Assessment Results Nurse Satisfaction or Engagement Survey (most recent) High Professional Practice: (EP3EO) Magnet EP3EO requires that nurse satisfaction/engagement data aggregated at the unit level outperform the mean, median, or other benchmark statistic of the national database used (effective April 2016). Survey data must include only and all nurses. ANCC Magnet Manual Update 2014: This SOE becomes effective April 1, 2016. Until that time, the 2008 EP3EO is in effect. 2008 Application Manual EP3EO: Nurse satisfaction or engagement data aggregated at the organizational, clinical groups of like-units or unit level outperform the mean, median, or other benchmark statistic of the national database used Submit data for the most recent nurse satisfaction survey within the previous 30-months before documentation submission. Include participation rates, analysis, and evaluation of the data Magnet Requirement: ANCC Updated Reporting Guidance December 2014: Presentation Each unit/clinic using guidance provided on page 44 of 2014 Magnet Application Manual Most recent Survey within the 30 months prior to documentation submission Magnet Update MPD Session October 2015: Beginning April 1, 2016 required format Data must be presented at unit/clinic/practice setting (all areas to be included) Verify with your vendor Magnet category alignment Present four of seven Magnet categories as shown on page 43 Categories must be the same for all settings Benchmark National (mean or median) and comparison cohort (all hospitals, all Magnet -recognized hospitals), may change graph to graph Expectation is to outperform in the majority of units at least three of four categories (majority)
Categories/Subscales Select four (4) of seven (7) categories noted on page 43 of Manual Refer to Manual Updates available at http://www.nursecredentialing.org/magnet/magnetmanualupdates Refer to vendor to align survey with categories Four (4) categories must be consistent across the organization (inpatient and outpatient) Level of data Unit/clinic-level data. If data are not available at the unit/clinic level, present at the next aggregated level available from the vendor (e.g., clinic groups). o Explain units/clinics within aggregated data o Explain any units not included Benchmark statistic Use of mean, median, or other measure of central tendency provided by the vendor s national database benchmark Comparison Group/Cohort Use of an appropriate comparison group may change between units/clinics Comparison group label must be depicted on table and graph Graph presentation Up to four (4) units/clinics may be presented on one graph o If there are multiple units on one graph, all elements (i.e., benchmark, cohort) must be consistent Single Unit/Clinic presentation A different mean or median may be used for each graph 2016 Magnet Requirements and NDNQI RN Survey Crosswalk- The following questions are the only questions that can be used in your application. New in 2016, the NDNQI RN Surveys both offer the option of selecting a Magnet module (offered for an additional $1250) that includes three additional Magnet nurse satisfaction
categories. By selecting the additional Magnet module, your organization will be able to survey on all seven categories and have the flexibility to select the best four for your application. 2014 Magnet Manual- RN Satisfaction Categories Practice Environment Scale (PES) RN Survey with Job Satisfaction Scales Autonomy Autonomy** Autonomy Professional Development (education, resources, etc.) Leadership access and responsiveness (includes nursing administration/cno) Inter-professional relationships (includes all disciplines) Fundamentals of quality nursing care Adequacy of resources and staffing RN-to-RN teamwork and collaboration Professional Development Opportunity OR Professional Development Access Nurse Manager Ability, Leadership, and Support of Nurses OR Nurse Participation in Hospital Affairs Interprofessional Relationships** Nursing Foundations for Quality of Care Staffing and Resource Adequacy Nurse-Nurse Interaction Professional Development Opportunity OR Professional Development Access Nursing Administration Interprofessional Relationships** Nursing Foundations for Quality of Care** Staffing and Resource Adequacy** Nurse-Nurse Interaction **Available only in the Magnet module. Review the Unit-level Summary of Outcomes for complete results Vendor: NDNQI Benchmark: All Hospitals Timeframe: 2016 Survey Type: JSSR TUH did not outperform an any of the indicators Plan to retake the survey in 2017 Potential underperformance of EP3EO
Evaluate data and initiate/continue implementing action plans for underperforming categories or areas Continue cycle and of survey administration, data evaluation, and action planning Implement measure to mitigate survey fatigue Nursing-Sensitive Indicator Data for all nursing units (eight quarters) High Culture of Safety: (EP22EO) Magnet EP22EO requires that unit/clinic-level nurse-sensitive clinical indicator data outperform the mean or median of the national database used over an 8-quarter 2-year period. The indicators are: Hospital-acquired pressure ulcers (HAPU) Stage 2 and above Falls with injury CLABSI CAUTI 1 nurse-sensitive core measure 1 nurse-sensitive indicator from primary/specialty ambulatory/outpatient services. Magnet Requirement: ANCC Magnet Manual Update 2014: Core measure: nurse sensitive clinical indicators from the Core Measure Sets must be benchmarked and presented at the organizational level. Acute care organizations with ambulatory/outpatient settings, present one indicator Acute care organizations without ambulatory/ outpatient, present two indicators ANCC Updated Reporting Guidance December 2014: Presentation Each unit/clinic must use the guidance provided on pages 48-52 of the 2014 Magnet Application Manual. Use the most recent eight quarters prior to documentation submission. Nurse-Sensitive Clinical Indicators Refer to table 5 on page 51 and 52 of the 2014 Magnet Application Manual for requirements specific to the organization type. Refer to Manual Updates
