ࡱ> 6y5|RUmhieY;M  u '` 3bjbj{P{P .X::+~t Z0Z0Z0Z0L0D 80111122 2B8D8D8D8D8D8D8$9h<h8$622$6$6h811}8777$6Z11B87$6B877710 `(C۰Z0~7.7&88087<74<7<7<2374)5222h8h87 2228$6$6$6$6  d t0Jz 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:  EMBED Word.Document.8 \s  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:  EMBED Word.Document.8 \s  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:  EMBED Word.Document.8 \s  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:  EMBED Word.Document.8 \s  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:  EMBED Word.Document.8 \s  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:  EMBED Word.Document.8 \s  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:  EMBED Word.Document.8 \s  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:  EMBED Word.Document.8 \s  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 providers 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. RNAs, 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:  EMBED Word.Document.8 \s  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:  EMBED Word.Document.8 \s   ?@EGIU[\ejkz| ~     & 3 4 ĽĦᚓ hhfU}hh>Zh{a5jBL h{aCJUVaJjh{aU h$ h{ah{a hnh{ahfU} hKhfU} hh h5 hfU}5 h{ah{ah{ah{a5 h{a59@Jk } ~  ($d%d&d'd@&NOPQgdqgd{a&$d%d&d'dNOPQgdq3 & 4  '&$d%d&d'dNOPQgd($d%d&d'd@&NOPQgdgd{a&$d%d&d'dNOPQgdq  !&'68GHUVopq{ǿ竣xqxiahnhn5h>Zh{a5 hnh{a hnhnhfU} hKhfU} hfU}5 hh h5hfU}hfU}5h>Zhq5 hnhqh{ah{a5 hn5j hqUjuBL hqCJUVaJhqjhqU hq5 h{a5 hg=h{ah{ah{ahq5%'HVpq{|efw6@[{cdugd{a&$d%d&d'dNOPQgd{|fvwx46;=?IKUZ[jlz{PQdtûôÁzÁhdh5#h{aB* CJOJQJ^JaJph hnh{a hnhnhfU} hKhfU} hfU}5 hh h5hfU}hfU}5h>Zhn5 hnhnh{ah{a5 h{a5hj8hnUjBL hnCJUVaJjhnU hn5hnhn5h{ahn'tuv +01@BSTacdϐǻϐϻ}y}qldjh$U h$5h$h$5h5h{ah>Zhn5 hnh{a hnhnhfU} hKhfU} hfU}5 hh h5hfU}hfU}5 hn5 hnhnh{ah{a5 h{a5jhnUjBL hnCJUVaJhnjhnUhnh{a5&u 1Td_h&$d%d&d'dNOPQgdq$gd{a&$d%d&d'dNOPQgd^_dfgqs\!]!""""""ԙԋ{wكo`jBL h$CJUVaJh$h{a5h5h>Zh{a5h$h$5 hnh$ hnh{a hnhn hKhfU} hfU}5 hh h5hfU}hfU}5 hn5 hnhnh{ah{a5 h{a5h{ajh$Ujq&h$UjBL h$CJUVaJh$%h""""""W#`#z#####&$d%d&d'dNOPQgdgd{a&$d%d&d'dNOPQgdq$""""###V#W#\#^#_#i#k#u#y#z############&&&&'' '!'"'#'$'&'/':'<''žʹ槠槠Ҙvnj9h$UjBL h$CJUVaJh$h$5h{a h;h{ah>Zh$5 hnh{a hnh$hfU} hKhfU} hfU}5 hh h5hfU}hfU}5 h$5 h$h$h{ah{a5 h{a5h$jh$Uj0h$U+###&&'$'%'&''''''''''**+$+%+&+gd{a&$d%d&d'dNOPQgd''''''''''''''''''''')(}(~())*e*o*r*******+++ +!+"+#+%+&+/+:+<+|+ĽиĴ˙{ h$h$j8Ch$UjBL h$CJUVaJjh$U h2sh{ah$h$5h$h{a h$5 hnh{a hnh$ h{a5h{ah{a5h hKh hh h5hfU}hfU}5h>Zh$50&+}+++++,,!,", ///>/?/@/A////gd{a&$d%d&d'dNOPQgd($d%d&d'd@&NOPQgd|+}++++++++++++++++,,,!,",,-"-%-J-m-/// /:/;/Zh{a5h$h$5h$h{a hnh{a hnh$ h{a5h{ah{a5 hKhh hh h5hfU}hfU}5 h$50//////////00 0*0+0333333333͹jdVhfU}UjBL hfU}CJUVaJhfU}jhfU}Uh{ah>ZhfU}5 hfU}5 hnh{a hnhfU} h{a5h{ah{a5hfU}hfU}5h hKh///0 0*0+0223333&$d%d&d'dNOPQgd ,1h/ =!"#$%  Dd 6  3 A?" 5S0]2?pyXD@=5S0]2?pyXgC͟ xX{PT>&DLR8t:`6i;1ZMHS1j6PD#6 "&(~X >{]|lqνw~~gb1!(lT;f=(DX!?>]G8 NyhaP?=r0#|D O< ~.y٣8sl\̟4z)y.NZ3'QELGs`:Myg>ۀh͏A[ZXs>D{Fg*t@OR$ ѷc~3$=6P 7hF Ge8̗hGykga7U^{_?yW3\D:0ꩅ8ZiZW{#h8G}5uзcA`puJ8ZhThz$Ai5IE͋jq*\${6mnSeѴuf[gƢ&c|괏p.8M1! 5RCO{fnCw/vzp04=^-җ&/ZlT\87E%EeK肻 Mh,KCIx'jqp;߂͸ r6b|#}prn4_&e's t.<"q~ /,^ T{>|ʇ=vIn$l}>rY8QŃrzC |{pjHO4?\'=\=vT|ɇcCi*Kȇá>-T#m~ysF%RgLbO`%6/bpJĪɂ|/~h쇶uM+[VKT|AaaFВ{ G6[b.:aj`[ -f kp yp>|ps>\я| ^~@7 Lʇtu|?^IYzo]D6̙I8w8׫:i.x\Nc.z;d4bDiiZ8UKRà"sr^ԧW,U"ůjhXx=_eZJwD:ZRѸ3h\h(N^8/s^oihfƠn_P_s6=[#kC^[K2%kpN2?#[y,'2 h:}Kn#T|;49q+zyG7]J%o,zgwu%)~,va]g=)^;s49)/W4g>o Xgw3&x[gZfe,|u ܫIy> ֪#h,dL=q℟-hw%8 I>$5=$H~#6>tNxCCCsKx5Pmr}50?t~yUn'M;p]^͸ދ/W{[n_ǂ9u{ǟc}<*̾#겂 wؠA*LCG+5oĹҽ8{4_CI%LqNgCY,$d`:N*ѸǍ{lþ=!j/7ulw*~/ obx Om2l' 1s1.LXR*$ct"FQ9[c"̴&hH1O(@ٓIKĸH]ʱBjeJc]^T$=4tQSD_gc+&=gEe!k އ2վcjꞨ&=uǗ~WL+b/&)YX"yb'mKG6&u%$yfԩ{s3)V Z4;qAhuQW2DXKM)+S}Aߑz]bG,D=If-r'h>>ƄiBT0#340[6_s`7>'koޠ}o/||7XiܓxsA w?.k#ϟA×0̄ލ#{qxE#'Y!?-ez77q=֠?] `r ,v]4Iz u8;~PGU8WhGE؛j`7UpןP  g.h%-pJ4IZT-ZB:/T {#8/5 ƽ31nz;$4jnz$4=.kj:eՋjQGc%(Nu`kQ6[3.E&u ~Qo\H ? O2حe0Ec\V( UGU-.f c BEki*ZJ|2 0CC~,ڑ]vjvdnpI`ɹV+5pML_ ~(#]H2أzDx$"󃼰4x4tS]N*sA(#h2 m34|/}~|8uwz}|Hԭ&5&/}؋Q_(#Cp622#=Qpq^pȇ&/cDRs>ȇ$4'ȇ}mj3v3y "%ņv&75>|#bPo!'ZjP4 97wkd8$Fz`aNJQ['FtcbN Ǩ EAֈ½D[vy]CFs,ei)OpN5'e}Z}_~<^FՉ,>xCKѠ).]NcC.e4j"a7P'&_8];7x4ԔjqO,?@ABCDEFGHIKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxq ~Root Entryg FpdC۰z#Data -`WordDocumentf.XObjectPoolipi!C۰pdC۰_1279447980 Fp#C۰p#C۰Data 8#1TableJ]CompObjqh$$IfP!vh5 53#v #v3:Vl t65\ 5laPytrh$$IfP!vh5 53#v #v3:Vl t65\ 5laPytrh$$IfP!vh5 53#v #v3:Vl t65\ 5laPytr$$IfP!vh5(#v(:V l40(65(4aPf4ytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrFDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytr$$IfP!vh5 5#v #v:V l0(65 54aPytrvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytr$$If!vh55H#v#vH:V $655H/ /  / 22 l4 yt1$$If!vh55H#v#vH:V $655H/ / / /  22 l4 yt1$$If!vh55H#v#vH:V $655H/ / / /  22 l4 yt1$$If!vh55H#v#vH:V $655H/ / / /  22 l4 yt1$$If!vh55H#v#vH:V $655H/ / / /  22 l4 yt1$$If!vh55H#v#vH:V $655H/ / / /  22 l4 yt1$$If!vh5` 5 5 #v` #v #v :V 65` 5 5 / /  / 22 l4 yt1$$If!vh5` 5 5 #v` #v #v :V 65` 5 5 / / / /  22 l4 yt1$$If!vh5` 5 5 #v` #v #v :V 65` 5 5 / / / /  22 l4 yt1$$If!vh5` 5 5 #v` #v #v :V 65` 5 5 / / / /  22 l4 yt1$$If!vh5` 5 5 #v` #v #v :V 65` 5 5 / / / /  22 l4 yt1$$If!vh5` 5 5 #v` #v #v :V 65` 5 5 / / / /  22 l4 yt1@@@ NormalCJ_HaJmH sH tH :@: _ Heading 1$@&5\DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List4U@4 x. Hyperlink >*ph4 @4 x.Footer  !.)@. x. Page Number4@"4 _Header  !j@3j _ Table Grid7:V0ee,-fe00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q  00:K $%&.123}~!"#$%&bcdiuv,[\m+,>LM^"-.@`ar,-.3>?Qhiz01i35d&& '!'6'7't''''P(Q(((())R)S))1*2*X*Z*667 79;:;;;DLLLLXPWWYXYiYjYrYyYYYYYYYYYYYYYZZ Z&Z+Z,ZYZlZZZZZZZZZZZZZZ[\z]^_abcLM^"-.@`ar,-3>?Qhiz01i35&&!'6'7't''''P(Q(((())R)S))1*2*X*Z*667 7:;DLLXPWWYjYrYyYYYYYYYYYYYYYZZ Z&Z+Z,ZYZlZZZZZZZZZZZZZ[\z]^_abc?ABCDFGHIJKLMNPQRSTUVWXZ[\]^_bcdghijklnq9&2` {%*e[[[ ]b]x]^^^^__2``aaCbbbcc|de:eeeFtFtFtFtFtFtFtFtFtFtFtXXXXXXXX  ")!!Text13Text14Text15'fe afe$> 4+> O> P> \P> P> P> Q> \Q> Q> Q> R> \R> R> R> S> \S> S> S> T> \T> T> T> U> \U> U> U> V> \V> V> V> W> \W> W> W> X> \X   " ""@@@@@AF[F[O[[[ \\\\]]]aa%afe      "!#  ##"""@@@A A AN[W[W[\\\\\\]]]$a+a+afe    "!#>*urn:schemas-microsoft-com:office:smarttags PostalCode:#*urn:schemas-microsoft-com:office:smarttagsStreet;$*urn:schemas-microsoft-com:office:smarttagsaddress=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType9!*urn:schemas-microsoft-com:office:smarttagsplace8"*urn:schemas-microsoft-com:office:smarttagsCity9 *urn:schemas-microsoft-com:office:smarttagsState t$#"! "! "! !!" !!!!!"8>8^9^9u9v9::W<W< > >>>)>)>AA A^AiAATBTBbBcBBB8EKEMEEE0F1FHGIGGGJJLLMMcOcOQQRRVVyXyXXXXXWYXYhYiYYYYYYYYYYZYZZZZZy\\\\LM^"-.@`ar,-.3>?Qhiz '!'6'7't''''P(Q(((())R)S))1*2*jYrYyYYYYYYYYYYYYYZZ Z&Z+Z,ZYZlZZZfe@Ip_ee`@` ` `````,@`@UnknownGz Times New Roman5Symbol3& z Arial7&  VerdanaG  MS Mincho-3 fg"1hCFCFF!V3!V3!4d e e2QHP ?x.2ONS Innovations Award Program vhapopmorrim VHACOMITCHR  !"#$%&'()*+,-./0123456789:;>?@ABCDEGHIJKLMNOPQRSTUVX[^beghijlmnopqrsuvwxyz|  FMicrosoft Office Word Document MSWordDocWord.Document.89q@  FMicrosoft Office Word Document MSWordDocWord.Document.89q@  FMicrosoft Office Word Document MSWordDocWord.Document.89qObjInfo WordDocument}4SummaryInformation( DocumentSummaryInformation8%` rbjbj 4̟̟=e'0AAA8A\PBl0X6CZ"E(JEJEJEJE0zEE X X X X X X X$"Zh\1XuMJEJEMM1XJEJEXRRRMJEJE XRM XRRRJEC .^4AM|R?SX0XR]#N]RR]REGlRI$4JEEE1X1X5R^EEEXMMMM00$"(00(000 Office of Nursing Services 2008 Annual Innovations Awards Application Form Professional Practice Environment for Nursing Excellence Title of SubmissionTechnology Based Nursing Systems RedesignFacility Name and AddressJohn J. Pershing VAMC 1500 N. Westwood Blvd. Poplar Bluff, MO 63901 VISN # 15 Names of Team Members (Note: At least two (2) team members are required.) Primary Author InformationNameGinger Potts, RN, BSNTitle of PositionPatient Safety ManagerTelephone Number573 - 778 - 4598 Extension:  FORMTEXT       FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NameKay Fox, RNTitle of PositionFacilitator Patient Care/NursingTelephone Number573 - 778 - 4259 Extension:  FORMTEXT      NameSydney Wertenberger, RN, MSN, CNAA, BCTitle of PositionAssociate Director of Patient/Nursing ServicesTelephone Number573 - 778 - 4625 Extension:  FORMTEXT      NameJanice VernonTitle of PositionFacility CIOTelephone Number573 - 778 - 4230 Extension:  FORMTEXT      NameDelinda BoundsTitle of PositionIT SpecialistTelephone Number573 - 778 - 4324 Extension:  FORMTEXT      NameClay Franklin, DPH, MSTitle of PositionSupervisor Staff PharmacyTelephone Number573 - 778 - 4240 Extension:  FORMTEXT      NameLynda FreyTitle of PositionInventory Management SupervisorTelephone Number573 - 778 - 4238 Extension:  FORMTEXT      NameKen VertTitle of PositionEnvironmental Care SpecialistTelephone Number573 - 778 - 4222 Extension:  FORMTEXT      NameGary CatesTitle of PositionChief Facility ManagerTelephone Number573 - 778 - 4704 Extension:  FORMTEXT      ONS Innovations Award Program Technology Based Nursing Systems Redesign Summary of Initiative: A Professional nursing practice environment is defined as an organizational work setting that supports, facilitates and encourages nurses to practice at their full potential. (Kramer & Schmalenberg, 2004) This type of practice setting is characterized by a culture that values concern for the patient, clinically competent nurses, autonomous nursing practice, healthy interdisciplinary relationships and pursuit of excellence. (Kramer & Schmalenberg, 2004). The VHA professional nursing practice environment is assessed utilizing the VA Nursing Outcomes Database (VANOD) RN Satisfaction survey. The three predictive subscales of this survey that most strongly predict overall RN job satisfaction include: Nurse participation in hospital affairs, the nurse managers ability to lead, support and ensure adequate resources to provide quality patient care, and staffing and resource adequacy which includes staff perception of not only numbers of staff but efficiency of information technology, and the nature of the care delivery system (ONS, 2008). In keeping with these concepts patient centric care we want to provide which includes patient safety, efficient and effective utilization of nursing time and energy, involvement of nurses in the development and implementation of the care delivery model that they utilize, good communication/continuity of care, involvement of patients in their own care and improved perception of the nursing staffs ability to provide appropriate care, increased interdisciplinary team work/collaboration, and improved patient and nursing satisfaction. As a facility we wanted to work toward accomplishing this paradigm of excellent nursing care, our goal. Our facility, utilizing the system redesign process empowered and supported an informal team which focused on patient safety, improved use of nursing time including workflow, and improved patient and staff satisfaction. Technology resources utilized as a tool to accomplish these goals was one prime consideration of the team as they looked for ways to accomplish their goals. Literature reviews were performed and other facilities were contacted to identify ways to have positive impact on these goals. Computer equipped bedside medication units were identified as a tool that the acute medical surgical unit would benefit from the most as the team looked for ways to accomplish their tasks. Bedside computer medication administration units were purchased for the acute medical surgical area of our facility. The acquisition of this equipment/resource allowed the nursing unit to change their delivery of nursing care, matching processes of medication administration and electronic documentation to their work environment and appropriate work flow. Prior to this the workflow had remained the same as it had been prior to the implementation of BCMA and the electronic medical record. Outcome measures for success of this change included:improvement in three nurse sensitive indicators of care, the facilities SHEPP scores and nurse satisfaction scores. The outcomes of this endeavor, utilizing all three criteria have been exceptionally positive. Additionally unanticipated benefits of this change have been identified, which benefit not only patients and nurses, but other members of the healthcare team as well. By utilizing an efficient, effective care delivery model, nurses now have a greater sense of satisfaction regarding their own professional practice. The project was implemented for the acute medical unit in the second quarter of 2007. Adoption of the Innovation: The John J. Pershing VAMC is a small rural facility. Our facility has an 18 bed acute medical inpatient unit, which has an average daily census of 11.6 patients who present with multiple disease entities yet we have only a 2.9 average length of stay resulting in rapid turnover of patients. Our average rate for admissions is 4 patients per day and 4 discharges per day. Nursing care includes three main activities which account for the majority of work: patient assessment, documentation, and medication administration. The rapid advancing technology in all aspects of nursing care delivery processes has changed dramatically in the administration and documentation of patient care. The catalyst for change for our team was the Institute of Medicine (IOM) report Keeping Patients Safe: Transforming the Work Environment of Nurses (2004). This report cites a study performed between 1994-1996 which tracked excess motion, inefficiencies, worker patterns, ergonomics, workspace organization, safety, and how time was spent by healthcare workers. Findings of the study revealed only 1.1-3.3 hours in a 12 hour period was spent in the patient room performing assessments and direct patient care. The majority of nursing time was spent in the nursing station, walking between patient rooms and in the nursing unit core (clean/dirty utility room, medication room, etc.). The IOM report recommends change in the work design process to make them more efficient, less conducive to the commission of errors, and more amenable to detecting and remedying errors when they occur. The recommendation is also made that healthcare organizations should consider medication administration as one of the first work design initiatives. A study in two tertiary care hospitals found that 38% of Adverse Drug Events had occurred during administration of the medication. Documentation accounts for 15-20% of nursing workload according to studies and had traditionally been completed by the nurses on computers at the central nursing station. Distractions related to congestion and disruptive conversations often occur when nurses congregate to the nurses station to complete documentation. Distractions are a common factor cited in Root Cause Analysis regarding medication errors. A healthy work environment is maintained through the participation of the nursing staff in identifying best practices and work processes that allow for the provision of quality patient care (Kramer & Schmalenberg, 2008). The acute care facilitator (head nurse) in collaboration with front line nursing staff evaluated the current work processes to identify potential for improved delivery of care. Together, they developed a vision that fueled the proposal for the Technology Based Nursing Systems Redesign initiative at our facility. This involved placing computerized medication unit at each bedside to be used for documentation to allow for improved workflow. As the facility team began researching similar redesign projects, we found that in 1999 the Methodist Hospital, Clarian Health Partners redesigned their nursing unit to include computer technology directly at the patients bedside. The result was a 70% reduction in medication errors and reduction of fall to a level of 2 falls per 1000 patient days. By placing a medication unit and a computer server in the patient room the tools to perform nursing care would be located at the location where the work was being performed--the bedside. Nurses would no longer be traveling back and forth from the nurses station to the room to document their assessments, and no longer would a med nurse be pushing a medication cart through the hall to administer medications. The expectation was that this would not only increase time spent with the patient but also the patients perception of time spent on their care while increasing patient observation time by nurses to allow for reduced fall rates. Improved patient outcomes would also positively influence the nurses perception of their practice. These concepts, with an emphasis on safety were submitted as an application for a national safety grant. The grant was funded, and the remaining monies for this initiative came from the medical center. The grant was written by the nursing team members. Processes/workflow Before implementationAfter implementationPharmacy provided daily restocking of unit medication carts.Pharmacy restocks individual patient cart.Interdisciplinary team members left patient rooms to enter documentation in patient records.Bedside access allows all team members access to real time data and documentation.Medications dispensed from unit cart down the hallway from room to room.Medications dispensed from individual cart with computer in patient room.Documentation by team members performed in crowded nursing station.Documentation performed in patient room.Assessment of patients at bedside with documentation and plan of care being developed at congested nursing station.Assessment and care plan developed in patients room with patient and family involvement in plan of care.Nursing Leadership and Collaboration: The Associate Director for Patient Services and Nursing is constantly seeking innovative ways to not only improve patient care, but to also improve staff satisfaction and morale. The facilitator of the area had wanted to institute bedside charting and an improved medication delivery work flow system. The patient safety manager had a strong focus on improving the facilitys patient safety culture. The facilitator and the patient safety manager, who led the informal team, identified this initiative as a way that all parties could meet their goals. Front line nursing staff input was also obtained to develop the best process and promote a sense of shared governance. This initiative was led by and implemented by nurses. The team members united in the effort to provide a professional practice environment with the shared goal of enhanced patient care by utilizing technology to deliver nursing care. The implementation of this plan was contingent on strong collaboration with multiple services, or the implementation would not be possible. Collaboration was required to: secure the support of the medical center to fund the portion of the project the grant funding did not cover, have pharmacy redesign their system of medication delivery to meet the new medication delivery process on the ward, with building management to clean the bedside carts, with IT and logistics to get the new bedside computer medication computers and with engineering to get the carts secured appropriately. This was accomplished both formally, and through frequent and at times robust ongoing informal dialogue. The cornerstone of the collaboration were built upon was the concept of improving patient care, something everyone could agree upon. Positive collaboration brought this initiative to the implementation stage. The nursing staff at the unit level collaborated among themselves to find the best way to provide nursing care now that they had the tools to improve their workflow, and change their practice environment. This involved all three tours of duty, and involved frequent input and feed back related to the redesigned work processes. The acute care facilitator and front-line nursing staff looked at the current process for medication administration, the design of the unit, and nursing workflow to customize the redesign of their workflow and improve efficiency through the use of technology. However, it would require a change in our nursing care model from team nursing to modified primary care nursing. Previously each nurse had specific tasks related to patient care on the unit according to model licensure (RN or LPN). The change resulted in the assignment of designated patients to nursing staff which perform all aspects of the patients care. Assignments are now made according to the level of care and monitoring the patient requires. By promoting each individual to practice at their maximum potential enhances the professional practice environment. Through leadership promoting shared governance among staff, leadership has promoted active involvement by those being led and who are part of the change processes (see below). This project has been distributed throughout the VA on several occasions. Scope of Initiative: This initiative impacts multiple goals and objectives of our facility, and our VISN. It has positively impacted our medical centers compliance with safety standards/goals, our compliance with Joint Commission standards for patient safety, assisted with improving our patient satisfaction performance measures, a medical center and VISN strategy, monitored through the SHEP scores, increased our Nursing satisfaction scores through technology support and the adequacy of resources as noted in the nursing satisfaction survey, and is a contributing factor to the decrease in acute care nursing turnover rate. Additionally, this initiative has also been a contributing factor to improved nursing team work, communication between nurses themselves, created an improved environment to hand-off necessary information, assisted with improved continuity of patient care, and improved multidisciplinary collaboration related to patient needs. This initiative opened the dialogue with other disciplines concerning what nurses need to provide excellent, high quality patient care. This initiative has the potential to be beneficial in multiple VHA settings, and have impact at the national level as facilities search for ways to enhance the professional work environment and look for tools to achieve this goal on behalf of nurses, their patients, and the healthcare team they are a part of. All facilities would benefit from increased patient satisfaction, decreased falls, improved nursing satisfaction with resources and technology support. Multiple informal consultations related to this project have been provided both within our VISN, and to others outside of our VISN. This project has been published and presented during this past year, by the patient safety manager, the nurse executive, and the acute care facilitator. The newsletter Topics in Patient Safety (TiPS) March/April 2006 references this project as a Patient Safety Initiative. This newsletter edition was also used in the national VA Leadership Patient Safety Training materials, and was distributed widely through out the VHA. In 2007 another facility utilized the same concept for a similar patient safety initiative named Move the Caregiver, and they utilized much of our preparation material as well as consultations from us to develop and implement their program. The core nursing leadership team of this project (patient safety manager, nurse executive and acute care facilitator) submitted an abstract for 2007 Veterans Health University (VeHU) conference, held in Orlando, Florida.Both the Tips newsletter and the VeHU abstract and poster remain online at their perspective websites for twelve months. The abstract was accepted and identified as one of the top ten abstracts submitted to the conference. The abstract was published in the VeHU daily paper at the conference and distributed to over 900 people. Additionally, facility team members presented a poster and a lunch and learn education session regarding the project and outcomes at the VeHU conference. The poster won the Peoples Choice Award for the 2007 VeHU conference. The team has been asked to again give a lunch and learn presentation for the 2008 VeHU conference. An overview of the project and implementation has been presented on several national teleconferences including: the VHA Patient Safety Managers teleconference in August of 2007 and a Nursing System Redesign teleconference in September 2007. Technology based nursing systems redesign was anticipated to provide an added safety barrier for medication administration. Medications would no longer be stored on carts which contained drawers of medications of all patients on that unit. This allows for reduction in medication errors which occur during administration. By having the medication for that patient located in a secured cart in the patients room, there is less potential for wrong patient error and for wrong drug error due to pulling the medication from the wrong patient drawer on a cart containing medications for multiple patients. Nurse satisfaction has been directly related to the quality of care provided; therefore, improving patient outcomes improves nurse satisfaction as well. The elimination of the nursing station as a center for multidisciplinary staff allows for less distractions and inefficiencies resulting in a less chaotic working environment and decreases amount of time spent moving between the patient room and the nursing station. When documentation occurred at the nurses station the patient perceived that very little time is being spent directly on their care. The time the nurse spends documenting is no longer at the nursing station but at the patient bedside allowing for increased monitoring of patients to identify changes in patient condition and decreased opportunity for patient falls.As a result of the computer system at the bedside the multidisciplinary care team has instant access to any patient information in the computerized medical record available in the same location as the patient. This allows for entry of vital signs, documentation of assessment details, retrieval of lab information, administration of medications, etc. This has also increased the ability of the patient to participate in care plan development and ability of staff to provide patient specific education. The patient now has a more accurate perception of the time being spent on their care resulting in improved SHEP scores related to overall customer satisfaction, with in-patient care. Impact: Results from the project have been phenomenal and have impacted three facility goals. We have had a significant and sustained improvement in nursing sensitive VANOD measures including a reduction in fall rate of over 50%. Prior to the implementation the average annual rate was 11.25/1000 BDOC, since implementation this has decreased to an average of 4.1/1000 BDOC. The average cost of a hip fracture in the VA is estimated at $33,000.00. This decrease offers us a potential savings of $792,000.00. We have also experienced a 50% decreased medication error rate going from pre implementation average rate of 4.3/1000 BDOC to post implementation average rate of 2.2/1000 BDOC. Resources cite the average cost of a medication error to be approximately $3500.00; this would be a potential savings of $21,000.00 Our SHEP scores have also shown significant improvement, moving from an average of 72.3% to 74.6%. Beyond the anticipated benefits there have been unanticipated improvements as well. Other disciplines of the healthcare team utilize the computerized medication units to complete their documentation while at the patient bedside including physical therapy, physicians, dieticians, and social workers. The patient has now become more involved in their healthcare due to the access of real time data entry allowing for one- on-one interaction with the patient when creating and reviewing care plan data. Also, there is a significant decrease in the amount of time the nurses spend at the nursing station with an increase in the amount of time spent at the bedside. Nurses report increased satisfaction with their practice environment and this is evidenced by a decreased turnover rate of from 8% to 0.8% since implementation. According to research patient outcomes are directly related to nurse satisfaction and eighty percent of nurses satisfaction is related directly to the ability of the nurse to provide quality patient care. (Kramer & Schmalenberg, 2004) This increases the awareness that nursing management must have regarding the nurses practice environment. Before initiation of the project the most prevalent concern expressed by nursing on the RN nurse satisfaction survey was IT support, following implementation this has dropped to a rank of 4th out of the 6 areas measured. This nursing systems redesign project has encompassed all members of the interdisciplinary team who report benefit from real time access to data during patient interaction. Additionally this initiative opened the dialogue with other disciplines concerning what nurses need to provide excellent, high-quality patient care. This work flow improvement utilizing technology as resource/tool and the tangible identified outcomes encouraged others to become a part of this initiative, enhancing their own practice patterns and workflow. It has improved access to patient information and simplified work procedures thereby reducing inefficiencies and increased time spent with the patient resulting in improved three nurse sensitive VANOD measures of nursing care for our facility. As a result of improved patient outcomes we have improved nursing satisfaction which fosters low nursing staff turnover rates. Outcome Monitors MeasureBeforeAfterPatient Fall Rate11.25/1000 BDOC4.1/1000 BDOCMedication Error Rate4.3/1000 BDOC2.1/1000 BDOCSHEP Average Scores72.3%74.6%Nursing Unit Turnover Rate8.03%0.8%Nursing satisfaction with Technology supportBelow VISN AverageNo longer in the top four concerns of our facility This has been a highly successful innovation. References: Agency for Healthcare Research and Quality (AHRQ). Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. URL:  HYPERLINK "http://www.arhq.gov/qual/aderia/aderia.htm" \o "blocked::http://www.arhq.gov/qual/aderia/aderia.htm" www.arhq.gov/qual/aderia/aderia.htm Institute of Medicine. Medication Errors Injure 1.5 Million People Cost Billions of Dollars Annual. Press Release. URL: http://www.nationalacadamies.org/onpinews/newitme.aspx?RecordID=11623 Institute of Medicine. Identifying and Preventing Medication Errors. URL:  HYPERLINK "http://www.iom.edu/?id=35942" \o "blocked::http://www.iom.edu/?id=35942" www.iom.edu/?id=35942 Board of Healthcare Service, Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses (2004). URL:  HYPERLINK "http://darwin.nap.edu/openbook.php?record_id=10851" \o "blocked::http://darwin.nap.edu/openbook.php?record_id=10851" http://darwin.nap.edu/openbook.php?record_id=10851 Topics in Patient Safety: Vol 7/Issue 3, May/June 2007, URL: www.  HYPERLINK "http://vaww.ncps.med.va.gov/Initiatives/psi/MayJuneTIPSArticleOnPSI.pdf" \o "blocked::http://vaww.ncps.med.va.gov/Initiatives/psi/MayJuneTIPSArticleOnPSI.pdf" http://vaww.ncps.med.va.gov/Initiatives/psi/MayJuneTIPSArticleOnPSI.pdf  K# , - . 0 } ~    2 4 6 > @ F 򵬵򡙡xZ;jhNh_CJOJPJQJU^JaJmHnHo(u#jhNh_CJUaJjhNh_CJUaJh_CJaJhNh_CJaJh_CJ\aJhNh_CJ\aJhy;h_6CJOJQJaJh_5B*CJ\aJph#h{h_5B*CJ\aJphhNh_5CJ\aJ#:KT}kd$$Ifl0 $\ l t0644 laPytr $Ifgdr$a$gd_$a$gd_$ *]^a$gd_ Jq $ % & . 1 x}kdj$$Ifl0 $\ l t0644 laPytr $Ifgdr1 2 3 } ~ ||tk $Ifgdr$a$gd_gd_}kd$$Ifl0 $\ l t0644 laPytr $Ifgdrfkd>$$Ifl4&(0(64 laPf4ytr $Ifgdrvkd$$Ifl0& 0(64 laPytr B $Ifgdrvkdn$$Ifl0& 0(64 laPytrB D F H $Ifgdrvkd$$Ifl0& 0(64 laPytrF H L N b d f 6 8 < > R T V  P v | ͸ۥgQChNh_6CJ]aJ+hNh_56CJ\]aJmHnHu/j hNh_56CJU\]aJ hNh_56CJ\]aJ)jhNh_56CJU\]aJ%hNh_5CJ\aJmHnHu)jhNh_5CJU\aJhNh_5CJ\aJ#jhNh_5CJU\aJhNh_CJaJh_CJaJH J L { $Ifgdrgd_vkd$$$Ifl0& 0(64 laPytr $Ifgdr  !gd_ckd$$Ifl&(0(64 laPytr  R $Ifgdrvkdt$$Ifl0& 0(64 laPytrR T v $Ifgdrvkd $$Ifl0& 0(64 laPytr 0X*,.68Hb$&6T| #j`hNh_CJUaJ#j hNh_CJUaJh_CJaJ;jhNh_CJOJPJQJU^JaJmHnHo(u#j hNh_CJUaJjhNh_CJUaJhNh_CJaJ6 2{{ $Ifgdrgd_vkd* $$Ifl0& 0(64 laPytr24X $Ifgdrvkd $$Ifl0& 0(64 laPytr: $Ifgdrvkdj $$Ifl0& 0(64 laPytr:<>Hd{{ $Ifgdrgd_vkd $$Ifl0& 0(64 laPytrdf $Ifgdrvkd $$Ifl0& 0(64 laPytr( $Ifgdrvkd $$Ifl0& 0(64 laPytr(*,6Vvm $Ifgdr  !$Ifgdrgd_vkd$$Ifl0& 0(64 laPytrVX| $Ifgdrvkdv$$Ifl0& 0(64 laPytr $Ifgdrvkd$$Ifl0& 0(64 laPytr  *V~&(*248:DX 468@BFV`p޵޵޵޵{޵#jbhNh_CJUaJ#j hNh_CJUaJh_CJaJ *hNh_CJ\aJhNh_CJaJ;jhNh_CJOJPJQJU^JaJmHnHo(ujhNh_CJUaJ#jhNh_CJUaJ0 *Xvm $Ifgdr  !$Ifgdrgd_vkd,$$Ifl0& 0(64 laPytrXZ~ $Ifgdrvkd$$Ifl0& 0(64 laPytr6 $Ifgdrvkdl$$Ifl0& 0(64 laPytr68:DZvm $Ifgdr  !$Ifgdrgd_vkd$$Ifl0& 0(64 laPytrZ\ $Ifgdrvkd"$$Ifl0& 0(64 laPytrD $Ifgdrvkd$$Ifl0& 0(64 laPytrDFHJLNPRTV`rvm $Ifgdr  !$Ifgdrgd_vkd$$Ifl0& 0(64 laPytr rt $Ifgdrvkdx$$Ifl0& 0(64 laPytrX $Ifgdrvkd$$Ifl0& 0(64 laPytr 24HJLTVZ\fz .0DFHPRVXZ1ޮޮ혏xihx.hx.5>*CJ\aJhx.h CJaJh hx.5CJaJh_5CJaJh_#jhNh_CJUaJ;jhNh_CJOJPJQJU^JaJmHnHo(u#jhNh_CJUaJjhNh_CJUaJh_CJaJhNh_CJaJ'XZ\f|vm $Ifgdr  !$Ifgdrgd_vkd.$$Ifl0& 0(64 laPytr|~ $Ifgdrvkd$$Ifl0& 0(64 laPytrT $Ifgdrvkdn$$Ifl0& 0(64 laPytrTVXZ\^`bdfhjlnprgd_vkd$$Ifl0& 0(64 laPytrrtvxz|~0$a$gd1$a$gd1gd_01i$$3$5$d'44 5!56575t55Vkd$$$If0H$H$622 l4ayt1 $$Ifa$gd1$a$gd$a$gd11Ljop\]| !! ")""#$3$_$~$c'd'(,G,,,,---f..//333444444hx.hx.>*CJaJh#CJaJhdCJaJhoCJaJh CJaJh CJaJhx.hx.5>*CJ\aJhaACJaJh%CJaJh%DCJaJh1CJaJhXkCJaJhx.hx.CJaJ14 5 56528Y88899: ::;';B;@=D===`>>>>R?m?@@AA BBB%B@BBBBCC/D0DnDDDDDE EdFuFFFGG?G^GuGvGGHŽŽŽŽŽŵŽŽŽŽŽŵŵŭŭŭŭťťЙťťťŽŽŽhx.hx.>*CJaJhTEFCJaJh%CJaJh1CJaJhaACJaJhx.hx.CJaJhx.hx.5CJ\aJh 56>*CJ\]aJ#hx.hx.56>*CJ\]aJ<555P6Q666GVkdr$$If0H$H$622 l4ayt1 $$Ifa$gd1Vkd$$If0H$H$622 l4ayt166)7R7S7718GVkd$$If0H$H$622 l4ayt1 $$Ifa$gd1Vkd $$If0H$H$622 l4ayt11828X8Z8DDE E9I:I;IRZZZZX^eWg$a$gd1Vkd|$$If0H$H$622 l4ayt1HHH8I9I:I;I8JWJuJvJ L LLLNNOO OO PPPPbPcPPPPPPPPQ!Q&Q+Q5QnQQQQQ8SKSMS0T1THUIUUUWXZZZZhx.5CJ\aJhx.haACJaJhx.h CJaJhdCJaJh CJaJhaACJaJh CJaJhx.h >*CJaJhx.CJaJhTEFCJaJhx.hx.CJaJ:ZZZZZ[[[\\\\D]c]F^U^__``ccddffffWgXghgigjggggggggg,h4hhhhheiλγγγΧγΜΆΆΆΆΆ~hx.CJaJh .CJaJhx.h15CJ\aJh15CJ\aJhx.hx.CJH*aJhaACJaJhx.h CJaJhdCJaJhx.hx.CJaJhx.h 5CJ\aJhx.5CJ\aJhx.hx.5CJ\aJ/WgXgigjgrgyggggggzikd*$$IfF $`   6    22 l4ayt1 $$Ifa$gd1$a$gd1$a$gd1 ggggg $$Ifa$gd1ikd$$IfF $`   6    22 l4ayt1ggggh $$Ifa$gd1ikd $$IfF $`   6    22 l4ayt1hh h&h+h $$Ifa$gd1ikdh!$$IfF $`   6    22 l4ayt1+h,hYhlhh $$Ifa$gd1ikd,"$$IfF $`   6    22 l4ayt1hhhhhhhhhhhhhiss dd[$\$gd1$dd[$\$a$gd1$a$gd1ikd"$$IfF $`   6    22 l4ayt1 eifiiiiiyjj k kbkckxkykllllllllllmmmmm>?@'(PQ GHJKMNPQS婽ԩ婽ԩԩԩԩh8jh8UU&jhx.hx.B*CJUaJphhx.hx.B*CJaJphh^CJaJ hx.hx.>*B*CJaJphhx.hx.CJaJjhx.hx.CJUaJ=ijzklm)IJLMOPRSUVabcnopqrh]hgdx. &`#$gd  dd[$\$gd1Topics in Patient Safety: Vol 10/Issue 5, Sept/Oct2007, URL:  HYPERLINK "http://vaww.ncps.med.va.gov/Initiatives/psi/TIPS_SeptOct07PSI07.pdf" \o "blocked::http://vaww.ncps.med.va.gov/Initiatives/psi/TIPS_SeptOct07PSI07.pdf" http://vaww.ncps.med.va.gov/Initiatives/psi/TIPS_SeptOct07PSI07.pdf National Center for Patient Safety: Patient Safety Initiative Summary of project and feedback survey responses, URL:  HYPERLINK "http://vaww.ncps.med.va.gov/Initiatives/psi/PatientSafetySummaryFINAL.pdf" \o "blocked::http://vaww.ncps.med.va.gov/Initiatives/psi/PatientSafetySummaryFINAL.pdf" http://vaww.ncps.med.va.gov/Initiatives/psi/PatientSafetySummaryFINAL.pdf Cox, Karen S.: Achieving Magnet Status: Demonstrating Nursing Excellence: Kansas Nurse, Aug 2005. URL:  HYPERLINK "http://findarticles.com/p/articles/mi_qa3940/is_200508/ai_nl5325215/print" \o "blocked::http://findarticles.com/p/articles/mi_qa3940/is_200508/ai_nl5325215/print" http://findarticles.com/p/articles/mi_qa3940/is_200508/ai_nl5325215/print Kramer, Marlene, and Schmalenberg, Claudia: Confirmation of a Healthy Work Environment, Critical Care Nurse 2008, April 2008, URL:  HYPERLINK "http://ccn.aacnjournals.org/cgi/content/short/28/2/56" \o "blocked::http://ccn.aacnjournals.org/cgi/content/short/28/2/56" http://ccn.aacnjournals.org/cgi/content/short/28/2/56     PAGE 6 PAGE 1 STVW]^_`acdjklmnpqrhx.hx.B*CJaJphh 960JmHnHuhh0JmHnHu h0Jjh0JUh8jh8U21h:px./ =!"#$% Oh+'0 ,8 X d p | ONS Innovations Award Programvhapopmorrim Normal.dot VHACOMITCHR2Microsoft Office Word@F#@ܳ@M]4@M]4!VQ      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~՜.+,D՜.+,` hp  Dept of Veterans Affairs3 e' ONS Innovations Award Program Title 8@ _PID_HLINKSAL0R66http://ccn.aacnjournals.org/cgi/content/short/28/2/56 r3Jhttp://findarticles.com/p/articles/mi_qa3940/is_200508/ai_nl5325215/print B0Jhttp://vaww.ncps.med.va.gov/Initiatives/psi/PatientSafetySummaryFINAL.pdf R=-Dhttp://vaww.ncps.med.va.gov/Initiatives/psi/TIPS_SeptOct07PSI07.pdf z$*Hhttp://vaww.ncps.med.va.gov/Initiatives/psi/MayJuneTIPSArticleOnPSI.pdf >'3http://darwin.nap.edu/openbook.php?record_id=10851 \$http://www.iom.edu/?id=35942 =e!+http://www.arhq.gov/qual/aderia/aderia.htm _1279448181 Fp#C۰p#C۰Data !1Table BwCompObjqh$$IfP!vh55 5#v5 #v:Vl t65\ 5laPyt$.h$$IfP!vh55 5#v5 #v:Vl t65\ 5laPyt$.h$$IfP!vh55 5#v5 #v:Vl t65\ 5laPyt$.$$IfP!vh5(#v(:V l40(65(4aPf4yt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.FDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.$$IfP!vh5 5#v #v:V l0(65 54aPyt$.DyK reji.john2@va.govyK Jmailto:reji.john2@va.govyX;H,]ą'c@@@ 0NormalCJ_HaJmH sH tH :@: M5 Heading 1$@&5\DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No ListHH  Balloon TextCJOJQJ^JaJ4@4 JHeader  !4 @4 JFooter  !.)@!. J Page Numberj@3j J Table Grid7:V06U@A6 M5 Hyperlink >*B*phii ghfgfg i@0q 00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q @0@0:K'(/[\]ij{EFWijy)*<HIZijy#$6DEVghw  "#5CDUfgv    2EFWfgv     vvCAB-= ! $$$%%%&[&&&&'N'''!((())_))*0*1*o*.00d02222%377+899@:;=@@AA(BBD_EEEEEFGHIKOOOO PSSGSUVWXY\h^s^t^ _a__"``aa?bbcocc@dd*ee/fffYggfhh\i]i_i`ibicieifihiiiiiiii000000 0 0 0 000 0 0 0 0 000 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 000 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 000000000000000000A00000 0 0 0 0 0 0 0 00000000000000000 0 0 00 0 0 00 0 0 0 0 0 0 00 0 0 0 0 0000000000000000000000000000000000000000000000000000000000000000000000000000000@0X00@0X00@0X00@0X00@0@0X00(0:K'(/[\]ij{EFWijy)*<HIZijy#$6DEVghw "#5CDUfgv   2EFWfgv     vvCAB-= $%&'(_))*0*1*o*.00d02222%37+899@:;=@@AA(BBDEEEFGHIOO PSGSUVWXYs^t^ _a__"``aa?bbcocc@dde/ffgi@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 @0@0@0 @0@0@0 @0@0@0@0Z00 @0 &o0`(| @0@0@0@0 @0 @0@0 @0 @0@0@0@0Z0'0w Z0'0w @0@0@0@0@0@0@0@0@0@0@0Z010R Z010R @0@0@0@0@0@0@0@0@0@0@0Z0>0H Z0>0H @0@0@0@0@0@0@0@0@0@0@0Z0K0> Z0K0> @0@0@0@0@0@0@0@0@0@0@0Z0X04 Z0X04 @0@0@0@0@0@0@0@0@0@0Z0d0+ Z0d0+ @0@0@0@0@0@0@0@0@0@0Z0p0" Z0p0" @0@0@0@0@0@0@0@0@0@0@0Z0}0 Z0}0 @0@0@0@0@0@0@0@0@0@0Z00 Z00 @0@0@0@0@0@0@0@0@0@0Z00 Z00 @0@0@0@0@0@0@0A@0@0@0@0@0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@0@0@0@0J0!0@0@0@0@0@0@0Z00,rZ00+Z00J0"0J0"0J0 0J0 0J0 0J0 0J0 0J0 0J0 0J0 0J0 0J010 Z00J020 Z0(0J020 J020 J040 J040 Z0,0Z0.0Z0,0J060 J040 Z0.0J00"J00"J00"J00"J00"J00"Z0708@/rZ070J00"J00Z0(0 Z0(0 Z0(0Z0<0 Z0?0 Z0?0 Z0A0 @0Z00Z00Z00Z00Z00Z00{00{00{00{00{00{00{00{00{00Y@0Z0 0{00{0 0{0 0@0 ***-, u /$'N*-}157";d?A.GJjNPRVaX[^edqq9CQnpqrsuvwxy{|}~[ i  E i  ) H i #Dg"Cf Ef/%;Q g`qq:<=>?@ABDEFGHIJKLMNOPRSTUVWXYZ[\]^_`abcdefghijklmotzq;),8   iFtFtX %'-!8@0(  B S  ?iText14Text15-i*i % & \B' |f( m) b* o+ o,  - L . d/ 0 1 T&2 &3 &4 @5  A6 LA7 28 $39 d3: 3; 3< = <> |? @ A <B |C D !<' aehr{**CCSESE\\ddi      &&G1 dgqz11CC\E\E\\ddi  >*urn:schemas-microsoft-com:office:smarttags PostalCodeB*urn:schemas-microsoft-com:office:smarttagscountry-region>*urn:schemas-microsoft-com:office:smarttags PersonName9*urn:schemas-microsoft-com:office:smarttagsState8*urn:schemas-microsoft-com:office:smarttagsCity=*urn:schemas-microsoft-com:office:smarttags PlaceType= *urn:schemas-microsoft-com:office:smarttags PlaceName9*urn:schemas-microsoft-com:office:smarttagsplace 跞    ajlpuyUY++33B&BrGvGNNNN^^^^ __"`'`-`4`````ua|aaaoctc!d,d@dGdMdRddd*e1eweeeeeeffffggggfhlh]i]i_i_i`i`ibicieifihiiisiwiiiiii%#%++B&BIIOQQVVWWWXXXt]}]^^a_c_bbc?d*eesffffgdh]i]i_i_i`i`ibicieifihiiisiwiiiiii3333333333333333333  /0(**9?++)/+/d7j7w7|777g8t8EEGG*H+HHHIIIIKKMMNNNNhOiOOOOOOOPPMQNQQQhRiRRRSS T TTTTTVVVVWWWWXXnZoZZZ;[<[[[\\\\s]u]]]^!^g^\i]i]i_i_i`i`ibicieifihiiisiwiiiiii]i]i_i_i`i`ibicieifihiiiiiiIxzk\R .Nn(^`(CJOJQJaJo(hH^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHh(^`(CJOJQJaJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHIk\R 0                 ov_5c!peafX e ;QO:4pB8B\v. h2cf !d%!&!B!h|"%F%*v%5&;'c'>?'?p'd~'})m5+N3,\,\q- .$.3.6/ 0r0~0)/1`D12Y2Ln2km4M52$57 8J9l:v;_<6<EG? @@@bA D ,Dm'HgzI5JmKGKHN/OiKOwO%P1QKQTQ R9T%UOV'W#GW}Xg`\:_`w6abEa|b@ciEemIopop+uaw^yhNz6,{c{*|e'}#~u~\&;CuqAe'COi.gM8>`C f= 4N6F8hHZ,7)<1h(2>be=Q[vgE lJPJAdwn&z1;bg+cY/1>ciu7W[ /XWb'(/[\ij{EFWijy)*<HIZijy#$6DEVghw  "#5CDUfgv    2EFWfgv  0Ci<@|Ii`@UnknownGz Times New Roman5Symbol3& z Arial7&  Verdana5& zaTahoma?5 z Courier New;Wingdings"1hhDFDF¢FY5Y5!4d(i(i 2QHP ?f 2Office of Nursing Services vhamadhartmm VHACOMITCHR  ObjInfoWordDocumentS8 SummaryInformation(DocumentSummaryInformation8%` qbjbj 8 ̟̟]i+hhhhxPxPxP8PQrtS:S(SSST"TT rrrrrrr$:thv?r[TT[[?rhhSSTrccc[h8SSrc[rcc:h,miShS cVM6xP]^Zi ljr0riR.w_.wmi.wmiTVDcXYTTT?r?rb^TTTr[[[[$(00hhhhhh Office of Nursing Services 2008 Annual Innovations Awards Application Form Professional Practice Environment for Nursing Excellence Title of SubmissionPatient Centered Shift HandoffFacility Name and AddressWm. S. Middleton Memorial Veterans Hospital 2500 Overlook Terrace Madison, WI 53705VISN #VISN 12 - VA Great Lakes Health Care System Names of Team Members (Note: At least two (2) team members are required.) Primary Author InformationNameMary HartmannTitle of PositionFee Basis/Special Projects Former/Retired(2/4/08), Chief, Inpatient Nursing Service and Chair of the shift handoff workgroupTelephone Number608 280 7080 E-mail AddressMary.hartmann@va.gov  FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NameBeverly PrieferTitle of PositionMagnet/Evidence Based Practice CoordinatorTelephone Number608 280 7080 E-mail AddressBeverly.Priefer@va.gov NameJacalyn SuttonTitle of PositionNurse ManagerTelephone Number608 - 334 - 3449 E-mail AddressJacalyn.sutton@va.gov NameSusan ClearfieldTitle of PositionStaff NurseTelephone Number608 280-7110E-mail AddressSusan.clearfield@va.gov NameSarah SchroederTitle of PositionStaff NurseTelephone Number608 280-7110E-mail AddressSarah.schroeder@va.gov NameDennis ClappTitle of PositionNurse ManagerTelephone Number608 334 - 3452E-mail AddressDennis.clapp@va.gov NameMolly BrunnerTitle of PositionStaff NurseTelephone Number608 280 - 7112E-mail AddressMolly.brunner@va.gov NameTeresa Van WagonerTitle of PositionNurse ManagerTelephone Number608 334 - 3455E-mail AddressTeresa.vanwagoner@va.gov NameLaura PaffordTitle of PositionStaff NurseTelephone Number608 280 - 7147E-mail AddressLaura.pafford@va.gov NameDonna MillerTitle of PositionNursing InstructorTelephone Number608 280-7080E-mail AddressDonna.miller3@va.gov NameMary SchmidtTitle of PositionStaff NurseTelephone Number608 280 - 7012E-mail AddressMary.schmidt@va.gov Submissions shall be in narrative format, in Times New Roman font, no less than 11 point, and NOT exceed five pages in length, including attachments. Submissions cannot contain embedded documents. Submissions which are noncompliant with these criteria will not be considered. Narrative shall include (a) title, (b) summary of initiative, (c) date of implementation, and (d) clearly identify each rating category being addressed followed by applicable narrative. The attached template serves as a face sheet for the narrative. All best practices shall be submitted electronically by the Nurse Executive with endorsements by the Facility Director/designee notifications of the VISN Director/designee. An electronic copy of the attached endorsement memo or equivalent electronic message addressed to Cathy Rick, RN, CNAA, FACHE, Chief Nursing Officer, Office of Nursing Services (108), is to be sent WITH the submission to Reji John (VHACO), Office of Nursing Services VACO (108), at  HYPERLINK "mailto:reji.john2@va.gov" reji.john2@va.gov (please note duplicate name in outlook). Deadline for submissions with endorsements is by COB May 31, 2008. Office of Nursing Services Annual Innovations Awards Title: Patient Centered Shift Handoff Summary of Initiative: We implemented a new change of shift handoff on the medical and surgical units at the Wm. S. Middleton Memorial Veterans Hospital in Madison, WI. Evidence guided the development of this handoff process, a process that highlights our nursing autonomy and our commitment to patient driven care. There are nine standardized components of our Patient Centered Shift Handoff Process: RN/patient assignments: Charge nurse (CN) posts assignments prior to the start of handoff. Charge Nurse Unit Overview: Off-going and oncoming CNs review activity scheduled for upcoming tour and identifies patients with safety/care issues. Patient Preview Information: All RNs review the Patient Preview Spreadsheet (replaces kardex) prior to verbal handoff. CPRS is reviewed prior to or shortly after bedside handoff. This preview triggers the RN to ask for additional information and provides an opportunity to seek some just in time learning for any care or interventions that are unfamiliar to the RN. RN to RN bedside patient handoff: Occurs in the patient room using a standard format PACE (patient/problem, assessments/actions, continuing/changes, evaluation) or SBAR(situation, background, assessment, and recommendations) along with informing the patient about the plan for the day/stay. The outgoing RN identifies and introduces the patient to the oncoming RN, reviews IV drips, lines, tubes, I&O, safety and preventive measures, dressings, positioning, etc. and updates the patients white board. On-coming RN clarification. RN clarifies any issues/concerns prior to the departure of the off-going RN and patients are encouraged to ask questions. LPN and UAP Assignments. The CN and the RNs assign care duties to LPNs and UAPs. The CN reviews assignments with LPNs and UAPs. Mid-shift update: RN staff and CN huddle during a prearranged time to review unit activity/workload, adjust assignments, and communicate patient specfic information. This also provides a time for RNs to coach novice RNs. Mid-shift update/huddle allows novice RNs to practice SBAR as they communicate patient information to the CN. End of shift verbal report by LPNs/UAPs: LPNs and UAPs report to responsible RNs patient observations and findings, unit activity, and information that the CN needs for the upcoming Charge Nurse Unit Overview. Date of Implementation: November 15, 2007 Identify each rating category being addressed followed by applicable narrative: Adoption of the Innovation Innovation is implemented in response to a designated need in the organization. Our patient centered handoff demonstrates a major nursing initiative that assists our organization in meeting three of its strategic goals: 1) Make patient goals a critical driver of patient care; 2) assist veterans to make informed choices regarding their own healthcare and 3) improve communication. In 2005, we identified a need for improved communication between nurses, among nurses and physicians, and among nurses and patients. Our first initiative focused on improving communication between RNs and MDs, specifically the communication that occurs when the RN reports critical changes in a patients condition. Three hospitals in our VISN collaborated to develop an education program that introduced the SBAR process for facilitating the delivery of critical information. Two of the hospitals, including Madison, were approved by their respective IRBs for a research project. We administered surveys before and approximately 2 months after the education program. Survey findings indicated that those RNs with the least experience perceived the greatest benefit from using SBAR. In 2007, we tackled our nurse-nurse and nurse-patient communication concerns and identified several problems with our shift handoff process. These problems included: 1) a taped report that was long (30+ minutes), focused on past events rather than anticipating care needs for the next shift, and bypassed critical bedside observations that could detect patient safety problems, 2) little or no direct discussion with the patient about the plan for the day/stay that contributed to patient/family uncertainty, and 3) missed opportunities for teaching novice nurses new skills and for fostering critical thinking since the off-going RN frequently left before the oncoming nurse had finished listening to report. We wanted a handoff process that focused on the relationship between the nurse and the patient since patient involvement in handoff discussions informs the patient and facilitates participation in care decisions. Our handoff goal was to develop a handoff process that 1) involved the patient; 2) improved patient safety; 3) increased patient satisfaction; and 4) made nurses accountable for their professional practice. Information published in professional literature is used to design or modify innovation Initially members of the handoff workgroup expressed resistance to a bedside handoff that would take place in the patients room. They were concerned about the elimination of the group report, diminished teamwork, breach of patient confidentiality, discomfort talking about care in front of the patient, and the amount of time required for the new handoff process. Our first step in overcoming this resistance was to search the literature for evidence that would help us address the above concerns. We found several articles describing handoff processes and we compiled an annotated bibliography of 22 of these articles that we included in staff orientation materials. The following key categories found in the literature guided the development of our handoff process. Patient Benefits: Patient satisfaction and safety improves when patients are empowered to contribute to discussion, ask questions, and clarify information. Bedside handoff promotes RN-patient communication and moves the relationship from parental to more collaborative. Staff are with patients during the handoff rather than sequestered in a room for an extensive period of time. Staff Benefits: Staff can immediately visualize patients, prioritize care for the shift, and are better prepared to answer MD questions. Opportunities for just-in-time learning, particularly with novice staff Improve communication and communication between shifts Process and Content: Bedside component takes about 2-3 minutes per patient Assignments are made prior to handoff, Staff talk with, rather than about, the patient and avoid medical jargon RNs physically double-check IVs, tubes, alarms, etc. Mid-shift huddles keep communication flowing and provide opportunity for seeking assistance. Handoff content improves by minimizing unnecessary information Standardized formats such as PACE/SBAR and use of multiple sources of information (written and verbal) focus on directing and planning upcoming care rather than reporting on care given in the past. Implementation Keep staff informed of the changes being planned Incremental changes to allow for feedback and changes Orientation materials such as scripted case studies, written handouts, guidelines for various patient situations Orient staff and patient a few weeks prior to implementation Pre-post survey to track changes Innovation is customized to fit the needs of the organization We knew that many staff had preconceived notions that a bedside handoff would not work and overcoming resistance was the focus of our implementation strategies. Workgroup members decided upon the basic handoff concepts and a basic handoff structure and then presented these concepts and structure to staff on their respective units. Unit staff were tasked with operationalizing the basic handoff structure during a 3-month period. They created and tested various reporting and overview tools using discovery learning to determine what did and did not work. During this 3-month period, the workgroup members met every two weeks to share the ideas and tools that their respective staff had created. Group members were energized by the ideas being tried on different units