ronald reagan ucla medical center magnet recognition handbook
TRANSCRIPT
Ronald Reagan UCLA Medical Center
Magnet Recognition Handbook
This handbook contains background information on The Magnet Recognition Program®, our
Magnet Re-Designation Journey, and examples of Magnet Sources of Evidence that have been
gathered from inpatient and outpatient nurses which demonstrates the environment of
Magnet excellence at RRUCLAMC.
RRUCLAMC 2014 Magnet Recognition Handbook Table of Contents
Page #
Background: What is Magnet? 1
Magnet Impact Rationale 1
Why Magnet? 2
What’s in it for Nurses? 2
Accessing the RRUCLAMC Magnet Document 3-5
The 5 Magnet Components and Sub-Components 6
How We Live the 5 Magnet Components at UCLA Health 7-26
Transformational Leadership – 7-10
– Nursing Strategic Plan 7-8
– Advocacy and Influence 9
– Visibility, Accessibility, and Communication 10
Structural Empowerment – 11-16
– Professional Development – Interprofessional Involvement 11
– Professional Development – RNs Involved in Professional organizations 11
– Degree and Certification Goals 12
– Teaching and Role Development 13
– Commitment to Community Involvement 14
– Recognition of Nursing 15
– UPC Accomplishments 16
Exemplary Professional Practice – 17-24
– Professional Practice Model 17
– Care Delivery System 18
– Staffing Scheduling, & Budget Processes 19
– Interprofessional Care 20
– Accountability, Autonomy, & Competency 21
– Ethics, Privacy, Security, and Confidentiality 22
– Culture of Safety 23
– Quality of care Monitoring and Nurse Sensitive Indicators 24
New Knowledge, Innovations, and Improvement 25-26
– Research 25
– Evidence-Based Practice and Innovation 26
2014 RRUCLAMC Magnet Document Unit Highlights 27-41
Bottom Line:
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Background: What is Magnet?
The Magnet Recognition Program® as we know it today is the culmination of over 30 years of research
initiated by the American Academy of Nursing (AAN) in response to a nation-wide nursing shortage in the early
1980s. By studying the practice environments of hospitals that were able to successfully attract and retain
nurses during this critical time, the AAN were able to identify similar qualities shared by these organizations,
which they named the “14 Forces of Magnetism” which has been refined to the “5 Magnet Components” we
recognize today:
Based on this ever-evolving research, the American Nurses Credentialing Center (ANCC) developed and
continuously perfects the Magnet Recognition Program®. Approximately every 4-5 years the ANCC updates
their rigorous Magnet requirement based upon evidence, shaping the advancement of successful nursing
practices and strategies worldwide. In fact, RRUCLAMC is one of the first Re-designating hospitals to submit a
document using the 2014 Magnet Manual!
Magnet Impact Rationale
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Why Magnet?
Why is Magnet Recognition Important?
Magnet Status is the highest honor awarded by the ANCC and nationally recognizes RRUCLAMC nurses’ ability
to provide quality patient care and initiate innovations in their professional nursing practice. 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
FAQ: We already provide good patient care! What benefit does Magnet Designation provide us?
ANSWER: IT IS THE RIGHT THING TO DO FOR OUR PATIENTS!
What’s in it for Nurses?
1. Improved Work Environment & Professional Autonomy
Culture that supports & encourages RN clinical decision-making at the bedside
Enhanced interdisciplinary collaboration & teamwork
Empowers nurses to utilize their full scope of practice & assume leadership positions
Environment recognizes & celebrates nurses’ accomplishments
2. Advance Nursing Standards & Practice
Professional growth & development opportunities
Educational opportunities
Leadership opportunities
3. Attract & Retain Top Nursing Talent
Increased RN retention
Increased RN job satisfaction
Lower nurse burnout
Lower turnover rates
Decreased RN vacancy rate
4. Focus on Improving Patient Care
Increased patient satisfaction
Decreased mortality rates
Decreased pressure ulcers
Decreased falls
Improved patient safety & quality
In addition,
Magnet provides a framework to measure:
The components influencing high-quality
nursing care
The factors contributing to a safer,
healthier environment
The forces that impact better patient
outcomes
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Accessing the RRUCLAMC Magnet Document
You can access the Magnet document through the UCLA Nursing website at
http://nursing.uclahealth.org/ in four easy clicks:
OR you can enter the web address in your browser: http://uclahealthmagnet.org
a) Enter User Name: uclarr
b) Enter Password: magnet8114
1
4(This will open a new window)
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1. Explore the site! Click on the ‘Magnet Model Components’ tab to navigate through our Magnet stories,
including those which your unit contributed!(Comprehensive list of Unit/Department contributions can
be found at the end of this booklet):
2.
magnet8114
uclarr
7
Blue links within the document can be clicked to access supporting documents:
If you have any questions or experience any trouble accessing the document, please contact
Charlene Collazzi at [email protected]
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3. The 5 Magnet Components & Sub-components:
1. Transformational Leadership - strong nurse leaders have the vision, knowledge, and influence to guide their team to where it needs to go, not just where it wants to go.
a. Nursing Strategic Plan
b. Advocacy and Influence
c. Visibility, Accessibility, & Communication
2. Structural Empowerment - strong nurse leaders create an environment where the hospital's mission
and vision come to life, and all nurses are encouraged to achieve desired results by being involved in
decision-making structures that establish standards of practice and address opportunities for
improvement.
a. Professional Development
i. Interprofessional Involvement
ii. Nurses Involved in Professional Organizations
b. Degree and Certification Goals
c. Teaching and Role Development
d. Recognition of Nursing
e. Shared Governance UCLA Health Nurses have cultivated excellence in Nursing Practice and
Patient Care this past year. Through the shared governance structure at UCLA Health, nurses
have led and participated in countless efforts to continue their education, develop their
professional practice, and contribute to the well-being of our patients and our community.
3. Exemplary Professional Practice - nurses practice, work together, communicate, and develop professionally to achieve the highest quality of care for patients and the community.
a. Professional Practice Model
b. Care Delivery System
c. Staffing/Scheduling Participation
d. Interprofessional Care
e. Accountability, Competence, and Autonomy
f. Ethics, Privacy, Security, and Confidentiality
g. Culture of Safety
h. Quality Care Monitoring and Improvement
4. New Knowledge, Innovations, & Improvements - nurses take the lead in research efforts, and have an ethical and professional responsibility to contribute new findings, evidence, and quality improvement to the nursing profession.
a. Research
b. Evidence-Based Practice & Innovation
5. Empirical Outcomes – strong nursing structures and processes are in place to achieve good outcomes, but nurses go further to show results and the impact of those results. Empirical outcomes move beyond what nurses do and how they do it to focus on: "What difference have you made?"
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How We Live the 5 Magnet Components UCLA Health:
Transformational Leadership Nursing Strategic Plan
At RRUCLAMC, the Nursing Department’s Mission, Vision, Values and Nursing
Strategic Plan align with UCLA Health’s priorities to improve performance.
The RRUCLAMC Department of Nursing shares the same Mission, Vision, and Values as the wider organization:
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 Nursing Strategic Plan is aligned with the UCLA Health Strategic Plan.
At the close of every fiscal year, the Nursing Strategic Plan is updated at the Annual Nursing Strategic Planning Retreat led by Chief Nursing Officer Heidi Crooks, MA, RN.
Nurse Executives, Unit Directors, and Clinical Nurses are invited to attend this Retreat, ensuring that contributions are included from all practice areas and service lines throughout organization.
Unit level goals and dashboards are then created using the Nursing Strategic Plan as a guide, thus providing an aligned vision and continuity across the organization.
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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
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2 3
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Transformational Leadership
Advocacy and Influence
At RRUCLAMC a strong trust exists between the CNO, Nursing Directors, and
Clinical Nurses. All nurses are aligned so that nursing is recognized as critically
important to the organization.
