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.

2017 Accomplishments

  • Re-named committee from “Policy, Procedure and Products” to “Clinical Practice” to better reflect the nature and scope of the committees work and its interprofessional nature.

  • Created campaign “Erase The Waste” where champions brought pictures of supplies which are wasted when a patient is discharged. Working with Materials Management, the cost of those items was tallied and averaged, showing that annually supplies costing $425,000 to $1,240.00 are wasted. This information was shared at the SAFER Fair.
  • Reviewed, revised and approved over ninety nursing procedures as well as non-nursing procedures/policies which impact patient care, such as medication policies.

2018 Goals

  • Nursing policies and products will continue to be reviewed by this Committee with the goal of ensuring safe, evidence-based nursing practice.

  • Champions will continue to bring forward opportunities to: improve patient care; identify practice issues/concerns in their department/unit.

  • Champions will continue to identify opportunities to decrease waste and costs by influencing their colleagues and continued collaboration with colleagues in materials management and other departments.

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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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