2016 nursing shared leadership council - magnet.mch.com...feb 02, 2016 · 2016 qso council goal #2...

2016 Nursing Shared

Leadership Council

February 17, 2016

RN Exchange Visit

Ana Bandin

CHILDRENS HOSPITAL OF ORANGE COUNTY, CA.

Ana Bandin BSN, RN, CPN

CHOC… Established in 1964 with only 62 beds, it is now a 279 bed hospital with outpatient center. It’s dedicated to reach all children in Orange County.

6 floors, brand new tower where all rooms are private. PICU, CVICU are individual rooms. NICU and SBU (small baby unit) hold total of 75 patients.

SBU: Babies 24-28 weekers most of them on high flow O2. Unit is very dark, quite; parents are expected to have hands on.

Babies up to 3 days or “dirty” (have been home and get admitted) can be admitted to the NICU because they have single rooms.

Vented patient’s will go to ICU’s

Primary clinics

Emergency Department is 1 year old.

Specialty Care Clinics

• CHOC offers over 30 specialty clinics, treating over 50,000 outpatients per year who require specialized care in areas including diabetes and endocrinology, orthopedics, allergy and asthma, neurology, oncology, pulmonology and more. Our specialty care services also include the CHOC BREATHMOBILE program – two mobile asthma and allergy units that provide screening and treatment for children at schools and community centers in various areas of Orange County.

Breast milk is collected by nurse, with labels, scanned when collected. Dietary picks it up, scans it. Fortifies it if needed, counts the calories and distributes them in individual PO syringes for feeds to last through the shift. Syringe comes with label with barcode to scan, patient’s information, milk information and expiration date. They do not double independent verification. Left over milk is stored in freezer and given to patient at discharge in a big bag with their information and it gets scanned when handed to patient.

Lactation champions

Speech and developmental team feed babies. They use Dr. Browns for babies with difficulty sucking and swallowing. It’s part of a study being conducted. Bottles are given to the parents when discharge.

Feeding Developmental team also has intense program for patients who have been GT fed all their life to transition to PO feed. Intense 3 week inpatient program including OT, speech and dietary. Patients leave PO feeding and most of them with GT removed.

Leadership…

Director Managers CNS

CNS- in charge of nursing sensitive indicators, research, best practices

Clinical educator- In charge of staff teaching, onboarding of new hires, skills check, competencies

Patient educator- Bedside nurse: plans teaching with clinical educator and disseminates information to patients and families.

Charge nurse- Manages shift, staffing on shift and oncoming shift. Meets with staff on quarterly basis, goes over goals, mentors, disciplines, does evaluations. If absolutely needed will take no more than 2 patients.

Very big on establishing relationship with staff, engages them, encourages them. Do their recognitions.

Staffing…

Staffing: 4:1 assignments with CA’s. No more than 2 nurses per CA= 9 pts. Have sitters who do 1:1.

Also have “breakers” (PRN nurses) on every shift to aide with breaks, medications, etc. Will get pull into staffing when needed if absolutely necessary.

Unit based staffing- will discuss need on bed tracking and will share nurses amongst floors- charge nurse will decide.

Score patients and staff based on score- SMT

Overtime is paid at double time and ESP bonus =$500/shift

Rely on travelers 40% of the time.

Self schedule (by hand) per unit. Charge nurse balances.

Recognition…

Nurses week- Hospital gave 10K. Massage therapist every day, food trucks, heating pads, ice cream. Partner with local bank, did a money cyclone. Appreciation buckets.

Hospital very big on recognition. Each unit has a “Spirit Team”- will do birthdays, organize outings quarterly, celebrate milestones on staff.

Employee of the month-picture and comments by staff posted for everyone to see

Magnet…

• Working on their 2nd designation

• PACE ladder: done by portfolios. Portfolios need to be submitted by a certain timeframe, RN seeking to advance level must sit through a panel interview. RN may be denied advancement. Appeals available.

• Shared Leadership Council include INTERPROFESSIONAL COUNCIL. It sits many disciplines other than nursing + an advisory council member (Nutrition, RT, SW, CM, Child Life, etc). Team work amongst all those involve with patients.

