4.3 Describe how staffing plans and practices are consistent with the ANA Principles of Nurse Staffing.

The MGH Department of Nursing (DON) embraces the recommendations and underlying

assumptions of the ANA Principles of Nurse Staffing. The evidence submitted in this document, as

well as OOD 15 and Forces 1, 4 and 5, demonstrates our strong commitment to and utilization of a

patient classification system to assure adequate staffing levels based on patient, staff and unit

variables; a well defined competency program for all direct care staff; a culture of valuing and

appreciating employees; and organizational policies that consider a balance of patient and staff

needs.

I. Patient Care Unit Related

a). Appropriate staffing levels for patient care unit reflect analysis of individual and aggregate

patient needs.

OOD 15 describes WinPFS® Acuity, Productivity and Benchmarking System (WinPFS®

System) used at MGH to identify individual patient care needs, classify patients, provide a measure

of nursing acuity, and calculate unit workload. The WinPFS® System groups patients into similar

categories based on nursing care needs and assigns a relative value to each category. Within each

category or patient type, the number of patients is multiplied by the relative value for that patient

type then the category workloads are added for a total unit workload. Thus, for any given time

period, information about specific patient needs, as well as overall unit workload, is available.

Previous Forces 1.5 and 1.6 describe how this system is used to monitor direct care staff

utilization, budget for direct care resources, and predict variable non-salary expenses. Forces 4 and

5 will include examples of how the data is used in scheduling and staffing plans. The WinPFS®

System has been used at MGH for over 20 years and is considered a credible tool for predicting and

justifying direct care resources to both nursing staff and those outside nursing, such as

administrators and financial officers.

b). There is a critical need either to retire or seriously question the usefulness of the concept

of nursing hours per patient day (NHPPD).

The data collected through the patient classification system is widely accepted at MGH.

When focusing on a measure of staffing effectiveness or adequacy, nursing leaders consistently use

the indicator of Hours Per Workload Unit (HPWI) provided by the classification system. HPWI is a

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much more refined measure of staffing than NHPPD, as it incorporates not only census, but also

factors in patient acuity, providing a weighted census which is then used in a ratio to measure direct

care staff hours per workload. Nursing leaders are very familiar with HPWI as a productivity

measure. Real-time data is available electronically on all clinical computers and nursing leaders are

attentive to the weekly monitoring reports that provide an on-going measure of staff adequacy in

meeting patient care needs.

The routine measurement of NHPPD for budgeting or tracking purposes was infrequent at

MGH prior to 2002. Since that time, participation in national databases for benchmarking (e.g.,

National Database Nursing Quality Indicators (NDNQI), National Quality Forum) and new State

requirements for data submission (e.g., Patients First) has necessitated quantifying staffing by

NHPPD. As not all hospitals have patient classification systems, NHPPD has emerged as a

universal measure that allows for comparable evaluation. In addition, most of the recently-

published articles suggesting relationships between direct care staffing levels and patient outcomes

have also referenced NHPPD.

MGH currently submits patient days and nursing hours by role group to NDNQI to provide

a comparison of MGH unit performance for Total Nursing Care HPPD, RN HPPD, and RN Mix

to NDNQI benchmarks (provided by unit type for hospitals with more than 500 beds). In addition,

through participation in the state wide Patients First initiative, each unit’s staffing plan (i.e., the

budgeted number of shifts by role group and the resulting worked HPPD) is available to the public

on a website. Actual data for each unit’s worked HPPD, is also posted on the web-site on an annual

basis.

Despite this recent trend of reporting HPPD externally, MGH nursing leadership remains

conscious of the serious limitations of this measure, especially when a more refined measure such as

HPWI is available. There is also concern regarding the ability of the public to be able to interpret

the NHPPD data in a meaningful way and to make accurate comparisons. For example, in 2006

MGH provided data for Ellison 18, one of the MGH pediatric general care units for the Patients

First initiative. This staffing plan included a planned or budgeted worked HPPD of 9.98

(attachment 4.3.a). The actual FY’2006 experience for Ellison 18, however, was a slightly lower

census (17.0 vs. 18.0 budget) and slightly lower patient acuity (1.65 vs. 1.72 budget), resulting in a

lower workload than expected (28.1 vs. 30.9 budget). To adjust to this variance, the unit used, on

average, 1.5 less direct care shifts per day (18.6 vs. 20.1 budget). The Workload/Productivity Report

for September 2006 YTD (attachment 4.3.b) demonstrated that despite this reduction in staffing, the

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unit maintained an HPWI that was slightly above budget and within 5% of their target (5.30 vs. 5.20

budget), indicating an appropriate reduction based on workload. In contrast, the data provided for

the Patients First initiative included an annual report of actual utilization, which showed a worked

HPPD of 8.95 against the planned or budgeted worked HPPD of 9.98. There is concern that this

single measurement could be interpreted by the public as providing “inadequate” staffing, when it

fact the staffing was appropriate for patient care needs.

c). Unit functions necessary to support the delivery of quality patient care also must be

considered in determining staffing levels.

Consideration of unit functions in determining staffing levels is most clearly seen in the

decisions regarding establishing a target HPWI target for a nursing unit. The WinPFS® System

staffing framework describes an expected range of four to seven hours of direct care time per unit of

work (HPWI). The organization determines its own target within that range. The HPWI, or

intensity of resources, allocated to specific units may vary as a result of a variety of issues around

patients, staff, support, and structure or logistics of the unit as noted in the attached flow chart

depicting the relationship of staffing to workload (attachment 4.3.c).

In general, the critical care units are targeted at a higher HPWI than the routine units,

because of logistical issues of reasonableness. For example, if one patient requires 18 hours of care

in a 24-hour period, there is not likely to be in that same unit another patient who requires only 6

hours of care; thus, the available average HPWI for the unit will increase. As another example, the

Pediatric Intensive Care Unit (PICU) is a small unit and historically has had significant fluctuations

in census and workload. At times, the unit must meet minimum staffing requirements (i.e., two staff

nurses on each shift if there are any patients at all in the unit or 48 hours of care per 24-hour period)

even if the one or two patients in the PICU require only a total of 24 hours of care in the 24-hour

period. Again, the average HPWI for the unit will be greater than would be necessary without this

logistical challenge.

There are also several units that include both critical care and general care patients that

receive care from one integrated staff, including the Burn Unit, the Transplant Unit, Ellison 14

(general oncology with designated bone marrow transplant), Bigelow 9 (chronic ventilator support

and general medicine) and Ellison 7 (general surgery with four bed Trauma Care Unit). The HPWI

for these units is calculated using a critical care-level HPWI for the critical care workload and a

routine-level HPWI for the general care workload. The result is a blended HPWI that reflects the

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broad range of patient care requirement on the same geographical unit. The delivery model may also

affect the targeted HPWI. On Bigelow 11 General Medicine, which has an all-RN model, the

targeted HPWI is lower than that of similar medical units because delegation to and supervision of

non-RN staff is not required of the Staff Nurses. Originally, the unit had primarily experienced Staff

Nurses and the HPWI target was about 12% lower than that of other general medical units.

However, for the past few years the unit has focused on recruiting new graduates and the HPWI has

subsequently been increased to within 6% of other general care units to accommodate for the larger

number of inexperienced Staff Nurses.

