Nursing Executive Council (NEC) Meeting Minutes

Transcription

1 Nursing Executive Council (NEC) Meeting Minutes Date: March 22, 2012 Time: 12:00PM 2:00PM Location: DR#1 The meeting was called to order by Judi Brendle, MSN, RN, NEA-BC ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Approval of 12/22/11 minutes The 12/22/11 minutes were approved. Judi Brendle Judi Brendle introduced Karen Flaherty-Oxler to the group. Karen commented briefly about her experience and what she is hoping to accomplish within the Nursing Leadership here a LGH. Introduction of NQC Chair-Elect Rhonda Price Rhonda Price reported that Katie Kimmet has been elected as the new NQC Chair-Elect, effective the end of April. Dress Code Rhonda Price Rhonda Price reported that the Nursing Quality Council has been reviewing the Dress Code as some staff have questions in regard to business casual dress or scrubs when coming in for meetings in case they are pulled to the unit during high census. The NQC looked at the dress code and it really is not clear in regard to this issue. A brief discussion followed. Judi Brendle added that at a recent council meeting she attended there were comments in regard to being at a meeting and the meeting being cancelled and staff are sent to the units. It seems when on the unit they don t know what to do with the staff that are pulled there. Val Adams is part of a group who are looking at this. It was suggested to look at what to do with staff in this situation overall, not unit specific. Judi commented that there had a been a discussion in looking at changing Wednesday council meetings to a different day, as it seems that high census will typically fall on a Wednesday. She suggested the council leaders develop a combined to ask that this be discussed at the council meetings. Nursing Sensitive Index 2 nd Quarter Judi Brendle For right now it should be suggested that staff wear business casual to meetings but be prepared to go to their unit if needed (not dressed in t-shirts). Judi Brendle reviewed the 2 nd Quarter Nursing Sensitive Index with discussion and comments as follows: #1 Pressure Ulcers Rhonda Price reported that we are trying to give better documentation and interpretation education for the staff. #2 Falls Judi Brendle reported that we have 16 areas that fall below the goal and then 5 areas outside of that. The Mental Health Unit is working on changing their area in regard to preventing falls. She also reviewed specific reasons for a few of the falls. #3 Symptomatic Catheter Associated UTI The number is higher than last quarter. #4 Hand Hygiene Judi Brendle reported that she has told the directors that she wants to discuss any Nursing Sensitive Index numbers that are low in their 1:1 meetings. There was a discussion regarding getting this compliance number back up for the next Magnet survey in 3 years. We must show 2 years worth of good compliance. This compliance is a quality Judi Brendle asked Rhonda Price to investigate and bring an update on #3 to the next NEC meeting.

2 Nursing Executive Council Extended Minutes March 22, 2012 Page 2 of 5 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP measure that will also affect our reimbursement in the future. Judi Brendle wants to be able to understand what all the teams are doing for improvement and their accountability. #5 Percent of Patients w/restraints We were doing very well, above the goal, however now it s gone down to the goal. Tina Martin commented that they are currently going to inpatient, looking at real time monitoring and real time education of restraints. #6 Nursing Related Med Errors This number has remained the same, slightly below the goal. Discussion regarding having orders entered accurately including verbal orders. Sometimes the problem is a patient moving from the ED to an inpatient unit, not knowing whether or not a med was given in the ED. Amanda Prusch in the pharmacy is looking at this. Starr Watts added that there is currently a group looking at this more closely, especially in regard to tagged meds; antibiotic pumps are problematic for the system. #7 (Overall Patient Satisfaction), #8 (Responsiveness of staff), #9 (Likelihood to recommend) - It was noted that the questions these responses are received from on the surveys are questions that are a combination from Press Ganey and HCAHPS. A discussion followed and Judi reminded the group their areas must remember their Core Values. #10 Risk Adjust LOS No change from 2010; 2012 is up a little bit from #11 Readmission Rate This score will be important for reimbursement. #12 ED LOS Believe this score is high due to the months within this quarter. #13 Number of Nurses Certified Stacey King reported since 7/1, there have been 14 new certified nurses. #14 How Well Pain Controlled Discussion regarding there are too many questions; from Press Ganey, HCAHPS, and our own. We are looking at taking some questions out. If a change is made to the survey, it will not be made until next FY. Also, pain assessment/management is different between ED, hospital and ambulatory. Want to have pain champions in areas on each shift. #13 - The goal number should be 386. Stacey King will have it changed. The Nursing Sensitive Index will be sent out with the above change. #15 Appropriate Care Measures It was noted that this score combines many different areas, and give us an overall score. #16 RN vacancy No discussion #17 RN vacancy for direct care providers We will be keeping an eye on this list.

3 Nursing Executive Council Extended Minutes March 22, 2012 Page 3 of 5 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP #18 RN direct care turnover Felt that this is due to there being more positions internally and externally available. #19 RN 0-3 turnover No discussion #20 Prod HPPD variance No discussion #21 Non prod HPPD variance Will keep an eye on this list. #22 Vaccination compliance & #23 Hosp Acquired Infection No discussion. Unit Based Shared Governance Bonnie Kuzma/Jen Wagner #24 Nursing employee falls & #25 Fall rate w/injury Have been reviewed within the Falls Committee. A brief background was given on the areas that have direct impact on nursing practice, such as; healthcare reform and advancing technologies, etc. A Shared Governance Task Force was developed to work on ways that we can meet the changes to come efficiently. The principles of the Shared Governance are; partnership, equity, accountability and ownership at the point of service. The Task Force found some opportunities for changes such as: Enhance RBC model and facilitate the principles inherit to it Enhance staff engagement Improve outcomes through a more focused approach Encourage creativity and innovation, through evidence based practice and research at the point of service Improve communication Manage financial and human resources more effectively Provide more flexibility to facilitate faster change The Task Force s proposed model for Unit Based shared governance is: One unit based council Governing Council/Steering committee Representatives of all staff levels Meeting once per month 2 8 hours in length An example was shown of the staff that would be part of the Unit Steering Committee. It was also reported that they are doing this on 5 West and it is working out well. There was a brief discussion after which the group approved the use of this model. The group was asked for suggestions for outcomes for measurement, with the following suggestions: Should relate to core measures

4 Nursing Executive Council Extended Minutes March 22, 2012 Page 4 of 5 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Employee engagement Decision making All about patient care Nurse feels good Center for Patient Advocacy Stacey King Stacey King gave an update on the Center for Patient Advocacy as follows: Rounding on patients began on 12/19/12 with a small group January 2012 the patient hotline was developed including a letter that goes to the inpatient upon admission with the phone number and explanation of the hotline January 2012 rounding rolled out on Duke Street February 2012, rounding rolled out to WBH March 2012, added all senior leaders to the list of leaders to round Hope to add ambulatory sites in May 2012 She reported that the leaders now rounding start with all directors on up to Mr. Beeman. The requirement is to round on 3 patients each week in the unit assigned to the leaders. There is a sheet with specific questions that are asked in a manner of a general conversation. Stacey reviewed the questions for the group. The data from the rounding sheet is being entered in a central location for review. It seems that when a patient responds no to the question of did they receive their letter from Marion McGowan regarding the patient hotline, it is found in the admission packet. Staff are supposed to hand the letter to the patient upon admission as an inpatient so they are aware of it. From the data collected thus far, the number 1 complaint is the call bells not being answered in a timely manner, and then the number 2 complaint is about the communication from physician to nursing and the patient care plan and that the white boards are not being used. She added that we are receiving a lot of praise about the rounding and the hospital. Miscellaneous The patient hotline so far has received 23 calls. The intent of the patient hotline is to resolve a legitimate patient complaint while they are still here in the hospital; only 5 of the 23 calls were from patients still in the hospital and true complaints. Some others were just that we fell short about something in the hospital or it was after discharge. If we receive calls on this hotline from a patient after they have returned to their home, those calls now get forwarded to Judy Errett. There was a brief discussion and the comment was made that perhaps the units would like to have feedback from those who are rounding. Judi Brendle reported that we have discovered that the NOC and NEC minutes and nursing bylaws have not been posted on the nursing website for over a year. The website will be updated soon. The bylaws will be sent out to you for review in your councils. Please have your changes ready so they can be reviewed at the May or June meeting.

