1. Pastorius, Dan

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It's no secret that only the best hospitals in the nation boast the Magnet seal of approval. However, gaining this accreditation is often easier said than done. Not only must your facility provide top-of-the-line patient care, but a safe and efficient environment-in addition to a multitude of other requirements-is necessary to receive this designation. The two facilities profiled here meet the Magnet criteria necessary for accreditation, and were pleased to share some of their tips and strategies with Nursing Management.


The Children's Hospital, Denver, CO

With a mission statement geared toward improving children's health through the provision of patient care, education, research, and advocacy, The Children's Hospital (TCH) is a private, not-for-profit pediatric healthcare network that's 100% dedicated to caring for kids. From medical breakthroughs to late-night fevers, TCH provides complete pediatric care through a network that includes five community-based after-hour care sites, eight specialty-care centers, and more than 400 outreach clinics held in three states each year.

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The Children's Hospital provides children and their families with an integrated pediatric healthcare delivery system based on an intrinsic set of values. These values revolve around quality patient care, teamwork, innovation, and overall employee excellence including Magnet certification.


"Achieving Magnet status has enhanced professional pride for nursing in general and for each and every nurse throughout the system," says Ann Froese-Fretz, RN, CPNP, MS, Magnet program coordinator. "Magnet status has raised the bar for not only expecting TCH to be a great place to practice nursing, but for improving nursing practice especially through research."


Quality of leadership


[white diamond suit] At TCH in Denver, nursing leaders are recognized throughout the institution as leaders in the care of children and families. They're seen as advocates for the nursing staff and encourage all nurses to take responsibility for their own practice and the children and families for whom they provide care.


[white diamond suit] The nursing philosophy and scope of practice is featured prominently in the nursing page on the TCH Web site. Nursing leaders at TCH and the division of nursing recognize today's turbulent healthcare environment and work in collaboration with other members of the healthcare team to develop and implement creative and innovative approaches to child healthcare services.


[white diamond suit] TCH nurses and nursing leaders are committed to providing leadership in the definition and delivery of quality care to children and their families through a strategy of proactive change with effective use of resources.


Organizational structure


[white diamond suit] At TCH, all nurses report directly or indirectly (through a matrix model) to the chief nurse officer (CNO).


[white diamond suit] Decisions about nursing are made by nurses. Other disciplines and leaders may have input, but the CNO is ultimately responsible for every aspect of nursing.


[white diamond suit] At the unit level, the clinical directors manage their total operations. They determine their own budget with a financial review, a vigorous process that ties in with the nursing strategic plan and the hospital-wide strategic plan. This includes planning unit-based equipment for the new hospital that's under construction.


[white diamond suit] Nursing units are self-governed. They use diverse models of shared governance. They're accountable for their own outcomes. Staff nurses are involved at all levels with committees, task forces, and projects.


Personnel policies


[white diamond suit] Professional nursing practice has been an important goal of nursing at TCH for many years. Various committees and task forces, whether for retention and recruitment or for furthering professional practice, have addressed the issues of salaries and benefits.


[white diamond suit] Self-scheduling has long been in place on the inpatient units, and nursing leadership has employed various flexible staffing models.


[white diamond suit] A recent revision of the clinical ladder allows for greater promotional opportunities.


[white diamond suit] Consistent support to further one's education encourages enhanced professional nursing practice and increases the chances of promotion.


Professional model of care


[white diamond suit] Across the hospital in every discipline, the Family Centered Care model is the underlying premise for every program and policy, and is a major component of the patient/family satisfaction surveys sent randomly to selected TCH patients/families.


[white diamond suit] Most units combine several models of care to provide the most effective treatments for the diverse needs of their patients. Primary care is provided in the inpatient units, and some also employ Dr. Jean Watson's Caring Theory in the "Attending Caring Team" (ACT) models on their units.


[white diamond suit] The ACT project is an evidence-based nursing practice model focused on implementing caring theory to improve pain management. It's a multidisciplinary endeavor designed to promote family-centered care and holistic nursing guidelines, and focuses on caring for self and each other through developing relationships and equal healthcare team partnerships with families and patients.


[white diamond suit] A care model for end-of-life transitions began in 1998 when the TCH oncology outpatient clinic recognized a need for palliative and end-of-life care designed to meet the needs of children and their families. The "Butterfly Program" was developed to provide pediatric-specific end-of-life care to children using home care benefits that provide a broader range of treatment options to these families. Treatment options included home transfusions and continuation of potentially life-prolonging treatments that wouldn't be permitted in a traditional hospice program.


Quality of care


[white diamond suit] Providing quality care is an organizational priority of TCH. The mission of the division of nursing is quality patient care, education, healthcare research, and child health advocacy.


[white diamond suit] Nurses practicing at TCH understand the importance of high-quality care for each patient and strive to provide it. In every clinical nurse job description, it reads, "In response to collected data, (the nurse) plans, implements, and evaluates nursing care designed to meet the individual health and illness needs of complex patients and their families in collaboration with other disciplines." Regardless of the skill level, every nurse who provides patient care is expected to use this nursing process to address the needs of patients and provide the highest quality of care.


Quality improvement


[white diamond suit] All nursing personnel are responsible for maintaining an awareness of and participating in the quality and patient safety process. This includes:


1. Knowing the mission and vision of TCH and how that drives the quality performance functions of the institution.


2. Knowing that there are TCH "hospital initiatives" that have gone through organization-wide planning and prioritization, and are ultimately approved by the Board of Directors.


3. Knowing how their department is involved in each initiative.


4. Providing input regarding house wide, divisional, and departmental quality performance activities.


5. As appropriate to the initiative, participating in planning for improvement, implementing interventions, and evaluation results.


Management style


[white diamond suit] Feedback and communication from all staff are encouraged at every level of the TCH organization, not just nursing. The Children's Hospital's chief executive officer (CEO) is highly visible on a daily basis and conducts twice yearly employee meetings. She also maintains an online site in which any employee can send her concerns, ideas, suggestions, opinions, and observations.


[white diamond suit] The CNO also emulates this visibility. She encourages all nurses to communicate their concerns and suggestions in multiple ways, and conducts monthly "Open Staff Meetings" on various days of the week at various times of day to encourage attendance.


[white diamond suit] The CNO chairs the Clinical Nurse Council, a group of over 20 staff nurses from various departments that meet monthly for the primary purpose of communication to and from the CNO.


[white diamond suit] The CNO presides over the monthly Nursing Forum for Leadership meetings that include all nursing leadership members (nursing VPs, directors, managers, APNs, and clinical and coordinator representatives).


[white diamond suit] An annual Divisional Leadership Retreat, under the leadership of the CNO, provides a forum to develop specific goals and measurable strategies and actions to impart a vision for the future of nursing at TCH.


[white diamond suit] Direct care nurses are involved in providing information and feedback that are used to change clinical care. When a need or concern is identified, the nurses are expected to provide insight into that clinical situation and develop changes to address the issue.


Consultation and resources


[white diamond suit] Professional nurses, especially advanced practice nurses (APNs), provide a wealth of knowledge and expertise for nurses at TCH as well as within the community. Regardless of the question, if it pertains to an area of pediatrics, TCH is likely to have an APN or other professional nurse with knowledge in that area.


[white diamond suit] The Children's Hospital employs well over 100 APNs who serve in the roles of clinical nurse specialists, family nurse practitioners, neonatal nurse practitioners, and pediatric nurse practitioners. They've all acquired advanced knowledge and skills in an area of specialization through graduate education (master's degrees or higher) and clinical experiences. Most APNs at TCH have prescriptive authority granted by the Colorado State Board of Nursing.




[white diamond suit] In the TCH nursing scope of practice, the importance of autonomy in nursing practice is addressed specifically. Each professional nurse practices autonomously and as a member of the team delivering child care services within a dynamic environment.


[white diamond suit] The importance of autonomy in nursing practice at TCH is reflected in the number of APNs who provide direct care to children and families, as well as education and consultation to staff nurses at the bedside, administration, and other healthcare colleagues.


[white diamond suit] Nurses at every level conduct research and identify issues related to patient care outcomes. They are encouraged to use their nursing judgment to solve patient care issues. Many have developed new programs to meet the needs of particular patient populations.


Community involvement


[white diamond suit] The Children's Hospital has had a long-term commitment to working collaboratively with healthcare institutions in the area, community physicians, and organizations committed to the special needs of children. Nurses have been involved at every level.


[white diamond suit] In partnership with Denver Public Schools, TCH has developed a multidisciplinary outpatient school program that focuses on academic, medical, and psychosocial needs of medically fragile or chronically ill children ages 7 to 21. The Medical Day Treatment program is located on the TCH campus.


[white diamond suit] In partnership with the Colorado Department of Human Services, TCH Health and Rehabilitation Services, and the Mental Health Corporation of Denver, a school program for psychiatric outpatients has been established at TCH. The Psychiatric Day Treatment Program treats children ages 6 to 18.


Nurses as teachers


[white diamond suit] Teaching is an integral part of a professional nurse's role at TCH. Nurses are involved in teaching the family and/or patient at the bedside or in community settings, peers or members of other professions who are new to their role, and nursing students. Teaching nursing students might be in the classroom or at the bedside.


[white diamond suit] Teaching is part of orientation and mentoring. TCH nurses teach clinical skills, how to be leaders at every level, and how to interact in multidisciplinary situations. They also teach how to advocate for themselves and their patients, and teach how to teach and mentorothers.


[white diamond suit] TCH nurses present their expertise nationally and internationally to educate others interested in caring for children and advancing professional nursing practices.


Image of nursing


[white diamond suit] Nursing at TCH has long held a strong and respected position. TCH nurses are well educated, most with BSNs, many with master's degrees and PhDs, and they're very knowledgeable in their areas of expertise.


[white diamond suit] The CEO provided leadership and mentoring for many years as senior vice president of nursing before assuming her role as CEO.


[white diamond suit] The CNO continues to provide leadership and enhance the image of nursing at TCH in her interactions with other professionals at all levels of the organization and in her role with the hospital Board of Directors.


Interdisciplinary relationships


[white diamond suit] At TCH, being involved in interdisciplinary activities at all levels is an integral part of the nursing culture and the larger hospital culture. The CNO interacts with the Board of Directors and sets the expectations for nurses to provide leadership, expertise, and/or involvement in every venue.


[white diamond suit] Nurses are viewed as essential members of the healthcare team. Not only are nurses involved in matters that directly relate to their patients, but also all facets of the organization including quality, safety, information systems, facility planning, human resources, and finance. Nurses from inpatient, ambulatory, community, and satellite operations are contributing members on interdisciplinary teams and are valued for their nursing and patient care expertise.


Professional development


[white diamond suit] Professional development has a long history at TCH. Since the late 1970s when our current CEO was our nursing administrator, the division of nursing has been striving to encourage nurses to further their education and obtain certifications in their specialty areas.


[white diamond suit] Nurses at every level are expected to be well informed, as research has brought new information about diagnoses and technological advances have changed how we care for patients. In the early 1980s, our CEO was instrumental in developing a policy to hire only BSN prepared RNs and transition to an all RN staff. RNs without a BSN degree were encouraged to use the tuition reimbursement program to complete BSN requirements. Many nurses went back to school for the BSN and on for their master's degrees.


Johnson City Medical Center, Johnson City, TN

With a history of providing quality healthcare services since 1911, Johnson City Medical Center (JCMC) is a 443-bed, not-for-profit, acute care teaching hospital. The facility is a major medical referral center with Level I trauma care, and is the region's only dedicated emergency medical air transport service. Johnson City Medical Center offers a full range of specialty and subspecialty care services, in addition to advanced diagnostic and surgical techniques that provide patients with dedicated, high-quality service.

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Throughout its tenure, JCMC has accumulated several distinct accreditations, one of them includes being selected as a Magnet hospital. In spite of this achievement, Kathryn Wilhoit, RN, CNAA, MSN, FACHE, vice president and chief nurse executive, Mountain States Health Alliance, states that the designation of Magnet status won't end the facility's lifelong quest for excellence.


"Achieving Magnet status is a great recognition for frontline nurses," says Wilhoit. "The journey and Magnet quest is a continual pursuit of excellence for patient care, nurses, the work environment, and leadership. It affirms our values and validates the contribution of nursing to create a successful organization."


Quality of leadership


[white diamond suit] Nurses have a significant voice in organizational systems at JCMC, and through that influence, are able to facilitate the delivery of nursing services across the continuum of care. The vice president (VP)/CNO is a member of the Executive Team for the facility and of the Executive Team for Washington County and Mountain States Health Alliance.


[white diamond suit] The VP/CNO, unit leaders, and staff nurses aren't only an integral part of the team, but are strong leaders in the creation and evaluation of interdisciplinary processes that promote patient-centered care.


[white diamond suit] The quality of nursing leadership is enhanced by the ongoing pursuit of knowledge and utilization of evidence-based management skills and techniques. Nurses in leadership positions, from shift leader upward, are eligible to participate in programs conducted by the Nursing Leadership Academy division of the Healthcare Advisory Board.


[white diamond suit] A critical part of maintaining the quality of nursing leadership is the grooming of nurses possessing exceptional energy and creativity for leadership positions. The VP/CNO encourages the development of new leaders through both formal and informal long-term mentoring of the new leader by an experienced nurse administrator within the system. The mentor and mentee meet frequently to discuss the learner's progress, and the mentor is available for consultation and support throughout the leadership program and beyond.


Organizational structure


[white diamond suit] The VP/CNO serves on the highest governing body of JCMC and Mountain States Health Alliance. She's an ad hoc member of the Patient Care Practice Council and the Performance Improvement Training Council, and is also an active participant of the Patient Care Leadership Council, the CNO Council, and the Research Council.


[white diamond suit] JCMC and its nursing services are dedicated to ensuring that organizational structures are conducive to using human and fiscal resources wisely and efficiently, and in a way that provides safe, effective, and culturally sensitive nursing care. The active participation of the frontline nurses in the shared leadership councils facilitates this goal.


Personnel policies


[white diamond suit] Continuing education is a benefit noted in the personnel policies that support continuing professional development through formal academic programs, conferences, and internal education through Mountain States Health Alliance University.


[white diamond suit] The nursing budget reflects significant expenditures for educational purposes for nursing professionals. Each department allocates funds for education, including travel and fees for professional meetings. JCMC nurses attend state, national, or international nursing meetings and seminars.


[white diamond suit] Reward programs and incentives are provided to JCMC nurses who contribute to quality improvement activities and to the delivery of patient-centered care. At any given time a caregiver may be recognized for outstanding customer serviceand commitment to the philosophy and guiding principles of patient-centered care.


[white diamond suit] Nursing certification is valuedby JCMC's leadership. Financial resources are allocated to pay for a nurse to attend a certification program, pay for testing, and financially reward the nurse once certification is achieved through salary increase.


Professional model of care


[white diamond suit] The professional model of care framework developed and used by nurses to guide nursing practice and patient care includes shared governance and patient-centered care. The shared governance model has been in place since 1997 and was established as a means to move from a hierarchal to a councilor structure in which the bedside nurse is the key to patient care and management decisions.


