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UCLA MEDICAL CENTER, SANTA MONICA
2013 Nursing Annual ReportHEALING HUMANKIND ONE PATIENT AT A TIME
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A Message from Our CNO: Edith Matesic
Through the Art of
Nursing, we strive to
heal humankind, one
patient at a time, by
delivering care that is
grounded on the
Relationship-Based
Care Model.
Nursing at Santa Monica has been transformed over the past year. Florence
Nightingale would be as proud as I am. I feel privileged to work beside you. You
have transformed the nursing care you provide every day here at UCLA Medical
Center, Santa Monica, in our community, and globally.
As your Chief Nursing Officer, I am proud to share with you our annual report,
set in the context of the five components of the Magnet Model. This report is
the culmination of your extraordinary and visionary work that has influenced
your development as transformational leaders and resulted in tremendous
improvements in our patient outcomes.
This year’s UPC summit showcased the work you undertook in an effort to
uphold our mission to society and to provide a safe caring environment for our
patients across the continuum from birth to a dignified death. Your autonomous
professional role as leader, scientist, transferor of knowledge, and practitioner
using Relationship Based-Care as a platform has transformed you into amazing
nurses during bedside report. You represent the model to retain for affordable
health care through implementation of the shift management tool and
understanding the quality indicator data displayed on your unit.
We are well on our way to achieving designation as a Magnet hospital, which
acknowledges the high caliber of our nursing staff and how professionalism
translates into excellence in patient care services. This year we held our first SM
Nursing Strategic Planning Retreat, which included our Magnet council chairs/co-
chairs. Our goals are set for the next year: each bedside nurse is a Magnet
Leader living our professional practice model. Continue to sit and connect with
your patients so as to develop a trusting relationship that will provide comfort
and change their lives. As defined by our own nurses: “Compassion – We pride
ourselves in meeting each patient’s individualized needs, and strive to give each
patient and family the attention, care, support, and comfort we would want for
our own loved ones.” I am grateful for your dedication and commitment to our
profession.
Edith Matesic, RN, MS, DNP, NEA-BC Chief Nursing Officer/Director of Nursing
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A Message from Our CAO: Paul Watkins
As we move toward year’s end, I would like to reflect on the accomplishments we have achieved, and we have had many this past year. Just to highlight a few: in January we completed the first year in our new hospital. While we continue to make operational flow improvements, the new facility is nothing short of outstanding, giving us a beautiful state-of-the art facility where we can care for our patients one at a time. In March, after months of incredible work by literally thousands of our staff, we launched our electronic health record system, CareConnect. In the usual UCLA Health way of doing things, we attempted the largest, most complicated implementation of this system ever, and within thirty days we were running proficiently. As we continue to refine the system, we are already recognizing the benefits of having all of a patient's information in their medical record immediately available at every point-of-care site in our system. On the financial front we also had a good year. A positive cash flow is essential for us to fund the many improvements we need to make, two of which I mentioned above and to support the academic mission of the medical school. Perhaps one of the most important accomplishments we still have yet to achieve is Magnet Accreditation for UCLA Medical Center, Santa Monica, but I am happy to report we are well on our way. Under CNO Edith Matesic’s leadership, we have developed Magnet councils involving many of our staff nurses. The councils develop performance improvement initiatives and help forge the path of our Magnet journey. Magnet Accreditation is important because it provides a structure to highlight and ensure we have high standards of care, a professional nursing practice model embedded in our patient care delivery systems, and opportunities for nurses at all levels to participate in innovation initiatives. Under the Magnet model, nursing collaborates with virtually every hospital department and our nursing department in Santa Monica is no exception. I have personally had the pleasure of working with our outstanding nursing leaders and staff on numerous projects. We are very fortunate to have such dedicated leaders and staff in our nursing department at Santa Monica. While the road is still long, I am confident we are well on our way and will achieve the high honor of Magnet Accreditation. I am, along with the rest of senior leadership of UCLA Health, in full support of our Magnet journey and thank all of our staff and leaders for the outstanding work thus far. Sincerely yours,
Paul H. Watkins, J.D. Chief Administrative Officer
Magnet Accreditation is
important because it
provides a structure to
highlight and ensure we
have high standards of
care, a professional nursing
practice model embedded
in our patient care delivery
systems, and opportunities
for nurses at all levels to
participate in innovation
initiatives.
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`
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Table of Contents
Empirical Outcomes 5
Transformational Leadership 8
Structural Empowerment 12
Exemplary Professional Practice 18
New Knowledge, Innovation and Improvements 22
Looking Ahead 27
American Nurses Credentialing Center http://www.nursecredentialing.org
UCLA Medical Center, Santa Monica (UCLA-SM) is a 266-bed, evolving academic medical center with a
longstanding tradition of community care.
As one of the two hospital campuses of UCLA Health, the medical center features many outstanding clinical services,
including its 24-hour Nethercutt Emergency and BirthPlace Maternity Centers and its family medicine programs. It is
also home to highly regarded inpatient geriatrics, orthopaedic, and general medicine programs. The collaboration of
1170 nursing staff members provides high quality care to patients.
Our Nursing
Staff: (1170 Total)
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Empirical Outcomes
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Under health care reform, new value-based purchasing policies link a portion of
Medicare reimbursements to clinical quality outcomes and patient satisfaction. In light
of these changes and a strong commitment to excellence, efforts were concentrated
on affecting and sustaining quality outcomes and patient satisfaction through the
Patient Care Affordability Project. Nursing sensitive quality indicators include falls,
hospital acquired pressure ulcers, central line infections, and ventilator-associated
pneumonia.
