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2005 Best Nurse Leader Leading by Example

Vol. 3 •Issue 22 • Page 12
2005 Best Nurse Leader Leading by Example

Maintaining a connection with nurses at every level is important to this year's Best Nurse Leader

A childhood plagued by severe chronic asthma and numerous visits to the ED gave Mary Holt Ashley, PhD, RN, CNAA,BC, chief nurse executive (CNE) for Harris County Hospital District (HCHD) in Houston, a chance to learn about nursing at a young age.

"When I left the EDs, I felt tremendously better. It was amazing to me that I could go from being critically ill to a stable state so quickly. That was the impetus for me to be a nurse," she said.

Although Dr. Ashley has moved up the ranks throughout her 37-year nursing career, the recent hurricanes in the Gulf Coast provided an opportunity for her to lead by example and work side-by-side with nurses at every level. Not only did this experience heighten her leadership visibility, it confirmed her long-held conviction that staff members want a professional and emotional connection to their leaders, she said.

Dr. Ashley's dedication to nursing has garnered her ADVANCE for Nurses' 2005 Best Nurse Leader award.

Challenges: Bring Them On

Learning to bring the field of nursing under one umbrella has been a challenge, according to Dr. Ashley. By analyzing situations, she ensured salient points of emphasis were embraced by all. The biggest challenge for a large organization like HCHD is money for special nursing programs to enrich the nursing environment, she noted.

"The vision for nursing is solid and accepted by nursing leaders," she noted. "The strength, courage and commitment to have a Center for Nursing Excellence require an enhanced budget, manpower and committed leadership at all levels."

These challenges were overcome by developing strong teams across the district to unite nursing as one, facilitating frequent summit meetings with leaders and staff, and ensuring communication via a newsletter to keep nursing staff informed.

"To acquire the monies needed for our research and evidence-based practice department, I will budget for it through a three-phase process until it is complete. To maintain support and ensure implementation, I have the support of three chief nursing officers who are committed to building the Center for Nursing Excellence," she explained.

Nursing has and continues to progress through the years, as with most professions. The biggest changes in nursing, according to Dr. Ashley, are the "respect for what nurses do, salaries, patient-nurse ratios, expanded roles for nursing, changes in practice standards and increased nurse accountability."

On a Personal Note

When not leading by example throughout numerous facilities within HCHD, Dr. Ashley often plays Scrabble on the computer and with her Scrabble club. As a goal-oriented woman, even when she's playing games she wants to be the best, and she strives to become a national player.

Dr. Ashley also spends time discussing various topics at her church and finds enjoyment in decorating her home. She is quick to acknowledge the support of her husband, Ellis Charles Ashley Sr., over the years.

Whether during a hurricane or in the day-to-day activities as CNE, Ashley continues to lead by example.

Mary Aucoin is regional editor at ADVANCE.

Mary Holt Ashley, PhD, RN, CNAA,BC Chief Nurse Executive

Harris County Hospital District, Houston

The patients were pouring in, acuities were ascending, staffing needs were soaring and desperately needed funding was fleeting. Despite the impact of these issues coupled with the infamous nursing shortage, Dr. Ashley remained resolute: "No, it can be done — and we will do it." Known for this consistent response, she refused to back down from challenges that had great potential for positive outcomes. It is this spirit of tenacity, fortified by her determination, that marks her signature of excellence.

Climbing the ranks from a nursing assistant graduate of a local community college to a doctoral-prepared chief nurse executive, this nurse leader with more than 3 decades of heartfelt commitment has made a monumental difference where I work.

Climbing the Career Ladder

As an emergency room nurse at a level I trauma center, Dr. Ashley saw cases ranging from gun shot wounds and broken bones to displaced organs and disfiguration, yet her first challenges entailed attending nursing school while working. Simple tasks for others, Dr. Ashley's daily journeys were (and at times, still are) laden with heaving and wheezing due to severe asthma and chronic lung disease – yet she never let it douse her fire.

Clinically astute, she later struggled with the decision to leave the fast-paced patient care arena to pursue a managerial position within the department, but her heartache was softened by her newfound love affair with nursing administration. Rising to the roles of nurse manager, assistant director, nursing director, vice president and chief nursing officer, she honed her critical-thinking skills, emotional intelligence, creative approaches and administrative expertise. These strengths culminated in preparation for the greatest challenge of her career: unifying the nursing departments of three hospitals, 13 community health centers, 11 homeless shelters and seven school-based clinics as the Hospital District's first chief nurse executive.