Level of Data Use unit/clinic-level data. If data are not available at the unit/clinic level, present at the next aggregated level available from the vendor (e.g., clinic groups). o Explain units/clinics within aggregated data. o Explain any units not included. Benchmark Statistic Use the mean, median, or other measure of central tendency provided by the vendor s national database benchmark. Comparison Group/Cohort Organizations may use a different appropriate comparison group for each unit/clinic Depict the comparison group label on the table and graph Graph Presentation Single unit/clinic presentation o Organizations may use a different mean or median for each graph Organizations may present up to four units/clinics on one graph o If there are multiple units on one graph, all elements (i.e., benchmark, cohort) must be consistent. Magnet Update MPD Session October 2015: Data must be nurse-sensitive clinical indicators Must include all areas that provide care for patients with devices or conditions Data must be submitted to a national database Comparison cohort of national benchmark can change from graph to graph but cannot change within a graph Use the most recent eight quarters of data o Timeframe could vary by indicator or by vendor Comparison must be from vendor s data report and national benchmarks HAPU Stage 2 and above inpatient only Core measure expectation/presentation is one nursesensitive measure from a Core Measure Set and presented at the organization-level Ambulatory/Outpatient Measure to include all units that collect the data o Should have a national benchmark o If not, does the professional organization associated with the measure have a benchmark or target goal?
o May use goal in literature 2016 NDNQI-PG Available Measures o Nurse Sensitive Clinical Measures: EP22EO Nurse Sensitive Clinical Indicator Patient Falls with Injury Hospital-acquired Pressure Ulcers stages 2+ Central Line Associated Blood Stream Infections Catheter Associated Urinary Tract Infections Ambulatory Measure NDNQI Measure Injury Falls per 1000 Patient Days Percent of Surveyed Patients with Hospital Acquired Pressure Ulcers Stage II and Above Central Line Associated Blood Stream Infections per 1000 Central Line Days Catheter Associated Urinary Tract Infections per 1000 Catheter Days Injury Falls per 1000 Patient Visits/Cases Ambulatory Measures (not nationally benchmarked) Ambulatory Measure Ambulatory Measure Ambulatory Measure Ambulatory Measure Ambulatory Measure Ambulatory Measure Ambulatory Measure Percent of Patients who Received Pending Results/Lab Information Percent of Patients who Received Education on Pending Results/Labs Information Percent of Patients who Received a Reconciled Medical List Percent of Patients who Received Education on Reconciled Medication List Median Minutes from ED Arrival to Departure for Pts Admitted to Facility-Excludes Obs and Psych Median Minutes Admit Decision to ED Departure for Admitted Pts- Excludes Obs and Psych Median Minutes Time from ED Arrival to ED Departure for Discharged ED Patients Review the Unit-level Summary of Outcomes for complete results One nurse-sensitive clinical indicator from Primary or Specialty Outpatient Services must be selected from the list provided on page 51 of the 2014 Magnet Application Manual Ambulatory data may be compared to internal goals and presented for each indicator until February 2018, if national benchmarks are not available Starting April 2018: ambulatory data, compared to national benchmarks, must be presented
TUH must select and present one Primary or Specialty indicator with an appropriate benchmark for a full eight quarters Only 4 quarters of CAUTI and CLABSI were provided Inpatient units: Vendor: NDNQI Benchmark: Academic Medical Centers Time frame: 2014Q2-2016Q1 Core Measure: Not provided One nurse-sensitive clinical indicator from the Core Measure Sets must be selected from the list provided on page 52 of the 2014 Magnet Application Manual The core measure selected must be benchmarked and presented at the organizational level TUH must select and present one core measure with an appropriate benchmark for a full eight quarters Site Visit: Nursing participates in three surveys: Employee Engagement, Culture of Safety and the RN Satisfaction survey Working on actions plans Underperformance of EP22EO Review each indicator to ensure: Appropriate contribution to a national database Database comparative cohort selection is advantageous to support clinical improvement and outperformance based on Magnet criteria Benchmark statistic is an appropriate comparison Each area (inpatient/outpatient, ambulatory/clinic) is collecting and reporting on the required number of nurse-sensitive indicators Magnet Requirement: Patient Satisfaction Data for all nursing units (eight quarters) High Quality Care Monitoring and Improvement: (EP23EO) ANCC Magnet Manual Update 2014 Ambulatory areas:
Ambulatory data may be compared to internal goals and presented for each indicator until February 2018, if national benchmarks are not available. Starting April 2018: ambulatory data, compared to national benchmarks, must be presented. Unit or clinic-level patient satisfaction data (related to nursing care) outperform the mean or median of the national database used. Magnet Update MPD Session October 2015 Organizations with pediatric and ambulatory services are required to report patient satisfaction Most recent eight quarters of data Organizations must use their vendor s data reports and national comparison benchmarks Validate with your vendor the appropriate questions to align with the Magnet categories (some questions are no longer accepted) ANCC Updated Reporting Guidance December 2014: Presentation Each unit/clinic must use guidance provided on page 54 of the 2014 Magnet Application Manual. Use the most recent eight quarters prior to documentation submission. Categories/Subscales Select four of nine categories noted on page 53 of the manual. Refer to Manual Updates Refer to the vendor to align patient satisfaction questions with the categories. o Select only patient satisfaction questions which the vendor has assigned to categories. Establish, with the vendor, that the vendor has collaborated with the Magnet Recognition Program on the alignment of questions to categories. Four categories must be consistent across the organization (inpatient and outpatient). Within each category, the specific question may vary from unit/clinic to unit/clinic. Level of Data
Unit/clinic-level data. If data are not available at the unit/clinic level, present at the next aggregated level available from the vendor (e.g., clinic groups). o Explain units/clinics within aggregated data. o Explain any units not included. Benchmark Statistic Use the mean, median, or other measure of central tendency provided by the vendor s national database benchmark. Comparison Group/Cohort Organizations may use a different appropriate comparison group for each unit/clinic. Depict the comparison group label on the table and graph. Graph Presentation Each graph must include the category and the specific vendor-aligned question. Single unit/clinic presentation o Organizations may use a different mean or median for each graph. Organizations may present up to four units/clinics on one graph. o If there are multiple units on one graph, all elements (i.e., benchmark, cohort) must be consistent. Review the Unit-level Summary of Outcomes for complete results Inpatient units: Vendor: Press Ganey Benchmark: All Database Time frame: 2014Q3-2016Q2 Ambulatory Units: Vendor: Press Ganey Benchmark: All PG Database (OAS); All Facility DB (OU, BMT) Time frame: 2014Q3-2016Q2 TUH did not outperform the national benchmark in Courtesy/Respect and Pain Potential underperformance of EP23EO Develop/update and implement action plans for categories and units/clinics with deficits Monitor results at minimum of quarterly
Utilize shared decision-making groups at unit and organizational level to support change and drive improvement Magnet Requirement: Certification Goals & Data (past 3 years) High Commitment to Professional Development: (SE3EOa, SE3EOb) Magnet SE3EO requires evidence that the organization has met a targeted goal for improvement in overall certification AND that the organization has met a targeted goal for improvement in a unit or division. 3 years of graphed data are required (baseline plus 2 years of goals and actual performance). The specific improvement goal is up to the organization, but it must be achievable since the organization must meet or exceed the goal. Magnet Update MPD Session October 2014: Must meet improvement goals The following examples are an illustration of goals; goals do not need to be the exact items listed below Two examples: 1. Organization level All nurse leaders All eligible nurses or eligible level II nurses (based on clinical ladder structure two years of practice for certification eligibility) 2. Unit or service line/division All eligible preoperative services nurses All eligible 6 West, adult intensive care unit (ICU) nurses Follow EO requirements on page 36-37 Graph baseline data plus two full years of post-goal data Goals should account for nurse attrition (be cautious of using percentage goals) Magnet Update MPD Session October 2015: SE3EOa o Organization must set a goal o Three years of graphed data must be included o Graph should show goal was met or exceeded SE3EOb
o Graph should display unit or division has met or exceeded goal Nursing certification only Include name of unit or division specifically Three years of graphed data must be included Goals and data must show equivalent metric (whole number to whole number, percent to percent) In the most recent Magnet demographic data report (April 2016), an average of 42.76% of clinical nurses and 58.33% of RN decision makers in hospitals of like size (> or = 701 licensed beds) are certified. A formal goal for nursing certification at TUH to meet the expectations set by SE3EO was not provided. Certification data was provided: 2014 234 2015 232 2016 238 Several initiatives in place to support professional certification (Differential, review courses, application fees, ANCC Success pays) Lack of data to support SE3EO request Potential underperformance of SE3EO Consider including professional certification as preferred or required in job descriptions for nurses at all levels to support a culture of nursing excellence and annual certification goals Evaluate unit and/or division-level certification data for previous years to establish baseline certification data and increase in certification based on goals to support SE3EO request Evaluate organization-level certification data for previous years to establish baseline certification data and increase in certification based on goals to support SE3EO request Continue to frequently and carefully monitor certification data; update action plan as indicated Shared Decision-Making Model and/or System- Charters and/or bylaws High Autonomy: (EP16)
