Structures that support the hospital’s mission of delivering high quality, safe and cost effective care include, but are not limited to an Associate Chief of Nursing dedicated to overseeing nursing practice and a state of the art automated Nursing Dashboard created in collaboration with eleven disciplines/departments that supports the hospital’s and nursing’s strategic priorities.  The Nursing Dashboard generates quarterly multivariate nursing quality indicator data benchmarked at the highest level possible for 72 clinical areas.  Unit-based, multidisciplinary governance councils led mostly by clinical mentors, the third level in our clinical ladder, develop action plans, which are reviewed by a house wide, multidisciplinary Quality and Patient Safety Council.  The actions of the governance councils are supplemented by house wide multidisciplinary clinical safety squads, who collaborate with nursing to initiate evidence-based performance improvement initiatives, which ultimately optimize patient outcomes.

Clinical mentors complete six modules of instruction on performance improvement, evidence-based practice, resource management, professional development, communication and meeting management acquiring the leadership skills to drive clinical quality.  Classes are taught collaboratively by hospital directors, a clinical nurse specialist, an organizational development specialist and performance improvement coordinator.