2023 Magnet Document

NewYork-Presbyterian/Columbia University Irving Medical Center

Table of Contents

OO1 - CONTEXTUAL INFORMATION

A description of the applicant organization, including history, demographics of the population served, demographics of the RN staff.

OO1 Documents

OO2 - REPORTS AND PLANS

The most recent copies of: Reports prepared annually for the organization’s stakeholders (including nursing and organizational reports; these may be combined); Quality plans; Patient safety plan; and Strategic plans for the organization and nursing services (including nursing and organizational plans; these may be combined).

OO2 Documents

OO3 - CNO

Provide: The current Chief Nursing Officer’s (CNO) job description; CNO’s curriculum vitae or resume; The organizational chart(s); The nursing organizational chart(s); A description of the CNO’s structural and operational relationships to all areas in which nursing is practiced; and Names and credentials, of all individuals serving as the CNO, in the 48 months preceding document submission. 

OO3 Documents

OO4 - PROFESSIONAL DEVELOPMENT

Provide the policies and procedures that govern and guide continuing professional development programs

OO4 Documents

OO5 - NURSING PROFESSIONAL GOVERNANCE

Provide a description and the policies, procedures, charters, or bylaws of the organization’s shared decision-making structure.

OO5 Documents

OO6 - CREDENTIALING, PRIVILEGING, AND EVALUATING OF ADVANCED PRACTICED REGISTERED NURSES

Provide a description and/or policies, or equivalent evidence of, the process by which the CNO (or designee) participates in the following: Credentialing, privileging, and evaluating of all Advanced Practiced Registered Nurses (APRNs); Reprivileging of all APRNs. 

OO6 Documents

OO7 - WORKPLACE ADVOCACY

Provide the policies, or equivalent evidence, that depict the organization’s workplace advocacy initiatives for all staff, regarding the following issues: Caregiver well-being; Diversity, equity, and inclusion; Rights; Confidentiality; Care for the impaired practitioner; and Zero tolerance for bullying, incivility, and workplace violence.

OO7 Documents

OO8 - DIVERSITY, EQUITY, INCLUSION, & CULTURAL COMPETENCE

Provide the policies, or equivalent evidence, that depict the organization’s initiatives for patients and families, regarding the following issues: Diversity, equity, and inclusion; Cultural competence

OO8 Documents

OO9 - PROFESSIONAL PRACTICE ENVIRONMENT

Provide the policy or equivalent evidence, which permits and encourages nurses to: Confidentially express concerns regarding their professional practice environment, without retribution. Address the identification and management of problems related to incompetent, unsafe, or unprofessional practice or conduct. Address interprofessional conflict.

OO9 Documents

OO10c - NURSING RESEARCH

Provide both of the following: A letter signed and dated by the chair of the governing body responsible for the protection of human research participants that attests to this requirement; A signed and dated attestation which states the organization has educated and trained appropriate staff to determine if the research is to be exempt from full IRB review. Include the exempt determinations are approved by the Human Research Protections Program governing body.

OO10c Documents

OO11 - NURSING RESEARCH TABLE

Provide a table of nursing research studies (ongoing and completed) within the most recent 48 months.

OO11 Documents

Transformational Leadership

TL1 - SURGICAL WOUND ACTION TEAM NURSING BUNDLE: AN INITIATIVE IN NURSING PRACTICE (CTICU)

Provide one example, with supporting evidence, of an initiative in nursing practice that is consistent with the organization’s mission statement.

TL1 Documents

TL2 - ENHANCING DIVERSITY AND INCLUSION IN THE OPERATING ROOM 

Provide one example, with supporting evidence, of a Nurse Assistant Vice President’s (AVP’s)/Nurse Director’s or Nurse Manager’s participation in an initiative which promoted workplace diversity, equity, and/or inclusion and is consistent with the organization’s strategic plan.

TL2 Documents

TL3EO - VTE PREVENTION BY OPTIMIZING VENODYNE USE 

Using the required empirical outcomes presentation format, provide one example of an improved patient outcome that aligns with a goal in the nursing strategic plan.

TL3EO Documents

TL4a - ADVOCATING FOR A PALLIATIVE CARE UNIT AND NURSING RESOURCES 

Provide one example, with supporting evidence, of a Nurse AVP’s/Nurse Director’s advocacy for resources to support an organizational goal.

TL4a Documents

TL4b - ADVOCATING FOR PSYCHOLOGICAL SUPPORT IN THE MICU

Provide one example, with supporting evidence, of a Nurse Manager’s advocacy for resources to support a unit goal.

TL4b Documents

TL5a - PROMOTING NURSE WELL-BEING: ACQUIRING A PANIC ALARM SYSTEM (MICU, SICU, 6GS, 6GN)

Provide one example, with supporting evidence, of the CNO’s advocacy for and acquisition of organizational resources specific to nurses’ well-being.

TL5a Documents

TL5b - PROMOTING NURSE WELL-BEING: ACQUIRING ANTI-FATIGUE MATS IN THE OPERATING ROOM

Provide one example, with supporting evidence, of a nurse’s(s’) (exclusive of the CNO) advocacy for and acquisition of resources specific to nurses’ well-being at the unit or department/division level.

