. • Team will: verify order, communicate with pt. nurse for triage, schedule chest x-ray, and document in power chart under the “Plan of Care” with length, notification and radiology findings. • The PICC nurse will relay tip confirmation to provider so they can place order: “PICC ready for use” and “PICC line care” 7

Announcements Yoga & Art: Expressing Oneself through Movement & Creative Arts (4 part series) Thurs. August 2, 9, 16, and 23, 2012 Time: 8:30 am—10:00 am More info: http://www.regonline.com/builder/site/ Default.aspx?EventID=1106374 Acupressure with Donna Audia Sat. July 28, 2012 Time: 10:00 am-4:00 pm More info: http://www.regonline.com/builder/site/ Default.aspx?EventID=1108327

Save the Date!!! End of Life Workshop September 18th and 25th All Day ANCC Magnet Conference October 10-12, 2012 Los Angeles, CA Oral Systemic Link October 29 UMB

September Healing Touch Level 1 Course Scheduled The Healing Touch Level 1 course is set for Sept 18-19 (Tues-Wed) Healing Touch is a nursing based continuing education program for registered nurses, physicians, body therapists, counselors, psychotherapists, other health professionals, and individuals desiring an in-depth understanding and practice of healing work using energy based concepts. Feel free to share the site and visit it for registration information. www.healingtouchprogram.com The Assessment of Spirituality and Religious Sentiments (ASPIRES) scale: An Empirically Sound Measure of the Numinous for Healthcare Professionals This workshop will present the ASPIRES model of spirituality, define its constructs, present validity evidence and demonstrate how to interpret scores. For registration and additional information about workshop and speaker go to: http://www.eventbrite.com/event/3772359228 Date: Thursday, July 26, 2012 Time: 1:00 pm – 4:00 pm Location: UMMC Auditorium Cost: Free for all UMMS employees The Oral Systemic Link: Creating Collaborative Initiatives Collaboration and interprofessionalism are hallmarks of innovative health care delivery. Join us for the first national conference highlighting dental hygiene and nursing collaborations! This conference will address the issues of interprofessional collaboration, institutional and policy challenges, and shared goals in providing optimal patient care. The symbiosis of oral and systemic health provides the perfect backdrop for interprofessional learning. Date: Monday October 29, 2012 Location: UMB Register and learn more at: http://nursing.umaryland.edu/oral-systemic 2 Day End of Life Nursing Care Workshop (ELNEC) Clinical Applications of Death & Dying and Fundamentals of Death & Dying Dates: September 18th and 25th. Although participants may register for one session, attending both sessions will best ensure an understanding of all aspects of end-of-life care. Please register in Healthstream and for questions contact Erica Bergstein ebergstein@umm.edu

July Nursing Grand Rounds: Date: July 17th Time: 2:00—3:30 pm Location: UMMC Auditorium Topic: Healthier Food in Healthcare Speaker: Louise Mitchell, PT, Sustainable Foods Program Manager, Maryland Hospitals for a Healthy Environment (MD H2E) & Denise B. Choiniere, MS, RN, Interim Director, Facilities Services, Sustainability Manager 8

July 2012 Volume 1, Issue 6S

UMMC Nursing Year End Report

Special Edition!

FY 12 Council Annual Reports *** UMMCâ&#x20AC;&#x2122;s PCS Governance Councils have had a productive FY 12 Please read the summaries provided by the councilâ&#x20AC;&#x2122;s leadership teams. Provided on page 2 is the Nursing and PCS Governance Council Structure for your reference. If you are interested in getting involved in the great work at UMMC, please contact your unit leadership

Nursing Coordinating Council Coordinated the work of the Nursing & PCS Governance councils based on the Nursing Strategic Plan and nursing and patient outcomes. Major focus included Joint Commission Readiness and data review around our Nursing Sensitive Quality Indicators. This Council provided a mechanism for enhancing inter-council communication and collaboration, while it educated all participants on the topic of incorporating process measures and data into work plans. NCC leadership developed a Nursing Council Intranet page, a "bullet point" communication system for providing monthly council updates. The Council creating a standard process for all councils to communicate membership expectations for all councils and subgroups, and a standardized annual reporting structure for councils.