IN THIS SECTION:
Nurse-Sensitive Indicators o Falls o Central Line Associated Blood Stream Infection (CLABSI) o Medication Errors o Catheter Associated Urinary Tract Infection (CAUTI) o Ventilator Associated Pneumonia (VAP) o Hospital Acquired Pressure Ulcers (HAPU)
Patient Satisfaction
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Nurse Sensitive Indicators
At a Glance
;
VENTILATOR ASSOCIATED PNEUMONIA
VAP rates remained at 0 for all four quarters during the fiscal year.
CATHETHER-ASSOCIATED URINARY TRACT INFECTION (CAUTI)
Quarterly rates represent CAUTI’s in the ICU and PICU, which outperform the NHSN pooled mean in each unit.
IMPROVEMENT PLAN: An interdisciplinary group is working collectively to reduce HAPU rates. Ongoing projects include:
Patient selected visual cue (PUPP) to identify at risk patients
Transparent display of data at every unit
Monthly peer-review case studies & annual awareness fair
Physician Reference pocket card
Post-HAPU Huddle
Physician Reference pocket card
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MEDICATION ERRORS
No Category E (where there was patient harm) or higher medication events in the past year.
Over the past year, the hospital has continued its efforts to improve the quality of reporting medication events to safe guard patient safety. Through multidisciplinary collaboration, the follow-up process has been standardized for all medication administration events involving wrong patient, wrong drug or wrong dose.
0
1
2
3
4
5
3Q 2012 4Q 2012 1Q 2013 2Q 2013
# of
infe
ctio
ns p
er 1
,000
line
day
s FY13 CLABSI Rates
UCLA SM Rate UCOP Benchmark
0
2
4
3Q2012 4Q2012 1Q2013 2Q2013
# o
f fa
lls
pe
r 1
,000
pat
ient
day
s*Retrieved from NDNQI 9/24/13
Fiscal Year 2013 (FY13) Fall Rates
UCLA SM Rate*
National Mean Rate* - Teaching Facility
0%
5%
10%
3Q 2012 4Q 2012 1Q 2013 2Q 2013
Perc
ent o
f hos
pita
l acq
uire
d pr
essu
re
ulce
rs
*Retrieved from NDNQI 9/24/13
FY13 Hospital Acquired Pressure Ulcers
UCLA SM Percent
National Mean - Teaching Facility
0 0
1.040.99
0
1
3Q 12 4Q 12 1Q 13 2Q 13
# o
f in
fect
ion
s/#
dev
ice
day
s *
100
0
CAUTI Rate
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Nursing care contributes greatly to the hospital’s patient satisfaction scores. The past year reveals
progress in patient communication with nurses, pain management and responsiveness of staff.
However, opportunities remain for improvement in the four nurse-sensitive patient satisfaction
dimensions below. Scores for recommendation and overall rating are currently outperforming the
National Research Organization Picker 50th percentile. This coming fiscal year, patient satisfaction will
continue to be a priority focus for all nursing units and Magnet Councils.
Patient Satisfaction
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75%
80%
85%
90%
3Q 2012 4Q 2012 1Q 2013 2Q 2013
FY13 Courtesy and Respect
UCLA SM NRC Score NRC 50th %ile
60%
65%
70%
75%
80%
3Q 2012 4Q 2012 1Q 2013 2Q 2013
FY13 Communication with RNs
UCLA SM NRC Score NRC 50th% ile
0%
20%
40%
60%
80%
3Q 2012 4Q 2012 1Q 2013 2Q 2013
FY13 Responsiveness of Staff
UCLA SM NRC Score NRC 50th %ile
73%
74%
75%
76%
77%
78%
79%
3Q 2012 4Q 2012 1Q 2013 2Q 2013
FY13 Pain Management
UCLA SM NRC Score NRC 50th %ile
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Transformational Leadership
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IN THIS SECTION:
Strategic Planning
Advocacy and Influence
Visibility, Accessibility, and Communication
The journey to Magnet® designation begins with transformational leadership. A
transformational culture is formed and evolves through trust, transparency, and strong
relationships. Transformational leaders help foster an environment of professional growth so
nurses can lead change from any position.
The Transformational Leadership Council drives nursing excellence by focusing on the
following:
1. Creating partnerships between administrators and direct care providers, so nurses can be active participants in strategic planning
2. Enhancing advocacy and influence of nurses at all levels of the hospital 3. Ensuring visibility, accessibility, and communication from Nursing leadership to direct-
care nurses
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Council Members: Yuki Arai, Rusela Bedrejo, Leonor Carrasco, Lubna Connor, Joanne Contreras, Lolly
Galvarole, Elizabeth George, Heather Hackett, Judy Haddy, Polly Hansen, Anne Heffernan, Julian
Hilario, Jason Kulangara, Danny Liew, Vera Lopez, Frances Lowe, Lauren Maggini-Miller, Elizabeth
Maister, Edith Matesic, Lindsay McKelvey, Francine Mehdian, Tina Morrison, Leilani Palad, Wilson
Phoeng, Adrienne Puglisi, Moreen Pushkin, Annette Reed, Michelle Robinson, Molly Samuel, Diane
Tamondong, Linda Tigert, Lyxander Ulandy, Mark Vaccarino, Remedios Villahermosa, Grettell Vitale,
Alison Wrigley, Cassie Yamaguchi, Jennifer Zanotti
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Strategic Planning
On June 25th, 2013 nursing leadership held the annual FY14 Nursing Strategic Planning
Retreat with Magnet® Chairs and Co-chairs. Fiscal year priorities and the Magnet® gap
analysis were studied. Members broke out into groups which identified unit- and council-
specific strategies and goals which include the following:
Enculturate professional practice model and provide staff with professional growth and development opportunities to advance clinical confidence and practice
Achieve excellence in patient satisfaction by improving nurse-driven patient satisfaction indicators
Provide coaching, standardize orientation and hold Magnet® and Unit Practice Council members accountable to their roles and responsibilities as Magnet® leaders
Enhance physician-nursing collaboration to drive coordination of care and quality improvement
Ensure optimal management of resources, including supplies and human capital
Mission Deliver leading-edge patient care, research and education by utilizing SMH
Nursing’s Professional Practice Model as a guide
Vision
Through the art of nursing, we strive to heal humankind, one patient at a time,
delivering care that is grounded on the Relationship-Based Care Model.
