NURSE EXECUTIVE COMMITTEE Monday October 8, :30 AM Administrative Conference Room

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1 NURSE EXECUTIVE COMMITTEE Monday 10:30 AM Administrative Conference Room Presiding: Present: Guests: Recording:, RN Barbara Bilconish, RN, Rita Holley, RN,, RN, Chris Mitchell, RN, Penny Pink, RN, Sharon Stagg, RN, Jo Anne Thomson, RN, Diane Walbridge, RN Martha Clark, RN, Amy Stafford, RN Pat Hales Approval of Minutes The minutes of September 6, 2012 were submitted for Approved with minor revisions. approval. Dress Code: Other departments have been seen using nursing department colors. McLeod Action Plans: If numbers are low, Diane will send out reminders. stressed the importance of McLeod Reports and Diane reminded the group that McLeod must be advised of any changes so they can do an adjustment. Report on Unit-Based Councils Martha reported on her unit s unit based council initiatives. Councils include: Leadership, Education, and Recruitment & Retention. A Leadership Council is starting in November and will cover education, quality and community service. Quality Improvement Projects: Martha Clark Bedside reporting initiated 8/27/12. Hourly rounding initiated first of the year. Fall prevention Pressure Ulcer prevention Joining the Purposeful Rounding pilot on October 15 th Professional Advancement: Tara Smith, Noemi Antonio, Jamie Reilly have advanced to RN III. 1

2 Page 2 of 5 Gina advanced to both RN III and IV. Recruitment & Retention: Luncheon for departing surgeon. Building relationship with new surgeon. Staff birthday board updated monthly. Celebrate achievements on the unit. Research: Stephanie Golebieski, RN III, is the SHS nursing research intern. The unit participates in research activities, such as, John Durcho s and Janet Wilson s surveys. Amy Stafford s and Jeanne Brower s research project was just published in Nursing Management. Professional Advancement Program Policy The following language was discussed and agreed upon for Sections and of the Professional Advancement Policy: Licensed RNs with one year of experience but not any previous acute care experience are hired into the CCU/GU program as an RN Level II A licensed RN without previous acute care experience but with other regular nurse experience will be hired into the CCU/GU Program and will have the previous experience accounted for in the initial salary offer. Therefore, these nurses will not be eligible for the $.50 per hour pay increase. $.50 raise is given 1-year postlicensure. Gail will advise managers to do a PAR when RNs finish CCU/GU Barbara Bilconish Competencies Still in progress. Tabled for a future meeting. Barbara Bilconish Pilot Project Management Urology This is a pilot to improve scheduling of urology procedures that vary based on complexity. Not knowing how much time is needed for cases of the same type makes scheduling difficult. Some cases take much longer than others. A pilot using subcategories of simple, standard or complex to improve scheduling was implemented. The pilot will be evaluated on 10/15 and it will either be extended or expanded to include Dr. Runz and Cespedes. It will then be taken to the Perioperative Penny Pink 2

3 Page 3 of 5 Committee for approval. asked that it be measured how many times a case was categorized correctly and how many times it was more complex than anticipated, i.e., how accurate is the process. He also asked for more information in the Translation section of the Pilot Project Management Form. This process was used for some of Dr. Kurtom s cases and was very successful. Strategic Plan Update Reminder that an update is due. Schedule separately. (2hrs.) Annual Report for Nursing Pilot Project Management Purposeful Rounding Criteria Based Performance Appraisals It is time to start work on the Annual Report. This is a pilot to determine if purposeful rounding will have a positive impact on fall rates, pressure ulcers, HA-UTI s and patient satisfaction. An education plan has been developed. It is built into Meditech and ready to roll out. Every hour either a nurse or a tech will make a purposeful rounding using the 5 P s (potty, pain, position, proximity and personal needs). The directors had the opportunity to provide input and all suggested changes were made. The new format was piloted by 4 managers who all felt it was faster, more objective and easier to use than what is currently in place. It was felt this would be an opportune year to rollout this out since no raises are involved. Peer Review: The directors felt the peer evaluation should mirror what the managers will use. The peer reviewer will need to get educational offerings, etc. from the manager. Chris Parker suggested allowing open access to the Magnet database for viewing only. Another suggestion was to have the employee print out the database for the peer evaluator. Barb noted that Health Stream is not on the database because it tends to be mandatory education. The policy now states 2 peers and 1 self eval are required. The opinion was split as to whether peer evals should be anonymous. Barb noted that Magnet requires peer and self evaluations for nurses in all A 4-hour meeting will be scheduled to start preparations. Pilot will be implemented on 2 East MHE. Outcomes to be evaluated January It is hoped to rollout the new appraisal form in January. For right now, only staff nurses will use the new form. All others will use the current form. Diane to look into access to the credentialing database for purposes of peer review. It was agreed that 2 peer and 1 self is the minimum requirement. Diane Walbridge 3

