Ronald Reagan UCLA Medical Center Magnet Recognition …...– Nursing Strategic Plan 4 – Advocacy...
Transcript of Ronald Reagan UCLA Medical Center Magnet Recognition …...– Nursing Strategic Plan 4 – Advocacy...
Ronald Reagan UCLA Medical Center
Magnet Recognition Handbook
AN OVERVIEW OF RRUCLA NURSING EXCELLENCE &
OUR JOURNEY TO MAGNET RE-DESIGNATION 2015
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RRUCLAMC 2015 Magnet Recognition Handbook Table of Contents
Page #
What is Magnet? - Background 3
Magnet Components & Magnet Document Highlights 4-22
Transformational Leadership – 4-7
– Nursing Strategic Plan 4
– Advocacy and Influence 5-6
– Visibility, Accessibility, and Communication 6-7
Structural Empowerment – 8-13
– Professional Development – Interprofessional Involvement 8
– Professional Development – RNs Involved in Professional organizations 8
– Degree and Certification Goals 9-10
– Teaching and Role Development 10-11
– Commitment to Community Involvement 11
– Recognition of Nursing 12
– UPC Accomplishments 13
Exemplary Professional Practice – 14-20
– Professional Practice Model 14
– Care Delivery System 15-16
– Staffing Scheduling, & Budget Processes 16
– Interprofessional Care 17
– Accountability, Autonomy, & Competency 17-18
– Ethics, Privacy, Security, and Confidentiality 18
– Culture of Safety 19
– Quality of care Monitoring and Nurse Sensitive Indicators 20
New Knowledge, Innovations, and Improvement 21-22
– Research 21
– Evidence-Based Practice and Innovation 22
Access to Online Resources 23
RRUCLAMC Magnet Champion Contact Information 24
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What is Magnet? The Magnet Recognition Program® is the gold standard in measuring a healthcare organization’s nursing
excellence. Magnet as we know it today is the culmination of over 30 years of research initiated by the
American Academy of Nursing (AAN) in response to a nation-wide nursing shortage in the early 1980s. By
studying the practice environments of hospitals that were able to successfully attract and retain nurses during
this critical time, the AAN was able to identify similar qualities shared by these organizations, which they
named the “14 Forces of Magnetism,” later refined to the “5 Magnet Components” we recognize today. Based
on this ever-evolving research, the American Nurses Credentialing Center (ANCC) developed and continuously
refines (or adapts?) the Magnet Recognition Program®. The ANCC periodically updates their rigorous Magnet
requirements based upon emerging evidence and healthcare trends, shaping the advancement of successful
nursing practice worldwide. Most recently, the ANCC updated their requirements in the 2014 Magnet Manual.
The 2014 Manual includes X sources of evidence (SOEs), each of which provide nurses with an opportunity to
demonstrate how their organization meets the Magnet standards. In fact, RRUCLA is one of the first re-
designating hospitals to submit a document using the 2014 Magnet Manual!
Why is Magnet Recognition Important? Magnet status is the highest honor awarded by the ANCC and recognizes RRUCLA nurses’ ability to provide
quality patient care and to initiate innovations in their professional nursing practice. It ensures that UCLA is
able to attract and retain the highest level of nursing professionals to provide excellent patient care. As the
public grows increasingly medically savvy, they rely on Magnet® designation as an important indication of
quality patient care when choosing healthcare providers.
The Magnet Recognition Program® advances 3 goals within health care organizations:
1. Promote quality in a setting that supports professional practice
2. Identify excellence in the delivery of nursing services to patients and families
3. Disseminate best practices in nursing care
You can access the Ronald Reagan UCLA Medical Center 2015 Magnet Redesignation Document by logging
on to the UCLA Health Nursing website at http://nursing.uclahealth.org/body.cfm?id=215
COMPONENTS OF MAGNET
MAGNET COMPONENT #1: TRANSFORMATIONAL LEADERSHIP
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Nursing Strategic Plan Magnet Standard:
Nursing’s mission, vision, values and strategic plan align with UCLA Health’s priorities to improve performance.
RRUCLA Evidence: The Department of Nursing shares the mission, vision, and values of UCLA Health:
MISSION: To deliver leading edge patient care, research, and education. VISION: Healing humankind, one patient at a time, by improving health, alleviating suffering, and
delivering acts of kindness. VALUES: Integrity, Compassion, Respect, Teamwork, Excellence, and Discovery.
Similarly, the Department of Nursing Strategic Plan is aligned with the UCLA Health Strategic Plan. The Nursing Strategic Plan is updated annually at the Nursing Strategic Planning Retreat led by Chief Nursing Officer Heidi Crooks, MA, RN. Nurse executives, unit directors, and clinical nurses participate ensuring contributions from all practice areas and service lines. Unit-level goals are then created using the nursing strategic plan as a guide, thus providing an aligned vision and continuity across the organization.
Access the RRUCLA Evidence:
Please view the UCLA Health Strategic Plan and the UCLA Nursing Strategic Plan by visiting the UCLA Nursing website:
http://nursing.uclahealth.org/body.cfm?id=216 You can also read more in the Magnet Document about how the UCLA Health Nursing Strategic Plan is utilized to influence and guide nursing practice in the following SOEs:
NURSING STRATEGIC PLAN - TL1EO
Enhancing the Practice Environment in Order to Reduce Nursing Turnover
Health System Float/Resource Nursing Admin Finance
Partnering to Decrease Sepsis Mortality Health System NRE Nursing Admin 4ICU QMS Overhead
ADVOCATING RESOURCES - TL2
Clinical Nurse Specialists Advocate for Specialty Surgical Surfaces
7ICU Entersomal Therapy 8W OR Admin
Nurse Residents Advocate for Products to Support Infection Prevention
8ICU TPN Services
MAGNET COMPONENT #1: TRANSFORMATIONAL LEADERSHIP
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Advocacy & Influence
Magnet Standard: At RRUCLA, a strong trust exists between the CNO, nursing directors, and clinical nurses. Nurses are empowered to advocate for the needs of patients and families, and nursing leaders use their influence to ensure that these needs are met.
