Ronald Reagan UCLA Medical Center Magnet Recognition Handbook

Transcription

1 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 and that demonstrate the environment of Magnet excellence at RRUCLAMC.

2 RRUCLAMC 2015 Magnet Recognition Handbook Table of Contents Page # Background: What is Magnet? 3 Magnet Impact Rationale 3 Why Magnet? 4 What s in it for Nurses? 4 Accessing the RRUCLAMC Magnet Document 5-7 The 5 Magnet Components and Sub-Components 8 How We Live the 5 Magnet Components at UCLA Health 9-28 Transformational Leadership 9-12 Nursing Strategic Plan 9-10 Advocacy and Influence 11 Visibility, Accessibility, and Communication 12 Structural Empowerment Professional Development Interprofessional Involvement 13 Professional Development RNs Involved in Professional organizations 13 Degree and Certification Goals 14 Teaching and Role Development 15 Commitment to Community Involvement 16 Recognition of Nursing 17 UPC Accomplishments 18 Exemplary Professional Practice Professional Practice Model 19 Care Delivery System 20 Staffing Scheduling, & Budget Processes 21 Interprofessional Care 22 Accountability, Autonomy, & Competency 23 Ethics, Privacy, Security, and Confidentiality 24 Culture of Safety 25 Quality of care Monitoring and Nurse Sensitive Indicators 26 New Knowledge, Innovations, and Improvement Research 27 Evidence-Based Practice and Innovation RRUCLAMC Magnet Document Unit Highlights Magnet Prep Advice 3 Unit Exemplars Directions & Templates Magnet Interview Advice The 12 P s for Success 55 RRUCLAMC Magnet Champion Contact Information 56 Bottom Line: MAGNET STATUS = EMPOWERED, ENGAGED NURSES = BETTER PATIENT OUTCOMES

3 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 was able to identify similar qualities shared by these organizations, which they named the 14 Forces of Magnetism, later 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. The ANCC periodically updates their rigorous Magnet requirements based upon emerging evidence and healthcare trends, 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 3

4 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 & to 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 4

5 Accessing the RRUCLAMC Magnet Document You can access the Magnet document through the UCLA Nursing website at in four easy clicks: 1 4(This will open a new window) OR you can enter the web address in your browser: a) Enter User Name: uclarr b) Enter Password: magnet8114 5

6 uclarr magnet Explore the site! Click on the Magnet Model Components tab to navigate through our Magnet stories, including those that your unit contributed! A comprehensive list of unit/department contributions can be found at the end of this booklet. 2. 6

7 Blue links within the document can be clicked to access supporting documents: If you have any questions or experience difficulties accessing the document, please contact Charlene Collazzi at 7

8 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 the 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 communicate and practice collaboratively 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?" 8

9 How We Live the 5 Magnet Components at UCLA Health: Transformational Leadership Nursing Strategic Plan At RRUCLAMC, the Department of Nursing s mission, vision, values and 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 the organization. Unit-level goals are then created using the nursing strategic plan as a guide, thus providing an aligned vision and continuity across the organization. 9

10 Please view the UCLA Health Strategic Plan and the UCLA Nursing Strategic Plan by visiting the UCLA Nursing website:

11 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. Chief Nursing Officer Heidi Crooks, MA, RN, nursing leaders, and clinical nurses serve on hospital committees to advocate for resources that ensure that nurses have the best practice environment to care for patients. Through unit practice councils, committees, and other structures, clinical nurses and nurse leaders have worked together to advocate for: o Safe patient handling equipment o Education and certification resources o Low beds and specialty mattresses o Expansion of roles for advanced practice nurses 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 the 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 led to safer care for our patients and families! 11

12 Transformational Leadership Visibility, Accessibility, and Communication Nurse leaders set 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 nurse leaders to increase their visibility and serve as advocates and role models for clinical nurses, 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 12

13 Structural Empowerment Professional Development Interprofessional Involvement The UCLA Health Department of Nursing utilizes structures and processes 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 that ensure nurses from all settings and roles 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 UCLA Health. Structural Empowerment Professional Development Nurses involved in Professional Organizations UCLA Nurses are involved with professional organizations, community groups, and initiatives. Most UCLA Health 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 Health 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 13

14 Structural Empowerment Degree and Certification Goals The RRUCLAMC Department of Nursing is committed to supporting and facilitating the educational and professional development of our nursing staff. Goals are set to increase the number of BSN and graduate degree-prepared nurses and the number of nurses with specialty certification. 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/RWJF Future of Nursing Recommendations. Ronald Reagan UCLA Medical Center % of RNs with BSN or Higher Degree Percentage of RNs 74% 72% 70% 68% 66% 64% 62% 60% % of RNs with BSN+ 63% 67% 73% Target 63% 66% 68% 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! # of certifications RRUCLAMC Results for Professional Nursing Certification Baseline Certified Nurses, Overall Organization Goal (whole number) 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 14

