2017 ORGANIZATIONAL OVERVIEW DOCUMENTS. Selected Evidence

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1 2017 ORGANIZATIONAL OVERVIEW DOCUMENTS Section: Contextual Information 1. A description of the applicant organization in terms of: History Population(s) served Include ethnicity of the nursing staff, client population, and community served. Writer: Georgia Peirce/Marianne Ditomassi 2. The current chief nursing officer s job description and curriculum vitae. Writer: Marianne Ditomassi Section: Transformational Leadership 3. Copies of the most recent: Annual reports (nursing and organization) Quality plans Patient safety plan Strategic plans for the organization and nursing services Writers: Marianne Ditomassi/Patti Shanteler 4. The administrative and nursing organizational chart(s). Describe the CNO s structural and operational relationships to all areas in which nursing is practiced. Writer: Marianne Ditomassi Section: Structural Empowerment 5. The policies and procedures that govern/guide continuing professional development programs, such as tuition reimbursement; access to web-based education; professional nursing certification; and participation in local, regional, national, and international conferences/meetings. Writer: Brian French 6. The learner assessment of the continuing education needs for nurses at all levels and settings, and the related education implementation plan. Writers; Brian French and Mary Ellin Smith 7. An action plan that includes a target and demonstrates evidence of progress toward 80% of registered nurses obtaining a baccalaureate or graduate degree in nursing by Include an assessment of the current status; an evaluation of methods and strategies to increase the educational level of the workforce; and an appraisal of established, realistic targets to meet the organization s strategy to increase the number of registered nurses with a degree in nursing (baccalaureate or graduate degree). 1 Description posted as outlined Current CV & Position Description posted Reports posted as outlined - MGH org chart - MGPO org chart - N&PCS org chart P & Ps posted Assessment tools and education plan posted Data presented re: % BSN or higher degrees in nursing; exceeds 80% threshold

2 2 Writers: Brian French/Nancy Raye Section: Exemplary Professional Practice 8. A schematic of the professional practice model(s) and a description of the care delivery system(s) in use in the organization. Writer: Marianne Ditomassi 9. Access to the state s Nurse Practice Act(s). It is sufficient to provide the web address(s) to access the most current version of the Act(s) available on the website. Otherwise, hard copy(ies) of the most current version of the Act(s) must be provided. Writer: Marianne Ditomassi 10. Blank templates are required for nurses at all levels (staff nurses up to and including the CNO): Self-appraisal tools Peer feedback tools Performance review tools Validation of completed forms will be at site visit. Writers: Marianne Ditomassi/Patti Shanteler 11. A description of the process by which the CNO (or his or her designee) participates in credentialing, privileging, and evaluating advanced practice registered nurses (APRNs). Include the frequency of reprivileging. Writer: Mary Ellin Smith 12. The policies and procedure that address: Patient privacy, security, and confidentiality Patient ethical issues and/or needs Promotion of a nondiscriminatory environment for patients and families Writer: Patti Shanteler 13. The policies and procedures that address the organization s workplace advocacy initiatives for staff, including the following issues: Caregiver stress Diversity Rights Confidentiality Writer: Patti Shanteler 14. The policies and procedures that permit and encourage nurses to confidentiality express their concerns about their professional practice environment, without retribution. Current PPM and PCDM posted. Link to BORN posted Forms posted: CNO/Nurse Executives Nursing Directors NPs, CRNAs, Midwives CNS/NPS Clinical Nurses Narrative describing: Credentialing policy Application form CREF form OPPE information/chart review form P & Ps posted P & Ps posted P & Ps posted

3 Writer: Patti Shanteler 15. The policies and procedures that address the identification and management of problems related to incompetent, unsafe, or unprofessional practice or conduct. Writer: Patti Shanteler 16. The policies and procedures regarding interprofessional conflict. Writer: Patti Shanteler 17. A description of the infrastructure, the organizational committees, and the decision-making bodies specifically designed to oversee the quality of patient care. Writer: Patti Shanteler Section: New Knowledge, Innovations and Improvements 18. The organization s policies, procedures, charters, or bylaws (including Institutional Review Board) that protect the rights of participants in research. Writer: Meg Bourbonniere 19. The organization s policies, procedures, charters, or bylaws designating that at least one nurse must be a voting member of the governing body responsible for the protection of human research participants, and that at least one nurse votes on nursingrelated protocols. Writer: Meg Bourbonniere 20. A table of ongoing or completed nursing research studies within the past 48 months. Writer: Meg Bourbonniere P & Ps posted P & Ps posted Q & S infrastructure described P & Ps posted Letter from IRB leader provided attesting to nurse involvement in IRB panels Table of ongoing or completed nursing research studies posted 3

