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MANUAL FOR
NursingPractice
Governance
Christman, 1976
Autonomy has, as its
basic components,
personal accountability
and shared power and
influence. An autonomous
nursing staff is feasible.
It is professionally exciting.
It cannot be done for nurses; it must be done by them.
2 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
MANUAL FOR NURSING PRACTICE GOVERNANCEIntroduction
This Manual for Nursing Practice Governance at Rush Oak Park Hospital is underscored by a commitment to our vision, to excellent nursing practice and to
professional accountability for our work environment, patient care delivery and our community as a whole.
Nursing Practice Governance is an activity that autonomous practitioners of the discipline of nursing must be committed to doing on a daily basis and throughout every structure and process that supports care delivery.
Only nursing can evaluate and govern its practice, and as such, must be ready to do so frequently, diligently and with a sober spirit, considering the burden of patient health.
Many of the tools in this manual are sculpted around the ROPH Nursing Professional Practice model.
Nurses in all roles and settings have developed these tools, to guide ROPH nursing practice and to seek to create exemplary patient, staff and environmental outcomes.
— Donabedian, 1976 in American Nurses Association Social Policy Statement, 2010
There is a social contract between society and the profession. Under its terms, society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their own affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality and performance is at the heart of this relationship. It is the authentic hallmark of the mature profession.
3
Rush Oak Park HospitalManual for Nursing Practice Governance PRACTICE IDENTITY
Structures That Guide
WE ARE NPGO
Rush MissionThe mission of Rush is to improve the health of the individuals and
diverse communities we serve through the integration of outstanding patient care, education, research and community partnerships.
Rush VisionRush will be the leading academic health system in the region
and nationally recognized for transforming health care.
Mission & VisionRush System for Health and Rush Oak Park Hospital
Mission, Vision, Strategic Themes & Values
Est. 2012
ROPH Nursing Vision
Rush Oak Park Hospital will be seen as the community medical center of choice in the region and in the nation. As a community of professional nurses, we will lead efforts to advocate patient- and family-focused health promotion
throughout the lifespan. We will be looked to by our community and beyond as a resource center for patient and family health education and support. We seek to scientifically and competitively pursue innovative care that supports
and sustains wellness in the lives of our patients, our community and beyond.
Innovation
Collaboration
Accountability
Respect
Excellence
Values
The Best Quality People
The Best Quality
The Best Programs
Highest Value
Strategic Themes
4 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PRACTICE IDENTITYStructures That Guide
Relationships and Caring
Sens
itivi
ty
Respect
Collaboration
Intentional Presence
Comm
unic
atio
n
CriticalThinking
EvidenceBased
Practice
TechnicalExpertise
Leadership
Foundation of Nursing Professional Practice Model
Relationships and Caring Built on sensitivity, collaboration,intentional presence, communication and respect
Care is patient and family centered: Set meaningful goals with patient and family Diversity of patient background taken into account in
culturally sensitive way Teaching atmosphere with patient and family is constant Awareness of patient and families’ feelings, space and needs Interactions are respectful, therapeutic and trusting Reflected in collaborative relationship with interdisciplinary team and colleagues
Supportive of educational environment Professional relationships extend outside unit to professional organizations, regulatory bodies, Board of Nursing
Looks for opportunities within the nursing team to act as coach, mentor and support
Evidenced-Based Practice Nurses employ science to patient care and environment Strategies are based on successful interventions for given patient population
Procedures, standards and protocols are substantiated by research or best practice by exemplars
Nurses contribute to body of evidence for best practice by questioning interventions and studying alternatives
NPGO provides a structure for evaluation of evidence and dissemination of best practice.
Creation and Translation of knowledge
Technical Expertise Use technology to deliver effective patient care Translate purpose of equipment and medical devices for patient and families Coordinate the medication administration process Coordinate the plan of care through the continuum
Critical Thinking Synthesize information and use reasoned clinical judgment which understands science, assures patient safety, advocates for patient and family, revises plan of care when needed
Inquire and ask clarifying questions Communicate and facilitate understanding among patient and others on the clinical team
Leadership Lead activities that evaluate current practice and stimulate change
Mentor other nurses regarding nursing practice and career development
Coordinate patient services beyond the clinical unit Plan nursing care for a group of patients for a period of time Communicate and advocate for additional resources when necessary to meet patient care needs
Definitions of Domains
T he models on page 4 and 5 are two sides of the same coin — how we practice as nurses and how we deliver
care within the team Rush Oak Park Hospital’s Professional Nursing Practice Model is a picture of our practice identity. Relationships and Caring encircle and support all that we do
as ROPH nurses. Supported by and through this, Technical Expertise, Evidence-Based Practice and Critical Thinking work in synergy to propel us as nurses towards Leadership of the complex healthcare environment to meet the needs of our patients and the environment.
5
Rush Oak Park HospitalManual for Nursing Practice Governance PRACTICE IDENTITY
Structures That Guide
WE ARE NPGO
The Nursing and Interprofessional Teams How care is organized within the nursing team
Team Nursing: RN directs and oversees patient care, sometimes including a CNL. Some tasks delegated and performed by patient care technicians or other ancillary staff. (examples: ED, OR, Med Surg Units, CDEC, ROPPG, Skilled, Rehab, Endoscopy(
Total Nursing: RN responsible for giving all care to patient. (examples: ICU, PACU, SDS) Primary Nursing: RNs responsible for care of a given number of patients around the clock
(examples: Wound Care Clinic nurse managed cohorts of patients) How initiatives are developed and implemented through the interprofessional team
Organizational committees (examples: PIPSC, Sepsis, Chest Pain, Stroke, Emergency Management, Environment of Care, etc.)
Caring Occasion: Moral Commitment to protect and enhance human dignity: Every interpersonal contact is viewed as a caring opportunity Ethics committee, Diversity committee, use of Institutional Review Board for research studies to protect patients
Carative Factors: Human Altruistic System of Value Transfer of patients between units, between institutions, between providers and along the continuum is shaped by our Care Delivery process
Focus on the Autonomous Patient: Through meaningful care plan development and management both inpatient and outpatient as well as community work in surrounding areas. Focusing on the pa-tient’s ability to be health literate and independent is supported also by patient education, social determinant screening and intervention as well as health promotion
Transpersonal Caring Relationship: Awareness of self with authentic present of caring How we shape interactions and initiatives within the interprofessional team Organizational and Nursing Code of Conducts
Patient- and Family-Centered Care: How we plan for care coordination within the interprofessional team to make sure the patient is cared for throughout their life, rather than just within our walls
Definitions of Domains
THE NURSING AND INTERPROFESSIONAL TEAMS
CARATIVEFACTORS
HUMAN, ALTRUISTICSYSTEM OF VALUE
CARINGOCCASION
MORAL COMMITMENTTO PROTECT ANDENHANCE HUMAN
DIGNITY
TRANSPERSONALCARING
RELATIONSHIPAWARENESS OF
SELF WITH AUTHENTICPRESENSE OF CARING
PATIENT& FAMILY
CENTEREDCARE
Nursing Care Delivery ModelT he Jean Watson Caring Care Delivery Model (CDM)
has been adopted at ROPH to assist our patients with gaining control, becoming more knowledgeable and thus promoting their health both within our walls and in their home. It is the theoretical foundation for our care delivery system which identifies how work is organized within the nursing team, how nurses are deployed and what each team member’s role is. Supported by the constructs of the Jean
Watson Care Delivery Model, nurses organize the activities of care around the needs and priorities of patients and their families. Delivery of care and how it is organized may differ between care settings, however the components of carative factors, caring occasion, transpersonal caring relationship and patient- and family-centered care drive initiatives through the nursing and interprofessional teams. (Watson, 1979)
6 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PRACTICE IDENTITYStructures That Guide
Nursing Professional Governance Organization
We Are NPGO
How is NPGO Organized?
Every Nursing Practice Area is RepresentedEXECUTIVE
COMMITTEE REPSGoverns the Operations of NPGO and
Nursing Practice throughout the OrganizationPresident, President Elect, Treasurer, 3 Center, 6West, Rush Oak Park Physician’s Group RNs,
APNs, Cath Lab/IR, CNO/Nursing Adminis-tration, Employee Health, Endoscopy, ED, ICU,
NGF, Dep of Nursing Practice, OR, PACU, Dept. of Clinical Effectiveness, Same Day Sur-gery, Telemetry, Cardiac Rehabilitation, CNLs
and Wound Care Clinic
NPGO STANDING COMMITTEES
Manage the Specific Areas Where Nursing Practice is Sculpted
Peer Review, Evidence-Based Practice and Research, Education, Clinical Practice and
Policy, Staffing Nurse Advisory Board, Awards and Recognition, APN Practice Council,
Population Health, Skin Care, CUSP, Safe Patient Handling and Falls, Nursing
Excellence
NPGO UNIT/DEPARTMENT AREA COMMITTEES
Manage Practice Pertaining to the Patient Populations Cared for in
Specialties Across Nursing3 Center, 6 West, Rush Oak Park Physi-cian’s Group RNs, APNs, Cath Lab/IR, Endoscopy, ED, ICU, NGF, OR, PACU,
Same Day Surgery, Telemetry, Cardiac Rehabilitation and Wound Care Clinic,
CNL Group
NPGOStanding
Committees
NPGOUnit Area
Committees(UACs)
Chief NursingOfficer
NursingAdministrative
Committee
Rush Oak Park HospitalBoard of Directors & President/CEO
NPGOPresident
NPGO ExecutiveCommittee
7
Rush Oak Park HospitalManual for Nursing Practice Governance PRACTICE IDENTITY
Structures That Guide
WE ARE NPGO
ROPH Quality StructureEnsuring Parity within Organizational Committee Structure
ROPH Board of Directors
MedicalExecutive
Committee
NursingProfessionalGovernanceExecutive
Committee(NPGO)
PerformanceImprovement &Patient Safety
Council (PIPSC)Chaired by CMO & CNO
Medical StaffCommittees
Peer ReviewMedical
Staff Quality
Health InformationManagement
Pharmacy andTherapeutics
Critical Care
Ethics
Departments/Sections
Quality-BasedCommittees
Pain
Employee Safety
Cultural Diversity
HCAHPS
Code Blue
Products
Core Measure Task Force: Diabetes, Chest Pain,
Stroke and Sepsis
Safe Campus
NPGOCommittees
Peer Review
Nursing Staff Excellenceand Quality Committee
Evidence-BasedPractice/Research
Staff Nurse AdvisoryBoard (SNAB)
Policies and ProceduresEducation Council
Awards and Recognition
Safe Patient Handling and Falls
Population Health
Skin Care
Falls
CUSP
8 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PRACTICE IDENTITYStructures That Guide
The Nursing Professional Governance Organization's
Mission
Principles
Code of Conduct
Professional RoleOur conduct is professional, respectful,
honest and full of integrity. We take pride in our professional role, in our
institution and our service to the com-munity. Skilled patient care is depen-dent on the healthy relationships with our colleagues and environment. We embrace change and constantly seek
improvement in patient outcomes.
Commitment to Teamwork
We support an environment of team-work and camaraderie. We see every
patient as our collective responsibility. We seek to incorporate the patient and family as well as other disciplines into
our team.
Respect of All VoicesWe support an environment where
every voice is valued, respected and listened to. Respectful personal
expression of diverse opinions is encouraged.
Authentic LeadershipWe demonstrate congruence between
words and actions. We lead from where we stand, remaining committed to pro-moting the health of our patients, their families, our colleagues, our institution
and our community as a whole.
Supportive of Open Environment
We are approachable and willing to participate in both giving and receiving of feedback. We create an environment where ideas are welcomed and encour-aged. We accept the responsibility to
give constructive feedback in a healthy, professional manner, always maintain-ing the other individual’s self-esteem.
Examples of Unhealthy Behaviors
Bullying and or incivility Establishment of cliques designed
to exclude staff Gossiping
Intimidation Passive Aggression
Refusing to give assistance Negative nonverbal behaviors
The Rush Oak Park Hospital Nursing Professional Governance Organization (NPGO) creates an environment supportive of the RUSH ICARE Values, the
Illinois Nurse Practice Act, the Rush Oak Park Nursing Professional Practice Model, the Rush Oak Park Nursing Care Delivery Model, the NPGO Bylaws
as well as components that reflect a Healthy Work Environment. This Code is a guideline for professional behavior for the NPGO with relation to fellow nurse colleagues, patients, families and visitors to our campus, members of the interdisciplinary team, students, our greater community and society as a whole. Our mission is to promote respectful behavior in an environment
free from abuse. We work towards collaborative teamwork that is reflective of professional, accountable and expert nursing care.
9
Rush Oak Park HospitalManual for Nursing Practice Governance PRACTICE IDENTITY
Structures That Guide
WE ARE NPGO
Preamble Excerpt
3.1 The purposes of the Nursing Professional Governance Organization are: To provide quality nursing care for patients admitted to or treated in any of the facilities, departments, or services of the Hospital;
3.2 To promote a high level of professional performance among registered professional nurses;
3.3 To define and review professional nursing practice;
3.4 To engage in programs that promote excellence in patient care, education, and scientific investigations;
3.5 To provide a mechanism for effective communication among Nursing Professional Governance Organization members;
3.6 To support collaboration between the Nursing Staff, the Medical Staff, and the Administrative Staff; and community resources (e.g., Emergency Medical Services (EMS), Oak Park Health Department).
3.7 To foster the professional growth of registered professional nurses;
3.8 To promote clinical competence and basic research essential to the advancement of professional knowledge and skill in nursing care;
3.9 To provide a stimulating clinical environment for students of Rush Oak Park Hospital affiliated colleges of nursing.
3.10 To support cooperative arrangements with nursing staff of other health care, research, and educational institutions within the Rush System for Health;
3.11 To establish and maintain regulations of nursing practice consistent with the corporate bylaws of the Institution, its policies and procedures, and rules of governance.
