BYLAWS · by those who practice nursing, which are focused on nursing practice, quality, standards, and outcomes. 2. Chief Nursing Officer, Directors of Nursing, and Nurse Managers:

Shared Governance 2017 1

Nursing Shared Governance

BYLAWS

2017

Shared Governance 2017

2

TABLE OF CONTENTS

PREAMBLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ARTICLE I. Name of the Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ARTICLE II. Purpose of the Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ARTICLE III. Composition of Councils, Committees, Special Meetings, Task Forces . . . . . . . 3

ARTICLE IV. Hospital-Level Council Accountabilities and Membership . . . . . . . . . . . . . . . . . 5

ARTICLE V. Council Membership Selection Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ARTICLE VI. Accountabilities of Council Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ARTICLE VII. Process and Guidelines for Nursing Shared Governance Decision Making: Change

Requests and Proposals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ARTICLE VIII. Meeting Schedules and Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A. Iowa Model of Evidence-based Practice to Imporve Quality of Care 19

B. Table to Populate Hospital-Level Council Membership 20

C. Current Shared Governance Application & Definitions of Councils 21

D. Shared Governance Application Scoring Grid 24

E. Nursing Shared Governance Council Agenda Template 27

F. Nursing Shared Governance Project Charter 26

G. Nursing Shared Governance Council Minutes Template 30

H. Nursing Cross-Charging for Nursing Shared Governance Hours

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GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32


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PREAMBLE

YALE NEW HAVEN HEALTH SYSTEM

Mission:

Yale New Haven Health is committed to innovation and excellence in patient care, teaching,

research, and service to our communities.

Vision:

Yale New Haven Health enhances the lives of those we serve by providing access to integrated

high-value, patient-centered care in collaboration with others who share our values.

Values:

INTEGRITY Doing the right thing

PATIENT–CENTERED Putting patients and families first

RESPECT Valuing all people

ACCOUNTABILITY Being responsible and taking action

COMPASSION Being empathetic

GREENWICH HOSPITAL NURSING

Mission:

The Department of Nursing at Greenwich Hospital exists to provide safe,

comprehensive, quality patient and family-centered care. Greenwich Hospital nurses

are committed to being responsive to dynamic influences that affect the provision of

healthcare by developing services that are recognized for quality outcomes,

collaboration, competence, caring and cost effectiveness.

Vision:

To be recognized for our excellence in nursing practice for Greenwich Hospital and

throughout YNHHS.

Our Guiding Principles:

• Empowering the staff nurse to effect positive change

• Supporting a High Reliability Organization focusing on safety

• Promoting best patient outcomes through evidence-based practice

• Influencing policy through meaningful deliberation and shared decision

making

• Encouraging a high level of satisfaction within the nursing role through

a “Just Culture” model

• Creating a culture of nursing with a commitment to excellence

• Increasing staff nurse involvement in nursing practice

• Supporting an environment that fosters mutual respect among its

members and provides for continual staff development


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ARTICLE I

Name of this organization shall be “Nursing Shared Governance” of Greenwich Hospital.

ARTICLE II

PURPOSE OF THE ORGANIZATION

A. Purpose: To support the mission, vision, values, and strategic plan of our organization and

nursing by engaging and empowering all nurses who are committed to the provision of

clinical excellence every day for every patient and family. Nursing Shared Governance

provides the infrastructure and support necessary to place ownership and accountability

for practice and its outcomes at the level of the clinical nurse. Cornerstones of

professional practice ownership and accountability are practice, quality, competence and

knowledge management.

1. The foundational element for Nursing Shared Governance is based on

shared decision-making. The purpose of shared decision-making is to

achieve a collaborative and efficient practice environment for all

nurses, which ensures the delivery of the highest quality, evidence-

based care for all patients and families.

2. The Nursing Shared Governance infrastructure supports processes

that are fluid, flexible, and supportive of practice excellence at the

point of service (e.g. practice setting ) in which the clinical nurse is the

center of control, where all processes assure that nurses have

opportunities to provide input to any council, and every nurse is

accountable for following the standards of practice.

B. Scope of Decision-Making Authority

1. Registered Nurse: Service-related accountabilities belong to the

nursing profession. Decisions about these accountabilities are made

by those who practice nursing, which are focused on nursing practice,

quality, standards, and outcomes.

2. Chief Nursing Officer, Directors of Nursing, and Nurse Managers:

Accountabilities at this level involve the system or context that

supports practice. Decisions about these accountabilities are

centered on human, material, and fiscal resources and the systems of

care. All financial decisions rest with the Chief Nursing Officer.

