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Spectrum Health Nursing Shared Leadership Bylaws | July 2017 1

Spectrum Health Grand Rapids

Spectrum Health Nursing Shared Leadership Bylaws


Evidence OO17-8, Spectrum Health Nursing Shared Leadership Bylaws, July 2017



Table of Contents Overview ................................................................................................................................ Page 3 Council Purpose and Goal Development .............................................................................. Page 3 Council Membership ............................................................................................................. Page 3-4 Attendance, Terms and Meetings ......................................................................................... Page 4 Chairperson .......................................................................................................................... Page 4 Orientation ............................................................................................................................ Page 4 Review of Bylaws .................................................................................................................. Page 5 Central Shared Leadership Council ...................................................................................... Page 5-7 Nursing and Allied Health Electronic Health Record (EHR) Oversight Council .................... Page 8-9 Nurse Manager Council ......................................................................................................... Page 10-12 Nursing Executive Council .................................................................................................... Page 13 Nursing Practice Council ...................................................................................................... Page 14-16 Nursing Quality and Safety Council ...................................................................................... Page 17-19 Nursing Research Council .................................................................................................... 0 Nursing Education Council .................................................................................................... Page 21 Shared Leadership Oversight Committee ............................................................................. Page 22 References ............................................................................................................................ Page 23 Approved by Nursing Executive Council: June 28, 2017





Spectrum Health Shared Leadership Bylaws SHGR Nursing Shared Leadership Structure Leadership is demonstrated by nurses in all roles throughout the organization. Shared leadership councils create and support an environment where we, as nurses, make decisions that affect our professional practice. The leadership councils that maintain responsibility and accountability for the management, operation, and integration of professional roles and activities within nursing are as follows:

Nursing Executive Council Central Shared Leadership Council Nursing Quality and Safety Council Nursing Practice Council Nursing Research Council Nursing Education Council Nursing and Allied Health Electronic Health Record (EHR) Oversight Council Nurse Manager Council

The Shared Leadership Oversight Committee is created to facilitate and coordinate efforts among shared leadership council chairs. To facilitate and coordinate decision making efforts, the following definitions are recognized:

Council: Ongoing group, chartered by the nursing executive council with responsibility for decision-making and action consistent with its function. Committee: Ongoing group, chartered by a council, with a designated scope of authority for decision-making and action in order to achieve pre-established outcomes. Workgroup: Short-term group, chartered by a council or committee, with a specific level of authority to collect information in order to make appropriate recommendations. Meetings: Non-chartered group, with a common interest, meeting to discuss current issues and strategy. A need for a committee or workgroup may develop from a meeting.

Council Purpose and Goal Development

Each council develops annual goals based on the council purpose. Goals are reviewed annually and a progress report is submitted annually to the Nursing Executive Council (NEC).

Membership

Membership is determined by role, leadership recommendation, or application process as appropriate. If used, applications must be submitted in writing to the employee’s manager for endorsement. The applicant is responsible for submitting applications to the chair of the intended council. If the number of applicants exceeds the identified need, the chair selects the most appropriate person based on their qualifications in relation to council needs. Responsibilities of council members include:

Attend and participate in council meetings and assigned work. Keep peers and co-workers informed of council activities and recommendations as

appropriate.




Spectrum Health Grand Rapids Gather information and opinions from staff to bring back to councils for consideration in decision-

making.

Attendance

The minimum expectation is that members must attend at least 80 percent of all scheduled meetings. Members should be proactive in making arrangements in order to attend meetings. The council chair follows up with members who miss meetings to assess interest in continuing council participation, barriers to attending meetings, and steps to achieve higher attendance.

Terms

Each council determines the term limit of their membership.

Meetings

Meetings are scheduled in the fall of each year, 12 months in advance. This allows rooms to be reserved and members to make arrangements to attend. Meetings are consistently held as scheduled. Council chairs may cancel meetings per their discretion. Cancellation notifications are sent to members by e-mail or via another method as determined by each council. Council members are expected to come prepared to all meetings by reading the minutes and agendas, as well as any relevant project work and e-mails. An administrative assistant is assigned to each central council. Meeting minutes are distributed to council members via e-mail. Approved minutes are posted to the nursing page on InSite so they are available for all staff. Official meeting minutes are retained for seven years. Maintenance of council minutes and other documents is the responsibility of the council chair and may be delegated to the administrative assistant assigned to support the council. Parliamentary procedure is followed. A quorum, defined as greater than 50 percent of voting membership, is necessary for taking action on decisions.