and shared these ideas with staff on their unit. Several different worksheets were designed and trialed by staff, but it was not until an RN, returning from deployment to Afghanistan, shared an example of a worksheet used at the military hospital, that the group enthusiastically accepted this worksheet as the worksheet. One unit was upset that the charge nurse would not hear the entire report on all patients. To solve this problem that unit implemented a mid-shift huddle whereby the team nurses update the charge nurse regarding patient issues. This mid-shift huddle also serves as an opportunity to coach novice nurses that may be struggling with some patient care issues. Innovation uses a creative, unique, or inventive approach or adaptation One of the major creative challenges for the handoff workgroup was to teach the staff how to incorporate successfully the patient into the shift handoff. One member of the workgroup developed patient scenarios that the staff used in role-playing exercises to practice the bedside handoff. Staff also started to more creatively use the whiteboards that are in the patient rooms. In addition to writing the nurses name on the board, the nurses write information about the plan for the day and/or write reminder notes to the patient such as Put on call light if you need to get up. Nursing Leadership and Collaboration Nurses participated in development and implementation of this nursing initiative. We established a handoff workgroup consisting of the manager and a staff nurse from each med/surg unit and the ED, a nursing instructor, nurse researcher, and nurse administrator. We met twice a month for one hour over a 3-month period. We used the group meeting time to reach consensus on the handoff concepts and the handoff componentsRN assignments, charge nurse unit overview, patient preview using some type of spreadsheet, bedside handoff, clarification, charge nurse review of LPN, UAP assignment, LPN/UAP report back. Workgroup members worked with their staff on developing and trialing different components of the process. Successes and failures were shared during the workgroup meetings. After the three month trial-and-error implementation period the workgroup membership was expanded to include at least two additional staff nurses from each unit for the evaluation component and to finalize the standardized process. The expanded workgroup systematically reviewed each component and reached consensus on the components or aspects of the component would be included in the final standardized core process. Staff nurses systematically participated in development and implementation of initiative through a wider nursing governance structure or innovative delivery model. Our Nursing Practice Council meets twice monthly and reviews and approves changes in nursing practice. Two of the staff nurses on the task force were also members of the Nursing Practice Council and served as liaisons between the two groups and kept the Practice Council informed throughout the project. The Practice Council reviewed and approved the proposed changes and the final standardized process. Innovation successfully demonstrates collaboration, teamwork, cooperation and/or multidisciplinary impact and /or involvement. Collaboration and teamwork occurred at several levels throughout this project. First, the workgroup consisted of nurses from four different units who, despite differences in unit specialties and day-to-day operations, identified and committed to a common handoff structure. Members of the core taskforce were comfortable raising concerns, questioning approaches, and refocusing discussions Second, the staff on each unit, under the direction of their respective workgroup representative, engaged in a trial and error process to determine which handoff tools and processes were and were not helpful. We saw wonderful leadership and collaboration between unit staff nurses in initiating changes, in sharing of ideas from one unit to another, and in generating enthusiasm as these nurses saw a success on another unit and brought the how to back to their own unit. The third level of collaborative teamwork occurred when the handoff project was presented to the interdisciplinary Coordination of Care Committee, a committee attended by the chiefs of the various services (nutrition, rehab, social work, pharmacy, lab, etc) involved in patient care. During the presentation, the interdisciplinary group members discussed how family members are often not aware of the plans for the patient. As result of this discussion, we decided to include the plan for the day on the patients white board so that when family members arrived, they could quickly be updated on the plan for the patient A fourth level of team work occurs daily during the mid-shift update/huddle as the staff come together to update each other and the charge nurse on the state of the unit. Throughout the development and implementation of this initiative we relied heavily on unit staff to figure out what worked and what didnt and to innovate and evolve the concepts into a process that worked for them. This innovation and sharing between unit staff was essential to success. Nurses have disseminated findings via paper or presentation;published. The new handoff process includes the use of the PACE standardized checklists. PACE was developed by one of our taskforce members and published in Nursing 2006 (Schroeder, 2006) and LPN 2007. The nurse executive at St. Marys Hospital in Madison (a magnet facility) learned about our bedside handoff process from our nurse executive and requested to visit the VA, along with several staff, to observe our new handoff process on April 7, 2008. These visitors accompanied our staff nurses on handoffs and then met as a group with members of our handoff workgroup to discuss barriers, concepts, and implementation strategies. On May 14, 2008, Sarah Schroeder, handoff workgroup member, presented Using the Evidence to Facilitate Bedside handoffs to attendees at the VISN 12 Evidence Based Practice Workshop in Milwaukee. Finally, we submitted a summary of our new Patient Centered Shift Handoff to the Great Lakes News (VISN 12 newsletter). Scope of Initiative Initiative impacts one or more strategies in a single area; Initiative impacts one or more strategies in multiple areas; and Initiative impacts one or more strategies facility wide. This initiative included all three of the medical/surgical units and the Emergency Department(ED). The ED workgroup member was actively involved in the group and applied the concepts implemented in the med/surg area to the ED. This initiative addresses two of the VHA Power of Performance-4 Goals. We are putting the patient and patient care first by including the patient in the handoff. Although initially uncomfortable for some of the staff, this handoff process now demonstrates a best practice at our facility. Progressive Leadership is evident throughout our process as we diligently and systematically work with the staff to help them understand that this new way of performing the shift handoff improves the care we provide to our veterans. Many unit staff led by example and action, sometimes by just doing it, or by trying something new. Additionally we have impacted Quality and safety and enhanced RN accountability through standardizing the content and process of our handoff, providing face-to-face exchange of information and questions, providing opportunities for learning at the bedside, encouraging patient participation in care, and RN review of lines, drips, and precautions at the bedside. Novice nurses have the opportunity to ask questions and seek advice one-on-one with more experienced nurses. At the heart of this initiative is the involvement of the patient in the handoff process; patient/family satisfaction with and involvement in care is addressed through introduction of oncoming staff to patient, providing opportunity for patients to provide input, discussion with the patient about the plan of the day, etc. The most recent inpatient satisfaction scores (SHEP Q3&4-FY08) for overall quality are Medicine 87.3 and Surgery 97.6; these are significantly better than the national average. Nursing students completing clinical rotations on the med/surg units are gaining first hand experience in this patient centered handoff process that will influence their future practice. A senior student is working on a project to further standardize and improve the handoff process for LPNs and NAs. And finally, Clinical efficiency has been improved through a decrease in the length of the shift handoff process. Many RNs were pleasantly surprised that the new handoff process takes less time than our previous process. Impact Demonstrated measurable process improvement Pre- and post-implementation surveys (approved by the University of Wisconsin/VA Minimal Risk IRB) of unit RNs were conducted to evaluate staff perceptions of the change. Overall, 79% of respondents in a post-survey indicated that the new shift handoff process was somewhat or significantly better than the previous process. The percent of respondents indicating that the amount of time for shift handoff was about right increased from 50% to 79%. This is an important finding because pre-implementation there was much resistance from staff who anticipated that the new handoff process would take longer. Sixty-one percent of respondents indicated that since implementation of the new handoff, they forget less often to pass along important information to the next shift. Demonstrated measurable impact on nurse satisfaction Post implementation survey data demonstrates that 61% of respondents indicate that the new change of shift handoff process has made their overall job satisfaction somewhat or significantly better. Additionally, there has been positive anecdotal information that staff (including those clinical experts who were initially resistant to the change) would not go back to the old handoff process. The 2008 VANOD Satisfaction data reflects an overall satisfaction average score of 3.3, 3.5, and 3.6 for the three medical-surgical units. This innovation will serve to impact on staff perceptions of participation and quality of care. We feel we have accomplished our handoff goals of developing a handoff process that 1) involved the patient; 2) improved patient safety; 3) increased patient satisfaction; and 4) made nurses accountable for their professional practice. Involved patients. Patients are encouraged to ask questions and participate in care decisions. One patient recently stood by the door with a clip board in his hand at the change of shift and said, Isnt it time to change nurses? Patient safety. The RNs together look at IVs, tubes, safety and preventive measures, etc. to ensure accuracy and appropriateness. The oncoming RN has the opportunity for just-in-time learning about anything unfamiliar and completes initial rounds during the first 30 minutes of the shift. Patient satisfaction. While we do not have any patient satisfaction data since the initiation of the handoff process, we do think our patients like the new handoff process, especially being informed about the plan of the day. Professional accountability and practice: Since the oncoming RNs are assigned patients when they come to the floor, they can focus on gathering and clarifying the appropriate information for their particular patients. The on-coming RN gathers this preview information from a variety of sources in preparation/follow-up to the verbal handoff. The off-going RN gives report to a specific RN instead of to a general group. Both RNs gain a common understanding of patient status and condition that serves as feedback to the off-going RN and serves as a reminder about things not done or new problems to be addressed. The oncoming RN has a better opportunity to improve understanding of infusions, tubes, procedures, etc. through review with the off-going RN Conclusion: Professional practice is the heart and soul of nursing. The handoff project at Madison is living proof of the dynamic professional values and relationships that are integrated in all we do for patients and their families. Staff are continuously changing our care delivery model in order to support the rapidly changing environment. Their autonomy in making clinical practice and delivery of care decisions comes shining through in this innovation award application. References Anderson, CD. Mangino, RR. Nurse Shift Report, Who says you cant talk in Front of the Patient? Nurs Admin Quarterly April- June 2006: 112-122. Arora, V. Johnson, J. A Model for building a Standardized Hand-off Protocol Journal on Quality and Patient Safety November 2006 646-655. Australian Council for Safety and Quality in Health Care Clinical Handover and Patient Safety: Literature Review Report March 2005 1-31. Bomba, DT. Prakash, R. A description of handover processes in an Australian public hospital Australian Health Review February 2005 68-79. Bourne, C. Intershift report: A standard for handovers NT Research Vol 5 No 6, 2000: 451-459. Caruso, EM. The Evolution of Nurse -to- Nurse Bedside Report on a Medical-Surgical Cardiology Unit MedSurg Nursing February 2007: 17-22. Clemow, R. Care plans as the main focus of nursing handover: information exchange model The Author. Journal Compilation Blackwell Publishing Ltd 2006: 1463-1465. Currie, J. Improving the Efficiency of Patient Handover Emergency Nurse June 2002:24-27. Davies, S. Priestly, MJ. A reflective evaluation of patient handover practices Nursing Standard February 2006: 49-52. Greaves, C. Patients perceptions of bedside handover Nursing Standard December 1999 32-35 Groah, L Hand Offs-A link to improving patient safety AORN Journal January 2006 Horn, J et al Handover of responsibility for the anaesthetized patient- opinion and practice Anaesthesia July 2004 658-663. Kassean, HK. Jagoo, ZB. Managing change in the nursing handover from traditional to bedside handover-a case study from Mauritius BMC Nursing January 2005: 1-6. Malestic, SL. A quick guide to verbal reports RN February 2003 47-49. Pothier, D. et al Pilot study to show the loss of important data in nursing handoverBritish Journal of Nursing 2005 14 (20), 1090-1093. Riegel, B. A Method of Giving Intershift Report Based on a Conceptual Model Focus on Critical Care August 1985 12-18. Schroeder, S Picking up the Pace: A new template for shift report Nursing 2006 Vol 36(10) : 22-23 Schroeder, S Improving intershift handoff and patient safety! LPN 2007 Vol3(2) :22-23 Sexton, A. et al Nursing Handovers: do we really need them? Journal of Nursing Management 2004 (12) 37-42. Strange, F. Handover: an ethnographic study of ritual in nursing practice Intensive and Critical Care Nursing 1996 106-112. Timonen, L. Sihvonen, M. Patient participation in bedside reporting on surgical wards Journal of Critical Nursing September 2000 542-548. Wallum, R. Using care plans to replace the handover Nursing Standard May 1995 24-26. Webster, J. Practitioner-centered research: an evaluation of the implementation of the bedside hand-over Journal of Advanced Nursing 1999 30 (6), 1375-1382.      PAGE 1 of  NUMPAGES 8  K& / Z h { ~  ) * , ĻĻĻİn%h8hM55CJ\aJmHnHu)jNh8hM55CJU\aJ#jh8hM55CJU\aJhM5CJaJh8hM5CJaJhM5CJ\aJh8hM5CJ\aJh8hM56CJOJQJaJ#h8hM55B*CJ\aJphh8hM55CJ\aJ&:KT}kd$$Ifl0 &\ l t0644 laPyt$. $Ifgd$.$a$gdM5$a$gdM5$ *]^a$gdM5 ]qqq ' ( / [ x}kdj$$Ifl0 &\ l t0644 laPyt$. $Ifgd$.[ \ ] ||s $Ifgd$.gdM5}kd$$Ifl0 &\ l t0644 laPyt$. $Ifgd$.  !$Ifgd$.fkd>$$Ifl4&(0(64 laPf4yt$. i $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.i j { $Ifgd$.vkdn$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd$$Ifl0& 0(64 laPyt$. { $Ifgd$.gdM5vkd$$Ifl0& 0(64 laPyt$., - 7 8 9   D W Z [ \ ] ` a b c g j x y   ( < G Z h j x y ꝒhM5CJaJh8hM5CJaJh8hM56CJ]aJ+h8hM556CJ\]aJmHnHu/jh8hM556CJU\]aJ h8hM556CJ\]aJ)jh8hM556CJU\]aJ4  $Ifgd$.  !gdM5ckdt$$Ifl&(0(64 laPyt$.   E $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.E F W i $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.i j y $Ifgd$.vkd> $$Ifl0& 0(64 laPyt$. ww $Ifgd$.  !gdM5vkd $$Ifl0& 0(64 laPyt$. $Ifgd$.vkd~ $$Ifl0& 0(64 laPyt$. $Ifgd$.vkd $$Ifl0& 0(64 laPyt$.  $Ifgd$.vkd $$Ifl0& 0(64 laPyt$.    ) {{ $Ifgd$.gdM5vkd^ $$Ifl0& 0(64 laPyt$.) * < H $Ifgd$.vkd $$Ifl0& 0(64 laPyt$.H I Z i $Ifgd$.vkd $$Ifl0& 0(64 laPyt$.i j y $Ifgd$.vkd>$$Ifl0& 0(64 laPyt$. {{ $Ifgd$.gdM5vkd$$Ifl0& 0(64 laPyt$. "6CVfhvw  !5BUeguv   2DWeguv *hM5CJ\aJh8hM5CJaJhM5CJaJhhM5CJaJQ $Ifgd$.vkd~$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.  $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.#vm $Ifgd$.  !$Ifgd$.gdM5vkd^$$Ifl0& 0(64 laPyt$.#$6D $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.DEVg $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.ghw $Ifgd$.vkd>$$Ifl0& 0(64 laPyt$.vm $Ifgd$.  !$Ifgd$.gdM5vkd$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd~$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.  "vm $Ifgd$.  !$Ifgd$.gdM5vkd^$$Ifl0& 0(64 laPyt$."#5C $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.CDUf $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.fgv $Ifgd$.vkd>$$Ifl0& 0(64 laPyt$.vm $Ifgd$.  !$Ifgd$.gdM5vkd$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd~$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.  $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.   vm $Ifgd$.  !$Ifgd$.gdM5vkd^$$Ifl0& 0(64 laPyt$. 2E $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.EFWf $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.fgv $Ifgd$.vkd>$$Ifl0& 0(64 laPyt$.vm $Ifgd$.  !$Ifgd$.gdM5vkd$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd~$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd$$Ifl0& 0(64 laPyt$. $Ifgd$.vkd$$Ifl0& 0(64 laPyt$.vvvvvvvh`hgdM5gdM5gdM5vkd^ $$Ifl0& 0(64 laPyt$. 4_e>Mdi# E۰ۜۅyj^hqh!p5CJaJhqhf 5<CJaJhqhf 5CJaJhM55CJaJh8hM50J5CJaJ&j h8hM55CJUaJ jh8hM55CJUaJh8hM56CJaJh8hM55CJ\aJh8hM55CJaJh8hM5CJaJ *h8hM5CJ\aJ$vvCAB `01$gd9w & Fgd-gd-gd $h`ha$gdh`hgdM5  ./0 (\uõܪwlcwXllMhqheaCJaJhqhe=CJaJh-5CJaJhqhE CJaJhqhE 5CJaJhqh45CJaJh-CJaJhqh<1CJaJhF%CJaJhqh4CJaJhqh45>*CJaJhqh5>*CJaJhqhf CJaJhF%5CJaJhqhf 5>*CJaJhqhf 5CJaJuv()6>I[ *<   Q\]^`һҝҝҝҳ鑈ҝҝҝҝҨҀҝҝҝhF%CJaJhF%5CJaJhqhuq5CJaJhqhuqCJaJhqhe=CJaJhiKOCJaJhqheaCJaJhqh46CJaJhqh4CJaJhqhE 5CJaJhqh45CJaJhqhE CJaJ1 )uv  9:Ct"ACklopxyɾɲԾɾɲݲԾɟɟɟɟɟɟɈɟɟzhqh45>*CJaJhqh+u5CJaJhqhiCJaJhqh+uCJaJhF%CJaJhqhuq5CJaJhqhuqCJaJhqh4CJaJhF%5CJaJhqh45CJaJhqh>n5CJaJhqh>nCJaJ/./ABH O a d h k l q ѿ}}rj_jTjIrhqhlCJaJhqh\q-CJaJhqh)/1CJaJh)/1CJaJhqh>nCJaJhqh;CJaJhqhiCJaJhqh7CJaJhqh\q->*CJaJh5CJaJhqh5CJaJ hqhhqhJCJaJhqhf CJaJhF%CJaJhqhf 5>*CJaJhqh9w5>*CJaJ-!=$$'(() ,,,---.[..../ & Fgd-h`hgdJh^hgdm5+gd-h`hgdhNzh`hgd\,$a$gd:_h`hgd !!*!+!,!-!e!f!m!t!v!{!!!!!!!!!!!)"*"/"6"="R"T"["]"h"i"""" #q#r#t########+$/$Ĺ⹮⮹ϣĘčύϣςhqh<1CJaJhqhYCJaJhqh;CJaJhqh;CJaJhqh!CJaJhqh7CJaJhqhCJaJhF%CJaJhqh)/1CJaJh)/1CJaJhqhiCJaJhqhlCJaJ3/$5$6$<$=$D$I$P$Q$T$U$s$$$$$$$$$$$$$%`%%%& & &&9&?&B&&&&&&''''ԾԨԾԠɕߨwwwhqhCJaJh-CJaJhqh/CJaJhqh)CJaJhF%CJaJhqhcCJaJhqhiCJaJhqh;CJaJhqhBCJaJhqh!CJaJhqh>nCJaJhqhYCJaJhqh<1CJaJ+'f'k''''''''''',(-(@(G(X(Y((()1):);)E)F)H)))))))N*궫~ss~s~shs]shqhiCJaJhqhEemCJaJhqhhCJaJhqhJCJaJhqh\q->*CJaJhqhm5+CJaJhqh/CJaJhqh 8CJaJhqh)CJaJhF%CJaJhqh>nCJaJhqhCJaJhqh:CJaJhqhw6aCJaJhqh;CJaJ"N*W*t*u**********9+A++++++++++ ,,D,E,I,Q,R,S,V,,,,,,,--$-1-9-=-N-n---̫̫נננ׉~נ׉הhqh2$5CJaJhqhCJaJhqhEem5CJaJhqhLn2CJaJhqhKQCJaJhqh/fCJaJhqh\q-CJaJhqhEemCJaJhqhJCJaJhF%CJaJhqhhCJaJhqh!CJaJ0----------............. / ////&/'/L/M/N/p///////0 0!0"0#0*0M000000000 1`1}1ѻѤљƙƤѤѤѤљѤѤѤљёѯѻhF%CJaJhqhiCJaJhqhEemCJaJhqh`C5CJaJhqh`CCJaJhqh2$5CJaJhqhJCJaJhqhCJaJhqhEem5CJaJhqh/f5CJaJ9/N///!000)1_1120212o2688d8::::%;h`hgd\,$a$gdbgh`hgdh`hgd_<^gd/gd- & Fgd-}1111111110212>2o2{2222233"3g3k3q3~33333333334444445Ǽ}u}}}jjjhqh>CJaJh-CJaJhqhCJaJhqh#GWCJaJhF%CJaJhqhCJaJhqh>?'CJaJhqh fCJaJhqh#~CJaJhqh/f>*CJaJhqhi>*CJaJhqhm5+CJaJhqhJCJaJhqh`CCJaJ(5&5'5(55565;5D5Q5R5W5Z5a5j5o5p5u555555555555555556'6/616?6I6w6x66666666677׶ꕫ׊׫hqh\CJaJhqh fCJaJhqh:_CJaJhqh0CJaJhqhuCJaJhqhGKCJaJhqh#GWCJaJhqhCJaJhqh&CJaJhF%CJaJhqh>CJaJhqh }CJaJ2777+70717<7?7\7a7r7777778888d88888889999:::::";Ϲڮunbhqhbg>*CJaJ hqhm5+hqh&5CJaJhqhCJaJhqh+cCJaJhqh/f>*CJaJhqhm5+CJaJhqh>CJaJhqhuCJaJhqhCJaJhqh#GWCJaJhqh0CJaJh-CJaJhqh\CJaJhF%CJaJ$";#;$;%;(;3;G;H;R;V;Z;f;h;w;;;;;<<2=3=4=?=M=^=l=======!>$>%>*>>>>>>>>>d?׫̫̫wh)/1CJaJhqhCJaJhqh6<CJaJhqh ,DCJaJhqh`CJaJhqhTQCJaJhqh%PCJaJhqhBCJaJhqh&CJaJhqh/fCJaJhqh}XCJaJhF%CJaJhqhbgCJaJ-d?j?w?|????????+@g@t@@@@@@@@@@@AAAA A$AZA[AAAAѺ{{pehqhm5+CJaJhqh&CJaJhqh>CJaJhqh }CJaJhqh|bCJaJhqhbgCJaJhqhXCJaJhF%CJaJhqh`CJaJhqh6<>*CJaJhqhbg>*CJaJhqh)/1CJaJh}XCJaJh)/1CJaJhv;CJaJ"%;??+@AA@BCEHHII(JJL_MMMMMNOPQh`hgd$a$gdh`hgdh`hgd\,h`hgd}XA@BBBBB CCQCRCC)DDDDDDDDDDDE#E)E,EEEQEVEYEEEEEF2FFFGGGG!G%G.G迴࿩թթթթթՈ}}}rhqhCJaJhqh5&CJaJhqhPCJaJhqhuCJaJhqhbACJaJhqh}XCJaJhqh }CJaJhqhB!CJaJhqh/CJaJhqhZCJaJhF%CJaJhqh2CJaJhqh}X>*CJaJ,.G2G7G8GHGIGgGjGGGDH\HHHHIIIIII(JIJMJSJTJ\JtJvJJJJJJJJJ׶׶~~rfhqh>*CJaJhqh6<>*CJaJhqh6<CJaJhqhB!CJaJhqh\CJaJhqhkm4CJaJhqh}X>*CJaJhqhe=CJaJhqhm5+CJaJhqhuCJaJhF%CJaJhqhPCJaJhqhCJaJhqh5&CJaJ$JJJJJJ2K9K[KtKyKKKK LLLLLL\LvLwLLLLL]M^MhMuMvMMMMMMM(N*NeNjNտʷିլିଡՕtitihqh_5CJaJhqh_<>*CJaJhqhw5CJaJh R5CJaJhqh R5CJaJhqh }CJaJhqh5JCJaJh)/1CJaJhqhCJaJhqh5&CJaJhqhm5+CJaJhF%CJaJhqh6<CJaJhqhz1>*CJaJ)jNNNNNOOOOOO*CJaJhqh_5>*CJaJ&PPPPPPPPQ Q QQQQQ9QIQWQfQQQQQQQQQQQRR*R+R/RIRJRRRcRkR{RRRRRRR˸thqhY2CJaJhqhe'CJaJhqhW[CJaJhqhWb6CJaJhqh RCJaJhqhW[6CJaJhqhWbCJaJh)/1CJaJhqhCJaJhqhCJaJhqh6CJaJhqh8CJaJhF%CJaJ-R$S&S*S-S@SESIScSSSS+T.TITsT{TTTTTTTTUUUUUUUUVVV4V9VVVVVVVߵ굪׋ttttttthqhQCJaJhqh R6CJaJhqhQ6CJaJhAJCJaJhqhCJaJhqhe=CJaJhqh~0CJaJhqhe'6CJaJhqhfCJaJhF%CJaJhqhe'CJaJhqh RCJaJhqhWbCJaJ*QSWWWW X[[G[]^_`adhfsftf g 0^`0gdM5 $0`0a$gdM5h`hgdwh`hgdgzIh`hgdvgh`hgdh`hgd\,$a$gdoph`hgdVVVVWWWW@WMWWWhWiWWWWWWWWW X X,X-X.X:XaX˿˴םsg\QF\Q\hqh/CJaJhqh .CJaJhqhgCJaJhqh .>*CJaJhqhw5CJaJh R5CJaJhqhM85CJaJhv;5CJaJhqh R5CJaJhqh RCJaJhqhh2CJaJhqh R6CJaJhqhh26CJaJhqhe=CJaJhF%CJaJhqhQCJaJhqhoCJaJaXbXkXlX|XXXXXYY+Y,YMYNYOYYYYYYYYYYYYYYZ)Z,ZVZhZiZzZZZZZZZZZZZ[[[[̫̕׊׊׊׊׊ׂh RCJaJhqh 8CJaJhqhcCJaJhqh RCJaJhqhh2CJaJhqhoCJaJhqh?CJaJhqh/CJaJhqhmCJaJhF%CJaJhqhgCJaJhqh .CJaJ1[[F[G[g[s[z[{[[[\\ \ \\\ \(\)\2\D\T\c\~\\\\\\\\\]]^^^ҼҼұҩҞҞǞҞǀuju_ǩhqhvgCJaJhqh .CJaJhqh@ciCJaJhqhX CJaJhv;CJaJhqh*CJaJhqh@ci>*CJaJhqhwCJaJ$^^^^_________````a(a)aaaanbobbbbc+c,c;c*CJaJhZhM5>*CJaJhM5CJaJhZhM5CJaJhZhM55CJaJhwCJaJhAJCJaJhF%CJaJ> gagg"hhii?jjkokk@ll*mm/nnnYoofpp\q]q_q`qh`hgdw 0^`0gdM5`qbqcqeqfqhqiqqqqqqqh`hgdw$a$gdJ dqfqgqiqjqpqqqrqsqwqxqqqqqqqqqqq㼸h\,hM5CJaJhlh%hbEahJhJCJaJh,0JCJaJmHnHuhJhJ0JCJaJ!jhJhJ0JCJUaJjhe Uhe 6&P1h:p<1/ =!"#$%  Oh+'0 (4 T ` l xOffice of Nursing Servicesvhamadhartmm Normal.dot VHACOMITCHR2Microsoft Office Word@@dTt@8.6@8.6Y՜.+,D՜.+,d  hp   Department of Veterans Affairs5(i' Office of Nursing Services Title 8@ _PID_HLINKSAlAemailto:reji.john2@va.gov. _1279448196 Fp#C۰pK&C۰Data 1TableVnCompObjq      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~h$$IfP!vh5 5,#v #v,:Vl t65\ 5laPytpYh$$IfP!vh5 5,#v #v,:Vl t65\ 5laPytpYh$$IfP!vh5 5,#v #v,:Vl t65\ 5laPytpY$$IfP!vh5(#v(:V l40(65(4aPf4ytpY$$IfP!vh5 5#v #v:V l0(65 54aPytpY$$IfP!vh5 5#v #v:V l0(65 54aPytpYvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytpYFDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPytpY$$IfP!vh5 5#v #v:V l0(65 54aPytpY$$IfP!vh5 5#v #v:V l0(65 54aPytpYvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytpY$$IfP!vh5 5#v #v:V l0(65 54aPytpY$$IfP!vh5 5#v #v:V l0(65 54aPytpY$$IfP!vh5 5#v #v:V l0(65 54aPytpYvDText13$$IfP!vh5 5#v #v:V l0(65 54aPytpYtDText6$$IfP!vh5 5#v #v:V l0(65 54aPytpYtDText7$$IfP!vh5 5#v #v:V l0(65 54aPytpYvDText10vDText11vDText12vDText13$$IfP!vh5 5#v #v:V l0(65 54aPytpYtDText6$$IfP!vh5 5#v #v:V l0(65 54aPytpYtDText7$$IfP!vh5 5#v #v:V l0(65 54aPytpYvDText10vDText11vDText12vDText13$$IfP!vh5 5#v #v:V l0(65 54aPytpYDyK reji.john2@va.govyK Jmailto:reji.john2@va.govyX;H,]ą'c$$If!vh5t55555T#vt#v#v#v#v#vT:Vl t'5t55555Tyt$$If!vh5t55555T#vt#v#v#v#v#vT:Vl t'5t55555TytXDd#hd  S @A 350015_figure_1R>&s)>*0l|Ft>&s)>*0lJFIF AppleMark    % #!,!#'(***.1-)1%)*(  (((((((((((((((((((((((((((((((((((((((((((((((((((  }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyzw!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz" ?F((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((I,pdX80y~3xźϊך^zfb dz=y,s m|þ*/%Ѧm8Ś(ٟ@ q;z#pz}=&y@ <iT7;/ i?ZX GC %I$0X =zQXKEsJ(S׈ j 6 <6`QU<8PGX|j:\i\M*D# ΁8qNHp7((((((((((($(,I=j;xn$ ȡԌA;PcPbEE OB טh>%%TQq;u98%cY~.t (nZ6CdpTתk~^)5Q!]zF@mk嘾ưac'#Z/;[~Ws[i~ G7{|ʰ Ys`Gr?%U媳cd3`clgN:nJԹw_1U[[#Jsֺz>?+*c+dc\c#NzOHaEPEPEPEPEPEPEPEPEPEPEPEP(4}RU ccݰc89S𞉧-l- ?,X-'=y[4Ri0|#2٣ȖV/@32w2 F['{MwHls, FFbvҺ*9=O$nCs,Xɍ]lO>ҴֽvdXƁs´ֳÚ&}ktodbym}ʹEnM#SVI_jWRM-;1g9`q]yss|1i2Keg佭|m3e9j(ͽM ̯)^%ISܚ}#Q]Unۭy(`ZPº^~dt[R+cV . ojҗ<ַ֏f A#2A r?էkQE=iZ@]jn]9H6X P3sZtQ@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@sÿ?C a`O$p:]=s Xÿ ? !Pz8!+GX I"!DF=+cT?~*f AR&۞OnOs,*ZΌ+#ЌA >U0G_JTn8=+(((((((((((() 1OjƵLETKDwF fϢާ Ll?/z<( @`C2]rMQEwnk'.~Sb/?I:TQEly^mog^^mog@EPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEPEP\ĩ/~*iQNtɅRH]=sHuE:=҂&}I  dI~Uuu=#"}At|5%wVhJT~EPEPEPEPEPEPEPEPEPEPEPEPX*DzV2:d}+buvR$yqQ?Μ*:;DDFR5 ;cѤ?@񭪎巔nT(NJh59*o h $wO g1<&MX:u%ѵyszMys33h((((((((((((((((((((((>(xr?jlb*J-F)\Ɗ/pa0gW9u&IuK(OE{{XeLA8ȪxGUkH>3ꋧ_m2Qʝ1 ̹829EZΧxHKe{fn9Y^} \DC"K2Aulu8[ {㑢wU+) zR x#X5ڨ`(_ ~$K_oju V'e[pq{4_ŭu=F yn6%V+Ar3֬׃oGƓZP[:^Eq"vl`o|uzvo#hW3FfEIbJ:K_wTO3dtbkHPr2| s߈7MW. }S]Y]HfC{dtIkku#n庺;{xPQrI'C4w$Ȓ"GFYH ׏x6>3𿌴"}OOemHmomA =1,)tkIt 0۔Τ~ai_!7oxooqw31[xU`2Brx^MoLԕ<1id-+O]#s6_'Жk Z{Ħz,nເ'r08 EX%]2s ŹnUe8%8E?O #I4*)]!eA\D(@GQך" $9$o5o>" {] ?0 vxOoZigP&m7IqPpe}iZycu ݴ1LGueW hZ\漓P,FdzZxZ.oVk0Ruu6ǠS/~7}[(#a#@@s crѻ2 $x:;w-be:I8X#S@=r𮥪j'QO,ˆGccZڳQEQEQEQEQEQEQE/xº?gŚEF$q6cy#Ǟ3E|Dյ-v  H:M#,$G}=uuk|!Y6!MVRU.P>nzx^ YF 9ˏ=k'MOZM Ln mVC>ga:eaV#BϿ9?N&Ͽ9?N=&(c;O菣_]ZGUgrV8=; ݢVtfSv?08|0~Mw&jS% ܑeI <׽vQWUukKO1 ~xsUΓf[|}9[']ȧw<_Go~)IoM~4я=9oz7l4 h7iX aE;oOWp <9gIm{oKu]Bb蜍yKO z_sAX&.Euȥd ,xt"hwu ţ[6rF|RNX@<=iٯ+~' km|83:Vo46,279Xi~.>5^H6S|E1PTqҾ 6[%-A7j>7 QIiy5'(|_7Ih]2hFB,YqNV>t!f(.X>I8\+{^䏝sX-"onj77 '/"8;d 0|'f`/4V<ߣ\ZLh7;8\kרQI%߆7v߯$[|3𦑢V+"1eEvl8zjռmhi+ WX}f3dIZ(Q\?X|ϙK,^4_~6uksq)m"I Ds3}m/Ķ!ujDv ٺol'/9x5U=ĭ?ik:~z ͵1)L8=}=؋þ,uk:*>qHLvO{dO߽av)<||2ym=qT|gzƺL'e2oqhvg8|J(z;E.Ú< Zw/-՜@3+mܔQE!Q@Q@Q@Q@Q@Q@YG\EoqW 3^O>3×QcMO.bR:J3)92AQ޾pW]xc[ 5y6['[zWMž߃__Š(PQEQEW1*1'ÿ+hMS #Ct|JRTFc2@~`@X*XڷŎL*O'<1J|;iCjr pstQEQEQEQEQEQEQEQEQEQEQEQEfx[h.X{(*U.Jv,Ai4׍К.aL.U{kwu8?0,Xn6|?.o:"c/b l9#zrCڴV?\SXG}WO<}FAĸ~xXg|/Ș>KFGބu\گ673zӯI673zӫ9I(a{/yqS9擲6B"I^OdtW!_/gfP2_D'ǚ.N^<]+5xO6X<Av~ m<O;W2x?ºދ{=Zd(Z)FcЏή/Sy,Ŵ2HY! X <.O'꒻k%YG{Eyk_/xjZ5梃2[[䧣@NT1t?QMOZΟi펗JZv>]Á9cgmkl4rCu~OdUm bXe?wEx獾2h<-mMiqJdg1P:8j-lkywj:pn=B{ morC@=)ۯK]lz ?t[8겈luK@ӱ?/!GNxZ^+ GkzorNKg83=7Q\ |bB?:Y.x]nqW+ڽև6h"jpHR d׭;ka_K}QHaEPEPEP^ujqj?6w,#Y=3PU`+sІ'=k>,SG.i֍(cw039=0x)}τZŤ m{HԭhVHE` >n9#T;~vo'~?x흎}Z 5le$<0s_EW(Jl8Ns^Z;뷡(((J_ߊџ{H#x=׌k/:Ğ _ٮwydyM%@*JJ|;iCjr pst3ï -H(F)vy ( ( ( ( ( ( ( ( ( ( ( ?}Oe0?ڬ]73:Tr>EʉeU??mQEg11e=6 5 GasQK{]GK=tFx@Go:1$? O Z]޵'?ޥB=Q9~Uӻ b]'P kG?J Xnt?ڬY>_H>?kɚ]4kGgz?5}QumjZur~Z>:c(I)T45$DKr>w,1߆xL.Y{h72ݤp$sߚ*+*aQ5$wa1Hԥ'}Ǖx >B}b6Hv ӯ"}ہFL}?G] o\MHWSVƘVO"+C 41Ix_<[xD*6e,. l+K-ny|iq>%봗^Q^IKFߏq^!3Q'Gt}KW3ʾ(}/sV3_iz|SYnH9$yⷈ2AXt/7ODռ( I.:qӌ^G Pˍ=visS╃/4x–vt /fb ӣW'C$mq_s5o|9>_RhȬI#K~o|xGOi~ ~M%/BZhF$+]{J<>x7(#PޠQOoEE G@3ȇn_cJH57ķ^)>mn-.,nvEбCw-D;4՚U乎Ud2U]^$Q9i&#|{i?Yj0_Z5<F!r2U&7^z>i [[TČ ~UtP|Vxi|37Je.kq$.w#rWǩ t8RN6zuNּKw궲fPp{v}-$1K24|tܠ)GPx Ih[ۻo6K7?o?|?m9"w'I$cwxᦍG,--OH5YCw*_/d֡EgaokdZ_\!K&MfЇt&?}11cF RwA+/0i_vڦ&qewcX4_$qö54_xSS-˵rSc^׵s -+iei/#|P kmk;-ҥYʅL=(i/xV"tKAHFnP:}M18r]z1l{Hl~ViѦ(RW(F;zxw-/BVk[\@# ]0$8} pFу-U[\Ox@7^5V{hŔp0{C(]ɮ)~3$ds_+4Wni?6bm|x4Hz5|}p[QӤ).Wl r8;s>kwgM- 4V}lf|fM'M{S(`U {b8lQk kOJ袊B ( ( (%U媳cd3`clgN:8w_1WJu<=Һz>?+*c+dc\c#NzO@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@ hyX,qwck/m,V{rOEӵKc"|lLqEC/^;JS⥗4ZYAQsWUt'QEQEQE|J.>UfǺfǒ=8~uLSߊ{@0'8Oӌ(j\;𯘪k%pzq9]=s Xÿ ? !Pz8%H#w`~U,ra`8xjħuq>|:%H|;SHt{L,@ZC >U0G_JTn8=+cᬉ/ÿ nGRTdB ( ( ( ( ( ( ( ( ( ( ŶLMSOKTy D5HpRk€˥h0)ATKY$tiN~Ttes,]_ada}#n~ I'kR^!It5Vv!55 `TTU*JKgE@QEʺZye*R˩g 0z-qgiI$c?MH?5z٧-k>ķ}:J"0W׎x_>m?ݍg0k x]k(5ޭE2A ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ;}s/_a{ @@pA#-1^/^!M]4],mo: ctWHKcܹǥxfiLv>6M_x_qoa?h|կcQ$ v2wLs{xd-D E2+Q%xx`}IZ;yQR0((cTÿ4GPXd$OҺz<BWI@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@)C+=HVnZ– J8"xJ%P<dc:j{a~a\cMFQ(PWE\ӵ sY< ?18S]G訢((+/&~en?$ϡꃁiGt5ӆn̚}Ά[An_jH5}QuZm;OXtykZtOmOZnJD>tbkg0*`((((((((((((((((((((V;PIj7K=׌AUI `|݀}_6E^k?鶺x/lԈA;H/82~oRY5ۼNqfR^33xVTZĮEy.i'卼gzWBzQHaEPEP\_MG&GkkI!"& J@Uh4]N-Twc['j:9[?镾F]vܡ3hcQEPQEVG$7Al* k^st榷Nj].=WL!UwNθ>:<"m4/'ɋ!4u=GiׂVQ['O:_YM/$c?[ ئ' ?H涫:6:sk4QEYQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEs35O\0G[M<1^]k:/4;Tnᑽ}}+Ťo¯x%y_׿nK4'F_Y@$@88 ohY(//ºÕ./{pP(D`?Lp+4S37s @YabrhBrszO](0((cTbO~*V,b"#ێG~ߊ4{XȅvߡUTGoTOnx+cb?~U,A[b&'۞n(((((((((_[郓]X2IF*ڬ_gzmL,_Okw:pO*oEVV]N!6F?ª2O+DvG1ŚX#N6R>X뢬?KoYnPۅ=VIݷ袷+׵q[GOK;Q\ ( (9; :ͯD= \su<=tY^m>C$O1sG >:j>~rQ+鷖.p0]=r hxU^g"շ8P@1) $RQEQEQEQEQEQEQEQEQEV/ 'PU?qX_j&E >YZڃ"qiP"O~Irago.?qbi:b;6 $tUΟh9lR#K]]*{OWrEEW)AEPEPEP?edӚ;S:@+en2Gѧ;$U Q`{6L^qJǩuH?5k.V(Di캅}̉[Uyt@p-(1~['XmfɯHڢ*`((((((((((((((((((((zǾ.tcխe򤴙 `(lok|%PJ4s!<.پ׻2.ޝv?JWv+x=q֟K mxNθ>&=O&{ᗎ+2cc\c'^:WO\P߅|Vo{\\ y+dJ((((((((wX՝*bpچk|UǢY`95u߈gc0X-3 imE:<˞n.]Ye}TWKəNC++ 0ͅ}_[ǻtiRTy<}삹X]'It!0÷jn0%h[+Hl,d,QW;Z1Ԛ(R(((Rj?,eͯbnǵVw,Q/bi o(8C0h9sS[rzi}ܹ&_(?֬/sesnnJM^ e}=:~EUQ@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@5AW2L`i;A {םx7Zཻm)B%2k٫ìkg|\/mh5贶t˓ TVFdηþ7ZY leb&:J!$A%U媳cd3`clgN:Թw_1U[[#Jsֺz>?+*c+dc\c#NzO@Q@Q@Q@Q@Q@Q@Q@fjzXȖ(V}DOx:Σ<he[ZI8{fmF%SY՛YHZK#}FVgKj-棂VXc` z(I-*TGyzQLu_xE1٬ö@dvE\ӵMwX&~*aϡe@yUӯ'Vou#h:numbpGZU' n-/藶ܯ1;Vb_ڮ C蒧#:]5 _AEUEPEFk˘m^i/hi9;%=3΋z'+W.oyZ۱=j͎\МᭋT{Qu'mW歱-#IGڼO@'5u??i6hoxO ej>i?5^sO(Ec}k/#Q#IG:}Z}G͚i58.Yj?4ĆjwP]72~z1U'a\،RJ{9>G,ʼJ`)k\D;ں닺LqT~^to~VQE3(((((((((({|Go?uO vsQqy^|I ZdmF%ROuehqڽ~<[KK{e++4Ļ A}GzU>w5(wM,D$q0C{hφG/kmQYX&ayU6~-]]Bo)0\q޽⫡=B(0((/⦥uiâ^6v$ۃ yU~UnW1)|;QXCt0Gq'9O^g#H]TJpH# u|5b*Z6cڌ62@@<>]=QEQEQEQEQEQT=ZJ^r$"]LEAԐ9JBSUfH$!5,HU@IXy74s\_dnuIۢg?E}/NnpGomC K#@UTQZŠ(AT5Mt]ReXEN|=js(M4aȺeT[U)mZOcCúchX U&2'*(799wցETQEQEQEW|=Giפכ|=GiQh],̪=R'O,kz/]E5=9'QG?̱ºkS6nLv2Ό~)~ߓ#>+e8FݾJ~-GKn?8ak^m ?zk5-euߪ5MX>^}4&mPIZ=+VQ-Ŝ4d$pTwMJ=ȩEs=4QEQQEQEQEQEQEQEQEQEQEWx?[k_ fHTn\2N9ޫuOC5}:L-[,*++:cӷؼCZiC(7,W78c',ێ:ck+|?Szgw-iVF|:qR0O8'QEQEQE|JGL:=Xp;s]=s;S0bt*90{uȐ"tqv"h{S:nןtc[koEsm[“ ȡɩ5-T]}Q-:.{z=<UM;Ta2Ka"0*7]O*}uiiFP (!EPEPEPEPEPEPEP{BNd6mʨ IԮ|E?ǂ4F.>sͨ LF8LqWÛzZUŗDR²F׊I'Ti'3aLǥ%X6$xDҭtv=S,,YaG&><]gmaG~-r!ԚHv_OjH(C +̼A_T+|'/ot/ږ( 3 Ϩÿv>?bL4N۞A r(Zz^PҬ.ny:d_T\ZLەYUJysB\>%H|;SHt{L,@Zg|CcX^]kmo=G$RAbIwᬉ/ÿ nGRTdB sq¯ *" #,J8 ]EQEQEQT-^JD7Lc9?wJBS,Uvgd8Vt;drEfyWRj?G]fkOOAMdXVCk AoCcjGU6Gۢ}~Zy ;{}{3jD=Diӓܚբ¥Iw/ )Q@Q@$޹f{9V+ D>jjn_j~3eԣFtT0A'9c]sFnӦnY˫@ִ>gS S9Ym~EVQEQEQEQEQEQEp_~$Kڤr_ut-$(͸ck—׌WKZ3t Mur$}2"PQMbi|S/k;+OGw{ "+BV}Y7ʤ*s^MF! u;څQHgT{H[5x/Kͼ]#Ԗ=Gix'mWs^4uXDWVb~|m+~7zWZ1$g8*x5^,4ZmzT; cr ' Ik|%kxz_p9H ÁGJt_jzwşxkF;(#+>CО>O o?D=t|J%w⥑hL X> ? D%t|5"wUB T$~E4gcQ}fTRUFI' kCrx,nufk$ӡ$)X*`+aҖ*.{];D:޲LZ 'ѵ9Ԙr^ ߅=*i%힁}@Ҵ@ 8QTެw__MQEg8QEQEQE6Ic7WX@YԓP3X){{+u<puGG, \GaL?'qiIkn/.|aG`+FUϷ{f P+3-# 뿭tƑFƊ*EeRY=-wՍ+QX(((((+; ck; ck[^t[4bdɐ{Ў8:]7$r'C?UGoԙlt4QEsQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQEQE|J%w⥑hL X>1*1'ÿ+hMS #C cHUcEE:=&$I$t|5Gª:=|X¤{sq]=TQd |TRjN͖ k>VEf?jV0񠚏SsFj+ۻ}( ( ( +Y ]]Eo=Yc^ =njO _.$Ҵ'|E#Z)JM'w޾Ry_ռGmLQG-*!l>npCEI3VGetK +ogbw9,}ɫ{hҏvZ ( ( ( ( ( ( ( ( o>:o>:gcse8W14.=U5bi1!y-4ɮnV'<[5xc_PiNRJ? k|JJbEW8Š((((((((((((((((((((((((Q>XGoXGn9+/⦛uwC_YEvd 19x=>V^4wb?~U,A[b&'۞ngGª<‚H^w$䞢 (٬Ms巒&b_. g4һ4SW4{Yif1r޹>k<%sZ/NXw79W;:c"[} __p#W`iVM-]u^FqKgK7|?EfwmH_ׄ2]g+fxgA6:.hGx-Q+N/]$i~z%7yxw\E[yVRGI렢kMmM|Ϲ>1-["ғbn=R%?lߓWCEYE۫W + A{3tJ('_Yh"cŶQ\Q@Q@Q@Q@Q@Q@Q@Q@yszMyszMQ@^9&|eGԬ|C\?ћFa؛0(o{WC]5B~V~[QEsQEQEQUFdu#??7[nzdb{ -QEG=\M)( 7J+ o^14֔(QROLL=m[\?2ZX\Cב\˹Q\$z=YgKhW2hogUivIه!=Gէկ ?*eaysuyǙ#d~Z/aӤ輦v⟃>&[M4\jV:vm ֶ8%C+q윃 w`28Z~i-ɔiEr:OM6OxfceEa,=~P3YuLmh bp}5W RWKi] I2Q\Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@sÿ?G+!bG zO~ #HN[¤tNryÿ *W׎EPEPEPEPEPEPEPEPEPEPEPEPEPEPEP^mog^^mog@EP_ռ=:GɃ TYvΏ)'YA*}zSa=?!ih^m-@ *ï'KSo?H"GY? N_]jLXR"]{jkjkvϹ}4E7O|W$:uǔC$_'s+{z.pO+[s+JK\j,oRA ۿ7z3DX;|0Cn8"H (Q +QE ( 3j @j0'D!Vp:oW6:]1͏A4k jU񍝳k RqGe&?,t4Q2d[hOOh6$r$F*r\ m{ f;{B}}Okv[iC8O?{Qa?O/訬7F?!@ɳFq G{֬$HHꈀ3RMa:s.YK]QH+ AQEQEQEQEQEQEQEQEQEQEQEQE|J~eVǺeǒG8nEÿyjY ['ӎ|5>WefǵUǒO8O~tÿ WӞEPEPEPEPEPEPEPEPEPEPEPEPEPEPEP^mog^^mog@EPEPEPEPEPEPEPEPEPEPEPEPEP=KI>ϩYAy9 4aQs^]j^<4t {P]Ot٤Oxŏ*ΙP c W],lc6^W<Υ\:?_//t-[񍖱W=csgKms$ȁԩًyA8'߱.լt;G9h H*JU+]؈3CoXHР8Q#f@~kGW?ڵhQOկG!?kW@M^yZņF.nLMt~? Es-_*-2P0P3GǠ~n<W?ڵ'(Ϳ Es-_*B~'\jI<W?ڵ'(ɦĸu-Xc%ݥݮD||'-mV ky9d>GaO֭?[VUOկ^Ey!?kQO+mZU4P?[VUOկ^Ey6zujSkTa\!K6O't{>pM>$G>lUoB~'\jW?ڵh6'? Es-_*&oB~'\jW?ڵh&?/@е=b_ 4z}Mnb? Es-_*[Lִ*1`VpM[6'? Es-_*&oB~'\j'ᧅw{ og_#װĎ :?~M cѼ=ٖgѽdc{8 PO+mZT?[VUzMOկY/%Vr]GaXmJI&䄟ИZiMچ'q,+@!?kQO+mZU4P?[VUOկ^Ey!?kQO+mZU4P?[VUgsk8KKK{\0Py5R=2-VUPiC6D2`zg=('? Es-_*&oB~'\jW?ڵh6'? Es-_*&oB~'\j?.vG?wiqt7k<*A<&fI[˪j6[FsZ6|\Ÿp?OկG!?kW@mO+mZT?[VUzMOկG!?kW@mO+mZUx^gԟU*nf8AYo[%c\Ar6J4?[VUOկ^Ey!?kV-;X~"llr/p7qQ@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@u-6XOmB*\Z|=W~գմ-'t/4J">z(hŠ((j~e%{d@8'IC⇄,O\\-LsV#i7eqrmƕ7^I@rN2q|wkOĭ*k"QœJzyv~K{'}t߫ ) ()HHꑠ,@I*;m>k㷶 +TP2I'j:>$4YM5tD1Nqw^fO/_ 7yY>cHxhdY"C#ʰ<+*jZGxWFY,ǚknԎk~C<9 7 $83 9R;t%tQE!Q@W<<fF}<3vݛsy⏌^~^$$<pNyxk:/4-B+Fm pT8 uiZ'xZ}f[" t.nćLDdWUv:w>{qo3,-Z"J `۷Z|`x.?[<5Wٛ{RV}onIv᭡<xTs3*Jb(Ĝ㞅8#6^"ӡS r T+zוxc\oƛh^d6}\$ ^ xN{v]fa#·?cgcW>fw2yŃ IsӓkZ2]ūxoĺ8/+6Ǹyt]3WW5XIGQ</4wۣq{ GY*!#%t5i{/+zznj>2h> @ou?%& +q!6x_ I8.jte4XiWS@1'8)hmFv/ ǰeh eHcj`783*_Io7V<ˋ]h3󊱦|Yޭ-Sֿk1i u >^G]/^<펍X|3ZYfM[WS';FӠ+\b%ԟN :oYBv1>7oˡVcѴϏ~ag[閶ru9BȪUJݒ۝T u4/:$V x{z%"kjV;w-~`ǃ2;9m=m_Gm"% HBlό烞k/y7V !6ڝ[rK͹뎵\q}WS]sX<iό;5-V,>Х `w׻' rm)Cm=FGJ|k㏌>X4 FVD%D8bU8o& h|!σ&. ֯K̪]Gy8Ȯ?;kP_|g_17{cO5&U.1(;HY 2o~kx|? -_6 HֵYa\YVs)Nx?0|q[ >[!I-.c|G.kxF>,ZϦq-[ܫwAz>i[?𘧉u'&gd!cP}莿5;i^ n5fg*P:CFKo CG`#x:x¶A]3WQ5XXuݞ24 1]}6^VJHi*F9 Wjri=o4/ kۍ?VL 4Sq08dV?Gzv ŎUSXۜ-g`{fP ֮`h~qgg,*uQ n켿v7j eچf Ʊge&Rz㞣#cykd,kY[χ/mR SI w$8'\zUiU_>yUnYJ>K',Ωx Jkh/ck)6pEf? W6NI5"UyzAԎ*ǭ.=oZK<&v H8#_Dž&ukPDۅ_EDSv]H^,it?|O$jZVֱA*@ |_ѼA/_ڴAkZ 8r}\gyWƉG׺-")KE VTQ FQ/K:m&֣cd\.N:)yROEU+7u:N:~Iٴ:+v*͸r0s߃\P&:߄N [x"wݒ PFrHT--CPW?=ϻ[:?8،1xI?Kiztvҝ& &2s<=c~k/iyk?vQ6dMF*lqs דBW8t}WTˉXzt'g'KRXãx|7zO#֥911zVNJ0h^÷~}Rh--Dq>lI2x+W}R-lἴfOY[k82y Rx|7/hZ+:|OsuX[f`XjPU?ŀOqȮDj:~k u2$YXy'|lɓT"ڍWR|eYTÀpGZj=]ߓ%$ 4arT*FnK ė[׏Ho2G8pxhp& ?:Ei ?5I5zϯ 55߲o&f7Ӻ<+&K׵-*=qXon͏#u^' V̗1jO2]b98 u Wxb_4{ C G1!4S(f Z6_hgxy?=tk/W,~ek5NNz8*?=+^62OE}ѐprG渍ڔ~;t>-|YhKnhQ[n2pOc]_khh|LߵǞ8_-BW~Ge>燭h^l<J$ Kd3n,%&-նŴ-ƣeF$Sz^$IvX(1n6IJKjw7G9eXc?DF ?+Ш'FO x-AK)3V .dCqqjon<9 /͐Dc =5Q@q#E[F]"ڳlrKV-NI3bA#5>- r6}HWQ@6-5ס+hmpev&9 qu};<+BRs{f:$L2g85NEn!⿅~ ^,wh|x`ݎ;U<7u-(4+q;YwkCF]K8[}Q ``)ݜZ㴿JJé̋͸TVv38wwPnY6kR,GUka~RJE |9i7%c00`+N|7{_F'۽帙NF/: *( o i[62 8:>9E Dg\yDs|f8]K_YmfðɶY99%V rz|Oi^t[Agc3!,ŏ,IOzӢ{:dž4}~LqO7|8pr+Z(#ľIWR|c5QB`Style1CJaJ00 >Style2CJaJ00 >Style3CJaJLO!L >Style Verdana 8.5 pt CJOJQJ:O2: >Times New Roman(B( lFStyle4(1R( lFStyle56U@a6 n\ Hyperlink >*B*phj@sj "' Table Grid7:V0*W* [PStrong5\.X. [PEmphasis6]B^@B [P Normal (Web)dd[$\$XOX $Times New Roman CharCJ_HaJmH sH tH HH w Balloon TextCJOJQJ^JaJ4@4 pYHeader  !4 @4 pYFooter  !VeSTXe00dQ@0q 00dQ@0q  00;L"3IJQTUVBCD    ();cduSTUZno 3 4 5 6 7 8 9 : m n @qrr "$$$') -.1/1C1a458:===>#?a????@@B DZDjDDDDDDDDDEEE E EF:GGIJlLmLLLLMNPPQQJRSTTUUVVWWWWXXXYY+[,[0\1\\]^__#````aabcfdHeIeJeKeLeMeNeOePeQeReSeTeUeXe0@0@0@0@0@0@0 @0 @0 @0 @0@0@0@0@0 @0 @0 @0 @0 @0@0@0@0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0@0@0@0@00000000000000000000000000000000000000000000000000000000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000000000000000000 0 00000000000000000000000000000000000000;LIJQTUVBCD ();cduSTUZno 3 @qrr$$$') -/1C1a458==@ DDDEEE E EJlLLLLMNPQQJRSTUUVVWWWXX+[,[0\1\\]^__#``aabcfdHeIeJeLeOeQeTeXe@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 @0@0 @0 @0@0 @0 @0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0J00KtݑJ00 J00 J00J00yJ00yJ00@J00J00uJ0 0 J0 0 J00J00J00@0J00J00 @0 @0 @0J00 @004 J0!0"`(J0!0 J0!0 0%0*  @0 J00J0e02J0j0J0n0J0n0J0j0 J0j0 J0p0J00J0t0J0u0J0w0J0w0J0y0J0*0w+ J0*0vJ0*0uJ00J0B0P0J0m0 J0m0 J0}0J0}0J00J00J00J00짽J00J00 $J00 J00 J0j0 J00 ̨J0p0J00 J00 J00 J000J000J0j0 J0m0ndJ0j0 @0@0 @00jx  ?"#&,14j9C=@AwD=HN2QDZ_h*l7@BLORTVWXYZ\]^_`abcdeghlmoqxyI T NH~("vMRST hi8:;<=>?ACDEFGHIJKMNPQSU[fijknpw9/;@DP~  !-2@LQZfl   mLLLMMMqOOP QTQQ7aaab+ccVeFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtXCXXXXXR 0e0e     @  8c8c     ?1 d0u0@Ty2 NP'p<'pA)BCD|E||s " 0e@        @ABC DEFGHIJK5%LMNOPQRSTUWYZ[ \]^_ `abN 5%  N 5%  N    5%    !"?N@ABC DEFGHIJK5%LMNOPQRSTUWYZ[ \]^_ `ab@0(  B S  ?Text13Text14Text15SEC10EQeXeAQeXe*β <ϲ $в dѲ Ҳ TӲ Բ ղ ֲ Tײ ز ٲ ڲ T۲ ܲ ݲ ޲ ,߲ l   , l   , l   , l    D    D    D""33@C# A A D/M/f/f/u@u@RRVVVWWW___6d6d@dee"eXe      "!#$%&(')22>BHH- L L L/T/m/m/@@RRVVVWWW___>dGdGd!e)e)eXe   "!#$%&(') :%*urn:schemas-microsoft-com:office:smarttagsStreet9"*urn:schemas-microsoft-com:office:smarttagsState>!*urn:schemas-microsoft-com:office:smarttags PostalCode>*urn:schemas-microsoft-com:office:smarttags PersonName;&*urn:schemas-microsoft-com:office:smarttagsaddress=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName8**urn:schemas-microsoft-com:office:smarttagsCity9)*urn:schemas-microsoft-com:office:smarttagsplace n *)*)&%*)"!*)"))*)*)*)**)*))))  H M JS22==LLMM"M+MNNNNPP=PFPwPPQQQQQQ6S:SCSISOSYSbShS.T5T;TBTKTPTUUUUVVWWWWXXYYYYZZZ"Z5Z=ZsZ}Z0[6[I[Q[l[r[O\V\\\a\$]']]]^ ^^^^^k^^^^_A_M_aaaa,b:bjdrd{ddddXe}CFe&j&$2'2@@G/HHH?MoMNNNOOPOQOPePPPPPQR#RRSSwSySSSSSTTTTTVV WWmYYYY[\\\8^^__#`(`N`X````aaabb^bbcc1d>dddXe333333333333333333333333333333333333333333: AA$F$FHHVLVLlLlLmLmLLLXeXeD@R=DJ|(K.v0B:t ^`OJQJo( ^`OJQJo( pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo( ^`OJQJo( ^`OJQJo( PP^P`OJQJo(^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(h 88^8`OJQJo(.h ^`hH.h  L ^ `LhH.h   ^ `hH.h xx^x`hH.h HLH^H`LhH.h ^`hH.h ^`hH.h L^`LhH.D@DJ|(0B:mY^m8y^y\f@,l}n 6         f l T= }jHH0 l <1#qNO$qNi0(0 ( B B B B@@)FA|*}j t;4~5=_<<"H@@)( B B B BbK Ni0(qN=_<?ST= KT0U<] KTY]o`%d"H2]e}jY]o` dd;TkqNkp?S  qqNdJuHHddF6T:0X_[8G53#- H5$Fyy?JKjHm_>En\VmKor1T M!/! "O$ c&s)(+<+8X+F-Y.Z{.qW053#h3v+6 G:gh:l:h;SN;f?h?L#CJC$XCiFI}yJwM!N[PguPS+TTUSIXqXpY ZA[^\g)a;.aPd#Jd2e0(f#hYi 1mojoq@swsxxyx9[yl~zl{z{}~==[$1)qO0#$*yF*9{3>fzOUvL &%*M?Y B f|?ez(vf-lNv1%1jlF9Y@ M!k!_S2RpvzXG l"'^=F\''uVtYyArWHI)!Ef;&^v,}V@CQK1t/|N6>IXX}~IV+b,\3(,fG8Kg8#0x0w$oC3=J' nW=@W}cKi&,&GIJQTUBCD    ();cduSTUZnoZDjDDDDDDDDDEEE E EWWWXe@I>?@:G:H:IJK[Ve`@` `@```$@`J`L`@`V`X`@`\`@`@Unknown Gz Times New Roman5Symbol3& z Arial7&  VerdanaG  MS Mincho-3 fgkTimesNewRomanPSMTTimes New Roman5& zaTahoma;Wingdings?5 z Courier New"qhCFCF1F7V37V3!24#e#e2qHP)?>2Specialty Case Management Incorporating Telehealth Monitoring, Medication Titration, and Outpatient IV Lasix to Reduce Hospitalizations and Cost in High-Risk Heart Failure Patients vhamindefuser VHACOMITCHR   ObjInfoWordDocument.SummaryInformation( DocumentSummaryInformation8@  FMicrosoft Office Word Document MSWordDocWord.Document.89q@  FMicrosoft Office Word Document MSWordDocWord.Document.89q@  FMicrosoft Office Word Document     l !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIKLMNOPQRSTUVWXYZ[\]^_`abcdefghijkopqrstuvwxyz{|}~%` bjbj .̟̟Ve::::;hT<>>>>G:G$Gfffffff$TjhlfPGGPPf>>gUUUP>>fUPfUUVi]@ ^>< 4:dS] dg0h]T~nfUd~n ^ ^~n`xHRUJUKTQMEHHHffU HHHhPPPPd &d &  Office of Nursing Services 2008 Annual Innovations Awards Application Form Professional Practice Environment for Nursing Excellence Title of SubmissionMinneapolis Heart Failure Telehealth ClinicFacility Name and AddressHeart Failure Telehealth Clinic Cardiology 111C Minneapolis VAMC 1 Veterans Drive Minneapolis, MN 55417VISN #23 Names of Team Members (Note: At least two (2) team members are required.) Primary Author InformationNameConnie Jaenicke, FNP, BC Title of PositionCHF Case ManagerTelephone Number612 - 467 - 4914 Extension:  FORMTEXT       FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NameJudy Wagner, ANP, GNP, BCTitle of PositionCHF Case ManagerTelephone Number612 - 467 - 5998 Extension:  FORMTEXT      NameAnne Steckler, RN, BSNTitle of PositionStaff Nurse (previous CHF Case Manager)Telephone Number612 - 467 - 3014 Extension:  FORMTEXT      Name FORMTEXT      Title of Position FORMTEXT      Telephone Number FORMTEXT     -  FORMTEXT     -  FORMTEXT      Extension:  FORMTEXT      Name FORMTEXT      Title of Position FORMTEXT      Telephone Number FORMTEXT     -  FORMTEXT     -  FORMTEXT      Extension:  FORMTEXT      Submissions shall be in narrative format, in Times New Roman font, no less than 11 point, and NOT exceed five pages in length, including attachments. Submissions cannot contain embedded documents. Submissions which are noncompliant with these criteria will not be considered. Narrative shall include (a) title, (b) summary of initiative, (c) date of implementation, and (d) clearly identify each rating category being addressed followed by applicable narrative. The attached template serves as a face sheet for the narrative. All best practices shall be submitted electronically by the Nurse Executive with endorsements by the Facility Director/designee notifications of the VISN Director/designee. An electronic copy of the attached endorsement memo or equivalent electronic message addressed to Cathy Rick, RN, CNAA, FACHE, Chief Nursing Officer, Office of Nursing Services (108), is to be sent WITH the submission to Reji John (VHACO), Office of Nursing Services VACO (108), at  HYPERLINK "mailto:reji.john2@va.gov" reji.john2@va.gov (please note duplicate name in outlook). Deadline for submissions with endorsements is by COB May 31, 2008. Office of Nursing Services Annual Innovations Awards (Submission Form Format) Title: Specialty Case Management Incorporating Telehealth Monitoring, Medication Titration, and Outpatient IV Lasix to Reduce Hospitalizations and Cost in High-Risk Heart Failure Patients at a VA Medical Center Summary of Initiative Date of Implementation: Identify each rating category being addressed followed by applicable narrative: Title: Minneapolis Heart Failure Telehealth Clinic Summary of Initiative: Escalating costs, transportation barriers, and need for close monitoring of patients have required innovative approaches in Heart Failure (HF) management. The Minneapolis HF Telehealth Clinic (MHFTC) is a nurse-managed clinic which incorporates a combination of case management, telehealth monitoring, optimization of HF medication, and intravenous (IV) medications using an outpatient observation (OBS) unit, with the goal of reducing hospitalizations and cost in high-risk HF patients. The clinic also titrates medications on medium-risk patients to see if titration can safely be done over the phone and reduce the number of patients needing Implantable Cardiac Defibrillators (ICDs) or Cardiac Resynchronization Therapy (CRT). Methods: The MHFTC has managed >400 patients using daily telehealth or telephone monitoring. Four separate analyses are reported: (1) The initial cost-savings analyses of 201 telehealth and telephone patients, (2) The first 101 patients (60 with reduced left ventricular (LV) function and 41 with preserved LV function) were monitored daily on telehealth equipment and completed >1 year of follow-up, (3) 93 patients with ejection fraction (EF) <35% who qualified for device placement and underwent assertive medication titration, and (4) patients in the clinic who were at risk for impending admission and were followed by telehealth staff <24 hours on the OBS unit while receiving IV therapy. Results: Initial cost savings of 201 telehealth and telephone patients demonstrated a cost savings of $3,299,575. A recent evaluation of 101 high-risk daily telehealth patients demonstrated a $602,333 savings including inpatient, outpatient, salary, and equipment costs. Out of 93 patients eligible for ICD/CRT device placement before medication titration, 48 patients were no longer eligible due to improvement in EF with an estimated cost savings of $1,152,000-1,560,000. Twenty-nine patients with impending decompensation were followed on the outpatient OBS unit by MHFTC staff on 57 occasions. The clinic was able to save 48 (84.2%) inpatient admissions at an estimated cost savings of $384,000. Dissemination of clinic strategies and outcomes has been conducted at the local, VISN, and national level. Conclusion: The MHFTC reduces cost through reduction in HF and all-cause hospitalizations (including length of stay), reduction in ICD or CRT device placement, and early intervention with outpatient IV diuretic therapy in patients with impending decompensating HF. Date of Implementation: January, 2006. Adoption of Innovation The MHFTC was initiated in 2004 in response to high-risk HF patients requiring intensive monitoring to prevent re-admissions. In 2006, staff began the telephone titration program, as well as strategies for improving medication titration (ACEI/ARB/ isosorbide/ hydralazine, beta-blocker, spironolactone, diuretics) in primary care. Information published in professional literature was used to design and continually modify this innovation. The prevalence and incidence of heart failure and subsequent morbidity, mortality, and cost has continued to climb (1, 2, 3, 4). The life-time risk of developing HF at age 40 is now estimated to be 20% (7). Approximately 2/3 of veterans seen at the VA Medical Centers die within 5 years of an initial HF hospitalization (8). Almost 1/5 of patients with a HF hospitalization in the VA system are readmitted within 2 weeks (9). Outpatient care is essential to reduce re-hospitalization risk, decrease healthcare costs, and improve patients' quality of life. Currently, most HF patients after discharge are followed by the primary care provider at infrequent intervals, and evidence-based medicine such as ACEI and beta-blockers are seldom titrated to target doses (10,11). Indriason (2002) performed a review with the VHA databases and found decreased mortality with either cardiologist care or mixed care (cardiologist + primary care provider) versus primary care alone (12). Several meta-analyses of mostly randomized controlled trials have further supported this notion with reductions in mortality (13), hospitalizations (14, 15, 16, 17, 18, 19, 20), and improved quality of life (18) in patients followed by disease management programs. These outcomes may partially be attributable to medication management which has long shown improved mortality with the use of ACE inhibitors/angiotensin-receptor blockers, beta-blockers, and aldosterone antagonists (21). Telehealth monitoring is another strategy which incorporates case management and technology to monitor and educate patients (22). Data regarding telehealth programs has been generally positive, but inconclusive. A meta-analysis of 14 randomized controlled trials concluded that telehealth monitoring should not replace specialist care (13). There are no reported studies that have combined telehealth monitoring originating out of a disease management program, remote medication titration, assertive risk factor reduction, ancillary management of co-morbidities that impact HF, and IV intervention in patients with decompensating HF, anemia, or electrolyte imbalance, such as the MHFTC. The MHTC was designed with the following algorithm to fit needs of the organization: (1) Prevention of re-hospitalization in patients with acute decompensated HF. (2) Titration of HF medications to evidence-based target doses. (3) Development of protocols, templates, etc. (4) Integration of evidence-based HF management on low-medium risk patients in primary care. (5) Training of NPs/RNs throughout the VISN. Future plans include incorporation of outpatient ultrafiltration and integrated palliative care program. The MHFTC has been using creative techniques and inventive approaches by (1) Being readily available by phone to reduce the number of patient clinic visits, (2) reducing travel time for patients by arranging blood draws locally and coordinating clinic appointments, and (3) collaborating with patients other care providers and case managers to improve continuity and avoid duplication of care. This streamlined approach not only reduces overall costs for the VA and the patient, but also improves patient satisfaction. Nursing Leadership and Collaboration The MHFTC nurses independently developed and implemented the MHFTC with only physician consultation since the initial initiative proposal, and have also provided extensive consultation and committee/group participation as a result of successful program development across other disciplines, specialty services, and the VISN. The nurses have created protocols, guidelines, templates, order sets, consult options, and a triage algorithm which are being used by the clinic, residents, primary care and OBS unit nurses, emergency dept (ED) staff, and other clinics. Nurses systematically participated in development and implementation of this initiative through a wider nursing governance structure or innovative delivery model via monthly and bi monthly participation in Care Coordination Home Telehealth conference calls and VISN 23 Chronic Disease conference calls. Other specific examples include training sessions for MVAMC Primary Care RNs and VISN Case Managers, and program presentations to VISN Nurse Leaders, home care staff, and Utilization Review RNs on "Ultrafiltration". Dissemination of specific program components were done regularly on the VISN shared drive for the VISN 23 Chronic Disease Management program. The MHFTC successfully demonstrates collaboration, teamwork, cooperation, and/or multidisciplinary impact and/or involvement via involvement on initial expert panels for the chronic disease program, expert panel for advanced care planning, numerous presentations, regular facilitators of meetings with Primary Care Providers and RNs, and through regular collaboration with the ED Staff, residents, and other sub-specialties. Initiation of the CHF Group Class for patients has involved ongoing multidisciplinary involvement from pharmacy, dieticians and physical therapy departments, as classes incorporate education on self-management strategies, medications, diet modifications, and exercise. Other specific examples include membership in the Veterans Affairs Quality Enhancement Research Initiative in CHF (CHF QUERI) and the Minnesota Heart Failure Consortium. The MHFTC staff have continually disseminated findings and presented on 17 separate occasions to hospital staff and 3 separate occasions to patients, not including regular CHF group classes. Aside from those presentations otherwise mentioned above, the staff presented "Telemonitoring: Can it Improve the Quality of Life for Your Patients?" at the Minnesota Heart Failure Consortium Fall Meeting in 2007 in collaboration with other community APNs. "Long-Distance Titration of Heart Failure Medications by Telephone Calls" was presented at the March, 2008 meeting of the American College of Cardiology in Chicago. "Specialty Case Management Incorporating Telehealth Monitoring, Medication Titration, and Outpatient IV Lasix to Reduce Hospitalizations and Cost in High-Risk Heart Failure Patients at a VA Medical Center" and "Intensive Titration of Heart Failure Medications Reduces the Need for Device Therapy" abstracts have been submitted for the Heart Failure Society of America Scientific meeting in September, 2008. Two manuscripts are also in progress. Scope of Initiative This initiative has impacted multiple strategies in a single area. (1) The ability of an APN/RN-led clinic to titrate medications remotely in HF patients has been successfully demonstrated. (2) Uptitration of HF medications was associated with approximately 45% reduction in the need for ICD/CRT device placement. (3) Prevention of hospitalization and improved health outcomes via specialty clinic APNs/RN case managing HF patients, who are utilizing a combination of telehealth monitoring, optimization of HF medication, and IV medications on an outpatient OBS unit is a unique combination. (4) Dissemination of a strategy for improved medication titration in the primary care has also been employed. These strategies have enabled APN/RN staff to work to their full scope of specialty practice. This MHFTC has or will potentially impact strategies in multiple areas: (1) Remote medication management could be considered for hyperlipidemia or hypertension in non-HF patients. (2) The MHFTC has become a local leader in the use of ultrafiltration for HF patients resistant to IV diuresis. The clinic is in the process of further promoting the early use of ultrafiltration to confirm reduced length of stay, readmissions, and renal impairment, even before aggressive IV diuresis (23, 24). (3) Through participation on the VISN 23 Chronic Disease Advanced Care Planning Expert Panel, the MHFTC has begun to incorporate a process to assist in facilitating transitions to palliative care and to establish earlier advanced care planning in all areas of chronic disease; and (4) intervening on co-morbidities (anemia, COPD, depression, CAD, dyslipidemia, hypertension, diabetes, sleep apnea) that have the potential to impact not only HF, but the veterans general health as well. This initiative impacted multiple strategies facility and VISN wide. Locally, clinic staff: (1) created approved order sets for outpatient IV lasix utilized by clinic and ED staff, and for ultrafiltration administration in the inpatient setting; (2) developed a protocol for medication titration by RNs in the primary care clinics; (3) presented HF guidelines at facility medical staff meetings; (4) created multiple templates for a streamlined clinic documentation process; as well as for ensuring that all inpatients are on the standard of care for HF and a referral to a HF clinic has been made prior to discharge. VISN-wide, the MHFTC clinic staff has served on the planning committee of the Chronic Disease Collaborative (CDC) and served as consultants for the initiation of health factors to assist in tracking outcomes. As stated previously, numerous presentations have been made to multidisciplinary audiences at VISN 23 Learning Sessions in 2006 and 2007, and participated in expert panels. There were 2 video sessions in 2007 to help train VISN Case Managers and Minneapolis Primary Care Nurses on HF management. Protocols, guidelines, practical techniques and strategies were shared via frequent telephone conference calls monthly within VISN 23. A VISN 23 telemedicine consult was developed to address a need for advice on the management of complex HF patients and clinic staff provided mentorship for APRNs and RNs within the VISN. Impact MHFTC staff has demonstrated significant measurable process improvements facility-wide by the development of a strategy for nurses to maximally utilize their advanced-practice education to improve patient care with the following algorithm: % Preventing re-hospitalization of patients with acute decompensating HF % Titration of HF medications to evidence-based target doses % Development of protocols and templates % Integration of HF management into primary care % Training of other RNs % Change in the process of device placement: An EP NP now screens all consults prior to referral for ICD/CRT and sends medical recommendations back to the site (Minneapolis is a tertiary center) for medication titration if patients are not on the standard of care for heart failure. The MHFTC has demonstrated measurable impact on nurse satisfaction via RN participant satisfaction evaluations administered independently by Education Support Staff after primary care and case management training sessions. When asked if faculty used up-to-date information, if they gained new skills/knowledge, and if the program was worthwhile, 100% of program participants answered "strongly agree" or "agree." The MHFTC demonstrated measurable long-term integration into structures and processes through successful implementation of program into primary care and the VISN, sustainable reduction in hospitalizations and cost as the program has continued, high patient satisfaction with group class (See Table 1), and continued invitations to and acceptance of presentations and posters. Table 1 Compilation of Patient Questionnaires Administered after Group Classes Class componentOrganization, slides, durationCHF NP presentationPT presentationDietician PresentationPharmacist PresentationRating (1-lowest; 5-highest)4.854.854.8The MHFTC has demonstrated measurable impact on nursing-sensitive quality indicators as evidenced by VISN RN evaluations administered independently by Education Support Staff after the primary care and case management training sessions. Of the 6 objectives analyzed, approximately 90% RNs felt that the program mostly or completely enabled them better care for CHF patients. The remaining 10% of participants felt that the program helped moderately or somewhat in 5/6 objectives analyzed. The MHFTC has demonstrated measurable impact on patient outcomes: % 201 telehealth and telephone patients from July, 2005 and September, 2006 demonstrated a cost savings of $3,299,575. % Hospitalization reduction in 101 high-risk daily telehealth patients from June, 2006 through November 2007 (see Figure 1). Length of stay was also reduced. Cost savings were calculated independently by the Decision Support System staff and demonstrated a $602,333 savings, including inpatient, outpatient, salary and all telehealth equipment costs. % 48/93 patients eligible for an ICD/CRT device before titration are no longer eligible for device implantation due to improvement in EF. Cost per device is $24-$39,000, therefore, cost saving are estimated at $1,152,000-1,560,000. This data also confirmed that it is feasible to conduct telephone titration of HF medications in patients who demonstrated compliance with medication and were capable of daily home vital sign monitoring. % From March 2006 thru March 2008, 29 patients with impending decompensation were followed on the outpatient observation unit by MHFTC staff on 57 occasions (43 for HF exacerbation, 6 for dehydration, 1 for anemia, 2 for HF exacerbation and anemia, and 4 for electrolyte replacement) The clinic was able to save 48 (84.2%) of inpatient admissions at an estimated cost savings of $384,000 based on 5-day length of stay.  