5 Nursing Executive Council Extended Minutes March 22, 2012 Page 5 of 5 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Judi Brendle briefly reviewed the toolkit on facilitating meetings she sent out to the group. The forms were reviewed and a brief discussion followed. It will be helpful for anyone who facilitates a meeting to use these forms. The group approved using this toolkit. Meeting Adjournment: There being no more time, the meeting was adjourned. Next meeting NEC Extended Thursday, April 26, p to 2p in Dining Room #1

6 Nursing Executive Council (NEC) Meeting Minutes Date: May 24, 2012 Time: 12:00PM 2:00PM Location: DR#1 The meeting was called to order by Judi Brendle, MSN, RN, NEA-BC ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Approval of 4/26/12 minutes The 4/26/12 minutes were approved. Judi Brendle Nursing Bylaws Approval The Nursing Bylaws were previously sent out for review. There was a discussion regarding Please send any Bylaw changes Judi Brendle membership list for some of the councils. to Joanne Bridgette prior to the next NEC meeting. Nursing Priorities Councils Updates All Councils Dana Irwin presented the Clinical Practice Council update. To improve relationships with patients and families, colleagues, and physicians utilizing RBC as LGH Nursing Model, the CPC task force implemented the following: Taskforce members included nurses from inpatient units, radiology, cardiology, ER, dialysis, PACU, anesthesia, endo, OR, a few transporters and an e-health rep Task force reviewed the TRIPS ticket currently utilized, developing a tool created through e-health Guidelines were established New TRIPS ticket go-live started June 10 th A discussion followed regarding TRIPS ticket new policy and what will occur in 6 months after it is no longer on the chart. To achieve top decile performance in at least 5 nursing sensitive indicators of quality (NDNQI): Nursing related med errors: Medication Management will present nursing med error trends quarterly to CPC; they will come to the meeting in June and July. How well was your pain controlled: Reinforcing pain reassessment 1 hour after medications are given; standard of practice sub-council developed and implemented an Interdisciplinary Pain Management Policy that has drastically improved Pain Documentation. Inpatient falls: Falls sub-committee to report to CPC quarterly will come in June; looking to have a CPC member attend Falls Committee meetings; Falls subcommittee holding falls summits for falls champions; Fall review committee is holding review sessions. She presented the previous and current Pain Document scores. All areas have increased. To provide efficient and quality care in the most appropriate setting: Judi Brendle gave presentation regarding HCAHP and the effects of reimbursement in regard to Medicare reform. Donna Bogari has been providing TJC and DOH updates to CPC. Provide monthly articles related to nursing in the current state, to CPC for review An e-health representative continues to attend CPC on a monthly basis; provide

7 Nursing Executive Council Minutes May 24, 2012 Page 2 of 6 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP CPC members with monthly e-health tips and updates. Mary Ann Winnerling provides updates on morphing of hospital protocols/procedure and guidelines Stephanie Shellhammer presented the Nursing Quality Council update. To improve relationships with patients and families, colleagues, and physicians utilizing RBC as LGH Nursing Model: Hand hygiene compliance by nursing (goal = 95%): Q1 = 81%; Q2 = 84%; Q3 = 83%; FYTD Overall = 81%. Work included simplified tool and posted on IC & NQC StarNet sites; NQC began a new process for Hand Hygiene data collection to ensure robust reporting. Hospital acquired infections per 1000 discharges (goal = 9.5): Q1 = 10.9; Q2 = 9.0; Q3 = 9.3; FYTD = 9.7. Work included case studies presented to NQC with lessons learned; re-education of Nurse Driven Protocol for foley removal and documentation in Epic. Discussion regarding mid-stream collection kits not having wipes in them. Hospital acquired pressure ulcer prevalence (goal = 9.2%): Q1 = 3.4; Q2 = 3.2; Q3 = 5.4; Q4 = 6.6; FYTD = 4.6. Work included: Shirley Heisey taking over as chair of Skin Care Subcommittee Working with Risk & QDS to hardwire process to; improve tracking and trending through MIDAS, more robust reporting, and drive unit accountability. New mattresses replaced hospital wide Skin rounds changed to quarterly Hard wire skin rounds process Face to face validation of skin case study tools Wound nurses validating identified pressure ulcer Epic documentation Education on wound documentation in Epic At their June meeting there will be a RCA on pressure ulcers. A discussion followed in regard that this initiative needs to move forward as it is very important. To achieve top decile performance in at least 5 nursing sensitive indicators of quality (NDNQI): Symptomatic Catheter-Associated UTI s per 1000 Foley days (goal = 0.6): Q1 = 1.0; Q2 = 1.3; Q3 = 1.5; FYTD = 1.3. Work included case studies reported to NQC & PDC with lessons learned; reinforce/re-educate on the removal of Foleys; corrected NDPFR displayed in e-health; NM continue to receive monthly infections.

8 Nursing Executive Council Minutes May 24, 2012 Page 3 of 6 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Percent of Patients w/restraints in ICU, TNU, IICU (goal = 3%): Q1 = 0%; Q2 = 2.0%; Q3 = 14.6%; Q4 = 8.1%; FYTD = 6%. Work included concurrent restraint chart checks on all restrained patients/completed by managers; data shared with restraint committee. To provide efficient and quality care in the most appropriate setting: Compliance with the appropriate care measures (for Pneumonia, AMI, CHF & SCIP) (goal = 90%): Q1 = 97.7%; Q2 = 92.3%; Q3 = 98.6%. Work included VBP Steering committee formed for operational leadership, meet monthly to discuss details and have increased awareness across all disciplines; PI Dept giving VBP presentation to nursing councils & staff mee4tings; e-health optimizations incorporating core measures. > Preventable serious adverse events (never events) (goal 0): Q1 = 1; Q2 = 1; Q3 = 0; FYTD = 2. Looking at wrong site surgery and medication errors. Rachel Hertzog presented the Professional Development Council update. Improved communication among nursing through nursing forums held in May In Touch with Nursing newsletter. Available on-line at PDC website Conferences and Education: Teach-back education completed 5/12 April 17, 2012 Robotics and the Perioperative Patient Conference May 11, 2012 Nursing Research Conference Preceptor Update: Time Management and Delegation April 11 Preceptor course for Healthcare Professionals April 23 Nurses Week May 8 Planning Professional Practice Conference for October 2012 Community Benefit priority: Assess current state of nurse involvement with community outreach programs. Contacted Live Well for a listing of current volunteerism that LG nurses could become involved. Council voted to participate with Healthy Beginnings Plus Nursing Certifications: information disbursed at PPC; certified nurses celebrations; certification requirements for Clinical Ladder Division of corporate education certification review courses; Pediatric, Certified Emergency Nursing Review Course, NAON Orthopedic Nursing Review Course, Med-Surg Certification Review Course, Cardiac Vascular Certification Review Course and PCCN/CCRN Certification Review Course. Judi Brendle asked Bonnie Kuzma to have the NMC look into ways of getting the staff to