4 2017 Sources of Evidence Source of Evidence: Strategic Planning TL1EO Nursing s mission, vision, values, and strategic plan align with the organization s priorities to improve the organization s performance. A. Provide one example, with supporting evidence, of an initiative identified in the nursing strategic plan that resulted in an improvement in the nurse practice environment. B. Provide one example, with supporting evidence, of an initiative identified in the nursing strategic plan that resulted in an improvement due to a change in clinical practice. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: A: Chris Annese B: Janet Madden Source of Evidence: Strategic Planning A: CLABSI reduction occurred in one unit secondary to changing the nurse practice environment through multiple interventions including redesign of CLABSI prevention processes, development of an online central line maintenance checklist, daily discussion re: on-going need for central line, weekly huddle to discuss findings from the CLABSI audits and number of weeks since last CLABSI. B: HAPU reduction occurred in one unit secondary to changing nursing practice from frequent turning of critically ill patients to utilizing Dolphin mattresses for a subset of the patient population. Units/Patient Areas Medical Intensive Care Unit (Blake 7) Cardiac Surgical Intensive Care Unit (Blake 8) Units/Patient Areas TL2 Nurse leaders and clinical nurses advocate for resources to support nursing unit and organizational goals. A. Provide one example, with supporting evidence, of a nurse leader s advocacy that resulted in the allocation of resources to support an organizational goal. A: Nurse Leader, Theresa Gallivan, advocated for the addition of FTEs for two adult units that experienced an increase in the volume and acuity of patients on Extra Corporeal Membrane Oxygenation (ECMO). Cardiac Surgical Intensive Care Unit (Blake 8) Cardiac Intensive Care Unit (Ellison 9) 4

5 B. Provide one example, with supporting evidence, of a clinical nurse s (or clinical nurses ) advocacy that resulted in the allocation of resources to support a nursing unit goal. Writer: A: Chris Annese B: Mandi Coakley B: Clinical Nurse, Holly Milotte, conducted a study of the efficacy of a specialized pillow to reduce pain in post-op nephrectomy patients and then advocated for the financial resources to purchase them for the unit when the results were favorable in reducing post-op pain, compared to standard care. Orthopaedics Unit (Ellison 6) Source of Evidence: Advocacy and Influence Units/Patient Areas TL3EO The CNO influences organization-wide change beyond the scope of nursing. TL4 Provide one example, with supporting evidence, of a CNO-influenced positive change that has organizationwide impact beyond the scope of nursing services. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: Amy Giuliano The CNO is a strategic partner in the organization s decision making. A reduction in LOS was achieved on one service secondary to the work of the Patient Progression Improvement Team, co-chaired by the CNO and inclusive of six primary interventions: Changes in interdisciplinary rounding Guardianship Pilot Risk Assessment Predictor Tool Early Discharge Pilot Estimated Discharge Date (EDD) Tool Post Acute Levels of Care education Neuroscience Service: Neuroscience Intensive Care Unit (Lunder 6) Neuroscience Unit (Lunder 7) Neuroscience Unit (Lunder 8) A. Provide one example, with supporting evidence, of the CNO s involvement in the organization s decisionmaking (not involving technology). A: A high-level organizational Diversity Committee was established as a result of the CNO s membership on the General Executive Committee (GEC) and the committee was co-chaired by the CNO. 5 B. Provide one example, with supporting evidence, of the CNO s involvement in the organization s technology decision-making. Writer: A: Brian French B: The CNO s involvement on the ecare Steering Committee allowed for the executive decision to discontinue use of the Blood Administration component of ecare until full testing and simulation demonstrated that it functioned as intended.

6 TL5 B: Ann Marie Dwyer Nurse leaders lead effectively through change. A. Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully guide nurses through unplanned change. A: Nurse Leaders Kevin Whitney and Theresa Gallivan utilized multiple strategies to educate nurses about Ebola and prepare them to care for patients with suspected or confirmed infection. Emergency Department (Ellison 1/Lunder 1) Medical Intensive Care Unit (Blake 7) Pediatric Intensive Care Unit (Bigelow B. Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully guide nurses through planned change. Writer: A: Janet Madden B: Janet Madden The CNO advocates for organizational support of ongoing leadership development for all nurses, with a focus on mentoring and succession planning. B: Nurse Leaders Annabaker Garber and Van Hardison prepared nurses for the implementation of ecare through the development and implementation of multiple strategies including the creation ebridge, specialized roles, resources, and training. TL6 Provide one example, with supporting evidence, of each of the following activities: A. Mentoring or succession planning activities for clinical nurses A: Clinical Nurse, Bethany Groleau was mentored by Barbara Cashavelley for a global health experience in Uganda. Lunder 9 (Hematology/Oncology Unit) B. Mentoring or succession planning activities for nurse managers B: Nurse Director, Melissa Joseph mentored by Gaurdia Banister for her current ND position, decision to pursue doctoral study, and associated scholarship opportunities. Ellison 12 (General Medical Unit) C. Mentoring and succession planning activities for nurse leaders (exclusive of nurse managers) C: Informatics Director Ann Marie Dwyer mentored by Jeanette Ives Erickson prior to and following Dwyer assuming her position Nursing &PCS Informatics D. Mentoring or succession planning activities for the chief nursing officer Writer: A: Mary Ellin Smith B: Mary Ellin Smith D: Jeanette Ives Erickson was mentored by Mary Dee Hacker for her new role as a Magnet Commissioner. Nursing Administration 6

