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Collaborative
Governance
Annual
Report
2006
Institute for Patient Care
Patient Care Services Department
January 2007

Collaborative Governance 2006
Annual Report
Table of Contents

Introduction

1

2006 Committee Leadership

2

2007 Committee Leadership

3

Collaborative Governance Meeting Schedule

4

Diversity Steering Committee

5

Ethics in Clinical Practice Committee

7

Nursing Practice Committee

12

Nursing Research Committee

15

Patient Education Committee

19

Quality Committee

23

Staff Nurse Advisory Committee

26

i

Introduction

The mission of Collaborative Governance is to stimulate, facilitate and generate knowledge
that will improve patient care and enhance the environment in which clinicians shape their
practice (Mission Statement). As one of the nine structures within Patient Care Services’
(PCS) Professional Practice Model, Collaborative Governance places the authority,
responsibility and accountability for patient care with practicing clinicians thus integrating
clinical staff into the formal decision-making process within Patient Care Services.
Grounded in the concept of empowerment, collaborative governance gives professionals an
opportunity to both influence the strategic direction of Patient Care Services and participates
in achieving the goals established by the PCS Executive Committee.
The ability to see possibilities is one of the core leadership skills that allow Collaborative
Governance members the opportunity to come together and make a difference in practice.
As one participant in the 2006 evaluation put it, “from concept to institutional change.” This
report is a story about the commitment, time, and collaborative efforts of busy clinicians who
accomplished many worthy goals.
In 2006, we again formally evaluated the Collaborative Governance structure based upon an
evidence-based management model, Kanter’s Theory of Structural Power in Organizations.
As in the past, we surveyed Collaborative Governance clinicians along with a random
sample of PCS clinicians. Measures of empowerment between both samples of clinicians
continue to show positive trends that reflect a vibrant, evolving professional practice
environment. Both samples perceived a high degree of meaning, competence, and
autonomy in their work at MGH. The Collaborative Governance respondents scored
significantly higher on the impact scale, suggesting that they can initiate actions and have an
impact on the organization.
We presented the findings of the evaluation to Patient Care Services Executive Committee,
Nurse Managers, Collaborative Governance leaders, and the entire MGH community. We
believe that organizational research is iterative in nature and requires both dissemination of
the findings along with meaningful feedback from multiple perspectives. The findings
identified areas for future growth and change such as better visibility and communication
surrounding Collaborative Governance and its work as well as more interdisciplinary
participation in research and education forums.
At the ten-year mark, Collaborative Governance continues to make positive contributions to
the professional practice environment by providing clinicians many opportunities to make
hospital-wide decisions that will enhance the practice environment for themselves and other
clinicians. In so doing, these decisions will ultimately improve our care environment, making
MGH a safer and better place for our patients and their families.
Please take a moment to read the report of each committee along with the goals outlined for
2007. If you are not already involved in Collaborative Governance, please visit our website
http://pcs.mgh.harvard.edu/ccpd/cpd_govern.asp for more information.
Respectfully submitted,
Susan Lee, RN, PhD, Clinical Nurse Specialist, Institute for Patient Care
Taryn J. Pittman, RN, MSN, BC, Patient Education Specialist/Manager
Blum Patient and Family Learning Center
Karla Valentin, Staff Assistant, Institute for Patient Care

1

Collaborative Governance
2006 Leadership
Diversity Steering Committee
Co-Chairs:
Carly Jean Francois, RN, Staff Nurse, Ellison 18, Pediatrics
Lourdes "Lulu" Sánchez, Manager, Interpreter Services
Coach:
Judy Newell, RN, BS, Nurse Manager, Ellison 17 & 18, Pediatrics
Advisor:
Deborah Washington, RN, PhDc, Director, PCS Diversity Program
Ethics in Clinical Practice Committee
Co-Chairs:
Regina Holdstock, RPh, Pharmacist, Ambulatory Oncology
Gayle Peterson, RNC, Staff Nurse, PH 21, General Medicine
Coach:
Ellen Robinson, RN, PhD, Clinical Nurse Specialist in Ethics, Institute for
Patient Care
Nursing Practice Committee
Co-Chairs:
Catherine Mackinaw, RN Staff Nurse, Ellison 12, Neuroscience
Edna Riley, RN, Staff Nurse, IV Therapy
Coach:
Joanne Empoliti, RN, MSN, Clinical Nurse Specialist, PH 22, Surgery &
WH 6, Orthopedics
Nursing Research Committee
Co-Chairs:
Catherine Griffith, RN, MSN, Clinical Nurse Specialist, Blake 8, Cardiac
Surgery ICU
Mary Larkin, RN, BSN, CDE, Manager of Clinical Research, MGH Diabetes
Center
Coach:
Virginia Capasso, APRN-BC, PhD, Clinical Nurse Specialist, Norman Knight
Nursing Center
Patient Education Committee
Co-Chairs:
Audrey Cohen, SLP, Speech Language Pathologist
Kathleen Reilly Lopez, RN, Staff Nurse, Ellison 7 & White 7, Surgery
Coach:
Taryn Pittman, RN, MS, Patient Education Specialist/Manager, Blum Patient
and Family Learning Center
Quality Committee
Co-Chairs:
Karen Lipshires, RN, Chemo Order Set Coordinator, Yawkey 8, Oncology
Patricia Wright, RN, Staff Nurse, Main Operating Room
Coach:
Lynda Tyer-Viola, RN, PhD, Clinical Nurse Specialist, Obstetrics
Advisor:
Joan Fitzmaurice, RN, PhD, Director, PCS Quality & Safety
Staff Nurse Advisory Committee
Chair:
Jeanette Ives Erickson, RN, MS,
Senior Vice President for Patient Care and Chief Nurse
Committee Leaders Meetings:
Leadership:
Marianne Ditomassi, RN, MSN, MBA, Executive Director, Patient
Care Services Operations
Dorothy Jones, RNC, EdD, FAAN, Senior Nurse Scientist, Munn
Center for Nursing Research
Susan Lee, RN, PhD, Clinical Nurse Specialist, Institute for Patient
Care
Taryn Pittman, RN, MS, Patient Education Specialist/Manager,
Blum Patient and Family Learning Center
Staff Assistants:
Kimberly Chelf
Nichole Forrester

2

Collaborative Governance
2007 Leadership
Diversity Steering Committee
Co-Chairs:
Carly Jean Francois, RN, Staff Nurse, Ellison 18, Pediatrics
Lourdes "Lulu" Sánchez, Manager, Interpreter Services
Coach:
Judy Newell, RN, BS, Nurse Manager, Ellison 17 & 18, Pediatrics
Advisor:
Deborah Washington, RN, PhDc, Director, PCS Diversity Program
Ethics in Clinical Practice Committee
Co-Chairs:
Susan Warchal, RN, Staff Nurse, Emergency Department
Gayle Peterson, RNC, Staff Nurse, PH 21, General Medicine
Coach:
Ellen Robinson, RN, PhD, Clinical Nurse Specialist in Ethics, Norman Knight
Nursing Center
Nursing Practice Committee
Co-Chairs:
Maureen Beaulieu, RN, Staff Nurse, Emergency Department
Edna Riley, RN, Staff Nurse, IV Therapy
Coach:
Joanne Empoliti, RN, MSN, Clinical Nurse Specialist, PH 22, Surgery &
WH 6, Orthopedics
Nursing Research Committee
Co-Chairs:
Catherine Griffith, RN, MSN, Clinical Nurse Specialist, Blake 8, Cardiac
Surgery ICU
Mary Larkin, RN, BSN, CDE, Manager of Clinical Research, MGH Diabetes
Center
Coach:
Virginia Capasso, APRN-BC, PhD, Clinical Nurse Specialist, Norman Knight
Nursing Center
Patient Education Committee
Co-Chairs:
Janet King, RN, Staff Nurse, Endoscopy Unit
Kathleen Reilly Lopez, RN, Staff Nurse, Ellison 7 & White 7, Surgery
Coach:
Taryn Pittman, RN, MS, Patient Education Specialist/Manager
Blum Patient and Family Learning Center
Quality Committee
Co-Chairs:
Karen Lipshires, RN, Chemo Order Set Coordinator, Yawkey 8, Oncology
Andrea Bonanno, RPT, Clinical Specialist, Physical Therapy
Coach:
Carol Camooso Markus, RN, MS, Staff Specialist, PCS Office of Quality &
Safety
Advisor:
Joan Fitzmaurice, RN, PhD, Director, PCS Office of Quality & Safety
Staff Nurse Advisory Committee
Chair:
Jeanette Ives Erickson, RN, MS,
Senior Vice President for Patient Care and Chief Nurse
Committee Leaders Meetings
Co-Chairs:
Marianne Ditomassi, RN, MSN, MBA, Executive Director, Patient
Care Services Operations
Dorothy Jones, RNC, EdD, FAAN, Senior Nurse Scientist, Munn
Center for Nursing Research
Susan Lee, RN, PhD, Clinical Nurse Specialist, Institute for Patient
Care
Taryn Pittman, RN, MS, Patient Education Specialist/Manager,
Blum Patient and Family Learning Center
Staff Assistant:
Karla Valentin