Chair Person

Officers of the councils are accountable for the ongoing leadership and coordination of that council. They represent their council in a variety of forums and are responsible for communicating council activities. In the absence of the chair, the vice chair or designee leads council meetings. Chair and vice chair terms are determined by individual councils—except with those councils whose chair position is a function of their role. Responsibilities of council chair persons include:

Lead council in achieving the council purpose Ensure meeting agenda development and distribution in advance Ensure minutes are approved by committee members for accuracy and meeting the intent of the

discussion Post minutes once approved Discuss council activities with the Central Shared Leadership Council (CSLC) Communicate pertinent council information to other council chairs Submit annual report for the fiscal year to NEC outlining goals, achievements, activities, barriers,

and member participation. Orientation

Every new council member will receive orientation as coordinated by the council chair person. This includes purpose and goals of the council and the role expectations of members.




Central Shared Leadership Council (CSLC)

Description/Purpose

CSLC provides leadership from direct care nurses to develop, implement and evaluate goals related to organizational and operational plans; nursing practice standards; quality of care; and patient, physician and staff satisfaction. CSLC provides a forum for discussion of clinical and professional practice concerns, resource utilization and trends, and recommendations for required action plans. Membership

CSLC direct care RN representatives are the chairs/vice-chairs of their respective Unit-based Shared Leadership Councils (UBSLC). Additionally, other roles within nursing have consistent representation. The following clinical units/departments have one consistent staff nurse representative as a voting member: SH Blodgett Hospital: ACE Unit (1D), Medical/Surgical (1E), Adult Critical Care (1H), Progressive Care (1G), Orthopedics/Center for Joint Replacement (3E/3G), Medical (3D), Neuro/Spine (3H), Inpatient Rehab Center (IRC) (4A/B/D), GI/GU (4G), Bariatrics (4H), Emergency Department, PACU, Surgery/OR, & Surgical Center SH MHC & Butterworth Hospital: Labor & Delivery (2/3 Center), Orthopedics/Progressive Care (2 South), Cath Lab (3MHC), OBSC/Mother-Baby/Women’s Health (4/6/7/8 Center), Neuro Critical Care (4MHC), Surgical Critical Care (4 MHC), Ortho/Trauma (4 North), Neuroscience (4 South), Medical/Surgical (4 West), Cardiothoracic Critical Care/CVRU (5MHC/2MHC), Medical Critical Care (5 MHC), Oncology (5 North), Oncology/BMT (5 South), BMT (5 Center), ED Observation (5 West), Cardiovascular (6 MHC), Heart Failure (6 North), Burn Center/Progressive Care (6 South), Cardiovascular (7 MHC), Gastrointestinal/Genitourinary (7 North), EMU (7 South), Medical (9 Center), Emergency Department, PACU, Surgery/OR, & Surgical Center SH Helen DeVos Children’s Hospital: Neonatal ICU (3CH/3W), Pediatrics (5CH), Pediatrics (6CH), Pediatrics (7CH), Pediatric Intensive Care Unit (8CH), Pediatric Oncology/Hematology/BMT (9CH), Pediatric Emergency Department, Pediatric Sedation Services, & Pediatric Surgical Services Other areas/departments represented: DeVos Cardiac Diagnostic Unit (Adult), Endoscopy, Interventional Radiology, Lake Drive Surgical Center, Nephrology (Adult), Pre-procedure Planning (PPP), Resource Center (NRC), and the South Pavilion Surgery Center The following representatives will be considered non-voting members: Director of nursing operations/Magnet program, nurse manager advisor, council administrative assistant, HR representative Transfer Center, Pharmacy Medication Safety Officer. The following representatives may be invited ad hoc to the council for specific requests: CNE/Vice-President of patient care services, CNS/Educator, infection control, and the chairperson for the Nursing Quality & Safety Council (NQSC), Nursing and Allied Health Electronic Health Record (EHR) Oversight Council, Nursing Education Council (NEdC), Nurse Manager Council (NMC), Nursing Practice Council (NPC), and the Nursing Research Council

Chair/Vice-Chair

The chairperson and vice-chairperson are elected positions from within the council. Individuals in the chair and vice chair roles may serve a maximum of two years per role, with




the provision of being reaffirmed by council members on an annual basis thereafter.

Orientation

Officers receive orientation to the role following the role transition standard work. In addition, it is the expectation when a direct care nurse is chair or vice chair of a central —not unit-based— council he/she will participate in the LINKS program (Leaders Interacting with Nurses to Increase Knowledge of Spectrum Systems). New council members also receive orientation, including a discussion of the purpose and goals of the council, and role expectations of members. It is the responsibility of each exiting member to complete the role transition standard work with the incoming member.

