December 2010
Recognized Excellence, Designated Magnet
VUMC Nursing
Clinical Workforce
Lou Kaelin, Robin Mutz &
Vicki Thompson
Clinical Workforce
Staffing and Scheduling
2010 Goal
Analysis of supplemental staffing needs
for inpatient and outpatient areas.
Accomplishments
Established Medical Assistant positions in the Clinical
Resource Center.
Float Pool Tier 3 Proposal
Improve satisfaction and retention of the
maturing workforce.
Develop and implement subspecialty
nursing fellowship.
Completed 14 FOCUS Groups and gathered data that
will be evaluated to obtain:
- Best practices regarding flexible staffing
- Identified organizational barriers to flexible
staffing
Pilot program in Women’s Patient Care Center started
in July 2010.
-4 participants
-Have been placed in L&D, 4East and Clinic
-To be completed in September 2011
- Next cohort scheduled to begin in January 2012
NDNQI Data 2010
Practice Environment Scale “Adequate Resources”
Vanderbilt
Adequate
Resources
Comparison
2007
2008
2010
2.78
2.83
2.85
Magnet Academic
Medical
Centers
2.84
CWC Impact on NDNQI scores has been accomplished by:
1) Implementation of PRN Tiers - March 2006
2) Standardized Scheduling Process – July 2004
3) VandyWorks Implementations Go Live– July 2006
4) VandyWorks Implementations (ED, Procedural) 2009 -2010
2.79
Safety and Scheduling
2010 Goals
Monitor data on maximum work hours per
week.
Addition of Certification Tracking to
VandyWorks with alerts sent to staff and
managers.
Accomplishments
Reviewed data for over 60 hours/week work
Schedule Period
CN
RN
CP
MR
Paramedic
4.11.10 to 5.22.10
1
1
1
4
0
5.23.10 to 7.03.10
0
0
1
4
0
7.04.10 to 8.14.10
1
1
1
0
0
8.15.10 to 9.25.10
0
2
2
1
0
9.26.10 to 11.06.10
0
0
0
2
1
Updated the Patient Care Services Scheduling Process
Policy (CL 20-06.25).
Track 19 certifications (8208 employees) in VandyWorks
Track 10 professional licensures (3701 employees) in
VandyWorks
Updated License, Registration and Certification
Verificaton/ Reverification Policy (CL 20-06.02)
2011 Goals
Pillar Goal :
Growth and Finance
Steps to accomplish
Measurements for success
Nursing Strategic Plan:
Vanderbilt Personalized Patient
Health Care Mode
Ensure that nursing work efforts Review 2010 NDNQI VUMC
include a coordinated plan to Organizational Data
standardize staffing and
scheduling practices and
Identify trends that relate to staffing
policies to support evidence
and scheduling
based care
Make recommendations to NEB for
workforce improvement based on
analysis of NDNQI scores
NDNQI Practice Environment Score
“Adequate Resources will
Continue to increase.
NDNQI RN “Plans for Next Year” will be
at benchmark.
Educate CWC and Managers on Staffing
Templates and benchmarking data.
Complete literature review on the use
of acuity tools in the current healthcare Will complete a gap analysis related to
best practice acuity tools and
environment.
requirements that match VUMC
Review VUMC policies as needed and practice.
make recommendations to HR and NEB.
2011 Goals
Pillar Goal:
People
Steps to accomplish
Measurements for success
Nursing Strategic Plan:
Transformational Leadership and
Professional Development
Work with Leaders and Staff
to understand and promote
flexible staffing strategies
that balance the needs of
the patients and quality of
work life for the staff.
Continue Focus Group Sessions
across the organization to
understand best practices for
flexible staffing currently used at
VUMC.
Literature review regarding best
practice flexible staffing options.
Monitor current internal and
external literature related to
staffing and scheduling.
Compiled index of best practices.
Analysis and make
recommendations to NEB
regarding flexible staffing options,
best practices and barriers.
Turnover data of nurses 50 years
and older
2011 Goals
Pillar Goal:
People
Steps to accomplish
Measurements for success
Nursing Strategic Plan:
Transformational Leadership and
Professional Development
Inform Leaders and others of Inform NEB on the current trends in Update to NEB and VUMC NLB
health care reform changes the literature and legislative actions annually and as needed.
and legislation that has an that affect staffing and scheduling
impact on workforce
strategy and management.
VUMC Clinical Workforce
Identify opportunities to present the Poster presentation at local and/or
Committee will contribute to work of the committee both
state level
the body of knowledge of
internally and externally
best practices in nursing
workforce.
