1. Do
2. Doing
3. Done
4. Nursing Operations
   1. Job Duties / Staffing Structure
   2. Retention and Turnover rate - tracking / trending / cost
   3. Processes - is it efficient & effective
   4. HMC validate staffing levels (CM)
      1. Studied Staffing of HHH comparison to other CAHs
   5. Altres CNAs Available for Call outs
   6. East Hawaii - LPN pay increase recruitment
   7. New Grad - RN = RPN 1 Hired 2
      1. Included in staffing count after - New Grad capable with CN or NM oversite
   8. Staffing
      1. Assessed with HR who is out on extended leave and created temporary positions
   9. Cross Train LTC CNAs to ED
      1. Choose CNAs according to core values / skill / attendance:
   10. Assessment of present Nursing Operations
   11. Hire capable / Skillful NM / Leaders
       1. Measure according to Core Values
   12. Meet 2-3 x's / week with NM to discuss leadership and goals
   13. Identify and assign focus topics for improvement program to each NM
       1. AT: Hydration, Falls, Inservice
       2. LL: Wounds, CAH, Admissions, Discharges, Education, Hourly Rounds CAH
       3. CH: Infection Control, Dining Room, Staffing
       4. FO: Outpt. services, ER Charges, Rapid Response, Disaster Prep, STEMI & HHH response
   14. Communicate: Appropriately, Hand off comm., SBAR, Chain of Communication
   15. Empower the Nurses to make decisions
       1. Various meetings with Nurses to teach leadership and problem solve
   16. Hourly Rounding
       1. Start with CAH
       2. then LTC
5. Resources Needed
   1. Secretary FT
   2. RN Case Manager / Quality Director
   3. Scheduler - Staffing Support
      1. Posted and interviewed - round 2 of interviews
6. Conduct Mock Surveys
   1. QIS Educator
   2. Abaqis
      1. Core Team to do assessments/interviews
   3. Admin. & DON Rounds
7. Inservice / Training Weekly
   1. Nurse Managers / DON
      1. Culture Sensitivity
         1. Kimo Almeeda Culture Diversity Training
      2. Regulations / P&Ps
   2. All Staff Meeting
      1. Campaign Kick off
   3. QIS Process for all Departments
   4. QIS Software / Implementer
   5. CAH Survey Prep.
      1. DON and New RN CM
   6. Hourly rounding Program
      1. Start with CAH
   7. Communication - Proper / efficient / appropriate / professional / Mode of comm. identified / time frames / Chain of Communication
8. Conduct SAFETY Audits Weekly
   1. Identify What we are Measuring
      1. Falls
      2. Medication Errors
      3. Care Plans Being Followed
      4. Medication Management
9. Update Policies & Procedures
   1. Focus on Safety P&Ps first
   2. Forumalize dates and accepting committee
   3. Handed to Admin. Secretary to coordinate
      1. NM reviewed Nursing P&Ps
   4. Notify Admin Sec. of deadline Feb. 2012
   5. Electronic access & update
10. Celebration Party
    1. Invite previous administration
    2. Invite HHSC Leaders
11. "Ho'oponopono"
    1. Community & HHH Leaders / Team
    2. Press Ganey Resurvey
    3. Third Party "Healer"
    4. Nurse Aides / Nurses / DON
    5. Re-blessing of Facility
    6. New Beginning
    7. Include family members to communicate to staff re: what it is like to put their love one here at HHH
12. Expectations - Communicated
    1. Ramifications if P&P or Care Plans not followed
    2. HR assistance - along with Union
13. Union Awareness of Campaign
14. Budget - Track Cost
    1. Discussion with Nursing Team regarding budget
    2. Staffing Assessment and Plan to decrease cost
       1. Better tracking of Travelers and decrease utilization
15. Fishbone: All high risk injuries / situations
    1. Create a process and Safe Culture for RCAs
    2. Root Cause Analysis for all high risk injuries / situations
    3. Debriefing Outpatient Services - IV.xmind
16. Quality
    1. PDCAs
       1. PDCAs HHH.xmind
    2. Complaint Process
    3. Incident Reporting
    4. APS Investigations
    5. EMR Go Live July 1
    6. My Inner View
    7. SilverChair
    8. Passed information & process to Next Quality Director
17. Safety Committee
    1. Culture of Safety
    2. Turn over to ASO & Quality Director
18. CORE VALUES
    1. Respect
    2. Mindfulness
    3. Trust
    4. Integrity
    5. Utilize Core Values in operations
       1. To make decisions
       2. To hire
       3. To provide Corrective Action
       4. To promote
19. Mission - Time - Cost
    1. Measure using Core Values
20. Decrease Alarms
    1. Decrease Alarms to one alarm and if appropriate
21. Leadership Training
    1. Customer Service
    2. DISC personality Leadership
    3. How to inspire others
       1. Why we do what we do
    4. Social Style Characteristics
    5. Hawaii Partners in Nursing Leadership
       1. NM and DON attended to train others
       2. Set up training classes: CH & CR
    6. Leadership Works
       1. Incorporate Leadership training to train NM and Nurses
22. Care Plan Improving the Process
    1. Careplan PDCA.xmind
23. Community Improvement Projects
    1. ED
       1. STEMI
          1. Big Island Stemi Work Group.xmind
       2. Helmet Safety
          1. Peace Parade 2012 - passed Helmets to comm. children
    2. CAH