The Health Network of
THE CHESTER COUNTY HOSPITAL
701 E. Marshall Street, West Chester, PA 19380
UNIT BASED COUNCILS TOOL BOX
Introduction
This tool box identifies nine areas to structure and guide unit based councils. The nine
areas are:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Goals of Council
Purpose and function
Membership and application
Leadership
Authority
Decision Making and Voting
Meetings
Evaluation
Communication
It is recognized that each unit is unique in its scope and population; therefore the tool box
should be adapted to the units needs. This tool box is designed to provide the framework
for your unit council.
It is recommended that an initial activity of the council is to develop a Mission and
Vision Statement specific to their unit in conjunction with the organizations mission and
vision. This will provide the foundation on which to build your council.
The mission of TCCH is to exceed the expectations of those served, maintain standards
of highest quality and promote a rewarding working environment.
The vision of TCCH is to be known as the health care provider of choice and employer of
choice.
The utilization of the Patient Satisfaction Performance Standards communication,
compassion, integrity, commitment and Teamwork, offers the frame work to further
develop the activities of council
1.
Goals & Ground Rules
Each unit will develop measurable, concrete goals/ground rules (see attached) for
their council that reflects the scope and needs of the unit and support the system
and nursing strategic plan. The recommendation is to start small.
2.
Purpose & Function
A few areas that the unit based councils may want to start with as projects are
the following:
A. Clinical Practice
a. Establish a schedule to review, evaluate and analyze based on best
practices, unit based policies and procedures, protocols, standards,
pathways, order sets and other documentation utilizing the Nursing
Quality Committee.
b. Identify high risk, problem prone, low volume issues and collaborate to
provide feedback to appropriate committees (i.e., Policy & Procedure)
c. Evaluate and make recommendations on quality improvement data
d. Update references utilizing information from specialty organizations
B. Performance Improvement
a. Review and develop unit key indicators
b. Ensure quality improvement activities reflect mission and vision of the
organization and scope of practice on the unit
c. Analyze unit specific and organizational quality data results and develop a
plan accordingly
i. increase staff awareness and solicit input regarding quality
improvement activities
C. Unit Patient/Family Education
a. Review current patient/family education material for availability and
appropriateness of clinical content
b. Index materials that are used by unit
c. Identify need for additional educational material
d. Recognize and utilize additional resources for review and development of
patient education material(i.e., Staff Development, Clinical Specialists)
D. Unit Satisfaction
a. Promote constructive feedback among peers/conflict resolution
b. Promote team building activities
i. collegiality within department
ii. collegiality with various departments and staff
c. Role clarification (i.e., RN, LPN, NA, US etc)
d. Accountability for activities and confidential communication
e. Employee surveys
 encourage participation
 communicate results
 develop action plans
f. Participate in new applicant interviewing
g. Determine HOD unit based “vows”
E. Unit Based Staffing and Scheduling Issues
a. Education and understanding of staffing grids and core staffing and
staying within budget in collaboration with Unit Based Staffing
Committee
b. Review effectiveness of current staffing and scheduling practices (i.e.
holiday scheduling, reassignments, weekends, shifts, requests for time off,
etc.)
c. Communication of unit based staffing and scheduling practices
F. Staff Education and Competency
a. Support for unit staff education in collaboration with Staff Development to
maintain competency and provide for professional growth
i. consider development of Department/Unit based Education
Committee
ii. review journal articles
iii. utilize research to investigate best practices
iv. input regarding unit specific competencies
v. identify new unit based key competencies
vi. establish a schedule for competencies and in-services
vii. plan for implementation of educational offerings
b. Technical ability
i. new/change technology
ii. utilization of policies and procedures for educational purpose
c. Unit orientation
i. new hire/reassigned staff/agency orientation
d. Certification/continuing education
i. increase awareness of certification and continuing education
opportunities and responsibilities
e. HOD Taskforce members will report information to unit council
i. increase staff awareness of HOD campaign and outcomes
3.
