100-16 Nursing Acute Care Divisin Charter Cmmittee Name: Nursing Acute Care Divisin Interdisciplinary Shared Gvernance Prepared By: Jeff Stut, MSN, RN, NEA-BC Renwn Health Vice President, Chief Nursing Officer Acute Care Divisin Date: June 1, 2015 A Purpse f the Cmmittee Primary Functins The purpse f the Shared Gvernance Cmmittee is t define, assign, versee and supprt clinical practice and perfrmance initiatives while instilling respnsibility, wnership, and leadership fr the cntinued imprvement f quality clinical practices and patient care envirnments. Gals/Objectives: Supprt the Clinical Strategic and Operatinal Plans and Standards Fulfill the Renwn Health cre values f Caring, Integrity, Cllabratin, and Excellence Review, revise and implement patient care standards, plicies and prcedures. Maintain and supprt a centralized clinical ladder advancement prgram fr nursing Cmmunicate patient care issues t maintain quality Identify and develp clinical educatin Supprt cultural diversity and cmpetency initiatives Assist in keeping standards/cntinuity f practice acrss Renwn Reginal Medical Center Supprt research initiatives and prvide educatin abut the initiatives Identify and develp facility and wrk frce envirnmental needs Identify and assist in health and safety issues Supprt and assist in recruitment and retentin initiatives Assist in identifying and prblem slving accreditatin issues Scpe f Authrity The Cmmittee shall be respnsible fr develping and implementing psitive changes relating t clinical prtcls, practices and educatinal needs. Members will nt exceed their Nevada State licensed scpe f practice. Cmmittee serves as the arena fr unit staffing cncerns and reprting. Cmmittee shall nt be peratinally respnsible fr financial, salary, benefit, r budgetary items/issues, but will have input int the budgeting prcess. Decisin Making Mechanisms Shared Gvernance Cmmittee decisins will be guided by evidence-based knwledge, research, and in accrdance with current standards f care. Current standards f care include but are nt limited t Renwn Health, prfessinal rganizatins, and ther regulatry bdies such as, but nt limited t, the Nevada State Practice Act and The Jint Cmmissin. A majrity vte will be required fr decisins with a minimum f tw-thirds vting cnstituents in attendance. 07/06/2015 Page 1 f 6
B Steering Cmmittee General Membership f Shared Gvernance Cmmittee The vting cnstituents f the Cmmittee shall be made up f ne direct care nurse representative frm each area where nursing is emplyed and ne ancillary service representative frm each area t include but nt limited t labratry, pharmacy, rehabilitatin services, envirnmental services, respiratry services, cardivascular services, transprt, scial services and dietary. The representatives can be part-time, full-time r per diem staffing prviding r supprting direct patient care prviders. The number f per diem nurses shall nt exceed twenty-five percent (25%) f the majrity. A per diem nurse may be elected int the psitin f Secretary. The CNO and/r representative will serve as ex-ffici members f the cmmittee with vting privileges (NRS 632.240). Cnstituents may nt be active in any disciplinary prcess within the last 12 mnths. Unit-based Shared Gvernance cmmittees will elect r appint new members frm their cmmittee cnstituents where applicable. Clinical areas withut the unit-based structure will prvide representatin based n their wn electin system. The membership term fr vting cnstituents is tw years*. The Chief Nursing Officer and/r representative shall nt have membership terms. The nn-vting cnstituents r resurce members f the Cmmittee shall be made up f a nurse directr representative, a nurse management representative, a clinical nurse specialist and/r clinical nurse educatr representative, a quality department representative, an ancillary representative, and ther departments nt listed. The representatives shall be part-time r full-time management/leadership staff. Cnstituents may nt be actively in any disciplinary prcess. The nnvting cnstituents shall nt exceed 30% f the ttal membership f the cmmittee. Nn-vting cnstituents shall nt hld elected psitins within the Cmmittee. The membership term fr nn-vting cnstituents is tw years*. * If a new representative is nt available frm unit/ area in questin, the current representative shall remain n the Cmmittee until a replacement is available. Rle f Representatives All representative cnstituents shall emulate the Standards f Cnduct established in Renwn Health Human Resurce plicies and be a rle mdel fr ther direct patient care prviders. All vting and nn-vting cnstituents shall be respnsible fr Cnveying Cmmittee infrmatin and decisins t their units r area f practice Sliciting their areas pinins n pertinent issues Encuraging ther staff t bring their issues t the Shared Gvernance Cmmittee Time will be alltted at unit-based/area staff level mnthly meetings t discuss this Cmmittee s infrmatin and decisins. If the Cmmittee representative is unavailable fr these meetings, the representative must find a replacement t discuss Shared Gvernance Cmmittee infrmatin at that meeting, i.e. ther staff member, ther unit-based practice cmmittee member