ronald reagan ucla medical center magnet recognition …the magnet recognition program® is the gold...

Ronald Reagan UCLA Medical Center

Magnet Recognition Handbook

AN OVERVIEW OF RRUCLA NURSING EXCELLENCE & OUR JOURNEY TO MAGNET RE-DESIGNATION 2015

http://nursing.uclahealth.org/workfiles/PDF/RRMCPPMBroch.pdf

RRUCLAMC 2015 Magnet Recognition Handbook

Table of Contents Page #

What is Magnet? - Background 3 Magnet Components & Magnet Document Highlights 4-22 Transformational Leadership – 4-7

– Nursing Strategic Plan 4 – Advocacy and Influence 5-6 – Visibility, Accessibility, and Communication 6-7

Structural Empowerment – 8-13 – Professional Development – Interprofessional Involvement 8 – Professional Development – RNs Involved in Professional organizations 8 – Degree and Certification Goals 9-10 – Teaching and Role Development 10-11 – Commitment to Community Involvement 11 – Recognition of Nursing 12 – UPC Accomplishments 13

Exemplary Professional Practice – 14-20 – Professional Practice Model 14 – Care Delivery System 15-16 – Staffing Scheduling, & Budget Processes 16 – Interprofessional Care 17 – Accountability, Autonomy, & Competency 17-18 – Ethics, Privacy, Security, and Confidentiality 18 – Culture of Safety 19 – Quality of care Monitoring and Nurse Sensitive Indicators 20

New Knowledge, Innovations, and Improvement 21-22 – Research 21 – Evidence-Based Practice and Innovation 22

Access to Online Resources 23 RRUCLAMC Magnet Champion Contact Information 24-25 Path to Prepare for Site Visit – aka “The 12 P’s” 26 A Few More Quick Tips for the Appraiser Interview… 27 Magnet Cart Rounds – Coming to your unit soon! 28

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What is Magnet? The Magnet Recognition Program® is the gold standard in measuring a healthcare organization’s nursing excellence. Magnet as we know it today is the culmination of over 30 years of research initiated by Nurse

Scientist Margaret L. McClure, RN, EdD, FAAN and the American Academy of Nursing (AAN) in response to a nation-wide nursing shortage in the early 1980s. McClure studied the practice environments of hospitals that were able to successfully attract and retain nurses during this critical time, teaming with the AAN to identify

similar qualities shared by these organizations, which they named the “14 Forces of Magnetism,” later refined to the “5 Magnet Components” we recognize today:

COMPONENTS OF MAGNET

Based on this ever-evolving research, the American Nurses Credentialing Center (ANCC) periodically updates their rigorous Magnet Recognition Program® requirements based upon emerging evidence and healthcare trends, shaping the advancement of successful nursing practice. Most recently, the ANCC updated their requirements in the 2014 Magnet Manual, requiring 49 exemplary examples of nursing excellence or “Sources of Evidence (SOE)”. These SOEs provide nurses with an opportunity to demonstrate how their organization meets the Magnet standards. In fact, RRUCLA is one of the first re-designating hospitals to submit a document using the 2014 Magnet Manual!

Why is Magnet Recognition Important? Magnet status is the highest honor awarded by the ANCC and recognizes RRUCLA nurses’ ability to provide quality patient care and to initiate innovations in their professional nursing practice. It ensures that UCLA is able to attract and retain the highest level of nursing professionals to provide excellent patient care. As the public grows increasingly medically savvy, they rely on Magnet® designation as an important indication of quality patient care when choosing healthcare providers.

The Magnet Recognition Program® advances 3 goals within health care organizations: 1. Promote quality in a setting that supports professional practice 2. Identify excellence in the delivery of nursing services to patients and families 3. Disseminate best practices in nursing care

You can access the Ronald Reagan UCLA Medical Center 2015 Magnet Redesignation Document by logging on to the UCLA Health Nursing website at http://nursing.uclahealth.org/body.cfm?id=215

http://nursing.uclahealth.org/body.cfm?id=215

MAGNET COMPONENT #1: TRANSFORMATIONAL LEADERSHIP

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Nursing Strategic Plan Magnet Standard:

Nursing’s mission, vision, values and strategic plan align with UCLA Health’s priorities to improve performance.

RRUCLA Evidence: The Department of Nursing shares the mission, vision, and values of UCLA Health:

MISSION: To deliver leading edge patient care, research, and education. VISION: Healing humankind, one patient at a time, by improving health, alleviating suffering, and

delivering acts of kindness. VALUES: Integrity, Compassion, Respect, Teamwork, Excellence, and Discovery.

Similarly, the Department of Nursing Strategic Plan is aligned with the UCLA Health Strategic Plan. The Nursing Strategic Plan is updated annually at the Nursing Strategic Planning Retreat led by Chief Nursing Officer Heidi Crooks, MA, RN. Here, nurse executives, unit directors, and clinical nurses collaborate to ensure contributions from all practice areas and service lines are included. Unit-level goals are then created using the Nursing Strategic Plan as a guide, thus providing an aligned vision and continuity across the organization.

Access the RRUCLA Evidence: Please view the UCLA Health Strategic Plan and the UCLA Nursing

Strategic Plan by visiting the UCLA Nursing website: http://nursing.uclahealth.org/body.cfm?id=216

You can also read more in the Magnet Document about how the UCLA Health Nursing Strategic Plan is utilized to influence and guide nursing practice in the following SOEs:

NURSING STRATEGIC PLAN - TL1EO Enhancing the Practice Environment in Order to Reduce Nursing Turnover

Health System Float/Resource Nursing Admin Finance

Partnering to Decrease Sepsis Mortality Health System NRE Nursing Admin 4ICU QMS Overhead

ADVOCATING RESOURCES - TL2 Clinical Nurse Specialists Advocate for Specialty Surgical Surfaces

7ICU Entersomal Therapy 8W OR Admin

Nurse Residents Advocate for Products to Support Infection Prevention 8ICU TPN Services

http://nursing.uclahealth.org/body.cfm?id=216


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Advocacy & Influence Magnet Standard: At RRUCLA, a strong trust exists between the CNO, nursing directors, and clinical nurses. Nurses are empowered to advocate for the needs of patients and families, and nursing leaders use their influence to ensure that these needs are met.

