Nursing Practice Governance

MANUAL FOR

NursingPractice

Governance

Christman, 1976

Autonomy has, as its

basic components,

personal accountability

and shared power and

influence. An autonomous

nursing staff is feasible.

It is professionally exciting.

It cannot be done for nurses; it must be done by them.

2 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE

MANUAL FOR NURSING PRACTICE GOVERNANCEIntroduction

This Manual for Nursing Practice Governance at Rush Oak Park Hospital is underscored by a commitment to our vision, to excellent nursing practice and to

professional accountability for our work environment, patient care delivery and our community as a whole.

Nursing Practice Governance is an activity that autonomous practitioners of the discipline of nursing must be committed to doing on a daily basis and throughout every structure and process that supports care delivery.

Only nursing can evaluate and govern its practice, and as such, must be ready to do so frequently, diligently and with a sober spirit, considering the burden of patient health.

Many of the tools in this manual are sculpted around the ROPH Nursing Professional Practice model.

Nurses in all roles and settings have developed these tools, to guide ROPH nursing practice and to seek to create exemplary patient, staff and environmental outcomes.

— Donabedian, 1976 in American Nurses Association Social Policy Statement, 2010

There is a social contract between society and the profession. Under its terms, society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their own affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality and performance is at the heart of this relationship. It is the authentic hallmark of the mature profession.

3

Rush Oak Park HospitalManual for Nursing Practice Governance PRACTICE IDENTITY

Structures That Guide

WE ARE NPGO

Rush MissionThe mission of Rush is to improve the health of the individuals and

diverse communities we serve through the integration of outstanding patient care, education, research and community partnerships.

Rush VisionRush will be the leading academic health system in the region

and nationally recognized for transforming health care.

Mission & VisionRush System for Health and Rush Oak Park Hospital

Mission, Vision, Strategic Themes & Values

Est. 2012

ROPH Nursing Vision

Rush Oak Park Hospital will be seen as the community medical center of choice in the region and in the nation. As a community of professional nurses, we will lead efforts to advocate patient- and family-focused health promotion

throughout the lifespan. We will be looked to by our community and beyond as a resource center for patient and family health education and support. We seek to scientifically and competitively pursue innovative care that supports

and sustains wellness in the lives of our patients, our community and beyond.

Innovation

Collaboration

Accountability

Respect

Excellence

Values

The Best Quality People

The Best Quality

The Best Programs

Highest Value

Strategic Themes


PRACTICE IDENTITYStructures That Guide

Relationships and Caring

Sens

itivi

ty

Respect

Collaboration

Intentional Presence

Comm

unic

atio

n

CriticalThinking

EvidenceBased

Practice

TechnicalExpertise

Leadership

Foundation of Nursing Professional Practice Model

Relationships and Caring Built on sensitivity, collaboration,intentional presence, communication and respect

Care is patient and family centered: Set meaningful goals with patient and family Diversity of patient background taken into account in

culturally sensitive way Teaching atmosphere with patient and family is constant Awareness of patient and families’ feelings, space and needs Interactions are respectful, therapeutic and trusting Reflected in collaborative relationship with interdisciplinary team and colleagues

Supportive of educational environment Professional relationships extend outside unit to professional organizations, regulatory bodies, Board of Nursing

Looks for opportunities within the nursing team to act as coach, mentor and support

Evidenced-Based Practice Nurses employ science to patient care and environment Strategies are based on successful interventions for given patient population

Procedures, standards and protocols are substantiated by research or best practice by exemplars

Nurses contribute to body of evidence for best practice by questioning interventions and studying alternatives

NPGO provides a structure for evaluation of evidence and dissemination of best practice.

Creation and Translation of knowledge

Technical Expertise Use technology to deliver effective patient care Translate purpose of equipment and medical devices for patient and families Coordinate the medication administration process Coordinate the plan of care through the continuum

Critical Thinking Synthesize information and use reasoned clinical judgment which understands science, assures patient safety, advocates for patient and family, revises plan of care when needed

Inquire and ask clarifying questions Communicate and facilitate understanding among patient and others on the clinical team

Leadership Lead activities that evaluate current practice and stimulate change

Mentor other nurses regarding nursing practice and career development

Coordinate patient services beyond the clinical unit Plan nursing care for a group of patients for a period of time Communicate and advocate for additional resources when necessary to meet patient care needs

Definitions of Domains

T he models on page 4 and 5 are two sides of the same coin — how we practice as nurses and how we deliver

care within the team Rush Oak Park Hospital’s Professional Nursing Practice Model is a picture of our practice identity. Relationships and Caring encircle and support all that we do

as ROPH nurses. Supported by and through this, Technical Expertise, Evidence-Based Practice and Critical Thinking work in synergy to propel us as nurses towards Leadership of the complex healthcare environment to meet the needs of our patients and the environment.

5



WE ARE NPGO

The Nursing and Interprofessional Teams How care is organized within the nursing team

Team Nursing: RN directs and oversees patient care, sometimes including a CNL. Some tasks delegated and performed by patient care technicians or other ancillary staff. (examples: ED, OR, Med Surg Units, CDEC, ROPPG, Skilled, Rehab, Endoscopy(

Total Nursing: RN responsible for giving all care to patient. (examples: ICU, PACU, SDS) Primary Nursing: RNs responsible for care of a given number of patients around the clock

(examples: Wound Care Clinic nurse managed cohorts of patients) How initiatives are developed and implemented through the interprofessional team

Organizational committees (examples: PIPSC, Sepsis, Chest Pain, Stroke, Emergency Management, Environment of Care, etc.)

Caring Occasion: Moral Commitment to protect and enhance human dignity: Every interpersonal contact is viewed as a caring opportunity Ethics committee, Diversity committee, use of Institutional Review Board for research studies to protect patients

Carative Factors: Human Altruistic System of Value Transfer of patients between units, between institutions, between providers and along the continuum is shaped by our Care Delivery process

Focus on the Autonomous Patient: Through meaningful care plan development and management both inpatient and outpatient as well as community work in surrounding areas. Focusing on the pa-tient’s ability to be health literate and independent is supported also by patient education, social determinant screening and intervention as well as health promotion

Transpersonal Caring Relationship: Awareness of self with authentic present of caring How we shape interactions and initiatives within the interprofessional team Organizational and Nursing Code of Conducts

Patient- and Family-Centered Care: How we plan for care coordination within the interprofessional team to make sure the patient is cared for throughout their life, rather than just within our walls

Definitions of Domains

THE NURSING AND INTERPROFESSIONAL TEAMS

CARATIVEFACTORS

HUMAN, ALTRUISTICSYSTEM OF VALUE

CARINGOCCASION

MORAL COMMITMENTTO PROTECT ANDENHANCE HUMAN

DIGNITY

TRANSPERSONALCARING

RELATIONSHIPAWARENESS OF

SELF WITH AUTHENTICPRESENSE OF CARING

PATIENT& FAMILY

CENTEREDCARE

Nursing Care Delivery ModelT he Jean Watson Caring Care Delivery Model (CDM)

has been adopted at ROPH to assist our patients with gaining control, becoming more knowledgeable and thus promoting their health both within our walls and in their home. It is the theoretical foundation for our care delivery system which identifies how work is organized within the nursing team, how nurses are deployed and what each team member’s role is. Supported by the constructs of the Jean

Watson Care Delivery Model, nurses organize the activities of care around the needs and priorities of patients and their families. Delivery of care and how it is organized may differ between care settings, however the components of carative factors, caring occasion, transpersonal caring relationship and patient- and family-centered care drive initiatives through the nursing and interprofessional teams. (Watson, 1979)



Nursing Professional Governance Organization

We Are NPGO

How is NPGO Organized?

Every Nursing Practice Area is RepresentedEXECUTIVE

COMMITTEE REPSGoverns the Operations of NPGO and

Nursing Practice throughout the OrganizationPresident, President Elect, Treasurer, 3 Center, 6West, Rush Oak Park Physician’s Group RNs,

APNs, Cath Lab/IR, CNO/Nursing Adminis-tration, Employee Health, Endoscopy, ED, ICU,

NGF, Dep of Nursing Practice, OR, PACU, Dept. of Clinical Effectiveness, Same Day Sur-gery, Telemetry, Cardiac Rehabilitation, CNLs

and Wound Care Clinic

NPGO STANDING COMMITTEES

Manage the Specific Areas Where Nursing Practice is Sculpted

Peer Review, Evidence-Based Practice and Research, Education, Clinical Practice and

Policy, Staffing Nurse Advisory Board, Awards and Recognition, APN Practice Council,

Population Health, Skin Care, CUSP, Safe Patient Handling and Falls, Nursing

Excellence

NPGO UNIT/DEPARTMENT AREA COMMITTEES

Manage Practice Pertaining to the Patient Populations Cared for in

Specialties Across Nursing3 Center, 6 West, Rush Oak Park Physi-cian’s Group RNs, APNs, Cath Lab/IR, Endoscopy, ED, ICU, NGF, OR, PACU,

Same Day Surgery, Telemetry, Cardiac Rehabilitation and Wound Care Clinic,

CNL Group

NPGOStanding

Committees

NPGOUnit Area

Committees(UACs)

Chief NursingOfficer

NursingAdministrative

Committee

Rush Oak Park HospitalBoard of Directors & President/CEO

NPGOPresident

NPGO ExecutiveCommittee

7



WE ARE NPGO

ROPH Quality StructureEnsuring Parity within Organizational Committee Structure

ROPH Board of Directors

MedicalExecutive

Committee

NursingProfessionalGovernanceExecutive

Committee(NPGO)

PerformanceImprovement &Patient Safety

Council (PIPSC)Chaired by CMO & CNO

Medical StaffCommittees

Peer ReviewMedical

Staff Quality

Health InformationManagement

Pharmacy andTherapeutics

Critical Care

Ethics

Departments/Sections

Quality-BasedCommittees

Pain

Employee Safety

Cultural Diversity

HCAHPS

Code Blue

Products

Core Measure Task Force: Diabetes, Chest Pain,

Stroke and Sepsis

Safe Campus

NPGOCommittees

Peer Review

Nursing Staff Excellenceand Quality Committee

Evidence-BasedPractice/Research

Staff Nurse AdvisoryBoard (SNAB)

Policies and ProceduresEducation Council

Awards and Recognition

Safe Patient Handling and Falls

Population Health

Skin Care

Falls

CUSP



The Nursing Professional Governance Organization's

Mission

Principles

Code of Conduct

Professional RoleOur conduct is professional, respectful,

honest and full of integrity. We take pride in our professional role, in our

institution and our service to the com-munity. Skilled patient care is depen-dent on the healthy relationships with our colleagues and environment. We embrace change and constantly seek

improvement in patient outcomes.

Commitment to Teamwork

We support an environment of team-work and camaraderie. We see every

patient as our collective responsibility. We seek to incorporate the patient and family as well as other disciplines into

our team.

Respect of All VoicesWe support an environment where

every voice is valued, respected and listened to. Respectful personal

expression of diverse opinions is encouraged.

Authentic LeadershipWe demonstrate congruence between

words and actions. We lead from where we stand, remaining committed to pro-moting the health of our patients, their families, our colleagues, our institution

and our community as a whole.

Supportive of Open Environment

We are approachable and willing to participate in both giving and receiving of feedback. We create an environment where ideas are welcomed and encour-aged. We accept the responsibility to

give constructive feedback in a healthy, professional manner, always maintain-ing the other individual’s self-esteem.

Examples of Unhealthy Behaviors

Bullying and or incivility Establishment of cliques designed

to exclude staff Gossiping

Intimidation Passive Aggression

Refusing to give assistance Negative nonverbal behaviors

The Rush Oak Park Hospital Nursing Professional Governance Organization (NPGO) creates an environment supportive of the RUSH ICARE Values, the

Illinois Nurse Practice Act, the Rush Oak Park Nursing Professional Practice Model, the Rush Oak Park Nursing Care Delivery Model, the NPGO Bylaws

as well as components that reflect a Healthy Work Environment. This Code is a guideline for professional behavior for the NPGO with relation to fellow nurse colleagues, patients, families and visitors to our campus, members of the interdisciplinary team, students, our greater community and society as a whole. Our mission is to promote respectful behavior in an environment

free from abuse. We work towards collaborative teamwork that is reflective of professional, accountable and expert nursing care.

9



WE ARE NPGO

Preamble Excerpt

3.1 The purposes of the Nursing Professional Governance Organization are: To provide quality nursing care for patients admitted to or treated in any of the facilities, departments, or services of the Hospital;

3.2 To promote a high level of professional performance among registered professional nurses;

3.3 To define and review professional nursing practice;

3.4 To engage in programs that promote excellence in patient care, education, and scientific investigations;

3.5 To provide a mechanism for effective communication among Nursing Professional Governance Organization members;

3.6 To support collaboration between the Nursing Staff, the Medical Staff, and the Administrative Staff; and community resources (e.g., Emergency Medical Services (EMS), Oak Park Health Department).