7 TL7 C: Mary Ellin Smith D: Marianne Ditomassi Nurse leaders, with clinical nurse input, use trended data to acquire necessary resources to support the care delivery system(s). Provide one example, with supporting evidence, where a nurse leader, with clinical nurse input, used trended data to acquire necessary resources to support the care delivery system(s). Writer: Chris Annese Source of Evidence: Visibility, Accessibility and Communication Nurse Leader Theresa Gallivan used trended data (HAPUs and financial re: special mattress and overlay rentals), as well as clinical nurse feedback from a bed fair, to support request for the capital budget resources to purchase new mattresses for adult general care beds. inpatient General Care Units Units/Patient Areas TL8 The CNO uses various methods to communicate, be visible, and be accessible to nurses throughout the organization. Choose two of the three below: Provide one example, with supporting evidence, of communication between the clinical nurse(s) and the CNO that led to a change in the nurse practice environment. Provide one example, with supporting evidence, of communication between the clinical nurse(s) and the CNO that influenced a change in nursing practice. Writer: A: Mary Ellin Smith C: Mary Ellin Smith A: Discussion between a clinical nurse and the CNO at a SNA meeting re: lack of efficiency in bed and stretcher management led the CNO to establish a tiger team that changed the nursing practice environment and led to improved patient care and nurse satisfaction. C: The CNO utilized the SNA to begin discussion with clinical nurses about making the peer review process more meaningful. Feedback about perceived barriers to peer review and a lack of knowledge for how to give constructive criticism led the CNO to work with Nurse Leader Kevin Whitney to embark on a process to develop a formal, more robust peer review process that included education for clinical nurses. TL9EO 7 Nurse leaders (exclusive of the CNO) use input from clinical nurses to influence change in the organization. Choose two of the three below (examples must be different

8 from those provided in TL8): Provide one example, with supporting evidence, of a change in the nurse practice environment that was influenced by the clinical nurses communication with a nurse leader (upd 3/14). Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Provide one example, with supporting evidence, of a change in nursing practice that was influenced by the clinical nurses communication with a nurse leader (upd 3/14). Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: A: Janet Madden C: Janet Madden Source of Evidence: Professional Engagement A: In response to feedback from Hemodialysis (HD) Unit clinical nurse Romina Mapa Santos, Nurse Leader Theresa Gallivan convened a task force that led to the ED being the primary location for HD for patients in need of this treatment emergently. C: Nurse Leader Debra Burke and Nursing Director Peggy Settle supported the work of clinical nurse Jeanne Gilbert in reducing hypothermia in newly-born extremely low birth weight infants by promising financial support for a new product to be used when transporting these infants from the LDR Unit to the NICU. Emergency Department (Ellison 1/Lunder 1) Hemodialysis Unit (Bigelow 10) Neonatal Intensive Care Unit (Blake 10) Units/Patient Areas SE1EO Clinical nurses are involved in interprofessional decisionmaking groups at the organizational level. 8 Provide two examples, with supporting evidence, of improvements resulting from the contributions of clinical nurses in interprofessional decision-making groups at the organizational level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: A: Janet Madden B: Janet Madden A. The membership of two clinical nurses, Kathleen Schultz and Katelyn Feins, on the ECMO Mortality and Morbidity Committee provided a forum to voice concerns about the moral distress associated with the new and unexpectedly high volume and acuity of patients receiving Extra Corporeal Membrane Oxygenation and led to a new practice of providing Optimum Care Committee Consults for this patient population. B. Clinical Nurse, Jennifer Albert s membership on the Medication Education Cardiac Surgical Intensive Care Unit (Blake 8) Pediatric Intensive Care Unit

9 SE 2EO The healthcare organization supports nurses participation in local, regional, national, or international professional organizations. Safety and Approval Committee (MESAC), provided the opportunity for her to identify the need to change the large volume pump library for Nicardipine, a process that she then led to completion as a result of her role as chair of the MESAC Pump Safety Sub-Committee. (Bigelow 6) Transplant Unit (Blake 6) Medical Intensive Care Unit (Blake 7) Cardiac Surgical Intensive Care Unit (Blake 8) Cardiac Catheterization Laboratory (Blake 9) Surgical Intensive Care Unit (Blake 12) Emergency Department (Ellison 1/Lunder 1) Surgical Intensive Care Unit (Ellison 4) Neuroscience Intensive Care Unit (Lunder 6) Operating Room (Gray 3, Lunder 2, 3, 4) Provide two examples, with supporting evidence, of improvements resulting from a change in nursing practice that occurred because of clinical nurse involvement in a professional organization Writer: A: Janet Madden B: Janet Madden A. Clinical Nurse, Debra Guthrie s membership in the Infusion Nurses Society provided her with the knowledge to advocate for and be an active participant in work to change the practice to confirm PICCs from x-ray to EKG. B. Several clinical nurse membership in AWHONN, in addition to an awareness of the breast-feeding policies of the CDC and WHO, promoted a change in nursing practice to make skin-to-skin care post C-section deliveries standard care, consistent with post vaginal deliveries. Adult and Pediatric Units Labor, Delivery and Recovery Unit (Blake 14) 9