Commensurate with this new strategic goal, Dr. Ashley is spearheading the effort of achieving the internationally acclaimed Magnet status recognition. Likening it to a "trip to the Super Bowl," she uses her charisma and sphere of influence to incorporate the Magnet criteria while facilitating changes in patient outcomes, interpersonal relationships and professional development.

Successful Endeavors

Among her greatest accomplishments that have made differences in patient outcomes are constructing an exclusive nursing model promoting the empowerment of the RN in the patient care role and injecting nursing philosophy with a healthy dose of evidence-based practice.

Her interpersonal relationships are equally laudable. She maintains constant interaction with all staff prefaced by an easily approachable demeanor. She champions widespread praise and recognition with an emphasis on self-actualization. Leading by demonstration, Dr. Ashley also has helped shape several District leaders, mentoring them through the ranks as a constant resource, careful not to limit her talents to nursing.

Her relationships are further strengthened through interdisciplinary collaboration where she has built noteworthy partnerships with physicians and allied health professionals. Rounding out the differences is her emphasis on professional development. She designs programs that place continuing education in the forefront, has markedly increased the attainment of nurses' professional certifications through innovative incentives, echoes the importance of higher education and nursing research, and religiously admonishes nurses to be active in professional organizations.

The success of these differences is partially due to Dr. Ashley's attentiveness to effectiveness and efficiency. She holds an excellent grasp on reaching the organization's goals while making the best use of its resources. This is especially significant in the Hospital District where county tax dollars make up the largest portion of our funding.

Dr. Ashley facilitates an annual, interdisciplinary performance improvement fair where staff members develop projects aimed at enhancing patient outcomes communicated through poster presentations and judged by industry experts; creating nursing councils and a governance model to employ nursing empowerment at the grassroots level; catalyzing excellence incentivized by peer and administrative recognition; and teaching staff specific strategies of resourcefulness — or as she puts it, "doing more with less."

Nurses' Advocate

Countless studies have shown that select improvements, even when monetary, have little impact if the overall working environment is unhealthy. As a proponent of this truth, Dr. Ashley constantly endeavors to improve the nurses' work environment. Her efforts entail creating an atmosphere conducive to growth and professional development, embracing and supporting spirituality and social sensitivity, and maximizing the benefits of infusing organizational culture with diversity.

Dr. Ashley further applies the managerial approach of transformational participative leadership. She enables staff to make meaningful contributions of their own through positive change, ingenuity and ownership. As a result, sowing her seeds of quality has yielded a bountiful harvest of excellence.

While countless nurses provide high-level patient care throughout the world, a small percentage pursue opportunities to transition into leadership. Even fewer seek roles with greater spans of control and potential for change. However, there exists an elite group of leaders that positively affects the environment long after employment. These leaders improve patient outcomes regardless of their place on organizational charts. They cultivate growth in interpersonal relationships and promote continuous professional development. Finally, they actualize organizational goals by mandating effectiveness and efficiency on each nursing unit while accomplishing outstanding feats amidst a barrage of personal and professional challenges.

Dr. Ashley is a nursing icon, proving daily that heaven's stars are within our reach.

Patricia R. Johnson, MN, RN

Vice President/Chief Nurse Executive Woman's Hospital, Baton Rouge, LA

Patricia R. Johnson, MN, RN, received a BSN in 1974 from Mississippi College School of Nursing. She has been a registered nurse for 30 years. She received her master's in nursing in 1987 from the Emory University School of Nursing in Atlanta.

Johnson has served in numerous nursing roles including staff nurse, clinical nurse specialist, consultant and manager/director. This vast nursing experience makes her uniquely able to understand and identify with nursing staff at every level in the organization. For the past 7 years, Johnson has led the nursing department of Woman's Hospital as vice president/chief nurse executive.

Encouraging Growth

Great strides have been made in unifying all nursing areas so that the common goal of providing excellent nursing care is always in the forefront. Johnson recently led the nursing staff in adopting Jean Watson's Theory of Human Caring as a basis for nursing practice.

