Shared Governance – Council Reports 2010

 In 2010, the Shared Governance structure at Catawba Valley Medical Center continued to evolve. The Nurse Executive Council worked in conjunction with the Nurse Practice Council to formulate a structure that will have oversight of nursing practice with a focus on safety and quality of patient care. The re-structuring of the Nurse Practice Council and the Nurse Executive Council occured in early 2010, as both councils’ members joined to form the new Nurse Practice Council to improve nursing practice at CVMC.


The new Nurse Practice Council (NPC) now has 24 members representing all unit based councils as well as the chairs of the Nurse Administrator Council, Nurse Manager Council, Clinical Development Coordinator Council, Patient Care Coordinator Council, Research and Evidence Based Practice Council as well as the Patient Care Standards, Policy and Practice Council. 

The focus for 2010 continued to evolve around improving the existing Shared Governance structure at CVMC. Beginning January 1st, 2011, leadership vision and authority will be added to the Nurse Practice Council as well as the Unit Based Shared Governance Councils (UBC) by means of including leadership as mentors and coaches for the direct care nurses leading the councils.

In this Partnership’, the NPC will continue to be chaired by a direct care nurse supported by Eddie Beard (Chief Nursing Officer), who will co-chair the NPC. At the unit based level this will  translate similarly with the chair being a direct care nurse and the manager serving as the co-chair of each unit based council.  Utilizing expertise from all levels of care, from direct care nurse to managers/director, will allow us to excell as ‘partners in care’ as well as collaborate professionally. Additionally, goal setting parameters and an accountability structure are implemented.

In a healthcare climate that ‘rewards’ or ‘punishes’ on the basis of outcomes, this structural change will facilitate necessary care decisions to be prioritized, established, and carried out at the point of service — at the bedside by Registered Nurses.


Area Accomplishments
Nurse Administrator Council

Sherry Hardee/Trish Beckman

Employer of Choice:

1. NDNQI nurse satisfaction scores


a) Planned and implemented repeat NDNQI survey on 4/10

b) Coordinated unit level plans for improvement and reporting based on Spring 2010 scores.

2. Promote professional development for direct care RNs


a) Specialty certification goal 43% of eligible RNs

    – Instituted new requirement for charge RN certification 

    – Facilitated CDC group and their unit based efforts to encourage certification

    – Result: 59% of all RNs and 55% of direct care RNs

b) Direct care RN degrees: goal BSN/MSN to 50%

    – Used CDC facilitation to support this goal

    – Result: at the end of 2010 achieved a 42.7% bachelors and a 4.7% MSN

3. Collaborated with NPC to redesign our unit based SG Structure

a) Created a partnership model with nurse managers and involved staff in setting unit based goals around clinical outcomes, patient satisfaction outcomes and nurse satisfaction outcomes.

Financial Vitality:

1) Fitness for Duty TAG formed and identified opportunities for deceasing time-line for employees to be cleared for duty especially following new hire evaluations.

Result: The process has been condensed into an eight day process and placed under the coordination of Human Resources. Regulatory compliance has been confirmed and strengthened through the group’s work.

2) Crosstraining/floating review.

Result: Practice at CVMC brought into JC compliance by documenting orientation and training to other units.

3) Reviewed salary staff and extra shift pay. Result: Process developed and cost effective changes made.

4) Evaluated pay for education practices. Result: Clarification provided and criteria developed for paying employees for voluntary education on site.


Provider of Choice:

1) Coordinated on-site training for CVMC leadership on Press Ganey patient satisfaction software on 2/15.  

Result: Developed process to track/monitor/set goals for patient satisfaction with nursing care.

2) Hand-off TAG coordinated by Adina to improve patient handoff and through-put for patients being admitted from the ED to a clinical unit.  

Result: Electronic + verbal handoff process developed.

3) Coordinated efforts for Joint Commission readiness including JC consultant Mock Survey 8/23-8/25 and follow-up on identified deficiencies.  

Result: achieved Joint Commission recertification in early 2011.

4) Pain Assessment Initiative – worked to identify appropriate leaders (Mike Helton and Amy Barnes) to coordinate house-wide improvement efforts.

Result: Pain documentation was brought into compliance with JC guidelines.

5) Magnet Redesignation effort: Reformatted our data presentation to stay in compliance with future document requirements.  

Result: Clinical and patient satisfaction indicator results reported at NPC with ownership assigned.

6) Magnet Gap Analysis 6/10. Looked at all points that scored a three or less in last document.  

Result: Developed Magnet Executive Team and Magnet Captain Group.

7) Peer review policy and committee established and approved through MEC and Performance Awareness Committee. Provided house-wide education through healthstream. Integrated the Just Culture framework. 

Result: Peer Review Council developed and implemented.

The Art of Nursing:

1) Coordinated a Strategic Planning Day and Accountability/Responsibility discussion. Participation included nursing leadership and Shared Governance Leadership 9/29/10.

Result: 80 attended

Science of Nursing:

1) Supported EBP clinic and crafted message to support Saturday class attendance.  

Result: 64 participants in the 2/20/10 research clinic.

Nurse Manager Council

Amanda Gaddy/Tracy Bombenger

  • Policy Revision: STAR Preceptor Program
  • Staff preparation for Joint Commission visit.
  • Assistance with individual departmental planning for BMV (Bedside Medication Verification) process.
  • Assistance with individual departmental planning for VDI (Virtual Desktop Interf.) rollout.

Clinical Development Coordinators Council

Ann Moore

Nursing Leadership Development

  • Preceptor Development
  • Charge Nurse/Shift Leader Development

Professional Development

  • Increase nursing certification rates
  • Establish a plan to increase advanced nursing degrees

Staff Nurse Development

  • Educational needs assessment survey
Patient Care Coordinators Council

Sandra Beckler/Shannon Hevner

  • Monitoring of restraint audit tools – continued monitoring of restraint use in ED and CCU.
  • Monitorting of Critical Value reporting – results improving.
  • Monitoring of EMTALA.
  • Implemented plan to improve process for interdisciplinary team notes.
  • Goal setting for 2011.

Nurse Practice Council

Nadin Knippschild

  • Establishment and implementation of the Nursing Peer Review
  • Revision and enhancement of Shared Governance structure
  • Introduction of the consensus seeking model for decision making
  • Completed project scoping for budget submission of implementation of Just Culture; made recommendation to Leadership to join Just Culture Collaborative through the NC Center for Hospital Quality and Patient Safety
  • In progress: Completion of Nursing Bylaws
Oncology/Infusion Center

Kim Weaver/Judy Parker

  • Monitoring and peer-accountability process for staff performing active rounding (focusing on 3 P’s)
  • Established focus areas based on NDNQI results with assistance of Lisa Wike
    • Falls Prevention strategies evaluated
    • Shared Governance Council Recruitment with 4 new members
  • In progess: Revision of Unit Council  Bylaws
  • In progress: completing literature review to support currently established Neutropenic Precautions
Day Surgery

Kelly Ward

  • Completed creation of “virtual tour” of Surgical Suite for patients; “tour” is available on internet
  • Revision of charters
  • Recruitment of members and possible new chair-elect
  • Goal setting for 2011

Mary Killian/Jennifer Hawk Nance

  • Collaboration with nursery shared governance council in relation revision of mother/baby visitation in the PACU.
  • Research & EBP – developed with assistance of Research & EBP council PACU journal club.
  • Research poster presentation at state level at North Carolina Association of PeriAnesthesia Nurses (NCAPAN) annual conference (effects of music therapy on pain) 
  • Research poster presentation at national level at the American Society of PeriAnesthesia Nurses (ASPAN) annual conference
  • Implementation of charge nurse carrying own spectralink when leaving PACU.
  • In progress: Initiative to increase compliance with Foley Catheter routine orders.
  • In progress: monitoring of orders being ‘noted off’ when coming from the ED to the PACU via OR.

Leah Long

  • Research, development, and implementation of ‘Bedside Report” – RN to RN report performed at the bedside.
  • Exploring presentation of ‘Bedside Report’ at a medical/srugical conference.
  • Community projects.
Surgical / Ortho-Neuro / Secure Care / Inpatient Rehab

Casey Mueller/Debbie Martin

  • Successful joining of councils.
  • Evaluation of medication errors.
  • Collaboration with Research & EBP council regarding EBP projetc “Quiet Zone” – no interruption zone to decrease medication errors.
  • Council received education about searching and appraising the literture.
  • Exploring the possibility of joning a national study about environmental influences and medication errors.
Critical Care Center

Natalie Johnson

  • Researched, developed, and implemented ‘Purple Heart Bundle’ – plan of care to support patients and their families during end of life or withdrawal of care:
  • bundle includes providing nourishment cart for families, providing music therapy, chaplain support, access to a family bereavement room for privacy and discussions with physicians.
  • ‘Purple heart sign’ is placed on the patient’s door to facilitate staff awareness and foster supportive and respectful environment.
  • Upon demise, the family receives a sympathy card signed by all unit staff expressing condolences as well as a packet of flower seeds to plant in memory of their loved one.
Emergency Department

Anita Herman/Aubry Parker

  • Sent 1,000 letters to NC State Senator, Representatives, and Govenor B. Perdue asking for support of a bill, if passed, would make it a felony to assault an ED staff while providing care.
  • Donated non-perishable food items to the corner table.
  • Participated in the Hospice house drive for tissues and bath products.
  • Began researching ED nurse schedule satisfaction. Explored self-scheduling and possible other alternatives to reduce the amount of required weekend shifts.
  • Designed a new ED T-shirt.
  • Donated books and DVD’s for the CVMC Outpatient Infusion Center.
  • In progress: various huddle ‘hints & tips’ to improve patient and family satisfaction in the ED.

Karen Ashley/LaDonna Earwood

  • Reorganization of a patient library cart.
  • Book drive for patient library.
  • Developed staff education bulleting boards displayed in the staff lounge on topics such as staff rounding, communication, fall prevention, prevention of patient agitation and injury on the psychiatric units.
  • ‘Christmas Treats’ for patients hospitalized during the holiday season.
  • Goal setting based on NDNQI results for the psychiatry unit.
  • ‘Go Green’ education for staff
  • Creation of the new role of Admission Nurse.
  • Collaboration in evaluating the new ‘psychiatric observation sheet’.
Birthing Center

Teresa Elmore

  • Opportunities organized by staff withthe goal of teambuilding and community service included:
  • Complete renovation of a room at the Women’s Shelter
  • Serving lunch at the Corner Table in Newton.
  • Easter Egg hunt for staff.
  • ‘Fall Festival’ with food, farm animals, and hay ride.
  • Test prostoring at St. Stephens High School.
  • Implementation of Birthing Center “Employee of the Quarter” program.
  • Collaboration with pharmacy regarding pain control resulting in ‘around the clock’ motrin administration program.
  • Development of new sign to better communicate with the dietary department once an epidural is initiated.
  • Development and implementation of new gestational diabetes education for staff.
  • Development of pamphlet on postpartum depression to be distributed with admission packet.
  • Resaearch Project ongoing (pain algorithm: data collection form created, IRB approval obtained, staff education developed).

Cynthia Huffman

  • Development of routine admission orders for diagnoses that result in frequent admissions (in collaboration with physicians.
  • Provided Thanksgiving dinner and a grocery gift to a family in need.
  • Addition to pediatric standing orders: LMX cream to reduce pain and anxiety related to needle stciks.

Chris Bowman

  • Continued monitoring of Feeding Readiness program
  • Participated in Toys for Tots
  • Continued ongoing recycling program
  • Implementing of a protocol for ‘extremenly low birth weight’ (ELBW) to include a power point presentation and a symbol to be used in the nursery to create awareness of ELBW.
  • Implementation of Developmental Care which includes the following elements:

           1)Kangaroo Care
           2)Noise Reduction
           3)Low Lighting
           4)Infant Positioning
           5)Re-warming with Mom

Operating Room

Rosanna Beal/Sue Stark

  • Brainstormed ways to improve patient satisfaction related to case delays.
  • Developing of a tool to facilitate communication with patients regarding delays.
  • Evaluation of Shared Governance structure in the OR.
Radiology/Diagnostic Services

Shea Lowman

  • Best practice initiative: initiation of CO2 monitoring for patients in Diagnotis Angiography Services (DAS).
  • Initiation of computerized nursing documentaion for Diagnostic Angiography Services.
  • Milestone: 100% specialty certification in DAS and Radiology.

Research and Evidence Based Practice

Lisa Wike

  • Expanded Council Membership
  • Sponsored 3rd Annual Research Theater with presentations from three CVMC nursing point-of-care research teams.
  • Sponsored 2nd Annual EBP Week with a poster session comprised of 1 senior nursing student practice improvement projects and 4 EBP project posters by CVMC nurses along with activities throughout the week including a facial tissue ‘mock research’ study.
  • Provided nursing student outreach for four area nursing schools by offering educational sessions of “Let’s Get Cooking with EBP” and “Appraising the Literature”.
  • Initiated a quarterly EBP Journal Club to facilitate discussion of topics applicable or all nursing specialty areas.
  • Established the Critically Appraised Topics (CATs) process, which is the means by which a library of best evidence summaries on relevant practice issues will be developed by staff nurses (criteria for PEP; CAT summary form and instructions).
  • Sponsored first ‘Research and EBP Saturday Morning Clinic’ to provide an opportunity for busy practitioners to takw as many as three courses in one half day session.
  • Contributed to the monthly newsletter, Progress Notes, by interviewing staff about what research & EBP means to their practice, by presenting staff professional accomplishments, and by writing lead articles.
  • Participated in the North Carolina Organization of Nurse Leaders (NCONL) 2010 Research Symposium at Wake Med, Raleigh North Carolina.

PEP Council

Miriam Jolly

  • PEP application rewiew for direct care RN’s and nurses in leadership.
  • Review and change to the PEP policy for the PEP application year 2010-2011.
  • Departmental support to staff leadership in the PEP aplication process.

Advanced Practice Nurse Council

Shelly Benfield

  • New formation of Council (members: Nurse Midwifes, Nurse Practitioners, Nurse Anesthetists, and Clinical Nurse Specialists).
  • Developed and implemented Peer Review for APN’s.
  • Patient Satisfaction Survey for APN’s.
  • In progress: Community Service initiative and PEP for APN’s