10 Source of Evidence: Commitment to Professional Development Units/Patient Areas SE3EO The organization supports nurses continuous professional development. A. Provide one example, with supporting evidence, illustrating that the organization has met a targeted goal for improvement in professional nursing certification. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. B. Provide one example, with supporting evidence, illustrating that nursing has met a targeted goal for improvement in professional nursing certification by unit or division (e.g., cardiac-vascular, gerontological, medical-surgical, nursing informatics, pediatrics, psychiatric-mental health.) Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: A: Tricia Crispi/Nancy Raye B: Tricia Crispi/Nancy Raye A: The organizational goal to increase nurse certification by one percent per year was realized through the implementation of multiple strategies geared toward encouraging certification. B: The nursing leadership of the Pediatrics Units set a goal of increasing the number of certified nurses on those units by developing a number of strategies to support clinical nurses application and preparation for a specific certification exam. Pediatrics Unit (Ellison 17) Pediatrics Unit (Ellison 18) SE4EO 10 Nurses participate in professional development activities designed to improve their knowledge, skills, and/or practices in the workplace. Professional development activities are designed to improve the professional practice of nursing or patient outcomes or both. May include interprofessional activities. Does not include orientation-related education. A: A professional development activity geared toward educating all nurses

11 A. Provide one example, with supporting evidence, of nurses participation in a professional development activity that demonstrated an improvement in knowledge, skill, and/or practices for professional registered nurses. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. about IPASS improved patient handovers as evidenced by an increase in the number of observations where all aspects of the formal handover process were completed after the educational offering, as compared to pre-education observations. SE5 B. Provide one example, with supporting evidence, of nurses participation in a professional development activity that was associated with an improvement in patient care outcome. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writers: A: Mary Ellin Smith B: Chris Annese Nursing education opportunities are provided for those interested in a nursing career. B: The HCAHPS related to pain management improved as the result of a pain management initiative on a general care unit. General Medicine Unit (Bigelow 11) Provide one example, with supporting evidence, of a career development opportunity provided by the organization for non-nurse employees or members of the community interested in becoming a registered nurse. This example may include community partnership activities. Writer: Mandi Coakley Source of Evidence: Teaching and Role Development Debra Nunes, Medical Assistant at MGH West, was able to attend Bunker Hill Community College through receipt of a Support Service Employees Grant. MGH West Units/Patient Areas SE6 The organization provides opportunities to improve nurses expertise in effectively teaching a patient or family. 11

12 Provide one example, with supporting evidence, of an educational activity provided by the organization focused on improving nurses expertise in teaching a patient or family. Writer: Brian French The leadership of the Maxwell and Eleanor Blum Patient and Family Learning Center provided an educational offering for new clinical nurse members of the Collaborative Governance Patient Education Committee. A pre- and posteducation evaluation revealed that the education enhanced the clinical nurse s expertise re: patient and family teaching. SE7 The organization facilitates the effective transition of registered nurses and advanced practice registered nurses into the work environment. Choose two of the four below: Provide one example, with supporting evidence, of how the organization facilitates effective transition of new graduate nurses into the nurse practice environment. Describe how the transition process is evaluated for effectiveness. A: The leadership of the Norman Knight Nursing Center recognized the need to supplement the traditional onboarding curriculum for the new graduate nurses hired to support ecare education. Five unique sessions were added and evaluated using the Casey-Fink Readiness to Practice Survey. Results showed increase in confidence re: communication with physicians, increase in opportunities to practice new skills, and greater comfort in caring for a dying patient. SE8 Provide one example, with supporting evidence, of how the organization facilitates effective transition of advanced practice registered nurses into practice within the organization. Describe how the transition process is evaluated for effectiveness. Writers: A: Mary Ellin Smith D: Mary Ellin Smith The organization provides educational activities to improve the nurse s expertise as a preceptor. D: Joelle Leacock, a newly-graduated Certified Nurse Midwife transitioned into practice with the guidance of Marie Henderson, CNM and evaluation and validation of Leacock s practice in many ways. Obstetrics/Midwifery Describe the organization s preceptor educational program(s) and how each program is evaluated on an ongoing basis. Provide supporting evidence Writers: Brian French/Mary Ellin Smith The Preceptor Program was significantly revised, and clinicians who took part in the initial revised offerings provided formal evaluation of the program. 12

13 Source of Evidence: Commitment to Community Involvement Units/Patient Areas SE 9 The organization supports nurses participation in community healthcare outreach. A. Provide one example, with supporting evidence, or organizational support for clinical nurse involvement in community healthcare outreach. B. Provide one example, with supporting evidence, or organizational support for nurse leader involvement in community healthcare outreach. Writers: A: Janet Madden B: Brian French/Mary Ellin Smith Tricia McCarthy, the year-round clinical nurse at the Boys and Girls Club of Boston, a position supported financially and administratively by MGH, developed and implemented a Sexual Health policy for teenage members. B: The annual Safer Fair was expanded to include outreach to community as a result of attention to the goals of the Center for Community Health Improvement. Charlestown Boys & Girls Club N & PCS Collaborative Governance SE10EO Nurses participate in the assessment and prioritization of the healthcare needs of the community. Provide one example, with supporting evidence, of an improvement in an identified healthcare need that was associated with nurses partnership with the community. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: Janet Madden Source of Evidence: Recognition of Nursing An interdisciplinary group, led by an APRN, reached out to numerous community resources to develop Acute Care Plans for patients with recurrent admissions to treat underlying issues of SUDs and mental illness in a more appropriate setting; led to a significant reduction in admissions for this population of patients. Emergency Department (Ellison 1/Lunder1) Units/Patient Areas SE Nurses are recognized for their contributions in addressing the strategic priorities of the organization.