Nursing Council interdisciplinary membership represents 25 divisions and 125 individual departments in the hospital (including all Nursing Divisions, IT, Lab Integration Team, Respiratory Therapy, Risk Management, Nutrition, Rehab Therapy, Chaplains, Social Work, and many others! Nursing Research Council FY12 Highlights Coordinated the restructuring of the council during the first three quarters of the fiscal year resulting on revamping of the We Discover Series, redesign of the Nursing Research Intranet and Internet pages, development of the introduction of EBP lecture into the orientation of new nurses, and revision of EBP workshop.

Clinical Education Council Marathon Trainer Education in July and February, and two Education Training New Marathons were held in August approach to 2010 and March/April 2012. Marathon Sessions began to include Unlicensed Assistive Personnel (UAP's) in the March 2012 marathon education. Decentralized marathon education was moved back to the unit and divisional levels for March/2012. A task force created 4 Preceptor Tools as part of its staff education model. Collaborated with the Clinical Practice Council when creating agendas. Supported hourly rounding and bedside safety check initiatives.

Graduate Nurse Advisory Committee (Subgroup of CEC) Restructured the cohort schedule and combined topics for New Graduate Nurse Residency Program, which resulted in additional time for new graduate nurse residents to spend in clinical time on their units in the beginning of their orientation. In response to potential preceptor burnout, GNAC shared multiple orientation strategies and alternative approaches with each unit representative. Developed a tighter structure and deliberate process to improve response rate UHC New

Competency Marathon Subgroup- Completed the design work for a new framework, and 1

the group was disbanded. Many members were absorbed into the larger Clinical Education council.

Special Report: FY12 Council Summaries Clinical Practice Council The CPC worked to complete timely review and revision of existing policies as well as collaborating with multidisciplinary groups to facilitate the development of new policies and practice guidelines as needed. Maintained the Hospital Policy Manual at 0% expired policies, and the Clinical Practice Manual with minimal expired policies, and actively worked with groups to move policies that had hospital wide impact over into the hospital manual. The council created a quarterly reporting structure to review data from Risk Management, Infection Prevention, Falls, and Skin Care Committee, and Pain Task Force in order to help define their work. CPC has established a multidisciplinary membership that is actively engaged in the work of the council. •

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Technology, Equipment, and New Products Subgroup - Expanded membership and is now called Med/Surg Critical Care Value Analysis/TENP to allow the dissolution of CC VA and reduced redundancy in meeting schedules for many attendees,. Implemented multiple product conversions hospital wide to achieve standardization of product and cost savings, including Dispatch wipes, Covidien SCDs, Microclave conversion, Safety Filter needles, Blood Pressure Cuffs, and oral care kits. Skin Care Committee (Subgroup) - The Skin Care Committee implemented new process for pressure ulcer data collection, rolled out new bed surfaces and new air beds in the Operating Room, and is continuing ongoing work with IT to implement a wound documentation system including a camera in FY13. Falls Committee (Subgroup) – Conducted root cause analysis of all Medical Center falls, and coordinated the purchased seventeen additional low beds to reduce rental costs. Developed a teaching toolkit program and bulletin board templates to assist each unit in their falls reduction programs.

Patient and Family Education Council Coordinated efforts to improve patient satisfaction scores on education of new medicines, medication side effects, and clear communication by nurses. Created specific reports for units with scores below the 75th percentile and coordinated plan of action targeting these areas and hospital wide. Created a consistent method of review and posting educational documents on the intranet. • Patient Education On-Demand Subgroup - Collaborated with Guest Services on the implementation of the new TV system, TIGR 7. Developed the patient on-demand education TV screens in collaboration with Public Affairs/Marketing. Increased utilization of educational programming through the publication of available programs and contests.

