In the 2026 Your Voice Matters survey, we asked for your feedback on our safety culture, specifically regarding your comfort in speaking up about patient safety. While our scores have improved since 2023 and remain above the National Children’s Healthcare Average, your feedback shows that this is still an important area for growth.

Over the coming months, we will continue to share stories and examples of psychological safety. To dive deeper into this topic, please explore the videos and guides on the Psychological Safety Cooknet page. Most importantly, we encourage you to start a conversation with your team about how you can collaborate to make your workplace even safer. Thank you for your daily commitment to our culture of safety! 

Cook Children’s employees have access to a host of resources to help you through the holiday season.

If you need help managing financial stress or assistance with holiday budgeting, financial wellness resources are available. If you are coping with grief and loss or need help navigating challenging family dynamics or just need someone to talk to, mental health resources are available. From our Employee Assistance Program (EAP) and counseling through CareATC, to our Spiritual Care Team and Responder Health –resources are available 24/7.  Confidential support and resources are available whenever you need them. For a full list, visit:

Employee Benefits & Self-Care

Suicide Prevention Hotline

Call or text 9-8-8 for free and confidential support

• Available 24/7, call or text 9-8-8 for access to mental health crisis services.
• Please note: the previous 1-800-273-TALK (8255) number will continue to work as well or visit the website.

Also, please don’t hesitate to reach out to your HR representative.

Your well-being matters. You matter. 

Mental Health

Mental Health

What’s Changing

You can now self-install Microsoft 365 (M365) Apps directly from the Software Center on your Cook Children’s computer — no IS request required. The latest versions of Word, Excel, PowerPoint, Outlook, OneNote, and Teams are available for installation.

Note: Microsoft Access will not be included in this installation.

Access databases are self-managed and not supported by IT, which creates security and support risks since we have no visibility into how data is used or stored. We’re actively contacting Access users to discuss options for moving data to more secure, supported platforms.

If you use Microsoft Access, you can continue using Office 2016 for now while IT works with you on next steps.

As Cook Children’s IT continues to adopt Microsoft tools, we’re taking a thoughtful, step-by-step approach. Updating Office to a supported platform is our top priority right now. While OneDrive offers great collaboration potential, we’ve temporarily paused its rollout so we can focus on getting the essentials right first. More updates will follow as we continue this modernization journey.

When can you install M365 Apps?

Starting Wednesday, November 12, you can begin installing Microsoft 365 Apps.

All users will need to complete this installation before Cook Children’s upgrades to Windows 11 in early 2026.

What you need to know before installation

1. For best performance: Install M365 Apps while connected to the Cook Children’s network with an ethernet cable (i.e. a desktop computer or docked laptop). Wi-Fi installation is possible, but may be slower.
2. Working from home? Ensure you're connected to the Cisco VPN before starting the installation.
3. When you are ready to install M365 Apps close all Microsoft Office applications. This will ensure a smooth installation process.
4. Installation time: The installation may take 10–20 minutes, depending on your system and network connection.

How to install Microsoft 365 Apps

1. Open the Software Center (search for “Software Center” in the Windows Start menu).
2. Go to the Applications tab.
3. Find Microsoft Office 365 (or Microsoft M365 Apps for Enterprise).
4. Click Install and follow the on-screen instructions.
5. Once complete, sign in with your work account to activate the apps.

Need help?

For help and training tools on Microsoft 365, please click here for the Microsoft Support website.

If you experience any issues, please contact the IS Service Desk.

Employees are required to receive the influenza vaccine each year to help protect our patient families, fellow employees, and our community, against this serious disease. Some departments will perform vaccinations for employees in their areas. We will also be offering several Flu Vaccine Fairs, where employees can drop in without an appointment for their vaccine. Employees may also supply proof of vaccination from an outside provider. 

To get the process started, employees will need to complete an electronic consent form. 

You must get your flu vaccine by the Oct. 17 deadline. Complete your employee influenza electronic consent form on the Enterprise Health portal starting Aug 4. .

Here is the link: Enterprise Health: Cook Childrens Hospital Prod Log In. 

The consent form must be completed by all Cook Children’s staff before Sept. 16. You can find the consent forms on your Enterprise Health Employee Portal site. TO FIND INSTRUCTIONS ON HOW TO FILL OUT THE CONSENT FORM, GO TO “DOWNLOADS” AT THE TOP RIGHT OF THIS PAGE. 

Flu Vaccine Fair schedule:

• Sept. 15: 7 a.m. – 2 p.m., Medical Center Atrium
• Sept. 16: 7 a.m. – 2 p.m., Medical Center Atrium
• Sept. 17: 7 a.m. – 2 p.m., Camelot Light Court
• Sept. 17: 8:30 a.m. – 4:30 p.m., 750 Building 4^th Floor Room 4303
• Sept. 18: 7 a.m. – 2 p.m., Camelot Light Court
• Sept. 19: 7 a.m. – 2 p.m., Camelot Light Court      
• Sept. 22: Noon – 8 p.m., Prosper Room 3332 and Room 3333
• Sept. 23: 9 a.m. – 11 a.m., Child Study Center
• Sept. 23: 1 p.m. – 3 p.m., South Rehab 8^th Ave.
• Sept. 24: 9 a.m. – Noon, Calmont Office Building
• Sept. 25: Noon – 3 p.m., Rosedale Office Building
• Sept. 29: 7 a.m. – 2 p.m., South Tower Conference Room 1163
• Oct. 1: 7 a.m. – 3 p.m., 901 7th Ave First Floor Atrium
• Oct. 8: 7a.m. – 2 p.m., Family Support Meeting Room A/B

Occupational Health and the Emergency Room are teaming up to provide additional evening flu fair dates at Medical Center - Fort Worth. Room 1163 (next to Goodies to Go by Emergency Room) from 7 - 10 p.m.