NURSING DIVERSITY
Nicole Herndon & Laura Kelley
Nursing Diversity
PURPOSE:
To cultivate an inclusive culture encompassing respect and
valuing individual uniqueness at all levels of Nursing within
Vanderbilt University Medical Center.
DEFINITION:
Diversity is defined as a broad spectrum of demographic
attributes and philosophical perspectives that encompasses
respecting and valuing each individual’s uniqueness at all levels
of nursing within Vanderbilt University Medical Center.
GOAL 2010
ACCOMPLISHMENT
Goal 1: Be unified in our
voice and message as
ambassadors for diversity at
Vanderbilt as well as finding
new ways to improve our
reputation in the community
to attract a diverse
workforce.
Completed a review of
possible opportunities to
collaborate with LDI, EAD,
and Nursing Education.
• Continue to collaborate
with Recruitment on
diversity recruitment.
• Metro Nashville
Partnership School Career
Exploration Fair.
• 139 schools
• 4000 (plus students)
Participated in the 2010
Metro Partnership School
Career Exploration Fair.
GOAL 2011
Goal 1: Be unified in our
voice and message as
ambassadors for diversity
at Vanderbilt while finding
new ways to highlight
nursing’s commitment to
diversity and a diverse
workforce.
• Plan a Diversity Job Fair
for Vanderbilt’s
employees.
• Explore the possibility of
developing a Diversity
Recruitment Plan.
GOAL 2010
ACCOMPLISHMENT
GOAL 2011
Goal 1: Partner with the
office of Client and
Community Relations to
participate in the 2011
Metro Partnership School
Career Exploration Fair.
GOAL 2010
Goal 2: Find new ways to
increase visibility and
awareness of resources
available at Vanderbilt
concerning our efforts to
encourage diversity in our
workforce.
ACCOMPLISHMENT
GOAL 2011
10 weeks of Nursing Alerts
for diversity programs and
resources (religious groupsPastoral Care).
Goal 2: Identify diversity
training opportunities
within current and new
venues.
Updated website to include
minority nurse associations
and added three websites
devoted to diversity and
cultural awareness.
• Hearts & Minds
• VUMC Orientation
• Nurse Residents
Collaborated with Nurse
Wellness on the Mature
Nurses Workforce.
• Generate a twice a year
diversity newsletter -“Nursing Diversity
NewsPepper”
GOAL 2010
ACCOMPLISHMENT
Completed four sessions of
“Diversity in Healthcare”
and Cultural
Competence/Awareness.
GOAL 2011
Goal 2: Identify diversity
training opportunities
within current and new
venues.
• Hearts & Minds
• VUMC Orientation
• Nurse Residents
GOAL 2010
Goal 3: Develop a diversity
training program for
leadership so that they are
more sensitive to:
• Diversity issues in hiring
practices.
• Respect and treatment
of the diversity in their
employees.
ACCOMPLISHMENT
CNO Diversity Breakfast.
Developed a draft for
Nursing Diversity Education
Pilot.
On-line Diversity Survey for
Managers and Assistant
Managers.
In collaboration with EAD
completed three diversity
training sessions.
GOAL 2011
Goal 3: Integrate diversity
into mission and strategic
goals based on best
practices.
Driver Diagram Analysis for
Diversity.
Benchmark with
institutions that have
demonstrated best
practices around diversity
initiatives.
Implementation of the
Diversity Education Pilot.
First 2 Years Retention
& Recruitment
Julie Foss & Debianne Peterman
F2YRR
PURPOSE
To assess, develop and implement effective strategies, program
and processes for recruitment, selection, orientation and support
for nurses during their first two years of employment at Vanderbilt
University Medical Center.
Goals 2010
Accomplishments
Use shared governance process to gather
feedback and share information to achieve
F2YRR goals, include VPH
• Committee members volunteered to
attend Staff Council meetings to hear
issues and obtain feedback on proposed
strategies:
o Buddy System
o Transfer Process
o Need to add routine reporting of
Staff Council feedback to F2YRR
monthly agendas
•
•
•
•
Debbie Arnow – Children’s Hospital
Ro Wallace – VPH
Julie Foss – VMG
Donna Ruth - VUH
Goals
Accomplishments
• Maintain or improve selection/hiring
process of new RN’s, including right
person to the right area/job.
Assessment was completed – 50% of
managers reported that peer interviewing
was not being utilized.
• Conduct assessment of managers who
currently use targeted selection and
peer interviewing – determine
educational needs.
Added Tammy Key to committee.
Dropped the registration fee.
Education sessions offered onsite at unit
when requested.
• Improve internal transfer process –
• Formed subcommittee
review current policy and create career • Identified “hills, skills, and will.”
development process to help guide
• Created a new Transfer Process
nurses requesting transfers.
algorithm.
