Nursing Councils Report from January through March

Nursing Councils Report from January through March

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

  • -Journal Club:


  • -Cathaleen Ley presented the new quality improvement bedside scientist grant at the December Power Hour and to the Nursing Research Council. As part of our ongoing effort to provide continued learning opportunities to Council members, Joyce Miller provided a presentation on manuscript writing in February and evidence based practice resources in March.
  • -The FY2017 call for proposals opened in January 2016 and are due on April 26, 2016.
  • -Work is underway to plan for the next Evidence Based Practice Fair which will be held on 10/28/2016 in conjunction with Professional Development Day. Each nursing quality council will present a poster on their quality improvement project. The call for poster abstracts will be in August 2016. Poster winners will be selected in advance and will present a brief presentation of their quality improvement project in a Professional Development Day session.


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

  • -Bedside Shift Report
    • Training began in February 2016 for coaches and March 2016 for staff nurses.
    • Training included a competency for both coaches and staff and focused on safety and quality.
    • “Bedside shift report (BSR) Resuscitation” went live on March 21, 2016 which will directly impact patient satisfaction through increased awareness and reinforced accountability to nursing staff.
  • -CAUTI
    • New urine specimen cups went live this quarter.
    • Bard Sure Step Foley kits have been approved. Training will begin in March.
    • A nurse driven protocol for Foley removal is in development.
    • CAUTI Best Practice training will be started in May for CAUTI Champions.
  • -Falls Committee
    • The committee is in the process of comparing the Posey chair pads and wall mounted alarms to the DeRoyal products.
    • A pilot study of the DeRoyal chair pads and alarms will be conducted on the Special Care Unit.
  • -Nursing Quality Peer Review
    • First case was reviewed in February and March 2016. Committee has had extensive training and mock case reviews to prepare for beginning of case reviews.
    • FAQ for nurses was developed and distributed to several committees including Professional Nurse Council (PNC) and Nursing Operations Leadership (NOPS) for feedback and modifications.
    • Blog article published and email sent to nursing distribution describing nursing peer review process to nursing staff.
  • -Verge System
    • The reporting of falls data was simplified by having all required fields in Verge.
    • In order to capture accurate quality data in a timely manner, unit Verge responders must complete all required fields as soon as possible after the report of an event.
  • -Patient and Family Education
    • AAMC is currently requesting proposals from vendors for a new interactive patient educational system.
    • Leadership and key stakeholders will review proposals and select a vendor that best meets our needs as an organization.


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

  • -DNR bands: PNC is looking at DNR wristbands to be used at the bedside.
  • -Nursing Satisfaction Survey: Unit PNC reps are preparing to help unit managers and directors achieve 100% participation with the survey in April. Additional education sessions on the survey will be discussed during the next two meetings. Holly Greever is emailing staff with reminders to send out Nursing Survey emails to PNC reps units. PNC reps and unit partners will have meal vouchers for those who complete their survey.
  • -Daisy Award/Nurse Excellence Awards: There will be another Daisy award celebration before summer. Twenty-five Nursing Excellence award nominations are being reviewed.
  • -Peer Review: Cathleen Ley and Deb Baden discussed the Nursing Peer Review process that will be starting in the upcoming months. Clinical peer review is practice-focused and fosters a continuous learning culture of patient safety and best practice. The process is safe and fair, objective, confidential, educational, and timely in providing feedback.
  • -Workplace Violence: We are looking at possible upcoming education sessions for PNC. This has become an area of interest among many of the nursing units. We are currently looking to work with HR on resources for staff and future education. PNC is working to have a poster board on workplace violence for the Nurses Week fair.
  • -Professional Practice Changes:
    • The new urine specimen collections systems are going house-wide.
    • Bedside Shift Report has rolled out with the resuscitation efforts for 100% compliance. Bedside Shift Report or workplace violence will be topic for the PNC poster during the upcoming nurse’s week fair.