Please do not wait until the week of Oct. 6 for flu vaccination in the evening. The last week may be cancelled if not necessary.

Evening dates are as follows:

• Sunday, Sept. 21
• Sunday, Sept. 28
• Wednesday, Oct. 1
• Thursday, Oct. 2
• Friday, Oct. 3
• Monday, Oct. 6 - dependent on prior attendance
• Thursday, Oct. 9 -dependent on prior attendance

Flu vaccines from an outside provider:

• If you get your flu shot at a non-Cook Children's provider, such as your doctor's office or a pharmacy, you must scan in your proof of vaccination on your Enterprise Health Employee Portal under My Medical tab.
  • Please do not send to the Occ Health email. This must be uploaded to the portal.
• Proof must include your name, date of birth, date of vaccination, provider information, lot number, manufacturer, and which arm received the vaccine. 
   
• We cannot accept a sales receipt or “waiting for vaccination by pharmacy” form. You must provide the actual documentation of the vaccine received.  

Exemption requests:

If you are requesting an exemption from influenza vaccination the upcoming year, a separate request form must be completed for medical or religious exemptions. The deadline for exemption requests is Oct. 6 to allow the Accommodations Committee to meet and make final determinations on requests in a timely manner. If you are requesting an exemption, please find the exemption request forms on your Enterprise Health Employee Portal site and identify whether you are requesting Medical or Religious exemption. Occupational Health will then send you the appropriate form, which must be completed, onto your portal. The completed forms must be uploaded back to your portal for the Accommodations Committee to review for a decision. Medical exemptions will need your physician to complete, so please keep the timeline in mind.

Flu vaccine pickup for department events

• Nursing departments in all companies will have the opportunity to request vaccine from Occupational Health and perform vaccinations for the people who work in their areas.
  • *Flu vaccine will be available around Sept. 15, please contact Kasee Williams and Jamie Kayser to confirm your pickup date.
• Cook Children's Physician Network: these groups will coordinate with Emma Price for these requests.
• Medical Center-Prosper: Location and Date to be communicated by Prosper Administration.
• ALL OTHER COMPANIES: please contact Kasee Williams and Jamie Kayser.

Annual Flu Compliance

2025 Deadline Date: October 17, 2025

Cook Children’s Health Care staff are expected to be compliant with influenza vaccination requirements annually. Occupational Health will set and publish the deadline date each year.

Failure to maintain compliance will result in disciplinary actions:

• Failure to complete by deadline – Written Warning
• Failure to complete within next 14 days – Final Written Warning
• Failure to complete within next 14 days – Suspension 

Referenced Policy HR800

Cook Children’s Health Care System is committed to providing a safe and healthy environment for our employees, patients and visitors. We treat patients who may present with highly contagious communicable diseases. To protect our employees from those diseases that require N95 Respirator Mask protection, we require patient and family facing staff to obtain an annual mask fitting.

As we saw with the global pandemic, these situations happen very quickly and it is necessary for Cook Children’s staff to be prepared and protected at all times.

In keeping with Our Promise, we are doing everything we can to protect those in our care while respecting your individual rights.

Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protect healthcare personnel and patients.

It takes just five moments to protect yourself and others! Using the five moments of hand hygiene, we should all clean our hands and change our gloves:

1.       Before touching a patient

2.       Before clean/aseptic procedures

3.       After body fluid exposures

4.       After touching a patient

5.       After touching the patient’s surroundings

Need help to remember these moments? Listen to this: link to the song/video

Keep areas free from trash.

Keep cords in patient care areas up off the floor. 

Keep computer cables neatly tied so they do not create a trip hazard.

Report hazards:

This area at 8^th and Terrell was reported and fixed by our facilities team.

If you notice a hazard such as this, call facilities at 682-885-4026 ext. 54026. Then place an event report using the facilities icon. The date of “event” would be the date you submitted if a fall event did not occur.

If there is an urgent safety need, call the appropriate department to address as soon as possible.

When there is a spill, stay with the spill and contact EVS supervisor via Vocera or operator.

Spill kits are available at each information desk. Simply pull a sheet and lay it over the spill, contact EVS and EVS will respond as soon as possible.

Thank you for all you do to help keep Cook a safe place to work and visit!

By Kaley Johnson

At Cook Children’s, safety is one of our values, both for our patients and our employees.  When the opportunity arose to use a tool that could help alleviate staff over-exertion, leaders wanted to make sure that our staff members were scheduled for training on to use the new equipment. The device will be available soon to help staff laterally transfer patients.

The Comfort Glide Air, an air assisted mattress created by Medline, allows staff to transfer patients from surgery beds to adult beds without putting physical strain on staff. The device is placed underneath the patient and inflated. Nancy Russell, RN, MS, CPN, CPPS, Nursing Quality Improvement Coordinator, compared the airflow technology to an air hockey table.