INCLUDEPICTURE "http://www.call4abstracts.com/hfsa/data/images/350015_figure_1.jpg" \* MERGEFORMATINET  References 1. Rosamond, W., Flegal, K., Friday, G., Furie, K., Go, A., Greenlund, K. et al. (2007). Heart Disease and Stroke Statistics-2007 Update. Retrieved October, 30, 2007 from  HYPERLINK "http://www" http://www.Doj: 10.1161/CIRCULATIONAHA.106.179918. 2. Massie B. M., Shah, N.B. (1997). Evolving trends in the epidemiologic factors of heart failure: Rationale for preventive strategies and comprehensive disease management. Americal Heart Journal; 133(6):703-712. 3. Bundkirchen, A. & Robert, H. G. (2004). Epidemiology and economic burden of chronic heart failure. European Heart Journal Supplements, 6(Supplement D). Retrieved October 30, 2007 from  HYPERLINK "http://eurheartjsupp.oxfordjournals.org/cgi/content/full/6/suppl_D/D57" http://eurheartjsupp.oxfordjournals.org/cgi/content/full/6/suppl_D/D57. 4. Krumholz, H. M., Parent, E. M., Tu, N., Vaccarino, V., Wang, Y., et al. (1997). Readmission after hospitalizastion for congestive heart failure among medicare beneficiaries. Archives of Internal Medicine, 157(1). Retrieved October 30, 2007 from  HYPERLINK "http://archinte.ama-assn.org/cgi/content/abstract/157/1/99" http://archinte.ama-assn.org/cgi/content/abstract/157/1/99. 5. Cowie, M. R., Mosterd, A., Wood, D. A., Deckers, J. W., Poole-Wilson, P.A., Sutton, G. C., et al. (1997). The epidemiology of heart failure. European Heart Journal, 18, 208-225. 6. McMurray, J. J., Petrie, M. C., Murdoch, D. R., & Davie, A.P. (1998). Clinical epidemiology of heart failure: public and private health burden. European Heart Journal, 19(Supplement P), P9-P16. 7. Lloyd-Jones, D. M., Larson, M. G., Leip, E. P., Beiser, A., D'Agostino, R. B., Kannel, W. B. (2002). Lifetime risk for developing congestive heart failure. Circulation; 106. Retrieved October 30, 2007 from http://circ.ahajournals.org/cgi/content/full/106/24/3068. 8. Ashton, C. M., Bozkurt, B., Colucci, W. B., Kiefe, C. I., Mann, D. L., Massie, B. M., et al. (2000). Veterans Affairs quality enhancement research initiative in chronic heart failure. Medical Care, 38(6), I26-I37. 9. Wray, N. P., Peterson, N. J., Souchek, J., Ashton, C. M., Hollingsworth, J. C. (1997). Application of an analytic model to early readmission rates within the Department of Veterans Affairs. Medical Care, 35(8), 768-781. 10. Fowler, M. B. , Lottes, S. R., Nelson, J. J., Lukas, M. A., Gilbert, E. M. , Greenberg, B., et al. Beta-blocker dosing in community-based treatment of heart failure. Am Heart J. 2007 Jun;153(6):1029-36. 11. Butler, J., Arbogast, P. G., Daugherty, J., Jain, M. K., Ray, W. A., & Griffin, M. R. (2004). Outpatient utilization of angiotensin-converting enzyme inhibitors among heart failure patients after hospital discharge. Journal of the American College of Cardiology, 43, 2036-2043. 12. Indriason, O. S., Coffman, C. J., & Oddone, E. (2002). Is specialty care associated with improved survival of patients with congestive heart failure? American Heart Journal, 145(2), 300-309. 13. Clark, R. A., Inglis, S, C., McAlister, F. A., Cleland, J. G., & Stewart, S. (2007). Telemonitoring or structured telephone support programmes for patients with chronic heart failure: Systematic review and meta-analysis. British Medical Journal, 334. Retrieved October 30, 2007 from http//:www. dol.10.1136/bmj.39156.5369.55 (published 10 April 2007). 14. Gonseth, J., Guallar-Castillon, P., Banegas, J. R., Rodriguez-Artalejo, F. (2004). The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: A systematic review and meta-analysis of published reports. European Heart Journal, 25(18), 1570-95. 15. Gwadry, -Sridhar, F. H., Flintoft, V., Lee, D. S., Lee, H., Guyatt, G. H. (2004). A systematic review and meta-analysis of studies comparing readmission  !LH Q S $ * 0 6 < D ^ ` t v x 窤p^p#jhNhpYCJUaJjhNhpYCJUaJhpYCJaJhNhpYCJaJhpYCJ\aJhkBhpYCJ hpY0JhNhpYCJ\aJhy;hpY6CJOJQJaJhpY5B*CJ\aJph#h{hpY5B*CJ\aJphhNhpY5CJ\aJhpY0J5>*CJ ;L $IfgdpY $IfgdpY$a$gdpY$a$gdpY$ *]^a$gdpYgdU  " 3 I xxxxxx $IfgdpY}kd$$Ifl0 ,"\ l t0644 laPytpYI J Q T xx $IfgdpY}kdj$$Ifl0 ,"\ l t0644 laPytpYT U V ||tk $IfgdpY$a$gdpYgdpY}kd$$Ifl0 ,"\ l t0644 laPytpY $IfgdpYfkd>$$Ifl4&(0(64 laPf4ytpY $IfgdpYvkd$$Ifl0& 0(64 laPytpY  $ $IfgdpYvkdn$$Ifl0& 0(64 laPytpYx r t x z ~  ǵjYAj+j+hNhpY56CJ\]aJmHnHu/jjhNhpY56CJU\]aJ hNhpY56CJ\]aJ)jhNhpY56CJU\]aJ%hNhpY5CJ\aJmHnHu)j$hNhpY5CJU\aJhNhpY5CJ\aJ#jhNhpY5CJU\aJhNhpYCJaJjhNhpYCJUaJ;jhNhpYCJOJPJQJU^JaJmHnHo(u { $IfgdpYgdpYvkd$$Ifl0& 0(64 laPytpY   Lt"$8:<DFVXlnpz|РР|Р#j hNhpYCJUaJ#j hNhpYCJUaJ;jhNhpYCJOJPJQJU^JaJmHnHo(u#j hNhpYCJUaJjhNhpYCJUaJhpYCJaJhNhpYCJaJhNhpY6CJ]aJ/ $IfgdpY  !gdpYckdJ$$Ifl&(0(64 laPytpY $IfgdpYvkd$$Ifl0& 0(64 laPytpY  $IfgdpYvkdt$$Ifl0& 0(64 laPytpY  $IfgdpYvkd $$Ifl0& 0(64 laPytpY N{{ $IfgdpYgdpYvkd* $$Ifl0& 0(64 laPytpYNPt $IfgdpYvkd $$Ifl0& 0(64 laPytpYH $IfgdpYvkdj $$Ifl0& 0(64 laPytpYHJLV~{{ $IfgdpYgdpYvkd $$Ifl0& 0(64 laPytpY~ $IfgdpYvkd $$Ifl0& 0(64 laPytpY .028:@BVXZbd~޵޵޵޵޵޵޵޵m޵޵#jhNhpYCJUaJ#j4hNhpYCJUaJ#jhNhpYCJUaJ#jHhNhpYCJUaJhNhpYCJaJ;jhNhpYCJOJPJQJU^JaJmHnHo(ujhNhpYCJUaJ#j4hNhpYCJUaJ# $IfgdpYvkd$$Ifl0& 0(64 laPytpYvm $IfgdpY  !$IfgdpYgdpYvkd $$Ifl0& 0(64 laPytpY$&LNbdflntv޵޵޵޵޵޵޵޵m޵޵#jhNhpYCJUaJ#j^hNhpYCJUaJ#jhNhpYCJUaJ#jhNhpYCJUaJhNhpYCJaJ;jhNhpYCJOJPJQJU^JaJmHnHo(ujhNhpYCJUaJ#jhNhpYCJUaJ#( $IfgdpYvkd4$$Ifl0& 0(64 laPytpY(*L $IfgdpYvkdH$$Ifl0& 0(64 laPytpY/Z`9H_d޵yneWejhpY5CJUaJhpY5CJaJh'hpYCJaJhNhpY6CJaJhNhpY5CJ\aJhpYCJaJhNhpY5CJaJ *hNhpYCJ\aJhNhpYCJaJ;jhNhpYCJOJPJQJU^JaJmHnHo(ujhNhpYCJUaJ#jJhNhpYCJUaJ wwwww$a$gdpYgdpYgdpYvkd$$Ifl0& 0(64 laPytpY >@tu029?ɾɞɋ|ui|u|eZLh8#hlF0J5>*CJhpY0J5>*CJhpYhpYCJOJQJaJ hpY5>*hN{hpY5>* hpY5hN{hpY5h0hpYCJaJhfphpY5CJaJhNhpY5CJaJhpYCJaJh'hpYCJaJhpY5CJaJhAhpY0J5aJjhpY5CJUaJ&j`hAhpY5CJUaJ23456789lm?!p"q""gdBgdUgdpY$a$gdpY?@klm/CGHKefkx}lo|ʾغسس؏؏؈z؈vrk h8#h8KhBh$ h8#hqX h8#h2e h8#hY h8#h@ h8#hJCh8#hF-6 h8#hF- h8#h h8#h(h6>h8#hf-0J5CJh8#hlF0J5>*CJ h8#hlFh8#hxx0JCJh8#hq0JCJh8#hlF0JCJ**+]`ghimopr2349D|Rqty~ h8#h2e h8#hF- h8#hqX h8#hV+h6> h8#hf? h8#hZ{.h$ h8#hFhB h8#h53 h8#h h8#h( h8#hlFh8#hlF5\h8#hm5\ h8#hL#C h8#h8K h8#h@1   !V_ ? E H W l m w ?!K!O!U!]!w!!!!!!!!!!""Ķ~ h8#h h8#h' h8#h_S h8#h9[y h8#hJK h8#hlF h8#hF h8#hF-h8#hlF5\h@ h8#h,h,hBhh&% h8#h<+h8#h<+5 h8#hZ{.h6>h$ h8#h2e."+"5"F"G"H"`"a"h"n"o"p"q""""""""=#>#x#y#z######˵˪|qf^f^f^ZSLSZS hT hT h8#hT hT hT 0JCJh8#ho0JCJh8#h,0JCJh8#hg)a0JCJh8#hI0JCJh8#h,0J5CJh8#h|0J5CJh8#h{0JCJh8#h?0JCJh8#h=0JCJh8#hlF0JCJh8#hlF0J5>*CJ h8#hF- h8#h h8#hJK h8#hr###### $ $+$,$2$7$B$D$R$`$$$$$$$$$ %%%%/%8%9%?%%%%%%%%&&ȽӧȠ}voovhh h8#h\ h8#hu h8#h h8#hI h8#hX h8#h* h8#h h8#hJK h8#h&^h8#hQK0JCJh8#h&^0JCJh8#hI0JCJh8#hzO0JCJh8#h|0JCJh8#hM!B*phhBB*phh8#ho0JCJhT ("#q&),.00035 9-=.=B=`@4DFIIIKDLLMvM`gd/!gdWH`gdFygdU`gdM!&=&p&q&&>'F'H'I'v'y''(((((((-)0);)>))))))**x*{*******.+N+y+,=,R,,,,üøøøøüüøñ򸣱{h8#hz0JCJhs) h8#hY h8#hE h8#hoh$ h8#hV h8#h? h8#h)hg h8#hr h8#h1t h8#hQKh8#h8#6hYi h8#h8# h8#h+T h8#h\ h8#h&^ h8#h.,,,,,,,,--......6/>/M/i/q/r//////080900000001궫ꫠ꠆{od{h8#hg)a0JCJh8#h|0J5CJh8#hv+60JCJh8#h|0JB*CJphh8#h=J0JCJh8#h_S0JCJh8#hj0JCJh8#h0JCJhYi0JCJh8#h|0JCJh8#h8#0JCJh8#h' 0JCJh8#hz0JCJh8#hzO0JCJ$111!1'1+1`1h1m111#2$2G2S2i2z222222233Z3_33333334.4M4a4w4|44444444ɾɾԠԫtԠԠth8#h0JCJh8#h|0JCJh8#hv10JCJh8#hh;0JCJh8#h&G0JCJhs)0JCJh8#h0JCJh8#h^\0JCJh8#hg)a0JCJh8#h=J0JCJh8#hv+60JCJh8#h0JCJh8#hI0JCJ-45*535F55555556$6(6L6M66666!7#7A7777^8 9999*9?9C9N9S9j9ɾԨԾ߾tti^ih8#hq0JCJh8#hv10JCJh8#h Z0JCJhO00JCJh8#hh;0JCJh8#h&^0JCJh8#h10JCJh8#h|0JCJh8#h0JCJh8#hI0JCJh8#hg)a0JCJh8#h"'0JCJh8#h&G0JCJh8#h0JCJh8#h0JCJ$j9s999::+:J:M::;';(;4;?;S;b;l;n;p;:<=<<<<<<<<<<,=-=.=B=C=߼߼ߩߢ~sg\h8#h|0JCJh8#h|0J5CJh8#hg)a0JCJ h8#h|hO0h$ h8#h"' h8#hk! h8#hKo h8#hqh8#hKo0JCJh$0JCJh8#hXG0JCJh8#hH\h8#h"'\h8#hKo\h8#hq0JCJh8#h"'0JCJh8#hv10JCJ#C=I=S=h===========>c>j>>>>>>>> ?r?u?z???@_@`@a@b@g@l@@@ɾɾԨԠߨߨɾߨ߳߆{p{hh=0JCJh8#hh?0JCJh8#h)q0JCJh8#hy0J5CJ h8#hv h8#hSN;hnW0JCJh8#hSN;0JCJh8#h&G0JCJh8#hv0JCJh8#hy0JCJh8#hXG0JCJh8#hC0JCJh8#h|0JCJh8#h*0JCJ&@@@@@@@@@@ AAAA.A/A0A6A=AlAuAAAAAAAAAAA̫̐zoz̐dYddh8#hG0JCJh8#h9Y0JCJh8#htY0JCJh8#hFy0JCJh8#h60JCJh8#h"'0JCJhe0JCJh=0JCJh8#hv0JCJh8#hC0JCJh8#hh?0JCJh8#hy0JCJhyF0JCJh8#h|0JCJh8#h)q0JCJh8#h l0JCJAAAAAB$B%B+B6BCBDBJBKBLBMBOBQBfBiBnBBBB"CAC`CeCfChCuC3D4D:D@DLDMD`DjDsDwD⣮̅☍zozozogohO00JCJh8#h|0JCJh8#hI0JCJhT 0JCJh8#h$XC0JCJh8#hFy0JCJh8#hh?0JCJh8#h#Jd0JCJh;.a0JCJh8#hy0JCJh8#h"'0JCJh8#h9Y0JCJhe0JCJh8#hG0JCJh8#h- 0JCJ(wDyDDDDDDDEOWOOOOOOOOOOPP/P1PPPPPPQ%Q2QĹĹzrzgz\h8#h,0JCJh8#hPd0JCJh@s0JCJh8#h#0JCJh8#hS0JCJh8#hAr0JCJh_[0JCJh8#h'0JCJh8#h}0JCJh8#hf;0JCJh8#h|0JCJh/!0JCJh8#h#Jd0JCJh$0JCJh8#h,0JCJh8#hN0JCJ$2QQQQ R RRXRYRRR SaSbSTTTT6UZVVVV0WWWXXZY^YjYYYYYYZZ1Z2ZDZͻ{wssohhh h8#hl:h#hhl~z h8#hc h8#h#hhl:hl:0JCJh8#h(+0JCJh8#h^=0JCJh8#h00J5CJh8#h00JCJ h8#ho h8#h"'h8#h"'0JCJh8#hS0JCJh8#h,0JCJh8#h#0JCJ(RRRRRS7.... $IfgdUkdC$$IflֈX &tT t0'44 laytSS S ST.%`gdM!kd$$IflֈX &tT t0'44 layt $IfgdUT9UVY[^^___``HbIbccdGeSf-g hgd gd0(fgd0(f @ ^@ `gd gd,gdl:gd`gdM!DZZZZZZ\\]J]]]{^^^^^^^ ______ _v_________ָvfYh8#h0(f0JB*phjh8#h0(f>*Uh8#h0(f0J>*CJ jh8#h0(f0J>*CJUh8#h0(f0J6CJh8#h0(f0JCJ h8#h0(f h8#h h8#h,0J5CJjh8#hSU h8#h,jh8#h,Uh530JCJh,h@hl: h8#hl:h"_````SaxaaaaaaaaEbFbHbAcBccccccc[dvdde.eeeSfgggg h hhhhhhhhپٰٜ쎜نن{s{s{hgh:OJQJh >hgh:OJQJhgh:0JCJjCh8#h0(fUjh8#h0(fUh8#h0(f0Jjh8#h0(fUjh8#h0(f0JCJUh8#h0(f0J6CJh8#h0(f0JCJh8#h0(f6 h8#h0(fh8#h0(f0J>*CJ- h hhhiii$& #$/-Ifgd#h & 0` P@1$7$8$H$gd#h & 0` P@1$7$8$H$gdgh:" & 0` P@d1$7$8$H$gdgh:hh'h(h*h,h-h.h6h7h9h;h*CJh8#h0(f0J6CJh8#h0(f0JCJh#h0JCJh8#h0(f6 h8#h0(fhgh:CJaJ h#hhgh: h#h6h#hh#h6h#hh#hOJQJh >hgh:OJQJhgh:OJQJ6iijjk)l*lbmcmgh6 Zgd}~gd0(fgd0(fSkd$$IfKL2 6 -6-34 44Kaytgh:*l,l9mSmambmcmemn:]hj,68  1CnoԮ}h8#h3(0Jj*h8#h3(Ujh8#h3(Uh8#h3(6 h8#h h8#h3(h8#h}~0JCJh8#h0(f0J>*CJh8#h0(f6 h8#h0(fh#hUh8#h0(f0J6CJh8#h0(f0JCJh#h0JCJ/rates and mortality rates in patients with heart failure. Archives of Internal Medicine, 64, 2315-20. 16. Louis, A. A., Turner, T., Gretton, M., Baksh, A., & Cleland, J. G. (2003). A systematic review of telemonitoring for the management of heart failure. The European Journal of Heart Failure, 5, 583-590. 17. McAlister, F. A., Lawson, F. M., Teo, K. K., & Armstrong, P. W. (2001). A systematic review of randomized trials of disease management programs in heart failure. The American Journal of Medicin, 110, 378-384. 18. Phillips, C. O., Wright, S. M., Kern, D. E., Singa, R. M., Shepperd, S., & Rubin, H. R. (2004). Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure. Journal of the American Medical Association, 291(11), 1358-1367. 19. Whellan, D. J., Hasselblad, V., Peterson, E., O'Connor, M., & Schulman, K. A. (2005). Metaanalysis and review of heart failure disease management randomized controlled clinical trials. American Heart Journal, 149, 722-9. 20. Center for Health Care Strategies. (2007). ROI evidence base: Studies on congestive heart failure. Retrieved January, 23, 2008 from http://www.chcs.org/usr_doc/ROI_Evidence_Base.pdf 21. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. (2005). Circulation, 112, e154-e235. Retrieved October 30, 2007 from  HYPERLINK "http://circ.ahajournals.org/cgi/content/full/112/12/e154" http://circ.ahajournals.org/cgi/content/full/112/12/e154. 22. Bondmass, M., Bolger, N., Castro, G., & Avitall, B. (1999). The effect of physiologic home monitoring and telemanagement on chronic heart failure outcomes. The Internet Journal of Asthma, Allergy, and Immunology, 3(2). Retrieved May, 16, 2007 from  HYPERLINK "http://www.ispub.com/ostia/index.php?xmlPrinter=true&xmlFilePath=journals/ijanp/vol3n2/chf.xtml./" http://www.ispub.com/ostia/index.php?xmlPrinter=true&xmlFilePath=journals/ijanp/vol3n2/chf.xtml./ 23. UNLOAD Trial Investigators. (2007). Ultrafiltration Versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure. Journal of the American College of Cardiology, 49, 675-683,. 24. Costanzo, M. R., Saltzberg, M., O'Sullivan, J., Sobotka, P. (2005). Early Ultrafiltration in Patients With Decompensated Heart Failure and Diuretic Resistance. Journal of the American College of Cardiology, 46, 2047-205. OgdXgdUgdx0gd$gdTgd NOabc]At}˴˥˗˃xj`T`M`T`T` h#h0J5h8#h$0J56h8#h$0J5h8#h$0J5CJaJh#h0J5CJaJh8#h$0JCJh8#hiF0Jjh8#hiFUjh8#hiF0JCJUh8#hiF0J6CJh8#h 0JCJh8#hiF0JCJh8#h0(f0JCJh#h0JCJh8#hiF0J>*CJh8#h3(0JCJh8#hlFOJQJh8#h>5OJQJh8#h}0J5CJh8#h[P0JCJh8#h c&0J>*CJh8#hX0JCJh8#hI0JCJ h8#hiFh8#hRp0JCJh8#hx00JCJ ,1h/ =!"#$% Oh+'0@`l      (08Specialty Case Management Incorporating Telehealth Monitoring, Medication Titration, and Outpatient IV Lasix to Reduce Hospitalizations and Cost in High-Risk Heart Failure Patientsvhamindefuser Normal.dot VHACOMITCHR2Microsoft Office Word@@i[m@Η4@Η47V՜.+,D՜.+, hp  VISN233#e' Specialty Case Management Incorporating Telehealth Monitoring, Medication Titration, and Outpatient IV Lasix to Reduce Hospitalizations and Cost in High-Risk Heart Failure Patients Title` P8T _PID_HLINKS_NewReviewCycle_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnceA$NEbhttp://www.ispub.com/ostia/index.php?xmlPrinter=true&xmlFilePath=journals/ijanp/vol3n2/chf.xtml./e KB9http://circ.ahajournals.org/cgi/content/full/112/12/e154e fy?;http://archinte.ama-assn.org/cgi/content/abstract/157/1/99e 4<Ghttp://eurheartjsupp.oxfordjournals.org/cgi/content/full/6/suppl_D/D57e ~+9 http://www/e Ae3mailto:reji.john2@va.gove 5 Innovation Award ApplicationTina.Lund@va.govLund, Christine A_1279448211 , FpK&C۰pK&C۰Data Y1Table JBCompObj qh$$IfP!vh5 51#v #v1:Vl t65\ 5laPyt%ph$$IfP!vh5 51#v #v1:Vl t65\ 5laPyt%ph$$IfP!vh5 51#v #v1:Vl t65\ 5laPyt%p$$IfP!vh5(#v(:V l40(65(4aPf4yt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pFDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V lC0(65 54aPyto""$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pDyK reji.john2@va.govyK Jmailto:reji.john2@va.govyX;H,]ą'cDyK yK Lhttp://vaww1.va.gov/IPEC/yX;H,]ą'c'KDd6#>  C AbJXI-+qJniJXI-+PNG  IHDRYwsRGB pHYsjIIDATx^Oy'h/v#E&,I.>Ƈԑ !)PS P]+2RZWv 5PԂ8,!6B.Q CF/=fvggfgfgwW~,Oy1cL!y9gl3 瑪C fL{SV*z*l#-mSq{,q fkh`N~[Fۖy/*̡h$@v1]R4TԙjSYE$Y>ے2b` ]%*ݒ:=-°NX,xgdfPr L$@% Nxg5NbH HE0IcaP @AY`+Wx8u?c$%0WójKG#% ؕz)`0^aʣh?~V/QHF1*  (6?*U K[=vQ7Oi:3] mapvsg @ve4ܛchgXAiVGq<</B_Rp/8&HQ &4x94ǩY{z-셯iӧI/bC>vjFm#if~rɑ҃1 !XӇȄdi&@"i{D᙮CrDj!J!1xDZ?V`ryI0"`9BL3XH KgLmaXթqAccms-յQє0 Me ХYw!yotKH x8L"}mƕqX)rudئP#˔H@ g,و=bh SKwvN`tH cB + d5Kk )8YfIHF@pDIH-̊D&'˕A$0re`2 J֜\$@$@!v1k/?'¨8#=HcMy"*#_k"D-LVLz^Hݸ]IkbGF13 ma߼Mݰ^>xzTkӵUݗ8' h Sai`f'PϠ`۳=6 i 3>z+V0AmVarh8}P Ӏ*Rc E!$$|P=l8$ˊEB[X SC˥#%6G|H"@[7?I1ʊ}xJVeS##È0Af-v݃vNO"՜R]6a$0WzQ,AT_v'RWJ֡׶tXH@$$@[XgP* tKgmd;998Fg>U'H83ff9P %#HH@|3 QV PFmarHH`dh GaHH 9H! 0i GIH`h gTHH!,$@$@s'@[X4gfO g#O TFhDgӊ#%¢ӊfb$@$GЏC LCg MWMMh/{ٛ;OHOe~pPIvx7X+\?_űc6Gm`%~a"UFӪ̖ i/_^a_l$&y.֯fɔ/϶o7nwM`>J~A{SccYH{m Zyɝ;wBw}w͏=X}:Hs/^:ذ!AG?a_X狿+y͖@~aݼysXi, ܻwbqft쳋իuk_[<@_Q;vrO@pQ@Qp$$Ov\W^?}4^OGۇ9FD{ƺ>`6U@N4}Nx[+u^{e{<>m2fXE> o>S$W\ME={O4^vşɊMU&p˖ţ'G b@biiڝnwyGݻw͚537+@Ԩ0 =Q~ƤߏjP>ͱ\[ORcP[+6&0 &Ct"pj,E`v>$@m~'8H'sd`V֏u ܽ{e,3N ǓFwN~n`s.lC5b׋G\Co]EjD|dQ-۴6!Q{}:i̵f0=^@1͈ eΝ;r7Cͭ.'?>L̏?+?to~8CϙQ#}>/VBǏK`L:LoyaHl?p֭[_eܬ 靯ӓák0-v5ŦB8$[hJ*Fq38S|_R=ES"GAPJU:饗P0YFn+nVklm0{)1/I z& lGO).u50/ (2+]+*rYp_uuX8^ހYX_!&`~) *D|@=rsMm˝gvaϬ/Şo/~i^`41ak!A79<9F /:*D$Ћb+N6C.#z,XIC ="@[E &V ﭷV92ba0&yBol!j!VbvOrz+paJ8* ='ʸj! kc'FUr^f lRl0ZP o0.KP_qf 4gƛ;.]Z[j?_2򍱕/..0) r^M^k0i0J8m3[ XA?d,>X|5IG%0zꂪgfϩ#apܿ_ ZQBl Lw 6X}a_׍,_H`zڏvG04': MZUzy9,h 2n9BsKܞ@+iO>6q!8E1 @`!9 +Ob[ÛpZNSSWl%Glc/vQGxR``эCG;ۻk-@Hɘ_H̺FQuLB_/bQXau` f.>#>-)r4m ݻm6IE{A{A[DTȘL@Oﴰm?5V^G{*EʁyX@KEL z^L f;hgr엯Q㑣d|v$be/`MRlqM?=z?\Gl!G. "CEagMd!"5eJюQ^|y8DY,jJGƈ_R) oVxFc4_I=}ẢQ;~?˨ٞ6ǟCV@V >a] * E:G0 C$| >s*bl2*s1#O ߙIyu` @ik)aCˑ+(1^/7\5 h ]~># cſ%CGi fxc3Jxƽ׭[LXXhr3_`iqgDKfӦMûw>w\?|0|M.nۭ4cGoTzH9SeC? VWwU+.&fPz̭yz+H`^5V0Y_gϞ#KRԱhbY-Wϱp1%cӧ_q39>&S7IGV]a&_}AC;v;[_ VRU0d| m򩧞BŠ&[+W&;كr3eX>:*KMex_I#P#FՓ@Z {>9ϰCd`/]* ]v}y 7nKҿ_3Ubwe@y% R Ujv:]2?@; msX*'B"x-|r-SBln[b_dSNmޜYd,]m+$;X\f:Hm= 䳅Zzq'ɺ5%lɴC%w×؅ _ԮPwjP=nTA ' ˿X 5!V;/;X,Ѹ!oR˽6E4C.O\q'SG_# kdq=_9zx%/~IMW/j~{BMё TI _XRr/ UrwtMs_V ´曔z!Keװ$i%Dv[9.;4LN%0[J+Q z/^GL3 nuwP{f ͌@ֺ83#PLҏX*2UAp!U~P9tk%.֪-&8U#iC2iՐ d $@#!@[XkF1FP5l4Tq s~I2Χd{j˙١|UHݧ")0GZwSkB:bKX5j)S {{mۦ/X joUJ'1XIHp,z)8B5v 6Vں`J*Յ|jOH4ӧOb9o>|:Y$#|Ғ8av}ܹT %x%US>k#!pvyfvϞ=/7yFa!bNbVkC7LaHs)bI|5ttRޅY VEn+ӽ!&{z'F[wjOΤ z$OƈT)OH?C&DM6W48=&AzQt#w%O ֱOR ޞ@Tݱe2BDR8ˆAiᑠ _ zL*Y\~~W6ر_U+~BƐ-3)4֝əBؘ8W)OobjB߾}_zUW00 |nҚ)/Wzm SR[AHc =  ٟcNNIU@7 3(ڴA}giAB`k-dNjz>O##иauxdn 39TuJV"-Ұ5Caz]WW:1΍膭(cTA#Xd @C,$@$@E 4amd-yÇ>ҹsAJ*ʛ͐@l@I@m1Yٳ7no6wMb;Pb-9:%]XA%f=3?s =zT63~m۷` }a0N!G4 lٲedΆ s븏~G4ZUH@_0ok sgz-|Aȑ#V## C Ð@g)c/?K>R+V1m۶59eD} $oQjEܹs'>cW8>e_1]V~O=(&2jlJcJ0R׵_wx! t%7슋 d!vcΝɒItts(pJ&Hxq޳-$B>p;w1˟`ћJ' #^\cY@*MgŘeoRS*Set+{(1x3g #ۆ/;fm5IH`+ePM~@e(Bmo捓ړ@&A6MΑY~SDOGMh} iT\o^3h fx}!oڻw#c`-mޏfJcJ@ρ@[kj[(=B{֌p,vt:b7{ϽͲGeY@#`w'N`;|c[3U 7QBw,U $$ #3H]~89~GHH;1µkڲGEF|v2a LimJ [*zHz-V^}l/_qY!  bbń^&KgZ}LNI>ygJ Aph < DΝ',jM&샏Y\wnrOI@H:jFZ)v%L>A Y< 𬴦tVMe'B?&_V޸q_7md='T,Hfj$E{}o߾hveG=t%'$G\^^H"nCB]gT$J>Pb O8ݻIFQH` 1b-7],ȗ1^TH:dPr[ٕ+ۣ^ㅇ!ly٣&HCQwbD'{ܞ)H;vKv2Q܉4mc!9Xj;?.J;h?rA]3˒KCc$zu=p&&yh< O+8 ezUQJD4B+nOPIr0Jxd~~aoݺ_֬YCi4#/jt SO'UMG{^&:X6p֭[aDq꡿&#Đ$F`JuJĒM(mac-ud 'Ԏ@Lj-6k(Xl 1P,tt"$Id?Ke EZ{|j|JK$@$@>R1۷o b>{t=_NYdGD`JuJQbHuG(!l͛ݚB+L?))?g$B&Rq. QM@ "$@$@&~P *, @B   -{ $@$@,$@$@s'|QX_~>yS  wMm܏gpo۶ԗ()ɛ.@>ڟ>}18 _qs(;  DHq*չ`\wM~ݳgM^$@FΝ;&B2< DHQwO8aM,p&ϯCPٳg7nhL26822@B gEgIc'ppQqp۶^{^SADH*N%識H`Ջ?oٲEذaTȗ y"} ?*ܹ#4a  )Qϊ!'P^|y&*訒c8?|pH#eݺuvA |IH / at|N@/?ܽ{|72"zI0#̚iSQ%4RkD_7{(^`<~~%mv+5z ,Oq+bέ @bU]Gj,^|pT(Q '|vw=Du9G@o0|9M'$^vmڵ&g0a2 H/0)Fx뭷R*v{oܸO5rpS*SeA*$GՅ ; g)<|p L$@$@ dڢʶ0f$@Lb C  BrS#Ebt8z>ɑ@4$@;yXUEcǎ:JHH`"^޽/7U|G0t/`5(S\Z9E/8et@F @:*H8 wP9#$+d\g$e(ȵi~UP@a0Jxܙ]iʹzZ\<Ӱ߯^7`֭[a2w؁KKKxl]V]$a`A ܙb1N 75k]ts+ & _@dKpM S笺t$Qi sg3"P~ΨHQlh eij'0j[(& ̇3F$0:[azq3a*@[8VH${c ! ǢI /cƩܹs'f, L@s=|6S2Ιx=y$ B͛7?c*Ó@* zk,bfB@PT6aćC8Tb^`   @E#*ysOGͰ僩Rq.A3!G:RTHH`&rLJTWZG G}@~b^`" ?Ɩ0*iS0YHB1sg<z E" {᠚2S´>% e7al `kVԧ'fonb^}h5 +d¨زGԓFUsVF@NHZ cT$@[DHVȄQ܀&T3aT$Sګ 6R"HɑH`h '3W0<ҙ$@$@#3tb μP}  m!  νP  B=|0&|m?84$TgH7]C⚊ޙ&5Ug#FO~}]x+nځC5 "@)  +W ͛E={4.#P"@)"tH}_ƾv-[H{dHGIHH$/_gyKpu奥#G+nڏtsCA`;'Pt$pB&:y05w֯_N:p>lݺձ˓O>1oHEbAer\]֭[_<(aN͛7Y/+[ڱc8OqG \ L!P-DkƍpYرcͣ>ߡyWDů}kCIƝW_!u$J#l*BZ'm!&_x{ ۰a*n02 _v _G(CLAbIU :q+-LH@xt$wH7w5"SIImA<5a * dP8,j Xt$@9 9wF&Š(<ˑΖCi*io)|H$j@buQ' @O«WSF 9AzAA&v 6N\X`Y]8 @&B)sh@ !`2`HE\`$@FAe)k VT_'H M|iIU ˢ~U%^NdafZ$@tE1V sal>Zd 2R<+!fVTG 0[`0 OxL Pi~IhdP믡#jSF5A*}ZS`YK/#'HH-D$>]t!XA\%YEU`دklp 6`9J,$D -5 ‹KՂw$b L7rOJ*EʣpcѪl0`jlhA2:L֥rdXBCl1eZdB˅`e:73M[_`奒\cC,gY]mm!wI0PThIeF*.V:TXN6|˹+sc & ijbnA2%UNT ]}/%^Q$âojs5u-BLLUB0%Z4&#$Q(Qj'#yP]á"]392Zkd\؝ Il>BŠI ,dH04廆6.#jL L>5K3#lhU)QQ$K׮]+m~GjFҹspB=G^xAe0.#` @ˊHqrmgΜE÷bƛd姟~ڨBɂ'0h@D+FA Kkc8[p "J)jH/ȁK/ U fL)\H%!ewnKKn!缸Iԙ\BVHXCde 1CNrZ~CBHdSbo*Lр$$o+)mi/Ԏ]qU(~"T=8PQ-!Jtu'Fe "PZi Ȱ3K2Ll #zij޵`Fc5^F7 )O~!N!ڀ$zb,0-TKjF5 5>g/Տ>ʞ2 HSzu1mnn_ vC2wPU<{y2J]m$cҘVGu+YeOg`@\C9USm#xGHUB$(9;=Jc.[toeou;.N čpXu{}#ZUJ&ا׆1-색ϒ PuJ[w U(d*9IU1Lq\rxֆ~ QBsUa-͢$> s/v$uJB~=!VBV4 H[ b$P%ԏ tk Sϔ_B5*GK'YFI[XEE!H -8(+6m? g/+5P73+mesb_BnDNku&ট9 F0mH BY,.XD_B#dqmUG/fA=+YF[XC@H =A[)d+55fS~g5[QH#+OZK(A-4Yyrc}c0}3I`(xV[K#ɑ@!ĨΟZ2C5wFa*$ߗwj((55ucИ83XgB$P462UPK s )9*G{5h6UE,&F9}; =C%Bs2Srԋ8i p10 H@:+Qi0K|ا"#|&uDwPP~QWBakP @4L1ZJ6jl#aZ!9U-HqGb+Y~ usށ1Ž"uh CI@y[ e[r,/!1&)h#dy~ 0өH H$@$@$ma*HH`h ǚsHH m˗0 Ν;JxBedӦMǎw^tlIthV'6ტv*3H @ A$ܑm LqJ`q6hsulw(C͠h9 xJmx$Z? $HB њ @kNV ա9i좟U:M.= I 1ʠDɓ$Nei ;1 TB -CheuP/vQW&R[Ou|Uǯr2'xLƳ@>8:\Eը#}5[ e;EAQ[N>hnFFF; J\RBH J*=!zܡ^*HM- a9[eQQmjpGEnMߪm|ְ7x-]m:,CI.n^-Tm7uIe y/ڡ-lݑfuB5H-s2!lCH߭^uE wMX@>;~Լw$sm">HwMu:M݀?+= )l8^(3K-FAtӝ.DEwƦYb Mܞ+ Mճ-- :Kh >R;4F۴z61 F *sq;}2m*qA{Vs8A*b8 cX6A'v m#'Y@C/{$ԧm$@ $r¨@[^A7@j(~RM&YU"VRCrbMq ٱW՘vW:(*-}nK:A|rB٦]B[NE-YA~o-@^皊B[Y5!PݙMآ Ӗ-[{6`_zMg6 pn/ T7Lup-1׮] Q{x'F!3,O -LL$Y}ޛ{@4I) !Fc$@$P J25A -(i&>=)? @_} y  -{R~  rqU{}_|F˪>|ӧ+WB RԼy >~5޽1!YCHPIyʖ-Tw#|0U7.u@: wr`=Ouϭ'!͝G{BAl/skiUB%4MUFnfFU$Mt oWN|1 <}}I%ti.ۊ:vTMLbÐ$@R[ȉ_1oj}[71TPݿj穥xp4k2wQ¨3*5+Q)&9;| b뫌tc*JNQr:6#Tۤcd\g/$է.[(%RڎeI'PlgHnOl* UնF3F; B]rqLΜF},AM@O/(~;$l}-Tb6Vaec?89m7:b'l[MݕDmlT̝A%LB)!~rض݇&oo|5MJX-&Dz|mHP$@g J%-4aI =1ڹ>>9Ar:X6yivua5;Ix@eF `ж{tQRQ0TVh--l;OEzJu72DZ$:_PŭP5j+%RU45ⱧEH mM\{)E>fݹllA`7Ҳº2BwR"ҭY}겅[xێ?>a`HK%6Τ=P7qcj'&I-]"Zav,!{vKe_upPԺ}MsxYS+a fŦQN;̦7[#: J$mlAIǎ-[=>Sرl{VNN8:_|ic Jz{'Nކc;`{s׍1 ?Bq _Bt%6N_8,$@$@} %IHNG:v(? @@/L)e $0l '<!  Nv"b  -xS=  NHH`h 'THHma'"  8‰g0# $@[؉HH&NpLHH: v"b  -xS=  NHH`h 'THH!$B0:IENDB`@@@ #NormalCJ_HaJmH sH tH :@: # Heading 1$@&5\DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List 4@4 #Header  !4 @4 #Footer  !j@j  Table Grid7:V06U@!6 l Hyperlink >*B*phFV@1F  jFollowedHyperlink >*B* phHBH N Balloon TextCJOJQJ^JaJ^^:K :PQXz{|01B`ao*IJXrsty+,    < = D;IIJ!$*,///369W>??@@@AABBBG`IcIrIVJYJSL@RCRRR5S6SSSTTSUTUVVVVWWUXVXYYYYKZMZ [ [)\*\K]L] ^ ^ ^ ^^^^^^^^000000 0 0 0 0000 0 0 0 0 0000 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00000000000000000000000000000000000000000000000000000000000000000000000000000000000000@0X00@0X00@0X00@0X00X00h:K :PQXz{|01B`ao*IJXrsty+,    < = D;I!*///369W>?@@@ABBBG`IcIrIVJYJSLCRRR5S6SSSTTSUTUVVVVWWUXVXYYYYKZMZ [ [)\*\K]L] ^^000000 0 0 0 0000 0 0 0 0 0000 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00000000000000000000000000H0]03H0]0200000000000000000000000000000000000000000000000000  )!$/9GJZRr\Kef4:?FJKLNOPQRSUVWYz  0 `  I r  <HS]ff5789;<=>@ABCDEGHIMTXZf6  . (B^FtFtXX8@0(  B S  ?Text14Text15 OLE_LINK5 OLE_LINK6YY^YY^+~ D lA A  T X X 4Y tY Y Y 4Z tZ Z  쵟 , l  춟 , l  췟 , l ^ D^ ^ ^ _ D_ _ _ ` D` ` ` a Da D    ::FJuu; H(H(R(](??@@@AAABBB^      !"#$&%')(*00DHOOyyE   Q(\(c(c(??@@@AAABBB^    !"#$&%')(* =)*urn:schemas-microsoft-com:office:smarttags PlaceName='*urn:schemas-microsoft-com:office:smarttags PlaceType8+*urn:schemas-microsoft-com:office:smarttagsCity9(*urn:schemas-microsoft-com:office:smarttagsplace;"*urn:schemas-microsoft-com:office:smarttagsaddress>*urn:schemas-microsoft-com:office:smarttags PersonName9**urn:schemas-microsoft-com:office:smarttagsState:!*urn:schemas-microsoft-com:office:smarttagsStreet>*urn:schemas-microsoft-com:office:smarttags PostalCode H+*)('())'"!(+*(*())'))'(+*())'"!'()(+*(+*y/ 0 7 8 < @@RRZ [ [5[ ^ ^ ^ ^ ^ ^ ^^^^^^^^yY @@RRZ [ [5[ ^ ^ ^ ^ ^ ^ ^^^^^^^^:9:Q/1_ay/ //BBhIqIeWW] ^ ^ ^ ^ ^ ^ ^^^^^^^^/ ^ ^ ^ ^ ^ ^ ^^^^^^^^K?P\c\cL},zDNK} ? ~\ b ]e$zG#/eJho_ j+o"wN O!o""aY"#2#ik#I$d%R'O*e+0D334?:5e5b8&%:S;ua<=1A5ACzmE mF%JGK4L MCMzdNOOdJPwQhRlTUU(U Y.]qaO_d,g;h-QiFci"ekYl1ofpqTs/tj vAF/(/%pxPQXz{01B`ao*IJXrsty!L^@~I^`@UnknownGz Times New Roman5Symbol3& z Arial5& zaTahoma"1hCFCFF P0 P0!4d]]LL2qHP ?#2Office of Nursing Servicessuzanne brungs VHACOMITCHRObjInfo" WordDocumentn8SummaryInformation(!#DocumentSummaryInformation8g%` fbjbj 8̟̟ ^ ***8++>`,L,,,,-J-$-^>`>`>`>`>`>`>$?h3B>6--66>,,>9996,,^>96^>999,T, 3*79<>0>9B28NB99"B: .`i092\w3K . . .>>9d . . .>6666$d Office of Nursing Services 2008 Annual Innovations Awards Application Form Professional Practice Environment for Nursing Excellence Title of SubmissionStriving for Excellence on a National LevelFacility Name and AddressCincinnati VA Medical Center Inpatient Evaluation Center - IPEC 3200 Vine Street. MDP 111 Cincinnati, OH 45220VISN #10 VA Healthcare System of Ohio Names of Team Members (Note: At least two (2) team members are required.) Primary Author InformationNameSuzanne Brungs RN, MSN, MBATitle of PositionClinical Program ManagerTelephone Number513 - 487 - 6686 Extension: Email addresssuzanne.brungs@va.gov  FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NameRachael Hasselbeck RN, MSN, MBATitle of PositionImplementation CoordinatorTelephone Number513- 861-3100 Extension: 5539Email addressrachael.hasselbeck@va.gov NameMarta L. Render M.D.Title of PositionInpatient Evaluation Center, ChiefTelephone Number513 - 475 - 6366 Extension: Email addressmarta.render@va.gov Submissions shall be in narrative format, in Times New Roman font, no less than 11 point, and NOT exceed five pages in length, including attachments. Submissions cannot contain embedded documents. Submissions which are noncompliant with these criteria will not be considered. Narrative shall include (a) title, (b) summary of initiative, (c) date of implementation, and (d) clearly identify each rating category being addressed followed by applicable narrative. The attached template serves as a face sheet for the narrative. All best practices shall be submitted electronically by the Nurse Executive with endorsements by the Facility Director/designee notifications of the VISN Director/designee. An electronic copy of the attached endorsement memo or equivalent electronic message addressed to Cathy Rick, RN, CNAA, FACHE, Chief Nursing Officer, Office of Nursing Services (108), is to be sent WITH the submission to Reji John (VHACO), Office of Nursing Services VACO (108), at  HYPERLINK "mailto:reji.john2@va.gov" reji.john2@va.gov (please note duplicate name in outlook). Deadline for submissions with endorsements is by COB May 31, 2008. Office of Nursing Services 2008 Annual Innovations Awards Inpatient Evaluation Center Cincinnati, Ohio Title: Striving for Excellence on a National Level Summary of Initiative: Beginning in FY 2005, and coincident with the Institute for Healthcare Improvement (IHI) Saving 100,000 Lives Campaign, the Department of Veterans Affairs decided to implement many of the IHIs Saving 100,000 Lives Campaign initiatives including those to reduce hospital acquired infections in VA Intensive Care Units (ICU). Addressing these IHI initiatives specifically as well as other missions, the VA Inpatient Evaluation Center (IPEC) employs two nurses (SB and RH) who function as the Implementation Coordinators. In order to be successful, the individual VA ICUs needed the resources and support during the upstart of these initiatives. The IPEC created a data collection instrument and instituted a program to systematically reduce central line associated bloodstream (CLAB) infections and ventilator associated pneumonias (VAP) through implementation of evidence based practices collaborating with 10N and the Program for Infectious Diseases. With leadership from the Implementation Coordinators, plans were made to develop two websites to promote the use of evidence based practices to improve the quality of patient care. Both websites are accessible off of the IPEC home page:  HYPERLINK "http://vaww1.va.gov/IPEC/" http://vaww1.va.gov/IPEC/ One of the websites created was a Sharepoint website that housed toolkits for the implementation of evidence based practices. The toolkits contain such items as: data collection tools, information about the practices to reduce infections, the literature to support these practices, examples of how to market and promote the project, graph templates to feedback infection rates to staff, educational materials, order sets, policies and protocols. These toolkits were built by collecting items from sites that were experiencing success in dropping their infection rates. These toolkits allowed sites who were just starting out the ability to access ready made information that they could tailor to meet their needs instead of having to start from scratch. Because the data was not collected nationally, the IPEC also developed a web based database to collect numerator and denominator data regarding hospital acquired infections in every VA ICU. Furthermore, this website collated information about each facilitys adherence to the evidence based practices. This database was fully operational in FY 2006. The national kick-off of both initiatives began with national web-based conference calls. The agenda for the conference calls included a national leader of the VA introducing the topic and its importance to veterans, an expert in the topic who presented the literature supporting processes that reliably reduced infections, followed by success stories from the field. Follow-up calls were held to update and answer questions again with success stories from the field. Educational modules were created to support the initiatives. The educational modules offered free continuing education credit which fostered the nurses ability to collect mandated nursing credits for license renewal. Through collaboration with Employee Education Services (EES), these modules were made available to every ICU nurse in the VA. Rates of hospital infections including the number of months without a single infection are reported quarterly to facility and VISN leaders. For those hospitals whose infection rates appeared resistant to improvement after 6 9 months, the VA IPEC notified hospitals, inviting them to participate in a mentoring process to identify local barriers and improve their results. In the two years since reducing infection rates has been a VA national initiative, central line infection rates have decreased by almost 40%. Ventilator associated pneumonia rates have decrease 37%. Date of Implementation: The implementation of evidence based practices began in 60 VA ICUs during the initial IPEC pilot in FY 2005. In the second quarter of FY2006, the practices were rolled out nationally. The implementation of these practices continues today throughout all approximately 192 VA ICUs. Identify each rating category being addressed followed by applicable narrative: 1. Adoption of the Innovation There have been multiple calls in the healthcare community to reduce the number of hospital acquired infections. In addition to the Institute for Healthcare Improvement (IHI) and their two recent campaigns (Saving 100,000 Lives, and Protecting 5,000,000 Lives From Harm), the Joint Commission has also supported implementing evidence based practices to improve patient outcomes. Before the initiative began, the VA nosocomial infection rates nationally were considered fairly high (well above the 50th percentile for the National Healthcare Safety Network (formerly National Nosocomial Infections Surveillance System). The practices to reduce infections are well-documented in the literature. The practices used to reduce central line infection include these practices to be followed during the insertion of the line: donning a sterile gown and gloves, wearing a mask and cap, prepping the skin with chlorhexidine, and covering the patient with a full body sterile drape. Practices to reduce the incidence of ventilator associated pneumonia include: elevating the head of the bed greater than 30 degrees, deep vein thrombis and stress ulcer prophylaxis, assessment of the patient daily for weaning, daily sedation vacations and daily spontaneous breathing trails. Literature outlining these practices are listed in the reference this of this application. These publications outline not only decreases in mortality, decreases in length of stay, but also outline cost savings from improving patient outcomes (please see the bibliography for a selected list of references outlining the evidence based practices) The evidence based practices to reduce these infections were variably implemented across the VA. There was a definite need to implement these practices. One of the first developments that IPEC committed to was the creation of a data management website. This was essential for the collection of national data on central line and ventilator associated pneumonia infection rates. On this website, all 190+ ICUs in the VA enter the numerators (number of infections) and denominators (number of device days). Additionally, all sites enter their data on compliance with all of the individual bundle elements present in the infection reduction bundle. Implementation and use of the data management website has been highly successful. When the website first was opened, it was mandatory for sites to enter their data monthly. However, even though use of this website has been voluntary for over a year now, well over 95% of the sites continue to enter all data elements on a monthly basis. One of the authors (SB) had recently implemented a successful local ten-hospital collaborative project aimed at reducing central line infections and surgical site infections. This project was awarded the Joint Commissions Ernest A. Codman Award. Adapting the successful collaborative process from that ten-hospital project to a national 192-site initiative was going to take some innovative approaches. One of the first developments we undertook was the creation of a toolkit for each of the initiatives we were tasked with. The toolkits contained items such as examples of policies and protocols, order sets, marketing tools, educational modules, data collection forms, bibliographies as well as a host of other items. These toolkits were placed on a Sharepoint website that anyone with a valid VA login had access to. This same website housed the Inpatient Evaluation Center risk-adjusted length of stay and mortality reports that were released twice a year. Furthermore, this Sharepoint website was seen as a one-stop shopping portal. Not only could they get their ICU reports, access national toolkits, they could also access slides from national calls on the topic and participate in a discussion board. Although Sharepoint websites are being used with increasing frequency over the past couple of years, when we first launched our Sharepoint website, it was the first Sharepoint website that many of our users had encountered. Another leading edge technology that we utilized at the kickoff of our project in 2005 was web conferencing technology. Although such technology is more commonplace now, when we held these kickoff calls, this was the first time that many participants had seen this used. In addition to viewing slides real time during the presentation and allowing for real time question and answers, this web conferencing tool allowed us to demonstrate how to use the Sharepoint and Data Management websites. We were able to show how to navigate through the systems and show all of the components of the two websites. Finally, as struggling sites were identified, they were offered a mentoring program by the IPEC Implementation Coordinators. This mentoring allowed us to customize the IPEC tools for their site. We completed monthly calls with the project leader and team members. During the calls we discussed barriers to the project, current infection details, as well as specific items they needed assistance with. This allowed the Implementation Coordinators to identify specific toolkit items that would be of help. We tailored specific items for their needs (i.e. graphs of their infections, data collection tools, posters for teaching, brochures, etc). We also developed action items with specific timelines for follow-up. 2. Nursing Leadership and Collaboration There are multiple ways in which nursing has participated in the development and implementation of this initiative. Both authors (SB and RH) are the Implementation Coordinator nurses who determined the data element fields for the Sharepoint and Data Management websites. We both also called every nurse manager and infection control nurse as this project was rolling out. Initially we contacted the 60 pilot ICUs and eventually the remaining 132 ICUs. In addition to inviting bedside nurses, infection control nurses and nurse executives to listen to the National web conferencing calls, we invited nurses to be presenters on our calls. They discussed the central line and ventilator associated pneumonia projects that were underway at their sites, including barriers, facilitators and success stories. These calls focused on field staff implementation of these initiatives, not just leadership involvement. The authors also assisted with getting nursing modules created on reducing central line infections and ventilator associated pneumonia. We worked with the National EES (Employee Education System) office to develop learning modules that all ICU staff nurses could complete for 4 CEUs. Along with the Implementation Coordinators, 3 other VA nurses assisted with the development and evaluation of the learning modules before being released to the field. After creation of these modules, emails were sent to all VA Nurse Executives and ICU Nurse Managers. The email explained how ICU staff nurses could complete the learning modules. This was also an innovative initiative that has been seen as a success by the EES staff nationally. As of early April 2008, over 600 nurses have completed both the central line and ventilated associated pneumonia modules. Infection control nurses, quality management nurses and ICU Nurse Managers were generally the project leaders assigned at the hospital level. These leaders were responsible for utilizing the sharepoint toolkit items and modifying them to fit their needs. Frequently, they revised policies and procedures that needed to go through committee structures at the hospital and even through the VISN. If they ran into roadblocks with the project, we provided assistance as well as other resources to overcome those barriers. Some nurses were also able to integrate some of the project initiatives into Goalsharing projects leading to even higher levels of success in implementation and buy-in. There are many examples of collaboration and multidisciplinary impact from this project. Beginning with the kickoff calls at the beginning of the project and follow-up national calls, participants on the calls included ICU nurse managers, quality management staff, ICU physician directors, Chiefs of Staff, ICU attending physicians, infection control practitioners, VISN office staff, staff nurses, respiratory therapists, as well as other disciplines. When the Implementation Coordinators worked with struggling sites, participants on these calls included ICU nurse managers, ICU physicians, infection control practitioners, respiratory therapists, ICU staff nurses and quality managers. As already mentioned previously, we developed a relationship with the national EES office regarding creation of national learning modules. The success of that program is leading to future IPEC program and nursing module development (i.e. the National Rapid Response Team/System initiative and glycemic control initiative). Collaboration on a national level continues as the national Office of Nursing Service has also placed links to the education modules on their homepage as well as links to the IPEC website. The process used by IPEC to implement these projects has been disseminated and discussed at various levels. One author (SB) has also presented at multiple Collaborative Learning Sessions and National Calls of the VA FIX (Flow Improvement Initiative) over the past year and a half and has presented outcomes of this project. Brungs SM, Hasselbeck RC, Render ML, Almenoff PL, Freyberg RW (2007) Effective Strategies for Implementing National Initiatives to Reduce Nosocomial Infections. Presented at The 14th National Evidence-Based Practice Conference, April 20, 2007, University of Iowa Hasselbeck RC, Brungs SM, Almenoff PL, Freyberg R, Render ML (2007) Collaborating Hospitals Successfully Reduce Intensive Care Nosocomial Infections. Sigma Theta Tau International Annual SONK Consortium Conference, Feb. 16, 2007, Cincinnati Ohio Hasselbeck RC, Brungs SM, Almenoff PL, Freyberg R, Render ML (2007) National VHA Initiative to reduce Intensive Care Nosocomial Infections. Presented at Building Collaborative & Community focused Evidence Based Approaches, October 19, 2007, University of Miami Florida. 3. Scope of Initiative As outlined above, the initiative of reducing central line infections and ventilator associated pneumonia in ICU patients has been a national effort since FY2006. The initiatives started off usually in only one ICU at each site. The practices then spread not only to all of the ICUs, but also to other areas of care including: med/surg wards, telemetry, the emergency department, the operating room, special procedures departments, and other areas in which the practices have spread. Regarding the central line infection project, the fact that many sites switched to a new standardized insertion tray made it easier to spread throughout the facility. The new trays acted as a forcing function to make the physicians insert the lines the correct way. The policies and protocols for the care ventilator patients have affected the care of ventilator patients in all areas of the facility as well. Although the main focus of the evidence based practices has been to decrease central line infections and ventilator associated pneumonias, the scope of the initiative is growing. Currently, we are working on a glycemic control toolkit to assist with the management of hyperglycemia in acute care patients. Furthermore, the toolkit for creation and implementation of Rapid Response Teams is well underway. Having worked with ICU nurse managers and infection control practitioners, we learned that often times they worked on a VISN level to achieve the goals of continuity of practices, establish ordering of supplies as a VISN, and reported their infection/compliance rates through their VISN QMO. The results of these national initiatives can be seen in the next section. 4. Impact Central line infection rates have decreased 48% (p<0.001) since the project was rolled out nationally in 2nd quarter FY 2006. Likewise, ventilator associated pneumonia rates have decreased 42% (P<0.001) in the same timeframe.  After the first two national kick-off calls for the central line and ventilator bundles, we surveyed call participants. 96% and 84% of the respondents respectively stated that the call was very informative. We also surveyed the users of the IPEC Sharepoint website and asked which toolkit items they were most satisfied with. Overall, the highest satisfaction with team leaders were with the definition of the bundles (84%) and education tools (85%). Overall satisfaction with IPEC resources was 89%. Most of the sites expect to see continued low rates because they have threaded the changes into the fabric of their daily work. For example, one of the largest changes involves new central line insertion trays. Most sites have changed to central line insertion trays that do not contain betadine, but instead, chlorhexidine comes standard. Additionally, the small localized sterile drapes were replaced by a sterile full body drape. Another movement that shows that these changes are long-term, instead of a short-lived project, is that policies and protocols were changed reflecting the evidence based practice bundle elements. These policies go through multiple layers in the facilities for approval. Specifically for the central line project, some nursing units purchased a traveling central line cart which has on it all of the approved central line insertion items. These carts include only the correct items and none of the old incorrect items, resulting in a forcing function that makes it easy to do it right and hard to do it wrong. Finally, although not officially part of the IHI ventilator bundle, many facilities began using standardized oral care kits for their ventilated patients. These kits, and the policy for administering oral care, were changed to provide oral care every two to four hours based on literature recommendations. These long term changes will continue to decrease infections resulting in lower mortality, lower lengths of stay and decreased patient suffering. Selected References for Central Line and Ventilator Best Practices Berenholtz SM, Pronovost PJ, Lipsett PA, et al. (2004) Eliminating Catheter-Related Bloodstream Infections in the Intensive Care Unit. Critical Care Medicine, 32:2014-2020. Centers for Disease Control and Prevention: Guidelines for the Prevention of Intravascular Catheter-Related Infections (2002). MMWR ,51(No. RR 10), 1-36. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. (2002) Chlorhexidine Compared w/ Povidone-Iodine Solution for Vascular Catheter-Site Care: A Meta-Analysis. Annals of Internal Medicine, 136(11), 792-801. Conti G, Montini L, Pennisi MA, et al A Prospective, Blinded Evaluation of Indexes Proposed to Predict Weaning from Mechanical Ventilation. Intensive Care Med 2004; 30: 830-836 Drakulovic MB, Torres A, Bauer TT, et al. Supine Body Position as a Risk Factor for Nosocomial Pneumonia in Mechanically Ventilated Pts: A Randomized Trial. Lancet. 1999; 354(9193): 1851-1858. Esteban A, Alia I, Tobin M, et al. Effect of Spontaneous Breathing Trial Duration on Outcome of Attempts to Discontinue Mechanical Ventilation. Am J Respir Crit Care Med 1999; 159: 512-518 Geerts WH, Pineo GF, et al. Prevention of Venous Thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. Sept 2004; 126 (3 Supply): 338S-400S. Hu KK, Lipsky BA, Veenstra DL (2004) Using Maximal Sterile Barriers to Prevent Central Venous Catheter-Related Infection: A Systematic Evidence-Based Review. Am J Infect Control, 32(3), 142-6. Kress JP, Pohlman AS, OConnor MF, Hall JB. Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. N. Engl J Med. 2000; 342(20): 1471-1477 National Healthcare Safety Network (NHSN), Patient Safety Protocol Component. Definition of Ventilator Associated Pneumonia. Quenot J, Ladoire S, Devoucoux F, et al. Effect of nurse-implemented sedation protocol on the incidence of ventilator- associated pneumonia. Crit Care Med. 2007; 35(9): 2031-2036. Rubinson L, Diette GB (2004) Best Practices for Insertion of Central Venous Catheters in Intensive Care Units to Prevent Catheter-Related Bloodstream Infections. J Lab Clin Med, 143, 5-13. Tablan OC, Anderson LJ, Besser R et al. CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for Preventing Health-Care Associated Pneumonia. 2003: Recomm of CDC and the Healthcare Infection Control Practices Adv Comm. MMWR Recomm Rep. 2004; 53(RR-3): 1-36. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V: Randomized Controlled Trial and Meta-analysis of Oral Decontamination with 2% Chlorhexidine Solution for the Prevention of Ventilator-Associated Pneumonia. Infection Control and Hospital Epidemiology. 2008; Feb (29): 131-136 Wall RJ, Ely EW, Elasy TA, et al (2005) Using Real Time Process Measurements to Reduce Catheter Related Bloodstream Infections in the Intensive Care Unit. Qual Saf Health Care (14)295-302.      :KO X Z y ѿ򱩛zne\eneSnH=hNh CJaJhNh,gCJaJhe+CJ\aJh CJ\aJho""CJ\aJhNh CJ\aJh~\ CJ\aJh~\ h~\ CJ\aJh~\ h CJ\aJhNh 5CJ\aJhdJPh?:56hNh,g5CJ\aJ#h{h#5B*CJ\aJphh?:55B*CJ\aJph#h{h 5B*CJ\aJphhNh#5CJ\aJ:KT}kd$$Ifl0 $\ l t0644 laPyt%p $Ifgd $a$gd?:5$a$gd#$ *]^a$gdhR  ff : P Q X z x}kdj$$Ifl0 $\ l t0644 laPyt%p $Ifgd z { | ||tk $Ifgd#$a$gd#gd }kd$$Ifl0 $\ l t0644 laPyt%p  $Ifgd#fkd>$$Ifl4&(0(64 laPf4yt%p     / 1 A B E H K N R \ a n o |iT)jhNh#56CJU\]aJ%hNh#5CJ\aJmHnHu)jNhNh#5CJU\aJhNh#5CJ\aJ#jhNh#5CJU\aJhNho""CJaJhe+CJaJho""CJaJho""h#CJaJmHsHho""ho""CJaJmHsHhNh CJaJhNh#CJaJ   0 $Ifgd#vkd$$Ifl0& 0(64 laPyt%p0 1 B ` $Ifgd#vkdn$$Ifl0& 0(64 laPyt%p` a o $Ifgd#vkd$$Ifl0& 0(64 laPyt%p { $Ifgd#gd#vkd$$Ifl0& 0(64 laPyt%p   ) * - / 7 A D H J W X q r s t x y ¬žxmxm^hua<hua<CJaJmHsHhNho""CJaJhe+CJaJho""CJaJhNh CJaJhNh#CJaJhNh#6CJ]aJ+hNh#56CJ\]aJmHnHu)jhNh#56CJU\]aJ/jhNh#56CJU\]aJ hNh#56CJ\]aJ! $Ifgd#  !gd#ckdt$$Ifl&(0(64 laPyt%p  $Ifgd#vkd$$Ifl0& 0(64 laPyt%p  * I ~~ $Ifgd#xkd$$IflC0& 0(64 laPyto""I J X r $Ifgd#vkdB $$Ifl0& 0(64 laPyt%pr s t y {{ $Ifgd#gd#vkd $$Ifl0& 0(64 laPyt%p $Ifgd#vkd $$Ifl0& 0(64 laPyt%p       H l m s y HLSWnrۧۛۛۛۄxmmmmmhNh_?CJaJhNho5CJaJhNhoCJaJhNhzdN5CJaJhNh#5CJaJ *hNh#CJ\aJhNhe+CJaJhe+CJaJhNh%pCJaJhua<CJaJhNh#CJaJhNh CJaJhua<h#CJaJmHsH* $Ifgd#vkd" $$Ifl0& 0(64 laPyt%p   $Ifgd#vkd $$Ifl0& 0(64 laPyt%p     +,<wwwwwrgd,$a$gd,gd#gd#vkdb $$Ifl0& 0(64 laPyt%p *+,Rax}.7|qhZhjh'5CJUaJh'5CJaJh'h'CJaJh'CJaJhNh#5CJaJhNh#6CJaJhNh,CJaJhNh,5CJ\aJhNhzdN5CJ\aJhNhhRCJaJhNh_?CJaJhNh_?5CJaJh,CJaJh#CJaJhNh#CJaJ./0WYwǼ{ocXMXA5hYlh,5CJaJhYlh5CJaJhYlhCJaJhYlh,CJaJhNh%p5CJaJhfphd%5CJaJhfph,5CJaJh,5CJaJhNh,g5CJaJhNh#5CJaJhNh_?5CJaJh,CJaJh'h'CJaJh'5CJaJhAh'0J5CJaJjh'5CJUaJ&j hAh'5CJUaJ :;RSUw_r'()򾲧{p{eVeDV#j hYlhzDCJUaJjhYlhhCJUaJhYlhhCJaJhYlh34CJaJhYlhG#CJaJhYlhPRCJaJhYlhN CJaJhYlhCJaJhYlhCJaJhYlhN 5CJaJhYlhN 5>*CJaJ *hYlh~\ 5>*CJaJhYlh~\ CJ\aJhYlh~\ CJaJhYlh,5>*CJaJ<=D;I !!I"J"""),24777;>AWFGGHgdCgd|gd?-gdgd,)BC:;<ksltOCUI J !!ø΁vkhYlhj vCJaJhYlhCJaJhYlh?CJaJhYlh YCJaJhYlhSCJaJhYlhCJaJhYlhCJaJhYlhN CJaJhYlh/tCJaJhYlhqaCJaJhYlhG#CJaJjhYlhhCJUaJhYlhh0JCJaJ)!!-!z!!!!=">"I"J"""""""###^$$$$$$$$$$ܻxmbWmbxbKbmhYlh;$CJH*aJhYlhpCJaJhYlh;$CJaJhYlhlvCJaJhYlh&4CJaJhYlhI$CJaJhYlh? CJaJhYlh/CJaJhYlhLCJaJhYlhL5CJaJhYlh?5>*CJaJhYlhj vCJaJhywwCJaJhYlh?-CJaJhYlh,5>*CJaJhYlh,CJaJ$(%*%v%(( ))))) +++,,,$-/--D.G.../Ҵᥖxi]iNNiNi?hYlh2#B*CJaJphhYlh;hB*CJaJphhB*CJaJphhYlh_.B*CJaJphhYlh]B*CJaJphhYlh/B*CJaJphhYlhxB*CJaJphhYlh? B*CJaJphhYlhxB*CJaJphhYlh&4B*CJaJphhYlhcB*CJaJphhYlh;$B*CJaJphhYlhlvB*CJaJph/0P2222223A3333334h44t5v5777777789ҴҴôååå|qeqZqZOhYlh~CJaJhYlhCJaJhYlhL5CJaJhYlhLCJaJhYlh"ekCJaJhYlh4LB*CJaJphhYlhofB*CJaJphhYlhB*CJaJphhYlh4.B*CJaJphhYlhxB*CJaJphhYlh"ekB*CJaJphhYlh2#B*CJaJphhYlhpB*CJaJph9999999;<>6@=@]@a@u@@AABBBBFCeCfCEEEEUFXFFFFFFGɾtitit^hO*h%JCJaJhO*h_CJaJhO*hGKCJaJhO*hTaCJaJhO*h>CJaJhO*hD3CJaJhO*hTqCJaJh/CJaJhO*h_.CJaJhO*h1oCJaJhO*h|CJaJhYlh|CJaJhYlh?CJaJhYlh~CJaJhYlh_.CJaJ$GGG'G.G1GGGGGGGOHUHWHHHHHIIIIJJJJJJĸĬĎshhd`XTPh#hLhLhL5hhOh/hb CJaJh hb 5CJaJh/hCCJaJmHsHh hC5CJaJmHsHh/hC6CJH*aJh/hC6CJaJh/hC5CJaJh/hCCJaJh hC5CJaJh_hO*hCCJaJhO*hGKCJaJhO*h_CJaJHHHIIJJJO`QcQrQVRYRST@ZCZZZ5[6[[[\\S]]gdB|gdB|$a$gdB|gd#gd,gdCJmKnKqKMRN7O8OOaQbQcQdQnQoQpQqQsQQQQQQRRURVRWRXRYRZR{jaXMhYlhzmECJaJhoJ5CJaJh=Bz5CJaJ jh#h#5CJUaJhO*h1ACJaJhO*hb8CJH*aJhO*hCJaJhO*hb8CJaJhb8h#hLhLhL5 hYl5hO*hLCJaJhO*h7CJaJhO*h&%:CJaJhO*hXCJaJh CJaJhO*h#CJaJZRSSSTTTTRTSTTTTTT UmU}UUUUW WYAZBZCZDZZZZ[%[[[[[[[\\%\&\r\׵ssskkhB|CJaJh18nhB|6CJ]aJh18nhB|CJaJh18nhB|CJaJmHsH hB|hB|hB|hB|CJaJ *hB|hB| *hYlhB|CJaJhYlh_.CJaJhYlh1ACJaJhYlh+GCJaJhYlhoJCJaJh/CJaJhYlh=BzCJaJ*r\\\\\.]@]]]^=^^^e_j___3`F`U`V```#b1bMbbc c c5cdd)d*dide1eKeԽ竜pahhB|B*CJaJph hhB|5B*CJaJphhhB|CJaJmHsHhB|CJaJmHsHhB|hB|CJaJmHsH"hB|hB|6CJ]aJmHsHhB|hB|CJaJhhB|6CJaJhhB|CJaJhB|CJaJh18nhB|CJaJh18nhB|6CJ]aJ&S]T]^^^^__U`V`aaaaKbMb c c)d*dKeLe f f f fffgd# gdB|gdB|KeLef f f f ffffffffh~ jh~ U h+Gh+GhhB|CJaJh18nhB|CJ]aJ hB|] fffffffgd#6&P1h:pC/ =!"#$%   Oh+'0 (4 T ` l xOffice of Nursing Servicessuzanne brungs Normal.dot VHACOMITCHR2Microsoft Office Word@F#@<)[%@*3@*3 P՜.+,D՜.+,d  hp   Department of Veterans Affairs0]' Office of Nursing Services Title 8@ _PID_HLINKSA M http://vaww1.va.gov/IPEC/Aemailto:reji.john2@va.gov_1279448228& FpK&C۰pK&C۰Data +1Table%(CompObj qh$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%ph$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%ph$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%p$$IfP!vh5(#v(:V l40(65(4aPf4yt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pDyK Susan.Thomason@va.govyK :mailto:Susan.Thomason@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt%pFDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pDyK Christine.Bennett@va.govyK @mailto:Christine.Bennett@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pDyK Paula.Boyle@va.govyK 4mailto:Paula.Boyle@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pDyK Anne.Dammers@va.govyK 6mailto:Anne.Dammers@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pDyK Heidi.Lacko@va.govyK 4mailto:Heidi.Lacko@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt(q$$IfP!vh5 5#v #v:V l0(65 54aPyt(qDyK Jane.Nichols@va.govyK 6mailto:Jane.Nichols@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt(q$$IfP!vh5 5#v #v:V l0(65 54aPyt(q$$IfP!vh5 5#v #v:V l0(65 54aPyt(qDyK Anatalia.Resulta@va.govyK >mailto:Anatalia.Resulta@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt(q$$IfP!vh5 5#v #v:V l0(65 54aPyt(q$$IfP!vh5 5#v #v:V l0(65 54aPyt(qDyK Candice.Watkins@va.govyK <mailto:Candice.Watkins@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt(q$$If!vh5X5l#vX#vl:Vl  t65X5lpytDc$$If!vh5X5l#vX#vl:Vl t65X5lytDc$$If!vh5X5l#vX#vl:Vl t65X5lytDc$$If!vh5X5l#vX#vl:Vl t65X5lytDc$$If!vh5X5l#vX#vl:Vl t65X5lytD$$If!vh5h55 #vh#v#v :Vl  t5h55 pytDv$$If!vh5h55 #vh#v#v :Vl t5h55 ytDv$$If!vh5h55 #vh#v#v :Vl t5h55 ytDv$$If!vh5h55 #vh#v#v :Vl t5h55 ytD$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl  t(65(55$ 5pp(ytD$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pytD$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pytD$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pytD$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pytD$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pytD$$If!vh5X5l#vX#vl:Vl  t65X5lpyt;c$$If!vh5X5l#vX#vl:Vl t65X5lyt;c$$If!vh5X5l#vX#vl:Vl t65X5lyt;c$$If!vh5X5l#vX#vl:Vl t65X5lyt;c$$If!vh5X5l#vX#vl:Vl t65X5lyt;$$If!vh5h55 #vh#v#v :Vl  t5h55 pyt;v$$If!vh5h55 #vh#v#v :Vl t5h55 yt;v$$If!vh5h55 #vh#v#v :Vl t5h55 yt;v$$If!vh5h55 #vh#v#v :Vl t5h55 yt;$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl  t(65(55$ 5pp(yt;$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pyt;$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pyt;$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pyt;$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pyt;$$If!vh5(55$ 5p#v(#v#v$ #vp:Vl t65(55$ 5pyt;      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefKklmnopqrstuvwxyz{|}~@@@ #NormalCJ_HaJmH sH tH :@: # Heading 1$@&5\DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List 4@4 #Header  !4 @4 #Footer  !j@j  Table Grid7:V06U@!6 l Hyperlink >*B*phFV@1F  jFollowedHyperlink >*B* phHBH N Balloon TextCJOJQJ^JaJ<+@R< a1 Endnote TextCJaJ>*@a> a1Endnote ReferenceH* jmc, ,),,,0,SHOV*Z-ZZ#[oooooceYU  x znj*-   00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q 00dQ@0q 0:K'F[\cefgRSd %DEW./05JK],-?tu .vw #$6no   ) ^ _ p   % m n       A h +,Ge5`!$9'(($))))`*z**(+|++ ,3,4,H,.../X/i///.0>0m001M11162X222&3334y44<5566 7f77?8$99 ;<B===>>>^>_>h>>?@@IAJAUAABBBBBYCCCdDDDDE%FFFGGGiGHnHlIIIIIIIIIIJJ J JdJgJlJ~JJJJJ K(K)K7K?̎ !*/49:DINSTcejopŏƏ@wɒʒ%qrԓ,-Hde}./!#ߘ<UVƚǚ$ʛ˛)}dޝߝHOPkBQRDFAB _xyڥFK˧̧(] deê#WЬѬ)fgí&Y[VWt[`=000000 0 0 0 000 0 0 0 0 0000 0 0 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00000000000000000000000000000000000000000000 0 0 00 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0000 0 000 0 00000000 0 0 0  0 0 0 0 0 0 0  0 0 0 0 00  0 00 0 0 0 0 0 0 0 00 0 000000 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000000000000000000000000000000000000000 0 0 00 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0000 0 000 0 00000000 0 0 0  0 0 0 0 0 0 0  0 0 0 0 00  0 00 0 0 0 0 0 0 0 00 0 000000 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000000000000000000000000000000000000000000000000@0X00@0X00@0X00@0X00X00l@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@000*:K'F[\cefgRSd %DEW./05JK],-?tu .vw #$6no   ) ^ _ p   % m n      A +e5`!$9'(`*z**(+|++ ,3,4,H,.../X/1M111X22&3334y49 ;<>>^>_>h>>IAJABBBBYCCCdDDDDE%FFFGGiGlIIIIIIIIIIJJ J JdJgJlJ~JJJ(K)KGKHK`KaKyKzKKKKKNO(OSOTOUUUVXeY[%\c^bbb e_hjclllBm^mm n:nnn?̎ !*/49:DINSTcejopŏƏ@wɒ%qrԓ,-Hde}./!#ߘ<UVƚǚ$ʛ˛)}dޝߝHOPDFA _x˧(] deêЬY[Vt=00000000000000000000 00 0 00 0 000000000000000000000000000000000000000000000000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00J00bJ00bJ00J00J003J00J005J005J004J002J00YJ0 0^J0 0^J00XJ00VJ0 0J0 0J00\J0 0*J0 0)J0 0J0 0J0 0J0 0J0 0J00J00J00J00J00@0@0J00J00J00J00IJ00HJ00 \J00J00J0!0J0!0J00J00@0@0J0!0>J0!0>J0*09J0*09J0*09J0*09J0-0.J0-0.J0-0J0-0J0-0J0R0J000J000J000J000J0R0J0-0 J0-0 J0-0 J0-0 J0-0 J0-0 J0R0J0/0 J0J0 J0J0 J0J0 J0J0 J0R0J0R0J0S0 J0S0 J0S0J0k0J0k0J0k0J0k0J00J0l0 J0l0 J0l0 J0l0 @0 J0M0J0M0N@0 J0O0P@0 J0Q0R@0 J0S0T@0 J0U0V@0 J0W0X@0 J00bJ00bJ00bJ00bJ00J00J003J00J00J00J005J005J004J002J00YJ0 0^J0 0^J00XJ00VJ0 0J0 0J00\J00\J00\J00\J00\J00\J0 0*J0 0)J0 0J0 0J0 0J0 0J0 0J00J00J00J00J00@0@0J00J00J00J00J00J00J00J00J00J00J00IJ00HJ00HJ00J00J00J00J0!0J0!0J00J00J00J00J00J00J00J00J00J00J00J00@0@0J0!0>J0!0>J0!0>J0!0>J0!0>J0*09J0*09J0*09J0*09J0*09J0*09J0*09J0-0J0-0J0-0J0-0J0-0J0-0J0-0J0-0J0R0J000J000J000J000J0R0J0-0 J0-0 J0-0 J0-0 J0-0 J0-0 J0R0J0/0 J0/0 J0J0 J0J0 J0J0 J0J0 J0J0 J0J0 J0R0J0R0J0S0 J0S0 J0S0J0k0J0k0J0k0J0k0J00J0l0 J0l0 J0l0 J0l0 @0 J0M0J0M0J0M0J0M0J0M0@0 J0O0J0O0J0O0J0O0@0 J0Q0J0Q0J0Q0J0Q0@0 J0S0J0S0J0S0J0S0@0 J0U0J0U0J0U0J0U0@0 J0W0J0W0J0W0J0W0@0 Z00Z00Z00Z00Z002Z001J00bZ00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00Z00 @00 Z00 00J00J00J00J00J00@0J00J00J00J0 0 J00J0 0 J0 0J00 J0 0J0 0 J00J0 0J0 0J00J00J00J00J00J00J00J00@0J00J00J00J0 0 J00J0 0 J0 0J00 J0 0J0 0 J00J0 0J0 0J00J00J00 00 ( Q ,4j6;&CYPGSSW^c=mv$xTsΣ/Z_fimquy e R  D . J ,tv#n^m e 34:DhFJLOQQ R~R(S7S`SySSSPTjx9 ܒPʕ> 9So,H `bcdeghjklnoprstvwxz{|}~aWZf,  XFtFtXXXXXXXText14Text15[X [ I l  4 |K lM    , | ̪  T G K  G H 4   t  ! D l , l? TH G TJ J $  T  4   x DH t t |+ 8  B l 7 ,;  4 $" " # \$ $ % Ԯ 4 Ďº ú ĺ tź THƺ $MǺ UȺ Xɺ $^ʺ 4g˺ D̺ oͺ l|κ Ϻ Hк tѺ  Һ |Ӻ Ժ lպ ֺ ,׺ dغ ٺ tں  ۺ ܺ ݺ ;޺ 4ߺ 4 4 D(  , ̈ 0 ,w E R dS T DW D[  ] dd ) tQ ,G Y t= I  % d   '  쥟 l} ̺ $q | ,   lL L W W d   $  d      l1 1   , l D    D  $Z dZ ` ` ,i li O  O! d "  # T$ % <:& |:' U( $V) *  + r, r- . /  0  1  2 $3 4 4 ''FFMU\ff())!),)o)o)}))))k*k*t*++$++++22^4^4qBqB_&_&_lllll/m/m=mMmMmZm+n+n4nnnnoooSvSvxx11@@KՔ MAALNY]]ccn*,7;;8 ;;p44=ddoȥȥߥߥ""q|xx44? ALPPM*5PPIIRyyݰݰ77      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~ &&EEKTZZamm()#)#)<)|))))))r*w*w*"+'+'++++22g4g4xBxB!_-_-_lllllAA!!JNTTU47WWPUU<<    !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~ =*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType>*urn:schemas-microsoft-com:office:smarttags PostalCode:*urn:schemas-microsoft-com:office:smarttagsStreet;*urn:schemas-microsoft-com:office:smarttagsaddress>*urn:schemas-microsoft-com:office:smarttags PersonName9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsStateBd*urn:schemas-microsoft-com:office:smarttagscountry-region dddddddddddd|h'r'++,,[-e---6/@/Q4[499)>1>BBICVCKKSS[gٓߓ1djvMaŕԕ.83W_jYdFQ;\{}p (:FLs}ǝ۝GMa~Tן;p$*Q["Vz|(*@it!^ۦ§ʧ-<K]io-/\bv©̩iȪ(P -9?fpͬ-7kȭѭ=?U~$(6sӰıαбֲײ߲BQ`r~3333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333:cgSd W0]?u.w6o) _ p % n   ߝ )tF$(!b=!$&a,$6Qq4.: JjLb-]<_"`Osrxhh^h`OJPJQJ^Jo(^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhh^h`OJPJQJ^Jo(^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHhh^h`OJPJQJ^Jo(^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHhh^h`OJPJQJ^Jo(^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhh^h`OJPJQJ^Jo(^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hH =!$(!JjLOs-]_"`&a,q4)t.: |                          |        |        |                          |                 65NK} 5eeJo jwaY"d%E&R'0a1?:5S;BIzdNOhRlTU(U,gGi-Qifp(q&{ B3{,DXh'WV)#<d*EOl"n;|u_?)%px[\cefRSd %DEW./05JK],-?tu .vw #$6no   ) ^ _ p   % m n    =>>>^>_>h>IAJAUABBBBDDDGGlIIIIIIIIIJJ J JdJgJ~JJJJJ K(K)K7K?̎ !*/49:DINSTcejop@I`@Unknown Gz Times New Roman5Symbol3& z Arial7&  Verdana3z Times?& Arial Black5& zaTahoma?5 z Courier New;Wingdings"1hDFDFFPPPP$@4d2qHP ?#2Office of Nursing Services vhacllyerarr VHACOMITCHR4         ObjInfo'*WordDocumentj8SummaryInformation()+;DocumentSummaryInformation8C      !"#$%&'()*+,-./0123456789:<=>?@ABDEFGHIJMNOPQRSTUVWXYZ[\]^_`abcdghijklmnopqrstuvwxyz{|}~%` bjbj 8̟̟ +>>>8v4T ’’’’’" $h? ’’ ?h’’T ’’ ’ p5>ϲyj0aZ4 ƜR??X dvJ:S;v:S Office of Nursing Services 2008 Annual Innovations Awards Application Form Professional Practice Environment for Nursing Excellence Title of SubmissionIntensive Cultivation of an Exportable Skin Management and Pressure Ulcer ProgramFacility Name and AddressJames A. Haley Veterans Hospital 13000 Bruce B. Downs Boulevard Tampa, Florida 33612VISN #8 Names of Team Members (Note: At least two (2) team members are required.) Primary Author InformationNameSusan S. Thomason, MN,RN,APRN-BC,CWON-APTitle of PositionClinical Nurse Specialist, Certified Advanced Wound, Ostomy Nurse Telephone Number813 972-2000 Extension: 6394 e-mail:  HYPERLINK "mailto:Susan.Thomason@va.gov" Susan.Thomason@va.gov  FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NameChristine Bennett, ARNP, CWOCNTitle of PositionCertified Wound, Ostomy, Continence Nurse SCI/Rehab/PolytraumaTelephone Number813 972-0000 Extension: 4766 e-mail:  HYPERLINK "mailto:Christine.Bennett@va.gov" Christine.Bennett@va.gov NamePaula Boyle, BSN,CWNTitle of PositionStaff Nurse Certified Wound Nurse NHCUTelephone Number813 972-2000 Extension: 4351 e-mail:  HYPERLINK "mailto:Paula.Boyle@va.gov" Paula.Boyle@va.gov NameAnne Dammers, BSNTitle of PositionStaff Nurse Wound, Ostomy, Continence Nurse NHCUTelephone Number813 -972-0000 Extension: 3792 e-mail:  HYPERLINK "mailto:Anne.Dammers@va.gov" Anne.Dammers@va.gov NameHeidi Lacko, BSNTitle of PositionStaff Nurse - Wound, Ostomy, Continence Nurse Medical-Surgical/AC/ICUTelephone Number813 - 972 -2000 Extension: 6701 e-mail:  HYPERLINK "mailto:Heidi.Lacko@va.gov" Heidi.Lacko@va.gov NameJane Nichols, MSN,RN,CWONTitle of PositionCertified Wound, Ostomy Nurse Medical-Surgical/AC/ICUTelephone Number813 - 972 -2000 Extension: 6602 e-mail:  HYPERLINK "mailto:Jane.Nichols@va.gov" Jane.Nichols@va.gov NameAnna Resulta, BSNTitle of PositionStaff Nurse - Wound, Ostomy, Continence Nurse SCITelephone Number813 - 972 -2000 Extension: 6602 e-mail:  HYPERLINK "mailto:Anatalia.Resulta@va.gov" Anatalia.Resulta@va.gov NameCandice Watkins, BSNTitle of PositionStaff Nurse Wound, Ostomy, Continence Nurse Medical-Surgical/AC/ICUTelephone Number813 - 972 -2000 Extension: 6601 e-mail:  HYPERLINK "mailto:Candice.Watkins@va.gov" Candice.Watkins@va.gov Office of Nursing Services Annual Innovations Awards INTENSIVE CULTIVATION OF AN EXPORTABLE SKIN MANAGEMENT AND PRESSURE ULCER PROGRAM Summary The advent of VHA Handbook 1180.2, Assessment and Prevention of Pressure Ulcers,  transformed practice related to skin and pressure ulcer management into a new era of Magnet-caliber nursing excellence. To optimize this opportunity, the organization conducted a comprehensive assessment to identify structure and process gaps and develop an action plan to address needs based upon the organizations goals. The initiative required that implementation be accomplished throughout the healthcare continuum: inpatient, outpatient, extended care, and many non-institutionalized care settings. Systematic planning encompassed information technology; saturating patients, families, caregivers, grass-roots nursing, and interdisciplinary staff with education, and; performance improvement and monitoring. Subsequently, a dynamic Skin Management and Pressure Ulcer Program evolved from a fragmented skin and wound care practice. In a relatively unprecedented move, leadership supported four staff Registered Nurses to obtain graduate education in wounds, ostomies, and continence; this provided an exponential expansion of expertise in this area. This submission describes the innovative approaches, pervasive deployment, capitalization of learning, and vertical and horizontal integration into the total organization. Outcomes have demonstrated a low incidence of healthcare-acquired pressure ulcers (HA-PU), improvement in peer review findings related to skin integrity, and a conducive practice environment for pressure ulcer research, participation in national initiatives, and other value-added endeavors. Date of Implementation 8/8/06 Present Adoption of the Innovation Organizational Need VHA Handbook 1180.2 was published in June 2006 partially as a result of a report by the VA Office of Inspector General;  this report identified multiple opportunities for improvement in the management of patients with pressure ulcers in VHA facilities. The enormity of Handbook 1180.2 in terms of resources, new processes, anticipated outcomes, and other factors, was daunting to VHA facilities across the nation. The James A. Haley Veterans Hospital (JAHVH), however, systematically launched a massive initiative that was spearheaded by nurses to create an environment in which these imperatives could be met and generously exceeded. Literature Review The professional literature is replete with evidence-based clinical practice guidelines (CPG) that endorse recommendations regarding the assessment, prevention, and management of patients with pressure ulcers. The initial major CPG emanated from the Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research.,  The Wound, Ostomy, Continence (WOC) Nurses Society published their CPG on pressure ulcer management in 2002. Population-specific CPG on pressure ulcers were also utilized due to a large 70-bed spinal cord injury (SCI) center at the JAHVH.  One of the nursing architects of the Program participated on the development panel for the SCI CPG and was a peer reviewer for the AHRQ CPG on pressure ulcer treatment. Organizational Customization Following publication of VHA Handbook 1180.2, an intensive assessment was conducted that focused on how to best deploy the Handbook throughout the organization. The initiative was tailored to JAHVH and Orlando, bridging all settings and care acuities. Input was obtained through formal meetings, forums, and informal discussions involving leadership, internal and external stakeholders, and interdisciplinary team members to grasp the implications of Handbook implementation for each Service. Collaboration among stakeholders was astounding, and leadership provided the energy and resources to ensure full implementation. Creative Approach Nursing developed a proposal to increase the existing resources of wound care specialists (WCS) from an anemic 2.4 positions to a proactive 8.4 positions for Tampa and Orlando. Finding a paucity of certified WOC specialists in the community, leadership was highly supportive of facilitating training of staff nurses within the organization. Four incumbent staff Registered Nurses (RN) with Bachelor of Science degrees were selected. The JAHVH funded these nurses to attend a web-based WOC Program; all four of these risk-taking nurses completed 10 graduate level hours to successfully complete this rigorous program while working full-time. The JAHVH provided fiscal support (e.g., tuition, books, external preceptor), clinical preceptorship of 160 hours for each nurse, and administrative support (e.g., proctoring exams, affiliation agreements). Concurrent with the educational program, the WCS and certified WOC nurses became catalysts for changes in policies, procedures, computerized applications, monitoring, performance improvement, product evaluation, clinical competencies, and research. Nursing Leadership and Collaboration Nurse Participation Nursing provided strong leadership for the assessment, development, implementation, and evaluation of this ambitious initiative. Nurses provided the clinical scaffolding of this venture under the tutelage of the Associate Director of Patient Care/Nursing Services and Chief Nurses of their respective services. Under the auspices of the interdisciplinary Hospital Skin Committee (HSC), nurses collaborated to conceptualize a Skin Management and Pressure Ulcer Program and identify creative strategies for implementation. Staff Nurse Delivery WCS participation is integral to the continued viability of the Program. The delivery system of WOC services in the JAHVH was renovated from primarily consultation to a more intense change in professional WOC practice. All WOC nurses actively participate on the HSC to ensure an open conduit of information to and from front-line staff nurses, forecast trends in WOC, analyze performance improvement data, and chart the course of future initiatives. They also coach front-line staff nurses to assess pressure ulcer risk using the Braden Scale, complete the pressure ulcer assessment and reassessment, initiate consults to the WCS, develop the plan of care for patients with WOC issues, provide discharge instructions and appropriate supplies, and provide patient, family, and caregiver education. Interdisciplinary Collaboration The professional practice environment is rich with interdisciplinary collaboration in WOC management. This fertility has its roots embedded on the unit level, where daily networking is accomplished among front-line staff and advance practice nurses, physicians, therapists, dietitians, social workers, psychologists, and other disciplines. The interdisciplinary HSC galvanizes these various perspectives to expand the breadth of the skin/wound care Program throughout the organization. Interdisciplinary collaboration is evident in clinical skin and wound rounds, consultations, and prevention and management strategies. Presentations & Publications Abundant inservices and presentations have been given by the WOC Nurses to unit nurses, interdisciplinary team members, affiliating students, and researchers since this initiative commenced in 2006. WOC Nurses have provided continuing education, state and national presentations, and professional publications, as follows: Presented/Accepted Platform Presentations: 12/07 Nichols, Jane S. Wound Assessment and Treatment. CME. Physicians, JAHVH, FL 5/07 Nichols, Jane S. Pressure Ulcers: Legal Issues. North Florida - South Georgia VA, Gainesville, FL. 8/08 Thomason, S.S. & Nelson, A. (Accepted) Emergence of an SCI Evidence-Based Tool for Monitoring Pressure Ulcers. 2008 Congress of Spinal Cord Medicine and Rehabilitation Orlando, FL. 5/07 Thomason, S.S. Implementation of the VHA Handbook 1180.2 Assessment and Prevention of Pressure Ulcers Con Ed-CME. SCI 101 lecture series. JAHVH, FL. 11/06 Thomason, S.S. Pressure Ulcer Assessment: A Breakthrough Collaborative. National SCI Strategic Healthcare Group IHI Collaborative Symposium. Seattle,WA. Presented/Accepted Poster Presentations:   Published/Accepted Articles:    Scope of Initiative Impacted Areas This initiative involved: medical-surgical and intensive care; rehabilitation, polytrauma, and SCI; NHCU; one of the largest VHA Ambulatory Care (AC) Services in the nation, and; select non-institutionalized settings (e.g., Care Coordination Home Telehealth, Home Care). The Orlando VA Outpatient Clinic/NHCU and the Baldomero Lopez State Veterans Home were also benefactors of the Program. Strategy examples include: Single Area: Research: Monitoring Pressure Ulcer Healing in Persons with Spinal Cord Impairment. HSR&D Nursing Research Initiative $522,000 (1/06 1/09). Identify pressure ulcer high risk populations for Ambulatory Care (AC) and determine implications for CBOCS and AC. Provide input into the Polytrauma Family Care Pathway. Multiple Areas: Develop/implement order sets for wound management. Develop/implement an educational plan for the VANOD Skin Assessment and Reassessment. Develop/implement a process for formal product evaluations. Facility Wide: Develop/implement a wound assessment template. Develop/implement specific interventions for the Braden Risk Assessment Scale. Propose/approve the WCS Educational Initiative for the web-WOC Program. Develop/approve HPM 111-55 Skin Management and Pressure Ulcer Program. Serve as a pilot site for VANOD Admission Assessment/Reassessment Skin templates. Develop a training module for Braden Risk Assessment Scale training. Revise the Interdisciplinary Patient Assessment, and Nursing Bedside Assessment. Refine outpatient Wound Clinics. Evaluate/replace bed frames/support surfaces in the JAHVH, Tampa and Orlando NHCU. Develop an approved educational brochure, Protect Yourself from Pressure Ulcers. Develop specific competencies for WCS. Develop/approve a Scope of Practice/Functional Statement for WCS based upon performance appraisal dimensions. Nation Wide: Participate on the national VHA IHI 5 Million Lives Pressure Ulcer Workgroup for the purpose of revising Handbook 1180.2. Research: Expert Panel (2007). Pressure Ulcers and Telehealth. Cleveland VAMC and QUERI. Participate on the SCI IHI Collaborative on Pressure Ulcers. Impact Process Improvement Measurable process improvement may be appreciated in both traditional and untraditional ways: Denial of a tort claim of $2.5m for a pressure ulcer incurred at another VA facility; subject facility attorney related that the denial was due to legal review by a JAHVH WCS. Cost deference of rental specialty support surfaces (e.g., low air loss) due to purchase of pressure redistribution surfaces; this change was made as a result of product evaluation and recommendations by our WCS and staff nurses. Cost deference by changing to more extended-wear topical wound dressings (e.g., silver, hydrocolloid) in lieu of dressings requiring an increased nursing time-burden. Sustained low incidence of HA-PU well below national benchmarks; reduction in HA-PU translate into decreased costs (e.g., dressings, caregiver time), increased wages for the patient, decreased morbidity, and decreased mortality. Nursing Satisfaction The 2007 All Employees Survey for a grouping of 17 nursing staff, including 5 WCS, indicated the following scores (Likert Scale: 1 dissatisfied 5 satisfied): Job Satisfaction: Scores 3 or > in work type/amount, co-worker, supervision, senior management; work conditions, customer satisfaction, praise, work quality, satisfaction, satisfaction-2 yrs; the vast majority of scores were in the mid-4 range. Score < 3 was in promotion opportunity (2.94). Organizational Assessment: Scores 3 or > in cooperation, conflict resolution, diversity acceptance, co-worker/supervisory support, customer service, innovation, resources, safety climate, leadership, rewards, employee development, planning/evaluation, job control, demands, retention, engagement, and civility; the vast majority of scores were in the mid-4 range. No scores were < 3. Culture: Scores 3 or > in group and rational; the vast majority of scores were in the mid-4 range. Scores < 3 were in entrepreneurial (2.88) and permanence and stability (2.88). Long-term Integration Subsequent to the activation of this initiative in 2006, there have been strong, sustained gains in the Skin Management and Pressure Ulcer Program. The revitalized Program is discussed in the context of Baldrige criteria.  ProcessApproachDeveloped an Action Plan based on organizational goals, needs, and impacted areas across program lines (e.g., resources). Identified and collaborated with significant internal and external stakeholders (e.g., veterans/families/caregivers, nursing/hospital leadership, interdisciplinary HSC members, staff RNs, vendors). Conducted a gap analysis to identify opportunities for improvement (e.g., need for systematic documentation). Implemented strategies to effect cultural change in skin and pressure ulcer management (See Scope of Initiative). Promoted workforce engagement through motivating interdisciplinary team members to adhere to Handbook 1180.2 (e.g., 1:1 discussion with WCS; educational initiatives; performance appraisals).DeploymentPenetrated multiple clinical disciplines throughout all clinical settings. Provided workforce training in CPRS applications, prevention, and treatment (e.g., VANOD template pilot site). Applied standardized principles of prevention and treatment of pressure ulcers throughout JAHVH, Orlando, and the Baldomero Lopez State Veterans Home (e.g., beds, support surfaces, wound products). LearningSignificantly enhanced skills and knowledge of WCS nurses (e.g., web-WOC graduate credit education and preceptorship). Educated interdisciplinary staff regarding Handbook 1180.2 and its relevancy to their roles (e.g., RN admission risk assessment). Educated patients/families/caregivers in the prevention and management of pressure ulcers along the continuum of care (e.g., brochure). Educated nursing colleagues regarding the innovation (e.g., informally, local and national e-mail, presentations, publications).IntegrationEnsured that processes in the assessment, planning, implementation, and evaluation of the Program were complementary across all units and services (e.g., HSC agenda items). Harmonized organizational processes to promote an understanding of relevant aspects of Handbook 1180.2 (e.g., ulcer risk assessment). Used national evidence-based CPG throughout the organization and in population-specific areas (e.g., SCI). Attained performance improvement in documentation and surveillance (e.g., disseminated External Peer Review Program {EPRP} results).  Outcome Impact Outcomes are examined based upon three primary sources: incidence of HA-PU for Acute Care and SCI FY07, results of EPRP for Skin Integrity FY08 Qtr I-II, and findings of National Database of Quality Indicators (NDNQI) FY06-07. Incidence of HA-PU: Acute Care 0.95% admissions (bench 3-14%); SCI 0.32% 1000 pt days. EPRP Skin Integrity: Four diagnoses were reviewed: Surgical Care, Acute Coronary Syndrome, Pneumonia, and Heart Failure. Patients were deemed at risk for pressure ulcers if they had one of the preceding diagnoses (32-46%) or if they had a SCI (100%). Supporting IndicatorTargetAverageScreened with Braden Risk Assessment Scale within 24 hours of admission100% 99.2%Developed a HA pressure ulcer0%2%Without a treatment plan for all Stage II pressure ulcers within 48 hours of observation0%11% (low sample size)NDNQI Percent of Surveyed Adult Patients with HA-PU Stages II and Above: AreaAverage Median JAHVHNational Comparative Mean** National Standard DeviationCritical Care2.297.8110.81Surgical2.442.123.91Medical*8.813.475.40Step Down2.043.596.89Rehabilitation03.656.96*Veterans older with > co-morbidities ** Bedsize 300-399 Conclusion The Program has burgeoned into a robust interdisciplinary initiative that provides quality throughout the care continuum. It is comprehensive, provides added value, and has been fully integrated into the organizations culture. Nurses have had a powerful influence on skin and pressure ulcer outcomes and have achieved excellence in cultivating a practice environment that is conducive to further innovation to improve documentation, employ emerging tools and concepts, promote WOC certification, foster research, and ensure education on all levels. REFERENCES Office of Nursing Services Annual Innovations Awards INTENSIVE CULTIVATION OF AN EXPORTABLE SKIN MANAGEMENT AND PRESSURE ULCER PROGRAM Summary The advent of VHA Handbook 1180.2, Assessment and Prevention of Pressure Ulcers,  transformed practice related to skin and pressure ulcer management into a new era of Magnet-caliber nursing excellence. To optimize this opportunity, the organization conducted a comprehensive assessment to identify structure and process gaps and develop an action plan to address needs based upon the organizations goals. The initiative required that implementation be accomplished throughout the healthcare continuum: inpatient, outpatient, extended care, and many non-institutionalized care settings. Systematic planning encompassed information technology; saturating patients, families, caregivers, grass-roots nursing, and interdisciplinary staff with education, and; performance improvement and monitoring. Subsequently, a dynamic Skin Management and Pressure Ulcer Program evolved from a fragmented skin and wound care practice. In a relatively unprecedented move, leadership supported four staff Registered Nurses to obtain graduate education in wounds, ostomies, and continence; this provided an exponential expansion of expertise in this area. This submission describes the innovative approaches, pervasive deployment, capitalization of learning, and vertical and horizontal integration into the total organization. Outcomes have demonstrated a low incidence of healthcare-acquired pressure ulcers (HA-PU), improvement in peer review findings related to skin integrity, and a conducive practice environment for pressure ulcer research, participation in national initiatives, and other value-added endeavors. Date of Implementation 8/8/06 Present Adoption of the Innovation Organizational Need VHA Handbook 1180.2 was published in June 2006 partially as a result of a report by the VA Office of Inspector General;  this report identified multiple opportunities for improvement in the management of patients with pressure ulcers in VHA facilities. The enormity of Handbook 1180.2 in terms of resources, new processes, anticipated outcomes, and other factors, was daunting to VHA facilities across the nation. The James A. Haley Veterans Hospital (JAHVH), however, systematically launched a massive initiative that was spearheaded by nurses to create an environment in which these imperatives could be met and generously exceeded. Literature Review The professional literature is replete with evidence-based clinical practice guidelines (CPG) that endorse recommendations regarding the assessment, prevention, and management of patients with pressure ulcers. The initial major CPG emanated from the Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research.,  The Wound, Ostomy, Continence (WOC) Nurses Society published their CPG on pressure ulcer management in 2002. Population-specific CPG on pressure ulcers were also utilized due to a large 70-bed spinal cord injury (SCI) center at the JAHVH.  One of the nursing architects of the Program participated on the development panel for the SCI CPG and was a peer reviewer for the AHRQ CPG on pressure ulcer treatment. Organizational Customization Following publication of VHA Handbook 1180.2, an intensive assessment was conducted that focused on how to best deploy the Handbook throughout the organization. The initiative was tailored to JAHVH and Orlando, bridging all settings and care acuities. Input was obtained through formal meetings, forums, and informal discussions involving leadership, internal and external stakeholders, and interdisciplinary team members to grasp the implications of Handbook implementation for each Service. Collaboration among stakeholders was astounding, and leadership provided the energy and resources to ensure full implementation. Creative Approach Nursing developed a proposal to increase the existing resources of wound care specialists (WCS) from an anemic 2.4 positions to a proactive 8.4 positions for Tampa and Orlando. Finding a paucity of certified WOC specialists in the community, leadership was highly supportive of facilitating training of staff nurses within the organization. Four incumbent staff Registered Nurses (RN) with Bachelor of Science degrees were selected. The JAHVH funded these nurses to attend a web-based WOC Program; all four of these risk-taking nurses completed 10 graduate level hours to successfully complete this rigorous program while working full-time. The JAHVH provided fiscal support (e.g., tuition, books, external preceptor), clinical preceptorship of 160 hours for each nurse, and administrative support (e.g., proctoring exams, affiliation agreements). Concurrent with the educational program, the WCS and certified WOC nurses became catalysts for changes in policies, procedures, computerized applications, monitoring, performance improvement, product evaluation, clinical competencies, and research. Nursing Leadership and Collaboration Nurse Participation Nursing provided strong leadership for the assessment, development, implementation, and evaluation of this ambitious initiative. Nurses provided the clinical scaffolding of this venture under the tutelage of the Associate Director of Patient Care/Nursing Services and Chief Nurses of their respective services. Under the auspices of the interdisciplinary Hospital Skin Committee (HSC), nurses collaborated to conceptualize a Skin Management and Pressure Ulcer Program and identify creative strategies for implementation. Staff Nurse Delivery WCS participation is integral to the continued viability of the Program. The delivery system of WOC services in the JAHVH was renovated from primarily consultation to a more intense change in professional WOC practice. All WOC nurses actively participate on the HSC to ensure an open conduit of information to and from front-line staff nurses, forecast trends in WOC, analyze performance improvement data, and chart the course of future initiatives. They also coach front-line staff nurses to assess pressure ulcer risk using the Braden Scale, complete the pressure ulcer assessment and reassessment, initiate consults to the WCS, develop the plan of care for patients with WOC issues, provide discharge instructions and appropriate supplies, and provide patient, family, and caregiver education. Interdisciplinary Collaboration The professional practice environment is rich with interdisciplinary collaboration in WOC management. This fertility has its roots embedded on the unit level, where daily networking is accomplished among front-line staff and advance practice nurses, physicians, therapists, dietitians, social workers, psychologists, and other disciplines. The interdisciplinary HSC galvanizes these various perspectives to expand the breadth of the skin/wound care Program throughout the organization. Interdisciplinary collaboration is evident in clinical skin and wound rounds, consultations, and prevention and management strategies. Presentations & Publications Abundant inservices and presentations have been given by the WOC Nurses to unit nurses, interdisciplinary team members, affiliating students, and researchers since this initiative commenced in 2006. WOC Nurses have provided continuing education, state and national presentations, and professional publications, as follows: Presented/Accepted Platform Presentations: 12/07 Nichols, Jane S. Wound Assessment and Treatment. CME. Physicians, JAHVH, FL 5/07 Nichols, Jane S. Pressure Ulcers: Legal Issues. North Florida - South Georgia VA, Gainesville, FL. 8/08 Thomason, S.S. & Nelson, A. (Accepted) Emergence of an SCI Evidence-Based Tool for Monitoring Pressure Ulcers. 2008 Congress of Spinal Cord Medicine and Rehabilitation Orlando, FL. 5/07 Thomason, S.S. Implementation of the VHA Handbook 1180.2 Assessment and Prevention of Pressure Ulcers Con Ed-CME. SCI 101 lecture series. JAHVH, FL. 11/06 Thomason, S.S. Pressure Ulcer Assessment: A Breakthrough Collaborative. National SCI Strategic Healthcare Group IHI Collaborative Symposium. Seattle,WA. Presented/Accepted Poster Presentations:   Published/Accepted Articles:    Scope of Initiative Impacted Areas This initiative involved: medical-surgical and intensive care; rehabilitation, polytrauma, and SCI; NHCU; one of the largest VHA Ambulatory Care (AC) Services in the nation, and; select non-institutionalized settings (e.g., Care Coordination Home Telehealth, Home Care). The Orlando VA Outpatient Clinic/NHCU and the Baldomero Lopez State Veterans Home were also benefactors of the Program. Strategy examples include: Single Area: Research: Monitoring Pressure Ulcer Healing in Persons with Spinal Cord Impairment. HSR&D Nursing Research Initiative $522,000 (1/06 1/09). Identify pressure ulcer high risk populations for Ambulatory Care (AC) and determine implications for CBOCS and AC. Provide input into the Polytrauma Family Care Pathway. Multiple Areas: Develop/implement order sets for wound management. Develop/implement an educational plan for the VANOD Skin Assessment and Reassessment. Develop/implement a process for formal product evaluations. Facility Wide: Develop/implement a wound assessment template. Develop/implement specific interventions for the Braden Risk Assessment Scale. Propose/approve the WCS Educational Initiative for the web-WOC Program. Develop/approve HPM 111-55 Skin Management and Pressure Ulcer Program. Serve as a pilot site for VANOD Admission Assessment/Reassessment Skin templates. Develop a training module for Braden Risk Assessment Scale training. Revise the Interdisciplinary Patient Assessment, and Nursing Bedside Assessment. Refine outpatient Wound Clinics. Evaluate/replace bed frames/support surfaces in the JAHVH, Tampa and Orlando NHCU. Develop an approved educational brochure, Protect Yourself from Pressure Ulcers. Develop specific competencies for WCS. Develop/approve a Scope of Practice/Functional Statement for WCS based upon performance appraisal dimensions. Nation Wide: Participate on the national VHA IHI 5 Million Lives Pressure Ulcer Workgroup for the purpose of revising Handbook 1180.2. Research: Expert Panel (2007). Pressure Ulcers and Telehealth. Cleveland VAMC and QUERI. Participate on the SCI IHI Collaborative on Pressure Ulcers. Impact Process Improvement Measurable process improvement may be appreciated in both traditional and untraditional ways: Denial of a tort claim of $2.5m for a pressure ulcer incurred at another VA facility; subject facility attorney related that the denial was due to legal review by a JAHVH WCS. Cost deference of rental specialty support surfaces (e.g., low air loss) due to purchase of pressure redistribution surfaces; this change was made as a result of product evaluation and recommendations by our WCS and staff nurses. Cost deference by changing to more extended-wear topical wound dressings (e.g., silver, hydrocolloid) in lieu of dressings requiring an increased nursing time-burden. Sustained low incidence of HA-PU well below national benchmarks; reduction in HA-PU translate into decreased costs (e.g., dressings, caregiver time), increased wages for the patient, decreased morbidity, and decreased mortality. Nursing Satisfaction The 2007 All Employees Survey for a grouping of 17 nursing staff, including 5 WCS, indicated the following scores (Likert Scale: 1 dissatisfied 5 satisfied): Job Satisfaction: Scores 3 or > in work type/amount, co-worker, supervision, senior management; work conditions, customer satisfaction, praise, work quality, satisfaction, satisfaction-2 yrs; the vast majority of scores were in the mid-4 range. Score < 3 was in promotion opportunity (2.94). Organizational Assessment: Scores 3 or > in cooperation, conflict resolution, diversity acceptance, co-worker/supervisory support, customer service, innovation, resources, safety climate, leadership, rewards, employee development, planning/evaluation, job control, demands, retention, engagement, and civility; the vast majority of scores were in the mid-4 range. No scores were < 3. Culture: Scores 3 or > in group and rational; the vast majority of scores were in the mid-4 range. Scores < 3 were in entrepreneurial (2.88) and permanence and stability (2.88). Long-term Integration Subsequent to the activation of this initiative in 2006, there have been strong, sustained gains in the Skin Management and Pressure Ulcer Program. The revitalized Program is discussed in the context of Baldrige criteria.  ProcessApproachDeveloped an Action Plan based on organizational goals, needs, and impacted areas across program lines (e.g., resources). Identified and collaborated with significant internal and external stakeholders (e.g., veterans/families/caregivers, nursing/hospital leadership, interdisciplinary HSC members, staff RNs, vendors). Conducted a gap analysis to identify opportunities for improvement (e.g., need for systematic documentation). Implemented strategies to effect cultural change in skin and pressure ulcer management (See Scope of Initiative). Promoted workforce engagement through motivating interdisciplinary team members to adhere to Handbook 1180.2 (e.g., 1:1 discussion with WCS; educational initiatives; performance appraisals).DeploymentPenetrated multiple clinical disciplines throughout all clinical settings. Provided workforce training in CPRS applications, prevention, and treatment (e.g., VANOD template pilot site). Applied standardized principles of prevention and treatment of pressure ulcers throughout JAHVH, Orlando, and the Baldomero Lopez State Veterans Home (e.g., beds, support surfaces, wound products). LearningSignificantly enhanced skills and knowledge of WCS nurses (e.g., web-WOC graduate credit education and preceptorship). Educated interdisciplinary staff regarding Handbook 1180.2 and its relevancy to their roles (e.g., RN admission risk assessment). Educated patients/families/caregivers in the prevention and management of pressure ulcers along the continuum of care (e.g., brochure). Educated nursing colleagues regarding the innovation (e.g., informally, local and national e-mail, presentations, publications).IntegrationEnsured that processes in the assessment, planning, implementation, and evaluation of the Program were complementary across all units and services (e.g., HSC agenda items). Harmonized organizational processes to promote an understanding of relevant aspects of Handbook 1180.2 (e.g., ulcer risk assessment). Used national evidence-based CPG throughout the organization and in population-specific areas (e.g., SCI). Attained performance improvement in documentation and surveillance (e.g., disseminated External Peer Review Program {EPRP} results).  Outcome Impact Outcomes are examined based upon three primary sources: incidence of HA-PU for Acute Care and SCI FY07, results of EPRP for Skin Integrity FY08 Qtr I-II, and findings of National Database of Quality Indicators (NDNQI) FY06-07. Incidence of HA-PU: Acute Care 0.95% admissions (bench 3-14%); SCI 0.32% 1000 pt days. EPRP Skin Integrity: Four diagnoses were reviewed: Surgical Care, Acute Coronary Syndrome, Pneumonia, and Heart Failure. Patients were deemed at risk for pressure ulcers if they had one of the preceding diagnoses (32-46%) or if they had a SCI (100%). Supporting IndicatorTargetAverageScreened with Braden Risk Assessment Scale within 24 hours of admission100% 99.2%Developed a HA pressure ulcer0%2%Without a treatment plan for all Stage II pressure ulcers within 48 hours of observation0%11% (low sample size)NDNQI Percent of Surveyed Adult Patients with HA-PU Stages II and Above: AreaAverage Median JAHVHNational Comparative Mean** National Standard DeviationCritical Care2.297.8110.81Surgical2.442.123.91Medical*8.813.475.40Step Down2.043.596.89Rehabilitation03.656.96*Veterans older with > co-morbidities ** Bedsize 300-399 Conclusion The Program has burgeoned into a robust interdisciplinary initiative that provides quality throughout the care continuum. It is comprehensive, provides added value, and has been fully integrated into the organizations culture. Nurses have had a powerful influence on skin and pressure ulcer outcomes and have achieved excellence in cultivating a practice environment that is conducive to further innovation to improve documentation, employ emerging tools and concepts, promote WOC certification, foster research, and ensure education on all levels. REFERENCES INTENSIVE CULTIVATION OF AN EXPORTABLE SKIN MANAGEMENT AND PRESSURE ULCER PROGRAM  Veterans Health Administration (2006). Assessment and prevention of pressure ulcers. VHA Handbook 1180.2. Washington DC: Department of Veterans Affairs. 2 Office of Inspector General (2006). Management of patients with pressure ulcers in veterans health administration facilities. Washington DC: Department of Veterans Affairs. 3 Bergstrom, N., Bennett, M.A., Carlson, C.E. et al. (1994). Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. AHCPR Publication No. 95-0652. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. 4 Bergstrom, N., Allman, R.M., Carlson, C.E. et al. (1992). Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline. No. 3. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. 5 Wound, Ostomy, and Continence Nurses Society. (2002). Guideline for prevention and management of pressure ulcers. Glenview: IL: Author. 6 Consortium for Spinal Cord Medicine. (2000). Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health-care professionals. Washington DC: Paralyzed Veterans of America. 7 Thomason, S., Nelson, A., Luther, S., Harrow, J., & Palacios, P. (Accepted 6/08). Poster: Pressure Ulcer Healing in SCI: A Novel Evidence-Based Tool. Wound, Ostomy Continence Nurses Society Annual Conference. Marriott, Orlando, FL. 8 Thomason, S., Nelson, A., Luther, S, Palacios, P. & Harrow, J. (2008). Poster: Establishing sensitivity, reliability, and validity of a pressure ulcer healing tool for persons with spinal cord impairment. The Symposium on Advanced Wound Care & Wound Healing Society. San Diego, CA. 9 Brown, P. & Bennett, C. (2008). Quick reference to wound care. 3rd ed. Boston: Jones and Bartlett. 10 Thomason, S.S., Evitt, C.P., Harrow, J.J., Love, L., Moore, D.H., Mullins, M.A., Powell- Cope, G., & Nelson, A.L. (2007). Providers perceptions of spinal cord injury pressure ulcer guidelines. Journal of Spinal Cord Medicine. 30(2), 117-126. 11 Thomason, S.S. (2006). Taking on the challenge of advance practice certification: One Nurses Journey with the CWON-AP process. Wound, Ostomy, Continence Nurse Certification Board Bulletin. 1(2), 1. 12 Bergstrom, N., Allman, R.M., Carlson, C.E. et al. (1992). Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline. No. 3. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.      Veterans Health Administration (2006). Assessment and prevention of pressure ulcers. VHA Handbook 1180.2. Washington DC: Department of Veterans Affairs. 2 Office of Inspector General (2006). Management of patients with pressure ulcers in veterans health administration facilities. Washington DC: Department of Veterans Affairs.  Bergstrom, N., Bennett, M.A., Carlson, C.E. et al. (1994). Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. AHCPR Publication No. 95-0652. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.  Bergstrom, N., Allman, R.M., Carlson, C.E. et al. (1992). Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline. No. 3. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.  Wound, Ostomy, and Continence Nurses Society. (2002). Guideline for prevention and management of pressure ulcers. Glenview: IL: Author.  Consortium for Spinal Cord Medicine. (2000). Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health-care professionals. Washington DC: Paralyzed Veterans of America.  Thomason, S., Nelson, A., Luther, S., Harrow, J., & Palacios, P. (Accepted 6/08). Poster: Pressure Ulcer Healing in SCI: A Novel Evidence-Based Tool. Wound, Ostomy Continence Nurses Society Annual Conference. Marriott, Orlando, FL.  Thomason, S., Nelson, A., Luther, S, Palacios, P. & Harrow, J. (2008). Poster: Establishing sensitivity, reliability, and validity of a pressure ulcer healing tool for persons with spinal cord impairment. The Symposium on Advanced Wound Care & Wound Healing Society. San Diego, CA.  Brown, P. & Bennett, C. (2008). Quick reference to wound care. 3rd ed. Boston: Jones and Bartlett.  Thomason, S.S., Evitt, C.P., Harrow, J.J., Love, L., Moore, D.H., Mullins, M.A., Powell- Cope, G., & Nelson, A.L. (2007). Providers perceptions of spinal cord injury pressure ulcer guidelines. Journal of Spinal Cord Medicine. 30(2), 117-126.  Thomason, S.S. (2006). Taking on the challenge of advance practice certification: One Nurses Journey with the CWON-AP process. Wound, Ostomy, Continence Nurse Certification Board Bulletin. 1(2), 1.  Bergstrom, N., Allman, R.M., Carlson, C.E. et al. (1992). Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline. No. 3. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.  Veterans Health Administration (2006). Assessment and prevention of pressure ulcers. VHA Handbook 1180.2. Washington DC: Department of Veterans Affairs. 2 Office of Inspector General (2006). Management of patients with pressure ulcers in veterans health administration facilities. Washington DC: Department of Veterans Affairs.  Bergstrom, N., Bennett, M.A., Carlson, C.E. et al. (1994). Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. AHCPR Publication No. 95-0652. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.  