Core Values (CV) implementation checks

1. Core Values (CV) implementation checks General awareness/ STRATCOM Facility-level program Unit-level program UPC involvement Leadership involvement • Is AN Creed posted prominently in all areas where nursing care is provided? • Does facility have a designated Core Values OIC? • Does unit have a designated Unit Core Values Leader? • Is facility command group briefed at least semi-annually by DNC on status of Core Values and broader ANSOC implementation? (strategic) • What % of Section Supervisors, CNOIC, and NCOICs know what comprises Core Values? (operational) • What % of Section Supervisors, CNOICs, and NCOICs can articulate the standards for the Core Values component? (operational) • What % of Section Supervisors, CNOICs, and NCOICs can accurately describe their unit’s Core Values program? (operational) • What % of nursing staff on unit know what comprises our Core Values? (tactical) • What % of new (<60 days) nursing staff know what comprises our Core Values? (tactical) • Does facility have a systematic program for identifying/recognizing nursing staff that exemplify the Core Values? • What % of nursing staff are aware of the Core Values recognition program and how to nominate/be nominated for recognition? • How often is a Core Values-related event or activity conducted at facility-level? • What % of nursing staff are aware of these facility-level events/activities? • What % of nursing staff can recall most recent facility-level Core Values event/activity? • What % of nurses know when next facility-level Core Values event/activity is? • Does nursing staff agree that events are relevant and held at appropriate times/locations to maximize attendance? • Does unit actively participate in facility program for identifying/recognizing nursing staff that exemplify the Core Values? • What % of nursing staff are aware of the Core Values recognition program and how to nominate/be nominated for recognition? • How often is a Core Values-related event or activity conducted at unit-level? • What % of nursing staff are aware of these unit-level events/activities? • What % of nursing staff can recall most recent unit-level Core Values event/activity? • What % of nurses know when next unit-level Core Values event/activity is? • Does nursing staff agree that events are relevant and held at appropriate times/locations to maximize attendance? • What % of UPC members say that they have significant input into unit Core Values events and activities? • Is UPC holding Unit Core Values Leader accountable for proper execution of Core Values component • Are facility and unit leaders actively participating in Core Values discussions, events, and activities? • What % of nursing staff say their unit/section/facility leader actively participates in Core Values discussions, events, and activities on a regular basis?

2. Shared Governance (SG) implementation checks General awareness/ STRATCOM Facility-level program Unit-level program Leadership involvement • Does facility have elected Facility NPC with approved charter and a designated Shared Governance OIC? • Does unit have an elected UPC with an approved charter? • Is facility command group briefed at least semi-annually by DCN on status of Shared Governance and broader ANSOC implementation? (strategic) • What % of Section Supervisors, CNOICs, and NCOICs can articulate the standards for Shared Governance? (operational) • What % of Section Supervisors, CNOICs, and NCOICs can accurately describe how their units implement Shared Governance? (operational) • What % of nursing staff on unit know who their UPC rep is? (tactical) • What % of new (<60 days) nursing staff know who their UPC rep is? (tactical) • How often is Facility NPC conducting meetings? • What % of Facility NPC is bedside nurses? • Is Facility NPC conducting semi-annual UPC round-ups? • What % of UPC chairs and co-chairs agree that the Facility NPC effectively supports them in their unit-level efforts • How often is a UPC meeting conducted? • What % of nursing staff are aware of these meetings and their schedule? • What % of nursing staff agree that their UPC rep asks for their input regularly? • What % of nursing staff agree that their UPC rep keeps them up-to-date on the outcomes of UPC meetings? • What % of UPC members attended the last 3 months of meetings? • What % of UPC members agree their meetings are well-organized and effective in accomplishing the UPC’s goals? • What % of UPC members agree that meetings are held at appropriate times/locations to maximize attendance? • What % of nursing staff and UPC members agree that the UPC is adhering to its charter, holding regular elections, and makes a positive difference on the unit? • Does the UPC have an effective plan in place for training new members in Shared Governance and ensuring continuity despite deployments and other turn-over? • What % of the time does the UPC meet its deadlines for proposals, implementation, etc? • Does the UPC have a track record of quick wins? Practice innovations? Successful implementation of other ANSOC components? • What % of UPC members agree that the Clinical Nurse OIC works collaboratively with the UPC? • What % of UPC members agree that the NCOIC works collaboratively with the UPC? • What % of UPC members agree they are allotted adequate time and space to conduct regular meetings?