Nancy, who has worked at Cook Children's for 39 years, and Randy Price CSP CIT CEAS, who is the Safety Manager, Occupational Health, are leaders of the Solutions For Patient Safety Employee/Staff Overexertion initiative. Many staff overexertion injuries are not caused by one event, Nancy said, but are due to a culmination of repeated transfers, boosting and patient handling activities.

The air assisted mattress provides “a seamless transfer that takes way less exertion than if we did it with a sheet under the patient,” Nancy said.

They coordinated with the Professional Development Council and Medline workers to provide multiple trainings for staff on how to use the tool.

Staff are excited about this equipment, Nancy said, which can be used for any patients in adult beds.

“It's just another tool in the belt for patient handling,” she said.

At a recent demonstration, Nancy and Randy showed the ease in which a patient can be moved when utilizing the device. Once the air mattress is underneath the patient, it only took about 20 seconds for three staff members to transfer the patient from a stretcher onto the adult bed - one staff member pushes the mattress toward the receiving person who uses the handles to help pull the patient into position, while another person supports the patient’s feet (for those taller patients).

Fortunately, the incident earlier this month was short-lived (lasting only 13 minutes) and the alert was cleared once deemed safe. However, it serves as a valuable opportunity to discuss security alerts and how we respond to them.

Types of Alerts and Response Protocol

1. Sense of Urgency: When a potential threat is identified, our security team strives to respond quickly and notify affected individuals. As David Hollar, Director of Security Services explains, "We prioritize safety and swift response, while acknowledging the dynamic and rapidly evolving nature of such situations."

2. Notifications: These alerts serve as a brief awareness update with concise instructions. We request that staff only call if directly involved or witness something impacting the incident's immediate safety. Calling PBX or Security Services for general inquiries hinders their ability to manage the event and maintain open lines for crucial communication.

Differentiating Security Alerts and Active Criminal Events:

Security Alert: Similar to a weather watch, it indicates a developing situation being closely monitored but not posing immediate danger. Remain vigilant, follow the instructions provided within the notification, stay put and continue you with your normal work activities unless otherwise notified. In the recent instance, no lockdown or evacuation was necessary.

Active Criminal Event: Comparable to a storm warning, it signifies an unfolding criminal act with a suspect still present and posing an active threat. Depending on the scenario, you may be instructed to flee, hide, or remain calm and follow further instructions.

Your Safety is Paramount. We prioritize your safety and appreciate your cooperation during such situations. Please remain calm and respect the evolving circumstances. We will strive to provide accurate information as quickly as possible based on confirmed facts.

We are grateful for our staff's vigilance and commitment to reporting any concerns. Together, we can contribute to a safe and secure environment for all at Cook Children's.

We made a video to show off the new space so you can see it for yourself!

If you would like an in-person tour, please email Kaysey Pollan, Director, Environmental Safety/Emergency Management, Safety.

Congratulations to the very first DAISY Nurse Leader Award winner: Samantha Corkum, MSN, RN, RNC-NIC, Neonatal Program Coordinator. She works in the NICU. 

The award was presented to Samantha during Nurses Week.

The DAISY (Diseases Attacking the Immune SYstem) Award is an international recognition program that honors and celebrates the skillful, compassionate care nurses provide every day.  The DAISY Foundation was established by the family of J. Patrick Barnes after he died from complications of an auto-immune disease in 1999. During his hospitalization, they deeply appreciated the care and compassion shown to Patrick and his entire family. When he died, they felt compelled to say “thank you” to nurses in a very public way. 

The DAISY Nurse Leader Award recognizes nurses who are extraordinary in the impact they have on compassionate patient care. Honorees can be any nurse leader who impacts patient care directly including supervisors, managers, educators, or nurses who specialize in case management, informatics, or patient flow.

This Nurse Leader impacts staff and/or the patient care they manage by:

• Role modeling extraordinary behavior     
• Creating an environment where attributes of trust, compassion, mutual respect, continued professional development, and ethical behavior are modeled and supported
• Motivating staff with a shared vision and enthusiasm to achieve better outcomes for themselves and for their patients
• Promoting and enhancing the image of nursing within the organization, the community, and the profession

Here's what her nominator wrote when submitting Samantha for the award: 

"2022 was probably one of the most trying years in our NICU.  We had a record average daily census and acuity, a significant transition of our medical and nursing leadership, numerous new hires to the unit, and to top it off, our designation survey to remain a Level IV NICU and serve our tiniest Texans at our very best. 

"But the chaos of the year could not have been managed without Samantha. As our Neonatal Program Coordinator, she led a quality team to provide real-time feedback on what worked and what needed to be done to improve the outcomes of our babies and our unit. She was a trusted advisor to help the new medical and nursing directors and nursing managers settle into their roles. She led orientation sessions for our new hires and regularly checked in on them to make sure they were doing okay when chaos reigned all around them. Burnout is real and she worked tirelessly to help combat it. And she led a designation team for us to have a flawless survey, allowing us to provide care at our utmost potential. 