Heidi Crooks, MA, RN, CNO, Directors of Nursing, and Clinical Nurses serve on hospital structures to advocate for resources to ensure nurses’ have the Best Practice Environment to care for patients. Through Unit
Practice Councils, various committees, and other structures, Clinical Nurses and Nurse Leader have worked together to advocate for:
o Safe Patient Handling Equipment o Education and Certification Resources o Low Beds, Specialty Mattresses o Increased positions of Nurse Practitioners o CHG bathing products o … And Much More!
Read more about the efforts of Nurses to increase education and serve as role models
for their patients, families, and next generation of Nurses in the following SOEs:
o TL3EO – CNO Organizational Influence
“CNO-Led Successful Implementation of Safe-Handling and Mobility Program”
o TL4 – CNO Involvement in Organizational Decision-Making
Part 1: “Redesigning for the Future of UCLA Health: The CNO’s Strategic Role”
Part 2: “Selection, Planning, & Implementation of a Fully Integrated Electronic Health Record: The CNO’s Strategic Role”
o TL5 – Nurse Leaders Guilding Change
Part 1: “Leading Through Emergent and Unplanned Change – Sigma Pump Functionality Challenges”
Part 2: “Implementation of a Bedside Report Practice Change on Inpatient Units”
o TL6 Developing Leaders
Part 1: “Mentoring and Succession Planning for Clinical Nurses: Professional Role-Based Coach Program”
Part 2: “Mentoring and Succession Planning for Nurse Managers: Succession Planning Program”
Part 3: “Mentoring and Succession Planning for Nurse Leaders: UCLA Health System Leadership Academy”
Part 4: “Mentoring and Succession Planning for the Chief Nursing Officer: CNO Succession Planning”
o TL7 – Data-Driven Resourcing
“Trended Fall Data Leads to Acquisition of Low Beds”
All efforts lead to safer care for our patients and families!
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Transformational Leadership
Visibility, Accessibility, and Communication
Nurse Leaders make a goal to be available to Clinical Nurses and are open to hearing nurses’ views and concerns.
Nurse leaders and clinical nurses work collaboratively to make decisions for the best interest of our patients, their families, and for our nurses.
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.
Read more about the efforts of Nurses Leaders to increase their visibility and serve as
advocates and role models for their Clinical Nurses, their patients, and families in the
following SOEs:
o TL8 – CNO Visibility and Accessibility
Part 1: “Clinical Nurse Advocacy for Patient Safety Around the Hospital”
Part 2: “Ensuring Clinical Nurse Competency”
o TL9 – Influencing ChangeCNO Involvement in Organizational Decision-Making Part 1: “Addition of Pediatric Nurse Practitioners in Response to Nurse Concerns
about Quality & Safety in the PICU” Part 2: “Creation of a Multidisciplinary Toolkit for Management of Escalating
Patient Behaviors in Response to Clinical Nurse Concerns about Safety and
Quality of Care”
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Structural Empowerment
Professional Development – Interprofessional Involvement
The UCLA Health Department of Nursing utilizes structures and resources to support 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.
UCLA Health supports structures and processes which ensure nurses from all settings and roles to 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.
Read more about the work of Clinical Nurses and Nurse Leaders on Interprofessional
Committees in the following SOEs:
o SE1EO – Interprofessional Decision-Making Groups o Part 1: “Improving the Care of Stroke Patients” o Part 2: “Ensuring Safe Access to Blood Products”
Nurses’ participation on these committees has led to improved patient outcomes and safer practices
throughout the UCLA Health System.
Structural Empowerment
Professional Development – Nurses involved in Professional Organizations
UCLA Nurses are involved with professional organizations, community groups,
and initiatives. Most UCLA 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 nurses utilize professional nursing organization standards
to improve clinical practice and patient outcomes at UCLA.
Read more about UCLA Health’s commitment to supporting the professional growth and
development of our nurses, enabling them to deliver excellence in patient outcomes:
o SE2EO – Professional Organization Participation o Part 1: “Use of ASORN Guidelines to Improve Surgical Site Markings” o Part 2: “Improving Delirium Assessment in the Neurotrauma ICU Based on AACN
Recommendations”
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Baseline 2011 2012 2013 2014
Certified Nurses, Overall 439 478 564 610 738
Organization Goal (whole number) 400 450 525 600 676
0100200300400500600700800
# o
f ce
rtif
icat
ion
s
RRUCLAMC Results for Professional Nursing Certification 2011-2014
Structural Empowerment
Degree and Certification Goals
The RRUCLAMC Department of Nursing is committed to facilitating and supporting the educational and professional development our nursing staff.
Goals have been set to increase the number of BSN & advanced Nursing degree-prepared nurses and Specialty Certification-prepared nurses.
RRUCLAMC 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 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!
Read more about the efforts to increase Education and Certifications for Nurses in the following SOEs: o SE3EO –Professional Nursing Certification
o Part 1: “Increasing Professional Nursing Certification at the Organizational Level” o Part 2: “Increasing Professional Nursing Certification at the Unit Level”
o SE4EO –Continuing Education Programs o Part 1: “Improving Referrals to Palliative Care in the ICU through Education” o Part 2: “Use of a Structured Infection Prevention Program to Decrease Rates of CLABSI”
o SE5 – Non-Nurse Career Programs o “Community Partnership with King Drew Magnet High School of Medicine and Science”
2012 2013 2014
% of RNs with BSN+ 63% 67% 73%
Target 63% 66% 68%
60%62%64%66%68%70%72%74%
Pe
rce
nta
ge o
f R
Ns
Ronald Reagan UCLA Medical Center % of RNs with BSN or Higher Degree
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Structural Empowerment
Teaching and Role Development
UCLA Nurses recognize the important role we play in ensuring that patients
understand their health. UCLA Nurses use evidence-based teaching strategies to engage patients in their health. Nurses serve on
leadership roles on the Patient Engagement Committee in the organization and have provided feedback in
teaching tools in Care Connect including discharge teaching resources and medication teaching resources.
Across the organization, nurses have led efforts to standardize teach back strategies to effectively insure
patients understand information about their health, hospitalization, medications, and discharge.
At UCLA Health, nurses never stop learning: The UCLA Health Department of Nursing Practice, Research, and
Education (NRE) has established an infrastructure to provide nurses with opportunities for lifelong professional
and educational growth for nurses across the system (RRUCLAMC, SMHUCLAMC, and RNPH).
Educational and Professional Development Programs are structured to best meet the unique requirements to
support the ability of UCLA Health nurses to deliver complex nursing care at our hospitals.
Classes are designed to provide current clinical and professional nursing content and are delivered using
Evidence-Based teaching/learning strategies.
Read More about the efforts of Nurses to increase education and serve as role models
for their patients, families, and next generation of Nurses in the following SOEs:
o SE6 – Nurses as Teachers o “Teach-Back Educational Summit and Meducation Toolkit to improve nurses’ expertise in
patient and family teaching”
o SE7 – Continuing Education Programs o Part 1: “Onboarding & Orientation of Newly Hired Experienced Nurses” o Part 2: “Onboarding & Orientation of New Graduate Nurses”
o SE8 – Developing Nurse Preceptors o “Growing Expert Preceptors through a Standardized Preceptor Program”
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Structural Empowerment
Commitment to Community Involvement
UCLA Health Nurses are committed to elevating local and international
Community Health, and are responsible for leading and supporting efforts to
ensure all people are provided the best healthcare possible.
UCLA Nurses have taken leadership and volunteer roles in over 100 Community Health Outreach
organizations. Nurses in these organizations work tirelessly to provide leading edge patient care and facilitate
a higher quality of life for all patients outside of our organization and around the world.
Read More about the efforts of Nurses to serve our local and international community
in the following SOEs:
o SE9 –Community Outreach
o Part 1: “UCLA Nurses Respond to Typhoon Haiyan”
o Part 2: “UCLA RN Orchestrates 27th Annual Oley Foundation Conference”
o SE10EO – Community Healthcare Needs Assessment
o “Facilitating a Camp Experience for Children with Heart Disease: The Camp
Del Corazon Experience”
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Structural Empowerment
Recognition of Nursing
Nurses are valued and recognized at UCLA
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. Sheri Monsein, RN, MN,
Manager of Nurse Recruitment was instrumental in initiating the DAISY Award Program at
UCLA and continues to administer the program. She describes it as a key component of our
strategy for recruitment and retention of excellent nurses.