• Vetted algorithm to NEB, NAB,
Managers and Recruiters.
• Developed operational processes
within NE&PD to manage 2011 Pilot.
Goals 2010
Accomplishments
• Retain 87% of new nurses during their
first two years at VUMC.
• Implemented the Preceptor Dish Nurse
Alerts!
• Implement Preceptor Nurse Alerts!
And provide ongoing educational
updates.
• Now offer ongoing development of
preceptors beyond initial course. 149
preceptors have attended since
7/1/10.
• Committee will review general
onboarding rounding tool that has
• Updated Nursing’s 30-90-180 day
been created and determine need to
rounding tool.
revise current Nursing Rounding 30-90180 day tool.
• Reviewed results from 7N.
• Explore the pilot of the “Buddy
System” implemented on 7N and
determine feasibility of rolling that
system out to all units/departments
• Currently conducting pilots on L&D
and MICU.
• Created evaluation tool for pilot units
for both the Mentor and “Buddy.”
PEER INTERVIEWING
NURSING STRATEGIC PLAN
F2YRR GOALS
TRANSFORMATIONAL LEADERSHIP
AND PROFESSIONAL
DEVELOPMENT
(Provide current and future
healthcare leaders and care
providers the environment, tools,
evidence and skill development to
lead during a time of healthcare
reform and transition.)
Increase the use of
Peer Interviewing
throughout the
enterprise.
EVIDENCE-BASED PRACTICE AND
EFFECTIVE PROCESSES
(Lead nation in producing
evidence that will drive nursing
practice, recognizing and
legitimizing the evolution of
knowledge in a rapidly changing
environment. Create passion and
discipline for the translation of
evidence into practice that will
optimize patient outcomes.)
MEASUREMENT
Currently only 50% of
inpatient managers
report using Peer
Interviewing.
Threshold Target Reach
60%
75% 90%
DIS* Peer Intervewing
subscale
Current 1.75 – 2.82
Threshold Target Reach
2.0
2.5
3.0
Next Year Compliance:
% of hires used peer
interviewing
STRATEGIES
• Partner with LD & SG Committees to
develop curriculum for Nursing leaders
specific to peer interviewing.
o Literature review peer interviewing
o List Serv survey
o Identify managers who have
completed Targeted Selection
(December Managers Meeting)
• Strategize with nursing leaders to develop
rollout plan for education of staff on peer
interviewing techniques.
• Meet with managers’ Council (Dec. 2010) –
identify barriers. Identify Managers who
have completed Targeted Selection.
• Follow-up on barriers identified by
managers.
*DIS = Decisional Involvement
• Develop calendar identifying slots for each
Scale
unit to place staff for PI education.
• Offer PI education session during AprilFest
2011.
• Develop compliance survey to send out to
managers quarterly.
BUDDY SYSTEM FOR NEW NURSES
NURSING STRATEGIC PLAN
TRANSFORMATIONAL
LEADERSHIP AND PROFESSIONAL
DEVELOPMENT
(Provide current and future
healthcare leaders and care
providers the environment, tools,
evidence and skill development to
lead during a time of healthcare
reform and transition.)
F2YRR GOALS
Rollout Buddy
System strategy
across inpatient
units as best
practice strategy
for assisting with
enculturation of
new nurses.
MEASUREMENT
STRATEGIES
2 units are currently
using a Buddy System
strategy.
• Partner with Leader Development and
Shared Governance Committees to develop
curriculum for (inpatient) nursing leaders
specific to the Buddy System.
Threshold Target Reach
25%
50% 75%
(Inpatient units)
• Outline “must haves” for successful
implementation.
• Complete evaluation of pilot units.
• Present pilot results to nursing leadership.
EVIDENCE-BASED PRACTICE AND
EFFECTIVE PROCESSES
(Lead nation in producing
evidence that will drive nursing
practice, recognizing and
legitimizing the evolution of
knowledge in a rapidly changing
environment. Create passion and
discipline for the translation of
evidence into practice that will
optimize patient outcomes.)
• Develop rollout plan with nursing leaders
and educators.
• Develop compliance survey to send out to
managers quarterly.
• Begin to develop strategies for
implementation in ambulatory, procedural,
ED, and Perioperative areas.
• Implement process in Children’s Hospital &
VPH, ED’s
• Begin thinking about rolling out for other
roles (Manager, CP, MR, PCT).