Advisor/Mentor

The Director of Nursing Operations/Magnet Program and one Nurse Manager have been appointed by the chief nurse executive (CNE) to mentor and advise direct care nurses assuming the role of chair or vice chair of the council. These advisors also meet with the council officers regularly to function as the council steering team. Meetings

Meetings are held monthly. Council members are expected to come prepared to all meetings by reading the minutes and agendas, as well as any relevant project work and e-mails. Attendance

Each unit will designate two individuals, a UBSLC chairperson and Vice-Chairperson, to represent the unit on the Central Shared Leadership Council. The UBSLC Chairperson is the primary CSLC member; the UBSLC Vice-Chair may attend CSLC to represent the unit only when the UBSLC Chair is unavailable. Any arrangements, which are necessary to enable a member to attend, are the responsibility of the individual member. Arrangements should be negotiated with the member’s manager in advance.

Attendance is maintained for performance management & EXCEL documentation purposes. The council chair follows up with members who miss meetings to assess interest in continuing council participation, barriers to attending meetings and steps to achieve higher attendance.




CSLC Charter Councils Unit Based Shared Leadership Council (UBSLC)

Description/Purpose

Each of the units/areas previously identified as part of the CSLC, have a Unit-based Shared Leadership Council. The focus of these councils is to develop, implement and evaluate unit-specific goals related to organizational and operational plans; nursing practice standards; quality of care; and patient, physician and staff satisfaction.

Goal Development

Each council develops annual goals based on their council purpose. Goals are reviewed annually before the end of the fiscal year and prior to membership turnover. The initial goals and final evaluation are both submitted electronically to the CSLC chairperson for the purpose of sharing with formal nursing leadership. Membership/Meetings

Membership consists of representatives from different roles within the unit. Meetings are held on a consistent basis; monthly or every other month based on unit needs. The nurse manager attends meetings as a resource to answer questions about organizational processes and to mentor staff leadership as appropriate. Chair/Vice-Chair

The chairperson and vice-chairperson must be a direct care RN elected by the council or appointed by the nurse manager, as determined by each UBSLC. The UBSLC chairperson is responsible for following the UBSLC standard work guidelines for their dedicated 8 hour monthly allocation. The chair of the UBSLC is the unit’s primary representative to CSLC; the vice-chair is the unit’s alternate

representative to CSLC. When CSLC attendance is alternated between roles, there must be an intentional hand-off of CSLC information and work in progress to keep both roles up to date and allow council business to continue seamlessly. The chair/vice-chair relationship is designed to mentor the vice-chair for the purpose of becoming the UBSLC chair in the future utilizing the role transition standard work guidelines.




Nursing and Allied Health Electronic Health Record (EHR) Oversight Council

Description/Purpose

"The Spectrum Health Nursing and Allied Health EHR Oversight Council (NAEOC) is accountable for the comprehensive strategy for the electronic health record, information technology and its integration into the nursing and Allied Health patient care processes. They will make decisions related to EHR clinical content embedded in nursing and allied health care flows, and other EHR decisions that require a collective clinical viewpoint. This Council will serve as a representative of the global perspective at Spectrum Health and include input from all clinical disciplines. The Council members serve as “ambassadors” for the work of this

council, bringing outputs and rationales for decisions back into each of their respective departments/areas/facilities, and serving as champions for the adoption of the Nexus Initiative and clinical adoption of the Epic electronic health record (EHR) Listed below are the EHR Oversight Committees chartered by NAEOC:

Adult Inpatient Nursing Informatics Committee BCMA Steering Committee Big Rapids & Reed City Hospitals Continuing Care CPM Group Emergency Department EHR Oversight Committee Gerber Hospital Inpatient Care Management & Utilization Management Laboratory Ludington Hospital Pennock Hospital Pediatric Services Pharmacy Radiology Rehabilitation Respiratory Therapy Surgical Services United & Kelsey Hospitals Women’s and Infants Services Zeeland Hospital"

Guiding Principles:

Spectrum Health embraces the Nexus philosophy with a continuous goal of improving patient care in the context of the organization’s vision. Embedded in the context of this initiative are these guiding principles:

Integrate Care across the delivery system and beyond creating One Patient Story. Employ Evidence Based Practice reducing variation and improving outcomes. Create a Consistent Exceptional Experience through patient and family centric care. Show Respect for People through less time charting, more time caring and by facilitating an

environment that is safe for patients and care providers. These principles will be supported by a deliberate focus on Quality, Safety and Continuous Improvement. Clinical and operational leadership from across Spectrum Health have developed a council structure to support standardization and decisions across the various clinical Process of Care Teams (POC), Clinical Improvement Programs (CIP), Clinical Service Lines (CSL), Patient Family Advisory Council (PFAC), and clinical applications. These groups work




collaboratively to accomplish these goals.

