Making a difference together, every day Nursing mainlinehealth.org/nursing Membership on the medical staff of Main Line Health hospitals does not constitute an employment or agency relationship. ANNUAL REPORT A Letter from the Chief Executive Officer Dear Colleagues, The character of our nursing staff is often highlighted during the most poignant moments in our patients’ lives. Whether welcoming a new baby or mourning the loss of a loved one, our nurses are by the bedside of our patients to provide safe, high-quality, compassionate care. I am constantly reminded of the spirit of our nursing staff when positive stories and notes of thanks pour in from grateful patients and their loved ones, as well as from our colleagues across the System. We have included patient stories throughout the annual report to exemplify the excellent care that is given on a daily basis. Behind these stories is the significant responsibility we have as health care professionals to truly care—physically and emotionally—for our patients and their family members. The letters and stories Main Line Health® receives demonstrate our staff ’s commitment to this responsibility in extraordinary ways, and I am humbled to be part of this team. The following annual report highlights the accomplishments of Main Line Health’s exceptional team of nurses, technicians, unit secretaries and clerks, all of whom are truly the backbone of our organization. Each page demonstrates the commitment, tenacity and professionalism of our group of more than 2,900 nursing professionals who tirelessly work to provide superior care to our patients and community members. Much of the success of our nursing staff is due to their unwavering commitment to working closely with all members of the team to ensure better outcomes for our patients. This is evident from our many accomplishments over the past year—most notably our first-ever System Magnet® designation, an accomplishment that we are incredibly proud of. This outstanding achievement is the result of the entire Main Line Health family coming together—employees, members of the medical staff, Board members, volunteers and community partners— to demonstrate nursing excellence and our collective commitment to delivering a superior experience and keeping our communities healthy. I want to commend our entire patient care team for continually working to exemplify and inspire the core values of nursing—compassion, knowledge, learning, communication and excellence. I look forward to the many achievements to come. Thanks for all you do every day in providing our patients with safe, high-quality, compassionate care. Contents About Main Line Health ..............................................3 Ebola and Papal Visit Preparation............................11 System Magnet Designation ......................................4 Transformational Leadership ....................................12 Structural Empowerment ............................................5 Awards and Recognition............................................13 Council Accomplishments ..........................................6 Clinical Outcomes ......................................................14 A Letter from the Chief Medical Officer ..................7 New Knowledge and Innovation..............................15 Exemplary Professional Practice ..............................8 Selected Publications and Research ......................16 A Letter from the Chief Nursing Officer ................17 Sincerely, Jack Lynch President and Chief Executive Officer Main Line Health 1 2 ABOUT MAIN LINE HEALTH 2015 DATA 1,348 Licensed beds across the System (including Bryn Mawr Rehab Hospital and Mirmont Treatment Center) 7,792 Births Founded in 1985, Main Line Health (MLH) is a not-for-profit health system serving portions of Philadelphia and its western suburbs. At its core are four of the region’s respected acute care hospitals—Lankenau Medical Center, Bryn Mawr Hospital, Paoli Hospital and Riddle Hospital—as well as one of the nation’s premier facilities for rehabilitative medicine, Bryn Mawr Rehab Hospital; Mirmont Treatment Center for drug and alcohol recovery; and Main Line Health HomeCare & Hospice, a home health service. Main Line Health also consists of Main Line HealthCare, one of the region’s largest multi-specialty physician networks, and the Lankenau Institute for Medical Research, a non-profit biomedical research organization located on the campus of Lankenau Medical Center. Main Line Health is also comprised of four outpatient health centers located in Broomall, Collegeville, Exton and Newtown Square. Main Line Health Hospitals, with more than 10,000 employees and 2,000 physicians, are the recipients of numerous awards for quality care and service, including System Magnet® designation, the nation’s highest distinction for nursing excellence. Main Line Health was also named among the nation’s best employers by Forbes magazine. Mission The mission of Main Line Health is to provide a comprehensive range of safe, high-quality health services, complemented by related educational and research activities, that meet the health care needs and improve the quality of life in the communities we serve. 