Chapter 1 – Health Care Governance and Administration

Policy

• California Correctional Health Care Services (CCHCS) shall provide all newly hired civil service Registered Nurses (RN), Licensed Vocational Nurses (LVN), Psychiatric Technicians (PT), Certified Nursing Assistants (CNA), Office Technicians (OT), and Medical Assistants (MA), who provide clinical or support services in California Department of Corrections and Rehabilitation (CDCR) institutions with orientation and training (Nursing Civil Service Staff Onboarding) that is relevant to the job duties for each classification.

• An abbreviated onboarding plan shall be developed for CDCR, CCHCS civil service nursing staff who are transferring from another CDCR institution that takes into account the onboarding, clinical competency, and professional performance evaluations conducted and the training provided for that staff at another institution.

• Nothing in this policy and procedure shall be construed as altering existing laws and regulations governing nursing staff scope of practice, probationary periods in civil service, or the provisions of any applicable bargaining unit contract.

Purpose

• To establish a comprehensive and standardized Nursing Civil Service Staff Onboarding process that:

• Promotes consistency and standardization among all institutions statewide regarding minimum onboarding expectations for new civil service nursing staff employees.

• Supports civil service nursing staff with relevant orientation and training by experienced subject matter experts during the probationary period.

• Facilitates adherence with applicable scopes of practice, standards of practice, and CDCR, CCHCS standards.

• Promotes job satisfaction while enhancing nursing staff effectiveness and efficiency.

Applicability

• This policy and procedure applies to all newly hired or transferring civil service nursing staff who are employed by CDCR who are performing services within or for CDCR institutions.

Responsibility

• Statewide

  • The Statewide Chief Nurse Executive (CNE) is responsible for statewide planning, implementation, and evaluation of this policy and procedure.

• Regional

  • Regional CNEs are responsible for the implementation of this policy and procedure at the subset of institutions within an assigned region.

• Institutional

  • The Institutional CNE is responsible for ensuring the implementation of the Nursing Civil Service Staff Onboarding Plan.

  • All new nursing staff are responsible for actively participating in and completing the standardized onboarding process including classroom orientation and on-the-job training and support during the probationary period.

  • The Supervising Registered Nurse (SRN) III, SRN II, or the Unit Supervisor (US), as appropriate, in coordination with the Nurse Instructor (NI), is responsible for validating successful completion of the Nursing Civil Service Staff Onboarding and Competency Checklists.

Procedure

• Orientation and On-the-Job Support during the Probationary Period

  • The SRN III, or SRN II, or the US, and NI shall individualize the Nursing Civil Service Staff Onboarding Plan, utilizing the Nursing Civil Service Staff Onboarding Plan Template, located on the Nursing Services Lifeline page under Resources.  Staff shall follow the plan during at least the initial three months of employment.

  • The SRN III or SRN II, or the US, NI, and appropriate subject matter expert shall use the Nursing Civil Service Staff Onboarding and Competency Checklist–Nursing Services Topics, and the Nursing Civil Service Staff Onboarding and Competency Checklist-General and Non-Nursing Topics, and implement the Nursing Civil Service Staff Onboarding Plan to ensure each newly hired staff completes, at a minimum, 12 weeks of formal orientation and training.  See the Sample Nursing Civil Service Staff Onboarding Plan, for examples on how to complete a Nursing Civil Service Staff Onboarding Plan.  The Checklists and the Sample Onboarding Plan are located on the Nursing Services Lifeline page under Resources.

  • The plan shall include, at a minimum, the following:

    • Initial introduction to the institution including:

      • Human Resources and Information Technology departments.

      • Overview of the institution’s missions and physical layout.

      • Overview of the new employee’s work space.

      • Issuance of the new employee’s identification card and other essential work items.

    • Institution-based onboarding covering the designated topics specified in the Nursing Civil Service Staff Onboarding and Competency Checklist–Nursing Services Topics pertaining to appropriate classification, and Nursing Civil Service Staff Onboarding and Competency Checklist–General and Non-Nursing Topics.

    • Non-custody New Employee Orientation shall be completed by all employees.  This training is composed of classroom and computer based modules. The classroom portion is provided by the institution’s In-Service Training Office.

    • Nursing civil service staff onboarding for nursing employees covered by this procedure shall be completed prior to performing patient care duties.

    • Electronic Health Record System (EHRS) training and competency validation shall be completed prior to providing and documenting patient care or scheduling in the system, including completion of CCHCS Learning Management System EHRS Modules plus designated instructor led training.

      • For nursing staff with RN, LVN, or PT licensure.

      • For CNAs, OTs assigned to nursing, and MAs.

    • For staff providing direct patient care, a minimum of four weeks of orientation and shadowing of nursing staff in patient care settings, on a specific watch, based upon the institution’s health care missions during which the following areas shall be covered:

      • Primary Care Clinics including huddles, nurse face-to-face line, and provider line.

      • Triage and Treatment Area.

      • Receiving and Release.

      • Outpatient Housing Units.

      • Correctional Treatment Center and other inpatient care areas.

      • Administrative Segregation Unit.

      • Specialty areas including Telemedicine, Utilization Management, and Public Health.

      • Mental Health including Mental Health Crisis Bed, Psychiatric Inpatient Program, and groups.

      • Hospice.

  • Transition to independent direct patient care duties shall begin no earlier than eight weeks after the hire date.

    • New staff shall be located where they can easily access other nursing staff familiar with their job duties for questions and assistance during the initial eight weeks of providing direct patient care.

    • For the first month after the staff begins independent direct patient care duties, an SRN, other supervisory nursing staff, or designee, or NI shall attend the morning huddles and other meetings or events and debrief with the new nursing staff afterwards to answer questions.

  • Within 12 weeks after the new staff hire date, the NI, or designee, in coordination with the institutional CNE, SRN III, or SRN II, or the US, shall ensure completion of the Nursing Civil Service Staff Onboarding and Competency Checklist–Nursing Services Topics pertaining to appropriate classification, and the Nursing Civil Service Staff Onboarding and Competency Checklist–General and Non-Nursing Topics, and shall review, sign, and maintain the completed forms in the employee’s training file (proof of practice file).

    • If unforeseen circumstances arise that delay the onboarding process and completion of the Nursing Civil Service Onboarding and Competency Checklists, additional time may be provided on a case-by-case basis to complete the onboarding process and the checklists as soon as possible after the 12th week.

    • If the new nursing staff member is delayed in completing the Nursing Civil Service Staff Onboarding and Competency Checklists, the SRN III or SRN II, or the US, in coordination with the institutional CNE, may provide additional time on a case-by-case basis to complete the onboarding process and the checklists as soon as possible after the 12th week.

• Probationary and Professional Practice Performance Evaluations

  • The SRN III or SRN II, or the US, in coordination with the institutional CNE or designee, shall ensure each new nursing staff completes competency skills validations for nursing assessments, processes, and procedures prior to providing patient care for patients who require that assessment, process, or procedure or within the timeframe noted in the Nursing Curriculum Lesson Plan, whichever occurs first after the hire date.