14 A. Provide one example, with supporting evidence, of recognition of a clinical nurse for his or her contribution(s) in addressing the strategic priorities of the organization. B. Provide one example, with supporting evidence, of recognition of a group of nurses for their contribution(s) in addressing the strategic priorities of the organization. Writer: Janet Madden Source of Evidence: Professional Practice Model EP 1 Clinical nurses are involved in the development, implementation, and evaluation of the professional practice model. Redesignating applicants: Provide a description, with supporting evidence, of the ongoing evaluation of the nursing professional practice model and how clinical nurses are involved. Writer: Mary Ellin Smith A: Clinical Nurse, Margaret McCleary received an Ether Dome Challenge Award that allowed her to develop the Cost to Cath initiative that reduced supply costs in one unit by nearly $1M; her work was recognized with Partners in Excellence Award. B: The work of the Informatics Analyst (IA) Team in assisting all staff with the transition to ecare was recognized by a Nesson Award for Teamwork. The PPM was revised in 2016 with significant clinical nurses input that was obtained from discussions at Staff Nurse Advisory and all Collaborative Governance Committee meetings and an invitation from the CNO in Caring Headlines. Cardiac Catheterization Lab (Blake 9) Units/Patient Areas EP2EO Clinical nurses are involved in the development, implementation, and evaluation of the professional practice model. 14 Provide one example, with supporting evidence, of an improvement resulting from a change in clinical practice that occurred because of clinical nurses involvement in the implementation or evaluation of the professional practice model. Supporting evidence must be submitted in the form of a graph with a data A group of clinical nurses in the PICU took the lead in an evidence-based CLABSI reduction effort and utilized several components of the PPM in the process. Pediatric Intensive Care Unit (Bigelow 6)

15 table that clearly displays the data. Writer: Mary Ellin Smith EP3EO Unit or clinic level nurse (RN) satisfaction data outperform the mean or median of the national database used. Nurse (RN) satisfaction survey must include questions related to the following seven categories. Data must be submitted on your choice of four of the seven categories. 1. Autonomy 2. Professional development (education, resources, etc.) 3. Leadership access and responsiveness (includes nursing administration/cno) 4. Interprofessional relationships (includes all disciplines) 5. Fundamentals of quality nursing care 6. Adequacy of resources and staffing 7. RN-to-RN teamwork and collaboration Writer: Marianne Ditomassi 2016 NDNQI NWI/PES survey results posted re: 1. Autonomy 2. Interprofessional relationships (includes all disciplines) 3. Fundamentals of quality nursing care 4. Adequacy of resources and staffing Source of Evidence: Care Delivery System(s) Units/Patient Areas EP4 Nurses create partnerships with patient and families to establish goals and plans for delivery of patient-centered care. A. Provide one example, with supporting evidence, of nurses partnering with patient and families to develop and individualized plan of care based on the unique needs of the patient. A: The complex needs of a patient with many medical issues and mental illness, who had difficulty expressing her needs, were met via the development of an Acute Care Plan by an interdisciplinary team. General Medicine Unit (Bigelow 11) B. Provide one example, with supporting evidence, of nurses partnering with patient and families to improve systems of care at the unit, service line, or B: The establishment of the Autism Collaborative provided a forum for nurses to work with the parents of adults and children with autism to provide better, more appropriate care across the organization. units that care for patients with autism 15

16 organizational level. Writer: A; Mary Ellin Smith B: Mandi Coakley EP5 Nurses are involved in interprofessional collaborative practice within the care delivery system to ensure care coordination and continuity of care. Provide two examples, with supporting evidence, of nurses involvement in interprofessional collaborative practice that ensure care coordination and continuity of patient care. Writer: A: Mary Ellin Smith B: Chris Annese A. The collaboration between Kelly Robichaud, clinical nurse in the ALS Clinic and Kelly Cruise, Attending Registered Nurse provided care coordination and continuity of care for a patient with ALS. B. The care of a young man who experienced a drug overdose was coordinated by the Addictions Care Team (ACT) which allowed for continuity and collaboration among care providers in the inpatient, rehab, and outpatient setting. Neuroscience Unit (Lunder 8) ALS Clinic Medical Intensive Care Unit (Blake 7) General Medical Unit (Ellison 16) Bridge Clinic Internal Medicine (Wang 6) EP6 Nurses incorporate regulatory and specialty standards/guidelines into the development and implementation of the care delivery system. Provide one example, with supporting evidence, of nurses incorporating specialty standards/guidelines into the delivery of care. Writer: Nancy Raye As active participants in the Anticoagulation Forum, nurses from the Anticoagulation Management Services have participated in the development of guidelines for patient self testing and utilized it to increase the number of patients who are managed in this way. Anticoagulation Service (POB 1) EP7EO Nurses systematically evaluate professional organizations standards of practice, incorporating them into the organization s professional practice model and care delivery system. 16

