Geisinger Health System - Organizational Profile by Ellen Jarvis

GEI SI N GER ME D IC A L CE NTE R O R G A N I ZA T I O N AL P R OF I L E

EVIDENCE 1 Information describing the applicant organization in terms of geographic location, services provided, number of beds, number of employees, and population served. Include the most recent demographic report regarding the client population that the organization is serving.

eisinger Medical Center (GMC) is one of three hospitals that, along with an alcohol and drug rehabilitation center and three ambulatory surgery centers, make up the Geisinger Health System (GHS). Serving 31 of Pennsylvania’s 67 counties, GHS has approximately 670 primary and specialty physicians, including the community practice service line of more than 200 primary care physicians at 38 locations. Geisinger Health System’s service area covers central and northeastern Pennsylvania. Eighteen counties within its service area are officially designated as rural and 22 are designated as medically underserved. Pennsylvania also has the third highest percentage of elderly (>65 years of age) in the nation. Geisinger Medical Center is the Geisinger Health System’s flagship hospital. Its clinical services are housed in the hospital, the Knapper Clinic, and the GMC Outpatient Surgery Center on Woodbine Lane. Three research centers are also located on the GMC campus: the Weis Center for Research, the Geisinger Center for Health Research, and the Geisinger Center for Clinical Studies. The Magnet application is for the Geisinger Medical Center as a single facility.

GEISINGER MEDICAL CENTER Geisinger Medical Center (GMC) is the largest tertiary and quaternary care teaching hospital in northeastern and central Pennsylvania. Located in Danville (Pa.), it is licensed for 404 beds. Geisinger maintains an active Level I Regional Trauma Center with additional qualifications in pediatrics—one of only four medical centers in the Commonwealth of Pennsylvania to hold such qualifications. The trauma program is supported by Life Flight®, a five-helicopter air ambulance service that provides system-wide advanced medical and life support across multiple counties. In FY07, Geisinger Medical Center treated and discharged more “Make my hospital than 22,000 inpatients, saw more than 748,000 outpatients, and delivered more than 1,500 babies. right. Make it the best.” Geisinger Clinic is Geisinger’s multidisciplinary physician practice —Abigail Geisinger group totaling more than 670 physicians. These physicians practice at Geisinger’s three hospitals—Geisinger Medical Center, Geisinger Wyoming Valley, and Geisinger South Wilkes-Barre—as well as at the Knapper Clinic, the GMC Outpatient Surgery Center on Woodbine Lane, nearly 40 community locations across 31 counties and at various community hospitals and outreach locations. Geisinger Clinic includes more than 75 specialties that span the integrated health system. It is home to one of the largest ambulatory care programs in Pennsylvania.

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G E I SI N GER ME D IC A L CE NTE R OR G A N I Z A T I O NA L P R OF I L E

THE WOMEN’S HEALTH PAVILION

The Women’s

Health Pavilion The Women’s Health Pavilion, on the GMC campus, features familyoriented birthing suites, semiprivate rooms, a nursery, and two cesarean delivery suites. The Geisinger Women’s Pavilion offers coverage by obstetricians, midwives, neonatologists, pediatricians, anesthesiologists, and expert nurses 24 hours a day, seven days a week. It serves both normal as well as complicated deliveries and receives transfers from a 250-mile radius for high-risk obstetrical complications. Outpatient services at the Women’s Pavilion include obstetrics, gynecology, breast care, and a fertility clinic among others.

THE JANET WEIS CHILDREN’S HOSPITAL

The Janet Weis

Children’s Hospital The Janet Weis Children’s Hospital, also part of GMC, is a comprehensive facility licensed for 80 beds. This regional center of excellence is comprised of newborn intensive care and special-care units, a pediatric intensive care unit, pediatric and adolescent medical and surgical units, and the Pennsylvania Kiwanis Children’s Heart Center. Its Neonatal Intensive Care Unit (NICU) is a regional, accredited Level III Critical Care Center staffed by a team of neonatologists, nurses, and respiratory therapists along with social workers and case managers. The Pediatric Intensive Care Unit (PICU) is a component of the Level I Pediatric Trauma Center and is staffed 24 hours a day. In 2005, Geisinger partnered with the March of Dimes Prematurity Campaign. Geisinger’s president and CEO, Dr. Glenn Steele, serves as the state’s honorary chair in this effort. In 2006, Geisinger became the first medical center to open a rural Neonatal Intensive Care Unit Family Support Program. Supported by Geisinger and a three-year grant from the March of Dimes, this program provides information and comfort to families of NICU babies. The program can be customized to meet the specific needs of NICU staff and parents and includes specific components to address the needs of siblings and extended family members.

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G E I SI N GER ME D IC A L CE NTE R OR G A N I Z A T I O NA L P R OF I L E

KNAPPER CLINIC The two-story, freestanding Knapper Clinic, which opened in 1990 as an outpatient community medical building, is also located on the GMC campus. It was named for Emma Jean Knapper, RN, who devoted her 48-year nursing career to ensuring quality patient care and promoting nursing education. The clinic houses family practice and general pediatrics and hematology/oncology services.

OUTPATIENT SURGERY CENTER—WOODBINE LANE

Knapper Clinic

GMC

Outpatient Located on nearby Woodbine Lane, the Surgery Outpatient Surgery Center is a 33,000Center on Woodbine square-foot, free-standing surgery center. Lane Opened in January 2005, it offers more than 50 different procedures, including pediatric outpatient surgery. The Outpatient Surgery Center—Woodbine Lane is staffed by a team of nurses, certified registered nurse anesthetists, surgical technicians, and board certified anesthesiologists. The center features state-of-the-art surgical suites, endoscopy procedure rooms, a sports medicine and rehabilitation clinic, and a fitness center. Since it opened, this outpatient surgery center has consistently reported patient satisfaction (Press Ganey) scores at the highest levels.

THE SIGFRIED AND JANET WEIS CENTER FOR RESEARCH

The Sigfried and Janet Weis Center for Research

Also located on the GMC campus, the Sigfried and Janet Weis Center for Research (Weis Center) is a facility of 65,000 square feet housing basic science laboratories equipped with state-of-theart instrumentation as well as conference areas, offices, and informal meeting areas. The center encourages collaboration between staff scientists and the medical and nursing community interested in basic research and the translation of new knowledge into patient application.

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G E I SI N GER ME D IC A L CE NTE R OR G A N I Z A T I O NA L P R OF I L E

The Weis Center has strong clinical and community ties, including an emphasis on training postdoctoral fellows, residents, and clinical fellows in research. The center conducts an ongoing lecture series. Highly competitive summer programs provide hands-on research opportunities for gifted undergraduate students, and a special summer camp for elementary students gives them a hands-on laboratory experience that focuses on nurturing a strong interest in scientific investigation. The Henry Hood Research Program in Human Genetics (named for Geisinger’s third president and CEO Henry Hood, MD) is housed in the Weis Center. Weis scientists have garnered national and international recognition for investigations into the cellular and molecular basis for diseases, the mechanisms of hormone signaling, the role of hormones and exercise in heart failure, the control of cell division, the differentiation of tumor cells, the development and regeneration of the peripheral nervous system, and genetics and its role in personalized medicine.

THE GEISINGER CENTER FOR HEALTH RESEARCH

The Geisinger

Center for Health The Geisinger Center for Health Research Research, another facility located on the GMC campus, promotes collaborative research programs with clinical departments and designs new models of efficient and effective patient care. The center conducts research in a number of study areas, including effectiveness of treatments and health services, epidemiology and disease etiology, health services and health economics, population-based and clinical genomics, medical needs of a rural population, and the links between environment and health. The center includes a Center for Nursing Excellence. Its primary function is nursing research led by a doctoral-prepared nurse researcher.

GEISINGER CENTER FOR CLINICAL STUDIES Few programs have the ability to directly impact clinical care as the Geisinger Center for Clinical Studies does. By leveraging the electronic health record, our researchers are able to rapidly identify patients who may be eligible to participate in trials on new drugs, devices, and therapies. Then researchers speak to these patients to discuss the particular parameters of a specific trial and assess interest in participation. Participation in nationally recognized clinical studies offers the patient an opportunity to help advance new clinical discoveries. GEISINGER MEDICAL CENTER CAMPUS: NUMBER OF EMPLOYEES Geisinger Medical Center: 4,788 Outpatient Surgery Center—Woodbine Lane: 87 Knapper Clinic: 83

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G E I SI N GER ME D IC A L CE NTE R OR G A N I Z A T I O NA L P R OF I L E

DEMOGRAPHICS OF POPULATION SERVED Inpatient population: Geisinger Medical Center FY07 AGE 01–04 05–09 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90–94 95–OVER Less than one year Total % Sex

FEMALE 281 221 262 527 731 782 647 603 682 677 685 761 689 813 830 880 824 467 182 38 1,013 12,595 52%

MALE 335 259 284 398 287 273 227 347 499 567 810 907 919 954 975 1,123 717 333 97 18

Total 616 480 546 925 1,018 1,055 874 950 1,181 1,244 1,495 1,668 1,608 1,767 1,805 2,003 1,541 800 279 56

1,263 11,592 48%

2,276 24,187 100%

GMC Outpatient Unique MRNs—FY 2007 Female 136,168 Male

95,661

Total

231,829

Admitting Top 10 Diagnoses: Geisinger Medical Center FY 2007 V3000 SINGLE LIVEBORN HOSPITAL W/O C-SECTION 41401 CORONARY ATHEROSCLEROSIS NATIVE CORONARY ARTERY V3001 SINGLE LIVEBORN HOSPITAL DELIV BY C-SECTION 4280 CONGESTIVE HEART FAILURE UNSPECIFIED 41071 ACUTE MI SUBENDOCARDIAL INFARCT INIT EPIS CARE 27801 MORBID OBESITY 486 PNEUMONIA, ORGANISM UNSPECIFIED 0389 UNSPECIFIED SEPTICEMIA 71536 LOC OSTEOARTHROS NOT SPEC PRIM/SEC LOWER LEG 5849 UNSPECIFIED ACUTE RENAL FAILURE

Source: DSS

DEMOGRAPHIC CHARACTERISTICS: 31-COUNTY SERVICE AREA 2006

2011*

% change

Total male population

1,162,681

1,174,996

1.1%

Total female population

1,198,731

1,209,395

0.9%

457,537

444,910

-2.8%

Females, child bearing (age 15-44) % Unemployment

5.8

% USA unemployment

5.7

*projected

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G E I SI N GER ME D IC A L CE NTE R OR G A N I Z A T I O NA L P R OF I L E

POPULATION/AGE DISTRIBUTION Age

2006

% of total

0-14

391,707

16.6

15-17

97,401

18-24 25-34

2011*

% of total

USA 2006 % of total

366,293

15.4

20.4

4.1

94,166

3.9

4.3

252,702

10.7

252,925

10.6

10.0

274,367

11.6

293,650

12.3

13.3

35-54

672,655

28.5

633,871

26.6

29.0

55-64

271,864

11.5

308,816

13.0

10.4

65+

400,716

17.0

434,670

18.2

12.6

*projected

EDUCATION LEVEL 2006 Adult education level Less than high school

Pop age 25+

% of total

USA % of total

92,944

5.7

7.5

Some high school

215,375

13.3

11.9

High school diploma

720,274

44.5

28.4

Some college/Associate degree

330,470

20.4

27.6

Bachelor’s degree or greater

260,539

16.1

24.7

1,619,602

100%

Total

HOUSEHOLD INCOME DISTRIBUTION Household income

2006

% of total

USA % of total

<$15K

150,010

16.0

13.3

$15-25K

135,491

14.5

11.0

$25-50K

292,109

31.2

27.0

$50-75K

181,529

19.4

19.5

$75-100K

87,289

9.3

11.8

Over $100K

89,464

9.6

17.5

935,892

100%

2006 pop

% of total

USA % of total

Total

RACE/ETHNICITY White non-Hispanic

2,204,156

93.3

66.4

Black non-Hispanic

62,529

2.6

12.1

Hispanic

53,419

2.3

14.5

21,279

0.9

4.3

Asian and Pacific Islands non-Hispanic All others Total

20,029 2,354,733

0.8

2.7

100%

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Physician Compensation

Division Chairs

Chief Medical Officer J. Bisordi, MD

GMC Operations Facilities Environmental/Food Services Human Resources/ Recruitment Supply Chain Research Infection Control

Service Line Ops System Therapeutics Heart Institute Neurosciences Vascular Surg Cancer Institute Peds/Children’s Svc Women’s Health Psychiatry Anesthesia Emergency Med Gen and MI surg Ophthalmology Dermatology GI Medicine Spec Radiology Lab Med Trauma Access and Care Mngt

CAO - Service Line L. Miller

Assoc. VP Nursing C. Muthler

Magnet Prog/ Nursing Ed. Director

GMC Operations Managers

Assoc. VP Nursing D. Beechay

CNO/CAO – GMC S. Hallick

EVP/COO F. Trembulak

Financial Liaisons

Ed System Svc. Director

Chief Financial Officer T. Sokola

GHS Executive Organizational Chart

Flagship Hospital GMC Leadership Team

President and CEO G. Steele, MD

G E I SI N GER ME D IC A L CE NTE R

OR G A N I Z A T I O NA L P R OF I L E

EVIDENCE 2

An administrative organizational chart

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OR Inventory Management Assistants

POD Coordinators

Materials Resource Coordinator

CSR Supervisor

OR Operations Manager

Operations Manager, Periop and IN/OUT

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GP2

Respiratory Therapy

PICU

NICU

AGP5 I.V. Therapy

BP5

AICU AICU South

WPLL1/L&D

CH2 CH3

SCU3 SCU4

Flex Pool

BP7

BP6 BP8

AGP4 Float Pool

CICU

BP2

Inpatient GMC Operations Managers

Outpatient GMC Operations Managers System Therapeutics Heart Institute Neurosciences Vascular Surgery Cancer Institute Peds/Children’s Services Women’s Health Psychiatry Anesthesia Emergency Med Gen and MI Surgery Ophthalmology Dermatology GI Medicine Spec Radiology Lab Med Trauma Access and Care Management GMC Operations Human Resources/ Recruitment Supply Chain Research Infection Control

Life Flight

Director ED System Services

Nursing Education

Magnet Program Director/ Director of Education

Transfer Center

Patient Placement

GMC Admin Supervisors

Denise Beechay, RN Associate Vice President of Nursing

Geisinger Medical Center Nursing Leadership August 2007

Surgical Suite Project & Strategic Planning Manager

Crystal Muthler, RN Associate Vice President of Nursing

Susan M. Hallick, RN CNO/CAO GMC

G E I SI N GER ME D IC A L CE NTE R

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A nursing organizational chart

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G E I SI N GER ME D IC A L CE NTE R OR G A N I Z A T I O NA L P R OF I L E

EVIDENCE 3 Provide a list and explanatory documentation of any unfair labor practices or charges involving a nurse (whether pending, arbitrated, or dismissed) that have been brought against the applicant organization before the NLRB, state, or international court within the three (3)-year period prior to the submission of written documentation.

Human Resources M.C. 30-36 100 North Academy Avenue Danville, PA 17822 570 271 6202 Tel 570 271 7299 Fax

James P. Cleary Associate Vice President System Labor and Employee Relations

December 4, 2007 Terri Bickert Nursing Project Director Nursing Magnet Program 01-50 Dear Terri: As I had communicated (via Email) to you, I have reviewed my case files over the last three years on any complaints lodged with the EEOC or PHRC or other agencies, of which I am aware. There were none that were involving Registered Nurses from the Geisinger Medical Center. It is my opinion, from dealing with the management and Human Resources individuals at the Geisinger Medical Center, that they are very proactive and appropriately interfaced with employees to resolve issues and assure fair and objective standards. If there are employees with performance problems, the Nursing Department attempts to rehabilitate the employee. Sincerely,

James P. Cleary cc:

Kristen Beech

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EVIDENCE 4 State Nurse Practice Act. It is sufficient to provide the web address of this document after validating that the most current version of the state Nurse Practice Act is available on the web site. If this is not the case, provide a hard copy of the most current version of the state Nurse Practice Act.

he Pennsylvania State Board of Nursing makes its RN and PN law and licensure information available in two ways: as an Adobe PDF file on the Pennsylvania State Board of Nursing web site and as a paper copy on request. Geisinger nurses can access the Pennsylvania State Board of Nursing web site through a direct link on the Geisinger Intranet nursing web page or they can obtain a paper copy (issued from the Board) from the Nursing Office. To view the RN and PN law, please see the links below: RN Law: http://www.dos.state.pa.us/bpoa/lib/bpoa/20/nurs_board/nurseact.pdf PN Law: http://www.dos.state.pa.us/bpoa/LIB/bpoa/20/10/pnact.pdf

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EVIDENCE 5 For U.S. applicants, case mix index information by service/product line for each of the two (2) one-year periods immediately preceding the submission of written documentation. CASE MIX: 2006 AND 2007 FY 2006* CMI

FY 2007* CMI

Difference in CMI

Anesthesia

1.29

1.25

(0.04)

Cardiovascular

2.65

2.58

(0.07)

Dermatology

0.55

0.46

(0.10)

Danville Medicine Specialties

1.41

0.00

(1.41)

Danville Surgical Specialties

1.41

1.34

(0.07)

Endocrinology

0.59

1.41

0.82

General/Minimally Invasive Surgery

2.11

(0.00)

Department

Medicine Specialties

0.00

1.40

Neurosciences

1.54

1.40

(0.14)

Obstetrics/Gynecology

0.65

(0.01)

Oncology

1.54

1.56

0.02

Ophthalmology

0.95

0.89

(0.06)

Orthopaedics

2.01

2.15

0.14

Otolaryngology

0.00

1.38

Pediatrics

1.32

1.31

(0.00)

Psychiatry

0.58

0.62

0.04

—

Medicine

4.69

4.68

(0.01)

Transplant

2.01

2.14

0.12

Urology

1.42

1.41

(0.01)

Pulmonary/Critical Care

Vascular Surgery

2.20

2.21

0.01

Grand Total

1.65

1.64

(0.01)

* Fiscal Year: July 1– June 30

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EVIDENCE 6 Total nursing care hours-per-patient-day (HPPD) by unit for each of the two (2) one-year periods immediately preceding the submission of written documentation. TOTAL NURSING CARE HOURS-PER-PATIENT-DAY: 2006* 1st quarter

2nd quarter

3rd quarter

4th quarter

AGP4

9.24

9.45

9.91

10.26

AGP5

10.27

10.76

10.97

11.37

AICU

17.00

17.15

17.03

16.07

BP2

6.39

7.13

6.70

7.53

BP5

6.89

7.12

7.20

8.06

BP6

7.74

7.87

7.68

8.00

BP7

7.73

7.72

7.81

8.12

BP8

8.14

8.41

8.32

8.22

CH2

9.70

9.87

10.63

11.06

CH3

10.16

10.46

10.51

11.35

CICU

18.91

18.57

18.34

18.67

AGP2

n/a

10.04

10.05

9.77

SCU3

13.39

13.84

13.95

14.59

SCU4

13.91

13.96

13.73

14.22

NICU

10.61

10.78

10.37

11.32

PICU

19.91

19.11

18.90

19.91

* Fiscal Year: July 1– June 30

TOTAL NURSING CARE HOURS-PER-PATIENT-DAY: 2007* 1st quarter

2nd quarter

3rd quarter

AICU

16.36

16.78

17.07

CICU

18.80

19.02

19.60

SCU3

14.62

14.57

14.77

SCU4

13.91

13.88

14.15

BP7

8.21

8.71

9.24

BP5

7.82

8.39

8.68

BP6

7.90

8.24

7.98

AGP4

9.98

10.30

10.32

AGP5

11.13

11.32

11.67

BP8

8.80

8.85

8.75

AGP2

9.43

10.27

10.63

PICU

19.22

19.54

19.42

NICU

10.58

10.53

10.07

CH2

10.49

11.08

11.71

CH3

10.51

11.21

11.02

BP2

7.27

7.14

7.57

4th quarter

[Terri: are we including 4th Q? Or should we delet this col?]

* Fiscal Year: July 1– June 30

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EVIDENCE 7 A description signed by the Chief Executive Officer (CEO) summarizing, from the CEO’s perspective, the investment and commitment the organization has made to recruiting and retaining nurses, resource allocation for excellence-focused management of patients/ residents/clients so that desired client-centered outcomes are achieved, the relationship and consistency between the goals and priorities of nursing and those of the organization as well as the accomplishments, advancements, contributions, and innovations realized within nursing. Executive Office M.C. 22-01 100 North Academy Avenue Danville, PA 17822 570 271 6168 Tel 570 271 6927 Fax

Glenn D. Steele, Jr., MD, PhD President and Chief Executive Officer

January 8, 2008 ANCC Magnet Reviewers Magnet Recognition Program 8515 Georgia Avenue Silver Springs, MD 21910-3402

Glenn D. Steele, Jr., MD, PhD President and CEO

To the ANCC Magnet Reviewers: Quality nursing has always been and will always be a priority at Geisinger. When Abigail Geisinger founded the George F. Geisinger Memorial Hospital in 1915, her charge was direct and powerful. “Make my hospital right. Make it the best,” she said. It is our honor and privilege to continue this tradition of innovation and excellence that began more than 90 years ago, and nurses are a major reason why Geisinger is known for providing both professional and compassionate care. With this history and commitment to the future, it is with great pleasure that I write this letter in support of Magnet status for our nursing services at Geisinger Medical Center. Nursing has “a place at the table” in the various committees and forums at Geisinger, including executive leadership, so the nursing perspective is included as plans are developed and decisions are made. Our nursing department is led by Susan Hallick, RN, BSN, MHA, who serves as Chief Nursing Officer for Geisinger Health System and Chief Administrative Officer for Geisinger Medical Center. Ms. Hallick has been associated with Geisinger since 1983, moving up through the nursing ranks to nurse management and administration. One of the wisest decisions I have made during my tenure at Geisinger was promoting her to lead nursing services throughout our entire health system. Ms. Hallick has shown exemplary skills in building a strong, autonomous nursing team that provides not only excellent clinical nursing care, but also promotes innovative recruitment and retention strategies. We

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are fortunate that our nursing vacancy rate at Geisinger Medical Center is 4 percent, while the vacancy rate in Pennsylvania is nearly 8 percent and the national rate is 16 percent. Our nurses have access to and are encouraged to participate in educational opportunities, career advancement ladders, and nursing research projects. A cooperative nursing educational program has been developed with Thomas Jefferson University where students can complete their class work and clinical obligations at Geisinger. All of this is being accomplished during a time of tremendous growth throughout Geisinger Health System. As Geisinger moves forward, Ms. Hallick admirably champions for the integrity of the nursing profession and for Geisinger nurses. I am confident that Geisinger Medical Center’s nursing team, with its professional nursing culture, leadership, work environment and nursing delivery model, make it an ideal candidate for Magnet status. Thank you for the opportunity to share my support of nursing at Geisinger. Sincerely,

Glenn D. Steele, Jr., MD, PhD President & Chief Executive Officer GDS/nt bc: S. Hallick, RN

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G EIS INGER MEDICA L CENTER ORGA N I ZAT I O N A L P ROF IL E

EVIDENCE 8 A description signed by the Chief Financial Officer (CFO) summarizing, from the CFO’s perspective, the investment and commitment the organization has made to recruiting and retaining nurses, resource allocation for excellence-focused management of patients/ residents/clients so that desired client-centered outcomes are achieved, the relationship and consistency between the goals and priorities of nursing and those of the organization as well as the accomplishments, advancements, contributions, and innovations realized within nursing. GMC/Clinical Service Lines 100 North Academy Avenue Danville, PA 17822-0150 570 271 8892 Tel 570 271 6490 Fax

Thomas P. Sokola Vice President, Finance Chief Financial Officer

January 14, 2008 ANCC Magnet Reviewers Magnet Recognition Program 8515 Georgia Avenue Silver Springs, MD 21910-3402 It is gratifying to me as the Chief Financial Officer at Geisinger Medical Center to see the significant investment and commitment the organization makes to recruit and retain excellent nurses. Not only does Geisinger Medical Center offer a highly competitive nursing wage and salary program, but is also creative with a recognition bonus, referral bonuses, and other recruitment and retention strategies. Further, the organization has a history and continued commitment to making sufficient capital investment to ensure our healthcare professionals have the appropriate facilities and technology to provide high quality patient care. Nursing has a “place at the table” at Geisinger, so their voice is heard when the organization is completing budgets and business plans and considering new or expanded services. In my role as CFO I am, obviously, involved with maintaining a strong financial performance. The “bottom line” at Geisinger is that reinvestment into the organization for the benefit of the people we serve remains our top priority. There is no doubt that this creates a strong foundation for our nursing professionals. Sincerely,

Thomas P. Sokola Chief Financial Officer Geisinger Medical Center

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EVIDENCE 9 A description of the issues with which the organization has zero tolerance including, but not limited to, harassment of any type, workplace violence, and discrimination.

he Geisinger Medical Center abides by the health system policies in place that express a zero tolerance. Employees must adhere to these policies or face sanctions up to and including immediate termination of employment. The Drug and Alcohol Policy (OP:9:A) and Drug-Free Workplace Policy (OP:9:B) are part of the Human Resources Manual (HRM). Applicants must successfully complete a drug-screening test before beginning employment. After being employed, Geisinger practices a zero tolerance for any employee who is under the influence of either any drug that has known mind- or function-altering effects or alcohol. This policy covers Geisinger Health System employees, Geisinger Health System contractors, Geisinger Health System Authorized Party, and Geisinger Health System Premises, which includes all Geisinger entities, corporate and business offices, and all owned or leased vehicles.

OP:9:A HUMAN RESOURCES MANUAL POLICY 330 SECTION: WORK EXPECTATIONS SUBJECT: DRUG AND ALCOHOL POLICY PURPOSE AND SCOPE 1. The purpose of this Drug and Alcohol Policy is to outline Geisinger Health System standards and procedures for dealing with Alcohol and Drug use or abuse by employees, applicants conditionally offered employment, and contractors. 2. Alcohol and Drug use or abuse may adversely affect the quality of the services provided; pose safety and health risks to Geisinger Health System employees, patients, and others; have a negative impact on work efficiency; and result in injury or loss of life, equipment and/or property. 3. In order to serve our patients, and provide a safe, healthful and efficient work environment, Geisinger Health System requires its employees to report for work fit to perform their jobs.Therefore, Applicants Conditionally Offered Employment must successfully complete a drug-screening test. 4. Geisinger Health System recognizes that it may contract independently with organizations or persons to provide services that may impact on patient care. In order to serve our patients, and provide a safe, healthful and efficient work environment, Geisinger Health System requires its contractors and their subcontractors or employees to be free from the influence or impairment of drugs and/or alcohol. 5. To this end, Geisinger Health System has established the following policies and procedures dealing with Alcohol and Drug use or abuse by employees, Applicants Conditionally Offered Employment, and contractors. DEFINITIONS 1. Alcohol means beer, wine, and all forms of distilled liquor containing ethyl alcohol. References to use or possession of alcohol include use or possession of any beverage, mixture or preparation containing ethyl alcohol. 2. Applicant Conditionally Offered Employment means someone who has applied for a position with a Geisinger entity and who has received a conditional offer of employment contingent upon, among other things, successfully completing a drugscreening test (no presence of Drugs). 3. Designated Laboratory means an available laboratory operated by one of the separate legal entities of the Geisinger Health System Foundations, i.e., Geisinger Medical Center, Geisinger Wyoming Valley Medical Center, or if such utilization is not practicable, a laboratory that is certified and/or accredited to perform such testing.

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4. Drug means any substance (other than Alcohol) that has known mind- or function-altering effects on a human subject, specifically including psychoactive substances and including, but not limited to, substances prohibited or controlled by Commonwealth or federal controlled substance laws.Testing for a Drug may involve testing for a metabolite of a Drug. 5. Drug Paraphernalia means all equipment, products and materials of any kind which are used, intended for use, or designed for use in planting, propagating, cultivating, growing, harvesting, manufacturing, compounding, converting, producing, processing, preparing, testing, analyzing, packaging, repackaging, storing, containing, concealing, injecting, ingesting, inhaling or otherwise introducing a Drug into the human body, including, but not limited to all equipment prohibited or controlled by Commonwealth or federal controlled substance laws. 6. Geisinger Health System refers to the system of healthcare comprised of the separate legal corporate parent, Geisinger Health System Foundation, and all of its separate legal corporate entities. 7. Geisinger Health System Authorized Party means the individual(s) in each Geisinger Health System region authorized to render final reasonable suspicion opinions and order Drug and Alcohol testing regarding employees who appear to be working under the influence of Drugs and/or Alcohol, as identified in Exhibit A of the Geisinger Health System Drug and Alcohol Policy Protocol. 8. Geisinger Health System Contractor means any individual or organization that contracts with Geisinger Health System to provide a service. For purposes of this policy, the term Geisinger Health System Contractor shall include all agents, subcontractors and employees of the Geisinger Health System Contractor who are designated to provide services to Geisinger Health System under the terms of the contract.The qualification for the applicability of this policy to a Geisinger Health System Contractor is that the Geisinger Health System Contractor is covered by this Policy only while on Geisinger Health System Premises. 9. Geisinger Health System Employee means any individual who uses Geisinger Health System facilities or resources to perform work, including, but not limited to, salary and wage earners, students, fellows, residents, staff physicians, consultants, and compensated researchers. 10. Geisinger Health System Premises means all Geisinger Health System owned or leased real estate, including but not limited to the Geisinger Health System Danville campus, including Geisinger Medical Center, Geisinger Clinic sites, Geisinger Health System Wyoming Valley Medical Center, Marworth, International Shared Services, Inc. corporate and business offices, and all Geisinger Health System owned or leased vehicles. 11. Policy means this Drug and Alcohol Policy. 12. Possess means to have on one’s person or in one’s personal effects or under one’s control. 13. Successful completion of a drug-screening test means the test results of the Applicant Conditionally Offered Employment are negative (i.e., no presence of Drugs) and the test was taken within four (4) calendar days after the receipt of the conditional offer of employment. 14. Under the influence or impaired means that an employee or contractor is affected by a Drug or Alcohol or the combination of a Drug and Alcohol.The symptoms of influence and/or impairment are not confined to those consistent with misbehavior, nor to obvious impairment or physical or mental ability such as slurred speech or difficulty in maintaining balance. A determination of use, influence and/or impairment can be established by a professional opinion, urine, blood or any other commonly used scientific valid tests, and in some cases by a lay person’s opinion. A Geisinger Health System EMPLOYEE OR CONTRACTOR WILL BE PRESUMED TO BE IMPAIRED AND IN VIOLATION OF THIS POLICY WHENEVER THE PRESENCE OF DRUGS OR ALCOHOL IN ANY AMOUNT WHATSOEVER IS DETECTED IN A SUBSTANCE ABUSE TEST ADMINISTERED UNDER THE TERMS OF THIS POLICY. COVERAGE, CONSENT, AND CONSEQUENCES 1. Any Geisinger Health System Employee or Geisinger Health System Contractor who performs services for Geisinger Health System shall be covered by this Policy and shall be deemed to have consented to testing as required by this Policy and consent is implied by the performance of such services. 2. Any Geisinger Health System Employee who refuses to cooperate in any aspect of the Drug and/or Alcohol testing process described in this Policy shall be subject to disciplinary action, including termination, for a first refusal or any subsequent refusal. 3. Any Geisinger Health System Employee who violates this Policy’s prohibition concerning Drug and/or Alcohol possession and/or use, in any manner whatsoever, shall be subject to disciplinary action, including termination for a first offense or any subsequent offense. 4. Any Geisinger Health System Contractor who refuses to cooperate in any aspect of the Drug and/or Alcohol testing process described in this Policy or who violates this Policy’s prohibition concerning Drug and/or Alcohol possession and/or use, in any manner whatsoever, shall be subject to contract termination.