  • For staff who have a one-year probationary period:  In accordance with civil service laws and regulations, the SRN III or SRN II, or the US shall complete, at minimum, a STD 636, Report of Performance for Probationary Employee, at 4 months, 8 months, and 12 months after hire to assess professional performance and clinical competency.

    • The 12-month STD 636 may be completed as soon as 11 months but no later than 12 months after the hire date.

    • Additional STD 636s may be completed as needed to assess professional performance and clinical competency.

  • For staff who have a 6-month probationary period:  In accordance with civil service laws and regulations, the SRN III or SRN II, or the US, shall complete, at minimum, a STD 636 at 2 months, 4 months, and 6 months after hire to assess professional performance and clinical competency.

    • The 6 month STD 636 may be completed as soon as 5 months but no later than 6 months after the hire date.

    • Additional STD 636s may be completed as needed to assess professional performance and clinical competency.

  • Two to four weeks prior to the end of the probationary period, the SRN III or SRN II, or the US, in coordination with the institutional CNE, shall meet to review the probationary and professional practice evaluations and other clinical observations in order to make a recommendation regarding permanent civil service employment.

  • A recommendation to reject the staff during the probationary period may occur any time prior to the completion of the final STD 636 if the previous performance evaluations, professional practice evaluations, competency validations, and other clinical observations show significant concerns regarding the staff’s performance.

  • After the probationary period ends, the SRN III or SRN II, or the US shall complete, at a minimum, an annual evaluation of the employee’s professional performance and clinical competency.

• Maintenance of Onboarding Documents

  • Onboarding documents shall be maintained in the employee’s proof of practice file (training file) including, but not limited to:

  • The completed Nursing Civil Service Staff Onboarding Plan, showing the onboarding activities for each day of the onboarding period.

  • The completed Nursing Civil Service Staff Onboarding and Competency Checklist–Nursing Services Topics.

  • The completed Nursing Civil Service Staff Onboarding and Competency Checklist–General and Non-Nursing Topics.

• Determination of Permanent Civil Service Status

  • After completion of the second STD 636, but no later than six weeks prior to the end of probation, the SRN III, SRN II, or the US, and institutional CNE shall organize a Performance Review meeting.

  • The meeting shall include the following individuals:

    • CNE, or designee.

    • SRN III.

    • SRN II or the US.

    • Health Care Employee Relations Officer (ERO) (if there are significant concerns regarding the staff’s performance).

    • Regional CNE (if there are significant concerns regarding the staff’s performance).

  • The purpose of the meeting shall be to discuss the findings and recommendations contained in the probationary and professional practice evaluations, competency evaluations, and other clinical observations in order to make a recommendation about whether to grant permanent civil service status.

  • If there are concerns regarding performance of the probationary employee prior to the occurrence of the performance review meeting described in this section, the institutional CNE, SRN III, and SRN II, or the US shall notify the Health Care ERO and the regional CNE as soon as issues are identified.

  • A recommendation to reject the staff during the probationary period may occur any time prior to the completion of the final STD 636 if the previous performance evaluations, professional practice evaluations, competency validations, and other clinical observations show significant concerns regarding the staff’s performance.

• Re-orientation of Nursing Staff (Re-entry Training)

  • For staff who are out (e.g., long term sick) or separated from service with CDCR:

    • If staff have been out for six months or less, the following is required:

      • There shall be documentation of previous completion of the Nursing Civil Service Staff Onboarding and Competency Checklist–Nursing Services Topics pertaining to appropriate classification, and Nursing Civil Service Staff Onboarding and Competency Checklist–General and Non-Nursing Topics.

      • Staff shall take all missed classes, updates, and mandatory training.

      • Skills competency validations shall be completed for the areas in which staff will be working.

    • If staff have been out for six months to one year, the following is required:

      • There shall be documentation of previous completion of the Nursing Civil Service Staff Onboarding and Competency Checklist–Nursing Services Topics pertaining to appropriate classification, and Nursing Civil Service Staff Onboarding and Competency Checklist–General and Non-Nursing Topics.

      • Staff shall take all missed classes, updates, and mandatory trainings including Block and In-Service Training.

      • Skills competency validations shall be completed for the areas in which staff will be working.

    • Staff who are out or separated for more than one year shall complete the onboarding process in its entirety upon return.

• Transferring Between Institutions Without a Break in Service or Performing Patient Care Duties at More Than One Institution

  • Each CDCR institutional CNE is responsible to ensure that all nursing staff working at that institution are competent to perform all the duties of the position for which the nursing staff has been hired, pursuant to the Health Care Department Operations Manual, Section 1.4.6.7, Nursing Competency Program.

  • The SRN III or SRN II, or the US in coordination with the regional CNE and institutional CNE, may develop an abbreviated Nursing Civil Service Staff Onboarding Plan, for the nursing staff as necessary that takes into account the onboarding, clinical competency, and professional performance evaluations conducted and training provided to that nursing staff at another CDCR institution.

  • Proof of completion of the onboarding process, clinical competencies, and professional performance evaluations shall be maintained at each CDCR institution.  This does not absolve each CDCR institutional CNE from ensuring the clinical competencies and professional performance evaluations are conducted or that nursing staff are competent to perform the duties required in their position.

Policy

• California Correctional Health Care Services shall provide all registry/contracted nursing personnel who provide clinical and support services in California Department of Corrections and Rehabilitation (CDCR) institutions with orientation and training relevant to the job duties for each registry/contracted nursing personnel.

• Nothing in this policy and procedure shall be construed as altering existing laws and regulations governing nursing personnel scope of practice, the provisions of any applicable bargaining unit contract, or registry agency contract.  Registry/contracted nursing personnel are not civil service employees of CDCR.

Purpose

• To establish a comprehensive and standardized registry/contracted nursing personnel onboarding process that:

• Promotes consistency and standardization among all institutions statewide regarding minimum onboarding expectations for registry/contracted nursing personnel.

• Supports newly engaged registry/contracted nursing personnel with relevant orientation and training by experienced subject matter experts prior to working in areas requiring that knowledge/training.

• Facilitates adherence with applicable scopes of practice, standards of practice, and CDCR standards.

• Enhances registry/contracted nursing personnel effectiveness and efficiency.

Applicability

• This policy applies to all newly engaged registry/contracted nursing personnel who are providing clinical and support services within or for CDCR institutions.

Responsibility

• Statewide

  • The Statewide Chief Nurse Executive (CNE) is responsible for statewide planning, implementation and evaluation of this policy and procedure.

• Regional

  • Regional CNEs are responsible for the implementation of this policy and procedure at the subset of institutions within an assigned region.

• Institutional

  • The institutional CNE is responsible for ensuring the implementation of the onboarding plan.

  • The Supervising Registered Nurse (SRN) III and/or II, or the Unit Supervisor (US), as appropriate, and the Nurse Instructor (NI) shall individualize the Registry-Contracted Nursing Personnel Onboarding Plan, located on the Nursing Services Resources Lifeline page under Resources, to ensure each newly engaged registry/contracted nursing personnel completes, at minimum, seven days/watches of formal onboarding (Refer to the Sample Registry-Contracted Nursing Personnel Onboarding Plan, located on the Nursing Services Resources Lifeline page under Resources).