“Every baby that has graduated from our NICU has been impacted by Samantha. Every person working in the NICU has been impacted by Samantha. She has created an environment where trust, compassion, respect, and continued personal and professional development can be attainable. She is the leader all units should strive to have and I, like others, consider ourselves fortunate to have her battling for us, our babies, and our families. I struggle to come up with the right words to describe how invaluable she is to the NICU, but I hope I do her justice in what I have said as she is highly deserving of the Nurse Leadership Daisy Award. ”

Pictured: Hevil Shah, M.D, Samantha Corkum, Deborah Boudreaux, Brittany McLaughlin        

Last year a young girl was involved in a high-speed motor vehicle accident in which her car collided with a disabled vehicle. She suffered a severe cervical injury. On the second day of her hospitalization our vascular access team placed a left femoral double lumen PICC line after attempting unsuccessfully to place a PICC in the upper extremities. On the tenth day following the accident she developed fever. Her halo pin sites had no drainage. A catheterized UA and urine culture were ordered. Time was required to collect supplies, perform the procedure, collect and apply labels, and send the specimen to the lab. Her morning chest X-ray, secretions, ventilation and oxygenation requirements were reviewed and a tracheal aspirate for gram stain and culture was ordered. PICC line blood cultures from each of the two lumens were ordered. Again this required time to collect supplies, to scrub each hub, collect and apply labels, collect the samples, and send to the bottles to the lab. Vancomycin, which required close monitoring of her renal function, was ordered every 6 hours to treat her infection.

Within 48 hours the lab reported that the white lumen of the CVL had grown gram positive cocci, later identified as Enterococcus faecium. Infectious diseases was consulted and antibiotic coverage was refined. Three more sets of daily blood cultures were ordered. It took 10 days of antibiotics to treat the infection. An echocardiogram was required to rule out endocarditis when she had another fever later.

Our patient’s infection was just one of great number of nationwide preventable hospital acquired infections over the last two years according to a Solutions for Patient Safety (SPS) collaborative review. Increased staff workloads, addition of inexperienced staff to the workforce, and practice drift were found to be the most commonly identified reasons for the huge jump in preventable infections.

 Please answer each of the following questions either True or False:

• Scrubbing the central line hub for 30 seconds and waiting 30 more seconds for it to dry might have prevented our patient’s central line from having to be accessed as many as 46 times.
•  This preventable infection required treatment with antibiotics that have risk of causing acute kidney injury and the infectious could have resulted in a heart valve infection.
•  Avoiding practice drift from line placement and maintenance bundles can make Zero Harm an achievable goal.

 Answers: Are All True.

SPS CLABSI Special Cause Investigation Report

There is power in moment!

“We thank you for responding to this important survey,” said Rick Merrill, President and CEO of Cook Chlldren's Health Care System. "You have given us meaningful insight into your world and your experience at Cook Children's, and we are grateful. We want to take thoughtful, meaningful action to make this a place where you always feel like family and are fulfilled working here. It will take us some time, but you have my full commitment that we will see this through."

As promised, we want to give you a quick update on how we are sharing survey results and steps we’re taking to act on what we learned.   

We started by sharing results with executives throughout the system, and each executive was asked to share the results with their leadership teams. If you haven’t already, you should learn the results from your manager or director very soon, as we’ve asked them to complete the rollout of survey results by April 30.

Based on the survey results, we identified approximately 60 departments as priority areas that need additional support. Starting in April, the burnout team will conduct focus groups with team members from these departments. These meetings will give us insight into any changes within the teams over the past few months. It will also give us the opportunity for open discussions about the survey’s findings so that we can delve deeper into ways to help.

In addition to the group focused specifically on burnout, we created an Experience Task Force to review data from all of the tools we use to listen to you, such as the Maslach Burnout survey, ID&E “Open Arms” survey and quality and safety and Magnet surveys. Using these resources, the task force has learned that there are common themes for the issues impacting staff throughout the system. These include:

• Education
• Inclusion
• Compensation
• Benefits
• Workload

The Experience Task Force has begun working with responsible areas to identify possible solutions and opportunities for each issue.  As an example, we are conducting listening tours with almost 1,000 employees regarding our employee benefit offerings.

Our physician wellness advocates, Sara Garza, M.D., and Kirk Pinto, M.D., have also been working to roll out physician burnout survey results and are holding listening tours with clinics and departments within the Cook Children’s Physician Network.  As part of these meetings, the team will be working with wellness champions from each area to take part in co-creating solutions for physicians. They hope to have most meetings completed by the end of May.

Results of the burnout survey for the System can be seen below.  If you have questions about your department’s results, please reach out to your manager or director.

And stay tuned for further updates on how we tackling the bulleted issues listed above.

Thank you for helping us connect the dots between the important job that you do and the positive and fulfilling work experience we want every employee to experience each day.

·         RNs Jordan Staggs and Andrea Knott, will present a session titled “Steps towards Savings: A Frontline Clinical Nurse-Led Research Project to Evaluate the Impact of an Early Ambulation Device.”

·         Natalie Palau, a Clinical Nurse Leader, Ashley Chreene, a Nurse Manager, and Leigh Anne Campbell, a Clinical Education Coordinator, will present “Connecting the Dots for High Fall Risk Patients: Implementation of Acute Fall Risk Interventions and Education on an Inpatient Neuroscience and Epilepsy Monitoring Unit.”

·         Sandy Manoushagian, a Clinical Education Coordinator will join RN Jordan Staggs to present “Something New is Taking Shape: Design and Implementation of a standardized Bedside Shift Report Using the ISHAPED Algorithm.”