r area manager All vting and nn-vting cnstituents will arrange an rientatin prcess fr their new area representatives as t their specific respnsibilities. The purpse is t facilitate the transfer f duties and respnsibilities and t frmulate the gals f the cmmittee fr the cming year Nn-vting r resurce cnstituents shall act as an expert in the arena designated by membership. Nn-vting cnstituents shall versee the develpment and implementatin f strategies and reslutins t clinical practice issues Nn-vting cnstituents shall reduce barriers t Cmmittee s effrt. The nn-vting cnstituents shall prmte and maintain cmmittee visibility via Nursing News, Mnitr, and Inside Renwn Website. Nn-vting cnstituents shall versee all materials distributed by the Cmmittee and the develpment f cntent that will be published in the Nursing News, Mnitr, r n the Inside Renwn Website Nn-vting cnstituents are respnsible fr infrming their peer grup abut Shared Gvernance infrmatin at their peer level mnthly meetings evidenced by dcumentatin in the meeting minutes Recall f a Representative A unit r practice area may recall a representative wh is nt adequately fulfilling their respnsibility at any time. The Chair will ntify the Membership Chair prir t the next scheduled meeting. The unit r practice area manager will be 07/06/2015 Page 2 f 6
respnsible fr ntifying the current cnstituent and replacing the cnstituent as prescribed in the general membership sectin. Attendance Attendance is mandatry. If unable t attend a meeting, the vting and/r nn-vting cnstituent must cntact the Membership Chair in advance, 2 hurs prir t a scheduled meeting time t ntify f absence. Cnstituents may call the hspital sick call htline and leave a message with the Nursing Administratin Manager (NAM) n duty r e-mail the membership chair prir t the meeting. Three ntified and/r tw nn-ntified absences may result in terminatin f membership and a new representative will be sught. If a unit replacement attends in the place f the cnstituent with ntificatin f the Membership Chair, the absence will nt be cnsidered tward absence cunt. The cnstituent may nly utilize replacement members fr 4 absences in their tw-year term. The replacement member will nt be a vting member f the cmmittee. Apprved leave f absences will nt be cnsidered tward absence cunt. C Steering Cmmittee Meetings Meeting Schedule and Prcess Shared Gvernance Cmmittee meetings will be held the first Wednesday f every mnth and ad hc as situatins and decisins dictate. Elected and Appinted Psitin and Respnsibilities Electins Nminatins fr the Office f C-Chair, Secretary, and Membership Chair will be held in May f selected years depending n term f psitin. The electin f the nminated ffices will be held in June with the new fficer beginning July 1 st. The C-Chair psitin will mve int the Chair psitin in July when new C-Chair is elected. Chair Qualificatins Current vting cnstituent f Shared Gvernance Cmmittee Nn-vting cnstituents shall nt serve in elected psitins Cnsented t serve in the psitin Full r part-time emplyment Term f Chair will be ne year. If Chair vacates ffice r is unable t perfrm the respnsibilities required, the C- Chair shall becme Chair and a new C-Chair will be elected. Respnsibilities Is the executive fficer f all business f the Cmmittee as stated in the By-laws Ensure Cmmittee s main fcus is t imprve quality clinical practice and patient care envirnments Serve as chief representative f the Cmmittee Cmmunicates t the emplyees f Renwn Reginal Medical Center the purpses f the Shared Gvernance Cmmittee Prepare a calendar and agenda fr general membership meetings. May delegate duty t C-Chair Supprt C-Chair in develpment f leadership skills in preparatin fr rle transitin Allw C-Chair t run meeting and make agenda frm beginning in May f the year term Delegate respnsibilities nt therwise handled by the cmmittee By-laws, t the cmmittee fficers r sub-cmmittees Cmmunicate the business, prjects and activities f the cmmittee t the cnstituents Ensure all reprts - including cmmittee By-laws, cmmittee elected cnstituent list, and membership list are up t date and available t all cnstituents 07/06/2015 Page 3 f 6
Meet with the Chief Nursing Officer r representative, at least quarterly t get the cmmittee's meetings n the rganizatins master calendar Oversee the develpment and implementatin f strategies that prmte and maintain cmmittee visibility via Nursing News, Mnitr and Inside Renwn Website Plan fr fficer transitin in June f each year Every June, write the Annual Executive Summary f the wrk the Shared Gvernance and its subcmmittees cmpleted fr each fiscal year. (Renwn Health s fiscal year runs July 1 thrugh June 30 th ) Participate as the Shared Gvernance Representative n the Nursing Excellence Fund/Staff Educatin Fund cmmittee fr disbursement f funds A. C-Chair Qualificatins Current vting cnstituent f Shared Gvernance Cmmittee Nn-vting cnstituents shall nt serve in elected psitins Cnsented t serve in the psitin Term f C-Chair will be ne year, elected every year in the mnth f June Respnsibilities Succeed int the Chair psitin at the end f a ne-year term f ffice. If Chair vacates his/her ffice r is unable t perfrm the