Offices

The APN Practice Council is made up of representatives from the various settings where APNs practice. The APN Practice Council has worked to promote the practice of advanced practice nursing at Cleveland Clinic through the development of:

• Continuing education programs
• A brochure that explains APN roles and functions
• A mentorship program for APNs
• A newsletter and Sharepoint site to facilitate communication for APNs throughout the organization
• APN week designed to increase recognition and understanding of the APN practice issues and recognition of our APN staff for their achievements
• An APN satisfaction survey, which led to an improved orientation plan for APNs, improved performance evaluation tools, and increased education of staff members regarding the APN role
• Quarterly continuing education programs along with simulation labs for advanced procedures
• Tools to educate others regarding the APN scope of practice

The APN Privileging Committee is composed of APN representatives from various APN practices throughout Cleveland Clinic as well as members of Human Resources, the medical staff, the Credentialing Committee, and Risk Management. These APNs serve as both peers and clinical experts in the APN privileging process. The APN Privileging Committee was instrumental in the development of credentialing and privileging procedures for APNs and the development of quality monitoring procedures for APNs.

The APN Privileging Committee reviews APN privilege requests for:

• Required documentation of primary source verification of education, licensure and certification
• Appropriate references
• Documentation of reports from the Office of the Inspector General and National Practitioner Data Bank
• Assesses evidence of current competencies
• Current standard care arrangement with collaborating physician
• Develop standards for focused professional practice evaluation and ongoing professional practice evaluation

All new procedure requests are reviewed for:

• Compliance with scope of practice
• Documentation of formal education related to the requested privileges
• Assessment and documentation of competency in relation to the new procedure
• Documentation of ongoing quality monitoring

Certified Registered Nurse Practitioners (CRNP) may be certified in a variety of specialty services including adult, family, pediatrics, acute care, psychology, neonatology, oncology and palliative care. These CRNPs provide primary and specialty care to their patients in collaboration with the medical staff and healthcare team in a variety of settings.

Certified Nurse Midwives (CNM) provide preventative and primary care services to adolescents and women. They manage and care for women during the normal birthing process and post-partum period may provide gynecologic care to women of all ages. Cleveland Clinic Nurse Midwives provide care at Cleveland Clinic and at a number of Cleveland Clinic health system (CCHS) hospitals and clinics.

Clinical Nurse Specialists (CNS) are advanced practice nurses, who provide and manage the care of individual or groups of patients with complex health problems. Through their advanced nursing education, they become clinical experts in a specific patient population such as acute care, community health, oncology, psychiatry/mental health, or medicine and surgery. They can function in a hospital setting or in a number of outpatient settings.

Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia under the supervision of an anesthesiologist in a variety of settings. CRNAs may also assist in the pre-operative evaluation and post operative management of patients, as well as the management of acute and chronic pain in a variety of settings. Cleveland Clinic CRNAs provide care at Cleveland Clinic and at a number of Cleveland Clinic Health System (CCHS) hospitals and clinics.

Nursing Informatics is not new, but it certainly is now. Technology is dramatically altering the ways in which we diagnose, treat, care for and manage patients. It is our past and it is our present.

Our Mission is to support evidence-based nursing practice and improved patient outcomes with technology solutions that enhance nursing communication, documentation and efficiency. We pursue our mission endlessly and passionately.

Nursing leadership at Cleveland Clinic has long recognized that superior quality of care depends on the alignment of people, processes and technology. The Department of Nursing Informatics, within the Zielony Nursing Institute, plays an essential role in defining and implementing the strategy for innovative technological systems and processes to support the delivery of quality patient care and to enhance nursing practice.

Nursing Informatics participates in multidisciplinary strategic planning to determine system solutions that support patient care, set standards for clinical applications, conform to accreditation standards and regulatory requirements, and transform clinical practice. The department also facilitates the development of automation policies, procedures and guidelines for nursing and is the primary liaison between Cleveland Clinic Information Technology Division and the Zielony Nursing Institute.

At the onset of the department, information technology needs within the Zielony Nursing Institute were focused on supporting mainframe applications, developing databases, maintaining desktop applications and deploying office computers. During this time, when various clinical systems were beginning to evolve and a clinical nurse manager interested in how technology could affect nursing practice and patient care, the first manager of the department was named. With the advent of an automated order entry/results reporting system, the role of the department quickly expanded along with the staff.

Initially referred to as Nursing Information Systems at its inception in 1988, the area was officially established as a department in 1993, one year before the American Nurses Association recognized Nursing Informatics as a specialty with ANCC Certification. The name change to Nursing Informatics was implemented in 2006 to coincide with current standards of practice and scope at that time.