RRUCLA Evidence: Chief Nursing Officer Heidi Crooks, MA, RN, nursing leaders, and clinical nurses serve on hospital committees to advocate for resources that ensure that nurses have the best practice environment to care for patients. Through unit practice councils, hospital committees, and other structures, clinical nurses and nurse leaders have worked together to advocate for improvement. All efforts led to safer care for our patients and families!

Access the RRUCLA Evidence: The great successes of RRUCLA nurses’ advocacy and influence are highlighted in the Magnet document and include the following SOEs:

CNO INVOLVEMENT IN ORGANIZATIONAL INFLUENCE - TL3 CNO-Led Successful Implementation of Safe-Handling & Mobility Program

Health System PT/OT Admin

CNO INVOLVEMENT IN ORGANIZATIONAL DECISION-MAKING - TL4 Redesigning for the Future of UCLA Health: The CNO’s Strategic Role

Nursing Admin Neurosurgery Emergency Dept Nutrition NRE Operations 6ICU Ambulatory 6N Physcian Support Anesthesiology PT/OT Inpatient Data Respository Risk Mngt Speech Clinic Social Work Performance Excellence Pharmacy

Selection, Planning, & Implementation of a Fully Integrated Electronic Health Record: The CNO’s Strategic Role

Anesthesiology Radiation Oncology Compliance, Privacy, & Security

Procurement & Strategic Sourcing

DOM Nursing Admin Enterprises Admin Surgery Family Medicine Urology NPI Clinical System Team Path & Lab Med EMR Peds Physician Support

NURSE LEADERS GUIDING CHANGE - TL5 Leading Through Emergent and Unplanned Change – Sigma Pump Functionality Challenge

4ICU 7E/5E 6E 7W Nursing Admin

Implementation of a Bedside Report Practice Change on Inpatient Units

RRUCLA Nursing Admin 7W


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DEVELOPING LEADERS - TL6 Mentoring and Succession Planning for Clinical Nurses: Professional Role-Based Coach Program

Health System External Consultant Nursing Admin 7E/5E

Mentoring and Succession Planning for Nurse Managers: Succession Planning Program

Nursing Admin Labor & Delivery 7W MOU 8W NICU Float/Resource PICC Radiology

Mentoring and Succession Planning for Nurse Leaders: UCLA Health System Leadership Academy

Nursing Admin Materials MGMT 7ICU IR Radiology Anesthesiology Operations Disaster Resource Center

Operative Services

Division of Infectious Disease

Performance Excellence

Emergency Department, System

Resnick Outpatient Programs

GIM & HSR RR General Surgery HR Operations & Staff Develop

Office of the Patient Experience

Mentoring and Succession Planning for the Chief Nursing Officer: CNO Succession Planning

Health System Nursing Admin

DATA DRIVEN RESOURCING - TL7 Trended Fall Data Leads to Acquisition of Low Beds 8N Nursing Admin

Enterostomal Therapy Nursing System Materials MGMT Procurement &

Strategic Sourcing

Visibility, Accessibility, & Communication

Magnet Standard: Nurse leaders are available to clinical nurses and are open to hearing nurses’ views and concerns. Nurse leaders and clinical nurses work collaboratively to make decisions in the best interest of our patients, their families, and our nurses.

RRUCLA Evidence: Heidi Crooks, CNO and the directors of nursing have brown bag sessions, attend various unit meetings, and have open-door policies to hear concerns. Through these venues, the nursing directors and CNO have advocated for practice changes.

Access the RRUCLA Evidence: Read more about the efforts of nurse leaders to increase their visibility and to serve as advocates and role models for clinical nurses, patients, and families in the following SOEs:


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CNO VISIBILITY AND ACCESSIBILITY - TL8 Clinical Nurse Advocacy for Patient Safety Around the Hospital

6E OR Operations Enterprises Admin

OR Admin Nursing Admin

Ensuring Clinical Nurse Competency

5E 6E HR 6N 6W NRE 7E 8N PICU NPH Emergency Dept. OR NICU Ambulatory

INFLUENCING CHANGE - TL9EO Addition of Pediatric NPs in Response to Nurse Concerns about Quality & Safety in the PICU

Nurse Recruitment Peds Nursing Admin PICU

Creation of a Multidisciplinary Toolkit for Management of Escalating Patient Behaviors in Response to Clinical Nurse Concerns about Safety and Quality of Care

7E/5E Internal Medicine 7W Nursing Admin 8ICU Operations Care Coordination Risk Management Pt Liaison Program Pt Placement & Transfer Ctr Emergency Preparedness, Safety, and Security

MAGNET COMPONENT #2: STRUCTURAL EMPOWERMENT

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Interprofessional Involvement

Magnet Standard: The UCLA Health Department of Nursing supports the continuous professional development of our nurses. UCLA Health nurses serve in leadership roles on interprofessional councils and participate in decision-making that improves care for patients.

RRUCLA Evidence: UCLA Health supports structures and processes that ensure nurses from all settings and roles actively participate in organizational decision-making groups such as councils, committees, and performance excellence teams. Nurse representatives serve on the Ethics Committee, Pharmacy and Therapeutics Committee, Clinical Effectiveness Committee, and a variety of other quality committees. Nurses volunteer, apply, or are appointed to decision-making groups and serve in various roles on the groups, including group leader or chair of the committee. Nurses’ participation on these committees has led to improved patient outcomes and safer practices throughout UCLA Health.

Access the RRUCLA Evidence: Read more about the work on interprofessional committees in the following SOEs:

INTERPROFESSIONAL DECISION-MAKING GROUPS - SE1EO Improving the Care of Stroke Patients 6ICU Neurosurgery Emergency Med

6N ED QMS Overhead Pharmacy PT/OT Admin-MP Neurology SMH Radiology

Ensuring Safe Access to Blood Products 7ICU Emergency Dept 8ICU Labor & Delivery

Nurses Involved in Professional Organizations Magnet Standard:

UCLA Health nurses are involved with professional organizations that help to shape practice and facilitate evidence-based change.