17 EP8EO Provide one example, with supporting evidence, of an improvement resulting from a change in clinical practice due to the application of a professional organization s standards of nursing practice (upd 3/14). The example provided may be at the unit, division, or organizational level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: Chris Annese Nurses use internal and external experts to improve the clinical practice setting. Nurses in an adult ICU reduced the number of ventilator days for their patient population through implementation of the ABCDE+F Bundle that is recommended by the AACN. Surgical Intensive Care Unit (Blake 12) Provide one example, with supporting evidence, of an improvement that occurred due to a change in clinical practice setting resulting from the use of internal experts. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: Brian French Through the development of a protocol for caring for intoxicated patients in the ED, that included cohorting this patient population in a designated area in the ED whenever possible, the percentage of patients who left without completing treatment was significantly reduced. Emergency Department (Ellison 1/Lunder1) Source of Evidence: Staffing, Scheduling, and Budgeting Processes Units/Patient Areas EP9 Nurses are involved in staffing and scheduling based on established guidelines, such as ANA s Principles for Nurse Staffing, to ensure that RN assignments meet the needs of the patient population. Provide two examples, with supporting evidence, from different practice settings when input from clinical nurses was used to modify RN staffing A: On one unit, the observations of clinical nurses Lisette Packer and Kelly Mullane, initiated an increase in the number of nurses per shift to support increased patient volume and acuity. Hematology/Oncology Unit (Lunder 9) 17

18 assignments and/or adjust the schedule to compensate for a change in patient acuity, patient population, resources, or redesign of care. Writers: A. Antigone Grasso/Peggy Shaw B. Antigone Grasso B: On another unit, clinical nurses, Nancy Dibona, Eleanora Ditocco, and Joan Tafe, were instrumental in changing the distribution of FTEs, as well as the nursing schedule when the ECT patient population was relocated. Post Anesthesia Care Units (Ellison 3, Lunder 2, 3, 4) EP10 Nurses use trended data in the budgeting process, with clinical nurse input, to redistribute existing nursing resources or obtain additional nursing resources. Provide two examples, with supporting evidence, from different settings where trended data was used during the budget process, with clinical nurse input, to assess actual-to-budget performance to redistribute existing nursing resources or to acquire additional nursing resources. Trended data must be presented. Writers: A. Antigone Grasso/Nancy Raye B. Antigone Grasso/Nancy Raye A: Clinical Nurses Jill Turner, Suzanne Murphy, Nate Herron, and Lauren Vaughn were part of the staffing decisions that were made when the Bigelow 9 RACU/General Medicine Unit became two physically distinct units and when the staffing in the RACU was in excess of that required for the workload. B: Input from clinical nurses supported ND s desire to advocate for an increase in FTEs, based on workload data, and also altered the staffing pattern. Respiratory Acute Care Unit (Bigelow 13) General Medicine Unit (Bigelow 9) Cardiac Intervention (Ellison 11) EP11EO Nurses participate in recruitment and retention assessment and planning activities. Provide one example, with supporting evidence, of clinical nurses participation in nursing recruitment activities and the impact on vacancy rates. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writers: Antigone Grasso/Megan Brown/Marianne Ditomassi Source of Evidence: Interprofessional Care A new graduate nurse residency program and an internal cross-training program for experienced general care nurses were two strategies used to mitigate the staffing challenges created by ecare training requirements. As a result of clinical nurse input from precepting these nurses on the units, many of the new graduate nurses, as well as experienced general care nurses learning ICU-level care, were able to remain on the units they were assigned to/moved to. Units/Patient Areas EP Nurses assume leadership roles in collaborative interprofessional activities to improve the quality of care.

19 Provide one example, with supporting evidence, of a nurse-led (or nurse co-led) collaborative interprofessional quality improvement activity. Writer: Janet Madden The Stay Connected Program, co-led by Jessica Smith Yang, was an interdisciplinary quality improvement program, piloted on six general Medicine units, that reduced the readmission rate of patients at high-risk of readmission. General Medicine Units (White 8, 9, 10) General Medicine Units (Ellison 12, 16) General Medicine Unit (Gray 9) EP13EO Nurses participate in interprofessional groups that implement and evaluate coordinated patient education activities. Provide one example, with supporting evidence, of an interprofessional patient education activity that was associated with an improved patient outcome. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: Brian French The interdisciplinary work of Kevin Mary Callans to improve both staff and patient/family education re: tracheostomy patients and a streamlined discharge plan and process led to a reduction in the LOS for pediatric patients with tracheostomies. Pediatric Intensive Care Unit (Bigelow 6) Neonatal Intensive Care Unit (Blake 10) Pediatric Units (Ellison 17&18) Source of Evidence: Accountability, Competence, and Autonomy Units/Patient Areas EP14 Resources, such as professional literature, are readily available to support decision-making in autonomous nursing practice. Provide two examples, with supporting evidence, of how resources are used to support evidence-based clinical decision-making in autonomous nursing practice. Writer: A: Mandi Coakley B: Mary Ellin Smith A: The desire of clinical nurse, Eleanor Mc Laughlin, to involve teenage patients in bedside rounds led to consultation with a nurse scientist and a clinical librarian and eventually to an evidence-based approach to changing practice to include these patients in rounds. B: Two clinical nurses, Kristen Kingsley and James Bradley, observed that elderly male patients often waited to have suprapubic urinary catheters inserted or replaced, which led them to question why Coude catheters were not used instead for these patients. Through their involvement in the Collaborative Pediatric Intensive Care Unit (Bigelow 6) General Surgery Unit (White 7) Respiratory Acute Care Unit (Bigelow 13) 19

