BIDMC Committee/Team Charter
Shared Governance Council:
Clinical Nurse Specialist Council
Fiscal Year: 2010
Vision: To establish the nursing division at BIDMC as recognized leaders of professional nursing
practice, education, quality patient outcomes and research within the local and national
community.
Mission: To enter collaborative partnerships with the nurse executive council, nurse manger
council and all shared governance forums. Within a collaborative model to ensure quality patient
outcomes, provide evidence based frameworks for patient safety, patient satisfaction, provide
education and mentoring for the continuing development of our staff, and increase nursing
focused research activity within the medical center.
Current Nursing portal definition:
Professional Nursing at Beth Israel Deaconess Medical Center is grounded in the values of
accountability, collaboration, and respect. Through our collaborative practice model, BIDMC
nurses continually strive for excellence in the delivery of care to our patients and families. In
supporting and advancing patient care, we continually pay attention to our professional
relationships, our work environment, patient care outcomes, and the development and
advancement of our nurses. In doing this, we steadfastly enhance our work to improve patient
safety and quality, to improve patient satisfaction, and provide care in a fiscally responsible way.
Every member of our team is valued for his/her contributions to our growing, evolving BIDMC
community.
Chairs: Kathy Baker and Simone Rinaldi
VP Sponsor: Marsha Maurer
Meeting Schedule: 1st & 3rd Tuesday of each month, 9:00–10:30am, Kirstein Living Room
Council Members
Ajl, Leslie
Baker, Kathy
Calder, Shelley
Carnevale, Kerry
Crafts, Susan
Devine, Joanne
Fealy, Natalie
Gillis, Jeanne
Gugllielmi, Charlotte
Kristeller, Chris
Lavieri, Mary
O’Donoghue, Sharon
Ouellette, Maryann
Rinaldi, Simone
Saba, Christine
Williams, Donne
Young, Susan
Area of Representation
Medical Psychiatry
Medical Oncology
Emergency Department
Medical Surgical
Labor & Delivery
Psychiatry
Surgical
Critical Care
Peri-Operative
Geriatrics
Critical Care Surgery
Critical Care Medicine
Nursery Newborn
Medical
Surgical
Critical Care Cardiology
NICU
Clinical Practice & Quality Improvement Initiatives
Goals
AOP Goals:
Improving Care at the Bedside
Patient Safety
Minimize Nosocomial Infections
Reliable Patient Transitions
Improve Responsiveness Scores
Adverse Events - Learning
Measures
Members of the CNS council have central roles
in the following quality improvement
initiatives/workgroups.
Patient Safety:
 Infection – VAP, surgical site infection,
HINI & seasonal influenza, UTI/CAUTI,
hand hygiene
 Falls
 Skin and Wound
CNS Council Goals:
 Central Venous Lines
CNS council members lead clinical
 CIWA
practice and quality improvement
 Code Purple/debriefing
initiatives (initiatives consistent
 Code Green/debriefing
with the AOP goals) at both the
 Code Pink/debriefing
local and institutional level.
 Code Blue/debriefing
 Code STEMI/debriefing
 GRACE
 ICU dialysis
 Aspiration
 PCA/Epidural
 (Nursing) Diabetes
 Trigger/case review
 Family Triggers
Staff

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Safety:
Safe Lifting
PPE
Infection
Workplace Violence
LEAN
Patient Transitions:
 Kardex/Careplans
 Handoffs
 STAAR
 Universal Protocol
 Medication Reconciliation
Responsiveness:
 Call light utilization/Zetler
 Hourly Rounding (“We Promise”)
 Leadership Rounding
Completion
Date
Ongoing.
Orientation /Continuing Competency/Professional Development
Goals
CNS Council Goals:
Ensure mechanisms are in
place to assist nurses’ to
identify the knowledge, skills
and personal attributes
required for practice.
Measures
Ongoing re-assessment of orientation programs;
medical-surgical, PCT, critical care, and other
specialty groups (e.g. Stat Nurse Role)
Continuing competence
1. Define core competencies for entry orientation
and continued generic competencies
Maintain practice environments
that support and foster
continuing competence.
2. Evaluate and revise core competencies for
specialty-specific orientation and continued
competencies
Provide continuing competence
programs including but not
limited to; orientation, annual
competency programs,
preceptorship, mentorship,
staff development programs
and the support of specialty
certification.
3. Identify the BIDMC regulatory/mandatory,
institution based, unit-specific and continued
professional development competencies:

Annual &
1/2010
6/2010
Create a competency submission and
ongoing review process.
4. Review validity of content, methods for
review, and delivery structure.
5. Develop a fiscally responsible competency day
institutional model by 2011

10/2010
Implement CC competency day pilot
2010.
Implement ED competency day pilot 2010
1/2010
Collaboration/coordination with Director of
Professional Development and Nursing Research
Education Council in the development of
continuing education programs.
4/2010
6/2010
Assist nurses in achieving their goals for clinical
advancement through attainment, development
and enhancement of clinical skills and critical
decision-making skills through the Clinical Nurse
Advancement Program.
Ongoing

Collaborate with Nurse
Managers in the continued
development of the leadership
team.
Completion
Dates
Annual &
1/2010
Partner with Nurse Managers, Unit Based
Educators, and Human Resources to develop
UBE position description; to identify any specific
competencies; and to create orientation process.
10/2010
Begin
3/2010
Assessment of the State of Nursing Practice
Goals
Measures
Completion
Dates
AOP Goals:
Improving Care at the Bedside
Patient Safety
Minimize Nosocomial Infections
Reliable Patient Transitions
Improve Responsiveness Scores
Adverse Events - Learning
CNS Council Goal:
Develop evaluation mechanism
and conduct an assessment of
the state of nursing practice at
BIDMC with recommendations
for improvement to the VP
Nursing
Phase 1: Develop and Implement Triangulated
Assessment Method (chart audit, observation of
nurse behaviors, staff self-assessment survey)
2009
Phase 2:

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Organize data for analysis – develop and
document a database structure that
integrates the various measures
Describe data with summary/graphical
analysis about the sample and the
measures.
Describe relationship between select
variables (to be determined)
Develop recommendations for
improvement in practice based on results
of triangulated assessment
1/2010
2/2010
Phase 3:
Develop process for the continuous assessment
of nursing practice, identification of issues,
development of solutions, creation of clear
objectives and implementation plan.
6/2010
Patient Education
Goals
Measures
AOP Goals/CNS Council Goals:
Improving Care at the Bedside
Patient Safety
Reliable Patient Transitions
Improve Responsiveness Scores
Create and implement process for
developing, reviewing, and updating
core patient education materials.
Fall 2010
Evaluate (select) existing patient
education material for credibility and
readability, and provide
recommendations for revisions
based on health literacy concepts:
2/2010 and ongoing.


Completion Dates
Nursing Diabetes Workgroup
STAAR Initiative (teach-back)
Develop nursing orientation that
provides teaching strategies nursing
staff can use to enhance patient
understanding of medical
information/improves health literacy
in order to obtain better outcomes
for our patient populations.
2/2010