  • The SRN III and/or II, or US, in coordination with the NI, is responsible for validating successful completion of the Registry-Contracted Nursing Personnel Onboarding and Competency Checklist, located on the Nursing Services Resources Lifeline page under Resources.

  • All newly engaged registry/contracted nursing personnel are required to actively participate in and complete a standardized onboarding process including classroom orientation and on-the-job training and support.

  • Newly engaged registry/contracted nursing personnel are required to complete the tasks related to the Registry/Contracted Nursing Personnel Onboarding and Competency Checklist.

Procedure

• Orientation and On-the-Job Support

  • The SRN III and/or II, or US, NI, and appropriate subject matter expert shall use the Registry/Contracted Nursing Personnel Onboarding and Competency Checklist, and implement the Registry/Contracted Nursing Personnel Onboarding Plan, to ensure each registry/contracted nursing personnel completes seven days/watches of formal onboarding.  The plan, at a minimum, shall include the following:

    • Initial introduction to the institution staff, overview of the institution’s missions, physical layout, and issuance of an identification card, work space, computer, and other essential work items.

    • Orientation and shadowing of nursing staff in the institution’s relevant patient care settings within which the registry/contracted nursing personnel will work prior to performing patient care duties.  If the registry/contracted nursing personnel services are engaged to work in more than one area of the institution, they shall be provided orientation to each specific area in order to achieve competency in providing patient care in that area of the institution.

    • Training and demonstrated competency for the registry/contracted nursing personnel in the Electronic Health Record System prior to performing and documenting patient care duties or scheduling in the system.

    • Transition to performing independent, direct patient care duties shall begin no earlier than seven days/watches after the engagement of services date.

      • Registry/contracted nursing personnel shall be assigned where they can easily access other nursing staff familiar with their job duties for questions and assistance during the initial 14 days/watches of providing independent, direct patient care.

      • For the first 14 days/watches after the registry/contracted nursing personnel begins independent, direct patient care duties, the SRN III and/or II, or US, or NI shall meet with the registry/contracted nursing personnel prior to the start of the shift and afterwards to debrief and answer questions.

    • Within the first seven days/watches after the registry/contracted nursing personnel’s engagement of services date, the SRN III and/or II, or US, or designee(s), in coordination with the institutional CNE and/or NI, shall ensure completion of the Registry/Contracted Nursing Personnel Onboarding and Competency Checklist.  The completed form shall be maintained in the registry/contracted nursing personnel’s proof of practice file.

• Clinical Competency and Professional Practice/Performance Evaluations

  • The SRN III and/or II, or US, in coordination with the institutional CNE, shall meet prior to each registry/contracted nursing personnel’s professional performance and clinical competency review to evaluate the clinical competency, professional performance and clinical observations in order to determine the continued engagement of services of the registry/contracted nursing personnel with CDCR. The performance of all registry/contracted personnel shall be evaluated as follows:

  • The SRN III and/or II, or US shall ensure each registry/contracted nursing personnel’s professional performance and clinical competency is evaluated at least every two months after the engagement of services date for six months to assess continued clinical competency and professional performance.

  • The SRN III and/or II, or US shall complete an evaluation of professional performance and clinical competency a minimum of annually thereafter.

  • The SRN III and/or II, or US may complete additional professional performance and clinical competency evaluations of registry/contracted nursing personnel more frequently as needed to ensure the continued professional performance and clinical competence.

  • Professional performance evaluations shall be documented on the Registry-Contracted Nursing Personnel Professional Performance Evaluation, located on the Nursing Services Resources Lifeline page under Resources.

  • Clinical competencies shall be documented on the Registry/Contracted Nursing Personnel Onboarding and Competency Checklist, and kept in a proof of practice file for that registry/contracted nursing personnel.

• Maintenance of Onboarding Documents

  • The following documents shall be maintained in the registry/contracted nursing personnel’s proof of practice file:

  • The completed Registry/Contracted Nursing Personnel Onboarding Plan, showing the onboarding activities for each day of the onboarding period.

  • The completed Registry/Contracted Nursing Personnel Onboarding and Competency Checklist.

  • Professional Performance Evaluations.

• Transferring Between Institutions Without A Break In Service or Performing Patient Care Duties At More Than One Institution

  • Each CDCR institutional CNE is responsible for ensuring that each registry/contracted nursing personnel working at that institution is competent to perform all the duties of the position for which the registry/contracted nursing personnel’s services have been engaged.

  • The SRN III and/or SRN II, or US, in coordination with the institutional CNE and/or the regional CNE may develop an abbreviated onboarding plan for registry/contracted nursing personnel covered in this section on a case-by-case basis that takes into account the onboarding, professional performance, and clinical competency evaluations conducted and training provided to the registry/contracted nursing personnel at another CDCR institution.

    • Proof of completion of the onboarding process, clinical competencies, and professional performance evaluations shall be maintained at each institution.

    • This does not absolve each CDCR institutional CNE from ensuring that professional performance and clinical competency evaluations are conducted or that registry/contracted nursing personnel are competent to perform the duties required in the position for which their services have been engaged.

• Registry/Contracted Nursing Personnel Converting to Permanent Civil Service Status

  • Registry/contracted nursing personnel who convert to permanent civil service status shall complete the new nursing civil service staff onboarding process including New Employee Orientation.

    • Topics on the Nursing Staff Onboarding and Competency Checklists, which must be tracked via a Business Event Type code and for which the registry/contracted nursing personnel did not have a Personnel Number for tracking purposes will need to be repeated.

    • Proof of completion of the Registry/Contract Nursing Personnel Onboarding and Competency Checklist, and competency skills validations shall be maintained with the Nursing Staff Onboarding and Competency Checklists in the proof of practice file.

  • Registry/contracted nursing personnel who convert to permanent civil service status shall complete the remainder of the onboarding process including, but not limited to:

    • Professional performance and competency evaluations.

    • Probationary evaluations conducted as per civil service rules and requirements.

    • Training to ensure all components of the onboarding process have been completed with proof maintained in the proof of practice file.

  • The SRN III and/or II, or US, in coordination with the institutional CNE and/or the regional CNE, may adjust the length of the onboarding plan on an individual basis to take into account the experience and competencies already achieved and demonstrated by the registry/contracted nursing personnel prior to converting to permanent civil service status.

Policy

• California Correctional Health Care Services (CCHCS) shall ensure nursing care services are planned, organized, and directed by a licensed professional Registered Nurse (RN) leader who has the education and experience commensurate with their responsibilities.  RN leaders shall have the responsibility and authority to ensure the quality of nursing practice within the California Department of Corrections and Rehabilitation.

Purpose

• To promote quality in the provision of safe, efficient, and competent nursing care in all areas of program delivery to include inpatient, outpatient, specialty care, patient scheduling, Triage and Treatment Area, Receiving and Release, and Reception Center.

Responsibility

• Chief Nurse Executive (CNE)

  • The Statewide CNE (SCNE) is responsible for statewide nursing strategic vision, nursing policy and program development, quality nursing outcomes and is accountable for CCHCS nursing standards of care and practice.