TRANSFER PROCESS
NURSING STRATEGIC PLAN
F2YRR GOALS
MEASUREMENT
TRANSFORMATIONAL
Decrease turnover Pillar Goals for turnover
LEADERSHIP AND PROFESSIONAL (nurses leaving
Threshold Target Reach
DEVELOPMENT
VUMC)
12.5% 12% 11.5%
(Provide current and future
healthcare leaders and care
providers the environment, tools,
evidence and skill development to
lead during a time of healthcare
reform and transition.)
STRATEGIES
Partner with Leader Development and
Shared Governance Committees to
develop education for nursing.
Leaders:
- Best practice
- Creating environment that
promotes career exploration
Staff: on transfer process itself
• Finalize Transfer Process algorithm.
EVIDENCE-BASED PRACTICE AND
EFFECTIVE PROCESSES
(Lead nation in producing
evidence that will drive nursing
practice, recognizing and
legitmizing the evolution of
knowledge in a rapidly changing
environment. Create passion and
discipline for the translation of
evidence into practice that will
optimize patient outcomes.)
• Develop assessment questionnaire.
• Develop optional shadowing experience
model.
• Provide career counseling through
Nursing Education and Professional
Development.
• Conduct pilot of Transfer Process.
• Evaluate pilot and share results.
Leader Development
Betty Sue Minton & Robin Steaban
2010 Goal:
Develop recommendations for span of control
Accomplishments
Ongoing
•
•
•
•
•
Defined variables in that influence
span of control
Completed focus groups to identify
the work of the management team
across the organization
Consolidated and reviewed the data
from the focus groups identifying the
work that is transformational.
Reconciled data with the behavioral
rating scale.
•
•
Make a recommendation regarding
leadership team roles and
responsibilities that are consistent
with span of control.
Quantify the work by area and
develop leadership team models.
Examine impact of span of control on
outcome metrics such as turnover,
staff satisfaction , NDNQI PES sores,
financial performance, etc.
2011 Goal:
Define the leadership model that is transformational and flexible
with leadership competencies and a menu of tools.
2010 Goal:
Implement manager behavioral rating tool consistent with job description.
Develop scoring templates for other leader roles.
Accomplishments
Ongoing
•
•
•
Behavioral Rating scale was finalized
and implemented
Survey has been completed and will
be distributed in Dec. to evaluate the
use of the tool at mid-year
conversations.
•
Evaluate the use of the manager 5
point behavioral rating scale - revise
and improve
Complete performance assessment
rating scale for assistant managers
and charge nurses.
2011 Goal:
Develop transformational leaders who can create and transform
programs/products/environments to meet the patient population needs and VUMC
organizational goals (People, Quality, Safety, Finances, Growth, and Innovation).
2010 Goal:
Collaborate with HR and Recruitment related to strategies for recruiting and
retaining managers
Accomplishments
Ongoing
•
•
On hold
2011 Goal:
Create a plan to begin this work
following implementation of
behavioral rating scale.
2010 Goal:
Develop collaborative working relationship with others in the organization,
creating leader development opportunities
Accomplishments
Ongoing
•
•
•
Have a connection through
Workplace Learning collaborative to
stay abreast of leader development
opportunities
Terry Minnen presented update on
elevate and how it aligns with the
efforts this group is overseeing.
•
Create a plan to begin this work
following implementation of
behavioral rating scale.
Map organizational learning
opportunities to 5 point rating tool to
assist managers to identify resources
that will help them be successful
2011 Goal:
Provide organizational learning opportunities for individual leaders and leadership
teams to learn together and obtain or create tools to meet their desired objectives.
Maturing Workforce
Adrienne Ames & Susie Lyons
Maturing Workforce
•
•
•
•
•
New focus for 2010
Conducted Gap Analysis
Phases of Maturing and Retirement
Identified targets for improvement
Retired Nurses Group
NURSING STRATEGIC PLAN
TRANSFORMATIONAL LEADERSHIP
AND PROFESSIONAL DEVELOPMENT
Provide current and future healthcare
leaders and care providers the
environment, tools, evidence and skill
development to lead during a time of
healthcare reform and transition.
MATURING
WORKFORCE GOALS
Create workplace
that values and
respects the
contributions and
expertise of the
maturing worker and
creates
opportunities to
Goal 1: Develop transformational
strengthen the
leaders who can create and transform organizations
environments to meet patient
commitment to and
population needs and VUMC
the retention of a
organization goals. (People)
maturing workforce.
Goal 2: Develop a recruitment and
retention philosophy that supports
flexible standard and consistent
requirement for leadership practice.
Goal 3: Provide organization learning
opportunities for individual leaders
and leadership teams to learn
together and obtain or create tools to
meet their desired objectives.
