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University of Colorado Hospital UEXCEL CREDENTIALING PROCEDURE: LEVEL III AND LEVEL IV

2013-2014

Dear Professional Registered Nurse, The UEXCEL Board is delighted you are interested in advancing by credentialing to a new level of clinical practice! Both regular and flex clinical registered nurses are eligible to advance in the UEXCEL Practice Program by portfolio submission. UEXCEL is one of the cornerstones of nursing practice at our hospital, and contributes to sustaining our excellence as a Magnet™ designated hospital.

UEXCEL is structured around the Magnet model components:

Exemplary Professional Practice – the goal is more than just the establishment of strong professional practice; it is what that professional practice can achieve. Transformational Leadership – transformational leaders identify and communicate vision and values and ask for the involvement of the work group to achieve that vision Structural Empowerment – the organizational structure acknowledges, values, supports and develops strong professional practice New Knowledge, Innovations & Improvements – establishes new ways to achieve new heights of quality, efficiency, and effectiveness.

UEXCEL is a professional practice program that offers the opportunity for promotion through submission of a portfolio demonstrating achievements of clinical nursing practice, and contributions to professional nursing at UCH and the community. The UEXCEL Board has prepared this material to help you with your portfolio development. Please read this information carefully so you are successful in advancement.

REQUIRED STEPS IN APPLICATION PROCESS

The UEXCEL Board wants you to be successful! Follow the steps outlined below. Remember to construct your portfolio so UEXCEL Board members who are not familiar with your specialty practice can clearly understand your work. Be very clear how you have met the advancement requirements. Level IV’s are required to submit a digital portfolio. Although digital portfolios are optional for Level III’s, this option is highly encouraged. Contact UCH-UEXCELDigitalP@uchealth.org for additional information. Please note: Beginning September 2014 (FY15), all Level III and Level IV’s are required to submit a digital portfolio; binders will no longer be accepted. Submit Independent and Completed Work

Your portfolio is documentation you are requesting a promotion. It shows how you are eligible to be promoted to a higher level of practice. Therefore, it represents your own completed work, not plans for the future or the work of others.

If you participate with others on a project, you must show your own distinct contribution, presented in your own words. Highlighting your own work by color coding is

suggested as a way to ensure your own work is clearly outlined as compared to others.

Do not copy material that a peer is submitting for their portfolio. Do not include material that others have created, only your original work.

If you feel your work might be similar to someone else’s, consult your manager/educator/advisor to ensure proper documentation of independent work.

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STEP ONE

The full copy of UEXCEL standards is on the UEXCEL website. Review the standards for the level you are applying to advance. [See UEXCEL Standards] You must demonstrate how you are currently performing at the level of advancement you are seeking.

STEP TWO

Register on Healthstream and complete the Healthstream Courses titled UEXCEL: Supporting and Advancing Your Nursing Career, Part I and Part II.

UEXCEL Workshops are available to help you be successful! Enroll via Healthstream:

Introductory workshop: general overview of the program and tips for success

Digital Portfolio Workshop: Provides an introduction and overview of how to navigate and set-up a credentialing portfolio site using the digital platform supported by UEXCEL. This workshop is strongly recommended if you plan to submit your portfolio in the digital format. The Digital Portfolio workshop is open to all candidates and the advisors of those credentialing candidates.

Resume/Narrative: tips for completion

Research and Evidence Based Practice Courses are available via Professional Resources Department Continuing Education website at http://www.uch.edu/classes-events/.

Creating a survey How to display data Creating a poster How to create an abstract

STEP THREE Discuss advancement with your manager. Obtain confirmation you are on track to be considered a ‘Role Model’ on your performance appraisal. Gain agreement for your project(s), administrative time, and your manager signature on the Intent to Credential Form. STEP FOUR Choose Your Advisor Carefully. Select your advisor from the list of certified advisors listed on the UEXCEL website. You must select an advisor who has attended a mandatory UEXCEL Advisor Course and is certified. This list will be posted and updated on the UEXCEL web as individuals become certified. Choose an advisor who knows the current process for advancement and is willing to take time to help you to advance. An advisor who has successfully advanced recently to the level you hope to credential is most helpful. Obtain their signature on the Intent to Credential Form. STEP FIVE

Scan and submit the Intent to Credential form to the UEXCEL Board Chair/Secretary by email to UCH-UEXCEL@uchealth.org no later than April 1, 2014.