RRUCLA Evidence: Chief Nursing Officer Heidi Crooks, MA, RN, nursing leaders, and clinical nurses serve on hospital committees to advocate for resources that ensure that nurses have the best practice environment to care for patients. Through unit practice councils, hospital committees, and other structures, clinical nurses and nurse leaders
have worked together to advocate for improvement. All efforts led to safer care for our patients and families!
Access the RRUCLA Evidence: The great successes of RRUCLA nurses’ advocacy and influence are highlighted in the Magnet document and include the following SOEs:
CNO INVOLVEMENT IN ORGANIZATIONAL INFLUENCE - TL3
CNO-Led Successful Implementation of Safe-Handling & Mobility Program
Health System PT/OT Admin
CNO INVOLVEMENT IN ORGANIZATIONAL DECISION-MAKING - TL4 Redesigning for the Future of UCLA Health: The CNO’s Strategic Role
Nursing Admin Neurosurgery Emergency Dept Nutrition NRE Operations 6ICU Ambulatory 6N Physcian Support Anesthesiology PT/OT Inpatient Data Respository Risk Mngt Speech Clinic Social Work Performance Excellence Pharmacy
Selection, Planning, & Implementation of a Fully Integrated Electronic Health Record: The CNO’s Strategic Role
Anesthesiology Radiation Oncology
Compliance, Privacy, & Security
Procurement & Strategic Sourcing
DOM Nursing Admin
Enterprises Admin Surgery Family Medicine Urology NPI Clinical System Team
Path & Lab Med EMR Peds Physician Support
NURSE LEADERS GUIDING CHANGE - TL5 Leading Through Emergent and Unplanned Change – Sigma Pump Functionality Challenge
4ICU 7E/5E
6E 7W Nursing Admin
Implementation of a Bedside Report Practice Change on Inpatient Units
RRUCLA Nursing Admin 7W
MAGNET COMPONENT #1: TRANSFORMATIONAL LEADERSHIP
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DEVELOPING LEADERS - TL6 Mentoring and Succession Planning for Clinical Nurses: Professional Role-Based Coach Program
Health System External Consultant Nursing Admin 7E/5E
Mentoring and Succession Planning for Nurse Managers: Succession Planning Program
Nursing Admin Labor & Delivery 7W MOU 8W NICU Float/Resource PICC Radiology
Mentoring and Succession Planning for Nurse Leaders: UCLA Health System Leadership Academy
Nursing Admin Materials MGMT 7ICU IR Radiology Anesthesiology Operations Disaster Resource Center
Operative Services
Division of Infectious Disease
Performance Excellence
Emergency Department, System
Resnick Outpatient Programs
GIM & HSR RR General Surgery HR Operations & Staff Develop
Office of the Patient Experience
Mentoring and Succession Planning for the Chief Nursing Officer: CNO Succession Planning
Health System Nursing Admin
DATA DRIVEN RESOURCING - TL7 Trended Fall Data Leads to Acquisition of Low Beds 8N Nursing Admin
Entersomal Therapy Nursing System
Materials MGMT Procurement & Strategic Sourcing
Visibility, Accessibility, & Communication
Magnet Standard: Nurse leaders are available to clinical nurses and are open to hearing nurses’ views and concerns. Nurse leaders and clinical nurses work collaboratively to make decisions in the best interest of our patients, their families, and our nurses.
RRUCLA Evidence:
Heidi Crooks, CNO and the directors of nursing have brown bag sessions, attend various unit meetings, and have open-door policies to hear concerns. Through these venues, the nursing directors and CNO have advocated for practice changes.
Access the RRUCLA Evidence:
Read more about the efforts of nurse leaders to increase their visibility and to serve as advocates and
role models for clinical nurses, patients, and families in the following SOEs:
MAGNET COMPONENT #1: TRANSFORMATIONAL LEADERSHIP
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CNO VISIBILITY AND ACCESSIBILITY - TL8 Clinical Nurse Advocacy for Patient Safety Around the Hospital
6E OR Operations
Enterprises Admin
OR Admin Nursing Admin
Ensuring Clinical Nurse Competency
5E 6E HR 6N 6W NRE 7E 8N PICU NPH Emergency Dept. OR NICU Ambulatory
INFLUENCING CHANGE - TL9EO
Addition of Pediatric NPs in Response to Nurse Concerns about Quality & Safety in the PICU
Nurse Recruitment Peds
Nursing Admin PICU
Creation of a Multidisciplinary Toolkit for Management of Escalating Patient Behaviors in Response to Clinical Nurse Concerns about Safety and Quality of Care
7E/5E Internal Medicine
7W Nursing Admin 8ICU Operations Care Coordination Risk Management Pt Liaison Program Pt Placement & Transfer Ctr Emergency Preparedness, Safety, and Security
MAGNET COMPONENT #2: STRUCTURAL EMPOWERMENT
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Interprofessional Involvement
Magnet Standard: The UCLA Health Department of Nursing supports the continuous professional development of our nurses. UCLA Health nurses serve in leadership roles on interprofessional councils and participate in decision-making that improves care for patients.
RRUCLA Evidence: UCLA Health supports structures and processes that ensure nurses from all settings and roles actively participate in organizational decision-making groups such as councils, committees, and performance excellence teams. Nurse representatives serve on the Ethics Committee, Pharmacy and Therapeutics Committee, Clinical Effectiveness Committee, and a variety of other quality committees. Nurses volunteer, apply, or are appointed to decision-making groups and serve in various roles on the groups, including group leader or chair of the committee. Nurses’ participation on these committees has led to improved patient outcomes and safer practices throughout UCLA Health.
