Success Stories – Page 2 – PatientCareLink

RI’s Kent Hospital Advances the Culture of Safety

Kent Hospital’s Good Catch Award is a way to demonstrate the hospital’s commitment to keeping patients, visitors and employees safe by rewarding those individuals who "speak up" to prevent harm and improve the culture of safety. The Good Catch Award creates positive incentives for providers and staff to report patient safety events.

Kent Hospital’s staff strives continuously to enhance the culture of safety and realizes the importance of recognizing individuals who promote safety. High-reliability organizations de-stigmatize failure. Medical errors that are detected and corrected before harming patients are called near-misses. High-reliability organizations treat these events differently from other hospitals. They encourage employees to come forward with near-misses and they focus on which processes and safeguards work best.

A near miss or a "Good Catch" is an error that happened but did not reach the patient, thereby avoiding any patient harm. These errors are captured and corrected either through staff awareness or designed system controls that have been put into place. Kent Hospital recognizes that good systems equal good outcomes and the Good Catch Award program supports this philosophy.

Risk Management and the hospital’s dedicated Management Team review and investigate all reported safety events daily. The investigations provide Kent the opportunity to identify systems or human factor variables to ensure that a similar event doesn’t occur again. Extensive research has shown that most events, both serious and catastrophic, were preceded by warnings or near-miss events. Reporting near miss-events is important to Kent Hospital, as these events occur usually at a much higher rate than actual events.

Risk Management tracks and trends all patient safety event data from the hospital’s electronic safety event reporting system – Quantros. That data, as well as lessons learned, is shared among senior leaders and other interdisciplinary team members at the weekly Performance Improvement and Patient Safety Committee (PIPS) meeting. At each weekly PIPS meeting, Kent Hospital’s management team members collectively review near-miss events in an effort to determine where there is a potential to improve current processes, procedures, and practices. By identifying areas of opportunity, the organization has a better chance of assuring positive outcomes by preventing similar occurrences from happening again.

Since the inception of the Good Catch Program in June 2016, the numbers of near-miss events that have been reported into Quantros have increased significantly. Remember: recognizing and reporting near misses – as opposed to ignoring them – is a positive trend to help improve systems and improve patient safety. To date Kent Hospital has awarded 136 Good Catch awards.

Here are just a few examples of near-miss events:

Near Miss: RN noted Heparin drip order set in Cerner was automatically changing the initial lab draw post initiation. This was a near miss event as it could have led to a delay and/or an omission in the initial post anti- factor Xa resulting in patient harm.

Actions: Heparin Nomogram in Cerner updated; initial 6 hour anti- factor Xa (after the start of infusion) is now automatically pre-checked for drawing by the lab.

Near Miss: RN noted there was 2g Magnesium in the 125mg Cardizem pockets of the Pyxis machines; both have similar packaging and are stored next to each other in the Pyxis.

Actions: Labels were placed on the Cardizem bags to differentiate them from the Magnesium in the pharmacy storage bins. The Cardizem and Magnesium vials were relocated to different drawers in all of the Pyxis machines.

Near Miss: CNA noted that the shower heads in rehab could easily shoot off the nozzle and potentially injure a patient.

Actions: Risk & Engineering investigated, design flaw of the shower heads noted, and all were changed out to a different model.

Any staff member who makes a “Good Catch” is presented with a Good Catch Award certificate, Good Catch lapel pin, and their picture is taken with Kent Hospital’s leadership team members. In addition, the award recipients have their pictures displayed prominently. The staff member’s name is published in Kent Hospital’s ‘Vital Signs’, which is sent not only to all of Kent Hospital, but also via e-mail to all Care New England employees as well.

At the end of each fiscal year, Kent Hospital nominates recipients for awards that are an extension of this program: The All Star Award (1 winner) and the Golden Glove Awards (1 winner from every clinical and non-clinical department within Kent Hospital). These nominees are presented to our Performance Improvement and Patient Safety Committee for voting. Click the link for Good Catch Program highlights.

At Cambridge Health Alliance, Delaying Baby’s Bath Improves Baby’s Health

Imagine you're a newborn, contentedly relaxing in a dark and warm place, bathed in amniotic fluid, when suddenly - BAM! - you're out in the world, surrounded by strange people, who are smiling and cooing at you but who are, nonetheless, very, very strange.

