Welcome to UPMC ST. Margaret Hospital Shared Governance Structure Nursing Councils Presentation February 17, 2012 1 2/14/2013
Shared Governance Model SMH Nursing Division: Based on the Professional Practice Model: Relationship Based Care Nurse Executive Council/CNO Nursing Leadership Council (D ecision 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 C hair-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 REASSESSMENT DOCUMENTATION NON Complete all sections. BEHAVIORAL (restraint ordered must match documentation) Initiation IPOC NEURO SECTION Adult SAFETY Restraint issues Physical Assess Comment addressed Section RESTRAINT Non Violent What was the patient IPOC doing specific to type of restraints and alternatives attempted RESTRAINT INITIATION Complete all sections. (restraint ordered must match documentation) RESTRAINT Q 2 HOUR
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 Future Current
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
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