MAGNET RECOGNITION PROGRAM SITE VISIT AGENDA MAGNET 20150902 VERSION 12 NOV 1, 2017 CNE: Jeanette Ives Erickson, RN, DNP, FAAN Magnet Program Director: Marianne Ditomassi, RN, DNP, MBA, FAAN Executive Director, Patient Care Services Senior Analyst: Srishti Singh Srishti.singh@ana.org Magnet Specialist: Marguerite Smalls Marguerite.smalls@ana.org MASSACHUSETTS GENERAL HOSPITAL 55 FRUIT STREET BOSTON, MA 02114 WYNDHAM BOSTON BEACON HILL HOTEL 5 BLOSSOM STREET, MA 617-742-7630 The purpose of the site visit is to verify, clarify, and amplify the information submitted in the application documentation. The appraisers will come with specific questions for each of the requested sessions. Unless requested on the agenda, prepared presentations or supplemental documentation for review will not be necessary. MGN 20160604 Appraiser Team Team Leader: Mary G. Nash, PhD, RN, FAAN, FACHE, NEA-BC Team Members Kathleen, DNP, RN, NEA-BC, RN, MSN, NEA-BC, DNP, RN, NEA-BC MPM-TMP-81 1
Day 1 Date: Monday November 6 Time Topic Session Leader Location & Attendees 7:00 am Appraisers Travel to Medical Center All appraisers 7:15 8:00am CNE, Magnet Program Director and Appraisers Review agenda and Deficiency SOEs Meet Escorts 8:00 8:15am Travel Time 8:15 9:15am Trustees Room, Bulfinch 225 9:30 10:45am Trustees Room, Bulfinch 225 President/Board Members/Physician Leadership/Executive Management Team Intent: Introductions, Mission/Vision/Values, Senior Leadership support to pursue Magnet designation, describe role of CNE at executive level, processes that enable the CNE to influence organizational wide changes and describe the current image of nursing within the organization, Financial support for nursing, involvement in Magnet journey, Community issues/needs and any workforce issues. Nurse Executive Committee Who to include: Nursing Senior Leaders, Magnet Program Director Intent: Describe the senior nursing leaders role in advancing nursing on the Magnet journey; perception of nursing throughout the organization, Discuss any changes in strategic plans, nursing goals, planning and decisionmaking processes, and budget issues. Staff involvement in the magnet designation process. 10:45 11:00am Travel Time 11:00 11:45am Unit Nursing Leadership Their Conference Nursing Leaders to include Nurse Managers/Directors Room, Their Building 11:45am Travel Time MPM-TMP-81 2
12:00 1:00pm FND 311 12:00 1:00pm Sweet Room, GRB 432 12:00 1:00pm Blum Center, White 1-110 12:00 1:00pm Bulfinch 222 Lunch with Clinical Nurses Randomly selected (~15) Lunch with Clinical Nurses Randomly selected (~15) Lunch with Clinical Nurses Randomly selected (~15) Lunch with Clinical Nurses Randomly selected (~15) 1:15 3:30pm Unit Visits: All visits will be approximately 30 minutes Who to include: Appraisers will randomly select direct care nurses and/or patients and or other staff members present in the department Unit Visits: Back Bay Health Center MGH West Waltham: Ambulatory Surgery, Obstetrics, Cancer Center 1:15 5pm Unit Visits: Lunder 8 Neuroscience Lunder 7 Neuroscience Lunder 6 Neuro ICU Blake 11 Psychiatry White 11 Medicine Bigelow 11 Medicine 1:15 5pm Unit Visits: Blake 14 L&D Blake 13 Family Newborn Ellison 13 Family Newborn Yawkey 8 Infusion 8E & Ped Hem/Onc 8B Temeer Yawkey 7A Yawkey 9 Oncology (visit 9A Breast & Lymphoma and 9E GYN and Neuro) MPM-TMP-81 3
1:15 5pm Unit Visits: Lunder 2 OR & Lunder 2 PACU Lunder 3 OR & Lunder PACU Lunder 4 OR & Lunder 4 PACU Gray 3 (Legacy) OR Ellison 3 PACU, 3:45 5pm Bulfinch 222 Human Resources: Recruitment and Retention, Employee Rights, Nurse Workers Comp, Employee Confidentiality, Harassment Policy, Code of Conduct and staff ability to make concerns known confidentially, Workforce Diversity, Workplace Safety and Advocacy and the Grievance and Evaluation Process 5:15pm 5:45pm 6:00pm Challenges and strategy including but not limited to recruitment and retention, nurse engagement, nurse reward and recognition, performance evaluation, peer review, cultural diversity and grievance process with any unresolved issues. Debriefing with CNE, MPD and appraisers Depart for Hotel Day 2 Date: Tuesday November 7 Time Topic Session Leader Location & Attendees 6:50am Appraisers meet in Hotel Lobby-Travel to Medical Center 7:00-7:30am Appraisers with CNE and MPD Review of day and assessment of visit process 7:15-7:45am Blum Center WHT 1-110 Private Session with Appraisers (if anyone would like to meet confidentially with an appraiser MPM-TMP-81 4
7:30 8:30am North Garden Room WHT Basement 008 7:30 8:30am East Garden Dining Room WHT Basement 010 7:30 8:30am FND 311 7:45 8:45am Blum Center WHT 1-110 8:45 9:00am Travel 9:00 9:45am Lunder 234 9:00 9:45am Wilkins Conference Room, FND 136 9:00 9:45am Sweet Room, GRB 432 Breakfast with Night Clinical Nurses 15-Randomly Selected Breakfast with Night Clinical Nurses 15-Randomly Selected Breakfast with Night Clinical Nurses 15-Randomly Selected Breakfast with Physician Leadership Who to include: Medical staff leadership, physicians who can attest to interdisciplinary projects, collaboration, planning and collegiality. Intent to discuss commitment to Magnet designation, perception of nursing within the organizations, MD/RN relationships Cultural Competency and Diversity Who to include: Department/Staff involved Intent: How nurses use resources to meet the unique and individual needs of patients and families and workplace advocacy Nurse Education Who to include, member of education department, committee, councils and include members Intent to discuss the educational process, changes and challenges with education and education budget. Review of policies and procedures for tuition reimbursement and ability for staff to review continuing education credits/units. Ethics Committee (including staff nurses and other interdisciplinary members). MPM-TMP-81 5
9:00 9:45am Bulfinch 222 Who to include Representatives to the ethics committee, (include lay person, community membership and nursing stewards) Intent to discuss the committee s relationship with nursing, process for staff nurses to access the committee for assistance, and to discuss the nursing s role on the committee. Staffing and Scheduling Meeting (including staff nurses from various units) Who to include Representatives from nursing staffing office, resource pool and finance who prepare budget, staffing models and schedules Intent to discuss the how financial decisions for nurse staffing are determined including determination of skill mix, HPPD per unit and workload indicators by hospital. To discuss the use of ANA Principles for Staffing. Describe processes for reassignment, staffing variances and orientation implementation plan. 9:45 10:00am Travel Time 10:00 11:45am Document Review Human Resources Director to review process for reporting the investigation of nurses for incompetent or unethical behavior Human Resources Director to review process for addressing noncompliance with nursing regulations and/or the state Nurse Practice Act in the jurisdiction of the organization Unit Staffing Plans provide a selection of unit staffing plans / nurse to patient ratios / patient assignments RN Satisfaction Data for FY 16 (Overall review) HCAHPS Patient Satisfaction Data (Most Recent) NDNQI data (Nurse Sensitive Indicators) (Most Recent) Performance Evaluation Documentation Process and Peer Review Policy Minutes of Shared Governance Council Meetings past 12 months Appraisers Only MPM-TMP-81 6
Review of Complaint Files/Logs Director, Professional Staff Services to provide a review of AP s Credential Files (2 hired in past 6 months, 1 NP from at least 5 different clinical areas/service lines/departments Performance Evaluation (Director with > 5 years of service and one Director with < 5 years, One NM manager recently hired into role < 1 year, One NM in role >5 years & 6 clinical nurses from OB, MS, CC, Ambulatory, OR and Oncology (3 new hires in last year and 3 > 5 years) IRB Minutes-two years with attendance and nurse voting evidence Travel Time 11:45am 12:00 1:00pm Lunch with Clinical Nurses Sweet Room, 15 Randomly Selected GRB 432 12:00 1:00pm Lunch with Clinical Nurses Lunder 234 15 Randomly Selected 12:00 1:00pm Lunch with Clinical Nurses Blum Center, 15 Randomly Selected White 1-110 12:00 1:00pm Lunch with Clinical Nurses Trustees Room, 15 Randomly Selected Bulfinch 225 1:00 1:15pm Travel Time 1:15 2:15pm Trustees Room, Bulfinch 225 1:15 2:15pm FND 244B Robbins Electronic Medical Record Committee and Nursing Informatics Who to include include information systems leadership, nursing informatics staff and the team that focuses on electronic medical record, include staff nurses. Intent - to discuss nursing involvement with information systems and new technology implemented within the last two years. Support Departments Who to include-departments that support nursing and clinical care MPM-TMP-81 7
1:15 2:15pm FND 311 1:15 2:15pm Sweet Room, GRB 432 Intent- to discuss teamwork and the interdisciplinary care coordination between nursing and support departments. Advanced Practice Nurses Who to include- Advanced Practice Committee Intent- To discuss role of Advance Practice Nurses and goals of APN leadership committee and examples of improvements made in the practice setting. Interdisciplinary Care Teams/Projects Who to include Teams that have been involved in interdisciplinary care across multiple settings to ensure the improvement in care delivery Intent to discuss collaboration with nursing on clinical projects and or ongoing change processes related to patient care delivery, discuss interdisciplinary performance improvement examples including those listed in document. 2:15 2:30pm Travel Time 2:30 3:30pm Nursing Research and Evidenced-Based Practice Blum Center, White 1-110 2:30 3:30pm FND 311 Who to include: Chair of Research Committee, Nursing Research Council, clinical nurses involved in research, Librarian, Staff Nurses with completed research, Directors, Nurse Managers, and Advanced Practice Nurses. Intent: to assess how nursing research is supported within the organization including review of research budget research educational opportunities for staff nurses, enculturation and dissemination of Evidenced Based Practice. Nursing Quality and Nursing Performance and Efficiency Sub-Committee Interdisciplinary Who to include- Committee members and staff nurses involved in patient safety initiatives. Intent- Discuss staff nurse involvement in patient safety initiatives and the annual report for Quality. Role of nursing in implementing an evaluation safety programs. Data reported to nursing and report mechanisms include examples of improvement. MPM-TMP-81 8
Review of falls from past 12 months for all hospitals using a national benchmark. 2:30 3:30pm Unit Visits: White 6 Orthopedics Ellison 6 Orthopedics White 8 Medicine 2:30 3:30pm Unit Visits: Chelsea Health Care 3:30 3:45pm Travel and Break Time 3:45 4:45 pm Social Work Conference Room, Enter ACC Lobby 023 to get to 037J Conference Room Nursing Clinical Recognition Steering and Review Committees Who to include: members of the clinical ladder committee Intent: To verify the committee responsibilities for: Clinical Excellence in clinical practice Promotion of a professional practice environment 3:45 4:45 pm FND 311 Risk Management and Patient Experience Department Who to include Staff directly involved in risk management and patient experience and invited staff nurses Intent - to review data for Patient and Staff Complaints, Incident Reporting and Patient Satisfaction. MPM-TMP-81 9
3:45 4:45 pm Blum Center, White 1-110 Public Open Session & Community Partners - Joint Session Who to include invitation for hospital employees/family members to talk to appraisers Intent Organizational support for Magnet Designation Community Partners Who to include: Community Stakeholders Intent: Assess the organization s partnerships and integration in the community. Discuss how the organization addresses the healthcare needs of the community and how the community recognizes the value of nursing to the community. Ann Mohan 4:45 5:45 pm Debriefing with CNO, MPD 5:45-6 pm Appraisers to Hotel Day 3 Date: Wednesday November 8 Time Topic Session Leader Location & Attendees 6:50 am Appraisers meet in hotel lobby-travel to medical center 7:00 7:30am Appraiser meeting with CNE and MPD 7:30 8:30am Breakfast with Night Clinical Nurses Blum Center, 15 Randomly Selected White 1-110 7:30 8:30am Breakfast with Night Clinical Nurses Lunder 234 15 Randomly Selected 7:30 8:30am Breakfast with Night Clinical Nurses North Garden 15 Randomly Selected Dining Room WHT Basement 008 7:30 8:30am Breakfast Review of Nursing Peer Review Process East Garden Dining Room MPM-TMP-81 10