"It's the greatest adventure of their lives," says Cheryl McInerney, R.N., IBCLC, a lactation consultant at Cambridge Health Alliance. "And it's very stressful."

Now McInerney and CHA's Newborn Nursery Hospitalist Anita Gupta, M.D., IBCLC have helped introduce a new post-birth practice that not only has reduced the shock of childbirth for all involved but has reduced the rate of hypoglycemia (low blood sugar) in newborns by almost 50% since April 1, 2013.

The new step is relatively simple: Cambridge Health Alliance waits 12 hours after birth for the baby's first bath, choosing instead to place the newborn with mother, skin to skin, to ease the transition from womb to world.

Gupta says that certain newborns - those born to diabetic mothers, big babies over 8 pounds 13 ounces, and smaller-than-average babies - are at greater risk for hypoglycemia. Babies expend a lot of energy being born, and expending energy means burning sugar.
Babies drop their blood sugar in the first two hours after birth and normally stabilize or increase it by six hours after birth. For certain at-risk babies, the initial sugar drop can be dangerous. CHA is intent in removing as much stress out of the baby's first hours in the world to prevent the levels from dropping even further.

"We check blood sugar levels in the first hour after birth," says Gupta, "and then we continue to encourage babies to breast feed, after which we check their levels again."

But unlike the common practices performed in many hospital nurseries across the U.S., Cambridge Health Alliance performs all newborn tests and procedures in the mother's room. For instance, the state mandates that all newborns receive a shot of Vitamin K to assist blood in clotting and erythromycin eye ointment to prevent infection. At many hospitals, the baby is immediately brought to the nursery, tested, scrubbed, and brought back to the parents.

"Why?" says McInerney. "Why do we have to do all of this right away? Why not leave baby with mom?"

Gupta says there's no clinical reason to bathe babies immediately and remove the lotion-like fluid that has protected them from wrinkling as they lay immersed in amniotic fluid. The baby is merely dried at CHA to keep it warm, and flecks of substances may be removed from its hair; but Gupta and McInerney believe keeping the baby in close contact with the mother as opposed to separating them for bathing is the new best practice. And their data backs them up.

The percentage of newborns experiencing hypoglycemia, which was 12.6% from December 2012 to March 2013, dropped to 6.5% from April to July 2013. "There were no other interventions aside from what we did with delaying the bath," Gupta says. "The results were dramatic."

When the baby is eventually bathed, it's a joyful experience for all involved, McInerney says. The mother is rested; the baby has begun to get it bearings; even the caregivers aren't rushing to conduct a bathing before their shift ends. (CHA will not delay a bathing if the mother has hepatitis B or C, HIV, or MRSA; there's a threat that the virus could be transmitted to caregivers.)

Plus, keeping baby with mom right after birth allows breastfeeding to occur earlier. Under a Joint Commission National Quality Forum-endorsed voluntary practice standard, hospitals are encouraged to promote exclusive breastfeeding during the newborn's entire hospitalization. The Joint Commission notes, "Exclusive breast milk feeding for the first 6 months of neonatal life has long been the expressed goal of World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG)."

A 2010 study by CHA's Dr. Melissa Bartick estimated that encouraging exclusive breastfeeding could lead to the reduction of 10 pediatric diseases, and save the U.S. healthcare system $13 billion a year.

"When we explain to moms, 'We're going to delay bathing your baby for 12 hours and here's the reasons why,' they really embrace it," McInerney says.

Gupta adds that the CHA team has presented their finding to other Massachusetts hospitals and they've also begun to embrace the new practice.

She adds, "It doesn't cost money. It saves money. It clearly improves clinical outcomes, and it's good for the patient - baby and mother. What's not to like?"

Beth Israel Deaconess Medical Center among the first-ever awardees in the National Awards Program to Recognize Progress in Eliminating Healthcare-Associated Infections

The US Department of Health and Human Services has named Beth Israel Deaconess Medical Center among the first-ever awardees in the National Awards Program to Recognize Progress in Eliminating Healthcare-Associated Infections.

The awards focus on central line infections and ventilator-associated pneumonia, two of the deadliest and most expensive hospital-acquired infections. Preventing hospital-acquired infections (HAI) represents a major national priority for the government and health care reform.