In the Obstetrics areas, standards common to the specialty, as well as risk management

recommendations, are consulted in determining staffing requirements. In addition to the specialty

standards for care of patients in labor, delivery and recovery and of mother-baby couplets, standard

time requirements have been established for other obstetrical activities such as triage, observation,

non-delivery admissions and related surgical procedures. The volume of these activities is projected

as a ratio of activities to deliveries, based on current and historical experience, and the staffing

projections incorporate the care needs for patients across the continuum. HPWI targets for the

Family Care Units reflect the specialty standards for mother-baby couplets, the patients’ needs for

nursing care identified through the classification system, and the logistical challenges of staffing

separate post-partum and nursery areas.

II. Staff Related

a). The specific needs of various patient populations should determine the appropriate

clinical competencies required of nurses practicing in that area.

The Norman Knight Nursing Center for Clinical & Professional Development (Norman

Knight Nursing Center) oversees the orientation and competency programs for Department of

Nursing (DON) employees. In addition to the orientation and annual competency assessment

described later in this document, Staff Nurse new hires, including RN contract agency staff,

complete a unit-based orientation specific to their practice area. The unit-based program is

competency based, involves assignment with a preceptor and extends for a designated period of

time that is tailored to the individual.

The average length of time for employee unit orientation is two to six weeks for general care,

six to 12 weeks for critical care, and up to six months for procedural areas such as the operating

room. During the orientation, a unit-specific competency checklist is completed for all employees.

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The competency checklists are created by the unit-based CNSs and include competencies specific to

the populations cared for on the unit. Agency Staff Nurses are required to complete the same unit-

specific competency checklist as MGH Staff Nurses. In general, the competency checklists have

several pages of competencies that are generic to nursing throughout the organization. Unit-specific

competencies that reflect the unit’s patient populations are then added to the form. Attachment

4.3.d contains samples of unit-specific items that have been added to the competency checklists for

the Yawkey Infusion Unit and Bigelow 9, the Respiratory Acute Care Unit.

b). Registered nurses must have nursing management support and representation at both the

operational and executive level.

As described in Force 2.1, the Chief Nurse represents Registered Nurses at the executive

level as a member of the senior management team, and as such, is responsible for coordinating the

development and implementation of programs to fulfill the patient care, research, and educational

missions of the organization. The Chief Nurse attends and participates in Board of Trustees and the

Chief’s Council, and is a voting member of the General Executive Committee and the Patient Care

Assessment Committee. The Chief Nurse is a strong advocate and support for nurses and patient

care in these executive level forums.

Force 2.3 describes the valuable role of the Associate Chief Nurses, who provide senior level

nursing management. The four Associate Chief Nurses provide oversight to their respective patient

care units and have high-level relationships with other leaders in the organization to support nursing

practice and promote patient care. Several examples are provided throughout the evidence to

demonstrate their role in strategic planning, program planning and facility changes, major

organizational projects (e.g., information system upgrades), service-line activities (e.g., Cancer

Center, Heart Center and Vincent Gynecology and Obstetrics), as well as unit leadership triad

suport.

Two of the members of the unit-based leadership triad, the Nursing Director and the

Clinical Nurse Specialist, provide nursing management support for unit-based operations. These key

nursing leadership positions assure that nursing is a strong presence and active participant in the

clinical operations of the unit, and that there is decentralized clinical decision-making and patient-

centered care.

c). Clinical Support from experienced RNs should be readily available to RNs with less

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proficiency.

The DON leadership is committed to providing clinical support to all nurses providing

direct care. Resources such as the Clinical Nursing Supervisors, the Rapid Response Team Staff

Nurses, Resources Nurses, Clinical Nurse Specialists, and expert Advanced Practice Nurses are

available to assist all nurses, regardless of years of experience, length of service, or competence in a

clinical specialty. In addition, nurse preceptors are an important resource for the less proficient

nurse.

Clinical Nursing Supervisors – In addition to their administrative role involving the

prioritization and triage of internal bed and external transfer requests, the Clinical Nursing

Supervisors (Supervisor) play a key role in supporting the Staff Nurse at the bedside. Three Clinical

Nursing Supervisors are scheduled each shift, seven days a week including holidays and weekends.

The Supervisor brings a strong clinical knowledge and expertise to both the clinical and

administrative processes, as well as an understanding of the available resources (i.e., ICU beds) and

their established relationships with the staff on the patient care units. The role of the Supervisor in

supporting patient care is described in their position description:

3.0 Patient Care Management - Serves as a clinical resource in the management of patient care.

3.1 Performs the role of central code call nurse and responds to patient care emergency

situations

3.2 Provides clinical consultation to staff

3.3 Assists staff in managing unit activity

3.4 Collaborates with other departments to facilitate/support patient care.

Rapid Response Team - As presented in Forces 1.3 and 1.7, the Rapid Response Team can

be deployed to units at the request of the unit staff or at the direction of the Clinical Nursing

Supervisor. They provide staffing for short periods of time to support fluctuations in volume or

acuity, to travel with high-risk patients to procedural or test areas, to assist with unit to unit patient

transfers, or to act as clinical resource and staff support around unfamiliar procedures and

equipment.

Staff Nurse Preceptors – The Staff Nurse Preceptor (Preceptor) is an experienced, clinically

competent Staff Nurse who works with newly-hired nurses to assist in their orientation to the unit

and hospital. The Preceptor serves as an educator, role model, facilitator, and clinical “coach”, as

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45

well as a partner in planning and guiding clinical experiences, professional socialization and role

transition. Force 4.7 highlights the improvement efforts involving the creation of a New Graduate

Task Force. This group held focus groups with new graduate nurses to obtain meaningful feedback,

which included positive remarks about the value of Preceptors.

Resource Nurses – The Resource Nurse role was developed in response to staff feedback

requesting additional support for unit-based, shift-to-shift operations. As described in Force 4.12,

the Resource Nurse supports the unit by “addressing staffing needs on an ongoing basis, facilitating

throughput of admissions and discharges, assisting with direct patient care as needed, and role

modeling effective collaboration and conflict management with patients, families and other

members of the healthcare team.” The Resource Nurse, in addition to the unit leadership triad, is

available to provide assistance to less experienced Staff Nurses, who often describe the transition

from orientation to Staff Nurse as stressful and clinically challenging.

Clinical Nurse Specialists – The Clinical Nurse Specialist (CNS) role is an integral part of the

unit leadership triad. Considered bedside “experts”, these master’s prepared Advanced Practice

Nurses provide clinical support to nursing staff and are responsible for unit-based educational and

competency programs. The CNSs also provide clinical specialty consultation to Staff Nurses on

other patient care units when requested (i.e., an obstetrical patient on the Burn Unit). As identified

in the CNS position description, the CNS “supports independent nursing practice of professional

nurses through collaborative, consultative, and role modeling activities, facilitates the acquisition of

advanced clinical skills in Staff Nurses through role modeling, practice, and consultation in the

clinical setting, develops, implements, and evaluates unit-based orientation programs, and supports,

participates, and designs educational programs for staff.”

