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  • 1.` Department of Clinical Education linical dvancement rogram January 2007 Final

2. UNMHSC Clinical Operations Clinical Advancement Program (CAP) Purpose: 1. To recognize and reward individual excellence. 2. To assist in recruitment and retention of quality nurses. 3. To encourage those with clinical expertise in advancing a programmed practice model of nursing. 4. To improve employee morale and job satisfaction. 5. To provide opportunities for professional growth. 6. To promote collaboration among nurses and multi-disciplinary health care teams. Getting Started in CAP: 1. Entry into CAP requires initiation of a CBO (completion by the anniversary), see section I professional Growth, Items 1 & 2. 2. CAP is subdivided into three categories of criteria: Professional Growth Research and Education Clinical Expertise 3. The CAP book offers specific descriptions of each category. These allow the participant multiple areas from which to choose for demonstration of professional achievements. 4. The Unit Director will verify CAP eligibility and advancement for departmental employees. Policy and Application: 1. The Clinical Advancement Program is voluntary. 2. The program is available to Registered Nurses (RNs) who are employed as 0.5 FTE, or greater, regular status and deliver patient care or are immediately responsible for patient care. The program is available from the date an employee becomes regular staff, if he or she meets all requirements. 3. All RNs entering the CAP program must have a performance appraisal rating that is satisfactory or above on his or her most recent evaluation. If a nurse disagrees with the performance appraisal s/he has received, s/he may appeal through the Human Resources Department. - 1 - 3. 4. CAP Level Criteria: Points Requ ired Level Requirements Compensation Level I 60 Total of 60 points Professional Growth, # 1 & 2. $1.50/hr over base pay Level II 90 Additional 30 Points for a total of 90 points. The 30 additional points may come from any category. $3.00/hr over base pay Level III 120 Additional 30 points for a total of 120 points. The additional 30 points must include one of the following: a national nursing certification a Master's Degree in Nursing an ADN in school for a BSN, a BSN in school for an MSN, (Three-year time limit on each). $5.00/hr over base pay 5. The Unit Director maintains CAP records for their employees. 6. The Unit Director must sign all CAP application forms. 7. Unit Directors will indicate at the bottom of the CAP verification form that the employees received a satisfactory or above performance appraisal rating on the most recent evaluation. If at any time the CAP participants performance appraisal falls below satisfactory, the employee will be removed from CAP via a personnel action, until such time as the performance has improved via documentation in the form of a participants performance appraisal. Verification: 1. The verification form is used to confirm that all activities have been completed or maintained within the last 12 months. Evidence of completion may include verification of necessary documents by the Unit Director. 2. Notification of CAP status will occur via the Unit Director. If all requested documentation for verification was not included, points will not be approved. The employee may resubmit documentation to the Unit Director. 3. Pay increases will become effective at the start of the first pay period following verification of CAP enrollment. CAP status will be in effect for the next 12 months. Maintaining CAP: - 2 - 4. 1. To maintain current CAP status, the employee must complete requirements, accumulate the appropriate number of points, and successfully carry out goal development/achievement (performance appraisals). 2. The Unit Director will note the appropriate CAP level on the employee's performance appraisal cover sheet. Upgrading CAP: 1. An employee may upgrade CAP status at any time. S/he must submit an application to the Unit Director, for only the additional points required. Management Responsibilities: 1. The Unit Director or designee will complete a personnel action to change the status of the employee entering, changing, or leaving CAP status via the appropriate HR system. The personnel action will be effective at the start of the first pay period following verification of CAP enrollment or disenrollment. 2. Employees wanting point allocation for an activity not listed in the CAP booklets must submit a proposal to the Unit Director to be forwarded to the Education Council. If the activity is approved, points will be assigned as deemed appropriate for the level of activity, with the information disseminated to the Unit Directors and the CAP book will be updated. Program Administration Policies: 1. The Education Council has the responsibility for evaluating CAP annually. 