HHS selected only 10 hospitals nationwide that demonstrated major progress in reducing both central line infections and ventilator-associated pneumonia. BIDMC is the only hospital in New England to be selected for prevention of both ventilator-associated pneumonia and central line infections.

See full press release >>

Beth Israel Deaconess Medical Center Wins $4.9 Million Grant for Program to Improve Patient Outcomes Within 30-Day Window of Discharge

One of only 26 national Center for Medicare and Medicaid Innovations Grants

Beth Israel Deaconess Medical Center will receive $4.9 million from the highly competitive first round of Center for Medicare and Medicaid Innovation Grants, to launch a Post-Acute Care Transitions (PACT) program designed to improve patient outcomes and prevent avoidable cost in the high-risk 30-day period following acute care hospitalization.

PACT will prospectively enroll all Medicare patients hospitalized at BIDMC through referrals from any one of six affiliated primary care practice sites that collectively account for approximately 30 percent of BIDMC Medicare readmissions.

The program will deploy nurse care transition specialist care coordinators and dedicated clinical pharmacists dually-sited between the hospital and primary care practice to reliably deliver a "bundle" of post-acute care interventions designed to address observed readmission risk.

"Avoidable 30-day readmissions represent a costly consequence of a fragmented care system that often falls short on the promise of better health for patients following acute care hospitalization," said BIDMC Senior Vice President of Health Care Quality Ken Sands, MD.

"Both published and organizational experience fails to identify "point" solutions that have proven effective in reducing readmissions across a generalized patient population. PACT is based in a model refined through an ongoing pilot intervention, and this grant will enable us to demonstrate the efficacy of such a program," he said.

The grant represents the first milestone for the newly announced Center for Healthcare Delivery Science, whose mission is to lead the medical center's efforts in applying rigorous, high-quality science to the evaluation of real-world innovations aimed at improving the quality, safety and value of health care.

Readmission rates can be driven by four basic factors, said Julius Yang, MD, Medical Director of Inpatient Quality at BIDMC who is leading the effort. They include a lack of continuity of post-acute care across the medical system; a widespread variation in disease-specific management following acute hospitalization; highly complex discharge medication regimens; and limited patient ability to advocate for needed medical attention in the high risk period following hospitalization.

"This innovative staffing model, utilizing personnel 'shared' between hospital and primary care practice, enables health care professionals to integrate into existing operational workflow in both sites, and to develop specialized healthcare worker expertise targeting patients' cross-continuum needs specific to the high-risk post-hospital recovery period."

The PACT program is initiated during hospitalization, continued after discharge via telephone and practice-based support, and addresses all potential transitions of care, including those involving home health agency providers and extended care facilities, in order to mitigate any identified risk factors that may contribute to avoidable readmission.

The program is anticipated to reduce the number of 30-day re-hospitalizations by 30 percent over three years, generating an estimated savings to Medicare exceeding $12 million during that time period.

BIDMC is the only Boston academic medical center to receive an Innovation grant. The Joslin Diabetes Center and the New England Asthma Regional Council were also recognized in the competitive grant process that generated approximately 3,000 applications.

"We can't wait to support innovative projects that will save money and make our health care system stronger," said Health and Human Services Secretary Kathleen Sebelius in announcing the 26 grants, funded by the Affordable Care Act, and designed to reduce health spending by $254 million over the next three years.

The projects include collaborations of leading hospitals, doctors, nurses, pharmacists, technology innovators, community-based organizations, and patients' advocacy groups, among others, located in urban and rural areas that will begin work this year to address health care issues in local communities.

For more information on the first round of awards go to: innovations.cms.gov/initiatives/innovation-awards/project-profiles.html.

To learn more about other innovative models being tested by the CMS Innovation Center, please visit: www.innovation.cms.gov.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org.

Beverly Hospital Implements Nurse-Led Program to Reduce Patient Falls

Beverly Hospital in Massachusetts has significantly reduced the rate of patient falls on its units by implementing a comprehensive fall prevention program, WCVB Boston reports.