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5. Offers of employment shall be withdrawn for an Applicant Conditionally Offered Employment who does not successfully complete a drug-screening test (no presence of Drugs).This applies to all offers of employment where the employment begins after December 31, 2002. ALCOHOL AND DRUG POSSESSION AND USE PROHIBITED 1. Prohibitions a. No Geisinger Health System Employee may use, possess, transport, promote or sell Alcohol, or any Drug or Drug Paraphernalia while performing work for Geisinger Health System, while on Geisinger Health System Premises (which includes being in personal vehicles in Geisinger Health System parking lots), while representing Geisinger Health System on Geisinger Health System business off-site, or while operating their own personal vehicle while on Geisinger Health System business, unless specifically permitted under Exceptions Section (A)(1) Alcohol below. b. No Geisinger Health System Contractor may use, possess, transport, promote or sell Alcohol, any Drug or Drug Paraphernalia while performing work for Geisinger Health System on Geisinger Health System Premises (which includes being in personal vehicles in Geisinger Health System parking lots). c. No Geisinger Health System Employee may report for work, or go or remain on duty while: 1. under the influence of or impaired by Alcohol; and/or 2. under the influence of or impaired by any Drug. d. No Geisinger Health System Contractor may provide services to Geisinger Health System while: 1. under the influence of or impaired by Alcohol; and/or 2. under the influence of or impaired by any Drug. e. No Applicant Conditionally Offered Employment, who fails to successfully complete the drug-screening test, will be employed. 2. Exceptions a. Alcohol.The purchase of Alcohol with Geisinger Health System monies and the serving of alcohol at Geisinger Health System sponsored functions within or without the Geisinger Health System Premises after normal business hours or the consumption of alcohol at a Geisinger Health System sponsored activity or social event held within or without Geisinger Health System Premises after normal business hours is not prohibited by the Policy if: 1. specifically permitted under the guidelines set forth in the Geisinger Health System Drug and Alcohol Policy Protocol, such as, for example, recruitment or business meals, receptions or other similar business—related events, or 2. specifically and expressly permitted by Geisinger Health System Executive Management in accordance with the guidelines set forth in the Geisinger Health System Drug and Alcohol Policy Protocol, and 3. the consumption of such alcohol is not inconsistent with the safe and efficient performance of the Geisinger Health System Employee’s duties. b. Prescribed and Over-the-Counter Drugs.The use of prescribed or over-the-counter Drugs and/or Drug Paraphernalia, or possession incident to such use, is not prohibited by this Policy, if: 1. the Drug and/or Drug Paraphernalia has been legally obtained and is being used for the purpose for which it was prescribed or manufactured; and 2. the Drug is being used at the dosage prescribed or authorized; and 3. the use of the Drug and/or Drug Paraphernalia is not inconsistent with the safe and efficient performance of the Geisinger Health System Employee’s duties or the safe and efficient provision of services by a Geisinger Health System Contractor. (See Section VII for information concerning a Geisinger Health System Employee’s obligation to report the use of prescription and over-the-counter Drugs). c. Transportation of Alcohol.The transportation of Alcohol in an unopened untampered manufacturer’s container is not prohibited by this Policy if: 1. the Alcohol container is placed in the individual Geisinger Health System Employee’s or Geisinger Health System Contractor’s personal vehicle upon receipt, or if not upon receipt, as soon as possible; and 2. the Alcohol container is kept wrapped while on Geisinger Health System Premises. 3. reasonable Judgment. Geisinger Health System Employees are expected to use their discretion and exercise reasonable judgment in the consumption of Alcohol or use of prescribed or over-the-counter Drugs while traveling or during normal business hours when representing Geisinger Health System off-site at meetings or conferences for continuing

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education purposes. While not strictly on Geisinger Health System business, Geisinger Health System employees do represent Geisinger Health System and, in some cases, their presentation and demeanor may be the only experience outside individuals and entities may have with Geisinger Health System.Therefore, Geisinger Health System Employees may rely on the exceptions contained in subsection above while traveling to and from and during normal business hours when attending such meetings provided the qualifications stated in the exceptions are met and the consumption of Alcohol or use of a prescribed or over-the-counter Drug is not inconsistent with the Geisinger Health System Employee’s ability to travel in a safe and efficient manner. EMPLOYEE SUBSTANCE ABUSE TESTS 1. In order to assure compliance with Geisinger Health System’s prohibitions concerning Alcohol and Drug use and as a condition of employment, Geisinger Health System Employees and Geisinger Health System Contractors are required to cooperate in Drug and/or Alcohol substance abuse testing procedures. Such tests may be administered upon reasonable suspicion of substance abuse, or after serious on-the-job accidents which result in (i) injury to a patient, Geisinger Health System Employee, or other person, or (ii) property damage in excess of Five Hundred Dollars ($500). Blanket testing of groups of Geisinger Health System Employees may be administered upon reasonable suspicion of a drug diversion where circumstances suggest that the Geisinger Health System Employees to be tested had access to the suspected diverted substance(s). 2. Tests shall be accomplished through the use of a breathalyzer, salivary test, analysis of urine and/or blood samples, or other clinically acceptable methods. A negative result on a breathalyzer or salivary test does not require further testing. A positive result must be confirmed by a blood alcohol test. 3. Prior to the testing or the collection of the urine and blood samples, the Geisinger Health System employee shall be notified in writing that the employee is being tested for the presence of Drugs and/or Alcohol. Where samples of blood or urine are used, Geisinger Health System will cause the samples to be identified by number to insure confidentiality. 4. If the test performed by the Designated Laboratory of the samples is positive for any Drug, (Drug metabolite[s] or Alcohol), the samples shall be tested a second time by other reliable methods. 5. Geisinger Health System will notify the Geisinger Health System Employee of the results of any test that is positive for any substance included in the procedure. In the case of a positive result, Geisinger Health System will provide the Geisinger Health System Employee with an opportunity to explain the presence of the identified substance prior to taking any disciplinary action.Test results will not be maintained in the Geisinger Health System Employee’s personnel records, but rather in a separate file as designated by the individual Geisinger Health System entity. APPLICANT SUBSTANCE ABUSE TEST In offering a position to a successful applicant, management will make the offer contingent upon successful completion of a drugscreening test (no presence of Drugs). If an Applicant Conditionally Offered Employment does not successfully complete the drugscreening test, the employment offer will be withdrawn.The individual may apply, and may be considered for a subsequent position. If conditionally offered the subsequent position, a drug-screening test must be successfully completed. VIOLATIONS Geisinger Health System Employees who violate this policy will be subject to discipline up to and including termination.

POLICY APPROVAL By:

Geisinger Health System Services Board of Directors

Date: October 27, 1992

DOCUMENT INFORMATION Devised

Revised/Reviewed

Source

10/93

Approved by the CNO and

System Leadership Council

Approved

MEC—3/07

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OP:9:B HUMAN RESOURCES MANUAL POLICY 331 SECTION: WORK EXPECTATIONS SUBJECT: DRUG-FREE WORKPLACE POLICY The unlawful manufacture, distribution, dispensing, possession or use of any controlled substance is prohibited at all Geisinger Health System entities, facilities and at any Geisinger Health System owned or leased properties. Geisinger Health System entity employees who violate this policy are subject to disciplinary action up to and including termination. PURPOSE This policy establishes Geisinger Health System’s commitment to maintain a drug-free workplace by informing employees about the dangers of drug abuse in the workplace, the availability of drug counseling, rehabilitation and employee assistance programs, and the disciplinary action guidelines that may be imposed upon employees for drug abuse violations occurring in the workplace. This policy acknowledges Geisinger Health System’s compliance with the federal Drug-Free Workplace Act of 1988. APPLICATION Sections on Policy, Purpose, Application and Policy Definitions apply to all Geisinger Health System employees and students of all Allied Health School programs.The section on procedures of this policy applies only to Geisinger Health System employees/ students who are directly engaged in the performance of a federal government procurement contract of $100,000 or more or a federal grant. POLICY DEFINITIONS 1. Controlled substance means a controlled substance in schedules I through V of section 202 of the Controlled Substance Act (21 United States Code 812) and as further defined in regulation at 21 Code of Federal Regulations 1308.11-1308.15. 2. Conviction means a finding of guilt (including a plea of no lo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the federal or state criminal drug statutes. 3. Criminal drug statute means a federal or non-federal criminal statute involving the manufacture, distribution, dispensing, possession or use of a controlled substance. 4. Drug-free workplace means a site for the performance of work where employees/students are prohibited from engaging in the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance. 5. In the workplace means in any Geisinger Health System owned or leased facility, on or in any Geisinger Health System owned or leased property, or in any setting related to an individual’s employment or education at Geisinger Health System. 6. Geisinger Health System is a registered fictitious name of Geisinger Health System Foundation for operating medical, nursing, and other healthcare educational programs through a multi-institutional healthcare system.Throughout this policy, the term “Geisinger Health System” shall refer to the entire system of healthcare comprised of Geisinger Health System Foundation and all corporate entities affiliated with or controlled by Geisinger Health System Foundation. 7. Grant means an award of financial assistance, including a cooperative agreement, in the form of money, or property in lieu of money, by a federal agency directly to a grantee.The term does not include technical assistance, which provides services instead of money, or other assistance in the form of loans, loan guarantees, interest subsidies, insurance or direct appropriations, or any veterans’ benefits to individuals. 8. Engaged employees/students are those Geisinger Health System employees/students directly engaged in the performance of a federal government procurement contract or a federal grant. PROCEDURE All Geisinger Health System entity employees/students and department heads directly engaged in the performance of a federal government procurement contract of $100,000 or more or a federal grant must abide by the following procedures. Other department heads and employees/students are encouraged to abide by the general guidelines of these procedures.

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EMPLOYEE/STUDENT CONVICTED OF CRIMINAL DRUG STATUTE VIOLATION OCCURRING IN THE WORKPLACE Agrees to satisfactorily complete a drug assistance or rehabilitation program as a minimal condition for continued employment. A second violation will automatically result in discharge/dismissal from employment or education program.

DOCUMENT INFORMATION Devised

Revised/Reviewed

8/89

Approved by the CNO and

Source

Approved

MEC—8/07

Any employee who is suspected of being impaired is asked to submit to immediate screening and, if on duty, is immediately relieved by a competent person. Any violation, including refusal of screening, is subject to disciplinary action, which may include immediate termination of employment. The Harassment Policy (OP:9:C) is also part of the Human Resources Manual. This policy includes a zero tolerance for any type of harassment, including verbal, physical, visual, and sexual harassment. The policy covers the entire Geisinger Health System and all corporate entities held by the Geisinger Health System Foundation. All complaints are investigated in a prompt and confidential manner. Any person in violation of this policy is subject to disciplinary action, which may include immediate termination of employment.

OP:9:C HUMAN RESOURCES MANUAL POLICY 310 SECTION: WORK EXPECTATIONS SUBJECT: HARASSMENT POLICY Respect for the dignity and worth of each individual is a basic tenet of Geisinger Health System, and, as such, Geisinger Health System is committed to providing a work environment free of discrimination. In keeping with this commitment, Geisinger Health System maintains a strict policy prohibiting harassment, including sexual harassment.This policy prohibits harassment in any form, including verbal, physical, and visual harassment. PURPOSE This policy defines certain types of harassment, including sexual harassment, and establishes a mechanism to investigate allegations of harassment. DEFINITIONS 1. Geisinger Health System is a registered fictitious name of Geisinger Health System Foundation for operating medical, nursing and other healthcare educational programs through a multi-institutional healthcare system.Throughout the document, the term “Geisinger Health System” shall refer to the entire system of healthcare comprised of Geisinger Health System Foundation and all corporate entities affiliated with or controlled by Geisinger Health System Foundation. 2. Harassment is defined as verbal, visual, or physical conduct which has the purpose or effect of substantially interfering with an individual’s work performance or creating an intimidating, hostile, or offensive work environment.

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3. Sexual harassment is defined as unwelcome jokes or comments, sexual attention, sexual advances, requests for sexual favors and other verbal, visual or physical conduct of a sexual nature when: a. submission to such conduct is made an implicit or explicit term or condition of an individual’s employment; b. submission to or rejection of such conduct is used as a basis for employment decisions affecting such individual; c. such conduct has the purpose or effect of substantially interfering with an individual’s work performance; or d. such conduct has the purpose or effect of creating an intimidating, hostile, or offensive work environment. GENERAL INFORMATION 1. Examples: Examples of sexual harassment include, but are not limited to, threatening adverse employment actions if sexual or other favors are not granted; promising preferential treatment in return for sexual or other favors; unwanted and unnecessary physical contact; excessively offensive remarks, including unwelcome comments about appearance, obscene jokes or other inappropriate use of sexually explicit or offensive language; the display in the workplace of sexually suggestive objects or pictures; and unwelcome sexual advances by clients or other visitors. Examples of harassment would be similar to the foregoing except that the nature of the harassment may not necessarily be sexual. Harassment could include any of the conduct aforementioned or a combination of such conduct that might tend to focus on race, national origin, ethnic background, religious affiliation, or other attributes of the person harassed. 2. Persons covered: This policy prohibits harassment of all professional and other employees and all applicants for employment. MULTIPLE OPTIONS OF REPORTING HARASSMENT An employee or applicant has many options for reporting concerns: the employee’s supervisor, manager, administrator, Human Resources, or regional administration. Harassment by a supervisor, coworker, agent, contractor, salesperson, patient, or any other person should be promptly reported. Supervisors, managers and administrators should immediately report received concerns to Human Resources, which has responsibility for overseeing/conducting the investigation. Human Resources shall receive assistance, as appropriate, from Legal Services. RETALIATION Retaliation in any form against a complainant is strictly prohibited and will itself be a source for disciplinary action. Management after consultation with Human Resources will be responsible for communicating the investigation process and policy on retaliation to any alleged harasser. INVESTIGATION AND RESOLUTION Geisinger Health System will investigate all allegations of harassment in as prompt and confidential manner as possible and will take corrective action as warranted. Any employee who is determined, as a result of an investigation to have engaged in harassment in violation of this policy will be subject to disciplinary action, up to and including termination of employment. Complainants, if they so wish, normally will be able to state a preference for having a male or female as their contact person in Human Resources during the investigation process. Management will assist in the scheduling of witnesses and may be asked to identify individuals who will conduct the investigation in cooperation with Human Resources. COMMUNICATION Geisinger Health System Human Resources will periodically disseminate information about this policy and the multiple options for remedying problems that all employees should be aware of our policy. STANDARDS Geisinger Health System Human Resources is available to discuss questions regarding this policy with employees or management. Employees may specifically request to speak to a male or female Human Resources representative or other supervisory personnel as applicable.

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DOCUMENT INFORMATION Devised

Revised/Reviewed

3/92

Approved by the CNO—3/07

Source

Approved

The Protection of Confidential Information and Sanctions Policy (OP:9:D) is also part of the Human Resources Manual. This policy covers patient information that falls under the HIPAA law as well as employee information, such as compensation, evaluations, personnel actions, and medical reports. In addition, the policy covers (but is not limited to) business/system information related to all Geisinger Health System affiliates, including finance, budget, payroll, marketing research and development, bid proposals, contract negotiations, and legal advice. Inappropriate use, such as release, access, manipulation, carelessness, oral communication, or electronic transmission results in disciplinary action up to, and may include, immediate termination of employment and possible reimbursement to Geisinger Health System for any monetary damages.

OP:9:D HUMAN RESOURCES MANUAL POLICY 360 PROTECTION OF CONFIDENTIAL INFORMATION AND SANCTIONS PURPOSE To provide policy for the use and disclosure of Confidential Information and to fulfill the regulatory requirements for the same, as set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). POLICY STATEMENT 1. The Geisinger Health System (GHS) is committed to ensuring appropriate confidentiality of information, which is entrusted to GHS and will sanction violations. 2. Access to information is a privilege based on the individual’s business or clinical need to know. 3. Members of the GHS Workforce with access to Confidential Information must be aware of and constantly adhere to the requirements for the access, possession, use, copying, modification, dissemination, and/or disclosure of such Confidential Information. 4. Members of the GHS Workforce are responsible for the protection of any information, which they might copy, download, access from outside computers, etc. 5. Violations of this policy will result in disciplinary action. Violations with more negative outcomes will affect the severity of disciplinary actions. 6. All members of the GHS Workforce are prohibited from accessing their own medical information as well as that of family members and others unless required to do so as part of their responsibility at GHS. Members of the GHS Workforce should only access the minimum amount of information necessary to perform their position responsibilities. Approved use of “My Chart” for one’s personal information is not affected by this prohibition. 7. Members of the GHS Workforce have a responsibility to report to their supervisor, administrator, or Human Resources, violations or reasonable belief of such violations of this policy by themselves or others. 8. GHS will not intimidate, threaten, coerce, discriminate against or take retaliatory action against a member of the GHS Workforce: a) for exercising their rights under HIPAA, b) for testifying, assisting or participating in an investigation, compliance review, proceeding or hearing under HIPAA or, c) for opposing any act or practice made unlawful by HIPAA; provided the

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member of the GHS Workforce has a good faith belief that the practice opposed is unlawful, and the manner of the opposition is reasonable and does not involve a disclosure of Protected Health Information in violation of HIPAA. 9. The obligations under this policy remain intact even after one has ceased to be a member of the GHS Workforce. 10. Some members of the GHS Workforce may be asked to sign Confidentiality Agreements.The presence of a signed agreement does not negate responsibilities or obligations of any member of the GHS Workforce under this policy. 11. Geisinger will provide training to all workforce members regarding this policy and federal regulations as appropriate for the position each workforce member holds. 12. If an individual has questions about this policy, he/she should contact his/her supervisor. DEFINITIONS A. Confidential Information Confidential information is defined as information to which access must be restricted by reason of law, regulation, ethical standards or business necessity. Confidential information includes, but is not limited to, the following information as communicated in any form, whether verbal, written or electronic: 1. Patient healthcare and financial records including, but not limited to, the patient's medical record, test results, billing information and insurance information. It is recognized that the strictest confidentiality standard is applied for legislatively protected patient information, including but not limited to HIV-related information, mental health-related information or drug and alcohol-related information. 2. Employee information (obtained through the performance of one’s job duties) including, but not limited to, personnel actions such as promotions, resignations, etc.; compensation; benefits; performance related information; and/or medical/psychological reports. This restriction does not prohibit employees from sharing and discussing their own information relating to wages, benefits, and working conditions as protected under the National Labor Relations Act. 3. Business/system information related to the GHS affiliates, and/or GHS, including, but not limited to, financial, budget, payroll, marketing, research and development, bid proposals, contract negotiations and legal advice. B. Disclosure Disclosure is defined as the release, transfer, provision of, access to, or divulging in any other manner Confidential Information outside GHS as described in the notice of privacy practice as defined in HIPAA Privacy Regulations. C. GHS Workforce Includes any person GHS allows to access Confidential Information. Employees (part-time, full-time, temporary and flex), volunteers, students, GWV non-employed admitting physicians and others are included in this definition. D. Need to Know Need to know means that a member of the GHS Workforce must access the information to perform his or her duties and responsibilities. E. Protected Health Information (PHI) PHI is defined as any information, whether oral or recorded in any form or medium, that is created or received by a healthcare provider and relates to the past, present or future physical or mental health or condition of an individual. F. Use Use is defined with respect to individually identifiable health information, the sharing employment, application, utilization, examination, or analysis of such information within the entity that maintains such information. SANCTION GUIDELINES A. Disclosure 1. Intentional/Malicious a. Employees are subject to disciplinary action up to and including immediate termination. b. Other members of the GHS Workforce are subject to loss of privileges to access, termination of contracts, and may be required to reimburse GHS for any momentary damages suffered by GHS. c. Members of the GHS Workforce with medical staff privileges are subject to the loss of those privileges in accordance with the applicable medical staff bylaws.

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2. Unintentional—The above sanctions for the various classes of GHS Workforce may be reduced at the sole discretion of GHS depending upon the severity of the offense or consequences to patients or GHS. B. Inappropriate Use Inappropriate use is inappropriate internal release, access, manipulation of Confidential Information or carelessness in protecting it. 1. Intentional/Malicious a. GHS employees are subject to disciplinary action up to and including termination. For offenses that are less severe in the opinion of GHS management, lesser action may be taken. b. Other members of the GHS Workforce—Disciplinary action up to and including loss of access, termination of contracts, and possible reimbursement to GHS for any monetary damages suffered by GHS may be imposed. For offenses that are less severe in the opinion of GHS management and Human Resources less stringent penalties may apply. c. For members of the GHS Workforce with medical staff privileges, disciplinary action up to and including the loss of medical staff privileges may occur in accord with the applicable medical staff bylaws. Examples of inappropriate use and disclosure of Confidential Information include (but are not limited to) the following: a. Acquiring/searching for information on any patient that is not under your direct care or for business purposes as authorized b. Discussing a patient's diagnosis in inappropriate areas inside the GHS hospital, including: hallways, elevators, cafeteria, as well as any place outside the GHS hospital c. Informing others that someone is a confidential admission d. Releasing patient, personnel, or business/system information to anyone unless it is for the purpose of providing care or service to a patient according to appropriate authorization e. Releasing the results of tests to anyone except the direct-caregivers of a specific patient except authorized caregivers or service providers f. Releasing any information obtained through your job about an employee or coworker that is personal or employment related to anyone inquiring via the telephone, in person, or in writing without written or policy driven authorization g. Electronic breach of security or improper entries, unauthorized programming instructions, sharing of passwords and unauthorized attempts to access computer systems h. Failure to protect Confidential Information that has been copied, carried outside of GHS, or viewed through personal electronic sources where others may see this information. C. Documentation The documentation for GHS employees including the investigation and disciplinary actions will be held in Human Resources for six (6) years. Documentation for the investigation and disciplinary action for non-employed members of the GHS Workforce will be held by the Privacy Office for six (6) years. PROCEDURE 1. Employees and GHS Workforce members should report violations of this policy to their supervisor, administrator or Human Resources. 2. Employees and GHS Workforce members should report any intimidation, coercion, threats, discrimination or retaliation prohibited by this policy to Human Resources, a supervisor or administration. RESPONSIBILITY Improper and/or authorized access, possession, use, copying, modification, dissemination, or disclosure of Confidential Information, written, spoken, or electronic, is prohibited at any time during or after employment or affiliation with GHS and its related organizations by policy and applicable law. GHS Workforce members who violate this policy are subject to discipline, up to and including termination of employment or access. Individuals who have knowledge of or reasonable belief that violations of this policy have occurred have a responsibility to report such violations to Human Resources or face disciplinary action. TRAINING All workforce members must be appropriately HIPAA-trained relative to their position responsibilities. Human Resources is

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responsible for incorporating general HIPAA training into the New Employee Orientation and documenting attendance at the orientation. Managers are responsible for non-employed workforce members. Where advanced HIPAA training is appropriate, management is responsible for providing the training within a reasonable period of time after the commencement of employment and retaining documentation that the advanced training occurred. When a material change occurs in required policies or procedures, training must be provided to the workforce members affected by the change within a reasonable time after the change is effective. MANAGEMENT The primary responsibility for safeguarding Confidential Information rests with management. Managers at every level of the organization should: 1. Ensure that Confidential Information is properly identified and marked. 2. Provide secure storage for Confidential Information during working hours and when not in use. 3. Ensure that recipients have a legitimate need to know. 4. Limit reproduction and distribution of Confidential Information to what is absolutely necessary. 5. Ensure that only secure means of transmittal are utilized. 6. Review these procedures with all members of the GHS Workforce and others, and as needed with all GHS Workforce members who are involved in the handling, or securing of Confidential Information. 7. Consult with Human Resources regarding disciplinary action. AUDIT Human Resources will audit the completion of basic HIPAA training every six (6) months. Human Resources will notify management annually of status of completion of advanced training.

DOCUMENT INFORMATION Devised

Revised/Reviewed

4/98

Approved 4/07—by CNO

Source

Approved

and MEC and system leadership

The Equal Opportunity Employment Policy (OP:9:E) is also part of the Human Resources Manual. It includes nondiscrimination in hiring policy in any part of the Geisinger Health System. It also defines working conditions, benefits, wages, and placement or promotions based on race, color, religion, sex, national origin, age, disability, handicap, or status as a Vietnam-era or special disabled veteran. The Geisinger Health System Human Resources Department is responsible for enforcing this policy. Anyone found negligent in this policy is subject to immediate disciplinary action, which may include termination of employment.

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OP:9:E HUMAN RESOURCES MANUAL POLICY 105 SECTION: GENERAL POLICIES AND PROCEDURES SUBJECT: EQUAL OPPORTUNITY EMPLOYMENT PURPOSE This policy assures that Geisinger Health System is an equal opportunity employer. POLICY Geisinger Health System is an equal opportunity employer. It is the policy of Geisinger Health System not to discriminate against any person with respect to hiring, wages, hours, fringe benefits, working conditions, placement or promotion because of race, color, religion, sex, national origin, age, disability, handicap, or status as a Vietnam-era or special disabled veteran in accordance with applicable federal laws. PROCEDURE 1. Geisinger Health System’s obligation includes equal opportunities in: a. Hiring, placement, promotion, transfer, or demotion b. Recruitment, advertising, or solicitation for employment c. Treatment and working conditions during employment d. Rates of pay and other forms of compensation e. Selection for training and educational programs f. Use of Geisinger Health System facilities and all other terms, conditions, and privileges of employment. 2. Geisinger Health System’s objective is to obtain individuals qualified or qualifiable for the available positions by virtue of jobrelated standards of education, training, experience, and personal qualifications. 3. All training and educational programs supported or sponsored by Geisinger Health System will be equally available to all employees on the basis of qualifications and within budgetary limitations. 4. Geisinger Health System Human Resources Department is responsible for safeguarding the rights, privileges, and benefits of all Geisinger Health System employees; administering employee programs in a uniform and consistent way within published policy; and interpreting policy for management.

EVIDENCE 9: SOURCES OF EVIDENCE OP:9:A HRM—Drug and Alcohol Policy

Policy 330

OP:9:B HRM—Drug-Free Workplace Policy

Policy 331

OP:9:C HRM—Harassment Policy

Policy 310

OP:9:D HRM—Protection of Confidential Information and Sanctions Policy

Policy 360

OP:9:E HRM—Equal Opportunity Employment Policy

Policy 105

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EVIDENCE 10—PART A With regard to the Chief Nursing Officer (CNO), applicants must submit: (a) job description. SYSTEM TITLE: CHIEF NURSING OFFICER DEPARTMENT: NURSING REPORTS TO: GEISINGER HEALTH SYSTEM EXECUTIVE LEADERSHIP—EVP, COO GEISINGER HEALTH SYSTEM DEPARTMENT OF HUMAN RESOURCES JOB DESCRIPTION JOB SUMMARY Functions as a tripartite management team member in collaboration with the Chief Medical Officer (CMO) and the Chief Administrative Officer (CAO) of Geisinger Medical Center.The tripartite management team will lead, direct, and coordinate in total the fiscal and operational accountability of the Geisinger Medical Center (GMC), its related clinics and the Danville-based Clinical Service Lines (The “Clinical Enterprise”) for current and continuing development, programmatic and fiscal effectiveness of the Geisinger Health System (GHS). • Directly responsible for nursing operations at GMC, Geisinger Wyoming Valley (GWV), Geisinger South—Wilkes-Barre (GSWB) and Nursing practice in GMC-based clinics throughout the system. Integrates system goals, objectives and vision. Directly responsible for the fiscal and operational performance of GMC. Ensures hospital operations and activities support the system’s vision, goals and strategies. • Receives direction from the President and Chief Executive Officer, Chief Operating Officer (COO), and from the Executive Vice President, Strategic Program Development. • Ensures the successful development, implementation, and management of an effective operating agenda for the GMC component of the Clinical Enterprise. Directly accountable to the Executive Vice President, Chief Operating Officer for operations of GMC, and to the Executive Vice President, Strategic Program Development, for program initiatives. MAJOR DUTIES AND RESPONSIBILITIES General Executive • Promotes GHS culture and ensures environmental issues support the Magnet culture, including integration with driving strategies and the GHS mission. • Translates system vision into GMC operations through staff and education. • Ensures teamwork is developed, maintained, and supported by operational behaviors throughout the Clinical Enterprise. • Budget compliance—Directly accountable for the management and development of the budget for GMC. Establishes performance parameters based on nationally-established benchmarks. • Develops, implements, and manages the patient services components of the computerized medical record process in coordination with Information Systems. • Quality performance—Directly accountable for the development and management of the GHS quality agenda for GMC and establishes a highly reliable process to support patient safety and quality performance. Chief Nursing Officer Role—GHS • Together with CMO, supports clinical outcomes, research, and education. • Responsible for theory of practice of nursing and other allied health professionals: standards of care, credentialing, licensing, and professional development for non-medical staff health professionals at a system level. • Develop joint ventures and relationships with major academic programs for nursing in coordination with the Academic Affairs Department. • Directly responsible for the development of system standards of care, regulatory compliance, leadership accountability and development, nursing recruitment, retention strategies, education and professional growth for all patient care services that involve nursing. Education and Research—GHS • Ensures a conducive work environment and balance between GMC patient care activities and education and research. • Defines and supports appropriate continuing education and research activities. • Participates in continuing educational programs to expand knowledge of professional discipline; participates in health-related associations to maintain expertise and promote interests of nursing and GHS.

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Hospital Operations—GMC • Ensures hospital management of Human Resources; ensures appropriate quantity and type of staff are available to support programs, market needs, and customer needs; monitors trends to predict and plan for staffing needs. • Fosters and plans a positive work environment with teaming, respect, and communication; supports personal growth and development. • Ensures effective acquisition and utilization of equipment and supplies through the use of system’s material management program. • Ensures effective public relations, including relationships with other providers, both internal and external to the system, and other relevant constituencies and the publics. • Attends meetings of GHS and Clinical Enterprise leadership and keeps members informed on issues affecting the group. Meets and visits with employees on a routine basis. • Leads and manages the business affairs of GMC including problem-solving and performance standard development. • Develops and ensures strategies and procedures exist to maximize financial resource management, including development and achievement of financial performance objectives. • Directly accountable for the preparation, performance, and management of the GMC budget. • Directly responsible for management of GMC to include the OR, RR, I&0, ED, Admissions Area, and Support Services area. • Directly responsible for management of nursing services within all GMC areas. • Directly responsible for GMC patient-care services that involve nursing and patient care. • Ensures that the patient safety improvement and management program will be given high priority and will support the program. SKILLS AND ABILITIES • Demonstrated excellent leadership, facilitation, and networking skills (ability to think strategically, leadership effectiveness competencies). • Demonstrated analytical and financial management skills (operating and capital budgets; organizational effectiveness competencies). • Demonstrated excellent change management skills (organizational effectiveness competencies). • Demonstrated competence in written and oral communication skills (interpersonal effectiveness competencies). EDUCATION AND/OR EXPERIENCE • Requires a current Pennsylvania RN license. • Bachelor of Science degree in Public Health, Hospital Administration, or equivalent healthcare-related discipline required. Masters Degree required in healthcare-related discipline and an in-depth knowledge of hospital operations. • Minimum of ten years of progressive GMC leadership experience in a healthcare organization with at least five years in a healthcare system required. WORKING CONDITIONS/PHYSICAL DEMANDS Work is typically performed in an office environment as well as settings throughout the region and surrounding communities. The specific statements shown in each section of this description are not intended to be all inclusive.They represent typical elements considered necessary to successfully perform the job. Revised 3/07 Revised 3/02 [Terri: Should this be Devised?]

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EVIDENCE 10—PART B With regard to the Chief Nursing Officer (CNO), applicants must submit: (b) performance appraisals for each year for the two (2) years immediately preceding the submission of written documentation. System Chief Nursing Officer Evaluation—Staff Nurse Review

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System Chief Nursing Officer Evaluation—Staff Review

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System Chief Nursing Officer Evaluation—Staff Review

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System Chief Nursing Officer Evaluation—Manager

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System Chief Nursing Officer Evaluation—Peer

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System Chief Nursing Officer Evaluation—Peer

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System Chief Nursing Officer Evaluation—Staff Nurse Review

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[Terri, We need original Excel file for these pages. the PDF does not reproduce well.]

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EVIDENCE 10—PART C With regard to the Chief Nursing Officer (CNO), applicants must submit: (c) evidence that the CNO has been in place for at least one (1) year prior to the submission of written documentation.

Contact: David Jolley Associate Vice President/Public Relations Office: 570-826-7717; Pager: 570-830-5070 Geisinger Restructures Executive Leadership (DANVILLE, PA—June 25, 2001)—Geisinger Health System President and CEO Glenn Steele Jr., MD, announced a restructuring of his executive leadership team, effective July 1. Current Geisinger Medical Center leaders Nancy Rizzo and Robert Spahr, MD, will represent the office of the president in their new, system-wide positions. Rizzo has been named senior vice president, community provider and business relations and Spahr, senior vice president, service quality. Spahr, who has been filling in during the past year as the interim physician leader at the medical center, will also continue his neonatology practice. At Geisinger Medical Center, Bruce Hamory, MD; Susan M. Hallick, RNC, BSN, MHA; and Theodore Townsend will work as a team to improve and expand patient services. Hamory retains his title of executive vice president and chief medical officer; Hallick becomes senior vice president, chief nursing officer, clinical enterprise; and Townsend takes the role of senior vice president, chief administrative officer, clinical enterprise. (more)

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Geisinger/Collaborative Partnerships Page 2 Hamory has also appointed five associate chief medical officers of the Geisinger Clinic. In their new system-wide roles, Drs. Joseph E. Bisordi, Steven B. Pierdon, Dennis Torretti, Gary L. Wolfgang, and Robert E. Albertini will help streamline the flow of information from staff physicians to Hamory. “Geisinger has many superb leaders who are an asset to this system and to their community,” Steele said. “Together, we will move forward with a common purpose—providing consistent, high quality, patientfocused care.” * Printed in the News Item, Shamokin, PA—June 26, 2001 * Printed in the Lewisburg Daily Journal, Lewisburg, PA—June 25, 2001

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EVIDENCE 10—PART D With regard to the Chief Nursing Officer (CNO), applicants must submit: (d) evidence that the CNO, or his or her designee, participates in the privileging process for advanced practice nurses.

he CNO—Sue Hallick, RN—provides final approval of the credentialing and privileging process for advanced practice nurses at the Medical Executive Committee, a subcommittee of Geisinger’s Board of Directors (OP:10:A and OP:10:B). The CNO has a nurse designee participate in the Credentialing Committee (OP:10:C and OP:10:D). Sue also meets routinely with the nurse practitioners. Doing so has enabled her to make sure privileging needs are met. She also provides information and guidance to keep the advanced practice nurses connected to the Nursing Department and to advance their practice in the clinical environment.