RRUCLA Evidence: Many UCLA Health nurses are members of professional nursing organizations. Some examples include the American Association of Critical Care Nurses (AACN), the Emergency Nurses Association (ENA), and the American Organization of Nurse Executives. UCLA Health nurses utilize professional nursing organization standards to improve clinical practice and patient outcomes at UCLA.

Access the RRUCLA Evidence: Read more about UCLA Health nurses’ involvement with professional organizations has helped improve delivery of care:

PROFESSIONAL ORGANIZATION PARTICIPATION - SE2EO Use of ASORN Guidelines to Improve Surgical Site Markings JSEI OR JSEI Pre/Post OP Unit

Improving Delirium Assessment in the Neurotrauma ICU Based on AACN Recommendations

6ICU NRE Neurosurgery


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Baseline 2011 2012 2013 2014Certified Nurses, Overall 439 478 564 610 738Organization Goal (whole

number) 400 450 525 600 676

0200400600800

# of

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tific

atio

ns

Professional Nursing Certification 2011-2014

Degree & Certification Goals Magnet Standard:

The RRUCLA Department of Nursing is committed to supporting and facilitating the educational and professional development of our nursing staff.

RRUCLA Evidence: RRUCLA nursing has set a strategic goal and has a plan to ensure that 80% of our nurses have a BSN or higher nursing degree by the year 2020, in alignment with the IOM/RWJF Future of Nursing Recommendations.

UCLA Health has supported nurses’ professional development by working to increase professional certification. We are happy to report that in 2014, our number of Certified RNs reached 738, 62 more than our goal!

Access the RRUCLA Evidence: Read more about the efforts to increase education and certifications for nurses in the following SOEs:

PROFESSIONAL NURSING CERTIFICATION - SE3EO Increasing Professional Nursing Certification at the Organizational Level

NRE

Increasing Professional Nursing Certification at the Unit Level

NRE Peds

2012 2013 2014% of RNs with BSN+ 63% 67% 73%Target 63% 66% 68%

60%62%64%66%68%70%72%74%

Perc

enta

ge o

f RN

s

% of RNs with BSN or Higher Degree


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Teaching & Professional

Role Development

CONTINUING EDUCATION PROGRAMS - SE4EO Improving Referrals to Palliative Care in the ICU through Education

4ICU

Use of a Structured Infection Prevention Program to Decrease Rates of CLABSI

4ICU 7N PEDS 6E 7W PICU 6ICU 8ICU NICU 7E/5E 8N Dialysis 7ICU 8W Float pool NRE Nursing Admin Infection Control

NON-NURSE CAREER PROGRAMS - SE5 Community Partnership with King Drew Magnet High School of Medicine and Science

Nursing Admin 8W 6ICU Cardiology Peds 6N IR Radiology ED 7E/5E GOU/4ICU Pt Escort Service Surgery - Recovery - MP

Teaching & Role Development Magnet Standard:

UCLA Health nurses recognize the important role we play in ensuring that patients understand their health.

RRUCLA Evidence: UCLA nurses use evidence-based teaching strategies to engage patients in their health. Nurses serve in leadership roles on the Patient Engagement Committee and have provided feedback about teaching tools in CareConnect, including discharge and medication teaching resources. Across the organization, nurses have led efforts to standardize teach-back strategies in order to ensure that patients understand information about their health, hospitalization, medications, and discharge plans.

At UCLA Health, nurses never stop learning. The UCLA Health Department of Nursing Research and Education (NRE) has established an infrastructure to provide nurses across the health system with opportunities for lifelong professional growth. Educational and professional development programs are structured to best meet the unique needs of our clinical nurses and to support them in their efforts to ensure consistently high quality care for our patients and their families. Classes are designed to provide current clinical and professional nursing content and are delivered using evidence-based teaching/learning strategies.

Access the RRUCLA Evidence: Read more about the efforts of nurses to increase education and to serve as role models for their patients, families, and next generation of nurses in the following SOEs:


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NURSES AS TEACHERS - SE6 Teach-Back Educational Summit and Meducation Toolkit to improve nurses’ expertise in patient and family teaching

7CCU DOM Diabetic Services 7W ED Nursing Admin NRE TPN Services

CONTINUING EDUCATION PROGRAMS - SE7 Onboarding & Orientation of Newly Hired Experienced Nurses

HR Recruitment HR NRE Operations Personnel

Onboarding & Orientation of New Graduate Nurses NRE

DEVELOPING NURSE PRECEPTORS - SE8 Growing Expert Preceptors through a Standardized Preceptor Program

Labor and Delivery NRE

Commitment to Community Involvement

Magnet Standard: UCLA Health nurses are committed to improving the health of both our local and international communities, and they are responsible for leading and supporting efforts to ensure all people are provided the best healthcare possible.

RRUCLA Evidence: UCLA nurses have taken leadership and volunteer roles in over 100 community organizations. In these organizations, our nurses work tirelessly to provide leading-edge patient care and to facilitate an improved quality of life for individuals in our community.

Access the RRUCLA Evidence Read more about the efforts of nurses to serve our local & international community in the following SOEs:

COMMUNITY OUTREACH - SE9 UCLA Nurses Respond to Typhoon Haiyan Pt Relations 6E Clinical System Team

PACU HR Materials Mgmt

UCLA RN Orchestrates 27th Annual Oley Foundation Conference

PICC RADIOLOGY 6ICU Resource Team TPN Services PEDS 7E/5E Enterostomal Therapy

COMMUNITY HEALTHCARE NEEDS ASSESSMENT - SE10EO Facilitating a Camp Experience for Children with Heart Disease: The Camp Del Corazon Experience

Catheterization Lab GONDA Float Pool PEDS


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Recognition of Nursing Magnet Standard:

Nurses are valued and recognized at UCLA Health.

