Nursing Inforums Advancing Excellence in Patient Care

1. Nursing InforumsAdvancing Excellence in Patient Care Kim Sharkey, Audra Farish, Marianne Baird, Karen Zorn

3. ANCC Magnet Designation You�ve done it again � historical 4th time

4. Other Recent Accomplishments NASCAR Angels Nursing Professionals Magazine:Top 100 Hospitals to work for Real Stories of Nursing Research: Magnet Hospital Experience with Research- CVICU study on management of thirst in postoperative patients Nursing Administration Quarterly, April-June 2009 : Elements of Leadership Excellence �Challenges in Sustaining Excellence Over Time�

5. Our Commitment to You Campaign Kim Sharkey, Audra Farish

6. Our Commitment To You Campaign Modify number of beds on units to allow for better RN/Patient ratios and storage 6W, 6E, 4W, 4S, 3SW, CCU/PCU, CVICU, MSICU Increase number of Clinical Nurse Specialists Marianne Baird: Acute Care and Magnet Program Director Risa Benoit: Critical Care and Critical Care Nurse Residency Program Fran Tawes: Perioperative Services Alice Kerber: Oncology Services Karen Zorn: Informatics and Shared Governance Karen Maxwell: Nurse Extern and Acute Care Nurse Residency Program

7. Our Commitment To You Campaign Implement Unit Based Nurse Educators Niti Patel: Inpatient Oncology Margaret Howell: MSICU Tammy Ortiz: CCU/PCU Haleh Eskandari: Cath Lab Bobbie Geiger: Operating Room Julia Bossie: ED Lin Byrd: GI services Alicia Bannis: Orthopedics Beth Hundt: CVICU Faith Pattavana: 5 East Bobbie Geiger: Main OR

8. Our Commitment To You Campaign Implement the Staffing/Care Delivery Model Implement Charge Nurse role with 0-2 patients How we will make this happen?

9. Our Commitment To You Campaign Gap Analysis underway Student Nurse Placement with larger number of BSN/Graduate students Grant Funded Extern Program New Graduate Nurse Residency (Intern) Program Critical Care Residency Program

10. Our Commitment To You Campaign Acquisition of Experienced Nurses: All Specialties Diverse Media Strategy : On-line and Print Media Campaign throughout the year Examples: Nursing Spectrum Advance for Nursing Pulse Other niche� websites Employee Referral Program Incentives for high vacancy areas

11. Proposed Changes to Nursing Shared Governance Marianne Baird, Karen Zorn

12. Shared Governance and the Staff Nurse A �Mature� Professional Practice Model The �birthplace� or �cradle� of shared governance Historical Review Begins in 1980s

13. Shared Governance and the Staff Nurse History 1980s: Groundbreaking work empowering staff nurses 1990s: Recognized by Magnet research to be an essential element of highly functional nursing organizations 2009: Time for reflection, review and revision based on outcomes Bylaws of the Professional Nursing Staff define structure and some processes

14. Nursing Shared Governance A Model for Empowering the Nurse Structures system to let patient care decisions be made where they legitimately belong 90% of nursing care decisions belong at point of service True shared governance is evidenced when clinicians make decisions about the standard of care, not just give input

15. Professionalism in Nursing The case for professionalism in nursing Are we hourly wage earners or are we advancing our profession? Can all professional work be done �at work?� Outcomes focus is everywhere (structure, process, outcomes) Paid by CMS based on outcomes Accreditation is largely based on outcomes Future Magnet status will be awarded based outcomes

16. Nursing Shared GovernanceDecision Making

17. Governance Structure of the Professional Nursing Staff

18. Current Shared Governance Structure Nurse Executive Council �chairs of all councils meet to integrate council work Nurse Leadership Council � management driven; decide on materials/staff/resources management Nurse Practice Council � annual policy/procedure reviews; HealthStream communication of changes Nurse Performance Improvement Council � review and oversight of house-wide and unit-specific PI projects Nurse Professional Development Council � oversight of skills labs, QPNSM, education of staff Nursing Research Council � oversight of nursing research, development of research capacity

19. Where We are Today

20. Transitional Model: Goal

21. Governance Structure of the Professional Nursing Staff

22. Nursing Executive Council (NEC) Utilize the NEC to develop a reasonable number of yearly goals Disperse goals to appropriate council and ensure focus on achievable outcomes 2009 ACT initiatives � Nurse Sensitive Ventilator Associated Pneumonia Catheter Associated UTIs Catheter Related BSIs Falls with Injuries Pressure Ulcers greater than Stage I

