Pathway to Excellence Self-Assessment

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Pathway to Excellence1: Shared Decision-Making

Does the organization foster and support a culture of inter-professional decision-making?
Does the organization periodically assess the effectiveness of the current shared decision-making structure?
Does the organization utilize evidence-based practice to implement changes in nursing practice?
Do nurses use the shared decision-making structure to select initiatives team members will participate in to promote community health?
Is there an inter-professional process in place to address ethical concerns within the organization?
Do direct care nurses collaborate with interprofessional colleagues to select and plan the implementation of new or upgrade to existing technologies?
Is input from direct care nurses included in the process when hiring new staff?
Do direct care nurses use the shared decision-making structure to plan and evaluate well-being initiatives.

Pathway Standard 2: Leadership

Does the organization have strategies to sustain a positive practice environment regardless of leadership or organizational changes?
Does the organization ask the nursing leadership team their input on which retention strategies would influence their intent to stay?
Does the organization use succession planning to develop nurses for nursing leadership roles?
Do new nurse managers identify their self-assessed needs on a needs assessment tool to facilitate the individualization of their own orientation?
Does the organization provide leadership development activities to enhance leadership competency?
Is feedback from peers or direct report staff incorporated into the performance evaluation of nurse managers?
Do nurse managers engage direct care nurses in collaborative cost management discussions?
Do nurse managers accommodate and actively support direct care nurses to participate in shared decision-making structure committees?
Are there strategies in place to be utilized by organizational leaders to support direct care nurses' continued involvement in the shared decision-making structure during times of planned and unplanned change?
Is the CNO accessible to nursing staff?
Are the nurse managers accessible to nursing staff?

Pathway Standard 3: Safety

Does the organization have a process(es) in place to involve direct care nurses in reporting, analysis, and identifying trends of patient-related safety events?
Does the organization have a process(es) in place to involve direct care nurses in reporting and improvement strategies to prevent nurse-related safety events from re-occuring?
Does the organization promote psychological and physical safety through a culture that is free from workplace violence among the healthcare team?
Does the organization safeguard nurses from abuse by patients and/or visitors?
Does the organization establish long-term staffing plans that reflect effective team composition? Does the organization support direct care nurses to communicate concerns about the long-term staffing plan?
Does the nursing leadership team address long-term staffing concerns expressed by the direct care nurses and communicate associated strategies back to the direct care nuses?
Do direct care nurses have input in daily staffing decisions?
Is an inter-professional decision-making process in place when transitioning patients from one level of care to another across the healthcare continuum?
Does the organization ensure that direct care nuses consistently plan and take meal and rest breaks during work?
Are direct care nurses supported to provide safe patient care when they are assigned to an area other than their primary area?
Do staff feel 1) safe to report discriminatory behaviors, 2) know that the reported concerns will be addressed, and 3) follow-up will be provided to the person reporting the concerns?

Pathway Standard 4: Quality

Does the organization engage direct care nurses to understand how their role and actions contribute to the mission, vision, values or goals of the organization?
Does the organization promote a culture of person and family-centered care?
Are direct care nurses and nurse managers in the organization educated about the concept and application of evidence-based practice?
Do direct care nurses implement evidence-based practice in patient care areas?
Does the organization's quality improvement process reflect inter-professional collaboration?
Is there a process in place to communicate updates regarding changes in quality initiatives and performance in quality measures?
Do direct care nurses lead quality initiatives to improve externally benchmarked outcomes?
Does the organization have a process to identify and address health disparities identified in the local community?
Does the organization promote a culture of diversity, equity, inclusion, and belonging (DEIB)? Does the organization assess the effectiveness of associated strategies to promote DEIB?
Does the organization encourage sharing of new ideas and support innovation in the workplace?

Pathway Standard 5: Well-Being

Does the organization raise awareness of 1) mental health issues prevalent among nurses 2) mental health services to address those issues, and 3) evidence-based strategies to enhance mental well-being during work hours?
Does the organization utilize results of employee physical health and mental wellness assessments in the development of health initiatives?
Does senior leadership integrate employee resilience and well-being into the organization's strategic planning?
Does the organization ask for suggestions from direct care nurses for future well-being initiatives?
Do nurse managers provide nurses opportunities to create work scheduled that support nurse well-being?
Does the organization support and recognize nurses' involvement in volunteer activities?
Does nursing leadership foster a lived culture of recognition?
Do nurses feel safe to self-report medical erros in the workplace?
Does the organization offer real-time opportunities to support the well-being of staff who experience adverse work-related situations?
Does the organization have support strategies to address the well-being needs of senior nursing leaders and nurse managers?
Does the organization have a strategy (ies) to address compassion fatigue experienced by the healthcare team?

Pathway Standard 6: Professional Development

Do orienting nurses assess their competencies on a needs assessment toll to facilitate the individualization of their orientation?
Is there a process in place for newly graduated nurses and newly hired experienced nurses to transition into practice?
Do direct care nurses have input into the selection of educational offerings?
Does the organization support direct care nurses to participate in professional development activities (excluding orientation)?
Does the organization support direct care nurses to pursue specialty certification?
Does the organization foster a mentoring environment?
Does the organization provide sessions to educate employees about respectful communication?
Does the organization foster growth of direct care nurses as emerging nurse leaders within or outside the organization?
Are nurses encouraged to share best practices with entities outside their organization?

General Pathway Questions

Are staff members aware of the WHY, and actively engaged in the Pathway to Excellence journey?