The Nursing Informatics department is now comprised of registered nurses, educators, systems analysts, a web analyst, a security coordinator and system administrators whose focus is to enhance nursing practice through the creative use of technology, maximizing nursing productivity, improving the work environment infrastructure and further supporting the Clinic’s world class excellence in patient care.

We support change, but not just for the sake of change. How can we ensure patient satisfaction, safety and outcomes? How can nursing staff leverage technology to improve the environment for providing exceptional nursing care? Providing unique solutions to these questions is our passion.

Clinical Analysts in the Department of Nursing Informatics are Registered Nurses who assess opportunities for innovative technology to improve clinical practices – by first analyzing clinical workflow to determine current practices. Based upon these observations, they facilitate the design and development, testing, implementation, training and evaluation of automated clinical systems. Informatics Clinical Analysts facilitate work groups from the nursing staff to validate the application design and to study and quantify technology impact on improvement of specific nursing practices and processes.

Clinical Instructors in the Department of Nursing Informatics, are also nurses providing centralized application training to nursing staff in support of new or revised clinical applications implemented on the nursing units. Working collaboratively with the nurse managers, nursing staff, and the Department of Nursing Education & Professional Development, Clinical Instructors provide instruction and user support to ease the introduction of new technology into nursing care workflows. Classes favor independent learning with directed computer lab environments as well as self-directed exercises, but also incorporate computer-based training, a component still evolving from yearly competencies and training in federal regulations to clinical applications training with competency assessment. Unit nursing staff responds positively to the computer-based training, which can be taken at times most convenient to them even from home.

The progressive evolution to electronic documentation of the medical record not only improves access to patient information at the point of care, it also greatly enhances nursing abilities to benchmark, monitor, audit and report quality measures in support of CMS, the Joint Commission and MAGNET initiatives. Additionally, collaborative nursing-led research is enhanced by the ability to support these projects with patient data that is more easily extracted electronically.

Supporting these efforts and initiatives is a dedicated team of clinical and system analysts who provide support for the development and management of information databases, systems and processes to bring efficiency to nursing-driven quality and research endeavors through informatics. Maintenance and support of all databases and desktops is provided with a team of system administrators within the department of Nursing Informatics whose efforts are driven by a strong sense of ensuring employee satisfaction through greater efficiency.

We bring our passion for nursing and our passion for innovation together to improve the way nurses communicate with one another, with other caregivers and with patients.

Informatics nurses see technology as a tool to support, rather than hinder, their love of nursing as well as impact future nursing practices. For this team, technology is leveraged for the benefit of nursing practice and improved excellence in patient care systems and processes. Informatics nurses routinely support staff in using automated applications in their daily assignments on the units and play an important interdisciplinary role that combines their passion for nursing with their love of technology, bringing a nursing perspective into the evaluation of innovative systems so that positive patient outcomes are achieved on all levels.

Technology and the effective use of it is our future. The future of nursing and Nursing Informatics is in alignment with the future of healthcare – growth in the use of technology to ensure safety, positive outcomes and satisfaction of patients. Nursing is at the forefront of this wave of technology innovation.

A visionary nursing project currently in place at Cleveland Clinic is the Nursing Unit of the Future.  This is a collaborative project between the Zielony Nursing Institute and Information Technology Division. Established on a foundation of defining the ways in which people, processes and technology can improve patient outcomes and nursing practice, the Nursing Unit of the Future staff evaluates the feasibility of innovative mobile devices, applications and other communication technologies that have the potential to support enhanced workflow, documentation of patient care and the satisfaction of patients and staff.

The Nursing Unit of the Future provides nurses with an opportunity to experience, assess benefits and provide feedback regarding new information technologies prior to implementation house-wide. As the nurses evaluate the clinical efficacy of devices and applications, the Nursing Informatics team also evaluates technical and clinical outcomes criteria including:

• How devices withstand normal wear and tear
• How easily information is gathered and recorded
• User friendliness
• Clinician satisfaction
• Time efficiency versus existing methods
• Impact on patient safety
• Impact on patient satisfaction
• Impact on caregiver satisfaction

Taking Patient Care to New Levels

The implementation of the electronic medical record, as with other Cleveland Clinic approaches to clinical medical practice, sets a high standard for innovation, collaboration and interoperability.