MEASUREMENT
STRATEGIES
Analyze workforce
demographics and establish
baseline metrics in various
age groups of 50+

Turnover

Satisfaction
o NDNQI
o Employee
survey
Hardwire exit interview of retired nurse

Monitor, report trends and address
issues
Involve nurses in Retired Nurses group

Creating engaging agenda and activities

Inform participants of Vanderbilt
initiatives and progress.
Create and make available tools and
information of interest to maturing
population.
Measure activity on Mature

Planning for retirement toolkit
Workforce web site.

Job flexibility and job redesign options
Increase awareness of maturing worker to
nursing management.

Collaborate with Clinical Workforce
regarding flexibility and job design

Increase volume of information and tools
on website
Create Advisory Group of senior employees

Collaborate with each BTB committee to
determine needs from this population.

Follow-up on suggestions/barriers
identified by group.
Nurse Wellness
Susan Hernandez & Diane Johnson
Goal 2010
Support the Wellness needs
of a Multigenerational
Nursing Staff
Accomplishment
• Partnership with Health Plus to achieve
79% Nursing participation in Go for the
Gold Wellness Program. Increased
participation this year by 136 nurses.
• Partnership with Health Plus to Promote
the Vanderbilt Farmers Market
• Partnership with Vanderbilt Child and
Family Center to promote 2 back-up care
options for adults and children: the Sitter
Service and Parents in a Pinch.
• Increased nurse participation in the
Wellness Commodores program
Goal 2010
Accomplishment
Advocate for the Health and
Wellness of Nurses by providing
communication and education
Promotion of Personal Safety
• VUPD offered monthly self defense classes
from January to May.
• The annual campus safety walk was not
conducted this year.
Support of Healthy Behaviors
• Flu shots -2008, 2,525
2009, 3,278-33% increase H1N1-2,215
Provided Targeted Messages
• Nurse Wellness Nurse Alerts subscribers
increased by 13% in 2010
Innovation
• Hey Florence
Serve in an Advisory capacity to
the Nurse Wellness Program
Advocated
• Work/Life Connections-EAP increased
psychological support services to nurses
including support for those who suffered
loss from the floods.
• Increased presence of Nurse Wellness
Program/EAP to off site staff
2011 Goals
Strategic Goal
EBP and Effective
Processes
Goal
Action Plan
Measurement
Increase the
• Spread awareness Percentage of nurses with
percentage of
of current
healthy BMI. (will follow
nurses with a
condition
CDC guidelines)
healthy BMI in an
effort to decrease • Identify unit
cost of care to
based Wellness
the organization
Commodores
• Educate nurses on
ways to improve
BMI
• Promote use of
Health and
Wellness
programs offered
by Vanderbilt
2011 Goals
Strategic Goal
EBP and Effective
Processes/
Transformational
Leadership
Goal
Action Plan
Measurement
Achieve cultural 3 year phased plan
• Pre and Post Survey of
change in an
• Year 1-Awareness
knowledge
effort to decrease
Campaign and
violence in the
education
• Leaders development
workplace
• Year 1-Identify
of innovative strategies
legislation and
to address workplace
policy related to
violence
workplace
violence
• Decrease in occurrence
• Year 2- Creation of
of workplace violence
protocols/strategi
es to help
• Year 3-Implement
identified
strategies and
measure
effectiveness
2011 Goals
Strategic Goal
EBP and Effective
Processes
Goal
Action Plan
Recommend
• Identify Wellness
needs and
Commodores for
themes for future
units
education and/or
intervention
• Support NWP
participation in
new leader
orientation
• Support weekly
rounds of NWP
Measurement
• Increase # of Wellness
Commodores across
the organization
• Pre and post tests after
educational offerings
• Increased use of NWP
• Increased compliance
with use of Smooth
Moves equipment
• Support injury
prevention efforts • Decreased patient
handling injuries
Shared Governance
Laura Beth Brown & Connie Ford
Goals 2010
Accomplishments
Work with Administrative Directors, Managers, Monitoring and Evaluation of Shared Governance
and Staff to strengthen shared decisionmaking and accountability in improving the
• Implementation of SG Dashboard to monitor
quality of care, safety and enhancing work life.
o SG website utilization
o SG Nurse Alerts
• Consideration of SG dashboard for the unit level
Transformational leadership and professional
development
All SG workshop offerings now in LMS for registration.
