Nursing Strategic Plan - WellSpan Healthcontent.wellspan.org/magnet/app/OOD 3 NSP.pdf · with RBC...

https://portals.wellspan.org/sites/yhcnei/magnet/Organizational Overview Empirical Outcomes/OOD 3 - FY'12 Nursing Strategic Plan-FINAL.docx 1

Nursing Strategic Plan

2011-2012

Strategy # 1: Patient Centered Care (Michelle DeStefano)

Initiatives Tactics Measure

(1 yr) Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

YH Professional Nursing Practice Model integrated with RBC (Nursing Care Delivery Model) Improve patient -experience as evidenced by HCAHPS score improvements in the following areas · Overall Rating · HCAHPS Nurse

Communication · HCAHPS Pain

Managment · HCAHPS Doctor

Communication · HCAHPS

Responsivemess of Staff

· HCAHPS Room and bathroom kept clean

· during stay

Define and measure outcomes of the PPM integrated with nursing care delivery model (RBC For Magnet Redesignation)

1) 4-tiered measurement target, which is dependent on a unit's performance level. Performance is based upon FY12 target metrics per Blue Book (BB) and Patient Experience Council (PEC) as follows:

· Reach the comparative mean · Reach mid-way point between

comparative mean and to 25% · Reach top 25% · Reach Top 10%

2) 50% of the units will outperform the mean 51% of the time in identified NRC Picker indicators (Magnet Redesignation):

· Staff listen carefully · Treated with respect and

courtesy · Confidence in the staff · Staff explained things so you

understood · Did everything to help my

pain

1) FY applicable targeted metrics per BB and PEC 2) 75% of the units will outperform the mean 51% of the time in the NRC/ Picker and NDNQI RN satisfaction indicators listed in Year 1

1) FY applicable targeted metrics per BB and PEC

2) We meet top 10% in HCAP scores

2) All of the units will outperform the mean and 25% will have a star performer (top 10%) in the NRC/Picker and NDNQI RN satisfaction indicators listed in Year 1

Michelle DeStefano

SDM Nursing Quality Council Results Council Practice Council Leadership Council Professional Development Council


Initiatives Tactics Measure (1 yr)

Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

2) And the nurse satisfaction (NDNQI) indicators related PPM:

· RN-Task · RN-RN · Autonomy · Decision-making

2) See increase in 75% of units 51% of the time to outperform the mean in RN-MD relationships, task, RN to RN in the NDNQI indicators.

Paula Coe

Implement Teach back and SBART

3) Work on standardizing and rolling out best practices in RBC in the following identified areas: (refer to Global action Plan)

3) All processes and initiatives are engrained and acculturated on all units.

Staff to articulate RN as coordinator of care and maintain consistency of patient assignments where applicable Service Communication

1) All staff in wave 1, 2, 3, and 4 are able to articulate staffing methodology and consistency in primary nursing assignments 2) Consistency in Primary Nurse assignment on at least 75% wave 1,2, and 3 and 50% wave 3 and 4; is tracked on RBC scorecard % of units that meet their increased targets

1) All nursing staff can articulate and embrace primary nursing consistency in assignments and staffing methodology 2)Consistency in Primary Nurse assignment 75% of all units is tracked on RBC scorecard 3) 10% of outpatient units should

Michelle DeStefano

Unit Practice Councils Hospital-wide Practice Council Every Nurse manager



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

have implemented RBC

Implement Phase 3 of the Robert Wood Johnson Aligning Forces for Quality (AF4Q) initiative. Accomplish the following Clinical Effectiveness Team (CET) Objectives: · Pneumonia CET:

Identify key drivers of WSH pneumonia mortalities

· ICU CET: 95% (ultimate goal 100%) of all mechanically ventilated patients in the intensive care setting shall receive all five elements of the ventilator bundle (HOB, Sedation Vacation, DVT prophylaxis, PU prophylaxis and oral care.).

· AMI CET: · CHF CET: Implement

the CHF CET transitional management recommendation for hospitalized CHF patients at high risk for readmission.

