We uphold the basic tenets of shared governance which include accountability-based practice, open communication, collaboration, coaching and mentoring, team building, and mutual respect and trust.

The Shared Governance program includes unit-specific Standards of Practice Committees and a house-wide Patient Care and Quality Council.

Committees of UMC

Education Council

The Education Council serves as a resource for Departmental Educators to meet the educational needs of the clinical staff at UMC. In coordination with the Nursing Education Department the meeting goals are to identify the educational learning needs for the facility and to then develop or assist in creating activities to meet those needs. The Council is then responsible for evaluating the effectiveness of the education. Education Council is chaired by the Nursing Education Director. Meetings are held the second Tuesday of every Month at 10 am in the Basement Classroom.

Performance Improvement Committee (PIOC)

The PIOC duties include:

• Measurement of outcomes, design of new processes to identify opportunities to improve quality of care, treatment, services, patient safety, and patient satisfaction.
• Design, planning and implementation of monitoring activities that are generally noted as traditional medical staff functions (blood administration, medical record review, operative and other procedures, etc.)
• Evaluation of individuals with clinical privileges whose performance is questioned as a result of the measurement and assessment of the Performance Improvement Plan.
• Communication to their respective service of the findings, conclusions, recommendations and action taken to improve organization.
• Participate in implementation of changes to improve performance.

Standards of Practice Committees

The Standards of Practice Committees are unit-based committees within the Shared
Governance model. These committees have members elected by their peers from every level of nursing and every shift worked.

The Nurse Director of the unit will serve as an ad-hoc member of the Standards of Practice Committee and attend the meetings upon invitation by the committee Chair or Vice-Chair.

The Standards of Practice Committee will meet at least 9 of 12 months in a calendar year and are held approximately two (2) weeks prior to the Patient Care Council meeting to allow time for investigation of issues presented at the Standards of Practice Committee.

The Standards of Practice Committee will address issues related to bedside nursing practice. If it is determined that issues are unit specific and will not require change in general nursing policy, the committee can determine course of action at the unit level and report to the Nurse Director. If the issue affects more than one nursing unit and/or will require change in general nursing policy, the Chair or Vice-Chair will take the issue to the Patient Care Council. The Nurse Director may also refer patient care issues to the committee for review and assistance in developing plans of corrective action. The Chair of the Standards of Practice Committee will be responsible for communicating with the Patient Care Council, the Nurse Director and the staff regarding the outcomes/actions of the committee meetings.

Nurse Directors Council

The Nurse Directors’ Council is composed of the Sr. Vice Presidents for Patient Care Services, and Nurse Directors and Assistant Nurse Directors of each nursing unit at UMC. This committee is organized to serve a continuing need for UMC nursing units.

The committee members disseminate information through minutes and verbal discussion, serving as a resource for committee representatives, make recommendations and/or identifying items, which require administrative or medical staff action, and identify and implement quality improvement activities relative to Nursing Service or with other departments that interact with nursing.

Nurse Directors’ Council meets every 2 weeks and addresses each of the Service Is Our Passion Service Pillars…Service, Teamwork, Quality and Safety, Finance, and Growth.

Patient Care Council

The Patient Care Council is composed of the Chairs of the unit specific Standards of Practice Committees and the three Sr. Vice Presidents of Patient Care Services. The Sr. Vice Presidents will serve in an advisory capacity.

The Patient Care Council will meet at least 9 of 12 months in a calendar year and will address patient bedside nursing practice referred from the unit specific Standards of Practice Committees. The Patient Care Council may also refer patient care issues to other committees such as the Infection Control Committee, Pharmacy and Therapeutics, Nurse Directors Council, etc. The Patient Care Council may also ask for guidance from these committees in resolving issues. Changes in patient care policy and procedure should be based on evidence-based practice.

The Standards of Practice Committee Chairs will be responsible for relating actions of the Patient Care Council back to their unit specific Standard of Practice Committee.

Nursing House-Wide Committees:

• Cancer Committee
• Clinical Ethics Committee
• Code Blue Committee
• Infection Prevention and Control Committee
• Operating Room Committee
• Pharmacy and Therapeutics Committee
• Performance Improvement Committee
• Sedation Committee
• Stroke Committee
• Transfusion Committee

Magnet Committees

• Magnet Council
• Magnet Steering Committee
• Magnet Nursing Leadership Committee
• Magnet Research Committee
• Magnet Marketing, Education & Communication Committee
• Magnet Writing Teams