3

Collaborative Governance
2007 Meeting Schedule
Diversity Steering Committee
1st and 3rd Tuesday of each month, 12-1pm
Bigelow 1030 Conference Room
Ethics in Clinical Practice Committee
1st Wednesday of each month, 1-3pm
O’Keeffe Auditorium
Nursing Practice Committee
2nd and 4th Tuesday of each month, 1-2:30pm
Yawkey 2210 Satter Conference Room
Nursing Research Committee
1st Friday of each month, 1-2:30pm
Blake 8 Conference Room
Patient Education Committee
2nd & 4th Wednesday of each month, 1:30-3pm
Bigelow 1030 Conference Room
Quality Committee
1st and 3rd Tuesday of each month, 1-3pm
Yawkey 2210 Satter Conference Room
Staff Nurse Advisory Committee
1st Tuesday of each month, 11:30am-12:30pm
Trustees Conference Room (Bulfinch 222)
Committee Leaders Meetings
2nd Thursday of each month, 11am-12:30pm
Bigelow 1030 Conference Room

4

Patient Care Services
Diversity Steering Committee
Annual Report 2006
Description of Committee:
The Patient Care Services Diversity Steering Committee is committed to supporting and
developing strategies, which transform our work setting into a more inclusive and welcoming
environment for staff and patients alike. The committee’s work includes professional
development, student outreach, programs centered on culturally competent care and input
into the development of patient education material specifically designed for use by clinicians
who care for a diverse patient population.
Charges:
♦ Professional development
♦ Culturally competent care and staff education
♦ Preparation of patient education materials
♦ Student outreach: MGH Foreign Nurses Group
♦ Develop a community, sensitive to each person as a human to be treated with dignity
and respect
♦ Create a climate of inclusion in activities throughout the system
Meeting Schedule: 1st and 3rd Tuesday of each month from 12pm to 1pm
Co-Chairs:
Carly Jean Francois, RN
Lourdes "Lulu" Sánchez
Coach:
Judith Newell, RN
Advisor:
Deborah Washington, RN
Members:
Claribell Amaya, RN
Mary Cunningham
Nancy D’Antonio, RN
Audrey Jasey, RN
Maria Kingston
Rabbi Benjamin Lanckton
Kathleen Myers, RN
Ivonny Niles, RN
Elizabeth Nolan
Firdosh Pathan, RPh
Georgia Peirce
Donna Perry, RN
Kerry Treacy, RN
Joy Williams, RN
Liang Yap, PhD

Staff Nurse, Ellison 18, Pediatrics
Manager, Interpreter Services
Nurse Manager, Ellison 17 & 18, Pediatrics
Director, PCS Diversity Program
Staff Nurse, White 6, Orthopedics
Director, Customer Service
Case Manager, Obstetrics
Staff Nurse, Ellison 16, General Medicine
International Patient Coordinator Int’l Office
Chaplain, Chaplaincy
Nurse Manager, Ellison 6 & White 6, Orthopedics
Staff Nurse, White 6, Orthopedics
Global Health Services Liaison, Partners Int’l
Pharmacist, Pharmacy
Director, Promotional Communications & Publicity
Professional Development Coordinator, Norman
Knight Nursing Center
Staff Nurse, Ellison 11, General Medicine
Staff Nurse, Radiology
Administrator, Neurology

Recorders:
Kim Chelf
Nicole Forrester
Goal: Continue raising awareness about diversity issue
2006 Accomplishments:
♦ Monthly publications in Caring Headlines

5

♦

A presentation in the O’Keeffe Auditorium highlighted unique health care needs of
the GBLT (Gay/Bisexual, Lesbian, Transgender) community: Caring for the
Invisible Patient. Speakers were Harvey J. Makadon, MD, Director of Educational
& Professional Training and Judith B. Bradford, PhD, Co-Chair & Director of Lesbian
Health Research, both of Fenway Institute, Fenway Community Health. The
discussion improved the audience’s knowledge and sensitivity to GBLT health care
issues.

Goal: Continue exploring the issue of healthcare disparities
2006 Accomplishments:
♦ As a group, we came up with a plain language definition of healthcare disparities and a
more “user friendly “definition than the one used by the Institute of Medicine.
Goal: Continue educating the workforce about cultural competence
2006 Accomplishments:
♦ Continue with yearly celebrations:
Hajj
African Pinning Ceremony
St. Patrick’s Day
Passover and Easter
Ramadan
Yom Kippur
Holidays around the World
Goal: Collaborate with other groups in collaborative governance
2006 Accomplishments:
♦ We collaborated with the Patient Education Committee and the Ethics in Clinical
Practice Committee on various issues.
Goal: Continue with community outreach
2006 Accomplishments:
♦ Participated in the New Bostonian, a daylong event sponsored by Mayor
Menino and the City of Boston so that new immigrants have the opportunity to
learn about services and resources available to them. Again this year,
committee members represented MGH, the only hospital participant.
♦ Participated in Familia y Saluda- an event dedicated to the health care of
Boston Latinos.
Goal: Increase membership and encourage new members to have an active voice.
2006 Accomplishments:
• Two of our new members wrote a paper about what being on the committee means to
them.
2007 GOALS
• To raise awareness about diversity-related issues by partnering with specialists and
other groups with similar agendas through presentations, meetings, and other
activities.
• To build a network of communication wherein employees are free to provide
feedback about how we can help make the hospital a more inclusive place for both
employees and patients.
• To sponsor a mentorship program for incoming nurses.
• To create a program targeted specifically towards the welcoming of new-hire
minority nurses.
• To continue looking at issues of healthcare disparities and how we can educate the
public.
• To revise and improve the culturally competent care agenda.
• To work with the homeless and homeless advocacy groups.

6

Patient Care Services
Ethics in Clinical Practice Committee
Annual Report 2006

Description of Committee:
The Patient Care Services Ethics in Clinical Practice (EICP) Committee is a multidisciplinary
committee, which was formed to develop and implement activities and programs to further
clinicians’ understanding of ethical aspects of patient care. The work of this committee
involves identifying strategies to integrate ethical judgment into professional practice.
Charges:
♦ Design and implement activities and programs to support the development of staff in
Patient Care Services in the area of health care ethics.
♦ Employ strategies to educate EICP members in the area of health care ethics.
♦ Identify and address ethical issues and conflicts faced by clinicians in Patient Care
Services.
♦ Provide consultation to the organization regarding policies, procedures and programs
with ethical implications.
♦ Expand the impact of EICP through collaboration with other Collaborative Governance
Committees, links with the organizational initiatives, and professional conference
participation.
Meeting Schedule: 1st Wednesday of each month from 1pm to 3pm
Co-Chairs:
Regina Holdstock, RPh
Gayle Peterson, RN
Coach:
Ellen Robinson, RN, PhD
Members:
Susan Anderson, RN
Sara Asekoff, RN
Sharon Brackett, RN
Anne Brandl, RN
Kathleen Bucci, RN
Janice Cameron-Calef, RN
Theresa Cantanno, RN
Alex FM Cist, MD
Valerie Cleverdon, RD
Regina Doherty, OTR/L
Carole Foxman, MS
Charlene Gorden, RN
Linda Gorham Ryan, RN
Audrey Jasey, RN
Cynthia Johnson, RN
Karon Konner, LICSW
Susan LaGambina, RT
Cynthia LaSala, RN
Marisa Legare, RN
Ann Letendre, RN
Katherine McNulty, RN
Jackie Michaud, RN
Christine Mitchell, RN
Denise Montalto, PT
Paul Montgomery, PhD
Joyce Murray, RN

Pharmacist, Ambulatory Oncology
Staff Nurse, Phillips House 21, General Medicine
Clinical Nurse Specialist in Ethics, Institute for Patient Care
Staff Nurse, Bigelow 9, RACU
Staff Nurse, Ellison 9, CCU
Staff Nurse, SICU
Staff Nurse, PACU
Staff Nurse, Bigelow 10 Dialysis
Staff Nurse, PH 21, General Medicine
Clinical Nurse Specialist, PH 20 & 21, General Medicine
Pulmonary and Critical Care Medicine
Registered Dietician, Nutrition & Food Services
Clinical Specialist, Occupational Therapy
Librarian, Treadwell Library
Staff Nurse, Bigelow 9, RACU
Staff Nurse, Phillips House 22, Surgery
Staff Nurse, Ellison 16, General Medicine
Clinical Nursing Supervisor
Social Worker, Social Services
Respiratory Therapist, Respiratory Care
Clinical Nurse Specialist, White 9, General Medicine
Staff Nurse, Blake 6, Transplant
Staff Nurse, Blake 12, Neuroscience ICU
Staff Nurse, White 10, General Medicine
Staff Nurse, White 13, GCRC
Ethics Consultant
Physical Therapist, Physical Therapy
Palliative Care
Staff Nurse, Ellison 10, Cardiac Telemetry