169,862 Vision Emergency room visits A superior experience for all patients, employees, physicians and our community. Values 956,820 Outpatient visits 16,207 HomeCare & Hospice patients 3 • Patient Safety • Excellence • Compassion • Integrity • Participation • Communication • Innovation • Diversity, Respect and Inclusion SYSTEM MAGNET DESIGNATION In March 2015, Main Line Health earned System Magnet designation—the highest distinction for excellence in nursing care, given to only seven percent of hospitals in the nation. This is the first time that the entire Main Line Health System has earned this designation. Lankenau Medical Center, Bryn Mawr Hospital, and Paoli Hospital earned their third consecutive designation, while Riddle Hospital and the Main Line Health HomeCare & Hospice division earned their first designation. Bryn Mawr Rehab Hospital also earned its first designation, making it one of four acute rehabilitation centers in the country, and the only one on the East Coast, to achieve Magnet status. Patients who are treated at a Magnet-designated hospital receive high-quality care from a nationally recognized and accredited nursing staff. Studies have shown that patients who are treated at a Magnet hospital as opposed to a non-Magnet hospital can experience benefits like increased patient satisfaction and patient safety and shorter hospital stays. In addition to allowing us to better serve our patients, our Magnet designation also allows us to attract top nursing talent from across the country to build a robust and skilled nursing staff. 1st time MLH has earned System Magnet designation 7% of hospitals in nation achieve Magnet designation 4 STRUCTURAL EMPOWERMENT COUNCIL ACCOMPLISHMENTS Nurses throughout Main Line Health are involved in decision-making councils and committees. The shared governance structure allows nurses to influence nursing practice and the Nursing Department’s strategic goals. Eileen Farley, MSN, RN, CRRN, NE-BC HEALTHY WORK ENVIRONMENT QUALITY IMPROVEMENT PROFESSIONAL DEVELOPMENT Oasis rooms and renewal centers Quality toolkit Back to school toolkit Rooms were created for staff to de-stress and rejuvenate during their work day. Oasis Rooms and Renewal Centers were opened at Lankenau Medical Center, Bryn Mawr Hospital, Paoli Hospital, Riddle Hospital and Bryn Mawr Rehab Hospital. An online orientation manual for incoming quality champions. The PowerPoint includes: A guide with tips and resources for nurses who are thinking about going back to school. The toolkit includes information about tuition reimbursement, online learning and searching for the right school. NURSING RESEARCH AND INNOVATION CLINICAL INFORMATICS CLINICAL PRACTICE Patient education and discharge instructions Medication safety • Quality Improvement Process • Main Line Health outcomes data • Key terms Administrative Director of Nursing, Bryn Mawr Rehab Hospital Nursing research day Updates were made to patient education to standardize and streamline documentation. Updates included: All Hospitals implemented medication safety practices to decrease distractions while a nurse is administering medications. Practices include: • Standardized disease-specific education forms • Visual cues to indicate medication administration in progress • Discharge instructions reformatted to make documentation easier • When possible, relocation of Pyxis to decrease interruptions A patient was in our rehab for two months after a brain aneurysm and a stroke, resulting in paralysis. Her husband spent time in the meditation room praying for a miracle. He later wrote a letter thanking our staff for doing God’s work and performing miracles for his wife. She is now on her way to good health. 5 A day dedicated to nursing research and evidence-based practice at Main Line Health. The conference features Main Line Health nurses and Villanova partners who are involved in nursing research. 