Staff Engagement Booklet

Staff Engagement Opportunities

PSTAM

Manager:

Cristina Loaiza
CSLs:

Laura Filingo, Jessica Swanger, Lindsey Kevetter, Angie Redovian, Chelsey Huff
Educator:
Jan Malone

Admin Assistant:
Tammy Wellman

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Contents

Ancillary Floor Assistant............................................................................................................................................................................................................................................................................. 3
Bedside Shift Report ................................................................................................................................................................................................................................................................................... 5
Certifications: CPN....................................................................................................................................................................................................................................................................................... 7
Certifications: TNCC .................................................................................................................................................................................................................................................................................. 10
Equipment/EOC Champs............................................................................................................................................................................................................................................................................. 12
Glucometer Super-users............................................................................................................................................................................................................................................................................ 14
Hand Hygiene Secret Shoppers............................................................................................................................................................................................................................................................... 15
Liver Tx Champs .......................................................................................................................................................................................................................................................................................... 16
Mentor Program........................................................................................................................................................................................................................................................................................... 17
MR TASTE Rep............................................................................................................................................................................................................................................................................................ 19
Nursing Staff Council Rep......................................................................................................................................................................................................................................................................... 20
Preceptor ...................................................................................................................................................................................................................................................................................................... 21
Preceptor for Nurse Residents................................................................................................................................................................................................................................................................ 23
Psych Pt Champ.. .......................................................................................................................................................................................................................................................................................... 25
QIA Nurse.................................................................................................................................................................................................................................................................................................... 27
Resuscitation Committee Reps.. ............................................................................................................................................................................................................................................................... 29
RSL Growth/Development.. ....................................................................................................................................................................................................................................................................... 30
Scheduling Board......................................................................................................................................................................................................................................................................................... 33
Security Taskforce .................................................................................................................................................................................................................................................................................... 34
Smooth Moves Super-users ...................................................................................................................................................................................................................................................................... 35
TB Skin Tester ............................................................................................................................................................................................................................................................................................ 36
TOPS Committee......................................................................................................................................................................................................................................................................................... 38
TOPS Committee Chair .............................................................................................................................................................................................................................................................................. 40
Unit Board Co-Chairs.................................................................................................................................................................................................................................................................................. 42
Work-Life Committee ................................................................................................................................................................................................................................................................................ 44
Project Work ............................................................................................................................................................................................................................................................................................... 45

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Committees/Projects with immediate need for volunteers include: Preceptors, Ancillary Floor
Assistant, Equipment Champ, Hand Hygiene Secret Shoppers, MR Taste Meeting Rep, QIA nurse,

Linen Project, MD Rounding Project, Smooth Moves Champs, Preceptors

Ancillary Floor Assistant

Summary
• To aid and assist the Administrative Assistant as well as other coworkers by providing the necessary support, including
but not limited to, offering a well-stocked supply room, delivery and retention of campus parcels, documentation and
data entry, organization of facilities, etc.

Objective
• Any high performing staff member who wishes to make the most of their down time by offering to assist the
Administrative Assistant with essential tasks.

Eligibility
• Medical Receptionist/ Care Partners

Benefits
• Ensuring that the necessary supplies are available when needed.
• Offering input on new procedures and utilizing your voice to make improvements to our day to day functions.

Expected Activities

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• Delivery and retention of campus parcels
• Inventory management assistance
• Data entry
• Organizational projects
Staff Engaged
• Lynn Lovvorn
• Rebecca Upchurch
Lead: Tammy Wellman

Reviewed 7/26/18 JS

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Bedside Shift Report Champs

Summary

• Bedside Report champs will help encourage their peers to provide a bedside report while engaging the
families and providing family centered care. Champs will consistently monitor this workflow and elevate and
challenges or issues along with constructive feedback to leaders.

Objectives

• To coach and encourage staff to complete bedside report.
• To share benefits and wins with staff on bedside report.
• To help complete bedside report annual competency check-offs.
• Help audit and score our completion of bedside report.

Member Eligibility

• RNs

Benefits

• Preparation towards clinical ladder advancement
• Opportunity to support an evidence-based practice and improve upon quality of care and patient safety
• Learning about project management, committee work and family centered care

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Expected Activities

• As you are completing your own bedside report, look around and ensure that your co-workers are as well.
Encourage them to go inside the patient’s room and do so.

• Complete secret shopper-style audits of bedside shift reports.
• Attend bedside shift report committee meetings

Engaged staff
• Claire Calamaio, Siobhan Scarfo, Jackie Lynn Cothron, Amanda Alfaro, Rachel Weingart,
Brady Franklin, Bridget McMahon, Margaret Kababik

Lead: Angie Redovian

Reviewed 6/18/19 AR

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Certifications: CPN

Summary

• The Certified Pediatric Nurse exam validates knowledge and expertise of pediatric nurses beyond basic RN
licensure.