Magnet Requirement: The Magnet expectation is that nurse autonomy and shared decision-making be supported and promoted through the organization s governance structure. EP16 requires 2 example of clinical autonomy that demonstrate the authority and freedom to make nursing care decisions, and 1 example of organizational autonomy that demonstrates the authority and freedom of nurses to be included in broader unit, service line, organization or system decision-making processes. Model (including orientation to council): Council Charters/Bylaws (expectations of members): Charters provided for: o Coordinating Council (undated) o Nursing Leadership Council (dated 4/8/16, but file name indicates this may be a draft) o Quality and Patient Safety Council (Undated) All provide the same outline: Purpose, goals, membership, decision making/voting, meetings, evaluation or measure of success, and communication PDEC working on Career Advancement Program and plan to implement in January 2017 PPC coordinated the development of the PPM Quality and Safety review of quality data and development of action plans (Nurse driven protocol for CAUTI (HOUDINI), Pilot for falls, Baby Box Research and EBP new council (only 3 meetings) planning to develop the research/ebp program for nursing at Temple
Reported most of the unit based councils function well but there are unit councils that need assistance No formal orientation for new members or chairs Does not appear there is dedicated time to work on agendas or minutes (reported doing the majority of work from home) Potential underperformance of EP16, possible inability to evidence shared decision-making and autonomy Continue/complete re-structuring of shared decisionmaking Evaluate/revise structure, including assessment of individual unit councils, after it is in place for a predetermined length of time Provide a description of the new model and its components (to define communication and dissemination strategies to ensure all staff receive shared decision-making information) Institute regular review/revision cycle for charters Performance Appraisal Policy & Tools for: CNO, Nursing Director, Nurse Manager, APRN, and Clinical Nurse High Professional Practice: (OO10 and EP15) Magnet Requirement: Magnet OO10 requires submission of performance review, peer feedback, and self-appraisal tools for nurses at all levels. EP15 requires the submission of evidence of clinical nurses and nurse leaders using performance review, self-appraisal, and peer feedback to enhance competence or professional development. Magnet Update MPD Meeting October 2014: OO10: Self-Appraisals, Peer Feedback, Performance Review Tools BLANK forms for each level for each of the three types of tool (manual update, March 2014) All levels, e.g., CNO, nurse leaders, nurse managers, clinical nurses, APRN/others One sample of each tool per level (if an organization has multiple levels of clinical nurses, submit just one) EP15: Requires recent, completed forms (signed, dated, blinded) Two levels represented: clinical nurses, nurse leaders
Must address enhancement of competence or professional development Position Performance Review Self- Appraisal Peer Appraisal Professional Learning Plan CNO Unclear Unclear Unclear AVP Unclear Unclear Unclear Director of Nursing Unclear Unclear Unclear Staff RN Unclear Unclear APRN Not provided Unclear Unclear Unclear CRNA Not provided Unclear Unclear Unclear Educator Not provided Unclear Unclear Unclear 2016 pilot peer appraisal form provided; unclear whether it is meant for use by all levels of nursing Manager tip sheet, dated 5/12/16, was provided to give managers guidance in the peer appraisal process; random assignment process is used Plan to implement house-wide One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Potential underperformance of EP15 Review current process and clearly describe and demonstrate how current tools are used for nurses at all levels to meet Magnet expectations for annual performance appraisal, self-appraisal, and peer review Develop policy(ies) as necessary to ensure language applies to nurses at all levels Revise/establish performance appraisal tools as necessary to meet Magnet expectations
Annual Organizational & Nursing Report (most recent) High Leadership: Organizational Alignment (OO3) Magnet OO3 requires submission of the organization and nursing annual report. Magnet Update MPD Session October 2014: Submit copies of the most recent reports. Magnet Requirement: If an organization has only a single annual report or strategic plan, the nursing department must have a distinct presence in these reports. If an organization submits a system-level report, the applicant organization must have a distinct presence in the report. During the site visit it was reported that a 2016 nursing annual report was in development There is not an organizational annual report One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Complete nursing annual report IRB and RN Membership/Voting: Policies, Procedures, Charters, or Bylaws Magnet Requirement: High New Knowledge, Innovations, and Improvements: (OO18 and OO19) Magnet OO19 requires evidence that a nurse must be a voting member of the IRB and the organization s policies, procedures, charters or bylaws designating that at least 1 nurse is a voting member of the governing body responsible for the protection of human research participants. July 2016 Magnet Update: Based on current practices and updated information regarding IRB processes, the nurse voting member of the IRB is NOT required to vote on nursing-related protocols.