7

Gordon Newbert, RN
Monsignor Felix Ojimba, PhD
Patricia Olsen, NP
Judy Pagliarulo, RN
Marion Parker, RN
Lois Richards, RN
Kathleen Ryan, RN
Judy Sacco
Shoshana Savitz, LICSW
Sarah Sciretta, RN
Denyce Stanton, RN
Maureen Thomassen, RN
Angelica Tsoumas, LICSW
Dana Villeneuve, RN
Marjorie Voltero, RN
Susan Warchal, RN
Robin Weingarten, RN
Kristen Wilson, RN
Mary Wilson, RN
Marilyn Wise, LICSW
Brenda Woodbury, NP

Staff Nurse, Bigelow 11, General Medicine
Chaplain, Chaplaincy
Nurse Practitioner, Surgery
Staff Nurse, SDSU
Staff Nurse, PH 20, General Medicine
Staff Nurse, Blake 14, Obstetrics
Staff Nurse, Blake 7, MICU
Operations Coordinator, Ellison 17 & 18, Pediatrics
Social Worker, Social Services
Staff Nurse, PH 22, Surgery
Staff Nurse, White 9, General Medicine
Staff Nurse, White 8, General Medicine
Social Worker, Social Services
Staff Nurse, Ellison 14, Vascular Surgery
Staff Nurse, Blake 4, Endoscopy
Staff Nurse, Emergency Department
Staff Nurse
Staff Nurse, White 10, General Medicine
Staff Nurse, Blake 14, Obstetrics
Social Worker, Social Services
Nurse Practioner, North End Community Health Center

Recorder:
Kimberly Chelf
Nichole Forrester
Goal: Continue to educate Ethics in Clinical Practice Committee members and members of
the PCS community.
2006 Accomplishments:
• Retrospective case study analyses at meetings
• “Ethics in the News,” ethical issues that are reported in general press are distributed and
discussed at meetings.
• Distribute relevant articles from professional journals.
• Guest speakers on topics relevant to members:
“War and Torture: Is It Ever Ethical?” by Pathan Firdosh, RPh
“DSS as Parent: Ethical Challenges for Pediatric Clinicians” by Brenda Miller
“HIV in Africa: Ethical Issues” by Monsignor Felix Ojimba
“Organ Donation: Ethical Issues with First Consent” by John Murphy, RN
•

•
•
•
•
•

Ethics Task Force/EICP Collaborative Programs
*Dancing with Porcupines: Clinicians’ Interactions with Big Pharma, Regina
Holdstock, facilitator
*Access to Health Care, Ruth Purtillo, Facilitator
Harvard Ethics Educational Program-participation of several EICP members as
participants and small group facilitators
Partners Ethics Retreat-participation of several EICP members as participants and
small group facilitators
3rd Annual Interdisciplinary Ethics Resource Program held at Dana Farber Cancer
Institute in collaboration with MGH, BWH and DFCI hosted close to 25 MGH
participants
Unit-based Ethics Rounds on PH 20-21,General Medicine, Blake 13-14, Obstetrics,
CCU, SICU, MICU, RACU, NICU, and Blake 6, Transplant.
MGH IHP Ethics Initiative-MGH EICP Committee have received a grant from the
Schwartz Center to sponsor the Compassionate Care Conference in February
2007, develop a teaching module for clinicians and students, and develop a
handbook for families.

8

•
•
•
•
•

B.O.A.T.I.N.G. (Before Offering Additional Treatment, Institute New Goals) This
was a dramatic presentation by EICPC members to illustrate the concepts of
advance care planning and end of life treatment, first seen as ASBH meeting.
End-of-Life Nursing Education Consortium (ELNEC) Program (some instructors from
EICP)
American Society for Bioethics and Humanities (ASBH) 2005 Nursing Affinity GroupPresentation of a case (Gayle Peterson, Keith Perleberg, Ellen Robinson, Marion
Parker)
ASBH Conference 2006-participation by several EICP members
Boston Medical Center Invitational Conference on Allocation of Resources: Ethical
Implications; EICPC leaders invited and attended.

Goal: Heighten awareness of clinician’s ethical obligation to address patients’ pain through
an interdisciplinary model. Specific strategies include utilization of data from the 2005 Staff
Perceptions Survey to assist in defining practice problems and areas in need of education;
collaborate with Pain Management Services and the Palliative Care Service in further
measuring, defining and addressing ineffective pain management issues in patients.
2006 Accomplishments:
•
•

•

Members participated in annual Burton Judith Heron Memorial Lecture, Scientific
and Political Perspectives on Fetal Pain at Brigham and Women’s Hospital (BWH).
MGH Pain Skills Knowledge Day, EICP Members participated as coaches
in collaboration with the Ethics Task Force, Pain and Symptom Management at End
of Life Presented; Ellen Robinson- Ethics; Paul Arnstein – Pain; Connie DahlinPalliative Care; Gayle Peterson - Facilitator
Presentation to the American Society of Pain Management Nurses Society; Ethical
Considerations in Pain Management- Ellen Robinson PhD, Gayle Peterson RN

Goal: Continue to educate the Patient Care Services community, patients and families,
about advance care planning through the support of the Advance Care Planning Task Force,
chaired by EICPC member, Sharon Brackett, RN.
2006 Accomplishments:
• PCS Health Care Proxy website: collaborated with Janet Madigan, Jean Callahan,
and Sally Millar to edit the agreement between MGH and Mass Health Decisions to
allow electronic versions of the Spanish and Portuguese Massachusetts Health Care
proxy form to be posted on the site at the request of the Primary Care health centers
and to explore options to make the site available to all of the health centers.
• The advance care planning brochures developed by the task force are now
distributed as MGH Standard Register documents. This pair of informational
brochures is now given to patients as part of the admission packet on inpatient floors
and other entry points to the hospital such as PATA. Approximately 20,000 of these
brochures have been distributed in 2006.
• Presentations on advance care planning concepts, facilitation skills, and
documentation options have been offered by ACP Task Force members at Palliative
Care Grand Rounds January 25, 2006 and ELNEC Curriculum October 13, 2006.
• In coordination with The Norman Knight Nursing Center for Clinical and Professional
Development and The Stoeckle Center for Primary Care Innovation, we provided
leadership and certified instructors in presenting the Respecting Choices Advance
Care Planning Facilitator for Primary Care Program on October 2006. This
groundbreaking collaborative effort between Primary Care and Patient Care
Services was made possible through a grant from the Esther Rabb Foundation. The
program certified 32 multidisciplinary clinicians as advance care planning facilitators,
including four clinicians from Beth Israel Deaconess Medical Center (BIDMC). This
program also provided the education in advance directives and advance care
planning for the CMS Care Management Program case managers hired to date for
the Medicare demonstration Project.
• Collaborated with The Blum Patient and Family Learning Center and The Stoeckle
Center to develop the content, marketing, and facilitators for monthly Advance Care

9

•

•

•

•

•

•

•

Planning Open Sessions, which were offered in July, August, and September.
Because attendance at the initial sessions was low, the task force is regrouping to
redesign marketing, space, and a new lunch hour time frame.
Members collaborated with trained ACP facilitators in The MGH Cancer Center to
develop the content and assist with facilitating monthly advance care planning
programs on the HOPES Program calendar. These programs have been offered
monthly since September. Currently the Task Force is collaborating with the Hopes
Program to explore expanding the number of Task Force ACP facilitators offering
the program to allow expanding the program into the Cox Radiation and Infusion
areas.
Developed the agenda and content for quarterly ACP facilitator update forums on
February 2, 2006 and August 3, 2006. The May forum was deferred to allow
facilitators to attend the EICP sponsored educational program B.O.A.T.I.N.G. a
moving and interactive play and panel discussion about advance care planning.
Sharon Brackett, RN, Chair of the ACP Task Force, has been asked to participate in
the MGH EOL CPM Team and the Partners Advance Care Planning IT Workgroup
to represent the ACP Task Force and share the expertise and knowledge gained in
their work to date within Patient Care Services.
Collaborated with Joanne Empoliti, the Nursing Practice Committee and leaders
from Medical Information systems to provide scanning of advance directive
documents into CAS and Red Sleeves in all inpatient gray charts to identify and
house advance directive documents.
Respecting Choices certified RN facilitators and designated AD champions with
leadership support from Sharon Brackett, RN, who guided the implementation of a
unit-based education initiative on advance directives and advance care planning on
inpatient adult units. This initiative was supported through Patient Care Services and
The Norman Knight Nursing Center for Clinical and Professional Development.
The Task Force developed a “Reflection Questions” sheet designed to serve as a
patient education tool, discussion/documentation guide for the patient and their
agent during an advance care planning discussion. The Cancer Center’s Patient and
Family Advisory Council and further revisions have reviewed the final draft of this
document or development will be considered after their feedback has been
reviewed.
Continue to maintain and update a Shared Drive PCS ACP area to house
presentations and minutes of all meetings, an Access database of all certified ACP
instructors/facilitators and their activities, and an email distribution list of all certified
ACP facilitator.

2007 GOALS
•

Continue to educate Ethics in Clinical Practice Committee members and members of the
PCS community about ethical issues in clinical practice. Specific strategies with existing
ethics committees and developing and implementing education programs (Ethics Task
Force, Harvard Ethics Leadership Council, Partners Ethics Committee, EICP sponsored
programs; committee case review and ethics in the news, Ethics Resource Program,
Unit-based Ethics Rounds, and the Harvard Ethics Consortium).