Objectives

• The CPN exam validates knowledge and expertise of pediatric nurses beyond basic RN licensure. This course
will aid the RN in the following: 1) assess, analyze, plan and implement nursing interventions, 2) evaluate
patient outcomes, 3) facilitate initial or on-going education for pediatric nurses, 4) conduct research about
patient outcomes or professional issues, and 5) provide management or leadership for pediatric nurses

• It is our goal that at least 3 nurses per shift per pod will have their CPN

Member Eligibility

• RNs/ RSLs
o Eligible RNs may have a diploma, associate's degree, BSN, MSN, or higher nursing degree and must have a
minimum of 1800 hours of pediatric nursing experience. CPN is a Category A certification for Magnet
recognition.
o Goals is to have 2-3 staff members represented on each pod for each shift, with the eventual goal of at
least 50% of staff certified

Expected Activities

• RNs interested will contact Jessica Swanger to be listed on waiting list
• When registration opportunity opens

o Nurse will sign/return CPN class agreement sent to them by leadership team
o Nurse will submit an in-service request in Vandyworks
o Nurse will register and attend class and take test within timeframe allowed
• Nurse will turn in a copy of certification to the office asap
• Nurse will recertify annually to maintain certification

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CPN Certified

Name Pod Shift Initial Date Expiration Date
Kayla Cross A Day 1/30/2013 2/28/2020
Roseli Hinds A Night 2/28/2020
Shanna Allen B Day 02/30/2014 2/28/2020
Margaret Kababik B Day 9/17/2013 2/28/2020
Anna Mertz B PRN 7/15/2008 2/28/2020
Safiya Paraparambil A Night 2/1/2016 2/28/2020
Jessica Swanger CSL Day 11/4/2009 2/28/2020
Lindsey Kevetter CSL Day 9/9/2014 2/28/2020
Natalie Christea B Night 6/13/2012 2/28/2020
Kristen Williams B Day 8/29/2017 2/28/2020
Courtney Cox B Night 7/30/2015 2/28/2020
Jennifer Scanlon A PRN 2/15/2017 2/28/2020
Christine Schueler B Day 4/18/2018 2/28/2020
Laura Filingo CSL Day 5/4/2018 2/28/2020
Kandy Diaz A Day 8/18/2018 2/28/2020
Lindsey McNally C Night 1/18/2017 2/28/2020

Bridget McMahon A Day 11/26/2018 2/28/2020
Chelsey Huff CSL Night 2/28/2020
Amy Butterfield B/ADT Day 12/7/2018 2/28/2020
Elyssa Champion B Day 12/27/2018 2/28/2020

8/23/2017
3/4/2019

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CPN Waitlist

Name Pod Shift

Katie Joiner B Nights
Becky Van Ryn A Days
Anne Ramsey B Nights
Savanna Atwood C Nights
Siobhan Scarfo B Days
Katelin Edlin B Nights
Sheree Burdette C Nights
Claire Calamaio B Days
Brady Franklin A Days
Emily Williams A Nights
Hillary Brians A Days
Emily Gallegos A Nights
Brittany Shollar C Nights
Amanda Alfaro A Nights
Blake Branning B Nights
Katie Blaser A Nights

Katelyn Freyou A Nights

Lead: Jessica Swanger

Reviewed 6/18/19 JS

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Certifications: TNCC

Summary

o The Trauma Nursing Core Course was developed by the ENA to establish a standardized body of
trauma nursing knowledge and to improve the care of all trauma patients.

Objectives

o Empowers nurses with the knowledge, critical thinking skills and hands-on training to provide expert
care for trauma patients. This course will help nurses with the following skills: 1)Rapid identification
of life-threatening injuries, 2) Comprehensive patient assessment and 3) Enhanced intervention for
better patient outcomes

o It is our goal that all 8B nurses and all RSLs have their TNCC

Member Eligibility

• RNs/ RSLs
o The only requirement is that you hold a current unrestricted RN license.
o Goal is for all 8B RNs and SLs to be certified

Expected Activities

• RNs interested will contact Jessica Swanger to be listed on waiting list
• When registration opportunity opens

o Nurse will sign/return CPN class agreement sent to them by leadership team
o Nurse will submit an in-service request in Vandyworks
o Nurse will register and attend class and take test within timeframe allowed
• Nurse will turn in a copy of certification to the office asap
• Nurse will recertify every four years to maintain certification

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Staff engaged

TNCC Renewals TNCC B Pod (Preferential List)

Name Recert Due Name Hire Date

Sheree Burdette 7/31/2019 Kaitlin Joiner 6/12/2017
Renie Meyer 7/31/2019
Natalie Christea 12/31/2019 Claire Calamaio 7/9/2018

Emma Lovitt 10/15/2018

Elyssa Champion 12/31/2019 Julia Anderson 4/15/2019

Amy Butterfield 1/27/2021 TNCC Waitlist

Jackie Lynn Cothron 4/31/2021 Name Date

Shanna Allen 7/31/2021 Emily Gallegos 2/23/2019
Christine Schueler 7/31/2021
Brittany Shollar 3/5/2019

