Mini Booklet pre-final

Keep Calm

and

Prepare for
Excellence in

Nursing

Preparation Booklet (2019)

Al Rahba Hospital Mission Toward Nursing Excellence

pg. 1

This booklet was prepared to serve as a guide
for Al Rahba hospital nurses in the mission to
achieve pathway to excellence (PTE)
designation.
Special acknowledgment to Al Rahba Hospital
PTE Taskforce for their invaluable efforts in
leading, coordinating and implementing the
certification project requirements.
PTE Taskforce Members:
o Ms. Haleimah Al Blooshi- CNO - Chair
o Mr. Muayyad Hussein ADON- Co-Chair
o Ms. Iman Othman & Ana Katrina Antonio
o Mr. Mustafa Elayan & Ms. Carlien Grabe
o Mr. Julies Vin Kurian & Ms. Maria Balmes
o Ms. Vinu Varghese & Mr. Ratish Shivraman
o Ms. Maysoon E'nouz & Ms. Thresiamma

Thomas
o Dr. Souher El Amouri & Ms. Bindu

Chittilapilly

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Contents:

 Brief Description of Al Rahba Hospital
 Overview of Pathway to Excellence

Program
 Section One : Brief Description of six PTE

practice standards
 Section Two: Common questions about

PTE practice standards
 References

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Brief Description of Al Rahba Hospital
Al Rahba Hospital (ARH) opened in 2003, is part
of the Abu Dhabi Health Services Company
(SEHA) network of public hospitals owned by the
department of health of Abu Dhabi. It is a 166-
bed advanced secondary care hospital, which is
located approximately 30 km outside of Abu
Dhabi City and provides diagnostic and
therapeutic management in obstetrics,
gynecology, internal medicine, pediatrics,
general surgery and emergency care. In 2018 the
hospital was certified for the 4th
time with Joint Commission International
Accreditation.

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Overview of ANCC Pathway to Excellence
Program:

The Program recognizes a health care
organization’s commitment to create a positive
practice environment that empowers and
engages staff; its owned by The American Nurses
Credentialing Centre (ANCC)

Benefits of Pathway to Excellence Designation
A positive working environment reaches to the
very depths of an organization’s success. From
patient outcomes to financial results,
Pathway to Excellence standards are strongly
associated with the following:
 Improving nurse satisfaction;
 Retaining the best staff and leaders
 Cultivating inter-professional teamwork
 Championing high quality nursing practice
 Supporting business growth.

Pathway to Excellence Standards

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Pathway to Excellence practice has 6 practice
standards that supports the essential
components of a healthy work environment,
they are as below:

1. Shared Decision Making standard
2. Leadership Standard
3. Safety Standard
4. Quality Standard
5. Wellbeing Standard
6. Professional Development standard
Each standard have multiple measurable
requirement which is called elements of
performance (EOP). The EOP measures the
availability of the needed structures and
processes to meet the standard focus.

Pathway to Excellence Appraisal process
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1. Review website information
2. Review manual
3. Conduct self-assessment (gap analysis)
4. Determine status and work for readiness
5. Submit pathway standards document

(ODF, OO, EOP)
6. Successful document review
7. Pathway Nurse Survey
8. Designation vote by commission on

pathway to excellence
9. Celebrate (Four-Year designation),

interim annual reports
10. Year 3, submit re-designation

application

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Pathway to Excellence Accreditation Evaluation
Process
Document Review
Team of expert nurses will review pathway
standard document, each appraiser reads &
independently evaluates, then a consensus score
is achieved for each standard. Review time
varies and may take several months.
If all standards are met, the establishment
threshold organization advances to Pathway to
excellence nurse survey.
The Pathway To Excellence Nurse Survey
A minimum of 60% of eligible responders must
complete the pathway to excellence survey
A minimum of 75% favourable score is required.

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Section One:

Brief description of the six pathway to
excellence practice standards and related
new processes and structures developed by
ARH team to meet requirements for each
practice standard.

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Highlight: The focus of this standard is that the
organization has an established & functioning
shared governance structure as the foundation
for involving direct care nurses in decision-
making.

