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Engage new nurses to ensure a sense of shared responsibility

Operationalizing the Pathway to Excellence® quality standard

By: Kerrie Guerrero, DNP, MBA, RN, NE-BC, and Sarah Fleming, MBA, BSN, RN, NE-BC 

Engage new nurses to ensure a sense of shared responsibility. 


  • The Pathway to Excellence Program quality standard requires that organizations have hard-wired processes for benchmarking, quality improvement, evidence-based practice, and education.
  • The Pathway to Excellence program provides a framework that fosters a supportive work environment that provides high-quality care, this is how one organization met the quality standards.
  • Houston Methodist The Woodlands Hospital operationalized the standard with interprofessional collaboration on quality initiatives.

Houston Methodist The Woodlands Hospital (HMTW), a 187-bed complex care medical center that opened June 26, 2017, is part of an eight-hospital academic medical center with facilities throughout the Houston metro area. In August 2019, HMTW received American Nurses Credentialing Center (ANCC) Pathways to Excellence® designation. The Pathway to Excellence Program requires organizations to meet six standards and offers a framework that fosters a supportive work environment for providing high-quality care.

HMTW has achieved high marks in quality assessments by external organizations, such as Vizient. In 2021, Vizient ranked HMTW as an overall top performer in a cohort of 121 similarly sized medical centers and first within the safety domain. The Pathway to Excellence Program quality standard—which requires that organizations have hard-wired processes for benchmarking, quality improvement, evidence-based practice, and education—enhances these efforts. HMTW creates interprofessional collaboration via evidence-based practice on hospital- and system-wide quality initiatives that align closely with the Houston Methodist mission, vision, value, and goals.


To aid in setting priorities, initiatives, and education, HMTW developed benchmarking procedures for external and internal metrics.


The HMTW quality management team (which includes a quality director, performance improvement coordinators, and direct care nurses) shares and discusses external benchmarking through shared governance. The team coordinates data collection across departments and compares findings against national sources, including the National Database of Nursing Quality Indicators (NDNQI), Centers for Disease Control and Prevention, National Healthcare Safety Network, Vizient Clinical Database, and, for specialty services, the American Heart Association and American Stroke Association. Based on these comparisons, the quality management team facilitates a Plan-Do-Check-Act (PDCA) cycle for strategic quality improvement. The team collects additional data to assess progress toward goals. (See External benchmarking in action.)

External benchmarking in action

Houston Methodist The Woodlands Hospital (HMTW) uses the National Database of Nursing Quality Indicators (NDNQI) to externally benchmark many nurse-sensitive indicators. Partnering with NDNQI allows HMTW to collect and analyze data, compare performance to peers across the country, and determine areas of opportunity. For example, HMTW used NDNQI to assess patient falls on an adult medical/surgical unit. This unit averaged 3.59 falls per 1,000 patient days, compared to 2.62 in the American Nurses Credentialing Center Magnet®-recognized cohort.

To address this assessment outcome, HMTW adopted the Hester Davis Fall Prevention Program with live classes (including skills demonstrations), online modules, and webinars. Bedside nurses served as champions for their units, conducting intervention audits. The fall champions led Plan-Do-Check-Act cycles to improve Hester Davis tool use, which increased from 51% to 97% adherence within 6 months. The unit’s fall rate decreased to 1.05.

Internal benchmarking  

Using a similar data collection and comparison process, the quality management team conducts internal benchmarking of several quality standards, including hand hygiene, blood culture contamination rates, specimen mislabeling, and barcode medication administration rates. These assessments, used across the Houston Methodist System, create unit-specific and system-wide benchmarks. (See Internal benchmarking in action.)

Internal benchmarking in action

Houston Methodist The Woodlands Hospital established an internal benchmark for barcode medication administration (BCMA) of 97% adherence. The quality and pharmacy departments collect and share BCMA adherence data with the nursing units. The data then are reviewed by the shared governance clinical informatics and technology council, which is led by the nurse informaticist and includes clinical nurses, nursing leadership, and the quality department. Initially, BCMA adherence averaged 95.6%. In conjunction with the pharmacy department, unit champions conducted Plan-Do-Check-Act cycles to identify issues related to reduced BCMA adherence. This careful review resulted in targeted educational outreach to address problems directly. HMTW now consistently achieves adherence above the goal.