Roseli Hinds 11/31/2021 Brady Franklin 3/21/2019

Erin Miller 1/31/2022
Lindsey McNally 1/31/2022
Siobhan Scarfo 1/31/2022
Margaret Kababik 3/31/2022
Courtney Angel 4/31/2022
Courtney Cox 4/31/2022
Katelin Edlin 6/31/2022
Danysha Maitre 6/31/2022
Anne Ramsey 10/31/2022
Chelsey Huff 10/31/2022
Lindsey Kevetter 2/28/2023
Jessica Swanger 2/28/2023
Mathias Payne 2/28/2023

Blake Branning 2/28/2023

Lead: Jessica Swanger

Reviewed 6/18/19 JS

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Equipment/ EOC Champ

Summary

• Equipment champs are designated staff members of our team who perform EOC (environment of care) audits and
equipment inventories on a regular basis.

• They follow up with any concerns by elevating any issues to the appropriate resource (i.e. email manager; enter issues
in the maintenance log, contacting plant ops, etc.).

• They also help educate other staff members on the correct steps to take when issues arise.

Objective

• To ensure that our unit follows all environment of care standards and that provides staff with all the needed tools to
complete their job.

Benefits

• These staff members help maintain a safe and clean work environment on our unit.
• They also help ensure staff has the needed equipment/supplies available to perform their patient care by collaborating

with unit management.

Expected Activities

• Equipment champs are required to complete and submit at least 2 equipment log audits per month.
• They are expected to follow up on any issue/concerns noted with each audit.
• They are also required to attend monthly meetings with CSL/manager to ensure all issues are being addressed

appropriately.

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Member Eligibility
• CPs

Staff Engaged:
• Needs volunteers

Lead
• Jessica Swanger/ Laura Filingo- completes Corrective Action Item Summaries and submits to VEHS for review

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Glucometer Super-Users

Summary
• Nurses that help check off other nurses on their annual glucometer competency

Objectives
• To have sufficient checkers to sign-off on peer glucometer competency
• To have sufficient glucometer super-users as resources on the floor

Benefits
• Knowledgeable resource nurses available on the floor to everyone else
• All staff have the opportunity to remain up to date glucometer competencies

Expected Activities
• Complete annual training to become a glucometer super-user/checker (registration in LMS)
• Help check off staff on their glucometer competency
• Serve as a resource on the floor to all other staff that may have questions about glucometers

Member Eligibility
• RNs, RSLs, CSLs

Staff Engaged
• Chelle Freeman, Sheree Burdette, Renie Meyer, Jessica Swanger, Angie Redovian, Bridget McMahon, Lindsey Kevetter

Lead: Jan Malone / Jessica Swanger

Reviewed 6/18/19

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Hand Hygiene Secret Shoppers

Summary:

• Staff members that have been trained to secretly audit and report hand hygiene practices on our floor

Objective:

• To ensure that hand hygiene practices are being completed on our floor to standard
• To provide data points for a monthly score to be developed for our department

Member Eligibility:

• RNs, CPs, MRs

Benefits:

• Increase knowledge surrounding hand hygiene standards and data collection process
• To provide an accurate score of hand hygiene for the department
• Increased awareness among staff about hand hygiene

Expected Activities:

• Complete hand hygiene training for secret shoppers (20 mins)
• Complete hand hygiene audits on a monthly basis and turn in for inclusion in monthly scores
• Maintain secret identity

Staff Engaged: TOP SECRET ☺

Lead: Jessica Swanger

Reviewed 6/18/19

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Liver Transplant Champs

Summary

• A group of registered nurses that serve as clinical resource for post liver transplant patients.

Objectives

• To provide resources for staff on the unit to care for the patient who is post-op liver transplant.
• To ensure best practices and process around liver transplant care.

Benefits

• Provide standardized care for post-op liver transplant patients on our unit.
• Increase the knowledge base of this patient population among our nurses.
• Additional support for RN advancement process.

Expected Activities:

• Team works together to be experts and resources for the care around liver transplant patients.
• Help to provide education to all staff on the unit on any changes to pathway or liver patient care.
• Attend bimonthly liver transplant champ meetings.

Member Eligibility

• RNs, RSLs

Lead: Laura Filingo/ Staff Leads: Courtney Angel and Christine Schueler

All CSL/RSL and B-pod nurses have required education
A-pod nurses completing education: Emily Gallegos, Kathleen Blaser, Jennifer Scanlon, Samantha Schultz, Brady Franklin-verifying
education completion.

