Shared Governance – A Reflection of the Calendar Year 2011

The calendar year 2011 was yet another good year for shared governance at CVMC. This year, we focused on putting the “shared” back in shared governance. Each unit based shared governance council added a member of the unit’s leadership team (director, manager, or coordinator) to function in the role of co-chair. 


This partnership allowed each of the unit councils to bring management and direct care nurses together to work on common goals that are consistent with the direction of the organization. 

Each council established at least one goal to make improvements in three broad categories: clinical indicator, patient satisfaction, and nurse satisfaction. As can be seen by our list of accomplishments, this new structure has served the organization well to produce the outcomes desired and to promote a culture of collaboration and professionalism.

In other news, 2011 marked the launch of our newly formed Nursing Peer Review Council (NPRC). This council involves the evaluation of an individual nurse’s professional performance, the quality of patient care rendered by the nurse, and determinations or makes recommendations regarding specific incidents including the identification of opportunities to improve individual practice. The NPRC uses the Just Culture investigation process followed by the application of the Just Culture algorithm. The council bases their evaluation on generally recognized standards of care. Through this process, nurses receive feedback for personal improvement or confirmation of personal achievement related to the effectiveness of their professional, technical, and interpersonal skills in providing patient care.

One final highlight from 2011 is the newly revised CVMC Professional Nursing Practice Model. Nurse Practice Council members worked diligently to update the model to reflect our professional evolution with a stronger focus on accountability, diversity, and outcomes. The newly revised model is scheduled to be rolled out in early 2012. 

List of Accomplishments for 2011

Area Accomplishments
Nurse Administrator Council

Sherry Hardee/Trish Beckman

Employer of Choice

  • NDNQI nurse satisfaction scoresResults:
  • Coordinated unit level plans for improvement and reporting based on Spring 2010 scores.
  • Prepared for FU survey in 2012
  • Promote professional development for direct Care RNsResults:
  • 2011 Goal for specialty certification: 56%; achieved: 65%
  • Direct Care RN degrees: goal BSN/MSN: 50.5%; achieved: 51%

Financial Vitality:

  • Holiday Incentive Pay considered.
    Result: 2011 Holiday incentives paid to all staff working Christmas Day and part of Christmas Eve.
  • Call pay evaluated for equity.
    Result: Nursing Call pay increased from $2.00 to $3.25 per hour house wide.

Provider of Choice:

  • Coordinated efforts for successful JC survey.
    Results: Achieved Joint Commission recertification in early 2011.
  • Falls risk identified as clinical are of improvement.
    Results: Falls consultant brought in to evaluate our process. Leadership and clinical staff attended trainings and evaluation sessions.
    Falls team restructured.
  • Emphasis placed on developing an organizational culture of safety.
    Results: Began participation in the Just Culture Collaborative with the NC Quality Center and educated management staff on this new model of approaching system improvements.
  • Need for improved surveillance of potential narcotic diversion activity identified.
    Result: Multidisciplinary TAG developed and implemented effective Monthly Narcotic Diversion Report for review by unit directors.

The Art of Nursing:

  • Nurse’s week activities considered
    Results: Luncheon and speakers jointly sponsored by FRMC. Well attended sessions for nursing staff at the Crown Plaza Hotel in downtown Hickory.
  • Performance Expectations on different units found to be individualized and incongruent.
    Results: Nursing leadership worked with HR to standardize all PCC, RC, CDC, and Director PEs.
  • Identified need for improved communication between Nurse Managers and Nurse Administrators.
    Result: Nurse Leadership Council formed and meeting every other week to maintain shared decision making and communication between nursing leadership.

The Science of Nursing:

  • Supported EBP clinic and achieved improved communication between management and staff to encourage attendance.
    Results: 38 attendees 89 course/activity registrations. 5 courses offered for CEs and two mini sessions.
  • Encouraged and facilitated attendance at the annual Research
    Results: 174 attendees 3 research projects highlighted.
  • Evidence Based Literature review revealed the effectiveness of a patient/family initiated rapid response team.  A TAG was formed to study implementation.
    Results: Nursing leadership standardized a new process for Family and/or Patient initiated rapid response.

Patient Perspective/Satisfaction:

  • Nursing leadership has a concentrated focus on patient satisfaction. Data is presented quarterly to the Nursing Leadership Council for review, identification of trends and areas for improvement.
    On the inpatient areas, methods used to increase staff awareness on patient satisfaction include:  
  • On unit level, data is disseminated through monthly dashboard displays, discussions at staff meetings, shift huddles
  • To increase awareness and accountability of front line staff, leadership implemented the Dynamic Priority Board on individual nursing units
  • Nursing units obtaining scores greater than 90 in patient satisfaction with nursing care have a banner displayed
  • Nursing leadership recognizes direct care staff receiving positive comments from patients with personalized notes and complimentary meal cards.
  • For the inpatient areas, nursing leadership has focused on 5 indicators for patient satisfaction.
    1. “Instructions care at home” 
    2.  “Friendliness of nurses”
    3. “Promptness/response to calls” 
    4. “Pain well- controlled”
    5.  “Nurses listen carefully”
    Goal for each indicator listed, greater than 50 % of the units outperformed like size hospitals greater than 50 % of time.
    Results: goal achieved.
Nurse Manager Council

Tracy Bombenger/Amy Barnes

  • Revision of Registry Guidelines for
    RNs, NAII (Nurse Aide II, Critical Care Technicians, ED Technician II, Psychiatry Technician or ANY Unit Secretary Combination Position), NAI (Nurse Aide I, ED Technician I, Unit Secretary)
  • evaluated and developed revisions of NAI and NAII Performance Expectations (to go in effect July 1, 2012)

Clinical Development Coordinators Council

Ann Moore

  • Increase certification by 1% among staff nurses at CVMC. This was completed in December 2011
  • Plan, implement and evaluate STAR preceptors during 2011-2012. Completed for this STAR year
  • Plan, implement and evaluate Basic Infection Control Education for Catawba County High Schools Health Occupation Classes in Fall of 2011. This was actually completed and we provided classes in Spring 2012 as well as Fall 2011. Things went so well in the Fall they asked us back in the Spring.
Patient Care Coordinators Council

David Solomon

  • 99% Compliance with EMTALA regulations
  • Decrease from 2010 to 2011 in restraint use rate and number of restraint days
  • 90% or > compliance achieved with critical lab results notification within 1 hour
  • 99% compliance with organ donation referrals  in timely manner
  • Interdisciplinary team at the bedside implemented on Medical and CCU.

Nurse Practice Council

Micah Wilson

  • Established Nursing Peer Review Council
  • Initiated Just Culture Collaborative
  • Reviewed, Revised, and Rolled-out updated CVMC Professional Nursing Practice Model.
  • Implemented restructuring of unit based shared governance councils to include manager/director as co-chair to align unit council initiatives with organization-wide goals.
  • Adopted consensus decisions making model.
  • Revised Unit charters for uniformity.
    Established each unit council would define a goal in the following three categories: 1) Clinical Indicator 2) Patient Satisfaction 3) Nurse Satisfaction.
Oncology/Infusion Center

Kim Sloop 

  • Reviewed Neutropenic Precautions policies from other hospitals, also reviewed literature in Life Links Journal Club regarding neutroopenia.
  • Started early phase of a research project with assistance from Dr. Tart.  Performed a literature review of “Queeze Ease” aromatheraphy. Project on hold due to info and time. 
  • Worked on Improving Clinical Indicators: Falls, Patient Indicator: Noise Level, and Nursing: Communication.
  • Shared Governance council voted on the name “Life Links Journal Club” which reviews articles related to oncology issues.
  • Created a Strength/ Weakness Evaluation form that consisted of each staff member naming one strength and weakness they have and then describing ways to improve each of them. This effort was made to help improve our pt satisfaction scores
  • Provided gifts to a family for Christmas and donated food and toiletry items for Christmas to Sipe”s Orchard Home.
Day Surgery

Kelly Ward

  • Began “Rounding” which has increased patient satisfaction scores.
  • Provided staff with an exact lunch time schedule which has increased nurse satisfaction within our department.

Jennifer Hawk Nance/Kathey Hutchins

  • Initiated routine B&O suppositories administered in the OR for urology patients for bladder spasms before they are reacted and transported to PACU.
  • Obtaining CEU’s for PACU journal club.
  • Identified staff resources in the afternoon for patient transport i.e. charge nurses carrying spectralink when out of the department and utilizing Day Surgery nurses in the evening hours for assistance.
  • Initiated rotation schedule to cover evening for call-ins and vacation requests.
  • Initiated call report from CRNAs to floor nurses to expedite quick transfer of in-house endoscopy patients.
  • Created patient discharge home folder for patients being home after hours from PACU so that discharge education is consistent and complete.

Leah Long/Miriam Smith

  • Initiated walking rounds for all nursing reports with 100% compliance.
  • Worked on improving staff morale with themed staff meetings.
  • Provided gifts for Sipes Orchard Children’s home for Christmas.
  • Clinical Indicator-Improved our CAUTI rates with zero CAUTI’s this year.
Surgical / Ortho-Neuro / Secure Care / Inpatient Rehab

Cindy Rose/Debbie Martin

  • Initiated and continue steps to implement research project: “No Interruption Zone” (NIZ):  a project  to decrease interruption of nurses  during the mediciation administration process.
Critical Care Center

Angela Herman

  • Discussed the use of CHG wipes for baths (we decided to not use them)
  • Started the use of Beta Clasp to hold IV lines
  • Re-educated and updated the Visitation policies
  • Assisted with staff meetings
  • Started a Fun Fund to buy prices for staff
  • Organized a Christmas dinner for the 5th floor
Emergency Department

Aubry Parker

  • Established unit goals:?
  • Clinical Indicator – Sepsis Prevention/Early Detection, re-educated staff via huddles and established Sepsis Bundle; presentation from BSN new grad Haley Suttles on sepsis project
  • Patient Satisfaction Indicator – Focused on communication/rounding, updating on plan of care, rounding hourly, focusing on patient survey data and sending out emails with positive/negative patient callback comments
  • Nurse Satisfaction –  emphasized that nurses not completely satisfied with schedule of working every other weekend; sent out survey; made this known to management, laid out possibilities of working every 3rd weekend using complete staffing list;currently management to start every third weekend shifts in March of 2012
  • Decreased wrong patient Pyxis pulls by 58%, from 87% to 26% wrong pulls from 2010 to 2011
  • Decreased department falls by 38% using more staff education and new “humpty dumpty” childrens’ fall scale



Karen Ashley/LaDonna Earwood

  • Establish unit goals:
  • Clinical Indicators, Patient Satisfaction Indicators, Work Environment Indicators, Professional Development Indicators
  • Define the role of the admission/ discharge nurse including a check list.
  • Place fall education in patient handbooks.
  • Discussed fall prevention articles and discussed findings.
  • Provided each SG member a binder that included the psychiatric charter goals and responsibilities.
  • Research project (13 nurses on committee)
    Phases completed Pico question, Searching the Literature, Appraising the Literature
    Went to a Research Symposium in Winston Salam 11/4.
  • Advised and organized a workflow sheet for both shifts.
  • Organized a date that Trudy Huey (wound care nurse) could come during staff meeting and educate nurses on wound documentation.
  • Initiated and assigned gatekeeper roles for the following topics- Falls, Certification, Patient Satisfaction, and Work Environment.
  • Unit wide clothing /hygiene products drive for patient clothing closet.
  • Education board on belongings/safety issues in staff break room.
  • Organize/assemble treat bags for our patients on Christmas day. (unit wide service project)
Birthing Center

Julia Peters

  • 100%  of staff completed monthly form for PQNCQ for intended vaginal birth.
  • Skin to skin is initiated with all stable newborns, staff has been educated and bulletin board prepared
  • Staff on Birthing Center have obtained  50% certification rate in areas of inpatient obstetrics, maternal newborn nursing or external fetal monitoring.
  • Staff on Birthing Center are now currently 50 %  ACLS certified
  • Resource manager is managing the schedule and is improving nurse satisfaction for staff schedule
  • Staff are asked to attend job interviews for current positions

Cynthia Huffman

  • unit council restructure and SG recruitment

Chris Bowman

  • Continue to monitor feeding readiness compliance, provided education for new hires.
  • ELBW (Extremely Low Birth Weight) implemented.
  • Developmental Care, continued to monitor.
  • Team Work- with upcoming Road Trip- offering education to surrounding hospitals-STABLE class.
  • March of Dimes
  • Kangaroo Care-continue to monitor.
  • Becoming the Voice of the Nursery- addressing concerns from the nurses in the unit.
Operating Room

Sue Stark


  • Survey sent to staff concerning orientation for feedback concerning his/her orientation and ideas for improvement.
  • Ditto (Daily interaction tool to orientation) tool developed by group to be used daily by new orientees.
  • Reviewed Pathways at staff meetings.
  • Orienting staff to all specialties that work in the OR.  All nurses should be able to work in all areas.  Decided that Endo nurses that are floated to the OR should be competent in 3 additional specialties. 

Clinical Indicator:

  • Skin issues related to positioning.  Purchased new positioning devices to use during lumbar surgery.  Additional pads were also ordered for hip positioned.
  • Worked with Business manager and Custom Pack Company to determine when holes are in outer packaging…is pack still sterile.   Staff no longer uses packs if any holes are found in outer packaging.
  • Reviewed nail polish policy.  Reviewed AORN standards.  Group decided NO nail polish in Surgical Suite.
  • Count Policy-reviewed AORN standards and several articles.  Policy updated to reflect group decisions.

Patient Satisfaction:

  • OR to call DS rounding nurse X 3528 to inform them of delays so can be communicated to next patient. 
  • OR nurses also talking to families instead of leaving message at DS lobby desk when time allows.
  • Worked with Anesthesia and PACU to improve patient privacy when blocks are being placed in PACU.  Making sure curtains are being pulled.
Radiology/Diagnostic Services

Shea Lowman/Melissa Goad

  • Development of new process for needle localization procedures: Use of emela cream 

Research and Evidence Based Practice

Lisa Wike

  • increased EBP Journal Club  offerings, Topics included sepsis, medication safety, suicide prevention in acute care settings , hospital acquired infection prevention and fall prevention.
  • council members providing mentorship for journal club facilitators
  • council members providing mentorship for staff for the completion of CAT ( Critically Appraised Topics) 
  • offered Saturday Research and EBP Saturday Am Clinic in January, offering 4 courses and an EBP journal club
  • sponsored EBP Week with the following activities:: mock research study on different cheese tasting, poster presentations by Lenoir Rhyne nursing students and CVMC staff and EBP Journal Club

PEP Council

Miriam Jolly

  • Revised PEP policy and application for 2011-2012 PEP cycle
  • Held 2 PEP exemplar writing workshops
  • Provided PEP “Tip of the Month” e-mails to staff
  • Developed and provided PEP Portfolio checklist for staff use
  • Changed PEP portfolio review process so that PEP Council will review all portfolios and make award determination

Advanced Practice Nurse Council

Shelly Benfield

  • Increase Professional Enrichment Program Participation by Advanced Practice Nurses (6 participant 2011-2012)
  • “Backpacks for Homeless” Drive – collected backpacks and filled them with items such as canned foods, can opener, blanket, clothing, toiletries, a tarp, and so forth.  
  • Backpacks ditributed for the Catawba County Point in Time count.

Resource Coordinator Council

  • Unit staffing: evaluated and revised current holiday schedules to ensure adequate coverage
  • Nurse Satisfaction: implemented ‘token of appreciation’ for staff floated to other units. lifesavers to thank floated staff between units