9 Nursing Executive Council Minutes May 24, 2012 Page 4 of 6 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP meetings, etc. Stacey King reminded the group that there should be an RRS representative from each unit attending each forum so they can take that information back to their unit. Also, the Certification Committee name has been changed to Professional Advancement Committee. Ingelis Ahlseen presented the Retention, Recruitment and Staffing Council update. Improve relationships w/ patients, families, colleagues and physicians. Livewell collaboration RN-PtCA relationship/delegation project Encourage shared staffing Continue Future Nurses Club Continue Career Days in Elementary Schools InTouch Nursing Spotlight Starann Watts presented the Nursing Research Council. Unit Based Shared Governance Bonnie Kuzma Improve relationships w/patients, families, colleagues and physicians. Establish key concepts for flow of knowledge Develop mentoring responsibilities/accountabilities for NRC members Create a framework to engage staff in the resource process Expand relationships beyond LG by participating in research consortium Achieve top decile performance in at least 5 nursing sensitive indicators of quality (NDNQI) Provide rapid critical appraisal of evidenced based practice Support utilization of EBP Expand membership to include AP RNs from The Heart Group Provide efficient and quality care in the most appropriate setting Create a database of current research projects Establish the NRC charter and solicit approval for formal incorporation into Nursing By Laws. Bonnie Kuzma reviewed the proposal for redesigning unit based shared governance. This proposal was previously presented to the Nursing Management Council and they are looking for approval to move forward with this plan from the Nursing Executive Council. A shared governance task force was formed to look at: Healthcare reform Advancing technologies IOM call for action Magnet expectations Faster need for change

10 Nursing Executive Council Minutes May 24, 2012 Page 5 of 6 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Need for innovative strategies Transform Practice Model from task to process focus Financial challenges/staffing and nonproductive time Shared governance is a framework of professional practice founded on principles of partnership, equity, accountability and ownership. Expectations and benefits of this proposed model by redesigning the framework of unit shared governance include: Integrate RBC model into shared governance structure Establish lines of communication Promote interdisciplinary collaboration related to unit goals and patient outcomes Facilitate flexibility in an environment of rapid change Engage staff by promoting ownership at the point of service, by providing opportunities for continuous learning and professional development. Achieve unit performance improvement goals by supporting innovative strategies to improve patient care and staff satisfaction and strengthen fiscal and HR management Bonnie reviewed the proposed model as follows: One unit based council Representatives of all staff levels Minimal expectation monthly meeting Annual goal setting aligned with nursing priorities and organizational goals Ongoing unit outcomes review Yearly evaluation of model s success Chair-Elect Candidate for NMC Bonnie Kuzma Nursing Sensitive Index Action Plan Judi Brendle Miscellaneous Bonnie presented an example of a current RBC Team, a currently unit shared governance model and the proposed unit governance model. Included in the proposed model would be champions, core work partners, dynamic work partners and interlocking/interdisciplinary partnerships. She also reviewed the tools, Harvard Mentor Management information, and the timeline. A discussion followed. Bonnie Kuzma distributed and reviewed information on Amy Sechrist in regard to asking the committee to vote on her becoming the new chair-elect for NMC. Judi Brendle briefly reviewed areas of concern from the previous meeting on the Nursing Sensitive Index. She asked the group to think about what we can do to decrease the number of pressure ulcers. We tend to develop 3 to 6 months plans for falls and ulcers, and we should be looking at what we can do today. The units should start with the sensitive indicator that they are having the most problem with. Judi Brendle commented on drug diversion. She reported that staff not following the drug This Unit Based Shared Governance Model is approved by the NEC. The NEC voted and approved Amy Sechrist for Chair-Elect of NMC.

11 Nursing Executive Council Minutes May 24, 2012 Page 6 of 6 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP All diversion policy will be disciplined. She asked that through the PDC decide what kind of education we can get out to the staff and also information so they know if they do not follow the policy they will be disciplined. Meeting Adjournment: There being no more time, the meeting was adjourned. Next meeting NEC Extended Thursday, June 28, p to 2p in Dining Room #1

12 Clinical Practice Council Amie Shellenberger, RN and Dana Irwin, RN May 24, 2012

13 Improve Relationships with patients and families, colleagues, and physicians utilizing RBC as LGH Nursing Model CPC Taskforce implemented Taskforce members included Nurses from the in-patient units, Nurses from Radiology, Cardiology, ER, Dialysis, PACU, Anesthesia, Endo, OR, and a few Transporters as well as an E-Health Representative. This taskforce reviewed the TRIPS ticket currently utilized and developed a tool that has been created through E-Health. Guidelines were established with the input from all on the taskforce. New TRIPS ticket to go-live started June 10 th with CPM Upgrade. Continued growth of the Standard of Practice sub-council through interdisciplinary relationships Finished Pain Management Policy changes which is interdisciplinary Working on Nursing Documentation changes, but also including other disciplines to incorporate other disciplines documentation to be more visible in the Doc flow sheets In discussion to have the SOP council being tasks next with reviewing and changing hand-off throughout the LGH system from department to department. (ex. ER to Nursing Floor, OR to Nursing Floor, etc..)

14 Achieve Top Decile Performance in at least 5 nursing sensitive indicators of quality (NDNQI). Nursing related med errors: Med management to present nursing med error trends and examples quarterly to CPC. How well was your pain controlled: Reinforcing pain reassessment 1 hr after medications are given. Standard of Practice sub-council developed an Interdisciplinary Pain Management Policy that since implementation has drastically improved our Pain Documentation throughout LGH. Inpatient falls: Falls sub-committee to report to CPC quarterly. Looking to have a CPC member attend the Falls Committee meetings. Falls sub-committee is holding Falls summits for the Falls Champions. Fall Review committee is holding review sessions on falls.

15 Pain Documentation Scores Previous Scores Comprehensive Pain Management consistent with condition 80% Pain Assessed Every 4 Hours 67% Pain Assessment considers age, cognitive level, and condition 98% Pain is treated or patient referred 97% Pain is reassessed within 60 minutes after intervention completed 67% Current Scores Comprehensive Pain Management consistent with condition 100% Pain Assessed Every 8 Hours 100% Pain Assessment considers age, cognitive level, and condition 100% Pain is treated or patient referred 100% Pain is reassessed within 60 minutes after intervention completed 67%

16 Provide efficient and quality care in the most appropriate setting. Judi Brendle gave a presentation regarding the H-Caps and the effects of reimbursement according to the changes with the healthcare reform. Donna Bogari has been providing JACHO & DOH updates to CPC Provide monthly articles to CPC for review and discussion that are related to nursing in the current state. E-Health An E-Health Representative continues to come to CPC meetings on a monthly basis Provide CPC members with monthly E-Health Tips and Updates Maryanne Winnerling provides updates on the morphing of the hospital Protocols/Procedure and Guidelines that are being created.

17 Nursing Management Council Bonnie L. Kuzma, BS, RN, ONC Jennifer Wagner, BSN, RN May 24, 2012

18 To meet outcomes, enhance RBC and improve staff satisfaction Redesign Unit Based Shared Governance

19 Nursing Quality Council Rhonda Price BSN, RN Stephanie Shellhammer BSN, RN May 24th, 2012

20 Improve Relationships with patients and families, colleagues, and physicians utilizing RBC as LGH Nursing Model. FY 12: Hand Hygiene Compliance by Nursing (Goal = 95%) Q1 Nursing = 81% Q2 Nursing = 84% Q3 Nursing = 83% FYTD Overall = 81% (includes MD s, Ancillary dept s, Nursing) Simplified tool posted on IC & NQC StarNet sites NQC began a new process for Hand Hygiene data collection to ensure robust reporting Hospital Acquired Infections per 1000 Discharges (Goal = 9.5) Q1 = 10.9 Q2 = 9.0 Q3= 9.3 FYTD = 9.7 Case Studies presented to NQC with lessons learned Re-education of Nurse Driven Protocol for Foley removal & documentation in Epic

21 FY 12 Achieve Top Decile Performance in at least 5 nursing sensitive indicators of quality (NDNQI). Hospital Acquired Pressure Ulcer Prevalence (Goal = 2.9%) Q1 = 3.4 Q2 = 3.2 Q3 = 5.4 Q4 = 6.6 FYTD = 4.6 Shirley Heisey, 5W NM taking over as chair of Skin Care Subcommittee Working with Risk & QDS to hardwire process to identify all PU s real time Improve tracking & trending thru MIDAS event reporting More robust reporting Drive unit accountability New mattresses replaced hospital wide Skin rounds changed to quarterly effort to give reps more time to f/u with unit opportunities Hard wire skin rounds process for committee through process flow map Face to face validation of skin care study tools by committee chair to ensure accuracy Wound nurses validating identified pressure ulcer Epic documentation Education on wound documentation standards in Epic