Reviewed 7/3/1 LF

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Mentor Program

Summary

• A program that seeks to designate a mentor/resource-person to each newly hired nurse on our unit following
orientation and lasting throughout their first year of employment

Objective

• Pair the newly hired nurse with an experienced mentor either during or shortly after his/her orientation
period

Benefits

• Improve the on-boarding process of newly hired nurses for our unit, thereby improving this group’s overall

satisfaction, engagement, and retention

• Engage more experienced staff further into the on-boarding and retention process
• Mentoring will apply towards experience needed for RN advancement

Expected Activities

• Mentors will be available to their mentees to answer questions, serve as a resource, and be a positive role
model of both the Credo and elements of job performance

• Mentors will check in with their mentees at pre-determined intervals to ensure that the transition from
orientation to staffing is as seamless as possible

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Member Eligibility

• Mentor: RN with at least 1 year of experience on our unit
• Mentee: RN newly hired to our unit; can either be a new graduate or a nurse with prior experience

Staff Engaged

• Natalie Christea, Siobhan Scarfo, Anna Mertz, Erin Miller, Falyn Davis, Kristen Williams, Becca Brown, Katie
Joiner, Courtney Cox, Morgan Acuff, Brady Franklin, Rachael Weingart, Brittany Shollar, Katie Blaser, Claire
Calamaio

Lead: Cristina Loaiza / Christine Schueler

Reviewed 6/19/19 JS

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MR Taste Meetings- Representative

Objective

• A high-performing MR who serves as a resource and leader to her co-workers and who represents the unit’s MRs in
a monthly house wide meeting.

Summary

• To represent PSTAM in the house wide MR Taste Meeting, to share our practices and to learn from the practices
of other units.

Eligibility

• Medical Receptionists/MRs

Benefits

• Standardization of MR work across the hospital by implementing what is learned at the meetings.
• Learning about new resources available to MRs
• Having the opportunity to help improve upon existing MR process

Expected Activities

• Attendance of monthly MR Taste Meeting
• Bringing information back to our staff by sharing it at the bi-monthly MR meetings
• Helping implement changes in our MR workflow
• Elevating concerns regarding MR workflow to Tammy Wellman

Staff Engaged: Need reps for this Lead: Tammy Wellman

Reviewed 7/3/19 JS

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Nursing Staff Council Representative

Description

• Staff member who attends monthly Nursing Staff Council meetings on behalf of PSTAM

Objectives

• To have representation from PSTAM in house-wide shared governance meetings, with the representative acting as a liaison and
information sharer between staff nurses on our unit and throughout the rest of the hospital, and vice versa

Member Eligibility

• RNs, decided by staff nomination/vote biannually

Benefits

• Participate in house-wide shared governance meetings
• Networking with staff nurses from other departments within VCH
• Interfacing with nursing executives
• Improved knowledge of house-wide initiatives and events

Expected Activities

• Attend Nursing Staff Council meeting (held the first Thursday of every month from 07:30-09:00)
• Bring information from meetings back to leadership team and staff via monthly minutes (shared on Freeform) and presentations at

Unit Board meetings
• Participate in Nursing Staff Council initiatives and projects as they arise

Staff Engaged: Courtney Angel/ Claire Calamaio—day shift representative Chelle Freeman—night shift representative
Lead: Lindsey Kevetter/ Cristina Loaiza

Reviewed 7/3/19 JS

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Preceptor

Summary

• Any staff member dedicated to precepting new staff and students on our unit and further acting as a
mentor even after the initial orientation has been completed. The preceptor ultimately plays a
significant role in the competency, development, and job satisfaction of our new staff.

Objectives

• To provide consistent guidance and support to the new staff member while they are on orientation.
Educating the staff member and being a resource to the Vanderbilt policies/protocols and unit
specific expectations.

Benefits

• Supports RN advancement and overall Leadership development.
• Contact Hours for additional trainings completed through Preceptor Skills Workshop
• Retention of our staff by feeling supported/ improved job satisfaction.
• Opportunity to train our new staff to be highly competent in our patient population and expectations.

Expected Activities

• Strongly encouraged to attend Preceptor 1 (Essential preceptor skills class -8hrs) and Preceptor 2
(Communication Skills for preceptors -4hrs).

• Orient new staff member for 3-8wks depending on how their orientation schedule is developed.
• Submit a weekly orientee feedback survey thru Red Cap or to the orientee’s CSL/ nurse educator.

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• Sign off skills check off forms as skills are completed by the orientee each shift.
• Submit orientee feedback for the orientee’s 90 day evaluation

Member Eligibility

• Medical Receptionist, Care Partners, and RNs

Staff Engaged
• Day RNs: Lori Werle, Mimi Arthur, Margaret Kababik, Claire Calamaio, Bridget McMahon, Kaylah Goines,

Anna Mertz

• Night RNs: Lindsey McNally, Sheree Burdette, Renie Meyer, Roseli Hinds, Chelle Freeman, Natalie Christea,

Danysha Maitre, Katie States

• Day CPs: Carmen McMillan, Tara Duncan
• Night CPs: Christine Robinson, Amanda Mason, Jessica Gordy

• MRs: Catrina Thompson, Terri Gentry, Kahla Pace

Lead: Jan Malone

Reviewed 7/26/19 JS/CL

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Preceptor for Nurse Residents

Summary

• Any staff member dedicated to precepting PNRs on our unit and further acting as a mentor even
after the initial orientation has been completed. The preceptor ultimately plays a significant role in
the competency, development, and job satisfaction of our new staff.