According to a recent state report, 70 percent of serious injuries in Massachusetts hospitals were caused by falls, with older adults proving particularly vulnerable. As a result, preventing falls has become a top priority at several Massachusetts facilities. Beverly Hospital, for example, implemented the Nurses Improving Care for Healthsystem Elders (NICHE) program, a national geriatric training program launched in 1992 by the Hartford Institute for Geriatric Nursing at New York University College of Nursing. As part of the program, the hospital first identifies patients at risk and uses this information to minimize the risk of patient falls by lowering the height of the bed; clearing pathways to bathrooms and other amenities to ensure that there are no obstacles; and ensuring that items, such as call buttons and phones, are within arm's reach.

According to the NICHE Web site, hospitals that implement NICHE report enhanced nursing knowledge and skills regarding the treatment of common geriatric illnesses; reduced length of stay, readmissions rates and costs associated with treating the elderly; increases in the length of time between patient readmissions; and enhanced patient satisfaction (WCVB Boston, 12/14/09; NICHE Web site).

Patient Falls

The National Quality Forum (NQF) defines a fall as an unplanned descent to the floor (or extension of the floor e.g., trash can or other equipment) with or without injury to the patient.

Beth Israel Deaconess Medical Center Will Collaborate in Two Additional Federal Innovation Grants

Beth Israel Deaconess Medical Center will collaborate in two additional federal innovation awards announced last week: one with Dartmouth-Hitchcock Medical Center as part of the High Value Healthcare Collaborative (HVHC) and one with Mayo Clinic.

These awards were announced as part of the second and final round of Innovation Grants awarded by the federal Center for Medicare and Medicaid Innovation.

The collaborations come in addition to the $4.9 million Innovation award received in May to launch a Post-Acute Care Transitions program designed to improve patient outcomes and prevent avoidable cost in the high-risk 30-day period following acute care hospitalization.

BIDMC is one of 15 large health systems across the nation to come together as the High Value Health Collaborative convened and facilitated by the Dartmouth Institute for Health Policy and Clinical Practice. The $26.2 million grant will fund a program to engage and implement shared decision-making for patients facing hip, knee or spine surgery, and for patients with diabetes or congestive heart failure across the HVHC member systems.

The bulk of the funding will be used to hire and train Patient and Family Activators at the 15 member organizations. Over the three-year grant period, 1,845 health care workers will be trained and an estimated 48 PFA positions will be created to engage in shared decision making with patients and their families, focusing on preferences and supplying sensitive care choices.

"The goals of this project are fully in keeping with our own efforts to create a truly patient-centered care experience where patents and their families work closely with their caregivers," says Ken Sands, MD, BIDMC's Senior Vice President of Health Care Quality and one of the principal investigators on the grant.

CMMI estimates the project will result in savings of $64 million over three years, largely due to reduced utilization and costs that have been shown to occur when patients are engaged and empowered to make health care decisions based on their own values and preferences.

Other members of the HVHC include Baylor Health Care System, Beaumont Health System, Denver Health, Intermountain Healthcare, Mayo Clinic, North Shore-LIJ Health System, MaineHealth, Providence Health and Services, Scott and White Healthcare, Sutter Health, UCLA Health System, University of Iowa Health Care, and Virginia Mason Medical Center.

HVHC members collectively serve 50 million patients in health systems across the United States. The Collaborative was founded in 2010 and identified nine high volume, high cost, high variation clinical areas to focus on, with the goal of improving care and outcomes, reducing variation, and lowering costs.

For the second award announced, BIDMC will be collaborating with the Mayo Clinic, the US Critical Illness and Injury Trials Group and Philips Research North America, in an effort to improve critical care performance for Medicare/Medicaid beneficiaries in intensive care units.

Daniel Talmor, MD, vice chair for critical care in the Department of Anesthesia, is one of three principal investigators, including Ognjen Gajic, MD, from the Mayo Clinic and Michelle Gong, MD, from Montefiore Medical Center in New York.

Data shows that 27 percent of such Medicare beneficiaries face preventable treatment errors due to information overload among ICU providers. The Mayo Clinic model will enhance effective use of data using a Cloud-based system that combines a centralized data repository with electronic surveillance and quality measurement of care responses.

"We believe this will reduce ICU complications and costs," says Talmor, adding BIDMC's role will be to lead the clinical and economic evaluation of the intervention.