C. Hallmarks of Shared Governance for Nursing

1. Efficient processes for evident-based practice changes

2. Effective communication among the nursing community and other

disciplines

3. Ongoing evaluation of nursing practice outcomes

4. Implementation of strategies that will promote exemplary outcomes

reflective of a high reliability organization

5. Satisfaction with the structure and function of the councils and

committees

6. Nurse autonomy

7. Nurse engagement


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ARTICLE III

COMPOSITION OF COUNCILS, COMMITTEES, SPECIAL MEETINGS, TASK FORCE

A. Composition: The Nursing Shared Governance is composed of councils, committees and,

when needed, special meetings and task forces.

1. Councils are the foundation of our shared governance model, which function at either

the hospital-level or the unit/department based level. Council members are

responsible for making decisions that affect the practice of nursing, which promotes

practice excellence, professional development, quality and safety and patient- and

family-centered care.

a. Hospital-Level Nursing Councils – There are five (5) councils composed of

members who represent the relationship that nursing has with all the people it

serves. The focus of the work is from a hospital-wide perspective, as these

members do not represent one specific unit or service population. Decisions

made by the hospital-level councils represent those that have an impact on the

entire nursing community. These councils include:

i. Practice Excellence

ii. Professional Development

iii. Quality & Safety

iv. Healing Environment

v. Coordinating Council

vi. Night Shift Council

2. Committees function in a support role to the councils based on their collective

knowledge, skills, and focused area of expertise. Committees report and provide

recommendations to the councils.

3. Special Meetings and Task Forces:

a. Special meetings may be called by the council chairs who will ensure that the

resources for extra meetings are secured prior to the meeting.

b. Task Forces are time limited working groups that are charged by a council to

examine issues related to a specific goal, which is outlined in the charter. All

task forces have specified start and completion dates.

B. These bylaws apply to both the Hospital Level Nursing Councils and will apply to

unit/department based councils when they are convened. They may not be amended without

the consent of the Coordinating Council. The Coordinating Council will review the bylaws every

2 years.

C. Release Time

1. There is a designated Nursing Shared Governance cost center that will be used for the

tracking of council members’ time for meeting attendance and related work. Council

members will swipe in and swipe out for all council meetings and project work.

2. The time required for council or committee meetings will be scheduled 1 year in

advance and members will have ad hoc time to do council or committee work.


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ARTICLE IV

HOSPITAL-LEVEL COUNCIL ACCOUNTABILITIES AND MEMBERSHIP

A. Practice Excellence Council

1. Role: The Practice Excellence Council reviews, revises, develops and communicates

standards of practice for professional nursing.

2. Key Accountabilities:

a. Ensures compliance with standards of professional practice including APRNs

b. Integrates research and evidence-based practice into policy development and

revision

c. Incorporates best evidence when evaluating practice changes

d. Acts as clinical consultants for supply chain product evaluation and

recommendations

e. In collaboration with the Professional Development Council identifies issues

and trends in nursing and their impact on practice

f. Evaluates and makes recommendations related to new technology and its

application to professional practice

g. Provides staff and leadership with ongoing formal progress updates

3. Council Leadership – consists of two (2-3) clinical nurses, one term as chair and one

term as chair-elect.

4. Membership

a. The Council is composed of greater than 50% clinical nurses. At least one member

will be an evidence-based practice (EBP) expert as delineated by the Iowa Model of

EBP for Quality Care (See Appendix A). See Appendix B for Table to Populate Hospital-

Level Council Membership

b. Composition:

i. A minimum of 10 members.

1. Clinical Nurse Chair, Clinical Nurse Chair Elect

2. Nurse Manager/Nursing Director as advisor

3. Unit Practice Council member from each service line

ii. Nurse Educator

iii. Resources invited as needed (Librarian, Pharmacist, Nursing Research & EBP

Committee Representative)

iv. Ad hoc representatives may be asked to attend council meetings based upon

council projects/activities (OT, PT, Speech, Nutrition, Respiratory Therapy)


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B. Professional Development Council

1. Role: The Professional Development Council promotes a culture of lifelong learning to

facilitate professional growth and ongoing competency for optimal patient outcomes


a. In collaboration with Education assists in the development and ongoing

review of unit-specific nursing orientation and competencies

b. Assists in the development of nursing educational goals:

i. Certification

ii. Career Ladder Advancement

iii. Ongoing Professional Education

iv. Staff Recognition

v. Human Resources

c. In collaboration with the Practice Excellence Council identifies issues and

trends in nursing and their impact on practice

d. Incorporates best evidence when considering changes to professional

development activities

e. Provides staff and leadership with ongoing formal progress updates

f. Continued evaluation of the Peer Review process

g. Participation in the Nurse Staffing Council

h. Continued evaluation of the Professional Practice Model

3. Council Leadership – consists of two (2-3) clinical nurses, once term as chair and one


4. Membership





b. Composition:





