JCMC Nursing Annual Report - Mountain States Health Alliance

Celebrating Strengths That Nursing Brings to Patient-Centered Care. 

Johnson City 

Medical Center 

2009 

Nursing Annual Report

From the Chief Nursing Officer 

It is with great 

pleasure that I am 

writing to you as the 

chief nursing officer 

to acknowledge the 

nursing excellence 

evidenced at Johnson 

City Medical Center. 

Being the first hospital 

in Tennessee to 

achieve Magnet status 

and redesignation 

has provided us with an opportunity to focus on our 

success as a Magnet organization by “Celebrating the 

Strengths That Nursing Brings to Patient-Centered 

Care.” These strengths are the key to excellence and 

our overall success at Johnson City Medical Center 

( JCMC). The strengths cross all Magnet forces and 

provided the basis for our redesignation success and 

the evidence that our nursing staff is continuously 

identifying new ways to improve how patient care is 

delivered. 

The exemplars identified by the Magnet Site 

appraisers included our strategic plan to eliminate 

travel nurses with the onboarding of 120 new grads 

and the hiring of 10.6 FTEs of support in clinical 

resource nurses and educational roles to support 

the transition of the new grads. The projected cost 

savings for elimination of contract labor, an 84-hour 

cardiovascular option, an Emergency Department 

weekend staffing option, the use of i-choice 

scheduling options and nursing role definitions have 

been estimated at $7.2 million. We also exceeded 

Magnet expectations in disseminating quality 

data throughout the organization. Our personal 

Blueprint cards, based on our four pillars of quality, 

Magnet cited as an exemplar for communicating 

quality data to all team members. We exceeded 

Magnet expectations in providing adequate resources 

for consultation and access to nursing expertise to 

nurses at all levels in the organization and fiscal 

allocations for affiliated schools and colleges of 

nursing based on the identification of needs within 

the nursing program to meet the goals for health care 

in the region. They commended the examples offered 

that demonstrate how nurses are used in promotional 

materials, brochures, advertisements, newspaper 

articles, television and radio advertisements, direct 

mailings, educational booklets, pamphlets and 

community activities. JCMC was congratulated on 

providing resources that include tuition support, 

scholarships and flex time to attend school, and 

demonstrating support to nurses, financially, to 

attend different conferences or symposiums. 

With our Magnet redesignation, it will truly be 

a year to celebrate our excellence. ANCC honors 

all the newly designated and redesignated Magnet 

organizations at the National Magnet Conference 

each year. We look forward to receiving this honor 

at the 2010 ANCC National Magnet Conference 

in Phoenix, Oct. 13-15, 2010, at the Phoenix 

Convention Center. 

We also realized a successful Joint Commission 

survey and achieved, for a second time, the TNCPE 

Governor’s Award for Excellence. 

Over the past five years, our organization 

has made significant investments in improving 

recruitment and retention. RN recruitment, turnover 

and retention are now blueprint measures for the 

CNO and her nursing leaders. We now have 150 

students enrolled in our scholarship program who 

will be employed at the completion of their RN 

program. We are developing LPN to RN and LPN 

to BSN programs. We have also implemented a 

JCMC Nurse Retention Committee. With these new 

initiatives and dedicated resources, our recruitment 

numbers have shown an increase for this year. 

In addition, to recognize and financially reward 

excellence at the bedside, the “BEST” Nurse (Bedside 

Excellence Shining Through) Clinical Advancement 

Program at Johnson City Medical Center is the spirit 

and practice of caring for patients, families and the 

community through leadership, knowledge and 

compassion. We believe that nursing is both an art 

and a science incorporating multiple realms of care 

including the physical, developmental, emotional, 

social, psychological, cultural and spiritual. Nursing 

2

exemplifies the highest degrees of accountability, 

integrity and honesty in all relationships with 

patients, families, colleagues and community. The 

nurse is a patient advocate committed to upholding 

the American Nurses Association’s Code of Ethics 

for Nurses and other professional and regulatory 

standards of nursing practice and patient care. The 

program supports nursing practice by assisting 

the retention of experienced, motivated bedside 

nurses in direct patient care by acknowledging their 

professional development. We now have 250 BEST 

nurses at JCMC. 

Many accomplishments, advances, contributions 

and innovations have been mentioned in the 

preceding paragraphs and will be expanded upon 

throughout the Annual Report. I applaud the efforts 

that have been undertaken that substantiate the 

achievement of Magnet redesignation. 

I am very proud of our nursing staff for 

their professional contributions, as well as their 

commitment to our patients, Johnson City Medical 

Center and our community. 

Congratulations on a year of excellence. This 

certainly is a time to celebrate our strengths. 

Inside 

Contents 

Congratulations from Senior Leadership............4 

New Magnet Model.................................................5 

Magnet Redesignation.............................................6 

Transformational Leadership.................................8 

Structural Empowerment.................................... 10 

Exemplary Professional Practice......................... 14 

New Knowledge, Innovation 

and Improvement.................................................. 18 

Imperical Quality Outcomes.............................. 21 

Niswonger Children’s Hospital.......................... 23 

Years of Service....................................................... 24 

Pressure Ulcers....................................................... 26 

Turnover.................................................................. 26 

Rapid Response...................................................... 27 

Pat Niday, VP, CNO 

bringing loving care to health care | www.msha.com 3

A Message from the CEO 

This was a year of 

accolades for nurses at 

JCMC and Quillen 

Rehabilitation Hospital. 

