Shared Governance Councils

The vision of the Nursing Advisory Council is to represent the voice for nursing in policy, practice and advocacy in alignment with the nursing strategic plan. Additionally, the Nursing Advisory Council will facilitate communication and collaboration between the unit/departments and across disciplines, and optimize operations while supporting the organization’s goals, mission, vision, and values.

Responsibilities/Functions:

• Serve as the system operational oversight and support nursing and organizational strategic goals
• Review and oversee practice standards, policy and procedures that impact nursing
• Encourage standardization build and workflows
• Oversee functioning and effectiveness of the shared governance process and unit/department management
• Improve efficiency and effectiveness of operations within units, across units and within the organization.
• Promote collaboration and foster innovation through partnerships

The Nursing Quality Council monitors the clinical, quality of care provided by the nursing staff, while assessing and ensuring compliance with established standards of care and practice. The Nursing Quality Council is responsible for Nurse Sensitive Indicators and Patient Satisfaction scores (HCAHPs) and ensuring a Culture of Safety and collaboration with organizational patient care outcomes councils and task forces.

Responsibilities/Functions:

• Endorse and monitor unit-based quality improvement plans. Review quality/safety data to identify trends and develop improvement strategies
• Integrate the nursing quality improvement process with the hospital plan and evaluate trends and patterns of performance that affect more than one department or service.
• Review and evaluate data (NDNQI, unit audit data, benchmarks, etc.) and incorporate the data to develop action plans in collaboration with unit practice committees in the department of nursing to ensure quality patient outcomes.
• Work with the Quality Department to ensure compliance with established state, federal and regulatory standards.
• Collaborate with other disciplines to monitor and evaluate compliance to standards and make recommendations to enhance continuous quality improvement and safety.
• Monitor and analyze data relative to nursing quality and safety practices seeking opportunities for continual improvement. Evaluate outcomes in conjunction with these initiatives.

The Nursing Practice Council implements and maintains standards of clinical nursing practice and patient care consistent with Evidence-Based Practice (EBP). These include the professional practice model, clinical products and equipment, nursing standards of practice, the patient care delivery model, ethical issues, strategies to promote staff retention and staff satisfaction, and nursing policies and procedures.

Responsibilities/Functions:

• Review current practice standards, EBP and evaluate the need for revision
• Conduct review, revision and approval of nursing policies, protocols and guidelines
• Validate, endorse and promote care practice guidelines
• Identify the need to evaluate and/or make recommendations regarding products, equipment and technology
• Serve as communication forum for practice changes and policies approved at individual practice councils
• Communicate changes in practice and policies to involved areas to ensure appropriate implementation within the Unit Practice Council
• Review quality/safety data to identify trends and develop improvement strategies in collaboration with the Nursing Quality Council
• Evaluate the effectiveness of improvement strategies 
• Identify and implement strategies to increase near miss and adverse event reporting

The purpose of the Professional Development and Evidence-Based Practice (EBP) Council is to create, recognize, and encourage a nursing culture that supports both a mindset of inquiry and interest in research to foster lifelong learning and the growth and development throughout the nurse’s professional career. This is a collaborative effort involving oversight by a nursing leadership representative and involvement of direct care nurses, nurse educators and management representatives. This group defines, implements, and evaluates educational opportunities that promote professional growth, ongoing clinical competency, and nurse retention and satisfaction. This group provides a forum for nurses to learn how to conduct research projects and evidence-based practice projects including opportunities to present ideas for projects impacting their practice environment.

Responsibilities/Functions:

• Support and recommend RN retention and engagement activities.
• Support Research activities
• Plan, implement, and evaluate activities that support professional development initiatives (e.g., professional certifications, BSN completion, etc.).
• Plan, implement, and evaluate at minimum 1 Nursing Grand Rounds seminars with CE offering each CY.
• Promote and support RN involvement in professional organizations.
• Plan, implement, and evaluate EBP projects to ensure that Research projects and EBP projects are completed in alignment with Magnet requirements

The Nursing Quality Council monitors the clinical, quality of care provided by the nursing staff, while assessing and ensuring compliance with established standards of care and practice. The Nursing Quality Council is responsible for Nurse Sensitive Indicators and Patient Satisfaction scores (HCAHPs) and ensuring a Culture of Safety and collaboration with organizational patient care outcomes councils and task forces.

Responsibilities/Functions:

• Endorse and monitor unit-based quality improvement plans. Review quality/safety data to identify trends and develop improvement strategies
• Integrate the nursing quality improvement process with the hospital plan and evaluate trends and patterns of performance that affect more than one department or service.
• Review and evaluate data (NDNQI, unit audit data, benchmarks, etc.) and incorporate the data to develop action plans in collaboration with unit practice committees in the department of nursing to ensure quality patient outcomes.
• Work with the Quality Department to ensure compliance with established state, federal and regulatory standards.
• Collaborate with other disciplines to monitor and evaluate compliance to standards and make recommendations to enhance continuous quality improvement and safety.
• Monitor and analyze data relative to nursing quality and safety practices seeking opportunities for continual improvement. Evaluate outcomes in conjunction with these initiatives.

The Unit Practice Council (UPC) provides a mechanism for clinical nurses and multidisciplinary team members to demonstrate leadership in the development of practice decisions, using True North – safest care and best outcomes, exceptional experience, compassionate, committed people, and affordable, efficient care – as the guide.

Responsibilities/Functions:

• Promote excellence in nursing care delivery and support an environment of health and healing within patient-centered care
• Develop processes that meet the expressed and unexpressed wishes of the patients, and promote wellness
• Identify and develop educational and professional growth opportunities for staff, and collaborate with Nursing Education to ensure programs are in place to meet those needs
• Integrate innovative ideas into practice, including EBP, research initiatives and process improvement initiatives
• Design initiatives to recognize and retain unit staff
• Promote and engage interdisciplinary collaboration within an environment of honest and respectful communication
• Engage in continuous quality improvement and innovation for the patient and nursing practice
• Support responsible and efficient use of resources