Reading Hospital Nursing Shared Governance Structure and Bylaws Article 1. Preamble Section 1: Definition These bylaws describe the governance structure and provide a framework for decisionmaking related to Nursing Practice. They describe the organization and the accountability of nursing staff within a shared governance model. Section 2: Purpose Shared Governance is based on the belief that healthcare professionals working closely with patients are in the best position to make decisions related to clinical practice. It supports a framework where staff and managers work collaboratively to deliver multidimensional care. Within this framework, professional staff lead decision-making and all clinical staff are empowered to participate. Section 3: Vision Statement Quality of Care and Administrative Practice: Best practice drives patient care. As advocates, we exceed patient and family expectations by living our core values. We are role models for our profession. All nursing staff is responsible and engaged in safety. Staff is empowered and shares in governance relative to practice and peers. Our vacancy and turnover rates are consistently below the national standards. Patient and employee satisfaction scores are consistently above the 98 th percentiles. Education: Advancing education promotes the value of nursing to the individual, the patient, the organization, and the community. Career advancement is supported and encouraged through individualized discussion, reimbursement assistance, and flexible scheduling. Increased knowledge improves critical thinking, collaboration, and influences outcomes. Collaboration: We come together as a healthcare team to collaborate and mutually support each member s contribution toward positive patient outcomes. Ethics: We support the Hospital s Code of Ethical Behavior. We value the importance of open and honest communication. We understand the various cultural diversities of our community and will not let our personal feelings, beliefs and values compromise our commitment to provide quality, compassionate and comprehensive care. Collegiality Each individual is a respected member of the healthcare team with a unique combination of talents, assets, and ideas. Together, we create a well-rounded environment in which to work and provide optimal patient care. 1
Resource Utilization Nursing effectively utilizes and distributes resources to provide optimal patient care integral to hospital operations. Research Knowledge is power and helps us develop confidence in our performance and competence in our profession. New knowledge, based on evidence, supports us in becoming experts in our field. Performance Appraisal The performance appraisal system validates behavior, knowledge, and clinical skills. Management and peer feedback are acknowledged as an opportunity for recognition and growth. Our performance is goal-driven enabling us to create action plans that achieve accountability and results. Section 4: Structure (Diagram) Article II. A. Executive Council Section 1: Mission Statement The Mission of the Executive Council is to coordinate the activities and functions of all nursing Councils; supporting professional practice through encouraging continuing education, continuous quality improvement, clinical decision making at the bedside, 2
leadership development, and effective management of resources in an environment of creativity, collaboration, accountability and excellence. Section 2: Activities Reviews and prioritizes issues presented and refers to the appropriate Council Reviews and revises Bylaws Provides guidance and support to the Chairs and Co-chairs of all the Councils Assists Councils in the resolution of issues that overlap two or more Councils Facilitates selection of nurses to multidisciplinary committees in the Medical Center Facilitates the annual goal setting process for the Department of Nursing, aligned with the Hospital s Strategic Plan Advises other departments regarding Nursing issues Reviews annually an Operational Calendar for the purpose of planning Council activities throughout the year Reviews and revises as needed the vision for Nursing Reviews, records and archives Council activities Communicates effectively with the nursing community Evaluates effectiveness of Shared Governance Section 3: Membership A. Executive Council Members Council Chairs from Quality, Practice, Education, Operations, and Leadership, VP Nursing; Director of Clinical Operations; Director of Clinical Practice; Division Department Head from Critical Care/ED/CVL, Maternal Child/OPS, MedSurg/Tele/Psych, PAC; Staff RN s (3). (Eligible staff RN s will have achieved CAP level three or higher. Self, peer, or supervisory personnel can nominate candidates who are willing to serve. Candidates will be selected through an election process). B. Terms of Office Each member will sit on the Council for a period of 2 fiscal years. Terms will be staggered to ensure the Council always has experienced representation. Members may stay on the Council longer provided it does not prevent new staff from assuming a place if they wish. C. Meetings Meetings will take place every month Quality Second Thursday of the month Practice Second Monday of the month Leadership Fourth Wednesday of the month Education Second Monday of the month Operations Second Monday of the month Executive Second Monday of the month D. Quorum Two thirds of the need to be present to make decisions. E. Decision-Making All decisions will be made by consensus. Consensus is a cooperative decision making process that requires the group to come to a jointly agreed upon/supported 3