(provide current and future healthcare leaders
and care providers the environment, tools,
Evaluation of educational portfolio to determine methods for
evidence and skill development to lead during a steamlining information and promoting shared governance
time of healthcare reform and transition)
across the enterprise
Developed 3 Dimensional Approach (Pilot in Adult and
Children's Hospitals)
• Shared Decision Making Data
• Employee Satisfaction
• Elevate Coaching and Rounding
Continue to meet individually with areas as needed
Goals
Work with Administrative Directors, Managers, and
Staff to sustain a purposeful shared decision-making
structure and process
Evidence-based practice and effective processes
(lead the nation in producing evidence that will drive
nursing practice, recognizing and legitimizing the
evolution of knowledge in a rapidly changing
environment. Create passion and discipline for the
translation of evidence into practice that will optimize
patient outcomes.)
Accomplishments
Unit Board Assessments (qualitative and quantitative).:
• Outpatient CY2010
• Inpatient CY2011
Gap Analysis of 2009 Inpatient Assessment Data continues with
dissemination of information completed to all groups in May
Operationalized Clinical Dispute Resolution Panel
• On-going education-nine RN3s, RN4s, APNs trained in
March
• Panel to be deployed as needed
• Evaluate process following panel meetings
Comprehensive review of VUMC SG nursing leadership structure
• NEB, NAB, and entity NLBs Jan – April
• Completed Review of Committee/Council/Board
Charters and
• Produced flying saucer graphic of our nursing
enterprise
Successful Bylaws Convention November 16, 2010
• 4 Substantive Amendments recommended by the
Boards, Councils, Committees and delegate retreat
representatives
• The composition of the Unit Clinic Boards includes
Administrative Directors
• The addition of the Entity Nursing Leadership Board to
our Bylaws and established Medical Center Nursing
Leadership Board
• The Shared Governance Committee becomes a Standing
Committee of the Nursing Staff Bylaws.
Goals
Work with Administrative Directors, Managers,
and Staff to sustain a purposeful shared
decision-making structure and process
Evidence-based practice and effective processes
(lead the nation in producing evidence that will
drive nursing practice, recognizing and legitimizing
the evolution of knowledge in a rapidly changing
environment. Create passion and discipline for the
translation of evidence into practice that will
optimize patient outcomes.)
Accomplishments
Agenda Crashers!!
• 6 NEB Meetings
• 1 NAB Meeting
• 8 ECNO Face to Face Meetings
• Entity NLBS
• 4 Staff Council Meetings
• 2 Staff Council Cabinet Meetings
Nursing Strategic Plan
SGTF Goals
Transformational leadership and
professional development
(provide current and future healthcare
leaders and care providers the
environment, tools, evidence and skill
development to lead during a time of
healthcare reform and transition)
Goal:
Work with Organizational Leaders,
Managers, and Staff to build and
optimize shared decision-making and
accountability in improving the quality
of care, safety and enhancing work life.
Goal :
Measurable:
Understand and design systems to
I have the opportunity to participate in maximize the benefit and utilize the full
decisions made by the person I report talents of the health care team.
to that affect my work environment
Th 68%
T 69%
R 71%
• Gap Analysis
• Pilot
I feel free to go to a higher boss than
• Pre and Post Measurement
the person I report to for discussing
any problems that are bothering me
Th 56%
T 59%
R 62%
Turnover Rate
Th 12%
T 11%
R 10%
SGTF Tactics to accomplish
Partner with Organizational
Development Specialist to create 3
Dimensional Approach
•
•
•
Elevate-coaching
HR-Satisfaction
SG-decision making
Monitoring and Evaluation of Work
•
•
Dashboard Implementation
Turnover Analysis
Collaborate with Leader Development
Task Force on leadership initiative
•
Health of the Unit
Nursing Strategic Plan
Evidence-based practice and effective
processes
(lead the nation in producing evidence
that will drive nursing practice,
recognizing and legitimizing the
evolution of knowledge in a rapidly
changing environment. Create passion
and discipline for the translation of
evidence into practice that will
optimize patient outcomes.)
SGTF Goals
GOAL :
Work with Organizational Leaders to
expand shared decision-making
structure and process
SGTF Tactics to accomplish
Develop and Implement Pilot 3
Dimensional Approach {Adult and
Children's Hospitals}
• Shared Decision Making
Data
• Employee Satisfaction
• Elevate Coaching and
Rounding
Gap Analysis of Data
Measurable:
Improve Outpatient Unit Board Chair
Election process:
Th 65%
T 75%
R 80%
Unit Board Assessments (qualitative
and quantitative).:
• Outpatient CY2010
• Inpatient CY2011
Improve Outpatient participation in
survey process:
Th 425
T 500
R 600
Operationalize
Clinical Dispute Resolution Panel
• On-going education
• Deploy panel as needed
• Evaluate process following
panel meetings
I have the opportunity to participate in
decisions made by the person I report
to that affect my work environment
RN Th 68%
T 69%
R
71%
LPN Th 64%
T 69%
R
71%
Nursing Strategic Plan
Evidence-based practice and effective
processes
(lead the nation in producing evidence
that will drive nursing practice,
recognizing and legitimizing the
evolution of knowledge in a rapidly
changing environment. Create passion
and discipline for the translation of
evidence into practice that will
optimize patient outcomes.)
