ND Pathways to Excellence Pilot Program Overview and Presenters (updated )

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ND Pathways to Excellence Pilot Program Overview and Presenters (updated 1-24-15)

Participating Hospitals

POC Strategic Priority Pathway to Excellence Action Learning

Goals

Month Consultant Time Altru Health

System

Pembina County Memorial Hospital

Altru: Margaret Reed [email protected]

Pembina County: Lisa LeTexier

[email protected]

Engagement of staff utilizing the processes of shared governance

SMART goal: By the end of the 4th quarter of 2015, Altru Nursing will have implemented the shared governance model through the use of ACT-N and unit council interventions and education.

Practice Standard 1: Nurses Control the Practice of Nursing

1. Identify structures and processes to support engagement of staff utilizing shared governance Jan 23, 2015 Marsha HR 12-1 EST Jamestown Regional Medical Center Pembina County Memorial Hospital Langdon Hospital

Jamestown: Trisha Jungels [email protected]

[email protected] Langdon: Jamie Nienhuis [email protected]

Is there evidence of how preceptors individualize the orientation of a nurse using actual needs assessment data, and is staffing adjusted to accommodate those needs? Is there a process that prepares preceptors for their roles?

Provide education resources for how to be a successful preceptor.

Expand our orientation program to include nurses’ evaluations and provide feedback throughout orientation process.

Are nurses evaluated and given feedback throughout the orientation process? SMART goal: Pembina County Memorial Hospital will have education training available for all preceptors by June 2014.

Practice Standard 1: Nurses Control the Practice of Nursing

1. Identify structures and processes to ensure staffing accommodates orientation of new nurses

Practice Standard 4: Orientation Prepares Nurses for the Work Environment

2. Identify structures and processes for how preceptors can individualize the orientation of a nurse using actual needs assessment data

3. Identify structures and processes supporting the preparation of preceptors for their roles

4. Identify structures and processes for evaluating and giving feedback throughout the orientation process

Feb 17,

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2 SMART goal: The pathways to excellence

committee will update the new employee orientation checklist, ER orientation, and surgical orientation by June 2015.

SMART goal: All new employees will complete a self-assessment upon hiring to be given to preceptor on Day 1 of orientation. The orientating employee will complete assessment at 3 weeks and give preceptor feedback.

SMART goal: An assessment will also be completed at end of orientation as well as can be done as needed. At the 3 week assessment period the preceptor will give feedback to the new hire.

SMART goal: Newly hired nurses will receive orientation.

1. Orientation will include opportunities to perform clinical skills and assessments. 2. Orientation will continue for up to several

weeks depending on the previous experience of the nurse.

3. At the start of orientation the orientating nurse and nursing administration will set specific goals to accomplish during the orientation period.

4. For the first 4 weeks orientating nurses will meet with the ADON, DON and clinical mentor each week to discuss progress toward goals.

5. If progress is adequate meetings about goals will become bi-weekly until orientation is considered complete.

5. Identify structures and processes to expand the orientation program to include nurses’ evaluations and provide feedback throughout orientation process

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3 6. At the end of orientation the newly oriented

nurse and the ADON, DON and clinical mentor will meet to discuss the orientation process and future goals for the newly oriented nurse.

7. Meetings and feedback will be documented in the employee file.

Langdon Hospital Fargo VA Health

Care System

Langdon: Jamie Nienhuis [email protected] Fargo VA: Andrea Haugen [email protected]

Is there a mentoring program for nurses at all levels to better develop professionally?

Is there a mentoring program in place that helps nurses at all levels develop professionally? SMART goal: Mentoring will be discussed with nursing staff at the January nursing staff meeting.

Input from staff will be sought about how they would like to see mentoring work within our staff mix.

In April a mentoring process will be established including all nurses who wish to participate. At the end of the year the program will be assessed for evidence of meeting the expectations of staff and changes considered for improving and continuing the program.

Practice Standard 6: Professional Development is Provided and Used 1. Identify structures and processes in

place to support a mentoring program for nurses at all levels to better develop professionally Feb 20 2015 Marsha HR 2-3 EST Altru Health System Sanford Health at Mayville

Sanford Health at Mayville:

Samantha Fugleberg

samantha.fugleberg@sanf ordhealth.org

Equitable compensation is provided. Does the organization evaluate compensation packages in the marketplace to ensure that nurses are compensated fairly, equitably and

competitively?