Under the leadership of Johnson, nursing has had a decrease in turnover and the turnover rate is well below the national average. Patient, nurse and physician satisfaction has been high. She believes in participatory leadership and involves staff nurses at every level in the decision-making process. Nurses have commented that they feel free to be creative in problem solving. They feel administrative support is very present, but not stifling. Nurses are allowed to practice in an atmosphere conducive to professional growth. Each nurse in the organization has a significant contribution to the success of Woman's Hospital.

Johnson believes the primary responsibility of nursing leadership is to support the nursing staff and enable them to provide the best care possible to the patients they serve. She accomplishes this by advocating successfully for resources such as equipment, staff, space, education and training necessary to provide quality care.

She has coordinated renovations in surgical services, labor and delivery, antepartal and neonatal intensive care. These renovations have greatly improved the environment for the nurses as well as for the patients and their families. A redesigned NICU opened in December 2004. During the planning of this redesign, Johnson arranged for NICU nurses to visit units all over the United States to assure the renovations would be state-of-the-art and designed to best meet the needs of the staff and this special population of patients.

Supporting Positive Change

Johnson has led many clinical quality improvement projects, including a major initiative to improve patient safety. She has presented on the topic of patient safety in several venues.

Due to her leadership in that area, Woman's Hospital was one of the first hospitals in the country to hire a patient safety officer dedicated to assuring patient care is provided in a safe manner. She also led the hospital in completing the Institute for Safe Medication Practices' self-assessment tool.

Other improvement projects include decreasing nausea and vomiting in postsurgical patients and reducing noise levels on nursing units. Currently, she is leading an effort to provide needed neurological follow-up to newborns through the development of an outpatient neurodevelopment clinic.

Because of her strong belief in the nursing excellence at Woman's Hospital, Johnson has spearheaded the effort to achieve Magnet recognition. The hospital applied for this prestigious designation in July 2004 and expects to complete the process successfully within 2 years.

Eye on Education

Johnson also is passionate about improving nursing education and orientation. Under her leadership, the budget for nursing education has more than doubled and at least three continuing education opportunities are offered to nurses each month.

She has presented numerous education offerings and enjoys teaching. Each year, she personally conducts a nursing preceptor workshop and nursing leadership retreat at Woman's Hospital. She has revised nursing orientation and personally speaks to all new nurses.

The Career Ladder program has been in place for 16 years, but Johnson has revised the program to incorporate Patricia Benner's model of novice to expert. This model also is taught by Johnson in the nursing preceptorship program. Nursing leadership development is of great importance to Johnson and she coordinates attendance at national meetings for nurses from each clinical area.

In addition to internal educational endeavors, she has presented at the VHA Regional Workshop, Tulane University and Our Lady of the Lake College. She also serves as a graduate clinical preceptor for Southeastern University School of Nursing and participates in VHA National Nursing Symposiums. Her work regarding implementing nursing diagnoses in perioperative documentation was published in the AORN journal in 1989.

All-Around Achiever

Johnson is very active in professional organizations. She is a member of the American Organization of Nurse Executives, American Nurses Association and the Sigma Theta Tau International Honor Society for Nurses. In addition, she serves as a board member for the Louisiana Organization of Nurse Executives.

In 2003, she received the Baton Rouge District Nursing "Outstanding Nurse" award. She also is part of the Baton Rouge Chamber Leadership Class of 2002. The Mississippi College School of Nursing recently named her Alumnus of the Year.

On a more personal note, Johnson has four children, teaches Sunday School, has formed a neighborhood book club and enjoys playing tennis. She has been involved in community service organizations such as Habitat for Humanity and the American Heart Association.

Pamela E. Windle, MS, RN, CNA, CPAN, CAPA,BC

Nurse Manager, PACU, Day Surgery Center & Surgical Observation Unit

St. Luke's Episcopal Hospital


Pamela E. Windle, MS, RN, CNA, CPAN, CAPA,BC, has made tremendous contributions to the growth of the nursing profession and has improved and enhanced patient outcomes. Windle has been the nurse manager of the post anesthesia care unit (PACU) since 1984 and also manages the day surgery center and the surgical observation unit.

Her previous experience involved med/surg ICU, OR and cardiovascular recovery/ICU as a staff nurse, educator, adjunct faculty, consultant and various management roles (preadmission testing, ambulatory surgery and endoscopy departments). She is an experienced leader for more than 20 years. She has supported the professional growth of her staff and has been the driving force behind running effective and efficient patient care areas.

