Children's Hospital Boston, Mass.
Children's Hospital Boston (CHB) is a 396-bed comprehensive center for pediatric healthcare that offers a complete range of healthcare services for children from birth through age 21. CHB is the primary pediatric teaching hospital of Harvard Medical School, at which most of its physicians hold faculty appointments. Research on pediatric diseases is conducted at the John F. Enders Pediatric Research Laboratories and the Karp Family Research Laboratories. CHB was ranked first in heart and heart surgery, neurology and neurosurgery, and orthopedics in the U.S.News Media Group's 2009 edition of "America's Best Children's Hospitals," and was one of only two hospitals to rank in the top five in all 10 specialties. In 2008, it was ranked number one in cardiac and orthopedic care by Parents magazine, and was named a top hospital by the Leapfrog Group.
"The success of our Magnet® journey is a clear reflection of the contributions made by nurses at every level of the organization. Having Magnet status underscores the fact that Children's has a world-class nursing organization that provides quality patient care and nursing excellence and produces innovations that improve professional nursing practice," says Senior Vice President of Patient Care Services and CNO Eileen M. Sporing, MSN, RN, CNAA-BC, of CHB's Magnet recognition.
Quality of leadership
The CNO has been the nursing leader at CHB for the past 18 years and is highly respected by the senior leadership team, the board of trustees, and the nursing staff. She has a high level of influence, credibility, value, and reputation across the organization. The CNO is responsible for nursing practice across all areas of nursing and is known throughout the organization as an active, careful listener who responds and takes appropriate action that supports not only nursing staff and practice, but also the organization as a whole.
The organizational structure at CHB is responsive and adapts to the constant changes in healthcare, technology, innovations, and the needs of patients, families, and staff. The CNO is a member of board committees and has operational accountability for all nursing practice. Nurses in nontraditional roles and interventional/treatment areas either report directly to the CNO or are involved in all nursing leadership committees and teams. The CNO fosters an environment that supports innovation and empowerment of all nurses. RNs at all levels are actively involved in committees and initiatives. Fiscal responsibility is a part of every nurse's responsibility at CHB; nurses from all levels and areas have input into budget processes.
Decision making is decentralized to staff and managers at the unit and program level. Nursing units are self-governed. There's a high level of expectation for staff nurses to be decision makers through job performance and clinical ladder expectations. New graduate nurses are also involved in decision-making activities. Shared governance structures have influence over how the nursing department is organized and how nurses from all levels are involved in decisions regarding nursing practice.The staff nurse council comprises staff nurses from every practice area and provides a conduit for each unit to the CNO.
The nurse recruitment and retention committee establishes goals and methods to attract new nurses and retain nursing staff, such as the new graduate program, relationships with schools of nursing, a co-op program, and the Student Career Opportunity Outreach program (SCOOP).
Staff in all units practice some form of self-scheduling and are paid partly on a salary structure and partially on flex hourly rate, which allows for flexible scheduling.
A supportive peer-review process focuses on improving practice by means of coaching and advising by the peer nursing leaders on the units. Nurses advance in the clinical ladder program via a peer-review process.
Professional model of care
The philosophy of nursing supports the primacy of patients, families, therapeutic relationships with patients and families, excellence in nursing practice, and leadership. The Synergy Model is used as a framework for aligning patient and nurse characteristics, both in the unit and at the patient level. The fundamental premise of the Synergy Model is that matching a patient's characteristics with the right nurse competencies results in a synergistic effect where optimal patient outcomes are more apt to occur. The model is also patient-/family-centric and considers that optimal outcomes are what patients or people of significance to them define as important. Each specialty unit is able to determine how the Synergy Model is operationalized to best fit specific populations, patient acuity, skill mix, and level of nurse competence. Unit-based huddles address patient needs as the census fluctuates. The model's dimensions of nursing care are embedded in staff nurse job descriptions, as well as annual performance appraisals and peer review.
The nurse-driven Comprehensive Complex Care Coordination program enhances communication and continuity for complex patients. Physicians make referrals to this program. Pharmacy coordination ensures continuity of complex medications for chronically ill patients. Patients are admitted to home units where relationships have already developed, promoting a smooth transition from outpatient/home back to inpatient care.
Quality of care
CHB has a high commitment to quality and safety and desires to provide positive patient outcomes. The Program for Patient Safety and Quality provides oversight for all quality and safety initiatives and includes staff nurses who are unit-based safety resources for their peers. Nurses are empowered to make recommendations for improvements in the workplace. CHB maintains a 5-year safety plan that includes a focus on metrics, with goals that are achieved at the 100% rate being retired and monitored quarterly or biannually. The nursing practice and quality outcomes measurement committee is a nursing shared governance structure that's accountable to outcomes. All nursing metrics are stratified by race and ethnicity as part of a grant program provided by the City of Boston to assess equability and outcomes across hospitals.
The executive team, including the CNO, performs rounds to solicit direct staff feedback regarding barriers to achieving quality goals. CHB maintains a shared computer drive that allows for the dissemination of quality data and outcomes that staff can access 24/7. All units, whether they're able to benchmark against national databases or not, perform EBP literature reviews in order to change practice. There's an expectation for individual nurse's involvement and accountability to quality improvement. Nurses receive paid time to attend meetings and are evaluated on quality improvement activities for professional advancement. Three nurse scientists provide support to nurses involved in quality improvement activities. Staff nurses drive all unit-based quality activities.
The CNO uses a situational and participative leadership structure and a shared governance structure throughout the nursing department. The framework for CHB's shared governance structure consists of councils, committees, task forces, subject matter expert groups, and forums. Council and committee chairpersons are appointed by the CNO, with the exception of the staff nurse council, for which chairpersons are elected from the membership. Meetings for most councils and committees are held monthly. Agenda are developed by the chairpersons with input from members.
Staff nurses and nurse leaders at CHB are mentored and mentor others through a variety of activites within the nursing department. Mentoring is part of succession planning that helps to build the next generation of nurse leaders. Staff nurses bring forward recommendations for change and are empowered to make the change. Leaders are visible. Senior leadership conduct quarterly open forums; the CNO has an open door policy and has visibility on the day, evening, and night shifts, as well as on weekends.
Consultation and resources
CHB resources range from unit-level subject matter expert staff nurses to resources committed for clinical experts. There are 141 APNs who are unit- and/or program-based. CHB employs 10 doctorally-prepared nurse scientists to guide and assist staff in EBP and nursing research.
CHB is affiliated with 26 schools of nursing and has developed relationships with several foreign nursing programs in Russia, China, and Peru. Seven national certification courses are offered on-site for nurses.
The nurse-run Center for Families is dedicated to helping families find the information and resources they need to understand their child's medical condition and take part in their care. The Pediatric Advanced Care Team (PACT) provides end-of-life care support. PACT APNs provide consultation and guidance on palliative care issues to staff, patients, and families and collaborate with the Initiative for Pediatric Palliative Care.
CHB has nursing standards and guidelines, shared governance structure, job documents, policies and procedures, and clinical practice guidelines that help ensure nurses practice autonomously and in accordance with national professional nursing standards.
Peer review has been a key component of the nursing department for more than 20 years. A peer-review policy broadly explains minimum expectations at the departmental level, and individual units have peer-review guidelines that further define the process. Peer review is a component of the professional advancement program and is an annual requirement for every nurse at CHB, requiring self-evaluation with input from peers.
CHB has developed an incident-based nursing peer-review committee, which reviews clinical practice issues that arise as a result of an undesired or unexpected outcome. The committee decides whether a nurse met appropriate standards of care and makes recommendations directly to the CNO for follow-up, depending on the decision. The findings of this committee might initiate further education of the nursing staff on a particular topic of care or identify possible process changes to ensure that the issues identified in the review don't occur again.
Nurses are involved in more than 137 different professional organizations, associations, and societies of specialty practice. Activities include chaperoning field trips, classroom lectures, food drives, toy drives, and participation in Bridge Over Troubled Waters, a program to help runaway children in Boston. Staff nurses and APNs provide educational programs for school nurses across the state on such topics as mental health issues, asthma, and allergies.
The SCOOP program offers a 6-week paid internship for high school students who express an interest in healthcare careers. This program is nurse driven and supported by staff nurses from all units. A certified asthma nurse educator coordinates CHB's Community Asthma program, including home visits and environmental assessments. The Center for Young Women's Health provides teenage girls with expert healthcare and special program and health information on a website specific to their needs.
Nurses as teachers
Teaching is an integral part of every nurse's role at CHB. Nurses teach patients and families, as well as student nurses, nursing colleagues, medical students, interns and residents, and community members.
Nurses at CHB offer clinical and professional expertise as consultants, authors, and presenters at local, national, and international conferences. Nurses from all levels serve as adjunct faculty. Staff development and unit-based educators offer programs to develop expertise.
Image of nursing
Nurse contributions are made visible when nurses receive awards, such as the Excellence in Nursing Award and the DAISY Award. Nurses are honored during Nurses Week celebrations and at the annual Department of Nursing dinner for all nurses. Nurses' contributions are also acknowledged in the organization's newsletters. CHB has a long history of supporting nurses in nontraditional roles. These nurses are widely accepted by patients and interdisciplinary staff. The community perception of nursing and nursing departments at CHB is one of respect and appreciation. Picker survey data of patient/family satisfaction with nursing care was 90% to 95%.
CHB is a highly collaborative environment that enables decision making. All nurses at CHB are expected to contribute to the advancement of nursing practice and the improvement of patient care. Nurses coordinate interdisciplinary care through all phases of hospitalizations and provide expert perspectives and assessments that are key to meeting patients' needs. Nurses work collaboratively with interdisciplinary teams and play an integral role that directly influences clinical outcomes.
Ensuring access for nurses to learn and grow is an important component of the Department of Nursing. Examples include funding for tuition, professional meetings and conferences reimbursement, and the Professional Advancement program. Nurses can receive additional monies for degree programs from a scholarship fund; to date, no nurse has been denied a scholarship. There are multiple on-site opportunities provided for continuing education (CE), and the hospital also offers online CE classes. Educational programming is prioritized for the year based on results of the education council needs assessment. Over 98% of nurse leaders hold bachelor's of science in nursing degrees or higher and some are enrolled in doctoral programs. Certification is at 89% among nurse leaders. Thirty-two percent of all eligible direct care staff are certified and many are planning to take a specialty exam in the next year. Over 30% of nurses at CHB belong to professional organizations.
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