Enterprise Award Projects



Bridging the Gap: CNRV Heart Failure Clinic

Carilion New River Valley Medical Center

Carilion New River Valley Medical Center readmission rate in fiscal year 2012 was 10.64%.

Analysis revealed that patients with congestive heart failure (CHF) were at highest risk for readmission. After a visit to SC Heart Failure Clinic in Spartanburg, S.C., a successful, multidisciplinary team approach to a CHF Clinic was established.

The official clinic opening was in March 2013 where education began during inpatient admission and continued through follow-up phone calls and visits for all enrolled patients. Since opening the CNRV Heart Failure Clinic, only one enrolled patient has been readmitted within 30 days and the 30-day readmission rate has decreased 3.5% on a goal of 2%.

Team members:

DeEtta Compton, N.P.

Karen Duck, L.P.N.

Becky Johnson

Pat Oney, R.N.

Jose Rivero, M.D.

Dhun Sethna, M.D.

Tina Smusz, M.D.

Farrah Vaughn, team leader

Karen Williams


Carilion Clinic Call Center Redesign

Carilion Clinic

A centralized call center structure and processes was not designed to support efficient, safe, quality call management for Riverside 3 and Postal Orthopedic practice locations.

Weekly practice level reports on call abandonment rates, service level and patient satisfaction were run and root causes were identified. With the implementation of live call answering and warm call transfers to appropriate staff to resolve the call, standardized orientation training, embedded clerical staff in practices and revised workflows for call routing across practice, the call center was able to reduce the call abandonment rate from 20% to 4%.

Additionally, the call center was able to answer 82% of calls within 20 seconds or less and reduce patient complaints by 90%.

Team members:

Kristen Arthur

Martha Devinney

Bill Flattery

Angela Gwodzik

Deb Hedrick

Anne Jessie, R.N., team leader

Don Love

Tom Miller, M.D., team leader

Tammy Nerenberg

Christina Pettersen

Ashley Quick

Darla Summers, R.N.

Katie Tankersley

Althea Thomas



Emergency Simulation in the OB/GYN Ambulatory Clinic Setting

Carilion OB/GYN Clinic

Current evidence-based practice suggests that simulation training is key to assuring emergency preparedness for unanticipated events in the ambulatory setting.

To increase the OB/GYN Clinic staff’s knowledge and skill confidence, as it relates to on-site precipitous delivery and maternal cardiac arrest, live simulation training was conducted and videotaped in the OB Clinic with designated staff participants and the Noelle simulator. The taped simulation was viewed by staff and incorporated in post training evaluation and debrief.

Compared to the pre-simulation assessment scores, the staff’s knowledge increased in all areas with better defined processes, communication plans and role delineation.

Team members:

Marian Belanger, R.N.

Ashley Bossard

Vickie Busic, R.N.

Carey Cook, R.N.

Misty Flinchum

Terri Gibson, N.P.

Sharon Gunn, L.P.N.

Cathy Heinemann, R.N.

Sara Kagarise

Haley Lowman, R.N.

Ellen McConnell, R.N.

Melissa Moore

Stephanie Phillips, R.N., team leader

Donna Sams, R.N.

Jennifer Turner, N.P.


OB Emergency Evacuation

Carilion Roanoke Memorial Hospital

In an emergency evacuation, the CRMH 13 South floor plan does not accommodate a lateral transfer location that could provide adequate patient care resources. This need for clinical care space and resources was highlighted when fire occurred on a lower floor in the South Tower.

An OB-specific emergency evacuation plan was developed and implemented with a prioritized internal unit and facility-wide patient movement plan, an Emergency Evacuation Worksheet for unit leadership and an education plan specific to 13 South.

The first live simulation drill was scheduled for September 2013 after the approved policies and procedures were put into place.

Team members:

Roger Glick

Johanna Lambert, R.N.

Steve Lugar

Claudia Newton, R.N., team leader

Larry Robinson

Donna Sams, R.N.

Ed Watkins

Sandy Weber, R.N.


PowerCAMPUS/PowerFAIDS Integration

Business Services, Enrollment Management, Technology Services Group

The two systems that house student data for the Jefferson College of Health Sciences, PowerCAMPUS and PowerFAIDS, were not integrated and resulted in poor data integrity and a large amount of manual labor.

This process was difficult and time consuming. In turn, this brought student services to a crawl and resulted in heightened levels of student frustration. Integration software was put in place to establish an automatic data transfer between the two systems. Data is now updated within 24 hours and student information is current and accurate.

This has paved the way for better customer service across all areas and a savings of $61,954 per year.