In the past few years, as MGH has hired larger percentages of new graduate nurses. As a

result, nursing leadership has made a purposeful decision to continuously review the scope of the

CNSs responsibilities and to decrease the scope when appropriate (see example in Force 1.7). The

DON has been successful in adding CNS positions, to support the inexperienced nurse as well as

the specialized needs of particular patient populations.

Year 2003 2004 2005 2006 2007

Budget CNS FTEs 45.7 50.2 52.3 56.1 62.5

Centrally-Based Expert Clinical Nurses Specialists – The DON is fortunate to have a

number of nationally-known nurse experts who are centrally based and remain available to Staff

Nurses to support clinical decision making in specialized areas. Two examples of this are the

doctorally-prepared CNS nurse experts in ethical decision-making and wound/skin care.

The Clinical Nurse Specialist in Ethics is available to support Staff Nurses throughout the

organization providing consultation about ethical quandaries or cases. Although there are

committees available for formal ethics consultations (e.g., the Pediatric Ethics Committee, the

Optimum Care Committee), many nurses benefit from discussing a particular case or concern prior

to taking the step of formal consultation. The Clinical Nurse Specialist in Ethics serves as a

sounding board and is available to discuss a case individually or may suggest that a nursing meeting,

or team meeting take place to process the case or issue.

Serving in the role of consultant and educator, the Clinical Nurse Specialist in Wound Care

is an expert resource for skin care and wound management. When a unit-based CNS or Staff Nurse

encounters a challenging wound care issue, he/she may request a telephone or bedside consultation.

The Wound Care CNS usually examines the patient with the Staff Nurse involved, assesses the

etiology and status of the wound, and develops or revises the plan of care. Identified interventions

often involve the selection of specific products based on the clinical assessment of the wound bed.

III. Staff Related

a). Organizational policy should reflect an organizational climate that values registered

nurses and other employees as strategic assets and exhibits a true commitment to filling

budgeted positions in a timely manner.

The leadership of MGH and Patient Care Services (PCS) is keenly aware of the link between

the valuable assets of its employees and the organization’s ability to meet strategic goals, such as

quality patient care, the growth of specific services, and new program development. As described by

the Hospital President in the most recent annual report:

“While new magazines, scientific breakthroughs, buildings and programs are tangible results of a

productive year, what truly defines MGH are its people – the physicians, nurses, other professionals,

administrators, supports staff and volunteers – the dedicated individuals who tend to the needs of patients and

families and ensure that the institution runs smoothly and effectively.”

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The PCS Collaborative Governance (CG) model (Force 2.3) also demonstrates the

importance and value of nurses and other health care professionals. CG places “the authority,

responsibility and accountability for patient care with practicing clinicians. CG is based on the beliefs

that a shared vision and common goals lead to a highly committed and productive workforce, that

participation is empowering and that people will make appropriate decisions when sufficient

knowledge is known and communicated.” CG optimizes staff participation in organizational

decision-making within and across disciplines.

MGH and PCS leaders appreciate the challenges and significant impact of shortages in

nursing and other clinical role groups, and believe that being positioned as the “employer of choice”

in Boston health care is essential. This inevitably involves multiple strategies aimed at both

recruitment of new staff and retention of employees. For PCS employees this includes competitive

wage programs, supportive work environments, recognition and rewards programs, and a dedicated

PCS Human Resource team. For Nursing Directors this requires organizational support, leadership

development, and local fiscal authority and accountability. Several years of MGH’s favorable

financial performance has allowed continuous growth in the organization, resulting in end-of-year

bonus checks for all PCS employees to recognize their contribution to the organization’s success

and further a positive work environment.

Once the fiscal personnel budget is approved, managers have the full authority to work with

Human Resources (HR) to fill all available positions. Each Director works with a designated HR

Generalist and/or Recruiter who is familiar with their unit and specialty area. The close working

relationship between HR and the Nursing Directors has resulted in a well-honed recruitment and

interview process. HR assists the Nursing Directors with resume distribution, prescreening of

candidates, scheduling of HR and Nursing Director interviews, checking references, extending offers

and managing the new hire process for candidates who accept a position. Although HR utilizes the

MGH website, other external websites, print advertisements, direct mail and recruitment fairs as

necessary to attract qualified staff, many candidates are referred by current employees.

To begin the hiring process, Nursing Directors communicate their staffing needs to HR. To

track vacancies and new hires, HR uses a vacancy tool, which is updated on a monthly or more

frequent basis by the Nursing Resource Coordinator. This process is extremely fluid, often involves

discussions with the Nursing Director to determine current or future unfilled positions on his/her

unit. If there are vacant positions within the annual approved budget, there is no further approval

47

process necessary and active recruitment begins at the request of the Nursing Director. Recruitment

for positions beyond the approved budget requires approval by an Associate Chief Nurse.

The Chief Nurse and Associate Chief Nurses consistently review and communicate the

expectation that Nursing Directors will fill vacant positions in a timely fashion. A Filled Position

Report that tracks budgeted Full Time Equivalents (FTEs), filled positions, employees hired into

positions but not yet started, vacant positions and percent of positions vacant is created on a

monthly basis and distributed to Nursing Directors and Associate Chief Nurses (attachment 4.3.e).

The unit level accountability for recruitment and hiring into approved positions has been

extremely effective. During most years, the Department of Nursing begins the year with a Staff

Nurse vacancy rate of about 5%, primarily due to the expectation for increased volume and the

resultant newly approved positions for the fiscal year. As the year progresses that vacancy rate

generally falls to about 1%.

b). All institutions should have documented competencies for nursing staff, including agency

or supplemental and traveling RNs, for those activities that they have been authorized to

perform.

The MGH Department of Nursing policy for Competence of Licensed and Unlicensed

Personnel is included as attachment 4.3.f. As is presented in that document, “The competence of

licensed clinicians who practice at Massachusetts General Hospital is maintained through a

combination of ongoing competence assessment and educational activities.” Competence

assessment includes assuring professional licensure, completion of a competency-based orientation

Month FY'06 FY'07

October 5.6% 4.9%November 5.3% 3.8%December 4.9% 4.6%January 5.9% 4.3%February 4.6% 4.1%March 4.6% 2.9%April 4.5% 2.9%May 3.6% 2.4%June 2.9%July 2.4%August 1.6%September 0.9%

Direct Care Staff Nurse Vacancy Rate

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program, the performance appraisal process, annual required training, annual hospital, departmental

and/or unit-specific competency achievement, age specific competencies, and on-going educational

activities.

The Norman Knight Nursing Center for Clinical & Professional Development oversees the

orientation and competency programs for PCS employees. All new employees, including RN agency

contracted staff, complete a day of hospital orientation followed by a Department of Nursing

(DON) orientation that is tailored to various clinical role groups. The DON component provides

an overview of the nursing service, introduces staff to key clinical practices, and evaluates some of

the required clinical competencies. For direct care nurses, the content includes culturally competent

care, patient rights and confidentiality, delegation and supervision, emergency response and

preparedness, review of equipment, infection control practices, blood product administration, and

resources available to staff. Skill demonstration and competency evaluation is completed for point-

of-care testing, medication administration, and arrhythmia interpretation. Staff Nurse new hires,

including RN contract agency staff, also complete a unit-based orientation specific to their practice

area, as described earlier in the document.

