We are excited to present the 2024 Nursing Annual Report, which highlights the achievements of our Memorial Health nursing teams and shows how their dedication to excellence has elevated patient care and strengthened our entire healthcare community.
Quality of care improvements continue to increase, related directly to innovative approaches to patient-centered care and the consistent pursuit of evidence-based practice. A culture of collaboration is also evident through a willingness to share knowledge, seek diverse perspectives, work as unified teams and partner on an interdisciplinary level.
Professional growth remains a priority. We expanded our continuing education programs, encouraged specialty certifications and implemented mentorship initiatives that empowered many to advance their clinical expertise. The eagerness of many to embrace these opportunities demonstrates a deep commitment to personal growth and the nursing profession.
This annual report showcases not only statistics and outcomes, but also human stories behind our success. It captures the compassion shown during difficult moments, the solutions developed for complex challenges and the acts of kindness that define our nursing practice.
Please take time to read the brief summaries of the important work listed within these pages. Thank you to everyone who helped make these achievements possible.
Warmest regards,
2024 Nurse Leader Retreat Focuses on “One Memorial Nurse”
More than 80 nurse leaders from throughout Memorial Health gathered for a retreat of learning and networking in April 2024.
The one-day retreat focused on the vision for the MH Nursing Strategic Plan, which is: “unified by a shared sense of purpose, nursing will collaborate across all settings to deliver exceptional patient, family and community-centered care.” Topics included local and national trends impacting nursing, a revised Nursing Professional Practice Model, moments that matter, resilience and preparing the next generation of nurse leaders.
Summer Student Nurse Internship Program Expands
Each summer, Memorial Health (MH) hosts a Summer Student Nurse Internship program.
In 2024, 52 students participated. Leaders from Human Resources, Nursing, Organization Learning, Outcomes Improvement and executive leadership collaborated to plan the internship at all five hospitals, expanding the program by 48% from 2023 and increasing the available number of clinical experiences.
The seven-week program provides hands-on experiences with a designated nurse preceptor for Associate Degree in Nursing (ADN) and Bachelor of Science in Nursing (BSN) pre-licensure nursing students who are entering their senior year or last semester of nursing school in the fall.
��This program is a win-win for student nurses and Memorial Health,” said Charla Warren, RN, SMH nurse manager and program lead.
“Not only do we help prepare the next generation of nurses, but they experience for themselves Memorial’s culture of providing the best possible care for our patients. The icing on the cake is that 24 participants chose to begin their next chapter as new registered nurses with Memorial after their graduation in 2024.”
The immersive experience increases student understanding of the multi-faceted clinical nurse role by practicing skills like assessment, critical thinking and communication with interdisciplinary teams. The internship also provides an opportunity for MH to recruit students into RN positions after graduation and hire students into patient care technician roles prior to graduation. In FY23, 60% of interns accepted positions as RNs with MH and retention for those participating in this program has experienced historic highs—75 to 85% at the two-year mark.
Nursing Professional Practice Model Evolves
A Nursing Professional Practice Model (PPM) provides the foundation and guidance for professional nursing practice, education and research.
Our PPM illustrates how nurses practice, collaborate, communicate and develop professionally and connects Memorial Health’s mission and vision with nursing culture and practice.
“MH has evolved with expanded sites of care, changing patient care needs and new members of the workforce, prompting the nursing leadership team to evaluate whether the PPM that has been in place since 2014 continued to reflect current nursing practice,” said Sue Krows, BSN, RN, CCRN, vice president and chief nursing officer for DMH.
In 2023, nurses across all practice settings were invited to participate in a survey to evaluate and redefine what it means to practice nursing at Memorial Health. Nearly 600 responses were themed, and while caring and compassion continued to be core to MH nursing practice, recommendations were made to expand on the following concepts:
- Advocating for equity and care of diverse populations (inclusivity)
- Care for self
- Autonomy and innovation
- Healthy work environment
- “We” statements of affirmation
Revising the Nursing PPM is a priority in the 2024-2026 MH Nursing Strategic Plan, describing what it means to practice as “One Memorial Nurse.” MH nurses are unified in a shared sense of purpose and collaboration across all care settings to deliver exceptional patient, family and community-centered care. The revised MH Nursing PPM was disseminated in fall of 2024 and embedded into orientation, shared governance, recognition, recruitment and more.