One of the clinical sites to take part in the trial is BIDMC-affiliated Lawrence General Hospital, and the medical center will collaborate with Tufts University in the evaluation.

The $16 million grant will train 1,440 existing ICU caregivers in four diverse hospital systems over three years to use new health information technologies effectively in managing ICU patient care. CMMI estimates the efforts will generate $81.3 million in savings.

Boston Medical Center Nurses Teach Pressure Ulcer Prevention

Three nurses at Boston Medical Center are taking a proactive rather than reactive approach to skin care. The skin team RNs - two full time and one part time - constantly emphasize the importance of assessing patients' skin from head to toe.

Because ongoing documentation of pressure ulcers is necessary to ensure Medicare reimbursement, the nurses review with staff on a regular basis how to properly report finding pressure ulcers and whether a patient already has one on admission. If patients fall at home but are not found for several days, for example, they often are admitted with pressure ulcers because of lack of hygiene and position changes.

If a pressure ulcer is noted by a nurse on assessment, that nurse puts in a consult for a nurse from the skin care team to examine the wound. To provide the best skin care possible for each patient, the skin care team collaborates with dietitians, CNAs, nursing directors, nurse managers and doctors.

One way the skin team reminds staff about proper skin assessment and care is through a mannequin referred to as "Uncle Ulcer", which features interchangeable wound and ostomy parts. The mannequin, purchased with grant funds, has proved to be a great hands-on teaching tool, says Lauren H. Laubenstein, RN, BSN, CWON, wound/ostomy nurse, because it helpf staff learn to recognize and care for different stages of pressure ulcers in the classroom setting. A skin Web site also is under development to reinforce what the nurses already know, says Siobhan Nevin, RN, BSN, CWOCN (NE Nurse.com, January/February 2010, p. 13).

Pressure Ulcers

A pressure ulcer or bedsore is an injury to the skin or underlying tissue usually over a bony protruding area of the body. Pressure ulcers can range in severity from minor skin reddening to deep wounds. Factors that cause pressure ulcers are unrelieved pressure on the skin, or slight rubbing or friction on the skin.

Boston Medical Center Tackles Alarm Fatigue and Noise

Hospitals around the country are grappling with the issue of alarm fatigue. The concern is that the constant noise of equipment alarms on hospital inpatient floors is so overwhelming that nurses can become desensitized, thereby creating potential patient safety risks. This issue is so pervasive that the Joint Commission--the accrediting body for hospitals nationwide--is implementing a new national standard aimed at reducing alarm fatigue.

BMC is tackling the issue head on, where a multidisciplinary team of BMC physicians, nurses and clinical engineers has designed a new approach to increase patient safety by reducing the number of clinically insignificant alarms. Their work is already getting national attention.

The approach was piloted on a unit that cares for cardiac patients and uses telemetry equipment to monitor heart rate, blood pressure, oxygen level and other vital signs. The alarm noise on the unit was constant. Many of the alarms indicated clinically insignificant events that required no action by staff, yet they competed with alarms indicating life-threatening conditions like critical heart rhythms.

"The warning alarms for clinically insignificant events were constantly going off and creating unnecessary background noise, causing us to struggle with alarm fatigue," says Deborah Whalen, NP, BMC Clinical Service Manager, Cardiology.
The team reviewed alarm data and developed a list of safe changes that would decrease the total number of alarms, while still ensuring that alarms continued for all events that required immediate attention.

During the six-week pilot, the number of alarms dropped from 87,823 to 9,967 per week - a stunning 89 percent decrease in audible alarms. Patient satisfaction rose. Staff satisfaction increased, too, with many nurses remarking on the quietness of the unit and noting that they could spend more time caring for patients than answering clinically insignificant alarms. Physicians indicated that patient alarm histories now were more meaningful and there was unanimous agreement that care was safer and better. The results were so successful that the program has been implemented in all inpatient adult general medical surgical units at BMC.

"We observed that while the number of alerts dropped drastically, we also had greater response to alerts because those that sounded were all actionable, and now the staff were keenly listening for alarms," says James Piepenbrink, director of the department of clinical Engineering at BMC.

Meanwhile, the novel approach of the pilot and the significant improvement in both patient care and patient and staff satisfaction is proving of interest to care providers nationwide, and in May, the BMC team presented their work in a Joint Commission webinar viewed by more than 1,000 health care institutions with more than 5,000 participants.

