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2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council Grid2022Sentara Healthcare System NursingPractice Forum, Council, and CommitteeShared Governance ToolkitUpdated fall 20211

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council Grid2022 System Nursing Forum, Council and Committee Chairs,On behalf of Sentara Healthcare we want to thank you for taking on this crucial role of System NursingChair to continue the advancement of evidence-based nursing practice and supporting improvement in ourpatient outcomes. Our collective mission for Sentara Healthcare is to improve health every day for ourpatients. Making a difference takes courage, integrity, passion, ingenuity, and advocacy. These endeavorsconnect all Sentara nurses. Our system work, through our nursing structures are based on a model ofshared governance in decisions and actions that guide our nursing vision, to create an environment ofhealth and healing.Your willingness to step up and take a leadership role for one of our System Nursing Practice Forums,Councils, or Patient Sensitive Committees allows us to come together to assess and adopt evidence-basedpractices across our diverse settings. Together we coordinate policies, procedures, job aids,competencies, and nursing standards to provide relationship-based care.We are committed to supporting you in this endeavor. We want to thank each of you for all you do as aprofessional nurse within Sentara. Consistent, highly reliable nursing care is what we strive for every day.We want this to be the hallmark of nursing at Sentara.Sincerely,GenemarieGenemarie McGee, MS, BSN, RN, NEA-BCCorporate Vice President, Chief Nursing OfficerSueSusan Winslow, DNP, RN, NEA-BCSystem Director Professional Practice/ Clinical Education2

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridTable of Contents1.2.3.4.5.TopicObjectivesProfessional Practice Model OverviewShared Governance Schematic & GuidelinesStructureRole & Responsibilities of executive sponsorRole & Responsibilities of chair(s) and chair(s) electRole & Responsibilities of evidence-based practice mentorRole & Responsibilities of direct care nurse memberRole & Responsibilities of formal leader memberRole & Responsibilities of education subject matter mentorPurpose StatementsMeeting ManagementCharter templateMembership grid templateTips for creating agendasAgenda templateMinute templateAnnual summary reportMonthly Nurse Executive Council update templateModified Roberts Rules of Order/voting guidelinesToolsCompliance 360 Policies, Procedures, Job Aids, and competenciesHandoff outline from previous chairCritical contactsAnnual specialty competency guidelines and sample templateContinuing Education ResourcesEducational ResourcesEvidence-Based Practice tip -2627282930313233-3435363

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridObjectives1.2.3.4.5.6.7.Positively impact nurse sensitive patient outcomes and strategic goals.Provide purpose of shared governance.Understand specific roles in successful system nursing structures.Understand how to successfully advance team.Facilitate successful meetings to achieve charter and strategic goals.Provide platform to efficiently determine common nursing standards, initiatives, and outcomes.Ensure a structure to support the voice of clinical nurses.4

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridProfessional Nursing Practice ModelShared nursingvisionPillars representingscope of nursingpracticeDivisions maychoose anadditional theoryor theoristCommonfoundations ofnursingpracticeRevised 2018Professional Practice Models (PPMs) serve as graphical depictions demonstrating how professional nursespractice, function, interact, and develop professionally to provide high quality care. Sentara Nursing’s PPMdescribes the foundation of our common nursing practice, provides a clear vision for nursing care, andhelps us to achieve optimal patient outcomes. The image of a Parthenon illustrates the commitment tocreate an environment of health and healing underpinned by a culture of safety and accountability withinrelationship-based care. A structure of power and strength, the Parthenon structure provides anunyielding, solid foundation to support nurses’ relationship to safe and accountable patient care.5

