**Title of Innovation:** Technology Based Nursing Systems Redesign

**VISN:** 15

**Facility:** John J. Pershing VAMC

**Primary Author:** Ginger Potts

**Team Members:**

Kay Fox

Sydney Wertenberger\
Janice Vernon\
Delinda Bounds\
Clay Franklin\
Lynda Frey\
Gary Cates

**Abstract:**

Acquisition of computer equipped bedside medication units allowed for a
transformation of nursing care delivery in the acute medical/surgical
patient care units in this small rural facility. A collaborative effort
was required including IT and logistics to obtain the equipment,
engineering to secure the carts, building management for cart cleaning,
and pharmacy to redesign delivery of medications. As a result of these
efforts, computer equipped bedside medication carts allowed for
medication administration and patient care documentation to be performed
at the patient bedside improving the work flow of patient care delivery.
Not only did medication errors decrease by 50%, but increasing nurse
time at the bedside resulted in a reduction in patient falls of 50%,
improvement in SHEP scores, and increase in nurse satisfaction as
evidenced by a decreased turnover rate to less than 1%.

**Full Submission:**

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**Title of Innovation:** Patient Centered Shift Handoff

**VISN:** 12

**Facility:** Madison VAMC

**Primary Author:** Mary Hartmann

**Team Members:**

Beverly Priefer\
Jacalyn Sutton\
Susan Clearfield\
Sarah Schroeder\
Dennis Clapp\
Molly Brunner\
Teresa Van Wagoner\
Laura Pafford\
Donna Miller\
Mary Schmidt

**Abstract:**

Redesigning change of shift handoff to occur at the patients' bedside in
medical and surgical units assisted veterans to make informed choices
about their own healthcare while also improving the accuracy of
nurse-to-nurse communication. To support this innovation, a standardized
handoff process was developed. After nurses review a patient preview
spreadsheet they then use a standard format called "PACE"
(patient/problem, assessments/actions, continuing/changes, and
evaluation) to communicate handoff information at the bedside along with
informing the patient about the "plan for the day/stay". One team member
published on the PACE template for shift report in a nursing journal,
Nursing 2006. Patients report high levels of satisfaction. In addition,
the new process takes less time; 79% of nurses reported that the new
process is better; and 61% reported that they forgot less often to
communicate important information to the next shift.

**Full Submission:**

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**Title of Innovation:** Minneapolis Heart Failure Telehealth Clinic

**VISN:** 23

**Facility:** Minneapolis VAMC

**Primary Author:** Connie Jaenicke

**Team Members:**

Judy Wagner\
Anne Steckler

**Abstract:**

Escalating costs, transportation barriers, and the need for close
monitoring of patients demand innovative approaches in management of
veterans with heart failure. To respond, a nurse-managed heart failure
telehealth clinic was established with physician consultation. The
clinic incorporates a combination of case management, telehealth
monitoring, optimization and titration of heart failure medications and
intravenous medication administration in an outpatient observation unit.
Costs in high-risk patients were reduced by over \$6000 per veteran. In
addition, telephonic titration of medication in medium-risk patients
reduced the number of patients needing implantable cardiac
defibrillators or cardiac resynchronization therapy by half.

**Full Submission:**

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**Title of Innovation:** Striving for Excellence on a National Level
(IHI initiatives on reducing central line infections and ventilator
associated pneumonias)

**VISN:** 10

**Facility:** Cincinnati VAMC

**Primary Author:** Suzanne Brungs

**Team Members:**

Rachael Hasselbeck\
Marta L. Render

**Abstract:**

Two nurses in the VA Inpatient Evaluation Center served as
Implementation Coordinators for the Institute for Healthcare Improvement
(IHI) Saving 100,000 Lives Campaign initiative to reduce hospital
acquired infections in VA Intensive Care Units. To support this
initiative they developed a SharePoint site that houses toolkits for the
implementation of evidence based practices to reduce central line
associated bloodstream infections and ventilator associated pneumonias.
The toolkit contains strategies for promoting the project, educational
materials, literature on practices to reduce infections, sample
policies, data collection tools, and graph templates to provide feedback
to employees. In addition, they supported improvements through web-based
conference calls and a mentoring program. In the past two years, within
VHA, both central line infection rates and ventilator associated
pneumonia rates have decreased by almost 40%.

**Full Submission:**

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**Title of Innovation:** Intensive Cultivation of an Exportable Skin
Management and Pressure Ulcer Prevention Program

**VISN:** 8

**Facility:** James A. Haley VAMC

**Primary Author:** Susan S. Thomason

**Team Members:**

Christine Bennett\
Paula Boyle\
Anne Dammers\
Heidi Lacko\
Jane Nichols\
Anna Resulta\
Candice Watkins

**Abstract:**

Fragmented skin and wound care practices were transformed through the
use of nursing experts, education, performance improvement, and
monitoring to a dynamic skin management and pressure ulcer program. The
work began by identifying structure and process gaps between existing
practices and a new VHA Handbook on "Assessment and Prevention of
Pressure Ulcers." Based on this assessment, an action plan was
implemented. Central to the success of the transformation was providing
advanced education to four staff nurses who coached other nurses in
state-of-the-art skin and wound care practices. A research study
reported that this nursing initiative resulted in saving over \$500,000
through improve skin care practices in veterans with spinal cord
impairment.