Read More about UCLA Health’s recognition and celebration of our outstanding Nurses
in the following SOEs:
o SE11 – Recognizing Nurses
o Part 1: “Recognition of a Clinical Nurse”
o Part 2: “Recognition of a Group of Clinical Nurses”
2014 Daisy Award Winner Maxine Pintado, RN being honored by Director of Inpatient Nursing Cathy Ward,
DSc, RN, and Chief Nursing Officier Heidi Crooks, MA, RN
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Structural Empowerment
RRUCLAMC 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 from over this past year:
Unit UPC Initiative Outcomes
Main OR
Implementation of 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
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 1
st dose of an
antibiotic
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 Implementation of 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 70
th %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
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Exemplary Professional Practice Professional Practice Model
Nurses are at UCLA own and live the Professional Practice Model to drive the
work of nursing forward for our patients, families, community, and the
organization.
A professional practice model (PPM) that is "exemplary" must be advanced over time. The purpose of the
Professional Role Development Strategic Initiative is to strengthen RN professional role autonomy and
decision-making authority, a component of UCLA's PPM, such that it is lived and experienced by all registered
nurses at UCLA.
Read More about RRUCLAMC’s Professional Practice Model and how our outstanding
Nurses utilize the PPM to advance Nursing Practice in the following SOEs:
o EP1 – Professional Practice Model o “Evaluation of the Professional Practice Model”
o EP2EO – Results of the Professional Practice Model o “Using the PPM to Implement a Teamwork-Based Care Delivery Model on 7W”
o EP3EO – Nurse Satisfaction Data o “Nurse Satisfaction Survey Overview”
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Exemplary Professional Practice Care Delivery System
RRUCLAMC Nurses are guided by the UCLA Health Department of Nursing’s
Professional Practice Model, Vision, and the Relationship-Based Care Delivery System 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 UCLA Health Electronic Health Record (E.H.R.). 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.
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 in care delivery on behalf of the patient.
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.
Read More about RRUCLAMC’s Care Delivery System and how our outstanding Nurses
utilize RBC to improve Patient Outcomes in the following SOEs:
o EP4 – Establishing a Plan of Care o Part 1: “Nurse as Patient – Providing Individualized Care to a Colleague” o Part 2: “Ensuring Optimal Care for Pediatric Patients Across the Continuum of Care”
o EP5 – Interprofessional Collaboration o Part 1: “Care Coordination for Liver Transplant Patients” o Part 2: “Care Coordination for Aortic Repair Patients”
o EP6 – Regulatory & Professional Standards o “Incorporating Vascular Access Standards into Care”
o EP7EO – Standards of Care and Practice o “Using AWHONN and Baby-Friendly Standards to Enhance Skin-to-Skin Initiation After Vaginal
Births” o EP8EO – Interal Experts
o “Internal Consultant facilitates reduction in adverse glycemic events: The Green Apple Project”
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Exemplary Professional Practice Staffing, Scheduling, & Budgeting Processes
The acuity and needs of the patients on the unit, along with the skill-mix of clinicians, affect staffing considerations and decisions. Working together, Nurse
Leaders and Clinical Nurses have developed staffing plans to strategically allocate staff resources to meet the needs of their patient population.
Clinical Nurses are empowered to adjust RN and support staff assignments/schedules, including recruitment and retention planning and
activities, to best adapt changes in patient and environmental conditions while maintaining 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 by:
o Performing acuity ratings for each patient every shift o Lead nurses consult with clinical nurses regarding needs and staffing o UCLA Acuity committee includes clinical nurses o Clinical nurses participate in self-scheduling
Nurses participate in Recruitment & Retention by:
o Participating in the Clinical Advancement Program o UCLA Acuity committee includes clinical nurses
Nurses participate in Budget Data Analysis by:
o Utilizing trended data related to resources to influence budget allocation decisions o Lead nurses consult with clinical nurses regarding resource needs and staffing o UCLA Acuity committee includes clinical nurses
Read More about RRUCLAMC’s Nurses are empowered to influence Staffing, Scheduling,
and Budgeting needs in the following SOEs:
o EP9 – Staffing/Scheduling Participation
o Part 1: “CTICU Nurse Advocates for Resources to Meet Acuity Demands”
o Part 2: “NICU Clinical Nurse Advocates for Resources Detriorating Neonate”
o EP10 – Budget Data Analysis
o Part 1: “Operating Room Clinical Nurses Shift Start Times to Provide Adequate Staffing”
o Part 2: “Creation of a Nurse-led Volunteer Companion Program to Subsitute for Constant Observation Aides”
o EP11EO – Recruitment & Retention
o “Clinical Advancement Program for Pediatric Intensive Care Nurses”
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Exemplary Professional Practice Interprofessional Care
At UCLA Health, healthcare providers recognize their role as a vital component of their patient’s Interprofessional Healthcare Team. For RRUCLAMC Physicians,
Nurses, Care Partners, Social Workers, Therapists, Admin staff, and others collaboration is key: From participation on hospital- and system-wide
Interprofessional Committees to the patient’s bedside, Interprofessional Care Teams are united in their shared goal of “Healing Humankind, one patient at a
time” using the best patient-centered treatment options possible.
Read More about RRUCLAMC’s Nurses are a vital part of an Interprofessional Team
united by their commitment to provide the best patient care in the following SOEs:
o EP12 – Nursing Leadership Roles
o “Transitioning Patients from the OR to Cardio-Thoracic ICU: An Interprofessional Standardized Handover”
o EP13EO – Patient Education Programs
o “Colorectal Surgery Education for Patients”
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Exemplary Professional Practice Accountability, Autonomy, & Competency
Accountability, Autonomy, and Competency assurance are essential in achieving and maintaining the highest level of Professional Nursing Care. Structures and
processes are in place to ensure all healthcare providers are held accountable for their work; to this end, Annual Competencies are conducted for all UCLA Health employees, including Self-Appraisal and Peer Feedback to provide a transparent,
360◦ Performance Evaluation. With their Clinical Competency assured, Clinical
Nurses are empowered to advocate for their patients, Nurse Leaders advocate on behalf of their Clinical Nurses, and so on up to our CNO’s, Heidi Crooks, MA,
RN, advocacy to provide the best practice environment possible at UCLA Health.
Read More about RRUCLAMC the Accountability, Autonomy, and Competency of UCLA
Nurses in the following SOEs:
o EP14 – Resources for Autonomous Practice
o Part 1: “Nurse-Driven Skin and Wound Care Practices”
o Part 2: “Early Mobility in the Medical ICU”
o EP15 – Performance & Peer Review
o Part 1: “Nursing Self-Appraisal and Peer Feedback Promote Professional Development for Clinical Nurses”
o Part 2: “Nursing Self-Appraisal and Peer Feedback Promote Professional Development for Nurse Leaders”
o EP16 – Nursing Autonomy
o Part 1: “Autonomous Nursing Practice in Complex Care Coordination”
o Part 2: “Autonomous Nursing Practice in Neonatal End-of-Life Care”
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Exemplary Professional Practice Ethics, Privacy, Security, and Confidentiality
At UCLA Health, all healthcare personnel are expected to adhere to a stringent Ethical protocol to ensure the Privacy, Security, and
Confidentiality of our patients and their families. There are many resources available to Clinical Nurses and Nurse Leaders to safeguard sensitive
information and help to guide this component of Professional Nursing Practice, such as:
UCLA Ethics Center provides 24-hour consultation for nurses and others to receive support for ethical situations
Clinical Nurses serve on UCLA Ethics Committee
Ethics Grand Rounds and Circle of Caring Retreat are two examples of educational and supportive resources available to nurses
All employees are trained annually on policies and procedures around confidentiality
The UCLA Privacy Management Office monitors patient privacy and compliance
Read More about RRUCLAMC the Ethics, Privacy, Security, and Confidentiality
Practices of UCLA Health in the following SOEs:
o EP17 – Ethical Issues
o “Ethics Center Services Support and Develop Ethical Nursing Practice”
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Exemplary Professional Practice Culture of Safety
At UCLA Health, the safety of our patients and our healthcare personnel is of the upmost concern, and structures are in place to ensure the highest level. There
are many resources available to Clinical Nurses and Nurse Leaders to help safeguard the health and well-being of their patients and peers. Several
successful safety interventions have been initiated by Clinical Nurses throughout RRUCLAMC.