respnsibilities required succeed int Chair psitin until the next electin Cmmunicate t the emplyees f Renwn Reginal Medical Center the purpse f the Shared Gvernance Cmmittee Learn the cmmittee s peratins and facilitate the achievement f gals and missin f the rganizatin Ensure Cmmittee s business imprves quality clinical practice and patient care envirnments Cmmunicate the business, prjects and activities f the cmmittee t the membership Make agendas and run meetings beginning in May f the year term Plan fr fficer transitin in June f each year B. Secretary Qualificatins Current vting cnstituent f Shared Gvernance Cmmittee Nn-vting cnstituents shall nt serve in elected psitins Cnsented t serve in the psitin Term shall be tw years. If vacates his/her ffice r is unable t perfrm the respnsibilities required during the twyear term a new Secretary will be elected Respnsibilities Arrange an rientatin prcess fr newly installed secretary specific t the secretary psitin. Recrd and type the minutes fr each business meeting The standard meeting minute frmat that Renwn Health had adpted will be utilized. Distribute minutes t all members Pst meeting minutes n the Inside Renwn Website fr Shared Gvernance Cmmittee. Keep an fficial recrd bk f the minutes f all business meetings t present t the succeeding secretary. C. Membership Chair Qualificatins Current vting cnstituent f Shared Gvernance Cmmittee Nn-vting cnstituents shall nt serve in elected psitins Cnsented t serve in the psitin 07/06/2015 Page 4 f 6
Term shall be tw years. If vacates his/her ffice r is unable t perfrm the respnsibilities required during the twyear term a new Membership Chair will be elected Respnsibilities Arrange an rientatin prcess fr newly elected Membership Chair specific t Membership Chair psitin. Recrd and maintain a recrd f membership terms fr all cnstituents. Ntify cnstituents and their respective manager tw mnths prir t membership expiratin. Keep a recrd f hw many times ntified respective manager fr membership requests per cnstituents. After three times, ntify Directr r representative. Recrd and maintain a recrd f members attendance at meetings. After tw unexcused absences r 3 excused absences in a ne-year perid, membership chair will ntify cnstituent and their respective manager t slicit a new member and ask that the current member be excused. After three times, ntify Directr r representative. Agenda The agenda will include ld business, new business, staffing issues, and reprts frm sub cmmittees. Any member f the Cmmittee is welcme t add items t the agenda. Agenda items shall be submitted t the Chair r C-Chair at least tw week prir t the meeting. Urgent agenda items will be allwed at the discretin f the Chair r C-Chair. The agenda will be distributed at the mnthly meeting. The standard agenda frmat that Renwn Health has adpted will be utilized. Distributin f Minutes The minutes will be distributed by the Secretary t members f the Cmmittee each mnth and will be psted n the Inside Renwn Website Shared Gvernance Cmmittee each mnth. Structure f Cmmittee Shared Gvernance cmmittee shall supprt cre cmmittees as determined by need f this cmmittee including, but nt limited t: Quality Evidence Based Research Clinical Ladder Pathway t Excellence/Magnet Recruitment and Retentin Plicy and Prcedure Executive Respnsibilities f Cre Cmmittees: Establish wn By-laws r Charter Carry ut decisins guided by evidence-based knwledge, research, and in accrdance with current standards f care. Current standards f care include but are nt limited t Renwn Health, prfessinal rganizatins, and ther regulatry bdies such as, but nt limited t, the Nevada State Practice Act and The Jint Cmmissin A majrity vte will be required fr decisins with a minimum f tw-thirds vting cnstituents in attendance Cntain a Chair psitin Cntain at least ne vting cnstituent frm the Shared Gvernance Cmmittee Mnthly, vting cnstituent shall reprt back t Shared Gvernance Cmmittee the sub cmmittee s busines. Cntain a nn-vting Clinical Management representative Cntain the apprpriate members fr cmmittee s initiatives 07/06/2015 Page 5 f 6
Review and Revisin f Bylaws The Shared Gvernance Cmmittee, and the CNO and/r representative shall review by-laws every tw years. Any member may recmmend changes in the By-laws by submitting the change t the Cmmittee. The prpsed change shall be placed n the agenda f the next regularly scheduled meeting. A majrity vte will be required fr decisins with a minimum f tw-thirds vting cnstituents in attendance. *Executive Cmmittee Purpse: Prvide a venue fr the review f staffing ccurrence reprts and identificatin/ implementatin f staffing actin plans Review quality indicatrs and staff lifting injuries and identify trends and actins t prevent Chart the strategic directin f Shared Gvernance Ensure prcesses are in place t achieve superir patient and family utcmes Cmmittee membership includes: Chair, Shared Gvernance C-Chair, Shared Gvernance Secretary, Shared Gvernance Membership, Chair Shared Gvernance Immediate Past, Chair Shared Gvernance Certified Nursing Assistant Rtating member at large CNO HR Representative Direct care prviders are ver 50% f Cmmittee 07/06/2015 Page 6 f 6