The achievement of 

redesignation as a 

Magnet Hospital for 

Nursing in 2009 was 

confirmation of the 

excellence of nursing and 

nurses at these hospitals. Many people worked long, 

hard hours to write the application that told our 

story about nursing and its accomplishments. We 

continued to make significant strides in improving 

the quality of patient care, including the aspects 

of patient care that are so dependent on nursing 

expertise, such as preventing falls and pressure ulcers, 

decreasing the rate of infections and preventing 

ventilator-associated pneumonia. This excellence 

was recognized by the Magnet examiners and in the 

granting of redesignation. 

We also received an excellent report from our 

Joint Commission survey, with no requirements 

for improvement in nursing cited. What a truly 

outstanding accomplishment! And if those 

accomplishments weren’t enough, nurses contributed 

significantly to the winning of the prestigious 

Tennessee Center for Performance Excellence Award 

after a site visit to our facilities in November 2009. 

Many other accomplishments are presented in this 

Annual Report for Nursing. Nurses are making major 

contributions to the improvement of patient care 

and safety in our hospitals, and their efforts are being 

recognized. As we navigate the uncertain future of 

healthcare reform, it is very clear to me that nurses are 

ready to take a significant leadership role in designing 

a system that works for our patients and communities 

and actually improves health and wellness and the 

ability of people to have better lives. 

I am very proud of every nurse who has contributed 

to the successes of the past year. Congratulations 

on this wonderful year of achievement, and I am 

privileged to work with you and support you in your 

efforts. 

Candace Jennings, senior VP, CEO 

4

New Magnet Model 

Global Issues in Nursing and Health Care 

Structural 

Empowerment 

Transformational 

Leadership 

Empirical 

Outcomes 

New Knowledge, 

Innovations & 

Improvements 

Exemplary 

Professional 

Practice 

Transformational Leadership: 

The CNO in a Magnet organization is a knowledgeable transformational leader who develops a strong vision 

and well-articulated philosophy, professional practice model and strategic and quality plans in leading nursing 

services. 

Structural Empowerment: 

Magnet structural environments are generally flat, flexible and decentralized. Nurses throughout the 

organization are involved in self-governance and decision-making structure and processes that establish 

practice and address issues of concern. 

Exemplary Professional Practice: 

A professional practice model is the overreaching conceptual framework for nurses, nursing care and 

interdisciplinary patient care. It depicts how nurses practice, collaborate, communicate and develop 

professionally to provide the highest quality of care for those served by the organization. 

New Knowledge, Innovations and Improvements: 

Magnet organizations integrate evidence-based practice and research into clinical and operational processes. 

Nurses are educated about evidence-based practice and research, which enables them to explore the safest and 

best practices and to generate new knowledge. 

Empirical Outcomes: 

Nursing makes an essential contribution to patient, nursing workforce and community outcomes. The 

measurement of quality outcomes is imperative and directly related to nursing leadership and clinical practice 

in Magnet organizations. 

American Nurses Credentialing Center. (2008). Application Manual Magnet Recognition Program. 

Silver Springs, MD: Author. 


Magnet Redesignation 

When Johnson City Medical Center was named 

a Magnet Hospital by the American Nurses 

Credentialing Center in 2005, it was the first 

hospital in the state to receive that prized distinction. 

Since that time, only Vanderbilt Medical Center 

in Nashville has also received the honor of being 

recognized as one of the state’s top places for a nurse 

to work. 

On Wednesday, Nov. 18, 2009, JCMC achieved 

Magnet designation for a second time. 

“The commission on Magnet was very impressed 

with the great work done at Johnson City Medical 

Center and Quillen Rehabilitation Hospital, and as 

a result of some outstanding work, the Commission 

voted unanimously to redesignate Johnson City 

Medical Center as a Magnet organization,” 

said Karen Drenkard, director of the Magnet 

Recognition Program. “When you reach the level 

that redesignation demonstrates, it shows such 

commitment, and it’s very, very difficult to have 

sustained effort toward quality. The excellence in 

patient care that was demonstrated at Johnson City 

Medical Center makes the community very fortunate 

to have such a team.” 

The ANCC is the arm of the American Nurses 

Association, and Magnet status is the ANCC’s 

highest honor. It is also considered one of the 

highest possible levels of achievement for a medical 

facility on any level. The award is bestowed only 

after criteria from a book of standards are in place, 

evidence is gathered to support the claim, review of 

written responses is complete and an on-site, threeday 

visit by a team of Magnet appraisers has taken 

place. A Magnet hospital is the gold standard in 

patient care and the highest honor of excellence, and 

only around 2 percent of the 6,000 hospitals in the 

United States have earned the title. 

As the news was delivered to more than 100 nurses 

and administrators gathered together inside 

Niswonger Children’s Hospital, President and CEO 

Dennis Vonderfecht said he was again filled with 

pride for the work of the nurses inside the hospital. 

“We are very honored. This is truly exciting knowing 

we were the first hospital in the state to receive the 

designation in 2005, and to know we are now the 

only hospital in Tennessee to earn the redesignation. 

The nursing staff at Johnson City Medical Center 

truly is bringing loving care to each and every one of 

its patients,” Vonderfecht said. 

Candace Jennings, MSHA senior vice president of 

Tennessee operations and a registered nurse, said, 

“This is a reflection of something we already know, 

and that is our nurses are wonderful and make The 

MSHA Difference.” 

6

inging loving care to health care | www.msha.com 7

Transformational Leadership 

(Forces of Magnetism: Quality of Nursing Leadership, Management Style) 


Structural 

Empowerment 


Leadership 

Empirical 

Outcomes 


Innovations & 

Improvements 

Exemplary 

Professional 

Practice 

Transformational leadership describes nurses who are 

knowledgeable, strong risk-takers who follow a wellarticulated, 

strategic philosophy in the day-to-day 

operations of nursing services. Nurses, at all levels of 

the organization, convey a strong sense of advocacy, 

vision and support for the nursing staff and for the 

patient. 