Job-related training is provided for those employees hired as Patient Care Associates (PCA),

Operations Associates (OA), and Unit Service Associates (USA). The length of the orientation

programs vary by role: PCA (3 to7 weeks); OA (4 weeks); and USA (2 1/2 weeks). All programs

include didactic lecture and classroom practice sessions and instructor-led learning activities in the

work setting.

Yearly, assessment of competence is documented at the time of the employee’s annual

performance review. Employees in PCS are considered in five categories and annual training and

competences are specific to each group’s work responsibilities. The employee categories and annual

required competencies for 2007 are included below.

CATEGORIES OF REQUIRED TRAINING

CATEGORY A Employees in Category A are in roles that do not require them to have direct contact with patients. Only the basic level of required training must be completed at time of hire and annually. CATEGORY B Employees in this group have roles which require them to be in the patient environment but who do not have hands on contact with patients. In addition to the basic requirements, these employees must annually complete the sections pertaining to Infection Control, Precautions, Bloodborne Pathogens, TB education, and PPD Testing.

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CATEGORY C Employees in this group work in a patient care environment but have limited hands on contact with patients. In addition to Category A and B requirements, these employees must complete BLS/CPR CATEGORY D Employees in this group have extensive contact with patients. These employees must complete additional components of required training which are within the scope of their role and consistent with the practice in their assigned environment. CATEGORY E This group consists of registered nurses who have extensive direct patient contact. They must complete additional specific required training components consistent with the scope of practice, the care environment in which they practice and the role.

TRAINING COMPONENTS CATEGORY ANNUAL REQUIRED TRAINING A B C D E

General Safety X X X X X Elect, Safety X X X X X Fire Safety/ Life Safety X X X X X Patient Safety X X X X X Emergency Prep X X X X X Confidentiality X X X X X Infection Control/ Std Prec/ Blood Borne Pathogens

X X X X

TB Education X X X X PPD Testing X X X X Restraints X X X Automatic External Defibrillation (AED) X Point Of Care Testing¹ X Defibrillation¹ X BLS/CPR (Biennial Requirement) X X X Procedural Sedation² X Radiation Safety³ X

Each year there are additional topics selected for competency assessment for each category.

A task force is gathered to develop a group of topics to be included in the competencies for the

coming year. The task force includes role group and practice representatives including Nursing

Directors, CNSs, OCs, Staff Nurses, Associate Chief Nurses, as well as representatives from PCS

Quality and Safety, the Nurse Practice Committee, and Management Systems Advisory Committee.

The annual competency checklist for direct care employees (e.g., Staff Nurses, PCAs, Surgical

50

Technicians) for 2007 is included as attachment 4.3.g. The annual competency checklists become a

part of the employee’s permanent human resource file.

c). Organizational policies should recognize the myriad needs of both patients and nursing staff.

The PCS Strategic and Operating Plan presented in Force 1.1 and OOD 13e clearly

demonstrates the commitment of the department to both patients and nursing staff. The Patient

Care Delivery Model (PCDM) is patient/family-focused and has environmental elements to enhance

patient outcomes. These elements include not only direct care staffing patterns, but also adequate

support and ancillary staff and effective communication systems that assure the reporting and

documentation of patient outcomes.

The PCDM is operationalized at the unit level through a leadership triad (Nursing Director,

Clinical Nurses Specialist, and Operations Coordinator (OC) and unit staff which includes Staff

Nurses, PCAs, OAs (clerical support) and USAs (environmental cleaning and other support). The

advantage of decentralized clerical and environmental cleaning staff, under the direction of the unit

OC, is timely attention to the environmental needs of patients and nursing staff.

Additional operational support is provided to the units by several ancillary service

departments, such as the Materials Management and Transportation Departments. The DON has

developed a close working relationship with the Materials Management Department, and in the past

few years has collaborated with them on various patient-focused, performance improvement

initiatives through the Nursing/Materials Management Task Force. During this fiscal year, a sub-

group of the task force was formed to focus on the availability of pediatric supplies, and in

particular, to consider moving some specific pediatric supplies from the special order process to the

MGH routine supply process so that nurses could access the items more easily and quickly.

The OCs from the two Pediatric General Care Units, the Pediatric Intensive Care Unit,

Neonatal Intensive Care Units, and Obstetric Units met with representatives from the Materials

Management Department and the hospital’s primary supply vendor. The group created a list of

current “special order” items for all of the Pediatric Units. Realizing there would be a need for

prioritization of selected items, and that decisions may involve standardization or alternative

products, the pediatric CNSs were added to the workgroup. The group has met every two weeks

since October 2006 and as of June 2007, over 40 pediatric items have been moved from special

order to unit-based supply carts. The group continues to use the list that was developed as a

valuable tool for future transitions from special order to routine pediatric stock items. In addition,

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they have developed a process for requesting new items that should be considered for addition to

the pediatric supply carts.

Supportive technology for direct care providers is an important focus of the Massachusetts

General Hospital and Massachusetts General Physician Organization’s (MGH/MGPO) Strategic

and Financial Plan. As stated in this plan’s “Key Elements of MGH Vision 2011” (OOD 13b):

• Patient care is supported by an electronic medical record and other information technology

An Information Systems Steering Committee is overseeing the creation of an electronic record and

other information technology approaches that will ensure effective patient care, efficient operations,

and the organization’s financial health. The Committee identifies the projects that are most

important for achieving the organization’s strategic vision in the context of information technology

demand that continues to grow exponentially and outstrip available resources. There is now an

institution-wide longitudinal plan for implementing large IS systems such as the Electronic

Medication Administration Project (eMAP) and Acute Care Documentation (ACD). Both of these

initiatives are linked to achieving our strategic goals.

The MGH is the largest non-governmental employer in Boston, with over 20,000 employees.

The hospital has a long history of supporting and recognizing employees. This is evidenced in

policies and practices that support employee education, training, and professional development; in

rewards that recognize exceptional employee performance, special accomplishments, and length of

service; and in competitive wage and salary programs.

One example of this spirit of recognition is the annual Ether Day celebration held each

October, on the Friday closest to the anniversary of the first use of Ether as an anesthetic, a

remarkable medical milestone at MGH that transformed the field of surgery. Ether Day is the time

designated to celebrate the anniversaries of MGH employees who have worked at MGH for 5, 10,

15, 20, 25, 30, 35, 40, 45, 50 and 60 years. There are two separate celebrations each year, a reception

for all employees who are being recognized for their years of service and a formal cocktail/dinner

event for employees who have over 20 years of service. The 2006 celebration, held on Oct. 13, 2006

honored 2,747 employees.

MGH was recognized by the American Association for Retired Persons (AARP) in 2006 as a

“Best Employer” and by Working Mother Magazine as one of the top 100 companies for working

women. The following excerpts were included in the MGH Hotline, a weekly employee publication,

about these accomplishments:

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AARP recognizes MGH as best employer for workers over 50

The MGH values all employees, particularly those who are close to retirement age or beyond. The many

benefits the MGH offers were recently recognized by the American Association of Retired Persons (AARP),

which is the leading nonprofit membership organization for people age 50 and over in the United States. The

hospital was selected as one of the best employers in the country for workers over the age of 50, making the

MGH one of two organizations – along with the Massachusetts Institute of Technology (MIT) – in

Massachusetts to earn this honor.