Objectives

• To provide consistent guidance and support to the new staff member while they are on orientation.
Educating the staff member and being a resource to the Vanderbilt policies/protocols and unit
specific expectations.

Benefits

• Supports RN advancement and overall Leadership development.
• Contact Hours for additional trainings completed through Preceptor Skills Workshop
• Retention of our staff by feeling supported/ improved job satisfaction.
• Opportunity to train our new staff to be highly competent in our patient population and expectations.

Expected Activities

• Work together in a pair to ensure continuity across the PNR’s orientation, floating with that PNR
across the unit

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• Strongly encouraged to attend Preceptor 1 (Essential preceptor skills class -8hrs) and Preceptor 2
(Communication Skills for preceptors -4hrs).

• Orient new staff member for 6-8wks depending on how their orientation schedule is developed
• Complete the orientation schedule for the new staff member
• Submit a weekly orientee feedback survey thru Red Cap or to the orientee’s CSL/ nurse educator.
• Sign off skills check off forms as skills are completed by the orientee each shift.
• Submit orientee feedback for the orientee’s 90-day evaluation
• Attend a bi-annual preceptor workshop/retreat

Member Eligibility

• RNs with excellent Credo behaviors and engagement in unit activities who have demonstrated excellence and
expertise in providing bedside patient care

Staff Engaged

• Day RNs: Siobhan Scarfo, Becca Brown, Kristen Williams, Christine Schueler, Dana Schmidt, Carolyn Von

Lunen, Amy Butterfield

• Night RNs: Kristen Fite, Blake Branning, Katie Blaser, Katelin Edlin, Becca Haseman, Katie Joiner

Lead: Cristina Loaiza

Reviewed 7/26/19 CL/JS

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Psych Pt Champ

Summary

• A core group of staff members (RN’s and CP’s) who are dedicated to caring for VCH admitted psychiatric
patients while waiting transfer to an appropriate psychiatric facility.

Objectives

• To have the knowledge and desire to provide safe patient care to the psychiatric population and be a
resource for the unit while maintaining consistent practices.

Benefits

• Increase adherence to hospital policy and procedure regarding the safe care of psychiatric patients.
• Decrease the potential of patients harming themselves or others.
• Provide a therapeutic environment while in the acute care setting.
• Additional support for RN advancement

Member Eligibility

• RN’s and Cp’s

Expected Activities

• Complete shadow experience at VPH to familiarize self with skills and expectations while caring for
psychiatric patients.

• Attend educational classes (ex. Handle with Care), lectures and opportunities available here and VPH.
• Provide staff education and be a resource for the unit.
• Be able to communicate and develop collaborative relationships with VPH staff, med/psych teams and CM’s to

help facilitate plan of care through discharge.

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Staff Engaged Shadow Experience Additional Education

Primary Staff Laura F. CSL 3/27/13/ Jessica
Lead- Laura Filingo S. CSL (3/28/17)

Dayshift RN’s 3/29/13
Lisa Hollifield
3/29/13
Lori Werle 5/11/16
Carolyn Von Lunen 3/21/2016
Kristin Williams

CP’s
Tara Duncan
Jessica Champlin

Nightshift Staff 3/22/17
Sheree Burdette 3/6/17
Chelle Freeman 4/12/19
Lindsey McNally 4/12/19
Brittany Shollar
Amanda Alfaro
Matt Payne
Raquel Williams

Leads: Laura Filingo

Reviewed 7/3/19 LF

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QIA Nurse

Summary

• RN who completes all chart audits to assess completion of all documentation standards by staff. RN also

audits bedside practice. Data is reported to PM&I department and scores are developed for our department.
RN works closely with management to report trends and help identify solutions.

Objective

• To closely monitor documentation and nursing practice and help improve to meet standards.

Member eligibility

• RNs

Expected activities

• This nurse reports to the PM&I manager and to the unit manager
• Completes a short orientation to understand all QIA nurse responsibilities
• Commits to one 12hr shift per week to complete QIA work.
• Recognizes trends in audit data and collaborates with management to improve upon these trends.
• Attends monthly QIA meeting, manager/educator meeting, TOPS committee meeting and quarterly

PM&I/manager meeting
• Provides coaching to staff and serves as a resource for documentation and practice standards
• Recognizes staff who consistently meet standards

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Benefits

• Close monitoring of documentation and practice
• Knowledgeable resource available on floor
• Support for RN advancement
• Coaching and recognition available for staff
• Data collection for generation of scores and trending to support improvement efforts.

Staff Engaged

• Volunteer Needed!

Lead: Cristina Loaiza/ Ashley Bonner, PM&I Manager

Reviewed 7/3/19 JS

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Resuscitation Committee Representative

Summary

• RN who attends resuscitation committee on a regular basis to participate in house-wide discussion regarding
resuscitation practices. They will remain up to date on unit data including need for improvement on rapid responses
and codes occurring on the floor.

Objective

• To ensure unit representation at monthly meeting, bringing concerns, questions, and ideas for improvement to
committee.