    • The SCNE is a full partner of the headquarters’ senior executive team as the Deputy Director (DD) of Nursing Services and shall report directly to the Director of Health Care Services.

    • The SCNE shall interpret and communicate organizational mission, programmatic goals, and objectives.

  • The Headquarters’ CNE (HQCNE) is responsible for programmatic delivery across all institutions. The HQCNE shall:

    • Provide direction, strategic leadership, planning, and organization, and ensure programmatic standardization and integration of nursing care into the health care delivery system.

    • Report directly to the DD of Nursing Services, SCNE.

  • The Regional CNE (RCNE) is responsible for coordinating nursing care services, informing policy and procedure, and ensuring implementation of statewide programs within a region spanning multiple institutions.  The RCNE shall:

    • Ensure institutional nursing practices comply with headquarters’ directives and the nursing standards of care and practice.

    • Direct report to the Regional Health Care Executive with functional nursing clinical practice oversight by the SCNE.

  • The institutional CNE shall coordinate nursing care services, inform policy and procedure, and ensure oversight for the professional practice of nursing and the provision of nursing care within an institution.  For the purposes of this subsection, oversight is defined as having responsibility for quality, service, resources, nursing staff competency, evaluation of the overall delivery of nursing care, and adherence with regulations.

    • The institutional CNE shall implement the statewide programs or directives into institution operations, ensuring 24-hour nursing services are available.

    • The institutional CNE is the institution’s senior nurse leader, full partner of the institutional executive team and shall report directly to the Chief Executive Officer with functional supervision by the RCNE.

• Institutional Assistant Nurse Executive (ANE) and Supervising Registered Nurse III (SRN III)

  • The ANE and SRN III shall inform policy and procedure and is responsible for organizing, developing, directing, and managing nursing services and ensuring the delivery of quality nursing care as defined by the CNE.

  • The ANE and SRN III are responsible for developing local operating procedures and administrative and internal management of clinical operations in keeping with policies, regulations, and standards.

  • In compliance with California Code of Regulations, Title 22, Section 79629, at least one ANE or SRN III shall be designated as Director of Nursing for licensed inpatient areas.  The ANE or SRN III shall report directly to the institutional CNE.

• Supervising Registered Nurse II (SRN II) or Nursing Coordinator (NC)

  • The SRN II or NC shall:

  • Assume the first line of leadership, supervision, and accountability for the delivery of patient care for day-to-day operations.

  • Facilitate efficient and cost-effective daily operations and monitor staff compliance with regulatory, clinical, and institutional requirements.

  • Assume leadership for their respective areas of program delivery.

  • Supervise licensed and unlicensed nursing staff and ensure competent nursing practice and quality patient outcomes.

  • Manage assigned facilities, patient flow, scheduling, and clinic operations to include patient care supplies and equipment.

  • Report directly to the SRN III or CNE in the event of an SRN III vacancy.

• Nursing Consultant, Program Review (NCPR)

  • The NCPR is responsible for the implementation, monitoring, and review of nursing programs, including service and projects in institutions, at the regional level and statewide. The NCPR shall:

  • Provide overall consultation, including recommendations and directions, to all nursing and health care services as assigned.

  • Serve as the subject matter expert in nursing professional practice, standards of care, and the health care delivery system.

  • Participate in the statewide and regional planning, development, implementation, evaluation, and monitoring of nursing services programs.

  • Assist in developing and providing consultation for compliance with nursing practice, regulatory standards, and policy and procedures. The NCPR shall provide direct and indirect patient care services for select health care populations or patients.

Policy

• California Correctional Health Care Services (CCHCS) shall maintain a Nursing Professional Practice Model, which consists of an associated framework to promote respectful, collegial interactions and informed decision-making at all levels of the organization and across all disciplines, as it relates to quality of care, professional expertise, and professional practice. Each component in the Nursing Professional Practice Model is integral to professional nursing practice and indicates how nurses collaborate, communicate, incorporate evidenced based practice, and develop professionally. The components of the model are depicted in the Nursing Professional Practice Model Diagram, located on the Nursing Services Resources Lifeline page under Resources.

• The nursing care delivery system for CCHCS shall:

  • Be based upon the Nursing Practice Act, Sections 2725-2742, Dorothea Orem’s Nursing Theory, American Nurses Association Standards, and other professional nursing standards to encompass the dependent, interdependent, and independent aspects of professional nursing in the provision of patient care.  The professional nurses’ role is to assist the patient in regaining their ability to provide self-care in any and all dimensions. This model supports the philosophy that all patients benefit from the full scope of nursing practice which is coordinated and individualized to meet the needs of the patient.

  • Utilize established evidence-based practices, protocols and disease-specific standards of care, as appropriate, and the nursing component of care management and care coordination from the Complete Care Model. The following licensures shall be utilized in the delivery of nursing care: Registered Nurses (RN), Licensed Vocational Nurses, Psychiatric Technicians, Certified Nursing Assistants, and Medical Assistants.

Purpose

• To ensure care is delivered through team-based care coordination, varying according to levels of care and patient acuity; and to ensure the RN utilizes all aspects of the nursing process including assessing the patient’s current health status and contributing factors, identifying and prioritizing the patient’s problems and needs, identifying mutual goals (expected outcomes), developing a plan to achieve mutual goals, implementing the plan or assigning others to implement it, evaluating the plan’s effectiveness, and adapting a plan based on the patient’s response.

Responsibility

• The Statewide Chief Nurse Executive, or designee, has the overall responsibility for the implementation of this policy.

Policy

• The California Correctional Health Care Services (CCHCS), California Department of Corrections and Rehabilitation (CDCR) shall maintain a program to evaluate nursing care and professional practice based on standards of clinical nursing practice established by regulatory agencies, accrediting bodies, and CCHCS health care policies and procedures.  At a minimum, this program shall include a statewide Nursing Professional Practice Council (NPPC) and organized processes for surveillance of professional nursing practice at all levels of the organization.

Purpose

• To evaluate the following state service classifications: Registered Nurses, Licensed Vocational Nurses, Psychiatric Technicians, Certified Nursing Assistants, and Medical Assistants for delivery of appropriate, timely, quality nursing care to patients within CDCR institutions.

Responsibility

• The Statewide Chief Nurse Executive (SCNE), or designee, has overall responsibility for the implementation, monitoring, and evaluation of this policy and procedure.

Procedure Overview

• This procedure outlines professional council structure and processes. Performs practice surveillance activities statewide, including identification of nursing professional practice deficiencies, best practices and processes, and system issues across institutions, regions, and the state. NPPC shall analyze common causal factors, root causes, and make recommendations for improvements.

Procedure

• NPPC Membership

  • The SCNE shall designate NPPC membership consisting of the following:

    • A Chairperson who shall serve for a period not to exceed two years.

    • Headquarters (HQ), regional, and institutional Chief Nursing Executives (CNEs).

    • Nurse Consultants, Program Review (NCPRs).

  • All NPPC members shall be voting members.  A minimum of three members in attendance (chairperson, one CNE, and one NCPR) is required for the NPPC to hold a meeting. A simple majority is required for any actions taken by the NPPC.