Core Values
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Advocacy and Influence
Nurse leaders, acting as CareConnect Super Users, prepared to guide nursing colleagues through the transition
to CareConnect by participating in countless training sessions. The tremendous devotion of nurses to support
CareConnect has not gone unnoticed, as nurses continue to hold significant roles in the effort to optimize the
new electronic health record. Nursing participation in optimization task forces, SWAT rapid response teams,
and workgroups facilitate continuous improvement of our system to enhance patient care, improve outcomes,
and create efficiency.
In addition to active operational involvement from clinical nurses and nurse leaders, the CareConnect and
MITS teams have strategically grown their clinical representation. With nurses responsible for everything from
training and computer resource mangement to system build and informatics, there is no shortage of
appreciation for the meaningful contributions nurses bring to the world of health informatics.
UCLA Santa Monica Nurse “super users” show off their red vests
during Go-Live, March 2013.
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Visibility, Accessibility and Communication
Shift Management Tool
The shift management tool is a quick, accurate, real time guide and resource for the
Administrative Nurse I (ANI) to balance staffing needs with patient census and unit financial
targets. Space is provided for the ANI to document and communicate with managers regarding
staffing decisions made and it allows the ANI to adjust staffing every four hours. The Patient Care
Affordability Project, in conjunction with the shift management tool, aims to enculturate fiscal
stewardship in all levels of nursing to ensure the viability of the hospital system and increase
resources available to provide excellent care to each patient.
Chronicles of Nursing Excellence
UCLA-SM celebrated the first year in circulation of its Quarterly Nursing Newsletter in January 2013. Every issue opens with a letter from the CNO. The newsletter includes updates on the Magnet Journey, highlights of projects and activities from various units, staff recognition and other nursing updates.
CULTIVATING LEADERSHIP: CONFERENCES AND WORKSHOPS
National Magnet Conference 2012, Los Angeles, CA
Early Mobility Conference, Baltimore, MD
Association of Nurse Executives (AONE) 46th Annual Meeting & Exposition, Denver, CO
Association of California Nurse Leaders, San Diego, CA
Nurses Improving Care for Healthsystem Elders (NICHE), Philadelphia, PA
Society of Pediatric Nurses National Convention, Nashville, TN
Evidence-Based Practice Conference, UCLA, Los Angeles, CA
Oncology Nursing Society Conference, Washington, D.C.
Catalyst Academy, Long Beach, CA
National Teaching Institute presented by AACN, Boston, MA
National Association of Orthopaedic Nurses, San Antonio, TX
Pediatric Emergency Nursing Conference, Los Angeles, CA
Patient Family Centered Care Conference, Los Angeles, CA
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Structural Empowerment
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Structural Empowerment is the Magnet® Model component that addresses how structures
and processes in the workplace environment support and encourage a strong professional
practice, as well as innovative efforts to improve outcomes and address organizational
priorities. This component also addresses the need to foster relationships and partnerships
across the health care continuum and promote a positive image of nursing.
IN THIS SECTION:
Professional Development
Commitment to Professional Development
Teaching and Role Development
Commitment to Community Involvement
Recognition of Nursing Structu
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Council Members: Sharon Ana, Susan Aquino-Cobar, Stephanie Carson, Michelle Corral, Jackie Cruz,
Cindy Hains, Jennifer Hebert, Jennifer Kwong, Vicky Landry, Everlyn Lee, Deborah Lorick, Edith
Matesic, Olivia Marshall, Nicole Oswell, Jessica Pancio, Pricilla Rivera-Maus, Laura Saldana, Maria
Straub, Grettell Vitale, Shanna Wheeler, Sandy Williamson, Jennifer Zanotti
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Professional Development
Professional Role Development Strategic Initiative
The Coach-Led Professional Role Development Program was enacted to ensure a strong and clear
professional role orientation to nursing enculturating the Professional Practice Model. Nursing requires
examination of current practice and ownership of professional role obligations. This self-reflection guides
exploration on how to improve practices as to have a significant and positive effect on the quality of care
and outcomes.
The Coach-Led Program is part of the larger Professional Role Development Strategic Initiative which
includes strategy work, coaching and management development, performance improvement activities, and
the development of a professional role expertise database, all aimed at supporting the professional role of
nurses. To facilitate this journey, the OnSomble© team, led by Dr. Maria O’Rourke, has been engaged.
Through application of her work, models and tools, the powerful role a professional RN plays in the delivery
of high quality care through high quality professional practice becomes visible. This level of quality in
professional practice advances not only the individual nurse, but the nursing profession as a whole.
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Updates to the Clinical Ladder Portfolio
The Clinical Nurse (CN) III Clinical Ladder Council has
evolved in the past year though transparency of the
promotion process. Activities and achievements include:
Two open houses for interested CN III applicants
Reviewed changes in the CN III promotion process
Provided guidance in the portfolio application
Hosted an open forum for current CNIII’s to
communicate changes in the portfolio process
Provided CNIII’s tools to mentor candidates
Developed a spreadsheet of all current CNIII
projects and involvement in health system activities
Revised council charter, Clinical Ladder Portfolio
Guide and submission deadlines are now easily
accessible through the UCLA Mednet home page
An increase in CNIII promotion by 10% is the goal for fiscal
year 2014.
