UPMC Passavant POLICY MANUAL SUBJECT: Organizational Plan, Patient Care Services POLICY: 200.142 DATE: November 2015 INDEX TITLE: Nursing MISSION: Patient Care Services at UPMC Passavant is integral to the overall organizational plan and supports its mission: To enhance the health of the communities we serve through clinical and service excellence. VISION: The vision for UPMC Passavant Nursing is: As nurses, we are leading the transformation of our nursing practice through evidence based practice, research and innovation, while fostering a healthy professional practice environment with our collaborative partners. We are dedicated to ensuring a compassionate patient and family centered experience, with a focus on safety and quality. PHILOSOPHY: Patient Care Services beliefs are based on those of the organization s Mission, Code of Conduct, Patient s Rights and Responsibilities, and the American Nurses Association, Pennsylvania Department of Health, and Joint Commission on Accreditation of Healthcare Organizations rules and regulations. Staff and leaders will live our mission, vision, and values with integrity everyday. Respectful communication will be the standard, with empathy and dignity, resulting in teamwork and collaborative practice, will be the standard. Leaders will be visible providing guidance, mentoring, and role modeling. Our shared leadership councils will drive and empower accountability and autonomy for all staff. Evidence-Based Practice (EBP) will be the foundation guiding our clinical practice to assure and support quality and safe patient outcomes. Our Professional Practice Model (PPM) will serve as the framework for our professional practice environment putting our patients and families at the center of everything we do. The Magnet program will be our structural framework to guide our strategic plan during our journey to Magnet. Patients, their families and our community are the primary focus of all Patient Care Service activities. All clinical, supportive, and leadership roles are positioned to support the provision of the highest quality care and service. We are committed to coordinating and delivering care that is supportive to or restorative of life and well-being.
TITLE: Organizational Plan, Patient Care Services Page 2 of 11 Our patients and families, as appropriate, have the right to be kept informed about all aspects of their health and to participate in the decisions that affect their care. Our patient/families right to privacy and confidentiality is respected and safeguarded at all times. The Caring Model (Watson, 1979) and The Patient and Family Centered Care Model provide a framework for which care is delivered. Nursing collaborates with all disciplines to provide holistic patient focused care, utilizing the nursing process. Our approach to care is one in which we meet or exceed the physical, mental, spiritual, and social needs of the patient/family and where individuality and cultural diversity are respected. Patient and family education is provided to begin the process of promoting self-care and independence and to assist with transitions to home. VALUES: COMMUNICATION: We communicate with dignity and respect in an open and honest manner through all interactions. ACCOUNTABILITY: We are accountable for our actions through personal integrity and responsibility to uphold our service excellence standards empowering our leaders through shared decision making, while adhering to the ANA Code of Ethics. RESPONSIBILITY & INTEGRITY: We perform our work with the highest levels of responsibility and integrity. EMPATHY: We listen to and care for our patients, their families, the community, and our fellow colleagues so we may provide the best patient experience and outcome. SAFETY AND QUALITY: Our nurses believe in providing safe, exceptional care and service excellence by demonstrating exemplary professional practice through nursing innovation. Our nurses grow professionally and advance the practice by utilizing evidence based practice and research to guide our work, professional affiliations and continuing education to guide our knowledge and activities that continually improve patient care outcomes. PURPOSE/OBJECTIVES: Outline the mission and philosophy of patient care services. Define the relationship of patient care services to other services and departments of the hospital both administrative and professional. Describe the inter-professional relationships within and between patient care services and other departments. Defines the role and responsibility of patient care services, education, and the schools of nursing for the education and training of nursing students. STANDARDS OF CARE: Assessment 1. Identifies assessment elements including nursing-sensitive indicators appropriate to a given patient population or organizational context. 2. Utilizes current research findings and current practice guidelines and standards to modify data collection elements.