Bergstrom, N., Allman, R.M., Carlson, C.E. et al. (1992). Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline. No. 3. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.  Wound, Ostomy, and Continence Nurses Society. (2002). Guideline for prevention and management of pressure ulcers. Glenview: IL: Author.  Consortium for Spinal Cord Medicine. (2000). Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health-care professionals. Washington DC: Paralyzed Veterans of America.  Thomason, S., Nelson, A., Luther, S., Harrow, J., & Palacios, P. (Accepted 6/08). Poster: Pressure Ulcer Healing in SCI: A Novel Evidence-Based Tool. Wound, Ostomy Continence Nurses Society Annual Conference. Marriott, Orlando, FL.  Thomason, S., Nelson, A., Luther, S, Palacios, P. & Harrow, J. (2008). Poster: Establishing sensitivity, reliability, and validity of a pressure ulcer healing tool for persons with spinal cord impairment. The Symposium on Advanced Wound Care & Wound Healing Society. San Diego, CA.  Brown, P. & Bennett, C. (2008). Quick reference to wound care. 3rd ed. Boston: Jones and Bartlett.  Thomason, S.S., Evitt, C.P., Harrow, J.J., Love, L., Moore, D.H., Mullins, M.A., Powell- Cope, G., & Nelson, A.L. (2007). Providers perceptions of spinal cord injury pressure ulcer guidelines. Journal of Spinal Cord Medicine. 30(2), 117-126.  Thomason, S.S. (2006). Taking on the challenge of advance practice certification: One Nurses Journey with the CWON-AP process. Wound, Ostomy, Continence Nurse Certification Board Bulletin. 1(2), 1.  Bergstrom, N., Allman, R.M., Carlson, C.E. et al. (1992). Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline. No. 3. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.  :K & ' Z c d   ( ѿ򱡓~~u~~j_T_TLT_TLhE&CJaJhNh#CJaJhNh CJaJhNh,gCJaJh CJ\aJhE&CJ\aJhNh CJ\aJhNh 5CJ\aJhy;h?:56CJOJQJaJhNh,g5CJ\aJ#h{h#5B*CJ\aJphh?:55B*CJ\aJph#h{h 5B*CJ\aJphhNh#5CJ\aJ:K T}kd$$Ifl0@ &\ l t0644 laPyt%p $Ifgd $a$gd?:5$a$gd#$ *]^a$gdhR  ' F [ \ c e x}kdj$$Ifl0@ &\ l t0644 laPyt%p $Ifgd e f g ||tk $Ifgd#$a$gd#gd }kd$$Ifl0@ &\ l t0644 laPyt%p $Ifgd#fkd>$$Ifl4&(0(64 laPf4yt%p  R $Ifgd#vkd$$Ifl0& 0(64 laPyt%p( Q S c d g h i j r s t } ӵӦtcQChNh#5CJ\aJ#jhNh#5CJU\aJ hh'hGi0JCJaJmH sH +jhh'hGiCJUaJmH sH hGiCJaJmH sH jhGiCJUaJmH sH hGihGiCJaJmH sH hGih CJaJmH sH hGih#CJaJmH sH hGihE&CJaJmH sH hNh CJaJhNh#CJaJh(qCJaJR S d $Ifgd#vkdn$$Ifl0& 0(64 laPyt%p  { $Ifgd#gd#vkd$$Ifl0& 0(64 laPyt%p W X Z [ e f g    $ % C E V W غ|fXMEME=Mh(qCJaJhE&CJaJhNh CJaJhNh#6CJ]aJ+hNh#56CJ\]aJmHnHu/jhNh#56CJU\]aJ hNh#56CJ\]aJ)jhNh#56CJU\]aJhNh#CJaJ%hNh#5CJ\aJmHnHu#jhNh#5CJU\aJ)jhNh#5CJU\aJ  % D $Ifgd#  !gd#ckd$$Ifl&(0(64 laPyt%pD E W $Ifgd#vkd9$$Ifl0& 0(64 laPyt%p . $Ifgd#vkd$$Ifl0& 0(64 laPyt%p     , - 0 4 5 I K \ ] j 湩vkckc[PhNh%pCJaJh(qCJaJhE&CJaJhNh CJaJ hh'hGi0JCJaJmH sH +jy hh'hGiCJUaJmH sH hGiCJaJmH sH jhGiCJUaJmH sH hGihGiCJaJmH sH hGih CJaJmH sH hGih#CJaJmH sH hGihE&CJaJmH sH hNh#CJaJ. / 0 5 J {{ $Ifgd#gd#vkd` $$Ifl0& 0(64 laPyt%pJ K ] $Ifgd#vkd $$Ifl0& 0(64 laPyt%p  $Ifgd#vkd $$Ifl0& 0(64 laPyt%p +->?mnsuĸĦwwow````hGih(qCJaJmH sH hGiCJaJh(qCJaJhNh#CJaJhNh%pCJaJ hGihGi0JCJaJmH sH #j@ hh'hGiCJUaJjhGiCJUaJhGihGiCJaJmH sH hGih%pCJaJmH sH hGihE&CJaJmH sH hGih#CJaJmH sH $,{{ $Ifgd#gd#vkd $$Ifl0& 0(64 laPyt%p,-?t $Ifgd#vkd $$Ifl0& 0(64 laPyt%ptu $Ifgd#vkdO$$Ifl0& 0(64 laPyt%p  -.uwԞqqqqbqVjhGiCJUaJhGih%pCJaJmH sH hGih(qCJaJmH sH h(qCJaJhNh#CJaJhNh%pCJaJhGih#CJaJmH sH  hh'hGi0JCJaJmH sH +jhh'hGiCJUaJmH sH hGihGiCJaJmH sH hGiCJaJmH sH jhGiCJUaJmH sH ! vm $Ifgd#  !$Ifgd#gd#vkd$$Ifl0& 0(64 laPyt%p.v $Ifgd#vkdb$$Ifl0& 0(64 laPyt%pvw $Ifgd#vkd$$Ifl0& 0(64 laPyt%p "6m)]p~~lZ~" *hGih(qCJ\aJmH sH #jQhh'hGiCJUaJhGihGiCJaJmH sH hGih(qCJaJmH sH h(qCJaJhNh(qCJaJ" *hGih#CJ\aJmH sH hGih#CJaJmH sH  hGihGi0JCJaJmH sH jhGiCJUaJ#jhh'hGiCJUaJ #vm $Ifgd(q  !$Ifgd(qgd#vkdq$$Ifl0& 0(64 laPyt%p#$6n $Ifgd(qvkd$$Ifl0& 0(64 laPyt(qno $Ifgd(qvkd$$Ifl0& 0(64 laPyt(qvm $Ifgd(q  !$Ifgd(qgd(qvkd$$$Ifl0& 0(64 laPyt(q)^ $Ifgd(qvkd$$Ifl0& 0(64 laPyt(q^_p $Ifgd(qvkdd$$Ifl0& 0(64 laPyt(q%lyyj^jL^; hGihGi0JCJaJmH sH #jhh'hGiCJUaJjhGiCJUaJhGihGiCJaJmH sH h(qCJaJhNh(qCJaJ" *hGih(qCJ\aJmH sH hGih(qCJaJmH sH  hh'hO0JCJaJmH sH +jhh'hOCJUaJmH sH hOhOCJaJmH sH hOCJaJmH sH jhOCJUaJmH sH vm $Ifgd(q  !$Ifgd(qgd(qvkd$$Ifl0& 0(64 laPyt(q%m $Ifgd(qvkd$$Ifl0& 0(64 laPyt(qmn $Ifgd(qvkd'$$Ifl0& 0(64 laPyt(q    AJKƺuulZEZl:h2hWCJaJ(h"8hW5CJaJeh r "hW5CJaJeh r hW5CJaJ hLhW5B*CJaJphhLhW5CJaJhW5B*CJaJphhGih,mH sH hGihWCJaJmH sH hWCJaJmH sH h,CJaJmH sH " *hGih(qCJ\aJmH sH hGih(qCJaJmH sH jhGiCJUaJ   w$a$gd(qgd#gd(qvkd$$Ifl0& 0(64 laPyt(q  Ah+,G e q$-D @&M a$gdWgdW$a$gdW3$$d!%d$&d!'d$-D @&M N!O$P!Q$a$gdW $@&a$gdW2$$d!%d$&d!'d$-D M N!O$P!Q$a$gdW  +,-FGNQ䬗jK: hJ/ hW5B*CJaJph<hW5B*CJaJeh fH phq r BhJ/ hW5B*CJaJeh fH phq r h; hWCJaJ(h"8hW5CJaJeh r "hW5CJaJeh r hR?hWCJaJjhW0JCJUaJhFX\hW0JCJaJhW5CJaJh2hWCJaJhWCJaJQacdejkmncd    0 2 4 ļـļti\iـļhWCJH*OJQJaJhjhWCJaJhjhW5CJaJ(hJ/ hW5CJaJeh r h!(hW5CJaJjhW0JCJUaJh_hhW0JCJaJhWCJaJhW5CJaJh"8hW5CJaJ"hW5CJaJeh r (h"8hW5CJaJeh r ! """"""'''4'5'='@'P'R'T'g)i)})~)),,,,Ʊ؏p_ƱƱSHh2,hWCJaJh2,hW5CJaJ hJ/ hW5B*CJaJph<hW5B*CJaJeh fH phq r BhJ/ hW5B*CJaJeh fH phq r (hJ/ hW5CJaJeh r "hW5CJaJeh r hW5CJaJhWCJaJh+hW5CJaJh+hWCJaJe "''5'`),9/00$1111`2z22(3|33 434@&gdW3$$d!%d$&d!'d$-D @&M N!O$P!Q$a$gdWgdW,,,9/?/A/[/]/^/_/'0*0+0000000$1112P2k2z222222223+3.3=3{333333344ڽگڐxxxxxhs4hWCJ\aJhhWCJ\aJhWCJ\aJh#fhWCJaJhW56CJaJh[ hW56CJaJh[ hWCJaJ"hW5CJaJeh r hWCJaJhW5CJaJ(hY>hW5CJaJeh r -44 4 4 444'4(4)4*4,4-4.40414243444G4H4R4U4`4b4d4666 6j6ռvn`\ThphW6hWhLhW56CJaJhWCJaJ(hLhW5CJaJeh r "hW5CJaJeh r hY>hW5B*CJaJphhW5B*CJaJphhW5CJaJhW56CJH*OJQJaJh[ hW56CJaJhW56CJaJ!jhW0J56CJUaJ3444H46667X7i777.8>8m889M9996:X:: & FgdW & FgdW & FgdW & FgdW@&gdWgdW$-D @&M a$gdW$a$gdWj6x666666666677W7X7e7g7h7i7{77.8;8<8>8W:X:h::::::::::::::%;&;;;;;;;ɾɲɾhLhWCJaJho(hW5CJaJhC#hW5CJaJho(hWCJaJhLhW6CJaJhW56CJaJhLhW56CJaJhphWCJaJh#hWCJaJhWCJaJhW hphW0::&;;;<y<<<==>> ?f???@$AA CDh^hgdW & FgdW0$d!%d$&d!'d$-D @&M N!O$P!Q$gdWgdW@&gdW & FgdW;;<'<=<[<^<_<y<<<<|========(A*A,A>A@ABAAA C&C뢑vavvavSShLhW56CJaJ(hLhW5CJaJeh r "hW5CJaJeh r hW5CJaJ hLhW5B*CJaJph<hW5B*CJaJeh fH phq r h,ZhW6CJ\aJhWCJ\aJhphW6 hphWhWhWCJaJh,ZhW6CJaJ&C'CDDDBECEXEYE\E=F>F^F_FhFJIUIJJJLLO!O.O/O1OP'P(PSPTPUPXPYP˶˭랍}˶˭qcXhGIhWCJaJjhW0JCJUaJhLhW6CJaJhWhthW5CJaJ h?hW5B*CJaJphh?hWB*CJaJphhW5CJaJ(hLhW5CJaJeh r "hW5CJaJeh r hLhW56CJaJhWCJaJhLhW5CJaJ"DBEE=F>F^F_FhFPkdF$$Ifl0X Xl  t0644 lapytD $IfgdDh^hgdWgdWhFFGHHIIJIUIIJJtk^^^ & F$IfgdD $IfgdD}kd$$Ifl0X Xl t0644 laytD & F$IfgdD JJJJYKKKdLL|sffYLL & F $IfgdD h$If^hgdD & F$IfgdD $IfgdDgdW}kdE$$Ifl0X Xl t0644 laytDLLLM%NNNOxkkkkx & F $IfgdD $IfgdD}kd$$Ifl0X Xl t0644 laytDOOOiOPnPlQQQQxxsssggg $$Ifa$gdDgdWh^hgdW}kd$$Ifl0X Xl t0644 laytD YP]PnPPPPPPPPkQlQQQQQQQR R RRRgR}R~RRRRRRRRS S)SGSϽߊߊ|k|k`hChWCJaJ hvhW5B*CJaJphhW5B*CJaJphhW56CJaJhOhW6CJaJhXhWCJaJ hOhW5B*CJaJphhOhWCJaJ hPIhWhWhLhW6CJaJhLhW56CJaJhWCJaJhGIhWCJaJ$QQQQQQJA555 $$Ifa$gdD $IfgdDkdt$$IflF !h  t0    44 lapytDQQRR Rpg[[ $$Ifa$gdD $IfgdDkd7$$IflF !h t0    44 laytD R RdRgRlR~Rpg[[[ $$Ifa$gdD $IfgdDkd$$IflF !h t0    44 laytD~RRRRR S(SpkbVVV $$Ifa$gdD $IfgdDgdWkd'$$IflF !h t0    44 laytD(S)S7S+" $IfgdDkd$$Ifl\x !($ p  t(0644 lap(ytD7S*CJaJhrW]hW5>*CJaJhrW]hW5CJaJhOhWCJaJhh"$hWCJaJ hLhW5B*CJaJphhW5B*CJaJphhGIhWCJaJhWCJaJhChWCJaJhW5CJaJ `SaSjSoStSyS[RFFF $$Ifa$gdD $IfgdDkd"!$$Ifl\x !($ p t0644 laytDySzSSSSS[RFFF $$Ifa$gdD $IfgdDkd!$$Ifl\x !($ p t0644 laytDSSSSSS[RFFF $$Ifa$gdD $IfgdDkdD"$$Ifl\x !($ p t0644 laytDSSTTPT[VV%0$d!%d$&d!'d$-D @&M N!O$P!Q$gdWgdWkd"$$Ifl\x !($ p t0644 laytDPTVVVVW(WSWTW]]]^`eac%dcfjj$-D M a$gda1gda1$a$gda12$$d!%d$&d!'d$-D M N!O$P!Q$a$gda1@&gdWgdWSW\W^WcWeWhWlWvWWWWWW]]]]]]]]]]]]^ļiJ<ha15B*CJaJeh fH phq r BhJ/ ha15B*CJaJeh fH phq r h; ha1CJaJhR?ha1CJaJjha10JCJUaJhFX\ha10JCJaJha1CJaJh2ha1CJaJ(h"8ha15CJaJeh r "ha15CJaJeh r ha15CJaJ^^^^!^#^$^%^^^^```````daeaa*b+b-b.bbb#c$ccԿԳ櫞ocXKha1CJH*OJQJaJhjha1CJaJhjha15CJaJ(hJ/ ha15CJaJeh r h!(ha15CJaJjha10JCJUaJh_hha10JCJaJha1CJaJh"8ha15CJaJ(h"8ha15CJaJeh r "ha15CJaJeh r ha15CJaJ hJ/ ha15B*CJaJphcccccccddddcfiflfzf|f~fjjjjjjkkkk'm)m=m콲eT hJ/ ha15B*CJaJph<ha15B*CJaJeh fH phq r BhJ/ ha15B*CJaJeh fH phq r h+ha15CJaJh+ha1CJaJha1CJaJ(hJ/ ha15CJaJeh r "ha15CJaJeh r ha15CJaJhjha1CJaJjj m_prctttBu^uu v:vvvm?m^p_pfphppprrssssssssctvt~tttttfuuuv+v:vBvvvvvvvvvŰŰ◌xlxlxlxlxlxlxlxhha1CJ\aJha1CJ\aJh#fha1CJaJha156CJaJh[ ha156CJaJh[ ha1CJaJ(hY>ha15CJaJeh r "ha15CJaJeh r h2,ha1CJaJha1CJaJha15CJaJh2,ha15CJaJ(vvv;wFwhwiwwwwwwwwwwwwwwwwwwwwwwwwxxxx x"x$xܧvav(hLha15CJaJeh r "ha15CJaJeh r hY>ha15B*CJaJphha15B*CJaJphha15CJaJha156CJH*OJQJaJ!jha10J56CJUaJha156CJaJh[ ha156CJaJha1CJ\aJhs4ha1CJ\aJ$$xyyyy*z8zWzYzezfzgzjzkzzzzz{{%{'{({){;{Z{{{{{~~(~D~E~S~X~\~k~l~~~~~~~~~ST~ho(ha15CJaJhC#ha15CJaJho(ha1CJaJhLha16CJaJha156CJaJhpha1CJaJh#ha1CJaJ hpha1hpha16ha1hLha156CJaJha15CJaJha1CJaJ1xyykzz{){\{{{{-|||| }_}}}~l~~~Tb9 & Fgda1 & Fgda1 & Fgda1 & Fgda1gda1T_`b~9Ltu<BCJL]_bȷyp^I^pp^I^(hLha15CJaJeh r "ha15CJaJeh r ha15CJaJ hLha15B*CJaJph<ha15B*CJaJeh fH phq r h,Zha16CJ\aJha1CJ\aJhpha16 hpha1ha1h,Zha16CJaJhLha1CJaJha1CJaJhLha156CJaJ9Cpɂ&X͆Oa $Ifgd;h^hgda1 & Fgda1/$d!%d$&d!'d$-D M N!O$P!Q$gda1gda1 & Fgda1͆OVW( ݒՓ­}­qcjha10JCJUaJhLha16CJaJha1htha15CJaJ h?ha15B*CJaJphh?ha1B*CJaJph(hLha15CJaJeh r "ha15CJaJeh r hLha15CJaJhLha156CJaJha1CJaJha15CJaJ%(h֋J g^QQQQQ & F$Ifgd; $Ifgd;kdf#$$Ifl0X Xl  t0644 lapyt; aЍxkkk & F$Ifgd; $Ifgd;}kd$$$Ifl0X Xl t0644 layt;]$|sffYLL & F $Ifgd; h$If^hgd; & F$Ifgd; $Ifgd;gda1}kde$$$Ifl0X Xl t0644 layt;_Pܒxkkkkx & F $Ifgd; $Ifgd;}kd$$$Ifl0X Xl t0644 layt;ܒݒޒ)Փ.,AHPxxsssggg $$Ifa$gd;gda1h^hgda1}kd/%$$Ifl0X Xl t0644 layt; .ABCG+,PǕɕʕՕߕ'=>?ADĖʖϽߊߊ|k|k hvha15B*CJaJphha15B*CJaJphha156CJaJhOha16CJaJhXha1CJaJ hOha15B*CJaJphhOha1CJaJ hPIha1ha1hLha16CJaJhLha156CJaJha1CJaJhGIha1CJaJ%PQJA555 $$Ifa$gd; $Ifgd;kd%$$IflF !h  t0    44 lapyt;ĕǕʕpg[[ $$Ifa$gd; $Ifgd;kdW&$$IflF !h t0    44 layt;ʕ˕$',>pg[[[ $$Ifa$gd; $Ifgd;kd&$$IflF !h t0    44 layt;>?̖pkbVVV $$Ifa$gd; $Ifgd;gda1kdG'$$IflF !h t0    44 layt;+" $Ifgd;kd'$$Ifl\x !($ p  t(0644 lap(yt; OF $Ifgd;kd($$Ifl\x !($ p t0644 layt; $$Ifa$gd; !()9:STYbopėŗ?@Alwɚʚ˚Ϛ#rs˺䯤vnenZh4`hWCJaJhW6CJaJhWCJaJjhW0JU h4`hW5B*CJaJphh4`hWB*OJQJphhWhOha1CJaJhh"$ha1CJaJ hLha15B*CJaJphha15B*CJaJphhGIha1CJaJha1CJaJha15CJaJhCha1CJaJ" !*/49[RFFF $$Ifa$gd; $Ifgd;kdB)$$Ifl\x !($ p t0644 layt;9:DINS[RFFF $$Ifa$gd; $Ifgd;kd)$$Ifl\x !($ p t0644 layt;STcejo[RFFF $$Ifa$gd; $Ifgd;kdd*$$Ifl\x !($ p t0644 layt;opŗƗ[VV'/$d!%d$&d!'d$-D M N!O$P!Q$gda1gda1kd*$$Ifl\x !($ p t0644 layt;@wɚʚ%qrԛ,c^YYYYYgdWgdW2$$d!%d$&d!'d$-D M N!O$P!Q$a$gdW3$$d!%d$&d!'d$-D @&M N!O$P!Q$a$gdW0$d!%d$&d!'d$-D @&M N!O$P!Q$gdWgda1 st-.dmefӞ/0b#$'3{Ġ #0kqtUVW\hr}ŢǢɢˢآʣˣͣΣĻĻhW6CJ]aJhWCJ]aJhW5CJ]aJhWCJH*aJhW5CJaJhW hW0JhWCJaJmHsHhW0JCJaJhW6CJaJhWCJaJh4`hWCJaJ:,-Hde}./!#ߠ<UVgdWgdWƢǢ$ʣˣ)}d¥ޥߥHgd#gda1@&gdWgdWgdWΣܣY%¥ޥߥFPQݽ݌o`Uh_hhWCJaJh_hhWCJaJmHsH!jh=hW0JCJUaJh=hW6CJaJh=hWCJaJjhW0JUhdjhdUhGih%p5CJaJmH sH ha1>*CJaJhW6CJaJhWCJaJ hW0JhWhW6CJ]aJhWCJ]aJhW5CJ]aJHOPkBQRDFAB gdWgdWȨAFTU5RSm #%FGJVvABCFS˺谬ÕÉ}ÕÕhu6ghW6CJaJhNhW6CJaJhhWCJaJhavhW5CJaJhWjhW0JUhW6CJaJhWCJaJh=hW6CJaJ!jh=hW0JCJUaJh=hWCJaJh_hhW6CJaJ/ ^dxyzí٭߭EKPQŻŰܰɰŇ|nbYbYbYbhWCJ]aJh=hWCJ]aJhavhW5CJ]aJh=hWCJaJ!jh=hW0JCJUaJhavhWCJH*aJhavhW5CJaJhavhWCJaJjhW0JUhWhWCJaJhhWCJaJhu6ghW6CJaJhu6ghWCJaJhavhW6CJaJ _xyڭFK˯̯(] deò#gda1gdWgdWۮ *GP{˯̯ͯЯ +,H/Ϳۅ|tttjf[h=ha1CJaJha1jha10JUhWCJaJhW6CJaJh=hW6CJaJhW6CJ]aJh[ hW6CJ]aJhWCJ]aJh[ hWCJ]aJhavhW5CJ]aJhWjhW0JUh=hWCJaJh=hWCJ]aJh=hW6CJ]aJ!/[Ա4efòݳV[ijѴҴ JghƵȵ"%*8:[\_kȽש薒{{ohNha16CJaJhha1CJaJhavha15CJaJha1jha10JUha16CJaJha1CJaJh_hha16CJaJh_hha1CJaJh_hha1CJaJmHsH!jh=ha10JCJUaJh=ha1CJaJh=ha16CJaJ+WдѴ)fgõ&Y[VWt[gda1gda112VWX[h5syҸָظZ躯ܤƤ󤘤܇|nbh=ha1CJ]aJhavha15CJ]aJh=ha1CJaJ!jh=ha10JCJUaJhavha1CJH*aJhavha1CJaJhu6gha1CJaJhavha16CJaJhavha15CJaJjha10JUha1ha1CJaJhha1CJaJhu6gha16CJaJ#Z`efĹй ?\eպ!@A]õф{sssohdha1CJaJha16CJaJh=ha16CJaJha16CJ]aJh[ ha16CJ]aJh[ ha1CJ]aJhavha15CJ]aJha1jha10JUh=ha1CJaJh=ha16CJ]aJh=ha1CJ]aJha1CJ]aJ%`=gd#gda1gda1 hGih%p5CJaJmH sH 6&P1h:p#/ =!"#@$@%   Oh+'0 (4 T ` l xOffice of Nursing Servicesvhacllyerarr Normal.dot VHACOMITCHR2Microsoft Office Word@@nH#@5@5P՜.+,D՜.+,d  hp   Department of Veterans AffairsP' Office of Nursing Services Title 8@ _PID_HLINKSAt0 Mmailto:Candice.Watkins@va.govS fmailto:Anatalia.Resulta@va.govS hmailto:Jane.Nichols@va.govS )]mailto:Heidi.Lacko@va.govS i mailto:Anne.Dammers@va.govS ,O mailto:Paula.Boyle@va.govS F&  mailto:Christine.Bennett@va.govS _)mailto:Susan.Thomason@va.govS _1279448242$D0 FpK&C۰pK&C۰Data L11Table-/f aCompObjqh$$IfP!vh5 51#v #v1:Vl t65\ 5laPyt}Jyh$$IfP!vh5 51#v #v1:Vl t65\ 5laPyt}Jyh$$IfP!vh5 51#v #v1:Vl t65\ 5laPyt}Jy$$IfP!vh5(#v(:V l40(65(4aPf4yt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}JyFDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}Jy$$IfP!vh5 5#v #v:V l0(65 54aPyt}JytDText6$$IfP!vh5 5#v #v:V l0(65 54aPyt}JytDText7$$IfP!vh5 5#v #v:V l0(65 54aPyt}JyvDText10vDText11vDText12vDText13$$IfP!vh5 5#v #v:V l0(65 54aPyt}JyDyK reji.john2@va.govyK Jmailto:reji.john2@va.govyX;H,]ą'cDd u5t$//0  # A"T[h@()G3"RǙ06q4cqjXa,2G0v!ҋ-^2t= 8 F#?BOMءž*}Gq#C'Fx^65gt8Quޝ{v $FMZZ63} h5"QsܷQoX++νUK/nno:PݒQnJrfr.܀IS-n$"k {ju4^o-z\)_(H/~.1gߋX9w%4}^L6Pt{v⺾;z2C_fi~)'I~a"COhz?ځjӶeiӶ-^ڋY?ijZ>fl[.$m1g;GP\[Dkm5y%@qܿ+5ȭqIr>P\0$c&D[rI::|:j,b91,B5S5Y煺~fuZZC_kC>duZ2C_fuZI~!j]YgyF_S\o5[ `~_g{ٙzFCh0_N~bO e)4o37 }o6e)_2/H^Cw5 Zc/wx0j}^;[{w^o᳽Sw;];<:wxdSwx^n |v7 \4$wй ^׎Aç͜>MȞF}ȃ]*zP}^;bӶ_gCav5N_.І_ۈ X3?`?\w^o6xtn<nw <ͣqMӳ p?@Ssiill1>x\lSxZ*a4O/t-xݚJlMe\%}BP  s =ßJQ?f%||G|WQhGhkE<Gos {Hp[ҹ5?oȳ?EE#GFǃ?.υ#Oy_/ n ?͟վ?f:`|!}S;ҹgl?:؃~OmGnT|S'Ƹ?ͣK!7r1@_ͯ_h{#}#$[ C~U:7V_/pwpz:mU?oȷswAߪzxtpp7_}|5϶o üi+;̘7)+~?oON ȫ:_C~dU!~ 9wȧ *|5{7iZ |ߘ7)_G'_iWYuN#pos_|#S yN6ãoCSR:;γCŸk_}:kmι>*pk5pO a)V_ͯσ- eWus%7 b{:&?nd|q)f4Ykv^~Ov?0K= w$:ywGU >:w%V+x핼3 >oVH]_eЭ*7cq1g{6O~8Y͉o|7/u A2I>ݫ{ڮԽMyU'j:pr3M̕)0["k&Hj8=SؖLmp$.Z2p'^&z2xK ߤ5~tm OOAGo0TMa H]WT։ )pd#J-:mCoP0 s<sB$ym!Ѿ,j6Bj֗nG  tffI3l2/:,}oXf%nұv[N03[SG>_7cyTQnn۠:#-$^ 5g5`sZ#ϟ#sa[q/q~[1'oϗ:6֕w_sq~:ίas[uqW}*uWJc^ 3LKk~],qM=KCbi j?q2*7쬶2A->:k;nn|-c5X✦?z34ZTg}4c~,1)KpˢMZz(59^:'MTU~VZ_ֺ,]UF>[ݫtU*Yu$ZyYX/dr҃tR aYftǵ/,T66gcPWǧڟZ汫.f'!-Ά#eM GJQ_2MͿ5eRr/Q7)T-of9{F?(((Y%5NK5q6-9rqjdLVr9Zt0t#5]9IK/2#x>5\qm7#]o䗩pDh@bnH~oWu9XQI?x _/LoA΀o~Li..9(2P:cWhŲ=T~J+Ns]:c6o`؀.9 6e\ n ߃(vY xXMHTQ>蔢EiTMA)H*~Y mZvQQBDK ZDQ.wιs̝{oL wϙ~yiBTp/ #&" $S2O@9 D )x5GncO:$1B2YC񤣸)!I1(flW"bS:PAh,f]tنQBrV(#1h3pRpz s+Ow58V|܎œe7P7՜/ks_uxכw"02W. [;*F`qɘ=>>X.Ԁhܣ{@~r+Cr:@ [*5ͅ5qw[f׺[){.j)?Aq?Z`nB?q9c.ēY'1k蘀ogoos{q a0gήAUHT>b[0)4($POR4s 8Mό4N"cRTWϠaOfKsKxNIfsv4*ǟ=+?:q4sz]!1CƚÞ\2s`fw1{szr8wی4]|v鯷jk7Y}4]rVlO_Xck~- =8S3ryJF${v ݞ*Uu@!Qu |8hް5A=<5os|V8Lgm%4G,4oŜ_^aq|ynb79W3Fs p9~W^ U2' mQ̵EN[ֺ@F~3S-іkۣy-_OȺ/z骔>kR).IlLQW{}PL5xS-g7@@@ aNormalCJ_HaJmH sH tH :@:  Heading 1$@&5\DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List4 @4 aFooter  !.)@. a Page Number6U@6 Za Hyperlink >*B*ph4@"4  Header  !j@3j  Table Grid7:V0 $-6CEQq^#"!  $-6CEQq   ^+,_J^00dQ@0q 00dQ@0q @00:K#89:AVWX  [\]-./4QRd{|+,-2FGYmn\ ] ^ `    b c V%W%|%S0T01123 388>>EEEGG^J_JOOKQDRRR#SSTTVVVWWXXXXYY[[i[j[;\<\\\]]]]]]]]]]]]]]]]]]]]]]^^^^^^^^!^"^*^+^7^8^9^:^E^F^e^f^^^^@0@0@0@0@0@0 @0 @0 @0 @0@0@0@0 @0 @0 @0 @0 @0@0@0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0@000000000000000000000000000000000000000000 0 0 0 0 000000000000000000000000000@0X00@0X00@0X00@0X00@0@0@0@0@0@0X00X000000000000000000000000X0>:K89:AVWX  [\]-./4QRd{|+,-2FGYmn\ ] ^    b c V%W%|%S0T01123 388>>EEEGG^J_JOOKQDRRR#SSTTVVVWWXXXY[i[j[;\<\\]]]]^^^^!^*^7^9^E^e^^@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 @0@0 @0 @0@0 @0 @0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00000000000000000000000000000000000000 0 0 0 0 0000@00000000J00J060 J060J00J00@0J00J00LM@0@0@0@0@0@0@0@0@0@0@0LM $$$'] ZL "'-#0:@HMPTY\H`cXgg(s4=AKMNPQRSTUVWXY[\]^_aceV [ - Q { + \4sOcg s5789:;<>?@BCDEFGHIJLOZ`bfr6]i2>DYek VVVWWXXXXZZ[^FtFtFtFtFtFtFtFtX_XXX  '!!Qln:lEF,"$C"AMlUv'E4@0 E (     ? 2( 3  s"*?n  c $X99?"` ? 2(~  6 ??E?̙  ? 2    Nv;{v;{A  ? ?q I((n -   #" &   S S" ?~  6 E?E?̙-   n    #" $" /  Z E?E?v2 @S" ?   ~  6E?E?̙"   BE?E?"    TE?E?v @"  )&   <E?E?̙ Fb    <E?E? ̙  J  ! <E?E?!̙!  " <E?E?"̙h*"x,N%  # BE?E?#̙ԔZ& B S  ?V^ t Text14Text15^^^! < t  [ T[ [ [ \ T\ \ \ ] _ ` T` ` ` a Ta a a Ԥ  T  ԥ  T  Ԧ   \##/2BB'MMR_t1t1{1111[Z[ZgZt\t\]^      -177 HH#1Q^ggy1}1}1111eZiZiZz\z\]^   >*urn:schemas-microsoft-com:office:smarttags PostalCode9*urn:schemas-microsoft-com:office:smarttagsState8!*urn:schemas-microsoft-com:office:smarttagsCity9 *urn:schemas-microsoft-com:office:smarttagsplace>*urn:schemas-microsoft-com:office:smarttags PersonName=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName ! ! ! !  !  !!  !! w { Z[[[[ []]]]]]]]]]]]]]]]]^^^ pZ[]]]]]]]]]]]]]]]]]^^`  W%|%WXX&XYYYYZ[[-[[<\]]]]]]]]]]]]]]]]]]^^^^^^^^ ^"^)^+^6^:^D^^Z[]]]]]]]]]]]]]]^N[ `[( v{G#6&v4$h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHhh^h`CJo(. 88^8`hH. L^`LhH.   ^ `hH.   ^ `hH. xLx^x`LhH. HH^H`hH. ^`hH. L^`LhH.^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHv{G&vN[`[(         (#0                           P~E'v6[Xh) o |<:u={kF[ \#q$i&%@'(&)<04|495&7,8n8M9R:]-;?C<o>7@`@QD F HdrI[fKLcMo@OvO,*R3S\^:Q_&`{e1xf?Siiiji%jqln?pkOp3Xpdph@r}Jy2|]|0Zp@a;;PAzF2 9LapEF6WY8nA6nMaRZaA hPhOguY(#'O]Ex-_`ZQ?Y4iP ~9%{W6t8 !3Y9 QUEHDG"xa>1AD,k9:AVW  [\]-./4QRd{|+,-2FGYmn!Y^@I4??:^^`@`` @`@UnknownGz Times New Roman5Symbol3& z Arial7&  VerdanaG  MS Mincho-3 fg?5 z Courier New;Wingdings"1hCFCFO/O/!4d]] 2qHP ? !In late 2003 VA Pittsburgh Healthcare System was experiencing a significant increase in mediastinitis following Cardiac Bypass Surgery (CABG) patientsCandace Cunningham VHACOMITCHR    MSWordDocWord.Document.89q@ FMicrosoft Graph ChartGBiff5MSGraph.Chart.89q B""$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$ObjInfo.9ObjectPool2pK&C۰pK&C۰_12722797294FpK&C۰pK&C۰Ole EPRINT36CompObjeObjInfo57Workbook8y l~J TB&, EMF$+#F, EMF+@XXF\PEMF+"@ @ $@ 0@?!@ @     !" !" !  Rp{"VerdanaXX po_0drd|0r|d&0r|d 0rd0pd #;+00>>>>>>>>>>>>>>>>>dv% RpY"VerdanaXX po_0ere|0r|e&0r|e 0re0pe 4$;+0mdv% % % % % % % " !%   m % " !%   m % " !%    M % " !%   ?% " !%   N% '%     V0IIIV0WzWzzWWzV0       &% % (   V0<oI||II|V0   V0 im v`v`  v% % % " !% % %   ?% % % " !% % %   m &% (   6% 666666=% 6z6z 6 =6=% % % " !% % %   m % % % % " !% % %   n   TT%h1 4և@@%hLP0jT`~p94և@@~pLT0.5j=jTT%w@4և@@%wLP1jT`~H4և@@~LT1.5j=jTT%O4և@@%LP2j% % % " !% % %   m % % % % " !% % %   n   TEE L 4և@@EE LhBG 60-69mg/dl[g/UU<UUS<S$TE 4և@@E LhBG 50-59mg/dl/UU<UUS<S$TE E  4և@@E E LdBG <50mg/dl[g/mUUS<S$% % % " !% % %   m % % ( % " m !  " !  ( ( " F4(EMF+*@$??FEMF+@ "#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)1Arial1Arial1Arial1hVerdana1hVerdana1@Verdana1Verdana1Arial=1),##0.00_ ` $yh` $yh` $a@` $l88̙33f̙̙3f3fff3f3f33333f33333\R3&STU BG 60-69mg/dl BG 50-59mg/dl BG <50mg/dlBefore(\?(\?Gz?After(\?(\? ףp= ?WYJ-= s>X4?@3d 3Q BeforeQQQ3_ M   MMd4E4 3Q AfterQQQ3_ O NM  MMd4E4D $% M0!3O&Q4$% M0!3O&Q4FA6f 2 3OAb3 b &! 43*@? &! 43" 444 Oh+'08D`lx    OlePres000<$WordDocument1:ySummaryInformation(;=@DocumentSummaryInformation8F,     WX !"#$%&'(*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUV([\]^_`abcdefghijklmnopqrstuvwxyz{|}~%` sbjbj y̟̟]%z2z2z282v3D[N4<5"^5^5t5C@"e@y@ ZZZZZZZ$\h^_Z9EG!@"C@EGEGZ^5t5 ZIJIJIJEGV^5t5ZIJEGZIJIJrTTtUt5B4 ,4z2HOU{X$[0D[]U`HN`UU`Vl@YBNIJC D@@@ZZIj@@@D[EGEGEGEGvv Office of Nursing Services 2008 Annual Innovations Awards Application Form Professional Practice Environment for Nursing Excellence Title of SubmissionGENIE IN A BOTTLE: The Magic of Nursing BrillianceFacility Name and AddressVA Pittsburgh Healthcare System (VAPHS) University Drive C Pittsburgh, PA 15240 VISN #VA Healthcare VISN 4 Names of Team Members (Note: At least two (2) team members are required.) Primary Author InformationNameCandace Cunningham, RNTitle of PositionMRSA Prevention CoordinatorTelephone Number412 - 688 - 6000 Extension: 815612; Candace.Cunningham@va.gov  FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NameMary V. Rudy, RN, CNAA, BCTitle of PositionNursing Program LeaderTelephone Number412 - 688 - 6000 Extension: 815803; Mary.Rudy@va.gov NameJoyce Ewing, BSN, MHA, CCRN Title of PositionNursing Program LeaderTelephone Number412 - 688 - 6000 Extension: 816292 NameR. Harsha Rao, MDTitle of PositionChief of EndocrinologyTelephone Number412 - 688 - 6000 Extension: 814394 Name FORMTEXT      Title of Position FORMTEXT      Telephone Number FORMTEXT     -  FORMTEXT     -  FORMTEXT      Extension:  FORMTEXT      Submissions shall be in narrative format, in Times New Roman font, no less than 11 point, and NOT exceed five pages in length, including attachments. Submissions cannot contain embedded documents. Submissions which are noncompliant with these criteria will not be considered. Narrative shall include (a) title, (b) summary of initiative, (c) date of implementation, and (d) clearly identify each rating category being addressed followed by applicable narrative. The attached template serves as a face sheet for the narrative. All best practices shall be submitted electronically by the Nurse Executive with endorsements by the Facility Director/designee notifications of the VISN Director/designee. An electronic copy of the attached endorsement memo or equivalent electronic message addressed to Cathy Rick, RN, CNAA, FACHE, Chief Nursing Officer, Office of Nursing Services (108), is to be sent WITH the submission to Reji John (VHACO), Office of Nursing Services VACO (108), at  HYPERLINK "mailto:reji.john2@va.gov" reji.john2@va.gov (please note duplicate name in outlook). Deadline for submissions with endorsements is by COB May 31, 2008. Office of Nursing Services Innovation Award Professional Practice Environment for Nursing Excellence GENIE in A Bottle: The Magic of Nursing Brilliance Summary of Initiative: The inability to embrace practice with autonomy and control is an ongoing, yet uniquely defining phenomenon for the profession of nursing (Hess, 2004). Research has given us some insights into why this phenomenon continues to be present for nursing, including organizational cultures of managerial control and non-empowering leadership styles (Porter OGrady, 2001). In response to the growing impact this phenomenon has on nurses professional satisfaction and commitment, strategies to support processes that would allow nurses to eradicate this trend in practice have been developed. One such strategy includes creating practice environments in which nurses can engage in shared governance. Shared governance, while manifest with theoretical and definitional ambiguities, can broadly be thought of as a dynamic care delivery model in which point-of-care decision-making serves as the framework for shaping organizational structures and processes (Anthony, 2004; Hess, 2004; Porter OGrady, 2001). The VA Pittsburgh Healthcare System (VAPHS) is an integrated three division system consisting of 629 operational beds serving a veteran population of over 360,000 patients. Services include acute care, long term care, and behavioral health as well as tertiary services such as cardiac surgery and liver and kidney transplantation. VAPHS is in the process of developing and implementing a formal shared governance model. Prior to implementation of shared governance, VAPHS had the opportunity to collaborate with Pittsburgh Regional Healthcare Initiative and Centers for Disease Control in a pilot project which utilized the Toyota Production System (TPS). TPS is a system engineering strategy used in manufacturing (Spear & Brown, 1999). It has as a central principle the expectation that all work processes are controlled experiments that are continuously improved by the people actually doing the work. This principle is consistent with shared governance in that point-of-care decision-making by nurses is essential. This startling approach to apply proven manufacturing strategies to nursing practice was initially viewed with skepticism. Our challenge was to facilitate a culture change so that nursing staff adopted TPS and the related interventions as a component of the traditional sacred nursing process. This cultural transformation would anchor the changes in practice, and sustain ongoing compliance. Supportive nursing and educational resources were dedicated to the program. Since TPS relies on the workers controlling the change, nursing staff were immediately engaged, empowered, and provided resources to be successful. In 2004, cardiac bypass surgery was teetering on the brink of being shut down due to poor patient outcomes including deep sternal surgical site infections. What a travesty this would have been given VAPHS stellar performance in cutting edge surgery! Not only would our record have been blemished but more importantly our veterans would be without this lifesaving surgery. How ironic during this same period we were emerging as a MRSA reduction authority through participation in the Toyota project, but yet we had patients dying as a result of infection. Date of Implementation: January 2004. Adoption of Innovation In late 2003 VAPHS noted a significant increase in mediastinitis following Cardiac Bypass Surgery (CABG). Other factors were also causing concern and placing the VAPHS cardiac surgery program at jeopardy. During the same period one of the Surgical Intensive Care Unit (SICU) nurses became the Perfecting Patient Care Team Leader (PPCT) for the TPS project in the SICU focused on MRSA reduction. At the direction of the Chief of Staff a multidisciplinary work group was formed to investigate reasons for the increase in mediastinitis; the new PPCT was assigned to this workgroup. One of the findings reported by the work group was that in spite of an insulin therapy protocol in place with which all post CABG patients were treated; all patients who developed mediastinitis had significant post-operative hyperglycemia. VAPHS is affiliated with the University of Pittsburgh and shares physicians with UPMC Presbyterian Hospital which was using another protocol at the time. VAPHS was given a copy of this protocol but when the protocol was entered into VAPHS CPRS it took six pages for the required orders. The SICU nurses were strongly opposed to implementing this protocol, they thought it was complicated, cumbersome and would contribute to increased errors. A small work group of nurses was formed to explore alternative protocols; this group included the PPCT, who was concurrently facilitating implementation of TPS in the SICU. In this capacity the PPCT was working with a TPS teacher who was an engineer. Multiple protocols were examined and evaluated, the nurses thought most were inadequate to meet patients need or too complicated to use for these patients whose status can change from minute to minute. The engineer, already working with the SICU to implement TPS, volunteered to participate in developing a computer interface which would decrease complexity at the point of use. The goal of this creative unique approach was to incorporate nurses input into designing a usable patient focused tight glucose control system. The VAPHS Chief of Endocrinology, who had been charged by the Chief of Staff to intervene in management of these patients, agreed to collaborate in the development. Van Den Berghe (2001) study highlighted improved outcomes associated with better glycemic management in critical care. Based on this study, we continued to target a blood glucose range of 80 to 110mg/dl, but our new protocol was designed to be more dynamic and aggressive. The protocol was developed through a collaboration of endocrinology, nursing and the engineer. A computer interface was designed which allowed the nurse to enter data and receive protocol instructions at the bedside with no calculations required. Facets of the new protocol were counter intuitive to the traditional practices the nurses were comfortable with and required them to utilize their expertise in critical thinking to understand the rational and dynamics of the protocol. For example, there may be instances in which the protocol will require simultaneous delivery of insulin and glucose source. Once training was completed and the protocol implemented, outcomes and processes was closely monitored by the development team. Revisions were made based on feedback from the SICU nurses; re-evaluation continued on a regular basis. The SICU nurses provided ongoing support to the design team and continue to do so today by their continued monitoring of protocol outcomes and processes. Nursing Leadership and Collaboration The SICU nurses formed a work group to examine multiple glycemic control protocols prompted by their concern regarding the complexity and safety of a physician proposed protocol. When that group failed to find a protocol to adopt, the decision was made to design a new protocol; make it safe and effective for the patient while being user friendly for the nurse. The result was a nurse driven collaboration enlisting development expertise from critical care nursing, the Perfecting Patient Care Team Leader (PPCT), endocrinology, critical care medicine, cardiac surgery and a TPS engineer. Furthermore, this protocol received oversight by the VAPHS IRB and R&D Committees. While our formal nursing governance structure was in its early development, SICU nurses and the PPCT actively engaged in shared decision strategies through their Critical Care Committee, Critical Care Steering Committee, and the Critical Care Planning Committee. Implementation of the protocol in the SICU heavily relied on the collaboration and expertise of staff nurses. The SICU nurses, along with the PPCT, worked with the development team as a whole providing vital feedback regarding function and performance that was invaluable in guiding improvement and modifications. The SICU nurses designed and worked independently with VAPHS research nurses to initiate a quality assurance examination which compared performance of the Tight Glucose Control Protocol with a standard formula protocol. The objective results of this comparison sustained the value of the new protocol and validated their efforts. SICU nurse participation resulted in a computer interface that allows precise glucose management. It does this by providing recommendations for insulin via both drip and bolus based on the unique algorithm developed. Blood glucose level is established upon arrival to the SICU; if it is elevated (at least 110) the nurse starts the protocol by entering the glucose level in the interface, which then provides a recommendation for starting insulin therapy via a drip in conjunction with a bolus when warranted. Blood glucose levels are then monitored every hour initially, followed by every 2 hours once goal has been achieved. If however, the glucose levels are not at goal, monitoring can vary between 15 minutes, 30 minutes, or 1 hour. The protocol requires close nursing supervision and at times frequent nursing intervention. At the same time, the protocol functions with minimal physician involvement thus demonstrating the nurses autonomy, authority, and control over practice in coordinating this vital therapy. The SICU nurses have adapted work routines, requested appropriate equipment and supplies, and collaborated with the critical care technicians to adapt practices as required. The PPCT conducted educational presentations regarding this protocol to in-house medical staff and to the medical community at large. The PPCT nurse presented an abstract summarizing the results of this protocol at the Association for Professionals in Infection Control and Epidemiology, Tampa, FL 2006. Nurses collaborated on a presentation at the American Diabetes Associations 67th Scientific Sessions, Chicago, IL 2007. Scope of Initiative The scope of the tight-glycemic control initiative has resulted in improved care in a concentrically growing number of areas ranging from the open-heart surgery program to the medical center level, to the national VA level, and perhaps beyond. The most immediate results of implementing and perfecting use of this software program were realized in the open-heart surgery program shortly after its inception. It was clear within the first months of using the program that the ability of the protocol to aggressively reduce and consistently control blood glucose levels (without lowering blood glucose below normal levels) was more efficacious than attempting to manage the glucose via traditional means. This resulted in fewer post-operative infections and consequently, fewer instances of mortality as compared to the data of 2003 and 2004. This translates directly into both real lives and preserved quality of life. Seven patients survived their hospital stay following open heart surgery in 2005 who likely would not have survived the previous year had the practice not changed. Additionally, still others avoided a post operative infection that would have prolonged length of stay and could have cause permanent disability. Moreover, in subsequent years, the positive results of the program continued as the rates of infections continued to drop as the program was perfected along with other measures which were instituted. The combined effect of these interventions is a current post-operative unadjusted mediastinitis rate in the open heart surgery program of only 1.4% (FY 07). It is the goal of VAPHS to continue to drive the surgical infections and all other infection rates to zero. An adjunct to the success of lower mortality and infection rates in the open-heart surgery patients in instituting the tight-glycemic control program is also a drop in the overall surgical site infection rates for all patient populations across the Surgical ICU. Likewise, surgical site infection rates in the Surgical Stepdown Unit (SDU) dropped directly attributable to improved glucose management in the ICU. The impact of decreasing rates on these two units also meant that the overall surgical site infection rates for VAPHS also dropped over the four years since the launch of the tight-glycemic control protocol. Further, to continue to capitalize on this success, an extrapolation of this program was developed in the form of a transitional protocol for patients in the SDU who continued to require aggressive management of glucose levels after the insulin infusion had been discontinued. The transitional protocol is predicated on the use of long acting insulin allowing for more predictable control of carbohydrate metabolism. Due to the improved clinical outcomes of aggressive glucose management witnessed at VAPHS, the transitional protocol using long-acting insulin is being launched on the general surgical floor for both vascular and orthopedic surgical patients. Likewise, within the Critical Care units, the tight-glycemic control program is currently being implemented for use in patients in multiple surgical specialties as current medical research has demonstrated the effectiveness of tight glucose control in these populations as well (Van Den Berghe et al., 2001). Beyond VAPHS, it is the goal that the tight-glycemic control protocol will become readily available to many more patients through a pending patent which will be the property of the VHA; VA Central Office determined that this bold innovation was noteworthy and significant in regards to excellent patient outcomes. As such, patients outside of VAPHS, including those across VISN 4 and perhaps even across the nation, could benefit from the effectiveness and safety of the protocol. No special equipment or skills are required to implement the program which can be loaded on computers within the clinical area. In addition, no special monitoring devices are required as the program uses standard insulin and dextrose infusions monitored by standard glucometer point-of-care testing. As a result, the program can be readily implemented in any ICU with little or no additional resources required. When compared to glycemic control programs reported in the current medical literature, our protocol is the only software program that provides a "soft landing" to protect against dangerously low blood glucose levels when aggressively attempting to lower the blood levels. This feature is a primary factor in what sets the program at VAPHS apart from any other approach in use today and consequently, afforded the opportunity for patenting of this program.In all, from initiation of the original tight-glycemic protocol in SICU through expansion to other VAPHS in-patient units, this nurse-driven program impacts facility wide strategies of getting to zero infections rates, as well as reducing hospital length-of-stay, reducing health-care costs, and improving overall quality of life within a patient-centered care paradigm. Impact Process Improvement - Measurable process improvement was readily evident in even the first few patient cases. For example, other automated glucose protocols demonstrate controlling to target ranges within 8-12 hours of implementation. In comparison, our protocol achieves target range levels within 2-4 hours. Equally important, our patients are maintained within this target range, thus contributing to minimizing the potential for infection throughout the post-operative course. Refer to Tables 1 and 2. Impact on nurse satisfaction - We found that staff satisfaction increased as evident by the National Database of Nursing Quality Indicators (NDNQI) in the area of shared decision making. Specifically, in comparison to all VAPHS acute inpatient units, the TPS pilot unit nurses had among the highest rating for shared decision making. We also found improvement in patient satisfaction as evident by The Survey of Healthcare Experiences of Patients (SHEP) scores increasing by more than 10% on overall inpatient quality and exceeding the national threshold. The Toyota Production System pilot and shared governance were both bridged by the innovative program described in this submission. Long Term integration into structures and processes - Previous utilization of physician orders resulted in the possibility of physician bias effecting the glycemic treatment delivered. The new delivery system eliminates bias and delivers standardized treatment influenced only by nurse practice and patient response. The information technology department was solicited to facilitate computer access interface and the required orders were integrated into CPRS. It has been determined that the CABG protocol can be modified by target goal and algorithm to standardize glycemic control in additional patient populations (Rozich, et al., 2004). The literature demonstrates decreased rate of complication and mortality with adequate glycemic control in acute myocardial infarction patients (Malmberg, 1997). As such, a modified protocol is being utilized in the coronary care unit. As a result of the broadcasting of success with the CABG patients, surgery has a heightened awareness of impact of glucose management in post-operative outcomes. Applications are being explored for multiple post-operative populations beyond those previously included. Communication of successes is not limited to VAPHS. As previously noted, VA Central Office determined that this bold innovation was noteworthy and significant in regards to excellent patient outcomes and asserted their option to seek a patent thereby insuring access across the VA system. Nurse Sensitive quality indicators - The National Quality Forum (2004) report detailed 15 national voluntary consensus standards for nursing sensitive care which viewed together provide consumers a way to assess the quality of nurses influence over outcomes. Our primary results related to nurse sensitive indicators is evidenced by: Decrease in the death among surgical inpatients with treatable serious complications (failure to rescue). Our deep sternal surgical site infections (DS-SSI) rate decreased from 4.3% (8 of 185) pre-intervention to 1.1% (2 of 177) post intervention. The post-operative mortality rate at < 90 days fell from 6.0% (11 of 183) to 2.3% (4 of 177). The number of surgical interventions for treatment of DS-SSI decreased 50% from 18 to 9. Mean LOS decreased from 13.2 to 11.2. Based only on the mean BDOC (bed days of care) cost, we documented a monetary savings of $1,965,898.00 during the post intervention year. While not measured specifically in this patient population, we can infer that the decrease in mortality and morbidity associated with tight glucose control impacts other nurse sensitive indicators such as central line infections. In summary, our nurse-driven initiative resulted in improved patient outcomes and a soon to be patented product named GENIE (Glycemic Expert for Nurse Implemented Euglycemia). Without the participation and expertise of the SICU nursing staff and the PPCT, these outstanding improvements in process and patient outcomes would not have been realized. The brilliance of nursing practice continues today and beyond thus broadcasting the professional practice environment for nursing excellence.   SHAPE \* MERGEFORMAT  Table 1 Dwell Time Table 2 Hypoglycemia Risk References Anthony, M. K. (2004). Shared governance models: The theory, practice, and evidence. Online Journal of Issues in Nursing, 9(1), Manuscript 4. Retrieved 9/21/07 from  HYPERLINK "http://www.nursingworld.org/ojin" www.nursingworld.org/ojin. Hess, R. G. (2004). From bedside to boardroom nursing shared governance. Online Journal of Issues in Nursing, 9(1), Manuscript 1. Retrieved 9/21/07 from  HYPERLINK "http://www.nursingworld.org/ojin" www.nursingworld.org/ojin. Malmber, K., & DIGAMI Study Group. (1997). Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ, 314, 1512-1515. National Quality Forum. (2004). National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC: NQF. Retrieved May 14, 2008, from  HYPERLINK "http://www.qualityforum.org/publications/reports/nsc.asp" http://www.qualityforum.org/publications/reports/nsc.asp. Porter OGrady, T. (2001). Is shared governance still relevant? JONA, 31(10), 468-473. Rozich, J., Howard, R., Justeson, J., Macken, P., Lindsay, M., & Resar, R. (2004). Standardization as a mechanism to improve safety in health care. Joint Commission Journal on Quality and Safety, 30(1), 5-13. Spear, S. & Brown, K.H. (1999). Decoding the DNA of the Toyota Production System. Harvard Business Review, September-October, 97-106. Van Den Berghe, G., Wouters, P., Weekers, F., Verswaest, C., Bruyninckx, F., Schetz, M., Vlasselaers, D., Ferdinande, P., Lauwers, P., & Bouillon, R. (2001). Intensive insulin therapy in critically ill patients. New England Journal of Medicine, 345(19), 1359-1367.     PAGE  PAGE 1 * P<0.01 * * % Mean BG (mg/dl) 1101.0 1341.6 Post-Wizard  K 7 A B P T U   " % ( , 9 Z [ ] 򵤵~oo~o~~~~`~h_<h B* CJaJphhGUh B* CJaJphhNh CJaJh B* CJaJphh Nh B* CJaJph hGUh B* CJ\aJphhNh CJ\aJhy;h 6CJOJQJaJh 5B*CJ\aJph#h{h 5B*CJ\aJphhNh 5CJ\aJ$:KT}kd$$Ifl0 $\ l t0644 laPyt}Jy $Ifgd}Jy$a$gd $a$gd $ *]^a$gd ggr # 8 9 : A V x}kdj$$Ifl0 $\ l t0644 laPyt}Jy $Ifgd}JyV W X ||tk $Ifgd}Jy$a$gd gd }kd$$Ifl0 $\ l t0644 laPyt}Jy $Ifgd}Jyfkd>$$Ifl4&(0(64 laPf4yt}Jy $Ifgd}Jyvkd$$Ifl0& 0(64 laPyt}Jy  [ $Ifgd}Jyvkdn$$Ifl0& 0(64 laPyt}Jy[ \ ] { $Ifgd}Jygd vkd$$Ifl0& 0(64 laPyt}Jy] ^ h i j nXJ;;;h Nh B* CJaJphhNh 6CJ]aJ+hNh 56CJ\]aJmHnHu/jhNh 56CJU\]aJ hNh 56CJ\]aJ)jhNh 56CJU\]aJhNh CJaJ%hNh 5CJ\aJmHnHu)jhNh 5CJU\aJhNh 5CJ\aJ#jhNh 5CJU\aJ $Ifgd}Jy  !gd ckd$$Ifl&(0(64 laPyt}Jy $Ifgd}Jyvkd^$$Ifl0& 0(64 laPyt}Jy - $Ifgd}Jyvkd$$Ifl0& 0(64 laPyt}Jy    , 4 P Q d z {     $ * 2 3 = >   46JLNXZ詻y#jhNh CJUaJ;jhNh CJOJPJQJU^JaJmHnHo(u#j hNh CJUaJjhNh CJUaJh j5h B* CJaJphhGUh B* CJaJphhNh CJaJh B* CJaJph/- . / 4 Q {{ $Ifgd}Jygd vkd$$Ifl0& 0(64 laPyt}JyQ R d { $Ifgd}Jyvkd> $$Ifl0& 0(64 laPyt}Jy{ | $Ifgd}Jyvkd $$Ifl0& 0(64 laPyt}Jy {{ $Ifgd}Jygd vkd~ $$Ifl0& 0(64 laPyt}Jy $Ifgd}Jyvkd $$Ifl0& 0(64 laPyt}Jy  + $Ifgd}Jyvkd $$Ifl0& 0(64 laPyt}Jy+ , - 2 vm $Ifgd}Jy  !$Ifgd}Jygd vkd^ $$Ifl0& 0(64 laPyt}Jy4\ $Ifgd}Jyvkdr $$Ifl0& 0(64 laPyt}Jy\^4 $Ifgd}Jyvkd$$Ifl0& 0(64 laPyt}JyZ$&(026813arffffhNh 5CJaJ *hNh CJ\aJ#jhNh CJUaJ#jhNh CJUaJ#jhNh CJUaJ;jhNh CJOJPJQJU^JaJmHnHo(u#j&hNh CJUaJjhNh CJUaJhNh CJaJ'468!Mzrrrr$a$gdY4gd;gd gd vkd$$Ifl0& 0(64 laPyt}Jy -> %37tuv!Lwl`h8h<05CJaJh0h CJaJhfph 5CJaJhAh 0J5CJaJ&jhAh 5CJUaJjh 5CJUaJh 5CJaJh'h CJaJhNh 6CJaJhNh 5CJ\aJhNh 5CJaJhNh CJaJh CJaJLM?A<BHJC  papRG*CJaJq!r!!###*$*//=/::;;;<<uBwBHHjOkOsOgd $1$7$8$H$a$gdY4$a$gdY4gd7@ !!!K!c!o!p!r!!!!!!!!!!!!+"1"I"m"""""""ȽԽߏyncXh8h(CJaJh8h1xfCJaJh8hCJaJh8hCJaJh8h&7CJaJh8h !CJaJh8h2CJaJh8h !5CJaJh8h\5CJaJh8hWCJaJh8hW5CJaJh8hCJaJh8hEFCJaJh8hkOpCJaJh8hPCJaJ!""""""#=#O###$$\$d$e$s$$$$$%A%%%%%%%&-&@&A&B&M&W&&&&'"'#':'\'d'q's''''''ԾԳԳԳ߳골ɳɳɝɝߝ߇߇h8hACJaJh8hUCJaJh8h[CJaJh8h2CJaJh8hCJaJh8ho@OCJaJh8hCJaJh8h !CJaJh8h&7CJaJh8h(CJaJh8h FCJaJ3'':(<(=(H(I(J(x(y(z(((~)))))))"*3*8*9*:*L*****+3+4+5+:+X+Z++,*,+,--"-#--ԾԾԾԳtttth8h%@'CJaJh8h2CJaJh8huCJaJh8h-CJaJh^h-CJaJh^CJaJh8huCJaJh8hUCJaJh8h'CJaJh8h[CJaJh8h8CJaJh8hACJaJh8h;CJaJ------..".M.O.l.m.s.y.z.../////=/?/A/B/E/00"0#0ɾ{pepepZpOh8hLCJaJh hzFCJaJh8h%@'CJaJh8hzFCJaJh8h\5CJaJh8h\CJaJh8h !CJaJh8h2CJaJh8h8CJaJh8hdrICJaJh8hhCJaJh8huCJaJh8hACJaJh8h-CJaJh8hEFCJaJh8huCJaJ#0001@1]1|1}1111112b3w3333 44/4C4V4\444h5i5q66666677777777 888889@9c999:::::(:_:`:::h8h{eCJaJh8h8CJaJh8hR:CJaJh8h:Q_CJaJh8hYCJaJh8hLCJaJh8hACJaJh8hOCJaJh8hzFCJaJ>:::C;m;q;r;;;;;;;;;;;<<_=c=m=o=q===>>!>B>C>>>? ?k?m?@@߷rcrccccrrrrh8h{eB*CJaJphh8h8B*CJaJphh8h]-;B*CJaJphh8h2|B*CJaJphh8h`5CJaJh8h:Q_5CJaJh9%h?CJaJh9%hzFCJH*aJ h9%hzFCJOJQJ^JaJh9%hzFCJaJh9%h:Q_CJaJh8hzFCJaJ&@@@@@iAkAAAABBB BrBtBwB}C~CCCCCDD3D4DDDDDDDEEFFFFFGCGdGuGwGGGGGHHHh]|h]-;B*CJaJphh8h]-;B*CJaJphh hM{h CJaJh8hZQB*CJaJphhqlB*CJaJphh8h{eB*CJaJphh8h8B*CJaJphh8h2|B*CJaJph3HHHHHHHHHHHHHHeIfIgIhIiIIIJ JMJNJJJKKK K;K?KKK*L,LLLL:M*CJaJh8h,*RCJaJh8h6nCJaJh8h8CJaJh8haCJaJh8hCJaJh8h3SCJaJh8hM9CJaJh,kCJaJh8hCJaJh8h5CJaJh8h85CJaJh8h6n6CJaJ+\\\\])]2]Q]R]n]o]]]U^f^s^}^^^^^^^^G_T_s_t__@`A`C`D`H`Ƚߧߧߧߧߧs_&hEx9B*CJOJQJ^JaJ@ph)jh:thExCJOJQJU^JaJhOCJaJh8h6CJaJh8h(5CJaJh8h(CJaJh8hACJaJh8h3SCJaJh8hq$CJaJh8h,*R5CJaJh8h6nCJaJh8haCJaJh8h,*RCJaJ!H`I```a`b`c`d`e``````5a[aaaaaaaabDbnbobbbbbbbccc󼴬ulal]X] hp@6hp@j)hZaUhhZa0Jj(hZaUjhZaU hZa6hZahCJaJh_CJaJh,*RhiCJaJh>1CJaJh|4CJaJhYCJOJQJ^JaJjY(hYhYCJUaJ"jhYCJUaJmHnHuhYCJaJjhYCJUaJ"cccd1d;dGdMdNdOd[dddddddddee*e+eeeeeeeeOfffgfhffXgվլɟ՘||sogbgo^h^ ho 6h@ho 6ho  *hCJaJh]|h]|6 h]|h]|h]| hZa6hZa h?ph?ph)hii0JCJaJ#j*h)hiiCJUaJhiihiiCJaJjhiiCJUaJhiiCJaJh?pCJaJhh?pCJaJ h?p6h?p hp@hp@#cdd*e+eeeffggggggggggggggggh]hgda &`#$gdagd^gd]|$a$gdY4gd?pXgwgyg|gggggggggggggggggggggggggggggggggg¸Žrr/hYhY5B*CJOJQJ\^JaJ@phhY)hYhYB*CJOJQJ^JaJ(phhh@r0JmHnHuh[ h[ 0Jjh[ 0JUhaRjhaRUh{CJaJh95CJaJhB*CJaJphh#'h^h^6h^ h^6$ggggggggggggggggggggggg 7$8$H$gdY $7$8$H$a$gdYh]hgda &`#$gdaggggggggggggggggg '(洜jh[R@#jrK hifhYCJUVaJhifhYCJjhifhYCJUU.hYhY59B*CJ OJQJ\aJ ph2hYhY59B*CJ OJQJ\^JaJ ph.hYhY59B*CJ OJQJ\aJ ph2hYhY59B*CJ OJQJ\^JaJ ph/hYhY5B*CJ OJQJ\^JaJ$phhY)hYhYB*CJOJQJ^JaJ0phPre-Wizard  EMBED MSGraph.Chart.8 \s  The Risk of Hypoglycemia (BG<70mg/dl) with Aggressive Intervention ()*+,pqrsؽh{CJaJhn,hYhY9B*CJOJQJ^JaJ@phhYhifhYCJjhifhYCJUj,hifhYCJU +,pqrs$a$gdY4 7$8$H$gdYgdY21h:p3/ =!"#$% @==C"AMlUv']> xXMHTQ>蔢EiTMA)H*~Y mZvQQBDK ZDQ.wιs̝{oL wϙ~yiBTp/ #&" $S2O@9 D )x5GncO:$1B2YC񤣸)!I1(flW"bS:PAh,f]tنQBrV(#1h3pRpz s+Ow58V|܎œe7P7՜/ks_uxכw"02W. [;*F`qɘ=>>X.Ԁhܣ{@~r+Cr:@ [*5ͅ5qw[f׺[){.j)?Aq?Z`nB?q9c.ēY'1k蘀ogoos{q a0gήAUHT>b[0)4($POR4s 8Mό4N"cRTWϠaOfKsKxNIfsv4*ǟ=+?:q4sz]!1CƚÞ\2s`fw1{szr8wی4]|v鯷jk7Y}4]rVlO_Xck~- =8S3ryJF${v ݞ*Uu@!Qu |8hް5A=<5os|V8Lgm%4G,4oŜ_^aq|ynb79W3Fs p9~W^ U2' mQ̵EN[ֺ@F~3S-іkۣy-_OȺ/z骔>kR).IlLQW{}PL5xS-g7In late 2003 VA Pittsburgh Healthcare System was experiencing a significant increase in mediastinitis following Cardiac Bypass Surgery (CABG) patientsCandace Cunningham Normal.dot VHACOMITCHR2Microsoft Office Word@@p4@p4O՜.+,D՜.+, hp  { VA Pittsburgh Healthcare System/]' In late 2003 VA Pittsburgh Healthcare System was experiencing a significant increase in mediastinitis following Cardiac Bypass Surgery (CABG) patients TitleL 8@ _PID_HLINKSAO$9http://www.qualityforum.org/publications/reports/nsc.aspD WM!!http://www.nursingworld.org/ojinD WM!http://www.nursingworld.org/ojinD Aemailto:reji.john2@va.govD   FMicrosoft Office Word Document _1279448259> FpK&C۰pK&C۰Data 1Table=@)ZCompObjWqh$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%ph$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%ph$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%p$$IfP!vh5(#v(:V l40(65(4aPf4yt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pFDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt$%$$IfP!vh5 5#v #v:V l0(65 54aPyt$%$$IfP!vh5 5#v #v:V l0(65 54aPyt$%DyK reji.john2@va.govyK Jmailto:reji.john2@va.govyX;H,]ą'c Dd N5$ooP  # AC"" U7ur @= U7urijp8Z x] l~w.1( ps E[B44 8 n *RrK)RB(Q#"UQCT)jU-$VJ(Ji)U/Q"%T{;3잽 Wvf7ۙvf;1,$9&z;\`xʏ^|3lm6k0d1 gN2` ރa/{S 5o~猉\r1K6v&'0Aoly|&z714bۃ&ˎC CV8Jt2'.K;@ >HÊW!n4 c^bͰ,aTćih;srkG'4<}r,{1yMcFq@EdK4r78u)H+SW^k5}5O+*W"_HGWR}Eq+R_R[xh3oTl_ۋ|"UM~ ڞdS~ӆ:__uο/e?#k岕^ZNrbxx5-űR=`x ^ߊ;n)l #fWE}OJ R ^Ϙ8eIEw(x(7qYR4KXTzAUmyGM-^!D!G/Z2#e3ΏCQ a3~n[`"Z;!Ɯ-x}?2tXe΢s9lG|#s3gѺCM)f&<&'837q{>O k%E db:*#NXUh#vM>,^r ̚B{ijw D=cS>Mǿ^.`E?Otm.ws_^q6. ?lx/9s?^2̞1S _$Nk(ll?;z\+H塚i0D]uޕ\_j\7~e\GIͥ{+|sHqzxX9VDڽŸ|B' FI0Q>_u?a) $y1j[x&#G[˟ؓ4|[ƊT_Ma.Y;_$c}%u9Qߕp ng'Zs(No=X%]WqE q#_{8ʸjAi^{kĎګҐ9zm#kn/}<=i/?@{q=kdz"c Z{UB{Oۃŀ[j>C+cji|iUM{}B{k bhGr; \w5|9Kk"S{q^2ؼ7{/ ۸Ĝhla2^մw_@B{5&veb@N|Ky/笞{ks>hsi?gĶkoלqs13gyלoamM>-{G{-VX?g^9#}k9~x9w[ly9Xayqiy/?m{w~μsFl{ʹw~θ9oټ ϙ~ΈmkI9מxay\{挻}wϙ~Έma{]k/;죽o8a/sk?g9l97s l~Έm`{$罸{u 6={~v-\{$3~l;9&9۵3bڣ[~x94sKs_9-ORJvlk͹i9->RwZ9NC}o k}C8]#~׈1;'ﻺ~q?uDyK @http://www.cdc.gov/cancer/colorectal/pdf/0607_colorectal_fs.pdfyK http://www.cdc.gov/cancer/colorectal/pdf/0607_colorectal_fs.pdf DyK &http://www.cdc.gov/cancer/colorectal/yK Lhttp://www.cdc.gov/cancer/colorectal/ DyK %http://www.ahrq.gov/qual/errback.htmyK Jhttp://www.ahrq.gov/qual/errback.htm@@@ #NormalCJ_HaJmH sH tH :@: # Heading 1$@&5\DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List 4@4 #Header  !4 @4 #Footer  !j@j  Table Grid7:V06U@!6 l Hyperlink >*B*phFV@1F  jFollowedHyperlink >*B* phHBH N Balloon TextCJOJQJ^JaJ.X@Q. 8Emphasis6]ZYbZ 8 Document Map-D M CJOJQJ^JaJZ`$%q klK`[`00dQ@0q 00dQ@0q 00dQ@0q @0@0@0@0@0@0@0P 0@00:KEFMbcd 1jklNOPUkl~<=N$%&+DEWopE F G c ~  & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M q kl]="&X(**b,m-2F9?DCFEFNF9HHUIJKL.MNqO Q>RTY[[[[[[ \ \]]]]^^__J`K`L`N`O`Q`R`T`U`W`X`[`00000K0K 0K 0K 0K 0K0K 0K 0K 0K 0K 0K00d0d 0d 0d 0d 0d 0d 0d 0d 0d 0d 0d 0d0d 0d 0d0d 0d 0d 0d 0d 0d 0d 0d 0d 0d0d 0d 0d 0d 0d 0d 0d 0d 0d 0d0d 0d 0d 0d 0d 0d 0d 0d 0d 0d0d 0d 0d 0d 0d 0d 0d 0d 0d 0d0d 0d 0d 0d 0d 0d 0d 0d 0d 0d0d0d0d0d0d000c 0c 0c 0c 0c 00 0 00 0 00 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M 0M  0M  0M  0M 0M 0M 0M 00EF0EF 0EF 0EF 0EF 0EF 0EF 0EF 0EF 0EF 0EF0EF0EF0EF0EF0EF0EF0EF0EF00[ 0[0[ 0[0[ 0[0[ 0[0[ 0[0[0@0X00@0X00@0X00@0X00X00:KEFMbcd 1jklNOPUkl~<=N$%&+DEWopE F G c ~  & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M q kl]="&X(**b,m-2F9?DCFEFNF9HHUIJKL.MNqO Q>RTY[[[[[[ \ \]]]]^^__J`K`[`0000000000000000000 00 0 00 0 0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 0 0 0000000 0 0 0 0 0 0 0 0 00000000000 00 00 00 00 0@00  D7=ZcnfKhZh5;?FQRSWXZ[]^b  j  N k  < $Do4qCNcZh689:<=>@ABCDEGHIJKLMNOPTUVY\Yh7lx }\\ ]~]]]^___Z`FtFtXXXXl,"$jۘc~-tAO 8@t(  <  # AB S  ?[Z`[`'k TText14Text15m[`[`  s  s  ޚ ,ߚ lߚ DD  D  D  E      ,  l          <  |      <  |      < //;? PP9)9)E))**%F%F1FP]P]0_0_;___[`     9=DD ]]C)G)G)) * */F3F3FU]U]9_>_>___[`  B*urn:schemas-microsoft-com:office:smarttagscountry-region>*urn:schemas-microsoft-com:office:smarttags PersonName>*urn:schemas-microsoft-com:office:smarttags PostalCode9*urn:schemas-microsoft-com:office:smarttagsState8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplace  Z_5?` d ''''B3G388::??eAjA8C=CMMNNQQZZZZ]]K`L`L`N`N`O`O`Q`R`T`U`W`X`[`  995A6A[[[[[[K`L`L`N`N`O`O`Q`R`T`U`W`X`[`33333Fdl= & K`L`L`N`N`O`O`Q`R`T`U`W`X`[` K`L`L`N`N`O`O`Q`R`T`U`W`X`[``[( 5-my҂jhh^h`CJo(. 88^8`hH. L^`LhH.   ^ `hH.   ^ `hH. xLx^x`LhH. HH^H`hH. ^`hH. L^`LhH.hh^h`B*OJQJo(phhH^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHhh^h`OJQJo(hH^`OJQJ^Jo(hHo  ^ `OJQJo(hH` ` ^` `OJQJo(hH00^0`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHopp^p`OJQJo(hH`[(y5-(#0        0                 :9NK} e3FeJo j8waY"d%R'*(w+/0?:5;S;zdNOhRlTU(U? \ ]:],g-Qi*nfp&{ {,'hUV)#$%/{*Elc"n4|u_?)X%pxEFMbc 1jklNOPUkl~<=N$%&+DEWop[`@~IZ``@UnknownGz Times New Roman5Symbol3& z Arial7&  Verdana5& zaTahoma?5 z Courier New;Wingdings"1hCFCF,Ŧ_Q1_Q1Y@4d``2qHP ?