ii. Nurse Educator






8


C. Quality & Safety Council

1. Role: The Quality & Safety Council oversees, directs and operationalizes select quality

and patient safety initiatives consistent with established state, federal and regulatory

standards


a. Develops approaches for improvement of selected clinical quality and patient

safety metrics aimed at improving patient outcomes

b. Reviews and analyzes trends in quality data to guide hospital-wide and unit

level quality initiatives including but not limited to:

i. NDNQI

ii. Performance Improvement

iii. Fall Safety

iv. Joint Commission Core Measures

v. Department of Health

c. Evaluates and makes recommendations related to new technology and its

application to quality metrics and initiatives

d. Provides staff and leadership with ongoing formal progress updates

3. Council Leadership – consists of two (2-3) clinical nurses, once serving as chair and

one serving as chair-elect.

4. Membership





b. Composition:





ii. Nurse Educator






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D. Healing Environment

1. Role: The Healing Environment creates, implements and evaluates strategies to

enhance the healing environment and promote a positive patient and family

experience


a. Develops approaches to care that allow patients and families to participate in

clinical decisions

b. Promotes a collaborative approach to accommodate patients cultural and

diverse needs to allow for the best patient and family experience

c. Provides educational opportunities for staff as it relates to the patient and

family experience

d. Evaluates and makes recommendations related to new technology and its

application to the patient and family experience

e. Incorporates best evidence when evaluating potential solutions to items

influencing the patient experience

f. Provides staff and leadership with ongoing respectful and healthy work

environment facilitated by a commitment to your co-workers



4. Membership





b. Composition:





ii. Nurse Educator






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E. Coordinating Council

1. Role: The Coordinating Council oversees and integrates the functions of the Shared

Governance councils


a. In collaboration with the system level councils, the Coordinating Council assists

in the development of annual strategic goals, monitors progress and removes

barriers in an effort to support completion

b. Ensures the work performed at the system council level is in alignment with the

Greenwich Hospital Strategic Plan

c. Leads annual review of Shared Governance bylaws and approves revisions

d. Fosters inter-council collaboration

e. Ensures that Shared Governance Chairs and members provide ongoing formal

progress updates to staff and leadership

3. Council Leadership

a. Chair- Chief Nursing Officer

b. Co-Chair- as appointed by Chief Nursing Officer

4. Membership

a. Composition:

i. Nurse Executive – Chief Nursing Officer

ii. Nursing Executive Council

iii. Clinical Nurse Chairs and Chair-elects of the Shared Governance Councils

1. Practice Excellence

2. Quality and Safety

3. Professional Development

4. Healing Environment

iv. Nurse Educator

v. Nurse Managers

vi. Unit Practice Council Chairs

vii. Clinical Coordinators


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F. Night Shift Council

1. Role: The Night Shift Council recognizes and establishes best practice for nurses

working the night shift and innovations in care they provide to their patients.


a. Develops strategies for self-care of the nurse working the night shift

b. Enhance communication and collaboration for night staff

c. Pursue educational opportunities for night shift staff



4. Membership





b. Composition:



2. Nursing Supervisor as advisor

3. Clinical nurses from each service line

ii. Nurse Educator






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ARTICLE V

COUNCIL MEMBERSHIP SELECTION GUIDELINES

A. Eligibility

1. Practicing as a registered nurse

2. Focused on building strong relationships between people and practice (i.e. friendly, energetic,

and approachable)

3. Committed to innovation, professional development, life-long learning, high quality and safe

patient care

4. Is an employee in good standing within the organization for the last 6 months (i.e. no formal

disciplinary action) and is verified by immediate supervisor

5. Demonstrates leadership practices that are consistent with the strategic goals of the

organization, are focused on building strong relationships between people and the work they

do, and are committed to professional development and life-long learning (Porter-O’Grady, T,

2013. Leadership in Nursing Practice, p. 85)

B. Criteria for Resignation from Council Membership

1. Voluntary resignation:

a. Unable to meet work demands of the council

b. Change in job title that would affect the staff nurse composition of the council

2. Involuntary resignation:

a. Failure to support decisions of the councils

b. Loss of good standing status. The employee’s Manager is required to notify the council

chair and review/discuss council member status

c. Failure to fulfill established accountabilities

d. In the event a resignation occurs, the council chair will determine if there is a need to

replace the vacant position for the remainder of the term. Every effort will be made to

recruit a representative from the same clinical practice area.

e. In the process of initial stages of disciplinary action


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C. Terms of Office

1. The terms of office will commence in January and run through December.

2. Appointment for the councils will be up to two years. No more than 50% of council

membership turnover each year.

