Massachusetts General Hospital Patient Care Services
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Patient Care Services


"promoting excellence every day
through knowledge and compassion"
Collaborative Governance Magnet Recognition Regulatory Readiness Innovation Units

Overview | Responsibilities | 2015 Accomplishments | 20016 Goals | Clinical Practice Champions

Collaborative Governance

Advisory Committees

Committee on Diversity and Inclusion

Ethics in Clinical Practice


Patient Education

Patient Experience

Clinical Practice Committee

Quality and Safety

Research and Evidence-Based Practice



Current Work:

  1. Effective September 5th all blood bank specimens must have 2 signatures, if they don’t, the sample will be discarded and need to be redrawn. The two signatures verify that the information on the specimen label and the information on the patient ID are a match.
  2. The work on cost containment continues some great ideas generated include: identifying your unit as a “green unit” to let patients know their linen will be changes as needed or every other day; small saving adds up when you factor in MGH has 1,000 patients and almost 5,000 discharges a month, that’s a lot of water pitchers in landfills.
  3. Two new policies- Discriminatory behavior and Patient leaving the floor policy were discussed; they will have significant impact on all staff so please discuss them with your colleagues.
  4. Our Magnet site visit is scheduled for November 6th - 9th. Be prepared and enjoy talking about your practice.
  5. Our hand hygiene scores have dropped, please remind all members on the team to ensure that we keep our patients and each other safe.
  6. MGH is launching a campaign to quickly identify and treat patients with sepsis. Use of the quick Sepsis Related Organ Failure Assessment (qSOFA) ensures that all members of the team are alerted when a patient is suspected of being septic.
  7. Ketamine will begin to be used in the ED to treat patients with severe agitation/excited delirium.

2016 Accomplishments

  • Champions reviewed and gave feedback on the transition of policy and procedure manuals from Trove to Ellucid.
  • Champions reviewed and gave feedback on multiple policies and procedures including: on Clinimix, IV Altepase, Zoll Vests, and Coude urinary catheter insertion. That feedback led to changes in those procedures and policies.
  • Champions reviewed and gave feedback on: Central Line and PICC Line removal procedures. Champions ensured that there were consistent practices in these procedures.
  • Committee champions partnered with members of the Respiratory Department regarding alignment of practices in procedures common to both disciplines, e.g. tracheostomy care, oxygen therapy.
  • Committee Champions gave feedback on the transfusion policy and procedure. Champions were able to offer insight into documentation changes and helped create a new form where required information could be captured. Champions identified opportunities where practices could be improved.
  • Committee champions have been actively involved in the review of new products and/or when the hospital has changed vendors; including new dressings and products for skin care. The champions are able to offer valuable input into value of these products based on their experiences in utilizing them in patient care.

2017 Goals

  1. Nursing policies and products will continue to be reviewed by this Committee with the goal of ensuring safe nursing practice as well providing the most advanced nursing care for our patients.
  2. Clinical practice issues will continue to be raised, and the content experts will participate in addressing and resolving those issues.
  3. Policies and Procedures and nursing practice will be updated to ensure that they reflect current evidence based practice.
  4. To continue to review products that will be cost saving for the institution as well as ensuring that patient care is not compromised.

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Meets the 2nd Tuesday of the month from 1-3:00 pm in the Sweet Room, Gray/Bigelow 432

Committee Contacts:

James Bradley, RN, Staff Nurse, Ellison 7

Kristen Kingsley, RN, Staff Nurse, Bigelow 9

Lillian Ananian, RN, CNS, Blake 7

Barbara Cashavelly, RN Nursing Director, Lunder 9


CG Clinical Practice Committee Champions

Clinical Practice Committee Overview

The Patient Care Services Clinical Practice Committee sub-Committee reviews and approves policies and procedures to ensure they are appropriately vetted and evidence-based. Champions review and approve products that are brought into the practice environment, including the plan for product roll-out. Champions should have an interest in influencing how the policies and procedures that guide practice are reviewed and implemented. They should also have an interest in being involved in the decisions to purchase and trial products in the clinical area. return to top


  • Enhance professional development.
  • Engage in joint projects with other Collaborative Governance committees.
  • Align the work of the committee with PCS strategic goals. return to top

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