20 Governance Policy, Procedure, and Products Committee, they launched an evidence-based practice journey that changed practice to include the use of Coude catheters. EP15 Nurses at all levels engage in periodic formal performance reviews that include a self-appraisal and peer feedback process for assurance of competence and continuous professional development. A. Provide one example, with supporting evidence, of clinical nurses using periodic formal performance review that includes a self-appraisal and peer feedback process to enhance competence or professional development. B. Provide one example, with supporting evidence, of nurse leaders using periodic formal performance review that include a self-appraisal and peer feedback process to enhance competence or professional development. A: The performance review process for Karen Rosenblum, Attending Clinical Nurse, is described. B: The performance review process for Debra Burke, Associate Chief Nurse, is described. Writer: A. Mary Ellin Smith B. Mary Ellin Smith EP16 Nurse autonomy is supported and promoted through the organization s governance structure for shared decisionmaking. A. Provide one example, with supporting evidence, of clinical autonomy that demonstrates the authority and freedom of nurses to make nursing care decisions (within the full scope of their practice) in the clinical care of patients. A: Clinical Nurse, Susan Ferretti, was able to delay the start of an operation after the patient revealed a history of an allergy to a substance that was likely in IV fluids and medications that she was about to receive. Operating Rooms (Gray 3, Lunder 2, 3, 4) 20 B. Provide one example, with supporting evidence, of B: Anne Que, CRNA, used her CPIP experience to implement a protocol for Operating Rooms (Gray 3,

21 organizational autonomy that demonstrates the authority and freedom of nurses to be involved in broader unit, service line, organization, or system decision-making processes pertaining to patient care, policies and procedures, or work environment. Writer: Meg Bourbonniere Source of Evidence: Ethics, Privacy, Security and Confidentiality determining what types of surgeries require blood to be prepared for transfusion and was able to have ecare ordering screens adapted to support this implementation. Lunder 2, 3, 4) Units/Patient Areas EP 17 Nurses use available resources to address ethical issues related to clinical practice and organizational ethical situations. Provide one example, with supporting evidence, of nurses using available resources to address ethical issues related to clinical practice. Writers: Brian French/Mary Ellin Smith Source of Evidence: Culture of Safety Clinical nurse Laura Lux reached out to Nurse Ethicist Ellen Robinson with regard to concerns about a patient whose family and surgical team had unrealistic expectations for a meaningful recovery. This led to family and team meetings that addressed everyone s interests and concerns and led to a peaceful death for the patient. Surgical Intensive Care Unit (Blake 12) Units/Patient Areas EP 18EO Workplace safety for nurses is evaluated and improved. 21 Provide two examples, with supporting evidence, of improved workplace safety for nurses resulting from the safety strategy of the organization. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writers: A: Janet Madden B: Janet Madden A: The work of the OR Sharps Safety Committee heightened awareness of staff re: needlestick and sharps injuries, identified the need for a safety zone for placement of sharp objects, and resulted in a reduction in sharps-related injuries for clinical nurses in the OR. B: A safe patient handling initiative that included heightened staff awareness of the risk of injury when moving patients manually, education related to ceiling lifts, streamlining the sling inventory, a safe-patient handling guideline, and a multi-step communication campaign resulted in a reduction in injuries related to patient handling for clinical nurses. Operating Rooms (Gray 3, Lunder 2, 3, 4)

22 EP19EO Nurses are involved in the facility- or system-wide approach focused on proactive risk assessment and error management. EP20EO Provide one example, with supporting evidence, of an improvement in patient safety that resulted from nurses involvement in facility- or system-wide proactive risk assessment or error management. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: A. Patti Shanteler B. Patti Shanteler Clinical nurses are involved in the review, action planning, and evaluation of patient safety data at the unit level. Nurses from all role groups developed a proactive risk assessment plan for chemotherapy administration issues before ecare was launched. When an increase in near-miss safety reports, as well as in real-time reports of issues occurred with the implementation, the nurses immediately began an error management plan that resulted in changes to the system and a reduction in the number of safety reports to below the pre-ecare baseline. Hematology/Oncology Unit (Lunder 10) EP21EO Provide two examples, with supporting evidence, of an improvement in patient safety that resulted from clinical nurses improvement in the evaluation of patient safety data at the unit level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: Patti Shanteler Nurses are involved in implementing and evaluating national or international patient safety goals. A: Clinical nurses on one unit used their falls data to develop a fall risk profile for their patient population that led to a reduction in the falls with injury rate. B: Charlene Bodolato s participation in the Collaborative Governance Restraint Solutions in Clinical Practice Committee made her aware of the importance of reviewing unit-based date and poised her to champion the use of restraint alternatives when she noted an increase in restraint use on her unit. Hematology/Oncology Unit (Lunder 9) General Medicine Unit (Bigelow 11) EP22EO 22 Provide one example, with supporting evidence, of nurses involvement in activities that address national or international patient safety goals that led to an improvement in patient safety outcomes. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Writer: Patti Shanteler Unit- or clinic-level nurse-sensitive clinical indicator data Nurses on one unit reduced the rate of CAUTI by customizing the bundle of reduction interventions to meet the specific needs of their patients and clinical nurses. MICU (Blake 7)