“Celebrate your
clinical expertise.”
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Commitment to Professional Development
Structures and Processes: Councils
UCLA SM Nursing Edith Matesic, CNO
CNIII Portfolio Review Group
Exemplary Professional Practice
New Knowledge, Innovation &
Improvements
Structural Empowerment
Transformational Leadership
CNIII, UD, CNS
Chair: Edith Matesic
Co-Chair: Annette Reed
Members: Designated Direct-
care RNs, UPC Chairs Additional Reps.:
UD, CNS
Chair: Michelle Corral
Co-Chair: Nicole Oswell
Members: Designated Direct-
care RNs Additional Reps.:
Marketing, Nursing Research and
Education liaison, UD, CNS
Chair: Michele Maines
Members: Designated Direct-
care RNs Additional Reps.:
NRE liaison, Quality Dept., Palliative Care, Pharmacist, Certified
Wound Nurse, Physical Therapy,
UD, CNS
Chair: Samantha Kunemoto
Members: Designated Direct-
care RNs Additional Reps.:
Director of Nursing Research Education,
IT/CareConnect, UCLA Innovation Institute, Biomed Librarian, UD, CNS
Impacting Change: Unit Practice Council Projects
o Caring and Healing Process – November 30th, 2012 o Improving Communication Between RNs and CCPs (3NW) o Rekindling the Culture of Caring for Our Patients, Colleagues and Ourselves (5MN) o Enhancing the Role of ACCPs in the Critical Care Services to Improve Teamwork (4CW) o Use of HEAT to Promote Healthy Conversations (NICU)
o Autonomy and Bedside Report – May 1st, 2013 o Increasing Compliance with Bedside Shift Report (3NW) o Improving Nurse to Nurse Bedside Care Report (4MN) o Bedside Report (4NW) o Autonomy Awareness (4SW) o Role-based Handover Report Using CareConnect (5MN) o Don't Drop the Baton: Transiting Change of Shift Report to the Bedside (5NW) o Increasing Patient Satisfaction and Nursing Autonomy Through Bedside Report (ED) o Improving Compliance with ICU Bedside Report in the Age of CareConnect (4CW ICU) o Improving Family-Centered Care through Communication (PICU) o Open 24 Hours (NICU) o Baby Steps Towards Keeping Our Patients Safe: Implementation of Bedside Reporting (PP) o Perinatal SBAR Report Tool (L&D) o Time for Change (6NW) o In Depth Review of Handover Report in Peri Operative Services (PTU-PACU-IR) o Integrating Resource and Float Pool Participation in Bedside Reporting: Utilizing Resource RNs
as Leaders of Change (Resource Pool)
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Teaching and Role Development
The Department of Nursing encourages professional development and professional certification. The lists
below recognize professional development achievements in the past year.
ACM (Accredited Case Manager)
Certification for Hospital/Health System Case Management Professionals
Diane Tamondong, RN, ACM (Pediatrics, 6NW)
CCRN (Critical Care Registered Nurse)
Certification for Adult, Pediatric and Neonatal Critical Care Nurses
Maria Domingo, RN, CCRN (Float Team)
Melissa Schafer, RN, CCRN (PICU, 4CW)
Kimberly Bravo, RN, CCRN (ICU, 4CW)
Josephine Villa, RN, CCRN (ICU, 4CW)
Jennifer Taylor, RN, CCRN (ICU, 4CW)
Kalpana Iyengar, RN, CCRN (ICU, 4CW)
Valerie Ewald, RN, CCRN (ICU, 4CW)
Jamie Petro, RN, CCRN (ICU, 4CW)
PCCN (Progressive Care Certified Nurse)
Certification for Progressive Care Nurses Hazel Lao, RN, PCCN (Int. Care, 5MN)
Vi Nguyen, RN, BSN, PCCN (Int. Care, 5MN)
Ace Panes, RN, PCCN (Int. Care, 5MN)
Veronica Mercado, RN, PCCN (Int. Care, 5MN)
Jason Kulangara, RN, BSN, PCCN (Int. Care, 5MN)
Seda Otun, RN, MSN, PCCN (Int. Care, 5MN)
Michelle Corral, RN, BSN, PCCN (Int. Care, 5MN)
Eva Kwong, RN, BSN, PCCN (Int. Care, 5MN)
RN-BC (Gerontology Certified Nurse)
Certification for Gerontology Nurses Damian Najera, RN-BC (Medicine, 4NW)
Agnes Tan, RN-BC (Geriatric, 5NW)
CMSRN (Medical-Surgical Certified Nurse)
Certification for Medical-Surgical Nurse Jacquelyne Wolfe, CMSRN (Med/Surg, 4MN)
RNC-OB (Registered Nurse Certified)
Certification for Obstetric Nursing Peggy Mathews, RNC (Obstetrics, 2SW)
Diana Ellis, RNC (Obstetrics, 2SW)
CPAN (Certified Ambulatory Perianesthesia)
Certification for Ambulatory Perianesthesia Nurses Yekuno Woldeyesus, RN, CPAN (Float Team)
CPN (Certified Pediatric Nurse)
Certification for Pediatric Nurse Carol Avalos, RN, PNCB (Pediatrics, 6NW)
CEN (Certified Emergency Nurse)
Certification for Emergency Nurse Kayla Reynolds, RN, CEN (ED)
Danielle Godino, RN, CEN (ED)
OCN (Oncology Certified Nurse)
Certification for Oncology Nurse Arvie Carino, RN, OCN
Erin Carr, RN, OCN
Jillian Kenney, RN, OCN
Christina Lane, RN, OCN
Lauren Michelson, RN, OCN
Mac Queyquep, RN, OCN
Karl Wolfsohn, RN, OCN
Cassandra Yamaguchi, RN, OCN
Sandy Protillo, RN, OCN
ONC (Orthopaedic Nurse Certification)
Certification for Orthopaedic Nurses Sarah Nunn, RN, ONC (Orthopaedic, 3NW)
CNOR (Cerified Nurse Operating Room)
Certification for Operating Room Nurse Katie Denisova, RN, CNOR (OR, 3MN)
Catherine Kamau-Ali, RN, CNOR (OR, 3MN)
CWCN (Certified Wound Care Nurse) Lakhena Grant, RN, CWCN (ICU, 4CW)
FNP-BC (Family Nurse Practitioner - Board Certified)
Certification for Family Nurse Practioner Sonia Velasco, FNP-BC (Med/Surg, 4MN)
FNP-C (Family Nurse Practitioner - Certified)
Certification for Family Nurse Practioner Jeanette Kidd, RN-BC, MSN, FNP-C (BMT, 6E)
BSN and MSN degrees earned within the last 12 months
Jill Scherrey, RN, MSN (PICU, 4CW)
Jose Lopez, RN, BSN (OR, 3MN)
Maryann Martinez-Garcia, RN, BSN (Med/Surg, 4MN)
Susan Aquino-Cobar, RN, BSN (Med/Surg, 4MN)