3. Optimized Performance (OP) implementation checks General awareness/ STRATCOM Facility-level program Unit-level program UPC involvement Leadership involvement • Does facility have designated Optimized Performance OIC? • Does unit have a designated Unit Optimized Performance Leader? • Is facility command group briefed at least semi-annually by DCN on status of OP and broader ANSOC implementation? (strategic) • What % of Section Supervisors, CNOICs, and NCOICs can articulate the standards for OP? (operational) • What % of Section Supervisors, CNOICs, and NCOICs can accurately describe how their units implement OP? (operational) • What % of nursing staff know about the OP program for their unit/facility? (tactical) • What % of new (<60 days) nursing staff know about the OP program for their unit/facility? (tactical) • What % of units submit unit dashboard by submission date on a monthly basis to Optimized Performance OIC? • What % of units submit at least 9 of the 10 priority metrics? 5 of the 10? • What % of nursing staff state that the facility/unit is supportive of honest reporting of performance metrics? • Does Optimized Performance OIC report on facility performance on a regular basis to facility leadership? • Are metrics posted and accessible to DCN, CNOICs, and RNEs? • What % of nursing staff are aware of the ten priority metrics? • Has unit controlled dashboard access to 1-2 nursing staff members? • Have unit metrics been posted in the past month? • What % of nursing staff know where to find the unit performance metrics posted? • What % of nursing staff report attending a meeting / Town Hall where performance of unit was discussed? • What % of nursing staff agree that performance metrics are relevant to unit? • What % of nursing staff know that units can define their own metrics via UPC and Unit Optimized Performance Leader? • Have initiatives been started to address Optimized Performance metrics on the unit? • Have any unit-specific metrics been added to the dashboard? • What % of nursing staff agrees that they are more aware of unit performance than six months ago? • What % of UPC members say that they have significant input into unit Optimized Performance metrics and activities? • Is UPC holding Unit Optimized Performance Leader accountable for proper execution of component? • Does UPC review metrics on a regular basis and monitor impact over time? • Are facility and unit leaders actively participating in Optimized Performance reviews at facility and unit levels? • What % of nursing staff say their unit/section/facility leader actively supports and/or participates in Optimized Performance activities on a regular basis?

4. Care Teams (CT) implementation checks General awareness/ STRATCOM Facility-level program Unit-level program UPC involvement Leadership involvement • Does facility have designated Care Teams OIC? • Does unit have a designated Unit Care Teams Leader? • Is facility command group briefed at least semi-annually by DCN on status of Care Teams and broader ANSOC implementation? (strategic) • What % of Section Supervisors, CNOICs, and NCOICs can articulate the standards for Care Teams? (operational) • What % of Section Supervisors, CNOICs, and NCOICs can accurately describe how their units implement Care Teams? (operational) • What % of nursing staff know about the Care Teams program for their unit/facility? (tactical) • What % of new (<60 days) nursing staff know about the Care Teams program for their unit/facility? (tactical) • What % of units conduct Safety Huddles at the beginning of every shift? • What % of units conduct Bedside Rounds with patients/families at the beginning of every shift? • What % of units conduct Collaborative Rounds during every shift? • What % of units conduct Hourly Nursing Rounds during every shift? • What % of units update whiteboards during every shift? • What % of units promote SBAR or another established communication tool (e.g., TeamSTEPPs)? • What % of nursing staff state that Care Teams have enhanced the care they provide to patients? • What % of nursing staff state that Care Teams have enhanced their job satisfaction? • What % of Charge Nurses state confidence in assigning Care Teams to balance consistency of care, competencies of staff, and development of staff? • What % of Care Teams assignments are completed by Charge Nurse before on-coming shift arrives? • What is the average number of Lead RNs caring for a patient during a length of stay on the unit? • How many clinical practice guidelines have been implemented on the unit through the Care Teams in the last year? • What % of patients/families can name their Lead RN? • What % of patients/families can name non-Lead RN members of their Care Team? • What % of nursing staff on unit state that Care Teams have enhanced the care they provide to patients? • What % of nursing staff on unit state that Care Teams have enhanced their job satisfaction? • What % of nursing staff report that they have an opportunity to be reassigned to another Care Team if requested? • What % of UPC members say that they have had significant input into unit Care Teams guidelines? • Is UPC holding Unit Care Teams Leader accountable for proper execution of Care Teams component? • Does UPC implement and track metrics to monitor impact of Care Teams sessions on unit performance? • Are facility and unit leaders actively promoting Care Teams at facility and unit levels? • What % of nursing staff say their unit/section/facility leader actively supports Care Teams sessions on a regular basis?