Eligibility
• RN

Expected Activities

• Attend monthly meeting held the first Friday of every month at 0930 am.
• Stay up to date on unit resuscitation practices and ideas for improvement
• Report back information to CSL lead on new information discussed at monthly meeting.
• Assist in implementing any needed changes on the unit surrounding resuscitation.

Benefits:

• Knowledgeable resource regarding resuscitation practices on the floor
• Support of staff in bringing ideas for improvement/questions to committee meetings

Staff engaged: Carolyn Von Lunen and Lindsey McNally CSL Lead: Jessica Swanger

Reviewed 7/3/19 JS

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RSL Growth/Development

Summary

• High performing nurses who have demonstrated an ability and desire to serve as resource and leader to their
co-workers, fill in the staff leader role when there is a need. During their shift as RSL, they serve as clinical
resource, bed management, decision-maker for staffing assignments, service recovery provider, and elevate
any other item to the in-house or on-call CSL that would require follow-up.

Objectives

• To develop the individual’s leadership skills by giving him/her an opportunity to lead on the unit.
• To engage potential leaders in the day-to-day processes of the unit.
• To grow and develop skills such as rounding, service recovery, staff development and involvement, and

ability to delegate in potential leaders.
• To empower and equip potential leaders to make decisions in real time that affect the unit, its staffing, and

quality of patient care.

Member Eligibility

• RNs with the following characteristics:

• One year’s experience at the bedside
• Must be in good standing regarding time and attendance
• Must be in good standing regarding job performance
• Must express a willingness and desire to lead, to learn, and to engage actively in the role
• Must be committed to the goals of the unit

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• Involvement in at least one engagement activity on the unit

Benefits

• Ability to have input into decision-making on the unit (i.e., serve as a resource to manager in decision-making
processes)

• Experience in a leadership role and honing of those skills
• Ability to mentor others that are interested in leadership role
• Preparation towards clinical ladder advancement
• A thriving, healthy patient care unit that excels in care of its patients, families and of its staff members
• Preferred scheduling
• RSL differential pay

Expected Activities

• One shift per week functioning in the staff leader role
• Attend and actively participate in 75% of RSL meetings
• Attend and actively participate in 50% of all staff meetings
• Read meeting minutes for the meetings that can not be attended

Additional Educational Requirements Before Completion of Orientation

• Complete Initial Liver compliance in LMS. If initial completed, complete continuing liver education annually
• Complete AIDET/HEARD online module
• VW admin Class (4 hours)

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Additional Educational Requirements Before 1 year of RSL

• Attend TNCC
• Attend CPN
• Apply for Advancement

Staff Engaged

• Days: Becky Hicks, Lori Werle, Kristen Williams, Margaret Kababik, Carolyn Von Lunen, Christine Schueler, Siobhan
Scarfo, Amy Butterfield

• Nights: Sheree Burdette, Chelle Freeman, Roseli Hinds, Renie Meyer, Lindsey McNally, Natalie Christea, Courtney
Cox, Anne Ramsey, Katie Joiner, Brittany Shollar, Emily Williams

CSL Lead: Chelsey Huff

Reviewed 7/26/19 JS/CH

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Scheduling Board

Summary
• A group of staff who assist the scheduler in identifying opportunities for improvement on scheduling
processes and provide education to co-workers.

Objective
• To educate staff on scheduling processes
• To improve staff satisfaction in the scheduling process

Benefits
• Improved staff satisfaction
• Decreased moves within the schedule
• Improve compliance with scheduling guidelines
• Staff involvement in the schedule

Member eligibility
• All staff

Expected Activities:
• Attend monthly meetings
• Provide education to staff as needed and serve as a resource for scheduling guideline questions.
• Provide staff concerns and/or what is working well
• Discuss potential solutions to scheduling dissatisfies and issues.

Staff Engaged: Roseli Hinds, Jackie Lynn Cothron, Chelle Freeman, Carolyn Von Lunen, Amanda Alfaro, Kay-Kay
Freyou, Renie Meyer

Lead: Cristina Loaiza/Chelsey Huff

Reviewed 7/26/19 CH/JS

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Security Taskforce

Summary
• A new group of staff invested in improving the physical safety and security of our unit/hospital

Objectives
• Identify gaps in current security measures
• Streamline safety/security processes
• Implement new/innovative solutions to enhance security on our unit

Benefits
• Support for RN advancement
• Knowledgeable resource available on floor
• Opportunity for staff to come together and work on improving the safety of our patients, visitors, and staff

Member eligibility
• All staff are eligible

Expected Activities:
• Meet monthly (schedule TBD)
• Participate in group problem-solving/brainstorming
• Project work/tasks delegated at time of committee meetings
• Gathering input/feedback from peers, educating peers, reporting back results to peers

Staff Engaged: Shanna Allen, Roseli Hinds, Courtney Angel, Christine Schueler, Emily Williams, Catrina Thompson
Lead: Angie Redovian

Reviewed 6/18/19 AR

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Smooth Moves Champs

Summary
• The Smooth Moves Champ is the go-to person for questions about smooth moves equipment. In this role, the staff
member would be keeping up to date on changes regarding recommendations about proper body mechanics and safety
involving smooth moves equipment. They would remain aware of educational needs/concerns of the floor and help to
implement changes that improve safety for patients and staff when using smooth moves equipment.

