Nursing Strategic Planning Retreat September 14, 2012

Accountability, Shared Governance Structure

and Nursing Strategic Plan

Accountability:

The ability and willingness to assume responsibility

for one’s actions and accepting the consequences of

one’s behavior

State of being responsible and answerable for one’s

own behavior

Autonomy Independence of functioning in

decisions and actions

Authority Power to do something

Responsibility Acting in a reliable, trustworthy

and credible manner at all times

To the Profession

ANA Code of Ethics

Nursing Quality and Assurance Programs

Participation in a Professional Organization

Utilize professional standards as a basis for practice

To Patients

Clinically competent to provide safe nursing care

Allow patients to truly participate in their care

Respect individual differences and not impose our

preferences

Altruistic intentions (putting patient’s above ours)

Advocacy for patients when the need arises

To Health Care Team

Brings specialized knowledge and skills to care delivery

Shares information with team members

Confronts if potential errors may occur or behavior is

inappropriate

Performs task with competence

Treats ALL with dignity and respect (no horizontal violence)

To Employer

Performs quality work

Protect against unsafe situations

Attitude is positive and supporting

To Myself

Lifetime of education and learning using professional standards as the basis for own practice

Take care of my health and the ones I love

Protect myself from harm (not engaging in behaviors or actions that could result in harm)

Be true to my own values and beliefs

Embrace accountability as basis for practice

Groundwork for Accountability Begins With:

Theoretical base for professional practice (our theorist—Jean

Watson’s Caring Theory as the basis for Relationship-Based Care

Clinical and Professional Competence

Leadership Skills (staff nurse as leader)

Ethical Framework

BSN and Beyond

Shared Governance/Professional Practice Model (5 elements:

values, professional relationships, a patient care delivery

model, a management approach and compensation and rewards)

Nursing Leadership must take accountability seriously and measure

success based on internal and external standards and build these into

your Strategic Plan.

“KEEP PATIENTS SATISFIED AND SAFE”

Most metrics for this simple phase is included in the ANA’s NDNQI

database. Using their benchmarks teach nurses to go beyond what is

expected and should be the basis for strategic planning.

Strategic Planning Process

System

• UPMC Strategic Plan

• H. Lorenz Strategic Plan for Nursing

Hospital

• Executive Management Plan for Hospital

• Nursing Division Strategic Plan

Business Unit

• Nursing Unit/Departmental Strategic Plans

• Nursing Councils Strategic Plan

UPMC System/Nursing

SMH Executive Management Group

SMH Nursing Division

SMH Units/Departments

Nursing Division Councils

SMH Shared Governance Structure and Process Premise: Staff-Driven Decision-Making is viewed as the Hallmark of

Excellence in a Magnet Organization

Nurse Executive Council

Unit Level

Nursing Division Councils

Nursing Leadership

Council Structure

Chair—Oversees committee work

Agenda preparation—content, guests, time management

Presides over formal and informal meetings

Establishes goals for committee and expectations for committee members

Directs council business assistant

Co-Chair—Assists Chair in committee work

Responsible for committee membership

Presides over meetings in the absence of chairperson

Mentor-Establishes a developmental partnership/collaboration to foster the professional growth of the council. Provides insight and expertise to provide problem-solving and goal achievement.

Advisor—Assists the council in meeting their goals by providing opinions and information whenever needed.

“Watchdog” of the group—keeps council activities on track

Helps group maneuver through administrative chain of command

Knowledgeable in hospital dynamics and structures to help guide council through necessary steps for successful outcomes.

Provides insight into problem-solving techniques

Sounding board for chair and co-chair

Meets with Chair/Co-Chair on frequent basis

Consultant—Experienced individuals who are trained to analyze and advise in order to help councils make the best possible choices.

Internal—within St. Margaret Hospital

External—outside of St. Margaret Hospital

System

Outside of System—Product Specialists, Professional Organizations and Advocacy Groups

What is the role of the Educator on the

Council? (New Knowledge, Innovation,

Improvements)

(1)

(2)

(3)

(4)

(5)

(6)

What are the expectations of the council members?

(Structural Empowerment) and who will hold them

accountable? (Transformational Leadership)?

(1)

(2)

(3)

(4)

(5)

(6)

#

What are the expectations for internal and external

consultants?

Internal

(1)

(2)

(3)

External

(1)

(2)

(3)

Nursing Councils Mission

GROUP EXERCISE

Process of the Nursing Councils—how the

work gets done

Overarching Principles for all Council Work

Outcome-Driven (pre/post data/rationale)

(Empirical Outcomes)

Use of Internal and External Consultants and

Groups

Use of ANA resources

Use the language of the Magnet Document

Council Mission Statements

Professional Development

Defines, implements, evaluates and maintains

educational standards that promote professional

growth, development and ongoing clinical

competency for staff and identifies strategies to

promote retention of the professional nurse.

