Facility-Wide Council Accomplishments – 2025

Quality & Safety Council
Chair/Co-Chair: Brandon Bert, BSN, RN & Mahedia Zadran, RN

Enhanced fall-prevention practices:
o Improved use of fall-risk signage.
o Implemented High Fall-Risk Scheduled Toileting initiative.
o Developed scripted communication for patients and families requesting restroom assistance.
o Expanded measurevention strategies.

Improved mobility outcomes:
o Reinforced documentation of Current Level of Function (CLOF) and Prior Level of Function (PLOF).
o Supported earlier, more consistent mobilization and increased compliance with mobility standards.

Advanced CLABSI, CAUTI, and HAPI bundle adherence.

Partnered with the Emergency Department to enhance Door-to-EKG, Door-to-Needle, and trauma workflows.

COUNCIL NAME: Professional Development Council

Chair/Co-Chair: Harminder Sahni, BSN, RN & Cassie Farinsky, DNP(c), MSN, RN, APRN, FNP-BC, PHN

Celebrated completion of New Grad Residency Cohorts 9 and 10, strengthening novice-to-expert transition.

Partnered with clinical areas to provide training on new technologies:
o B Braun pump integration.
o Thoraguard.
o Sonopet surgical aspirator.

Guided rollout of peer evaluation process, aligning practice expectations with the Nursing Strategic Plan.

Supported specialty education across ED, ICU, and Perioperative Services:
o Mock codes.
o Code Blue enhancements.
o Certification preparation.
o Advancement on clinical ladders.

Patient Care Services Orientation
o Refreshed format, reassessed needs, and made meaningful change to ensure a smooth onboarding for newly hired staff

Nursing Practice Council
Chair/Co-Chair: Ayumi Saito, BSN, RN & Marcus Colón, RN

Led multidisciplinary practice change for multi-dose vial insulin administration:
o Collaborated with Pharmacy, Nutrition, and Nursing Leadership.
o Ensured compliance with infection control, safe medication administration, waste reduction, and cost-effective practice standards.
o Transitioned Adult Services, Maternal-Child Health, and ICU units to Pyxis-based vial practice.
o Achieved significant organizational cost savings (estimated $190,000 annually).

Updated Daisy Award process:
o Shifted to biannual voting.
o Standardized nominee notification.
o Established designated spaces to honor award recipients.
o Began redesigning patient-facing recognition signage.

Transitioned Bee Award to Petal Award to align with Northern California Kaiser Permanente’s recognition framework.

Advanced the Throughput Improvement Project to enhance patient flow and operational efficiency.

Coordinated one Grand Round in 2025.

Updated telemetry parameter practice to restore frontline staff autonomy and reduce alarm fatigue.

Supported education rollout for throughput initiative and designed infographic for organization-wide dissemination.

Established new subcommittees:
o Geriatric RN Champions (using the 4M’s framework of an Age-Friendly Health System).
o Congestive Heart Failure (approved in late Q3 2025; recruitment and planning underway).

Supported Palliative Care Services implementation of new signage for patients transitioned to comfort care.

EBP & Research Council
Chair/Co-Chair: Shavinderpal Sanga, MSN, RN, CNS, ACCNS-AG, GERO-BC & Kevin Ho, BSN, RN, CCRN

Supported development and progression of multiple research studies:
o ICU’s Virtual Reality for Delirium Reduction.
o MCH’s Early Labor Walk initiative.

Participated in the 2025 Research & Innovation Academy Conference Program in Pleasanton, CA.

Enabled bedside nurses to present posters on innovative topics:
o Ultrasound-Guided Peripheral Intravenous Insertion.
o Stopping Sepsis: Empowering the Community through Education and Prevention.

Care Experience Council
Chair/Co-Chair: Milanelle Guiao-Tranchina, BSN, RN, CMSRN, PCCN & Shelly Kolb, BSN, RN

Launched “Care Experience Saturdays”:
o One-minute huddles each Saturday shift to discuss care experience data, trends, and best practices.
o Communicated practice to all leaders for sustainability.

Integrated care experience education into new staff orientation and annual professional development days.

Planned dedicated care experience stations for future annual PDDs.

Partnered with Caring Science during Nurses Week:
o Hosted a station with raffle prizes for staff answering RN communication questions.

Enhanced RN communication and bedside handoff practices:
o Created wider awareness of bedside handoff and care board updates.
o Provided real-time coaching and validation by leaders.
o Achieved nurse listen data above benchmark (66.1).

Improved MD/RN consistent information through collaborative rounds:
o Promoted RN and MD rounding collaboration in MCH.
o Achieved favorable data above benchmark (69.0).

Collaborated with EVS to improve cleanliness and comfort scores in inpatient units (above benchmark at 61.9).

Provided comfort items and meaningful engagement for ED boarding patients, with ongoing efforts to meet rounding compliance targets.

Improved discharge communication in ambulatory surgery settings, with ongoing data collection.

Raised “Likely to Recommend” hospital scores above benchmark (68.5) through targeted improvement tactics.

Heart Science Council
Chair/Co-Chair: Michelle Rowe, BSN, RN & Mary Rose Andres, MSN, RN

Promoted Caring Science and HeartMath techniques:
o Hosted Caring Heart Day during Nurses Week, reaching 126 staff and encouraging self-care rituals.
o Provided staff appreciation through café table, fair giveaways, and raffle prizes.

Established Caritas Corners in Periop and 4North:
o Created healing environments and respite spaces for staff.
o Received positive staff feedback for providing sanctuary during breaks.

Increased resilience and self-care:
o Placed HeartMath Quick Coherence decals in high-traffic areas.
o Surveyed staff, finding 60% familiar and 31% practicing daily.
o Continued offering The Resilience Advantage program.

Opened a Memorial Garden for staff:
o Provided a peaceful space for reflection and healing.
o Fostered community, reduced stress and anxiety, and improved staff morale and job satisfaction.

Facilitated Nurse Honor Guard services:
o Honored the lives and service of nurses lost in the facility.
o Co-officiated the ribbon cutting of the Memorial Garden.

Distributed monthly Self Care Calendars to all PCS nurses and chaplains, supporting consistent well-being practices.