• Hospital very big on certifications and advance education. Each RN wears a badge with titles: MSN, BSN, DNP, ARNP, etc.

• Respiratory- do not use vapotherm due to increase nosocomial infections, instead HIGH FLOW is used. It’s used on the floor with certain guidelines until 40% Flow. If higher then transfer to ICU. (Flow charts)

• Respiratory participates in rounds and do asthma teaching. Staff according to hours estimated to spend with patients. Each units has therapist plus unit charge and hospital supervisor on shift.

• RT are asthma certified

• ER has an asthma pathway to treat patients without having to admit them.

• Trying to establish RRT having trouble using it. High percentage of code blues on floors.

• Specialty nurses: ECMO, Dialysis, Wound, etc, only work when they have a case.

• Tracheostomy Nurse: Follows every trach patient in and out patient. Serves as the CM, SW, CNS.

Research

• Research and EBP: Dr. Susan Elliot, Nursing Research and Innovation Council and APN council administrative Advisor. In charge of all Research. Rounds with nurses and MDs frequently. Evidence Based Medicine (diagnosis-article-this is how I treated) vs. EBP (nursing, best practice, individual cases, patient and family involvement).

• Research scholars and Fellows: 2x/year. Dr. Elliot works together with director/manager to understand, support and allow scholar the time needed to work on research.

• Nurse Residency Program:

…

Nursing Innovations: any ideas are brought up in the council. CHOC 1st

pediatric hospital to have a dedicated Pediatric Innovation Program. Partnered with a lab who would recreate, build, map out any innovative ideas brought to the table. Nurses encouraged to bring in ideas. They can patent them. CHOC hosted a Conference in January.

Research department is partnered with UCIrvin Medical and receives grants from donors.

Currently, about 5-7 research studies going on in the hospital.

Research and Evidence based practice workshops are done twice a year. Dr. Elliot is a quantitative researcher. She seeks qualitative researcher speakers to workshops.

CNO- Dr. Melanie Patterson- over 1 year in position, being mentor by Cincinnati children's

Big cut on administrative positions, 50% in the last year.

4 directors: Acute care-medical surgical, ICUS, Ancillary and ED services

Each area has 1 manager only. Recently piloting 1 manager at night for Acure care-medsurg area (4 units).

Using a high% of travelers

Actively looking to revamp salary to match neighbor hospitals (lower than others)

Very big on making herself visible and instilling the family culture.

CNO comes in every other Monday at 3am and Wednesday during the day to each unit to talk to the nurses (rounds). Writes email “from Melanie’s desk” every Monday with blunt brief information about current events. Answers staff questions.

Open door policy

QUALITY…

High % in BSIs, CLAVSIS and VAPs

Line infections and BSIs=basic hygene. Change blue port with tubing change every 96 hours.

When lines cultured, skin surfaced bacteria found. 1-2-3 chart central lines. Information lost on change dates; more than 1 week without dressing changes.

Monday dressing change day

Heparin flush vs NS flush on catherers with valves. Study currently being done on heplocks once a week, 3X week or daily.

Pain assessment- developed new faces for different population.

INFUSION UNIT

CHILD LIFE:

Do parent night- volunteers to stay with patient to let parents out. Parent info night- once quarterly with food, educator will host

information session for parents about drugs, hygene, support, open questions.

Family room outside ICU’s for families only- kitchen with snacks, sofas, computers.

Seacrest Studios Theater lollipop: Screen movies not yet out to the public for special

cases. Cooking classes- Therapy for food aversion Mother and Father funday: BBQ, Massage, Nails, Football game on

screen Sibling education and activities

Documentation

Pre-op, Post-op still paper chart. Behind on Electronic documentation.

Trauma room- ER

Cost savings initiative- Medsurg unit

THE end!

Quality and Safety Outcomes Council

Chair: Kavita AmacheCo-chair: Facilitator:

Quality & Safety Outcomes (QSO)

2016 QSO Council Goals

Focus on reduction of CLABSI throughout the

hospital

Partner with patients and families to develop

at least one hospital-wide improvement project based on underperforming nursing sensitive

indicators by Q3 2016.

