Shared Leadership Councils By-laws UPMC Shadyside Hospital

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1 Article I. Preamble Shared Leadership Councils By-laws Vision Statement Maintaining excellent individualized patient care through multidisciplinary collaboration, consistently providing the right care, to the right patient, at the right time, every time. Purpose Statement Our Shared Leadership model exists to facilitate continual cultural growth in alignment with the organization s mission. Within this framework, professional staff lead decision making and all staff are empowered to participate. Guiding Principles Shared Leadership promotes patient and family centeredness as well as staff vitality through: Culture of mutual respect and recognition Continuous and open communication Shared ownership and accountability for meeting the patients needs Providing a proactive learning environment Supporting autonomy and authority for decision making Council Structure: 7 Councils With the exception of the Operations Council, the Facilitator and Chair of each Council reports the work of their Council to the Steering Committee. This Shared Leadership Steering Committee reports to the hospital Operations Council as indicated. Operations Council Professional Practice and Development Council (PPD) Evidence-Based Practice and Research Council (EBPR) Quality and Safety Council (QS) Informatics and Technology Council (IT) Support Services Council (SSC) Transformational Leadership Council (TLC) Specialty Committees Committee reports are submitted semi-annually to the appropriate Council: Nursing Assistant Committee PPD HUC Committee content dependent Pain Resource Nurses Committee QS Council Skin Care Committee QS Council Diabetes Resource Committee QS Council Clinician Committee TLC Stroke Committee QS Council Sepsis Committee EBPR Council Infection Control content dependent Last reviewed 2/27/2014 1

2 Research Committee EBPR Council Nursing Nutrition Committee content dependent Facilitator s Role Facilitate initial election process for Chair and Co-chair Non-voting advisor of the Council Appointed by Chief Nursing Officer (CNO) Member of the Nursing Executive Leadership Team (Nurse Exec Team) The Shared Leadership Steering Committee The Steering Committee acts as the consulting and advisory body for the work of: Professional Practice and Development Council (PPD) Evidence-Based Practice and Research Council (EBPR) Quality and Safety Council (QS) Informatics and Technology Council (IT) Support Services Council (SSC) Transformational Leadership Council (TLC) Membership of this Council is comprised of the Council Facilitators, Council Chairs and Co-chairs, and the CNO. Other members to this committee are by appointment of the CNO. Former Chairs, Co-chairs and Facilitators are welcome to attend this meeting but are not considered active members of the Steering Committee. This Council meets monthly to review and communicate the work of all Councils and discuss any advisory topics as indicated. Article II. Councils Operations Council Section 1: Purpose Statement The purpose of the Operations Council is to provide direction to hospital managers and leaders to promote a positive, safe, and efficient environment to enhance patient outcomes and customer satisfaction. This Council operates differently than the other Councils in that it has three executive leadership Facilitators who share Chairing responsibilities. All Shared Leadership Councils report through the Operations Council, providing information to be disseminated appropriately. Section 2: Membership A. Members Last reviewed 2/27/2014 2

3 Membership is comprised of division leaders or designee, inclusive of departments with reporting responsibility to the Vice Presidents of UPMC Shadyside. B. Meetings The two-hour meetings occur eight times annually. Decision Making/Responsibility Finalizes decisions regarding proposals and resource allocation that require administrative approval. Communicate decisions made within the Executive Management Group (EMG) in support of the Health Systems strategic plans. Communicate the Nursing Division strategic plan. Ensures that the unit-based performance improvement plans are implemented and operational. C. Attendance It is expected that representatives miss no more than three meetings annually. Section 3: Chair Shared Chairmanship by the UPMC Shadyside Vice Presidents of Ambulatory Services, Operations, and Patient Care Services. Responsibilities of Chairs: Prioritize Agenda Items Coordinate provision of written reports Appoint project coordinators Provide mentoring activity for professional growth and development of members Member of EMG Section 4: Reporting Minutes are recorded, tracking topic, discussion, decisions, accountability, and due date for outstanding items. Minutes are completed and distributed within 7two hours of the meeting and available to all members. Quality and Safety Council Section 1: Purpose Statement The purpose of the Quality and Safety Council is to promote, ensure and enhance consistent fiscally responsible quality patient care. Improvement initiatives of the Council will align with The Joint Commission s National Patient Safety Goals which are Last reviewed 2/27/2014 3

4 identified annually, as well as other appropriately identified initiatives, to promote and improve the safety and quality of each patient care experience. Utilizing evidence-based practice as the foundation for decisions, the Quality and Safety Council will prioritize and support projects as defined by identified quality indicators and collaborate with other disciplines as necessary to improve outcomes. Success will be measured by evaluating quality outcomes. This Council will communicate with and utilize the Evidence-Based Practice and Research Council as a resource for research related to quality project initiatives, as well as collaborating with the Informatics and Professional Practice Councils to enhance and implement improvement initiatives. Section Two: Membership A. Membership Criteria Good, solid, strong performance on most recent performance evaluation. Demonstrates professionalism. Effective change agent. Positive attitude. Effective communication skills. Knowledge driven decision maker. Members consist of one representative from the following departments/committees: RN representative from each inpatient nursing unit and an alternative representative, if needed, will be designated through a unit-based decision process. The following departments will select a representative and alternate representative at the department level: All departments providing services at UPMC Shadyside. B. Nomination Process New Applicants o Self-nomination acceptable. o Complete application. o Submit application to manager. Membership Renewal o Self-nomination is acceptable. o Completed application. o Submit to manager and Council Chair. o Council Chair and manager will collaborate to determine approval for continued membership. C. Term Each member will sit on the Council for a period of two calendar years. Members may serve consecutive terms on the Council or longer provided it does not prevent new Last reviewed 2/27/2014 4

5 qualified staff from serving on the Council. Every effort will be made to maintain a balance of experienced and new members. Current Council members wishing to remain on Council must follow the nomination guidelines. Nominations must be submitted by October 1st of Year two. Decisions on members for upcoming term will be announced on November 1st of Year two. Attendance will be expected beginning in January of Year 1 of new term. D. Membership Transition The Annual Shared Leadership Conference will be the transition meeting to allow for conversion from previous to newly appointed members. New member transition will take place annually in March. The Council Chair/Co-chair will review the by-laws and member expectations at the January meeting to assure all members are apprised of the expectations of the group. E. Meetings Meetings will take place once a month for a 4-hour time block. Meetings may occasionally be extended on an as-needed basis to perform timely work of the Council. Council members are expected to be able to devote an additional 4 hours per month outside the allotted meeting time to perform Council work. F. Quorum Two-thirds of the members need to be present to make decisions. All decisions will be made by consensus. Consensus is a cooperative decision-making process that requires the group to come to a jointly agreed upon/supported decision. Although members may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, members agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Nursing Executive Leadership Team. G. Decision Making/Responsibility Identifies barriers to quality care delivery. Core measure and report card data reviewed. Identifies issues and develops recommendations to refer to the appropriate Councils for further action. Evaluates the effectiveness of the performance improvement programs consistent with or exceeding the requirements of regulatory agencies. All decisions will be made by consensus. H. Attendance Attendance at each monthly meeting is mandatory. Council members commitment to the work of the Council and the organization will be measured by attendance and participation. Council members who accrue two or more absences within a 12-month time period will be served notice and evaluated by the Council Chair and the member s manager. This evaluation may result in the Council member s removal. Last reviewed 2/27/2014 5

6 Council members who secure a substitute to attend a meeting in their absence will not be marked absent for that meeting. Extenuating circumstances may warrant an excused absence which will not be counted against the individual s attendance record as determined by the Chair/Co-chair. Council members who are absent are expected to review the meeting minutes and perform assigned project work prior to the next meeting. I. Apologies for absence All apologies for absence must be submitted prior to the meeting to the member s manager and the Chair, or Co-chair in the absence of the Chair. If unable to attend a meeting, the member may send an alternate. J. Resignations Members Resignation from the Council will be submitted in writing to the member s manager, the Chair, and the facilitator. Chair In the case of resignation of the Chair, the Co-chair will assume the role for the balance of the term. A new Co-chair will then be elected by the membership for the balance of the term. Co-chair In the case of resignation of the Co-chair, a new Co-chair will then be elected by the membership for the balance of the term. In the case of resignation of both Chair and Co-chair the replacements will then be elected by the membership for the balance of the term through the voting process. Section 3: Chair A. Chair Selection Bachelor s degree preferred. Council experience preferred. Must possess and demonstrate characteristics and motivation of a nurse leader. The Chair will be elected from within the membership of the Council The Chair serves a term of two calendar years. The Chair may serve two consecutive terms following the nomination and election process. Nominations will be accepted in September of the election year. Nominees for Chair and Co-chair will be reviewed by the Council Facilitators and advisors prior to presenting to the membership for elections. Nominees who have met criteria and accepted the nomination will be presented to the membership at the October meetings. Elections will occur in October of year two of each term. Last reviewed 2/27/2014 6

7 B. Responsibilities of Chair Make decisions on behalf of the Council in the event the Council cannot meet, on decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting. Establish agenda according to priority. Facilitate decision making and consensus. Communicate activities of other Councils. Coordinate provision of written reports. Appoint project coordinators. Foster mentoring activity for professional growth and development of members. Advise, guide, and mentor Co-chair in planning and conducting meetings. Attendance at monthly Steering Committee meetings. Collaborate with advisors and Facilitators as needed. Attend monthly Total Patient Safety and Quality Meeting. Attend monthly WISH meeting and report as appropriate. Section 4: Co-chair A. Co-chair Selection Bachelor s degree preferred. Council experience preferred. Must possess and demonstrate characteristics and motivation of a nurse leader. At least one year s experience as a Council member. Co-chair will be elected from within the membership of the Council. Co-chair serves a term of up to two calendar years. B. Responsibilities of Co-chair Assists Chair. Establishment of agenda according to priority. Maintain accurate Council member attendance records. Facilitate decision making and consensus. Communication of activities of other Councils. Coordinate provision of written reports. Mentoring activities for professional growth and development of members. Assumes responsibilities of the Chair in his/her absence. Section 5: Reporting Minutes will be recorded by the Council Co-chair or designee and will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed, and distributed within 10 days of the meeting by posting on Share Point. The Council will maintain a copy of all minutes for five years. Last reviewed 2/27/2014 7

8 Professional Practice and Development Council Section 1: Purpose Statement The Professional Practice and Development Council is a team of professional and innovative leaders throughout UPMC Shadyside brought together to communicate, problem solve and create valued multidisciplinary partnerships. Section Two: Membership A. Membership Criteria Good, solid, strong performance on most recent performance evaluation. Demonstrates professionalism. Effective change agent. Positive attitude. Effective communication skills. Knowledge driven decision maker. Members consist of one representative from the following departments/committees: RN representative from each inpatient nursing unit and an alternative representative, if needed, will be designated through a unit-based decision process. The following departments will select a representative and alternate representative at the department level: All departments providing services at UPMC Shadyside. B. Nomination Process New Applicants o Self-nomination acceptable. o Complete application. o Submit application to manager. Membership Renewal o Self-nomination is acceptable. o Completed application. o Submit to manager and Council Chair. o Council Chair and manager will collaborate to determine approval for continued membership. C. Term Each member will sit on the Council for a period of two calendar years. Members may serve consecutive terms on the Council or longer provided it does not prevent new qualified staff from serving on the Council. Every effort will be made to maintain a Last reviewed 2/27/2014 8

9 balance of experienced and new members. Current Council members wishing to remain on Council must follow the nomination guidelines. Nominations must be submitted by October 1st of Year two. Decisions on members for upcoming term will be announced on November 1st of Year two. Attendance will be expected beginning in January of Year 1 of new term. D. Membership Transition The Annual Shared Leadership Conference will be the transition meeting to allow for conversion from previous to newly appointed members. New member transition will take place annually in March. The Council Chair/Co-chair will review the by-laws and member expectations at the January meeting to assure all members are apprised of the expectations of the group. E. Meetings Meetings will take place once a month for a 4-hour time block. Meetings may occasionally be extended on an as-needed basis to perform timely work of the Council. Council members are expected to be able to devote an additional 4 hours per month outside the allotted meeting time to perform Council work. F. Quorum Two-thirds of the members need to be present to make decisions. All decisions will be made by consensus. Consensus is a cooperative decision-making process that requires the group to come to a jointly agreed upon/supported decision. Although members may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, members agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Nursing Executive Leadership Team. G. Decision Making/Responsibility Develops and conducts peer review. Develops implements and coordinates programs to recognize individual nurses and units or clinics within the medical center for their contributions to nursing and the community. This includes, but is not limited to Nurse s Week celebration, Cameos of Caring, Rookie of the Year and implementation of grant-funded professional practice initiatives. Assists in evaluating programs within the nursing division. One member will serve on the Health System Professional Practice Council. All decisions will be made by consensus. H. Attendance Attendance at each monthly meeting is mandatory. Council members commitment to the work of the Council and the organization will be measured by attendance and participation. Council members who accrue two or more absences within a 12-month Last reviewed 2/27/2014 9