decision. Although may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus a vote will be cast. All will vote except the VP of Nursing. F. Attendance Attendance will be considered a commitment and time will be given. It is expected that representatives miss no more than three meetings in a 12 month period. Failure to attend may result in loss of a seat on a Council. G. Apologies for absence All apologies for absence must be submitted to the Chair or Co-chair in the absence of the Chair. If unable to attend a meeting, you may send a representative, preferably the Co-chair. H. Resignation Resignation from the Council should be in writing to the Chair. I. Progression The Chair of the organizational Council will be a member of the Executive Council. Section 4: Chair A. Chair Selection The Chair will be elected from within the hip of the Council The Chair serves a term of 2 fiscal years If both the Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Chair Empowered to make decisions on behalf of the Council in the event the Council cannot meet, for decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting. Establish agenda according to priority Facilitate decision-making and consensus Coordinate provision of written reports Appoint project coordinators Assure mentoring activity for professional growth and development of Advise, guide, and mentor Co-chair in planning and conducting meetings Section 5: Co-chair A. Co-Chair selection Co-chair will be elected from within the hip of the Council Co-chair serves a term of up to 2 fiscal years If both Chair and Co-chair resign, the will decide on a replacement. 4
B. Responsibilities of Co-Chair Assists Chair: With the establishment of agenda according to priority To facilitate decision-making and consensus With communication of activities of other Councils To coordinate provision of written reports With appointment of project coordinators With mentoring activities for professional growth and development of By assuming responsibilities of the Chair in his/her absence Section 6: Reporting Minutes will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed and distributed within two weeks of the meeting. Executive Council minutes will be sent to team. Council Chairs will share with their associated Council. The Council Chair will maintain a hard copy for 5 years. B. Quality Council Section 1: Mission Statement The mission of the Quality Council is to promote and ensure consistent quality care. Utilizing evidence-based practice as the foundation for decisions, the Quality Council will prioritize and support projects as defined by identified quality indicators and collaborate with other disciplines as necessary to improve outcomes. Success will be measured by evaluating quality outcomes and their impact with respect to internal and external customers. Section 2: Activities Develops, revises and approves Nursing Quality Improvement Plan which supports the Hospital s Strategic Plan Establishes quality improvement priorities Monitors and ensures compliance with established state, federal and regulatory standards Monitors and ensures compliance with established standards of Practice, Education, Leadership, and Operations Councils Supports, endorses and monitors Unit Quality Improvement Nurses and unit based teams through Division Quality Councils Collaborates with other disciplines and makes recommendations for CQI in order to achieve quality outcomes Evaluates quality outcomes utilizing evidence-based practice Facilitates participation in the ANA Quality Indicator Program Section 3: Membership 5
A. Quality Council Members Divisional Team Leaders for Critical Care, Maternal Child, Med/Surg, Psych/Onc/Neuro-Gyn, Telemetry, CVL, OR, ED, PAC, OPS; School of Health Sciences Nursing Program; Staff Development; Div. Dir./Facilitator; Nurse Manager; and consultants as needed. B. Terms of Office Each member will sit on the Council for a period of 2 fiscal years. Terms will be staggered to ensure the Council always has experienced representation. Members may stay on the Council longer provided it does not prevent new staff from assuming a place if they wish. C. Meetings Quality Council meets every fourth Thursday of the month. D. Quorum Two thirds of the need to be present to make decisions. E. Decision-Making All decisions will be made by consensus. Consensus is a cooperative decision making process that requires the group to come to a jointly agreed upon/supported decision. Although may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Executive Council. F. Attendance Attendance will be considered a commitment and time will be given. Organizational Council Chairs will receive eight hours of council work time each month. Council meetings will occur on those days. In addition, Organizational Council will receive eight hours of council work time per quarter. That time will also be scheduled on Council meeting days. It is expected that representatives miss no more than three meetings in a 12-month period. Failure to attend Council meetings may result in loss of a seat on a Council. G. Apologies for absence All apologies for absence must be submitted to the Chair or Co-chair in the absence of the Chair. If unable to attend a meeting, you may send a representative, preferably the Divisional Co-Team Leader. H. Resignation Resignation from the Council should be in writing to the Chair. I. Progression The Divisional Team Leader will be a representative on the organizational Council. From the of the organizational Council, a Chair and Co-chair will be elected. Another member of the division will replace that Chair as Team Leader of the Divisional Council. 6