6 A Letter from the Chief Medical Officer EXEMPLARY PROFESSIONAL PRACTICE Exemplary Professional Practice is evidenced by efficient care processes, interdisciplinary collaboration and superior patient outcomes. These outcomes are a result of practicing within our Professional Practice Model: PARTNERS. Dear Colleagues, Professional Practice Model (PARTNERS) On behalf of Main Line Health’s medical staff, I would like to take this opportunity to offer my sincere thanks to our entire nursing staff. Without the compassionate care and expertise our nurses provide to our patients, in addition to their commitment to partnering with all members of a patient’s care team, Main Line Health would not be what it is today— a thriving System that provides superior care to our patients. The PARTNERS model illustrates the environment of excellence Main Line Health nurses live in as key partners, providing high-quality service through superior patient care in a culture of safety. We commit to these principles every day through leadership, collaboration, evidence-based practice, engagement and professional development. By fostering an environment of interprofessional collaboration, our mission to provide a superior patient experience is carried out each and every day. Thank you to each member of our nursing team for your hard work and dedication to our patients and to the nursing profession. Marianne Harkin, BSN, MS, RN, NEA-BC, CNRN Vice President of Patient Care Services, Bryn Mawr Hospital A former Bryn Mawr Hospital patient, who was so appreciative of the compassionate care she received after her stroke, thanked the staff of the Neuro Cardiac Intensive Care Unit (NCICU) by presenting her care team with ornaments designed as “homes.” In a Sincerely, note from the patient, she thanked the staff for her exceptional care and hoped that the ornaments would remind them of all the patients they have helped Andrew Norton, MD get home over the years. Chief Medical Officer Main Line Health 7 8 PATIENT SAFETY ACCOUNTABILITY RESEARCH Red Rule Training For all staff Riddle Hospital Intensive Care Unit Three years without ventilator-associated pneumonia “Could this happen to you?” Prompts nurses to evaluate their care process Foley Fridays Nurses audit necessity of Foley catheter use Nursing Competency Model Application of adult learning principles to verify competencies with case studies, exemplars, and quality improvement monitors Eleven Nurse Leaders in EvidenceBased Practice Fellowship Attendees at Main Line Health Nursing Research Day Decrease in catheterassociated urinary tract infections Quality Toolkit Created by Quality Champions to orient nurses into their new role Six Institutional Review Board-approved nursing research studies Improves knowledge in providing optimal end of life care Lankenau Medical Center Emergency Department Nurses Educate the community during Domestic Violence Awareness Month EXEMPLARY PRACTICE Reflect, Renew, Restore Holistic Fall Conference at Lankenau Medical Center hosted by the Main Line Area Chapter of the American Holistic Nurses Association RELATIONSHIPS HomeCare & Hospice: 2015 HomeCare Elite Awarded to the top 25% of agencies in the nation for home health performance Nurse leaders serve on Southeast Pennsylvania Organization of Nurse Leaders Board Nurse serves as President of the Northeast Region Wound Ostomy Continence Nurses Society Clinical Nurse serves as chapter lead of American Holistic Nurses Association SUPERIOR PATIENT CARE Family Partner Advisory Councils • Lankenau Medical Center American Association of Critical-Care Nurses (AACN) Beacon Award • Bryn Mawr Hospital: Intensive Care Unit (ICU) and Neuro Cardiac ICU (NCICU) Magnet Ambassador Community Service Project Nurses Improving Care for Healthsystem Elders (NICHE) designation • Lankenau Medical Center • Bryn Mawr Hospital • Riddle Hospital • Bryn Mawr Hospital • Riddle Hospital “I Am The Patient Experience” training for all MLH staff • Paoli Hospital: Progressive Care Unit (PCU) and ICU • Riddle Hospital: ICU Main Line Health HomeCare & Hospice nurses teach Villanova students about transitional care 9 NURSES AS LEADERS End of Life Nursing Consortium Nurses in Research Fellowships Nursing Peer Review A committee that reviews and trends patient safety events TEACHERS Bryn Mawr Hospital’s Pediatric Unit Hosted the Halloween Diabetic Candy Exchange for children with Juvenile Diabetes Press Ganey Guardian of Excellence Awarded to Paoli Hospital for reaching the 95th percentile in each reporting period Collaboration with physician partners in Clinical Environment Workgroups • Bryn Mawr Rehab Hospital Nurse leader serves as President of PA Organization of Nurse Leaders Clinical nurse serves as President of the Association for Rehab Nurses Main Line Health is in the top decile for management of stage II or greater pressure ulcers Main Line Health’s Chief