Scan and submit the certificates showing you completed the UEXCEL courses Part I and Part II along with your Intent to Credential Form. The certificates can be printed at the end of completing each course, on the Certificate of Completion page. STEP SIX Construct your portfolio according to the following requirements: The majority of your activities documented in your portfolio must have taken place between September 1, 2013 and August 22, 2014. (Activities may be started prior to September 1.) All materials must be dated. A. Place all components in a three-ring, hard cover binder or within your digital portfolio. Place only essential materials in notebooks. Excessive documentation, such as, multiple emails, does not help your

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application. Limit emails to a snapshot of what relates to a particular project.

Paper Notebooks up to 3” in depth. Do not exceed 3”.

Type all documents (Does not apply to raw data or revisions to policies and procedures).

Type labels for tabs, cover, and side seam of binder. Section tabs should be visible.

Include the following information on the cover and seam labels: name, date, unit, application level.

Digital Portfolio applicants may submit a ¼” binder or send an email to UCH-UEXCELDigitalP@uchealth.org with the web address and password of your weebly.com account.

B. The portfolio must include 4 sections labeled as follows:

1. Exemplary Professional Practice 2. Transformational Leadership 3. Structural Empowerment 4. New Knowledge, Innovations & Improvements

C. Type an introduction and timeline for EACH SECTION to provide the Board with an overview of your work and achievements. This typed introduction and timeline must then be followed by the supporting documentation behind each section tab. D. View successful portfolios! Credentialing Nurses may come to Professional Resources to view a portfolio between 0800 and 1700 Monday through Friday. For digital portfolios, Credentialing Nurses may contact UCH-UEXCELDigitalP@uchealth.org for digital portfolio samples. E. Note: Any journal club activity, regardless of where placed in the portfolio must include CE application,

attendance record, evaluation summary, completed critique form and copy of article. F. Level IV Applicants: It is strongly recommended you attend a UEXCEL Level IV Committee meeting. It is also recommended you select a Level IV Advisor that may be on a different service, to promote impartiality regarding your work. Contact the Level IV RNs at UCH-LevelIVRN@uchealth.org

STEP SEVEN

Place this UEXCEL Credentialing Procedure Form in the front of your portfolio. Use this form to review the contents of your portfolio with your advisor prior to submitting the portfolio. Your advisor must initial in each box to indicate that the portfolio has been reviewed and is ready for submission, then sign at the bottom. Advisors will not sign this form unless they feel your portfolio is ready for Board review.

STEP EIGHT

Submit portfolio no later than August 22, 2014 to the UEXCEL Board Secretary/Chair in the department of Patient Services, Leprino Office Building 10th floor north, suite #1049. Deliver the portfolio in person. We cannot be responsible for misplaced portfolios left in other offices or sent via campus mail. If you are submitting a digital portfolio, you must drop off your ¼ inch binder in person to the location stated above or email to the UCH-UEXCELDigitalP@uchealth.org. Every portfolio is reviewed and rated by at least two different Board members. If there are questions about a portfolio, a third review takes place. This process is considered peer review and is confidential. If you are not approved for advancement, the procedure followed is outlined in the UEXCEL Bylaws, published on the UEXCEL Website [See UEXCEL Bylaws].

STEP NINE (Optional for Level III, Required for Level IV)

You are encouraged to present your portfolio personally to the UEXCEL Board at one of the Board portfolio review sessions. Those who choose this option will be given 10 minutes to present their portfolio. Presenters should be prepared to present detailed highlights of each section. If you choose not to present in person it will not affect the Board’s credentialing decision. If you are applying for Level III and you choose to present before the board, you must notify the UEXCEL Board Secretary at the time of portfolio submission. All Level IVs will be contacted after submitting their intent to credential to

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arrange a time for their presentation to the board. [See UEXCEL Guidelines for Presenting Your Portfolio]

STEP TEN

You will receive information about the UEXCEL Board’s decision via delivery and receipt email on the date of the last portfolio review session (typically, this is the last week in September.). If your promotion is approved by the Board, your promotional increase in pay will be awarded according to Human Resources timelines.

ADDITIONAL TIPS FOR SUCCESS

If you are considering Level IV, the Board requires a portfolio that will reflect an expert level of clinical practice. If you are in a clinical registered nurse or permanent charge registered nurse job description, but you regularly float administrative hours to serve in an alternative role such as Outcomes Coordinator, your UEXCEL Portfolio MUST reflect work accomplished in the clinical nurse role, not the alternative role. Please contact a UEXCEL Board member if you have further questions. You may choose an in-depth project and carry this through the entire portfolio as one way to meet the expectations for this top level of practice.

This document also serves as the Advisor check off. Advisor: Please initial in the box adjacent to the requirement. If the documentation is not complete

and you cannot initial, the portfolio should not be submitted. Thank you.

Portfolio Criteria Level III Level IV

Advisor Check-

off. Please initial

A Remove all patient identifiers. Mandatory Mandatory

B When you include a literature review in your portfolio, you must include appropriate levels of evidence identified for each citation.

Mandatory Mandatory

C A literature search/review is required for the following sections Transformational Leadership, Structural Empowerment and New Knowledge, Innovations & Improvements.

Mandatory Mandatory

D

Place a timeline and all supporting evidence behind the introduction for the following sections: Transformational Leadership, Structural Empowerment and New Knowledge, Innovations & Improvements.

Mandatory Mandatory

E Committee membership alone does not fulfill the requirements of any section. You must demonstrate advanced participation and contribution.

Mandatory Mandatory

F Provide evidence of engaging stakeholders and seeking appropriate committee approval prior to implementing change(s).

Mandatory Mandatory

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Exemplary Professional Practice Level III Level IV

Advisor Check-

off. Please initial

Section Notes

You must complete section A-F under Exemplary Professional Practice.

Mandatory Mandatory

A Include your resume. Mandatory Mandatory

B

Documentation of Education: Provide a Xeroxed copy of your ADN, BSN, MSN, or RN to MSN diploma. In lieu of a misplaced diploma, an official transcript is required with the seal of the school affixed. No exceptions will be made to this requirement. If you are an ADN applicant:

You must be enrolled in a BSN program, or RN to MSN program

In addition to your ADN diploma, you must submit an official transcript showing courses you are currently taking from a college registrar. If submitting a digital portfolio, official transcripts must be included in the ¼ inch binder.

Taking prerequisites or confirmation of future acceptance/ coursework does not represent active enrollment. You must have a transcript showing current nursing courses to meet the requirement of active enrollment. Your transcript must show progress toward completion of your BSN degree within the three (3) year limit from the date of credentialing. No exceptions will be made to this requirement.

Mandatory Mandatory

C

If applying for Level IV, include documentation of certification in your specialty area. Additionally, documentation of education must show that you have completed a BSN per Level IV standards and advancement requirements.

~ Mandatory

D

Letters of Recommendation: Applicants need 2 signed letters of recommendation:

1 RN manager/director*

1 RN peer (other than your advisor).

Letters must be on UCH letterhead and signed.

Letters need to clearly and completely outline how you demonstrate the qualifications necessary for promotional advancement. You may include an additional letter, but it will not influence Board review of your portfolio.

*Note: If you are an ambulatory nurse applicant and are supervised by a non- nurse practice manager, please include an additional letter from an ambulatory nursing director.

Mandatory Mandatory

E

Performance Appraisal: Include one copy of your 2013-2014 Human Resources performance appraisal. The appraisal must be signed by your manager/director and show you reached Role Model status at your current level.

Mandatory Mandatory

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Exemplary Professional Practice Continued

Level III Level IV

Advisor Check-

off. Please initial

F

Clinical Narrative: Clinical narratives are reflections of clinical nursing practice, originally described in Benner’s book From Novice to Expert (Benner P. From Novice to Expert. Menlo Park, CA: Addison Wesley Publishing; 1984). This book does not need to be your actual philosophy or values, but it describes how clinical narratives reflect your level of practice.

The clinical narrative must describe your philosophy of values of nursing practice and how you integrate this philosophy/these values into your practice.

What do you believe about nursing and your practice?

The clinical narrative must give details of clinical practice using a clinical example/case within the credentialing year that shows the Board how you are practicing at the level you are applying to credential. How do you practice differently now that you are working to advance to the next level? You may use historical anecdotes, but the clinical narrative example(s) must relate to your current practice.

Mandatory Mandatory

Level IV

Level IV RNs are expected to give a specific practice example that is of a more detailed and expert level to show their level of practice.

~ Mandatory

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Transformational Leadership Level III Level IV

Advisor Check-

off. Please initial

Section Notes

Your typed introduction and timeline for the Transformational Leadership section must explain how your project was value added to your unit. You must complete sections A and B under Transformational Leadership

Mandatory Mandatory

A

Unit/Organizational Projects: Review the UEXCEL Leadership Standards carefully. Projects need to be a value added component to a position. Value added means additional contribution(s) above and beyond job position responsibilities. For example, acting as permanent charge RN fulfills the charge RN job description; you are evaluated on this practice by your performance appraisal.

Examples of implemented projects are: implementing how unit report is given, improving meal breaks, new methods for improving MD/RN communication, changing care delivery flow and function, improving staff/patient education and implementing a clinical evidence-based practice QI project.

Tips for organizational projects are as follows:

Work on depth of projects rather than excessive quantity. You only have to do one value-added project. Your leadership project can have many components that provide supportive documentation for other sections of your notebook, such as instructing staff on your project, or measuring outcomes of your project, in those sections of the portfolio.

Document a literature search/review, with levels of evidence, to show the rationale for your project.

Explain how this project added value, and what were the outcomes.

If serving on a committee also demonstrate your leadership, include a copy of:

Sample committee minutes Attendance record Participation and

contributions beyond committee membership must be demonstrated.

Compliance with committee membership expectations.

Mandatory Mandatory

Level IV

Level IV: Focus on projects that support how you function as a

leader either within your unit, dept. or UCH in a broader scope.

This project must show you are a leader in your specialty, taking

the lead on a project you feel passionately about to improve

patient care. The project can be clinical or administrative, but

must demonstrate independent initiative, critical thinking and

interprofessional or interdepartmental collaboration. Projects

must be evaluated in depth for effectiveness, and analysis

conducted as to impact and outcomes.

~ Mandatory

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Transformational Leadership Continued

Level III Level IV

Advisor Check-

off. Please initial

B

Policy and Procedures/Standards/Guidelines: Professional practice requires a commitment to improve UCH nursing by setting professional standards/policies using evidence-based practice. Examples of this requirement are:

Developing or revising policies and procedures, guidelines, standards of practice, protocols, teaching standards, or patient teaching materials.

Before creating a new policy and procedure or guideline, be sure to confirm that a policy and procedure does not already exist on the topic by checking the online policies, procedures and guidelines.

Use citations from literature (print out literature search titles, articles if not extensive numbers, or article abstracts) and levels of evidence in your work.

Document that materials were approved or in process of approval by those in authority in your clinical service/hospital.

A typed description must be included in this section, following the initial summary description.

Documentation Required: Copies of the standards, policies and procedure, guideline and order sets must be included in this section:

o Original o Drafts, with email documentation from

stakeholders o Final approved copy using the hospital

approved template*.

If you are revising an existing policy and procedure or guideline your personal revisions or modifications should be clearly noted by highlight, underlining, etc.

Personal publications of any type are part of the Structural Empowerment section, not this section.

* For Ambulatory Services nurses, please refer to the Ambulatory Service guideline process and appropriate templates for developing guidelines and protocols for Ambulatory Clinics.

Mandatory Mandatory

Level IV

Level IV: Level IV nurses have experience with implementing change through previously updating or creating a policy and procedure, guidelines or standards for practice. Choose a project that shows your advanced knowledge of performing a literature review and using EBP to make improvements. This should be more than a few changes and needs to show your understanding of the process for making improvements at UCH. An example is a policy that impacts the hospital, across divisions, or a care standard for a population across two hospitals.

~ Mandatory

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Structural Empowerment Level III Level IV

Advisor Check-

off. Please initial

Section Notes

Your typed introduction and timeline for the Structural Empowerment section must include a description of how you share your expertise with peers. You must complete two of the following three sections (A-C) under Structural Empowerment.

Mandatory Mandatory

A

Preceptor: Documentation Required:

Certificate

Evaluations

Attendance Records from unit Preceptor Council meetings or the Preceptor Advisory Committee, if applicable

Two of the three sections

(A-C) in Structural

Empowerment are mandatory.

Two of the three sections

(A-C) in Structural

Empowerment are mandatory.