Collaborate with leaders to have at least 90% of

staff obtaining a certification by Q4.

2016 QSO Council Goal #1Goal #1: Reduction of CLABSI Nursing Strategic Plan Alignment

1Q2016 Goal: Focus on reduction of CLABSI throughout the hospital

Pillar: 2: QualityPartner with patients and families to provide a consistent high quality environment of care.

2Q2016 Goal:The Quality and Safety Council will collaborate with risk, quality and infection prevention departments to analyze unit-based results that encourage meeting or exceeding established benchmarks. Action plans will be developed when results fall near or below the benchmarks.

Strategic Focus: 2.3: Encourage nurses to analyze data and develop action plans for quality and performance improvement through inter-professional collaboration. 2.7: Proactive risk assessment and error management.

3Q2016 Goal:The Quality Council will work collaboratively with departmental leaders, Risk, Quality and Infection Prevention to reduce errors, including medication variances and near misses.

Magnet SOE Evidence: Q1 & Q2 GoalsEP 19 EOEP 23 EOEP 20 EOEP 12Q3 & Q4 GoalsEP 19 EOEP 16SE 1 EO

4Q2016 Goal:The Clinical Excellence Index goal will be achieved.

Evidence of Accomplishment:CLABSI infections have been reduced throughout the hospital.

2016 QSO Council Goal #2Goal #2: Nursing Strategic Plan Alignment

1Q2016 Goal:Partner with patients and families to develop at least one hospital-wide improvement project based on underperforming nursing sensitive indicators by Q4 2016.

Pillar: 1 PeopleFoster a culture of professional nursing through recruitment, retention & talent development.

2Q2016 Goal: Strategic Focus: 1.5: Empower & support clinical nurses to lead collaborative improvement efforts.

3Q2016 Goal: Magnet SOE Evidence: EP 12

4Q2016 Goal: Evidence of Accomplishment:Nursing actions and projects related to improving Quality and Safety Outcomes will promote adherence to standardized processes> ensure ongoing preparedness and readiness for accreditation by The Joint Commission.

2016 QSO Council Goal #3Goal #3: Foster a culture of professional nursing. Nursing Strategic Plan Alignment

1Q2016 Goal:Over a two year period:• Increase certification by 3%• Increase BSNs or higher by 3%• Increase the MSN prepared nurses by end of year 2.

Pillar: 1: PeopleFoster a culture of professional nursing through recruitment, retention & talent development.

2Q2016 Goal:Nurses that are not certified will attend certification preparedness classes offered by hospital.

Strategic Focus: 1.10: Promote professional growth in alignment with the Institute of Medicine (IOM) Future of Nursing Report.

3Q2016 Goal:• Certification of nurses increase by 2%.• 2% of nurses to be enrolled in a MSN program in an

accredited school

Magnet SOE Evidence: 007

4Q2016 Goal:• Certification of nurses increased by 3%.• Nurses enrolled in accredited MSN programs will

increase by 3%.

Evidence of Accomplishment:Nurses are certified or enrolled in MSN programs and are more prepared to move into leadership roles within the hospital.

Nursing Research & EBP Council

Chair: Ana TrykalaCo-chair: Facilitator:

Nursing Research & Evidence-Based Practice (NR&EBP) Council

2016 NR&EBP Council Goals

Improve best practices and quality

outcomes through translation of

knowledge

Increase knowledge of NR & EBP

Promote communication and

collaboration interdepartmentally within Nursing units

and Research Institute

2016 NR&EBP Council Goal #1Goal #1Improve best practices and quality outcomes through translation of knowledge

Nursing Strategic Plan Alignment

1Q2016 Goal: Establish NR/EBP topics of focus for 2016.

Pillar: Quality

2Q2016 Goal:Develop a standard checklist for NR/EBP projects.

Strategic Focus: 2.4 Enhance patient outcomes through implementation of evidence based practices

3Q2016 Goal:Provide learning session on analyzing credibility of nursing literature.

Magnet SOE Evidence: NK3Clinical Nurses evaluate and use evidence-basedfindings in their practice

4Q2016 Goal:Provide resources for writing and submitting an abstract.

