(download as pdf)
Plan For Providing Nursing Care
Nursing, a profession based on knowledge, is the protection, promotion, and optimization of health, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations. (Adapted from the American Nurses Association "Nursing's Social Statement.")
Section 1. Nursing Mission
To provide exceptional nursing care to the people of our region.
Section 2. Nursing Vision
To be the best place to receive care, the best place to work and the best place to practice Nursing.
Section 3. Nursing Values
Team work, compassion and integrity.
Section 4. Nursing Philosophy
We believe the Forces of Magnetism are the foundation for excellence. Our highest priorities are caring, advocacy, innovation and education for our patients, ourselves, and each other. Those priorities and the following guiding principles support our quest for nursing excellence:The power and impact of nurses and nursing.
- Leaders who advocate and support staff.
- Leadership styles that promote shared decision making, continuing education and ownership for exceptional individual practice.
- Provision of exceptional nursing care through continuous process improvement.
- Interdisciplinary collaboration that welcomes all contributions.
- Promotion of wellness through education and information.
- Environments that support mentoring and nurturing of each other.
- Commitment to life long learning, education, and career growth.
- Recruitment and retention of the best nurses.
Section 5. Purpose of Nursing Bylaws
The purpose of the Nursing Bylaws is to describe the Professional Nursing Practice Model across the organization and provide a framework for participation, collaboration, coordination, shared decision making, reward and recognition, and professional relationships related to patient care in accordance with the Nursing Practice Act of the State of North Carolina. The bylaws are based on the principle that nursing is a self-directed and self-governing profession which is ultimately responsible and accountable to the Administration and Board of Trustees for the best possible nursing care of patients and significant others and for the highest level of conduct and practice of the nursing staff within the organization. In a dynamic, responsive, and changing organization, the bylaws are built around the Forces of Magnetism recognizing the importance, worth, and individuality of the consumer and the provider of nursing care at High Point Regional Health.
Section 6. Role of the Registered Nurse
The Registered Nurse assumes responsibility and accountability for the delivery of nursing care within the institution and its subsidiaries in accordance with the Health System mission, vision, values, policies, procedures and bylaws. The role of the Registered Nurse is guided by the North Carolina Nursing Practice Act, the rules and regulations of the North Carolina Board of Nursing, the professional code of ethics, national professional and specialty nursing practice standards and the Joint Commission Nursing Care Standards. The Registered Nurse is responsible for coordinating, prescribing and delegating nursing care based on patient problems and/or needs for initiating the nursing process in the everyday practice of nursing.
Nursing Staff Membership
Section 1. Definition of Membership
Nursing staff membership consists of ten categories that include Nursing Leadership, Nursing Education Specialists, Coordinators, Nursing Supervisors, Professional Registered Nurse Staff, Advanced Practice Nursing Staff, Nurses in non-traditional roles, Nursing Support Staff, Interim Staff, and Adjunct Staff.
Membership is a privilege for nurses who meet the qualifications, standards, and requirements defined in these bylaws and the personnel policies of High Point Regional Health.
Section 2. Professional Registered Nursing Staff
The membership of the Professional Registered Nursing Staff includes the Health System-employed individuals who are licensed Registered Nurses classified in full-time, part-time or prn positions. This category includes staff that has completed the required nursing orientation/probationary employment period and is meeting the performance standards of their positions. The Vice President-Chief Nursing Officer holds called meetings with the Professional Registered Nursing Staff as needed and/or requested. The Professional Registered Nursing Staff will meet with the Director/Manager of their assigned area on a regular basis.
Section 3. Coordinators
The membership of the Coordinator staff includes individuals who have completed the nursing orientation/probationary employment period and meet performance standards. Responsibilities, qualifications, performance requirements, and evaluation criteria for the Coordinator staff are delineated in the departmental position description summaries/standards. Coordinators are knowledgeable, risk takers, able to articulate and be role models of the nursing philosophy and advocate and provide support to the nursing staff.
