Patient Resources

Structural Empowerment

Clinical nurses have a voice within the UT Southwestern shared governance organizational structure, which is built on a solid foundation of teamwork and collaboration. Shared decision-making and accountability empower nurses with a process for determining professional nursing practice. These organizational standards are developed through staff-led interdisciplinary committees, task forces, and councils to improve patient outcomes and experiences. Nurses at all levels take conscious ownership of patient care, safety, ethics, research, performance improvement, and evidence-based practice. Our shared governance structure supports the practicing nurse as a key decision-maker with a credible, sought-after perspective. This model strengthens practice by supporting relationships and partnerships among clinical areas, providing an innovative and collaborative environment to bolster our quality patient outcomes.

Shared governance structure

UTSW Shared Governance Structure

UTSW has a strong shared governance structure that includes all staff from all areas and disciplines, as reflected in the accompanying diagram.

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Educational Levels

A significant body of research indicates that a more highly educated nursing workforce can help ensure the U.S. population has access to high-quality, patient-centered care. Having at least 80% of nurses holding a bachelor’s degree or higher by 2023 was a key recommendation of the Institute of Medicine (IOM). The UTSW Nurse Executive Cabinet works to increase reimbursement for nurses pursuing higher education.

The UTSW Nurse Executive Board is responsible for attaining the IOM’s 80% B.S.N. goal. As illustrated in the graph at right we have maintained high levels of performance in this metric.

Clinical Ladder

The UT Southwestern Nursing Clinical Ladder program is committed to recognizing superior performance and rewarding nursing excellence in the provision of direct patient care. The newly improved program offers a unified, point-tiered system for all eligible nursing staff throughout UT Southwestern. Within this program, participants may select options unique to their individual professional development and nursing practice in areas of continuing education, quality improvement, leadership, and evidence-based practice.

The UTSW Nursing Clinical Ladder is open to all clinical nurses involved in direct patient care.

Advanced Practice Provider Incentive Program

In fiscal year 2023, the Advanced Practice Provider (APP) Clinical Ladder program was replaced with the APP Incentive program, which incorporated quality and productivity goals while keeping the professional contribution goals that were paramount in the Clinical Ladder program. The Incentive program was developed with feedback from APPs and key organizational stakeholders. The Professional Contribution domain provided an opportunity to receive an incentive from activities including:

  • Involvement in quality improvement, evidence-based practice, and research projects
  • Serving as a podium speaker or presenting a poster abstract at a conference
  • Publishing in a scholarly journal or book
  • Supporting UTSW’s educational mission through precepting and/or teaching
  • Serving on UTSW or professional organization committees

In FY 2023, 156 advanced practice registered nurses received an incentive payment for their professional contributions to the organization and our profession.

Advancing the Clinical Ladder Program

As UT Southwestern Medical Center continues to grow and change, many of its long-existing programs are transforming as well. Our Health System Nursing Clinical Ladder program offers an important way for employees to actively participate in their own professional growth and development. Because the Nursing Clinical Ladder programs between inpatient and ambulatory services were operating independently from one another, a need was identified by the Office of Nursing Excellence to make the Nursing Clinical Ladder one unified, systemwide program.

As one would imagine, it takes a team of individuals collaborating to overhaul such an extensive program. To achieve this unified purpose, a workgroup composed of unit/hospital leaders, the department of Nursing Excellence, nursing research, direct patient care representatives, education teams, and nursing executive leadership was launched.

The Nursing Clinical Ladder workgroup analyzed the program guidelines of other health care facility clinical ladders as a basis for best practice. The workgroup compared and matched corresponding options between the ambulatory and inpatient programs. The standard options were then combined and weighted according to the importance of the work performed. Determinations were made collectively by hospital and unit leaders, Office of Nursing Excellence and Nursing Research Council members, direct patient care representatives, nursing education teams, and nursing executive leadership.

Notable improvements to the program include:

  • Biannual submissions now allow greater access for new participants.
  • Point system has been updated to a weighted system, allowing higher-priority work and long-term projects to be eligible for more credit.
  • Participants can use two years of work toward their submission.
  • Participants are now eligible for ladder pay over two years.