Building an organizational atmosphere of shared
decision-making can be attained by expanding
the number of staff involved in making practice
decisions. This could occur through shared
governance structure, which provides frontline
staff with the venue for decision making
regarding issues that affects practice.
The key principles for shared decision making at
the point of service.

1. Partnership,
2. Equity
3. Accountability
4. Ownership

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ARH Nursing Shared Governance
Structure: Is a councillor model,
consists of 6 interrelated
levels

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1. Unit-Based Council (UBC) - a forum for direct
care nurses to make practice decisions based on
the best available practice evidence.
2. Divisional Council- a forum for all UBC chairs
to share best practices between units.
3. Central Council- a forum to support UBC in
specific practice area, through guidance of
senior subject matter expert.
4. Nursing Advisory Council- a forum for UBC
chairs and administrative nurses including CNO
to meet, discuss, and finalize nursing
department wide issue.
5. Senior leadership Committee - A forum for all
departments’ executives to set and follow up on
ARH strategic matters, chaired by CEO.
6. Management Oversight Committee – A
forum for ARH executives to discuss strategic
matters with SEHA (governing body) executives.
The only council that has the authority to
increase or decrease the set hospital annual
budget.

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Chairs of the Unit-based Councils

Jansy Alex Sony Punnoose Marwa Talal
ED UBC ICU UBC OT UBC

Deepa Varghese Bindu Saji Alya Ali Huwail
Pediatric Ward Puduparambil Beshr
Ob-Gyn & Maternity OPD UBC
UBC
UBC

Tisha Anna Simon Krizette Ann Buan
NICU UBC and Divisional Council GMU & GSU UBC

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Chairs of the Central Councils

Vinu Varghese Carlien Grabe
Practice and Quality Management

Maysoon E’Nouz Souher El Amouri
Retention and Well-being Professional
Development

Iman Yassin Othman Haleimah Al Blooshi, ACNO
Nursing Informatics Nursing Advisory Council

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Highlight: The focus of this standard is that
leadership fosters a shared decision making
environment in which nurse leaders are
accessible to direct care nurses.
To attain the pathway to excellence designation
and its assoscaited benefits , the highest nursing
leadership (CNOs and nurse managers), must be
willing and advocatting for shared decision
making with direct care nurses.
Nursing leaders must continuously strive to
increase their core knowledge and role
competency including a shared leadership
competency, through leadership development
activities along with performance feedback from
colleagues .

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The below new structures and
processes were developed by
ARH team to meet the
excellence requirements for leadership standard
elements of performance:
1. Allocation of resources for the shared
governance structure to support shared
decision making
2. Enhancement of the performance evaluation
process for nurses in leadership role to
include peer review feedback.
3. Development of leadership succession
planning program.

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ELEMENTS OF PERFORMANCE
Standard 3- Safety

Highlight: The main focus of this standard is that
the organization protects the safety of staff, and
patients through safety policies and processes.
In ARH Safety is kept as foremost priority in
which the organizattion has systems and policies
developed to safeguard patienst, staff, visitors
from an unforeseen events. All staff are engaged
in devoplpoing and implementing ARH safety
measures, as well in the resolution of safety
related events.

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The below new structures and
processes were developed by
ARH team to meet the

excllence requirements for
safety standard elements of performance:
1. Supervisor Staffing Huddle to support the

involvement of direct care nurses in daily
staffing decisions
2. Enhancement of the process of patients’
transition from one level of care to another
to become an inter-professional decision
making process.

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ELEMENTS OF PERFORMANCE
Standard 4- Quality

Highlight: This standrad is intended to assess if
there is a strong inter-professional collaboration
within the organization that advocates for better
patient outcomes , and if this collaboration
effectivness is monitored through quality
measures that are internally and externally
benchmarked.

In 2013 the Institute of Medicine defined health
care quality as the degree to which health care
services for individuals and populations increase
the likelihood of desired health outcomes and
are consistent with current professional
knowledge.

In ARH the executive leadership advocates for
quality and we have a set of key performance
indicators (KPIs) that are set by Department of
health (DOH), SEHA and ARH to measure service
and care outcomes. Our KPIs are benchmarked
internally or externally based on latest practice
evidance recommendations.
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The below new structure and
processe were developed by ARH
team to meet the excellence
requirements for Quality standard elements of
performance:
ARH implemented using the National
Database of Nursing Quality Indicators
(NDNQI), which provides robust analytics to
support the importance of nurse sensitive
measures.