Nursing Officer serves as an ambassador of the American Heart Association’s “Go Red for Women” movement Stratus Technology Video language translation and American Sign Language interpretation for patients 10 Margie Iacobacci, MSN, RN, NEA-BC, CNOR Vice President of Patient Care Services, Lankenau Medical Center After an elderly patient passed, leaving behind her husband who was close to 90, our day shift nurse, Marianne Antes, came to his rescue. The man was distraught over losing the love of his life, and our nurses sat with him as much as they could, cried with him, and stayed with him as his wife passed. Marianne was extremely concerned about him getting home that night, so after her 12-hour shift, PREPARING FOR EBOLA AND THE PAPAL VISIT TRANSFORMATIONAL LEADERSHIP The safety of Main Line Health’s patients, employees, medical staff and volunteers is our number one priority. Over the past year, the staff and physicians across Main Line Health have had the opportunity to prepare for both the potential Ebola outbreak and a visit from Pope Francis to the Philadelphia region. Although the planning for each was very different, both required the unique ability to learn and take action. Transformational Leaders at Main Line Health inspire and stimulate others to achieve extraordinary outcomes. Our dedicated team of highly trained clinicians and administrators worked closely with local and state health officials to prepare for the possibility of caring for a patient with Ebola for several months, and the safety and well-being of all of our staff, patients, visitors and community members remained paramount during the entire process. As part of the preparation, Main Line Health established a cross-campus, multi-disciplinary Ebola Workgroup comprised of representatives from Emergency Management, Infection Control, Medical Staff, Nursing, Infectious Diseases, and Administration. Maximum infection prevention processes and precautions were in place across the System to isolate potential patients. Over 1,500 nurses, physicians and infection prevention personnel were trained in the donning and doffing of Personal Protective Equipment (PPE). For over three months prior to the arrival of Pope Francis, staff across Main Line Health prepared as a System to welcome the Pontiff to the Philadelphia region. From the construction of a Community Medical Tent at Lankenau Medical Center and the Main Line Health Papal Hotline Operators at Paoli Hospital, to the HomeCare & Hospice staff who traversed traffic barriers to reach patients, Main Line Health was ready to serve any needs of our communities and visitors to the region during this historic moment for the Philadelphia area. Many members of the staff made sacrifices to be away from their families and loved ones for the weekend, and were committed to providing superior care to patients and visitors to the area. Our preparedness was a true team effort with our local and state Law Enforcement, Fire and EMS leaders, governmental officials and other event organizers. Our team of Emergency Preparedness staff and all Hospital System Incident Command Teams and physician leaders worked together, covering several shifts, to ensure our readiness. The organization came together in the spirit of Systemness for both of these momentous events, and this is something for the entire Main Line Health community to celebrate. Through times of planned and unplanned change, Main Line Health nursing leaders influence nurses by providing a vision, support and a commitment to nursing excellence. NURSES INVoLVED IN STRATEGIC PLANNING SESSIoNS The Main Line Health Nursing Strategic Plan: Delivering superior patient care in an environment of excellence 200+ In the summer of 2015, the Nursing Department brought together over 200 nurses across the System to participate in strategic planning. There were several working sessions in which all nurses in attendance participated in a Systemwide SOAR (Strengths, Opportunities, Aspirations, Results) activity. Prior to the event, all the System nursing councils and individual campuses participated in a SOAR to reflect on past accomplishments and prioritize short-term and long-term goals. Nurses in attendance 25 SoAR highlights Average years as a nurse • Nurses of varying roles were in attendance (clinical nurses, educators, coordinators, nursing leadership and quality/patient safety representatives) • Participation of all nurses in developing the strategic plan 16 Average years at MLH NURSING VISION 3,372.5 Total years experience she took the time to drive him home. Our nursing staff consistently goes out of their way like this to show kindness and compassion to our patients. 