Clinical Information Council Provided feedback and approved several requests for changes to the clinical information system including revisions to the IV APAP alert, revisions to the downtime documentation process and policy, and enhancements to the Quality Dashboard and other electronic tools. Launched the CIC Education Committee to address the ongoing educational needs of clinicians pertaining to electronic documentation. Continued to monitor order management practices related to scope of practice and quality. The Clinical Documentation Workgroup continued providing design decision support for pending electronic nursing documentation

Advanced Practice Nursing Council Identified CLABSI, CAUTI and pain control to be areas of focus of APN initiative to promote positive patient outcomes and to meet benchmarks set by Magnet and other bodies. The APN Council worked to strengthen the relationship with the University of Maryland School of Nursing by increasing SON membership on the council and by developing a plan to collaborate with DNP students on their capstone projects. Promoted APN Grand Rounds as a vehicle to showcase the accomplishments of APNs and to share this valuable information with other clinicians. 3

WOW!

Special Report: FY12 Council Summaries Professional Advancement Council Educated council members about the Professional Advancement Model (PAM). Developed and completed a three-part series coaching and development workshop. Mentored council members to be stewards for PAM throughout the organization. Analyzed organizational and division/unit based promotion data to identify ways to educate and to increase participation in the PAM at the unit/division level. • Professional Advancement Review Team (Subgroup) The PART subgroup meets quarterly to review submitted applications for promotion. • In FY12, PART reviewed 52 applications submitted by nurses from 29 units. 47 applicants were recommended for promotion by PART. • Certification Support Subgroup - Provided quarterly education to staff through submissions to the “Certification Corner” in the quarterly publication of News & Views. Developed a Certification “Tool Box Strategies for Success”, which has been incorporated on the Nursing page of the UMMC Intranet. • Committee members continue to work to grow the percentage of nurses who are certified and to recognize those who are. The annual Certification Recognition/Celebration Breakfast was held for staff on certification day in March 2012. • Charge Nurse Council Subgroup - Increased membership and participation. Coordinated two Charge Nurse Workshops for over 63 UMMC and Kernan staff members.

Estimated 470 governance council members in FY12 Staff Nurse Council The SNC was instrumental in Identifying a number of actual and potential situations that impacted patient or staff safety and collaborated with leadership to develop corrective action plans. • Worked in partnership with a multidisciplinary team to develop guidelines for patients leaving units with and without supervision. • Queried members regarding the status of peer review in their respective clinical areas and will continue to focus on enculturation and consistency of peer review approach with other nursing governance councils. Magnet Champion Group (Subgroup) - Members of this subgroup served as volunteers for the 2011 ANCC Magnet Conference in Baltimore, MD. • The group provided exemplars that will be included in the 2013 Magnet re-designation document. • Members serve as unit champions for initiatives aimed at improving patient safety and satisfaction, such as Hourly Caring Rounds.

Medication Oversight Council Through the oversight and coordination of MOC, workgroups reporting to the MOC demonstrated the following accomplishments for FY12: Defined the employee groups may have access to the medication rooms, and added language and appropriate job descriptions to the hospital policy to indicate type of access. The group revised preprinted order sheets to be more prescriptive with range dosing; decreased the amount of stock-outs for inhalation medications. The group created plans for a number of projects that will continue in FY13, including refining the heparin nomagram, standardizing the discharge medication process, strategizing to decrease medication override rates, and decreasing the number of excessive withdrawals from the Omnicell. • Medication Profess Improvement Committee (Subgroup) – Developed Medication Room standards for use with new construction and available for consideration for current med rooms. • MPI coordinated nurse-pharmacy share days, that were completed in all satellite pharmacies. • Implemented the Pharmacy tech pilot. • The group began developing guidelines, policy changes, and education plans to address new CMS requirements for timely & accurate medication administration. 4