·         Inpatient Psychiatry RN Christina Tan, Hematology & Oncology RN Andra Alfaro, and Valerie Shorten, who started as a cook in the Cook Children’s cafeteria and worked her way up to unit secretary and then a NICU RN after earning her BSN, will present “Bundle Up & Sleep Tight! An Evidence-Based Project to Increase Awareness on Healthy Sleep Hygiene Habits and Interventions for Pediatric Patients with Behavioral Health Needs.”

·         Nursing Quality Improvement Coordinator Nancy A. Russell, Wound/Ostomy Nurse Coordinator Mitsy McCutchen, and PICU Clinical Nurse Leader Cammie Larson will present “Hard-wiring Skin Assessment to Reduce Cervical Collar Pressure Injuries.”

·         Clinical Nurse Ceileigh King and Stacey Bancroft, Clinical Practice & Advanced Education Specialist, Level II, will present “Transpyloric Feeding Tube Placement at the Bedside: Streamlining Measurement, Insertion and Maintenance.”

·         Renee M Twaddle, an RN in the Ear, Nose & Throat Clinic, will present “Examining Pain Memory in Pediatric ENT patients with Foreign Body Removals: An Interdisciplinary Evidence-Based Practice Project.”

·         RN Theresa McMinn will present “Building an Educational Bridge with Evidence-Based Practice on the Use of Near-Infrared Spectroscopy in Pediatric Critical Care.”

·         Julie Van Orne, an EBP/QI Coordinator, will present “The State of Tracheostomy Education Programs Across the United States: A National Survey of Children's Hospitals” with a colleague from Texas Children’s Hospital.

·         Katy Walthall and Abbie Garcia, Clinical Practice and Advanced Education Specialists II, will present “Virtual Preceptor Workshop: Bridging the Gap Between Preceptor Demand and Traditional In-Person Learning.”

·         Jennifer Stephen, a Clinical Practice and Advanced Education Specialist, and Vicki Kelly, Assistant Direct of the Family Services Department, will be joined by a parent mentor to present “Connect, Collaborate, and Elevate the Patient Experience: Outcomes and Successes of an Interdisciplinary Hispanic Family Advisory Council.”

·         Jennifer Horn, a Quality Improvement Coordinator, and Alex Frejer, a Psychiatry Nurse Manager, will present “Implementation of a Behavioral Emergency Response Team in Pediatric Medical Center to Support Bedside Nurses and Improve Safety Outcomes.”

·         Jennifer Stephen will present “An Ethnonursing Study Exploring the Culturally Congruent Care Needs of Spanish Speaking Parents, Who Speak Little to No English, Whose Children Were Hospitalized.”

·         Mary Cazzell, the Director of Nursing Research and Evidence-Based Practice, will present “Relationships among Psychological Safety, High Reliability (HRO) Perception and Safety Reporting Intentions in the Pediatric Nursing Workforce.”

March is Women’s History Month. While the country commemorates the role of women in American History, at Cook Children’s Health Care System, we celebrate the role of women in building one of the largest free-standing pediatric health centers in the country. 

After all, it was the vision and generosity of two women that started it all. 

One, a former postmistress with few financial resources, Mrs. Ida L. Turner, dreamed of a place where fragile babies would be cared for regardless of their family’s ability to pay. Her vision and hard work led to the opening of the Fort Worth Free Baby Hospital in 1918. 

The other was a wealthy heiress who wanted to honor her late husband by helping sick children. In 1929, Mrs. Missouri Matilda Nail Cook dedicated the oil royalties from the Cook Ranch to build the W.I. Cook Memorial Hospital. 

Eventually, the two children’s hospitals became one and grew to be one of the finest pediatric medical institutions in the country with more than 1.5 million patient encounters every year.

Throughout our 105-year history, the women of Cook Children’s have championed children; nurtured the sick and hurting; led innovation in science, medicine and technology; and steered the business of health care with imagination, safety, generosity, kindness, respect and collaboration.

While these women number in the thousands throughout Cook Children’s history, this year, we’re highlighting a few who have made their mark in medicine. Each comes from different backgrounds, different specialties and different decades, but they all share two things — a passion for their work and the Promise to improve the well-being of every child in our care and our communities.

Elizabeth Leeper, MSN, RN, CNOR

Manager of Surgical Clinical Excellence

Years at Cook Children’s: 27

Elizabeth Leeper has been a staple in Cook Children’s surgery department since she began as an operating room nurse in 1996. Today, she is the manager of surgical clinical excellence, a role she pioneered in 2017 and built from the ground up. So far, she is the first and only one to hold the position. 

Leeper and her team of three reviews every single surgical case at Cook Children’s Medical Center to monitor for quality and safety. It’s no small feat for her small department. Under Leeper’s leadership, their hard work earned Cook Children’s a Level I designation as a Children’s Surgery Verified program from the American College of Surgeons. 

To achieve this designation, hospitals must meet a rigorous set of safety standards and demonstrate they have the resources needed to provide children with high-quality surgical care. There are only five pediatric hospitals in Texas that have this designation, and Cook Children’s was the first in North Texas to be named a Children’s Surgery Verified program in 2019. 

“By the time I finished our application, it was over 100 pages,” Leeper said. “They look at basically any part of the hospital system that might potentially touch a patient, and want to know information about that. I had to gather information from the lab, pharmacy, radiology, transport, all our surgeons, administration … you name it. I'm in the middle of our renewal application right now, so I'm working on pulling that information together.”

Leeper doesn’t mind the endless information collection and review. She follows in the footsteps of her childhood inspiration and founder of modern professional nursing, Florence Nightingale, who also used statistics and data to improve health care as far back as the mid-1800s.