Pat Niday, VP and CNO, conveys a strong and 

supportive role as our chief nursing officer at Johnson 

City Medical Center. Under the CNO’s scope of 

practice, Pat has direct-line authority responsibilities 

and matrix responsibilities where nursing is practiced 

at JCMC. Pat is the leader with the development 

of our MSHA Nursing Strategic Plan that outlines 

strategies for optimizing outcomes through improved 

clinical processes, enhancing financial performance 

and creating a safe environment for patients and 

caregivers. Promoting patient safety, quality nursing 

care, and patient and nursing satisfaction are major 

components in ensuring Patient-Centered Care, 

positive patient outcomes and integrity in everything 

we do. 

8

Results from the 2009 NDNQI RN Satisfaction Survey demonstrate an increase in Nursing Management 

T-Scores over this past year. Our nursing leaders, Pat Niday and Candace Jennings, RN, senior vice president/ 

CEO of Washington County Operations, serve as strong and visible leaders for the front-line team members 

of JCMC. Pat and Candace attend the newly restructured Nursing Retention Committee, which is 

co-chaired by front-line nurses and the manager of Human Resources. 

Johnson City Medical Center 

Nursing Management T-Scores 


Structural Empowerment 

(Forces of Magnetism: Organizational Structure, Personnel Policies and Programs, Community and the 

Healthcare Organization, Image of Nursing, Professional Development) 

Structural 

Empowerment 



Leadership 

Empirical 

Outcomes 


Innovations & 

Improvements 

Exemplary 

Professional 

Practice 

Magnet nurses throughout Johnson City Medical 

Center and Quillen Rehab Hospital are involved 

in self-governance, decision-making structures, 

processes that establish standards of practice, address 

issues of concern and information dissemination. 

The front-line team member is the central core to 

our Shared Governance structure. Nurses and other 

care providers contribute through multidisciplinary 

partnerships throughout the organization to improve 

patient outcomes and the health of the communities 

they serve. 

Unit-based councils are the functioning units or 

the “worker bees” that give and receive information. 

The flow of information is bidirectional and 

horizontal between and among professional nurses 

at the bedside, the leadership team and the CNO. 

Nurses extend their support and commitment to the 

professional growth of nursing through these shared 

governance councils, professional organizations and 

community service. 

BEST Nurse Program 

The BEST Nurse Clinical Advancement Program is based on the Synergy Model and Jean Watson’s Theory 

of Human Caring. The BEST (Bedside Excellence Shining Through) Nurse Clinical Advancement Program 

was developed by and for bedside nurses at MSHA. The BEST Nurse program recognizes the value of the 

clinical bedside nurse by evaluating the following eight characteristics: clinical judgment, advocacy and moral 

agency, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitator 

of learning. The BEST nurse exhibits knowledge-seeking behaviors and takes advantage of educational 

opportunities that enhance optimal evidence-based care. 

The BEST program supports nursing practice by facilitating the retention of experienced, motivated bedside 

nurses by supporting their professional development, diversity in field of practice and clinical excellence at 

the bedside. Nurses achieve points in the BEST program that translate into a higher level in the program 

and an increase in wages. Points are earned for professional education, teaching, volunteering and preceptor 

achievements. For each level achieved, the nurse receives a percentage increase in base pay. After a successful 

6-month introductory period, nurses can apply to the program, where the applications are peer reviewed 

by a panel of BEST nurses. Since August 2008, 33% of 750 eligible RNs have participated in the program, 

compared to 3-5% participation in the previous program. 

10

NDNQI Scores 

The NDNQI RN Satisfaction Survey measures different aspects of the nurse’s satisfaction with his/her work. 

Included here are graphs depicting RN-RN Interactions, Decision Making and Professional Development. 

All of these characteristics showed an improvement from 2008 to 2009. 

RN-RN Interactions 

RN-RN Interactions is the combination of scores related to the following comments: Nursing personnel pitch 

in and help each other when things get in a rush, it is hard for new nurses to feel “at home” on the unit, there is 

a good deal of teamwork among nursing personnel, the nurses on our unit support each other. 


Rn-Rn Interactions T-Scores 

Decision Making 

Decision Making is the combination of scores related to the following comments: There is ample opportunity 

for nursing staff to participate in administrative decision-making processes, they can count on nursing 

administrators to back them up, nursing administrators generally consult with the staff on daily problems. 


Decision Making T-Scores 

11 

bringing loving care to health care | www.msha.com

Professional Development 

Professional Development is the combination of scores related to the following comments: They have career 

development opportunities, they have access to regional and national conferences, they have opportunities for 

advancement, they have clinical nurse specialists who provide patient care consultations. 


Professional Development T-Scores 

Volunteering Enhances Image of Nursing in the Community 

Magnet nurses contribute to the organization and 

community and are recognized for their positive 

effect on patients and families. Nurses who volunteer 

enhance the image of nursing in the community. The 

exemplar written by Candy Mink, RN, expresses in 

her own words her volunteering experience during 

the RAM (Remote Area Medical) event held in 

Wise, Va. Candy is a registered nurse at Quillen 

Rehabilitation Hospital. 

“Volunteering to work the RAM event was 

something I had wanted to do for several years. 

When I registered for the event, I was not sure what 

I would be assigned to do because I registered as a 

volunteer after all the nursing positions had been 

filled. 

“Driving to the location (Wise County Fairgrounds) 

at 5:30 a.m. was the beginning of the day’s adventure. 

Soon after turning onto the small, two-lane road 

leading into the site, the traffic stopped. There was 

bumper-to-bumper traffic heading to the fairground. 