D. Membership for Shared Governance Councils

1. Members of the councils will be selected from applications submitted to the Shared

Governance Coordinating Council. See Appendix C for Application to Greenwich Hospital

Memberships are composed of the following Members:

a. Nurse Managers

b. Clinical nurses

c. Advanced Practice Nurse

d. Nurse Educator

e. Nursing Director

2. Members may be appointed or elected for no more than two consecutive terms on the

same council. A term is 2 years.

3. The Coordinating Council will facilitate the application and appointment process.


E. Election of Chair and Chair-elect for all other Councils

1. The Chair and Chair Elect will be nominated and elected by the council members.

a. Elections will be by majority vote (50% +1). In the event no candidate gets 50%

+1, there will be a second ballot of the top two candidates.

b. Chair-elect will attain the Chair position as it is vacated.


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ARTICLE VI

ACCOUNTIBILITIES OF COUNCIL MEMBERS

A. Council Accountabilities: All council decisions are based on the scope of authority of the

clinical nurse that is focused on nursing practice, quality, standards, and outcomes.

1. Accountabilities of the Chair:

a. Collaborates with facilitator

b. Prepares the Council Agenda using the standardized agenda template (see Appendix E)

c. Leads the meeting and adheres to time parameters

d. Guides council members in discussion of agenda items

e. Guides council members in representing practice area and clarifying information

f. Negotiates work assignments with council members and monitors project work

progress (See Appendix F)

g. Facilitates decision-making and consensus building, whenever possible

h. Reviews meetings accomplishments at end of meetings.

i. Assures minutes are recorded and posted at the end of each meeting using Council

Minutes template (see Appendix H). Minutes will capture key points and are not meant

to be narrative of the meeting.

j. Seeks approval of minutes by council members at next scheduled meeting

k. Communicates decisions for urgent issues that occurred in the interim to the council

l. Mentors the Chair-elect and other council members

m. Reports council’s activities and progress at Coordinating Council meeting.

n. Presents accomplishments annually and guides Council in setting goals

2. Accountabilities of Chair-Elect

a. Conducts council meetings in the absence of or at the request of the chair.

b. Leads monthly meetings during the last three months of their term as Chair-elect.


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c. In conjunction with the chair, negotiates work assignments with council members

d. Acts as the facilitator for all meetings to ensure that standard processes are followed

3. Accountabilities of the Members

a. Is prepared for all meetings and actively participates

b. Reports predicted absences to the chair and manager

c. Attends 80% or more of council meetings

d. Assures hours participating in council meetings and project work are within the allotted

budged hours

e. Supports all council decisions

f. Completes work assignments within the prescribed timeline

g. Communicates with peers and obtains their perspective on issues

h. Disseminates information to peers

4. Accountabilities of the Advisor

a. Informs councils and leaders about related initiatives in Patient Care Services

b. Provides latest evidence in the substantive area of the council

c. Guides the strategic plan of the council using expert knowledge

d. Utilizes knowledge from council’s discussions to inform departmental initiatives

e. Facilitates discussion by providing theoretical frameworks

f. Integrates the work of the council into departmental strategic initiatives

B. Environment

1. The council will maintain an environment that facilitates trust, support and open discussion.

Inherent within this process will be efforts directed toward the development of individual

members.

2. Meeting ground rules:

Start and end on time

Everyone participates

Raise hand for turn to speak

Respect each other’s ideas

One person talks at a time

Check your title at the door

Complete all assignments


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No side conversations

No use of electronic devices unless meeting related

Determine if quorum is met

Decisions are made by consensus provided the quorum is met

Support the decisions of the council

3. Council members uphold the Greenwich Hospital Nursing commitment to your co-worker

WE AGREE TO:

1. BE OPEN AND HONEST.

― BE OPEN-MINDED, UNBIASED AND OBJECTIVE WITHOUT FEAR OF

JUDGMENT.

2. LISTEN.

― SEEK FIRST TO UNDERSTAND; THEN TO BE UNDERSTOOD

3. SHARE OUR KNOWLEDGE AND BE A RESOURCE TO EACH OTHER.

― TREAT EACH OTHER AS EQUALS, SUPPORT TEAM MEMBERS AND

SHARE ALL RELEVANT INFORMATION.

4. SOLICIT AND GIVE FEED BACK.

― ASK FOR OPINIONS REGARDING OUR BEHAVIOR AND ACTIONS AND

BE WILLING TO ACT AND GIVE THE SAME.

5. THINK AND ACT AS A TEAM.

6. COME PREPARED TO PARTICIPATE TO REACH AND SUPPORT THE

CONSENSUS.