[white diamond suit] The councils are led by staff nurses, and membership consists of frontline interdisciplinary representatives. The VP/CNO monitors and actively supports the councils by assisting to overcome barriers to successful implementation of council recommendations that positively impact patient care and staff needs. The shared governance system enables the caregivers within the organization to assess, plan, implement, and evaluate changes that promote patient-centered care.


[white diamond suit] JCMC nurses participate in and lead professional organizations, and use the standards developed by professional organizations to guide their practice. Standards, such as those of the Oncology Nursing Society, American Association of Critical-Care Nurses, and American Nurses Association, are used to develop protocols for practice within the facility. Nurses at JCMC, through their affiliation with nursing organizations, help to shape nursing practice and social policy through the standards of the organizations, and use those standards to develop protocols and policies for JCMC.


Quality of care


[white diamond suit] The VP/CNO has a direct and active role in the use of data in decision making and achieving desired quality of care outcomes.


[white diamond suit] The excellent quality of patient care associated with JCMC is dependent on competent, skilled, professional nurses. To ensure this professional expertise, nurses' competency is evaluated at the time of initial employment through procedures and testing during orientation to the facility. A significant part of professional skill is the ability to think critically and to translate data gathered in patient assessment for diagnosis and intervention.


[white diamond suit] The VP/CNO fosters an environment that integrates and implements evidence-based nursing practices. Adequate time is allotted for nurses' participation in meetings in which to consider and plan the implementation of evidence-based nursing practices. Specific nursing practices and protocols are based on evidence from research at JCMC.


Quality improvement


[white diamond suit] The nursing performance improvement (PI) program at JCMC is a dynamic, energy-filled process that's integrated into the daily life of the caregivers. The nursing PI activities are collaborative and interdisciplinary, and are linked with the PI plan for the entire system.


[white diamond suit] At JCMC, the PI Council monitors and guides the continuous improvement efforts at the facility level. Reporting to the PI Council, the PI Training Council is charged with oversight of the National Database of Nursing Quality Indicators (NDNQI) and with educating staff members in PI processes.


[white diamond suit] The VP/CNO is an ad hoc member of JCMC's PI Training Council. Her role is to assist the committee by identifying resources for data collection, to provide administrative support for the group, and to shape the work of the committee by using pertinent data to provide the basis for PI projects.


[white diamond suit] Nursing leadership is highly valued in JCMC's PI process, and the importance of nurse-sensitive quality indicators is recognized and supported by the PI Council's interdisciplinary group through the collection, monitoring, and use of data such as infection control findings, medication error reports, findings of the Department of Organizational Development, Patient Care Practice Council reports, patient satisfaction results, and NDNQI data.


[white diamond suit] Frontline staff nurses are participants or leaders of PI initiatives at system, facility, and unit levels.


Management style


[white diamond suit] Management style is assessed globally every 2 years through the employee opinion survey. The executive team, directors, and managers are evaluated, in addition to the employee benefits program and employee work environment. Feedback from these surveys is provided to the executive team, directors, and managers who are challenged to establish an action plan to address areas of deficiencies.


[white diamond suit] The participatory management style of the VP/CNO has led to the formation of a Nursing Operations Council, including all directors with nurses in their departments that provide direct patient care activities (radiology, pharmacy, outpatient oncology, cardiovascular service, and surgical services). The council meets monthly to identify and respond to patient care and frontline nursing needs.


[white diamond suit] The VP/CNO establishes the milieu for her nurse leaders through her management style, which fosters two-way communication.


[white diamond suit] The management style of the nursing directors at JCMC is one of visibility and availability. The directors make walking rounds, maintain an open-door philosophy, have a presence at staff meetings, and seek constructive feedback from staff.


Consultation and resources


[white diamond suit] Culturally sensitive care is enhanced by the Center for Cultural Diversity. The Center offers consultation and resource assistance to staff for the understanding of cultural differences through educational programs, materials, and consultation.


[white diamond suit] Ethics consultants are available 24/7 to nurses as part of the strategy to address ethical dilemmas on the clinical units in an effective and sensitive manner. The consultants are senior, highly experienced members of the ethics committee (three of whom are nurses) who are available for consultation and decisions on very complex and complicated ethical cases.