How each nursing professional can assist in our

Practice Standard 1: Nurses Control the Practice of Nursing (EOP1.1.0-1.10)) 1. Identify structures and processes for

supporting nursing professional to assist in the recruitment and retention in staff

Feb 19

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Langdon Hospital Pembina County Memorial Hospital

Langdon: Jamie Nienhuis [email protected] Pembina County: Lisa LeTexier

[email protected]

recruitment and retention in staff?

SMART goal: Establish processes with Human Resources dept and Learning and

Organizational Development to create a 5 year Man-Power plan to increase retention

and recruitment of nurses (with emphasis on bedside staff) to be available for 2016 budget planning by the end of 2nd quarter of 2015. SMART goal: Facility will reward longevity of nursing staff by matching 401K hours worked at rate and interval as following: 1% at 10 years, 1.5% at 15 years, 2% at 20 years, 2.5% at 25 years, 3% at 30 years, etc. within 1 year. SMART goal: Facility will increase shift differentials to the following: NOC

weekday: $2.25, weekend day shift: $1.50, weekend PM shift: $2, weekend NOC shift: $3.50 within 6 months.

Practice Standard 7: Equitable Compensation is Provided

2. Identify structures and processes to ensure equitable compensation is provided.

3. Identify structures and processes for evaluating compensation packages in the marketplace to ensure that nurses are compensated fairly, equitably and competitively Jamestown Regional Medical Center Fargo VA Health Care System Sanford Health Pembina County Memorial Hospital

Jamestown Trisha Jungels [email protected] Fargo VA: Andrea Haugen [email protected] Sanford Health at Mayville: Smantha Fugleberg samantha.fugleberg@sanf ordhealth.org

[email protected]

Are there programs and policies in place that reflect a commitment to a balanced lifestyle for employees?

Are there programs/policies in place that reflect a commitment to balanced lifestyles for employees?

Practice Standard 9: A Balanced Lifestyle is Encouraged

1. Identify structures and processes that a commitment to a balanced lifestyle for employees

March

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5 Sanford Health at

Mayville

Pembina County Memorial Hospital

Sanford Health at Mayville: Samantha Fugleberg samantha.fugleberg@sanf ordhealth.org

[email protected]

Collaborative relationships are valued and supported. Are there education sessions that address how to facilitate communication or collaboration among employees?

SMART goal: Begin quarterly meetings that include each department to discuss problems, concerns, and expectations of each department within three months.

SMART goal: Facility will implement a mandatory discipline policy for disrespectful behavior, berating, bullying, etc. within 2 months.

SMART goal: Construct an updated Epic how-to-guide that is specific to the Mayville facility within 6 months.

Practice Standard 10: Collaborative Relationships are Valued and Supported 1. Identify structures and processes for

ensuring collaborative relationships are valued and supported.

2. Identify structures and processes addressing how to facilitate

communication or collaboration among employees April 2015 Marsha HR 1hr Altru Health System Langdon Hospital Sanford Health Mayville Pembina County Memorial Hospital

Langdon: Jamie Nienhuis [email protected] Sanford Health at Mayville: Smantha Fugleberg samantha.fugleberg@sanf ordhealth.org

[email protected]

Skill obtainment of utilizing evidence based findings to develop initiatives that improve nursing practice.

SMART goal:

Establish deliberate use of evidence based Nursing practice initiatives as identified by nursing leadership, care management and the direct patient care nursing staff through establishment of a structure that identifies said initiatives(to be in place by April 2015). By 4th quarter of 2015, Altru will also have in place a structured "train the trainer" program to assist nurses in transferring knowledge

Practice Standard 12: Evidence Based Practices are Used

1. Identify structures and processes ensuring skill obtainment of utilizing evidence based findings to develop initiatives that improve nursing practice

April

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6 Pembina County

Memorial Hospital Langdon Hospital

[email protected] Langdon: Jamie Nienhuis [email protected]

Have nursing staff involved in direct care complete a quality study on a health care initiative?

Are direct care nurses provided multiple opportunities for participating in and learning about quality initiatives?

SMART goal: Beginning in January quality assurance data for the month will be presented to nursing staff through staff meetings and e-mailed reports.

Staff will be given the opportunity to collect quality improvement data through various means including assisting with ER data collection, inpatient data collection and nightly checklists.

When areas of deficiency are discovered an ad-hoc committee of nursing staff will be convened to assess and implement improvement plans. Members of these committees will be selected based on expertize and interest in the given area.

Practice Standard 12: A Quality Program is Used

1. Identify structures and processes for involving direct care nursing staff in a quality study on a health care initiative 2. Identify structures and processes to

provide direct care nurses opportunities to participate in and learning about quality initiatives?