7. RESPECT EACH OTHER.

8. TRUST EACH OTHER.

― TRUST YOURSELF AND THE TEAM IN OUR ACTIONS, THOUGHTS,

AND DECISIONS.

9. BUILD EACH OTHER UP AND SUPPORT EACH OTHER.

10. HAVE FUN!

― ENJOY WHAT WE DO!


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ARTICLE VII

PROCESS AND GUIDELINES FOR NURSING SHARED GOVERNANCE DECISION MAKING: CHANGE

REQUESTS AND PROPOSALS

A. Open Comment Period Guidelines

1. Prior to implementing a council decision, all nurses will have an opportunity to review and

provide feedback during the Open Comment Period. It is essential to provide evidence,

whenever possible, to support feedback.

2. The exception will be those decisions that are based upon professional standards and legal

or regulatory requirements, and in this case the Open Comment Period will be about how

best to implement the proposed change.

3. The Open Comment Period will begin the second Wednesday of each month and will remain

open for 14 days. A summary of the Shared Governance Change Proposal will be posted for

all nurses to review and provide feedback. After 14 days, the Open Comment Period is closed

and will not be available for review and feedback after this date.

4. All ideas are openly explored and considered by the responsible Council(s) prior to finalizing

the Shared Governance Change Proposal.

B. Decision-Making Guidelines

1. A quorum must be met in order for the council to make decisions. Without a quorum the

council can meet, but it may not make decisions. A quorum is 50% of Council membership

+1.

2. Voting quorum - two criteria must be met:

a. There must be 50% + 1 present, and

b. Of the 50% + 1, there must be a majority of clinical nurse council members present.

3. There is shared ownership and individual accountability for decisions.

4. Decisions will be made on the basis of consensus whenever possible. If consensus is

unreachable, a vote will be taken requiring a 2/3 majority vote for approval.

5. Council members who will be absent may give their proxy for the purpose of a decision or

vote on specific agenda items; the proxy is not for new business.

6. Decisions will be made within time frames specified by the Council or negotiated with

Coordinating Council.

7. Emergent organizational priorities, although rare, may take precedence over Nursing Shared

Governance Council meetings.

8. After decisions are made, it will not be reopened for discussion unless it is formally placed on

the agenda prior to the next meeting.


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PROCESS AND GUIDELINES FOR NURSING SHARED GOVERNANCE DECISION MAKING: CHANGE

REQUESTS AND PROPOSALS

9. Council decisions may not be over-turned other than by the Council that made the decision.

10. All members are required to support the final decision.

11. Urgent decisions will be reviewed by the appropriate Council at the next regularly scheduled

meeting and may be revised.


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ARTICLE VIII

MEETING SCHEDULES AND GUIDELINES

A. Meeting Schedules

1. All Councils shall meet monthly:

a. First Tuesday at 1100-1200

i. Professional Development Council

b. Second Tuesday at 1100-1200

i. Practice Excellence Council

c. Third Tuesday at 1100-1200

i. Quality and Safety Council

d. Fourth Tuesday at 1100-1200

i. Healing Environment

e. Fourth Tuesday at 1000-1130

i. Coordinating Council

f. Second Wednesday at 0200-0300

i. Night Shift Council

B. Meeting Guidelines

1. Council members are accountable for working with their directors or managers to ensure that

their schedules are set to enable attendance of all meetings.

2. Special Meetings and Task Forces may be called by the Chair, and the Chair will ensure that

the resources for extra meetings are secured prior to the meeting.


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APPENDIX A

Iowa Model of Evidence-based Practice to Improve Quality of Care


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APPENDIX B

Table to Populate Hospital-Level Council Membership

COUNCIL:___________________________

Service Lines

EBP

Expert

(Yes, No)

Role (Clinical

Nurse, Nurse

Manager) Discipline

Name Practice Setting

1 Ambulatory

2 Critical Care

3 Emergency

4 Maternal Child Health

5 Medicine

6 Oncology

7 Perioperative/Procedural

8 Surgery

9 Nurse Manager

10 Nurse Educator

11 Case Management

12 Clinic (Adult & Pediatric)

13 IV Team

14 IDAP

15 Community Health

16 Cardiology

17 OR

18 GI

19 ASU/PACU

20 Librarian

21 Other

Requirements: 10 members; greater than 50% clinical nurses; remaining composed of Nurse Managers, Advanced Practice

Nurse; Nurse Educator; Members from disciplines outside of nursing deemed important to achieve accountabilities of the

council. Consultants may be invited to attend council meetings based on council needs. There will be a clinical nurse chair

and a clinical nurse chair-elect.