Section 4. Nursing Supervisors
The membership of the Nursing Supervisor staff includes individuals who have completed the nursing orientation/probationary employment period and meet performance standards. Responsibilities, qualifications, performance requirements, and evaluation criteria for the Nursing Supervisor staff are delineated in the departmental position description summaries/standards. Nursing Supervisors are knowledgeable, risk takers, able to articulate and be role models of the nursing philosophy and advocate and provide support to the nursing staff. The Nursing Supervisor serves as the administrative liaison for the Health System and is responsible for ensuring a safe environment for patients, visitors and hospital staff.
Section 5. Advanced Practice Nursing Staff
The membership of the Advanced Practice Nursing staff includes the Health System employed Registered Nurses with advanced practice credentials (ex. Nurse Practitioner) in full time or part time positions. This category includes staff that has completed the advanced practice credentialing process, the required orientation/probationary employment period and is meeting the performance standards of their positions.
Section 6. Nursing Education Specialists
The membership of the Total Care University staff includes individuals who have completed the orientation/probationary period and are meeting performance standards. The Education Specialists meet with the Director/Manager of their assigned areas at least monthly for ongoing planning and evaluation of education and participate in the monthly clinical management meetings.
The Education Specialists are responsible for ongoing evaluation and development of the orientation program, in-service education and competency assessment-assuring a dynamic program that meets the needs of all staff. The Education Specialists coordinate skill training/competency assessment of licensed/unlicensed nursing staff, medication administration, and Basic Life Support and participate in the annual goal setting/planning for education activities. The Education Specialists facilitate performance assessment/improvement activities, decision making, and teamwork between nursing leadership, clinical nursing specialties, and other health care disciplines/departments.
Section 7. Nurses in Non-Traditional Roles
The membership of Nurses in Non-Traditional Roles consists of Health System employees who are serving in support, leadership, advisory roles in departments throughout the Health System. Included in this category (but not limited to) are: Patient Safety, Clinical Informatics, System Excellence, Business Intelligence, Patient Care Coordinators. These Registered Nurses have completed the required orientation/probationary period and are meeting the performance standards of their positions.
Section 8. Nursing Support Staff
The membership of the Nursing Support Staff includes Health System employed individuals who are Licensed Practical Nurses, Nursing Assistants, Unit Secretaries and Staffing Personnel. This category includes staff that has completed the required nursing orientation/probationary employment period and is meeting the performance standards of their positions. The Nursing Support Staff is responsible for supporting the Registered Nurse in performing functions related to patient care and maintaining standards of excellence in providing patient care.
Section 9. Interim Staff
The membership of the Interim Staff shall include the non-Health System-employed and the Health System-employed individuals who are classified in a temporary position. This category shall include staff that has completed the required nursing orientation in addition to the agency/ registry requirements. Classifications in this category shall include Registered Nurses who are employed by the Health System to fill temporary positions.
The Interim Staff will be responsible for implementing the functions related to patient care/nursing practice activities according to the adopted standards, policies, and procedures of Nursing and for maintaining standards of excellence in providing nursing care. The Interim Staff is under the direction/supervision of the Coordinator, Manager, and Director of assigned area, and shall be accountable to these persons for performing required patient care functions.
Section 10. Adjunct Staff
The membership of the Adjunct Staff includes non-Health System-employed individuals who are involved in providing patient care associated with various nursing or health-related educational programs. This category includes individuals who have completed the required nursing orientation to Health System in addition to the institution's requirements. Classifications in this category include Nursing School Instructors/Students, EMS Instructors/Students, Refresher Nurse Instructors/Students, and Occupational Health Instructors/Students. Written agreements with the educational institutions are obtained/kept current. The Director of Total Care University/Designee will serve on the Joint Clinical Resources Planning Committee of the Educational/Health Agencies of the Greensboro AHEC region and participate in all meetings of this committee. The Vice-President-Chief Nursing Officer holds individual meetings/conferences with Deans/Directors of Nursing Schools as needed or requested. Qualified nursing staff hold Adjunct faculty appointments in the area schools of nursing.