Section 4: Chair A. Chair Selection The Chair will be elected from within the hip of the Council The Chair serves a term of 2 fiscal years If both the Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Chair Empowered to make decisions on behalf of the Council in the event the Council cannot meet, for decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting Establish agenda according to priority Facilitate decision-making and consensus Communicate activities of other Councils Coordinate provision of written reports Appoint project coordinators Assure mentoring activity for professional growth and development of Advise, guide, and mentor Co-chair in planning and conducting meetings Section 5: Co-chair A. Co-chair selection Co-chair will be elected from within the hip of the Council Co-chair serves a term of up to 2 fiscal years If both Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Co-Chair Assists Chair: With the establishment of agenda according to priority To facilitate decision-making and consensus With communication of activities of other Councils To coordinate provision of written reports With appointment of project coordinators With mentoring activities for professional growth and development of By assuming responsibilities of the Chair in his/her absence Section 6: Reporting Minutes will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed and distributed within two weeks of the meeting. Quality Council minutes will be sent to Quality and Executive Council. Council Chairs will share with their associated Council. The Council Chair will maintain a hard copy for 5 years. 7
C. Practice Council Section 1: Mission Statement The mission of the Practice Council is to promote positive patient outcomes through care delivery that is based on professional standards and research, and by these practices, promote consistent nursing care throughout the institution. Section 2: Activities Acts as a final clearing house for approval of procedures related to practice and care issues Develops and reviews policies and procedures to ensure consistency across departments and best practice Develops, reviews, and revises nursing practice standards Establishes and ensures consistency of nursing roles and responsibilities Determines, reviews, and reaffirms patient care delivery system Collaborates with other disciplines on multidisciplinary issues that impact patient care Ensures nursing practice and care delivery is supported by evidence based research Section 3: Membership A. Practice Council Members: Divisional Team Leaders for Critical Care, Maternal Child, Med/Surg, Psych/Onc/Neuro-Gyn, Telemetry, CVL, OR, ED, PAC, OPS; School of Health Sciences Nursing Program; Staff Development(2); Div Dir/Facilitator; Nurse Manager; and consultants as needed. B. Terms of Office Each member will sit on the Council for a period of 2 fiscal years. This will be staggered to ensure the Council always has experienced representation. Members may stay on the Council longer provided it does not prevent new staff from assuming a place if they wish. C. Meetings Practice Council meets every fourth Monday of the month. D. Quorum Two thirds of the need to be present to make decisions. E. Decision-Making All decisions will be made by consensus. Consensus is a cooperative decision making process that requires the group to come to a jointly agreed upon/supported decision. Although may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council 8
is unable to reach consensus after concerted effort, the issue will be brought to the Executive Council. F. Attendance Attendance will be considered a commitment and time will be given. Organizational Council Chairs will receive eight hours of council work time each month. Council meetings will occur on those days. In addition, Organizational Council will receive eight hours of council work time per quarter. That time will also be scheduled on Council meeting days. It is expected that representatives miss no more than three meetings in a 12-month period. Failure to attend Council meetings may result in loss of a seat on a Council. G. Apologies for absence All apologies for absence must be submitted to the Chair or Co-chair in the absence of the Chair. If unable to attend a meeting, you may send a representative, preferably the Divisional Co-Team Leader. H. Resignation Resignation from the Council should be in writing to the Chair. I. Progression The Divisional Team Leader will be a representative on the organizational Council. From the of the organizational Council, a Chair and Co-chair will be elected. Another member of the division will replace that Chair as Team Leader of the Divisional Council. Section 4: Chair A. Chair Selection The Chair will be elected from within the hip of the Council The Chair serves a term of 2 fiscal years If both the Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Chair Empowered to make decisions on behalf of the Council in the event the Council cannot meet, for decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting Establish agenda according to priority Facilitate decision-making and consensus Communicate activities of other Councils Coordinate provision of written reports Appoint project coordinators Assure mentoring activity for professional growth and development of Advise, guide, and mentor Co-chair in planning and conducting meetings 9
Section 5: Co-chair A. Co-chair selection Co-chair will be elected from within the hip of the Council Co-chair serves a term of up to 2 fiscal years If both Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Co-Chair Assists Chair: With the establishment of agenda according to priority To facilitate decision-making and consensus With communication of activities of other Councils To coordinate provision of written reports With appointment of project coordinators With mentoring activities for professional growth and development of By assuming responsibilities of the Chair in his/her absence Section 6: Reporting Minutes will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed and distributed within two weeks of the meeting. Practice Council minutes will be sent to Practice and Executive Council. Council Chairs will share with their associated Council. The Council Chair will maintain a