4 Page 4 of 5 departments. Per Diems: Diane felt per diems cannot be evaluated this way and the responsibilities should stay as is for them. It was questioned whether the responsibilities could just be in a different order for the per diems or is there a better way to address them. The group recommended using their current responsibilities, but Diane thought that the per diems should use the same form as the other RNs. Penny noted that a lot depends on how much a per diem works. suggested re-ordering the form so per diems are at the bottom of the form since a lot of the form does not relate to them. They have a supplemental job description, which is slightly different from regular RN s. Christmas Party and Catering Magnet Logo RMC Next Year s Goals Budget Patient Care Services The regular caterer is holding the date. He wants to be paid the day of the event. Jo Anne volunteered her house for the party. As of December 31 st, the old logo needs to be purged throughout the system and the new logo used everywhere. Barb said that things are being updated as they come up. We are in the process of designing the infrastructure process changes for the new building. We need an individual to run the process change teams and to develop a plan for the actual move. Chris would like to make process changes now instead of waiting for the new building. He also wants to put in for a.5 person for paperwork, etc. Senior Leadership is still working on goals. The finance goal will be similar to last year s. It is already apparent that Corporate quality goals cannot be met but may have to go into the goals regardless. Others include a system financial goal, core measures, falls, hand hygiene and readmissions. We are better than budget at the moment, but annualized out, the budget will be over by at least $600,000. suggested dissolving this group and setting up Lunch & Learn instead. It was agreed that rotating the chair The party this year will be at Jo Anne Thomson s Main Street, Trappe, MD 12/31 is the hard date for logo change. Old logos throughout the system to be purged. An individual to report to Chris and Jerry will be selected. Next 30 days, SL goals should be finalized. Directors can start on theirs. Keep on calendar and have it when needed. Chris will hold 4

5 Page 5 of 5 Advanced Degree Nursing Council does not work well. Agenda items need to be sent one week prior or the meeting will be cancelled. the meeting when his calendar is free. Sharon reported that the council will be changing to include all Sharon Stagg nurses with Masters degrees. Those working on their Masters will also be invited. 1 st meeting is a dinner meeting on 12/4. to discuss Waiver Test. Sharon will put in the Beacon and send invitations. Nursing Research Update Sent out prior to the meeting. Nursing Informatics Cut/Copy/Paste: There is a lot more work to be done on Jo Anne Thomson addressing documentation that is carried forward. OR Management Changes Penny Pink Magnet Conference Behavioral Health Bridge/Posting Orders Susan Walbridge will be taking Mary Sutphin s place as OR Manager. Sydney Milliken will act as the interim coordinator for SS and PACU. Susan is keeping posting responsibilities. Phyllis will continue doing payroll, Kronos, etc. Phyllis will also maintain Infusion and report to Jackie Mowbray. This is essentially a five-day work week for those who go to the conference. Behavioral Health Phase 4 construction will be finishing up in another week or so and then move into the final phase. The unit will not open until all phases of construction are complete. A pilot is being discussed. This is a dual process for requesting beds while the hospitalist writes orders. We will be tracking how accurately we request appropriate beds. approved 40 hours of pay for attendees. Chris Mitchell ISTAT This is going back to New Services Implementation. Chris Mitchell Adjournment There being no further business, the meeting was adjourned at approximately 1:00 PM. Next Meeting Thursday, November 1, :00 PM 3 rd Floor - DGH 5