OP:10:A GEISINGER MEDICAL CENTER MEDICAL EXECUTIVE COMMITTEE APRIL 11, 2007—12:00 NOON – 2:00 PM MEETING MINUTES PEER REVIEW GENERATED DOCUMENT SOLELY FOR QUALITY IMPROVEMENT PURPOSES PURSUANT TO 63 P.S. §425.1 ET SEQ—NOT FOR REDISTRIBUTION OUTSIDE THE SYSTEM'S PEER REVIEW COMMITTEE. Members Present

Absent

Guests

Joel Berberich, MD

Joseph Bisordi, MD

Camille Barilla

Domnick Conca, MD

Linda Famiglio, MD

Janet Anderson

Edie Derian, MD

Stephen Paolucci, MD

Todd Gibson

Susan Hallick, CNO

Lynn Miller

Joan Topper

Frank Maffei, MD for Linda Famiglio, MD

Joanne Wade

Renee McCloskey

Paul Kettelwell, MD for S. Paolucci, MD

Sue Trewhella

Michael Ryan, DO

Albert Bothe, MD

Conrad Schuerch, MD

Alice Garry-McCoy, MD

William Strodel, MD

Lauren Johnson-Robbins, MD

Dennis Torretti, MD

Evan Norfolk, MD

REVIEW AND APPROVAL OF MINUTES The March 14, 2007 Medical Executive Committee minutes were reviewed and approved with the following corrections: Sue Hallick was in attendance at the March meeting. APPOINTMENTS Appointments Susan Hallick, CNO, has reviewed and approved the licensed healthcare providers (LHPs) seeking privileges at the April meeting. *Names may not be included.

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ANNOUNCEMENTS OLD BUSINESS QUALITY TIME NEXT MEETING The next meeting of the Medical Executive Committee is scheduled to take place Wednesday, May 9, 2007 at 12:00 noon in the GMC Administrative Conference Room. ADJOURN The meeting was adjourned at 2:15 p.m. Respectfully submitted,

Reviewed by,

William S. Strodel, MD

Glenn D. Steele, Jr., MD, PhD

Associate Chief Medical

President and Chief Executive Officer

Officer, Surgery cmb

OP:10:B GEISINGER MEDICAL CENTER MEDICAL EXECUTIVE COMMITTEE MAY 9, 2007 MEETING MINUTES PEER REVIEW GENERATED DOCUMENT SOLELY FOR QUALITY IMPROVEMENT PURPOSES PURSUANT TO 63 P.S. ﾂｧ425.1 ET SEQ窶年OT FOR REDISTRIBUTION OUTSIDE THE SYSTEM'S PEER REVIEW COMMITTEE. Members Present

Absent

Guests

Joel Berberich, MD, PhD

Dominick Conca, MD

David Franklin, MD (attending for Dr. Strodel)

Joseph Bisordi, MD, Chair

Bruce Hamory, MD

Evan Norfolk, MD

Albert Bothe, MD

Cindy Mull

Paige Hornberger (attending for Cindy Mull)

Edie Derian, MD

William Strodel, MD

Linda Famiglio, MD

Joanne Wade

Cathleen Woomert, MD (attending for Dr. Judy Klock Conca)

Sue Hallick, RN

Tom Weir

Lynn Miller Stephen Paolucci, MD Michael Ryan, DO Conrad Schuerch, MD Dennis Torretti, MD

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CALL TO ORDER Dr. Bisordi called the Medical Executive Committee to order at 12:05 p.m. APPOINTMENTS/CREDENTIALLING Susan Hallick, CNO, has reviewed and approved the LHPs (licensed healthcare providers) seeking privileges at the May meeting. *Names of providers may not be included here. NEXT MEETING The next meeting of the Medical Executive Committee is scheduled to take place Wednesday, June 13, 2007 at 12:00 noon in the GMC Administrative Conference Room. ADJOURN The meeting was adjourned at 1:50 p.m. Respectfully submitted,

Reviewed by,

Joseph E. Bisordi, MD

Glenn D. Steele, Jr., MD, PhD

Chief Medical Officer, GMC

President and Chief Executive Officer

mec-min-may07 mec 05/12/07

OP:10:C GEISINGER HEALTH SYSTEM PROVIDER CREDENTIALS MARCH 1, 2007 LOCATION: DIVISION OF MEDICINE ACR Members Present

Legal Representatives

Credentials Staff

Terri Bickert, RN (CNO designee)

Kristen Beech, Esquire

Paige Hornberger

Seth Fisher, MD, Chairperson

Cindy Mull

Charles Maxin, MD*

Melinda Robinson

Thomas Schaeffer, PA-C* George Valenta, MD* Valerie Weber, MD David Weiss, MD Excused Linda Famiglio, MD David Felicio, Esquire David Franklin, MD Toni Macario Hesham Nagi, MD Larry Robbins, MD

*Via conference call

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CALL TO ORDER The meeting was called to order at 4:25 p.m. MINUTES The minutes of February 1, 2007 were approved as presented OUTSTANDING ISSUES A. Bylaws referred to for language to be used for staff categories of the Professional Staff. Bylaws will need further review B. Screening Criteria CREDENTIALING ISSUES None NEW ISSUES None APPOINTMENTS/REAPPOINTMENTS Appointments Motion: On motion duly made, seconded and carried unanimously, the Geisinger Health System Provider Credentials Committee approved all appointments for a two year period. Reappointments *Names of the providers appointed or reappointed may not be included. MOTION On motion duly made, seconded and carried unanimously, the Geisinger Health System Provider Credentials Committee approved all reappointments, as presented and will recommend approval to the respective Committees and to the Board of Directors. ADJOURNMENT The meeting adjourned at 5:15 p.m. Respectfully submitted, Seth Fisher, MD

Cindy L. Mull

Chairperson

Manager, System Credentialing

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OP:10:D GEISINGER HEALTH SYSTEM PROVIDER CREDENTIALS JUNE 12, 2007 LOCATION: DIVISION OF MEDICINE ACR Members Present

Legal Representative

Terri Bickert, RN* (CNO designee)

David Felicio, Esquire

Linda Famiglio, MD

Credentials Staff Paige Hornberger Toni Macario

David Franklin, MD Acting Chairperson

Cindy Mull

Hesham Nagi, MD

Melinda Robinson

Valerie Weber, MD David Weiss, MD Excused Kristen Beech, Esquire Seth Fisher, MD, Chairperson Charles Maxin, MD Larry Robbins, MD Thomas Schaeffer, PA-C George Valenta, MD

*Via conference call

CALL TO ORDER The meeting was called to order at 5:10 p.m. MINUTES The minutes of May 3, 2007 were approved as presented. OUTSTANDING ISSUES Bylaws referred to for language to be used for staff categories of the Professional Staff. Bylaws will need further review Screening Criteria CREDENTIALING ISSUES None NEW ISSUES None APPOINTMENTS/REAPPOINTMENTS Appointments Appointments to Geisinger Clinic, Geisinger Medical Center (names of providers excluded) MOTION On motion duly made, seconded and carried unanimously, the Geisinger Health System Provider Credentials Committee approved all appointments for a two-year period.

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REAPPOINTMENTS Reappointments to Geisinger Clinic, Geisinger Medical Center (names excluded). MOTION On motion duly made, seconded and carried unanimously, the Geisinger Health System Provider Credentials Committee approved all reappointments, as presented and will recommend approval to the respective Committees and to the Board of Directors. System transfers, status changes, and informational items were presented. MOTION On motion duly made, seconded and carried unanimously, the Geisinger Health System Credentials Committee approved all status changes, transfers and informational items as presented. ADJOURNMENT The meeting adjourned at 5:55 p.m. Respectfully submitted, David Franklin, MD

Cindy L. Mull

Acting Chairperson

Manager, System Credentialing

EVIDENCE 10—PART D: SOURCES OF EVIDENCE OP:10:A Medical Executive Committee (MEC) Minutes, April 2007 OP:10:B MEC Minutes, May 2007 OP:10:C Credentialing Minutes, March 2007 OP:10:D Credentialing Minutes, June 2007

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EVIDENCE 10—PART E With regard to the Chief Nursing Officer (CNO), applicants must submit: (e) description of the CNO’s mentoring activities that have been completed to promote the profession of nursing including, but not limited to, public speaking and submitting articles for publication in the nursing literature.

NO Sue Hallick has been active in mentoring activities at all levels of nursing services. She continues to maintain an active role in mentoring Pat Dietos, RN, the CNO at Geisinger South Wilkes-Barre, and Mary Gilda, RN, the CNO at Geisinger Wyoming Valley. Sue demonstrates her commitment to mentoring these nursing leaders with day-to-day discussions offering guidance and encouragement.

MENTORING NURSE LEADERS Geisinger South—Wilkes-Barre (GSWB) is the newest Geisinger hospital, having been acquired in late 2005. At that time, Sue actively began to mentor Pat Dietos, a GSWB nurse leader, so that Pat could excel in our system. During the same time frame, the nurse leader at the other Geisinger hospital in Wilkes-Barre, Geisinger Wyoming Valley (GWV), accepted a position with another organization, leaving a void in leadership on that campus. Sue’s familiarity with the other GWV nursing leaders enabled her to identify Mary Gilda, RN, as a potential replacement for GWV’s CNO. Sue encouraged Mary’s professional growth, enabling Mary to be promoted from an interim CNO role to permanent CNO. Sue has set educational and performance expectations with these new leaders to help guide their development. She encourages them to engage in public speaking and represent Geisinger nursing at all times. They are also encouraged to take advantage of other learning opportunities, such as participating in Quality Initiatives focus sessions on microsystem improvement and Frontline Leadership sessions focused on communication and management skills. Another example of Sue’s ongoing mentoring is demonstrated by her mentoring of Denise Beechay, RN, the associate vice president of nursing for Geisinger Medical Center. Under Sue’s watchful eye and guiding hand, Denise has been able to grow from her previous role as an operations manager to be promoted to a nursing vice president. Sue continues to provide Denise with expanding responsibilities, assigning her to quality and safety initiatives, patient through-put discussions and action plans, and various other activities. Crystal Muthler, RN, is an associate vice president of nursing within the medical center. She assumed this role after demonstrating her potential in her former role as director of the surgical suite. Sue has consistently invested time, effort, and guidance in Crystal’s leadership growth.

A MENTOR FOR NURSE MANAGERS AND STAFF For Sue, mentoring is a natural behavior. She makes a practice of engaging other members of the management team and nursing staff in discussions that provide an opportunity for her to coach and guide them. Sue routinely interacts with the operations managers about day-to-day operations as well as their long-term professional growth. She has been involved in developing performance expectations for the

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operations managers and the grid evaluation tool that gives them feedback on the development of their decision-making and leadership skills. Sue includes suggestions for growth and coaches them on operational decision making. Sue also meets regularly with staff nurses at the Nursing Councils and through Quality Rounds. She takes these opportunities to help the nursing staff gain perspective on current and anticipated issues. The staff truly enjoys the time the CNO spends with them because she is a respected leader.

PROMOTING THE PROFESSION OF NURSING Sue promotes the profession of nursing at every opportunity. Other nursing vice presidents seek her out as the “go to” person for nursing issues. She offers guidance on patient care practices, work environment improvements, and innovative compensation policies. As part of Sue’s expanded system role, she has also been able to foster the development of the Community Practice Service Line’s nurse leaders. (The Community Practice Service Line has 40 primary care locations serving 31 counties.) Sue is a mentor to these nurse leaders. Her efforts in this area encourage professional growth within our entire system. Sue promotes nursing by highlighting nursing activities at the Geisinger Health System Board of Directors meetings, the Medical Executive Committee of the Board of Directors, and the Medical Affairs Committee of the Board. At each of these meetings, staff nurses are included. The CNO is also involved in affiliation meetings with Bloomsburg University, Thomas Jefferson University, and others. Sue also engages in public speaking events and has published numerous articles in the nursing literature to promote the nursing profession. Some of these are listed below.

CNO’S PUBLIC SPEAKING ENGAGEMENTS • • • • • • •

Monthly speaker at Nursing Council meetings: Clinical Practice Council, Nursing Retention and Communication, and Nursing Services Quality and Performance Improvement Annual speaker at the Excellence in Nursing Awards Regular speaker at Advisory Board meetings held for community members Speaker at Professional Development Day Speaker at Thomas Jefferson University Orientation for new nursing students Speaker at Geisinger Authority Meetings attended by community members Speaker at Medical Affairs Committee of the Board of Trustees

CNO’S PUBLISHED ARTICLES • • •

Nurses Notes—a system publication for nurses Danville news article during Nurses Week 2006 “A Rural Academic—Service Partnership” published in JONA (February 2006 [36]:63-66, West, M., Hallick, S., Schaal, M., McGinley, A., Bickert, A.) The CNO collaborated with GMC’s director of nursing education and nursing leaders from Thomas Jefferson University to publish this article. It is another example of Sue’s leadership and is a source of pride to the nurses and administration at Geisinger Medical Center.

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EVIDENCE 10—PART F With regard to the Chief Nursing Officer (CNO), applicants must submit: (f) a list and/or description of the CNO’s professional development activities that have been engaged in during the two (2) year period immediately preceding the submission of written documentation. CNO PROFESSIONAL DEVELOPMENT ACTIVITIES COURSE CODE

CLASS NAME

COMPLETION DATE

SED2064405

2007 GOALS—Security Guidelines

05-01-2007

RSK0500105

2007 GOALS—Corporate Compliance

05-01-2007

PTS1105305

2007 GOALS—Patient Safety—Your Role

05-01-2007

EQA4230005

2007 GOALS—Electrical Safety

05-01-2007

BOD4210505

2007 GOALS—Back Safety and Workplace

05-01-2007

NSG2070505

2007 GOALS—Violence in the Workplace

05-01-2007

FAS1081705

2007 GOALS—Fire Safety

05-01-2007

FAS2061505

2007 GOALS—Emergency Management

05-01-2007

HAZ1181705

2007 GOALS—Right to Know: Chemical Safety

05-01-2007

INT11250

Abandoned Newborns: Safe Haven Policy

05-01-2007

EPI11232

EpicCare Inpatient Phase 2

06-17-2007

HPA11247HS

HIPAA 201—Security Rule—For Your Eyes Only

04-01-2007

HEI11156

HEICS

01-19-2007

NSG88199

OB/GYN Emergencies

01-18-2007

EQA4230004

2006 OSCAR—Electrical Safety

10-01-2006

FAS1081704

2006 OSCAR—Fire Safety

10-01-2006

FAS2061504

2006 OSCAR—Emergency Management

10-01-2006

HAZ1181704

2006 OSCAR—Right to Know: Chemical Safety

10-01-2006

BOD4210504

2006 OSCAR—Back Safety and Workplace

10-01-2006

PTS1105304

2006 OSCAR—Patient Safety—Your Role

10-01-2006

NSG2070504

2006 OSCAR—Violence in the Workplace

10-01-2006

SED206404

2006 OSCAR—Security Guidelines

10-01-2006

INT00766

2006 JCAHO National Patient Safety Goals

08-18-2006

HEI11156

HEICS

08-11-2006

NSG20534

Patient Care Conference

03-17-2006

SED2064405

2005 OSCAR—Security Guidelines

12-01-2005

RSK0500105

2005—Corporate Compliance

12-01-2005

PTS1105305

2005 OSCAR—Patient Safety—Your Role

12-01-2005

EQA4230005

2005—Electrical Safety

12-01-2005

BOD4210505

2005 OSCAR—Back Safety and Workplace

12-01-2005

NSG2070505

2005 OSCAR—Violence in the Workplace

12-01-2005

FAS1081705

2005 OSCAR—Fire Safety

12-01-2005

FAS2061505

2005 OSCAR—Emergency Management

12-01-2005

HAZ1181705

2005 OSCAR—Right to Know: Chemical Safety

12-01-2005

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ADDITIONAL CNO PROFESSIONAL DEVELOPMENT ACTIVITIES DATE

SPEAKER

TOPIC/TITLE

01/25/05

David Raible, State Director

March of Dimes and Geisinger PA Prematurity

Pennsylvania Chapter, March of Dimes 02/22/05

Robert Gavin, MD

GE and Enterprise Relationships and Pay-for-Performance

Director of Global Healthcare and Robert Kirkpatrick General Manager, Enterprise Development General Electric Company 03/22/05

David Lansky, PhD

Transforming U.S. Healthcare

Director of Health Program, Markle Foundation 04/26/05

Robert Cunningham

Journal and Beltway Views

Deputy Editor, Healthcare Issues

Relating to Healthcare Issues

Health Affairs Journal 05/24/05

Carolyn F. Scanlan President and CEO The Hospital and Health System Assoc. of Pennsylvania (HAP)

Hospitals—Vital to our Community

07/26/05

Judith Miller Jones, Director, National Health

Federal Health Issues and Geisinger Health System

Policy Forum (NHPF) and Adjunct Professor Department of Healthcare Sciences George Washington University 09/27/05

Marc Smolonsky

Biomedical Research—Current Challenges and Vision for the Future

Associate Legislative Director National Institutes of Health (NIH) 11/22/05

Robert B. Helms, PhD

American Enterprise Institute

Resident Scholar American Enterprise Inst. 01/24/06

Margaret E. O’Kane, President and Founder

Overview of the National Committee for Quality Assurance

National Committee for Quality Assurance (NCQA) 02/28/06

Greg Simon

Faster Cures

President, Faster Cures 03/28/06

John Tooker, MD Executive VP and CEO American College of Physicians

American College of Physicians

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SPEAKER

TOPIC/TITLE

04/25/06

Barry Straube, MD

Clinical Standard

CMO and Director Centers for Medicare and Medicaid Services 05/23/06

Norman Wolmark, MD

Principle Investment

Chairman National Surgical Adjuvant, Breast and Bowel Project 07/25/06

Carolyn Scanlon

PA Political Policy and Health Environment

President and CEO The Hospital and Health System Assoc. of PA (HAP) 09/19/06

Janet Corrigan, PhD, MBA

National Quality Forum

President and CEO 12/19/06

Scott Wallace

The Alliance for Health IT

President and CEO 03/27/07

James Firman

National Council on Aging

President and CEO 04/24/07

Lynn Etheredge

Rapid Learning

Health Consultant George Washington University 05/22/07

Robert Dickler

AAMC

Sr.VP, Health Affairs 06/26/07

Paul Ginsburg, PhD

Reforming Physician Payment

President, Center for Health System Change 07/22-24/07 Leadership Summit

Health Forum and American Hospital Association

10/2-5/07

American Nurses Credentialing Center

National Magnet Conference Atlanta, GA

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EVIDENCE 11 Any information related to any violations of any regulations or laws that have been substantiated against the organization within the past five-year period immediately preceding the submission of written documentation.

T •

• • •

here have been no violations of any regulations or laws that have been substantiated against Geisinger Medical Center in the past five years. Additionally:

We are fully accredited by the Joint Commission on Accreditation of Healthcare Organizations; effective date: July 18, 2007. The Joint Commission’s results were announced to all GMC employees in Connections, a Geisinger employee newsletter (OP:11:A). We are fully licensed and Medicare-certified by the Pennsylvania Department of Health Rules and Regulations for Hospitals; effective date: May 15, 2007. We are fully licensed by the Pennsylvania (PA) Department of Health (http://www.health.state.pa.us); effective date: May 15, 2007. According to our Legal Department, there have been no violations of regulations or laws related to laboratory requirements, radiology safety requirements, tax code violations, and billing or human research regulations.

OP:11:A CONNECTIONS: DANVILLE EDITION JULY 18, 2007 JOINT COMMISSION SURVEY RESULTS “BEST IN THE COUNTRY” PERFORMANCE To all GMC employees: Congratulations! The Joint Commission’s accreditation survey of Geisinger Medical Center concluded last week with excellent results and high praise from the survey team. The Joint Commission was extremely impressed with GMC’s accomplishments since the last survey in 2004. As a rule, the examiners are not lavish with compliments, but in a number of areas, they said our performance was the best in the country. After a thorough review of GMC records and processes, the examiners found no unsigned verbal orders, no outdated medications and no medication reconciliation errors.They also found no examples of dangerous abbreviations, an unprecedented achievement according to the reviewers, and a superb accomplishment by our entire team. It was a profound pleasure to watch you all interact with the examiners and show such confidence and competence.You are truly outstanding. Successful accreditation is an important expression of our commitment to Geisinger Quality. It is the result of personal dedication and skill which each of you contribute, and the commitment you have made to patient-centered care. Congratulations to you all for a job well done. Joseph Bisordi, MD GMC Chief Medical Officer Susan Hallick, RNC System Chief Nursing Officer Lynn Miller GMC Chief Administrative Officer Connections 7-16-07 edition

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EVIDENCE 12 The organization’s and nursing services’ most recent annual report. GEISINGER HEALTH SYSTEM ANNUAL REPORT Geisinger Health System’s annual report is distributed in August of the following year. Therefore, the 2006 Annual Report is currently available in hard copy or online in an Adobe PDF file. To view it, go to http://www.geisinger.org/shared/about/06_ar.pdf

NURSING SERVICES ANNUAL REPORT Geisinger Medical Center’s Nursing 2006 Annual Report is available in hard copy or online in an Adobe PDF file. To view it, go to http://www.geisinger.org/professionals/nursing/ar.html

[Terri: Do we need to reference the hard copy of the annual report that will be included in the packet?]

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EVIDENCE 13—PART A: NURSING Mission, vision, strategic plan, priorities report, and performance improvement plan of both the organization and the nursing services.

ursing has played an integral role in Geisinger Medical Center’s (GMC) success since the hospital was founded by Abigail Geisinger more than 90 years ago. Nursing was charged with the same strong commitment that Abigail Geisinger expected of the new hospital when she stated, “Make my hospital right. Make it the best.” Building on this history of excellence, GMC’s Nursing Department is committed to providing quality patient care that is based on and evolves with new knowledge and best practices while always remaining compassionate and respectful of those we serve. The Nursing Department is also committed to the long tradition of nursing and nursing’s future. We are dedicated to providing a supportive work (and educational) environment that meets the needs of nurses at all career levels. We always strive to be the best.

OUR MISSION The Nursing Department’s mission is to create and sustain a healthy work environment in which professional nurses thrive in patient care, education, research, community service, and leadership. All nurses are challenged to adapt and excel in the dynamic, high-tech, and rapidly changing world of healthcare. Advanced leadership skills are necessary for Geisinger’s Nursing Leadership Team to engage, guide, and direct our nurses toward achieving our mission while supporting Geisinger Health System’s overarching vision. The nursing strategic plan, priorities report, and performance improvement initiatives (to name a few) focus these departmental efforts.

OUR VISION In line with the system’s programmatic areas identified in its most recent five-year vision statement, nursing has aligned its goals around these areas: • securing Geisinger’s nursing legacy through leadership and a supportive work atmosphere • ensuring that quality nursing practice remains at the forefront of the system’s priorities • continually looking for innovative approaches to nursing care • matching nursing staff with the needs of the patient population. Our vision is driven through the primary Nursing Department Councils (OP:13:A) and other formal and informal committees and workgroups. Since the hospital’s founding in 1915, Geisinger nurses have been held to high performance standards and expected to be skilled and compassionate professionals. We uphold these expectations today. Knowing that the residents of central and northeastern Pennsylvania expect—and deserve—no less, we strive to provide the very best in nursing practice.

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OP:13:A POLICY 100 NURSING DEPARTMENT MISSION, VISION, CONCEPTUAL MODEL, AND PHILOSOPHY MISSION STATEMENT The mission of the Nursing Department is to create and sustain a healthy work environment in which nurses excel in patient care, education, research, and community service. VISION STATEMENT The Nursing Department vision is to secure the Geisinger legacy through leadership, quality nursing practice, innovation, and market growth.The vision will be actualized by the practice and performance of the nursing councils and nursing constituents to meet the care needs of our patients and communities. Nursing services is instrumental in leading our increased reliability quality process, securing the legacy in growth and development of our staff and innovative processes to deliver care. NURSING CORE VALUES 1. Professionalism—Everyone in the Nursing Department is committed to quality patient care through continuous learning and clinical job competence. 2. Teamwork—We pride ourselves in our ability to come together as teams to meet the patient care needs. All team members strive together for performance improvement and service excellence. 3. Leadership—We are fortunate to have many resources at our command to guide, direct, and create positive outcomes in nursing practice, education, research, and service. 4. Securing the Legacy—We are proud of our rich history we have built and securing the legacy of our future. 5. Market Growth—Pursuit of our mission requires successful resource management recognized as an essential value to our organization’s survival and growth. 6. Caring—We engage in compassionate caring in our human-to-human interactions and treasure the uniqueness of the nurse-patient relationships. NURSING CORE VALUE STATEMENTS 1. Promotes a reciprocal, respectful relationship with patients, visitors, colleagues and other members of the healthcare team. 2. Reflects a professional image in appearance, attitude, and behavior. 3. Views the nursing profession as one that embodies the attributes of dedication, selflessness, professional and personal growth, knowledge, and empathy. 4. Demonstrates individual accountability in nursing practice that is inclusive of behavior and interactions with patients, colleagues, and others in the community, profession, and organization. 5. Exhibits leadership characteristics that will influence patient outcomes, work environment, and job satisfaction. 6. Practices the “art of nursing” displaying compassionate caring for patients and families and supporting one another on a daily basis. 7. Values education and evidence-based research remain current in the scope of practice. 8. Celebrates the uniqueness of the professional nurse-to-patient relationship. Serves as a patient/family advocate. CONCEPTUAL MODEL At Geisinger Medical Center, we care for patients across the lifespan with various health problems. A conceptual framework guides movement through the nursing process in an organized manner in complex practice settings. Roy’s Adaptation Model and Jean Watson’s Theory provide the structure to organize, analyze, and plan patient care decisions and interventions. Consistent with Roy’s Adaptation Model, the goal of GMC nursing practice is to increase the person’s adaptive responses and decrease ineffective responses in an effort to promote an optimal state of being or becoming. Adaptive responses are responses to the internal or external stimuli that promote survival, growth, reproduction, and mastery. Ineffective responses are those responses that do not promote adaptive responses.

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Adaptation (Roy) and Caring (Watson) are the central themes of everything we do. We help the patient achieve the maximum outcome for their particular state of being. Watson's Caring is emphasized to highlight the uniqueness of the nurse-patient relationship and manner of human-to-human interaction. (Jean Watson) Our view of each of the elements of the nursing metaparadigm will be described as they correlate to Roy and Watson: • Person is a holistic view of individual, group, or community as a bio-psycho-social-cultural adaptive system. • The environment of “person” consists of internal and external factors that are constantly interacting and changing. • Health occurs on a continuum and is viewed as a state of being and becoming an integrated, whole person. • Nursing is skilled, knowledgeable, caring human interaction to promote adaptation of the person to his environment. According to the Roy Adaptation Model, the focus of nursing is on the adaptive system (individual, group or community) responses to a constantly changing environment. Nursing action is required when “problems in adaptation arise when the adaptive system is unable to cope with or respond to constantly changing stimuli from the internal and external environments in a manner that maintains integrity of the system” (Andrews and Roy, 1991). Nursing practice occurs anywhere there is a recipient: individual, group, or community. In addition, it occurs whether the recipient is well or sick. PHILOSOPHY OF NURSING Nursing is skilled, knowledgeable, caring human interaction to promote the patient’s adaptive responses to environmental stressors. The patient can be an individual, family, or group that is in a state of being that is adaptive or maladaptive. We are committed to providing quality nursing care to assist the patient to attain, maintain, or regain an optimal level of health or die with dignity. Nursing practice and performance will be in accordance with the ANA Code of Ethics, the Geisinger Code of Conduct, established policies and procedures, and related regulatory stipulations (State Nurse Practice Act, DOH, etc.).To achieve our mission and vision, we accept the challenge to provide comprehensive nursing care. Nursing Practice Quality and Innovation will be: • provided in a holistic, caring, professional manner. • provided at a level of excellence in all aspects of care. • seeking continuous performance improvement and quality via highly reliable processes. • provided in an environment that is supportive and safe. • based on best practice standards and evidence-based research. • in accordance to the Patient’s and Nurses’ Bill of Rights. • in collaboration with other partners of the multidisciplinary team to achieve the best possible patient outcomes. Secure the Geisinger Legacy: • Practice transformational leadership style and presentation. • Provide strong leadership based on Nursing’s vision. • Foster an environment conducive to personal and professional growth. • Embrace a shared governance structure to foster staff involvement. • Support quality and data-driven decision making in a shared governance model. • Participate in the responsibility for continuing growth through education and professional development. • Contribute to the nursing profession through quality and highly reliable processes in patient care, ongoing education, evidencebased research, and service excellence. • Create a supportive and caring environment that recognizes each person’s unique contribution to the team. MARKET GROWTH • Assure fiscal responsibility of resources within the department. • Foster an environment conducive to retention of staff. • Contribute to the nursing profession through quality and highly reliable processes in patient care, ongoing education, evidencebased research, and service excellence.

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DEPARTMENTAL OBJECTIVES 1. Securing the Geisinger Legacy will be achieved through transformational leaders guiding professional growth and development of staff to achieve higher levels of excellence in practice, education, research and service. 2. Quality will be achieved through highly reliable processes focused on providing optimal patient outcomes and staff satisfaction. 3. Innovation occurs in the implementation of evidence-based practice changes or application of new technologies. 4. Market Growth presents opportunity for nursing services to develop plans to recruit and retain the nursing staff to meet the increasing demands associated with growth. Devised 3/98 Revised 3/07

STRATEGIC PLAN Nursing’s strategic plan is organized using the model of Forces of Magnetism. Geisinger nurses are leaders in professional practice. To constantly “raise the bar” on practice achievements, we have embarked on this journey to achieve Magnet excellence. The nursing staff and employees throughout GMC embrace the 14 characteristics of a Magnet culture. These include nursing leadership, professional models of care in the delivery of patient care, and professionalism. As the primary tertiary/quaternary healthcare facility in rural central and northeastern Pennsylvania, Geisinger’s Nursing Department is in a unique position to be a leader in supporting the Forces of Magnetism within our region.

Nursing Leadership Accountability and Balance (FORCE 1 and FORCE 3) According to national sources, the main reason that nurses leave their positions is a poor relationship with their immediate manager. Recognizing this issue, Geisinger’s CNO Sue Hallick has set high performance expectations for nurse managers in employee relations, quality standards, and fiscal accountability. To ensure success, our strategic initiatives include: • a positive “can do” attitude • creative problem solving • a “quick test of change” mind set • quality and data-driven decision making • basic “blocking and tackling” (identifying and removing barriers that care providers may encounter to assure the job gets done with excellent quality for the patient) • manageable span of control with “right fit” in style and personality • investments in mentorship and education • interdisciplinary relationships. Leadership development is essential to provide current and future nurse leaders with the knowledge and skills needed to navigate successfully through the changing healthcare landscape. Geisinger’s Nursing Leadership Team is committed to mentoring the growth and development of our nurses and nursing leaders. Geisinger has developed relationships with academic partners who can provide opportunities to expand leaders’ understanding of healthcare and market trends, professional nursing best practices, and ongoing professional development.

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Organizational Structure of the Nursing Service Line (FORCE 2) Sue Hallick, Geisinger’s CNO, is responsible for nursing practice throughout the entire system. She has built strong relationships with the nurses who report directly and indirectly to her. She emphasizes building relationships that result in “getting the job done” for patients, nurses, and the entire care team. As part of Geisinger’s nursing strategic plan, Sue has focused nursing on these key elements: • Striving for Perfection (meeting regulatory requirements and establishing quality improvement performance initiatives) • Ongoing effective education • Professional growth and development • Shared governance council structure • Evidence-based nursing practice to assure a high standard of performance • Evidence-based and best practice policy and procedure processes.

Effective Management Practices (FORCE 3, 4, and 9) Visible and effective nursing leadership in all aspects of operations is a Nursing Department expectation. Interactions among nurses, nursing leaders, physicians, and other personnel occur on a daily basis. Geisinger nurse leaders (CNO, assistant vice presidents, directors, operations managers, and team coordinators) interact fairly and consistently with nursing care team members (licensed and unlicensed direct-caregivers and secretarial support). Collaboration among all members of the healthcare team is the standard. The focus of our best practice staffing model includes: • nursing presence and bedside clinical leadership • budgeted and actual best practice nursing care hours • nurse-to-patient ratios that promote staffing effectiveness • efficient and fiscally responsible care models • a “no mandatory overtime” philosophy and staffing processes.

Recruitment and Retention of Staff (FORCE 4) Challenges in today’s healthcare arena demand proactive and aggressive strategies to recruit and retain qualified nurses (OP:13:B). Geisinger continues its successful approach, focusing on innovative strategies for recruitment and retention, including promoting flexible work schedules through: • shared staffing processes • maximizing the computerized staffing system known as ANSOS (Automated Nurse Staffing Operating System) • a focus on key drivers of retention • process- and plan-driven actions • leadership oversight and guidance.