B

Teaching Activities: Review the UEXCEL Structural Empowerment Standards. Type a description of what you taught; include copies of supporting documentation. Examples of teaching activities include but are not limited to:

Conducting an inservice, include sign in sheet and evidence of content development

Educational Poster, include sign in sheet and picture of poster or poster content

Conducting a CE class, include CE application, attendance record, and evaluation summary

Developing content and teaching a class or Skills Lab, include evidence of content development and sign in sheet

Two of the three sections

(A-C) in Structural

Empowerment are mandatory.

Two of the three sections

(A-C) in Structural

Empowerment are mandatory.

C

Journal Club – research based article Clinical Article Review – Conducting a Live or Virtual Journal Club or Clinical Article Review: journal clubs must be value added. Describe how this impacted your area. Documentation Required:

CE application

Attendance record

Evaluation summary

Completed critique form

Copy of article

Copy of blog comments (Virtual Journal Club only)

If you are co-facilitator, you must document your contribution.

Two of the three sections

(A-C) in Structural

Empowerment are mandatory.

Facilitate a clinical article

review or a journal club.

Two of the three sections

(A-C) in Structural

Empowerment are mandatory. Facilitate one

journal club per year.

Optional:

Your CE Record Community activities

Optional Optional

Level IV

Level IV: Choose teaching activities that show how you function as an expert clinician. Demonstrate how you share this knowledge with others. Examples: hospital wide teaching of a change initiative or journal club conducted in more than one area.

~ Mandatory

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New Knowledge, Innovations, & Improvements

Level III Level IV

Advisor Check-

off. Please initial

Section Notes

Your typed introduction and timeline describing your outcome activities and copies of data results or other documentation must be included under New Knowledge, Innovations & Improvements.

Mandatory Mandatory

Describe your leadership role in outcome activities. Include data collection of a specific project and a plan for follow up. Examples:

FOCUS-PDCA

Change initiatives (may include a business plan)

QI project Documentation required:

Samples of attendance Minutes Literature reviews with level of evidence. Actions

taken for improvement per above details. Outcome initiatives must include collection of pre and post data. Data must be illustrated in graph or chart form. You are required to provide graphs, charts and/or data above and beyond graphs from other sources (i.e., NDNQI, OPIT)

Include “n”, or number, to describe sample size.

Include samples of raw data and or completed audit forms.

Describe plans for follow up, regardless of results.

Mandatory Mandatory

Level IV

Level IV: Choose projects that demonstrate your expert knowledge, critical thinking and leadership skills. This information must be presented first in abstract form, which must include an explanation of background, methods, results, and implications for practice. Projects that have implications in other areas across the organization or system must show plan for dissemination of best practice(s), i.e. revamping the code lab results for inpatient services, hypothermia protocol for ED and critical care, and heart failure education for ambulatory services.

~ Mandatory

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University of Colorado Hospital Intent to Credential Application UEXCEL Level III and Level IV

Name: Employee ID:

Home Address:

Unit/Clinic:

Date:

Current UEXCEL Level: Level Applying to Credential:

Manager/Director: Manager/Director Mail Stop:

Manager/Director Signature:

UEXCEL has a mandatory advisor program, effective 2010. Please review the Certified Advisor list on the UEXCEL Website, as well as the UEXCEL Board member list, select an advisor, then write the advisor preference below. Please remember your advisor must have already recently advanced to Level III or Level IV, the same level you desire to credential.

Name of Advisor:

ADVISOR COMMITMENT STATEMENT:

I agree to be a UEXCEL Advisor. I understand this commitment means I am currently knowledgeable about the UEXCEL requirements and I will support the advancement process. I attest to having completed an Advisor Certification course. I agree to review the notebook and the advancement criteria with this applicant prior to portfolio submission.

Signature: Date:

I have reviewed the UEXCEL Standards for the Level I am applying to advance.

I have completed the Healthstream courses titled UEXCEL: Supporting and Advancing Your Nursing Career, Part I and II. Please print out the certificates to document you have prepared for portfolio submission, and attach to this application.

I have reviewed the written material on the Credentialing Procedure: 2013-2014 Level III & Level IV.

Deadline

Your Intent to Credential form must be scanned and emailed to the UEXCEL Board Chair/Secretary at UCH-UEXCEL@uchealth.org no later than

April 1, 2014. You will receive a confirmation email.