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridThe original PPM was developed in a collaborative effort between the system entities at that time. In late2017 a formal evaluation of the PPM was launched to assess the current alignment of the PPM withpractice, mission, vision, philosophy, and values. Modifications were suggested and by 2018 an updatedPPM was accepted and adopted.The PPM foundation is a base of safety and accountability, relationship-based care, and nursingfoundations unique to each division’s culture. Pillars represent the nursing scope of practice. The roofreflects the nursing vision, to create an environment of health and healing. The theoretical framework forSentara Nursing is Relationship-Based Care (RBC). RBC includes the focus on the caregivers’ relationshipwith self and other team members, in addition to the caring relationship with patients and families. TheCare Delivery Model (CDM) predominantly used across Sentara Nursing is modified primary nursing usingan RN as the primary care giver supported with unlicensed assistive personnel. The CDM is integrated withthe PPM and describes: the context of care, the manner in which care is delivered, the skill set requiredand expected outcomes.Shared governance is part of the PPM providing a framework for shared decision making throughout thehealth system. Within Sentara Healthcare, shared decision making is defined as a working model ofparticipatory governance in which nurses make decisions about clinical practice standards, qualityimprovement, staff and professional development, and nursing research. Shared decision making ensuresconsistency in nursing care and defines nursing’s authority, autonomy, and accountability for patients andfamilies. The structure of system, divisional, and unit nursing forums, councils and committees allowsnursing staff to be involved and/or heard through representation. Throughout Sentara Healthcare, everynurse is a leader and the structure and processes defined in the PPM support this vision.6

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2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridShared Governance GuidelinesSystem nursing forums, councils, and committees assume responsibility for the professional practice ofnursing at Sentara Healthcare. Shared governance enables evidence-based practice standardization acrossthe organization. Division-based councils focus on topics and needs of their division for local developmentof nursing. System Nursing Practice Forums are nursing meetings where evidence-based practice clinicalissues on particular specialty practice issues are exchanged and formalized. The forum membership iscomprised of majority of staff level representatives to support nursing strategic priorities and patientoutcomes. Nursing Councils are system level advisory-type groups formally organized and meetingregularly to support nursing practice. System Patient Sensitive Measure Committees are ad-hoc groups ofnurses monitoring nurse-sensitive clinical outcomes, sensitive to those interventions performed primarilyby nursesStructureTeams establish a charter to include membership, strategic goals, structure, format, authority,recordkeeping and communication. Annually, teams review and develop key actions reflective of thecharter in alignment with nursing strategic plans and clinical priorities. Chairs report monthly on the statusof those goals, formal recommendations, and potential barriers to the Nursing Executive Council.General Membership GuidelinesEach division has the opportunity for membership. Members are selected through divisional nominationswith rotations each calendar year. An orientation workshop is conducted each year for the upcomingChairs. Orientation for new members should be included as a formal agenda item during the first quarterof every year. Each nurse member is responsible for communicating the issues to their division and providebi-directional feedback to represent the collective voice of their division. Certain Practice Forum havenamed speciality representatives representing specialty patient populations. All Practice Forums andpatient sensitive measure (PSM) Committees will have an evidence-based practice and educationalmentor(s) to guide nursing practice decisions.ChairsThe forum and committee chair roles requires a three-year commitment: one year as the chair-elect, oneyear as the chair and one year as the past chair. The Chair will establish the ground rules for acceptablebehavior during meetings following simplified Robert’s Rules of Order and will set the agenda with inputfrom the members and the executive sponsor. Teams may opt to have a co-chair model, with two leads forthe team. Chairs may serve more than one term. Chairs of the Councils do not change each year unlesstheir formal position transitions.Attendance and RepresentationTo support the concept of allowing nursing staff members to be involved and/or be heard through9

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council Griddivisional representation, meetings are open to all nursing staff. Voting members will include thoseformally representing their division. Each forum and council will have an executive sponsor for guidanceand facilitation.Forums and Select CouncilsDivisions will elect direct care nurse members to comprise at least 50% of the membership of the practiceforums and PSM committees. Members will serve one-year terms and may be re-elected or re-appointed.Each division will have two members per forum: one a direct care clinical nurse and a second formal leaderor educational representative. If a member misses more than 3 consecutive meetings, then the chairshould request a new representative. Ad hoc or interdisciplinary members may be requested as needed toachieve goals. Councils will name members who represent each involved role, division, or area related tothe purpose of the council.Decision Making/VotingTopics will be noted on agendas and open for discussion with all members. Each council member, includingthe Chair, is allowed one vote. Voting shall be majority rules of members present known as unanimousconsent. The process involves asking if there's any objection to adopting the motion. If no one objects,then the motion is adopted. If even one member objects, then the group proceeds to take a vote.Quorums are not required. If the vote is too close to call a roll-call vote is used. When confirming arecommendation involving formal policies, procedures, or job aids; a roll call method should be used andfor divisions not present proxy voting or electronic voting should be used to ensure their awareness andconsent. Ad hoc members do not vote. The record of how each member votes is recorded in the minutes.In the event of a tie the motion will be escalated to the Nursing Executive Council for resolution.Scope of AuthorityEach forum council and committee will make recommendations to the Nursing Executive Council (NEC).NEC will make final decisions on recommendations. Interdisciplinary agenda items may require HighPerformance Teams (HPT) communication.RecordkeepingEach council will record minutes to include attendance by name, title, credentials and work area/unit;topic, evidence supporting the topic, and a brief summary of discussions and actions. Agendas andminutes will be posted on Sentara Intranet sites.Meeting Times and FormatA structured meeting sequence has been established. Each council will meet monthly as needed for aperiod not to exceed a recommended two hours. No two consecutive meetings shall be cancelled. Ideally aface-to-face retreat will occur at the beginning of the year and near the end of the year, as appropriate.Online meeting technology will be used for all meetings to allow for participation of remote members.10

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridDivisional members are highly encouraged to gather together in person at their site to join onlinemeetings.MondayTuesdayWednesdayThursdayWeek OnePatient Sensitive Measure (PSM) Committees; CLABSI, CAUTI, HAPI, FallsWeek TwoDivisional Shared Governance CouncilsWeek ThreeSystem Practice System PracticeForumsForumsWeek FourWeek FiveFridaySystem lForums*( 9-3; ALLsystem PFchairs & C360liaison attend12:30 -1:30)System Councils; Education, Research, Supply, Pharmacy/Nursing, Excellence, NACOptional retreats or symposiums11

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridExecutive Sponsor Roles and Responsibilities1.2.3.4.5.6.7.8.9.10.11.12.Provide clear direction and linkages to strategic goals to group.Report or provide access to quality, financial and satisfaction metrics pertinent to team goals.Develop a strong partnership with the council chair(s) providing active leadership mentoring.Help to set the agenda in partnership with the chair.Contribute management knowledge to decision making.Use expertise to balance staff and patient needs with realities of business.Invite and support interdisciplinary members in the work of the council.Secure or clarify project resources related to goals and projects of team.Ensure use of evidence-based findings to support recommendations.Champion executive level awareness and buy-in.Act as formal liaison to Nurse Executive Council.Celebrate successes through recognition of achievements and lessons learned.12

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridChair(s) Role and ResponsibilitiesThe Chair(s) of the Nursing Forums and Committees are strongly encouraged to be a clinical staff memberfrom the clinical or service area that represents subject matter expertise in the practice area. Chair(s) ofCouncils are typically those responsible through job profile for the team outcomes.1.2.3.4.5.6.7.8.9.10.11.12.13.Chair(s)The Chair will coordinate meetings, communicate activities, role model effective communication skills, andfacilitate the development and work of the forum or council on an ongoing basis under the mentorship ofthe executive sponsor.Guide planning and prioritizing annual strategic goals.Oversee process of initial and revision of forum aligned policies, procedures, job aids, initial and annualcompetencies.Establish monthly agenda and disperse to council members before each meeting in a timely fashion.Facilitate meetings according to guidelines including appointing a timekeeper and minute taker.Maintain current roster of members; replace members missing meetings per guidelines.Use evidence-based findings to support recommendations.Ensure divisions are appropriately considered when creating documents guiding nursing practice.Ensure council agendas, minutes, rosters, meeting times, and general information is communicated.Help to build consensus by ensuring all voices are heard.Solicit volunteers for special projects and follow through to ensure completion of projects.Mentor co-chair so they can step into role of chair the following year.Attend NEC virtually each month to present key actions and recommendations.Prepare a brief year-end summary of accomplishments and actions.Chair-Elect Role and Responsibilities1.2.3.4.5.6.7.8.Work in conjunction with Chair and Executive Sponsor to establish monthly agenda.Help set annual goals.Assist with meeting facilitation.Work with chair; learn the process for posting and disseminating information.Support work of council via participation on subcommittees or special projects as needed.Assume the Chair position if it is vacated.Conducts council meetings in the absence of or at the request of the chair.Leads monthly meetings during the fourth quarter of their year with support of Chair.13

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridEvidence Based Practice (EBP) Mentor Roles and ResponsibilitiesEach Practice Forum and PSI Committee will have an EBP Mentor(s). EBP Mentors will be aligned based ontheir nursing expertise and patient population roles. Ideally, EBP Mentors will have been formally preparedin evidence-based practice through formal academic education.1.2.3.4.5.6.7.8.9.Role of EBP MentorChampion current and evolving evidence-based practice standards in area of expertise for clinicalstandardization of best practices through creation and revision of policies, procedures, and job aids.Access and interpret professional practice arena guidelines, standards, research findings, or othervalidated findings.Guide team’s interpretation of new EBP findings to assess potential impact on practice.Navigate performance improvement, EBP evaluation projects, and need for nursing research.Demonstrate respect for colleagues, patients, and families.Regularly attend monthly meetings, with minimum absences.Celebrate successes with specific recognition strategies.Seek opportunities for dissemination of projects, studies, and literature reviews.Identify needed areas of nursing research to formalize scientific findings on areas lacking robust evidenceto support.Selection of Member1. EBP Mentor is recruited based on expressed interest in participation and expertise in practice area; theSystem Director of Advance Practice and Patient Outcomes will confirm appointments.2. Mentors requested to commit to participate in a one-year term. After the initial term, members mayindicate ongoing desire to serve a subsequent term.14

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridDirect Care Staff Member Roles and ResponsibilitiesMembers will:1. Engage in active, regular attendance at meetings with active participation.2. Join in person (if feasible) at division with other representatives in virtual meetings.3. Review agenda prior to meeting and query coworkers to represent division’s collective input whenappropriate, regarding discussion items and problem-solving.4. Disseminate critical information and talking points to unit-department staff as agreed to by unitleadership and staff.5. Be responsible for contributing toward positive team function, application of active communicationskills and creating a problem-solving environment with colleagues.6. Champion evidence-based practice standards in area of expertise for clinical standardization of bestpractices through creation and revision of policies, procedures, and job aids.7. Demonstrate respect for colleagues, patients, and families.8. Proactively plan coverage with manager to attend meetings to represent input as expected.Selection of Member:Divisional direct care staff is recruited by manager based on expressed interest in participation in practicearea. After the initial term, members may indicate ongoing desire to serve a subsequent term. If more thanone person indicates interest an election should be held.15

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridDivisional Formal Leader/Educator Roles and ResponsibilitiesRole of a Council, Committee or Forum Leader/Educator Member1. Support strategic goal identification and actions to positively achieve.2. Formally communicate between council meetings with divisional counterparts to ensure that divisionalperspectives as well as their own are represented at council meeting.3. Contribute toward positive team function, application of communication skills (active listening, seeking toenrich own perspective), and creating a learning environment with colleagues.4. Champion evidence-based practice standards in area of expertise for clinical standardization of bestpractices through creation and revision of policies, procedures, and job aids.5. Demonstrate respect for colleagues, patients, and families.6. Regularly attend monthly meetings, with minimum absences. If unable to attend a meeting, make everyeffort to find an alternative to attend the meeting to represent division input.7. Celebrate successes with specific recognition strategies.8. Partner with council or forum divisional front line staff member. Attend or partner all meetings withrepresentative to mentor front line staff.9. Enhance the integration of new members as well as build a membership succession.Selection of Member1. Formal leader or educator is recruited by executive and peers based on expressed interest in participationand expertise in practice area.2. Members requested to commit to participate in a one-year term. After the initial term, members mayindicate ongoing desire to serve a subsequent term.16

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridEducation Subject Matter Mentor Roles and ResponsibilitiesEach Practice Forum and PSI Committee will have a system level clinical education or simulation NursingProfessional Development subject matter expert Mentor. Education Mentors will be aligned based on theirnursing expertise and patient population roles.1.2.3.4.5.6.7.8.Role of Education MentorChampion adoption into practice and knowledge of evidence-based practice standards in area of expertisefor clinical standardization of best practices through competencies, simulation scenarios, virtual andinstructor led education.Access and interpret procedural guidelines, standards, research findings, or other validated educationalresources to support patient care.Guide team’s adoption and skill validations to impact practice.Navigate performance improvement or care variation data to prioritize needed interventions.Demonstrate respect for colleagues, patients, and families.Regularly attend monthly meetings, with minimum absences.Celebrate successes with specific recognition strategies.Seek opportunities for dissemination of projects, studies, and literature reviews.Selection of Member1. Education Mentor is assigned by the System TC for Simulation or the Director of System ProfessionalPractice and Clinical Education.17

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridSystem Nursing Committee Forum, Council and Committee Purpose StatementsNursing Executive Council (NEC): Provide system level nursing executive team which establishes and isaccountable for nursing functions, actions, and outcomes across all divisions of Sentara Healthcare topromote and advance evidence-based nursing. Serves as shared governance entity for systemwide executive nursing decisions. Functions as the single voice for nursing across the care continuum topositively impact patient and families.NEC Nursing Professional Practice Advisory Council (NPPC): Provide a system level nursing advisory groupwhich coordinates nurses that represent all divisions of Sentara Healthcare to promote and advanceprofessional nursing practice guided by the Sentara Nursing Professional Practice Model (PPM).System Practice Forums:Med Surg Nursing Practice Forum: lead general nursing initiatives at Sentara Healthcare through anemphasis on quality, safety, and evidence-based practice. Standardize best practice to enhance clinicalcare. Involve bedside nurses in decision making to improve patient outcomes. Delineate the scope ofpractice in the general clinical practice setting. Advance the practice of nursing through sharedgovernance/partnership councils. Utilize evidence-based practice resources to align nursing practice.Required membership seats to represent Oncology, Ortho, Neuro, Geriatrics, and Cardiac.Ambulatory Nursing Practice Forum: Determine and disseminate ambulatory nursing standards, guidelinesand policies/procedures based on evidence and/or best practices to positively impact patient outcomes.Foster a supporting environment within Sentara, which guides the practice of nursing and nursing researchfor those in nursing positions within the non-hospital ambulatory setting. Provide a venue forcommunication and collaboration of nurses across non-hospital ambulatory service lines.Behavioral Health Nursing Practice Forum: Focus attention on providing high-quality, evidenced based,patient centered Behavioral Health services. Focus on standardization of services across the system,measurement of quality outcomes, encouraging staff involvement, attention to quality programming, andensuring that comprehensive orientation is offered to for newly hired Behavioral Health staff.Critical Care Nursing Practice Forum: Provide strategic oversight to optimize Sentara Healthcare’s criticalcare patient care/experience and nurse retention through translation of research, evidence based (EBP)and best community practices, processes and technologies by: Prioritizing, leading and evaluatingmeaningful care and practice initiatives; Reviewing and evaluating critical care protocols, policies, andprocedures using collective decision making ; Providing an interdisciplinary forum for staff mentorship tooptimize knowledge, satisfaction and engagementEmergency Nursing Practice Forum: ensure consistent dissemination of information across all EmergencyDepartments. To establish system wide standardized practice based on evidence-based practice.Intermediate Care Nursing Practice Forum: Advance patient safety outcomes for the Intermediate Carepatient populationMaternal Infant Newborn Nursing Practice Forum (MINPF): Promote the creation and retention of ahighly skilled maternal-child nursing workforce focused on improving patient safety, care, satisfaction, and18