In 2023, a record number of nurses participated in the Clinical Ladder program, including 103 ambulatory nurses and 142 inpatient nurses. The Nursing Clinical Ladder workgroup merged the inpatient and ambulatory programs into a cohesive, unified program. A trial run involved a pilot group of 15 successful participants who submitted their packets in September 2023. Moving forward, submission deadlines will be set for Feb. 1 and Aug. 1 annually.

“FedEx” meeting attendees:

  • Christi Nguyen, D.N.P., RN, FACHE, NEA-BC, CENP, Associate Chief Nursing Officer of Nursing Excellence
  • Dawn Brown, M.S.-M.A.S., B.S.N., RN, NE-BC, Director of Med & Inpatient Special Pathogens, Inpatient Nurse Clinical Ladder Committee Member/Leader
  • Linda Chan, M.S.N., RN, CMSRN, OCN, 11 Green Oncology Services
  • Kim Collier, B.S.N., RN, CNOR, Director of Surgical Services for OSC, Inpatient Nurse Clinical Ladder Committee Member/Leader
  • Kerry B. Copeland, M.S.N., RN, CNRN, CRRN, NPD-BC, Accredited Provider Program Director, Program Manager Professional Development, Clinical Education and Professional Development
  • Kaitlyn M. Gore, M.S.N., RN, CCRN, Patient Care Services, Assistant Nurse Manager, Clements University Hospital, Chair of Inpatient Nurse Clinical Ladder Committee
  • Tasha Grismore, B.A.S., Program Coordinator for CEPP, Inpatient Nurse Clinical Ladder Coordinator
  • Alison Isabelle, M.S., B.S.N., RN, Manager of Clinical Operations, Ambulatory Nursing
  • Veronica Kogera, M.S., B.S.N., RN, Assistant Manager of Patient Care Services, Inpatient Nurse Clinical Ladder Committee Member/Leader
  • Mari Ann Lewis, B.S.N., RN, AMB-BC, NPD-BC, Manager, Clinical Education and Professional Development
  • Michelle Rachubinski, B.S.N., RN, Ambulatory Clinical Nurse Educator, Ambulatory Nurse Clinical Ladder Program Facilitator
  • Cheryl Schuch, M.S.N., RN, CMSRN, Practice Transitions Manager
  • Sharlynne Serapio, M.A.E.M., B.S.N., RD, RN, Clinical Nurse Educator, Ambulatory Nursing Operations, Facilitator for Ambulatory CMOA Clinical Ladder Programs
  • Emily Smith, M.S.N., RN, Nursing Professional Development Practitioner, Psychiatry and Rehab, Clinical Education and Professional Development
  • Shinto Thomas, M.S.N., RN, PCCN-K, Interim Director, Clinical Education and Professional Development 
  • Calli Wood, M.S.N.-Ed., RN, NPD-BC, Director of Ambulatory Nursing, Education, Training, and Professional Practice

Committee members consulted during development process

In addition to committee members listed above who participated in FedEx meetings, Inpatient Nurse Clinical Ladder and Ambulatory Nurse Clinical Ladder committee members were kept apprised of updates and given the opportunity to provide verbal feedback prior to finalization. The following committee members also contributed written feedback during the refinement stage:

  • Stephanie Barnes, B.S.N., RN, OCN, Infusion Oncology Nurse
  • Teresa Davis B.S.N., RN, Ambulatory Nurse, Urology Clinic
  • Brittany Doyle, B.S.N., RN, CCRN, SCRN, 3 Orange Neuro-Surgical Intensive Care Unit Nurse.
  • Jennifer Goodman, B.S.N., RN-OCN, Oncology RN, SCC Hem-Onc Infusion
  • Marissa McDaniel, B.S.N., RN, SCRN, 8 Orange EMU/ASU Nurse
  • Norma Sonier, B.S.N., RRN, CCRN, Rapid Response Team Nurse
  • Donna Stephens, B.S.N., RN, RN-BC, Zale 5th Nurse
  • Jessy Thomas, B.S.N., RN, CNOR 3 Orange Prep and Recovery Nurse
  • Tamla Wells, B.S.N., RN, CCRN, Zale PACU Nurse
  • Fatemeh Youssefi, Ph.D., RN-OCN, Oncology RN, SCC Hem-Onc Infusion