Provide evidence that a nurse is a voting member of the IRB, and the organization s policies, procedures, charters, or bylaws designating that at least 1 nurse is a voting member of the governing body responsible for the protection of human research participants OR Provide a letter signed and dated by the chair of the governing body responsible for the protection of human research participants that attests to this requirement. A template for the letter is available at: http://www.nursecredentialing.org/magnet/magnet- FormsTemplates/Magnet-TablesTemplates/Template-IRB- Attestation Lack of documentation for IRB nurse membership and voting- not provided During site visit it was reported that the IRB is through the medical school and there is currently not a nurse who is a member Perception that studies are difficult to get through the IRB process with out a physician PI One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Potential underperformance of OO19. OOs are not scored, but documents must be present for application review to progress Review IRB policies and other documents to determine whether they require IRB nurse membership; request that language be added if necessary Review documentation of nurse voting on nursing protocols; request policy/process changes if necessary Confirm that policies are current and the most recent version; request updated review if necessary Ongoing monitoring of nursing membership and participation in IRB
Summary of Nursing Research Projects (past 48 months) High New Knowledge, Innovations & Improvements: (OO20, NK2) Magnet OO20 requires completion of a table of nursing research studies for the preceding 48 months, along with the description of one completed study in NK1EO. Magnet NK2 also requires evidence of clinical nurse involvement in disseminating research. Magnet Requirement: Note: There is no required number of studies to be included on the table; however, there must be one completed study meeting all the requirements listed in NK1EO. Magnet Update MPD Session October 2015: Nursing Research must be within the organization Primary Investigator or Co-primary investigator must be a nurse and employee of the organization Improvement projects or evidence-base projects are not acceptable Nurse research study utilized in NK1EO must be from this list The ANCC research table was not provided During the site visit there was discussion that there were some potential studies for NK1EO Research and EBP Council is new and plans to develop a program of research and EBP There is support for internal/external dissemination of research including the new to practice residents The nursing research table is one of 20 required documents for the Organizational Overview One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded... If the missing documents are not provided after five (5) business days, the review is concluded Potential underperformance of OO20, NK1EO, and/or NK2.
Complete an IRB-approved research study Review current projects to determine whether they are nursing research or EBP projects Use and implement an update cycle for the ANCC research table to reflect the most recent 48 months of nursing research at TUH Consider partnering with educational institutions for research support Review structure and process for dissemination of nursing research (internal and external) to ensure evidence is available to support NK2 Magnet Requirements: Educational Needs Assessment & Plan (most recent) High Professional Development: (OO6, SE4EO, and SE6) Magnet OO6 requires submission of the learner assessment of the continuing education needs for nurses at all levels and settings, and the related education implementation. Levels include: Clinical nurses, nurse managers, APRNs, nurse educators, nurse directors/vps, CNO. Settings include all settings where nurses practice (inpatient, outpatient, procedural, etc.). SE4EO, Provide one example, with data, of nurses participation in a professional development activity that demonstrated an improvement in knowledge, skills, and/or practices for professional registered nurses. SE6 requires an example of an educational activity provided by the organization focused on improving nurses expertise in teaching a patient or family. Magnet Update MPD Session October 2014: Learner assessment of continuing education needs All levels, e.g., CNO, nurse leaders, nurse managers, clinical nurses, APRN/others All settings (describe) Related education implementation plan All levels, e.g., CNO, nurse leaders, nurse managers, clinical nurses, APRN/others All settings (describe) Magnet Update MPD Session October 2015: All Nurses..All Levels of nursing within your organization
All Settings Inpatient ICU, Med-Surg, Peds, etc. Ambulatory Clinics, ED, Ambulatory Surgery, etc. An educational needs assessment was not provided During the site visit HR reported that they conduct a needs analysis of all staff at TUH Recent survey had greater than 1500 respondents (unclear how many nursing responses) Other informal methods of assessing educational needs were discussed, but unclear whether if it includes nurses at all levels One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Lack of evidence of assessment at all levels and in all settings; lack of evidence of education plan for all levels and in all settings/none Evaluate needs assessment(s) and identify nurses not included Review documents provided and formalize assessment and plan for nurses at all levels and settings Implement education plans for newly identified nursing groups Consider developing standard annual needs assessment process Consider developing standard assessment tools, results summary format, and education plan format Ensure that at least one educational activity focused on improving nurses teaching expertise is offered during the Magnet time frame (48 months) Organization and Nursing Strategic Plans (most recent) Moderate Leadership: Organizational Alignment (OO3 and TL1EO)