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OP:13:B PATIENT CARE MANUAL POLICY 200 SECTION: JOB GUIDELINES SUBJECT: EMPLOYMENT CRITERIA FOR NURSING DEPARTMENT PERSONNEL DOMAIN: ADMINISTRATION 1. Licensed providers are required to submit the original hard copy display portion of their Pennsylvania Nursing License or their original Pennsylvania Temporary Practice Permit to the NAO on their first day of employment. Originals are kept on file in the Nursing Office. 2. When Geisinger Nursing Department RNs and LPNs are due for license renewal, they will be given two weeks to produce the original hard copy display portion of their license to the NAO as long as e-verification of the Pennsylvania State Board of Nursing web site demonstrates that their license is current. If the nurse has not produced the original license to the NAO after the two-week grace period, the nurse will not be permitted to work until the license is produced.The same two-week grace period is extended to the Practical Nurse and the Graduate Nurse to produce their LPN and RN license once they have passed boards. 3. If e-verification states that the license has lapsed, the nurse will not be permitted to work until the license is in good standing. Devised 7/79 Revised 1/07

Care Delivery (FORCE 5), Autonomy (FORCE 9), and Nurses as Teachers (FORCE 11) Shared governance is key to our Nursing Department’s success. Nurses are actively engaged in the care delivery process. They maintain nursing autonomy in their work in the hospitals and outpatient units. Autonomy is accomplished through the nursing councils (OP:13:C). Ongoing support of this shared governance structure is a leadership priority.

OP:13:C POLICY 100A NURSING SHARED GOVERNANCE STRUCTURE DEPARTMENTAL RELATIONSHIPS The Nursing Department values a multidisciplinary approach to patient care. It is expected that there will be a cohesive working relationship with all departments and partners in care related to the Medical Center.The operations manager or team coordinator of the involved unit should be contacted by nursing staff members or personnel from other departments if a patient-related issue arises.The Team Coordinator, if present, or the Administrative Supervisor may be contacted if issues arise during the evening or night shift. Primary Nursing Department Councils: The Nursing Councils utilize adaptation and caring principles to analyze, plan, organize, and evaluate nursing action to achieve the organizational and departmental vision and mission.The councils are led and/or cochaired by staff nurses.The nursing councils serve as the infrastructure for nursing services comprised of inpatient and outpatient staff nurses, nurse educators and nurse operations managers and the CNO.The councils strive to guide nurse performance to attain or maintain the highest level of excellence in patient care. Nursing Councils: 1. Nursing Executive Council

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2. Clinical Practice Council 3. Nursing Performance Improvement 4. Retention and Communication Council 5. Research Council 6. Administrative Council (Inpatient/Outpatient Operations Managers) 1. Nursing Executive Council The Purpose is to: • coordinate activities of the nursing councils. • integrate principles of theoretical framework (adaptation and caring) into nursing practice policies or standards when appropriate. • make key decisions regarding nursing council activities and related issues. • communicate shared information with respective councils. The Functions of the Nursing Executive Council are to: • serve as a resource for nursing council issues. • collaborate with nursing leadership/CNO to identify and resolve nursing practice issues. • discuss methods of seamless changes across all councils. • communicate calendars and barriers in purpose of each council and develop a collaboration method. DECISION MAKING A majority of the council members present shall constitute a quorum of such group. MEETING TIME The council shall meet for one hour every other month the second Tuesday of the month 0800 a.m. to 0900 a.m. MEMBERSHIP The council membership shall consist of, but not be limited to, the following representatives: • Cochairs of the Primary Nursing Councils: Clinical Practice, Performance Improvement, Retention and Communication, Inpatient/Outpatient, and Research • CNO and Director of Nursing Education—cochair • Consultants will be utilized as necessary. TERMS OF MEMBERSHIP Members will be determined at the council level through selection of Council cochairs. MEMBER RESPONSIBILITIES • Attend at least 75 percent of the scheduled council meetings. • Serve as an active participant. • Elicit input from council; represent council concerns, needs and desires. • Incorporate adaptation and caring theoretical framework principles that promote the best possible outcomes for the whole (patient, unit, peer, hospital, and community) into Council activities when appropriate. • Make decisions based on the best practice outcomes and regulatory standards while taking into consideration the impact to the organization during implementation (patient, hospital, unit, peer, etc).

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2. Nursing Clinical Practice Council The Purpose is to: • analyze, plan, and organize nursing action utilizing best practice/evidence-based practice and regulatory requirements. • integrate principles of theoretical framework (adaptation and caring) into nursing practice policies or standards when appropriate. • make key decisions regarding nursing clinical practice and related issues. • define the parameters of nursing clinical practice and performance through the development and implementation of policies and procedures via evaluation of evidence-based practice and regulatory requirements. The Functions of the Clinical Practice Council are to: • serve as a resource for nursing clinical practice issues. • collaborate with unit-based councils and nursing leadership/CNO to identify and resolve nursing practice issues. • address nursing practice issues that affect other disciplines. • review and approve existing and newly developed policies/procedures, standards of care, and nursing practices. • collaborate with Patient Education Coordinator to coordinate for patient education materials. • define Unit representatives’ roles and responsibilities • collaborate with Performance Improvement to evaluate the effect policy revisions have had on improving nursing practice. DECISION MAKING A majority of the council members present shall constitute a quorum of such group. MEETING TIME The council shall meet for eight hours monthly the second Tuesday of the month 0700 a.m. to 1530. MEMBERSHIP The council membership shall consist of, but not be limited to, the following representatives: • Staff nurse, CNE, and outpatient team leaders serve as cochairs; inpatient operations manager serves as advisor and mentor • CNO (ad hoc member) • Staff nurse(s) from each inpatient and outpatient unit • Outpatient clinical staff nurse(s) • Regulatory PI Coordinator • Ad hoc members: EPIC®, Infection Control, Nursing Administration, and Magnet • Consultants will be utilized as necessary. TERMS OF MEMBERSHIP Members will be determined at the Unit level. Members shall hold a minimum two-year term with rotation of not greater than one-half of council membership on a yearly basis each July. • All units shall assume responsibility of the selection process of representation from their respective area(s), either by election or appointment thereof. • Council Leadership, along with Unit Management, will be responsible to ensure members are meeting their responsibilities. MEMBER RESPONSIBILITIES • Attend at least 75 percent of the scheduled council meetings. • Serve as an active participant. • Serve as a resource to the units concerning nursing clinical practice issues. • Elicit input from units; represent unit concerns, needs, and desires.

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• Incorporate adaptation and caring theoretical framework principles that promote the best possible outcomes for the whole (patient, unit, peer, hospital, and community) into nursing policies and procedures when appropriate. • Make decisions based on the best practice outcomes and regulatory standards while taking into consideration the impact to the organization during implementation (patient, hospital, unit, peer, etc). • Communicate in a timely manner—goals, actions, decisions, and rationale to the unit staff and Nursing Administration. 3. Nursing Services Quality/Performance Improvement Council The Purpose is to: • provide a structure to support a culture of continuous performance improvement, safety and survey readiness. • provide leadership in aspects of process improvement (measurement, analysis, and evaluation) and promote individual member accountability. • develop and coordinate the mechanisms (tools) for monitoring compliance with selected policies and procedures to promote quality patient care. • evaluate nursing services performance related to organizational and regulatory policies and procedures. • collaborate with other nursing and hospital based councils to determine appropriate action that will enable achievement of the Organizational and Nursing Department’s mission and vision. The Functions are to: • identify nursing quality indicators to be monitored for improvement of patient care. • educate PI membership related to monitoring compliance with selected policies and procedures. • develop tools used to measure compliance and performance improvement. • direct the formulation of the annual indicator calendar. • report and review monitoring results via a data board. • annually reevaluate the nursing services Performance Improvement Plan. DECISION MAKING A majority of the council members present shall constitute a quorum of such group. MEETING TIMES The council meetings are held on the third Wednesday of each month for eight hours (0730 to 1530).The morning session is generally located in the Anesthesia Conference Room and the afternoon session will be in the School of Nursing Room 2. Meeting notices and agenda are prepared and distributed by the council Chairperson. MEMBERSHIP The council membership shall consist of, but not be limited to, the following representatives: • Staff nurse, CNE, and outpatient team leaders serve as cochairs; inpatient operations manager serves as advisor and mentor • CNO (ad hoc member) • Staff nurse(s) from each inpatient and outpatient unit • Outpatient clinical staff nurse(s) • Staff member(s) from Respiratory Care Services • Regulatory PI Coordinator • Ad hoc members: EPIC, Infection Control, Nursing Administration, and Magnet • Consultants will be utilized as necessary. Meeting minutes will be generated and available to members. TERMS OF MEMBERSHIP Members of the council shall hold a minimum two-year term with rotation of not greater than one-half of council membership on a yearly basis each July.

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• All units shall assume responsibility of the selection process of representation from their respective area(s), either by election or appointment thereof. MEMBER RESPONSIBILITIES • Attend at least 75 percent of the PI Council meetings per year. • Conduct monitoring of PI Indicators as required and submit results at monthly PI Council meetings. • Review and report practice issues where performance improvement can occur at the PI Council meetings. • Participate in analysis discussions of trended data reports. • Actively participate in problem solving to recommend practice or process improvement. • Communicate PI Council activities and results to unit based leadership and staff members monthly via data board containing minutes and audit reports. • Incorporate adaptation and caring principles that promote the best possible outcomes for the whole (patient, unit, peer, hospital, and community) into nursing performance activities when possible. • Educate coworkers regarding PI monitoring processes and practice/process improvement activities. • Collaborate with unit management in the development of annual PI goals based on scope of service and important aspects of care. • Complete an annual evaluation report for their responsible patient care areas. 4. Nursing Retention and Communication Committee (NRCC) The Purpose is to: • facilitate discussion and planning regarding overall nursing services staff retention goals and objectives with specific attention to Healthy Work Environment Initiative, Nursing Recognition/Nurses Week, Patient Satisfaction, and Nurse Satisfaction. • develop retention plans regarding ideas within the scope of control of the council to present to CNO. • enhance the retention of nursing personnel through: teamwork, communication, identification of actual or potential problems, and problem solving. The Functions are to: • identify major areas of work and environment dissatisfaction within the nursing units and outpatient areas and recommend improvement activities to enhance retention of staff. • engage the nursing staff in effective, constructive problem solving processes when dealing with issues (related to job satisfaction or general topics). • enhance relationships between departments through communication and networking. • plan, coordinate, and facilitate all Nurses Week activities. • serve as representatives of the nursing staff to Nursing Administration, Human Resources, and Public Relations. • promote a positive nursing image through personal action and recognition of peers. • promote the Magnet culture through the Healthy Work environment initiative, professional development, and mentoring of new employees. • participate in recruitment functions as needed. DECISION MAKING A majority of the council members present shall constitute a quorum of such group. MEETING TIMES Meetings are held monthly on the fourth Thursday of the month from 0700 – 1530 in the Anesthesia conference room. MEMBERSHIP The council membership shall consist of, but not be limited to, the following representatives:

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• Staff nurse, CNE, and outpatient team leaders serve as cochairs; inpatient operations manager serves as advisor and mentor • CNO (ad hoc member) • Staff nurse(s) from each inpatient and outpatient unit • Outpatient clinical staff nurse(s) • Staff member(s) from Respiratory Care Services • Regulatory PI Coordinator • Ad hoc members: EPIC, Infection Control, Nursing Administration, and Magnet • Consultants will be utilized as necessary. TERMS OF MEMBERSHIP Members of the council shall hold a minimum two-year term with rotation of not greater than one-half of council membership on a yearly basis each July. MEMBER RESPONSIBILITIES • Represent the council in other forums. • Serve as a resource to the units concerning nursing retention and communication issues. • Elicit input and feedback from coworkers and present their opinions, concerns, needs, and desires. • Make decisions based on adaptation and caring principles that promote the best possible outcomes for the whole (patient, unit, peer, hospital, and community). • Timely communication of council activities to the unit staff and Nursing Administration. • Complete council related duties as assigned. 5. Nursing Research Council The Purpose is to: • provide education related to evidence-based practice and research. • provide guidance and direction to nurses interested in conducting nursing research. • initiate, facilitate, and utilize nursing research in order to enhance professional nursing practice. The Functions are to: • provide guidelines for submitting proposals and conducting nursing research. • review and approve internally and externally generated nursing research proposals for submission to IRRB. • provide research education for Nursing. • promote and encourage nursing research activities for Nursing. • identify and disseminate information of potential areas for investigation. • assist in identifying funding sources for nursing research. • assure protection of human rights in accordance with federal and institutional guidelines. • ensure high-quality nursing research by providing ongoing review of open projects. • maintain council representation on IRRB. • assure compliance with the critical issues of human rights, moral and ethical issues, informed consent, subject safety, and confidentiality. • increase staff awareness of utilizing research in practice. DECISION MAKING A majority of the council members present shall constitute a quorum of such group.

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MEETING TIMES The research council will meet the third Monday of every month from 1400 – 1530 in the Foss 7 Library. Expanded meetings will be held as the demand necessitates. MEMBERSHIP The council membership shall consist of, but not be limited to, the following representatives: • Staff nurse, CNE, and outpatient team leaders serve as cochairs; inpatient operations manager serves as advisor and mentor • CNO (ad hoc member) • Staff nurse(s) from each inpatient and outpatient unit • Outpatient clinical staff nurse(s) • Staff member(s) from Respiratory Care Services • Regulatory PI Coordinator • Ad hoc members: EPIC, Infection Control, Nursing Administration, and Magnet • Consultants will be utilized as necessary. TERMS OF MEMBERSHIP Members of the council shall hold a minimum two-year term with rotation of not greater than one-half of council membership on a yearly basis each July. MEMBER RESPONSIBILITIES • Represent the council in other forums. • Serve as a resource to the units concerning evidence-based practice and nursing research. • Incorporate adaptation and caring principles that promote the best possible outcomes for the whole (patient, unit, peer, hospital, and community) into nursing research activities when possible. • Complete council related duties as assigned. 6. Administrative Council (Inpatient/Outpatient Operations Manager Council) The Purpose is to: • guide and direct the departmental operations to achieve mission and vision of the Nursing Department and the Organization. • coordinate a cohesive approach to the assessment, planning, implementation, and evaluation of material and human resource management issues in both the inpatient and outpatient arenas. The Functions are to: • discuss and address adequacy of staffing to maintain safe and quality patient care (staffing incentives, agency personnel, etc.). • communicate unit-specific practices or performance that may affect the other units. • share internal best practice related to practice, education, research, or service excellence. • coordinate a multidisciplinary approach to patient care by collaborating with leaders of other departments when appropriate. • provide leadership to nursing and ancillary departments. • position the nursing department to achieve the mission and vision of the department and the organization. • focus and share information regarding regulatory compliance. DECISION MAKING A simple majority of the council members present shall constitute a quorum of such group.

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MEETING TIMES The meetings are held on the first and third Tuesdays of every month from 1200 – 1400. Location is primarily the Nursing Administrative Conference Room. MEMBERSHIP The council membership shall consist of, but not be limited to, the following representatives: • Staff nurse, CNE, and outpatient team leaders serve as cochairs; inpatient operations manager serves as advisor and mentor • CNO (ad hoc member) • Staff nurse(s) from each inpatient and outpatient unit • Outpatient clinical staff nurse(s) • Staff member(s) from Respiratory Care Services • Regulatory PI Coordinator • Ad hoc members: EPIC, Infection Control, Nursing Administration, and Magnet • Consultants will be utilized as necessary. TERMS OF MEMBERSHIP Membership is active while serving in one of the above-mentioned leadership roles. MEMBER RESPONSIBILITIES • Participate in council activities in a manner that promotes achievement of the purpose and functions of the council. • Provide leadership and guidance toward goal achievement and problem solving. • Serve as liaisons/representatives from this council to all other nursing (and multidisciplinary) councils. • Support decisions made in this council in all forums. INSTITUTIONAL COMMITTEES Nursing representatives participate in all appropriate medical staff, administrative, and interdepartmental committees, including but not limited to, the committees listed in the following table. Medical Executive

Pharmacy and Therapeutics

Bioethics

Clinical Enterprise

Pharmacy and Nursing

Intravenous Therapy

Clinical Effectiveness & Performance Improvement

Clinical Utilization Evaluation

Blood Conservation and Management

Medical Records and Forms

Emergency Preparedness

CPR

Information Technology & EPIC

Infectious Disease

Care Management

Research Review

Trauma

Children’s Miracle Network

Service Line Team

CME

Volume Accommodation Committee

Operative Services

Core Capital Committee

Devised 3/98 Revised 6/07

Safety and Quality Agenda: Key to Success (FORCES 6 and 7) Emphasis on a culture that creates a demand for quality and safety leads to workflow improvements and improved outcomes. The Nursing Performance Improvement Plan involves direct-care providers to validate the level of quality patient care provided (OP:13:D). Utilizing highly reliable processes to identify issues

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and develop action plans is part of our culture. At Geisinger Medical Center, we focus on quality and safety everyday as we strive for perfect patient care delivery. The strategic initiatives for safety and quality are: • Striving for perfection in all we do (the mantra of the system’s Vision for the Second Century) • unit-specific initiatives that constantly “raise the bar” • a nursing practice that is grounded in evidence-based research and best practice strategies • active participation in the configurations of nursing documentation forms in the EPIC electronic health record (EHR) • reconfiguring nursing workflow to leverage the strengths of Geisinger’s fully integrated EHR • continued review of the National Database of Nursing Quality Indicators (NDNQI) and benchmarking results.

OP:13:D NURSING PERFORMANCE IMPROVEMENT PLAN NURSING SERVICE QUALITY PERFORMANCE IMPROVEMENT PLAN 2007 PURPOSE The Chief Nursing Officer (CNO) works in collaboration with the Vice Presidents of Service Lines and Associate Vice Presidents of Nursing, Operations Managers, Clinical Coordinators, Clinical Nurse Educators, and Administrative Supervisors to continually evaluate quality and effectiveness of nursing care delivery, patient outcomes, and professional practice. The approach to the Nursing Service Quality Performance Improvement Plan incorporates the following elements: • Nursing representatives from inpatient and outpatient clinical areas with additional representation from various ancillary services • Ongoing nursing performance and focus on patient care and patient safety, including the reduction and prevention of medical errors and nosocomial infections, etc. • Compliance with all external regulatory bodies • Continuing education to nursing staff on performance improvement plans and implementation • Open two-way communication with nursing staff for avenues of improvement of patient care and safety of patients and employees. SCOPE OF SERVICE The Department of Nursing Service is responsible for all nursing practice for inpatient services at Geisinger Medical Center and Geisinger Danville based clinics. AIM STATEMENT All nursing departments have an ongoing and specific Performance Improvement Plan. Monthly performance improvement data is sent to the Chief Nursing Officer, Operations Managers, and Geisinger Medical Center Performance Improvement Committee.The ultimate responsibility relative to the optimal delivery of care in a cost-effective manner rests with the Geisinger Health System Board of Directors.The responsibility is delegated to the Geisinger Medical Center Performance Improvement Committee in accordance with the Medical Staff ’s Bylaws as approved by the Board of Directors. Overall responsibility for performance improvement activities in each department is assigned to the Operations Manager who oversees the Unit Performance Improvement Committee.The Nursing Clinical Practice Council and the Nursing Services Quality Performance Improvement Council (NSQPI Council) in collaboration with the CNO for the system, and operation managers evaluates policies and procedures to enhance the development of nursing practice. Measures of performance improvement include: • activities to enhance the practice and quality of nursing, such as nursing practice/NSQPI Council activities.

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• indicators used to monitor quality and effectiveness of actions as they relate to the representatives unit specific PI Plan. • measurement, analysis, and evaluation of the compliance with policy and procedures utilizing data to plan and implement process improvement activities within nursing services to enhance the delivery of patient care to improve patient outcomes through collaboration of all caregivers. • identified opportunities to enhance care providers’ knowledge utilizing clinical data gathered using performance improvement process to develop interventions to improve the quality of patient care. • communication of gathered, analyzed, and trended data to a variety of sources; i.e., CNO, operation managers, Clinical Practice Councils, Geisinger Medical Center Performance Improvement Committee, Infection Control, and caregivers at the unit level, making recommendations for practice change based on data findings in conjunction with applying NSQPI tools. PERFORMANCE IMPROVEMENT ACTIVITIES Data collection is from a variety of sources including, but not limited to: • EHR/Medical records • patient satisfaction scores • evidence-based practice outcomes • regulatory guidelines • direct observation. All activities follow the current organizational Performance Improvement format for identifying, prioritizing, and studying a potential Performance Improvement concern. MONITORING/EVALUATION/REPORTING/ACTION RESPONSIBILITIES • Frequency: Continuous Focus • Data Collection: Unit-Based Performance Improvement Committee • Data Submitted to: Unit Operations Manager, CNO, and Performance Improvement Coordinator. • Performance Improvement Coordinator summarizes patient unit reports and this report is submitted to CNO who presents it to the Medical Executive Committee. • CNO responsible to review and recommend further study or changes as necessary. • Nursing Service Quality Performance Improvement Plan is reviewed annually by the NSQPI Council.

Geisinger’s Nursing Department is in a unique position to be a leader in conducting nursing research in a rural area. The Geisinger Center for Health Research, located on the GMC campus, provides great opportunities for nursing. The Center for Nursing Excellence was initiated this past year with the recruitment of a doctoral-prepared (PhD) nurse researcher, Adele Spegman. Dr. Spegman earned her BSN in nursing from Niagara University, School of Nursing (Niagara, NY), her MS from the University of Minnesota School of Nursing (Minneapolis), and her PhD from Oregon Health Science University School of Nursing. Working with the center’s scientists and clinical leaders, Dr. Spegman will research best nursing practices and measure outcomes in near real-time using our electronic health record (EHR). Some of her key goals are fostering nursing interest in research, providing research mentorship, and assembling a team of nurses that can support and encourage the pursuit of nursing research. Continuing to improve nursing practice, improving patient outcomes, and establishing new knowledge around nursing care that can be adopted nationally are some of the primary objectives of this nursing research program.

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Educational Partnerships and Collaborations (FORCE 10 and FORCE 14) Nursing education has always been one of the cornerstones of Geisinger’s rich nursing history. The Geisinger School of Nursing graduated its first class of diploma nurses in 1918 and continued to successfully educate and train new nurses until 1998 when the school closed its doors. When the national nursing shortage became apparent at the turn of this century, our Nursing Leadership Team began to seek out innovative options to address this worrisome trend. In 2004, nursing education was again offered onsite at GMC through a partnership with Thomas Jefferson University. This partnership created an Associate of Science in Nursing degree program with ongoing education opportunities that drive graduates toward a Bachelor’s degree. The first class graduated in May 2006. The program’s graduate nurses are already joining the ranks of Geisinger Medical Center and our other two hospitals and outpatient clinics, contributing to the success of our recruitment efforts. They also work in non-Geisinger hospitals and practices. GMC is the regional leader in continuing education activities and programs for nurses. Geisinger has the human and financial resources to engage Geisinger nurse experts in a variety of specialties to provide practice updates for nurses throughout the surrounding communities. Key strategies to continue our commitment to the education of future nurses include: • “grow our own” employees (plant the seed for our future bedside nurses) • continued support for the Career Enhancement Program (CEP) for direct-care nurses • celebration of the new CRNA program opening (the program was developed in partnership with Bloomsburg University) • expansion of the partnership with Thomas Jefferson University to increase the number of our nurses who are engaged in their online BSN and doctoral programs.

Geisinger Nursing Image (FORCE 12) GMC is committed to improving the health of the residents in the communities we serve. Professional nurses lead educational sessions on campus and in community settings. These sessions are focused on addressing the health needs of patients and their families. We are committed to promoting and improving the image of nursing in multiple community settings. Current and future strategies related to the image of nursing include: • using the “pediatric model” of family-centered care to increase the involvement of our patients and families in the care we provide • increasing our clinical leaders’ involvement in professional organizations • increasing the cultural and diversity competence through education and work environment standards • increasing bedside-care providers’ participation in physical and emotional wellness programs • developing valuable roles for highly experienced nurses who can no longer work at the bedside so that they remain active in our workforce.

NURSING PRIORITIES FOR THE FUTURE Geisinger Medical Center has many priorities for the future of nursing. CNO Sue Hallick has collaborated with several nurses and nursing councils to formulate a vision for the future and has disseminated this

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vision throughout the organization. Nurses are actively engaged in the journey to achieve and maintain Magnet certification. The priorities for this nursing vision are: • Nursing Quality Agenda—identified as Striving for Perfection in all aspects of care delivery, patient and family satisfaction, best clinical outcomes, documentation, and ongoing regulatory compliance • Patient safety embedded in our culture • Centers of Excellence of Nursing Care—highly reliable quality processes, a quality forum via Magnet certification, and nursing research • Development of the Center for Nursing Excellence within the Geisinger Center for Health Research with the successful recruitment of the new doctoral-prepared researcher, Dr. Adele Spegman • Nursing staff retention through an environment geared toward recognizing and enhancing the professional nurse’s role; nursing participation in enriching the nursing work environment through communication, collaboration, and councils that actively solve problems • The economic value of nursing defined through the use of outcomes data, optimizing the EHR’s rich data capabilities • Innovative nursing compensation strategies • Clinical partnerships to enhance nursing education and patient care, such as the Certified Registered Nurse Practitioner (CRNP) and Doctor of Nursing Practice (DNP) programs in partnership with Thomas Jefferson University and the Certified Registered Nurse Anesthetist (CRNA) program with Bloomsburg University. EVIDENCE 13: SOURCES OF EVIDENCE OP:13:A

Nursing Department: Mission,Vision, Conceptual Model, and Philosophy, Purpose, and Function

Policy 100

OP:13:B

PCM—Employment Criteria for Nursing Department Personnel Policy 200

OP:13:C

Shared Governance Structure

OP:13:D

Nursing Performance Improvement Plan

Policy 100a

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EVIDENCE 13—PART B: ORGANIZATION Mission, vision, strategic plan, priorities report, and performance improvement plan of the organization.

eisinger Medical Center (GMC) is part of an integrated health system known as Geisinger Health System (GHS). Therefore, the Geisinger Health System’s mission, vision, strategic plan, priorities report, and performance improvement plan apply to GMC.

ORGANIZATIONAL MISSION To enhance the quality of life through an integrated health service organization based on a balanced program of patient care, education, research, and community service.

ORGANIZATIONAL VISION FOR THE SECOND CENTURY As Geisinger expands its vision for the next century, its core guiding themes remain as important as ever. These themes are: • Quality—providing superb care uniformly across the organization • Value—providing care where and when it is needed, efficiently and effectively • Partnerships—collaborating with other providers, businesses, and educational institutions • Advocacy—championing causes for improving rural health.

ORGANIZATIONAL STRATEGIC PLAN AND PRIORITIES REPORT Strategic Priorities Four major programmatic areas were identified when Dr. Steele joined GMC as president and CEO. These initial five-year strategic priorities were: • understanding and developing the clinical market • integrating multispecialty clinical services into system-wide service lines • expanding education, research, and advocacy (with links to the clinical programs) • developing entrepreneurial venture products. In each of these areas, “road maps” (work plan models outlining specific goals and objectives) were developed. With a completion timeline and assigned responsibilities, these road maps were used as a mechanism to track progress. They were developed in concert with the system’s five-year strategic plan, the rolling five-year financial model, annual operating and capital budgets, and the master facilities plan. Having successfully completed its initial programmatic goals, Geisinger has now identified strategic themes for the next five years: • Geisinger Quality—Striving for Perfection Striving for perfection will drive every action, decision, and strategic initiative. Striving for perfection is the responsibility of every Geisinger Health System family member. Geisinger will provide the highest quality continuum of care with complete focus on each patient. • Expanding the Clinical Market Geisinger’s clinical market strategy centers on program development, market expansion, and

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•

collaborative opportunities predicated on reproducing and disseminating Geisinger Quality across a wide, geographic region. We will bring Geisinger Quality close to where patients live and work. Innovation Geisinger’s commitment to innovation and remaining at the leading edge centers around five main areas: patient care, research, education, technology, and ventures. – Patient care innovation enlists and empowers patients as key participants in their healthcare and capitalizes on technology to extend care into patient homes. MyGeisinger (the patient’s Internet access to their EHR) gives patients secure, convenient online access to their health records and management tools. Users can view portions of their electronic health record (such as lab results, medication lists), access health and fitness information, and communicate with their doctor’s office for prescription renewals, appointment requests, and medical advice for nonurgent questions and concerns. – Geisinger is a national leader in the use of health information technology. A model of seamless delivery of electronic information across a large, geographically diverse region, the electronic health record is in place in all outpatient settings. Inpatient implementation was completed in late 2007. Along with regional partners, Geisinger has formed the Central Pennsylvania Health Information Collaborative, a Regional Health Information Organization (RHIO). This initiative works to electronically connect regional healthcare professionals with information needed to provide the best care for their patients. – Geisinger Ventures is the business arm that leverages Geisinger’s innovations in health services, research, and technology. Geisinger Ventures assesses business opportunities, initiates funding, and facilitates venture start-ups, generating sources of capital for Geisinger’s goal of providing quality patient care. Securing the Legacy In order to recruit and retain the best employees now and in the future, Geisinger must provide career opportunities that recognize the value of every individual’s work and career growth path. Training and mentoring physicians, residents, medical students, nurses, technicians, pharmacists, administrative leaders, and support staff will provide a pipeline for our success.

Priorities Report Geisinger Medical Center’s priorities report is also drawn from Geisinger Health System’s priorities report. Geisinger Health System Foundation is a 501(c)(3) not-for-profit corporation that coordinates and supervises the activities of all the system’s affiliated entities. The foundation is not a licensed healthcare provider nor does it provide healthcare services to patients. It serves to ensure that system-affiliated entities have adequate financial resources to fulfill their missions and to initiate and administer grant and philanthropic support for all Geisinger entities. Geisinger’s core programs consist of complementary components: • Geisinger Medical Center (GMC)—a 404-bed tertiary and quaternary teaching hospital located in Danville (Pa.) and the GMC Outpatient Surgery Center located on Woodbine Lane • Geisinger Clinic—a multiple specialty physician group practice that includes approximately 670 employees; more than 200 of these are primary care physicians; Geisinger physicians practice in

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more than 75 specialties, with community clinic sites totaling nearly 40 • Geisinger Health Plan—one of the largest rural, managed-care companies in the country (approximately 215,000 members) • Geisinger Wyoming Valley Medical Center—a 177-bed community hospital and secondary referral center in Wilkes-Barre (Pa.) • Geisinger South—Wilkes-Barre—a 176-bed community hospital with 20 skilled nursing beds and a 10-bed adolescent psychiatric unit (new to the system in late 2005) • Marworth Alcohol and Chemical Dependency Treatment Center (Waverly, PA)—with 91 inpatient and outpatient beds, Marworth is recognized as a national leader in addiction medicine. More than 1.5 million outpatients are seen at Geisinger Health System facilities each year. Of this total, more than one third are seen at GMC outpatient clinics (during fiscal year 2007: July 1, 2006 to June 30, 2007). More than 36,000 inpatients were discharged system-wide; more than 22,000 discharges were from GMC. Geisinger delivers more than 2,400 babies each year; approximately 65 percent of these babies are delivered at GMC. The system performs more than 31,000 surgeries annually; more than 20,000 are performed at GMC. More than 80,000 patients are seen annually in one of our Emergency Departments (ED); nearly 38,000 of these are seen at GMC’s ED. Finally, more than 2,500 patients are transported by one of our five air ambulances (Life Flight); nearly 70 percent of these are transported to GMC. Geisinger is the largest employer in Danville. Staff recruitment, training, mentoring, and retention of quality employees are priorities. In FY05, Geisinger Health System employees (by FTE) totaled more than 8,196, including 580 physicians/scientists. The following year, FTE count rose to 9,243, including 610 physicians/scientists. That total represents more than 11,000 employees (by head count). The system currently has more than 12,000 employees. GMC PERFORMANCE IMPROVEMENT MANUAL AND PLAN PURPOSE To continuously improve the performance of important functions, processes, and outcomes through measurement and evaluation using current performance improvement models.This is in concert with Geisinger’s mission to enhance quality of life through an integrated health-service organization based on a balanced program of patient care education, research, and community service. It is also supportive of Geisinger’s commitment to the pursuit of high quality care and the welfare and safety of our patients, employees, medical staff, and visitors. OBJECTIVES Performance improvement To take a proactive approach to improve the organization’s performance and focus on improved patient care and patient safety, including the reduction and prevention of medical errors. • To assure improvement in systems in order to improve processes and patient outcomes. • To promote a collaborative and interdisciplinary approach to improving performance through the annual development of a Performance Improvement Work Plan. • To integrate performance improvement patient safety and risk management activities throughout Geisinger Medical Center. • To identify (via data collection and analysis) practice patterns, risk assessment, and other activities in order to improve performance and patient outcomes. • To evaluate the effectiveness of the Performance Improvement Program and all of its components.