Team members:

Tonia Andrew

Vicki Brown

Michael Buck

Connie Cook

Scott Hensley

Debra Johnson

Jennifer Martin

Anna Millirons, team leader

Marlene Perrott

Jennifer Romeiser

Margie Vest, team leader

Wesley Vorberger

Linda Williams

Michael Womack


Proactive Discharge Planning Improves PRC Scores in Critical Access Hospital

Carilion Giles Community Hospital

The mean PRC Inpatient Discharge Information Score for CGCH’s inpatient unit was 57.45%. CGCH’s Discharge Planning Team identified root causes including failure to notify community agencies, lack of post-discharge follow-up and failure to adequately include frontline nurses in the planning process.

Improvements such as discharge call backs, a written procedure manual and a patient discharge folder inter-disciplinary checklist were implemented in 2011. The team was then reorganized in 2012. Inpatient nursing leadership routinely audits discharge checklists and reviews PRC scores quarterly.

CGCH’s mean PRC Inpatient Discharge Information Score has since risen to 91.53% as of June 2013.

Team members:

Mark Bunker

Melissa Dunford, R.N., team leader

Stephanie Hampton

Mary Kozar, R.N.

Michael McMahon, M.D

Susan McPeak

Christina Thomas

Karen Turpin, R.N.

Amy Westmoreland

Michelle Williams


R3 – Reduce Readmission Rates

Carilion Tazewell Community Hospital

CTCH’s 30-day readmission rate was nearly 20% in November 2012, compared to the regional benchmark of 11.1%.

CTCH formed a Readmission Team to address the problem, with a goal of reducing readmissions to

11.1% by December 2013. Chart reviews found root causes such as a geriatric population with high chronic co-morbidity rates, patient/family bias against nursing and hospice care and physician and medication access issues at nursing homes.

Solutions included admission rounding, physician education on nursing homes, additional case management resources, a Decision Tree and collaboration with local nursing homes and senior citizen groups. The team conducts monthly readmission audits to track progress.

As of May 2013 the 30-day readmission rate at CTCH is down to 4.9%.

Team members:

Monica Baldwin, P.A.

Alicia Bales

Kim Brown, R.N.

Trish Casey

Kathren Dowdy, R.N.

Donna Downs

Kristin Dryer, N.P.

Jennifer Edwards

Patti Fowler

Laura Hall, R.N

Davina Hieatt, R.N.

John Quintier

Loretta Remines, R.N.

David Vance

Carol Weaver, R.N., team leader


Raising the Bar on Pneumonia Perfect Care

Carilion Franklin Memorial Hospital

The core measures for pneumonia had seen improvement in all individual measures, but obtaining the Perfect Care Score of greater than 95% was a challenge at Carilion Franklin Memorial Hospital.

Each month, charts were abstracted and reports were run to look for failures. A notification was sent each month to the provider or staff member who contributed to the failure describing why the failure occurred and what the correct therapy or action would have been.

To achieve a score of 95% or greater, antibiotic recommendation charts were posted in all physician work rooms, data was reported in medical staff committee meetings and in physician and employee newsletters and pharmacy reviewed antibiotics choices and notified providers if selections did not meet current recommendations.

As a result, scores for Perfect Care Pnemonia rose and hit 100% for six consecutive months.

Team members:

Lyne Aigner, M.D.

Donna Castillo, R.N.

Virginia Crouch, R.N.

Lori McClure

Mary Smith, R.N.

Sharon Scott

Kathy Wood, R.N., team leader

Robin Wunderlich


Reducing Early Term Elective Delivery

Carilion Roanoke Memorial Hospital

Elective (non-medically-induced) early term delivery contributes to increased risk of operative delivery, maternal complications and infant morbidity.

CMC OB/GYN did not measure elective early term delivery rates before October 2009 and had no restrictions on elective delivery practice. A multi-disciplinary team investigated root causes and developed the “Scheduling Passport” process for elective delivery. This effort included physician and staff training alongside patient education. This process was implemented and monitored daily.

CMC has experienced zero non-medical elective deliveries over the past 22 months, compared to a national Joint Commission target of less than 5%.

Team members:

Sharon Bass, R.N.

Rebecca Monard, R.N.

Claudia Newton, R.N.

Donna Sams, R.N., team leader

Kristi Thomas

Sandy Weber, R.N.

Patrice Weiss, M.D.


Sepsis Alerts

Carilion Medical Center

Sepsis has been a top length of stay (LOS) opportunity at CRMH for some time, with the current LOS of 13.35 days being 7 days above the 6.98-day benchmark.

The CRMH Emergency Department, where 76% of sepsis patients are admitted from, investigated the issue.