Hospital & Ambulatory Clinical Education & Professional Development

Clinical education and professional development (CEPD) advance the philosophy, mission, and vision of UTSW Nursing Services. CEPD provides support to clinical staff by offering education, training, and professional development activities. This includes clinical orientation, student placement, and education on care standards and quality improvement. Our practice transition team supports and facilitates the transition to practice experience while cultivating an inclusive learning environment for the RN and PCT residents and nurse fellows. We are accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. We offer educational hours to the events that support nursing continuing professional development (NCPD) and improve patient outcomes. CEPD is committed to providing clinical staff with education and resources to deliver safe, compassionate, patient-centered care in an engaging environment of quality, evidence-based, and professional practice.

Our commitment to excellence in education is evidenced by employing the Nursing Professional Development Practice Model (ANPD, 2016) to leverage learning to meet and exceed organizational outcomes. Our Nursing Professional Development (NPD) practitioners are master’s degree-level prepared nurses and require NPD certification within 18 months of hire. NPD practitioners operationalize environmental scanning, proactively plan educational programming, and work collaboratively with unit-based educators to meet the learning needs at the individual, unit, and organization level.

The Brainy Points Initiative

The Neuroscience ICU (NSICU) developed the Brainy Points initiative to improve staff satisfaction and retention through rewards and recognition. This need was identified after a steady rise in staff turnover and survey feedback indicating employees felt inadequately recognized for their work.

In 2022, a critical need for improvement in employee satisfaction in the NSICU became apparent from responses in the annual employee engagement Glint survey categories of "lack of intent to stay" and “feelings of inadequate recognition.”  In the same year, the department's staff turnover rates steadily increased. The department hypothesized these metrics correlated, and an aim to reduce turnovers by improving staff morale through positive recognition was put into action using shared governance. The Brainy Points initiative was created collaboratively with the Unit-Based Council (UBC) and unit leadership.

After the 2022 Glint survey results, the initiative team sent an anonymous survey for feedback on what recognition meant to staff. The team then created a list of difficult tasks/situations and developed a points-based system of non-monetary rewards. The resulting tasks and corresponding points awarded were gathered into a “playbook” submitted to upper management before rollout during Nurses Week in May 2023. The team created a QR code for a submission portal where staff could nominate themselves or peers for points. At the end of the month, points are reviewed by committee members, tallied, and sent out to the whole unit to cash in points or save them for higher-level rewards.

The annual Glint survey provides operational insight for opportunities to improve. Before the inception of Brainy Points, “Recognition” was consistently a top survey result needing improvement, with scores of 73 in 2021 and 68 in 2022. Staff retention was critical as the turnover rate jumped from 7.8% in 2021 to 27.4% in 2022. After rollout, these rates decreased (monitored monthly): 14.3% in January, 18.6% in February, and 0% from March to July. In August 2023, a spike of 10.3% was correlated to a change in management, and then the rate lowered to 1.4% from September to October. UBC has tracked 325 staff nominations and awarded 304 Brainy Points. In the 2023 Glint survey results, “Recognition” was no longer a top need for growth.

  • Samanta Allen, RN, NSM, UBC Secretary
  • Rachel Anderson, B.S.N., RN, CCRN, SCRN, UBC Chair
  • Molly Ormand, B.S.N., RN, UBC Co-Chair
  • Anjali Perera, B.S.N., RN, CCRN, Assistant Nurse Manager
  • Lisa Smith, B.S.N., RN, CCRN, Assistant Nurse Manager
  • Christine Villarama, B.S.N., RN, UBC Past Secretary

Expanded Professional Development for APPs

The UTSW Office of Advanced Practice Providers (OAPP) organizes monthly educational lectures to provide participants with continuing education and contact hours. This lecture series is designed primarily for advanced practice providers (APPs) to attend sessions on various multidisciplinary topics. The lectures, usually delivered by APPs specializing in relevant fields, are attended by nurse practitioners and physician assistants but also attract clinical nurse specialists, certified nurse-midwives, certified registered nurse anesthetists, and physicians. The content typically focuses on a specific disorder or disease, covering signs and symptoms, diagnostic strategies, and treatment options based on the latest evidence or accepted best practices. Prior to 2023, there were typically 11 lectures each year.