Measurable:
Complete SG Education Portfolio
redesign
Improve participation and
communication via web portal:
Average page views/month
Th 200
T 350
R 500
Improve to .70 of expected mortality
rate
SGTF Goals
GOAL :
Work with Organizational Leaders to
expand shared decision-making
structure and process
SGTF Tactics to accomplish
Nursing Bylaws to BOT for approval
Redesign SG Education Portfolio
Initiate development SG/Board Basics
modules for online learning via LMS
Partner with Education Experts and BTB
Chairs on combined learning
experiences that include staff nurses.
Plan/execute Bylaws Convention
• Implement approved SG
structure for VUMC Nursing
leadership boards
• Ensure alignment across the
enterprise
• Understand the impact and
coordinate skill set with the
work
o Organizational
Development Leader
position
Collaborate with Nursing Research and
CCI on Quality Initiatives
• Implement standing agenda
item for UB’s related to
system quality initiative
Service Improvement
Brent Lemonds & Todd Reimer
Service Improvement
PURPOSE
To identify and resolve issues hindering/preventing faculty and
staff from doing their bedside duties that ultimately impacts
meeting the needs of our patients and their families.
Major Accomplishments
• Mapped all Measureable Outcomes to Pillars and
Nursing Goals
• Food Service
• Using CCI Consultant to Implement Lean Principles to
Performance Improvement – Scores went Up !!
• EVS & Patient Transportation
• Continued results improvement
• Implemented Teletracking for Dashboard results
SERVICE IMPROVEMENT COMMITTEE
SEMI-ANNUAL REPORT
Brent Lemonds
Todd Reimer
GOALS
Maintain Scorecard, Reporting Track
Metrics, and Facilitate Course Corrections
as a Team
Communicate with Manager's Council
ACCOMPLISHMENTS
2009- Established Service Agreements
with all service areas between service
departments and nursing areas.
2010 -Teletracker in place. Steady
improvement noted in Patient Transport.
Meeting metrics in Linen Services,
Information Systems, Supplies/Equipment,
Bed Delivery.
2009 Identified responsibilities between
units and service areas for equipment/area
cleaning
ONGOING WORK
Establish New Metric for Admitting
? Early morning admitting times
Establish New Metric for Bed Management
? Patient fall off queue in three days
Requested CCI Consult for Nutrition
Services 6/2010 due to no progress toward
meeting metrics
Point of Use System installation to improve
supply distribution.
Patient Transport Subcommittee
Accomplishments
• Hired Additional Staff
• Increased Patients Transported by
Patient Transport to 81% of
discharges to home.
• 75% of transports are completed
within 35 minutes
• Average transport time is 28
minutes
Service Standard
• Patient will be ready for transport
when transporter arrives for
patient
– (Service – overall teamwork;
Quality of Care)
• Patient Transport will complete
all transports within 35 minutes
– (Service, Quality of Care)
• Decrease the number of Bed
Transport Tracking, increase
stretcher transports.
– (Service – improve efficiency,
Overall Teamwork, VUMC Results
of Operations)
Environment Subcommittee
Accomplishments
•
•
•
Average response time is 27 minutes.
Average cleaning time 34 minutes.
The turn around time from when the
patient is discharged till the room is
ready has been an average of 61
minutes.
Service Standard
• Turnaround time completed
within 90 minutes during peak
hours of 1-8 pm.
– Service – meeting volumes,
Quality of Care
• Isolation rooms will be completed
within 2 hours from central
dispatch notification
– Service, Quality of Care, Meeting
Volumes
Nutrition Services
Accomplishments
• Lean Management Improvements
• Metrics went “green” on
scorecard
Service Standard
• Meal Rounds. Visit 7% of the
patient Population.
• Service – Patient Satisfaction
• Food is rated excellent 19% of the
time.
• Service – Patient Satisfaction
• Test Tray scores will be at 90% or
better.
• Service - Quality
• At your Request Service Trays will
be delivered to patient within 44
minutes.
• Service - Timeliness
Materials Management
Accomplishments
• Preparing to implement Point of
Use
• Linen services preparing to
provide manager statistics
through on-line portal
Service Standards
• Turn around time for supplies 20
minutes 90% of the time.
• Linen items available on each unit
98% of the time.
Equipment Subcommittee
Accomplishments
Service Standard
• Delivery of product after request
made to Service Center within 20
minutes 95% of the time.