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council Gridquality of care while reflecting the organization’s strategic goal of reducing variation and creating andmaintaining an evidence-based nursing culture.Pediatric Nursing Practice Forum: The purpose of the Sentara Pediatric Practice Forum is to promoteexcellent clinical practice and outcomes in pediatric care. Our focus is on providing consistent care of thepediatric patient across the Sentara system with an emphasis on quality, safety, and evidence-basedpractices. Important to the process of consistent care is effective dissemination of information tocaregivers across the system.Procedural Area Practice Forum: Promotion of patient and family centered nursing care of the highestquality in the interventional suites and designated procedural areas that embody a professional practiceenvironment.Surgical Services Nursing Practice Forum: Lead surgical service nursing initiatives at Sentara Healthcare byimproving care to surgery patients with an emphasis on quality, safety, evidence-based practice andefficiency.Councils:Acute Care Pharmacy and Nursing Practice Council: Systemwide strategic evidence-based decisionsrevolving around intersection of pharmacy and nursing delivery of care in the hospital setting aligning withVirginia and N.C. Boards of Nursing and Pharmacy, Federal mandates, and Centers for Medicare andMedicaid Services guidelines. Endorse health and safety of patients and employees during the practice ofmedication administration.Clinical Supply/Equipment Council: Act as nursing governance body for patient care products/bedsideequipment throughout the system. Obtain recommendations from system councils and specialty areacommodity groups to ensure that there are standardized nursing processes and products for promotingbest practices in patient care. Collaborate with education department to develop a systematic approach toimplementation of products to ensure that end users have the information available to provide optimalpatient care.Education Council: Validate the sequential development of clinical nursing team member’s progressionfrom novice to expert status by providing system wide strategic oversight of meaningful education andprograms forged through evidence-based, best practice learning principles aimed to verify/validate theknowledge, skills, behaviors and attitudes essential to deliver high quality, safe care and achieve strategicgoals.Nursing Advisory Council: To provide oversite, governance, guiding principles and processes for nursingdocumentation content and workflows in Epic, Sentara Healthcare’s electronic medical record. Overseeand provide guidance to recommended changes concerning the electronic medical record (EMR) workflowand data collection lifted up through system nursing shared governance.Nursing Excellence and Recognition Council: Provide strategic oversight and ensure evidence-basedpractices are embedded for supporting nurse retention and aspects of recognition as part of healthy workenvironments.19

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council GridNursing Research Council (NRC): The System-wide Nursing Research Council is accountable for promotingresearch and evidence-based practice activities for nursing throughout Sentara Healthcare (SH) by:Fostering an environment that supports and guides nursing research to enhance the practice of nursing.Cultivating an expectation that nursing use research and evidence-based knowledge in their practice toenhance patient and nursing outcomes. Promoting the dissemination and translation of new knowledgeinto the delivery of nursing care across all settings and venues where nursing and patient care services areprovided. Developing processes across the system to promote nursing research. Providing a forum forcommunication and collaboration for nurses interested in research thro

2016 Sentara Nursing Forum and Council Grid2016 Sentara Nursing Forum and Council Grid 9 Shared Governance Guidelines System nursing forums, councils, and committees assume responsibility for the professional practice of nursing at Sentara Healthcare. Shared governance enables evidence-based practice standardization across the organization.