Nursing Informatics, in collaboration with the Information Technology Division, is implementing an electronic medical records system from Epic Systems of Madison, WI. Electronic documentation of the patient’s medical record is transforming clinical practice for nursing, allied health and medical practitioners at Cleveland Clinic. After using EpicCare successfully in ambulatory outpatient services for two years, the Clinic is currently undergoing a phased implementation of the Epic system in the inpatient setting enabling health care providers to examine any patient record across the entire continuum of care in all Cleveland Clinic facilities. The current implementation includes Provider order entry (CPOE), nursing care documentation, medication dispensing and administration, and results reporting. Cleveland Clinic patients may even access their own records and request prescription renewals via the internet with MyChart.

Innovative Use of Technology

The Department of Nursing Informatics encourages nursing staff, patients and their families to suggest ideas for greater patient satisfaction. The department supports the resulting suggestions as much as is feasible and to that end, has made computers available for patients who have extended hospital stays. Dedicated solely to patients and their families, the computers provide access to the Internet for emailing friends and loved ones, interaction with support groups, researching information or playing computer games.

All Cleveland Clinic nursing staff have an email account in addition to access to the Zielony Nursing Institute Intranet site complete with Cleveland Clinic policies and procedures, clinical references, announcements of educational classes and opportunities for professional growth, hospital and nursing award opportunities.  Everything the nursing staff needs to know is in a comprehensive, easy-to-access site.

In 2006, wireless Voice-over-IP (voice carried over internet protocol networks) phones were implemented in all nursing units to facilitate ease of communication and coordination of patient care between staff, physicians, ancillary departments and patients. Voice-over-IP technology is the most state-of-the-art telecommunications methodology available commercially today and is fast becoming the standard for voice communications globally. The results improved communication and enhanced efficiency to improve patient care and satisfaction.

Until 2003, Nursing Quality had been part of the Department of Nursing Education, Quality and Research for more than 15 years. But the three areas were made into three separate departments as the role of each is of growing importance to nursing leadership. However, these three departments continue to work together hand-in-hand. In 2008, the Magnet Recognition Program ® and Nursing Patient Safety were combined with the Nursing Quality department.

Nursing Quality works collaboratively with Cleveland Clinic's Quality and Patient Safety Institute in promoting quality patient care and providing education on national quality initiatives.

Staff in Nursing Quality regularly recommend and participate in research related to nursing interventions, patient safety initiatives, shared governance, and promoting the forces of magnetism.

The department's guiding principle is that quality is based on evidence-based practice and effective processes.

Nursing Quality staff members coordinate and report to the National Database for Nursing Quality for select indicators. They coordinate nursing initiatives for JCAHO Core Measures, National Safety Forum initiatives, and for the National Patient Safety initiatives.

Nursing Quality sends monthly quality reports to nurse managers. In addition, the information is shared with the Nursing Institute Shared Governance Quality Council and Unit Based Shared Governance Councils. The department is accessible to all nurses in the hospital, by phone or email.

Key nursing care quality indicators in conjunction with hospital measurements have gone from in-house measurements to public information with performance scores and comparisons accessible to all health care consumers. In this time of heightened awareness, the staff of the Department of Nursing Quality strives to improve patient care by communicating evidence-based standards and by monitoring and reporting the progress of key nursing quality indicators.

Nursing Quality staff consists of Quality and Accreditation Nurses, a Nursing Patient Safety Officer (CNS), Data management support, Certified Skin Care Nurse Coordinators (WOCN) eliminate these initials, Magnet® Program Manager, and Magnet Program Coordinator. The nursing staff is required to have at least three years of hospital in-patient experience to be part of the quality and the skin care teams. The Skin Care Nurse Coordinators must have the equivalent experience with a concentration in wound and skin care and complete the training program at Cleveland Clinic's R.B. Turnbull Jr., MD, School of Enterostomal Therapy Nursing. The Quality and Accreditation Nurses receive training in performance improvement and group facilitation.

The department's major activities include:

• Assisting the department to stay current with meeting and exceeding nursing and industry standards
• Maintaining and communicating the Zielony Nursing Institute Online Nursing Standards which include administrative and clinical standards
• Collecting, analyzing and reporting on multiple nursing or industry quality indicators, including monthly Quality Indicator reports for the Zielony Nursing Institute, as well as for individual units
• Representing nursing's role and perspective on multiple hospital wide committees and task forces, in order to improve multidisciplinary interventions for patient care
• Leading the Skin Care and Prevention initiative for Hospital Acquired Pressure ulcers
• Communicating and maintaining compliance with the National Patient Safety Goals within the Zielony Nursing Institute
• Facilitating the ANCC Magnet Recognition Program® and identifying the forces of magnetism within nursing practice

Known the world over for its strong basic science and its fundamental mission as a clinical research hospital, Cleveland Clinic is placing renewed emphasis on the importance of research by nurses. Although nurses have long been involved in clinical research efforts, nurses at all levels of nursing practice—bedside, clinical nurse specialists, educators, managers—are being encouraged to engage in scientific inquiry. Cleveland Clinic nurses have the opportunity to raise a question about nursing practice, and through the research process, investigate that question with the goal of promoting and assuring evidence-based nursing practice and optimum patient care.