WHT Basement 010 8:30 8:45am Travel time 8:45am 8:45am 8:45am 8:45am 12:00 12:15pm Travel Time 12:15 1:15pm Trustees Room, Bulfinch 225 Who to include: Those involved in this process plus one nurse from all levels in the organizations that can speak to the process and provide examples Intent: To discuss MGH use of the nursing peer review process for review of nursing practice and subsequent education about nursing clinical practice. Unit Visits: Everett Health Center Blake 6 Transplant Ellison 4 SICU Blake 7 Medical ICU Unit Visits: Revere Health Center Charlestown Health Center Unit Visits: MGH North Shore: Surgery and Oncology Phillips House 21 Gyne/Oncology Phillips House 22 Surgery Unit Visits: Lunder 10 Hem/Onc/BMT Lunder 9 Hem/Onc White 7 Surgery Ellison 7 Surgery Ellison 2 Radiology, 2-210 Bigelow 9 Medicine/Bigelow13 Respiratory Acute Care Lunch with Clinical Nurses (20 randomly selected by appraisers) 12:15 1:15pm Lunch with Clinical Nurses (20 randomly selected by Lunder 234 appraisers) 1:15 1:30pm Travel Time 1:15 3:30pm Unit Visits: Emergency Department Lunder 1 MPM-TMP-81 11
Bigelow 7 short stay (same staff as Bigelow 12 ED Observation which is being moved) Blake 10 Neonatal ICU White 12 Research Unit 1:30 3:30pm Unit Visits: Lunder 2 &3 Radiation Oncology Yawkey Proton Beam Anticoagulation Management Unit CRP Endoscopy 1:30 3:30pm Unit Visits: Wang 3 Center for Perioperative Care (CPC) Ellison 8 Cardiac Surgery Ellison 9 Cardiac ICU Phillips House 20 Medicine 1:30 3:30pm Unit Visits: White 9 Medicine Blake 9 Cardiac Catheterization Unit Blake 4 Endoscopy Ellison 10 Cardiac Telemetry Ellison 11 Cardiac Intervention 3:45 5:00pm O Keeffe Auditorium 5:15 5:45pm 6:00pm Magnet Champions Who to include- All members and leadership who participate in the Magnet document development and Magnet Champions Intent Discuss the role of the individuals and groups in professional development and preparation of the Magnet application. Discuss how members are selected. Resources allocated to the committee work Review committee responsibilities: Support of the Magnet Champions Disseminating Magnet Goals and initiatives Promotion of professional development and certification. Debrief with CNE and MPD Appraisers to Hotel MPM-TMP-81 12
Day 4 Date: Thursday 9 th Time Topic Session Leader Location & Attendees 6:45am Appraisers travel to Medical Center 7:00 7:30am Appraisers with CNE and MPD 7:30 8:30am North Garden Dining Room WHT Basement 008 7:30 8:30am East Garden Dining Room WHT Basement 010 8:45 9:00am Travel Time Breakfast with Night Clinical Nurses ~ 20 Randomly Selected Breakfast with Night Clinical Nurses ~ 20 Randomly Selected 9:00 10:00am Unit Visits: Bigelow 10 Dialysis White 10 Medicine Yawkey 4F OB Clinic Yawkey 4E Gyne Clinic Ellison 16 Medicine Yawkey 6D Pediatric Clinic Ellison 12 Medicine Bigelow 6 Pediatric ICU 10:15am Blum Center, White 1-110 Meeting with Colleges of Nursing Who to include: Deans and Professors from affiliations Intent: To discuss partnerships/relationships and identify how resources are allocated to support education of students. MPM-TMP-81 13
10:15am FND 240 Thrall Conference Rm 10:15am ED Classroom, FND 130 10:15am 12:15 1:15pm Sweet Room, GRB 432 12:15 1:15pm FND 244B 12:15 1:15pm Blum Center, White 1-110 12:15 1:15pm Meeting with Shared Governance Councils Who to include: Leaders of all councils Intent: To discuss how the councils work to support nursing practice and how councils support nurses at all levels and all settings to actively participate in organizational decision making groups. Nurses in Specialty Roles/Internal Consultants/Experts Who to include: Nurses in roles such as WOCN, Diabetes, IV/PIC, Lactation Consultant, Infection Control, etc. Intent: How nurses in specialty roles work with clinical nurses to support and improve practice with examples of improvements in the practice setting. Unit Visits: Blake 12 ICU Ellison 14 Burn and Plastics Bigelow 14 Vascular Surgery Lunch with Clinical Nurses (15 randomly selected by appraisers) Lunch with Clinical Nurses (15 randomly selected by appraisers) Lunch with Clinical Nurses (15 randomly selected by appraisers) Lunch with Clinical Nurses (15 randomly selected by appraisers) Bulfinch 380D 1:15 1:45pm Unit Visits: Ellison 17 Pediatrics Ellison 18 Pediatrics 1:15 1:45pm Unit Visits: Ellison 19 Thoracic Surgery Neuro Clinic Wang 8-835 1:15 1:45pm Unit Visit Wang 5 Bulfinch Medical Group Wang 6 Internal Medical Associates MPM-TMP-81 14
1:15 1:45pm Unit Visit: Blake 8 Cardiac Surgical ICU EP Lab Gray 2:00-2:30 Appraiser Only Meeting All Appraisers 2:30 3:00pm Debrief with CNE and MPD and others selected by CNE All Appraisers Trustees Room 3:00pm Appraisers to Airport All Appraisers MPM-TMP-81 15