Responsibilities and Goals: Review key clinician specific concerns, clinical processes, and clinical application builds. Assure the Epic EHR is designed and built to support defined clinical standards, care flows and promote evidence-based patient care practices. Our goal is to deliver a system which supports safe, timely, effective, efficient, equitable, and patient-centered care in support of the Mission and Values of Spectrum Health by:

• Ensuring aligned decision making with Nexus and clinical technology initiatives • Ensuring that the priorities set for standardization support Spectrum Health’s clinical quality and

safety initiatives and promote integration of care within the acute and ambulatory environment. • Develop and monitor strategies to analyze and communicate adoption metrics, adherence to

documentation. • Advising on policy changes that affect the use of technology for clinical practice and processes. • Advising the SH Nurse Executive Council (NEC) and the CNO Council on enterprise clinical

decisions specifically affecting nursing and allied health clinician populations and on key policy issues that could affect Nexus EMR adoption.

• Providing input into a Nursing and Allied Health communication, engagement and training plan for Nexus, as well as reviewing and approving the plan.

• Bidirectional coordinating (receiving input and facilitating collaborative decision-making with all Nexus councils / POCs / CIPs, CSL and the Provider EHR Oversight Council (PEOC) as applicable).

• Increase staff awareness of and promote competency in the design, planning, use and evaluation of information technologies.

• Establish standards for the use of information technology. • Establish criteria for the prioritization and coordination of requests and approve requests for the

development, implementation and optimization of information technology impacting nursing and allied health clinicians.

• Partner with non-clinical departments on technology processes which will impact nursing and allied health clinicians.

• Collaborate across disciplines and departments to create and maintain downtime processes and make modifications as necessary.

Membership The council charter will be reviewed and updated annually as part of the membership ratification process, voted on by the incoming membership, and signed off by the outgoing and incoming council chair/co-chairs.

1. Voting Members: The NAEOC shall invite the co-chairs of the Charter Committees. The co-chairs are the informatics and clinical lead for each standing committee. Other representatives within the community hospitals and service lines will be included. Voting members are expected to attend at least 80% of meetings held in the fiscal year.

2. Extended, Non-Voting Members: May also be identified to ensure specific areas of representation are made available to the council as required by the project. They will receive meeting minutes, have access to the InSite page and will be included in relevant decisions.

Chairs

The Manager of Nursing Informatics and Lead Clinical Informatics Specialist serve as co-chairs. Meetings

Meetings are held at least monthly.




Nurse Manager Council (NMC)

Description/Purpose

Purpose: The purpose of the Nurse Manager Council (NMC) is to promote consistent and collaborative leadership amongst departments and hospitals within Spectrum Health Grand Rapids (SHGR). We strive to keep patients at the center; always taking into consideration safety, quality, patient and staff satisfaction, and efficiency when making decisions. As a reflection of our Magnet designation, nurse managers will foster excellence in nursing leadership by supporting all components of the Professional Practice Model. Membership

Voting Members: Members have an attendance requirement of 80% and each hold a vote for the group specific meetings they are invited to.

Example: If you are only invited to Group 1’s meetings, you would only vote in Group 1’s meetings.

■ One chair (two year term rotating). ■ One vice-chair (two year term rotating). ■ Chair and vice-chair are elected from the nurse managers of SHGR. Chair and vice-chair serve a two

year term (one year as the vice-chair and one year as the chair). ■ All Nurse Managers at SHGR (SHGR defined by Magnet designation definition) who have

responsibility for clinical nurses as defined by Magnet. ■ Extend membership to include leaders who have responsibility for clinical nurses as defined by

Magnet, but do not necessarily have the title of nurse manager. ■ Requests for membership will be reviewed by the NMC steering team and will be brought to the

council as needed. Non-voting members: Members invited to attend and participate in NMC meetings to help provide input into decision making but do not hold a vote. Non-voting members have an 80% attendance requirement and will be invited to Group 1 and Group 2 meetings. List of non-voting members is below (all inclusive):

■ One nursing director ■ One administrative secretary (chair or vice chair’s admin) ■ One human resources representative ■ Central Shared Leadership Chair ■ Magnet Program Director ■ One education representative ■ One CNS representative ■ One process improvement representative ■ One nursing informatics representative

Ad-hoc members: Members invited to attend NMC periodically to help provide input into specific topics as content experts. Ad-hoc members can also be considered nurse managers who do not hold a vote for their area (exp. If an area wants to send one representative from the leadership team who will hold the vote for their area, the rest of the leaders for that area would be considered ad-hoc). Ad-hoc members are non-voting and do not have an attendance requirement. Examples of ad-hoc members are below (list not all-inclusive):