2. The Executive Director of Education with input from educators, staff, managers and executive directors is charged with the administration of CAP. 3. The established standards of CAP shall not be part of the collective bargaining agreement. 4. It is the responsibility of the Education Council to establish or modify, as needed, the standards of performance for attaining, progressing and maintaining positions in the various levels of the program. 5. The Education Council shall be consulted for its input concerning the adoption or modifications of standards prior to any changes being implemented. This council shall also have the sole authority, under the direction of the Executive Director of Education, to administer and interpret the standards of this program as well as any disputes that may arise concerning its application. The final responsibility and ultimate approval for standards and modifications rests with the hospital. NOTE: Employees entering the program in no way relinquish their rights to representation, grievance and arbitration as provided in the collective bargaining unit in other matters. - 3 - 5. This page is blank intentionally. - 4 - 6. A. Professional Growth Achievement Minimum Requirements Points Employee demonstrates the ability and willingness to promote his/her own professional practice through personal accountability for the learning and demonstration of essential elements to advance skills and knowledge level. 1. Competency-based Orientation Requirements for New Employees On-line competencies completed CBO/Equivalent Initiated Basic Life Support completed. Demonstrates accountability for receiving Unit/Department communication of Policies, Procedures and/or Guidelines. 1. Cap I Category: 60 points Employee demonstrates the ability and willingness to promote his/her own professional practice through personal accountability for the learning and demonstration of essential elements to advance skills and knowledge level. 2. Maintenance of Annual Competencies On-line competencies completed Annual skills competencies completed -Skills verified by UBE/CNS/Educator consistent with Patient Care Plan Highest level of age-appropriate Life Support based on Patient Care Plan for Unit/ Department completed. (2nd certification is worth additional 15 points). Demonstrates accountability for Unit/Department communication of Policies, Procedures and/or Guidelines 2. Cap I Category: 60 points - 5 - Revised: November 2005 7. Employee demonstrates the ability and willingness to promote his/her own professional practice through personal educational achievements in the field of nursing and participates for the advancement of nursing. NOTE #1: Courses must be applicable to the RNs current position for CAP points. 3. Completes instructor or Provider requirements for: ACLS TNATC ILS ALSO (Obstetrics) CPR (Instructor Only) First Aid (Instructor Only) TNCC PALS Neonatal Resuscitation (NRP) S.T.A..B.L.E. Emergency Nurse Pediatric Course (ENPC) RALeS Provider RALeS Enhanced Provider Fundamentals of Critical Care Support Advanced HAZMAT Life Support Advanced Disaster Life Support Psychiatric Nurse specific from CON: Advanced Physical Assessment Psychopharmacology 3. Instructor (Completed instructor course and taught a minimum number of courses for UNM Hospitals Clinical Operations to maintain instructor status): 20 pts. No maximum. Community Training Center (CTC) will provide CAP verification to instructor. 1st Provider certification applies to 60 points in CAP I. 2nd Provider certification applies to CAPII at 15 points on year of certification. 4. Instructors only: Acts as a skill validator at UNM Hospitals Clinical Operations for above stated courses beyond instructor maintenance requirements on his or her own time. 4. 1 pt. per hour of Instruction. Max 30 pts. per course. - 6 - Revised: November 2005 8. NOTE #2: Tuition reimbursement is available for successfully obtaining a national nursing specialty certification. See UNMHSC Personnel Policy Tuition Reimbursement for the guideline. 