Shared Decision Making at St. Elizabeth's

Council for Nursing Excellence Charter
Nursing Peer Review Council Charter
Unit Practice Council Charter
Evidence Based Practice Council


Shared Governance

Council for Nursing Excellence Charter

The Council for Nursing Excellence (CNFE) is a peer based group of colleagues with the following responsibilities:
  1. Provide leadership in the application of professional standards
  2. Lead in performance improvement
  3. Align with regulatory compliance
  4. Contribute to colleague and patient satisfaction
  5. Enhance organizational improvement
  6. Re-invigorate nursing process efficiency and problem solving
  7. Collaborate with interdepartmental relations
  8. Nursing concerns determined by a UPC will be brought forth to the CNFE
The activities of the CNFE may involve other hospital departments that directly or directly influence the delivery of patient care.
  1. The CNFE will utilize the individual department Unit Practice Councils for collaborative interdepartmental activities.
  2. The CNFE/UPC will reflect on the “CNFE Visual Guide” in regards to communication and decision making processes.
CNFE representation will be comprised of members of nursing reflective of clinical units within HSHS St. Elizabeth’s Hospital.
  1. The following units have representation within the CNFE: Rehabilitation, Maternal-Child Services, Care Coordination, Surgical Home/Outpatient Surgery, Operating Room, Post Anesthesia Care Unit (PACU), Critical Care Unit, Endoscopy, Interventional Pain Management, Medical-Surgical, Emergency Department, Telemetry A & B, Patient Placement, Cardiac Cath Lab, Infusion Services, Nurse Navigators.
  2. The CNFE representative will serves as the chair for the UPC.
  • CNFE chairs are responsible for communication dissemination to the UPC.
  • The CNFE chair in conjunction with the UPC must establish a mode of shared communication within the unit as a whole.
  1. A member of the UPC may attend as an alternate to the CNFE chair when unavailable.
  • The CNFE chair is responsible for communicating a known absence and name of an alternant.
  • It is the professional responsibility of the CNFE chair to review meeting minutes and required deliverables even for meetings not attended.
  1. CNFE representatives will serve on the council for a two year term.
  • Terms may be extended at the discretion of the unit manager.
  • CNFE members must demonstrate active participation within the UPC.
  • UPC participation may be reviewed in the CNFE application process.
  1. Unit Directors/Managers of each department are expected to support the UPC by ensuring the representative is available to attend scheduled meeting.
  2. Membership requirements:
  • Possess a positive image of nursing
  • Possess good communication skills
  • Willing to represent staff members
  • Willing to arrend at least 75% of the meetings a year
  • Willing to review reading materials sent prior to the meeting
  • Willing to work towards council goals outside of the scheduled meeting time.
    • Approximately 4 hours a month may be allocated to unit projects
  • Demonstrate respect for other council members
  • Perform timely follow-up when I miss a meeting
  • Can be removed for failure to notify the Council Chair of my inability to attend a meeting
  • Can be removed for missing more than two meetings (subject to review of the circumstances)
  • Not on probationary status
  1.  A resource from the CNFE will be present for UPC meetings to serve in an advisory role.
  • The resource member will be responsible for facilitating communication needs with ancillary services as needed.
CNFE Leadership Responsibilities
  • CNFE members must attend monthly scheduled meetings at the discretion of the council.
  • CNFE leader will prepare meeting agendas in preparation for UPC attendants.
  • Meeting agendas are recommended to be shared tentatively one week prior to the meeting.
  • Meeting minutes are to be shared with all members of the UPC and maintained within unit binders.

The visual above reflects the discipline of Nursing. Bedside nurses guide practice and care beliefs for patients and families at HSHS St. Elizabeth's Hospital. Knowing exceptional care is built of components of quality and research, resources are allocated to provide assistance as needed. Nursing also acknowledges many subdivisions must collaborate for overall success. To aid with efficiency, resources work in conjunction with the pillars to provide the support needed for nursing productivity.


Council for Nursing Excellence Model of Care

  • The cross symbolizes our religious background and foundation the sisters set forth
  • The distal concepts of the cross impact our “mind body and spirit
  • Patients and family sit at the middle of all we do and most impacted by key forces
  • The outer circle reflects  nursing as a constant cycle of knowledge change
  • The Brent-Vines model:
    • Acknowledges phases a nurse moves through as experience is gained
    • Proposes even “Distinguished” colleagues may become a “Aspirants” as practice changes
    • All phases of expertise impact patient experience

Nursing Peer Review Council Charter

By establishing a council for improving nursing performance on an individual and aggregate level, HSHS St. Elizabeth’s Hospital will accomplish the following goals:

1.    Improve patient outcomes
2.    Enhance nursing performance
3.    Increase efficiency of the process for nursing staff
4.    Identify process barriers impacting patient care
5.    Maintaining educational goals (in nursing)
6.    Improve use of support resources

The nursing peer review council will be responsible for evaluating and improving nursing performance in the areas of clinical quality, patient safety, nursing responsiveness, and documentation issues.
Individual nursing care review:
  • Initial review of cases of sufficient complexity of management or seriousness of outcome requiring nursing peer review based on cases referred from:
    • Quality management
    • Generic nursing screens
    • Department or specialty-specific measures
    • Risk management
    • Nursing or medical staff
    • Case management staff for quality issues
    • Nursing leadership
    • Unit-based quality initiatives
    • Nursing committees
  • Obtain reviews and recommendations from nursing clinical experts when required
  • Communicate with the nurse involved in the case to obtain input prior to making determinations when opportunities for improvement may exist
  • Make determinations regarding opportunities for individual or system improvements based on individual case review
Use of rate and rule indicators:
  • Regular review of indicators and of patterns, trends, and outlier status for rate indicators relevant to nursing performance within the scope of the committee to identify individual or system opportunities for improvement and determine whether additional analysis or focus studies are needed
  • Make final determinations regarding opportunities for individual or system improvements based on the results of rate or rule indicators
Improvement opportunities:
  • Addressing improvement opportunities will be the role of the appropriate Nursing Committee, Quality Department, and/or Nursing Leadership
  • The role of the nursing peer review council is to ensure that, when opportunities for improvement are identified, the appropriate individuals are notified of the issues and a reasonable improvement plan is developed
  • This will be accomplished by:
    • Communicating individual improvement opportunities to nursing leadership, who develop an improvement plan if necessary
    • Communicating system improvement opportunities to the appropriate Nursing Committees, Quality Department, and/or Nursing Leadership
    • Tracking responses and improvement plans
    • Reviewing the improvement plan
Improvement opportunities:
  • Annual (minimal) review of the indicators, screening tools, and referral systems for effectiveness in collaboration with the nursing staff and recommend changes to nursing leadership

The following area is considered outside the committee’s scope:  Individual nursing performance issues regarding nursing behavior will be the responsibility of nursing leadership.
  • RNs will be volunteers and can be recommended/nominated
  • RNs will be in good standing
  • RNs who possess sound clinical skills and judgement
  • RNs who are professional and able to be objective
  • RNs from all departments with various levels of experience (Novice to Expert).
The council will meet monthly for 60-90 minutes (agenda dependent).  The Council member(s) who performed the review is expected to be at the meeting to present the review.  Confidentiality, professionalism and respect for our peers are expected by all members and guests of the council.
The council will report monthly to unit based leaders as needed.  Nursing Leadership will have NPRC reporting as a standing agenda item.  Additional information may be reported to Quality on non-peer review activities (system improvements) and to Nursing Administration on peer review activities and actions.  Physician activities will be referred to the Medical Staff Peer Review chairperson.
  • We are proud to have councils of shared governance at HSHS St. Elizabeth’s allowing us to lead with a 360 degree lens.
  • Our councils ensure that we are initiating evidence based practice initiatives that center our mission and vision

Unit Practice Council Charter

Purpose: The Unit Practice Council empowers clinical staff to implement and maintain standards of practice and patient care consistent with evidence-based practice and requirements of regulatory agencies. The purpose of the council is to:
  • Review and revise policies ,procedures, and standards of care
  • Incorporate evidence-based practice findings into clinical practice
  • Consult interdepartmental issues that impact patient care
  • Participate in the adoption of new clinical products and equipment
  • Provide input for the revision and approval of nursing documentation standards
  • Support peer review and quality improvement
  • Provide a forum for exchange of ideas, news and find solutions to workplace challenges
  • Recognize achievements in nursing practice
  • Membership: bedside nursing
  • Membership Responsibility: Members will be responsible for attending meetings and reporting activities and disseminating minutes/information to their respective units.

Evidence Based Practice Council

  • Made up of nurses from all departments of the organization, the Evidence Based Practice Council reviews practice and process changes proposed by the Unit Practice Councils and the Council for Nursing Excellence. The council members review nursing journals and literature for best practice and provide information and data regarding best practices back to the UPC’s and CFNE. Members can also research information for policy review and development as well as conduct independent research with a goal of publishing.
Each department has an infection prevention champion.
  • Purpose: To provide our patients with committed, additional scrutiny decreasing their likelihood of developing a hospital acquired infection.
  • Goal: The inpatient units will have a nurse infection prevention champion on all shifts. The infection prevention champion will: attend the monthly infection prevention committee meeting and share any educational updates. He or she will perform monthly hand hygiene audits and submit results to the infection prevention manager. The infection prevention champion will present unit data on hospital acquired infections, hand hygiene compliance and isolation compliance at monthly staff meetings.
  • Training includes with our infection prevention nurse.
Each department has a wound care champion
  • Purpose: To provide our patients with the appropriate education, support and healing opportunities and to provide staff with additional resources for optimal wound care.
  • Goal: The inpatient units will have a nurse wound champion available on all shifts. The wound champion will: be the unit resource for wound care concerns, assist with troubleshooting ostomy issues and assist with wound vacuum application. He or she will complete monthly wound prevalence data and audits, and share this information, along with education updates at monthly staff meetings. Wound champions will insure unit competencies in following skin integrity policies and protocols by implementing proper bed usage to decrease the incidence of pressure ulcers.
Wound care training
  1. Skin and Wound Care
  2. Ostomy Care
  3. Wound Vac Class
  4. Advanced/Chronic Wound Care in the Wound Clinic
  5. Wound Care with WOCN and WCC in Effingham
After training, the wound champions will receive recourse numbers to reach out to vendors with any questions or issues.
Each department has pain champions.
  • Purpose: To ensure our patients have appropriate education, support and interventions to manage their pain.
  • Goal: The impatient units will have nurse pain champions available on all shifts. They will assist providing nurses will a resource to implement an effective pain management plan for each patient.
Each department has fall prevention champions.
  • Purpose: To ensure our patients are safe from falls during their hospital stay by providing education and support to staff to ensure appropriate precautions are in place.
  • Goal: The inpatient units will have a nurse fall prevention champion available on all shifts. These champions will act as a resource to staff to implement effective strategies to keep our patients safe from falls.
Each department has education champions.
  • Purpose: To provide staff with educational opportunities that elevates their practice and allows them to provide the highest quality of care for our patients.
  • Goal: The inpatient units will have a nurse education champion on all shifts to provide information that allows staff to function at their highest level. These champions speak to new policies and procedures and help new colleagues acclimate to the unit.

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