■ Pharmacy representative




■ Quality representative ■ Chief Nursing Executive ■ Transfer Center representative ■ WOC representative ■ Finance representative

Meeting Attendance Requirements

Voting and non-voting members are expected to attend 80% of each meeting group, as specified in the meeting structure below. Attendance will be reported out annually to the member’s up line. Approved

medical leaves and PTO will not be counted against attendance. There will not be a conference line or WebEx set up for NMC to allow for in-person discussion and participation. Meeting Structure Group 1: NMC-SHGR

■ Group 1 meetings occur the fourth week of every other month from July-May. Additional meetings can be added if necessary.

■ Group 1 includes Group 2 and is defined as all entities under SHGR Magnet designation: BW, BL, HDVCH, Surgical Services (including ambulatory surgical centers), Radiology, Cardiovascular Services, Nephrology, and Lemmen-Holton.

Group 2: NMC-BW/BL ■ Group 2 meetings occur the second week of the month from July-June. Additional meetings can be

added if necessary. ■ Group 2 is defined as all BW/BL nurse managers of adult inpatient units, inpatient rehab, adult ED,

adult resource center, women’s and infant services, and adult observation.

Month

Group 1 Meeting (4

th week

of the month)

Group 2 Meeting (2

nd week

of the month)

July x x August

x

September x x October

x

November x x December

x

January x x February

x

March x x April

x

May x x June

x

NMC Steering Team

NMC Steering Team will consist of the chair and vice chair and one nurse manager representative from each area: adult inpatient Butterworth, adult inpatient Blodgett, adult outpatient/ED/Nephrology, HDVCH, Women’s and Infant Services, Surgical Services, Radiology/Cardiovascular Services, and Lemmen-Holton. The areas that the chair and vice chair represent will fulfill the areas above and additional representatives from those areas are not needed. Representatives will be on a volunteer basis. If there are no volunteers, a representative will be chosen by the




director(s) for the area. Approximately half of the committee will switch out on an annual (fiscal year) basis according to the guidelines below. Meetings will be held at least monthly and will be up to the chair to organize and plan. The NMC Steering Team will discuss and plan NMC meeting topics and agendas to ensure applicability to the greatest audience and will also organize NMC development activities. The team will own the Department Orientation Validation Record (DOVR) and will update this document at least annually. Switch out schedule

Even year switch out (Example FY18): Odd year switch out (example FY19):

Adult Inpatient BW Adult Inpatient BL

Adult Outpatient/ED/Nephrology HDVCH

Surgical Services Radiology/Cardiovascular Services

Lemmen-Holton Women’s and Infant Services




Nursing Executive Council (NEC)

Description/Purpose

The Nursing Executive Council: Using the Spectrum Health system strategic vision as a framework, creates a strategic vision for

nursing services at Spectrum Health. NEC develops and implements action plans to achieve nursing goals, demonstrating innovation, sustainability, participation, acculturation, and progressive outcomes.

Participates in the promotion and recognition of the nursing profession. Serves as the information hub for SHGR nursing initiatives and activities. Reviews the purposes and goals of councils within the nursing shared governance structure,

progress toward goals, momentum within councils, barriers to attaining goals, and national, regional, and local trends or emerging issues that affect nursing operations and require staff nurse decision-making. All nursing shared leadership councils are accountable to NEC.

Membership NEC consists of the CNE/vice president of clinical operations, vice president of operations/nursing services Helen DeVos Children’s Hospital, vice president of surgical services, all nursing directors, director of clinical

operations finance and Resource Center, chairs of all councils within the nursing shared governance structure, a nurse educator, Human Resources business partner, project manager nursing operations, and the nursing process engineer.

In the event of a director vacancy, department representative (s) may be appointed by the CNE/vice president of clinical operations.

Voting members consist of the CNE/vice president of clinical operations, vice president of operations/nursing services Helen DeVos Children’s Hospital, vice president of surgical services, all nursing directors, director of clinical operations finance and Resource Center, and the chairs of all councils within the shared governance structure. All others are considered affiliate members without voting privileges.

Chair

The CNE/vice president of clinical operations or designee serves as chair. Meetings

Meetings are held monthly and may change at the discretion of the chair and as council business requires. Evaluation

A formal participative summit meeting is held on an annual basis to evaluate progress toward goals and revise or create new goals for the following year’s nursing operational plan.