5. Successfully completes one of the following single day courses (one time only): Moderate Conscious Sedation Course First Aid provider Rapid Sequence Intubation Course Difficult Airway Management Course Advanced Procedural Sedation Course Mechanical Ventilation Curriculum (3 courses 5 pts each, cannot be combined with RALES EP) Diabetes Management Curriculum (2 courses-5points each) Asthma Management Course Spirituality Course Cardiac Surgery Course Citywide Chemotherapy Course Psychiatric Specialties Course Care of the Post-operative Patient Course Care of the Patient needing Pain Management Course Care of the Geriatric Patient Course Hemodynamics Course Diabetes during Pregnancy Intermediate 12-lead EKG Cardiac Pacing Pediatric Oncology Fundamentals States Of the Heart I or II Triage in the Emergency Department When You Dont Speak Pediatrics Ambulatory Adult and Pediatric Physical Assessment Telephone Triage for Ambulatory Tracer Training and Continuous Readiness for Staff Quality In Ambulatory Care Ambulatory Core Curriculum Other new courses as they are developed: 5 points per 4-hour class. 5. 5 pts. 6. Successfully completes one of the following multi-day courses (one time only): Essentials of Critical Care Orientation Course Critical Care/Sub-acute Care Course Pediatric Critical Care Course Perinatal Nursing Management Course Continuum of Neonatal Care Course Basic Arrhythmia Course Trauma Nurse Qualification Course Neurosciences Qualification Course Psychiatric Emergencies Series 6. 15 pts - 7 - Revised: November 2005 9. 7. Completion of any of the jointly sponsored College of Nursing Institutes not listed above: e.g. End of Life Care. 7. 15 pts 8. Possesses and maintains a national nursing specialty certification. NOTE#3: Effective 2005 and onward, some certification requirements include a BSN. While Clinical Education makes every effort to keep the CAP book updated, the sheer number of certifications makes this difficult. It is advised that the nurse contact the company prior to the application to assess for current requirements and those upcoming in the near future. 8. CAP III category: 30 pts. 9. Possesses and maintains one of the following specialty certifications: Healing Touch practitioner Treatment Guardian Forensic Specialty Specific Therapeutic approaches: EMDR, LMFT, CISM, CADAC, Art Therapy, Experiential Therapy 9. 15 pts. Renewal with demonstration of patient- centered activities such as treatment sessions or cases: 15 per year. 10. Enrolled in an academic program towards a degree. (CLEP work excluded.) 10. 1 pt. per completed credit hour. Max 20 pts. per year All points are not additive: Unit Points-all employees of the unit can take points whether directly involved or not. They assist the unit in sending representation. These may not be added to points below. Employee specific points for active member participation on a unit committee. These may be added to hospital wide committee points below. Employee specific points for unit representation on a hospital wide committee. 11. Shared Governance activities: Department or Unit actively and consistently has representation and participation in Shared Governance Committees (Conferred by Hospital Shared Government Council Chair). Unit/department attends >90% of the time at meetings and on projects. Department or Unit actively and consistently has representation and participation on Magnet Committees (Conferred by Hospital Magnet Committee Chair). Unit/department attends >90% of the time at meetings and on projects. Department or Unit actively has a Retention and Recruitment Committee (Conferred by Unit Shared Governance Committee). Unit/department attends > 90% of the time at meetings and on projects. Employee actively and consistently participates in Department/Unit Shared Governance Committee. (Conferred by Executive Director) Employee attends monthly meetings > 90% of the time and participates in >90% of the projects. Paid time is permitted, though neither OT/DT. Employee actively and consistently participates in Department/Unit Magnet Committee. (Conferred by Executive Director). Employee attends monthly meetings > 90% of the time and participates in >90% of the projects. Paid time is permitted, though neither OT/DT. Employee actively and consistently participates in Department/Unit Retention & Recruitment Committee. (Conferred by Executive Director). Employee attends monthly meetings > 90% of the time and participates in >90% of the projects-at least 4 per year. Paid time is permitted, though neither OT/DT. Employee actively and consistently represents Department/Unit in Hospital-wide Shared Governance Committees. (Conferred by Shared Government Council ED) Employee attends meetings > 90% of the time and participates in >90% of the projects. Paid time is permitted, though neither OT/DT. 11. 