• Referral Sources

  • Referrals to the NPPC may be submitted by, but are not limited to:

  • HQ nursing staff.

  • Mortality Review Unit.

  • Institution health care leadership.

  • Clinical programs (Dental, Medical, Mental Health, Nursing).

  • Health Care Correspondence and Appeals Branch.

  • Patient Safety Program.

  • Peer review committees.

  • California Board of Registered Nurses, California Board of Vocational Nurses and Psychiatric Technicians, and other licensing bodies.

  • Office of the Receiver.

• Referral Criteria

  • Referrals to the NPPC shall be made for clinical practice issues including, but not limited to, the following:

  • Departures or suspected departures from standards of nursing care and evidence-based practice that place patients or the organization at risk.

  • The repeated failure to provide the required nursing care.

  • Failure or suspected failure to provide care or exercise caution in a single situation which the nurse knew or should have known could result in patient harm.

  • NPPC shall not participate in any nursing staff disciplinary actions, litigations, and any other issues pertaining to labor bargaining units or memorandum of understandings.

• Referral Documentation Requirements

  • All referrals shall be submitted in writing and shall include the following:

    • A concise statement about the nursing best practice or deficiency implicated in the referral.

    • Supporting evidence.

    • Identification of nursing staff involved, if indicated.

    • Patient demographic information.

    • Referral source and contact information.

  • NPPC referrals shall be sent electronically to the NPPC mailbox at “CDCR CCHCS Nursing Professional Practice Council” or CDCRCCHCSNPPC@cdcr.ca.gov.

• Assignment of Case

  • The NPPC shall assign the referral to an NCPR.

  • Upon initial review of the referral summary, the NCPR shall present the case to the NPPC for review and to determine if it meets the referral criteria. In the event of a disagreement, a majority vote shall decide.

• Types of Review

  • The NCPR shall conduct one or more of the following reviews to include, but is not limited to:

  • Nursing Practice Review.

  • Pattern of Practice Review.

  • Mortality Review.

  • Competency or other trainings on record review.

• Review Process

  • The NCPR shall conduct a factual review of the events reported in the referral utilizing relevant information gathered from a variety of sources including, but not limited to the following:

    • Patient health records and any other relevant documentation.

    • Site visits.

    • Current CCHCS, CDCR policy documents.

    • Licensing Agency Practice Acts and position statements.

    • American Nurses Association or other Professional Practice Organization standards of competent practice statements.

    • Context in which care was delivered (e.g., inpatient, outpatient, higher level of care).

    • Complexity and risk stratification of the patient.

    • Continuity and coordination of care (patient handoff).

  • When appropriate, the NCPR shall identify extenuating circumstances, external factors, and barriers to care that may have contributed to the event or practice under review.

  • After gathering the facts, the NCPR shall prepare a written report in the format appropriate for the type of review being conducted.  The review shall address the following:

    • The reason for referral or review.

    • A summary of findings.

    • Source documents, case materials, and identification of involved staff if indicated.

    • Additional information or materials considered.

    • Documented statements.

    • Identification of nursing best practices or deficiencies.

    • Identification of extenuating circumstances, external factors, and barriers to care.

    • Reviewer recommendations.

  • The NCPR shall submit the completed report to the NPPC for discussion and adjudication.

  • Approved reports shall be saved to the NPPC shared folder.

• NPPC Data Collection and Analysis

  • The NPPC shall meet regularly, but not less than once a month.

  • Support staff shall collect and store data as well as NPPC recommendations from each meeting.  This data shall be compiled and made available for clinical evaluation and analysis.

  • Staff shall evaluate and analyze the data and generate statewide reports on a regular basis and as requested by nursing leadership or other stakeholders, for quality improvement efforts, policy updates, and nursing professional development.

• Reporting Requirements

  • When indicated, the NPPC shall report findings to the appropriate institution Chief Executive Officer and CNE, and the appropriate HQ Governance forum.

  • NPPC shall recommend to the institution hiring authority and institution CNE to take appropriate action to address any opportunities for improvement in nursing practice. NPPC shall work with institutional leadership to ensure implementation of quality improvement initiatives.

Policy

• California Correctional Health Care Services (CCHCS) nursing standards shall be guided by the Nursing Practice Act, American Nurses’ Association Standards, and/or other regulations.  Standards shall be directed and informed via policies, procedures, protocols, and guidelines.  Standards that contain elements of medical management shall be developed in collaboration with the headquarters’ (HQ) medical executive team and other HQ clinical executives as indicated.  These standards shall be reviewed, at a minimum, every three years for conformance with current evidenced based practice and updated as indicated.

• Correctional Registered Nurse (RN) Standards of Practice

  • CCHCS RNs shall comply with the following standards of practice:

  • Assessment: The RN shall collect comprehensive data pertinent to the patient’s health and/or the situation.

  • Diagnosis: The RN shall analyze the assessment data to determine the diagnoses, health concerns, or organizational issues.

  • Outcome Identification: The RN shall identify expected outcomes for a plan individualized to the patient or the situation.

  • Planning: The RN shall develop a plan, in accordance with the clinical pathway, that prescribes strategies and alternatives to attain expected outcomes.

  • Implementation: The RN shall implement the identified plan by:

    • Coordinating care delivery.

    • Employing strategies to promote a healthy and safe environment.

  • Evaluation: The RN shall evaluate progress toward attainment of outcomes.

• Correctional Nursing Standards of Professional Performance

  • CCHCS nursing staff shall:

  • Practice nursing ethically.

  • Attain knowledge and competence that reflect current nursing practice.

  • Integrate evidence and research findings into practice.

  • Contribute to quality nursing practice.

  • Communicate effectively in a variety of formats and in all areas of practice.

  • Demonstrate leadership in the professional practice setting.

  • Collaborate with the patient, correctional facility administration, and other health care professionals in his/her conduct of nursing practice.

  • Evaluate his/her own nursing practice in relation to professional practice standards and guidelines, relevant statutes, and rules and regulations.

  • Utilize appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible.

  • Practice in an environmentally safe and healthy manner.

• Development/Revision

  • CCHCS nursing standards shall be changed as needed to reflect the dynamics of the nursing profession as new patterns of professional practice are developed and accepted by the nursing profession and the public.

  • Additional standards may be identified in response to a variety of sources including, but not limited to, the following:

    • Nursing staff.

    • Other disciplines.

    • New patient populations.

    • New technologies.

    • Quality improvement initiatives.

    • Research.

    • New regulations.

Purpose

• To direct and guide nursing care provided to patients across the continuum of care within CCHCS as well as to establish and ensure conformance with professional nursing standards.

Responsibility

• The HQ Chief Nursing Executive and nursing executive team are responsible for the development of nursing standards of care and practice as informed by the Complete Care Model.

Policy

• The California Correctional Health Care Services (CCHCS) Nursing Services Branch maintains a competency program to ensure nursing practice is consistent with the nursing process and practice established by the California state nursing licensing and certification agencies.