To ensure the series met the needs of its attendees, the Advanced Practice Provider Continuing Professional Development Committee (APPCPDC) conducted annual gap analyses through surveys distributed to all UTSW APPs. Their feedback indicated a demand for more frequent offerings and diverse topics. Specifically, there was a call to include nursing contact hours with pharmacotherapeutic content to fulfill APRN licensing requirements and to expand the educational content to cover acute care and pediatric subjects.

In 2022, the interprofessional APPCPDC responded to the gap analyses by adopting a multifaceted strategy. The committee decided to increase the frequency of lectures, planning three sessions every month on Mondays. Each session was designed to cater to different areas: one for general advanced practice topics, another focusing on acute care, and the third on pediatric issues. The committee grew to include more members with expertise in critical care and pediatrics to support this expanded scope. Subcommittees were formed to manage the planning of this new format efficiently.

Four advanced practice nurses completed NCPD (Nursing Continuing Professional Development) nurse planner training, enabling activities to be organized within the OAPP. Collaboration was established with the Office of Nursing Excellence and NCPD teams to create a new process for reviewing and designating pharmacotherapeutic hours on NCPD certificates. We also found a system for providing enduring materials for CME and NCPD credits, allowing APPs to earn credits even if they could not attend the live sessions. A widespread call for APP speakers was issued, resulting in a comprehensive lecture schedule. The APPCPDC also actively mentored speakers to ensure quality and relevance.

The acute care lecture series was launched in September 2022, and the pediatric lecture series followed with implementation in January 2023. In FY 2023, the quantity of lectures nearly tripled, fulfilling several objectives. This expansion met our APPs’ growing needs for CME, NCPD, and pharmacotherapeutic hours. Also, by increasing the number of sessions, more APPs could lecture, enhancing professional development for the attendees and speakers. The growth and restructuring of the committee allowed for greater member involvement in the continuing education process.

  • (Adult Committee Chair) Ashley Boothe, M.S., APRN, AGACNP-BC, FNP-C
  • (Pediatric Committee Chair) Courtney Campbell, M.S.N., APRN, NNP-BC, C-NPT
  • (Executive Sponsor) Brad Goettl, D.N.P., FNP-C, AGACNP-BC, ENP-C, FAANP, FAAN
  • (Program Coordinator) Vanessa White, B.S.
  • Kaitlin Alexander, M.S.N., RN, CPNP-PC
  • Carolina Carvajal, M.P.A.S., PA-C
  • Keri Draganic, D.N.P., APRN, ACNP-BC
  • David Haggard, D.N.P., APRN, NNP-BC, NEA-BC, C-NPT
  • Daniella Hall, M.P.A.S., PA-C
  • Laura Hanna, M.P.A.S., PA-C
  • Denise Link, M.P.A.S., PA-C
  • Anitha Litty, D.N.P., APRN, FNP-C, CDE
  • Arpita Patel, M.P.A.S., PA-C

Decreasing Delays for Early Mobility

Early mobility is associated with preventing hospital-acquired conditions such as falls, pressure injuries, and infections. Delay in physical activity can lead to less-than-optimal outcomes for patients, including increasing risk of deconditioning, extending lengths of stay, and contributing to readmission rates, all of which are very costly. In Q4 of 2022 on the 2 Orange Unit, it was noted that 18% of patients experienced at least a one-day delay between the time of the physical/occupational therapy ordered and its initiation. Further investigation disclosed that for the physical therapy daily care assignment, if the order was received after 7 a.m., the therapy was not initiated until 24 hours later.

Seeking to improve patient care collectively, the 2 Orange Surgical ICU team decided to improve patient mobility and decrease length of stay by decreasing delayed mobility therapy services. Delayed therapy was defined as: therapy orders received in which no evaluation was completed until the next date or later. The unit goal was to improve communication between SICU provider and therapy to decrease delayed initiation of physical therapy by 50% as of April 30, 2023.

As with many hospital initiatives, it was clear to the 2 Orange team that multiple collaborators from various disciplines and shifts would be needed to impact practice and improve outcomes. The interventions reflected this team's thoughtful and thorough approach to addressing the delay in patient care.