2 points 2 points 2 points 5 points 5 points 5 points 15 points 15 points - 8 - Revised: November 2005 10. Employee actively and consistently represents Department/Unit in Hospital-Wide Magnet Committees. (Conferred by Magnet Council ED). Employee attends meetings > 90% of the time and participates in >90% of the projects. Paid time is permitted, though neither OT/DT. Employee actively and consistently represents Department/Unit in Hospital-wide Retention & Recruitment Committees. (Conferred by R&R Committee Chair). Employee attends meetings > 90% of the time and participates in >90% of the projects. Paid time is permitted, though neither OT/DT. 15 points - 9 - Revised: November 2005 11. A. Professional Growth (cont.) Achievement Minimum Requirements Points (continued) 12. Possesses a Bachelors Degree in a health-related field. 12. 15 pts. NOTE: CAP Points may not be earned for credit hours or research projects and attainment of a degree if the degree is awarded in the same year. 13. Possesses a BSN Degree. 13. 30 pts. 14. ADN actively enrolled in a BSN program for a maximum of three years. (Not combined with #9.) 14. CAP III Category 30 Points 15. Possesses a Masters Degree in a health-related field. 15. 20 pts. 16. Possesses a MSN Degree. 16. CAP III Category 30 pts. 17. BSN actively enrolled in an MSN program for a maximum of three years. (Not combined with #9.) 17. CAP III Category 30 pts. 18. Possesses a Ph.D. in a health care related field. 18. 50 pts. 19. Possesses a Ph.D. in Nursing. 19. 60 pts. 20. Receives an Outstanding Nurse Award at UNMHSC within the current evaluation year. 20. 15 pts. 21. Receives an award from a professional nurses association (i.e., Sigma Theta Tau, AACN). 21. 20 pts. 22. Member of a local or national nursing professional association. Must show proof of active participation, such as attending a minimum of two meetings or seminars per year, participating in committee work for the organization, or disseminating information back to the unit via a staff meeting or in-service. NOTE: If the parent and local sections are considered one organization, 5 points are allotted total. If the parent and local sections are considered separate organizations, 5 points are allotted for each membership. 22. 5 pts. per organization (see NOTE). Max 15 pts. 23. Participates in a UNMHSC committee on his or her own time. Documents a minimum of 5 hours per year of active participation. This requires documentation by a chairperson of the participants attendance and the total number of hours of participation for the year. 23. 5 pts. for the first 5 hours of participation, 1 pt. per hour thereafter. 24. Serves as a member of the Planning Committee for a City, Regional or Statewide educational nursing program (i.e. Critical Care Course) on his or her own time. 24. 1 point per hour. Max 30 pts. 25. Serves on the Board of Directors or holds an office in a professional nursing association. 24. 10 points per year - 10 - Revised: November 2005 12. B. Research and Education Achievement Minimum Requirements Points Promotes the professional practice of others by planning and providing educational opportunities using adult learning principles. 1. Develops one new patient education tool guide on his or her own time. Introduces the new tool to staff via a brief presentation and coordinates this activity with the Patient Education Department. Documentation is to include approval from the PFEC (Patient and Family Education Committee). 1. 10 pts. No maximum. 2. Significantly revises or updates an existing patient education tool for UNMHSC Clinical Operations on his or her own time. Presents the tool to staff via a brief presentation and coordinates this activity with the Patient Education Department. Documentation is to include approval from the PFEC Patient Education Committee. 2. 5 pts. No maximum. NOTE: CAP points may not be earned for attending a conference or receiving CEUs. However, CAP participants may earn points by preparing and conducting an in-service on a topic from the conference. 3. Prepares, conducts, evaluates and documents on his or her own time the following, based on needs assessment: a. A 30+ minute in-service given to all shifts with prior approval from the Unit Director, Clinical Nurse Specialist (CNS), or area Clinical Educator. Documentation is to include an outline of the in-service. b. An existing in-service, lecture or presentation. 1. Without revision, within 6 months of the original presentation. 2. With revision, within 6 months of the original presentation c. A poster session, which must include pre- and post-tests. d. An application for and obtainment of CEU credit for a given in-service. 3. a. 10 pts. b1. 2 pts. per repetition. b2. 5 pts. per repetition. c. 5 pts. d. 10 pts. 4. Self-learning Modules: a. Develops an original self-learning module on his or her own time. Must coordinate with Clinical Education or a Clinical Nurse Specialist (CNS) in conjunction with Clinical Education before starting a project. b. Reviews/evaluates a computer assisted instruction (CAI) module on his or her own time. c. Develops a computer assisted instruction (CAI) module on his or her own time. d. Significantly revises an existing self-learning module on his or her own time. S/he must coordinate with Clinical Education or a Clinical Nurse Specialist (CNS) in conjunction with Clinical Education before starting a project. 