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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 12 

Leadership That Transforms, Engaging
Nurses in Innovative Solutions

The Magnet® model recognizes that while yesterday’s leaders focused on stabilization and growth, today’s healthcare environment calls for transformational leadership. Transformational leaders exhibit courage and sensitivity as they draw from their clinical knowledge and expertise as well as their ability to cast vision and influence others.1

Nurses at Children’s Hospital demonstrate transformational leadership through a variety structures and processes that improve the effectiveness and efficiency of the services we provide. Nursing’s involvement in strategic planning and nursing governance provide examples of transformational leadership at Children’s Hospital.

Strategic Planning
Annually, the Chief Nursing Officer (CNO) and Nursing Executive Directors, in collaboration with executive and administrative leaders, Medical Staff and the Board of Trustees, identify operating initiatives that will support Children’s long-range goals and short-term strategies.

Priorities are established based on the following established criteria:

  • Relationship to Mission, Vision, Strategic Plan, Critical Success Factors
  • High-risk, high-volume, or problem-prone diagnoses and treatments
  • Relationship to regulatory and accrediting requirements
  • Impact on customer satisfaction (patient, family, physician and staff)
  • Impact on patient outcome
  • Measurability of outcome(s)
  • Impact on efficiency or operating costs
  • Relationship to staffing effectiveness
  • Relationship to community needs and changes
  • Relationship to changes in the environment of care
  • Sustainability of benefit

The initiatives for fiscal year 2012 were revised based on a refreshed vision and mission statement and are centered on six goals related to financial performance:

  1. clinical excellence,
  2. provision of secondary and tertiary pediatric and adolescent care,
  3. community partnerships across the continuum of care,
  4. philanthropy and
  5. promoting a professional practice environment where the best and brightest work.

In alignment with the organizational Strategic Plan, further delineation of initiatives are identified and expanded, as needed, to create the Patient Care/Nursing Strategic Plan. The Executive Nursing Council (ENC) provides leadership and oversight for the governance of nursing services and is responsible for the strategic direction of nursing services. Unit-based goals are established based on the Patient Care/Nursing Strategic Plan to meet the unique needs of the patient population served. These goals may be outcome- or process improvement-based.

Nursing Governance
Nursing Governance Councils/Committees support performance improvement goals based on their scope of services. Examples of achievements that have improved the effectiveness and efficiency of patient care have included:

  • Nursing Informatics Council – Development of the inpatient electronic documentation system as part of Advanced Clinical Systems (ACS) and support in the implementation of ACS and ongoing system enhancement development.
  • Practice Council – Establishment of an every-four-hour standard for vital signs and assessments in adjunct to the Pediatric Early Warning System Score (PEWSS).
  • Nursing Research Council – Establishment of a quarterly Journal Club meeting to review and analyze journal articles and discuss their application.
  • Nurse Practitioner Council – Served as coaches for the implementation of Computerized Provider Order Entry (CPOE).
  • Professional Development Council – Coordinated, developed and provided training for new equipment and practice changes including ACS.
  • Lactation Committee – Obtained First 5 Fresno and Madera Counties mini-grants to purchase insulated bags for mothers to transport breastmilk.
  • Family-Centered Care Steering Committee – Enhanced Visitor Policy to further support the principles of family-centered care.

Unit Governance
Nurses initiate changes to improve patient care, nursing practice and/or the work environment. The process begins with ensuring feedback from nurses is incorporated into the operations of the organization. Children’s Hospital promotes and encourages feedback at all levels and between levels. Participative leadership is a cornerstone of employee satisfaction, engagement and retention. Children’s Hospital supports unit-based governance committees and task forces. Governance committees are comprised of staff nurses, nurse leaders, Clinical Nurse Specialists, Educators, and interdisciplinary team members. Committees, subcommittees and task forces are utilized to manage the work of the department in several broad areas and are assigned specific accountabilities. A sampling of these accountabilities is as follows:

  • budget planning and preparation
  • strategic goal development and monitoring
  • leadership development and continuing education
  • clinical policy and procedure review
  • evidence-based research relating to clinical practice
  • environment of care/safety
  • patient/family satisfaction
  • performance improvement initiatives (quality)
  • unit-based governance oversight
  • coordination and utilization of unit resources and systems
  • compliance to standards set by professional, government and regulatory agencies

Units may combine or separate the functions within their governance structure. Examples of the accomplishments over the past several years are presented below.