Interventions deployed incorporated improvement of activities during both shifts. An example of this was a rounding tool created for the nightshift charge nurse to readily access the list of patients with existing orders for physical therapy. With this list used during nightshift interdisciplinary rounds, patient goals were discussed sooner and communication to initiate therapy services was prioritized. These activities facilitated the earlier initiation of therapy services because they were now being ordered immediately using the workstation on wheels. Cooperatively, the daytime physician collaborated with therapy services to plan the best time for the patient to receive therapy. With this efficient communication plan in place and the preemptive activities of timely ordering of therapy services, effective changes to the process were made.

Barriers such as communication between nursing, physicians, and therapy services can be removed by initiating interdisciplinary partnerships and using existing technology. Due to this project's success, there are plans to initiate this program in all the five ICUs at UT Southwestern Medical Center.

Gloria Menard, M.S.N., RN, NE-BC

6 Green Improves Nursing Turnover Rates

For hospitals, nursing turnover can lead to significant costs associated with replacing, hiring, and training new employees. Aside from the negative monetary impact on hospital units, nursing turnover can also affect the quality of care provided to patients and can lead to increases in staff burnout. In short, turnover directly or indirectly affects budget, employee satisfaction, and patient satisfaction. The combination of these factors often results in a decrease in overall unit morale as staff try to adjust to the effects of turnover. This was the case on the 48-bed 6 Green Surgical Unit (6 Green), where nursing turnover was identified as an ongoing issue.

Nursing leaders on 6 Green monitor turnover as a common visible source of excess labor cost. At the start of the COVID-19 pandemic, 6 Green saw an increase in nursing turnover, which continued through the end of fiscal year 2022. By the end of FY 22, the nursing turnover rate on 6 Green was 22%, which was above the UTSW fiscal year benchmark. At the start of FY 23, 6 Green unit leadership and the unit-based council (UBC) set a unit goal focused on improving nursing retention. The agreed-upon goal was to decrease the nursing turnover rate on 6 Green from 22% to less than or equal to 10% by the end of FY 23.

The 6 Green nursing turnover reduction team, made up of nursing leadership, the UBC, and the 6 Green unit-based educator, developed an action plan to improve engagement, decrease turnover, increase productivity, and boost employee morale.

The team’s multifaceted interventions included actions in four of the six major components of the American Association of Critical Care Nurses (AACN) Healthy Work Environment: appropriate staffing, skilled communication, authentic leadership, and meaningful recognition. The team developed these specific changes as part of their action plan:

Adequate staffing ratio:

  • Reinstated the admit/discharge RN to help with the workflow in the unit, to increase efficiency, and to expedite discharges.
  • Ensured that the nurse-to-patient staffing ratios are adequate for the unit's workflow.

Streamline onboarding process:

  • Preceptors are hand-selected by the leadership team using personality-matching criteria to ensure appropriate pairing.
  • New hires and nurse residents are welcomed to the unit with “goodie” bags.
  • Constructive feedback and positive reinforcement are maintained by weekly 1:1 discussions with new hires and residents during orientation.


  • Leadership will be responsible for creating and promoting a supportive environment for all staff that focuses on accountability, transparency, and teamwork.
  • Open-door policy will be maintained by the nursing leaders to promote communication transparency.
  • Turnover rates and hiring data will be openly shared during monthly staff meetings.
  • A CMSRN study group was initiated by the ANMs to help staff achieve their nursing certification.
  • Personal and professional growth development will be promoted through committee membership.

Sunshine Committee:

  • Staff potlucks and parties were initiated to promote engagement and celebrate wins.
  • Increase recognition and award nominations.

The 6 Green nursing turnover reduction team identified several experiential changes that resulted from the interventions. Improved retention helped to increase the number of experienced and knowledgeable nurses on the unit, which resulted in a tangible improvement in the quality of patient care. The one-on-one meetings offered employees a chance to be coached, allowed opportunities for growth, and provided tools and resources for them to perform to the best of their abilities. Consistent communication with the staff allowed leaders to give timely input while monitoring progress in real time. And helping with development and professional growth has kept staff engaged within the organization.