Nursing Practice Council (NPC)

Description/Purpose Establishes, evaluates, and reviews standards of nursing practice at Spectrum Health through the

review of policies, procedures, equipment, products, and powerplans. Provides a forum for discussion, collaboration and approval of nursing practice standards that affect patient outcomes.

Advance the practice of nursing across Spectrum Health to achieve outcomes as an expert in direct care, systems leadership, collaboration, coaching, research, ethical decision making, consultation, and/or change agent related, but not limited to:

o Safety events o Nursing Quality Indicators o Process Improvement o Systems evaluation o Scope of practice o Incorporate new/current evidence into practice

Enhances EMR in collaboration with other disciplines, including: o Powerplans o Nursing documentation

Partners with nursing education to disseminate standards of practice. Engages the team to provide mentoring and professional development of new committee members

and each other through an engagement steering committee.

Membership All practicing Clinical Nurse Specialists throughout Spectrum Health. All practicing Nurse Practice Associates. Appropriate nursing representative from community hospitals that are responsible for nursing

practice but do not have CNS. Appropriate nursing representative from those areas impacted by nursing practice that do not have

CNS representation. Manager of Nursing Quality. Senior Nurse Researcher. Nurse Manager. Nurse Educator. Principle, Interprofessional Practice Director of Nursing Operations and Magnet Program. Director of Professional Nursing Practice

Chair/Vice-Chair An elected Clinical Nurse Specialist will serve as chair for 1 year. An elected Clinical Nurse Specialist will serve as vice chair for 1 year and then assume the chair

role. Chair of the Nursing Practice Council/designee will attend Nursing Executive Council meetings; in

the event the chair is unable to attend the vice chair will attend. Chair/ Vice-Chair will attend Shared Governance Oversight Committee.




Meetings Meetings will be held twice a month.

Voting Privileges All members will have voting privileges.

NPC Charter Committees Nursing Sensitive Indicator (NSI) Committees Description/Purpose

The NSI committees identify and implement current, evidence-based strategies to prevent patient harm. Data is reviewed monthly to evaluate progress and to identify areas needing additional intervention and support. Each NSI committee maintains a charter in which the purpose, vision, guiding principles, regulatory requirements, membership, expectations, annual goals and deliverables are identified. A Clinical Nurse Specialist is the lead for each NSI committee which are:

Skin Injury Prevention Committee* Catheter Associated Urinary Tract Infection (CAUTI) Prevention Committee Central Line Associated Blood Stream Infection (CLABSI) Prevention Committee Fall Prevention Committee Restraint Committee

*The Skin Injury Prevention Committee maintains the standard work and expectations for the skin champion Membership

Identified by each NSI team Chair

The chair is a Clinical Nurse Specialist. Meetings

Meetings are held monthly and may be scheduled more often as needed

Voting Privileges

All members will have voting privileges.




NPC Charter Committees Nursing Functional Area Policy Committee (FAPC) Description/Purpose

The Nursing Functional Area Policy Committee (FAPC): Provides direction, guidance and oversight for policies, procedures, protocols and guidelines related to the clinical management of patients. The committee is a resource which serves both as advisors and as support for other document writers within the Nursing FAPC and at their entity for subject matter and expertise. The committee ensures content created not only meets Spectrum Health standards for patient care and quality but also promotes Spectrum Health values of inclusion and diversity. To ensure that current, evidence-based resources are available to staff the Nursing FAPC:

Coordinates the process of policy, procedure, protocol and guideline review and revision at Spectrum Health.

Provides a comprehensive review mechanism to ensure that all policies, procedures, protocols and guidelines meet regulatory requirements and are evidence-based.

Membership

Minimum of one Pediatric CNS Minimum of one Adult CNS Minimum of one Nurse Practice Associate A chair-person of NPC The Policies Coordinator Director of Professional Nursing Practice All Nursing Entity Representatives* * A Nursing Entity Representative is a point person at a specific entity for policy development, review and adoption. The Nursing Entity Representative is responsible for having a structure in place at their entity to engage all stakeholders needed for document review and funnel all document requests through the document review cycle and/or through the Nursing FAPC. Chair or Nursing FAPC Lead

The chair is the Clinical Nurse Specialist for Policies and Procedures Meetings

Meetings are held bi-monthly and may be scheduled more often as needed




Nursing Quality and Safety Council (NQSC)

Description/Purpose NQSC is the strategic planning, implementation and evaluation group that functions to identify and prioritize nursing quality and safety process improvement and outcome activities. The council promotes and communicates the activities and results of the overall Nursing Quality and Safety program. The NQSC and the Spectrum Health Hospitals Quality Department work collaboratively to determine the mechanisms to best meet goals and initiatives identified by the Hospital board and Nursing Operational Plan. NQSC interfaces as appropriate with the organizational quality and safety committees. NQSC uses the Spectrum Health framework and model for quality improvement, plan-do-study and act. The purpose of NQSC is to:

Support nursing staff to improve organizational performance and promote improvement of patient outcomes through involvement in quality and safety initiatives

Efficiently unite to discuss common issues from all clinical areas Increase communication among clinical units Oversee the integration and coordination of quality and safety activities across nursing care areas Recommend, as needed standard work. Assist with the interpretation and use of data from internal and external sources to improve patient

care outcomes Identify potential trends using Event Reporting System (ERS) Reporting Sponsors the following committees with request for at least a quarterly update:

o Nursing Peer Review (NPRC) The sponsored committee will maintain and review the committee description annually.

NQSC incorporates the following confidentiality/protections statements on all committees’ generated documents:

“RECORDS, DATA AND KNOWLEDGE, INCLUDING MINUTES COLLECTED FOR AND BY

INDIVIDUALS OR COMMITTEES, OR COMMITTEES ASSIGNED PEER REVIEW FUNCTIONS

ARE CONFIDENTIAL, ARE NOT PUBLIC RECORDS AND ARE NOT AVAILABLE FOR COURT

SUBPOENA IN ACCORDANCE WITH MCL 333.20175, 333.21513, 331.21515, 331.531, 331.532,

AND 331.533 (ORC 2305.24, 2405.25, 2305.251, ORC 2305.252, ORC 2305.253, and ORC

1751.21) (MN MSA 145.61-67; 144E.32) (NDCC Chapter 23-34) and applicable case law.” Membership Staff members are Quality Safety Officer (QSO) representatives and High Reliability Mentors (HRM) from each department/clinical area. Additional members include: nursing quality, nursing director, clinical nurse specialist, nursing informatics, quality, nurse manager, project managers, infection preventionist, and other roles as appropriate. Staff educators will be invited as needed using request for education. Department/clinical areas include, but not limited to departments from SH Grand Rapids Hospitals.

Membership Responsibilities Dissemination of information within the scope of your responsibility (i.e. unit, department, other councils) Creation of tools and venues to disseminate information Identify quality issues, participate in design of quality improvement audit tools, analyze data and make

recommendations for action plan and strategies QSO/HRM will attend and or participate in a Quality and Safety Informational Session on a

bi-annual basis. Membership is not time limited.




Chair/Vice-Chair The manager of nursing quality serves as chair. Vice chair is a staff volunteer from membership and is not time limited.

Meetings

Meetings are held monthly for one and ½ hours.




NQSC Charter Committees Nursing Peer Review Committee (NPRC) Description/Purpose The NPRC is a subcommittee of the Nursing Quality and Safety Council. This committee utilizes a just culture of accountability to evaluate the quality of nursing care provided through application of current standards of care and the Michigan Public Health Code. The intent is about learning and improving the care provided to patients. Membership Membership includes manager of nursing quality; staff RNs representing inpatient, ambulatory and procedural areas.

NQSC Charter Committees Departmental Quality and Safety Description/Purpose To evaluate the effectiveness of nursing quality and safety at the departmental level. Membership Every unit’s nursing quality and safety officer will participate in their department council as appropriate. Additional representation includes clinical nurse specialist, nurse manager and nursing director. Staff educator participation is determined at the each department. Chair Each departmental council will elect a chair. Meetings Meetings are held monthly. Departmental committees may meet quarterly after performance has been established.




Nursing Research Council (NRC)

Description/Purpose

The Nursing Research Council serves to promote a collaborative research/inquiry environment, communicate nursing research findings and other inquiry projects conducted at Spectrum Health, and advance evidence-based practice. Purposes: Support opportunities for nursing research and inquiry

Facilitate involvement in nursing and interprofessional inquiry projects Facilitate review of nursing research/inquiry proposals and developed projects

Promote an environment of evidence-based practice Facilitate review and application of evidence to clinical practice and operations.

Provide professional development of nurses Plan and offer professional development opportunities to equip nurses to understand and apply

research findings; to conduct research and inquiry projects; and to use evidence-based processes for practice/operational changes.

Communicate NRC inquiry activities and findings Membership

Membership includes nurses with advanced degrees to both participate in research and provide oversight to nursing research and inquiry projects, and clinical bedside nurses who are interested in participating in research. Individuals from the Spectrum Health system and its community partners, including nursing faculty, health science librarians, and representatives from the Spectrum Health Office of Research Administration will be invited on an ad hoc basis for input, expertise, and collaboration.