• Licensed and unlicensed CCHCS nursing staff shall demonstrate the knowledge, skills, and abilities required to achieve an appropriate level of competency and perform within their scope of practice.  Nursing staff competency shall promote compliance with CCHCS and California Department of Corrections and Rehabilitation policies and procedures, federal and state laws and regulations, and nationally accepted nursing standards.

• The competency program includes:

  • Educational programs

  • Competency validation

  • Monitoring for compliance

• Competency validation occurs on a continuum. This continuum shall include assessment of competencies during the hiring process, during the orientation period, and throughout employment as the requirements of the job and needs of the organization change.

Purpose

• To ensure the following:

• Competent nursing staff

• Positive patient outcomes

• Patient safety

Responsibility

• The Statewide Chief Nurse Executive (CNE) is responsible for statewide implementation of this policy, and the institutional CNEs are responsible for the local implementation of this policy.

Procedure Overview

• The CCHCS Nursing Services Branch shall maintain a competency program to include educational programs, competency validation, and monitoring for compliance to ensure competent nursing staff, positive patient outcomes, and patient safety.

Procedure

• Educational Trainings and Competencies Development

  • Educational trainings and competencies shall be developed by CCHCS headquarters (HQ) Nursing Services based upon internal and external requirements.  Nursing Leadership shall review and update all nursing educational training and competencies developed by Nursing Services, as needed.

• Education and Competency Validation Components

  • Registered Nurses (RNs)

  • The Nursing Practice Act sets forth the duties that all RNs, regardless of role, population, or specialty are expected to perform competently. Additional education and training shall be provided to the RN in order to maintain and further develop knowledge, skills, and abilities for practicing at the highest level of RN scope of practice. The components include, but are not limited to:

    • Each of the elements of the Nursing Process (assessment, diagnosis, outcome identification, planning, implementation, coordination of care, health teaching and health promotion, and evaluation).

    • The dependent, independent, and interdependent functions identified for the RN in the various health care areas of the correctional nurse setting.

    • Patient advocacy and clinical and administrative leadership as defined for the correctional health RN.

    • Leadership and engagement in striving for quality patient care outcomes.

    • Ongoing development of proficiency in communications with patients, to include evolving practice in effective communication, and communications with the health care team.

    • Ongoing development of proficiency in the use of the Electronic Health Record System for clinical documentation.

    • Emerging health care best practices in areas such as health equity, trauma-informed care, and motivational strategies.

  • Licensed Vocational Nurses (LVNs) and Psychiatric Technicians (PTs)

    • LVNs and PTs shall be provided education and training within their scope of practice and shall be expected to perform competently.  The components include, but are not limited to:

    • Medication management – The LVN and PT follows the six rights of medication administration; is knowledgeable in the medication classifications and common side effects of medications being administered; and provides patient education related to medication indications, use, adherence and side effects.

    • Subjective and objective data collection – The LVN and PT collects data pertinent to the patient’s health or situation.

    • Therapeutic interventions – The LVN and PT provides basic nursing care, treatments, and techniques as ordered or delegated.

    • Patient education and group facilitation – The LVN and PT provides evidence-based patient teaching and employs techniques for facilitating psycho-educational and psycho-social rehabilitation groups.

  • Certified Nursing Assistants (CNAs)

    • CNAs shall be provided education and training within their scope of practice and shall be expected to perform competently.  The components include, but are not limited to:

    • Assisting or providing patients with their activities of daily living.

    • Observing and data collection for changes in the patient’s condition (1:1 suicide watch and suicide precaution), obtaining vital signs, weights, and measuring a patient’s intake and output.

• Education and Competency Validation Frequency

  • Education and competency validation is conducted:

  • Quarterly for new hires for first year, annually thereafter, and as needed based upon:

    • Quality improvement

    • A performance evaluation

    • Performance improvement plan

    • New policies or procedures

    • When a deficiency is identified

  • Competency validation results shall be part of an employee’s performance appraisals.

• Education and Competency Validators

  • Nursing clinical staff shall demonstrate competency prior to teaching educational trainings and validating competency of nursing staff.  Methods to acquire knowledge or skills include, but are not limited to:

  • Continuing education programs

  • Review of policies and procedures

  • In-service education

  • Training-for-Trainers

  • Simulation exercises

  • Observation and demonstration

• Competency Validation Methods

  • Competency validation methods used to measure the abilities of an individual for a specific competency standard include, but are not limited to:

    • Test

    • Skills validation

    • Observation

    • Case Studies

    • Exemplars

    • Peer Reviews by Nursing Professional Practice Council

    • Mock Events

    • Quality Improvement Monitors

  • Some competencies may require a combination of validation methods.  The nursing leadership shall determine the validation methods for each competency developed by HQ Nursing Services.

• Education and Competency Validation: Documentation and Tracking

  • Nursing staff’s competency shall be documented in the:

  • Supervisory File

  • Proof of Practice (Training File)

  • Education and Competency Tracking Database

Policy

• California Correctional Health Care Services (CCHCS) shall maintain standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders to legally allow nursing staff within CCHCS to perform direct and indirect patient care utilizing evidence-based nursing practices consistent within the scope of practice of each nursing classification.

• Standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders are developed and approved collaboratively at the headquarters level by a multidisciplinary practice group whose membership consists of nurses and physicians and conform to the requirements of the California Code of Regulations (CCR), Title 16, Sections 1366-1366.4, Sections1379, and Sections 1470-1474.

Purpose

• To provide direction, promote consistency, and support the practice of nursing utilizing standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders within CCHCS in accordance with all applicable statutes, rules, and regulations.

Applicability

• This policy is applicable to all Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), Psychiatric Technicians (PTs), Certified Nursing Assistants (CNAs) and Medical Assistants (Mas) employed by, contracted with, or volunteering for the State of California while providing services to patients within the care of the California Department of Corrections and Rehabilitation (CDCR).

• This policy is not applicable to inpatient facilities licensed by the California Department of Public Health under the CCR, Title 22, unless the standardized procedure, protocol, order set, clinical pathway, and standing order are also adopted in writing by the appropriate governing body as required by CCR, Title 22.

Responsibility

• CDCR and CCHCS departmental leadership, at all levels of the organization, within the scope of their authority, shall ensure administrative and clinical systems are in place and appropriate tools, training, and levels of resources are available so that nursing staff can successfully implement the provision of evidence-based nursing services to patients under the care of CCHCS/CDCR.

• The Deputy Director, Nursing Services, is responsible for statewide planning, implementation, and evaluation of the nursing services provided within CCHCS/CDCR.  For the purposes of this policy, the Deputy Director, Nursing Services, shall collaborate with the Deputy Director, Medical Services, for implementation.

• Regional Health Care Executives (RHCEs) are responsible for implementation of this policy at the subset of institutions within an assigned region.

• The Chief Executive Officer (CEO) is responsible for implementation of this policy at the institution level.  The CEO may delegate this responsibility to the institutional Chief Nurse Executive (CNE) and Chief Medical Executive (CME) but retains overall responsibility.

Procedure Overview

• This procedure provides direction to promote consistency and support professional practice by nurses providing services within the CDCR and CCHCS to the fullest extent of their licensure using standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders in accordance with all applicable statutes, rules, and regulations.