Magnet OO3 requires submission of the organization and nursing strategic plan. TL1EO requires evidence of initiatives identified in the nursing strategic plan that resulted in improvements in the nurse practice environment and clinical practice. Magnet requirement: Magnet Update MPD Session October 2014: Submit copies of the most recent reports. If an organization has only a single annual report or strategic plan, the nursing department must have a distinct presence in these reports. If an organization submits a system-level report, the applicant organization must have a distinct presence in the report. An organization may submit quality and safety plans at the organization level and may combine them in one document and with separate sections for quality and for patient safety An organizational strategic plan was not provided A copy of the Nursing Strategic Plan 2015-2017 was provided during the site visit There was discussion during the site visit about initiatives but not certain if they were in the strategic plan which is not a living document Reported that the plan was presented at the council meetings Conducted a nursing leadership retreat where the strategic plan was discussed CNO provides the staff periodic updates about the plan Two of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Lack of evidence/data to support TL1EO Consider the following guidelines when formatting a nursing strategic plan: The nursing strategic plan should set the stage for the following three to five years and include the associated time frame, goals, and measurements to be achieved
It should communicate and align the organization s as well as nursing s mission, vision, values, and goals and set the agenda for committees and councils for the associated time frame of the plan The plan generally includes broad umbrella concepts such as developing or expanding departments and services, clinical outcomes, employee development and engagement, and fiscal targets which align with the organization s strategic plan These categories create the framework for conducting the business of providing patient care, and nearly all of nursing operations is included under these concepts Credentialing, Privileging & Evaluation of APRNs: Policy and/or Bylaws Magnet Requirement: Moderate Professional Practice: (OO11) Magnet OO11 requires submission of the process by which the CNO participates in credentialing, privileging, and evaluating APRNs. Professional Medical Staff Bylaws, amended and approved by the Medical Staff on 10/7/16, was provided Lack of clarity related to APRN credentialing, privileging, and evaluation process, although CNO is an ex-officio, nonvoting member of the Medical Staff Executive Committee who has responsibility for credentialing and privileging Privileging lasts for 2 years One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Review all policies and documents for evidence of CNO participation (or delegation) in credentialing, privileging, and evaluating; revise as necessary Assess APRN credentialing, privileging, and evaluation process and policies; revise as necessary Consider adding language to job description concerning the relationship with nursing
Collaborate with medical staff to revise policy to evidence CNO role in credentialing, privileging, and evaluating APRNs if necessary Confirm that all APRNs are evaluated by nurses; institute self-evaluation and peer feedback if not already in place (reference guidance provided in Performance Appraisal review) Magnet Requirement: Budgeting Policy/Process Moderate Budgeting: (TL2, TL7, and EP10) Magnet TL2 requires 1 example of a nurse leader s advocacy that resulted in resources for an organizational goal and 1 example of a clinical nurse s advocacy that resulted in the allocation of resources to support a nursing unit goal. TL7 requires 1 example of a nurse leader, with clinical nurse input, using trended data to acquire necessary resources to support the care delivery system. EP10 requires 2 examples from different practice settings where trended data and clinical nurse input was used during the budget process. Plan for the Provision of Care policy, dated last reviewed 2/3/16, was provided Policy discusses involvement by department directors and managers in budgeting process Budget considers new program submissions as well as existing program needs for upcoming year Nursing collaborates with physician department chief and chair to review anticipated growth Clinical nurses have limited involvement with operational and capital budgeting process Lack of supporting evidence for TL2, TL7 and EP10 CNO and Nurse Leaders monitor organizational, division, and/or unit examples to support TL2, TL7, and EP10 Utilize clinical nurse input in relation to budgeting process Be alert for examples and/or suggestions for equipment requests from clinical nurses to support TL7 IOM Education Action Plan Moderate
Magnet Requirement: Commitment to Professional Development: OO7 Magnet OO7 requires the submission of an action plan with target and demonstration of progress toward 80% of RNs with a BSN or higher by 2020. Magnet Update MPD Session October 2015: Include an assessment of the current status; the methods and strategies to increase the educational level of Registered Nurses; and an evaluation of the established goals to meet the initiative to increase the number of nurses with a BSN or MSN degree Narrative defines current status, goal(s) and Action Plan (methods/strategies) Graph to show baseline AND goal(s) Recent Magnet demographic data (April 2016) indicates hospitals of like size (> or = 701 licensed beds) have an average of 64.35% BSN and 4.39% MSN RN direct-care staff. Professional Development and Education Council meeting minutes, dated 7/6/16, detail discussion to have BSN be entry level at TUH In 2015, 58.42% staff had BSN; in 2016, 70.507% had BSN No formal goal provided One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Complete development of written plan and gather data on progress toward 80% goal. Formally evaluate progress toward goal based on time frame identified in action plan. Magnet Requirement: Professional Practice Model Moderate Professional Practice: (OO8, EP1, and EP2EO) Magnet OO8 requires submission of a schematic of the PPM. The schematic should depict how nurses practice, collaborate,