TL5b Documents

TL6 - EXECUTING STRATEGIC CHANGE: CNO ALIGNS TEAMS AND PROCESSES ON ROAD TO QUALITY PATIENT SAFETY GOAL

Provide one example, with supporting evidence, of the CNO’s leadership that led to a strategic organizational change beyond the scope of nursing.

TL6 Documents

TL7 - GUIDING NURSES THROUGH UNPLANNED CHANGE: THE GREAT FLOOD (HIP 14)

Provide one example, with supporting evidence, of Nurse AVP/Nurse Director’s or Nurse Manager’s leadership that successfully guided nurses through change.

TL7 Documents

TL8EO - STANDARDIZING ET CARE TO REDUCE MDRPIs (WOCN)

Using the required empirical outcomes presentation format, provide one example of an improved patient outcome, associated with a Nurse AVP’s/Director’s OR Nurse Manager’s membership in an organization-level, decision-making group.

TL8EO Documents

TL9a - MENTORSHIP PLAN FOR CLINICAL NURSE (SICU)

Provide one example, with supporting evidence, of an individual mentoring plan or an established mentoring program for clinical nurse(s).

TL9a Documents

TL9b - NURSE MANAGER MENTORSHIP PLAN (IR)

Provide one example, with supporting evidence, of an individual mentoring plan or an established mentoring program for Nurse Manager(s).

TL9b Documents

TL11EO - ADVOCATING RESOURCE TO SUPPORT PATIENT- AND FAMILY-CENTERED CARE (8HN)

Using the required empirical outcomes (EO) presentation format, provide one example of an improved outcome where a clinical nurse(s) used data to advocate for the acquisition of a resource, in support of the care delivery system(s).

TL11EO Documents

TL12 - NURSE ADVOCACY TO CONGRESS: PROMOTING HEALTH OF MOTHERS AND INFANTS IN THE UNITED STATES

Provide an example, with supporting evidence, of a nurse’s(s’) advocacy for individual or community health promotion at an external forum where decisions impacting healthcare are made.

TL12 Documents

TL13EOb - IMPROVING STROKE CARE THROUGH OPTIMIZED ED INTAKE PROCESS 

Using the required empirical outcomes (EO) presentation format, provide one example of an improvement in patient care OR the nurse practice environment, associated with communication between Clinical nurse and the Nurse AVP/Nurse Director.

TL13EOb Documents

TL13EOc - IMPROVING CLEANLINESS ON 5GN

Using the required empirical outcomes (EO) presentation format, provide one example of an improvement in patient care OR the nurse practice environment, associated with communication between Clinical nurse and the Nurse AVP/Nurse Director.

TL13EOc Documents

Structural Empowerment

SE1EOa - IMPROVING COMMUNICATION WITH NURSES THROUGH BEDSIDE SHIFT REPORT (8HS)

Using the required empirical outcomes (EO) presentation format, provide an example of an improved patient outcome associated with the participation of clinical nurse(s) serving as a member(s) of an organization-level interprofessional decision-making group.

SE1EOa Documents

SE1EOb - IMPLEMENTING STRETCHER ALARMS IN THE ED TO DECREASE FALLS

Using the required empirical outcomes (EO) presentation format, provide an example from an ambulatory care setting, of an improved patient outcome associated with the participation of clinical nurse(s) serving as a member(s) of an organization-level interprofessional decision-making group.

SE1EOb Documents

SE2EOa - IMPLEMENTING NURSING HANDOFF TO DETECT AND TREAT HEMORRHAGIC TRANSFORMATION POST-MECHANICAL THROMBECTOMY (INR)

Using the required empirical outcomes (EO) presentation format, provide one example of an improved outcome associated with an evidence-based change in nursing practice that occurred due to a clinical nurse’s(s’) affiliation with a professional organization.

SE2EOa Documents

SE2EOb - MULTIFACETED HAPI PREVENTION PROGRAM IN THE SICU

Using the required empirical outcomes (EO) format, provide one example of an improved outcome associated with the application of nursing standards of practice implemented due to a clinical nurse’s(s’) participation in a nursing professional organization.

SE2EOb Documents

SE3 - COMMITMENT TO PROFESSIONAL DEVELOPMENT THROUGH CERTIFICATION

Provide a narrative description of the organization’s action plan for registered nurses’ progress toward obtaining professional certification. Must include: state the targeted goal; how the target was established; what strategies were utilized to achieve or maintain the target; how the nurses are supported to achieve or maintain professional board certification.

SE3 Documents

SE4EO - COMMITMENT TO PROFESSIONAL DEVELOPMENT THROUGH CERTIFICATION (DATA)

Provide graphed data (displayed as a percentage) of baseline data, plus two years of data, demonstrating nursing has met or exceeded a targeted goal at the organizational level, for improvement in professional board certification.

SE4EO Documents

SE5 - INCREASING CERTIFICATION RATE IN 9GN

Provide a narrative description of a unit's or division's action plan for RNs progress toward obtaining professional board certification. The narrative must include state the targeted goal, how the target goal was established, what strategies were used to achieve or maintain the target, and how the nurses are supported to achieve or maintain professional board certification. Supporting evidence is not required.

SE5 Documents

SE6EO - INCREASING CERTIFICATION RATE IN 9GN (DATA)

Provide graphed data (displayed as a percentage) of baseline data, plus two years of data, demonstrating nursing has met or exceeded a targeted goal at the unit or division level, for improvement in professional board certification.

