January 1, 2012- June 30, 2012 SHARED GOVERNANCE CONSOLIDATED 6 MONTH UPDATE Clinical Practice Council Chair: Jackie Morgan Co-Chair: Kelsey Archibald January New Chairperson, Jackie Morgan, introduced. Condition S policy submitted to council for review by Bobbie Jo Skurko. Lippincott Online introduced to council. System wide launch on Lippincott Online expected early in the spring. Council reviewed discipline report from Human Resources from October through December 2011. Council found tardiness as a large violation. February Council investigating possible reasons for tardiness on the 3p- 11p shift for nursing staff. Parking issues suggested by members as a possible reason for tardiness. Jim Lowman and Frank Cambest invited for discussion on current procedure for parking staff working 3p-11p. Donations requested and collected for Take you child to Work day. Upcoming Lippincott launch discussed and preparations reviewed. Kim Klamut gave presentation on ULearn available for Lippincott Online. Informatics update given Nursing Education, Research & EBP Council Chair: Rita Cook Co-Chair: Ruth Harris January Council begins planning work on 2012 Annual Clinical Research Forum to be held on May 18, 2012. Generating New Knowledge and Innovation through Nurse Driven Research. Call for Abstracts, Save the Date, Submission form all go out to the System. February Updates from current Nursing Research Fellows as they progress to IRB submission. Met with ISD Representative to discuss Ring of Knowledge online conversion. Announced 2012 J. Patrick Barnes Research Grant Program for nurses interested in Research for patients with cancer and auto immune diseases. Lisa Lehman addresses council on the need for tracking tool to help maintain Research Projects in alignment with Magnet expectations. March Key Note Speaker for 2012 Clinical Research Forum: Dr. Kim Noble who will present: Sowing the Nursing Operations Council Chair: Tonya Alcorn Co-Chair: Mary Jo Klebine Researched data on the importance of setting daily goals on hospitalized patients. Started with the development of Daily Goals to be completed by our inpatient. Discussed the appropriate place for documentation. Proposed three trials that were conducted on 5A, 5B, and 4B with different methods of communication and way to gather data. Two staff members from each unit participated. Developed a screen save that went to all desktops introducing daily goals. Developed education that went out to the Nurses regarding daily goals. Held a Patient Goal setting activity day in the Café with Hockey as a theme, gained permission from Nursing Administration allowing all staff to wear Hockey Jerseys in support of the day. Educated all staff as they came to participate. Each staff member was given the opportunity to shoot a goal after identifying an appropriate goal and outcome. Provided education to staff. Had door prizes and Nursing Quality Council Chair: Judy Tinelli Co-Chair: Gina Koch January Meeting canceled due to Department of Health inspection. Safe Patient Handling Grand Rounds was held, Safe Patient Handling Survey Monkey was sent to nursing staff. February Busy box construction and distribution by Kathy Fowler. Critical Positioning Team and ANA Safe Patient Handling task force initiated. Safety Rounds form created and given to Lisa Lehman for the Magnet Ambassadors to complete. Unit issues to be addressed by unit directors. Trending issues to be followed by the Nursing Quality Council. Safe Patient Handling Task Force: look at staff injuries and equipment. Condition M questionnaire devised by the council to be used for trending. Questionnaire now with Jay Wright/Kim Klamut. Safe Patient Handling Survey Results: 314 responses. Sent out survey monkey to ancillary departments concerning prevention of falls. GOAL: to help increase Professional Development Council Chair: Aimee Wilson Co-Chair: Linda Zsolcsak January Defined New Hire target group to address Orientation survey issues. Update the PDC SharePoint site with ANA document devised by Anna Kalafut and one click easy access to the My Nursing Career Ladder process, added log for other councils/committees to list suggested topics for future Sr. Professional Contributions. Retention: Obtain Senior Nurse list, plan Spring Tea Notice sent to UDs to inform the PDC of any new degrees or certifications to enable a Congratulatory Email sent to the staff nurse. Congratulatory Emails will also be sent to Sr. Professional Staff Nurses after their contribution is approved. February Jay Wright Peer Review discussion and PDC expectations for education of peers on this process. Council Professional Practice Council Chair: Tina Mourra Co-Chair: Karen Soltez January Meeting canceled. Action plans being developed for hospital and unit results NDNQI Nurse Satisfaction Survey. February Action plan for NDNQI Nurse Satisfaction Survey: Unit level plans presented verbally and copy of action plans submitted to be added to SharePoint. 1A action plan deferred. Hospital level action plan initiated by council, focusing on job enjoyment and professional status of nursing. Tina Mourra and Karen Soltez will have a follow-up meeting with Mary Barkhymer and Lisa Lehman to assign responsibilities and discuss timeline of actions. Haitian Families First donation drive was a huge success. An itemized list was sent to Ryan Witt for records (many items of clothing, blankets, diapers, and