Quality improvement

HMTW uses shared governance to facilitate nurse-led, evidence-based best practice initiatives, which share three key features to promote success: evidence-based practice, specific patient outcomes, and interprofessional context. The interprofessional shared governance group includes representatives from each hospital department, both clinical and nonclinical. Empowering frontline staff who help drive change and quality initiatives was a precedent set on day one. By embracing a culture of evidence-based practice, HMTW employees commit to providing unparalleled patient care and meeting quality standards.

For example, HMTW created an initiative to address malignant hyperthermia in labor and delivery. The process began with an interprofessional drill that included nursing, pharmacy, physicians, and anesthesia. After the drill, participants debriefed together and identified areas for improvement. Next, an interprofessional team with representatives from labor and delivery, emergency services, critical care, endoscopy, surgical services, imaging, anesthesia, and pharmacy convened to address concerns and develop a new workflow. The policy and procedure council (which includes members from nursing, respiratory therapy, pharmacy, education, and quality) reviewed and approved the new workflow and policy, which has been reinforced through ongoing quarterly drills. Successful initiatives such as this create a sense of pride and accountability for the interprofessional team.


High-quality patient care requires staff education. HMTW provides education across multiple platforms based on ongoing quality improvement initiatives and goals, including during orientation and via continuing education opportunities throughout the year.

New employee orientation  

New nurse employees participate in orientation that provides insight into the Houston Methodist experience, including the organization’s mission, vision, and values. They then attend a multiday clinical orientation (which includes didactic sessions, guest speakers, and skill competency validations) to review specific processes, policies, and clinical practices. This valuable time ensures new employees feel prepared to integrate into their units, where additional education occurs.

New employees meet several weeks into their orientation in a setting that provides a safe, open forum where they can ask questions and offer feedback on their orientation experience. This follow-up allows educators to course-correct the orientation process as needed. For example, educators have received feedback related to electronic health record (EHR) training. The educators took this information to the EHR training team, which made adjustments to the orientation schedule.

The chief nursing officer (CNO) also meets with a few new nurses about 90 days into their employment to touch base and get their feedback on orientation. The CNO shares this feedback with the appropriate department and changes are implemented when appropriate.

Continuing education  

To facilitate continuing education, all nurses receive an annual needs assessment survey. The results help guide the education department’s strategies for the coming year. The department creates quarterly competency training and seminars to focus on identified needs and to re-engage staff with essential initiatives. Service quality skill labs, lunch and learns, and online learning opportunities provide avenues for increasing knowledge and competence.

The system’s organizational development department (which includes educators and an organizational development specialist) leads the Houston Methodist Academy of Leadership and Learning to provide professional development opportunities to all staff. To help staff grow as professionals and leaders, Houston Methodist offers additional courses, including charge nurse classes, leadership development courses, and other organizational improvement opportunities. To meet staff needs, the classes (which include topics such as communication and conflict management) are available in-person and online. These offerings engage employees and create an opportunity to build shared values and promote professional development. As a result, 92.25% of the organization’s nursing staff have bachelor’s degrees and 8.72% have received a master’s degree or higher. In addition, 41.45% of nursing staff are nationally certified in a specialty.

Engagement culture

All HMTW employees are encouraged to participate in evidenced-based quality improvement. This sense of shared responsibility for patient care has created a culture of active engagement that enables large-scale initiative success. The Pathway to Excellence quality standard sets the foundation for achieving safe, high-quality patient care goals.

The authors work at Houston Methodist The Woodlands Hospital in The Woodlands, Texas. Kerrie Guerrero is vice president and chief nursing officer. Sarah Fleming is associate chief nursing officer. 


American Nurses Credentialing Center. 2020 Pathway to Excellence® Application Manual. Silver Spring, MD: American Nurses Credentialing Center; 2020.

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