15 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 in leadership roles on the Patient Engagement Committee and have provided feedback about teaching tools in CareConnect, including discharge and medication teaching resources. Across the organization, nurses have led efforts to standardize teach-back strategies in order to ensure that patients understand information about their health, hospitalization, medications, and discharge plans. At UCLA Health, nurses never stop learning: The UCLA Health Department of Nursing Practice, Education, and Research (NRE) has established an infrastructure to provide nurses across the health system with opportunities for lifelong professional growth. Educational and professional development programs are structured to best meet the unique needs of our clinical nurses and support them in their efforts to ensure consistently high quality care for our patients and their families. 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 Teaching & Professional Role Development 15

16 Structural Empowerment Commitment to Community Involvement UCLA Health nurses are committed to improving the health of both our local and international communities, and they 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 organizations. In these organizations, our nurses work tirelessly to provide leading-edge patient care and to facilitate an improved quality of life for individuals in our community. 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 27 th 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 16

17 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. Manager of Nurse Recruitment Sheri Monsein, MN, RN, was instrumental in initiating the DAISY Award Program at UCLA Health and continues to administer the program. It is 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, DNSc, RN, and Chief Nursing Officer Heidi Crooks, MA, RN 17

18 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 Emergency Depart. MICU Peds OB NICU Implementation of practice change to improve communication during Patient Handovers Security Improvements Teach Back Initiative Bug Buster Committee efforts, including 2 RN Dressing Changes OFRAS Tool Development Improving Turnaround Time for the First Dose of in Antibiotic in the NICU Safer Handovers; medication safety compliance; teamwork at handover Enhancement of Patient & Provider Safety Reached 73 rd Percentile in HCAHPS: RN explained things in a way you could understand. 170 days without a CLABSI Improved OB fall rate Tool disseminated nationally 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 6ICU Implementation of new change of shift visitation guidelines to include family members Received Joint Commission recognition as Best Practice HCAHPS - Reached 90 th %ile for Medication Communication Reached 90 th %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 7ICU 7CCU 7 West 7COU 8 East Role-Based Practice Quality Improvement Champions Program initiated Home is Where the Heart Is Discharge Teaching Handbook Communication Workshops, Crucial Conversation Skills Collaborative Teamwork with Fall Prevention Toileting Program 5 Minute Time Out Transforming Tragedy to a Safe Practice Change Opportunity: Icodextrin Protocol Reduction in CLABSIs Above 70 th %ile for HCAHPS Medication Communication for 2013 Improvement in RN-RN Communication, Interdisciplinary Communication, & RN-Patient Communication on Unit 4 Months without a Bathroom related fall! 7 Months with 0 Falls with Injury Improved HCAHPS Score: Treated with Courtesy and Respect from 80% 91% 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 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 Cath Lab Always Project MD-RN Verbal callback with medications during procedures in RN teach-back protocol knowledge and compliance, in patient satisfaction Improved RN-MD communication, increased patient safety 18

19 Exemplary Professional Practice Professional Practice Model Nurses at UCLA Health 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 19

20 Exemplary Professional Practice Care Delivery System RRUCLAMC Nurses are guided by the UCLA Health Department of Nursing s Professional Practice Model, our organizational vision, and the relationship-based care delivery model 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 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 into care delivery on behalf of the patient. The 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 model and about 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 20

21 Exemplary Professional Practice Staffing, Scheduling, & Budgeting Processes The acuity and care needs of 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 that strategically allocate staff resources to meet the needs of their patient population. Clinical nurses are empowered to adjust RN and support staff assignments/schedules to best adapt to changes in patient and environmental conditions while maintaining the 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: o Acuity ratings are documented for each patient every shift o Lead nurses consult with clinical nurses regarding staffing needs o Clinical nurses participate in self-scheduling Nurses participate in recruitment & retention: o Participation in hiring interviews o Mentorship to novice nurses Nurses participate in budgetary data analysis: o Trended data is used to influence budget allocation decisions o Lead nurses consult with clinical nurses regarding staffing needs Read more about how 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 21

22 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, administrative and clinical care partners, social workers, and therapists, collaboration is the key to positive patient outcomes. From participation on hospital- and system-wide interprofessional committees to multidisciplinary care at the patient s bedside, interprofessional care teams are united in their shared goal of, Healing Humankind, one patient at a time. Read more about how nurses at RRUCLAMC are a vital part of the interprofessional team 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 22

23 Exemplary Professional Practice Accountability, Autonomy, & Competency Accountability, autonomy, and competency assurance are essential to achieving and maintaining the highest level of professional nursing care. Structures and processes are in place to ensure that all healthcare providers are held accountable for their work; to this end, competencies are assessed annually for all UCLA Health employees. These competency assessments are combined with self-appraisal and peer feedback to provide a transparent, 360 performance evaluation. Clinical nurses are thereby empowered to use their clinical expertise to advocate for patients and families, in the same way that nurse leaders advocate on behalf of their clinical nurses, and that CNO Heidi Crooks advocates for nurses and nursing practice across the health system. Read more about the accountability, autonomy, and competency of nurses at RRUCLAMC 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 23