January 1, 2012- June 30, 2012 on search engine available to find policies. March Jim Lowman and Frank Cambest presented finding from a three day survey on parking for the oncoming 3pm shift. Decision made by Security and K7 to have an attendant visible to assist employees find a parking space in the park and lock section from 2:45p-3pm. Subcommittee formed to review results of the actions taken. Lippincott update given by Kim Klamut. Members stated not all desktops and clinical PCs in some areas, such as the OR. Link to connect the computer forwarded to all members. Members asked to check all computer on their units for connectivity. Applications for the Pittsburgh AANN Chapter handed out to members. April Human Resources disciplinary reports for January 2012 through March 2012 presented. Goals for upcoming six months discussed and formatted. Lippincott online links will begin to be added to nursing policies. Policies due for review in May will be the first to include the links. Lippincott books will remain on floors until all policies are updated with links. Seeds of Nursing s Future: Evidenced Based Practice and ASPAN Grassroots Research. Jessica Lindenberger, RN accepts the role of co-chair for the council. Council works on judging of Abstract Submissions for the CRF > Subgroup formed and leadership provided by Laura Kling, Ann Ciak, Colleen Sunday to help in abstract review process. April Council works on developing a Structure and Process pertaining to Abstracts/Research Projects/ Evidenced Based Projects. Featured article by Colleen Sunday in Channel E April edition explaining process of need to capture staff achievements, accomplishments, and accolades. Finalization of details for the Clinical Research Forum: Duty/Description List for council members. Council works on ideas for Poster Display for the upcoming SHOWCASE ST. MARGARET May 2012. May Clinical Research Forum help May 18, 2012. 80 attendees from all over the health system and evaluation had very favorable responses. You are all to be commended! Awesome Day! Thank you for the opportunity! drawing that included authentic Pittsburgh Penguin equipment. The mascot of the Penguins volunteered his time to celebrate with us at St. Margaret. The council provided examples of proper documentation. Education packets were developed and sent to all units including ancillary departments. Educated over 60 nurses and 100 non nursing staff. Developed new process for reporting med errors. Members were educated by Nursing Education member and members repeated education on each unit. Reviewed outcomes on patient goals determined the best practice here was the use of the white boards and documentation under IPOC in erecord. Report to unit directors for their support and follow through. NOP reviewed process based on best practice to deliver heat as ordered dry heat vs moist heat when ordered. Educational flyer developed and distributed to all staff. Pharmacy update. NOPC educated all staff that Zoyson will be administered over three hours based on best practice. Surveyed physicians to determine the main reasons for phone calls during office hours. It was brought to our attention that the nurses were making multiple surveillance for patients at risk for falls. Plan to develop interdisciplinary education concerning falls. Council to develop universal visual identification to alert all staff of patients at high risk for falls. Prevalence Thursday: Unit-based skin education being done. Nursing Education providing 1:1 education with nurses on skin, falls at bedside. March Kate Brownlee, UPMC Corporation Improvement Specialist presented Quality 101. Kathy Fowler noted that Central Supply has ordered more chair alarms. Fall Icons from the Interdisciplinary Falls Task Force have been approved by the council and will be shown at Nursing leadership for approval. PowerPoint for the interdisciplinary falls education is being assembled fall icons will be part of this education. Council goals for 2012 discussed patient satisfaction, falls, skin, and safe patient handling. Gait belts are part of EBP and noted in OSHA and ANA guidelines for safe patient handling. Gait belts were shown for show and tell from the Posey company. Looking at performing a trial on the units. Zuma is here on 6B. Multi-prong bed plugs not fitting correctly and affecting call chairs from the PDC and PPC developed four SMH specific Nurses Week Awards, criteria assisted the Hospital Week and Nurses Week Planning Committee during the planning stage. Assisted the take your Child to Work Committee during the planning stages and drive for art supplies. March Conducted Certification Day celebration, awards, distribution of information with the assistance of Magnet Director, Lisa Lehman, the Nursing Education Department, and CNO, Mary Barkhymer on March 19, 2012. Spring Tea was held March 16, 2012. 386 invited, 111 attended. Refreshments provided. Wonderful poster display from each unit highlighting their nurses with 10 years or more of service. Winners of raffle items published in Extra and Channel E. Further developed New Hire Focus Group criteria. April Conference Application Approval discuss with need to clarify process from formula). Take your child to work donation drive was also successful. Thank you for the art supplies. Continuing to volunteer at Shepherd Wellness Community on 4 th Friday all are welcome. March Lisa Lehman was voted in as advisor. Trading Spaces Nurses are taking turns shadowing each other in two hour increments. The time spent away from the unit is indirect time. They are going with a specific assignment, mainly focused on nurse-to-nurse communication, but are also going as secret shoppers to the units. Will hear a report at the next meeting. Hope to continue this project and extend it to interdisciplinary areas as well. The trades were based on the nurse s top two choices of where to go. If nurses did not request by the deadline, assignments were given. One of the big items for the NDNQI action plan. April Overview of expectations of council members was presented:
January 1, 2012- June 30, 2012 Council will present a Lippincott Online poster in the upcoming Showcase St. Margaret on May 8 th. Informatics reports EChannel will include the newest additions to Lippincott Online released by the system. May Council created goals for the next six months focusing on Lippincott Online completion and education to staff nurses on locating the link and searching for procedures. Council will also continue focus on evaluation and recommendation for performance improvement opportunities for nursing by reviewing disciplinary reports provided by human resources. Education reported Lippincott online does not distinguish who is permitted to perform procedures. Suggestions taken from council members on how to remedy the issue and educate nurses. erecord update given from informatics nurse regarding new restrain order set. Magnet website is being updated for Magnet Re-designation. June Presentation and approval of newly created policy, NP1401. Policy created for nurses to reference regarding which previously separate procedures Terri Calderone gave a brief overview of Nursing Central and Nurse Talk to council. Date for next year s Clinical Research Forum announced: May 24, 2013. Nursing Research Fellows presented in Magnet Illuminations. Four active research fellows and their work featured. Council begins work on introducing recruitment for Nursing Research Fellows 2013. June Submission of New Council Goals completed. Updates from System Review Committee (Jessica Lindenberger and Colleen Sunday). Current Research Fellows will have certain elements redirected since projects are in IRB process. Subgroup lead by Amy Haugh, Doris Cavlovich, Ann Ciak will work with fellows and mentors. 2013 Research Fellowship Recruitment Media Blitz. ASK-IT Initiative council begins work on reenergizing this initiative developed to stimulate ideas for improving EBP and Nursing Research possibilities. phone calls to them during the day. Visited and reworked the SBAR tool to be used by the bedside nurses on each unit. Education and forms were distributed to the clinicians. They educated staff on using forms when appropriate prior to calling MDs or leaving the work area while calls are pending so that the person covering them can answer questions appropriately. Developed a screen saver to suggest ASK another Nurse prior to calling the MD (collaboration). ADVICE: Ask another nurse, Don t panic, Investigate, Collaborate, Execute. Meet with CRNP to incorporate their knowledge and guidance as to advice prior to calling MD. Currently working on finding a solution to improving ambulation with our inpatients. light activation. Jim Harkins, engineering, is evaluating this with a correction action using a low profile pin. Nurses to make sure bed plugs have a proper connection. Judith Tinelli spoke with the therapy department regarding this. April Kate Brownlee, UPMC Corporation Improvement Specialist presented PDSA. New room arrangement on 5B: all furniture is moved to window side of bed, leaving clear pathway for patient to ambulate to bathroom and enables stretchers to be moved in and out without moving furniture. Falls reduced after this initiative. Housekeeping to rearrange all rooms to fit this pattern. Falls task force: Discussion about new falls sign to be placed in patient room and outside door as visual reminder to all staff that patient is fall risk. Skin bins with skin products initiated on nursing units. Safe patient handling: continuing with Zuma list trial on 6B and in ED. May Kate Brownlee, UPMC Corporation Improvement Specialist presented Quality Metrics. Reviewed definition of bathroom supervision. New NA/PCT documentation, HEN engagement. 4B developed a submission to approval from CNO. Suggested to become routine to prompt staff to update conference attendance through eprofile at the time of annual performance appraisal. New Hire Focus Group criteria, agenda for session, and questions for discussion developed. May Nurses Week/Hospital Week activities: Impatiens for Inpatients delivered by PDC members to all inpatients to kick off Hospital/Nurses Week activities. Donations will go to the St. Margaret Foundation professional Development Fund. First annual SMH specific Nurses Week and Hospital Week Awards. Participated in display during the Showcase SMH Event as a format for educating the nursing staff on the My Nursing Career and benefits of Certification within a specialty. Presentation by Colleen Sunday addressing the members individual perception and definition of personal professional development. New Hire Focus Group dates and attendees announced. Importance of attendance at meetings, including sending an alternate when unable to attend and notification of the council chair and/or scribe. Timely submission of monthly unit based reports. Timely response to email requests and deadlines Accountability for participation in and timely response to selection process for awards i.e. Cameos of Caring and DAISY; if unable to meet deadline, suggests delegating a peer. Accountability for participation in community initiatives. Reiterated professional responsibilities as related to membership on the council. Council members were asked to give serious though to their roles and time commitments required for membership to the council. Members should discuss concerns with Tina Mourra and/or their unit director. Recommendation made to develop a toolkit for new members to include information on the nursing shared governance structure, unit based councils, etc. and the possibility of developing a buddy system.