Pediatric Intensive Care Unit (PICU) Participatory Governance Structure

PICU Leadership Council

  • Each Charge Registered Nurse (RN) created self-development plans and
    reviewed them monthly with his or her Supervisor.
  • Planning was completed for an eight-bed expansion

PICU Professional Development Council

  • Applied and received the Beacon Award from American Association of
    Critical Care Nurses (AACN); submitting application for recertification.
  • Developed resource of Clinical Advancement Program and educational
    opportunities for RNs pursuing advancement.

PICU Practice Council

  • Established a process for the assignment of all staff to a policy
    review team in order to facilitate timely review of

PICU policies and procedures

  • Made recommendations for changes in practice to
    improve outcomes based on data analysis.

PICU Recruitment and Retention Council

  • Developed and implemented “Ask Me” button as a customer service measure.

Neonatal Intensive Care Unit (NICU) Participatory Governance Structure

Quality Infant Care Council

  • Provided oversight and assisted councils with implementing ideas.

NICU Recruitment, Retention, Recognition Council (RRR)

  • Acknowledged staff through Employee-of-the-Month award and recognition program.
  • Created NICU staff Facebook page.

NICU Partners in Care Council (PIC)

  • Promoted parent involvement in decision-making.
  • Enhanced visitation policy to promote improved family
    satisfaction and involvement in care.
  • NICU Palliative Care Subcommittee
  • Provided education to staff on palliative care.
  • NICU Photo Subcommittee
  • Provided photo memories to families of holidays.

Quality, Teaching, Professional, Investment Council (QTPI)

  • Established Children’s Hospital as a host site for neonatal RN
    certification exam and provided review sessions for staff.
  • Produced and implemented the Baby Steps manual,
    a resource guide for NICU staff.

NICU Practice Makes Perfect Council (PMP)

  • Began breast milk/donor milk program.
  • Enhanced staff participation in policy reviews.

NICU Developmental Care Subcommittee

  • Increased frequency of mother pumping and skin-to-skin mother-infant
    supporting breastfeeding and reduced length of stay.
  • Partnered with families to promote developmental care with all aspects of their infants.

Emergency Department (ED) Participatory Governance Structure

Emergency Department (ED) Leadership Operations Council

  • Enhanced patient safety through initiation of new patient
    throughput process, dramatically reducing door-to-provider times.
  • Established collaborative process for planning and mentoring
    between Charge Nurses and Relief Charge Nurses.

ED Charge Nurse/Relief Charge Nurse Team

  • Established a Forum for exemplars of RN IV clinical ladder advancement.
  • Held monthly brainstorming sessions regarding workflow, assignments,
    and staffing efficiencies and consistency.

ED/Trauma Department Practice, Quality, and Safety Council

  • Developed Patient Safety Rounds to recognize departmental safety
    risks on a monthly basis providing solutions.
  • Introduced “Hot Topics” including pharmacy protocols, and
    high-risk, low-frequency interventions.

ED/Trauma Professional Development Council

  • Developed bimonthly educational bulletin with topics such as
    Diabetes, Psychological Emergencies, Choking Game, Poisonings, etc.
  • Promoted advanced degrees, professional certifications, and involvement in professional
    organizations through increased awareness, study groups and peer support.

ED/Trauma Recruitment, Retention and Recognition Council (RRR)

  • Recognized the department’s outstanding accomplishments in patient throughput.
  • For four consecutive years, the Spirit of the Holiday family sponsorship has been
    a project that allows staff to become involved in helping a family in need.

Ambulatory Care Participatory Governance Structure

Ambulatory Professional Practice Council (APPC)

  • Enhanced proficiency with literature searching to support the
    development and review of evidence-based policies and procedures.
  • Development of an RN competency assessment questionnaire.

The Ambulatory Patient Care Committee (APCC)

  • Implementation of customized hand hygiene surveys for patients to note if they observed their providers and clinical staff “gel in and gel out” during their visit to enhance patient/family collaboration in care.
  • Development of an Environment of Care audit tool for the ambulatory practices.