The Adjunct Staff is responsible for implementing selected functions related to patient care/nursing practice activities within the adopted standards, policies, and procedures of the Nursing Department and for maintaining standards of excellence in the provision of nursing care at High Point Regional Health. The students of the educational institutions are under the direction/supervision of their Registered Nurse instructors when performing selected patient care functions. The instructors/students of the educational institutions are accountable to Coordinators and Charge Nurses for completing selected patient care assignments. The Vice President-Chief Nursing Officer holds final administrative responsibility and authority for the Adjunct Staff in providing patient care in the hospital.
Section 11. Nursing Leadership
The membership of Nursing Leadership (Directors, Managers) includes individuals who have completed the nursing orientation/probationary employment period and meet performance standards. Responsibilities, qualifications, performance requirements, and evaluation criteria for the Nursing Leadership staff are delineated in the departmental position description summaries/standards. Nursing leaders are knowledgeable, risk takers, able to articulate and be role models of the nursing philosophy and advocate and provide support to the nursing staff.
The Vice President-Chief Nursing Officer holds the final responsibility and authority for the Nursing Leadership staff. The Directors and Managers, using the Forces of Magnetism as the foundation, are responsible for setting goals, priorities, strategies, and time lines regarding patient care/nursing practice activities, evaluating budgetary needs for human/material resources; coordinating departmental/interdepartmental activities impacting patient care/nursing practice; promoting/setting standards of excellence through nursing policies, standards of care/practice, and program/position statements; developing/promoting an environment that provides shared decision making and nursing practice based on evidence, supervising nursing staff and evaluating their performance/competencies in providing quality, compassionate, and cost-effective nursing care; collaborating with nursing, medical, and Health System staff and outside clinical/educational agencies for improvements in patient care/nursing practice.
Total Care Nursing Professional Practice Model
Nursing Governance Structure
The Governance Structure promotes/provides collaboration and shared decision making across the organization in nursing matters/issues related to patient care/patient outcomes and nursing practice. The Professional Registered Nursing Staff has ninety percent representation on the governance councils to ensure that decisions are patient centered and promote professional nursing practice.
Section 1. Governance Councils
There are seven governance councils that are responsible for nursing and patient care functions across the Health System. The councils are: Nursing Leadership Council, Nursing Manager Council, Professional Practice Council, Patient Experience Advisory Council, Evidence Based Practice and Research Council, Magnet Council and Peer Review Council.
Section 2. Nursing Representation
Departmental nursing representatives are Registered Nurses that provide direct patient care. Nursing representatives are selected from each department on a rotating basis with some tenure of service overlapping so that at no time shall the councils be made up of entirely new members. Unplanned vacancies on councils are filled with a staff RN appointed by the Director/Manager of the affected department. Selected representatives serve a minimum of two year term beginning in January of each year.
Section 3. Officers
The officers of the councils are designated as Chair, Chair-elect, and Secretary and are expected to fulfill the requirements of the office. The Chair, Chair-elect and Secretary of each council are elected by the members of the council. The term of office for the Chair is one year. The Chair-elect serves one term as Chair-elect until assuming the role of Chair. The term of office for the Secretary is no less than one year. A designated Nursing Manager serves as facilitator for each council (Professional Practice, Patient Experience Advisory, Evidence Based Practice and Research, Magnet and Peer Review). A designated Nursing Director serves as an advisor for each council. The Vice President/Chief Nursing Officer serves as advisor to Nursing Leadership, Nursing Managers and Professional Practice Councils.