•

Continue to heighten awareness of clinician’s ethical obligation to address patients’ pain
through an interdisciplinary model. Specific strategies include utilization of data from the
2006 Staff Perception Survey to assist in defining practice problems and areas in need
of education; collaborate with Pain Management Services and the Palliative Care
Service in further measuring, defining and addressing ineffective pain management
issues in patients.

•

Discussion of the ethical issues related to patient access to care from primary care to
emergency care; Develop strategies to raise awareness and possible solutions.

10

•

Continue to educate and advise the Patient Care Services community, patients, and
families about advance care planning through the support of the Advance Care Planning
Task Force and through its members’ representation on MGH and Partners EOL Teams.

•

Through examination of the Massachusetts legislation on “First Consent,” we worked
collaboratively with MGH/New England Organ Bank representatives to develop
educational initiatives for professionals and public. Strategies may include 1) Caring
Headlines article, 2) letter to editor of The Boston Globe, and 3) develop additional
educational programs.

11

Patient Care Services Nursing Practice Committee
Annual Report 2006

Description of Committee:
The Patient Care Services Nursing Practice Committee reviews, revises and communicates
standards of practice for progressive nursing at MGH. This work includes reviewing and
approving new products, new practice recommendations, and communicating of outcomes
and revisions to staff throughout Patient Care Services.
Charges:
♦ Consult and approve standards of practice including clinical care and documentation
guidelines.
♦ Approve clinical practice recommendations (including integration of new Patient Care
Delivery Model).
♦ Determine and communicate standards for professional nursing practice at MGH.
♦ Communicate committee outcomes throughout Patient Care Services and to others as
appropriate.
♦ Communicate changes and additions to clinical pathways.
♦ Approve clinical product selections.
Meeting Schedule: 2nd and 4th Tuesday of the month from 1:30 pm to 3:00 pm
Co-Chairs:
Catherine Mackinaw, RN
Edna Riley , RN
Coach:
Joanne Empoliti, RN
Members:
Sami Ahmed, RPh
Mimi Bartholomay, RN
Maureen Beaulieu, RN
Kate Boyle, RN
Sheila Burke, RN
Margaret Callen, RN
Diane Carroll, RN
Rhianna Casale, RN
Cecilia Catone, RN
Gina Cenzano, RN
Margaret Chernaik, RN
Elena Clifford, RN
Gregory Conklin, RN
Leslie Delisle, RN
Michelle Dever, RN
Erica Edwards, RN
Jean Fahey, RN
Karla Farrer, RN
Kathleen Flynn, RN
Eileen Gardner, RN
Susan Gavaghan, RN
Christine Grady, RN
Kathleen Gottbrecht, RN
Mary Guanci, RN
Amy Guillemin, RPh
Sioban Haldeman, RN
Kathleen Hoffman, RN
Marian Jeffries, RN

Staff Nurse, Ellison 12, Neuroscience
Staff Nurse, IV Therapy
Clinical Nurse Specialist, White 6, Orthopedics & Phillips 22,
Surgery
Pharmacist, Pharmacy
Clinical Nurse Specialist, Yawkey 8, Oncology
Staff Nurse, Emergency Department
Staff Nurse
Clinical Educator, Norman Knight Nursing Center
Staff Nurse, Blake 11, Psychiatry
Clinical Nurse Specialist, Ellison 11, Cardiac Access
Staff Nurse, White 9, General Medicine
Staff Nurse, Endoscopy
Staff Nurse, Bigelow 13, Obstetrics
Staff Nurse, Dialysis
Staff Nurse, Emergency Department
Staff Nurse, Bigelow 9, RACU
Staff Nurse, White 8, General Medicine
Staff Nurse, Ellison 7, Surgery
Staff Nurse, Ellison 9, CCU
Clinical Nurse Specialist, Ellison 12, Neuroscience
Staff Nurse, White 11, General Medicine
Staff Nurse, Blake 8, Cardiac Surgical ICU
Staff Nurse, Ellison 18, Pediatrics
Clinical Nurse Specialist, Bigelow 9 RACU
Staff Nurse, Ellison 8, Cardiac Surgery
Clinical Supervisor, Nursing Supervisor
Clinical Nurse Specialist, Blake 12, Neuroscience ICU
Pharmacist, Pharmacy
Clinical Nurse Specialist, Ellison 11, Cardiac Access
ICP, Infection Control
Clinical Nurse Specialist, Ellison 19, Thoracic Surgery

12

Donna Jenkins, RN
Stephen Joyce, RN
Cindy Knauss, RN
Donna Lawrence, RN
Sharon Maginnis, RN
Stacey Margardo, RN
Cristina Matthews, RN
Christine McCarthy, RN
Julie McCarthy, RN
Suzanne McCarthy, RN
Nancy Mermet, RN
Sheila Moran, MLIS
Linda Nichols, RN
Kerin O’Grady, RN
Leanne Otis, RN
Erin Pelletier, RN
Jane Ritzenthaler, RN
Erin Salisbury, RN
Claire Seguin, RN
Nancy Swanson, RN
Aileen Tubridy, RN
Pam Wrigley, RN

Nurse Manager, Ellison 19, Thoracic Surgery & PH 22,
Surgery
Staff Nurse, SICU
Staff Nurse, Ellison 14, Oncology
Staff Nurse, Ellison 10, Cardiac Telemetry
Staff Nurse, White 13, GCRC
Staff Nurse, Ellison 19, Thoracic Surgery
Staff Nurse, White 12, Neuroscience
Staff Nurse, Blake 7, MICU
Staff Nurse, PACU
Staff Nurse, Main OR
Staff Nurse, PH 22, Surgery
Librarian, Treadwell Library
Staff Nurse, Blake 12, Neuroscience
Staff Nurse, White 6, Orthopedics
Staff Nurse, Ellison 11, Cardiac Access
Staff Nurse, Main OR
Clinical Nurse Specialist, Blood Transfusion Service
Staff Nurse, Ellison 6, Orthopedics
Staff Nurse, PH 21, General Medicine
Infection Control Practitioner, Infection Control
Nurse Manager, Ellison 10, Cardiac Telemetry
Staff Nurse, SDSU

Recorder:
Kim Chelf
Nichole Forrester
Goal:
• Review and approve nursing procedures, and current and new practices for
patient safety and efficiency.
• Review issues and concerns regarding nursing practice.
2006 Accomplishments
• Reviewed and approved peri-operative beta blockade guidelines
• Reviewed and made recommendations for creation of PAML
• Discussed and approved on-line safety reporting system
• Reviewed and approved verification process for red checking
• Reviewed and approved policy for range orders and link to pain scale
• Approved and made recommendations for vital sign changes for blood transfusions
• Reviewed and approved subcutaneous administration of pain medications and symptom
management by Palliative Care
• Reviewed and recommended changes concerning duplicate patient names
• Reviewed and approved use of sedation for intractable distress of a dying patient
• Reviewed and approved universal respiratory care procedures
• Reviewed and approved assessment and removal of PICC lines
• Approved and made recommendations to develop guidelines and a teaching plan for
PCAs to assist with oxygen saturations
• Reviewed and approved the Safe Hand Off Policy, regarding the transfer of
responsibility of care between RNs and providers
Goal:
Collaborate with the Quality and Research Committees and Pharmacy to facilitate practice
changes. Continue to communicate with Operations Improvement Teams regarding changes
in nursing practice.
2006 Accomplishments
• Reviewed and approved standard KCl infusions from pharmacy Medication Education
Safety and Approval Committee.
• Reviewed and approved chemotherapy guidelines for infusion unit.

13

•
•

Approved and made recommendations concerning change of TPN hang time
Reviewed and approved code cart changes and updates

Goal:
Evaluated and approved new and current products for patient safety, efficiency, and cost
effectiveness. Continue to maintain relationship with Materials Management as frontline
evaluators for products.
2006 Accomplishments
• Reviewed and approved portable bed alarms
• Discussed PCA pump requirements and made recommendations
• Reviewed and approved new patient beds and furniture
• Reviewed and approved new specimen collection bags
• Discussed and approved trial of new sterling gloves
• Reviewed and discussed recommendation to change from tie gowns to snap gowns for
patient safety
Goal:
Evaluate nursing documentation for appropriateness and quality.
2006 Accomplishments
• Reviewed and helped develop anticoagulation sheets
• Reviewed and made recommendations for PCA sheets
• Reviewed and approved health care proxy
• Approved and helped implement policy concerning red sleeves
• Reviewed and approved pressure regulation of isolation rooms with daily documentation
and performance of tissue test, when in use
• Continued to review updates concerning trial of new documentation policy
Goal:
Continue to improve communication with committee members, encourage
staff to attend and participate in committee meetings.
2006 Accomplishments
• Communicated with members via E-mail. Review of upcoming policies and procedures
• Continued to encourage use of online manual and provide direction for accessing Trove
2007 GOALS
•
Promote patient safety by reviewing current and new nursing practices for safety and
efficacy.
•
Review issues and concerns regarding nursing practice.
•
Develop, review and update Nursing Procedures to reflect practice.
•
Utilize evidence and research in approval of nursing procedures and practice.
•
Evaluate and approve products related to nursing practice. Continue to maintain
relationship with representatives from Materials Management.
•
Transform Nursing Practice Committee utilizing structure that has main committee and
subcommittees, that include: 1) Patient at Risk, 2) Products, Procedures,
Documentation, and 3) Population-Specific Practice, such as Cancer Center, Cardiac,
Medical, and Ambulatory.