RRUCLA Evidence: At UCLA Health, outstanding nurses are recognized for their contributions to our vision of healing humankind, one patient at a time. Nurses are recognized as individuals for exemplary performance, as well as in teams demonstrating high levels of collegial support and collaboration to achieve extraordinary results. One program that enables us to appreciate both individuals and teams for their contributions to our strategic priorities and mission at UCLA Health is the biannual DAISY Award Program.

Patients, family members, and health system employees may nominate nurses for a DAISY Award. Nomination forms are available on all inpatient units and clinics for anyone to complete, and are collected by the Human Resources Department. Manager of Nurse Recruitment Sheri Monsein, MN, RN, was instrumental in initiating the DAISY Award Program at UCLA Health and continues to administer the program. It is a key component of our strategy for recruitment and retention of excellent nurses.

Access the RRUCLA Evidence: Read More about UCLA Health’s recognition and celebration of our outstanding nurses in the following SOEs:

RECOGNING NURSES - SE11 Recognition of a Clinical Nurse

SON PICU 8N Nurse Recruitment 6W 5E OB 7ICU Nursing Admin

Recognition of a Group of Nurses

7E/5EMS Nursing Admin Nurse Recruitment

2014 Daisy Award Winner Maxine Pintado, RN, being honored by Director of Inpatient Nursing Cathy Ward, DNSc, RN, and Chief Nursing Officer Heidi Crooks, MA, RN


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RRUCLA Unit Practice Council Accomplishments The Unit Practice Councils and the subcommittees of the Nursing Quality Outcomes Council, led by Nurse

Subject Matter Experts, can be proud of their accomplishments this past year: Unit UPC Initiative Outcomes

Main OR Practice change to improve communication during Patient Handovers

Safer Handovers; ↑ medication safety compliance; ↑ teamwork at handover

Emergency Depart. Security Improvements Enhancement of Patient & Provider Safety

MICU Teach Back Initiative Reached 73rd

Percentile in HCAHPS: “RN explained things in a way you could understand.”

Peds Bug Buster Committee efforts, including 2 RN Dressing Changes 170 days without a CLABSI

5E OB OFRAS Tool Development • Improved OB fall rate

• Tool disseminated nationally

NICU Improving Turnaround Time for the First Dose of in Antibiotic in the NICU

↑ Percentage of patients that received their 1st

dose of an antibiotic within an hour

PICU Nurse Rounding Script ↑ in Parent Satisfaction “RN Discussed Plan of Care Daily” Scores

6 East Medication Teaching Cards • Received Joint Commission recognition as Best Practice

• HCAHPS - Reached 90th

%ile for Medication Communication

6ICU New change of shift visitation guidelines to include family members

Reached 90th

%ile for HCAHPS question: “RN explained things in a way you could understand.”

6 North Patient Falls Initiative Decrease in Patient Injury Falls: 9 Months with 0 Falls with Injury

6 West Implemented Green Apple Project Improved glucose control in diabetic patients

7E/5E MS Role-Based Practice Quality Improvement Champions Program initiated Reduction in CLABSIs

7ICU “Home is Where the Heart Is” Discharge Teaching Handbook

Above 70th

%ile for HCAHPS Medication Communication for 2013

7CCU Communication Workshops, Crucial Conversation Skills

Improvement in RN-RN Communication, Interdisciplinary Communication, & RN-Patient Communication on Unit

7 West Collaborative Teamwork with Fall Prevention Toileting Program

• 4 Months without a Bathroom related fall! • 7 Months with 0 Falls with Injury

7COU 5 Minute Time Out Improved HCAHPS Score: “Treated with Courtesy and Respect” from 80% → 91%

8 East Transforming Tragedy to a Safe Practice Change Opportunity: Icodextrin Protocol

• 100% Compliance with new Icodextrin Protocol; 0 Icodextrin Events since implemented

8ICU CUSP Initiative to reduce CLABSI Overall reduction in CLABSI rates; 0 CLABSI occurrences in Jan. 2014

8 North Modified Floating Policy in January 2013 Increase in primary nursing/continuity of care

8 West HAPU Prevention Hospital Acquired Pressure Ulcers for 4 Months; ↑HCAHPS Scores

GOU ‘Always’ Project ↑in RN teach-back protocol knowledge and compliance, ↑in patient satisfaction

Cath Lab MD-RN Verbal callback with medications during procedures Improved RN-MD communication, increased patient safety

MAGNET COMPONENT #3: EXEMPLARY PROFESSIONAL PRACTICE

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Professional Practice Model Magnet Standard:

Nurses at UCLA Health own and live the Professional Practice Model to drive the work of nursing forward for our patients, families, community, and the organization.

RRUCLA Evidence:

The Professional Practice Model (PPM) at UCLA Health is exemplary because it was conceived and advanced over time through the collaborative efforts of clinical nurses and their nurse leaders utilizing the Professional Role Development Strategic Initiative. The purpose of this Initiative is to strengthen RN professional role autonomy and decision-making authority, ensuring empowerment is lived and experienced by all registered nurses at UCLA.

Access the RRUCLA Evidence:

Read more about RRUCLA’s Professional Practice Model and how our outstanding nurses utilize the PPM to advance nursing practice in the following SOEs:

PROFESSIONAL PRACTICE MODEL - EP1 Evaluation of the Professional Practice Model Nursing Admin 7E/5EMS

RESULTS OF THE PROFESSIONAL PRACTICE MODEL - EP2EO Using the PPM to Implement a Teamwork-Based Care Delivery Model on 7W 7W

NURSE SATISFACTION DATA - EP3EO Nurse Satisfaction Survey Overview All Units

http://nursing.uclahealth.org/workfiles/PDF/RRMCPPMBroch.pdf


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Care Delivery System Magnet Standard: RRUCLA nurses are guided by the UCLA Health Department of Nursing’s Professional Practice Model, our organizational vision, and the relationship-based care delivery model to create partnerships with patients and their families. Nurses strive to understand each patient as a unique person with individualized goals and preferences. Further, in order to ensure continuity of care, nurses document these specific needs in CareConnect. The “patient story” screen enables nurses to capture information that is meaningful to the patient and facilitates a context for patient and family partnership with clinicians.