“After arriving and registering in, I was given a name 

badge that read ‘support staff.’ In other words, do 

whatever needed to be done. 

“The number of volunteers was amazing, and 

they were from all walks of life. Volunteers were 

needed for everything from emptying trash cans to 

performing surgery. I met people who had traveled 

from Oregon and Michigan just to volunteer at this 

event. 

“The services provided were huge. There were 

medical services, mammograms, bone density tests, 

pap tests, vision care with eyeglasses, and dental care 

from cleaning, fillings, X-rays and extractions to 

oral surgery. There were pharmacy services, social 

services, and a tent with free clothes and toys. There 

were many teaching activities, and free samples with 

educational literature. 

“The patients were the primary concern for the event, 

and all were very grateful for the care they received. 

They were either uninsured or under-insured and 

continued 

12

unable to afford health care. It seemed the biggest 

need for the majority of the patients was for dental 

care. Patients waited in long, hot lines for hours for 

dental services. The tents for the dental services were 

full of rows and rows of dental chairs and they were 

all filled with patients. As soon as one person got up, 

another was waiting to take their place. 

“One of my duties as support staff was to escort 

patients from one area to another area. Another task 

was to take a patient’s place in line while they either 

had to have a restroom break or go to a different area 

for a different service. I didn’t do any actual nursing 

duties, but I worked side by side with students, 

secretaries, housewives, nurses and even a hospital 

CEO in assisting the patients to obtain the care they 

needed. 

“What I learned from this experience is that there are 

people in our own back yards in dire need of health 

care. These people each have their own stories to tell. 

Often the look on their faces is a glimpse into their 

life struggles. 

“Another thing I learned is that the world is still full 

of good people. People are willing to give days at a 

time out of their schedule to volunteer and in some 

way be a help to another person. 

“At the end of the day, I was hot, tired and dirty, but 

grateful for the experience. The things I learned that 

day were things that could not be learned from a 

classroom or a book.” 

13 


Exemplary Professional Practice 

(Forces of Magnetism: Professional Models of Care, Consultation and Resources, Autonomy, Nurses as 

Teachers, Interdisciplinary Relations, Quality of Care: Ethics, Patient Safety and 

Quality Infrastructure, Quality Improvement) 


Leadership 


Structural 

Empowerment 

Empirical 

Outcomes 


Innovations & 

Improvements 

Exemplary 

Professional 

Practice 

A professional practice model is the overarching 

conceptual framework for nurses, nursing care and 

interdisciplinary relationships. It is a schematic 

description of a system or theory that depicts how 

nurses practice, collaborate, communicate and 

develop professionally to provide the highest quality 

of care for those served by the organization. 

Candace Jennings, senior VP, CEO, and Pat Niday, 

VP, CNO, as part of their roles and responsibilities, 

are to ensure that adequate resources for consultation 

and access to nursing experts are available to all levels 

of nurses in the organization. Whenever the need 

for this resource arises, filling that need is discussed 

at various council meetings with the stakeholders 

involved. The discussion also includes identification 

and availability of the individual who is best suited 

for the task required. The clinical resource nurses 

and clinical educators are an asset to Johnson City 

Medical Center. Nurses in this capacity work various 

shifts, helping with classroom instruction as well 

as bedside demonstration, providing guidance and 

support to the front-line nursing team. 

National Nursing Conference Involvement 

Poster abstracts and podium presentations at national 

nursing conferences are rewarding both to the nurse 

presenting and the conference attendees. Applying 

to present a poster or podium presentation is very 

competitive. Some national conferences receive up 

to 1,600 poster abstract or podium presentation 

submissions from nurses all over the country. It 

is believed and supported by our nursing leaders 

that nurses at all levels grow professionally through 

attending local and national conferences. National 

conferences serve as meeting places for nurses all 

over the country to network, provide support and 

guidance, and to experience “like” opportunities for 

improvements or celebrations. The following list 

includes our nurses who have presented at national 

conferences: 

14

Lisa Anderson, RN, MSN, CCRN, CCNS, APN 

Physical Violence Against Nurses 

National Association of Clinical Nurse Specialists 

(NACNS) 

Portland, Ore. 

Beverly Gugliotta, RN, Nursing Quality Facilitator 

Jeannette Clark, RN, Nurse Manager 

Quillen Rehab Hospital 

Falls Reduction at Quillen Rehabilitation Hospital 

National Database of Nursing Quality Indicators 

(NDNQI) Conference 

New Orleans 

Millie Wykoff, RN, Apache Coordinator 

Lisa Boghozian, RN, MSN, ICU Clinical Educator 

JCMC ICU Outcomes 

Society for Critical Care Medicine Conference 

Miami 

Millie Wykoff, RN, Apache Coordinator 

JCMC ICU Outcomes Data 

Cerner Presentation 

Kansas City, Mo 

Cathy Ivory, RN, MSN, Corporate Director of 

Women’s Health 

Presentation: Healthcare IT and Perinatal Safety: 

Friends or Foes? 

Cerner Health Conference Women’s Health Track 

Kansas City, Mo 



Presentation: CPOE: Challenges and Opportunities 

AWHONN Informatics Breakfast 

San Diego 



Presentation: Healthcare IT and Perinatal Safety: 

Friends or Foes? 

AWHONN 

San Diego 



Presentation: Technology and Evidence-Based 

Practice 

FL/GA/AL/TN AWHONN Conference 

Atlanta 

Patricia Niday, RN, Ed.D. 

Presentation: Achieving Clinical Excellence: 

Putting Evidence into Practice 

Tennessee Hospital Association 2009 Nursing and 

Quality Leadership Summit 

Nashville, Tenn. 