TITLE: Organizational Plan, Patient Care Services Page 3 of 11 3. Identifies and documents the necessary resources to support data collection, and advocates for appropriate resources. 4. Analyzes the workflow related to effective and efficient processes in the target environment. 5. Develops, maintains, and evaluates systems for efficient data collection and reporting as part of the overall institutional data collection system. 6. Initiates processes to modify information systems as needed to meet changing data requirements and needs. 7. Works in conjunction with appropriate departments. Diagnosis 1. Promotes an organizational climate that supports validation of diagnoses. 2. Initiates collaborative forums which include staff and managers in problem identification and plan of correction. 3. Identifies and advocates for adequate resources for decision-making and analysis in conjunction with appropriate departments and leadership team. Identification of Outcomes 1. Participates in the design and development of interdisciplinary processes to establish and maintain standards consistent with the identified patient/ family-centered outcomes. 2. Facilitates nurse and other staff member participation in interdisciplinary identification of desired patient/family-centered outcomes. 3. Assists in identification, development, and utilization of databases that include nursing-sensitive indicators for quality and desired patient/family-centered outcomes. 4. Promotes the integration of clinical, human resource, and financial data to support decision making at all levels of nursing. Planning 1. Contributes to the development and continuous improvement of organizational systems that support patient/family centered care and produce optimal outcomes across the continuum of care. Advocates organizational processes that allow for creativity and innovation in the development of an evidence-based approach to care. Fosters and encourages interdisciplinary planning and collaboration that focuses on the individuals and populations served. 2. Promotes the integration of applicable contemporary management and organizational theories, nursing and related research findings, and practice standards and guidelines into the planning process. 3. Assists and supports staff in developing and maintaining competency in the planning and change process. 4. Advocates integration of policies into action plans for achieving desired client-centered outcomes. Implementation 1. Collaborates in the design and improvement of systems and the identification of resources that support interventions that are consistent with the established plans. 2. Collaborates in the design and improvement of systems and processes that assure interventions are implemented by the most appropriate personnel.
TITLE: Organizational Plan, Patient Care Services Page 4 of 11 3. Collaborates in the design and improvement of systems to assure appropriate and efficient documentation of interventions. 4. Facilitates staff participation in decision making regarding the development and implementation of organizational systems, and the specification of resources necessary for implementation of the plan. 5. Works collaboratively with appropriate departments to achieve desired outcomes. Evaluation 1. Promotes implementation of processes and resources that deliver data and information to empower staff to participate meaningfully in clinical decision making. 2. Utilizes appropriate research method and findings to improve care processes, structures, and measurement of client-centered outcomes. 3. Sets priorities for allocation of resources. 4. Advocates for and supports a process of shared governance that includes participation of nurses. 5. Participates in the peer review and privileging process for advanced practice nurses. 6. Promotes the development of policies, procedures, and guidelines based on research findings and institutional measurement of quality outcomes. 7. Utilizes data generated from outcome research to develop innovative changes in patient care delivery. STANDARDS OF PROFSSIONAL PERFORMANCE: Patient Care Services promotes professional performance by supporting the organization s code of conduct, cultural attributes, and upholding the performance expectations of those listed in job descriptions and performance evaluations. The organization supports the professional performance through the growth and development opportunities including formal education through tuition reimbursement, certification reimbursement, leadership development, and frequent continuing education. In addition, the standards of performance include: Scope of Nursing Practice Patient Care Management with Caring Interventions Professional Image and Conduct Communication Adherence to Hospital/ Department Policy PROFESSIONAL PRACTICE MODEL The Professional Practice Model (PPM) is built upon six key components: 1. Values for Patient Care 2. Patient and Family-Centered Care 3. Shared Leadership 4. Professional Partnerships 5. Relationship Based Care Delivery 6. Professional Growth and Development
TITLE: Organizational Plan, Patient Care Services Page 5 of 11 Our professional practice model is symbolized by a mosaic tree which represents the caring contributions and combined efforts of every staff member at UPMC Passavant. COLLABORATIVE RELATIONSHIPS AND LINES OF COMMUNICATION The Chief Nursing Officer (CNO)/Vice President (V.P.) of Patient Care Services, who reports directly to the President/Chief Executive Officer (CEO) of the hospital, actively participates in daily operations and strategic direction of the organization through a variety of mechanisms such as Executive Management Group, Medical Executive Committee, Board of Trustees, Physician Advisory Council, and Quality Patient Care Committee meetings. Therefore, the CNO/V.P. of Patient Care Services acts as a conduit of information to/from the senior leaders with members of Patient Care Services. To facilitate open lines of communication with nurses, the CNO/V.P. of Patient Care makes frequent rounds in the clinical areas, has quarterly chat sessions (open forum meetings), conducts change of shift staff meetings, maintains an open door policy, and publishes a weekly clinical update and a bi-monthly newsletter. Annually, a staff satisfaction survey is conducted, feedback shared and validated with staff and benchmarks with other organizations. Top priority items identified by the staff are incorporated into the agenda of the Professional Practice Council or Divisional Strategic Plan. During daily operations, Patient Care Services interacts with members of the healthcare team in order to provide quality care and meet the patient needs via documentation in the medical record and/or verbal communications. Following chain of command is the process for pulling the help chain and is encouraged by any employee within the organization. Human Resources and Risk Management is available for staff concerns as well.