Evidence of Accomplishment:2 completed unit EBP’s by 2016 accompanied by written abstract.

2016 NR&EBP Council Goal #2Goal #2:Increase knowledge of NR and EBP


1Q2016 Goal:Create NR & EBP newsletter including educational material, updates, and resources.Develop survey to poll staff on NR & EBP interests.

Pillar: People

2Q2016 Goal:Develop Twitter account specifically for pediatric NR & EBP article posts.

Strategic Focus: 1.4 Provide and support professional development opportunities across all levels

3Q2016 Goal:NR & EBP fair: Completed NR/EBP will be displayed for staff members to view

Magnet SOE Evidence: NK 1 EOThe organization supports the advancement of nursing research

4Q2016 Goal:Hold a NR & EBP workshop

Evidence of Accomplishment:Quarterly newsletter sent to staff. Staff attendance to NR & EBP workshop.

2016 NR&EBP Council Goal #3Goal #3:Promote communication and collaboration interdepartmentally with nursing units and research institute


1Q2016 Goal:Create Google Docs Template, and promote the use of Google Docs for NR & EBP collaborative projects.

Pillar: Service

2Q2016 Goal:Identify an NR/EBP topic conducive to collaboration between different units.

Strategic Focus:5.5 Support nursing and inter-professional collaboration to ensure care coordination & continuity of care

3Q2016 Goal:Collaborate with NCH medical library to keep staff informed of available nursing literature

Magnet SOE Evidence: EP 12Nurses assume leadership roles in collaborative inter-professional activities to improve the quality of care.

4Q2016 Goal:Hold a workshop for NR/EBP participants to evaluate each other’s NR/EBP projects wit a focus on providing input, suggesting improvements, and sharing of information/ideas.

Evidence of Accomplishment:Collaboration between nursing units on 1 EBP project in 2016.

Clinical Practice Council

Chair: Emily ZubiriaCo-chair: Facilitator:

Clinical Practice Council (CPC)

2016 CPC Goals

Educate nurses about APEX and the benefits of a

professional development

ladder

Increase clinical nurses

participation in policy review and revision

Promote professional development opportunities amongst NCH

staff

2016 Clinical Practice Council Goal #1Goal #1: Educate nurses about APEX and the benefits of a professional development ladder.


1Q2016 Goal: Develop talking points related to APEX and the professional development focus of the ladder. Distribute pre-data surveys

Pillar: People

2Q2016 Goal: Meet with nurses, nursing leaders and TM&E to review the 2016 performance review process related to APEX and to gather feedback. Focus discussions with nurses based on survey feedback.

Strategic Focus: 1.4: Provide and support professional development opportunities across all levels.

3Q2016 Goal: Distribute post intervention surveys Magnet SOE Evidence: SE3 EO: The organization supports nurses’ continuous professional development.

4Q2016 Goal: Review survey data and plan follow up interventions as needed

Evidence of Accomplishment: Increase in knowledge of APEX purpose and structure amongst eligible nurses as evidenced by pre and post intervention survey scores.

2016 Clinical Practice Council Goal #2Goal #2: Increase clinical nurses participation in policy review and revision.


1Q2016 Goal: Educate nurses on the policy review process and incorporation of best practice standards. Review first clinical policy and revise if necessary.

Pillar: Quality

2Q2016 Goal: Review second clinical policy and revise if necessary.

Strategic Focus: 2.4: Enhance patient outcomes through the implementation of evidence based practices.

3Q2016 Goal: Review third clinical policy and revise if necessary.

Magnet SOE Evidence: NK3- Clinical nurses evaluate and use evidence based findings in their practice

4Q2016 Goal: Review fourth clinical policy and revise if necessary.

Evidence of Accomplishment: Four clinical policies will be reviewed and revised if necessary by the end of 2016. CPC members will report increased knowledge in the policy review/revision process at NCH.

2016 Clinical Practice Council Goal #3Goal #3: Promote professional development opportunities amongst NCH staff


1Q2016 Goal: Discuss the impact that professional development has on a nurses’ career and professional path. Educate related to why certification and continuing education is important and the resources NCH has to support professional growth.