Equity and Safe Sleep for Infants (ESSI) Initiative Advances
In partnership with the Illinois Perinatal Quality Collaborative (ILPQC), DMH, JMH and SMH’s commitment to providing equitable, safe and compassionate care to all families has never been stronger.
A multidisciplinary ESSI Quality Improvement Team—including a neonatologist, family practice provider, nursing leadership and staff—works closely with neonatal care teams to promote a safe sleep environment from birth.
Safe sleep education is initiated upon admission, reiterated at the birth of the baby, reinforced if any unsafe sleep environment is observed and finalized at discharge. This vital information is not just provided by our nurses, but also by our committed neonatal providers, emphasizing shared responsibility in keeping newborns safe.
In addition to education, every family admitted receives a Social Determinants of Health screening to identify unmet needs that may affect their transition home. A key question focuses on ensuring the baby has a safe place to sleep. When a need is identified, the team acts swiftly. Through a new partnership with SIDS of Illinois, Cribettes are provided to families in need—tangible tools to help ensure every infant has a safe sleep space at home.
Also, teams meet monthly to review progress, analyze data and explore new ways to enhance impact. The meetings provide opportunities to innovate, collaborate and elevate the care provided. The ESSI Safe Sleep Initiative exemplifies our commitment to equity, education and excellence in care.
Evidence-Based Interventions Help Reduce Hospital Acquired Pneumonia Rates
Hospital acquired pneumonia (HAP) is one of the most prevalent hospital acquired infections and a leading threat to patient safety.
A quality project driven by the Nursing Performance and Outcomes Council worked to reduce HAP incidents through implementing evidence-based nursing practice changes to positively impact patient outcomes.
The project resulted in a standardized process for assessing aspiration risk, a comprehensive oral care policy and procedure, HAP prevention bundled approach to care and improved provision and documentation of oral care for adult acute care patients in the hospital setting. The bundle includes oral care, mobility interventions and pulmonary hygiene. By November 2024, the HAP complication rate decreased from 1.0% to 0.50% one-year post go-live of the quality project. Length of stay decreased from 18.5 to 13.5 days, and the mortality rate decreased from 0.15% to 0.09%.
“A key takeaway is that nurses in acute care inpatient settings can definitely influence outcomes and reduce the incidence of hospital acquired pneumonia related to oral care as a primary source,” said Stacey Taylor, MSN, RN, and director of professional nursing practice.
“These efforts are making a vital difference for our patients.”
Two-Pronged Approach Helps Reduce ED Length of Stay
During the first half of FY24, the JMH Emergency Department (ED) logged a mean length of stay of 208.7 minutes for discharged ED patients, which was well above the <171-minute target.
“Reducing length of stay was a top priority for the JMH nursing team,” said Carrie Carls, DNP, RN, CHRN, affiliate vice president and chief nursing officer for JMH.
“A data review of timestamps for discharged patients revealed two common bottlenecks for length of stay.”
The first bottleneck was the 40 minutes on average it took to collect a urine specimen after ordered. The following interventions were implemented and helped reduce length of stay by 25 minutes per discharged patient, which equals 358 patient care hours saved monthly.
- Urine cups were stored at triage with the expectation that a triage nurse dispenses cup to patient in anticipation of urine testing, when it is clinically indicated.
- A charge nurse role was created for busiest discharge hours, 1000-2230, with prioritization of outflow from department, to expedite final treatments for patients being discharged.
- A dashboard was created to monitor both metrics and give performance feedback with automated communication.
The second complicating factor was the 30 minutes it took to dispense treatments after results were completed. The Lean Six Sigma Belt team for “JMH: Reducing Length of Stay for ED Discharged Patients” performed data measurement, root cause analysis and made recommendations for improvements. They found:
- When patients receive treatment after their last result, this adds 30 more minutes to their length of stay. The team recommended staffing a dedicated RN from 1200-2200 to expedite discharges and other throughput mechanisms.