“I discovered how much of a data nerd I really am,” she said. 

Today, Leeper draws inspiration for life and work from her daughter. 

“We have an adult daughter with a really rare neuromuscular disease,” she explained. “She lives with us and is wheelchair-bound. Knowing that she gets up every day and watching her deal with what she has to deal with, I know that if she can do it, I can do whatever is before me.”

When the load gets heavy, Leeper leans on her faith and prayer to carry her through.   

“Just being able to know that there is a God, and he does love us and that he takes care of us is an important part of my life,” she said. “I know that he's there even though, sometimes, it's hard to see.”

By Ashley Antle

The choice of pediatrics over adult medicine was an easy one for Matthew Carroll, M.D. It came down to the one thing that all kids, be them sick or well, know and love — a good dose of fun!

“Kids are more fun,” Dr. Carroll said. “A kid could be going through horrible stuff and yet somehow they still manage to have a smile on their face and a positive attitude, and they can still laugh. I know if I was going through even half of what they were going through, I would be crabby. I would be grumpy. I would certainly not be smiling or laughing, but that's just the purity of pediatrics and kids.”

Although his roles as a hospitalist and Cook Children’s Associate Chief Quality Officer are serious ones, Dr. Carroll likes to have a little fun of his own. He credits weekly racquetball games with fellow Cook Children’s physician Danny Rafati, M.D., as an outlet for both entertainment and exercise.

Who’s the better player? It may depend on who you ask.

“I would say me, but I’m probably lying,” Dr. Carroll said with a chuckle and a grin. “He probably beats me about 60% of the time and I probably win about 40% of the time, but even the games where I lose they’re still close matches.”

Outside the racquetball court, Dr. Carroll is laser focused on health care quality and safety. Four years ago, he transitioned from full-time hospitalist to Associate Chief Quality Officer. He still maintains some hospitalist clinical hours, but about 75% of his time is spent poring over quality measures and outcomes data, identifying systems that need improvement and working with others to promote quality and safety within their practices.

“High quality, safe care is our ‘product,’ ” Dr. Carroll said. “It's what we ‘sell.’ It's what we do. I think high quality, safe care is to Cook Children's as the search box is to Google or the F-150 is to Ford. So it's incredibly important in terms of how we support our physicians and staff in delivering high quality care.”

Dr. Carroll’s role is to help make sure physicians and staff have the support they need to deliver that ‘product.' He regularly reviews events and asks what can be learned from them, what can be improved and what systems can be put in place as a safeguard for the future. These systems are more important than ever before, he says, because physicians and staff are stretched as thin as they’ve ever been.

“Part of why people work here is because they're passionate about delivering high quality and safe care to our patients, but at the same time, we're all humans,” he said. “We are imperfect creatures working in an imperfect system. And so how do we construct and build systems that are able to anticipate the inevitable mistakes that are going to come with being human? How do we prevent those mistakes from reaching the patient?”

It all starts with listening, Dr. Carroll says. Listening to understand another provider’s perspective. Listening to understand their unique work situations and what will and will not work on the frontlines and in their individual clinics and practices. Listening to build relationships.

“I think the more you listen to people, the more you learn, and the more others are willing to work with you,” he said.

His proudest achievement so far? The development of quality and safety education for physicians, which has now branched into other disciplines. He’s eager to give credit to the team that made it happen.

“It has been a great effort between Quality, Education, Legal, Pharmacy and Nursing to share learnings about these important topics and has been well received by those who have participated in them,” Dr. Carroll said. “Hopefully it helps to contribute to the exceptional care we deliver here at Cook Children’s.”

Dr. Carroll knew he wanted to be a doctor as a teenager. He attended a health sciences magnet high school in Laredo, Texas—one of the many Texas towns his family lived in throughout his early childhood. He recalls that for the first 12 years of his life, his family moved to a different part of the state every few years for his dad’s job, but never to the D/FW area. It wasn’t until Dr. Carroll moved to Fort Worth eight years ago to work at Cook Children’s that he spent any meaningful time in Cowtown. Now, he’s content to call it home for himself, his wife and their two children—a 4-year-old boy and 2-year-old girl. It’s laidback and chill, he says, and home to plenty of great Mexican restaurants where he can enjoy his favored chips and salsa.

Playing with his kids at the end of a long day is how Dr. Carroll turns off work and turns on rest. Once they’re in bed, you’ll likely find him relaxing on the couch with his wife as they unwind while watching a TV show or two. It’s time he holds dear as he works to balance work, family and his own health.

Taking time to rest is important for physicians, Dr. Carroll contends, but easier said than done for people who chose a profession devoted to helping others. It’s a balance he’s still trying to achieve for the good of himself, his family, his patients and his work.

“I know it’s a lame comparison, but I think it’s really similar to whenever you fly and, during the safety briefing, they tell you to put the oxygen mask on yourself first before you assist anyone else with theirs,” he said. “Before we can take good care of others, we have to take care of ourselves first. If we’re drained, constantly stressed and our tanks are on empty, it’s hard to find much to give our patients. Taking care of ourselves means that we are in a much better place to empathetically listen to our patients and partner with them and their parents to come up with the best treatment plan.”

During his early days of training at Baylor College of Medicine and then Cincinnati Children’s Hospital, Dr. Carroll never imagined his medical career would take its current trajectory into administration and Quality, but he loves the unexpected path he’s venturing and the people he’s working with along the way.