Pillar: People

2Q2016 Goal: CPC Members will prepare an informational poster or flyer for their area containing information about a specialty certification.Members will help promote internal professional development opportunities (certification reviews, lectures, etc.)

Strategic Focus: 1.4: Provide and support professional development opportunities across all levels. 1.9: Encourage active participation in professional nursing organizations. 1.10: Promote professional growth in alignment with the IOM Future of Nursing Report.

3Q2016 Goal: CPC will host a professional development fair for NCH staff.

Magnet SOE Evidence: SE2 EO: The healthcare organization supports nurses’ participation in local, regional, national and international professional organizations. SE3 EO: The organization supports nurses’ continuous professional development.

4Q2016 Goal: CPC will support the registered nurse exchange visit in order to promote idea sharing and the incorporation of best practices.

Evidence of Accomplishment: Increase in staff knowledge regarding specialty certifications, increase in participation in nursing organizations, increase in certification rates.

Finance Council

Chair: Michele MorenoCo-chair: Facilitator:

Finance Council

2016 Finance Council Goals

Increase 2015 cost savings by

10%.

Develop an innovative employee

discount/perk program.

Increase compliance of charge nurses

completing Clairvia Patient

Assignment on a regular basis.

2016 Finance Council Goal #1Goal #1: Increase 2015 cost-savings by 10% by December 2016. Nursing Strategic Plan Alignment

1Q2016 Goal: • Determine need for savings in each unit and hospital-wide.• Develop plans and cost-savings projects.

Pillar: Margin

2Q2016 Goal:• Implement cost-savings projects in each unit and hospital-wide,

as determined necessary by council members.

Strategic Focus: 3.4 Promote implementation of LEAN methodology and cost-reduction initiatives.

3Q2016 Goal:• Evaluate effectiveness of cost-savings projects.

Magnet SOE Evidence: SE 1 EO Clinical nurses are involved in interprofessional decision-making groups at the organizational level.

4Q2016 Goal:• Measure 2016 cost-savings.

Evidence of Accomplishment: The Finance Council will exceed 2015 cost0savings by 10%.

2016 Finance Council Goal #2Goal #2: Develop an innovative employee discount/perk program.


1Q2016 Goal:• Determine what types of discounts and perks will

create greater employee satisfaction.• Meet and discuss employees’ interests with Clinical

Supply.

Pillar: People

2Q2016 Goal:• Form connections with businesses in the community

to determine their willingness to participate in our discount program.

Strategic Focus: 1.7 Nursing and TM&E collaboration to strengthen recruitment, retention and succession planning endeavors.

3Q2016 Goal:• Work with supply chain to formulate discounts on

items for employees to purchase at discounted rates.

Magnet SOE Evidence: EP 11 EO Nurses participate in recruitment and retention assessment and planning activities.

4Q2016 Goal:• Develop formal employee discount program.

Evidence of Accomplishment: The Finance Council will develop an employee discount/perk program that will provide employee satisfaction.

2016 Finance Council Goal #3Goal #3: Increase compliance of charge nurses completing Clairvia Patient Assignment on a regular basis.


1Q2016 Goal:• Evaluate current patient assignment usage.

Pillar: Margin

2Q2016 Goal:• Provide charge-capable nurses with education

regarding the importance of and proper way to complete Clairvia Patient Assignment.

Strategic Focus: 3.3 Increase Clairvia utilization and optimization for staffing effectiveness.

3Q2016 Goal:• Implement new usage strategies.

Magnet SOE Evidence: EP 9 Nurses are involved in staffing and scheduling based on established guidelines, such as the ANA’s principles for Nurse Staffing, to ensure that RN assignments meet the needs of the patient population.

4Q2016 Goal:• Evaluate usage after teaching is provided.

Evidence of Accomplishment: Patient assignment is completed by all charge nurses, in order to provide the staffing coordinators with appropriate data, so that staffing is adequate for the census and acuity throughout the inpatient units.