Access the RRUCLA Evidence: Read more about the work on interprofessional committees in the following SOEs:
INTERPROFESSIONAL DECISION-MAKING GROUPS - SE1EO
Improving the Care of Stroke Patients 6ICU Neurosurgery Emergency Med 6N ED QMS Overhead Pharmacy PT/OT Admin-MP Neurology SMH Radiology
Ensuring Safe Access to Blood Products 7ICU Emergency Dept 8ICU Labor & Delivery
Nurses involved in Professional Organizations Magnet Standard:
UCLA Health nurses are involved with professional organizations that help to shape practice and facilitate evidence-based change.
RRUCLA Evidence: Many UCLA Health nurses are members of professional nursing organizations. Some examples include the American Association of Critical Care Nurses (AACN), the Emergency Nurses Association (ENA), and the American Organization of Nurse Executives. UCLA Health nurses utilize professional nursing organization standards to improve clinical practice and patient outcomes at UCLA.
Access the RRUCLA Evidence: Read more about UCLA Health nurses’ involvement with professional organizations has helped improve delivery of care:
PROFESSIONAL ORGANIZATION PARTICIPATION - SE2EO
Use of ASORN Guidelines to Improve Surgical Site Markings JSEI OR JSEI Pre/Post OP Unit
Improving Delirium Assessment in the Neurotrauma ICU Based on AACN Recommendations
6ICU NRE Neurosurgery
MAGNET COMPONENT #2: STRUCTURAL EMPOWERMENT
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Baseline 2011 2012 2013 2014
Certified Nurses, Overall 439 478 564 610 738
Organization Goal (wholenumber)
400 450 525 600 676
0
200
400
600
800
# o
f ce
rtif
icat
ion
s
Professional Nursing Certification 2011-2014
Degree & Certification Goals Magnet Standard:
The RRUCLA Department of Nursing is committed to supporting and facilitating the educational and professional development of our nursing staff.
RRUCLA Evidence: RRUCLA nursing has set a strategic goal and has a plan to ensure that 80% of our nurses have a BSN or higher nursing degree by the year 2020, in alignment with the IOM/RWJF Future of Nursing Recommendations.
UCLA Health has supported nurses’ professional development by working to increase professional certification. We are happy to report that in 2014, our number of Certified RNs reached 738, 62 more than our goal!
Access the RRUCLA Evidence:
Read more about the efforts to increase education and certifications for nurses in the following SOEs:
PROFESSIONAL NURSING CERTIFICATION - SE3EO
Increasing Professional Nursing Certification at the Organizational Level NRE
Increasing Professional Nursing Certification at the Unit Level NRE Peds
CONTINUING EDUCATION PROGRAMS - SE4EO
Improving Referrals to Palliative Care in the ICU through Education 4ICU
2012 2013 2014
% of RNs with BSN+ 63% 67% 73%
Target 63% 66% 68%
60%
62%
64%
66%
68%
70%
72%
74%
Pe
rce
nta
ge o
f R
Ns
% of RNs with BSN or Higher Degree
MAGNET COMPONENT #2: STRUCTURAL EMPOWERMENT
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Teaching & Professional
Role Development
Use of a Structured Infection Prevention Program to Decrease Rates of CLABSI
4ICU 7N PEDS 6E 7W PICU
6ICU 8ICU NICU 7E/5E 8N Dialysis 7ICU 8W Float pool NRE Nursing Admin Infection Control
NON-NURSE CAREER PROGRAMS - SE5
Community Partnership with King Drew Magnet High School of Medicine and Science
Nursing Admin 8W 6ICU Cardiology Peds 6N IR Radiology ED 7E/5E GOU/4ICU Pt Escort Service Surgery - Recovery - MP
Teaching & Role Development Magnet Standard:
UCLA Health nurses recognize the important role we play in ensuring that patients understand their health.
RRUCLA Evidence: UCLA nurses use evidence-based teaching strategies to engage patients in their health. Nurses serve in leadership roles on the Patient Engagement Committee and have provided feedback about teaching tools in CareConnect, including discharge and medication teaching resources. Across the organization, nurses have led efforts to standardize teach-back strategies in order to ensure that patients understand information about their health, hospitalization, medications, and discharge plans.
At UCLA Health, nurses never stop learning. The UCLA Health Department of Nursing Research and Education (NRE) has established an infrastructure to provide nurses across the health system with opportunities for lifelong professional growth. Educational and professional development programs are structured to best meet the unique needs of our clinical nurses and to support them in their efforts to ensure consistently high quality care for our patients and their families. Classes are designed to provide current clinical and professional nursing content and are delivered using evidence-based teaching/learning strategies.
Access the RRUCLA Evidence: Read more about the efforts of nurses to increase education and to serve as role models for their patients, families, and next generation of nurses in the following SOEs:
NURSES AS TEACHERS - SE6
Teach-Back Educational Summit and Meducation Toolkit to improve nurses’ expertise in patient and family teaching
7CCU DOM Diabetic Services 7W ED Nursing Admin NRE TPN Services
MAGNET COMPONENT #2: STRUCTURAL EMPOWERMENT
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CONTINUING EDUCATION PROGRAMS - SE7
Onboarding & Orientation of Newly Hired Experienced Nurses
HR Recruitment Human Resources NRE Operations Personnel
Onboarding & Orientation of New Graduate Nurses NRE
DEVELOPING NURSE PRECEPTORS - SE8
Growing Expert Preceptors through a Standardized Preceptor Program
L&D NRE
Commitment to Community Involvement
Magnet Standard: UCLA Health nurses are committed to improving the
health of both our local and international
communities, and they are responsible for leading and
supporting efforts to ensure all people are provided the
best healthcare possible.