14

Patient Care Services Nursing Research Committee
Annual Report 2006
Description of Committee:
The Patient Care Services Nursing Research Committee exists to foster the spirit of inquiry
around clinical practice. The committee supports nurses in the research utilization process
and communicates the results of nursing research activities.
Philosophy:
Passion and purpose fueled by energizing forces builds great achievements.
Charges:
• Foster a spirit of inquiry around clinical practice.
• Promote awareness of institutional nursing research activities.
• Encourage and provide support for research-based practice.
Meeting Schedule:
1. General Committee meeting
1st Friday of each month, 1-2:30pm
2. Subcommittees
Upon joining the NRC, each new member joins one of the subcommittees:
a. “Did You Know…” Posters: 1st Friday; 12pm - 1pm immediately before
NRC monthly meeting;
b. Research Day Planning: 1st Friday; 12pm - 1pm immediately before NRC
monthly meeting
c. Journal Club Subcommittee: 2nd Wednesday, 1:15pm - 2:15pm
Co-Chairs:
Catherine A. Griffith, APRN-BC
Mary E. Larkin, RN, CDE
Coach:
Virginia Capasso, APRN-BC, PhD
Members:
Stephanie Ball, RN, MS
Chelby Cierpial, APRN-BC
Susan Croteau, RN
Kathleen Egan, RN
Patricia Flaherty, APRN-BC
Katherine Fillo, RN
Elise Gettings, RN
Talli McCormick, APRN-BC
Victoria Morrison, RN, PhD
Catherine O’Malley, RN
Carolyn Paul, MSLS, MPH
Sharon Kelly-Sammon, RN
Steve Sampang, RN
Joan Stack, RN, MSN
Susan Stephens, APRN-BC
Theresa Vanderboom, RN
Kathleen Walsh, RN, PhD(c)

Clinical Nurse Specialist, Cardiac Surgery
Manager of Clinical Research, MGH Diabetes
Center
Clinical Nurse Specialist, Norman Knight Nursing
Center; Nurse Scientist, Yvonne L. Munn Center for
Nursing Research
Staff Nurse, ED; Faculty, Salem State College
CNS Ellison 11, Cardiac Access Unit
Staff Nurse, PATA
Staff Nurse, White 13, GCRC
Nurse Practitioner, Transplant Services
Staff Nurse, Bigelow 11, Adult Medicine
Research Nurse, Ellison 4, Anesthesia
Faculty, MGH Institute of Health Professions
Staff Nurse, White 11, General Medicine; Faculty
Salem State College
Staff Nurse, Main Operating Room
Senior Librarian, Treadwell Library
Staff Nurse, PACU
Staff Nurse, PH 21, Adult Medicine
Staff Nurse, Bigelow 14, Vascular Surgery
Nurse Practitioner, Weight Loss Clinic
Coordinator, Radiology
Case Manager, ED & Case Management

Recorder: Kimberly Chelf
Nichole Forrester

15

2006 Overall Goal: Expand current initiatives:
The subcommittee infrastructure of the Nursing Research Committee was further
strengthened through operationalizing our model of Succession Planning, as each
subcommittee seamlessly transitioned into having a recognized Subcommittee Chair. This
infrastructure was put in place in 2005 and is modeled after the larger Research Committee
to foster development of future leaders through mentorship, delegation and increased
participation in committee decision-making. The structure is meant to serve as a guide for
future NRC Coaches and Chairs. Each subcommittee is designing a “How To… Manual” as
a guide to future committee leaders in running the NRC initiatives. A Nursing Research
Committee business card was designed for networking at national conferences to increase
visibility of the MGH NRC.
1. Host Nursing Research Day
Accomplishments:
• Nursing Research Day 2006 was very successful:
- Three research teams presented the results of their Yvonne L Munn
Nursing Research Award-winning studies, “Evaluating the Drug-Dosage
Calculation Guide on the Registered Nurse’s Achievement Scores and
Multi-Step Calculations on an Orientation Medication Assessment; The
Giraffe Study; The Recognition and Prevalence of Delirium in Patients Who
Fall While Hospitalized in the Acute Care Setting.”
- Dr. Loretta Sweet Jemmott was the Yvonne L. Munn Nursing Research
Visiting Professor, who met with staff caring for adolescents and pediatrics,
members of the Nursing Research Committee, and awed the audience with
her presentation about innovations in the area of health promotion.
- The 2006-2007 Yvonne L. Munn Nursing Research Award was presented
to Kelly Trecartin, RN, and Nicole Spano-Niedermeier, RN, for their work in
the Blake 9 - Cardiac Catheterization lab on “The effects of informal reports
of anxiety levels of waiting family members during invasive cardiac
procedures.”
- A total of 40 posters were displayed throughout the Fruit St. campus
during Nurse’s Week representing work from original research, research
utilization, and performance improvement projects.
• To strengthen staff nurse’s knowledge and skills related to writing research
abstracts for poster presentations, the NRC hosted a session of Nursing Grand
Rounds to provide guidance for nurses in “Writing Research Poster Abstracts”
and “How Do I Know Which IRB Form to Use.”
2. “Did You Know….” Research Utilization Posters
Accomplishments:
• The system for providing the poster boards to clinical areas was redesigned.
• During calendar year 2006, three “Did You Know…?” research utilization
posters were written and produced by the “Did You Know…?” Subcommittee.
The posters, which are available on the MGH Nursing Research Committee
website, include:
-

PLAN, DO, CHECK, ACT: The Model for performance improvement at
MGH

-

Decreasing the Risk of Surgical Site Infections - Does your perception
of the professional practice environment count?

-

Pulmonary Hypertension

16

3. Nursing Research Journal Club Subcommittee
Accomplishments:
For the MGH nursing community, the Nursing Research Committee Journal Club continued
to provide opportunities for staff nurses to hear nurse researchers present original published
nursing research via bi-monthly Journal Club presentations.
• The Subcommittee created a “Mini Journal Club” that has a permanent slot on
the agenda of the NRC monthly meeting preceding the Journal Club’s regular
session. Embedded in the Mini Journal Club format is a summary and review of
the program of research of the Nurse Researcher who is presenting at the
Journal Club main session. This format is designed to develop the expertise of
subcommittee members in reading, critiquing and presenting research reports.
• Collected “Web Trends” data 2002 - 2006 which tracks website usage.
o Worked collaboratively with a Treadwell Librarian and IS to develop
a streamlined marketing strategy to facilitate access to presenters’
journal publications and comply with copyright regulations.
• Expanded the Journal Club marketing to both the online and print versions of
Nursing Spectrum.
• The process for selecting journal club presenters was refined.
o We instituted a slide loop, which is designed as a recruitment tool,
for display as attendees assemble for the Journal Club.
o The Journal Club Subcommittee further engaged in community
outreach to five local academic institutions inviting those interested
to present their original published research at the Journal Club.
o We provided links to articles on our website.

•
•

-

Carroll, D.L. (2005). Capacity for direct attention in patients undergoing
percutaneous coronary intervention: The effects of psychological distress.
Progress in Cardiovascular Nursing, 20(1), 11-16.

-

Horowitz et al. (2001). Promoting responsiveness between mothers with
depressive symptoms and their infants. Journal of Nursing Scholarship, 33
(4), 323-329.

-

Rawdin, L. (2000). Oncology patients' perceptions of quality nursing care.
Research in Nursing & Health,23(3), 179-190.

-

Read, C.Y., Perry, D.J., & Duffy, M.E. (2005). Design and psychometric
evaluation of the Psychological Adaptation to Genetic Information Scale.
Journal of Nursing Scholarship, 37(3):203-8.

-

Mahoney, D.F., Cloutterbuck, J., Neary, S., & Zhan, L. (2005). African
American, Chinese, and Latina family caregivers' impressions of the onset
and diagnosis of dementia: Cross-cultural similarities and differences.
Gerontologist. 45(6):783-92.

-

Mahoney, E.K., Trudeau, S.A., Penyack, S.E., &. MacLeod,C.E. (2006).
Challenges to intervention implementation: Lessons learned in the Bathing
Persons with Alzheimer's Disease at Home study. Nursing Research, 55(2
Suppl):S10-16.

Developed a database for tracking Journal Club attendance and attendees.
A Two-Session Teleconferencing Pilot was conducted to determine the
resources needed for remote broadcasting. The pilot was done from Satter
Conference Room at 2210 Yawkey to White 13 conference room. The need for
funding to support technical personnel was identified as a primary barrier for
teleconferencing as a form of expanding Journal Club distribution.

