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Shared Governance Structure

Nursing Councils Presentation

February 17, 2012 2/14/2013 1

Shared Governance Model SMH Nursing Division: Based on the Professional Practice Model: Relationship Based Care

Nurse Executive Council/CNO

Nursing Leadership Council

(Decision Making /Clinical Oversight)

Nursing Division Councils

(Professional Practice, Professional Development, Clinical Practice)

(Nursing Quality, Nursing Operations, Nursing Education, Research and EBP)

Unit-Based Professional Practice Councils (present on every unit)

Nurses at the Bedside

Nursing Education, Research and Evidence Based Practice Council

Chair-Rita Cook RN,BSN,RDCS,CMSRN,

PCCN

Co-chair-Ruth Harris BSN, RN,ONC

Advisors:

Ann Ciak RN PhD

Laura Kling MSN,RN,CNS,CPAN, CAPA

Colleen Sunday MSN, RN

Involving The Bedside Nurse in Conducting Research

Goal of Council: To Educate, Initiate and Develop Evidence-Based Practice and Nursing Research at SMH

Development of Nursing Research Fellowship Program –NCSI(Nursing Care Success Innovators):

Angie Durci, RN 4B Surgical

Michelle Regas, RN Lawrenceville HBC

Shawna Breghenti, RN Perianesthesia

Michele McLain, RN 5B Medical

Promote /Stimulate Positive Change that affects Patient Care-ASK IT INITIATIVE

Nursing Innovation Summit: Hot Topics in Nursing at SMH—March 5, 2012

Annual Clinical Research Forum at SMH—May 18, 2012

Oversees/Directs all Nursing Research at SMH

Nursing Operations Council

Chair-Tonya Alcorn MSN,RN

Co-Chair-Mary Jo Klebine BSN,RN,CMSRN

Advisors:

Traci Fick MSN RN

Lisa Lehman MSN,RN

Jay Wright, MSN, RN

Nurses Making Changes From The Bedside……….

Respiratory care and suctioning patients

Blood administration policy review and recommendations incorporated into practice

Change in procedure for delivering trays to patients in isolation to improve patient satisfaction related to meal temperature and times

Daily patient centered goal setting by the RN, caregiver and the patient—piloting projects on 5A, 5B, 4B

Nursing Quality Council

Chair-Judy Tinelli MSN,RN,ONC,CNL,CRRN Co-Chairs-Jackie Morgan BSN,RN,CMSRN

Gina Koch, MSN, RN, CMSRN

Advisors-Kathy Fowler BSN, RN

Tanya Hoebel MSN,RN,CNML

Lori Kelly BSN,BS,RN,CEN

Doing It The Right Way—Unit Based Action Plans

Restraint Education

Laminated tip card for restraint documentation developed to assist RN’s—see next slide—was reviewed with all SMH Nurses.

No restraint concerns/citations during recent DOH visit

Noise at Night

Involved Ancillary Departments (Housekeeping and Engineering) in noise reduction—new carts, door jam silencers, 5B RN ―White Noise‖ research study, Nite Chimes

Pressure Ulcers

Development of laminated informational cards and SMH Nurse Education—see next slides

RESTRAINT DOCUMENTATION NON BEHAVIORAL

Initiation

NEURO SECTION Adult Physical Assess Comment Section

What was the patient doing specific to type of restraints and alternatives attempted

RESTRAINT INITIATION Complete all sections. (restraint ordered must match documentation)

RESTRAINT Q 2 HOUR

REASSESSMENT

Complete all sections. (restraint ordered must match documentation)