Ronic Brooks, RN, MSN (Float Team)
Tabitha Benga, RN, BSN (Float Team)
Nancy Freeman, RN, MSN, MBA (Quality Management)
Nursing School Affiliation UCLA SM enacts its commitment to nursing excellence through teaching partnerships with the
following community nursing programs: University of California, Los Angeles (139), Santa
Monica College (88), Mount St. Mary’s College (78) and Los Angeles Valley College (135).
Twenty-two student preceptors participated in the education of 440 students.
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Spotlight on Success: Oncology Unit’s Dramatic Increase in OCN® Certification Rates
Certification clearly communicates not only the high quality of nursing care to patients, but it ensures
patients each certified nurse is a specialist in oncology. Over the past year, the OCN® certification rate of
eligible nurses increased from 26% to 50%. This dramatic increase represents the passion of 4SW
Oncology Unit Director Deborah Lorick. Upon joining UCLA Santa Monica in March 2012, Lorick performed
performance evaluations in which OCN® certification was added as a goal to obtain within the next year.
Lorick facilitated resources to reduce barriers to certification. First, Clinical Nurse Specialist Patti Jakel’s
four-day preparative course became a valuable resource to prepare for successful test taking. Second,
awareness was raised about the Oncology Nursing Society’s online course. Third, Lorick and Jakel
identified the “By Your Side” grant sponsored by the Mason’s of California that supports oncology nurses
seeking specialty certification. Upon successful completion of OCN® certification, nurses may apply for
funding from the “By Your Side” grant that covers preparatory and testing expenses. Several SM oncology
nurses received this award.
Proud of their recent achievement, OCN®-certified nurses brought this enthusiasm into the work-place.
Coworkers took notice of the validation as an expert certification provided and the newfound pride in
oncology nursing encouraged additional nurses to pursue certification. A culture of excellence through
OCN® certification flourished and continues to grow. Currently, several additional nurses are preparing to
take the exam this fall and new graduate interviews included the expectation of OCN® certification within
the first few years of employment.
Lorick’s passion for OCN® certification and clinical specialty excellence initiated a movement of
professional development and excellence in care that will continue for many years to come.
Lauren Michelson, Arvie Carino and Christina Lane (left to right), three of nine newly certified nurses, celebrate OCN® certification
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Nurses reached beyond the hospital walls,
participating in and contributing to community
development and outreach both locally and
internationally.
Samantha Kunemoto, RN, MSN, Operating Room Medical Missions in Kenya, Africa and Tecate, Mexico
Stephanie Carson, RN, MSN, 4SW Medical Mission in Kenya, Africa
Sarah Nunn, RN, 3NW Medical Mission in Nicaragua
Leotine Burgess, RN, MSN Medical Mission in Belize
Randi Sue Quat, RN PTU/PACU Medical Missions in Mexico
Theresa Bercier, RN, Pediatrics Medical Mission in Haiti
Amber Reynolds, RN, PICU Medical Mission in South America
Amber Franklin, RN, CCRN, 4CWICU Medical Mission in Burkina Faso, Africa
Community Engagement
Recognition of Nursing
Board of Advisor Scholarship Award Winners:
Maricea Muhammad Alissa Miyake Melissa Chinn
Maria Madden Cassandra Coleman
Shoba George Weiching Chiang Teresa Tanabe Christina Kim
Vinetta Basutkar Jhordice Munoz Jamie Repholz Shirley Wong Bret Barrett
Jane Lee Almina Vastani
Cynthia Carsten Kelly Twarowsk Olivia Marshall Jessica Graham
Compassion Award Pattie Jakel
Innovation Award Marina Agueev
Mentor Award Gladys Fernandez and Matt Dartt
Patient Safety Award Katherine Huang and
Michelle Corral
New Grad RN of the Year Award Natalia Lagman
Admin. Nurse II of the Year Award Amy Goldberg
Community/World Service Award Sarah Nunn
RN of the Year Award Jamie Troxel
Exemplar Leader of the Year Award Paulette Madley
Healthy Work Environment Award 4 North Wing Team
Daisy Award Winners: Britney Casillas-Moller (5MN)
Lisa McAuley (4SW) Mac haven Queyquep (4SW)
Geralyn Thompson (4MN) Margaret Moore (4ICU)
Community Events in 2013 Northern Trust Golf Tournament – Brenda Fies, ANII, event
Coordinator, Polly Hansen, ANI, Kathleen Shinn, CNII, Donna Ellis,
ANI, Kimberly Ternavan, UD, Maureen Wright CNII, Riya Zelcer, CNII,
Suzanne Travis, CNII, Neal Ketchum, CNII
Care Harbor LA Free Clinic – Debbie Nagata, RN, Grettell Vitale, RN
Venice Family Clinic – Neal Ketchum, CNII
Hollywood for the Homeless, Heal the Bay, LA Food Bank, Global
Grins – Randi Sue Quat, RN
Amber Franklin, RN, CCRN, 4CWICU Medical Mission in Burkina Faso, Africa
Laura Maszak, RN, Emergency Dept. Medical Mission in Guatemala
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IN THIS SECTION:
Care Delivery System(s)
Professional Practice Model
Culture of Safety
Exemplary nursing practice means having a comprehensive understanding of the role of
nursing and applying this knowledge with patients, families, communities and the
interdisciplinary team. The Exemplary Professional Practice Council focuses on cultivating
interdisciplinary relationships, ensuring appropriate patient safety and quality
infrastructures, and promoting quality improvement.