17

4. Extranet Website
• Extranet Website content and categories were reorganized.

5. Increase in Total Membership
• As a result of the expansion and growth of the NRC initiatives, the total
committee membership was increased from 16 to 25 to allow for
management of growth and innovation within the subcommittees.
6. Scholarly Publications:
• A writing group was formed to write a scholarly publication about the
creation and operation of the Nursing Research Committee. A manuscript
entitled, “Massachusetts General Hospital - Nursing Research Committee:
Promoting Research Utilization from the Perspective of the PARIHS
Framework” was submitted to JONA in October 2006 and is under review.
•

Additional articles are planned to showcase various aspects and activities of
the committee with the overall goal of developing scholarship among the
committee members.

2007 GOALS
Overall, our goal is to carry our agenda forward into the next year—to facilitate member
participation and leadership within the sub-groups to promote personal and professional
growth, and to prepare future nursing leaders.
1. Expand Nursing Research Day into Nursing Research Week
a. Host a Research Fair under the Bulfinch Tent on the Friday of National
Nurse Recognition Week. The Research Fair will include a Research
Consultation Section with MGH Nurse Researchers available to nurses to
gain direction with clinical research questions. Representatives from
Treadwell Library, Sigma Theta Tau International, Clinical Research
Program, the Munn Center, Mallinkrot Unit and several book vendors, who
publish nursing research books, will be available.
2. “Did You Know….” Research Utilization Posters
a. Create an online system to award nursing contact hours to those reviewing
the “Did You Know…” research utilization posters on the Nursing Research
Committee website.
b. Publish 6 DYK Posters
c. Write the DNS footprint of a DYK poster.
d. Revise the “Instructions to the Author - Guidelines for Creating A DYK
Poster.
e. Consider ways to measure DYK poster effectiveness.
3. Nursing Research Committee Journal Club
a. Publish a methods paper on the Journal Club
b. Analyze and interpret the WEB TRENDS data which tracks web page use.
c. Formalize the structure of the Mini Journal Club presentations.
d. Evaluate effectiveness of the Mini Journal Clubs.
e. Develop a research proposal to measure the impact of the Journal Club on
staff nurse practice utilizing focus groups.
f. Broaden the circle of reach of the Journal Club.
4. Continue to update and revise the Extranet Web Page

18

Patient Care Services Patient Education Committee
Annual Report 2006

Description of Committee:
The goal of the Patient Education Committee is to support clinical staff in developing their
role in patient education activities that reflects the diverse patient population served. The
committee supports these activities through stimulating, facilitating and generating
knowledge of Patient Education materials, programs and systems that will improve patient
care and enhance the environment in which clinicians shape their practice.
Charges:
♦ Develop strategies to assist healthcare providers in patient education design and
implementation.
♦ Encourage joint projects between other Collaborative Governance Committees
♦ Disseminate patient education information and activities to the larger MGH community.
♦ Collaborate with Center for Professional Development to develop patient education
programs to benefit PCS staff
♦ Participate in JCAHO task force to promote interdisciplinary education tools.
♦ Recommend systems and technology to support the cataloging, dissemination,
documentation and evaluation of patient education activities and materials.
♦ Assure activities and materials reflect diversity of the population served.
Meeting Schedule: 2nd and 4th Wednesday of each month from 1:30 pm to 3:00 pm
Co-Chairs:
Audrey Kurash Cohen, SLP
Kathleen Reilly Lopez, RN
Coach:
Taryn Pittman, RN
Members:
Carolyn Bartlett, RN
Cheryl Brunelle, PT
Diana Darby, RN
Claire Farrell, RN
Mary Margaret Finley, RN
Judy Gullage, RN
Michelle Hazelwood, LICSW
Elizabeth Johnson, RN
Janet King, RN
Donna Lawson, RN
Kathy Reilly Lopez, RN
Carol Mahony, OTR/L
Alexa O’Toole, RN
Jill Pedro, RN
Kristen Samatis
Angela Sorge, RN
Martha Stone
Laura Sumner, RN
Elizabeth P. West, RN
Mary Wyszyncki, RN

Speech Language Pathologist
Staff Nurse, White 7 & Ellison 7, General Surgery
Patient Education Specialist/Manager, Blum Patient
& Family Learning Center
Staff Nurse, SDSU
Clinical Specialist, Physical Therapy
Staff Nurse, White 6, Orthopedics
Staff Nurse, PATA
Staff Nurse, Ellison 13, Obstetrics
Patient Education Nurse, PFLC
Social Worker, Cancer Resource Room
Clinical Nurse Specialist, Ellison 14, Oncology
Staff Nurse, Endoscopy
Staff Nurse, Bigelow 11, General Medicine
Staff Nurse, White 7/Ellison 7, General Surgery
Senior Occupational Therapist
Staff Nurse, Blake 13, Obstetrics
Clinical Nurse Specialist, Ellison 6, Orthopedics
Health Educator, Blum Patient & Family Learning
Center
Staff Nurse, Ellison 11, Cardiac Access Unit
Librarian, Treadwell Library
Clinical Educator, Norman Knight Nursing Center
Staff Nurse, Blake 14, Obstetrics
Staff Nurse, NICU

Recorders:
Kimberly Chelf
Nichole Forrester

19

Goal:
Increase staff awareness and utilization of patient education television channel by 50%
2006 Accomplishments:
1. Patient Education Resource Fair and Film Fest conducted in July 2006. A hallway
display was set up in the White 1 corridor containing samples of patient education
resources available to staff. The Blum Patient and Family Learning Center housed
the film fest where staff could learn how to operate the television system and
preview a patient education video.
2. A comprehensive video title list was made available on-line as well as a brief
description of each video and instructions on how to use the patient education
television system. Video usage increased from 156 titles viewed in FY05 to 174 titles
viewed in FY06 (an increase of about 15%)
3. Gullage, J., Lawson, D. & O’Toole, A. (2006, June 15). The MGH patient education
TV channels. Caring Headlines, 2006, pp. 4, 13.
Goal:
Participate in preparation for 2006 JCAHO survey
a. Review and revise “Patient and Family Education” Clinical Policy and Procedure
b. Review and revise “Patient Education: A Nursing Practice Guideline”
c. Complete documentation audit of the Interdisciplinary Patient and Family Teaching
Record
2006 Accomplishments:
1. “Patient and Family Education” clinical policy and procedure reviewed and revised in
March (2006) Revised & Approved: Clinical Policy and Record Committee
(12/06/02) (7/14/06) Approved Medical Policy Committee (12/23/02) (7/05/06)
2. Patient Education: A Nursing Practice Guideline” reviewed and revised March 2006.
Submitted to Practice committee for review and approval March 06.
3. Documentation audit not conducted. The JCAHO steering committee implemented
Tracer Methodology monitoring of patient care units, which included documentation
on the Interdisciplinary Patient and Family Teaching Record. The committee did,
however, review the form on request of the steering committee and made a
recommendation to keep the Teaching Record as part of documentation as it meets
all JCAHO standards related to patient education.
4. Sumner L, Brunelle C, and Pittman T, JCAHO and patient education: what you need to
know, Caring Headlines, 2006, April 8; p:8-9
Goal:
Develop and implement a Patient Education Committee website.
2006 Accomplishments:
1.Web site developed (http://www.mghpted.org) and went live in July 2006. The
committee presented the new web site at the Sept 5th Combined Leadership meeting
with good response. The web site has received 379 unique visits from July through Sept
2006. Content on the website includes:
a. Committee description, charges and general information about meeting
schedule and members
b. Goals and accomplishments
c. Patient education policies, clinical practice guideline and competency packet
d. Links to patient education electronic resources
e. Links to information on how to evaluation a health website for quality
information
f. Links to plain language (health literacy) information
g. A link “contact us” to send an email to the committee with questions or
comments.

20

Goal:
Increase competency of staff in accessing and using electronic patient education resources.
a. Plan and implement 3 workshops to assist staff in identifying on-line patient education
resources
b. Work with KNCCPD staff to have Patient Education listed as a staff competency for
FY07
c. Hold a hallway display day to promote patient education resources available at MGH.
2006 Accomplishments:
1. Three 2-hour workshops were scheduled in the FND 6 computer workroom for the months
of February, May and September 2006. The May workshop was cancelled due to low
attendance. The workshops were advertised in the KNCCPD online calendar, Caring
Headlines, and emails sent out to unit NM’s and CNS. Total attendance for the Feb and
Sept workshops was 9 clinicians. Evaluations of the workshops were overwhelmingly
positive.
2. A patient education staff nurse competency was developed by the committee and
submitted for consideration to the PCS competency taskforce that met in April and May
2006. The competency included learning objectives, the newly revised patient education
practice guideline, a listing of electronic patient education resources for nurses to practice
accessing, a five question quiz to validate knowledge, and a requirement for staff to access
one DrugNote document to submit to the Nurse Manager as well as a sample of their
documentation on the Interdisciplinary Patient and Family Teaching Record. The task force
did not select the annual competency. The committee then made a presentation at the Sept
5, 2006 Combined Leadership meeting announcing that the competency packet was
available on the Patient Education Committee website and could be used as a unit based
competency for those who saw value in having their staff demonstrate competence in patient
education.
3. A patient education hallway display was held in July 2006. Committee members provided
samples of patient education materials and electronic resources. A sample of appropriate
documentation was also provided.
Goal:
Communicate and disseminate Patient Education information and activities to the larger
MGH community.
a. Write a quarterly column in Caring Headlines related to patient education projects
and initiatives.
b. Disseminate results of the Patient Education Survey conducted by the committee.
2006 Accomplishments:
1.Caring Headlines articles published quarterly and targeted specific committee initiatives
including: JCAHO preparation (April 06), MGH patient education TV channel (July 06),
patient education practice survey results (Sept 06), The Nov 13th “Essence of Patient
Education” workshop (Dec 06)
2. The Patient Education practice survey conducted in the fall of 2005 gave the committee
information related to clinical staff’s practice around patient education assessment, access to
resources, teaching skills, evaluation of teaching, and documentation. The committee
disseminated survey results during 2006 through the following venues:
a. Development of an abstract that was submitted for Nursing Research Day
b. Creation of a poster highlighting the survey purpose and objectives, implementation,
results, written comments, conclusions, and future considerations involving patient
education practice at MGH.
c. King, J., Mahony, C., & West, E. (2006, September 7). Patient education: current
practices and future direction. Caring Headlines, pp: 4-5.