10 time period will be served notice and evaluated by the Council Chair and the member s manager. This evaluation may result in the Council member s removal. Council members who secure a substitute to attend a meeting in their absence will not be marked absent for that meeting. Extenuating circumstances may warrant an excused absence which will not be counted against the individual s attendance record as determined by the Chair/Co-chair. Council members who are absent are expected to review the meeting minutes and perform assigned project work prior to the next meeting. I. Apologies for absence All apologies for absence must be submitted prior to the meeting to the member s manager and the Chair, or Co-chair in the absence of the Chair. If unable to attend a meeting, the member may send an alternate. J. Resignations Members Resignation from the Council will be submitted in writing to the member s manager, the Chair, and the facilitator. Chair In the case of resignation of the Chair, the Co-chair will assume the role for the balance of the term. A new Co-chair will then be elected by the membership for the balance of the term. Co-chair In the case of resignation of the Co-chair, a new Co-chair will then be elected by the membership for the balance of the term. In the case of resignation of both Chair and Co-chair the replacements will then be elected by the membership for the balance of the term through the voting process. Section 3: Chair A. Chair Selection Bachelor s degree preferred. Council experience preferred. Must possess and demonstrate characteristics and motivation of a nurse leader. The Chair will be elected from within the membership of the Council The Chair serves a term of two calendar years. The Chair may serve two consecutive terms following the nomination and election process. Nominations will be accepted in September of the election year. Nominees for Chair and Co-chair will be reviewed by the Council Facilitators and advisors prior to presenting to the membership for elections. Nominees who have met criteria and accepted the nomination will be presented to the membership at the October meetings. Elections will occur in October of year two of each term. Last reviewed 2/27/

11 B. Responsibilities of Chair Make decisions on behalf of the Council in the event the Council cannot meet, on decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting. Establish agenda according to priority. Facilitate decision making and consensus. Communicate activities of other Councils. Coordinate provision of written reports. Appoint project coordinators. Foster mentoring activity for professional growth and development of members. Advise, guide, and mentor Co-chair in planning and conducting meetings. Attendance at monthly Steering Committee meetings. Collaborate with advisors and Facilitators as needed. Attend monthly Total Patient Safety and Quality Meeting. Attend monthly WISH meeting and report as appropriate. Section 4: Co-chair A. Co-chair Selection Bachelor s degree preferred. Council experience preferred. Must possess and demonstrate characteristics and motivation of a nurse leader. At least one year s experience as a Council member. Co-chair will be elected from within the membership of the Council. Co-chair serves a term of up to two calendar years. B. Responsibilities of Co-chair Assists Chair. Establishment of agenda according to priority. Maintain accurate Council member attendance records. Facilitate decision making and consensus. Communication of activities of other Councils. Coordinate provision of written reports. Mentoring activities for professional growth and development of members. Assumes responsibilities of the Chair in his/her absence. Section 5: Reporting Minutes will be recorded by the Council Co-chair or designee and will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed, and distributed within 10 days of the meeting by posting on Share Point. The Council will maintain a copy of all minutes for five years. Last reviewed 2/27/

12 Evidence-Based Practice and Research Council (EBPR) Section 1: Purpose Statement The purpose of the EBPR Council is to promote positive patient outcomes through care delivery that is based on professional standards and research These practices, promote consistent evidenced -based patient care throughout the institution. The mission of the EBPR Council is to promote optimum patient care delivery through utilization of research discovery and dissemination of best practice. Incorporating a multidisciplinary approach, the Council members review current literature and professional standards to make recommendations for patient care with the ultimate purpose of improving patient outcomes. The Vision of the EBPR Council is to advance the practice of providing Evidence-Based care as a standard of care at UPMC Shadyside and ultimately across the UPMC Health System. The council promotes and supports members of the EBPR Council to present their findings through dissemination at conferences, publications, national networking and consultation. Lastly, the EBPR Council is a bridge to the Research Committee which guides and supports nurses and other healthcare professionals in conducting clinical research. Section Two: Membership A. Membership Criteria Good, solid, strong performance on most recent performance evaluation. Demonstrates professionalism. Effective change agent. Positive attitude. Effective communication skills. Knowledge driven decision maker. Members consist of one representative from the following departments/committees: RN representative from each inpatient nursing unit and an alternative representative, if needed, will be designated through a unit-based decision process. The nursing and specific multidisciplinary departments will select a representative and alternate representative at the department level. B. Nomination Process Last reviewed 2/27/

13 New Applicants o Self-nomination acceptable. o Complete application. o Submit application to manager. Membership Renewal o Self-nomination is acceptable. o Completed application. o Submit to manager and Council Chair. o Council Chair and manager will collaborate to determine approval for continued membership. C. Term Each member will sit on the Council for a period of two calendar years. Members may serve consecutive terms on the Council or longer provided it does not prevent new qualified staff from serving on the Council. Every effort will be made to maintain a balance of experienced and new members. Current Council members wishing to remain on Council must follow the nomination guidelines. Nominations must be submitted by October 1st of year two. Decisions on members for upcoming term will be announced on November 1st of year two. Attendance will be expected beginning in January of year 1 of new term. D. Membership Transition The Annual Shared Leadership Conference will be the transition meeting to allow for conversion from previous to newly appointed members. New member transition will take place annually in March. The Council Chair/Co-chair will review the by-laws and member expectations at the January meeting to assure all members are apprised of the expectations of the group. E. Meetings Meetings will take place once a month for a 4-hour time block. Meetings may occasionally be extended on an as-needed basis to perform timely work of the Council. Council members are expected to be able to devote an additional 4 hours per month outside the allotted meeting time to perform Council work. F. Quorum Two-thirds of the members need to be present to make decisions. All decisions will be made by consensus. Consensus is a cooperative decision-making process that requires the group to come to a jointly agreed upon/supported decision. Although members may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, members agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Nursing Executive Leadership Team. G. Decision Making/Responsibility Last reviewed 2/27/