As a result of these combined actions, the 6 Green nursing turnover rate decreased from 22% at the end of FY 22 to 0% at the time of this publication. In addition, the unit saw a concurrent improvement in its Values in Practice (VIP) engagement survey results, achieving “Engagement” scores of 88 in FY 23 (12 points above benchmark) and “Intent to Stay” scores of 86 (four points above benchmark).

New initiatives and innovations helped 6 Green reduce nursing turnover effectively. Teamwork and strong camaraderie between employees have promoted cohesiveness within the team.

  • Julie Abraham, B.S.N., RN
  • Zehra Aziz, B.S.N., RN, Unit-Based Educator
  • Zeina Barakat, B.S.N., RN
  • Lauren Brosin, B.S.N., RN
  • Shari Ann Dino-Vu, B.S.N., RN, CCRN-K, NE-BC
  • Beena Johnson, M.S.N., RN, RN- BC
  • Lisa Kielpinkski, RN
  • Megan Low, B.S.N., RN
  • Emily Nguyen, B.S.N., RN
  • Nina Pacheco, B.S.N., RN
  • Amor Remoto, B.S.N., RN
  • Asha Samuel, B.S.N., RN

Improvements in Staff Recognition on 7 Green

Glint survey results from 2022 highlighted the need to enrich both staff recognition and satisfaction, with the potential to positively impact retention rates by fostering a greater sense of belonging among the 7 Green staff. The goal for this project was to collaborate with the unit-based council (UBC) and brainstorm strategies that not only highlighted sincere appreciation for the staff's dedication but also promoted a stronger sense of coherence among the team.

To facilitate this project, initiatives were developed to help staff decompress and engage in enjoyable activities. Staff members were nominated and received awards such as the Safety Catch award, the Meritorious Award, and the Top Safety Poster award for the Fall Poster Competition. Honorees were prominently displayed on the department bulletin board, and dedicated time during staff meetings was allocated to discuss their professional achievements. In addition, the team began sending congratulatory emails sharing complimentary comments and praises staff members received during Nobl rounding. The 7 Green UBC also began highlighting the top-performing staff (nurse and patient care technician) based on the volume of positive feedback received during unit meetings. In addition, to build camaraderie and instill a sense of belonging, the 7 Green unit hosted several potlucks throughout the year, which proved instrumental in enhancing culture and nurturing understanding among staff through the sharing of delicious food.

The feedback from staff members on these activities has indicated increased satisfaction, and  7 Green’s retention rate has improved. The nurses and patient care technicians have especially enjoyed being able to receive patients’ comments about them during the leader rounds. Staff now recognize that their opinions and suggestions are taken seriously by the unit leaders. This effort has brought the team closer together and enhanced overall efficiency.

  • Lilie Anne, RN
  • Hannah Barentine, RN
  • Kelly Baxter-Duke, RN
  • Sanhit Dhakal, B.S.N., RN-BC, Assistant Nurse Manager 7 Green
  • Manju George, M.S.N, RN, CMSRN, Nurse Manager 7 Green
  • Alice Johnson, B.S.N., RN, CMSRN, Assistant Nurse Manager 7 Green
  • Kimberly Johnson, B.S.N., RN, CMSRN, Assistant Nurse Manager 7 Green
  • Jocelyn Ponce, B.S.N., RN, CMSRN, Assistant Nurse Manager 7 Green
  • Kirsten Venghaus, RN
  • Unit-Based Council of 7 Green

Preventing Falls on 10 Blue

Transplant patients are at increased risk for falls after they have received their transplant. Muscle wasting is common immediately post-transplant, and it is a prominent indicator of all falls in lung and heart transplant patients.

To prevent falls, it is vital to identify causes, involve stakeholders, and create preventive measures. When the team on 10 Blue Unit identified that patients were experiencing a high number of falls, they began working together to assess and address the issue. On 10 Blue, 28 falls occurred from November 2021 to October 2022, which was higher than the other inpatient units during this period at UTSW. From audits and chart reviews, the team determined that most falls were contributed to patients' reported leg weakness. The goal of this project was to reduce the number of falls by 10% on 10 Blue with a focus on preventable falls.

