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. Please share Brian French’s tutorial on ellucid with you colleagues Ellucid tutorial
  2. If you are having trouble finding a document in ellucid, it might be because the title of the procedure needs to change, or a search word needs to be added. Email Mary Ellin at
  3. Ellison 8, 10, 11 and Lunder 10 will be authorized in the drug library, to administer KCL through central lines at ICU rates.
  4. IV Therapy will be piloting the Arrow Endurance Catheter which is placed via ultrasound. During the trial the IV team will be performing dressing changes and drawing bloods.
  5. There are changes coming to IV medications (Diltiazem, Enalaprilat, Hydralazine, Labetalol, Metoprolol) RNs on general care units can push. Champions have asked pharmacy to work with the CNS/NPS group on a safe and efficient roll out of this major practice change.
  6. Circle Up Huddles have been found to be helpful in sharing key information on: Stress Recognition , Operational issues and Safety & Clinical issues. They are held twice a day and all members of the team are invited and encouraged to attend.
  7. The need for a new line for either TPN or PPN is determined by a collaborative discussion of risk vs. benefits with the responding clinicians, nutrition support and the patients nurse.
  8. Femoral central non-procedural catheters should only be removed by responding clinician on general care units. Hemodialysis and ICU RNs may remove femoral catheters, introducers, or non-procedural sheaths on their respective units unless precluded by unit-specific guidelines. Femoral or IJ catheters, introducers, or non-procedural sheaths >12 Fr should only be removed by the provider.

2020 Goals

  • Collaborate with CNS/NPS and medical librarians on ensuring that procedures are safe and evidence-based.
  • Promote champions knowledge of resources and opportunities to develop their knowledge of evidence-based practices.
  • Create greater opportunities for champions to bring forward issues, concerns and opportunities, that they encounter in their practice, which will improve the delivery of safe, effective care.
  • Continue to educate staff nurses on new and revised procedures at the unit/department level and across the MGH community.

2020 Accomplishments

  • Champions bring concerns/issues from the practice setting to address and resolve including:

            Photosensitive label
            Multi-dose packaging
            Lack of slings on the units

  • Reviewed, gave feedback and approval over 30 procedures and guidelines
  • Collaborated with Materials Management on supply/product concerns, new products and their roll-out.
  • Provided a forum for clinical staff to discuss the impact of the pandemic on their professional lives. Provided resources to assist them in managing and coping.

2021 Goals

  • Collaborate with CNS/NPS and medical librarians on ensuring that procedures are safe, and evidence based.
  • Promote champions knowledge of Ellucid and other resources to support their practice.
  • Continue to address and bring to resolution champions practice concerns.
  • Continue to communicate with staff nurses on new and revised procedures at the unit/department level and across the MGH community.


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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, Surgery, White 7

Leila Bucchino, RN Surgery, Staff Nurse, Phillips House 22

Lillian Ananian, RN, CNS, Blake 7


Mary Ellin Smith, RN, The Institute for patient Care

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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