3.7 To foster the professional growth of registered professional nurses;

3.8 To promote clinical competence and basic research essential to the advancement of professional knowledge and skill in nursing care;

3.9 To provide a stimulating clinical environment for students of Rush Oak Park Hospital affiliated colleges of nursing.

3.10 To support cooperative arrangements with nursing staff of other health care, research, and educational institutions within the Rush System for Health;

3.11 To establish and maintain regulations of nursing practice consistent with the corporate bylaws of the Institution, its policies and procedures, and rules of governance.

3.12 To provide assessment of needs and subsequent outreach to the community with an emphasis on vulnerable populations. Outreach is defined as provision of education and access to care as well as other needs as identified by NPGO Executive committee and associated committees.

3.13 To encourage nursing presence/voice in national healthcare issues (e.g., professional organizations, publications

Nursing Professional Governance Organization

Bylaws

Purposes Description

NPGO MembershipMembership in the Nursing Professional Governance Organization is extended only to registered professional nurses who are employed by Rush Oak Park Hospital.

As members of the Nursing Professional Governance Organization, we recognize and accept responsibility for

the quality of nursing care, nursing education, clinical nursing research and intentional health outreach to our community at Rush Oak Park Hospital. In assuming this responsibility, we are subject to the ultimate authority of the Rush Oak Park Hospital Board of Trustees. We recognize further that the best interests of patients, and patient care, as well as students and nursing education, are protected by a collaborative and cooperative effort.

We pledge ourselves to the continuing pursuit of excellence in care, education, research, care of the members of our

community and to the articulated goals of Rush Oak Park Hospital and the Rush System for Health. Our commitment is to ensure attainment of these goals through time and effort, with particular involvement in nursing education beyond the expectations required for usual employment. Thus, as professional nurses who have responsibility for nursing care to patients, the clinical environment, the instruction of students, and for maintaining personal interdependence with other health care professionals, we hereby accept membership in the Nursing Professional Governance Organization of Rush Oak Park Hospital and the obligation set forth in these bylaws.



Cross-Walking Structures That Impact Our Identity

As Rush Oak Park Hospital nurses, our identity can be described by our Professional Practice Model. Each of

the five domains describes a different component of our professional practice.

As experts in our field of knowledge, Rush Oak Park Hospital nurses are leaders relative to practice excellence, professional accountability and autonomous practice. This is largely because our identity is supported by relationships and caring, critical thinking, technical expertise and evidence-

based practice while being propelled by transformational leadership in all roles of our nursing structure. We live out these components by: managing our practice at the bedside and various decision-making tables, collaborating within the interdisciplinary team, and making the patient and family the center of our initiatives. See the crosswalk below to understand how our practice model is supported by and works contextually with other key structures in our environment.

Who Are You

Professional Practice Model CrosswalkHow the Professional Practice Model looks in context to other structures

Promote patient- and family-focused health promotion throughout the lifespan

Pursue care that sustains wellness in the lives of our patients, community and beyond

Utilized by our community and beyond as a resource center for patient and family health, education and support

Seen as community medical center of choice in region and in nation

Scientifically and competitively pursue innovative care

CARE DELIVERY MODEL

NPGO BYLAWS & CODE OF CONDUCT

RUSH SYSTEM FOR HEALTH I CARE VALUES

AACN HEALTHY WORK ENVIRONMENTSTANDARDS

ANCC MAGNETMODEL DOMAINS

ROPH NURSINGVISION

PROFESSIONAL PRACTICE MODEL


Critical Thinking

Technical Expertise

Leadership

Evidence-based Practice

The Nursing and Interprofessional teams

Caring Occasion: Moral commitment to protect and enhance human dignity

Carative Factors: Human, altuistic system of value

Transpersonal Caring Relationship: Awareness of self with authentic presence of caring

Patient- and family-centered care

Based on respect for every individual,

Encourages high level collaboration

Demonstrate congruence between words and actions

Foster professional growth of NPGO members

Define and review professional nursing practice

Engage in programs that promote excel-lence in patient care, education and scientific investigations

Promote clinical competence

Responsible and accountable to manage nursing practice

Committed to pursue excellence in care, education and research

Collaboration Respect

Skilled Communication True Collaboration Meaningful Recognition

Exemplary Professional Practice

Structural Empowerment

Innovation Accountability

Appropriate Staffing Effective Decision Making

New Knowledge Innovation and Improvement


Innovation Accountability



Excellence Authentic Leadership

Transformational Leadership


Accountability Effective Decision Making

Effective Decision Making


Empirical Outcomes

11



WE ARE NPGO

The Practice Evaluation CycleThe Professional Practice Model is a picture

of our practice identity as ROPH nurses. Wherever there is a nurse, the 5 domains

of the practice model are driving description of practice, evaluation of practice, recognition

of practice as well as recruitment and retention of our practitioners. All of these activities are done by and for

nurses, with our discipline specific standards, scope and body of knowledge.


Sens

itivi

ty

Respect

Collaboration

Intentional Presence

Commun

icat

ion

CriticalThinking

EvidenceBased

Practice

TechnicalExpertise

Leadership

THE PROFESSIONAL PRACTICE MODEL

DESCRIBES OUR PRACTICE:Every RN, in every role at ROPH has 5 domains of

the Professional Practice Model in their job descriptions.Competency statements reflect our practice model

and propel our practice from every specialtyrole to have maximum impact.

Job Descriptions


EVALUATES AND DEVELOPSOUR PRACTICE:

Wherever there is a RN at ROPH, another RNevaluates their practice. Because nursing is a disciplinespecific to itself, only nurses can and should evaluate

the practice of other nurses.

Orientation of New Graduate NursesPerformance Evaluation

Peer EvaluationMid-Year Evaluation

Shared Governance Practice Imrovement ProjectsAPRN Credentialing and Priviledging

NPGO Peer Review Committee


RECRUITS AND RETAINSEXCELLENT PRACTITIONERS:

The domains of our professional practice model guideinteractions and initiatives aimed at bringing high quality

practitioners to our campus and supporting theirprofessional development throughout their career at ROPH.

Hiring and Interview Process for RNsNew Graduate Nurse Support Program

Exit Interview ProcessStructural Empowerment Policy

Leadership Development Program


RECOGNIZES EXCELLENTPRACTICE:

Nurses elected from their specialty areas utilizethe Professional Practice Model to recognize

excellent practice.

Clinical AdvancementOngoing Maintenance of RN 3 Status

Awards


MEANINGFUL PROCESSES TO GUIDE PRACTICEPractice Tools

P = Problem I = InterventionC = ComparisonO = Outcome

STUDYANALYZINGWHAT WORKS

DOPLANGENERATION OFA GOOD IDEA

SMALL TESTOF CHANGE

ACTADJUST ANDDO AGAIN

FOCUS-PDSA

F = Find a process to improveO = Organize a team that knows the processC = Clarify current knowledge of the processU = Understand the causes of process variationS = Select the process improvement

P = Plan data collection and improvementsD = Do; Implement the action planS = Study data; analyze if process improvement workedA = Act to hold gains or re-evaluate action plans

YES

NO

QI PROCESS

GOALS MET?

NO EVIDENCEEVIDENCE

EVIDENCE-BASEDPRACTICE RESEARCH

STRUCTURE PROCESS OUTCOMEParts of a care system or elements that facilitate care or the environment of care:

Resources Equipment Numbers of Staff Qualifications/cre-dentials of staff

Work space or allo-cation

Required medical record content

Policies

The procedures, methods, means, or sequence of steps for providing or delivering care and producing outcomes.

CLINICAL PROCESSESWhat practitioners do for patients and what patients do in response, such as:

Assessments Treatment Planning Medication Administration Education Discharge Planning

CARE DELIVERY PROCESSESThe support activities utilized by practitioners and all suppliers of care and care products to get the product to the patient:

Services, such as: registration, room cleaning, transport, lab

Systems, such as: medication dispensation, equipment delivery

ADMINISTRATIVE AND MANAGEMENT PROCESSES:

Activities performed in the gover-nance and management systems of the organization

The results of care, ad-verse or beneficial, as well as gradients between; the product of one or more processes

Clinical: Results of treat-ments and procedures, complications, adverse events, mortality

Functional: ADLs, patient progress toward meeting goals

Perceived: Patient/fam-ily satisfaction, patient level of understanding, peer acceptability

Performance Improvement Model and Evidence Based Practice Guidelines

Definition

Process

Structure

Outcome

Examples

RESEARCHEVIDENCE BASEDPRACTICE (EBP)

QUALITY IMPROVEMENT (QI)

Applies a methodology to generate new knowledge or validate existing knowl-edge based on a theory

Translates best clinical evidence from research to make patient care decisions

Systematic, data-driven, evalu-ation of processes of care and clinical outcomes based on EBP and research

Process of systematic, scientific inquiry, rigorous methodology to answer a research question and test a hypothesis

Process begins with a question that may be founded from a problem or knowledge gap

Literature review of EBP and Research to guide and support process improvement strategies

Process begins with a question and systemat-ic review of literature, including critical appraisal, to identify knowledge gaps

Practice guidelines may include clinical expertise and knowledge gained through experience

Systematic method for improving processes and outcomes within an organization based on phi-losophy of continuous quality improvement

Rapid Cycle Process: Plan, Do, Study, Act

Reduce the number of patients who develop pressure ulcers while in the hospital

Measurable variables to describe, explain, predict, develop meaning, dis-covery, or understanding about a phenomenon

Providing adequate nutrition and supplements to hospitalized older adults is a clinical factor that reduces the likelihood of developing a pressure ulcer

Systematic review of lit-erature, including critical appraisal, to find the best available evidence and whether the evidence sup-ports practice change

Assess risk for pressure ulcer development using the Braden Scale

Relationships Among QI, EBP & Research

13

Rush Oak Park HospitalManual for Nursing Practice Governance MEANINGFUL PROCESSES TO GUIDE PRACTICE

Practice Tools

WE ARE NPGO

DMS ELEMENT CHARACTERISTICS

Daily Readiness Huddles with Problem Escalation

Success Metrics

Improvement Ideas

Flow and Adjust

Standard Work with Confirmation

Everything in place for a successful shift/day… if not, fix immediately or escalate

Understanding organizational metrics and aligning departmental improvement work

Everyone’s problem-solving creativity and capacity is fully utilized

Ensuring that the important work flows smoothly through the department or unit

Everyone follows the “one current/best way” to perform critical processes – helps build “Right the first time” mindset

Continuous Pursuit of Excellence Lean Program

Continuous Pursuit of Excellence (CPE) is our philosophy and system to organize and improve our work everyday, in every role and in

every setting. Rush Oak Park Hospital does this because we must respond to the significant challenges facing health care in the US. CPE can only be accomplished by leveraging the problem solving power of all our employees. One of the goals of CPE is to increase value as defined by quality versus cost. CPE enables these three pillars to be successful: methods, management and mindset.

Methods Performance Improvement Methodologies Six Sigma, Rush Way, Lean

Individual Tools PDSA, Fishbone, 5 Whys, Spaghetti Diagram, Value Stream Analysis, Root Cause Analysis, A3

Management Strategy Deployment To focus the organization on a critical few breakthrough objectives

Cross-Functional Management To organize and manage across functional silos for the benefit of the customer

Daily Management System (DMS) To support the work of the front-line resulting in reliable process performance and continuous improvement

Mindset Traditional Management

Leader directs work

Leader produces metrics and feeds back when not met

Leader is assignor of work

Team meets goals set by leader

Rigid enforcer of rules and regulations

Information controller

Technical expert

Servant Leadership Leader sets directions with humility

Team produces metrics and defines actions to close gaps

Leader teaches/coaches

Team sets/meets goals aligned with true north

Self directed teams based on expectations

Information conduit

Facilitates root cause analysis

CPE & DMS Principles

DMS Levels and Purpose

Patient as Customer

Escalate Issues

Design Work to

Surface & Fix Problems

Make Things Visual

Respect & Use

Everyone’s Talents

Workon the

Critical: Few

Visual Management: Problem Solving, Focus on the Customer, Lean Leadership

DMS is a system that delivers more than the sum of all levels.

Flipping the Pyramid



Just Culture AlgorithmThe Just Culture algorithm is intended as an aid to help determine system failures, individual accountabilities and corrective action

following a Safety Event.

This algorithm may not apply in all cases and is not intended to restrict the Medical Center’s rights to manage, to alter existing employment relationshios or to supercede existing policies and procedures.

Larsen D, et al. Nursing Standard. 2007; 21(48):35-40NHS Incident Decision Tree National Patient Safety Agency 2003ADAPTED FROM

Deliberate Harm Test

Impairment Test

Foresight Test

Substitution Test

STARTHERE

Were the actions deliberate?

Were adverse consequences

intended?

Were there significant mitigating

circumstances?

Pattern of unsafe or

problematicacts?

Corrective action is warranted, consult

with HR. If malicious action, duties should

be suspended pending investigation.

A

The individual is accountable and

needs retraining or support. Corrective action or EAP may

be warranted.