SE6EO Documents

SE7 - COMMITMENT TO PROFESSIONAL DEVELOPMENT THROUGH EDUCATION

Provide a narrative description of the organization's action plan for RNs progress toward obtaining a baccalaureate degree or higher degree in nursing. The narrative must include state the targeted goal, how the target goal was established, what strategies were used to achieve or maintain the target >/80%, and how the nurses are supported to achieve or maintain baccalaureate or higher degree in nursing. 

SE7 Documents

SE8EO - COMMITMENT TO PROFESSIONAL DEVELOPMENT THROUGH EDUCATION (DATA)

Provide graphed data (displayed as a percentage) of baseline data, plus two years of data, demonstrating the organization progressing toward (or maintaining) ≥80% of professional registered nurses who have earned a baccalaureate or higher degree in nursing.

SE8EO Documents

SE9EO - PROFESSIONAL DEVELOPMENT ACTIVITY “BACK TO BASICS” REDUCES CLABSI RATES ON BMT HP11

Using the required empirical outcomes presentation format, provide an example of an improved patient outcome associated with knowledge gained from a nurse’s(s’) participation in a professional development activity.

SE9EO Documents

SE10EOa - CLABSI REDUCTION EDUCATION PLAN TARGETS LEARNING NEEDS AND IMPROVES CLABSI RATES (7HS)

Using the required empirical outcomes (EO) presentation format, provide an example of an improved patient outcome associated with a nursing needs assessment and a related implementation plan at the ambulatory care setting, unit, or division level.

SE10EOa Documents

SE10EOb - EDUCATION PLAN TARGETS LEARNING NEED ON IMPROVED COMMUNICATION AMONG TEAM MEMBERS AND IMPROVES RETAINED SURGICAL ITEMS RATES (OR)

Using the required empirical outcomes (EO) presentation format, provide an example of an improved patient outcome associated with a nursing needs assessment and a related implementation plan in an ambulatory care setting.

SE10EOb Documents

SE11a - NYP NURSE RESIDENCY PROGRAM

Provide evidence of a nationally accredited transition to practice program. A copy of the certificate awarded by the nationally accredited program is sufficient evidence to meet the standard.

SE11a Documents

SE12a - COMMITTING TO HEALTHY PEOPLE 2030 THROUGH PARTICIPATIO IN THE 2021 WINTER COAT DRIVE (5GN)

Provide one example, with supporting evidence, of the organization’s support of a nurse(s) who volunteer(s) in a local or regional community healthcare initiative which aligns with Healthy People 2030 or the United Nations’ Sustainable Development Goals.

SE12a Documents

SE12b - SUPPORTING UTAH'S INTERMOUNTAIN MEDICAL CENTER DURING THE COVID-19 PANDEMIC (MICU)

Provide one example, with supporting evidence, of the organization’s support of a clinical nurse(s) who volunteer(s) in a population health outreach initiative, either local or global.

SE12b Documents

SE13a - NURSES DELIVERING SOCIALLY SENSITIVE CARE IN 7HS

Provide one example, with supporting evidence, of a nurse or group of nurses in the delivery of culturally and/or socially sensitive care.

SE13a Documents

SE13b - NURSES DELIVERING CULTURALLY SENSITIVE CARE IN THE PACU

Provide one example, with supporting evidence, of a nurse or group of nurses delivering culturally and/or socially sensitive care in an ambulatory area.

SE13b Documents

SE14a - CLINICAL NURSES RECOGNIZED FOR CLINICAL EXCELLENCE AND PATIENT-CENTERED CARE (7HS)

Provide one example, with supporting evidence, of the organization’s recognition of a clinical nurse(s) for their contribution(s) in addressing the strategic priorities of the organization.

SE14a Documents

SE14b - NURSE LEADER RECOGNIZED FOR CLINICAL EXCELLENCE AND PATIENT-CENTERED CARE (CATH LAB)

Provide one example, with supporting evidence, of the organization’s recognition of a nurse(s) in an ambulatory care setting for their contribution(s) in addressing the strategic priorities of the organization.

SE14b Documents

SE15 - RECOGNIZING THE PACU TEAM FOR EXCELLENCE IN CLINICAL CARE

Provide one example, with supporting evidence, of the organization’s recognition of an interprofessional group (inclusive of nursing) for their contribution(s) in influencing the clinical care of patients.

SE15 Documents

Exemplary Professional Practice

EP1EOa - FROM HOURLY ROUNDING TO PURPOSEFUL ROUNDING: AN EVIDENCE-BASED CHANGE (9GS)

Using the required empirical outcomes presentation format, provide one example of an improved outcome associated with an evidence-based change made by clinical nurses in alignment with the organization’s professional practice model (PPM).

EP1EOa Documents

EP1EOb - USING A VASCULAR CLOSURE DEVICE TO ENHANCE THE PATIENT EXPERIENCE IN THE EP LAB

Using the required empirical outcomes presentation format, provide one example, from an ambulatory care setting, of an improved outcome associated with an evidence-based change made by nurses in alignment with the organization’s professional practice model (PPM).

EP1EOb Documents

EP2 - EXPANDING THE BED CAPACITY IN 7HS THROUGH SHARED DECISION-MAKING

Provide one example, with supporting evidence, of clinical nurses using shared decision-making to change the nurse practice environment.

EP2 Documents

EP3EO - NURSE SATISFACTION DATA

Provide all eligible registered nurse satisfaction/ registered nurse engagement data to demonstrate outperformance of the benchmark provided by the vendor's national database. Provide unit- or ambulatory care setting-level data for all settings (inpatient care, ambulatory care, and administrative settings) and include all registered nursing levels where collected and benchmarked by the vendor.

EP3EO Documents

EP4 - INSTALLATION OF A QUENCH MACHINE THROUGH COLLABORATION WITH PFAC

Provide one example, with supporting evidence, of nurse(s) collaborating with patient(s), families, or both, to influence change in the organization.

EP4 Documents

EP5EO - UTILIZING DAILY FOCUSED ROUNDS TO DECREASE CLABSI ON 8HS

Using the required empirical outcomes presentation format, provide one example of an improved patient outcome associated with one or more experts’ recommended change in nursing practice.

EP5EO Documents

EP6a - COORDINATING CARE FROM INPATIENT ACUTE REHABILITATION TO HOME HEALTHCARE SERVICES

Provide one example, with supporting evidence, of nurse’s(s’) participation in interprofessional collaborative practice to ensure coordination of care from an inpatient setting to an ambulatory care setting.

EP6a Documents

EP6b - CARE COORDINATION OF A KIDNEY AND BONE MARROW TRANSPLANT PATIENT (PANORAMA)

Provide one example, with supporting evidence, of nurse’s(s’) participation in interprofessional collaborative practice to ensure coordination of care from an ambulatory care setting to an inpatient setting.

EP6b Documents

EP7EO - WAITING TO EXHALE: REDUCING THE AVERAGE LENGTH OF STAY AMONG POST-CARDIAC SURGERY PATIENTS (CTICU)

Using the required empirical outcomes presentation format, provide one example of an improvement in a specific patient population outcome associated with nurse’s(s’) participation in an interprofessional collaborative plan of care.

EP7EO Documents

EP8EOa - OPTIMIZING INTERDISCIPLINARY ROUNDS AND DISCHARGE MILESTONES TO REDUCE AVERAGE LENGTH OF STAY (7GS)

Using the required empirical outcomes presentation format, provide one example of an improved outcome associated with an interprofessional quality initiative led or co-led by a nurse (exclusive of the CNO).

EP8EOa Documents

EP8EOb - IMPLEMENTING COLON SURGICAL SITE INFECTION (SSI) PREVENTION BUNDLE (OR)

Using the required empirical outcomes presentation format, provide one example from an ambulatory care setting of an improved outcome associated with an interprofessional quality initiative led or co-led by a nurse (exclusive of the CNO).

EP8EOb Documents

EP9EO - IMPROVING POST-DISCHARGE CARE THROUGH INTERPROFESSIONAL EDUCATION (6GS/WOCN)

Using the required empirical outcomes presentation format, provide one example of an education activity led or co-led by a nurse(s) (exclusive of the CNO) for an interprofessional team which led to an improved patient outcome.

EP9EO Documents

EP10a - ADDRESSING STAFFING NEED IN THE EMERGENCY DEPARTMENT

Provide an example with supporting evidence, when a clinical nurse(s) collaborated with a Nurse Assistant Vice President (AVP)/Nurse Director to evaluate data to address a unit-level staffing need.

EP10a Documents

EP10b - ADDRESSING SAFETY CONCERNS IN TREATING POSTPARTUM PATIENTS THROUGH NEW POSTPARTUM HEMORRHAGE KIT WORKFLOW (OR)

Provide one example with supporting evidence, when nurse(s) collaborated with a Nurse AVP/Director to evaluate data to meet an operational need (not workforce related).

EP10b Documents

EP11 - IMPROVING STAFF SAFETY THROUGH ACQUISITION OF MOTORIZED REVERSE OSMOSIS MACHINE CARTS (DIALYSIS)

Provide one example, with supporting evidence, when nurse(s) collaborated with a nurse AVP/Nurse Director and/or Nurse Manager during budgeting to acquire new or redistribute existing resources.

EP11 Documents

EP12EO - IMPROVING NURSE TURNOVER THROUGH RECOGNITION, WELLNESS, AND ENGAGEMENT

Provide one example, with supporting evidence, of the organization meeting a targeted goal at the organizational level, for improvement in the nurse turnover rate associated with clinical nurses’ participation in nursing retention activities.

EP12EO Documents

EP14 - CLINICAL NURSES HAVING THE AUTONOMY TO TITRATE HEPARIN INFUSION (5GN)

Provide one example, with supporting evidence, of clinical nurses having the autonomy to make nursing care decisions within the full scope of their nursing practice.

EP14 Documents

EP15 - APPLYING RESOURCES TO ADDRESS AN ETHICAL ISSUE (CCU)

Provide one example, with supporting evidence of nurse(s) as participant(s) of an interprofessional team, applying available resources to address ethical issues related to clinical practice.

EP15 Documents

EP16EO - PREVENTING WORKPLACE VIOLENCE TOWARDS NURSES THROUGH PATIENT PROPERTY AND SAFETY ROUNDS

Using the required empirical outcomes (EO) presentation format, provide one example of an improved workplace safety outcome for nurses, specific to violence (e.g., physical or psychological violence, threats of incivility) toward nurses in the workplace.

EP16EO Documents

EP17EO - ADDRESSING NURSING TURBULENCE TO DECREASE FALLS (6HN)

Using the required empirical outcomes presentation format, provide one example of an improved patient safety outcome associated with clinical nurse involvement in the evaluation of patient safety data at the unit level.

EP17EO Documents

EP18 - CLINICAL NURSE CO-LED PATIENT EXPERIENCE IMPROVEMENT INITIATIVE BASED ON PATIENT FEEDBACK (9H)

Provide one example, with supporting evidence, of an initiative led or co-led by a clinical nurse(s), to address patient experience based on patient feedback from patient(s) and/or families.

EP18 Documents

EP19EOa - INPATIENT NURSE SENSITIVE QUALITY INDICATORS: FALLS WITH INJURY

Provide four nurse-sensitive clinical quality indicators for all eligible patient units. Data provided must reflect eight of the most recent consecutive and complete quarters of inpatient, unit-level graphed data to demonstrate outperformance of the benchmark provided by the vendor’s national database

EP19EOa Documents

EP19EOb - INPATIENT NURSE SENSITIVE QUALITY INDICATORS: HAPI STAGE 2 AND ABOVE

Provide four nurse-sensitive clinical quality indicators for all eligible patient units. Data provided must reflect eight of the most recent consecutive and complete quarters of inpatient, unit-level graphed data to demonstrate outperformance of the benchmark provided by the vendor’s national database

EP19EOb Documents

EP19EOd - INPATIENT NURSE SENSITIVE QUALITY INDICATORS: CATHETERASSOCIATED URINARY TRACT INFECTION (CAUTI)

Provide four nurse-sensitive clinical quality indicators for all eligible patient units. Data provided must reflect eight of the most recent consecutive and complete quarters of inpatient, unit-level graphed data to demonstrate outperformance of the benchmark provided by the vendor’s national database

EP19EOd Documents

EP19EOg - INPATIENT NURSE SENSITIVE QUALITY INDICATORS: DEVICE-RELATED HAPI

Provide four nurse-sensitive clinical quality indicators for all eligible patient units. Data provided must reflect eight of the most recent consecutive and complete quarters of inpatient, unit-level graphed data to demonstrate outperformance of the benchmark provided by the vendor’s national database

EP19EOg Documents

EP20EOa - AMBULATORY NURSE SENSITIVE QUALITY INDICATORS: FALLS WITH INJURY

Provide three nurse-sensitive clinical quality indicators for all eligible ambulatory care settings. Data provided must reflect the most recent eight consecutive and complete quarters of ambulatory setting graphed data to demonstrate outperformance of the benchmark provided by the vendor’s national database or at the highest available level.

EP20EOa Documents

EP20EOb - AMBULATORY NURSE SENSITIVE QUALITY INDICATORS: PATIENT BURNS

Provide three nurse-sensitive clinical quality indicators for all eligible ambulatory care settings. Data provided must reflect the most recent eight consecutive and complete quarters of ambulatory setting graphed data to demonstrate outperformance of the benchmark provided by the vendor’s national database or at the highest available level.

EP20EOb Documents

EP20EOc - AMBULATORY NURSE SENSITIVE QUALITY INDICATORS: SURGICAL ERRORS

Provide three nurse-sensitive clinical quality indicators for all eligible ambulatory care settings. Data provided must reflect the most recent eight consecutive and complete quarters of ambulatory setting graphed data to demonstrate outperformance of the benchmark provided by the vendor’s national database or at the highest available level.

EP20EOc Documents

EP21EOa - INPATIENT PATIENT EXPERIENCE: CARE COORDINATION

Provide four inpatient patient experience category data for all eligible inpatient units. Provide eight quarters of inpatient, unit-level data to demonstrate outperformance of the benchmark provided by the vendor’s national database.

EP21EOa Documents

EP21EOb - INPATIENT PATIENT EXPERIENCE: CAREFUL LISTENING

Provide four inpatient patient experience category data for all eligible inpatient units. Provide eight quarters of inpatient, unit-level data to demonstrate outperformance of the benchmark provided by the vendor’s national database.

EP21EOb Documents

EP21EOe - INPATIENT PATIENT EXPERIENCE: PATIENT EDUCATION

Provide four inpatient patient experience category data for all eligible inpatient units. Provide eight quarters of inpatient, unit-level data to demonstrate outperformance of the benchmark provided by the vendor’s national database.

EP21EOe Documents

EP21EOf - INPATIENT PATIENT EXPERIENCE: PATIENT ENGAGEMENT

Provide four inpatient patient experience category data for all eligible inpatient units. Provide eight quarters of inpatient, unit-level data to demonstrate outperformance of the benchmark provided by the vendor’s national database.

EP21EOf Documents

EP22EOc - AMBULATORY PATIENT EXPERIENCE: COURTESY AND RESPECT

Provide four ambulatory care setting patient experience category data for all eligible areas. Provide eight quarters of ambulatory care setting-level data to demonstrate outperformance of the benchmark provided by the vendor’s national database.

EP22EOc Documents

EP22EOd - AMBULATORY PATIENT EXPERIENCE: PAIN

Provide four ambulatory care setting patient experience category data for all eligible areas. Provide eight quarters of ambulatory care setting-level data to demonstrate outperformance of the benchmark provided by the vendor’s national database.

EP22EOd Documents

EP22EOe - AMBULATORY PATIENT EXPERIENCE: PATIENT EDUCATION

Provide four ambulatory care setting patient experience category data for all eligible areas. Provide eight quarters of ambulatory care setting-level data to demonstrate outperformance of the benchmark provided by the vendor’s national database.

EP22EOe Documents

EP22EOh - AMBULATORY PATIENT EXPERIENCE: SAFETY

Provide four ambulatory care setting patient experience category data for all eligible areas. Provide eight quarters of ambulatory care setting-level data to demonstrate outperformance of the benchmark provided by the vendor’s national database.

EP22EOh Documents

New Knowledge, Innovations, and Improvements

NK1 - AN INFRASTRUCTURE SUPPORTING NURSING RESEARCH

Provide a description, with supporting evidence, of the infrastructure that supports nursing research in the organization.

NK1 Documents

NK2 - COVID-19 HEALTHCARE PROVIDER SURVEY STUDY

Provide a synopsis of one completed nursing research study conducted in the applicant organization that is institutional review board-approved (IRB-approved) or determined exempt by organizational review.

NK2 Documents

NK3a - NURSES' ATTITUDES TOWARDS MENTAL ILLNESS (9GN)

Provide two examples, with supporting evidence, of how clinical nurses disseminated the organization’s completed nursing research study to internal audiences.

NK3a Documents

NK3b - NURSING COMPREHENSION OF THE BRADEN SCALE AND ITS SUBSCALES (WOCN)

Provide two examples, with supporting evidence, of how clinical nurses disseminated the organization’s completed nursing research study to internal audiences.

NK3b Documents

NK4 - EMERGENCY DEPARTMENT USE BY YOUNG ADULTS WITH CHRONIC ILLNESS BEFORE AND DURING THE COVID-19 PANDEMIC 

Provide one example, with supporting evidence, of how clinical nurses disseminated the organization’s completed nursing research study to external audiences.

NK4 Documents

NK5a - IMPLEMENTING REVISED POST-STROKE MONITORING GUIDELINES DURING THE COVID-19 PANDEMIC SURGE (ED)

Provide one example, with supporting evidence, of how a clinical nurse(s) implemented an evidence-based practice that is new or a revision to existing practice within the organization.

NK5a Documents

NK5b - IMPLEMENTING NOVEL ISOLATION PRECAUTIONS FOR COVID-19 PATIENTS IN THE ED

Provide one example, with supporting evidence, of how a clinical nurse(s) implemented an evidence-based practice that is new or a revision to existing practice in an ambulatory care setting within the organization.

NK5b Documents

NK6 - IMPLEMENTING SINGLE NEEDLE OPTION TO REDUCE CENTRAL VENOUS CATHETER PROCEDURES (APHERESIS)

Provide one example, with supporting evidence, of how clinical nurse(s) implemented a professional organization’s specialty standards or guidelines in the organization.

NK6 Documents

NK7 - IMPLEMENTING AN INTERPROFESSIONAL MOBILE PRONE TEAM DURING THE COVID-19 PANDEMIC (MICU)

Provide one example, with supporting evidence, of an innovation implemented within the organization involving nursing.

NK7 Documents

NK8EOa - ADOPTION OF PUPILLOMETER TECHNOLOGY TO DETECT STROKE IN ECMO PATIENTS (MICU)

Using the required empirical outcomes presentation format, provide one example of an improved outcome in a care setting associated with a clinical nurse(s) involvement in the adoption of technology.

NK8EOa Documents

NK8EOb - BARCODE SCANNING TECHNOLOGY DECREASES PATIENT MEDICATION ERROR RATES (INTERVENTIONAL CARDIOLOGY)

Using the required empirical outcomes (EO) presentation format, provide one example of an improved outcome in an ambulatory care setting associated with a clinical nurse(s) involvement in the adoption of technology.

NK8EOb Documents

NK9EOa - DECREASING AVERAGE LENGTH OF STAY BY REDESIGNING THE 9TH FLOOR UNITS

Using the required empirical outcomes presentation format, provide one example of an improved outcome associated with nurse involvement with the design or redesign of the physical environment.

NK9EOa Documents

NK9EOb - REDESIGNING THE WORKFLOW TO IMPROVE PATIENT EXPERIENCE (THERAPEUTIC INFUSION)

Using the required empirical outcomes (EO) presentation format, provide one example of an improved outcome associated with clinical nurse involvement with the design or redesign of workflow.

NK9EOb Documents

Organizational Overview

OO1 – CONTEXTUAL INFORMATION

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OO2 - REPORTS AND PLANS

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OO3 - CNO

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OO4 - PROFESSIONAL DEVELOPMENT

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OO5 - NURSING PROFESSIONAL GOVERNANCE

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OO6 - CREDENTIALING, PRIVILEGING, AND EVALUATING OF ADVANCED PRACTICED REGISTERED NURSES

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OO7 - WORKPLACE ADVOCACY

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OO8 - DEI & CULTURAL COMPETENCE

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OO9 - PROFESSIONAL PRACTICE ENVIRONMENT

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OO10c - NURSING RESEARCH

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OO11 - NURSING RESEARCH TABLE 

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Transformational Leadership

TL1 - SURGICAL WOUND ACTION TEAM NURSING BUNDLE: AN INITIATIVE IN NURSING PRACTICE

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TL2 – ENHANCING DIVERSITY AND INCLUSION IN THE OPERATING ROOM

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TL3EO – VTE PREVENTION BY OPTIMIZING VENODYNE USE

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TL4a – ADVOCATING FOR A PALLIATIVE CARE UNIT AND NURSING RESOURCES

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TL4b – ADVOCATING FOR PSYCHOLOGICAL SUPPORT IN THE MICU

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TL5a– PROMOTING NURSE WELL-BEING: ACQUIRING A PANIC ALARM SYSTEM

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TL5b – PROMOTING NURSE WELL-BEING: ACQUIRING ANTI-FATIGUE MATS IN THE OPERATING ROOM

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TL6 – EXECUTING STRATEGIC CHANGE: CNO ALIGNS TEAMS AND PROCESSES ON ROAD TO QUALITY PATIENT SAFETY GOAL

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TL7 – GUIDING NURSES THROUGH UNPLANNED CHANGE: THE GREAT FLOOD

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TL8EO – STANDARDIZING ET CARE TO REDUCE MDRPIs

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TL9a – MENTORSHIP PLAN FOR CLINICAL NURSE

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TL9b – NURSE MANAGER MENTORSHIP PLAN

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TL11EO – ADVOCATING RESOURCE TO SUPPORT PATIENT- AND FAMILY-CENTERED CARE

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TL12 – NURSE ADVOCACY TO CONGRESS PROMOTING HEALTH OF MOTHERS AND INFANTS IN THE UNITED STATES

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TL13EOb – IMPROVING STROKE CARE THROUGH OPTIMIZED ED INTAKE PROCESS

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TL13EOc – IMPROVING CLEANLINESS ON 5GN

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Structural Empowerment

SE1EOa - IMPROVING COMMUNICATION WITH NURSES THROUGH BEDSIDE SHIFT REPORT

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SE1EOb - IMPLEMENTING STRETCHER ALARMS IN THE ED TO DECREASE FALLS

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SE2EOa – IMPLEMENTING NURSING HANDOFF TO DETECT AND TREAT HEMORRHAGIC TRANSFORMATION POST-MECHANICAL THROMBECTOMY

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SE2EOb – MULTIFACETED HAPI PREVENTION PROGRAM IN THE SICU

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SE3 – COMMITMENT TO PROFESSIONAL DEVELOPMENT THROUGH CERTIFICATION

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SE4EO - COMMITMENT TO PROFESSIONAL DEVELOPMENT THROUGH CERTIFICATION

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SE5 – INCREASING CERTIFICATION RATE IN 9GN

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SE6EO – INCREASING CERTIFICATION RATE IN 9GN

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SE7 – COMMITMENT TO PROFESSIONAL DEVELOPMENT THROUGH EDUCATION

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SE8EO – COMMITMENT TO PROFESSIONAL DEVELOPMENT THROUGH EDUCATION

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SE9EO – PROFESSIONAL DEVELOPMENT ACTIVITY “BACK TO BASICS” REDUCES CLABSI RATES ON BMT HP11

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SE10EOa – CLABSI Reduction Education Plan Targets Learning Needs and Improves CLABSI Rates

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SE10EOb – EDUCATION PLAN TARGETS LEARNING NEED ON IMPROVED COMMUNICATION AMONG TEAM MEMBERS AND IMPROVES RETAINED SURGICAL ITEMS RATES

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SE11a – NYP NURSE RESIDENCY PROGRAM

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SE12a – COMMITTING TO HEALTHY PEOPLE 2030 THROUGH PARTICIPATIO IN THE 2021 WINTER COAT DRIVE

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SE12b – SUPPORTING UTAH'S INTERMOUNTAIN MEDICAL CENTER DURING THE COVID-19 PANDEMIC

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SE13a – NURSES DELIVERING SOCIALLY SENSITIVE CARE

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SE13b – NURSES DELIVERING CULTURALLY SENSITIVE CARE IN THE PACU

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SE14a – CLINICAL NURSES RECOGNIZED FOR CLINICAL EXCELLENCE AND PATIENT-CENTERED CARE

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SE14b – NURSE LEADER RECOGNIZED FOR CLINICAL EXCELLENCE AND PATIENT-CENTERED CARE

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SE15 – RECOGNIZING THE PACU TEAM FOR EXCELLENCE IN CLINICAL CARE

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Exemplary Professional Practice

EP1EOa – FROM HOURLY ROUNDING TO PURPOSEFUL ROUNDING AN EVIDENCE-BASED CHANGE

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EP1EOb – USING A VASCULAR CLOSURE DEVICE TO ENHANCE THE PATIENT EXPERIENCE IN THE EP LAB

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EP2 – EXPANDING THE BED CAPACITY IN 7HS THROUGH SHARED DECISION-MAKING

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EP3EO – NURSE SATISFACTION DATA

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EP4 – INSTALLATION OF A QUENCH MACHINE THROUGH COLLABORATION WITH PFAC

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EP5EO – UTILIZING DAILY FOCUSED ROUNDS TO DECREASE CLABSI ON 8HS

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EP6a – COORDINATING CARE FROM INPATIENT ACUTE REHABILITATION TO HOME HEALTHCARE SERVICES

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EP6b – CARE COORDINATION OF A KIDNEY AND BONE MARROW TRANSPLANT PATIENT (PANORAMA)