Membership/Application Process
a. Membership will be determined at the unit level by staff and manager
through application process.
b. Membership may include but not limited to:
i. RN
ii. LPN
iii. Charge Nurse
iv. Weekend Staff
v. All Shifts Represented
vi. Full & Part Time Staff
vii. NA, Us, Techs any ancillary staff
c. Ancillary departments invited as needed
d. Size of unit determines number of members required (average unit would
have five permanent staff members- must take into consideration the
business needs to the unit)
e. No substitution for members (except extended leaves)
f. Members are required to attend 80% of the meetings
g. New applications will be accepted when vacancies occur
h. Optional- have staff member attend meeting to observe
A. Length of Membership
a. Initial term- two 2 years- a membership should start date should be kept
on each members
b. After the two year mark, one half (1/2) of the members will be replaced
each year at committee’s discretion
i. every year at the inception date of the Unit Council, the council
member’s team will be examined. Whoever has met the 2 year
commitment will be on a list to be replaced.
ii. in the event of an insufficient number of volunteers willing to step
down, the Unit Council will have a random draw to decide
additional members who will be replaced
iii. staff may continue to serve on Unit Council after the two year term
if there are no applicants or at the discretion of the Unit Council
B. Application Process
a. Unit Council will make applications available to staff 3 months prior to
the two year date. (application on nursing web site)
b. Interested staff should complete an application prior to the two year date
c. For the first committee selection- if an excess of applications on one given
shift is received the other shift council members will be given the charge
to select that member with Clinical Manager assistance
d. If further consultation is needed then the Nursing Director will provide
support
e. After the first term, new applications will be reviewed by the unit based
council prior to voting
4.
Leadership
a. The chair will be elected by the committee within six (6) months and
every two (2) years thereafter. The Clinical Manager or Director will serve
as facilitator and coach in the interim
b. Chair person will be up to a 2 ½ year term, serving the last six (6) months
as a resource for new chair
c. In order to facilitate the Clinical Practice Model the Unit Council chair
will be an RN. In the event that there is a transition of council leadership
and no available candidates, current council members will identify a chair
from within the council
5.
Authority
a. Approval body for evaluation/validating unit standards, policies &
procedures, based on the evidence.
b. Provide recommendations and decisions for, but not limited to:
i. staff education and competency
ii. unit patient/family education
iii. performance/quality improvement
iv. unit staffing/scheduling issues
c. Unresolved recommendations/decisions from the unit-based council to be
forwarded to the appropriate referral committee (see attached chart):
6.
Decision Making/Voting
a. Formal decision-making process by majority rules with 2/3 of voting
members. Director, Clinical Manager, Staff Development Educator are
excluded from voting.
b. Voting may be by present or absentee ballot
7.
Resources
a. Nursing Governance Flow Chart
i. The Nursing Governance Flow Chart identifies the following
committee/teams:
a. Quality
b. Management
c. Education
d. Technology/Soarian to assist unit councils with the pursuit
of their goals
e. (See addendum- Nursing Shared Governance Flow chart)
8.
Meetings
a. Monthly, to be determined at unit level by staff and Clinical Manager at a
pre-set day every month
b. Calendar should be set for one year in advance to allow for scheduling
c. Minimum of 10/year
d. Length of meeting to be determined by the unit council (recommendation)
4-8 hour meetings up to one (1) year, then decrease to 1-2 hours
9.
Evaluation
a. Evaluate progress of goals quarterly
i. group will evaluate their progress June of each year
b. Minutes of previous meetings will be reviewed at each meeting
c. Each agenda will begin with current goals
d. Each council will compile an annual review of accomplishments to share
with unit, council chairs of like areas and nursing administration
10.
Communication
a. Monthly meeting minutes/attendance will be maintained by the chair
b. Recorder responsibilities will be rotated among the members
c. Key issues for communication will be identified at each meeting
d. Communication may be organized under Patient Satisfaction Performance
Standards, communication, compassion, integrity, commitment and team
work.
e. Communication methods will be established by the unit council. Methods
may include:
i. Communication board
ii. Staff meetings
iii. Communication tree- each council member/designee is responsible
for verbally communication key issues to assigned staff and
bringing information back to committee
iv. Unit newsletter
v. Nursing Web Site
vi. e-mail
f. Key communication updates will be shared by council chairs with council
chairs of like areas.
UNIT BASED COUNCIL GROUND RULES:
Formulate your own Unit Council Ground Rules as part of your first meeting.
Feel free to use the Studer Ground Rules as a starting point!
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“Be Present” i.e., actively engaged and prepared to participate
Be on time
Begin and end the meeting on time
No backing up to catch up late members
No hidden agendas
Members must notify Chairperson if unable to attend meeting
Council members will speak freely and will listen attentively to others
No interrupting each other
All comments should be phrased in a positive manner
Each council member gets their say, not necessarily their way
Silence equal agreement
Once we agree, we will speak with one voice
Members must respect the confidentiality of the council
All council members are equally important
No sidebar conversation
Processes will be discussed, analyzed or attacked, not people
Always have a timekeeper, facilitator and minute taker
Purpose identified on the agenda
Get agenda and assignment out prior to council meetings