The team found no standardized process in place for early recognition of sepsis, leaving little chance for an early intervention. After conducting literature reviews, the team implemented a sepsis alert process where patient responses to screening questions trigger staff to assess for signs of infection using an order set. A sepsis alert is then triggered if certain criteria are met, resulting in prompt admission and treatment protocols.

All ED R.N.s received education on the protocol.

A recent analysis found that patients receiving the sepsis alert protocol showed lower average LOS of 6.15 days versus the 13.35-day baseline.

Team members:

Josh Clark, R.N.

Doris Duff, R.N.

Elizabeth Gilbert, R.N., team leader

Brandon Jones, R.N.

Jenny Lane

Gary Meadows, R.N.

Jack Perkins, M.D.

Leann Plott, R.N.


Wellborn Nursery Bassinet Replacement

Carilion Medical Center

Safety concerns with new bassinettes installed on CRMH 12 South Mother/Baby Unit and Wellborn Nursery have been voiced since the department was consolidated and moved to CRMH.

The bassinets had maneuverability issues and could easily be tipped over, while the Plexiglas was prone to cracking and breaking, leading to infection control concerns. Investigations found all 35 devices to be defective. The team worked with the vendor to make several design changes aimed at improving safety. After the vendor failed to correct the identified problems, the staff collaborated with OB/GYN leadership, CMC’s Safety Department and Purchasing to acquire new devices from a different vendor.

No defects or safety issues have been found since the new bassinets were installed in March 2013.

Team members:

Cindy Booth, R.N., team leader

Donna Sams, R.N.

Cecelia Talbott

Stephen Underwood

Cynthia Willis, R.N.



Workplace Violence Prevention

Carilion New River Valley Medical Center

The staff survey at Carilion New River Valley Medical Center revealed concerns about safety in the Emergency Department and specifically in the triage room.

The Workplace Violence Team implemented projects to renovate four ED treatment rooms, add a second door, camera and panic button to the triage room, along with other safety measures. Additionally, workplace violence is placed on the agenda at monthly hospital safety meetings and the Workplace Violence Team will continue to meet monthly.

Results from a recent survey show a 115% increase in the level of safety in triage by all nursing staff and a 16.4% increase in overall level of safety by the nursing staff.

Team members:

Rita Boland, R.N.

Carol Haynes

Janice O’Brien

Glenn Reed

Rita Turpin

Tammy Turpin

Katherine Oakley, R.N.

Bobbi Weeks

Joyce Yearout, R.N., team leader


Category Winner:


Workplace Possibilities

Carilion Clinic Human Resources, Carilion Design Group, Technology Services Group

The Workplace Possibilities Program (WPP) is a partnership between Carilion Clinic and the Standard, our life and disability carrier.

WPP provides interventions and accommodations for employees having difficulties at work due to a medical condition. Internal data from the Standard/WPP and the benchmarking database of the International Benefits

Institute indicates reduced disability claim durations of an average of 17.7% with WPP, and a steady increase in the number of stay-at-work (SAW) interventions as a percentage of total interventions.

WPP was launched in October 2011, and Carilion’s experience in year 1 did not compare favorably to the benchmark data.

The formation of a centralized process through Human Resources, TSG and Carilion Design Group in addition to internal sources of referrals was essential to increasing the days saved through WPP. In year 2, we have experienced 568 days saved year-to-date (that’s more than 2 FTEs) and 16 SAW interventions year-to-date.

Team members:

Jim Bohn

Leanne Carico

Lynda Kelly, team leader

Wes Killen, R.N.

Kim Tiller


MVP Winner:

Collaborative Heparin Project

Carilion Medical Center

Carilion Roanoke Memorial Hospital experienced numerous heparin-related medical errors, despite an intervention in 2010 to fix the issue. Over 200 such errors were observed from January 2011 through June 2012.

A multi-disciplinary team reviewed the errors and conducted a detailed review of the heparin infusion process in June 2012. The team identified knowledge gaps, lack of workflow consistency and communication errors between units as root causes.

Interventions included recurring multi-disciplinary meetings, a new process incorporating recommendations from the TJC Sentinel report on anti-coagulants and new communication procedures. The improvements were piloted and implemented in several phases, with assessment of results after each phase.

The project has resulted in zero harm-causing heparin-related errors at CRMH since June 2012.

Team members:

Jen Bath, R.N.

Kathleen Baudreau, R.N.

Stacey Bryant

Rebecca Dampeer, R.N.

Victor Delapp

Lakricia Duncan

Jennifer Hasis

Melissa Hobbins

Jason Hoffman, team leader

Hannah Martin

April Overfelt, R.N.

Margaret Perry, R.N.

Bridgette Smigiel

Charlene Waybright