The professional nursing shared governance structures at Mary Washington
and Stafford Hospitals are the mechanism by which nurses, in collaboration
with our colleagues in the organization, execute the principles of shared
governance and decision making in processes that impact daily clinical
practice and goal setting with MWHC. The professional nursing shared governance
structure is designed to engage nurses at all levels of the organization
in an equitable fashion so that the decisions made reflect the needs of
both patient and staff and provide for quality outcomes.
The professional Nursing Shared Governance Councils Bylaws are established
with MWHC’s culture of collaborative decision making in conjunction
with a healthy work environment, promoting patient centered care and professional
work life satisfaction.
Clinical Practice Council - Mary Washington Hospital
Clinical Practice Council (CPC) is accountable to the Coordinating Council
(CC) for development, implementation and evaluation of nursing practice
guidelines, procedures, documentation and standards.
- Improved process for liquid protein supplement administration documentation
thereby increasing compliance with documentation.
- Completed central line policy review and provided recommendations for revision
- Hypoglycemia protocol.
- Reviewed and made revisions to Ticket to Ride process to ensure ongoing
communication of patient status/needs between departments.
- Created Electronic Chart Check policy.
Nursing Quality Council - Mary Washington Hospital
Purpose/Mission of Council
- To promote the image of nursing and elevate the standard of care through
a continual diligence in performance improvement processes
- Former name – Performance Excellence Council
- Created NQC Dashboard for centralized reporting of Nursing Sensitive Indicator
- Developed Performance Improvement Portfolio to track unit-based projects
- Recognized 12 nurses with Daisy Award
- Developed Daisy Award tracking tool in Smartsheet which improved efficiency
and appropriate nurse recognition
- Supported Magnet Survey
- Implemented Smartsheet technology to improve access and distribution of
NQC Dashboard & Portfolio
- Revised Daisy Award process to facilitate evaluation of Daisy nominees
against award requirements
- Collaborated with wound care team to develop HAPU debrief tool
- Spearheaded initial development of non-nurse Associate recognition program
- Collaborated with C-diff Taskforce to reduce hospital-wide infection
Education and Development Council - Mary Washington Hospital
To develop and facilitate learning activities (such as continuing education)
intended to build on the education and experience of nurses and promote
professional practice through specialty certification and advanced nursing
- Development of new hire RN/CNA orientation and Skills day
- Development of the celebration for certified nurses
- Development of a house wide education needs assessment
- Revision of the NetLearning process regarding who receives CBLs
- Development of house wide regulatory annual skills day
All in one computers placed on all nursing units to provide staff with
ready access to complete ongoing education requirements.
Nurse Leadership Council - Mary Washington Hospital
To create a culture that empowers nursing through innovative and Evidence
Based Nursing Leadership.
The Nurse Manager Orientation was initiated
Peer to Peer mentorship established in conjunction with Human Resources,
Learning & Organizational Development.
Quality Excellence Council - Stafford Hospital Mission
To develop and support performance improvement processes and projects,
through evidence based practice, that promotes positive outcomes through
Nursing Sensitive Quality Indicators (NSQI) and the Quality Tier One goals.
- Successful completion of appreciation calendar
- Revision of regulatory readiness checklist to include infection control
- Initiation of Quiet Time project
- Wound Care debrief in Soarian database
- Mentoring/Retention Program in conjunction with Education Council
Education Council - Stafford Hospital
- To develop and facilitate learning activities intended to build on the
education and experience of nurses and caregivers
- To enhance nursing practice, education, administration, research, or theory
development with the goal of improving the health status of the community
- To contribute to the development, maintenance, and enhancement of competent
nursing practice through evidence based practice and critical thinking.
- Developed port access validation form and identified RNs to serve as validators
- Provided inpatient education on mobility protocol
- Offered Lunch & Learns where contact hours provided
- Created tools to assist staff in accessing policies and procedures from
Clinical Practice Council - Stafford Hospital Mission
To define and develop methods to ensure excellence in clinical practice
through best practice identification, benchmarking and performance improvement
- Instituted Quiet Time
- Improved nursing staff/physical therapy communication to improve patient mobility
- Initiated Acudose Optimization project
Clinical Informatics Council - MWHC
To evaluate, incorporate and apply computer technology and information
systems to facilitate communication and enhance the nursing process.
- Created/revised new assessments to enhance patient care and improve compliance
(C diff, MEWS, Chart Check, Interdisciplinary Rounds, Clinically Aligned
Pain Assessment (CAPA), Advance Directive, Cancer Navigator.
- Increased usability of viewing data in the electronic system – created
display groups and clinical summary views as well as re-organized nursing
orders to increase clarity (display groups for disease specific diagnosis
such as heart failure and stroke, new clinical summaries for respiratory.
Research Council - MWHC
To foster a culture of nursing research and promote application of evidence-based
practice that facilitates optimal outcomes in healthcare. To educate and
mentor nurses and nursing students in their understanding of clinical
research and evidence-based practice. Assist facilitate the integration
of research in the clinical setting, translate evidence based practice
into clinical practice and facilitate conducting nursing research. 2015 Accomplishments
Coordinate a hospital based research project annually:
- “Proper Identification and Documentation of Skin Assessment is Dependent
on Adequate Staffing” study completed and poster presented during
Nurse Week 2015
- Approval by Institutional Review Board – “Barriers to Shared
Translation of evidence based practice into clinical practice with Lunch
- “The Mandate for BSN at the Bedside, What does the RESEARCH tell
us” presented by Dr. Pamela McCullough CPNP – Dean of Nursing,
University of Mary Washington
- “What does research tell us regarding central line care” presented
by Bonnie Smith, Genetech
- ANA Webinar – Ethical Practice – Quality Care
- “How to create an effective poster presentation”
- Literature reviews
- Step by step review of the research process
- Webinar series from the US Department of Health & Human Services, Office
of Human Research Protections