Section Editor(s): Thede, Linda Q. PhD, RN-BC
* Governance structure supports nursing informatics
* Structure of governance committees supports engaged nursing practice
* Governance committee work is aligned with organization wide goals
Nurses, as providers of direct patient care, are the most frequent users of electronic medical records (EMRs). When Gillette Children's Specialty Healthcare first developed and implemented an electronic record, nursing was one of the few departments actively engaged with the process. Nursing engagement was clearly a factor in the successful implementation of this early electronic record. The planning and development for a new electronic record led us to formalize this engagement through our nursing governance structure.
Gillette Hospital was founded in 1897 by Dr Arthur Gillette, an orthopedic surgeon, and Jessie Haskins, an advocate for people with disabilities. Today, we have grown to include a 60-bed inpatient hospital, a 10-bed pediatric intensive care unit (PICU), and multiple outpatient clinic sites that offer care for children and adults with childhood-acquired disabilities. In June 2009, the PICU was certified as the first and only level I pediatric trauma facility in Minnesota. We also have a Commission on Accreditation of Rehabilitation Facilities-accredited pediatric rehabilitation unit, a postsurgical unit, a medical/trauma unit, and an adult unit.
Our outpatient clinics serve clients from across the country and around the world with centers of excellence focused on cerebral palsy, craniofacial services, gait and motion analysis, spina bifida and pediatric neurosciences, orthopedics, rehabilitation, and rheumatology.
Gillette, in recognition of the value of nursing in healthcare, actively promotes the full engagement of nursing in the care we provide. Currently, there are four nurses with doctoral-level education (two PhDs, two DNPs) on staff, more than 25 nurses with master's degrees, and roughly 75 nurses certified in pediatrics, rehabilitation, informatics, orthopedics, and operating room. Our Vice President of Patient Services is a nurse executive who is fully engaged in critical organizational decisions, sitting on the administrative council, and the information systems steering committee. For an organization with less than 300 nurses, these are remarkable statistics.
On the journey toward Magnet designation, which we achieved in 2008, Gillette nursing administration supported the redesign of the nursing governance structure. At that time, four committees, Clinical Practice, Nursing Research, Education and Professional Development, and Policy, Procedure and Process Design and Development, emerged as the new governance structure. In 2009, to better serve our patients, two new committees were formed: Advanced Practice Nursing and Nursing Informatics. This latter committee was seen as needed to formalize the work required for planning and implementing a new electronic record. Each committee develops its own charter that describes the purpose of the committee and the work for which the committee is responsible and the level of decision-making authority the committee holds within the organization.
To ensure adequate representation of all nurses, even those in smaller units, Gillette nurses are divided into representative districts, with one representative elected to sit on each committee. There are between 25 and 50 nurses in each district, with the nurses in a district having a logical connection to each other (Table 1). For example, all the nurses who work with the adult population, both in the inpatient unit and the adult outpatient clinic, are in one district. This allows the district representatives from each committee to report information back to their district members, their constituents, regarding the work of their governance committees.
When first formed, the Nursing Informatics Governance Committee (NI Governance Committee) was chaired by the NI specialist. Nine district nursing representatives and seven ad hoc members were initially identified and appointed to serve a 2-year term. The nursing district representatives were selected because of their expressed interest or background in informatics. Some of the initial members of the committee were nursing application content experts (ACEs) and were some of the first staff nurses to have direct input into the design of the current EMR. The ad hoc members representing health information management, respiratory therapy, new patient services, pharmacy, and quality improvement were invited to attend to assist in the development of the charter and identification of work areas for the committee. These initial committee members brought a strong background of organizational and informatics knowledge to the committee's work.
One of the first jobs of this newly formed committee was to draft a charter. This charter would be the guiding document for the work of the committee along with designating the responsibilities of and the rules governing the committee. The first section of the charter represents the mission of the NI Governance Committee and reads as follows:
The Committee on Nursing Informatics provides ongoing leadership in the implementation and development of information technology and electronic solutions for patient care and nursing practice. The committee provides structure and support to individuals and groups who interface with or are impacted by the implementation of information technology in the workplace.
In addition to the purpose of the NI Governance Committee, the charter includes sections that address (1) scope of work including responsibilities, accountability, and limits of authority; (2) the alignment of the work with department goals and coordination of work with other departments that might be affected; (3) management of communication including preparation of minutes and distribution of results of the work of the committee; (4) membership including the designation of chair and vice-chair positions; (5) criteria for evaluation including reporting structure to the coordinating governance council; (6) designation of a voting quorum; and (7) meeting requirements. The draft was presented to and endorsed by the coordinating council, which consists of the chair and vice chair of each committee, all nursing specialists and representative from the patient services management team including the Vice President of Patient Services, unit managers, and supervisors.
The work plan of the NI Governance Committee, like all the other governance committees, is derived from the overall hospital strategic plan, the Patient Services Annual Plan, and the annual Patient Services Quality Improvement initiatives. Governance work is assigned to the appropriate committee by the Vice President of Patient Services and is overseen by the coordinating council. Throughout the year, the NI Governance Committee meets on a regular basis, refers to the work plan, and reports on the outcomes of the committee's work. Each nurse representative is expected to attend these meetings and to communicate back to district constituents the decisions, actions, and results of the committee's work. An example of the first year's work plan for the NI Governance Committee is included in Table 2.
Examples of the work assigned to the NI Governance Committee in its inaugural year included the following:
* design and complete a computer competency survey for all nurses in the organization;
* evaluate the current patient tracking system for the outpatient clinic;
* demonstrate, trial, and evaluate hardware options;
* support the Go-Live initiative for the electronic nursing flow sheet; and
* support a real-time charting initiative for inpatient nurses.
Gillette is currently in the process preparing a report for Magnet redesignation that will include information about the development of the NI Governance Committee. We will highlight the influence of this committee on Gillette's nurses and how that translates to and benefits both the patients we serve and the community in which we practice. The impact of this committee within our facility has been widespread. It has led to interdepartmental team collaboration that contributes to better care for our patients. Nursing informatics committee members appreciate and demonstrate the benefits of an integrated record of care. They are leading the way in recommending both practice and policy changes required to meet the challenges of implementing this new electronic record.
As we move toward a new electronic record, more time has been dedicated to support the work of building the new electronic record. Some of the NI committee governance members have been redeployed to full-time work on the project, or as consultants on an as-needed basis. The majority of the second year's work has been to provide ample support to the electronic record project. Another task is to support another hospital initiative, Transforming Care at the Bedside (TCAB), a project funded in part by the American Organization of Nurse Executives. The NI Governance Committee supports the unit-based TCAB nurses by
* providing demonstration of hardware devices for evaluation,
* developing and recommending workflow processes that can be built into the new electronic record, and
* participating in TCAB meetings to offer guidance when informatics issues arise.
Members of the NI Governance Committee were first in line to be recommended and recruited as super users for the Go-Live for the new electronic record. Once the process for "Requests for Changes or Upgrades to the Electronic Record" is defined, the NI Governance Committee will play a key role in approving such requests and/or designing the changes requested. This committee will continue to be the central body for addressing the strategic goals and initiatives defined within Gillette related to NI.
One key initiative that we will be addressing in the future is the inclusion of a standardized nursing terminology within the electronic record. Once this standardized nursing terminology is established, the NI Governance Committee can begin to develop plans for educating nurses on its use. We will also engage in nursing outcomes research, which is strategic to improving the care of our unique population of individuals with disabilities. At the time of writing this article, we have completed 2 years of the NI Governance work. The committee has been acknowledged throughout the organization as having a very successful beginning.
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