The Chair of each council, in collaboration with the assigned facilitator, plans/conducts the meetings, assures documentation of the proceedings, and manages the business of the council. The Chair convenes a called meeting when deliberation is needed by the full council for any immediate/emergency decisions. The actions of the council meeting are reported at the next regularly scheduled meeting for review/approval. In the absence of the Chair, the Chair-elect assumes the responsibilities of the Chair. The Secretary of each council assures the minutes are distributed/published on the intranet at least 1 week prior to the next scheduled meeting. The Chair of each council represents his/her council on the Professional Practice Council.
Section 4. Nursing Leadership and Staff Representation on Health System Committees
The Vice President-Chief Nursing Officer represents and speaks for the Nursing Department and other Clinical Departments providing nursing care on matters related to nursing care and practice at designated Health System committees, i.e., Traditional Good Management Committee, Professional Improvement Committee (ex-officio), Medical Executive Committee, Medical Staff Therapeutics Committee, Group Practices, and Joint Patient Care Committees.
The Directors, Managers, Nursing Supervisors, Education Specialists, Coordinators, and/or Staff Nurses represent Nursing on other designated Health System committees as appointed, i.e., Cancer Care Committee, Environment of Care Committee, Ethics Committee, Infection Control Committee, Institutional Review Board, Group Practices, and Joint Patient Care Committees. Nursing leadership and nursing staff representation on Health System committees are provided as a means to collaborate with hospital, medical, and nursing staff across the organization on patient care issues and matters requiring multidisciplinary assessment and action plans to improve patient care delivery/outcomes and hospital systems/operations.
Nursing Care Delivery Model
The Nursing Care Delivery Model at High Point Regional Health, based on the belief that nursing is the link that facilitates person-centered care, consists of four concepts: nursing, person, health, and environment.
Nursing practice includes, but is not limited to, initiating and maintaining comfort measures, promoting and supporting human functions and responses, establishing an environment conducive to well-being, providing health counseling and teaching and collaborating on certain aspects of the health regimen with the goal of helping patients attain, maintain and restore health or experience a dignified death. This practice is based on understanding the human condition across the life span and the relationship of the individual within the environment.
Any individual who interfaces with High Point Regional Health.
A person’s perception of his/her state of wellbeing that encompasses mental, physical, spiritual, and emotional factors.
The location where programs and/or services are provided by nurses of High Point Regional Health.
Patient Care Goals
Provide exceptional care that ensures optimal patient outcomes, compassionate and cost effective care.
Provide timely and appropriate patient assessments by qualified and competent nursing staff on admission and throughout the patient's hospital stay.
Initiate goal-directed, individualized, and coordinated care planning consistent with the patient's physiological, psychosocial, learning, developmental, spiritual, and cultural needs.
Collaborate with the medical staff and other health care disciplines in providing timely, integrated, and appropriate patient care, patient/family education, and discharge planning on admission and throughout the continuum of care.
Promote the active involvement and participation of the patient, family, and significant others in making choices and decisions regarding patient care.
Maintain a positive relationship with all customers to increase the satisfaction of patient, family, significant others, physicians, other health care disciplines, support staff, students/faculty, and volunteers.
Council Membership, Role, and Responsibilities
Section 1. Nursing Leadership Council
A. Membership. The membership of the Nursing Leadership Council consists of the Vice President-Chief Nursing Officer who serves as the Chair, and Directors of nursing departments across the organization.
B. Mission. To provide leadership, guidance and support for the Total Care Professional Practice Model to ensure that nursing care is patient centered.
C. Responsibilities. The specific responsibilities of the Nursing Leadership Council are:
promote the integration of nursing into the organizational functions of the Health System by recommending nursing staff appointments to Health System committees, Group Practices and Special Committees or Task Forces.
provide an environment of shared decision making and evidence based practice.
provide leadership to the Professional Practice Council that establishes expectations for quality, service, people, value and access.
evaluate recommendations for process improvements, new supplies/equipment, and allocation of human and financial resources and approve/disapprove.
collaborate with the Deans, Directors, and/or faculty of Nursing Schools utilizing the Health System as a clinical facility and make recommendations related to the curricula and clinical and/or managerial learning experiences of LPN, ADN, BSN, and MSN students.
provide leadership in the promotion of research of nursing practice by serving as mentors and/or co-investigators.
review any questions and make interpretations regarding the scope of nursing practice for the Registered Nurse, Licensed Practical Nurse, and Nurse Aid I/II as defined/interpreted by the N.C. Board of Nursing and Nursing Practice Consultants.