hard copy for 5 years. D. Education Council Section 1: Mission Statement The mission of the Education Council is to assess and coordinate the development of continuing education of staff and facilitate the education of patients. The Council assures the support to achieve these tasks, evaluate the processes, and measure outcomes. Section 2: Activities Coordinates Nursing Grand Rounds Supports SDD activities, including orientation, mandatory in-service, clinical/professional development and continuing education Reviews and recommends educational activities Coordinates, develops, and implements patient education strategies Section 3: Membership A. Education Council Members: Divisional Team Leaders for Critical Care, Maternal Child, Med/Surg, Psych/Onc/Neuro-Gyn, Telemetry, CVL, OR, ED, PAC, OPS; School of Health Sciences Nursing Program; Staff Development(3); Div. Dir./Facilitator; Nurse Manager; Patient Education Coordinator; and consultants as needed. 10
B. Terms of Office Each member will sit on the Council for a period of 2 fiscal years. This will be staggered to ensure the Council always has experienced representation. Members may stay on the Council longer provided it does not prevent new staff from assuming a place if they wish. C. Meetings Education Council meets every third Monday of the month. D. Quorum Two thirds of the need to be present to make decisions. E. Decision-Making All decisions will be made by consensus. Consensus is a cooperative decision making process that requires the group to come to a jointly agreed upon/supported decision. Although may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Executive Council. F. Attendance Attendance will be considered a commitment and time will be given. Organizational Council Chairs will receive eight hours of council work time each month. Council meetings will occur on those days. In addition, Organizational Council will receive eight hours of council work time per quarter. That time will also be scheduled on Council meeting days. It is expected that representatives miss no more than three meetings in a 12-month period. Failure to attend Council meetings may result in loss of a seat on a Council. G. Apologies for absence All apologies for absence must be submitted to the Chair or Co-chair in the absence of the Chair. If unable to attend a meeting, you may send a representative, preferably the Divisional Co-Team Leader. H. Resignation Resignation from the Council should be in writing to the Chair. I. Progression The Divisional Team Leader will be a representative on the organizational Council. From the of the organizational Council, a Chair and Co-chair will be elected. Another member of the division will replace that Chair as Team Leader of the Divisional Council. Section 4: Chair A. Chair Selection The Chair will be elected from within the hip of the Council 11
The Chair serves a term of 2 fiscal years If both the Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Chair Empowered to make decisions on behalf of the Council in the event the Council cannot meet, for decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting Establish agenda according to priority Facilitate decision-making and consensus Communicate activities of other Councils Coordinate provision of written reports Appoint project coordinators Assure mentoring activity for professional growth and development of Advise, guide, and mentor Co-chair in planning and conducting meetings Section 5: Co-chair A. Chair selection Co-chair will be elected from within the hip of the Council Co-chair serves a term of up to 2 fiscal years If both Chair and Co-chair resign, the will decide on a replacement. B. Responsibilities of Co-Chair Assists Chair: With the establishment of agenda according to priority To facilitate decision-making and consensus With communication of activities of other Councils To coordinate provision of written reports With appointment of project coordinators With mentoring activities for professional growth and development of By assuming responsibilities of the Chair in his/her absence Section 6: Reporting Minutes will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed and distributed within two weeks of the meeting. Education Council minutes will be sent to Education and Executive Council. Council Chairs will share with their associated council. The Council Chair will maintain a hard copy for 5 years. E. Operations Council Section 1: Mission Statement 12
The mission of the Operations Council is to provide direction to units to promote a positive, safe, and efficient environment to enhance patient outcomes and customer satisfaction. Section 2: Activities Oversees the evaluation process including peer review process Oversees staff scheduling and material resource utilization Monitors patient acuity system Manages the environment of care Coordinates development of a universal Code of Conduct Coordinates employee reward and recognition activities Participate in Recruitment and Retention programs in collaboration with Human Resources Section 3: Membership A. Operations Council Members: Divisional Team Leaders for Critical Care, Maternal Child, Med/Surg, Psych/Onc/Neuro-Gyn, Telemetry, CVL, OR, ED, PAC, OPS; School of Health Sciences Nursing Program; Div. Dir./Facilitator; Nurse Manager; and consultants as needed. B. Terms of Office Each member will sit on the Council for a period of 2 fiscal years. This will be staggered to ensure the Council always has experienced representation. Members may stay on the Council longer provided it does not prevent new staff from assuming a place if they wish. C. Meetings Operations Council meets every fourth Friday of the month. D. Quorum Two thirds of the need to be present to make decisions. E. Decision-Making All decisions will be made by consensus. Consensus is a cooperative decision making process that requires the group to come to a jointly agreed upon/supported decision. Although may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Executive Council. F. Attendance Attendance will be considered a commitment and time will be given. Organizational Council Chairs will receive eight hours of council work time each month. Council meetings will occur on those days. In addition, Organizational Council will receive eight hours of council work time per quarter. That time will also be scheduled on Council meeting days. It is expected that 13
representatives miss no more than three meetings in a 12-month period. Failure to attend Council meetings may result in loss of a seat on a Council. G. Apologies for absence All apologies for absence must be submitted in to the chair or Co-Chair in the absence of the Chair. If unable to attend a meeting, you may send a representative, preferably the Divisional Co-Team Leader. H. Resignation Resignation from the Council should be in writing to the Chair. I. Progression The Divisional Team Leader will be a representative on the organizational Council. From the of the organizational Council, a Chair and Co-chair will be elected. Another member of the division will replace that Chair as Team Leader of the Divisional Council. Section 4: Chair A. Chair Selection The Chair will be elected from within the hip of the Council The Chair serves a term of 2 fiscal years If both the Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Chair Empowered to make decisions on behalf of the Council in the event the Council cannot meet, for decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting Establish agenda according to priority Facilitate decision-making and consensus Communicate activities of other Councils Coordinate provision of written reports Appoint project coordinators Assure mentoring activity for professional growth and development of Advise, guide, and mentor Co-chair in planning and conducting meetings Section 5: Co-chair A. Co-Chair selection Co-chair will be elected from within the hip of the Council Co-chair serves a term of up to 2 fiscal years If both Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Co-Chair Assists Chair: With the establishment of agenda according to priority To facilitate decision-making and consensus 14
With communication of activities of other Councils To coordinate provision of written reports With appointment of project coordinators With mentoring activities for professional growth and development of By assuming responsibilities of the Chair in his/her absence Section 6: Reporting Minutes will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed and distributed within two weeks of the meeting. Operation Council minutes will be sent to Operation and Executive Council. Council Chairs will share with their associated Council. The Council Chair will maintain a hard copy for 5 years. F. Leadership Council Section 1: Mission Statement The Nursing Leadership Council is a team of professional, innovative leaders throughout TRHMC brought together to communicate, problem solve and support the professional development of the nursing staff in order to create valued partnerships between the nursing profession and our internal and external community. Section 2: Activities Make strategic recommendations to support the 5 pillars of excellence: people, growth, financial, safety/quality and service. Reviews and approves Nursing Administrative policies relating to resource and systems management. Collaborates across venues of care and with other disciplines to achieve optimal clinical and professional practice. Create a climate for effective communication to assure organizational activities are supported and action is taken at the unit level. Examines National initiatives and determines appropriate application and implementation in connection with the strategic plan of organization. Section 3: Membership A. Leadership Council Members: VP of Nursing, Directors of Nursing, Divisional Directors, Nursing Leaders from all areas in which Nursing is practiced. Representatives from: Staff Development, RN Staff, School of Health Sciences Nursing Program. B. Terms of Office Nurse Leaders will remain as for the tenure of their position. Other will sit on the Council for a period of 2 fiscal years. Members may stay on the Council longer provided it does not prevent new staff from assuming a place if they wish. 15
C. Meetings Meetings will take place every fourth week on Wednesdays from 1300-1500. D. Quorum Two thirds of the need to be present to make decisions. E. Decision-Making All decisions will be made by consensus. Consensus is a cooperative decision making process that requires the group to come to a jointly agreed upon/supported decision. Although may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the Executive Council. F. Apologies for Absences All apologies for absence must be submitted to the chair or Co-Chair in the absence of the Chair. If unable to attend a meeting, you may send another management representative. G. Resignation Nurse Leaders will remain as for the tenure of their position. Other resignation from the Council should be in writing to the Chair. Section 4: Chair A. Chair Selection The Chair will be elected from within the hip of the Council The Chair serves a term of 2 fiscal years If both the Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Chair Empowered to make decisions on behalf of the Council in the event the Council cannot meet, for decisions that are time sensitive. Critical decisions will then be reviewed at the next Council meeting Establish agenda according to priority Facilitate decision-making and consensus Communicate activities of other Councils Coordinate provision of written reports Appoint project coordinators Assure mentoring activity for professional growth and development of Advise, guide, and mentor Co-chair in planning and conducting meetings Section 5: Co-chair 16