4. a. 20 pts. 6 b. 5 pts. 7 c. 20 pts. 8 d. 10 pts. 5. Functions as a skill evaluator on his or her own time at a skills lab held for nurses or allied health professionals. Minimum of 5 hours of skills labs must be done within UNMHSC Clinical Operations. 5. 1 pt. per hour. Max 30 pts. per year. - 11 - Revised: November 2005 13. B. Research and Education (cont.) Achievement Minimum Requirements Points (continued) 6. Speaks publicly on health-related issues in a 30+ minute presentation. Public speaking is defined as speaking outside UNMHSC on his or her own time. Documentation is to include an outline of the presentation and a letter from the sponsoring organization on letterhead. 6. 10 pts.; 2 pts. if someone else creates the presentation. 7. Repeats an existing public speaking lecture on his or her own time. a. Without revision, within 6 months of original presentation. b. With revision, within 6 months of original presentation. 7. a. 2 pts. per repetition. b. 5 pts. per repetition. 8. Performs as a preceptor, with documentation of attending the UNMHSC Preceptor Course after 1993. This includes being a preceptor for RN/ LPN employees, RN residents, TVI or UNM nursing students, Paramedic Students or students from other licensure programs. 8. 40 pts. per 120 hours of precepting. Not prorated for more or less than 120 hours. No maximum. NOTE: CAP Points may not be earned for credit hours or research projects and the attainment of a degree if the degree is awarded in the same year. 9. Implements/completes a nursing research project. This includes generating a proposal, collecting data, analyzing data, implementing the proposal and implementing the findings. Examples: a. Implements a research-based project on the unit. b. Implements a research-based utilization project on the unit and provides evaluations of implementation. c. Participates in a research project headed up by another principal investigator. d. Implements/completes a nursing research project. This includes generating a proposal, collecting data, analyzing data, implementing the proposal and implementing findings. e. Presents research findings for the Clinical Operations program. f. Presents research findings at a conference outside of the UNMHSC Clinical Operation. g. Writes and publishes research findings of his or her own research or research utilization project. h. Writes and publishes clinical findings in a peer-reviewed professional journal. 9. a. 10 pts. b. 30 pts. c. 15 pts. d. 40 pts. e. 15 pts. f. 25 pts. g. 40 pts. h. 25 pts. 10. Volunteers as a UNMHSC Clinical Operations representative on his or her own time, performing hands-on nursing care and utilizing any component of the nursing process. 10. 1 pt. per hour. Max 30 pts. 11. Writes an article for a clinically based, professional newsletter (i.e. Health Smart) on his or her own time. 11. 5 pts. per article. 12. Editor for a unit/area based informational newsletter on his or her own time, pre-approved by the Unit Director and Executive Director, publishing a minimum of six per year. 12. 10 points/yr. 13. Editor for a unit/area based clinically oriented newsletter on his or her own time, pre-approved by the Unit Director and Executive Director, publishing at least quarterly. 13. 20 points/yr. 14. CHACE Nurse: One Charge Nurse per clinic. 14. 15 points per year. - 12 - Revised: November 2005 14. C. Clinical Expertise Achievement Minimum Requirements Points Demonstrates clinical expert skills in the RNs area of specialty. 1. Develops a new unit/area policy/guideline in proper format on his or her own time. Obtains staff, physician and nursing administrative input and approval. Must present changes to staff via an in-service. 1. 5 pts per policy/guideline 2. Revises a unit/area policy/guideline in proper format on his or her own time. Obtains staff, physician and nursing administrative input and approval. Must present changes to staff via an in-service. 2. 5 pts. for 80% or more revision. 3 pts. for 40% or more revision. 1 pt. for review with no revision. 3. Revises or develops a patient care policy in proper format on his or her own time. Obtains staff and nursing administrative input and approval. Must present changes to staff via an in-service. 3. 5 pts. for 80% or more revision. 3 pts. for 40% or more revision. 1 pt. for review with no revision. 