RRUCLA Evidence:
UCLA nurses have taken leadership and volunteer roles in over 100 community organizations. In these organizations, our nurses work tirelessly to provide leading-edge patient care and to facilitate an improved quality of life for individuals in our community.
Access the RRUCLA Evidence
Read more about the efforts of nurses to serve our local & international community in the following SOEs:
COMMUNITY OUTREACH - SE9
UCLA Nurses Respond to Typhoon Haiyan Pt Relations 6E Clinical System Team
PACU HR Materials Mgmt
UCLA RN Orchestrates 27th Annual Oley Foundation Conference
PICC RADIOLOGY 6ICU Resource Team TPN Services PEDS 7E/5E
Enterostomal Therapy
COMMUNITY HEALTHCARE NEEDS ASSESSMENT - SE10EO
Facilitating a Camp Experience for Children with Heart Disease: The Camp Del Corazon Experience
Catheterization Lab GONDA
Float Pool PEDS
MAGNET COMPONENT #2: STRUCTURAL EMPOWERMENT
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Recognition of Nursing Magnet Standard:
Nurses are valued and recognized at UCLA Health.
RRUCLA Evidence: At UCLA Health, outstanding nurses are recognized for their contributions to our vision of healing humankind, one patient at a time. Nurses are recognized as individuals for exemplary performance, as well as in teams demonstrating high levels of collegial support and collaboration to achieve extraordinary results. One program that enables us to appreciate both individuals and teams for their contributions to our strategic priorities and mission at UCLA Health is the biannual DAISY Award Program.
Patients, family members, and health system employees may nominate nurses for a DAISY Award. Nomination forms are available on all inpatient units and clinics for anyone to complete, and are collected by the Human Resources Department. Manager of Nurse Recruitment Sheri Monsein, MN, RN, was instrumental in initiating the DAISY Award Program at UCLA Health and continues to administer the program. It is a key component of our strategy for recruitment and retention of excellent nurses.
Access the RRUCLA Evidence:
Read More about UCLA Health’s recognition and celebration of our outstanding nurses in the following SOEs:
RECOGNING NURSES - SE11 Recognition of a Clinical Nurse
SON PICU 8N Nurse Recruitment
6W 5E OB 7ICU Nursing Admin
Recognition of a Group of Nurses
7E/5EMS Nursing Admin
Nurse Recruitment
2014 Daisy Award Winner Maxine Pintado, RN, being honored by Director of Inpatient Nursing Cathy Ward,
DNSc, RN, and Chief Nursing Officer Heidi Crooks, MA, RN
MAGNET COMPONENT #2: STRUCTURAL EMPOWERMENT
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RRUCLA Unit Practice Council Accomplishments The Unit Practice Councils and the subcommittees of the Nursing Quality Outcomes Council, led by Nurse
Subject Matter Experts, can be proud of their accomplishments this past year:
Unit UPC Initiative Outcomes
Main OR Practice change to improve communication
during Patient Handovers
Safer Handovers; ↑ medication safety compliance; ↑ teamwork at
handover
Emergency Depart.
Security Improvements Enhancement of Patient & Provider Safety
MICU Teach Back Initiative Reached 73rd
Percentile in HCAHPS: “RN explained things in a way you could understand.”
Peds Bug Buster Committee efforts, including 2 RN Dressing Changes
170 days without a CLABSI
OB OFRAS Tool Development Improved OB fall rate
Tool disseminated nationally
NICU Improving Turnaround Time for the First Dose of in Antibiotic in the NICU
↑ Percentage of patients that received their 1st
dose of an antibiotic within an hour
PICU Nurse Rounding Script ↑ in Parent Satisfaction “RN Discussed Plan of Care Daily” Scores
6 East Medication Teaching Cards • Received Joint Commission recognition as Best Practice
• HCAHPS - Reached 90th
%ile for Medication Communication
6ICU New change of shift visitation guidelines to include family members
Reached 90th
%ile for HCAHPS question: “RN explained things in a way you could understand.”
6 North Patient Falls Initiative Decrease in Patient Injury Falls: 9 Months with 0 Falls with Injury
6 West Implemented Green Apple Project Improved glucose control in diabetic patients
7E/5E MS Role-Based Practice Quality Improvement Champions Program initiated
Reduction in CLABSIs
7ICU “Home is Where the Heart Is” Discharge Teaching Handbook
Above 70th
%ile for HCAHPS Medication Communication for 2013
7CCU Communication Workshops, Crucial Conversation Skills
Improvement in RN-RN Communication, Interdisciplinary Communication, & RN-Patient Communication on Unit
7 West Collaborative Teamwork with Fall Prevention Toileting Program
• 4 Months without a Bathroom related fall! • 7 Months with 0 Falls with Injury
7COU 5 Minute Time Out Improved HCAHPS Score: “Treated with Courtesy and Respect” from 80% → 91%
8 East Transforming Tragedy to a Safe Practice Change Opportunity: Icodextrin Protocol
• 100% Compliance with new Icodextrin Protocol; 0 Icodextrin
Events since implemented
8ICU CUSP Initiative to reduce CLABSI Overall reduction in CLABSI rates; 0 CLABSI occurrences in Jan. 2014
8 North Modified Floating Policy in January 2013 Increase in primary nursing/continuity of care
8 West HAPU Prevention Hospital Acquired Pressure Ulcers for 4 Months; ↑HCAHPS Scores
GOU ‘Always’ Project ↑in RN teach-back protocol knowledge and compliance, ↑in patient satisfaction
Cath Lab MD-RN Verbal callback with medications during procedures
Improved RN-MD communication, increased patient safety
MAGNET COMPONENT #3: EXEMPLARY PROFESSIONAL PRACTICE
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Professional Practice Model Magnet Standard:
Nurses at UCLA Health own and live the Professional Practice Model to drive the work of nursing forward for our patients, families, community, and the organization.
RRUCLA Evidence:
A professional practice model (PPM) that is "exemplary" must be advanced over time. The purpose of the Professional Role Development Strategic Initiative is to strengthen RN professional role autonomy and decision-making authority such that it is lived and experienced by all registered nurses at UCLA.
Access the RRUCLA Evidence:
Read more about RRUCLA’s Professional Practice Model and how our outstanding nurses utilize the PPM to advance nursing practice in the following SOEs:
PROFESSIONAL PRACTICE MODEL - EP1
Evaluation of the Professional Practice Model Nursing Admin 7E/5EMS
RESULTS OF THE PROFESSIONAL PRACTICE MODEL - EP2EO
Using the PPM to Implement a Teamwork-Based Care Delivery Model on 7W 7W
NURSE SATISFACTION DATA - EP3EO Nurse Satisfaction Survey Overview All Units
MAGNET COMPONENT #3: EXEMPLARY PROFESSIONAL PRACTICE
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Care Delivery System
Magnet Standard: RRUCLA nurses are guided by the UCLA Health Department of Nursing’s Professional Practice Model, our organizational vision, and the relationship-based care delivery model to create partnerships with patients and their families. Nurses strive to understand each patient as a unique person with individualized goals and preferences. Further, in order to ensure continuity of care, nurses document these specific needs in CareConnect. The “patient story” screen enables nurses to capture information that is meaningful to the patient and facilitates a context for patient and family partnership with clinicians.
RRUCLA Evidence:
UCLA Health’s Care Delivery System is Relationship-Based Care (RBC). Key elements of RBC include:
Professional nursing practice is patient-centered; all decisions are centered around the unique needs of our patients and their families.
Interprofessional communication and teamwork is incorporated into care delivery on behalf of the patient.
The patient and the patient’s family are seen as persons (body, mind, and spirit) by all care providers.
Careful scheduling of patient assignments allows for continuity of care.
“Care of self” is important to maintain optimum health. This fosters empathy for the experience of others and for being a productive member of the nursing care team.
Nurses know that each person’s unique life story determines how he or she will experience an illness.
Access the RRUCLA Evidence:
Read more about RRUCLA’s care delivery model and about how our outstanding nurses utilize RBC to improve patient outcomes in the following SOEs:
ESTABLISHING A PLAN OF CARE - EP4
Nurse as Patient – Providing Individualized Care to a Colleague 4ICU
Ensuring Optimal Care for Peds Patients Across the Continuum of Care ED Peds
INTERPROFESSIONAL COLLABORATION - EP5
Care Coordination for Liver Transplant Patients 8N 8ICU
Care Coordination for Aortic Repair Patients UCLA Aortic Center
REGULATORY & PROFESSIONAL STANDARDS - EP6
Incorporating Vascular Access Standards into Care
7E/5E PICU
Case Management CCTT
GOU NRE
ED SIM LAB
STANDARDS OF CARE AND PRACTICE - EP7EO
Using AWHONN and Baby-Friendly Standards to Enhance Skin-to-Skin Initiation After Vaginal Births
5E OB L&D
MAGNET COMPONENT #3: EXEMPLARY PROFESSIONAL PRACTICE
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INTERNAL EXPERTS - EP8EO
Internal Consultant facilitates reduction in adverse glycemic events: The Green Apple Project
6W 8N 7E Diabetes Services 7E/5E Nursing Admin 7W Pharmacy
Staffing, Scheduling, & Budgeting Processes Magnet Standard: The acuity and care needs of patients on the unit, along with the skill-mix of clinicians, affect staffing decisions. Working together, nurse leaders and clinical nurses have developed staffing plans that strategically allocate staff resources to meet the needs of their patient population.
RRUCLA Evidence: Clinical nurses are empowered to adjust RN and support staff assignments/schedules to best adapt to changes in patient and environmental conditions while maintaining the quality of care. Further, through the work of the UPC and other shared governance structures, clinical nurses are empowered and encouraged to utilize trended data gathered on their unit to influence budgetary spending and allocation of resources.
Nurses participate in staffing and scheduling:
o Acuity ratings are documented for each patient every shift o Lead nurses consult with clinical nurses regarding staffing needs o Clinical nurses participate in self-scheduling
Nurses participate in recruitment & retention:
o Participation in hiring interviews o Mentorship to novice nurses
Nurses participate in budgetary data analysis:
o Trended data is used to influence budget allocation decisions o Lead nurses consult with clinical nurses regarding staffing needs
Access the RRUCLA Evidence: Read more about how RRUCLA’s nurses are empowered to influence staffing, scheduling, and budgeting needs in the following SOEs:
STAFFING/SCHEDULING PARTICIPATION - EP9
CTICU Nurse Advocates for Resources to Meet Acuity Demands 7ICU
NICU Clinical Nurse Advocates for Resources for Detriorating Neonate
NICU
BUDGET DATA ANALYSIS - EP10 Operating Room Clinical Nurses Shift Start Times to Provide Adequate Staffing
OR
Creation of a Nurse-led Volunteer Companion Program to Subsitute for Constant Observation Aides
Nursing Admin Peds
RECRUITMENT & RETENTION - EP11EO
Clinical Advancement Program for PICU Nurses PICU
MAGNET COMPONENT #3: EXEMPLARY PROFESSIONAL PRACTICE
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Interprofessional Care Magnet Standard:
At UCLA Health, healthcare providers recognize their role as a vital component of their patient’s interprofessional healthcare team.
RRUCLA Evidence:
For RRUCLA physicians, nurses, administrative and clinical care partners, social workers, and therapists, collaboration is the key to positive patient outcomes. From participation on hospital- and system-wide interprofessional committees to multidisciplinary care at the patient’s bedside, interprofessional care teams are united in their shared goal of, “Healing humankind, one patient at a time.”
Access the RRUCLA Evidence: Read more about how nurses at RRUCLA are a vital part of the interprofessional team in the following SOEs:
NURSING LEADERSHIP ROLES - EP12 Transitioning Patients from the OR to Cardio-Thoracic ICU: An Interprofessional Standardized Handover
7ICU Anesthesiology
PATIENT EDUCATION PROGRAMS - EP13EO Colorectal Surgery Education for Patients
Infection Control 8E OR Admin Enterostomal Therapy 8N PERIOP Hemapheresis 8W Urology QMS Overhead SOM Surgery Anesthesiology OR DOM Sterile Processing PEDS Pharmacy
Accountability, Autonomy, & Competency Magnet Standard:
Accountability, autonomy, and competency assurance are essential to achieving and maintaining the highest level of professional nursing care. Structures and processes are in place to ensure that all healthcare providers are held accountable for their work.
RRUCLA Evidence: Competencies are assessed annually for all UCLA Health employees. These competency assessments are combined with self-appraisal and peer feedback to provide a transparent, 360◦ performance evaluation. Clinical nurses are thereby empowered to use their clinical expertise to advocate for patients and families, in the same way that nurse leaders advocate on behalf of their clinical nurses, and that CNO Heidi Crooks advocates for nurses and nursing practice across the health system.
Access the RRUCLA Evidence:
Read more about the accountability, autonomy, and competency of nurses at RRUCLA in the following SOEs:
MAGNET COMPONENT #3: EXEMPLARY PROFESSIONAL PRACTICE
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RESOURCES FOR AUTONOMOUS PRACTICE - EP14 Nurse-Driven Skin and Wound Care Practices
Enterostomal Therapy
PICU
Early Mobility in the Medical ICU 4ICU
PERFORMANCE & PEER REVIEW - EP15
Nursing Self-Appraisal and Peer Feedback Promote Professional Development for Clinical Nurses
7W NRE
Nursing Self-Appraisal and Peer Feedback Promote Professional Development for Nurse Leaders
7W NRE
NURSING AUTONOMY - EP16 Autonomous Nursing Practice in Complex Care Coordination Children's Heart Center
Clinical Nutrition
Social Work
Autonomous Nursing Practice in Neonatal End-of-Life Care
NNP Program L&D Respiratory Therapy NICU Spiritual Care Peds
Ethics, Privacy, Security, and Confidentiality Magnet Standard:
At UCLA Health, nurses are guided by the ANA Code of Ethics in their care delivery.
RRUCLA Evidence:
There are many resources available to clinical nurses and nurse leaders to help to guide this component of their professional practice, including:
UCLA Ethics Center, which provides 24-hour consultation for ethics-related matters
Clinical nurses participation on the UCLA Ethics Committee
Ethics Grand Rounds
Circle of Caring Retreat
Annual training on policies and procedures around confidentiality
The UCLA Privacy Management Office, which monitors patient privacy and compliance
Access the RRUCLA Evidence:
Read more about the ethics, privacy, security, and confidentiality practices of UCLA Health in the following SOE:
ETHICAL ISSUES - EP17 Ethics Center Services Support and Develop Ethical Nursing Practice
Ethics Center NRE NICU
MAGNET COMPONENT #3: EXEMPLARY PROFESSIONAL PRACTICE
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Culture of Safety Magnet Standard:
At UCLA Health, the safety of our patients and our healthcare personnel is of the utmost concern.
RRUCLA Evidence:
There are many resources available to clinical nurses and nurse leaders to help safeguard the health and well-being of patients, families, and health system employees. Several successful safety interventions have been initiated by clinical nurses throughout RRUCLA.
Access the RRUCLA Evidence: Read more about RRUCLA’s culture of safety practices in the following SOEs:
WORKPLACE SAFETY - EP18EO Reducing Needlestick Injuries through Standardization of Safety Needles
4ICU Enterostomal Therapy 6E Infection Control 6N Materials mgmt 7E/5E TPN Services 7ICU Occupational Health 7N PT/OT Inpatient 8ICU Respiratory Therapy OR Admin PICU
Procurement & Strategic Sourcing
Improving Nurse Safety in the Emergency Department by Targeting Workplace Violence
ED Nursing Admin Security Department
PROACTIVE RISK MANAGEMENT - EP19EO Nurses improve Safety by Reducing Medication Errors
6N 8ICU Diabetic Services
6E 8N Nursing Admin 6W 7E/5E ED 7E PEDS Anesthesiology 8W 7W IT Help Desk
EVALUATING PATIENT SAFETY DATA - EP20EO Implementation of the ‘Bug Busters’ Committee on Acute Care Pediatrics
Infection Control Peds
NRE
Implementation of SBAR Standardized Practice to Reduce Time to Transport by the CCTT
Critical Care Transport Team
PATIENT SAFETY GOALS - EP21EO Nurses Leading Improvement in Medication Labeling and Communication in Perioperative Settings
Main OR
MAGNET COMPONENT #3: EXEMPLARY PROFESSIONAL PRACTICE
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Quality of Care Monitoring and Nurse Sensitive Indicators Magnet Standard:
At UCLA Health, measures of the safety of our patients, quality of nursing care, and patient satisfaction are collected throughout the year. Our data is then sent to the American Nurses Association (ANA) National Database of Nursing Quality Indicators (NDNQI) and to the National Healthcare Safety Network
(NHSN), where it is incorporated into the national mean score for all academic medical centers. Our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are also reported to the Center for Medicare and Medicaid Services’ (CMS) Hospital Compare website.