B

Individual is accountable and needs coaching or retraining. Corrective action may be warranted. Individ-ual may participate in teaching others les-

sons learned. Address system issues.

C

Individual is accountable and needs coaching.

Individual may participate in teaching others lessons learned. Address system issues.

D

The system supports error.System’s leaders are accountable and should ensure safety solutions are implemented. Individual should be consoled.

E

YES

Is there evidence of illness, substance abuse or known

medical condition contributed to the behavioral choice?

YES

YES

YESYES

YES

YES

YES

YES YES YES YES

YES

Did the individual

depart from established protocols, policies or safe proce-

dures?

Were the pro-tocols, policies and safe proce-dures available, workable, intel-ligible, correct and in routine

use?

Were there any deficiencies in training,

experience or supervision?


circumstances?

Is there evidence that the

individual took an

unaccept-able risk?


circum-stances?

Pattern of disre-garding policy or pro-

cesses?

NO

Would another individual coming from the same pro-fessional group, possessing comparable qualifications and experience behave in the same way in similar

circumstances?

Consider

Mitigating Factors

including intention of

employee, motivation, what

information was available,

speed at which decisions

were required, degree

of awareness of risk and

self-reporting.

!

NO

NO

NO

NO

NO NO NO

NONONO

NO

NO

15


Practice Tools

WE ARE NPGO V.3 ROPH Nursing Practice and Peer Review, Corrective Action, and Appeals process. Approved by NPGO Executive Committee, December 2020.

NPGO Peer Review, Corrective Action and Appeals Process

Annual Practice Evaluation with associated Performance Improvement Action Plan (rated

2 or below) with final decision for rating on evaluation.

Reject for lack of

merit and communicate with sender

If clear lack of nursing practice adherence and no trend noted, review with UD/

Employee via corrective action

process and communicate with

sender

NPGO Peer Review conducts

full review and renders recom-

mendation:Exemplary Recog-nition Letter Sent

to Inform Em-ployee of Review,

Manager, CNO and NPGO Pres CC’d, placed in

file/portfolio

NPGO Peer Review conducts full

review and renders recommendation:Informational and

Professional Devel-opment Letter Sent to Inform Employee of Review, Manager,

CNO and NPGO Pres. CC’d, placed

in file

NPGO Peer Re-view conducts full review and renders recom-

mendation:Final Letter of Determination, showing if cor-rective action

process or other professional development activity is set to elicit more information

from employee and/or manager,

CC’ing CNO and NPGO Pres,

placed in file

NPGO Peer Review has seen more than one instance requiring

informational, educational,

action planning, inquiry or

final deter-mination letters on an individ-ual nurse, requiring additional

consideration, review,

consultation

If lack of clarity exists, potential for trend exists

and there is need for peer exper-tise to evaluate, send to NPGO

Peer Review for evaluation and

recommendation consultation and

communicate with sender

Review for annual practice privilege, clear lack of nursing

practice adhered and no trend

noted, review with UD for appro-priate action

planning

CNO and NPGO President review all quality memos, identifying what pathway for further review to follow - using all mechanisms

listed herein and tracking all that come with outcomes elicited

If deemed HR Issue follow HR process

If Staff Appeals:

Follow HR Fair Treatment

Process

If practice related, UD can:

1. Reject for lack of merit,

2. Confer with practitioner,

3. Request UAC review and,

4. Render final determination based on UAC

review.

Corrective action may be requested by any

RN at any time: General accountability for practice by any RN/

APN (Bylaws 6)

Accountability Pathway

Appeal within 14 calendar days to CNO or NPGO President

President Reviews with NPGO Executive Committee and creates

recommendation Recommendation reviewed

by CNO and NPGO President, considering evidence and making

final non reviewable decision

Staff Appeals Process

Practice Review PathwayAdditional RN/APN Practice

Review Mechanisms(Organizational Performance

Improvement Initiative/Taskforce with findings related to Nursing Practice

Safety Event with Findings Related to Nursing Practice

NPGO Executive Committee or other NPGO Committee Request for Review

of Nursing Practice Trend

Annual Review Pathway

RN/APN Annual Review Process and Nursing

Practice Privilege ReviewBylaws 4.4-2 and 5

Complete Nursing Practice Form and Submit to Unit

Director

Complete Nursing Practice Form and submit to CNO/NPGO President for review, tracking and support

Staff Appeals: Follow Above Process

NPGO Peer Review

conducts full review

and renders recommen-

dation: Educational Letter Sent to Inform Employee of Review, Manager, CNO and

NPGO Pres CC’d, placed

in file

NPGO Peer Review

conducts full review and

renders rec-ommendation:

Letter of Inquiry is

sent to elicit more infor-mation from

employee and/or manager, CC’ing CNO and NPGO

Pres, placed in file

NPGO Peer Review

conducts full review

and renders recommen-

dation:Action Plan Letter Set to Inform Employee of Review, Manager, CNO and

NPGO Pres CC’d, placed

in file



Portfolio DevelopmentHere are some examples of documents you might use to fulfill the

requirements for the different categories in the clinical advancement process.

SECTION 1

Introduction & Professional Overview

SECTION3

Critical Thinking

CV/Resume

Letter of Intent to Advance

Copy of current level of education and proof of enrolled continuing education

Proof of Certification

Other items listed in professional overview section of clinical advancement requirements

Any Continuing Education Proof, Credits Earned, Topics, Content Utilized on Unit

Any Preceptor or Charge Workshops attended, as well as other workshops- EKG, ACLS, etc.

Proof of “Super user” or “Expert” Status on unit- skin, palliative care, Epic, etc.

Performance evaluation and Peer Review

Required exemplars and documents from clinical advancement process

Your Projects and any future EBP projects that you do with references and slides and outcomes

Your involvement in development or revision of any nursing standards of practice or care and any related education or presentation

Use of EBP to drive unit quality improvement or nursing practice projects- with examples


Active engagement in charge or preceptor role and proof of such

Involvement in unit committees, care rounds, Unit/Clinic Advisory Committee, Department Advisory Committee, NPGO Standing Committees or other institutional groups

Involvement in Professional Organizations and proof of information sharing to unit from such

Any innovations to unit not listed in projects as above, especially those that denote leading of staff from unit towards new practices, communication techniques, teambuilding exercises, recognition practices


Extras…Any articles you have written, membership listings, things not listed above

Letters of recommendation from colleagues, patients, families, preceptors, faculty

Stories of Interactions within Care Delivery team of advocacy and compassion

Award nominations describing your interactions with others

Any involvement within the community or volunteer experience utilizing nursing expertise


Stories of complex patient situations, expert assessment skills

Development of Education- Inservices, Bulletin Boards, Journal Clubs to assist fellow staff and students in critical thinking and problem solving

Involvement in Quality Improvement Projects/Audits


Development of Portfolio begins when you get your license and continues throughout your career.

Present in Formal Presentation Binder

Keep in mind- moving up the ladder means that you are already showing some evidence of proficiency at the level that you wish to move to.

Use your Annual Performance Evaluation Journal to daily track your caring and professional stories

When presenting patient stories, please be careful to not describe any patient identifiers, which would violate HIPAA.

TIPS BEFORE YOU BEGIN

Designing Your Portfolio

SECTION 2


SECTION 4

Technical Expertise

SECTION 5

Evidence-Based Practice

SECTION 6

Leadership

SECTION 7

References

17


Practice Tools

WE ARE NPGO

Clinical Advancement RN1 to RN2

CV/Resume Letter of Intent Letter of Support from UD CE credits earned BLS- submit copy of card ACLS (unit-based)- submit copy of card* PALS (ER only)- submit copy of card New Grad Residency 12 month attendance proof Attend Preceptor Workshop Attend Charge Nurse Workshop*

* Not required for ambulatory RNs

In the following section mark any of the examples provided or add others in the blank spaces. An example from each competency in each domain is the minimal expectation to move to a level RN2. (Unless otherwise specified)

Proficiency in each can be demonstrated in one or more of the following ways (unless specified within the individual section):

Exemplar Official Document Letter from Patient, Peer colleague, Supervisor, Physician, etc.

Portfolio Review and Leveling: Level RN1 to Level RN2

Demonstrated proficiency in all of the below areas required:

I have signed and have been able to meet the expectations defined in the code of conduct.

I am able to coach as-sistive personnel while maintaining an effective relationship.

I am capable of collabo-rative interaction within my care delivery team.

I Participate in conflict resolution that enhanc-es team relationship. (provide example)

I have and show respect and sensitivity toward diverse cultures and/or vulnerable populations.


I have developed and(or used evidence-based research for patient care.


I provide effective patient education.

I am able and willing to help my co-workers while still completing my own work.

I use ROPH policies in care decisions.

Approval checklist letter from UAC


I adapt care plans to meet changing needs of patients. (Submit a screen shot of a care plan.)


I am a Committee(Council member who attends my meetings regularly. (Provide evi-dence of attendance)

I participate in conflict resolution during pa-tient care and/or within my team.

I am able to delegate responsibilities effec-tively and consistently.

Describe how you are making progress toward your annual goals.

Proof must be provided for the elements in each columnProfessional Practice Model Domain

Professional Overview (Required) Domains of Practice

CRITICAL THINKING

EVIDENCE-BASED PRACTICE LEADERSHIP

TECHNICAL EXPERTISE

RELATIONSHIPS AND CARING



Clinical Advancement RN2 to RN3

CV/Resume Letter of Intent Letter of Support from UD CE credits earned BLS- submit copy of card ACLS (unit-based)- submit copy of card* PALS (ER only)- submit copy of card Attend Preceptor Workshop Attend Charge Nurse Workshop*


In the following section mark any of the examples provided or add others in the blank spaces. An example from each competency in each domain is the minimal expectation to move to a level RN3. (Unless otherwise specified)

Proficiency in each section can be demonstrated in one or more of the following ways:(unless specified within the individual section)

Exemplar Official Document Letter from Patient, Peer colleague, Supervisor, Physician, etc.

Portfolio Review and Leveling: Level RN2 to Level RN3


I have signed and have been able to meet the expectations defined in the code of conduct.

I am able to maintain coaching of assistive per-sonnel while maintaining an effective relationship.

I am capable of collabo-rative interaction within my care delivery team.

I participate in commu-nity or volunteer experi-ence through ROPH.

I have and show respect and sensitivity for diverse cultures and/or vulnerable populations.

I serve as role model for interpersonal communication.

Demonstrated proficien-cy in one or more of the below areas required:

Poster/podium pre-sentation – internal or external

EBP, QI or research project team member or leader

Policy or standards development/revision

Manuscript/abstract submission and/or publication

ROPH Grand Rounds presentation

Unit or Hospital-based Evidence-Based Project

Literature Review


I provide effective pa-tient education.

I am able and willing to help my co-workers while still completing my own work.

I use ROPH policies in my patient care deci-sions.

I am a “Super-User” or Unit Expert in some clinical area.



I adapt care plans to meet changing needs of patients. (submit a screen shot of a care plan.)

I have participated in the development of ed-ucational materials. (eg, bulletin boards, in-ser-vices, journal club)

I have been a PI/QI proj-ect team member.

I support less experi-enced staff in man-agement and review of complex patient situa-tions in order to identify practical solutions.


I am a committee/council member who attends my meetings regularly. (provide evidence of attendance)

I lead in conflict resolu-tion that enhances team relationship.

I am able to delegate re-sponsibilities effectively and consistently.

Describe how you are making progress toward your annual goals.

I am a member in a profes-sional organization. (submit copy of membership card)

I function as a regular charge nurse or preceptor. (for either staff or students)

I am/have been part of a Unit-based/hospital inno-vation. (eg., teambuilding, recognition, new practices)


CRITICAL THINKING


TECHNICAL EXPERTISE


Specialty certification as determined by your UAC is required within one year after leveling to RN3. If you transition to another specialty area, in order to maintain RN3 status, you must take the new area’s approved certification within 1 year of elibility to maintain RN3 status.

Certification


19


Practice Tools

WE ARE NPGO

Maintenance of RN3 Status

CV/Resume Letter of Intent-What you’ve done in the past year and what you plan to do in the upcoming year.

Letter of Support from UD CE credits earned BLS- submit copy of card ACLS (unit-based)- submit copy of card* PALS (ER only)- submit copy of card Attend Preceptor Workshop Attend Charge Nurse Workshop* Letter of approval and/or suggestions from prior portfolio submission


In the following section mark any of the examples provided or add others in the blank spaces. An example from each area is the minimal expectation to maintain a level III RN. (Unless otherwise specified)Proficiency in each section can be demonstrated in one or more of the following ways: (unless specified within the individual section)

Exemplar Official Document Letter from Patient, Peer colleague, Supervisor, Physician, etc. The examples must be current and from the past fiscal year.

Portfolio Review and Leveling: RN3 Maintenance


Meet the expectations defined in the code of conduct.

I participate in commu-nity or volunteer experi-ence through ROPH.

I have and show respect and sensitivity for diverse cultures and/or vulnerable populations.