2,099 Total combined years at MLH 11 12 AWARDS AND RECOGNITION CLINICAL OUTCOMES Main Line Health nurses and nursing units are continually recognized for their outstanding patient care, community work, and quality improvement initiatives. Our nurses are recognized through internal awards, regional recognitions, and national forums. 2015 GREATER PHILADELPHIA NURSE.CoM G.E.M. AwARD FINALISTS DAISy AwARDS BRyN MAwR HoSPITAL Barb Brogan Neonatal Intensive Care Unit— 100% eligible nurses with specialty certification Bryn Mawr Hospital Mary deSimone Bryn Mawr Hospital Patient and Staff Management Meghann Horst Paoli Hospital Volunteerism and Service Deb Mantegna Laurie Burns Riddle Hospital Elena Casanova-Ghosh Lankenau Medical Center Lynn Caramanico Lankenau Medical Center Riddle Hospital Home, Community and Ambulatory Care Caitlin Davalos Eileen Phillips Lauren Foley Riddle Hospital Advancing and Leading the Profession Riddle Hospital Bettyanne Sunderland Riddle Hospital Paoli Hospital Home, Community and Ambulatory Care Joan Landmesser Lankenau Medical Center Jackie Giallombardo Pediatrics—Highest percentage of Clinical Ladder nurses 6A—Zero CAUTI/CLABSI for greater than one year 4C—Greatest increase in patient satisfaction for communication with nurses 3B—Largest increase in percent of nurses with specialty certification Terre Mirsch, BSN, MS, CHPN, CHPCA Bryn Mawr Hospital Laurie Watson Dana Mahan Lankenau Medical Center Volunteerism and Service Bryn Mawr Hospital Director, Main Line Health HomeCare & Hospice PAoLI HoSPITAL Deb Ruddy Brittany Maze 2015 NIGHTINGALE AwARDS oF PENNSyLVANIA FINALISTS 6C—Zero hospital-acquired pressure ulcers for greater than one year Lankenau Medical Center Richard Hader Visionary Leader Award Caitlyn Ward Melissa Winters Bryn Mawr Hospital Sandy McAleer Award A HomeCare & Hospice patient was at an increased risk for a fire Mary Beth Hoban Main Line Health HomeCare & Hospice Nursing Educator in her home. After finding out LANkENAU MEDICAL CENTER RIDDLE HoSPITAL Paoli Hospital Clinical Practice RN Mary Ann Finnegan Jan Nash Joyce Foresman-Capuzzi Paoli Hospital Nursing Administration-Executive/CNO Advanced Practice Award Kathleen Pardini (winner) Leadership/Management Award Main Line Health HomeCare & Hospice Community Nursing Jackie Gerzabeck Laurie Watson Carol McCardle Lankenau Medical Center Community Nursing Clinical Nurse Award Nurse Legend Award Leadership in Nursing Award Barbara Kurtz Leadership in Nursing Award 13 Paoli Hospital Clinical Practice RN A one year educational program and immersion experience focusing on the science, the art, and the heart of Palliative Care. Bryn Mawr Hospital initiated this fellowship over five years ago and has graduated 26 staff. Nurse of the Year Evidence-Based Practice Fellowship Louise Hummel A mentorship program that educates and supports nurse leaders on how to conduct evidence-based practice projects. ENA Mary Bailey Award asked the lieutenant of the local fire department to visit the patient and install the proper detectors. The patient was extremely appreciative of our nurse going above and beyond to care for her health and her home. Emerging Leadership Award Advanced Practice Nurse Council BRyN MAwR REHAB HoSPITAL Victoria Welch Ellen Weaver System Palliative Care Fellowship Debbie Peterson Annette Frawley that there were no smoke detectors in the patient’s home, our nurse, Rosie, Marianne Collins Meghann Horst NEW INITIATIVES FOR 2016 Essence of Caring Award A council that links advanced practice nurses to Main Line Health nursing. Also provides a forum for professional development, networking and peer support. Judy Latham Excellence in Management Award 14 NEW KNOWLEDGE, INNOVATIONS, AND IMPROVEMENTS Our organization continuously incorporates evidence-based practice into patient care. With education in the nurse residency program and the research and evidence-based practice fellowships, clinical nurses and nurse leaders are offered tools to be innovative and explore new practices to provide exemplary care. Matthew Magargal, MHA, BSN, RN, PHRN, NE-BC Vice President of Patient Services, Paoli Hospital A trauma patient was admitted to our Critical Care Unit after a house fire. His 12-year-old son ran inside to try One way Main Line Health nurses share their innovative work is through posters, podiums and publications. Illustrated above is the continued growth in these areas. SELECTED PUBLICATIONS AND RESEARCH Wound Care Made Incredibly Easy! AORN Journal Chapter on Basic wound Care Procedures Developing Strategies for on Call Staffing: A working Guideline for Safe Practices Written by Kathleen McLaughlin, MSN, RN, CWOCN