Section 2. Nursing Manager Council
A. Membership. The membership of the Nursing Manager Council consists of managers responsible for nursing departments across the Health System.
B. Mission. To provide leadership in development of environments through shared decision making that promotes and facilitates the practice of professional nursing.
C. Responsibilities. The specific responsibilities of the Nursing Manager Council are:
provide an environment of shared decision making.
evaluate trends related to outcomes and recommend, and implement improvement strategies.
provide input for purchase of new supplies/equipment.
provide input for allocation of human and financial resources.
provide leadership to assigned councils.
develop and implement linkage strategies for optimal outcomes.
collaborate with education specialists to develop appropriate and meaningful learning strategies.
collaborate with patient care coordinators to develop appropriate and meaningful patient care continuum strategies.
Section 3. Professional Practice Council
A. Membership. The membership of the Professional Practice Council consists of the Vice President-Chief Nursing Officer, Magnet Council Chair, Evidence Based Practice and Research Council Chair, Patient Experience Advisory Council Chair, Peer Review Council Chair, at least one registered nurse representative involved in direct patient care from each nursing specialty, one nursing manager and one nursing director.
B. Mission. To provide leadership in development and promotion of a nursing care delivery system that is patient centered and creates a professional practice that is nurse centered.
C. Responsibilities. The specific responsibilities of the Professional Practice Council are:
participate in the development, review, and revision of the nursing mission, goals, bylaws, strategic/operation plans, budget/resource allocations, and the nursing administrative standards and policies.
participate in the development and review of the Nursing Balanced Scorecard and development and implementation of corrective action plan when indicated.
submit input to the Vice President-Chief Nursing Officer in the development, review, and revision of the Nursing and Health System mission, goals, strategic/operation plans, budget, resource/space allocations, and administrative policies.
promote the integration of the Forces of Magnetism as the foundation of nursing excellence.
facilitate the coordination and collaboration in and between nursing and other Health System departments by the appointment of nursing representatives from all departments providing nursing care to the clinical councils and special committees.
promote coordination, communication, collaboration and shared decision making between the medical, nursing, Health System staff and clinical councils on matters related to patient care delivery/outcomes and systems/operations.
review the performance data and performance improvement recommendations/action plans related to patient care processes/outcomes and make further recommendations as indicated.
review the nursing sensitive data (National Database for Nursing Quality Indicators) and performance improvement recommendations/action plans and make further recommendations as needed.
evaluate the progress/status of Nursing goals, priorities, strategies, time lines, and accomplishments on an ongoing/annual basis.
evaluate suggestions for process improvements and recommend teams to develop and implement action plans.
pursue innovative and cost-effective strategies to improve the productivity, efficiency, and effectiveness in the care of patients/significant others and the clinical/managerial performance of the nursing staff.
develop/support/evaluate the nursing credentialing system and staffing plans for providing sufficient and competent nursing staff.
develop/support/evaluate nursing programs that promote the recruitment/retention, recognition/reward, and development/education of the professional nursing staff, which may include but are not limited to certification, specialty provider and advanced degrees.
participate in the evaluation, selection, and implementation of health care technology and information management systems that support and/or improve patient care/nursing practice.
collaborate with internal/external nursing leaders regarding patient care/nursing practice issues and legal/regulatory requirements affecting nursing practice and elicit recommendations for improving the quality of patient care/nursing practice.
promote and support the research of nursing practice by nursing staff and nursing students/faculty in BSN, MSN, and PhD programs and refer all investigators to the Evidence Based Practice and Research Council for review/approval of nursing research proposals.