Letter from a colleague or member of the interdisciplinary team displaying how you em-body relationships and caring in the workplace.

Demonstrated proficien-cy in two or more of the below areas required:

Poster/podium pre-sentation – internal or external

EBP, QI or research project team member or leader

Policy or standards development/revision

Manuscript/abstract submission and/or pub-lication

ROPH Grand Rounds presentation

Unit or Hospital-based Evidence-Based Project

Literature Review


I am a “Super-User” or Unit Expert in some clinical area.


20 CEU’s per year


I have participated in the development of ed-ucational materials. (eg, bulletin boards, in-ser-vices, journal club)

I support less experi-enced staff in man-agement and review of complex patient situa-tions in order to identify practical solutions.


I am a committee/council member who attends my meetings regularly (provide evidence of attendance) and active involvement.

I am a current member in a professional organi-zation. (Submit copy of membership card.)

I function as a regular charge nurse or precep-tor. (for either staff or students.)

I am/have been part of a Unit-based/hospital innovation. (eg., team-building, recognition, new practices.)


CRITICAL THINKING


TECHNICAL EXPERTISE


Specialty certification as determined by your UAC is required within one year after leveling to RN3. If you transition to another specialty area, in order to maintain RN3 status, you must take the new area’s approved certification within 1 year of elibility to maintain RN3 status.

Certification




Structural Empowerment PolicyRush Oak Park Hospital is committed to actively seeking

nursing input in organizational decisions when possible. The Department of Patient Care Services is committed to empower the Professional Nursing Staff by providing opportunities for exemplary professional practice and development; opportunities to increase in professional knowledge, skills, innovations, and improvements; participation

in transformational leadership with the ability to access and mobilize resources in order to meet organizational goals, access information and support in order to practice nursing and enhance the effectiveness of work; and outreach for community healthcare. ROPH nurses will support organizational goals, advance the nursing profession, and enhance their professional development by extending their influence to professional and

The ROPH nursing organization will be a flat structure to minimize layers between the Chief Nursing Officer (CNO) and front-line nursing staff. To achieve this flatted structure, the roles of unit manager and director will be combined, when possible. The CNO will oversee nursing practice in all areas of the organization regardless of direct reporting structures.

A decentralized structure for empowering the professional nursing staff in all areas of ROPH is:

The Nursing Professional Governance Organization Executive Council The Unit Advisory Councils on each nursing unit Nursing representatives on corporate quality and management councils that

provide feedback that channels to hospital administration and ultimately the ROPH Board of DirectorsThe structure promotes the multidirectional flow of information and decision-

making among front-line nurses, leadership, interprofessional teams, and the CNO. The CNO serves on the highest-level decision-making bodies; resource to the ROPH Board of Directors, the ROPH Executive Senior Leadership, Management Team, Patient Care Services Leadership Council, and Nursing Professional Governance (NPGO) Executive Council. The CNO will participate in Rush corporate Nursing Strategic Planning and initiatives in both the university and the medical center.

The CNO will participate in the development of the mission, vision, values, nursing practice model, and nursing care model and will be responsible for alignment of strategic objectives and goals.

Nurse leaders throughout the organization will serve on ROPH corporate committees that develop and evaluate organizational activities related to quality & safety, finance, staffing, and rewards: Nursing Peer Review, Staff Nursing Advisory Board (SNAB), Performance Improvement Coordinating Committee (PICC), NPGO Executive Committee, Infection Control task forces, Skin Care Committee, Patient Satisfaction task forces, Evidence-based Clinical Practice Committee, Policy and Procedure Committee, Retention and Recruitment Committee, Pain Management Committee, Fall Reduction Committee, Employee Recognition, UACs, and other goal-specific committees. The purpose is to address excellence in patient care and the safe, efficient, and effective operation of the organization. Innovation will be encouraged through idea generation and approval to trial new approaches with a culture of collaboration and cooperation.

It is the role responsibility of each nurse leader and any committee member to represent and communicate back to those nurses being represented. Improved communication to the nursing staff may be through multiple avenues such as staff meetings, bulletin boards, newsletters and e-mails.

The CNO and Nurse Leaders will support a lifelong learning culture that includes professional collaboration, promotion of role development, academic achievement, and career advancement.

Internal inservices will be based on a needs assessment from staff input and regulatory requirements.

Nursing education for nursing staff and support staff is promoted through the availability of tuition reimbursement.

A BSN will be the minimum level of nursing education for incoming nurses with the following exceptions.

The formalized interview process for nursing positions will seek candidates that meet the mission, vision, and values of the organization and demonstrate attributes of self-efficacy to promote the nursing philosophy and vision.

Whenever possible, ROPH will promote from within and provide the necessary orientation and structure as well as direct support to make promotion successful.

ROPH will be committed to supporting clinical rotations of area nursing university programs.

Nurse Leaders functioning as quality preceptors are recognized in the Nursing Levels of Practice.

Participation in professional organizations is encouraged.

Nursing Grand Rounds will be held to expand nursing knowledge.

Abstracts for poster and/or podium presentations at professional events will be encouraged within the budgetary confines to support attendance or based on the individual’s willingness to pay all or a portion of the trip.

Professional publications will be evidence-based or research-based to support clinical practice.

An Annual Report for nursing will highlight the recent activities and accomplishments of nursing with their colleagues.

Nursing partnerships with the community will be encouraged to promote patient outcomes and advance the health of the five communities of Oak Park, Forest Park, River Forest, Elwood Park, and Riverside as determined by the highest volume of served patients by zip codes. Nurses will be recognized for community service

at least annually in the performance review process, and may also be recognized through other recognition initiatives (e.g., Daisy, Shout Out, Thank You notes) since these efforts enhance and support the value and image of nursing in this venue.

Above is an abbreviated version of the Structural Empowerment Policy, please visit the Rush intranet to review full policy.

Organizational Structure

Professional Development

Community Commitment

21

Rush Oak Park HospitalManual for Nursing Practice Governance PROFESSIONAL DEVELOPMENT RESOURCES

Practice Tools

WE ARE NPGO

Leadership DevelopmentLeadership Development, Mentorship & Succession Planning Program

Professional Practice Shared Governance

Transparency


Team Building

Negotiation

Sources of Power and Empowerment

Adapting to Change

Environmental Factors

Meaningful Recognition

Manager as Nurse Retention Officer

Staff Management Labor-Management Relations

Employee Motivation

Hiring and Privilege Approval

Collective Bargaining

Performance Evaluation

Performance Management

Scheduling/Staffing

Agency Agreements and Management

Job Description Development

Program Evaluation & Research Program Evaluation

Data analysis

Research

Project Planning

Dissemination of Information

Utilizing EBP in Practice

Policy Review and Development

Knowledge Translation

Dissemination of Evidence Based Practices or New Knowledge

Legal & Regulatory Issues Federal Laws and Regulations

State Programs

Accreditation and Credentialing

Contracts and Agreements

Healthcare Economics Budget planning and reporting

Technology and Information Systems

Budget Planning and Reporting

Measuring productivity

Reimbursement

Cost Containment

Marketing

Ordering Supplies

Change Management

Professionalism & Ethics Moral Theories and Ethical Principles

Ethical Foundations of Corporate Decision Making

Business and Healthcare Problems

Ethics Committees/Issues

Compliance

Confidentiality

Assessing Safety & Risk Continuous Quality Improvement

Interpreting Data

Professional and Institutional Liability: UOs, Risk Management

Important Metrics to Follow

How to Develop Goals and Metrics

FEMA

Emergency Preparedness

Incident Command Process

Case Management

Bed Management

Leadership & Management Leadership Theories

Governance

Organization and Structure

Mission and Philosophy

Planning Continuum

Strategic Planning

Contingency Planning

Innovation

Healthcare Environment Practice Environment

Institutional Environment

External Environment

Physical Environment

Educational Institutions

Professional Growth Planning a Career Trajectory

Professional Roles, Organiza-tions and Presentations

Emergence as a Leader

Mentorship and Growth of Others

Succession Planning

Communication Transparency

Conflict and Conflict Resolution

Negotiation

Effective Use of Electronic Communication

Building Consensus

Professional Practice Model DomainCRITICAL THINKING


TECHNICAL EXPERTISE


ProgramROPH Nursing Leadership

Development Mentorship Program

WhoAll new managers, leaders and

any RN or APN that requests

Program StartInitiated between leader and

designated or chosen facilitator, with timeline tailored to individual

Check out pages 22 & 23 to review full Leadership

Development, Mentorship & Succession Planning Program Checklist

Mary Parker Follett, The Creative Experience, 1924

Leadership is not defined by the exercise of power but by the capacity to increase the sense of power among those led. The most essential

work of the leader is to create more leaders.

DMS

Setting Goals

Process Improvement

Collecting/ Interpreting Data

Schedule

Payroll

Budget

HR functions (hiring, link, FMLA etc.)

How the pager works

Google Docs

Performance Evaluations

Intro to Outlook


PROFESSIONAL DEVELOPMENT RESOURCESPractice Tools

Leadership Development, Mentorship & Succession Planning Program

This tool works as an adjunct to the overall ROPH Nursing LDMS Program Checklist to guide timeline, tactics and details relative to each unit and employee’s specific needs. It is sculpted in the domains of the American Organization of Nurse Leaders Nurse Executive Competencies and should guide active mentorship, succession planning, transition to practice and developmental activities between a new or aspiring leader and their primary manager or mentor.

Operational Task Checklist

Overview

Who does what

Getting to know staff and culture

Diversity and inclusion

How does every-thing fit together

Regulatory stuff

Building Collabora-tive relationships

Intro to Shared Governance

Process

Fair Treatment

AEP

Just Culture

Prioritization

LSW

Dealing with the politics & managing up

Interacting with the community

Strategic Planning

Facilitator:

Start Date:

Targeted Completion Date:

Mentee Name:

1x per week for first month

1x every other week for second and third month

TIMETABLE

STEP 1Organizational/

Unit Assessment & Orientation

STEP 2Functions

& Processes

STEP 3Intro to

Corrective Action

STEP 4Leader

Standard Work

STEP 5Quality

Improvement, CPE

STEP 6Advanced

Leadership Skills

WEEK 1 Unit/Organizational Assessment and OrientationHow do I contact people?Phone and email lists

Regulation

Policies

TJC Guidelines, IDPH regulations, unit-specific: Sexual Assault ER, Long-term Care, SCU

How to locate policies, Unit-specific, Review expectations

Intro to Shared GovernanceMeet with NPGO President and Magnet Coordinator

Current Unit MetricsWhat are they? Where do I find them?

Roles/Responsibilities/Opinions Building Collaborative RelationshipsSharing your goals/hopes for unit, going right, needs improve-ment, leadership style and role, meet with the CEO, all VPs, all Directors and Physicians

Getting to know staff & cultureHR Diversity and Culture training course10-minute meeting with each staff member What is going right? What would be the biggest improvement? What is most helpful to you in a leader?

How does everything fit together?Study Org chart, bring any questions to mentor

23


Practice Tools

WE ARE NPGO

WEEK 3 Introduction to Corrective Action

ROPH Process Employee Assistance Program

Fair Treatment Just Culture

WEEK 2 Functions and Processes

Unit Processes Other

HR Functions

Schedule, Payroll, Budget How the pager worksIntroduction to OutlookGoogle Docs (scheduling, record keeping, etc.)