have been deleted because of Lippincott Online. Informatics gave presentation of the role of an informatics nurse and offered assistance to all staff with issues. Council reviewed and accepted revisions to policy review process, by adopting the current format used by the Hospital Policy and Procedure Committee to review hospital-wide policies. program to identify patient at risk for fall on discharge and is working with the interdisciplinary team to evaluation and communicate best practice. They initiated an orange form for interdisciplinary communication of fall risks into the car at discharge. June Just Culture vision reviewed at this meeting. A Falls Enhancement Program was developed by Nursing Education to be utilized by the nursing departments. Focus on Falls report tracks how many days since last fall on each unit monthly and is sent to the staff nurses. The Safe Patient Handling Team is working on a policy. Members visited UPMC Passavant to identify best practice. 5A will be trialing gait belts and the clinician and education will be organizing the pilot. Kathy Fowler met with CNO to discuss lost time/restricted days and annual cost of employee injuries. Veronica Findley reviewed the FY Highmark Quality Blue Final Scoring Estimate. The total P4P score for SMH was 102.5, the highest of the UPMC group. The council voted to have the Skin Team representative train annually with a 2 hour NDNQI module. 122 nurses attended the Nursing Grand Rounds on skin prevalence. Patient June Guest speaker Amy Haugh, SMH Librarian, provided an education session and addressed nurses barriers to literature searches, thereby offering multiple walk-in sessions monthly in the library to provide assistance with literature searched, APA format, completing contributions or research project literature references, as well and nurses continuing their education or ongoing professional development. Developing PDC goals for 2013 to address Career Opportunities, Retention, and Professional Development. T. Mourra shared poster abstract that was developed for submission to local and national conferences. Poster will be highlighted at Showcase St. Margaret during nurses/hospital week. T. Mourra distributed version of the behavioral standards for posting in departments. Members are required to participate in a minimum of two community projects per year. Reminder to submit information of volunteerism outside of the council to K. Soltez for tracking. Council goal is to complete 120 cumulative hours of community service in 2012. All agreed that Trading Spaces experience is very worthwhile. Creates opportunity to provide peer review feedback. Youthworks job shadowing hosted by PPC members. May Volunteers were asked to work on developing a toolkit for new members as discussed in April. Dress for Success Campaign was held during Nurses/Hospital week. Verbal updates of council reports were given. Many unit based councils are
Safety Fair November 1, 2012. NQC will have four tables: Falls, Skin, Patient ID, safe Patient Handling. Initial leads selected to head the tables. facing similar challenges with membership and staff engagement. Many ideas shared on ways to help engage staff. June Working with subgroup for developing a toolkit for new council members. Updates will be provided when available. Council members were welcomed to join the subgroup or send ideas to T. Mourra. Overview of the Gold Standards for Excellent Customer Service the 6B Gold Standards of Patient Care was presented. Council members were encouraged to submit their efforts for inclusion on the tracking mechanism for community projects. Council is on track with the goal set for this calendar year. Council members were thanked for their respective reports and reminder and encouraged to submit reports each month with the goal being that there is no department on the nothing to report list beginning in July. Terri Calderone provided a demo of the newly developed Nurse Talk and Nurse Central
SharePoint site. General discussion was held on the overall comfort level of nursing staff in accessing and navigating SharePoint. Council members were asked and agreed to lead a renaming contest for the site. The timeframe for the contest was Monday July 2- Friday July 20. Members agreed to promote the contest at a unit level. Results will be presented at July meeting.
June 30-December 31, 2012 Clinical Practice Council Chair: Jackie Morgan Co-Chair: Kelsey Archibald July Discussed new Lippincott Policy NP1401; all Lippincott policies need to list who is able to do the procedure (i.e. RN, LPN, NA, PCT). Cheryl Lenhart attended and discussed with the council the importance of having a tracking form for each policy that is reviewed, including unitbased policies. Reviewed how to access the Nursing Dashboard in erecord. Reviewed and approved policies for July and assigned policies for August. Council members are to begin creating a unit based interdisciplinary team to conduct unit-based policy review. Medical Librarian, Amy Haugh gave a presentation to help educate the council members on updating references. August Informatics nurses updated the council on missed medications on the missed med report and ordered labs that are canceled by SunQuest. Council discussed creating a SharePoint site for each unit to post their policies on. Chair, Jackie Morgan, presented a unit-based policy Nursing Education, Research & EBP Council Chair: Ruth Harris Co-Chair: Angie Durci July Four research fellows attended class. Afterward the IRB was called to discuss the studies and their status. A meeting was held with the mentors. No applications submitted for the next fellowship: recruitment underway. The original Ask It guidelines and the suggestions on reviving the initiative were discussed. First session of the new myresidency cohort occurred on 7/12/12 and was well attended, staff showed great interest. The session focused on team building exercises, My Nursing Career, delegation and time management, and introduction to EBP, a clinical focus on tubes/drains, and the Share Governance Councils were invited to speak. Homework was assigned for next session on storytelling each participant to present a nursing dilemma with a patient, family, co-worker, etc. and how the situation was dealt with. Session two of this cohort scheduled for 8/9/12. August UDs were emailed to encourage Nursing Operations Council Chair: Diana Fox Co-Chair: Christine Huey July Nurse Talk Demo- Terry Calderone. ADA Updates- Lisa Santimauro. What is available for us to use as a resource? New MD View- Ambulating Patients- 20 min/day is considered ambulating. What can be done to