22 FY 12 Achieve Top Decile Performance in at least 5 nursing sensitive indicators of quality (NDNQI). Symptomatic Catheter-Associated UTI s per 1000 Foley Days (Goal = 0.6) Q1 = 1.0 Q2 = 1.3 Q3 = 1.5 FYTD = 1.3 Case studies reported to NQC & PDC with lessons learned Reinforce & re-educate on the removal of Foleys per NDPFR Corrected NDPFR displayed in E-Health NM continue to receive monthly infections Percent of Patients with Restraints in the ICU, TNU, IICU (Goal = 3%) Q1 = 0% Q2 = 2.0% Q3 = 14.6% Q4 = 8.1% FYTD = 6.0% Concurrent restraint chart checks on all restrained patients to be completed by managers as a follow up action step for DOH findings Data shared with Restraint Committee

23 FY 12 Provide efficient and quality care in the most appropriate setting. Compliance with the Appropriate Care Measures (for Pneumonia, AMI, CHF, & SCIP) (Goal =90%): Q1 = 97.7% Q2 = 92.3% Q3 = 98.6% VBP Steering Committee formed: Operational leadership Committee meets monthly to discuss details & action steps of VBP OFI s Increased awareness across all disciplines & levels Wendy Fitts & PI Dep t giving VBP presentation to nursing councils & staff meetings E-Health optimizations incorporating core measures Preventable Serious Adverse Events (never events) (goal = 0) Q1 = 1 Q2 = 1 Q3 = 0 FYTD = 2 wrong site surgery Medication Error

24 Professional Development Council Rachel Hertzog and Katrina Fetter May 2012

25 STRATEGIC GROWTH: Develop a culture within Nursing responsive to innovation and change Improved communication among nursing through Nursing Forums Nursing Forums May 2012 LGH: 49 WBH: In Touch with Nursing newsletter promotes communication and awareness with colleagues and physicians by recognizing accomplishments (certifications, advanced degrees, clinical ladder), education provided in cover story, and letters from leadership team. Available on-line at PDC website Spring/ Summer 2012 being finalized Feature Certified Nurse Celebration events

26 STRATEGIC GROWTH: Develop a culture within Nursing responsive to innovation and change Conferences and Education Promoted Teach-Back education completed 5/12 April 17, 2012 Robotics and the Perioperative Patient Conference May 11, 2012 Nursing Research Conference Preceptor Update: Time Management and Delegation April 11 th Preceptor course for Healthcare Professionals: April 23 rd, Nurses Week: May 8 th : Nursing Professional Day. Promoted Nursing certifications and supported Professional Organizations Planning Professional Practice Conference for October 2012

27 COMMUNITY BENEFIT Priority: Assess current state of nurse involvement with community outreach programs. Contacted Live Well for a listing of current volunteerism that LG nurses could become involved Council voted to participate with Health Beginnings Plus

28 Nursing Certifications: EXTRAORDINARY PEOPLE Number certified Nurses Information disbursed at Professional Practice Conference Certified Nurses celebrations held March 19th Certification requirements for Clinical Ladder 2013 Division of Corporate Education Certification Review courses Pediatric: January 2012 Certified Emergency Nursing Review Course: March 6-7, 2012 NAON Orthopedic Nursing Review Course: March 21, 2012 Med-Surg Certification Review Course: May 17 & 18, 2012 Cardiac Vascular Certification Review Course: June 19-20, 2012 PCCN/CCRN Certification Review Course: August 16-17, 2012

29 Retention, Recruitment and Staffing Ingelis Ahlseen BSN, RN Lisa King, BSN, RN May 24, 2012

30 Improve Relationships with patients and families, colleagues, and physicians utilizing RBC as LGH Nursing Model. RRS s role in improving relationships Livewell Collaboration RN-PTCA relationship/delegation project to be presented to RRS on 6/11. Encourage shared staffing- updated PtCA/UC document Continue Future Nurses Club: End of year field trip was a huge success! (April 16 th ) Continue Career Days in Elementary Schools InTouch Nursing Spotlight developed by Recognition Sub.

31 Nursing Research Council Starann Watts BSN, RN, CRNI, VA-BC Maribeth LeBreton, MSN, ANP-BC May 24, 2012

32 Improve Relationships with patients and families, colleagues, and physicians utilizing RBC as LGH Nursing Model. Establish key concepts for flow of knowledge: Knowledge generation Knowledge translation Knowledge utilization Develop mentoring responsibilities/accountabilities for NRC members Engage library director in active participation with the council Establish NRC as the nursing connection to vet research resources Create a framework to engage staff in the resource process Create opportunities to gain experience by participating in ongoing studies Focus research on areas of deficiency or opportunity that support sensitive indicators Expand relationships beyond LG by participating in research consortium: SOUTH CENTRAL PENNSYLVANIA EVIDENCE-BASED PRACTICE CONSORTIUM

33 Achieve Top Decile Performance in at least 5 nursing sensitive indicators of quality (NDNQI). Provide rapid critical appraisal of evidence based practice and define focus on research opportunities when EBP is not clearly identified. Support utilization of EBP to achieve top decile performance. Expand membership to include AP RNs from Heart Group Improve heart failure outcomes

34 Provide efficient and quality care in the most appropriate setting. Create a database of current research projects to provide direction and focus to resources Establish the NRC charter and solicit approval for formal incorporation into Nursing ByLaws.

35 Redesigning Unit Based Shared Governance NMC May 9, 2012

36 Shared Governance Task Force Holly Eaton BSN, RN, Staff Nurse Rebecca Hartley, MSN,RN,CPAN, Nurse Manager Bonnie Kuzma, BS, RN, ONC, Nurse Manager Vickie Siegrist, MSN, RN, Director of Nursing TammyJo Stetler, BSN, RN,CCRN, CMNL, Nurse Manager Elizabeth Thompson, MBA,BSN, RN, CCRN, Nurse Mgr Jennifer Wagner, BSN, RN, Nurse Manager Alyssa Waite, MSN, MHA, RN, Nurse Manager Star Watts, BSN, RN, CRNI, Nurse Manager

37 Forces Impacting Nursing Practice Healthcare reform Advancing technologies IOM Call for Action Magnet Expectations Faster need for change Need for innovative strategies Transform Practice Model from task focus to process focus Financial challenges in managing staffing and nonproductive time

38 Definition of Shared Governance A framework of professional practice founded on principles of: Partnership Equity Accountability Ownership at the point of service

39 Expectations and Benefits of Proposed Model Redesign framework of Unit Shared Governance Integrate RBC model into shared governance structure Establish lines of communication Promote interdisciplinary collaboration related to unit goals and patient outcomes Facilitate flexibility in an environment of rapid change

40 Expectations and Benefits of Proposed Model Engage staff by promoting ownership at the point of service Provide opportunities for continuous learning and professional development Achieve unit performance improvement goals Support innovative strategies to improve patient care and staff satisfaction Strengthen fiscal and HR management

41 Proposed Model for Unit Based Shared ONE Unit Based Council Governance Representatives of all staff levels Minimal expectation Monthly meeting Annual goal setting aligned with nursing priorities and organizational goals Ongoing unit outcomes review Yearly evaluation of model s success

42 Current RBC Team Model Example CPC Jill Honafius RN, CRNI Quality RRS Peg Stanley RN Marian Brandt RN, CRNI Non-Voting Nurse Manager Star Watts BSN, RN, CRNI IV Team Unit Based RBC Steering Committee Professional Development Council Lisa Kephart RN PtCA N/A RN Maryann Norton RN LPN Unit Clerk Wayne Vandernick LPN N/A