Evidence-Based Initiatives

Over the years, she has made major contributions in nursing through her involvement in mentorship, improving patient care, research and education. She has numerous published nursing research as the primary investigator or co-investigator. Findings from these research studies have brought about a change in practice, leading to better patient outcomes and improved staff morale.

Windle has consistently motivated her staff to constantly look at their practice so that processes are streamlined in order for patients to get high-quality and cost-effective care. As an example, under her leadership, the staff has adopted fast tracking in surgical outpatient. A research study on this topic was done and the fast-tracking protocol revealed a higher degree of patient satisfaction compared to the traditional protocol where patients were mobilized in day surgery. Early mobilization and ambulation activities are now initiated in PACU instead of day surgery so patients' length of stay is shortened.

Another successful initiative was the opening of the 23-hour observation unit for patients unable to go home. This unit, in its fourth year of operation, has been so highly esteemed that surgeons request to have their patients admitted here.

Giving Back to the Profession

As an expert in perianesthesia nursing, Windle is well sought by her peers, staff and colleagues. She constantly presents completed research studies at various national and international conferences. The most recent presentation was in Chicago, wherein five successful practice/QI posters and one safety research poster were presented. She has done oral research presentations at past national conferences of the American Society of PeriAnesthesia Nurses (ASPAN). She is active with several ASPAN committees and coordinates the oral and poster research track during national conferences.

Windle is a member of the editorial board with Lippincott's Case Management and a research columnist with the Journal of PeriAnesthesia Nursing. She has been invited to speak on perianesthesia nursing, not only locally, but also nationally and internationally. She has published numerous articles in books, journals and newsletters. Windle has been publishing over the past 13 years.

As an avid advocate for active involvement in professional nursing organizations, Windle has recruited 100 percent of her staff to join ASPAN. She has encouraged holding elective office as evidenced by her staff holding six out of seven positions in the present officer lineup for the Texas Association of PeriAnesthesia Nurses (TAPAN) District 1 Houston-Gulf Coast.

Every year, 60-80 percent of her staff attends the local and state conferences and sends 5-7 nurses to the ASPAN national conferences. She has served as the ASPAN Region 2 director encompassing 10 states in the Midwest/South Region. She has held office as president of TAPAN and actively serves on multiple national, state and district level committees in the ASPAN/TAPAN organization. Recently, she was elected as the president-elect/vice president of ASPAN.

Over the past 10 years, she consistently represents nurses in her role as the Texas Nurses Association (TNA) delegate-District 9, serving on the board of directors and on several committees. She is currently the president of TNA District 9. She participates actively with state regulations regarding nursing practices and has assisted other nursing leaders in the development of state and local bills.

Encouraging Staff

Despite her achievements and her status as a nursing leader, Windle continues to be there for her staff when we need her. She allows her staff to have a say on issues that affect the unit. She believes in shared governance as part of the shared leadership model. She gives her input, guides us to make decisions and abides by the team decisions.

She will bend over backward to accommodate our requests within the limitations imposed by staffing and policy. She is a coach, mentor and counselor. She takes a personal interest in her staff's personal and professional growth. She is the only nurse manager in our hospital that has 90 percent specialty-certified staff overall, with one of her departments receiving the "ABPANC Leadership Circle" award for achieving 100-percent certified staff for 2 consecutive years.

Through her leadership, she initiated the nurse liaison role for surgical patient/family, which has been very successful, leading to improved customer satisfaction.

Windle is an amazing leader. She not only manages three outstanding departments, but also coaches her staff and produces excellent patient outcomes. Her turnover rate is below 4 percent overall (one department has zero percent turnover). She constantly encourages her staff to reach their maximum potential and allows for systems and structures that make it possible. She wears multiple hats and can juggle her personal and career life. Excellence is her hallmark and she truly is a leader "extraordinaire."

Laura Fortin, MBA, BSN, RN, CHE

COO/CNO, Department of Nursing

CHRISTUS St. Joseph Hospital


Laura Fortin, MBA, BSN, RN, CHE, came from the ranks of a nursing director at CHRISTUS St. Joseph Hospital to become the CNO in 1999. Armed only with a bachelor's in nursing and no DON experience, Fortin took on the daunting task of leading a nursing staff of 320 RNs with a 23 percent turnover rate and high vacancy rate. Low morale and low participation by nursing staff were commonplace.