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• To promote/support a Patient Safety Program throughout Geisinger Medical Center. • To promote quality care along a continuum. • To assure compliance with all external regulatory bodies. Service Coordination • To provide one uniform level of care regardless of race, color, creed, and the ability to pay for service. • To advocate patient rights and responsibilities. Quality Education • To relate results of performance improvement, patient safety, and risk management activities to educational programs. • To facilitate communication among healthcare providers. Risk Management • To provide systems that enable management to identify and evaluate risks to patients and visitors. • To continuously measure outcomes to determine priorities for improving systems and processes as related to patient safety and medical error reduction. • To promote the four step risk management process. PERFORMANCE IMPROVEMENT PROGRAM STRUCTURE Scope The Performance Improvement Program is an ongoing, well-defined, written plan designed to objectively and systematically measure and evaluate the care provided in both clinical and administrative departments and services. In addition, the Performance Improvement Program, demonstrated by the integration of risk management, patient safety, and performance improvement, eliminates (or mitigates) the potential for clinical risk, medical errors, and variation in patient care while promoting best practices, safe patient care, optimal clinical outcomes, and organizational efficiencies. Overall responsibility for all performance improvement activities in each department and specialty is assigned to the unit director and/or operations manager.This individual may delegate monitoring and evaluating activities but is ultimately responsible for the department’s Performance Improvement Program. Conflict of Interest No one involved in performance improvement activities shall review any cases in which that person was professionally involved or has fiduciary interest as defined by the Social Security Administration. Plan The activities of the Geisinger Medical Center Regulatory Performance Improvement Department that promote and/or enhance performance improvement and promote process reliability throughout the organization include, but are not limited to: • assisting in the design/redesign, measurement, assessment, and implementation of performance improvement activities. • reviewing performance improvement activities from all departments/services and making recommendations as appropriate. • supporting the Community Practice Service Line Performance Improvement (PI) Plan. • integrating performance improvement information throughout the organization. • coordinating follow-up on reports of external review bodies (for example: Joint Commission, Department of Health). • educating personnel in the performance improvement process. • educating medical staff in the performance improvement process and risk management process. • serving as a resource to healthcare providers. • reporting unresolved issues and opportunities for improvement to the Performance Improvement Committee. • assisting with developing and/or modifying forms and hospital policies, as appropriate.

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• preparing summaries of information that will assist in identifying opportunities for performance improvement. • preparing summary reports of performance improvement activities. • conducting tracer readiness Joint Commission/DOH surveys. • serving as staff for the Performance Improvement Committee. • designing and conducting studies as necessary and/or as requested. • performing focused, concurrent reviews as necessary and/or as requested. • coordinating performance improvement annual evaluations, committee structures, and performance improvement plans. • performing medical record reviews for the Medical Record and Procedure Committee. Confidentiality All data, reports, and minutes used to measure the performance of care provided by the medical staff and/or other healthcare providers is considered confidential information and is only communicated on a “need to know” basis. All performance improvement/peer review activities, data, information, discussions, and reports related to the Performance Improvement Program and Plan are protected as profiled in the following statement: PEER REVIEW GENERATED DOCUMENT SOLELY FOR THE QUALITY IMPROVEMENT PURPOSES PURSUANT TO 63 P.S. 425.1 ET SEQ. NOT FOR REDISTRIBUTION OUTSIDE THE SYSTEM’S PEER REVIEW COMMITTEE. Evaluation and Reporting • All medical staff committees, hospital departments, and hospital-wide committees direct performance improvement activity information to the Regulatory Performance Improvement Department of the Geisinger Medical Center for review. • The Chief Medical Officer presents the quarterly reports to the Medical Executive Committee (the CNO is a member) and the Board of Directors. • Incidents and issues placing patients, families, employees, and visitors at risk are reported every month to the Safety Committee, identifying actions taken that may have an impact on safety management. • The Regulatory Performance Improvement Department and the Infection Control Committee report monthly to the Safety Committee, identifying safety management issues. • Each patient unit, ancillary department, and medical staff section evaluates its Performance Improvement Plan annually and submits a written evaluation to the Regulatory Performance Improvement Department. • The Regulatory Performance Improvement Department submits the written evaluations from patient units, ancillary departments, and medical staff departments to the Performance Improvement Committee.The Chief Medical Officer submits the written evaluations to the Medical Executive Committee and Board of Directors. • The Performance Improvement Program for the Geisinger Medical Center and Geisinger Hospital-Based Clinic is evaluated for effectiveness on an annual basis by the Regulatory Performance Improvement Department in conjunction with the Performance Improvement Committee and is submitted to the Medical Executive Committee and Board of Directors via the Chief Medical Officer. • The Performance Improvement Program is reviewed and/or revised annually by the Regulatory Performance Improvement Department and the Performance Improvement Committee and submitted to the Medical Executive Committee and the Board of Directors via the Chief Medical Officer. The effectiveness of educational programs and inservice programs is reflected in employee performance evaluations. Reviewed 4/07

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EVIDENCE 14 Theoretical/practical framework(s) stylized within the nursing services that structure various aspects of professional practice (e.g., patient care, nursing research, staff development, and performance evaluation and improvement) and performance.

t Geisinger Medical Center (GMC), we care for patients with various levels of complex health problems across their lifespan. A theoretical/conceptual framework guides movement through the nursing process in an organized manner in complex practice settings. Roy’s Adaptation Model provides the primary structure we follow to organize, analyze, and plan patient care decisions and interventions. In addition, the Concept of Caring, which is associated with Jean Watson’s Theory of Human Caring, provides an additional value element to our professional nursing practice. The theoretical/conceptual framework of the Department of Nursing at Geisinger Medical Center is depicted here. Geisinger Medical Center Nursing Conceptual Model

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The patient, which is represented as the center circle, is the center of our nursing theoretical/conceptual model. The overlapping circles surrounding the patient in the center of the figure demonstrate the interrelatedness of the four elements of the Nursing Paradigm: nurse, patient, health, and environment. These elements in reference to our conceptual framework are integrated into our nursing actions (via job descriptions and evaluations, assessments, etc.) and influence behavior and performance. The key components of the Nursing Department’s vision are Quality, Securing the Legacy, Innovation, and Market Growth. They are vital to achieving the system’s mission and the nursing mission. The Nursing Department’s mission affirms the Geisinger organizational mission and incorporates the same terminology, but translates the terms into nursing action elements: nursing practice, nursing education, nursing research, and nurses in service to our communities. The diamond surrounding the mission and values in the figure are bordered by terms representing these concepts: Heal. Teach. Discover. Serve. Our goal is to be the leader in each of these elements. This vision, therefore, is central to the aim of the nursing councils. The vision is actualized by the practice and performance of the nursing councils and their constituents (the nursing staff ). The Nursing Department also has shared governance nursing councils (OP:13:C, page XXXX) that use adaptation and caring principles to analyze, plan, organize, and evaluate nursing action to achieve the organizational and departmental vision and mission. Comprised of staff nurses, nurse educators, and nurse managers, the councils are the infrastructure for the Nursing Department. They strive to guide nurse performance and evaluate the outcomes of patient care to attain or maintain the highest level of quality patient care and ultimately achieve our mission. The outer aspect of the figure is framed with the words “Adaptation” and “Caring.” These themes are the concepts that provide the foundation for everything we do in nursing services. GMC, as part of a larger healthcare system, promotes nurse adaptation and nurses (in collaboration with the healthcare team) promote adaptation of the patient. Nursing practice and performance focus attention on assisting patients to increase adaptive responses and decrease ineffective responses in a constantly changing environment. We help patients achieve the maximum outcomes for their particular state of being. Caring is emphasized to highlight the uniqueness of the nurse-patient relationship and interdependence of the human-tohuman interaction.

USE OF ADAPTATION MODEL IN PATIENT CARE Determining the theoretical/conceptual framework applicable to the Nursing Department in a large rural tertiary/quaternary medical center is a challenging and exciting task. As with many other large institutions, nursing care at GMC occurs in diverse settings with various types of patients in differing degrees of health. The organization’s complexity, the comprehensiveness of the overall mission, and the various nursing care providers add to the difficulty of determining one theoretical/conceptual framework stylized within the entire nursing services. GMC continues to incorporate the theoretical/conceptual framework used systemwide into the overall nursing practice throughout the GMC organization. Sister Callista Roy signed a poster of our conceptual model! A group of GMC nurses met Sister Callista Roy at the Eastern Nursing Research Society’s annual conference in April 2007. The nurses contacted Sister

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Roy before the conference, sent her a copy of their model, and then met with her at the conference. The nurses were excited to talk to Sister Roy about how the adaptation model was selected and how it fit with Geisinger. They were also able to ask Sister Roy some questions regarding the implementation of the model. The nurses came back charged with excitement having met the author of the model they chose. A couple of the nurses also had taken one of Sister Roy’s books, The Roy Adaptation Model, to be autographed. After returning to Geisinger, they gave one of the copies to the CNO to be held in care for the Nursing Department.

The Process Begins The process began with our nurses. We gathered a group of nurses to review and discuss several primary nursing conceptual models and theories to find compatibility with our values. The group’s first response was to develop a synergy model that responded to the pluralism of models practiced by individual nurses. The intent was to identify the conceptual model/theory most congruent with general nursing practice throughout the organization. The selection of models was narrowed down and then discussed with several groups of nurses in our nurse councils. Roy’s Adaptation Model was chosen as the best fit. Our view of each of the elements of the Nursing Metaparadigm as that they correlate to Roy’s model are described as follows: • Patient is a holistic view of the individual, group, or community as a bio-psycho-social-culturalspiritual adaptive system. • Environment of the “person” consists of internal and external factors that are constantly interacting and changing. • Health occurs on a continuum, from peak wellness to death, and is viewed as a state of being and becoming an integrated, whole person even with the end-of-life stage. • Nursing is skilled, knowledgeable, caring human interaction to promote adaptation of the person to one’s environment. Consistent with Roy’s Adaptation Model, the goal of GMC’s nursing practice is to increase the person’s adaptive responses and decrease ineffective responses in an effort to promote an optimal state of being or becoming. All aspects of nursing practice focus on the individual as a bio-psycho-social-cultural-spiritual adaptive system. Adaptive responses are responses to the internal or external stimuli that promote survival, growth, reproduction, and mastery of human responses for healing to occur. Ineffective responses are those responses that do not promote adaptive responses to internal and external stimuli. Nursing interventions are planned in conjunction with the patient and their significant others to promote an interdependent relationship and achievement of positive patient outcomes. The use of Roy’s Adaptation Model in practice is well documented in the literature. It has been shown to guide nursing practice in patients of all ages in a multitude of practice settings. According to Roy’s Adaptation Model, the focus of nursing is on the adaptive system (individual, group, or community) responses to a constantly changing environment. The nurse and the environment produce the stimuli that can be modified to promote patient adaptation. If the stimuli are too high or a patient’s adaptive mechanisms are too low, then behavioral responses are ineffective for coping. With the interdependence mode of Roy’s model, nursing action is required when “problems in adaptation arise when the adaptive system is unable to cope with or respond to constantly changing stimuli from the internal and external

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environments in a manner that maintains integrity of the system” (Andrews and Roy, 1991; Roy, 1989). Geisinger’s professional nursing staff works to adjust the stimuli (modify the internal and external environment) and/or assist patients in adjusting their level and ability for effective coping and adaptation.

Core Elements The core elements of the mission and vision of the Nursing Department are consistent with the system’s five-year vision, adapted to nursing. They are evident in all aspects of nursing practice: • Quality refers to nursing practice • Securing the Legacy refers to the education of our patients (and their significant others) and ourselves, an integral aspect of practice • Innovation substantiates the use of research utilization and evidence-based research, the foundation of our practice • Market Growth refers to outreach services to our surrounding communities to ultimately meet our community’s patient care needs. These core elements are incorporated into nursing practice anywhere there is a recipient: an individual, a group, or a community. In addition, it occurs whether the recipient is well or sick. For example, in the inpatient areas, the recipient is already sick. Maladaptive responses by the person to the internal and external environment have resulted in the need for hospitalization. In contrast, in outpatient areas, the person may be seeking preventive or screening services to increase adaptive responses to maintain an optimal state of being. Preventive and screening intervention often reduces the amount of adaptive/coping responses required. However, most outpatient areas also provide care for patients suffering acute or chronic illnesses. In these cases, the person is experiencing suboptimal coping responses to changing or stressful environments and requires interventions aimed at restoring or achieving an optimal level of health. The influential role of General Systems Theory was significant in the development of Roy’s Adaptation Model. This aspect increased the compatibility of Roy’s model with GMC’s nursing practice, which focused heavily on a systems approach. Furthermore, the documentation tools at GMC use a systems approach for needs identification, data collection, and plan of care development.

ROY’S MODEL AND THE GMC NURSING PROCESS The review group determined that the specific nursing process detailed by Roy is most consistent with the nursing process used at GMC. The nursing process, according to Roy, contains six elements: “assessment of behavior, assessment of stimuli, nursing diagnosis, goal setting, intervention, and evaluation” (Fawcett, 1995). At GMC, the nursing process contains five elements: assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment includes both internal and external stimuli and behaviors in addition to body systems. The professional nurse gathers and organizes person-, individual-, or group-/family-specific data during the firstlevel assessment phase. The documentation tools most commonly used are the admission database and the nursing flow sheet. For example, we assess fluid and electrolyte balance and neurological function associated with regulator activity, and we assess the emotional status and ability to learn included in cognator activity. Body image and sense of self, which are encompassed in the self-concept mode, are determined through

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interaction with the patient and family. When actual or potential issues in any of these areas are identified, intervention occurs. As a tertiary/quaternary medical center, most assessment activities at GMC are focused on first priority needs. According to Roy’s Adaptation Model, the first priority is behaviors that threaten survival. In most of the inpatient and outpatient settings at GMC, these survival needs are primarily physiological and psychological needs encompassed in the bio-psycho-social-cultural components. In some instances, assessment of other priorities identified by Roy (growth, reproduction, mastery) is included in the secondlevel assessment and action. Second-level assessment is also accomplished by means of direct observation and interview techniques. It is evaluated by equipment that measures physiologic parameters that are consistent with the adaptation model. The person is involved in the assessment of the responses to the environment, whenever possible. The next steps of the nursing process in relation to Roy’s model include nursing diagnosis and planning. These steps occur simultaneously as the nursing care plan is developed. Nurses use professional judgment to process assessment data to describe the person’s adaptation status or develop a nursing diagnosis. When determined, the plan of action is developed. The indicators of positive or negative adaptation used by Roy’s model were found to be consistent in our practice. Roy believes in planned nursing action in conjunction with patients, especially in addressing the interdependence mode. When possible, the patient is included in the planning of care. We plan actions and interventions in conjunction with the patient and the significant other, aimed at increasing positive adaptive responses by the patient. The development of open visitation in GMC’s Adult Intensive Care Unit is an example of the interdependence mode. Patients and their significant others were surveyed regarding their desires related to visitation. Research, in conjunction with patient input, was used to change nursing practice. In GMC’s Children’s Hospital, the patient and significant others (parents) are included in planning actions and interventions. The remaining steps, nursing intervention and evaluation, are interrelated as well as we move through the nursing process. As nursing intervention occurs, the nurse evaluates the effectiveness of each intervention and determines if an adjustment is needed. Evaluation, in turn, leads to assessment in an effort to determine the patient’s responses. The nursing process is a continuous and fluid cycle.

AN INTEGRATED PROFESSIONAL NURSING PRACTICE The theories associated with Roy’s Adaptation Model—the person as an adaptive system, the physiological mode, the self-concept mode, the role function mode, and the interdependence mode—are congruent with our professional nursing practice. For example, the theory of adaptation is applied when nursing interventions effectively change ineffective responses to adaptive responses or when adaptive responses remain positive. The theory of the physiological mode is to consistently assess and plan nursing intervention developed to assist each patient to reach their highest level of functioning. The self-concept theory applies to nursing intervention and evaluation related to the patient’s body image, growth, morale, and spiritual and ethical aspects of patient care. For the theory of role function, “nurses assist the patient to achieve the appropriate role function” (Fawcett, 1995).

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Lastly, related to the theory of interdependence, nurses assess and include the patient and significant others (family or community) in the plan of care. From review of the literature describing the utility of Roy’s intervention and evaluation in practice, GMC’s professional nursing practice is consistent with practice supported by the adaptation model. All of these elements are integrated in our professional nursing practice and evaluation of patient outcomes.

Applying the Physiological Mode The physiological mode is applied in professional nursing practice throughout the organization. The nursing process is used on an ongoing basis to assess, plan, implement, and evaluate the patient’s physiologic status. As a tertiary/quaternary care medical center, the initial focus of GMC’s nursing is often on physiological integrity. Many nursing interventions are aimed at helping patients meet their physiologic needs. For example, the need for oxygenation is met by administering oxygen when needed; helping the patient to eat or providing enteral feedings to meet nutritional needs; repositioning the patient when needed or assisting in ambulation to improve mobility and activity; and keeping the patient safe, enabling them to rest. The selfconcept mode is incorporated into assessment and interactions. For example, if a chaplain is needed to support the spiritual needs of a patient and significant other, one is called to assist them. The role function and interdependence theories are addressed by engaging the patient in conversations about his or her family, job, or personal interests.

THEORY OF HUMAN CARING An additional key element incorporated into professional nursing practice and the theoretical/conceptual framework is associated with the Theory of Human Caring developed by Jean Watson. Caring beliefs are widely held and applied by the nursing staff. Watson’s Theory of Human Caring focuses on the concepts of caring and caring behaviors as the “core of nursing” (Watson in Parker, 2001). Watson further asserts that caring processes, referred to as clinical caritas, extend beyond the science of nursing to include the art of genuine human-to-human interaction. Watson draws on themes from the history of nursing: The future of nursing is ironically tied to Nightingale’s sense of “calling,” guided by a deep sense of commitment and a covenantal ethic of human service; cherishing our phenomena, our subject matter, and those we serve . . . it is more than just a job, it is a career for a lifetime of growth and learning. (Watson in Parker, 2001, p. 345.) Nursing history also impacted the original assumptions associated with Watson’s theory. These assumptions are: • View of the human person as a valued person in and of himself or herself to be cared for, respected, nurtured, understood, and assisted; in general, a philosophical view of a person as a fully-functional integrated self (the human is viewed as greater than and different from the sum of his or her parts) • Emphasis on the human relationship and transaction between persons and their environment and how they affect health and healing in a broad sense • Emphasis on the human-to-human care transaction between the nurse and the person and how it affects health and healing in a broad sense • Emphasis on the nonmedical processes of human care and the nurse’s caring for persons with various health/illness experiences

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• •

Concern for health; the promotion of health and well-being Position that nursing human care knowledge is distinct from, but complementary to, medical knowledge (Watson, 1988). The incorporation of Watson’s theory is important for current professional nursing practice because it is based on the idea that nursing care is not only about administering medications or providing various treatments, which are dependent nursing functions, but also that nursing is a profession concerned with the recipient of these interventions as a unique human being. A transpersonal caring relationship occurs between a nurse and patient as they connect and harness both physical and spiritual healing energies (Watson, 2001). Watson’s “caring moment or occasion” refers to the unique relationship between a nurse and a patient that opens the possibilities for healing and human connection beyond basic physical interaction (Watson, 2001). We believe compassionate (transpersonal) caring is inherent in the professional practice of nursing. We strive to develop authentic caring relationships during our patient interactions. Whether occurring in a brief moment or in an extended relationship, we convey our human interest and commitment to providing the best patient care possible, keeping in mind each person’s uniqueness.

ADAPTATION AND CARING CONCEPTS IN RESEARCH UTILIZATION AND NURSING RESEARCH One element of Geisinger’s vision and mission is “Quality” through research utilization and research. The use of the Adaptation Model and the Theory of Human Caring in nursing research is well established in the literature. For example, the Adaptation Model was used by Hammer (1989); Doyle and Rajacich (1991); Rogers, Jones-Paul, Clark, Cackay, Potter, and Ward (1991); Thornbury and King (1992); Chiou (2000); Araich (2001); and Whittemore and Roy (2002). In addition, Watson’s Human Caring Theory was used in nursing research by McNamara (1995), Watson (1997), Fawcett (2002), Malinski (2002), Bernick (2004), and Smith (2004). Hence, it has been demonstrated that both frameworks have been useful in supporting nursing practice through nursing research. Geisinger Medical Center’s Nursing Clinical Practice Council uses evidence-based research as the foundation for its policies and procedures. The online policies and procedures serve as a great resource for nurses as the basis of their practice. Support for involvement in nursing research is evident in the development of the Center for Nursing Excellence with nursing at the forefront of the Geisinger research agenda. There is also a large presence of nurses that function as nursing research coordinators who facilitate research at GMC. Their presence on the nursing units and their interactions with nursing colleagues increases the awareness of Geisinger’s commitment to research. In addition, the Nursing Research Council’s commitment to improving the understanding and utilization of nursing research in practice remains strong. This council has sponsored several educational programs to expand the understanding of evidence-based nursing practice and research utilization. For example, one of the larger programs (in October 2007) was cosponsored with the clinical research coordinators and was attended by interested nurses from across the region. Another program, held during Nurses Week (May 2007), highlighted evidence-based practice related to diabetes. The Nursing Research Council continues to promote the use of Roy’s Adaptation Model and Watson’s Human Caring Theory as the basis for nursing research and includes them in proposals. QUA L IT Y • SECUR I NG THE LEGAC Y • INNO VATIO N

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The future is bright for the growth of nursing research at GMC, especially with the addition of the Center for Nursing Excellence led by a PhD nurse researcher, Dr. Adele Spegmen.

USE OF ADAPTATION AND CARING MODELS IN STAFF DEVELOPMENT The Nursing Department as an entity is seen as an adaptive system with each individual in the system having adaptive and coping abilities. The goal of staff development, through formal and informal education, is to enhance each member’s own adaptive and coping abilities and abilities to form therapeutic, caring nurse-patient relationships. The effectiveness of the Nursing Department in adapting to internal and external environmental stimuli is influenced by the combined adaptive responses of each member. Developing the individual staff member’s ability to grow and develop in a unique way and and the staff ’s ability to develop relationship skills with each other is an essential investment in achieving quality patient care. A major stressor for a staff nurse is a perceived (or actual) lack of knowledge about patient care requirements, which may impact the nurse’s coping abilities or adaptive responses. We believe that the focus of staff development is to increase the staff ’s ability to adapt to the environment by arming them with the knowledge and skills necessary to provide optimal patient care. Increasing the staff ’s abilities includes personal and professional development as well as building their knowledge of how to assess the patient’s adaptive status and how to implement the right nursing interventions in a professional and caring manner. The primary benefit of a theoretical/conceptual model is that the framework helps the professional nurse to organize the information gained from assessment and observation, to think critically and analyze the data for priorities of care, to apply the appropriate nursing interventions, and to evaluate the effectiveness of care in accord with patient outcomes and evidence-based practice. Staff development activities help nurses adapt to changes in the environment. In turn, nurses promote patient adaptation. The element of staff development is an essential component of the Nursing Department’s and the organization’s vision and mission (Quality, Securing the Legacy, Innovation, and Market Growth). In the diagram on page XXX, these terms pertain to the educational activities for nurses, patients, and the community. However, in this section, the focus is on nursing education.

NURSING STAFF EDUCATION AND DEVELOPMENT In accordance with Roy’s Adaptation Model, the goal of staff development/educational activity is to increase the nursing staff ’s ability to adapt to a changing environment. The method of increasing the adaptive ability of each person is through formal or informal education. Change is constant; therefore, the need for new information and professional education is ever present. The CNO engages in and is supportive of staff education. She leads educational sessions with the Nursing Leadership Team to enable them to optimize their adaptation and performance. The CNO also looks for opportunities to communicate and educate staff nurses about the many issues facing the organization and the Nursing Department. Daily, the leadership team educates, coaches, and participates in problem-solving with staff regarding personal or professional issues. They also assist and encourage staff in formulating goals directed at professional development. Many universities in the area provide nurses with opportunities to pursue formal professional education (in addition to the informal education gleaned from the collegial and networking relationships developed with faculty from our nursing affiliates). QUA L IT Y • SECUR I NG THE LEGAC Y • INNO VATIO N

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The Shared Governance Nursing Councils provide an avenue for staff development. Through discussion and investigation, the council members improve the Nursing Department’s ability to adapt and move forward through problem solving and policy development and implementation. An additional benefit that comes from the council process is the person-to-person, professional-to-professional connection that occurs, which enlightens the members on the impact that changes have on each person and care team. The hope is that caritas behaviors toward each other, professional-to-professional, will be displayed. Most important in the staff development process is the education that occurs among staff members as they work side-by-side in the clinical arena. Some education is more formal, such as preceptoring. However, it is commonplace to see staff helping each other to better understand or learn to complete a task. Of course, the Nursing Education Department helps the staff develop their abilities to adapt to the environment. Clinical nurse educators, representatives of the Nursing Education Department, engage the staff both formally and informally in learning opportunities in classrooms and clinical settings. They teach a variety of topics, ranging from orientation to the department to advanced pathophysiology. In addition, these educators help the staff understand new policies, procedures, practices, or equipment changes. The clinical nurse educators have been instrumental in the successful implementation of the Electronic Health Record (EHR). Nurses and clinical leaders throughout the Nursing Department contribute to staff development by coaching, mentoring, and role modeling. Because of the complex practice setting and the comprehensiveness of patient issues, education focuses on one or more of Roy’s strategic priorities of survival, growth, reproduction, and mastery, depending on the audience. Educational activities at GMC relate to the first priority, survival of the adaptive systems (the patients). Therefore, education regarding the assessment of the person’s adaptive or maladaptive responses to the internal and external environment is essential. The primary focus of education is related to the biological, psychological, social, cultural, or spiritual aspect of the physiologic and self-concept modes. Aspects that address the role concept and interdependence modes are included in educational efforts. The professional nursing staff is taught assessment skills to recognize and analyze the person’s adaptive responses and the appropriate nursing interventions to help increase adaptive responses to the medical disease processes. Educational activities focus on helping the nurse to recognize pertinent data, organize and analyze the patient data to develop a plan for nursing interventions, or evaluate the effectiveness of the intervention. In addition, most educational activities include caring (caritas) behaviors required to increase the effectiveness of the interpersonal relationships. Geisinger offers its nurses numerous opportunities for staff development, including tuition assistance for formal and informal education, internal and external continuing education programs, and clinical affiliations. Throughout the 2007 calendar year, the Nursing Education and Continuing Medical Education Departments offered more than 600 continuing education programs. Five primary and about ten secondary clinical nursing affiliations provide opportunities for professional nurses to both teach and learn from the students.

PERFORMANCE EVALUATION AND IMPROVEMENT Performance improvement activities are noted on the GMC nursing theoretical/conceptual framework model. One of GMC’s primary nursing councils serves as the entity for performance evaluation and performance improvement. However, activities associated with performance evaluation and improvement QUA L IT Y • SECUR I NG THE LEGAC Y • INNO VATIO N

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occur in each of the other councils and nursing units as they move through the process to achieve their objectives. According to Roy’s Adaptation Model, the Nursing Department, as a collective whole, can be viewed as an adaptive system possessing combined abilities to adapt to the environment. Therefore, when we conduct a performance improvement audit or revise a policy or procedure, we are, in fact, evaluating the department’s performance to determine if we comply with established standards of care. We are assessing the professional nursing staff ’s ability to adapt to the healthcare environment’s demands. We are then able to plan and implement changes as needed to increase the adaptive responses to environmental stressors for all department members. The evaluation process and plan for improvement occurs in varying degrees in all of the councils as they address nursing practice, communication and retention, nursing research, and nursing management issues.

A CULTURE OF QUALITY A couple of years ago, GMC launched an initiative through a partnership with the Joint Commission to achieve a “Culture of Quality” on the GMC campus. The primary goal is to provide quality care for every patient who enters our institution. It involves continuously raising the bar for our performance expectations. A culture of quality requires more than periodic audits of performance; it requires ongoing process improvements and alertness by all caregivers. All stakeholders are responsible for continuous performance improvement. This process has expanded and is seen in the Striving for Perfection mantra set by the system’s second five-year vision and carried through to nursing. Thus, each of the primary councils (and unit-based councils) is responsible for performance evaluation. The Nursing Clinical Practice Council evaluates professional nursing practice. The Communication and Retention Council evaluates the effectiveness of recruitment and retention strategies. The Nursing Services Quality and Performance Improvement Council evaluates the adherence to regulatory stipulations and other nursing policies. The Nursing Research Council evaluates nursing research protocols and research utilization. The Administrative (Management) Council evaluates the effectiveness of operational practices. Members of the Administrative Council are also responsible for the formal annual performance evaluation of individual staff members. The formal performance appraisal process occurs annually for each employee. The management team, through direct observation and input from team members, completes an evaluation form and reviews it with the employee. The performance evaluation evaluates staff on core organizational and departmental concepts, such as service, teamwork, accountability, and safety. The effectiveness and proficiency with which a nurse assesses the adaptive state of a person, increases the person’s adaptive or coping responses, and performs nursing interventions is part of the job-specific competency. When the management team has identified the need for performance improvement, steps are outlined in a developmental action plan. Performance evaluation also occurs informally every day on every shift as experienced nurses supervise and assist novice coworkers. Many units have mechanisms—such as the Outstanding Employee Award given once a month on GMC’s AP5 unit or the Unit Employee of the Month on the BP6 unit—to allow staff to offer each other positive feedback about performance. Everyone plays a part in improving performance and recognizing each other for both positive and negative levels of performance and improvement. QUA L IT Y • SECUR I NG THE LEGAC Y • INNO VATIO N

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References Andrews, H.A., and Roy, C. (1991). Essentials of the Roy Adaptation Model. Norwalk, CT: AppletonCentury-Crofts. Araich, M. (2001). “Roy’s Adaptation Model: Demonstration of theory integration process into process of care in coronary care unit, ICUs, and Nursing.” Web Journal. July-October. Issue 7. Bernick, L. (2004). “Caring for Older Adults: Practice Guided by Watson’s Caring-Healing Model.” Nursing Science Quarterly, 17(2), 128-134. Chiou, C.P. (2000). “A Meta-analysis of the Interrelationships Between the Models in Roy’s Adaptation Model.” Nursing Science Quarterly, 13(3), 252-258. Doyle, R., and Rajacich, D. (1991). “The Roy Adaptation Model: Health Teaching About Osteoporosis.” American Association of Occupational Health Nursing Journal, 39, 508-512. Fawcett, J. (1995). Analysis and Evaluation of Conceptual Models of Nursing. 3rd ed. Philadelphia: F.A. Davis. Fawcett, J. (2002). “The Nurse Theorist: 21st Century Updates-Jean Watson.” Nursing Science Quarterly, 15(3), 214-219. Hamner, J.B. (1989). “Applying the Roy Adaptation Model to the CCU.” Critical Care Nurse, 9(3), 51-61. Malinski, V.M. (2002). “Developing a Nursing Perspective on Spirituality and Healing.” Nursing Science Quarterly, 15(4), 281-287. McNamara, S.A. (1995). “Perioperative Nurses’ Perceptions of Caring Practices.” AORN, 61(2), 377-385. Rogers, M., Jones-Paul, L., Clarke, J., Cackay, C., Potter, M., and Ward, W. (1991). “The Use of Roy Adaptation Model in Nursing Administration.” CINA, June, 21-26. Roy, C. (1989). The Roy Adaptation Mode. In J.P. Riehl-Sisca, Conceptual Models for Nursing Practice. 3rd ed., 105-114. Norwalk, CT: Appleton and Lange. Roy, C. (1987). “Response to ‘Needs of Spouses of Surgical Patients: A Conceptualization within the Roy Adaptation Model’.” Scholarly Inquiry for Nursing Practice: An International Journal, 1(1), 45-50. Smith, M. (2004). “Review of Research Related to Watson’s Theory of Caring.” Nursing Science Quarterly, 17(1), 13-25.

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Thornbury, J.M., and King, L.D. (1992). “The Roy Adaptation Model and Care of Persons with Alzheimer’s Disease.” Nursing Science Quarterly, 5(3), 129-133. Watson, J. (2001). Theory of Human Caring in M.E. Parker, Nursing Theories and Nursing Practice. Philadelphia: F.A. Davis. Watson, J. (1997). “The Theory of Human Caring: Retrospective and Prospective.” Nursing Science Quarterly, 10(1), 49-52. Watson, M.J. (1988). “New Dimensions of Caring Theory.” Nursing Science Quarterly, 1, 175-181. Whittemore, R., and Roy, C. (2002). “Adapting to Diabetes Mellitus: A Theory Synthesis.” Nursing Science Quarterly, 15(4), 311-317.