· Diabetes CET: improve glycemic control by optimizing the care of WSH inpatients with



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

hyperglycemia and diabetes and in preventing hypoglycemia. Improve the percentage of DM2 patients that are on a basal/bolus insulin during hospitalization by 25% from the current baseline of <25%.

· Perinatal CET: decreased rate of staphylococcal and gram negative septicemias or bacteremias in newborns.

· Surgical Care CET: evidence-based rec’n for the preop prep of the patient.

· Chronic Pain CET: Evaluate the Chronic Pain Plan Pilot Project at Hayshire Family Medicine.

· Delirium CET: Pilot a delirium prevention bundle with patient activities toolkit on 6 South for high-risk delirium patients identified by the Nursing Delirium Screening Scale (Nu-Desc.) Measure compliance and feasibility then pilot on T2. Develop and test an electronic



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

version of Nu-Desc screening tool, survey nursing staff with a goal of 100% compliance on the interventions.

Complete an in-depth evaluation and develop an approach for improvement of the patient safety indicator, PSI-4 and achieve less than the national average expected rates at each acute-care hospital of the following selected patient safety indicators:

· PSI-11 post-op respiratory failure

· Falls and trauma Identify the improvements necessary for YH to return to Top 100 Hospital status. Develop a plan and begin to implement strategies to regain the award.

Achieve $7 million in total savings by implementing $5 million of process improvement projects in the major expense areas of WSH and by achieving a non-labor cost reduction goal of $2 million.

Improve employee satisfaction in targeted



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

WSH areas as identified in the annual Employee Opinion Survey.

Reconfigure inpatient bed allocation based on redistribution of patients to the WSRH.

YH will restructure the management of observation (EOC) and outpatient surgeries with extended stays (OPP) for proper use of observation day status.

· Reduce the volume of EOC by 8%:

From baseline of 18% to 10%. · Maintain/reduce the reported rate

of Medicare “one-day stay DRG” volume-Baseline=9%

· Decrease the LOS of observations by 8% or 2 hours: Baseline Average LOS for EOC = 26.7 hours and OPP = 22.1 hours

Streamline documentation increase the charge capture and revenue for observation by 12%: YH baseline of $1600 to a target of $1800

Increase the percent of time YH inpatients nursing staff spends at the bedside by 10% on 2 pilot units by utilizing Lean and Transforming Care at the Bedside (TCAB) principles. Spread TCAB best practice(s) and processes to at least 1 additional med/surg unit

Increase reported beside care time by 10% 1) Identify best practices – roll out to other units and organizations (Expansion of current TCAB work to at least one additional unit.)

1.) Identify best practice and roll out within the organization

1.)Best practice fully implemented and sustained on all inpatients units

CNO Michelle DeStefano

Astrid Davis Abi Strouse S. Donley R. Cooley M. Jurewicz Michelle DeStefano J. Gunther Tower 3 UPC

Development of glide path for each department to move to Action O-I/Solucient data to 50th percentile

Increase NDNQI RN HPPD and align total care hours with Solucient

1.) Continue to progress to the mean of NDNQI benchmark for RN HPPD while sustaining a positive trajectory 2.) Attain and maintain the mean for ancillary HPPD 3.) Align Solucient and RN HPPD as applicable

1.) Continue to progress to the mean of NDNQI benchmark for RN HPPD while sustaining a positive trajectory 2.) Attain and maintain the

1.) Continue to progress to the mean quartile of NDNQI benchmark for RN HPPD while sustaining a positive trajectory 2.) Attain and maintain the mean for ancillary HPPD 3.) Align Solucient and RN HPPD as applicable

All Clinical Directors

Leadership Council Clinical Directors Nurse Managers



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

mean for ancillary HPPD 3.) Align Solucient and RN HPPD as applicable

Transitioning the patient care from inpatient to other providers (Blue Book Goal 2.A.1)

1.) Implement Depart at YH Sept 7th and 14th 2011.

1.) Assure that hospitalized patients followed by a WMG provider are seen within at least seven days of discharge from the hospital at least 95% of the time, unless otherwise specified.

1.) Determine success of the depart process as defined by meaningful use

Astrid Davis Michelle DeStefano

WSH Steering Group drives this initiative

The practice of cultural diversity.

1) Cultural Diversity for Topic at JDS for 2012

2) Data collection for ethnicity at time of registration

1.) Achieve 100% compliance with attendance at the Diversity for nursing leadership team 2) 450 registrants for JDS

1.) 100% compliance for staff and leadership completion of diversity program 2.) Two Cultural Diversity best practices are implemented

1.) A total of 5 Cultural Diversity best practices are implemented 2.) Begin to educate from exemplars

Michelle DeStefano Connie Gutshall Paula Coe

Professional Development Council CNS Leadership (statistics and training)



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

3) Baseline data of discharge phone calls being obtained during September 2011 of patient’s cultural diversity needs

3). Follow up patient survey July 2012. 4.) Identify most common cultural diversity needs of patients based upon results of survey

Patient Flow & Bed Management

Reconfigure inpatient bed allocation based on redistribution of patients to the WSRH

Reduce error from 5-10/week to 1-2/week

Zero occurrences should occur.

Ann Kunkel/ New CNO CNO NET Michelle DeStefano

Leadership Council



Strategy # 2: Safety and quality focused patient care built on evidence-based practice (Stephanie McKoin)

Initiatives Tactics Measure

(1 yr) Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

Crew Resource Management

1. Implement CREW resource management in the following areas · CVS

procedural areas

· ICU Procedural areas

2. Implement a method of validation and accountability to maintain process in all procedural areas

1. Collaborate with MD counterparts to develop a plan for CRM in procedural areas (CVS ICU)

2. Develop a mechanisms to

measure patient outcomes (SSI, wrong site surgery, etc.); because of the implementation of CRM (crew resource management), inefficiencies;

1. Improve culture of safety thru improved scores

1. Improve culture of safety thru improved scores on

Stephanie McKoin

Gary Merica, PSO Service Line Leadership teams

Enhance Culture of patient and staff safety

Improve the culture of safety at York Hospital by establishing an observational methodology to ensure consistent performance of effective time-outs prior to all applicable invasive procedures Utilizing patient safety survey as guide to improvements of the culture of safety

· 100% Performance of effective time out procedures

· 100% compliance with all components of time-out procedure

· % increase of key

indicators within patient safety survey

Implement the next Develop a 1. Develop improvement 1. Continue to evaluate 1. Continue to evaluate Astrid Safe patient



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

phase of the Comprehensive Accident and Injury Program including the Musculoskeletal Injury Prevention policy, continued deployment of assistive lifting devices, and enhanced training and support

comprehensive Ergonomic improvement plan proposal related to moving patients (Safe Patient Handling Oversight Team). Participation in 5 Year Strategic Plan for Safe Patient Handling

plans based on evaluations and Ergonomics Improvement proposal

effectiveness of action plans by measuring staff injury rates

2. Implement, or continue to implement, ergonomic improvement proposal (i.e. patient lifts)

effectiveness of action plans by measuring staff injury rates

2. Implement, or continue

to implement, ergonomic improvement proposal (i.e. patient lifts)

Davis/ Michelle DeStefano

Handling Oversight Team

Evidence-based Practice

Continue support for EBP/NR within all the service lines.

1) Help to build support by continuation of the dissemination of knowledge about the YH research model, focusing both on internal and external audiences.

1) 1.) Budgeted, formalized YH process (establish Center of Nursing Research)

1) 100% unit participation (could be collaboration with another unit)

Barb Buchko Paula Coe

EBP/NR council SL councils

2) All service lines involved in an EBP projects or research

2) Implement practice changes (number to be determined) based on EBP projects and research conducted here at YH

3) Choose a nursing leadership EBP project (managerial topic)

4) Develop a mechanism to help staff translate current EBP and research findings into actionable nursing care changes

Continue the EBP fellowship program

1) One EBP/NR fellow in fall 2011 and spring 2012

2) FT doctoral program researcher

3) Increase fellowship to four per year

1) Continue to increase EBP fellowships as appropriate

Resources to support

Dissemination of EBP/research projects

Every unit has an EBP champion.

1) nursing research project per service line annually --1



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

dissemination of projects will be available.

publication per service line annually

Actively engage in SCPaEBP consortium

Increase participation and attendance in the consortium

Identify 1 EBP and 1 NR project for mutual collaboration

Identify 3 EBP and 3 NR projects for collaboration

YCP/YH EBP student mentoring program

Continue fall and spring student collaborative

Ensure smooth, application of the Electronic Health Record Cerner programs

1) Drive and prioritize enhancements Align quality /regulatory reports 2) Expand Care Aware and iAware auto-programming and infusion management 3) Assist and support the implementation of DEPART process 4) Assist and support activities related to “Meaningful Use” strategies 5) ID quick wins to stream line nursing documentation 6) Implement M-Pages 7) Implement and utilized Smart Pump tech in additional inpatient ICU’s YH OB #7 8) Implement IPOC throughout YH in a phased in approach

1) Continue to build reports so that data / metrics can be retrieved automatically. Improve compliance with patient safety initiatives such as medication administration, scanning for patient identifiers, etc.

2) Evaluate the effectiveness of the nurses progress notes initiative to tell the clinical patient story accurately and succinctly.

3) Establish documentation process/ elements for observation patients

1) Take nursing document to 100% electronic house-wide.

2) Initiate outpatient

documentation

Complete outpatient documentation

CNO Sharon Muller

CareDoc Team Nursing IT Steering Committee Practice Council

Implement and Sharon



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

utilize smart pump technology in additional inpatient intensive care units

Muller/ NET

Reach target for all nursing specific indicators (NSI); nursing specific core measures; Blue Book objectives FY 2011; and Patient Experience across all service lines in conjunction with CETs.

1) Assure compliance with current fall prevention policy and Utilization of Fall Prevention protocol across all units.

2) Develop plan to

meet national benchmarks for all NSI’s at unit level

3) Maintain

balance between patient safety and staffing effectiveness

1. Out-perform the mean national benchmark with 50 % of the units outperforming the mean 51% of the time (5 out of 8 quarters of data( on the following NSIs: Prevalence and incidence-decubitus, falls, BSI, and CAUTIs

2. Maturation of outpatient

PI plans with benchmarks 3. Unit based nursing quality

(PI) council staff members can articulate unit outcomes, metrics and mechanisms utilized for improvement

1. 75% of the units achieve outperforming the mean in the identified NSIs 51% of the time. (5 out of 8 quarters of data)

2. Staff at large is able

to speak about unit quality issues and what has been done to improve them and can speak more clearly on unit PI initiatives.

1) Sustain a positive outcome trajectory

All Clinical Directors/ Paula Coe for consulting Greg Gurican-data analysis and trending Paula Coe Greg Gurican Sue Wisotzkey All CDs

Hospital and unit-based SDM Nursing Quality councils Nursing Leadership

Meet targets for Blue Book objectives: TOP 4: · Hand Hygiene

1. Each unit has an action plan related to hand hygiene compliance rates and will meet 90% compliance rate for 6 months in FY 2011.

2. Each non inpatient patient care area has a plan to monitor and improve hand hygiene compliance to meet above goal (90% for 6 months).

Meet 90% for 12 months all patient care areas

VTE prophylaxis/ VTE prophylaxis improvement



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

treatment

initiatives are to be monitored and implemented at the unit level as per BB goal (specifics TBD)

1. Developing CPOE Order sets to meet the requirements of meaningful use.

Culture of Safety

See above category of “Enhancing the Culture of Safety”

Transitions of Care Manage Transition of Care specific initiatives at the unit level as per BB goal (specifics TBD)

Meet Core measure compliance of 98% for each indicator (as applicable to nursing)

All nursing controlled core measures are at 98% or above compliance

YH SDM Councils YH PIC CET



Strategy # 3: Mutually respectful and collaborative Interdisciplinary relationships (Abi Strouse)


Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

Nurse/Physician Collegial Relationships

1) Disseminate the tenets of a professional RN/physician relationship 2) Form group of NL/PL to identify mutual tenants of collaboration. 3) Develop process for sharing RN MD scores with MEC 4) Structure and process 5) Nursing Grand Rounds focusing on RN/Physician Interactions

1)Tenets are disseminated & accepted through MEC, OLT, NLT and SL leadership 2) 25% units are at or above NDNQI mean for RN/physician relationships

1) Model is operationalized 2) 50% units are at or above NDNQI mean for RN/physician relationships

1) NDNQI Indicators RN/MD relationships are in the top 10% 2) 100% of units are above 90%

Abi Strouse

Unit and/or service line nurse/physician dyads Medical Staff leadership Results Council Team

1.) Identify the work groups that are below the mean in NDNQI for RN/MD relationships

1.) In collaboration with the physician leader a plan is developed such as rounding with physicians

1.) Increase in RN-Physician Interaction NDNQI scores for Physician /RN saying the same thing. Increase in RN satisfaction 2.) Physician/RN aligned (Picker) increase 3% from implementation

1. NRC picker indicators in the top 10%; for RN/Physician said same thing 2. NDNQI RN satisfaction scores for RN-Physician at top 75% Top 10%

Abi Strouse

SL Leadership



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

NLT Leadership Development

1) Conduct Nursing leadership development assessment Bi- Annually 2013 2) Create action plan from top items from Needs Assessment: a) Financial/Budget b) Problem Solving c) Strategic planning d) Strategic Goal Alignment e) Performance Improvement

3). LEO Program (NET) 4) Complete NL

satisfaction survey Bi-annually

5) Explore the feasibility of a Leadership Fellowship track that is grant funded.

1) Create development and education plan based on the NLT assessment findings 3) Follow up on action plans from LEO 5) Search for grants that can fund a Leadership Fellowship.

1) Provide education programs based off of NL assessment

1) Novice to expert nursing leaders are educated based on their level and perform at increasingly higher levels of leadership competency As measured by turnover rates (NM and staff); staff satisfaction (NDNQI); SL evals; 360 evals; Magnet designation

Abi Strouse

Leadership Council



Strategy # 4: Autonomy, empowerment and accountability (Sue Wisotzkey /Paula Coe)


Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

Develop Strategies for recruitment and retention of RNs

1) Through the development of the framework for a nurse residency program and subsequent implementation (based on research, literature review and IOM recommendations.) 2. Develop NDNQI RN satisfaction action plans 3. ID and replicate best practices at YH for RN Sats 4.) Identify and develop a plan for the units with high RN turnover 5.) Re-evaluate RN staff needs every 6 months 6) Develop a three

1) YH vacancies rate will be < the Pa. state average for RN vacancy rate (baseline from most recent stats in 2011 14%) Nurse residency framework developed 2) Include nursing satisfaction

outcome measures and determine baseline for top 2 from Leadership Council

Develop RN Sat Advisory Council 3) Explore the feasibility of IT for patient acuity measure 4) Explore and develop ideas 1. ICU Float pool 2. Cross-train 3. CRT for orientation for planned retirement

1) YH vacancies rate will decrease by 1% overall and be maintained < the Pa. state average for RN vacancy rate Nurse residency implemented and evaluated quarterly based on vacancy statistics and turnover data 2) % improvement

1.) YH vacancies rate will decrease another 1% overall and be maintained < the Pa. state average for RN vacancy rate Nurse residency evaluated biannual and based on vacancy statistics and turnover data 2.) % improvement

Sue Wisotzkey

Leadership council (R&R subcommittee) Nurse Managers Clinical Directors



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

year rolling plan of staffing needs to avoid RN shortage 6) Develop strategy for keeping “wisdom” workers: Identify alternative roles, alternative shifts, benefit modification options for key positions

1.) Maintain competitive market position Monitor Market competition at least by annually

1)Salaries minimally at 65th percentile in 1 year 2) maintain RN-Pay NDNQI benchmark above

1. Salaries ≥ 65th percentile as economy allows 2. Maintain competitive PRN program

Salaries greater than 65 percentile as economy allows

CNO/All CDs

CD/VP

Magnet Redesignation

1. Maintain infrastructure for redesignation process 2. Sustain (the components) throughout the professional practice environment/nursing units and departments applicable for Magnet Redesignation

1. Begin data collection and place stories in portal and word documents for electronic submission. 2. 50% Magnet document outlined and sources of evidence completed 3. Evidence gathering teams functional and meeting timelines for writing and submitting document. 4. Submit DIF January 2012 to ANCC

1. Continuous Magnet readiness 2. Magnet enculturated into the entire organization 3. Submit electronic version of Magnet SOE for Redesignation (February 2013) 4. Coordinate successful appraisal visit. 5. Plan for celebration: Begin redesignation prep 6. Complete DIFfor ANCC 7.Complete Biennial Monitoring 2015

1. Continue process for re-designation 2.Complete annual DIF to ANCC

Paula Coe All Councils/Evidence Gathering teams, CD’s. NLT,



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

SDM 1.) Integration of councils with accountabilities/ ownership 2.) Evaluate SDM structure changes annually 3.)Coaching/mentoring council chairs

1.) Identify and implement core structure that needs to be in place at the unit level RN Decision Making and Autonomy RN Satisfaction scores 2.) Decisions made at SDM system à entity àunit are reflected in minutes 3)SDM structure confirmed to meet our professional practice needs 4.) Develop an evaluation tool for SDM effectiveness and communication at the hospital and unit level

1.) All staff able to articulate the decisions/ changes made in professional practice at unit and hospital wide level 2.) YH and GH integration as appropriate 3.) NDNQI RN satisfaction scores continue to outperform the mean 51% of the time or above for autonomy and decision making

1.) 100% units at mean or above for autonomy and decision making on NDNQI RN sat

CNO Paula Coe

Coordinating Council

Finances 1)Maintain at or below 50% in Solucient data

1) Nurse managers to attend Solucient training 2) Continuously evaluate appropriate comparison groups in Solucient 3) Develop proposal for next year’s budget process 4.) Implement Kronos scheduling system

1) Formalized plan to meet staffing needs on a consistent, continuous basis

NMs and CDs Bonita Trapnell Connie Gutshall

Leadership Council



Strategy # 5: Professional development, education and clinical advancement (Connie Gutshall/Michelle DeStefano)


Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

Enhance leadership professional development and education

1.) Implement Nurse leader pathways 2). Develop and implement Clinical Nurse advancement pathway 3). Link pathway to nursing portal 4). Communicate to ensure staff awareness of the existence of the pathway

1). Successful transition of nurse leaders-clinical staff through the pathway. 2). Encourage promotions from within as a result of this program and report % promotion from within 3). Evaluate the utilization of the pathway

1.) Build on current pathway and expand to CNO. 2.) Evaluate the utilization of the pathway 3). Increase Promotions from within as a result of this program

1.) Successful transition of nurse leaders through the pathway

NET Michelle DeStefano Paula Coe Abi Strouse

Professional Development Council

1.) Develop and implement a comprehensive nurse residency program (orienting, precepting and mentoring)

1). Define hospital wide infrastructure and process needed for the residency program 2). Identify appropriate clinical staff at all levels (orienting, precepting and mentoring)

1.) All units will have implemented residency programs 2.) Follow NDNQI RN-RN scores (RN/RN Interactions) 3.) Follow RN recruitment and retention metrics analyzed based on the retention of new RN hires. 4). Evaluate the

1.) Show significant increase in the NDNQI scores. (outperforms the mean 51% of the time)

Astrid Davis Sue Wisotzkey Kay Bozart

Leadership Council



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

effectiveness of the residency program.

Develop a peer case review system for staff nurses at all levels – based on EBP.

1.) Peer Case Review for staff nurses for nursing practice 2). Comprehensive review of all cases identified for unit based peer case review.

1) Provide education for peer case review process

2.) Evaluate infrastructure needed to support peer case review and makes changes as identified 3.) Identify the units participating in peer case review 4.) 25 % of units perform peer case review 5). Well functioning peer review process that follows outcomes of the case and dissemination of shared learnings

1). 50% of units will be performing peer case review 2.) Re-evaluate process

1) 100% of units perform peer case review 2.) Re-evaluate process

Paula Coe Deb Yommer Sue Dayhoff

Nursing Quality Council

Professional development

1) Promote educational advancement for RNs to achieve BSN, MSN, PhD, DNP, or DSN.

1) Evaluate the unit progress toward increased BSN/ MSN/ doctoral degree. 2). 100% of NM with BSN by January 2013.

1). Achieve a target of 60% of direct care staff hospital wide with BSN by July 2015

1.)Achieve a target of 80% of direct care staff hospital wide with BSN by 2020 (IOM Report) 2). Meet ANCC and exceeds the ANCC benchmarks.

Astrid Davis Connie Gutshall

Leadership Council

2) Promote RN staff to achieve professional certification

2a) Achieve a target of 5% of staff per unit with professional certifications Aggregate total of 40% Of RN’s with certification.

2) Meet certification goal for Magnet Redesignation source of evidence (SE)

3.) Increase the percentage of nursing

3.) Explore and identify financial assistance available



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

leadership with Masters degree

for advanced degrees

4) Identify ANCC benchmarks and develop a plan for meeting them.

4.) Measure if we are on track to meet the ANCC benchmarks (upward trajectory).

5.) 100% eligible nurse managers, clinical directors and CNO need to be certified in nursing administration by June 30, 2012.



Strategy # 6: Nursing leaders who are mentors, coaches, risk takers, and servant leaders (Bonita Trapnell/Astrid Davis)


Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

Revised leadership orientation

1. Complete nurse leader orientation within one year of hire. 2. Formalize orientation calendar and appts and ensure calendar is up to date minimally on an annual basis . 3.) Explore and review external programs that will support internal orientation of nursing leadership.

1). Utilize the core competencies checklist and 2). Develop expectations for all CD, NM, and assistant NM, CNS, nurse educators, and house supervisors. 2.) Completed Leadership orientation check list, core competencies identified as the AONE Leadership Core Competencies. (ACHE Core Competencies.)

1). ).New NLT members report high satisfaction with orientation

1. Nursing Leadership Orientation is identified as a best practice.

Bonita Trapnell Connie Gutshall Stephanie McKoin Kay Bozart Michelle DeStefano

VP/CD with Ed Services Leadership Council Sub-team

4. Implement YH CBO for NMs. 5). Develop a formal process for mentoring Provide mentor for 1 year – role of mentor is specific. .

3. Evaluate and revise the NL orientation

4. Establish SL expectations

5. Establish core clinical time 6. Continuous evaluation of

internal curriculum and revise

7. Utilize the NLT pathway is developed for internal and external orientation



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

opportunities as well as novice to expert for each role:

NM, CD, CNS, Educator house supervisor

Identify strengths and opportunities for leadership

1.) Provide coaching while reviewing their 360’s every other year (even years)

1) Incorporate professional developmental goals into performance appraisals

1.) Performance enhancement of NLT members based on growth plan

1.) Measurable improvement based on professional growth plan from previous year

NET

Connie Gutshall Paula Coe Leadership Council Sub-group

2.) Develop a process for administering 360”s and sharing that information with individuals.

2.) Conduct bi-annual 360 degree evaluations for leadership positions

2.) Outperforming the NDNQI mean in perception of a good leader in nurse manager

Career Development

1) Review at employee annual performance review

1) Establish baseline of nursing leadership satisfaction 2.) Review and update novice to expert grid on an annual basis.

1) Measureable improvement in satisfaction survey results

1.) Continue to increase housewide BSN numbers

CNO

2) Identify current and future competencies

3) Achieve LPN-RN program goals

3) Educate interested individual regarding available resources (i.e. tuition reimbursement)-

4.) Link to nursing portal for easy access of staff to retrieve this information

Nurse Manager Satisfaction

1) Managers select two priority action items from the NM renewal program for discussion and

1) Implement two action items 2). Develop a plan to decrease span of control where appropriate

1.) Decreased nurse manager turnover rate due to job frustration

1.) Individual units will reflect high NDNQI survey results and low vacancy, low staff turnover rate

Clinical NET



Measure (3 yrs)

Measure (5 yrs)

Point Person

Responsible Team

implementation 2). Identify themes and action items from Nursing Leadership Satisfaction Survey.

3). Each service line to develop individual plan .

Nursing Strategic Plan - WellSpan Healthcontent.wellspan.org/magnet/app/OOD 3 NSP.pdf · with RBC...

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