Read more about RRUCLAMC’s Culture of Safety Practices of UCLA Health in the following SOEs:
o EP18EO – Workplace Safety
o Part 1: “Reducing Needlestick Injuries through Standardization of Safety Needles”
o Part 2: “Increasing Nurse Influenza Vaccination Rates”
o EP19EO – Proactive Risk Management
o “Nurses improve Safety by Reducing Medication Errors”
o EP20EO – Evaluating Patient Safety Data
o Part 1: “Implementation of the ‘Bug Busters’ Committee on Acute Care Pediatrics”
o Part 2: “Implementation of SBAR Standardized Practice to Reduce Time to Transport by the Critical Care Transport Team”
o EP21EO – Patient Safety Goals
o “Nurses Leading Improvement in Medication Labeling and Communication in Perioperative Settings”
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Exemplary Professional Practice Quality of Care Monitoring and Nurse Sensitive Indicators
At UCLA Health, clinical measures concerning the safety of our patients, quality of provided Nursing care, Patient Satisfaction, Nurse Satisfaction, and data
concerning other Nurse-Sensitive Indicators are collected throughout the fiscal year. Our data is then sent to the American Nurses Association (ANA) National
Database of Nursing Quality Indicators (NDNQI), where it is incorporated into the National Mean score for all Academic Medical Centers. Some highlights are
shared below: We benchmark our performance against the American Nurses Association (ANA) National Database of Nursing Quality Indicators (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 RRUCLAMC (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 RRUCLAMC (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 RRUCLAMC (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 RRUCLAMC 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, in addition to house-wide surveillance beginning in Q2 2014, the organization has also 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.
Read more about RRUCLAMC’s Quality of Care Monitoring & Nurse Sensitive Indicators in the following SOEs:
o EP22EO – Nurse Sensitive Quality Indicators
o “Nurse-Sensitive Quality Indicators: Data Collection & Benchmarks”
o EP23EO – Patient Satisfaction
o “Patient Satisfaction Survey Overview”
27
New Knowledge Innovations and Improvement Research
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. As nurses conduct research, there are multiple structures in place to support dissemination
internally, including but not limited to:
• 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 Nursing 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
Read more about RRUCLAMC’s Nursing Research in the following SOEs: o NK1EO – Advancing Nursing Research
o “Improving the Care Experience for Children with Complex Chronic Conditions and their Families in the PICU: Parent and Nurse Perceptions”
o NK2 – Disseminating Research Knowledge
o Part 1: “Nursing Grand Rounds Support Internal Dissemination of Nursing Research”
o Part 2: “Dissemination of Nursing Research to External Audiences: The Annual UCLA Nursing Research and Evidence-Based Practice Conference”
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New Knowledge Innovations and Improvement Evidence-Based Practice and Innovation
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
Nurse Research Fellowship Program
Nursing Grand Rounds
EBP newsletter “The Investigator”
Annual Research and EBP Conference
Access to UCLA Medical Sciences Library
UCLA Chief Nursing Informatics Officer and Informatics Nurses make decisions regarding technology
RNs are paid for their time in roles such as Super User
Read more about RRUCLAMC’s Evidence-Based Practice and Nursing Innovations in the following SOEs:
o NK3 – Integrating Evidence-Based Findings into Practice
o Part 1: “Use of the Clinical Practice Council to Develop New Early Mobility Practices”
o Part 2: “Use of the Clinical Practice Council to Revise Urinary Catheter Management Practices”
o NK4 – Nursing Innovation
o Part 1: “Interprofessional Innovation in Fall Prevention”
o Part 2: “Innovation in Pediatric Sepsis Management”
o NK5EO – Implementing Technology
o Part 1: “Enhancing Nurse Immunization Screening Using E.H.R. Functionality”
o Part 2: “Improvement in Patient Experience with Technology”
o NK6EO – Improving Work Flow and Space Design
o “Nurses Leading Efforts to Reduce Waste”
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The inspirational work of our RRUCLAMC Nurses is highlighted in the following SOEs:
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
TL1EO – Part 1 Nursing Strategic
Plan
“Enhancing the Practice Environment in Order to Reduce Nursing Turnover”
Nursing's mission, vision, values and strategic plan align with the organization's priorities to improve the organization's performance.
Provide one example, with supporting evidence, of an initiative identified in the nursing strategic plan that resulted in an
improvement in the nurse practice environment.
UCLA Health System RRUCLAMC Nursing Admin Float/Resource Pool Finance
TL1EO – Part 2 Nursing Strategic
Plan
“Partnering to Decrease Sepsis Mortality” Nursing's mission, vision, values and strategic plan align with the
organization's priorities to improve the organization's performance. Provide one example, with supporting evidence, of an initiative
identified in the nursing strategic plan that resulted in an improvement due to a change in clinical practice.
UCLA Health System RRUCLAMC Nursing Admin QMS Overhead Nursing Research & Edu (NRE) 4ICU
TL2 – Part 1 Advocating for
Resources
“Clinical Nurse Specialists Advocate for Specialty Surgical Surfaces”
Nurse leaders and clinical nurses advocate for resources to support nursing unit and organizational goals. Provide one example, with
supporting evidence, of a nurse leader's advocacy that resulted in the allocation of resources to support an organizational goal.
7ICU 8W Entersomal Therapy OR Admin
TL2 – Part 2 Advocating for
Resources
“Nurse Residents Advocate for Products to Support Infection Prevention”
Nurse leaders and clinical nurses advocate for resources to support nursing unit and organizational goals. Provide one example, with
supporting evidence, of a clinical nurse's (or clinical nurses') advocacy that resulted in the allocation of resources to support a nursing unit
goal.
8ICU TPN Services
TL3EO CNO
Organizational Influence
“CNO-Led Successful Implementation of Safe-Handling and Mobility Program”
The CNO influences organization-wide change beyond the scope of nursing. Provide one example, with supporting evidence, of a CNO-
influenced positive change that had organization-wide impact beyond the scope of nursing services.
UCLA Health System PT/OT Admin
TL4 – Part 1 CNO Involvement in Organizational Decision-Making
“Redesigning for the Future of UCLA Health: The CNO’s Strategic Role”
The CNO is a strategic partner in the organization's decision-making. Provide one example, with supporting evidence, of the CNO's
involvement in the organization's decision-making (not involving technology).
RRUCLA Nursing Admin Emergency Dept Nursing Research & Edu (NRE) 6ICU 6N Anesthesiology Data Respository Neurosurgery Nutrition Operations Performance Excellence Pharmacy Services Physcian Support Services PT/OT Inpatient Risk Management Speech Clinic Social Work Ambulatory Admin
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SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
TL4 – Part 2 CNO Involvement in Organizational Decision-Making
“Selection, Planning, & Implementation of a Fully Integrated Electronic Health Record: The CNO’s Strategic
Role” The CNO is a strategic partner in the organization's decision-making.
Provide one example, with supporting evidence, of the CNO's involvement in the organization's technology decision-making.
Anesthesiology Compliance, Privacy, & Security
DOM
Enterprises Admin
FAMILY MEDICINE
NPI
PATH & LAB MED
PEDS PHYSICAN SUPPORT SERVICES Procurement & Strategic Sourcing
Radiation Oncology
RRUCLAMC Nursing Admin
SURGERY
UROLOGY
Clinical System Team Electronic Medical Record (EMR)
TL5 – Part 1 Nurse Leaders
Guilding Change
“Leading Through Emergent and Unplanned Change – Sigma Pump Functionality Challenges”
Nurse leaders lead effectively through change. Provide one example, with supporting evidence, of the strategies used by nurse leaders to
successfully guide nurses through unplanned change.