23. Nursing Executive Council Provide a forum for interdepartmental and inter-council communication Assure issues are referred to the appropriate council or subgroup Provide a forum for caregiver feedback 10-12 direct care nurses from all practice areas will be selected monthly for a breakfast or lunch �Town Meeting� with the council to discuss our work environment

24. Nursing Executive Council Membership Chaired by Direct Care Nurse Chairperson of the Professional Nursing Staff Direct Care Nurse Chairs of the Primary Councils (4) 1 Nurse Director 1 Nurse Manager 1 Clinical Nurse Specialist Chief Nursing Officer Magnet Program Director Chair Nursing Peer Review Committee Chair Clinical Nursing Advancement Panel (CNAP) Guests As needed to promote the best possible communication and facilitation of council outcomes attainment

25. Nursing Executive Council Subcommittees Nursing Peer Review Clinical Nurse Advancement Program (CNAP/Levels)

26. Nursing Leadership Council Differentiate role as unique from NEC Management of human, material, and fiscal resources Subcommittees Recruitment, Selection and Retention Nurse Managers Membership CNO RN Vice Presidents Nursing Directors Chair Nurse Managers Administrative Supervisors Ad hoc HR representative Chair of NEC? ? Name change from Nursing Operations Council

27. Nurse Practice Council ? Change name to Evidence Based Practice Council Evolve to a problem based focus when developing policies, procedures and standards of care; Problems may identified by: Unit-based councils or Individual staff RNs CHE and Regulatory agencies Collaborate with other councils to implement changes and drive outcomes Network with Research Committee to develop use of current evidence in practice

28. Nurse Practice Council Should the current Research Council become the Advisory Board for the Nurse Practice Council?? Expand the number of specialty based subcommittees formally reporting to Practice Council Acute Care (Med-Surg) Critical Care Perioperative Emergency Department Oncology

29. Nurse Practice Council Expand Membership of direct care nurses Broader representation of unique/specialty practice areas to build continuum of care Lessen number of areas for which each council representative is responsible Align membership with manager group Change administrative rep from Service Line/Director to Nurse Manager Develop unit based SG within new clusters Problem based, outcomes focused teams ? Name change to Evidence Based Practice Council?

30. Proposed Membership NPC Direct Care Nurse Chair Clinical Nurse Specialist Manager Representative CCU *PCU MSICU CVICU 3E, 3W 3S, GIDU 4E, 5E 4W, Dialysis 4S, 5W 6E, Float/Flex Pool Oncology: 6W, 3SW, OP Onc, Rad Onc, Gamma Knife ED, Specials Rad, 1 West Inpatient Periop Outpatient Periop Cath Lab, EP Lab, ARU WCC, WOCN, IV Therapy Cardiac Rehab, Women�s Health, CV Screening Care Management Patient Safety and Quality Management

31. Nursing Professional Development Council Develop and implement hospital wide and unit specific educational activities linked to practice outcomes Ensure consistency with orientation of the clinical staff Support professional development, role development and career advancement

32. Nursing Professional Development Council Restructure Primary Council Membership to include all Clinical Resource Nurses Increase participation of direct care nurses in subcommittees and unit based councils Members would include: Clinical Nurse Specialists Unit based Nurse Educators Educational Specialist from ODE Direct Care Nurse Chairpersons of Subcommittees

33. Nursing Professional Development Council Subcommittees Facilitate meaningful specialty based unit level education programs Focus on issues related to nurse sensitive indicators Direct Care Nurses and Clinical Resource Advisors Report at least quarterly to Main Council Current Subcommittees (may need revision based on primary problem focus and orientation needs) Quarterly Professional Nurse Staff Meeting Mock Codes General RN and CCP Skills Labs Unit Based Orientation Clinical Advisor Development Program

34. Nursing Performance Improvement and Nursing Research Councils Coordination Clearinghouse with Subcommittees: Merge NR and NPI Councils and include Patient Safety and Quality Management Members of Clearing House: Include chairpersons and key members of subcommittees: Research, Unit Based PI, Patient Safety and Quality Focus: Address initiatives from all regulatory bodies who have a role in development of standards of care Supportive Role: Ensure Nursing Practice Council maintains current evidence base

35. Nursing Performance Improvement and Nursing Research Councils 3 Subcommittees Research: Support research project development, review proposals, attend/monitor IRB, act as advisory board for Nurse Practice Council�s evidence based practice development Unit Based PI: Monitor and support each unit�s individual PI projects; review data/progress; support manager in monitoring house wide initiatives Patient Safety and Quality: Monitor and support hospital wide projects, including core measures, tracers and patient safety goals; review data/progress

36. OR�Using the new Magnet Model� Clinicians and administrators would work together in non-traditional ways to solve problems and attain both clinical and financial performance outcomes Many, many possibilities for changes!!