Lisa Carter, RN, MSN 

Presentation: Retinopathy of Prematurity 

Tennessee Hospital Association 2009 Nursing and 

Quality Leadership Summit 

Nashville, Tenn. 

15 


RN-MD Interactions 

RN-MD Interactions have been tracked for the past five years through NDNQI. Results continue to 

demonstrate high satisfaction with our nurses and physicians. JCMC is a teaching hospital for many colleges 

that train nurses, physicians, allied healthcare team members and pharmacy students. Students at all levels 

of learning form relationships with team members and develop communication skills and interactions that 

provide them with positive learning experiences. Nurses have a direct line to the physician during rounds, 

communicating and reciprocating needs and concerns regarding patient care. Physicians and nurses need 

reliable processes, transparency and effective communication in order to provide the best care to our patients. 


RN-MD Interactions T-Scores 

Autonomy 

Autonomy t-scores demonstrated an increase from 2008 to 2009. Nursing leadership believes the changes 

to the practice, quality and research councils in addition to the stabilization of nursing leadership has had 

a positive impact on the autonomy of our nurses. The Shared Governance councils facilitate autonomy by 

offering opportunities for direct care, advanced practice, nurse leaders, nurses in non-traditional roles and 

other clinical disciplines, to bring forward practice issues into a forum that helps them identify opportunities 

and assists in implementation of action plans. The councils also function to facilitate team member education 

regarding the importance of small tests of change, Plan-Do-Check-Act Model of Performance Improvement, 

use of evidence-based clinical practice and literature search. 


Autonomy T-Scores 

16

Exemplary Professional Practice in Action 

Exemplary Professional Practice is the manner 

in which our nurses provide Patient-Centered 

Care every day (Professional Model of Care). It 

embodies the relationships among nursing and other 

disciplines. Follow a nurse as she displays Exemplary 

Professional Practice: 

Katie, Mr. Richards’ nurse for the day, enters his room 

with a knock on the door and a smile on her face. 

“Hello Mr. Richards, my name is Katie, and I will 

be your nurse today.” Katie examines Mr. Richards 

and explains what the plan for the day will be. She 

tells him that she will be coming in to check on him 

approximately every hour, and to ring his call light if 

he needs anything before she returns. Before exiting 

his room, she asks “How well is your pain managed?” 

Mr. Richards does admit that his pain level is a 5. 

Katie explains that he has medication available that 

will manage his pain and that she will return shortly 

with his medication (Autonomy). 

Later in the morning, Katie sees Mr. Richards’ 

physician in the alcove. She approaches to round with 

the physician (Interdisciplinary Relationship). When 

they enter the room, the physician explains test 

results and some new medications that he will order 

for Mr. Richards. Katie mentions to the physician 

that Mr. Richards is not eating well, and requests 

a consult for the dietitian to assist Mr. Richards in 

finding a more palatable diet. The physician agrees 

and writes the consult (Consultation and Resources). 

As midday approaches, the physical therapy assistant 

presents on the unit. He has worked with Mr. 

Richards to increase the distance Mr. Richards can 

ambulate. The physical therapy assistant sees Katie 

in the alcove charting and he asks how Mr. Richards 

is doing. She tells him that Mr. Richards is up in 

the chair and ready to ambulate (Interdisciplinary 

Relationship). Katie assists the PTA with ambulating 

Mr. Richards in the hallway, and as they return and 

assist him into bed, Katie notices some redness to 

Mr. Richards’ backside. Katie calls the wound care 

nurse to evaluate Mr. Richards’ skin and bed surface 

and give input on other interventions that could be 

used to prevent further pressure to Mr. Richards’ skin 

(Autonomy and Consultation and Resources). 

Now that Mr. Richards is settled in his bed, it is 

time for Katie to administer his new medications. 

She reviews each medication with Mr. Richards as 

she scans the barcode in MAK. She explains what 

the medications are for and how they will help him 

(Nurses as Teachers). 

As Katie is finishing her shift, Mr. Richards thanks 

her for the care she has provided him today. He tells 

her how her care has made a difference and that he 

feels he is one step closer to returning to wellness. 

As Katie steps back and watches Mr. Richards 

enjoy his dinner meal (after some adjustments by 

the dietitian), with a manageable pain level (after 

administration of his PRN medications during the 

day), and with a pressure-relieving bed surface (after 

discussion with the wound care nurse), she feels 

proud to know the impact her exemplary professional 

practice has made on her patient. 

The true essence of a Magnet organization stems 

from exemplary professional practice within nursing. 

This entails a comprehensive understanding of 

the role of nursing; the application of that role 

with patients, families, communities and the 

interdisciplinary team; and the application of new 

knowledge and evidence. The goal of this component 

is more than the establishment of strong professional 

practice; it is what that professional practice can 

achieve. 

17 


New Knowledge, Innovation and Improvement 

(Forces of Magnetism: Quality of Care: Research and Evidence-Based Practice, Quality Improvement) 


Structural 

Empowerment 


Leadership 

Empirical 

Outcomes 

Exemplary 

Professional 

Practice 


Innovations & 

Improvements 

Research Conference 

In June 2009, the Nursing Research Council held its 

4th annual research conference. As an annual event, 

we have the opportunity to invite researchers from 

all disciplines to participate and share their original 

research in podium presentations or as posters. Our 

presenters come from our own organization, and 

as far away as Lexington, Ky. We have also had the 

good fortune of hearing Dr. Mona Baharestani, 

Ph.D., APN, CWOCN, CWS, noted expert in the 

prevention and care of wounds and pressure ulcers, 

as our keynote speaker at the 3rd annual conference. 

Most of our presentations and posters come from 

local nurse researchers from Mountain States Health 

Alliance and other organizations in our region. 