communicate, and develop professionally to provide the highest quality care. EP1 and EP2EO require evidence that clinical nurses are involved in the development, implementation, evaluation, and revision of the PPM, and that clinical practice improvement results. Professional Practice Model (PPM): Undated document provided describing the process used by the Professional Practice Council to create the PPM was provided PPC solicited words from nurses that describe the practice at TUH. Collated them into themes and developed a banner with the top words. Used the most frequently selected themes to incorporate into the PPM Planning on implementation in 2017 Education will be provided at nursing grand rounds and at unit level Potential underperformance of OO8, EP1, and/or EP2EO. One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present: The review is suspended
The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Lack of PPM enculturation and evidence to support clinical nurse involvement in the development Complete review and revisions of the PPM Add a date to the schematic and other documentation After review and revision, develop and implement dissemination and enculturation plan, including staff education and posting the model in all clinical areas Focus efforts on the education, integration, adoption, and enculturation of the PPM for each setting, unit, and clinic where nursing is practiced Document clinical nurse participation in all aspects of the review and revision process Incorporate PPM and CDS into discussions of nursing issues, meetings, educational programs, and relevant nursing publications Initiate a cycle of regular evaluation of the PPM Be alert to examples of clinical nurse involvement in the PPM resulting in clinical practice improvement Job Descriptions for: CNO, Nursing Director, Nurse Manager, APRN, and Clinical Nurse Magnet requirement: Low Professional Practice: (OO2-CNO) and Eligibility Criteria (Nurse Leader/Manager) Magnet eligibility criteria require that the CNO holds a minimum of a master s degree. If the master s is not in nursing, then either a baccalaureate or higher degree must be in nursing. 100% of nurse managers and nurse leaders must have a degree in nursing (baccalaureate or graduate degree). Magnet Definition of Nurse Leader: Nurse Leader (06/2015) Nurse leaders must have a degree in nursing (bachelor's or higher). Nurse leader is not a title and should not be interpreted as such for the purpose of the written documentation.
The definition of nurse leader is exclusive of the chief nursing officer (CNO). Nurse educators who serve in the top educator role and are responsible for other nurse educators are considered nurse leaders. Nurse leaders may have clinical oversight and responsibility for nurse managers or for other nurses who influence clinical care. Nurses may be represented on only one eligibility table either the Nurse Manager or Nurse Leader Eligibility Table. Only nurse leaders annotated on the Nurse Leader Eligibility Table may be selected when a nurse leader example is required by the SOE. Note: For applicants with flat organizational structures without nurse managers, the nurse leader may be substituted for nurse manager SOE examples. Nurse leaders may report directly or indirectly to the CNO. Nurse leaders practice (clinical and nonclinical) in a variety of settings (inpatient, ambulatory, or other environments) throughout the organization. Other registered nurses who may broadly influence or impact the clinical practice of nurses in the organization may be considered a nurse leader. If these nurses are referenced as nurse leaders in the organization's Magnet application, they must meet the educational criteria (bachelors in nursing or higher) and report directly or indirectly to the CNO. Examples may include, but are not limited to, RN director of risk management or quality, RN director of nursing informatics, infection preventionists, and wound ostomy nurses. A table substantiating eligibility must be submitted upon initial application and upon submission of documentation. OO2 requires submission of the CNO job description and CV. Title CNO/VP Reporting Structure Executive Director Minimum Education Requirement Master s degree in Nursing or Business; Doctorate preferred Advanced Certification Requirement Review Date None listed 7/2010
ACNO Director of Nursing Nurse Manager Clinical Nurse VP Patient Care Services, CNE Not listed Not listed Not listed BSN required; Master s degree in Nursing or Business required BSN required; Master s degree in Nursing or Business preferred; Combination of relevant education and experience may be considered in lieu of degree BSN required; Masters in Nursing or healthcare related field preferred; Combination of relevant education and experience may be considered in lieu of degree Graduate from an accredited school of nursing; Bachelor s degree preferred None listed 8/2010 National certification in nursing or healthcare related specialty preferred National certification in nursing or healthcare related specialty preferred Professional education, training, or additional certifications may be required by specialty area 7/3/13 2/19/13 6/13/13 APRN Not provided Clarity related to CNO oversight of APRN; inconsistent presentation of job descriptions and revision dates. One of twenty required documents for the Organizational Overview. If any of the requested documents in the twenty (20) Organizational Overview items are not present:
The review is suspended The organization is notified and will have five (5) business days to provide the missing documents If the missing documents are not provided after five (5) business days, the review is concluded. Underperform requirements of eligibility or OO2. Applications will not be accepted if eligibility criteria are not met. OOs are not scored, but documents must be present for application review to progress All job description documents should be dated and revision dates should be noted Language used for nurse leader/manager education requirements should be clarified to meet the eligibility criteria for Magnet designation Consider including professional certification as preferred or required for nurses at all levels to support a culture of nursing excellence and annual certification goals Magnet Requirement: Career Advancement Plan Low Professional Development and Leadership: (TL5, TL6, TL7, TL8, TL9EO, SE4EO, SE5 SE6, SE7, and SE8) A career advancement plan (CAP) is not required for Magnet designation but is best practice for support of professional nursing practice Meeting notes (dated 6/1/16) and meeting minutes (dated 7/6/16) from the Professional Development and Education Council were provided Discussed creation of clinical ladder program voted by the nursing staff to be named PRIDE (professional recognition in developing excellence) Uses Patricia Benner s novice to expert approach for 3 levels in program including competent, proficient, and expert Monetary awards are recommended for each level Plan to roll out in January 2017 Lack of evidence to support professional and leadership development Potential underperformance of TL5, TL6, TL7, TL8, TL9EO, SE4EO, SE5 SE6, SE7, and SE8