4. Coordinates a multi-disciplinary care conference to meet the needs of patients requiring complex care. Documents the conference, generates appropriate patient care plans and communicates the information to staff. For psychiatric nurses: presentation of multidisciplinary care conference at Grand Rounds. 4. 10 pts. No maximum. 5. Completes self-learning modules (excluding IV Therapy modules) on his or her own time. 5. 2 pts. per module. 6. Completes the Perinatal Grief: Guideline to Helping Families Class, the Loss and Grieving in Pregnancy and the First Year of Life self-study module. Precepts with a perinatal loss support person on the unit and follows a minimum four families per year. Submits appropriate documentation. 6. 10 pts for the self-study module and 5 points per family with a minimum of 2 families. 5 pts. for each additional family. 7. Acts as an OR service coordinator. Attends weekly OR in-services for technical or procedural teambuilding and demonstrated competence. 7. 10 pts per in-service. 1 pt per every 2 in-services attended. 8. Participates on his or her own time in an approved unit/clinic patient information program or follow-up program. Documents patient education and demonstrates appropriate follow-up intervention. 8. 1 pt. per hour. Max 20 pts. 9. Completes initial requirements for: CAVH/CVVH Intra-aortic Balloon Pump (IAPB) (requires refresher drills quarterly the first year) ECMO Specialist Basic Fetal Heart (FH) Monitoring 9. 10 pts. 10. Maintains requirements for the above courses. For CAVH/CVVH and IAPB: must either provide direct care for a patient on CAVH/CVVH/IAPB quarterly or attend quarterly refresher drills. For ECMO Specialist: fulfills the requirements for maintenance per the ECMO coordinator. For FH monitoring: documentation of a minimum of eight (8) FH strip reviews per year or attendance at 10. 5 pts. - 13 - Revised: November 2005 15. AWHONN Fetal Heart Monitoring Principles and Practices workshop. 11. Completes requirements to be a relief ECMO coordinator (includes ECMO specialist points). 11. 15 pts. - 14 - Revised: November 2005 16. C. Clinical Expertise (cont.) Achievement Minimum Requirements Points (continued) 12. Completes requirements for PICC/VART: a. Attend PICC class and become certified by successfully completing 5 PICC placements. b. Re-verify PICC by performing 6 PICC placements. c. Upon meeting the requirements for PICC verification, the CAP participant can continue PICC placement completion of either (a) or (b) above. d. Attend VART class and actively participate on the team. e. Be a preceptor for PICC/VART activities (ports/assessments), and troubleshooting (declots/removal). f. In-services will be awarded points as outlined in the CAP book. 12. a. 15 pts. One time only. b. 10 pts. c. 1 pt. per completion. No maximum. d. 5 pts. e. 1 pt. each. No maximum. f. See Research & Education, Sect. 3. 13. Acts as the Pediatric Trauma liaison RN for University Hospital Trauma Services. 13. 5 pts. 14. Attends a 30+ minute UNMHSC Clinical Operations in-service program, outside of regular working hours on his or her own time. This includes grand rounds. Compensated in-services are not included. 14. 1 pt. per in-service 15. Completes requirements for Telemedicine Fellowship. 15. 5 pts. 16. Facilitates telemedicine conference for a UNM Hospital patient/family with documentation of patient/family initial and date of facilitation. 16. 1 point/facilitation. 17. Administration and reading of staff annual PPDs, flu shots, and /or N-95 fit testing. 17. 2 points: 0 to 19 staff 4 points: 20 to 39 staff 6 points: 40-59 staff 8 points: 60-79 staff 10 points: 80 to 99 staff 15 points: 100+ staff 18. Unit/Department specific Press-Ganey patient satisfaction score meets or exceeds benchmark for the 6 month period prior to CAP renewal. If Unit/Department does not have a specific patient satisfaction score use the Overall Hospital score for that category: I. Inpatient II. Medical Practice (Ambulatory) III. Tests and Treatments IV. Ambulatory Surgery V. Inpatient Mental Health VI. Outpatient Mental Health VII. Emergency Department 18. 15 points - 15 - Revised: November 2005 17. 