23 23 outperform the mean or median of the national database used. (except for Core Measure which is benchmarked at organizational level). For an acute care organization with or without ambulatory/outpatient services, six nurse-sensitive clinical indicators are required. The required indicators for both include falls with injury, hospital-acquired pressure ulcers stages 2 and above, central line-associated bloodstream infection, and catheter-associated urinary tract infection. The remaining two nurse-sensitive clinical indicators must be selected as follows: Chose one from the Core measures sets (page 52 in 2014 manual) and select one from primary or specialty outpatient services. Core measure: nurse sensitive clinical indicators from the Core Measure Sets must be benchmarked and presented at the organizational level. Writers: PCS Office of Quality and Safety Staff A: A robust falls prevention program (LEAF) led to 25 of 40 (63%) of inpatient units reporting falls with injury data favorable to the benchmark more than 50% of the time in 2015 and B: Multiple interventions geared toward the prevention of stage 2 and greater HAPUs (e.g. increased attention to friction and shear and nutritional risk, a bed surface algorithm, and change in incontinence pads) led to 29 of 37 (78%) of units being favorable to the benchmark greater than 50% of the time in 2015 and C: Multiple interventions (e.g. central line checklist, standardized central line insertion kit, CHG skin prep and bathing, Curos caps, and daily discussion re: ongoing need for central line) led to 32 of 43 (74%) of units being favorable to the benchmark for rate of CLABSI more than 50% of the time in 2015 and D: A multi-pronged approach to CAUTI reduction by the CAUTI task force, including the development of a Nurse Driven Protocol for foley catheter removal led to 37 of 38 (97%) of units being favorable to the benchmark for rate of CAUTI more than 50% of the time. E: The percentage of ischemic stroke patients who received IV tpa within 60 minutes of arrival in the ED was above the benchmark (favorable- higher percentage of patients received treatment within 60 minutes) throughout 2015 and 2016 as the result of on-going efforts to make this possible (e.g. streamlining the process from triage to CT, routine quality reviews, case reviews, and education). F: In 2015 and 2016, 95% of eligible ambulatory sites had falls with injury rates that out-performed the benchmark (lower rates of falls with injuries) as a result of interventions that included an audit of risk assessment, focused attention to pediatric patients and all patients having procedures in Radiology, Inpatient Units Inpatient Units Inpatient Units Inpatient Units Emergency Department (Ellison 1/Lunder 1) Ambulatory Care/Health Centers

24 changes in screening tools, and staff education. Source of Evidence: Quality Care Monitoring and Improvement Units/Patient Areas EP 23EO Unit- or clinic-level patient satisfaction data (related to nursing care) outperform the mean or median (upd 11/13) of the national database used. Provide 8 quarters of inpatient, pediatric, and ambulatory/outpatient patient satisfaction data at the unit- or clinic-level collected within the previous 30 months before documentation submission. Select and report data for four of the nine categories listed below: 1. Patient engagement/patient-centered care 2. Care coordination 3. Safety 4. Service recovery (may be ambulatory) 5. Courtesy and respect 6. Responsiveness 7. Patient education 8. Pain 9. Careful listening Writers: Amy Giuliano/Chris Wilterdink A: Courtesy & Respect data for 2015 and 2016 is provided in graph form and is reflective of interventions driven by the Collaborative Governance Patient Experience and Diversity Committees and the adaptation of relationship-based care as a philosophical framework to guide patient care. B: Careful Listening data for 2015 and 2016 is provided in graph form and is reflective of interventions driven by multiple interventions (e.g. introducing patient experience goals in orientation, a unit welcome letter, white boards for communication, a revised patient guide, and sharing of best practices for improving responsiveness). C: Patient Education data for 2015 and 2016 are provided in graph form and is reflective of the impact of post-discharge phone calls and a discharge envelope. D: Care Coordination data for 2015 and 2016 are provided in graph form and is reflective of the implementation of I-PASS and the pilot of the Stay Connected Program on a cohort of units in Medicine. inpatient, pediatric, and ambulatory units/clinics inpatient, pediatric, and ambulatory units/clinics inpatient, pediatric, and ambulatory units/clinics inpatient, pediatric, and ambulatory units/clinics Source of Evidence: Research Units/Patient Areas NK1EO The organization supports the advancement of nursing research. Provide one completed IRB-nursing research study. Use MGH was a participant in the ANCC-commissioned multi-site READI Cardiac Medicine Unit (Ellison 10): 24