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Council Members: Bertram Amon, Charito Ansay, Antonia Ascencio, Geri Braddock, Grace Burgos,
Trena Carpenter, Clara Chavez, Lucy Cook, Franz Cordero, Zohra Dodhia, Cathleen Doriquez, Gerry
Fulgentes, Lolly Galvarole-Lew, Theresa Haley, Anne Heffernan, Julian Hilario, Anila Ladak, Mary
Lawanson-Nichols, Betty Lee, Jason Madamba, Paulette Madley, Michele Maines, Edith Matesic, Jilu
Matthew, Brenna McCarthy, Jeannette Meyer, Debbie Nagata, Anna Nichik, Samantha Pomar, Diana
Ramirez, Denise Scalercio-Ribeiro, Diane Shao, Mary Smith, Grace Sund, Hyde Tungala, Sonia Velasco,
Grettell Vitale, Cindy Westhafer, Coleen Wilson, Jennifer Zanotti
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Culture of Safety: Structures, Processes & Outcomes
Four interprofessional subcommittees within the Exemplary Professional Practice Council
are tasked with addressing quality of care priorities. The boxes below highlight some key
achievements the sub-committees have accomplished.
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Pain Improved Pain Management NRC Score by 2%
Developed and revised a Pain Audit tool
Systematized tool catered to CareConnect
Achieved all-time highs in several pain quality measures
Fall and Pressure Ulcer Prevention Reduced HAPU prevalence from 5% to 0.59%
Maintained fall rates below NDNQI National Mean
Implemented falling star sign and post-fall huddles
Utilization of SMH Everyone e-mail announcements
Used fall prevention videos
Educated nurses on use of gait belts on 5NW
Initiated early mobility protocol education
Obtained bedside commodes in every room
Educated nurses and care partners about patient privacy in bathroom
Developed tracking tool to analyze trends on why patients fall
Infection Prevention Formed new subcommittee this year
Forged partnership with infectious disease director, Dr. Uslan, and formulated subcommittee’s role among other infection prevention groups within the system
Developed focus on nurse education related to new nurse-driven sepsis bundle and protocol
Initiated hand washing campaign beginning with improved and streamlined data collection effort
Nursing Pharmacy Revised MAR audit tool based on audit findings in preparation for CareConnect to protect patient safety
Addressed issues: o High-alert medications without
double signature o Staggering to standard administration
times o Allergy and medication reconciliation
Educated nurses regarding independent verification, staggering medications to standard times, outcomes, and consistent allergy reconciliation
Conducted literature review on reducing errors via bar-coding as well as common errors
Educated nurses on common errors via huddle messages
Collaborated with HCAHPS subgroup to encourage RNs to educate patients on medication side effects
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Nursing Professional Practice Model
UCLA Medical Center, Santa Monica Professional Practice Model
The Professional Practice Model is a schematic description that describes how nurses
practice, collaborate, communicate and develop professionally to prove the highest
quality care for those served by the organization. The dotted lines between the
circles represent the intersecting, fluid relationships between the concepts. By using
a nursing professional practice model we can ensure that the professional practice of
nursing is consistent throughout the organization, regardless of the unit, setting or
functional role of the nurse (e.g. direct care, charge, clinical specialist, manager,
research, practitioner, etc).
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Nursing Quality Dashboard
In fiscal year 2013, Santa Monica Nursing developed and implemented a process by which
nurse-sensitive quality data and patient satisfaction indicators are aggregated and disseminated.
The project was undertaken in collaboration with the Quality Management Department, unit
directors, and staff nurses represented on Magnet® councils. Prior to the project, unit-specific
quality outcomes data were not readily accessible, resulting in a lack of knowledge and
accountability among staff for their quality and patient satisfaction outcomes, such as falls, unit-
acquired pressure ulcer rates and
responsiveness to patient needs.
The Nursing Data Project streamlines
reporting, enhances transparency and
improves communication and understanding
of nurse-sensitive outcomes patient
satisfaction data. Spearheaded through the
Exemplary Professional Practice Council
(EPP), the project brought unit-specific and
nurse-sensitive indicators into one central,
shared drive (right). Each unit maintained a
folder on the shared drive that contains unit-
specific dashboards and graphs (below). Data entry is performed in collaboration with Quality
Management and Nursing Administration.