RRUCLA Evidence: We benchmark our performance against the ANA’s NDNQIacademic medical center mean for falls with injury and hospital-acquired pressure ulcers – stage II & above.
Falls with Injuries: The majority of inpatient units at RRUCLA (14/17) outperformed the NDNQI benchmark mean for the majority of the last eight quarters reported for falls with Injury.
Hospital-Acquired Pressure Ulcers (HAPU): The majority of inpatient units at RRUCLA (10/15) outperformed the NDNQI benchmark mean the majority of the last eight quarters reported for HAPU – stage II & above.
For central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), UCLA Health has chosen to benchmark our performance against the National Healthcare Safety Network (NHSN) Centers for Disease Control and Prevention (CDC) cohort pooled mean.
Central-Line Associated Bloodstream Infections: The majority of inpatient units at RRUCLA (12/23) outperformed the NHSN benchmark mean the majority of the last eight quarters reported for CLABSI.
Catheter-Associated Urinary Tract Infections: The majority of RRUCLA inpatient units (2/8) did not outperform the NHSN benchmark mean the majority of the last eight quarters reported for CAUTI.
To improve our CAUTI rates, house-wide surveillance began in Q2 2014. Additionally, the organization has created a multidisciplinary taskforce to review best practices, create a nurse-driven protocol to remove indwelling urinary catheters, and provide house-wide education on the details of the maintenance bundle practices. This taskforce includes participation from nursing leadership, physicians, IT leaders, and clinical nurses.
Access the RRUCLA Evidence: Read more about RRUCLA’s nurse-sensitive indicators and patient satisfaction scores in the following SOEs:
NURSE SENSITIVE QUALITY INDICATORS - EP22EO
Nurse-Sensitive Quality Indicators: Data Collection & Benchmarks
All Units Nursing Admin
PATIENT SATISFACTION - EP23EO
Patient Satisfaction Survey Overview All Units Nursing Admin
MAGNET COMPONENT #4: NEW KNOWLEDGE, INNOVATIONS, & IMPROVEMENT
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Research Magnet Standard:
The Department of Nursing at Ronald Reagan UCLA Medical Center offers a variety of resources to support the development of clinical nurses in their professional roles of scientist and transferor of knowledge.
RRUCLA Evidence: As nurses conduct research, there are multiple structures in place to support dissemination internally, including: • The “Investigator” newsletter • Nursing Research Grand Rounds • The Annual Nursing Research and Evidence-based Practice Conference
These structures and processes are supported through the Nursing Practice Research Council. UCLA Health nursing leadership created the Nursing Practice Research Council (NPRC) with a vision to develop and support innovations that heal humankind through the application of evidence-based knowledge to clinical practice. The NPRC laid the foundation for research and evidence-based practice (EBP) at UCLA Health and continues to focus on its mission of increasing the scientific foundation of practice through research conduct and utilization activities in the following four areas of work:
1) Research development - providing consultation in the design, implementation, analysis, and publication of nursing research
2) Research utilization – identifying and disseminating clinical research findings that are sufficient and appropriate to apply to nursing practice
3) Research education – occurring through classes throughout the year and through the annual Research and Evidence-Based Practice Conference
4) Research dissemination - providing structures and processes for the dissemination of research and other levels of evidence
Access the RRUCLA Evidence: Read more about RRUCLA’s nursing research in the following SOEs:
ADVANCING NURSING RESEARCH - NK1EO Improving the Care Experience for Children with Complex Chronic Conditions and their Families in the PICU: Parent and Nurse Perceptions
PICU
DISSEMINATING RESEARCH KNOWLEDGE - NK2 Nursing Grand Rounds Support Internal Dissemination of Nursing Research
7W NRE DOM PICU
ETHICS
Dissemination of Nursing Research to External Audiences: The Annual UCLA Nursing Research and Evidence-Based Practice Confernece
SOM Neurology
MAGNET COMPONENT #4: NEW KNOWLEDGE, INNOVATIONS, & IMPROVEMENT
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Evidence-Based Practice & Innovation Magnet Standard: Nurses at UCLA Health are encouraged and supported to understand the evidence base for their clinical practice and to adapt practice to reflect the most current evidence. They are further supported to design and implement innovative adaptations to care when the current evidence is lacking or an improvement in care is needed.
RRUCLA Evidence: There are many resources to promote nursing research, evidence-based practice, & innovation, including but not limited to:
UCLA Nursing Research and EBP Program
Clinical practice council
Mosby’s on-line resource
Nurse EBP fellowship program
Nursing grand rounds
“The Investigator” newsletter
Annual Research and EBP Conference
Access to UCLA Medical Sciences Library
UCLA Chief Nursing Informatics Officer and nurse informaticists
Access the RRUCLA Evidence: Read more about RRUCLA’s evidence-based practice and nursing innovations in the following SOEs:
INTEGRATING EVIDENCE-BASED FINDINGS INTO PRACTICE - NK3 Use of the Clinical Practice Council to Develop New Early Mobility Practices
4ICU PACU PT/OT Admin-MP
6ICU PICU Respiratory Therapy
7CCU 8ICU CCTT
7ICU
Use of the Clinical Practice Council to Revise Urinary Catheter Management Practices
8W 7E GOU
6E 7N 6N
NURSING INNOVATION - NK4 Interprofessional Innovation in Fall Prevention
6E 8N 6N Nursing Admin
6ICU OR 7E/5E
Innovation in Pediatric Sepsis Management QMS Overhead Peds ED PICU
IMPLEMENTATION - NK5EO Enhancing Nurse Immunization Screening Using E.H.R. Functionality
7E/5E Nursing Admin Infection Control PICU
ISS/CareConnect QMS Overhead ED
Improvement in Patient Experience with Technology
6E 8N L&R
8ICU GOU
IMPROVING WORK FLOW AND SPACE DESIGN - NK6EO Nurses Leading Efforts to Reduce Waste 8E Materials Management
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Would you like to learn more about Magnet & UCLA Health’s Magnet Journey? Please visit the UCLA Health Department of Nursing website at
http://nursing.uclahealth.org/default.cfm
Simply click on the ‘Magnet Journey’ tab at the top of the page to gain access to:
Ronald Reagan UCLA Medical Center’s Magnet Document
UCLA Health’s Annual Nursing Report
UCLA Health Strategic Plans
Magnet Site Visit Resource materials
And much more!
