HIGH POINT REGIONAL
HEALTH SYSTEM NURSING BYLAWS
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as pdf)
Plan For Providing Nursing Care
Article I
Preamble
Section 1. Purpose of Nursing
Bylaws
The purpose of the Nursing Bylaws is to describe the governance
structure of Nursing across the organization and provide
a framework for participation, collaboration, coordination,
and shared decision making related to patient care and nursing
practice in accordance with the Nursing Practice Act of
the State of North Carolina. The bylaws shall be based on
the principle that nursing is a self-directed and self-governing
profession which is ultimately responsible and accountable
to the Administration and Board of Trustees for the best
possible nursing care of patients/significant others and
for the highest level of conduct/practice of the nursing
staff within the organization. In a dynamic, responsive,
and changing organization, the bylaws shall be built around
the Forces of Magnetism recognizing the importance, worth,
and individuality of the consumer and the provider of nursing
care at High Point Regional Health System.
Section 2. Definition of Nursing
Nursing, a profession based on knowledge, is the protection,
promotion, and optimization of health, prevention of illness
and injury, alleviation of suffering through the diagnosis
and treatment of human response, and advocacy in the care
of individuals, families, communities and populations. (Adapted
from the American Nurses Association "Nursing's Social
Statement.")
Section 3. Mission
To provide exceptional nursing care to the people of our
region.
Section 4. Vision
To be the best place to receive care, the best place to
work and the best place to practice Nursing.
Section 5. Values
Team work, compassion and cost effective care.
Section 6. Philosophy
We believe the Forces of Magnetism are the foundation for
excellence. Our highest priorities are caring, advocacy,
innovation and education for our patients, ourselves, and
each other. Those priorities and the following guiding principles
support our quest for nursing excellence:
• The power and impact of nurses and nursing.
• Leaders who advocate and support staff.
• Leadership styles that promotes shared decision
making, continuing education and ownership
for exceptional individual practice.
• Provision of exceptional nursing care through continuous
quality improvement.
• Interdisciplinary collaboration that welcomes all
contributions.
• Promotion of wellness through education and information.
• Environments that supports mentoring and nurturing
of each other.
• Commitment to life long learning, education, and
career growth.
• Recruitment and retention of the best nurses.
Section 7. Nursing Care Delivery
Model
The Nursing Care Delivery Model at High Point Regional Health
System, based on the belief that nursing is the link that
facilitates person-centered care, consists of four concepts:
nursing, person, health, and environment.
Nursing
Nursing practice includes, but is not limited to, initiating
and maintaining comfort measures, promoting and supporting
human functions and responses, establishing an environment
conducive to well-being, providing health counseling and
teaching and collaborating on certain aspects of the health
regimen with the goal of helping patients attain, maintain
and restore health or experience a dignified death. This
practice is based on understanding the human condition across
the life span and the relationship of the individual within
the environment.
Person
Any individual who interfaces with High Point Regional Health
System.
Health
A person’s perception of his/her state of wellbeing
that encompasses mental, physical, spiritual, and emotional
factors.
Environment
The location where programs and/or services are provided
by nurses of High Point Regional Health System.
Patient Care Goals
Provide the patient quality, compassionate, and cost-effective
health services through integrated nursing and patient care
services based on the Collaborative Patient Care Management
Delivery Model.
Provide timely and appropriate patient assessments by qualified
and competent nursing staff on admission and throughout
the patient's hospital stay.
Initiate goal-directed, individualized, and coordinated
care planning consistent with the patient's physiological,
psychosocial, learning, developmental, spiritual, and cultural
needs.
Collaborate with the medical staff and other health care
disciplines in providing timely, integrated, and appropriate
patient care, patient/family education, and discharge planning
on admission and throughout the hospital stay.
Promote the active involvement and participation of the
patient, family, and significant others in making choices
and decisions regarding patient care.
Maintain a positive relationship with all customers to increase
the satisfaction of patient, family, significant others,
physicians, other health care disciplines, support staff,
students/faculty, and volunteers.
Article II
Role of the Professional Registered Nurse
In keeping with the North Carolina Nursing Practice Act
and the Rules and Regulations of the North Carolina Board
of Nursing, national professional/specialty nursing practice
standards, professional Code of Ethics, and the JCAHO Nursing
Care Standards, the professional Registered Nurse assumes
the responsibility and accountability for the delivery of
nursing care within the institution and its subsidiaries
in accordance with the Health System mission, vision, values,
policies, procedures, and bylaws. The Registered Nurse shall
be responsible for prescribing, delegating, and coordinating
nursing care based on patient problems/needs and for initiating
the nursing process in the everyday practice of nursing.
Legally, the Registered Nurse is responsible and accountable
for all nursing acts that are outlined in the Nursing Practice
Act. In support of the Collaborative Patient Care Management
Model, the Registered Nurse shall collaborate with the patient/significant
other, the physician, other health care disciplines, support
staff, and volunteers in the performance of direct and indirect
patient care activities.
Article III
Nursing Staff Membership
Section 1. Definition of
Membership
Nursing staff membership consists of nine categories that
include Nursing Leadership, Performance Coach, Nursing Education,
Collaborative Patient Care Management Staff, Unit Coordinators,
Professional Staff, Nursing Support Staff, Interim Staff,
and Adjunct Staff.
Membership is a privilege for nurses who meet the qualifications,
standards, and requirements defined in these bylaws and
the personnel policies of High Point Regional Health System.
Section 2. Nursing Leadership
The membership of Nursing Leadership includes individuals
who have completed the nursing orientation/probationary
employment period and meet performance standards. Responsibilities,
qualifications, performance requirements, and evaluation
criteria for the Nursing Leadership staff are delineated
in the departmental position description summaries/standards.
Nursing leaders are knowledgeable, risk takers, able to
articulate and be role models of the nursing philosophy
and advocate and provide support to the nursing staff.
The Vice President-Chief Nursing Officer holds the final
responsibility and authority for the Nursing Leadership
staff. The Directors are responsible for the management/evaluation
of the Performance Coaches. The Director of Patient Throughput
is responsible for the staffing/scheduling functions and
the management/evaluation of the Staffing Coordinators and
the Nursing Supervisors. The Evening/Night/Weekend Supervisors
provide leadership/direction for the Unit Coordinators and
Charge Nurses on these assigned rotations. Using the Forces
of Magnetism as the foundation, the Nursing Leadership staff
is responsible for setting goals, priorities, strategies,
and time lines regarding patient care/nursing practice activities,
evaluating budgetary needs for human/material resources;
coordinating departmental/ interdepartmental activities
impacting on patient care/nursing practice; promoting/setting
standards of excellence through nursing policies, standards
of care/practice, and program/position statements; develop/promote
an environment that provides an environment of shared decision
making and nursing practice based on evidence, supervising
nursing staff and evaluating their performance/ competencies
in providing quality, compassionate, and cost-effective
nursing care; collaborating with nursing, medical, and Health
System staff and outside clinical/educational agencies for
improvements in patient care/nursing practice.
Section 3. Performance Coach
The membership of the Performance Coach staff includes individuals
who have completed the nursing orientation/probationary
employment period and meet performance standards. Responsibilities,
qualifications, performance requirements, and evaluation
criteria for the Performance Coach staff are delineated
in the departmental position description summaries/standards.
Performance Coaches are knowledgeable, risk takers, able
to articulate and be role models of the nursing philosophy
and advocate and provide support to the nursing staff.
The Performance Coach is responsible for the management/evaluation
of the Unit Coordinators. The Performance Coach participates
in setting goals, establishing priorities, strategies and
time lines regarding patient care/nursing practice activities.
The Performance Coach promotes standards of excellence through
nursing policies, standards of care/practice. He/She promotes
an environment of shared decision making and nursing practice
based on evidence, supervising nursing staff and evaluating
their performance/competencies in providing quality, compassionate,
and cost effective nursing care: collaborates with nursing,
medical, and Health System staff and outside clinical/educational
agencies for improvements in patient care/nursing practice.
At least one Performance Coach participates on the Clinical
Practice Team, Evidence Based Practice Team, Strategic Planning
Team, and Magnet Team.
Section 4. Nursing Education
The membership of the Organizational Development staff includes
individuals who have completed the orientation/probationary
period and are meeting performance standards. The Staff
Educators meet with the Director of their assigned areas
at least monthly for ongoing planning and evaluation of
education and participate in the monthly clinical management
meetings.
The Director of Clinical Practice is responsible for development
and maintenance of current clinical practice standards and
job standards in compliance with the North Carolina Board
of Nursing, the coordination of GNOSIS program and Clinical
Practice Team activities. The Staff Educators are responsible
for ongoing evaluation and development of the orientation
program, in-service education and competency assessment-assuring
a dynamic program that meets the needs of all staff. The
Staff Educators coordinate skill training/competency assessment
of licensed/unlicensed nursing staff, medication administration,
and Basic Life Support and participate in the annual goal
setting/planning for education activities. The Staff Educators
facilitate performance assessment/improvement activities,
decision making, and teamwork between nursing leadership,
clinical nursing specialties, and other health care disciplines/departments.
At least one staff educator participates on the Clinical
Practice Team, Evidence Based Practice Team, Strategic Planning
Team and Magnet Team.
Section 5. Collaborative
Patient Care Management Staff
The membership of the Collaborative Patient Care Management
staff includes individuals who have completed the orientation/probationary
period and are meeting performance standards of the position
classification. The directors meet with the Patient Care
Coordinators at least monthly for ongoing planning and evaluation
of case management and utilization management activities.
The Patient Care Coordinators meet with the Director of
their assigned clinical area(s) at least monthly for ongoing
planning and evaluation of the CPCM program.
The Directors are responsible for facilitation of Collaborative
Patient Care Management activities including daily operations
and goal setting. Using the forces of Magnetism, the Patient
Care Coordinators are responsible for coordinating the standard
plan of care for patients with selected diagnosis/procedures,
performance assessment and improvement patient/family education,
coordinating Group Practice activities, implementing utilization
and case management strategies, and conducting nursing research.
At least one Patient Care Coordinator participates on the
Clinical Practice Team, Evidence Based Practice Team, Strategic
Planning Team, and Magnet Team.
Section 6. Unit Coordinators
The membership of the Unit Coordinator staff includes individuals
who have completed the nursing orientation/probationary
employment period and meet performance standards. Responsibilities,
qualifications, performance requirements, and evaluation
criteria for the Unit Coordinator staff are delineated in
the departmental position description summaries/standards.
Unit Coordinators are knowledgeable, risk takers, able to
articulate and be role models of the nursing philosophy
and advocate and provide support to the nursing staff.
Section 7. Professional
Staff
The membership of the Professional Nursing Staff includes
the Health System-employed individuals who are licensed
Registered Nurses classified in full-time or part-time positions.
This category includes staff who have completed the required
nursing orientation/probationary employment period and are
meeting the performance standards of their positions. The
Vice President-Chief Nursing Officer holds called meetings
with the Professional Nursing Staff as needed and/or requested.
The Registered Nursing Staff will meet with the Director/Manager
of their assigned area on a regular basis.
Section 8. Nursing Support
Staff
The membership of the Nursing Support Staff includes Health
System employed individuals who are Licensed Practical Nurses,
Nursing Assistants, Unit Secretaries and Staffing Personnel.
This Category includes staff who have completed the required
nursing orientation/probationary employment period and are
meeting the performance standards of their positions. The
Nursing Support Staff is responsible for supporting the
Registered Nurse in performing functions related to patient
care and maintaining standards of excellence in providing
patient care.
Section 9. Interim Staff
The membership of the Interim Staff shall include the non-Health
System-employed and the Health System-employed individuals
who are classified in a temporary position. This category
shall include staff who have completed the required nursing
orientation in addition to the agency/ registry requirements.
Classifications in this category shall include Registered
Nurses who are employed by the Health System to fill temporary
positions.
The Interim Staff will be responsible for implementing the
functions related to patient care/nursing practice activities
according to the adopted standards, policies, and procedures
of Nursing and for maintaining standards of excellence in
providing nursing care. The Interim Staff is under the direction/supervision
of the Unit Coordinator, Performance Coach, and Director
of assigned area, and shall be accountable to these persons
for performing required patient care functions.
Section 10. Adjunct Staff
The membership of the Adjunct Staff includes non-Health
System-employed individuals who are involved in providing
patient care associated with various nursing or health-related
educational programs. This category includes individuals
who have completed the required nursing orientation to Health
System in addition to the education institution's requirements.
Classifications in this category include Nursing School
Instructors/Students, EMS Instructors/Students, Refresher
Nurse Instructors/Students, and Occupational Health Instructors/Students.
Written agreements with the educational institutions are
obtained/kept current. The Director of Organizational Development
will serve on the Joint Clinical Resources Planning Committee
of the Educational/Health Agencies of the Greensboro AHEC
region and participate in all meetings of this committee.
The Vice-President-Chief Nursing Officer holds individual
meetings/conferences with Deans/Directors of Nursing Schools
as needed or requested. Qualified nursing staff hold Adjunct
faculty appointments in the area schools of nursing.
The Adjunct Staff is responsible for implementing selected
functions related to patient care/nursing practice activities
within the adopted standards, policies, and procedures of
the Nursing Department and for maintaining standards of
excellence in the provision of nursing care at High Point
Regional Health System. The students of the educational
institutions are under the direction/supervision of their
Registered Nurse instructors when performing selected patient
care functions. The instructors/students of the educational
institutions are accountable to Unit Coordinators and Charge
Nurses for completing selected patient care assignments.
The Vice President-Chief Nursing Officer holds final administrative
responsibility and authority for the Adjunct Staff in providing
patient care in the hospital.
Article V
Nursing Governance Structure
The Clinical Team Structure promotes/provides collaboration
and shared decision making across the organization in nursing
matters/issues related to patient care/patient outcomes
and nursing practice. The Professional Nursing Staff has
the opportunity to provide input/feedback through these
teams.
Section 1. Clinical Teams
There are six (6) clinical teams that take responsibility
for nursing functions across the Health System. The teams
are: Nursing Leadership Team, Relay Team, Evidence Based
Practice Team, Clinical Practice Team, Strategic Planning
Team, and Magnet Team.
Section 2. Nursing Representation
All nursing representatives of teams or special committees
are selected by each nursing department. Nursing representatives
are selected on a rotating basis with some tenure of service
overlapping so that at no time shall the teams be made up
of entirely new members. Unplanned vacancies on teams are
filled by the Director of the affected department. Selected
representatives serve a two year term beginning in January
of each year.
Section 3. Officers
The officers of the teams are designated as Chairperson,
Co-chairperson, and Secretary and are expected to fulfill
the requirements of the office. The Chairperson, Co-chairperson
and Secretary of each team are elected by the members of
the team. The term of office is no less than two years to
allow for continuity of leadership. A designated member
of the Nursing Leadership Team serves as facilitator for
each team.
The Chairperson of each team in collaboration with the assigned
facilitator plans/conducts the meetings, assures documentation
of the proceedings, and manages the business of the team.
The Chairperson convenes a called meeting when deliberation
is needed by the full team for any immediate/emergency decisions.
The actions of the team meeting are reported at the next
regularly scheduled meeting for review/approval. In the
absence of the Chairperson, the Co-chairperson assumes the
responsibilities of the Chairperson. The Secretary of each
team assures the minutes are distributed/published on the
intranet at least 1 week prior to the next scheduled meeting.
The Chairperson of each team represents his/her team on
the Relay Team.
Section 4. Nursing Leadership
and Staff Representation on Health System Committees
The Vice President-Chief Nursing Officer or Vice President-Inpatient
Nursing represents and speaks for the Nursing Department
and other Clinical Departments providing nursing care on
matters related to patient care/nursing practice at designated
Health System committees, i.e., Traditional Good Management
Committee, Professional Improvement Committee, Ethics Committee,
Medical Executive Committee, Medical Staff Therapeutics
Committee, Group Practices, and Joint Patient Care Committees.
The Directors, Nursing Supervisors, Performance Coaches,
Patient Care Coordinators, Staff Educators, Unit Coordinators,
and/or Staff Nurses represent Nursing on other designated
Health System committees as appointed, i.e., Cancer Care
Committee, Environment of Care Committee, Ethics Committee,
Infection Control Committee, Institutional Review Board,
Group Practices, and Joint Patient Care Committees. Nursing
leadership and nursing staff representation on Health System
committees are provided as a means to collaborate with hospital,
medical, and nursing staff across the organization on patient
care issues and matters requiring multidisciplinary assessment
and action plans to improve patient care delivery/outcomes
and hospital systems/operations.
The Senior Nursing Leaders and Performance Coaches serve
on the Nursing Leadership Team and as facilitators of the
assigned clinical teams to support the active participation
of the nursing staff and the shared responsibilities/decision
making of the teams related to patient care and nursing
practice as outlined in the Nursing Bylaws.
Article VI
Nursing Team Membership, Role,
and Responsibilities
Section 1. Nursing Leadership
Team
A. Membership
The membership of the Nursing Leadership Team consists of
the Vice President-Chief Nursing Officer who serves as the
Chairperson, the Vice President, Inpatient Nursing, the
Directors or Managers of Clinical Nursing Specialties (Critical
Care Nursing, I.V. Nursing, Maternal-Child Nursing, Medical
Nursing, Restorative Care, Surgical Nursing, Cardiology,
Behavioral Services, Emergency Services, High Point Surgery
Center, Surgical Services, Inpatient Rehab and Adult Health
Center), the Directors of Collaborative Patient Care Management,
the Director of Organizational Development, the Director
of Clinical Information Services, the Human Resources Nurse
Recruiter, the Director of Clinical Practice, Cardiac Services
Program Manager, Director of Patient Throughput, the Nursing
Supervisors, the Performance Coaches, and chairs from the
Clinical Teams (Practice, Evidence Based Practice, and Magnet).
B. Mission
To provide leadership in development and promotion of a
nursing care delivery system that is patient centered and
creates a professional practice that is nurse centered.
C. Responsibilities
The specific responsibilities of the Nursing Leadership
Team are:
1. participate in the development, review, and
revision of the nursing mission, goals, bylaws, strategic/operation
plans, budget/resource allocations, and the nursing administrative
standards and policies.
2. participate in the development and review
of the Nursing Balanced Scorecard and development and implementation
of corrective action plan when indicated.
3. submit input to the Vice President-Chief
Nursing Officer in the development, review, and revision
of the Health System mission, goals, strategic/operation
plans, budget, resource/space allocations, and administrative
policies.
4. promote the integration of nursing into the
organizational functions of the Health System by recommending
nursing staff appointments to Health System committees,
Group Practices and Special Committees or Task Forces.
5. promote the integration of the Forces of
Magnetism as the foundation of nursing excellence.
6. promote/support an environment of shared
decision making and evidence based practice.
7. facilitate the coordination and collaboration
in and between nursing and other Health System departments
by the appointment of nursing representatives from all departments
providing nursing care to the clinical councils/teams and
special committees.
8. promote coordination, communication, collaboration
and shared decision making between the medical, nursing,
and Health System staff on matters related to patient care
delivery/outcomes and systems/operations.
9. review the performance data and performance
improvement recommendations/action plans related to patient
care processes/outcomes and make further recommendations
as indicated.
10. review the nursing sensitive data (National Database
for Nursing Quality Indicators) and performance improvement
recommendations/action plans and make further recommendations
as needed.
11. evaluate the progress/status of Nursing goals, priorities,
strategies, time lines, and accomplishments on an ongoing/annual
basis.
12. evaluate suggestions for process improvements and sanction
teams to develop and implement action plans.
13. pursue innovative and cost-effective strategies to improve
the productivity, efficiency, and effectiveness in the care
of patients/significant others and the clinical/managerial
performance of the nursing staff.
14. develop/support/evaluate the nursing credentialing system,
compensational program, recognition/retention programs,
and staffing plans for providing sufficient and competent
nursing staff with the assistance of Employment Manager
(Nurse Recruiter) and Organizational Development Director.
15. develop/support/evaluate nursing programs recommended
to promote the recruitment/retention, recognition/reward,
and development/education of the professional nursing staff,
which may include but are not limited to certification specialty
provider and advanced degrees.
16. evaluate nursing programs recommended to promote the
recruitment/retention, recognition/reward, and development/education
of the clinical, managerial and educational nursing staff.
17. participate in the evaluation, selection, and implementation
of health care technology and information management systems
that support and/or improve patient care/nursing practice.
18. collaborate with internal/external nursing leaders regarding
patient care/nursing practice issues and legal/regulatory
requirements affecting nursing practice and elicit recommendations
for improving the quality of patient care/nursing practice.
19. collaborate with the Deans, Directors, and/or faculty
of Nursing Schools utilizing the Health System as a clinical
facility and make recommendations related to the curricula
and clinical and/or managerial learning experiences of LPN,
ADN, BSN, and MSN students.
20. promote and support the research of nursing practice
by nursing staff and nursing students/faculty in BSN, MSN,
and PhD programs and refer all investigators to the Clinical
& Research Team for review/approval of nursing research
proposals.
Section 2. Relay Team
A. Membership
The membership of the Relay Team consists of the Vice President
of Inpatient Nursing who serves as Chairperson, the Vice
President-Chief Nursing Officer, the chairpersons and facilitators
of the Evidence Based Practice Team, the Clinical Practice
Team, the Strategic Planning Team and the Magnet Team.
B. Mission
To communicate and review decisions/outcomes of Clinical
Team meetings and determine work lists/priorities for each
team.
C. Responsibilities
The specific responsibilities of the Relay Team are:
1. collaborates, coordinates and shares decision making
related to the clinical team functions.
2. provides input to the Nursing Leadership Team in the
development, review, revision of strategic operation/plans
and clinical policies on matters related to patient care
delivery/outcomes and systems/operations.
Section 3. Strategic Planning
Team
A. Membership
The membership of the Strategic Planning Team consists of
at least one registered nurse representative involved in
direct patient care from each area where nursing care is
provided, at least one registered nurse representative from
each of the clinical teams, and at least two members of
the Nursing Leadership Council. The Vice President-Chief
Nursing Officer serves as facilitator.
B. Mission
To create a vision and direction for Nursing’s preferred
future at High Point Regional Health System.
C. Strategic Planning Team Responsibilities
The specific responsibilities of the Strategic Planning
Team are:
1. participate in the review and revision of the nursing
strategic plan including: Mission, Vision, Values, and Priorities,
and in alignment with the High Point Regional Health System
Strategic Plan.
2. participate in the review and analysis of the RN satisfaction
survey, determine areas of concern, establish priorities
for action and assign to appropriate team for development
and implementation of action plan.
Section 4. Clinical Practice
Team
A. Membership
The membership of the Clinical Practice Team consists of
at least one registered nurse representative involved in
direct patient care from each nursing specialty and each
category of nursing leadership (director, performance coach,
staff educator, patient care coordinator). The Directors
of Clinical Practice and Clinical Information Services serve
as facilitators.
B. Mission
To develop, implement and improve processes which enhance
patient care and patient outcomes through interdisciplinary
collaboration across the Health System.
C. Clinical Practice Team Responsibilities
The specific responsibilities of the Clinical Practice Team
are:
1. participate in the evaluation, selection, and implementation
of health care technology and information management systems
that support and improve nursing practice and patient outcomes.
2. develop, deploy and evaluate clinical information systems
which support the clinical data repository and the legal
medical record.
3. review any questions and make interpretations regarding
the scope of nursing practice for the Registered Nurse,
Licensed Practical Nurse, and Nurse Aid I/II as defined/interpreted
by the N.C. Board of Nursing and Nursing Practice Consultants.
4. review the standards of care recommendations submitted
from the Evidence Based Practice Team and develop, deploy
and evaluate the processes that support these standards.
5. communicate recommendations for performance improvement
activities/research projects to the Evidence Based Practice
Team.
6. participates in the review and revision of nursing job
standards.
Section 5. Evidence Based Practice
Team
A. Membership
The membership of the Evidence Based Practice Team consists
of at least one registered nurse representative involved
in direct patient care from each nursing specialty and each
category of nursing leadership (director, performance coach,
staff educator, patient care coordinator) who is Master’s
prepared. The Directors of Collaborative Patient Care Management
serve as facilitators.
B. Mission
To assure a quality standard of patient care through research
and performance measurement.
C. Responsibilities
The specific responsibilities of the Evidence Based Practice
Team are:
1. Explore related scientific/nursing literature
and internal/external professional/specialty practice standards
as a basis for changing and improving nursing standards
of care, practice, and performance across the organization.
2. set performance expectations/goals for improvement
opportunities/processes and initiate performance improvement
action plans.
3. identify important aspects of patient care
and define process/outcome performance measures of indicators
for each clinical area.
4. initiate systematic/coordinated performance
assessment and data collection across the Health System
on a concurrent and continuous basis using defined performance
measures or indicators, sampling techniques, evaluation
methods, and various data sources.
5. review and analyze performance assessment
findings, patterns, or trends, undesirable variations, and/or
single clinical events including the use /interpretation
of statistical quality improvement tools.
6. evaluate the effects of action plans taken
through ongoing performance assessment, measurement and
improvement activities.
7. communicate recommendations for performance
improvement/practice changes to the Clinical Practice Team
and/or appropriate Group Practice(s).
8. serve as a resource in promoting the understanding
and effective use of organizational, management, and nursing
theories and research.
9. promote and support nursing research by the
nursing staff, council members, nursing students/faculty
of BSN, MSN, PhD programs and encourage collaboration between
nursing staff and faculty of area nursing schools.
10. review, evaluate, and make recommendations for approval,
approval with special requirements, and/or non-approval
of all clinical research proposals submitted to the council
from nursing staff/medical staff, students, and faculty.
11. send any clinical research proposals involving human
subjects to the Health System Institutional Review Committee
for review/approval.
12. review and evaluate the written findings and the verbal
presentations of the findings of all nursing research conducted
within the institution.
Section 6: Magnet Team
A. Membership
The membership of the Magnet Team consists of at least one
registered nurse representative from each nursing specialty
and each category of nursing leadership (director, performance
coach, staff educator, patient care coordinator). The Directors
of Medical Nursing and Patient Throughput serve as facilitators.
B. Mission
To assure a professional practice environment through the
deployment of the Forces of Magnetism.
C. Responsibilities
The specific responsibilities of the Magnet Team are:
1. participate in the review, communication and maintenance
of the ANCC Magnet Designation.
2. identify internal/external organizational/management
mechanisms in the nursing practice setting to promote positive
nurse satisfaction, recognition, and retention and submit
recommendations to other appropriate teams.
3. administer the Health System nursing advancement, recognition,
reward programs.
4. provides staff education related to program requirements
and celebration activities as requested and at least annually.
5. promotes and supports professional growth through certification
and recertification.
6. promote annual RN satisfaction survey, report results
and collaborate with nursing leadership to set priorities
for improvement.
ARTICLE VII
Collaborative Patient Care Management and Group Practice
Structure
Section 1. Group Practice
A. Membership
The membership of the Group Practices consists of physician,
nursing, and allied health representatives from the clinical
disciplines and support departments providing patient care
to the specific case type including: Laboratory, Rehabilitation
Services, Respiratory Care, Pharmacy, Nutritional Services,
Social Services, and Nursing. When appropriate, membership
shall also include representatives from physician office
staff, home health agencies, and community agencies. The
membership shall also consist of the assigned Patient Care
Coordinator with patient/family education functions, the
assigned Educator with staff orientation/education functions,
the assigned Director and/or Performance Coach with management/leadership
functions, and the Case Management Director. The assigned
physician and Patient Care Coordinator serve as Co-chairpersons
of the assigned Group Practice.
B. Mission
To enhance the health outcomes of citizens in our community
through the promotion of quality, cost-effective care, disease
management, and health education.
C. Responsibilities
The specific responsibilities of the Group Practice are:
1. collaboratively define the standard of patient
care through the incorporation of relevant clinical practice
guidelines/parameters, specialty standards, scientific and
clinical published literature, and reference data bases.
2. develop/review/revise the standard plan of
care for assigned case type including process and outcome
performance measures.
3. define comprehensive process and outcome
performance measures which incorporate the relevant dimensions
of performance to determine the existing level of performance,
design and assess new processes, and identify areas for
possible improvement.
4. measure on a continuous basis existing processes
and outcomes of patient care.
5. identify clinical patterns or trends, undesirable
variations, or single clinical events that require intensive
assessment.
6. identify and prioritize potential improvement
strategies involving the relevant departments and individuals.
7. recommend improvement strategies to the appropriate
organizational committees or departments.
8. document and report measurement data, assessment,
and improvement strategies on a quarterly basis to the appropriate
departments/committees.
9. pursue innovative and cost-effective strategies
to improve the productivity, efficiency, and effectiveness
in patient care and clinical practice.
10. assess and evaluate patient and family education resources
and develop/revise processes and materials to meet the educational
needs of patients and families.
11. serve as a resource for health care team members in
the management of the specific case type.
12. develop goals, priorities, and strategies designed to
direct Group Practice activities on an annual basis and
evaluate the progress/status and accomplishments in meeting
those goals.
ARTICLE VIII
Special Committees
Section 1. Formulation of Standing/Special
Committees
Standing/special committees and multidisciplinary task teams
involving nursing staff are formed and convened at the request
of the Health System/Nursing Leadership including the Vice
Presidents, Nursing/Department Managers, and Clinical Councils/Teams.
The Standing/Special Committees are formed to facilitate
coordination, collaboration and shared decision making between
nursing leaders/staff and other Health System leaders/staff
regarding mutual concerns or action plans related to patient
care delivery, nursing/systems and processes, and professional
practice issues.
Section 2. Other Special Committees/Multidisciplinary
Task Teams
Other special committees or multidisciplinary task teams
are named at the time the group is formed and purposes/objectives
established. The committees meet to collaborate on patient
care and systems/process concerns which require multidisciplinary
assessment, planning, evaluation, and performance improvement
strategies/recommendations to improve the relevant dimensions
of nursing/organizational performance, i.e. efficacious,
appropriate, available, timely, effective, coordinated,
safe, efficient, caring and respectful.
ARTICLE IX
Meetings
Section 1. Clinical Team Meetings
All Clinical Team Meetings are business meetings and are
held at least monthly to carry out the respective responsibilities
and work. The Chairpersons, Co-chairpersons, and Secretaries
fulfill the responsibilities of officers as outlined. Minutes
are recorded at all team meetings according to the adopted
format.
Section 2. Group Practice Meetings
All Group Practice meetings are held monthly. A physician
and Patient Care Coordinator co-chair the Group Practice
meetings. Minutes are recorded according to the adopted
format, and disseminated by or at the next regularly scheduled
meeting, and placed in the Inpatient Administration office
manuals.
Section 3. Meetings of Other
Special Committees
Meetings of other special committees or multidisciplinary
task teams are held as frequently or as long as needed to
complete the assigned or designated tasks/purposes. These
committees or teams are dissolved when the tasks/purposes
are completed, documented and reported to the appropriate
councils/teams, departments, or individuals. Minutes are
recorded at all meetings of other special committees according
to adopted format, are disseminated by or at the next regularly
scheduled meeting, and are signed/placed in the appropriate
unit/ department, and Inpatient Administration office manuals.
Section 4. Nursing Staff Meetings
Nursing Department/Staff meetings of all clinical nursing
specialties are held at least quarterly. Meetings are scheduled
according to unit/staffing patterns to facilitate attendance/participation
of all nursing personnel to discuss/collaborate on opportunities
to improve patient care and resolve any problems or concerns
related to patient care/nursing practice. Agendas for nursing
staff meetings include reports from all clinical team meetings,
the educator(s) and Patient Care Coordinators. The Director/Performance
Coach/Unit Coordinator facilitates the meeting.
Section 5. Called Meetings
Special meetings of any of the categories of nursing staff,
any of the Nursing Teams or Standing Special Committees
are called at any time by the Vice President-Chief Nursing
Officer or at the request of the Health System President,
Vice Presidents, Nursing Leadership, Chairpersons of Teams
or any representative group of the nursing staff. At any
special called meetings, there will be no business transacted
except that stated in the notice of the called meeting.
Minutes are recorded at the discretion of the person conducting
the called meeting.
Section 6. Order of Business
The order of business at any regularly scheduled meetings
of the clinical councils/teams, standing special committees,
nursing staff meetings and nursing management meetings is:
A. Call to order
B. Approval of minutes
C. People
D. Quality
E. Innovation
F. Access
G. Value
H. Adjournment
The order of business at special or called meetings shall
be:
A. Call to order
B. Reading the notice of called meeting
C. Transaction of business for which meeting called
D. Adjournment
Section 7. Voting
One-half (1/2) of the total representation of a team or
committee constitutes a quorum and shall be deemed appropriate
for conducting the business of a council/team or committee
and for voting on any issues not agreed upon through group
consensus. All nursing representatives with the exception
of the Nursing Leadership facilitator, present at any given
meeting have one equal vote when voting on an issue is required.
The Chairperson is allowed to vote only when breaking a
tie vote is needed. Ex-officio members and Interim or Adjunct
staff are not allowed to vote. Provisional staff are not
allowed to vote during the orientation/probationary employment
period. The vote of the majority of nursing representatives
at any given meeting shall rule.
Issued: 2/80
Reviewed: 2/81; 1/83; 1/85; 1/86; 1/87; 10/91; 7/93
Revised: 2/82; 1/84; 1/88; 3/90; 12/90; 1/94; 1/97; 1/00;
4/01; 7/03; 11/04; 3/06; 7/06; 10/06
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