Section 4. Patient Experience Advisory Council
A. Membership. The membership of the Patient Experience Advisory Council consists of at least one registered nurse representative involved in direct patient care from each nursing specialty, and at least one representative from Respiratory Therapy, Laboratory, Rehab Services, Radiology and Pharmacy.
B. Mission. To develop, implement and improve processes which enhance patient care and patient outcomes through interdisciplinary collaboration and coordination across the Health System.
C. Responsibilities. The specific responsibilities of the Patient Experience Advisory Council are:
- develop/support/recommend changes to patient care delivery that embraces the concepts of an exceptional patient experience.
- review the standards of care recommendations submitted from the Evidence Based Practice and Research Council and develop, deploy and evaluate the processes that support these standards.
- communicate recommendations for performance improvement activities/research projects to the Evidence Based Practice and Research Council.
- in collaboration with the Evidence Based Practice and Research Council, initiate systematic/coordinated performance assessment and data collection across the Health System on a concurrent and continuous basis using defined performance measures or indicators, sampling techniques, evaluation methods, and various data sources.
- in collaboration with the Evidence Based Practice and Research Council, review and analyze performance assessment findings, patterns, or trends, undesirable variations, and/or single clinical events including the use /interpretation of statistical quality improvement tools.
- in collaboration with the Evidence Based Practice and Research Council, evaluate the effects of action plans taken through ongoing performance assessment, measurement and improvement activities.
Section 5. Evidence Based Practice and Research Council
A. Membership. The membership of the Evidence Based Practice and Research Council consists of at least one registered nurse representative involved in direct patient care from each nursing specialty.
B. Mission. To assure a quality standard of patient care through research and performance measurement.
C. Responsibilities. The specific responsibilities of the Evidence Based Practice and Research Council are:
explore related scientific/nursing literature and internal/external professional/specialty practice standards as a basis for changing and improving nursing standards of care, practice, and performance across the organization.
set performance expectations/goals for improvement opportunities/processes and initiate performance improvement action plans.
identify important aspects of patient care and define process/outcome performance measures of indicators for each clinical area.
communicate recommendations for performance improvement/practice changes to the Patient Experience Advisory Council and/or appropriate Group Practice(s).
serve as a resource in promoting the understanding and effective use of organizational, management, and nursing theories and research.
promote and support nursing research by the nursing staff, council members, nursing students/faculty of BSN, MSN, PhD programs and encourage collaboration between nursing staff and faculty of area nursing schools.
review, evaluate, and make recommendations to the IRB for approval, approval with special requirements, and/or non-approval of all clinical nursing research proposals submitted to the council from nursing staff, students, and faculty.
submit any clinical research proposals involving human subjects to the Health System Institutional Review Committee for review/approval.
review and evaluate the written findings and the verbal presentations of the findings of all nursing research conducted within the institution.
in collaboration with the Patient Experience Advisory Council, initiate systematic/coordinated performance assessment and data collection across the Health System on a concurrent and continuous basis using defined performance measures or indicators, sampling techniques, evaluation methods, and various data sources.
in collaboration with the Patient Experience Advisory Council, review and analyze performance assessment findings, patterns, or trends, undesirable variations, and/or single clinical events including the use /interpretation of statistical quality improvement tools.
in collaboration with the Patient Experience Advisory Council, evaluate the effects of action plans taken through ongoing performance assessment, measurement and improvement activities.
Section 6: Magnet Council
A. Membership. The membership of the Magnet Council consists of at least one registered nurse representative from each nursing specialty.