The MGH was selected because of the many programs and services the hospital offers that not only serve

more mature workers but also are valued by all of employees. These include the training and career

development programs, health benefits for current employees and for retirees, the range of options for retirement

savings plans, financial planning services, flexible work hours, accommodations made to work environments

and the many recognition awards and celebrations of service.

Working Mother magazine recognizes MGH as top company for working mothers

Because of the many benefits and services the MGH offers that support working mothers, the hospital

was recently selected as one of the top 100 companies in the nation for working mothers by Working Mother

magazine. In its 20th year of publishing the top 100 list, Working Mother evaluates thousands of

submissions and determines the list based on the submitting company’s on-site childcare options,

compensation, company culture that is family oriented, areas of work/life and family-friendly policies.

The hospital offers a variety of programs that help MGH working mothers take care of their families,

such as child care options, maternity and adoption leaves, flexible work schedules, and many of the Employee

Assistance Programs (EAP) that address family issues. The MGH also offers programs that help working

mothers with building their careers and refining their work skills through ongoing course offerings, on-the-job

training, career development opportunities as well as scholarships and grants. And the MGH has programs

that help working mothers take care of themselves, like health and wellness programs, support programs

through EAP and convenient on-site services that help employees take care of personal errands.

PCS also embraces this philosophy of employee recognition. Several awards and recognition

programs are conducted each year to celebrate practice at MGH:

• Ben Corrao-Clanon Memorial Scholarship

The scholarship was created in 1987 by Regina Corrao and Jeffery Clanon to recognize a

Newborn Intensive Care Unit Staff Nurse whose practice demonstrates excellence and a

53

commitment to primary nursing.

Eligibility: NICU Staff Nurses Award $500 (one recipient)

• Orren Carrere Fox Award for NICU Caregivers

The award was created in 1997 by Henry Fox and Elizabeth DeLana to acknowledge the

exceptional care given their son at the time of his birth. The award is for all individuals,

professional and non-professional alike, who work in the Newborn Intensive Care Unit.

Eligibility: Professional and non-professional NICU staff Award $1000 (one recipient)

• Stephanie M. Macaluso, RN, Excellence in Clinical Practice Award

The award was established in 1996 to recognize direct care providers whose practice

exemplifies the expert application of the values reflected in our vision. The award provides a

means to make this practice more visible and to enhance the image of MGH health

professionals on campus as well as in the community.

Eligibility: Professional staff in PCS Award $1000 (multiple recipients)

• Yvonne L. Munn, RN, Nursing Research Award

The Department of Nursing established the Yvonne L. Munn Nursing Research Awards

program to enhance MGH nursing and its tradition of, and commitment to, research-based

practice. The Yvonne L. Munn Nursing Research Award will support research initiated by

MGH staff for the purpose of improving the care of their patients and families by advancing

nursing knowledge and theory.

Eligibility: Nurses at all levels in PCS Award (support of research)

• Marie C. Petrilli Oncology Nursing Award

Each year two MGH nurses are recognized for their commitment and compassion in caring

for cancer patients.

Eligibility: Nursing staff in PCS that care for cancer patients. Award $1000 (two

recipients)

• Paul W. Cronin and Ellen S. Raphael Award for Patient Advocacy

Paul and Ellen, as well as their families, were so impressed with the care provided by the

staff of Phillips House 21 they established an endowment fund for the staff on this unit.

Beginning in 2000, this endowment has funded an annual award for all staff of Phillips

House 21.

Eligibility: Staff on PH 21(nurses and support staff alternate) Award $500 (one recipient)

54

• Anthony Kirvilaitis Partnership in Caring Award

The purpose of this award is to recognize and celebrate those in non-clinical roles that

exemplify excellence in service and therefore share some of the same attributes that Tony

demonstrated.

Eligibility: MGH employees in non-clinical roles Award $1000 (each for two recipients)

• Cancer Career Development Award

The award is administered by the Cancer Affairs Nursing Subcommittee to recognize a

professional staff nurse for meritorious practice. The award provides financial assistance for

the recipient for continuing education that will further the nurse’s professional goals.

Eligibility: Nursing staff in PCS that care for cancer patients. Award $1000 (one recipient)

• Norman Knight Preceptor of Distinction Award

The Norman Knight Preceptor of Distinction Award is designed to recognize a clinical staff

nurse who consistently demonstrates excellence in educating, precepting, mentoring, and

coaching nurses.

Eligibility: Staff nurses in PCS Award (one recipient – tuition or buyout time)

• Brian M. McEachern Extra Ordinary Care Award

The purpose of this award is to recognize staff whose passion and tenacity exceeds the

expectations of patients, families and colleagues by demonstrating extraordinary acts of

compassionate patient care and service.

Eligibility: PCS staff across all role groups Award $1000 (one recipient)

• Norman Knight Clinical Support Excellence Award

This award recognizes direct care clinical support staff members within Patient Care Services

who demonstrate patient advocacy, provide care that is compassionate and thoughtful and a

commitment to quality patient care.

Eligibility: PCS direct care clinical support staff Award: $1000 (one recipient)

• Jean M. Nardini, RN, Nurse of Distinction Award

Award was designed to recognize a clinical staff nurse who consistently demonstrates

excellence in clinical practice, leadership and a strong dedication to the profession of

nursing.

Eligibility: Staff nurses in PCS Award: $1000 (one recipient)

55

Attachment 4.3.a

16.15,877

Direct Caregivers

Scheduled Hours Mon Tues Wed Thurs Fri Sat Sun Total Weekly

Shifts

RN 7am-3pm 6.50 6.50 6.50 6.50 6.50 6.00 6.00 44.50

PCA 7am-3pm 2.00 2.00 2.00 2.00 2.00 2.00 2.00 14.00

58.5

RN 3pm-11pm 6.00 6.00 6.00 6.00 6.00 5.00 5.00 40.00

PCA 3pm-11pm 1.50 1.50 1.50 1.50 1.50 1.00 1.00 9.50

49.5

RN 11pm-7am 5.00 5.00 5.00 5.00 5.00 4.00 4.00 33.00

11pm-7am

33.0

141.00

Budgeted FY 2006

Subtotal Shifts

Number of Staff

DAY SHIFT

EVENING SHIFT

NIGHT SHIFT

Pediatrics Med/Surg Combined

Avg. Number of Pts Per Day:Total Patient Days:

Massachusetts General Hospital902 Licensed Beds

Tertiary - Academic Medical Center

Pediatrics Ellison 18

Budget Worked Hours Per Patient Days (WHPPD) 9.98

56

57

MGH - Patient Care ServicesFY'06 Patient Volumes - Patient Classification UnitsYear-to-Date Performance for Fiscal Month EndingSeptember

Census Acuity Workload HPWI SH/24Serv/Unit Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual Variance Budget Actual VarianceCA SICU 13.5 12.3 (1.2) (2.3) (0.17)

(3.2) (0.02) (6.2) (0.24)(0.5) (0.08) (2.4) (0.15)(0.7) (0.07) (3.5) (0.55) (1.2)(2.1) 0.02 (2.7) (0.27) 0.2(7.7) (0.01) (17.1) (0.30)(0.1) (0.04) (1.0) 0.16(1.5) 0.08 (1.6) (0.20)0.7 2.0 (0.50) (2.9)