make sure this happens within the first 24 hours, how does 6A manage to fit in their day every day? It is RN s responsibility to ambulate, must be held accountable. Updates whiteboards to reflect ambulation. Pharmacy Updates- Do not use Biohazard bags to return meds to pharmacy. All bags envelopes must be labeled. Starting to use IV push for protonix, continuous drip would be mixed by pharmacy so RN s would not have to hang every 5 hours. August Volunteer Ambassador Ambulation Program would not work at SMH, too many barriers due to competencies and evaluations, and from a regulatory standpoint, too high risk. JC and Anticoagulation Documentation current period review has us at 50-60% Nursing Quality Council Chair: Megan Rupp Co-Chair: Shawna Breghentti July HAPU: Present on Admission documentation education: targeted interventions for the reduction of HAPU Heels. Falls: 18 in patient fails in June which is a downward trend. HEN (Hospital Engagement Network) project initiated and a Self-Assessment Tool was conducted to look for areas of concern. An action plan will be developed for areas needing improvement. Staff awarenessstaff will be updated weekly on how many falls for their units along with how many assisted falls and remedial education will take place on preventable falls. Patient Safety Fair November- 1 st - Pick a President Motto assignment for our four quality tables. (Falls/Skin/Patient Identification/Safe Patient Handling) two members assigned to organize each table. Transition of New Chair- Erica Greenwald and new Co-Chair- Megan Rupp will take place over the next two months. Professional Development Council Chair: Darcy Lutz Co-Chair: Jessica Wilson July Three approved projects for June: Julie Farren- Harmar OR- Preceptor Champion Ophthalmology Services; Chris Sulkowski- 6A- Increase Patient Satisfaction by the Implementation of a Discharge Follow Up Program; Darcy Green- ED Palliative Care rep in the ED. Reviewed Council bylaws, reviewed attendance rules. Advertised APA session held by Amy Haugh in the library to help nurses with professional writing. Subgroup discussion as follows: Group 1: Certification Encourage Certification. Group 2: New Hire Retention Preceptor/Nurse Goals look into more education with the green book or change the green book. Group 3: Nurse Retention Offsite criteria to be included in educational programs (traveling program). August Contributions: Virginia Wright Harmar OR Competency Coordinator, Kathy McKeag, Radiology Improving the Professional Practice Council Chair: Karen Soltez Co-Chair: Lisa Leonzio July Verbal reports were given by unit representatives on NDNQI nurse satisfaction action plans for their individual units. Members reminded to send written updated action plans that would be uploaded to SharePoint. Cardiology and radiology departments will be sharing council responsibilities to help cover the two departments. Voted on new names for Nurse Talk and Nursing Central. August Admission order process discussed with Tonya Alcorn (Operations Council). Some confusion about who to call, many nurses saying they are getting the run around. Discussions were help regarding the barriers. Tonya will take to next operations meeting for discussion. Jay Wright spoke to the council regarding peer review. Members gave feedback regarding peer review process and ideals discussed on how to formalize the process. Jessica Lindenberger spoke to the council regarding Research and
January 1, June 30-December 31, 2012 review PowerPoint. Council members are responsible for educating staff in their departments regarding the new Lippincott Policy NP1401. Policy Timeline was reviewed. August policies were reviewed and approved and September policies were assigned. September Informatics nurses reviewed barcode scanning with the council members and informed the members how to use the electronic Help Desk Self Service Ticketing system. HR disciplinary report for June 1- August 31, 2012 was distributed. Council suggested that all units do a double check for lab errors; Jackie Morgan will present this at Nursing Leadership. Members are to discuss the unit-based policy review process with their unit directors and begin creating a list of committee members. Brittany Shaw gave a brief demonstration of how to make changes to a policy without using track changes. September policies were reviewed and approved and October policies were assigned. October Blaine Lester explained the review process of the nurses to apply for the research fellowship; the email also noted that a project team is acceptable and encouraged. The council cochair to attend next PPC to promote fellowship program. The council reviewed a spreadsheet of 2011 s applicants; some of those applicants no longer working here or reduced their hours. Next research fellowship class scheduled for 8/21/12. The council is trying to revive the Ask it Initiative; it was discussed at the July meeting to stimulate ideas and spark interest thus, the Research in Action newsletter came to fruition. The council is working on a mechanism to track EBP projects. Fliers were distributed to council for 10/30/12 EBP workshop hosted by the UPMC Evidence Based nursing Council. Changes to the policy that reflect current review by the UPMC EBP committee before submission to the IRB was reviewed. For the 8/9/12 MyResidency class there was a panel consisting of one new nurse, an experienced nurse, a UD, a clinician, and educator, and a PCT. The goal of the panel was to discuss each person s role and how it contributes to patient care. The Residents were asked to prepare compliance over last two years; must get that score up higher. 