14 Develops, revises, and disseminates the clinical nursing standards including standards of care and standards of practice. Recommends and collaborates in the development and review of policies relevant to patient care. Reviews and participates in all patient focused research and quality improvement projects. Promotes and facilitates evidence-based practice at the unit level through training of clinical staff and monitoring of research activities. Receives reports regarding evidence-based practice issues from units and clinics. Makes recommendations regarding unit-specific issues as related to evidencebased practice. Reviews current literature related to proposed EBP projects. Evaluates feasibility and relevance of proposed EBP and QI projects. Refers any ethical issues directly to the Nurse Executive Council for investigation and review. Reviews the progress of all Nursing EBP and reports to the Shared Leadership Steering Committee. Facilitates process of the applications for QI projects for EBP projects Tracks the ongoing progress of such projects through periodic reports and final reports when projects are completed. Formal reports of all subcommittee work and recommendations will be sent to both the Professional Practice and Development Council and the Quality and Safety Council. Reports will be sent to other Councils and committees as appropriate. The Facilitator will serve on the system-wide Evidence-Based Practice Nursing (EBN) Council All decisions will be made by consensus. The Facilitator will serve on the IRB. H. Attendance Attendance at each monthly meeting is mandatory. Council members commitment to the work of the Council and the organization will be measured by attendance and participation. Council members who accrue two or more absences within a 12-month time period will be served notice and evaluated by the Council Chair and the member s Unit Director. This evaluation may result in the Council member s removal from the committee. Council members who secure a substitute to attend a meeting in their absence will not be marked absent for that meeting. Extenuating circumstances may warrant an excused absence which will not be counted against the individual s attendance record as determined by the Chair/Co-chair. Council members who are absent are expected to review the meeting minutes and perform assigned project work prior to the next meeting. I. Apologies for absence Last reviewed 2/27/

15 All apologies for absence must be submitted prior to the meeting to the member s manager and the Chair, (or Co-chair in the absence of the Chair). If unable to attend a meeting, the member may send an alternate. J. Resignations Members Resignation from the Council will be submitted in writing to the member s manager and the Chair. Chair In the case of resignation of the Chair, the Co-chair will assume the role for the balance of the term. A new Co-chair will then be elected by the membership for the balance of the term. Co-chair In the case of resignation of the Co-chair, a new Co-chair will then be elected by the membership for the balance of the term. In the case of resignation of both Chair and Co-chair the replacements will then be elected by the membership for the balance of the term through the voting process. Section 3: Chair A. Chair Selection Bachelor s degree preferred. Council experience preferred. Must possess and demonstrate characteristics and motivation of a nurse leader. The Chair will be elected from within the membership of the Council The Chair serves a term of two calendar years. The Chair may serve two consecutive terms following the nomination and election process. Nominations will be accepted in September of the election year. Nominees for Chair and Co-chair will be reviewed by the Council Facilitators and advisors prior to presenting to the membership for elections. Nominees who have met criteria and accepted the nomination will be presented to the membership at the October meetings. Elections will occur in October of year two of each term. B. Responsibilities of Chair Make decisions on behalf of the Council in the event the Council cannot meet, on decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting. Establish agenda according to priority. Facilitate decision making and consensus. Communicate activities of other Councils. Coordinate provision of written reports. Last reviewed 2/27/