RRUCLA Evidence: UCLA Health’s Care Delivery System is Relationship-Based Care (RBC). Key elements of RBC include: • Professional nursing practice is patient-centered; all decisions are centered around the unique needs of

our patients and their families. • Interprofessional communication and teamwork is incorporated into care delivery on behalf of the

patient. • The patient and the patient’s family are seen as persons (body, mind, and spirit) by all care providers. • Careful scheduling of patient assignments allows for continuity of care. • “Care of self” is important to maintain optimum health. This fosters empathy for the experience of

others and for being a productive member of the nursing care team. • Nurses know that each person’s unique life story determines how he or she will experience an illness.

Access the RRUCLA Evidence: Read more about RRUCLA’s care delivery model and about how our outstanding nurses utilize RBC to improve patient outcomes in the following SOEs:

ESTABLISHING A PLAN OF CARE - EP4 Nurse as Patient – Providing Individualized Care to a Colleague 4ICU Ensuring Optimal Care for Peds Patients Across the Continuum of Care ED Peds

INTERPROFESSIONAL COLLABORATION - EP5 Care Coordination for Liver Transplant Patients 8N 8ICU

Care Coordination for Aortic Repair Patients UCLA Aortic Center REGULATORY & PROFESSIONAL STANDARDS - EP6

Incorporating Vascular Access Standards into Care

7E/5E PICU Case Management CCTT GOU NRE ED SIM LAB

STANDARDS OF CARE AND PRACTICE - EP7EO Using AWHONN and Baby-Friendly Standards to Enhance Skin-to-Skin Initiation After Vaginal Births

5E OB L&D


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INTERNAL EXPERTS - EP8EO Internal Consultant facilitates reduction in adverse glycemic events: The Green Apple Project

6W 8N 7E Diabetes Services 7E/5E Nursing Admin 7W Pharmacy

Staffing, Scheduling, & Budgeting Processes Magnet Standard: The acuity and care needs of patients on the unit, along with the skill-mix of clinicians, affect staffing decisions. Working together, nurse leaders and clinical nurses have developed staffing plans that strategically allocate staff resources to meet the needs of their patient population.

RRUCLA Evidence: Clinical nurses are empowered to adjust RN and support staff assignments/schedules to best adapt to changes in patient and environmental conditions while maintaining the quality of care. Further, through the work of the UPC and other shared governance structures, clinical nurses are empowered and encouraged to utilize trended data gathered on their unit to influence budgetary spending and allocation of resources.

Nurses participate in staffing and scheduling: o Acuity ratings are documented for each patient every shift o Lead nurses consult with clinical nurses regarding staffing needs o Clinical nurses participate in self-scheduling

Nurses participate in recruitment & retention: o Participation in hiring interviews o Mentorship to novice nurses

Nurses participate in budgetary data analysis: o Trended data is used to influence budget allocation decisions o Lead nurses consult with clinical nurses regarding staffing needs

Access the RRUCLA Evidence: Read more about how RRUCLA’s nurses are empowered to influence staffing, scheduling, and budgeting needs in the following SOEs:

STAFFING/SCHEDULING PARTICIPATION - EP9 CTICU Nurse Advocates for Resources to Meet Acuity Demands 7ICU NICU Clinical Nurse Advocates for Resources for Detriorating Neonate

NICU

BUDGET DATA ANALYSIS - EP10 Operating Room Clinical Nurses Shift Start Times to Provide Adequate Staffing

OR

Creation of a Nurse-led Volunteer Companion Program to Subsitute for Constant Observation Aides

Nursing Admin Peds

RECRUITMENT & RETENTION - EP11EO Clinical Advancement Program for PICU Nurses PICU


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Interprofessional Care Magnet Standard:

At UCLA Health, healthcare providers recognize their role as a vital component of their patient’s interprofessional healthcare team.

RRUCLA Evidence:

For RRUCLA physicians, nurses, administrative and clinical care partners, social workers, and therapists, collaboration is the key to positive patient outcomes. From participation on hospital- and system-wide interprofessional committees to multidisciplinary care at the patient’s bedside, interprofessional care teams are united in their shared goal of, “Healing humankind, one patient at a time.”

Access the RRUCLA Evidence:

Read more about how nurses at RRUCLA are a vital part of the interprofessional team in the following SOEs:

NURSING LEADERSHIP ROLES - EP12 Transitioning Patients from the OR to Cardio-Thoracic ICU: An Interprofessional Standardized Handover

7ICU Anesthesiology

PATIENT EDUCATION PROGRAMS - EP13EO Colorectal Surgery Education for Patients

Infection Control 8E OR Admin Enterostomal Therapy

8N PERIOP

Hemapheresis 8W Urology QMS Overhead SOM Surgery Anesthesiology OR DOM Sterile Processing PEDS Pharmacy

Accountability, Autonomy, & Competency Magnet Standard:

Accountability, autonomy, and competency assurance are essential to achieving and maintaining the highest level of professional nursing care. Structures and processes are in place to ensure that all healthcare providers are held accountable for their work.

RRUCLA Evidence: Competencies are assessed annually for all UCLA Health employees. These competency assessments are combined with self-appraisal and peer feedback to provide a transparent, 360◦ performance evaluation. Clinical nurses are thereby empowered to use their clinical expertise to advocate for patients and families, in the same way that nurse leaders advocate on behalf of their clinical nurses, and that CNO Heidi Crooks advocates for nurses and nursing practice across the health system.

Access the RRUCLA Evidence: Read more about the accountability, autonomy, and competency of nurses at RRUCLA in the following SOEs:


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RESOURCES FOR AUTONOMOUS PRACTICE - EP14 Nurse-Driven Skin and Wound Care Practices

Enterostomal Therapy PICU

Early Mobility in the Medical ICU 4ICU PERFORMANCE & PEER REVIEW - EP15

Nursing Self-Appraisal and Peer Feedback Promote Professional Development for Clinical Nurses

7W NRE

Nursing Self-Appraisal and Peer Feedback Promote Professional Development for Nurse Leaders

7W NRE

NURSING AUTONOMY - EP16 Autonomous Nursing Practice in Complex Care Coordination Children's Heart Center

Clinical Nutrition Social Work

Autonomous Nursing Practice in Neonatal End-of-Life Care

NNP Program L&D Respiratory Therapy NICU Spiritual Care Peds

Ethics, Privacy, Security, and Confidentiality Magnet Standard:

At UCLA Health, nurses are guided by the ANA Code of Ethics in their care delivery.