The project aim was to promote accountability among leaders and staff, set safety goals, and align staff with purpose. Three key stakeholders from 10 Blue – the unit RNs, the nursing leadership team, and the unit-based council (UBC) – played a significant role in this project's success. The stakeholders held a meeting to categorize falls as avoidable or unavoidable and discuss ways to improve. The team focused on avoiding falls to enhance patient safety and collaborated on implementing the following action plans:

  • Continue weekly fall audits performed by Fall Team staff.
  • Meet with pulmonary transplant advanced practice practitioners (APPs) to align on fall precautions.
  • Collaborate with physical therapy (PT) leadership to prevent future falls and document PT recommendations.
  • Engage APPs and attending physicians in safety metrics and supporting noncompliant patients.
  • Put up “Falling Stars” signs in rooms where patients have fallen during their current hospital stay or within the past 30 days, inform float staff, and update the staff assignment sheet.
  • Explore adding fall-related data to Epic for staff access.
  • Revamp the Hustle Award – assisted by the UBC chair and health unit coordinator – which recognizes and rewards prompt responses to alarms.
  • Create a communication tree, assigning reps to discuss falls and expectations with staff.
  • Highlight common fall issues on a board and during shift-change meetings.
  • Develop a fall prevention pamphlet for patient distribution within three to six months.
  • Implement a "Leaders on Call for Falls" protocol where staff contact the unit manager/assistant nurse manager in case of a fall. The primary nurse and the PCT complete the fall debrief with the manager and director; compliance in this measure improved to 100% from February to December 2023.
  • Schedule the Director of Safety to discuss falls at an upcoming staff meeting.
  • Standardize weekly quick hits in the event of patient refusal and escalation processes.

There were three crucial data elements for designing the project: leveraging the RL event report platform, monitoring monthly fall rates, and ensuring compliance through weekly fall audits. Patient falls were monitored through reports, rates were tracked monthly, and improved communication measures after falls were deployed. Compliance with provider participation in the fall escalation process was secured. Educating patients and supporting the 10 Blue nurses increased with the standard escalation process compared to compliance measures in 2022. Additionally, the fall prevention project aimed to improve the well-being of transplant patients by initiation of physical therapy, mobility training, and targeted fall prevention measures. Key practices implemented included patient and staff education, an evidence-based HD fall risk assessment tool, leadership support, a standardized fall escalation process, and environmental modification. Leaders of this initiative were responsible for ensuring accountability, purpose-driven actions, and removing barriers that could jeopardize patient safety and care quality.

The 10 Blue fall prevention project positively affected the target population by decreasing the number of falls and fall-related injuries. From November 2022 through October 2023, 14 falls occurred compared to 27 falls in the same time period the previous year. 10 Blue had four falls with injury in the November 2022-October 2023 period compared to 5 falls with injury in the November 2021-October 2022 period. Fall-related injuries continue to have room for improvement compared to the other service-line units.

To reduce falls on 10 Blue, the service-line director, safety director, unit managers, assistant nurse managers and charge nurses played a vital role in establishing action plans and collaborating with nurses and other multidisciplinary teams in forming a safe patient environment. The project continues to benefit heart and lung transplant patients, reducing their hospital stays. This work has reduced financial burdens of unexpected medical costs and improved patient muscle strength and overall functional status. The project led to personal growth and reflection for the 10 Blue team, which achieved its goal to significantly decrease falls by 10%.

10 Blue staff members:

  • Pamela Dunham, M.S.N., RN, PCCN
  • Courtney Huckaby, B.S.N., RN
  • Patricia Rejda, B.S.N., RN
  • Elizabeth Samuel, M.S.N., RN
  • Anitha Thomas, M.S.N., RN, PCCN

Education Is for Everyone! Empowering PCTs in the Epilepsy Monitoring Unit

The Epilepsy Monitoring Unit (EMU) is a highly specialized unit that requires specific training and orientation for the registered nurse prior to safe and competent care of epilepsy patients. However, the same standard of training did not exist for patient care technicians (PCTs) or sitters. Upon examination, the UTSW standard orientation pathway did not meet sufficiently prepare PCTs to work on this specialized unit, and an educational gap was identified.

A learning needs assessment was conducted at a quarterly PCT meeting where it was found that the EMU PCT staff did not feel confident responding to seizure alarms and their role in providing patient safety. Outside of a three-shift clinical orientation with a preceptor, new-hire PCTs did not have any formalized or standardized training detailing the principles of safety in the EMU and seizure management, much less PCTs floating into the unit.