4ICU
6E
7E/5E
7W
RRUCLAMC Nursing Admin
TL5 – Part 2 Nurse Leaders
Guilding Change
“Implementation of a Bedside Report Practice Change on Inpatient Units”
Nurse leaders lead effectively through change. Provide one example, with supporting evidence, of the strategies used by nurse leaders to
successfully guide nurses through planned change.
RRUCLA Nursing Admin 7W
TL6 – Part 1 Developing
Leaders
“Mentoring and Succession Planning for Clinical Nurses: Professional Role-Based Coach Program”
The CNO advocates for organizational support of ongoing leadership development for all nurses, with a focus on mentoring and
succession planning. Provide one example, with supporting evidence, of mentoring or succession planning activities for clinical nurses.
UCLA Health System RRUCLAMC Nursing Admin External Consultant 7E/5E
TL6 – Part 2 Developing
Leaders
“Mentoring and Succession Planning for Nurse Managers: Succession Planning Program”
The CNO advocates for organizational support of ongoing leadership development for all nurses, with a focus on mentoring and
succession planning. Provide one example, with supporting evidence of Mentoring or succession planning activities for nurse managers.
RRUCLAMC Nursing Admin 7W 8W Float/Resource Pool Labor & Delivery MOU NICU PICC Radiology
31
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
TL6 – Part 3 Developing
Leaders
“Mentoring and Succession Planning for Nurse Leaders: UCLA Health System Leadership Academy”
The CNO advocates for organizational support of ongoing leadership development for all nurses, with a focus on mentoring and
succession planning. Provide one example, with supporting evidence, of mentoring or succession planning activities for nurse leaders.
Nursing Admin
7ICU
Anesthesiology
Disaster Resource Center
Division of Infectious Disease
Emergency Department, System
GIM & HSR
HR Operations & Staff Develop
IR Radiology
Materials MGMT
Office of the Patient Experience
Operations
Operative Services
Performance Excellence
Resnick Outpatient Programs
RR General Surgery
TL6 – Part 4 Developing
Leaders
“Mentoring and Succession Planning for the Chief Nursing Officer: CNO Succession Planning”
The CNO advocates for organizational support of ongoing leadership development for all nurses, with a focus on mentoring and
succession planning. Provide one example, with supporting evidence, of mentoring or succession planning activities for the chief nursing
officer.
UCLA Health System RRUCLAMC Nursing Admin
TL7 Data-Driven Resourcing
“Trended Fall Data Leads to Acquisition of Low Beds” Nurse leaders, with clinical nurse input, use trended data to acquire necessary resources to support the care delivery system(s). Provide
on example, with supporting evidence, where a nurse leader, with clinical nurse input, used trended data to acquire necessary resources
to support the care delivery system(s).
8N
Entersomal Therapy
Materials MGMT
Nursing Admin
Nursing System
Procurement & Strategic Sourcing
RRUCLAMC Nursing Admin
TL8 – Part 1 CNO Visibility and
Accessibility
“Clinical Nurse Advocacy for Patient Safety Around the Hospital”
The CNO uses various methods to communicate, be visible, and be accessible to nurses throughout the organization. Provide one
example, with supporting evidence, of communication between the clinical nurse(s) and the CNO that led to a change in the patient
experience.
6E
Enterprises Admin
Operations
OR
OR Admin
RRUCLAMC Nursing Admin
TL8 – Part 2 CNO Visibility and
Accessibility
“Ensuring Clinical Nurse Competency” The CNO uses various methods to communicate, be visible, and be
accessible to nurses throughout the organization. Provide one example, with supporting evidence, of communication between the
clinical nurse(s) and the CNO that led to a change in the nurse practice environment.
5E 6E 6N 6W 7E 8N
Ambulatory
Emergency Department
NICU NPH NRE Operating Room PICU UCLA System HR
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SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
TL9 – Part 1 Influencing
Change
“Addition of Pediatric Nurse Practitioners in Response to Nurse Concerns about Quality & Safety in the PICU”
Nurse leaders (exclusive of the CNO) use input from clinical nurses to influence change in the organization. Provide one example, with supporting evidence, of clinical nurse communication with a nurse leader that influenced a change in the nurse practice environment.
Nurse Recruitment
Nursing Admin
Peds
PICU
TL9 – Part 2 Influencing
Change
“Creation of a Multidisciplinary Toolkit for Management of Escalating Patient Behaviors in Response to Clinical
Nurse Concerns about Safety and Quality of Care” Nurse leaders (exclusive of the CNO) use input from clinical nurses to influence change in the organization. Provide one example, with
supporting evidence, of a change in nursing practice that was influenced by the clinical nurse(s') communication with a nurse
leader.
7E/5E
7W
8ICU
Care Coordination Emergency Preparedness, Safety, and Security
Internal Medicine
RRUCLAMC Nursing Admin
Operations
Pt Placement and Transfer Center
Risk Management
UCLA Patient Liaison Program
SE1EO – Part 1 Interprofessional Decision-Making
Groups
“Improving the Care of Stroke Patients” Clinical nurses are involved in interprofessional decision-making
groups at the organizational level. Provide examples, with supporting evidence, of improvements resulting from the contributions of clinical
nurses in interprofessional decision-making groups at the organizational level.
6ICU
6N
Emergency Department
Emergency Medicine
Neurology
Neurology RESEARCH & SUPPORT
Neurosurgery
Pharmacy Services
PT/OT Admin-MP
QMS Overhead
SMH Radiology
SE1EO – Part 2 Interprofessional Decision-Making
Groups
“Ensuring Safe Access to Blood Products” Clinical nurses are involved in interprofessional decision-making
groups at the organizational level. Provide examples, with supporting evidence, of improvements resulting from the contributions of clinical
nurses in interprofessional decision-making groups at the organizational level.
7ICU
8ICU
Blood Donations
Clinical Labs - Blood Bank
DOM
Emergency Department
Labor & Delivery
Pathology & Lab
Primary Blood Procedures
SE2EO – Part 1 Professional
Organization Participation
“Use of ASORN Guidelines to Improve Surgical Site Markings”
The healthcare organization supports nurses' participation in local, regional, national or international professional organizations.
Provide two examples, with supporting evidence, of improvements resulting from a change in nursing practice that occurred because of
clinical nurse involvement in a professional organization.
JSEI OR
JSEI Pre/Post OP Unit
OPHTHALMOLOGY
33
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
SE2EO – Part 2 Professional
Organization Participation
“Improving Delirium Assessment in the Neurotrauma ICU Based on AACN Recommendations”
The healthcare organization supports nurses' participation in local, regional, national or international professional organizations.
Provide two examples, with supporting evidence, of improvements resulting from a change in nursing practice that occurred because of
clinical nurse involvement in a professional organization.
6ICU
NEUROSURGERY
Nursing Research & Edu (NRE)
SE3EO – Part 1 Professional
Nursing Certification
“Increasing Professional Nursing Certification at the Organizational Level”
The organization supports nurses' continuous professional development. Provide one example, with supporting evidence, illustrating that the organization has met a targeted goal for
improvement in professional nursing certification.
Nursing Research & Edu (NRE)
NSG ADMIN
SYSTEM
SE3EO – Part 2 Professional
Nursing Certification
“Increasing Professional Nursing Certification at the Unit Level”
The organization supports nurses' continuous professional development. Provide one example, with supporting evidence,
illustrating that nursing has met a targeted goal for improvement in professional nursing certification by unit or division
Nursing Research & Edu (NRE)
Nursing Admin
SE4EO – Part 1 Continuing Education Programs
“Improving Referrals to Palliative Care in the ICU through Education”
The organization provides opportunities to improve nurses' expertise in effectively teaching a patient or family. Provide one
example of nurses’ participation in a professional development activity that demonstrated an improvement in knowledge, skills,
and/or practices for professional registered nurses.