– Service – Teamwork
– Finance - Volumes
• Delivery of owned specialty bed
after call is placed to the Service
Center within 30 minutes (if beds
are available) 90% of the time.
– Service – Quality of Care
ED Registration, Admitting,
Bed Management
Accomplishments
• Met previous metrics
• Determining New Metrics
Service Standards
• Phone calls answered by
designated response 88% of the
time.
• Calls requiring transfer will follow
protocol 88% of the time.
Evaluation
Nancy Wells
Overall Goal
Recruit and retain excellent professional nurses
Annual RN Turnover
18
16
National
Benchmark
Percent of Turnover
14
12
10
8
6
4
2
0
2005-06
2006-07
2007-08
2008-09
2009-10
Data Sources
Source
Staff Satisfaction Survey
Unit Board Assessment
NDNQI RN Satisfaction Survey
Date
Sample
Fall 2009
Fall 2009
Summer 2010
2358
503
2288
Job Plans for Next Year
Job Plans
VUMC 2010
AMC
Remain in direct care at
hospital
90
88
Direct care at a different
hospital
4
5
Leave direct care
4
4
Change careers
1
1
Retire
0
1
NDNQI RN Survey 2010
Nurse Residency Recruitment
250
200
Number of Recruits
191
150
100
160
117
129
114
50
0
Summer 2008 Winter 2009 Summer 2009 Winter 2010 Summer 2010
Nurse Resident Retention
Duration of Employment
12 months
18 months
Retention
90%
80%
Developing Leaders
• Frontline Leadership Academy
– Staff and charge nurse development
• S3
– Charge nurse development
• E3
– Manger development
Nurse Manager Ability
4
Mean Scale
3.5
3
2008
2.5
2010
2
1.5
1
VUMC
NDNQI RN Satisfaction Survey 2010
AMC
90th
Recognition for a Job Well Done
RN
VUMC
Best in Class
0
Staff Satisfaction Survey 2009
20
40
60
Percent Favorable
80
100
Staffing & Resource Advocacy
4
Mean Scale
3.5
3
2008
2.5
2010
2
1.5
1
VUMC
NDNQI RN Satisfaction Survey 2010
AMC
90th
Enough People Available to
Accomplish Necessary Workload
RN
VUMC
Best in Class
0
Staff Satisfaction Survey 2009
20
40
60
Percent Favorable
80
100
Change in Overtime Worked
0.5
0.4
0.3
Mean Scale
0.2
0.1
0
-0.1
Series 1
VUMC 2010
-0.2
-0.3
-0.4
-0.5
NDNQI RN Satisfaction Survey 2010
AMC
Use of EAP Program by Nurses
350
292
Number of Consults
300
250
218
228
06-07
07-08
198
200
135
150
211
138
107
100
66
76
50
0
00-01
01-02
02-03
03-04
04-05
05-06
08-09
09-10
Had Enough People to Lift/Move
100
Percent Yes
80
60
40
20
0
2010
NDNQI RN Satisfaction Survey 2010
AMC
90th
Nurse Participation in Hospital Affairs
4
Mean Scale
3.5
3
2008
2.5
2010
2
1.5
1
VUMC
NDNQI RN Satisfaction Survey 2010
AMC
90th
Good Communication Among Work
Group
RN
VUMC
Best in Class
0
Staff Satisfaction Survey 2009
20
40
60
Percent Favorable
80
100
Opportunity to Participate in Decisions
RN
VUMC
Best in Class
0
Staff Satisfaction Survey 2009
20
40
60
Percent Favorable
80
100
Inpatient Unit Board Assessments
Year
2003
2005
2007
2009
Unit
Interviews
38
44
39
39
Surveys Completed
All
982
586
662
790
Nurses
527
408
451
503
Percent of Units with Unit Boards
100
97
95
97
2005
2007
2009
Percent
80
60
68
40
20
0
2003
Unit Board Assessments 2003 - 09
Group Cohesion Over Time
7
Mean Scale
6
5
4
3
2
1
2003
Unit Board Assessments 2003 - 09
2005
2007
2009
Satisfied with Involvement in Decisions
5
Mean Scale
4
3
2
1
2005
Unit Board Assessments 2003 - 2009
2007
2009
Decisional Involvement Scale
5
Mean Scale
4
3
Actual
2.74
2
2.26
2.67
2.09
1
2007
Unit Board Assessments 2007 - 09
2009
Preferred
Collaborative
Decision
Making
Work Group Values Diversity
5
Mean Scale
4
3
Series 1
2
1
2005
Unit Board Assessments 2003 - 2009
2007
2009
Striving to
Reach the
top