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EP7EO – WAITING TO EXHALE: REDUCING THE AVERAGE LENGTH OF STAY AMONG POST-CARDIAC SURGERY PATIENTS

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EP8EOa – OPTIMIZING INTERDISCIPLINARY ROUNDS AND DISCHARGE MILESTONES TO REDUCE AVERAGE LENGTH OF STAY

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EP8EOb – IMPLEMENTING COLON SURGICAL SITE INFECTION (SSI) PREVENTION BUNDLE

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EP9EO – IMPROVING POST-DISCHARGE CARE THROUGH INTERPROFESSIONAL EDUCATION

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EP10a— ADDRESSING STAFFING NEED IN THE EMERGENCY DEPARTMENT

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EP10b – ADDRESSING SAFETY CONCERNS IN TREATING POSTPARTUM PATIENTS THROUGH NEW POSTPARTUM HEMORRHAGE KIT WORKFLOW

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EP11 – IMPROVING STAFF SAFETY THROUGH ACQUISITION OF MOTORIZED REVERSE OSMOSIS MACHINE CARTS

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EP12EO – IMPROVING NURSE TURNOVER THROUGH RECOGNITION, WELLNESS, AND ENGAGEMENT

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EP14 – CLINICAL NURSES HAVING THE AUTONOMY TO TITRATE HEPARIN INFUSION

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EP15 – APPLYING RESOURCES TO ADDRESS AN ETHICAL ISSUE

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EP16EO – PREVENTING WORKPLACE VIOLENCE TOWARDS NURSES THROUGH PATIENT PROPERTY AND SAFETY ROUNDS

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EP17EO – ADDRESSING NURSING TURBULENCE TO DECREASE FALLS

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EP18 – CLINICAL NURSE CO-LED PATIENT EXPERIENCE IMPROVEMENT INITIATIVE BASED ON PATIENT FEEDBACK

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EP19EOa – INPATIENT NURSE SENSITIVE QUALITY INDICATORS: FALLS WITH INJURY

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EP19EOb – INPATIENT NURSE SENSITIVE QUALITY INDICATORS: HAPI STAGE 2 AND ABOVE

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EP19EOd – INPATIENT NURSE SENSITIVE QUALITY INDICATORS: CATHETER- ASSOCIATED URINARY TRACT INFECTION (CAUTI)

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EP19EOg – INPATIENT NURSE SENSITIVE QUALITY INDICATORS: DEVICE-RELATED HAPI

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EP20EOa – AMBULATORY NURSE SENSITIVE QUALITY INDICATORS: FALLS WITH INJURY

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EP20EOb – AMBULATORY NURSE SENSITIVE QUALITY INDICATORS: PATIENT BURNS

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EP20EOc – AMBULATORY NURSE SENSITIVE QUALITY INDICATORS: SURGICAL ERRORS

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EP21EOa – INPATIENT PATIENT EXPERIENCE: CARE COORDINATION

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EP21EOb – INPATIENT PATIENT EXPERIENCE: CAREFUL LISTENING

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EP21EOe – INPATIENT PATIENT EXPERIENCE: PATIENT EDUCATION

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EP21EOf – INPATIENT PATIENT EXPERIENCE: PATIENT ENGAGEMENT

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EP22EOc – AMBULATORY PATIENT EXPERIENCE: COURTESY AND RESPECT

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EP22EOd – AMBULATORY PATIENT EXPERIENCE: PAIN

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EP22EOe – AMBULATORY PATIENT EXPERIENCE: PATIENT EDUCATION

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EP22EOh – AMBULATORY PATIENT EXPERIENCE: SAFETY

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New Knowledge, Innovations, and Improvements

NK1 – AN INFRASTRUCTURE SUPPORTING NURSING RESEARCH

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NK2 – COVID-19 HEALTHCARE PROVIDER SURVEY STUDY

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NK3a – NURSES' ATTITUDES TOWARDS MENTAL ILLNESS

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NK3b – NURSING COMPREHENSION OF THE BRADEN SCALE AND ITS SUBSCALES

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NK4 – EMERGENCY DEPARTMENT USE BY YOUNG ADULTS WITH CHRONIC ILLNESS BEFORE AND DURING THE COVID-19 PANDEMIC

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NK5a – IMPLEMENTING REVISED POST-STROKE MONITORING GUIDELINES DURING THE COVID-19 PANDEMIC SURGE

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NK5b – IMPLEMENTING NOVEL ISOLATION PRECAUTIONS FOR COVID-19 PATIENTS IN THE ED

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NK6 – IMPLEMENTING SINGLE NEEDLE OPTION TO REDUCE CENTRAL VENOUS CATHETER PROCEDURES

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NK7 – IMPLEMENTING AN INTERPROFESSIONAL MOBILE PRONE TEAM DURING THE COVID-19 PANDEMIC

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NK8EOa – ADOPTION OF PUPILLOMETER TECHNOLOGY TO DETECT STROKE IN ECMO PATIENTS

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NK8EOb – BARCODE SCANNING TECHNOLOGY DECREASES PATIENT MEDICATION ERROR RATES

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NK9EOa – DECREASING AVERAGE LENGTH OF STAY BY REDESIGNING THE 9TH FLOOR UNITS

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NK9EOb – REDESIGNING THE WORKFLOW TO IMPROVE PATIENT EXPERIENCE

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