4ICU
MEDICINE
SMH PALL CARE
Supportive Services Program
UCSF
SE4EO – Part 2 Continuing Education Programs
“Use of a Structured Infection Prevention Program to Decrease Rates of CLABSI”
The organization provides opportunities to improve nurses' expertise in effectively teaching a patient or family. Provide one
example, with supporting evidence, of an educational activity provided by the organization focused on improving nurses' expertise
in teaching a patient or family.
4ICU
6E
6ICU
7E/5E
7ICU
7N
7W
8ICU
8N
8W
DIALYSIS INPT
FLOAT POOL
Infection Control
NICU
Nursing Research & Edu (NRE)
Nursing Admin
PEDS
PICU
RNPH 4N
TPN SERVICES
34
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
SE5 Non-Nurse Career
Programs
“Community Partnership with King Drew Magnet High School of Medicine and Science”
Nursing education opportunities are provided for those interested in a nursing career. Provide one example, with supporting evidence,
of a career development opportunity provided by the organization for non-nurse employees or members of the community interested in
becoming a registered nurse. This example may include community partnership activities.
Nursing Admin
Pt Escort Service
System
6ICU
6N
7E/5E
8W
Cardiology
EMER CTR
GOU/4ICU
IR Radiology
PEDS
Surgery - Recovery - MP
SE6 Nurses as Teachers
“Teach-Back Educational Summit and Meducation Toolkit to improve nurses’ expertise in patient and
family teaching” The organization provides opportunities to improve nurses'
expertise in effectively teaching a patient or family. Provide one example, with supporting evidence, of an educational activity
provided by the organization focused on improving nurses' expertise in teaching a patient or family.
7CCU
7W
Diabetic Services
DOM Electronic Medical Record (EMR)
Emer Medicine
Nursing Research & Edu (NRE)
Nursing Admin
Nursing TPN Services
SE7 – Part 1 Transitioning New
Nurses into Practice
“Onboarding & Orientation of Newly Hired Experienced Nurses”
The organization facilitates the effective transition of registered nurses and advanced practice registered nurses into the work
environment. Provide one example, with supporting evidence, of how the organization facilitates effective transition of newly hired
experienced nurses into the nurse practice environment. Describe how the transition process is evaluated for effectiveness.
HR Recruitment
Human Resources
Nursing Research & Edu (NRE)
Operations Personnel
SE7 – Part 2 Transitioning New
Nurses into Practice
“Onboarding & Orientation of New Graduate Nurses” The organization facilitates the effective transition of registered
nurses and advanced practice registered nurses into the work environment. Provide one example, with supporting evidence, of how
the organization facilitates effective transition of new graduate nurses into the nurse practice environment.
Nursing Research & Edu (NRE)
SE8 Developing Nurse
Preceptors
“Growing Expert Preceptors through a Standardized Preceptor Program”
The organization provides educational activities to improve the nurse’s expertise as a preceptor. Describe the organization's preceptor educational program(s) and how each program is
evaluated on an ongoing basis.
Labor & Delivery Nursing Research & Edu (NRE)
35
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
SE9 – Part 1 Community
Outreach
“UCLA Nurses Respond to Typhoon Haiyan” The organization supports nurses' participation in community
healthcare outreach. Provide one example, with supporting evidence, of organizational support for clinical nurse involvement in community
healthcare outreach.
6E, UNION
CIP - EHR Ambulatory Rollout
Clinical System Team Electronic Medical Record (EMR)
MATERIALS MGMT
PACU
PT RELATIONS & HR
SYSTEM
SE9 – Part 2 Community
Outreach
“UCLA RN Orchestrates 27th Annual Oley Foundation Conference”
The organization supports nurses' participation in community healthcare outreach. Provide one example, with supporting evidence, of organizational support for nurse leader involvement in community
healthcare outreach.
6ICU
7E/5E
Enterostomal Therapy
Nursing TPN Services
PEDS
PICC RADIOLOGY
Resource Team
SMH PTU
SE10EO Community
Healthcare Needs Assessment
“Facilitating a Camp Experience for Children with Heart Disease: The Camp Del Corazon Experience”
Nurses participate in the assessment and prioritization of the healthcare needs of the community. Provide one example, with
supporting evidence, of an improvement in an identified healthcare need that was associated with nurses' partnership with the
community.
Catheterization Lab
Float Pool
GONDA
PEDS
SMH PEDS
SE11 – Part 1 Recognizing
Nurses
“Recognition of a Clinical Nurse” Nurses are recognized for their contributions in addressing the
strategic priorities of the organization. Provide one example, with supporting evidence, of recognition of a clinical nurse for his or her
contribution(s) in addressing the strategic priorities of the organization.
Nurse Recruitment
Nursing Admin
SON
6W
6W
7ICU
MAP - Admin Ambu Nursing
PICU
RNPH 4E
RNPH 4N
SMH 4CW
SMH 4MN
SMH 5MN
SMH AMBU CARE
5E OB
8N
SE11 – Part 2 Recognizing
Nurses
“Recognition of a Group of Nurses” Nurses are recognized for their contributions in addressing the
strategic priorities of the organization. Provide one example, with supporting evidence, of recognition of a group of nurses for their
contribution(s) in addressing the strategic priorities of the organization.
7E/5EMS
Nurse Recruitment
Nursing Admin
36
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
EP1 Professional
Practice Model
“Evaluation of the Professional Practice Model” Clinical nurses are involved in the development, implementation
and evaluation of the professional practice model. Provide a description, with supporting evidence, of the ongoing evaluation of the nursing professional practice model and how clinical nurses are
involved.
Nursing Admin 7E/5EMS
EP2EO Results of
Professional Practice Model
“Using the PPM to Implement a Teamwork-Based Care Delivery Model on 7W”
Clinical nurses are involved in the development, implementation and evaluation of the professional practice model. Provide one
example, with supporting evidence, of an improvement resulting from a change in clinical practice that occurred because of clinical nurses' involvement in the implementation or evaluation of the professional
practice model.
7W
EP3EO Nurse Satisfaction
Data
“Nurse Satisfaction Survey Overview” Unit or clinic level nurse (RN) satisfaction data outperform the
mean or median of the national database used. Provide unit-based, national benchmarked nurse (RN) satisfaction data from the most recent survey administered within the previous 30 months before
documentation submission.
All Units!
EP4 – Part 1 Establishing a Plan
of Care
“Nurse as Patient – Providing Individualized Care to a Colleague”
Nurses create partnerships with patients and families to establish goals and plans for delivery of patient-centered care. Provide one
example, with supporting evidence, of nurses partnering with patients and families to develop an individualized plan of care based on the
unique needs of the patient.
4ICU
EP4 – Part 2 Establishing a Plan
of Care
“Ensuring Optimal Care for Pediatric Patients Across the Continuum of Care”
Nurses create partnerships with patients and families to establish goals and plans for delivery of patient-centered care. Provide one
example, with supporting evidence, of nurses partnering with patients and families to improve systems of care at the unit, service line or
organizational level.
Emergency Department Peds
EP5 – Part 1 Interprofessional
Collaboration
“Care Coordination for Liver Transplant Patients” Nurses are involved in interprofessional collaborative practice
within the care delivery system to ensure care coordination and continuity of care. Provide two examples, with supporting evidence,
of nurses' involvement in interprofessional collaborative practice that ensures care coordination and continuity of patient care.
8N Liver In-House Transplant Care
Liver Post Transplant Care
Liver Acquisition
EP5 – Part 2 Interprofessional
Collaboration
“Care Coordination for Aortic Repair Patients” Nurses are involved in interprofessional collaborative practice
within the care delivery system to ensure care coordination and continuity of care. Provide two examples, with supporting evidence,
of nurses' involvement in interprofessional collaborative practice that ensures care coordination and continuity of patient care.
UCLA Aortic Center
37
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
EP6 Regulatory & Professional
Standards
“Incorporating Vascular Access Standards into Care” Nurses incorporate regulatory and specialty standards/guidelines
into the development and implementation of the care delivery system. Provide one example, with supporting evidence, of nurses
incorporating specialty standards/guidelines into the delivery of care.