**Full Submission:**

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**Title of Innovation:** Genie in a Bottle: The Magic of Nursing
Brilliance (glycemic control protocol)

**VISN:** 4

**Facility:** Pittsburgh VAMC

**Primary Author:** Candace Cunningham

**Team Members:**

Mary Rudy\
Joyce Ewing\
R. Harsha Rao

**Abstract:**

Veterans undergoing cardiac bypass surgery were developing deep sternal
surgical site infections at a concerning rate. A workgroup discovered
that in all patients who had developed mediastinits and significant
post-operative hyperglycemia, available glycemic protocols were either
inadequate to meet patients needs or so complicated that they were prone
to error. As a result, a team of nurses designed and educated their
colleagues on a usable patient-focused tight glucose control system.
Within the first month, improvement occurred. Ongoing performance
improvement work resulted in GENIE (Glycemic Expert for Nurse
Implemented Euglycemia), a computer interface that allows for precise
glucose management that is soon to be patented.

**Full Submission:**

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**Title of Innovation:** Improving the Early Detection and Case
Management of Colorectal Cancer

**VISN:** 4

**Facility:** Pittsburgh VMC

**Primary Author:** Nicole Hicks

**Team Members:**

Joann Moorhead\
Joan Zolko\
Kimberly Toland\
Robert Monte\
Frederick DeRubertis

**Abstract:**

The staffing methodology and care delivery model were structurally
redesigned to improve colorectal cancer screening compliance and patient
access to the Gastroenterology (GI) clinic and lab. Some resulting
changes included having a nurse call patients three-days pre-procedure
to review prep instructions, training in intravenous administration to
eliminate delays while waiting for IV access, additional escort staff to
facilitate transportation, hiring a nurse practitioner as a colorectal
cancer coordinator to improve processing of patients with positive fecal
occult blood test results. As a result, colorectal cancer screening
rates increased by from 50 to 76%, productivity in the GI lab improved
by 23% and waiting times were reduced to 12 days.

**Full Submission:**

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**Title of Innovation:** Applying Evidence Based Practice through Shared
Governance Structure

**VISN:** 8

**Facility:** James A. Haley VAMC

**Primary Author:** Diane Mayes

**Team Members:**

Patricia A. Quigley

**Abstract:**

A formalized shared governance structure created a work environment for
nursing staff to be actively involved in decision making and use
evidence to drive decisions for patient care and nursing practice. A
coordination council integrates the work of four other nurse-led
councils on quality, advocacy, professional development, and practice. A
formalized process was developed for nursing staff to present issues for
council consideration. A wide variety of patient care and work
environment improvements have been made including implementing medical
response teams, developing a standardized handoff process, ensuring that
policies and procedures are evidence based, and redesigning work
processes so that non-nursing tasks were performed by appropriate
services.

**Full Submission:**

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**Title of Innovation:** Use of Restorative Nursing Assistants in the
Critical Care Units

**VISN:** 22

**Facility:** Los Angeles VAMC

**Primary Author:** Mari Kelley

**Team Members:**

Brooks Kabo\
Abbas Ardehali\
Margaret M. Kohn\
Cathy A. Bradish\
Adina Katz

**Abstract:**

Long intensive care unit (ICU) lengths of stay were related to medical
provider's lack of confidence that nursing staff outside of the ICU
would ensure that patients received adequate physical therapy and
rehabilitation. Restorative Nursing Assistants (RNAs) were hired and
educated to supplement rehabilitative activities of patients provided by
nursing staff. RNA's, under the direction of nurses, assisted patients
in the intensive care units, progressive care units and medical-surgical
wards to sit in a chair to eat meals, ambulate, use an incentive
spirometer, and other rehabilitative activities. In addition to
decreasing median LOS in the critical care areas from 10 to 5 days, the
cost and quality of care for patients were improved.

**Full Submission:**

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**Title of Innovation:** Centralizing Nursing in a Care Line Model:
Creating the SAVAHCS Culture of Caring

**VISN:** 18

**Facility:** Tucson VAMC

**Primary Author:** Sheila Thompson

**Team Members:**

DJ Smith\
Charles Silveri\
Martha Kates

**Abstract:**

A Nursing Reorganization Design Team coordinated the transformation of
nursing from a decentralized model to one in which inpatient nursing
resources were consolidated into one care line and the entire nursing
practice environment was strengthened through a nursing committee
structure. In a retreat, the work of nursing was coalesced by
establishing a "Culture of Caring" and a redefined mission, vision,
values, and theory. Unit councils were established to increase nursing
staff control over their practice environment. Not only are nurses
reporting higher satisfaction levels but also the use of outside agency
staff has been reduced by more than 50% and patient outcomes have
measurably improved.

The Nurse Executive was charged with gathering nursing leaders and staff
representatives to develop a plan to centralize nursing and increase the
standardization of nursing practice across the organization

**Full Submission:**

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