NURSE EXECUTIVE COMMITTEE
Monday – October 8, 2012 – 10:30 AM
Administrative Conference Room
Presiding: Chris Parker, RN
Present: Barbara Bilconish, RN, Rita Holley, RN, Ruth Ann Jones, RN, Chris Mitchell, RN, Penny Pink, RN, Sharon Stagg, RN, Jo Anne Thomson, RN, Diane Walbridge, RN
Guests: Martha Clark, RN, Amy Stafford, RN
Recording: Pat Hales
TOPIC DISCUSSION ACTION RESPONSIBLE PARTY
Approval of Minutes The minutes of September 6, 2012 were submitted for approval.
Dress Code: Other departments have been seen using nursing department colors.
McLeod Action Plans: If numbers are low, Diane will send out reminders. Chris Parker 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.
Approved with minor revisions.
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:
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 15th Professional Advancement:
Tara Smith, Noemi Antonio, Jamie Reilly have advanced to RN III.
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 1.4.2.1 and 1.4.2.2 of the Professional Advancement Policy:
1.4.2.1 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.
1.4.2.2 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 post-licensure.
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
Committee for approval. Chris Parker 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.) Ruth Ann Jones
Annual Report for
Nursing It is time to start work on the Annual Report. A scheduled to start preparations.4-hour meeting will be Ruth Ann Jones
Pilot Project Management
– Purposeful Rounding 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).
Pilot will be implemented on 2 East MHE. Outcomes to be evaluated January 2013.
Ruth Ann Jones
Criteria Based
Performance Appraisals 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.
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.
Ruth Ann Jones
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
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.
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. Chris Parker 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 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.
The party this year will be at Jo Anne Thomson’s - 3881 Main Street, Trappe, MD
Ruth Ann Jones
Magnet Logo As of December 31st, 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.
12/31 is the hard date for logo change. Old logos throughout the system to be purged.
Chris Parker
RMC 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.
An individual to report to Chris
and Jerry will be selected. Chris Parker
Next Year’s Goals 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.
Next 30 days, SL goals should be finalized. Directors can start on theirs.
Chris Parker
Budget We are better than budget at the moment, but annualized out,
the budget will be over by at least $600,000. Chris Parker
Patient Care Services Chris Parker suggested dissolving this group and setting up
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.
Advanced Degree
Nursing Council Sharon reported that the council will be changing to include all nurses with Masters degrees. Those working on their Masters will also be invited.
1st meeting is a dinner meeting
on 12/4. Chris Parker to discuss Waiver Test. Sharon will put in the Beacon and send email invitations.
Sharon Stagg
Nursing Research Update Sent out prior to the meeting. Ruth Ann Jones
Nursing Informatics Cut/Copy/Paste: There is a lot more work to be done on
addressing documentation that is carried forward. Jo Anne Thomson
OR Management
Changes 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.
Penny Pink
Magnet Conference This is essentially a five-day work week for those who go to the
conference. Chris Parker approved 40 hours of pay for attendees.
Behavioral Health 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.
Ruth Ann Jones
Bridge/Posting Orders 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.
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.