Making a Difference

Today, Fortin has her MBA and is a certified healthcare executive. She has advanced to become the COO in addition to the CNO role at the facility. Most importantly, she has orchestrated a total turnaround for this now "Magnet-hopeful" organization. She has developed, along with the staff, nursing bylaws, a shared governance structure for nursing and clinical ladders so that, through nursing excellence, nurses can add financial bonuses.

Structured self-scheduling to provide control and flexibility to nurses' schedules, a tiered float pool to use in-house staff as opposed to agency when need arises, and Resignation Recovery and High Touch Alumni Network to retain current nursing staff were all best practices Fortin adopted for the recruitment and retention of the nursing staff. She instituted shift bidding in the organization where nurses can bid on open shifts on the Internet to earn more money while working at their "home hospital."

To improve communications for the nurses, Fortin writes a monthly newsletter. She secured e-mail for all nurses and has provided each of the nursing departments with their own Web site (RVoice) where nurses can access shift bidding opportunities, unit and hospital calendars, schedules and information all from either a hospital work station or the comfort of their own home.

Nurses now run their own meetings, provide input into management and clinical decisions, conduct research and journal clubs, strive for certification and climb the clinical ladders. Today, the turnover rate is 15 percent and the vacancy rate is 5.02 percent.

Fostering Quality

What effect has Fortin's leadership had on the nurses? Well, in 2003 and again in 2005, the RN staff participated in a National Data Base of Nursing Quality Indicators RN satisfaction survey. The rise in scores in just 2 years was extremely noteworthy. All categories experienced a rise in satisfaction while "autonomy in practice" rose 7 points and "professional status" rose 6.5 points. This was clearly indicative of the "voice in practice" that Fortin has fostered in the St. Joseph nurses.

What about her nursing directors? They were not left by the wayside. Fortin brought in Nursing Leadership Academy speakers to help address the issues facing middle management with practical, proven solutions. A management book club was instituted where directors read and discuss current management books and how they apply to their workplace situations.

Testimony to a True Nurse

Fortin is a nurse's nurse who has a passion for her staff and a true desire to see them grow and develop.

What do the nurses say about her? Here are some comments that staff RNs have made about Fortin and her leadership:

• "She has done a phenomenal job supporting staff to grow and excel beyond what is expected of us."

• "She is a friendly face in the hallway and she knows all of us."

• "Fortin encourages nurses to be proactive and initiate change that benefits the patient."

• "We have never been so stimulated with projects."

• "Fortin is a good listener; I feel completely comfortable addressing concerns and issues with her."

These testimonials from the staff nurses say it all. Fortin is deserving of the 2005 Best Nurse Leader Award.

Excellence Abounds

Five more nurse leaders who raise the bar for the nursing profession

Picking the best nurse leaders from a talented pool of entries is no easy task and typically little separates the winners from the runners-up. That is why we offer congratulations to the following five nurse leaders who earned honorable mention in the 2005 ADVANCE Best Nurse Leader contest.

Ingrid Steinbach, RN

Director of Emergency & Trauma Services

Valley Baptist Medical Center in Brownsville

High Customer Satisfaction — Steinbach has successfully completed several initiatives with her department to increase patient care and customer satisfaction. They include:

• successful level III trauma designation;

• development of an Express Care Unit that has improved patient flow and customer satisfaction within the ED; and

• implementation of cutting-edge technology in the ED of electronic tracking and charting.

Under Steinbach's leadership the ED has earned recognition as the best ED among 123 Tenet hospitals on three different occasions and 2005 outstanding customer service from PRC.

Maggie D. Willis, MSN, FNP

Coordinator of Health Services

Garland Independent School District

Improving the Lives of Children — Willis developed and implemented several innovative programs in her school district. She was instrumental in having automated external defibrillators placed in all the district's schools and athletic stadiums. Because of this initiative, a school nurse using an AED was able to save the life of a student athlete this year.

In addition, Willis has made arrangements for coaches and high-risk teachers to obtain hepatitis B vaccinations. And she ensures that appropriate bus drivers and aides are trained to handle medical emergencies such as seizures, suctioning and transporting ventilator-dependant students.

