Nursing Councils Report for May

Nursing Councils Report for May

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

  • The June Journal Club was led by Rae Leonard, Abuse/Domestic Violence Coordinator, who reviewed an article on intimate partner abuse. The Journal Club meets on the third Monday of every month from 12-1pm in the South Tower, 2nd floor conference room. Please bring your lunch and explore how to incorporate research evidence into practice.
  • The Nursing Research Council reviewed and selected four Bedside Scientist Grants to be funded in FY2016.

Principal Investigator

  • 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

  • Quality Metrics:
  • The majority of the units outperformed the NDNQI benchmark for the following clinical indicators in FY2015 Q2 – hospital acquired pressure ulcers (HAPU) stage 2 or above, central line associated blood stream infections (CLABSI), and catheter associated urinary tract infections (CAUTI).
  • The majority of the units did not outperform the NDNQI benchmark for falls with injury. Units that did not outperform are developing unit-based actions plans within their nursing quality councils to improve performance.
  • For non-NDNQI quality metrics, the majority of the units did outperform their internal goals for nurse-sensitive indicators.
  • AAMC outperformed the Hospital Compare national average for both core measures goals in FY15 Q3 – VTE prophylaxis given day of or day after hospital admission and urinary catheter removed by post-op day 2.
  • Nurse Sensitive Patient Satisfaction Indicators:
  • The majority of the units outperformed their benchmark in FY15 Q3 for the following indicators:  courtesy and respect, responsiveness of hospital staff, pain management, patient education, and careful listening.


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

  • Reviewed the AAMC Professional Practice model to assure it is reflective of the current nursing practice.  Will make suggestions for revision at the June meeting.
  • FY2016 PNC goals developed to reflect the role of PNC as the voice of nursing and nursing practice.
  • Nursing Excellence Award nomination forms  for 2016 were revised based on feedback from staff completing the nominations.
  • COPE:
    1. Nine new members were added to the COPE team which brings the total number of persons on the team to 31.
    2. Two Skills Days will be held in order to help train current team members in caring for employees during critical/stressful events.
    3. Bimonthly mock COPE sessions will be held to assure ongoing competency of the team.
    4. COPE team will present during this year’s Magnet Conference.


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

The Clinical Education Council did not have a formal meeting. This month has been spent preparing the next Joint Commission Mock Tracer packet for upcoming mock tracer rounds and events.  More to come, we are still in the planning phases.


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

  • The Manage Orders tab should be used to view all active, soon to expire, and discontinued orders. This is a comprehensive list of all orders for the patient for this encounter.
  • Reminder: only take verbal and/or telephone orders in an emergency.  If staff do take a telephone order from a licensed practitioner, it is policy to document the practitioner’s badge number in the comments section of the order sign off screen.
  • The Pharmacy bedside dispensing program is going live on MSU as a trial program. MSU staff have the parameters for the program and the times that it is in operation.


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):
    • ADM 1.1.81 Family Presence & Visiting – revised to add role of “support person” per JC and the state
    • SNP 15.5.02 Arteriography/Angiography, Nursing Management- revised and renamed policy to incorporate current practice for patients undergoing diagnostic and interventional cardiology or radiology procedures
    • SNP 15.5.08 Use of Femoral Compression Device- revised to reflect current practice
    • SNP 15.7.12 Radial Artery Compression Device– revised to reflect current practice
    • SNP 15.2.70 Pediatric Sedation-revised to reflect current practice for pediatric sedation; SSU added to list of appropriate settings, however sedation will not occur in this area until a process is developed to care for these patients safely
    • SNP 15.1.02 Oral chemotherapy/hazardous biotherapy administration- revised to reflect current practice
    • GNP 14.7.09 Diagnostic bladder ultrasound (bladder scan)- three year review, updated Mosby link
    • SNP 15.2.08 Labor Check- three year review, minor changes to reflect RIE changes in triage
    • SNP 15.2.162  Epidural catheter removal in L&D- three year review
    • Adult, Pediatric and NICU blood policies- revised to include new blood scanning process for increased patient safety and to remove green sticker process
    • #TBD Banked Allograft Tissue Management- addresses how blood bank will store and distribute all tissue throughout the hospital
  • CPC approved to RETIRE the following policy:
    • SNP 15.5.03 C-Port patient post angioplasty- appropriate information incorporated into SNP 15.5.02 Arteriography/Angiography, Nursing Management policy


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

  • After a recent RIE to assess the “clean bed to floor” process, we are working on consistently improving throughput times from the Emergency Department to the floors
  • Rapid order sets are being used by the hospitalist groups to reduce the time it takes for a patient to go from the ED to the floor.
  • Charge Nurses were part of the first Lighthouse Shelter Transitions Project which helped to transition one family from the shelter to their own home. Generous donations of furniture, home goods, cleaning supplies and gift cards were obtained to help with the family’s smooth transition. The project was a huge success and plans for the next transition are in the works!


Nursing Operations Council
Chair:  Irma Holland, MSN, RN

  • In the process of amending the council charter and developing goals for FY16.
  • The council reviewed and made suggestions to improve the draft charter.
  • A brainstorming session was used to gather the opinion of the council members on what goals NOPs should prioritize. There will be follow up at the next meeting.

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