3B piloting 1:1 education and saw compliance jump from 20-30% up to 80-90%. IV Infiltrates 165 documented infiltrate between Jan-June. More people are documenting in Risk Master. RNs are not documenting flushes. IV Team sent out a PowerPoint to the units. Should policy be changed to re-start every 4 days? Weights not being properly documented, mistakes from Lbs. to Kilos. Beds must be zeroed out each time, plus you must look at previous documented weights for comparison, to correct mistakes. Orders Example- PT PCA.2 changes to.1 by MD; Charge RN reviewed order by never made staff RN aware of change. Should charge RN be reviewing orders? Vote answer: NO. September Bylaws updated. Barrier to CT Ask your staff what they think the barriers are; do they call Radiology or go off the sheet that is faxed? Home Meds There is no current policy re: home meds. Best practice is to send home with family member upon Admission. If not an option, call pharmacy, they have special envelopes for home August Officers: Erica Greenwald and Megan Rupp were elected unanimously as chair and cochair respectively. Patient Safety Fair- November 1, 2012- Quality Council will have a falls table, a safe patient handling table, a patient identification table, and a pressure ulcers tables. Safe Patient Handling: Team is working on completion of the policy. Kathy Fowler described Safety Champions to the council. Each department should have at least one safety champion or at least two for the nursing units. Quality Updates: The action plan for the HEN falls pilot on 6B and 3B was submitted August 17, 2012. The Pressure Ulcer Debriefing Form Pilot began August 16, 2012. The form should be completed by the nurse who finds the pressure ulcer and forwarded to the unit director. Quality council members responsibility: educating staff about information from the quality council through bulletin boards, emails, staff meetings, and other methods preparing staff for Magnet visit. Number of most Commonly Reported Risk Master Incidences in SMH Radiology Dept., Susan Ober- Harmar OR Regulatory Champions. My Residency Update: Doris presented an agenda used for the MyResidency program. Doris shared some comments from the sessions and all were positive and scored the highest they could. The program has been very well received and nurses are engaged. Third session in September 6. Typically 12-14 participants, but can only send 2 per unit at a time. Due Sept 7 number of certified, working towards certification, eligible to be certified, BSNs, MSNs. Joyce will send out the bible sheet and questions to everyone. Survey Monkey to be created to ask questions about certification. Adele presented educational survey monkey results from 2011. Membership questionnaire was sent out. Linda will be stepping down as chair and Darcy Lutz will take the position. Linda reviewed the council bylaws. September Certification Congratulations: Linda Zsolcsak, Certified Bariatric Nurse Exam; Becky EBP, information was given on the 2012 Nurse Researcher Fellowship Program. Community Volunteer tracking exceeded our 2012 goal of 120 cumulative hours. Members are encouraged to continue with their volunteer work. September Reviewed the functions of the PPC with members, council members were asked to review the current by-laws, mission statement, goals/objectives, and membership responsibilities prior to the October meeting. Council members were also asked to reflect on what they would like to see our PPC accomplish as goals for the upcoming year. Members were asked to submit ideas for community initiatives that they would like to host and be involved in for the future. Discussion was held regarding the need and obligations of a co-chair, members were encouraged to apply for this position. At the request of Renee Carolan, discussion was held on feedback/observations from peers related to the negative perceptions of patients, visitors, staff, and physicians with the use of computers on wheels. A lengthy
Administrative Policy and Procedure committee. Mary Barkhymer attended to thank the council for their efforts in shared governance and to stress that the focus of the Clinical Practice Council is accountability. Cheryl Lenhart discussed the importance of policies and policy review with the council. When deciding who should review a policy, keep in mind, Who does the work? Ray Probst, Director of the Lab, attended to explain the verification process when collecting blood for a type and screen order. All council members are to report their number of unit based policies as well as a list of unit based council members who will review these policies. Reviewed and approved October policies and assigned November policies. November Council reviewed and approved mission, goals, and strategic plan and council by-laws for 2013. Informatics nurses gave demonstration of accessing patient education documents in erecord. Unit Directors and the Clinical practice Council both agreed that two signatures on lab reqs should be a tool that is utilized to help decrease lab errors; this is the best way to a few questions for the panel. This session was very well received. September Several nurses interested in applying for research fellowship; no applications officially been submitted. Current research fellow project update was provided to council. Current OSIRIS users (i.e. those who completed modules 1 and 2 at some time in the past) have one year to complete the new requirements by 3/31/13. After that date no individual can be listed on an IRB protocol or can obtain access to OSIRIS unless required CITI modules are completed. Doris Cavlovich disseminated the update to the SMH physicians and nurses. Megan Gold to be featured in the first Research in Action newsletter; will be sent to SMH Nurse in October. Council cochair attended the August PPC discussed research and EBP projects; she is currently devising tracking tool. Doris Cavlovich hosting Nursing Innovation Summit Fall 2012. Hot Topics in Nursing on 10/15/12- all council members were encouraged to attend. Colleen Sunday briefly reviewed the SMH Nursing Division meds. If needed, a pharmacist will come speak to the patient while he/she inventories the narcotics. There is a policy that allows MD to okay usage of home meds through an order. Once order is placed, a pharmacist comes to the floor to inventory; they must be stored in the med room. Non-Urgent Med Requests Proper way to contact pharmacy for nonurgent med request is to DIAL 4128 than hit option #1. If you have an urgent med request best practice is to contact your unit based pharmacist. Regulatory- Blaine Lester would like two members to attend the Medication error Report meeting and the medication Management meeting. October Approval of minutes. Approval of By-Laws. Anticoagulation Documentation- 79.5% compliant handed out stats by unit, to take back to unit. Barriers to CT- CT fax a schedule to units each morning instead of calling the floors. Staff Nurses expect a call and believe it is more appropriate since it is so hectic in the AM, will invite CT to next meeting. Committee Goals- initiatives will be generated at floor staff levels and brought to the councils. Each initiative will be reported back to September Education: Ronnie Findley presented What the Heck is HACs? This stressed the important of nursing documentation POA ulcers and devices. Reviewed the importance of identifying high risk fall patients with particular attention to oriented patients admitted with neurological deficits. There is an increased risk for injury d/t age, post-op status, and medications. Assignments for