Professional Governance

Patient Care Council endorses, integrates, and reviews hospital unit-based improvement plans for Nurse Sensitive Quality Indicators, Patient Experience, and Nurse Satisfaction. This council identifies practice issues that impact more than one area and ideates and collaborates to incorporate evidence-based practice, research, and innovation.

Achievements:

• Consult for patient refusal of bed alarms and conducted the organizational assessment, referred and made recommendations to UH Seidman Cancer Center and acute care service lines, PCC input on system guideline
• Consult for nurses not pulling central lines per policy and conducted the organizational assessment, referred and made recommendations and action plans for UH Seidman Cancer Center and acute care service lines
• Consult for Mediport education and performed the organizational assessment of nursing educational needs. Recommended tip sheet, videos on nursing education page, increased training of IV team to act as a clinical resource
• Quarterly data evaluation of patient experience in all UH Cleveland Medical Center areas
• Quarterly data evaluation of HAPI in all UH Cleveland Medical Center areas
• Members led PCC governance discussion with Magnet appraisers during a site visit
• Facilitated a discussion of Coude catheter use with a focus on patient safety and recommended tip sheet for nurse education and insertion kits
• Led discussion on RN satisfaction, evidence-based workshops conducted to teach unit co-chairs and managers how to create an RN satisfaction action plan
• Shared consult (with WEC) for efficient nurse access to food ordering for patients, shared nurse hotline information, and further collaboration with Sodexo 
• In-depth analysis of HAPI protocols in pediatric areas versus acute care to share best practices
• Reviewed new INS standards and recommendations for documentation of IV attempts to improve documentation and prioritization of patients for picc line placement
• Consult surrounding dophoff stylets not being pulled before use and recommended for EMR instructions made
• Partnered with acute care service line in making recommendations for nursing retention strategies that were presented to HR

Work Environment Council identifies trends in workplace violence issues and informs on mitigation plans. Review and communicate new clinical products, workflows and equipment in collaboration with Supply Chain, IT, Pharmacy and other stakeholders. Address nursing ethical and legal issues.

Achievements:

• Collaborated and informed the Workplace Violence Committee and evaluated workplace violence trends, such as injury from assaults and code violet response times. Evaluated suicide and high alert sign usage for inpatient areas. Conducted nursing vote and recommended for universal signage “see RN before entering” as the standard. Consult on increased use of four-point restraints: providing feedback on process improvement plans for UH Cleveland Medical Center. (e.g., increased education and knowledge about the violence risk indicator, CPI training for new hires or anyone who wants to take a course, professional conduct PASS reporting system, etc.)
• Collaborated with UH Cleveland Medical Center Interdisciplinary Restraint Committee & Workplace Violence Taskforce.
• Evaluated and made recommendations for BCMA compliance and process improvements. Disseminated BCMA playbook, improved BCMA rates across UH Cleveland Medical Center. Created a playbook of best practices that were shared with nursing management, recommendations for basic infusions, and omni cell override reasons.
• Facilitated discussion on the legal issue regarding surgical consents and how the POA is not always the one signing the consent. Power of Attorney versus next of kin versus guardianship in regards to an emergency situation, ethics consulted.
• Analyzed evidence-based literature for Code Lavender, an emotional response program collaborated with Cleveland Clinic Foundation holistic nurses, created an ongoing committee and process to standardize Code Lavender across UH Cleveland Medical Center. The goal is to ensure all nurses have access to a support program.
• Implemented a standard tool for innovation adoption. Used to determine if medication lock-boxes were an efficient, practical purchase for UH Cleveland Medical Center lockboxes were not acquired.
• Advocated for a set schedule of battery maintenance for WOWs.
• Implemented SYSTEMIC change for a safe medication wasting process with RX destroyer.
• Collaboration with Patient Care Council: efficiency for ordering patient trays.
• Collaboration with Edgility and system leaders to standardized tier 0 safety huddle lens.
• Ongoing collaboration with CSR representative regarding supply backorders, substitutions and conversions for Prevalon boots, curos caps, PPE, Enfit conversion, Prevantics, and tough cuffs.
• Ongoing collaboration with HR representative regarding OD&L offerings; evaluation portfolios, employee assistance programs, UH4U, etc. Incentives or pay increases for 2021, feedback and recommendations are given to HR regarding website not being user friendly to outside candidates; retirement contribution and UH matching, employee referral page on DWP, COVID-19 attestation, and 2021 Wellbeing Fair.

Task forces created in response to consults:

• Code Lavender and nursing compassion, resiliency and fatigue
• PACU handoff tool to improve patient transfers
• Narcotic drawers on WOWs utilized the innovation tool to determine if a need was identified (there was not)

Consults and practice reviewed:

• Ticket to Ride revamp in EMR, collaboration with Policy and Practice Council in writing SOP
• EMR enhancement for skin parameter (medication patch) in A&I and Adult ER regarding trauma documentation of medications given, waste and POC, CHG bathing, pain reassessment
• UH Cleveland Medical Center visitor policy(ies)
• Advocated for removal of nurses’ name on bottom of printed discharge instructions
• Risk Management and Quality delirium bundle and Code Brown policy, Code of Conduct (professional conduct pass report)
• Recommendations PEG tube medication administration, labeling IV lines and tubing for CVAD policy
• Labs being canceled related to timing Elevated concerns to SNL regarding pneumatic tube

Professional Enhancement Council promotes the recruitment, retention, and recognition of the professional nurse and partners with Nursing Education Department to inform on competency based orientation programs, competency review, and provide feedback on the Clinical Ladder.

Michelle Donnelly, BSN, RN
Co-chair

Becky Jones, MSN, RN-BC, NPD-BC, FABC, ONC, OCN
Co-chair

Amy Berardinelli, DNP, RN, NE-BC, CPAN
Secretary

Achievements:

• Magnet prep and virtual site visit with a successful 4th designation
• Monitored and made recommendations for BSN and Certification rates
• Review PNEF guidelines for UH Cleveland Medical Center and distribute funds per council vote
• Created subcommittee for Nurses Week planning and implementation
• Consult: PRN RN to be eligible for certification reimbursement – moved to Shared Leadership
• Begin to investigate the mentorship program. Hosted Jennifer Gebbie, RN to present MICU mentoring program
• Discussed recruitment and retention ideas and options shared with Human Resources/Recruitment
• 15 nurses were chosen from each service line to attend National Magnet Conference in November 2021 – total attendance of 26 nurses attended to accept our 4th designation
• Reviewed and discussed ANA scope of standards
• Partnered with IWU for RN to BSN program for UH cohort only

Nursing Policy and Procedure Council creates, review, and approve nursing policies, procedures, practice guidelines, and patient information sheets to assure nursing practice is based on evidence and best practices, assures that education and communication occurs before the implementation of the policy, procedure, and guidelines in collaboration with other stakeholders.

Achievements:

• Members led policy discussion with Magnet Appraisers
• Policies and guidelines reviewed or created: G-601 Therapeutic Phlebotomy, Wound Vac, G-582 Guidelines for cleaning, treating & transporting instruments prior to sterilization, G-470 - Patient Care After Death & Transport to Morgue, PD-100 PNEF guideline
• Multiple policies and guidelines archived to achieve systemness or utilization of available clinical resources
• Reviewed input on system policy: CP 105- Sage Warmers, CP 136 Pain policy, NP 41 Implantable Port: Accessing and Deaccessing, NPG 856 Voiding Trial, Adult, CP 112-Medication Reconciliation, NP 39 Peripheral Intravenous Catheter (PIV)

Research and Innovation Council facilitates the spirit of inquiry and engage nursing staff in research activities, establishes the link between quality improvement, evidence-based practice, and research, increases nursing research visibility within the institution, regionally and nationally.

Achievements:

• Members led research discussion with Magnet Appraisers
• Planned and hosted Annual Research and Innovation conference with over 500 participants registered across the UH System and within the Northeast Ohio nursing community
• Developed a plan for system research and innovation
• Invited to present educational sessions describing how to conduct research at UH
• Participated in Nurses Week and provided education on conducting research
• Convened a subgroup of nurse scientists to conduct a COVID-19 study and has been presented within UH and at international, state, and regional conferences
• Convened a subgroup of UH nurse scientists across roles and departments  
• Initiated the fifth cohort of nursing research interns
• Updated policies and procedures related to nursing research
• Clarify the credentialing policy
• Submission of several Hillman Letter of Intent; invited for full proposal
• Grant submission to American Nurses Foundation: Reimagining Nursing Initiative
• Consulted on conceptualization, development, and implementation of individual research projects and projects preparatory to research

Shared Leadership appropriates necessary resources for the professionals in practice (human, fiscal, material, support, and systems), integrates the professional governance process with the other services and roles, directs issues and concerns that impact more than the hospital to the CNO for final determination of action and provides direct access to CNO.

Achievements:

• Advocated for PRN certification reimbursement to system leaders
• Supported and engaged in helping hands model
• Recommended EMR liaisons for council support
• Support for top of license initiatives
• Multiple compensation models reviewed, discussed, moved to system leaders
• Pneumatic tube improvements recommendations and advocacy
• Nurses week & magnet implementation and financial support
• Bridged system initiatives with UH Cleveland Medical Center representation of the System Handoff Committee, Research and Innovation, COVID-19 protocols and communications
• Partnered with Senior Leadership on initiatives to promote nursing resiliency, retention and wellness

Advanced Practice Provider Council provides a forum for discussion of issues relevant to APPs, promoting advanced practice, collaborates with clinical and leadership healthcare teams, evaluates professional practice and contributes to practice advancement.

Tiffany Reichert MSN, APRN-CNP
Secretary

Achievements:

• Expansion of council from UH Cleveland Medical Center based to system-wide working towards the systemization of our APP groups
• Coordination of APP councils throughout the system with a monthly report to provide system insight
• Integration of Lake Health into our network
• System APP Council Charter in final revision stages with vote set for first part of January
• Focus on health CDI documentation
• Centralized point for education resources
• Built stronger network for APP foundation
• Increased system attendance from average 15 participants to average 50 per meeting

Ambulatory Council creates theoretical framework and professional development plans for ambulatory nursing practice, reviews and implements quality plans, policies, guidelines, and standards of care across clinical services.

Kathy Day
Co-Chair

Tonya Whitmeyer
Co-Chair

Achievements:

• Approved nitrous oxide use guideline for ambulatory
• Quality GPS sent out to help staff understand the clinical quality measures to improve patient outcomes
• Senior Quality Improvement RN and an Infection Preventionist RN added to the Ambulatory Practice Team
• Implemented and supported patient safety days and safety days
• Advocate for nurse development on clinical pathway
• Implemented and supported falls assessment, screening, reporting and improving patient outcomes in ambulatory area