Pathways to Excellence

Standard 1: Shared Decision Making

Leader Rounding/Staff Meetings to obtain feedback.                      

• Interprofessional collaboration   
• Daily Shift Huddles/MDRs/Safety Huddles
• Falls Prevention Committee/Quality Improvement & Patient Safety Committee
• Facility-Based Shared Governance Committee
• CNC Role Development & Implementation
• Cardiac Implementation of CHG Baths for all patients with central lines.
• Change in Fall Risk Assessment to JHFRAT
• Postpartum Depression Program P3 
• Nurses involved in Ethical Concerns
• Nurses evaluating equipment and product trials
• Nurse and staff input on every new employee

Standard 2: Leadership

Nursing Leadership is accessible and advocate for direct care nurses, staff, and patients.

• CNO accessible by attending staff meetings, Town Halls, rounding, open door policy, email, nursing orientation
• Nurse leaders accommodate Facility-Based Shared Governance schedules, virtual meetings available for RNs & staff
• Nurse leaders accessible for staff via text, call, 1:1, email, staff meeting, rounding
• CMs & CNCs involved in staffing decisions
• Assesses and facilitates readiness for change
• Staff leadership development activities/opportunities
• Annual RN Peer Feedback
• Quarterly Daisy Awards
• Retention, succession planning and Professional Development
• Monthly Nursing Grand Rounds

Standard 3: Safety

MHMC works to provide a safe and secure environment for staff and patients in our care.

• RL Occurrence Reporting, Daily Safety Huddle, 7A/7P Shift Huddles, Compliance Hotline, RCAs, Bedside Shift Report
• Unit Success Boards
• Good Catch Awards
• Env of Care Rounds, Leader Rounding, Conduct Policies, Secure Family Birth Center, Safety Drills
• Workplace Violence Taskforce
• MOAB De-escalation Training for CNCs/staff
• Procedural and surgical time outs

Standard 4: Quality

Quality initiatives are evidence based and established using benchmarks.

• Monthly Quality Improvement & Patient Safety Committee with direct care nurses and nurse leaders
• Quality information & trends shared at staff meetings, Town Halls, posted in departments
• Quality initiatives are aligned with the mission, vision, and values of MHMC
• Cardiac badge buddies to ensure correct discharge instructions
• Evidence-based practice, Wound Care Champions, Quarterly Prevalence Study and dressing change conversion

Standard 5: Well-Being

Work-life balance and personal health is encouraged and supported for all staff.

• Community involvement/Volunteerism is promoted and recognized
• Work-life bounce is supported
• Annual Wellness Survey with staff participation
• Self-scheduling, flexible schedules
• Recognition/awards: DAISY, ICARE Champions Month/Year, Wellness incentives, Compsych
• Sunshine Cart, Interfaith Chapel, Chaplains
• Critical Incident Peer Support Team (CIPS), gift shop, outpatient pharmacy, farmers market

Standard 6: Professional Development

Lifelong learning, ongoing education, and professional development is valued and supported.

• Tuition Assistance for advanced degrees; specialty certifications/MHS Pays Program
• Internships, Nurse Residency Program, Professional Development
• Nurses are educated to new equipment and processes
• Monthly Nursing Grand Rounds, virtual option available
• Educational events are offered at different times to accommodate staff attendance
• Clinical Nurse Coordinator (CNC) development with implementation plan