Exemplary Professional Practice Council

Chair: Lidia RosadoCo-chair: Facilitator:

Exemplary Professional Practice (EPP)

2016 EPP Council Goals

Increase council

involvement in community

outreach.

Develop & implement a peer review

process across all nursing

levels.

Evaluate thePPM and outcomes

related to it’s application.

2016 EPP Council Goal #1Goal #1: Increase council involvement in community outreach.


1Q2016 Goal: • Establish a relationship with MCHF regarding the 5K event

potential for EPP members to provide healthcare screening.• Determine next Special Olympics screening event dates.• Collaborate with Wendy Johnson (Learning & Development

Services Dept.) to plan EPP involvement in various community outreach events.

Pillar: Growth

2Q2016 Goal:• Collaborate with MCHF & Strategy Dept. to determine health

screening services to provide in alignment with the community needs assessment.

• Collaborate with Wendy Johnson to recruit staff for career day events.

Strategic Focus: 4.1: Enhance community healthcare outreach and health promotion activities.

3Q2016 Goal:• Host 5K health screening event with EPP tent (September).• Collaborate in the coordination & preparation for the Day in the

Life of a Nurse event

Magnet SOE Evidence: SE9: The organization supports nurses participation in community healthcare outreach

4Q2016 Goal:• Host the Day in the Life of a Nurse event (November).• Council will support holiday community outreach events.

Evidence of Accomplishment:EPP council members participation in community healthcare outreach

2016 EPP Council Goal #2Goal #2:Develop & implement a peer review process across all nursing levels.


1Q2016 Goal:• Bring in Magnet consultant to assist in peer review

process education & development.

Pillar: People

2Q2016 Goal:• Create survey to collect pre-data on current peer

review knowledge. • Provide house wide education on the new peer review

process and expectations through engaging and innovative activities.

Strategic Focus: 1.6: Promote an environment of professionalism and excellence through transparency, self-regulation & peer review.

3Q2016 Goal:• Each unit and level of nursing will develop at least 1

peer review process.

Magnet SOE Evidence: EP15: Nurses at all levels engage in periodic formal performance reviews that include a self-appraisal and peer feedback process for assurance of competence and continuous professional development.

4Q2016 Goal:• Disseminate first post-survey (followed by 2 more)

after peer review implementation.• Measure outcomes related to specific unit and nursing

level peer review processes.

Evidence of Accomplishment:Successful development & implementation of a peer review process across all nursing levels.

2016 EPP Council Goal #3Goal #3:Evaluate the Professional Practice Model (PPM) and outcomes related to it’s application.


1Q2016 Goal:• Review & evaluate the PPM with council members

and obtain feedback on potential modifications. • Provide house-wide educational reinforcement on the

PPM.

Pillar: Service

2Q2016 Goal:• Revise PPM based on council modification input. • Council members will identify a specific component of

the PPM to improve outcomes.

Strategic Focus: 5.4: Promote application of the PPM and embed within internal & external customer experiences.

3Q2016 Goal:• Evaluate & monitor outcome data related to the

identified PPM component.

Magnet SOE Evidence: EP2EO: Clinical nurses are involved in the development, implementation, and evaluation of the professional practice model.

4Q2016 Goal:• Demonstrate improved outcomes related to the PPM

component and celebrate successes!

Evidence of Accomplishment:Improved outcomes related to PPM evaluation.

Advanced Practice Nurse Council

Chair: Michelle BurkeCo-chair: Facilitator:

Advanced Practice Nurse (APN) Council

2016 APN Council GoalsAdvance Practice Nurses (APNs) will

increase participation in NCH nursing committees,

local and national professional

organizations.

APNs will utilize funds from Medical

Education for professional nursing

fees, conferences and professional

development

Implement the standardized

onboarding process for Advance Practice

Nurses into the organization.

2016 APN Council Goal #1Goal #1: Advance Practice Nurses (APNs) will increase participation in NCH nursing committees, local and national professional organizations.


1Q2016 Goal: Obtain information on APNs participation in nursing committees and professional organizations

Pillar: People / Growth

2Q2016 Goal: Develop template to track data of APNs in committees and professional organizations

Strategic Focus: 1.9 Encourage active participation in professional nursing organizations.