Nursing Leadership and Nursing Professional Development & Educational Council Review and edit CAP documentation to ensure dates of revision and/or review occur within the most recent 48 months prior to document submission Evaluate the connection between the RN satisfaction survey categories and questions and the professional development services provided; formulate action plans to ensure nurses comprehend the level of organizational investment (consider using Shared-decision making councils) Review all documents related to nursing orientation to ensure nurses at all levels and settings are included Institute an evaluation cycle for all documentation to ensure they remain consistent with current practice and timely for each successive Magnet designation period Magnet Requirement: Innovation Low New Knowledge and Innovation (NK4EO, NK5EO & NK6EO) Magnet NK4EO requires two examples, with supporting evidence of an improvement that resulted from an innovation in nursing Magnet NK5EO requires one example of an improvement that occurred due to a change in nursing practice from clinical nurses involvement with design and implementation of technology and one example of an improvement in the patient experience that resulted from clinical nurses involvement with design and implementation of technology. Magnet NK6EO requires one example of nurse involvement in the design and implementation of work flow that resulted in operational improvement, waste reduction or clinical efficiency OR one example of nurse involvement in the design and implementation of work space that resulted in operational improvement, waste reduction or clinical efficiency. Recent implementation of EPIC in the organization Clinical RNs were involved in the development, education, and implementation of the EHR and the selection of devices Clinical nurses have requested a Clinical Informatics Council be developed within the shared decision-making structure RICU space redesign
Baby box provided for all new babies at discharge to prevent falls Underperformance of NK4EO NK6EO Evaluate observations listed above for nursing input and data to support Magnet requirements Review examples of clinical nurse involvement in the design of new departments for examples to support NK5EO and NK6EO Review examples of clinical nurse involvement in EPIC implementation or changes to support NK4EO, NK5EO, and NK6EO Continue to support nursing involvement in the design and implementation of technology to improve the patient experience and nursing practice Continue to support nursing involvement in the design and implementation of work flow improvements and space design to enhance nursing practice Be alert for evidence to support improvement in processes Magnet Requirement: Mentoring/Succession and Visibility/Accessibility of RN Leaders Low Professional Development and Leadership: (TL6, TL8, TL9EO) TL6 requires the organization to provide 1 example of mentoring or succession planning for clinical nurses, nurse managers, nurse leaders, and the CNO. TL8 requires 1 example of communication between the clinical nurses and the CNO that led to a change in the nurse practice environment, a change in the patient experience or a change in nursing practice. TL9EO requires 1 example of clinical nurse communication with a nurse leader that influenced a change in the nurse practice environment, a change in the patient experience, or a change in nursing practice. There was discussion of informal succession planning within a specific department Professional goals and future leadership involvement is discussed at the time of performance appraisal Leadership Academy available for professional development Management Council recently completed a Manager Binder
The CNO uses various methods to communicate, be visible, and be accessible to nurses throughout the organization Clinical nurses spoke of Breakfast with Betty Reported CNO and other leaders are visible, make rounds, are easy to access, and have an open door policy Lack of evidence to support professional and leadership development Potential underperformance of TL6, TL8, TL9EO Be alert for examples of clinical nurse input and/or communication with CNO or nursing leadership to support TL6, TL8, and TL9EO Shared Decision-Making Council Minutes (last set from each council- centralized and unit) Magnet Requirement: Low Professional Practice: May support all Sources of Evidence Meeting minutes are used as evidence to support Magnet documentation, and they need to identify: council initiatives, goals, measures, dates (initiation, projected completion, and final completion), and meeting participants. 3 sets of minutes provided All use a standardized template and include headers: agenda item, action, presenter, discussion, and outcome/follow-up Opportunity exists to provide more detail, specifically in the outcome/follow-up section so it is clear what action is resulting from council discussions/work (please note, this is a small sample of minutes and may not represent the full picture) Incomplete documentation of nursing decisions and clinical nurse participation in decision-making Possible inability to link the work of a council and nurses participating in decisions Implement standard minute s format that includes names of chair(s), recorders, etc. Implement pre-developed attendance roster as one component of minutes with members full names, credentials, titles, and unit/department Institute standard format of using either full names or first initial with full last name within the body of minutes Add to minutes the names of those who propose actions or make major suggestions/comments.