“I love what I do within Quality, but I am one small piece of a much larger department with everyone doing a fantastic job,” Dr. Carroll said. “I don't want any of this to give the impression that it's just me working out there on my own, doing all of this great stuff. It is a team effort and I'm fortunate and lucky enough that I’m part of such a great team of dedicated people. That just makes it easy and fun.”

A special thank you to Javier Gelvez, M.D., PICU physician, and the Sepsis Committee team members who are leading the way. 

All Cook Children's employees can learn more about sepsis and earn the chance to win prizes by completing a special crossword puzzle and wordsearch. You can download both files on the upper right-hand side of this page.

To be eligible for a prize basket, be sure to email your completed puzzles to zeroharm@cookchildrens.org by Monday, Sept. 19.

Prize basket #1: Family Theme

• Zoo tickets
• Movie tickets
• Top Golf gift card
• S’mores supplies

Prize basket #2: Out on the Town Theme

• Pin Stripe Bowling gift card
• Top Golf gift card
• Movie tickets
• Gift cards to local restaurants

Treva's commitment to excellent quality, safety AND service was absolutely phenomenal recently. We had a surgical patient family on our medical floor that should have left the previous day but were waiting on home supplies and equipment. An outside home health company delivered the supplies on this day, but it was all of the wrong equipment. The parents were highly frustrated and flustered. When they received the boxes of medical supplies and

Once the correct equipment had been delivered, and the patient was ready to leave, there were MANY things happening on the unit and the bedside RN was not available to go over the AVS, and get discharge vital signs. Treva showed up and volunteered to go over the AVS, and she even got vital signs for this patient. She knew that this patient and her family had a less than ideal experience, for reasons that we couldn't control. However, to prevent any further delay, Treva jumped in willingly to discharge this patient when it was definitely not her job. She knew she could help get the patient out and she didn't hesitate to do it. 

We are so grateful for people like Treva who are willing to provide exceptional quality service and go above and beyond their regular job description to take such incredible care of patients, families and our staff. She is so deserving of being recognized as a PEAK Performer!

As a nurse practitioner, Maranda has always gone above and beyond in taking care of patients and their families. In one particular instance, it was through her careful notice to details, a critical lab abnormality was identified in a patient who could then receive appropriate therapy. It is important that I point out that she has played a crucial role in ensuring that children with malignant diagnosis get appropriate care and eventually go on to live a full life.

​In addition to her every day extremely busy clinical schedule, she has volunteered to participate in several efforts in program billing – in particular, her role in support of the histiocytic disorder program has made a critical difference in children with LCH and HLH. Maranda is the heart and soul of the inpatient oncology department. She works very hard ensuring thorough, efficient and safe care for each of our patients. She is on multiple committees focused on quality and safety within the oncology department and abroad. 

Maranda goes above and beyond doing more than her share of the work and always does this with a kind word and a smile. Her door is always open, helping educate nurses and coworkers. She is humble in her vast knowledge and experience and the first to ask questions if she is not familiar with the answers. As a department we are so lucky to have her. 

We're spotlighting three nurses this week:

• Patrice Reznicek, RN, Psychiatry 
• Laura Portillo, RN, Hematology-Oncology
• Anthony Garcia, RN, Dialysis 

Watch this video to hear about their favorite nursing moments, nurse heroes and what keeps them going every day!

Kaylan Branson, RN, MSN, has accepted the promotion to the director of Nursing Quality and Magnet Program. Kaylan has been a growing leader within our organization since she joined our nurse residency program in 2011. Since that time she has worked as staff nurse, charge nurse, and preceptor on 4 Pavilion (TCU/RCU). In 2017 she was promoted to the clinical nurse leader role, co-leading efforts to facilitate family discharge, research and

She has had numerous poster and podium presentations for her participation in work related to the boot camp discharge innovation, achievement of quality goals, use of a Gemba Board, trach care and partnership with clinical leaders and educators to improve patient care and nurse satisfaction. 

Kaylan completed her Bachelors of Science in Nursing in 2011 from Tarleton State University, Master of Science in Nursing Education in 2016 from the University of Texas in Arlington, and Clinical Nurse Leader post-graduate certificate in 2019. Kaylan is enrolled in a Doctorate of Nursing program at the University of Texas Medical Branch with a projected graduation of May 2024.

She shall transition from her CNL role on 4NT to her new role on April 24. Please join us in congratulating Kaylan!

Red allergy band details: 

• Red bands pre-printed with “ALLERGY” should be placed only on patients with allergies 
• No NKDA bands 
  • If the patient does not have an allergy, they will NOT receive a band 
• Allergy bands will NOT list allergies 
  • No handwriting allergies on the band 
• Why red for allergies? 
  • Red signifies stop, reminding staff to verify allergies 

Yellow fall risk band details:

• Yellow “FALL RISK ” bands will replace the orange Humpty Dumpty bands 
  • This applies only to patients who score High Risk in the Humpty Dumpty Scale 
• Why yellow for fall risk? 
  • Yellow alerts everyone to take caution and slow down 

By Anu Partap, M.D.

If you are interested in Quality and Safety, then you love data!  And data is everywhere! Dashboards, publications, meetings, social media, email, even the news (sometimes accurate)!  