0.03 (3.3)(0.7) (0.8) (0.76) (4.4)(3.0) (5.1) (0.53) 0.80.3 (0.03) 0.0 (0.55) (1.6)

(0.06) (1.3) (0.38) (1.0)(2.5) 0.01 (2.4) (0.30) (10.1)0.2 1.1 (0.15) (1.7)(0.7) (0.09) (4.4)(0.4) (0.5) (0.69) (2.3)(0.2) 2.1 (0.41) (3.2)1.1 (0.11) (0.74) (2.9)

0.11 (0.16) (3.0)0.16 (2.7)

(2.2)(0.32) (1.8)

(0.01) (0.26) (1.7)0.10 (0.20) (25.9)

0.16 (1.2)(1.2)

(0.04) (1.5)(0.4) (0.4) (0.27) (1.3)0.2 1.5 (0.17) (2.8)(0.7) (0.01) (1.3)0.4 (0.05) (4.3)

(0.12) (2.9)(0.03) (8.5)

(0.4) 0.62 2.7(0.4)(0.6) (0.11) (2.4) (0.97) (0.1)(1.2) 0.10 (0.9) 0.18 1.1(1.0) (0.07) (2.8) (0.10)(2.8) (0.02) (6.10) (0.19)(1.1) 0.07 (0.8) (0.25) (0.3)0.1 (0.07) (0.7) 0.00 0.6

(1.0) (1.5) (0.11)(0.1) 1.6 (0.40) (2.6)(5.5) (3.9) 0.48 5.1(5.6) (2.3)(17.1) 10.9 (0.16) (36.3)

3.41 3.55 0.14 46.0 43.7 6.40 6.57 36.8 35.9 0.9EL 8 27.5 24.3 1.78 1.76 49.0 42.8 5.50 5.74 33.7 30.7 3.0EL 9 CCU 12.6 12.1 2.86 2.78 36.0 33.6 6.40 6.55 28.8 27.5 1.3EL 10 30.2 29.5 1.84 1.77 55.6 52.1 5.50 6.05 38.2 39.4EL 11 31.5 29.4 1.59 1.61 50.1 47.4 5.50 5.77 34.4 34.2Cardiology 115.3 107.6 2.05 2.04 236.7 219.6 5.81 6.11 171.9 167.7 4.2SICU 16.5 16.4 3.75 3.71 61.9 60.9 6.48 6.32 50.1 48.1 2.0BG 13 18.1 16.6 1.97 2.05 35.6 34.0 5.82 6.02 25.9 25.6 0.3BL 6 13.0 13.7 1.68 1.74 0.06 21.8 23.8 5.72 6.22 15.6 18.5WH 7 21.3 23.1 1.8 1.77 1.87 0.10 37.7 43.1 5.4 5.06 5.03 23.8 27.1EL 7 29.8 29.1 1.77 1.78 0.01 52.7 51.9 5.19 5.95 34.2 38.6EL 19 23.8 20.8 1.79 1.80 0.01 42.5 37.4 5.20 5.73 27.6 26.8PH 22 15.1 15.4 1.51 1.48 22.8 22.8 5.20 5.75 14.8 16.4BG 14 22.0 22.0 0.0 1.85 1.79 40.7 39.4 5.06 5.44 25.8 26.8Surgical 159.6 157.1 1.98 1.99 315.7 313.3 5.52 5.82 217.8 227.9MICU 15.2 15.4 2.80 2.83 0.03 42.5 43.6 6.40 6.55 34.0 35.7EL 16 32.5 31.8 1.63 1.85 0.22 52.9 58.7 5.8 5.20 5.29 34.4 38.8PH 20 19.0 18.6 1.63 1.63 0.00 30.9 30.4 5.20 5.89 20.1 22.4PH 21 18.9 18.7 1.75 1.88 0.13 33.0 35.1 5.20 5.61 21.4 24.6BG 9 14.9 16.0 1.94 1.83 28.9 29.2 0.3 5.78 6.52 20.9 23.8BG 11 22.7 23.3 0.6 1.75 1.86 39.7 43.3 3.6 4.85 5.01 24.1 27.1WH 9 22.6 22.6 0.0 1.58 1.82 0.24 35.6 41.1 5.5 5.20 5.04 23.2 25.9WH 8 23.5 24.2 0.7 1.75 1.89 0.14 41.1 45.7 4.6 5.20 5.06 0.14 26.7 28.9WH 10 18.4 18.7 0.3 1.85 1.86 0.01 34.1 34.8 0.7 5.20 5.52 22.2 24.0WH 11 21.4 21.9 0.5 1.88 1.87 40.3 40.9 0.6 5.20 5.46 26.2 27.9Medical 209.1 211.2 2.1 1.81 1.91 379.0 402.8 23.8 5.34 5.54 253.2 279.1EL 14 22.3 22.8 0.5 1.84 1.93 0.09 41.0 43.9 2.9 5.57 5.41 28.5 29.7Oncology 22.3 22.8 0.5 1.84 1.93 0.09 41.0 43.9 2.9 5.57 5.41 0.16 28.5 29.7WH 6 24.4 25.0 0.6 1.49 1.53 0.04 36.4 38.3 1.9 5.20 5.24 23.6 25.1EL 6 29.5 29.1 1.57 1.58 0.01 46.3 45.9 5.20 5.47 30.1 31.4Orthopaedic 53.9 54.1 1.53 1.56 0.03 82.7 84.2 5.19 5.37 53.7 56.5BL 12 15.0 14.3 3.22 3.48 0.26 48.3 49.8 1.5 6.40 6.41 38.6 39.9EL 12 28.7 29.1 1.66 1.85 0.19 47.6 53.8 6.2 5.20 5.25 31.0 35.3WH 12 19.6 20.0 0.4 1.61 1.76 0.15 31.6 35.2 3.6 5.20 5.32 20.5 23.4Neurosciences 63.3 63.4 0.1 2.01 2.19 0.18 127.5 138.8 11.3 5.65 5.68 90.1 98.6BL 11 23.1 22.7 1.74 1.81 0.07 40.2 41.0 0.8 4.58 3.96 23.0 20.3Psychiatric 23.1 22.7 1.74 1.81 0.07 40.2 41.0 0.8 4.58 3.96 0.62 23.0 20.3 2.7PICU 6.4 5.8 2.97 2.86 19.0 16.6 6.40 7.37 15.2 15.3EL 17 14.3 13.1 1.81 1.91 25.9 25.0 5.20 5.02 16.8 15.7EL 18 18.0 17.0 1.72 1.65 30.9 28.1 5.20 5.30 20.1 18.6 1.5Pediatrics 38.7 35.9 1.96 1.94 75.8 69.7 5.50 5.69 52.1 49.6 2.50BG 7 15.4 14.3 1.66 1.73 25.6 24.8 5.20 5.45 16.6 16.9NICU 13.6 13.7 2.45 2.38 33.3 32.6 6.40 6.40 26.7 26.1