5. Peer Feedback (PF) implementation checks General awareness/ STRATCOM Facility-level program Unit-level program UPC involvement Leadership involvement • Does facility have designated Peer Feedback OIC? • Does unit have a designated Unit Peer Feedback Leader? • Is facility command group briefed at least semi-annually by DCN on status of Peer Feedback and broader ANSOC implementation? (strategic) • What % of Section Supervisors, CNOICs, and NCOICs can articulate the standards for Peer Feedback? (operational) • What % of Section Supervisors, CNOICs, and NCOICs can accurately describe how their units implement Peer Feedback? (operational) • What % of nursing staff know about the Peer Feedback program for their unit/facility? (tactical) • What % of new (<60 days) nursing staff know about the Peer Feedback program for their unit/facility? (tactical) • What % of units conduct Peer Feedback on a regular basis at least every six months? • What % of licensed nursing staff report having provided feedback to a peer in the past 6 months? 3 months? • What % of licensed nursing staff report having received a development discussion to receive feedback from peers in the past 6 months? 3 months? • What % of licensed nursing staff report confidence in anonymity of Peer Feedback? • What % of licensed nursing staff report feeling satisfied with Peer Feedback process? • How many of the 16 ANA Standards were assessed in the first year of Peer Feedback? • What % of licensed nursing staff participated in last round of Peer Feedback? • What % of Peer Feedback tools sent to licensed nursing staff were submitted by due-date? • What % of licensed nursing staff were assessed by >3 Assessors in last round of Peer Feedback? • What % of licensed nursing staff report having provided feedback on >1 peer in last round of Peer Feedback? • What % of developmental discussions occurred within 30 days of Peer Feedback submission? • What % of licensed nursing staff say their Clinical Nurse OIC / NCOIC provides constructive feedback that helps them to develop as professionals? • What % of licensed nursing staff report confidence in anonymity of Peer Feedback on the unit? • What % of licensed nursing staff report feeling satisfied with Peer Feedback process on the unit? • What % of UPC members say that they have significant input into unit Peer Feedback events and activities? • Is UPC holding Unit Peer Feedback Leader accountable for proper execution of Peer Feedback component? • Does UPC implement and track metrics to monitor impact of Peer Feedback sessions on unit performance? • Are facility and unit leaders actively promoting Peer Feedback at facility and unit levels? • What % of licensed nursing staff say their unit/section/facility leader actively supports Peer Feedback?

6. Skill Building (SB) implementation checks General awareness/ STRATCOM Facility-level program Unit-level program UPC involvement Leadership involvement • Does facility have designated Skill Building OIC? • Does unit have a designated Unit Skill Building Leader? • Is facility command group briefed at least semi-annually by DCN on status of Skill Building and broader ANSOC implementation? (strategic) • What % of Section Supervisors, CNOICs, and NCOICs can articulate the standards for Skill Building? (operational) • What % of Section Supervisors, CNOICs, and NCOICs can accurately describe how their units implement Skill Building? (operational) • What % of nursing staff know about the Skill Building program for their unit/facility? (tactical) • What % of new (<60 days) nursing staff know about the Skill Building program for their unit/facility? (tactical) • How often is a Skill Building session conducted at the facility-level? • What % of nursing staff know when next facility-level Skill Building session is? • What % of nursing staff agrees they have opportunity to attend facility-level Skill Building sessions if they desire? • How often is a Skill Building session conducted on the unit? • What % of nursing staff are aware of these sessions? • What % of nursing staff can recall most recent Skill Building session? • What % of nurses know when the next Skill Building session is? • What % of nursing staff attended last 3 months of Skill Building sessions? • What % of nursing staff agrees that sessions are on relevant topics and are effective training opportunities? • What % of nursing staff agrees that Skill Building sessions are held at appropriate times/locations to maximize attendance? • What % of nursing staff agrees that they have input into topics and methods of instruction? • What % of nursing staff agrees that they have opportunities to present and are well-supported in that effort? • What % of UPC members say that they have significant input into unit Skill Building sessions? • Is UPC holding Unit Skill Building Leader accountable for proper execution of Skill Building component? • Does UPC implement and track metrics to monitor impact of Skill Building sessions on unit performance? • Are facility and unit leaders actively participating in Skill Building sessions at facility and unit levels? • What % of nursing staff say their unit/section/facility leader actively supports and/or participates in Skill Building sessions on a regular basis?