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EVIDENCE 15 Methods that are used to meet patient needs. A description of the mechanisms used to ensure that an appropriate skill mix of adequate numbers of staff is available.

nsuring the right skill mix and numbers of staff available on each shift to meet patient needs is obviously the greatest challenge confronting nursing today. Facing the nursing shortage in a rural geographic location adds to this challenge. Geisinger has been successful in using creative methods to maintain low vacancy and low turnover rates. We have a systematic, comprehensive process for ensuring that we have the appropriate skill mix and adequate numbers of staff to meet patient needs. Coordination and teamwork are key and include: • Each unit’s charge nurse assesses staff needs every four hours to ensure ongoing patient care needs are met. • These efforts are supported by professional judgment, adequate budgeting (for example: development of staffing calculators, staffing grids, and acuity tools), proactive schedule planning, and recruitment and retention efforts. Staffing calculators and associated staffing grids are tools designed as part of the budget process to assure that the foundation for 24/7 resource needs are included in the budget. This process is based on the benchmarked patient care hours required per patient day and the actual patient acuity mix. The staffing calculators also include nonproductive care hours that address personal time off, time for meetings, education time, and new staff orientation. The Automated Nurse Staffing Office System (ANSOS) is a computerized staffing system that provides the Staffing Office, administrative supervisors, operations managers, charge nurse, and staff nurses with an accurate, up-to-date staffing list for the upcoming four-week schedule. Hard (paper) copies of the next day’s staffing are also sent daily to each unit for review and posting, giving the charge nurse on each shift an opportunity to review staffing for the following shift and to assure accuracy.

PROFESSIONAL JUDGMENT The skilled and experienced nurses in charge of each unit are responsible for identifying adequate staffing that meets patient needs. Their professional judgment determines the correct real-time staff and skill mix for their unit’s patient needs. The process also looks ahead to enable the charge nurse to determine unique staffing needs for the next shift regardless of the previously scheduled staff. The charge nurses on medicalsurgical units frequently evaluate the acuity of the patients to guide the number and skill level of the staff needed for each shift. Our goal is to staff for all of our patients by providing the right, competent nurse at the right time. If the acuity or census is lower than average, a process driven by our nurses begins to assess whether a nurse may be reassigned to another unit for a block of four hours. Based on ongoing assessment by the charge nurse at the end of the first four hours, a determination is made as to whether the nurse would return to the home unit or continue working on the assigned unit. More importantly, when additional staff is required because of increased acuity (such as patients requiring one-on-one staffing or volume), the charge nurse collaborates with the nursing leadership to develop the

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best overall plan for the patients. The administrative supervisor on each shift can facilitate staff assignments to best meet all patient care needs. Policies and procedures, such as the Flex-Up and Flex-Down policies and the Time-Planning and Holiday Policies (OP:15:A), guide staffing schedules. Nurse leaders and direct-care staff also collaborate on programs for overtime incentives to support the voluntary overtime philosophy so that additional staffing is an option, if needed.

OP:15:A PATIENT CARE MANUAL POLICY 301 TIME PLANNING POLICIES OBJECTIVES 1. To provide the most competent nurse at the right time to provide the best possible care to all of our patients. 2. To provide proactive planning processes with staff involvement and leadership. GENERAL INFORMATION 1. Responsibility for schedules will be maintained by the operations manager or the team coordinators.The final decision for time planning and time trades will rest with the Management Team in collaboration with the unit council guidelines. Unit-based shared-scheduling is essential. Unit-based guidelines are on each work area. 2. Refer to UDC Manual for UDC Schedule policies. ANSOS INFORMATION 1. Any changes or corrections made to the Master Scheduling Plan after it has been submitted to the Nursing Administration Staffing Office can be done by several methods depending upon the urgency of the change. Changes for the same day or next day should be phoned to the Staffing Office, day, evening, or night. In addition, they should be written on the daily ANSOS report. Changes for the same week can be made by writing them on the daily ANSOS report. Changes occurring in the following week can be made on the weekly ANSOS report. Changes made to the Master Plan after submitted, and up to ten days before the Master Plan begins can be corrected on the ANSOS printed schedule.This should be resubmitted for corrections and to be reprinted. 2. Master Plans should be submitted to the Nursing Administration Staffing Office three weeks prior to the first day of the new four-week plan. Blank plan sheets are sent the first week of a schedule for the Master Plan, which begins five weeks later. 3. Weekly ANSOS reports are sent to the units ten days prior to the start of that week.They must be corrected and returned by Friday three days before that week begins. 4. Daily ANSOS reports, with corrections and changes, should be returned to the Nursing Administration Staffing Office by 9:00 the following morning. 5. Overtime greater than 24 hours old must be approved by the Unit Management before entering the ANSOS system. HOLIDAYS 1. Employees may be scheduled to work three of the six holidays. Refer to HR Holiday Policy # 210. Holidays begin with nightshift on the eve of the holiday and include dayshift and evening shift on the holiday. The designated holiday is where the majority of the hours are worked. For example, a 0.9 night shift employee is scheduled 7p-7a, the evening of the holiday— they will receive 12 hours of holiday pay. 2. Full-time employees will receive time-and-a-half and are entitled to a compensable day off for working the holiday, not to exceed over 12 hours. Part-time employees will receive time-and-a-half for working the holiday, but will not receive a compensable day. 3. If an employee is absent on a fixed holiday and doesn't have an approved absence, the employee must work their next unscheduled holiday.

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4. To be eligible for holiday pay, the employee must work their scheduled day before and after their paid holiday off or have an approved absence. FMLA absences included. VACATION TIME/PAID TIME OFF (PTO) 1. The vacation schedule is posted on each unit in January and must be approved by the operations manager. 2. Each unit is responsible for the number of people granted primary paid time off and may limit the number of weeks granted per person in high demand times.This policy is part of each unit council guidelines for scheduling. ABSENTEEISM 1. When personnel request paid time off for an unscheduled absence, the operations manager or unit scheduling council makes the decision on the outcome of request. 2. If an employee has an unscheduled, unapproved, absence between 3:00 p.m. Friday and 7:00 a.m. Monday the employee may be rescheduled within a three-month time frame (excludes permanent weekend employees) based on unit needs, FMLA absences included and at manager’s discretion. 3. When calling the Nursing Administrative Office, extension 16095, to report illness/absence, it is essential that the following call-in policy is used: DAYS

CALL-IN TIME

7:00 a.m. – 3:30 p.m.

5:00 a.m.

7:00 a.m. – 7:00 p.m.

5:00 a.m.

11:00 a.m. – 7:30 p.m. 11:00 a.m. – 11:30 p.m.

7:00 a.m.

7:00 a.m. EVENINGS 3:00 p.m. – 11:30 p.m. 7:00 p.m. – 7:00 a.m.

11:00 a.m. 3:00 p.m.

NIGHTS 11:15 p.m – 7:15 p.m.

7:00 p.m.

4. For a full time employee, six (6) occurrences of unscheduled, unapproved, non-FMLA absences in a 12-month period will be considered excessive and may result in the disciplinary process. Part-time absenteeism will be prorated based on budgeted FTE (example: 0.5 = 3 occurrences). REQUESTS FOR SPECIAL TIME Continuing education is a priority for the Nursing Department.To assure planning for adequate staffing, educational requests must be discussed with the unit management prior to registering for a class to determine a plan for accommodation. All trades must be done so that each person involved in the trade works his required number of shifts in the pay period. TEMPORARY REASSIGNMENT OF PERSONNEL Nursing Administration reserves the right to temporarily reassign personnel as indicated to meet the patient’s needs. (See Policy 328) UNSCHEDULED LEISURE TIME 1. Indications: Unscheduled leisure time can be requested when it appears that staffing will exceed the staffing needs of the unit. Requests should be made no greater than five days in advance of the requested shift, and no less than 24 hours in advance of

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the scheduled shift.The request should indicate the date and shift (and how much of the shift) the request is for. PTO that is needed for a specific purpose (wedding, party, trip, etc.) should be requested in the form of the usual PTO request to the schedule committee. 2. Approval of Request: Approval of the request will be based on the staffing needs of all nursing units. Write your request for conditional leisure time on the daily ANSOS or call the staffing office to request conditional leisure time. Please use the term “conditional leisure time” when making your request in writing or when talking to the staffing office on the telephone. Conditional leisure time will be granted in the order that the requests are received in the staffing office. Staffing specialists will document the request for conditional leisure time on a “Conditional Leisure Time Log Sheet.” Conditional leisure time will be granted on four (4) hour blocks only. Staff requesting conditional leisure time should call the staffing office no earlier than two (2) hours before the start of their scheduled shift to see if their conditional leisure time has been approved. OVERTIME Every attempt will be made to allow 8 hours between shifts. Employees will not be expected to work more than 16 consecutive hours, unless emergent/unexpected circumstances exist. STAFF-UP/STAFF-DOWN GUIDELINES I. Purpose: 1. To serve as a guide for increasing or decreasing the number of staff assigned to each specific unit based on patient census and acuity.These guidelines are designed to provide consistency in the decision-making process, to facilitate communication and cost savings within nursing services, and maintain productive hours within each unit’s budgeted HPPD. II. Procedure 1. Staffing determinations will be evaluated every four hours with the exception of night shift. 2. The charge nurse will determine the number/mix of staff needed based on the units’ HPPD/acuity. 3. The staffing office will coordinate and facilitate all staff-up/staff-down efforts in conjunction with the charge nurses and administrative supervisors. A. Staff-up sequence 1. Assess float/flex availability. 2. Available resources from within the Nursing components. 3. Utilize additional scheduled shifts by staff budgeted as .8 FTE receiving full-time benefits. 4. Extra shifts by part-time employees. 5. Voluntary overtime. 6. Cancel committee/meeting/education time. B. Staff-down sequence 1. Cancel per diem/agency. 2. Cancel overtime on unit. 3. Relocate flex to another unit within defined component: a. Regular flex b. Contracted flex 4. *Cancel flex: a. Regular flex b. Contracted flex 5. *Cancel extra shifts of part time staff. 6. *Cancel extra scheduled shifts of .9 FTE with benefits. 7. Relocate regularly scheduled staff to other areas as needed. 8. Project time (must be approved by management). 9. Voluntary paid/unpaid time off.

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10. Involuntary paid/unpaid time off. 11. Agency staff. * The order of cancellation of flex and extra shifts (# 3, #4, and #5) can be as stated or in a different order at the discretion of the individuals involved.

DOCUMENT INFORMATION Devised

Revised/Reviewed

Source

Approved by the CNO—2/07

Operations Managers

Approved

and Supervisors

Each area also has its own process to identify staffing needs and resources to supplement and assure adequate staffing. Nurses pre-plan themselves on a number of shifts that may be available for additional time on each schedule so they can plan family and child care in advance. Four-week schedules are developed by unit-based scheduling committee members to meet the number and level (skill mix) of staff required to meet core staffing needs. There are centralized guidelines for scheduling (such as the time planning policy and leisure time policy that guide time-off practices. However, unit-based shared scheduling committees create their own guidelines to meet the needs of their unit. We have found that unit-based, flexible scheduling improves staff retention—an essential step toward ensuring patient needs are met by experienced nursing levels. Unit-based scheduling councils, made up of staff nurses, enable nurses to participate in the scheduling process. More examples of active scheduling councils will be discussed later in the document.

BUDGET PROCESS Identifying staffing resources begins with the annual budget process (discussed in more detail later in document). The nursing operations managers collaborate with direct-care nurses, the CNO, and the nursing services financial liaisons during the budget process to review volume projections and identify future staffing needs. National benchmarked hours-per-patient-day (HPPD) data are used to drive the budgeting process for each individualized area according to the anticipated type and acuity of patients, such as medical-surgical or critical care. The nurse manager and CNO discuss and review any adjustment to the HPPD target using historical benchmarked data and unit-specific data, such as patient volume, patient acuity, and staff feedback to drive necessary change in the HPPD. The nurse manager develops a plan (with feedback from direct-care nurses) using the staffing calculator tool to identify the core number of FTEs in each skill level required to handle the average projected census and acuity type. The numbers of FTEs are then converted into actual positions and numbers of staff to meet the needs of the unit’s staffing plans and processes.

RECRUITMENT We are fortunate to have an active Recruitment Department with three full-time recruiters assigned to the Nursing Department. One recruiter focuses primarily on advanced practice nurse positions. The recruiters

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handle nursing recruitment system-wide (on and off the GMC campus). Collaborating with the operations managers, they evaluate each nursing application. They also have a distinct presence at recruitment events conducted at nursing schools and nursing conferences as well as job fairs at high schools. (We discuss recruitment activities in more detail in FORCE 4.) Our Nurse Recruitment Department personnel communicate our mission, vision, and values to each nurse they encounter. Our goal is to recruit the most competent nurses who are professionally motivated to stay abreast of the changing landscape of healthcare in technology and continuing education. Our nurse recruiters were able to hire more than 60 new nursing graduates who started in Spring 2007 at the medical center, a number we continue to grow and exceed each year. The balance of new graduates and experienced nurses continues to foster preceptorship, mentoring, and good leadership in our Nursing Department.

RETENTION We have a strong track record in retaining staff. A large percentage (41 percent) of our nursing staff has been here for more than 10 years. We attribute this to the staff ’s strong commitment to Geisinger and to the patients we serve and to our commitment to “grow” our employees. Staff involvement in decision making through our shared governance structure has also had a positive effect on retention. Maintaining a balance of professional judgment, staffing grids, budgets, recruitment, and retention plays an important role in providing patients with the appropriate nursing skill mix and adequate staff.

EVIDENCE 15: SOURCES OF EVIDENCE OP:15:A

Time Planning Policies

Policy 301

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EVIDENCE 16 The satisfaction survey completed by nurses who provide direct patient/client/resident care in the past twelve (12)-month period.

he following pages contain the National Database of Nursing Quality Indicators (NDNQI): RN Satisfaction—2007 Preliminary Report for Geisinger Medical Center.

ADAPTED NURSING WORK INDEX AND JOB ENJOYMENT INDIVIDUAL-FOCUSED ITEM T-SCORES Limited to hospitals selecting the RN Survey with Job Satisfaction Scales instrument option *Excluded from Short Form < 40 = low satisfaction, 40-60 = moderate satisfaction, > 60 = high satisfaction NDNQI-Adapted Nursing Work Index Item T-Score Career development * opportunities Average of All Comparison

63.33

Nurse manager is good leader*

Satisfied with CNO*

Satisfied with my job T-Score

60.92

58.16

62.64

Top Quartile Cut Point

68.80

67.15

63.96

68.14

Upper Confidence Limit

63.59

61.20

58.44

62.87

Lower Confidence Limit

63.06

60.64

57.87

62.40

Adult Critical Care

62.04

59.55

54.17

59.88

Top Quartile Cut Point

67.48

65.05

60.40

64.71

Upper Confidence Limit

62.86

60.50

55.19

60.65

Lower Confidence Limit

61.22

58.59

53.14

59.11

Adult Step-down

65.08

61.45

57.70

60.00

Top Quartile Cut Point

70.06

67.68

63.96

65.91

Upper Confidence Limit

66.07

62.54

58.82

60.98

Lower Confidence Limit

64.08

60.36

56.57

59.03

Adult Medical

65.49

62.08

59.28

59.81

Top Quartile Cut Point

70.59

67.31

64.77

65.32

Upper Confidence Limit

66.33

62.98

60.24

60.62

Lower Confidence Limit

64.66

61.17

58.31

58.99

Adult Surgical

65.09

60.97

58.86

59.58

Top Quartile Cut Point

70.17

66.75

65.00

65.05

Upper Confidence Limit

66.01

62.10

59.93

60.53

Lower Confidence Limit

64.17

59.83

57.79

58.62

Adult Medical-Surgical

64.62

61.75

59.13

60.19

Top Quartile Cut Point

69.49

67.68

63.96

65.41

Upper Confidence Limit

65.45

62.64

60.01

60.93

Lower Confidence Limit

63.79

60.87

58.26

59.45

Obstetrics

63.68

58.49

57.72

63.41

Top Quartile Cut Point

68.52

64.38

63.57

68.81

Upper Confidence Limit

64.70

59.75

58.84

64.33

Lower Confidence Limit

62.65

57.24

56.60

62.50

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Neonate

Career development * opportunities

Nurse manager is good leader*

Satisfied with CNO*

Satisfied with my job T-Score

63.22

60.54

58.18

65.31

Top Quartile Cut Point

68.11

68.93

62.96

69.67

Upper Confidence Limit

64.75

62.61

59.66

66.43

Lower Confidence Limit

61.68

58.47

56.70

64.19

Pediatrics

65.26

62.19

60.48

64.65

Top Quartile Cut Point

69.77

67.55

65.36

69.12

Upper Confidence Limit

66.30

63.39

61.76

65.59

Lower Confidence Limit

64.21

60.98

59.19

63.72

Psychiatry

61.57

59.80

58.63

62.84

Top Quartile Cut Point

67.65

66.75

63.78

68.38

Upper Confidence Limit

63.19

61.35

60.09

64.06

Lower Confidence Limit

59.95

58.26

57.18

61.62

Surgical Services

60.41

58.82

55.90

62.97

Top Quartile Cut Point

65.67

65.36

61.63

68.14

Upper Confidence Limit

61.14

59.63

56.66

63.58

Lower Confidence Limit

59.69

58.02

55.14

62.37

Rehabilitation

64.90

62.78

60.94

62.11

Top Quartile Cut Point

69.93

68.26

66.95

67.86

Upper Confidence Limit

66.38

64.39

62.64

63.84

Lower Confidence Limit

63.43

61.17

59.24

60.39

Emergency

61.73

60.22

56.02

61.13

Top Quartile Cut Point

67.49

65.98

61.17

66.74

Upper Confidence Limit

62.99

61.54

57.27

62.27

Lower Confidence Limit

60.48

58.90

54.77

59.98

Ambulatory Care

64.07

62.48

60.88

66.83

Top Quartile Cut Point

69.93

68.99

66.56

72.06

Upper Confidence Limit

65.14

63.50

61.92

67.71

Lower Confidence Limit

63.01

61.46

59.83

65.96

Interventional Labs

61.47

60.85

57.09

64.70

Top Quartile Cut Point

67.59

67.86

64.55

69.96

Upper Confidence Limit

62.40

61.79

58.12

65.45

Lower Confidence Limit

60.55

59.92

56.05

63.94

Other Comparison data are not provided for this unit type category because the wide variety of units included invalidates its use for comparison purposes. Comparison data are owned by ANA and may not be published by NDNQI member hospitals. See separate Survey and Scoring Guide for a detailed description of each data table. Report published 10/17/2007.

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Chart 1. Practice Environment Scale Mean Scores Limited to hospitals selecting the RN Survey with Practice Environment Scales instrument option 4 3 2 1 0 Nurse Particpation in Hospital Affairs

Nursing Foundations for Quality of Care

Nurse Manager Ability, Leadership & Support of Nurses

Average of All Comparison Units in All Comparison Hospitals

Staffing & Resource Adequacy

Collegial Nurse-Physician Relations

Mean PES Score

Average of All Units in Your Hospital

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Chart 2. Job Enjoyment Scale T-Score 80 70 60 50 40 30 20 Job Enjoyment T-Score

Average of All Comparison Units in All Comparison Hospitals

Average of All Units in Your Hospital

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Chart 3. Adapted Index of Work Satisfaction T-Scores Limited to hospitals selecting the RN Survey with Job Satisfaction Scales instrument option *Excluded from Short Form 80 70 60 50 40 30 20 Task

RN-RN Interactions*

RN-MD Interactions*

DecisionMaking

Autonomy*

Professional Status*

Pay*

Chart 4. Adapted Nursing Work Index T-Scores Limited to hospitals selecting the RN Survey with Job Satisfaction Scales instrument option *Excluded from Short Form 80 70 60 50 40 30 20 Professional Development

Nursing Management

Nursing Administration

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EVIDENCE 17—PART A Organizational policies and procedures related to confidentiality of staff personal information.

mployee personal information records are maintained on a confidential basis. Access to these records is restricted, and policies are in place that prohibit inappropriate access, use, disclosure, electronic transmission, or verbal disclosure of confidential information. Sanctions for such breeches in policy include discipline up to and including immediate termination of employment. All electronic policies include personal health information (PHI) as well as business-sensitive information (BSI), which includes all information relating to employees (including social security numbers, passwords, compensation, and information about personal residence, marital status, and dependents).

OP:17:A HUMAN RESOURCE MANUAL POLICY 140 EMPLOYEE HUMAN RESOURCE RECORDS POLICY Employee Human Resource records are treated on a confidential basis. Access to these records shall be restricted to the employee, management, and supervisory personnel with responsibility for the employee, interviewing personnel, and other authorized persons. An employee has the right to reasonable access to his/her personnel file maintained in the Human Resources Department. References as current or former employees are to be referred to Human Resources.The exceptions are that medical resident/fellow references should be referred to the Medical Education Departments, and credentialing references for providers should be referred to the Medical Staff Office at GWV (34-71) for GWV providers and to the Credentialing Office in Danville (30-22) for all other providers. PROCEDURE The particular reason for an employee reviewing his/her file shall be indicated in order to facilitate the review process and so that the documents may be made available to him/her. It shall take place during the hours in which the Human Resources Department is normally open for business. A Human Resource Department representative shall be present during the review of the employee’s file.The employee may take notes of items that relate to his/her particular concern, but no removal of documents will be allowed. STANDARDS For purposes of reviewing one’s Human Resources file, the term “employee” refers to any person currently employed by Geisinger Health System, including employees on authorized leaves of absence. “Personnel file” includes the employment application form, wage, and salary information, including promotion and other salary increases, performance appraisals, attendance records, and notices of commendation or of a disciplinary or warning nature. Excluded from review are letters of reference, interview evaluations, medical records, and documents used in preparation of possible civil, criminal, or grievance or disciplinary procedures. Relative to references on current or former employees, investigators are not allowed to visit various departments, interviewing supervisors or coworkers. On the medical center campuses, all onsite investigators shall be referred to the Human Resources Department for reference checks. Only the employee name, job title, dates of employment, and verification of salary shall be given by Human Resources unless the investigator has written authorization for release of further information. The official record is maintained in the Human Resources Department and: 1. Employees have the right to request correction or removal of inaccurate, irrelevant, outdated, or incomplete information.The manager and Human Resources shall respond considering the nature of the information. 2. Employees have the right to submit rebuttal data or memoranda to their records.

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When an outside agency (federal, state, county, or other) requests information, that information shall be provided if the agency offers proof of legal right to information. If a request is made by such an agency and no proof of legal right is provided, the agency will have to use subpoena power to obtain the information, unless the employee authorizes the release. APPLICATION X Employees Paid Biweekly X Administration/Professional Staff X Residents

DOCUMENT INFORMATION Devised

Revised/Reviewed

9/87

Approved by HR—3/07

OP:17:B HUMAN RESOURCE MANUAL POLICY 360 PROTECTION OF CONFIDENTIAL INFORMATION AND SANCTIONS (EXCERPT) PURPOSE To provide policy for the use and disclosure of Confidential Information and to fulfill the regulatory requirements for the same, as set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). POLICY STATEMENT A. Definitions: Confidential Information Confidential information is defined as information to which access must be restricted by reason of law, regulation, ethical standards, or business necessity. Confidential information includes, but is not limited to, the following information as communicated in any form, whether verbal, written, or electronic: Employee information (obtained through the performance of one’s job duties) including, but not limited to, personnel actions such as promotions, resignations, etc.; compensation; benefits; performance-related information; and/or medical/psychological reports.This restriction does not prohibit employees from sharing and discussing their own information relating to wages, benefits, and working conditions as protected under the National Labor Relations Act. Business/system information related to the GHS affiliates, and/or GHS, including, but not limited to, financial, budget, payroll, marketing, research and development, bid proposals, contract negotiations, and legal advice. B. Disclosure Disclosure is defined as the release, transfer, provision of, access to, or divulging in any other manner Confidential Information outside GHS as described in the notice of privacy practice as defined in HIPAA Privacy Regulations. C. GHS Workforce Includes any person GHS allows to access Confidential Information. Employees (part-time, full-time, temporary, and flex), volunteers, students, GWV non-employed admitting physicians and others are included in this definition. D. Need to Know Need to know means that a member of the GHS Workforce must access the information to perform his or her duties and responsibilities.

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E. Protected Health Information (PHI) PHI is defined as any information, whether oral or recorded in any form or medium, that is created or received by a healthcare provider and relates to the past, present, or future physical or mental health or condition of an individual. F. Use Use is defined, with respect to individually identifiable health information, as the sharing of employment, application, utilization, examination, or analysis of such information within the entity that maintains such information. SANCTION GUIDELINES A. Disclosure 1. Intentional/Malicious 1. Employees are subject to disciplinary action up to and including immediate termination. 2. Other members of the GHS Workforce are subject to loss of privileges to access, termination of contracts, and may be required to reimburse GHS for any momentary damages suffered by GHS. 3. Members of the GHS Workforce with medical staff privileges are subject to the loss of those privileges in accordance with the applicable medical staff bylaws. 2. Unintentional—The above sanctions for the various classes of GHS Workforce may be reduced at the sole discretion of GHS depending upon the severity of the offense or consequences to patients or GHS. B. Inappropriate Use Inappropriate use is inappropriate internal release, access, manipulation of Confidential Information or carelessness in protecting it. 1. Intentional/Malicious 1. GHS employees are subject to disciplinary action up to and including termination. For offenses that are less severe in the opinion of GHS management, lesser action may be taken. 2. Other members of the GHS Workforce—Disciplinary action up to and including loss of access, termination of contracts, and possible reimbursement to GHS for any monetary damages suffered by GHS may be imposed. For offenses that are less severe in the opinion of GHS management and Human Resources less stringent penalties may apply. 3. For members of the GHS Workforce with medical staff privileges, disciplinary action up to and including the loss of medical staff privileges may occur in accord with the applicable medical staff bylaws.

DOCUMENT INFORMATION Devised

Revised/Reviewed 3/07

EVIDENCE 17—PART A: SOURCES OF EVIDENCE OP:17:A

HRM—Employee Human Resource Records

Policy 140

OP:17:B

HRM—Protection of Confidential Information and Sanctions

Policy 360

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EVIDENCE 17—PART B Organizational policies and procedures related to confidentiality of patient personal information.

umerous policies related to maintaining the confidentiality of patient personal information are in place. These policies protect patient information in all areas of patient care, electronic information, and financial/insurance information. The policies outline Geisinger’s expectations that every employee will handle all information with confidentiality. The consequences of misuse, carelessness, or deliberate disclosure of information include discipline up to and including immediate termination of employment. Although the primary objective of these policies is to protect the confidentiality of patient information, GMC’s Information Security Department also maintains numerous policies to protect patient information.

OP:17:C PATIENT CARE MANUAL POLICY 409 SECTION: PATIENT CARE POLICIES PROCEDURE FOR HANDLING CONFIDENTIALITY The Nursing Department supports the concept of confidentiality and the patient’s right to privacy.To demonstrate this support, standards have been developed with the understanding that breach of confidentiality is grounds for disciplinary action. We also acknowledge the importance of communicating essential information to agencies or personnel who have or have had responsibility for providing care to a Geisinger Medical Center patient. The Geisinger Medical Center has adopted the following standards: 1. Case discussions, consultations, examinations, and treatments will be conducted in a confidential and discrete manner. 2. Personnel may read the patient’s medical record when they are involved in the patient’s treatment program or when they are monitoring the quality and appropriateness of care. Medical records may be reviewed by medical and nursing students when appropriate to their educational program. 3. Employees of the medical center who have relatives or significant others who are patients may read the medical record only after written permission has been obtained from the patient. 4. Operations managers, team coordinators, or administrative supervisors after proper screening (identification of need to see the medical record, relationship of individual to patient, such as care provider, case worker) may release the medical record for review by other hospital professionals. The Nursing Department has adopted specific standards, including examples of confidential behavior.These examples are not allinclusive, but serve to illustrate our commitment to confidentiality. 1. Any external persons or agencies involved in past or future care of the patient (Interim Healthcare, nursing homes, state facilities, or referring hospitals and physicians) making inquiry will be asked for their name, the name of their institution, phone number, and the patient’s name. A return phone call will be made by recipient of original call to verify the identity of the caller. After verification has been established by the calling GMC staff member, information regarding condition, care requirements, length of stay or expected date of discharge may be given. Other more extensive requests should be referred to the appropriate Geisinger physician. 2. Any representatives of insurance agencies requesting review of a patient’s medical record should be referred to the Medical Records Department for authorization. 3. Discussion concerning patient’s care or condition should not be held in elevators, hallways, coffee shop, cafeteria, or any public area.

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4. Discussion concerning the patient’s care or condition is inappropriate outside the medical setting (shuttle bus, public transportation, or public places). 5. Patient care discussions at the nursing station should be discreet due to the availability of this area to patients, visitors, or other medical center personnel. 6. Information concerning an individual patient must not be shared with another patient or family. 7. Computerized results of laboratory tests and medical treatments should not be obtained unless pertinent to the application of direct patient care. 8. Communicate information to other institutions, departments, or nursing units when necessary for patient care, staff education, or follow-up on therapeutic interventions. 9. Information relative to employee confidentiality will be shared by managers with other managers on a need to know basis only. 10. Detailed information concerning a patient’s condition or status of discharge should not be provided to officers of the law. 11. Requests for information concerning prisoners should be referred to the Public Affairs Department. 12. Detailed information concerning a patient’s condition or treatment should not be released to the media, but rather referred to Public Affairs. 13. Patient care discussions outside a patient’s room (either inpatient or outpatient) should be very discreet, keeping in mind the possibility of the discussion being overheard. 14. Discretion should be used regarding the delivery of personal information to patients and families in public areas, such as family waiting rooms or hallways.

DOCUMENT INFORMATION Devised

Revised/Reviewed

4/85

Approved by the CNO—4/07

OP:17:D INFORMATION SECURITY MANUAL POLICY 06.038 AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) REQUIRED BY FEDERAL REGULATION EFFECTIVE DATE 04/14/2003 POLICY STATEMENT Authorization is required when the PHI is used in any manner or for any purpose not generally necessary for the treatment, payment, or healthcare operations of the covered entity. Geisinger Health System will obtain the patient’s or the legal representative’s authorization to disclose protected health information unless the use or disclosure is permitted or required by regulation. SCOPE/DEFINITIONS Protected health information means individually identifiable health information: 1. Except as provided in paragraph (2) of this definition, that is: i. transmitted by electronic media. ii. maintained in any medium described in the definition of electronic media at Policy 162.103 of this subchapter. iii. transmitted or maintained in any other form or medium.

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2. Protected health information excludes individually identifiable health information in: i. education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g. ii. records described at 20 U.S.C. 1232g(a)(4)(B)(iv). iii. employment records held by a covered entity in its role as employer (HIPAA). Electronic media means the mode of electronic transmission. It includes the Internet (wide-open), Extranet (using Internet technology to link a business with information only accessible to collaborating parties), leased lines, dialup lines, private networks, and those transmissions that are physically moved from one location to another using magnetic tape, disk, or compact disk media. Disclosure means the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information (HIPAA). Legal Representative means the person who has guardianship, power of attorney, or other legally recognized power to act on behalf of the patient/individual. Treatment means the provision, coordination, or management of healthcare and related services by one or more healthcare provider, including the coordination or management of healthcare by a healthcare provider with a third party; consultation between healthcare providers relating to a patient; or the referral of a patient for healthcare from one healthcare provider to another. Payment means: 1. The activities undertaken by: i. A health plan to obtain premiums or to determine or fulfill its responsibility for coverage and provision of benefits under the health plan; or ii. A healthcare provider or health plan to obtain or provide reimbursement for the provision of healthcare; and 2. The activities in paragraph (1) of this definition relate to the individual to whom healthcare is provided and include, but are not limited to: i. Determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), and adjudication or subrogation of health benefit claims; ii. Risk adjusting amounts due based on enrollee health status and demographic characteristics; iii. Billing, claims management, collection activities, obtaining payment under a contract for reinsurance (including stop-loss insurance and excess-of-loss insurance), and related healthcare data processing; iv. Review of healthcare services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges; v. Utilization review activities, including precertification and preauthorization of services, concurrent and retrospective review of services; and vi. Disclosure to consumer reporting agencies of any of the following protected health information relating to collection of premiums or reimbursement: A. Name and address; B. Date of birth; C. Social security number; D. Payment history; E. Account number; and F. Name and address of the healthcare provider and/or health plan. Healthcare operations mean any of the following activities of the covered entity to the extent that the activities are related to covered functions: 1. Conducting quality assessment and improvement activities, including outcomes evaluation and development of clinical guidelines, provided that the obtaining of generalizable knowledge is not the primary purpose of any studies resulting from such activities; population-based activities relating to improving health or reducing healthcare costs, protocol development, case management, and care coordination, contacting of healthcare providers and patients with information about treatment alternatives; and related functions that do not include treatment; 2. Reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, health plan performance, conducting training programs in which students, trainees, or practitioners in areas of healthcare learn

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under supervision to practice or improve their skills as healthcare providers, training of non-healthcare professionals, accreditation, certification, licensing, or credentialing activities; 3. Underwriting, premium rating, and other activities relating to the creation, renewal, or replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for healthcare (including stop-loss insurance and excess of loss insurance), provided that the requirements of Policy 164.514(g) are met, if applicable; 4. Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs; 5. Business planning and development, such as conducting cost-management and planning-related analyzes related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies; and 6. Business management and general administrative activities of the entity, including, but not limited to: i. Management activities relating to implementation of and compliance with the requirements of this subchapter; ii. Customer service, including the provision of data analyzes for policy holders, plan sponsors, or other customers, provided that protected health information is not disclosed to such policy holder, plan sponsor, or customer; iii. Resolution of internal grievances; iv. The sale, transfer, merger, or consolidation of all or part of a covered entity with another covered entity or an entity that following such activity will become a covered entity and due diligence related to such activity; and v. Consistent with the applicable requirements of § 164.514, creating de-identified health information and fundraising for the benefit of the covered entity. Use means, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information (HIPAA). PROCEDURE A valid authorization is required in order for GHS to use or disclose protected health information to the following: 1. Non-GHS employed physicians (except if the requesting physician authored the document being requested or he/she referred or ordered the test/service per documentation within the medical record). If they do not qualify as an exception, a signed and dated authorization from the patient will be required to verify the care relationship with the patient. 2. GHS employed physicians for drug/alcohol info only unless they were the physician providing the drug/alcohol treatment. 3. Other healthcare facilities. 4. Attorney. 5. Insurance companies (except where contractually approved, such as Medicare, Medical Assistance, Blue Cross, and GHP). 6. Law enforcement officers. 7. Veterans Administration. 8. Other government agencies. 9. Use or disclosure to patients for personal use. 10.Use for marketing of health and non-health items and services. 11.Disclosure prior to an individual’s enrollment in a health plan, to the health plan, or healthcare provider for making eligibility or enrollment determinations. 12.Disclosure to an employer for use in employment determinations. 13.Use or disclosure for fundraising purposes. 14.Research with identified protected health information. Required elements of a valid authorization include: 1. Patient’s name, birth date, or social security number to confirm correct medical record number. 2. Treatment dates or time period to be released. 3. A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion. 4. Purpose of request.