RRUCLA Evidence: There are many resources available to clinical nurses and nurse leaders to help to guide this component of their professional practice, including:

• UCLA Ethics Center, which provides 24-hour consultation for ethics-related matters

• Clinical nurses participation on the UCLA Ethics Committee • Ethics Grand Rounds • Circle of Caring Retreat • Annual training on policies and procedures around confidentiality • The UCLA Privacy Management Office, which monitors patient privacy and compliance

Access the RRUCLA Evidence: Read more about the ethics, privacy, security, and confidentiality practices of UCLA Health in the following SOE:

Culture of Safety

ETHICAL ISSUES - EP17 Ethics Center Services Support and Develop Ethical Nursing Practice

Ethics Center NRE NICU


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Magnet Standard: At UCLA Health, the safety of our patients and our healthcare personnel is of the utmost concern.

RRUCLA Evidence: There are many resources available to clinical nurses and nurse leaders to help safeguard the health and well-being of patients, families, and health system employees. Several successful safety interventions have been initiated by clinical nurses throughout RRUCLA.

Access the RRUCLA Evidence: Read more about RRUCLA’s culture of safety practices in the following SOEs:

WORKPLACE SAFETY - EP18EO Reducing Needlestick Injuries through Standardization of Safety Needles

4ICU Enterostomal Therapy 6E Infection Control 6N Materials mgmt 7E/5E TPN Services 7ICU Occupational Health 7N PT/OT Inpatient 8ICU Respiratory Therapy OR Admin PICU

Procurement & Strategic Sourcing

Improving Nurse Safety in the Emergency Department by Targeting Workplace Violence

ED Nursing Admin Security Department

PROACTIVE RISK MANAGEMENT - EP19EO Nurses improve Safety by Reducing Medication Errors

6N 8ICU Diabetic Services 6E 8N Nursing Admin 6W 7E/5E ED 7E PEDS Anesthesiology 8W 7W IT Help Desk

EVALUATING PATIENT SAFETY DATA - EP20EO Implementation of the ‘Bug Busters’ Committee on Acute Care Pediatrics

Infection Control Peds NRE

Implementation of SBAR Standardized Practice to Reduce Time to Transport by the CCTT

Critical Care Transport Team

PATIENT SAFETY GOALS - EP21EO Nurses Leading Improvement in Medication Labeling and Communication in Perioperative Settings

OR


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Quality of Care Monitoring and Nurse Sensitive Indicators Magnet Standard:

At UCLA Health, measures of the safety of our patients, quality of nursing care, and patient satisfaction are collected throughout the year. Our data is then sent to the American Nurses Association (ANA) National Database of Nursing Quality Indicators (NDNQI) and to the National Healthcare Safety Network (NHSN), where it is incorporated into the national mean score for all academic medical centers. Our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are also reported to the Center for Medicare and Medicaid Services’ (CMS) Hospital Compare website.

RRUCLA Evidence: We benchmark our performance against the ANA’s NDNQI academic medical center mean for falls with injury and hospital-acquired pressure ulcers – stage II & above.

Falls with Injuries: The majority of inpatient units at RRUCLA (14/17) outperformed the NDNQI benchmark mean for the majority of the last eight quarters reported for falls with Injury.

Hospital-Acquired Pressure Ulcers (HAPU): The majority of inpatient units at RRUCLA (10/15) outperformed the NDNQI benchmark mean the majority of the last eight quarters reported for HAPU – stage II & above.

For central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), UCLA Health has chosen to benchmark our performance against the National Healthcare Safety Network (NHSN) Centers for Disease Control and Prevention (CDC) cohort pooled mean.

Central-Line Associated Bloodstream Infections: The majority of inpatient units at RRUCLA (12/23) outperformed the NHSN benchmark mean the majority of the last eight quarters reported for CLABSI.

Catheter-Associated Urinary Tract Infections: The majority of RRUCLA inpatient units (2/8) did not outperform the NHSN benchmark mean the majority of the last eight quarters reported for CAUTI. To improve our CAUTI rates, house-wide surveillance began in Q2 2014. Additionally, the organization has created a multidisciplinary taskforce to review best practices, create a nurse-driven protocol to remove indwelling urinary catheters, and provide house-wide education on the details of the maintenance bundle practices. This taskforce includes participation from nursing leadership, physicians, IT leaders, and clinical nurses.

Access the RRUCLA Evidence: Read more about RRUCLA’s nurse-sensitive indicators and patient satisfaction scores in the following SOEs:

NURSE SENSITIVE QUALITY INDICATORS - EP22EO Nurse-Sensitive Quality Indicators: Data Collection & Benchmarks

All Units Nursing Admin

PATIENT SATISFACTION - EP23EO Patient Satisfaction Survey Overview All Units

Nursing Admin

MAGNET COMPONENT #4: NEW KNOWLEDGE, INNOVATIONS, & IMPROVEMENT

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Research Magnet Standard:

The Department of Nursing at Ronald Reagan UCLA Medical Center offers a variety of resources to support the development of clinical nurses in their professional roles of scientist and transferor of knowledge.