16 Appoint project coordinators. Foster mentoring activity for professional growth and development of members. Advise,guide, and mentor Co-chair in planning and conducting meetings. Attendance at monthly Steering Committee meetings. Collaborate with advisors and Facilitator as needed. Attend monthly Total Patient Safety and Quality Meeting. Attend monthly WISH meeting and report as appropriate.???? What are these? Section 4: Co-chair A. Co-chair Selection Bachelor s degree preferred. Council experience preferred. Must possess and demonstrate characteristics and motivation of a nurse leader. At least one year s experience as a Council member. Co-chair will be elected from within the membership of the Council. Co-chair serves a term of up to two calendar years. B. Responsibilities of Co-chair Assists Chair. Establishment of agenda according to priority. Maintain accurate Council member attendance records. Facilitate decision making and consensus. Communication of activities of other Councils. Coordinate provision of written reports. Mentoring activities for professional growth and development of members. Assumes responsibilities of the Chair in his/her absence. Section 5: Reporting Minutes will be recorded by the Council Co-chair or designee and will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed, and distributed within 10 days of the meeting by posting on Share Point. The Council will maintain a copy of all minutes for five years. Section 6: Nursing Research Definition of nursing research: Research is defined as a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge (45 CFR d). The Standard Operating Procedures (SOP) for the conduction of nursing research at UPMC Shadyside outlines the standardized processes for the conduction of nursing research for both internal and external studies. Contact the Nurse Scientist and Epidemiologist for a copy of the SOP document. Last reviewed 2/27/

17 All nursing research at UPMC Shadyside must involve at least one nurse on the research team. The Nurse Scientist will be the voting member of the University of Pittsburgh Internal Review Board (IRB) which is responsible for the protection of human research subjects. The Nurse Scientist votes on nurse-related protocols. Additionally, the Nurse Scientist serves as an active member of the UPMC System-wide Nurse Research Advisory Board. Informatics and Technology Council Section 1: Purpose and Mission Statement The purpose of the Informatics and Technology Council is to serve as a forum that will promote and advocate for nursing care and practice that is supported by the implementation of technology in the clinical environment. The Council will provide a forum for staff to offer feedback regarding the technology incorporated into the clinical environment. Staff will have the opportunity to present new ideas and discuss areas in need of improvement. The members of this Council believe that this specialty is helping to shape the future of nursing. This multidisciplinary team is purposed with the task of shaping the future of information based patient care, through staff education, utilization of ergonomics, managing information and information system issues, improving everyday workflow and decreasing the charting steps through standardization and staff driven changes. Section Two: Membership A. Membership Criteria: Good, solid, strong performance on most recent performance evaluation. Demonstrates professionalism. Effective change agent. Positive attitude. Effective communication skills. Knowledge driven decision maker. Members consist of one representative from the following departments/committees: RN representative from each inpatient nursing unit and an alternative representative, if needed, will be designated through a unit-based decision process. Last reviewed 2/27/

18 The following departments will select a representative and alternate representative at the department level: All departments providing services at UPMC Shadyside. B. Nomination Process New Applicants o Self-nomination acceptable. o Complete application. o Submit application to manager. Membership Renewal o Self-nomination is acceptable. o Completed application. o Submit to manager and Council Chair. o Council Chair and manager will collaborate to determine approval for continued membership. C. Term Each member will sit on the Council for a period of two calendar years. Members may serve consecutive terms on the Council or longer provided it does not prevent new qualified staff from serving on the Council. Every effort will be made to maintain a balance of experienced and new members. Current Council members wishing to remain on Council must follow the nomination guidelines. Nominations must be submitted by October 1st of Year two. Decisions on members for upcoming term will be announced on November 1st of Year two. Attendance will be expected beginning in January of Year 1 of new term. D. Membership Transition The Annual Shared Leadership Conference will be the transition meeting to allow for conversion from previous to newly appointed members. New member transition will take place annually in March. The Council Chair/Co-chair will review the by-laws and member expectations at the January meeting to assure all members are apprised of the expectations of the group. E. Meetings Meetings will take place once a month for a 4-hour time block. Meetings may occasionally be extended on an as-needed basis to perform timely work of the Council. Council members are expected to be able to devote an additional 4 hours per month outside the allotted meeting time to perform Council work. F. Quorum Two-thirds of the members need to be present to make decisions. All decisions will be made by consensus. Consensus is a cooperative decision-making process that requires the group to come to a jointly agreed upon/supported decision. Although members may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, members agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any Last reviewed 2/27/

19 decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Nursing Executive Leadership Team. G. Decision Making/Responsibility Identify barriers to proper electronic documentation Identify real-time and potential issues and make suggestions for proposed changes Develop a plan to improve scanning compliance (patient and medication) to meet organizational goals Develop an educational plan for targeted areas of focus Evaluate the effectiveness of the EHR from a multi-disciplinary perspective H. Attendance Attendance at each monthly meeting is mandatory. Council members commitment to the work of the Council and the organization will be measured by attendance and participation. Council members who accrue two or more absences within a 12-month time period will be served notice and evaluated by the Council Chair and the member s manager. This evaluation may result in the Council member s removal. Council members who secure a substitute to attend a meeting in their absence will not be marked absent for that meeting. Extenuating circumstances may warrant an excused absence which will not be counted against the individual s attendance record as determined by the Chair/Co-chair. Council members who are absent are expected to review the meeting minutes and perform assigned project work prior to the next meeting. I. Apologies for absence All apologies for absence must be submitted prior to the meeting to the member s manager and the Chair, or Co-chair in the absence of the Chair. If unable to attend a meeting, the member may send an alternate. J. Resignations Members Resignation from the Council will be submitted in writing to the member s manager and the Chair. Chair In the case of resignation of the Chair, the Co-chair will assume the role for the balance of the term. A new Co-chair will then be elected by the membership for the balance of the term. Co-chair In the case of resignation of the Co-chair, a new Co-chair will then be elected by the membership for the balance of the term. Last reviewed 2/27/