To encourage research by nurses, Nursing Research assigns a PhD trained nurse researcher to each Cleveland Clinic institute who serves as a mentor to clinical nurses. A mentor stimulates and supports the development of research questions or generates ideas regarding nursing practice changes that will prompt evaluation of current practices and foster improved standards for patient care. Mentors assist nurses in every step of research, as needed; from identifying clinical problems, initiating research questions, completing paperwork for Institutional Review Board approval and grant funding groups, conducting and analyzing research, and presenting and disseminating findings. Research findings will determine how nurses deliver care, educate each other, and manage their practice. When nursing practice is evidence-based, patients are more likely to receive nursing care that is safe and effective, promotes comfort and facilitates the best outcomes.

Additionally, each PhD nurse researcher has her own program of research that is actively pursued. In this way, researchers are always current with governing rules of research, are aware of grant and other opportunities open to those they mentor and can include staff nurses in their projects, to aid in general nursing research growth.

Staffed by doctoral prepared registered nurses, research by nurses helps generate new knowledge to firmly establish nursing practice that is evidence-based. Nurses may initiate projects that broaden the scope of nursing practice, utilize new methods to assess, plan, deliver or evaluate nursing care or work collaboratively with other Cleveland Clinic teams to manage patient populations more effectively. In addition, nurses who learn the research process can become mentors to other clinical nurse peers who are inexperienced in research, with the goals of:

• improving the confidence of clinical nurses in their ability to conduct basic research
• aiding clinical nurses in the processes of conducting research
• guiding clinical nurses in anticipating results and promoting practice changes based on results
• supporting dissemination of research through presentation at a national meeting and publication in a peer-reviewed journal

Research findings will help determine how nurses deliver care, educate each other and manage their practice. Nursing research may be descriptive / correlational (e.g., noise levels on a unit) or quasi-experimental / experimental (e.g., assessing the effect of a new patient intervention); it may be qualitative (understanding complexity of nursing care) or quantitative; or it may be retrospective, prospective or longitudinal in design. Nurse researcher mentors assist nurses in instrument development (when needed) and assure content validity and reliability of new tools when doing so. For example, a clinical nurse specialist and a team of nurses on the medical intensive care unit at Cleveland Clinic developed an algorithm for sedation for patients on respirators and breathing tubes. The goal was to improve patient rest, reduce anxiety and decrease irritation in the throat. After conducting a fully researched and documented trial, with data collection and analysis, the team determined that the new sedation algorithm was safe and effective. Their research led to a sedation protocol that became the standard of practice.

For many nurses, nursing research is valued and they want to make time to complete processes associated with research initiatives. We have implemented many research systems and processes to reduce the time needed to complete research related work. Emphasis is placed on the importance of evidence-based practices through scientific knowledge. Cleveland Clinic believes the future of nursing practice will be strongly influenced by findings from both local and multicenter nursing research. Thus, we are always looking for new ways to make time for nurses to conduct, translate and disseminate research projects in a way that does not negatively impact patient care.

By participating in research projects, nurses become leaders in their own departments by working to improve nursing practice and patient care. Nursing researchers can mentor a clinical nurse through the entire research process, as needed. We also provide opportunities to share completed research among peers internally, through oral and poster presentations at our annual Research Day, held in May each year (during Nurses Week) and oral presentations at our fall workshops.

Prior to publication, nurses have the opportunity to present their findings at national meetings, thereby influencing patient care and nursing practice at a national level. Research provides the opportunity to further knowledge, to gain recognition and prominence in setting standards for patient care and nursing practice, and to grow personally and professionally. Nursing research activities can be used to clinical ladder activities.

The Cleveland Clinic Nursing Research Fund (NURF) is a privately supported internal grant-making system that supports nursing research. Annually, multiple awards are approved to nurses working in any capacity on Cleveland Clinic main campus or in one of the regional ambulatory practices. Internal grant funds are encouraged and sought to overcome costs associated with the research process.

• Find out more about the Nursing Research Fund award