(NPC) Minutes Date: January 28, 2013 Time: 1:00 PM 2:30 PM Location: Dining Rm #3 The meeting was called to order by Karen Flaherty-Oxler Approval of 12/17/ minutes and Welcome New Committee Karen Flaherty-Oxler The 12/17/12 minutes of the Nursing Executive Council (Extended) were approved with one minor change that the meeting was called to order by Karen Flaherty-Oxler, not by Judi Brendle. Minutes of 12/17/12 approved Ms. Flaherty welcomed the new Committee which is comprised of the combined group of the Nursing Executive Committee and the Nursing Executive Committee (Extended) and the new Communications Officers: Gretchen Thomas and Julie Lipisko. Additional members will be added to this newly formed Committee. There are three co-chairs: Stephanie Shellhammer, Katrina Fetter and Karen Flaherty-Oxler, in a supporting role. Shared Governance Structure PCC- Stephanie Shellhammer PAE- Katrina Fetter Stephanie Shellhammer reported that the second meeting of the Patient Care Council (PCC) Will take place on February 14, 2013. Also in February, there will be a meeting regarding the development of a tutorial for new council chairs that will be videotaped for future use of the council chairs and the sub-council members. Katrina Fetter reported that the Professional Advance & Engagement Council (PAE) met January 21, 2013. Letters and minutes were distributed to the sub-council members. Both PCC and PAE members will be working together to coordinate Charters and Bylaws. Certification will be a priority to be addressed. Katrina and Stephanie will be gathering feedback from the staff. It was noted that the Charters should include: - The Research Council Membership - Magnet Document Wording The group discussed the need to include on the NPC, Communications Ambassadors at the sites listed below. Also listed is the NPC member responsible for researching the best candidates to be invited to act as a liaison between the NPC and their respective areas. Ambulatory Services Liz Thompson will contact Terri Ridley WBH Megan Gillespie Surgical Svcs Donna Straley or Stephanie McKoin Mental Health Unit Sarah Roher ED Amy Sechrist Moving forward with adding these new members at the February 28, 2013 meeting
January 28, 2013 Page 2 of 4 Susan Stoltzfus will contact Cindy Hudson, HP Clinical Mgr, Cardiac Rehab, regarding the Ambulatory Nursing Committee at the SOP. Karen Oxler stated that she would like to keep the NPC membership at not more than 30 members. PAE/PCC Nursing Sensitive Quality Indicators Lanyce Horn Lanyce presented the dashboard of Nursing Sensitive Indicators. Of special note: Inpatient Fall Rate is 1.4 as compared to 2.91 in FY 12 Pressure Ulcer Rate is < l.67 as compared 2.40 in FY 12 CAUTI ix exceeding goal at <.5 as compared to 1.92 in FY 12 HCHAPs rating reduced by 4 points since end of FY 12 - Press Ganey questions reduced from 80 to 29-80% Top Box rating Communications Officers Update Julie Lipisko Gretchen Thomas Julie Lipitski reported that a nursing newsletter entitled E-Pulse Keeping the Beat with Nursing is being developed with the assistance of Frieda Schmitt (Public Relations), Pam Gunzenhauser (Marketing) and Patti Peters (IS). The newsletter with be issued on a monthly or bi-monthly basis. There was discussion regarding the distribution of the newsletter and who will be included in the routing list. - Julie and Gretchen are working with Ryan Rosser to update the Starnet Nursing Web site. - Communication Ambassadors will be invited to join the NPC. They will have the responsibility of keeping their designated areas up-to-date (as noted above). Lean Spread Lanyce Horn Lanyce Horn reported on the Lean Spread that is led by Lanyce, along with Wendy Fitts and Carla Leed. LOS represents the largest umbrella. Go Live will be launched January 31, 2013. 4 North and 5 North are the pilot units. Wendy Fitts noted that the following classes are available: - 2-hr Lean Course (similar to the ED Day in Nov,) - 4-hr Advanced Course Anticipating the development of a 3 rd Advanced course to summarize and link all the classes. Magnet Updates Tina Martin - Daisy Award National Award National award created by a family who lost a family member. This award recognizes nurses who show exemplary performance and caring.