43 Current Unit Shared Governance Model

44 Unit Shared Governance Model Unit Specific Representative

45 New Concepts Champions Core Work Partners Dynamic Work Partners Interlocking/interdisciplinary partnerships

46 Tools HMM Toolbox for Meeting Management HMM Checklist for Strategic Planning Communication Tree

47 HMM: Meeting Mgmt

48 HMM: Strategy Execution

49 Communication Network Example

50 Rewards of Successful Implementation OUTCOMES!

51 Timeline Shared Governance Timeline Powerpoint draft Powerpoint final Presentation to NMC Presentation to NEC Management consensus and Discussion Implementation Nurse Manager Check point Evaluate Unit Alignment Annual Strategic Goal setting/evaluation of model 4/23/12 5/8/12 5/9/12 5/14/12 5/21/12 6/8/2012 7/1/2012 8/1/2012 9/1/ /10/2012 1/9/2013 7/10/2013 Reverse Huddle

52 How do you start Evaluate current projects and regulatory requirements NDNQI The Joint Commission Organizational goals What stays and what goes? Prioritize and reorganize initiatives Evaluate composition of Unit Governing Council and establish communication networks Identify interlocking/interdisciplinary partnerships Set expectations for unit outcomes

53 Moving Forward/Consensus Vote

54 References Bower, J. L. & Gilbert, C. G. (February 2007). How managers everyday decisions create or destroy your company s strategy. Harvard Business Review. Koloroutis, M. (2004). Relationship-Based Care: A model for transforming practice. Creative Health Care Management, Inc. Neilson, G. L., Martin, K. L., & Powers, E. (June 2008). The Secrets to Successful Strategy Execution. Harvard Business Review. Porter-O Grady,P., & Swihart,D. (2011). Shared Governance A Practical Approach to Transforming Professional Nursing Practice (2nd ed.)(pp.82-85). HCPro, Inc

55 Nursing Executive Council (NEC) Extended Meeting Minutes Date: June 28, 2012 Time: 12:00PM 2:00PM Location: DR#1 The meeting was called to order by Judi Brendle, MSN, RN, NEA-BC ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Approval of 5/2412 minutes The 5/24/12 minutes were approved. Judi Brendle Moratorium on Meetings Stacey King reviewed the concern regarding the Phase II for Epic with Physician Order Stacey King entry this fall and training, what to do with the meetings. Val Adams took this issue to Management Council for recommendations. The 3 options follow: Option 1 Cancel council meetings for 2 months but continue to specified subcouncils. Option 2 Continue meetings but only send a representative from each floor or specialty. Rotate attendance each month. Option 3 Hold meeting in September and then cancel October during the majority of the training. Epic Phase II Education Lanyce Horn Shared Governance Structure Judi Brendle After lengthy discussion the committee came up with Option 4 Meet in September, cancel October meeting and have only sub-committees meet in November. Lanyce Horn gave an update as follows: Five weeks of training needed for all RNs with 4 hour classes Credentialed trainer from the college will be in the classrooms with the RNs College trainers will also shadow nurses on the floor so the trainers know what happens on the floor The trainers will have 72 hours in over the summer so they will be ready when training begins Pre-phase II, over the summer, will be using the ESPs to prepare. Their roles will be redefined to focus them more intensely on the ESP role. The managers will be informed of how much time the ESPs will be needed. All staff will complete two CBLs by September (basic and advanced) Medication order entry will be first and then focus on the rest Judi Brendle commented that a lot of work has gone on this past year on changing the shared governance structure in regard to meeting our goals for the patients. She reviewed changes in the healthcare marketplace and how it affects our strategic plan. Our care needs to be patient driven care. The employee satisfaction will go together with the patient satisfaction. New rules to initiate this new structure would include: Patient first, department second Simplify Create relationships where they do not exist or are damaged Integrate disciplines and roles where appropriate No budget increases, resources finite or decreasing No decrease, in fact, increase quality. Option 4 Shared governance meets continue through September, no meetings will be held in October & subcommittee meetings will occur in November - was approved. No follow up indicated

56 Nursing Executive Council Minutes June 28, 2012 Page 2 of 3 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Principles of new structure: Partnerships are essential Change must occur at every level Locus of control must be at the point of service Every role has value and contributes Accountability is generated within the role, not delegated Accountability is about outcomes an individual performs to a level of expectation clearly defined Patients are our focus Ownership means investment on the part of every person Single focused strategy Apply the mission and vision Simplify Support strategic plan Work together Grow by design, not by accident Shared governance requires a commitment to partnership to work effectively Shared governance is not a democracy It is an accountability based approach to structure in which there are clear expectations that all members of a system participate in its work. Lower costs Judi introduced a Patient Care Council proposal: Integrates disciplines of the system Focus on the most important aspects of patient care Combines design of clinical policies, procedures and Clinical Practice Guidelines (CPGs) and Quality program Resolves conflicts and problems related to integration of disciplines Builds relationship structures Adjusts to the needs of the organizations Responds to external influences Place where staff confront model of care issues and express partnership in making decisions that affect the entire system Representation means taking into account the whole, not just those who sent you. Each member represents a perspective not a single group Combines current NQC and CPC All current chairs will sit on Patient Care Council Both Nursing Liaisons will support This team will determine who sits on this 15 member council and develop charter

57 Nursing Executive Council Minutes June 28, 2012 Page 3 of 3 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Multiple task forces and committees will form under this committee Falls, restraints, pressure ulcers, UTI would report through this structure Would look to place current members on the task forces and committees under this structure Nursing Bylaws Miscellaneous Judi Brendle All The Patient Care Council will report to NEC. A discussion followed regarding Research Council to continue what they are doing; should the RRS and PDC be combined; and that a celebration should occur at any last council meetings to celebrate the hard work done within the council. It was agreed to move forward with this, and to discuss with the councils and bring back presentations to NEC for the August meeting. Judi Brendle distributed hard copies of the revised Nursing Bylaws, mentioning that only minor changes were made. She asked the committee members to take them and review them for the September meeting. Judi Brendle reported that there are currently no goals for 2013; however, we do need to get to the top deciles in the nursing sensitive index and patient satisfaction scores. Motions were made to immediately begin forming the Patient Care Council and for PDC and RRS to combine and move forward. The motions were approved. Nursing Bylaws were Approved and will be posted on the intranet. These Bylaws will be reviewed again in September. Wendy Fitts suggested having the NEC meetings be the extended group until the September meeting. All agreed. Meeting Adjournment: There being no more time, the meeting was adjourned. NEC will be extended group until September. Next meeting NEC Extended Thursday, July 26, p to 2p in Dining Room #1

58 Council Meetings During Phase II

59 3 Meeting Options Option1-Cancel Council Mtgs for 2 months but continue to specified subcouncils Option2-Continue meetings but only send a representative each floor or specialty. Rotate attendance each month. Option3-Hold meeting in September and then cancel October during the majority of training

60 PROS CONS Option1-Cancel Council Mtgs for 2 months but continue to specified subcouncils Less time off the schedule Allows for project work to continue Could result in Staff dissatisfaction Option2-Continue meetings but only send a representative each floor or specialty. Rotate attendance each month. Less impact on the schedule Council work still continues Dependent on reps to communicate to multiple areas Could have some staff dissatisfaction Option3-Hold meeting in September and then cancel October during the majority of training Training and council mtgs only overlap one month Council work missed for 1 month

61 06/28/2012 Shared Governance Making What We Do More Meaningful

62 The Changing Healthcare Marketplace Single payments Physician Manages care Do more make more High Hospital occupancy Referrals money maker Primary Care-Low Treat disease Contracts Third party care Do more, make less Shift in hospital occupancy Money loser High status Improve Health status

63 The Changing Healthcare Marketplace Vertical Organizations Inpatient Care Ignoring Waste Assumption of provide competency Assumed outcomes Patient as recipient Physicians and Hospitals Separate Complex Adaptive Continuum based Designing out waste Report Cards Outcome Measurement Participant As one

64 Influencers of Quality and Effectiveness in Hospitals Growth in Healthcare costs Increase in Public Expectations Greater competition Managed Care Government, Employers, Insurers, HMOs, Pressure for Reform More Informed Patients in Desiring More Choices Changes in Physician Practice Increase in Underinsured Population

65 Old Way of Health Care Every dollar spent on patient care, three to four were spent on Waiting for it to happen Arranging to do it Writing it Down

66 Problems with Traditional Structure Fragmented care No coordination of care Task orientation versus outcome orientation Turf issues of duplica tion Non productiv e downtime No accounta bility of the big picture Cost management instead of producing value

67 Leadership The role of leadership is primarily directed toward breaking down old frameworks and practices, making organizations and people ready for newer configurations

68 Patient Driven Care Managing Lives is different from treating sickness you must know the person before you can be successful in keeping him or her healthy.