October: 1. Identify four unit specific quality issues 2. Identify unit bulletin board that can be dedicated to NQC for educational purposes. October Education: Brittany Shaw gave a PowerPoint presentation on navigating through the Outlook Calendar and the Nursing Quality SharePoint site. Reviewed email accounts and make-a-meeting. Lisa Nicholas showed the council how to update their eprofiles. Stressed the importance that all eprofiles must be updated for Magnet. By-Laws were reviewed, revised, and approved by council members. Mission and Vision: Marjorie Jahn, CMSRN; Michelle McClain, CMSRN; Megan Rupp, CMSRN Contribution Congratulations: Kimberly Yurchick, The ABCDE Bundle: A Delirium Management Tool; Donna Dzvonick, Patient Satisfaction Representative for 4B. Dress Code Discussion possible to roll out January 1, 2013. RN/LPN may wear ceil blue or white scrubs. Permitted to wear grey, white, or blue undershirts with appropriate undergarments. Permitted to wear printed scrub jackets overtop of solid colored scrubs (no hoodies or sweatshirts). Permitted to wear any official UPMC t-shirt rather than scrub top. Staff must be approved before they can pay for a conference, must also use UPMC travel. Just because someone applies, does not mean they are approved to go unit directors must consider FMLA, PTO, etc. before approving. Need to present to the medical staff why they should provide staff with more money for conferences. Approved PDC Mission Statement. Peer Review Discussion with Jay Wright. discussion included the following observations: Take the computer of wheels to the patient s bedside so that if the patient has questions, the nurse can refer to the electronic record for real time information. Talk to the patient while documenting in electronic record so they do not feel ignored; explain to the patient what you are doing (paper vs. computer); capturing information in real time. Talk to the patient about technology; that health information is in electronic record and may be viewed between disciplines and facilities for the most accurate, up-to-date information. Talk to family members; involve them so they feel like they are contributing; provides transparency of information between patient-family-nursephysician. When you see a peer yelling from the hall, address in real time
decrease lab errors without corrective action. Reminded members to report unit based policies. Reviewed and approved November policies and assigned December policies. December Nursing leadership determined that double signatures on lab reqs should be based on unit guidelines. Janine Sharer reviewed the miscellaneous note section in erecord. Kristen Schmidt distributed an Informatics Education Booklet to each unit and announced that Informatics will be forming a council. Jenny Bender, Infection Control, briefly discussed infection control issues. Jackie Drahos discussed signing off on medication and missed medications. Cheryl Lenhart explained and gave a demonstration of how to review a policy. Kim Klamut, nursing education, presented a PowerPoint on Improving Communication with Doctors. December policies were reviewed and approved and January policies were assigned. Strategic Planning from 9/14/12 nurse exec retreat. The changes made to our council mission statement were also reviewed. October Doris Cavlovich sent an email to the SMH physicians and nurses regarding the IRB module updates and the completion of them by 3/31/13. IRB module update was also presented at the Nurse Leadership meeting on 10/16/12. Lengthy discussion regarding nurses frustration with accessing Nurse Talk on the clinical desktops; Terri Calderone was brought in to help troubleshoot. Our council cochair presented Journal Club on 10/3/12 outlining the differences and similarities among QI, EBP, and research. As on 10/11/12 eight research fellowship applications were submitted. The original 9/30/12 submission deadline was extended to 10/15/12 and the council devised a selection committee. Current fellow was extended to 10/15/12 and the council devised a selection committee. Current fellow project updates were provided by Doris Cavlovich. Council reviewed new EBP reporting tool. Council members were asked to complete the form and return it the council every month until completed; provide a collaborative work atmosphere for all Nursing Professionals to actively participate on initiatives. NOC is here to facilitate on behalf of the bedside Nurse and staff. November Magnet Moment- Lisa Lehman spoke about the RN satisfaction scores from 2010/2011. Spoke about the importance of the upcoming NDNQI survey in April 2013. Also looking to improve BSN levels at least 8% this year we are currently at 34%. Barriers to CT Update CT is faxing all the units; RNS asked not to schedule in Patient CT between 7-8am due to shift changes and they agreed. Cytology Specimens Dr. Gup requested that we look into what that barriers are, some of which are orders being canceled and not re-ordered by MD. It was suggested that each time Cytology sees missing orders that a Risk Master is completed so it can be tracked. Blood Transfusion policy- Blood bank has no concerns without policy. Lippincott suggests anywhere between 3-15 min for plasma. Medications Jackie Drahos brought up the concern that meds are not being signed off when patients are transferred. Jacobs and Kathy Fowler discussed creating a mission and vision. Council members broke up into groups to brainstorm. Council members created a new mission and vision statement. Council member s assignments for November meeting: Bulletin board subcommittees are to work on forming a template for a Nursing Quality Bulletin Board for each unit. Recognition Plan: Pictures of the council members and the quality council will be taken and mounted near the Quality bulletin board to assist the staff in identifying their unit representative. November Education: Amy Haugh did a presentation on introduction to literature searching. Goal for the members: identify a problem on their unit and complete an improvement project. Council officer position vacant (co-chair) Megan Rupp has taken Chair position. Announcement: accepting nominations. Vote for co-chair will occur in December. Template for Quality Bulletin Boards distributed. October Contributions: Abena Baskin- OT Harmar The Journal Club: Where Membership Means Quality of Practice ; Rebecca Jahn- 5B Improving Communication between nursing and Ancillary Staff Check and Balance: When a certification or degree is obtained you should notify Human Resources so they can enter into Peoplesoft, in addition to that you must also enter it into eprofile. Lisa Lehman gave a presentation on demographics, conference central, and NDNQI. By 2020 the Institute of Medicine wasn t 80% of direct care nurses to have bachelor s degree currently at 47.6%. A new abbreviated form with a 5 point subscale will now be used for NDNQI survey. The survey is optional, however if your unit does not get more than 72% compliance you will not be nationally ranked which is why we strive for 100% participation. Karen Kasely survey monkey: reviewed open ended answers; most indicated that cost was a concern or they were not educated on UPMC reimbursement process. Emailed to approximately 600 nurses. 