IPOC

SAFETY Restraint issues addressed

RESTRAINT Non Violent IPOC

Skin and Pressure Ulcer Assessment

Review Skin Integrity UPMC System Policy HS-NA0415 Please go to iView and document pressure ulcer stage:

iView → Physical Assessment → Skin →Pressure Ulcer

*This documentation will automatically trigger an ET RN consult

Clinical Practice Council

Chair-Jackie Morgan, BSN, RN, CMSRN

Co-Chair-Kelsey Archibald, BSN, CMSRN

Advisors-Dawn Vocke MSN,RN,CNOR

Jess Graff, BSN, CMSRN

PAST

Current

Future

New policy development format

Re-evaluation: policy vs. procedure (reduced number of ―nursing policies‖ from 170 to 85)

Integration of Lippincott procedure book as our nursing procedure manual

Informatics

Monthly System Informatics Council Update

E-Record Issues reviewed/discussed/recommendations made

Review and Discussion of all Go-Live Planning and Implementation

Nursing SBAR

Review/critique of documentation optimization changes

Project example: Medication reconciliation and depart process

Looking to expand SBAR technique with all MD communications, especially when MD calls to inquire about pt

Education of council members related to understanding advances in technology:

SharePoint—how to utilize

Policy revisions with using track changes

Medication documentation enhancements (last dose given)

Professional Development Council

Chair-Aimee Wilson MSN,RN,ACM,CMSRN

Co–Chair-Linda Zsolcsak BSN,RN,

Advisors-

Colleen Sunday, MSN, RN

Katherine Kline MSN,RN

Professional Development Council accomplishments

Magnet Re-Designation kickoff—what that means to the nurse at the bedside

Coordinated Nurses and Hospital Week activities

Credit Union ―Focused Professional Development Shares‖ initiative

Identified need for 3 sub committees to focus work of Council

Professional Development Council Focus

Retention/Recruitment-Spring Tea, Exit RN Interview Reviews

Orientation- Developed survey for New Hires, Review Orientation Evaluation data—recommendations

My Nursing Career- Review Senior Professional Nurse Survey Results; Professional Certification Education

Professional Practice Council Chair: Tina Mourra, BSN, RN, CEN

Co-Chair: Karen Soltez, BSN, RN

Advisors: Mary Barkhymer, MSN, MHA, CNOR

Professional Practice Council

Council Focus:

Patient Satisfaction, Nurse Satisfaction, Community Outreach, Fiscal Planning, Nurse Recognition, Peer Review

Patient Satisfaction:

Nurse Behavioral Standards—see next slide

Nurse Satisfaction:

NDNQI Nurse Satisfaction Survey

UPMC St. Margaret Nursing Behavioral Standards Below are standards of behavior that we, the Professional Nurses of UPMC St. Margaret, hold to ourselves and to all of our peers. We solemnly pledge to uphold these standards to the best of our ability in every interaction, with a commitment to the highest standard of care to each of our patients and their families. I will:

Ensure all of my patients’ needs are met to the best of my ability.

Maintain a positive attitude in my communications.

Maintain honesty in my communications.

Support inclusion by treating my colleagues, our patients and their families, our customers, and our business partners with dignity and respect

Use AIDET in all of my patient and family interactions.

Communicate by using terms our patients/families can understand.

Maintain complete and current information on communication tools to keep my patients and their families informed.

Collaborate with Physicians and Case Management to keep patients and families informed of their plan of care and any obstacles that may delay patient discharge.

Always stop and actively listen.

Hold regular interdisciplinary huddles within the nursing unit to provide updates and communicate patient and family needs.

Not say, ―It’s not my job‖ nor ―I cannot help you‖. If I truly do not know what to do, or do not have an answer, I will find someone who does.

Not participate in nor promote ―never behaviors‖.

Provide and accept routine, timely, and continuous feedback to my peers regarding their performance and behavior.

Community Outreach:

Family in Need Projects

Dress for Success

Shepherd Wellness Community—see picture

Fiscal Planning:

Unit Council Budget Requests

Nurse Recognition:

DAISY Award- celebrating two—years of DAISY

Nurses’ Week Awards---‖SMH Nursing Excellence Awards‖

Peer Review:

Driven by PPC on unit level

Collaboration with Professional Development Council