Empowerment of Sparrow Nurses is founded on decision-making closest to the issue. Thus, staff nurses engage in unit-based councils to have input where they work everyday. Further, our evolving shared decision-making model offers participation at Council and Committee levels where their ideas impact nurses across all departments.

 

Patient Experience

Sparrow Hospital uses a comprehensive and systematic Listening Post Approach in how we leverage opportunities to communicate with our patients and families. We use Nurse Leader Rounding on patients, Hourly Rounding by caregivers, Discharge Phone Calls, Bedside Shift Report, and Patient Communication Boards to ensure ample opportunity in enhancing the patient experience.

Nurse Leaders round on our patients daily. Nurse Leaders use this opportunity to validate that standardized best practices, identified through the Sparrow Way, are being utilized to ensure quality outcomes, and that patient expectations are managed to ensure a positive patient experience.

Patients are contacted via phone 1-3 days (up to 10 days, as necessary) post-discharge to identify post-care needs, determine their level of satisfaction with the care they received, and provide recommendations for improvement. It is our opportunity to provide our patients with a “final hug of quality.” Nurses also conduct Hourly Rounding, using a standard list of questions and expected behaviors to ensure consistency relative to patient safety and the needs of the patient. One example of success with patient safety is a reduction in pressure ulcers.

We quantify patient satisfaction through HCAHPS Survey Results, and ED, OP Surgery, and Outpatient Patient Satisfaction Survey Results. We also use the Sparrow Patient Relations Tracking System to review and investigate complaints and provide a plan of resolution acceptable to our patients and families. Comprehensive reports capturing aggregate analysis of data by patient segment provide detail needed to exceed patient expectations. The information that we capture via quantifiable methods is translated into actionable information through the determination of key drivers for each patient segment. One example of a report is seen below:

Sparrow HCAHPS

HCAHPS Graph

 

MISSING CONTENT

Patient Falls

After the implementation of the Falls Bundle in 2010 there was a 60% drop in falls noted in 2011. As the data reflects, that decrease was maintained throughout 2012, but not improved upon. It is interesting to note that there was a dramatic decrease in the use of restraints during this time and no significant rise in falls occurred. The Falls Prevention Team focus for 2012 was to work with the falls champions to go “Beyond the Bundle” and focus on why a given patient is at High Fall Risk since not all patients are at risk for the same reason.

One important project in 2012 was to transition all of our falls information from paper charting to electronic charting. We were successful in having admission and shift assessment documentation, Post Fall documentation, as well as nursing care plan information available when the hospital went live with the Electronic Medical Record (EMR) on Dec. 1, 2012.

 

Restraints

A restraint-free culture continues to be a focus of all bedside caregivers at Sparrow, keeping the patient at the center of care and maximizing safety practices. A decrease of over 90% of restraint use throughout our facility puts Sparrow in the top decile for Magnet hospitals. Education and communication continue in an effort to maintain our successes and keep our patients safe. Sparrow’s interdisciplinary team continues to support a culture that promotes safety, awareness, and alternatives to restraint use. This practice has been hard wired and embedded in our culture of nursing care.

 

Adult Critical Care Central Line Associated Bloodstream Infections

 

2009

2010

2011

2012

Total infections

5

9

12

4

Total Rate / 1000 line days

1.01

1.35

1.48

0.48

NHSN 25th percentile

0.50

0.60

0.30

0.00

NHSN 50th percentile

1.50

1.70

1.30

1.00

 

Adult Critical Care Ventilator Associated Pneumonia

 

2009

2010

2011

2012

Total infections

1

5

7

2

Combined Adult Critical Care Ventilator-associated Pneumonia

0.17

0.68

1.22

0.33

NHSN 25th percentile (Med/Surg Major teahing)

1.30

0.90

0.00

0.00

NHSN 50th percentile (Med/Surg Major teaching)

2.30

2.00

1.20

1.10

 

Nursing Sensitive Indicators Scorecard (8 Quarters; 1Q 2011–4Q 2012)

Hospital Acquired Pressure Ulcers

Restrains

Falls

PIC Infiltrations

CLABSI

Pain

VAP

CAUTI

Unit Totals

CICU

2/8

8/8

4/8

4/8

7/8

4/4

3/6

ICU

3/8

8/8

2/8

5/8

6/8

3/4

4/6

Neuro ICU

6/8

8/8

3/8

5/8

6/8

2/4

4/6

4F Cardiac Progressive

7/8

7/8

6/8

5/7

4/4

5/5

4S Cardiac Step Down

7/8

7/8

3/8

5/6

3/4

4/5

7F Medical Intermediate

1/8

7/8

8/8

3/7

5/5

3/4

4/6

Neuro Step Down

6/8

7/8

2/8

5/7

2/4

3/5

8S Medical Specialty

6/8

6/8

2/8

4/6

4/4

4/5

5W Oncology

3/8

7/8

4/8

3/6

4/4

2/5

6W Orthopedics

4/8

8/8

7/8

6/6

4/4

4/5

7N Surgical Specialties

3/8

7/8

7/8

5/6

3/4

4/5

6S Ortho/Neuro

6/8

8/8

3/8

5/6

4/4

4/5

7S Women's Pavilion

5/8

8/8

8/8

4/6

4/4

5/5

6F adult rehab

6/8

8/8

4/8

3/4

4/4

4/5

PICU

8/8

7/8

7/8

6/8

6/6

8/8

4/4

7/7

Pediatrics

8/8

8/8

6/7

4/7

4/4

5/5

RNICU

8/8

8/8

8/8

7/8

7/8

8/8

6/6

GERI Psych

5/8

8/8

2/2

Indicator Totals

12/18

18/18

5/14

3/3

13/16

3/3

6/6

14/16

74/94

Scoring: Each unit must meet or exceed the national mean in at least 5 of 8 rolling quarters; the majority of units in total must exceed the national mean to maintain Magnet status