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5. The requestor’s name. 6. An expiration date. 7. Signature and date. 8. If the authorization is executed by a legal representative or other person authorized to act for the individual, a description of his or her authority to act or relationship to the individual documentation must be presented and kept on file attesting to the legal representative’s right to act on behalf of the patient/individual and kept within the medical record. 9. For records containing mental health and/or drug and/or alcohol information, a statement in which the individual acknowledges that he or she has the right to revoke the authorization, except to the extent that information has already been released under the authorization. I. Patients need not authorize the release of protected health information in the following situations for routine medical-surgical information (Note: Records that include mental health, drug and/or alcohol, or HIV/AIDS information are not considered routine medical-surgical information): 1.Non-GHS employed physicians with a care relationship to the patient that is properly documented in the medical record. 2.Geisinger-employed physicians or another Geisinger facility. 3.An authorized agent of the Worker’s Compensation Board of Pennsylvania is permitted to review the portion of the record related to the condition for which the compensation case patient is receiving Worker’s Compensation benefits. 4.Employers of patients who have received services under Worker’s Compensation Statute are entitled to copies of the patient’s records related to the Worker’s Compensation claim.THIS ONLY PERTAINS TO COPIES GOING TO THE EMPLOYER; ANY OTHER REQUESTORS REQUIRE AN AUTHORIZATION. 5.Investigational Research and Review Board (IRRB) has reviewed and approved the release as part of a research study. 6.Suspected child abuse cases must be reported to the appropriate legal authorities. 7.Subpoena duces tecum. A subpoena duces tecum is a binding order to produce documents for court proceedings. It must be personally served or mailed to an individual who has the power to produce their records. (Note: Drug and/or alcohol, HIV-related records or mental health records require either a special authorization signed by the patient or a court order). 8.Use/Disclosure required by mandatory reporting regulation. (Communicable diseases reportable to Dept. of Health, cancer patient data reportable to Pa. Cancer Registry, patient data reportable to Pa. Healthcare Cost Containment Council PHC-4, etc.). 9.In medical emergency situations, if a valid authorization cannot be obtained and when disclosure of privileged information would be in the patient’s best interest, protected health information should be released in the following manner: • Obtain identifying information from the caller (name, address, and telephone number of the healthcare provider; name, date, and address of the patient; exact information to be released; and the purpose of the request). • Indicate that a return call and/or FAX transmission will be made after the information has been verified and the medical record retrieved. • Attempt to verify the identity of the caller by reviewing the telephone directory, physicians’ index, or other available resources. • Return the call and further verify the identity of the caller by asking for the healthcare provider by name. • Document why authorization was not obtained. 10. Dates of hospitalization may be given to payer. II. Patients need not authorize the release of protected health information in the following situations for mental health or HIV/AIDS information: 1.Non-GHS employed physician who is the physician providing the mental healthcare. 2.GHS employed physicians or another GHS facility. 3.Use/Disclosure required by mandatory reporting regulation (Communicable diseases reportable to Dept. of Health, New Cancer cases reportable to Pa. Cancer Registry, patient data reportable to Pa. Healthcare Cost Containment Council [PHC4], etc.). 4.n medical emergency situations, if a valid authorization can not be obtained and when disclosure of privileged information would be in the patient’s best interest, protected health information should be released in the following manner:

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• Obtain identifying information from the caller (name, address, and telephone number of the healthcare provider; name, date, and address of the patient; exact information to be released; and the purpose of the request). • Indicate that a return call and/or fax transmission will be made after the information has been verified and the medical record retrieved. • Attempt to verify the identity of the caller by reviewing the telephone directory, physicians’ index, or other available resources. • Return the call and further verify the identity of the caller by asking for the healthcare provider by name. • Document why authorization was not obtained. 5. Dates of hospitalization may be given to payer. III. Patients need not authorize the release of protected health information in the following situations for drug and/or alcohol information: 1. Non-GHS-employed physician who is the physician providing the drug or alcohol treatment. 2. GMC-based physicians have access to GMC site drug/alcohol information within the paper medical records. 3. Use/Disclosure required by mandatory reporting regulation. (Communicable diseases reportable to Dept. of Health, cancer patient data reportable to Pa. Cancer Registry, patient data reportable to Pa. Healthcare Cost Containment Council [PHC-4], etc.). 4. In medical emergency situations, if a valid authorization cannot be obtained and when disclosure of privileged information would be in the patient’s best interest, protected health information should be released in the following manner: • Obtain identifying information from the caller (name, address, and telephone number of the healthcare provider; name, date, and address of the patient; exact information to be released; and the purpose of the request). • Indicate that a return call and/or fax transmission will be made after the information has been verified and the medical record retrieved. • Attempt to verify the identity of the caller by reviewing the telephone directory, physicians’ index, or other available resources. • Return the call and further verify the identity of the caller by asking for the healthcare provider by name. • Document why authorization was not obtained.

DOCUMENT INFORMATION Devised

Revised/Reviewed (3/07)

Source

Revised: 10/31/2003

Release of Psych, D&A, HIV (Zych)

HIPAA MR Privacy Workgroup

OP:17:E HUMAN RESOURCES MANUAL POLICY 360 PROTECTION OF CONFIDENTIAL INFORMATION AND SANCTIONS (EXCERPT) PURPOSE To provide policy for the use and disclosure of Confidential Information and to fulfill the regulatory requirements for the same, as set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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POLICY STATEMENT 1. The Geisinger Health System (GHS) is committed to ensuring appropriate confidentiality of information, which is entrusted to GHS and will sanction violations. 2. Access to information is a privilege based on the individual’s business or clinical need to know. 3. Members of the GHS Workforce with access to Confidential Information must be aware of and constantly adhere to the requirements for the access, possession, use, copying, modification, dissemination, and/or disclosure of such Confidential Information. 4. Members of the GHS Workforce are responsible for the protection of any information, which they might copy, download, access from outside computers, etc. 5. Violations of this policy will result in disciplinary action.Violations with more negative outcomes will affect the severity of disciplinary actions. 6. All members of the GHS Workforce are prohibited from accessing their own medical information as well as that of family members and others unless required to do so as part of their responsibility at GHS. Members of the GHS Workforce should only access the minimum amount of information necessary to perform their position responsibilities. Approved use of "My Chart" for one's personal information is not affected by this prohibition. 7. GHS will not intimidate, threaten, coerce, discriminate against, or take retaliatory action against a member of the GHS Workforce: a) for exercising their rights under HIPAA, b) for testifying, assisting or participating in an investigation, compliance review, proceeding or hearing under HIPAA or, c) for opposing any act or practice made unlawful by HIPAA; provided the member of the GHS Workforce has a good faith belief that the practice opposed is unlawful, and the manner of the opposition is reasonable and does not involve a disclosure of Protected Health Information in violation of HIPAA. 8. Geisinger will provide training to all workforce members regarding this policy and federal regulations as appropriate for the position each workforce member holds. 9. If an individual has questions about this policy, he/she should contact his/her supervisor. DEFINITIONS A. Confidential Information Confidential information is defined as information to which access must be restricted by reason of law, regulation, ethical standards or business necessity. Confidential information includes, but is not limited to, the following information as communicated in any form, whether verbal, written, or electronic: 1. Patient healthcare and financial records including, but not limited to, the patient's medical record, test results, billing information, and insurance information. It is recognized that the strictest confidentiality standard is applied for legislatively protected patient information including, but not limited to, HIV-related information, mental health-related information, or drug and alcohol-related information. 2. Employee information (obtained through the performance of one’s job duties) including, but not limited to, personnel actions such as promotions, resignations, etc.; compensation; benefits; performance-related information; and/or medical/psychological reports.This restriction does not prohibit employees from sharing and discussing their own information relating to wages, benefits, and working conditions as protected under the National Labor Relations Act. B. Need to Know Need to know means that a member of the GHS Workforce must access the information to perform his or her duties and responsibilities. C. Protected Health Information (PHI) PHI is defined as any information, whether oral or recorded in any form or medium, that is created or received by a healthcare provider and relates to the past, present, or future physical or mental health or condition of an individual. D. Use Use is defined as with respect to individually identifiable health information, the sharing of employment, application, utilization, examination, or analysis of such information within the entity that maintains such information.

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SANCTION GUIDELINES A. Disclosure 1. Intentional/Malicious 1. Employees are subject to disciplinary action up to and including immediate termination. 2. Other members of the GHS Workforce are subject to loss of privileges to access, termination of contracts, and may be required to reimburse GHS for any monetary damages suffered by GHS. 3. Members of the GHS Workforce with medical staff privileges are subject to the loss of those privileges in accordance with the applicable medical staff bylaws. 4. Unintentional—The above sanctions for the various classes of GHS Workforce may be reduced at the sole discretion of GHS depending upon the severity of the offense or consequences to patients or GHS

DOCUMENT INFORMATION Devised

Revised/Reviewed 3/07

OP:17:F HUMAN RESOURCES MANUAL POLICY 380 ELECTRONIC COMMUNICATIONS AND COMPUTING POLICY POLICY The Geisinger Health System (Geisinger) provides utilization of its electronic communications and computing systems to employees and certain other persons for business purposes. Geisinger sets the standards for appropriate utilization of these resources; all users are responsible for complying with these standards. Failure to comply with the standards is grounds for discipline up to and including termination. All use of company-provided electronic communications is subject to monitoring. STANDARDS 1. Geisinger provides utilization of its electronic communications and computing systems to employees for business purposes. Occasional personal use of systems may be permitted provided that, in management’s opinion, there is no added cost or interference with productivity and that such use is not in violation of this or other policies governing appropriate use of the technology. Management has the right to define and correct inappropriate or excessive use. 2. Information Technology (IT) provides internal training for enhancement of skills in using electronic technology. Employees are encouraged to participate in training, which enhances their efficiency and productivity. 3. Users are expected to protect patient confidentiality as well as trade secrets and business information (HR Policy 360).They must handle this information in accordance with the Geisinger Data Access Policy (ISM Policy 06.005) and Data Sensitivity Policy (ISM Policy 06.003). Access to patient information and other confidential information is only permitted when necessary as part of the patient’s care or to perform the duties of one’s position. 4. The proper protection of passwords is essential. Passwords and individual access codes are not to be shared (ISM Policy 06.005). 5. All information processed through company-provided equipment or systems is company property; therefore it may be accessed by Geisinger. Passwords are not entered to protect individuals’ privacy, but to protect Geisinger’s information and authenticate/identify user’s activity. Geisinger may override user passwords to monitor appropriate use of resources. 6. Using company resources for solicitation or distribution of literature for any non-company purpose or for one’s personal gain is not permitted. Likewise, the advancement of one’s political, religious, or personal views or for the forwarding of chain letters is inappropriate.

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7. The use of electronic communications and computing systems for the viewing, transmission, saving, downloading, or possession of any material that may be construed by others as harassment or offensive on the basis of sex, race, color, religion, national origin, age, disability, marital status, veteran status, or any other non-job-related factor is prohibited.This includes pornography. 8. The downloading, installation, and/or sharing of improperly licensed copyrighted material (directly or indirectly) is illegal and prohibited in all cases on the Geisinger network and on any Geisinger device.This is to include programs, applications, and music files. File types include but are not limited to the following: WAV, MP3, RMX, RMJ, WMA, EXE, BAT, COM, PIF,VBS, INF, INI, JS, SCR, XML, HTA, HTM, HTML, HTT. 9. Geisinger purchases licenses or obtains permission to use software; all users shall abide by laws protecting copyrighted material. See the Copyright Policy (ISM Policy 06.007). 10. At times, Geisinger allows contractors, vendors, students, volunteers, or other person’s access to all or a part of the electronic communications or computing systems. In such instances, appropriate signed agreements must be obtained from each such user agreeing that they will abide by the standards of this policy. 11. Unauthorized connection of non-Geisinger equipment to Geisinger communications systems is not permitted. 12. Users must comply with the IT Internet Policy (ISM Policy 06.007) and all IT policies. 13. Users having access to highly confidential information may be required to sign specific access and confidentiality agreements. DEFINITIONS 1. Company-provided refers to all electronic communications equipment, hardware, software, or access provided by or leased by Geisinger for business use. 2. Electronic communications refers to Intranet and Internet systems, Email, voice mail, paging systems, computers, etc.

DOCUMENT INFORMATION Devised

Approved by

Source

Approved

2001

SLC 4/07

EVIDENCE 17—PART B: SOURCES OF EVIDENCE OP:17:C

PCM—Procedure for Handling Confidentiality

Policy 409

OP:17:D

Information Security Authorization for the Use and Disclosure of Protected Health Information (PHI) to External Entities

Policy 06.038

OP:17:E

HRM—Protection of Confidential Information and Sanctions Manual

Policy 360

OP:17:F

HRM—Electronic Communications and Computing Policy Manual

Policy 380

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EVIDENCE 17—PART C Organizational policies and procedures related to the documentation of patient/residents/clients care activities and staffing.

eisinger Medical Center completed implementation of the electronic medical record, called EPIC, for the inpatient areas in late 2007. Organizational policies and procedures related to documentation for staff and students, nursing care plans, and ongoing medical record reviews will be listed. Each department has a performance improvement committee, which does routine chart reviews. The staffing of each unit is done in four-week blocks. The Nurse Staffing Office maintains a master schedule for the hospital and is responsible for working with the charge nurse to ensure safe staffing levels at all times. Staffing needs are reviewed every four hours to determine a change in staffing.

OP:17:G NURSING PROCEDURE MANUAL POLICY 8 DOCUMENTATION GUIDELINES OUTCOME Documentation provides information on the patient’s condition and the type of care the patient is receiving. GENERAL INFORMATION 1. The patient’s medical record is a legal, confidential document and is the property of Geisinger Medical Center. a. Information from the record cannot be given to anyone without authorization of the patient. b. Only personnel directly concerned with the patient’s care are allowed access to the medical record. c. Documentation on the record protects a healthcare provider legally. 2. All entries in the patient’s medical record are to be made in black ink. 3. Military time and the metric system are used for all appropriate entries. 4. Identify patient’s name and medical record number on every side of each 8 x 11 sheet. 5. Sign all narrative entries made in the electronic medical record. Use first initial, last name, and postscript (RN, NA, LPN). Example: J. Doe, LPN. Initials can be used on flow sheets as indicated in procedure. 6. All entries must be documented as soon as possible after the event has occurred. 7. Late entries, when documenting out-of-time sequence, state current time, “late entry,” and time of occurrence. When documenting occurrence from a previous date, enter incident on current date (now date) and state “late note,” time, and date incident occurred. 8. Assessment will be done by an RN on admission, discharge, transfer, postoperatively, and whenever a change in patient condition warrants. 9. All forms used only on a specific unit may be located in that unit’s Nursing Practice Book (i.e., Labor and Delivery, Psych, Rehab, In and Out Surgery, Preop Holding, PACU). 10. Check marks, X marks, and initials are acceptable when completing flow sheets, but they must be completed with a final full signature of the clinician completing the form. All blank areas are addressed and considered not applicable. 11. The admitting time and the arrival time on the unit are separate times.The arrival time is defined as the time the patient arrives in the room and should be documented as such.

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ADDENDUM TO DOCUMENTATION POLICY Documentation Guidelines—Electronic Record Flow Sheet Systems Review 1. The following systems are documented routinely in flow sheets: Cardiac, Neurological, Genitourinary, Gastrointestinal, Respiratory, Integumentary, Lines, and Drains. 2. Standard: Both normal and abnormal findings on nursing system reviews are documented. 3. Within normal limits (WNL) is defined for each system in the flow sheet section. 4. If a system is determined to be WNL: a. select a “YES” in the WNL row. 5. If a system is determined to be outside of normal limits: a. document “with exception of.” b.complete the more detailed appropriate rows in that flow sheet section.

DOCUMENT INFORMATION Devised

Revised/Reviewed

Reference

3/05

Approved by the CNO—4/07

Jarvis, Carolyn, MSN, RNC, FNP. Physical Examination and Health Assessment. 3rd Edition. W.B. Saunders Co., 2000. Rules and Regulations for Hospitals, Pennsylvania Department of Health, Bureau of Quality Assurance, Division of Hospitals.

OP:17:H NURSING PROCEDURE MANUAL POLICY 8.1 DOCUMENTATION GUIDELINES FOR STUDENT NURSES OUTCOME Documentation provides information of the patient’s condition and the type of care the patient is receiving. GENERAL INFORMATION Mentoring Activities: • Foster a professional and nurturing relationship with the students. Nursing Documentation: • Nursing flow sheet documentation in the electronic medical record by the student nurse does not require a cosignature. • Progress Note documentation by the student nurse does require the cosignature by the nursing instructor. • The Geisinger employee, as the experienced provider, remains responsible for the patient. • The Geisinger employee is required to conduct and document a physical assessment and document flow sheet notes and any other pertinent notes related to patient care provided by the employee. Skill Acquisition: • Geisinger employee should confirm with the student’s nursing instructor to determine the process for student skill acquisition (dressings, Foleys, NG tubes, etc.). ° Most instructors prefer to be present to oversee the procedure to evaluate the student’s performance.

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° There are times when a staff nurse has agreed to act as a clinical preceptor for a senior student practicum. At that point, the instructor will meet with the student and staff nurse preceptor to clarify privileges and expectations. Medication Administration: It is recommended the instructor at least cosign the top of the medication administration record of the students. ORAL MEDICATIONS • The nursing instructor will determine IF the student may administer oral medications without a licensed provider accompanying the student to the patient bedside. • The student nurse is responsible for knowing whether an instructor is needed for medication administration. • If the student is not permitted to give the oral medications independently, the instructor is responsible to oversee the student’s performance and administration. • If the student is permitted to give oral medications independently (are signed off), then administration does not need to be witnessed.The staff nurse has discretion to double check or observe administration if there is a question of safety. INJECTABLE MEDICATION • The nursing instructor will determine IF the student may administer “injectable medications” independently with the exceptions indicated below: ° INSULIN must always be double checked/cosigned by a licensed nurse—staff or instructor—NO EXCEPTIONS.The student may administer to the patient without an instructor present if signed-off on subcutaneous injections. ° I.V. PIGGYBACK MEDICATIONS must be double-checked and cosigned by a licensed nurse-staff or instructor.The student may administer to the patient without an instructor present if signed off on technique. ° INTRAVENOUS PUSH MEDICATIONS of any kind must be double checked/cosigned and administration witnessed by the nursing instructor.

DOCUMENT INFORMATION Devised

Revised/Reviewed

Reference

2/05

Approved by the CNO—2/07

Nursing Clinical Practice Geisinger Health System Legal Services

OP:17:I NURSING PROCEDURE MANUAL POLICY 8.3 NURSING CARE PLAN DOCUMENTATION GUIDELINES OUTCOME Documentation provides information of the patient’s condition and the type of care the patient is receiving. GENERAL INFORMATION 1. The care plan will be initiated within 24 hours of admission to hospital. 2. Care plans will be updated at least every 5 days, or with change in patient condition, change in status, or transfer based on level of care. 3. Care plans will be filed per unit preference (examples: mini-chart, patient Kardex, main chart). 4. NICU and BP2 will review and document per unit-specific policy.

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DISTRIBUTION Inpatient areas.

DOCUMENT INFORMATION Devised

Revised/Reviewed

Reference

7/05

Approved by the CNO—2/07

Rules and Regulations for Hospitals Pennsylvania Department of Health, Bureau of Quality Assurance, Division of Hospitals

OP:17:J NURSING PROCEDURE MANUAL POLICY 8.2 MEDICATION RECONCILIATION GUIDELINES PURPOSE Accurately and completely reconcile medication across the continuum of care. GENERAL INFORMATION 1. Identify ALL medication taken by the patient (including prescriptions, patches, inhalers, eye drops, OTC, herbals, and supplements). 2. Information will be gathered at point of entry to healthcare facility. 3. Any licensed personnel can gather information on the medication reconciliation form. 4. If unable to obtain medication history, a reason must be documented. 5. If unable to obtain history at time of admission, a new form must be completed at such time when information is available. 6. In the event of transfer between units, the receiving unit will review the form and the MAR at time of transfer.This form does not need to be completed if the patient is being transferred to a different bed on the same unit. 7. The medication reconciliation form will be completed at time of admission to the unit, transfer due to change in patient condition, discharge, or change of service. MEDICATION RECONCILIATION PROCESS Admission 1. Each time the patient enters the health system at the ED, OR, or an ambulatory clinic site, the patient’s medications will be reviewed and recorded in EPIC, with all changes being documented. 2. At the point that a decision is made to admit the patient, a medication reconciliation form will be initiated. 3. The nurse/provider/pharmacist responsible will use the list printed from EPIC to begin the process of completion of the medication reconciliation form. a. The RN/LPN or provider will confirm with the patient, family member, or other appropriate source, the current medications and schedule, including date and time of last dose. b.If the patient does not have a list of medications in EPIC, the RN/LPN or provider will complete the medication reconciliation form using the patient, family, or other appropriate information source. 4. If there are medications, which the patient has that are unidentifiable or questions regarding the medication history, the RN/LPN or provider can consult the pharmacy to assist with the medication history.

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5. Once the medication history is obtained, the RN will compare this medication history with the medications that have been ordered on admission. If a home medication has not been ordered on admission and justification for not ordering the medication is not given, then the RN needs to indicate this on the medication reconciliation form and the provider must be contacted to address any discrepancies that occurred. It is very important that all home medications be accounted for, either through an admission order or a reason indicating why that medication has not been ordered. Discrepancies in dose and frequency must also be addressed. 6. The provider MUST either order the appropriate medications from the home medication list or document on the list the reason the home medication is not ordered on admission. 7. Both the RN and the provider MUST sign/date/time the medication reconciliation form.This acknowledges completion of the admission medication reconciliation process. 8. Once the admission medication reconciliation process is completed, the form will be faxed to the pharmacy and placed in the medical record in front of the DDI; this copy will be used to document ALL further medication reconciliation. Transfer 1. A transfer is defined as a patient who is moved from one level of care and/or service that results in medication orders being rewritten. 2. When a patient is being transferred to a different level of care or service, all medications must be reviewed at the completion of the actual transfer process. a. Comparison of the patient’s pre-transfer medications with the post-transfer medications. b.Comparison of the home medication with the post-transfer medications making sure all home medications are accounted for at the point of transfer. 3. Once the post-transfer orders have been written, the RN will compare the list of medications from the pre-transfer MAR to the post-transfer orders. Any medications that are not reordered or reconciled, write “transfer” and date on the next blank line on the medication reconciliation form and record all medications not accounted for through the physician order sheet or providers transfer note. Check the column for not reconciled and contact the provider and date/time/sign the medication reconciliation form. a. All medications that the patient was on prior to transfer MUST be accounted for post-transfer, either by reordering those medications post-transfer or documentation in the chart as to why the medications are no longer needed. 4. The home medication list must be reconciled with the post-transfer orders. Medications that were not ordered prior to transfer may need to be ordered after the transfer, based on the patient condition.The RN will compare the home medication list with the post-transfer orders. If these medications are not ordered or accounted for, the nurse must document that discrepancy on the home medication reconciliation form and contact the provider and request they reconcile these medications. Reconciliation can occur by either ordering the appropriate medications or documenting the reason the medication is to be discontinued. 5. After the completion of the documentation of any transfer medication discrepancies and contacting the provider about these discrepancies, the RN must sign and date the transfer signature lines on the medication reconciliation form. 6. This process is to occur each time the patient is transferred. Discharge 1. At the time of discharge, the provider should review the medication reconciliation form and indicate on that form any medications that the patient was taking prior to discharge that are NOT to be continued post-discharge. A reason must be indicated for each medication that is not to be continued post-discharge. 2. The provider should then complete the DDI form, listing all medications the patient is to be discharged on and also indicating on the medication reconciliation form which medications the patient was on prior to admission that are NOT to be continued post-discharge. a. The DDI should include both medications to be continued from those medications the patient was on prior to admission and any new medications to be added at the time of discharge. b.The DDI should clearly indicate any preadmission medications that are NOT to be continued after discharge. 3. When the provider has completed both the medication reconciliation form and the DDI, then he/she must sign/date/time the physician line under the “On Discharge” section of the medication reconciliation form in order to indicate the medications have been appropriately reviewed and reconciled.

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4. When the patient is ready to be discharged, and after the provider has completed their part of the discharge process, the RN will then compare the list of medications on the DDI with those on the medication reconciliation form. For each medication, the RN will indicate if the medication has been addressed at discharge (either a discharge order has been written for that medication or a reason for not ordering has been indicated on the form). 5. If all medications have been accounted for on discharge, the RN can continue with the discharge process. If there are medications that are not accounted for the RN MUST write “Discharge” and date on the next available line on the medication reconciliation form and list all medications that have not been reconciled and sign/date/time and document provider contacted.The discharge process cannot be completed until all medications are appropriately accounted for at the time of the discharge. Discharge may be placed on hold for one hour for the provider to reconcile medications on discharge.

DOCUMENT INFORMATION Devised

Revised/Reviewed

Reference

9/05

Approved by the CNO—1/07

IHI Saving 100,000 Lives Campaign, 2005

EVIDENCE 17—PART C: SOURCES OF EVIDENCE OP:17:G

NPM—Documentation Guidelines

Policy 8.0

OP:17:H

NPM—Documentation Guidelines for Student Nurses

Policy 8.1

OP:17:I

NPM—Nursing Care Plan Documentation Guidelines

Policy 8.3

OP:17:J

NPM—Medication Reconciliation Guidelines

Policy 8.2

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EVIDENCE 18 A description of the steps taken and mechanisms put in place to ensure that patients/ residents/clients are cared for in a safe and healthful environment.

eisinger Medical Center takes pride in its ability to provide quality healthcare to the residents of northeastern and central Pennsylvania. Quality is one of GMC’s four theme messages driving our vision for the next five years.

Patient Satisfaction Graph Press Ganey Reports November 2007 100%

90%

80% Safety & Security

Cleanliness

Attention to Needs

Cared for You

GMC Rates Better than Same Size Hospitals from National Database

QUALITY: STRIVING FOR PERFECTION GMC’s commitment to quality drives every patient care decision. All employees view quality as their first and foremost responsibility. State-of-the-art tools and equipment support this quality mission. New technologies, such as diagnostic imaging systems and surgical and pharmaceutical robotics, play a major role in providing caregivers with tools to make the best decisions for each patient. Leadership is committed to ensuring a safe and healthful environment for our patients, visitors, and employees. For example, SimMan™ and SimBaby™ automated mannequins are used to teach clinical methods and decision-making skills in realistic patient scenarios, reducing risks because technique proficiency is confirmed before it is used on a patient. GMC’s senior leadership places quality and safety at the forefront through routine “Quality and Safety Rounds.” The leaders directly observe compliance with handwashing guidelines and environmental hazards. They also interact with staff to validate staff knowledge of safety practices. Quality issues are discussed during staff interviews and reviews of clinical documentation. Leaders often interact with patients’ and families during these rounds as well to assess the patient’s and families’ perceptions of care.

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NURSING ROLE IN SAFETY AND QUALITY Nurses are great advocates of patient safety, both in patient care and in ensuring a safe environment. Attention to care detail protects the patient and ensures high quality practice based on best practice guidelines. Pharmacy and nursing work together to make sure patients receive the right medication at the right time. Routine actions to maintain safety for patients include the Five Rights: Right patient, Right drug, Right time, Right dose, and Right route when administering medications. Patient identification practices are strictly followed, equipment function is monitored, and any other environmental issues that may affect patient, family, or staff safety are flagged for immediate remedy. Nurses receive education regarding safety issues upon orientation, routinely throughout the year, and during the required annual educational courses. Operations managers are responsible for ensuring that unit staff members are compliant with educational requirements. To maintain safe, high quality care, nurses receive education for new equipment, whenever a policy is changed, or when new procedures are introduced.

Patient Satisfaction Graph Press Ganey Reports November 2007 100%

90%

80% Attention to Needs

Emotional Needs Addressed

Nursing Care

GMC Rates Better than Same Size Hospitals from National Database

Nurses attention to needs 99%, emotional needs met 99%, and nursing care 98%

INFECTION CONTROL DEPARTMENT More than two million square feet make up the GMC campus. To maintain cleanliness and promote a healthful environment, education is key. During initial orientation, infection control policies are covered to educate staff about cross-contamination prevention, bacteria, viruses, cleaning solutions, isolation environments, personal protection clothing, and hazardous materials reporting and handling. The education occurs routinely throughout the year whenever changes occur and during annual required education.

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An example of GMC’s commitment to patient safety is evident through the process that the medical center followed during the implementation of the handwashing campaign. Patients and families were surveyed and included in the planning, implementation, and evaluation of the process. Handwashing Campaign FLyer

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Handwashing Patient Survey Results January 2007 100% 75% 50% 25% 0% Did you know the importance of washing hands

Did you talk to the nurse about handwashing

Yes

Did you ask the doctor

Were you comfortable asking anyone if they washed their hands

HOSPITAL SAFETY MECHANISMS Several committees and departments are charged by leadership to continually evaluate and maintain the safety of all who visit the GMC campus.

Patient Safety Committee The Patient Safety Committee has oversight of patient safety activities and concerns. The committee meets monthly to review and act on recommendations issued by all regulating and accrediting agencies. It also reviews performance improvement reports to identify trends and opportunities for improvement. The committee then makes recommendations to the appropriate leaders (OP:18:A).

OP:18:A GEISINGER MEDICAL CENTER PATIENT SAFETY COMMITTEE POLICY 2.01 PATIENT SAFETY COMMITTEE Composition—The Patient Safety Committee is an interdisciplinary committee composed of individuals with organizational responsibility for quality, safety, and risk management.The committee is composed of the medical facilities patient safety officer, three healthcare workers of the medical facility that include medical and nursing staff, and two residents of the community served by the medical facility who are not agents, employees, or contractors of the medical facility. Meeting Frequency—The Patient Safety Committee will meet monthly. Functions—The Patient Safety Committee: • provides the oversight and management of the patient safety program; assures compliance in meeting requirements of ACT 13. • guides the development and revision of organization-wide and departmental-specific patient safety policies and procedures to ensure compliance with law, regulation, and accreditation standards and to foster a nonpunitive environment for error reporting. • evaluates and recommends systems for the reporting, tracking, and trending of incidents and other risk management investigations/activities to assure compatibility with required reporting specifications.

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• reviews and analyzes incidents, near misses, serious events, sentinel events, and infrastructure failures to identify trends or opportunities for improvement in collaboration with the Performance Improvement Department. • reviews all serious events to determine whether the review has been thorough and credible in ascertaining the causal factors for the event and that action plans are appropriate. • recommends corrective action resulting from review and analysis related to any type of event to appropriate hospital and medical staff committees. • identifies and participates in opportunities for sharing appropriate information within the organization to demonstrate the impact of the patient safety program to medical staff, employees, and the board of directors. • reviews and acts on recommendations issued by regulatory and accrediting agencies (as the Joint Commission on Accreditation for Healthcare Organizations, the National Quality Forum, the Food and Drug Administration, the Centers for Disease Control and Prevention, the Patient Safety Authority, the Pennsylvania Department of Health, the Institute for Safe Medication Practices, the Occupational Safety and Health Administration, the Agency for Healthcare Research and Quality, and other groups as appropriate). • researches and coordinates implementation of best practice ideas gained from networking and literature reviews. • recommends and assists in development of patient safety education and training opportunities for medical staff and employees based on identified needs. • reports on activities and results of patient’s safety program, including adequacy of resources allocated to patient safety activity and to the governing body annually.