A key goal of the project was to communicate clear expectations and increase accountability for
nurse-sensitive data and patient satisfaction
with nursing staff members. EPP
representatives, UPC Chairs/Co-Chairs and
managers received training on accessing the
data, understanding benchmarks, and analyzing
the data.
Managers and staff appreciate a central source
for each unit’s data. EPP council members print
and display their unit’s data for the rest of
staff. Managers disseminate the data during
staff meetings. In addition, these reports have been useful in unit-based performance
improvement projects undertaken by Unit Practice Councils.
There are still opportunities to enhance staff knowledge regarding nurse-sensitive data and
patient satisfaction, but this project represents a major stepping stone to promote
transparency and accountability.
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New Knowledge, Innovation & Improvements
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Nursing practiced from a scientific and evidenced-based approach results in more effective
care and better outcomes for patients. The New Knowledge and Innovations Council works to
ensure that the organization continues to advance the practice and profession of nursing and
contribute to the Science of Nursing. The council focuses specifically on the following:
Strengthening structure for evidenced-based practice
Building nursing research capacity
Developing innovations in nursing practice
IN THIS SECTION:
Research
Evidence Based Practice
Innovation
Council Members: Devie Aguilar, Karen Auyeung, Marilou Bharwani, Melinda Catubig-Espiritu, Ermina
Cavcic, Lubna Connor, Lisa De Reyes, Kristian Del Rosario, Adele Dobry, Donna Ellis, Virginia Erickson,
Stefan Fajeau, Dorothy Fox-Nuccilli, Amber Franklin, Cindy Hains, Theresa Haley, Louella Hondrade,
Somayah Ibrahim, Pattie Jakel, Nancy Kearsley, Neal Ketchum, Samantha Kunemoto, Mary Lawanson-
Nichols, Lauren Lindhart, Vera Lopez, Tonya Martinez, Edith Matesic, Norma McNair, Deborah Miller,
Vivian Nguyen, Chinette Salveron, Grettell Vitale, Jennifer Zanotti
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Research & Evidence-Based Practice
Establishing new ways of achieving high-quality, effective and efficient care is the outcome of
transformational leadership, empowering structures and processes, and exemplary professional practice
in nursing. Ensuring a culture of innovation, evidence-based practice, research and technology creates
the foundation for nurses to provide the most advanced level of quality care. UCLA’s Nursing Practice
Research Council sponsors an annual conference to assist nurses, educators, and clinical and
administrative leaders with infusing the latest, innovative and evidence-based practices into current
nursing practice and provides opportunities for networking and education. At this year’s conference,
Santa Monica’s Units took home top prizes for their projects.
Category Award Project Title Authors
Performance Improvement
2nd
Place Bridging the Gap on HCAHPS:
Communication with “My Hospital Diary”
Jason Kulangara, RN, BSN, PCCN
Roel Estrada, RN, BSN, PCCN
Hannah Carballo, RN, BSN, PCCN
Mary Smith, CAN
Michelle Corral, RN, BSN, PCCN
Trish Marte, RN, BSN
Nerissa Manset, RN, BSN
Seda Otun, RN, BSN, PCCN
3rd
Place Don’t Drop the Baton: Transforming
Change of Shift Report to the Bedside
Tammy Huang, RN
Tina Morrison, RN, BSN
Evidence-Based Practice
1st
Place Improving Pain Satisfaction Using the
Appropriate Tool and Proper
Documentation in the ICU
Jeannet Odero, RN, BSN
3rd
Place Interventions for Decreasing Pressure
Ulcers in an ICU Setting
Melinda Catubig-Espiritu, RN, BSN, CCRN
Bret Barrett, BSN, PHN
Research 1st
Place Peer-to-Peer Type Communication (2RN
skin assessment program) and the 5MN
Unit-Acquired Pressure Ulcer Rate
Gerry Fulgentes, MSN, RN, CWOCN, PCCN
3rd
Place Professional Socialization of RN in a
Pediatric Acute Care Setting
Miya Villanueva, RN
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Clinical Practice Council
The Clinical Practice Council (CPC) develops, reviews, and disseminates clinical nursing policies,
guidelines, and practice alerts. Staff nurse representatives from each unit in the hospital represent the
needs of their specific unit. Members contribute toward shaping nursing practice at their unit level
and system-wide. The CPC ensures nursing practice documents are based on the latest research and
evidence based practice. Moreover, the CPC representatives collaborate with unit leadership to
educate staff nurses about nursing practice changes. The Clinical Practice Council completed and
disseminated fifteen practice documents. Practice alerts and post-tests are available to the staff
nurses on the intranet website.
Key Elements of the Clinical Practice Council:
Provide a forum for identifying clinical practice issues requiring evidence-based practice
solutions
Staff nurse representatives are supported by Clinical Nurse Specialists, Educators, Unit
Directors and Evidence-Based Practice Mentors
Council meetings promote the active, exciting and innovative sharing of ideas, group work,
computer use, library use, and consulting with other institutions and professional
organizations
Completed Evidence-Based Practice Documents 2013
Ventilator Associated Pneumonia
Developmental Supportive Care for the Infant
Needleless Injections
Nasal Atomizer
Family Presence during Cardiopulmonary Resuscitation
Early and Progressive Mobility in the Adult
Nasogastric Tube Insertion and Management
Arterial Puncture
Non Invasive Blood Pressure
Developmental Supportive Care for the Pediatric Patient
Pediatric Oxygen Therapy
Hypoglycemia in the Neonate/Infant
Pediatric Vaccine
Pediatric Pulmonary Hygiene
Adult Pulmonary Hygiene – Chest Physiotherapy and Incentive Spiromety
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Evidence Based Practice Geriatrics Finds Its Niche!