3Q2016 Goal: Implement template and gather data of APNs in committees and professional organizations.

Magnet SOE Evidence: SE 2EO The healthcareorganization support nurses’ participation in local, regional, national, international professional organizations.

4Q2016 Goal: Evaluate APNs participation in committees and professional organizations.

Evidence of Accomplishment: Involvement and attendance at NCH committees and professional organizations.

2016 APN Council Goal #2Goal #2: APNs will utilize funds from Medical Education for professional nursing fees, conferences and professional development


1Q2016 Goal: Inform APNs of the funds available ($1500/ per person per year) from Medication Education and process to apply for funds.

Pillar: People

2Q2016 Goal: Gather data of funds utilized by APNs from medical education in 2015

Strategic Focus: 1.4 Provide support and professional development opportunities across all levels.

3Q2016 Goal: Create tracker to determine if APNs utilization of funds have increased from 2015

Magnet SOE Evidence: SE 4EO Nurses participate in professional development activities designed to improve their knowledge, skills, and/ or practices in the workplace. Professional development activities are designed to improve the professional practice or nursing or patient outcomes, or both.

4Q2016 Goal: Evaluate funds allotted in relation to APNs professional development.

Evidence of Accomplishment: Data on funds utilized for professional development and fees.

2016 APN Council Goal #3Goal #3: Implement the standardized onboarding process for Advance Practice Nurses into the organization.


1Q2016 Goal: Reviewed information developed by APNs in 2015 of the APN orientation process.

Pillar: People

2Q2016 Goal: Educate the APN group of the hospital wide standardized onboarding process.

Strategic Focus: 1.8 Develop standardized onboarding and orientation programs for nurses across all levels.

3Q2016 Goal: Develop a checklist for new APN hires to navigate the onboarding process.

Magnet SOE Evidence: SE 7 The organization facilitates the effective transition of registered nurses and advanced practice registered nurses into the work environment.

4Q2016 Goal: Evaluate new hire APN onboarding process and develop changes if required.

Evidence of Accomplishment: All new hires will follow standardized onboarding processes

Engagement and Recognition

Chair: Natalie BlancoCo-chair: Facilitator:

Engagement & Recognition (EAR) Council

2016 EAR Council GoalsCreate an

environment of engagement

among staff by implementing

monthly recognitions

Increase council member

involvement in hosting staff recognition

events

Show increase in participation,

satisfaction and recognition with a pre and post

assessment survey

2016 EAR Council Goal #1Goal #1: Increase staff engagement through the implementation of monthly recognitions


1Q2016 Goal: • Collaborate with administration in allowing monthly ‘spirit day’ • Decide on monthly themes• Create appreciation gift toward unit being recognized

Pillar:People

2Q2016 Goal:• Collaborate with staff on improvements for monthly recognitions• Ensure night shit involvement of spirit day

Strategic Focus: 1.2: Enhance staff engagement through innovative strategies.

3Q2016 Goal:• Maintain constant “pass it on gift” to be included in recognition

gift

Magnet SOE Evidence: EP 3 EO: RN satisfaction data outperform the mean or median of the national database used

4Q2016 Goal:• Have full participation of all units on spirit day

Evidence of Accomplishment:All units will participate in spirit day, successful rotation of the appreciation basket throughout the organization & increased engagement scores in the 2017 employee engagement survey.

2016 EAR Council Goal #2Goal #2: Increase council member involvement in hosting staff recognition events


1Q2016 Goal: • Host Certified Nurses’ Day event • Host Daisy representative event• Discuss, plan, and decide all hospital-wide Nurses Week activities

by March 14, 2016• Have hospital wide nurses’ week winners decided by March 31st

• Identify and recognize Daisy Award Recipient(s) at least one nominee per month (on-going)

Pillar: People

2Q2016 Goal:• Host Nurses’ week event May 6 – 12 • Identify and recognize Daisy Award Recipient(s) at least one

nominee per month (on-going)

Strategic Focus: 1.1: Support an environment of peer and interprofessional recognition.