24 Exemplary Professional Practice Ethics, Privacy, Security, and Confidentiality At UCLA Health, nurses are guided by the ANA Code of Ethics in their care delivery. There are many resources available to clinical nurses and nurse leaders to help to guide this component of their professional practice, including: UCLA Ethics Center, which provides 24-hour consultation for nurses and others for ethics-related matters Clinical nurses participation on the UCLA Ethics Committee Ethics Grand Rounds Circle of Caring Retreat Annual training on policies and procedures around confidentiality The UCLA Privacy Management Office, which monitors patient privacy and compliance Read more about the ethics, privacy, security, and confidentiality practices of UCLA Health in the following SOE: o EP17 Ethical Issues o Ethics Center Services Support and Develop Ethical Nursing Practice 24

25 Exemplary Professional Practice Culture of Safety At UCLA Health, the safety of our patients and our healthcare personnel is of the utmost concern. There are many resources available to clinical nurses and nurse leaders to help safeguard the health and well-being of patients, families, and health system employees. Several successful safety interventions have been initiated by clinical nurses throughout RRUCLAMC. Read more about RRUCLAMC s culture of safety practices in the following SOEs: o EP18EO Workplace Safety o Part 1: Reducing Needlestick Injuries through Standardization of Safety Needles o Part 2: Improving Nurse Safety in the Emergency Department by Targeting Workplace Violence 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 25

26 Exemplary Professional Practice Quality of Care Monitoring and Nurse Sensitive Indicators At UCLA Health, measures of the safety of our patients, quality of nursing care, and patient satisfaction are collected throughout the 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 hospitalacquired 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, house-wide surveillance began in Q Additionally, the organization has 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 nurse-sensitive indicators and patient satisfaction scores 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 26

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: 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 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 27

28 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 Nursing grand rounds The Investigator newsletter Annual Research and EBP Conference Access to UCLA Medical Sciences Library UCLA Chief Nursing Informatics Officer and nurse informaticists 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 28

29 The inspirational work of our RRUCLAMC nurses is highlighted in the following SOEs: SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED Enhancing the Practice Environment in Order to Reduce UCLA Health System Nursing Turnover RRUCLAMC Nursing Admin Nursing's mission, vision, values and strategic plan align with the Float/Resource Pool organization's priorities to improve the organization's performance. Finance 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. TL1EO Part 1 Nursing Strategic Plan TL1EO Part 2 Nursing Strategic Plan TL2 Part 1 Advocating for Resources TL2 Part 2 Advocating for Resources TL3EO CNO Organizational Influence TL4 Part 1 CNO Involvement in Organizational Decision-Making 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. 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. 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. 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 CNOinfluenced positive change that had organization-wide impact beyond the scope of nursing services. 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). UCLA Health System RRUCLAMC Nursing Admin QMS Overhead Nursing Research & Edu (NRE) 4ICU 7ICU 8W Entersomal Therapy OR Admin 8ICU TPN Services UCLA Health System PT/OT Admin 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 29

30 SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED 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. TL4 Part 2 CNO Involvement in Organizational Decision-Making TL5 Part 1 Nurse Leaders Guilding Change TL5 Part 2 Nurse Leaders Guilding Change TL6 Part 1 Developing Leaders TL6 Part 2 Developing Leaders 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. 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. 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. 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. 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) 4ICU 6E 7E/5E 7W RRUCLAMC Nursing Admin RRUCLA Nursing Admin 7W UCLA Health System RRUCLAMC Nursing Admin External Consultant 7E/5E RRUCLAMC Nursing Admin 7W 8W Float/Resource Pool Labor & Delivery MOU NICU PICC Radiology 30

31 SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED TL6 Part 3 Developing Leaders TL6 Part 4 Developing Leaders TL7 Data-Driven Resourcing TL8 Part 1 CNO Visibility and Accessibility TL8 Part 2 CNO Visibility and Accessibility 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. 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. 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). 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. 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. 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 UCLA Health System RRUCLAMC Nursing Admin 8N Entersomal Therapy Materials MGMT Nursing Admin Nursing System Procurement & Strategic Sourcing RRUCLAMC Nursing Admin 6E Enterprises Admin Operations OR OR Admin RRUCLAMC Nursing Admin 5E 6E 6N 6W 7E 8N Emergency Ambulatory Department NICU NPH NRE Operating Room PICU UCLA System HR 31

32 SOE SOURCE OF EVIDENCE DESCRIPTION UNITS/DEPTS FEATURED TL9 Part 1 Influencing Change TL9 Part 2 Influencing Change SE1EO Part 1 Interprofessional Decision-Making Groups 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. 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. 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. Nurse Recruitment Nursing Admin Peds PICU 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 6ICU 6N Emergency Department Emergency Medicine Neurology Neurosurgery Pharmacy Services PT/OT Admin-MP QMS Overhead SMH Radiology SE1EO Part 2 Interprofessional Decision-Making Groups SE2EO Part 1 Professional Organization Participation SE2EO Part 2 Professional Organization Participation 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. 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. 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. 7ICU 8ICU Emergency Department Labor & Delivery JSEI OR JSEI Pre/Post OP Unit 6ICU Neurosurgery Nursing Research & Edu (NRE) 32