Mary Ann Bush, MA, RN, CRM

Chief Nursing Officer

Medical Center of Arlington

Greatest Quality Improvement — As a new CNO, Bush faced many challenges both within the nursing ranks, and also within the community the hospital served. With high contract labor and low employee moral, the Medical Center of Arlington and Bush were faced with a poor community opinion of this 326-bed acute-care hospital. Physicians and patients alike had very poor satisfaction scores for the hospital and for nursing care.

Bush has directed a major change in all of these challenging areas. Recent polling indicates that in the past 6 months, physician satisfaction specifically with nursing care has increased 8 percent and it continues to rise. Patient satisfaction scores related specifically to nursing care have climbed from very low numbers to the second quartile and Bush wants to bring them even higher.

Patricia Daniels, RN

Assistant Chief Nursing Officer

Nacogdoches Medical Center

Strong Patient Advocate — During her 30-year tenure at this East Texas facility, Daniels has assisted in the development and implementation of a geriatric unit that greatly decreased the rate of nosocomial decubitus in elderly patients. She has been directly involved in development, implementation and maintenance of patient safety programs involving restraints, moderate sedation and fall precautions.

Daniels also was instrumental in the redesign of care delivery for cardiac catheterization and CABG patients. This included the transition of a telemetry unit so all post-cardiac cases were cared for in one area of the hospital. In addition, she was a member of the transformational team that established the hospital's Chest Pain Center.

Daniel F. Kelly, MBA, BSN, RN

Chief Nursing Officer

North Austin Medical Center

Bolstering the Future of Nursing — Kelly has worked with local colleges of nursing to bring senior level students to the medical center. The facility has RN student externs work during the summer months on the various nursing units and graduate advanced practice nursing students working with the nurse educators on projects in their specialty areas.

Through Kelly's enthusiasm and vision, St. David's Healthcare Partnership sponsors a graduation party twice a year. The students are honored for their hard work and accomplishments and network with the nursing directors and managers. The partnership also holds NCLEX review courses for the students and assists them in many ways to successfully attain their licensure.

Meet the Distinguished Judges

We wouldn't be able to do this contest without them! Entries for the ADVANCE for Nurses 2005 Best Nurse Leader contest were read by three nurses from the areas of Indiana and Illinois to avoid any possibility of conflict of interest in this contest.

Judges scored the contest based on the challenges the nurse leader has faced, how the leader has made a difference in patient outcomes, interpersonal relationships and professional development, the effectiveness and efficiency of the unit, and the overall working environment.

A special thanks to the following judges for the 2005 Best Nurse Leader contest.

Bette Case Di Leonardi, PhD, RN,BC, owns a consulting practice in Chicago and assists her clients in achieving their goals using educational, competency management and quality improvement strategies. Dr. Case Di Leonardi enjoys a national reputation as a dynamic speaker. She has designed and delivered hundreds of presentations and workshops at national conferences and on programs sponsored by nationally recognized medical centers, universities and other providers of continuing education. Prior to establishing her consulting practice, Dr. Case Di Leonardi held leadership positions at Michael Reese Hospital and Medical Center in Chicago.

Rebecca J. Rufo, DNSc, RN, CCRN, recently became the operations director for the eICU at Provena Health in Mokena, IL. Here, she leads a team of healthcare professionals in providing the highest quality of care for the hospital's ICU patients. Prior to this position, she served as nurse educator for Resurrection Health Care in Chicago. Dr. Rufo has received numerous honors during her 20 years of nursing. She received a Golden Lamp Society Scholarship, a $10,000 award for distinctive scholarly research at the doctoral level; a Kellogg Scholarship Award from Rush University; and the Rush University Medical Center Nurses Association Alumni Award.

Marsha M. King, MS, MBA, RN, CNAA, serves as the chief nursing officer at Saint Joseph Regional Medical Center, South Bend/Mishawaka Campuses in Indiana. She has many years of nursing leadership experience and is a former president of the Indiana State Board of Nursing. Prior to her position at Saint Joseph, King was the vice president of patient care services for Arnett HealthSystem in Lafayette, IN, and the division director of patient care services at St. Mary Medical Center in Hobart, IN. In 2002, she received the Sagamore of the Wabash award, the highest honor bestowed by the governor of Indiana for distinguishing attributes of loyalty, wisdom and leadership.


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