Hiring Process, Navigating Link, FMLA, Performance Evals

WEEK 3 Leader Standard Work

Concept of LSW Prioritization StrategiesPower Point, Article, Sample Forms, Interview other leaders, Create

WEEK 5-ONGOING Advanced Leadership SkillsDealing with the Politics & Managing Up Strategic Planning

Interacting With the Community

https://skillpath.com/search

WEEK 4 Quality Improvement, Continuous Process ImprovementDMS Process Improvement Process

Setting Unit & Personal Goals Collecting & Interpreting Data

Read LEAN book, Meet with CPE coordinator CPE Coordinator, Quality Department

CPE Coordinator CPE Coordinator, Quality Department



Leadership Development, Mentorship & Succession Planning Program

The Rush Oak Park Hospital Leadership Development, Mentorship and Succession Planning Program is meant to support both interested nurses or APNs in all roles of nursing or their managers toward professional advancement. Nurses and APNs can express interest to the office of the CNO or their manager for program onboarding, mentorship connection and succession planning, via internal or external mechanisms. Development, mentorship and succession planning activities will take into account the individual’s strengths, weaknesses, professional goals and be tailored to the individual with the eventual achievement of agreed upon professional journey benchmarks. Rush Oak Park H

ospital believes leadership development, mentorship and succession planning is a result of healthy structural empowerment and that developing leaders is an imperative for

Needs Assessment & Checklist

RELATIONSHIPS AND CARING RELATIONSHIPS AND CARING

GOALS AND PROCESS

Professional PracticeONGOING ONGOING

ONGOING

ONGOING ONGOING

ONGOING

ONGOING ONGOING

ONGOING

ONGOING ONGOING

ONGOING

ONGOING ONGOING

ONGOING

ONGOING ONGOING

ONGOING

ONGOING ONGOING

ONGOING

ONGOING ONGOING

ONGOING

ONGOING ONGOING

ONGOING

ACHIEVED ACHIEVED

ACHIEVED

ACHIEVED ACHIEVED

ACHIEVED

ACHIEVED ACHIEVED

ACHIEVED

ACHIEVED ACHIEVED

ACHIEVED

ACHIEVED ACHIEVED

ACHIEVED

ACHIEVED ACHIEVED

ACHIEVED

ACHIEVED ACHIEVED

ACHIEVED

ACHIEVED ACHIEVED

ACHIEVED

ACHIEVED ACHIEVED

ACHIEVED

Shared Governance Labor-Management Relations

Program Evaluation

Sources of Power and Empowerment

Performance Evaluation

Dissemination of Information

Structural Empowerment Hiring and PriviledgeApproval

Research

Environmental Factors Scheduling/Staffing

Policy Review and Development

Transparency Employee Motivation

Data Analysis

Adapting to Change Performance Management

Utilizing EBP in Practice

Team Building Collective Bargaining

Project Planning

Meaningful Recognition Agency Agreementsand Management

Knowledge TranslationManager as Nurse Retention Officer

Job Description Development

Dissemination of Evidence Based Practices or New Knowledge

Staff ManagementEVIDENCED BASED PRACTICE

Program Evaluation and Research

Facilitator:

Start Date:

Targeted Completion Date:

Mentee Name:

25


Practice Tools

GOALS AND PROCESS

ONGOING

ONGOING

ONGOING

ONGOING

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

Federal Lawsand Regulations

Accredidation andCredentialing

State Programs

Contracts and Agreements

TECHNICAL EXPERTISE

Legal

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

Budget Planningand Reporting

Budget Planningand Reporting

Cost Containment

Change Management

Technology andInformation Systems

Reimbursement

Ordering Supplies

Measuring Productivity

Marketing

TECHNICAL EXPERTISE

Healthcare Economics

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

Moral Theories and Ethical Principles

Business and Healthcare Problems

Confidentiality

Ethical Foundations of Corporate Decision Making

Compliance

Ethics Committees/Issues

CRITICAL THINKING

Professionalism and Ethics

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

Leadership and Management

Governance

Planning Continuum

Innovation

Leadership Theories

Mission and Philosophy

Contingency Planning

Organization and Structure

Strategic Planning

LEADERSHIP

Leadership and Management

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

Practice Environment

External Environment

Institutional Environment

Educational Institutions

Physical Environment

LEADERSHIP

Healthcare Environment

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

Planning a Career Trajectory

Emergence as a Leader

Professional Roles, Organiza-tions and Presentations

Succession Planning

Mentorship and Growth of others

LEADERSHIP

Professional Growth

ONGOING

ONGOING

ONGOING

ONGOING

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

Transparency

Negotiation

Conflict and Conflict Resolution

Effective Use of Electronic Communication

LEADERSHIP

Communication

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ONGOING

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

ACHIEVED

Continuous Quality Improvement

Professional and Institutional Liability

FEMA

Bed Management

Interpreting Data

How to DevelopGoals and Metrics

Case Management

Important Metrics to Follow

Emergency Preparedness

CRITICAL THINKING

Assessing Safety and Risk



New Graduate Nurse Residency Program

Transition to Practice Program

Conceptual FrameworkGuided by Patricia Benner’s (1984) conceptual framework for transition to practice, “From Novice to Expert,” which outlines five levels of competency in clinical practice: novice, advanced beginner, competent, proficient and expert, the graduate nurse enters the residency program as an advanced beginner nurse who may have the necessary theoretical knowledge but lacks the clinical or situational experience to apply intuition, clinical judgment and contextual knowledge to nursing practice.

Appreciative, Inclusion Based ApproachThe NGNRP at ROPH seeks to approach this process from an appreciative stance, taking ownership for a culture that will support success in this program, and girded by a just culture, the expectation is that all new graduate nurse hires will successfully transition into excellent practicing ROPH nurses.

Every New Grad from any area entered into program Partnership between NPGO and Nursing Administration oversees program

NPGO administers clinical advancement between RN1 and 2 based on successful completion of this year long program

Guided by Best Current Evidence and Performance MeasuresBased on 6 elements of the ANCC transition to practice program as well as feedback, both formal (Casey Fink validated survey) and informal (through monthly feedback from residents) as well as regular assessment of performance measures such as retention rates

Program LeadershipCNO, Director of Nursing Practice, CNL Liaison, Unit Director, New Graduate Float Pool and other facilitators of program

Organizational Enculturation Through HR and Nursing specific orientation Through Preceptor and Orientation Pathway Through Nursing administration support of four hours monthly spent at residency meetings

Through the NPGO requirement of full attendance at sessions for RN1-2 advancement

Through 1:1s with CNO at time of hire on topics such as mission, vision for nursing excellence, nursing empowerment, professional governance, professional development, just culture, among others.

Development and Design Year Long Program, with 4 hour sessions, in cohorted groups, done monthly

Cohorts are created based on quarter of hire Facilitators are either CNLs or RN2s and RN3s with speakers from across the organization on a variety of topics

Simultaneously, the new graduate is entered into a phased orientation program, where they are oriented throughout the organization with the end goal of transfer from New Grad Float Pool into a designated, open FTE on one of the clinical areas.

NGNRP Orientation Pathway is as follows:1. Initiation: Central orientation with scenario-based education and classroom discussion (1 week)2. Adaptation: Adjustment to the new environment, orientee is based on unit with preceptor3. Assimilation: Able to receive new facts and information, the orientee is unit based with preceptor, taking on more challenging situations and cases4. Synthesis: Deductive reasoning with the combining of new information in to a new coherent system of information. Orientee is unit-based with preceptor but becoming more independent and able to take on increasingly complex case. No further paperwork at this phase, just a cognizance by the charge nurse that the NGNRP resident is “off orientation” and will be still in touch with preceptor and manager as needed.

Practice Based Learning Multifaceted learning and teaching approaches are utilized throughout the year long program.

The orientation pathway integrates practice based learning which is continual into the clinical setting with a preceptor reviewing the following:

Assessment and Evaluation Emergency Equipment/Devices Skills and Interventions Medications Documentation and Education Psychosocial Other/Resources/Policies Added/Individualized Learning Needs

27


Practice Tools

WE ARE NPGO

PHASE 1Initiation

Central Orientation with sce-nario-based education and

classroom discussion.

PHASE 2AdaptationAdjustment to the new

environment. Orientee is based on unit with preceptor.

PHASE 3Assimilation

Able to receive new facts and infor-mation. Orientee is unit-based with

preceptor. Taking on more challenging situations and cases.

PHASE 4Synthesis

Deductive reasoning with the combining of new information into a new coherent sys-tem of information. Orientee is unit-based with preceptor but becoming more inde-pendent and able to take on increasingly

complex cases.

New Graduate Nurse Orientation Pathway Phases

New nurse will meet with preceptor and manager at regular intervals throughout this process MONTH 1

Resiliency Moral Courage, Crucial Conversations, Chain of Command and Just Culture

Welcome, Letter to Self and Magnet Planner

MONTH 2 HR/Nursing Admin Policies and Self-scheduling

Time Management and Delegation Basic Assessment and Lines/Tubes/Drains

MONTH 3 Remote Tele/ED Specific Topics 12 Lead EKG Tales From the Bedside Risk Management

MONTH 4 Advanced Directives, Ethics, and Goals of Care CNL program/Interprofessional collaboration RRT and MEWS/ED Specific topics Crash Cart

MONTH 5 End of life/Post-Mortem Care Care of the Stroke Patient Tales From the Bedside Dietary/Nutrition

MONTH 6 Respiratory Health Literacy Magnet Planner Fluid and Electrolytes

MONTH 7 Clinical Advancement and Certification Care of the Pre-Op/Surgical Patient Break Journal Reflection Mock Code

MONTH 8 EBP/Research Care of Delirium/Dementia Patient ABGs Interpreting Cardiac Rhythms

MONTH 9 Care of Psych Patient Anticoagulants and Stroke Medications Quality Management and NSIs Journal Reflection Diabetic Educator

MONTH 10 Cath Lab SANE/Human Trafficking Patient Experience Trach Care, Chest Tubes and PleurX Catheters

MONTH 11 Shadowing

MONTH 12 Light Breakfast and Nurse Panel Professional Role, ANA Social Policy, Career Planning, Business Case For Top of License, Mentorship Availability, and Leadership Development Program

Escape Room Magnet Planner and Final Evaluation Certificate Presentation

New Graduate Nurse Residency Program Schedule

Nursing Professional Development SupportThe NGNRP is focused on retaining nurses at ROPH and growing them into leaders that will affect a diverse array of settings and populations into their professional career, even if that career is outside of ROPH.

This is supported by the Structural Empowerment and Professional Development policies

Other professional development activities are offered regularly to all nurses in the organization and are open to the new graduate nurse from time of hire

Library, tuition reimbursement, Rush system educational offerings and support for on and offsite professional development activities are offered from time of hire

Quality Outcomes Validated survey instrument is administered, with permission at months 1, 6 and 12 to assess for program progress and curriculum needs

Turnover, engagement scores, monthly curriculum evaluations are all utilized in addition to assess programmatic success



Leap Enhancement & Tuition Reimbursement

Who Is Eligible?All RUMC and ROPH benefits-eligible employees may be eligible to participate in the tuition reimbursement programs after satisfying the length of employment requirements. Participants in the Employee Enhancement program must be employed by Rush for

at least three months. Participants in the Internal and External tuition programs must be employed by Rush for at least one year. (Although note: Employees hired or with job offers dated before January 11, 2016, must be employed by Rush for only three months.)

Employees with spouses, civil union partners or dependent children participating in the Spouse/Dependent tuition program must be employed by Rush for at least one year.

What Is the Purpose of this Program?The purpose of the Employee Educational and Tuition Assistance program is topromote and encourage the pursuit of higher education opportunities and professional development.

What Are the Details?Employee professional development is an important component of the Medical Center’s mission, vision and values. This is currently accomplished through a variety of formal and informal training programs. One of the most critical program components of our employee development efforts is through the tuition assistance program. The professional development programs at Rush have two goals:

1. Employee career development2. Contributing to the Medical Center’s business and/or clinical goals.

The Medical Center may adjust, alter or discontinue any of the terms of this program based on its business need.

How Do I Get Paid? Submit Your Forms HereInternal [email protected] eligible Rush employees enrolled as students in one of Rush’s Colleges

External [email protected] employees for tuition reimbursement for coursework taken at other accredited institutions

Employee [email protected] employees for attendance at outside conferences or seminars

Tuition Reduction [email protected] Spouses, Civil Union Partners or Dependents of eligible employees pursuing a degree at Rush College of Nursing, the Graduate College or the College of Health Sciences

Enhancement ProgramsEmployees who sign up for an enhancement (e.g., not taxable) class are generally reimbursed under the rules that were in effect during the fiscal year in which they registered.

Degree ProgramsEmployees who sign up for a class as part of a degree program are generally reimbursed under the rules that are in effect during the calendar year in which payment is made. All tuition reimbursement payments are made in accordance with the IRS rules for such payments that are in effect at the time the payment is made. Questions of tax liability for tuition reimbursements are answered by referring to the IRS rules in effect at the time payment is received, not the rules that were in effect at the time of class registration.

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Practice Tools

WE ARE NPGO

Nursing Interview ToolWe utilize our professional practice model to evaluate the practice of RN candidates to our institution.

We also use this opportunity to meet a nursing colleague and share our vision for nursing as well as our identity as practitioners. The following is a tool to use during interviews of nursing candidates.

MISSIONThe mission of Rush is to improve the health of the individuals and diverse communities we serve through the integration of outstanding patient care, education, research and com-munity partnerships.

RELATIONSHIPSAND CARING

Tell me about your most rewarding experience as a nurse.

Tell me a time you were really upset at someone or some circumstance … how did you deal with it and what was the outcome?

Tell me about a time when you had to successfully complete a project with others.

Give an example of how you have supported and engaged other in shared governance.

Did they describe caring, compassion, interpersonal skills?

What was their communication style for this experience?

Are they willing to negotiate?

Do they exhibit traits of team and relationship building?

EVIDENCE-BASED CARE Can you give us an example of how you have utilized current evidence or best practices to work on an improvement in patient care or the environment?

What are some examples of resources you would seek to bring to your patients and their families?

Tell me about a time when your opinion differed strongly from someone or a group … what did you do?

Did they use literature or data?

Do they describe past use of good resources?

Do they seek out evidence, literature or best practice readily?

TECHNICAL EXPERTISE Can you give us an example of a time that you applied the teaching process to a patient, family or nursing staff and the subsequent outcome(

What are some strategies you have used to support education in peers or staff that report to you?

Did they display good listening — a solid level of understanding?