Acute Care (Craycroft) Participatory Governance Structure

Craycroft Clinical Practice Council

  • Utilizing the evidence-based Chemotherapy-Biotherapy core course developed by the Association for Pediatric Hematology Oncology Nurses (APHON), the Practice Council implemented the use of this national course/certification to standardize to ensure consistent practice.

Craycroft Recruitment, Retention and Recognition Committee

  • Promoted staff recognition, such as new staff, newly obtained
    national certifications, and staff project leaders.
  • Promoted a positive work environment and collaborated with
    unit leadership to address opportunities to enhance employee satisfaction.

Craycroft Safety Committee

  • Monitored unit compliance with National Patient Safety Goals through unit-based auditing focused on patient identifiers, read back, critical results, medication labeling, family involvement, and medication reconciliation.

Acute Care (Explorer) Participatory Governance Structure

Explorer Professional Development Committee

  • Identifying subject matter experts to assist in verifying staff competency for annual
    needs such as metered-dose inhaler (MDI) administration, peripherally inserted
    central catheter (PICC) line care, and Broviac repair.
  • Reviewed the unit orientation checklist and pathway to align with
    new competency program and organizational standards.

Explorer Clinical Practice Committee

  • Reorganized the policy review teams to include new staff and create clinical advancement program opportunities. The group promoted national certification and the advancement of nurses in the organization’s clinical advancement program.

Explorer Patient and Family Education and Satisfaction Committee

  • Initiated medical record review for complex patients to ensure applicable teaching documentation is present.

Explorer Recruitment, Retention, Recognition Committee

  • Created a picture board of staff for families to view.
  • Organized events for staff.

Acute Care – Rehabilitation, Apollo and Discovery (RAD)

RAD Professional Development Council

  • Developed a process for staff to identify appropriate projects for clinical ladder.
  • Developed and implemented qualifications and accountabilities for Relief Charge Nurses, Preceptors and Coordinators of care.

RAD Practice Council

  • Enhanced the process for the identification and management of patient home medications to ensure these medications are sent home with patient at discharge through communication.

Unit Practice Teams – Two teams were established in 2011 to address specific opportunities for improvement with two patient populations.

  • Apollo Respiratory Care Committee – Initiated review of national Cystic Fibrosis guidelines to develop patient care policies.
  • Discovery: Home Total Parental Nutrition (TPN) Team – Developed a teaching plan for families in managing TPN at home.

Perioperative Services Governance Structure

Practice Council

  • RNs continued to mentor each other on the policy revision and review process. Council members were dedicated to helping RNs achieve the job performance requirements.

Hospital Orientation Program (HOP) Council

  • Developed patient orientation binder in English and Spanish for Imaging Department.
  • Created Hospital Orientation Program (HOP) Flyer for use by schedulers working with families in the clinics to encourage families to attend the HOP sessions.

Professional Development Council

  • Provided recommendations on how to best inform staff of policy changes and new policies.
  • Developed a nurse’s resource list of staff willing to be called upon to assist with special expertise.

Infection Control Council

  • Tracking changes in endoscopy and monitoring improvements.

Retention and Recognition Council

  • Developed Employee-of-the-Quarter program
  • Provided and coordinated individual and professional society recognition events

Patient Safety Council

  • Improved sizing and quality of patient slippers
  • Improved mops for the Operating Room (OR)

Patient and Family Satisfaction Council

  • Developed and launched process for families to provide feedback via a form submitted in boxes located in Day Surgery.
  • Created a patient “thank you” postcard signed by the patient’s caregivers and sent to their home.
  • Recruited a parent partner to advise our team and provide feedback.

Periop Operations Council

  • Created an environment where all Council Chairs report accomplishments and share ideas.
  • Provided updates from each Council to staff via newsletters and the Director’s Quarterly Update.

Nurses throughout the organization serve as transformational leaders through engagement in their professional practice, addressing challenges, developing innovative solutions and supporting a successful integration of these solutions into clinical practice.



1 2012 American Nurses Credentialing Center, Magnet Recognition Program®
Retrieved from



In This Issue

Magnetically Charged

Leadership That Transforms

Empowered Nursing

Exemplary Care

Innovations In Nursing

The Magnet Culture

Meditech Scanning and Archiving