69 Transition to Patient Focus Professional Teams Clinical Standards Manage around routine Task Oriented Narrow job scope Document by profession Work Faster Customer focused Priorities/Outcomes Manage resources Outcome Oriented Broad role scope Multidisciplinary record Work Smarter and better

70 Considerations to Transform Team Attitudes and Baggage Turf battles Manager versus leadership roles Corporate Culture Change quotient Risk quotient Current and future performance Current and future external environment

71 New Rules Patient First, Department Second Simplify, Simplify, Simplify Create relationships were they do not exist or are damaged Integrate disciplines and roles where appropriate No budget increases- Resources finite or decreasing No decrease, in fact increase, Quality

72 Principles of the New Structure Partnerships are essential Change must occur at every level Locus of control must be at the point of service Every role has value and contributes Accountability is generated within the role, not delegated Accountability is about outcomes-an individual performs to a level of expectation clearly defined

73 Principles of the New Structure Patient s are our Focus Ownership means investment on the part of every person Single focused strategy Apply the mission and vision SIMPLIFY Support Strategic Plan Work together

74 Principles of the New Structure Grow by design, not by accident Shared governance requires a commitment to partnership to work effectively Shared governance is not a democracy-it is an accountability based approach to structure in which there are clear expectations that all members of a system participate in its work. Lower Costs

75 What did NEC Say Patients are our focus We enjoy what we do in shared governance Roles sometimes are unclear Who is responsible for what How do we fit into goals Redundancy and overlap Agree we need to partner-interdisciplinary Scared what that may mean

76 Patient Care Council Proposal Integrates disciplines of the system Focus on the most important aspects of patient care Combines design of clinical policies, procedures and Clinical Practice Guidelines (CPGs) and Quality program Resolves conflicts and problems related to integration of disciplines

77 Patient Care Council Proposal Builds relationship structures Adjusts to the needs of the organizations Responds to external influences Place where staff confront model of care issues and express partnership in making decisions that effect the entire system Representation means taking into account the whole, not just those who sent you. Each member represents a perspective not a single group.

78 Patient Care Council Proposal Combines current NQC and CPC All current chairs will sit on Patient Care Council Both Nursing Liaisons will support This team will determine who sits on this 15 member council and develop charter Multiple task forces and committees will form underneath this committee

79 Patient Care Council Proposal Falls, Restraints, Pressure Ulcers, UTI would report through this structure Would look to place current members on the task forces and committees under this structure

80 Discussion and Questions

81

82 Nursing Executive Council (NEC) Extended Meeting Minutes Date: July 26, 2012 Time: 12:00PM 2:00PM Location: DR#1 The meeting was called to order by Judi Brendle, MSN, RN, NEA-BC ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Approval of 6/28/12 minutes The 6/28/12 minutes were approved with one change. Judi Brendle e-health Update Lanyce Horn reported that go-live date remains set at 11/6 and there will be more Lanyce Horn information forthcoming. FY13 Goals Judi Brendle commented that there will be two company-wide goals for FY 2013 and that Judi Brendle nursing will have a third goal, as follows: Goal #1 to increase top-box results for Likelihood to Recommend from 73.5% to 75.4% Goal #2 to meet the expense budget for 2013 and reduce length-of-stay. (The target for this goal is not yet determined) Goal #3 (Inpatient Nursing) Improve the composite score for the inpatient nursing-sensitive indicators: Inpatient fall rate Inpatient pressure ulcers Catheter-associated UTI H-CAHPS rating for the % of patients responding always for staff responsiveness. Judi reported that the 2 system-wide goals will be weighted at 50% each and the 3 nursing goals will be weighted 33% each. Joint Commission Judi Brendle Judi also commented on a recent presentation that Shirley Heisey gave which included the amount of money spent due to pressure ulcers. There was a brief discussion on the falls rate. Judi Brendle briefly reviewed areas of concern from previous Joint Commission visits Outdated supplies Logs on the code cart (old ones) PCs not locked Documentation in regard to the changed format style of our documentation. She reminded everyone that the surveyors still do tracers, so they will physically be on the units. It works well if the front line staff welcome them to the unit. Lanyce Horn commented that there was an e-health meeting with managers today in regard to adding a whole house pain assessment column. Since it is new, they will mention that to the Joint Commission surveyors. Also in the patient education and care plan, remind your staff that they can drill down for individuality and that it is easy on the new documentation. Judi Brendle also reminded the group about the Universal Protocol and that you have to show it was followed if a procedure was done on the floor.

83 Nursing Executive Council Extended Minutes July 26, 2012 Page 2 of 3 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Shared Governance Model Val Adams reviewed the proposal for the Shared Governance Model. All The Advisory Council for Professional Advancement & Engagement, would consist of (reporting back to this council): Staff development RBC Communication Professional advancement Community outreach Membership: Chair/Co-chair Human Resources 2 Managers (Duke St & WBH) Nursing Director (2) Corporate Education Faculty Nursing Supervisor Liaison A brief discussion followed regarding recruiting members and staff to be on the different task forces. The education is built for nursing, what about the other departments, i.e., respiratory, physical therapy, etc.? Does nursing build the education for them? Judi Brendle commented that this is a great start, now we need to look at including the outliers. The Patient Care Council would consist of: Nursing Interdisciplinary (with the CPG task force under this) Patient Safety & Quality Membership: Chair/Co-chair (2) Director Liaison (2) Sub-council/Chairs (6) Pharmacy PM&R Social Work/Case Management APRN Physician Surgical Services

84 Nursing Executive Council Extended Minutes July 26, 2012 Page 3 of 3 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Emergency Department Mental Health Ambulatory Lanyce Horn mentioned the difficulty that she and Mary Ann Winnerling are having with the Nursing Policies and having them reviewed for Epic. This work has been in progress and really needs to keep moving. There was question whether the standards of practice should be under patient safety. Also in the membership it was suggested to add e-health and WBH representation. Judi Brendle commented that we have one month to have a presentation ready for management, and then one month to pull people together. There was a discussion regarding sending out the communication. She added that we will expect the large group to meet in December, but not the task forces. Meeting Adjournment: There being no more time, the meeting was adjourned. New Shared Governance Structure voted on by NEC membership and approved unanimously. Judi Brendle will develop a communication with John Lines to be sent out in August. Next meeting NEC Extended Thursday, August 23, p to 2p in Dining Room #1