21

2007 GOALS
•
•
•
•
•
•
•
•

Implement a marketing plan for the Patient Education Committee website.
Maintain, update, track and monitor usage of the committee website.
Write and publish 3 Caring Headlines articles reflecting work of the committee.
Repeat the Patient Education Practice survey and compare survey results with 2005
data.
Track usage of unit-based Patient Education Competency program within Patient Care
Services Nursing Department.
Develop strategies to bring patient education in-service education to patient care units
and allied health departments.
Enhance committee members’ knowledge of patient education theory and practice.
Develop and implement strategies to involve disciplines outside of nursing in patient
education initiatives.

22

Patient Care Services Quality Committee
Annual Report 2006
Description of Committee:
The Patient Care Services Quality Committee is a multidisciplinary committee responsible
for identifying opportunities to improve patient care. Members develop knowledge and skill in
using the quality improvement process. The committee works closely with the Director of
Quality, PCS. The committee co-chairs represent PCS as active members of the PCAC.
Members use the quality improvement process to identify high risk and problem prone
aspects of care from their clinical settings and from analysis of hospital wide patient
incidents. Systems analysis and improvement recommendations are referred to appropriate
work groups for action and/or implementation.
Charges:
• Recommend quality activities based on important aspects of care and services (high
volume, high risk, problem prone).
• Identify strategies to improve quality.
• Provide an arena to evaluate and disseminate program development regarding quality
initiatives not specifically initiated by this committee.
• Provide increased communication and awareness of system improvement programs.
• Review findings and recommend departmental actions related to Department of Quality
and Safety evaluations.
Meeting Schedule: 1st and 3rd Tuesdays of the month from 1:00 to 3:00 pm
Co-Chairs:
Karen Lipshires, RN
Patricia Wright, RN
Coach:
Lynda Tyer-Viola, RN
Advisor:
Joan Fitzmaurice, RN
Members:
Jean Bernhardt, RN
Andrea Bonanno, PT
Diane Brindle, RN
Keith Brinkley
Shawna Butler, RN, JD
Jo Ann David-Kasdan, RN
Linda Cutting, RN
Thomas Drake
Monique Gauthier, RN
Sheila Golden-Baker, RN
Susan Gordon, RN
Deborah Jameson, RN
Amy Levine, RN
Margaret Munson, RN
Elena Pittel, RN
Susan Riese, RN
Joseph Roche, RN
Maryalyce Romano, RN
Mary Stacy, RN
Kathleen Tiberii, RN
Carol Upham, RN
Purris Wiliams
Denise Young, RN
Patricia Zelano, RN

Chemo Coordinator, Yawkey 8 Infusion Center
Staff Nurse, Main Operating Room
Clinical Nurse Specialist, Blake 14, Obstetrics
Director, PCS Quality & Safety
Director, North End Community Health Center
Clinical Specialist, Physical Therapy Services
Staff Nurse, Blake 12, Neuroscience ICU
Operations Coordinator, Ellison 14, Oncology
Staff Nurse, White 10, General Medicine
Research Nurse, General Medicine
Staff Nurse, Hemodyalisis Unit
Training Specialist, Knight Nursing Center
Staff Nurse, Bigelow 9, RACU
Clinical Educator, Knight Nursing Center
Staff Nurse, Ellison 9, Cardiac ICU
Librarian, Treadwell Library
Staff Nurse, SDSU
Staff Nurse, IV Therapy Team
Staff Nurse, Blake 13 & 14, Obstetrics
RN Coordinator, Pediatric Oncology
Staff Nurse, SICU
Staff Nurse, Ellison 7, General Surgery
Staff Nurse, PH 22, General Surgery
Staff Nurse, Blake 4, Endoscopy
Staff Nurse, Ellison 19, Thoracic Surgery
Respiratory Therapist, Respiratory Therapy
Clinical Nursing Supervisor, Bigelow 14, CRT
Staff Nurse, PATA

23

Recorder:
Linda Devaux
Goal: Promote the use of interdisciplinary teams in creating a safe care environment
2006 Accomplishments:
• Collaborated with numerous stakeholders to evaluate the environment of care for
opportunities to improve patient safety. Stakeholders and topics include but are not
limited to:
Office of Patient Advocacy
Patient at Risk Task Force
Safe Patient Transport: Safe handoffs program
Pain Management Program
EMAP project
MESAC
Adverse Drug Reactions
Occupational Health Annual Report
Patient Identifiers; new ID band implementation
CNS role in Wound Care management
Infection Control Quarterly Report
Blood Transfusion Task Force
Biomedical engineering Smart Pumps Project
NICHE-Networking to Improve the Care of Health System Elders:65+ Plus vs. +
Smoking Cessation Program
Floor communicators project
Partner’s Ergonomics Program
RLI don’t know what RL stands for web based Incident Reporting System
Low dose Chemotherapy Floor Administration task force
Performance Indicators: Dashboard quarterly review
Web based Environmental Services project roll out
Nursing Supervisor Team role review
Patient lift project: Implementation of ceiling lifts
JCAHO Tracer methodology review
Anticoagulation project
Work scheduling analysis
PAML task force and medication reconciliation
Medical Records/Health Information Systems
Tracheotomy Care Program
Documentation Updates
Morse Fall Scale program
• Monthly case presentations by Office of Quality and Safety
The purpose is to review events and recommend to the MGH Patient Care Assessment
Committee whether or not the events meet criteria for reporting to the Patient Care
Assessment arm of BORM. These criteria include but are not limited to Death or major
or permanent impairment of bodily function that was not ordinarily expected as a result
of the patient's condition on presentation. Case reviews also provide the opportunity to
evaluate lessons learned from good practice or omissions. The reporting of events has
become more transparent to include case scenarios, discussion of standards of care
and potential outcome improvements. Some changes that were implemented related to
reviews:
• Examples of practice changes related to case review are:
• Bed alarm system changes
• Patient lifts
• Enhancements to the Falls Precautions Program
• Collaboration with other Collaborative Governance Committees
• Nursing Research Committee.: Karen Lipshires, RN and Julie Whelan,
Librarian, Prepared “Did You Know Poster” on using Plan Do Check Act as the
performance improvement

24

• Nursing Practice Committee directed review of policies and procedures in
response to review of safety reports in collaboration with the Office of Quality
and Safety.
Committee members increased visibility and collaboration with numerous task forces.
• Joe Roche, RN, Karen Lipshires, RN, and Mary Alice Romano, RN
collaborated with EMR and IBM documentation system evaluation team: EMAP
project
• Diane Brindle, RN, collaborated with Patient at Risk Task Force
• Andrea Bonanno, PT and Sheila Golden-Baker, RN, NICHE-Networking to
Improve the Care of Health System Elders
• Sue Gordon, RN Patient at Risk Task Force
• Deb Jameson, Librarian, Amy Levine, RN, and Linda Cutting, RN to join
Ergonomics Best Practice Committee
• Marianne Killackey, RN RL web based Incident Reporting System
• Sheila Golden-Baker, RN, MESAC chair, Magnet Core Group, Blood
Transfusion Task Force.
• Denise Young, RN, Low-dose Chemotherapy Floor Administration Task
Force, Magnet Core Group
Goal: Include opportunity for discussion of relevant articles from Quality focused
literature
Accomplishments:
• Numerous articles to support discussion were provided and disseminated by
Julie Whelan, Librarian and Deb Jameson, Librarian.
GOALS FOR UPCOMING YEAR
Goal:
Work with Collaborative Governance Leadership to create expectations and standards
regarding communication of committee activities.
Rationale: To increase awareness and to reach more staff regarding activities and
outcomes of committee work, possible solutions, newsletters, posters, bulleted meeting
minutes to post.
Goal:
To identify and shape the committee’s work in collaboration with the newly designed PCS
Office of Quality and Safety to improve patient care and systems, provide action
recommendations, and desired outcomes.
Rationale: To create a seamless link with PCS and the MGH Quality Initiative. To provide a
service based perspective to the redesign and crafting of our new quality programs.
Goal:
To act as a focus group and to provide feedback to content and design of the Quality and
Safety Website.
Rationale: As a reactor group, the committee is able to provide service based knowledge to
improve the website content.
Goal:
To continue to review MGH patient safety data for Board of Registration in Medicine
reporting in tandem with the Patient Care Assessment Committee.
Rationale:
Evaluation of patient safety data by the multidisciplinary committee allows for reflection on
how to ensure safe practice and improve the overall hospital experience.