3Q2016 Goal:• Initiate and distribute Nurses’ week ballots• Identify and recognize Daisy Award Recipient(s) at least one

nominee per month (on-going)

Magnet SOE Evidence: SE 11: Nurses are recognized for their contribution in addressing the strategic priorities of the organization.

4Q2016 Goal:• Continue voting for Nurses’ week• All nurses’ week nomination forms to be collected by January 31st

• Identify and recognize Daisy Award Recipient(s) at least one nominee per month (on-going)

Evidence of Accomplishment:Accomplish participation in all events and in turn increase morale and participation among council members and staff.

2016 EAR Council Goal #3Goal #3: Show increase in participation, satisfaction and recognition with a pre and post survey


1Q2016 Goal: • Have staff complete a pre-assessment survey on their

participation, satisfaction and recognition within the organization.

Pillar:People

2Q2016 Goal:• Review pre-assessment survey results and identify opportunities

for improvement.

Strategic Focus: 1.7 Nursing and TM&E collaboration to strengthen recruitment, retention and succession planning endeavors.

3Q2016 Goal:• Ensure that areas requiring improvement have been addressed.

Magnet SOE Evidence: EP 11EO Nurses participate in recruitment and retention assessment and planning activities.

4Q2016 Goal:• Have staff complete post-assessment survey in regards to their

engagement and recognition throughout 2016.

Evidence of Accomplishment:Increase in all areas surveyed among staff.

Nursing Operations Council

Chair: Debbie Hill-RodriguezCo-chair: Facilitator:

Nursing Operations Council (NOC)

2016 NOC Council Goals

Goal 1

Establish a universal means of

communication amongst nursing

leaders across all levels

Goal 2

Create open line of communication with

staff via Q&A platform enhancing transparency

by providing staff ability to ask any

question to the nursing leadership team

Goal 3

Identification of Magnet SOEs in support of the

2017 Magnet Re-Designation Process

2016 NOC Council Goal #1Goal #1: Establish a universal means of communication amongst nursing leaders across all levels


1Q2016 Goal: Establish standing quarterly reports fromall MCHS nursing entities.

Pillar: Quality, Margin

2Q2016 Goal: Quarterly reports from ED, UCC and OR in addition to monthly inpatient reporting.

Strategic Focus: 2.4, 2.53.2

3Q2016 Goal: Continue presentations based on alignment of MCHS priorities

Magnet SOE Evidence: NK 3EP 6TL2, TL 5, TL 7

4Q2016 Goal: Determine effectiveness of presentations by members.

Evidence of Accomplishment: Minutes

2016 NOC Council Goal #2Goal #2: Create open line of communication with staff via Q&A platform enhancing transparency by providing staff ability to ask any question to the nursing leadership team


1Q2016 Goal: Create a survey monkey that is sent to the nursing distribution list each month. Present and answer questions in a stimulated collaborative forum.

Pillar: Service

2Q2016 Goal: Ensure that questions are answered by the 15th of each month. Implement or action plan items.

Strategic Focus: 5.1- Support an environment of transparency

3Q2016 Goal: Survey staff for feedback into the process.

Magnet SOE Evidence: TL 8

4Q2016 Goal: Identify changes in format based on survey feedback and develop a plan based on the suggestions.

Evidence of Accomplishment: Emails sent to staff, continued questions monthly.

2016 NOC Council Goal #3Goal #2: Identification of Magnet SOEs in support of the 2017 Magnet Re-Designation Process


1Q2016 Goal: Complete work sessions during each meeting to identify SOEs occurring through out MCHS.

Pillar: All

2Q2016 Goal: Identify key owners in for the identified SOEs.

Strategic Focus: All

3Q2016 Goal: Work collaboratively with Jennyfor continual identification of SOEs.

Magnet SOE Evidence: All

4Q2016 Goal: Submit written SOEs utilizing the Magnet Excellence Template.

Evidence of Accomplishment: Documentation of SOEs in the Magnet Submission Document.

Adjournment

Chair: Flavia SchimelCo-chair: Betty BogartFacilitator: Laura Hernandez

2016 nursing shared leadership council - magnet.mch.com...feb 02, 2016 · 2016 qso council goal #2...

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