TITLE: Organizational Plan, Patient Care Services Page 6 of 11 A decentralized model is utilized to provide decision-making, accountability, and authority for patient care at the staff level and unit level. A registered nurse will be responsible for planning and overseeing the care of each patient. Individualized plans of care will be developed and implemented for patients based on established stands of care promoting continuity and progression of patient care during hospitalization and through the discharge process. Patient Care Services members are represented on various interdisciplinary teams at various levels in the organization including Hospital committees, Medical Staff meetings, and Patient Care Service meetings based on individual areas of expertise and interest. The responsibility of the participant is to present identified problems or concerns, ideas, assisting with problem solving and implementation, and communication back the other members of the patient care service team. Interdisciplinary Committees which have Patient Care Services representation include but are not limited to: Department Management Meeting Quality Oversight Safety Committee Ethics Committee Utilization Management Emergency Department Patient Risk and Safety Policy and Procedure Committee Quality Patient Care Committee Pharmacy and Therapeutics Critical Care Committee Infection Control Operating Room Committee Medication Error Reporting Committee Patient/Family Education/Discharge Team OVERVIEW OF SHARED GOVERNANCE/ SHARED LEADERSHIP DECISION MAKING PHILOSOPHY The shared leadership philosophy is supportive of a participative management style which fosters autonomy and decision making at the point of care. We consider our professional staff nurses to be leaders. This structure supports interdisciplinary collaboration and effective communication to make safe, quality patient care decisions. Shared leadership empowers front line staff to engage in the decision making process regarding the organizational work within their department or service. The outcome of shared leadership is greater accountability for practice, greater nurse satisfaction, improved clinical outcomes and greater efficiency. Shared Leadership/Shared Decision-Making Structure: Nurse Executive Council Coordinates, integrates and facilitates activities and communication between councils in a decision making framework for the nursing division. Membership includes: Vice President, Patient Care Services/Chief Nursing Officer; Director of Nursing, Clinical Directors, Director of Clinical and Operational Informatics, Director of Care Management. Coordinating Council This council meets bi-monthly to provide over-site and coordination between and among the councils. Chaired by elected Nurse Leader Co-Chairs, the membership includes: all chairs and cochairs of the various councils, Nurse Executive Council, Clinician representative, and Regional Director for Quality, Risk, and Safety.