Nurses with graduate degrees are especially encouraged to serve on NRC, though all nurses are welcome. To become an NRC member, complete the Application for Nursing Research Council Membership and request your manager’s approval. NRC members and their managers commit to meeting NRC member expectations. NRC members serve a 3-year term, with extensions or adjustments made with manager and NRC chairperson approval. NRC members are allotted 4 hours paid time per month to accomplish NRC objectives. Chairperson

The chairperson is a senior nurse researcher or a clinical nurse specialist. Administrative Assistant

The NRC is supported by the Administrative Assistant assigned to Nursing Research.

Meetings

Meetings are held every other month, but may occur more often as needed. Council hours may be utilized outside of the meeting time to support nursing research.




Nursing Education Council

Description/Purpose

The purpose of the Nursing Education Council is to foster intentional collaboration across the system through a forum to:

Define, design, implement, facilitate, and evaluate educational activities (orientation, competency, continuing education, in-services)

Determine best practices in educational methodologies Develop and support staff preceptors Promote professional development of educators

Membership Members include nursing educators from the following areas:

Spectrum Health Grand Rapids (including Surgical Services and Helen DeVos Children’s Hospital) Spectrum Health Continuing Care Spectrum Health Reed City Hospital Spectrum Health United Memorial Hospital/Kelsey Spectrum Health Gerber Memorial Hospital Spectrum Health Zeeland Hospital Spectrum Health Medical Group (including Urgent Care) Spectrum Health Ludington Spectrum Health Big Rapids Spectrum Health Pennock Corporate: Clinical Call Center & Healthier Communities Additional members may be included on an ad hoc basis.

Chair: The chair is the Director of Nursing Practice and Development. The Director of Clinical Operations & Performance Improvement of the Medical Group serves as Co-Chair.

Meetings: Meetings of the whole are held bi-monthly.

Subgroup meetings are held monthly:

Orientation In-services/Requests for Education Competencies Continuing Education Curriculum Preceptors Professional Development




Shared Leadership Oversight Committee

Description/Purpose

To provide communication and coordination between shared leadership councils regarding committees, and task forces that impact nursing and/or patient care. The purpose is to:

Share council, committee, and task force information on a monthly basis. This is inclusive of goals, objectives, and work of the councils

Facilitate integration and coordination of council goals, objectives, and work in order to avoid duplication and maximize efficiency

Provide a forum for questions or issues common to multiple councils Additionally a function of the shared leadership oversight committee includes acting as the Magnet Steering Committee:

Assisting in the alignment of the nursing strategic plan, goals of shared leadership councils and Magnet sources of evidence.

Providing oversight to structure and processes in maintaining Magnet designation. Maintain high level awareness of sources of evidence and required supported elements. Actively support Magnet designation and champion nursing excellence throughout Spectrum Health

Grand Rapids.

Review of Bylaws

Shared Leadership Oversight Committee ensures the bylaws are being reviewed annually by the councils of the Shared Leadership Structure. The Nursing Executive Council approves bylaws annually.

Membership

Members include: Chair or designee from each of the central councils Director, Nursing Operations and Magnet Program

Facilitator Director, Nursing Operations and Magnet Program Meetings

Meetings are held minimally monthly.




References Abbington Memorial Hospital. (2006). Shared governance structure. Abbington: Abbington Memorial

Hospital. The Advisory Board Company. (2005). Toward staff-driven decision making: Assessing, building, and

sustaining a shared governance model. Washington, D.C.: The Advisory Board Company. The Advisory Board Company. (2005). Strategies to provide coverage for RNs participating on shared

leadership committees. Washington, D.C.: The Advisory Board Company. Coluccio, M. & Havlick, K. (1998). Shared leadership in a newly merged medical center. Nursing

Administration Quarterly, 22, 36-39. Hess, R. (2004). From bedside to boardroom- nursing shared governance. Online Journal of Issues in

Nursing. 9(1). Retrieved online from www.nursingworld.org/ojin/topic23/tpc23_1.htm. Medical Center of Central Georgia. (2006). Shared governance, shared practice councils. Macon: Medical

Center of Central Georgia Porter-O’Grady, T. & Hitchings, K. (2006). Elements of successful shared governance: How to create a

pathway to professional nursing. [audioconference]. Marblehead, MA: HCPro, Inc. The Reading Hospital. (2006). Statement of governance bylaws. Reading: The Reading Hospital and

Medical Center. Summit Health. (2005). Collaborative governance structure. Chambersburg: Summit Health. Swihart, D. (2006). Shared Governance: a practical approach to reshaping professional nursing practice.

Marblehead, MA: HCPro, Inc.



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