- To expedite this phase of patient flow, a dedicated colleague monitored patients for last results, focusing on providing medication or other interventions. This freed up the primary care team to care for newer patients, which improved overall efficiency within the department.
UTI Instances Come Down after Complications of Care Project
In 2023, the observed/expected ratio for inpatient complications at LMH was 56% higher than expected.
Urinary tract infections (UTIs) were identified as LMH’s most frequent complication with 3.07% of acute care/swing bed patients developing a UTI during their stay. Hospital-acquired UTIs can result in longer length of stay, increased antibiotic usage and higher cost of care.
Using the DMAIC framework (Define, Measure, Analyze, Improve and Control), the project team identified multiple opportunities related to improving hydration, intake and output documentation, patient hygiene and Foley catheter care, urine specimen ordering and collection and coding accuracy. Improvement strategies included education, communication and visual cues, as well as process changes like the creation of a bathing schedule and supervisor validation of UTIs coded as Present on Admission (POA).
“I’m so proud of my team on the Acute Care unit,” said acute care nurse manager Lydia Allen, RN. “Because of the interventions and process improvements, they were able to reduce UTI complications by 51%!”
5S Methodology Helps with Medication Pass-Through Optimization
In the summer of 2023, LMH observed an increase in the number of incorrect med/dose/strength events entered in the patient safety event reporting system.
More than half of reported events were related to dispensing, and 60% of those dispensing errors involved medications placed in the Acute Care Unit (ACU) medication pass-through cabinets.
Crowded, overflowing patient medication bins were a common concern after close analysis of the pharmacy medication cart fill/check/pass and nursing medication administration processes. A multidisciplinary team from Pharmacy, Nursing and Quality used the 5S methodology to sort, set in order, shine, standardize and sustain.
“5S can be an impactful tool to improve workplace organization and flow, and each step contributed to the optimization of LMH’s medication pass-through cabinets,” said Roxanne Stelle, BSN, RN, CHPN, RHCNOC, and director and chief nursing officer for LMH. “Use of the methodology led to process improvements and increased overall safety in the medication pass-through process.”
Risk Assessment Tool Helps with Outpatient Antibiotic Treatment
Many patients who are medically appropriate for discharge may still require ongoing intravenous (IV) antibiotic therapy.
In most cases, IV antibiotic therapy is an outpatient option; however, clinicians may have concerns about abuse potential among patients with a history of substance use.
At SMH, a risk assessment tool was developed to meet diverse patient care needs, foster best practice development and optimize stewardship. SMH sought a consistent process to determine whether patients with a history of substance use could appropriately be considered for discharge with IV outpatient antibiotic treatment (OPAT).
An OPAT review team (OPAT-RT), consisting of a psychosocial risk evaluator, a PharmD specialist in antimicrobial stewardship and a patient care facilitator was deployed.
“The review team evaluates patients who require long-term IV antibiotic therapy and have a history of substance use,” said Megan Kirkpatrick, RN, with SMH care transition team.
“We collaborate with the physicians to develop creative discharge recommendations that help patients get home, which is where they want to be.”
From April 2023 to February 2024, there were 38 referrals for an OPAT-RT Risk Assessment, and 17 screens were completed. Notably, 10 patients were discharged without a central line and received outpatient antibiotics via daily IVs to finish the course of antibiotic treatment. Only two failed the outpatient plan, requiring readmission to the hospital. Implementation of the OPAT-RT Risk Assessment process resulted in 326 hospital days saved, an average 19.17 days for length of stay reduction—all in a high-risk patient population.
$619,400 was saved in avoidable cost of care.
Quality Improvement Awards and New Technology for Family Maternity Suites
The Illinois Perinatal Quality Collaborative (ILPQC) is a nationally recognized network consisting of hospitals, clinicians, patients and policymakers working to improve health and outcomes for mothers and infants.
Every two years, ILPQC identifies key quality initiatives. The SMH Family Maternity Suites leadership team received Quality Improvement Excellence Awards during the annual 2024 ILPCQ Obstetrics and Neonatal annual meeting for their work on behalf of those initiatives.
For 2022–2024, the three ILPQC priorities included vaginal birth, birth equity and safe sleep.
Promoting Vaginal Birth
The Promoting Vaginal Birth initiative strives to reduce cesarean section rates and promote vaginal delivery as a best practice. The SMH team implemented a pre-cesarean checklist reviewed at the patient’s bedside to promote shared decision making, offered a Spinning Babies® workshop to train labor nurses on techniques to assist in successful vaginal delivery and closely monitored cesarean rates. The team reduced the rate of primary cesarean sections in low-risk women from 25% to 21.48%, exceeding the ILPQC goal of 23.6%.
Birth Equity
The Birth Equity initiative also focused on addressing social determinants of health (SDOH) to improve connections to care, provide equitable care to all and narrow the gap of disparities and mortality. As a result, all patients were screened upon admission for SDOH and provided resources for identified needs. Colleagues completed implicit bias training and signed Respectful Care Practices commitment forms. Patients completed the Patient Reported Experience Measure (PREM) survey to provide feedback on the respectful care commitment.
Equity and Safe Sleep for Infants
The Equity and Safe Sleep for Infants (ESSI) goal was to reduce risk of sudden infant death syndrome. Colleagues received safe sleep training. Our team also partnered with SIDS of Illinois for portable cribs for families in need and educated parents on safe sleep practices.
Also, SMH Family Maternity Suites continues to advance clinical care and safety for mothers and infants. In January, the team introduced a new device to support newborns who have trouble breathing after birth. Standard of care is to offer continuous positive airway pressure (CPAP) to support breathing, but now a bubble CPAP machine is available for infants with respiratory distress. This device is gentler and reduces the risk of trauma to the infant’s lungs from pressurized airflow.
In February, the team acquired a new portable monitoring device that allows mothers to move freely during labor, while continuing to monitor the unborn baby. Traditional fetal monitoring often requires the mother to remain in bed with cables attached to her, limiting her ability to change positions. Portable telemetry systems are wireless, allowing the mother to walk, change positions or use birthing tools like a birthing ball, which can be beneficial in managing labor discomfort. Continuous monitoring is critical for detecting any signs of distress in the fetus or the mother, and the new wireless monitoring system ensures both the baby’s and mother’s well-being throughout labor.
Safety Pilot Program: Behavioral Response Team Launches
Last June, a Behavioral Response Team (BRT) was deployed at SMH using specially trained nurses as part of a pilot program designed to better support the management of patients with behavioral difficulties on non-psychiatric units.
Caring for patients who display challenging behaviors is difficult, especially in non-psychiatric settings where a team does not have the skills and resources to address these behaviors. General medical-surgical nurses feel unprepared and often lack the confidence and competence to manage severe behavioral symptoms and/or advocate for use of psychotropics. Sometimes nurses struggle to distinguish psychiatric disorders from dementia and delirium. As a result, teams often call security to help manage these incidents when they become overwhelming.
Tamsyn Weaver, PhD, director of nursing for psychiatry, was determined to develop a coordinated response to help intervene during behavioral escalation in ways that address the underlying pathology.
“The evidence is clear,” she said. “BRTs have been shown to effectively support nursing staff and increase confidence while also decreasing assaults and restraint utilization.”
The BRT nurses proactively see patients experiencing substance withdrawal, delirium, dementia, psychosis, suicidal/self-harm behaviors and violence towards others. They work with the bedside team of nurses and providers to develop a trauma-informed plan of care, role model de-escalation techniques, minimize use of restraints and liaison between the medical and psychiatric teams.
3E IMC Quality Improvement Work: Bloodstream Infections
A Central Line Associated Bloodstream Infection (CLABSI) occurs when bacteria enter the bloodstream through a patient’s central line or long-term IV catheter.
Most of these infections can be prevented with stringent clinical practice and proper patient hygiene. CLABSIs are a primary measure of the quality of nursing care performance.
Following an increased trend in CLABSIs on the 3E intermediate care (IMC) unit at SMH, an interdisciplinary team formed that included nursing leadership, direct care nurses and patient care technicians, plus quality improvement and infection prevention representatives.
“I knew the Plan, DO, Check, Act (PDCA) process improvement methodology was the best approach to address practice issues on the unit and see rapid improvement,” said Kristi Zimerman, RN, and nurse manager on 3E.
Over a five-month period, the 3E nursing team used hands-on return-demonstration to validate nurse competency in caring for patients with central lines, closely monitored compliance with prevention strategies and the removal of unnecessary central lines to reduce risk of infection. As a result, 3E IMC had a 42% reduction in central line utilization and zero infections since January 2024. Last June, the team was awarded the Chasing Zero award for their quality outcomes.
Karaoke, Headphones and Bongos for Psychiatric Patients
Music therapy can reduce patient anxiety and depression within a safe and supportive environment, healing trauma and building resilience.
Over the past several years, the SMH inpatient psychiatry team has sought ways to incorporate music into their therapeutic options for patients. With support from the SMH Foundation, they purchased a karaoke machine in November 2022. Initially the evening karaoke sessions seemed like a fun way to keep patients engaged, but it soon became clear that music elevated the mood of the unit in important ways. Participating patients expressed their feelings and processed experiences. They often mentioned the karaoke in patient satisfaction surveys and described the positive impact it had on their self-esteem and confidence.
Next, the leadership team applied for and received a $1,692 grant from The Community Health Giving Circle, a not-for-profit organization associated with the Sangamon County Medical Society Foundation, to purchase Bluetooth headphones for patients. The headphones debuted in October 2023, each connected to one of three available music stations based on patient preference.
“Patients use music to help self-soothe and cope with overwhelming emotions,” said Dan Welch, 5A nurse supervisor. “The use of the headphones has led to a noticeable change in the number of violent episodes since implementation.”
In December 2024, bongos were purchased with foundation funds, and a drumming circle was added as an option for group therapy. Studies show group participation in drumming reduces stress and anxiety and helps to release endorphins. Since the start of music therapy options in 2022, assaults on colleagues have decreased by 60%, restraint utilization is down 15% and seclusion episodes have decreased 45%.
National Rural Rating System (NRRS) Awards TMH Four-Star Rating
TMH was recognized with a four-star rating from the National Rural Rating System (NRRS), an organization that issues quality ratings for rural and critical access hospitals.
Hospitals are evaluated by NRRS on patient satisfaction, high-quality care and performance-based HCAHPS and CMS data.
“This ranking is like the CMS stars issued to larger hospitals and showcases the high-quality care and experience we provide to the patients and communities we serve,” said Eli Heicher, DNP, RN, CENP, and chief nursing officer at TMH.
The TMH four-star rating showcases the high-quality care and experience provided to patients. The National Rural Rating System was developed in 2022 to establish credible criteria for a rating system for rural and critical access hospitals, emergency departments and clinics. Small hospitals still strive to achieve high patient satisfaction scores and improvements with little recognition for these efforts.
The goal of the NRRS ratings program is to help hospitals achieve greatness, receive recognition for improvements in quality of care and celebrate the successes of similarly sized hospitals meeting these high standards. The standards are based on the CMS Care Compare initiative but altered to accommodate the 100 annual discharge threshold and other metrics.
TMH OR Volume Increases Significantly
TMH OR logged more than 1,500 surgical procedures in 2024, an increase of more than 32% over the past year and more than double since 2020.
Adding increased anesthesia hours and nursing support has allowed surgeons more operating room availability to schedule cases.
One area in which TMH has seen significant growth has been endoscopy procedures including colonoscopies and EGDs. Cataract procedures have also been added with new providers. Orthopedic procedure volume continues to increase and includes open reduction internal fixations, total joint replacements (knees, hips and shoulders) and repairs to shoulders through a scope.
While most of the growth has been in the outpatient surgical population, TMH has also added new surgeries on the inpatient side as well. The overall growth has been intentional, made possible by building new partnerships, adding procedures and flexing the entire nursing staff at TMH to meet needs.