DIRECTIONS:

• Please complete all pages in one session to ensure all data is captured on submission.
• Complete ALL sections (1 - 9) of this application.
• Type your responses. Do not use abbreviations.
• Attach a resumé or curriculum vitae and letter of support from your employer. If necessary, send your letter of support separately to leigh.hume@ana.org so as not to delay your application.

Use your legal name on the application.

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The formal essay is an opportunity to showcase your ability to communicate in a clear, concise and grammatically correct manner.

Included below are three Pathway to Excellence Standards from a previous manual. Responses from submitted documents are provided that address a specific Element of Performance (EOP) within each of those standards. Please describe how each of the three (3) narratives written by the organization meets or does not meet the EOP associated with the identified standard.

Example One:
PRACTICE STANDARD 1: SHARED DECISION-MAKING
Overview of Standard: Organizations achieving Pathway to Excellence® designation have an established shared governance structure as the foundation for involving direct care nurses in decision-making. Allowing direct care nurse input into decision-making influences care delivery, work flow, hiring, and
product evaluation. Interprofessional collaboration is also integral within the organization, engaging staff, building teamwork, and strengthening the shared governance culture.

Element of Performance 1.9:
Describe how the organization includes input from direct care nurses in the hiring process for new staff.
AND
Provide an example of how input from direct care nurses influenced a hiring decision. Include the outcome of the decision.

Applicant Response to EOP 1.9
Kite Medical Center nurses are empowered to participate and make recommendations in the hiring of nurses. There are multiple levels of the interview process and those candidates selected to move to an interview, go through the peer review process, regardless of the position for which they are applying. The peer review process assists the Operations Director in creating a work environment that has the right employee in the right position. Peer interviewing has proven to be an effective retention tool for KMC. It provides the direct care nurse with a sense of ownership in attaining successful integration of the new employee to the culture of the unit. The Peer Interview Guide and Peer Review Guide are tools used by the direct care nurse to learn about the peer interview process and the legal aspects of interviewing. The peer interview questions are developed by direct care nurses in collaboration with the Human Resource Partner for nurse to leader interviewing and peer to peer interviewing. The peer input is reviewed by the Manager or Operations Director and becomes a critical step in making the final decision for applicant(s).

Post Intensive Unit Nurses Interview RN Applicants
In 2015, dayshift direct care nurses, TX RN, and LB, RN, conducted a peer interview on two applicants for a night position using the peer interview tool. They found both applicants had qualities that aligned with our mission and would be excellent team members. The two applicants were then interviewed for a second round of peer interviews with direct care nurses on the night shift, JT RN and KP RN. The night nurses had expressed they were looking for a RN who would be dedicated to working the night shift for at least two years and had strong team relationship skills. Upon completion of the second peer interview, they selected the applicant they felt best met the night shifts needs. This information was shared with the Operations Director and the position was offered to the applicant recommended by the night staff. The applicant accepted the position and has become a valuable member of the team.

Example Two:
PATHWAY STANDARD 2: LEADERSHIP
Overview of Standard: Leadership within Pathway to Excellence-designated organizations fosters the foundation of collaboration among staff and supports a shared governance environment. CNOs and nurse managers actively engage direct care nurses for input in the areas of resource allocation, cost management, and patient advocacy.

As leadership champions within the organization, the CNO and nurse managers are accessible and effective advocates for direct care nurses and patients, especially in times of organizational change. Leaders continuously strive to increase their core knowledge and role competency through leadership development activities along with feedback from colleagues and nursing staff.

Element of Performance 2.12:
Describe methods nurses in leadership roles use to stay current on the issues or challenges faced by direct care nurses.
AND
Provide one example when a nurse in a leadership role used a method(s) to stay current on the issues or challenges faced by direct care nurses.

Organization’s narrative response for EOP 2.12
Using Evidence Based Practice to assist direct care nurses

Driven to provide quality patient care, the CNE at Kite Medical Center is always seeking opportunities to stay abreast of current healthcare trends and issues especially those where she can provide support to the nursing staff. After attending “The Accountable Healthsystem: Today and Tomorrow” Conference the CNE, M*R*, reviewed the Kite Medical Center’s Fall Data and reviewed evidenced based practice data for 1500 character limit comparison. Falls is an issue that impacts direct care nurses. After meeting with PPC’s and UPC’s, the hospital wide practice council chaired by the CNE, set a goal to decrease patient falls with an overall goal to move to zero occurrences.

The CNE encouraged and supported the creation of a Care Redesign Fall Mobility Team which would focus on this goal. The team utilized evidence based published research findings to design the new fall prevention plan. The CNE also encouraged review and use of the State Hospital Association, Road Map to a Comprehensive Fall Prevention Program (2014) to guide their work. The road map is a compilation of published research findings from the VA Hospitals and the Institute for Healthcare Initiatives. The Fall Care Redesign team utilized the road map as a template of best practices to conduct the gap analysis. With the CNE as their mentor, the team scored the best practices from the road map and then focused on incorporating the areas of opportunities identified from the gap analysis into the new fall plan. An KMC Fall Prevention Care Bundle was developed and metrics established to measure success.

