Unit Based Councils Tool Box Introduction This tool box identifies nine areas to structure and guide unit based councils. The nine areas are: 1. Goals of Council 2. Purpose and function 3. Membership and application 4. Leadership 5. Authority 6. Decision Making and Voting 7. Meetings 8. Evaluation 9. Communication It is recognized that each unit is unique in its scope and population; therefore the tool box should be adapted to the units needs. This tool box is designed to provide the framework for your unit council. It is recommended that an initial activity of the council is to develop a Mission and Vision Statement specific to their unit in conjunction with the organizations mission and vision. This will provide the foundation on which to build your council. The mission of TCCH is to exceed the expectations of those served, maintain standards of highest quality and promote a rewarding working environment. The vision of TCCH is to be known as the health care provider of choice and employer of choice. The utilization of the Patient Satisfaction Performance Standards communication, compassion, integrity, commitment and Teamwork, offers the frame work to further develop the activities of council 1. Goals & Ground Rules Each unit will develop measurable, concrete goals/ground rules (see attached) for their council that reflects the scope and needs of the unit and support the system and nursing strategic plan. The recommendation is to start small. 2. Purpose & Function A few areas that the unit based councils may want to start with as projects are the following: 1
A. Clinical Practice a. Establish a schedule to review, evaluate and analyze based on best practices, unit based policies and procedures, protocols, standards, pathways, order sets and other documentation utilizing the Nursing Quality Committee. b. Identify high risk, problem prone, low volume issues and collaborate to provide feedback to appropriate committees (i.e., Policy & Procedure) c. Evaluate and make recommendations on quality improvement data d. Update references utilizing information from specialty organizations B. Performance Improvement a. Review and develop unit key indicators b. Ensure quality improvement activities reflect mission and vision of the organization and scope of practice on the unit c. Analyze unit specific and organizational quality data results and develop a plan accordingly i. increase staff awareness and solicit input regarding quality improvement activities C. Unit Patient/Family Education a. Review current patient/family education material for availability and appropriateness of clinical content b. Index materials that are used by unit c. Identify need for additional educational material d. Recognize and utilize additional resources for review and development of patient education material(i.e., Staff Development, Clinical Specialists) D. Unit Satisfaction a. Promote constructive feedback among peers/conflict resolution b. Promote team building activities i. collegiality within department ii. collegiality with various departments and staff c. Role clarification (i.e., RN, LPN, NA, US etc) d. Accountability for activities and confidential communication e. Employee surveys encourage participation communicate results develop action plans f. Participate in new applicant interviewing g. Determine HOD unit based vows E. Unit Based Staffing and Scheduling Issues a. Education and understanding of staffing grids and core staffing and staying within budget in collaboration with Unit Based Staffing Committee b. Review effectiveness of current staffing and scheduling practices (i.e. holiday scheduling, reassignments, weekends, shifts, requests for time off, etc.) c. Communication of unit based staffing and scheduling practices 2
F. Staff Education and Competency a. Support for unit staff education in collaboration with Staff Development to maintain competency and provide for professional growth i. consider development of Department/Unit based Education Committee ii. review journal articles iii. utilize research to investigate best practices iv. input regarding unit specific competencies v. identify new unit based key competencies vi. establish a schedule for competencies and in-services vii. plan for implementation of educational offerings b. Technical ability i. new/change technology ii. utilization of policies and procedures for educational purpose c. Unit orientation i. new hire/reassigned staff/agency orientation d. Certification/continuing education i. increase awareness of certification and continuing education opportunities and responsibilities e. HOD Taskforce members will report information to unit council i. increase staff awareness of HOD campaign and outcomes 3. Membership/Application Process a. Membership will be determined at the unit level by staff and manager through application process. b. Membership may include but not limited to: i. RN ii. LPN iii. Charge Nurse iv. Weekend Staff v. All Shifts Represented vi. Full & Part Time Staff vii. NA, Us, Techs any ancillary staff c. Ancillary departments invited as needed d. Size of unit determines number of members required (average unit would have five permanent staff members- must take into consideration the business needs to the unit) e. No substitution for members (except extended leaves) f. Members are required to attend 80% of the meetings g. New applications will be accepted when vacancies occur h. Optional- have staff member attend meeting to observe A. Length of Membership a. Initial term- two 2 years- a membership should start date should be kept on each members 3