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ELEMENTS OF PERFORMANCE
Standard 5- Well-being

Highlight: The main focus of this standard is that
the organization advocates for the welfare of
staff , through ensuring activities to achieve a
balance between work and personal life. As well
this standard is intended to assess organization
initiatives to support community wellbeing.

ARH established a wellbeing council that main
objective is to promote staff welling within and
outside working hours. The councils organizes
activities based on direct care nurses feedback.
As well the council oversees nurse driven health
promotion activities such as outreach activities,..
etc.
Since the establishment of this council, the
organization implemented a process to
encourage and reward nurses driven health
promotion activities

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The below new structures and
processes were developed by ARH
team to meet the excellence
requirements for Well-being standard elements
of performance:
Establishment wellbeing Council which of the
shared governance central councils below are
some of councils achievements:

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ELEMENTS OF PERFORMANCE
Standard 6- Professional Development

Highlight: The main focus of this standard is that
the organization support nurses to get knowledge
and skills required to deliver of safe and effective
patient care.
ARH has a comprehensive orientation program
that includes individualization of learning needs
and clinical experiences to allow smooth
transition into practice. As well the organization
value and support lifelong learning through
ongoing professional development activities such
as sponsoring conferences attendance ,
encouraging specialty certification .. etc. .

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The below new structures and
processes were developed by ARH
team to meet the excellence
requirements for Professional Development
standard elements of performance:
1. Implemented Career ladder program
2. Developed a process for supporting direct care
nurses to pursue speciality certification.
3. Developed Mentorship workshop

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Section two:

Common questions with their answers
about elements of performance for six
pathway to excellence practice standards.

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1. Describe how the organization promotes a
culture of inter-professional decision-
making.

 All decisions are guided by policies and
guidelines that are made based on inter-
professional inputs.

 Hospital councils & committees are inter-
disciplinary in composition e.g. OSHMS, POCT,
etc.

 Rounds are multi-disciplinary e.g. Patient
rounds, environments rounds, leadership
rounds and so forth.

2. Describe how the organization obtains the
input for direct care nurses prior to
implementation of changes that affect care
delivery or work flow.
Direct care Nurses have the ability to give their
input through shared governance structure
(UBC, Central Councils or NAG)
Alternatively, through direct communication
during staff meetings, leadership rounds,
huddles.

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3. Describe the inter-professional process that
addresses how ethical concerns are
managed within the organization.

The ethical concern are escalated through the
line manager then to the senior leader/admin on
call to the concerned committee or department
as below:

Clinical ethical issues Non-Clinical Ethical issues
Managed by the
Medical Ethics Managed by Human
Resource Department and
the Legal Adviser.

4. Describe how direct care nurses are made
aware of the support processes in place for
situations where they are faced with an
ethical concern

 Awareness are made through staff education:
CME, CNE, Unit presentations, JCI fair. All
nurses have access for related Policies

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5. Describe how the organization engages
direct care nurses in the decision-making
process regarding product evaluation.

Direct care nurses are the ones who governs the
pilot phase for products used by nurses and gives
feedback to Product Evaluation Committee (PEC)

6. Describe how the organization includes
input from direct care nurses in the hiring
process for new staff

Direct care nurses are involved during the
candidate interview process using the objective
structured clinical examination (OSCE) interview
method.

7. Describe how the organization fosters
leadership succession planning.

Through the implementation of leadership
succession planning program based on need
assessment.

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8. What is the process used by the organization
to monitor safety related events?

The use of incident reporting portal (UHC Safety
Intelligence), which is a web-based real-time
incident management and reporting system.

9. What is the process for resolving a safety
issue in our organization?

Once a safety event is reported, review process
will take place through the event analysis team
meeting including the concerned SI managers. As
well, front line staffs (including direct care nurses)
will be involved in the review process directly and
indirectly depending on their involvement in the
incident reported. To learn from the defects and
improve the process or care delivery, the incident
event analysis result will be shared in the staff
through meetings, CUSP meetings and the Safety
Intelligence reporting status.