January 28, 2013 Page 3 of 4 - Tina circulated annual reports from other institutions, providing a great learning source. The communications officers will work with Tina to circulate information. Next meeting NPC February 28, noon 2 PM, DR #1 Attendance MEMBER ATTENDED Artman, Tara Staff RN, PACU/Postop X Deibler, Aarin Staff RN, ED X Dougherty, Judy Staff RN, WBH Periop X Fetter, Katrina Staff RN, 8L X Fitts, Wendy Director Perf Improvement X Fidler, Ashley Staff RN X Heisy, Shirley NM, 5 West X Horn, Lanyce Director of Nursing X Kimmet, Katie Staff RN, 8N X LeBreton, Maribeth APRN X Lipisko, Julie Staff RN, 5N X Martin, Christina Magnet Program Coordinator X Miceli, Elizabeth HR Rep X Mooney, Claire Director of Nursing X Oxler, Karen CNO X Sechrist, Amy As NM ED --- Shellhammer, Stephanie Staff RN, 7N X Stoltzfus, Sue Staff RN, Cardiac Rehab X Straley, Donna Director Surgical Services --- Thomas, Gretchen Staff RN, 8L X
January 28, 2013 Page 4 of 4 Wagner, Jennifer NM, 6 West X Wallace, Michelle NM, NICU X Watts, Starann NM, IV Team X
(NPC) Minutes Date: Time: 12:00 2:00 PM Location: Dining Room #2 The meeting was called to order by the Partner Chairs at 12:00 p.m. For Attendance see end of the Minutes Approval of Minutes The November 7, 2013 minutes of the Nursing Partners Council (NPC) were approved and Minutes of November 7, 2013 Partner Chairs seconded as written. meeting were approved. Healthwise Update Katie Kimmet Met with Marianne and developed a Power Point for the Healthwise Education Campaign, using clinical references through Healthwise in Epic, how to properly document education, and teach back. On January 8, 2014 took to Nursing Leadership Council as a proposal and how to roll-out: Attend Communication Ambassador meeting in January. Use Communication Ambassador as well as Nurse Managers to partner & go back to unit. Have Steering Committee take ownership and find the best education for their patient population. Offer one hour training sessions in March, 2014. Go to the Nursing Units and talking. Ambassadors are excited..discussion: We have found that utilization of Healthwise documentation is not consistent. We can start with the above, but will need to spread across the health system. Educating our patients is an opportunity and privilege. Core piece of our job. Education and documentation lays a foundation for upcoming shifts. D.O.H. comes at the end of the month, and we will need to know how to navigate, and get to all of the educational pieces. o Developmental work to be done in the next couple of weeks. o Top of mind, where it all lives. o.not intuitive Partner Chairs support the plan. NDNQI High Level Overview Claire Mooney Training has just begun for Managers, only one session to date, then a roll-out action planning piece with the staff.
Page 2 of 6 Survey has been completed, with a high return rate. Below 6 individual responses there will not be unit specific results. Variations depending on if your site is LGH, WBH, ABBCI, etc. NDNQI is our National database. Actionable items: Craft with the Leadership Team; Partners Council, how best to move forward. Pick out three or four actionable items to tackle, driving performance alignment. Create three of four actionable items; what we tackle should drive the performance, to fold in nicely with Magnet, Shared Governance. Follow-up to Rounding All Round the room perception of effectiveness of Rounding: When rounding at the Cancer Center Institute, they were eager and proud to show how things worked there. When rounding at WBH, they appreciated being visited, were very engaged, felt it was well received. When rounding at the Health Pavilion, they seemed excited and engaged. Felt it was a good experience, a lot to cover time wise, had opportunity to sit down in the waiting room and chat. Had opportunity to talk with a patient and bring information back to the Nurse. Good experience NICU was happy to say what was going on. Loves rounding. Talks about e-pulse, and verifying they get e-pulse. Rounding on the Behavioral Health Unit was very educating. Rounded NICU Couplet Care Positivity at individual units is very strong. Cardiac Rehab, Surgery Center, Pain Center felt discontent with Shared Governance. Didn t want to engage in clinical ladders. Didn t navigate through StarNet. Cardiac Rahab has great things toing-on. Surgery Center felt disconnected. How do we reach out and engage? First rounding was day two of go-live. The 1 st minute or so is a little awkward. Should a schedule go out before rounding? Coordination of scheduling is difficult dependent on in-patient or out-patient. Difficult to find names of who is in-charge.
