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New system makes nurses accountable
When the quality improvement council at St. Marys Hospital Medical Center in Madison, WI, decided to improve the registered nurse evaluation process, it looked for some good benchmarks in the literature and at other hospitals. What it found was that nobody had what the council was looking for, so it created its own benchmark in the form of a new process called privileging.
The hospital had already put in place a shared governance system that spreads accountability among staff members for institutional goals such as quality improvement, education, research, and management, says Karen Brennan, RN, BSN, chairwoman of the quality improvement council. But something was missing: nurses’ personal accountability for their individual jobs and their professional development.
"We’re moving away from being management-driven to being professional nurse-driven," she says. "Management’s primary responsibility is overseeing the resources whereas the staff has the accountability for the quality of the practice and the practitioners."
Employee surveys revealed that the nurses wanted to be treated as professionals and recognized for the work they did above and beyond completing an eight-hour shift, Brennan says. To respond to that concern and to provide a mechanism for better evaluations, the council came up with a professional development model that defines clear expectations for achieving desired outcomes in four categories: intellectual, technical, interpersonal, and ethical.
Charts delineate the general functions nurses are expected to perform, followed by specific job responsibilities in those areas. (See sample charts, "Evaluation Process" and "Housewide Credentials," inserted in this issue.) For example, one of the functions calls for nurses to assume responsibility and accountability for their own professional practice, continuous education, and competency, and to share their knowledge with their peers.
The nurses are required to demonstrate these skills:
The evaluation process was built on the framework of the professional development model, Brennan says, giving nurses a chance to document what they’re already doing and see areas in which they need improvement. The privileging process encompasses three arenas: credentialing (meeting required standards such as CPR certification and TB skin testing), competency (demonstrating the ability to operate equipment and other skills), and evaluation.
In the credentialing arena, managers used to remind nurses when it was time to update testing, Brennan says. Now, the nurses are responsible for keeping track of when they need to get recertification and must provide documentation when they’ve completed it. Competencies were expected before, but they weren’t always checked, she says. Now, the requirements are spelled out, and the nurses must demonstrate their knowledge during a meeting with their peers. If they aren’t able to use a piece of equipment properly, the other nurses will teach them how to do it right then.
Perhaps the key to the success of the whole process: Evaluations are no longer the sole domain of the managers. Nurses now do a self-evaluation that explains how they’ve grown in each of the categories, reviews progress toward goals, and sets new goals for the coming year. "We were encouraged to set goals before, but it was more of an afterthought," Brennan says. "They were arbitrary goals and no one ever checked on whether you met them."
The self-evaluation and those written by three peers are part of the evaluation with the unit director. "Nurses collect their own evaluations and set up their own appointments to review their performance with their managers," she says. "It’s a much more valuable evaluation because you get the chance to reflect on your own practice, you get feedback from your peers, and you’re more accountable."
Peggy Weber, RN, BSN, who has worked as a nurse at St. Marys for 30 years, says evaluations of the past didn’t come close to the effectiveness of the current system. "Because we nurses developed it, it’s thorough and it’s real. We own it, and we can change it if we don’t like it," she says. "Having the peer evaluations is very real because those are the people working with you right at the hip. My head nurse doesn’t see me in action as much as my peers do. Before, people were evaluating you who don’t know what you do. The head nurses aren’t there when you pass your meds and get your people up and interact with the family and when you call the social worker and at your team meetings. I become a better nurse because I work on my weak points and then I can give better patient care."
The hospital has plans to take the privileging process housewide based on the first year’s success with RNs. LPNs started the process last fall. By the end of the year, certified nursing assistants; unit assistants; unit secretaries; clinical nurse specialists; and technicians in the operating room, obstetrics unit, and emergency services will also participate.
Giving nurses a framework in which to improve their professional skills has a direct benefit on the quality of care, Brennan says. "The nursing accountability and the improved evaluation definitely benefit patient care," she says. "The nurses are more professional; they own their own practice. They aren’t just saying, This is the way I was taught.’ They have much more buy-in to the way things are done. They’re much more vocal."
[For more information on the privileging process, contact:
Karen Brennan, St. Marys Hospital Medical Center, 707 South Mills St., Madison, WI 53715. Telephone: (608) 258-6151.]