1. Beffa, Alisyn MHA, BSN, RN, NE-BC
  2. Farr, Amy MSN, RN, NE-BC

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At SSM Health St. Clare Hospital in Fenton. Mo., we utilize the councilor model of shared leadership, which includes central councils and unit practice councils (UPCs).1 After it was determined that data needed to be brought to the bedside to advance outcomes, a unit-based champion pilot was implemented. The goal was for each UPC to have "champions" who are supported by content experts within our ministry (hospital) and act as influencers for change within their areas, as well as liaisons for their units. Following the American Nurses Association's Peer Review Guidelines, the unit-based champion pilot group identified gaps in care, resolved concerns critical to quality outcomes, and acknowledged that nurses must share feedback on a consistent and constructive basis to ensure patient safety.2,3 The pilot took a two-pronged approach: unit-based champions and event discovery reviews.

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Unit-based champions

The unit-based champion pilot began by identifying infection prevention champions (IPCs). The organization's infection preventionist and the administrative director of nursing operations created a structure to support nurses to assume a higher level of responsibility and accountability for the quality of care provided to patients. It was determined that the IPCs would participate in monthly champion meetings focused on professional development and enhancing leadership character, and report to their UPC on a routine schedule.


The infection preventionist guided the IPCs through evidence-based literature, professional organizations' recommendations, and industry standards. In addition to education on how to interpret and analyze quality data, the IPCs were trained on the peer review model and learned how to give timely, focused feedback.


The IPCs and infection preventionist met monthly for 30 minutes to receive updated education; review data; and plan prevalence day audits, which compared evidence-based practice recommendations with observed practices at the bedside. IPCs were empowered to give real-time feedback and make changes in the moment. What couldn't be changed immediately was discussed at the next meeting.


At the first monthly meeting in December 2015, the team identified the need to improve catheter-associated urinary tract infection (CAUTI) rates despite educational efforts and protocol initiations. During the first prevalence day audit, the team focused on catheter insertion. They quickly identified areas of opportunity from the OR to inpatient units and discovered that the solutions they were being asked to implement didn't match what was happening in actual practice. The IPCs' focus on quality allowed staff members to identify process flaws that were impeding the ability to achieve best practice, empowering them with the data and knowledge to positively impact outcomes.


The IPC on one of the medical-surgical units used information learned from the champion meeting and available unit-level data to educate her teammates on indwelling catheter insertion, catheter maintenance, and indication for insertion. The catheter utilization ratio declined from 0.20 in 2015 to 0.10 as of November 2018.


Event discovery reviews

UPCs review current practices monthly, including CAUTI, central line-associated bloodstream infection, and falls data. In October 2016, the orthopedic UPC reviewed their falls data after detecting an increased number of falls. In 2016, the unit experienced 8 falls in the first quarter, 2 falls in the second quarter, and 11 falls in the third quarter. During this detailed review, the UPC identified trends in their patient population: falls occurred for patients ages 30 to 70 within 24 to 48 hours after a procedure. The practice on the unit was to not use bed alarms for this age group because it was believed they had the ability to make safe decisions for themselves, including calling for help when getting up. However, postprocedure decision-making may be impaired due to anesthesia recovery or a patient may overestimate his or her ability, leading to unsafe decisions.


The UPC recommended increasing the usage of bed and chair alarms for all patients 24 to 48 hours after a procedure. This simple yet effective practice change reduced the unit's falls to three in 2017 (two in the first quarter and one in the second quarter).


During this same time, a clinical nurse advocated to increase the availability of gait belts. The nurse leader performed a cost analysis, finding that transitioning to patient-specific cloth gait belts was more cost-effective than reusable plastic belts. The UPC identified that gait belts should be used for all joint patients and placed in the room on admission. The gait belt was also incorporated into patient/family education to support discharge planning. This approach enhanced interprofessional relationships, aligning physical and occupational therapy with patient care plans.


Quality improvements

The initiation of unit-based champions and event discovery reviews through our UPCs has led to increased patient safety at St. Clare. Champions are empowered to review current practice and align it with desired process to improve outcomes for all patients. Champions report out to the UPCs to further align strategic priorities and are the link between UPCs and process review. Many quality improvements are a direct result of the champions' work and their influence at the unit level in defining safe, quality care.




1. Guanci G, Medeiros M. Shared Governance That Works. Minneapolis, MN: Creative Health Care Management; 2018. [Context Link]


2. American Nurses Association. Peer Review Guidelines. Kansas City, MO: American Nurses Association; 1988. [Context Link]


3. Haag-Heitman B, George V. Peer Review in Nursing: Principles for Successful Practice. Sudbury, MA: Jones and Bartlett Publishers; 2010. [Context Link]