#2Office of Nursing Services vhacllyerarr VHACOMITCHR   MSWordDocWord.Document.89q@  FMicrosoft Office Word Document MSWordDocWord.Document.89q@  FMicrosoft Office Word Document MSWordDocWord.Document.89q@ObjInfo?BYWordDocumentZSummaryInformation(ACDocumentSummaryInformation8:%` Zhbjbj ̟̟L` $<<<8H<l<$lU=p>>>>?"?? TTTTTTT$ WhtYUkEg?"?kEkEU>>S&UHHHkET>>THkETHHVP@Q>= E4<FQ RdhNh CJaJhNh,gCJaJh*(CJ\aJhNhw+/CJ\aJh CJ\aJhw+/hw+/CJ\aJhw+/CJ\aJhNh CJ\aJhNh 5CJ\aJhy;h?:56CJOJQJaJhNh,g5CJ\aJ#h{h#5B*CJ\aJphh?:55B*CJ\aJph#h{h 5B*CJ\aJphhNh#5CJ\aJ:KI}kd$$Ifl0@ &\ l t0644 laPyt%p $Ifgd $a$gd# $@&a$gd8 $@&a$gd8$ *@&]^a$gd8LhYh E F M b x}kdj$$Ifl0@ &\ l t0644 laPyt%p $Ifgd b c d |vne $Ifgd#$a$gd#@&gd8gd }kd$$Ifl0@ &\ l t0644 laPyt%p $Ifgd#fkd>$$Ifl4&(0(64 laPf4yt%p  0 1 4 7 : = A K N T i l m w x y m\ hNh#56CJ\]aJ)jhNh#56CJU\]aJ%hNh#5CJ\aJmHnHu)jhNh#5CJU\aJhNh#5CJ\aJ#jhNh#5CJU\aJh*nCJaJhCJaJh4CJaJhw+/CJaJhNh CJaJhNh#CJaJ!  $Ifgd#vkd$$Ifl0& 0(64 laPyt%p 1 j $Ifgd#vkdn$$Ifl0& 0(64 laPyt%pj k l { $Ifgd#gd#vkd$$Ifl0& 0(64 laPyt%p        # - 0 6 M P T U a f j l } ~ ҼҮxmhNh%pCJaJh*nCJaJhCJaJh4CJaJhw+/CJaJhNh CJaJhNh#CJaJhNh#6CJ]aJ+hNh#56CJ\]aJmHnHu)jhNh#56CJU\]aJ/jhNh#56CJU\]aJ* $Ifgd#  !gd#ckd$$Ifl&(0(64 laPyt%p  $Ifgd#vkd^$$Ifl0& 0(64 laPyt%p   N $Ifgd#vkd$$Ifl0& 0(64 laPyt%pN O P U k {{ $Ifgd#gd#vkd$$Ifl0& 0(64 laPyt%pk l ~ $Ifgd#vkd> $$Ifl0& 0(64 laPyt%p $Ifgd#vkd $$Ifl0& 0(64 laPyt%p     & ; = M N Q T W X Y Z _ h k q #%&+CWnĹڹhCJaJhNhCJaJ *hNh#CJ\aJhcCJaJh*nCJaJhNh%pCJaJh4CJaJhNh#CJaJE  {{ $Ifgd#gd#vkd~ $$Ifl0& 0(64 laPyt%p   < $Ifgd#vkd $$Ifl0& 0(64 laPyt%p< = N $Ifgd#vkd $$Ifl0& 0(64 laPyt%p vm $Ifgd#  !$Ifgd#gd#vkd^ $$Ifl0& 0(64 laPyt%p $Ifgd#vkd $$Ifl0& 0(64 laPyt%p $ $Ifgd#vkd $$Ifl0& 0(64 laPyt%p$%&+Dvm $Ifgd$%  !$Ifgd$%gd#vkd>$$Ifl0& 0(64 laPyt%pDEWo $Ifgd$%vkd$$Ifl0& 0(64 laPyt$%op $Ifgd$%vkd~$$Ifl0& 0(64 laPyt$%EFGc~{{ssngd,$a$gd, $@&a$gd8gd#vkd$$Ifl0& 0(64 laPyt$% "ACYZ[7;Cg !&2KTUcfiwܺܺܺܺܺܲܞܞܓ܅wlܓhNh,CJaJhNh,5CJ\aJhNhzdN5CJ\aJhNhhRCJaJhNh_?5CJaJh,CJaJh#CJaJhNh_?CJaJhNho5CJaJhNhoCJaJhNh#CJaJhNhzdN5CJaJhNh#5CJaJ&HLM[_ 367CDŽyqe\PDhfphd%5CJaJhfph,5CJaJh,5CJaJhNh,g5CJaJh,CJaJhAh'0J5CJaJ&jhAh'5CJUaJjh'5CJUaJh'5CJaJh'h'CJaJh'CJaJhNh_?CJaJhNh_?5CJaJhNh#5CJaJhNh#CJaJhNh#6CJaJDEGH}$&'Mq^DF^kIJ#żsg[[ghh8CJH*aJhh8>*CJaJhh8CJ\aJh5Hh8CJ\aJhh8CJaJ hh85B*CJaJphhh85CJaJh85CJaJh%p5CJaJh,hN{h,5>* h,5hN{h,5h,5CJaJhNh%p5CJaJh0h#CJaJ &'()*+,-./01234gd#gd,@&gd8$a$gd,456789:;<=>?@ABCDEFGHIJKLMq $<@&a$gd8gd#qkl] #&='*.X022b4m5:FAGLCN & Fxgd8 & Fgd8<gd8xgd8gd8$a$gd8^] \#]###&E&F&&<'='r'u'5)B)**,..*B*CJaJphhh85CJaJhh8B*CJaJphhh8B*CJaJph3fhh8CJH*aJhh8>*CJaJhh8CJaJh5Hh8CJaJ37C8 :4::::;C<<<===o?p?EAFAhABBFFGGIPIdIeIKLLLMBNCNDNENNN{N}NST-UhVV=Z퀑uhW,h8CJaJ hh85B*CJaJphhh8CJ\aJhh86CJaJhh85CJaJhh8h l'CJaJhh8B*CJaJph3fhh8B*CJaJphhh8>*CJaJhh8CJaJh8CJaJ.CNENNN9PPUQRST.UVqW Y>Z\acccccc 7$8$H$gd8 x7$8$H$gd8xgd8 & Fxgd8 & Fgd8@&gd8gd8=Z>ZZZ[Z\Z[[\] ]!]9^:^______@`A`bbbbbbcccccccƹ܏Ԅynj^hjnh8>*CJaJh8jh#h8Ujhh8Uh%h8CJaJhh8B*CJaJph3fh8B*CJaJphhh8B*CJaJphhh8CJ^JaJhh8CJH*^JaJh8CJaJhh8CJaJhh8>*CJaJhh85CJaJ!ccccccccccccd5d6d}d~dddd e e:e;eCeDe~eeeeeee ffnfǼ׼q׼׼Zq׼,jhh8B*CJUaJph!hh80JB*CJaJph,jMhh8B*CJUaJphhh8B*CJaJph&jhh8B*CJUaJphhh8CJaJh8hawh8>*CJaJh8CJaJhjnh8CJaJhjnh8>*CJaJh8>*CJaJ#c d deeeeffggJhKhLhNhOhQhRhThUhWhXhYhZhgd#gd8 & Fgd8$a$gd8 $7$8$@&H$a$gd8nfqffffffgYg^g_gggggggggggh'h)hhGhIhKhűŚ}jYKh8B*CJ^JaJph!hh8B*CJ^JaJph$hh86B*CJ^JaJphh8B*CJaJph!hh80JB*CJaJph,jhh8B*CJUaJph&jhh8B*CJUaJphhh8B*CJaJphhh80JCJaJhh86CJaJhh8CJaJh8CJaJKhLhMhOhPhRhShUhVhYhZhhjhUhNh85CJaJ 6&P1h:p#/ =!"#@$@%   @= jۘc~-tAO`R( )B$` x\{TcfvW + ,tTi"%J))IVB  рBkSHØZMJM[MHl̞=ٹ;2Sn>wyc?544rф0%iu:QɨqDUL$cQӫIVS>ww /w}Ewnw=De\Oܗ‡l˕ZͰH(q_L}'Ho+h>h@6X ߅qGS@7i҉4y$U/?J:. dvBnvՋeը>o`:fJ> ?o";Hu!zR=oDB%Ϟ,c{BAwVǨk:M`з*x+ȇGژryrJ1FKqJ~b̉<(t;ѩ8>G{^6dNDnBfg ]6mvfrTR,^L|F{V][o5mSsY]C/Yٻ}]gX2';g3{Ps_{rrǨq moc Ir>|1[rtrT{_+E~*>Yc5fŘ,>^~şSJc9O^E{͊>Zz_VD[/{wo2:~O7_8xR:E~A%1qu^_:5l7}anu}a_b9}af {ahcV/ֹcx3Ұ4 jjhį0lW}֣q{yj=FoRLG;ڍ'ڳ^@q3&Q=\<Stq>k inc56i7/s>}^>Mm_}/CBnpXZ{W['qq5A>U C2+a_&\Ĩr0FQn ,nطK=1i*CQn8yUmw!."FuNa,oO g7CC:Y%Y{&C,>n}sc\m؜ \R9VTK3ҝqHw¾U깈Q}MY;^Ƹz{a!\Ĩ>Scۙq- 7Za#\˜+u9庘ߪ]ZnA+燐Ņ(z_9n0ymf f9^Oj~&.(AIbOo;~g~iƯ~qٷ?/zp%/@J1̥4,$ޡlfC4~%?cW*`qTIxӰl5OZoPJ|og]Oق$#x߭|]lMψjfJm F8ιpsr~Վ5}^S>giJ1oog4҈bwGֹ(>lJxCՀQ2 Z$k>]Ǔ>΀&mq"EZ_=ƨl+>;st8Sy8p%q!KF;,: &&b&azۺ.1tmG[I[']5#]FVCGVߏ;KzqCuςc_QܷCuQ+rq7mHO=Jh3OIG7+UBW癎j؋g.yJ9:e:f6[3f2^^e$9ڙ /O/3{-z[wFF[vl` ߻ H%M;}^60BoCAV91(C J91(/?O#==A Pw{7 !ϑuecP^  E>/d"X>/"znl` {A uuecP^[T#r ߛ\EНHcnl` ۛO/."tp>{ ]@Hۻ1(y`AFMw31J]Nd.-}oUK=qƼt.)o*u!r3~'MN{%[d'.f'.w}#= -֍n2~Q&cE7.{<_X:>G3^\/^}x{.[>^k&y}/? >4fj{<9]':WL;%i q _9S<`fۊ~9eJ(n7#ʉg(uD=/JD3#cGR'Z!$~KN53T|׿] .IV2[:G:WTM3q,[M$HGhA% w\k3Oh+'0 (4 T ` l xOffice of Nursing Servicesvhacllyerarr Normal.dot VHACOMITCHR2Microsoft Office Word@@iR@94@94_Q՜.+,D՜.+,d  hp   Department of Veterans Affairs1`' Office of Nursing Services Titleh 8@ _PID_HLINKSA NW%http://www.ahrq.gov/qual/errback.htm` U &http://www.cdc.gov/cancer/colorectal/`  @http://www.cdc.gov/cancer/colorectal/pdf/0607_colorectal_fs.pdf` Aemailto:reji.john2@va.gov` _1279448276<LF FpK&C۰pK&C۰Data 1TableEHACompObjZqh$$IfP!vh5 53#v #v3:Vl t65\ 5laPyt00h$$IfP!vh5 53#v #v3:Vl t65\ 5laPyt00h$$IfP!vh5 53#v #v3:Vl t65\ 5laPyt00$$IfP!vh5(#v(:V l40(65(4aPf4yt00$$IfP!vh5 5#v #v:V l0(65 54aPyt00$$IfP!vh5 5#v #v:V l0(65 54aPyt00DyK Diane.Mayes@va.govyK 4mailto:Diane.Mayes@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt00FDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPyt00$$IfP!vh5 5#v #v:V l0(65 54aPyt00$$IfP!vh5 5#v #v:V l0(65 54aPyt00vDText11vDText13DyK Patricia.Quigley@va.govyK >mailto:Patricia.Quigley@va.gov$$IfP!vh5 5#v #v:V l0(65 54aPyt00$$IfP!vh5 5#v #v:V l0(65 54aPyt00$$IfP!vh5 5#v #v:V l0(65 54aPyt00$$IfP!vh5 5#v #v:V l0(65 54aPyt00DyK reji.john2@va.govyK Jmailto:reji.john2@va.govyX;H,]ą'cy$$If!vh55 5 #v#v #v :Vl t655 5 ytw#y$$If!vh55 5 #v#v #v :Vl t655 5 ytw#y$$If!vh55 5 #v#v #v :Vl t655 5 ytw#y$$If!vh55 5 #v#v #v :Vl t655 5 ytw#y$$If!vh55 5 #v#v #v :Vl t655 5 ytw#y$$If!vh55 5 #v#v #v :Vl t655 5 ytw#y$$If!vh55 5 #v#v #v :Vl t655 5 ytw#M$$If!vh5##v#:Vl t65#yt M$$If!vh5##v#:Vl t65#yt M$$If!vh5##v#:Vl t65#yt M$$If!vh5##v#:Vl t65#yt M$$If!vh5##v#:Vl t65#yt M$$If!vh5##v#:Vl t65#yt M$$If!vh5##v#:Vl t65#yt M$$If!vh5##v#:Vl t65#yt M$$If!vh5##v#:Vl t65#yt ;DyK .www.nursingworld.org/ojin/topic23/tpc23_4.htmyK jhttp://www.nursingworld.org/ojin/topic23/tpc23_4.htm?DyK /www.nursingworld.org/ojin/topic23/tpc23ntr.htmyK lhttp://www.nursingworld.org/ojin/topic23/tpc23ntr.htmDyK 'www.nursingworld.org/ojin/topic23_6htmyK \http://www.nursingworld.org/ojin/topic23_6htm7DyK -www.nursingworld.org/ojin/topic23/tpc23_1htmyK hhttp://www.nursingworld.org/ojin/topic23/tpc23_1htm7DyK -www.nursingworld.org/ojin/topic23/tpc23_3htmyK hhttp://www.nursingworld.org/ojin/topic23/tpc23_3htm;DyK .www.nursingworld.org/ojin/topic23/tpc23_2.htmyK jhttp://www.nursingworld.org/ojin/topic23/tpc23_2.htm7DyK -www.nursecredentialing.org/magnet/index.htmlyK hhttp://www.nursecredentialing.org/magnet/index.htmlWDyK 5www.unitedspinal.org/publications/nursing/2006/05/01yK xhttp://www.unitedspinal.org/publications/nursing/2006/05/01      !"#$%&'()*+,-./0123456789=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~@@@ NormalCJ_HaJmH sH tH L@L  Heading 1$$@&a$5CJOJQJ\@@  Heading 2$$@&a$5\FF  Heading 3$@&5CJOJQJ\DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List<[< $dE-mail Signature6U@6 l" Hyperlink >*B*ph4 @4 ;rFooter  !.)@!. ;r Page NumberH2H 2w Balloon TextCJOJQJ^JaJj@Cj ][ Table Grid7:V0FVQF *FollowedHyperlink >*B* phTbT 9;xl392dd%d'dOQ[$\$6>r6 Title$a$ 5>*\B'B Comment ReferenceCJaJ<<  Comment TextCJaJ@j@ Comment Subject5\4@4 lHeader  !{{:K89@BCDopq(): {@0@0@0@0@0@0@0@0 @0@0@0 @0@0@0 @0@0@0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0@0 @0 @0 @0@0@0@0@0@0@0@0@0@0 @0 @0 @0 @0@0@0 @0@0@0@0@0@00:K'89@BCDopq(): # $ PQ}!&.I/U3V3x3=AB1BFB[B\BBBBBBBBC$C-Cċ |tŋ Ƌ NNj lOȋ ɋ TPʋ DRˋ ̋ ͋ 4΋ dϋ ''.2$MMMMQJQ_Q_Qjjjj@q@qIqrr%s%s,ssssGtGtNttttttttwuwuuvvvvvvvwvwwhxhxqxzxYy{      !"#$%&'()*+,-./0132465798:;<&&,077.MMMMQQQdQdQjjjjHqQqQqrr*s3s3ssssLtUtUttttttttuuu vvvvvvwwwoxsxsxx_y{  !"#$%&'()*+,-./0132465798:;< =7*urn:schemas-microsoft-com:office:smarttags PlaceName=4*urn:schemas-microsoft-com:office:smarttags PlaceType9:*urn:schemas-microsoft-com:office:smarttagsplace;=*urn:schemas-microsoft-com:office:smarttagsaddress8;*urn:schemas-microsoft-com:office:smarttagsCity99*urn:schemas-microsoft-com:office:smarttagsState>8*urn:schemas-microsoft-com:office:smarttags PostalCode:<*urn:schemas-microsoft-com:office:smarttagsStreet>3*urn:schemas-microsoft-com:office:smarttags PersonNameB2*urn:schemas-microsoft-com:office:smarttagscountry-region v=<;:987:74322:2;;:;;9:;7:477;:9;:9;:97777;:9;:9;:9:;9:;9:;9::p]t]mlylnooo!o"ooozzzzzzzzzzzzz{ { {{{{" !!H%J%//91E1EEE5GEG>VEV^^aa#i,i9iviwiiijj'jjjjj/k7kkk]lellmmmm0n2n:nGnqnrnnnooooompppqq q-q_q`qqqrr-rrr8s@sXsssssVtZt`ttt(uuuuvvvvwwyxxxxx!yXy_yy zzzzzzzzzzzzzz{ { {{{{3333333333333333333333333333333333333333333333333333333 novzzzzzzzzzzzz {{{nozzzzzzzzzzzz {{{K8IGJ6eq .-C   K*\'b\)Aw ,$^*b4#v,V5 1d,0t5]$5E         ;.eXʈxA.c>$5EXN*گV}&|~U8 F t                  .l\0g,eTdE΁"vsXB          v̶qݬD5tJj(n8                  $ Ump0آn]j-Q̪`b,B(*QN0                   -Q̪`b,B(*QN0j? UCi(!n*_l^{N2ZZK!nF>]OZZwYC!nZZL a~ 2;~ WW* F G^IiR  /)0> /)"2;|/)0 U{!np!n. U%qZ!nA:^=ZZZ|[!ZZiS?<G^/)F>9/)k/)/)tO"ZZT p$p%/)4!&m0)B^`*2;o".2;/ 3t3/8|^oj8/)"_9 U>?:UQcA:2;b[S?<D`2= UlH=ZZt?}$Nck8@UQc[A!nmqGXHXJ!n vJUQc3L2;eoMG^ N/)N* }$N O%qRv!T Or(BT2;.TUQcA;U/) UmqGWWo_Wt?GRX/)_HY!n|[!Z+Q I( Z"M#Im#i$e&I&7^&u&{'V)(*\*00.233z3W4\4Is45 5*T6~u7{7 :3V:[:S,;9;qS;_;Kw=R8>C@A!A]9BU>BQ\CwCDc2D8Dd>DF0FpFwF 7I[I6JWJsJLIMZMNLNWO4O [OfP,P QIQ{RSR9RWR.TATJOT3rTnUJuU&WQW}]W XEYX{X!Z[][\1\<\z\]^^ed^q^t^!_`G`*b]ZdaeseNff`gcRi^isi_jcDkkl35mH~m.ptpz`qFr-s!ttKuiu]w2wXwxy9#y GzQGzwzLO}MI~=L~=+rTkT`hgh -iA5 +UYw#q !VeHVbff<6U$I u|C#HXh>!4dzz 2qHP ?F2Office of Nursing Services vhatamwhites1 VHACOMITCHRt                     ObjInfoGJ\WordDocument<4SummaryInformation(IKDocumentSummaryInformation8'%` bjbj 4̟̟z%ppp@@@8H@$A,,B>C"`C`C`CD1E4eE$תh?,9p,QDD,Q,Q,`C`C;eUUU,Ql`Cp`CU,QUUD,p`C B zz6@Q:{0.Rͭ Uͭt.ͭpTE\HfUCK/MEEE,,UjEEE,Q,Q,Q,QDL-L- Office of Nursing Services 2008 Annual Innovations Awards Application Form Professional Practice Environment for Nursing Excellence Title of SubmissionApplying Evidence Based Practice Through Shared Governance Structure Facility Name and AddressJames A. Haley VAMC 13000 Bruce B Downs Blvd Tampa, FL 33612VISN #8 Names of Team Members (Note: At least two (2) team members are required.) Primary Author InformationNameDiane Mayes, MS, RN, CCRNTitle of PositionUAN/FNA PresidentTelephone Number813 - 929 - 2000 Extension: 1726 e-mail:  HYPERLINK "mailto:Diane.Mayes@va.gov" Diane.Mayes@va.gov  FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NamePatricia A. Quigley, PhD, ARNP, FAANTitle of PositionAssistant Director, VISN 8 Patient Safety Center of InquiryTelephone Number813 -  FORMTEXT  558   - 3912 Extension:  FORMTEXT      e-mail:  HYPERLINK "mailto:Patricia.Quigley@va.gov" Patricia.Quigley@va.gov NameTitle of PositionTelephone Number Submissions shall be in narrative format, in Times New Roman font, no less than 11 point, and NOT exceed five pages in length, including attachments. Submissions cannot contain embedded documents. Submissions which are noncompliant with these criteria will not be considered. Narrative shall include (a) title, (b) summary of initiative, (c) date of implementation, and (d) clearly identify each rating category being addressed followed by applicable narrative. The attached template serves as a face sheet for the narrative. All best practices shall be submitted electronically by the Nurse Executive with endorsements by the Facility Director/designee notifications of the VISN Director/designee. An electronic copy of the attached endorsement memo or equivalent electronic message addressed to Cathy Rick, RN, CNAA, FACHE, Chief Nursing Officer, Office of Nursing Services (108), is to be sent WITH the submission to Reji John (VHACO), Office of Nursing Services VACO (108), at  HYPERLINK "mailto:reji.john2@va.gov" reji.john2@va.gov (please note duplicate name in outlook). Deadline for submissions with endorsements is by COB May 31, 2008. 2008 INNOVATION AWARD PROGRAM Title: Applying Evidence Based Practice Through A Shared Governance Structure Summary of Initiative: The spirit of inquiry with a solid framework to translate research and evidence into practice has been a longstanding culture within the James A. Haley Veterans Hospital Nursing Service. This culture was the foundation leading to a formalized shared governance structure as an innovative approach to enhance the implementation of evidence based practice (EBP) to improve patient care and staff perception. Haley was the first VA to receive Magnet designation (2001) and redesignation (2005) and shared governance is an evolution of the administrative structure to create a work environment for staff to be actively involved in decision making and using evidence to drive decisions for patient care and nursing practice. This includes EBP in clinical as well as administrative areas. The shared governance structure was designed based on the best evidence available which ranges from case study exemplars to formalized research.1 It also has theoretical underpinnings from organizational, management and sociological theories including practices such as autonomy, empowerment, and involvement in decision making. This structure contributes support to the research base on shared governance through our 5 year study on effectiveness. Additionally, shared governance is now the routine structure through which all councils define, implement, and evaluate EBP. This integration of theory, research and practice is illustrated by our shared governance structure and visible in our strategic goals which include Evidence-Based Decision-Making. The shared governance structure for nursing practice reorganized nursing services into five councils: Quality, Advocacy, Professional Development, Practice, and Coordinating. The council purposes and functions were defined in the bylaws. The bylaws also addressed member composition along 7 practice areas: 1) ambulatory care, 2) long-term care, 3) mental health, 4) medical/surgical, 5) acute care, 6) diagnostic, and 7) rehabilitation. These areas were planned for the purpose of having nurses from similar practice areas to address issues. Each practice area has representation on each council with a staff nurse serving as chair. The model was designed to be inclusive for all registered nurses (RN) regardless of their reporting structure. Those RNs who work outside of Nursing Services have the opportunity to be an active participant in shared governance by aligning with the practice area that most closely matches their specialty. In fact the current chair of the Practice Council is an advanced practice nurse (APN) in Polytrauma reporting to the Medical Director. The Coordinating Council is the exception to staff leadership, with the chief nurse executive serving as chair. At least one nurse manager and one APN sit on each council. In addition, each council is assigned a professional advisor. The governing council structure is composed of RNs and the unit based councils are comprised of all levels of nursing staff or any discipline. For example, clinical unit councils and workgroups include social workers, facilities management personnel, rehabilitation therapists and physicians in their unit activities. The unit is empowered to determine its structure according to its needs. A Transition Team was formed in this unique hybrid model to lead the systematic implementation of shared governance at the council and unit levels based on the literature that identified successful strategies and limitations of other models. Implementation was formally introduced January 2004 with 3 elections in 2005, 2006 and 2007. Date of Implementation: The design team was charged by the chief nurse executive to develop a structure in 2002. The formal implementation of shared governance began January 2004.The primary goal of the design team was to develop a model that would incorporate the values of nursing service and include multiple avenues for nurses to be involved at the unit as well as organizational level. Communication processes were established to ensure the flow of communication occurred between and among units and councils. The utilization and evaluation of EBP and research utilization was incorporated in all documents developed by the design team. These include the bylaws, mission, vision, and philosophy statements, and the initial shared governance evaluation plan. Through literature review it was evident that many organizations experienced a strong implementation phase but were unable to sustain momentum over time. The design team decided to create a mentoring process to assist units with the implementation and maintenance of shared governance activities. These mentors were collectively referred to as the Transition Team since their role was to help units, and even councils, transition to an integrated organization wide shared governance structure. The Transition Team completed its 2 year role and the continuing support comes from educators, managers and advisors. Another task of the design team was to evaluate the organizational structure of nursing service to develop a process that would facilitate nurses with like practices working together on research and practice related issues. 1. Rationale/motivation for the innovation: Improvement of current nursing practices is demonstrated through the councils work to ensure that policies and procedures for practice are evidence based. The formal forum for interdisciplinary collaboration improves communication and dialogue to ensure nursings position and supporting rationale are presented. The Shared Governance structure to support EBP provides evidence of a Magnet culture and the work environment that empowers nurses and supports autonomy.2,3,4,5,6 This structure increases staff involvement at both the unit and governing councils. And the scientific base for practice is substantiated by incorporating standard hierarchies and strength of evidence via Nursing Research and Practice Council (AHRQ hierarchy and US Preventive Services Task Force [USPSTF]). Improvement of patient/staff satisfaction. RN satisfaction data for 2005 reveals the following dimensions were statistically significantly better than the mean: Decision Making, Task, Autonomy, Job Enjoyment, Nursing Administration, Nursing Management and Professional Development. The 2006 results in the following dimensions were statistically significantly better than the mean: Decision Making, Task, Nursing Administration, Nursing Management RN-MD Interaction, Professional Development and Professional Status. For those areas in which improvement is needed, unit and governing councils have been actively involved in action plans (e.g. RN-RN Interaction). For example, focus groups of staff nurses were convened to address issues and present to the Chief Nurse Executive. In turn the issues that cut across services are brought to senior leaders (e.g. Pay). The relationship of staff perception to the Shared Governance structure is only indirect;7 assuming that the staffs focus on patient centered care improves the overall experience the inpatient perception with overall quality of care has consistently been 90-100 since June 2006. Replication of EBP published in professional literature. Tim Porter OGradys expert work on shared governance models was a key resource as well as analyzing models such as Seton Healthcare Network, Overlake Hospital Medical Center, Barnes-Jewish Hospital, Hartford Hospital, and London NHS Trust.8,9,10 A hybrid model was designed that included key concepts from the councilor and unit based shared governance models described in the literature. The lack of support during the transition to a shared governance structure was cited as a limitation to success in other institutions. The formation of a transition team within our model was a result of this evidence and proved to be the continued motivation to see the process of implementation to a successful end. A 5 year research study to determine the impact of a redesigned organizational structure on nurses opinion of shared governance, satisfaction and autonomy was initiated in 2004 based on the measures of success identified in the literature and using the Nursing Opinion Questionnaire and the Index of Work Satisfaction. The findings from this study provided evidence that our nursing staff wanted a new model of governance, increased autonomy in decision-making at the organizational level, and thus set the foundation for our shared governance model. To advance our nursing service commitment to data-based practice in all settings, our Nursing Research Committee set the stage for adopting a model of evidence-based practice in 2005. Members of this committee examined RU/EBP models (Iowa, Stetler, Larrabee and Rosswurm) and their fit with our Shared Governance Councilor Model, and selected tools for rating evidence strength and scientific rigor of literature. We standardized our approach to evidence-based nursing practice. The results were presented to the Coordinating Council for approval to adopt the Iowa Model, the rating scales and the process for verifying evidence levels for practice changes. Through this work, EBP will be implemented in a consistent manner for all staff. Cultural transformation has occurred within the organization as seen with staff nurses leading councils and participating in decision making through strategic planning and development of priorities. Staff nurses make decisions at the unit level about patient care, nursing practice, and the work environment. Staff nurses develop/refine policies, and procedures using an evidence based structure (e.g. high risk medications and blood transfusion procedures). A new Fellowship was recently developed to strengthen our capacity for research and implementation of EBP. This proposal was validated with other organizations that have a similar model (such as John Hopkins) and approved by the Coordinating Council. The implementation of the first Fellowship in 2007 is based on clinical priorities established by Practice Council and approved by Coordinating Council. Workshops have been held on EBP, hierarchies and strength of evidence (as well as using the literature, research designs and data). These workshops were led by the Nursing Research Committee and jointly sponsored by a Shared Governance Council. Development of web based courses on these materials has also ensured resources are disseminated widely and offer contact hours. This education supports the transition to a new lexicon for staff in the implementation and sharing of EBP. 2. Evidence of nursing leadership Nurses are clearly designated as leaders and experts of the initiative. A staff nurse led the nursing design team that was charged to develop a shared governance structure. The team was to ensure evidence based practice for both the model and continuing evidence to support nursing practice (Practice Council). The design team consisted of staff nurses, midlevel practitioners, and management nurses from every area of the hospital and its major clinics. This team designed the model, initiated education (including a self-study booklet) of nurses on all levels, the senior executive board and labor partners, and began the implementation process. The literature suggested that a transition team would be needed to help change and maintain the culture of a traditionally governed institution. A nurse led transition team was formulated (2004) to continue the implementation and begin the transitional process. The 16 nurses (staff, advanced practice, management), and labor partners spent two years in continued education on the unit and council level. The team provided assessment, support, and evaluation to councils and units through attendance at shared governance council meetings and requested attendance at unit based meetings. Additionally the team created implementation tools (e.g. unit-based shared governance needs assessment, unit based facilitator guide, state of council assessment, and nurse manager guide). All forms of media were used: flyers, electronic communication and newsletters to educate, support and advise councils and units on how to develop and sustain the new structure. Interdisciplinary collaboration was evident and included research to identify shared governance models, supporting evidence for the model and the best evidence that would lead to initial and continuing success. For example the use of a Transition Team to provide mentorship during the introduction and implementation of this structure was a key example of the best evidence for success. Next, education was required across all levels of nursing staff regarding shared governance and how to engage direct care nurses as well as support nursing management in transforming their traditional roles into one of staff empowerment. Administrative collaboration was required at the nursing and senior level as the changing structure presented a new way in which policies, practices and procedures impacting nursing would be developed through the council structure. Labor partners (AFGE and FNA) were included in the design phase to enlist support. Current interdisciplinary collaboration is evident in using evidence for improving practice in an ongoing manner. Examples of Interdisciplinary Collaboration in Shared Governance Activity of CollaborationDisciplines InvolvedLevel of InvolvementDeveloped and implemented Medical Response TeamNursing Medicine Respiratory Therapy PharmacyUnit level team in MICU to address house wide needDeveloped organization wide HPM on HandoffNursing Medicine Patient Safety Diagnostics (e.g. Radiology)Practice Council to support organization needDeveloped Passcode HPMNursing HAS AdministrationUnit level team in MICU to address house wide needImproved availability of linen for nursesNursing FMSUnit level team on 4South with new CNLCompliance with Dysphagia DirectiveNursing Food and Nutrition Speech Therapy Pharmacy Quality ManagementPractice Council Compliance with Directive on Smoking and use of OxygenNursing Safety InformaticsNursing Safety Committee Quality CouncilDemonstrates responsiveness to all relevant stakeholder interests and concerns. The introduction of the Shared Governance structure was generated from nurses feedback on early surveys (2000-2002) in which they indicated a need for greater voice and role in decision making about nursing practice. This structure met needs of staff nurses, advanced practice nurses, and nursing leadership. It met concerns of Nursing and senior leaders to fulfill the requirements for the ANCC Magnet Recognition Program.11 This structure exceeded expectations for accreditation entities and was consistent with a focus on front line caregivers demonstrating their knowledge and role of managing the quality and safety of patient care. It met concerns of patients to have a knowledgeable and competent nursing workforce that practiced using the best evidence, and it met concerns of other services that interact with Nursing with an accessible vehicle. Nursing leaders have formally disseminated information on initiative through multiple formats. At the Local level, Shared Governance has been incorporated into new employee orientation. This helps integrate the model with new nurses. Additionally, multiple workshops have been held through the Nursing Research Committee on EBP, literature reviews, analyzing data, and the strength of evidence.12,13,14,15 At the State level, Daniel ONeal III and Dr. Pat Quigley presented at the 4th Florida Magnet Nursing Research Conference on how our structure integrated EBP at the unit level through Transforming Care At the Bedside (TCAB). At the National level multiple presentations have been given by the Chief Nurse Executive describing EBP linkage to our infrastructure of Shared Governance. 16,17,18,19,20 Additionally, the VA Nurse Executive monthly conference calls on Magnet Culture have had presentations by Dr. White on the Shared Governance structure and discussion of unit council function by nurses Ms. Kendall and Ms. Boardman. Presentations on our Magnet journey (too numerous to count) always include a segment on our shared governance structure and councils including sharing with international visitors from Singapore, Taiwan and the Netherlands. Publications on Shared Governance implementation and support for nursing in EBP include our recent articles in JONA 21 and SCI Nursing 22. 3. Scope of initiative Our initiative began with the culture of inquiry led by the chief nurse executive, formalized during our Magnet journey and specifically focused in 2002 with the design team. The design team consisted of 16 nurses of varying levels including labor partners (65% clinical and 35% management mix based on the best evidence for shared governance). This team performed research, collaborated with a national expert, and sought nurse input into applying evidence for the structure to meet our organizations needs. Initiative impacts multiple areas. The shared governance structure was implemented across the entire nursing service including the main Tampa hospital, 2 VA nursing homes as well as large off site clinics in Orlando, Brevard and Pasco. The expectation has been set that all councils will use evidence as the basis for practice. Every council uses current evidence to make improvements. This is perhaps best illustrated with Practice Council which will be adding hierarchies of evidence and strength of evidence into policies and procedures; however Advocacy Council also uses evidence in decisions such as floating guidelines, educational leave and non-nursing tasks. Similarly, the Quality Council uses evidence to identify measures and benchmarks, while Professional Development Council incorporated hierarchies of evidence and strength of evidence into Journal Club presentations. Initiative impacts facility wide. The entire nursing service across multiple sites is part of shared governance. The structure is recognized throughout the organization by other services as the vehicle for collaborating on policies, procedures or other team actions. For example, the Patient Safety Manager recently presented a recommendation from an RCA team to Practice Council on use of independent checks for insulin. The Practice Council will consider current evidence, standard of care, and medication errors before making a decision. The Lab requested to develop a joint position with Nursing on single use tourniquets and again presented to Practice Council. Quality Council routinely invites Hospital Quality Management, Infection Control and Patient Safety to present on issues and presents reports of nurse sensitive indicators to the Hospital Performance Improvement Council. The Professional Development Council has a representative from the Continuing Education Committee. Initiative shows promise of usefulness to VHA. Shared governance is an evolution in Nursing as the structure to implement EBP. This structure can definitely be exported to other VAMCs. The councilor model, bylaws, sample practice areas and implementation plan can be easily shared, and in fact a presentation has already been made through the VA Nurse Executive Magnet Culture Call describing Haleys model. This shared leadership structure is essential in achieving Magnet designation which many VAMCs are working toward. 4. Impact Demonstrated process improvement can readily be seen in the following examples. Improvements in Process: Formalized communication process developed for staff to address issues via 1) Council Action Request Form, 2) Practice Area Representatives, and 3) Unit Council Facilitators.Tracking method developed to ensure Nursing policies and procedures have defined accountability and completion process.Floating guidelines and evaluation process implemented and reported to Advocacy Council based on staff feedback.Use of AA on weekends addressed into policy generated from staff request.Strength of evidence to be documented into policies & procedures based on Nursing Research Committee recommendations.Survey readiness and national patient safety goals incorporated into all Council agendas for continuous preparation.Shifting non-nursing tasks to appropriate services based on staff evaluation (e.g. HUCs to answer call lights and adding transporters). Involved staff in the review and approval process for the PI Plan, measures and benchmarks as well as analysis of data for improvement.Implemented use of evidence based bundles for VAP and catheter related infections in all ICUs for the IHI and IPEC campaigns.Demonstrated impact on patient/staff experience. Shared Governance changes the very fabric of the nurses role in managing patient care and innovating practice. In chairing each of the councils, staff nurses provide direction, expertise and accountability. They develop professionally as seen in team hiring practices for the unit, self-scheduling, and pursuit of certification. Their active involvement in strategic planning ensures a complete communication loop for goal achievement and this structure shifts managerial paradigms to shared leadership not just participative management. This directly impacts patient care in daily goal setting and better discharge planning and is evident in decisions about patient care as well as patient involvement on teams (e.g. TCAB). Demonstrated impact on nursing-sensitive quality indicator. Data indicate the following: Fall rates per 1000 patient days have continually declined over the past 3 years and compared to NDNQI mean and top quartile cutpoint benchmarks, our performance is better than the mean and often better than benchmark. Programs utilize evidence on falls and reducing harm. Fall with injuries rate (segmentation of data) is better than NDNQI mean benchmarks in our medical and surgical units. The percent of falls with moderate or greater injuries is better than NDNQI benchmarks in all but one unit (stepdown).There have not been any moderate or major injuries from falls for six months. Our performance on pressure ulcer prevalence is better than the NDNQI mean and benchmark in all units. Our total HPPD and RN HPPD average about 2 hours lower than the NDNQI benchmark for the time we have entered into this database, but we have kept pace and actually have a higher percentage of licensed staff than NDNQI. Demonstration of long-term integration into structures and processes is seen as Shared Governance has become the Haleys way of doing business through Councils. New employee orientation introduces shared governance while additional support by educators ensures integration throughout all units and shifts. This has been achieved through the unit guides, educational sessions and mentoring. Other departments ask to be on the agenda and we now utilize the councils for decisions on practice. The council chairs have been fully integrated into our nursing strategic planning process to ensure communication, staff views and support for implementation and accountability. The strategic objectives and actions assign responsibility to councils which then ensure action and reporting. The basis for shared governance is evidence based and it now supports the continuation of EBP for Nursing. References: 1.Anthony, G. (2004). Shared governance models: The theory, practice, and evidence. Online Journal of Issues in Nursing. Retrieved at  HYPERLINK "http://www.nursingworld.org/ojin/topic23/tpc23_4.htm" www.nursingworld.org/ojin/topic23/tpc23_4.htm. 2.Porter, OGrady, T., Hawkins, M. A., & Parker, M. L. (1997). Whole-systems shared governance. Architecture for integration. Gaithersburg, MD: Aspen. 3.Porter, OGrady, T. (2001). Is shared governance still relevant? Journal of Nursing Administration, 31(10), 468-473. 4.Porter, OGrady, T. (2004). Overview and summary: Shared governance: Is it a model for nurses to gain control over their practice? Online Journal of Issues in Nursing. Retrieved at  HYPERLINK "http://www.nursingworld.org/ojin/topic23/tpc23ntr.htm" www.nursingworld.org/ojin/topic23/tpc23ntr.htm 5.Kramer, M., & Schmalenberg, C. (2003). Magnet hospital nurses describe control over nursing practice. Western Journal of Nursing Research, 25(4), 434-452. 6.Green, A., & Jordan, C. (2004). Common denominators: Shared governance and work place advocacy: Strategies for nurses to gain control over their practice. Online Journal of Issues in Nursing. Retrieved at  HYPERLINK "http://www.nursingworld.org/ojin/topic23_6htm" www.nursingworld.org/ojin/topic23_6htm. 7.Brooks, B. (2004). Measuring the impact of shared governance. Online Journal of Issues in Nursing. Retrieved at  HYPERLINK "http://www.nursingworld.org/ojin/topic23/tpc23_1htm" www.nursingworld.org/ojin/topic23/tpc23_1htm. 8.Jones, K., & Redman, R. (2000). Organizational culture and work redesign: Experience in three organizations. Journal of Nursing Administration, 30(12), 604-610. 9.Thompson, B., HateleyP., Molloy, R., Fernandez, S., Madigan, A. L., Thrower, C., & Cain, A. (2004). A journey, not an event: Implementation of shared governance in NHS trust. Online Journal of Issues in Nursing. Retrieved at  HYPERLINK "http://www.nursingworld.org/ojin/topic23/tpc23_3htm" www.nursingworld.org/ojin/topic23/tpc23_3htm. 10.Caramanica, L. (2004). Shared governance: Hartford Hospitals experience. Online Journal of Issues in Nursing. Retrieved at  HYPERLINK "http://www.nursingworld.org/ojin/topic23/tpc23_2.htm" www.nursingworld.org/ojin/topic23/tpc23_2.htm. 11. ANCC. Magnet Recognition Program. Retrieved at  HYPERLINK "http://www.nursecredentialing.org/magnet/index.html" www.nursecredentialing.org/magnet/index.html 12.Janzen, S. K. (May 6, 2005). Evidence-based practice James A. Haley Hospital Nursing Research Committee Workshop, Tampa, Florida 13.Quigley, P. A. (October 2006). Evaluating the Strength of Evidence facilitated by a team from the Nursing Research Committee, Tampa, Florida. 13.Quigley P.A. (May 2007). Evaluating the Strength of Evidence facilitated by a team from the Nursing Research Committee, Tampa, Florida. 15.White, S. V. (May 2004). Interpreting Statistical Information: Using Data, James A. Haley Hospital Nursing Research Committee Workshop, Tampa, Florida 16.Janzen, S. K., & Mayes, D. (October 16, 2004). Labor partnerships: Success by design, ANCC Eighth Annual Magnet Conference, Sacramento, CA. 17.Janzen, S. K. (April 15, 2004). Evidence based practice for nurse leaders Panel presentation. VA Annual Nursing Program, Phoenix, AZ, 18.Janzen, S. K. (October 4, 2003). Use of a system of performance to attain research excellence in a nursing service Magnet Conference: Magnet 2003: The bridge across the quality chasm, Houston, TX, 19.Janzen, S. K. (August 15, 2003). Model for evidence based practice: Linking research and practice, Tampa Bay Organization of Nurse Executives, Clearwater, FL 20.Janzen, S. K. (October 22, 2002). Evidence based practice: Relationship to the VA nurse qualification standard Researching the Opportunities: Evidence based nursing practice, Dept of VA, Puget Sound Health Care System, Seattle, WA, 21.Dunbar, B. Park, B., Berger-Wesley, M., Cameron, T., Lorenz, B. T., Mayes, D., & Ashby, R. (2007). Shared governance. Making the transition in practice and perception. Journal of Nursing Administration, 37(4), 177-183. 22.Dunbar, B., Mayes, D., Park, B., Ashby, R. A., Berger-Wesley, M., Cameron, T., Lorenz, B. T., & Veneman, M. (2006). Designing a shared governance model: Soaring to new heights. SCI Nursing (Journal of the American Association of Spinal Cord Injury Nurses). Retrieved at  HYPERLINK "http://www.unitedspinal.org/publications/nursing/2006/05/01" www.unitedspinal.org/publications/nursing/2006/05/01     PAGE   K 7 8 @ B  1 2 Y 򵬠xmxm^R^jhlCJUaJh"hlCJaJmH sH h1FhlCJaJhlCJaJhNhlCJaJhNhlaJh1FhlCJ\aJh1Fhl6CJaJhl6CJaJhNhlCJ\aJhy;hl6CJOJQJaJhl5B*CJ\aJph#h{hl5B*CJ\aJphhNhl5CJ\aJ:KT}kd$$Ifl0 $\ l t0644 laPyt00 $Ifgd00$a$gdl$a$gdl$ *]^a$gdl  ' 8 9 @ B x}kdj$$Ifl0 $\ l t0644 laPyt00 $Ifgd00B C D ||tk $Ifgd00$a$gdlgdl}kd$$Ifl0 $\ l t0644 laPyt00 $Ifgd00fkd>$$Ifl4&(0(64 laPf4yt00 $Ifgd00vkd$$Ifl0& 0(64 laPyt00  o $Ifgd00vkdn$$Ifl0& 0(64 laPyt00Y Z [ m n q r | } ~ ynYH0Y/jhNhl56CJU\]aJ hNhl56CJ\]aJ)jhNhl56CJU\]aJhNhlCJaJ%hNhl5CJ\aJmHnHu)j}hNhl5CJU\aJhNhl5CJ\aJ#jhNhl5CJU\aJh"hlCJaJmH sH  h"hl0JCJaJmH sH jhlCJUaJ#jhh'hlCJUaJo p q { $Ifgd00gdlvkd$$Ifl0& 0(64 laPyt00 N t ƻx_K_9#j h1FhlCJUaJ'h"hlCJPJaJmHnHsH u0jh1FhlCJPJQJUaJmHnHu#jm h1FhlCJUaJjh1FhlCJUaJh"hlCJaJmH sH hlCJaJh1FhlCJaJhNhlCJaJhNhl6CJ]aJ)jhNhl56CJU\]aJ+hNhl56CJ\]aJmHnHu $Ifgd00  !gdlckd$$Ifl&(0(64 laPyt00 P $Ifgd00vkd-$$Ifl0& 0(64 laPyt00P R t $Ifgd00vkd$$Ifl0& 0(64 laPyt00   l n p 1\b;JafȼȪȎuiuiuiuiuauiuiuSuhNhl5CJ\aJhlCJaJhNhl5CJaJhNhlCJaJ *hNhlCJ\aJh1FhlCJaJ h"hl0JCJaJmH sH #jY hh'hlCJUaJjhlCJUaJh"hlCJaJmH sH 0jh1FhlCJPJQJUaJmHnHujh1FhlCJUaJ {{ $Ifgd00gdlvkd< $$Ifl0& 0(64 laPyt00 $Ifgd00vkd $$Ifl0& 0(64 laPyt00  $Ifgd00vkd| $$Ifl0& 0(64 laPyt00wwww$a$gdABgdlgdlvkd $$Ifl0& 0(64 laPyt00  @BvwymdmXOh1\5CJaJhr&hAB5CJaJh~u75CJaJhr&h;r5CJaJh0hlCJaJhfphl5CJaJhAhl0J5CJaJ&j hAhl5CJUaJjhl5CJUaJhl5CJaJh'hlCJaJhlCJaJhNhl5CJaJhNhlCJaJhNhl6CJaJ#$!!P'Q'}'*/7I8U<V<x<gdr&gdgd!Agdq&gd6UgdS,;gd\m $a$gdAB(#=u~霓xphp`pUMh\m CJaJh\m h\m CJaJhF%CJaJh[CJaJhrKCJaJh CJaJh!h!CJaJhygCJaJhr#5CJaJhOhr5CJaJh~5CJaJh\CJaJh-sCJaJhdcCJaJhqS;CJaJhr#CJaJhWCJaJh.2CJaJhOh+5CJaJh+hFCJaJN"# PT]`g:OPNQ[༴zrzjrjrbhdcCJaJh CJaJhCJaJheCJaJh{}hS,;5CJaJh{}hS,;5CJ\aJhS,;hS,;CJ\aJhS,;hS,;5CJaJhS,;CJaJhF%CJaJh CJaJh\*CJaJhvhvCJH*aJh]ZdCJaJhLiCJaJh\m CJaJh[CJaJ&[beux:9;NS_`x89X[gjs (Mv0 3 5 J ! ! !ШȘh-iCJaJhUCJaJh\m CJaJh@hCJaJh*bCJaJhCJaJhdcCJaJhLiCJaJh CJaJhtpCJaJh[CJaJhCJaJh CJaJ< !!!%!&!'!z!}!~!!4#7#%o&&'1'P'Q'T'{'|'}'''((M((û˳sj\TLTLThCJaJh3CJaJhxhq&56CJaJhq&>*CJaJhbahq&>*CJaJhbahq&5>*CJaJhq&5>*CJaJh~5>*CJaJh_jCJaJh[CJaJh6UCJaJh QCJaJh\CJaJh2CJaJh.2CJaJhrCJaJhOh+5CJaJh~5CJaJheCJaJ( )P)Y)t))))))))*********+ +++----H.I.J...../5/?/Ƹԙԙ}ughxh]w56CJaJhn0CJaJhCJaJh<\h>*CJaJhDCJaJhCJaJhSV6CJaJhxhq&56CJaJhxh!A56CJaJhxh56CJaJhJuUCJaJh QCJaJhvhvCJH*aJh3CJaJh!ACJaJ&?/@/A/S/U/V/]/v/}///107090222 223F3d34'4(44445 5>5?5@5i5r566k6667777+7κβΪΪޚ޲thxhq&56CJaJhCJaJhZCJaJhhCJaJhCJaJh/CJaJh@hCJaJh:CJaJhU>BCJaJhvhvCJH*aJhG`CJaJheCJaJhfCJaJh!ACJaJh]wCJaJh]w6CJaJ,+7Q7_7o7r7{77777777888-8.8G8H8I8o8s8888888888I9: ::<:=:R:]:s:t:~:::::; ;L;g;i;j;;;;;;;;;;;;T<U<V<ȸظȭh~5>*CJaJhNCJaJhhCJaJh!ACJaJh*bCJaJh/CJaJhfCJaJhCJaJhrTCJaJhCJaJBV<Y<x<<<<<<<<<<<<<<<<<==???? @ @@DD4DyDDEEE˽ٽٴ~vvnff[h{hCJaJhCJaJhU>BCJaJh 5CJaJh{h{5CJaJh{Rh{>*CJaJh'CJaJh{h{CJaJh&Wh]wCJaJh]w6CJaJhxhq&56CJaJhxh35m56CJaJhxh]w56CJaJhbahq&5>*CJaJhq&5>*CJaJ#EEF F)FAFFFFFFFFF9H@HHH'I+IIJJ+JcJdJJJJKKKK0K1K=KLKZK\KKwnwfhCJaJh5CJaJh5CJaJh5CJaJh hse5CJaJh hY5CJaJhYCJaJhfCJaJh QCJaJh*T6CJaJh!ACJaJhZMCJaJhxhq&56CJaJhxh]w56CJaJh{h{CJaJhCJaJ'x<FJK1KFK[K\KKPG $Ifgdsekd$$IflFsP#  t06    44 laytw# $$Ifa$gd^$a$gdYgd!Agd{KKKKKKLLXLYLLLLLLLLLLLMM#M$MKMMMMMMMMMNNNDNENNNNNNNNNNNN OnOP*CJaJh\h\CJaJhvCJaJhvhvCJH*aJh QCJaJh>*CJaJh*T6h!A>*CJaJhCJaJh6CJaJhxh!A56CJaJhCJaJhCJaJhnCJaJhCJaJh!ACJaJhCJaJ=TITJTNTOTUTVT\TcTlTtTzTTTUUU&UOUQUcUUUUUUUUUUV6V_V1W4WCWDWHWLWMWOWPWTW_W˯🗟蟏wohQ\CCJaJhQ\ChQ\CCJH*aJh3rTh6CJaJhzCJaJh QCJaJhCJaJh CJaJh!ACJaJhvCJaJhvhvCJH*aJh3rTCJaJh\>*CJaJh*T6h!A>*CJaJhCJaJh\CJaJh*bCJaJ+_W`WbWcWdWeWhW|WWWWWGXHXJXdX|XXXYpYxYyYzY{YYYYYYYĶwwl^VNhbECJaJhXGCJaJhxhq&56CJaJh"Zh GzCJaJhJuUCJaJh{RCJaJhu|CJaJh CJaJh"ZCJaJhXG6CJaJhxhXG56CJaJhehq&5>*CJaJhq&5>*CJaJh~5>*CJaJh QCJaJhQ\CCJaJhQ\ChQ\CCJH*aJhQ\C6CJaJYgZ[[[[f\g\\\\\\]]]*]`j``````DaGa\agauaaaabbȺwog\ghekhWCJaJh'CJaJh*bCJaJhxhq&56CJaJhehW6CJaJhWCJaJhu|CJaJhbECJaJh[:CJaJh`h6CJaJhxh`h56CJaJhWCJaJhFrCJaJhfCJaJh^iCJaJhrLCJaJh"ZCJaJhJuUCJaJ bbgbybbbbbbbcc/c0c*CJaJhq&5>*CJaJh~5>*CJaJhWh*CJaJhWRCJaJh?CJaJbb0cJcccrd|jkd$$Ifl(## t0644 layt $IfgdbEgdbEgd Gzgdq&rdsddd jkd$$Ifl(## t0644 layt $IfgdbEjkdK$$Ifl(## t0644 layt e.e0epeeeffPfjflffffffg-g0ggggggggh ijjjjkkkȋxmbhfPhWJCJaJhhZ"CJaJhCJaJhSVhq&CJaJhu&CJaJhSVCJaJh*6CJaJhxh*56CJaJhxhq&56CJaJhJOTCJaJh'CJaJh*bCJaJh]9BCJaJhCJaJhWCJaJhwCJaJh.pCJaJ"d/e0ee $IfgdbEjkd$$Ifl(## t0644 layt $IfgdWeeff jkd$$Ifl(## t0644 layt $IfgdbEjkd8$$Ifl(## t0644 layt fff/gjkd$$Ifl(## t0644 layt $IfgdbE/g0ggg jkdt$$Ifl(## t0644 layt $IfgdbEjkd%$$Ifl(## t0644 layt gjk!l\mmnr"r#rssss.t/t\u]uuu1w2wxxgd$gd XgdG$a$gdq&gd & Fgd3 & FgdWJgdWgdAkkk lSltllm\mmmmmnnnnnnnnno>o?o$p7pCpGpUpYp{pppʾʶzrjbjZjbjbjbjbhwzCJaJhbECJaJhBCJaJh]^^CJaJh]^^6CJaJhxhq&56CJaJhxh]^^56CJaJhpFhfP>*CJaJhfPhfPCJaJh3CJaJhfPh3>*CJaJhfPh3CJaJhfPh [OCJaJh'CJaJhfPhWJCJaJhfPhWJ>*CJaJ pppppp:qrrrr r!r"r#rwrrrrrrrrrss^sstttظذsfZNh$hG6CJaJhehG6CJaJh^HhG0JCJaJ#jh^HhGCJUaJh hGCJaJjhGCJUaJh hG6CJaJhGCJaJh`gCJaJh9Rhq&CJaJhOhq&5CJaJh5CJaJhq&CJaJhbECJaJht^CJaJhBCJaJhCJaJtttu*u+u,uZu[uuuuuvvvvvvwww.w/w1w2w4wrwwwwwyqyeyYQh*CJaJjh*CJUaJh$h$6CJaJhLO}CJaJh$CJaJ#j=h^HhGCJUaJhnShGCJaJhnShG6CJaJh Xh XCJaJh hG6CJaJh^HhG0JCJaJ#jh^HhGCJUaJh$hGCJaJhGCJaJjhGCJUaJwwwwwxxxxxmyyyyyyyyyzzzzz`zzzϺqd\Ph h$6CJaJhLO}CJaJh^HhG0JCJaJ#jh^HhGCJUaJhnShGCJaJjhGCJUaJhnShG6CJaJh$hG6CJaJhGCJaJh$CJaJh^Hh*0JCJaJjh*CJUaJ#j\h^Hh*CJUaJh*CJaJh*h*CJaJxxxzz{{{{5|6|||W}X}}}~~vwUVgdLO}gd$gdGzzzzzzz{{{;{<{O{{{}{~{{{{{|s}t}u}}}}G빭xmaSxKh8DCJaJh hGCJ\]aJh hGCJ\aJh hGCJaJhGCJ\]aJh;hG0JCJaJ#jh;hGCJUaJh XhGCJaJjhGCJUaJhGCJaJh^Hh$0JCJaJ#jh^Hh$CJUaJh h$CJaJh$CJaJjh$CJUaJGHvwz"GVYgh Ŧ垚yuh^h{0JmHnHuUh9; h9;0Jjh9;0JUhI( jhI( Uh^HhLO}0JCJaJ#j<h^HhLO}CJUaJjhLO}CJUaJhM#hLO}6CJaJhLNCJaJhLO}CJaJhGCJaJhGhGCJaJ)V h]hgd;r &`#$gdbgdLO}PAGE 1 21h:pSV/ =!"#$% Oh+'0 (4 T ` l xOffice of Nursing Servicesvhatamwhites1 Normal.dot VHACOMITCHR2Microsoft Office Word@@{߼@5@5Xh՜.+,D՜.+,d  hp   Department of Veterans Affairs>z' Office of Nursing Services Title 8@ _PID_HLINKSA8B8r*<http://www.unitedspinal.org/publications/nursing/2006/05/01 79'4http://www.nursecredentialing.org/magnet/index.html $ $5http://www.nursingworld.org/ojin/topic23/tpc23_2.htm z!4http://www.nursingworld.org/ojin/topic23/tpc23_3htm x4http://www.nursingworld.org/ojin/topic23/tpc23_1htm {[.http://www.nursingworld.org/ojin/topic23_6htm U6http://www.nursingworld.org/ojin/topic23/tpc23ntr.htm $ 5http://www.nursingworld.org/ojin/topic23/tpc23_4.htm Aemailto:reji.john2@va.gov amailto:Patricia.Quigley@va.gov !Rmailto:Diane.Mayes@va.gov _1279448291^P FpK&C۰pK&C۰Data p1TableMOj?CompObj]q      !"#$%&)LK+,-./0123456789:;<=>?@ABCDEFGHIJOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~$$If!vh50*#v0*:V l400*650*4af4ytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytkFDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$If!vh50*#v0*:V l00*650*4aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54ayt$$If!vh5@ 5#v@ #v:V l00*65@ 54ayt$$If!vh5@ 5#v@ #v:V l00*65@ 54ayt$$If!vh5@ 5#v@ #v:V l00*65@ 54ayt$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytk$$If!vh5@ 5#v@ #v:V l00*65@ 54aytkADd &G0  # A" C~JK:[?S@= C~JK:[?~J_/_x= tUv}3a4BEu: ѬD@XZ*BYAwJer nYݣݸJO,vRX稫gLϖyy?ͻwH!p1r!j}Vb!̙%O= "!DEߝ,{Z.-; %Aq_i)@Svv79̻\B:*ʨq\r(CSiGuΘ`Ѵȅ/SEv Н˖VBc0qR*~%)z|" 78F8^э%Hm< WG|՟ድnJǚ-dȊբ^}*&WU3ωՕß@x]YQRQ L凴*ʼn߹1]14qoHEXB4 bf(7t%!yw?zћKrb ~&pO,`! 2Ӯ]J:р/VȵX?~]Q-'+=_t ޼+r{{yO N^r gC 7ߢ :]낎.3tKb_޿x7@7U~ u潎#5x."&Be[`ᓿtIWwS)0|]ݙ Jm?5 N9Ǩ;·pug o(4Vxs.JVKd0ԝo2,j]K B+6s݉{|zt>4[ 8D?ª,s1F~ǘass%'ogˬ||ʎqq`Z)jq ě4quBSŃtЋH'r oV`_7C2as;X6~,[|7f 12e!_rz%'ס\[D?Fao?m_`iu7 ;Lx;3x+2n[|+71x/ce ^kс蹉-GHBJWтJ6/BJtLn$[r eҢ7M!Ehq ڄm;a3`{9EG KP9n_FZ2hbZ:;e]?-niq?l#K!ep!)ohߢĶp~!5)G!v\{HICߥ5Gw]C H^-zty?7l >GeD_V>۩ao@KyA7R (S$ӆ:AfAvuT~zď>=Dhgl >G!C;a/,u9;uf|G`|O:3xLsB$;oә;5NN&,u/Zwk (>Gj2V  b=׉{׋?%zpp&LKiEF8jğo'ۯѰk J@ub*%7GW!ene/zjŽ&9'ŭ qi4!}wdUҹ?ɳgur5gS'/=Cgpz [@{o\5Oן됴חJ@SuFuW^ExUâ>r-:/AoORm f6K}A_5 ~q?Ԙ0?,3?f)}YTPTDﵔ~ 7S-oP4WМ>*| okXD8VZp, c/c@8!vj-uwlq9o/˼/zd[= V5bX ~R8F;);^i׬%g:l%պչ5%3z]n!eµd5,{ZLUIlՆ&9H4ޫ^g@emB@|szuO|E>2+eo|w,4,5 n*s2pU6?wR?h!/߱A{lbE<%̫4\Nl H *ނoF@|n_mTX;ᗂ3pط26z/ӔU׭SN ~;ey}7>:E<;ّgB-ɪ(;YpxkLՖO LV e·?ĭeꍪ!oWG`lO~/֙b ,|7J^La~,[j^ tsw޷F~H6w4ZF+i,7fܲ7YfQ<ڲm2~uL}G{za7w@y9o=Jna]n7[֫wͷŲooN;}GqA'˻ǥ;7s?e>IY$;d<)qI@|l];4W^_^w);2X)Xc@f`-1_i Hqmc!T|Evjy٦x_p@u/ټ/~:>˛n8>~2_OB=K 6-L=*}*kjȓ6ݏ[ƈK?m Y}m9B%oJ Bb{ՋW}}#77EߥE@ZSqh=­Y#_C)* s㴘ᒴhӿ{ b|0nvnȿAQ7w׸;lꊩoέz"[3Tn e,Qu1: 7yQjff^M"-ދy4}wcҳu^dW"-#7d0]y{3o<7##DcˑgdZo˨~|aZᱎbnJ8=pOGL*ͶқNo˴ ߑaⷶӟ;l(757ynKϨ ;4)>g#GuDs寍:@sUmiXy1P/vzjp-UV/~o.j^9TM@ou0Mz`W_;?(\鞙yt<+B6a~ m: ھE ƬμUy_dl>792aoMԝ%\_r[mT }+*Vm@X۷xElH׾=`7gkoσ}Ͼͯ7 `߼7ܛ[Duhoǟ/ Ӹ?T՝d6Z՝Q{q9(zOֈ'Ō!W-[\&[5nZj\UbZ: O^% [;t63,Sd&73q#Ź31ugqu1/%4:x.+-L4aWt' zz~^ {5vbMwLi4lB[qm=lWVJuWՐc5Uv\L42, Ȩ9A<\o 6u&/d;I!CB^hVX9k6:m<ac>Xp y}q:r>,vO76Mj+v,ħ_+՘fQ(Eє`yz6Ϙs}|G?-9Η^\ &Rܫxx˶Ĉڷy0]F1w\e]~ 7RY~kumt1%ݻv2-a'Mv < 8/eIDd ob  c $A? ?3"`?"Hf ~)qѬ~ qH'S@=Hf ~)qѬ~ qq 8 DH 3QHx|TEgC7Ԁj(ɝ@BHA"l<E@wP+"DEADADٳ˚d lw3s=Bwk!opӦSQ5THpqh!tAOͥC u`10Wۓ0]RtaZWhپ4^rb(UH̯ tlb*+TyRb(4]Fm%XǸ֟ P6?eMG%t2=ݛbi6s60M†?=MU^t4IA> w&O*t1r1r3TI'aQ>۸$'m|9l}XT>oG^lXL/Y_WD !!|M[ۯtn5M]*LjֹE?~]Vd 8˄^ܢ `o[e`""څ>Rm osu1M#4mS9>._ƭh CVb.i/ϿbpvVy [}#DLW6Xi~E^3<}/*.֭}_zHr>!"/.j0޷Q9ȼ|] vy\Ӆ\סesگy[x>tޞ]79_{H*]#`,9`,_6`o|qo]ծm ??r:olvN1@49?]|1_R1\m^Xc/>"+Ho[Y'&w]{PV4-7&yK&WfRzzI"͉09ѣE9E~*&ᕕ X&}i ǎH X>aiXfN¢ S /-^eW&_oNؽk~/C _:~ۯ¹PgHYh9/,Z>H_Ή/8_|H?s~v?':w&gd^g)̜1,fy4YZ<#`{y'3π9^bg%`]X+U לkր{qi7;[l:lsv؁弽ge޻b}9?tA!'`ݎ8s/_:_<0@%-&W\ľ?TJ.x*pAi(Yt|2GJSOTO=YQbg$}|k$|/VrK5%䲥%rzrǃ|rի kIr&r횦r8DnX\nB1#7 oJGnyܺܶ5IX;;w];JWrv=޷;Hcw:,w&?x:.ǞBk`oR&E!s*X?DOKqnE`UJdc=o~RR$fo)jTO).űnRUǻH1:)RӰ.Je')ubt)bK]ϷO I&aƶj%R -GRR-l3l8)l"ERm(ER[֓b[)Z֖beM)*אb^5)Wk_ $F'+HR۹[R4ʿJKR*&"Xs Jq" GHq4LR"GoGğq{GMqѓu-#xcGt>#fvG&f>;zGqđW G<3^r/8b䳎qG {c8"c>ʞ5L?`ɎXro'8ܭ80 b@Gt 枰.HѩJiXGL㈂5Gr:#6vĶ(G wį!w8z.AL; N%c ' bxo(#A,|3A$ObU8 B|:A>eJ1sĺ b}X. b KKߧ`9'mY7A쫂}I0,W8z:^c"}#^<>^ļŋ̿ ]'`^-Wa:mn5}B-T衅T+|[KgzK|~1>#vL*qձdQկc9wsř^LyAÜqy;ZXK*Cb?G*C\b@C*DbA?*DܣbB;*.DbC7*>D\bD3*NDbE/*^DܢbF+*nDbG'*~D\bH#*DbI*DܡbJ*DbK*D\bL*DbM*DܠbN *DbO*D\bP*EbQUbUܿUY3&MRq뽓'u}uԩ*1}cg͜b߯9^v7_7nT7P7T1Rq[Ucv?ڹS{vVq޷VＣ}ｧb_W?T>R1'#XO?U?W1ǎU} +*63S⧿Nߟ9bA?=bs?_E_*^ǩ/{<9 q{HH@/_>9{hh1|XXq|xxX>""BNE<)!ϟ?>**J@l_@9}, #/\XH"Es+VLE_xq9%䃈K,)#(U|yUW]%F.Pti@tt\ꫯ)SF>ܠlٲQʕ!G(_|yB *V(D#BPR%4ʕ+g;\s5YUT!Z|yDj %W._D>QF 9E͚5K+jժ% ]\N:rruʗgԫWO.GQ~}Fll\A 6"hԨ\q5 M44mTA.'"i֬\yr=-Z MZl)7"?#GIHHo OqGⰗ&D9KV[[Zn- wIJJ[$''maڴi##III;˴mVD>*w!i׮܍}rr:ȷtQEөS'Ν;w\{=;iiirr뮻NK.>]vtM@Խ{w!=zȃȅz)?B>ԫW/y9Q޽ȋ#?Antȏ+ Gׯy 7 ?CԿ9ȣș(!o4hqOC _" QC'KtM+SÆ S >\~o 1bD~5rH-r,+C5j(y-" =z9׭*@5f#rcʳȿƍ'B6~x3 &sn6 o];!/;.'??!Oy^GpM9{c)XbJ-)T&bN=)XbRM)FXbV])XbZm)ƥXb^})Xbb)FXbf)Xbj)ƦXbn)Xbr)FXbv)Xbz)ƧXb~)\r (G\r(\r -(Ǡ\r=(\rM(G\r](\rm(ǡ\r}(\r"ʍ(G\r&ʝ(\r*ʭ(Ǣ\r.ʽ(\r2(G\r6(\r:(ǣ\r>(\rB )G\rF)\rJ-)Ǥ\rN=)\rRM)G\rV])\rZm)ǥ\r^})\rbʍ)G\rfʝ)\rjʭ)Ǧ\rnʽ)\rr)G\rv)\rz)ǧ\r~N ΀N΁"N&*΂.2N6#<@.׍P ՕPIC\Bu,T҂^&?P{u5`]t]MHu5!I}"=[Oݎ(Lw=Tweai ЀvD!G[G5jtܷߞ6*}@ף4*,J:`=J%XG ֣Q(z`=J%XG ֣Q(V~8g$ʺ_*~ʶ3SdcU;fOtf[`Igo ֏G#`H~$X? ֏G#`H~} R\wrۙx]Lb8>ŦO {0qߔ$gciM8`uEVu54X$9Ut l-q_%g\LOʏ1(x<טƒ)OeO,C~NϾ}},:& c?s۴,r?7u͋fY$+̯0p70j0?&`~ C_7&`cbdy]GqyK] \fl,mPfl<.|e*Yqq2fSJ.s{6e4(Q6eN2fSD2gSf;.llgPfl,eʦRe62s:oFyy޸5^y?0w 8n"/Mb:M pqϱopRp m\Zm(| ϻvs=q0k? vünp4ػn <\ohPe(1cF1DGf=q=qm0=F4y$羯+Tuݳ6{' 6-? h^/)WWK]+T^pi wgQ,2bܴ׺'I>vO H]ܜllllllllllll ց!/rرˬyYaXQ :®zv9=cu^.'||smߦp;¼.|q|;X6(p}tsӽMx :P*sYfҲ]ޏ$fߏ${>Zۆx ju]pJͶBretܤv!8"̊w>ns7ϓ쮗1xk8$hfv!Z1b(F ?ybğ+-b Qꜜ*~K4ͯkb_D?E-U)W?FیMWnEo#pTIZx Aͧ}b1*C٨-!Xuꦝ~ALꚆVz|&ka8)?D!=x=i"3IuB/ru,,߅O]t/Ϸ< -;C_lEφӠ6iIN2x.OZ\A˯X~Eq"g\_-9`˗5țLΗrP(y8<' ǡ|9r&"es6-O.r7q`l6]?v1^""&0q@\CkUqV;!&kɦ@bDLrU^+wy̑(MnNkHL,N37sKaxemN@)ba?(m"rvi ߆@.v2_CIT[1$$3 WN@ ߆P|1Ctf8?(m䂡3 ?~|+-Z0C;,3^ʷa(ּ1CofH ( |qq 0BPЏV0lԘa!3l Э*|R3 '5C6~A CFN0Cp?Cv~GAC } 5CG~A ;p>9Mg׏Ap Da\=8;!CK.zDgB}n[zVʷo`x a;CqoÐ$cEf |{l.ca';ou0f 4؇sP- ;fvG/x 00 8ȷa(q 3/ ؗRqouo9f(g LAu  3e*߆)Sf8;seYf4czL36 O7fcTo8ȷa0c1C[fbNۊ!fLcpf_q+1pfC3naV0\3{1f( R/8ȷa:g1lfxF3nYU0T;טifؤB{{tY+3 5Cֆ~m251~fM3Ԇn6 uzȘWfgn*S6 u,0fcRRϕE?jB{ xԕ>^eOu>Oݩa+ uiF>ם0㕭V~v>R1t.nba l-*mߘffA ߆ 73xVͰ6 3f 4zoP0TXf6^늃|+Q7RU7rՋWe> ]m [m1ib"EȜȕ9y\,LNxq9!wޗU3U0ױg(WΜfX**A ߆B afꊃ|s̰B3TՀ~ A C3,gM.*mTI3fxkЯ8ȷaV͜a3 aЏU0ԨaΰhXXc7V0Ԫu1~fT34A?NqoP9fJ3Z@ ߆^. ';xA CllWcof9w6 v3f [)m76g3%A?Iqoдiwc|>! m6 ͚0fd⚡ ,|-z3ch͐ k|^ fh|1g 54CGصпVqoЪUc@3\ .|b!N3tu~7A C6} `=Cqoжm?cfhzzC ߆]Rf +m:toБjaOqoЩc.G3~A õ4f 5C R0\w cA0\3 A C׮1-al(*mwb0 Caá?\qoг 3=a8lG(mzjp73L #`?Jqop7?0l0 66 }7f 5hXU0p 066 0fxh; ߆aР /1Zp? ߆a1fxC3vQ0 :ʘufحMdA ða3f5d4OS0| 0 636 #G1f8 ?kП8ȷa5j1Og [|ѣ3Db4ؓRqo0fcfH O–B ߆aܸی02Ͱ{y2.Ͱ!?T> Ž@ȡ]ߕeӚ) 1O(mF0N '`Jqo0|h:0C p S0t=83T ~|o4wW`YU9)1LUfh~/|ch_`@A Cqu3 _|~dfR]5̘3 “!A? ?0P3n8yw`4C8t#80Z3DB (f @ )>j<3kB- h-##>gW~>fC$K*v&3 %{Ru}\fXn4y]o - ##W̰X3nyW9=q^dW4Cy@?FqϳV2k!_Iqo eocṴI3TnWQ0$$?