20 In the case of resignation of both Chair and Co-chair the replacements will then be elected by the membership for the balance of the term through the voting process. Section 3: Chair A. Chair Selection Bachelor s degree preferred. Council experience preferred. Must possess and demonstrate characteristics and motivation of a nurse leader. The Chair will be elected from within the membership of the Council The Chair serves a term of two calendar years. The Chair may serve two consecutive terms following the nomination and election process. Nominations will be accepted in September of the election year. Nominees for Chair and Co-chair will be reviewed by the Council Facilitators and advisors prior to presenting to the membership for elections. Nominees who have met criteria and accepted the nomination will be presented to the membership at the October meetings. Elections will occur in October of year two of each term. B. Responsibilities of Chair Make decisions on behalf of the Council in the event the Council cannot meet, on decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting. Establish agenda according to priority. Facilitate decision making and consensus. Communicate activities of other Councils. Coordinate provision of written reports. Appoint project coordinators. Foster mentoring activity for professional growth and development of members. Advise, guide, and mentor Co-chair in planning and conducting meetings. Attendance at monthly Steering Committee meetings. Collaborate with advisors and Facilitators as needed. Attend monthly Total Patient Safety and Quality Meeting. Attend monthly WISH meeting and report as appropriate. Section 4: Co-chair A. Co-chair Selection Bachelor s degree preferred. Council experience preferred. Must possess and demonstrate characteristics and motivation of a nurse leader. At least one year s experience as a Council member. Co-chair will be elected from within the membership of the Council. Co-chair serves a term of up to two calendar years. Last reviewed 2/27/

21 B. Responsibilities of Co-chair Assists Chair. Establishment of agenda according to priority. Maintain accurate Council member attendance records. Facilitate decision making and consensus. Communication of activities of other Councils. Coordinate provision of written reports. Mentoring activities for professional growth and development of members. Assumes responsibilities of the Chair in his/her absence. Section 5: Reporting Minutes will be recorded by the Council Co-chair or designee and will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed, and distributed within 10 days of the meeting by posting on Share Point. The Council will maintain a copy of all minutes for five years. Support Service Council Section 1: Purpose Statement The purpose of this council is to demonstrate that the culture of Shared Leadership at UPMC Shadyside is inclusive of all of those who equally share in the ability to impact the overall patient experience. Patient satisfaction results will be one of the methods to achieve outcomes within this group. The Support Service Council will have a connectedness to nursing to enhance and drive changes to impact patient centered outcomes that showcases our values within Your Care Our Commitment. Section Two: Membership A. Membership Criteria: Good/Solid performance evaluation. Demonstrates professionalism. Effective change agent. Positive attitude. Effective communication skills. Knowledge driven decision maker. Employed at least 6 months Not eligible if at a 3 day suspension or above in last 6 months Lab Techs PCT/NA Patient Access Security EVS HUC AOD Parking Last reviewed 2/27/

22 Dietary staff Patient Relations Central Supply Imaging Services Transport Phlebotomy Team Surgical Tech Cafeteria Services IT hardware HR Recruiters Biotronics/clinical engineering Pastoral Services Volunteer Services Engineering and Maintenance B. Nomination Process New Applicants o Self-nomination acceptable. o Complete application. o Submit application to Council Chair and Co-chair o Council Chair and Co-chair will collaborate to determine approval for o continued membership Membership Renewal o Self-nomination is acceptable. o Completed application. o Submit application to Council Chair and Co-chair. o Council Chair and Co-chair will collaborate to determine approval for continued membership C. Term Each member will sit on the Council for a period of two calendar years. Members may serve two consecutive terms on the Council or longer provided it does not prevent new qualified staff from serving on the Council. Every effort will be made to maintain a balance of experienced and new members. Current Council members wishing to remain on Council must follow the nomination guidelines. Nominations must be submitted by October 1st of Year two. Decisions on members for upcoming term will be announced on November 1st of Year two. Attendance will be expected beginning in January of Year 1 of new term. D. Membership Transition The Annual Shared Leadership Conference will be the transition meeting to allow for conversion from previous to newly appointed members. New member transition will take place annually in January. The Council Chair/Co-chair will review the by-laws and member expectations at the January meeting to assure all members are apprised of the expectations of the group. E. Meetings Meetings will take place once a month for a 4-hour time block. Meetings may occasionally be extended on an as-needed basis to perform timely work of the Council. Council members are expected to be able to devote an additional 4 hours per month outside the allotted meeting time to perform Council work. Last reviewed 2/27/

