Nursing Council Reports for the month of July

Nursing Council Reports for the month of July

Nursing Research Evidence-Based Practice Council
Chair: Cathaleen Ley, PhD, RN
Co-Chair: Cheryl Briggs, BSN, RN

  • Three new members welcomed to the Council – Nancy Kemp (staff nurse, IR), Gloria Oshegbo (RN System Analyst, IS), and Kimberley McCarthy (staff nurse, HVU).
  • Reviewed and approved UMBC student Rand Obeidat’s doctoral dissertation entitled, “Technological disruptive change within Healthcare environment: An Examination of Change management factors that influences nurses’ attitudes toward implementing disruptive change.”  This study will be conducted in September and October 2015. Cathaleen Ley will be the Site-Primary Investigator.
  • FY2016 goals were reviewed and formally approved.
  • Institutional Review Board (IRB) training will now be required of all members within six months of joining Council.
  • Bedside Scientist grants are funded throughout the year. Please contact Cathaleen Ley at for more information.

Nursing Quality Council
Chair: Cathaleen Ley, PhD, RN
Co-Chair: Lauren Stylc, RN

  • NDNQI Data Summary: CY15 Q1 Results:
Indicator Number of Units Outperforming
Inpatient Injury Falls








Outpatient Total Falls


Outpatient Injury Falls


  • Approval of FY2016 Council Goals:
    • The majority of the units, the majority of the time outperform their NDNQI benchmark for the following indicators: falls with injury, hospital acquired pressure ulcers (HAPU) stage 2 and above, central line associated urinary tract infections (CLBSI), and catheter associated urinary tract infections (CAUTI).
    • The majority of the units, the majority of the time, outperform their benchmarks(s) or internal goal(s) on nurse-sensitive indicators(s).
    • AAMC outperforms the Hospital Compare national average on VTE prophylaxis given day of or day after hospital admission.
  • CAUTI Committee:
    • July prevalence study was conducted the week of July 27 in collaboration with BARD.
    • Two-person Foley insertion, though not required, is being encouraged as a way to decrease CAUTI.
    • The CCU had adopted a Foley insertion process that includes a standby assistant in order to support positioning of the patient and ensure aseptic technique.
    • A special urine specimen collection system has been approved for use and will be implemented house-wide beginning in August. The system includes preservatives in a closed system which will prevent contamination of the specimen for improved accuracy of laboratory results interpretation.
  • HAPU:
    • Next prevalence study will be conducted in September 2015.
    • Quarterly Hospital Pressure Ulcer Collaborative meetings will resume in July 2015, unit-based champions are expected to attend these educational meetings.
    • Matching Baden sub-scale scores to linked interventions in EPIC in order to decrease HAPU.
  • Clinical Policy and Procedure Review Process:
    • Unit-based nursing clinical policies are to be reviewed by the unit-based quality councils. If the policy crosses units, it is to be reviewed by the Nursing Service Line Quality Council.
    • All policies that involve medications must be reviewed and approved by the Pharmacy and Therapeutic Committee (P&T) in advance of the Clinical Practice Council (CPC).
    • All service line specific multi-disciplinary policies are to be reviewed and approved at the service line interdisciplinary quality councils (i.e.  Medicine Quality Council, Surgical Services Quality Forum).

Professional Nurse Council
Chair: Carrie Jackson, MSN, RN
Co-Chair: Daniel Shields, RN
Initiatives: SNAC, Diversity/Advocacy, Community, COPE

  • Represented Nursing in developing interview questions, making suggestions on interview panel participants and reviewing the position specifications and competencies for the new chief nurse candidate.
  • Engaged with staff at the unit level to encourage completion of the Nursing Workforce Data Questionnaire, which helps guide resource allocation and planning.
  • PNC and HR working in collaboration on the retention and recruitment of nursing staff to include participation in the upcoming Nursing Recruitment Fairs.
  • Professional Practice Models on the units to be updated continuously.
  • In June, 213 lunches, two gift cards and two cases of water were delivered to the Light House Shelter.
  • Staff encouraged to volunteer to at the Light House Shelter to either facilitate a health education workshop or staff the health clinic. Link to volunteer opportunities on the Nursing website. 

Clinical Education Council
Chair:  Melody Kennedy, BSN, RN
Co-Chair: Gena Kosmides, BSN, RN
Initiatives: Professional Development

  • Master of My Story was presented by Lisa Walker, Organizational Development Specialist, on August 6, 2015. This Preceptor Enrichment Workshop was an opportunity for nursing preceptors to seek support from peers and an HR specialist, and find answers to questions related to precepting challenges.
  • EPIC Changes:  (All tip sheets will be available from your educators and eventually on the new intranet site)
    • Insulin pumps can now be added to the PTA med list.
    • Insulin pumps can now be added through order entry for continued use while in the hospital.
    • “Adverse Drug Reaction” has been added to the allergy documentation piece along with intolerance, allergy and contraindication.
    • Tube feeding connectors will soon have a universal connection that only other feeding tube equipment will  share. This is a patient safety measure. More information will be released in the coming months as the change is predicted to occur around the beginning of 2016.

Interdisciplinary Informatics Council
Chair: Bill Moore, BSN, RN
Co-Chair: Jennifer Dupre, MSN, RN

  • Bedside Shift Report (BSR) going live for all in-patient units on August 18, 2015. Access handoff of care screen through SBAR report. Tip sheet and education is planned.
  • PCA order sets for Morphine and Dilaudid to incorporate logic and make suggestions to Physician for dose adjustment (i.e. drug interactions and patient age). Go-live was August 4, 2015.
  • Height and weight will be required documentation for all admitted patients which will need to be entered/updated within 24 hours of admission. BMI and BSA needed for medication dosing. Go-live will be August 18, 2015.
  • Insulin pump may now be included on PTA med list. Search “pump” to add medication. Currently in production.

Clinical Practice Council
Chair: Tina Andersen, BSN, RN
Co-Chair: Denise Matteson, BSN, RN, CAPA

CPC approved the following policies to move on to the Hospital Policy Review Committee (HPRC):

  • GNP 14.2.17 Inpatient Therapeutic Phlebotomy– 3 year review, references updated
  • MED 16.1.19 Adverse Drug Reaction- policy updated to state that opioid induced itching is not considered an adverse drug reaction (ADR)
  • GNP 14.2.14 Venipuncture for Blood Samples- 3 year review, order of lab draws revised to mirror Mobilab order
  • GNP 14.2.16 Capillary Specimen Collection– 3 year review

CPC approved to RETIRE the following policy:

  • GNP 14.7.17 Ekg:  electronic imaging and 12-lead ekg- staff complete an annual competency on current machine; policy not needed

Please note:  Policies are not finalized or posted online until signed by Sherry Perkins or designated VP.

Charge Nurse Council
Chair: Marianne McKiernan, RN
Co-Chair: Barbara Buckley, BSN, RN

Charge Nurses in process to elect a new co-chair to the Council.

Nursing Operations Council
Chair:  Irma Holland, MSN, RN

  • Nursing Leaders asked to encourage nurses to complete the Nursing workforce survey which was 24% complete.
  • A report on the Clinical Ladder participation provided for each unit. The goal is 30% of all eligible nurses.
  • Patient scanners are being distributed on each unit to help increase scanning compliance.
  • Joint commission prep is underway. Directors will meet with nurse educators at the August 13 meeting to discuss JC prep activities.
    • Care plan audits and chart audits will be review monthly at NOPs
    • JC will be a standing agenda item
    • Directors/owners of provision of care documents are asked to review the documents for needed changes.

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