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GOT MAGNET QUESTIONS? DO NOT HESITATE TO CONTACT ANY OF THE FOLLOWING MAGNET CHAMPIONS AT RONALD REAGAN UMC!
UNIT NAME & ROLE EMAIL ADDRESS UCLA Health Jennifer Zanotti, MN, RN – MPD [email protected]
UCLA Health Charlene Collazzi – Magnet Analyst [email protected]
UCLA Health Jennifer Baird, PhD, RN [email protected]
4ICU
Ana Andress, RN Vicky Ramirez, BSN, RN
Xueqing Xu, RN Yu-Han Kao, MSN, RN, CNS
Ariana Bruno, RN Taylor Gorman, RN Chelsea Stone, RN
[email protected] [email protected]
[email protected] [email protected]
[email protected] [email protected] [email protected]
6E
Kathleen Caparoso, RN Kristine Greene
Michel Queen, BSN, CNIII Stephanie Jackson, MSN, RN, CNS
[email protected] [email protected] [email protected] [email protected]
6ICU
Barbara Anderson, BSN Kaitlyn Lattanzio, BSN, RN
Kathryne Figuracion-Cheng, BSN,RN Scott Demar, RN
[email protected] [email protected]
[email protected] [email protected]
6W Norma McNair, PhD, RN, ACNS-BC
Sheila Richardson, MSN [email protected]
6N
Derek Wilcox, MA, RN Pamela Nye, RN, MS
Paulette Salg, BSN, RN, CNIII, PHN Kathy Cheetham, RN
Sarah Jividen Taylor, RN
[email protected] [email protected] [email protected]
[email protected] [email protected]
7CCU/7N/ 7COU
Shubjeet Dhillion, BSN, RN Anthony Chan, BSN Mimmi Lowrie, RN
Wendy Tsau, RN, MN, CNS
[email protected] [email protected] [email protected] [email protected]
7E/5EMS Michelle Zadunayski, BSN
Beki Heffler, MN Tina Mamais, MSN
[email protected] [email protected] [email protected]
7ICU
Charlene Earnhardt, MSN Dalya Lovy, BSN, RN, CCRN
Gilbert Barco, RN
[email protected] [email protected] [email protected]
7W Cherie Neil, MSN, PCCN
John-Gabriel Pantaleon,BSN Renee Appleby, RN
[email protected] [email protected] [email protected]
8E Linda Chao, MSN, RN
Monica Choi, MSN [email protected]
8N Andrew Baird, RN, BSN
David Eskenazi, BSN, CCTN Vivien Lee, RN
[email protected] [email protected]
SOU Michele Puzon, MS, RN [email protected]
UNIT NAME & ROLE EMAIL ADDRESS
8W Leilani Quiambao, RN
Noelle Hunter, MSN, RN Poni Agarwala, BSN
[email protected] [email protected]
8ICU
Jennifer Do, MSN Jill Dowds, BSN, CCRN
Jyotpreet Jagpal, BSN, RN, Melanie Donovan, RN
Mo Keckeisen, MSN, RN
[email protected] [email protected] [email protected]
[email protected] [email protected]
Admin Cait Walsh, MSN Tracy Guy, MPH
[email protected] [email protected]
ED Marcia Santini, RN
Manny Pastoriza, RN [email protected]
Float Pool/ Resource
Team
Anndalos Bindra, MSN Melissa DeJesus, MSN Susanne Polka, BSN
Kim King, RN
[email protected] [email protected]
[email protected] [email protected]
GOU
Amelia Morva, BSN John Sy, BSN, RN
Marcy Trinidad, BSN, RN Miriam Gonzales-Lopez, MSN, RN
[email protected] [email protected]
[email protected] [email protected]
GOU/4ICU Mark Flitcraft, MSN [email protected]
JSEI OR Rochelle Torres, BSN [email protected]
MITS Meg Furukawa, MN [email protected]
NICU
Anahit Sarin-Gulian, BSN Brittany Laddusaw, BSN, RN, CNII
Heaven Holdbrooks, CNS Mae de Vera Reyes, MSN
Yolanda Kastner, BSN
[email protected] [email protected] [email protected] [email protected] [email protected]
OR Lauren Fujihara, MA [email protected]
Pall. Care Edith O’Neil-Page, MSN, RN [email protected]
Peds
Chai-Chih Huang, MSN Donna Estrella, BSN
Khanh Luu, MSN Margo Goldman, RN Sufia S. Husain, MSN
[email protected] [email protected]
[email protected] [email protected] [email protected]
Perinatal
Debbie Suda, MSN Nicole Casalenuovo, MSN, RNC-OB
Jennifer Barnato, RN Caroline Armstrong, RN
[email protected] [email protected]
[email protected] [email protected]
PICU Angela Rotuno, RN
Janine Carr, RN [email protected]
Cath Lab Angelica Lewis, NP [email protected]
Quality Brenda Clemens, BHA, RN [email protected]