37. Where are We Going?

38. New Magnet Model

39. Transformational Leadership Strategic Planning Advocacy and Influence Visibility, Accessibility and Communication Encompasses roles of CNO, directors, managers and executive councils Focuses on leadership which helps facilitate the ongoing evolution of evidence based patient centered care

40. Structural Empowerment Professional Engagement Commitment to Professional Development Teaching and Role Development Commitment to Community Involvement Recognition of Nursing Largely reflects the tenets of our Center for Nursing Excellence The organization must strive to promote community relationships which help advance the nursing profession, supports organizational goals, promotes personal and professional growth and development.

41. Exemplary Professional Practice Professional Practice Model Care Delivery Systems Staffing, Scheduling, and Budgeting Processes Interdisciplinary Care Accountability, Competence, Autonomy Ethics, Privacy, Security and Confidentiality Diversity and Workplace Advocacy Culture of Safety Quality Care Monitoring and Improvement Reflects unit level leadership and clinicians work together towards creating an environment in which high quality, safe patient care is delivered

42. New Knowledge, Innovations and Improvements Research Evidence Based Practice Innovation Strives to conscientiously integrate evidence based practice and research into clinical and operational processes. Magnet organizations maintain cutting edge practice

43. Empirical Outcomes Measurable outcomes attained by efforts of all groups Data is shared with all staff members on all PI initiatives on a regular basis If data is not maintained, it is unclear whether new processes have resulted in changes in nursing practice If data is not available, obtaining financial resources to sustain more costly practice changes is very difficult for nursing administrators Regulatory agencies are looking for outcomes data As NURSES, we should be aware of the impact of our actions on patient safety

44. 4 Council Magnet Model: Decision Making Structure Changes Adopting the new Magnet Model as a councilor structure would involve significant changes in the way clinicians and administrators make decisions If interested, we can try to create it May have to do an interim step or transitional model before we�re ready!

45. Proposed Changes to the Clinical Nurse Advancement Program (Levels) Kim Sharkey

46. Clinical Nurse Advancement Program Developing a new program � Why? Participation: Nurses interest in the current program waning; indication it is not meeting needs Focus: Current program implies a nurse will be proficient/expert in the roles of clinical practice, educator, and management � is this realistic? Planning: Current program does not sustain succession planning for future clinical experts/educators/leaders Outcomes: Current program does not allow for full development, implementation, and evaluation of projects undertaken due to timing of portfolio submission Documentation: The largest group of staff nurses (level I) are not expected to submit portfolios or otherwise engage in reflective assessment of personal/professional growth

47. What will the program look like? Will more closely align with Patricia Benner�s Novice to Expert Model for Knowledge and Skills Acquisition Novice: Student Nurses/Nurse Extern Advanced Beginner: Graduate Nurse Competent: Staff Nurse Level I Proficient: Staff Nurse Level II Expert: Staff Nurse Level III

48. What will the program look like? Anticipate direct care nurses will be able to develop proficient/expert knowledge and skills along 1 of 3 tracks Clinical Practice Staff education Unit Management Program redesign will occur within the Clinical Nurse Advancement Panel Many opportunities will present for staff nurses at all levels to give input into the redesign

49. What will the program look like? Anticipate routine submission of portfolio to the CNAP Panel will occur less frequently than annually; every 2 years, every 3 years? Will allow staff nurse to develop and implement individual projects with sufficient time to assess effectiveness and outcomes Will allow individual to work collaboratively with others on projects/programs that will result in outcomes

50. What will the program look like? Anticipate nurses at all levels will submit a professional portfolio Graduate Nurse to Level I: Portfolio to Program Coordinator at end of 1st year Staff Nurse Level I: Annually to Nurse Manager for use in developing Performance Appraisal Staff Nurse Level II and III: Annually to Nurse Manager for use in developing Performance Appraisal At defined intervals to the CNAP Panel for maintenance assessment

51. Timeline and Transition 12 to 18 months 2009 Portfolio submission to the CNAP Panel: will be suspended for 2009 to allow the panel time to focus on program redesign Portfolios will be submitted to Nurse Managers: by July unless otherwise directed to allow for completion of annual performance evaluation due in September Nurse Manager will utilize the CNAP Panel checklist: for annual evaluation New applications: will be suspended for the remainder of 2009

52. We help create our future