TITLE: Organizational Plan, Patient Care Services Page 7 of 11 Patient Care Leadership Council Assures implementation of the nursing practice, quality, and nursing standards and coordination with members of the health care team to effectively plan and coordinate patient care within UPMC Passavant. Membership includes: Members of Nurse Exec Council, Unit Directors, Senior Professional Staff Nurse, Clinician Representative, Vice President Operations, Ancillary Support Directors, Educator and Human Resource Representative. Professional Practice /Education and Professional Development Council A forum comprised of professional staff nurses to generate and discuss issues that impact not only the delivery of patient care, but also that affect the morale and work environment for the clinical staff. The Education & Professional Development Council will assist in the advancement of professional practice by providing direction for innovative educational programming and support structures to promote professional growth and development based on the needs of the nursing profession, our patients and the organization. Membership includes: staff nurses from all departments providing patient care, clinical education specialist and inter-professional ad hoc members. In support of the council, there are four mentor/advisors: Vice President, Patient Care Services/Chief Nursing Officer, Director of Nursing, Director for Education and Research, and an Education Specialist. The mission of the UPMC Passavant Professional Practice Council is to serve as the vehicle by which the voices of all professional nurses within UPMC Passavant act as a catalyst by bringing together knowledge, information, and problem-solving solutions to initiate change that promotes the best nursing practice for our patients. Interdisciplinary Informatics Council The group will strive to communicate understanding and application of informatics and emerging technologies to ensure that our interdisciplinary partners are able to provide healthcare that is safe and efficient while achieving optimal outcomes. Through collaboration and education, utilizing evidence based care and/or best practices; we will act as advocates to clarify informatics processes for staff. Membership includes staff representatives from all patient care areas, and members of the informatics department; chaired by the Director of Clinical and Operational Informatics. Evidence Based Quality Council The purpose of the Evidence Based Quality Council is to identify, review and analyze data used to measure and monitor nurse-sensitive patient outcomes, and recommend further action as a result of data analysis. This council coordinates and disseminates nursing quality information throughout the organization; promoting and supporting optimal patient outcomes and clinical expertise through identification and implementation of evidence-based practice. They work to establish evidence based policy and procedures, develop inquiry skills among our council members and staff at large to design an EBP project, and educate staff about EBC processes. Comprised of staff nurse representatives from each patient care areas, clinical education specialists, and the hospital librarian The council is chaired by a Clinical Education Specialist and a staff member, and facilitation is provided by the Director, Education and Research and a DNP Faculty Member and a PhD Faculty Member from affiliated schools of nursing in the area.
TITLE: Organizational Plan, Patient Care Services Page 8 of 11 Nursing Committee Structure Fall Prevention Team The Fall Prevention Team reviews patient falls and identifies trends that need to be addressed to prevent further falls. This team meets monthly and membership includes Risk and Safety, Nursing, Physical Therapy, Pharmacy, and others as needed such as Engineering and Maintenance. Skin Saver Team The purpose and scope of the Skin Savers is to provide a collaborative effort to promote skin health in the prevention of hospital acquired pressure ulcers through evidence based practice and to collect and provide monthly NDNQI pressure ulcer prevalence data. This committee identifies reviews and analyzes the NDNQI data to recommend further action. The Skin Savers coordinate and disseminate nursing information related to skin, wound and stoma, and continent care throughout the organization. Interdisciplinary Pain Team and PRN Pain Resource Nurse Team The charter defines the goal to improve patient satisfaction with management as evidenced by meeting or exceeding established HCAHPS targets. The objective is to have a collaborative, innovative approach to pain management with input from physicians, nurses, patients and administrator Diabetes Multidisciplinary Liaison Committee The mission of the Diabetes Multidisciplinary Task Force is to serve our community by providing outstanding patient/family diabetes care and to shape tomorrow s health system through clinical and technological innovation, research, and education. Our goal is to empower clinicians through shared decision making, provide education related to diabetes management, and serve as collaborators who act as catalysts to promote consistent change in current diabetes management focusing on quality & safety that support the vision & mission of UPMC Passavant. Pharmacy-Nursing Process Improvement Team Our Goals include analyzing key issues/problems that create barriers or negatively impact provision of pharmacy services to all patient care areas, address these issues/problems with solutions developed from a multidisciplinary team approach and to improve customer service and departmental collaboration. We focus on erecord implementations & issues, general operational opportunities for improvement between departments, and feedback & education related to Passavant and Health System Pharmacy & Therapeutics Committee decisions. Infection Control Liaison Committee The purpose of this interdisciplinary committee is to provide pertinent IC information to staff representatives, who then disseminate and share the information with floor personnel. Discussion includes, but is not limited to, monthly infection rates per nursing department and hospital wide, pertinent and current Infection Prevention and Control topics in the news, specific hospital IC issues, and any Infection Prevention & Control questions or concerns that are brought to the meeting from hospital staff. We have developed a questionnaire for potential candidates who would consider becoming a member of our committee, and I have copied it below for your use.