CDC: Hospitals Continue Progress in Preventing Infections

The Centers for Disease Control and Prevention today announced significant gains in hospitals' efforts to prevent healthcare-associated infections in 2010. These include a 33% reduction in central line-associated bloodstream infections, 18% reduction in healthcare-associated invasive MRSA (methicillin-resistant Staphylococcus aureus), 10% reduction in surgical-site infections, and 7% reduction in catheter-associated urinary tract infections, according to data submitted to the CDC's National Healthcare Safety Network. Data on Clostridium difficile infections and MRSA bloodstream infections will be available from the network next year. "Today's news reflects the enormous amount of work and effort by hospitals, physicians, nurses and other caregivers," said John Combes, M.D., AHA senior vice president and senior fellow at the Health Research and Educational Trust. "We applaud their efforts to improve quality for patients."

>> Full Press Release

Cooley Dickinson Hospital’s Positive Culture Led to Pressure Ulcer Improvements

In the past eight quarters since the end of 2007, Cooley Dickinson Hospital - a 140-bed facility in Northampton, Massachusetts - has had three quarters with zero incidents of pressure ulcers (bed sores).

It's impressive because even under the best circumstances, bedsores "happen." That is, patients enter hospitals with their skin severely compromised from long illnesses. Or their treatment is so stressful on their bodies - either because they are on ventilators or constrained to their beds - that energy is diverted from the largest organ (skin) to where it is most needed.

It takes constant focus to combat pressure ulcers, and in the case of Michele Craig, Cooley Dickinson's Wound and Ostomy Nurse, a large measure of good will.

"I'm kind of relentless," she says, adding with a laugh, "and I try not to be too grumpy."

Because of the financial pressures under which many Massachusetts hospitals are operating, Craig's staff was cut; she's now the sole wound care practitioner on staff. But she's quick to point out, she's not solely responsible for Cooley Dickinson's good pressure-ulcer-reducing numbers; it's a team effort that involves everyone from the nursing staff, through nutrition, physical therapy, and even housekeepers, since an improperly made bed can cause the shearing and friction forces that aggravate skin.

"I post the results of my audits on each floor and I try to be as positive as I can," Craig says. "I often write on the reports, 'Down 3%! Great job!' or 'Keep Up the Good Work!' "

Each patient admitted to the hospital is checked for pressure ulcers. Each pressure ulcer is photographed upon admission. Craig surveys every unit, except childbirth, quarterly. Each pressure ulcer is charted to record whether it is facility-acquired or not. If it is the result of the hospital stay, Craig writes a case study and brings it to a meeting of the caregivers on the floor where it occurred. What could have been done differently? How did it occur?

"If I wasn't consulted, I need to know why," she says. "I need to look back on the chart to see who noticed it. Did the staff document precautions correctly? Did they miss the assessment at admission?"

Craig says that while she is relentless in getting to the bottom of the issues, she is never judgmental, and sees no need for pointing fingers at staffers.

"It's not about assigning blame," she says. "It's about improving the process."

After the issue is identified, Craig assesses the patient, and has a physician sign the orders for the wound care. Then Craig works with another main component of the care team in many cases - the family of the patient to ensure that once the patient leaves the hospital the pressure relief measures continue.

"People who are on prednisone, who are diabetic or who have low albumin levels - they're at risk," she says. "Sometimes there are people who are just experiencing skin failure." She stresses that some patients just require more care than others to prevent pressure ulcers and that in some cases preventing them is extraordinarily difficult.

Craig regularly assesses the lotions that Cooley Dickinson uses to prevent wounds and she has a say on one of the most important wound-fighting tools - the beds the hospital has bought and rent.

"Right now the newest thing is a 'micro-climate' covering," Craig says, explaining that it's a top layer on the mattress that doesn't trap moisture or heat.

But lotions, beds and other tools, such as waffle boots and chair cushions, all ultimately depend on the staff overseeing their use. The human connection is where Michele Craig finds herself focusing more and more attention.

"I try to be available to the nurses. I try to be positive because, let's face it, direct patient care is difficult and labor intensive, and people respond well to praise," she says.