Page 3 of 6 Felt people want to be able to talk to Karen. How do we crate opportunity? Excited that CNO was rounding on Thanksgiving. Felt people were really engaged. People on Mike s unit thanked us for hiring him. Nice experience. People showed pride of work on their units. Willing to talk. Communication Ambassador was excited to show what she does. Asked about e- Pulse Couplet Care & NICE Teamwork. Very engaged. During Nurses week round at off sites. Discussion / Ideas: Spotlight a unit? In Touch? E-Pulse? Employee recognition = unit recognition. Daisy awards have energy and vibrancy. Highlight best practices outside of LG? Highlight in Experience? Update Nursing website Who are we?, What are we doing? o Community Outreach o Share what we are doing with rounding. o Include pictures, videos? Small group to break out and bring back recommendations. Revisit Governance Structure Changes All Note sent December 31, 2013 in regards to Revisiting Governance Structure Changes: let s revisit, as it has been a year, how everything is going; effectiveness of structure, communication, etc. with lively and open discussion. Please come prepared with Ideas, Thoughts and Suggestions; as well as What have we accomplished and done well?; what could we improve? Attachment **Review of Shared Governance A year in Review January 2013 January 2014. Professional Advancement & Engagement Council: Staff Development: Professional Practice Conference, Educational Needs Assessment, Nurse Residency, Grant proposal, Preceptor Resource Binder/Competencies Community Outreach: Girls n Grams, Stuff the Bus x 2, Future Nurses Club added schools/new curriculum, NICE program, WITW Career Days Maryanne and Katie to work on initiative.
Page 4 of 6 Staffing: Facilitator Role/curriculum Professional Advancement: Intranet Page Redesign/Demographic Tool, New Certification Policy, Certification recognition/celebration, School Fair Staff Satisfaction: MyHealthy Living initiatives, DAISY award, Nurses Week, NDNQI/EES review, created addition of Patient Satisfaction Council Patient Care Council: PCC: Delirium Policy, Healthwise education, Inter-relations between inpatient & oupatient (i.e./care Connections, CIWA, CPOE risk assessment, advanced certification for palliative care) Infection Control: Isolation safe zone, curos caps compliance, ICD website, hand hygiene, quarterly review on VAE, CLABSI, CAUTI, SSIs, SCIP Performance Improvement: Weight Kaizen, Pain action plan, hourly rounds, no pass zone, stopping IV solutions plan Nursing Standards of Practice: reviewed, revised, and reformatted all existing policies and procedures to correlate with CPGs and EBP Interdisciplinary Standards of Practice: phase 2 of report hand-off, rounding report, 24-hour chart check policy, alarm fatigue, reviewed and approved Skin Care and Delirium policies Communication Ambassadors: Creation and implementation of e-pulse Education/development of Unit Starnet sites Monthly Communication Ambassador meetings Guest lecturers related to Mission/Vision of Department of Nursing Staff education of 24-hour chart checks Best Practice Presentations NewsGator pilot Main PAEC and PCC minutes Nursing Partners Council: Rounding Including Outpatient Participation Bedside Representation/Engagement DAISY Award Approval for Recognition Co-chairs CNO and staff nurse council leads Transparency of the council; acceptance Positive energy; can do Safe, trusting environment Every 6 week meetings Transformational Leadership Developing Leaders
Page 5 of 6 Discussion: Anniversary addition of e-pulse Rolling pictures of shared governance leadership/councils/other team members Recap what we have accomplished Involve comm. Ambassadors more; decision-making Re-emphasize the importance of bidirectional feedback of e-pulse Look at unit structure/involvement of comm. ambassadors Can these two councils support all of current work/changes coming? Utilize more task forces Open Discussion / Hot Topics All Communication Ambassadors: Managers meet monthly with Ambassadors. How do we grow the Ambassador role? Managers to utilize the Ambassador role as a special assistant. An evolving role. Next Meeting The next meeting is scheduled for Thursday, February 20, 2014; Meeting Room Location Stager #1; Meeting 12:00 Noon 12:50 p.m.; Rounding 12:50 1:40 p.m.; Debrief from 1:40 2:00 p.m. Recorded by: Paula Jones LANCASTER GENERAL Nursing Partners Council ATTENDANCE LIST MEMBER ROLE ATTENDED Artman, Tara Staff RN, PACU/Post-op X Deibler, Aarin Staff RN, ED X Dougherty, Judy Staff RN, ABBCI X
Page 6 of 6 Fetter, Katrina Co-chair Staff RN, 8L X Ashley Fidler Staff RN, X Fitts, Wendy Director, Performance Imp X Hartley, Becky NM, 4L X Heisey, Shirley Director of Nursing X Killinger, Mike NM, 5 East X Kimmet, Katie Co-chair Staff RN, 8N X LeBreton, Maribeth APRN X Lipisko, Julie Staff RN, 5N X Martin, Christina Magnet Program Coord X Martin, Sherry Staff RN, 6E X Maule, Katrina NM, 4N X Mooney, Claire Director of Nursing X Oxler, Karen Flaherty- - Chair CNO X Snyder, Kimberly Staff RN,, Geriatrics Assoc Stetler, TammyJo NM, 8L X Stoltzfus, Sue Staff RN,, Cardiac Rehab X Thomas, Gretchen Staff RN, 8L X Starann Watts NM, IV Team Additional Attendees: