7/22/22 - Professional Governance Gazette Edition 1 (NC)

Professional Governance Gazette Edition 1

May 2022

Q u a rt e r ly c h a i r r e p o rt

by: Charity Patterson, Past Chair

Welcome to the first edition of Professional Governance Gazette. Here you will have quarterly updates on all the excellent work being done by your very own Excela Health professional nurses and nursing teams, through their hard work and commitment to engaging in Nursing Professional Governance councils and committees, they have brought forth innovation and new technology that has improved patient and family care and outcomes. Each quarter the Professional Governance Gazette will inform and highlight ongoing projects and current outcomes of those projects. We are continually looking to add motivated energetic drivers of change to our councils and committees. This is an excellent opportunity for you to have your voice heard and to enhance your professional growth and take a step into leadership as you become a role model to the profession of nursing. There is no better time than now to get involved in the advancement of your profession by sharing your experiences, thoughts and ideas as we march into the future of new and improved nursing practices.

The profession of nursing requires nurses with vision, resilience, strategic critical thinking, credibility, and the ability to work with, empathize and influence others to get involved in change and bring bedside issues to the table. As the backbone of every health system nurses everywhere are always in a position to drive change. Change that creates better and safe patient outcomes, healthier work environments, and new and improved practices that add excellence to quality care. When you make the decision to join a Professional governance council or committee you are making a decision that will grow you as a professional and open opportunities for advancement while having your voice heard. As a member of Professional Governance, you ensure others of your intention and motivation to improve the profession of nursing and seeking ways to continually improve patient care. As an Excela Health staff nurse, you are invited to seek this opportunity to build your career profile and engage and network with others who care as much as you do. You will find there are a variety of ways to get involved in community outreach, policy making, quality improvement, and exemplary practices that will help you to become an advanced clinical leader who pushes for innovation and technology that will enhance patient care and open doors for work environment improvements that reward everyone.

Professional Governance is a model of nurse governing that provides nursing a voice in decision-making and embraces shared responsibility with interdisciplinary collaborative teams. The model of Excela Health’s Professional Governance is built around patient and family relationships that strive to create extraordinary outcomes for every life we touch. As a member of any council or committee, you are provided with a platform to facilitate change through sharing and exchanging ideas for improvement. A Professional Governance networks professionals together allowing professional nurses to implement, evaluate and improve professional nursing practices that encompass the highest standards of evidence-based practice in a continuous hands-on approach that results in excellent care and excellent outcomes.

INSIDE this edition: Leadership Council Staffing Committee Nursing Professional Practice Eval. Committee Professional Governance Committee Practice Excellence Council Innovation, Tech. & Informatics Committee

2 2 3 3 4 4

Evidence-Based Practice & Research Committee Professional Development Council Management Council Retention & Recognition Committee Advanced Practice Provider Council Primary Care Council

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The Gazette is available on the Intranet under “Nursing” then “Professional Governance”

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Leadership council

Staff Nurse Chair: Deb Bowman | Past Chair: Lydia King Facilitator: Vickie Jellison | Mentor: Helen Burns Meets 4th Thursday of the month from 1:30 to 2:30 p.m.

Goals, Progress & OUTCOMES •

Strengthen the frontline staff engagement and involvement in order to influence through opinion sharing, exploring ideas, shared decision making, and achieve outcomes.— Working towards a goal of 80% of our UBPC chairs must attend our leadership meetings that occur the fourth Thursday of every month. UBPC committees are required to send monthly rosters in order to ensure participation. Also requested quarterly updates on what every UBPC is working toward.

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Improve patient satisfaction within our healthcare system.— Improving our patient satisfaction scores by focusing on our key drivers which include staff working together, staff cared for the patient as a person, courtesy of nursing staff, nurses took the time to listen, and nurses respond to requests and concerns to name a few. Each chair is taking ideas back to their units and doing what is best on their unit to improve satisfaction.

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NDNQI- focusing on decreasing incidents of falls with injuries and hospital acquired pressure injuries as determined by our Practice Excellence council.— Working diligently toward improving these measures to keep are patient safe and provide the best care possible. Leadership council encourages our UBPC to bring forth ideas on how to improve these measures as a system and on a unit level.

N u r s e s ta f f i n g c o m m i t t e e

Staff Nurse Chair: Deb Kuhn | Past Chair: Michelle DeLancey Facilitator: Glenn Repko | Mentor: Helen Burns Meets 2nd Tuesday bi-monthly from 2:00 to 3:00 p.m.

Goals, Progress & Outcomes •

Review workforce summary reports

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Review/track no lunch punch out reports

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Review nurse injury reports

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Budget/FTE review

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Teamwork initiative/tech partner workgroup

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Casual position policy/guideline review

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Employee pull survey restructuring

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Productivity tool launch

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Call off policy revision review

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Work place violence education review

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Nursing professional practice Evaluation committee Staff Nurse Chairs: Bridget Rafferty-Himler | Facilitator: Kate Rosatti | Mentor: Helen Burns Meets 2nd Tuesday of the month from 10:00 to 11:30 a.m.

P ro f e s s i o n a l G o v e r n a n c e C o m m i t t e e

Staff Nurse Chair: Mary Mogle | Facilitator: Christy West | Mentor: Helen Burns Meets Quarterly from 7:00 to 8:00 a.m.

Goals, Progress & Outcomes •

Support and improve communication across the Excela Health System between committees and councils.

— Three Take Aways process changed to the Top Three Actions and includes: The take away, Action item(s), Outcome

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Update the nomination process for committee membership in the By-laws. — Nomination process for council/committee membership changed and approved

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Support and improve communication concerning committee and council outcomes across the Excela Health System — It was decided that the quarterly newsletter will take the place of the quarterly report. Executive Assistant Amber Carney will create the template and send out.

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Create schematic for Professional Governance to share with new hires — Nursing Education has requested a member of Professional Governance to present during orientation. Charity Patterson has volunteered to do this

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Update Professional Governance Model Logo — First draft of logo was created and was presented at Nurse Executive meeting in November 2021.

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Develop orientation program for committee/council chairs and members including associated materials.

— This is an on-going project and will continue during 2022

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Create a learning platform for ANA Standards of Ethics — This is an on-going project and will continue during 2022

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P r ac t i c e e xc e l l e n c e co u n c i l

Staff Nurse Chair: Abby Johnston | Past Chair: Teresa DeVito Facilitator: Tammy Vogel | Mentor: Traci Fick Meets 4th Tuesday of the month from 9:00 to 11:00 a.m.

Goals, PROGRESS & Outcomes •

Ensure IV Manual Policy and Procedures are updated based on Infusion Therapy Standards (INS) — IV policy and procedures reviewed by IV RN’s. IV policies and procedures updated based on INS standards and posted on intranet. Information shared at PEC meeting.

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Improve consistency of Omnicell Narcotic Inventory count process on units. — PEC members and Pharmacy discussed inconsistency of narcotic counts in with the new Omnicell machines. Pharmacy will send nurse leaders weekly compliance audits. Created education and sent out via PDF to all RNs on how to complete narcotic count, expectation that all Omnicell machine will have an accurate narcotic count done weekly

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Improve patient experience with Caffeine Restriction on inpatient units. — Information on patient complaints of caffeine restrictions due to being placed on a PCU unit. She presents information to make caffeine restrictions a required field when being ordered on Cerner. In progress– Getting final approval. Plan for final review and approval in April PEC meeting

Innovation, technology & informatics committee Staff Nurse Chairs: Mike Widmann| Facilitator: Pending | Mentor: Mary Mantese Meets 3rd Tuesday of the month from 1:30 to 3:00 p.m.

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E v i d e n c e - ba s e d p r ac t i c e co m m i t t e e

Staff Nurse Chair: Jessica Love | Facilitator: Karen Scanlan | Mentor: Deb Lewis Meets 3rd Tuesday of the month from 9:30 to 11:00 a.m.

Goals, PROGRESS & outcomes •

Provide educational opportunities for Nursing Management, EBP committee members and champions, and nursing staff. — Amy Opsitnick from the Office of Medical Affairs reviewed all of the open IRB studies in May. Amy also reviewed the process for submitting and closing an open study. Anyone submitting a study to the IRB must complete CITI training. All committee members were encouraged to complete CITI training

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Assist to explore and develop EBP projects. — Committee reviewed current nurse resident projects: postcardiac cath; EKG times, probiotics, and music therapy.

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Showcase EH EBP projects and activities through EBP and Research Forum. — The Annual EBPR Forum occurred on Sept. 30. There were 108 in attendance between the 3 hospitals and Webex. All speakers scored well above 4.0 on a 5-point scale. Dr. Sheridan Miyamoto from Penn State University keynote speaker 4.92. Report and Survey Monkey evaluation reviewed with committee. Having presentations live at all 3 hospitals was a positive along with the 4-hour format.

P ro f e s s i o n a l D e v e l o p m e n t C o u n c i l

Staff Nurse Chair: Nicole Komenda | Facilitator: Wendy Reynolds | Mentor: Mary Mantese Meets 4th Tuesday of the month from 8:00 to 9:00 a.m.

Goals, Progress & outcomes •

Increase awareness and donations for the Caring Cabinet- More departments want to be a part of the program and donate items — We have had more interest and were able to educate more staff on the program.

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Develop the Nursing Professional Advancement Program — There have been two nurses that were approved for the Look Back period and have earned the monetary increase. We have 5 enrolled in the ongoing period and 5 applicants for the upcoming period.

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In collaboration with the Nurse Recruitment, Retention, & Recognition Committee, develop an award for ancillary staff similar to the Daisy Award — The BEE award has been developed with the brochure currently in marketing, waiting for final changes. The nomination process will mimic that of the Daisy Award.

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Increase awareness of certification — A total of 212 staff responded to the survey. Ongoing initiative to make the process of reimbursement for certification simple.

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M a nag e m e n t co u n c i l

Chair: Michelle Lewis | Past Chair: Katie Crovak | Mentor: Maryann Singley Meets fourth Tuesday of the month from 1:30 to 4:00 p.m.

Goals, Progress & Outcomes •

Med Scanning - Compliance- Our goal for Inpatient scanning is 95% — If after 3 months, staff member is still not compliant, they can be eligible for formal discipline.

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Nursing Clinical Professional Advancement: The Clinical Career Progression Pathway is a model for direct care Registered Nurses that define the characteristics, behaviors, activities, roles and responsibilities of bedside clinicians. — Self-appraisal, peer feedback and professional development are key components in sustaining a safe practice environment and achieving quality outcomes. Discussions between the Manager and staff to support the employee in achieving their professional goals. Applications will be accessible via intranet and contributions of participants will be reviewed twice a year to keep momentum in the program and provide encouragement to participants.

Diversion Detection Policy: Pharmacy is working hard to improve upon this policy. — Review of Cases by Diversion Detection Team and subsequent follow-up/discipline (including but not limited to: employee interviews, pulling of records, drug testing, employee suspension, revocation of privileges/accesses, etc.

Performance Appraisal Process: To assure nurses participate in a peer review process — All annual evaluations and peer review evaluations completed between the Clinical Director/Manager and the employee.

Productivity Tool — Benchmark productivity for appropriate staffing Highmark Quality Metrics Review — Highest reimbursement to Excela from Highmark.

Budget Prep/Review — Yearly Budget 2021 Protenus Anti Diversion Software — Flagged cases review. Safer medication administration. Stronger documentation.

Excellence in Action Awards — Recognition of excellent work.

Nurse retention & Recognition committee

Staff Nurse Chairs: Gretchen Peske | Facilitator: Marjorie Thomas | Mentor: Maryann Singley Meets 2nd Wednesday of the month from 9:30 to 10:30 a.m.

Goals, Progress & outcomes •

Cameo of Caring: Honor the Cameo of Caring recipients nominated and selected for the 2020 year. — The three Cameos were honored at the Virtual Gala (at the MCC, WH). They graciously accepted the style of the Gala; attended with them were two guests, the CNO, and a Board Member, in addition to other nursing leaders.

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Two @ Two: Identify and thank the night shifts of the Health system, who work on the weekends when the clocks change semi-annually – This initiative was well received by all of the staff. FANS prepared attractive carts, with different themes. The popcorn and apples were a real hit with the staff. Definitely reached more people than in the past.

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Recognition for Advanced Studies: Thank those who have achieved advanced degrees, specialty certification or retirement during this year — Favorable response from people who have received the cards.

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Retain the EH staff during the pandemic by planning and implementing action activities– The system is maintaining a core group of nurses with increasing longevity and loyalty to the Health system. The turnover rate is within the national benchmark

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Identify methods to increase a sense of value and self worth – There were several efforts on this topic. The staff of the hospitals demonstrate smiles and thanks when the Tea Cart if pushed to their unit, acknowledging appreciation from the working team members. For the Joe Tye videos, measuring the response was difficult. Many nurses were unaware of the videos, many said that they enjoyed watching. Due to staffing pressures, many nurses said “they didn’t have time”.

The committee voted unanimously not to purchase the videos this year. Blessing of the Hands began in 2021. Approximately 100 people were blessed at WH, 40 at LH and 35 at Frick. This activity was so well received that the time for the blessings for 2022, will be doubles at each campus, as well as provided on a Saturday evening at each campus.

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Select Community organizations for Excela Health Nurses to support during Nurse Month as a Community Give Back Project. — Excela Health employees and the public were invited to write memos of thanks on these Gratitude Wall Hangings, and the glass art work at WH and Frick. Subsequently, in many nursing units are special bulletin boards with grateful notes written to one another, written by the team members of that unit. Over $200 was collected at the first Twilight Walk. The COVID pandemic put a limitation on the involvement in Community organizations. It is hoped that this project can move forward in 2022

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Increase visibility of Excel Health nursing within Professional circles across the region, at the state level and nationally — Limited by the COVID pandemic during 2021, the committee will look forward to posting nominations for the various categories of the Nighttingale Awards during the 2022 season. The initiative to send treat bags to inpatient and ambulatory care sites was very well received by all of the offices and nursing units. An overwhelming number of emails were received from EHMG administration and practice managers, supporting the initiative 8. Foster interest in Excela Health for young people- The COVID pandemic has limited the times the students can participate, but as the pandemic

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A d va n c e d p r a c t i c e p ro v i d e r c o u n c i l

Staff Nurse Chair: Lauren Cowan | Past Chairs: Rebecca Sullivan/Leah Fontana| Facilitator: Brian Berry | Mentor: Helen Burns Meets 3rd Wednesday of the month from 4:00 to 5:00 p.m.

P r i m a ry c a r e c o u n c i l

Staff Nurse Chairs: Kim West | Facilitator: Nancy Friedline | Mentor: Helen Burns Meets 4th Wednesday of the month from 8:30 to 9:30 a.m.

Goals, Progress & outcomes The UBPCPC had a productive year despite the challenges and limitations posed by Covid: • In the first half of the year, we developed a Preceptorship Program to facilitate the orientation of new EHMG employees. We not only looked to our individual offices for their input, but surveyed new hires for feedback as to their own experiences and what we are doing well and where we fell short.

• We were also involved in safety and emergency management improvements. A need for universal signage related to medical equipment/emergency supplies, was recognized. Signage was created and distributed to out patient offices, helping to adequately identify locations of AEDs, oxygen and emergency boxes. Along with this, education for out patient settings was brought into focus and helped to identify the need for the video ‘Managing Medical Emergencies in the Office/Clinic’, by Dr Bill Jenkins, along with the production of reference cards now kept with each emergency box. This led to a NetLearning for staff to watch the video and sign an attestation statement that was written by the UBPCPC., and adding this education to the orientation checklist.

• The second half of our 2021 was equally as busy as we addressed other areas in need. We were tasked with creating an Audit Calendar for 2022, to be used in the EHMG offices. We based this off of safety goals, as well as prevention and awareness topics. From handwashing and depression screening with the PHQ-9 to Colorectal cancer and Breast Cancer screening awareness, each month has a new topic. Another focus was the lack of consistency in the Data Logger Workflow, office to office. We looked at what is correct workflow and a member created a step-by-step workflow, including photos for reference.

Lastly, we looked at ways to prevent blood and body fluid exposures during in office procedures. This allowed us to brainstorm key points to maintaining awareness during and preparing prior to, any procedure. Tips, such as using safety devices at all times when possible, placing sharp boxes in an unobstructed/accessible area prior to a procedure and speaking up when something doesn’t feel right or puts yourself or others at risk.

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