Toni Acello, MSN, RN to save him, and tragically lost his life. The father was bed-bound with limited mobility. Our team went above and beyond to arrange transportation with an ambulance to his son’s funeral, and Journal for Nurses in Professional Development Leaders’ Perception of Value of Nurse Residency Program Journal of Emergency Nursing Rita Linus, MSN, RN-BC CSI and U Collection and Preservation of Evidence in the Emergency Department Archives of Physical Medicine and Rehabilitation Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P a nurse and surgeon even volunteered to go with him and care for him so he could say goodbye to his son. We received gentleman, who told us how eternally Medical Complications During Inpatient Rehabilitation Among Patients with Traumatic Disorders of Consciousness grateful he was for the compassionate Barbara Merges, BSN, MHA, CRRN a letter several weeks later from the care he received. Nurse Leader The New Health Care Landscape: Disruptive Behaviors Influence work Environment, Safety, and Clinical outcomes Eileen Philips, RN, DNP, NE-BC 15 16 A Letter from the Chief Nursing Officer Dear Colleagues, I am proud to share with you a summary of the many accomplishments of the Main Line Health nursing staff in 2015. In my role as Chief Nursing Officer at Main Line Health, I have witnessed an amazing group of staff who work diligently to ensure a superior experience for our patients, their family members and our community. The level of engagement and commitment to the nursing profession is evident when walking through the halls of our hospitals and facilities across the System. As you have seen highlighted in this document, the past year has been filled with many notable accomplishments—our most remarkable being our first-ever System Magnet® designation. This honor was something achieved not only because of the work of our dedicated nursing staff, but because of the physicians and staff across the entire System. The valuable contributions of all levels throughout the organization led to the third consecutive designation for Lankenau Medical Center, Bryn Mawr Hospital, and Paoli Hospital, and the first designation for Riddle Hospital, Bryn Mawr Rehab Hospital and the Main Line Health HomeCare & Hospice division. Bryn Mawr Rehab Hospital is one of only four acute rehabilitation centers in the country, and the only one on the East Coast, to achieve Magnet status. Some of the other accomplishments of the Main Line Health nursing staff highlighted throughout this document include: Rosemary Wurster, BSN, RN, MPH, CEN, NEA-BC Vice President of Patient Care Services, Riddle Hospital • Decrease in hospital-acquired conditions • Recognition of Main Line Health nurses internally and in the community • Dissemination of nursing innovation and best practices through posters, presentations and publications As part of our nursing mission and vision, Main Line Health remains committed to professional development. As nurses, we are leaders and teachers, working to meet and exceed the expectations of our patients. To do this, we must participate in professional development activities and embrace evidence-based practice. As part of Main Line Health’s commitment to learning and changing, we have established goals toward achieving 100% BSN rates across the System. Aligning with the Institute of Medicine’s Future of Nursing Report, by 2020, Main Line Health is committed to attaining 80% BSN rate, 90% by 2025, and 100% BSN rate by 2030. I value the education and experience of our nurses and encourage them to be lifelong learners. I want to thank our entire nursing staff for the care they provide to our community and to each other. Main Line Health is an outstanding place with an amazing staff of nursing professionals. It is my privilege and pleasure to serve you. I hope you have enjoyed this report that highlights our many accomplishments, achieved by working together in the spirit of Systemness. Riddle Hospital staff planned and held a wedding ceremony for a patient, who was dying of cancer, and her long-time partner. The couple, who had been together for 38 years, said they had wanted to get married for a very long time. Our PCU administrative coordinator organized the wedding, with flowers, decorations and a minister, and made their dreams come true. Warm Regards, Barbara Wadsworth Chief Nursing Officer Main Line Health 17 18 Making a difference together, every day Nursing mainlinehealth.org/nursing Membership on the medical staff of Main Line Health hospitals does not constitute an employment or agency relationship. ANNUAL REPORT
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