Our goal is to not only showcase the research being 

conducted in our area, but to also give our local 

nursing community the opportunity to network 

with nurse researchers. This networking opportunity 

encourages collaboration and partnerships to help 

generate and use evidence to improve practice and 

the quality of care delivered. As we currently plan our 

5th annual nursing research conference, we hope to 

continue to see the interest and enthusiasm that has 

been evident in increasing attendance. 

Chest Pain Center/ Emergency Department Nurse Liaison Position 

One of the entries for the Quality Awards Banquet 

was the submission by Rebecca Pullon, RN, and 

Lori Kelley, RN, to improve proper utilization of the 

Chest Pain Center while decreasing ED wait times 

and limiting unnecessary inpatient admissions for 

low-risk cardiac patients. The plan was to implement 

a Chest Pain Center/Emergency Department 

Nurse Liaison. This nurse would assess, educate and 

assist with the evaluation of criteria for inpatient or 

observed care. 

A 90-day pilot study was implemented with the 

CPC/ED Nurse Liaison based in the ED. Improved 

ED wait times and reduced inpatient admissions 

for low-risk cardiac patients were identified. This 

has led to greater patient satisfaction and decreased 

healthcare costs to the patient. 

18

Falls Prevention Program: 

Decision Making by Front-Line Nurses 

FALL RISK 

Direct-care nurses were asked to use the Hendrich 

and Morse fall risk tools on each of their patients for 

a two-week period trial in 2008. From their input, 

the Morse risk assessment tool was determined to 

be most appropriate for our nursing practice. The 

Hendrich fall risk assessment tool received a mean 

rating of 2.66 out of 4.00 on a Likert scale, while the 

Morse tool received a mean score of 3.27. 

On July 27, 2009, the new Fall Prevention Program 

using the Morse fall risk tool was implemented. This 

was a very comprehensive undertaking regarding 

the change of policy, forms and practice throughout 

MSHA. Using the yellow armband with “Fall 

Risk” inscribed on the band was adopted by our 

organization as the method of identifying patients at 

high risk for falls. 

Nationally recognized as the color for high fall 

risk patients, the yellow armband is just one of 

the colored armbands that identify patients with 

special needs. The adoption of a uniform colorcoded 

armband system by MSHA in July 2009 

presents a clearly defined practice for identifying and 

communicating patient risk factors, or special needs, 

by standardizing the use of color-coded armbands 

to support safe patient care based upon the patient’s 

assessed needs and wishes. 

JOHNSON CITY MEDICAL CENTER 

PATIENT FALL RATES 

Rate = falls per patient days x 1000 

4.00 

3.50 

3.00 

2.50 

2.00 

2010 

1.50 

2009 

1.00 

2008 

0.50 

0.00 

JAN FEB MAR APR MAY JUN JUL 

AUG SEP 

OCT 

NOV 

DEC 

New Fall Program 

started July 27, 2009 

2008 

2009 

2010 

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 

2010 3.59 3.16 

2009 3.37 3.00 2.48 3.04 3.29 2.85 3.55 1.98 3.79 2.89 3.75 2.74 

2008 3.30 2.44 2.02 1.59 2.23 2.46 3.39 1.89 2.57 2.60 2.31 3.27 

Aquapheresis 

A new treatment for congestive heart failure 

was made available to our patient population in 

2009. Aquapheresis, a pump that filters blood and 

removes only water and sodium, was purchased in 

2009 with the first utilization starting in August 

2009. Congestive heart failure patients are able to 

get out of bed during this therapy, which is much 

more comfortable for them. Most patients receive 

the treatment for 3 days, with most seeing a drastic 

weight loss between 15 and 30 pounds in 3 days. 

Patients have been able remove their bipap apparatus 

or oxygen therapy after the aquapheresis treatment. 

Swelling is dramatically decreased in all areas so 

patients who have had severe pain secondary to 

swelling are able to mobilize more freely. 

19 


Quality Awards 2009 

Individual Award Winner: Katie Rice, RNC 

Holding the Gains: Operational Effectiveness 

After implementation of Centricity Perinatal (CPN), 

missed charges were dramatically reduced and charges 

generated by CPN were found to be consistently 

correct when nursing documentation was correct and 

complete. Nurses in the Center for Women’s Health 

continually monitored for correct capture of patient 

charges. The nurse caring for the patient must verify 

and sign the electronically generated charge form prior 

to submitting it, and as a double-check the clerical 

associate who entered charges notified the CPN 

system administrator if anything seemed unusual. In 

addition, a review of all available charts for a 5-week 

period was conducted 2.5 years after implementation 

of CPN charge capture to verify that gains were indeed 

being held as well as we perceived. Over the past two 

years, CPN has correctly captured 100% of patient 

charges when nursing documentation is correct and 

complete, and nursing staff is consistently reviewing 

charges and ensuring accuracy before submission of 

charges. This method of charge capture, which started 

with the Obstetrics unit at JCMC, has been expanded 

to the OB units at JCSH, SSH and IPMC. 

Team Award Winner: Lisa Carter, MSN, RN, Nurse 

Manager of PICU 

Renee’ Lowe, RN, Nurse Manager of NICU 

Jill Naylor, RN, Assistant Clinical Leader of NICU 

Dr. William Devoe, MD, Neonatologist 

Retinopathy of prematurity is a condition affecting 

premature infants in which blood vessels in the eye 

begin to grow abnormally. In 2006, the overall NICU 

rate was found to be 75%. We have since decreased 

this rate to 24%, and the rate for severe ROP dropped 

from 14.3% to 2%. To ensure continued success with 

the ROP protocol, specific elements are monitored 

monthly by nursing and respiratory staff. The 

results from these monitors show that the staff have 

consistently maintained compliance rates at 94% or 

greater with following the ROP protocol. We have 

continued to see drastic reductions in the number of 

infants diagnosed with severe ROP (stage 3 or greater), 

and have continued to see fewer infants requiring 

surgical interventions. Only two infants have needed 

treatment in the last 12 months. The rate for severe 

ROP has dropped from our initial rate of 14.3% to 2%, 

which is well below the national average. The rates for 

any stage of ROP have dropped from 75% to 24%. 