85 Nursing Executive Council (NEC) Extended Meeting Minutes Date: August 23, 2012 Time: 12:00PM 2:00PM Location: DR#1 The meeting was called to order by Judi Brendle, MSN, RN, NEA-BC ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Approval of 7/26/12 minutes The 7-26/12 minutes were approved as written. Judi Brendle e-health Update Lanyce Horn gave an e-health update as follows: Lanyce Horn New role of unit clerks there is not final proposal as to what their work will include, and will not truly be determined by the time of go-live on 11/6/12. Medication order entry simulation labs are going well. She added that they already heard nurses comment about work around the telephone orders. Therefore a notice is going to be added that states if you work around this work flow you are outside your scope of practice and jeopardizing your license. Drs. Ripchinski and Martin will be attending the next Management Council meeting to update them on what the physicians have been doing and training. She thanked everyone for the support they have received from NEC. Shared Governance Update The new Shared Governance Restructuring Model was presented. This model will include All the Patient Care Council and the Professional Advancement and Engagement Council. Both council purpose, goals and membership were presented to the group. Discussion followed regarding: Responsibilities Representatives (include outpatient nursing) Adding a research representative to each of these councils Interest forms they should not be too complicated For councils already in place; if a member is currently not participating remove them These two councils together will make a recommendation back to NEC Timeline both councils need to be in place by December. NEC voted and approved moving forward with this After lengthy discussion, vote was taken. restructuring. The rest of the meeting was dedicated to the council members discussing agreed upon changes to the proposal. The discussion focused on membership of each council. Meeting Adjournment: There being no more time, the meeting was adjourned. Next meeting NEC Thursday, September 27, p to 2p in Dining Room #1

86 Professional Advancement and Engagement Council-Draft A. Role The Professional Advancement and Engagement Council will create, support, and sustain an atmosphere of nursing professionalism and engagement. This will be achieved by governing and providing guidance for: staffing, community outreach, relationship-based care, staff development, and professional advancement. Interdisciplinary collaboration will be encouraged at all levels of the council in support of its mission. B. Responsibilities -Council is responsible for governing all sub-committee accountabilities and will also address engagement and professionalism initiatives and concerns on an ongoing basis. a. Staffing - Address issues related to work schedules and resource management - Incorporate available resources such as ANA Principles of Nurse Staffing (ANA, 2005) or appropriate specialty organization staffing guidelines -Partner with nursing productivity on ongoing staffing and productivity initiatives -Revisit and redefine shared staffing guidelines on an ongoing basis b. Community Outreach -Establish service projects within nursing and other departments to benefit members of the community. Foster a therapeutic relationship between LGH and the community -Improve nursing image by participating in local, regional, and national programs (including recognition programs) -Oversee the nursing externship program and the Future Nurse s Club/health care career days in conjunction with the Human Resources Department -Collaborate with Human Resources, Marketing, and the Division of Corporate Education on key nursing recruitment initiatives -Oversee and coordinate opportunities for outreach to facilitate entry into the nursing profession c. Relationship-Based Care -Collaborate with Human Resources on key retention initiatives -Promote a safe work environment through partnering with Employee Health (LiveWell) and based on the ANA recommendations -Foster and grow relationships within and outside nursing -Review employee opinion survey results and collaborate with Human Resources to develop action plans as needed -Develop and maintain a nursing recognition program -Collaborate with nurse managers on nursing award programs d. Staff Development -Support and build valuable programs for nursing orientation, precepting, and mentoring -Collaborate with the Division of Corporate Education to facilitate ongoing clinical competence via annual competencies -Establish programs necessary to promote quality patient care and evidence based practice

87 -Participate in the development of the ongoing educational needs assessment and planning and evaluation of educational programs for staff throughout the year -Disseminate and encourage the education of the nursing staff regarding current professional nursing standards and the scope and standards of nursing practice -Develop and maintain a nursing journal club -Provide oversight, guidance, and support for preceptors via biannual continuing education sessions and the preceptor course e. Professional Advancement -Encourage, support, and acknowledge nursing certifications -Collaborate with the Division of Corporate Education to evaluate nursing certification needs and plan/promote courses appropriately -Encourage, support, and acknowledge nurses participating in professional organizations -Disseminate improvements in practice settings as a result of nurse involvement in professional organizations -Encourage, support, and acknowledge advances in nursing educational degrees -Plan and provide a Certified Nurses Day celebration and regular certification pinnings -Support and promote lifelong learning -Define, review, and revise the professional clinical ladder program -Establish and oversee communication systems within nursing to advance nursing practice and the professional practice model for LGH -Provide oversight, guidance, and support for the Magnet Champions -Establish and oversee quarterly Nursing Forums with Vice President of Nursing -Create an awareness of national, regional, and state nursing issues including legislation related to work environment and staffing -Develop, maintain, and distribute the In-Touch with Nursing newsletter D. Membership -Membership of the Advisory Council will also include ad hoc sub-council members and interdisciplinary members -Nurse Chair -Professional Interdisciplinary Member -Nurse Co-chair -PtCA - Sub-committee chairs (5 nurses) -PtCA or Unit clerk -2 elected Staff RNs (clinical ladder 3 or 4) -Human Resources Representative -1 Nurse Manager-2 initially until council settled -2 Nursing Directors -Division of Corporate Education Faculty -Nursing Supervisor (ad hoc) E. Meetings The Professional Advancement and Engagement Council meets monthly and is responsible for the work delineated within the responsibilities section.

88 Charter of the Patient Care Council DRAFT Purpose The Patient Care Council (PCC) is responsible for leading quality and performance management initiatives. The PCC develops, implements, and monitors standards of practice using evidence within an interdisciplinary framework. Responsibilities This council is responsible for the following: 1. Drive clinical performance measures to achieve or exceed nursing and organizational goals. 2. Maintain nursing policies, standards, and practice guidelines that drive evidence-based practice. 3. Develop and advance the interdisciplinary practice environment through collaborative partnerships in all the work conducted by PCC. Membership Chair and co-chair Dana Irwin Katie Kimmet Amie Shellenberger Steph Shellhammer Wendy Fitts Director Liaison Lanyce Horn Director Liaison Shirley Heisey Skin Care Committee Tracy Mousley Falls Committee? Lisa Brosey Patient Safety & Quality PM&R Pharmacy Surgical Services Emergency Department Mental Health Social Work/Case Management APRN Physician Ambulatory Adhoc Membership at the Taskforce level E-health Materials Management

89 Patient Care Council Interest Form Thank you for your interest in participating within this new council structure! We are excited for this change and anticipate positive outcomes! Please write your thoughts below & return this to the nursing office. NAME: UNIT: 1. Which area of interest do you have? a. Infection Control b. Performance Improvement Initiatives c. CPG s upgrades d. Quality Outcomes (HCAHPS, Press Ganey) e. Nursing Policy and Procedures 2. Why are you interested?

90 Shared Governance Restructuring

91 Patient Care Council Patient Safety & Quality NDNQI Nursing Policies / Guidelines Standards of Practice SubCouncil* CPG Taskforce* *Interdisciplinary Falls Pressure Ulcers HCAHPS/ Press Ganey LOS / Expense Reduction Medication Management Infection Control

92 Purpose Statement The Patient Care Council is responsible for leading quality and performance management initiatives. The Patient Care Council develops, implements, and monitors standards of practice using current evidence within an interdisciplinary framework.

93 Goals Drives clinical performance measures to achieve or exceed nursing and organizational goals. Maintain nursing policies, standards, and practice guidelines that drive evidence-based practice. Develop and advance the interdisciplinary practice environment through collaborative partnerships in all the work conducted by PCC.

94 Membership Chair/ Co-chair (2) Director Liaisons (2) Sub-council/ Chairs (6) Pharmacy PM&R Social Work/ Case Management APRN Physician Surgical Services Emergency Department Mental Health Ambulatory E-Health adhoc at the taskforce level Materials management adhoc at the taskforce level

95 PCC Breakdown PCC encompasses a redefined structure with quality/performance measures representing the body of the work. All policy, CPG, NDNQI, standard development informs the central focus and drives the projects. PCC strategizes and prioritizes the work to be done including the requirements for timelines. PCC evaluates the need to conduct ongoing tasks for a short period of time.

96 Professional Advancement & Engagement Council Staff Development RBC Staffing Professional Advancement Community Outreach

97 Purpose The Professional Advancement and Engagement Council will create, support, and sustain an atmosphere of nursing professionalism and engagement. This will be achieved by governing and providing guidance for: staffing, community outreach, relationship-based care, staff development, and professional advancement. Interdisciplinary collaboration will be encouraged at all levels of the council in support of its mission.