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

  • -New Clinical Education Council CHAIR – Robin Colchagoff
  • -New Clinical Education Council CO-CHAIR – Mary Cohn
  • -New pulmonary disease navigator in Respiratory Care is Jennie Sayles
  • -SKILLS DAYS 2016
    • Station sign-up sheet > ask your educator for the sheet
    • DATES:  April 28, 29, & 30; May 16, 17, 23, & 24
    • For nurses and escorts >  tip sheets with your unit educators
    • Patient’s OWN medication should be sent home with family contact
    • Hundreds of dollars’ worth of medications are thrown away every month because they are not retrieved before discharge
    • New inpatient, Clatanoff, and Emergency areas have purple papers for navigating the EPIC system. Have you ever tried to figure out what the details of the surgery or procedure were? Have you tried to view details of your patient’s emergency room visit (labs drawn, etc.). These tip sheets help you find the details of your patient’s encounter.
    • Tip sheets will be available through your unit directors and educators.
    • Training completed and go-live coming
    • Thank you for your enthusiasm!
  • -Professional Development
    • HP Skills Days are scheduled for April 28, 29, 30 and May 16, 17, 23, 24, 27, 2016. W&C’s services skills days start on 4/4/16 and be completed  by 5/25/16.
    • Planning for the Epic upgrade continues with demonstration of new content.
    • Continuing JC readiness strategies and outcomes discussed.
    • Review of three pain policies presented by Amanda Chipko with review of changes to pain and pain reassessment documentation that is coming soon.


Interdisciplinary Informatics Council
Chair: Jennifer Dupre, MSN, RN-BC
Co-Chair: Lindsey Alexander, RN

  • -Best Practice: “Link” IV fluids to their correct line in the MAR.
  • -Document when a patient is on isolation – under “safety interventions.”
  • -The LDA documentation has been updated to include the second person when inserting an in-dwelling foley catheter.
  • -On the “Ticket to Ride” please note whether or not medications went with the patient.
  • -An education point will be added to the Patient Education tab in the medical record pertaining to Bedside Shift Report.  This will be used to document explanation of bedside report to the patient upon admission to the unit.  Go-live March 29.
  • -Ability to chart prescription verification began March 29 as well. A check off box will be added to the Discharge Note in the Discharge Navigator to verify that the prescription handed to the patient actually belongs to that patient.
  • -Oxygen BPA for nursing will go live after April 5 after all of the order sets have been updated to reflect the oxygen orders. The BPA will fire for any patient that has been placed on oxygen without a physician’s order.
  • -Escorts will be able to transport patient medications with the patient in mid-April once training is completed.
  • -An Active Orders hyperlink will be placed onto the Snapshot page right above the Sticky Notes.


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

  • -CPC approved the following policies to move on to the Hospital Policy Review Committee (HPRC):
    • SNP 15.9.01 Outpatient Infusion Center, Patient Care Documentation – abbreviations were corrected in this policy.
    • # TBD Adult Neurological Assessment (Neuro Checks) – neuro checks pulled out of Adult assessment policy to make a new policy.
    • SNP 15.2.56 Cord Blood Gas Analysis – changed and simplified to reflect current practice and labeling.
    • SNP 15.2.52 Fetal fibronectin – 3-year review.  References have been updated.
    • SNP 15.4.06 Traffic patterns in the surgical suites – 3-year review with the addition of the Hepa Filter for infection control.
    • SNP 15.4.235 Unintended Intraoperative Awareness During General Anesthesia – policy has been updated to reflect current practice.
    • SNP 15.4.266 Hysteroscopy Fluid Monitoring – updated to reflect current practice needs to go to P & T for medication clarification.
    • SNP 15.2.30 Assisting with a Circumcision Procedure – updated to reflect verification process.
    • GNP 14.6.01 Pre-Procedure Verification Process for Preventing Wrong Site – Procedure – Person Surgery/Procedure – updated to reflect changes from RCA.
    • IC 5.1.10 Management of Multi-Drug Resistant Organisms (MDRO) – this policy fast tracked to reflect current practice, purpose added with up dated references.
    • IC 5.1.06 Standard Precautions – this policy fast tracked, added scope and purpose.
    • IC 5.1.03 Isolation Precautions, Transmission-Based – this policy fast tracked, content states no gowns for visitors, masks used by visitors for droplets.
    • IC 5.1.## Outbreak Control Plan – this policy is for hospital protocol during outbreak.
    • MR 7.1.07 Verbal Disclosure of Protected Health Information – policy updated to reflect new language and process.
    • Definition of the “critically ill” patient for Point of Care Glucose Meter Testing – AAMC needs a policy defining the patients we can no longer test for finger stick glucose (this policy will go to Deb Baden for appropriate language and action.
  • -CPC members were asked to review 3-year review policy list to determine if any policies could be retired or if MOSBY’s could be used instead of a policy.
  • -CPC approved to RETIRE the following policy:
    • SNP 15.9.03 Outpatient Infusion Center, Required Nursing Education – information for this policy is now included in the Chemo Administration policy.
  • -Three policies from the Three-Year Policy Review List were approved to move on to HPRC once references updated:
    • GNP 14.2.18 – Massive Transfusion
    • GNP 14.6.06 – Critical Values
    • NAP 12.1.23 – Outpatient risk assessment for falls