Did they verify their own expertise and subsequent learning of patients?

CRITICAL THINKING Can you give us an example of a time you recog-nized a change in patient or family needs/health and what you implemented to address that need?

Tell me about some situations in which you had to adjust quickly to changes in the organization or departmental priorities. How did the changes affect you?

Did they seem to have good clinical knowledge, logic, willingness to advocate?

Do they seem versatile?

Do they keep quality and safety top of mind?

LEADERSHIP What activities have you been involved in thus far that support your involvement in professional or-ganizations and/or activities, or leadership therein?

Have you ever helped a co-worker to improve his(her performance at work?

Tell me about a time when you accomplished something on your own.

Tell me about a time when someone was not doing their job or not doing it correctly. What did you do?

Give an example of a time when you were a role model for others.

Do they describe elements of mentorship or teaching?

Do they display independence and initiative?

Can they hold others accountable?

Did they talk about professionalism, culture and mentorship?

Interview Question Things to Look for RatingMVP/PPM Domain Share your three greatest accomplishments to date. How do these align with our mission?

VISIONAt Rush Oak Park, our vision is “to be utilized by our community and beyond as a resource center for patient and family health promotion and support ( and to scientifically and competitively pursue innovative care that supports and sustains wellness in the lives of our patients, our community and beyond.”

If you could change Nursing to be your ideal world, what would it look like?

Was there evidence of self efficacy, initiative, innovation, outreach?

PHILOSOPHYAt Rush Oak Park, our philosophy is that “nurses are proactive and responsive to the needs of individuals, groups and communities across the life span in a variety of settings.”

Can you give examples of interventions for your patients or their families beyond the walls of the organization?

Either for their care continuum or the community?

Give examples of advocacy or empowerment of fellow staff or those reporting to you.

Does this candidate see the patient as a person with lifetime health care needs?

1 2 3 4 5DOES NOT MEET PARTIALLY MEETS MEETS EXCEEDS GREATLY EXCEEDS

4 5321

4 5321

4 5321

4 5321

4 5321

4 5321

4 5321

4 5321

APN PrivilegesCore APN Privileges include but are not limited to: Order appropriate pharmacological agents and non-pharmacological interventions; evaluation of consults on inpatients and ED patients; diagnosis based upon history and physical exam and clinical findings; initiate referrals to appropriate physicians or other healthcare professionals; interpret diagnostic tests; obtain consents for treatment; obtain history and physical; order and perform consults; order blood and blood products; order diagnostic testing and therapeutic modalities; order and initiate tests, treatments and interventions; prescribe medications; write admission orders; write discharge orders and corresponding plans of care; write transfer orders based on the plan for the care transition.



Advanced Practice Nurse

Credentialing and privileging (if applicable) must be completed prior to practicing as an APN. The Joint Commission requires that all APNs be privileged through the medical staff process or a procedure that is equivalent to the medical staff process. It must follow criteria set forth in the Joint Commission credentialing and privileging regulations.

APN Credentialing and Priviledging Process

DefinitionsProfessional Practice ModelJob Description for APNThe ROPH Professional Practice Model Domains of rela-tionships and caring, technical expertise, critical thinking, evidenced-based practice and leadership define the com-petencies in the job descriptions of all APNs at ROPH.

CredentialingCredentialing is the process for validating licensure, clinical experience, educational preparation, and certification for specialty practice. This process is required for all APNs.

PrivilegingPrivileging is an entitlement process whereby nurses in ad-vanced practice roles are granted authority to provide spe-cific healthcare services to patients at ROPH practice sites. APNs requesting privileges must identify a physician, with active privileges for the same procedures requested by the APN. This process is required for all APNs requesting privi-leges for procedures beyond the APN Core Privileges.

APN Credentialing and Privileging Process

All APNs applying for credentials or privileges through the Medical Staff Office (MSO) will do so using a pre-ap-plication form. The pre-application must be completed in full by the APN applicant. Once a complete pre-applica-tion is returned by email to the MSO, MSO staff verify licensure, run a National Practitioner Data Bank report and Clerk of the Circuit Court check.

The Credentialing and Privileging (C&P) Committee then reviews pre- applica-tion, Curriculum Vitae and Licensure status, and gives approval for the candidate to progress through further application steps.

A member of the NPGO APN practice council sits on the MSO C&P Committee as an additional re-source/representative for the APN applicant approval process.

The MSO’s receipt of this authorization will trigger them to have Rush Health (CVO) launch the electronic credentialing and privileging applica-tion, which will be sent directly to the applicant by email.

Once the verifications have been completed, a representative from the NPGO APN Prac-tice Council, Chief Nursing Officer and the department chair will be contacted to review the applica-tion, for approval prior to being sent to the Medical Staff C&P Committee.

The APN application packet is then sent to the MSO C&P, Exec-utive Committee and Board for approvals.

Medical Staff office notifies APN applicant of approval and pro-cess is complete.

STEP ONE STEP TWO STEP THREE STEP FOUR STEP FIVE STEP SIX

31

Rush Oak Park HospitalManual for Nursing Practice Governance

WE ARE NPGO


APN Job Description Addendums

APN Onboarding Process

Employed APNs Non-employed APNs (RUMC or Private)

Requirements for All APN Credentialing

1. CMO, CNO and APN committee interviews and decides to hire

2. Medical Staff begins credentialing process 3. APN is sent a 2 page pre-application

from the Medical Staff Office (MSO) to complete and return to us with required copies of licenses and CVs.

4. APN returns pre-application and it is re-viewed by the MSO. Pre-application is sent for approval to the Credentials Committee

5. Within 48 hours of receipt of Pre-appli-cation from MSO, Central Verification Office (CVO) will e-mail the practitioner an electronic application where the APN will have to log into the portal to complete and sign off on.

6. Once the application is received, the CVO will begin verifying peers, affiliations, past insurances, licensure, etc.

7. During the CVO's verifying process, the MSO requests(

a. Epic training date b. LEAP Number c. Application processing fee d. Privilege Request approval by spon-

soring physician e. Epic account request8.( The MSO will receive notice from the CVO

when practitioners credentialing applica-tion is complete.

9. MSO will have completed application reviewed and approved by the CNO, Peer APN and/or APN Committee, Department Chair, Credentials Committee, Medical Executive Committee and Board.

10. The date that the APN's privileges are approved by the Board are the date their privileges will become active. The MSO will notify account provisioning to acti-vate epic account.

The process will be similar with the exception of the involvement of the CMO, CNO, and APN committee. It is also required that non-em-ployed APN pre-applications be approved by the Credentials Committee (last Thursday of the month) prior to sending to the CVO to begin processing.

What the practitioner needs to have for the Credentialing process( Active NPI Number Active State License Active State Controlled Substance License Active DEA license (cannot obtain DEA until Controlled Substance License is obtained – the CMO is allowing EMPLOYED practitioners to work under the hospital DEA, if CSL is active, on a case by case basis)

Privileged/credentialed through ROPH medical staff for ER skills(procedures

Documents assessment, treatment, response to treatment and disposition

Orders and interprets labs, imaging, EKG. CPR, ACLS, PALS within 1 year of hire for regularly scheduled NPs as classes are available through ROPH/RUMC.

Moonlighting NPs will need CPR only. Attends 25% medical staff quarterly meetings and 50% ER Control meet-ings for regularly scheduled NPs. Attends APN Meetings 50% of time Board certified as Family Nurse Practitioners or Emergency Nurse Practitioner.

Function as direct provider of emergency care services.

Coordinate care with community organizations including nursing facilities, hospitals, private practice practitioners, and home care and hospice agencies.

Promote coordination between lev-els of care, striving for best practice

Improve perception of APN and role in coordination

Collect and report data on clinical practice, work towards develop-ment of patient outcome measures

Identify and address palliative(hospice needs beginning with initial assessment.

Discuss end of life issues as appropriate. Initiate coordination of end of life enhancement/care where appropriate.

Privileged/credentialed through ROPH medical staff


Orders and interprets labs, imaging, EKG. CPR, ACLS, within 1 year of hire for regularly scheduled NPs as classes are available through ROPH/RUMC

Attend 25% of medical staff quar-terly meetings

Attends APN Meetings 50% of time Board certified as Acute Care, Adult or Family Nurse Practitioner


Function as expert on care of geriatric population. Remain current with best practices in geriatric care

Promote coordination between lev-els of care, striving for best practice across the care continuum.


Collect and report data on clinical practice, work towards develop-ment of patient outcome measures


Discuss end of life issues as appropriate. Initiate coordination of end of life enhancement/care where appropriate.

Privileged/credentialed through ROPH medical staff


Orders and interprets labs, imaging, EKG. CPR, ACLS, within 1 year of hire for regularly scheduled NPs as classes are available through ROPH(RUMC

Attends 25% medical staff quarter-ly meetings

Attends APN Meetings 50% of time Board certified as Acute Care Nurse Practitioners.



Collect and report data on clinical practice, work towards development of patient outcome measures


Discuss end of life issues as appropriate. Initiate coordination of end of life enhancement/care where appropriate

Attend 25% of medical staff quarterly meetings

Privileged/credentialed through ROPH medical staff Documents assessment, treatment, response to treatment and disposition Follow patients through periop-erative experience, interviewing preoperatively, assessing history and background for anesthesia, Advising and advocating for patient from anesthesia perspective Coaches and provides supervision for support of patient with respira-tory care needs Responsible to maintain currency of anesthesia expertise and com-petency as well as maintenance for re-certification Orders and interprets labs, imaging, EKG. CPR, ACLS, within 1 year of hire for regularly scheduled NPs as classes are available through ROPH(RUMC Board certified as Certified Regis-tered Nurse Anesthetists. Collect and report data on clinical practice, work towards development of patient out come measures

Privileged/credentialed through ROPH medical staff Documents assessment, treatment, response to treatment and disposition Orders and interprets labs, imaging, EKG. CPR, ACLS, within 1 year of hire for regularly scheduled NPs as classes are available through ROPH/RUMC Attends 25% medical staff quarterly meetings Attends APN Meetings 50% of time Board certified as Acute Care, Adult or Family Nurse Practitioner Coordinate care with community organizations including nursing facilities, hospitals, private practice practitioners, and home care and hospice agencies. Improve perception of APN and role in coordination

Collect and report data on clinical practice, work towards development of patient outcome measures


Discuss end of life issues as appropriate. Initiate coordination of end of life enhancement/care where appropriate

Attend 25% of medical staff quarterly meetings

CRNAGERIATRIC APN OUTPATIENT/CLINIC APNINPATIENT APNER APN

32 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCEWE ARE NPGO

The Magnet Planner

First-time Login Process

Demographic Profile

The Magnet Planner helps us collect demographic information about our nursing population but you can also harness the Planner to track your personal

professional development

Password Reset

roph.magnetplanner.com

Using Chrome, navigate to roph.magnetplanner.com and click “New User” Enter your ROPH email address, click Submit. After clicking Submit, an email will be sent to your ROPH inbox with a one-time link to set a password. After setting your password, you will be redirected to the login page. Use your employee ID and the password you just set to login.

Navigate to navigate to roph.magnetplanner.com, click “Returning User” Click link at the bottom labeled “Forgot Your Password” Enter your work email address, click “Submit” After clicking “Submit” and an email will be sent to your work inbox with a one-time link to set a password. After reset your password, you will be redirected to the login page. Use your employee ID and the password you just set to login.

You may logout at anytime by scrolling all the way to the bottom of the profile page.

Complete all fields that are marked with a red asterisks. Don’t forget to add you FTE information as well as your education & certification information! Your progress will not be saved unless you click the “Save Progress” button. You may save your progress and return later to add new information at any time.

You may export all of the data on your Demographic Profile to multiple file types, including Word, Excel and PDF by hovering over the Demographic Profile button. You may also download proof of certification.

SUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION

Practice Tools

33

Rush Oak Park HospitalManual for Nursing Practice Governance SUPPORT FOR NURSING GROWTH, WELLNESS,

SAFETY AND MEANINGFUL RECOGNITION

Practice Tools

Self Care Guide & ResourcesThe best thing health care workers can do is take care of themselves.

insiderush.rush.edu/wellnessmore info

Take care of your body.

Try to eat healthy, exercise, sleep when

possible and avoid alcohol and other drugs. The needs

of others are not more important than your own

needs and well-being.

Connect with others.

Share your feelings with a colleague, family member

or friend. Maintain relationships and rely on

your support system.

Take breaks.It is not selfish to take

breaks. Working to exhaustion does not

mean you will make your best contribution.

Breathe.If you feel the common signs of stress (below), consider reaching out

through one of our Rush Wellness resources.