3.12 To provide assessment of needs and subsequent outreach to the community with an emphasis on vulnerable populations. Outreach is defined as provision of education and access to care as well as other needs as identified by NPGO Executive committee and associated committees.
3.13 To encourage nursing presence/voice in national healthcare issues (e.g., professional organizations, publications
Nursing Professional Governance Organization
Bylaws
Purposes Description
NPGO MembershipMembership in the Nursing Professional Governance Organization is extended only to registered professional nurses who are employed by Rush Oak Park Hospital.
As members of the Nursing Professional Governance Organization, we recognize and accept responsibility for
the quality of nursing care, nursing education, clinical nursing research and intentional health outreach to our community at Rush Oak Park Hospital. In assuming this responsibility, we are subject to the ultimate authority of the Rush Oak Park Hospital Board of Trustees. We recognize further that the best interests of patients, and patient care, as well as students and nursing education, are protected by a collaborative and cooperative effort.
We pledge ourselves to the continuing pursuit of excellence in care, education, research, care of the members of our
community and to the articulated goals of Rush Oak Park Hospital and the Rush System for Health. Our commitment is to ensure attainment of these goals through time and effort, with particular involvement in nursing education beyond the expectations required for usual employment. Thus, as professional nurses who have responsibility for nursing care to patients, the clinical environment, the instruction of students, and for maintaining personal interdependence with other health care professionals, we hereby accept membership in the Nursing Professional Governance Organization of Rush Oak Park Hospital and the obligation set forth in these bylaws.
10 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PRACTICE IDENTITYStructures That Guide
Cross-Walking Structures That Impact Our Identity
As Rush Oak Park Hospital nurses, our identity can be described by our Professional Practice Model. Each of
the five domains describes a different component of our professional practice.
As experts in our field of knowledge, Rush Oak Park Hospital nurses are leaders relative to practice excellence, professional accountability and autonomous practice. This is largely because our identity is supported by relationships and caring, critical thinking, technical expertise and evidence-
based practice while being propelled by transformational leadership in all roles of our nursing structure. We live out these components by: managing our practice at the bedside and various decision-making tables, collaborating within the interdisciplinary team, and making the patient and family the center of our initiatives. See the crosswalk below to understand how our practice model is supported by and works contextually with other key structures in our environment.
Who Are You
Professional Practice Model CrosswalkHow the Professional Practice Model looks in context to other structures
Promote patient- and family-focused health promotion throughout the lifespan
Pursue care that sustains wellness in the lives of our patients, community and beyond
Utilized by our community and beyond as a resource center for patient and family health, education and support
Seen as community medical center of choice in region and in nation
Scientifically and competitively pursue innovative care
CARE DELIVERY MODEL
NPGO BYLAWS & CODE OF CONDUCT
RUSH SYSTEM FOR HEALTH I CARE VALUES
AACN HEALTHY WORK ENVIRONMENTSTANDARDS
ANCC MAGNETMODEL DOMAINS
ROPH NURSINGVISION
PROFESSIONAL PRACTICE MODEL
Relationships and Caring
Critical Thinking
Technical Expertise
Leadership
Evidence-based Practice
The Nursing and Interprofessional teams
Caring Occasion: Moral commitment to protect and enhance human dignity
Carative Factors: Human, altuistic system of value
Transpersonal Caring Relationship: Awareness of self with authentic presence of caring
Patient- and family-centered care
Based on respect for every individual,
Encourages high level collaboration
Demonstrate congruence between words and actions
Foster professional growth of NPGO members
Define and review professional nursing practice
Engage in programs that promote excel-lence in patient care, education and scientific investigations
Promote clinical competence
Responsible and accountable to manage nursing practice
Committed to pursue excellence in care, education and research
Collaboration Respect
Skilled Communication True Collaboration Meaningful Recognition
Exemplary Professional Practice
Structural Empowerment
Innovation Accountability
Appropriate Staffing Effective Decision Making
New Knowledge Innovation and Improvement
Exemplary Professional Practice
Innovation Accountability
New Knowledge Innovation and Improvement
Exemplary Professional Practice
Excellence Authentic Leadership
Transformational Leadership
Structural Empowerment
Accountability Effective Decision Making
Effective Decision Making
New Knowledge Innovation and Improvement
Empirical Outcomes
11
Rush Oak Park HospitalManual for Nursing Practice Governance PRACTICE IDENTITY
Structures That Guide
WE ARE NPGO
The Practice Evaluation CycleThe Professional Practice Model is a picture
of our practice identity as ROPH nurses. Wherever there is a nurse, the 5 domains
of the practice model are driving description of practice, evaluation of practice, recognition
of practice as well as recruitment and retention of our practitioners. All of these activities are done by and for
nurses, with our discipline specific standards, scope and body of knowledge.
Relationships and Caring
Sens
itivi
ty
Respect
Collaboration
Intentional Presence
Commun
icat
ion
CriticalThinking
EvidenceBased
Practice
TechnicalExpertise
Leadership
THE PROFESSIONAL PRACTICE MODEL
DESCRIBES OUR PRACTICE:Every RN, in every role at ROPH has 5 domains of
the Professional Practice Model in their job descriptions.Competency statements reflect our practice model
and propel our practice from every specialtyrole to have maximum impact.
Job Descriptions
THE PROFESSIONAL PRACTICE MODEL
EVALUATES AND DEVELOPSOUR PRACTICE:
Wherever there is a RN at ROPH, another RNevaluates their practice. Because nursing is a disciplinespecific to itself, only nurses can and should evaluate
the practice of other nurses.
Orientation of New Graduate NursesPerformance Evaluation
Peer EvaluationMid-Year Evaluation
Shared Governance Practice Imrovement ProjectsAPRN Credentialing and Priviledging
NPGO Peer Review Committee
THE PROFESSIONAL PRACTICE MODEL
RECRUITS AND RETAINSEXCELLENT PRACTITIONERS:
The domains of our professional practice model guideinteractions and initiatives aimed at bringing high quality
practitioners to our campus and supporting theirprofessional development throughout their career at ROPH.
Hiring and Interview Process for RNsNew Graduate Nurse Support Program
Exit Interview ProcessStructural Empowerment Policy
Leadership Development Program
THE PROFESSIONAL PRACTICE MODEL
RECOGNIZES EXCELLENTPRACTICE:
Nurses elected from their specialty areas utilizethe Professional Practice Model to recognize
excellent practice.
Clinical AdvancementOngoing Maintenance of RN 3 Status
Awards
12 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
MEANINGFUL PROCESSES TO GUIDE PRACTICEPractice Tools
P = Problem I = InterventionC = ComparisonO = Outcome
STUDYANALYZINGWHAT WORKS
DOPLANGENERATION OFA GOOD IDEA
SMALL TESTOF CHANGE
ACTADJUST ANDDO AGAIN
FOCUS-PDSA
F = Find a process to improveO = Organize a team that knows the processC = Clarify current knowledge of the processU = Understand the causes of process variationS = Select the process improvement
P = Plan data collection and improvementsD = Do; Implement the action planS = Study data; analyze if process improvement workedA = Act to hold gains or re-evaluate action plans
YES
NO
QI PROCESS
GOALS MET?
NO EVIDENCEEVIDENCE
EVIDENCE-BASEDPRACTICE RESEARCH
STRUCTURE PROCESS OUTCOMEParts of a care system or elements that facilitate care or the environment of care:
Resources Equipment Numbers of Staff Qualifications/cre-dentials of staff
Work space or allo-cation
Required medical record content
Policies
The procedures, methods, means, or sequence of steps for providing or delivering care and producing outcomes.
CLINICAL PROCESSESWhat practitioners do for patients and what patients do in response, such as:
Assessments Treatment Planning Medication Administration Education Discharge Planning
CARE DELIVERY PROCESSESThe support activities utilized by practitioners and all suppliers of care and care products to get the product to the patient:
Services, such as: registration, room cleaning, transport, lab
Systems, such as: medication dispensation, equipment delivery
ADMINISTRATIVE AND MANAGEMENT PROCESSES:
Activities performed in the gover-nance and management systems of the organization
The results of care, ad-verse or beneficial, as well as gradients between; the product of one or more processes
Clinical: Results of treat-ments and procedures, complications, adverse events, mortality
Functional: ADLs, patient progress toward meeting goals
Perceived: Patient/fam-ily satisfaction, patient level of understanding, peer acceptability
Performance Improvement Model and Evidence Based Practice Guidelines
Definition
Process
Structure
Outcome
Examples
RESEARCHEVIDENCE BASEDPRACTICE (EBP)
QUALITY IMPROVEMENT (QI)
Applies a methodology to generate new knowledge or validate existing knowl-edge based on a theory
Translates best clinical evidence from research to make patient care decisions
Systematic, data-driven, evalu-ation of processes of care and clinical outcomes based on EBP and research
Process of systematic, scientific inquiry, rigorous methodology to answer a research question and test a hypothesis
Process begins with a question that may be founded from a problem or knowledge gap
Literature review of EBP and Research to guide and support process improvement strategies
Process begins with a question and systemat-ic review of literature, including critical appraisal, to identify knowledge gaps
Practice guidelines may include clinical expertise and knowledge gained through experience
Systematic method for improving processes and outcomes within an organization based on phi-losophy of continuous quality improvement
Rapid Cycle Process: Plan, Do, Study, Act
Reduce the number of patients who develop pressure ulcers while in the hospital
Measurable variables to describe, explain, predict, develop meaning, dis-covery, or understanding about a phenomenon
Providing adequate nutrition and supplements to hospitalized older adults is a clinical factor that reduces the likelihood of developing a pressure ulcer
Systematic review of lit-erature, including critical appraisal, to find the best available evidence and whether the evidence sup-ports practice change
Assess risk for pressure ulcer development using the Braden Scale
Relationships Among QI, EBP & Research
13
Rush Oak Park HospitalManual for Nursing Practice Governance MEANINGFUL PROCESSES TO GUIDE PRACTICE
Practice Tools
WE ARE NPGO
DMS ELEMENT CHARACTERISTICS
Daily Readiness Huddles with Problem Escalation
Success Metrics
Improvement Ideas
Flow and Adjust
Standard Work with Confirmation
Everything in place for a successful shift/day… if not, fix immediately or escalate
Understanding organizational metrics and aligning departmental improvement work
Everyone’s problem-solving creativity and capacity is fully utilized
Ensuring that the important work flows smoothly through the department or unit
Everyone follows the “one current/best way” to perform critical processes – helps build “Right the first time” mindset
Continuous Pursuit of Excellence Lean Program
Continuous Pursuit of Excellence (CPE) is our philosophy and system to organize and improve our work everyday, in every role and in
every setting. Rush Oak Park Hospital does this because we must respond to the significant challenges facing health care in the US. CPE can only be accomplished by leveraging the problem solving power of all our employees. One of the goals of CPE is to increase value as defined by quality versus cost. CPE enables these three pillars to be successful: methods, management and mindset.
Methods Performance Improvement Methodologies Six Sigma, Rush Way, Lean
Individual Tools PDSA, Fishbone, 5 Whys, Spaghetti Diagram, Value Stream Analysis, Root Cause Analysis, A3
Management Strategy Deployment To focus the organization on a critical few breakthrough objectives
Cross-Functional Management To organize and manage across functional silos for the benefit of the customer
Daily Management System (DMS) To support the work of the front-line resulting in reliable process performance and continuous improvement
Mindset Traditional Management
Leader directs work
Leader produces metrics and feeds back when not met
Leader is assignor of work
Team meets goals set by leader
Rigid enforcer of rules and regulations
Information controller
Technical expert
Servant Leadership Leader sets directions with humility
Team produces metrics and defines actions to close gaps
Leader teaches/coaches
Team sets/meets goals aligned with true north
Self directed teams based on expectations
Information conduit
Facilitates root cause analysis
CPE & DMS Principles
DMS Levels and Purpose
Patient as Customer
Escalate Issues
Design Work to
Surface & Fix Problems
Make Things Visual
Respect & Use
Everyone’s Talents
Workon the
Critical: Few
Visual Management: Problem Solving, Focus on the Customer, Lean Leadership
DMS is a system that delivers more than the sum of all levels.
Flipping the Pyramid
14 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
MEANINGFUL PROCESSES TO GUIDE PRACTICEPractice Tools
Just Culture AlgorithmThe Just Culture algorithm is intended as an aid to help determine system failures, individual accountabilities and corrective action
following a Safety Event.
This algorithm may not apply in all cases and is not intended to restrict the Medical Center’s rights to manage, to alter existing employment relationshios or to supercede existing policies and procedures.
Larsen D, et al. Nursing Standard. 2007; 21(48):35-40NHS Incident Decision Tree National Patient Safety Agency 2003ADAPTED FROM
Deliberate Harm Test
Impairment Test
Foresight Test
Substitution Test
STARTHERE
Were the actions deliberate?
Were adverse consequences
intended?
Were there significant mitigating
circumstances?
Pattern of unsafe or
problematicacts?
Corrective action is warranted, consult
with HR. If malicious action, duties should
be suspended pending investigation.
A
The individual is accountable and
needs retraining or support. Corrective action or EAP may
be warranted.
B
Individual is accountable and needs coaching or retraining. Corrective action may be warranted. Individ-ual may participate in teaching others les-
sons learned. Address system issues.
C
Individual is accountable and needs coaching.
Individual may participate in teaching others lessons learned. Address system issues.
D
The system supports error.System’s leaders are accountable and should ensure safety solutions are implemented. Individual should be consoled.
E
YES
Is there evidence of illness, substance abuse or known
medical condition contributed to the behavioral choice?
YES
YES
YESYES
YES
YES
YES
YES YES YES YES
YES
Did the individual
depart from established protocols, policies or safe proce-
dures?
Were the pro-tocols, policies and safe proce-dures available, workable, intel-ligible, correct and in routine
use?
Were there any deficiencies in training,
experience or supervision?
Were there significant mitigating
circumstances?
Is there evidence that the
individual took an
unaccept-able risk?
Were there significant mitigating
circum-stances?
Pattern of disre-garding policy or pro-
cesses?
NO
Would another individual coming from the same pro-fessional group, possessing comparable qualifications and experience behave in the same way in similar
circumstances?
Consider
Mitigating Factors
including intention of
employee, motivation, what
information was available,
speed at which decisions
were required, degree
of awareness of risk and
self-reporting.
!
NO
NO
NO
NO
NO NO NO
NONONO
NO
NO
15
Rush Oak Park HospitalManual for Nursing Practice Governance MEANINGFUL PROCESSES TO GUIDE PRACTICE
Practice Tools
WE ARE NPGO V.3 ROPH Nursing Practice and Peer Review, Corrective Action, and Appeals process. Approved by NPGO Executive Committee, December 2020.
NPGO Peer Review, Corrective Action and Appeals Process
Annual Practice Evaluation with associated Performance Improvement Action Plan (rated
2 or below) with final decision for rating on evaluation.
Reject for lack of
merit and communicate with sender
If clear lack of nursing practice adherence and no trend noted, review with UD/
Employee via corrective action
process and communicate with
sender
NPGO Peer Review conducts
full review and renders recom-
mendation:Exemplary Recog-nition Letter Sent
to Inform Em-ployee of Review,
Manager, CNO and NPGO Pres CC’d, placed in
file/portfolio
NPGO Peer Review conducts full
review and renders recommendation:Informational and
Professional Devel-opment Letter Sent to Inform Employee of Review, Manager,
CNO and NPGO Pres. CC’d, placed
in file
NPGO Peer Re-view conducts full review and renders recom-
mendation:Final Letter of Determination, showing if cor-rective action
process or other professional development activity is set to elicit more information
from employee and/or manager,
CC’ing CNO and NPGO Pres,
placed in file
NPGO Peer Review has seen more than one instance requiring
informational, educational,
action planning, inquiry or
final deter-mination letters on an individ-ual nurse, requiring additional
consideration, review,
consultation
If lack of clarity exists, potential for trend exists
and there is need for peer exper-tise to evaluate, send to NPGO
Peer Review for evaluation and
recommendation consultation and
communicate with sender
Review for annual practice privilege, clear lack of nursing
practice adhered and no trend
noted, review with UD for appro-priate action
planning
CNO and NPGO President review all quality memos, identifying what pathway for further review to follow - using all mechanisms
listed herein and tracking all that come with outcomes elicited
If deemed HR Issue follow HR process
If Staff Appeals:
Follow HR Fair Treatment
Process
If practice related, UD can:
1. Reject for lack of merit,
2. Confer with practitioner,
3. Request UAC review and,
4. Render final determination based on UAC
review.
Corrective action may be requested by any
RN at any time: General accountability for practice by any RN/
APN (Bylaws 6)
Accountability Pathway
Appeal within 14 calendar days to CNO or NPGO President
President Reviews with NPGO Executive Committee and creates
recommendation Recommendation reviewed
by CNO and NPGO President, considering evidence and making
final non reviewable decision
Staff Appeals Process
Practice Review PathwayAdditional RN/APN Practice
Review Mechanisms(Organizational Performance
Improvement Initiative/Taskforce with findings related to Nursing Practice
Safety Event with Findings Related to Nursing Practice
NPGO Executive Committee or other NPGO Committee Request for Review
of Nursing Practice Trend
Annual Review Pathway
RN/APN Annual Review Process and Nursing
Practice Privilege ReviewBylaws 4.4-2 and 5
Complete Nursing Practice Form and Submit to Unit
Director
Complete Nursing Practice Form and submit to CNO/NPGO President for review, tracking and support
Staff Appeals: Follow Above Process
NPGO Peer Review
conducts full review
and renders recommen-
dation: Educational Letter Sent to Inform Employee of Review, Manager, CNO and
NPGO Pres CC’d, placed
in file
NPGO Peer Review
conducts full review and
renders rec-ommendation:
Letter of Inquiry is
sent to elicit more infor-mation from
employee and/or manager, CC’ing CNO and NPGO
Pres, placed in file
NPGO Peer Review
conducts full review
and renders recommen-
dation:Action Plan Letter Set to Inform Employee of Review, Manager, CNO and
NPGO Pres CC’d, placed
in file
16 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
MEANINGFUL PROCESSES TO GUIDE PRACTICEPractice Tools
Portfolio DevelopmentHere are some examples of documents you might use to fulfill the
requirements for the different categories in the clinical advancement process.
SECTION 1
Introduction & Professional Overview
SECTION3
Critical Thinking
CV/Resume
Letter of Intent to Advance
Copy of current level of education and proof of enrolled continuing education
Proof of Certification
Other items listed in professional overview section of clinical advancement requirements
Any Continuing Education Proof, Credits Earned, Topics, Content Utilized on Unit
Any Preceptor or Charge Workshops attended, as well as other workshops- EKG, ACLS, etc.
Proof of “Super user” or “Expert” Status on unit- skin, palliative care, Epic, etc.
Performance evaluation and Peer Review
Required exemplars and documents from clinical advancement process
Your Projects and any future EBP projects that you do with references and slides and outcomes
Your involvement in development or revision of any nursing standards of practice or care and any related education or presentation
Use of EBP to drive unit quality improvement or nursing practice projects- with examples
Required exemplars and documents from clinical advancement process
Active engagement in charge or preceptor role and proof of such
Involvement in unit committees, care rounds, Unit/Clinic Advisory Committee, Department Advisory Committee, NPGO Standing Committees or other institutional groups
Involvement in Professional Organizations and proof of information sharing to unit from such
Any innovations to unit not listed in projects as above, especially those that denote leading of staff from unit towards new practices, communication techniques, teambuilding exercises, recognition practices
Required exemplars and documents from clinical advancement process
Extras…Any articles you have written, membership listings, things not listed above
Letters of recommendation from colleagues, patients, families, preceptors, faculty
Stories of Interactions within Care Delivery team of advocacy and compassion
Award nominations describing your interactions with others
Any involvement within the community or volunteer experience utilizing nursing expertise
Required exemplars and documents from clinical advancement process
Stories of complex patient situations, expert assessment skills
Development of Education- Inservices, Bulletin Boards, Journal Clubs to assist fellow staff and students in critical thinking and problem solving
Involvement in Quality Improvement Projects/Audits
Required exemplars and documents from clinical advancement process
Development of Portfolio begins when you get your license and continues throughout your career.
Present in Formal Presentation Binder
Keep in mind- moving up the ladder means that you are already showing some evidence of proficiency at the level that you wish to move to.
Use your Annual Performance Evaluation Journal to daily track your caring and professional stories
When presenting patient stories, please be careful to not describe any patient identifiers, which would violate HIPAA.
TIPS BEFORE YOU BEGIN
Designing Your Portfolio
SECTION 2
Relationships and Caring
SECTION 4
Technical Expertise
SECTION 5
Evidence-Based Practice
SECTION 6
Leadership
SECTION 7
References
17
Rush Oak Park HospitalManual for Nursing Practice Governance MEANINGFUL PROCESSES TO GUIDE PRACTICE
Practice Tools
WE ARE NPGO
Clinical Advancement RN1 to RN2
CV/Resume Letter of Intent Letter of Support from UD CE credits earned BLS- submit copy of card ACLS (unit-based)- submit copy of card* PALS (ER only)- submit copy of card New Grad Residency 12 month attendance proof Attend Preceptor Workshop Attend Charge Nurse Workshop*
* Not required for ambulatory RNs
In the following section mark any of the examples provided or add others in the blank spaces. An example from each competency in each domain is the minimal expectation to move to a level RN2. (Unless otherwise specified)
Proficiency in each can be demonstrated in one or more of the following ways (unless specified within the individual section):
Exemplar Official Document Letter from Patient, Peer colleague, Supervisor, Physician, etc.
Portfolio Review and Leveling: Level RN1 to Level RN2
Demonstrated proficiency in all of the below areas required:
I have signed and have been able to meet the expectations defined in the code of conduct.
I am able to coach as-sistive personnel while maintaining an effective relationship.
I am capable of collabo-rative interaction within my care delivery team.
I Participate in conflict resolution that enhanc-es team relationship. (provide example)
I have and show respect and sensitivity toward diverse cultures and/or vulnerable populations.
Demonstrated proficiency in all of the below areas required:
I have developed and(or used evidence-based research for patient care.
Demonstrated proficiency in all of the below areas required:
I provide effective patient education.
I am able and willing to help my co-workers while still completing my own work.
I use ROPH policies in care decisions.
Approval checklist letter from UAC
Demonstrated proficiency in all of the below areas required:
I adapt care plans to meet changing needs of patients. (Submit a screen shot of a care plan.)
Demonstrated proficiency in all of the below areas required:
I am a Committee(Council member who attends my meetings regularly. (Provide evi-dence of attendance)
I participate in conflict resolution during pa-tient care and/or within my team.
I am able to delegate responsibilities effec-tively and consistently.
Describe how you are making progress toward your annual goals.
Proof must be provided for the elements in each columnProfessional Practice Model Domain
Professional Overview (Required) Domains of Practice
CRITICAL THINKING
EVIDENCE-BASED PRACTICE LEADERSHIP
TECHNICAL EXPERTISE
RELATIONSHIPS AND CARING
18 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
MEANINGFUL PROCESSES TO GUIDE PRACTICEPractice Tools
Clinical Advancement RN2 to RN3
CV/Resume Letter of Intent Letter of Support from UD CE credits earned BLS- submit copy of card ACLS (unit-based)- submit copy of card* PALS (ER only)- submit copy of card Attend Preceptor Workshop Attend Charge Nurse Workshop*
* Not required for ambulatory RNs
In the following section mark any of the examples provided or add others in the blank spaces. An example from each competency in each domain is the minimal expectation to move to a level RN3. (Unless otherwise specified)
Proficiency in each section can be demonstrated in one or more of the following ways:(unless specified within the individual section)
Exemplar Official Document Letter from Patient, Peer colleague, Supervisor, Physician, etc.
Portfolio Review and Leveling: Level RN2 to Level RN3
Demonstrated proficiency in all of the below areas required:
I have signed and have been able to meet the expectations defined in the code of conduct.
I am able to maintain coaching of assistive per-sonnel while maintaining an effective relationship.
I am capable of collabo-rative interaction within my care delivery team.
I participate in commu-nity or volunteer experi-ence through ROPH.
I have and show respect and sensitivity for diverse cultures and/or vulnerable populations.
I serve as role model for interpersonal communication.
Demonstrated proficien-cy in one or more of the below areas required:
Poster/podium pre-sentation – internal or external
EBP, QI or research project team member or leader
Policy or standards development/revision
Manuscript/abstract submission and/or publication
ROPH Grand Rounds presentation
Unit or Hospital-based Evidence-Based Project
Literature Review
Demonstrated proficiency in all of the below areas required:
I provide effective pa-tient education.
I am able and willing to help my co-workers while still completing my own work.
I use ROPH policies in my patient care deci-sions.
I am a “Super-User” or Unit Expert in some clinical area.
Approval checklist letter from UAC
Demonstrated proficiency in all of the below areas required:
I adapt care plans to meet changing needs of patients. (submit a screen shot of a care plan.)
I have participated in the development of ed-ucational materials. (eg, bulletin boards, in-ser-vices, journal club)
I have been a PI/QI proj-ect team member.
I support less experi-enced staff in man-agement and review of complex patient situa-tions in order to identify practical solutions.
Demonstrated proficiency in all of the below areas required:
I am a committee/council member who attends my meetings regularly. (provide evidence of attendance)
I lead in conflict resolu-tion that enhances team relationship.
I am able to delegate re-sponsibilities effectively and consistently.
Describe how you are making progress toward your annual goals.
I am a member in a profes-sional organization. (submit copy of membership card)
I function as a regular charge nurse or preceptor. (for either staff or students)
I am/have been part of a Unit-based/hospital inno-vation. (eg., teambuilding, recognition, new practices)
Professional Overview (Required) Domains of Practice
CRITICAL THINKING
EVIDENCE-BASED PRACTICE LEADERSHIP
TECHNICAL EXPERTISE
RELATIONSHIPS AND CARING
Specialty certification as determined by your UAC is required within one year after leveling to RN3. If you transition to another specialty area, in order to maintain RN3 status, you must take the new area’s approved certification within 1 year of elibility to maintain RN3 status.
Certification
Proof must be provided for the elements in each columnProfessional Practice Model Domain
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Rush Oak Park HospitalManual for Nursing Practice Governance MEANINGFUL PROCESSES TO GUIDE PRACTICE
Practice Tools
WE ARE NPGO
Maintenance of RN3 Status
CV/Resume Letter of Intent-What you’ve done in the past year and what you plan to do in the upcoming year.
Letter of Support from UD CE credits earned BLS- submit copy of card ACLS (unit-based)- submit copy of card* PALS (ER only)- submit copy of card Attend Preceptor Workshop Attend Charge Nurse Workshop* Letter of approval and/or suggestions from prior portfolio submission
* Not required for ambulatory RNs
In the following section mark any of the examples provided or add others in the blank spaces. An example from each area is the minimal expectation to maintain a level III RN. (Unless otherwise specified)Proficiency in each section can be demonstrated in one or more of the following ways: (unless specified within the individual section)
Exemplar Official Document Letter from Patient, Peer colleague, Supervisor, Physician, etc. The examples must be current and from the past fiscal year.
Portfolio Review and Leveling: RN3 Maintenance
Demonstrated proficiency in all of the below areas required:
Meet the expectations defined in the code of conduct.
I participate in commu-nity or volunteer experi-ence through ROPH.
I have and show respect and sensitivity for diverse cultures and/or vulnerable populations.
Letter from a colleague or member of the interdisciplinary team displaying how you em-body relationships and caring in the workplace.
Demonstrated proficien-cy in two or more of the below areas required:
Poster/podium pre-sentation – internal or external
EBP, QI or research project team member or leader
Policy or standards development/revision
Manuscript/abstract submission and/or pub-lication
ROPH Grand Rounds presentation
Unit or Hospital-based Evidence-Based Project
Literature Review
Demonstrated proficiency in all of the below areas required:
I am a “Super-User” or Unit Expert in some clinical area.
Approval checklist letter from UAC
20 CEU’s per year
Demonstrated proficiency in all of the below areas required:
I have participated in the development of ed-ucational materials. (eg, bulletin boards, in-ser-vices, journal club)
I support less experi-enced staff in man-agement and review of complex patient situa-tions in order to identify practical solutions.
Demonstrated proficiency in all of the below areas required:
I am a committee/council member who attends my meetings regularly (provide evidence of attendance) and active involvement.
I am a current member in a professional organi-zation. (Submit copy of membership card.)
I function as a regular charge nurse or precep-tor. (for either staff or students.)
I am/have been part of a Unit-based/hospital innovation. (eg., team-building, recognition, new practices.)
Professional Overview (Required) Domains of Practice
CRITICAL THINKING
EVIDENCE-BASED PRACTICE LEADERSHIP
TECHNICAL EXPERTISE
RELATIONSHIPS AND CARING
Specialty certification as determined by your UAC is required within one year after leveling to RN3. If you transition to another specialty area, in order to maintain RN3 status, you must take the new area’s approved certification within 1 year of elibility to maintain RN3 status.
Certification
Proof must be provided for the elements in each columnProfessional Practice Model Domain
20 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
MEANINGFUL PROCESSES TO GUIDE PRACTICEPractice Tools
Structural Empowerment PolicyRush Oak Park Hospital is committed to actively seeking
nursing input in organizational decisions when possible. The Department of Patient Care Services is committed to empower the Professional Nursing Staff by providing opportunities for exemplary professional practice and development; opportunities to increase in professional knowledge, skills, innovations, and improvements; participation
in transformational leadership with the ability to access and mobilize resources in order to meet organizational goals, access information and support in order to practice nursing and enhance the effectiveness of work; and outreach for community healthcare. ROPH nurses will support organizational goals, advance the nursing profession, and enhance their professional development by extending their influence to professional and
The ROPH nursing organization will be a flat structure to minimize layers between the Chief Nursing Officer (CNO) and front-line nursing staff. To achieve this flatted structure, the roles of unit manager and director will be combined, when possible. The CNO will oversee nursing practice in all areas of the organization regardless of direct reporting structures.
A decentralized structure for empowering the professional nursing staff in all areas of ROPH is:
The Nursing Professional Governance Organization Executive Council The Unit Advisory Councils on each nursing unit Nursing representatives on corporate quality and management councils that
provide feedback that channels to hospital administration and ultimately the ROPH Board of DirectorsThe structure promotes the multidirectional flow of information and decision-
making among front-line nurses, leadership, interprofessional teams, and the CNO. The CNO serves on the highest-level decision-making bodies; resource to the ROPH Board of Directors, the ROPH Executive Senior Leadership, Management Team, Patient Care Services Leadership Council, and Nursing Professional Governance (NPGO) Executive Council. The CNO will participate in Rush corporate Nursing Strategic Planning and initiatives in both the university and the medical center.
The CNO will participate in the development of the mission, vision, values, nursing practice model, and nursing care model and will be responsible for alignment of strategic objectives and goals.
Nurse leaders throughout the organization will serve on ROPH corporate committees that develop and evaluate organizational activities related to quality & safety, finance, staffing, and rewards: Nursing Peer Review, Staff Nursing Advisory Board (SNAB), Performance Improvement Coordinating Committee (PICC), NPGO Executive Committee, Infection Control task forces, Skin Care Committee, Patient Satisfaction task forces, Evidence-based Clinical Practice Committee, Policy and Procedure Committee, Retention and Recruitment Committee, Pain Management Committee, Fall Reduction Committee, Employee Recognition, UACs, and other goal-specific committees. The purpose is to address excellence in patient care and the safe, efficient, and effective operation of the organization. Innovation will be encouraged through idea generation and approval to trial new approaches with a culture of collaboration and cooperation.
It is the role responsibility of each nurse leader and any committee member to represent and communicate back to those nurses being represented. Improved communication to the nursing staff may be through multiple avenues such as staff meetings, bulletin boards, newsletters and e-mails.
The CNO and Nurse Leaders will support a lifelong learning culture that includes professional collaboration, promotion of role development, academic achievement, and career advancement.
Internal inservices will be based on a needs assessment from staff input and regulatory requirements.
Nursing education for nursing staff and support staff is promoted through the availability of tuition reimbursement.
A BSN will be the minimum level of nursing education for incoming nurses with the following exceptions.
The formalized interview process for nursing positions will seek candidates that meet the mission, vision, and values of the organization and demonstrate attributes of self-efficacy to promote the nursing philosophy and vision.
Whenever possible, ROPH will promote from within and provide the necessary orientation and structure as well as direct support to make promotion successful.
ROPH will be committed to supporting clinical rotations of area nursing university programs.
Nurse Leaders functioning as quality preceptors are recognized in the Nursing Levels of Practice.
Participation in professional organizations is encouraged.
Nursing Grand Rounds will be held to expand nursing knowledge.
Abstracts for poster and/or podium presentations at professional events will be encouraged within the budgetary confines to support attendance or based on the individual’s willingness to pay all or a portion of the trip.
Professional publications will be evidence-based or research-based to support clinical practice.
An Annual Report for nursing will highlight the recent activities and accomplishments of nursing with their colleagues.
Nursing partnerships with the community will be encouraged to promote patient outcomes and advance the health of the five communities of Oak Park, Forest Park, River Forest, Elwood Park, and Riverside as determined by the highest volume of served patients by zip codes. Nurses will be recognized for community service
at least annually in the performance review process, and may also be recognized through other recognition initiatives (e.g., Daisy, Shout Out, Thank You notes) since these efforts enhance and support the value and image of nursing in this venue.
Above is an abbreviated version of the Structural Empowerment Policy, please visit the Rush intranet to review full policy.
Organizational Structure
Professional Development
Community Commitment
21
Rush Oak Park HospitalManual for Nursing Practice Governance PROFESSIONAL DEVELOPMENT RESOURCES
Practice Tools
WE ARE NPGO
Leadership DevelopmentLeadership Development, Mentorship & Succession Planning Program
Professional Practice Shared Governance
Transparency
Structural Empowerment
Team Building
Negotiation
Sources of Power and Empowerment
Adapting to Change
Environmental Factors
Meaningful Recognition
Manager as Nurse Retention Officer
Staff Management Labor-Management Relations
Employee Motivation
Hiring and Privilege Approval
Collective Bargaining
Performance Evaluation
Performance Management
Scheduling/Staffing
Agency Agreements and Management
Job Description Development
Program Evaluation & Research Program Evaluation
Data analysis
Research
Project Planning
Dissemination of Information
Utilizing EBP in Practice
Policy Review and Development
Knowledge Translation
Dissemination of Evidence Based Practices or New Knowledge
Legal & Regulatory Issues Federal Laws and Regulations
State Programs
Accreditation and Credentialing
Contracts and Agreements
Healthcare Economics Budget planning and reporting
Technology and Information Systems
Budget Planning and Reporting
Measuring productivity
Reimbursement
Cost Containment
Marketing
Ordering Supplies
Change Management
Professionalism & Ethics Moral Theories and Ethical Principles
Ethical Foundations of Corporate Decision Making
Business and Healthcare Problems
Ethics Committees/Issues
Compliance
Confidentiality
Assessing Safety & Risk Continuous Quality Improvement
Interpreting Data
Professional and Institutional Liability: UOs, Risk Management
Important Metrics to Follow
How to Develop Goals and Metrics
FEMA
Emergency Preparedness
Incident Command Process
Case Management
Bed Management
Leadership & Management Leadership Theories
Governance
Organization and Structure
Mission and Philosophy
Planning Continuum
Strategic Planning
Contingency Planning
Innovation
Healthcare Environment Practice Environment
Institutional Environment
External Environment
Physical Environment
Educational Institutions
Professional Growth Planning a Career Trajectory
Professional Roles, Organiza-tions and Presentations
Emergence as a Leader
Mentorship and Growth of Others
Succession Planning
Communication Transparency
Conflict and Conflict Resolution
Negotiation
Effective Use of Electronic Communication
Building Consensus
Professional Practice Model DomainCRITICAL THINKING
EVIDENCE-BASED PRACTICE LEADERSHIP
TECHNICAL EXPERTISE
RELATIONSHIPS AND CARING
ProgramROPH Nursing Leadership
Development Mentorship Program
WhoAll new managers, leaders and
any RN or APN that requests
Program StartInitiated between leader and
designated or chosen facilitator, with timeline tailored to individual
Check out pages 22 & 23 to review full Leadership
Development, Mentorship & Succession Planning Program Checklist
Mary Parker Follett, The Creative Experience, 1924
Leadership is not defined by the exercise of power but by the capacity to increase the sense of power among those led. The most essential
work of the leader is to create more leaders.
DMS
Setting Goals
Process Improvement
Collecting/ Interpreting Data
Schedule
Payroll
Budget
HR functions (hiring, link, FMLA etc.)
How the pager works
Google Docs
Performance Evaluations
Intro to Outlook
22 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PROFESSIONAL DEVELOPMENT RESOURCESPractice Tools
Leadership Development, Mentorship & Succession Planning Program
This tool works as an adjunct to the overall ROPH Nursing LDMS Program Checklist to guide timeline, tactics and details relative to each unit and employee’s specific needs. It is sculpted in the domains of the American Organization of Nurse Leaders Nurse Executive Competencies and should guide active mentorship, succession planning, transition to practice and developmental activities between a new or aspiring leader and their primary manager or mentor.
Operational Task Checklist
Overview
Who does what
Getting to know staff and culture
Diversity and inclusion
How does every-thing fit together
Regulatory stuff
Building Collabora-tive relationships
Intro to Shared Governance
Process
Fair Treatment
AEP
Just Culture
Prioritization
LSW
Dealing with the politics & managing up
Interacting with the community
Strategic Planning
Facilitator:
Start Date:
Targeted Completion Date:
Mentee Name:
1x per week for first month
1x every other week for second and third month
TIMETABLE
STEP 1Organizational/
Unit Assessment & Orientation
STEP 2Functions
& Processes
STEP 3Intro to
Corrective Action
STEP 4Leader
Standard Work
STEP 5Quality
Improvement, CPE
STEP 6Advanced
Leadership Skills
WEEK 1 Unit/Organizational Assessment and OrientationHow do I contact people?Phone and email lists
Regulation
Policies
TJC Guidelines, IDPH regulations, unit-specific: Sexual Assault ER, Long-term Care, SCU
How to locate policies, Unit-specific, Review expectations
Intro to Shared GovernanceMeet with NPGO President and Magnet Coordinator
Current Unit MetricsWhat are they? Where do I find them?
Roles/Responsibilities/Opinions Building Collaborative RelationshipsSharing your goals/hopes for unit, going right, needs improve-ment, leadership style and role, meet with the CEO, all VPs, all Directors and Physicians
Getting to know staff & cultureHR Diversity and Culture training course10-minute meeting with each staff member What is going right? What would be the biggest improvement? What is most helpful to you in a leader?
How does everything fit together?Study Org chart, bring any questions to mentor
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Rush Oak Park HospitalManual for Nursing Practice Governance PROFESSIONAL DEVELOPMENT RESOURCES
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WE ARE NPGO
WEEK 3 Introduction to Corrective Action
ROPH Process Employee Assistance Program
Fair Treatment Just Culture
WEEK 2 Functions and Processes
Unit Processes Other
HR Functions
Schedule, Payroll, Budget How the pager worksIntroduction to OutlookGoogle Docs (scheduling, record keeping, etc.)
Hiring Process, Navigating Link, FMLA, Performance Evals
WEEK 3 Leader Standard Work
Concept of LSW Prioritization StrategiesPower Point, Article, Sample Forms, Interview other leaders, Create
WEEK 5-ONGOING Advanced Leadership SkillsDealing with the Politics & Managing Up Strategic Planning
Interacting With the Community
https://skillpath.com/search
WEEK 4 Quality Improvement, Continuous Process ImprovementDMS Process Improvement Process
Setting Unit & Personal Goals Collecting & Interpreting Data
Read LEAN book, Meet with CPE coordinator CPE Coordinator, Quality Department
CPE Coordinator CPE Coordinator, Quality Department
24 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PROFESSIONAL DEVELOPMENT RESOURCESPractice Tools
Leadership Development, Mentorship & Succession Planning Program
The Rush Oak Park Hospital Leadership Development, Mentorship and Succession Planning Program is meant to support both interested nurses or APNs in all roles of nursing or their managers toward professional advancement. Nurses and APNs can express interest to the office of the CNO or their manager for program onboarding, mentorship connection and succession planning, via internal or external mechanisms. Development, mentorship and succession planning activities will take into account the individual’s strengths, weaknesses, professional goals and be tailored to the individual with the eventual achievement of agreed upon professional journey benchmarks. Rush Oak Park H
ospital believes leadership development, mentorship and succession planning is a result of healthy structural empowerment and that developing leaders is an imperative for
Needs Assessment & Checklist
RELATIONSHIPS AND CARING RELATIONSHIPS AND CARING
GOALS AND PROCESS
Professional PracticeONGOING ONGOING
ONGOING
ONGOING ONGOING
ONGOING
ONGOING ONGOING
ONGOING
ONGOING ONGOING
ONGOING
ONGOING ONGOING
ONGOING
ONGOING ONGOING
ONGOING
ONGOING ONGOING
ONGOING
ONGOING ONGOING
ONGOING
ONGOING ONGOING
ONGOING
ACHIEVED ACHIEVED
ACHIEVED
ACHIEVED ACHIEVED
ACHIEVED
ACHIEVED ACHIEVED
ACHIEVED
ACHIEVED ACHIEVED
ACHIEVED
ACHIEVED ACHIEVED
ACHIEVED
ACHIEVED ACHIEVED
ACHIEVED
ACHIEVED ACHIEVED
ACHIEVED
ACHIEVED ACHIEVED
ACHIEVED
ACHIEVED ACHIEVED
ACHIEVED
Shared Governance Labor-Management Relations
Program Evaluation
Sources of Power and Empowerment
Performance Evaluation
Dissemination of Information
Structural Empowerment Hiring and PriviledgeApproval
Research
Environmental Factors Scheduling/Staffing
Policy Review and Development
Transparency Employee Motivation
Data Analysis
Adapting to Change Performance Management
Utilizing EBP in Practice
Team Building Collective Bargaining
Project Planning
Meaningful Recognition Agency Agreementsand Management
Knowledge TranslationManager as Nurse Retention Officer
Job Description Development
Dissemination of Evidence Based Practices or New Knowledge
Staff ManagementEVIDENCED BASED PRACTICE
Program Evaluation and Research
Facilitator:
Start Date:
Targeted Completion Date:
Mentee Name:
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Rush Oak Park HospitalManual for Nursing Practice Governance PROFESSIONAL DEVELOPMENT RESOURCES
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GOALS AND PROCESS
ONGOING
ONGOING
ONGOING
ONGOING
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Federal Lawsand Regulations
Accredidation andCredentialing
State Programs
Contracts and Agreements
TECHNICAL EXPERTISE
Legal
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Budget Planningand Reporting
Budget Planningand Reporting
Cost Containment
Change Management
Technology andInformation Systems
Reimbursement
Ordering Supplies
Measuring Productivity
Marketing
TECHNICAL EXPERTISE
Healthcare Economics
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Moral Theories and Ethical Principles
Business and Healthcare Problems
Confidentiality
Ethical Foundations of Corporate Decision Making
Compliance
Ethics Committees/Issues
CRITICAL THINKING
Professionalism and Ethics
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Leadership and Management
Governance
Planning Continuum
Innovation
Leadership Theories
Mission and Philosophy
Contingency Planning
Organization and Structure
Strategic Planning
LEADERSHIP
Leadership and Management
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Practice Environment
External Environment
Institutional Environment
Educational Institutions
Physical Environment
LEADERSHIP
Healthcare Environment
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Planning a Career Trajectory
Emergence as a Leader
Professional Roles, Organiza-tions and Presentations
Succession Planning
Mentorship and Growth of others
LEADERSHIP
Professional Growth
ONGOING
ONGOING
ONGOING
ONGOING
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Transparency
Negotiation
Conflict and Conflict Resolution
Effective Use of Electronic Communication
LEADERSHIP
Communication
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ONGOING
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Continuous Quality Improvement
Professional and Institutional Liability
FEMA
Bed Management
Interpreting Data
How to DevelopGoals and Metrics
Case Management
Important Metrics to Follow
Emergency Preparedness
CRITICAL THINKING
Assessing Safety and Risk
26 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PROFESSIONAL DEVELOPMENT RESOURCESPractice Tools
New Graduate Nurse Residency Program
Transition to Practice Program
Conceptual FrameworkGuided by Patricia Benner’s (1984) conceptual framework for transition to practice, “From Novice to Expert,” which outlines five levels of competency in clinical practice: novice, advanced beginner, competent, proficient and expert, the graduate nurse enters the residency program as an advanced beginner nurse who may have the necessary theoretical knowledge but lacks the clinical or situational experience to apply intuition, clinical judgment and contextual knowledge to nursing practice.
Appreciative, Inclusion Based ApproachThe NGNRP at ROPH seeks to approach this process from an appreciative stance, taking ownership for a culture that will support success in this program, and girded by a just culture, the expectation is that all new graduate nurse hires will successfully transition into excellent practicing ROPH nurses.
Every New Grad from any area entered into program Partnership between NPGO and Nursing Administration oversees program
NPGO administers clinical advancement between RN1 and 2 based on successful completion of this year long program
Guided by Best Current Evidence and Performance MeasuresBased on 6 elements of the ANCC transition to practice program as well as feedback, both formal (Casey Fink validated survey) and informal (through monthly feedback from residents) as well as regular assessment of performance measures such as retention rates
Program LeadershipCNO, Director of Nursing Practice, CNL Liaison, Unit Director, New Graduate Float Pool and other facilitators of program
Organizational Enculturation Through HR and Nursing specific orientation Through Preceptor and Orientation Pathway Through Nursing administration support of four hours monthly spent at residency meetings
Through the NPGO requirement of full attendance at sessions for RN1-2 advancement
Through 1:1s with CNO at time of hire on topics such as mission, vision for nursing excellence, nursing empowerment, professional governance, professional development, just culture, among others.
Development and Design Year Long Program, with 4 hour sessions, in cohorted groups, done monthly
Cohorts are created based on quarter of hire Facilitators are either CNLs or RN2s and RN3s with speakers from across the organization on a variety of topics
Simultaneously, the new graduate is entered into a phased orientation program, where they are oriented throughout the organization with the end goal of transfer from New Grad Float Pool into a designated, open FTE on one of the clinical areas.
NGNRP Orientation Pathway is as follows:1. Initiation: Central orientation with scenario-based education and classroom discussion (1 week)2. Adaptation: Adjustment to the new environment, orientee is based on unit with preceptor3. Assimilation: Able to receive new facts and information, the orientee is unit based with preceptor, taking on more challenging situations and cases4. Synthesis: Deductive reasoning with the combining of new information in to a new coherent system of information. Orientee is unit-based with preceptor but becoming more independent and able to take on increasingly complex case. No further paperwork at this phase, just a cognizance by the charge nurse that the NGNRP resident is “off orientation” and will be still in touch with preceptor and manager as needed.
Practice Based Learning Multifaceted learning and teaching approaches are utilized throughout the year long program.
The orientation pathway integrates practice based learning which is continual into the clinical setting with a preceptor reviewing the following:
Assessment and Evaluation Emergency Equipment/Devices Skills and Interventions Medications Documentation and Education Psychosocial Other/Resources/Policies Added/Individualized Learning Needs
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Rush Oak Park HospitalManual for Nursing Practice Governance PROFESSIONAL DEVELOPMENT RESOURCES
Practice Tools
WE ARE NPGO
PHASE 1Initiation
Central Orientation with sce-nario-based education and
classroom discussion.
PHASE 2AdaptationAdjustment to the new
environment. Orientee is based on unit with preceptor.
PHASE 3Assimilation
Able to receive new facts and infor-mation. Orientee is unit-based with
preceptor. Taking on more challenging situations and cases.
PHASE 4Synthesis
Deductive reasoning with the combining of new information into a new coherent sys-tem of information. Orientee is unit-based with preceptor but becoming more inde-pendent and able to take on increasingly
complex cases.
New Graduate Nurse Orientation Pathway Phases
New nurse will meet with preceptor and manager at regular intervals throughout this process MONTH 1
Resiliency Moral Courage, Crucial Conversations, Chain of Command and Just Culture
Welcome, Letter to Self and Magnet Planner
MONTH 2 HR/Nursing Admin Policies and Self-scheduling
Time Management and Delegation Basic Assessment and Lines/Tubes/Drains
MONTH 3 Remote Tele/ED Specific Topics 12 Lead EKG Tales From the Bedside Risk Management
MONTH 4 Advanced Directives, Ethics, and Goals of Care CNL program/Interprofessional collaboration RRT and MEWS/ED Specific topics Crash Cart
MONTH 5 End of life/Post-Mortem Care Care of the Stroke Patient Tales From the Bedside Dietary/Nutrition
MONTH 6 Respiratory Health Literacy Magnet Planner Fluid and Electrolytes
MONTH 7 Clinical Advancement and Certification Care of the Pre-Op/Surgical Patient Break Journal Reflection Mock Code
MONTH 8 EBP/Research Care of Delirium/Dementia Patient ABGs Interpreting Cardiac Rhythms
MONTH 9 Care of Psych Patient Anticoagulants and Stroke Medications Quality Management and NSIs Journal Reflection Diabetic Educator
MONTH 10 Cath Lab SANE/Human Trafficking Patient Experience Trach Care, Chest Tubes and PleurX Catheters
MONTH 11 Shadowing
MONTH 12 Light Breakfast and Nurse Panel Professional Role, ANA Social Policy, Career Planning, Business Case For Top of License, Mentorship Availability, and Leadership Development Program
Escape Room Magnet Planner and Final Evaluation Certificate Presentation
New Graduate Nurse Residency Program Schedule
Nursing Professional Development SupportThe NGNRP is focused on retaining nurses at ROPH and growing them into leaders that will affect a diverse array of settings and populations into their professional career, even if that career is outside of ROPH.
This is supported by the Structural Empowerment and Professional Development policies
Other professional development activities are offered regularly to all nurses in the organization and are open to the new graduate nurse from time of hire
Library, tuition reimbursement, Rush system educational offerings and support for on and offsite professional development activities are offered from time of hire
Quality Outcomes Validated survey instrument is administered, with permission at months 1, 6 and 12 to assess for program progress and curriculum needs
Turnover, engagement scores, monthly curriculum evaluations are all utilized in addition to assess programmatic success
28 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PROFESSIONAL DEVELOPMENT RESOURCESPractice Tools
Leap Enhancement & Tuition Reimbursement
Who Is Eligible?All RUMC and ROPH benefits-eligible employees may be eligible to participate in the tuition reimbursement programs after satisfying the length of employment requirements. Participants in the Employee Enhancement program must be employed by Rush for
at least three months. Participants in the Internal and External tuition programs must be employed by Rush for at least one year. (Although note: Employees hired or with job offers dated before January 11, 2016, must be employed by Rush for only three months.)
Employees with spouses, civil union partners or dependent children participating in the Spouse/Dependent tuition program must be employed by Rush for at least one year.
What Is the Purpose of this Program?The purpose of the Employee Educational and Tuition Assistance program is topromote and encourage the pursuit of higher education opportunities and professional development.
What Are the Details?Employee professional development is an important component of the Medical Center’s mission, vision and values. This is currently accomplished through a variety of formal and informal training programs. One of the most critical program components of our employee development efforts is through the tuition assistance program. The professional development programs at Rush have two goals:
1. Employee career development2. Contributing to the Medical Center’s business and/or clinical goals.
The Medical Center may adjust, alter or discontinue any of the terms of this program based on its business need.
How Do I Get Paid? Submit Your Forms HereInternal [email protected] eligible Rush employees enrolled as students in one of Rush’s Colleges
External [email protected] employees for tuition reimbursement for coursework taken at other accredited institutions
Employee [email protected] employees for attendance at outside conferences or seminars
Tuition Reduction [email protected] Spouses, Civil Union Partners or Dependents of eligible employees pursuing a degree at Rush College of Nursing, the Graduate College or the College of Health Sciences
Enhancement ProgramsEmployees who sign up for an enhancement (e.g., not taxable) class are generally reimbursed under the rules that were in effect during the fiscal year in which they registered.
Degree ProgramsEmployees who sign up for a class as part of a degree program are generally reimbursed under the rules that are in effect during the calendar year in which payment is made. All tuition reimbursement payments are made in accordance with the IRS rules for such payments that are in effect at the time the payment is made. Questions of tax liability for tuition reimbursements are answered by referring to the IRS rules in effect at the time payment is received, not the rules that were in effect at the time of class registration.
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Rush Oak Park HospitalManual for Nursing Practice Governance PROFESSIONAL DEVELOPMENT RESOURCES
Practice Tools
WE ARE NPGO
Nursing Interview ToolWe utilize our professional practice model to evaluate the practice of RN candidates to our institution.
We also use this opportunity to meet a nursing colleague and share our vision for nursing as well as our identity as practitioners. The following is a tool to use during interviews of nursing candidates.
MISSIONThe mission of Rush is to improve the health of the individuals and diverse communities we serve through the integration of outstanding patient care, education, research and com-munity partnerships.
RELATIONSHIPSAND CARING
Tell me about your most rewarding experience as a nurse.
Tell me a time you were really upset at someone or some circumstance … how did you deal with it and what was the outcome?
Tell me about a time when you had to successfully complete a project with others.
Give an example of how you have supported and engaged other in shared governance.
Did they describe caring, compassion, interpersonal skills?
What was their communication style for this experience?
Are they willing to negotiate?
Do they exhibit traits of team and relationship building?
EVIDENCE-BASED CARE Can you give us an example of how you have utilized current evidence or best practices to work on an improvement in patient care or the environment?
What are some examples of resources you would seek to bring to your patients and their families?
Tell me about a time when your opinion differed strongly from someone or a group … what did you do?
Did they use literature or data?
Do they describe past use of good resources?
Do they seek out evidence, literature or best practice readily?
TECHNICAL EXPERTISE Can you give us an example of a time that you applied the teaching process to a patient, family or nursing staff and the subsequent outcome(
What are some strategies you have used to support education in peers or staff that report to you?
Did they display good listening — a solid level of understanding?
Did they verify their own expertise and subsequent learning of patients?
CRITICAL THINKING Can you give us an example of a time you recog-nized a change in patient or family needs/health and what you implemented to address that need?
Tell me about some situations in which you had to adjust quickly to changes in the organization or departmental priorities. How did the changes affect you?
Did they seem to have good clinical knowledge, logic, willingness to advocate?
Do they seem versatile?
Do they keep quality and safety top of mind?
LEADERSHIP What activities have you been involved in thus far that support your involvement in professional or-ganizations and/or activities, or leadership therein?
Have you ever helped a co-worker to improve his(her performance at work?
Tell me about a time when you accomplished something on your own.
Tell me about a time when someone was not doing their job or not doing it correctly. What did you do?
Give an example of a time when you were a role model for others.
Do they describe elements of mentorship or teaching?
Do they display independence and initiative?
Can they hold others accountable?
Did they talk about professionalism, culture and mentorship?
Interview Question Things to Look for RatingMVP/PPM Domain Share your three greatest accomplishments to date. How do these align with our mission?
VISIONAt Rush Oak Park, our vision is “to be utilized by our community and beyond as a resource center for patient and family health promotion and support ( and to scientifically and competitively pursue innovative care that supports and sustains wellness in the lives of our patients, our community and beyond.”
If you could change Nursing to be your ideal world, what would it look like?
Was there evidence of self efficacy, initiative, innovation, outreach?
PHILOSOPHYAt Rush Oak Park, our philosophy is that “nurses are proactive and responsive to the needs of individuals, groups and communities across the life span in a variety of settings.”
Can you give examples of interventions for your patients or their families beyond the walls of the organization?
Either for their care continuum or the community?
Give examples of advocacy or empowerment of fellow staff or those reporting to you.
Does this candidate see the patient as a person with lifetime health care needs?
1 2 3 4 5DOES NOT MEET PARTIALLY MEETS MEETS EXCEEDS GREATLY EXCEEDS
4 5321
4 5321
4 5321
4 5321
4 5321
4 5321
4 5321
4 5321
APN PrivilegesCore APN Privileges include but are not limited to: Order appropriate pharmacological agents and non-pharmacological interventions; evaluation of consults on inpatients and ED patients; diagnosis based upon history and physical exam and clinical findings; initiate referrals to appropriate physicians or other healthcare professionals; interpret diagnostic tests; obtain consents for treatment; obtain history and physical; order and perform consults; order blood and blood products; order diagnostic testing and therapeutic modalities; order and initiate tests, treatments and interventions; prescribe medications; write admission orders; write discharge orders and corresponding plans of care; write transfer orders based on the plan for the care transition.
30 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
PROFESSIONAL DEVELOPMENT RESOURCESPractice Tools
Advanced Practice Nurse
Credentialing and privileging (if applicable) must be completed prior to practicing as an APN. The Joint Commission requires that all APNs be privileged through the medical staff process or a procedure that is equivalent to the medical staff process. It must follow criteria set forth in the Joint Commission credentialing and privileging regulations.
APN Credentialing and Priviledging Process
DefinitionsProfessional Practice ModelJob Description for APNThe ROPH Professional Practice Model Domains of rela-tionships and caring, technical expertise, critical thinking, evidenced-based practice and leadership define the com-petencies in the job descriptions of all APNs at ROPH.
CredentialingCredentialing is the process for validating licensure, clinical experience, educational preparation, and certification for specialty practice. This process is required for all APNs.
PrivilegingPrivileging is an entitlement process whereby nurses in ad-vanced practice roles are granted authority to provide spe-cific healthcare services to patients at ROPH practice sites. APNs requesting privileges must identify a physician, with active privileges for the same procedures requested by the APN. This process is required for all APNs requesting privi-leges for procedures beyond the APN Core Privileges.
APN Credentialing and Privileging Process
All APNs applying for credentials or privileges through the Medical Staff Office (MSO) will do so using a pre-ap-plication form. The pre-application must be completed in full by the APN applicant. Once a complete pre-applica-tion is returned by email to the MSO, MSO staff verify licensure, run a National Practitioner Data Bank report and Clerk of the Circuit Court check.
The Credentialing and Privileging (C&P) Committee then reviews pre- applica-tion, Curriculum Vitae and Licensure status, and gives approval for the candidate to progress through further application steps.
A member of the NPGO APN practice council sits on the MSO C&P Committee as an additional re-source/representative for the APN applicant approval process.
The MSO’s receipt of this authorization will trigger them to have Rush Health (CVO) launch the electronic credentialing and privileging applica-tion, which will be sent directly to the applicant by email.
Once the verifications have been completed, a representative from the NPGO APN Prac-tice Council, Chief Nursing Officer and the department chair will be contacted to review the applica-tion, for approval prior to being sent to the Medical Staff C&P Committee.
The APN application packet is then sent to the MSO C&P, Exec-utive Committee and Board for approvals.
Medical Staff office notifies APN applicant of approval and pro-cess is complete.
STEP ONE STEP TWO STEP THREE STEP FOUR STEP FIVE STEP SIX
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Rush Oak Park HospitalManual for Nursing Practice Governance
WE ARE NPGO
PROFESSIONAL DEVELOPMENT RESOURCESPractice Tools
APN Job Description Addendums
APN Onboarding Process
Employed APNs Non-employed APNs (RUMC or Private)
Requirements for All APN Credentialing
1. CMO, CNO and APN committee interviews and decides to hire
2. Medical Staff begins credentialing process 3. APN is sent a 2 page pre-application
from the Medical Staff Office (MSO) to complete and return to us with required copies of licenses and CVs.
4. APN returns pre-application and it is re-viewed by the MSO. Pre-application is sent for approval to the Credentials Committee
5. Within 48 hours of receipt of Pre-appli-cation from MSO, Central Verification Office (CVO) will e-mail the practitioner an electronic application where the APN will have to log into the portal to complete and sign off on.
6. Once the application is received, the CVO will begin verifying peers, affiliations, past insurances, licensure, etc.
7. During the CVO's verifying process, the MSO requests(
a. Epic training date b. LEAP Number c. Application processing fee d. Privilege Request approval by spon-
soring physician e. Epic account request8.( The MSO will receive notice from the CVO
when practitioners credentialing applica-tion is complete.
9. MSO will have completed application reviewed and approved by the CNO, Peer APN and/or APN Committee, Department Chair, Credentials Committee, Medical Executive Committee and Board.
10. The date that the APN's privileges are approved by the Board are the date their privileges will become active. The MSO will notify account provisioning to acti-vate epic account.
The process will be similar with the exception of the involvement of the CMO, CNO, and APN committee. It is also required that non-em-ployed APN pre-applications be approved by the Credentials Committee (last Thursday of the month) prior to sending to the CVO to begin processing.
What the practitioner needs to have for the Credentialing process( Active NPI Number Active State License Active State Controlled Substance License Active DEA license (cannot obtain DEA until Controlled Substance License is obtained – the CMO is allowing EMPLOYED practitioners to work under the hospital DEA, if CSL is active, on a case by case basis)
Privileged/credentialed through ROPH medical staff for ER skills(procedures
Documents assessment, treatment, response to treatment and disposition
Orders and interprets labs, imaging, EKG. CPR, ACLS, PALS within 1 year of hire for regularly scheduled NPs as classes are available through ROPH/RUMC.
Moonlighting NPs will need CPR only. Attends 25% medical staff quarterly meetings and 50% ER Control meet-ings for regularly scheduled NPs. Attends APN Meetings 50% of time Board certified as Family Nurse Practitioners or Emergency Nurse Practitioner.
Function as direct provider of emergency care services.
Coordinate care with community organizations including nursing facilities, hospitals, private practice practitioners, and home care and hospice agencies.
Promote coordination between lev-els of care, striving for best practice
Improve perception of APN and role in coordination
Collect and report data on clinical practice, work towards develop-ment of patient outcome measures
Identify and address palliative(hospice needs beginning with initial assessment.
Discuss end of life issues as appropriate. Initiate coordination of end of life enhancement/care where appropriate.
Privileged/credentialed through ROPH medical staff
Documents assessment, treatment, response to treatment and disposition
Orders and interprets labs, imaging, EKG. CPR, ACLS, within 1 year of hire for regularly scheduled NPs as classes are available through ROPH/RUMC
Attend 25% of medical staff quar-terly meetings
Attends APN Meetings 50% of time Board certified as Acute Care, Adult or Family Nurse Practitioner
Coordinate care with community organizations including nursing facilities, hospitals, private practice practitioners, and home care and hospice agencies.
Function as expert on care of geriatric population. Remain current with best practices in geriatric care
Promote coordination between lev-els of care, striving for best practice across the care continuum.
Improve perception of APN and role in coordination
Collect and report data on clinical practice, work towards develop-ment of patient outcome measures
Identify and address palliative(hospice needs beginning with initial assessment.
Discuss end of life issues as appropriate. Initiate coordination of end of life enhancement/care where appropriate.
Privileged/credentialed through ROPH medical staff
Documents assessment, treatment, response to treatment and disposition
Orders and interprets labs, imaging, EKG. CPR, ACLS, within 1 year of hire for regularly scheduled NPs as classes are available through ROPH(RUMC
Attends 25% medical staff quarter-ly meetings
Attends APN Meetings 50% of time Board certified as Acute Care Nurse Practitioners.
Coordinate care with community organizations including nursing facilities, hospitals, private practice practitioners, and home care and hospice agencies.
Improve perception of APN and role in coordination
Collect and report data on clinical practice, work towards development of patient outcome measures
Identify and address palliative(hospice needs beginning with initial assessment.
Discuss end of life issues as appropriate. Initiate coordination of end of life enhancement/care where appropriate
Attend 25% of medical staff quarterly meetings
Privileged/credentialed through ROPH medical staff Documents assessment, treatment, response to treatment and disposition Follow patients through periop-erative experience, interviewing preoperatively, assessing history and background for anesthesia, Advising and advocating for patient from anesthesia perspective Coaches and provides supervision for support of patient with respira-tory care needs Responsible to maintain currency of anesthesia expertise and com-petency as well as maintenance for re-certification Orders and interprets labs, imaging, EKG. CPR, ACLS, within 1 year of hire for regularly scheduled NPs as classes are available through ROPH(RUMC Board certified as Certified Regis-tered Nurse Anesthetists. Collect and report data on clinical practice, work towards development of patient out come measures
Privileged/credentialed through ROPH medical staff Documents assessment, treatment, response to treatment and disposition Orders and interprets labs, imaging, EKG. CPR, ACLS, within 1 year of hire for regularly scheduled NPs as classes are available through ROPH/RUMC Attends 25% medical staff quarterly meetings Attends APN Meetings 50% of time Board certified as Acute Care, Adult or Family Nurse Practitioner Coordinate care with community organizations including nursing facilities, hospitals, private practice practitioners, and home care and hospice agencies. Improve perception of APN and role in coordination
Collect and report data on clinical practice, work towards development of patient outcome measures
Identify and address palliative(hospice needs beginning with initial assessment.
Discuss end of life issues as appropriate. Initiate coordination of end of life enhancement/care where appropriate
Attend 25% of medical staff quarterly meetings
CRNAGERIATRIC APN OUTPATIENT/CLINIC APNINPATIENT APNER APN
32 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCEWE ARE NPGO
The Magnet Planner
First-time Login Process
Demographic Profile
The Magnet Planner helps us collect demographic information about our nursing population but you can also harness the Planner to track your personal
professional development
Password Reset
roph.magnetplanner.com
Using Chrome, navigate to roph.magnetplanner.com and click “New User” Enter your ROPH email address, click Submit. After clicking Submit, an email will be sent to your ROPH inbox with a one-time link to set a password. After setting your password, you will be redirected to the login page. Use your employee ID and the password you just set to login.
Navigate to navigate to roph.magnetplanner.com, click “Returning User” Click link at the bottom labeled “Forgot Your Password” Enter your work email address, click “Submit” After clicking “Submit” and an email will be sent to your work inbox with a one-time link to set a password. After reset your password, you will be redirected to the login page. Use your employee ID and the password you just set to login.
You may logout at anytime by scrolling all the way to the bottom of the profile page.
Complete all fields that are marked with a red asterisks. Don’t forget to add you FTE information as well as your education & certification information! Your progress will not be saved unless you click the “Save Progress” button. You may save your progress and return later to add new information at any time.
You may export all of the data on your Demographic Profile to multiple file types, including Word, Excel and PDF by hovering over the Demographic Profile button. You may also download proof of certification.
SUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION
Practice Tools
33
Rush Oak Park HospitalManual for Nursing Practice Governance SUPPORT FOR NURSING GROWTH, WELLNESS,
SAFETY AND MEANINGFUL RECOGNITION
Practice Tools
Self Care Guide & ResourcesThe best thing health care workers can do is take care of themselves.
insiderush.rush.edu/wellnessmore info
Take care of your body.
Try to eat healthy, exercise, sleep when
possible and avoid alcohol and other drugs. The needs
of others are not more important than your own
needs and well-being.
Connect with others.
Share your feelings with a colleague, family member
or friend. Maintain relationships and rely on
your support system.
Take breaks.It is not selfish to take
breaks. Working to exhaustion does not
mean you will make your best contribution.
Breathe.If you feel the common signs of stress (below), consider reaching out
through one of our Rush Wellness resources.
Common signs of stress
Feelings of exhaustion,
anxiety or fear
Anger or short temper
Difficulty sleeping or changes in
appetite, energy, and activity levels
Emotional blunting
Increased use of alcohol, tobacco
or other drugs
1. Creation of a culture of wellness, including programs to address burnout, support resilience, and increase joy in work.2. Increased support for mental health, including access to care, reduction in stigma, and strategic partnerships to prevent suicide.3. Production of leading research through an emphasis on data and analytics.Services
The following services are currently available:Well-Being Coach: Work with one of our Well-Being Advocates to identify and meet your wellness goals. Counseling: Our Well-Being Advocates are trained mental health professionals and are here to support you. Mini Wellness Retreats: Recharge your well-being - spend 60 minutes at the Center for Clinical Wellness enhancing your well-being through a special, targeted experience (includes access to Energy Pod).
Center for Clinical WellnessThe Center for Clinical Wellness (CCW) will seek to address three primary goals
34 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
SUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION
Practice Tools
How to Get HelpPain Safety
Staffing
Clinical
CONCERNS Your patient’s pain is not managed
Your patient has end-of-life pain issues that are not being addressed
SOLUTIONS Consult Comfort Menu in the patient admission packet
Talk with physician about consulting Case Management or Goals of Care Consult
Contact Palliative Resource Nurse - Pager: 85 x 2080
Talk with physician about putting in a Palliative or Pain Care Consult
Consider contacting Chaplain - Pager: 85 x 6844
CONCERNS Your patient/patient’s family/visitor is disruptive or abusive
You don’t feel comfortable with your surroundings
SOLUTIONS Contact Security - Ext: 62211
Contact a Behavioral Resource Nurse - Pager: 85 x 5112
Call to initiate the Behavioral Action Response Team (BART) – Ext. #63333
Talk with physician about putting in a Psychiatric Consult
Gain knowledge by completing the CPI Non-violent Crisis Intervention Class
Contact Psychiatry - Pager 85 x 5588
CONCERNS You feel that your unit has inadequate staffing
SOLUTIONS Discuss with Charge Nurse
Discuss with Nursing Supervisor/Unit Director
Discuss with UAC (or unit representative)
Discuss with NPGO Staff Nurse Advisory Board (SNAB) (or department representative)
CONCERNS You believe your patient is not getting the proper treatment
You believe your patient is at risk or your practice is at risk
You believe your patient is showing signs of decline
SOLUTIONS (Policy #IM1005)Chain of Command:1.) RN and MD Discuss Patient Issue2.) Charge RN3.) Unit RN Manager/Nurse Shift Supervisor4.) Chief Nursing Officer5.) Chair of Physician Department6.) Chief Medical Officer7.) Executive Administrator on Call
Contact the Rapid Response Team – Ext. #63333
Contact the Infection Control Hotline – Ext. #62045
Call the Rush Hotline for confidential and anomyous – 877-RUSH009 – rush.ethicspoint.com
Contact Sexual Assault Resource Nurse - Ext. #62685, Pager 85 x 5984
Illinois State Nurse Practice Act: nursing.illinois.gov/nursepracticeact.asp
CONCERNS You feel distressed or show signs of suffering
Sick calls
Patient care avoidance
Withdrawal
Depression
Lashing out at co-workers/patients
SOLUTIONS Place an Ethics Consult (Policy #LD0004)
Contact the Employee Assistance Program
Talk with a Chaplain – Pager #85-6844
Make use of Respite Room. Available on second floor
Utilize Rush Wellness Resources at The Center for Clinical Wellness
CONCERNS You feel distressed and/or burned out due to a particular aspect of the patient’s treatment plan
You feel distressed due to limited options shared with the patient/family
SOLUTIONS Place an Ethics Consult (Policy #LD0004)
Talk with a Chaplain – Page #85-6844
ANA Code of Ethics – nursingworld.org/codeofethics
Moral Distress
Ethical Dilemas
A situation where you know the ethically appropriate action to take but are unable to act upon it. You act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity.
A complex situation that involves a mental conflict between principals originating in a person’s mind that compels them to act.
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Rush Oak Park HospitalManual for Nursing Practice Governance SUPPORT FOR NURSING GROWTH, WELLNESS,
SAFETY AND MEANINGFUL RECOGNITION
Practice Tools
WE ARE NPGO
Why Take a Break?
CULTURE Culture of watching out for others Expectation that RNs and PCTs work together to cover each other’s patients while on break Culture that insists that others take breaks Having a preceptor who teaches me to take a break and strongly encourages it Fostering peace of mind … “Knowing that my patients are fine because my team is watching out for them” “Unit culture must emphasize breaks and how to break so you can leave your patients for short periods of time. There is a skill to breaking efficiently but units must support break times.”
Environment conducive to restfulness: quiet, away from patients, away from call lights, clean
RESTFUL ENVIRONMENT Maintaining a quiet, clean break-room, where staff is respectful of one another. Environment free from call lights and patients
ENVIRONMENTAL SUPPORTS ANA Principles for Nurse Staffing, ROPH Policy, Illinois Law, Federal Law
PLANNED COVERAGE Extra Shifts/Floaters cover for people during breaks Lunch Buddies: Charge nurse assigns at beginning of shift which makes covering for each other comes easier Lunch Partners: Worked out independently “People are assigned for breaks/lunches on our unit so everyone gets a break and lunch or a long lunch” Communicating to patients about breaks and who is covering Sign up for breaks at beginning of shift
EDUCATION Time management education Education of staff to let clerk, charge nurse, PCTs know when you are breaking for accountability in coverage Education on what covering RN should do Education on what to delegate to covering RN Education for charge nurses on how to better staff by acuity/fairness
LEADERSHIP SUPPORT Better Staffing - charge nurse with less patients to cover, CC/CNLs taught to cover, UD taught to cover and support others doing so Held as part of RN3 role to foster breaks and rest periods Interdisciplinary support and collaboration Request provider orders be put in before lunch period
Professional nurses are
responsible to take breaks so that they are refreshed and reengaged for the dynamic environment.
Refreshed and engaged
caregivers will provide
higher quality care, keeping
themselves and patients safer.
Each professional
nurse remains autonomous in his or her time management;
and breaks should be
considered, in a healthy
culture, to be necessary.
We strive to instill a culture where we take care of each
other, looking out for and
resourcing for those nurses who have not yet been able
to break.
All staff, both direct care and administration
need to own the creation of
cultures and environments
that encourage breaks.
Where possible, breaks should
be free of patients and in an environment
that is set apart from the
patient care area.
Meal Break Tools
36 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
SUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION
Practice Tools
How Nursing Education Is Administered
NPGO Executive Committee
Clinical Nurse Leader Department
Drives Practice Education Strategy, Learner NeedsAssessment, Approves Curriculum and Success Metrics
NPGO Education Committee Creates and Analyzes Learner Needs Assessment, Collaborates
with Internal/External Experts to deliver education, Creates Tactics for Nursing Education Housewide and Collaborates with Educators, Collabo-
rates with Nursing Administration to strategize regulatory, compliance and other operational educational needs and collaborates across Rush
System for symmetry of programs
Drives standingorganizational education,
assists with “Just in Time” or “Burst” education based
in clinical settings, Supports mentorship,
preceptorship and clinical practice in areas of clinical
expertise, collaborates across Rush System for symmetry of programs
ROPH RNs and APNsParticipate in delivering education based on their
areas of expertise
Liaison RN RolesBehavioral, Palliative,
Sexual Assault: Deliver and manage educational needs related to popula-tion of focus and related
clinical areas, may coordi-nate education with other disciplines serving same
populations for synergy of performance improve-
ment, drive metrics related to area of focus
Based on Focused Strategy to Improve Nursing Practice and Learner Expressed Needs, Education is delivered at ROPH.
37
Rush Oak Park HospitalManual for Nursing Practice Governance
WE ARE NPGO
SUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION
Practice Tools
Creating a Pipeline of the Next Generation
ROPH Nursing, comprised of approximately 330 RNs and APNs facilitates clinical experiences from six partner schools to
support a pipeline of nurses and certified nursing assistants into the healthcare industry. Approximately 250 students are facilitated each year from the following partners: Rush University College of Nursing, Lewis University, Loyola University, Dominican University, College of DuPage and Oak Park River Forest High School.
Nursing Professional Governance Organization (NPGO) Executive Committee oversees and approves these rotations and the Department of Clinical Nurse Leaders facilitates a liaison CNL to organize and manage the clinical groups in partnership with Human Resources and Employee Health.
Quarterly, Preceptor classes are offered to RNs at ROPH to expand competence on precepting both students and new graduate employees. The preceptor class covers the following:
Definition of a Preceptor Guide at the Side Experienced and competent RN with training Role model and resource person to newly employed staff
Responsibilities Assess learning needs, set goal Teach time management, prioritization Evaluate clinical competence and documenting. Provide constructive feedback, coaching Facilitate social interaction and acclimatization to the organization’s and unit’s culture.
Foster an environment of caring Acting as Role Model Clinical Knowledge Provide explanations — prioritization, shift report Knowledge of the system/unit Chain of command, Policies and Procedures Evaluate, Red Flags Educate( Give feedback and Listen
Educational Programs OfferedPrograms are offered and conducted by the Department of Clinical Nurse Leaders. Some programs are offered at all three Rush System organizational sites. Every unit and clinical specialty performs population and area-specific education to supplement those listed below.
Education Provided PurposeOrientation ............................................................. Onboarding/Patient Safety/CompetenceAnnual Competency Training: Leap Online Education ..................Staff Support/CompetenceAnnual Competency Training: Hand-On Education ......................Staff Support/CompetenceNurse Residency Program ........................................ Retention/Staff Support/EmpowermentCharge Nurse Program ............................................ Retention/Staff Support/EmpowermentPreceptor Program .................................................. Retention/Staff Support/EmpowermentCrisis Prevention Intervention Training .............. Violence Mitigation/De-Escalation TrainingGrand Rounds .......................................................................................................... VariousGamma Phi Grand Rounds ....................................................................................... VariousNIHSS .............................................................................................. TJC Stroke CertificationAHA BLS New provider and recert ................................... Competence/Certification UpkeepAHA ACLS new provider or recert .................................... Competence/Certification UpkeepAHA PALS ........................................................................ Competence/Certification UpkeepNurses's Role In Management Of Cardiac Arrest - PEDS ............................PALS prep courseNurses's Role In Management Of Cardiac Arrest - ADULT ................. ACLS certification prepEKG - Support Staff ......................................................................... Patient Safety InitiativeEKG for RNs .................................................................................... Patient Safety InitiativeInpatient Epic for New RN Employees ..........................................................................EPICInpatient Epic for Students and Student Orientation .....................................................EPICInpatient Epic for New PCT Employees ..........................................................................EPICProcedural EPIC for New RN, PCT and Students ............................................................EPICED EPIC for New RN, PCT and Students .........................................................................EPICRush Leadership Academy ............................................................. Leadership DevelopmentSimulation Lab ....................................................... Onboarding/Patient Safety/CompetenceRRT for ICU RNs .............................................................................. Patient Safety InitiativeSBAR ................................................................Patient Safety/Handoff/Improve ThroughputHazmat Training ...............................................................Emergency Management TrainingNIMS ................................................................................Emergency Management TrainingMalignant Hyperthermia ...........................................................................Updates in PolicyO2 Tanks Segregation Education ....................................................................TJC educationAbuse and Neglect .......................................................................Annual Leap CompetencyCompliance, Privacy & Security .....................................................Annual Leap CompetencyDiversity and Inclusion .................................................................Annual Leap CompetencyDSC & NICHE ................................................................................Annual Leap CompetencyEmergency Preparedness ..............................................................Annual Leap CompetencyFire Safety ....................................................................................Annual Leap CompetencyHazard Communication ................................................................Annual Leap CompetencyInfection Control ..........................................................................Annual Leap CompetencyPatient and Employee Safety ........................................................Annual Leap CompetencyRadiation Safety ..........................................................................Annual Leap CompetencyCybersecurity ................................................................................Annual Leap CompetencyPersonal Protective Equipment .....................................................Annual Leap CompetencyBraden Competency .....................................................................Annual Leap CompetencyDiabetes .......................................................................................Annual Leap CompetencyFalls and Purposeful Rounding .....................................................Annual Leap CompetencyROPH General Stroke Information ...............................................Annual Leap CompetencyHeparin Protocol ..........................................................................Annual Leap CompetencyNeedlesticks-Sharps-Splash Injuries ............................................Annual Leap CompetencyPain Management ........................................................................Annual Leap CompetencyPain Management Clinical Ancillary Staff .....................................Annual Leap CompetencyPreventing HAI’s ...........................................................................Annual Leap CompetencyProcedural Sedation .....................................................................Annual Leap CompetencyReprocessing of Reusable Medical Devices ..................................Annual Leap CompetencyWorkplace Violence ......................................................................Annual Leap Competency
38 RUSH OAK PARK HOSPITAL MANUAL FOR NURSING PRACTICE GOVERNANCE
SUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION
Practice Tools
Meaningful Recognition Through Awards
Award Name Award Description
NURSE MENTORSHIP AWARD
Professional Practice Model Domain
RELATIONSHIPS AND CARING
The Nurse Mentorship Award is presented to recognize the exemplary mentorship qualities of one nurse who promotes the growth of others, fosters interpersonal commu-nication in the healthcare setting, is a frequent educator and a positive role model. This nurse is willing to share knowledge, seeks to fit the mentees strengths into the right iniatives and provides a multitude of experiences that the mentee can learn from.
ADVANCING AND LEADING THE PROFESSION AWARD
CLINICAL EXCELLENCE AWARD
LEADERSHIP
The Advancing and Leading the Profession Award is presented to recognize the outstanding efforts of one nurse who promotes the profession of nursing through outstanding leader-ship, advancing and/or strengthening nursing, either as a profession or in the delivery of patient care within and/or beyond his or her own healthcare facility.
PROFESSIONAL PRACTICE MODEL AWARD
EVIDENCEBASEDPRACTICE
The Rush Professional Practice Model (PPM) defines who we are as nurses at Rush Oak Park Hospital. Award given to a person who exemplifies all domains of our practice at ROPH.
DAISY FOUNDATION AWARD
ROOKIE AWARD
The Daisy Award was creating by the Barnes family after the loss of their son, Patrick. They wanted to honor the nurses who gave him exemplary care. The DAISY award is an acronym for Diseases Attacking the Immune System — which is symbolic of the disease that killed Patrick. The Daisy award thanks nurses for “the super-human work RNs do everyday in direct care of patients and families, funds nursing research and celebrates extraordinary compassion and skill by nursing students and honors nursing faculty.” (http://daisyfoundation.org)
PROFESSIONAL PRACTICE MODEL AWARD
PROFESSIONAL PRACTICE MODEL AWARD
KAREN MAYER INNOVATION AWARD
PROFESSIONAL PRACTICE MODEL AWARD
PROFESSIONAL PRACTICE MODEL AWARD
CRITICALTHINKING The Rush Professional Practice Model (PPM) defines who we are as Nurses at Rush Oak
Park Hospital. Award given to a person who exemplifies all domains of our practice at ROPH.
The Rush Professional Practice Model (PPM) defines who we are as Nurses at Rush Oak Park Hospital. Award given to a person who exemplifies all domains of our practice at ROPH.
The Rush Professional Practice Model (PPM) defines who we are as nurses at Rush Oak Park Hospital. Award given to a person who exemplifies all domains of our practice at ROPH.
The Rush Professional Practice Model (PPM) defines who we are as nurses at Rush Oak Park Hospital. Award given to a person who exemplifies all domains of our practice at ROPH.
TONYA REDDY ADVANCED PRACTICE REGISTERED NURSE EXCELLENCE AWARD
TECHNICALEXPERTISE
The candidate demonstrates authentic leadership, and is a role model as a clinician and mentor. The candidate has made a significant contribution to the improvement of patient care through evidence based practice. She/he promotes a healthy work environment. The candidate provides educational opportunities to patients, nurses, and other members of the health care team. She/he has found creative ways to address issues that impact APN practice, the Institution, and/or the community. The candidate actively participates on professional committees, either within or outside of Rush and mentors other APNs to do the same.
The Clinical Nursing Excellence Award is presented annually to recognize the outstanding clinical performance of one nurse.
The Nursing Professional Governance Organization Karen Mayer Innovation and Scholar-ship Award recognizes and celebrates ROPH nurse-led innovation that improves patient or population safety, outcomes, experience and or the nursing practice environment.
This award honors an extraordinary new nurse. It highlights a new team member who has shown a willingness to help colleagues, while continuing to show tremendous progress in the profession.
39
Rush Oak Park HospitalManual for Nursing Practice Governance
WE ARE NPGO
SUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION
Practice Tools
Resources
Involvement in Nursing Professional Organizations can be at the city, state, region or national level. They help nursing practice grow, expand sphere of connections to other nurses and grow leaders in all settings and roles. Most organizations have a yearly meeting/conference which is focused on the membership(s greatest educational needs/updates. Most of these organizations offer a specialty nursing certification. Nurs-ing certification is another way to show expertise in any given field. In order to advance in the clinical ladder, you must have an ANCC-ap-proved certification. These certifications are listing on your Demogrpahic Profile in The Magnet Planner.
ILLINOIS
Chicago Chapter of NAPNAP
Illinois Society for Advanced Practice Nursing
Illinois organization of Nurse Leaders (chapter of AONE)
Illinois Ambulatory Nurse Practice Consortium
(chapter of AAACN)
Gamma Phi Chapter of Sigma Theta Tau International
Illinois Ambulatory Nurse Practice Consortium
(local networking group of AAACN)
Chicagoland Chapter AMSN
Chicagoland Chapter NAON
NATIONAL
Academy of Medical-Surgical Nurses
Academy of Neonatal Nursing
ACNP- American College of Nurse Practitioners
Advanced Practice Nurses of the Ozarks
Advanced Practice Nurses of the Permian Basin
Advanced Practitioners for the River Region
Air & Surface Transport Nurses Association
Alliance for Psychosocial Nursing
Alliance of Nurses for Healthy Environments
Alzheimer’s Association
American Academy of Ambulatory Care Nursing
American Academy of Nursing
American Assembly for Men in Nursing
American Assisted Living Nurses Association
American Association for Respiratory Care (AARC)
American Association for the History of Nursing
American Association of Colleges of Nursing
American Association of Critical Care Nurses
American Association of Diabetes Educators
American Association of Heart Failure Nurses
American Association of Legal Nurse Consultants
American Association of Managed Care Nurses
American Association of Moderate Sedation Nurses
American Association of Neuroscience Nurses
American Association of Nigerian Nurses
American Association of Nurse Anesthetists
American Association of Nurse Assessment Coordinators
American Association of Nurse Attorneys
American Association of Nurse Life Care Planners
American Association of Nurse Practitioners
American Association of Occupational Health Nurses
American Association of Spinal Cord Injury Nurses
American Board for Occupational Health Nurses
American Board of Nursing Specialties
American College Health Association
American College of Cardiovascular Nurses
American College of Nurse Midwives
American Diabetes Association
American Forensic Nurses
American Heart Association: Council on Cardiovascular Nursing
American Holistic Nurses Association
American Long Term & Sub Acute Nurses Association
American Medical Association
American Medical Informatics Association/ Nursing Informatics
Working Group
American Nephrology Nurses Association
American Nurses Association
American Nurses Credentialing Center
American Nursing Informatics Association
American Organization of Nurse Executives
American Psychiatric Nurses Association
American Radiological Nurses Association
American Society for Pain Management Nursing
American Society for Parenteral and Enteral Nutrition: Nurses
Section
American Society of Ophthalmic Registered Nurses
American Society of Peri-Anesthesia Nurses
American Society of Plastic & Reconstructive Surgical Nurses,
Inc.
American Thoracic Society: Nurses Section
Army Nurse Corps Association
Arthritis Foundation
Association for Nursing Professional Development
Association for Radiologic & Imaging Nursing
Association of Camp Nurses
Association of Child Neurology Nurses
Association of Community Health Nursing Educators
Association of Faculties of Pediatric Nurse Practitioners
Association of Nurse Practitioners in Business, Inc.
Association of Nurses in Aids Care
Association of Nurses in AIDS Care
Association of Pediatric Oncology Nurses
Association of periOperative Registered Nurses
Association of Rehabilitation Nurses
Association of Women’s Health, Obstetric and Neonatal Nursing
Baromedical Nurses Association
Carolinas Association of Neonatal Nurse Practitioners
Center for American Nurses
Center to Champion Nursing in America
Certification Board of Perioperative Nursing
Chi Eta Phi Sorority, Inc.
Coalition for Nurses in Advanced Practice
Developmental Disabilities Nurses Association
Dermatology Nurses’ Association
Eastern Nursing Research Society (ENRS)
Emergency Nurses Association
Endocrine Nurses Society
Federal Nurses Association
Gerontological Advanced Practice Nurses Association
Home Healthcare Nurses Association
Hospice and Palliative Nurses Association
Infusion Nurses Society (see intravenous)
International Association of Clinical Research Nurses
Lupus Foundation of America
Midwest Nursing Research Society
Muscular Dystrophy Association
NAPNAP Foundation
National Academy of Dermatology Nurse Practitioners
National Association Directors of Nursing Administration/
Long Term Care
National Association of Bariatric Nurses
National Association of Clinical Nurse Specialists
National Association of Directors of Nursing Administration in
Long Term Care
National Association of Disease Management & Wellness
Professionals
National Association of Hispanic Nurses
National Association of Independent Nurses
National Association of Licensed Practical Nurses
National Association of Neonatal Nurses
National Association of Nurse Practitioner Faculties
National Association of Nurse Practitioners in Women’s Health
National Association of Orthopaedic Nurses
National Association of Pediatric Nurse Practitioners
National Association of Rural Health Clinics
National Association of School Nurses
National Association of State School Nurse Consultants
National Black Nurses Association, Inc.
National Certification Board of Pediatric Nurse Practitioners
and Nurses
National Coalition of Ethnic Minority Nurse Associations
National Council of State Boards of Nursing
National Federation for Specialty Nursing Organizations
National Federation of Licensed Practical Nurses
National Fibromyalgia Partnership
National Gerontological Nurses Association
National Heart Lung and Blood Institute
National Hospice & Palliative Care Organization
National Institute of Diabetes and Digestive and Kidney
Diseases
National Institute of Nursing Research
National League for Nursing
National Multiple Sclerosis Society
National Nurses in Business Association
National Nursing Staff Development Organization
National Organization for Associate Degree Nursing
National Organization of Associate Degree Nurses
National Organization of Practical Nursing Education and
Service
National Practitioner Associates for Continuing Education
National Private Duty Association
National Student Nurses Association
Navy Nurse Corps Association
NCNA Council of Nurse Practitioners - Coastal Region
NCNA Council of Nurse Practitioners Eastern Region
NCNA Council of Nurse Practitioners Wake Central Region
North American Nursing Diagnosis Association
Northeast Pediatric Cardiology Nurses Association
Northern Nurse Practitioner Association
Northwest Organization of Nurse Executives
APN Council of Miami-Dade
Nurse Practitioner Healthcare Foundation
Nurse Practitioner Society of the Dermatology Nurses’
Association
Nurse Practitioners in Women’s Health
Nurse Practitioners: It’s About Time
Nurse Without Borders
Nurses Christian Fellowship
Nurses Organization of Veterans Affairs
Nurses Peer Support Network
Nursing Ethics Network
Nursing Network on Violence Against Women International
Oncology Nurses Society
Pediatric Endocrinology Nursing Society
Philippine Nurses Association of America
Respiratory Nursing Society
Sigma Theta Tau, Delta Beta, Chapter-At-Large
Sigma Theta Tau, International Honor Society of Nursing
Society for Vascular Nursing
Society of Gastroenterology Nurses and Associates, Inc.
Society of Nurses in Advanced Practice
Society of Otorhinolaryngology and Head/Neck Nurses
Society of Pediatric Nurses
Society of Trauma Nurses
Society of Urologic Nurses and Associates
Southern Gulf Coast Nurse Practitioner Council
The National Association of Pediatric Nurse Associates and
Practitioners
The National Association of School Nurses for the Deaf
The National Forum of State Nursing Workforce Centers
Transcultural Nursing Society
Travel Nursing
Treasure Coast Nurse Practitioners
Uniformed Nurse Practitioner Association
Valley Advanced Practice Nurse Association
Visiting Nurse Associations of America (VNAA)
Volusia Flagler Advanced Practice Nursing Council
West Coast Council of Advanced Nursing Practice
West Sound Advanced Practice Association
Wound, Ostomy and Continence Nurses Society (WOCN)
American Nurses Association (ANA) Standards of Practice
and Scope:http://www.nursingworld.org/scopeandstandardsofpractice
ANA Code of Ethics:http://www.nursingworld.org/mainmenucategories/ethicsstandards/codeofethicsfornurses/code-of-ethics.pdf
Illinois State Nurse Practice Act:http://nursing.illinois.gov/nursepracticeact.asp
Illinois State Nurse Staffing By Acuity Legislation:http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=095-0401
ROPH Mission, Vision, PhilosophyROPH Intranet
NPGO BylawsROPH Intranet
NPGO Code of ConductROPH Intranet
Patient Care Services Strategic Plan and Associated TacticsROPH Intranet
NPGO Manual for Nursing Practice GovernanceROPH Intranet
Policies and ProceduresROPH Intranet
ROPH meeting and Presentation TemplatesROPH Intranet
Rush System for Health Nursing Sharepoint WebsiteAccess via Rush applications
Nursing Organizations
Table of Contents
January 2021
Structures That GuidePRACTICE IDENTITY3 Mission & Vision4 Professional Practice Model5 Nursing Care Delivery Model6 We Are NPGO7 ROPH Quality Structure8 Code of Conduct9 Nursing Professional Governance Organization Bylaws10 Cross-Walking Structures That Impact Our Identity11 The Practice Evaluation Cycle
Practice ToolsMEANINGFUL PROCESSES TO GUIDE PRACTICE12 Performance Improvement Model and
Evidence Based Practice Guidelines13 Continuous Pursuit of Excellence Lean Program14 Just Culture Algorithm15 NPGO Peer Review, Corrective Action and Appeals Process16 Portfolio Development17 Clinical Advancement RN1 to RN218 Clinical Advancement RN2 to RN319 Maintenance of RN3 Status20 Structural Empowerment Policy21 Leadership Development
Practice ToolsPROFESSIONAL DEVELOPMENT RESOURCES22 Operational Task Checklist24 Needs Assessment & Checklist26 New Graduate Nurse Residency Program28 Leap Enhancement & Tuition Reimbursement29 Nursing Interview Tool30 Advanced Practice Nurse
Practice ToolsSUPPORT FOR NURSING GROWTH, WELLNESS, SAFETY AND MEANINGFUL RECOGNITION32 The Magnet Planner33 Self Care Guide & Resources34 How to Get Help35 Why Take a Break(36 How Nursing Education Is Administered37 Creating a Pipeline of the Next Generation38 Meaningful Recognition Through Awards39 Resources & Nursing Organizations