Council of Nurses. Annual Report

Transcription

1 Council of Nurses Annual Report

2 Members of the Executive Committee of the Council of Nurses are pleased to submit the Annual Report of the Council of Nurses for a 18th consecutive year. Once more you will be able to appreciate the extent of nurses contribution to patient safety and quality of care as well as the general wellbeing of our organization. Feel free to contact us if you have any questions. 2

3 Highlights of CII Achievements Recruitment and Retention The CII has continued working in close collaboration with the Recruitment and Retention team to maintain and optimize recruitment and retention rates especially through our Comité de la relève. Throughout , the following activities were organized: monthly presentations during orientation of new nurses; various career fairs held in CEGEPs and universities in the province of Quebec as well as in the annual OIIQ Congress; Open House at the JGH. Overall there is a slight decrease in turnover rate compared to last year (11.4% vs. 12% last year) with a national average of 19.6%. Our retention rate remains stable at 88% (89% last year). The JGH remains a very competitive and attractive employer in nursing which was acknowledged this year with the JGH being one of Montreal s Top Employers for 2013 by Mediacorps, an organization that recognizes employers that are offering exceptional places to work. Outreach The CII continued to maintain a close relationship with the Representative on the Regional Nursing Board and being informed of challenges and issues at the regional level. The CII also maintained a close relationship with the Association des CII du Québec (ACIIQ) which aims at: providing the necessary support to CIIs in the province in achieving their goals and responsibilities, and ensuring proper provincial representation at the Ordre des infirmières et infirmiers du Québec (OIIQ) and Ministry of Health and Social Services levels. CII members attended their Annual General Assembly and Symposium. 3

4 Quality of Care and Patient Safety Nursing Documentation Review This past year the Nursing Documentation Committee (NDC) chaired by Ms. I Gourdji, N. Nurse Specialist-Clinical Information, reviewed over 46 newly developed or revised legal Nursing documents for clarity and patient safety concerns. NDC members were instrumental in leading the Therapeutic Nursing Plan section of the Improvement Plan submitted to the OIIQ, in January 2012, following Professional Inspection. The overall global results pertaining to the form and clinical content were excellent. Collective Orders The Nursing Committee on Collective Orders is cochaired by Ms. Valerie Schneidman, Assistant Head-Nurse in ER, and Ms. Judy Bianco, Associate Nursing Director Medicine, Geriatrics and Emergency Department. Following the development of "Nursing Guidelines for the Development of Collective Orders at the JGH", the Committee expanded its membership and guidelines to include other professional groups and standardize Interprofessional approaches to collective orders. This year, the following collective orders were approved: 001 Carboplatin Dose Adjustments in Gyne Oncology (Pharmacy) 003 Drug Levels Initiation (Pharmacy) 005 Redirecting ED patients to CRIU Herzl (Nursing) 017 Acticoat Initiation (Enterostomal Nurse) 018 Aquacel AG Initiation (Enterostomal Nurse) 019 Aquacel Initiation (Enterostomal Nurse) 020 Inadine Initiation (Enterostomal Nurse) 021 Iodosorb Initiation (Enterostomal Nurse) 022 Mesalt Initiation (Enterostomal Nurse) 023 Nu-Gel Initiation (Enterostomal Nurse) 024 Silvercel Initiation (Enterostomal Nurse) 025 Preoperative INR (Nurses) 026 Urinary Catheterization (Nurses) 027 Removal of an Indweling Urinary Catheter (Nurses) 4