Women & Infants 29.0 28.0 2.03 2.05 0.0 58.9 57.4 5.88 5.99 43.3 43.0 0.3EL 13 24.0 23.9 1.18 1.25 0.07 28.3 29.9 5.75 6.15 20.4 23.0BL 13 37.4 31.9 1.10 1.17 0.07 41.1 37.2 5.75 5.27 29.6 24.5Obstetrics 61.4 55.8 1.13 1.20 0.07 69.4 67.1 5.76 5.66 0.10 50.0 47.5 2.5Subtotal 775.7 758.6 1.84 1.90 0.06 1426.9 1437.8 5.51 5.67 983.6 1019.9

Attachment 4.3.b

Attachment 4.3.c

STAFFINGSHIFTS

RN SHIFTS

NON RN SHIFTS

PATIENTISSUES

STAFFISSUES

SUPPORTISSUES

STRUCTUREISSUES

LOGISTICISSUES

HOMOGENEITY OFPATIENT

POPULATION

DESIREDOUTCOMES

CARE STANDARDS

PATIENTEXPECTATIONS

EXPERIENCE/KNOWLEDGE

COMPETENCE/CAPABILITIES

DELIVERY MODEL

STAFF TURNOVER

LEADERSHIP/CLINICAL

OTHERPROFESSIONAL

OTHERANCILLARY

CLERICAL/SERVICE

PHYSICALLAYOUT

SUPPLIES/EQUIPMENT

SYSTEMS

TECHNOLOGY

VARIABILITY OFWORKLOAD

PATIENTTURNOVER

MINIMUMSTAFFING

WHAT ISREASONABLE

HPWI /Resource Intensity Staffing Mix

WORKLOAD / STAFFING

WORKLOAD

VOLUME

CENSUS

UNITS OFSERVICE

ACUITY

COMPLEXITY

CARE NEEDS

58

Note: Sample section from Yawkey Infusion Unit Competency Checklist

IV Therapy

Evaluation Method

Competency Level

Evaluator’s

Initials

Date Evaluated

Reviews IV line insertion/access & care. • Central Implanted • Central Tunneled • PICC • Peripheral

Reads IV Therapy-related Policies & Procedures. • Clinical Policy & Procedure Manual • Nursing Procedure Manual

Uses IV infusion Pumps. • Demonstrates use of large volume (3M) infusion pump • Programs secondary function on large volume infusion pump • Verifuse Pump

Reviews care of implanted hepatic artery pumps. • Isomed • Arrow

Describes Phase 1 administration and monitoring guidelines Reads related Policies & Procedures in the Clinical Policy & Procedure Manual

Evaluation Method

A. Direct Observation E. Written Test B. Customer Feedback F. Verbalizes Knowledge C. Documentation Review G. Other (please describe) D. Analysis of Data

Attachment 4.3.d

59

Attachment 4.3.d continued

Sample section from Bigelow 9 (Respiratory Acute Care Unit) Competency Checklist

Care for a Patient Requiring Ventilatory Assistance/Respiratory Support

Evaluation Method

Competency Level

Evaluator’s

Initials

Date Evaluated

Demonstrates set-up of pulse oximeter A Demonstrates set-up of oxygen delivery system. A Moniters mechanical ventilation A Ambus and suctions artificial airways, NT suctioning A Changes ET tube tape and rotates tube A Performs tracheostomy care A Interperts ABG’s F Collects sterile tracheal sputum specimen A Assists with intubation/extubation A Assists with weaning A Cares for the patient on noninvasive ventilation A Flolan Administration Packet F Mechanical Ventilation Packet F Score >85 on Respiratory Exam E

Evaluation Method

A. Direct Observation E. Written Test B. Customer Feedback F. Verbalizes Knowledge C. Documentation Review G. Other (please describe) D. Analysis of Data

60

MGH - PATIENT CARE SERVICESSTAFF RN FILLED POSITION REPORT

Budget FY 07 Auth Positions Direct Care RN Filled Positions as of 6/4/2007 Note: Sample Portion of Multiple Page Report

CostCenter Budget On Staff Hired Total Filled % Filled Vacant % Vacant Agency

Super Group 848: Cardiology/Cardiac Surgery Nursing ServiceCardiac SICU MG4511 58.9 51.8 - 51.8 88.0% 7.1 12.0% 2.7

Ellison 8 MG4146 43.1 43.9 - 43.9 101.8% (0.8)(2.2)2.0

(0.2)5.9

(4.4)3.8

(0.2)3.4

(0.9)1.7

(2.0)(0.1)(3.2)2.6

(5.8)1.6

(2.9)(0.7)0.1

(1.0)0.1

-1.8% 0.9 Ellison 9 CCU MG4515 42.3 43.6 0.9 44.5 105.2% -5.2% 0.9

Ellison 10 MG4133 53.8 51.8 - 51.8 96.3% 3.7% 1.8 Ellison 11 CAU MG4134 48.8 49.0 - 49.0 100.3% -0.3%

Subtotal Cardiology/Cardiac Surgery Nsg. 246.9 240.1 0.9 241.0 97.6% 2.4% 6.3

Super Group 849:Surgical Nursing ServiceSICU MG4529 76.1 80.5 - 80.5 105.8% -5.8% 0.9

Burn / Bigelow 13 MG4513 MG4127 39.0 35.2 - 35.2 90.3% 9.7% - Transplant / Blake 6 MG4163 MG4530 24.1 23.3 1.0 24.3 100.8% -0.8% 4.5

White 7 MG4160 37.2 32.8 1.0 33.8 90.9% 9.1%Ellison 7 MG4145 50.5 50.4 1.0 51.4 101.8% -1.8% 0.9

Ellison 19 MG4136 41.5 39.8 - 39.8 95.9% 4.1%Phillips House 22 MG4152 23.1 22.4 - 22.4 97.0% 0.7 3.0% 1.0

Bigelow 14 MG4128 37.3 34.5 2.0 36.5 97.9% 0.8 2.1%Subtotal Surgical Nursing 328.8 318.9 5.0 323.9 98.5% 4.9 1.5% 7.3

Super Group 850:Medical Nursing ServiceBlake 7 - MICU MG4525 50.8 47.1 - 47.1 92.7% 3.7 7.3% 5.4

Ellison 16 MG4144 49.6 45.5 - 45.5 91.7% 4.1 8.3%Phillips House 20 MG4150 27.4 26.1 - 26.1 95.3% 1.3 4.7%

Phillips House 21 MG4151 30.6 32.6 - 32.6 106.5% -6.5%Bigelow 9 MG4123 32.3 31.4 1.0 32.4 100.2% -0.2%

Bigelow 11 MG4534 41.5 44.7 - 44.7 107.6% -7.6% 1.8 White 9 MG4130 35.0 30.4 2.0 32.4 92.6% 7.4% 2.8 White 8 MG4155 39.2 36.3 - 36.3 92.6% 2.9 7.4%White 10 MG4162 30.7 31.5 5.0 36.5 118.9% -18.9%White 11 MG4125 35.9 34.3 - 34.3 95.5% 4.5% 2.7 White 13 MG4157 7.3 10.2 - 10.2 139.7% -39.7%

Dialysis MG7433 12.7 13.4 - 13.4 105.6% -5.6%Anticoagulation Services MG5221 7.5 7.4 - 7.4 98.7% 1.3%