Responsibility

• Statewide

  • CDCR and CCHCS departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance and levels of resources are available so that CCHCS health care staff can successfully implement this procedure.

• Regional

  • RHCEs Regional CNEs are responsible for implementation of this procedure at the subset of institutions within an assigned region.

• Institutional

  • The CEO has overall responsibility for implementation and ongoing oversight of a system to provide management of the patient care services to include the implementation of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders at an assigned institution.  The CEO delegates decision-making authority to designated institutional health care executives for daily operations and ensures adequate resources are deployed to support the system.

  • All members of the institutional leadership team are responsible for ensuring all necessary resources are in place to support the successful implementation of this procedure at all levels of the institution.

  • All members of the institutional leadership team shall ensure access to and utilization of equipment, supplies, health information systems, patient registries and summaries, and evidence-based guidelines necessary to implement this procedure.

  • All members of the institutional leadership team as a part of the quality management process on an ongoing basis shall:

    • Review health care staff performance including the overall quality of services, health outcomes, assignment of consistent and adequate resources, utilization of dashboards, patient registries, patient summaries, decision support tools, and address issues pertaining to the use of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders.

    • Provide health care staff with adequate resources including training, staffing, physical plant, information technology, and equipment/supplies necessary to accomplish tasks required during the use of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders.

  • The CNE and the CME shall develop an interdisciplinary process to ensure that each health care staff member utilizing standardized procedures, protocols, and order sets shall have at a minimum:

    • Training on policies and procedures during orientation; whenever new standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders are issued; and as needed.

    • Demonstrated competency in the use of each standardized procedure, protocol, order set, clinical pathway, and standing order prior to their performance of the tasks outlined in the standardized procedure, protocol, order set, clinical pathway, and standing order.

    • An established training file (proof of practice file) containing documentation of the health care staff member’s training and initial and ongoing competency evaluations for each standardized procedure, protocol, order set, clinical pathway, and standing order used by the health care staff member.

Procedure

• General Requirements

  • Each standardized procedure, protocol, order set, clinical pathway, and standing order shall be developed and implemented using an interdisciplinary process that meets the following minimum requirements:

  • Uses an interdisciplinary team appropriate to the item being developed (i.e., nursing, medicine, pharmacy, mental health, dental, etc.).

  • Ensures that each standardized procedure, protocol, order set, clinical pathway, and standing order developed is evidence-based, conforms to any applicable departmentally approved Care Guide, and supports the Complete Care Model Policy as outlined in the Health Care Department Operations Manual (HCDOM), Section 1.4.6.7, Nursing Competency Program.

  • Identifies the parties responsible for the training and implementation of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders.

  • Determines the method and frequency of competency testing and the documentation of the results.  Competency testing shall, at a minimum, meet the requirements of HCDOM, Section 1.4.6.7, Nursing Competency Program.

  • Ensures the requirements of Section (f)(3)(E) are met.

  • Identifies a method of ensuring the distribution of approved standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders to all staff within the organization.  The placement of a signed copy of the documents on a departmentally-approved intranet webpage accessible to all heath care staff meets the requirements of availability for the purposes of this paragraph.

• Standardized Procedures/Nurse Protocols

  • Standardized procedures/nurse protocols shall be developed at the statewide level under the direction of the Deputy Directors of Nursing Services, Medical Services, Mental Health Program, Dental Services (as applicable), and the Chief of Pharmacy Services (as applicable).

  • The Deputy Directors of Nursing Services, Medical Services, Mental Health Program, Dental Services, (as applicable), and the Chief of Pharmacy Services (as applicable) shall ensure that an interdisciplinary  process, which includes input from all appropriate disciplines and regional and institutional subject matter experts, is used during the development of standardized procedures and nurse protocols.

  • Standardized procedures/nurse protocols shall be approved and signed at the statewide level and issued to the field for implementation to ensure standardization of patient care, full implementation within the Electronic Health Record System (EHRS), improvement of patient outcomes, and management of risk throughout the organization.

  • Standardized procedures shall be in writing, dated, and signed by the departmental designated staff (i.e., Deputy Directors of Nursing Services, Medical Services, Dental Services, and other Deputy Directors as applicable) and shall, at a minimum:

    • Specify which standardized procedure functions RNs may perform and under what circumstances.

    • State any specific requirements that are to be followed by RNs in performing particular standardized procedure functions.

    • Specify any experience, training, and/or education requirements for performance of standardized procedure functions.

    • Establish a method for initial and continuing evaluation of the competence of those RNs authorized to perform standardized procedure functions.

    • Provide a method of maintaining a written record of those persons authorized to perform standardized procedure functions.

    • Specify the scope of supervision required for performance of standardized procedure functions (e.g., immediate supervision by a provider).

    • Set forth any specialized circumstances under which the RN is to communicate immediately with a patient’s provider concerning the patient’s condition.

    • State the limitations on settings, if any, in which standardized procedure functions may be performed.

    • Specify patient record-keeping requirements.

    • Provide a method of periodic review of the standardized procedures.

• Clinical Pathways

  • Clinical pathways shall be developed at the statewide level under the direction of the Deputy Directors of Nursing Services, Medical Services, Mental Health Program, Dental Services, and the Chief of Pharmacy Services (as applicable).

  • The Deputy Directors of Nursing Services, Medical Services, Mental Health Program, Dental Services (as applicable), and the Chief of Pharmacy Services (as applicable) shall ensure that an interdisciplinary process, which includes input from all appropriate disciplines and regional and institutional subject matter experts, is used during the development of clinical pathways.

  • Clinical pathways shall be approved and signed by the departmental designated staff (i.e., Deputy Directors of Nursing Services, Medical Services, and other Deputy Directors, as applicable) at the statewide level and issued to the field for implementation to ensure standardization of patient care, full implementation within the EHRS, improvement of patient outcomes, and management of risk throughout the organization.

  • Clinical pathways shall contain the following elements at a minimum:

    • A statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and characteristics.

    • Means of communication among the care team members and with patients.

    • The coordination of the care process by coordinating the roles and sequencing the activities of the interdisciplinary care team and patients.

    • An explanation of who may perform individual elements of the clinical pathway if there are limitations based on the individual scopes of practice for the members of the care team (i.e., a task may be performed by the RN but not the LVN/PT).

    • Requirements for documentation, monitoring, and evaluation of variances and outcomes.

    • Identification of the appropriate resources necessary to implement the clinical pathway.

    • Specification of any experience, training, and/or education requirements for performance of functions listed in the clinical pathway.

    • A method for initial and continuing evaluation of the competence of health care staff authorized to perform clinical pathway functions.

    • A method of maintaining a written record of those persons authorized to perform clinical pathway functions.

    • Specification of the scope of supervision required for the performance of clinical pathway functions (e.g., immediate supervision by a provider).

    • Directives for any specialized circumstances under which the health care staff is to communicate immediately with a patient’s provider concerning the patient’s condition.

    • Limitations on settings, if any, in which clinical pathway functions may be performed.

    • Patient record-keeping requirements.