A. Co-Chair selection Co-chair will be elected from within the hip of the Council Co-chair serves a term of up to 2 fiscal years If both Chair and Co-chair resign, the will decide on a replacement B. Responsibilities of Co-Chair Assists Chair: With the establishment of agenda according to priority To facilitate decision-making and consensus With communication of activities of other Councils To coordinate provision of written reports With appointment of project coordinators With mentoring activities for professional growth and development of By assuming responsibilities of the Chair in his/her absence Section 6: Reporting Minutes will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed and distributed within two weeks of the meeting. Leadership Council minutes will be sent to Leadership and Executive Council. Council Chairs will share with their associated Council. A hard copy will be kept on file in Nursing Administration for 5 years. Article III Divisional Level Section 1: Membership A. Qualifications: Council candidates need to demonstrate basic competency and hold a satisfactory evaluation. Council candidates must possess skills in facilitating communication and the ability to identify and represent unit/division concerns and opinions. Division and hospital wide Councils will be composed of professional staff. Each division will define their Divisional Council Membership. B. Selection Process: 1. Each unit will nominate a slate of candidates for the Divisional Councils. 2. Self, peer, or supervisory personnel can nominate eligible candidates who are willing to serve. 3. The staff of each unit will select their representative(s) from this slate. C. Terms of Office Each member will sit on the Council for a period of 2 fiscal years. This will be staggered to ensure the Council always has experienced representation. Members may stay on the Council longer provided it does not prevent new staff assuming a place if they wish. 17
D. Meetings Each Divisional Council will meet once each month. E. Quorum Two thirds of the need to be present to make decisions. F. Decision-Making All decisions will be made by consensus. Consensus is a cooperative decision making process that requires the group to come to a jointly agreed upon/supported decision. Although may not entirely agree with the decision, they must at least agree to support the decision. By supporting the decision, agree to do their best to ensure successful implementation. All opinions need to be voiced in person or by proxy before any decision can be reached. If the Council is unable to reach consensus after concerted effort, the issue will be brought to the organizational Council. G. Attendance Attendance will be considered a commitment and time will be given. It is expected that representatives attend at least one meeting per quarter. For those meetings that are not attended, documented contribution to the group will be given to the Team Leader prior to the missed meeting. Failure to attend or contribute may result in loss of a seat on a Council. H. Apologies for absence All apologies for absence must be submitted to the Team Leader or Co-Team Leader in the absence of the Team Leader. If unable to attend a meeting, you may send a representative. I. Resignation Resignation from the Council should be in writing to the Team Leader. J. Progression Up to three representatives from a unit will sit on a Division Council. From that group s hip, a Team Leader and Co-Team Leader will be elected. The Divisional Team Leader will be a representative on the organizational Council. Section 2: Team Leader A. Team Leader Selection The Team Leader will be elected from within the hip of the Council The Team Leader serves a term of 2 fiscal years If both the Team Leader and Co-Team Leader resign, the will decide on a replacement B. Responsibilities of Team Leader Establish agenda according to priority Facilitate decision-making and consensus Communicate activities of other Councils Coordinate provision of written reports 18
Appoint project coordinators Assure mentoring activity for professional growth and development of Advise, guide, and mentor Co-Team Leader in planning and conducting meetings Section 3: Co-Team Leader A. Co-Team Leader selection Co-Team Leader will be elected from within the hip of the Council Co-Team Leader serves a term of up to 2 fiscal years If both Team Leader and Co-Team Leader resign, the will decide on a replacement B. Responsibilities of Co-Team Leader Assists Team Leader: With the establishment of agenda according to priority To facilitate decision-making and consensus With communication of activities of other Councils To coordinate provision of written reports With appointment of project coordinators With mentoring activities for professional growth and development of By assuming responsibilities of the Team Leader in his/her absence Section 6: Reporting Minutes will track topic, discussion, decisions, accountability, and due date for outstanding items. They will be completed and distributed within two weeks of the meeting. Divisional Council minutes will be sent to Divisional Council, Divisional Nurse Managers, Divisional PCC, and organizational Council Chair. Divisional Council Team Leaders will share with their associated Council/Team. The Divisional Team Leader will maintain a hard copy for 5 years. 19
Nursing Council Structure Org Level Organizational Executive Council Organizational Councils Org. Level Quality Practice Education Operations Leadership Division Coord Council Div Level Division Quality Council Division Practice Council Division Operations Council Division Education Council Division Leadership Council Unit Level Units Units Units Units Units Written 12/13/04; Rev. 12-06 20