5 Nursing Informatics Committee This past year the Nursing Informatics Committee (NIC) chaired by Ms. I. Gourdji, N., Nurse Specialist in Clinical Information, focused on evaluating the results from the ICU pilot project launched on November 16, 2011 that examined the use of ipod Touches for nurses to enable them to easily access evidence based information at the point of care, with the potential of improving patient outcomes and nurse satisfaction. In collaboration with the Head Nurse of the ICU, roll out to the rest of ICU nurses was provided to nurses interested in the technology that do not already have their own devices. This project was led by the Nursing Informatics Committee in partnership with Dr. Steve Rosenthal, Ms. F. Guimont, Clinical Analyst, and Ms. J. Raboy-Thaw, Head nurse of the ICU. Committee work is currently on hold until new technologies become available (e.g. electronic charting, mobile Oacis to provide an interface to labs, electronic chart, imaging results, pathology, etc.). Continuous Quality Improvement and Risk Management The ultimate goal of the Quality Program at the Jewish General Hospital is the reinforcement of quality of patient care and safety in service delivery. The Quality & Risk Management Committee is an interprofessional team co-chaired by the Associate Nursing Director and the Director of Professional Services. Members of the Council of Nurses bring a significant contribution to the activities of this committee. In , the following were some of the highlights: - Formalization of the interdisciplinary Medication Reconciliation CQI Team - Formalization of an interdisciplinary Hand Hygiene CQI Team - New antimicrobial stewardship program with a dedicated pharmacist. - Ongoing activities and work for the 2 JGH Failure mode and effect analysis (FMEA) teams: (1) Laundry hazards and (2) the Prescription of narcotics in the ED. - Continued rise in the number of incident / accident AH-223 reports completed (which reflects increased staff awareness and participation). 5

6 - Hospital wide Patient Satisfaction reports are conducted yearly (70 questionnaires are sent out each week to discharged patients). - Focus of Quality Program was to support the Accreditation Process. It supported 22 Accreditation Canada Teams. - Accreditation visit occurred during the week of November 25-29, Report was received in December 2012 and responded to in order to obtain an Accreditation with Exemplary Standing. Quality Indicators on the Web was recognized by Accreditation Canada as a Leading Practice. - Quality & Safety Grand Rounds - a record number of rounds (24) were given in order to be able to capture all the patient safety areas required by the Accreditation Canada ROPs. - A very successful Patient Safety Week during the week of Oct 29 - Nov 2, 2012, with record attendance and participation by CQI Teams and JGH staff. - A unit specific score card was introduced in October 2012, providing each unit with unit specific results for key safety indicators. - Starting in January 2013, Quality Program started providing data collection and analysis support to various CQI projects: Surgical Site Infections (SSI), Community Acquired Urinary Tract Infections (CAUTI), audits of grey zone cleaning, transport of ICU patients for testing. Wound Care Committee and Pressure Ulcer Prevention Pressure Ulcer Prevention (PUP) is a hospital wide quality initiative aimed at reducing Hospital Acquired Pressure Ulcer (HAPU). All units are now involved in pressure ulcer prevention. Formal PUP programs are ongoing on the majority of the hospital units and all units will be reached by the end of this year ( ). We are maintaining our prevalence goal of 10% with quarterly results of 6%, 9%, 8%, and 11% last year. Interprofessional and Interdepartmental Initiative aiming at reducing rates of C. difficile CII members have been very involved in all activities aiming at reducing our rates of C. difficile. Continued activities are still required in order to optimize our interventions and reduce our rates below provincial average. 6

7 Specialized Approach to Senior Care The Specialized Approach to Senior Care is an initiative aimed at overseeing care of elderly patients in an acute care setting and throughout the continuum of care. Through this interdisciplinary approach, nurses play a key role since they are present at patients bedside throughout their hospital stay. Implementing all of the different components of the Specialized Approach to Senior Care is a government mandate targeting all hospitals in the province. During , nurses were involved in program planning, development of tools and indicators, and training of resource people in order to begin the implementation of those strategies on the units in W, 8NW, and ER will be the first nursing units to pilot test this program and work is in progress to prepare them to initiate the process. Nursing Innovation Project In , the Nursing Innovation Awards were renewed for a third consecutive year led by Ms. Charline Elhabre and Ms. Debbie Teasdale, members of the Council of Nurses, and made possible by the generous contribution of Amgen. Members of the CII were invited to submit a project addressing patient safety and quality of care. All submissions were evaluated for their level of creativity, leadership, quality, efficiency and patient safety. Awards were presented at the CII Annual General Assembly in May

