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Category 1: Leadership Structures and Systems –

Unit leaders are integral to ensuring a healthy work environment that focuses on the delivery of the best care for patients and families. On the unit, the best care may be reflected in a commitment to systematically develop and train nurse leaders; ensure accountability; advocate and participate in decision making; and provide meaningful recognition to staff. Creating a sustainable healthy work environment can improve the care delivery environment, thereby improving clinical outcomes, patient and family satisfaction, and staff satisfaction and retention.

The criteria questions in this category are aimed at soliciting information about how your unit leaders support and maintain a healthy work environment. For each question reviewers will evaluate the comprehensiveness of your approach; application and integration across staff and key stakeholders; and evidence of continued evaluation, shared learning and process improvement.

Criteria Questions
1 For unit leaders identified in the Unit Profile:

a.      Describe how they are trained to meet and maintain the responsibilities of their role. For example, how are unit leaders held accountable by managers, staff or interdisciplinary stakeholders?

b.      Describe how unit leaders guarantee joint accountability between medical, nursing and other leaders.

c.       Describe how this group works together to ensure integration of patient care within and outside of the unit.

Notes: Unit leaders are defined as anyone who has daily responsibility for unit function and may include managers, supervisors, charge nurses or directors. This may also include physicians and other non-nursing personnel. Some examples of accountability may include formal processes such as peer review, performance evaluation and/or performance against measurements and goals; it may also include informal feedback mechanisms or surveys. Integration of patient care includes the processes and systems used to ensure sustained quality of care between your unit and supporting units (such as dialysis or radiology) and/or outpatient care settings (such as clinics, offices and rehabilitation facilities).

Response The units nursing director is accountable for all unit outcomes and is the formal unit leader for ICU and the emergency room.  The director completed a formal orientation and was partnered with a mentor. The mentor is another nursing director who has been at the hospital for several years. The unit’s nursing director has been a leader for many years in various facilities and several states. She has extensive training in managing employees, difficult situations and providing positive customer experiences. Most importantly she possesses an incredible ability to work closely with her staff and takes the time to listen to staff concerns.  The nursing director is also a board certified nurse executive. She completes  continuing education requirements to maintain her certification.

Larkin Community Hospital is a teaching hospital and promotes leadership and staff professional development. Nurse director attends national conferences and maintains Specialty area CEU via webinars and on-line courses.

Staff and director work collaboratively to attain all goals and maintain patient safety. Every shift has a charge nurse that is assigned by the staff on the unit. An ICU unit Chair present at hospital leadership council meetings brings information back to the unit and shares it with staff from all shifts. Director also presents information at staff meeting where ideas are introduced and decisions are often made. Evidence-based practice recommendations are provided via several forums to include: interdisciplinary patient rounds, staff meetings or informally as the need arises based on patient and staff needs. Every hospital inpatient department has a chair. Each department/unit chair meets quarterly. During these meetings the chairs discuss patient care issues, staff concerns and generate suggestions or processes that the staff nurses would like to incorporate into daily practice.

An example is hand-off of communication. The staff in the Intensive Care Unit (ICU) felt that hand-off communication should be verbal where they are afforded the opportunity to ask questions. The staff brought the concern to the director who then collaborated with the director in the medical surgical unit. The joint commission standards on handoff of communication where reviewed collaboratively between the different departments and based on the recommendations from the staff and the evidence-based research from Joint commission; all reports between ICU and medical surgical units are provided verbally staff to staff.

ICU’s medical director is a board certified pulmonary intensivist. The medical director is active in meeting with the units nursing director and the hospital CEO. The director maintains an open door policy, and together with the medical director, promotes collaboration among the various disciplines. The directors provide all staff with their personal phone numbers maintaining themselves highly accessible. Residents play an active role in the collaborative process. Patient care decisions are made as a team.

2 Describe how unit leaders interact with staff to:

a.      Build relationships, provide timely feedback and ensure patient-centered care.

b.      Encourage/ensure frank, two-way communication throughout the unit.

c.       Share key hospital decisions and information.

Notes: Your response may include the frequency of interactions and modes of communication, both formal and informal.

Response ICU enjoys an open communication process where leaders are easily accessible and provide their personal number to all staff. Communication occurs via several medians and in both formal and informal methods. Staff report is received from nurse to nurse and then the director huddles with the nurses and

unit secretary to share unit plan of action and care for patients. The leader ensures that all staff has report for all the patients on the unit and that all staff agrees on unit plan for the day.

Patients plan of care and unit plans are evaluated three times a week during interdisciplinary rounds. Various departments collaborate on a plan of care for each patient on the unit and goals are set, continued or modified as a result of interdisciplinary collaboration. The interdisciplinary team consists of nursing director, staff nurses, dietary, pharmacy, infection control, patient family members if present, unit secretary, case manager, residents from various disciplines, respiratory therapy, laboratory at least once a week and wound care nurse and physical therapy as needed.

Communication boards also keep all staff and unit visitors informed of unit activities and quality outcomes. The use of emails and monthly staff meetings is yet another form of communication between staff and leadership. All staff meeting minutes are posted so that staff who is unable to attend can read and signoffthat they read minutes. Many times staff will follow-up by calling director to obtain information directly from her.

Quality improvement measures are a continuous process for ICU staff. Improvement measures derived from informal staff meetings are brought to director who then collaborates with other department leaders and the practice council so that improvements or suggestions are considered for change and implementation in efforts to consistently provide optimal patient care and obtain the highest quality outcomes.


3 Describe how licensed staff is held accountable by unit leaders for practicing within their individual scope of practice. Describe how other unlicensed personnel employed on the unit are held to the expected level of professional practice.

Notes: Scope of practice defines the boundaries/limits of practice for individual care providers, i.e., the ability to do a particular activity based on education, license or training and may include facility, state or federal regulations. Professional practice is defined by the standards of practice and standards of care set by the profession and provide a framework for evaluating how a particular group meets the expected outcomes.

Response The ICU is staffed by licensed professionals. Each staff is held accountable and is empowered to ensure that all work accomplished is within the established unit criteria and nursing scope of practice. All staff is trained to care for patients in critical conditions. Unit outcomes are tracked and all and residents receive training on nursing scope of practice and hospital guidelines. Protocols are in place that empowers nursing staff to practice within their licenses’ scope according to the state regulations and best practices. Reporting system reinforces the culture of autonomy and nurse empowerment. Performance improvement tracks and trends incident reports generated and any nursing issues are reported to CNO,

Director and unit staff. Root cause analysis is conducted if required to implement necessary changes which usually involve lack of knowledge from the new medical residents.


4 What facility- and/or unit-level reward and recognition programs are currently in place? How do unit leaders take an active role in providing and encouraging reward and recognition?
Response Staff is rewarded and recognized by the established Shout out program. All staff is encouraged to take part in the shout out program. Every time any staff wants to recommend another for making a difference a shout out is completed and posted for all to see. A reward system of shout out points

defines the reward received. Rewards include free meal, movie tickets, free valet parking, lunch with director, lunch with CNO, up to holiday of choice off. Other recognition systems include nominating nurses for March of Dimes nurse of the year award. Nominating staff for RN of the month and RN of theyear, recognizing staff for going above and beyond in staff meeting. Larkin recognize’s nurses who do not call out making a positive impact on staffing. This is done at staff meetings and certificates of recognition are given to nurses who stand out to make a difference. Other categories include recognizing nurses who make an impact on a patient or family when the nurse’s work is praised in patient or family letters. Staff is also rewarded by maintaining self-scheduling. Staff who maintain excellent work ethics by having 6 months with no call outs or tardy are given a free weekend off the schedule therefore only having to work one weekend a month for the corresponding schedule

5 How do unit leaders evaluate the effectiveness of reward and recognition programs? Include mechanisms for soliciting staff feedback and how reward and recognition programs are improved based on evaluation results.
Response The reward and recognition adopted by the unit is created and maintained by the staff on the unit.

When the staff generates new ideas and means of recognizing and rewarding their peers the unit

director is open and creative in adopting the new idea. The pulse is kept during staff meetings when the agenda is opened for staff feedback. The staff verbalizes the type of recognition that they want to receive. This is how the free Holiday of choice off came about. One staff proposed the idea during a staff meeting and it was adopted by all including the unit leader. This collaboration meant that for every holiday an extra nurse would need to be assigned to cover the nurse whose turn it may have been to work and yet won the opportunity to have the holiday off.


6 How does the unit select, collect, align and integrate data and information for tracking unit performance?  How is key comparative data and information selected?

Notes: Performance measurement data is used in fact-based decision making for setting and aligning unit direction and resource use with organizational strategy and operations. Comparative data and information is obtained by benchmarking and seeking competitive comparisons.  Benchmarking refers to identifying processes and results that represent best practices and performance for similar activities, inside or outside of your unit.

Response Data collection is accomplished in collaboration with the hospitals performance improvement department as well as non-clinical nursing departments (education, informatics, etc.). Unit specific data is collected and reported monthly. Some ofthe data collected is determined based on NDNQI recommendations and NHSN requirements for ICU units including: Central Lines Associated Blood Stream infections (CLABSI), and Ventilator Associated Pneumonia (VAP). Data collection based on National standards such as core measures are currently collected and analyzed with the patient’s in­ house stay. The results are reported via dashboards that are updated and displayed on the units communication boards. When any measure falls below the national expected rate, nurses conduct research to learn about best practices that have worked at other facilities with like unit. The research findings are shared during huddles and interdisciplinary rounds.

Catheter Assisted Urinary Infection (Cauti) rates are also collected. Other non-clinical measures include nursing certification and level of education. This is one of the unit’s newest initiatives and the nursing  and medical directors are working with staff to promote and encourage professional educational growth. Staff has access to to conduct research when practice changes need to be incorporated to meet national standards.

Patient safety and performance improvement committee meets monthly. During this meeting every unit’s data is presented, unit staff is present to discuss unit specific data and performance.


7 What are the key unit performance measures for patient and clinical outcomes (report results in Category 5)? Patient and family satisfaction (report results in Category 5)?

Notes: Staff-related measures should be identified in the Category 2 – Appropriate Staffing and Staff Engagement.

Response Key unit performance measures include VAP and Cauti rates, patient to nurse ratio, medication administration scanning compliance as a strategy to prevent medication errors, incidence of decubitus and patient days to track length of stay. Patient and family satisfaction is reported as a total impatient score. HCAPS is used to determine patient and family satisfaction of services and care rendered. The Jackson Group has been contracted to provide the organization with said data
8 How does the unit use the data and information to support unit decision making and process improvement?
Response Interdisciplinary rounds are the forum used to discuss patient care and outcomes including unit specific measures. During these rounds all disciplines present collaborate and develop a plan for improvement or change. Evidence-based research is presented during the next rounds on the issue or concern at hand and then nursing staff meet independently and create a plan. The nurses present the plan for change to the director who is present at rounds when the nursing staff shares with the team the plan generated to impact the units performance. The plan is implemented at time without any further feedback for change at time after a request to add or change a minor part of the plan, this change is usually a collaborative between the medical director and the nurse practitioners input. The new plan is put is place, track and trending for six months and evaluated then for its effectiveness or revision. Continuous process improvement is always at play and part of the interdisciplinary team functions. The unit nurse representative will then report unit trends at leadership practice council.
9 How do unit leaders ensure the performance measurement system can be modified in a timely manner to respond to ongoing changes in organizational or external reporting requirements?
Response This process was briefly explained on number eight. The benefit of the organization is that it is a teaching hospital. As such medical residents are always present. Of greater importance are the robust

interdisciplinary rounds that are held three times a week in the ICU. The rounds allow for free flow of dialoguing on unit performance measure. Evidence based data is easily accessed as every staff has access to online research site. Changes are implemented at times within the same day. This is a benefit the unit enjoys because the unit are part of a small community hospital. One of the main reasons staff nurses have been working on the unit for many years. The nursing director together with the medical director maintains the CEO and CNO abreast of all changes.



Category 2: Appropriate Staffing and Staff Engagement

Appropriate staffing is key to ensuring the provision of safe, quality, patient-centered care; it also ensures the safety, satisfaction and retention of competent staff. Although staffing can be complex, ensuring an effective staffing plan can positively affect the measurable outcomes on the unit.

The criteria questions in this category are aimed at soliciting information about how your unit engages, manages and develops staff. For each question, reviewers will evaluate the comprehensiveness of your approach; application and integration across staff and key stakeholders; and evidence of continued evaluation, shared learning and process improvement.

Criteria Questions
1 Describe how staffing needs and the staffing plan are determined for the unit including staffing levels and skill mix based on required skills and competencies. Describe how adjustments to the staffing plan are made during seasonal variances, times of low or high census, or sudden increase in patient acuity.

Notes: Skill mix describes how many of each type of care providers are generally available for each patient care shift.

Response The ICU at the hospital always staffed by two nurses at a minimum. The ICU nurses respond to codes throughout the facility. The staffing ratios remain at 1:2 unless there is a patient that requires a higher level of acuity in which case staff is assigned accordingly or called in to help. The unit has not implemented a culture of on-call or cancellations according to census. If the shift starts with three nurses for 5 patients and the census drops to 4 patients then the unit is staffed with aS” nurse. The nurse will conduct PI round on the rooms and check equipment functioning beds and cables for monitors as an example. The unit chair and staff are working on creating an on-call and cancellation policy that is a win-win for employees and the organization alike.


2 What are the key measures used to evaluate the effectiveness of staffing decisions (report performance results in Category 5)? How are these measures used to assess staffing and adjust changing staffing needs after a plan is established?
Response The Unit’s staff is proud to maintain excellent unit specific Performance Improvement measures. Due to

the current staffing ratios and the staffs fluidity, when census goes down staff is not cancelled so everyone pulls together to ensure that the unit is clean and that equipment is in proper working order. The staff also enjoys the privilege of having a wound care nurse team that rounds on all new admissions and on patients that RN’s rate as high risk for skin breakdown. This is a huge benefit in keeping the nosocomial rate at zero and ensures high quality patient care for all patients not only in the ICU. Staff is very united. When the acuity increases or patients start being admitted the staff is provided the autonomy to call a peer and have them come in to help. No one abuses the system because the director has given us the autonomy to call upon unit peers as needed to meet the unit needs.


3 Describe the processes to ensure an effective alignment between patient clinical, spiritual and cultural needs and nurse competencies.

Notes: Examples may include formal or informal acuity-based systems and competency tracking information.

Response       All patients at Larkin Community Hospital are assessed on admission for any specific spiritual and cultural needs that may affect the care, treatment and other services provided during their stay. Nursing staff are evaluated for cultural competency at least annually and are regularly in-serviced regarding the provision

of culturally competent care. Competencies are maintained in the employee record. Clinical skills of all staff are maintain by conducted annual skills fair and education department conducts a staff needs survey that is strictly based on what staff RN’s feel they need further education and training on.


4 How does the unit recruit, hire, place and retain staff? Describe how staff nurses and interdisciplinary stakeholders participate in staffing decisions, including planning, recruiting, hiring, orientation, education and evaluation.

Notes: Examples of staff participation in staffing decisions might include peer reviews, group interviews or nurse shadowing. Also include staff participation in orientation, education and evaluation, although further description of these processes will be requested in a later category.

Response The only unit turnover in the last year was the director. The new director opened two fulltime positions

and the candidate was hired after a group of nurses conducted a panel interview. First the director meets the candidates then the candidate interview with the panel. The panel documents their findings and scores the sheet. The scores are collected by one staff and taken to the director and together the scores are calculated and comments reviewed the best candidate is the one who is offered the position. Every employee first attends general orientation then depending on each new hires experience and need is what determines the length of each new hires orientation. For example one of the new hires was experienced and only required unit orientation and policy and procedure review. The other candidate had less experience and spend four week with a mentor assigned each shift until both mentor and new staff felt comfortable for new candidate to work with a team by herself.


5 Describe how the unit maintains a safe, secure and supportive work environment.
Response Safety rounds are conducted every month by safety officer. As previously mentioned though, unit staff check rooms almost daily and they assess unit and patient needs. The director is a true safety advocate and is proactive in getting things fixed, supplies needed on unit, and gives us the staff the autonomy to

call upon a peer to come in and help when the acuity is high. Staff respects the amount of trust they have for each other and that the new director has for them. For this reason no one takes advantage of their autonomy and everyone feels supported. Nursing supervisors are also supporting and play an active role in ensuring that the unit and hospital overall are safe and secure.

The ICU is a locked unit with exit only access via stairwell and a ring in system where one can see via use of camera who is requesting to come in. Voice communication is also available between the person requesting to enter unit and staff inside unit.


6 Describe the formal and/or informal methods and key measures to determine staff safety and satisfaction (report results in Category 5).

Notes: Formal or informal methods to determine staff satisfaction could include formal surveys, absenteeism rates, turnover, list of applicants waiting to transfer to the unit or informal feedback.

Response Turnover has not occurred for almost a year, staff is highly satisfied and for the first time this year in mid­ September the organization will host the first NDNQI survey. The unit staff is excited to be able to

participate in this national survey and look forward to seeing how they compare to other hospitals in the nation. No other nursing surveys have been administered to the staff either informal or formal. In 2012, the AHRQ was administered. The survey results showed a unit that is highly cohesive and engaged.

Staff meetings provide a venue for staff to express any concerns or suggestions. There are many applicants that apply to work on the unit. At present within the last 3 months over 20 applications have been received for the ICU alone. Several Medical-Surgical nurses have expressed interest in transferring to ICU however only two new positions were created one which was offered to an ICU working nights who wanted days and the other two were night positions. The ICU is proud to uphold its current reputation. The staff and director work closely as maintain the reputation they have worked towards

creating. No results avail to report on Category 5 specific to staff. The NDNQI survey results will be avail in October 2014.



Category 3: Effective Communication, Knowledge Management, Learning and Development

Skilled communication is an important component of a healthy work environment and supports true collaboration to provide quality patient-centered care. Continued growth and development through education and training in the ever-changing field of healthcare can improve outcomes and satisfaction.

The criteria questions in this category are aimed at soliciting information about how your unit ensures effective communication among all staff that provide care; staff competency among those who provide care; and manages and encourages knowledge sharing. For each question reviewers will evaluate the comprehensiveness of your approach; application and integration across staff and key stakeholders; and evidence of continued evaluation, shared learning and process improvement.

Criteria Questions: Effective Communication
1 Describe how all staff and interdisciplinary stakeholders become skilled in effective communication and collaboration.

Notes: Examples of ensuring effective communication may include formal training or coaching.

Response ICU is unique because all the staff celebrates their ability to maintain open lines of communication with the nursing director, medical director, residents, and other hospital departments and among their peers.

All staff is empowered to speak up especially when it comes to patient safety and quality care. Working with residents provides a unique experience for all nursing in the organization. The nursing director encourages and ensures that aiiiCU staff is empowered to speak to physicians and medical residents and work collaboratively with all disciplines.

Interdisciplinary rounds are conducted three times per week with representatives from various disciplines. During said rounds everyone is provided with an opportunity to speak without limitation to topic. Topics range from education, to patient treatment to patient safety. An excellent example involves having negative pressure rooms. The hospital is old, the unit used to use portable devices that would blow air out through the window to maintain negative pressure when indicated. Being that the hospital is in an old building the ICU rooms are tight for space. The portable machines took up most of the space in one of the corners. The staff brought this up during interdisciplinary rounds when presenting a case. This was excellent because the nursing director medical director and infectious disease nurse met afterwards to come up with a plan to see if a different system existed that would not occupy same amount of space. Today the unit has witnessed the fruit of effectively communicating patient, family and staff needs. Negative pressure machines are installed on the roof. No floor space is occupied provided the needed space for patient and family to enjoy.


2 Describe how all staff and key stakeholders effectively communicate and collaborate for optimal patient care.

Notes: Examples of stakeholder communication processes may include interdisciplinary care teams, plans of care or daily goal sheets.

Response Interdisciplinary rounds are conducted three times a week and consist of the following disciplines: Medical Director, ICU nursing director, staff nurses, Case management, pharmacy, nutrition services,

infection control, residents, respiratory, laboratory, consulting physician and a nurse practitioner. During these rounds all patient cases in the ICU are discussed and full collaboration among the team takes place for each patient to meet and maintain optimal patient care. Daily nurse huddles are also conducted among the staff in the ICU. This occurs during both shifts. Every staff member is present during the huddle. Huddles are conducted to plan the day and set daily goals for patients and staff. The unit director stresses the importance of daily goals for all. Daily goals assist in keeping goals aligned to provide patient holistic care. Patient’s culture, wishes and family presence is discussed. Next shift staffing is also discussed and as a team the ICU nurses always attempt to match nurse to patient if the

nurse has cared for patient before or if family request specific nurse. This is an important part of creating

daily assignments and meeting patient needs.


3 Describe how your unit ensures effective processes and systems for patient transfer to and from your unit.  What formal and/or informal methods and measures are used to determine the satisfaction of these interactions?

Notes: Examples of effective processes for inter-unit communications may include tools or expectations to address safe patient hand-off and medication reconciliation.

Response All patient transfers to and from the ICU start with establishing that patients meet criteria for ICU. Once established nurse to nurse report is given. Report must be with two nurses on phone able to ask

questions and communicate. No report is provided on paper or given to the unit secretary only nurse to nurse report is accepted. Resident may collaborate however does not replace the hand-off from nurse to nurse. Transfers out from the ICU is a collaborative efforts discussed and planned during rounds then

solidified between nurse and case manager if the patient is being discharged out of the facility. Director to director collaboration is often witnessed as directors in the organization work closely together.


4 How does the unit identify and resolve care-related ethical issues?  Other issues that create moral distress for staff?  How is learning from these issues shared?

Notes: Examples of identifying and managing issues that create moral distress may include monitoring the clinical climate, critical stress debriefings or grief counseling.

Response                       Care related ethical issues are addressed first among staff and director. If an issue arises and cannot be resolved among staff and director then the ethics committee is called upon to help. Because most of the patient demographics match those of the staff RN’s there have been no ethical issues that have forged forward in the recent years. When a staff member is uneasy about a decision a family member has been reference a patient then the case is discussed during rounds and the staff is provided opportunity to express feelings. The issue is also presented by the staff member at the staff meeting where everyone is provided opportunity to discuss. If any research needs to be shared the staff is asked to conduct the

research as part of their learning process. A board has been used before to share unit issues and what was learned by the individual so that all staff shares the learning experience.



5 Describe how the unit addresses and eliminates abusive or disrespectful behavior. Include the role of unit leaders, staff and other key stakeholders in your response.

Notes: Examples to address abusive or disrespectful behavior may include zero tolerance policies or joint nurse/physician elevation and resolution processes.

Response The hospital serves inmates and these are the patients that usually become abusive or disrespectful. The adult population served is an older generation and have demonstrated to be a very respectful

generation of individuals. No issues have ever come up with abusive or disrespectful behaviors from the adults that are served other than the occasional prisoner. When an inmate becomes an ICU patient the staff provide a comfortable environment for both patient and correction officers. The unit has only experienced one or two episodes of disrespect form this patient population. The corrections officers are integral in helping the unit to remain a safe environment for all. These patients are usually easy to calm and together with the correction officer’s presence and setting clear goals for the patients the nurses are able to bring about change of behavior. The staff has learned that if they come up with a within limits plan of care that accommodate patient wishes and medical care the patients calm down and refrain

from being disrespectful.


Criteria Questions: Knowledge Management, Learning and Development
1 Describe how all staff members (including new staff, float pool nurses, contract staff and temporarily assigned staff) are oriented and competent to provide safe care to patients to whom they are assigned. Include how feedback from orientees is incorporated into the orientation process and how orientation plans are tailored to meet individual needs.

Notes: Examples of orientation processes may include formal orientation or mentor programs.

Response Larkin Community Hospital does not use a staffing agency or temporary staff. The ICU is staffed by ICU and ER nurses only. A nurse cannot work in ICU if he/she has not been trained to do so. Initial training starts with the education department. AIIICU nurses go over Telemetry course and a full ABG course. Then the nurses are paired with a mentor. The mentor is an experienced ICU nurse. Orientation period ranges based on the individual’s needs. No nurse is released to care for full team on their own until their mentor clears them to do so and has covered all their competencies. Larkin practices a continuous learning environment. During Interdisciplinary rounds the nurse educator takes notes from lesson provided by medical director. She then conducts research on a specific disease process covered during rounds. The educator sends the education shout outs to all the ICU and ER staff along with the research used to support the material presented. Yearly education fairs help gauge the need for further education along with the ability to complete the education needs assessment biennially. This assessment is automatically sent to the nursing education department which then creates either online courses or in house courses for all the staff to complete
2 Describe the unit’s learning and development structure, including how learning needs are identified and validated by individual staff members and unit leaders; how learning and development needs translate into action; and how new knowledge and skills are reinforced on the job. Discuss how this structure supports skill competency and professional growth and development.

Notes: Examples to identify learning and development needs may include quality indicators, patient satisfaction results or regulatory requirements. Examples of tools to translate learning needs into action may include department education or individual development plans. Examples of continued professional growth and development may include specialty certification, continuing professional education or continuing academic education.

Response                   Nursing director assesses staff learning needs as a continuous improvement process. Nursing director is active on unit and spends time with staff, working side by side, listening and observing. Along with this method the nursing director works closely with the risk to gather data from Incident reports. Incident

reports are tracked and specific nursing issues are reviewed and used as opportunities for learning. Many of the staff meeting education topics reflect the findings form an incident report. During each month staff meeting a staff member will have a topic to present to their peers. This is done on a story board with correct and incorrect ways of doing things and specific examples are always provided. This has proved to be extremely effective ways to have staff participate in the learning process. Staff nurses in the ICU enjoy being active participants of the staff meetings.

The hospital promotes and encourages all staff to continue education and to become certified in area of specialty. The organization is committed to provide the resources and materials needed for the staff to study and successfully attain certification. Specialty area certification books and online courses have been purchased for any interested staff to use. The organization also reimburses staffs who successfully obtain certification.

There is also a section in the nurses’ yearly evaluation where one can indicate learning wishes and another area where the nursing director provides feedback to the staff in reference to education needs or continued education assigned to staff. The nurse and director agree on a date by which recommended education should be completed.


3 Describe how the objective evaluation of the results of patient care decisions, including delayed decisions and indecision, is accomplished. How is this information shared for unit-wide learning and continuous improvement?
Response The organization is proud to practice a non-punitive culture.  This culture encourages all nurses to report care issues or concerns. Each event is used as a learning experience for all. When an issue arises the nursing director will usually meet one on one with the nurse and have the nurse present the issue to the peers during the staff meeting. The individual does so via story board or as a case study where all staff

has opportunity to learn and bring up concerns, issues or recommendations on the subject at hand.


The ICU staff holds each other accountable and come together as a group to ensure that they always provide patients with the best care. The senior most staff enjoys educating the younger staff. This enhances  the culture of continuous learning and education that one enjoys in the ICU here at Larkin.




Category 4: Evidence-Based Practice and Processes – 200 Points

The ever-changing healthcare environment demands that patient care practices are based upon the most current and relevant information. To do this requires continual assessment, innovation and improvements.  Ensuring evidence-based practices directly relates to positive patient outcomes and satisfaction.

The criteria questions in this category are aimed at soliciting information about how your unit engages all staff to achieve better patient outcomes, improve processes, and stay current with evidence-based practice and research. For each question, reviewers will evaluate the comprehensiveness of your approach; application and integration across staff and key stakeholders; and evidence of continued evaluation, shared learning and process improvement.

Criteria Questions
1 Describe how the unit ensures that policies, procedures and protocols in the unit are current, relevant and based on nationally recognized evidence, standards and best practices. In your response include the sources of evidence employed.
Response Staff is expected to practice within their scope and by the policies and protocols set by the nursing department. All nursing policies and protocols are set by nursing department in a collaborative effort among all units the policies, procedures and protocols will affect. Every protocol and procedure is based on national evidence-based research and findings. The education department works closely with all nursing directors to provide research needed to create and approve all policies, protocols and procedures.

The hospital staff have access to Library and Its eResources (URN) where they can access, PubMed, Cinahl, EBSCO Host, ProQuest to name a few of the resources. Nursing leadership attend yearly conferences and seminars related to topics in area of specialty. On occasion staff is invited to attend with the director. An example one can provide is that next year two medical surgical nurses will be attending the national orthopedics conference.

As the organization continues to grow there will be more opportunities for the staff to attend conferences. The CNO is working on creating a foundation where in-kind donations can be used to support nursing education for the bedside nurse.


2 Describe how a culture of inquiry is fostered within the unit. In your answer include:

a.      How unit staff stays current with the latest advances to support clinical practice.

b.      How new knowledge is translated from evidence-based research into bedside/unit practice.

c.       How new knowledge is shared with others.

Notes: Examples of processes to support a culture of inquiry may include unit research and nursing accountability for research as exemplified by data collection, primary investigator or performance improvement activities.

Response staff. Staff has access to web-based resources as needed. Education department plays an active role in the continuous learning environment the staff enjoy at Larkin. During interdisciplinary rounds the

nursing practitioner provides education based on the latest research. Education department sends out weekly education shout outs for all hospital staff to learn about a specific disease or diagnosis as they present within the patient population. New knowledge is shared via several venues. To mention a few: staff can complete online courses, read out or listen to education blurbs during staff meetings or unit huddles, yearly education fair, during interdisciplinary rounds or when staff chooses to become certified in area of specialty. The organization provides all the materials needed for staff to prepare for certification exam in their area of specialty. Research council has recently been initiated and there is a new energy that this council has created among staff. The members are energetic and very active in the research process. There is excitement and much conversation on finding something to accomplish so that the group can publish their work. This group has also established relationship with the medical researcher who has become active in conducting research with the nurses. There is currently one ICU nurse who is a member of the research council

3 Describe how the unit ensures safe medication practices and the reporting mechanisms to evaluate compliance.  (Report results for errors and medication reconciliation in Category 5.)
Response Medication reconciliation is one of the methods practiced to ensure continuous patient safe care is maintained throughout patients stay and upon patients discharge to the community. Bar scanning is

another method used to ensure medication administration safety. All medications are scanned prior to being administered. The nurse scans the medication administration record, the medication and the patient prior to administering any medication. there is a group that has recently been created in working on educating medical residents to correctly and efficiently complete a medical reconciliation form upon patient’s arrival to the emergency room. This is a process that once firmly established will help staff nurses attain compliance. The nurses used to complete the form and have to wait for hours before the resident would sign off the order for medications based on the medication reconciliation. Having the residents begin the process reminds them to sign the order and promotes quicker patient transition from emergency room to admitting unit.

Once admitted it is the nurse’s responsibility to update medication reconciliation form. If a patient is transferred between different units in the hospital the nurses on respective units most complete medication reconciliation form. Compliance is being tracked to attain 100% compliance.


4 Describe how the unit ensures consistent pain management of all patients. Include in your response:

a.      What pain management or measurement tools are used?

b.      How does the unit ensure pain scale inter-rater reliability among care givers.

Notes: Examples of ensuring consistent pain management may include policies, procedures or protocols, measurement tools appropriate to your unit patient population, or training to ensure inter-rater reliability for pain management tools.

Response The Wong Baker Faces Scale and the Mankoski Numerical Scale are the tools adopted at the hospital to

assess patient’s pain.Pain assessment and reassessment policy guide staff practice on pain assessment and effective management of the patient’s pain. At a minimum, all patients will be assessed for pain upon admission and every shift thereafter. Patient’s receiving medication for pain management are assessed upon administration of the pain medication.

Training and education of pain management ensure that Inter-rater reliability among care givers is maintained. Many times staff will consult with each other in the ICU when a patient’s pain is not relieved with the prescribed regimen. Residents will also be consulted to ensure that all patients receive the proper pain management when pain is not relieved by prescribed regime. Alternative measures are also initiated to promote pain relief. Examples practiced in the ICU include: closing blinds to allow enough light as per patient request, the glass doors are closed to diminish sound to patient’s room, for patient’s that require bed baths, the RN’s will employ a soft body rub with appropriate hospital lotions as per patient comfort level

5 Describe how evidence-based design features and effects of the physical environment promote healing and improve patient outcomes and satisfaction.

Notes: Examples of evidence-based design features and effects may include single-occupancy rooms, use of natural light, encouraging day/night rhythm and visitation or hospitality programs.

Response The ICU has five private single-occupancy  rooms. All ofthese rooms have double windows with lots of natural light coming through providing a bright environment. The organization is moving towards adopting patient and family care model therefore becoming less strict on visiting hours. Family members are encouraged to stay with the ICU patients regardless if the patient is in a single-occupancy room or not. The organization has patient guest relations personal which provide hospitality services.  Hallways are large

and clear of all clutter as equipment is not kept in the hallways. The patient’s family members have a resting area and a quiet room where they can meet with physicians to discuss patient’s case

6 Describe how the unit incorporates perspectives of patients and their families into patient care decisions.

Notes: Examples of incorporating patient and family perspectives into care decisions may include formal or informal patient/family satisfaction programs, communication mechanisms, a defined decision-making process or patient/family education.

Response The organization uses HCHAPs results to gauge patient and family satisfaction of services received. At the current time the leadership is in process of making final decisions between Press Ganey and Jackson

group to formally collect data on patient satisfaction. Follow-up phone calls are made to local Assisted Living Facilities where many of the patients reside. These calls are conducted frequently however as an informal process.

There is no formal system or established questionnaire that guides the caller. Staff and leadership conduct round on patients and families and their perception of care received is gathered during these rounds. Larkin Community Hospital maintains a patient relations coordinator who addresses any patient or family concerns. If any issues arise they are addressed at the moment so that no one patient leaves without knowing that their concerns were addressed. Patient and family members are provided with an anonymous complaint line in the event that they choose this method of communication.


7 Describe how the unit provides palliative and end-of-life care to patients and their families. In your response include the mechanisms available to support staff in this process.
Response Larkin hospital has a policy that every nurse in the organization adheres to. ICU nurses understand that providing end of life care is done so in an interdisciplinary and safe approach. Palliative care rendered inpatient for terminally ill patients is coordinated with physician, pain management, case management, RN, patient and family, and legal representative. Once the team is established the case manager  requests for hospice evaluation. Larkin’s palliative care program includes admitting patients to hospice care. The patient’s room becomes a hospice bed. Hospice staff becomes resource to the hospital RN for any questions or concerns about the hospice care. Care is taken to ensure that patient’s surrounding are comfortable and pleasant, providing patients and family every opportunity for privacy and home-like atmosphere. Pain and symptom management are the primary goals with every effort being directed at

achieving the comfort level for the patient. Bereavement support for family and hospital staff is provided by both hospital and hospice services as needed


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