19. Unit/Department specific Quality Indicators meets or exceeds benchmark for the 6 month period prior to CAP renewal. . If Unit/Department does not have a specific patient satisfaction score use the Overall Hospital score for that category: I. Ambulatory Indicators: a. Achieve First Class access in ambulatory settings of 5 days for specialty clinics. b. Achieve First Class access in ambulatory settings of 1 day in primary care clinics. c. Ensure telephone abandonment rate is no greater than 5%. d. Ensure quality of APC documentation is at 95%. e. Registration audit database accuracy >95%. f. 90% of hanging visits billed within 5 days. g. 95% compliance with National Patient Safety Goals as measured by JCAHO accreditation manager tool and/or tracer scores. h. Follow national guidelines for immunizations at 80% (influenza, pediatric, pneumovax, etc). i. Smoking Cessation education documented 90% within the last 12 months. j. Two forms of ID checked 100% with medications and blood draws. k. Observed hand washing audit at 100% before and after caring for patient. l. Mislabeled specimens by nursing to zero. II. Inpatient Indicators: a. 95% compliance with National Patient Safety Goals as measured by JCAHO accreditation manager tool and/or tracer scores b. Plan of care elements at 95% (e.g. nutrition, pain management, spirituality, education, etc.) Ensure all magnet nursing indicators are within national guidelines: c. Patients will be assessed for risk of falls 90%, with implementation of fall protocol as applicable. d. Skin assessment/Braden scores at 90%, with implementation of pressure reduction protocol as applicable. e. 100% compliance with nursing restraint documentation. f. Follow national guidelines for immunizations at 80% (influenza, pneumovax, pediatric etc). g. Discharge summary documented 90% for smoking cessation education for patients or parents. h. No avoidable medication errors with a harm score of G or higher/worse within the Nursing Division. i. Ensure no more than an average of 6 admitted patients waiting in the ED per day. j. Decrease LOS in the main ED from 8.3 hours to 6 hours in main ED. k. Referral of deaths reported to Organ Procurement Agency >95%. l. All CMS indicators >90% (1 point each): -AMI 2: aspirin prescribed at discharge -AMI 3: ACE-I or ARB for Left Ventricular Systolic Dysfunction -AMI 4: Smoking cessation advised and documented at discharge -AMI 5: Beta-blocker prescribed at discharge -AMI 8a: PCI within 120 minutes of arrival -HF 1: discharge instructions: 6 topics (see specific form) -HF 2: left ventricular function assessment -HF 3: ACE-I for Left Ventricular Systolic Dysfunction -HF 4: Smoking cessation advised and documented at discharge -PN 2: Pneumococcal Vaccination, Eligible Patients 19. 2 points each Quality Indicator - 16 - Revised: November 2005 18. -PN 4: Smoking cessation advised and documented at discharge -PN 5b: Initial antibiotic within 4 hours -PN 6b: Initial antibiotic selection, Non-ICU, appropriate -PN 7: Influenza vaccination (September-March) m. Two forms of ID checked 100% with medications and blood draws. n. Time out checklist will be utilized and documented in 100% procedure and moderate sedation cases o. Reduce missing armbands to zero within the Nursing Division. p. Observed hand washing audit at 100% before and after caring for patient. q. Mislabeled specimens by nursing to zero. r. No delays in discharges on the unit due to PICC need. III. ED Indicators: a. LOS < 6 hours average per patient b. All CMS indicators at > 90% (1 points each): -AMI 1: aspirin on arrival -AMI 6: beta blocker on arrival -AMI-8a: PCI within 120 minutes of arrival -PN 1: oxygen assessment -PN 5b: Initial antibiotic within 4 hours c. APC accuracy at >95% d. Pain Documentation at >95% e. Medical Supplies by Action OI at < 25th Percentile of UHC peers f. Patient Satisfaction at raw score of >/= 80 g. Physical restraint documentation at 100% compliance h. Referral of deaths reported to Organ Procurement Agency >95%. i. Time out checklist will be utilized and documented in 100% procedure and moderate sedation cases k. Reduce missing armbands to zero within the Nursing Division. l. Observed hand washing audit at 100% before and after caring for patient. m. Mislabeled specimens by nursing to zero. IV. ICU specific Indicators: a. Bacteremia rates (line sepsis) in the +/++ range or equivalent. b. Ventilator related pneumonias in the +/++ range or equivalent. V. Surgical Indicators: a. Decrease total cancellation cases from 20% to 15% b. Ensure OR start times at the 15-minute mark will be 85%. c. Ensure OR start times in room at the one-minute mark will be at 65%. d. Room turnover measured as time out of room to time in room for next patient. Should not exceed 35 minutes average in the Main OR and 28 minutes average in the OSIS. e. Time out checklist will be utilized and documented in 100% procedure and moderate sedation cases. f. No unintended retained objects per PSN. g. PACU patients receive care from Nursing within 2 minutes of arrival >95% of the time. h. Reduce missing armbands to zero within the Nursing Division. i. Observed hand washing audit at 100% before and after caring for patient. j. Mislabeled specimens by nursing to zero. - 17 - Revised: November 2005 19. VI. Lifeguard Indicators: a. Missed flights at