7E/5E
Case Management
CCTT/SIM LAB
Emergency Department
GOU
Nursing Research & Edu (NRE)
PICC RADIOLOGY PICU
SMH 6NW PEDS
SMH ER SMH PICU SMH RADIOLOGY
EP7EO Standards of Care
and Practice
“Using AWHONN and Baby-Friendly Standards to Enhance Skin-to-Skin Initiation After Vaginal Births”
Nurses systematically evaluate professional organizations' standards of practice, incorporating them into the organization's
professional practice model and care delivery system. Provide one example, with supporting evidence, of an improvement resulting from
a change in clinical practice due to the application of a professional organizations' standards of nursing practice. The example provided
may be at the unit, division or organizational level.
5E OB Electronic Medical Record (EMR)
L&R
EP8EO Internal Experts
“Internal Consultant facilitates reduction in adverse glycemic events: The Green Apple Project”
Nurses use internal and external experts to improve the clinical practice setting. Provide one example, with supporting evidence, of an improvement that occurred due to a change in clinical practice
setting resulting from the use of internal experts.
6W
7E
7E/5E
7W
8N
Diabetes Services
Nursing Admin
Pharmacy
EP9 – Part 1 Staffing/
Scheduling Participation
“CTICU Nurse Advocates for Resources to Meet Acuity Demands”
Nurses are involved in staffing and scheduling based on established guidelines, such as ANA's Principles for Nurse Staffing, to ensure that RN assignments meet the needs of the patient population. Provide two examples, with supporting evidence, from different
practice settings when input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate
for a change in patient acuity, patient population, resources or redesign of care.
7ICU
EP9 – Part 2 Staffing/
Scheduling Participation
“NICU Clinical Nurse Advocates for Resources Detriorating Neonate”
Nurses are involved in staffing and scheduling based on established guidelines, such as ANA's Principles for Nurse Staffing, to ensure that RN assignments meet the needs of the patient population. Provide two examples, with supporting evidence, from different
practice settings when input from clinical nurses was used to modify RN staffing assignments and/or adjust the schedule to compensate
for a change in patient acuity, patient population, resources or redesign of care.
NICU
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SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
EP10 – Part 1 Budget Data
Analysis
“Operating Room Clinical Nurses Shift Start Times to Provide Adequate Staffing”
Nurses use trended data in the budgeting process, with clinical nurse input, to redistribute existing nursing resources or obtain
additional nursing resources. Provide two examples, with supporting evidence, from different practice settings, where trended data was used during the budget process, with clinical nurse input, to assess
actual-to-budget performance to redistribute existing nursing resources or to acquire additional nursing resources. Trended data
must be presented.
OR OR Admin
EP10 – Part 2 Budget Data
Analysis
“Creation of a Nurse-led Volunteer Companion Program to Subsitute for Constant Observation Aides”
Nurses use trended data in the budgeting process, with clinical nurse input, to redistribute existing nursing resources or obtain
additional nursing resources. Provide two examples, with supporting evidence, from different practice settings, where trended data was used during the budget process, with clinical nurse input, to assess
actual-to-budget performance to redistribute existing nursing resources or to acquire additional nursing resources. Trended data
must be presented.
Nursing Admin
EP11EO Recruitment and
Retention
“Clinical Advancement Program for Pediatric Intensive Care Nurses”
Nurses participate in recruitment and retention assessment and planning activities. Provide one example, with supporting evidence, of clinical nurses' participation in nursing retention activities and the impact on turnover rates. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
PICU
EP12 Nursing
Leadership Roles
“Transitioning Patients from the OR to Cardio-Thoracic ICU: An Interprofessional Standardized Handover”
Nurses assume leadership roles in collaborative interprofessional activities to improve the quality of care. Provide one example, with
supporting evidence, of a nurse-led (or nurse co-led) collaborative interprofessional quality improvement activity.
7ICU
Anesthesiology
EP13EO Patient Education
Programs
“Colorectal Surgery Education for Patients” Nurses participate in interprofessional groups that implement and
evaluate patient education activities. Provide one example, with supporting evidence, of an interprofessional patient education activity
that was associated with an improved patient outcome.
8E 8N 8W Anesthesiology DOM Enterostomal Therapy Hemapheresis Infection Control
OR & OR Admin PEDS PERIOP AREAS Pharmacy Services Support QMS Overhead Urology Surgery SOM Sterile Processing
SMH Quality Improvement
39
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
EP14 – Part 1 Resources for Autonomous
Practice
“Nurse-Driven Skin and Wound Care Practices” Resources, such as professional literature, are readily available to support decision-making in autonomous nursing practice. Provide two examples, with supporting evidence, of how resources are used to support evidence-based clinical decision-making in autonomous
nursing practice.
Enterostomal Therapy
PICU
EP14 – Part 2 Resources for Autonomous
Practice
“Early Mobility in the Medical ICU” Resources, such as professional literature, are readily available to support decision-making in autonomous nursing practice. Provide two examples, with supporting evidence, of how resources are used to support evidence-based clinical decision-making in autonomous
nursing practice.
4ICU
EP15 – Part 1 Performance &
Peer Review
“Nursing Self-Appraisal and Peer Feedback Promote Professional Development for Clinical Nurses”
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. Provide one example, with supporting evidence, of
clinical nurses using periodic formal performance review that includes a self-appraisal and peer feedback process to enhance competence or
professional development.
7W NURSING RESEARCH & EDU (NRE)
EP15 – Part 2 Performance &
Peer Review
“Nursing Self-Appraisal and Peer Feedback Promote Professional Development for Nurse Leaders”
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. Provide one example, with supporting evidence, of
nurse leaders using periodic formal performance review that includes a self-appraisal and peer feedback process to enhance competence or
professional development.
7W NURSING RESEARCH & EDU (NRE)
EP16 – Part 1 Nursing
Autonomy
“Autonomous Nursing Practice in Complex Care Coordination”
Nurse autonomy is supported and promoted through the organization's governance structure for shared decision-making.
Provide one example, with supporting evidence, of clinical autonomy that demonstrates the authority and freedom of nurses to make
nursing care decisions (within the full scope of their practice) in the clinical care of patients.
Children's Heart Center
Clinical Nutrition
Social Work
SMH PEDS
EP16 – Part 2 Nursing
Autonomy
“Autonomous Nursing Practice in Neonatal End-of-Life Care”
Nurse autonomy is supported and promoted through the organization's governance structure for shared decision-making. Provide one example, with supporting evidence, of organizational
autonomy that demonstrates the authority and freedom of nurses to be involved in broader unit, service line, organization or system
decision-making processes pertaining to patient care, policies and procedures, or work environment.
L&R NICU NNP Program
PEDS
Respiratory Therapy
Spiritual Care
EP17 Ethical Issues
“Ethics Center Services Support and Develop Ethical Nursing Practice”
Nurses use available resources to address ethical issues related to clinical practice and organizational ethical issues. Provide one
example, with supporting evidence, of nurses using available resources to address ethical issues related to clinical practice.
ETHICS
NICU
Nursing Research & Edu(NRE)
40
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
EP18EO – Part 1 Workplace Safety
“Reducing Needlestick Injuries through Standardization of Safety Needles”
Workplace safety for nurses is evaluated and improved. Provide two examples, with supporting evidence, of improved workplace safety for
nurses resulting from the safety strategy of the organization.
4ICU 6E 6N 7E/5E 7ICU 7N 8ICU
Enterostomal Therapy Infection Control
Materials MGMT
Nursing System Nursing TPN Services OCC HEALTH FACILITY OR Admin OWENS, Product Committee
PICU Procurement & Strategic Sourcing PT/OT Inpatient Respiratory Therapy
EP18EO – Part 2 Workplace Safety
“Increasing Nurse Influenza Vaccination Rates” Workplace safety for nurses is evaluated and improved. Provide two examples, with supporting evidence, of improved workplace safety for
nurses resulting from the safety strategy of the organization.
Float Pool
Human Resources
Nursing Admin
Occupational Health
EP19EO Proactive Risk
Assessment
“Nurses improve Safety by Reducing Medication Errors” Nurses are involved in the facility- or system-wide approach focused
on proactive risk assessment and error management. Provide one example, with supporting evidence, of an improvement in patient
safety that resulted from nurses' involvement in facility- or system-wide proactive risk assessment or error management.