20

Empirical Quality Outcomes 

(Forces of Magnetism: Quality of Care) 


Structural 

Empowerment 


Leadership 

Empirical 

Outcomes 


Innovations & 

Improvements 

Exemplary 

Professional 

Practice 

Nursing Excellence: Empirical Outcomes 

During our celebration of nursing excellence 

and Magnet redesignation, we discussed the 

components of the new Magnet nursing excellence 

model. Empirical outcomes are a common thread 

throughout the Magnet model for nursing excellence. 

These outcomes are the identified endpoints for each 

aspect of the model using measurable quantitative 

data, as well as qualitative data. They are based on 

using existing evidence as well as generating that 

evidence. We discussed two models for using the 

evidence and one model for generating the evidence. 

We were reminded that research occurs in all practice 

arenas including administration, clinical, education 

and research. We must evaluate the evidence 

and its impact on healthcare resources, patient/ 

participant preferences and actions, level of evidence, 

and settings and circumstances. Clinical or area 

expertise is needed to integrate all the information to 

determine if the evidence fits our environment. 

When evidence is generated, practice, theory and 

education are part of a continuous cycle to support 

our practice and contribute to nursing’s body of 

knowledge. There are internal and external factors 

that affect how evidence is used, and both research 

and non-research evidence should be included. Using 

the evidence or generating the evidence both will 

lead to quality outcomes in all areas of practice. This 

will result in improved quality and a continuation of 

nursing excellence at Johnson City Medical Center. 

21 


MSHA receives TNCPE Excellence Award for second time 

Mountain States Health Alliance was formally 

recognized as the recipient of the 2009 Excellence 

Award at the Annual Conference of the Tennessee 

Center for Performance Excellence (TNCPE) in 

Nashville, Tenn. MSHA previously received this 

recognition in 2005, thus making MSHA the only 

healthcare organization in Tennessee to receive this 

recognition twice. 

“A large number of our leadership attended the 

events of the conference, which featured past 

Baldrige National Quality Award recipient speakers, 

as well as several of our team who have been involved 

in helping lead MSHA’s quality journey,” said MSHA 

President and CEO Dennis Vonderfecht. 

Vonderfecht and MSHA Vice President of Quality 

Tamera Fields both presented at the conference, 

sharing the healthcare system’s model for quality 

delivery of health care and its performance 

improvement process. 

2009 

Excellence Award 

22

Niswonger Children’s Hospital Opening 

The dream has finally become a reality. After 

nearly five years of fundraising, community support 

and steady construction, Niswonger Children’s 

Hospital opened March 3, 2009. The $36 million, 

69-bed hospital for children admitted patients 

approximately one year ago. 

“This is truly a great and momentous day for our 

region,” said Dennis Vonderfecht, president and 

CEO of MSHA. “With the opening of Niswonger 

Children’s Hospital and its associated Children’s 

Emergency Department, the Tri-Cities joins the 

other four metropolitan areas of Tennessee in 

having a full-service children’s hospital.” Niswonger 

Children’s Hospital is named after lead donors Scott 

and Nikki Niswonger of Greeneville, Tenn., who 

gave $10 million toward the construction. 

Using natural light to provide feelings of comfort 

and healing, the main entrance lobby and threestory 

glass atrium-lined hallways provide bountiful 

light. The stained glass kite gallery suspended from 

the ceiling provides a calming environment to the 

patients and families. Direct care nurses’ feedback 

was crucial to the design and work flow of the patient 

care provision areas in the new Niswonger Children’s 

Hospital for efficient delivery of patient care. Directcare 

nursing team members were involved in all of 

the renovation and refurbishment projects for the 

patient care units. Women’s and Children’s nursing 

team members participated on multiple teams in the 

design of the new Niswonger Children’s Hospital. 

23 


Years of Service 

Donna Ledbetter 

Donna Ledbetter, RN, ONC, 

director of the Ortho/Neuro/ 

Trauma SSU, is very dedicated 

to the development and 

advancement of the nursing 

profession. As a team member 

of MSHA for 40 years, 

Donna’s devotion to Patient- 

Centered Care is well-known by all team members at 

JCMC. She is a nurse with high integrity, regarded 

by her peers as kind and accessible, and a strong 

patient and nursing advocate. She exudes grace and 

a soft-spoken manner in which her experienced 

voice is heard and respected. Donna is a member of 

the American Association of Critical Care Nurses 

and the Advisory Council for the Surgical Tech and 

Cardiovascular Technician Program at Northeast 

State Technical Community College. She is a 

member of the American College of Healthcare 

Executives and an American Heart Association 

Board Member. She was certified as an orthopedic 

nurse in 2007, and is a member of the National 

Association of Orthopaedic Nurses (NAON). Other 

memberships include the North East Tennessee 

Organization of Nurse Executives (NETONE), 

TONE, Tennessee Hospital Association (THA) 

and Tennessee Nurses Association. She received the 

Nurse of Distinction Clinical Award from TNA 

in 2005. Donna’s knowledge, devotion to Patient- 

Centered Care and advocacy to the profession of 

nursing truly exemplify The MSHA Difference. 