Common signs of stress

Feelings of exhaustion,

anxiety or fear

Anger or short temper

Difficulty sleeping or changes in

appetite, energy, and activity levels

Emotional blunting

Increased use of alcohol, tobacco

or other drugs

1. Creation of a culture of wellness, including programs to address burnout, support resilience, and increase joy in work.2. Increased support for mental health, including access to care, reduction in stigma, and strategic partnerships to prevent suicide.3. Production of leading research through an emphasis on data and analytics.Services

The following services are currently available:Well-Being Coach: Work with one of our Well-Being Advocates to identify and meet your wellness goals. Counseling: Our Well-Being Advocates are trained mental health professionals and are here to support you. Mini Wellness Retreats: Recharge your well-being - spend 60 minutes at the Center for Clinical Wellness enhancing your well-being through a special, targeted experience (includes access to Energy Pod).

Center for Clinical WellnessThe Center for Clinical Wellness (CCW) will seek to address three primary goals



Practice Tools

How to Get HelpPain Safety

Staffing

Clinical

CONCERNS Your patient’s pain is not managed

Your patient has end-of-life pain issues that are not being addressed

SOLUTIONS Consult Comfort Menu in the patient admission packet

Talk with physician about consulting Case Management or Goals of Care Consult

Contact Palliative Resource Nurse - Pager: 85 x 2080

Talk with physician about putting in a Palliative or Pain Care Consult

Consider contacting Chaplain - Pager: 85 x 6844

CONCERNS Your patient/patient’s family/visitor is disruptive or abusive

You don’t feel comfortable with your surroundings

SOLUTIONS Contact Security - Ext: 62211

Contact a Behavioral Resource Nurse - Pager: 85 x 5112

Call to initiate the Behavioral Action Response Team (BART) – Ext. #63333

Talk with physician about putting in a Psychiatric Consult

Gain knowledge by completing the CPI Non-violent Crisis Intervention Class

Contact Psychiatry - Pager 85 x 5588

CONCERNS You feel that your unit has inadequate staffing

SOLUTIONS Discuss with Charge Nurse

Discuss with Nursing Supervisor/Unit Director

Discuss with UAC (or unit representative)

Discuss with NPGO Staff Nurse Advisory Board (SNAB) (or department representative)

CONCERNS You believe your patient is not getting the proper treatment

You believe your patient is at risk or your practice is at risk

You believe your patient is showing signs of decline

SOLUTIONS (Policy #IM1005)Chain of Command:1.) RN and MD Discuss Patient Issue2.) Charge RN3.) Unit RN Manager/Nurse Shift Supervisor4.) Chief Nursing Officer5.) Chair of Physician Department6.) Chief Medical Officer7.) Executive Administrator on Call

Contact the Rapid Response Team – Ext. #63333

Contact the Infection Control Hotline – Ext. #62045

Call the Rush Hotline for confidential and anomyous – 877-RUSH009 – rush.ethicspoint.com

Contact Sexual Assault Resource Nurse - Ext. #62685, Pager 85 x 5984

Illinois State Nurse Practice Act: nursing.illinois.gov/nursepracticeact.asp

CONCERNS You feel distressed or show signs of suffering

Sick calls

Patient care avoidance

Withdrawal

Depression

Lashing out at co-workers/patients

SOLUTIONS Place an Ethics Consult (Policy #LD0004)

Contact the Employee Assistance Program

Talk with a Chaplain – Pager #85-6844

Make use of Respite Room. Available on second floor

Utilize Rush Wellness Resources at The Center for Clinical Wellness

CONCERNS You feel distressed and/or burned out due to a particular aspect of the patient’s treatment plan

You feel distressed due to limited options shared with the patient/family

SOLUTIONS Place an Ethics Consult (Policy #LD0004)

Talk with a Chaplain – Page #85-6844

ANA Code of Ethics – nursingworld.org/codeofethics

Moral Distress

Ethical Dilemas

A situation where you know the ethically appropriate action to take but are unable to act upon it. You act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity.

A complex situation that involves a mental conflict between principals originating in a person’s mind that compels them to act.

35

Rush Oak Park HospitalManual for Nursing Practice Governance SUPPORT FOR NURSING GROWTH, WELLNESS,

SAFETY AND MEANINGFUL RECOGNITION

Practice Tools

WE ARE NPGO

Why Take a Break?

CULTURE Culture of watching out for others Expectation that RNs and PCTs work together to cover each other’s patients while on break Culture that insists that others take breaks Having a preceptor who teaches me to take a break and strongly encourages it Fostering peace of mind … “Knowing that my patients are fine because my team is watching out for them” “Unit culture must emphasize breaks and how to break so you can leave your patients for short periods of time. There is a skill to breaking efficiently but units must support break times.”

Environment conducive to restfulness: quiet, away from patients, away from call lights, clean

RESTFUL ENVIRONMENT Maintaining a quiet, clean break-room, where staff is respectful of one another. Environment free from call lights and patients

ENVIRONMENTAL SUPPORTS ANA Principles for Nurse Staffing, ROPH Policy, Illinois Law, Federal Law

PLANNED COVERAGE Extra Shifts/Floaters cover for people during breaks Lunch Buddies: Charge nurse assigns at beginning of shift which makes covering for each other comes easier Lunch Partners: Worked out independently “People are assigned for breaks/lunches on our unit so everyone gets a break and lunch or a long lunch” Communicating to patients about breaks and who is covering Sign up for breaks at beginning of shift

EDUCATION Time management education Education of staff to let clerk, charge nurse, PCTs know when you are breaking for accountability in coverage Education on what covering RN should do Education on what to delegate to covering RN Education for charge nurses on how to better staff by acuity/fairness

LEADERSHIP SUPPORT Better Staffing - charge nurse with less patients to cover, CC/CNLs taught to cover, UD taught to cover and support others doing so Held as part of RN3 role to foster breaks and rest periods Interdisciplinary support and collaboration Request provider orders be put in before lunch period

Professional nurses are

responsible to take breaks so that they are refreshed and reengaged for the dynamic environment.

Refreshed and engaged

caregivers will provide

higher quality care, keeping

themselves and patients safer.

Each professional

nurse remains autonomous in his or her time management;

and breaks should be

considered, in a healthy

culture, to be necessary.

We strive to instill a culture where we take care of each

other, looking out for and

resourcing for those nurses who have not yet been able

to break.

All staff, both direct care and administration

need to own the creation of

cultures and environments

that encourage breaks.

Where possible, breaks should

be free of patients and in an environment

that is set apart from the

patient care area.

Meal Break Tools



Practice Tools

How Nursing Education Is Administered

NPGO Executive Committee

Clinical Nurse Leader Department

Drives Practice Education Strategy, Learner NeedsAssessment, Approves Curriculum and Success Metrics

NPGO Education Committee Creates and Analyzes Learner Needs Assessment, Collaborates

with Internal/External Experts to deliver education, Creates Tactics for Nursing Education Housewide and Collaborates with Educators, Collabo-

rates with Nursing Administration to strategize regulatory, compliance and other operational educational needs and collaborates across Rush

System for symmetry of programs

Drives standingorganizational education,

assists with “Just in Time” or “Burst” education based

in clinical settings, Supports mentorship,

preceptorship and clinical practice in areas of clinical

expertise, collaborates across Rush System for symmetry of programs

ROPH RNs and APNsParticipate in delivering education based on their

areas of expertise

Liaison RN RolesBehavioral, Palliative,

Sexual Assault: Deliver and manage educational needs related to popula-tion of focus and related

clinical areas, may coordi-nate education with other disciplines serving same

populations for synergy of performance improve-

ment, drive metrics related to area of focus

Based on Focused Strategy to Improve Nursing Practice and Learner Expressed Needs, Education is delivered at ROPH.

37


WE ARE NPGO


Practice Tools

Creating a Pipeline of the Next Generation

ROPH Nursing, comprised of approximately 330 RNs and APNs facilitates clinical experiences from six partner schools to

support a pipeline of nurses and certified nursing assistants into the healthcare industry. Approximately 250 students are facilitated each year from the following partners: Rush University College of Nursing, Lewis University, Loyola University, Dominican University, College of DuPage and Oak Park River Forest High School.

Nursing Professional Governance Organization (NPGO) Executive Committee oversees and approves these rotations and the Department of Clinical Nurse Leaders facilitates a liaison CNL to organize and manage the clinical groups in partnership with Human Resources and Employee Health.

Quarterly, Preceptor classes are offered to RNs at ROPH to expand competence on precepting both students and new graduate employees. The preceptor class covers the following:

Definition of a Preceptor Guide at the Side Experienced and competent RN with training Role model and resource person to newly employed staff

Responsibilities Assess learning needs, set goal Teach time management, prioritization Evaluate clinical competence and documenting. Provide constructive feedback, coaching Facilitate social interaction and acclimatization to the organization’s and unit’s culture.

Foster an environment of caring Acting as Role Model Clinical Knowledge Provide explanations — prioritization, shift report Knowledge of the system/unit Chain of command, Policies and Procedures Evaluate, Red Flags Educate( Give feedback and Listen

Educational Programs OfferedPrograms are offered and conducted by the Department of Clinical Nurse Leaders. Some programs are offered at all three Rush System organizational sites. Every unit and clinical specialty performs population and area-specific education to supplement those listed below.

Education Provided PurposeOrientation ............................................................. Onboarding/Patient Safety/CompetenceAnnual Competency Training: Leap Online Education ..................Staff Support/CompetenceAnnual Competency Training: Hand-On Education ......................Staff Support/CompetenceNurse Residency Program ........................................ Retention/Staff Support/EmpowermentCharge Nurse Program ............................................ Retention/Staff Support/EmpowermentPreceptor Program .................................................. Retention/Staff Support/EmpowermentCrisis Prevention Intervention Training .............. Violence Mitigation/De-Escalation TrainingGrand Rounds .......................................................................................................... VariousGamma Phi Grand Rounds ....................................................................................... VariousNIHSS .............................................................................................. TJC Stroke CertificationAHA BLS New provider and recert ................................... Competence/Certification UpkeepAHA ACLS new provider or recert .................................... Competence/Certification UpkeepAHA PALS ........................................................................ Competence/Certification UpkeepNurses's Role In Management Of Cardiac Arrest - PEDS ............................PALS prep courseNurses's Role In Management Of Cardiac Arrest - ADULT ................. ACLS certification prepEKG - Support Staff ......................................................................... Patient Safety InitiativeEKG for RNs .................................................................................... Patient Safety InitiativeInpatient Epic for New RN Employees ..........................................................................EPICInpatient Epic for Students and Student Orientation .....................................................EPICInpatient Epic for New PCT Employees ..........................................................................EPICProcedural EPIC for New RN, PCT and Students ............................................................EPICED EPIC for New RN, PCT and Students .........................................................................EPICRush Leadership Academy ............................................................. Leadership DevelopmentSimulation Lab ....................................................... Onboarding/Patient Safety/CompetenceRRT for ICU RNs .............................................................................. Patient Safety InitiativeSBAR ................................................................Patient Safety/Handoff/Improve ThroughputHazmat Training ...............................................................Emergency Management TrainingNIMS ................................................................................Emergency Management TrainingMalignant Hyperthermia ...........................................................................Updates in PolicyO2 Tanks Segregation Education ....................................................................TJC educationAbuse and Neglect .......................................................................Annual Leap CompetencyCompliance, Privacy & Security .....................................................Annual Leap CompetencyDiversity and Inclusion .................................................................Annual Leap CompetencyDSC & NICHE ................................................................................Annual Leap CompetencyEmergency Preparedness ..............................................................Annual Leap CompetencyFire Safety ....................................................................................Annual Leap CompetencyHazard Communication ................................................................Annual Leap CompetencyInfection Control ..........................................................................Annual Leap CompetencyPatient and Employee Safety ........................................................Annual Leap CompetencyRadiation Safety ..........................................................................Annual Leap CompetencyCybersecurity ................................................................................Annual Leap CompetencyPersonal Protective Equipment .....................................................Annual Leap CompetencyBraden Competency .....................................................................Annual Leap CompetencyDiabetes .......................................................................................Annual Leap CompetencyFalls and Purposeful Rounding .....................................................Annual Leap CompetencyROPH General Stroke Information ...............................................Annual Leap CompetencyHeparin Protocol ..........................................................................Annual Leap CompetencyNeedlesticks-Sharps-Splash Injuries ............................................Annual Leap CompetencyPain Management ........................................................................Annual Leap CompetencyPain Management Clinical Ancillary Staff .....................................Annual Leap CompetencyPreventing HAI’s ...........................................................................Annual Leap CompetencyProcedural Sedation .....................................................................Annual Leap CompetencyReprocessing of Reusable Medical Devices ..................................Annual Leap CompetencyWorkplace Violence ......................................................................Annual Leap Competency



Practice Tools

Meaningful Recognition Through Awards

Award Name Award Description

NURSE MENTORSHIP AWARD

Professional Practice Model Domain


The Nurse Mentorship Award is presented to recognize the exemplary mentorship qualities of one nurse who promotes the growth of others, fosters interpersonal commu-nication in the healthcare setting, is a frequent educator and a positive role model. This nurse is willing to share knowledge, seeks to fit the mentees strengths into the right iniatives and provides a multitude of experiences that the mentee can learn from.