    • A method of periodic review of the clinical pathway.

• Order Sets

  • Order sets may be proposed at the statewide, regional, or local level.

  • Order sets shall be approved at the statewide level and issued to the field for implementation to ensure standardization of patient care, full implementation within the EHRS, improvement of patient outcomes, and management of risk throughout the organization.

  • Order sets shall be developed using an interdisciplinary process as outlined in Section (g)(1) above.  No order set shall be used without first being approved through the appropriate Quality Management Committee approval process and signed by the departmental designated staff (i.e., Deputy Director of Nursing Services, Medical Services, and other Deputy Directors as applicable).

  • When developing and approving order sets, consideration shall be given to the following at a minimum:

    • Order sets are reflective of current “best practices.”

    • Order sets are comprehensive and consider other disciplines as required by the actions being performed (e.g., screen patient for smoking history.  The RN shall provide smoking cessation counseling if the patient has smoked within 12 months).

    • Automatic orders are pre-selected to reduce the possibility of their being overlooked.  Pre-selected automatic orders on a paper document shall include the following line, “Strike through entire line to cancel a pre-selected order.” Pre-selected orders in the EHRS (i.e., on the PowerPlan) can be deselected to individualize the order.

    • Order sets are reflective of national performance measures as appropriate (e.g., Joint Commission Standards and National Hospital Inpatient Quality Measures).

    • Order sets are reflective of national patient safety goals, if appropriate (e.g., provides vital sign parameters and parameters for notifying the provider).

    • Infection control measures are considered, as appropriate.

    • Equipment and medications listed are readily available at the institution and on the formulary.

    • Instructions are complete, unambiguous, and clear (i.e., designate no range orders without objective measures to determine the correct dose; avoid overlapping parameters to guide medication administration that make it difficult to interpret the correct directions).

    • The use of symbols is kept to a minimum; avoid letters, numbers, and abbreviations that may be easily confused or misinterpreted.

    • Attempts are made to remove or reduce look-alike or sound-alike items, and “tall-man lettering” is used for all look-alike names and words.

    • Upper case letters are used appropriately (e.g., when lower case letters are used, “PRN” can be easily misread as “pm”).

    • Paper orders are written on one side of the sheet only.  Orders written on the reverse side of sheets are often overlooked.  The reverse side of orders are best used only for references, additional information, etc.

• Standing Orders

  • Standing orders may be proposed at the statewide, regional, or local level.

  • Standing orders shall be approved at the statewide level and issued to the field for implementation to ensure standardization of patient care, full implementation within the EHRS, improvement of patient outcomes, and management of risk throughout the organization.

  • Standing orders shall be developed using an interdisciplinary process as outlined in Section (g)(1) above.  No standing order shall be used without first being approved through the appropriate headquarters Quality Management Committee approval process and signed by the departmental designated staff (i.e., Deputy Director of Nursing Services, Medical Services, and other Deputy Directors as applicable).

  • Standing orders shall:

    • Be conditioned upon the occurrence of certain clinical events.

    • Be initiated by the treating health care provider.

    • Demonstrate a patient/provider relationship.

    • Be patient specific.

  • Once the triggering event is identified, an allied health professional or licensed independent provider may initiate treatment pursuant to a standing order.

  • No standing order shall authorize a health care staff member to exceed their scope of practice or level of training.

  • When developing and approving standing orders, consideration shall be given to the best practices noted in Section (g)(4) above regarding order sets including the following at a minimum:

    • Standing orders are reflective of current “best practices.”

    • Standing orders are comprehensive and consider other disciplines as required by the actions being performed.

    • Standing orders specify the circumstances under which the drug or treatment is to be administered and/or provided.

    • Standing orders specify the types of medical conditions of patients for whom the standing orders are intended.

    • If the standing order addresses the administration of medications, it must be initially approved by the Pharmacy and Therapeutics Committee and be periodically reviewed by that committee.

    • Standing orders are specific as to the drug, dosage, route, and frequency of administration of any medication.

• Statewide Nursing Standardized Procedures Committee

  • Statewide leadership shall designate a standing committee that will be responsible for the development and review of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders at an organizational level.  Permanent members of the committee shall be the Deputy Directors of Nursing Services and Medical Services.  Other Deputy Directors shall be invited as the subject matter of the standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders (i.e., Pharmacy, Ancillary Services, etc.).

  • The committee shall coordinate actions with the Clinical Guidelines Committee, the Pharmacy and Therapeutics Committee, and/or other statewide stakeholders as indicated to ensure that the developed decision-support tools conform to evidence-based practice and are supported by other statewide policies and procedures.

  • The committee shall ensure that all material(s) necessary to support the full implementation of decision-support tools are provided in conjunction with their release.  Examples of these materials include, but are not limited to, lesson plans, competencies, webinars, and Learning Management System training sessions.

  • The committee shall ensure that all approved decision-support tools are signed by the appropriate Deputy Directors and/or Directors.  Decision-Support Tools approved at the statewide level do not require additional approval at the regional or institutional level.

  • Decision-Support Tools shall not be modified at the regional or institutional level.  Recommendations for change shall be submitted using the process described below in Section (g)(7)(D).

• Institutional Nursing Standardized Procedures Committee

  • Institutional leadership shall designate a standing committee reporting to the local Quality Management Committee for oversight of the training, implementation, maintenance, record-keeping, and review of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders at the institutional level.  The committee shall:

  • Take corrective action as needed to identify issues related to the implementation and use of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders within the institution.

  • Take the appropriate corrective action to resolve and/or elevate concerns identified in the review.

  • Document all reviews and actions taken and forward to the local Quality Management Committee.

  • Make recommendations to the statewide committee for the development of new standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders and/or the review of existing decision support.

• Institutional Nursing Standardized Procedures Monitoring Program

  • The CEO and institutional leadership team shall establish an ongoing monitoring program to periodically assess the quality of the training, implementation, maintenance, record-keeping, and review of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders.  The monitoring process shall include, but is not limited to:

  • A review of the competency program results for health care staff including trends identified during didactic and hands on training (i.e., common deficiencies).

  • Rates of utilization for each standardized procedure, protocol, order set, clinical pathway, and standing order.

  • A review of order sets to ensure that they are being utilized appropriately and that the orders continue to meet the patient care needs of the institution’s population, current policy, and health care “best practices.”

  • A review of trended outcome data (i.e., registry “improvements”) for each standardized procedure, protocol, order set, clinical pathway, and standing order in use.  Variances from the expected standardized usage shall be reviewed, trended, and considered during the periodic review conducted as described in item five below.

  • Status of the periodic review for each standardized procedure, protocol, order set, clinical pathway, and standing order utilized within the institution.

  • A periodic review of local population management session reports to identify local trends in patient care needs and outcomes that might benefit from the development (or modification) of a standardized procedure, protocol, order set, clinical pathway, and standing order.  The committee shall make a recommendation with supporting data to the regional executive leadership team when a potential need is identified.

  • Adherence to policy guidelines, protocols, and decision-support tools as they relate to the development, training, and usage of standardized procedures, protocols, order sets, clinical pathways, guidelines, and standing orders.