RRUCLA Evidence: As nurses conduct research, there are multiple structures in place to support dissemination internally, including:

• The “Investigator” newsletter • Nursing Research Grand Rounds • The Annual Nursing Research and Evidence-based Practice Conference

These structures and processes are supported through the Nursing Practice Research Council. UCLA Health nursing leadership created the Nursing Practice Research Council (NPRC) with a vision to develop and support innovations that heal humankind through the application of evidence-based knowledge to clinical practice. The NPRC laid the foundation for research and evidence-based practice (EBP) at UCLA Health and continues to focus on its mission of increasing the scientific foundation of practice through research conduct and utilization activities in the following four areas of work:

1) Research development - providing consultation in the design, implementation, analysis, and publication of nursing research

2) Research utilization – identifying and disseminating clinical research findings that are sufficient and appropriate to apply to nursing practice

3) Research education – occurring through classes throughout the year and through the annual Research and Evidence-Based Practice Conference

4) Research dissemination - providing structures and processes for the dissemination of research and other levels of evidence

Access the RRUCLA Evidence: Read more about RRUCLA’s nursing research in the following SOEs:

ADVANCING NURSING RESEARCH - NK1EO Improving the Care Experience for Children with Complex Chronic Conditions and their Families in the PICU: Parent and Nurse Perceptions

PICU

DISSEMINATING RESEARCH KNOWLEDGE - NK2 Nursing Grand Rounds Support Internal Dissemination of Nursing Research

7W NRE DOM PICU ETHICS

Dissemination of Nursing Research to External Audiences: The Annual UCLA Nursing Research and Evidence-Based Practice Confernece

SOM Neurology

MAGNET COMPONENT #4: NEW KNOWLEDGE, INNOVATIONS, & IMPROVEMENT

22

Evidence-Based Practice & Innovation Magnet Standard: Nurses at UCLA Health are encouraged and supported to understand the evidence base for their clinical practice and to adapt practice to reflect the most current evidence. They are further supported to design and implement innovative adaptations to care when the current evidence is lacking or an improvement in care is needed.

RRUCLA Evidence: There are many resources to promote nursing research, evidence-based practice, & innovation, including but not limited to:

• UCLA Nursing Research and EBP Program • Clinical practice council • Mosby’s on-line resource • Nurse EBP fellowship program • Nursing grand rounds • “The Investigator” newsletter • Annual Research and EBP Conference • Access to UCLA Medical Sciences Library • UCLA Chief Nursing Informatics Officer and nurse informaticists

Access the RRUCLA Evidence: Read more about RRUCLA’s evidence-based practice and nursing innovations in the following SOEs:

INTEGRATING EVIDENCE-BASED FINDINGS INTO PRACTICE - NK3 Use of the Clinical Practice Council to Develop New Early Mobility Practices

4ICU PACU PT/OT Admin-MP 6ICU PICU Respiratory Therapy 7CCU 8ICU CCTT 7ICU

Use of the Clinical Practice Council to Revise Urinary Catheter Management Practices

8W 7E GOU 6E 7N 6N

NURSING INNOVATION - NK4 Interprofessional Innovation in Fall Prevention

6E 8N 6N Nursing Admin 6ICU OR 7E/5E

Innovation in Pediatric Sepsis Management QMS Overhead Peds ED PICU

IMPLEMENTATION - NK5EO Enhancing Nurse Immunization Screening Using E.H.R. Functionality

7E/5E Nursing Admin Infection Control PICU ISS/CareConnect QMS Overhead ED

Improvement in Patient Experience with Technology

6E 8N L&R 8ICU GOU

IMPROVING WORK FLOW AND SPACE DESIGN - NK6EO Nurses Leading Efforts to Reduce Waste 8E Materials Management

23

Learn more about Magnet Designation® & UCLA Health’s Magnet Journey!

Please visit the UCLA Health Department of Nursing website at http://nursing.uclahealth.org/body.cfm?id=99

Simply click on the ‘Magnet Journey’ tab at the top of the page to gain access to:

• RRUCLAMC’s Magnet Document

• UCLA Health’s Annual Nursing Report

• UCLA Health Strategic Plans • Magnet Site Visit Resource materials

• And much more!

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UNIT NAME & ROLE EMAIL ADDRESS UCLA Health Jennifer Zanotti, MS, RN Magnet Program Director [email protected]

UCLA Health Charlene Collazzi, BA – Magnet Analyst [email protected]

UCLA Health Jennifer Baird, PhD, RN [email protected]

UCLA Health Elizabeth Rowan, BSN, RN - Magnet Fellow [email protected]

UCLA Health Megan Sitrin MSN, RN - Magnet Fellow [email protected]

Float Pool/ Resource Team

Susanne Polka, BSN, RN Bethany Reichard, BSN, RN Anndalos Bindra, MSN, RN

Kim King, RN Maya King, RN

Rolanda Florence, BSN, RN Natalia Cardenas, RN

Brittany Marmion, BSN, RN Kristin Helstrom, RN

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

ED

Gene St. Pierre, MSN, RN Kerry Gold-Tsakonas, BSN, RN

Marcia Santini, MS,RN Erik Coll, BSN, RN

Kayla Vandegrift, BSN, RN

[email protected] [email protected] [email protected] [email protected] [email protected]

GOU Amelia Morva, BSN, RN

John Sy, RN Marcy Trinidad, RN

Miriam Gonzales-Lopez, MSN, RN

[email protected] [email protected] [email protected] [email protected]

OR Lauren Fujihara, MSN, CNS, RN [email protected]

Cath Lab Angelica Lewis, MSN, RN, NP [email protected]

PTU/PACU/TRU

Linsey Weigt, MSN, RN Joseph Floody, BSN, RN

Cherrylin McLarney, MSN, RN Michele Puzon, MS, RN (TRU)

Linda Delgizzi , MSN, RN (PTU) Linda Olson MSN, RN (PACU)

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

MPU Linsey Weigt MSN, RN Camilla Kodama, RN

[email protected] [email protected]

4ICU

Xueqing Xu, MSN, RN Yu-Han Kao, MSN, RN Ana Andress, BSN, RN

Vicky Ramirez, BSN, RN Ariana Bruno, RN

Taylor Gorman, BSN, RN Chelsea Stone, RN

Melissa Viloria, BSN, RN Elijah Lee, RN

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

5N Perinatal

Debbie Suda, MSN, RN Nicole Casalenuovo, MSN, RN

Jennifer Barnato, BSN, RN Caroline Armstrong, BSN, RN


5 NICU

Heaven Holdbrooks, MSN, CNS, RN Anahit Sarin-Gulian, MSN, RN

Brittany Laddusaw, BSN, RN Mae de Vera Reyes, MSN, RN

Yolanda Kastner, BSN, RN


Quality Brenda Clemens, BHA, RN [email protected]