98 Responsibilities Council is responsible for governing all subcommittee accountabilities and will also address engagement and professionalism initiatives and concerns on an ongoing basis.

99 Overview of Responsibilities Staff Development: preceptor/orientation, conference development, educational needs assessment, competencies RBC: EOS, Live Well, recognition program Professional Advancement: clinical ladder, certifications, magnet champions, newsletter, nursing forums Community Outreach: service project, Future Nurses Club, externs Staffing: productivity, shared staffing guidelines

100 Membership Nurse Chair Nurse Co-chair Sub-committee chairs (5 nurses) 2 elected Staff RNs 1 Nurse Manager-2 initially until council settled 2 Nursing Directors Nursing Supervisor (ad hoc) Professional Interdisciplinary Member PtCA PtCA or Unit clerk Human Resources Representative Division of Corporate Education Faculty

101 Parking Lot Are all units prepared for this work? Have they remodeled their shared governance? Level setting from an educational perspective re: PI and EBP development Communication plan at the unit level and between the new infrastructure How do we get buy-in from every bedside nurse? Engagement, passionate about the issues and the care concerns. Accountability The need to define how we will measure success. Need to define and ensure interdisciplinary engagement Well-defined target dates and timeline so that planning stages are completed on schedule

102 Nursing Executive Council (NEC) Extended Meeting Minutes Date: September 27, 2012 Time: 12:00PM 2:00PM Location: DR#1 The meeting was called to order by Judi Brendle, MSN, RN, NEA-BC ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP Approval of 8/23/12 minutes The 8/23/12 minutes were approved as written. Judi Brendle Go-Live Update Judi Brendle gave a brief Go-Live update as follows. We are on target for the November 6 Judi Brendle go-live and it is estimated there will be a 60 minute downtime. An additional 300 computers were put in place across the organization. Shared Governance Update The new Shared Governance Structure final draft was reviewed. All Structure for the Patient Care Council: This council covers Patient Safety & Quality. Areas covered include; falls, pressure ulcers, HCAHPS/Press Ganey, LOS/Expense reduction, medication management and infection control. Purpose Statement: The Patient Care Council is responsible for leading quality and performance management initiatives. The Patient Care council develops, implements, and monitors standards of practice using current evidence within an interdisciplinary framework. Goals: Drives clinical performance measures to achieve or exceed nursing and organizational goals. Maintain nursing policies, standards, and practice guidelines that drive evidencebased practice. Develop and advance the interdisciplinary practice environment through collaborative partnerships in all the work conducted by PCC. Membership: Chair/Co-chair (2), Director Liaisons (2), Sub-Council/Chairs (6), Pharmacy, PM&R, Social Work/Case Management, APRN, Physician, Surgical Services, Emergency Department, Mental Health, Ambulatory, E-Health-adhoc at the taskforce level, Materials management-adhoc at the taskforce level. Structure for Professional Advancement & Engagement Council: This council covers: Staff Development, Staff Satisfaction, Staffing, Professional Advancement & Community Outreach Purpose Statement: The Professional Advancement and Engagement Council will create, support, and sustain an atmosphere of nursing professionalism and engagement. This will be

103 Nursing Executive Council Extended Minutes July 26, 2012 Page 2 of 3 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP achieved by governing and providing guidance for; staffing, community outreach, relationship-based care, staff development, and professional advancement. Interdisciplinary collaboration will be encouraged at all levels of the council in support of its mission. Overview of Responsibilities: Staff development; preceptor/orientation, conference development, educational ends assessment, competencies Staff satisfaction; EOS, Live Well, recognition program Professional advancement; clinical ladder, certifications, magnet champions, newsletter, nursing forums Community outreach; service project, future nurses clubs, externs Staffing; productivity, shared staffing guidelines Membership: Nurse chair, Nurse co-chair, sub-committee chairs (5 nurses), 2 elected staff RNs, 1 Nurse Manager, 2 Nursing Directors, Nursing supervisor (adhoc), professional interdisciplinary members, PtCA, PtCA or unit clerk, human resources representative, Division of Corporate Education Faculty There were shared governance discussion forums held in lieu of the September nursing forums that were scheduled. Attendance was very low. The Interest Forms were sent out for approval, to the managers, directors and councils. There is a meeting scheduled on October 5 with all the council chairs to review applications. Areas of further discussion included: Getting information out to all. There is anxiety in that we will lose face to face brainstorming and also where will staff acquire information on what is in the works. There was a recent meeting with John Lines, with many good suggestions for communication, i.e., a nursing portal with a blog for live chats. Interactive back and forth if there are questions or subjects currently being addressed. Other suggestions included perhaps a video of the steering people and their discussions for the staff to have access to. Everyone feels that the staff are on board and getting more comfortable with the new structure. At their next meeting will need to be putting people in place, as the deadline is the end of October to have these two councils established. Suggested to have help and direction from the directors in the selection process for membership. Vickie Siegrist volunteered to be the director support for PCC. Tina Martin will also help, for

104 Nursing Executive Council Extended Minutes July 26, 2012 Page 3 of 3 ISSUES/TOPICS DISCUSSION ACTIONS/FOLLOW-UP involvement for Magnet. Judi Brendle commented that they need to develop a timeline so they know what must be accomplished then by December. If these councils need any help, contact Judi Brendle or Karen Oxler. New Business The October and November NEC meetings will be cancelled. All Tina Martin commented that for the Magnet Conference this coming year she wants to submit 10 abstracts. She wants to be kept up to date and involved with the new Shared Governance information as it can be used for one of the abstracts. Meeting Adjournment: There being no more time, the meeting was adjourned. Next meeting NEC (Extended) Thursday, December 27, p to 2p in Dining Room #1

105 Shared Governance Restructuring

106 Patient Care Council Patient Safety & Quality NDNQI Nursing Policies / Guidelines Standards of Practice SubCouncil* CPG Taskforce* *Interdisciplinary Falls Pressure Ulcers HCAHPS/ Press Ganey LOS / Expense Reduction Medication Management Infection Control

107 Purpose Statement The Patient Care Council is responsible for leading quality and performance management initiatives. The Patient Care Council develops, implements, and monitors standards of practice using current evidence within an interdisciplinary framework.

108 Goals Drives clinical performance measures to achieve or exceed nursing and organizational goals. Maintain nursing policies, standards, and practice guidelines that drive evidence-based practice. Develop and advance the interdisciplinary practice environment through collaborative partnerships in all the work conducted by PCC.

109 Membership Chair/ Co-chair (2) Director Liaisons (2) Sub-council/ Chairs (6) Pharmacy PM&R Social Work/ Case Management APRN Physician Surgical Services Emergency Department Mental Health Ambulatory E-Health adhoc at the taskforce level Materials management adhoc at the taskforce level

110 PCC Breakdown PCC encompasses a redefined structure with quality/performance measures representing the body of the work. All policy, CPG, NDNQI, standard development informs the central focus and drives the projects. PCC strategizes and prioritizes the work to be done including the requirements for timelines. PCC evaluates the need to conduct ongoing tasks for a short period of time.

111 Professional Advancement & Engagement Council Staff Development Staff Satisfaction Staffing Professional Advancement Community Outreach

112 Purpose The Professional Advancement and Engagement Council will create, support, and sustain an atmosphere of nursing professionalism and engagement. This will be achieved by governing and providing guidance for: staffing, community outreach, relationship-based care, staff development, and professional advancement. Interdisciplinary collaboration will be encouraged at all levels of the council in support of its mission.

113 Responsibilities Council is responsible for governing all subcommittee accountabilities and will also address engagement and professionalism initiatives and concerns on an ongoing basis.

114 Overview of Responsibilities Staff Development: preceptor/orientation, conference development, educational needs assessment, competencies Staff Satisfaction: EOS, Live Well, recognition program Professional Advancement: clinical ladder, certifications, magnet champions, newsletter, nursing forums Community Outreach: service project, Future Nurses Club, externs Staffing: productivity, shared staffing guidelines