Recognized by the South Carolina Hospital Association (SCHA) with the Drive to Zero Suicide Award in 2023. 
• Led the organization in initiatives for Zero Suicide in the patient population through the incorporation of the suicide risk assessment in Epic. Also, developed strategies for suicide prevention in the IOP patient population, including monitoring of patients, documentation, care team member education, and interventions. 
• Met the “Likelihood to Recommend” goal in the Press-Ganey patient experience surveys a second consecutive year.
• Achieved the highest Bar Code Medication Administration rates for MUSC for the third consecutive fiscal year. 
• IOP was the only team to meet the Service Composite goal for MUSC Charleston in FY 23. 
• Improved from prior years in the Employee Engagement Survey results with three Tier 1 units, two Tier 2 units, and 1 Tier 3 unit with an overall Tier 2 rating. 
• Reduced the patient use and time in seclusion and restraints for the second consecutive fiscal year.

The MH ICCE/IOP/D-Pod teams were led by nurse leaders who were committed to the patient safety and quality goals that they had established. They demonstrated consistency in addressing the actions that their unit teams would take to meet these goals and to ensure patient safety. Teamwork is their strength and they communicated best practices and obstacles with each other to achieve these goals. The nursing leaders worked with their interdisciplinary healthcare team to maintain a focus on the actions that they needed to take to give high quality care to the patients in IOP and the D-Pod. The leaders met twice a month to discuss the metrics for each goal and the actions that were needed to improve these metrics. Monthly meetings with care team members shared the metrics and sought input on the successes and barriers that they may be experiencing. They used the daily Tier 1 and Tier 2 huddles to drill down to specific issues that may be impacting patients. They had quarterly QAPI meetings with their Quality & Safety manager and others to review metrics and their tactics to achieve these goals. In addition, regular Safety Rounds with the healthcare team and other stakeholders facilitated their efforts. The success in achieving a greater than 95% rate in BCMA was the result of enhanced communication with care team members and follow-up by managers with individuals who had a lower rate of BCMA. This has resulted in three consecutive fiscal years of achieving a BCMA rate above 98%. The IOP/Dpod nursing units are immensely challenged with fall risks due to their patient populations’ mental illness symptoms and sedating medications used to reduce those symptoms. However, the MH ICCE reduced falls by 21.1% from FY22 to FY23 which was the first reduction in falls in over three years.

Another significant achievement of the MH ICCE nursing team is the reduction of seclusion and restraints. Given the severe mental illnesses their patient populations live with daily, the least restrictive means to maintain patient and CTM safety can be the utilization of seclusion and restraints. Over the last three years, the MH ICCE nursing leaders have worked tirelessly to develop strategies and tactics to reduce the use of these interventions. As a result, the MH ICCE nursing leaders have staggering results demonstrating their efforts. Since FY20 (907), they have reduced the use of seclusion and restraints by 67.5% in FY23 (449). Patient engagement in the Mental Health population can be difficult to achieve due to many factors. The leaders assisted care team members in having discussions with the hospitalized patients to understand the purpose of the survey and how their feedback helps the team to make improvements in their care going forward. For many years, receiving survey feedback from this patient population has been low but the IOP team has now seen two consecutive years of increased return rates on surveys and an improvement in the “Likelihood to Recommend” score that has met their goal.

The Drive to Zero Suicide award from the SCHA is recognition of the MH ICCE/IOP/D pod teams’ efforts to address a serious issue in healthcare. The team started an initiative to address suicide risk and prevention in the hospitalized population that resulted in improved assessment of patients and documentation. This work resulted in improved patient safety in the IOP/D pod and campus-wide. The teamwork by these leaders and inclusivity with their care team members also resulted in an improvement in their Employee Engagement surveys in FY23. The MH ICCE/IOP/D pod nurse leaders were able to increase care team member engagement in the achievement of improved patient care quality and safety. The care team members in the Mental Health ICCE sometimes deal with impulsive and unpredictable patients on a daily basis and are exposed to physical harm/workplace violence. They practice and train in de-escalation techniques to keep all care team members.