By Anila Ladak, RN, MSN, Geriatric Clinical Nurse Specialist
NICHE (Nurses Improving Care for Healthsystem Elders) is the leading evidence-based nurse-
driven program designed to help hospitals improve care of older patients. The Geriatric Unit began
the NICHE journey in October 2012 and received designation in February 2013. The vision of
NICHE is for all patients 65 or over to be given sensitive and exemplary care. The mission of NICHE
is to provide principles and tools to stimulate a change in the culture of healthcare facilities to
achieve patient-centered care for older adults. NICHE, based at the NYU College of Nursing and
comprised of almost 470 hospitals and healthcare facilities throughout North America, engages
hospitals and their affiliates in achieving and sustaining the NICHE designation. NICHE designation
demonstrates a hospital's organizational commitment and continued progress in improving
quality, enhancing the patient and family experience, and supporting the hospital's efforts to serve
their communities.
The first initiative of Santa Monica NICHE leadership committee is for all Registered Nurses on the
Geriatric Unit to become Geriatric Resource Nurses (GRN) through NICHE GRN core curriculum,
which is designed by NICHE to educate nurses in best practices for older hospitalized adults.
Geriatric’s goal is to have 100% of its nurses trained to be “champions for older-adult care,” says
Unit Director Valerie Yeo. Simultaneously, Clinical Care Partners are taking the Geriatric Patient
Care Associate (GPCA) core curriculum consisting of active learning modules aimed at developing
geriatric-sensitive care within their role. Subsequent initiatives in the future include making these
core curriculums and other NICHE tools available to all units starting in early 2014 to enable
Registered Nurses and Clinical Care Partners to provide geriatric-sensitive care to hospitalized
older adults.
Top row: Elizabeth Mora, Eli Latham, Charlotte Decosta; Middle row: Iris Melendez, Anila Ladak, Sally De Silva, Carolina Gastman, Ruth Gunn, Valerie Yeo, Erin Castle, Annette Norwood-Dunlap, Salve Arriola; Lower row: Tina Morrison, Luela Ramos, Agnes Tan, Dawn Gottula
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The transition to CareConnect in March of 2013 has allowed nursing to promote efficient and safer patient care, improve the nurse-to-nurse change of shift report, ensure completion of core measures, and expedite procedures and tests, while greatly reducing the amount of paper used for patient care. The successful transition to this innovative technology is a direct result of nurse involvement in planning, development and implementation of CareConnect.
CareConnect's electronic MAR (eMAR), with the system's barcode scanning capability has already greatly reduced the number of medication errors hospital-wide. The eMAR includes a built-in messaging feature system that allows nurses to electronically communicate with pharmacy. This feature has significantly reduced the number of phone calls between nursing units and pharmacy.
The organization of CareConnect, with the system's organized sections, navigators, and subsets of tabs, accomplishes the goal of streamlining the workflow of nursing care. These features are especially beneficial during the admission, transfer, and discharge of patients. Another useful tool is the "Handover Report" screen, which allows nurses to look at one summary screen to see nearly all of the patient's pertinent information for the current admission during bedside shift report. The CareConnect system also promotes the completion of core measures during a patient's stay. The initiation of core measures will prompt physicians and nurses to activate best practice advisories to fulfill core measure requirements.
CareConnect has eliminated the masses of paper used in patient hard charts and the physician-nurse conflicts of difficult-to-read handwriting. In addition, the unit secretaries and staff nurses are no longer required to fax medication orders to pharmacy, nor process handwritten orders for labs and other procedures. These orders are automatically processed once a physician enters the orders in CareConnect. The system also allows physicians to enter orders remotely and off-campus, nearly eliminating the need for nurses to take telephone verbal orders and avoid the potential for errors when receiving verbal orders.
In addition, prior to the transition to CareConnect, many individual applications were required for a nurse to understand and operate, resulting in a very fragmented system. Separate software systems were required for nurse documentation, entering lab orders, viewing lab results, performing admission/transfer/discharge, and entering non-laboratory tests/procedures (i.e. x-rays and IR therapies). The use of CareConnect has allowed all of these tasks to be completed by one, stable system. The defragmentation into one system improves the daily workflow for nurses and streamlines the training and orientation of new-hire nurses.
The conversion to CareConnect, though expensive, will pay for itself over time with the benefit of reducing medication errors, increasing efficiency, and improving the job satisfaction of nurses. The decision to switch to CareConnect provides clear evidence that UCLA Health and its Santa Monica campus are eager to embrace new technology that will improve the quality of care and safety for patients, reduce waste, and promote nursing retention and job satisfaction.
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Looking Ahead
http://nursing.uclahealth.org/
Acknowledgments
Nursing Administration would like to thank each and every person for their valuable
contribution to this report. It is a representation of outcomes reported by nurses and
interprofessional members throughout the hospital.
At the beginning of every fiscal year, the Nursing department establishes and communicates its strategic
priorities to staff nurses through the Magnet councils. Priorities are formulated to ensure alignment with the
hospital and health system’s operational plan. This year our priorities are centered around five broad areas:
Education, Training and Development
o Continue Role-Based Strategic Initiative
o Increase BSN, CNIII and certification rates
Quality, Safety and Service
o Improve outcomes of nurse-sensitive indicators
Operations, including Magnet application readiness
Strategic Growth and Development
o Strengthen nurse-physician bedside collaboration to improve throughput
Finances
o Maintain efficient resource management via the Shift Management Tool and Patient Care Affordability Project