[|i*Эj##vbh9VfأAk(m77g 5C ֆ~mA C\3f ݺЯ82rh)&M| G5C]և~}A CFm0>g5C}6~CA CaN1XqoPy3pN34nS7U0ԭk33 M6 k" ͡xA C͚ >R!OTuPV3$B5[+dfZC7)nGZiB?Uqi2C ͐ ݎ82rs%7giOS9ap%W0C'͐.82\F!7;2Cw=Cqono_/KfhV_ ѝI1]6KzrȺ.2f߶{,ߧ"Vd1ʷk1ãfLP 8ȷkh43, U`չ}|۵s|Ԙa)3 a5}|u۵s4gX jЯ8mǜfXjjS8ȷaHL|̘a-3l au@m0nm3AZQHN~ܘa33 `OmRR0f okX+ ײBj9fx_345~#A CO3c1h|3G1 (e_Ν2f8 j&8Dv Gf5~3/ҵ G+ ւ4SsgN27%[*e=5f -a OP01f8`]IP]Cs7)?T^~3`+3aLh3dV3Pb Id'+eߝC˜!fH><ʷk1C$3 m`)+eo^bPkX*#JQ ׻̘3 vo8}nŜ$3DkvܗmnecPN3u~G5vrcPQ3tq?U0˜3T aYqx-r~+ Uf tuV Ýw3TgښZX)e_5f 4C:_8ȷaU ufօ]|׌bem1tum]o0yjc8fhѸCTw8o1C fp4CwX_]6 S5fH`V'{*e߾3$2Cf ^|373$1C{ }6 go4fh 4Cϰm}ݘ#3t q?o0&c.S3ײo6f 4 8ȷaX-c0@3 @A ãn1f 5@ o9P6 ?՘a3 `?Xqx-z>6caf }>+߆駷3 c[4P9D6 =Әa3L Caà?Lqx-ncpfN)߆ᥗ3 htm-{ǘnf #`#?Rqx-._n0iQum^y=c0S3[ײUf04fx `80AcǙ90voS^Ǜ6}d,3n6 72fxkawBNA ֭3 i;a?Qqoð}cṴA3L 6 v}j̰6kaOW01Ṵ̂U3&A ߆aޣ [0 v/U0 {af6S6 1fҧ(߆a s0 63ײO4fNhYП8ȷa裯N0÷al6g+m>kcLfY3̆op7 ?1a.A?8c|i1}0V0|w >aB/T0=zژ!JkǠ ߆/3\5V1ؓ. eׇma=C#^f8;cR~^/>e/5gLqx-/}83 8&)?'p vr QgwpvR9'c|ݟ'`x,븚q!(p Q^q\r_gطVqyVfJ3| ; ӊ7K1C{Oe(;|;n ik{/;0C R^1urSSk{2 5[B;0C3zW`_oðma(hzg<6 oy;fhNf/yW^˱rSoߞ:k0ߘBj|? i =k9Qn1COo\ 5̐.|)^{ߘ73 ]򾱕2..+|s3 Ѝ~ZbŻ f㙡,B >(G)oÒ%o3d! _Pq0P12tA+e&jB-"k930f 5C~1A~^ `)t}\ebnu3L š[%r̭ܴ 4C P%P_Kq PK76_-œ73G6t@Z ~P3t+#3| G5C]Pvc_p\3ԇn,crlNjX6~A~^s? jmF5N"]߸jCn=8 g5Cc6~_`4CA?Nq` j86~3A C^ 0CH-Bqxt}Cf㯛 4CP|82]nZ8#Ø=fدjA6k+La~fH3Ԇ/'%L\'3dO4Cօ~]ő)b`> uˋ#Ӡ=W3at}y1qosf8CחGKw1pR3BחGѯ fZ34//&LaG3|B)LaGOb̐AחGA:՘ 3 MG'( fh]_qdkˎܴi ?3o)t}đ)*On+3 LaWWQa c?fho82]]Eř3fp?Cs趄~Kőibf2f 1DjЍ~ ߆3D0C]_= qdˎ\0D1C͐]_= qd :*g3f82]M0f( 4n"6 1f( њ!4hcCsJ3C IOR®ިƼy 噡fH82 fP3 1P]3$CW_D®3TcZ!mVqd Z3b-t}Eđi0;ڹ`eƚtCvuWzȘ3i|:`h t;A4h-33Cf]+KSm c`1C 3 iߥ)+U]!+dW!S]G濴mKLV)m`B 0گWqótgr؎= Vu:`xj)x0rP_Qqd v8eoefxE3Tn cGAl~V2k!_IqdΎr.V1ZP @őiЧJ=(zfA?=Q+M>O@Ћ u K+Vjs1QQ[KI|*!D{Be{Ybh 4u.l7L !9dܯ.'õݠMqnC~d6w&4Ju6#ze RI}O-/GE??$vuֲ\+G<5)6(ӴoʯͿ۟d0޹zY Y.T^/l_w͞[hzsqhjOD 3K-nA ibX 4nVA Ci6 İVhm|rϨa93Aw;+mL+̰Z3lP0>$טafݝߩ8ȷa0}E kaf ]ߥ8ȷa0}B af߭8ȷa0}@ o0Ͱ{Gqo`́bat߆ۊ|_\>|7l3ntpwܹ߫U<1h;/wo15{=,*mxK[Obˈl`s3vG83xch1CvgGl<3ނoQ b}v1bfX@w+*1s2 Ͱ۠Mq4.iİ^ ۠A!;o=g 3 ۡ;Ark̰N3NT b=2FͰKq4. 4.nq f̰E3Q b#bat߆ۊAp:~ۘ .3fJD3f0fH73v Z=CNu7r"r=sIӽ5|bX3~M$I"`kN&zLm%pm΍BmqLcMu}A\57>MB*g$emRٻ &r-Yҿ{:41k[f*z[Z%sL:RQ_FKjْ/UheO u9Y㻎=$ ؃Dt\iHsxD&$g2_tzQAHۤ/M/_<ۿs̗_%uϬI gR|*eYh{Rf|\6"s9/\K$ͅb?|ɿQٜ[8ts _<2uK[1b8rΑՆJ_վ9A㝋D̞E j۰chm*lٶ{{_-} 4ur2G^"t"}'i_VbUتybJX$QCo6O,r: v_y}8dC>0/lu^Ou>5qR4o|_ww$T ,'47aNֳ14iϓbv>em<8/þ~os8Wy2<v_yJ.]˵!*캿'4OdwChb#[?XZ*]f?Ů!kDaFO2@@@ KrNormalCJ_HaJmH sH tH :@: Kr Heading 1$@&5\\@\ tM Heading 2$<@& 56CJOJQJ\]^JaJDA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List4@4 KrHeader  !:O: tMabstractdd[$\$O tMti4U@!4 tM Hyperlink >*phH:{/EFTxyz 2G]^l23Aefgl-.<YZ[`tu{2349HIOvw>!">? >!?!e!f!t#u#%%&&'*(*A*B*(,),0,1,=-?--004'445A679<<=DdE:FHH0000 0 0 0 0 0 0 0 0 000 0 0 0 0 00 0 00 0 0 0 0 0 0 000 0 0 0 0 00 0 0 0 0 0 0 000 0 0 0 0 00 0 0 0 0 0 0 000 0 0 0 0 00 0 0 0 0 0 0 000 0 0 0 0 00 0 0 0 0 0 0 000 0 0 0 0 @0@0@0@0@0@0@0@0@0@0@0@00000000000000000000000000000000000000000000000EFxyG]^l23ef-.<YZtu23HIvw>>? ?!e!f!t#u#%%&&'*(*A*B*(,),0,1,=-?-004'445A679<<=DdE:FHH00@000@000@000@000 @00 0 @0J0 0/ J0 0 @000 00 @0J00+ J00 @000 00 @000 00 "0J 00 00 b|0\ 0 0! @F0" 0"0# @0UU 0000 00 00 00 00 0(000  @0 0$0% Ni'9'$)'*')') 0&0' j'80'(')')' ) J0.0/ J0(0 i':')' *'', 0*00*0 r'2' 3'x)',#4 0$0% 0&0' 0&0' 0(0) 0304`0(0 0*00*00*0  @0 00/00.00,00+00*000000J00@0J000 0" 0 0 0000$00$00$00$00$00$J00000$00$00@0J00@0@000J00@0{00{0000@0@0@0@00"0 0"0@00'00$0{00@0 00 _ 45@2HKPP)09GJKLME x ] 2 e - Y t 2Hv14P*,-./12345678:;<=>?@ABCDEFHIP+z---7777888999u:::X;b;;< <=w>>>T?]?`?1@:@=@AA"AABBBBBCC $ d   ! $" d# $ % $& d' ( ) $* d+ , - $. d/ 0 1 $2 d3 4 5 $6 d7 8 9 $: d; < = $> d? @ A $B dC D E $F dG H I $J dK L M $N dO P Q $R dS T U $V dW X Y $Z //<?22GGTW),$'+9AAIc6c6g<"E"E+EH     ! "#$%&')(*+,-./1023456789:;<=..:>DDFFRV\\'+11"&,,5?GPPj6j6i<*E3E3EH  ! "#$%&')(*+,-./1023456789:;<= 8>*urn:schemas-microsoft-com:office:smarttagsCity9=*urn:schemas-microsoft-com:office:smarttagsplace;<*urn:schemas-microsoft-com:office:smarttagsaddress98*urn:schemas-microsoft-com:office:smarttagsState>7*urn:schemas-microsoft-com:office:smarttags PostalCode:;*urn:schemas-microsoft-com:office:smarttagsStreetB*urn:schemas-microsoft-com:office:smarttagscountry-region= *urn:schemas-microsoft-com:office:smarttags PlaceType= *urn:schemas-microsoft-com:office:smarttags PlaceName >=<;>=87>=<;>=87=>8>=<;>=87>=<;>=87>=<;>=87>=<;>=87 >=8== = Yet|M(R(3333'4-4I4O444444444445 555555555A6G6K6S6W6_6n6u666667788v::9<E<U<\<a<f<<<<<<<x>}>U?Z?2@8@AAAABBCC|EEEEEEFF F$F GGHv$y$T444455c6j6< <j<<GJHHHH333333333{/z Gl<9<HHHHTQ) "+{,F@JgikKr@wtM3gxP@{EFTxyz ]^l23Aefgl-.<YZ[`tu{2349HIOvw<H@IH`@UnknownGz Times New Roman5Symbol3& z Arial"qhDFDF =% =%Y24HH 2qHP)?Kr2Office of Nursing Services VA Employee VHACOMITCHRObjInfoN[_ObjectPoolRpK&C۰pK&C۰_1270275145VdO)pK&C۰pK&C۰Ole ` dO)Microsoft PowerPoint SlideMSPresentationPowerPoint.Slide.89q %_{ AZvhaglakellem1vhaglakellem1Oh+'0 X`p  CompObjSUauObjInfocPicturesTX*@Current UserdG@=@mM WXA۳`\B=.E@x|@zPB@ d$$@!TA:K"CPD " ŧHo*J"A"B眹{3Ơ7WqܝﻻaΜ0cg q&Vmپs%"C[Sr ܀cp(FPGɠuHV-n۫_-WmTO=_oQ})"8M _(DY;匌 QR. U2n|;:n v HK0w X%N'yBůse#i8sܢ^\64F|%~]-zb:g<o .\ܝω:<-p\vҏ{W4?Q]k?[gy׽ZQc1m"|풩~Q+k>-[}w#.Xߪyxdkբܧϧs{!o{G&3Cod>$iZwElxu^]{tw!F*{}L߭bvY/eYfa۔eY_eDze,wɲ~,wȲ~hCzµ}qo-#vnwop|ߏ[qo߹E;>c.y c; xsÌ`挂z<10~sysÓJ~v0R`~iX YT?sV%UK*~a UeU?kx5`+5?wXj-X6>^oh?[oÚk" X1 ' p? o |[m[%ر% vl _m`oo;} >=|QqG >4 C]gC;=^$7|u/ Nӧקp]p[8H?/\H pp~< ~>р6\Xze|~~\Ayy!ȸ9/oT1vs01.?e1ޙbFAX aQc b9D$ƚ `,"Ɯȁ1>Ghh$ncW Ƃa  *{A,= aw6x.b +@D~ ZD  DBOԼD Juq+]@|ij) t#ۃx- v ]"Z ߓO |@ԲA19ѸnS|@DHn}h^Z [DF5Vq2~& TT[oQ,n4KKY "naoq8ĉ< h7mq[,j؟lq{[MY[Eö}}l٢n[7L|=ߵE Zgco7l5[L_ŰeY[ܳ-Eړ9X7_OE\w-Vv;GP[,Eҝ#m12۶Ehil m1-n kUmqg%N-/mm-ő9=nzĉ+1G$'=G,Ewx="vG5q5="yH|y#Bg{1Q\/w.pw%{p=ۃn6yj|y/S<ލqb'cDoGX!FcLjاbi>7>`jc^s~s!Ÿ B ;֢w\m!6q/6CdHT QA C %CWŐ]-dzLd/}ܟբc}/GWfܻܷ8wN9/9w* +~N}"xEo 5ր[ܷߜ|^?7缷$Lͳ}ݯnO97?ZOX'r<w;a;sPnPo_mw$zz_0Ͱ^2lP 16܄R $FŰc#odMa6b2: >ܖM9编q27_+y Rerv8YYqk\]hd\?hv8h_\c3|K_sSsf,h"Cs9tX[p]\&wXp yXcp{x5s݇\4xL5 rǨ\ &׃XKqM5ׅX;qm5ׇX+q5׉Xq5׋X q͈5׍Xp5׏Xp 5בXp-5 דXpM5 וXpm5 חXp5 יXp5 כXp͉5םX{p5ןXkp 5סX[p-5ףXKpM5ץX;pm5קX+p5שXp5׫X p͊5׭xϵ+s\1>ױxlϵ,s=6i״LuGvcq};}4qgΘuZwOp;wy7O=ŵ ]\/~{Y.Y ?5˖q]K/qmW>^\#r%ɫ^ko[o5kpݼnZ׿7lM~Zzs=޶u+;ozΝ\_ٽk}{rчr㏹O>x݇gqs ~QÏ%'S'OrM\=sks|oBz:k/]z˗fnpի\r^u7ǯ>b=oYLš>((Ұϕ+L>wyGϛ7/L:?_|04 (ӱ/X nX*T.\f* E'(EٳBb`ΜbPxq;8(Q+%K', J*KKC2e`2PlYX,~ӷCr`Ѣr<˗ŋC g+@Ŋ*BJ`ɒJ KBʕ+C*U@ժUaٲPZ5xjPzuxPF xPfMx啚˗AZWkAڵaŊPNXԭ[^{.ԫW^ԯ_V 47h 6իBxx8f84jzDDD5 o 7kC&M`ݺ&M6Bf`Æf 7FCaӦoض >@ll,l qqqqТE ز֭񐐐۶%@˖-aЪU+رnvl kW"ivnm۶={Bv`v%AC࣏:@ǎ;Brr2ߟ :uO>))))йsg8p3t]vCBnnн{wУG8rqw@Ϟ=/zB^^pw±cwB޽/{C>}>зo_꫾Я_?8qN S0h Ap]w3wpw7 s;w 2v{p0tPHO Æ 0bti9~$5 ._w}0zh0f10vX¸qʕqpի<׮=> ˃ _L0~uTSO> ?@>@> +@> ;@>K?A>[A>kA>{A>!䋐?B> %䛐B> )䫐B> -仐B> 1ː?C> 5ېC>9됿C>=C>A ?D>ED>I+D>M;D>QK?E>U[E>YkE>]{E>a䋑?F>e䛑F>i䫑F>m仑F>qˑ?G>uۑG>y둿G>}G> ?H>!H>"+H>#;H>$K?I>%[I>&kI>'{YV䋒?J>iM?%Ԃ_%5]%6Z~-7OAA| 3="5<{ aGɥBE`]gS\3KTG'`T9B83,˷1/PQ2TV 1*~e܄b %CMP&dMBCjJ0P# Ør*U:j3Iz! cMUKf'(z PsPnP>CP14h r0}!R14ĈDH܄vN !J1DbD~sPnP>CdV QѨ0ԯ-bC4F 0& vf bCM5`K8ŀIM97ag !#㙃r&Mj3K!%dM6R2$*0DGwfH mC"F[o0fh+C[$ObMl[!I2tT IQ#sPnSdHQ 1RP?9(7a͐"(.߅9(7ahNm.b 1& [f&P 0@;r6mh3!z);0z~/܄] $Co 7fMڷ[2U 1~_܄c }%c`M:u0@2 R 0 ܄s $`0c0fMv0X2 Q 1܄{HaP0q`mab13& zݭ0\2T 1FH܄;h3 HѨ?9(7a^mђab12& f+P c1@ri3< R `<1& y +0Frk3<,&+1&d܄{Fh3L Sd?9(7aQ >a* ԟ0 v6 0G1srGk3̑ 9(7a9r6ɰD1,XKrͰD2T K0VJ܄a̘VJ}a%>}')}PsPd8aCc̑v d8aDA}b8q0& C<#)3PsPn0dHms;p;9(7an wQ2sPnp]v_ ?*?̑v0p1̏b*_eM?*+Q:sPnзqupC1\Ǹ7r޽AX>4nMYu6iC. 4̦sв]o yC.͋yry%Cbȋ C0DA}b(PsPo?d( nQ/ۗ+*+[3G-#dqPR1Gݒ_9(O[R2V %Q4fW eCi-ere%Cb(!iUw_H !u+~HEosdU P7CrgJʊ!u+~e܄$C5Pu~5܄џ[&j(j[k0G-C5$Cba04k&(0ԭur(9:bPsݢџ14nA=@1C߀9(7a?dhn#o0H2D*FA CEJ&!u~܄^=}&bhPsPnP9Z$Cbh10Ԫ#bC Ƣ~,sPc%C -PsP'[HVBVA#m%C+MDD&J$ŐIiwW$C&~2s~ɒ!E1$n 0Gޭ9ay)bHAnߍ9(ap.Go߽zkX_rgr]M(ŹaQ<W.\=F9&DVOgd<?y-G.2XC=P_1èckg!!Ym^C}A}MZzN+ton gaD}p1"p,9(7ahv6C){>Dpn)+H8֘9&:tXwah%N48}(T1Da4ű5yѹ M]/ѲESΕ|A!Z24W q9sx ntLd(0& ={qp<:I}7ǭlXfa~^fuqb1dXͮQ|E!aÈ=@87Fq6CdHP  8^#3$8 -eͮQ|U|o^(޻B #QBiŹ 6Cdh1Xa1B҆sQ^fh+)psx {J'#Iiǹ رoh3$I! u`a?fK0t(t܄:΁Q 1ę0-mdI1$ct±NA ĉk:8 0RdN0͐0`tyR87a5 z9 ]1A]97axwIFw^DӦmf.z(=psPn0cFmbz2& fmf0%{%܄aΜwzz%9 0z^I87axzK>7F^>Mof#)>psPnh3 C?8֟9(7ax- ]=dϨ0fM}6Xpbq?^j6abc0^2<c:dcSrO>Za0c7sh3L T869}:0]2T 1fL܄Ͼf)f)plsPnj3rtfȃ=gqnpym9ab11װ_k3̓ <869(7a8~;mab2& 'N\fX(+ql1sPnp%mŮ~b%bM{m%abX ǖ1װٳ?h3, 289(7a8wGmabX V1& ͰJ2S 0:܄!=6:ɰ]1؎cۙr%Űca? 89(bd8cıA> GA#8v9(#>c1p\18cǙk؃5'nwbucXs㇓b8qN3װlNN: 1~9W?X 9 >>'+sqsmuGuWߐ Fe0װ?rN| Wd!-Or mbqвYXVffB]7s/[rI܊!F5۟h32E; Q˹-o C^͇kث7>f'+|3/ ([ 0& +Vf( nS P6Կ9(Y}P铝˷1.mBb(EPsx {vm"b(PsPYbNbϏ*.J([K0װoxN+aewJ/_d(Jn)/^ 3 eC)-er?Ya0A]gy/1b; e%C9Puˡ~9O>C9ur9#3B>C:}x٬{Nί ** [+2װ{N3(*)[ +1>߾OaN4^dP+상N4^6e?i>CePU1TFݪ_9srJU+Pui\8$CuP u~uuIխ̾CuurugՐ 5C ԭ5kܸ=I$C-Puk~-Ւ C-ԭr_XʼPu rmo֑ uCԭukxo\ZʼǁPu{r]^z+X8}QP׹A/_!'57 Cm kx\P2+As !u#P?9(Vd_uDJƊ!u~cgwH(uP?9(w(T1DnSo0T2D+AX}QP׹E/G[#{-^^C= sPSe2bcE"kJb$$.-PS;%ߔ#_<=#<<Ȼ#ߎ<;ȫ#<:ț#_<9ȋ#<8{#ߍ<7k#<6[#_<5K# Hd xdr.<>sÌ`挂z<10~sysÓJ~v0R`~iX YT?sV%UK*~a UeU?kx5`+5?wXj-X6>^oh?[oÚk" X1 ' p? o |[m[%ر% vl _m`oo;} >=|QqG >4 C]gC;=^$7|u/ Nӧקp]p[8H?/\H pp~< ~>р6\Xze|~~\Ayy!ȸ9ѩT Rõ}-/69<9N-ej)Q4(Z|dFUK(7{A8v ѵBtZ!aU z>@]1h3T 5X5Q&sPn!L1aA C^f XPsPn? $Cmŀ#Vmԯ0CmPW1U2F 6C]P_1U3& 倡dhpj rB9`h *~C܄pL6CCp Gp܄H%C#ŀ#V#o14oH2D*"Q?9(7bf MXMP sPnP4 M$Cb+ rb͚i3DIGߔ9(7a(!Z1ACӦ ђp򠾇9(7a( bF}9(7a([2b PrRMh3dS 8bš~sPnи6CdHP 8b%~sPn͐ Z)Z~+܈!"BdHT 8b%~"sPnP: b aM4jF2tV 8buFACx6CgE1 1: nĊ^Xqɪb:,lQ~W‹wS_ HM痆i9(013w}x}{sRqt<ǝuG]ܫXO:SfUc+MA0T 5Cu̪}cȓV0@]&t?1OPxđ.|9`2n! uo8(7vsPZxđ.|ii %CPu10G0ً䀡; uP׉#]P~ u%C=Pu11G0倡; P#]P^#h3Է2=>:?qPn倡; P#]7zQmV04D]'ta6P: V0G0o(F!B14B]̬܈am+sa@]g85z0epci3DJƊ!u13G0(V܇uHCSXsCu:r Ӧi3DYsC:sđ.]*NT24S MQ3s yJ3fh34 C3j0Μ\2(樋0T~qm+saA]g·85zQeP5 +sa3ClڬY 90بG0 b.fV,sPnPclmX+saE]gމ85aePsm8P3+9҅Xܹ V\qkʎV̹0!u/Hfpfh%Z+V՚9҅<\'fhme΅9 Qי"t~X1CV1A]̬̑.<6C[N1E]̬vA C0 C;j=e?_dHV Q#]Vv ,fH ]C2vd+seeue:bL>P5L5Lc)zѯ=\Q{ 9rŊub&l * ̃Ay`[&ʍr:*O*0ќA߾ *)[ +1G0*OmJ!T1TBPet{.e**+Pԭ#]K1TC1TFݪ_9584]dsZEsoˤ''Erȕ'ws{:r& 7<]x TUŒKm.&JQ*KO$χ|(:U9?Ÿl61(RP?9(g_ kS )d5]P s\3WI2t+ptaB__߹<]竔Zq]_*uyeuɟ(Vmz.4u}|,WE/f,ocY,]<%Y"<|c˷=GcI?.ee6f2 f͟yZ6er۳jmFd rsmFf6r}fm6f6kgRl"ypt=?7s<4G<_󔻟n"?D 1Y[sI#p|- (<)(y]iSwqt̙Y}vhP|# KMc!],QuU6Fve}ݾ v?}>\ F F788q Ԫbs={,!)]Tys[FTcWҿmg]יrc]M:6(m֑K:y[ C@ nCqY{!ͬq'rxfuA"sq;B<~D-SHj"Ll-oS7(abu܄ADM [݊[r25&Jmbئ600Qj6ݎۙr>61P Qw`Mt](ab؁;Q'sPn {DM N݅r'Jmbحvn0^;QjŰu܄A؉R*=2: &ǺuF3O}vv e?4>|8?DVP٥g{AY.m!9siZ;n㕧#"2\{N K/38g>p|9sΙ38g>p|G`#0xsA:N=aNr{dw>ȑk3| (Pw oa1,[SadتV5=cط6VɰM1lEm9k{dp%mmab؆Q;s֘Ȏ…+ %Űuw81W߇ab؁;Q's֘NɰK1D]9k{.ɰ[1Bݨ9k{տ%Űu81CNN {݋{Ƽ]sy2dFs#A%y®k}\ܮZVrmy+pVz0?1_tNuy]EK_o.T~9?NOiOSummaryInformation(WYf,PowerPoint Document(ZN&{DocumentSummaryInformation8k$WordDocumentQ\4Slide 1vhaglakellem1vhaglakellem110Microsoft Office PowerPoint@|@@ʣ@@ụ՜.+,0    $ oOn-screen ShowDept of Veterans Affairs' r 7  (a     Chart MSGraph.Chart.80*Microsoft Graph Chart/ 0LDArial00(~ (ׯ0("@ .  @n?" dd@  @@``   /X$"$mM WXA۳`@ 0@ ʚ;ʚ;g4+d+dn~ @ׯ0ppp@ 80___PPT10 ?  %X    0` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> f(    6P>~   `} ~  T Click to edit Master title style! !  0*  04M~  ^  ~  @*  0 R~  ^ ` ~  @*H  0޽h ? 3380___PPT10.ɣ? Default Design  0 $ (   0 HA  ?PP  ~   < ~ "`` f2CT Patients Discharge Home vs. Transferred to Ward33H  0޽h ? 33___PPT10i.ɣ?+D=' ~ = @B +iHx`T?'&iRDz B%PBM"E&ѫX@WQRDA/MD ?{f'KH{﮾d9ggw}:7'.ew"ȏ?RVVu͆eo[O1 MQSŭ9rxZt<+l![]{Wbqd,]LCx+#2ܧO!n 9~ia{}t?⾈>UGlzƻWhkq];n}ncCZ!~O~Ng.-"c!.ѶH)fZa?eBU]  UՀՄEîՂՆՁՅՃՇ55555baq~ma-`-a VDXs!$,k k'샶,    KM?   %b X8tdLyaa`aS`Sa`a3`7nwmfn͂otXh^5>c_RnfvX>X~XXAX!XaXXQX1XqX 5HX)Xiص2r `a`aU`Ua`QoOi*}cULo/o᝗܍>ǻ9uҴIcGu:|بçNomƍӌ⍍xc⧖L R5 5klPfFM jPE Gĩjz wVwR컪ΠUWU˶9zw3iʫsjjx|+{g(׋GV:*F5y(_ju鮁N9!՗py0xRl wq|{Qu [jϊq8s n FuwI8#YUըA\)-:<x ,*<:Uo|cQ'Ny%c?42K jlݺ2Ėc'El !V+ ۘb^[ "ۋͤڻcD޽EPY83fXlNƈc)m 3ŢcP5؏n=# +"Rg^4#Ԋ Q+rH EH2= s +?rH>}ӧEm:;:? 2C쭽8fԩGEMwQp&46d)ew}/+"QҾcD+;=V8 g}aNB\Mg|Y8`Iq P>Y|g:©$Q=׫\,YЛ{h-Q Zn3&ȆhSֶO !͡LV(&l(8㑢.{,h}϶p._g=XG|y'Z?qۤy;Bwآnn/WZl߲*##yU8O}W^QOƓܳ}gY-"࣠+Aw;~uЯc[upx-H,u\]8^ .^Ǧc>bEK ԽxwF#85FGVkz9G[|RI]%""OѤ1"{\G=_cDs_] zC~)wK\s[G#YnDȪZ\Ώ8S <>z rT[\o,+uW_I[$-=~2wNT¹YTo))pnP@r,T}^3o~ oNGPdGPc:Ϡ{t?&"l/iN[-q%dt,@aHu:ɒH[OUZKQ}OԱ5FRyo ~MDKR&t8_MƧr*Үk{R\[\5xodT,(ݟ rd+Fn=BwlڷFr~?v&hhM#XfːՓ mnS߾Nr_I-#+5ʭz,:=ٲ_._;·M 5g76>LY#VbMfx\T|4zD;7&Gm^?lbҡ[MI;3qQҢ>4h?zDmKQ7ېG0m6y~75T;ί[}5fD@2*c}|IT٦Q4JT{fM-=NN^4E)8"Ө8OSOڟ}oҘMz_cJec2 \mKSύ3޷us_9gs-.l[r>sW}9ؿwؿ[r_)Bs6yo[@w|?yWxFϱ=/ mN}t.zsz9A2lnNV?ߥ}nK 5W6"Y `Y"{_#heEm%(032ZooMND;Uޚx1"i齑IOJzy]$Ѿdž%~rOZ0>7iCaUIϭY}%mڸoMzwng_ҧ~ǒ>s>_~g= ܽ<>PƳ A\OE{[SxYZggwwz6= 8=_XwN󟟦{~?fzN]cg…`YggezQ*'Sgyk<ϯ] 9tg/yN8xxg<|ٳx{~<RI5?VE|\+|\d |Ԓk-˵Օϯ'_x1 _gCҋ亗Kc䫯4+ql 74_8NM- -$濒[ozַ#yN}[ı$wh'wl/w q\=v$YU~A7Ǜr=$=y`Pyǡg#%I忿"{)O.O!O)q__#|uq+zFmxcX+ϝ(?7Ix?"aiǶ 7_~Y8zC☗...͒ l>:vblXR<+{}#``C>_nb9,R!X[} `/$ER4.EUi*Ł)R=< {nx [>A&lR'Ryn)-ŦQR|6R #( .EaR9DH$ERO}.RKzJ1ix,ݥ8UH1M:I]Owb@{<'7O ##==ⶽ]cG3L,~# 6yD8GGz#><V{ĨU[7{GT{CcmGt澰#&"V =$<#f6u<⅚1t*y9 a vߩnau9wPnPcF:l#od0T2Ęabؤ66!& C6)͚al3of0a ao A C^9_ly0ޱ@>g=2,W0-?GX Y׊n1#wՆ}^R/gɕ)YYdL i8g\ 玜!G m8wù?o8᜚s9s>s\py99ù#wȍ8CNyr!q܇s>܅sB,"W9 M8GDNy"rp܃sF7"9-8DNy$r %Cp>܁sJ W"W9 8DNy&r5ps9qy\\"\y8|sWs{aq^y,9͞spN;o\ku ,vE.nsu[se>yC˗s>#?cZs'xVxͳrn8?~9G~}6Ωwy]8_}=α?x}γ}!wν?Sο99ysǏs>~IO%gsoo339G?w??O?9_~s~?~sK/rJf ,KF>!}' ϟ?}\ *THޅr"E-*"/V\xr1r%JȻ_s5rɒkdɒ%={#eRҥdҥ}^{ke2ee˖>XV+WN.[VN/_^._^^VPA>Pyu++V?\QVTI>H%Yre裕e*UcUUV?^UVVM\YMFEEUdOT5jԐO>YC֬YS^]SFGG˧_|eZ3Ԓkז>[[֩SGYSG֭[W>\]Y^=vm=Y~}e /4 6gC٨Q#⋍dƍK/5M45111cdӦM+4Wce\\|8٬Y3~}3ټysaCs/_=^hBnBlRnR&$$͛dV-dbb|D$$x${Iޒ299Ynݚ,[n-~lӦ|62%%Enۖ"۶m+oo+۵k'wh'۷o/wl/;t w SSSݩcǎw;N:={:Ν;,t""v*֭n{˴4o_ѣgϞ{^z{޽{zty`ӧ (( $$,?|2d!rС* &&..G!O!G)O)G%O%G-r3f<}zW_ ǎ+Ϝ+Ǎ'z7(Ǐ/33 &o ^;8q<{v4iTՂ&D!QjFT;ՒD%1QjNT{բ&E)QQjVTղE-qQj^T¨&F1QjfT;ҨF5QjnT{&G9QjvTG=Qj~T &HARjT;"HE1RjT{$"&IIQRjT&2IMqRjTjT(HcU͔jTCZj1U[kUs+`TMjETj;p5p { 7#"LEDQ$W9oUÍ*V6:Wuo*VkXhv&Փh6ZUߟ9wбcaf|7 ;5fk?9wе0caf C|7 ݻ7fFh?9wУcaf|7 z4fhQ1?9wÐ>ʘab!8 C߾)als3/ asa„ RͰ2n&Nf̰T1, Ka9sa JͰW2nNɘabx^3=3nO٘yŰW3<ۋ{s!>||bh#nCo_bh#nSoa1;T1iqAƍ)!q#~s CÆ CKq["~K CZ*Dq?9wP9CbH AP&+6!q ~ C(s-( GAP朶W ="~*s!fHE.߅9|yWA4CMC4q r.vb'd_5_CaeNzO[3D>߇97a|h%t͚N+{M= \a >PͺYb~%)YYs1J\ n^!Cx=z 1c^!y=^#k=ɹ]H952v} 1F5B][ _;5 V}dQ컩S6o1C ji̕9wТ9CbaZ>nGbHHxĘbj"|vnEb9CPW3ԁE_]\1gk4aHN~Ԙbh53|ܮMsfhkFu~G۶34R M4C#fۍ\1o1 F34kã/9.HM5gQ !X CN+bCfk늡Ks8L3sx]cҭ*cf!^34C 񊡅f@_ \KW'Z(fv W O3$(V! }r=}W3R I, }IA2fHR ͐qq;àA Őn'b1Yc֊!E3kn]Q3(!}mr]1c*v-^Ǝ}Θbh\[3W =^SRCG͐ 눾uϤI C'fvGW SӘb::3sx]14mڋ Cf-vgW 3fdE1t ]`׍9.9喗y)^LUk!m9+4Fsr]3_1fHS =4Cz0nfz՘bz5|!#5cf ׄqTs7f5CoX:c`̐ht.uc>f닾uFւ*~/1n-lO1 `79wðdcafq{+K0fk0{}.ݭo3 V C4` a˵–-j0D1 C`79wðb p0 6}Ù|7 <1p0B3 =cm3fFj^k\ݘabF|'v3R c4(Vm{] cX06}crݶg}טab|3S 58^֎{+ anOp3LT 4D$Mb5^}u1$0E3LMA Æ 3LQ 4S\1lxabo:sx]yAcafq{+78d0C1ܬfnFu6ߛo~bpbE3 }0nn=lpbM3 }1nm̘60S3A;3T 4L,b01,Őf2Зaس afȀFl ޽njf+;5l؝軓9w'T 4ÝyaS |0fn?ԩV*՚a%l5V3O`̰Z1 akз9wp̏ kËa Ea曟^T 4Ë a̼`̰A1 `;з9ȿŰG3A j{>Ͱ}اh};_χf8;A<j0{=]_ p`˵}CB1 _5}}⪟?W '5qIdC9: 'a>nFs |xh/a>n[9s3p aCEQ jo`ߢ[ C(9ٷfv}g|7 g9pv}瘃|7 ~xҘb8}>3W ?isx]MJ'pA3 APjWϚ^ v4~ ?~E߯u>G~U k_a>n?5f]1\ u}vFw(틊!K3\e/9.ƟS|Z,W uPlb4|l eR 4>n[Bʧk|3Z寽1C~PP3G\{rbe,b( "n!/^륿 CPq ~ C(cECQPq"~Q ڵ3U 5CQ-ř|7 ̕(JhkvqW O?ۘb(J nI/^?Ncf(s!9DCiP q}.!Tõ4^2)V1 "f׺ben]PV3Aܲ_9._ܜb("ny/aeeyPA3G\{|˻b3TP 5Cĭr PVT 4CEĵq+ŋ*)*k:Ůj*[2uB^U1T UWc027b ׾\1(P]3D!} \1̞mP]1 &d)򛕚!Z3D\: >ntow!qGzPK3\|ܾ CmP qk#~m𺼮M73fjڈ[2nB`]PO3Ez_9w!)״q+P~Z_14 7`kfhu5|na*ƚ!q5>BtcD34F&߄9.ƛ(qc?9wcCfAXďe0@b k__XW i8m͘Z'?mL1kfAP׈W -4C<@A~Z(q?9wz+!Q3$ }\1LbH Iuy͗PIR ͐0nw7g(dA\z3>n{\1Sbh5fk߄.Uk`4W.{@m 03nxs_ˋG{\aϘZ+abžA{^adOسI=(YtUvYI,ruՈU0zO{{5>g3>; 鼀1s:WF:u$\)<~O9忔oQM~M }0knl+XTӣ"8wJ/ՠi¨6Oc4VAh܄o {i}SD1X ;4.}Lسhh>IF(h>C4/[a_If Ш=ݢsGFh?EQ_=G3%aه^nk:^c0][m8$1ʚvmC{qk4C(kW 4C{zQqA1t #wd0cGY3tDΈߙ9wʚCqkUC(kvQ ]5C]YU1ik_/BY 6M1 ik_/mw eMܞf艸sx ݕ!{)t q-\DŽ!.؟fVENt [:2U9y=}=fmdjڰn]{Q]3 ׊g\cw _,|u _,|u _,|uuׁ _u2b_H]SZ5,kvkP*+^VF+C$omPݥAF1D^g%Zg+("ZKT)Lu+3S sHOec*lwSG CPd"~ úufs!'PU3T9_9ȿCUPM3T9_9w7b~Q}j{TףGuDu5%^kg%<[[uk+_[O|}c@φu/58+/W_i*_{5Vؐ7oh.7/q͛Z-I3%ɷȭoIGvk6rcIN^A⸒{(I}1&?xnr߇%7G={{I{tɡ>'}%C٧ȣGJ1DPS8>\<1B:9RX-:=FV~8͍ǰפyʣDdZYUzrR#E٫GE(vLB2]7eªl Uڕ R3TU 5zڈ_9wCmPG3Ǫu|7 =c:f@U2nPW1 !~= C)=VobHJ2fhiXsx Cc̀17f0bhc5A&Ak(̀+c|7 %C`Q M5zߔ9wЪ1CSc!~s!!!N14 豚#~s Cd Cf@AR-[3+=V oa(C Őc% ~sE cŐc%!~sxc$ }=_xu>5Oɮ/gd/kXvP$ϺϭwsjpbG\xV-4X*7!0R 5C-ĵkđi>Tn g6fhڈk׶#`}\k!0Q u5CĵkA!0U 4C]ĵkđiFUuUϘb!.<>sdQk=ѐh@{W 4o}0ڵxb4X*9YP34@\xVC4X*c C#q4X*׺ߝw34R 5C#ĵ|Wu+&1điVus(q4XS+:O 1fA\{<82 ʍB MCfhX üy !N3"=&Azp]w3)f!qY͘#`]*L14 !Lurc<1Cs#=.Ba`1Cbh!Lrcp1C R3@\xVK4X[,7j3T 4CKągb0D-^lJ1$jV Jd0TncDŐ"LrcCbh$ĵLJ#`},1f(cV3 =NFfP7fh8qd+3W 4C{ągu`Lurc CGqq24X7+7!0tT 4CGągubLurexAcNf脸A!0tV ]5CgągueLreX̘bH ]Ә#`ݬ._n̐5C[d0s1^6_:GA֋kumdkd &_[oZ5fڵ&l-Bx48~\O VMS98 9<G` ;yao9#;~xIme{g;]sZݘtP&;&:lVσWd/p?gi7dqs=|}$qc8hҚ,Hm^K^(aCDFq≔\\\߫;h@!{@x^p)kךr\Rq? V+6t-Y}Ujzf[F 8̗4];gM h9w`,iwwoc0;טabخ!val,ޡ#a0][`M ;5݉;|7 gb.Ͱqw!. ogİ[3B݈9w`Y*61v#.s7TlbأE=9w`Y*61 {soϚCjsk9?߳rס=p j4Fظ?QKm{-6W-ڝg<׍rֱ|u}K tl_5>OJʊج ~V?N[č)yyqGx܎{獴meuv]8CQy#yΓ'ӘmfxqAwGn W2fxG1l 6 =rcػ16Ű]3lC툿9{ ,+\'@7+{9cw`̇ Hr{ξ1ŰS3@ܝ9S1 ;wbCc$٥vk]w3!1?ڭ ]9ϒw.A=q`$7P>S(4}cCc$~q5H W#k#m&c$mh1RgkIst&/">Z~μ[Td-ұM F1Ηt<wTakH3doޓُ24*lϡA"]oފGXt$DŽ |J+W˾oG|eoEZO7|B#L#E[5z:mh-_TNrF9ӳSszʏ> yf??~(τlhSj~]+uώ|DHDufM-hz[5?( TKQ" JEQ~e[[ԣ2xcRnj`/ZYo=+[iߺEo][[}zOov[Qzk%#(/zWs{1x%W5|g{r? wBI1+[UbZQLko"6jo3Έ7io$6k'4{XӔ ^OkzeMVEmM>=GHNx_X/fg߿OO bA@XA *NNC4礼T4α*N%*yV%IyoPUwTLH,57KlT1PdUKUJU`U4oTTͪ;)  Ű*Ncc*@ Ժ*11A@*y)~'yniltm3 ϸΧrr?Qȶ\wP Jb韷N.bU?wO];~"lV<;>=xvjGXkN@h_{5oSP;Ū;O2ɪ;7y+fΩL+xvjXOENfފ`BWV%IEFފ.Ah_2oK0[KQ|Eʼ[Da~gV,kv X5P) J|B**NVJoHVJ}g~߹Vxų*NuVJ*RY|'Ey+B%ݲqSYͷx7w-ohrV6je- PY14{] AQ~ϥ6ho:<fI B~6@{M@dk7?#"̾R[8d=l7p,B&W7^J}_mFV%IѾ&FފaUwRp&fmfUk8(n7X[r?絏f*V!𩣵Uw*ګ&BE;E5JkI,=tMbe5ugGUg'*lY/}P9"=PΪ>]W[jnAjC6\6*N5jtXj Y|'贠 a֘UwRU+bcX5aU 8V%I^A`PgU4KZبQϠ D%*NM @ê;)6m;jY|'Ÿa)PKaU7OkvJb}*B-UwRLHT1 jX|'~A;@ WJb*vZOV%I1%e`PŞPͪ;)k7(boXaU;tT?*N; 6jY|'ΝU Jb׮Â* PV%I{AF@mأLj#`6UwRkdPQ1Pê;) 86jX|'ž}GUJbc*MDV%Iq*NMdV%IqРqA'æAm8dȍAf@m8l3`BVV%IqĈ AoY|'QAo;X|'1c&U6jsX|'űc'UJ7N 8jX|' U\[ Jĉӂ*.-rV%IqAVBm%8uMAWžJ7U|j{Y?˸vjY?<QV]1Fk}vjY|1qؗPUwR?>{KaUǍT ;}Ǫ;)pCO`vUwR=:y؏PU}W_8rdOa?CgV%Iq ?~JС ]EV%IqaZv}'ŁUOZ>V%I'T B tnV*VUwRt:, bP+ƪ;):J `UK@%jJS P+ͪ+fϔJaUr2P)rJS^X*VUwRt]+@*y2וRjUXw(`5*PZTJuUgUT:Tͪ;)&%DCj+[ ^:Pê;)l\TC>W* ֐U}W^جYjaC4ZcV%I166xE1TB)*qPcU7^kJs5gU6 *-֒UwR_?x%TȪ;)֭\1*PKfU>jmX|'E6PiJR{B-UwRtJJuaU3B4A'zOV[iL'T@ۣ&#>N2b#Zf"BW@(XfҷآEph=fvbB#Ak1SGc+ցՅZ]Vz<落hP0{\mWlkF51Kb#=v#G؄KC-U#Ʃc`PeU;uZT1f=إKp8X35cUvn*6٣>n7sT#b<Z`W'*>npTLO2bZ`oA[Ī;)TP$=vA=d:aUXaULc>n';*lP0{ mF k 50fLpŶ0{Vmǎ}.b;X{:scU|o\T=̞gv{GEPȪ^ &Wg.QqʔU ά51mڋA;ӯh=73N3fT Ժ`-T̞]v7Gn FԬ51s+A`=փUwR5ՠ=` {8*fdT'̞ܒ9sUMlUsKT1f)q;Q^j}Yk0[eMAA露h栊`6UwR\dKP0{ދ.}#@=m5nsTܿˠa U3<Tq!l1*N|UPŰ%P[ª;)~A9w>n/qTV%Ͼc=iuP;̪W{0̞U?> j_`g0{_㰓P;ɪ^N'aWO/aW:}}oXk0طPUwRt:vjgY|'E󞳂DeIOUו<"~b+ 'A~bI<֖gZ3N;w~go?TV$5NoiPadg;;aYPbUlg5 frq;Q)WOly!`qmccc?` 6l xMU"P @iQ"DHH %DHU*^ Q^zJz{3{Ciެ?ޝ}U:EEbѓm翏i!;gn=P*UϾ+yoKToFs턶l E⧟>wBV*Œ(?@ѽs_#wGPvAj6F??^wA m7KT׼ݢ(ՇRlR}ݣ=u(+Yre]?(Zճ-j3<3_Ϻ$޾Hflj,[oj๷t/%hӽs$Qj/LBij6F~MJ ZU%QjwMA#rEm8 E ~Z}7Zl l1R{3ϳ4.R? Z nB =z!-(hlqoy/RlU%QZKwg#.:XD lRN(zF;E7~)vAc6r/ruCj6hY㭇uI}X-ixq%9Eoa?hfcXyջȘmuIhҬY͖X*J8eKA㞂2 mlQ5Ra(#FXX_z)ZxDףPƠ1G>e8Kԇ} V)D=((2mlIx)(ЦYX1PfͰJ$J>fT0)3(MgͲZ:{(GNxV1>4/9}yL4iJZlĘ(̺zDVuc(ҹ^7=soc%)x1V)ŁHq  V)Ecm*8e$6MrV) ihӬR,4 ~M@yˬRu\ vNQ\4~V3ZY(^ %-PZ;Cq BeR}g={(Vg6(Bg7x.;g42EYH5Ʒ"MraV}gͽ )R4Pu;koHA삢U>{H]"bLr-ȇUlb]"w UζP/P;g2Dce3EH 7"~(X PtُTٺ c5x .;g ŤM<EHhfvU^adfO@9 $sPL߼)r )V)Ds=7x .;[@BY)$hgG)$[n݊OC6*Œj9gG/M%5lqh6Pe<%s9{9|/Ѿ+W \ux"EV\1?d-R\mռ3W Es$e2yg6q V\1=Oe*yg9BYjޙ+נC[g5P6mw (=`5bf@y!ygh+?sſs8q'ʊO7kV:r?ݣٰ=([|ߋc/NҺw]ukUH{-6Ndr@J5z0 ArialDefault DesignMicrosoft Graph ChartSlide 1  Fonts UsedDesign TemplateEmbedded OLE Servers Slide TitlesOh+'0 ( H T `lt|Office of Nursing Services %` Pbjbj 4̟̟H&&&&D`&;P'l((((("(( A;C;C;C;C;C;C;$x<h>g;4((44g;((|;9898984n((A;984A;989898(D' @nD5&6v988;0;98j?q7j?98j?98\(jh,p98.0(((g;g;/8 (((;4444dx x Office of Nursing Services 2008 Annual Innovations Awards Use of Restorative Nursing Assistants in the Critical Care Units PRIMARY AUTHORNAMEMari Kelley, RN, CNN, CHTP, CHTITITLENurse Manager, Progressive Care UnitFACILITY NAME ADDRESSGreater Los Angeles Healthcare System 11301 Wilshire Blvd. Los Angeles, CA 90073TELEPHONE NO.310 - 478 - 3711 EXTENSION: 48686  FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NAMEBrooks Kabo, RN TITLEAssociate Chief Nurse, Med/SurgFACILITY NAME ADDRESSGreater Los Angeles Healthcare System 11301 Wilshire Blvd. Los Angeles, CA 90073TELEPHONE NO.310 - 478 - 3711EXTENSION: 83962 NAMEAbbas Ardehali, MDTITLEChief of Cardiac Surgery FACILITY NAME ADDRESSGreater Los Angeles Healthcare System 11301 Wilshire Blvd. Los Angeles, CA 90073TELEPHONE NO.310 - 478 - 3711 EXTENSION: 83135 NAMEMargaret M Kohn, RN, MSNTITLECardiothoracic Surgery Nurse Practitioner , First AssistFACILITY NAME ADDRESSGreater Los Angeles Healthcare System 11301 Wilshire Blvd. Los Angeles, CA 90073TELEPHONE NO.310 - 478 - 3711 Pager 3027 NAMECathy A Bradish, RNTITLECardiothoracic Case ManagerFACILITY NAME ADDRESSGreater Los Angeles Healthcare System 11301 Wilshire Blvd. Los Angeles, CA 90073TELEPHONE NO.310 - 478 - 3711 EXTENSION: 44191 NAMEAdina Katz, RNTITLEManagement Analyst, Quality ManagementFACILITY NAME ADDRESSGreater Los Angeles Healthcare System 11301 Wilshire Blvd. Los Angeles, CA 90073TELEPHONE NO.310 -268-3580 Use of Restorative Nursing Assistants in the Critical Care Units _____________________________________________________________________________ Summary Extensive length of stay in the intensive care units (ICU) cardiothoracic patient (CT) population was a problem identified by leadership and staff, and was found to be related to medical providers lack of confidence in nursing staff outside the ICU to provide adequate out of bed and rehabilitative activities to their patients. A review of the literature revealed prolonged (>10 days) postoperative Intensive Care Unit (ICU) stay results in negative long-term outcomes and poor quality of life (Gaudino et al., 2007). In addition, patients remaining in ICU for more than 14 days suffer higher mortality and cost (Williams et al., 2002). The Society of Thoracic Surgeons (STS) National Data Base reports that the length of stay (LOS) for CT patients is a mean of 6.9; the medium is 5.0; 78% is 6 days and 25% of patients is 4 days. The VA and VISN FY 2007 Continuous Improvement in Cardiac Surgery Program and Expansion Projects data on Coronary Artery Bypass Grafting (CABG) revealed that VA Greater Los Angeles Healthcare Systems (GLAHS) LOS was a large outlier when compared with national VA and VISN results (16.3 days). The Interdisciplinary team implemented a program late in 2007 to utilize Restorative Nursing Assistants (RNAs) in supplementing rehabilitative activities of patients provided by nursing staff. The team also provided up to date information to nursing staff on clinical pathways and protocol to improve patients timely progress. Successful implementation of the program included collaboration with Nursing Leadership, Physical Therapy, Restorative Therapy Coordinator, Cardiac Surgeons, CT Nurse Practitioner, CT Case Manager and nursing staff. As a result, the program reduced the median length of stay from 10 days to a total of 5 days in the critical care units. The program also resulted in decreased costs and improved patient and staff satisfaction. Date of Implementation: August 2007 Adoption of the Innovation VA GLAHS has always tried to find ways to improve efficiency in patient throughput. One of the problems noted in 2007 was that cardiothoracic (CT) patients had an extensively long hospital stay in the surgical intensive care unit (ICU) with a mean baseline length of stay of 11.1 days (median of 6 days) between December 2006 and March 2007. This was thought to be due to surgeons not transferring their patients to lower levels of care. After discussion with surgical staff, it was found that surgeons feared that patients would not obtain adequate physical therapy and rehabilitation. It was thought that the higher staffing ratio in the surgical ICU (2 patients to 1 nurse) would permit increased mobility for patients on the unit to be up for meals and other activities such as ambulation more often than if they were transferred to the Progressive Care Unit (PCU), which had a ratio of 3 or 4 patients per 1 nurse, or medical-surgical ward. To address this problem, nursing leaders and managers designed a multi-strategy approach. First, a Surgical ICU RN was hired as the CT Case Manager to facilitate patient disposition and discharge plans. Second, a plan to utilize Restorative Nursing Assistants (RNAs) was presented and approved to improve and facilitate cardiac rehabilitation activities in CT patients. Finally, staff education provided an update to staff on the role of the nurse in facilitating clinical pathways and providing rehabilitation for CT patients. According to a study done at the University of Ottawa, Ottawa, Ontario, it was found that contracture significantly worsened in one-third of patients with prolonged stays in the ICU resulting in functional disability (Clavet et al., 2008). Designated RNAs have been used successfully in the rehabilitation and nursing home settings (Pullenayegum et al., 2005; Remsburg et al., 1999); however, the concept of having RNAs focusing their work on CT patients and in critical care units is new. The RNAs were placed on the PCU unit on one of two shifts, 5:30a-2p; 9:30a 6p. This gave the unit 3 people per day to help with rehabilitative activities with an average daily census of 12 patients seen 2-3 times per day. The goal was for the RNAs to start in the ICU with the CT patients and begin to get them up out of bed for breakfast, and then move to the PCU and get those patients up for breakfast. They followed the patient from ICU, to PCU, to the medical/surgical ward and then to the rehabilitation unit, providing the activity support needed. After breakfast, they would assist patients back to bed as needed. Other activities included ambulation, use of incentive spirometer, chest postural drainage, range of motion and other rehabilitative activities. The RNAs worked to increase the patients walking distance and activities every day so that their tolerance and endurance increased according to the patients ability. The RNAs activities also included documentation. The Nurse Manager (NM) and the RNA staff collaborated with Physical Therapy and rehabilitation services to design a form for documentation to be pilot tested. This template was pilot tested and revised. As a result, the RNAs showed progression in their documentation of the patients rehabilitation. This template in the patients electronic medical chart allowed for trending of patients functional status (e.g., distance the patient ambulated in feet) and rehabilitation, and assisted in improving communication among team members. Use of protocols to improve rehabilitation strategies and advance nursing intervention has previously been shown to successfully improve patients functional status (Zevola et al., 1999). After a review of the literature and best practices on functional mobility, the nurse managers and leaders in critical care developed and evaluated an innovative approach to rapid recovery by use of a protocol that included education for staff nurses, training and supervision of recovery by RNAs who assisted with the rehabilitation activities. Staff education resulted in 93% of respondents stating that the session expanded their current knowledge of topics and nursing actions. The CT Nurse Practitioner and Case Manager also worked with the CT attendings/surgeons so that trust was built between medicine and nursing staff outside the critical care units, and to provide state of the art rehabilitation for CT patients. In addition, all CT patients were given a cardiac transmitter which allowed more mobility for the patients who could now get up and move around without being tethered to equipment. Nursing Leadership and Collaboration Collaboration among the Associate Chief Nursing Service, Medical/Surgical, risk management and nurse managers produced a plan to propose having RNAs facilitate the rehabilitative activities needed by CT patients. This proposal was supported by the Nurse Executive initially as a pilot project. They proposed this plan to the resource committee for a restorative health technician in PCU. In April 2007, the Nurse Managers of PCU and Rehabilitation Unit interviewed individuals for this position and five RNAs were hired. The PCU Nurse Manager took the lead in designing the RNA role, creating the curriculum, designing the documentation templates, collecting CT trend data and implementing the pilot testing. The Restorative Coordinator for the Nursing Home Care Unit conducted a 2-week training in August 2007 for the RNAs. Another part of the training was provided by the CT Nurse Practitioner who explained the cardiothoracic clinical pathway, the expected activity protocol and the recovery schedule for CT patients. Recreation Therapy and Physical Therapy added some training to expand the RNAs competencies. Nursing staff provided feedback regarding how the new program was working through monthly staff meetings and daily communication. Several nurses have approached the Nurse Manager to give spot awards to the RNAs who have become indispensible in the unit. GLA Nursing Service Strategic Goals. The use of RNAs in the Critical Care Units supported the VA GLAHS Strategic Goals of Nursing. Patient outcomes improved by means of nursing practice effectiveness and improved documentation, as evidenced by decreased length of stay, faster patient rehabilitation and recovery. Winning the Unit Customer Service Award during the year increased GLAs customer service scores. The magnet journey of GLA was supported through the new process of bedside staff participation in continued collaboration with the RNAs. In addition, improved efficiency in the delivery of nursing service was attained by utilizing a different model of nursing care with the RNAs which resulted in patients obtaining timely nursing care and getting out of bed, ambulating, and participating in out of bed activities earlier and more often. Scope of the Initiative This program was rolled-out in the ICU, PCU, medical, surgical and rehabilitation units in GLAHS. The executive team has adopted this new program and supports its use throughout the Critical Care Units. Future plans include rolling this program out to focus on general surgery and orthopedic patients. Dissemination of this project and its findings are being reviewed at this time and include publication and presentation in annual conferences of nursing professional organizations. Impact The mean length of stay in SICU decreased from a baseline of 11.1 days (median of 6.0 days) to 4.3 days (median of 3.0 days) in December 2007. The mean length of stay in PCU also decreased from 5.4 days (median of 5.0) to 4.5 days (median of 2.0) see graph below.  It was also noted that more patients were being discharge directly to home from the PCU as opposed to being transferred to other wards.  EMBED PowerPoint.Slide.8  One benefit of reduced length of stay is reduced medical center cost in caring for the patient. The FY 07 Dashboard contract cardiology cost per day is $1,850. The median length of stay for these GLA patients has been reduced from 10 days to 5 days total. Using the Dashboard cost per day as a rough estimate for GLA cost in the ICU, $1,850 x 5 days saved on average per patient = $9,250 per patient saved on average. With an average of 12 procedures per month, assuming that 10 do not have significant complications, 10 patients per month x $9,250 per patient saved on average = $92,500 projected cost savings per month by the use of this innovative program, or an estimated $1,110,000 per year. In addition to decrease in length of stay and cost-saving, the Customer Service Scores for PCA have been so high that they won the GLA Outstanding Customer Service Trophy in January 2008 and consistently exceeded the national expectations. The Cardiothoracic attending physicians and the CT Nurse Practitioner have also expressed satisfaction with the reduced length of stay. Narrative data from the CT Nurse Practitioner indicates that the RNAs are noticing symptoms and problems and reporting them in a timely manner to the CT Nurse Practitioner, thus decreasing complications. In several instances, the RNAs have noticed dyspnea or a chest tube leaking and this early warning has saved the patient from experiencing severe complications. In addition, the physical therapy, recreational therapy and cardiac team have expressed high satisfaction with the RNA work and documentation. References: Clavet H, Hebert PC, Fergusson D, Trudel G. Joint contracture following prolonged stay in the intensive care unit. CMAJ. 2008 Mar 11; 178 (6); 691-7. Gaudino M, Piscitelli M, Martinelli L, Della Vella C, Schiavello R, Possati G. Long-term survival and quality of life of patients with prolonged postoperative intensive care unit stay: Unmaking an apparent success. J Thorac Cardiovasc Surg 2007; 134:465-469. Morris PE, Heridge MS. Early intensive care unit mobility: future directions. Critical Care Clinical, 2007 Jan; 23(1):97-110. Ortrud V, Birnbaum J, Wernecke K, England M, Konertz, W, Spies, C. Prolonged Intensive Care Unit Stay in Cardiac Surgery: Risk Factors and Long-Term-Survival. Ann Thorac Surg 2006; 81:880-885.  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ott%20RA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Ott RA,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gutfinger%20DE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Gutfinger DE,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Miller%20MP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Miller MP,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Alimadadian%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Alimadadian H,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tanner%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Tanner TM. Rapid recovery after coronary artery bypass grafting: is the elderly patient eligible?  HYPERLINK "javascript:AL_get(this,%20'jour',%20'Ann%20Thorac%20Surg.');" Annual Thoracic Surgery. 1997 Mar; 63(3):634-9. Pullenayegum S, Fielding B, Plessis ED, Peate I. The value of the role of the rehabilitation assistant. British Journal of Nursing 2005; 14(14): 778-784. Remsburg RE, Armacost KA, Radu C, Bennett RG. Two models of restorative nursing care in the nursing home: Designated versus integrated restorative nursing assistants. Geriatric Nursing 1999; 20(6):321-326.  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22St%C3%B6hr%20IM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Sthr IM,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Albes%20JM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Albes JM,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Franke%20U%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Franke U,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Wippermann%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Wippermann J,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Cohnert%20TU%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Cohnert TU,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22H%C3%BCttemann%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Httemann E,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Wahlers%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Wahlers T. Outcome of patients after cardiac surgery transferred to other hospitals following prolonged intensive care stay.  HYPERLINK "javascript:AL_get(this,%20'jour',%20'Thorac%20Cardiovasc%20Surg.');" Thoracic Cardiovascular Surg. 2002 Dec; 50(6):329-32 VHA FY 07 Operational Efficiency Measures through September: VISN 22, VA Greater LA HCS, and Contract Hospital Cardiology Discharges/Contract Cardiology Cost. Williams M, Hartnett E, Kavarana M, Mehnet O, Sladen, R. Long-term survival and quality of life in cardiac surgical patients with prolonged intensive care unit length of stay. Ann Thorac Surg 2002; 73: 1472-1478.  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Zevola%20DR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Zevola DR,  HYPERLINK "http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Maier%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus" Maier B. Improving the care of cardiothoracic surgery patients through advanced nursing skills.  HYPERLINK "javascript:AL_get(this,%20'jour',%20'Crit%20Care%20Nurse.');" Critical Care Nurse. 1999 Feb; 19(1):34-44 9:z{s w z { ˱֜tcKt/jVhchKr56CJU\]aJ hchKr56CJ\]aJ)jhchKr56CJU\]aJ%hchKr5CJ\aJmHnHu)jhchKr5CJU\aJ#jhchKr5CJU\aJhKrCJaJhchKrCJaJhchKr5CJ\aJh "5CJ\aJ hKr5\hchKr5\:{vv $Ifgdkfkd$$Ifl4|&0*00*64 laf4ytk $Ifgdk$a$gdKr $@&a$gdKrP $Ifgdkvkd$$Ifl0|&@ 00*64 laytk / E $Ifgdkvkd0$$Ifl0|&@ 00*64 laytkE F T x $Ifgdkvkd$$Ifl0|&@ 00*64 laytkx y z { $IfgdkgdKrvkdp$$Ifl0|&@ 00*64 laytk l | _ ƻudUI:hchKrB*CJaJphh "B*CJaJphh "hKrB*CJaJph!h "h "B*CJ^JaJph$h "h "B*CJ\^JaJphh "B*CJ\^JaJphhchCJaJhCJaJhJgCJaJhKrCJaJhchKrCJaJhchKr6CJ]aJ)jhchKr56CJU\]aJ+hchKr56CJ\]aJmHnHu $Ifgdk  !gdKr^kd6$$Ifl|&0*00*64 laytk $Ifgdkvkd$$Ifl0|&@ 00*64 laytk 2 G ] $Ifgdkvkd`$$Ifl0|&@ 00*64 laytk] ^ l $Ifgdkvkd$$Ifl0|&@ 00*64 laytk {{ $IfgdkgdKrvkd$$Ifl0|&@ 00*64 laytk $Ifgdkvkd@ $$Ifl0|&@ 00*64 laytk   2 $Ifgdkvkd $$Ifl0|&@ 00*64 laytk2 3 A e $Ifgdkvkd $$Ifl0|&@ 00*64 laytk_ d f g l N X [ ` s { | ,1349GOanou ">>GtthtMB*^JaJphhXhtMB*^JaJph hhOhtMhtM htM5>* htM5h htM5h@wCJaJhKr5CJaJhchxCJaJhCJaJhxCJaJhch "CJaJhKrCJaJhchKrCJaJh "CJaJ)e f g l {{ $IfgdgdKrvkd $$Ifl0|&@ 00*64 laytk $Ifgdvkd $$Ifl0|&@ 00*64 layt   - $Ifgdvkd` $$Ifl0|&@ 00*64 layt- . < Y $Ifgdvkd $$Ifl0|&@ 00*64 laytY Z [ ` t vm $Ifgdk  !$IfgdkgdKrvkd $$Ifl0|&@ 00*64 laytt u { $Ifgdkvkd@$$Ifl0|&@ 00*64 laytk $Ifgdkvkd$$Ifl0|&@ 00*64 laytk 2 $Ifgdkvkd$$Ifl0|&@ 00*64 laytk2349Hsj $Ifgdk  !$Ifgdk$a$gdKrvkd $$Ifl0|&@ 00*64 laytkHIOv $Ifgdkvkd$$Ifl0|&@ 00*64 laytkvw $Ifgdkvkd`$$Ifl0|&@ 00*64 laytk $Ifgdkvkd$$Ifl0|&@ 00*64 laytk>!">?|||||||||||gdtM$a$gdtMvkd$$Ifl0|&@ 00*64 laytk  !>QO P ""$$$$'''H(L(=)>)?)@)e) **.....'2(2?2q3t3)414/545鸰hD,chtMB*phhtM6>*] htM6>* htM5>* hpJhtM h{ShtMhmKChtMB*phhhOhtM5>*htM hhOhtMhXhtMB*phA ""$$''>)?)e)f)t+u+--..'2(2A2B2(4)40414 [$\$gdtMgdtMgdtM14=5?5588<'<<=A>?9DDELdM:NPPgd@wgdtMgdtM45=5>5?55555555t9v9::;;< <<'<<<==>'>>>????????@@ƻܷ}q}a}q}q}hhOhtM0J5CJ\aJhhOhtM5CJaJ jhhOhtM5CJUaJhhOhtM0J5>*CJaJhhOhtM0J5CJaJhhOhtMCJaJhtMj'h htMUjIܶK htMCJUVaJ h htMjh htMU h[0"htMj@h:htMU hhOhtM&@@@@@AAAAAAuBvBBBBBXCYCbCcCCCCDD D!D8DDDzEEEEEwFxFFFFFTGUG]G^G`GaG1H2HŲŲř~hVhtM0J5CJaJhtM0J5>*CJaJhtM0J5CJaJhhOhtM0J5CJaJ$jhhOhtM0J5CJUaJhhOhtM0J5CJaJhhOhtM5CJaJ jhhOhtM5CJUaJhhOhtM0J5CJ\aJ12H:H;H=H>HIII I"I#IIIJJJJJJJJJJKKKK;L*CJaJhtM0J5CJaJhhOhtM0J5CJaJ$jhhOhtM0J5CJUaJhhOhtM0J5CJaJhhOhtM5CJaJ jhhOhtM5CJUaJhhOhtM0J5CJ\aJ4KPLPPPPPPPP뿴hP@htM0J5CJaJhhOhtM0J5CJaJhhOhtM0J5CJaJhhOhtM0J5>*CJaJ'jhhOhtM0J5>*CJUaJ21h:ptM/ =!"#$% SummaryInformation(]tDocumentSummaryInformation8_1279448305` FpK&C۰pK&C۰Data ^VA Employee Normal.dot VHACOMITCHR2Microsoft Office Word@@35@35 =  FMicrosoft Office Word Document MSWordDocWord.Document.89q@Oh+'0 4 H՜.+,D՜.+,L hp  GLAHS%H' Office of Nursing Services Title 8@ _PID_HLINKSAdfe95javascript:AL_get(this, 'jour', 'Crit Care Nurse.');F 86http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Maier%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF 33http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Zevola%20DR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF 90<javascript:AL_get(this, 'jour', 'Thorac Cardiovasc Surg.');F Qd-http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Wahlers%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF &W*http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22H%C3%BCttemann%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF Uy'http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Cohnert%20TU%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF }V$http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Wippermann%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF pT!http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Franke%20U%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF !http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Albes%20JM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF  #http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22St%C3%B6hr%20IM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF u5javascript:AL_get(this, 'jour', 'Ann Thorac Surg.');F 5http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tanner%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF K{http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Alimadadian%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF &http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Miller%20MP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF 0 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gutfinger%20DE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF Rj http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ott%20RA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusF h$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%ph$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%ph$$IfP!vh5\ 5l#v\ #vl:Vl t65\ 5laPyt%p$$IfP!vh5(#v(:V l40(65(4aPf4yt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%pFDText14hPlease provide the following information for the other team members. Use a separate sheet if necessary.DText15(Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members)$$IfP!vh5(#v(:V l0(65(4aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPytg$$IfP!vh5 5#v #v:V l0(65 54aPytg$$IfP!vh5 5#v #v:V l0(65 54aPytg$$IfP!vh5 5#v #v:V l0(65 54aPytg$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p$$IfP!vh5 5#v #v:V l0(65 54aPyt%p1Table_b<CompObj{qObjInfoad}WordDocument &<                       ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~  @@@ #NormalCJ_HaJmH sH tH :@: # Heading 1$@&5\DAD Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List 4@4 #Header  !4 4 #Footer  !j@j  Table Grid7:V06U!6 l Hyperlink >*B*phFV1F  jFollowedHyperlink >*B* phHBH N Balloon TextCJOJQJ^JaJZYRZ  Document Map-D M CJOJQJ^JaJDKqr5KEK@0@0@0@0@0 00E5KEK00dQ@0q @00:K8J[\f,CDUwxy017HIJOcdv  !2TU[opqv%&'()*+,-./0123i j OPqr@e|}UVABe!f!g'h'+,,,@,A,h.i.11,5-57888,=3=4=Y@Z@FF2H3HJJ5K6K8K9K;KK?KAKBKEK000000 0 0 0 000 0 0 0 0 0000 0 0 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 000000000000000000000000000000000000000000000000000000000000000000000@0X00@0X00@0X00@0X00X00:K8J[\f,CDUwxy01JOcdv  2Tqv'i j OPqr@e|}UVABe!f!g'h'+,,,@,A,h.i.11,5-57888,=3=4=Y@Z@FF2H5KEK000000 0 0 0 000 0 0 0 0 0000 0 0 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0@0 @0 @0 @0 @0 @0 00 0 0 0 0 0 0 0 0 0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00  3$7DS*/4<HJ  C w 0 H c T o %2B#RDS+-.012356789:;=>?@ABCDEFGIKCS,yDKFtFtl,b$Qedݤ0jhp8@((    C PA8red shite blue culture logo"`B S  ?DKU TText14Text15zEKEK < $(= $> j? ė@ dkA ,ڗB LC ܨD E ,8844:::EK II44:::EK 8*urn:schemas-microsoft-com:office:smarttagsCity=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName9 *urn:schemas-microsoft-com:office:smarttagsplace:*urn:schemas-microsoft-com:office:smarttagsStreet; *urn:schemas-microsoft-com:office:smarttagsaddress     378;<G'(%()(45;;s;w;@@BB5K6K6K8K8K9K9K;KK?KAKBKEK2*1z++22330>?@@5K6K6K8K8K9K9K;KK?KAKBKEK333333333/67bem1IO^ !2p&'5K6K6K8K8K9K9K;KK?KAKBKEK375K6K6K8K8K9K9K;KK?KAKBKEK?>NK} /eeJoz jwaY"d[%d%R'\b)*uY*0?:5S;X#BzdNOhRlTU(UHrVcY^Y,gq7i-QiNknSofp8w&{ xu{,'V)#g9 *El"nu!|u_?X/)%px[\f,CDUwxy017HIJOcdv  !2TU[opqv%&EK@|IDK`@UnknownGz Times New Roman5Symbol3& z Arial7&  Verdana5& zaTahoma"1hCFCF&9 ?&9 ?&$@4dKK2QHP ?#2Office of Nursing Services vhacllyerarr VHACOMITCHR                           ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 s 9 : ; < = > ? A B C D E F G I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p t w x y z { | } ~  %` DSbjbj &<̟̟6K +++8<+4p+8$X,(,,,,G."i.}. E8G8G8G8G8G8G8$9hR<k81%."G.11k8,,84441,,E841E8444,L, Cb3+w245t8084<G3<4<4./h4/T/...k8k8Y4d...81111<dd< Office of Nursing Services 2008 Annual Innovations Awards Application Form Professional Practice Environment for Nursing Excellence Title of SubmissionCentralizing Nursing in a Care Line Model: Creating the SAVAHCS Culture of CaringFacility Name and AddressSouthern Arizona VA Health Care System (SAVAHCS) 3601 S 6th Avenue Tucson, AZ 85723VISN # 18VISN 18 VA Southwest Health Care Network Names of Team Members (Note: At least two (2) team members are required.) Primary Author InformationNameSheila Thompson, RN, FACHETitle of PositionAO to Nurse Executive Telephone Number520 - 792 - 1450 Extension: 6894  FORMTEXT Please provide the following information for the other team members. Use a separate sheet if necessary.  FORMTEXT (Important Note: Only those making significant contributions to the initiative should be listed in this section as the $10,000 award will be divided equally among the team members) NameDJ Smith, RNTitle of PositionSAVAHCS Deputy Nurse Executive Telephone Number520 - 792 - 1450 Extension: 5934EmailDJ.Smith3@va.gov NameCharles Silveri, RNTitle of PositionClinical Nurse ManagerTelephone Number520 - 792 - 1450 Extension: 6607EmailCharles.Silveri@va.gov NameMartha Kates, RNTitle of PositionClinical Nurse LeaderTelephone Number520 - 792 - 1450 Extension: 4270emailMartha.Kates@va.gov NameSheila Thompson, RN, FACHETitle of PositionAdministrative Officer to the Nurse Executive Telephone Number520 - 792 - 1450 Extension: 6894EmailSheila.Thompson@va.gov 2008 ONS Innovations Award: Professional Practice Environment for Nursing Excellence Title: Centralizing Nursing in a Care Line Model; Creating the SAVAHCS Culture of Caring. Summary of Initiative: For eight years the Southern Arizona VA Health Care System (SAVAHCS) nursing service had been decentralized with nurses assigned into their respective care lines. While there was a Nurse Executive identified, most nurses saw their chain of command as going through their care line up to their Chief who then reported to the Director. As nursing leaders within each care line changed and new leaders who had not been part of the pre-care line structure were chosen, nursing practice became less standardized across the facility making preparation for accreditation and regulatory surveys challenging. Sharing nursing personnel resources was difficult across care lines when acuity or census went up or staffing resources went down. Most importantly, there was a diminishing sense of Nursing as a unique identity as nurses identified with their multi-disciplinary care line. SAVAHCS leadership met and decided that a strong, centralized nursing service was critical to meeting the SAVAHCS goal of providing care to veteran patients. 