ADVANCING AND LEADING THE PROFESSION AWARD

CLINICAL EXCELLENCE AWARD

LEADERSHIP

The Advancing and Leading the Profession Award is presented to recognize the outstanding efforts of one nurse who promotes the profession of nursing through outstanding leader-ship, advancing and/or strengthening nursing, either as a profession or in the delivery of patient care within and/or beyond his or her own healthcare facility.

PROFESSIONAL PRACTICE MODEL AWARD

EVIDENCEBASEDPRACTICE

The Rush Professional Practice Model (PPM) defines who we are as nurses at Rush Oak Park Hospital. Award given to a person who exemplifies all domains of our practice at ROPH.

DAISY FOUNDATION AWARD

ROOKIE AWARD

The Daisy Award was creating by the Barnes family after the loss of their son, Patrick. They wanted to honor the nurses who gave him exemplary care. The DAISY award is an acronym for Diseases Attacking the Immune System — which is symbolic of the disease that killed Patrick. The Daisy award thanks nurses for “the super-human work RNs do everyday in direct care of patients and families, funds nursing research and celebrates extraordinary compassion and skill by nursing students and honors nursing faculty.” (http://daisyfoundation.org)



KAREN MAYER INNOVATION AWARD



CRITICALTHINKING The Rush Professional Practice Model (PPM) defines who we are as Nurses at Rush Oak

Park Hospital. Award given to a person who exemplifies all domains of our practice at ROPH.

The Rush Professional Practice Model (PPM) defines who we are as Nurses at Rush Oak Park Hospital. Award given to a person who exemplifies all domains of our practice at ROPH.



TONYA REDDY ADVANCED PRACTICE REGISTERED NURSE EXCELLENCE AWARD

TECHNICALEXPERTISE

The candidate demonstrates authentic leadership, and is a role model as a clinician and mentor. The candidate has made a significant contribution to the improvement of patient care through evidence based practice. She/he promotes a healthy work environment. The candidate provides educational opportunities to patients, nurses, and other members of the health care team. She/he has found creative ways to address issues that impact APN practice, the Institution, and/or the community. The candidate actively participates on professional committees, either within or outside of Rush and mentors other APNs to do the same.

The Clinical Nursing Excellence Award is presented annually to recognize the outstanding clinical performance of one nurse.

The Nursing Professional Governance Organization Karen Mayer Innovation and Scholar-ship Award recognizes and celebrates ROPH nurse-led innovation that improves patient or population safety, outcomes, experience and or the nursing practice environment.

This award honors an extraordinary new nurse. It highlights a new team member who has shown a willingness to help colleagues, while continuing to show tremendous progress in the profession.

39


WE ARE NPGO


Practice Tools

Resources

Involvement in Nursing Professional Organizations can be at the city, state, region or national level. They help nursing practice grow, expand sphere of connections to other nurses and grow leaders in all settings and roles. Most organizations have a yearly meeting/conference which is focused on the membership(s greatest educational needs/updates. Most of these organizations offer a specialty nursing certification. Nurs-ing certification is another way to show expertise in any given field. In order to advance in the clinical ladder, you must have an ANCC-ap-proved certification. These certifications are listing on your Demogrpahic Profile in The Magnet Planner.

ILLINOIS

Chicago Chapter of NAPNAP

Illinois Society for Advanced Practice Nursing

Illinois organization of Nurse Leaders (chapter of AONE)

Illinois Ambulatory Nurse Practice Consortium

(chapter of AAACN)

Gamma Phi Chapter of Sigma Theta Tau International

Illinois Ambulatory Nurse Practice Consortium

(local networking group of AAACN)

Chicagoland Chapter AMSN

Chicagoland Chapter NAON

NATIONAL

Academy of Medical-Surgical Nurses

Academy of Neonatal Nursing

ACNP- American College of Nurse Practitioners

Advanced Practice Nurses of the Ozarks

Advanced Practice Nurses of the Permian Basin

Advanced Practitioners for the River Region

Air & Surface Transport Nurses Association

Alliance for Psychosocial Nursing

Alliance of Nurses for Healthy Environments

Alzheimer’s Association

American Academy of Ambulatory Care Nursing

American Academy of Nursing

American Assembly for Men in Nursing

American Assisted Living Nurses Association

American Association for Respiratory Care (AARC)

American Association for the History of Nursing

American Association of Colleges of Nursing

American Association of Critical Care Nurses

American Association of Diabetes Educators

American Association of Heart Failure Nurses

American Association of Legal Nurse Consultants

American Association of Managed Care Nurses

American Association of Moderate Sedation Nurses

American Association of Neuroscience Nurses

American Association of Nigerian Nurses

American Association of Nurse Anesthetists

American Association of Nurse Assessment Coordinators

American Association of Nurse Attorneys

American Association of Nurse Life Care Planners

American Association of Nurse Practitioners

American Association of Occupational Health Nurses

American Association of Spinal Cord Injury Nurses

American Board for Occupational Health Nurses

American Board of Nursing Specialties

American College Health Association

American College of Cardiovascular Nurses

American College of Nurse Midwives

American Diabetes Association

American Forensic Nurses

American Heart Association: Council on Cardiovascular Nursing

American Holistic Nurses Association

American Long Term & Sub Acute Nurses Association

American Medical Association

American Medical Informatics Association/ Nursing Informatics

Working Group

American Nephrology Nurses Association

American Nurses Association

American Nurses Credentialing Center

American Nursing Informatics Association

American Organization of Nurse Executives

American Psychiatric Nurses Association

American Radiological Nurses Association

American Society for Pain Management Nursing

American Society for Parenteral and Enteral Nutrition: Nurses

Section

American Society of Ophthalmic Registered Nurses

American Society of Peri-Anesthesia Nurses

American Society of Plastic & Reconstructive Surgical Nurses,

Inc.

American Thoracic Society: Nurses Section

Army Nurse Corps Association

Arthritis Foundation

Association for Nursing Professional Development

Association for Radiologic & Imaging Nursing

Association of Camp Nurses

Association of Child Neurology Nurses

Association of Community Health Nursing Educators

Association of Faculties of Pediatric Nurse Practitioners

Association of Nurse Practitioners in Business, Inc.

Association of Nurses in Aids Care

Association of Nurses in AIDS Care

Association of Pediatric Oncology Nurses

Association of periOperative Registered Nurses

Association of Rehabilitation Nurses

Association of Women’s Health, Obstetric and Neonatal Nursing

Baromedical Nurses Association

Carolinas Association of Neonatal Nurse Practitioners

Center for American Nurses

Center to Champion Nursing in America

Certification Board of Perioperative Nursing

Chi Eta Phi Sorority, Inc.

Coalition for Nurses in Advanced Practice

Developmental Disabilities Nurses Association

Dermatology Nurses’ Association

Eastern Nursing Research Society (ENRS)

Emergency Nurses Association

Endocrine Nurses Society

Federal Nurses Association

Gerontological Advanced Practice Nurses Association

Home Healthcare Nurses Association

Hospice and Palliative Nurses Association

Infusion Nurses Society (see intravenous)

International Association of Clinical Research Nurses

Lupus Foundation of America

Midwest Nursing Research Society

Muscular Dystrophy Association

NAPNAP Foundation

National Academy of Dermatology Nurse Practitioners

National Association Directors of Nursing Administration/

Long Term Care

National Association of Bariatric Nurses

National Association of Clinical Nurse Specialists

National Association of Directors of Nursing Administration in

Long Term Care

National Association of Disease Management & Wellness

Professionals

National Association of Hispanic Nurses

National Association of Independent Nurses

National Association of Licensed Practical Nurses

National Association of Neonatal Nurses

National Association of Nurse Practitioner Faculties

National Association of Nurse Practitioners in Women’s Health

National Association of Orthopaedic Nurses

National Association of Pediatric Nurse Practitioners

National Association of Rural Health Clinics

National Association of School Nurses

National Association of State School Nurse Consultants

National Black Nurses Association, Inc.

National Certification Board of Pediatric Nurse Practitioners

and Nurses

National Coalition of Ethnic Minority Nurse Associations

National Council of State Boards of Nursing

National Federation for Specialty Nursing Organizations

National Federation of Licensed Practical Nurses

National Fibromyalgia Partnership

National Gerontological Nurses Association

National Heart Lung and Blood Institute

National Hospice & Palliative Care Organization

National Institute of Diabetes and Digestive and Kidney

Diseases

National Institute of Nursing Research

National League for Nursing

National Multiple Sclerosis Society

National Nurses in Business Association

National Nursing Staff Development Organization

National Organization for Associate Degree Nursing

National Organization of Associate Degree Nurses

National Organization of Practical Nursing Education and

Service

National Practitioner Associates for Continuing Education

National Private Duty Association

National Student Nurses Association

Navy Nurse Corps Association

NCNA Council of Nurse Practitioners - Coastal Region

NCNA Council of Nurse Practitioners Eastern Region

NCNA Council of Nurse Practitioners Wake Central Region

North American Nursing Diagnosis Association

Northeast Pediatric Cardiology Nurses Association

Northern Nurse Practitioner Association

Northwest Organization of Nurse Executives

APN Council of Miami-Dade

Nurse Practitioner Healthcare Foundation

Nurse Practitioner Society of the Dermatology Nurses’

Association

Nurse Practitioners in Women’s Health

Nurse Practitioners: It’s About Time

Nurse Without Borders

Nurses Christian Fellowship

Nurses Organization of Veterans Affairs

Nurses Peer Support Network

Nursing Ethics Network

Nursing Network on Violence Against Women International

Oncology Nurses Society

Pediatric Endocrinology Nursing Society

Philippine Nurses Association of America

Respiratory Nursing Society

Sigma Theta Tau, Delta Beta, Chapter-At-Large

Sigma Theta Tau, International Honor Society of Nursing

Society for Vascular Nursing

Society of Gastroenterology Nurses and Associates, Inc.

Society of Nurses in Advanced Practice

Society of Otorhinolaryngology and Head/Neck Nurses

Society of Pediatric Nurses

Society of Trauma Nurses

Society of Urologic Nurses and Associates

Southern Gulf Coast Nurse Practitioner Council

The National Association of Pediatric Nurse Associates and

Practitioners

The National Association of School Nurses for the Deaf

The National Forum of State Nursing Workforce Centers

Transcultural Nursing Society

Travel Nursing

Treasure Coast Nurse Practitioners

Uniformed Nurse Practitioner Association

Valley Advanced Practice Nurse Association

Visiting Nurse Associations of America (VNAA)

Volusia Flagler Advanced Practice Nursing Council

West Coast Council of Advanced Nursing Practice

West Sound Advanced Practice Association

Wound, Ostomy and Continence Nurses Society (WOCN)

American Nurses Association (ANA) Standards of Practice

and Scope:http://www.nursingworld.org/scopeandstandardsofpractice

ANA Code of Ethics:http://www.nursingworld.org/mainmenucategories/ethicsstandards/codeofethicsfornurses/code-of-ethics.pdf

Illinois State Nurse Practice Act:http://nursing.illinois.gov/nursepracticeact.asp

Illinois State Nurse Staffing By Acuity Legislation:http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=095-0401

ROPH Mission, Vision, PhilosophyROPH Intranet

NPGO BylawsROPH Intranet

NPGO Code of ConductROPH Intranet

Patient Care Services Strategic Plan and Associated TacticsROPH Intranet

NPGO Manual for Nursing Practice GovernanceROPH Intranet

Policies and ProceduresROPH Intranet

ROPH meeting and Presentation TemplatesROPH Intranet

Rush System for Health Nursing Sharepoint WebsiteAccess via Rush applications

Nursing Organizations

Table of Contents

January 2021

Structures That GuidePRACTICE IDENTITY3 Mission & Vision4 Professional Practice Model5 Nursing Care Delivery Model6 We Are NPGO7 ROPH Quality Structure8 Code of Conduct9 Nursing Professional Governance Organization Bylaws10 Cross-Walking Structures That Impact Our Identity11 The Practice Evaluation Cycle

Practice ToolsMEANINGFUL PROCESSES TO GUIDE PRACTICE12 Performance Improvement Model and

Evidence Based Practice Guidelines13 Continuous Pursuit of Excellence Lean Program14 Just Culture Algorithm15 NPGO Peer Review, Corrective Action and Appeals Process16 Portfolio Development17 Clinical Advancement RN1 to RN218 Clinical Advancement RN2 to RN319 Maintenance of RN3 Status20 Structural Empowerment Policy21 Leadership Development

Practice ToolsPROFESSIONAL DEVELOPMENT RESOURCES22 Operational Task Checklist24 Needs Assessment & Checklist26 New Graduate Nurse Residency Program28 Leap Enhancement & Tuition Reimbursement29 Nursing Interview Tool30 Advanced Practice Nurse

Practice ToolsSUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION32 The Magnet Planner33 Self Care Guide & Resources34 How to Get Help35 Why Take a Break(36 How Nursing Education Is Administered37 Creating a Pipeline of the Next Generation38 Meaningful Recognition Through Awards39 Resources & Nursing Organizations