[white diamond suit] Nurses at JCMC have the autonomy to be creative and innovative as they provide nursing care.


[white diamond suit] Nursing has the autonomy to consult ancillary support staff as needed from dietician, cardiac rehabilitation, pastoral care, and case management.


[white diamond suit] JCMC nurses, as autonomous professionals, place their first professional and personal loyalty with the well-being of the patient. This is visible in the willingness of nurses to take leadership roles in solving problems that could compromise the patients' best level of care.


Community involvement


[white diamond suit] JCMC nurses understand the significance of the combined efforts of the community and the hospital to create programs to benefit society. For example, a teenage pregnancy education program has been in existence for 16 years and is led by the bedside nurse that initiated the program.


[white diamond suit] Nurses provide educational direction at the middle- and high-school levels to prepare for health careers through programs staffed by RNs and sponsored by JCMC.


[white diamond suit] The Health Resource Center, a nurse-initiated program, is a model program throughout the United States. The program demonstrates the value for community health when there's easy access to RNs who provide health education information and screening.


Nurses as teachers


[white diamond suit] Patient, staff, and community education are an integral part of professional nursing practices at JCMC. Bedside nurses have a critical role in assisting the transition to practice for the new graduate.


[white diamond suit] Research Council members serve as teachers as they educate nurses and other disciplines about nursing research, in addition to challenging practices to be validated through evidence.


[white diamond suit] Nurses as teachers of patients, families, peers, and other healthcare providers is an expectation of the RN, as stated in the job description. Mandatory education hours may in part be met by teaching hours for a formal class. The class is assigned credit hours for development and presentation. These hours contribute toward the achievement of the annual educational requirement of 12 hours for staff, 24 hours for managers, and 40 hours for directors.


[white diamond suit] Nurses as teachers at professional conferences are supported by the nursing leadership. The frontline staff at JCMC has served as speakers at local, state, and national professional meetings.


Image of nursing


[white diamond suit] Nurses are respected throughout JCMC and the community. The nurses serve on boards of directors for organizations such as the American Heart Association, American Cancer Society, Ronald McDonald House Charities, and Rotary International.


[white diamond suit] Nurses lead hospital- and system-wide initiatives. For example, the transition to electronic medical records is being facilitated by a nurse.


[white diamond suit] Because of their expertise and knowledge, nurses fulfill many nontraditional roles at JCMC. Nurses comprise the majority of the electronic record transition team and are employed by pharmacy as liaisons, work as educators in Organization Development and corporate compliance with Health Insurance Portability and Accountability Act (HIPAA) oversight policy, and perform as quality outcome managers.


Collegial relationships


[white diamond suit] JCMC nurses collaborate extensively with other professionalsand the public to promote health. Within the institution and the community, nurses join with other disciplines to ensure that community needs are met.


[white diamond suit] At JCMC, the development, implementation, and evaluation of programs and services are interdisciplinary processes that foster collegial relationships to improve quality of care. Nurses are deeply involved in these collaborative activities.


[white diamond suit] Nurses serve as members and leaders of performance improvement groups such as the Performance Improvement Council, Patient Care Practice Council, Resource (Patient Education) Council, and the Research Council. These groups engage professionals from all practice disciplines and support units as appropriate for problem-solving related to the improvement of patient safety and satisfaction.


Professional development


[white diamond suit] Nurses at JCMC are actively engaged in the advancement of the profession. They participate and take leadership roles in multiple nursing and other professional organizations at local, state, and national levels.


[white diamond suit] Generous tuition policies support JCMC nurses as they seek BSN and graduate degrees, as well as attend and teach continuing professional education programs.


[white diamond suit] JCMC nurses are exceptionally active in the education of undergraduate and graduate nursing students, serving as preceptors for students from several schools and colleges of nursing.