B. Mission. To champion a professional practice environment through the deployment of the Forces of Magnetism.
C. Responsibilities. The specific responsibilities of the Magnet Council are:
participate in the review, communication and maintenance of the ANCC Magnet Designation.
identify and promote mechanisms in the nursing practice setting to facilitate nurse satisfaction, recognition and retention in collaboration with other appropriate councils.
administer reward and recognition programs for nursing advancement and nurse retention.
provide staff education related to program requirements and annual celebration activities.
promote and support professional growth through certification and recertification.
promote annual RN satisfaction survey, report results and collaborate with nursing leadership to set priorities for improvement.
Section 7: Peer Review Council
A. Membership: The membership of the Peer Review Council consists of one registered nurse from the following specialty “clusters”:
Day Hospital, Endoscopy, PACU
ICU, SICU, CCU, CTU, Critical Care Corp
5N, CBS, Nursery
OCU, Radiation Therapy
ED, SANE, Critical Care Transport
Supplemental Staff, Float Pool, IV Therapy, Patient Flow Nursing
Behavioral health (Inpatient, Outpatient)
OR, Specials, Cardiology, Cardiac Observation, Cath Lab
7N, MTU, Dialysis
Diabetes Center, Wound Care Center, Adult Health Center
B. Mission: To improve patient outcomes and enhance nursing performance by supporting a Just Culture.
C. Responsibilities: The specific responsibilities of the Peer Review Council are:
enhance nursing performance through assessment, education and/or coaching.
provide a mechanism to promote improvement through mutual accountability and assessment by peer group.
D. Membership Qualifications:
- Direct Care Nurse
- Minimum of 5 years experience in nursing; not confined to HPRHS
- 2 years experience in area of specialty
- No disciplinary issues
- Ability to be objective, unbiased, impartial and non-judgmental
- Recommendation from Manager/Director
E. Term of Service: 2 year term; staggered rotation – the term of implementation – 50% (6 staff nurses) would rotate off after serving 2 years and the other 50% (6 staff nurses) would come off after serving 36 months.
Section 8. Collaborative Patient Care Management Group Practice
A. Membership. The membership of the Group Practices consists of physician, nursing, and allied health representatives from the clinical disciplines and support departments providing patient care to the specific case type including: Laboratory, Rehabilitation Services, Respiratory Care, Pharmacy, Nutritional Services and Social Services. When appropriate, membership shall also include representatives from physician office staff, home health agencies, and community agencies.
B. Mission. To enhance the health outcomes of citizens in our community through the promotion of quality, cost-effective care, disease management, and health education.
C. Responsibilities. The specific responsibilities of the Group Practice are:
collaboratively define the standard of patient care through the incorporation of relevant clinical practice guidelines/parameters, specialty standards, scientific and clinical published literature, and reference data bases.
develop/review/revise the standard plan of care for assigned case type including process and outcome performance measures.
define and assess comprehensive process and outcome performance measures and identify areas for possible improvement.
measure on a continuous basis existing processes and outcomes of patient care.
identify clinical patterns or trends, undesirable variations, or single clinical events that require intensive assessment.
identify and prioritize potential improvement strategies involving the relevant departments and individuals.
recommend improvement strategies to the appropriate organizational committees or departments.
document and report measurement data, assessment, and improvement strategies on a quarterly basis to the appropriate departments/committees.
pursue innovative and cost-effective strategies to improve the productivity, efficiency, and effectiveness in patient care and clinical practice.
assess and evaluate patient and family education resources and develop/revise processes and materials to meet the educational needs of patients and families.
serve as a resource for health care team members in the management of the specific case type.
develop goals, priorities, and strategies designed to direct Group Practice activities on an annual basis and evaluate the progress/status and accomplishments in meeting those goals.
Section 1. Formulation of Standing/Special Committees
Standing/special committees and multidisciplinary task teams involving nursing staff are formed and convened at the request of the Health System/Nursing Leadership including the Vice Presidents, Directors, and Clinical Councils. The Standing/Special Committees are formed to facilitate coordination, collaboration and shared decision making between nursing leaders/staff and other Health System leaders/staff regarding mutual concerns or action plans related to patient care delivery, nursing/systems and processes, and professional practice issues.