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APPENDIX C

Application to Greenwich Hospital Nursing Shared Governance Councils

Please email to: [email protected] or FAX to: (203) 863-3875 Application Deadline: __________

Last Name: Greenwich Hospital Email address:

First Name: Manager: Scheduled Hours:

Eligibility Criteria: 2 year commitment to council membership

A. Practiced as a registered nurse

B. Demonstrates leadership practices consistent with organization’s/nursing’s strategic goals

C. Focused on building strong relationships between people and practice (i.e. friendly, energetic, and

approachable)

D. Committed to innovation, professional development, life-long learning, high quality and safe

patient care

E. Is in good standing within the organization (i.e. no formal disciplinary action within the last 12

months)

F. Willing to serve in a council leadership position

Key Accountabilities of Members:

Attends all meetings prepared and actively

participates

Participants in Council work – must

lead/serve on task forces or in other

capacities (i.e. elected to chair position)

deemed necessary by the Council

Supports all decisions made by the Council

Serves as a communication liaison to

colleagues

Current role is:

Nurse Clinician

Clinical Resource Nurse

Clinical Coordinator

CNS

Nurse Educator

Nurse Manager

Nursing Director

APRN

Other : _________

Indicate your current unit/ practice setting:

____________________________________

Employment history:

I have been practicing as a Nurse for:

_______Years

I have been employed as a Nurse at Greenwich

Hospital:

_______Years

Education:

AD PhD

BSN

MSN

DNP

Please check which of the Hospital-level Councils you are applying to (please indicate your 1st , 2nd , and 3rd choices)

See attached for more information.

HOSPITAL-LEVEL COUNCILS

___Practice Excellence Council

___Quality and Safety Council

___Professional Development

___Healing Environment Council

___Coordinating Council

___Night Shift Council

___Unit Practice Council

List previous Shared Governance positions held (if any):

Chair Chair Elect Council Member

Please indicate on which Council you held this position ____________________________________________

Please list any committee(s) you currently participate on.

Describe why you want to participate in Nursing Shared Governance.

By signing this form I agree that I meet eligibility criteria and if selected will maintain the key accountabilities of membership.

Signature : Date:

I verify the applicant is in good standing in the organization and not under formal disciplinary action in the last 12 months (Does not include verbal warnings)

Signature of Manager/Director: Date:

Administration use only: Return receipt email sent to Candidate Date: Time:

Return receipt email sent to Candidate’s Manager Date: Time:


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APPENDIX C (continued)

DEFINITIONS OF NURSING SHARED GOVERNANCE COUNCILS

Purpose: To support the mission, vision, values, and strategic plan of our organization and nursing; by

engaging and empowering clinical nurses who are committed to the provision of clinical excellence

every day for every patient and family. Nursing Shared Governance provides the infrastructure and

support necessary to place ownership and accountability for practice and its outcomes at the level of

the clinical nurse. Cornerstones of professional practice ownership and accountability are practice,

quality, competence and knowledge management.

Shared decision-making, a foundational element for shared governance, is used to achieve a

collaborative and efficient practice environment for all nurses that ensure the highest quality, fiscally

accountable patient/family care.

Composition of Councils: Councils function at the Hospital-level (6 councils). Members are responsible

for making decisions that affect the practice of nursing. Council work is based on the Nursing Strategic

Plan.

Six Hospital-Level Nursing Councils - members represent the relationship that nursing has with the

people it serves. The focus of the work is from a hospital-wide perspective, as their members do not

represent one specific unit or population. Decisions made by the Hospital-Level Councils represent

those that have an impact on the entire nursing community. Chairs and chair-elects of each council

are members of the Coordinating Council.

1. Practice Excellence Council: The Practice Excellence Council reviews, revises, develops and

communicates standards of practice for professional nursing.

Key Accountabilities:

- Ensures compliance with standards of professional practice including APRNs

- Integrates research and evidence-based practice into policy development and

revision

- Incorporates best evidence when evaluating practice changes

- Acts as clinical consultants for supply chain product evaluation and

recommendations

- In collaboration with the Professional Development Council identifies issues and

trends in nursing and their impact on practice

- Evaluates and makes recommendations related to new technology and its

application to professional practice

- Provides staff and leadership with ongoing formal progress updates

2. Professional Development Council: The Professional Development Council promotes a culture

of lifelong learning to facilitate professional growth and ongoing competency for optimal

patient outcomes.


- In collaboration with Education assists in the development and ongoing review of

unit-specific nursing orientation and competencies

- Assists in the development of nursing educational goals:

Certification

Career Ladder Advancement

Ongoing Professional Education


24

Staff Recognition

Human Resources

- In collaboration with the Practice Excellence Council identifies issues and trends in

nursing and their impact on practice

- Incorporates best evidence when considering changes to professional development

activities


- Continued evaluation of the Peer Review process

- Participation in the Nurse Staffing Council

- Continued evaluation of the Professional Practice Model

3. Quality and Safety Council: The Quality & Safety Council oversees, directs and operationalizes

select quality and patient safety initiatives consistent with established state, federal and

regulatory standards.