b. After the two year mark, one half (1/2) of the members will be replaced each year at committee s discretion i. every year at the inception date of the Unit Council, the council member s team will be examined. Whoever has met the 2 year commitment will be on a list to be replaced. ii. in the event of an insufficient number of volunteers willing to step down, the Unit Council will have a random draw to decide additional members who will be replaced iii. staff may continue to serve on Unit Council after the two year term if there are no applicants or at the discretion of the Unit Council B. Application Process a. Unit Council will make applications available to staff 3 months prior to the two year date. (application on nursing web site) b. Interested staff should complete an application prior to the two year date c. For the first committee selection- if an excess of applications on one given shift is received the other shift council members will be given the charge to select that member with Clinical Manager assistance d. If further consultation is needed then the Nursing Director will provide support e. After the first term, new applications will be reviewed by the unit based council prior to voting 4. Leadership a. The chair will be elected by the committee within six (6) months and every two (2) years thereafter. The Clinical Manager or Director will serve as facilitator and coach in the interim b. Chair person will be up to a 2 ½ year term, serving the last six (6) months as a resource for new chair c. In order to facilitate the Clinical Practice Model the Unit Council chair will be an RN. In the event that there is a transition of council leadership and no available candidates, current council members will identify a chair from within the council 5. Authority a. Approval body for evaluation/validating unit standards, policies & procedures, based on the evidence. b. Provide recommendations and decisions for, but not limited to: i. staff education and competency ii. unit patient/family education iii. performance/quality improvement iv. unit staffing/scheduling issues c. Unresolved recommendations/decisions from the unit-based council to be forwarded to the appropriate referral committee (see attached chart): 4
6. Decision Making/Voting a. Formal decision-making process by majority rules with 2/3 of voting members. Director, Clinical Manager, Staff Development Educator are excluded from voting. b. Voting may be by present or absentee ballot 7. Resources a. Nursing Governance Flow Chart i. The Nursing Governance Flow Chart identifies the following committee/teams: a. Quality b. Management c. Education d. Technology/Soarian to assist unit councils with the pursuit of their goals e. (See addendum- Nursing Shared Governance Flow chart) 8. Meetings a. Monthly, to be determined at unit level by staff and Clinical Manager at a pre-set day every month b. Calendar should be set for one year in advance to allow for scheduling c. Minimum of 10/year d. Length of meeting to be determined by the unit council (recommendation) 4-8 hour meetings up to one (1) year, then decrease to 1-2 hours 9. Evaluation a. Evaluate progress of goals quarterly i. group will evaluate their progress June of each year b. Minutes of previous meetings will be reviewed at each meeting c. Each agenda will begin with current goals d. Each council will compile an annual review of accomplishments to share with unit, council chairs of like areas and nursing administration 10. Communication a. Monthly meeting minutes/attendance will be maintained by the chair b. Recorder responsibilities will be rotated among the members c. Key issues for communication will be identified at each meeting d. Communication may be organized under Patient Satisfaction Performance Standards, communication, compassion, integrity, commitment and team work. e. Communication methods will be established by the unit council. Methods may include: i. Communication board ii. Staff meetings 5
iii. Communication tree- each council member/designee is responsible for verbally communication key issues to assigned staff and bringing information back to committee iv. Unit newsletter v. Nursing Web Site vi. e-mail f. Key communication updates will be shared by council chairs with council chairs of like areas. Unit Based council Ground Rules Formulate your own Unit Council Ground Rules as part of your first meeting. Feel free to use the Studer Ground Rules as a starting point! Be Present i.e., actively engaged and prepared to participate Be on time Begin and end the meeting on time No backing up to catch up late members No hidden agendas Members must notify Chairperson if unable to attend meeting Council members will speak freely and will listen attentively to others No interrupting each other All comments should be phrased in a positive manner Each council member gets their say, not necessarily their way Silence equal agreement Once we agree, we will speak with one voice Members must respect the confidentiality of the council All council members are equally important No sidebar conversation Processes will be discussed, analyzed or attacked, not people Always have a timekeeper, facilitator and minute taker Purpose identified on the agenda Get agenda and assignment out prior to council meetings 6