PATIENT SAFETY EDUCATION Medical Staff and Employee Education GMC recognizes the importance of educating its medical staff and employees regarding patient safety. Patient safety, with specific focus on the elements of Act 13, will be part of staff and physician orientation. Education programs will be presented on an ongoing basis.

Patient and Family Education GMC recognizes the importance of patient and family education, generally, and particularly as applied to patient safety. GMC actively educates patients and family members through many methods, including but not limited to, ongoing physician/staff discussions with the patient and the patient’s family when appropriate, distribution of Patient Rights and Responsibilities and Speak Up brochures, and the activities of Patient Liaison Office and other dedicated staff. Additionally, valuable patient information/feedback/ follow-up communication is obtained through the Patient Complaint and Grievance Process and ongoing patient satisfaction surveys. A wide range of patient and family education issues will be addressed by the Patient Safety Committee with particularly valuable input from the community members. Safety Committee The Safety Committee, chaired by the campus Safety Officer, is charged with the development, oversight, and maintenance of policies and procedures related to environmental safety. In addition, a Safety Management Plan was developed by this committee to set standards that support an environment that is free of hazards (OP:18:B).

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OP:18:B GEISINGER MEDICAL CENTER PATIENT SAFETY PROGRAM AND PLAN OVERVIEW AND PURPOSE Attention to maintaining and improving patient safety and well-being is inherent in Geisinger Medical Center’s commitment to the relief of suffering and improvement in the quality of life to those in the community it serves. In committing ourselves to safeguarding individuals, Geisinger Medical Center (GMC) must fully understand the processes and systems that are utilized by the organization to deliver patient care. From this deeper understanding, GMC will be able to analyze, evaluate, develop, and implement changes that will continuously improve the way we deliver care to patients. The results of these efforts will: • demonstrate GMC’s commitment to the community it serves. • create a culture whereby individuals who work and practice at GMC respond appropriately to adverse events, proactively identify risk-reduction strategies, and participate in process and system redesigns to reduce risk of patient harm. • allow GMC to implement reliable processes, technology, or systems that will reduce the risk of errors reaching patients and causing harm. • promote greater medical staff and employee involvement in improving clinical care, which will result in improved employee and medical staff satisfaction. • translate into a more efficient and cost-effective model of care at GMC. • begin the healing process for those individuals suffering from serious events. GMC leadership, medical staff, managers, and employees must actively embrace and support the patient safety improvement and management program in order to achieve the results outlined above.The purpose of the patient safety plan is to provide a framework for the implementation of various components of the patient safety program at GMC. PRINCIPLES GMC’s patient safety plan is based on the following principles: • The leadership of GMC will keep the board of directors apprised of any adverse outcomes, safety problems, and efforts directed at improving patient safety. • Communication about the importance of patient safety must be well conceived, repeated, and consistent across the entire organization. In its communication with physicians, managers, employees, and patients, GMC will stress that safety problems are quality problems and that all persons must be involved in the patient safety reporting system, identifying deficiencies in current care processes, and in designing and executing solutions needed to create safer systems. • Responsibility and accountability for patient safety must be clearly articulated to physicians, managers, and employees. GMC will incorporate patient safety accountability into position descriptions, orientation, and ongoing education and training. • The sharing of events, lessons learned, and actions taken to make improvements in the care delivery system is important. GMC will provide methods for communicating patient safety initiatives and actions taken to prevent future adverse events. • Punitive approaches toward individuals involved in various events pushes reporting and disclosure underground, thereby preventing an opportunity for the organization to appropriately intervene to correct the underlying problems. GMC is committed to developing ways to reward rather than discourage reporting of errors or patient safety concerns and will celebrate successes at improving the reporting of patient safety concerns and errors and how such information has been used to make improvements in hospital processes, systems, and care delivery. Failure to report may also cause GMC to report a licensed healthcare professional to his/her respective state professional licensure board in accordance with Pennsylvania’s Medical Care Availability and Reduction of Error Act (Act 13). • At GMC, employee accountability may include any or all of the following: acknowledging the risks involved with complex healthcare delivery; acknowledging that an error occurred with possible resultant injury; providing remedial or restorative care; assisting in possible root cause analysis of the processes involved; and cooperating in fixing the problem(s) in the processes. • GMC will attempt to create reliable processes, functions, and services to enhance patient safety.This will be accomplished by using available information from within and external to the organization to design or redesign processes to minimize risk to patients.

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• GMC will seek to reduce variation in how patients are cared for in the organization and will devise strategies to avoid reliance on memory through the use of standardized protocols, checklists, work processes, and use of technology/automation and other proven human factors tools. • Patients are encouraged to actively participate in care decisions. Those who are informed of their treatment plan and properly educated and coached to question something that doesn’t seem right can often prevent an error from occurring. GMC will include patients as active participants in their care and promote patient and family questioning of the organization’s routine, procedures, and processes whenever something does not “look” or “feel” right. GMC will disclose information about serious events that cause harm to that patient and/or patient’s family in fulfilling its ethical responsibility and as a means of demonstrating the organization’s commitment to patient safety and the community that it serves. In the event of a serious event, the confirmation of this disclosure will be made in writing to the patient or patient’s family within seven days of the occurrence or discovery of the serious event. • Patients are encouraged to report patient safety concerns to their healthcare provider and to speak up when they have questions regarding their care or the care of a loved one. GMC provides patient education materials to support patient safety. Additionally the patient or patient’s representative can report safety concerns through the hospital’s Action Line. • As the field of patient safety evolves, the effectiveness of various approaches to improving patient safety will be studied and evaluated. GMC will consult the literature, examine the experiences of others who have responded to similar issues, and consider recommendations made by various authoritative groups in developing alternatives to reduce the possibility of error or having the error reach the patient. SCOPE AND COMPONENTS OF THE PROGRAM Internal Reporting Management of Events and Reporting A. Immediate Management of Event B. Patient Safety Reporting System A. POLICY The Geisinger Health System fosters a culture of improvement throughout all activities. In order to comply with the state law and regulations, Geisinger Health System leadership requires a systematic approach to determination of events, action to be taken, and follow-up to the events that could have compromised patient safety.The attached algorithm, decision tree, and taxonomy are used to make clear consistent rational-based decisions involving patient safety events. See Management of Events & Reporting under “PA-PSRS” in the Clinical Risk Management and Patient Safety Manual [WHERE’S B????] C. DISCLOSURE Discussions with the patient or family may be warranted if there is a change in the treatment plan or unanticipated event or outcome of which the patient may not otherwise be aware. All serious and sentinel events, errors that do not harm patients and do not have the potential to do so (insignificant or minor incidents), do not require disclosure to the patient. Disclosure of serious/sentinel events should be made to affected patient and, when appropriate, the patient’s family or designated decision-maker. D. EXTERNAL REPORTING Depending on the severity of the event or incident, the appropriate authorities, including the Patient Safety Authority and/or the Department of Health, will be notified utilizing the Patient Safety Authority Reporting System (PA-PSRS) by completion of required fields. Additional reporting will be completed, as appropriate, pursuant to the GHS Sentinel Event Policy. AUTHORITY AND RESPONSIBILITY Board of Directors—The overall authority for direction of the patient safety program rests with the GMC board of directors.The board of directors delegates its authority to implement and maintain the various components of the patient safety program to the president and chief executive officer of GMC. President and Chief Executive Officer—The president and chief executive officer in collaboration with administrative, managerial, and clinical staff ensures that the patient safety program is implemented throughout the organization and integrated appropriately with other activities within the organization, which contribute to the maintenance and improvement of patient safety, such as

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performance improvement, environmental safety, and risk management.The president and chief executive officer designates a qualified individual in the organization to manage the organization-wide patient safety program at GMC. Patient Safety Officer—An individual designated by the president and chief executive officer who is responsible for the organization-wide patient safety program.The patient safety officer will: • oversee the creation, review, and refinements to the patient safety program. • coordinate and prioritize the activities of the patient safety committee. • develop and implement adequate information and management systems to support the activities of the patient safety program. • identify and secure the necessary resources to fully implement the patient safety program. • ensure compliance with serious event, incident, and infrastructure failure reporting requirements as mandated by law/regulations or to meet accreditation standards. • oversee the investigation of serious events and, as appropriate, identified incidents. • ensure that disclosure of serious events to patients and/or families is carried out in accordance with organizational policy and law/regulations. • devise strategies to enlist medical staff, employee, and patient family input into the organization’s patient safety plan. • serve as the direct link to the board of directors and chief executive officers on all matters related to patient safety. • ensure that the organization conducts proactive hazard analyzes. • serve on the Patient Safety Committee. • report to the Patient Safety Committee regarding any action taken to promote patient safety as a result of investigation.

EMERGENCY DRILLS AND PREPAREDNESS Periodically, the hospital announces practice codes to prepare staff for handling emergencies. These practice codes help to educate staff about appropriate measures to ensure patient safety during emergencies—such as severe weather, hazardous waste spill, dangerous person(s) or situations, or fire. Patient-specific safety codes include emergency codes (99) and adult and pediatric full arrests (44 and 22, respectively) to mobilize a response team. Another method that has been instrumental in increasing patient safety is the initiation of the Rapid Response Team (RRT). This team consists of a critical care-ready nurse, a respiratory therapist, and a physician to help a patient in potential distress. The goal is to assist the direct-caregiver with communication, assessment, and intervention as necessary. The RRT has proven to be successful in preventing a number of compromised patients from progressing to full arrest (OP:18:C)

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OP 18:G RRT Calls vs Codes-per-Floor: Jan 2006 thru Sept 2007 20 18 16 14 12 10 8 6 4 2 0 AGP2

AGP4

AGP5

BP2

BP5

RRT Calls

BP6

BP7

BP8

Codes

HUMAN RESOURCES All GMC employees are carefully screened for job competency. They are also given a health screening and are drug tested. A criminal background check is run after a job offer is made and accepted but before the work start date. Employees must have verification of all credentialing (if licensure is required) before completion of the hiring application. The Human Resource Department’s job descriptions and subsequent evaluations cover the need for employees to know and meet safety performance expectations. For example, safety is one of four primary categories on the annual performance appraisals of all employees (OP:18:C). When an employee is terminated, the employee’s access to the system is terminated immediately to prevent reentry to secure work areas.

OP18:C SAFETY CATEGORY FROM ANNUAL PERFORMANCE APPRAISAL 5d. Safety 1. Inform patients and families about care, medications, treatments, and procedures; encourage them to ask questions and participate with caregivers in the development of their treatment plan. 2. Participate in required organizational and departmental patient safety education programs and other activities designed to improve departmental and organizational patient safety. 3. Promptly report serious events and incidents in accordance with established polices and procedures. 4. Assume responsibility for identifying processes or systems that could lead to errors and adverse events. 5. Know and follow organizational and departmental policies and procedures applicable to assigned duties.

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FACILITIES A safe and healthful environment starts as early as the building plans. All GMC buildings are built to meet regulations that satisfy standards for patient room size, air exchange, lighting, electrical, medical gas, water, fire safety, and exits. Facilities staff is educated on storage and use of hazardous materials, fire and emergency responses, and keeping patient and visitor areas free of fall hazards. An ongoing Hazard Surveillance Program is conducted by the Safety Committee, which completes an entire campus survey every six months. The Building Management Program surveys one floor each week to check fire doors, ceiling tiles, flooring, handrails, hall access, and lighting. There is ongoing preventative maintenance performed for all utilities, including electric, gas, water, medical gases, elevators, and medical equipment. Facilities staff perform risk assessments on an ongoing basis for infection control. They use construction barriers and negative pressure machines around construction areas. Risk Assessment also looks at appropriate use and storage of chemicals and performs surveys to identify fire hazards or potential fall areas. All MSDA materials are reviewed on an ongoing basis to confirm their use and possible risks for patients and employees. For example, the continuous review of the safety and use of hazardous materials resulted in the elimination of mercury that formerly was used in blood pressure cuffs, thermometers, and dilators as well as two types of sterilizers (gluteraldehyde and ethylene oxide).

SECURITY The GMC campus covers more than two million square feet and is made up of multiple buildings. Geisingerâ&#x20AC;&#x2122;s Security Department, which provides coverage around-the-clock, is charged with protecting patients, families, and employees from harm (or fear of harm) and protecting personal and institutional property from misuse, vandalism, and theft. Department members carry out this responsibility by controlling access to facilities, through camera surveillance (campus and parking lots), by driving and walking patrols, and with the help of intrusion alarms, panic alarms, and coded locks. All areas are well lit and well marked. Construction and renovation generally take place during off hours and weekends to minimize disruption of the general traffic flow. The security team also directs and assists visitors. A response plan is also in place to respond to possible threats to public safety, threats of danger, hostage situations, and bomb and terrorist threats. Areas that are considered high risk include pharmacy, cashier stations, areas with cash boxes, medical records, human resources, nuclear medicine, the emergency department, and the operating rooms. These areas have high patrol monitoring, closed circuit camera monitoring, coded access, and alarm systems. The security team interacts with outside agencies as needed to address and maintain a safe environment. The Security Department is also involved in community safety initiatives related to disasters and terrorism prevention and response teams. Each member of the Security Department has a radio system that can switch directly to the emergency 911 call centers and be in direct contact with emergency response teams. An important part of patient and visitor safety is the transportation of prisoners through the medical center. In 2006, more than 1,100 prisoner escorts for outpatient services were required, and there is usually at least one prison inpatient in the institution at any given time. The prisoners are kept away from the general public areas as much as possible and are escorted to the clinical areas by GMC security as well as guards from the prison.

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An overview of all safety procedures is outlined in the GMC Hospital Safety Manual, available on the Info Web, GMC’s online information system.

ENVIRONMENTAL SERVICES To maintain cleanliness and promote safety on a two-million square foot campus, education is key. During initial orientation, Infection Control policies are covered to educate staff about cross-contamination, bacteria, viruses, cleaning solutions, isolation environments, personal protection clothing, and hazardous materials reporting and handling. Environmental Services supervisors conduct continuous surveys. An Environment of Care Committee (meeting monthly) addresses any environmental problems that might impact visitor, staff, and patient safety. Life Safety Rounds, conducted by a subgroup of the Environment of Care Committee, are conducted to identify issues that should be brought to the committee for discussion and action. Environmental Services has a strong relationship with Infection Control to ensure that both departments are kept abreast of appropriate procedures for isolation and patient, staff, and visitor safety in isolation environments.

FOOD SERVICES All diets are managed through a Computrition program that manages diet orders as well as food allergies and food substitutions. Patients requiring kosher meals are provided with ready-to-eat meals. Other cultural requests are addressed by paging the dietary supervisor. Dietary workers wear black and white uniforms so they can be easily identified and to distinguish them from medical staff. Servers are assigned to patient floors and become a team member of that unit. This continuity helps to ensure high quality patient service. Meal distribution is dependent on two ways of identifying the patient before patient meals are served. In the first method, the patient must be able to correctly give his or her name and date of birth. For nonverbal or disoriented patients, the patient’s primary care nurse must verify the patient’s identification. GMC follows a thorough and comprehensive approach to maintaining a safe and healthful environment for all staff and patients along with their families and visitors. In all aspects of care, GMC is striving for perfection. EVIDENCE 18: SOURCES OF EVIDENCE OP:18:A

Patient Safety Committee

OP:18:B

Patient Safety Program and Plan

OP:18:C

Safety Category from Annual Performance Appraisal

Policy 2.01

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EVIDENCE 19 A description of the steps and mechanisms put in place to ensure that nurses practice in a safe and healthful environment.

T •

•

he GMC Safety Manual outlines the policies that directly involve all departments and facets of employee safety. GMC nurses and nursing units are given additional health and safety considerations. Examples follow. As areas are being repainted or refurbished, the Facilities Department updates flooring and walls to ensure appropriate lighting and reduced noise levels. Two industrial hygienists are on staff at GMC to do ergonomic assessments of work stations so that computer keyboards, monitors, telemetry equipment, fax machines, and work surfaces contribute to a safe work environment. They are also in the process of creating quiet zones around nursing work stations as a way to avoid interruptions that may lead to transcription errors. Quiet work zones also help foster a calmer environment for appropriately retrieving, returning, and documenting medications and treatments. Attention to a healthful work environment that is free of clutter enables nurses to ambulate patients easily. An equipment storage initiative helps support a clutter-free work environment and has resulted in a collaboration that involves several departments. Nursing worked closely with Facilities, Admissions, and Housekeeping to develop a plan to remove equipment that is not currently being used. It has improved the care environment for nurses, patients, and families. Nurses and coworkers no longer handle nitrogen cylinders. This medical gas is now bought and stored in bulk. Again, GMC is the only hospital in Pennsylvania that has made this safety improvement for nurses and staff. A Lift Team is available to assist with patient lifts and transfers. The team was implemented to help avoid lift injuries. The Lift Team does regular rounds and is available by pager. Nursing education on the safe transfer of patients is part of nursing and safety orientation. Sling lifters have been placed on all floors. These are easy to use and have scale and transport capability and disposable slings to control infection.

SECURITY GMC has van buses that make continuous pick-up and drop-off rounds through the employee parking lot—providing not only a safe escort, but also high visibility to parking locations. Panic phones in the middle of each level of the parking lot and continuous camera surveillance add another level of safety. Security is available to escort employees who have safety concerns.

EDUCATION Continuing education plays a major role in maintaining a safe and healthful environment for nurses. As new equipment is implemented, inservices are held on every shift by a nurse educator. Continuing education for fire safety, medication administration, disaster planning, proper medical waste disposal, radiation safety, proper lifting protocols, and universal precautions and infection control protocols are provided on an annual basis through our internal educational sessions, known as “GOALS.”

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INFECTION CONTROL On the recommendation of the Infection Control Committee, a Handwashing Campaign occurred. Waterless soap stations have been placed throughout the hospital and in key high-traffic areas to reduce bacterial and viral transmission to keep nurses, staff, and patients healthier.

HEALTH AND FITNESS We are committed to our patients’ and employees’ health. During a period of several months, GMC made steady progress to a smoke-free campus with staged reduced tolerance of smoking on campus grounds. In November 2007, GMC became a smoke-free campus. During the past two years, GMC established an Employee Fitness Center located in the GMC Ambulatory Surgery building on Woodbine Lane. The center offers a full range of exercise equipment and aerobic training. Employees can engage a fitness trainer to personalize their exercise regime.

FACILITIES At GMC, all power runs on uninterruptible power sources. GMC is the only hospital in Pennsylvania to have a central utility that manages power to the campus providing continuous power to operating rooms, imaging equipment, high-level units, the emergency room, and computer charting stations. All water is treated with chlorine dioxide and intensive sampling and culturing is done at 56 locations throughout GMC to protect patients and employees. GMC uses municipal water sources as its primary lines. However, the campus has its own 500,000-gallon reservoir and its own well; both serve as back-up, particularly for heating and air conditioning units. Any turbidity in our water source results in closure of a valve, flushing of the line, and opening of a new source with no interruption in water service.

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EVIDENCE 20 Identification of important/key changes made in nursing services as a result of data gained from participating in national benchmarkable studies regarding quality, productivity, safety, and cost associated with delivering services to clients.

triving for Perfection—the organization’s mantra—is the responsibility of every Geisinger Medical Center family member. We provide the highest quality continuum of care with complete focus on each patient. The GMC experience will be one of consistent excellence—no matter where patients are seen or who in the organization takes care of them. Leadership understands and values the perspective gained from data obtained from national benchmarked studies to drive decision making. Comparing our performance to the results achieved by other organizations provides perspective and validation of our practices and challenges us to be the best we can be at all times.

PRESS GANEY Press Ganey is a company that provides national comparison data for patient satisfaction. A large random sample of our patients is surveyed routinely to determine satisfaction levels with the care they received throughout our organization. The survey results are stratified from the overall score down to the unit and provider levels. This data is useful in determining whether process and education changes are needed to assure the standard of compliance we strive for. Within the Nursing Department, changes in practice have occurred as a result of the Press Ganey Patient Satisfaction reports. As one example, staff involvement and authority have been increased to address issues as soon as they are noticed. Another example is the implementation of patient “call backs” that involve a staff nurse or manager from each inpatient unit calling patients after discharge. The goal of these call backs is to express our concern for the patients and to find out if they were pleased with the care we provided. Managers make daily patient rounds to interact with patients. They answer questions and let patients know our goal is to provide the best care possible. A third example of a change that occurred from Press Ganey feedback is the initiation of a discharge letter given to each patient. The letter provides the manager’s contact information so the patient can call with questions. This initiative is discussed in more detail in later chapters along with samples of the results.

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GMC Patient Satisfaction Percent 300-449 Bed Hospital (includes Inpt, Outpt, JWCH, OSW combined) 100% 80% 60% 40% 20% 0% Overall Average

July - Dec 2006

Overall Care

Recommend

Jan - June 2007

July - Sept 2007

NATIONAL DATABASE FOR NURSING QUALITY INDICATORS Participation in the National Database for Nursing Quality Indicators (NDNQI) has been valuable in improving and gaining perspective about the quality of care we provide. The fact that we need to report the number of certified nurses we employ has sparked an increased interest in obtaining professional certification. The increase in the number of certified nurses in our medical-surgical areas has been substantial.

NDNQI - RN Certification Medical-Surgical Unit 70% 60%

40% 20% 0% AGP5

BP5

BP6

BP7

BP8

National Mean

% with National Certification

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Nursing also uses NDNQI hours-per-patient-day (HPPD) data to gain perspective on our staffing plan. Overall, we compare very positively with the national data. Most GMC units had a higher HPPD rating than national figures for like units. A few units, however, had an HPPD lower than the national benchmark. Sue Hallick, our CNO, and the nurse managers worked with staff nurses to evaluate the data. The result was an increase in the HPPD and RN-to-patient ratio on several units. The goal of increasing the number of direct-care providers is to improve the care provided to our patients. NDNQI Graph Hours Per Patient Day Medical-Surgical Combined 3-Year Trending 15

0 AGP4

AGP5

BP5

4Q05

4Q06

BP7

BP8

3Q07

Pressure Ulcer Incidence reporting has heightened our level of awareness and focus on documenting wound care. Changes in nursing practice resulting from the data obtained included a policy revision; education on prevention, assessment, and care of pressure wounds; and the increased frequency with which the Skin Team does an adult hospital evaluation of prevalence.

NDNQI Hospital Acquired Pressure Ulcers – AGP5 8 7 6 5 4 3 2 1 0 3Q05

AGP5

3Q06

Hospital Average

3Q07

National Mean

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ORYX MEASURES Geisinger participates in other national benchmarked studies as well, including ORYX measures conducted by the Joint Commission. This study compared GMC’s performance with four key diagnosis and associated care parameters. One key change that occurred as a result of our involvement was the focus of the nursing staff on completing smoking cessation education for acute myocardial patients, congestive heart failure patients, pneumonia, and stroke patients.

INSTITUTE OF HEALTHCARE IMPROVEMENT COLLABORATIVE The Institute of Healthcare Improvement (IHI) Collaborative is a not-for-profit organization leading the improvement of healthcare throughout the world. The institute helps accelerate change in healthcare by cultivating promising concepts for improving patient care and timing those ideas into action. Numerous changes in nursing practice have come about as a result of data generation by IHI. A few examples of the changes in the Saving 100,000 Lives Campaign (now the 5 Million Lives Campaign) associated with the IHI include: • The VAP (ventilator-associated pneumonia) Prevention Program drove changes in nursing practice related to the care of ventilated patients, such as keeping the head of bed at 30 degrees, changing oral care techniques and frequency, and securing the endotracheal tube, among several others.

VAP Compliance January 2005 - December 2007 100%

90%

80%

70%

January 2005

December 2005

January 2006

December 2006

January 2007

December 2007

VAP Compliance

• The Central Line Bundle was implemented to decrease the potential for blood infections resulting from contamination of central-line catheters. Examples of changes in nursing practice that resulted from this program were the development of hospital-wide line carts that contain all needed supplies, new physician order sets, standardized procedures, and more.

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• The Sepsis Prevention Program resulted in educating the nursing and physician staff about early identification of patients suspected of becoming septic (a severe blood infection). The RRT (Rapid Response Team) also came about because of this program. RRT is a team available 24 hours a day, seven days a week to assist a nurse who has determined that her patient is at risk of becoming compromised. The nurse can contact the RRT by a designated phone number so she can easily notify the team of her need for help. (The RRT is discussed in more detail in later chapters.)

CLINICAL EFFECTIVENESS DEPARTMENT Geisinger has a comprehensive approach to quality. Many of these activities are driven by the Clinical Effectiveness Department. The department is led by a nurse, Karen McKinley, RN. The activities spearheaded by this department are discussed in greater detail in FORCE 6; however, one example is the Geisinger Quality Institute, which consists of interdisciplinary teams that look at processes or focus on care provided to certain patient populations. Nurses are coleaders and staff nurses are engaged in the problemsolving, decision-making process. Several nursing practice changes occurred as a result of the institute’s efforts, such as the Proven Care for interventional cardiac catheterizations now includes a pre-cath medication of bicarbonate for patients with renal insufficiency, the use of coude catheters in males 50 years of age or older to decrease the risk of urinary tract infections, and the improvement in the triage process in the Emergency Department and isolation practices. Another example of GMC’s quest to provide excellence in quality and perform above known benchmarks occurred with the medical center’s designation as an Accredited Chest Pain Center by the Society of Chest Pain Centers. GMC is the seventh hospital in Pennsylvania to receive full accreditation. The medical center is well below the state and national target of 90 minutes for door-to-balloon evaluation and initiation of intervention. GMC performed well when compared to the chest pain treatment benchmark of hospitals across the state. Staff nurses, educators, and nurse managers were involved in the process. As a result of this initiative and nurses’ involvement in the success, nurses drove practice changes to further improve patient care by developing an annual 12-lead electrocardiogram competency and developing a required online program for all employees (housekeepers to administrators) to teach the warning signs and symptoms of a heart attack.

SAFETY A commitment to safety goes hand-in-hand with quality at Geisinger Medical Center. We use several benchmarked studies to glean perspective on safety issues. We conduct a biannual safety survey to evaluate the safety of all work environments. All employees are asked to participate. The information is compared to that from previous years and benchmarked with external organizations. Changes that have resulted from this data include adjusting the bus service that transports staff to and from the parking areas and initiation of the “quiet zone” for medication administration. Facilities staff use benchmarked data related to facility maintenance. One example of this information that had a very positive impact on nursing was the initiation of the “Zone maintenance” concept. A team of maintenance professionals is assigned to certain areas of the hospital. The Zone maintenance teams have

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become familiar with the nursing staff and vice versa. This concept has improved communication and the speed with which unit-based maintenance issues are addressed. Staff nurses and the maintenance worker can interact directly to identify and solve potential safety issues. The Healthcare Cost Containment Council (HC4) provides yet another source of benchmarked safety data that Geisinger uses to improve nursing services. Information regarding “device days” (information about the length of time that various devices are used) is reported in this study. The impact on nursing practice has been positive. For example, the number of urinary catheter days has been decreased by the nurses reporting the information and has resulted in an increased awareness of the impact of these devices on the patients.

COST ANALYSIS The awareness of product and service cost is essential if an organization is to remain vital and growing. The Materials Management Department (Purchasing) uses benchmarked data provided by the Premier Buying Group to identify opportunities to reduce cost and increase quality. This effort led to a significant change in nursing practice through the development of the Clinical Use Evaluation (CUE) committee, a multidisciplinary committee that discusses, evaluates, and makes decisions regarding products used throughout the organization. The committee is made up of many staff nurses and is cochaired by a clinical nurse educator. One example of change is the replacement of patient bathing products with new ones. GMC is committed to using national and state benchmarked studies to improve care. Nurses are involved in all aspects of these studies through the selection, data collection, and evaluation of the results. The information provides valuable perspectives on nursing practice and the process applied during patient care. As valuable members of the interdisciplinary care team, nurses are involved in evaluating data gleaned from studies to improve their process of care delivery each and every day. Service cost analysis (such as costper-patient-day) assists in resource management and efficiency.

GEISINGER MEDICAL CENTER—COST-PER-PATIENT-DAY FY 2007 FY 2008 November YTD (annualized) UNIT

FY 2007

BP5

$382.29

ANNUALIZED November YTD 2008 $423.87

AGP5

$495.48

$560.78

BP6

$398.50

$446.65

BP8

$423.88

$448.63

BP7

$394.28

$440.34

AGP4

$451.00

$531.35

AGP2

$458.43

$545.53

BP2

$348.18

$552.53

$1,016.61

$1,169.48

AICU SCU3 AICU SOUTH

$764.97

$799.96

$1,211.04

$1,053.90

FY 2007 FY 2008 November YTD (annualized)

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UNIT

FY 2007

ANNUALIZED November YTD 2008

CCU

$1,182.74

$1,268.69

SCU4

$756.74

$803.57

NICU

$676.50

$717.66

PICU

$1,318.20

$1,422.77

CH2

$629.37

$739.96

CH3

$566.53

$261.38

LDRP

$819.28

$787.89

NSY

$124.75

$101.96

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EVIDENCE 21 A description of the steps taken within the organization to address the identified needs of nurse employees.

he CNO recognizes the need for continual and close communication with nursing staff at all levels. This need is satisfied by high visibility in rounds, meetings, Nursing Notes (the nursing newsletter), the Nursing Channel on the GMC Intranet, and in high-traffic areas such as the employee cafeteria. The CNO has an open-door policy. In addition, she gives routine updates on the status of Geisinger’s organizational and nursing mission and vision, construction plans, patient satisfaction data, communication on activities throughout the system, accreditation status, and other information pertinent to the hospital and nursing leaders, council members, and direct-care providers. The flat structure of the Nursing Department works to develop future nursing leadership at the unit and mid-level of nursing to address any issues, provide suggestions, and solve problems. The nursing staff has a dynamic and strong presence in daily operations and a role in the success of their units and the units’ environment and the fulfillment of patient needs.

QUALITY: EDUCATION An inpatient and outpatient Career Enhancement Program (Clinical Ladder) is in place to promote professional growth and development. This program includes mentoring, education, certifications and performance improvement, leadership, and committee memberships on both unit-based and hospital-based committees. Sue Hallick, the CNO, and her team are committed to supporting the continuing education of the nursing staff. Geisinger has continued to increase funding for nursing units to promote and support continuing education for nurses at both internal and external conferences. There is a strong and active nursing education department that provides education to nurses on all shifts. Involvement in professional organizations and the pursuit of certification is supported by the nursing leadership. Nurses may also receive a bonus for successful completion of this professional activity. Nursing budgets support the purchase of professional books and journals for continuing education and as resources for nursing staff.

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GMC RN Certification NDNQI - 2nd Quarter 2007 60 50 40 30 20 10 0 Adult Critical Care

Adult Step Down

Adult Medical-Surgical Combined

Peds Critical Care

National

Neonatal Critical Care

Peds Medical-Surgical Combined

Psychiatry

GMC

INNOVATION The CNO has developed nurse leaders who facilitate a shared governance structure at the unit level. Nurses are involved in decision making on practice issues and work schedules. Innovative staffing programs—like the Weekend Program and Supplemental Staffing Incentive—have been developed to support the 24-houra-day/7-day a week staff. Participate in Hospital Decision Making NDNQI RN Satisfaction Results 4 3 2 1 0 2006

2007

National Score

GMC Score

HUMAN RESOURCES Nursing recruitment is done continually, not just when an open position occurs. This is especially true for hard-to-recruit positions, such as nurses in the ICU, CCU, OR, and ED. Geisinger is committed to ongoing market analysis of nursing compensation to ensure competitive salaries. In fact, during the past three years, nurses have received increases twice each year. We have

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developed flexible staffing options set by each unit. (Some units prefer to have all 12-hour shifts and others prefer a mix of 8-hour and 12-hour shifts.) Each unit has a council that handles staff scheduling that meets the needs of their unit and its employees. Personal needs are also considered in the unit scheduling process.

NDNQI RN Satisfaction Staffing Adequacies 3-Year Trending (2005, 2006, 2007) 100% 80% 60% 40% 20% 0% Discharged Pts Prepared Adequately (% yes)

GMC 2005

Inadequate Staffing Affect Admits, Transfer & Discharges (% no)

GMC 2006

GMC 2007

Had Enough Time to Document (% no)

National 2007

SAFETY The safety of Geisinger nurses is a priority system-wide. Ongoing environmental assessment occurs and all aspects of safety are addressed. As noted in EVIDENCE 19, a Lift Team is in place to aid in difficult lifts. Hydraulic lifts are also available. A needleless system has been in place for more than five years as a protection against accidental needlesticks and an I.V. team is available for difficult I.V. placement. Shuttle buses are available to bring nurses and other employees in from remote parking lots. Members of the Security Department are available on request to escort employees to their cars. NDNQI RN Satisfaction Lifting 3-Year Trending (2005, 2006, 2007) 100% 80% 60% 40% 20% 0% 2005

2006

National Score

2007

GMC Score

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