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10. Who is responsible for resolving safety issues
within the organization?
Safety issues are resolved by all the staff involved
in the issue plus the unit managers, quality
department and safety officer. If there’s a trend
in the SI reports, then it will be made into a
performance improvement project where the
direct care nurses are part of the planning,
implementation and evaluation

11. What are the expectations regarding
professional practice behaviour within our
organization?

Al Rahba Hospital emphasize the importance of
code of conduct and maintaining good
professional practice behaviour. ARH has
developed certain policies to ensure these
practices are monitored, and implemented.
Employees are required to make an annual
declaration in hospital online portal and to agree
that they are following the code of Conduct

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policy. Violators will face disciplinary actions as
per this policy
12. What are the safety related policies in ARH ?
 In Al Rahba hospital staff safety is addressed

in several policies which is under the OSHMS
(Occupational Safety Health Management
System). OSHMS policies are developed and
reviewed by multidisciplinary committee
members.

13. What is the process to address safety related
events sustained at work?
If a staff member sustained safety related event
at work such as an injury, it should be reported to
their immediate Supervisor and the Staff must
seek medical care (in the emergency
department). Then thus injury/Incidents must be
reported through the Safety Intelligence System.

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14. What security measures are in place to protect
patients, families or staffs?
ARH provides below security measures but not
are limited to:
 Access control for all hospital sensitive areas
(E.g. Neonatal ICU has risk for infant
abduction there for is access controlled with
security in the door).
 Security incident-reporting program
 Identification for an individual within
hospital premises as either staff, patient,
visitor … etc.
 Code white
 CCTV controlled system
 24 hours police
 Staff training to identify potentially violent
acts
 Furthermore conducts regular proactive risk
assessments to identify areas of security risk
to implement more measures.

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15. How are you or any other direct care nurse
involved in daily staffing decision?
Each start of shift the Charge Nurse (CN) takes
input from all primary nurses regarding their
patient acuity to decide with them on
requirement of adequate staffing. And if
additional staff is required, the CN will escalated
it to nurse manager & or nursing supervisor who
will support safe nurse-patient ration either by
calling additional staff (on-call or float) as
needed or transferring patients in coordination
with medical team.

16. How are staffing assignments determined in
our units?
Patient-nurse ratios are determined based on
the following factors:
 Total number of patients
 Patient Acuity and Care requirements
including relevant infection control and
safety precautions need

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 Expected admissions, transfer, transports,
discharges, and surgeries/procedures

 On shift nursing staff level of competency.

17. How do direct care nurses communicate
concerns about staffing?

Following are the different venues available for ARH
staff to express staffing concerns:
 Calling for shift Huddle with unit nurses &

charge nurse
 Direct reporting to nurse manager
 Supervisor’s huddle
 Safety Intelligence (SI)

18. How to activate the process of patient
transition from one level of care to another?
Through the multidisciplinary team decision to
transit patient care to another level . This
decision must be made at least by the most
responsible physician and patient primary nurse.

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19. What is benchmarking, and why it is
important?

Bench marking is a measurement of the quality
of an organization's policies, products,
programs, strategies, etc., and their comparison
with standard measurements, or similar
measurements of its peers or within its own best
practices. The objectives of benchmarking are
(1) to determine what and where improvements
are called for, (2) to analyse how other
organizations achieve their high performance
levels, and (3) to use this information to improve
performance.
External benchmarking Internal benchmarking
is a process of evaluating is process of evaluating
metrics or best practices metrics or best practices
from another similar from own organization
external organizations or best practices or
standard measurements processes

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20. What database does our organization use
for external benchmarking?

We are externally benchmarking with Johns
Hopkins International (JHI), CDC’s National
Healthcare Safety Network (NHSN) &
Department of Health (DOH) – JAWDA. Recently
we added National Database of Nursing Quality
Indicators (NDNQI).

List some of the nursing outcome measures
used in ARH organization?

 Hospital acquired pressure injury (HAPI)
 Fall incidents
 Catheter Associated Urinary Tract Infection

(CAUTI)
 Central Line Associated Blood Stream

Infection (CLABSI)

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21. What is an inter-professional collaborative
practice and why is it important?

Inter-professional collaborative practice is where
members of different disciplines work together for
better patient outcomes. It is important as it
empowers team members, closes communication
gap, enables comprehensive patient care, promotes
a team mentality and promotes patient centred
care.