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. The resulting redesign of the SAVAHCS Office of the Nurse Executive, an Inpatient Nursing Care Line, and a Nursing Committee structure improved performance on many nursing and organizational goals. This new Nursing identity increased off-tour nursing staff support through the Senior Clinical Officer (Nursing supervisor), enhanced staffing plans on all inpatient units, improved staffing while reducing agency staff expenditures by two and a half million dollars, supported new graduate nurses through creation of Clinical Nurse Leader positions, and created a Culture of Caring as the SAVAHCS professional nursing identity and model of care. The Culture of Caring is the basis for the SAVAHCS professional practice environment for Nursing excellence. It is the mission of SAVAHCS Nursing to provide the highest quality nursing care to our veteran patients in a Culture of Caring. It is the vision of SAVAHCS Nursing to create a Culture of Caring so strong and pervasive that SAVAHCS is recognized as a Magnet hospital and is seen as the Health Care System of choice for veterans seeking care, students furthering their education, and nurses seeking a career they love. In honoring veterans SAVAHCS Nurses dedicate themselves to Trust, Respect, Commitment, Compassion, and Excellence. The SAVAHCS Watson-Orem hybrid nursing theory is one which reflects that nursing is both art and science. The Watson theory of caring strengthens the SAVAHCS Culture of Caring where nurses care for patients, colleagues and students. The Orem theory explains the theory-based nursing skills and decisions made to bring patients to optimal health. Date of Implementation: October 2003 Adoption of Innovation In 1995 SAVAHCS had adopted the care line model of healthcare organization. In 2002, for the first time, SAVAHCS struggled with preparation for its Joint Commission (JC) survey, finding that the care line focus on their area of practice led to inconsistency in implementation of organizational-wide policy. The Executive Leadership Triad (Director, Associate Director, Chief of Staff) called a meeting of SAVAHCS leadership (Nurse Executive and Care Line Chiefs) to discuss the situation. The Care Line Chief for Performance Management proposed that the biggest problem faced with the JC preparation was a lack of standardized Nursing care across the care lines. He stated that it was Nursing who was present in the hospital every hour of every day, it was Nursing who was the most informed and influential in supporting organizational policy and that if Nursing was more centralized, all organizational processes would become more standardized. The Chief of Medicine supported the proposal with her simple statement that patients were admitted to the hospital for Nursing care and so Nursing was the key to SAVAHCS success. The discussion grew to include other organizational concerns such as the growing nurse staffing agency costs and the communitys hospital bed increase during a time of nursing shortage. SAVAHCSs chief competitor for BSN graduates from the local university was advertising its 1 RN to 4 patients staffing ratio and had applied for Magnet recognition. From this meeting the idea of reorganizing Nursing into a more centralized entity was born. The Nurse Executive was charged with bringing SAVAHCS nursing leaders and staff from across the organization together to design and implement a centralized nursing service structure. It seemed the perfect storm was coming together as the SAVAHCS interest in centralizing nursing occurred as Linda Aikens research and resulting Magnet program gained publicity, as concern over medical errors and patient outcomes were linked to RN staffing, and the VHA moved toward a performance measure system of quality review. The Nurse Executive gathered resources and information on all these topics to be used as the redesign team work began. Nursing Leadership and Collaboration The Nurse Executive chartered the members to the Nursing Reorganization Design Team to include the Nurse leaders from every care line, informal Nurse leaders such as nurse educators and the NOVA chapter president, staff nurses representing varied areas and shifts, and the Nursing Union (AFGE) representative. The Nurse Executive also included important non-nursing stakeholders including the manager of human resources and the Care Line Chiefs of Medicine and Surgery. The stated goal of the redesign team was to improve the environment in which nurses work and to ensure delivery of nursing care in a cost effective manner. The most basic question for the team to answer was whether to bring all nurses into an organization wide Nursing service or to limit the change to creating an Inpatient Nursing Care Line. The group decided that the best course for the organization was to bring inpatient nursing resources together into one care line and strengthen the entire nursing practice environment through enhancement of a nursing committee structure. With this decision made the team proceeded to design an inpatient nursing care line to address three major concerns: Nursing staff were most concerned with improved staffing, stakeholders were most concerned that the new design would not negatively impact their patients access to care (i.e. that an inpatient nursing care line would maintain or increase the surgical bed availability for the surgical schedule, medical admits, etc.) and SAVAHCS leadership were concerned with budget management and cost savings. Citing the research on nurse staffing and patient outcomes, the Nurse Executive proposed to the group that this was the time to make the bold move from the team nursing delivery model in inpatient care to an all RN staffing model. To answer the team concern that this was a risky decision to make in times of a nursing shortage the Nurse Executive countered that an all RN staffing plan would address the nursing staffs interest in improved RN staffing, that the resulting increase in satisfaction would improve recruitment and retention, and that in turn would address the stakeholder concerns with access and costs. The Nurse Executive also argued that the move was necessary to compete with new staffing ratios at other local hospitals. Staff nurse interest in moving to an all RN staffing model was overwhelming and so the team moved forward with a proposal that included an Inpatient Nursing Care Line organization chart and a staffing plan using an all RN model. Executive leadership approved the proposal and the Inpatient Nursing Care Line was implemented in October 2003. The plan included not only an all RN staffing model but also provided other positions to enhance the inpatient nursing practice environment including a Deputy Nurse Executive position to serve as Care Line Chief, a Staffing Coordinator to oversee facility-wide nursing schedules and manage the supplemental staffing program, additional SCO (nursing supervisor) positions to support the off tour shifts, a nurse educator and administrative support staff. The change was communicated to nursing staff in a variety of ways. Staff meetings were held on all units moving to the Inpatient Nursing Care Line. No LPNs lost their jobs with the change. LPNs were assisted in applying for positions in outpatient settings or in using National Nurse Education Initiative funds to pursue their RN. The organization chart and staffing plans were reviewed at the Nurse Leadership Council meetings. A SAVAHCS Nursing newsletter, News You Can Use was started to communicate with nurses across the organization. The SAVAHCS success was shared outside the facility in a variety of ways as well. The Nurse Executive has provided consultation to other VA Nurse Executives wishing to centralize their nursing services. The Nurse Executive was chosen to represent the VA on a panel discussion held at the Arizona Nurses Association annual conference on RN models of care. As chair of the VISN 18 Nurse Executive Committee, the SAVAHCS Nurse Executive added nursing care delivery models, nursing service organization, evidence-based practice and Magnet forces as recurring topics to the monthly agenda. Both the Prescott and Phoenix VAHCS have moved to a more centralized nursing service model. Scope of Initiative The original Nursing Reorganization Design Team focused on creation of an Inpatient Nursing Care line and staffing plans and costs. Improving the practice environment across the entire organization is carried out as an ongoing activity through annual Nursing retreats. Through these retreats the SAVAHCS Nursing mission, vision, values were established, the committee structure was reviewed and enhanced, and nursing improvement activities are prioritized. Nursing managers, leaders, and staff from across the organization are invited to participate. The first retreat was held early in 2004. At this meeting the SAVAHCS Nursing Mission, Vision, Values, and theory were chosen as presented in the executive summary. The group coined the Culture of Caring term to capture SAVAHCS Nursings commitment to our patients, our students, and ourselves. It was also at this retreat that the Nurse Executive presented the Magnet program concepts, published outcomes, and support for Magnet as a means to improving the SAVAHCS nursing environment. The group agreed to adopt Magnet tenets as framework for improvement activities. This work became the basis for all future nursing improvements. Two activities with organizational-wide impact resulting from these retreats have been the reorganization of the Nursing Committee structure and the creation of the Clinical Nurse Leader positions. To achieve Magnet status and to strengthen nursing standardization across the organization, nursing leaders redesigned the Nursing Committee structure to be in line with Magnet Forces. The 2 main goals achieved by the reorganization was; 1) alignment of committee scopes with Magnet and accreditation activities and 2) innovative ways to increase staff nurse participation. A common committee meeting day was chosen so that units could staff up to allow nurses to go to their meetings. Virtual meetings were supported and off tour staff were encouraged to volunteer for committees such as Policy and Procedure where much of their review work could be done on off tours. Achieving Magnet became a goal on the SAVAHCS strategic plan in 2006. Another success is the partnership of our evidence-based practice committee with the Phoenix and Prescott VAs in a consortium to share best practices. Unit councils were added to the committee structure to give staff more control over their own practice environment. Unit councils were designed and are now led by unit staff. Their work is reported quarterly at the SAVAHCS Nurse Executive Board meetings. Unit councils have worked on their own improvement initiatives such as implementation of 12 hour shifts, improved orientation and daily checklists for unit charge nurses and unit celebrations. Unit councils have also been assigned organization initiatives such as gathering staff information for the VHA non-nursing task survey, choosing unit level improvement activities based on VANOD RN satisfaction survey results, and suggesting policy or process improvements to increase use of the SAVAHCS patient discharge center. Another improvement in the nursing practice environment was creation of the Clinical Nurse Leader (CNL) role. SAVAHCS has the Directors financial support, Human Resources recruitment support, the Education Departments administrative support, and our nursing staffs clinical expertise to build the largest VA Learning Opportunities Residency (VALOR) program in the nation. Most VALOR students choose to stay with SAVAHCS. SAVAHCS is also successful in recruiting from our Student Nurse Technician (SNT) program so supporting new graduate RNs is a priority. With VHA support of the Clinical Nurse Leader initiative, the SAVAHCS Nurse Executive partnered with the University Of Arizona College Of Nursing to develop a CNL curriculum. CNLs are now present on our critical care, medical / surgical and long term care units. The CNLs have been key drivers in promoting evidence-based care and improving the nursing care environment by leading the implementation of the Rapid Response Team (RRT), implementation of the 5 Million Lives campaign bundles in the ICU and creation and education on the Pressure Ulcer Prevention bundle. SAVAHCS has shared the success of the CNL program at the Arizona Nurses Association Meeting and the Tucson Nurses Week Foundation Showcase. Impact Centralizing Nursing had many positive effects for SAVAHCS. The most striking is assuring that staffing matrices are met while decreasing agency staffing costs. In 2002 the costs for supplemental staffing had reached an all time high of $3,000,000.00. Having the new Staffing Coordinator reviewing and planning for facility wide staffing schedules reduced supplemental staffing costs to $1,000,000.00 in 2004, $540,000.00 in 2005, $480,000.00 in 2006, and $524, 000.00 in 2007. This was done while assuring that staffing matrices for all inpatient units were met. To honor the staffing plans, the SAVAHCS Director has also provided separate funds for traveling nurses. This allows SAVAHCS to flex up the number staffed beds during our high census season while still keeping to each units staffing ratio. The VANOD satisfaction survey and the Proclarity data mining software have given SAVAHCS powerful tools to measure the effects of centralizing Nursing on RN satisfaction across the organization. The Nurse Executive provides VANOD data to each unit manager and unit council. The data includes the VHA National score, SAVAHCS score, their units score and a comparison to the previous years results so units can celebrate their successes and plan for their next improvement activity. An example is how the October 2006 survey results showed that the critical care areas had the least satisfied staff. It was suggested that the VHAs Civility, Respect, and Engagement in the Workforce (CREW) program might be helpful. The objectives of the CREW program matched well with the critical care areas low scores in RN-MD Relationship scores. The Nurse Executive proposed the ICU participate in CREW and the unit council agreed. Both the CREW evaluation scores and the VANOD satisfaction scores demonstrate the effectiveness of the program with the 2007 ICU overall satisfaction scores being higher than the VHA National score. All nursing areas use the VANOD satisfaction data as an important tool to target improvement actions with their unit councils. The 2007 SAVAHCS VANOD RN Satisfaction Survey results show improvement in all but one questions scores from the 2006 results and the overall satisfaction score of 3.65 is higher than the VHA National score. SAVAHCS 2007 All Employee Survey data shows that nursing staff are consistently more satisfied than other employees. Satisfaction effects recruitment and retention. SAVAHCS has several challenges including a highly competitive community with increasing hospital bed numbers. SAVAHCS has reduced our vacancy rate to 3.3% (2007 VHA rate was 9.4%) despite increasing the number of RN FTE. We effectively use our VALOR and SNT programs as recruitment tools. We market the NNEI program as an opportunity for nurses interested in pursuing their education. Clinical measures of care have improved with the nursing reorganization. Implementation of the RRT has reduced the number of code blues. New graduate RNs have stated they appreciate having the clinical expertise of the RRT available to them. The organizations MRSA rate reached 0 in March 2008. Implementation of the Pressure Ulcer program and surveillance has resulted in increasing the size of the Wound Care team enhancing expert consultation to staff nurses. The organizational impact of the Nursing reorganization has been immensely positive. The importance of Nursing has been further recognized with the inclusion of the Nurse Executive in the executive leadership team and increased status of the Nurse Leadership Council to become the Nurse Executive Board.      :K / 1 7 8 @ B Z b e f m o r ѿ򱡓~u~u~ul~^~U~LuLh^YCJ\aJhxCJ\aJhq7ihq7iCJH*\aJh CJ\aJhHrVCJ\aJhq7iCJ\aJhNh CJ\aJhNh 5CJ\aJhy;h?:56CJOJQJaJhNh,g5CJ\aJ#h{h#5B*CJ\aJphh?:55B*CJ\aJph#h{h 5B*CJ\aJphhNh#5CJ\aJ:KI}kd$$Ifl0@ &\ l t0644 laPyt%p $Ifgd $a$gd# $@&a$gd $@&a$gd$ *@&]^a$gd6SCS 8 J [ \ f x}kdj$$Ifl0@ &\ l t0644 laPyt%p $Ifgd  |vne $Ifgd#$a$gd#@&gdgd }kd$$Ifl0@ &\ l t0644 laPyt%p   + , B D T U X [ ^ a e o r v y z ŷŏzi hNh#56CJ\]aJ)jhNh#56CJU\]aJ%hNh#5CJ\aJmHnHu)jhNh#5CJU\aJhNh#5CJ\aJ#jhNh#5CJU\aJhq7iCJaJhNh#CJaJhNh CJaJhNh,gCJaJ  $Ifgd#fkd>$$Ifl4&(0(64 laPf4yt%p  , C $Ifgd#vkd$$Ifl0& 0(64 laPyt%pC D U w $Ifgd#vkdn$$Ifl0& 0(64 laPyt%pw x y { $Ifgd#gd#vkd$$Ifl0& 0(64 laPyt%p       ( + / 1 6 7 H I J N O ^ b d u v ҼҮ}}uujhNh%pCJaJhgCJaJhNh9CJaJh9CJaJhxCJaJhNh CJaJhNh#CJaJhNh#6CJ]aJ+hNh#56CJ\]aJmHnHu)jhNh#56CJU\]aJ/jhNh#56CJU\]aJ) $Ifgd#  !gd#ckd$$Ifl&(0(64 laPyt%p $Ifgd#vkd^$$Ifl0& 0(64 laPyt%p  0 $Ifgd#vkd$$Ifl0& 0(64 laPyt%p0 1 7 H $Ifgd#vkd$$Ifl0& 0(64 laPyt%pH I J O c {{ $Ifgd#gd#vkd> $$Ifl0& 0(64 laPyt%pc d v $Ifgd#vkd $$Ifl0& 0(64 laPyt%p $Ifgd#vkd~ $$Ifl0& 0(64 laPyt%p  2 5 8 ; > B O S U Z [ o p q u v  %&'(,3ڼڼڼڼڼڼǸ hu!5hu!5CJaJh%p5CJaJh,hNhgCJaJhNh9CJaJh9CJaJhgCJaJhNh%pCJaJhxCJaJhNh#CJaJ< $Ifgd#vkd $$Ifl0& 0(64 laPyt%p {r $Ifgdd[% $Ifgd#gd#vkd $$Ifl0& 0(64 laPyt%p w $Ifgdd[% $Ifgd#vkd^ $$Ifl0& 0(64 laPytg ! 2 T w $Ifgdd[% $Ifgd#vkd $$Ifl0& 0(64 laPytgT U [ o w $Ifgdd[% $Ifgd#vkd $$Ifl0& 0(64 laPytgo p q v vm $Ifgd#  !$Ifgd#gd#vkd>$$Ifl0& 0(64 laPytg $Ifgd#vkd$$Ifl0& 0(64 laPyt%p  $Ifgd#vkd~$$Ifl0& 0(64 laPyt%p% $Ifgd#vkd$$Ifl0& 0(64 laPyt%p%&'()*+,-./012wwwwww$a$gdu!gd#gd,vkd$$Ifl0& 0(64 laPyt%p 23ijOPqr@e|}U!V!##A#B#@ ^@ gdu!gdu!L]Lgdu!$a$gdu!36NO9:;LNPx|?@WXe|#A#B#,4@4$7οر}رvر hhChu!h0 Fhu!5he@hu!6hqhu!6 hShu!jhu!UmHnHu hL5hu!hu!hN{hu!5>*hEhu!>* hu!5>*hEhu!5>*hEhu!5hrBhu!56hV Uhu!5 hu!5h>hu!5-B#%%e)f)g/h/+4,4@4A4h6i699,=-=7@8@,E3E4EYHZHNN2P3PRRgdu!$7577@8@,E2E3EXHYH5S6S7S9S:Shu!6 hu!5hEhu!5 h91hu!hu!hL2hu!6R5S6S8S9S;SS?SASBSCSDSgd#gdu! 6&P1h:p#/ =!"#@$@%   nQedݤ0jhpPNG  IHDR, sRGB pHYs+IDATx^dWy&|n:$"(,Pl;^M>^߻16d @$DArܱr9wNUuhF.ROwխ{=_x4e0 d]fLWH c crmE&a~ѣzG@z>[%r"yqU46YsGm*S > #*B)ŗpJ.>ʁ.%LF9d{uS//_9lz⋃VS\3gg v?H'ybz v=V |p6UUgYZfiK0kl6~ٖHbPMqx`6>܍G 3^SJO M'FЪ)D@߱ 0gA}WrF:7`+RI oIYnXvueWB=XCv-[5 Wu,TII +߆u~F|.)'ܑaNcG0{ms!ĵx[2dS8 L*x5h#k[rs;JN._toGz])4n&])l(Ću: r,_jāܹ>d/Ey=AYbpCvS/ݞs/$aEb#e Xp0\? M"0HnR&K(JJq{!ە<d9{WmQMRkXx߮sL Zp.,ZNw>DSDLiXjOg:>\H=x#,|OP eFF aDZz_X(i)SFY: T`02# wC{mtt+tKL]󊽰eJ9=e2v a.7>X]כ7 o›qltR\hG<`n'=%3_DìBG(/~X:##;#ه0FXw=2/qVP͐y_Юw$t\V)fMW)LnlB(u9T;^X7 >n|~rPrITG9 qX'KѻS89`S9MF`B"ta0VXXAneTs,Jv10& @3l7IrT2b9 DMÂBߎ|-M4Xp}Xi=]3|-%{ xJWY?V[W AX)?;fߜȾXsZhƿ/1[;,/i\Z>ob]Yַ>h* ij1KSS(T&/ݱG`nBɢ?xj,v7+:sSVⱅ][QR͇E( \qV z7 o ۭp)*+x5̴{l_uN6e_0Z`Dqcsgq2>\| f.m5\55Yvڬ\EIF-8Fsqc`nc)%s7`VeYQ;+ߞl6#i9I\Ip8|Q;b@Nc$@g`C,| p!s44,2Kݨg 'Ў[ LV/ؚԩnVx 8\>w%۟d|Ïpq$MOqЃ;&hZ4LcV-ʫK P3(I'nO=t>tCHMG( \@Rצ_mO=]י!bؕ#cۨUT~3#HnC\`t\phլ}v{;flrMB7 ٸ,?a͝ubs+ΊeΪ'wv2mB- }?0 prV|4z-""#CJ~ 8lmR2b 3\pihq!Oa;@`U[CJľ!q; uF}ovV2UFYqdJenď𠾰>߰'  BrXľPR*6]X9Z5Xf܆[`M6bXIZ*a2vcM[*Y; ]0|*w+/ol6"`f[aq㿿 J[VS]UEO59>!`towqE5#BBqٰzGan`nÃ!Ty@1,ITps2D+uu+%tH[ l]'HrLV$2F}ySxG,3?0sddS5 wA[-fE$үVcOX}i#0Um(B'<H;l>0oQ *HD Ƥ$B=R Hզ2Pl/26@%+r,0݉{-S 3[Go&'2IlGt|KαT b>bs(zوZxbh`WjE+lFGKnzh̟H/qULRfb[{T Bk2O氓'ȋPq$}EjrO~/Αmڷ'JLȼϓ2CހƟJՌUn4c}BK~c Ghm:a<٩u'B ?jЗn~9gnQQNomxʕphpW e[#\\'_h0_bfW]JNNW4< ͷ҅sq/c~R.M?ťԐp_Ar}6 詅5!tMyw 3emg{(m%#ss M0&;‰euB*]R]N>NKU97V+ N'$`Q MJx\rk5z}׬tM#ɬPi/F^w]T38r7 X\jzi4qv(|mxՌ#;!.:Yj:HV|̺#[L%82` ߾/~ᑋ^]L,þ[ '6| ,ُ*k펻Ҩm]>e"a"K`:X^.Q R3Dd3˅:z]ʲ CszQA+FQW2;{T}oF '@m),A~ԁ=Ǜ^Ij+vMvo~˸Oec3%{l&[ycrj=Aӛ%Ug(My<40Hz֍fT -ZŌQ4+0'𑞆П  YzgPPR&t[_Mꂘ\^r-2g.J 䭵*%H~-"S 19;{7O9 嚚TGEI> 8 vS呉U2%U71^"ÜEaFNqu`ȇF[rucBA=)6Ϻi'*e2ou0E]YOO|C@I\#[Iz) lA>PJn>(YhhG]B&gwgGvdRF~Ԉ—~7~aQaeܢ݇:>/}ov7O~ g|__qZ*Ɗŭ[^ϟ/z4 ?+>E7ď̦H剫5P}Ÿ{=.܏_xfhJF@< Hn ]uoVL7{iߢ(8EEo s]浱'&:[ֿ+ ձ@&Up +. i6zxΨ!8ȑ.Tdhp&Y4tC4NR8 K8WfldX  E65| ܷ3W.P{M9kf{Wr4[7-xNOcrY軷}W1ϻ- /9~/.~KU_H߾_xW. J ;rcg]~ۯݻ~$ahTaة Sݟk9Q܅KjC,|ꃅRn]w'gvM@*Wg9=qMά(VӰm]3b4;sJL% ps¬f2Y6Zy+`F. Zpd48Rύ:ğ@u%c35x+5Vj18bQRR㗿uLz~si]j{Lg(ڹl'e=* ]Vap<7"^t,u{_}MKh?v3z'ZM#Uc97_zJ~s377KcgbۍVG&|'GĚvD4~)McHW#p4(kv|RZGQH#+XJiF+!H@*TRqA YUDH6B#25FR=Uj*T)8c  iSbZMVm|kr%QTivv}Ι;k_uw68!9eM|]߼+WbE $k:{^ƣC֎%B}Ǜq7n^4c'F2M;aڼk7-^Wkq~?v˿%Q07x`~#hWqqlEIk1|HvA#ȱG}vF`sk"s<>aM 0Qb*LՉvC&sߢ__Kj=1  Fc)WOVu^{ߒ)2Y2<%$#;L&ľN e7l_5d<㾤4-7S͜(m?`n/bUž}vF :gNE3 \%a9ԉ_]Y^RķS54EHRM uQs\A>QPR>i]an`DBҾO2AbE5&+9X`~ nw樭qv(G`s,6dD/A*I X|k +;o}[SyTg/GUh`An\޴ןwN R=ES{i QFB_LR]P3efe*CcW3{+J$CnXuu~?P9; ϼ~]vx9Hj+pWkNebYtU~odRK*Eކ_3s|fV_%تV+oZAī$vo6i<>FβH E3v12h28@y޵3Ngc1%JB6}vh;#pOgmDS"_R[K0gwJ~>*]ad 2uWMV̚fwwzfcNOw6*UR?jG|/2'z=L/@frz_LgD E+I=06+L^myR(.l[R {Wp2Lh$a(ǎҀq7K䕭9~s9Q76%#YFzݩl qwvRt'iu_;pgy IF~Z;ZO2LTRPOR%|֍1VEC<FۡӮ.W曗{uHsJF0IqN {jdS [֑7)RՉzȒ;(nLZTBisA>@<_oI~+_g-Z*=K7^F $G".ԠCBSc;%wf|agZVu EJc뒟S_,I̕^b&\y_a,8>V[+r80.eҝqf崌Dؕf+~F6e}%Ԡ£&xcpzBXO!Ax^,tf>{ɿFRClU~߄LnoGũO:Z{lG?.+[UQx4`5 q &g אfrWF)C#︝XۘhC8ᲣP|-Eӈf KC Y<<7ewBS7*I;[SGer>U5KO-/ZR͂wh-Muk+H[VQO(u]6#mWXNW%RMmK7ڽ`ZȘjT/ƽ4VԌ >OZ,LвbkA= }m[m8 >']ύeX/d8Ww^:ᄗSrbNxf8qށyƭ|>Z`ԩgǪ̇̄;շ=#KI}9s.!7ta_| ,$A$0)i׽-Wk"x]Ĺ"|RuNH 1о3*X{7 {uoai"Uuͦw}hfN~M%8δDӚkT Kj0mu vq<ۍ| =gӭ%YdnRy.d;.o'BnifUjLb_/'!.:^'jT@ UVg$ Ubjg6g(6q7fc;>u$El\kuZk2xr|^9O6;I3"Uaq8BEF:&UI1*(0hwA/YFŐJikXr;5֊K4#CC1lZA7*U$Hf|ShvA|ɕKf35TU]Z ?HEJ:kNwd7JՍQ/!Q܂ 5p)1V%pTN_alP%86^gP˧cݥڔa*uJJRZ^^NnBs+,C7#[c[FjGCĵQm%Ǜ.^k*yg,,=cȬ:n9MI\mzMu ֡y-HNCQ mg䫿%V1lՈ 5<6B╱$,,%axٻ͔}dW>W[ᏖW=~; :Q"f':5XLƴ丬~8P c\ & "M5@*|yQ*l;]I&y,g FKMddšG56VfB < &V[*TC7jIth6Z\ Sf2 HZzsY h\M i`P%:*,U`1ng2@Dc6.8N؛놝SA/M!)ƪ"AMrZar~e YEY4mu۽j%iSC'aQҖÉ^>f0Vo$( 8_⻆>pk88Al",f(ݠ­J̔\wTC1sԠUocGmbe1:TɈͰ5/to*w/b85qCwIvBѪזMKGB"v{~6c@s@b 2ޜΟN0x9tuG^? D|,"`("I/6w~Ҟ\8ok>HT~?V~mͻ jF=2HKzB%*x*O2_?GSr[66p$x:@TA"K!hhNb/?_Chn5'NB\ܩM'!+# >Z-;dR=&Tm׎{D]x ;w _uY ںZGGzxɨN4}PUM?ƘQfu]yos2wUfNW;܎A|u*0"5@45%[,L,wq(xmkj $\`uwяD #JAǃ %хRR}D 4g•{c|CcrB87#1"Z 1hHC_>G#p/gv9̾K`ZYU]z>B*>?GRB67F'e5ݭ[IM.@y/9K Б /c''6ٽX'g<7T8Qdu]dif葀H^h7}{c9Eoߞg|0M @D E94ܞl)6Pi2!sv-LG= RRH}7|r\uWQu.CcL|3Oo^/f5h_Bh D}C;J9-@Ey&g^js]o9FQͮ䊿IǽkfH`ߵf63VZ¹,*={>;n}bGju+L3UEC p2 u|<3>̗JMeUUuc5/ !k'Qs<]ů{#;7_ʢ ({U<_VSLG sHw-9h*Ap"$^'[gAjDJ+Ju{%/2* !^?3ӻ[Qqhznݭ[µ8CW/ NLRt iv>8LNpWa&&*[rvqc%<<tϚCk$D6{"먲'(ym-#Bl@(c /4$+F`s|j_? [QE##H. YB0h)JϜ;Ir&څaA"wyo{Y~[*z F(4HR8m_,W8Q(Hѽ+ _@B&&&hjá1yT*BqR7AU,C搌> Ih JQNLܫu25'I34,Z2 B /%QT@gP0lxܭ|֫ȹ$9*DmdF02VAEmv ŜOV<k%9͞ڣ^.zocvkdna+0-c(Y.*@֠^d A2Cu?ZXw=irfvJU%MC(&DlTh"A\tS%U<}$"\؞~H{ 4QB/yru L"&Þk> M4 Ԇr4&C8`+1홌A =pP |痚lpRbKسX)NZ]B F(mO AǃPm!@d|n]_\|)*Ov-MF @\zVh=/A@tǶ*j]P3^2"B:<̈z?['BwdziM+ىlyjjRZ{ xlv` ,~aPWةR|9tK R X:77;WDF9`]$K`[,CPIRXLQ6S@}lG#p<^@ 3vyCuw>zocX,fBpMmhԚV"QދW|݆=V[םӥ Vgf6=2WΎs(i"c"ohG1u$<嫈g 8zǾ([a|h> ki L}xXeKI`3'+3X.o^6+&ue0Fط 9Sɬo4H |CX լ8T,o'fRP\3EYDCUTwfY@֋2@= jO60d鎴hH3rA4iusT?_:=.T*aנ="Y!? Ѱa<`\`.jnz~ޅ3KGYvj07mC˫G ,-JXIP/ztlA5vwiqeYO߬@z\B0^4t}chHJ`#e-Gۿ?E!1Q!D=g 1Mw>>\(-8f2dјm//E_ʶ\[n={vMN\z9PJ` UBm,sSƑ7+qQa0ܢ'ۋRW=|F70 -;{ɭ0F`…ʘieffg `qXV)Jlkk+?^oY,Q OYcŹBjpQH@v)kCfGխwhy+;u,YDh;P[_~Ǭl]UqdZ R]O<-9tRMW`:]C$@Z~QW:NIU MJfOJkXZK{ XF1VyH*#I:`\_anNV\%ziɏ3j6Ó\-e.CML⋸[~C >FƇ9&kkCCIX҆85,f +ݷ픝m}D#U]rn4nV$[pilO6pOۈ~]%diW@ ܗTBVՙѦ5>([r&H6#gǝ4XDB_W $l]ē^ME9ŕ#2Ci%57!4A"7uz|?t{:nqj0b!essv.iTh!'0ahZi͕ji(Jo-BV'hRH Muo ZE*z61~2ⳕB.Bih?E.'"2 IbJD~S[+NWXX? iv[}٪֝.@JȦAV_KN {)A4l:D!ة\TC7jOx =P$`k7q:TV쀭.q ~ye-816m'܎%5%d78?hsqIK}irʷ~mt\ϱY͖Jǰ4Tk}3e$V;0Z q%D̎wCss]xؿU8CM87u{.7XOL5m61{mo:mk "- aێ,AKKP2 7Ys84%_]v皷l  )%߸OJ]=!F㸘|{>@>6빨9%Wq{nTҳH7KQ6P^='fW\Yp{ǡ&Ǯzld#5Ʊ+ 4X:rIN.+`5FQvͯ\u?Bg-hVpOezMZǜǝp&31\X6V>NyO~X]W5e@/j+˹l75)" \냑>&5ԶA*#PjPmoݶ/ X FuXA7Ibr7b&@?9S{獴3A.^RRt5}@Ϙ3q<@:5#)~ }·q(脉X_kn7odh0G 7⥂yl걗pQ'}?TjOSCg ЎuNC]-kFMkx 9VԤc6 ay1g*Ҙ8X'6Hqotپ,1leJHhћMkXblGنkjZ.tF1V\gT*0?SP߹s,oAU$!FzFLBIU ?c7T!I>>"wѦ#/))7^#܋nj6S m'3gBQU)Ca`t$KCUӚH-L hWoi_vq.sWoކ1oׂ4mfh}fB6ƋVރ}pМ6:}8>|&{ܝA&\OL!lUJsVj樺}I'/PƎ73Te XxͶ噶\FW,9) M(u#ToS*ϼobEO},*ym4j:=7ң}rѹnc5pkUdlcB}!y}jR 5bu%ii/F9H%C`2`ZLOTp)TmKLʑ hGPP v*`3F1BiT cN@1"D9ag D:!XGjXFncLR [N?{U3(p$! hb2U{|VðXl^wT(%p/o~u,ś_Zk>,3pZm<׷"Z/qAUsNӺDL#G&̑>_Xd_ ryB_hY]ia3"反4$T:D;U/A_ ?scQNf@hd|!"8hߗ@G8Ws(o$2Hlkh&O[ʷcN2ǰ]?"ler͐^4u)kb4;G~FB/\lftvR]w]q@2-@!s=lsC2%lpeVo?tˇ>o=P GDEao]hAFfGυu 55 KYRxDGj(N.u6$%U^C0'Rp#VV[J3ٸoډq*npj 4)=^⩉hG8R,?7js/v.牬N)6N6gf|,  FTs&xB2Hᜒn0`Qbh,Dd=B]0yNNdwO72=iz /Yw:$!j;MWmoR#  G 36%rH#{ި-_Wv#.Ypa %J&*"KPXvh7+%w]K!}zPKi CW)\bOpE+UFİkRT$0rp˙&ZWa˕w󝯹zkS)3k e[YVxgvso?=V\膔ueBz0|Tqf<s?2a.B'x!Elbv+~U'Vnsgd2:F^W5";rY}52A3V" 2* Dr&LC KyjFS(H|ELRdl%ïyݻӭ?zY3>R*btΪi֔Yo^ n'zWg_Ox+=#L=}G&aZ.,Uiq?(r0B]1t$PPA=`(Ɖ%^(o= ru\ \0@ ðXOrIEA6 (K^q;y`c-(2`W:AAqH.S rBZJ.\,)A?gȄB= ƚAKE)٭`$}٥ҰkH=UQ:88?Ij{xeh7wc*2=UW=W$lyUW|Yr3!Dьب8 2u%ī *bQ׳-Oq%37{[L~vMׇ*vaT@/02(掅λ)W!L6 oSm8lw\F"ZCun}MCy֬$|1a֚/~/ȷbLĸZCޗQխ_lbA-Q]uLE}+yﺎ-}Wtk[:e}P>m,q}X+0KШ[]A ᨪAiϭs KQOz7D>+#H,WJu1]mLJ Ph#Xj:f{/!yeSu~EN[h/{G B(o=?= p3n||0w`F)M)W4YI?J6;m%%Ly+μ"Y@ RCQlWZ# ~Nd1!!S~3w假бU .1 va.yǟuxgx,up5o /ue$$#-/o5obroѨf*BImú(Gn=0ԡS ~2l2ktѶf3v<8_6Fc TbF@yD}Qlټvs0U2zW 3Q:#bDžrO;lPza&~>`Yo+Bp ?u($b6D:0ş?&%/*AM3Dl1d\m EBIhR :=S/>nVbnݴwx[h)" 19Yt܅%DYo]&'!|VVw7<ɝ1Wk$+*klaA.I=;H}_ExȔ0\)0t,8+> aUզjˡO=JBبw~BwR[կ N 1jIh* E6``j+\z J>Ec~ߓ8r"ZA&a l}>0~AG:⸙45 K^XnA.#^='<*xZ%BkـDcu&EޝN YTNȰhbj+/}uU.tYD75\獛v,3AëChuw>||6'=5cAƄ2 n/NG&ŢT*6Ϡ}1pܔUP)2ܣ%3\p_޳O,Cym=b:IJyz.5ȋ@SuX H3MqyN VV5|p`aa/_&0~ W"B eARU B,HMRU2>$CFG2]w-ѮQsy-d!Z2?0b ^-/k6'$QwmFV tC,ik?ꐁ*ڨ7i;F8ؕ @^ H@Ӄlg90~m+cB{הpӺdM%l"Tp߼j8@ ]OSX7g V %k.\j5 2لEf³ ?GfyK$Ep<,ElȺ#h#0'%=W,zZ; |o UJ.Bof ) 51/9Q!R7殥( U +ceH/i8PBH_~,.gSLȗT Q _dyD{ŽB7q֊WҼ~B~m<⇎9ÃCrXW urygPk dE֠q1;$sJ:jBEh6[ϻh ,-Jfq!D0Hb˥Ѵ| PS 9= iݶm>`[F|q,ذoaƒHd'TD0$u4Vj=1`LHֶM @V&P+?e?pa#sᨬ{(Ղ &s{xT=B1/#$PS\'J!0Ⱦ { 3%_Sx(mPK< >L.db}T% g`M/Gy50ͤ]th|`vޓ686Tv oZ·IU;R.)h ?!=jh:YGGdpD#XOhoPCD,T0(fUWVAVڇv`$RǃWy{!(lvJҁQ9:I.i+#!)ʱ`a*:A )l=tfhk:6a cD $BXo7w}˵rgB3yܵ.tNVL m8 .k.{`ܚ+uM&7D iM9P̠jAx.V fiˎ}\ovپ}c(F|JIϏTinB1M~ŧlQߍA^U\>7v&{dMoG N=XFCM߯ߪOoVGjMƈxQUt2EH݄`Ku< #`:+1-GȄ9 D̋J˜N"bs0ZXe nWNR]ۘP<ƙӟv?w{*2}sq7^ 7L^" _,RQ 9rۮӡv b3$܉6բ4](v\[`(5wDM`.*"{ǐ )07MM6;w\(NwMMI+Ы&qF4T7<h-2ueĊ:t v7t$9kK޼Y57ե%o2X yꕕئK͕l*83PF7 X)L:y=OKҽ߻W#+Bʴ$s8C0XNq7DdL)hr~4\'z8^JF.U&qD>_B+ŝBJg >eXd+%1,1pjyp q~U㏃) >OqdqVB~H:K۶oW-% m$Ss2 yq[ Q-t2V|ryl9/cQOoJa E}7fu- pFzC;aC{$ivY7\(o~&by9 NJө|lO7NȍS уew)u sk B/*Osp= s!ŇvʶneVUWcGrkH S۶ gY? \'l` ,VrZu.8䑏߽/̀Tc BaG@#FAv]xWŢcu|/2[ZZ87 p ce4)t$Vmˋӟ:lVniڐCH0bБu2䐏P!# )dJɾU%8<v^/_VSD2 ]*PoY-ԃnw2(mt >['-N -rܲ#*TAZԻQQw&5߷#G&̡l 2Ihc\C6(6h4uHZHnv4юkܳeoDWxһdhROee`OieU]<~wC/Cnt߲uiN3?Q( gNc6)bAEp6iԗl6̯І _~QM\C ,`GO(ɒ$eu›πTQ-%A :45Į\Xܞn ,֛'<2F2^ofk9m0լOUXe A/WB~:'f  V{Hs S-M-!m! `M`ߜgei#2`!]=OˎLM;kxE&Wc"fQve@Yh\,LD5O*ڼ=J(PsBwzdW.is;@9 3Nq%#aQdmmÿ- Ѱ0:ܝz{LREի jLapD.Eܠ'vUPN*3u!e4ӥV>OpBP@e t''GHCt(x0P4ϐUR3ȰЈvML[$Zڋ3ν/~[ŝCK#n%˻ø]CQbPЌ0!YC2F'/`0 PLQ/?ko?];N:/_!ie˽VF;|E@W cCkc&"5lyRMcUpfpPh+E3cN"8Q25o<tga#hU97\ǂPgci)xI\Hj{&3Dա$nFr֝.%_`Z4: ?|V3zʪ"I{fXr@+W76xѩG-/YOUD SMeDrpZy[Ln80>=E'g;=RC*.![ȱr.њjlKJKuy|ݗ]P?V^ ؾA/A|wnW7d-\zJӠu/=N[G7}/ˏW|g>*TS!7np@r!Ɖd%䊒+ȿ)~o* \*ڏAwL9 Rr}#okV}qq>|nc#HEm20!J 4} {g)н~mgq~\n,4-|ipGvx 8t GaBU,.|=K# oo0>&*1xYHTpI'q 1÷dt'_.5RV2aR@[nP7ojz }ijTyöSl_杇k+<;%A9@%|Mp;JΆE"c˺c&UXYW}NE/ջ=o?:o9.9{GS t$$lC4 Ca4UОCO5$w6<y&ێL9JL)6;;+ڶ{~Q/ nA>o빼-F"`LM,g0)/~AFF ]DmmjjC1/A KknNB_ <(PCd]ϴr%*LU!ILLJMGDj8@NkvGF\%[ &X ݎ4ZTP!~\Zٔ5˗헞/6E$>PlvAS!0ZvIal&?YfKڏoկ9_z̍d,;1?ϳmƓP=t+A1_f'M]v(U./NBZnCܼo} 5}1 Ay.T{]̩Y DQGB驹F^Eسg(r!@~mdEmvh*:Fbǒjq\m@.-uעZʛot]/y]/%J) =”{pII:uhk"eeVUpk}g{YL1O`X`~OtdʂӑBx.VMY0UTHD77w ߵ}Ͽ7(06+A՜DBRs1z>w DdK[#R7;1Du-Jn[Б7 6Ku@.S+fn3VG`Kp=(J4A%rz#t:>Ffkmpj] 9?859Õx<L=)_Vyǐ4T@I];a~c(CNA`je +ba_fP]=y\4BHݱCV$*;+8j b0MqR0Z.r6.NzE @x =#9gۊ-' H yU8vL(8n;lg?so8qg [d\>0Ї)NC\4ւ(+tKB\)y#oWᰠ7}tֵBmB%Wz(}b ΃G 9bgo~%?.b[?f.p#oI39L} X(Im_[?B @.9 ^b+:X#/Ghamf/5Qa]bNnA:1M65%_`8ZEY=dguc@{)%ki]!GRٙ}mE6 R]N&$CWq\"z|")CȩP)-7@\ds~ hToܛ=昆@pEقpj&x}`mfMcY#{`7MeTKc&k>;0VGH!a#"6sި u9 TfDG 73Rb[aI\CB#O2 x'}_FT^=m ܆sU/uX^ U7kY?uxD7W!~I_QͯF$W8?&iU&@BPGzDL%XDXi^ׇ-Qy5P=>Sueq"R4{o]}ً+|4/-f PX^-9zaSdv_ ,i~!8m./Oվc{$󈄹␸|F K+?wu'J_`w?&t x: t W k6EZ6 Ǿ _clŖT:ufnr q:ps9)2b$"ȀCIpk҂Lj$wF/va2!=S,ۍJx d^ĉ6`'6hsB>T&ʛJr!Bɟ)Y ҳ{~,vG_,Ai}yvq\0Pٵ-Wu>Frq"b RW :U#qC_s9\zDœXkZ]< reYFW~w/IZ$ Jbeխ6Q37{qB8[s'\x-!%'?8 $zLySLDI3  γf h) w46DB o|!`^o};܇*\mm)xi$W (AG;":v0KNWRP<7 }oqI粰Xj0U^HaV-m=p& >|E^FJV[r @iRꑿ1_X'q* RE, (;n_Y^/{e6ɝ5G[A6gFmi0p2QA>?i?Maa6H1W- @ڀtTQP? 1A .t>9i@{')&//,56o>v) ˆ( ĠM"(ǃ\3]Jf}<^p-]>:8?p_/uEu=SK>6QN@5NfSIdlI_b ņ 8"$Y]䣶<ԅ, FbJ ZlB,t!W{}?vzN*3— yWnS83iu[[cطO{K@\g3a.wZ 4yϕHEU[7V,[n0Va5Tz/qw2 Gh)OX?io?e;gylѬ)VeXY-91`E#0hyK(r$xKa~-;A <Ҭ6e|QXU{Z^+.oB^-zQ%J ;Vsmn bij+˻ SIYq(5ThIv)!O~SA4Y⇈,=7X?J{˦ EA0G oURfˠO%ՁM,j+M}/c4u/_e$PyZ "3RCW Fm`A`S-VB1; auڂWЂ&ri:F!rߨb@59m\r%7nfFﺯrȨq13P1AT0oqUK^o5`!Rt#Lo!oi(\t+ xs`>ŏ_:NCƘė%1Rn3uzmc+T? Lp>g SA} sOk ^VIm\.#ʋ. swO r. -l ##F"+s8pÈP Gσ᥎zkji~㨣J%em %K4͑BZ:60?ᘅŽ!jK('6dF_8)Bod0p {08n]RKX_ +9::?C۞,Ƈj @- *Q@Ej2nBO|J)8v=a]FcWkS3vͷ=*ׁ=2P1e/n~iGWAN[q>`!9@dIv킔8qՃ?GJ3ٹbJsiA$#h`Obxh ԓ)ͫP(ɣ>Z ÓxCj %R;`˅ظQ&vu?ɟse Ɇ*2o# sfp,]y-_(Kh?U-Ez8VzpW,۞<6Юf+%J(Eec{۶mu9hWPy_3xT7X!$ttTJ<6 DB +!wq|&~@hg`t=.R2qar&9?ߧyS`]͎iT rHjjtѝ_6] i!$Py!a}x.֌ }*0-lY,vuU^%Qv_vu[oeE>a$J̒M8"4h"1¢|,Rصg㎟7o*_ D(1LWpp˛;"6^kݻwnn5W[A棏>Wg7Jt۫"jCd{B_5"CIlL4cDEPU{=|햡2g CD pXq1|VvMB%2N81sIlJ*Ɯf{b|i c٥\ 1V- 25iHf)[o(ꤦ|_u;s22 lO7 h+ky7<" BO:+fJ-F/8g= A{a/4,[(L]3GBw*%jujuaLE[~+UvJ3!p܆a]{~:tӟID^#ޟM-uF®_w?>_s*Mm~yx\гm*m imcsB рyb|Xfnbb^گMs`𤓷{ ;O15z YsOIx4fffVU䑆Nt#H|^ݝ:ON_:T)zF:0nΏo.Wy:?8r, ŚO#AGtno 26ZPA2R]:OOaR!jЋ9kcia(Y #cͪ7|#\fNj1^5!wЬ2eZߪZފlx^:ONN?i;vSyzsbݵ՜SNqcɀ aD۷0vHňs*^P1:~w,7݁}_3n6?,!)zDՐ&߂Vן;MM-hF[ ]k&TSf 2neh FUa>(3@@wG[o$#! ݩg~ Jk \? &*RvsKsO=yV'CfAqҋTjvo&t{|?'f-:K.5GԼB$- :/ƉDt.t=ц/:,-!a A,ѤAqI~ [UM Ξ-/ljD mBlN"9-" ;('FћU3@M[ZZ~ؽ$I3՗FtqKkdm_0mz *?/?olJb;R6fiw"ԎƗv:Xs]신s Ã7 Cmq謍gJT7=Fy'u&;?8խ[':eYylH-ky4lZ\\Ě6-Uҿ?ԧ qv0^.j`{^5o;MNlQݔaD1YXa*P 5d8he#vRÄr#h7(CK U8|Lٙ-w5K::or@iN߀A{!Ay+kj -}[}W~@0  ` G!<@w4"E߽A azfq`nV<s>R{7\jXԜTn~\Qa_ 53 :H≵N9iLy(:ȚceI]k#@ |+fsC"vŕmz#&Ch6S:A V\X 509zuv^6g,.|ʉnP(>NĭC(x]蕿kWkriayDAxOa-q!WD158~ I8$)W'?1@զkV;B2?ßRK%6Z=!J\K W5qΥAĥ_%{Tҧ`Y(⇥t@҅E1@Ds3;jﾣdp MB}n IPkJ."2m'2,^Ι_+kqlpnbHyN˔Z3u$J6/$P0~1z KNfTe\MD`0ׇGL'DT߷'*6<$"t>)]QXBgb\6hXm`HsXf %[^7'60gZ)֚Dx񎈢5FGX%Y*NdqFmֽgO2y( Y= 5aDo|9+ovҏ<{ZkSk[hokɇ>?  83yR"K?'orF4Rб6 ׎pK-qF}\+g1>5::0CXxN'n 75"ݻnyӛNcϢZA4(9lF AkP}rBLx.A/:ϙ{` 3n7_jdv2jgR{ev>ölbEBL ֑:OѨ5kNd;Pf Ys861U 2drkiD"y|C*[d=wOdy l (q>Hvz踘V2],02|* drүn:fG~W#6?9trf:![Sv.@8h̪h`+jkOJ.NC+L1O"]@X?'KծF5Cù;{=Mѧ )[k0zs,D#}xHbv_?c :j8ABͫhZ~kJ1SI꺩m\$r@lWkt a; o?q59;d+9G?3/:yöKLZ/2=d480fMQAjhg $sF4.&0x>~ݯf}sU#e恶k>$$0`ݩPց%1FU &V4hq7J])oBDK/^% l(D_ru)ГJ AxK˨nE %TItЦP*f[Zeq 6-tzΒtſAeE㝿G!ݞmnmȄf8r"m'6HM?\$?M;ffэ`M)X r%xp=FCH利~.$SM?4A駒7ɩ(Ro¢O\|7NbsGb/7(Rl)DD8A;-[x\ *I$TV&d7]e(7$Mۄ]y^X X'lRp.jJM4\RrCm %Pve//~Lf)-lb S䍃 Lxj{& ~B{ LKͷ9PԈUW3H,UqsQYdH C6,$̌^ ^Hcjc.7W٥]qS藂 G9J.% u۹sY5җn7Q2R'?M@I]H8G{K a%kvT8GdQ!CA5Y(ߋr KtIN9>oYgQ{~w * _Њ=qShu"1|lndͭ0W]ê@l7^C}+ >V,,C@VkwjTij\(o 8"%!DZ1(Jo& ZO'8x}3Q݂ pJԒAK.r>w] ξ]J@'S~]=%>۝jGd0HTˀ!nuQuN׈H4| {pvv[ב+7e[ 14DJ/D! v=|x֕+Ca7KmZ.X`moi.lu}(tBJ> ($]deZ +e8  )=rjwts!pX|t￯2V՞w+L궃59<2o!Յ4C炈1}b0M4T BU.>oL4/|Dɑec @;2Mǽ-z~Ҍ,ƵBюγ s:OdBfMg X֫vRkaXHW[7-T@h.&/ >Pf^`n-gL1A2;= }!H{+cifjzX\?ǥh5#_ [2t_߲q>T#A݇iv 1OF^bs0G>{%lR{و6԰˝v6}=m[)H o=#Zܚ'XR9Jq‚ Fm谪bP0G}Y$e`ʡ8 +?C= sB*jjłzu jm'Ŝ.BW?m mT\/4(~/$QQK#|CsX uC?G+9 @'$@\it57!;<(vȫ0%ކB AYŅZ#C#;OVD<d)A7tzPzvgg(N(P(-k!w'@u}PJ(tܹr|Y- JƲ l{ O릺:KXʷФHZɍUU1rC.'ـO 5[1^"PTT jհP$H2C1k@@!&GbW%Tks}mUAFR wM'o(n3vpz\V_yC%8~?cJRX#q K#QDFbE'؝IK-TNHT(yMp u0<n :z`H̕ww1 CN  ?@zf2`~u{DNW$lX+RLlwL=aSKbcH)us{lN#ZEA6/jS6Z+en IļTV b!q= ad ^O@G"wpt+sуҮU;.P)сoA~@*3|E U)߲>.헌ʫ0 J` "]ڂ&*g`,ڲ6Gn_+o, c=3M =5ug.$Z0AM8#P|I\4WFI[9?bBv7i6P] :B1BlHG(nʎɕ1G+pA>l&݂D&|QŕCbVPHeT9Q3Xe2Ȱ-_Қێ 3~ǀdB1*u/H`1Sbb3ʓ<%Ƞ)TQÄL8.#mnM۵Z?zҐ"q͌ "[HY4qxOFEXhK**tnBŒJ tB!p"~ޡ麰AZ֩x *~Pժ*1GŦ %M`uf-2[Ho_'ueYyGXKT*mP&&1^un7Bd:ӯ?vbٴYƜݜPe(_Iq;AQ Q}m*䕯y)XX.W:w!"ˁ2ǃJIv]\Lvt&}j46;!ՉrlX䨅 Fƴ9ZDC~D_D{犎lo}8L+>/!* zUDĶ%űNMoZt}3PciXl,cp (l/$8`pe_;* a W}SErbWb4||~v9/۶!1Ws+dm,Z:{+W'T!7<`1c⢦4II'"Ɗ3 զ[d i2MJ~`EWjD}b|?#R[ۻTBbw?z1׏rpvB5^-d$Aji6{YsL!%7'u!u*ԿmPyb9iN0zE4*jzSAp9nnc, ̼$ 9L,TFC|9#0_-DN"MLT})eI;eӵQ?t :9za. [U YԾo(cQ&٭J\*EwPԞ 챾HuC"QBtX_`Pruq<բ'yn*|OD9$^POwp.QHrrej Q#iOOUKr\R{~_R242%Ls$=dU=WcTt67Cs?^yϹbM?6$<^xA$8`C "Tsalb.H9^Ҡf-`b3k[dyȂ8d(y LiuaJ%hZV.M5-txZhs謷Y)ǤK鐐1bnm#jq^xP|5Ñ@{OZ*x}wX:$=)jx:XH5j,>\k̜B1# s#9rfo~Hv;++ie\5_V ?{Py|ѰiYLusgzõuDPVTCr1G_QEx౏RESOg-u J${o}"!JTA.SQz%FLK pGe/,;Z ZjCbn?8.^Y+x|Ȓo|IPrB q_|ac-)0P 3\rNCE)~uk]h% ^y o64%?Zq\$s-KG/_4y`jB, b<@DXYt}E|Z6R~t' HeTIW,/FA,E aai|H aCՌ>DE |PS Jq2L182Ra;Vf-|$%7O8{3)AhusmίOBЯMAR+QvW>iKtE7PSDq8W:v9 V +hsT-(nΥHu )N{Dw߹QU`¶@t$.4ԑXy8D Zbzuʘ2t6Gҁa͞5g/n)o>PSq4a*8ē(YQ,Kc⯬ LB a;'A0l%Hvp ߇]/؅N[OSw^aMnwtIY *ɯ#YC@s4 0Har"EKtJ`Dh+9ph:y :s`M'#چx뫯 YDP{*v9;w Mv0_ ?:o~Z"0+ky !B1SЄ·':+mVLf53TCQa|..|EWq1W^L̕ s瑘cJ.b@\6,vMo Rݦ`I/G y^}LMmT@z,_3oY2lSbIM7}82]p@]S# hPJ1^&/ùw!t]7d*s؁>Z7U4T<.J>rtiDZWO}db wo h.p*3P^|Mw&wJXG#ɖu!SiDMJ- o|(έ  9@Mf吹—-K/(q%g:\mǸLR)F;E!`A_t9%o=6pT?HUw~7PیsZ`mk} ?!1vJX )6I#)@+66TKn]VAk T /;5X4? i]z)xEE@ r)-X:!D GG\/s, 7۟۫΢E M#tT[$[XjHФ*7*J ~eQ*nacp^(umFу'ĉ]O{CDSv=Ka4nXXi7w-kbDKtS̅@%7&rcF"U** ~BԾbiCɃ 0GɄq[!PsOo봌$ǟǾbTGR<JfV&CQyW%(Yŧd75>.̡( YAH`\͜H>2K /[k4ldHfGnOM0]tYqeNahJ^`Jr^LijŢqT*6ڎ;a}7u-h.ݰjkjYED\f?w GWu=Ue `rJN(3Yßo]S.7w Ђ jt(AG9v?kI>/<(--ތ7+,eu"fQ2NMTY:xƠBrVеpyɻ y|QҠb4H:zRr?xw; F Q+ ^0ebL8cGMMN~.%M.*\Ug,C*BvZ,5 ,,n-O2BV4uRQgl\:Cb}?NTiK%a)M[jjz}mib[}<O~Pa ²eR!Jyᾞn!\k }щgY]iSGu%ڃ^ԥGdPF=[@I eH!r;:ɴеqk?0J.:b6l xO9vq8[B0n?t}UrE K2C`q@mjz&vyQ'ݝ[^nqEe@ cƵp0$dzcp95!AmTTHz7NZ<-ꚺ:5sI!cP]3죗gHrK7|xc{N#^U,FRJjD_0(S U^x+ŀK!%[nmsDcxdg"1nǹ3 ~7tI&xQ1tVduuM?G}w3|H{҅F%cuхSDan3c,YqvTK%y dPUˤsͭl*oksE3=jx}_`Ͻ݁04 Pxy>nF=f]zJ<#RghT?nM!d\hIDIl6)# 1KĞaw_(.0i?l[b.sۓm -rn'K(ªT/̗ @߉y XT%S11v)i4:"q6a2Gl1 2 }E<1KypT5zrg)3qCV%N%q4̀/_{G2ܶ){w~^L:6 @Av-0D#;L9bɷƏ);$b%n- }7:|yB8Bth*}>|=6i[-z {\|O %ZnqQ[ !t76os˜%zD]0Nd2fJ$-"$H)U8^v )ۧպA @c5v@&BkYTGWRį4e` 6mE:bQbյ)BYKt@ٓ :On0$[KXf_`9ZXWe_uC>zG6fvuǪ%dwB~bMywgi3>u&+'3f{ O .{J5pRq!STw8)M_\y NH0Ųt؂TZ d P2GIU5*IF\W:?/t5j[NY4к|N CBmѸ9}y8 DV\}rО=0d]cGSW\t la͐hfبy Z,h/z25/;kc/6Yw׺z֛V8豩BomOK%Ry>a\G;\!z@9$]晴[C~ r3)fPD;~=e :e<J^4 6}Y]ͶFdH[CD'6 "d2{ܸ|H[ѩdu$r.2ԃdIF>&|!.3mPgyϞ{(Zn3f k ln|hozF7;'8 \AuCJHu[HaA+ʳG&{y*jf4Vy`n{2nmX/n|8tãcKf~p?,XCǯ*ǸD1 DM R}!VdIQ$~b-*@dShS1$Dሯ?C'wTVdbZtYmmۀ;Xve[NǔڳLƚeɜS77>E(&ß1\U^VE>X dL\a]Lbѽ*㰻-CxJ{>o. `XZ7rܚOֈ_q3 r@>#tVg64mdYX2?etyRAm^g8PsČW>3ۿѐ .wg%B>( qٲSWg=-b+!ջ܊" j%?{Pe.j:'rdS4rf k({׏^OP]}cLL1ڟWy9CbS ۗr3YE7$N 2 #S[Ab1"pȜG~QPZæ?.1P g[;򩧆4ɥh;y>VYx}mj$9fdF"FfRv@ {s aܘNٷpnO:fNhqNP,DQ8!$ &E=Oz ?UxPaxOZ |F^- 0eCch* T8(ZPB@!M`KvߞxRH梐{w|胄mM-,pM_k08Lbzz.}qTBb'l % Gh, @P1bdFci`喢^ C!D/==8"JwČO("53~MO?Ԗ_8᭠rJT]H+wLmHd w:P*A6W .8-9R+L՛: Omp߽.<_c 1鉀x^.ѝ _ (ǚ= Q+z:geJ4CfF>_/e Ac#+fXyn4Gx'eyp{jQW+;`F+9iPU.3DzU <2W`sȧQڍӫ&P=,ۅx0gxU :n=K4hcW+jQj\7lゃߘћL|>B{K>!Q Iԭ,NفZ\A.KgD] lx&o~ )^ ~eft.HDeMvY|)jF~~ʃt Ex:!dMYCbǕΧUDvc ɖwvs:C@&-;i#)Ԇ[pnr>ϞV<*զPKGw\زzNka x3JB/GRiYkz{f/|,b G? *P0ל9K;EK755]&jDDj&r#ULiPCbn\7ȸ{|HJOU8rBo_Ch 4!M/6+fI+H<Y}3F＿W5:zߑ}1:Wlu#XНEKs~CBNjYJҍ,Bu.Xd)(툗䳈[m}v#IR(v1XX$⿆n=zztCIgIt6+q7WC_`xDo7_dxmɜ3dR&@ 0Č4WDz^})_3RvfPc1~6궛9"t;<Iaa'D &'J.:<\Ûou{Z2!JhsHr& 1yX4h~n{Mrm`2D*Ҕ_ю q`k+-l DWwI]q9W4?t5{}JހS7|$ԟwv7wI#/ *2//DgWj>j6%/ 'N;IXvA6}޺rkr@9GҋVLKɮ)fu5oEÑ|q55AU=$Bj6|nR;I[~sٌ HډUD$GPBXT@F4Vth-ٖj_zK'Q(Yyy-խGeՌϏH STDG:JA++1&w龼j (a)_X4K}a@(NxP?t(ڑTald(E[PuW)al Xw#]4w'-0E;K"dQN% /~ٜ3lE(u@Ьw} ~}}e9Tvj^v[N)1w:tЋ(% ' gGshkZ݁3{^,I&pP5Yz7v;`Z|D d/G%R $ȘË1}׎y hApQ@ L0SBkނ>󛽅Qײ9hޤ.'6ك MRe-w|"xz cTS@䌀$f67Hȥ[6o`kE i"b ϩ\Xrv9- EjJ ju 'I/1FPm%ӕ+|],”v$BF5笽Z^^"YYˢs΄ai[YTDP?rIjȹBhT.Ll%!|~yXĝqOi]P9'=7Mp:f1ywl Kmｗ۳97_hƈd8vU6 QI:O@5D4L )£th~f: g6g4aMCIoTeg0_kGI~D &:%&xm$% Xt$IxClaQn :֟4~,ɉks|tB:FڛׄgoٜK}LRDպC#:^/ b  L0jR}U@y4&x|RW^/_Kh$BX|?b߇/bףޘNpES\.gz!'WZG$T<Ngkor4RoN4nrJ&_iɞ u~uFb5~U(is8 5ć ;gásހ%9GE.J~M6M18tʿ!1fmeI/QN,1vw,:ԾNҖ;lʶ9T?·>㩍,=ZRx'`r2(Pw+RC&[hvTP5C 1;LS'~G)ڞfZsXK؇x{ .#%ݑֆ)׬M YO(O+\_r\Gؗ^bؼ&HNMM)zcv8!y(cyH4^'RouQddBU|l@yMXxy%i3E#gw±qS\<[tCbn- wɡO҃\WYUN?qgjSF=R2^d[Jp`^N+*De^^uOAS(ܨS✨jH+ c"K&?z,;W6z˭:tWL7cmbÒEqt,1+:p-g=AH"C3:vo֦#'7 E큏5!@!u͋.6 R BHV Zj^jJV*C4dW+G_=}Kͦ֝8 @U =0+ks o0ش_tQɄnڳQkrCӬeZqfל%P#jȀbr v+AE$XG,dwZi4 _7M&^`Y#H9h[" 74.NzoJxS͕@~@85sB)B `Op 4;]T^~Wqu A3|P 'ԭPD-`撣Fț,M$U:'jҹeCP%T9SBH6eO5-/)MIc;bmxdZ6]\jYP'%Wvc.+Q0 I=1/ߺ(M8f9˛˦4`nzdWz! 8 !K]b"6  ( z<жvo:b6˓뎏iH`%E@i$"ЃkH+Uo4$aX E=]nQ6mLid # JtCes STC[" 0VYt@mT8 w l=Z@ngMhotԺjؽV;oa"]S^`\*'}1DaJ<WU槓Jnd۩۲}ҙۿ2 ۖk d@j<}=b=H~x[xq2B&/ ˆ/RUSk$jdzeB_ѫjOuf_=A>(1=!uC}4& YTV4CEp~ALfq|;60l@ͭcUjss@dMޱ-WWr)!ʤkla6*n!~*z`h]imae9| +%Ҿ%ld჎xq_3=~ǷH/u Gaj Dnw=}[=~'3Z|Q]Nq ] Npu1U)}"6媾' ~eizjK5GI-XDxm,`*YBPB9 lE\xȃ'Hki=6vEdxTA:Cp#K H-ݣBgq8,`Sȑ#c>˦SY|9h]/ g>ZԜ2H\5-]s6~V聡)SY&tMfO&ϑ6t/F<}cZwqyqz[ZDwCd8I``Gc 6 y>-µ%K+NB< d9N3Et(Isv*;/ ?NJD??wQs\"$ *m峤˰xU'#kEU᠂lͫ]㵘l:H@_ZkOf+a6T[[Չ8u4m]΀kF0n*`eYi6#UNg7kseƬ6ᰴKLUH'CB> Po@=cAd*i'.-Ђ骋=B,xC.@_dJӖ0zI̯&EC7`Bv%]CkDŽ{쩟߹w ۷ڻ=\ G4Q)R%1*jv;4/D<"AOv2 fN-#/N3rߞKXټ6l`sx)Bvǣmn =j^rAr Z$gm8^lΈ &(9=4Ȃ1& t-VK:uE[YHƠ1~v!8KfjZ1H9gT"EA +a)ۨgMgC;6pa(́g:R ktCwb@Z .*(+'#*@,j=B^8UI`VV,[<=3 HS&\9yH9X0 T#?yl( )-YTs:>|MfOYUn-hE3YFr𾐽HH-2F(ɰS$l>zQQE;6g7?YpxPJ:qՆʶ~@.UU1A)U OH6k/o')s*J(K<ʡ"`"y`K wqCAP\VzB@%)he?8#:L㙵 /vI .VSxY(ĄFR$#S щ!-ҍ.@فa^9x9wkTdk ؇efRDEsP4)f!­:qQ 撵upy09)9q@xlT"]덷SY)\r@̡:h65+Tu身!1 WȀC"y*35٨=zq@aLQiuj>*JK mvKۻ|PM1Ds.`bȦ8Mq92..K_:ƴ;FRWMH7ZGka~K חJ U9 RC}g&;}7kSq؈P|ef95`]VO4a\֦?>bP]N#m6wq3\+Fa# 6-= ̛Bm%#qi&wxvD件L{NNqE"5z]1)d5 APg&]IaL1Rx 5|?ugz>T)#'ϧt&#1ʀUq5pZ^ς]6g'-xᵇLWqwz/g* ?)t 7Hq, K2rȢ&V/'Q ;Ji2j[?ѫ`{Y%4ݟ'df>Ii+Y&?qO\ӟԺskWq.*nra P$ϙ:ڃuriTi y3 J6B>?ߜpbwo L#=|sÛVbeU˸T@ΪhiLF[ I" $ !8=tPx˪}~+[@ Pv.$gYĚ=eG',v_q>a)Ā&QS$h-&*Ze7dUԞJr\PNsDk(' WP q чLS]._eW\b0`AfFӫgFc80td˒t$E$ڞ&УVE.7HGA,8:M^s%w(J +}H/10+mh3@A iwZTBUUھ&:S]Vʕ#B5UV卟xLњ;N]L֫&iTT2BJgY6(e!n|1f9ݣ[-.ؑkp60,}`m6ধ|3"X]Mb3GQq0QɅ7\.G`0fKL{{`Hs!_P. ;Ttv r k/zOw|ޜWn}lve$ Kf* 4$`N]~tHH@8^qD Nɮ@ %N8oK/վ }6*Eӫnr6 6YX[ǹN Q-/. ,Me{eZnm^WٺP ynW(AH{ WF+KSA/*KzF)gea-9|&d5n @kN+4jD2<T|1QXMo6yD" d+P-2ǛR:ÞL@A{!odbzTO?-؝&L- _|("K[mW/;\&$:0{^3ˈT *ab9Tfjb뷞LW2PU֚j]n[__>ܖ䐮V ?y^r٬FpIj@G*|<=|^*Bn/1$HW՞w{U2n>d]pp9h(j+s-ZJ 頀%4>0 G0$mIDATo\{T./nE jإ֚9>bkJ.?료[oۙswq<m+Qmm弽-UB*]@㽇/|{ އ?~4ErHȶ^~s9gMQ/LQc|>E-G}D4az|q״Ha!a l*YM`P+$$sYf^*6c=(yf r 7+ _pzn74W&]e˻G܍?ഷ|7|~! w+j,T$D)4=(r Ԃpk/0$8K!/LW__wz kNҜWpCu;uQ1&88f.]1u)^ڹqDd(.G.-P£&ZDM7[~PjF-^_ _9"Q9O[&W4Pxz~2[(d+c.HvInoo B$7\Ko@AC*)8d/d0+Ddf%lpKXz UrYWo#krYk*m^- >p)[\-LVx^?j1j[,2h? NI`S8+t,,Zx"9NlL j\I93y t0jAoV9Teߢ܏ MB`]y:$` h- _{ٰE 89yM2\˼jJߔV%NNMlqHW)fMqȃ>& ky@--Sε  ѓUH$ɢ͂Ӆ(Yv |nv'4Ibnts\MDIGen:w6IXص֌)'16# "lP } dP]tdH5bBAȂ.pYTȺX J֗)uEӂ+Y":u$NH7ue{`4%dw=h}ں B`HPƲb4/PYtSN+zԂ}}NIPtdwPPhs\R al3Ɔf<Z"eħ]~Tv+(&}ؿET^D J`@< ?h"8.s"e zAq<+P0<[~4҃sʪ$`-ؕ*jՑVQQ4PI.؅hX)R '7rfDQdA)Rp̫@`# vp_UWWdfh:wu 'ᄑ$[gG|3>h"ǒHm6vF4646E~6LlQb@|Ï Qt@MO!_b<N7 \G4i4+jf>~&ؒ2Y*XaٴVSg;rJu4 *\KwѳaX,e ]3|7ޕOyGmƉ~??`8Qa h*47 [NGC‰b?[9|@Q[J {@ KN9A:w|(9̃9lۊ6 ^&10@.VieJѐ VQ;.Y9ׁ+vg 7tbʼ'SS.X=0,L?$wkQ=3 < )[ṜD 6Oo};zjÊ+ꅼ152H(L|xCT"y7Kx]˅+r<އ*3{3Y ";fߛˈuM_GVQ`*3lܘt}ß|U QTj;5@ }6nl ‡q:@>=ȅoYꫯOYtD@z;a҅ݱzV1~jQiD<šiϔ[U"*KĢٚ:հ:څqp'ؘP ~lf}ƾ:l.r+M(B4bbJ/i & n6`>lW\ޒc9eXcCC}cs LD ?J>So>XL-9|ghNH5ЧU4b@/hgD*ɮ\JhAfۙg_3{'_zM7y l0rM1 2 0yw }Eou,D,QG` ,⽂ P͚]6U#'ީO-ƇB3[o;ODp㡰0*J:@§D |KBb9擐0 ̝uhc(4 V>U(ej*ch7e,6"2`)SJ m8sn1&w?Uْ1 (jw,B}HHt,n݆gPȗLŚkۗ"^;HJ~3pJ M7b7?|{ =;[4O%Q@ͥ2 M"ͼ:!r}{]Fj^M70fBt,"K5 [(8y!" #F3Voem?DIG!+;X3NɄ4 ja,1FT\%)E-s,.&$OZrނ/Zv9q~M+u5Hn'n-.U-qdēݲ'Rif9IgnEKq'7"12!4JQ]Q%(+<~.sўXcvd1V*dрxǔ3>N{l|ߎNePb wdņM&{92d"s)"pgPe9]h`U3_)-+]/ӄ}fƊ]!2躆假A9JOG"T"꠳)Y8H()Iݻ.5'^w>"58Gp~ g9ZRf%Dxg4 K\"β젠3^l,s8Tǧ). gM&&%ljKhv[H!gl#]?f l:y5NKRUCDZMC*tYH:h_O= !GL(p'e a&Ci/~}W4NlnniM~M {V&1#xi *m, 0!\m |ܳ0 =v:CqVO̞4OhencG{aꭝ]VJw)"/f*Σ 96|Ffiq501WUo]Pe|M6 m돁›"NOͮ;|4%T`Z0UYU f~K>r&1 AXPHƤa~o+,N t;5Y!BiN3n *ſR ?YGOٽR/(q<tj)p>F{p)7#f@_AMK`d$d)g- h;uMwOZߋU 1p %[s\iY*KU9U[ f8vFK,\aw?pW-D"\`_\cO<iIm#-H"{$Ҳttt*HMK,S9/Eb13&#wSr0G\OU9NC  A\'vE (6v<yؽ#@%M{lfRB)6R >O>%1W 0mcXutӹltBa&Z [G2IQfVw V\y*: ``Eҕ:X.+v+_cQt7 \s[iΘ&6Ͽzx™-;0)k^U3y4YF_^ ʴ,'+ŖfEU"9eƠi:=g{-\KM m`)ɔXty y )wwsOoCc¸:G?~ 05emwjZu#˰PࡖuIqG}<s!pf,-\>*zd vS=XWл| d 2TdD-n`BDN`@"0 !vA粺NjVMu;>ErĺNmf t;7jeW"6l%w& u5-aÒPD4 __]h/™X:nKTNmf# b"݉ r  G @XSdh0++c;*2@:p„\q /4h-;mG G+r2eF/ j/?S÷|Xjeq߽锼t.?nsRVEl8Z'K& bTJԿt: ݰp:7-{=T" P֬Kӏb p2 Lu9@(Z [M#A'f<;5:9ԢtXGޭu #ODpb  [ҭ?z<"-NсLCTwDKU(AߚE ʯ+T=|oaZi<6%/=ޏL/cY ӂ'+ɁMXU1Rq>ܲ  S3g~w% ^mKQ2k^{ ~*:}}9l}wʂK='Lݻ2;}D^fY(;1JsAt삒̓}3zhANRD]VԊebaBy# hIAI8h.-67)\<<$ 5l)d\& NWW)UՎ>FK%DIQћJ ..RBнS;p@KAl!Mw ˂Xqd3”É`=D YE$CȸLz^2x%| ,(c,(x ̓M'됰iaS_QT6kfs|`5e|n}X:~'32nEԶA0 HR f;Cg!j,O/ O$/ wʒ j )c+ HudUG,DzᰣGc:ktv)TU@A$/|.U IG1Ar=-ptClln[c^ H.7B{C$d?C&*1?0es4:Xdp$^12II"%[ޅSy؀CCH@5:<$(z.t |~4!ꁼTP!KVWQ/()jlH&!,8_t56vg ʊCh MP$AK9ͤ ?؋>dP̂ v-p kòr,A tDe-1SHYiP.3# L&婀1G} …&DObdcM}hta n%g}CV?=ޢ*5b`u%Z5~ al1,hI,SKl.]NGA.?[G塮{ ía{{ZðCV%` 1b9T"gcRY+dN 0l 䟚. g&0$H"Nށ^JA Ec!+u>w(ἊoyM-/B>H@S"!L$xXTyol}lesIQPHZ,˂Yz^gaca3}6}͆ .?6PA )uDS!R:;vяI/D$Ԑ.ğ3з(u?0v:ƅ giLp$JHŕX%Pipl arsQ]4Q(d( 0fĜ"͟.,,M)ʉvt&|7"TP u^J8eI8-YB$kS%rÇ轌)R&tÒ~ `d)я9츥^P K":ʶ $PHQYs10~|!cCsKHyao`.?t^4hwxdK˗t2e1ن,-a%<4P d %A&%i/b}.m۔ڪ%|moþܴۙdaro;yo `; Q s&dP|ibK"ƅo勬bVB76t%,wW m(Z7}w?[cv8I- ?}eXJGGwtl^ab"sgsE~G56Գ[x^~yZWϒ?swv9lpȈE8G}' SvOjH)］?0|c8^r(.HVD2;6;ly ᔽcG7opKGLdUE*#b:\˺#, kxkanboz?#;CE뮧(zj ALloj>>e.nK(7,+4cSROsOt O]?~3yë8 NR*BGb?Rz"֋޸Ӟf0&9Nk?iڔofu:`鯼44uhA3Oi9E24%7xׂE]kn/[n" PȷE^,LGЋHjH_xuXAU }9<8x[&`WdP?guH\Ԭp mO2;jt:˽Glt衻4s)%1@4K/~צ+MLDJP,!;Npqg~B z8dᙧ˖< >OBvƛZ#>f֬\`rQD &5RVE|OraUu6 =2}_F:7#ъm0`y˖-VmW CUPf'nz6rȼ7naO_+h\9_۝@' 7.]5jLZxrH~P mI̭7'T v C8{s6 +Y*y"S= Rom^v|stCJ3$0\y`>%h%66hÐBJKZH'=c.! _}u.}χCÒ 3oG}ѹ𖠆 j"=;.5wytTG:ɅQd)i<0THB?+ئ::)L}=ˁPTY~puhȆmGoKa vIb0)l7x ~_M:kXA 3QRIJ+t(0498BA&]fhϋ$%qLW~ G~no&R,$IrN4u^ask3>YD2.*Ģښ1cM&c -Lz?^Y"MA7x upTd\)'6goon&D'ÿ'ŋ:}7^n?wLDBζz[gȭћجBagzGŮ)> z8fpoۮ1!)[V[lĿzL*\ה&yH Gn9&J/& $OV35(ti4xWhg<]馣N;(9QPi^ۤbPsA\Ni *1/Wӎ 8𭷺W(ϟn WڋS_x=%츳OT2 [ ïcj_ )((Ar7߯p78y䙧^]lB֖0<),fP?UW_vƙ';35Vp(CxW_?Y Oxl7߿};>y댏k?xP-{އ.}r nڠ;{NFFv hIM% Olh9 R@iHBS?1/K'mBf35A?syIW^u /]7Sλ [ ~ ~ swuGNS֥uZ^unn@wEm&GnL@ !-- LYzeO`Gw3sC>?cy09Ա &!u ]$hjfI‡̽;̱Xu| UDU4o֐G>cx3p/ ?hwv]o% `Olhh\ ft]|^λ~ OZjj:F^Gvmg8 nhap^_8PpM CE|jN{\2y:D'%>t# |11cFe@L&.iiJ(slX d!P}ni"@ +4Cx|qȴ^wuA&`".!R345F[L[u>@Vh؄޾~FWt{$.<}p_\L2;kѵn s/8n=JKςjA.bM,ԏ'@nwg/ ;s0A'} Lja] mL mB_ :hG8!j?#@gd>/wqmZa9LXWaza$cˆCu6̨1b r-kzmr+dSҋ~.h)ctQDS/jhniGfi,E1lʹǡU:.*U(nQEl;CـR嗹{}h/<*}w2`@*m )d?r݄"i%DxJCٚR@Zu`caADH ()h]e҄ќALh0-dRqcmnVO}!|Ց>Wfox}zD]]sMeNm艸 iِ BIpn6[P ٵ^D^FF .`_ߺ~Ю` l; ^z{<,F5R$z덢anDNB{[?cǛo X˦yblUR u~:ix .ԩS&MjLN 0& cBy#FjBֳ%RU?_E.;O93Z0HH,a Ov{O3b ><Zbg{ XU&d ԇT@2>9eKR7%MؒJ|m&Qĩ*GLQF01tp.T@ )²D9(d)(MF rt2\ Ca{-ݺ,-_ގt 6…F{P<"QP{v-sPЀ bS;A炛5\;#[O dda_n'襗^4vp~sKKW펎N<<8)DK~a؈X)eW=:&X4,x._N@3Wm-Ddb~|XRb-Dr!+MwBt(5f*|D8q(b*얥a%˖=}m/>##|s^y< !ٳpT/[IQX˪`X,)rM'|Ⱦ0ot@+;ewKK &]w߀N1Dlr0a,}N; 3&$ΆF Ъ#8$Fhh3_;s[na[ӴvM3zLK@SS{fsNt-?~?0UK:f}}ӕ7(;Y]W 46za#bH- /S{Kavߊ*Q 1 E^,7vj)W m$9(ttS,5ADFB. bE = Zqr 8#d{ !1m2б/vNb]o"hR/.f[s9VkэA/Fw1ø͇K/k'MŅ@vKKc ΄"c\FL(_sNƄ'v@Ξ ~]aڴ_M]&z+NTxR>l駟~1n->We 1GJz湩 )ܓ_i5H}!JL]\'^uAUlkpփQBE.ЌO{#^OÏD5Rwف!D $ﶽՂ$0Zq[#傡=  r`hW7eL]lyo23. 3fokTYP^ccR 2D(*AL^ m#X5Y@Uݽ@UlmgX`Ćݷp1u!?(%q}7KGԚ^4S3I؋ (ՃkPW`\hĒe|}vNGHYo6HfSP:3fHn\(ŧPgwˤG3cf; s:aTp<qHHs3w^iOU{aہh@| t&$L~F@p]v"\?w@%c@SY=`/]A3F}}#Ő?|TZr][ 3 I?kf~UW^ggb8>L{{O9- ,w hHQs kYGwAQ>:g3D&AC Z֓%a#?h$`rPK i%Xp%cǎO9n0 rlן<64G >a8!B^Sc+}דq5vmYwesWs~,DH쨤=pSzhW9Ԭt& s~šCL2*E(墰&I>]yglw;fa򷧜rw}#;_V5~PAV͔Mr 2x~(Ke酎wḶ*']0)AU!>B+*A1m<{far |hMBmqDH5pz \MbJnP]n)ti]Tg*s9!لJ &:q)<(SH Q&+,&Hk8ME ~SO= d"CDXF!ڮ#̘a¯ŏח_.8CO=s7vlRTʣS hTտ[b @q R0$E@97'V%F +M \>V[dH65(+CJ0`DۊdS?7;m[`-aFSׁ] URb}ڄ *yM ߂L?3Ip3l/SM=/0%,Ѭ!- /!o:{+>aUO w_ڮ z!EkyÇ@%BƐG.DaODR ϻ?[7{bXM !,] le,nMeVx>djj1C(@dL)ڏ=e\4r/_&@>$em]8\E춠c[fǧHDJ +%¢Eؕ)$Hig[ʻh˗8YOD[MGc4۱^ ^IY@ i ?bDk!02bh   *ݴCÈvSVR³` Hf.|#UCoE@S;{b&1bhBĬK"lvۏm ݃'y qzYyp(0qo h/No~>Н8_5X 1\CO)µW:Ɛ|E`)`j5ƀlbkYM[wLILh/z.1|x V~80ʊVf,lu55uVԕeH&_U+$ݓzI&.K-\Ǣ\]ֺ5`jvbX;$R̥9sg? 8gBN] (Y-t a}Շ}=Hr >$f8ʽqHR)X-.JA,D%~t =C$VF:PL4bJ.6EWqɭC;_gPP ?>cM߯v^z~٫=dS/L~ ^(&΅ 8Ŋ.RT!$ @tfOw? |=Gb;Wln ̜!_-H̉Ađ3 ~r`AUf(%R̂6}l˗0ri"bXY¢*\-@}&7d -QidPҭ-v"! L<ډhVi\Hԑ٦5~X@&Y6*i .CxP}BS; Qe zcc--1'=] ^w{us}Ӧ?yǝׁ k~ WtK`zMnc96@d.^Kk.<&՝aAapah+J#ڠ* ̏AdմxWD*Gǒ5 }'vIe?);;o}B)vF.2t闚=k!B4 x A;|yB<`'2e"[#ܙDCms">b*XF"+2u'+ڐN jCpQ< ݉`WNFR=gE |Rn'{$Hr;Q^sid$n!M7|Ui)(l@fkIH@S\ ;:#F>0Ғ7*Q.aFk %Q8xfTCd 9iaZ˃G.y;00qc~lWt'd61m`b)pT/,vtAMN8x:Ƒ*ԕd|jOiKӝjD+nj_d LZ\>#'r,]Py8щQ3R[p9>{&=`hDە^x}C/7bcK0b{x@"EQfyP+Gx%Ip MdciFH$[ pDs}7.jbI$oZ[n.gGwEc+sp$ڙM' vG!?@+ح=2bz΍6c|yCIU dnu}?yz:[1OG)yQeTe 7[V16B`UB:a0N(," X @5k3>" r60t!7M2!-Rj!ݵ~:ROa@c WZ e1[@3aP2eO$ Щ"ge\ NhW:>C\og!MЋ' ̑h߯񐃏B4ꠓ@c`vCSY,¦Il?p;5zKMzڌDў"[`J,2>(IBe+ hfs }v0sy8 `vv&aÆI239][4lT B#&=&'ᬳκۆXde\7 aJ`pI}t LYS(~٥Wa96p4K=AfBTcfK!;FFzL5ٝ~W&P[oy_whDAHAlhc!L4@pw:\r%4p+-)LC$IYI T|8X, Q2`# 7SIB] d^VS42́V@q4!DD,j !ĜafÑr;}kj<<2A,^N@@\]Q' f@_ԂH%7Vv~fA)ag[3\7._NMU r@oO84HW O9 ?KY*cIX?'>D,̙309ߎMtj%># Kd.SˑWbX>J4C&vwBm^O+!$~(ХGmM-tt$ߍttrn@p;Gc8BI T 9p86jp;!`A0lq3bKC x{0"4s9Zܦ1RNW(HvLY*> ]aAwֽt{RS* Q ɁkÆph0XPӈaBڀPǣD y'oOi~֗XPUA,Ʊ<_WuzD06<;3 1Ѯwu!o#vBl~@G̒́ATt+ Py0|COR6H:T:pM8J( &pg-7J )sɘМ 8ASK%\w4K.PJb $ू2{0 Ԡ9sv.l&V i^#ԯD<'O(G6+&LDyk0|{|]]E*k!==Sve|,KPAB\ha~,{.[ډ.%`${ D 4)*5۱9wHF:2 r0a QoΝ<,>y*(>Lzlm2:;b=955?~A*epD j<0y {-iIeRÁ6rT M!%rHd7:NL1y@'ׅldL򻧿ɍ7ƪS\S$;@4'⠐2s|<o%{zkm|~:̨3N?ZJn>rېhhDgC&]@T:`Kl6_+UЫЋ 8DȖbWgg7u9PYB/2p[A&bHÀM>DT@Lq1=眓еrʁ h5J{|e3-0ʍM8+;w@Wğ~/%~q# OJ $Syujfv.>q&݀qi2YbY[!]mgq!z|>Ϸޜg&BaWG_c8HN`^]ԓϞu_&LI"3%& IIC5i;6ȸSO>1l,T:O1d_I@ӎ8za dZ{?%Jh| rR'7 bWߊa, ݢEmO= -d&xx;yi8IBPO)TBd4ǎUߓzpӆ>AE=@_y%&"*ȒBDWmGrhk.﨏}38zm4=.x2–"-+l8j-SWNɽ⛟~9wL .MLP;HOJsR;Ͻc0R;ZEyA}dڴWob aoOd- _Vu@i|ϛ>}@p E/^$v/@ve[+ks99I% =[gQc$YGH?x}lrU`O= ޜѣGx9ɎTdB`͈bIT(L#p?% ,Us8 r L?:|?cvQ6 5SxmW}^sӝw ;S̈񸲼w ӮZL|X< Nϵtr09n"/lXT@IidFCyΎλMxݒ,[xb)FcRX/o'=}Qx'ab-# tlWù;n}}t.M$\ӷHrZ#FzzVj1NJ2jyb:E[os;{/^د[m~;ǔsTJ1gA8o<~0Ǐ&9 6[NQzM|qǝ|YBpM 8x@"YI{ BxBEGv0%zӗ-(!2/^x뿞wSOwvv>odQҨCv: /lM7?&[u AhiokkGD#5)?nzhUp8,X?ؿ8~ 3s}^o3:tпH2M6>Ñp-Б/\+^}m8,-8]dNbC~Ҿ{]Nt&$l>'U(Z[#e `(@#bnub.)/gD.NuYW,5\/uZ?yNC,i ש*-#NX.`B`L䥘e򘞳Ǹ;xmnkj2^0e:{"鴣>3 :Ata)`*! "AtǜrՋ;R#MO% Ft{=B@RPр„-M{=TWpΈ cĭ"P -q@/~P`l$rى!J|suJ!6X@hr*3~)cD3aKcCtZ(zL C[o}zSן{\K5O=>ֲ)IhtTb?\sDz~Cԓv(ӡV1[#H l"Y.\:YGv>#g J1#=+;;1\ɧ\=ȶCkpyiRޫ g߾vW {⦾hkSɥ`)v]O9e_nJuJAv>{ѬF{*9de% w`SӟyY  m*C8W &M3,]*^[퓫Al|, ]?xA_6WR|i_4 D^8/ǟwiXŝaX*rנ0.8Qiw8?B!a3@2L ly52Xı&#}ɧ^~Ƒau@_ @`t͚owײa-zѣ#X-݁2G|6ÒT[naITG"[>hH,*6^rԑbƠz&d@ xv FN; o֟ "'w'iOvdGFXP@Zۻۃ5d+vX8lcx[@N?L.fxPj"p*)N(}x_}MɈ^mќ#&\w51"4 @[<*7?" e!&T>Wƒ{.{_q0"r ;?gd6h,ŁiY&cRت(o.ʼnn' f ﮒ 6Z?uQS\NZ@(1lnҤV?" "lcW P{B<~-R#8pF瀡C~XА)ڬ/򃺒 INBSӀy#,Sܛ'@cI5t~A(ssك*wdLz *"( b{GEkY bõQ)JG){g!|63'3s빧|3B27Zbh|pĪ_:s?Qxe=*58!"H8%jnalH^hʕ% ?UC8SO=HKG͐4q@CL'ږUS@ 5a4jhk6Ϙ~.-vf7j~Lϻ ]7uY~x*֪n$EJ# sۦ;3_}LvҠy,*ygVN1IC*fNPԆ/%!. V]]3{ڌ[!/H@v~N  ީ^~%H' 5 )=-aꜳ޻Xc%~Io5+{ űN>q܋o]W?q9Cn_>*X9)|Gjek[lC6֝졤!/aͷZ+|،>1e!TcdB!{##sQdYas7<1ًo;䳢{ V!HJAW9PDŽn[6H dgI1Ds8a-AWI82rc,e[e#`C VT=$.o7UEbQQ_ StN: ډ#Cvѹ=De~ .VTMf6Q'# H G:l$1P R*K3pE,;XV/$>!!j9y*jVDhyI8:+z1 pߪ |>;ERΆ/eZ|v3gjpxj4Ji3;tWZbHGA! /8.ٺzI8C>䟊NsFM[n2sIw &j*:V t %S$#o 4v!S-A~PuK/(rIbv; Q)mNv̀ԼГ.'~Z(P(<ˣlQ8tbt! 34\8=PihOmDևO4#Ƌ K"='B)/#_ eh&=[4JmT'Z*[)@MDb[UW`B_jH,t/ cc , =kHlM4m~%%l-[iw1I-۷!Z[ȝ@d%]{gqm&J44Ԧ9?>ϬLh3w'{j,i |h6e?qrhBdO*QruT~~mITNSP7e*max9JzIM4G=Kn+|6HsUYn悲d&x YO p^*%y"X2F)q- v<$Ev*31iQzT֠dKh.sƘj;*QQR Q-G>9d)Gd_Dk(Tw)2!=C ج$q `XՄM4A[*D8[CbbH SsSYS@ʠ+]"!9c6o\~f&I0;*&K {::kxs qz3,Rʑ44E&)/wfv*y^ nN.rt抸Ϲ3R)ц4byٮSatBqq j,q'W!ո"5,%H}( uߪ-^qXgG$]yn091?PhbȪf4Nk MO=Kk)OimfANd&tMKbp"5V,C>oi+F'2FU(M' m;s'dASŌ)G^H)lX[N%a h"^$j2fOm֢}gBP,C҄=a׏[X8Z![H˪K~w~xcW"ߐkB)23'\q#H 8P^0/koz;^;'8Cu)j,7U0E4rӃYjD]H,V{I>T\9QހK7dѰIUHڭlI> xr.Jg=4jL`r1,X!0a.>J9 15=ds$NbߤXȑ{]N""zD|I_ { g$.t:AV! 9ʒL"6 2 "TJ\C11LrQA@砷_LhQ@`g(ݖ;"aFoj_3 SRjd!tduMYҁ=y9uTIrO*ۈ`]BMu-P eoFReE13 %!~F(aT%rFS["X+=+B^=,qj gR?`sC(O@ {sd`Kjd)Q<}곣ܵ/={FY 2@&)kI [^K 9˦RkZzD})HVY~Lc橢`Ɍպ\e13м]T DPRhy]Uԏ**k#{jX'<]Ј2F!7. w,8AD*'@#~sk69j%ʳ8*C~g6lankże;W=FժVqOcxoAluwU/TϹYе$P FN5ɟ 2%5NMg9XHt+ |rBnI4=Vx-;(ꡩFKo %OeZ3mYxp&Yp!` NfF5dqIn?tl_? 61!Zkn.=>%m6e6Z 9^ȲZ'ʰ}t ךZh׬MTWO2 If?74{-]yiQol}i\"}ʈ*A%-hFo2M@5!GG>W()$UfE$ZL/3DBycރH65Y'\Fh.-/.lƐ5U\ 쒒-İF(3G\lo(Q B IIXYeÒ)S2e7 V8B,7b5{30 DDY?Hą[{2 X 5TЩSAH(5I!/P=N,݀]<ۙN)3*e[ ‰٠J'UkZj8N:+(qP]0"?CT;a))Lb;a%Q7@Bdz|볤ռ}ɕ&>;lWaO8~3u.yMբe%"æ+7LS)q˔p)w37 g^,K1FSR* aa9KC5q0|+O~r;wRVnB-H4s.)A,k=yGm3_1rDr>JNn0xXZ%'*v{cQa b/dO?jo6kK~\*uFdDy栆n 䋹w2j*,Dž QS)?!AD߸΃ @P9FM %4yD׭aC^KvԌG0&^u9n?mCo}w>Me>q#!%!#J2._D!Xd"Q#t$Y%doÆC`udAZԈBq }L V _'oޅ._UI3*#(:R)ICe H5aL}NFE0+Sr9L,XJfXz$ C nR|]CS̢5I-o}ng _~9)STW!UkSeЁ Lbe=HUm鯏]_gBUlDU4l(g'F(F0bTZjAڃ=gǮǏp7|σ`%B B1xkt-C%"\\$N V*#[F4"e{RbO1g!vc {ؼFK{B*=d-Oo5Ϙ ߻X~eU/r]OveO<2ֻԚ_^t fQAx7r/ڳd朌z}׮AۈIw ௷~ _Úq~У|˃F mKOhSnQYQpWmIn|\˯3u4yn]~;wv\eks&9L?ĉVCŔQCc~<y^aԺxO?KEe 9 [+<vj uko9fVJ35i}0լ[sZ6Tyy/>߹L>v7{Ho׻7(슀3=n+5YBl^ Xdq/*=լNՃOoXXѬd#O?[`Ն}g&<ԧ? QLbGrW݂*ПYojk}z܅f 1Kd P@90HOf͉Ł/Qf ?6՘4_N63bΈHw1fxRL0ћ՘8W.v17EL43"C&&FJ?f#HV-.`nڲrçSYխ;^GL][T'Z3?㎧G4U^jq,R/\8f޷]vyQ$ߟx˳O8oߘv蒶\ܐez'|[*Z%vgg sOQ<TkVX_V[Or>-CnAGE.G =C 1l-:y;\_-~U Dt.&i7_oȀySZ4g9݋:?&Q:vA71V.wl29g+*Xw<[vEu9SvcUTC1 =* M[mC]gV\kVmXK0c-K \TnĖf7믬Nr]`UqsfF +Sw&;+ޕiCLCܽnAq`b '" Ӄ> AO`ʬhTCRU] pQ:oY=6l[ A1mRſoMdܮ={P[pصu<'M\֤nťw݃jE}킌 {aC4xA9d]8[!&_ TôS GԩWXˏV\tJϙv}.6$ ]K r:8Z7'#of Z]'r蜸Ƙy]%;;L_2Hjֲ&lbA97m 8r%\']0_]{go$BVn.ЧtEY&3ſnjز VC +r= ܴis @Nbmsu=Bܰe.-6⋹'Q`[:BMGeEY# ]5}Ș=[gXxiV^b;V7R@2Wd@AÌ64ϑMZΧnVfqS!"]rFiVALڼ qaSFw_ht֩. h]L9>POWn]yfjEe{u˼6*SxK#vB3Jz>4誒] regQ_zlvѬ٪Xʍ4'ze7|ģUFA*vP9xp.$Cc}ߞ1 jW5ӎtyZh_Mt$ʻ~ＫٱхV.ccM:W-;4 5bItxǟIxeR5BEw*}ҹPM4G{OKv6}w폈r4f-=R(NwI͵\Ɉ:ZL˷ܧQ/F6_oRGNձ5u 㚌||=//I$qf캧(nͅ(Ty,%[~Ұrmo z?x>/WwO\.+! zt0|p@̤3{U'\sKǒߠQo9{=8 ;.y*i9߮x2 %8Swos|:ũ>yƝu?o ǿMEKWgn{rW%9>=B޼`%.9]3(G>9):'W)>C.ճjBM|A5/+0<7u~"~|OyT#"vVnqgԄoݞM]Au7 `BSL\nحDQ mA]-0qKI5@ht^.*rdg <<,Z3C$ >?B[%A"̵K_7Im!UN[H&yW$#qNCn$G^FőbE4 PdURN7Dz~9%zؙ5ek>7j/zK0Dc5O=ǒ#0n1Qe/~!CGYQqcvgdIuXI = pB/V=o $JVLI63}u4UkIץA)}0ݦC^01Gh&PieY~NiNIAcrp]`꒛n sN';:oB^Ѣڤ0K)`@"M0^ew)MJ;=^ŝ09I]ǀ;\ "怒O_߲ם߸IoE deJi(WtHPgiJw7!!7Ea# ʢ^gE=N>c#8Xx73VXNѣ紶xꝘsJ3*@awΙ]4_D?ō`|%3pH\Gt>h:ڳK]}5pDI鞾{~j R(;6Ș3g#k 2KFY4yŚsG&N4p#.իkw$)TÂb99UE˦?1Mqp s1Q".7Zk~/|z}yaH$~p81&D8) p@׊n*;ͱ2=h~\e{5k6Fѵkk"͡0ur!\L4"r#OBn?F@]jFCmڴp Q m6v.8/ZSJ̙8o.A#Q{)]Z" 7Y$G=i1'h ~ zj!Ĝa&4 yCJ)v馈 2.FOL;t_Hx /* 5iԖAOKHAj2)'SBYnuzJ|\thэUTfQKgAdMPO^qbkP* Qz5K yQFTCQQ#\/枱ןҐ9`x/]7R,abR:z-<P$HQ95vS8DXԠFE{Mz& ұF>4OyRE@"Riz-Ϙ@3?sZE^r/;HCÈ W6:|+ 7w7| 1WLO$<}G6v}5#12 ߎJ}_3 Lj+2E7$"5'5ſ,y: w-0ZH\Q>zQb#PF !$'= 1W?ԃHz0ɉ.&F~@BO>1`bLr#s{O@=bb$\D#PF !$'= 1W?ԃHz0ɉ.&F~@BO>1`bLr#s{O@=bbnXIENDB`SummaryInformation(ce8 DocumentSummaryInformation8@ 1Tablev <SummaryInformation(h~Oh+'0 (4 T ` l xOffice of Nursing Servicesvhacllyerarr Normal.dot VHACOMITCHR2Microsoft Office Word@@f@}3@}39 ?՜.+,0  hp   Department of Veterans Affairs&K' Office of Nursing Services Title~O_蕽_Agp3p{g^=E98/x֫VI6;#E;M^4%7},yza ccc;ؾ 8ܙ_ἧ|Z8|@ػ ӷ3&xZfE"|u ܫIy>dVSke!:*`>M="MrϚ5g:{j35iPRޣO^~7ac@C*\:/@iZ-)N򅿼+p]^͸ދDſ%ίc=yg{^~_ _M᫗ܖv[uIx;fРKFgn߈Cp2GEQ6f2q  2tTRQ~,g ӧ?}?۰nq /NRo T^<$bx=ݬ"pGxiL1=|`F|b):/F(}*D=3hic)kQlc JSƄP]ÆBjiFccvX(4zuaO@>zY%gLz \"Yqں#ں5Q7O$7_v?mJVhLWųPsē"i\#GK\rmʸ{&kڢ54mMͨM;h[FX lfhE30jam|}7ғSLXEmLYA>ɗ۩R?Ͱ>|ӗx< a Dd 0  # A" 4V3E/*2|@=4V3E/*2gC͟ xXypU>(PJ?:qFK-UD@VS5 eMXBB*Hؗl/˞|=orϽ~~}aBJ*L-g,n!~D;851xpD1޽j @,s8!~4L "'fc~Pk%?/yjƿQosgbB:j+]8uV.Bw [Cdz|Z/2_بpnXɋ ҋK/J%)+NDxT`cq5o݌9qi\Z p>sS>T&EJܜ c mKimG/N䅭ʧr(#;wCF㗙h8|H2Spm?o .n|Hٔ5=/׏@h}=6ץ#=pt^pȇ?^W4M_g}8J>!PSH>$ ?&lNz D¬$v0Qb9uGX +_tO^b O { МU QWb#piJ/5>V>l'bpCvԠ) Q7l.:$;lw͎~G3657f0nW AֈƽDCκE}o9֣> MzN{3]To}H}i ּ0gf4Wރ &cꢫUMkަ]N {C 5M׬~|4<.I}.[!,J_GG> u>w& W.KCcn4KFSqnufߔ ^^ QUseֵ'rj$sPhX*~Q_RG]^*9 \'=s?Ka;"}dE wFw\X+kġ0奔ǥ2)֣iHN!? k>'yFa 8X78ڙ_㼧|lX,t6"3oӷ3&x[fZfYL|u ܫMy>gnCh*˃xT=y to%8 ^I}{%%w}걜A۹c>\o@ T\f ,_~^=|?gƯn6 \G1W3no"?_oomX08'.6ps^pw?PW$ĢYQQ3(4(ydw68Sg(©C *ɂt|s eO B${„{6[1^y#e’aN}!-1O,;&q f' VVR<9xi$1!Tpb NJ#t=mByn]zfˊW#ZHM\N:umE0gc5+&=O~'T&!}ԾjNT &L~HxQmQ\x^"f1 j'TQ6TQjo̘c w4fi̍w)H]=LwxMG(T ɻg^<=W'B/Oڧ[ӟ1δgh\v*:% Dd 0  # A" : uo`@=: uo`gC͟ xX{PT>&9Id$äjL&iN۱I i4cMV-B$@@ *" `!D`y-,}ww\<޳{|LB GBX@-׼^}?ߣw N!i%r~'Q@6_iw>Paܨ mM?y;пwj_~g/-l9+XƯd3xa A7܊DR \&4;Ư`:h;GtBgv$2?5#t}[&C_ į1w,pn1NbpXl*Z8̗hG؛ka7Ux `8nwk icV8%z$-ΫJ:Z.\ {8'5 Y:9N:%}jiz$4=.kj:%ՋjQGS%.0.`gQv[ .F&e~OP/Oa`L eG anPK56Z\87EeEUB2܇'d aߋƼ8#;P%ڎڬm?E͇'Fkb28 @H?@ڔ^#'䅥ѣr2S{ ABWh/K|8hapt'x}|H…f5=7L_ncPF&m etPGz<нmU5ݩN_nǨ<d{}(%NEh.$N'o[xPp^vGg-|oϒH}?/Jl}"g#S~f ׋^td’_>Jڄ(qcDk}Th>!bQo!;ZjP4 QktA8%{aa׊1[Ƭvu`bN ǘ EAֈ{9[}KB^F%nGs,̥N5'e}Z}~Q6_ ُ 7!G?v9 > |97Ƈ5T~ea P{._lg ֆRè"sr\Q­&Sy}+c(M]1k=ZkQ>s9 [HCGt%8G|loȅ8oI~Ӂ%2uN:/.5MўhviG)/*?ŐTɩk<$ ){ ڎk}OFHMv&O#-ϼz =p^DZخTI6;#Y;M^4&7L5Kuޓq3?F~򱻶E{Y"D^Es73&x;RfE<|m #y6f'PbX+ Y ,#R%wl QJp>z]>&5{쇗-(w87а <?|%ܾ6>Y:V{Gܧ6\:xb^͸1 o:sk#8{D27s&`qLn>Y_sFT* p s8o"/c8C(?vP6 wL|:aM?xЮmIocLP]ӅZ邱TMdQ!^9]L =ҴNqNg#R+>m Ls2+g*l3U`6FK0]ڦ0nCO ~zY&%WLzO Oz/Tf&djViV?D1>yE;ү%9E+,H־=1=ogZ&=(D"ͱag O߆?7Ҥo8+M!wPd Dd 0  # A" ݵޗY_1 ]&@=ݵޗY_1 ]gC͟ xX{PT>FXtTM:iHiұvlc8ɤI|V,'&AI4`}*Q|,oq߹E?rǏs{LB&L'L",!cBObֳ\H{H{ĘÏ0Y@If+r'|vXGc a>Gxgi0;|B[y^.Nq|d٣(iVoU ;/ o='ڀ30;h‹h;Htd} kGLNހ%A߁0/+0w6'qv0Lz8,7l Gu58ZaG%8/XK8s߬Y ƭ.pv"8m QO=~]b:ͤ"57*a ݉Sv.iQCW#qYdVl~\Vh!hFUС,Pz,nbkŴ(ԦnF͡OQ .$ #(&Vj;'B`O褱~+>ǣE"E 3yrEz{pPz <eh:07 z.\݁q5;W2r縤P{(Rh&&/ˈV1p. MV=">ٍky;>di>GbG. g>ň/AICW~8Ot/vU CgڇcXRs>"NIh,!o[xPp^vdDg42xR"iO$88Kb r}='IA|Q=zѥ֋fX?/ЖɛQ%q=.u6JT|AC<FrbEЖuW쇣WbFu`jpG-f pxPtd>(+On/~6ca>FTsR֧ޛ1zFsŹp<ˣ-0 c|4 nà.7;} Y;8&Aj趴W͓׬z0l|U:!|\ڤ>\ׇ@K#Vcz \ _깎ꉅ߭T O, a>K7BSQͦW%@mߐiyúQR_KDC^ Zbјs{TMT'FQ)&淖IN]乐<pN2?#Gy2,Sh9{BFlښ9qh(xy\NT:3RTECIgA׮0::m|_O{Ϋ(͌gM*>X^VrN^KY7$8'Gr6f'P[mh,L64=gm] g[kҠGGqd?noD9FGM}鴇:?כW&קQ;K痟jqTq!_q ܣܫw{K^;r:8 M?#8{Ց$t\񎚲1 wԠA?[O:J%٨*"d(2ͱtTRQq4g G3g>]a9oDBX;I=o897H \d}0HҦv?8I? /,5 T e@/OeDC=҇ɇ;p5oׇ,͇HOHSANa4p27ic(=?In|hKpT{v HXruׇ18uEapca֌p췞AOJ$.xLb+b׋S%6A"f#%>)ȟ/'^/z}uK>FsV&m@Mbĵp\پN5>` {5bɇh\7%5([sw5G_=]]w0aŠV Z1`1Kn]cㅢ kDA^A})wi ~Wķ 4ʇ||>-ތ mi/g,AR\p0 >P]˾iy*ÎojK\eLy7.I 6!E*^ԧ vW~tu2n[P]a <1C9q-xy/vNx:3Rtċڢς$?]?ahhg?^|_O{Ƕe(Όg!M7,U?+O߉rNX+Y!ͺ7$8'Gr6f'P [u GRli{i?w%8 nIb}%w3CDžn\o>n_ T\F ,_~^!ʼn<Ŀx/n6\:G1W3nǯ"?_oo˭X08'.6ps^pwWW%x;r*C $|;sF+އGsTeH!8So )8M(;rOن}sވxrz~SxЎ-NÁb+4o4׆xd`lg%?{@gLSB*W~#ѵ_d72Fzt&ZEy&\L[BBikX3QHMi 屛FN_4ul`]rŤ瑌a |o@Boo6'fM~HxIۢҏ%>/y+)JH,DwkuKӮ 3p |mͨSwA,X+BʧI yî'֠k$ް=1vyz 3asկT3׬mv=~y Dd 0  # A" 7["՜@9@=7["՜@gC͟ xXyPU>*YI2$#t:N&44i;IRi&5!*QVl#N5AI4b ; DxP_ǹ XFB@!mBMbsz?Ř-0<0ҴDDߧ{D Vј(O4 =ADj'9=@;7o]AJҾֈ%/ckbg΋97܉Hz\49/a: =hٿ>bfA{A4:6:?-cע'u5RV/y)0ߎɀF8Ia"ag 8ڮz%8Z.|:YM5ןF5Oa0a_ҽ6e1ZHG3F=pG5Uao&MhuWOF ]RemrZMRCqQtIKeС,Pz,nbkenDOP1ΥgS(&NjK~/Ѭ]P4ؠ:i섫 h|QcŅsL^\^Y闿<;PTf"MGSPSIph؎_ʾmrbgP7Zh"5pMIf1p. MV="tf}xnB]8p|(OCcp|8<և|جƃj#'ʇ?3yI?4-x؃YH|t'sSEEZ/Naćߣ-g:7>-FZBl_'QՇ=C<}(MC[A8p 1GHo7=6t[1bՂ6 [:iWx>Q}PWPh-_EkhPh`~xCLJ#>>\;椬O }7c'S #땙L;^0Rc}4 nà.7Eq>_;8Qj趴ׄ͒Ǭz0l|U&%pI}x!+ϖ_G-AG*\9N߭Tg|Od" |hoȅoH~ӁE2uN:ίGwK 5+ cZXwjܣzen:1_O191,Kr&Os?;*a9)}0lFazd6_d;ޙI3|},`eخTI6ϦoFvJh(Ko4LFGGqvblzx}ȯpS>v^Byn"> E |:=};~?k9cemV7ޔɽϚgCE^"lu֔#$m]OJp>z]>"5=$wK~#*6> 4h: 'Y:_Qʼn=CĿp/qo ܣܫ{ܟ_onɭX08'.6ps^poWW$V[Q8&w4hґ[7\>=Z,gJ8S%9p6:SC{US?۰n1q VNPo ڶU_x4D- >m.M]:x읅xet15Lp Z|؃ vOk#(}*D3dim%Wn"W 1El苏FcJBlad!5?!?2>:}vȧE0gc#3&=D.s3 އhk;|ϵk6`Hoڵ/kKTH[g #E ^s4axORttK\rv`wi&  Ռko|-iP؇[nX~!"ּد?I>,!؏㵨mn9>ij Dd 0  # A" )I;vFt|C@=)I;vFtgC͟ xXyPU>*YI2$#&UNgit̴YmLLjbTbZu8!%ш ;"D c|=pyi'wrgb!'1·͸WB>s|{NJQ[a_ C,H=CjXJcr?W3w axsnjNA7Soܠnũ_aC󝗱1ox_ca?n(m\zԟ>`:]h޻-a:C[~,sWÚ :>-}%V;ez7@H; h8&Bkp] 2-0_<M`o!T{)دU~$?{3\]f8;p6F3hS¨Nhi1J&xjYi[npvҨ"H(=.kj:mW5ҏ դ,U۱ IZ Ӯ`ۢi"=]->-FˌCMT ilq&%bB:kޤw >BpYehzZ/2_بpnɋҋ]Kf%= @73T#)? S%j6\ٷ B힍sB8|+}prnJ \˲ (x{Hiswi?8I?T\d~:N@Gsv=P?ZEln;M>rYq8ѠŃrzC }{hpiHO4?\'\M#vT|ȇCi*JȇC>:-T#1~yD[KŶB%?S  EEV/N`̏?5{֠.5NJb j7rX.v!W>K n5?΂p 1G_pO6 wY1lkǰՂV Y:iz}5^A}`9c^%pe&-'e}ZOQ2_/MC^ |nQAqq9 Q> |}\ɏe34~ǣ?K ]95X]l#nP}Kxڤ>T͏pfIoc}r \=N\鍅ߣWftڎ,M6|`oȅD?UoH~Ӂ`ߪy2uNS>Hߣ{濜h)N@CAסnٻWc7"wlm̫ǡ$_?| J8)cYHNaKR>إo#7ќXg[s\<_Ή-~'k2r[HF~~=߈r~ ΢q/wHHOu~7?~ MOo/W8v؞$/ ϝ7ׅQ Ռ뽈OM/r:8 M?#8{Th-oUm# da?]?sF-݃3G5\BNTq6;ʢLB*$n{ć~6[y!5’1u}Am?;"B,mDMa $J*FY_WL#O.6Gܟ(qp6r7BUV!KL+\]4L B7D>a191>Jװ|x_Xc/>z;z"ϳ^ֱuGÂދwE=֭~i"iԵ/%*}֙"/t*"<#ާ8-si?Tܩ.mKSc㔾j1?u>Mx,Gy4G̗y0ԏu"9Ş@oXL3 a!74!,7jў 6 Ajn9>goT Dd 0   # A " 4$^*;-sM@=4$^*;-sgC͟ xX{PT>cd1#&UNgiv̴ۤ&6&Ljb4`qBhD#6y(I( ,ey|=w.>H;#>}w.gb(+i¿;OB<!-mcw FTॐлELj`ڿW{HhL 'JtGCDLOyB\>?QF߻7ۭ(Kl\4z oxs NR7cE#ٰ܅ƽ[д ?CXŠ5cس?B[pBGJt&/Gwt|ћ8}[ upw+Bvp5_%\\֋p5uՄ3pZ*9 8D_ Ov+<H:0멁ZZg?W]Лi[lpw6Ө$H(={n:-tҏ U,\پpDtZUӦk =M~-zˈEuTUlʿp&9bB:ꫥ$cvBomءu3t=>-җF/zlT\87EEE׮#dC׉Ʋt4H2j'R5 V Wmƕ/qyF\݀q!sW>T>97.K \#f%{0xHiz;t_*.2? [OC;HGC6Ћrte|8"$lh&1(Pbpp6NekVtܧ)s~&Gmf?zrsC{]Y ~_ќ1kP+q5!7(bEX.C"kfMih΋=+<p%1gv :Z1ha6u;u}^hFt4'-I| ϱˠ|HP{hgWmsR֧ޛq7wz@KSvT=^ 4C^Cv7^>[w9q< \ak &YEaa99iRCeRm5jTC])^M+|q)j8am/>~[]h94:)V&nc}Ȝ789>k[{@3:Wj`+1xZUs!o:?Ő ih<9Z t%o*~__蔽-,zgzϼFj|p^}\7z,ii9Gmqrgᒟn0443|ވϝO5{ǶK(Ng D>7 >};~?k9eίemVDƷ^ɽϚݔgCiN"եWFKE'rGdH)S&oްX|&x& sPj0zIf;l}rdsKx5Pmr}50? ~yUCY+p]^͸ыdWsKnǂ9u{ǟcޟ"Ϲ-awȤA,HE'+knߌ%{pH\>Cl*·3QQAHG4$حsOlӺ j"^&,0ԶXx8L)>6Y!!,[YIEO⥩ŤӡK,+$t1AQ}.D=3leeב` "DpH*4&%EVROsks"yѯ3Po;]zRy:ְ.9cHV蘨з#8>7}!Q[=֭~1Eҽ'k^PKTƶ@3,g)NĻrh{%.?V3}f:#PkjfmƵA\L1b6e<ht26EzVy3OE\ӄ;q+5A5AWw⾟0Q#P Dd 0   # A  " mVbiȔV@=mVbiȔgC͟ xXyPU>4:&#'UNg"vƎc4[mX4ƸVl#NMhĺ (I( nxK/}sg'C&4BSV$3>5c~[:%E{jtƭ@ѽw ,BÔRk@ 0܆67 7hW਻ {M"2ث~[hXwf icԓ:8%z$-sa#)u\;<Nڛ$4*6H=JZ+c崚g-MEm9Gu. ;fmhVnѴ[-.D"y~Oq)_A1!RC?V][xH_ehQq0פV_wo;=/NF]Q"jOƣDL{Q[qކC[q=s oմ/pEPq0Rh&/JN'܃ ] ݦyDx$PqA^XZ.?nUΤ)|'}}|87r|P>FrFGV gC?}=6KGz<Խڭ4-) :s<> KI6p|8E>&|8N>ÿ >lA5yٜǟH{sD¼K{)~e"r? v (_4O|^j Ӷ9q$nFr:/5h>P>!bpCVVoW_/=]ptuHwnCf[-knD,{v ~nY#n'7/.ca>B~?nޮ夬O 7Oև&c+qxWߛ31Gi.x\Nc=.Ze4nz,aǙp#RCAltyI }6[j( 6O/0h޾ƫyc7zchݥh,<3Ih*J@0ݡr6?֏|\q:Pw^Xa]Gޙ4g4~7R"QdGÜKs5o?ŐւɩkKf.n#u{{5^z/b9^es~{On_ǂ9u{ǟc}> #{({P<0hPr[7R!\< Ndq!?TQr4 %Gj?}ab8uVآT^<"%b(ߨ f'' ƮVVRBp ZŊSt6NQs~*DҴUhH18q"}KXgLt-6bt k ՙaeX\1y2-8 <-xa&!}'Ծ(!g^U[TX3"^L1ALl"=/F%G:Fmji a_sZP:ʹ,Z)VӸֻ~c8p/p>Bh.τe⟒?G6OC4׬kG<T t   @Title of Innovation: Technology Based Nursing Systems Redesign VHACOMITCHR Normal.dot vhacoreynok2Microsoft Office Word@F#@,@n<۰@n<۰]%՜.+,0( hp| DocumentSummaryInformation8XCompObjq VAO+' @Title of Innovation: Technology Based Nursing Systems Redesign Title  FMicrosoft Office Word Document MSWordDocWord.Document.89q @@@ {aNormalCJ_HaJmH sH tH DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List +X z z z z z z zw @'+@Jk}~&4  ' H V p q { | e f w 6@[{cdu 1Td_hW`z$%&""#$#%#&#}#####$$!$"$ '''>'?'@'A''''''( (*(+(**++++!!!!!!!!! !!!! !!!!!!! !!!! !!!! !!!!!!!!!!! !!!! !!!!!!!!!!!v: !!!! !!!!!!!!!!! !!!! !!!!!!!!!!! !!!! !!!!!!!!!!! !!!! !!!!!!!!!!! !!!! !!!!!!!!!!! !!!! !!!!!!!!!!!! !!!!!! @Jk}~&4  ' H V p q { | e f w 6@[{cdu 1Td_hW`z$%&""#$#%#&#}#####$$!$"$ '''>'?'@'A''''''( (*(+(**++++@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00@0@0@0@00@0@0@0@0@0@0@0@0@00@0@0@0@0@0@0@0@0@0@0@0@0@0@00@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@Jk}~&4  ' H V p | e f w 6@[{cdu 1Td_hW`z%&""#%#&#}#####!$"$ '''?'@'A''''''(+(**++++@0 @0 @0 @0Z00@0@0Z00Z00Z00<Z00< Z00;Z00Z00< @0 @0 @0Z00=Z00=Z00=Z005@0Z002@0Z00Z00fOZ00@0Z00c@0 @0Z00=@0Z00/@0Z00,@0Z00. (Z00- @0Z0"0W@0 @0Z00=Z0 0< @0Z0'0(Z0'0&@0Z00@0Z0-0J@0 @0Z00=Z0!0Z000)1FZ000$Z010&Z0!0Z0!0@0Z070>@0 @0Z00=Z0 0>Z0 0> Z0 0=Z090@0Z0>0?lFZ0'0@0Z0B02@0 @0Z00=Z0 0;@0Z00=Z0H0@0Z0J0KZ0.0 @0Z0N0$@0 @0Z00=@0Z0Q0RZ0Q0Z0Q0@0Z0U0VZ030 @0Z0Y0@0 @0Z00=@0@0@0Z0^0 @0Z0`0 a0Z090 X090 X0t0  @0@0 @0Z00=Z00;@0@0@0@0Z0k0 @0  @0  {t"'|+/3 !#%')* 'uh#&+/3"$&(+3 w u "# #"#':'<'++++::::::::::8@0(  B S  ? _1280835038+@+ *d |*d <*d )d )d |)d <)d (d (d |(d <(d 'd 'd |'d <'d |%d <#d .d +dYY   KKsskk##''+     cc ! ! UU}}uu##''+     9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCity DK J T DL%,6>\f######$ $%#%O&Y& ((+/|  +:::| o+++ 5$q$3WSfU}{aqn~+33@+p@Unknowngz Times New RomanTimes New Roman5SymbolG& z ArialHelvetica"qh³&]%O]%O!24d++3qHX)?{a2?Title of Innovation: Technology Based Nursing Systems Redesign VHACOMITCHR vhacoreynok