30 Plus Years of Service 

Linda Allen 

Lana Renfro 

Brenda Campbell 

Delores “Ann” Wilson 

Mitchell Hathaway 

Martha K. Smith 

Pat Looney 

Mary Farrington 

Karen Adkins 

Connie Hatcher 

Vickie Torbett 

Pamela Kubisiak 

Uta Lewey 

Richard Blevins 

Carolyn “Charlie” Wishon 

Harriet Fitzgerald 

40 years 

38 years 

38 years 

38 years 

37 years 

36 years 

36 years 

35 years 

35 years 

35 years 

34 years 

34 years 

34 years 

34 years 

34 years 

34 years 

Cassandra Moore 

Mary “Peep” Adams 

Teresa Bailey 

Connie Jessee 

Ernestine Hatcher 

Patrick Kiernan 

Treva Williams 

Sharon Johnson 

Donna Rice 

Wilmetta Collie 

Sharon Jarrett 

Amy Belcher 

Victoria Privette 

Loreta “Sue” Clark 

Beverly Gugliotta 

33 years 

33 years 

33 years 

32 years 

32 years 

32 years 

32 years 

32 years 

32 years 

31 years 

31 years 

30 years 

30 years 

30 years 

30 years 

24

Georgita Washington 

On Dec. 19, 2009, Georgita 

Tolbert Washington, Ph.D., 

RN-BC, MSN, CCRN, 

received her doctor of 

philosophy in nursing 

from East Tennessee State 

University in Johnson City, 

Tenn. A native of Charleston, 

S.C., she received her bachelor of science in nursing 

from Clemson University and her master of science 

in nursing from the Medical University of South 

Carolina. 

Dr. Washington’s dissertation research, titled, 

“Effects of Anxiety-Reducing Interventions on 

Performance Anxiety in Graduate Nurses,” was 

conducted to determine the best methods of 

reducing anxiety in those newly graduated from 

nursing school. This would hopefully facilitate 

their transition from student to professional nurse, 

helping to contribute to strategies to ease the nursing 

shortage. She plans on further research in this 

area to facilitate the retention of new nurses to the 

profession and to Mountain States Health Alliance. 

Georgita is a 10-year team member at Mountain 

States Health Alliance and is currently the director of 

nursing education for Johnson City Medical Center. 

She has a clinical background of 26 years in critical 

care nursing, with 18 as a critical care clinical nurse 

specialist. Her role at MSHA also includes chair of 

the nursing research council, which is very active in 

mentoring new researchers. 

25 


N u m b e r o f H o s p ita l A c q u ire d P re s s u re U lc e rs 

30 

20 

10 

0 

3Q 

08 

4Q 

08 

1Q 

09 

2Q 

09 

3Q 

09 

4Q 

09 

1Q 

10 

Stage I 7 21 13 6 6 12 3 

Stage II 20 18 16 18 11 5 14 

Stage III 10 2 0 3 0 1 0 

Stage IV 1 0 0 0 0 0 0 

2Q 

10 

3Q 

10 

Stage I 

Stage II 

Stage III 

Stage IV 

DTI 

Unstageable 

Indeterminate 

The prevention of hospital-acquired pressure ulcers 

is a constant priority at JCMC. The skin care team 

and wound care nurses are available to assist bedside 

nurses with treatments, education and appropriate 

selection of wound care dressings and specialty 

beds. Quarterly pressure ulcer prevalence surveys are 

Pressure Ulcers 

conducted by a group of nurses educated in pressure 

ulcer assessment with validation from the wound 

care experts. Tracking of in-house specialty beds has 

been enhanced over the past year to determine the 

right bed for the right patient at the right time for 

prevention and treatment of pressure ulcers. 

Turnover 

26

Percentage of Non-ICU Code Blue Occurence 2009 

45 

40 

35 

30 

25 

Percentage 

20 

Actual 

Target 

15 

10 

5 

0 

Jan Feb March April May June July Aug Sept Oct Nov Dec 

January - December 

Rapid Response Team 

One of our quality care initiatives, started in 2005 

and continuing today, was the development of the 

Rapid Response Team. Opportunities were identified 

to bring critical care expertise, RNs and respiratory 

therapists to the bedside of patients whose condition 

was deteriorating or uncertain. There is a large 

amount of variability in both quality of care and the 

safety of patients in health care today. This variability 

is evident in hospital mortality rates. There are 

three main systemic issues that contribute to the 

problem such as failures in planning (assessment, 

treatments, goals), failure to communicate (patient 

to staff, staff to staff, staff to physician), and failure 

to recognize deteriorating patient condition. These 

fundamental problems can often lead to a failure 

to rescue. Establishing rapid response teams stands 

to impact this problem by identifying unstable 

patients and those patients likely to suffer cardiac or 

respiratory arrest. If identified in a timely fashion, 

their unnecessary deaths can often be prevented. 

Successful 

Joint Commission Survey at 

JCMC/QRH/Woodridge !!! 

27 


Patient -Centered Care 

10 Guiding Principles 

Care is based on continuous healing relationships. 

The patient is the source of control for their care. 

Care is customized and reflects patient needs, values and choices. 

Families and friends of the patient are considered an essential part of the care team. 

All Team Members are considered as caregivers. 

Care is provided in a healing environment of comfort, peace and support. 

Knowledge and information are shared freely between and among patients, care 

partners, physicians and other caregivers. 

Transparency is the rule in the care of the patient. 

Patient safety is a visible priority. 

All caregivers cooperate with one another through a common focus on the best interest 

and personal goals of the patient. 

400 N. State of Franklin Road 

Johnson City, TN 37604

JCMC Nursing Annual Report - Mountain States Health Alliance

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