- Develops approaches for improvement of selected clinical quality and patient

safety metrics aimed at improving patient outcomes

- Reviews and analyzes trends in quality data to guide hospital-wide and unit level

quality initiatives including but not limited to:

i. NDNQI

ii. Performance Improvement

iii. Fall Safety

vi. Joint Commission Core Measures

vii. Department of Health


application to quality metrics and initiatives


4. Healing Environment Council: The Patient & Family Experience Council creates, implements

and evaluates strategies to enhance the healing environment and promote a positive patient

and family experience.


- Develops approaches to care that allow patients and families to participate in

clinical decisions

- Promotes a collaborative approach to accommodate patients cultural and diverse

needs to allow for the best patient and family experience

- Provides educational opportunities for staff as it relates to the patient and family

experience


application to the patient and family experience

- Incorporates best evidence when evaluating potential solutions to items influencing

the patient experience

- Provides staff and leadership with ongoing respectful and healthy work

environment facilitated by a commitment to your co-workers


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5. Coordinating Council: The Coordinating Council oversees and integrates the functions of the

system level Shared Governance councils.


- In collaboration with the system level councils, the Coordinating Council assists in

the development of annual strategic goals, monitors progress and removes barriers

in an effort to support completion

- Ensures the work performed at the system council level is in alignment with the

Greenwich Hospital Strategic Plan

- Leads annual review of Shared Governance bylaws and approves revisions

- Fosters inter-council collaboration

- Ensures that Shared Governance Chairs and members provide ongoing formal

progress updates to staff and leadership

6. Night Shift Council: The Night Shift Council recognizes and establishes best practice for nurses

working the night shift and innovations in care they provide to their patients.


- Develops strategies for self-care of the nurse working the night shift

- Enhance communication and collaboration for night staff


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APPENDIX D

Nursing Shared Governance Council Application Scoring Grid

Name: Role:

Council Applied for : New Grad: YES NO

CRITERIA POINT VALUE TOTAL POINTS

Statement 0-3 Points

Prior Committee or Council Experience Yes (1)/No (0)

Prior Chair/Co-Chair Yes (1)/No (0)

Applied to Other Councils NOT SCORED □YES □ NO

TOTAL SCORE 0-5 Points

Name: Role:








Name: Role:









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APPENDIX E

Nursing Shared Governance Council Agenda Template

Nursing Shared Governance Council

Name of Council

Date, Time

Place

AGENDA

Time Topic Respondent

1100-

1110

Welcome & Approval of Minutes CHAIR

1110-

1120

Magnet News Magnet Program Director

1120-

1130

Old Business: ALL

1130-

1145

New Business: ALL

1145-

1155

Recap CHAIR

Future Meeting

Council decisions are based on the clinical nurse scope of authority- focused on nursing practice, quality, standards, and outcomes.

All financial decisions (human, material, and fiscal resources) rest with the Chief Nursing Officer


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APPENDIX F

Greenwich Hospital Nursing Shared Governance

Project Charter 2017/2019

Council Name

Council Chair

Council Chair-Elect

Task Force Point Person &

Members

Council Project Initiative

Strategic Plan Focus From

the GH Strategic Plan

Project Goals

Summarize findings from

literature and identify

knowledge gaps

How you will measure

success (baseline data &

goal data)

Identify Stakeholders

Impact


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APPENDIX F

(continued) Greenwich Hospital

Nursing Shared Governance Project Charter

2017/2019

TASK LIST/WHAT WHO BY WHEN

STATUS

RED (R)

YELLOW (Y)

GREEN (G)


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Greenwich Hospital Name of Council/Committee

Date: Time: Place: Chair:

Chair-elect:

Agenda item

Presenter

Discussion

Outcome/Follow Up

Responsible Party

Shared Governance Amended 4/2016 31

Agenda item

Presenter

Discussion

Outcome/Follow Up

Responsible Party

Respectfully submitted, NAME 2016 BH

Shared Governance 2017 32

APPENDIX H

Nursing Cross-Charging Process for Nursing Shared Governance Hours Effective Date December 1, 2014

Eligible Staff: Direct Care Nursing Staff (non-exempt)

Councils and Committees Identified for Inclusion:

Professional Development

Practice Excellence

Quality & Safety

Healing Environment

Coordinating Council

Night Shift Council

Process:

Instructions for Charging Your Meeting Time

Swipe In for Council or Committee Meetings

1) Press the button "Cost Center Transfer"