April

2015 Marsha HR 1hr

Pembina County

Memorial Hospital Pembina County: Lisa LeTexier [email protected]

Educate all staff members on our application, acceptance and encourage participation to the Pathway to Excellence designation.

1. Review of the Pathway to Excellence Program focusing on application process and staff member participation to the Pathway to Excellence

designation

May

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7 Consultants

SHARON A. CUSANZA, MSN, RN, NEA-BCSharon Cusanza brings over 32 years of nursing experience to her consultation practice, including nursing leadership, quality improvement, and Magnet® experience. She is currently the Hospital RM and

Education Specialist for LAMMICO and previously the director of Magnet at Ochsner Medical Center. She has successfully written two sets of Magnet application documents and coordinated the accompanying site visits, most recently in 2013. Sharon possesses in-depth understanding and analysis of the Magnet Recognition Program® Application Manual and is a Fundamentals of Magnet™ certificate holder. She also has over 15 years of experience developing local and regional conferences for professional organizations. In addition to consulting, she has presented at ANCC Magnet workshops.

Summary of Services

 Conducts gap analysis and readiness assessments, and provides strategies for success  Develops customized education and training to support organizational needs

 Assists organizations with document development and review  Electronic document submission

 Conducts comprehensive on-site reviews in preparation for site visits  Works with all stakeholders to achieve organizational goals

Education

 BSN, Louisiana State University Health Science Center, New Orleans, LA  MSN in executive nursing, University of South Alabama, Mobile, AL

Certifications and Certificates

 American Nurses Credentialing Center—Nurse Executive, Advanced

 American Nurses Credentialing Center—Fundamentals of Magnet™ Certificate Holder Professional Memberships

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8 Marsha Hughes-Rease MSOD, MSN, RN With 30+ years of experience in health care and over 10 years of consulting experience, Marsha Hughes-Rease brings a wealth of knowledge about organization effectiveness, culture change management, and group process to her consulting practice. She integrates this knowledge with her consulting expertise to help health care organizations operationalize the Magnet® model to achieve a professional practice environment focused on achieving empirical outcomes in a changing healthcare environment.

Marsha has consulted with health care administrators, nurse leaders, and clinical nurses in 30+ health care organizations that have earned Magnet Recognition®, or who are on the Magnet® or Pathway to Excellence® journey. Using an intentional and inclusive consulting approach, she focuses on engaging clinical nurses, nurse managers, and other key stakeholders to accelerate the achievement of Magnet Recognition® or Pathway to Excellence®. She collaborates with senior nurse leaders and the chief nurse executive to identify and take strategic actions to create organizational alignment and commitment to the organization's mission and vision.

Marsha's consulting specialty areas include providing an organizational assessment and gap analysis for Magnet Recognition® or Pathway to Excellence®, identification of concrete actions to close the gaps, facilitating the development and implementation of a professional practice model, facilitating the development and implementation of a shared decision-making model compatible with the organization's governance structure, review of written documents for Magnet Recognition® and Pathway to Excellence submission, readiness preparation for a Magnet Recognition® site visit, and customized training. Marsha regularly facilitates the 2-day Journey to Magnet Excellence® workshop. She has also co-designed and facilitates the 1-day workshop, Empirical Outcomes: Exceeding Magnet Expectations that provides participants with an integration of practical tools to excel as

change leaders. Summary of Services

 Helps to determine readiness to submit a Magnet® or Pathway to Excellence® application based on a gap analysis  Conducts a self-assessment that familiarizes participants with the Sources of Evidence in the Magnet® Model while

simultaneously gathering quantitative data to use as part of the gap analysis report

 Conducts a self-assessment that familiarizes participants with the Pathway to Excellence® Elements of Performance while engaging them in action planning to address perceived gaps

 Conducts comprehensive on-site readiness assessments in preparation for Magnet site visits which includes helping clinical nurses learn a communication technique that reflects self-confidence, competence, and articulates the value of nursing at the unit level

 Provides transformational leadership development including facilitating peer coaching techniques to address complex issues

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9  Uses creative strategic planning techniques to increase staff nurse engagement, alignment with organizational and nursing strategic goals, and effective execution at

the unit level

 Customizes education and just-in-time training on transformational leadership, structural empowerment, and change management  Works with senior leaders to design strategic interventions to address performance gaps

 Works with nurse executives to address challenges at all levels that may potentially derail the Magnet Recognition® or Pathway to Excellence® designation process Education

 BSN, University of Kentucky, Lexington, KY

 MSN, Nursing Administration, George Mason University, Fairfax, VA  MS, Organizational Development, Johns Hopkins University, Baltimore, MD

Certifications

 Fundamentals of Magnet™ Certificate

 Graduate Certificate, Leadership Coaching, Fielding Graduate University, Santa Barbara, CA  Graduate Certificate, Skilled Facilitator, Johns Hopkins University, Baltimore, MD

Professional Memberships

 American College of Healthcare Executives  American Nurses Association

 American Organization Nurse Executives  Institute of Coaching

 International Coaching Federation  International Leaders Association  Plexus Institute

 Sigma Theta Tau International Special Acknowledgements

 Published numerous articles and book chapters including a chapter on Transformational Leadership in the award-winning text, Nursing Management Principles and Practice (2011, Oncology Nursing Society)

 Served as adjunct faculty member at George Mason University College of Nursing and is a faculty member at Duke Corporate Education, and is a certified Executive coach.

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10 RHONDA R. FOSTER, EDD, MPH, MS, RN, NEA-BC Energetic, visionary, and insightful, Dr. Rhonda Foster is a published and highly sought-after hospital consultant with a penchant for driving change, quality, and organizational improvement. While she served as the vice president of patient care services and chief nursing officer for the Children's Hospital of Michigan, Dr. Foster's

collaborative and transformative leadership style led to innovative patient-care programs and the esteemed Magnet® recognition. An expert in a variety of healthcare topics, Dr. Foster has been a featured presenter at American Nurses Credentialing Center (ANCC) conferences and seminars, and over the course of her esteemed professional career, Dr. Foster has traveled the globe conducting lectures and seminars on quality healthcare delivery, hospital administration, and leadership. During her tenure as chief nursing officer of the St. Joseph Health System of Sonoma County, Dr. Foster was considered an empathetic advocate and was lauded for her ability to inspire and motivate others toward a common vision.

Dr. Foster's primary strength is her ability to put theory into practice. Understanding the benefits of technological advances in healthcare administration, Dr. Foster, a catalyst and early adopter, led the implementation of an electronic medical record system that provided computerized physician order entry and ease in nursing documentation and medication administration. In addition, prior to its becoming a widely accepted practice, Dr. Foster implemented a nurse residency program for new graduate nurses that resulted in a 40% reduction in turnover.

Credible and scholarly, Dr. Foster's work can be found in the Journal of Nursing Management, Oncology Nursing Society

publications, and other reputable print and online resources. Dr. Foster has a Master of Science degree from Georgetown University, a master in public health degree from the Northwest Ohio Consortium, and a doctorate of education in leadership studies from Bowling Green State University.

Summary of Services

 Conducts readiness assessments and provides strategies for success  Develops customized education and training to support organizational needs  Assists organizations with document development and review

 Submits electronic documents

 Conducts comprehensive on-site assessments in preparation for site visits

 Works with all stakeholders to achieve organizational goals and strategic alignment Education

 ADN – Michael J. Owens Technical College  BSN – University of Toledo

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11  MSN – Nursing Administration in Health Services – Georgetown University

 Master's in Public Health Administration – Northwest Consortium for Public Health  Doctorate of Education in Leadership Studies – Bowling Green State University

Certifications

 American Nurses Credentialing Center – Board-Certified Nurse Executive, Advanced Professional Memberships

 American College of Health Care Executives  American Nurses Association

 American Organization of Nurse Executives  National Association of Health Service Executives  Sigma Theta Tau International

KAREN GABEL SPERONI, PHD, MHSA, BSN, RN Dr. Speroni helps hospitals and hospital systems through all phases of their Magnet and Pathway to Excellence journey. She is also an acknowledged research process expert who facilitates research and evidence based practice infrastructures for Magnet® designation and re-designation.

Dr. Speroni has nearly 30 years' experience in biomedical and evidence-based practice research, including consulting work with academic medical centers, Institutional Review Boards, and community hospitals. She currently chairs the University of Maryland Shore Regional Health Nursing Research Council, serves as a clinical scientist on two Institutional Review Boards

and provides research consultation for other hospitals. She is a prolific author and presents her research findings and processes nationally and internationally. An active mentor, she guides nurses in research and evidence-based practice.

Her childhood obesity research project, Kids Living Fit™, and also Nurses Living Fit™, was profiled as an innovation of excellence by the Agency for Healthcare Research and Quality (AHRQ). In 2012, she received the Virginia Magnet® Consortium Nursing Excellence Award for leadership. Summary of Services

 Conducts organizational assessments

 Reviews application documents for Magnet and Pathway to Excellence

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12  Prepares organizations for successful ANCC site visits working with hospital groups, shared governance councils, and clinical nurses

 Assists with strategic planning for nursing excellence

 Mentors and works with teams to successfully achieve strategic outcomes

 Helps organizations develop effective shared leadership and decision-making structures, processes and outcomes, shared governance models and professional practice models

 Research process expert

 QuERY (Quality improvement, Evidence-based practice, Research and You) process expert: facilitates incorporation of quality improvement, evidence-based practice, and research at the unit level

Education

 PhD—Business Administration-Health Care Management, Eastern University  MHSA—Policy, Planning and Marketing, The George Washington University  BSN—Research College of Nursing-Rockhurst University

Certifications

 American Nurses Credentialing Center—Fundamentals of Magnet™ Certificate Holder Professional Memberships

 American Nurses Association  Virginia Nurses Association  Sigma Theta Tau International

Selected Publications

Wilson, J., Speroni, KG, Jones, RA & Daniel, M.G. (2014). Exploring how nurses and managers perceive shared governance. Nursing2014, 22: 19-22. www.Nursing2014.com DOI-10.1097/01.NURSE.0000450791.18473.52

Duffy, M.T., Friesen, M.A., Speroni, K.G., Swengros, D.A., Shanks, L., Waiter, P. & Sheridan, M.J. (2014). Bachelor of Science in Nursing Degree Completion Barriers, Challenges, Incentives and Strategies. Journal of Nursing Administration. 44(4), 232-236.

Speroni K.G., Fitch T., Dawson E., Dugan L., & Atherton M. (2013). Incidence and cost of workplace violence perpetrated by hospital patients or hospital visitors. J Emerg Nurs. 1-11. doi:10.1016/j.jen.2013.05.014.

Friesen, M.A., Herbst, A., Turner, J.W., Speroni, K.G. & Robinson, J. (2013). Developing a Patient-Centered ISHAPED Handoff With Patient/Family and Parent Advisory Councils. Journal of Nursing Care Quality, (28)3, 208-216.

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13 Speroni, K.G., Fisher, J., Dennis, M., & Daniel, M. (2013). What causes near-misses and how are they mitigated? Nursing 2013, 43(4), 19-24.

McLaughlin, M., Speroni, K.G., Kelly, K.P, Guzzetta, C., & Desale, S. (2013). National Survey of Hospital Nursing Research, Part 1. Research Requirements and Outcomes. Journal of Nursing Administration, 43(1), 10-17. Reprinted 2013, 43(10), S28-S35.

Kelly, K.P., Turner, A., Speroni, K. G., McLaughlin, M., and Guzzetta, G. (2013). National Survey of Hospital Nursing Research, Part 2. Facilitators and Hindrances. Journal of Nursing Administration, 43(1), 18-23. Reprinted 2013, 43(10), S36-S41.

Speroni, K.G., Earley, C., Seibert, D., Kassem, M., Shorter, G., Ware, C., Kosak, E. & Atherton, M. (2012). Effect of Nurses Living Fit™ Exercise and Nutrition Intervention on Body Mass Index in Nurses. Journal of Nursing Administration, 42(4), 231-238.

Westerfield, H.V., Stafford A.B., Speroni, K.G., & Daniel, M.G. (2012) Survey Research of Patients' Perceptions of Patient Care Providers with Tattoos and/or Body Piercings. Journal of Nursing Administration, 42(3), 160-164.

Stagg, S., Sheridan, D., Jones, R. A., & Speroni, K. G. (2011). Evaluation of a Workplace Bullying Cognitive Rehearsal Program in a Hospital Setting. The Journal of Continuing Education in Nursing, 42(9), 395-403.

Speroni, K.G., Lucas, J., Dugan, L., O'Meara-Lett, M., Putman, M., Daniel, M. & Atherton, M. (2011). Comparative Effectiveness of Standard Endotracheal Tubes versus Endotracheal Tubes with Continuous Subglottic Suctioning on Ventilator-Associated Pneumonia Rates Journal of Nursing Economic, 29(1), 15-21. Speroni K.G., Earley, C., & Atherton, M. (2007). Evaluating the Effectiveness of the Kids Living Fit™ Program: A Comparative Study. Journal of School Nursing, 23(6), 329-336.