This project's purpose was to develop a learning intervention to increase PCT knowledge, skill, and confidence in taking care of patients with epilepsy. A workgroup from 8 Orange including unit leadership, PCTs, and the education department was assembled to tackle identified gaps. The team worked together to design a comprehensive learning module consisting of a video tour of the EMU and specialized equipment, the PCT role in responding to seizures, and videos of different seizure scenarios the PCT could be responding to. EMU PCTs were provided personal support through mentoring by the assistant nurse manager and unit-based educator. The PCTs participated in reflective learning by writing a script and acting out videos for the module. PCT knowledge and confidence were assessed pre- and post-education intervention to determine the impact of the training.

Based on those assessments, PCTs demonstrated positive quantitative and qualitative results. As part of onboarding, the module is now assigned to all new-hire PCTs in the EMU through our learning management system.

An unintended positive effect was increased engagement experienced by our EMU PCTs from being included in the education design process. We plan to use this education in the future as orientation material to cross-train the PCT float pool to deliver safe and competent care in the EMU and increase staffing options. Training 8 Orange EMU PCTs has worked to promote patient safety and resulted in increased employee confidence in caring for this specialized patient population.

  • Lisa Aloy, Ph.D., RN
  • Nathaneal Beck, PCT
  • Alexa Collins, M.B.A., B.S.N., RN, SCRN
  • Anna Ellis, B.S.N., RN, CCRN, SCRN
  • George Ogbonna, PCT
  • Jenny Vo, B.S.N., RN, CMSRN

Post-Op Vital Signs Project

Obtaining accurate vitals is a fundamental assignment of nursing care. Vital signs establish baseline measurements for patient status and are often one of the first indicators of changes in patient condition, particularly for postoperative patients. The 11 Orange unit-based council (UBC) identified a gap in the vital sign (VS) process for immediate postoperative patient admissions to the unit. The VS orders were not standardized, causing confusion among staff. VS data were often missed due to unclear orders or inability to locate machines. Missing VS data were identified as contributing factors for delayed recognition of emergent patient transfers to ICU or back to the OR.

In March 2023, the 11 Orange UBC made the Post-Op Vital Signs Project its unit quality improvement initiative. The goals of the project were to standardize unit postoperative requirements through streamlining of order sets used by the oncology surgeons and to increase the number of VS machines on the unit.

UBC members conducted a literature search and identified best practices within the articles. In addition, the UBC created and distributed a survey to gauge staff awareness of current order sets and to determine barriers for fulfilling post-op VS requirements. Survey results confirmed a large practice gap among the staff, both registered nurses and patient care technicians. The UBC also coordinated with the advanced practice providers (APPs) from each of the surgical teams to discuss their VS order sets. Lastly, the UBC advocated to nursing leadership for the purchase of additional VS machines.

The following interprofessional groups collaborated on this initiative: 

  • 11 Orange UBC (RNs, PCTs, HUC)
  • 11 Orange Leadership team (ANMs + NM)
  • Surgical Oncology APP
  • Gynecology Oncology APP

Due to this initiative, postoperative VS order sets were standardized for all surgical teams. Leadership approved the purchase of enough VS machines to have one in each patient room. Laminated signs will be attached to each machine with the order set requirement. The UBC plans to send out a post-survey to reevaluate staff awareness and barriers once the VS machines arrive.

  • Leigh Baxter, B.S.N., RN 
  • Tammy Berry, CNA 
  • Ruben Castillo, D.N.P., RN, CCRN, NE-BC 
  • Eliana Crabtree, B.S.N., RN, OCN 
  • Alma Hernandez, HUC 
  • Soyun “Catherine” Hong, B.S.N., RN, OCN 
  • Agifatou Kurbally, CNA 

  • Chelsea La Fond, B.S.N., RN, OCN 
  • Sharon Le Roux, M.S.N., RN, OCN 
  • Maryann Maramba, B.S.N., RN 
  • Morgan Parker, B.S.N., RN, OCN 
  • Ashley Stone Ryan, M.P.A.S., PA-C 
  • Hanaa Syed, HUC 
  • Nerissa Uy, B.S.N., RN, OCN