Section 2. Other Special Committees/Multidisciplinary Task Teams
Other special committees or multidisciplinary task teams are named at the time the group is formed and purposes/objectives established. The committees meet to collaborate on patient care and systems/process concerns which require multidisciplinary assessment, planning, evaluation, and performance improvement strategies/recommendations to improve the relevant dimensions of nursing/organizational performance (i.e. appropriate, available, timely, effective, coordinated, safe, efficient, caring and respectful.)
Section 1. Council Meetings
All Council Meetings are business meetings and are held at least monthly to carry out the respective responsibilities and work. The Chairs, Chair-Elects, and Secretaries fulfill the responsibilities of officers as outlined. Minutes are recorded at all council meetings according to the adopted format.
Section 2. Group Practice Meetings
All Group Practice meetings are held at least quarterly. A physician chairs the Group Practice meetings. Minutes are recorded according to the adopted format.
Section 3. Meetings of Other Special Committees
Meetings of other special committees or multidisciplinary task teams are held as frequently or as long as needed to complete the assigned or designated tasks/purposes. These committees or teams are dissolved when the tasks/purposes are completed, documented and reported to the appropriate councils/teams, departments, or individuals. Minutes are recorded at all meetings of other special committees according to adopted format, are disseminated by or at the next regularly scheduled meeting, and are signed/placed in the appropriate unit/ department, and Inpatient Administration office manuals.
Section 4. Nursing Staff Meetings
Nursing Department/Staff meetings of all clinical nursing specialties are held at least quarterly. Meetings are scheduled according to unit/staffing patterns to facilitate attendance/participation of all nursing personnel to discuss/collaborate on opportunities to improve patient care and resolve any problems or concerns related to patient care/nursing practice. Agendas for nursing staff meetings include reports from all clinical council meetings and the Education Specialists. The Director/Manager/Coordinator facilitates the meeting.
Section 5. Called Meetings
Special meetings of any of the categories of nursing staff, any of the Nursing Councils or Standing Special Committees are called at any time by the Vice President-Chief Nursing Officer or at the request of the Health System President, Vice Presidents, Nursing Leadership, Chairs of Councils/Teams or any representative group of the nursing staff. At any special called meeting, there will be no business transacted except that stated in the notice of the called meeting. Minutes are recorded at the discretion of the person conducting the called meeting.
Section 6. Order of Business
The order of business at any regularly scheduled meeting of the clinical councils, standing special committees, nursing staff meetings and nursing management meetings is:
A. Call to order
B. Approval of minutes
The order of business at special or called meetings shall be:
A. Call to order
B. Reading the notice of called meeting
C. Transaction of business for which meeting called
Section 7. Voting
One-half (1/2) of the total representation of a council or committee constitutes a quorum and shall be deemed appropriate for conducting the business of a council or committee and for voting on any issues not agreed upon through group consensus. The Peer Review Council will base all decisions by vote. The vote must be decided by a two-thirds result. All nursing representatives with the exception of the Nursing Leadership facilitator, present at any given meeting have one equal vote when voting on an issue. The Chair is allowed to vote only when breaking a tie vote is needed. Ex-officio members and Interim or Adjunct staff are not allowed to vote. Provisional staff are not allowed to vote during the orientation/probationary employment period. The vote of the majority of nursing representatives at any given meeting shall rule.
Reviewed: 2/81; 1/83; 1/85; 1/86; 1/87; 10/91; 7/93
Revised: 2/82; 1/84; 1/88; 3/90; 12/90; 1/94; 1/97; 1/00; 4/01; 7/03; 11/04; 3/06; 7/06; 10/06; 1/09; 10/09; 1/12
This policy is published as a guide to employees. The standard of care or procedure, for any particular situation is dependent on many factors, which impact decisions and the care given to patients. We recognize the applications of policies are subject to common sense, good judgments, laws, rules and regulations