MITS Meg Furukawa, MN, RN [email protected]

Admin Cait Walsh, MSN, RN Tracy Guy, MPH


RRUCLAMC MAGNET CHAMPIONS

mailto:[email protected]























































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UNIT NAME & ROLE EMAIL ADDRESS

5West/3 Peds

Chai-Chih Huang, MSN, RN Donna Estrella, BSN, RN

Khanh Luu, MSN, RN Margo Goldman, BSN, RN

Sufia S. Husain, DNP, RN


5 PICU/PCTU Janine Carr, BSN, RN [email protected]

6ICU

Barbara Anderson, MSN, RN Kaitlyn Lattanzio, BSN, RN

Kathryne Figuracion-Cheng, BSN, RN Scott Demar, MSN, RN


6N

Derek Wilcox, BSN, RN Pamela Nye, MS, RN

Paulette Salg, BSN, RN, PHN Kathy Cheetham, BSN, RN

Sarah Jividen Taylor, BSN, RN


6E

Kathleen Caparoso, BSN, RN Kristine Greene BSN, RN Michel Queen, BSN, RN

Stephanie Jackson, MSN, RN, CNS


6W Norma McNair, PhD, RN Sheila Richardson, MSN, RN


7ICU

Charlene Earnhardt, MSN, RN Dalya Lovy, BSN, RN

Gilbert Barco, RN

[email protected] [email protected] [email protected]

7N 7CCU/COU

Anthony Chan, BSN, RN Wendy Tsau, MN, CNS, RN

Shubjeet Dhillon, BSN, RN (COU) Mimmi Lowrie, BSN, RN (CCU)


7E/5EMS

Tina Mamais, MSN, CNS, RN Michelle Zadunayski, MSN, RN

Beki Heffler, MN, RN Tammi Burns, BSN, RN


7W Cherie Neil, MSN, RN

John-Gabriel Pantaleon, BSN, RN Renee Appleby, BSN, RN


8ICU

Jennifer Do, MSN, RN Mo Keckeisen, MSN, RN

Jill Dowds, BSN, RN Jyotpreet Jagpal, BSN, RN

Melanie Donovan, BSN, RN


8N Andrew Baird, BSN, RN

David Eskenazi, BSN, RN Vivien Lee, BSN, RN


8E Linda Chao, MSN, RN Monica Choi, MSN, RN


8W Leilani Quiambao, BSN, RN

Poni Agarwala, MSN, RN Jean Oriondo-Fournier MSN, RN


Stein Eye OR Marcia Wicktor MSN, MPH, RN Rochelle Torres, BSN, RN


Bowyer Jenneh Bockari, BSN, RN [email protected]

Ambulatory Quanna Batiste, MSN, RN

Toyin Lawal, BSN, RN Noelle Hunter MSN, RN


Pall. Care Edith O’Neil-Page, MSN, CNS, RN [email protected]

RRUCLAMC MAGNET CHAMPIONS
























































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A few more quick tips for the Appraiser Interview:

MAGNET APPRAISER VISIT IS THE EXACT OPPOSITE OF A

JOINT COMMISSION VISIT!

Speak up! Be excited to share the great work you do for pts every day! Appraisers are peers – They want you to succeed! More questions = Appraiser’s curiosity: They want to learn more

about the Best Practice on your unit, not grill you! Clarify, Amplify, Verify – Appraisers are here to validate the great things

they read in our Magnet Document – so be sure to read up on where your unit is mentioned! (www.uclahealthmagnet.org Login = uclarr Password = magnet8114) Also, share your unit’s 3 Exemplars!

WHEN TELLING YOUR STORY…

Describe then demonstrate Provide an overview of a larger topic, then narrow focus to your unit/practice/etc. EXAMPLE: “At RRUCLAMC, RNs have many resources to ensure conditions are safe & sanitary for our patients. On our unit, we are proud of our efforts around implementing a new hospital-wide standard for CHG bathing…”)

No Cognitive Leaps! The details – people & committees involved, their actions, etc. – are the most interesting and compelling part of the story. Take a few minutes to brag about the exceptional work you & your colleagues accomplished!

LANGUAGE ADVICE:

Stay Pronoun- Free! Don’t assume the Appraiser knows who you are talking about when you say “We” or “They” – who/which committee did this work? Recognize colleagues & resource structures by name! Fun Fact– the only pronoun allowed is “I”

No Passive Voice! Advances in Professional Nursing Practice don’t “just happen” – You move it forward every day through your dedicated & strategic actions, so make sure you use an “active voice” when sharing your great work! EXAMPLE: Not: “We saw CLABSI rates were high, so the unit-based Infection Prevention group as formed.” Instead: “The UPC recognized our unit’s CLABSI rates were high, and decided to form an Infection Prevention group. The UPC did this by recruiting staff via email and during staff meetings…”

Pass the Ball! Share the story telling! Make sure no one person dominates the interview, chime in if your colleague forgets to mention a detail, plan beforehand and split the story between your colleagues!

Praise your colleagues for a job well done! Recognition and comradery between colleagues is always viewed as a positive – Plus it feels pretty darn good, too!

http://www.uclahealthmagnet.org/

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COMING SOON TO YOUR UNIT: MAGNET CART ROUNDS! Be on the lookout for a visit from the Magnet Cart on your unit, say ‘Hello’ to the wonderful

Resource Team Magnet Champions, and get ready to have some Magnet fun!

Play a Magnet game, learn more about our Magnet Journey, prep for our upcoming site visit, and grab a treat!

For more information, please contact Magnet Fellows Megan Sitrin, MSN, RN at [email protected] &/or Elizabeth Rowan, MSN, RN at [email protected]



ronald reagan ucla medical center magnet recognition …the magnet recognition program® is the gold...

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