Objectives
• To ensure the safety of our patients and staff when using Smooth Moves Equipment.
• To grow and develop knowledge and expertise surrounding the use of our Smooth Moves Equipment.
• To equip all staff with the knowledge needed to remain safe and keep patient’s safe while moving patients.

Member Eligibility:
• RN’s/CP’s

Benefits
• Ability to improve our practices on the floor involving Smooth Moves Equipment
• Ability to be a part of positive change on our unit.
• Helping to provide a safe, supportive environment for staff and patients in situations involving difficult patient
moving/sliding/transfers.

Expected Activities
• Education to staff on how/when to use Smooth Moves Equipment. (Using check off sheet)
• Attend Smooth Moves class(Search “Smooth Moves” in LMS-Class is 4 hours and offered monthly)
• Finding ways to improve safety within our existing processes around Smooth Moves Equipment
• Report out challenges or completed work to CSL lead/management.

Staff engaged: Kristen Williams, Jessica Gordy Lead: Angie Redovian

Reviewed 6/18/19 AR

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TB Skin Tester

Summary

• Effective July 31st, 2015 all TB skin tests administered to patients or staff must be by a Licensed
Representative who has completed the appropriate training. Training includes completion of the VUMC TB
Skin Test Bundle in LMS and completion of hands on check off session through Occupational Health. The
CDC guidelines recommend that all nurses be trained in the administration, assessment, and documentation
of TB skin tests.

Objectives

• To provide reliable administration, assessment, and documentation of TB skin test for staff, faculty,
and patients through a standardized process.

Benefits

• Allows for an increased volume of staff to complete training and maximize efforts for patient and
staff testing.
• No annual recertification.
• It is also an additional benefit to support the RN advancement process.

Expected Activities

• Administer TB skin tests as needed to staff and patients
• Read TB skin tests, and record result in Easy Reader for staff or Star Panel for patients.
• Order and pick up TB solution as needed through Occupational Health Website.

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Member Eligibility

• RNs (licensed staff only); Required for RSLs

Staff Engaged

• Dayshift: Lindsey Kevetter, Angie Redovian, Jackie Lynn Cothron, Lori Werle, Kristen Williams, and
Jessica Swanger
• Nightshift: Renie Meyer, Roseli Hinds, Chelle Freeman, and Sheree Burdette.

Lead: Jessica Swanger

Reviewed 7/3/19 JS

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TOPS Committee

Summary:

• Committee members work together to gather feedback, review data, research best practices, brainstorm
new processes and educate staff about patient safety and quality nursing metrics tracked for our unit.

Objective:

• To improve upon all nursing quality metrics tracked for our unit: hand hygiene, CLABSI, CAUTI, vascular
access, pressure ulcers, med errors, and falls.

Member Eligibility:

• RNs/ CPs

Benefits:

• Opportunity for staff to come together and work on improving the safety and quality of care offered to our
patients

• Increase of knowledge base for staff who are engaged about quality metrics
• Support for RN advancement

Expected Activities:

• Attend monthly TOPS meeting
• Attendance of house wide monthly or quarterly PM&I meeting for metric chosen; if unable to attend a

delegate must be sent in place of committee member

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• Report out to TOPS committee every meeting regarding house-wide meeting, projects, etc.
• Help brainstorm ideas to improve upon metrics
• Gather feedback from staff about possible challenges to meet all quality standards
• Provide education to staff through a variety of means:

o Friday Facts updates monthly
o Fishbowl Quality Board updates at least monthly
o Report out to staff at least yearly during a staff meeting
o As needed education/interventions as decided upon by committee member/team
• Help implement initiatives on the floor about our quality nursing metrics

Staff Engaged:

• Hand hygiene- Jessica Swanger
• MUSIC- Carolyn Riley, Siobhan Scarfo
• Pressure Ulcers- Chelle Freeman, Danysha Maitre
• VA (CLABSI/PIVIE)—Christine Schueler, Emily Gallegos, Katie Joiner
• CAUTI- Anne Ramsey
• Falls- Natalie Christea, Becca Haseman
• Staff Injury Prevention--

Lead: Jessica Swanger

Reviewed 7/3/19 JS

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TOPS Committee Chair

Summary:

• Staff nurse that helps lead all TOPS committee meetings and serves as an expert resource to committee
members. Chair helps ensure that committee has enough members and they are able to progress in their
work

Objectives:

• To have a staff nurse lead TOPS committee meetings and work

Member Eligibility:

• RSLs

Benefits:

• Support for RN advancement
• Opportunity to learn and develop leadership skills

Expected Activities:

• Schedule and invite committee members to monthly TOPS meetings
• Review and report out monthly VERITAS reports at monthly meetings
• Help committee members brainstorm on ideas to improve upon metrics
• Serve as a knowledgeable resource to committee members

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• Ensure that committee work progresses and that all members complete designated tasks (as outlined in the
TOPS Description)

• Record and report out all meeting minutes to members and to management

Staff Engaged:

• Sheree Burdette

Lead: Jessica Swanger

Reviewed 7/3/19 JS

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Unit Board Co-Chairs

Summary

• Staff RNs come together to lead our Unit Board meeting by collecting staff feedback about patient care
and floor policies/procedures and presenting it at the Unit Board meeting.