25

Patient Care Services Staff Nurse Advisory Committee
Annual Report 2006
Description of Committee:
The Patient Care Services Staff Nurse Advisory Committee provides a forum for
communication between nursing leadership and clinical nurses at the Massachusetts
General Hospital. Committee members representing all patient care units engage in
dialogue with nursing leaders about matters of patient care and professional development.
Charges:
• Provide dialogue between chief nurse executive and clinical nurses.
• Dialogue includes matters affecting patient care delivery and clinical and professional
development in the Department of Nursing.
• Opportunity is provided for two-way communication.
Meeting Schedule: 1st Tuesday of each month from 11:30 am to 12:30 pm
Membership: Staff nurses representation from each unit
Chair: Jeanette Ives Erickson, RN, MS
Senior Vice President for Patient Care and Chief Nurse
Members:
Dorothy Aiello, RN
Suzanne Algeri, RN
Kevin Babcock, RN
Wendylee Baer, RN
Immacula Benjamin, RN
Kathleen Blais, RN
Lynne Bozzi, RN
Maureen Brecken, RN
Sheila Brown, RN
Tammy Carnevale, RN
Paul Cella, RN
Ellen Coccoluto, RN
Darleen Crisileo, RN
Katie Dakin, RN
Brenda D’Alessandro, RN
Tracey Dimaggio, RN
Rosemary Doherty, RN
Stephanie Fuller, RN
Alice Edmonds, RN
Christa Gambon, RN
Laura Ghiglione, RN
Deb Guthrie, RN
David Hiett, RN
Rebecca Johnston, RN
Linda Kafkas, RN
Megan Knecht, RN
Martin Lantieri, RN
Susan Leroux, RN
Jamie Liu, RN
Marissa Legare, RN
Patricia Lynch, RN
Deborah Lynch-Roden, RN
Terry MacDonald, RN
Mary Macleod, RN

Bigelow 9, RACU
Ellison 10, General Medicine
Emergency Department
White 6, Orthopedics
Ellison 18, Pediatrics
Blake 2, Infusion Unit
Blake 14, Labor & Delivery
Post Anesthesia Care Unit
Radiology Oncology
Partners Continuing Care/Rockland
White 11,General Medicine
White 12, Neurology
Blake 8, Cardiac ICU
PH20, General Medicine
Ellison 13, Obstetrics
PH 21, General Medicine
Bigelow 7, GYN
Ellison 6, Orthopedics
Infertility
White 10, General Medicine
Ellison 14, Hematology/Oncology
IV Therapy
Radiology
Bigelow 14, Vascular
Cox 1, Oncology Infusion
Bigelow 11, General Medicine
Ellison 7, Surgery
White 7, Surgery
Blake 6, Transplant
Blake 6, Transplant
Same Day Surgical Unit
Rapid Response Team
Blake 10, NICU
Ellison 4, SICU

Mary Anne Malloy, RN
Shean Marley, RN
Lee McCloskey, RN
Arlene Meara, RN
Cynthia Meglio, RN
Jane Miller, RN
Denise Morelli, RN
Hilda Morrison, RN
Harriet Nugent, RN
Susan O’Brien, RN
Norine O’Malley-Simmler, RN
Joanne Parhiala, RN
Amy Pironti, RN
Bernadette Quigley, RN
Cynthia Rappa, RN
Julie Robinson, RN
Janet Roche, RN
Karen Rosenblum, RN
Erin Salisbury, RN
Brenda Girasella, RN
Heidi Simpson, RN
Meg Soriano, RN
Amie Stone, RN
Susan Tower, RN
Billie Jo Watson, RN
Deborah Zapolski, RN
Martha McAuliffe, RN

Bigelow 10, Dialysis
Internal Medicine Associates
Blake 12, Neuroscience ICU
Operating Room
EP Lab
Yawkey 8, Infusion Unit
Phillips House 22, Surgery
PATA
Blake 14, Labor & Delivery
Ellison 17, Pediatrics
Ellison 9, CCU
Blake 11, Psychiatry
White 8, General Medicine
Blake 7, MICU
Ellison 12, ED Observation Unit
Ellison 11, General Medicine
Blake 4, Endoscopy
Blake 11, Psychiatry
Ellison 6, Orthopedics
Ellison 11, General Medicine
Ellison 3, PICU
Bigelow 11, General Medicine
Ellison 19, Thoracic Surgery
Newborn
Ellison 16, General Medicine
White 9, General Medicine
Ellison 7, General Surgery

Goal
Continue to provide input into, and feedback about, MGH Nursing’s recruitment and
retention strategies and image campaign.
Accomplishments
•
•
•
•
•
•
•
•
•
•

Advertisements in Big Help edition of the Boston Globe 9.10.06, Boston Metro, T
stations
Open houses for recruitment of MGH nurses and support staff
Nursing website enhancement to include a career section citing open positions in the
Department of Nursing
MGH Brand identity initiative
RN Market adjustment and employee bonus
Invitation to attend a reception on the USNS Comfort ship, to honor the MGH nurses
who served during the time of the tsunami disaster; marked kick-off of Nurse
Recognition Week 2006
Distribution of the four-part Boston Globe series, The Making of an ICU Nurse”
MGH hosted the Massachusetts Student Nurses Association Annual Convention on
4.1.06
Highlighted events for Nurse Recognition Week 2006
Brainstormed ideas for Norman Knight Nursing Center “serenity/rejuvenation” room for
MGH nurses (to be housed on Founders 3).

Goal
Identify issues impacting care delivery and/or quality of work life and identify strategies to
address them.
2006 Accomplishments
Presentations regarding:
• Ongoing updates re: mandated staffing ratio legislation

27

•
•
•
•
•
•
•
•
•
•

Patients First Initiative – an initiative involving Massachusetts Hospitals to make staffing
information transparent.
Collaborative Governance Evaluation
Staff Perceptions of the Professional Practice Environment Survey 2006 (administered
on-line and paper copy)
Cbeds (bed tracking system)
Circles, a complimentary, concierge service offered to MGH nurses
Parking and shuttle bus services
Environment of care: update and challenges
Creating a culture of safety: discussion about work hours/fatigue
Automated Patient Assessment Tool pilot
Staff Nurse performance appraisal process

Issues raised included:
• Brakes on new beds are problematic; vendor worked to ensure every bed is operating
properly.
• Specimen cups for collecting specimens that require transport on ice were discontinued;
Materials Management worked to identify an alternative.
• Need for directional signs to the morgue (installed); additional morgue stretchers have
been ordered
• Explore feasibility of providing childcare services for nurses working 12-hour shifts;
Human Resources has determined not feasible at this time due to insufficient demand
• Parking garage bull’s eye monitors need to be lowered so staff/visitors do not have to et
out of their cares to connect with the electronic beam when entering/leaving the garage.
• Explore providing healthier food choices at Coffee Central, e.g. fresh fruit, yogurt, etc.
• On-line policy and procedure manual takes too long to obtain information
• PCA/epidural pumps are being replaced with “smart” pumps.
Goal
Participate in planning for upcoming JCAHO accreditation visit.
Accomplishments:
Presentations re:
• JCAHO “questions and answers” information distributed to membership
• Patient Identification Campaign: Match it, Catch it, and Attach it.
• JCAHO National Safety Goal: Safe Hand-Offs of Patients using SEAM framework
(communication that provides overall situation and that comments on every active issue
and the management of each issue)
• Quit Smoking Services for MGH patients.
• Tracer methodology
2007 Goals
•

Operate as the clearinghouse committee to determine best group(s) and/or individual(s)
to address identified issues (e.g. promoting a “green” organization).

•

Protect the nurse/clinician relationship with patients and families through promotion of
customer service, patient- and family-centered care, and safety initiatives (e.g. use of
cell phones by staff while caring for patients and families).

•

Identify and provide input into prioritization of educational offerings (e.g. new or
enhanced, practice changes, technology, input into web site redesign).

•

Serve as a liaison between unit-based colleagues and senior nursing leadership
regarding day-to-day clinical and quality of work-life issues.

•

Seek clarification as it relates to questions or concerns that the healthcare team raises
(e.g. rumor control).

28

•

Shape nursing’s image and advertising campaign by providing input into the key
processes of design, selection and evaluation.

•

Disseminate key information about services that promote work-life balance (e.g.
CIRCLES concierge service, back-up childcare).

•

Participate in planning for, and communication of key information, for upcoming JCAHO
accreditation and Magnet Re-designation reviews.

29

Collaborative Governance
2006
Senior Vice President for
Patient Care and Chief
Nurse

PCSEC

Committee Leaders

Diversity
Steering

Ethics in
Clinical
Practice

Nursing
Practice

Patient
Education

Quality

Nursing
Research

Staff
Nurse
Advisory

Professional
Development
(disbanded)



---

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