Implementation:
The Fall Prevention Care Bundle was reviewed at the Medical Surgical PAC for suggestions and approval and was implemented in patient care areas: The plan was rolled out to staff utilizing several venues and at various stages: These are as follows:

• The fall prevention plan were outlined in the March 23, 2015 Required Clinical Read.
• Team Leads on all units attended a mandatory orientation and demonstrated competency to the fall prevention plan changes. This orientation also included a competency of safe patient handling given by physical therapists. Each team lead then provided mandatory education and competency checks for all employees.
• A Standard Operation Procedures provided an easy guide to the post fall huddle.
• The morning safety huddles were modified to include reviewing all patients at fall risk and to ensure appropriate precautions are being utilized.
• Leaders rounded daily on the units to assess staff understanding of the new process and to assess patient knowledge of their personal fall prevention practices.
• Staff attended two Safety Fairs. The first fair was a patient room assessment and post fall intervention competency for all KMC employees with patient contact. The second fair focused on safe patient handling equipment and the new Fall Prevention Plan.

Example Three
PRACTICE STANDARD 4: QUALITY
Overview of Standard: Quality initiatives in Pathway to Excellence organizations are developed through interprofessional collaboration. The organization-wide quality initiatives are evidence-based, focused on improving patient outcomes, and implemented based on internal and external benchmarking. These initiatives include developing and revising patient care standards and policies as well as staff education. Interprofessional teams within Pathway organizations are patient advocates driven by strong missions, visions, goals, and values.

Element of Performance 4.1
Describe the process for external benchmarking.
AND
Provide one example of unit-based, nurse-led quality initiative that was implemented based on an external benchmark that was not being met. Include the benchmark and the name of the source of the agency of the external benchmark used.

Organization’s narrative response for EOP 4.1:
KMC uses the rapid cycle quality improvement process of Plan, Do, Study and Act (PDSA). This process is used for problem identification, redesign, evaluation and improvement. If benchmarks are not met, then a quality improvement process is implemented. Evidence-based practices (EBP) are evaluated, put into operation and refined while progress is measured by the established benchmarks.For example, patient satisfaction is benchmarked using an external vendor, which allows us to benchmark our patient satisfaction at a national level by hospital and unit type for inpatient and outpatients. This data has led to the quality initiative of the “nursing care bundle” which includes nurse leader rounding and nurse hourly rounding with a focus on pain, repositioning and bathroom needs. Other examples of quality improvement initiatives based on external benchmarks include the fall prevention program, hospital acquired conditions, readmissions, and core measures.

Reduction in 30 Day Congestive Heart Failure Readmissions
In 2012, the Affordable Care Act 3025 was implemented by CMS. A quality of care focus of this act included a reduction in 30 day post discharge readmission rates. KMC uses the Midas+DataVision, a national comparative database, to benchmark 30 day readmission rates. The KMC Quality Committee met and was analyzing KMC 30 day readmission data, and found KMC’s readmission rate from FY12 (19%) to FY13 (30%) had almost doubled with the patients with a diagnosis of heart failure (HF).

In October 2014, KMC set a target of 13.2%, which is the top 15 percentile of the Midas+DataVision HF readmission rates. AN RN-student from nearby community college researched the LACE program and presented her research paper to the Unit Director who invited her to the next Quality Committee meeting. Based on the article published in 2010 by Van Walraven, Dhalla, Bell, et al., and the collaborative discussion, the committee agreed KMC should focus on reducing 30 day post discharge readmissions. The key indicators of the LACE program include:

• L = Length of Stay – risk goes up with length of stay
• A = Acuity – risk goes up with emergent or urgent admissions
• C = Comorbidity – risk goes up with certain comorbidities
• E = ED visits – risk goes up with number of ED visits in the past 6 months

Patients with a LACE score of 9 or above are identified as at a higher risk for readmission. The basis behind LACE is that by identifying high readmission risk patients shortly after admission and implementing specific care interventions, readmissions can be reduced. One strategy is to improve transitions and coordinate care across the continuum. Four key areas to improve the transitions from the hospital to post-acute care settings include: assessment of post-hospital needs; effective teaching; posthospital care follow-up; and real time hand over communications. A readmission prevention protocol, Care Path, and Standard Operating Procedure were developed utilizing evidence-based interventions. Staff volunteereed to be champions of their new program.

The LACE tool quality improvement initiative at KMC has led to a dramatic decrease in the 30 day post discharge readmission rates for HF patients from 19% risk adjusted for same months, to well below the established benchmark.

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*Your typed name is sufficient as a signature. If appointed, you will be asked to sign official forms.

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