Objective

• To have engaged nurses leading our unit board meeting; helping identify patient care challenges and
implement solutions based on feedback, and represent our unit at nursing staff council.

Member Eligibility

• RN3 or RN4 (or working towards advancement)

Benefits

• Staff leadership of shared–governance forum
• Staff representation at nursing staff council
• Opportunity to learn and develop nursing leader skills
• Support for RN advancement
• Opportunity to create needed change on the floor and work along-side co-workers for many projects

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Expected activities

• Leadership of all unit board meetings bi-monthly
• Gathering of staff feedback about pt care challenges or needs
• Collaboration with Nursing Staff Council Representatives
• Report out of nursing staff council information
• Monthly agenda-planning meeting with CSL lead and unit manager
• Work on and solicit staff involvement for follow-up projects to correct patient care challenges
• Report out follow-up projects and work completed at unit-board meetings

Staff engaged

• Chelle Freeman, Courtney Angel, Claire Calamaio

Lead: Lindsey Kevetter

Reviewed 7/2/19 LK

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Work-Life Committee

Summary
• A group of energetic staff dedicated to providing activities and opportunities to promote comradery and rapport-
building among staff.

Objectives
• To provide activities for staff to be involved in while at work or outside of work with a goal of increasing staff
satisfaction. (I.e. potlucks, games, outings, holiday activities)

Benefits
• Increases morale as well as helping to build relationships among coworkers.
• Additional support for participation and engagement for RN advancement process.

Expected Activities
• Attend quarterly meetings to plan activities and participate in monthly activities when available.

Member Eligibility
• CPs, MRs, RNs, RSLs

Staff Engaged
• Day shift: Lori Werle, Courtney Angel, Kristen Williams
• Night shift: Sheree Burdette, Chelle Freeman, Danysha Maitre, Jessica Gordy
Leads: Lindsey Kevetter

Reviewed 7/2/19 LK

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Project Work (not currently within committees)

Supply Par Project

• Project aiming to improve supply scanning compliance, organization of supply rooms, and restructure par
system.

• Staff Involved: Katelin Edlin, Becca Haseman, Anne Ramsey

Acuity Tool Revision

• Project aiming to adopt/revise a validated acuity tool to improve acuity tracking on the unit, and apply

acuities to staffing levels and ratios

• Staff Involved: Amy Butterfield, Claire Calamaio, Jackie Lynn Cothron, Christine Schueler

Treatment Room Utilization

• Project aiming to look at EBP around treatment rooms, and develop guidelines/processes around using our

treatment room for treatments/procedures (when not being used as a patient room)

• Staff Involved: Emily Williams, Dana Schmidt, Sam Schulz

Pain Assessment/Reassessment and Interventions

• Project aiming to oversee assessment and reassessment compliance with pain medication administration, as

well as improve upon overall pain assessment and intervention practices

• Staff Involved: Christine Schueler

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Staff Kudos/Level-Up Board

• Project aiming to provide recognition for peers through bulletin board with kudos, level up coins, and a shop
• Staff Involved: Kristen Williams

Linen Project

• Project aiming to correct linen pars, eliminate waste in our pars and processes, and restructure linen

stocking and use for our unit

• Staff Involved: Needs Volunteers

MD Rounding

• Project aiming to improve rounding practices and communication between nursing staff and MDs, with a goal

of improving overall communication and to better provide family-centered care

• Staff Involved: Needs volunteers

Nutrition Pars Project

• Project aiming to examine current nutrition pars regarding food/drinks stocked on the unit, and adjust these

pars to improve patient care/satisfaction

• Staff Involved: Kay-Kay Freyou, Lori Werle, Margaret Kababik

Wellness Newsletter

• Monthly newsletter aiming to promote wellness and work-life balance, as well as share information about

VUMC wellness events

• Staff Involved: Kristen Williams

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Other opportunities…

Frontline Leadership Program

• 18 month program available to all staff to learn how to assess their work environment for improvement
opportunities and how to implement solutions effectively. Interest in this should be expressed to Cristina
Loaiza.

Evidence-based Practice Fellowship

• Available to nurses who wish to learn more about research, data collection and implementation of clinical
practice. Interest in this should be expressed to Cristina Loaiza.

Isolated Pilots or Projects

• Examples: Discharge/Transport Pilot; Bedside Report Champion; or you can always present your own idea to
management to start working on your own project…