119 responded. Results peer review. Decision made to draft cards for Computer Etiquette that would be accessible on all computers on wheels. October Lisa Leonzio, RN, 5B Medical/Surgical was voted in as co-chair and will also represent St. Margaret at System PPC. Chair position will be assumed by Karen Soltez (current co-chair) in November, decision made that Tina Mourra will remain part of council as advisor/mentor. By-laws were reviewed and approved. Card content for Computer on Wheels (COW) was reviewed and final draft prepared. Drafted and approved Professional practice Council strategic Plan and Goals 2013. Distributed Member Toolkit available on SharePoint and hard copy given to each member. Encouraged to update regularly, augment to suite need of department PCP and pass on to the next nurse to take on PPC position. November Tina s last meeting as chairperson. Tina was thanked for her dedicated service to the PPC council for the past two
to council chair and co-chair one week prior to each monthly meeting. Council representatives were advised to go over the form with their UDs as one may be doing school projects or something the UDs know about that others are not aware of. Planning committee devised for 2013 Clinical Research Forum. The council reviewed the needs assessment survey that was last sent out in July 2011 and made revisions where necessary. November Terri Calderone attended meeting and listened to council s concerns regarding SharePoint and Nurse Talk. The Clinical research Forum planning committee had their first meeting on 11/6/12 and selected a program title Meeting the Challenge of Change: Empowering Nurses through Clinical Research and theme change. They would like to send out poster requests earlier this year to try and draw more than we had last year. The planning committee is still looking for a keynote. The current group of research fellows will be incorporated to present at the 2013 research forum. Updated was provided on current group of research Policy needs to be followed and RN who missed sign off should be held accountable. Pharmacy Updates Look for an email from Pharmacy about re-timing meds. Kim Klamut will re-educate NA/PCT on weighing patients and on Kilos. December Introduction of new co-chair Christine Huey. Verbal Order Presentation by Kim Klamut. ASK do not assume; apply SBAR when speaking with MDs. NEVER hold meds without an order, never take verbal orders on admission. Medication Event Committee Liz Forsberg discussed the importance of this committee. Asked for staff RN attendance. Specimen Update Dr. Gup and Walters state it is not a computer issue but a collection issue. Diana Fox surveyed her unit and found 6 patients that were to have specimens collected that did not happen for 48 hours. Utilize whiteboards for specimen collection; hold staff accountable. Weights Dr. Lagnese suggested we use whiteboards for patient weights so we can correct or visualize error faster. Peer evaluations a more effective way to be rolled out soon. RN to RN handoff- Diana Fox presented a PowerPoint on the pros. Pharmacy December Co-chair position: Shawna Breghenti accepted the co-chair position for the quality council. Safe Patient Handling: Currently recruiting safety coaches. This training will begin in January, Work Partners liaison (N. Batth) reviewed the Safety and Injury Prevention Summary Report for SMH. HAPU: Devices related to pressure ulcers identified as a current issue. Purple pads have replaced the quilted pads as of November 30, 2012. HEN-PU initiative being piloted on 6A and ICU. Focus is to reduce incidence of pressure ulcers by 20% in hospitalized patients by the end of 2013. Unit based quality projects: Each member described their progress thus far with the unit based projects. Education: Anna Kalafut reviewed a presentation on nasopharyngeal cultures for influenza. Nurses are now allowed to perform these cultures. Just culture: Kathy Fowler discussed the Just Culture team. This team will be part of the quality council. only show first 100 responses. November Projects: Leonard Slade- 3B understanding Cardiac Medication Safety and Administration to Reduce Medication Errors ; Michelle McClain-5B Use of Sound Masking to evaluate Patients perceptions of rest on 5B ; Vittoria Zenone- 3B Patient Hourly Rounding to Increase Patient Satisfaction and Decrease Patient Falls. Educational presentation from Emergency nurse Association Conference: Prolonged OT Syndrome presented by Jessica Lindenberger and Kaela Funtal. Conference Application process- Gina Koch, International Stroke Symposium. Application forwarded to Cheryl for manager s approval. Determine who notifies the applicant if they are approved and provide clear direction for the application process. Research if the conference budgets are public knowledge and if there is a set maximum limit approved per conference. Reviewed Goals and Action Plans. December Contributions: Kim Hitrik, 4A- years and presented her with a small token of appreciation. Lisa Leonzio was welcomed officially as the new co-chairperson. Final card content for Computer Etiquette was reviewed and approved by council. The Computer Etiquette final design was turned over to Renee Carolan for final draft and distribution. Subgroups were developed for each goal and lists were distributed via email to council members. Subgroups were asked to begin preparation for developing their action plans. Each subgroup was given the name of an internal consultant that they will be available to give the group direction and guidance as they develop their action plans. Each subgroup will present their action plan at the January meeting. After the January meeting, council will collaborate as a group to complete each action plan with the members of the subgroups taking the lead for their particular goals. Community Initiatives SMH Sharing the Warmth and Holiday Mail for Heroes. December A representative from each subgroup gave an update and brief description of the action plan