23 F. Quorum Two-thirds of the members need to be present to make decisions. All decisions will be made by consensus. Consensus is a cooperative decision-making process that requires the group to come to a jointly agreed upon/supported decision. Although members may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, members agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Nursing Executive Leadership Team G. Decision Making/Responsibility Identifies barriers to quality care delivery. Press Ganey and report card data reviewed. Identifies issues and develops recommendations to refer to the appropriate Councils for further action. Evaluates the effectiveness of the programs consistent with or exceeding the requirements of regulatory agencies. H. Attendance Attendance at each monthly meeting is mandatory. Council members commitment to the work of the Council and the organization will be measured by attendance and participation. Council members who accrue two or more absences within a two-month time period will be served notice and evaluated by the Council Chair and the member s manager. This evaluation may result in the Council member s removal. Council members who secure a substitute to attend a meeting in their absence will not be marked absent for that meeting. Extenuating circumstances may warrant an excused absence which will not be counted against the individual s attendance record as determined by the Chair/Co-chair. Council members who are absent are expected to review the meeting minutes and perform assigned project work prior to the next meeting. I. Apologies for absence All apologies for absence must be submitted to the member s manager and the Chair, or Co-chair in the absence of the Chair. If unable to attend a meeting, the member may send an alternate. J. Resignations Members Resignation from the Council will be submitted in writing to the member s manager and the Chair. Chair In the case of resignation of the Chair, the Co-chair will assume the role for the balance of the term. A new Co-chair will then be elected by the membership for the balance of the term. Last reviewed 2/27/

24 Co-chair In the case of resignation of the Co-chair, a new Co-chair will then be elected by the membership for the balance of the term. In the case of resignation of both Chair and Co-chair the replacements will then be elected by the membership for the balance of the term through the voting process. Section 3: Chair A. Chair Selection At least one year s experience as a Council member. The Chair will be elected from within the membership of the Council The Chair serves a term of two calendar years. The Chair may serve two consecutive terms following the nomination and election process. Nominations will be accepted in March of the election year. Nominees for Chair and Co-chair will be reviewed by the Council Facilitators and advisors prior to presenting to the membership for elections. Nominees who have met criteria and accepted the nomination will be presented to the membership at the April meetings. Elections will occur in April of year two of each term. B. Responsibilities of Chair Make decisions on behalf of the Council in the event the Council cannot meet, on decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting. Establish agenda according to priority. Facilitate decision making and consensus. Communicate activities of other Councils. Coordinate provision of written reports. Appoint project coordinators. Foster mentoring activity for professional growth and development of members. Advise, guide, and mentor Co-chair in planning and conducting meetings. Attendance at monthly Steering Committee meetings. Collaborate with advisors and Facilitators as needed. Attend monthly Total Patient Safety and Quality Meeting. Section 4: Co-chair A. Co-chair Selection At least one year s experience as a Council member. Co-chair will be elected from within the membership of the Council. Co-chair serves a term of up to two calendar years. Last reviewed 2/27/

25 B. Responsibilities of Co-chair Assists Chair Establishment of agenda according to priority. Maintain accurate Council member attendance records. Facilitate decision-making and consensus. Communication of activities of other Councils. Coordinate provision of written reports. Mentoring activities for professional growth and development of members. Assumes responsibilities of the Chair in his/her absence. Section 5: Reporting Minutes will be recorded by the Council Co-chair or designee and will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed, and distributed within 10 days of the meeting by posting on Share Point. The Council will maintain a copy of all minutes for five years. Transformational Leadership Council Section 1: Purpose and Mission Statement To earn the satisfaction of our customers, the respect and trust of those who govern us and the pride of our employees. To be a resource to our staff, patients and families. To attract, develop, motivate and retain a workforce within a supportive environment. To provide leadership while supporting the mission of the organization. Section 2: Membership A. Members Members will be comprised of unit directors from inpatient/ outpatient nursing units, procedural areas or the nursing coordinator of these areas that report to the Vice Presidents of UPMC Shadyside. B. Meetings Meetings will be held on the first and fourth Friday of each month for a two-hour block of time. C. Decision Making/Responsibility All decisions will be made by consensus. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Executive Leadership Team. D. Attendance Last reviewed 2/27/

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