6N 6E
6W 7E 7E/5E 7W
8ICU
8N
8W PEDS
Diabetic Services
Nursing Admin Emergency Department
Anesthesiology
IT Help Desk Electronic Medical Record (EMR)
EP20EO – Part 1 Evaluating Patient
Safety Data
“Implementation of the ‘Bug Busters’ Committee on Acute Care Pediatrics”
Clinical nurses are involved in the review, action planning and evaluation of patient safety data at the unit level. Provide two
examples, with supporting evidence, of an improvement in patient safety that resulted from clinical nurses' involvement in the
evaluation of patient safety data at the unit level.
Infection Control
Nursing Research & Edu(NRE)
PEDS
41
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
EP20EO – Part 2 Evaluating Patient
Safety Data
“Implementation of SBAR Standardized Practice to Reduce Time to Transport by the Critical Care Transport
Team” Clinical nurses are involved in the review, action planning and evaluation of patient safety data at the unit level. Provide two
examples, with supporting evidence, of an improvement in patient safety that resulted from clinical nurses' involvement in the
evaluation of patient safety data at the unit level.
CRITICAL CARE TRANSPORT
EP21EO Patient Safety
Goals
“Nurses Leading Improvement in Medication Labeling and Communication in Perioperative Settings”
Nurses are involved in implementing and evaluating national or international patient safety goals. Provide one example, with
supporting evidence, of nurses' involvement in activities that address national or international patient safety goals that led to an
improvement in patient safety outcomes.
Main OR
EP22EO Nurse Sensitive
Quality Indicatiors
“Nurse-Sensitive Quality Indicators: Data Collection & Benchmarks”
Unit- or clinic-level nurse-sensitive clinical indicator data outperform the mean or median of the national database used.
All Units Nursing Admin
EP23EO Patient
Satisfaction
“Patient Satisfaction Survey Overview” Unit- or clinic-level patient satisfaction data (related to nursing care) outperform the mean or median of the national database
used.
All Units Nursing Admin
NK1 Advancing
Nursing Research
“Improving the Care Experience for Children with Complex Chronic Conditions and their Families in the
PICU: Parent and Nurse Perceptions” The organization supports the advancement of nursing research.
Provide one completed IRB-approved nursing research study. Results of data analysis (quantitative) or findings (qualitative); must have
occurred within the four (4) years before documentation submission.
PICU
NK2 – Part 1 Disseminating
Research Knowledge
“Nursing Grand Rounds Support Internal Dissemination of Nursing Research”
Nurses disseminate the organization's nursing research findings to internal and external audiences. Provide one example, with supporting evidence, of how clinical nurses disseminated to internal audiences’ knowledge obtained
through the organization's nursing research.
7W
DOM ETHICS
Nursing Research & Edu(NRE)
PICU SMH 4SW
NK2 – Part 2 Disseminating
Research Knowledge
“Dissemination of Nursing Research to External Audiences: The Annual UCLA Nursing Research and
Evidence-Based Practice Conference” Nurses disseminate the organization's nursing research findings to internal
and external audiences. Provide one example, with supporting evidence, of how clinical nurses disseminated to external audiences’
knowledge obtained through the organization's nursing research.
SOM Neurology
42
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
NK3 – Part 1 Integrating
Evidence-Based Findings into
Practice
“Use of the Clinical Practice Council to Develop New Early Mobility Practices”
Nurses disseminate the organization's nursing research findings to internal and external audiences. Provide one example, with
supporting evidence, of how clinical nurses used evidence-based findings to revise an existing practice to improve care.
4ICU
6ICU
7CCU
7ICU
8ICU
BIOMED LIBRARY
CRITICAL CARE TRANSPORT
PACU
PICU
PT/OT Admin-MP
Respiratory Therapy
NK3 – Part 2 Integrating
Evidence-Based Findings into
Practice
“Use of the Clinical Practice Council to Revise Urinary Catheter Management Practices”
Nurses disseminate the organization's nursing research findings to internal and external audiences. Provide one example, with
supporting evidence, of how clinical nurses disseminated to internal audiences’ knowledge obtained through the organization's nursing
research.
8W
6E
6N
7E
7N
GOU
SMH 4MN
SMH 5NW
NK4 – Part 1 Nursing
Innovation
“Interprofessional Innovation in Fall Prevention” Innovation in nursing is supported and encouraged. Provide two
examples, with supporting evidence, of an improvement that resulted from an innovation in nursing.
6E
6ICU
6N
7E/5E
8N
NA
NRRU
Nursing Admin
OR
SMH ER
NK4 – Part 2 Nursing
Innovation
“Innovation in Pediatric Sepsis Management” Innovation in nursing is supported and encouraged. Provide two
examples, with supporting evidence, of an improvement that resulted from an innovation in nursing.
QMS Overhead
Emergency Department Electronic Medical Record (EMR)
Emergency Department
PEDS
PEDS OPERATIONS
PICU
QUALITY MGMT
43
SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED
NK5EO – Part 1 Implementing
Technology
“Enhancing Nurse Immunization Screening Using E.H.R. Functionality”
Nurses are involved with the design and implementation of technology to enhance the patient experience and nursing practice. Provide one example, with supporting evidence, of an improvement that occurred due to a change in nursing practice that resulted from
clinical nurses' involvement with design and implementation of technology.
7E/5E Electronic Medical Record (EMR)
Infection Control
ISS CareConnect
Nursing Admin
PICU
QMS Overhead
QUALITY MGMT
Emergency Department
NK5EO – Part 2 Implementing
Technology
“Improvement in Patient Experience with Technology” Nurses are involved with the design and implementation of
technology to enhance the patient experience and nursing practice. Provide one example, with supporting evidence, of an improvement in the patient experience that resulted from clinical nurses' involvement
with design and implementation of technology.
6E
8ICU
8N
GOU
L&R
NK6EO Improving
Workflow and Space Design
“Nurses Leading Efforts to Reduce Waste” Nurses are involved in the design and implementation of work flow
improvements and space design to enhance nursing practice. Provide one example, with supporting evidence, of nurse involvement
in the design and implementation of work flow that resulted in an operational improvement, waste reduction or clinical efficiency.
8E Materials Management
44
Appraiser Visit Prep:
FOLLOW THE PATH TO PREPARE FOR YOUR SITE VISIT
PRIDE Smile! Remember this is the only few minutes you will have to dazzle the
appraisers with examples of excellence in your practice area
POSTURE Sit up straight! Lean in! Make eye contact. Convey eagerness and
excitement. Look confident …even if you need to work on it.
PLAN
Prepare ahead. Decide what you want the appraisers to hear…rather
than focus on worrying about their questions. Come up with at least 3
examples of excellence that reflect Magnet standards in each area
PLANT
Identify the person who will take the lead to share a great example. Rely
on that person to fill the rest of the group in on details of the initiative
during practice sessions
PRACTICE Makes perfect! Most of us are not used to stopping long enough to talk
about our work. Talk out loud.
PROMPT
If you are talking and think someone in your group has something great
to add, prompt them by saying: “Mary, how about sharing what’s going on
in …?”
PIGGYBACK While one person is speaking, everyone else should be thinking: “How
can I hinge or add to what she/he saying?” Keep the conversation going.
The more you speak, the less time there is for appraisers to question.
PARTNER
Remember to share examples of great collaboration between clinical
nurses and their managers…and between departments…and with your
CNO
PLAY BALL
This is a team sport. Don’t let one person monopolize or talk too much.
Go ahead and interrupt respectfully. “Hey, Mary, I’d like to add something
to that.”
PRAISE Recognize each other! Celebrate the work of other nurses, your
manager, director, CNO as well as other personnel and MDs
PUNCTUAL Be on time for every interaction. Be waiting at the entrance to your unit.
Arrive at meetings 10 minutes early
PASSION
Overall, take a deep breath and remember why you became a nurse in
the first place. Let the appraisers witness your dedication to the nursing
profession
KMS/ NCP 2014