Charge Nurse Council
Chair: Lisa Davis, RN
Co-Chair: Devra Cockerille, RN

February Meeting Report

  • -Shirley Knelly reviewed quality based reimbursement metrics and the pay for performance programs in Maryland and its impact as well as AAMC’s performance.
  • -Katrina Martin from SCU reviewed restraint documentation and a checklist created by the SCU team to assist charge nurses in ensuring documentation is complete when patients have restraints .
  • -Devra Cockerille reported on the donations provided to the family by the Charge Nurse group for Christmas. Lisa Davis provided information for the sock drive held in February.
  • -Capacity report updated by Lil Banchero to include the opening of 10 beds on 5 North as well as 10 beds in EDTU by Flex staff to assist with high census.
  • -Barbara Jacobs updated the group on the Weekend Alternative program. Barbara also discussed the roll out of the Bedside Shift Report training.
  • -The group discussed the title of “Unit Charge Nurse” and agreed another title is appropriate, we will bring other options back to the group at the next meeting.

March Meeting Report

  • -Information has been gathered regarding duties of Unit Charge Nurses. We will be compiling the data and comparing the job description to present and decide on a new job title.
  • -Holly Greever communicated that the RN satisfaction survey will be April 14-April 24, RNs are encouraged to participate and it was stressed this is anonymous and voluntary.
  • -Throughput was discussed and 1 south is now being staffed by Flex Nursing Staff, this is a transition unit for patients waiting for inpatient beds.
  • -Bedside shift report will be presented at Leadership Council Wednesday 3/16.
  • -The group discussed how new products are presented to the staff and suggested all products be previewed by CEC.


Nursing Operations Council
Chair:  Irma Holland, MSN, RN

  • -NOPs developed a task force of directors to develop recommendations about Educational leave time, and how to support staff to go to conferences.
  • -Cathaleen Ley and Deborah Baden gave updates on training for Peer Review process.
  • -Beth Christy discussed the new urine cup conversion and the workflow change around sending specimens to the Lab.
  • -Karen Cash reviewed the Storage of PCA devices, a proposal  for a patient transporter to  take medications along with the patient to next area.
  • -Deborah Baden reviewed Top Risk Management Issues: alarm hazards – inaccurate alarm configurations and inadequate policies around alarms; data integrity –ability to tell the story of a patient’s journey through data collection in EMR; managing patient violence – de-escalation strategies; incorrect connection of IV lines, with missed meds; care coordination events related to med reconciliation; failure to conduct independent medication double checks; opioid oversedation; reprocessing surgical instruments; patient handoff.
  • -Jan Clemons presented the new Bedside Shift Report Resuscitation – Focus on Safe Handoff, Safety, Quality, Pro-actively Engaging Patients.
  • -Welcome Barbara McGuinness, New HVU Director.
  • -Phillips conversion update.
  • -Review of restraints daily report to be conducted by all units and reported out at bedboard each morning.
  • -Reviewed Joint commission action plans chief concerns:
    • NPSG- alarm safety being addressed by the Alarms Committee, working to optimize alarm parameter, an audit conducted each month
    • Suicidal Patient: safety, process being reviewed to tighten sitter process and documentation
    • Pain management
    • Individualized care plans – telling the patient story

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