Clinical Practice Council

Develops standards of care, policy and

procedures and protocols; implements

standards into practice documents, e.g.,

practice guidelines, documentation tools,

and policies; implements and advances

technology for nursing and approval of

electronic documentation standards.

Professional Practice Council

Oversees scope of nursing practice as defined

by the American Nursing Association;

represents nursing perspective in ethical/legal

issues; incorporates the Pennsylvania Nurse

Practice Act as appropriate; assures nurse

representation on hospital/system committees.

Nursing Education, Research and EBP

Provides a structure for all nursing research at

SMH by fostering a spirit of inquiry on

evidence-based clinical practice improvements;

promoting awareness of nursing research

efforts; establishing educational endeavors to

support nursing research as a foundation of

nursing practice.

Nursing Quality Council

Monitors the appropriateness and

effectiveness of care provided by nursing staff

while assessing and assuring compliance with

established standards of care and practice.

Oversees nurse sensitive indicators, monitors

and evaluates patient outcomes/dashboards

and collaborates with the Hospital and System

Quality Groups to ensure delivery of safe

patient care.

Operations Council

Defines, promotes and evaluates nursing

practice within the organization by identifying

issues related to patient care and clinical

practice; develops strategies to resolve issues

and process change; assures consistent nursing

practice and standardization; assessment of

new products/services.

Nursing Councils Responsibilities

Group Exercise

CATEGORY COUNCIL

ASSIGNED

REPORTING

FUCTION/BY

WHOM

Strategic Planning Operations

Council

Nursing’s Mission, Vision, Values Professional

Practice Council

Advocacy for Fiscal and Technology Resources Clinical Practice

Council

Professional Engagement

• Committees

• Councils

• Task Forces

• Participation in Nursing Organizations

Professional

Development

Council

Professional Development

• Formal Education (BSN, MS, PhD)

• Professional Certification

• Continuing Education for all levels and settings

• Nursing Orientation

Professional

Development

Council

Community Involvement (Professional)

• Allocation of resources for affiliations with

schools/colleges/universities

• Consortiums

• Community Outreach Programs (professional)

Professional

Practice Council

Recognition of Nursing (Internally) Professional

Practice Council

CATEGORY COUNCIL

ASSIGNED

REPORTING

FUCTION/BY WHOM

Culture of Safety for Patient and Nurses Quality

Quality Care Monitoring and

Improvement/Allocation of Resources Quality

Nurse Satisfaction/Engagement (NDNQI) Professional

Patient Satisfaction PPC

Nursing Research/Evidence Based Practice

• Develop, expand, advance nursing

research

• Approval/Tracking of all nursing research

Nursing Ed,

Research, and EBP

Council

Innovation in Nursing Practice CPC

E-Profiler CPC

Nurse Talk Clinical Practice

Nursing Organizational Structure

(Organizational Chart) OP

Legislature– Policy Advocacy (PA State Board,

NLN, ANA, PSNA) CPC

Patient Rights Report only to PPC Renee Carolan

CATEGORY COUNCIL

ASSIGNED

REPORTING

FUCTION/BY WHOM

Recognition of Nursing (Externally) Professional

Development

Council

Professional Practice Model Professional

Practice Council

Care Delivery System(s) Nursing Operations

Council

Staffing and Scheduling Nursing Operations

Council

Budgeting Process (Unit and Divisional) Nursing Operations

Council

Interdisciplinary Care/Collaboration Nursing Quality

Council

Accountability Clinical Practice

Council

Competence Nursing Education,

Research and EBP

Council

Autonomy Nursing Education,

Research and EBP

Council

Ethics/Privacy/Confidentiality Report only to

Operations Council

Diversity Professional

Development

Council

Workplace Advocacy

• Caregiver stress

• Patients Rights

• How to manage problems related to

incompetent/unsafe/unprofessional

conduct

Nursing Quality

Council

Work Partners

CATEGORY COUNCIL

ASSIGNED

REPORTING

FUCTION/BY WHOM

Performance Appraisal Tools Report to

Professional

Development

Council

Joyce Doody

Student Experiences Nursing Education,

Research and EBP

Council

External Experts Nursing Education,

Research and EBP

Council

Work Environment Changes Nursing

Operations

Council

Nurse Recognition within the local, state,

national, and international communities Professional

Development

Council

Conference Attendance Professional

Development

Council

Just Culture Report to Quality

Peer Review Professional

Practice Council