When working with data, we routinely look critically - “Is the denominator the right one”?  Or “Did the authors make an analytical mistake with their confidence interval?” 

Health disparity/equity work adds interesting dimensions to data interpretation.  Smaller subpopulations are often included in larger data sets.  Subgroup results can often differ in surprising ways when compared to the data as a whole. 

Health equity analyses asks us to uncover “What hidden pearls are buried in these data when they are stratified/divided into subgroups?” 

Cook Children’s teams are analyzing data for health disparities more and more, both internally and as a national partner with peer hospitals.  Sometimes the answers or “hidden pearls” of information are reassuring; sometimes the findings are concerning, leading us to ask “What do we do now?”

In either direction, looking at data with a health equity lens is gratifying, as it naturally aligns with our Promise to every child.  To help everyone get started on analyzing data for health disparities/equity, below are sample health equity questions you can ask of any (accurate) data from (most) any source to look at subgroups to find “hidden pearls”: 

1.  Are data stratified and provided by:

• Families with different economic resources or insurance plans?
• Patient races/ethnicities?
• Patient ages?
• Patient geographies? 
• Patient/caregiver spoken languages for health care?
• Patient sex, sexual orientation or gender identities?

2)      Do stratified/subgroup data show differences from the whole and against other subgroups?  If yes, why and what do we do next? 

Try one out!  Share what you find!  We’d love to hear from you. anu.partap@cookchildren.org. 

Patient safety is a top priority for our Cook Children's staff. Click here to read how our NICU and PICU teams came together to improve the care of our patients. 

“The tremendous improvement is a testament to the quality care we provide our patients,” said Sheralyn Hartline, NICU director. "I couldn’t be more proud of the team!. 

Click here to read this important story. You must be on the Cook Children's Network to read.

On Nov.  8, 2021, 3 Pavilion celebrated an important safety anniversary.   This would be an amazing feat for any medical unit, but especially remarkable for them. As a COVID-19 unit, staff members are unable to go in and out of rooms as frequently as they once did.

So how did 3P do it?  What is their magic power?

 Ashley Kovacev, unit manager, attributes their success to Family Engagement. As the COVID unit, staff rely on families to help monitor the PIV site, and that partnership has paid off in a big way! 

Click here to read the entire story. You must be on a Cook Children's Network. 

Pressure Injuries are one of the leading causes of hospital acquired harm across the nation and at Cook Children’s Medical Center. Nancy has gone above and beyond in leading the Cook Children’s Medical Center pressure injury team. Her leadership has been critical in ensuring that frontline nurses are engaged at the unit level in skin and wound assessment. Nancy has worked in collaboration with the wound care team to recruit and engage over 48 skin wound assessment nurses with representation on every clinical unit. She also facilitates an apparent cause analysis with teams when any serious pressure injury is reported to determine causes and she has put processes in place to prevent further injuries. Nancy's hard work, dedication and leadership is one of the main reasons for the decrease in Cook Children's reportable pressure injuries in 2020. They were reduced from eighteen in Fiscal Year 2019 to seven in the following year.

​Quarterly skin surveillance is required to maintain our magnet status and enhance pressure injury reduction. As the NDNQI Nursing Coordinator, Nancy has ensured the completion of quarterly skin surveillance rounds on the all of the medical/surgical units and monthly skin surveillance on the critical care units. This requires 25-30 trained nurses performing head-to-toe skin assessments of all patients on the same day. This has been no easy feat in 2020 especially with COVID concerns but Nancy continues to make it all happen. This will go a long way in making sure we continue receiving our Magnet status. For these reasons and many more, Nancy Russell is a Peak Performer!

This patient went from the ER to the OR, to the CT scanner, and then to the PICU. 

This was a very high stakes, tenuous situation and I want to commend everyone  involved in helping to get this child taken care of:

• ER: The ER nurse was very helpful and got the patient ready for the OR in record time and the ER doctor readily recognized the seriousness of the situation without delay. 
• CT: The CT tech accommodated our stat request for a CT to be done immediately upon leaving the OR.
• PICU: The PICU team was ready and waiting for us upon our arrival and jumped right in to get this child settled in the PICU with her tenuous airway. 
• OR: The entire team, from the preop nurses to the anesthesia techs worked seamlessly. We had so much help in the OR and everyone was jumping in where they were needed to help out. They retrieved countless sets for me that I had not anticipated needing and therefore had not asked for. I think every person working last night was in our room helping out - nurses, CST, anesthesia techs. We had 2 fabulous CRNAs helping us. the CSTs were working like a bucket brigade retrieving equipment and helping me with the procedure. When went to the PICU, the OR staff continued to help by bringing down a scope and some equipment we needed to re-secure the ETT. They stayed until the patient was fully tucked in.

There is no way I can mention everyone by name because there were just too many people helping; and quite frankly, in some cases, people jumped in without even being asked, and in the case of the ER nurse, she was so quick in prepping this patient that I did not even have time to get her name. Drs. (Jose Olarte-Motta) and (Chandra Reynolds) were the PICU M.D and MDA involved and I am eternally grateful to them. 

This team is why I work here. This teamwork is why I think Cook Children's is the best hospital in the world. This teamwork is why this patient made it through this situation. This team epitomizes Cook Children's Culture. And I want every person involved in this child's care to know that they made a difference for me, and more importantly for the patient. 

She is alive because of them. 

Thank you,

Michelle Marcincuk