TITLE: Organizational Plan, Patient Care Services Page 9 of 11 Staff Safety Solutions This is a monthly multidisciplinary meeting of frontline staff who come together to discuss A Just Culture and apply the just culture algorithm to actual events that occur. Case studies are reviewed and feedback is solicited to identify system failures, improve processes and promote patient safety. Nursing Safety Committee This committee is comprised of clinical nurses, educators and nurse leaders to develop and implement structures and processes to enhance nurse safety to reduce the incidence of injury in nurses through assessment of barriers to safety, education and development of safety standards implementation resulting in a culture of safety. Magnet Steering Committee The purpose of the UPMC Passavant Magnet Steering Committee is to provide structure and guidance for the development and implementation of all initiatives that support the hospital s pursuit of ANCC Magnet Recognition. The Committee serves to link all organizations and committees within the hospital community in this pursuit. Magnet Champions Committee The Magnet Champions Committee is comprised of front-line employees from across the organization, including clinical, nursing and non-nursing support departments, who ensure that a culture of excellence is created in each department where staff is able to live/ speak to the Magnet Model and help to ensure a culture of excellence throughout the hospital.
TITLE: Organizational Plan, Patient Care Services Page 10 of 11 OPERATIONAL OVERSIGHT OF FUNCTIONS OF PATIENT CARE SERVICES: Patient Care Services is maintained under the direct leadership of the CNO/Vice President of Patient Care Services who is responsible to the Chief Executive Officer. With this organizational pattern, the functions of Patient Care Services are as follows: 1. To provide and implement a departmental plan of administrative authority which clearly delegates responsibilities and duties of each category of nursing personnel. 2. To estimate the requirements for the Department of Patient Care Service and to recommend and implement policies and procedures to maintain an adequate and competent nursing staff. 3. To employ those persons best fitted by knowledge, skill and experience to perform prescribed work. 4. To define and implement the philosophy, objectives and policies for nursing care of patients. 5. To maintain effective methods of regular communication between Nursing Administration and employees. 6. To participate in the formulation of personnel policies, to implement established policies and evaluate their effectiveness.
TITLE: Organizational Plan, Patient Care Services Page 11 of 11 7. To develop and maintain an effective system of clinical and administrative nursing records and reports. 8. To participate in and/or facilitate competency based orientation programs and educational programs that include student experience in the Department of Patient Care Services. 9. To participate in the design and implementation of interdisciplinary processes to establish and maintain standards consistent with identified patient centered outcomes. AFFILIATED SCHOOLS Following the organizational policy for affiliated schools, Patient Care Services encourages active involvement with nursing schools. Nursing schools are collaboratively matched with the most appropriate Patient Care area. Orientation is completed by the Education Department. Patient Care Services offers senior student rotations of preceptor-led experiences for undergraduates, preceptor experiences for masters programs. Faculty, students and preceptors participate in providing feedback to each other to continuously improve the experience. Current affiliation agreements are maintained with a variety of schools of nursing and allied health professions within the region. Affiliation agreements are located in the Nursing Education Office and coordinated and executed, on behalf of the hospital, at UPMC Legal Services. CROSS INDEX: Hospital Plan for the Provision of Patient Care, Administrative Manual Patient Rights and Responsibilities, Administrative Manual Code of Conduct, Administrative Manual Organization Chart, Nursing Policies EVIDENCE BASED REFERENCES The American Nurses Association, Nursing: Scope and Standards of Care, (2004), Silver Springs, MD, Nursingbooks.org Pennsylvania Department of Health, Section 109.11 http://www.pacode.com Joint Commission on Accreditation Healthcare Organizations, 2008 Signature: Susan E. Hoolahan, CNO/ VP Patient Care Services UPMC Passavant Steward: PH Orig: 6/79 Reviewed: 10/90, 10/94, 7/99, 5/00, 5/02, 7/05, 10/08 Revised: 11/91, 11/93, 5/95, 11/96, 6/97, 5/01, 5/03, 5/04, 6/04, 8/04, 6/06, 07/07, 9/09, 9/10,12/11, 4/13, 4/14, 11/15