Subtotal Medical Nursing 400.5 390.8 8.0 398.8 99.6% 1.7 0.4% 12.7

Super Group 850 Oncology Nursing ServiceCox 1 Infusion MG5310 7.0 5.3 - 5.3 75.0% 1.8 25.0%

Ellison 14 BMT MG4137 MG4518 43.0 44.0 - 44.0 102.3% -2.3% - Yawkey Infusion Center MG5244 43.6 43.5 - 43.5 99.7% 0.3% 4.9

PCS Proton Therapy MG5125 4.0 4.0 - 4.0 100.0% 0.0 0.0%PCS Radiation Oncology MG5124 6.0 7.0 - 7.0 116.7% (1.0) -16.7%

Subtotal Oncology Nursing 103.6 103.7 - 103.7 100.1% (0.1) -0.1% 4.9

Attachment 4.3.e

61

62

Attachment 4.3.f

MASSACHUSETTS GENERAL HOSPITAL Department of Nursing

TITLE: COMPETENCE OF LICENSED AND UNLICENSED PERSONNEL POLICY: The manager is accountable for assessment of staff competency. A manager may delegate

this function to a designee who is skilled in competency assessment. COMPETENCE OF LICENSED CLINICIANS

The competence of licensed clinicians who practice at Massachusetts General Hospital is maintained through a combination of ongoing competence assessment and educational activities. Documentation of competence assessment is required and includes the following elements:

A. Licensure B. Completion of a competency based orientation with a preceptor C. Performance appraisal D. Annual required training E. Hospital, departmental and/or unit-specific competency achievement F. Management of age specific needs of patients (Attachment A) G. Inservice and educational activities H. Completion of cross-training (if applicable)

Optional Element: I. Professional certification

COMPETENCE OF UNLICENSED PERSONNEL POLICY: The competence of unlicensed personnel who practice at Massachusetts General Hospital

is maintained through a combination of ongoing competence assessment and educational activities. Documentation of competence assessment is required and includes the following elements:

A. Completion of a competency based orientation B. Performance Appraisal C. Annual required training D. Hospital, departmental and/or unit-specific competency achievement E. Age-specific care of patients (Attachment B) F. Inservice and educational activities G. Completion of cross-training (if applicable)

Attachment 4.3.f continued ADMINISTRATIVE PROCEDURE: 1. Annually, The Knight Nursing Center for Clinical and Professional Development will coordinate

review and/or revision of competencies to be assessed. 2. The Knight Nursing Center will communicate the competencies to clinical leadership prior to the

implementation time-line. 3. The manager will designate an evaluator(s) for his/her practice area. 4. The evaluator will document on the Annual Competency Assessment and Required Training Record,

the employee’s ability to meet identified competencies. The remainder of Record will be completed by each employee and reviewed by the evaluator at the time of performance evaluation.

5. The Annual Competency Assessment and Required Training Record will be attached to the

completed Performance Appraisal at the time of evaluation and retained in the employee’s file in Staff Records. (see Performance Evaluation policy in the Human Resources Policy and Procedure Manual, http://is.partners.org/hr/manual/manual/manual/perfomance.htm)

Revised and approved: Department of Nursing 8/20/02 Revised and approved: Nursing Executive Operations 08/06

63

Attachment 4.3.g Massachusetts General Hospital Department of Nursing

Annual Competency Assessment 10/1/06-9/30/07

Direct Care Providers

Employee Name: Number:

Evaluation Method Competency Levels A. Direct Observation B. Customer Feedback C. Documentation Review D. Analysis of Data

E. Written Test F. Verbalizes Knowledge G. Other (please describe)

1. Competency Met 2. Competency Not Met 3. Not Applicable

Competency Suggested

Evaluation Method

Competency Level

Competency Evaluator’s Signature

Date Evaluated

Verifies patient identification using two identifiers prior to providing care.

A, B, F

Uses on-line safety reports for all patient, employee and visitor incidents/events.

A, B, C, D, F

Provides age-specific care (Nursing Practice Manual 1.42.01). Check all that apply: Neonate Infant

Toddler Preschool School Age Adolescent Adult

Elder (Older Adult)

A, B, C, E

RN’s only: Performs read-back of critical lab values, verbal and telephone orders

A, B

RN’s only: Transcribes patient orders utilizing approved abbreviations

A, C

RN’s only: Performs safe handoffs of patients

A, B

RN’s only: Completes medication reconciliation process on assigned patients

A, C, D, F

RN’s only: Administers blood products in accordance with MGH policies/procedures*see below

A, B, C, D, E, F

Note: For any unmet competencies, please include your comments and a developmental action plan for improvement in Section X of the employee’s performance appraisal. * Blood Transfusion Competency: • Blake 11 is excluded from this requirement – RNs will remain verifiers only • General care units will have Blood Transfusion Post-test and Transfusion Competency

Assessment with administration of a blood product • Specialty care units will answer post-test questions in annual competency assessment

materials packet

64

Attachment 4.3.g continued

Massachusetts General Hospital Department of Nursing

Required Training, Inservice and Continuing Education Record

To Be Completed By The Employee: All employee are accountable for completing required training annually by their Performance Appraisal due date. Please complete the following information and submit this record to your nurse manager or supervisor by your appraisal due date. Please write the date of completion or check the N/A box in the space provided if any aspect is not a requirement of your job or not a practice in your area. The following are annual required training topics. Refer to the Nursing Practice Manual 1.42.02 to determine your requirements.

Topic/Item Date N/A Topic/Item Date N/A Emergency Preparedness Infection Control, Standard Electrical Safety Precautions, Bloodborne General Safety Pathogens Life Safety/Fire Safety Restraints Patient Safety Defibrillation/AED Tuberculosis Education Radiation Safety - Ell 6, 7, PPD Testing 11, 16; PhillipsHouse 20, 21 For each of the following Point of Care Tests, please indicate completion date and attach a Training and Assessment Record as proof of annual competency (Nursing Procedure Manual 14-3-1, 14-4-1, 14-5-1).

Topic/Item Date N/A Topic/Item Date N/A Hemoccult Urine Dipstick Gastroccult For Blood Glucose Monitoring, you must complete a high/low/control test as demonstration of annual competency (Nursing Procedure Manual 14-6-1) and enter the date in the grid below. If you fail to complete the high/low/control test within the year timeframe, you must repeat the initial certification process in its entirety. If you repeat the initial certification process, enter the date in the grid below and attach a Training and Assessment record.

Topic/Item Date N/A Annual Competency Demonstration: Performs Blood Glucose Monitoring High/Low/Control Test

Repeat of Initial Certification Process The following are biannual (every other year) training. Please enter the date of your training in the grid below.

Topic/Item Date N/A Topic/Item Date N/A Basic Life Support/CPR Procedural Sedation

65

66

Attachment 4.3.g continued Continuing Education and Training: Include any internal/external presentations, programs, seminars and/or job training you have attended. Include the date you attended in the space provided. Attach additional sheets as required. Inservice Education: Include any equipment and policy/procedure inservices you have attended in the past year. Include the date you completed the training/education in the space provided. Attach additional sheets as required. Other Activities and Certifications: Include items such as committee memberships, special projects, publishing, or advanced certifications such as ACLS or CCRN. _____ _________________ __________________

Employee Signature Date