8 Winners: First Place: Implantation d un programme de formation infirmière visant l amélioration des soins palliatifs à travers l hôpital. «Soins palliatifs en capsule». Marie-Laurence Fortin, inf., M.Sc.N., CHPCN (c); Kim Sadler B.Sc.inf., Ph.D. (c) Second Place: Toothbrushing for Better Oral Care. Marineh Carapetian, Clinical Nurse Specialist, 7W; Vicky Lizote, N., 7W; Jessica Emed, Clinical Nurse Specialist, 7W Third Place: Better be safe than sorry! Fall Prevention Strategies. Yuijie Hu, N., 8NW; Lucie Bourdeau, N., Clinical Nurse Educator; Véronique Roger, Head-Nurse, 8NW All winners and participants were highlighted during Nurse's Week at the CII s General Assembly. Winners are expected to present their progress to the CII in Professional Inspection The JGH Department of Nursing and CII worked in close collaboration in order to coordinate all activities related to preparation for, and achievement of a successful professional inspection. Feedback from the Ordre des infirmières et infirmiers du Québec (OIIQ) was highly positive and results obtained were found to be the highest in the province as stated by OIIQ representatives. Following the report from the OIIQ, an Improvement Plan was developed and approved by the OIIQ. Activities mentioned in the plan were implemented this year and a progress report was submitted to the OIIQ. All of the submitted documents were well-received and approved by the OIIQ. 8

9 Goals and Objectives Recruitment and Retention: The CII will continue to be involved in activities organized to achieve staff recruitment and retention objectives of the Department of Nursing. Outreach: The CII will continue to work in close collaboration with the Regional Nursing Board representative. The CII will renew its membership and continue to participate in the activities of the Association des CII du Québec, including its Annual CII/Regional Nursing Board Seminar. Quality of Care and Patient Safety: The CII will maintain at least one representative on each of the following committees aimed at optimizing quality of patient care: 1. Nursing Documentation Committee 2. Committee on Collective Orders 3. Continuous Quality Improvement and Risk Management Committee 4. Pressure Ulcer Prevention Committee The CII will continue to support the implementation of innovative projects that impact the quality of patient care and services through the Nursing Innovation Award each year. All three award recipients must implement their project within two years. The CII will continue to support activities of the Council of Licensed Practical Nurses (CIIA) related to quality of care and patient safety. The CII will continue to be involved in activities of the Department of Nursing aimed at achieving the following objectives: 1. Maintaining our prevalence of pressure ulcer lower than 10% 2. Improving our current C. difficile rates 3. Implementing specific aspects of the Specialized Approach to Senior Care to maintain their functional autonomy 9

10 Committee Membership Elected members: - François Aubé, N., Clinical Nurse Specialist in Neurosurgery, President - Marylise Nguyen, N., NICU, Vice-President - Charline Elhabre, N., ICU, Chair of the Nursing Innovation Awards - Yujie Hu, N., 8NW, Secretary and Website Developer - Ryan Lomenda, N., NICU, Electoral Officer - Anne Ross, N., Head-Nurse, 3NW Reserve member: - Ryan Muscott, N., Oncology Clinic Ex officio member: - Johanne Boileau, N., Director of Nursing Consultants: - Karine Lepage, N., Head-Nurse, 7NW, Co-Chair Comité de la relève - Sophie Pouliot, N., Dialysis, Co-Chair Comité de la relève - Sonia Joly, N., Continuity of Care Nurse Coordinator, Representative to the Board of Directors - Rosalie Johnson, N., Nursing Resource Center Coordinator, Representative of Quality and Risk Management - Iris Gourdji, N., Nurse Specialist - Clinical Information, Representative of Nursing Informatics and Nursing Documentation - Louise Samuel, N., ETN, Representative of Pressure Ulcer Prevention Committee 10