22. What evidenced based search engine ARH
offers for its staff?

SEHA e- library, which contains different
resources like CINAHL, Clinical Key, Springer Link,
Access Medicine, Cochrane, AI, and Nature

23. What are some example of flexible
scheduling options available in ARH ?

Examples of flexible scheduling options are:
staffs are allowed to place 4 personal requests for
the following month schedule , during exiting
month staff are allowed to exchange shifts with
other staff with similar skill-mix, .. Etc.

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24. Why is it important that updates such as
performance and quality measures, and
information about new quality initiatives,
reach all employees?

Ensuring that everyone is updated enhance
timely adoption of practice improvements and its
crucial to spread lessons learned from defects to
prevent re-occurrence.
25. How do all employees receive quality

updates?
By emails about lessons learned, during councils
meetings, team huddles as well through quality
board updates.
26. Review. How the mission, vision, values and

goals of our organization are conveyed to
staff beyond orientation?
The mission, vision and values of the organization
is displayed in various places throughout the
organization. Employees are expected to set their
personal and professional objectives in alignment
with organizational goals or objectives.

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27. What is professional development? Why it is
important?

Professional development is the process of
improving practice by continuing education and
training. Staying current in nursing practice is a
key component of professional development
which involves attending continuing education
opportunities that bring us up to date on the
latest technology, techniques, and ways to
practice and it can also lead to career
advancement.

Professional Development is beneficial for
employees’ career progression and
advancement. It helps to keep the knowledge and
skills up-to-date., Continuous Professional
Development also promotes greater work
engagement from the workforce and contributes
to maximizing staff potential, improves staff
morale.

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28. How can staff in this organization impact the
planning and evaluation of initiatives that
support their own personal well-being?
Wellbeing initiatives are planned and evaluated
through the wellbeing council, this council
reach-out for nurses through its members who
representatives’ the council in the UBC. As well
the council conducts surveys for both planning
and evaluation purposes.

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29. Describe how the organization provides
opportunities for direct care nurses to avail
themselves to organization wellbeing
initiatives.

Wellbeing initiatives organised by ARH wellbeing
council are offered free of cost, with no attendance
maximum limit and all nurses have similar
opportunities to attend through the flexible
scheduling options. Moreover, nurse managers are
responsible to ensure all nurses in the unit
participated in at least one event throughout the
year.

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30. How does the organization determine the
success of a well- being initiative?
Each wellbeing initiatives have a set objective
(s) as well-set evaluation. The evaluation usually
occurs through post event feedback survey.

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31. Provide example of health care concerns
specific to our community and how the unit or
organization partnered with the community or
health care organization or regulatory agencies
to promote the community wellbeing?

Vehicle safety is a major health care concern for
ARH community due number of Vehicle related
trauma cases seen in ARH emergency
department. For the 3rd year in 2018 ARH
partnered with Abu Dhabi traffic police, Abu
Dhabi Blood bank and Department of health to
conduct a trauma awareness week for ARH
community which included below events:

1. Educational booths about trauma
prevention in the hospital , Al Raha mall
and Al Wahda club

2. Blood donation stations with education
about trauma prevention in the
hospital

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32. What are some examples of nurse driven
activities in ARH?
Campaigns for: Breast cancer, cervical cancer,
Flu Campaign

33. How can nurse driven activities benefit
patients within a target population?
Such activities build awareness, enhances
Screening, early detection, compliance with
treatment plan as well reduces complications.

34. Describe ARH strategy to transient newly
graduate nurses into practice?

In ARH, all new Graduates go through a graduate
nurse internship (GNI) program, which is 6 month to
one year structured transition to practice program
as based on the new graduate individual needs. It
includes several workshops administered in variety
of modes including didactic, simulation, group
discussion and reflection.

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35. How does the organization prepare nurses to
function competently when they are assigned to
an area other than their primary area?
The nurse will be assigned to an area other than
their primary area only if the new area skill
requirement is similar or lower than what the
nurse is equipped with or if the nurse is Cross-
trained to the new area

36. What is specialty certification?
Specialty certification is a formal recognition that
the staff has mastered a specialized body of
knowledge, skills and experience to promote
optimal health outcomes

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