2) Enter the 4 digit Magnet cost center: 1304

3) Press the enter button (return symbol)

4) Swipe Badge

Swipe Out of Council or Committee Meetings and Project Work

5) If leaving for the day, swipe out as normal

a. If going to your unit repeat above instructions 1-4 and enter the cost center you are

going to

(Hours cross charged per individual is not to exceed budgeted hours, no overtime will be paid

for council work)


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GLOSSARY OF TERMS

Accountable

A person’s obligation to accept responsibility for outcomes

Advanced Practice Nurse (APN)

A registered nurse who has completed an accredited graduate-level education program preparing

him/her for 1 of 4 recognized APRN roles and has passed a national certification examination that

measures APRN, role and population-focused competencies and who maintains continued

competence as evidenced by recertification in the role and population through the national

certification program. These roles include: certified registered nurse anesthetist (CRNA), certified

nurse-midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP).

Chair

The person who is appointed or elected to be responsible for the overall council operations (setting the

agenda, conducting the meeting) and assures that the council meets its key accountabilities.

Chair-Elect

The person who facilitates the meeting and assumes the responsibilities of the chair in his or her

absence; Succeeds to the position of chair at the end of the chair’s term of office.

Clinical Nurses

Are registered nurses who serve as core members of the care delivery team by providing direct patient

care in the inpatient or ambulatory settings.

Clinical Systems Resource Team (CSRT)

Are registered nurses who serve as Epic content experts.

Consensus

A general agreement about an issue that is shared among all members of the council.

Consistently Assigned Experts

Consistently assigned representatives from key nursing or hospital committees (e.g. Research, Clinical

Ladder) or other disciplines (e.g. pharmacy, care coordination, respiratory therapy) who are positioned

to provide information or expertize needed to assist with the shared-decision making process.


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Employee In Good Standing

For a period of 12 months prior to application, the employee must not be in any formal disciplinary

action, which must be verified by employee’s immediate supervisor. According to Human Resources,

verbal warnings are not considered formal disciplinary action.

Evidence-Based Practice Expert

Person who has experience in the use of the Iowa Model of Evidence-Based Practice for Quality Care to

critique and synthesize the literature and other forms of evidence needed to make practice decisions;

and/or served as principal investigator or mentor for research, evidence-based practice or quality

improvement projects.

High Reliability Organization (HRO)

An organization working in a high risk industry that has demonstrated a record of high safety over long

periods of time. HROs have an infrastructure that is grounded in five processes of collective

mindfulness: 1) a preoccupation with failure; 2) reluctance to simplify interpretations; 3) sensitivity to

operations; 4) commitment to resilience; and 5) deference to expertise.

Iowa Model of EBP For Quality Care

A framework used by nurses and other clinicians to make practice decisions that affect patient care

outcomes. The 10-step model begins by encouraging staff nurses to identify practice questions,

triggered either through identification of a problem or through new knowledge. If the practice question

is aligned with organizational priorities, a team is formed and is comprised of key stakeholders in the

practice change. The team critiques and synthesizes available evidence to determine if it is sufficient

to make a practice decision or if not, consider conducting more research. The team pilots the practice

change to determine the feasibility and effectiveness. If the pilot results in positive outcomes, roll-out

and integration of the practice is facilitated through leadership support, education, and continuous

monitoring of outcomes. Sharing project reports within and outside of the organization through

presentations and publications supports the growth of an evidence-based practice (EBP) culture in the

organization, expands nursing knowledge and encourages EBP changes in other organizations.

Nurse Educator

A registered nurse with advanced education whose role is dedicated to teaching nurses from all levels

of the organization. They share knowledge and skills needed to prepare nurses for effective practice.

There are several positions in the organization that encompass the nurse educator role including

nursing education specialists, and service/unit based educators

Nursing Shared Governance

Is both a structure and an environment that legitimizes nurses’ control over professional practice and

permanently extends influence to staff and clinicians in areas that were previously controlled

exclusively by managers.


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Open Comment Period

A process that allows for the posting of Shared Governance Change Proposals for fourteen (14) days

wherein written feedback is sought from the community of nursing.

Point Of Service

Point where care is provided to patients by professional and support services team members.

Proxy

The authority to act for another.

Shared-Decision Making

A collaborative cognitive process among council members that explores several alternative options

established to find solutions to an existing problem or issue, which results in the selection of a final

course of action.

Urgent Issues

Situations that arise that is a potential or real threat to safety requiring immediate action.

Documents

BYLAWS · by those who practice nursing, which are focused on nursing practice, quality, standards, and outcomes. 2. Chief Nursing Officer, Directors of Nursing, and Nurse Managers: