Shared Governance Council Reports

In 2009, 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 these councils will occur in early 2010, as the Nurse Executive Council and the Nurse Practice Council members join together to improve nursing practice at CVMC

Area Accomplishments
Nurse Administrator Council

Adina Andreu

  • 2008 NDNQI Nurse Satisfaction Survey: Continue to monitor action plans and improvements implemented
  • Developed education for nursing leadership on ethical leadership
  • Worked on development of a “package” to communicate current efforts related to needs of the mature nurse
  • Working on process to increase patient satisfaction with pain management,  especially in the Medical unit & ED
  • Submission of Magnet document to ANCC and preparation of  nursing staff for Magnet site visit
  • Developed plans for areas of improvement based on Nurse Administrators 360 Peer Review 
Nurse Manager Council

Jackie Miller/Amanda Gaddy

  • Policy Development: Clinical Flexibility ; Safety Attendant
  • Policy Revision: STAR Preceptor Program
  • Revised registry guidelines for RN, LPN and NA
  • Revised Charge Nurse Job Description
  • Refined Application/Hiring Process
  • Revised Nurse Manager Peer Review

Clinical Development Coordinators Council

Beth Rudisill

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

  • Restructure Nursing Orientation
  • Continue CNIP program
  • Create nursing education repository
Patient Care Coordinators Council

Sandra Beckler

  • Revised restraint education and restraint audit tool
  • Established process and related to  improve timely death reporting for organ procurement
  • Established process for reviewing and ensuring advance directive summary completion
  • Participated on Rounding TAG for  development of nurse rounding process on each nursing unit
  • PCC representatives participated in development of education for CHF and Stroke patients
  • PCC representation on Stroke Team
  • Updated annual competency for diabetic patient education to includeU-500 insulin
  • Provided consult to Pandemic Planning committee on family care
  • Implemented colored education sheets for patient charts to assist in alerting nursing of patient education needs  prior to discharge
  • Implemented plan to improve process for interdisciplinary team notes
Nurse Practice Council

Nadin Knippschild

  • Data collection for use of intradermal Lidocaine for IV cannulation; plan to analyze data to determine further action
  • Continue to peer review incidents of medication errors related to wrong patient identification
  • In progress: Completion of Nursing Bylaws
  • In progress: Establishment of Nursing Peer Review process
  • 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
Oncology/Infusion Center

Kim Weaver

  • Combined Oncology and Infusion Center SG Councils: March 2009
  • Organized activities to increase staff morale including:
    • Read Who Moved My Cheese? as a unit project, having weekly email discussions, cheese promotional, and a “Cheese” Party as a grand finale
    • Instituted Motivational Sayings posted on the units  weekly
    • Shared Governance Council Recruitment with 4 new members
  • Organized “Chemo Brain” Literature Group Review with discussion involving all nursing staff
  • Instituted PI Project to decrease CLABSI during the 4th quarter
  • H1N1 education for staff
  • 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
  • Requested and received approval for the addition of alcohol based hand sanitizer dispensers to each  Day Surgery cubicle and additional dispensers in the department in an effort to increase hand washing compliance by staff

Mary Killian

  • Research project, ” The Impact of Music on the PACU Patient’s Perception of Discomfort” accepted for publication in the Journal of PeriAnesthesia Nursing
  • Research poster presentation at state level at North Carolina Association of PeriAnesthesia Nurses (NCAPAN) annual conference
  • Research poster presentation at national level at the American Society of PeriAnesthesia Nurses (ASPAN) annual conference
  • Developed PACU family visitation guidelines with plans to develop brochure to give to patient families
  • In progress: Development of distribution of workload tactics to promote a more cohesive workforce
  • Collaborated with Birthing Center to modify post c-section orders to include option for physician to order first dose of post-op IM pain medications to be administered in PACU

Leah Long

  • Developed “scripting” to ensure consistency for admission process
  • Developed “Welcome to Medical” brochure
  • Provided Thanksgiving dinners for 2 needy families
  • Provided Angel Tree gifts for 8 families that included 13 children
Surgical / Ortho-Neuro / Secure Care / Inpatient Rehab

Casey Mueller

  • Combined Inpatient Rehab and Secure Care SG councils with existing Ortho-Neuro/Surgical council: March?2009
  • Developed education for all staff on  telephone etiquette
  • Created employee recognition cards; cards are given by other staff members as a “thank you” for a job well done or for “going above and beyond the call of duty”
  • Drafted and implemented a routine order set for the post-op care and monitoring of patient’s receiving Total Joint “cocktail” injections in the OR
  • In progress: Creation of survey for nursing staff to complete to identify needs related to diabetes education
  • In progress: Continuing efforts to decrease medication errors 
Critical Care Center

Natalie Johnson

  • Revised visitation policy for CCU
  • Created family information pamphlets on CCU and Telemetry  Units
  • Created contact information booklets for quick reference to phone numbers needed by Critical Care Center
  • Created quick reference policy booklet
  • Revised scheduling guidelines for CCC staff related to floating, low census, etc. 
  • Established TAG to develop structure and ongoing education/competence needs for centralized monitoring technicians
  • Designed communication boards for CCC patient rooms
Emergency Department

Anita Herman

  • ED Research Project: Rectal temperature measurements versus temporal artery thermometer measurements in pediatric patients presenting through triage.
  • Donated over $800 to charities  with money raised by volunteering on several occasions to work the concession stands for the Hickory Crawdad’s games.
  • Held a Shared Governance membership drive and raised membership by 50%!
  • Recycling of plastic bottles by members of the committee.
  • Recycling of any opened bottles of peroxide, sterile water, saline, etc. for donation to the Humane Society for use at the animal shelter.
  • Canned food drive in November, with items collected donated to the Corner Table.
  • Raised money to purchase a Memorial Stone in memory of an ED nurse who succumbed to cancer.
  • In Progress: ED Policy and Procedure revisions.
  • In progress: Education for nursing staff regarding MARs for psychiatric hold patients.  Obtained in-patient green medical record charts to be utilized for the psychiatric hold patients.

Karen Ashley

  • Completed development of a patient library
  • Developed patient education on Hepatitis C protection 
  • In progess: 1) working with pharmacy to improve scheduled medication administration times in an effort to improve patient satisfaction;  2) based on process reviewed in a recent publication,  revising the psych observation sheet to trend patient behaviors and incorporate nurse rounding; 3) expanding group learning experiences for patients and attempting to have patient families more involved in group sessions
Birthing Center

Teresa Elmore

  • Led evidence based initiative resulting in practice change and creation of an Antepartum order set
  • Provided staff & visitor hand hygiene education: included obtaining culture samples from various surfaces within the unit; teaching and reinforcing proper hand washing techniques through use of the “Glitterbug” station
  • Provided Pregnancy Loss Awareness education day for hospital employees
  • Implemented 100 % participation by full-time RN staff in committee service
  • Created “Community Service” subcommittee to foster professional growth and development for unit staff
  • Submitted research project for approval and subsequently formed 4th formal nursing research team
  • Implemented a “Discharge” divider tab to bring continuity to staff practice, thereby assisting physicians’ discharge process and minimizing delay during discharge
  • Identified needs and developed action plans to improve nursing documentation, resulting in planned  Chart Audits for all staff to begin January 2010
  • Volunteered at The Corner Table on three separate occasions

Sharon Hicks

  • Development of  an intervention screen for RN double checks for pediatric patient IV fluids containing heparin
  • Created multi-aged layette packets that include clothing, hat, and blanket to provide to children in need 
  • Collaborating with SCN to develop floating/cross training guidelines between the units
  • Exploring new print designs for pediatric nursing staff uniforms
  • Developed pediatric focused isolation pamphlets for parents/families

Chris Bowman

  • Promoted Feeding Readiness program to staff for increased compliance
  • Adopted two Christmas Care families
  • Participated in Toys for Tots
  • Continued ongoing recycling program
  • In progress: 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

  • Reorganized SG structure to include  multiple sub-committees to give more staff the opportunity to participate; chair of each sub-committee comprises the new SG . Council
  • Collected and donated blankets to the homeless shelter and items for the Ronald McDonald House and the  Women’s Resource Center
  • In progress: Investigating the interest of staff in participating in monetary donations to support a designated charity organization as an annual project 
Radiology/Diagnostic Services

Shea Lowman

  • Created education packets for TEE, Angio and Tilt Table procedures.
  • Created education sheet for patients having PICC insertion
  • Assisted in RN education on preparing IIb and IIIa inhibitors for coronary angioplasty patients in cath lab